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UBC Theses and Dissertations

Juvenile sex offender treatment outcome and conduct disorder diagnosis Pond, Michael James 1995-12-31

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. JUVENILE SEX OFFENDER TREATMENT OUTCOME AND CONDUCT DISORDER DIAGNOSIS by MICHAEL JAMES POND R.P.N., A l b e r t a H o s p i t a l School o f Nursing, 1978 B.S.W., The U n i v e r s i t y o f V i c t o r i a , 1993 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE  REQUIREMENTS FOR THE DEGREE OF. MASTER OF SOCIAL WORK in  THE  FACULTY OF GRADUATE STUDIES SCHOOL OF SOCIAL WORK  We accept t h i s t h e s i s as conforming to the r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA May 1995 ©  M i c h a e l James Pond, 1995  In  presenting  this  thesis  in  degree at the University of  partial  fulfilment  of  the  requirements  for  an advanced  British Columbia, I agree that the Library shall make it  freely available for reference and study. I further agree that permission for extensive copying of  this thesis for  department  or  by  his  or  scholarly purposes may be granted her  representatives.  It  is  by the  understood  that  head of  my  copying  or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  Coc/Ct^.  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  11  Abstract  U s i n g a d e s c r i p t i v e d e s i g n , t h i s study i n v e s t i g a t e d the d i f f e r e n c e s i n treatment o f f e n d e r s who  outcomes between j u v e n i l e sex  were d i a g n o s e d w i t h Conduct D i s o r d e r  t o DSM-III-R (APA,  1987)  (according  c l a s s i f i c a t i o n system c r i t e r i a )  those w i t h a non-conduct d i s o r d e r d i a g n o s i s .  The  clinical  r e c o r d s of 100 j u v e n i l e males c o n v i c t e d w i t h a s e x u a l who  were c o u r t o r d e r e d  a t Youth Court  C l i n i c between January 1, 1989 The  Services/Out-patient  and January 1, 1993  were  r e s u l t s i n d i c a t e d t h a t the youths d i a g n o s e d w i t h  Conduct D i s o r d e r d i s p l a y e d a s i g n i f i c a n t l y h i g h e r f o r u n s u c c e s s f u l treatment  the j u v e n i l e sex o f f e n d e r who  The  youths  f i n d i n g s suggest  i s d i a g n o s e d as conduct  be a subtype who  u n s u c c e s s f u l l y completing  probability  outcome as compared t o those  w i t h a non-conduct d i s o r d e r d i a g n o s i s .  d i s o r d e r e d may  offense  for a psychiatric/psychological/social  assessment and treatment  studied.  and  i s a t h i g h e r r i s k of  treatment,  s p e c i a l i z e d form of i n t e r v e n t i o n .  and may  r e q u i r e a more  Furthermore, the f i n d i n g s  suggest t h a t t h e r e are l i m i t a t i o n s t o the DSM-III-R c l a s s i f i c a t i o n system w i t h t h i s p o p u l a t i o n .  Ill  TABLE OF CONTENTS  Page Abstract  i i  Table o f Contents  i i i  L i s t o f Tables Acknowledgements  viii -  ix  CHAPTER ONE  1  INTRODUCTION  1  Statement o f Purpose  1  T h e s i s Overview  2  J u v e n i l e Sex O f f e n d e r s Impact on S o c i e t y  4  The E x t e n t o f t h e Problem  5  The J u v e n i l e Sex O f f e n d e r and O f f e n s e s  7  Legal D e f i n i t i o n  7  Canadian L e g a l D e f i n i t i o n s Meaning o f Consent  9 11  Medical D e f i n i t i o n  12  The Modal J u v e n i l e Sex O f f e n d e r . .  19  The H e t e r o g e n e i t y o f J u v e n i l e Sex O f f e n d e r s  22  Sociocultural Factors  25  iv S o c i a l Competence  26  S e x u a l Adjustment..  28  C o g n i t i v e F a c t o r s and Academic A b i l i t y  29  Victim Characteristics  30  L e v e l o f A g g r e s s i o n and V i o l e n c e  32  P s y c h i a t r i c F a c t o r s and Conduct D i s o r d e r  33  CHAPTER TWO  37  PSYCHIATRIC DIAGNOSIS AND SEXUAL OFFENDING IN ADOLESCENTS  37  Introduction  37  H i s t o r y o f DSM C l a s s i f i c a t i o n System  38  M u l t i a x i a l C l a s s i f i c a t i o n System  43  Evaluation of M u l t i a x i a l  System  C r i t i c a l A n a l y s i s o f DSM R e v i s i o n s  45 49  C l i n i c a l Bias  51  Strengths  53  and L i m i t a t i o n s o f DSM  Pathologizing Children Changes i n DSM C a t e g o r i e s  and C r i t e r i a . . .  54 56  Hierarchical Structure  56  D i a g n o s t i c Rules  58  DSM-III-R and DSM-IV: More S c i e n t i f i c and A c c e s s i b l e  60  DSM C l a s s i f i c a t i o n o f Conduct D i s o r d e r  63  V  D i s r u p t i v e Behaviour Disorders E v o l u t i o n o f Conduct D i s o r d e r  63 Subtypes  66  E v a l u a t i o n o f DSM C l a s s i f i c a t i o n f o r Conduct D i s o r d e r  ...72  Diagnostic Thresholds  73  Conduct D i s o r d e r  74  Symptoms  Treatment Outcome  77  Research Purpose and Hypotheses CHAPTER THREE  ..84 91  RESEARCH DESIGN  91  Introduction  91  Method  92  Subjects  92  Measures  93  Diagnostic Variable  93  Alternate Diagnostic Variable  93  Conduct D i s o r d e r  95  Symptom V a r i a b l e  P r e v i o u s Non-sexual O f f e n s e V a r i a b l e  95  Treatment Outcome V a r i a b l e  95  R e l i a b i l i t y and V a l i d i t y  97  Data A n a l y s i s  99  vi CHAPTER FOUR  101  RESULTS  101  Treatment Outcome....  101  P s y c h i a t r i c Conduct D i s o r d e r A l t e r n a t e Conduct D i s o r d e r  (PCD)  (ACD)  101 102  A l t e r n a t e and P s y c h i a t r i c D i a g n o s i s  104  Conduct D i s o r d e r B e h a v i o r a l V a r i a b l e s  105  P r e v i o u s Non-sexual O f f e n s e s  107  P s y c h i a t r i c Conduct D i s o r d e r  107  A l t e r n a t e Conduct D i s o r d e r  108  CHAPTER FIVE  110  DISCUSSION  110  Implications  110  Limitations  117  Conclusions  120  Biliography  121  Appendices  153  Appendix 1: Youth C o u r t S e r v i c e s L e t t e r of Approval Appendix 2: UBC Request f o r E t h i c a l Review  154 155  vii Appendix 3: UBC O f f i c e o f Research S e r v i c e s C e r t i f i c a t e of Approval  1.64  Appendix 4: P s y c h i a t r i c A d m i s s i o n Worksheet Appendix 5: F o r e n s i c P s y c h i a t r i c S e r v i c e s  165 Commission  P r o v i s i o n a l Diagnosis  178  Appendix 6: M e d i c a l and B e h a v i o r a l A l e r t s Appendix 6: F o r e n s i c P s y c h i a t r i c S e r v i c e s  179 Commission  A d m i s s i o n Data  180  Appendix 8: M e d i c a l P r o c e d u r e s / P s y c h o l o g i c a l Appendix 9: S o c i a l H i s t o r y Format Appendix 10: N u r s i n g Assessment  Guidelines  Tests....183 .....184 187  Appendix 11: P s y c h o l o g i c a l I n t e r v i e w  190  Appendix 12: C l o s i n g Summary  202  Appendix 13: D i s c h a r g e / D i s p o s i t i o n D i a g n o s i s  203  vm LIST OF  Table 1:  Percentages  TABLES  o f Conduct D i s o r d e r e d and Non-Conduct  D i s o r d e r e d S u b j e c t s With S u c c e s s f u l and U n s u c c e s s f u l Treatment Outcomes  Table 2:  103  I n d i v i d u a l Conduct D i s o r d e r B e h a v i o u r s  Diagnosis  and S u c c e s s f u l Treatment Outcome  Table 3:  Percentages  106  o f Conduct D i s o r d e r e d S u b j e c t s  and Non-Conduct D i s o r d e r e d S u b j e c t s P r e v i o u s Non-sexual Offenses  With 109  ix Ac knowledgements  To my w i f e , Rhonda, who c o n t i n u o u s l y supported  w i t h p a t i e n c e and l o v e and endured a l l my  sons, T a y l o r , Brennan, and Jonathan, who f r e q u e n t l y absent f a t h e r . and l o v e d me  has  efforts.  was  my  put up w i t h a  To Armond and Doreen, who  i n more ways than they can imagine.  mother, Merva, who  To  t h e r e when I needed h e r .  supported  To To  my my  a d v i s o r , Mary R u s s e l l , f o r always s h a r i n g her time and me  guiding  through a sometimes p a i n f u l yet s p e c i a l l e a r n i n g p r o c e s s .  To the s t a f f a t Youth Court S e r v i c e s f o r t h e i r a d v i s e access t o the c l i n i c a l r e c o r d s . A l l of you gave me s t r e n g t h t o complete t h i s p r o j e c t .  the  and  1 CHAPTER ONE INTRODUCTION  Statement o f Purpose The purpose o f t h i s t h e s i s i s t o examine t h e a s s o c i a t i o n between t h e p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r and treatment outcomes o f j u v e n i l e sex o f f e n d e r s .  To a c h i e v e  this  purpose, t h e c l i n i c a l r e c o r d s o f a p o p u l a t i o n o f a d o l e s c e n t male sex o f f e n d e r s were s t u d i e d t o determine  i f the diagnosis  has any impact on o u t - p a t i e n t treatment outcomes.  The  j u v e n i l e sex o f f e n d e r diagnosed w i t h Conduct D i s o r d e r possesses  unique c h a r a c t e r i s t i c s t h a t d i s c r i m i n a t e him from  o t h e r a d o l e s c e n t sex o f f e n d e r s .  As such, t h e p s y c h i a t r i c  d i a g n o s i s o f Conduct D i s o r d e r may be one way o f i d e n t i f y i n g a s p e c i f i c subtype  o f j u v e n i l e sex o f f e n d e r who i s more l i k e l y  to have u n s u c c e s s f u l treatment outcomes as compared t o t h e o f f e n d e r who i s n o t diagnosed w i t h Conduct D i s o r d e r . s t u d i e s on p o s s i b l e d i s c r i m i n a t i n g dimensions  Previous  for identifying  subgroups w i t h i n t h e sex o f f e n d e r group have been devoted t o the a d u l t p o p u l a t i o n .  The h e t e r o g e n e i t y o f a d u l t sex  o f f e n d e r s has been w e l l documented  and r e c e n t s t u d i e s (eg.  K n i g h t & P r e n t k y , 1990; K n i g h t , 1992) have i d e n t i f i e d more  2  homogeneous subgroups f o r t h e purposes o f i m p r o v i n g and enhancing d i s p o s i t i o n a l a c c u r a c y .  prediction  However, no comparable  taxonomic s t u d i e s have been u n d e r t a k e n f o r j u v e n i l e sex offenders  (Knight & P r e n t k y , 1993).  Most o f t h e e m p i r i c a l  s t u d i e s on j u v e n i l e sex o f f e n d e r s a r e l i m i t e d t o s i m p l e t a l l i e s of the frequencies of p a r t i c u l a r d e s c r i p t i v e c h a r a c t e r i s t i c s o f these o f f e n d e r s and t h e i r o f f e n s e s , such as,' t h e i r ages, t h e h i s t o r y o f t h e i r p r e v i o u s s e x u a l and non-sexual  o f f e n d i n g , t h e types o f s e x u a l crimes they have  committed, and t h e ages and sexes o f t h e i r v i c t i m s .  The  l i t e r a t u r e p r o v i d e s o n l y weak s p e c u l a t i o n s about t h e importance o f p a r t i c u l a r d i s c r i m i n a t i n g  dimensions.  T h e s i s Overview T h i s c h a p t e r w i l l d i s c u s s some o f t h e more s i g n i f i c a n t dimensions t h a t may a c t as s t a r t i n g p o i n t s f o r c l a s s i f y i n g j u v e n i l e sex o f f e n d e r s i n t o more homogenous subgroups.  This  p r o v i d e s a background t o i n v e s t i g a t i n g Conduct D i s o r d e r d i a g n o s i s as a p o s s i b l e  d i s c r i m i n a t i n g dimension f o r  i d e n t i f y i n g a p a r t i c u l a r subtype o f o f f e n d e r .  The i n t e n t i o n  o f t h i s c h a p t e r i s t o i n t r o d u c e t h e background and problem area o f t h i s t h e s i s .  To a c c o m p l i s h  t h i s purpose, I s h a l l ,  3  f i r s t , d e f i n e and d e s c r i b e the problem i n terms of s o c i e t y ' s awareness and response t o j u v e n i l e s e x u a l a s s a u l t .  Second, I  w i l l o f f e r a d e f i n i t i o n of j u v e n i l e s e x u a l a s s a u l t from the l e g a l , as w e l l as, the mental h e a l t h p e r s p e c t i v e .  Third, I  w i l l examine- o f f e n s e and o f f e n d e r c h a r a c t e r i s t i c s i n an attempt t o demonstrate the h e t e r o g e n e i t y of t h i s p o p u l a t i o n . In so d o i n g ,  I w i l l d i s c u s s c e r t a i n t y p o l o g i e s t h a t may  divide  t h i s heterogeneous p o p u l a t i o n i n t o m e a n i n g f u l subgroups. F i n a l l y , I w i l l o f f e r a p r e l i m i n a r y d i s c u s s i o n o f the p s y c h i a t r i c d i a g n o s i s of  Conduct Disorder  as a subgroup  c l a s s i f i c a t i o n and i t s r e l e v a n c e t o the treatment j u v e n i l e sex  outcomes of  offenders.  Chapter two p r o v i d e s a review of the e x i s t i n g  literature  i n terms of p s y c h i a t r i c d i a g n o s i s a c c o r d i n g t o the v a r i o u s e d i t i o n s of the D i a g n o s t i c and S t a t i s t i c a l Manual of M e n t a l Disorders  (American P s y c h i a t r i c A s s o c i a t i o n ) .  In a d d i t i o n ,  c h a p t e r two p r o v i d e s a r e v i e w of the l i t e r a t u r e on  the  d i a g n o s i s of Conduct D i s o r d e r and i t ' s r e l e v a n c e t o the assessment and treatment  of a d o l e s c e n t  sex o f f e n d e r s .  Chapter  t h r e e o u t l i n e s the r e s e a r c h d e s i g n and Chapter f o u r p r o v i d e s the r e s u l t s of t h i s study.  Chapter f i v e d i s c u s s e s  r e s e a r c h i m p l i c a t i o n s , l i m i t a t i o n s and  conclusions.  the  4  The J u v e n i l e Sex O f f e n d e r ' s Sexual a s s a u l t i s now  r e c o g n i z e d as one o f the more  severe problems i n modern western nonsexual  Impact on S o c i e t y  society, ranking with  crime, p o v e r t y , e n v i r o n m e n t a l  abuse as a s o c i e t a l i l l .  damage and  substance  The p r e v e n t i o n o f s e x u a l a s s a u l t  w i l l depend on the e x t e n t t o which i n d i v i d u a l s can be from c o m m i t t i n g these c r i m e s .  A l a r g e body o f r e s e a r c h has  i n d i c a t e d t h a t a v e r y h i g h percentage  o f a d u l t sex o f f e n d e r s  began t h e i r o f f e n d i n g c a r e e r as a d o l e s c e n t s L e i t e n b e r g , 1987; Longo, 1983;  stopped  Groth, 1977;  (Davis &  Groth, Longo & McFadin,  Longo & Groth, 1983)  1982;  and i t i s i m p e r a t i v e t o  c o n c e n t r a t e on j u v e n i l e o f f e n d e r s i n o r d e r t o d e t e c t the problem e a r l y and p r e v e n t or reduce l a t e r v i c t i m i z a t i o n . Ryan, Lane, D a v i s , and I s a a c  (1987) contend t h a t e a r l y  i n t e r v e n t i o n i s i n d i c a t e d b o t h f o r the p r e v e n t i o n o f m u l t i p l e v i c t i m i z a t i o n s and t o i n t e r r u p t the r e i n f o r c i n g n a t u r e o f deviant sexual behaviours.  Furthermore,  suggest t h a t sex o f f e n d e r s may d u r i n g adolescence i n t e r v e n t i o n may Becker,  1985;  several studies  be more amenable t o  treatment  r a t h e r than d u r i n g a d u l t h o o d and t h a t e a r l y  have p r e v e n t a t i v e v a l u e  Groth, et a l . ,  1982;  (Abel, Mittleman, &  O l i v e r , Nagayama H a l l ,  Neuhaus, 1993). Crime s t a t i s t i c s i n d i c a t e t h a t a h i g h  &  5 p e r c e n t a g e o f s e x u a l o f f e n s e s are committed by p e r p e t r a t o r s under the age o f 18 D e i s h e r , 1986).  (Fehrenbach, Smith, Monastersky, &  In a d d i t i o n , a m a j o r i t y o f a d u l t sex  o f f e n d e r s i n d i c a t e t h a t the onset o f t h e i r d e v i a n t behavior occurred i n  sexual  adolescence.  The E x t e n t o f the Problem P r i o r t o e a r l y 1980's, the predominant view o f the s e x u a l o f f e n s e s committed by a d o l e s c e n t s was  t h a t these were  considered simply nuisance behaviours  with a discounted  e s t i m a t e o f the s e v e r i t y o f the harm produced. behaviours  These  were not seen as a s s a u l t i v e , but more as examples  of experimentation  and t h e r e f o r e as i n n o c e n t .  seen as the normal a g g r e s s i v e n e s s adolescents.  As such, i t was  of s e x u a l l y maturing  Some s o c i a l s c i e n t i s t s viewed t h i s b e h a v i o u r  be the r e s u l t o f the m a r g i n a l s t a t u s of  to  the a d o l e s c e n t male  and the consequent r e s t r i c t i o n s o f h i s p e r m i t t e d s e x u a l outlets 1950;  ( F i n k l e h o r , 1979;  R e i s s , 1960;  Roberts  Gagnon, 1965;  Maclay, 1960;  e t a l . , 1973).  Others saw  as a r e f l e c t i o n o f a g e n e r a l problem o f a n t i s o c i a l T h i s tendency t o m i n i m i z e  Markey, i t more  behaviour.  j u v e n i l e sex o f f e n d i n g has  reduced c o n s i d e r a b l y over the l a s t 15 y e a r s , m a i n l y because  6 t h e r e i s an i n c r e a s e d awareness o f the numbers o f j u v e n i l e offenders.  Twenty p e r c e n t o f a l l rapes and between 30%  sex  and  50% o f a l l c h i l d m o l e s t a t i o n s are p e r p e t r a t e d by a d o l e s c e n t males (Becker, Kaplan, Cunningham-Rathner, & K a v o u s s i , Brown, Flanagan,  & McLeod, 1984;  C l a r k , & Fehrenbach, 1982; The U.S.  1986  1986;  D e i s h e r , Wenet, Paperney,  G r o t h , Longo, & McFadin,  1982).  arrest s t a t i s t i c s report that approximately  20%  o f a l l s e x u a l l y a g g r e s s i v e crimes are committed by males under 19 years o f age  ( F e d e r a l Bureau o f I n v e s t i g a t i o n ,  1987).  A b e l , Becker, Cunningham-Rathner, Rouleau, K a p l a n , & R e i c h (1984) c l a i m t h a t the average a d o l e s c e n t sex o f f e n d e r w i l l , w i t h o u t t r e a t m e n t , go on t o commit 380 s e x u a l crimes d u r i n g his lifetime.  Moreover, numerous s t u d i e s suggest t h a t  a p p r o x i m a t e l y h a l f o f a l l a d u l t sex o f f e n d e r s r e p o r t s e x u a l l y d e v i a n t b e h a v i o u r i n adolescence  (Abel e t a l . ,  K a p l a n , Cunningham-Rathner, & K a v o u s s i , 1986; 1983;  1985;  Becker,  Longo & G r o t h ,  Longo & McFadin, 1981; McConaghy, B l a s z c z y n s k i ,  Armstrong,  & K i d s o n , 1989;  Consequently,  Ryan, Lane, D a v i s , & I s s a c , 1987).  e a r l y i n t e r v e n t i o n might be more e f f i c a c i o u s  than t r e a t i n g a d u l t s as the problem  i s t r e a t e d i n an  i n d i v i d u a l b e f o r e the b e h a v i o u r becomes more entrenched i n adulthood  (Green, 1987;  Stenson  & Anderson,  1987)  7 The J u v e n i l e Sex O f f e n d e r and O f f e n s e s Introduction It i s very d i f f i c u l t to e s t a b l i s h a concise d e f i n i t i o n of the j u v e n i l e sex o f f e n d e r and h i s o f f e n s e s .  I w i l l attempt t o  d e f i n e these terms from b o t h t h e l e g a l and t h e m e d i c a l p e r s p e c t i v e s , and conclude t h i s s e c t i o n w i t h a d i s c u s s i o n o f the l i m i t a t i o n s o f these p e r s p e c t i v e s .  Legal D e f i n i t i o n The minimum age o f j u v e n i l e c o u r t j u r i s d i c t i o n i n N o r t h A m e r i c a v a r i e s from 6 t o 12, w i t h many U.S. s t a t e s s e t t i n g 10 as t h e lowest age o f c r i m i n a l r e s p o n s i b i l i t y ; Canada has a minimum age o f 12.  Depending upon t h e s t a t e o r p r o v i n c e , t h e  maximum age o f j u v e n i l e c o u r t j u r i s d i c t i o n runs from 15 t o 17. In Canada a d u l t h o o d  b e g i n s f o r c r i m i n a l law purposes a t t h e  18th b i r t h d a y , w i t h t h e r e f e r e n c e date b e i n g t h e date o f t h e commission o f t h e a l l e g e d o f f e n s e .  J u v e n i l e s charged w i t h  more s e r i o u s s e x u a l o f f e n s e s may be s u b j e c t t o t r a n s f e r i n t o the a d u l t system f o r t r i a l ;  i f c o n v i c t e d t h e r e , t h e y may f a c e  more severe a d u l t sentences and can be i n c a r c e r a t e d i n a d u l t facilities. The l e g a l d e f i n i t i o n o f what c o n s t i t u t e s a s e x u a l  offense  8  v a r i e s from one s t a t u t e to another.  Those seeking to invoke  the c r i m i n a l law i n t h e i r work with adolescent sex o f f e n d e r s should be aware o f the s p e c i f i c d e f i n i t i o n s i n t h e i r j u r i s d i c t i o n s and a v o i d r e l y i n g simply on c l i n i c a l or m o r a l i s t i c n o t i o n s of what c o n s t i t u t e s a p p r o p r i a t e or inappropriate  behavior.  In every j u r i s d i c t i o n , person  touching the g e n i t a l i a o f another  f o r a sexual purpose, whether or not t h i s i n v o l v e s  i n t e r c o u r s e , i s a c r i m i n a l o f f e n s e u n l e s s the other f r e e l y consents.  person  This would encompass such o f f e n s e s as rape,  sexual a s s a u l t , and aggravated  sexual a s s a u l t .  In some  j u r i s d i c t i o n s o f the U n i t e d S t a t e s , there i s a s t a t u t o r y minimum age f o r c e r t a i n types o f sexual o f f e n s e s , such t h a t a youth below a s p e c i f i e d age, such as 14, i s regarded as l e g a l l y incapable o f committing  such an o f f e n s e .  Every j u r i s d i c t i o n i n North America has l e g i s l a t i o n t h a t p r o t e c t s c h i l d r e n and adolescents from sexual involvement  with  those who are l e g a l l y regarded as being i n a p o s i t i o n to e x p l o i t the y o u t h f u l n e s s of the v i c t i m .  This  renders what would otherwise be consensual criminal offense.  legislation  sexual r e l a t i o n s a  There i s s u b s t a n t i a l v a r i a t i o n i n how such  " s t a t u t o r y rape" p r o v i s i o n s are d r a f t e d , and some  9 jurisdictions  c r i m i n a l i z e what o t h e r j u r i s d i c t i o n s  l e g a l l y acceptable.  r e g a r d as  For example, i t i s an o f f e n s e f o r a 15-  y e a r - o l d t o be i n v o l v e d i n a c o n s e n s u a l  sexual r e l a t i o n s h i p  w i t h a 1 3 - y e a r - o l d i n New York, but not i n Canada.  However,  i n Canada i t i s a c r i m i n a l o f f e n s e f o r a 1 6 - y e a r - o l d t o be s e x u a l l y i n v o l v e d with a 13-year-old.  Canadian L e g a l D e f i n i t i o n s Under t h e Canadian C r i m i n a l Code t h e r e a r e s e v e r a l t y p e s of sexual o f f e n s e s .  I w i l l o f f e r a b r i e f overview o f t h e most  r e l e v a n t types a p p l i c a b l e t o j u v e n i l e sex o f f e n d e r s . Sexual i n t e r f e r e n c e .  "Every person who, f o r s e x u a l  purpose, touches, d i r e c t l y o r i n d i r e c t l y , w i t h a p a r t o f the body o r w i t h an o b j e c t , any p a r t o f the body o f a p e r s o n under the age o f f o u r t e e n y e a r s . . . "  ( M a r t i n ' s C r i m i n a l Code o f  Canada, 1994; p. CC/220). Invitation  to sexual touching.  "Every p e r s o n who,•for  s e x u a l purpose, i n v i t e s , c o u n s e l s o r i n c i t e s a p e r s o n under the age o f f o u r t e e n years t o touch, d i r e c t l y , o r i n d i r e c t l y , w i t h a p a r t o f the body o r w i t h an o b j e c t , the body o f any person,  i n c l u d i n g the body o f the p e r s o n who so i n v i t e s ,  c o u n s e l s o r i n c i t e s and the body o f the p e r s o n under the age  10 of fourteen years..."  ( M a r t i n ' s C r i m i n a l Code o f Canada,  1994;  p. CC/221). Incest.  "Every one commits i n c e s t who,  knowing t h a t  another p e r s o n i s by b l o o d r e l a t i o n s h i p h i s o r her  parent,  c h i l d , b r o t h e r , s i s t e r , grandparent o r g r a n d c h i l d , as the case may  be, has s e x u a l i n t e r c o u r s e w i t h t h a t p e r s o n "  C r i m i n a l Code o f Canada, 1994, Indecent a c t s . act  (Martin's  p.232).  "Every one who  w i l f u l l y does an  indecent  (a) i n a p u b l i c p l a c e i n the p r e s e n c e o f one o r more  persons,  or  (b) i n any p l a c e , w i t h i n t e n t t h e r e b y t o i n s u l t o r  o f f e n d any p e r s o n . . .  Every p e r s o n who,  i n any p l a c e , f o r a  s e x u a l purpose, exposes h i s o r her g e n i t a l organs t o a p e r s o n who  under the age o f f o u r t e e n y e a r s . . . . "  Code o f Canada, 1994; Sexual a s s a u l t .  (Martins C r i m i n a l  p. CC/245). "Sexual a s s a u l t i s an a s s a u l t , w h i c h i s  commited i n c i r c u m s t a n c e s  o f a s e x u a l n a t u r e such t h a t the  s e x u a l i n t e g r i t y o f the v i c t i m i s v i o l a t e d . . . . " C r i m i n a l Code o f Canada, 1994;  (Martin's  p. CC/444).  Sexual a s s a u l t w i t h a weapon o r c a u s i n g b o d i y harm. "Everyone who,  i n commiting s e x u a l a s s a u l t , (a) c a r r i e s , uses  o r t h r e a t e n s t o use a weapon o r an i m i t a t i o n t h e r e o f ,  (b)  t h r e a t e n s t o cause b o d i l y harm t o a p e r s o n o t h e r than  the  11 complainant,  (c) causes b o d i l y harm t o the c o m p l a i n a n t . . . . "  ( M a r t i n s C r i m i n a l Code o f Canada, 1994, p. CC/445). Aggravated sexual a s s a u l t .  " . . . i n commiting  a sexual  a s s a u l t , wounds, maims, d i s f i g u r e s o r endangers t h e l i f e o f the c o m p l a i n a n t "  ( M a r t i n ' s C r i m i n a l Code o f Canada, 1994, p.  CC/447).  Meaning o f  "Consent"  "Consent means the v o l u n t a r y agreement o f the complainant t o engage i n t h e s e x u a l a c t i v i t y i n q u e s t i o n .  No consent i s  o b t a i n e d where (a) the agreement i s e x p r e s s e d by the words or conduct o f a p e r s o n o t h e r than the c o m p l a i n a n t ;  (b) the  complainant i s i n c a p a b l e o f c o n s e n t i n g t o the a c t i v i t y ;  (c)  the accused i n d u c e s the complainant t o engage i n the a c t i v i t y by a b u s i n g a p o s i t i o n o f t r u s t , power o r a u t h o r i t y ; (d) the complainant e x p r e s s e s , by words o r conduct, a l a c k of agreement t o engage i n the a c t i v i t y ; o r (e) the c o m p l a i n a n t , h a v i n g consented t o engage i n s e x u a l a c t i v i t y , e x p r e s s e s , by words o r conduct, a l a c k o f agreement t o c o n t i n u e t o engage i n the a c t i v i t y . "  (Martin's Criminal  Code, 1994; p. CC/448) Consent no defence.  Under s e c t i o n 150.1 o f the C r i m i n a l  12 Code o f Canada (1994) i t s t a t e s  t h a t when t h e o f f e n d e r i s  charged w i t h a s e x u a l o f f e n s e and t h e v i c t i m i s under t h e age of 14 i t i s n o t a defense t h a t t h e v i c t i m consented.  However,  i f t h e v i c t i m i s 12 t o 13 y e a r s o f age i t i s n o t a defense t h a t t h e v i c t i m consented u n l e s s t h e o f f e n d e r i s : (a) 12 t o 15 years o l d ;  (b) l e s s than two y e a r s o l d e r  (c) n e i t h e r  than t h e v i c t i m ; o r  i n a p o s i t i o n of t r u s t or authority  towards t h e  v i c t i m n o r i s t h e v i c t i m i n a r e l a t i o n s h i p o f dependency w i t h the  offender. In summary, i t i s apparent t h a t t h e l e g a l d e f i n i t i o n o f  what c o n s t i t u t e s another.  a sexual offense varies  from one s t a t u t e t o  Furthermore, t h e l e g a l d e f i n t i o n a l o n e i s inadequate  i f the p r o f e s s i o n a l  desires  a c l e a r understanding of j u v e n i l e  s e x u a l o f f e n d i n g and t h e o f f e n d e r .  As such, I w i l l o f f e r a  medical d e f i n i t i o n that presents the p s y c h i a t r i c p e r s p e c t i v e o f t h i s - problem.  Medical D e f i n i t i o n Paraphilia.  " P a r a p h i l i a " i s the medical or p s y c h i a t r i c  term o f c h o i c e f o r s e x u a l l y d e v i a n t b e h a v i o u r . paraphilias  d e s c r i b e d here i n c l u d e  Frotteurism, Pedophilia,  Exhibitionism,  The Fetishism,  S e x u a l Sadism, Voyeurism, T r a n s v e s t i c  13 F e t i s h i s m , and P a r a p h i l i a U n s p e c i f i e d . S t a t i s t i c a l of Mental Disorders  The D i a g n o s t i c and  (APA, 1994) d e s c r i b e s t h e  e s s e n t i a l f e a t u r e o f t h e p a r a p h i l i a s as " r e c u r r e n t s e x u a l urges and s e x u a l l y a r o u s i n g  intense  fantasies generally  i n v o l v i n g e i t h e r (1) nonhuman o b j e c t s ,  (2) t h e s u f f e r i n g o r  h u m i l i a t i o n o f o n s e l f o r one's p a r t n e r ,  o r (3) c h i l d r e n o r  n o n c o n s e n t i n g persons (p. 552)".  Therefore,  s i g n i f i c a n t number o f sex o f f e n d e r s "paraphiliacs."  According  obviously, a  would be d i a g n o s e d a  t o A b e l e t a l . (1985), 100% o f  a d u l t c h i l d m o l e s t e r s can be d i a g n o s e d as  "pedophiles."  P e d o p h i l i a i n v o l v e s sexual a c t i v i t y w i t h a prebuescent c h i l d ( g e n e r a l l y age 13 y e a r s o r younger) and  the i n d i v i d u a l  d i a g n o s e d w i t h P e d o p h i l i a must be age 16 y e a r s o r o l d e r and a t l e a s t 5 y e a r s o l d e r than t h e c h i l d However, a c c o r d i n g  (DSM-IV, APA, 1994).  t o t h e DSM-IV (APA, 1994), "For i n d i v i d u a l s  i n l a t e a d o l e s c e n c e d i a g n o s e d w i t h P e d o p h i l i a , no p r e c i s e age d i f f e r e n c e i s s p e c i f i e d , and c l i n i c a l judgement must be used; b o t h t h e s e x u a l m a t u r i t y o f t h e - c h i l d and t h e age d i f f e r e n c e must be t a k e n i n t o account" (p. 527). As such, those p e r p e t r a t o r s , i n e a r l y and m i d d l e a d o l e s c e n c e who a g a i n s t s m a l l c h i l d r e n do not q u a l i f y f o r t h i s Moreover, one must r e l y on t h e p r o f e s s i o n a l ' s  offend  diagnosis. clinical  14 judgement when d i a g n o s i n g those in late The  offenders  adolescence. p a r a p h i l i a c focus i n E x h i b i t i o n i s m i n v o l v e s t h e  exposure o f one's g e n i t a l s t o a s t r a n g e r and sometimes t h e i n d i v i d u a l masturbates w h i l e e x p o s i n g h i m s e l f .  The p a r a p h i l i c  focus i n F e t i s h i s m i n v o l v e s r e c u r r e n t , i n t e n s e sexuallya r o u s i n g f a n t a s i e s , s e x u a l urges, o r b e h a v i o r s i n v o l v i n g t h e use o f n o n l i v i n g o b j e c t s .  F r o t t e u r i s m i n v o l v e s t o u c h i n g and  r u b b i n g a g a i n s t a nonconsenting his  person.  The i n d i v i d u a l rubs  g e n i t a l s a g a i n s t t h e v i c t i m ' s t h i g h s and b u t t o c k s o r  f o n d l e s h e r g e n i t a l i a o r b r e a s t s w i t h h i s hands.  The b e h a v i o r  u s u a l l y o c c u r s i n crowded p a l c e s from which t h e i n d i v i d u a l can more e a s i l y escape a r r e s t . observing unsuspecting  Voyeurism i n v o l v e s t h e a c t o f  i n d i v i d u a l s , u s u a l l y s t r a n g e r s , who a r e  naked, i n t h e p r o c e s s o f d i s r o b i n g , o r engaging i n s e x u a l activity.  Among r a p i s t s , d i a g n o s i s i s n o t so s t r a i g h t f o r w a r d .  The o n l y p a r a p h i l i a p r e s e n t l y l i s t e d i n DSM-IV t h a t r e l a t e s t o rape i s Sexual Sadism, b u t i t would a p p l y o n l y t o those r a p i s t s who appear t o g a i n s e x u a l p l e a s u r e from t h e s u f f e r i n g of t h e i r v i c t i m . As demonstrated, d e f i n i n g what c o n s t i t u t e s s e x u a l abuse w i t h j u v e n i l e o f f e n d e r s i s a c o m p l i c a t e d endeavour.  The same  15 a p p l i c a t i o n as a d u l t o f f e n d e r s  i s appropriate  with respect  to  the degree of i n t r u s i v e n e s s and amount of c o e r c i o n used. However, the c r i t e r i o n of age  d i f f e r e n c e between p e r p e t r a t o r  and v i c t i m cannot be a p p l i e d i n a s t r a i g h t f o r w a r d manner.  The  use of age d i f f e r e n c e s i s a r e f l e c t i o n of the l a c k o f adequate knowledge as t o what c o n s t i t u t e s "normal" a d o l e s c e n t behaviour.  sexual  I t seems more c o n s t r u c t i v e t o examine the  b e h a v i o u r s i n v o l v e d , p a r t i c u l a r l l r y i n terms of the degree o f c o e r c i o n and the i s s u e of consent than t o r e l y on e s s e n t i a l l y a r b i t r a r y age-difference Hudson, 1993). for  criteria  As such, i t may  the j u v e n i l e sex o f f e n d e r  (Barbaree, M a r s h a l l ,  &  be t h a t p s y c h i a t r i c d i a g n o s e s  are b e i n g made based on  b e h a v i o u r s i n v o l v e d and not the s t r i c t age  criteria  the  as  d i c t a t e d by the D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l Disorders. Therefore,  I w i l l o f f e r another d e f i n i t i o n o f j u v e n i l e  s e x u a l a s s a u l t i n terms of b e h a v i o u r s , r e l a t i o n s h i p s , dynamics and  impact.  Second, I w i l l o f f e r a p r o f i l e of the modal (or  most commonly i d e n t i f i e d ) j u v e n i l e sex o f f e n d e r .  Third, I  w i l l p r e s e n t an a n a l y s i s of p a r t i c u l a r d i s c r i m i n a t i n g f e a t u r e s t h a t do not f i t w i t h the modal p r o f i l e , thus s u g g e s t i n g heterogeneity  of the j u v e n i l e sex o f f e n d e r  population.  the  16 F i n a l l y , I w i l l c l o s e w i t h a p r e l i m i n a r y d i s c u s s i o n of p s y c h i a t r i c d i a g n o s i s of Conduct Disorder  the  as a subgroup  c l a s s i f i c a t i o n and i t s relevance, t o t r e a t m e n t outcomes of j u v e n i l e sex  offenders.  J u v e n i l e Sexual O f f e n s e . j u v e n i l e s e x u a l o f f e n s e s may  be c h a r a c t e r i z e d by one or more  of a wide a r r a y of b e h a v i o u r s , d e v i a n c y may  As i n d i c a t e d p r e v i o u s l y ,  and more than one  be seen i n a s i n g l e i n d i v i d u a l .  younger c h i l d r e n or p e e r s may and/or p e n e t r a t i n g b e h a v i o u r s .  Molestation  involve touching, Rape may  P e n e t r a t i o n may  v a g i n a l and d i g i t a l , p e n i l e , or o b j e c t i l e . i n c l u d e exhibitionism,  obscene communication  voyeurism,  frottage,  of  rubbing,  i n c l u d e any  a c t p e r p e t r a t e d w i t h v i o l e n c e or f o r c e ; l e g a l often include penetration.  type of  sexual  definitions  be o r a l , a n a l , o r Hands-off  offenses  fetishism,  (such as obscene phone c a l l s , and  and  verbal  o r w r i t t e n s e x u a l harassment). In e v a l u a t i n g the s e x u a l abuse of c h i l d r e n by a d u l t s , d i f f e r e n t i a l and b e h a v i o u r s are adequate to d e f i n e problem.  However, when concerns a r i s e r e g a r d i n g  i n t e r a c t i o n s i n v o l v i n g j u v e n i l e s , age  and  age  the  sexual  behaviour  i d e n t i f i e r s are o f t e n inadequate and f u r t h e r assessment i s required.  Thus, i n any s e x u a l i n t e r a c t i o n , the f a c t o r s t h a t  17 are u s e f u l when a s s e s s i n g  t h e presence o r absence o f  e x p l o i t a t i o n a r e e q u a l i t y , consent, and c o e r c i o n . The i s s u e o f e q u a l i t y addresses d i f f e r e n c e s  i n physical,  c o g n i t i v e , and e m o t i o n a l development, p a s s i v i t y and assertiveness,  power and c o n t r o l , and a u t h o r i t y .  Although  p h y s i c a l d i f f e r e n c e s can be r e l a t i v e l y easy t o a s s e s s , c o g n i t i v e and e m o t i o n a l d i f f e r e n t i a l s may be more r e f l e c t i v e of l i f e e x p e r i e n c e .  That i s ,  regardless  o f age d i f f e r e n c e s ,  the a c t may be c o n s i d e r e d e x p l o i t i v e i f t h e two p a r t i e s a r e not d e v e l o p m e n t a l l y e q u a l .  S i m i l a r l y , power and c o n t r o l  i s s u e s and p a s s i v i t y and a s s e r t i v e n e s s  may be used t o d e f i n e  the r o l e s o f two j u v e n i l e s i n an i n t e r a c t i o n i n o r d e r t o c l a r i f y t h e e q u a l i t y o r i n e q u a l i t y o f t h e two i n a p a r t i c u l a r situation.  I n a d d i t i o n , a u t h o r i t y o f one c h i l d over t h e o t h e r  may e x i s t .  F o r example, i n t h e case o f an o l d e r c h i l d b e i n g  put  i n charge o f a younger i n a b a b y s i t t i n g r e l a t i o n s h i p o r  when one c h i l d t a k e s on t h e r o l e o f " p a r e n t " o r " t e a c h e r " i n a play s i t u a t i o n .  More s u b t l e l e v e l s o f a u t h o r i t y may  the i m p l i c a t i o n s o f f a m i l y p o s i t i o n s , p o p u l a r i t y , t a l e n t s and s u c c e s s .  include  competence,  The j u v e n i l e who f e e l s inadequate may be  v i c t i m i z e d by a peer j u s t as r e a d i l y as a younger c h i l d may be v i c t i m i z e d by an o l d e r  adolescent.  18 The second f a c t o r i n d e f i n i n g s e x u a l e x p l o i t a t i o n i s consent.  A l t h o u g h a r b i t r a r y ages have been c o n s i d e r e d i n t h e  l e g a l d e f i n i t i o n o f t h e "age o f consent", a s s e s s i n g consent demands more than a l e g a l d e f i n i t i o n o r an age i d e n t i f i e r . The elements o f consent have been d e f i n e d as f o l l o w s : Agreement i n c l u d i n g a l l o f t h e f o l l o w i n g :  (1) u n d e r s t a n d i n g  what i s proposed based on age, m a t u r i t y , developmental l e v e l , f u n c t i o n i n g , and e x p e r i e n c e ; (2) knowledge s t a n d a r d s f o r what i s b e i n g proposed; p o t e n t i a l consequences agreements  of s o c i e t a l  (3) awareness o f  and a l t e r n a t i v e s ;  (4) assumption t h a t  o r disagreements w i l l be r e s p e c t e d e q u a l l y ; (5)  v o l u n t a r y d e c i s i o n ; and, (6) mental  competence ( N a t i o n a l Task  Force on J u v e n i l e S e x u a l O f f e n d i n g , 1988). The assessment o f consent may cause c o n f u s i o n , p a r t i c u l a r l y i n terms o f t h e d i s t i n c t i o n s between c o m p l i a n c e , c o o p e r a t i o n , and c o n s e n t .  Consent i m p l i e s f u l l  u n d e r s t a n d i n g , and c h o i c e ; whereas,  knowledge,  c o o p e r a t i o n i m p l i e s an  active p a r t i c i p a t i o n regardless of personal b e l i e f or desire and may o c c u r w i t h o u t consent.  Compliance may a l l o w o r  p a s s i v e l y engage t h e v i c t i m w i t h o u t r e s i s t a n c e i n s p i t e o f opposing b e l i e f s or d e s i r e s 1987) .  (Ryan, Lane, D a v i s , & I s a a c ,  19 Coercion,  the t h i r d f a c t o r i n d e f i n i n g e x p l o i t a t i o n i n  j u v e n i l e sexual i n t e r a c t i o n , r e f e r s to the pressures the v i c t i m f r e e c h o i c e . perceptions  t h a t deny  Once a g a i n , p h y s i c a l s i z e and/or  o f power o r a u t h o r i t y a r e o f t e n e x p l o i t e d t o  coerce cooperation  and c o m p l i a n c e .  secondary g a i n s o r l o s s e s .  Coercion  can a l s o i n v o l v e  For example, t h e o f f e n d e r w i l l use  b r i b e r y i n t h e form o f money, t r e a t s , f a v o u r s , i n r e t u r n f o r sexual involvements.  or friendship  Or, t h e o f f e n d e r may use  more s u b t l e and r e f i n e d forms o f c o e r c i o n w i t h i n t h e e x p l o i t i v e r e l a t i o n s h i p t h a t a r e based upon h i s m a n i p u l a t i v e use o f c a r i n g and n u r t u r a n c e o f t h e v i c t i m . v i c t i m w i l l comply w i t h t h e o f f e n d e r ' s r e j e c t i o n o r abandonment. coercion l i e s  As such, t h e  wishes so as t o a v o i d  F i n a l l y , t h e more b l a t a n t form o f  i n the use o f t h r e a t s and v i o l e n c e .  Although  a c t s o f v i o l e n c e a r e used, t h r e a t s o f f o r c e o r v i o l e n c e a r e more common.  T h i s form i s p a r t i c u l a r l y e v i d e n t  abuse o f c h i l d r e n  i n the sexual  s i n c e a c h i l d i s more e a s i l y c o e r c e d  w i t h o u t r e s o r t i n g t o v i o l e n c e as compared t o s e x u a l  assaults  against peers or a d u l t s .  The Modal J u v e n i l e Sex O f f e n d e r W i t h t h e l e g a l and m e d i c a l d e f i n i t i o n s i n mind, t h e  20 j u v e n i l e sex o f f e n d e r i s d e f i n e d as a youth (age 12-17 i n Canada) who commits any s e x u a l a c t w i t h a p e r s o n o f any age a g a i n s t t h e v i c t i m ' s w i l l , w i t h o u t consent, o r i n an a g g r e s s i v e , e x p l o i t i v e , o r t h r e a t e n i n g - manner (Ryan & Lane, 1991).  Although  s t u d i e s i n d i c a t e t h a t no one s i n g l e p r o f i l e  can be a p p l i e d t o every j u v e n i l e sex o f f e n d e r , i t i s p o s s i b l e to p r e s e n t what Ryan and Lane (1991) c a l l t h e modal (or most o f t e n i d e n t i f i e d ) o f f e n d e r and o f f e n s e as a composite.  Using  p a r t i c u l a r s t u d i e s o f j u v e n i l e sex o f f e n d e r s as r e f e r e n c e , one i s a b l e t o d e s c r i b e s e v e r a l f e a t u r e s t h a t a r e s i m i l a r i n most samples (Awad, Saunders, 1989;  Becker, Kaplan,  & Levene, 1984; Awad & Saunders,  Cunningham-Rathner, K a v o u s s i ,  198 6;  Davis & L e i t e n b e r g , 1987; Fehrenbach, Smith, Monastersky, & Deisher,  1986; K n i g h t  Wasserman & Kappel,  & Prentky,  1993; Ryan e t a l . , 1987;  1985; Wheeler, 1986)).  As such, t h e modal  j u v e n i l e sex o f f e n d e r i s a f o u r t e e n year o l d w h i t e m i d d l e c l a s s male o f average- i n t e l l i g e n c e w i t h some form o f l e a r n i n g difficulty.  He would have been l i v i n g w i t h two p a r e n t s  time o f h i s o f f e n s e .  Although  at the  he has had no p r e v i o u s  convictions f o r sexual a s s a u l t , t h i s i s quite l i k e l y not h i s f i r s t offense or f i r s t v i c t i m .  He w i l l p r o b a b l y d i s c l o s e t h a t  he has been a v i c t i m o f s e x u a l abuse by some one he knows,  21 such as a neighbour or r e l a t i v e .  H i s v i c t i m i s most l i k e l y a  seven o r e i g h t year o l d female who o f f e n d e r by b l o o d or m a r r i a g e . i n v o l v i n g g e n i t a l touching,  i s not r e l a t e d t o the  The  assault i s coercive  and q u i t e o f t e n p e n e t r a t i o n .  There i s a 33% chance t h a t he has been c o n v i c t e d o f n o n s e x u a l delinquent behaviour p r i o r to t h i s a r r e s t . T h i s b r i e f t h u m b n a i l s k e t c h suggests t h a t j u v e n i l e offenders  are an homogeneous group. However, the  d i s c u s s i o n supports  and  Moreover, i t i s argued t h a t some of these  c h a r a c t e r i s t i c s may subgroups.  following  the c o n t e n t i o n t h a t t h e y are heterogeneous  and p r e s e n t w i t h a wide range of c h a r a c t e r i s t i c s dimensions.  sex  The  be d i s c r i m i n a t e d t o form  more homogeneous  dimensions f e a t u r e d i n t h i s d i s c u s s i o n  i n c l u d e : s o c i o c u l t u r a l f a c t o r s ; s e x u a l adjustment; s o c i a l competence; c o g n i t i v e and academic a b i l i t y ; c h a r a c t e r i s t i c s ; l e v e l of a g g r e s s i o n disturbances;  victim  and v i o l e n c e ; b e h a v i o r a l  and p s y c h i a t r i c d i a g n o s i s .  A l t h o u g h a l l these  f a c t o r s can be l i n k e d t o the assessment and t r e a t m e n t of j u v e n i l e sex o f f e n d e r s , the focus of t h i s t h e s i s i s on  the  p s y c h i a t r i c d i a g n o s i s of Conduct D i s o r d e r and i t s r e l a t e d b e h a v i o r a l symptoms as t h e y r e l a t e t o t r e a t m e n t outcome. Furthermore, I s h a l l suggest t h a t Conduct D i s o r d e r  may  22  f a c i l i t a t e the i d e n t i f i c a t i o n of a  j u v e n i l e sex o f f e n d e r  subtype who i s l e s s amenable t o t r e a t m e n t , and may r e q u i r e a highly specialized intervention.  The H e t e r o g e n e i t y o f J u v e n i l e Sex O f f e n d e r s The  study o f t h e h e t e r o g e n e i t y o f j u v e n i l e sex o f f e n d e r s  i s i n i t s infancy.  K n i g h t and P r e n t k y  (1993) o f f e r t h r e e  arguments t o support t h e c o n t e n t i o n t h a t j u v e n i l e o f f e n d e r s are a t l e a s t as heterogeneous as s e x u a l l y c o e r c i v e a d u l t s . F i r s t , a s i g n i f i c a n t p o r t i o n o f a d u l t sex o f f e n d e r s have engaged i n s e x u a l l y c o e r c i v e b e h a v i o u r as j u v e n i l e s  suggests  t h a t t h e h e t e r o g e n e i t y found among a d u l t o f f e n d e r s may e x i s t among j u v e n i l e o f f e n d e r s .  Second, t h e low r e c i d i v i s m r a t e s  r e p o r t e d f o r j u v e n i l e o f f e n d e r s i n d i c a t e t h a t t h e r e may be a s u b s t a n t i a l subgroup o f these o f f e n d e r s whose d e v i a n t b e h a v i o u r does n o t p e r s i s t i n t o a d u l t h o o d .  Third, juvenile  o f f e n d e r samples t y p i c a l l y comprise b o t h r a p i s t and c h i l d m o l e s t e r subgroups. determined  A l t h o u g h degree o f a g g r e s s i o n was  i n t h i s study, r a p i s t and c h i l d m o l e s t e r  were n o t d i f f e r e n t i a t e d .  subgroups  Given t h a t t h e s u b j e c t s s t u d i e d f o r  t h i s r e s e a r c h were a l l o u t - p a t i e n t a d o l e s c e n t males, most were determined  t o be l e s s s e r i o u s o f f e n d e r s , t h e m a j o r i t y b e i n g  23 child  molesters. As many as 50% o f a d u l t sex o f f e n d e r s r e p o r t t h a t t h e i r  f i r s t s e x u a l a s s a u l t o c c u r r e d d u r i n g adolescence Mittleman,  &  Becker,  (eg., A b e l ,  1985/ Becker & A b e l , 1985; Groth, Longo,  & McFadin, 1982; Smith,  1984).  This i n d i c a t e s that a large  subsample o f a d u l t sex o f f e n d e r s were a l s o j u v e n i l e sex o f f e n d e r s and, as such c o u l d p r o v i d e evidence h e t e r o g e n e i t y o f j u v e n i l e sex o f f e n d e r s .  f o r the  K n i g h t and P r e n t k y  (1993) i n t h e i r study o f 564 a d u l t male sex o f f e n d e r s ' c l i n i c a l r e c o r d s compared t h e t y p o l o g i c a l assignments  of  those men who were j u v e n i l e sex o f f e n d e r s and those who were not j u v e n i l e sex o f f e n d e r s . The j u v e n i l e sex o f f e n d e r group i n t h i s sample o n l y i n c l u d e d those males whose s e x u a l l y c o e r c i v e behaviour  p e r s i s t e d i n t o adulthood.  The o v e r a l l r e c i d i v i s m  rates of j u v e n i l e offenders are reported s u b s t a n t i a l l y than those o f a d u l t o f f e n d e r s 1989;  Smith,  (Furby, W e i n r o t t ,  lower  & Blackshaw,  1984; Smith & Monastersky, 1986).  I t appears t h a t t h e r e i s marked h e t e r o g e n e i t y o f t h e j u v e n i l e sex o f f e n d e r p o p u l a t i o n , however, t h e r e i s l i t t l e concern  f o r a p p l y i n g taxonomic s p e c i f i c a t i o n among these  offenders.  Perhaps t h i s l a c k o f concern  consequence o f t h e m i s t a k e n  i s simply a  view t h a t a d o l e s c e n t s commit few  24  s e x u a l o f f e n s e s of s e r i o u s consequence.  Furthermore, i t may  be a r e f e c t i o n o f the g e n e r a l r e l u c t a n c e of c l i n i c i a n s t o a p p l y d e v i a n t l a b e l s t o c h i l d r e n (Longo & Groth,  1983).  C l i n i c a l l a b e l s can have some n e g a t i v e consequences. by r e f r a i n i n g from a p p l y i n g l a b e l s we may o f d i s c e r n i n g causes,  However  f o r f e i t our chances  o f d e s i g n i n g i n t e r v e n t i o n programs t h a t  address the more s p e c i f i c needs o f subgroups, o f i d e n t i f y i n g v u l n e r a b l e i n d i v i d u a l s who  might p r o f i t from p r i m a r y  p r e v e n t i o n programs, and o f i m p r o v i n g our  dispositional  d e c i s i o n s about s p e c i f i c subgroups of o f f e n d e r s . t o g a i n an u n d e r s t a n d i n g  o f and make d e c i s i o n s  The  ability  about.these  young o f f e n d e r s depends on the r e l i a b i l i t y and the v a l i d i t y o f the c a t e g o r i c a l s t r u c t u r e s t h a t are generated (Knight & P r e n t k y ,  and a p p l i e d '  1993).  As mentioned p r e v i o u s l y , most o f the e m p i r i c a l s t u d i e s on j u v e n i l e sex o f f e n d e r s are l i m i t e d t o t a b u l a t i o n s o f the f r e q u e n c i e s o f p a r t i c u l a r d e s c r i p t i v e c h a r a c t e r i s t i c s of o f f e n d e r s and t h e i r o f f e n s e s .  these  To date o n l y a. few s t u d i e s have  a c t u a l l y compared j u v e n i l e sex o f f e n d e r s t o d e l i n q u e n t or normal c o n t r o l s ; however, s e v e r a l d i s c r i m i n a t i n g f e a t u r e s are h e l p f u l f o r taxonomic p u r p o s e s .  25 Sociocultural  Factors  J u v e n i l e sex o f f e n d e r s come from a l l r a c i a l , e t h n i c , r e l i g i o u s , and geographic  groups i n approximate p r o p o r t i o n t o  these c h a r a c t e r i s t i c s i n t h e g e n e r a l p o p u l a t i o n .  However, i n  s t u d i e s from t h e U n i t e d S t a t e s t h a t r e p o r t r a c e as a demographic v a r i a b l e , between 33% and 55% o f t h e s u b j e c t s were b l a c k , 21-32% were H i s p a n i c and 12-46% were w h i t e Cunningham-Rathner, e t a l . , 198 6; Becker,  Kaplan,  (Becker, e t a l . 198 6;  Van Ness, 1984; Vinogradov, D i s h o t s k y , Doty, & T i n k l e n b e r g , 1988).  As such, these s t u d i e s appear t o i n d i c a t e t h a t non-  w h i t e youth a r e over r e p r e s e n t e d , p a r t i c u l a r l y i n terms o f f o r c i b l e rape (Brown, e t a l . , 1984). are b i a s e d a g a i n s t these r a c i a l  However, a r r e s t r a t e s  subgroups  and t h e  apprehensions o f non-whites a r e g r e a t e r as compared t o w h i t e s . A l t h o u g h most j u v e n i l e sex o f f e n d e r s a r e l i v i n g i n twop a r e n t homes a t t h e time o f d i s c o v e r y , over h a l f r e p o r t some p a r e n t a l l o s s such as d i v o r c e , i l l n e s s ,  death o f a p a r e n t , o r  permanent o r temporary s e p a r a t i o n s from t h e p a r e n t s . Furthermore, f a m i l y i n s t a b i l i t y ,  frequent v i o l e n c e , high rates  o f d i s o r g a n i z a t i o n , s e x u a l and p h y s i c a l abuse have been commonly observed offenders  as p r e v a l e n t i n t h e h i s t o r i e s o f j u v e n i l e  (Awad e t a l . , 1984; Awad & Saunders, 1989; Becker,  26 Kaplan, et a l . , 1986; al.,  1986;  Deisher et a l . , 1979;  Becker, Cunningham-Rathner, & K a p l a n , 1982;  Fehrenbach e t a l . ,  Longo, 1982; Robertson,  Ness, 1984).  1990;  1986,  Smith, 1988;  Lewis e t Van  Reported r a t e s range from 19% t o 47% o f  a d o l e s c e n t s i n sample's o f s e x u a l a g g r e s s o r s who  were  themselves  the v i c t i m s o f s e x u a l abuse (Becker, K a p l a n , e t  al.,  Fehrenbach e t a l . ,  1986;  1986;  Longo, 1982).  In a s t u d y  t h a t i n c l u d e d i n c a r c e r a t e d a d o l e s c e n t homosexual p e d o p h i l e s , 73% r e p o r t e d t h a t they were s e x u a l l y abused as c h i l d r e n (Robertson, 1990).  Moreover, Becker  (1988) argued t h a t the  r a t e s r e p o r t e d by j u v e n i l e sex o f f e n d e r s may underestimate samples,  actually  the p r e v a l e n c e o f s e x u a l v i c t i m i z a t i o n i n these  because the r e p o r t i n g o f s e x u a l abuse o f t e n emerges  o n l y a f t e r the a d o l e s c e n t has been i n t h e r a p y .  On the o t h e r  hand, the e s t i m a t e s o f the p r e v a l e n c e o f t h i s v i c t i m i z a t i o n i s based on o f f e n d e r s ' s e l f - r e p o r t s which may  be i n t e r p r e t e d as  s e l f - s e r v i n g i n the sense t h a t they seem t o a t t e n u a t e the offenders' r e s p o n s i b i l i t y f o r t h e i r crimes.  S o c i a l Competence F a m i l y d y s f u n c t i o n and r e l a t e d s o c i a l f a c t o r s have been l i n k e d t o s o c i a l competence as a s i g n i f i c a n t v a r i a b l e i n  27 d i f f e r e n t i a t i n g j u v e n i l e sex o f f e n d e r subtypes.  Marshall  (1989a) has o u t l i n e d t h e b a s i s o f a t h e o r y l i n k i n g a l a c k o f i n t i m a c y i n peer r e l a t i o n s t o a p r o c l i v i t y t o engage i n o f f e n s i v e sexual behaviours.  T h i s study i n d i c a t e d t h a t a  sample o f a d u l t sex o f f e n d e r s more f r e q u e n t l y f a i l e d t o r e p o r t i n t i m a c y i n t h e i r l i v e s and expressed  greater feelings of  l o n e l i n e s s than d i d n o n o f f e n d e r c o n t r o l s .  As such, l a c k o f  assertiveness i n s o c i a l i n t e r a c t i o n , d e f i c i e n c i e s i n intimacy s k i l l s and s o c i a l i s o l a t i o n have been i d e n t i f i e d i n a d o l e s c e n t sex o f f e n d e r s  (Becker  & A b e l , 1985; Fehrenbach e t a l . ,  Attachment t h e o r i s t s argue t h a t poor s o c i a l  1986).  r e l a t i o n s are a  f u n c t i o n o f inadequate bonds w i t h p a r e n t s d u r i n g i n f a n c y and early childhood Weiss, 1982).  (Bowlby, 1973; Grossman & Grossman, 1990; Awad e t a l . (1984) found t h a t 88% o f t h e i r  sample o f j u v e n i l e sex o f f e n d e r s had been s e p a r a t e d parents  f o r prolonged  occasion.  from t h e i r  p e r i o d s o f time on a t l e a s t one  Furthermore, t h e p a r e n t s o f these boys l a c k e d  commitment t o each o t h e r and had weak attachments t o t h e i r children. ' Fagan and Wexler (1988) found t h a t 78% o f t h e j u v e n i l e sex o f f e n d e r s i n t h e i r sample were more s o c i a l l y i s o l a t e d t h a n c h r o n i c a l l y v i o l e n t j u v e n i l e s , and t h i s i s o l a t i o n was more  28 apparent i n t h e i r l a c k o f r e l a t i o n s w i t h peer-aged  females.  F u r t h e r s t u d i e s have found t h a t j u v e n i l e e x h i b i t i o n i s t s , c h a r a c t e r i s t i c a l l y report t h e i r parents  who  t o have been  r e j e c t i n g , have c o n s i d e r a b l e d i f f i c u l t i e s w i t h i n t i m a c y and f e e l l o n e l y and i s o l a t e d from l o v e r e l a t i o n s  (Marshall et a l . ,  1991) . However, c e r t a i n o f f e n d e r types may d i s p l a y a h i g h e r l e v e l o f s o c i a l competence than o t h e r s . A r e c e n t study Saunders, 1989) found s i g n i f i c a n t l y g r e a t e r s o c i a l i n a sample o f c o u r t - r e f e r r e d a d o l e s c e n t  child  (Awad &  isolation  molesters,  compared t o o t h e r male d e l i n q u e n t s matched f o r age, socioeconomic s t a t u s , and time o f r e f e r r a l .  In addition,  Saunders e t a l . (1986) found t h a t w h i l e 60% o f t h e e x h i b i t i o n i s t s and 72% o f the c h i l d m o l e s t e r s had no c l o s e f r i e n d s , o n l y 32% o f the r a p i s t s were so i s o l a t e d et a l . ,  1986).  (Saunders  Thus, i t would appear t h a t s o c i a l competence  may p l a y an i m p o r t a n t  r o l e as a d i f f e r e n t i a t o r among subtypes  of j u v e n i l e sex offenders'.  Sexual Adjustment At t h i s w r i t i n g , c o n t r o l l e d s t u d i e s of the p a t t e r n s of s e x u a l a r o u s a l and o f s e x u a l f a n t a s i e s o f a d o l e s c e n t  sex  29 o f f e n d e r s have n o t been conducted.  However, Becker  (1988)  proposed t h a t t h e r e i s a d i s t i n c t i o n between j u v e n i l e o f f e n d e r s w i t h s e x u a l l y d e v i a n t r e c u r r e n t f a n t a s i e s and a preference f o r s e x u a l l y deviant a c t i v i t y  and those f o r whom  sexual aggression i s simply a part of t h e i r behaviour.  impulsive  T h i s d i s t i n c t i o n may be s i g n i f i c a n t i n terms o f  developing d i f f e r e n t  offender  subtypes.  C o g n i t i v e F a c t o r s and Academic A b i l i t y The  s t u d i e s on IQ and c o g n i t i v e a b i l i t i e s a r e somewhat  inconsistent, offering al.  contrasting results.  A l t h o u g h Awad e t  (1984) found t h a t t h e i r sample o f a d o l e s c e n t sex o f f e n d e r s  had s i g n i f i c a n t l y lower IQs than d e l i n q u e n t c o n t r o l s , T a r t e r , Hegedus, A l t e r m a n ,  and K a t z - G a r r i s (1983) found no d i f f e r e n c e s  between two s i m i l a r groups.  Although  academic performance  i n v o l v e s more v a r i a b l e s than IQ l e v e l , i t i s s i g n i f i c a n t t o r e p o r t t h a t over 80% o f t h e sex o f f e n d e r s i n Awad e t a l . ' s (1984) sample had e x p e r i e n c e d  learning d i f f i c u l t i e s  during  some p a r t o f t h e i r s c h o o l c a r e e r ; and 71% had r e q u i r e d remedial education. 1989)  A more r e c e n t study  (Awad & Saunders,  found a s i g n i f i c a n t l y g r e a t e r degree o f s e r i o u s l e a r n i n g  problems i n a sample o f c o u r t - r e f e r r e d a d o l e s c e n t  child  30 molesters,  compared t o o t h e r male d e l i n q u e n t s  matched f o r age,  s o c i o e c o n o m i c s t a t u s , and time o f r e f e r r a l . Lewis e t a l . (1981) have found c o g n i t i v e d i f f e r e n c e s between v i o l e n t j u v e n i l e sex o f f e n d e r s  and d e l i n q u e n t s ,  b u t no  d i f f e r e n c e s on these dimensions between t h e sex o f f e n d e r s and v i o l e n t , non-sex j u v e n i l e o f f e n d e r s .  R e s u l t s from t h e s e and  o t h e r s t u d i e s seem t o suggest t h a t t h e c o g n i t i v e impairments may be more a s s o c i a t e d w i t h v i o l e n c e i n g e n e r a l with sexual violence i n p a r t i c u l a r . t h a t j u v e n i l e sex o f f e n d e r s  r a t h e r than  In f a c t , the hypothesis  a r e c h a r a c t e r i z e d by a c l u s t e r o f  f e a t u r e s t h a t i n c l u d e c o g n i t i v e impairment, below average IQ, and  increased incidence of aggressive  t r u e o f more v i o l e n t sex o f f e n d e r s . suggest t h a t t h e d i s c r e p a n c i e s  b e h a v i o u r , may o n l y be I n a d d i t i o n , one may  across  s t u d i e s on c o g n i t i v e  a b i l i t i e s between j u v e n i l e sex o f f e n d e r s  and n o n s e x u a l young  o f f e n d e r s might be accounted f o r by t h e v a r i a t i o n s i n t h e f r e q u e n c y o f v i o l e n t sex o f f e n d e r s  i n d i f f e r e n t samples.  Victim Characteristics Fehrenbach e t a l . (1986) found t h a t 62% o f t h e v i c t i m s o f t h e i r sample o f abusers were l e s s than 12 y e a r s o f age, w i t h 44%  l e s s than 6.  I n b o t h D e i s h e r e t a l . ' s (1982) and  31 Wasserman and Kappel's samples, 50-60% o f the v i c t i m s were under 10 y e a r s o f age.  The o n l y e x c e p t i o n seems t o be w i t h  n o n - c o n t a c t o f f e n d e r s , such as  obscene phone c a l l e r s  and  e x h i b i t i o n i s t s ; whose v i c t i m s are g e n e r a l l y peer age o r a d u l t s (Fehrenbach e t a l . , 1986). o n l y 6-9  As such, the v i c t i m s are t y p i c a l l y  y e a r s o f age, w i t h male v i c t i m s b e i n g younger than  female v i c t i m s  (Awad & Saunders,  1989; Becker, Cunningham-  Rathner, & K a p l a n , 1986; P i e r c e & P i e r c e ,  1987).  The m a j o r i t y (69-84%) o f the v i c t i m s o f s e x u a l a s s a u l t s by j u v e n i l e s are female, p a r t i c u l a r l y w i t h n o n - c o n t a c t offenses  (Awad e t a l . , 1984; G r o t h , 1977;  Fehrenbach  et a l . ,  1986; Longo, 1982; Van Ness, 1984; Wasserman & K a p p e l ,  1985).  However, s t u d i e s seem t o i n d i c a t e t h a t as the age o f the v i c t i m d e c r e a s e s , the v i c t i m i s more l i k e l y t o be male, g i v e n t h a t 45-63% o f the c h i l d v i c t i m s o f a d o l e s c e n t o f f e n d e r s are male (Awad & Saunders, 1984).  1989; Shoor e t a l . , 1966; Van  Ness,  G e n e r a l l y , the c h i l d m o l e s t e r knows h i s v i c t i m s ,  e i t h e r as r e l a t i v e s , c h i l d r e n o f f r i e n d s o f the p a r e n t s , o r c h i l d r e n the o f f e n d e r had been b a b y s i t t i n g 1989)..  (Awad & Saunders,  I n c o n t r a s t , the a d o l e s c e n t r a p i s t tends t o v i c t i m i z e  strangers  (Vinogradov, e t a l . , 1988).  T h e r e f o r e , t h e r e appear  to be subgroups w i t h i n the r a p i s t and c h i l d m o l e s t e r  32 c a t e g o r i e s i n terms o f v i c t i m age and gender p r e f e r e n c e .  Level of Aggression  and V i o l e n c e  A wide range o f c o e r c i o n and v i o l e n c e has been r e p o r t e d i n t h e s e x u a l a s s a u l t s committed by j u v e n i l e s , r a n g i n g from no i n t i m i d a t i o n o r t h r e a t , through t h r e a t , p h y s i c a l f o r c e , and extreme v i o l e n c e (Fehrenbach, e t a l . , et a l . ,  1981; Wasserman & Kappel,,  1986; Groth> 1977; Lewis  1985).  I n t h e i r study o f  the types o f j u v e n i l e sex o f f e n d e r b e h a v i o u r  o f 279 males,  Fehrenbach e t a l . (1986) found t h e f o l l o w i n g f i g u r e s : f o n d l i n g , 59%; rape, 23%; e x h i b i t i o n i s m , 11%; and o t h e r nonc o n t a c t o f f e n s e s , 7%.  I n a s i m i l a r study o f 161 male young  o f f e n d e r s , Wasserman and Kappel (1985) found: 59% p e n e t r a t i o n , 31% i n t e r c o u r s e , 12% o r a l - g e n i t a l c o n t a c t , 16% g e n i t a l f o n d l i n g and 12% n o n - c o n t a c t o f f e n s e s .  I t appears as t h e  o f f e n d e r age i n c r e a s e s rape and more v i o l e n t sex o f f e n s e s increases.  V i c t i m s r e p o r t h i g h e r l e v e l s o f c o e r c i o n than  o f f e n d e r s , and younger v i c t i m s seem t o be s u b j e c t t o l e s s force one  (Davis & L e i t e n b e r g , 1987).  These s t u d i e s i n d i c a t e t h a t  t h i r d o f o f f e n s e s p e r p e t r a t e d by a d o l e s c e n t s  physical injury.  result i n  T h i s v a r i a t i o n suggests t h a t l e v e l o f  v i o l e n c e may p l a y a taxonomic r o l e i n j u v e n i l e sex o f f e n d i n g .  33  P s y c h i a t r i c F a c t o r s and Conduct D i s o r d e r The most common i n d i c a t o r s o f b e h a v i o u r d i s o r d e r from the p s y c h i a t r i c p e r s p e c t i v e are t a k e n t o be a h i s t o r y o f d e l i n q u e n c y , p r i o r a r r e s t s f o r b o t h s e x u a l and n o n s e x u a l c r i m e s , and p s y c h i a t r i c diagnoses such as Conduct D i s o r d e r and O p p o s i t i o n a l D e f i a n t D i s o r d e r (France & Hudson, 1993). A d o l e s c e n t sex o f f e n d e r s f r e q u e n t l y have h i s t o r i e s o f o t h e r criminal activity  (Saunders, e t a l . ,  1986).  For example, a  number o f s t u d i e s found t h a t 28-50% o f the s u b j e c t s  committed  a t l e a s t one p r i o r n o n s e x u a l o f f e n s e (Becker, CunninghamRathner, e t a l . , Kaplan et a l . ,  1986; Becker, K a p l a n , e t a l . ,  1986; Fehrenbach e t a l . ,  1986).  1984;  Becker,  Several other  r e l a t e d s t u d i e s put t h e s e f i g u r e s a t 46-82% o f the cases (Awad et a l . ,  1984; Becker, K a p l a n et a l . ,  1986; P i e r c e & P i e r c e ,  1987).  Furthermore, a g g r e s s i v e a c t s and o t h e r a n t i s o c i a l  b e h a v i o u r were e v i d e n t i n 50-8 6% o f cases (Awad & Saunders, 1989; Shoor e t a l . ,  1966; Van Ness, 1984).  Consequently, the  presence o f o t h e r n o n s e x u a l b e h a v i o r a l d i s t u r b a n c e s suggests t h a t the s e x u a l o f f e n s e i s not n e c e s s a r i l y a sex c r i m e , but i s s i m p l y one way o f a c t i n g out  (Davis & L e i t e n b u r g , 1987).  On  the o t h e r hand, a l a r g e group, p a r t i c u l a r l y n o n - a g g r e s s i v e and  34  hands-off  p e r p e t r a t o r s do not engage i n o t h e r  behaviours.  The  antisocial  range of r a t e s f o r n o n - s e x u a l o f f e n d i n g found  i n these s t u d i e s i s p a r t l y e x p l a i n e d by the type of offending.  sex  More s e r i o u s and a g g r e s s i v e hands-on o f f e n d i n g i s  a s s o c i a t e d w i t h h i g h e r r a t e s of non-sexual o f f e n d i n g et a l . ,  1988;  Lewis e t a l . ,  Although  1979;  (Kavoussi  Smith, 1988).  t h i s study w i l l not s p e c i f i c a l l y address type  of  sex o f f e n d i n g , i t l o o k s a t the r e l e v a n c e of the i s s u e of previous non-sexual offenses. s e x u a l o f f e n s e s may  be one  That i s , a h i s t o r y of non-  element of the Conduct D i s o r d e r  subtype t h a t has c l i n i c a l r e l e v a n c e i n terms of  treatment  outcome. Although  a more thorough and e x t e n s i v e d i s c u s s i o n o f  >  p s y c h i a t r i c d i a g n o s i s w i l l be d i s c u s s e d i n the n e x t i t i s necessary  t o b r i e f l y address t h i s i s s u e as i t r e l a t e s t o  exploring characteristics for classifying juvenile offenders.  chapter,  sex  In so d o i n g , a b r i e f o v e r v i e w o f the t h i r d r e v i s e d  e d i t i o n of the D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l Disorders  (DSM-III-R) (American P s y c h i a t r i c A s s o c i a t i o n ,  d i a g n o s i s of Conduct Disorder  and i t s r e l e v a n c e t o  w i l l be o f f e r e d as a t r a n s i t i o n t o the next  1987)  treatment  chapter.  A p s y c h i a t r i c d i a g n o s i s i s f r e q u e n t l y g i v e n t o the  35 j u v e n i l e sex o f f e n d e r i n 70-87% o f t h i s p o p u l a t i o n (Awad & Saunders, 1989; Awad e t a l . ,  1984; Lewis e t a l . ,  1979).  Moreover, p r i o r p s y c h i a t r i c treatment had been r e q u i r e d i n 33% o f young sex o f f e n d e r s (APA,  (Awad & Saunders, 1989).  The DSM-III-R  1987) c l a s s i f i c a t i o n o f Conduct D i s o r d e r was g i v e n i n  48% o f young sex o f f e n d e r s , w i t h r a p i s t s l i k e l y than c h i l d m o l e s t e r s ( K a v o u s s i , Kaplan, substance  & Becker,  (75%) b e i n g more  (38%) t o r e c e i v e t h i s d i a g n o s i s 1988).  The d i a g n o s i s o f  abuse was g i v e n i n over 10% o f a sample i n K a v o u s s i  e t a l . ' s (1988) study o f a d o l e s c e n t sex o f f e n d e r s .  In  a d d i t i o n , j u v e n i l e sex o f f e n d e r s appear t o have e x h i b i t e d h i g h r a t e s o f e m o t i o n a l problems (Deisher e t a l , 1982; G r o t h , 1977; Shoor e t a l . ,  1966; Van Ness, 1984).  J u v e n i l e sex o f f e n d e r s  d i s p l a y e d d i s t u r b e d e m o t i o n a l f u n c t i o n i n g and d i s r u p t e d peer relations.  I n a d d i t i o n , they d i s p l a y e d g r e a t e r a n x i e t y and  estrangement and l e s s e m o t i o n a l bonding t o peers than seen i n other j u v e n i l e s  (Blaske e t a l . ,  1989).  As a l l u d e d t o e a r l i e r , s e v e r a l s t u d i e s have sought t o e s t a b l i s h t h e r a t e s o f nonsexual  d i s t u r b a n c e s o f conduct i n  j u v e n i l e sex o f f e n d e r s by examining through diagnoses assessment.  records of delinquency or  o f conduct d i s o r d e r based on p s y c h i a t r i c  These s t u d i e s have e s t a b l i s h e d t h a t  approximately  36 h a l f of j u v e n i l e sex o f f e n d e r s have a h i s t o r y of n o n s e x u a l a r r e s t s and t h a t the m a j o r i t y of these can be d e s c r i b e d conduct d i s o r d e r e d al.,  1986;  Kavoussi  (Awad & Saunders, 1989; et a l . ,  1988).  as  Becker, K a p l a n e t  Therefore,  i t seems t h a t  the r e l a t i o n s h i p between n o n s e x u a l d i s t u r b a n c e s of conduct  and  j u v e n i l e sex o f f e n d i n g i s r e l e v a n t g i v e n t h a t a s i g n i f i c a n t number of j u v e n i l e sex o f f e n d e r s engage i n o t h e r c r i m i n a l a c t s and may shares  be d i a g n o s e d as conduct d i s o r d e r e d . s e v e r a l important  d i s t a l c a u s a t i v e and  Each c o n d i t i o n prognostic  f a c t o r s and t h e r e are s i m i l a r i t i e s i n the v a r i o u s attempts t o s u b c l a s s i f y both.  F i n a l l y , the c o e x i s t e n c e of conduct  d i s o r d e r and j u v e n i l e sex o f f e n d i n g may  have c l i n i c a l  s i g n i f i c a n c e i n terms of i d e n t i f y i n g a d i s c r e e t subtype of o f f e n d e r as w e l l as f o r p r e d i c t i n g treatment  outcome.  sex  37 CHAPTER TWO PSYCHIATRIC DIAGNOSIS AND SEXUAL OFFENDING IN ADOLESCENTS  Introduction The purpose o f t h i s c h a p t e r  i s t o d e s c r i b e and e v a l u a t e  the D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l D i s o r d e r s i n g e n e r a l , and more s p e c i f i c a l l y , assess t h e u t i l i t y o f p s y c h i a t r i c d i a g n o s i s as i t r e l a t e s t o conduct d i s o r d e r and the s e x u a l o f f e n d i n g b e h a v i o u r  of adolescents.  Psychiatric  d i a g n o s i s may be one way o f i d e n t i f y i n g subtypes w i t h i n t h e j u v e n i l e sex o f f e n d e r p o p u l a t i o n .  This chapter w i l l  look at  the c l i n i c a l r e l e v a n c e o f t h e p s y c h i a t r i c d i a g n o s i s o f conduct d i s o r d e r , i t ' s 13 b e h a v i o r a l symptoms, and h i s t o r y o f nons e x u a l o f f e n d i n g as elements f o r p r e d i c t i n g treatment The  D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l  outcome. Disorders  (DSM) has been d e s c r i b e d as a major advance i n p s y c h i a t r i c c l a s s i f i c a t i o n since the p u b l i c a t i o n of the f i r s t e d i t i o n i n 1952  (American P s y c h i a t r i c A s s o c i a t i o n , 1987).  However, s i n c e  t h a t time and t h e r e c e n t p u b l i c a t i o n o f DSM-IV i n 1994, t h e p r o c e s s has encountered c r i t i c i s m and c r e a t e d c o n t r o v e r s y  from  the n o n - p s y c h i a t r i c p r o f e s s i o n a l s , and i n some i n s t a n c e s , t h e m e d i c a l p r o f e s s i o n as w e l l .  38 F i r s t , a g e n e r a l r e v i e w o f t h e D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l D i s o r d e r s system and p r o c e s s w i l l be o f f e r e d from an h i s t o r i c a l p e r s p e c t i v e i n c l u d i n g t h e e v o l u t i o n o f t h e m u l t i - a x i a l c l a s s i f i c a t i o n system.  Second, a d i s c u s s i o n o f  the s t r e n g t h s and l i m i t a t i o n s o f t h e DSM c l a s s i f i c a t i o n w i l l be p r e s e n t e d ,  addressing i t s u t i l i t y f o r c l i n i c a l  p r a c t i c e ; more s p e c i f i c a l l y , conduct d i s o r d e r e d .  i n terms o f youth d i a g n o s e d as  T h i r d , t h e conduct d i s o r d e r d i a g n o s i s  w i l l be d e s c r i b e d and a n a l y z e d reliability  system  i n terms o f i t s v a l i d i t y ,  and u t i l i t y i n c l i n i c a l p r a c t i c e . F o u r t h , an  e v a l u a t i o n o f t h e u s e f u l n e s s o f t h i s d i a g n o s i s as i t r e l a t e s to treatment presented.  outcomes o f j u v e n i l e sex o f f e n d e r s w i l l be Finally,  a d i s c u s s i o n of the p r e d i c t i v e v a l i d i t y  of t h e d i a g n o s i s w i l l conclude t h i s  chapter.  H i s t o r y o f DSM C l a s s i f i c a t i o n  System  The c l i n i c i a n ' s d e s i r e t o c l a s s i f y s i g n s and symptoms o f d i s e a s e i n t o d i s c r e t e d i s o r d e r s has been an i s s u e o f c o n t e n t i o n f o r many y e a r s .  T h i s need t o c l a s s i f y and l a b e l  d i s o r d e r s has l e d t o t h e c r e a t i o n , r e v i s i o n and demise o f numerous c l a s s i f i c a t i o n systems (Reid & Wise, 1989).  In the  f i e l d o f mental h e a l t h t h e r e a r e c u r r e n t l y two w i d e l y used c l a s s i f i c a t i o n systems: f i r s t ,  the I n t e r n a t i o n a l  39 C l a s s i f i c a t i o n o f D i s e a s e s (ICD) and; second,  the Diagnostic  and S t a t i s t i c a l Manual o f M e n t a l D i s o r d e r s (DSM).  The ICD i s  a worldwide s t a t i s t i c a l d i s e a s e c l a s s i f i c a t i o n system f o r a l l m e d i c a l c o n d i t i o n s , i n c l u d i n g mental d i s o r d e r s .  The DSM,  p u b l i s h e d by t h e American P s y c h i a t r i c A s s o c i a t i o n , c o n s i s t s o f a s e r i e s o f D i a g n o s t i c and S t a t i s t i c a l Manuals o f M e n t a l D i s o r d e r s , t h e l a t e s t o f which i s t h e DSM-IV. The o f f i c i a l c l a s s i f i c a t i o n o f mental d i s o r d e r s i n N o r t h America was f i r s t attempted i n t h e 1840 U.S. census when a l l mental i l l n e s s was c l a s s i f i e d i n a s i n g l e c a t e g o r y , "idiocy/lunacy".  T h i s was l a t e r expanded  i n t h e 1880 census  t o i n c l u d e e i g h t d i f f e r e n t mental d i s o r d e r c a t e g o r i e s ( W i l l i a m s , 1988).  By t h e l a t e 1920's, n e a r l y e v e r y m e d i c a l  t e a c h i n g f a c i l i t y used a d i f f e r e n t c l a s s i f i c a t i o n system f o r mental d i s o r d e r s .  The r e s u l t was a d i v e r s e nomenclature  that  t y p i c a l l y l e a d t o meaningless communications and arguments between mental h e a l t h p r o f e s s i o n a l s . order  I n an attempt t o b r i n g  t o the terminology, the Standard C l a s s i f i e d  Nomenclature o f D i s e a s e (SCND) was p u b l i s h e d i n 1933. However, World War I I caused a c r i s i s i n p s y c h i a t r i c t e r m i n o l o g y , as o n l y 10% o f t h e t o t a l cases seen by m i l i t a r y p s y c h i a t r i s t s c o u l d be c l a s s i f i e d u s i n g t h e SCND  (American  40 Psychiatric Association, postwar p e r i o d ,  1952).  In a d d i t i o n , during the  t h r e e s e p a r a t e U.S. nomenclatures e x i s t e d : t h e  SCND, t h e Armed Forces nomenclature, and t h e V e t e r a n s Administration  system.  Moreover, none o f t h e s e was  with the I n t e r n a t i o n a l Diagnostic The  consistent  C l a s s i f i c a t i o n (IDC) system.  c o n f u s i o n over t e r m i n o l o g y r e s u l t e d i n t h e Committee  on Nomenclature and S t a t i s t i c s o f t h e American P s y c h i a t r i c A s s o c i a t i o n p r o p o s a l o f a r e v i s e d c l a s s i f i c a t i o n system. S u b s e q u e n t l y , t h e f i r s t e d i t i o n o f t h e D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l D i s o r d e r s was p u b l i s h e d  i n 1952.  When i t became apparent t h a t r e v i s i o n s would be needed, t h e manual l a t e r became known as DSM-I.  DSM-II was t h e r e s u l t o f  an i n t e r n a t i o n a l c o l l a b o r a t i v e e f f o r t t h a t a l s o c u l m i n a t e d i n the mental d i s o r d e r s  section i n the Eighth  I n t e r n a t i o n a l C l a s s i f i c a t i o n of Diseases  Revision (ICD-8).  of the DSM-II and  ICD-8 went i n t o e f f e c t i n 1968. In a n t i c i p a t i o n o f ICD-9's 1979 s c h e d u l e d p u b l i c a t i o n d a t e , t h e development o f DSM-III began i n 1974. However, t h e l a c k o f d e t a i l f o r r e s e a r c h and c l i n i c a l a p p l i c a t i o n i n t h e mental d i s o r d e r s  s e c t i o n proposed f o r ICD-9 r e s u l t e d i n t h e  American P s y c h i a t r i c A s s o c i a t i o n and  Statistics  Task Force on Nomenclature  development o f a new c l a s s i f i c a t i o n system.  T h i s development p r o c e s s i n c l u d e d 14 a d v i s o r y consultants  from a s s o c i a t e d f i e l d s , l i a i s o n committees w i t h  p r o f e s s i o n a l o r g a n i z a t i o n s , c o n f e r e n c e s , and DSM-III was  committees,  field  trials.  seen as a d r a m a t i c d e v i a t i o n from i t ' s  predecessors.  In t h e i r DSM  t r a i n i n g guide, R e i d and Wise  (1989) i d e n t i f y the major i n n o v a t i o n s  of the DSM-III:  1  D e f i n i t i o n of the term mental  disorder;  2  P r e s e n t a t i o n of d i a g n o s t i c c r i t e r i a  f o r each  disorder; Diagnosis  according  to a m u l t i - a x i a l e v a l u a t i o n  -system; 4  R e d e f i n i t i o n of major d i s o r d e r s ;  5  A d d i t i o n of new  6  H i e r a r c h i c a l o r g a n i z a t i o n of d i a g n o s t i c  7  S y s t e m a t i c d e s c r i p t i o n of each d i s o r d e r ;  8  Decision trees for d i f f e r e n t i a l  9  G l o s s a r y of t e c h n i c a l terms;  diagnostic  categories; categories  diagnosis;  10  A n n o t a t e d comparative l i s t i n g of DSM-II and DSM-II  11  D i s c u s s i o n of ICD-9 and  12  P u b l i c a t i o n of r e l i a b i l i t y d a t a from f i e l d  13  I n d i c e s of d i a g n o s t i c terms and  The  development and g o a l s of the DSM-III-R were s i m i l a  ICD-9-CM; trials;  symptoms (p. 5)  42 t o those o f DSM-III. Twenty-six a d v i s o r y  committees were  formed, each w i t h membership based on e x p e r t i s e particular  area.  ina  In a d d i t i o n , the experience gained i n using  the DSM-III d i a g n o s t i c  criteria,  particularly i n certain  r e s e a r c h s t u d i e s , p l a y e d a s i g n i f i c a n t r o l e i n proposed modifications.  The f o l l o w i n g new appendices were added t o  DSM-III-R:  Proposed d i a g n o s t i c  categories  n e e d i n g f u r t h e r s t u d y (eg.  l a t e l u t e a l phase d y s p h o r i c d i s o r d e r , personality disorder;  and s e l f - d e f e a t i n g  d i s o r d e r ) ; an a l p h a b e t i c and  sadistic personality  l i s t i n g o f DSM-III-R diagnoses  codes; a n u m e r i c a l l i s t i n g o f DSM-III-R d i a g n o s e s and codes; an index o f s e l e c t e d symptoms (Reid & Wise, 1989, p.5)  DSM-IV was f i r s t p u b l i s h e d  i n 1994 and demonstrated some  s i g n i f i c a n t changes as compared t o i t ' s p r e d e c e s s o r s . A c c o r d i n g t o t h e DSM-IV Task Force, t h e t h r e s h o l d  f o r making  r e v i s i o n s i n . DSM-IV was s e t h i g h e r than t h a t f o r DSM-III and DSM-III-R.  I n a d d i t i o n , i n an e f f o r t t o i n c r e a s e  u t i l i t y o f DSM-IV, t h e c r i t e r i a  the c l i n i c a l  s e t s were s i m p l i f i e d and  43 clarified.  The American P s y c h i a t r i c A s s o c i a t i o n c l a i m e d  commitment t o " . . . h i s t o r i c a l t r a d i t i o n  (as embodied i n DSM-III  and DSM-III-R), c o m p a t i b i l i t y w i t h ICD-10, e v i d e n c e from reviews of the l i t e r a t u r e , analyses of unpublished data s e t s , r e s u l t s o f f i e l d t r i a l s , and consensus o f t h e f i e l d . " (APA, 1994, p. x x ) .  The APA f u r t h e r a s s e r t s t h a t t h e i r r e l i a n c e on  d a t a g e n e r a t e d t h r o u g h s c i e n t i f i c r e s e a r c h promotes a t r a n s i t i o n from a d e s c r i p t i v e c l a s s i f i c a t i o n system t o an e t i o l o g i c a l c l a s s i f i c a t i o n system  (Reid & Wise, 1989).  This  t r a n s i t i o n i s f u r t h e r f a c i l i t a t e d by t h e use o f a m u l t i - a x i a l • c l a s s i f i c a t i o n system.  Multi-axial Classification  System  The m u l t i - a x i a l c l a s s i f i c a t i o n system was f i r s t i n t r o d u c e d i n DSM-III i n 1980, and w i t h p a r t i c u l a r m o d i f i c a t i o n s , remains as an i n t e g r a l component o f DSM-IV. T h i s system " . . . i n v o l v e s an assessment on s e v e r a l axes, each of which r e f e r s t o a d i f f e r e n t domain o f i n f o r m a t i o n t h a t may h e l p t h e c l i n i c i a n p l a n t r e a t m e n t and p r e d i c t outcome" (APA, 1994, p. 2 5 ) . The f o l l o w i n g i s an o v e r v i e w o f t h e f i v e axes i n DSM-IV: Axis I  C l i n i c a l Disorders  44  Other C o n d i t i o n s Clinical Axis I I  That May Be a Focus o f  Attention  Personality Mental  Disorders  Retardation  Axis I I I  General Medical  Conditions  A x i s IV  P s y c h o s o c i a l and E n v i r o n m e n t a l Problems  Axis V  G l o b a l Assessment o f F u n c t i o n i n g  A x i s I and A x i s I I a r e used t o d e s c r i b e t h e c l i e n t ' s current condition.  When n e c e s s a r y ,  diagnoses on b o t h axes, a r e made. syndromes p r e s e n t the same.  m u l t i p l e diagnoses, or Axis I l i s t s  clinical  o r i f no mental d i s o r d e r i s p r e s e n t ,  reports  A x i s I I r e p o r t s t h e P e r s o n a l i t y D i s o r d e r s and  Mental Retardation.  A x i s I I can a l s o be used t o r e c o r d  prominent m a l a d a p t i v e p e r s o n a l i t y f e a t u r e s t h a t do n o t meet the t h r e s h o l d f o r a P e r s o n a l i t y D i s o r d e r and any r e p e t i t i v e defense mechanisms t h a t i m p a i r t h e c l i e n t ' s a b i l i t y t o function. Axis I I I i s f o r r e p o r t i n g current general  medical  c o n d i t i o n s t h a t are r e l e v a n t t o the understanding management o f t h e i n d i v i d u a l ' s mental d i s o r d e r .  or For example,  the p h y s i c a l c o n d i t i o n may be c a u s a t i v e as i n t h e case o f  45 hypomanic or manic symptoms due  to  hyperthyroidism.  A x i s IV i s f o r the r e p o r t i n g of p s y c h o s o c i a l environmental treatment,  problems t h a t may  and p r o g n o s i s  and  a f f e c t the d i a g n o s i s ,  of mental d i s o r d e r s .  These problems  are grouped t o g e t h e r i n n i n e s e p a r a t e  c a t e g o r i e s ; two  being,  group" and  "problems w i t h p r i m a r y  support  examples  "economic  problems". A x i s V i s f o r r e p o r t i n g the c l i n i c i a n ' s judgement of the i n d i v i d u a l s o v e r a l l l e v e l of f u n c t i o n i n g on the G l o b a l Assessment of F u n c t i o n i n g s c a l e (GAF).  The  GAF  Scale i s a  r a t i n g from 1 t o 100 w i t h r e s p e c t o n l y t o p s y c h o l o g i c a l , s o c i a l and o c c u p a t i o n a l f u n c t i o n i n g .  A c c o r d i n g t o the DSM-IV  commentary on the m u l t i - a x i a l system, the GAF i n p l a n n i n g treatment  Scale i s u s e f u l  and measuring i t s impact, and i n  p r e d i c t i n g outcome (APA,  1994).  E v a l u a t i o n of M u l t i - a x i a l System The DSM-III-R made s u b s t a n t i a l changes t o the m u l t i - a x i a l system, such as the i n c l u s i o n i n A x i s I I , i n s t e a d of A x i s I , of M e n t a l R e t a r d a t i o n and P e r v a s i v e Developmental D i s o r d e r s t o g e t h e r w i t h s p e c i f i c developmental d i s o r d e r s , f o r they represent enduring  c h a r a c t e r i s t i c s w i t h onset d u r i n g  childhood.  R u t t e r and S h a f f e r  (1980) s e v e r e l y c r i t i c i z e d t h e  DSM-III f o r h a v i n g - t h e s e d i s o r d e r s p l a c e d w i t h i n A x i s I because t h e y d i d n o t p e r c e i v e these as c l i n i c a l d i s o r d e r s i n need o f a t t e n t i o n .  However, i n t h e DSM-IV t h e d e v e l o p m e n t a l  d i s o r d e r s have been r e l e g a t e d t o A x i s I because t h e y a r e now considered  t o be a focus o f c l i n i c a l a t t e n t i o n , whereas mental  r e t a r d a t i o n has been m a i n t a i n e d  as an A x i s I I d i s o r d e r .  As  such, Conduct D i s o r d e r i s p l a c e d w i t h i n A x i s I as i t i s considered  a c l i n i c a l d i s o r d e r i n need o f a t t e n t i o n .  This i s  a l s o t h e case f o r any o f t h e P a r a p h i l i a s t h a t a j u v e n i l e sex o f f e n d e r may be d i a g n o s e d w i t h .  Many j u v e n i l e sex o f f e n d e r s  r e c e i v e m u l t i p l e diagnoses as t h e y p r e s e n t w i t h a m y r i a d o f problems r e q u i r i n g a t t e n t i o n .  F o r example, a 16 year o l d may  be d i a g n o s e d w i t h P e d o p h i l i a , Developmental D i s o r d e r (eg. learning d i s a b i l i t y ) ,  A t t e n t i o n D e f i c i t Hyperactive  Disorder  and Conduct D i s o r d e r a l l on A x i s I as c o n d i t i o n s i n need o f attention.  On o c c a s i o n , a j u v e n i l e sex o f f e n d e r may a l s o be  d i a g n o s e d w i t h M e n t a l R e t a r d a t i o n which w i l l be e n t e r e d on Axis I I . In terms o f t h e use o f A x i s I I I and t h e r e p o r t i n g o f current medical  c o n d i t i o n s r e l e v a n t t o t h e i n d i v i d u a l ' s mental  d i s o r d e r , youth d i a g n o s e d w i t h Conduct D i s o r d e r o r a  47 P a r a p h i l i a w i l l on o c c a s i o n r e c e i v e a d i a g n o s i s on t h i s A x i s . For example, severe cases o f acne may have impact on t h e youth's s e l f - e s t e e m and subsequent s o c i a l competence.  Other  c o n d i t i o n s , f o r example, may i n c l u d e d i a b e t e s o r asthma, each of which can have impact on t h e young person's  behaviour.  In DSM-III-R t h e c l i n i c i a n was asked t o l i s t and r a t e on A x i s IV a l l t h e p s y c h o s o c i a l s t r e s s o r s judged t o have c o n t r i b u t e d t o t h e development o r e x a c e r b a t i o n o f t h e c u r r e n t disorder/s.  Furthermore, i t added t h e c o m p l i c a t i o n (not  i n c l u d e d i n DSM-III) t h a t t h e c l i n i c i a n s h o u l d s p e c i f y whether the s t r e s s o r s a r e "predominantly months) o r "enduring months). 1987;  Studies  acute e v e n t s "  circumstances"  (Rey, Stewart,  (less than s i x  ( d u r a t i o n o f more t h a n s i x  Plapp, B a s h i r & R i c h a r d s ,  1988) suggest t h a t A x i s IV r a t i n g s a r e u n r e l i a b l e ; t h a t  i d e n t i f i c a t i o n o f s t r e s s f u l events ( p a r t i c u l a r l y t h e m i l d e r ones) d u r i n g an u n s t r u c t u r e d c l i n i c a l i n t e r v i e w i s l a r g e l y i d i o s y n c r a t i c , and t h a t r a t i n g s e v e r i t y o f s t r e s s o r s d e c r e a s e s r e l i a b i l i t y even more.  As such, i n DSM-IV t h e c l i n i c i a n i s no  l o n g e r r e q u i r e d t o r a t e o r s p e c i f y whether t h e p s y c h o s o c i a l s t r e s s o r s a r e acute o r e n d u r i n g .  I n terms o f j u v e n i l e sex  o f f e n d e r s and youth d i a g n o s e d w i t h Conduct D i s o r d e r , A x i s IV i s r a r e l y i f ever used.  48 A x i s V, f i r s t i n t r o d u c e d i n DSM-III, had t h e c l i n i c i a n r a t e the highest l e v e l of adaptive  f u n c t i o n i n g of the c l i e n t .  In DSM-III-R, t h i s continuum became a c o m p l e t e l y  new s c a l e ,  the G l o b a l Assessment o f F u n c t i o n i n g S c a l e o r GAF s c a l e , t o assess p s y c h o l o g i c a l , s o c i a l and o c c u p a t i o n a l f u n c t i o n i n g on a h y p o t h e t i c a l continuum o f mental h e a l t h - i l l n e s s . are r e q u e s t e d  Clinicians  t o r a t e t h e i r c l i e n t s on a continuum  from:  "1. p e r s i s t e n t danger o f s e v e r e l y h u r t i n g s e l f o r o t h e r s (eg. r e c u r r e n t v i o l e n c e ) OR p e r s i s t e n t i n a b i l i t y t o m a i n t a i n m i n i m a l p e r s o n a l hygiene OR s e r i o u s s u i c i d a l a c t w i t h c l e a r e x p e c t a t i o n o f death" t o : "90. Absent o r m i n i m a l symptoms (eg. m i l d a n x i e t y b e f o r e an exam), good f u n c t i o n i n g i n a l l a r e a s , i n t e r e s t e d and i n v o l v e d i n wide range o f a c t i v i t i e s , effective, generally s a t i s f i e d with l i f e . . . "  (p.22).  socially I n DSM-  IV t h e r a t i n g i s now from 1 t o 100, f o l l o w e d by t h e time p e r i o d r e f l e c t e d i n t h e r a t i n g i n p a r e n t h e s e s ; f o r example, " ( c u r r e n t ) , " "(highest l e v e l i n past year)," " ( a t discharge)." L i t t l e r e s e a r c h has been p u b l i s h e d on t h e s u b j e c t o f assessment o f f u n c t i o n i n g t o warrant t h e d r a m a t i c A x i s V (Rey e t a l . , 1988).  changes on  The GAF s c a l e i n DSM-III-R'has  p o t e n t i a l problems because i t s content  i s a mixture  o f symptom  s e v e r i t y and/or s o c i a l f u n c t i o n i n g , f o r example: "60. Moderate  49  symptoms (eg. f l a t a f f e c t and c i r c u m s t a n t i a l speech, o c c a s i o n a l p a n i c a t t a c k s ) OR moderate d i f f i c u l t y i n s o c i a l , o c c u p a t i o n a l , o r s c h o o l f u n c t i o n i n g (eg. few f r i e n d s , c o n f l i c t s w i t h co-workers)"  which i s l i k e l y t o c r e a t e  c i r c u l a r i t y and s p u r i o u s a s s o c i a t i o n s .  DSM-IV has made an  attempt t o address these i s s u e s w i t h t h e I n t r o d u c t i o n o f a proposed S o c i a l and O c c u p a t i o n a l  F u n c t i o n i n g Assessment S c a l e  (SOFAS) i n Appendix B (APA, 1994, p. 7 60).  Although the  p s y c h o s o c i a l axes a r e c o n s i d e r e d i n v a l u a b l e w i t h i n nonp s y c h i a t r i s t d i s c i p l i n e s , very l i t t l e research or c l i n i c a l i n t e r e s t has been g e n e r a t e d by t h e DSM Task Force ( W i l l i a m s , 1985;  W i l l i a m s , S p i t z e r , & Skodol,  1985).  Not one o f t h e r e c o r d s o f t h e s u b j e c t s i n t h i s i n c l u d e d d a t a on e i t h e r A x i s IV o r V.  study  C r i t i c s o f t h e use o f  DSM see t h i s as a s i g n i f i c a n t o m i s s i o n and misuse o f t h e m u l t i - a x i a l system.  C r i t i c a l A n a l y s i s o f DSM R e v i s i o n s Williams  (1986) g i v e s t h r e e reasons t o j u s t i f y t h e  r e v i s i o n s i n t h e DSM-III-R.  F i r s t , i t had become apparent  t h a t statements i n t h e t e x t and c r i t e r i a were n o t c l e a r l y worded and were i n c o n s i s t e n t w i t h o t h e r statements i n t h e  50 manual s i n c e the p u b l i c a t i o n o f DSM-III. suggested  Second, i t was  t h a t a r e v i s i o n was n e c e s s a r y because new  also  research  had appeared w i t h n o v e l i n f o r m a t i o n which c o u l d be i n c o r p o r a t e d i n the c l a s s i f i c a t i o n . understandable,  T h i s seems l e s s  f o r DSM-III was p u b l i s h e d i n 1980  r e v i s i o n p r o c e s s was  commenced i n 1983.  and  the  Since a research  p r o j e c t t y p i c a l l y t a k e s about 3 t o 4 years from the time o f c o n c e p t i o n t o the p o i n t o f a c t u a l p u b l i c a t i o n , i t i s apparent t h a t the b u l k o f the r e s e a r c h r e f e r r i n g t o the DSM-III c l a s s i f i c a t i o n c o u l d not have begun a p p e a r i n g u n t i l 1983 the e a r l i e s t .  Thus, t h i s j u s t i f i c a t i o n does not appear t o be  w e l l founded, p a r t i c u l a r l y DSM-III-R (APA,  at  1987)  it  when i n the i n t r o d u c t i o n o f the states:  " . . . i n attempting to evaluate proposals f o r r e v i s i o n s i n the c l a s s i f i c a t i o n and c r i t e r i a , o r f o r adding c a t e g o r i e s , the g r e a t e s t weight was  new  g i v e n t o the  o f e m p i r i c a l support from w e l l conducted  presence  research  s t u d i e s , though, f o r most p r o p o s a l s , d a t a from e m p i r i c a l s t u d i e s were l a c k i n g .  T h e r e f o r e , p r i m a r y importance  u s u a l l y g i v e n t o some o t h e r c o n s i d e r a t i o n " ( p . x x i ) . T h i r d l y , w i t h the DSM-IV h a v i n g f i n a l l y been p u b l i s h e d i n  was  51 1994,  a f t e r 14 y e a r s had e l a p s e d between r e v i s i o n s , i n d i c a t e d  a too l o n g a p e r i o d .  Any  c l a s s i f i c a t i o n takes time t o  permeate through the m e d i c a l ,  research, a d m i n i s t r a t i v e  and  t e a c h i n g s t r u c t u r e s and p r a c t i s i n g c l i n i c i a n s need time t o d i g e s t the changes and i n c o r p o r a t e the ones t h a t  are  considered u s e f u l i n t o t h e i r p r a c t i c e .  Clinician  Bias  Numerous s t u d i e s have r a i s e d concerns r e g a r d i n g  the  s c i e n t i f i c and e m p i r i c a l b a s i s f o r some of the d i a g n o s e s c r i t e r i a s e t s t h a t were proposed or i n c l u d e d i n DSM-III DSM-III-R (Achenbach, 1980; 1988;  Bayer & S p i t z e r , 1982;  Dell,  Fenton, McGlashan, & H e i n s s e n , 1988,  1983;  K e n d e l l , 1988a; Quay, 1986;  Rey,  1980;  Schacht, 1985;  Zimmerman, 1988).  T y r e r , 1988;  and  Caplan,  1987;  1988;  and  Kaplan,  Rutter & Shaffer, I t has  been suggested t h a t some d e c i s i o n s r e f l e c t e d p r i m a r i l y the t h e o r e t i c a l b i a s e s of the p a r t i c i p a n t ( s ) or the s p e c i f i c i t y the s e t t i n g s and e x p e r i e n c e s  i n which t h e y p r a c t i c e d or  researched  Kernberg, 1984;  (Gunderson, 1983;  M i l l o n , 1981). the p e r s o n n e l  Michels,  of  1984;  As such, i t i s f e l t t h a t d e c i s i o n s depend upon and the p e r s o n a l i t i e s who  the c o n s t r u c t i o n of the DSM  are on a committee  c o u l d s u f f e r from an  and  unreliability  52  in  i t s c o n s t r u c t i o n t h a t i s comparable  a c l i n i c a l diagnosis.  t o the u n r e l i a b i l i t y o f  The diagnoses and c r i t e r i a s e t s would  r e f l e c t the committee membership r a t h e r than the c l i n i c a l and e m p i r i c a l l i t e r a t u r e , j u s t as u n r e l i a b l e c l i n i c a l diagnoses r e f l e c t who  i s making the d i a g n o s i s r a t h e r t h a n the syndromes  b e i n g diagnosed.  With each new DSM,  new diagnoses  and  c r i t e r i a would appear, changing w i t h whomever has been' g i v e n or has o b t a i n e d the r e s p o n s i b i l i t y  f o r making the d e c i s i o n s .  The c l i n i c a l and r e s e a r c h l i t e r a t u r e f o r the DSM i s not i n f a l l i b l e and i s o f t e n i n a d e q u a t e . c l i n i c i a n who  process  Similarly,  i g n o r e s the DSM-III-R c r i t e r i a may  a  a t times  p r o v i d e a more v a l i d d i a g n o s i s than would be p r o v i d e d i f the c r i t e r i a were f o l l o w e d b l i n d l y ,  g i v e n the l i m i t a t i o n s  and  f a l l i b i l i t y o f any s e t o f d i a g n o s t i c c r i t e r i a (Fenton, Mosher, & Mathews, 1981; W i d i g e r e t a l . , 1990). i n d i c a t e d t h a t a s y s t e m a t i c assessment  Research  has  and adherence  t o the  DSM-III-R c r i t e r i a f o r the p e r s o n a l i t y d i s o r d e r s can a t t i m e s y i e l d e i g h t o r more p e r s o n a l i t y d i s o r d e r diagnoses (Skodol, R o s n i c k , Kellman, Oldman, & H y l e r , 1988; W i d i g e r , T r u l l , H u r t , C l a r k i n , & F r a n c e s , 1987).  D e c i s i o n making i n the DSM i s  c o n s i d e r e d by some t o be an i m p l i c i t p r o c e s s h a v i n g i n s u f f i c i e n t empirical basis for particular  decisions  andthere  53 i s o f t e n l i t t l e documentation of the d e c i s i o n p r o c e s s t o i n d i c a t e otherwise G a r f i e l d , 1986; 1987;  Garmezy, 1978;  T a y l o r , 1983;  Strengths The  Tyrer,  use of- the DSM  Caplan, 1987;  K a p l a n , 1983;  1988;  and L i m i t a t i o n s of  p s y c h o l o g i s t s , and settings.  (Achenbach, 1980;  Dell,  1988;  K o c s i s & Frances,  Walker, 1987).  DSM  i s w i d e s p r e a d among p s y c h i a t r i s t s ,  s o c i a l workers employed i n a v a r i e t y of  However, i n a comprehensive survey of p s y c h i a t r i s t s  (Jampala, et a l . , 1986), 35% s t a t e d t h e y would s t o p u s i n g  the  DSM  or  i f i t were not r e q u i r e d and  fewer than 50% used t h r e e  more of the axes t o r e c o r d a d i a g n o s i s .  The  authors concluded  t h a t a s i g n i f i c a n t p r o p o r t i o n of p s y c h i a t r i s t s are u n e n t h u s i a s t i c about the DSM  and t h a t " . . . t h e r e  i s a danger  t h a t complex d i a g n o s t i c systems, even i f v a l i d and might e v o l v e  i n the course o f time t o be mere e x e r c i s e s  paper t h a t are o f t e n p r a i s e d but seldom p r a c t i c e d " Kutchins  reliable, on  (p.23).  & K i r k (1988) i n t h e i r s t u d y of the DSM-III  c l i n i c a l s o c i a l work o f f e r s e v e r a l advantages d i s a d v a n t a g e s t o the system.  and  They s t a t e t h a t the DSM  d i a g n o s t i c c r i t e r i a f o r each d i s o r d e r , t h a t these i n c r e a s e d i a g n o s t i c r e l i a b i l i t y , as w e l l as  and  includes  criteria  facilitate  54 communication and enhance d i a g n o s t i c s k i l l s .  However,  K u t c h i n s & K i r k ' s (1988) conclude t h a t the d i s a d v a n t a g e s out weigh the advantages.  F i r s t , they r e p o r t t h a t v e r y  a t t e n t i o n i s g i v e n t o a l l 5 axes.  T h i s was  far little  evident i n t h i s  study as none o f the r e c o r d s i n c l u d e d r e p o r t s on A x i s IV o r V. Second, t h e r e e x i s t s an overuse  o f c e r t a i n diagnoses  o f the t h e o r e t i c a l o r i e n t a t i o n of the p r a c t i t i o n e r .  because This  may  be e v i d e n t i n the d i a g n o s i s o f j u v e n i l e sex o f f e n d e r s who not meet the d i a g n o s i s f o r P e d o p h i l i a g i v e n t h e i r age, p a r t i c u l a r l y the youth i n e a r l y a d o l e s c e n c e .  relative Third, i t  i s not s e n s i t i v e t o r a c i a l and c u l t u r a l d i f f e r e n c e s . the DSM  do  Fourth,  c l a s s i f i c a t i o n system does not a c c u r a t e l y r e f l e c t  c l i e n t s ' problems and i s more a management t o o l than a clinical tool.  F i n a l l y , K u t c h i n s & K i r k suggest i t does not  a d e q u a t e l y r e f l e c t i n t e r a c t i o n a l problems.  Pathologizing Children Kutchins & K i r k  (1988) found t h a t s o c i a l workers r e j e c t e d  the m e d i c a l i z a t i o n o f mental d i s o r d e r s and thought  that  DSM-  I I I p l a c e d m e d i c a l l a b e l s on p s y c h o s o c i a l problems and i n p a r t i c u l a r l a b e l l e d too many problems o f c h i l d h o o d as pathological.  Furthermore,  the DSM  has i n c r e a s e d the number  55 of c h i l d h o o d d i s o r d e r s t o i n c l u d e many b e h a v i o u r s which a r e troublesome b u t not, i n t h e i r o p i n i o n , p a t h o l o g i c a l . s o c i e t y has a tendency t o m i n i m i z e and n o r m a l i z e adolescent  sexual behaviour,  However,  c h i l d h o o d and  which i n f a c t may be s e x u a l abuse  and r e q u i r e s p e c i a l i z e d i n t e r v e n t i o n .  In the diagnostic  c r i t e r i a o f Conduct D i s o r d e r t h e b e h a v i o u r s " o f t e n l i e s " , "truancy",  and " r u n n i n g  receive this diagnosis.  away" q u a l i f y t h e i n d i v i d u a l t o I n some c i r c l e s these c r i t e r i a may be  p e r c e i v e d as normal a c t i n g out o r r e b e l l i o u s a d o l e s c e n t behaviour.  On t h e o t h e r hand, t h e d i a g n o s t i c c r i t e r i a may  have c l i n i c a l r e l e v a n c e  i n terms o f p r e d i c t i n g t r e a t m e n t  outcomes as i s h y p o t h e s i z e d Kutchins  i n t h i s study.  In t h e i r  study,  & K i r k (1988) found t h a t many p s y c h i a t r i s t s approach  d i a g n o s i s i n an i n d i v i d u a l and u n s y s t e m a t i c c o n f o r m i t y w i t h DSM c r i t e r i a .  Diagnosis  way and n o t i n  s h o u l d be i n t i m a t e l y  r e l a t e d t o t r e a t m e n t b u t o n l y 33% o f t h e p s y c h i a t r i s t s s u r v e y e d found DSM h e l p f u l i n t r e a t m e n t p l a n n i n g i n h i b i t s understanding  of i n d i v i d u a l c l i e n t s  and t h a t i t  (Kutchins & K i r k ,  1988) . In a s i m i l a r study, p s y c h o l o g i s t s found DSM-III as t h e l e a s t f a v o u r a b l y endorsed d i a g n o s t i c o p t i o n and r e j e c t e d t h e i d e a t h a t mental d i s o r d e r i s a subset o f m e d i c a l  d i s o r d e r , and  56 c o n c l u d e d t h a t t o o l i t t l e e f f o r t had been made to.promote a l t e r n a t i v e s t o DSM-III (Smith & K r a f t , 1983).  They s t a t e d  t h a t t h e DSM l a b e l s c l i e n t s and i s n o t h e l p f u l i n t r e a t m e n t planning  ( R a f f o u l & Holmes, 1986).  They go on t o s t a t e t h a t t h e t h r e s h o l d f o r making r e v i s i o n s i n DSM-IV i s much h i g h e r than was t h e case f o r DSMI I I and DSM-III-R, u t i l i z i n g :  "comprehensive, s y s t e m a t i c , and  consensus r e v i e w s o f t h e p u b l i s h e d  l i t e r a t u r e ; reanalysis of  r e l e v a n t c o l l e c t e d d a t a s e t s ; and f i e l d . t r i a l s al.,  1991).  (Francis et  They a l s o c l a i m t h a t i t i s more d i f f i c u l t t o  remove something t h a t was a l r e a d y i n c l u d e d i n DSM-III-R than to introduce  something new t h a t has been suggested f o r DSM-IV  (Frances e t a l . , 1991)  Of p a r t i c u l a r s i g n i f i c a n c e i s t h i s  quote: "This i s n e c e s s a r y t o a v o i d f r e q u e n t  and a r b i t r a r y  d i a g n o s t i c changes t h a t impede c l i n i c a l d i s c o u r s e ,  training,  and r e s e a r c h .  reason t o  There has t o be a f a i r l y c o m p e l l i n g  change t h e c l a s s i f i c a t i o n "  (Frances e t a l . , 1991, p. 172).  Changes i n DSM C a t e g o r i e s Hierarchical  and C r i t e r i a  Structure  One o f t h e main changes i n t h e c r i t e r i a f o r d i a g n o s i s r e f e r s to the h i e r a r c h i c a l s t r u c t u r e .  Most o f t h e  57  c l a s s i f i c a t i o n s a c t u a l l y i n use i n p s y c h i a t r y have a hierarchical structure.  That i s , the d i f f e r e n t d i s o r d e r s are  o r g a n i z e d i n l e v e l s i n such a way  t h a t each l e v e l of  pathology  i s a l l o w e d t o e x h i b i t the c h a r a c t e r i s t i c f e a t u r e s o f a l l lower l e v e l s but not any of a h i g h e r l e v e l .  T h i s approach makes  p o s s i b l e the use of a s i n g l e d i a g n o s i s d e s p i t e the f a c t t h a t m u l t i p l e symptoms of d i f f e r e n t l e v e l s may time.  appear a t any  The DSM-III-R has l a r g e l y done away w i t h  p r i n c i p l e s which are m a i n t a i n e d  given  those  o n l y i n two a r e a s : the  mental d i s o r d e r s , which r u l e out a d i a g n o s i s o f almost  organic any  o t h e r d i s o r d e r , and s c h i z o p h r e n i a which a l s o preempts most other diagnoses.  However, the h i e r a r c h i c a l o r g a n i z a t i o n has  been r e l a x e d s i g n i f i c a n t l y .  For example, a d i a g n o s i s o f  A n x i e t y D i s o r d e r or M a j o r D e p r e s s i o n concurrent  can be made d e s p i t e a  d i a g n o s i s of A t t e n t i o n D e f i c i t H y p e r a c t i v i t y  D i s o r d e r o r Conduct D i s o r d e r .  These changes appear t o be a  response t o c r i t i c i s m s of the e x c l u s i o n c r i t e r i a o f DSM-III and of the h i e r a r c h i c a l h y p o t h e s i s  on e m p i r i c a l grounds,  and  t h a t c o r r e l a t i o n s between diagnoses f o r which e x c l u s i o n c r i t e r i a were not used were sometimes s t r o n g e r than when they were s p e c i f i e d  (Robbins & H e l z e r , 1986).  Furthermore, the  r e l a x a t i o n o f the h i e r a r c h i c a l s t r u c t u r e has r e s u l t e d i n an  58 i n c r e a s e o f t h e number o f i n d i v i d u a l s w i t h m u l t i p l e d i a g n o s e s . However, r e s u l t s from s e v e r a l s t u d i e s (eg. Loeber e t a l . , 1994; Russo e t a l . ,  1994) support t h e h i e r a r c h a l o r g a n i z a t i o n  of d i s r u p t i v e b e h a v i o u r d i s o r d e r s i n c h i l d r e n .  That i s ,  Conduct- D i s o r d e r i s p e r c e i v e d as an advanced and more severe form o f O p p o s i t i o n a l D e f i a n t D i s o r d e r .  T h i s i s s u e w i l l be  d i s c u s s e d i n more depth i n t h e f o l l o w i n g s e c t i o n s o f t h i s chapter.  Diagnostic Rules Most o f t h e s p e c i f i c d i a g n o s t i c r u l e s p r e s c r i b e d i n DSM ( i . e . minimum number o f symptoms, minimum l e n g t h o f time d u r i n g which symptom s h o u l d be p r e s e n t ,  e t c . ) have never been  t e s t e d e m p i r i c a l l y ( R u t t e r & S h a f f e r , 1980; Wakefield, system"  & Friedman, 1983).  Eysenck,  Moreover, t h e "Chinese menu  (Klerman, 1978), i n which symptoms a r e a s s o r t e d  into  groups w i t h t h e requirement t h a t symptoms from a l l groups be p r e s e n t t o be a b l e t o make a d i a g n o s i s , has been l a r g e l y abandoned.  Consequently, t h i s has r e s u l t e d i n even  l i s t s o f symptoms.  These " l a u n d r y l i s t s "  longer  (Klerman, V a i l l a n t ,  S p i t z e r , & M i c h e l s , 1984) which make l i t t l e sense, a r e i m p o s s i b l e t o remember, and which i n many cases have become de  59 facto  r a t i n g s c a l e s , but w i t h o u t  psychometric a n a l y s i s .  h a v i n g been s u b j e c t e d  An example of t h a t i s Conduct  to Disorder  i n the DSM-III-R w i t h a l i s t of 13 symptoms, 3 i f which must be p r e s e n t  t o make a d i a g n o s i s .  I r o n i c a l l y , the DSM-IV has  responded t o t h i s i s s u e by adding two more symptoms. In a d d i t i o n , as i f t o compromise, the 15 symptoms are now  divided  i n 4 groups, however the 3 n e c e s s a r y c r i t e r i a need not come from e v e r y group t o make a d i a g n o s i s . criteria  continue  standardised  As such, d i a g n o s t i c  t o seem more s u i t e d f o r use  with  i n t e r v i e w s c h e d u l e s and computer a l g o r i t h i s m s ,  t h a n f o r a p p l i c a t i o n i n e v e r y day c l i n i c a l p r a c t i c e . DSM-III-R a l s o expanded the d e s c r i p t i o n of s e v e r i t y , which i s i n c l u d e d i n most d i a g n o s t i c c r i t e r i a .  Clinicians  are  encouraged t o make s e v e r i t y s p e c i f i c a t i o n s : m i l d , moderate, severe,  i n p a r t i a l r e m i s s i o n and i n f u l l r e m i s s i o n .  This i s  p a r t i c u l a r l y r e l e v a n t f o r Conduct D i s o r d e r d i a g n o s i s , as  the  c l i n i c i a n i s asked t o make a d i s t i n c t i o n i n the l e v e l s of severity.  In f a c t , t o p r e s e n t  a new  and e m p i r i c a l l y based  p e r s p e c t i v e , the f i r s t v e r s i o n of the DSM-IV O p t i o n s Book (APA,  1991)  i n c l u d e d an attempt t o i n t e g r a t e O p p o s i t i o n a l  D e f i a n t D i s o r d e r and Conduct D i s o r d e r i n a single', a l t e r n a t i v e , d i s r u p t i v e b e h a v i o u r syndrome w i t h t h r e e l e v e l s  60 of s e v e r i t y : a modified o p p o s i t i o n a l d i s o r d e r intermediate  l e v e l o f Conduct D i s o r d e r  l e v e l o f Conduct D i s o r d e r  (ACD)  (MODD), and  (ICD), and an advanced  (Russo, e t a l . , 1994).  DSM-III-R and DSM-IV: More E m p i r i c a l and A c c e s s i b l e W i t h the l i m i t a t i o n s i n mind, the DSM-III-R and DSM-IV are more e m p i r i c a l and a c c e s s i b l e than t h e i r p r e d e c e s s o r s because "a much b r o a d e r , more r e p r e s e n t a t i v e a r r a y o f d i a g n o s t i c and r e s e a r c h e x p e r t i s e was brought t o b e a r on t h e s e v e r s i o n s o f the Diagnostic 1994, p. 103).  and Statistical  Manual"  (Nathan,  Nathan goes on t o s t a t e t h a t " i n t h e i r  numbers, d i s c i p l i n a r y bases, gender, r a c i a l d i v e r s i t y ,  and  p r i m a r y work s e t t i n g s , the s e v e r a l hundred mental h e a l t h p r o f e s s i o n a l s who c o n t r i b u t e d t o the development o f  DSM-IV  were markedly d i f f e r e n t from those who d e v e l o p e d the p r e v i o u s f o u r e d i t i o n s " (p. 103).  Only a s m a l l number o f s e n i o r  p s y c h i a t r i s t s from the most p r e s t i g i o u s departments o f p s y c h i a t r y were i n v o l v e d i n the development o f DSM-I and I I i n 1952 and 1968 r e s p e c t i v e l y .  DSM-  However, a much l a r g e r  number o f p s y c h i a t r i s t s w i t h a b r o a d e r scope o f  expertise, a  p s y c h o l o g i s t , and a s o c i a l worker worked on DSM-III which was published  i n 1980.  A c c o r d i n g t o Nathan  (1994) t h i s p r o c e s s o f  61 b r o a d e n i n g the base o f c o n t r i b u t o r s a c c e l e r a t e d  progressively  d u r i n g the development of the DSM-III-R and the  subsequent  development of the DSM-IV.  The  development of t h i s  current  r e v i s i o n r e s u l t e d i n the i n v o l v e m e n t of a l a r g e and  diverse  group of mental h e a l t h p r o f e s s i o n a l s t h a t i n c l u d e d  three  p s y c h o l o g i s t s and a s o c i a l worker j o i n i n g the p s y c h i a t r i s t s on the Task Force, a dozen or more p s y c h o l o g i s t s and numerous mental h e a l t h p r o f e s s i o n a l s of o t h e r d i s c i p l i n e s on the Work Groups, and over 100 n o n - p s y c h i a t r i s t s s e r v e d  as  advisors.  Furthermore, a s u b s t a n t i a l number of these i n d i v i d u a l s i d e n t i f i e d themselves as c l i n i c i a n s r a t h e r than u n i v e r s i t y faculty.  In a d d i t i o n , a s i g n i f i c a n t number of women had  p r e v i o u s l y , and q u i t e c o n s p i c u o u s l y , development  been absent i n the  DSM  process.  Several studies i n d i c a t e that n e g l i g i b l e e m p i r i c a l data i n f o r m e d e i t h e r the DSM-I or DSM-II p r o c e s s e s Michels,  1984;  Skodol et a l . 1988;  (Garfield,  1986;  W i d i g e r et a l , 1990).  Moreover, a l t h o u g h b o t h DSM-III and DSM-III-R were f a r more grounded i n s c i e n t i f i c r e s e a r c h  considered  than t h e i r  p r e d e c e s s o r s , i n r e a l i t y o n l y p a r t s of e i t h e r c l a s s i f i c a t i o n system were the r e s u l t of e m p i r i c a l r e s e a r c h .  Nathan (1994)  c o n t r a s t s t h i s , s t a t i n g t h a t the c r i t e r i o n s e t s i n n e a r l y  62 every major d i a g n o s t i c c a t e g o r y i n DSM-III-R and DSM-IV were i n f l u e n c e d s i g n i f i c a n t l y by thorough l i t e r a t u r e r e v i e w s , and the r e s u l t s o f b o t h t h e a n a l y s e s o f e x i s t i n g d a t a and extensive f i e l d t r i a l s .  Furthermore, i n c o n t r a s t t o p r e v i o u s  e d i t i o n s where r e s e a r c h f i n d i n g s were i n f r e q u e n t l y p u b l i s h e d , the r e s u l t s o f Work Groups' a n a l y s e s o f e x i s t i n g d a t a s e t s and f i e l d t r i a l s has been made e a s i l y a c c e s s i b l e i n t h e s e v e r a l volume's o f DSM-IV Sourcebooks  of published reports.  S e v e r a l s t u d i e s show t h a t DSM-III was c o n s t r u c t e d through d e c i s i o n s based on e x p e r t consensus, as r e s e a r c h on t h e d i a g n o s i s o f mental d i s o r d e r s was o f t e n l i m i t e d 1988b; Robins & H e l z e r , 1986; S p i t z e r , 1985).  (Kendell, The development  of DSM-IV b e n e f i t s from t h e s u b s t a n t i a l i n c r e a s e i n r e s e a r c h and i n t e r e s t i n d i a g n o s i s g e n e r a t e d i n p a r t by DSM-III.  The  d i a g n o s i s o f mental d i s o r d e r s p r i o r t o DSM-III was u n r e l i a b l e to  t h e p o i n t t h a t t h e i r v a l i d i t y was suspect  (Blashfield &  Draguns, 1976; Rosenhan, 1975; S p i t z e r & F l e i s s , 1974).  The  major i n n o v a t i o n o f DSM-III w i t h r e s p e c t t o t h e improvement o f r e l i a b i l i t y was t o p r o v i d e e x p l i c i t d i a g n o s t i c c r i t e r i a t h a t made d i a g n o s i s more s y s t e m a t i c and r e p l i c a b l e  (Spitzer et a l . ,  1980) . The most r e c e n t s t u d i e s s t a t e t h a t t h e DSM-IV i s much  63 b e t t e r i n f o r m e d by e m p i r i c a l d a t a than any o f i t s p r e d e c e s s o r s and t h a t not a l l d i a g n o s t i c c r i t e r i a have b e n e f i t t e d as from e m p i r i c a l f i n d i n g s as have o t h e r s K l i n e , 1994;  (Frances, Davis &  Frances, P i n c u s , & W i d i g e r , 1994;  Frances, D a v i s , W i d i g e r , & F i r s t , 1994). D i s r u p t i v e Behaviour  fully  Pincus,  For example, i n the  D i s o r d e r s g r o u p i n g , a number o f  o v e r l a p p i n g c r i t e r i a are shared by the v a r i o u s diagnoses are l e s s s p e c i f i c than o t h e r DSM  diagnoses,  such  and  as  Schizophrenia. A c c o r d i n g t o Nathan (1994) t h i s d u a l emphasis on e m p i r i c a l f i n d i n g s and f u l l a c c e s s i b i l i t y of those f i n d i n g s c l e a r l y d i s t i n g u i s h e s the DSM-IV p r o c e s s from those o f i t s predecessors.  In a d d i t i o n , he s t a t e s t h a t t h i s d u a l emphasis  s h o u l d ensure t h a t the r e l i a b i l i t y , v a l i d i t y , and u t i l i t y  will  be h i g h e r than i n the p r e v i o u s i n s t r u m e n t s .  DSM  C l a s s i f i c a t i o n o f Conduct D i s o r d e r  D i s r u p t i v e Behaviour  Disorders  The D i a g n o s t i c and S t a t i s t i c a l Manual o f M e n t a l (DSM-IV, APA,  1994)  Disorders  i s the most w i d e l y used c a t e g o r i c a l  d i a g n o s t i c system o f c h i l d h o o d disorders.. M a j o r A x i s I diagnoses  d e s c r i b i n g c h i l d h o o d and a d o l e s c e n t d i s t u r b a n c e s o f  64 conduct a r e grouped as a s u b c l a s s c a l l e d D i s r u p t i v e B e h a v i o u r Disorders.  These d i s o r d e r s a r e c h a r a c t e r i z e d by s o c i a l l y  d i s r u p t i v e behaviour that i s of greater d i s t r e s s t o others than t o the diagnosed i n d i v i d u a l .  The s p e c i f i c d i a g n o s t i c  syndromes a r e A t t e n t i o n - D e f i c i t H y p e r a c t i v i t y D i s o r d e r , O p p o s i t i o n a l D e f i a n t D i s o r d e r , and Conduct D i s o r d e r . The  d i a g n o s t i c term Conduct Disorder  from t h e t h i r d  r e v i s e d e d i t i o n o f t h e D i a g n o s t i c and S t a t i s t i c a l Manual o f Mental Disorders 1987)  (DSM-III-R, American P s y c h i a t r i c A s s o c i a t i o n ,  includes the f o l l o w i n g  s e t of behaviours l i s t e d i n  d e s c e n d i n g o r d e r o f d i s c r i m i n a t i n g power: (1) has s t o l e n w i t h o u t  c o n f r o n t a t i o n o f a v i c t i m on  more than one o c c a s i o n  ( i n c l u d i n g forgery)  (2) has r u n away from home o v e r n i g h t while l i v i n g i n parental or parental  at l e a s t twice surrogate  home (3) o f t e n l i e s  (other than t o a v o i d p h y s i c a l o r s e x u a l  abuse) (4) has d e l i b e r a t e l y engaged i n f i r e - s e t t i n g (5) i s o f t e n t r u a n t from s c h o o l (6) has broken i n t o someone e l s e ' s house, b u i l d i n g , o r car  65 (7) has d e l i b e r a t e l y d e s t r o y e d o t h e r s ' p r o p e r t y (8) has been p h y s i c a l l y c r u e l t o  animals  (9) has f o r c e d someone i n t o s e x u a l a c t i v i t y w i t h him o r her (10) has used a weapon i n more than one  fight  (11) o f t e n i n i t i a t e s p h y s i c a l f i g h t s (12) has s t o l e n w i t h c o n f r o n t a t i o n o f a v i c t i m (13) has been p h y s i c a l l y c r u e l t o p e o p l e ,  (p. 58)  Conduct D i s o r d e r i s c o n s i d e r e d the most severe o f the D i s r u p t i v e Behaviour  d i s t u r b a n c e s , h a v i n g as i t s e s s e n t i a l  f e a t u r e "a r e p e t i t i v e and p e r s i s t e n t p a t t e r n o f b e h a v i o u r i n which the b a s i c r i g h t s o f o t h e r s o r major s o c i e t a l norms are v i o l a t e d "  (APA,  1994,  age-appropriate p.53).  This  e s s e n t i a l f e a t u r e i s l i t e r a l l y unchanged s i n c e DSM-III, o t h e r than the use o f the a d d i t i o n a l term " r e p e t i t i v e " and the  use  o f the word " b e h a v i o u r " i n s t e a d o f "conduct" .in the DSM-IV . This behaviour situations persons  i s t y p i c a l l y observed  to occur  across  (at home, a t s c h o o l , and i n the community), a c r o s s  ( p a r e n t s , p e e r s , and s t r a n g e r s ) , and a c r o s s t i m e .  DSM-III-R s p e c i f i e s a  The  d u r a t i o n o f a t l e a s t s i x months, d u r i n g  which a t l e a s t t h r e e of the o f the b e h a v i o r a l symptoms are present.  T h i s symptom t h r e s h o l d was  i n c r e a s e d from o n l y  one  66  b e h a v i o r a l c r i t e r i a as p e r t h e DSM-III t o make a d i a g n o s i s . The DSM-IV changed t h e time t h r e s h o l d t o s t a t e :  "...the  presence o f t h r e e (or more) o f t h e f o l l o w i n g c r i t e r i a i n t h e p a s t 12 months, w i t h a t l e a s t one c r i t e r i o n p r e s e n t i n t h e p a s t s i x months"  (APA, 1994, p.90).  I n a d d i t i o n , as mentioned  e a r l i e r , t h e number o f a p p l i c a b l e d i a g n o s t i c items have been i n c r e a s e d from 13 t o 15 d i s c r i m i n a n t b e h a v i o r a l i t e m s .  These  two new items a r e : " o f t e n b u l l i e s , t h r e a t e n s , o r i n t i m i d a t e s o t h e r s " , and " o f t e n s t a y s out a t n i g h t d e s p i t e p a r e n t a l p r o h i b i t i o n s , b e g i n n i n g b e f o r e age 13 y e a r s " (APA, 1994, p. 90) . S t e a l i n g and p h y s i c a l a g g r e s s i o n a r e p r i m a r y t o t h e d i a g n o s i s , a l t h o u g h o t h e r b e h a v i o u r s such as r u n n i n g away from home and l y i n g were r e p o r t e d t o be h i g h i n d i s c r i m i n a t i n g power based on t h e r e s u l t s o f a n a t i o n a l f i e l d t r i a l o f DSMIII-R c r i t e r i a  (APA, 1987).  E v o l u t i o n o f Conduct D i s o r d e r (CD) Subtypes I t i s c l e a r t o a l l who s t u d y a n t i s o c i a l b e h a v i o u r i n youths t h a t CD i s a heterogeneous d i a g n o s t i c c a t e g o r y ( F a r r i n g t o n , 1987; K a z d i n , 1987; Loeber, subtypes have been proposed  1988).  Therefore,  i n an e f f o r t t o c a p t u r e  67 d i f f e r e n c e s i n b e h a v i o u r , developmental t r a j e c t o r i e s , assumed e t i o l o g y . the DSM  and  S u b c l a s s i f i c a t i o n s from e a r l i e r e d i t i o n s of  have d i s t i n g u i s h e d subtypes of CD on the b a s i s of  c a p a c i t y of the youth f o r m a i n t a i n i n g  the  social relationships,  the presence or absence of a g g r e s s i o n ,  age of o n s e t , and  the  presence o r absence of comorbid d i a g n o s i s . S o c i a l i z a t i o n and a g g r e s s i o n .  The  d i s t i n c t i o n between  s o c i a l i z e d and u n d e r - s o c i a l i z e d CD i n DSM-III was  based on a  number of s t u d i e s of p s y c h i a t r i c o u t p a t i e n t s and  incarcerated  j u v e n i l e delinquents Jenkins  beginning  (Jenkins & H e w i t t ,  w i t h the p i o n e e r i n g  1944;  Jenkins  studies  and Glickman, 1947).  These s t u d i e s i n d i c a t e d t h a t youths w i t h u n d e r - s o c i a l i z e d are more a g g r e s s i v e , facilities,  of  CD  adjust l e s s w e l l to j u v e n i l e detention  are l e s s l i k e l y t o v i o l a t e p r o b a t i o n  and  be  r e a r r e s t e d a f t e r r e l e a s e than youth w i t h s o c i a l i z e d CD e t a l . , Quay, 1986b, 1987).  However, e x p l i c i t  (Henn  operational  c r i t e r i a i s n e c e s s a r y i n o r d e r t o make a m e a n i n g f u l d i s t i n c t i o n between s o c i a l i z e d and u n d e r - s o c i a l i z e d The  s o c i a l i z e d and u n d e r - s o c i a l i z e d subtypes of  d i s t i n g u i s h e d i n DSM-III were each s u b d i v i d e d and n o n - a g g r e s s i v e subtypes. b e l i e f t h a t youths w i t h CD who  into  CD. CD aggressive  There i s evidence t o support are p h y s i c a l l y a g g r e s s i v e  the  68 s h o u l d be d i s t i n g u i s h e d from those who a r e n o t (Olweus, 1979; Henn e t a l . ,  1980).  S t u d i e s have shown t h a t h i g h l e v e l s o f  a g g r e s s i o n as e a r l y as age 10 a r e h i g h l y p r e d i c t i v e o f p e r s i s t e n t a d u l t male c r i m i n a l i t y , e s p e c i a l l y v i o l e n t and d e s t r u c t i v e crime  (Henn e t a l . ,  1980; S t a t t i n & Magnusson,  1989) . The s y m m e t r i c a l s u b t y p i n g o f CD i n DSM-III a l o n g b o t h t h e s o c i a l i z e d - u n d e r - s o c i a l i z e d and t h e a g g r e s s i v e - n o n - a g g r e s s i v e dimensions was dropped i n DSM-III-R i n f a v o u r o f two subtypes that captured aggressive  some a s p e c t s o f these d i s t i n c t i o n s .  A  solitary-  type was d i s t i n g u i s h e d , b u t no s o l i t a r y non-  a g g r e s s i v e subtype was p r o v i d e d on t h e assumption t h a t few such cases o f CD would be i d e n t i f i e d .  The group type can  i n c l u d e b o t h a g g r e s s i v e and n o n - a g g r e s s i v e youths, b u t no d i s t i n c t i o n was made on t h e b a s i s o f a g g r e s s i o n i n t h i s subtype.  I n support o f t h i s d i f f e r e n t i a t i o n o f subtypes, poor  peer r e l a t i o n s h i p s have been demonstrated l a t e r maladjustment  t o be p r e d i c t i v e o f  i n t h i s p o p u l a t i o n (Roff & W i r t , 1984).  I t may be p o s s i b l e t o d i f f e r e n t i a t e subtypes w i t h i n t h e j u v e n i l e sex o f f e n d e r p o p u l a t i o n who a r e conduct d i s o r d e r e d based on t h e i r l e v e l o f a g g r e s s i o n and s o c i a l i z a t i o n .  That  i s , t h e more a g g r e s s i v e , u n d e r - s o c i a l i z e d sex o f f e n d e r may be  69 one subtype o f Conduct D i s o r d e r who i s more l i k e l y t o have poor treatment  outcome.  o f f e n d e r diagnosed  I n the DSM-III-R, t h e j u v e n i l e sex  as "Conduct D i s o r d e r : s o l i t a r y  t y p e " may f i t i n t o t h i s  aggressive  category.  A study by Rogeness e t a l . (1983) i s c o n s i s t e n t w i t h t h e DSM-III-R approach t o subtypes o f CD.  Among 345 p s y c h i a t r i c  i n p a t i e n t c h i l d r e n and a d o l e s c e n t s g i v e n a DSM-III d i a g n o s i s o f CD, 46% were g i v e n the d i a g n o s i s o f s o c i a l i z e d  aggressive  CD, and 38% were g i v e n the d i a g n o s i s o f u n d e r - s o c i a l i z e d a g g r e s s i v e CD.  Fourteen p e r c e n t r e c e i v e d a d i a g n o s i s o f  s o c i a l i z e d non-aggressive  CD, but o n l y 2% o f t h e youths w i t h  CD r e c e i v e d a d i a g n o s i s o f u n d e r - s o c i a l i z e d n o n - a g g r e s s i v e  CD.  However, these r e s u l t s a r e q u e s t i o n a b l e because i n p a t i e n t samples may not be r e p r e s e n t a t i v e o f a l l c l i n i c - r e f e r r e d youths w i t h CD. Age o f o n s e t .  C e r t a i n s t u d i e s have been a b l e to-  d i s t i n g u i s h between e a r l y and l a t e onset forms of. j u v e n i l e delinquency,  i n t h a t l a t e onset d e l i n q u e n t s t e n d . t o be l e s s  severe i n t h e i r o f f e n d i n g , p a r t i c u l a r y i n e x h i b i t i n g a g g r e s s i o n , and have a b e t t e r p r o g n o s i s offending  less  f o r desistance i n  ( F a r r i n g t o n , 1987; Loeber, 1982, 1988).  Similarly,  Robins (1966) found t h a t youths whose CD onset b e f o r e age 11  70  were t w i c e as l i k e l y t o r e c e i v e a d i a g n o s i s o f A n t i s o c i a l Personality Disorder  (sociopathy) i n a d u l t h o o d as those w i t h  an onset a f t e r age 11.  McGee e t a l . (1992) i d e n t i f i e d a v e r y  l a r g e group o f male and female youths who e x h i b i t e d DSM-III CD for  t h e f i r s t time a f t e r age 11.  Furthermore,  t h i s group were  l e s s l i k e l y t o be a g g r e s s i v e , and e x h i b i t e d h i g h e r v e r b a l a b i l i t y and r e a d i n g s c o r e s . An i m p o r t a n t g o a l o f t h e DSM-IV f i e l d t r i a l s was t o a s s e s s t h e u t i l i t y o f s u b t y p i n g CD.  Thus, t h e subgroups were  compared t o see i f they d i f f e r e d i n terms o f impairment, f a m i l y h i s t o r y , c o m o r b i d i t y , and o t h e r c l i n i c a l l y variables.  important  A l t h o u g h a s i g n i f i c a n t body o f r e s e a r c h  t h a t m e a n i n g f u l l y d i s t i n c t subtypes  suggests  o f CD s h o u l d be  d i s t i n g u i s h e d , DSM-IV f i e l d t r i a l s and r e l a t e d s t u d i e s have determined  t h a t d i s t i n c t i o n s o f s o c i a l i z a t i o n and a g g r e s s i o n  were redundant and i d e n t i f i e d t h e same subgroups o f youths w i t h CD ( F r i c k e t a l . , 1994; Loeber e t a l . , 1993; Lahey e t al.,  1994).  However, t h i s same r e s e a r c h determined  that i t  was u s e f u l t o d i s t i n g u i s h between two d e v e l o p m e n t a l l y l e v e l s o f s e v e r i t y w i t h i n CD.  staged  As such, DSM-IV o f f e r s two  subtypes based on age o f onset: " c h i l d h o o d - o n s e t t y p e :  onset  o f a t l e a s t one c r i t e r i o n c h a r a c t e r i s t i c o f Conduct D i s o r d e r  71 p r i o r t o 10 y e a r s " and " a d o l e s c e n t - o n s e t t y p e : absence o f any c r i t e r i a c h a r a c t e r i s t i c o f conduct d i s o r d e r p r i o r t o age 10 years"  (APA, 1994, p.91).  Thus, i t may be p o s s i b l e t o  i d e n t i f y subtypes o f j u v e n i l e sex o f f e n d e r s d i a g n o s e d w i t h Conduct D i s o r d e r based on age o f o n s e t .  T h i s would have  c l i n i c a l r e l e v a n c e i n terms o f p r e d i c t i n g t r e a t m e n t outcome i n t h a t those j u v e n i l e sex o f f e n d e r s d i a g n o s e d w i t h e a r l y onset Conduct D i s o r d e r a r e more l i k e l y t o have poor t r e a t m e n t outcome. Comorbidity.  There i s some e v i d e n c e t h a t youths w i t h CD  and comorbid A t t e n t i o n D e f i c i t H y p e r a c t i v e D i s o r d e r (ADHD) e x h i b i t a more severe and p e r s i s t e n t d i s o r d e r than youths w i t h CD a l o n e ( O f f o r d e t a l , 1979; Schachar e t a l . , 1981; Walker e t al.,  1987; Werry e t a l . , 1987).  Furthermore, t h e y c o n c l u d e d  t h a t o n l y t h e g r e a t e r c o g n i t i v e impairment a s s o c i a t e d w i t h ADHD and t h e g r e a t e r s o c i a l impairment a s s o c i a t e d w i t h Conduct D i s o r d e r d i f f e r e n t i a t e d t h e two groups a c r o s s t h e m a j o r i t y o f s t u d i e s reviewed.  However, g i v e n t h e p r e v i o u s r e s e a r c h  f i n d i n g s one would expect t h a t those j u v e n i l e sex o f f e n d e r s w i t h b o t h CD and ADHD would have p o o r e r t r e a t m e n t outcomes than those w i t h a s i n g l e d i a g n o s i s .  72  E v a l u a t i o n of DSM  C l a s s i f i c a t i o n f o r Conduct  Three major c r i t e r i a  f o r the e v a l u a t i o n of  systems were o u t l i n e d by Quay (1986a).  The  Disorder classification  first  requires  t h a t f e a t u r e s be o p e r a t i o n a l l y d e f i n e d and c o v a r y .  The  second  i s r e l a t e d t o the r e l i a b i l i t y of the o b s e r v a t i o n s .  The  rating  s c a l e s commonly used i n these i n v e s t i g a t i o n s have been r e p o r t e d t o have g e n e r a l l y good i n t e r r a t e r r e l i a b i l i t y between p a r e n t s ; Achenbach & E d e l b r o c k , 1983). c l a s s i f i c a t i o n must be v a l i d .  According  (eg.  Finally,  the  t o Baum (1989)  dimensions d e f i n e d by m u l t i v a r i a t e approaches are d i s c r i m i n a b l e from each o t h e r and p r o v i d e for  an e m p i r i c a l b a s i s  i n v e s t i g a t i n g group d i f f e r e n c e s i n e t i o l o g y , b e h a v i o r a l  c o r r e l a t e s , c o u r s e , outcome, and response t o t r e a t m e n t . However, the e x t e n s i v e n e s s  of the b e h a v i o u r s a s s e s s e d and  c o m p a r a b i l i t y of dimensions a c r o s s  s t u d i e s are  the  valid  c r i t i c i s m s of these approaches (Quay, 1986a). U s i n g Quay's c r i t e r i a  (1986a) t o e v a l u a t e  the DSM-III-R,  t h i s r e v i s i o n appears t o o f f e r improvements over  previous  v e r s i o n s i n the o p e r a t i o n a l i z a t i o n of d i a g n o s t i c c r i t e r i a  by  the use of s p e c i f i c d e s c r i p t i o n s of o b s e r v a b l e b e h a v i o u r s . However, c l i n i c a l judgement i s s t i l l r e q u i r e d i n terms of f r e q u e n t l y a b e h a v i o u r must o c c u r t o meet the  criteria.  how  73 C e r t a i n d i s c r i m i n a t i n g c r i t e r i a of Conduct D i s o r d e r have been found t o l o a d on s e p a r a t e f a c t o r s i n m u l t i v a r i a t e (Baum, 1989) .  research  For example, a l t h o u g h " s t e a l i n g w i t h o u t  c o n f r o n t a t i o n of a v i c t i m " i s l i s t e d as h i g h e s t d i s c r i m i n a t i n g power and  in  " s t e a l i n g with confrontation" i s  o f the 13 DSM-III-R c r i t e r i a  (APA,  p. 5 5 ) ,  12th  t h e f t i s commonly  a s s o c i a t e d w i t h the group type conduct d i s o r d e r p a t t e r n and i s r a r e l y seen i n the s o l i t a r y a g g r e s s i v e  type p a t t e r n .  TV,.  Diagnostic The  Thresholds  diagnostic thresholds  f o r b o t h ODD  and CD were r a i s e d  i n DSM-III-R by e l i m i n a t i n g the m i l d e r symptoms and  increasing  the number of symptoms r e q u i r e d f o r each d i a g n o s i s , r e s u l t i n g i n d e c r e a s e d p r e v a l e n c e of the two 1994).  The  disorders  changing c r i t e r i a of DSM-III and  (Lahey, et a l . , DSM-III-R  c r i t e r i a f o r Conduct D i s o r d e r have been c o n t r o v e r s i a l f o r main r e a s o n s .  First,  some r e s e a r c h e r s  have c h a l l e n g e d  the d i a g n o s t i c t h r e s h o l d f o r Conduct D i s o r d e r  to  two  raising  three  symptoms i n DSM-III-R because some e v i d e n c e suggests t h a t even one  or two  conduct d i s o r d e r symptoms i n c h i l d h o o d  predict  adverse a d u l t outcomes (Lahey, Loeber, Quay, F r i c k , & Grimm, 1992;  Lahey Loeber, Quay, F r i c k , & Grimm, 1994;  Robbins &  74. P r i c e , 1991; Russo, Loeber, Lahey, & Canaan,.1994).  Second,  o t h e r s have suggested t h a t o p p o s i t i o n a l d e f i a n t d i s o r d e r  (ODD)  i s m e r e l y a m i l d e r form o f Conduct D i s o r d e r and s h o u l d n o t be considered  as a s e p a r a t e  disorder  ( F r i c k , Lahey, A p p l e g a t e ,  Kerdyk, O l l e n d i c k , Hynd, G a r f i n k l e , G r e e n h i l l , Biederman, B a r k l e y , McBurnett, Newcorn, & Waldman, 1991; Lahey e t a l . , 1994).  Lahey e t a l . (1994) r e v i e w e d e x i s t i n g r e s e a r c h i n an  attempt t o e v a l u a t e t h e v a l i d i t y o f t h e DSM approach to. t h e d i a g n o s t i c c r i t e r i a f o r ODD and CD.  These e f f o r t s  provided  c o n s i s t e n t e v i d e n c e o f a s t r o n g developmental r e l a t i o n s h i p between o p p o s i t i o n a l d e f i a n t d i s o r d e r and conduct d i s o r d e r . I t appears t h a t a h i g h p e r c e n t a g e o f youths who meet c r i t e r i a f o r conduct d i s o r d e r b e f o r e t h e age o f p u b e r t y met c r i t e r i a , f o r O p p o s i t i o n a l D e f i a n t D i s o r d e r a t an e a r l i e r age (Lahey e t al.,  1994) .  Conduct D i s o r d e r  Symptoms  There have been no r e s e a r c h s t u d i e s f o r t h c o m i n g t o e m p i r i c a l l y d i s t i n g u i s h between d i f f e r e n t s e v e r i t y l e v e l s w i t h i n Conduct D i s o r d e r . t o assess  Ongoing e x t e n s i v e r e s e a r c h i s needed  the u t i l i t y of a l l p o t e n t i a l d i a g n o s t i c c r i t e r i a f o r  the d i s r u p t i v e b e h a v i o u r d i s o r d e r s .  Lahey e t a l . (1992) c l a i m  75 t h a t t h i s can be done i n three general  ways.  F i r s t , the  c o n d i t i o n a l p r o b a b i l i t y that i f a youth e x h i b i t s symptom X the youth w i l l a l s o e x h i b i t symptom Y may be so h i g h t h a t symptom Y i s redundant and adds l i t t l e o r nothing criteria.  t o the d i a g n o s t i c  Thus, i t may be p o s s i b l e to drop one or more  redundant d i a g n o s t i c c r i t e r i a that s i m p l i f y the d i a g n o s t i c c r i t e r i a without s a c r i f i c i n g d i a g n o s t i c p r e c i s i o n .  Second,  u s i n g a s t r a t e g y developed by Loeber et a l . (1993), the power of each symptom to p r e d i c t the f u l l d i a g n o s i s  can be compared.  This s t r a t e g y may allow the e l i m i n a t i o n o f some symptoms that are not c l e a r l y and s p e c i f i c a l l y a s s o c i a t e d with the diagnosis.  T h i r d , when symptoms are i d e n t i f i e d f o r p o s s i b l e  d e l e t i o n i n these ways, the prevalence, v a l i d i t y o f the d i a g n o s i s  r e l i a b i l i t y , and  can be assessed before  and a f t e r the  d e l e t i o n o f the symptoms to be sure t h a t they have not changed. As mentioned e a r l i e r , previous some o f the more p r e v a l e n t  evidence suggested that  DSM-III and DSM-III-R symptoms o f  conduct d i s o r d e r might more accurate Disorder Therefore,  (CD) than of O p p o s i t i o n a l  symptoms o f Conduct  Defiant Disorder  (ODD).  a new a l t e r n a t i v e f o r the d e f i n i t i o n o f  o p p o s i t i o n a l d e f i a n t d i s o r d e r and conduct d i s o r d e r was  76  presented  i n t h e DSM-IV O p t i o n s Book (APA, 1991) .' I n t h i s  d e f i n i t i o n t h e symptoms o f f i g h t i n g , b u l l y i n g , and l y i n g would be moved from conduct d i s o r d e r t o o p p o s i t i o n a l d e f i a n t disorder.  T h i s o p t i o n was r e j e c t e d on t h e b a s i s o f r e a n a l y s e s -  of e x i s t i n g data s e t s 1993;  ( F r i c k e t a l . , 1994; Loeber, e t a l . ,  Russo, e t a l . , 1994) and symptom u t i l i t y a n a l y s e s  of the  f i e l d t r i a l s sample (APA, 1991) . F r i c k e t a l . ' s (1994) a n a l y s e s  o f CD symptoms i n t h e DSM-  IV r e v e a l e d t h a t t h e two symptoms n o t i n c l u d e d i n DSM-III-R criteria, and  "often b u l l i e s , threatens, or intimidates others"  " o f t e n s t a y s o u t a f t e r dark w i t h o u t p e r m i s s i o n ,  before  beginning  13 y e a r s o f age" were h i g h l y p r e d i c t i v e o f t h e  diagnosis.  T h i s study a l s o i n d i c a t e d t h a t a l t e r i n g t h e  d e f i n i t i o n s o f two symptoms i n c r e a s e d t h e i r e f f i c i e n c y i n p r e d i c t i n g the d i a g n o s i s .  When t h e d e f i n i t i o n o f l y i n g was  a l t e r e d t o i n c l u d e o n l y l y i n g t o "con o t h e r s " b r e a k s promises t o o b t a i n goods o r favours")  ("often l i e s o r and t h e  d e f i n i t i o n o f t r u a n c y was a l t e r e d t o l i m i t i t t o t r u a n c y beginning  b e f o r e age 13, t h e d i a g n o s t i c e f f i c i e n c y o f t h e  symptoms was i n c r e a s e d .  As such, these a l t e r n a t i v e  d e f i n i t i o n s o f " l y i n g " and " t r u a n c y " v e r s i o n s o f these CD symptoms.  r e p l a c e d t h e DSM-III-R  The d e c i s i o n t o l i m i t  77  " t r u a n c y " t o youths i n which t h e t r u a n c y began b e f o r e t h e age o f 13 was made t o a v o i d m i s a t t r i b u t i n g t h i s symptom t o normal a d o l e s c e n t s , i n whom t r u a n c y i s common. changes i n t h e DSM have i n c r e a s e d Conduct D i s o r d e r d i a g n o s i s , changes would a l s o have  Given that  these  the p r e d i c t i v e v a l i d i t y of  one c o u l d  speculate that  these  s i g n i f i c a n t c l i n i c a l relevance i n  terms o f p r e d i c t i n g t r e a t m e n t outcomes f o r j u v e n i l e sex offenders receiving t h i s  diagnosis.  Treatment Outcome There i s wide agreement t h a t j u v e n i l e sex o f f e n d e r s a r e e x t r e m e l y noncompliant and u n m o t i v a t e d toward t r e a t m e n t .  As  such, i t i s commonly f e l t t h a t court-mandated t r e a t m e n t i s necessary.  However, even w i t h t h e p r e s s u r e o f t h e c r i m i n a l  j u s t i c e system many j u v e n i l e sex o f f e n d e r s f a i l t o complete treatment s u c c e s s f u l l y f o r a v a r i e t y of reasons.  F o r example,  s e v e r a l o f these reasons i n c l u d e : unmanageable due t o behavioral  d i s t u r b a n c e ; v i o l a t i o n o f agency r u l e s ; • and/or,  r e o f f e n s e and i n c a r c e r a t i o n .  A l l these reasons r e f l e c t  b e h a v i o u r s found i n conduct d i s o r d e r e d youth.  However, a r e  those j u v e n i l e sex o f f e n d e r s who a r e more r e s i s t a n t t o t r e a t m e n t a d i s c r e e t subtype who a l s o meet t h e c r i t e r i a f o r  78  Conduct D i s o r d e r .  As such, one may s p e c u l a t e t h a t those  i n d i v i d u a l s d i a g n o s e d w i t h Conduct D i s o r d e r would be more noncompliant and as .a r e s u l t more prone t o n o t s u c c e s s f u l l y completing  t r e a t m e n t as compared t o those w i t h a non-conduct  disordered  diagnosis.  For t h i s study,  t r e a t m e n t outcome, was d e t e r m i n e d based  on whether t h e youth s u c c e s s f u l l y o r u n s u c c e s s f u l l y completed the o u t - p a t i e n t t r e a t m e n t program.  T h i s was d e t e r m i n e d from  the c l i n i c a l r e c o r d n o t e s on f i l e t h a t i n c l u d e d a d i s c h a r g e r e p o r t w r i t t e n by t h e p r i m a r y t h e r a p i s t . considered  The youth was  t o have s u c c e s s f u l t r e a t m e n t outcome i f he  completed t h e program and r e c e i v e d b e n e f i t from t h e program. I n a d d i t i o n , t h e youth was c o n s i d e r e d u n s u c c e s s f u l evaluated  as a t h i g h r i s k t o r e o f f e n d based on a p h a l l o m e t r i c  measure o f d e v i a n t a r o u s a l p r i o r t o d i s c h a r g e program.  i f he was  from t h e  I n summary, t h e t r e a t m e n t outcome v a r i a b l e was  d e t e r m i n e d based on c l i n i c a l judgement and t h e p h a l l o m e t r i c measure. P h a l l o m e t r i c assessment.  I n p h a l l o m e t r i c assessment,  changes i n p e n i l e tumescence a r e a s s e s s e d  while the subject i s  exposed t o a v a r i e t y o f s e x u a l and n o n s e x u a l s t i m u l i ( e i t h e r s l i d e s or audiotapes).  Cognitive-behaviorally oriented  79 researchers  have r e l i e d h e a v i l y on p h a l l o m e t r i c assessment o f  s e x u a l i n t e r e s t p a t t e r n s , p o i n t i n g out t h a t s e l f - r e p o r t i s o f t e n d i s t o r t e d and i n c o n s i s t e n t w i t h more o b j e c t i v e measurement (Freund, 1981).  There i s a c o n s i d e r a b l e body of  l i t e r a t u r e on the use of p h a l l o m e t r i c assessment w i t h a d u l t o f f e n d e r s but t h e r e i s sparse juvenile population. molesters  r e s e a r c h on i t s use w i t h a  S t u d i e s have shown t h a t a d u l t  child  can r e l i a b l y be d i f f e r e n t i a t e d from non-sex  o f f e n d e r s based on degree of response t o s t i m u l i d e p i c t i n g c h i l d r e n and t h a t h i g h indexes of d e v i a n t a r o u s a l  are  a s s o c i a t e d w i t h a g r e a t e r l e v e l of s e x u a l o f f e n d i n g more v i c t i m s ) 1985).  (Barbaree & M a r s h a l l , 1989;  I t i s estimated  (i.e.,  E a r l s & Quinsey,  t h a t over 175 j u v e n i l e sex  offender  t r e a t m e n t programs i n the U n i t e d S t a t e s and Canada r e p o r t u s i n g p h a l l o m e t r i c assessment w i t h j u v e n i l e s . , In a d d i t i o n , a c o g n i t i v e - b e h a v i o r a l model i s the most f r e q u e n t l y c i t e d t h e o r e t i c a l o r i e n t a t i o n of c l i n i c i a n s t r e a t i n g t h i s  population  (Knopp, Freeman-Longo, & Stevenson, 1992). Becker, Hunter, Goodwin, K a p l a n , and M a r t i n e z assessed  (1992)  the t e s t - r e t e s t r e l i a b i l i t y of a u d i o t a p e d s t i m u l i  developed s p e c i f i c a l l y f o r an a d o l e s c e n t population.  sexual  offender  Statistically significant test-retest reliability  80 was. demonstrated f o r 15 o f the 19 a u d i o t a p e d  vignettes.  The  h i g h e s t c o r r e l a t i o n s were found f o r those s e x u a l b e h a v i o u r s  in  which the a d o l e s c e n t had engaged, w i t h ' s i g n i f i c a n t c o r r e l a t i o n s r a n g i n g from .48 t o  .83.  Schram, M i l l o y , and Rowe (1991) examined d e v i a n t  sexual  a r o u s a l i n r e l a t i o n s h i p t o r i s k f o r r e c i d i v i s m . These i n v e s t i g a t o r s f o l l o w e d 197 male a d o l e s c e n t s e x u a l o f f e n d e r s average o f 6.8  years f o l l o w i n g c o m p l e t i o n o f t r e a t m e n t .  an  Sexual  r e c i d i v i s t s were found t o be more l i k e l y t o have d e v i a n t s e x u a l a r o u s a l p a t t e r n s as w e l l as a h i s t o r y o f t r u a n c y , c o g n i t i v e d i s t o r t i o n s , and a l e a s t one p r i o r c o n v i c t i o n f o r a sexual offense.  No p h a l l o m e t r i c assessments were used.  I n s t e a d , i n v e s t i g a t o r s r e l i e d on c l i n i c i a n assessments o f d e v i a n t a r o u s a l and response t o  treatment.  Furthermore, e m p i r i c a l support  f o r the r e l i a b i l i t y  and  v a l i d i t y o f p h a l l o m e t r i c assessment o f j u v e n i l e s e x u a l o f f e n d e r s i s growing. j u v e n i l e s may  However, t h e r e i s growing evidence  be more g l o b a l i n t h e i r s e x u a l i n t e r e s t  that  and  a r o u s a l p a t t e r n s than a d u l t o f f e n d e r s , and t h a t p h a l l o m e t r i c d a t a s h o u l d not be i n t e r p r e t e d i n a manner p a r a l l e l t o t h a t o f adult offenders  (Hunter  Methodological  & Becker,  Issues.  1994).  The u t i l i t y o f the  clinical  81 i n t e r v i e w and p s y c h o l o g i c a l t e s t s i n the e v a l u a t i o n j u v e n i l e sex o f f e n d e r s & Becker, 1994). supportive  of  appears t o be w e l l e s t a b l i s h e d  (Hunter  A l t h o u g h some s t u d i e s have not been  (eg. Hanson, S t e f f y , & G a u t h i e r ,  Quinsey, & H a r r i s , 1991)  1993;  Rice,  of programs (such as the one  in this  study) of a multicomponent, c o g n i t i v e - b e h a v i o r a l n a t u r e , have produced p r o m i s i n g molesters  results, e s p e c i a l l y with  (see M a r s h a l l & Barbaree, 1990).  many  child  I t i s important to  note t h a t some of these s t u d i e s used more s o p h i s t i c a t e d e v a l u a t i o n methods, u s i n g d e s i g n s t h a t i n c l u d e comparison groups, adequate f o l l o w - u p p e r i o d s , and m u l t i p l e outcome measures. Marques, Day, methodological sex o f f e n d e r s Weinrott,  N e l s o n , & West (1994) i d e n t i f y i m p o r t a n t  r e q u i r e m e n t s f o r sound outcome r e s e a r c h based on s e v e r a l p r e v i o u s  and Blackshaw, 1989;  studies  Grossman, 1985).  with  (eg. Furby, These  r e q u i r e m e n t s i n c l u d e comparison groups, r e c i d i v i s m measures, attrition, One  c l i n i c a l judgement and  s t a t i s t i c a l methods.  of the most d i f f i c u l t o b s t a c l e s i n e v a l u a t i n g  t r e a t m e n t programs f o r sex o f f e n d e r s  i s o b t a i n i n g an adequate  comparison or c o n t r o l group. I t i s v i r t u a l l y i m p o s s i b l e t r u l y determine how  e f f e c t i v e treatment i s without a  to  82 comparison group o f s i m i l a r o f f e n d e r s who intervention.  d i d not r e c e i v e the  An i d e a l comparison group would be  similar  o f f e n d e r s randomly a s s i g n e d t o an u n t r e a t e d c o n t r o l group (Furby e t a l . ,  1989;  M a r s h a l l & Barbaree,  1990).  I t has been  argued t h a t such d e s i g n s are u n e t h i c a l because t h e y r e q u i r e w i t h h o l d i n g treatment need t h e r a p y 1990;  (Becker & Hunter, 1992;  M a r s h a l l et a l . , Although  treatment  from o f f e n d e r s who  may  d e s i r e and/or  Marshall &  Barbaree,  1991).  t h e r e i s no consensus on the b e s t c r i t e r i o n f o r  f a i l u r e , most r e s e a r c h e r s use the recommission o f a  sex o f f e n s e  (e.g., M a r s h a l l & Barbaree,  (e.g., R i c e e t a l . , persons as w e l l .  1991)  1988), w i t h some  c o n s i d e r i n g o t h e r crimes  against  However, t h e r e i s a l s o c o n s i d e r a b l e  v a r i a b i l i t y a c r o s s s t u d i e s r e g a r d i n g the use o f o f f i c i a l (such as r e c o r d s o f a r r e s t or c o n v i c t i o n s ) and  data  unofficial  i n f o r m a t i o n (such as s e l f - r e p o r t s ) . O f f i c i a l l y r e p o r t e d numbers o f sex o f f e n s e s are w i d e l y r e c o g n i z e d t o be gross u n d e r e s t i m a t e s  of the t r u e number o f  crimes t h a t have been committed (Repucci & C l i n g e m p e e l , R u s s e l l , 1982).  1978;  Marques e t a l . (1994) s t a t e t h a t the types  l e g a l charges and c o n v i c t i o n s t h a t are r e c o r d e d are a r e s u l t not o n l y o f the a c t s committed but a l s o o f the p o l i c i e s  and  of  83 p r a c t i c e s o f l o c a l law enforcement, p r o s e c u t o r s , and c o u r t s . S e l f - r e p o r t s by sex o f f e n d e r s are c o n s i d e r e d  very  u n r e l i a b l e g i v e n t h e i r h i g h degree o f d e n i a l and m i n i m i z a t i o n of t h e i r o f f e n d i n g behaviours.  However, when a b s o l u t e  c o n f i d e n t i a l i t y i s p r o v i d e d , o f f e n d e r s e l f - r e p o r t s have r e v e a l e d l a r g e numbers o f crimes t h a t have not r e s u l t e d i n arrest  (Abel e t a l . ,  1987;  Weinrott  & S a y l o r , 1991).  In terms o f a t t r i t i o n , r a t e s o f treatment  withdrawal  and  t e r m i n a t i o n v a r y w i d e l y depending on a number o f f a c t o r s (eg. o f f e n d e r m o t i v a t i o n , program r e q u i r e m e n t s , consequences).  legal  I n some s t u d i e s (Maletzky, 1991), i n c l u d i n g  t h i s study, any o f f e n d e r who considered unsuccessful. treatment  dropouts  Barbaree,  1990).  d i d not complete treatment  However, o t h e r s t u d i e s have  (e.g., A b e l e t a l . ,  1988;  was excluded  Marshall &  In A b e l et a l . ' s (1988) case, a t t r i t i o n  was  indeed a s i g n i f i c a n t f a c t o r , w i t h n e a r l y 35% o f those e n t e r i n g the program f a i l i n g t o complete i t . In terms o f c l i n i c a l judgement, Foa and Emmelkamp (1983) s t a t e t h a t a treatment  program's v a l u e i s measured not o n l y by  the success o f those who who  complete i t but a l s o by the number  r e f u s e the i n t e r v e n t i o n s or drop out a f t e r  treatment.  I n e v a l u a t i n g treatment  beginning  outcomes, schemes must be  84 d e v i s e d t o account f o r these o f f e n d e r s and determine t h e i r success and  f a i l u r e r a t e s as w e l l .  T h i s study accounted f o r  t r e a t m e n t dropouts and f a i l u r e s and i n c l u d e d them as unsuccessful  subjects.  W i t h r e s p e c t t o s t a t i s t i c a l methods, the u s e f u l n e s s  of  l i n e a r r e g r e s s i o n methods i s l i m i t e d , because the outcome t o be p r e d i c t e d i s o f t e n a b i n a r y v a r i a b l e , r e o f f e n s e , which r e q u i r e s the use of n o n l i n e a r models ( A l d r i c h & N e l s o n , 1984). The  e v a l u a t i o n of t r e a t m e n t e f f e c t i v e n e s s w i t h sex  offenders  r e q u i r e s the most r i g o r o u s and comprehensive r e s e a r c h  designs  possible. A l t h o u g h t h i s study s u f f e r e d from a l a c k of comparison groups, r e c i d i v i s m data and a n a l y t i c methods t h a t c o n t r o l f o r discrepant a t - r i s k periods, i t did include a t t r i t i o n factors, c l i n i c a l judgement and s t a t i s t i c a l measures.  Research Purpose and The  Hypotheses  o v e r a l l purpose of t h i s t h e s i s i s t o examine the  a s s o c i a t i o n between the p s y c h i a t r i c d i a g n o s i s of Conduct D i s o r d e r t r e a t m e n t outcomes of j u v e n i l e sex o f f e n d e r s . uniqueness of t h i s study l i e s w i t h the f a c t t h a t t h i s  The  85 d i a g n o s i s has never been e v a l u a t e d w i t h t h i s p o p u l a t i o n i n terms of t r e a t m e n t outcomes.  However, as mentioned  p r e v i o u s l y , t h e r e are c e r t a i n  limitations  t o the  c l a s s i f i c a t i o n s system and d i a g n o s t i c p r o c e s s , with this  DSM  particularly  population.  Notwithstanding  these l i m i t a t i o n s ,  t h i s study attempts t o  demonstrate t h a t j u v e n i l e sex o f f e n d e r s d i a g n o s e d w i t h Conduct Disorder  ( a c c o r d i n g t o DSM-III-R c r i t e r i a ) have a h i g h e r  probability  of u n s u c c e s s f u l  t r e a t m e n t outcome and those not  d i a g n o s e d w i t h Conduct D i s o r d e r are more l i k e l y demonstrate s u c c e s s f u l t r e a t m e n t outcome i n an o u t - p a t i e n t t r e a t m e n t program.  L i n k t o Hypotheses As mentioned p r e v i o u s l y , the DSM essential  states that  "the  f e a t u r e of Conduct D i s o r d e r i s a r e p e t i t i v e  and  p e r s i s t e n t p a t t e r n of b e h a v i o u r i n which the b a s i c r i g h t s o t h e r s or major a g e - a p p r o p r i a t e violated"  (APA,  1994,  p. 85).  of  s o c i e t a l norms o r r u l e s are Given t h i s e s s e n t i a l  feature  f o r d i a g n o s i s , one would f i n d i t d i f f i c u l t not t o argue t h a t a l l j u v e n i l e sex o f f e n d e r s  are conduct d i s o r d e r e d .  However,  the c l i n i c i a n must determine i f the s e x u a l m i s b e h a v i o u r i s a  •86 one time event, o r "a r e p e t i t i v e and p e r s i s t e n t p a t t e r n " .  A  d i f f i c u l t t a s k i n a p o p u l a t i o n renowned f o r i t ' s h i g h degree o f d e n i a l and m i n i m i z a t i o n . Through t h e e x a m i n a t i o n o f r e c o r d s o f d e l i n q u e n c y and/or through t h e diagnoses  o f Conduct D i s o r d e r based on p s y c h i a t r i c  assessment, s t u d i e s have attempted nonsexual  to e s t a b l i s h the rates of  d i s t u r b a n c e s o f conduct i n j u v e n i l e sex o f f e n d e r s  w i t h a view o f d i a g n o s i n g them as Conduct D i s o r d e r e d . Kaplan, Cunningham-Rathner, and K a v o u s s i  Becker,  (1986) found t h a t 50%  o f t h e i r sample o f j u v e n i l e male p e r p e t r a t o r s had a r e c o r d o f p r e v i o u s non-sexual  a r r e s t s , and t h a t 63% o f those  f o r p s y c h i a t r i c assessment c o u l d be diagnosed Disordered.  T h i s r a t e o f nonsexual  available  as Conduct  a r r e s t s i s h i g h e r than t h e  s e l f - r e p o r t e d r a t e (28%) among a more v a r i e d group o f j u v e n i l e sex o f f e n d e r s s t u d i e d by Becker e t a l . (1986), b u t i s s i m i l a r t o f i g u r e s f o r non-sexual  delinquencies reported i n other  samples o f j u v e n i l e sex o f f e n d e r s  (Awad & Saunders, 1989;  Awad, Saunders, & Levene, 1984; Fehrenbach, Monastersky, 1988;  & Deishner,  Smith,  1986; K a v o u s s i , Kaplan,  P i e r c e & P i e r c e , 1987).  & Becker,  A d u l t sex o f f e n d e r s who were  diagnosed w i t h A n t i s o c i a l P e r s o n a l i t y D i s o r d e r ( c o n s i d e r e d t h e a d u l t c o u n t e r p a r t o f Conduct D i s o r d e r )  i n conjunction with  87 t h e i r s e x u a l l y a b u s i v e b e h a v i o u r s were more l i k e l y t o r e o f f e n d b o t h s e x u a l l y and n o n s e x u a l l y Rosenberg, & S c h n e i d e r , P r o c t o r , 1986;  (Bard, C a r t e r , Cerce,  1987;  H a l l , Mauiro, V i t a l i a n o , &  Henn, J e r j a n i c , & V a n d e r p e a r l ,  1976).  Moreover, s t u d i e s i n d i c a t e t h a t those o f f e n d e r s who complete treatment or nonsexually  Knight,  fail  to  are more l i k e l y t o r e o f f e n d e i t h e r s e x u a l l y  ( A b e l , M i t t l e m a n , & Becker,  Jones, Ward, Johnston,  & Barbaree,  1991).  1985; M a r s h a l l , Thus, i t would make  sense t o s p e c u l a t e from these s t u d i e s t h a t youth w i t h Conduct D i s o r d e r would have poor treatment  diagnosed outcomes.  However, g i v e n the q u e s t i o n a b l e r e l i a b i l i t y and v a l i d i t y o f the DSM  p r o c e s s i n g e n e r a l ; and more s p e c i f i c a l l y ,  instability  the  and c o n t i n u a l l y changing d i a g n o s t i c c r i t e r i a  and  the d e b a t a b l e a p p l i c a t i o n o f the Conduct D i s o r d e r d i a g n o s t i c p r o c e s s , does t h i s p a r t i c u l a r d i a g n o s i s have c l i n i c a l relevance' i n the assessment and treatment o f j u v e n i l e offenders. 1987)  Conduct D i s o r d e r d i a g n o s i s i n the DSM-III-R  l a c k s p r e c i s i o n and the presence  diagnostic behavioral c r i t e r i a , may  sex  of r a t h e r " s o f t "  such as " l y i n g " and  c r e a t e the o v e r - d i a g n o s i s o f youth who  sexual offending.  (APA,  "truancy"  are. c o n v i c t e d o f  On the o t h e r hand, i s i t p o s s i b l e t h a t  assessment and treatment  f o r m u l a t i o n s f o r Conduct D i s o r d e r has  88 u s e f u l e x p l a n a t o r y power f o r at l e a s t some t y p e s o f sex  juvenile  offending. France and Hudson (1993) suggest t h a t a s i g n i f i c a n t  number of j u v e n i l e sex o f f e n d e r s engage i n o t h e r c r i m i n a l or may  be d i a g n o s e d as conduct d i s o r d e r e d and  c o e x i s t e n c e of d i s t u r b a n c e s o f conduct and offending  may  be  reoffending.  that  juvenile  few  and  the sex  s i g n i f i c a n t f o r p r e d i c t i n g r i s k of  However, s t u d i e s  on the importance of Conduct  D i s o r d e r as a p r o g n o s t i c i n d i c a t o r i n j u v e n i l e sex are  acts  show c o n f l i c t i n g r e s u l t s .  MacKenzie (1988) s t a t e d t h a t 50% t r e a t m e n t program, who  had  p r i o r to the sex o f f e n s e ,  offending  Henderson, E n g l i s h ,  and  of the youths i n t h e i r  victim related criminal histories continued to e x h i b i t  a s s a u l t i v e behaviour a f t e r treatment.  sexually  However, Smith  and  M o n a s t e r s k y (1986) found o n l y a s l i g h t t r e n d between a h i s t o r y of a g g r e s s i v e and  d e s t r u c t i v e b e h a v i o u r and  the l i k e l i h o o d of  reoffense. At t h i s w r i t i n g , t h e r e appears to be o n l y one compares the d i f f e r e n t i a t i n g c h a r a c t e r i s t i c s of o f f e n d e r s who  subjective  treatment.  that  juvenile  s u c c e s s f u l l y complete t r e a t m e n t t o those  f a i l t o complete and  study  sex  who  Based on c l i n i c i a n assessment  judgment, Joseph Randazzo (1992) found t h a t  89 o f f e n d e r s who s e l e c t e d v i c t i m s near i n age t o themselves, blamed t h e i r a c t s on a l c o h o l and/or drugs and who  had s c h o o l  t r u a n c y problems were d i s t i n g u i s h e d as b e i n g a t h i g h e s t o f treatment  drop-out o r f a i l u r e .  (1992) suggests  who  risk  Furthermore, Randazzo  t h a t non-completers were p e r c e i v e d by t h e i r  t h e r a p i s t s t o be more a g g r e s s i v e , more a n t i - s o c i a l , and more dangerous than o t h e r s u b j e c t s .  T h i s suggests  j u v e n i l e sex o f f e n d e r s who f a i l e d t o complete d i s p l a y e d many o f t h e b e h a v i o u r s  that  those  treatment  found i n Conduct D i s o r d e r and  may have been so diagnosed. Given t h e p r e v i o u s r a t i o n a l e , s p e c i f i c hypotheses r e g a r d i n g treatment  outcome a r e s t a t e d as f o l l o w s :  1) J u v e n i l e sex o f f e n d e r s who have been g i v e n a p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r w i l l have l e s s s u c c e s s f u l treatment  outcomes.  2) J u v e n i l e sex o f f e n d e r s who meet t h e c r i t e r i a  according  t o t h e DSM-III-R c l a s s i f i c a t i o n o f Conduct D i s o r d e r w i l l have l e s s s u c c e s s f u l treatment  outcomes.  3) The p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r i s a s s o c i a t e d w i t h an a l t e r n a t e c l a s s i f i c a t i o n made a c c o r d i n g t o the  DSM-III-R c r i t e r i a .  T h i s h y p o t h e s i s was t e s t e d t o  determine i f t h e s u b j e c t s d i d indeed meet t h e f u l l  criteria  90  f o r Conduct D i s o r d e r . t e s t whether 4)  I n a d d i t i o n , t h i s h y p o t h e s i s sought t o  these youth were b e i n g  over-diagnosed.  Conduct D i s o r d e r symptoms a r e a s s o c i a t e d w i t h  s u c c e s s f u l treatment  outcome.  As mentioned p r e v i o u s l y ,  s t u d i e s have shown t h a t s i n g l e Conduct D i s o r d e r 'symptoms such as " l y i n g " have p r e d i c t i v e v a l i d i t y f o r t h e d i a g n o s i s .  This  hypotheses was t e s t e d t o determine i f s i n g l e Conduct D i s o r d e r behaviours  a r e a s s o c i a t e d w i t h u n s u c c e s s f u l treatment  5) A d o l e s c e n t  sex o f f e n d e r s w i t h p r e v i o u s  outcome.  non-sexual  o f f e n s e s w i l l be l e s s l i k e l y t o s u c c e s s f u l l y complete treatment. 6). A d o l e s c e n t  sex o f f e n d e r s w i t h p r e v i o u s  non-sexual  o f f e n s e s a r e more l i k e l y t o be g i v e n a p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r . 7)  Adolescent  sex o f f e n d e r s w i t h p r e v i o u s  non-sexual  o f f e n s e s a r e more l i k e l y t o meet t h e f u l l DSM-III-R for  a d i a g n o s i s o f Conduct D i s o r d e r .  criteria  91 CHAPTER THREE RESEARCH DESIGN  Introduction Using a d e s c r i p t i v e / a s s o c i a t i v e design, t h i s  study  examined t h e c l i n i c a l r e c o r d s o f j u v e n i l e sex o f f e n d e r s t o determine  i f those diagnosed w i t h Conduct D i s o r d e r were more  l i k e l y t o be u n s u c c e s s f u l a t c o m p l e t i n g treatment who were n o t diagnosed w i t h Conduct D i s o r d e r . measure was t h e treatment  then  The outcome  completion status i n a court-  mandated o u t - p a t i e n t j u v e n i l e sex o f f e n d e r treatment as determined  those  and r e c o r d e d by t h e p r i m a r y c l i n i c i a n .  program The  p r i m a r y c l i n i c i a n was e i t h e r a p s y c h i a t r i s t , a p s y c h o l o g i s t , a s o c i a l worker o r a p s y c h i a t r i c nurse who was i n charge o f t h a t p a r t i c u l a r s u b j e c t ' s case. determined  The d i s c h a r g e s t a t u s was  from m u l t i d i s c i p l i n a r y treatment  team r e v i e w o f t h e  subject's progress. In a d d i t i o n , I attempted  t o p r o v i d e an a l t e r n a t e  d i a g n o s t i c c l a s s i f i c a t i o n o f each s u b j e c t , independent o f t h e p s y c h i a t r i c d i a g n o s i s g i v e n on t h e c l i n i c a l r e c o r d , i n an e f f o r t t o determine  i f t h e s u b j e c t d i d i n d e e d meet t h e f u l l  d i a g n o s t i c c r i t e r i a a c c o r d i n g t o t h e DSM-III-R  (APA, 1987).  92  Method Subjects C l i n i c a l r e c o r d s of one hundred a d o l e s c e n t males, aged 12-18  a t the time of a d m i s s i o n ,  who  had completed a c o u r t -  o r d e r e d p s y c h o s o c i a l assessment and were a d m i t t e d t o the Adolescent  Sex Offender  Treatment Program a t Youth Court  S e r v i c e s / O u t p a t i e n t Department, Burnaby, B.C.  were p i c k e d  randomly from the time frame between January 1, 198 8 December 31,  1992.  Mean s u b j e c t age was was  12 and the o l d e s t was  15 y e a r s , the youngest i n the sample 18.  Twenty-four p e r c e n t of the  s u b j e c t s had a grade 7 e d u c a t i o n or l e s s , grade 8 and 10, whereas 13 p e r c e n t higher.  and  Seventy-three  63% had between  a c h i e v e d grade 11 or  p e r c e n t of the s u b j e c t s had  Caucasian  e t h n i c background, 23% were of F i r s t N a t i o n s h e r i t a g e , and were c o n s i d e r e d o t h e r .  4%  A t the time of the o f f e n s e 41% of the  s u b j e c t s l i v e d w i t h t h e i r n a t u r a l mother and her p a r t n e r , l i v e d w i t h t h e i r n a t u r a l mother and n a t u r a l f a t h e r , 9%  8%  lived  w i t h t h e i r n a t u r a l f a t h e r and h i s p a r t n e r , 5% l i v e d w i t h a d u l t relatives,  7% l i v e d w i t h a d o p t i v e p a r e n t s , and 30% l i v e d w i t h  f o s t e r p a r e n t s or i n a group home.  93  Measures Diagnostic variable.  The d i a g n o s t i c  (independent)  v a r i a b l e was measured by t h e c l i n i c a l d i a g n o s i s by t h e a s s e s s i n g p r o f e s s i o n a l  (PCD) p r o v i d e d  expert  ( p s y c h i a t r i s t / p s y c h o l o g i s t ) on t h e w r i t t e n r e p o r t t o c o u r t . T h i s d i a g n o s i s was made a f t e r a thorough m u l t i d i s c i p l i n a r y assessment was completed by a p s y c h i a t r i s t , a p s y c h o l o g i s t , a c l i n i c a l s o c i a l worker and a p s y c h i a t r i c n u r s e .  This  assessment i n c l u d e s : a face t o face p s y c h i a t r i c i n t e r v i e w w i t h the youth; a f u l l b a t t e r y o f p s y c h o l o g i c a l t e s t s and an extensive  s o c i a l h i s t o r y t h a t i n c l u d e s an i n t e r v i e w w i t h t h e  young person's care g i v e r s , s o c i a l workers, probation  teachers,  o f f i c e r s , extended f a m i l y and any o t h e r  significant  p e o p l e w i t h i n h i s s o c i a l environment. A l t e r n a t e d i a g n o s t i c v a r i a b l e (ACD).  This v a r i a b l e  was  measured i n d e p e n d e n t l y by t h i s r e s e a r c h e r  t o assess i f the  s u b j e c t d i d i n d e e d meet t h e f u l l c r i t e r i a  according  DSM-III-R C l a s s i f i c a t i o n Manual (APA, 1987). were a n a l y z e d  to the  Clinical  and coded t o ensure t h a t t h e c l i n i c a l  on r e c o r d met t h e minimum 3 b e h a v i o r a l c r i t e r i a  records  diagnosis  necessary  94 w i t h i n t h e minimum 6 months time frame.  The 13 b e h a v i o r a l  symptoms o f Conduct D i s o r d e r i n c l u d e d t h e f o l l o w i n g i t e m s : . (1) has s t o l e n w i t h o u t more than one o c c a s i o n  c o n f r o n t a t i o n o f a v i c t i m on ( i n c l u d i n g forgery)  (2) has r u n away from home o v e r n i g h t  at l e a s t twice  while l i v i n g i n parental or parental  surrogate  home (3) o f t e n l i e s  (other than t o a v o i d p h y s i c a l o r s e x u a l  abuse) (4) has d e l i b e r a t e l y engaged i n f i r e - s e t t i n g (5) i s o f t e n t r u a n t from s c h o o l (6) has broken i n t o someone e l s e ' s house, b u i l d i n g , o r car (7) has d e l i b e r a t e l y d e s t r o y e d  others'  property  (8) has been p h y s i c a l l y c r u e l t o a n i m a l s (9) has f o r c e d someone i n t o s e x u a l a c t i v i t y w i t h him or h e r (10) has used a weapon i n more t h a n one f i g h t (11) o f t e n i n i t i a t e s p h y s i c a l f i g h t s (12) has s t o l e n w i t h c o n f r o n t a t i o n o f a v i c t i m (13) has been p h y s i c a l l y c r u e l t o p e o p l e . (APA,  1987, p. 58)  95  I f the c l i n i c a l r e c o r d s i n d i c a t e d t h a t the s u b j e c t  met  the minimum 3 c r i t e r i a i n the minimum 6 month time frame he was  g i v e n an A l t e r n a t e Conduct D i s o r d e r  However, i f he met  (ACD)  classification.  l e s s than 3 c r i t e r i a he was  A l t e r n a t e Non-conduct D i s o r d e r  given  an  (AN-CD) c l a s s i f i c a t i o n .  Then,  a comparison was made between the two d i a g n o s t i c v a r i a b l e s : A l t e r n a t e Conduct D i s o r d e r Disorder  (PCD).  v a r i a b l e was  (ACD)and P s y c h i a t r i c Conduct  The a l t e r n a t e conduct d i s o r d e r d i a g n o s i s  then recoded t o i n c l u d e the dichotomous v a r i a b l e :  a l t e r n a t e conduct d i s o r d e r (ACD); o r , a l t e r n a t e non-conduct disorder  (AN-CD).  Conduct D i s o r d e r symptom v a r i a b l e .  A yes/no response  was  g i v e n f o r each o f the 13 b e h a v i o r a l symptoms o f Conduct D i s o r d e r a c c o r d i n g t o the d a t a on f i l e .  Furthermore, each o f  these items had t o meet the DSM-III-R c r i t e r i a i n terms o f the 6 month time  frame.  P r e v i o u s non-sexual  o f f e n s e v a r i a b l e . The p r e v i o u s non-  s e x u a l o f f e n s e v a r i a b l e was  d e t e r m i n e d from the c l i n i c a l  r e c o r d s which r e p o r t a l l p r i o r c r i m i n a l charges c o n v i c t i o n s o f a s e x u a l or non-sexual Treatment outcome v a r i a b l e .  and  nature.  The t r e a t m e n t  completion  (dependent) v a r i a b l e was measured a c c o r d i n g t o the c l i n i c a l  96  r e c o r d s on f i l e r e c o r d e d by t h e p r i m a r y t h e r a p i s t s i n charge o f t h e s u b j e c t ' s case.  T h i s v a r i a b l e was coded i n t o ' f o u r  c a t e g o r i e s o f c o m p l e t i o n s t a t u s t h a t i n c l u d e d : t e r m i n a t e d due t o noncompliance  w i t h program r u l e s and/or c r i m i n a l  p r o b a t i o n ended and d e c l i n e d f u r t h e r t r e a t m e n t ;  charges;  completed  program s u c c e s s f u l l y ; and, completed program u n s u c c e s s f u l l y . The t r e a t m e n t c o m p l e t i o n v a r i a b l e was then recoded t o i n c l u d e the dichotomous c a t e g o r i e s : (1) t e r m i n a t e d due t o noncompliance  w i t h program r u l e s and/or c r i m i n a l charges, and  completed program u n s u c c e s s f u l l y ; o r , (2) s u c c e s s f u l l y completed program.  A d i f f e r e n t i a t i o n was made between those  youth who s i m p l y completed t r e a t m e n t and those who were considered s u c c e s s f u l treatment completers.  That i s , many  j u v e n i l e sex o f f e n d e r s complete t r e a t m e n t , b u t were c o n s i d e r e d t o be o f h i g h r i s k t o r e o f f e n d .  still  Therefore,  t r e a t m e n t c o m p l e t i o n may be more t h e r e s u l t o f a c o m b i n a t i o n o f p r e s s u r e from t h e c r i m i n a l j u s t i c e system and o t h e r s u p e r v i s o r y s u p p o r t s and t h e degree o f compliance i n t h e individual offender.  The s u b j e c t was determined  successful,  i f t h e d i s c h a r g e r e p o r t i n d i c a t e d t h a t he r e c e i v e d maximum b e n e f i t from t h e program and was c o n s i d e r e d a t low r i s k t o reoffend.  The s u b j e c t was determined u n s u c c e s s f u l i f he had  97 zero t o m i n i m a l b e n e f i t from the program and was  considered at  moderate t o h i g h r i s k t o r e o f f e n d a f t e r c o m p l e t i o n o f the program.  Reliability  and  Validity  I n t e r r a t e r r e l i a b i l i t y o f the p r e v i o u s non-sexual  offense  v a r i a b l e , the treatment outcome v a r i a b l e and the 13 Conduct D i s o r d e r symptom v a r i a b l e s was performed by the r e s e a r c h e r a Master o f S o c i a l Work s t u d e n t a t Youth Court S e r v i c e s was  and  who  i n s t r u c t e d on the c o d i n g o f v a r i a b l e s and r a t i n g ;  procedures. sample.  Twelve cases were p i c k e d randomly from the  total,  The degree o f agreement on a l l 15 v a r i a b l e s o f 12  r a t i n g s between the two r a t e r s was  93%.  V a l i d i t y was measured a c c o r d i n g t o the DSM-III-R c l a s s i f i c a t i o n manual c r i t e r i a c l i n i c a l notes on f i l e .  and the e x t e n s i v e p r o f e s s i o n a l  As p a r t o f the i n t e r r a t e r  measure, f o r the a l t e r n a t e d i a g n o s i s (ACD) notes were a n a l y z e d t o determine Disorder c r i t e r i a  were met.  reliability  the c o n t e n t s o f the  which o f the 13 Conduct  Of the 12 c l i n i c a l r e c o r d s p i c k e d  randomly and a n a l y z e d , i n t e r r a t e r r e l i a b i l i t y on these  13  items showed a 94% degree o f agreement between the two  raters.  98  V a l i d i t y o f t h e P s y c h i a t r i c D i a g n o s i s was augmented by m u l t i p l e sources  o f i n f o r m a t i o n gathered by v a r i o u s members o f  the m u l t i - d i s c i p l i n a r y c l i n i c a l team. and/or p s y c h i a t r i c nurse gathered  The s o c i a l worker  i n f o r m a t i o n from t h e f a m i l y ,  t e a c h e r s , p r o b a t i o n o f f i c e r s and o t h e r s i g n i f i c a n t  people,  based on q u e s t i o n s d i r e c t l y r e l a t e d t o t h e presence o r absence of t h e Conduct D i s o r d e r c r i t e r i a .  The p s y c h i a t r i s t  assessed  the youth based on a one-to-one p s y c h i a t r i c i n t e r v i e w and s u b j e c t s e l f r e p o r t s o f t h e presence o r absence o f t h e Conduct Disorder behavioral c r i t e r i a .  The p s y c h o l o g i c a l assessment  was based on f u l l b a t t e r y o f p s y c h o m e t r i c to-one p s y c h o l o g i c a l assessment.  t e s t i n g and a one-  These members t h e n  c o l l a b o r a t e d t o determine DSM-III-R d i a g n o s t i c c l a s s i f i c a t i o n . However, t h e p s y c h i a t r i s t , g i v e n h i s / h e r m e d i c a l p r o f e s s i o n a l s t a t u s , would have f i n a l d e t e r m i n a t i o n t o make t h e d i a g n o s i s . V a l i d i t y o f outcome measures was o b t a i n e d by a s i m i l a r c o l l a b o r a t i v e process discharge  t o determine treatment  from t h e program.  The p r i m a r y  s t a t u s upon  t h e r a p i s t would t h e n  complete a s t a n d a r d i z e d d i s c h a r g e r e p o r t i n d i c a t i n g t h e subject's progress  i n treatment  and treatment  completion  s t a t u s based on b e n e f i t r e c e i v e d , degree o f d e v i a n t a r o u s a l , a b i l i t y t o suppress d e v i a n t a r o u s a l , and subsequent r i s k t o  99  reoffend.  Data A n a l y s i s Hypothesis  1.  To t e s t the h y p o t h e s i s  that i n a  p o p u l a t i o n o f j u v e n i l e sex o f f e n d e r s a p s y c h i a t r i c d i a g n o s i s of Conduct D i s o r d e r i s a s s o c i a t e d w i t h outcome o f o u t - p a t i e n t treatment,  a c h i - s q u a r e and P h i were computed between these  two v a r i a b l e s . Hypothesis  2.  To t e s t t h e h y p o t h e s i s  that i n a  p o p u l a t i o n o f j u v e n i l e sex o f f e n d e r s an a l t e r n a t e conduct disorder diagnosis  (ACD) i s a s s o c i a t e d w i t h outcome o f o u t -  p a t i e n t treatment,  a Chi-square  and P h i were computed between  these two v a r i a b l e s . Hypothesis  3.  To t e s t t h e h y p o t h e s i s  that i n a  p o p u l a t i o n o f j u v e n i l e sex o f f e n d e r s a p s y c h i a t r i c d i a g n o s i s of Conduct D i s o r d e r  (PCD) i s a s s o c i a t e d w i t h an a l t e r n a t e  Conduct D i s o r d e r c l a s s i f i c a t i o n  (ACD) a C h i - s q u a r e  and P h i  were computed between these two v a r i a b l e s . Hypothesis  4.  To t e s t the h y p o t h e s i s  Conduct D i s o r d e r b e h a v i o u r s outcome a Chi-square variables.  that a single  i s associated with  treatment  and P h i were computed between these  two  100  Hypothesis  5.  To t e s t the h y p o t h e s i s t h a t p r e v i o u s non-  s e x u a l o f f e n s e s a r e a s s o c i a t e d w i t h t r e a t m e n t outcome i n a p o p u l a t i o n o f j u v e n i l e sex o f f e n d e r s i n o u t - p a t i e n t t r e a t m e n t , a C h i - s q u r e and P h i were computed between these two v a r i a b l e s . Hypothesis  6.  A C h i - s q u r e and P h i were computed t o  measure a s s o c i a t i o n between p r e v i o u s non-sexual p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r Hypothesis  7.  A Chi-square  and  (PCD).  and P h i were computed t o  measure a s s o c i a t i o n between p r e v i o u s non-sexual A l t e r n a t e Conduct D i s o r d e r c l a s s i f i c a t i o n  (ACD).  o f f e n s e s and  101 CHAPTER FOUR RESULTS  Treatment Outcome P s y c h i a t r i c Conduct D i s o r d e r Hypothesis  1.  (PCD)  In the present  sample o f j u v e n i l e sex  o f f e n d e r s 50% o f s u b j e c t s were d i a g n o s e d d i s o r d e r e d by t h e p s y c h i a t r i s t  (PCD).  as conduct  Tabulations o f data  r e v e a l e d t h a t 45% p e r c e n t o f s u b j e c t s had s u c c e s s f u l outcome.  treatment  I n a s s e s s i n g whether t h e r e was an a s s o c i a t i o n  between PCD and s u c c e s s f u l treatment  outcome a n e g a t i v e  %  c o r r e l a t i o n was observed,  [X = 37.1, P h i = -.38, p <  .001],  P s y c h i a t r i c non-conduct d i s o r d e r (PN-CD) a d o l e s c e n t sex offenders  (71%) were s i g n i f i c a n t l y more l i k e l y t o have  s u c c e s s f u l treatment  outcome than n o t (29%).  p s y c h i a t r i c conduct d i s o r d e r (PCD) s u b j e c t s l i k e l y t o have u n s u c c e s s f u l treatment  In contrast, (67%) were more  outcome t h a t n o t (33%).  Table 1 p r o v i d e s f u r t h e r r e s u l t s o f t h e d i s t r i b u t i o n s o f s u c c e s s f u l and u n s u c c e s s f u l outcomes w i t h o r w i t h o u t a p s y c h i a t r i c conduct d i s o r d e r d i a g n o s i s  (PCD).  102 A l t e r n a t e Conduct D i s o r d e r H y p o t h e s i s 2.  (ACD)  From t h e t o t a l sample o f 100, a h i g h e r  p e r c e n t a g e (68%) o f s u b j e c t s were g i v e n an a l t e r n a t e conduct disorder diagnosis  (ACD) when d i a g n o s i s was dependent upon t h e  DSM-III-R c r i t e r i a as compared t o 50% f o r t h e p s y c h i a t r i c conduct d i s o r d e r d i a g n o s i s  (PCD).  A negative  a s s o c i a t i o n was  o b s e r v e d between a l t e r n a t e conduct d i s o r d e r d i a g n o s i s and  (ACD)  s u c c e s s f u l t r e a t m e n t outcome, [X = 37.0, P h i = -.59, p <  .001],  S i m i l a r l y , a l t e r n a t e non-conduct d i s o r d e r d i a g n o s e d  (AC-ND) j u v e n i l e sex o f f e n d e r s  (88%) were s i g n i f i c a n t l y more  l i k e l y t o have s u c c e s s f u l t r e a t m e n t outcome than not. c o n t r a s t , a l t e r n a t e conduct d i s o r d e r d i a g n o s i s  In  (ACD) s u b j e c t s  were s i g n i f i c a n t l y more l i k e l y t o have u n s u c c e s s f u l  treatment  outcome (75%) than n o t (25%) (see t h e bottom h a l f o f Table 1 f o r f u l l r e s u l t s o f these d i s t r i b u t i o n s ) .  103 Table 1  /  Percentages o f Conduct D i s o r d e r e d and Non-conduct D i s o r d e r e d S u b j e c t s W i t h S u c c e s s f u l and U n s u c c e s s f u l Treatment Outcomes  OUTCOME  Successful ASSESSMENT  n  Unsuccessful n  Psychiatric Conduct D i s o r d e r (PCD)  13  26%  Non-conduct D i s o r d e r (PN-CD)  32  64%  Conduct D i s o r d e r (PCD)  17  25%  Non-conduct D i s o r d e r  28  37  74% 36%  Alternate  Total  (PN-CD)  45  45  51  75%  4  12%  55  55%  104 Alternate  (ACD) and P s y c h i a t r i c D i a g n o s i s  Hypothesis  3.  (PCD)  The a s s o c i a t i o n between t h e p s y c h i a t r i c  d i a g n o s i s and t h i s r e s e a r c h e r ' s a l t e r n a t i v e assessment was significant,  [X = 19.4, P h i = .43, p < .0001].  Eighty-eight  p e r c e n t o f those s u b j e c t s g i v e n a conduct d i s o r d e r e d  diagnosis  by t h e p s y c h i a t r i s t were g i v e n t h e same c l a s s i f i c a t i o n by t h e a l t e r n a t e assessment.  Although  t h e t o t a l degree o f agreement  was 70%, 80% o f t h e j u v e n i l e s who were not d i a g n o s e d as conduct d i s o r d e r e d by t h e p s y c h i a t r i s t were c o n s i d e r e d d i s o r d e r e d by t h e a l t e r n a t e assessment.  conduct  105 Conduct D i s o r d e r  Behavioral  H y p o t h e s i s 4.  Variables  A C h i - s q u a r e and P h i were computed t o  measure a s s o c i a t i o n between each o f the 13  behavioral  v a r i a b l e s l i s t e d f o r DSM-III-R Conduct D i s o r d e r  diagnosis  the dependent v a r i a b l e , s u c c e s s f u l t r e a t m e n t outcome.  Table 2  shows the v a l u e s f o r s i g n i f i c a n t a s s o c i a t i o n s between s u c c e s s f u l c o m p l e t i o n o f t r e a t m e n t and the s e v e r a l o f t h e behavior v a r i a b l e s .  and  106 Table 2 I n d i v i d u a l Conduct D i s o r d e r B e h a v i o u r s and S u c c e s s f u l Treatment Outcome Successful  Outcome 2  Behaviour  %  . x  49  24.1  steals  59  15.4  truant  61  17.5  runs away  70  18.2  c r u e l t o people  72  17.7  physical  fights  74  15.1  property  destruction  75  16.1  fire-setting  77  —  break and e n t e r  82  —  c r u e l t o animals  3  —  robbery  7  —  weapon use  5  —  f o r c e d sex  97  —  often  lies  Note. significant  depicts i n s i g n i f i c a n t values, values.  p < .001 on a l l  107 P r e v i o u s Non-sexual Hypothesis  5.  p r e v i o u s non-sexual  Offenses F i f t y - f o u r p e r c e n t o f s u b j e c t s had offenses.  A s i g n i f i c a n t a s s o c i a t i o n was  observed between p r e v i o u s non-sexual  charges  and s u c c e s s f u l  treatment outcome, [X = 14.1, P h i = -.38, p < .001]. j u v e n i l e s w i t h no p r e v i o u s non-sexual more l i k e l y t o have s u c c e s s f u l  charges were somewhat  treatment outcome  Table 3 p r o v i d e s the f u l l r e s u l t s  The  (67%).  f o r d i s t r i b u t i o n s of  s u c c e s s f u l and u n s u c c e s s f u l outcomes f o r those w i t h and w i t h o u t p r e v i o u s non-sexual  P s y c h i a t r i c Conduct D i s o r d e r Hypothesis  6.  offenses.  (PCD)  A s i g n i f i c a n t a s s o c i a t i o n was  between j u v e n i l e s h a v i n g p r e v i o u s non-sexual  observed  o f f e n s e s and  h a v i n g a p s y c h i a t r i c conduct d i s o r d e r d i a g n o s i s (PCD), [X = 16.1,  P h i = p < .001].  The j u v e n i l e s w i t h no p r e v i o u s non-  s e x u a l charges were more l i k e l y t o n o t have a p s y c h i a t r i c conduct d i s o r d e r d i a g n o s i s (72%).  Table 3 p r o v i d e s  r e s u l t s o f t h e d i s t r i b u t i o n o f p r e v i o u s non-sexual p s y c h i a t r i c conduct d i s o r d e r d i a g n o s i s .  full charges  and  108 A l t e r n a t e Conduct D i s o r d e r (ACD) H y p o t h e s i s 7.  A p o s i t i v e c o r r e l a t i o n was o b s e r v e d  between j u v e n i l e s h a v i n g p r e v i o u s n o n - s e x u a l charges and h a v i n g an a l t e r n a t e conduct d i s o r d e r d i a g n o s i s 32.6, P h i = .57, p < .0001].  (ACD), [X =  Those j u v e n i l e s w i t h p r e v i o u s  n o n - s e x u a l charges were more l i k e l y t o have an a l t e r n a t e conduct d i s o r d e r d i a g n o s i s  (74%) than n o t .  Those j u v e n i l e s  w i t h no p r e v i o u s n o n - s e x u a l charges were more l i k e l y t o n o t have an a l t e r n a t e conduct d i s o r d e r d i a g n o s i s shows f u l l d i s t r i b u t i o n s o f t h e s e r e s u l t s .  (88%) . Table 3  109 Table 3 Percentages  o f Conduct D i s o r d e r e d S u b j e c t s and Non-conduct  D i s o r d e r e d S u b j e c t s With P r e v i o u s Non-sexual Offenses Assessment  '  Offenses No o f f e n s e s  n  %  n  %  37  74  13  26  17  34  33  66  50  74  18  26  4  12  28  88  Psychiatric Conduct D i s o r d e r  (PCD)  Non-conduct D i s o r d e r  (PN-CD)  Alternate Conduct D i s o r d e r (ACD) Non-conduct D i s o r d e r  (AN-CD)  110 CHAPTER FIVE DISCUSSION  Implications The o v e r a l l purpose o f t h i s study was c l e a r l y understand  t o examine and more  the r e l e v a n c e o f Conduct D i s o r d e r d i a g n o s i s  i n the assessment and treatment  o f j u v e n i l e sex o f f e n d e r s i n  o r d e r t o determine which v a r i a b l e s might be u s e f u l i n p r e d i c t i n g treatment  outcome.  The  f o l l o w i n g d i s c u s s i o n of  each o f the seven hypotheses o f f e r s c l i n i c a l i m p l i c a t i o n s r e l a t e d t o the purpose o f the  Hypothesis The  study.  1  study suggests  t h a t i n a p o p u l a t i o n o f j u v e n i l e sex  o f f e n d e r s i n o u t - p a t i e n t treatment,  those who  are g i v e n a  p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r are more l i k e l y have u n s u c c e s s f u l treatment j u v e n i l e sex o f f e n d e r s who  outcomes.  Furthermore,  to  those  are not c l a s s i f i e d as Conduct  D i s o r d e r are more l i k e l y t o have s u c c e s s f u l treatment outcomes.  Although  t h i s , i n and o f i t s e l f , may  not be a  r e v e l a t i o n t o most c l i n i c i a n s working w i t h t r o u b l e d adolescents  ( g i v e n the non-compliant,  a n t i - s o c i a l nature  of  I.  Ill t h i s p o p u l a t i o n ) , i t suggests t h a t t h e r e may be a sub-group o f j u v e n i l e sex o f f e n d e r s who a r e l e s s amenable t o t r e a t m e n t .  At  the same time,, i t suggests t h a t j u v e n i l e sex o f f e n d e r s who a r e not c o n s i d e r e d conduct d i s o r d e r e d may a l s o be a sub-group w i t h unique c h a r a c t e r i s t i c s making them more amenable t o  treatment  approaches.  Hypothesis  2  T h i s s t u d y suggests t h a t those j u v e n i l e sex o f f e n d e r s meet t h e c r i t e r i a  who  f o r a d i a g n o s i s o f Conduct D i s o r d e r ,  a c c o r d i n g t o t h e DSM-III-R (APA, 1987), a r e s i g n i f i c a n t l y more l i k e l y t o have u n s u c c e s s f u l treatment  outcomes and those  who  do n o t meet t h e c r i t e r i a a r e s i g n i f i c a n t l y more l i k e l y t o have s u c c e s s f u l treatment  outcomes.  The r e s u l t s from t h i s  component o f t h e study r e i n f o r c e s the s u g g e s t i o n t h a t Conduct D i s o r d e r i s a s s o c i a t e d w i t h treatment  outcome.  Moreover, i f  g i v e n an a c c u r a t e d i a g n o s i s o f Conduct D i s o r d e r , t h e r e i s even s t r o n g e r a s s o c i a t i o n between j u v e n i l e o u t - p a t i e n t outcome and the d i a g n o s i s .  treatment  The degree o f agreement between  the p s y c h i a t r i c assessment and the a l t e r n a t e assessment i s h i g h e r than most p r e v i o u s comparative s t u d i e s on p s y c h i a t r i c diagnosis.  However, g i v e n t h a t 80% o f the s u b j e c t s who were  112 not g i v e n a p s y c h i a t r i c d i a g n o s i s o f Conduct D i s o r d e r were c l a s s i f i e d as such i n the a l t e r n a t e assessment, one would have t o c o n s i d e r t h i s a r a t h e r low degree o f agreement i n terms o f underdiagnosing.  Thus, t h i s s t u d y s u g g e s t s t h a t  Conduct  D i s o r d e r e d j u v e n i l e sex o f f e n d e r s are b e i n g u n d e r - d i a g n o s e d i n t h i s sample and t h i s f i n d i n g may be g e n e r a l i z a b l e t o the p o p u l a t i o n from which t h i s sample was t a k e n .  Hypothesis 3 The f i n d i n g s suggest t h a t the p s y c h i a t r i c assessment a l t e r n a t e assessment were h i g h l y c o r r e l a t e d .  and  However, as  mentioned i n the p r e v i o u s paragraph, the v a r i a n c e i n the.two assessments s u g g e s t s t h a t the p s y c h i a t r i c assessment  under-  diagnoses t h i s p o p u l a t i o n i n terms o f g i v i n g a d i a g n o s i s o f Conduct D i s o r d e r .  A l t h o u g h the r e s u l t s show t h a t j u v e n i l e sex  o f f e n d e r s are b e i n g a c c u r a t e l y d i a g n o s e d as conduct d i s o r d e r e d , a s i g n i f i c a n t p e r c e n t a g e o f those youth who  do  meet the DSM-III-R c r i t e r i a are i n f a c t not b e i n g d i a g n o s e d as conduct d i s o r d e r e d by the a s s e s s i n g p s y c h i a t r i s t . p o s s i b l e e x p l a n a t i o n s can be put f o r w a r d h e r e .  Several  One,  the  p s y c h i a t r i s t may not be d i a g n o s i n g conduct d i s o r d e r u n l e s s t h e youth b l a t a n t l y demonstrates the d i a g n o s t i c c r i t e r i a .  Two,  113 the youth may a l r e a d y be d i a g n o s e d w i t h P a r a p h i l i a , P e d o p h i l i a , and A t t e n t i o n D e f i c i t H y p e r a c t i v e  Disorder  (and/or  some o t h e r d i s o r d e r ) and t h e r e i s a r e s i s t a n c e t o . g i v e m u l t i p l e diagnoses.  Thus, a l t h o u g h t h e o f f e n d e r does meet t h e  c r i t e r i a o f Conduct D i s o r d e r , t h e d i a g n o s i s i s n o t g i v e n f o r fear of overdiagnosing.  Or, t h r e e , t h e d i a g n o s i s i s s i m p l y  not r e p o r t e d on t h e p s y c h i a t r i c assessment.  Another  e x p l a n a t i o n may be t h a t t h e c l i n i c i a n who works w i t h t h i s p o p u l t i o n e x c l u s i v e l y , and over a l o n g p e r i o d o f time, may become d e s e n s i t i z e d t o t h e youth who p r e s e n t s w i t h Conduct Disorder behaviors.  That i s , t h e youth may demonstrate a l l  the b e h a v i o r s n e c e s s a r y  t o meet t h e d i a g n o s i s , b u t t h e  c l i n i c i a n may n o t p e r c e i v e him as " t h a t bad" r e l a t i v e t o t h e youth who demonstrates t h e more a g g r e s s i v e and v i o l e n t behaviours  against others.  I n any event,  between p s y c h i a t r i c d i a g n o s i s (ACD) i n t h i s study i s m i n i m a l ,  the discrepancy  (PCD) and a l t e r n a t e d i a g n o s i s w i t h t h e a l t e r n a t e (ACD)  f i n d i n g s b e i n g s i m i l a r except somewhat s t r o n g e r on most variables.  Hypothesis  4  An o b s e r v a t i o n o f t h e a s s o c i a t i o n between t h e i n d i v i d u a l  114 b e h a v i o u r s o f conduct d i s o r d e r and s u c c e s s f u l  treatment  outcome suggests t h a t t h e d i s c r i m i n a t i v e u t i l i t y o f i n d i v i d u a l symptoms a r e s i g n i f i c a n t l y a s s o c i a t e d w i t h s u c c e s s f u l t r e a t m e n t outcomes. lies",  P a r t i c u l a r y , b e h a v i o u r s such as " o f t e n  " r u n n i n g away", " t r u a n c y " , and " p h y s i c a l c r u e l t y t o  humans" a r e a s s o c i a t e d w i t h u n s u c c e s s f u l t r e a t m e n t outcome. That i s , j u v e n i l e sex o f f e n d e r s i n o u t - p a t i e n t t r e a t m e n t who e x h i b i t any o f these b e h a v i o u r s and even more so t h e s e b e h a v i o u r s i n c o m b i n a t i o n a r e more l i k e l y t o have u n s u c c e s s f u l t r e a t m e n t outcomes.  However, each b e h a v i o u r must be examined  more f u l l y t o get a c l e a r e r u n d e r s t a n d i n g o f i t ' s r e l e v a n c e . "Often l i e s " may suggest t h a t t h e i n d i v i d u a l e x h i b i t s a h i g h e r degree o f d e n i a l than h i s c o u n t e r p a r t s and i s u n w i l l i n g t o accept he has a problem and t h u s , be more r e s i s t a n t t o treatment.  The youth who i s o f t e n " t r u a n t " from s c h o o l may be  more l i k e l y t o a l s o be t r u a n t from t h e t r e a t m e n t program.  As  such, he i s e x p e l l e d from t h e program f o r b r e a k i n g t h e r u l e o f compulsory  attendance.  The b e h a v i o u r " p h y s i c a l c r u e l t y t o  o t h e r s " may suggest t h a t t h i s i n d i v i d u a l i s a more s e r i o u s o f f e n d e r and i s more a g g r e s s i v e and engages i n a h i g h e r l e v e l of o f f e n s e s e v e r i t y .  For example, t h e r a p i s t o r o f f e n d e r who  uses p h y s i c a l f o r c e as compared t o t h e o f f e n d e r who i s n o t  115 a g g r e s s i v e o r engages i n h a n d s - o f f  offenses.  As such, t h e  more s e r i o u s o f f e n d e r may be a more a n t i - s o c i a l and/or a more a g g r e s s i v e conduct d i s o r d e r e d j u v e n i l e sex o f f e n d e r , making •him much l e s s amenable t o t r e a t m e n t .  Hypothesis The  5  f i n d i n g s show t h a t i n a p o p u l a t i o n o f j u v e n i l e sex  o f f e n d e r s i n o u t - p a t i e n t treatment  those who have p r e v i o u s  n o n - s e x u a l a r r e s t s a r e more l i k e l y t o have u n s u c c e s s f u l treatment  outcome as compared t o those who have no h i s t o r y o f  non-sexual offenses.  T h i s suggests t h a t these s u b j e c t s may be  a d i s c r e e t subgroup who a r e more a n t i - s o c i a l , more d e l i n q u e n t , and c o n s e q u e n t l y  more s e v e r e l y conduct d i s o r d e r e d .  Logically,  t h i s would make them l e s s amenable t o t r e a t m e n t .  Hypothesis  6 and 7  These f i n d i n g s show t h a t a p o p u l a t i o n o f o u t - p a t i e n t j u v e n i l e sex o f f e n d e r s w i t h a h i s t o r y o f n o n - s e x u a l o f f e n s e s are more l i k e l y t o be d i a g n o s e d w i t h Conduct D i s o r d e r t h a n those w i t h no h i s t o r y n o n - s e x u a l o f f e n s e s .  Once a g a i n ,  these  f i n d i n g may suggest t h e e x i s t e n c e o f a d i s c r e e t subgroup t h a t i s a t h i g h e r r i s k o f u n s u c c e s s f u l treatment  outcome.  On t h e  116  o t h e r hand, i t may  a l s o suggest a d i s c r i m i n a t e subtype o f  j u v e n i l e sex o f f e n d e r who  does not engage i n t y p i c a l  delinquent a n t i s o c i a l behaviours.  Furthermore, t h i s  may  suggest d i s c r e e t subtypes based on l e v e l o f a g g r e s s i o n . However, the presence or absence o f non-sexual may  offenses  s i m p l y be a b r o a d i n d i c a t o r o f the Conduct D i s o r d e r  behaviours  t h a t are c r i m i n a l a c t s .  Conduct D i s o r d e r non-sexual "robbery",  "fire-setting",  For example, the DSM-III-R  behaviours,  such as  "theft",  "break and e n t e r " , " d e s t r u c t i o n o f  p r o p e r t y " , " p h y s i c a l f i g h t s " , and "weapon use" are a l l criminal offenses.  As such, non-sexual  offenses  simply  i n c r e a s e the l i k e l i h o o d of the j u v e n i l e sex o f f e n d e r w i t h a h i s t o r y o f non-sexual Disordered.  a r r e s t as b e i n g diagnosed  as Conduct  Thus, once a g a i n , the q u e s t i o n must be asked; i s  t h i s a d i s c r i m i n a t e subtype o f sex o f f e n d e r , or i s " f o r c e d sex" j u s t another b e h a v i o u r  o f a Conduct D i s o r d e r e d  juvenile.  However, i t i s s i g n i f i c a n t t o r e p o r t t h a t the r e s u l t s o f t h i s study showed no s i g n i f i c a n t d i f f e r e n c e i n the f i n d i n g s when the A l t e r n a t e Conduct D i s o r d e r o f the " f o r c e d sex" DSM  was  assessed  independent  b e h a v i o r a l item.  A t the same time, how behaviour  (ACD)  does the r e s e a r c h e r d e f i n e the  " f o r c e d sex". I f the j u v e n i l e sex o f f e n d e r i s not  117 a g g r e s s i v e and uses no form of o v e r t c o e r c i o n , does he meet this behavioral c r i t e r i a .  The  c l i n i c i a n must then make a  judgment based on the i s s u e s d i s c u s s e d i n the f i r s t c h a p t e r  of  t h i s paper; such as, the l e v e l of e q u a l i t y , consent, c o e r c i o n and a g g r e s s i o n between the o f f e n d e r and the v i c t i m . Taken t o g e t h e r these f i n d i n g s suggest t h a t t h e r e i s a j u v e n i l e sex o f f e n d e r subtype t h a t can be d i f f e r e n t i a t e d is  l e s s amenable t o o u t - p a t i e n t t r e a t m e n t .  who  T h i s subtype i s  c h a r a c t e r i z e d by h a v i n g a h i s t o r y of n o n - s e x u a l o f f e n s e s  and  by meeting the f u l l c r i t e r i a f o r Conduct D i s o r d e r d i a g n o s i s . Moreover, t h i s subtype more l i k e l y demonstrates the f o l l o w i n g conduct d i s o r d e r symptoms: o f t e n l i e s , runs away, i s t r u a n t and i s p h y s i c a l l y c r u e l t o o t h e r s .  As such, the f i n d i n g s  suggest t h a t the more severe and a g g r e s s i v e Conduct j u v e n i l e sex o f f e n d e r i s l e s s amenable t o  Disordered  treatment.  Limitations T h i s study s u f f e r e d from s e v e r a l l i m i t a t i o n s . d a t a c o l l e c t i o n and c o m p i l a t i o n was  First,  the  based on the a v a i l a b l e  c l i n i c a l r e c o r d documentation on f i l e .  As such, I r e l i e d  on  the premise t h a t the c l i n i c i a n s ' g a t h e r i n g and r e c o r d i n g o f  118 i n f o r m a t i o n was  v a l i d , r e l i a b l e and a c c u r a t e .  Second, the  p o p u l a t i o n I sampled from were c o n s i d e r e d by the p r o f e s s i o n a l s t a f f t o be the more s e r i o u s and r e s i s t a n t j u v e n i l e sex o f f e n d e r s r e c e i v i n g o u t - p a t i e n t treatment B.C.  i n the p r o v i n c e  of  That i s , a s i g n i f i c a n t p e r c e n t a g e of the youth r e f e r r e d  f o r treatment  t o the Youth Court  Department i n Burnaby, B.C.  Services/Out-patient  c o u l d not be t r e a t e d as r e a d i l y i n  the o u t l y i n g areas of the p r o v i n c e where t h e r e was support  a lack  s e r v i c e s and p r o f e s s i o n a l c l i n i c i a n s s p e c i a l i z e d i n  the treatment  of j u v e n i l e sex o f f e n d e r s .  s i g n i f i c a n t p e r c e n t a g e (89%)  However, a  of the s u b j e c t s i n t h i s  were housed i n s p e c i a l i z e d r e s i d e n c e s  study  f o r adolescent  sex  o f f e n d e r s , and were c o n s i d e r e d as more s e r i o u s o f f e n d e r s . such, t h i s d a t a then may  not be r e p r e s e n t a t i v e of the  o u t - p a t i e n t j u v e n i l e sex o f f e n d e r who  typical  i s u s u a l l y considered  l e s s s e r i o u s an o f f e n d e r , as a t l e s s r i s k t o r e o f f e n d , and more amenable t o t r e a t m e n t .  There may  be an  As  as as  over-  r e p r e s e n t a t i o n o f conduct d i s o r d e r e d s u b j e c t s r e l a t i v e t o the g e n e r a l p o p u l a t i o n of j u v e n i l e sex o f f e n d e r s r e c e i v i n g o u t p a t i e n t treatment.  On the o t h e r hand, the f i n d i n g s of t h i s  s t u d y are c o n s i s t e n t w i t h p r e v i o u s s t u d i e s on the i n c i d e n c e of Conduct D i s o r d e r f o r t h i s p o p u l a t i o n .  Third, this  study  1  119 lacked r e c i d i v i s m data. . Although s u c c e s s f u l l y complete t r e a t m e n t , w i l l not reoffend.  a j u v e n i l e sex o f f e n d e r may t h e r e i s no guarantee t h a t he  Furthermore, a l t h o u g h s t u d i e s r e p o r t t h a t  o f f e n d e r s who s u c c e s s f u l l y complete treatment  a r e a t lower  r i s k t o r e o f f e n d , many o f f e n d e r s who complete treatment f a c t go on t o r e o f f e n d .  do i n  A f o u r t h l i m i t a t i o n , was t h a t t h i s  study was d e s c r i p t i v e i n n a t u r e , summarizing f r e q u e n c i e s and measures o f a s s o c i a t i o n between v a r i a b l e s . A l t h o u g h t h e f i n d i n g s were s i g n i f i c a n t , they must be i n t e r p r e t e d w i t h caution.  Without a c o n t r o l group, o r a t t h e v e r y l e a s t a  comparison sample o f j u v e n i l e non-sexual  offenders  diagnosed  w i t h and w i t h o u t Conduct D i s o r d e r , one can o n l y s p e c u l a t e on the s i g n i f i c a n c e o f these f i n d i n g s .  A f i f t h l i m i t a t i o n was  t h a t a l t h o u g h t h e f r e q u e n c i e s o f o t h e r diagnoses examined, t h e i m p l i c a t i o n s o f any diagnoses  were  o t h e r than Conduct  D i s o r d e r , and/or t h e impact o f m u l t i p l e d i a g n o s i s on treatment outcome was n o t examined.  For example, many youth  w i t h Conduct D i s o r d e r a r e a l s o diagnosed D e f i c i t Disorder  (27% i n t h i s sample).  diagnosed  with Attention This  may have a  s e r i o u s impact on t h e i n d i v i d u a l ' s a b i l i t y t o s u c c e s s f u l l y complete t r e a t m e n t .  A f i n a l l i m i t a t i o n , was t h e f a c t t h a t  t h i s was a c o n v e n i e n c e / a v a i l a b i l i t y sample o f e x i s t i n g  120 a r c h i v a l data.  The d a t a was c o l l e c t e d e n t i r e l y from c l i e n t  r e c o r d s and, as mentioned e a r l i e r , I r e l i e d c o m p l e t e l y on t h e v a r i o u s c l i n i c i a n s ' a c c u r a t e i n f o r m a t i o n g a t h e r i n g and recording of the data.  A more r o b u s t study would have t h e  researcher c o l l e c t a l l data using a standardized d i a g n o s t i c measures, such as t h e D i a g n o s t i c I n t e r v i e w S c a l e f o r C h i l d r e n (DISC-2) ( S h a f f e r e t a l . ,  1992).  T h i s would i n v o l v e e x t e n s i v e  i n t e r v i e w s w i t h t h e youth, c a r e g i v e r s , and t e a c h e r s , p r e and post treatment.  Such an endeavour w i t h t h e same sample s i z e  would t a k e a p p r o x i m a t e l y 2 years o f c o n c e n t r a t e d e f f o r t on data c o l l e c t i o n alone.  Conclusions.. T h i s s t u d y ' s f i n d i n g s suggest t h a t t h e r e i s a Conduct D i s o r d e r subtype o f j u v e n i l e sex o f f e n d e r who i s l e s s t o have s u c c e s s f u l treatment outcome. suggests t h a t t h e r e may be a subtype  likely  A t t h e same time, i t o f j u v e n i l e sex o f f e n d e r  who i s n o t Conduct D i s o r d e r e d and who i s more amenable t o treatment.  As such, i t may be n e c e s s a r y t o p r o v i d e more  s p e c i a l i z e d treatment d i a g n o s t i c assessment.  f o r these subtypes based on t h i s For example, t h e Conduct D i s o r d e r  j u v e n i l e sex o f f e n d e r may n o t be s u i t e d f o r t h e t y p i c a l o u t -  121 p a t i e n t c o g n i t i v e - b e h a v i o r a l , d i d a c t i c program. more i n t e n s i v e , p r o c e s s  Perhaps a  o r i e n t e d approach i n a c l o s e d s e t t i n g  would be more a p p r o p r i a t e . T h i s study suggests t h a t t h e r e a r e subtypes w i t h i n t h e j u v e n i l e sex o f f e n d e r p o p u l a t i o n t h a t a r e l e s s o r more amenable t o treatment  based on Conduct D i s o r d e r d i a g n o s i s and  i t s behavioral c r i t e r i a .  T h i s may mean t h a t c e r t a i n  b e h a v i o r a l i n d i c a t o r s a r e i n d i c a t i v e o f poor p r o g n o s i s i n terms o f s u c c e s s f u l treatment  outcomes.  W i t h t h i s i n mind,  s t u d i e s comparing subgroups o f j u v e n i l e sex o f f e n d e r s a r e needed, p a r t i c u l a r l y w i t h r e s p e c t t o Conduct D i s o r d e r and r e c i d i v i s m i n response t o s p e c i f i c treatment i n t e r v e n t i o n s . T h i s s t u d y a l s o suggests t h a t t h e p s y c h i a t r i c d i a g n o s i s of Conduct D i s o r d e r i s underdiagnosed f o r t h i s p o p u l a t i o n .  As  such,-more r i g o r o u s and exact d i a g n o s i n g may enhance t h e c l a s s i f i c a t i o n o f Conduct D i s o r d e r j u v e n i e l s e x u a l and s u b s e q u e n t l y ,  offenders  more a c c u r a t e l y i d e n t i f y those y o u t h who a r e  more o r l e s s l i k e l y t o be s u c c e s s f u l i n t r e a t m e n t . F a c t o r s such as l e v e l o f i n t e l l e c t u a l f u n c t i o n i n g , presence o f l e a r n i n g d i s a b i l i t i e s , degree o f s o c i a l and l e v e l o f impulse treatment  skills,  c o n t r o l must be c o n s i d e r e d when s t u d y i n g  outcomes w i t h t h i s p o p u l a t i o n .  This i s e s p e c i a l l y  122 r e l e v a n t , g i v e n t h a t s t u d i e s show t h a t a s i g n i f i a n t number of adolescent areas.  sex o f f e n d e r s  s u f f e r from d e f i c i t s i n a l l these  Treatment success might be a f f e c t e d by the a b i l i t y  l e a r n t h a t which i s o f f e r e d i n therapy.  This i s  to  important  when c o n s i d e r i n g t h a t c o g n i t i v e - b e h a v i o r a l t h e r a p y has  a  s t r o n g " t e a c h i n g " component, as i s the case f o r the program accessed f o r t h i s  study.  In outcome s t u d i e s of j u v e n i l e sex o f f e n d e r s , numerous extenuating  f a c t o r s must be c o n s i d e r e d .  The  leverage of  the  c r i m i n a l j u s t i c e system i n terms of the c o l l a b o r a t i v e e f f o r t w i t h the t r e a t m e n t team and c a r e g i v e r s i s n e c e s s a r y t o compel a v e r y r e s i s t a n t p o p u l a t i o n t o engage i n and remain i n outp a t i e n t t r e a t m e n t f o r the d u r a t i o n .  Furthermore, s t u d i e s  examining the e f f i c a c y of o u t - p a t i e n t as compared t o i n p a t i e n t t r e a t m e n t p a r t i c u l a r l y f o r the more r e s i s t a n t and unmanageable a d o l e s c e n t  Conduct D i s o r d e r e d  sex o f f e n d e r  are  necessary. F i n a l l y , f u t u r e s t u d i e s are needed t o address the  issue  of the i n c r e a s e d r e l i a b i l i t y and v a l i d i t y o f the DSM-IV as compared t o i t ' s p r e d e c e s s o r s . analyses criteria,  of the CD b e h a v i o r s  Of p a r t i c u l a r r e l e v a n c e  i s an  not i n c l u d e d i n the DSM-III-R  " o f t e n b u l l i e s , t h r e a t e n s , or i n t i m i d a t e s o t h e r s "  123 and " o f t e n s t a y s out a f t e r dark w i t h o u t p e r m i s s i o n , b e g i n n i n g b e f o r e 13 years o f age". diagnosis  These are h i g h l y p r e d i c t i v e o f  (eg. F r i c k , e t a l . ,  u t i l i t y f o r treatment  1994)  and may  CD  have p r e d i c t i v e  and r e c i d i v i s m outcomes.  Studies also  i n d i c a t e t h a t a l t e r i n g the d e f i n i t i o n o f l y i n g t o "cons o t h e r s " and the d e f i n i t i o n o f t r u a n c y t o " t r u a n c y b e g i n n i n g b e f o r e age 13" has i n c r e a s e d the d i a g n o s t i c e f f i c i e n c y o f these b e h a v i o u r s , e s p e c i a l l y t h e i r p o s i t i v e p r e d i c t i v e v a l u e ( F r i c k , et a l . ,  1994).  In a d d i t i o n , the i n c r e a s e i n the  window f o r DSM  Conduct D i s o r d e r  one year  1994)  (APA,  may  b e h a v i o r s from 6 months t o  enhance the d i a g n o s t i c p r e c i s i o n f o r  the j u v e n i l e sex o f f e n d e r p o p u l a t i o n . presence  time  o f conduct d i s o r d e r b e h a v i o u r s  The  s i g n i f i c a n c e o f the  i n juvenile  sex  o f f e n d e r s w i l l depend on r e s e a r c h t h a t overcomes m e t h o d o l o g i c a l and c o n c e p t u a l problems t h a t were e v i d e n t i n t h i s study and p r e v i o u s r e l a t e d r e s e a r c h . The c l i n i c i a n and r e s e a r c h e r a l i k e must contemplate Kazdin  what  (1989) s t a t e s i s the most i m p o r t a n t c o n s i d e r a t i o n i n  the d i a g n o s i s o f Conduct D i s o r d e r : the s t a b i l i t y , b r e a d t h , i n t e n s i t y o f the b e h a v i o u r s , r a t h e r than s i m p l y the o f any p a r t i c u l a r b e h a v i o u r . must be t a k e n t o determine  and  presence  As such, c a r e f u l c o n s i d e r a t i o n  i f the s i g n i f i c a n t b e h a v i o u r s  have  124 been i n e v i d e n c e f o r the minimum 12 month time window.  This  i s i m p o r t a n t , p a r t i c u l a r l y when a s s e s s i n g the degree o f s e v e r i t y o f the d i s o r d e r .  Furthermore, the "age o f o n s e t "  subtype c r i t e r i a f o r Conduct D i s o r d e r (DSM-IV, APA, must be a s s e s s e d c a r e f u l l y .  1994)  This i s p a r t i c u l a r l y important  i n the e v a l u a t i o n o f t r e a t m e n t outcome, g i v e n t h a t e a r l y onset Conduct D i s o r d e r youth have been found t o be much l e s s amenable t o i n t e r v e n t i o n as compared t o the l a t e onset subtype. Furthermore, t h e r e i s a need f o r d i a g n o s i s t o expand a l o n g d i f f e r e n t dimensions and s o c i o c u l t u r a l f a c t o r s niust be taken i n t o c o n s i d e r a t i o n .  C u r r e n t l y , the e x p l i c i t  orientation  o f c l i n i c a l d i a g n o s i s i s on the "problem o f the c h i l d " .  The  b e h a v i o u r must be viewed i n the c o n t e x t o f a l t e r n a t i v e systems, p a r t i c u l a r l y t h a t o f the f a m i l y .  The  empirical  l i t e r a t u r e c o n s i s t e n t l y p o i n t s t o the f a m i l y as a t r a i n i n g ground f o r a n t i s o c i a l b e h a v i o u r and as a p r e d i c t o r o f l o n g term course ( K a z d i n , 1987).  Thus, i n the assessment  of  Conduct D i s o r d e r and i n the making o f p r e d i c t i o n s i n terms o f t r e a t m e n t outcome, f a m i l y f a c t o r s need t o be t a k e n i n t o account. F a m i l y d y s f u n c t i o n , p a r e n t a l p s y c h o p a t h o l o g y , and  social  125 d i s a d v a n t a g e a r e j u s t some o f t h e s o c i o c u l t u r a l dimensions t h a t a r e r e l e v a n t t o t h e conduct d i s o r d e r e d y o u t h .  To expand  the model o f d i a g n o s i s , m u l t i p l e dimensions o f f u n c t i o n i n g must be a d d r e s s e d .  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W i l l i a m s , J.B.W., S p i t z e r , R.L., & Skodol, A.E. (1985). DSMIII  i n residency  t r a i n i n g : Results o f a n a t i o n a l survey.  American J o u r n a l o f P s y c h i a t r y , 142, 755-758. W i l l i a m s , J.B.W. (1986). DSM-III-R: What's a l l t h e f u s s about?. H o s p i t a l and Community P s y c h i a t r y , 37, 549-550. Zimmerman, M. (1988). Whay a r e we r u s h i n g t o p u b l i s h DSM-IV?. Archives  o f G e n e r a l P s y c h i a t r y , 45, 1135-1138.  APPENDICES  Sunmary of methodology and procedures. (Must be typewritten in this space). MOTE If deception, you must also complete page 8, the "Deception F o r m " .  your  study involves  Data w i l l be obtained from the medical records (archival data) at Youth Court Services/Out-Patient Treatment Program for adolescent sex offenders. Subjects w i l l be selected via individual medical f i l e s of out-patient adolescent males who completed a f u l l court-ordered biopsychosocial assessment and who were recommended for and court-ordered to complete the treatment program. A l l the subjects are males who were charged with sexual offences and consequently evaluated between Jan. 1/90 - Dec.31/92 w i l l be included (n••= 156) in this study. A l l f i l e s w i l l be separated based on completers vs. non-completers according to psychology/psychiatric reports. Each record w i l l be examined to determine diagnosis according to the DSM-III-R classification system and the related features of the diagnosis.  SCRIPTION OF POPULATION 13  How many subjects will be used? How many in the control group?  156  no control group  Who is being recruited and what are the criteria for their selection?  Medical/Clinical records of 156 juvenile sex offenders court-ordered • for assessment and treatment at the Youth Court Services/Out-Patient Sex Offender Treatment Program at the Burnaby Clinic between Jan. 1/90  and Dec. 31/92.  page 5 15  What subjects w i l l be excluded from p a r t i c i p a t i o n ?  Nil  16  How are the subjects being recruited?  (If  i n i t i a l contact  is by l e t t e r or i f a recruitment notice is to be posted,  attach a copy.) NOTE that UBC p o l i c y discourages i n i t i a l contact by telephone. However, surveys which use random d i g i t d i a l i n g may be allowed.  If your study involves such contact, you must a l s o complete page 9,  the  "Telephone  Contact form".  Retrieval of medical/clinical records.  17  If  a control group i s involved, and i f t h e i r s e l e c t i o n and/or recruitment d i f f e r s  from the above, provide d e t a i l s .  No control group.  ROJECT DETAILS  18  -  Where w i l l the p r o j e c t  be conducted?  (room or area)  Youth Court Services/Out-Patient Program 19  Who  w i l l a c t u a l l y conduct the study and what are t h e i r  Burnaby, B.C.  qualifications?  Michael J . Pond, RPN, BSW 20  Will  the group of subjects have any problems g i v i n g informed consent on t h e i r own behalf?  mental c o n d i t i o n , age,  language, or other  Consider physical or  barriers.  - Age 12 - 17 yrs. young offenders - consent has been obtained through Youth Court Services - Clinical Director  21  If  the subjects are not competent to give f u l l y  informed consent, who w i l l consent on t h e i r  behalf?  N/A  22  What is known about the r i s k s and benefits issue?  of the proposed research?  Do you have a d d i t i o n a l opinions on t h i s  Risks - None Benefits - Assist in screening process of high risk offenders not completing treatment.  page 4 ll  What discomfort or incapacity are the subjects  l i k e l y to endure as a r e s u l t  of the experimental  158  procedures?  None-confidentiality i s ensured„  IU  If  monetary compensation is to be offered  the subjects,  provide d e t a i l s of amounts and payment schedules.  None  >5  How much time w i l l a subject have to dedicate to the  project?  None >6  How much time w i l l a member of the c o n t r o l group ( i f any) have to dedicate to the  project?  None  TA 17  Who w i l l have access to the data?  Researcher Only  >8  How w i l l c o n f i d e n t i a l i t y of the data be maintained?  - A l l f i l e s will remain on site. - A l l f i l e s will be numerically coded to maintain confidentiality 29  What are the plans for future use of the raw data (beyond that described i n t h i s protocol)?  How and when w i l l  data be destroyed?  None  50  Will  any data which i d e n t i f i e s  i n d i v i d u a l s be a v a i l a b l e to persons or agencies outside the U n i v e r s i t y ?  No individuals will be identified  31  Are  there any plans for feedback to the  NO  subject?  the  CHECKLISTS W i l l your p r o j e c t  use:  (check)  (  )  Questionnaires (submit a copy)  (  )  Interviews (submit a sample of  (X)  (  Observations (submit a b r i e f  )  Tests (submit a b r i e f  questions)  description)  - indirect observation of archival data in Medical Records.  description)  FORMED CONSENT 33  Who w i l l consent?  (check)  (  )  Subject  (  )  Parent/Guardian (Written parental consent i s always required for research in the schools and an opportunity must be presented e i t h e r v e r b a l l y or i n w r i t i n g to the students to refuse to p a r t i c i p a t e withdraw. A copy of what i s written or s a i d to the students should be provided for review by the Committee.)  ( x)  or  Agency O f f i c i a l ( s )  ln the case of p r o j e c t s c a r r i e d out at other has been r e c e i v e d . Please specify below:  institutions,  the Committee requires written proof that agency consent  (  )  Research c a r r i e d out i n a h o s p i t a l - approval of h o s p i t a l research or ethics committee.  (  )  Research c a r r i e d out i n a school - approval of School Board and/or P r i n c i p a l . (Exact requirements depend on i n d i v i d u a l school boards: check with Faculty of. Education Committee members for d e t a i l s . )  (  )  Research c a r r i e d out i n a P r o v i n c i a l Health Agency - approval of Deputy M i n i s t e r  ( > x  other,  specify:  Dr. Roy 0 Shaughnessy, Clinical Director Youth Court Services/Out-Patient Department Burnaby, B.C. 1  page 6 34  UBC P o l i c y requires w r i t t e n subject consent i n a l l cases other than questionnaires which are completed by the subject (see item #35 for consent requirements). Please check each item i n the following l i s t before submission of t h i s form to ensure that the w r i t t e n consent form attached contains a l l necessary items. If your research involves i n i t i a l contact by telephone, you need not f i l l out t h i s s e c t i o n .  (  )  Consent form must be prepared on UBC Department  letterhead  ( x)  T i t l e of  ( x)  I d e n t i f i c a t i o n of i n v e s t i g a t o r s ( i n c l u d i n g a telephone number). Research for a graduate thesis should be i d e n t i f i e d as such and the name and telephone number of the Faculty Advisor i n c l u d e d .  ( X)  B r i e f but complete d e s c r i p t i o n IN LAY LANGUAGE of the purpose of the project and of a l l procedures to be c a r r i e d out i n which the subjects are involved. Indicate i f the project involves a new or n o n - t r a d i t i o n a l procedure whose e f f i c a c y has not been proven i n c o n t r o l l e d s t u d i e s .  ( x)  Assurance that i d e n t i t y of the subject w i l l be kept c o n f i d e n t i a l and d e s c r i p t i o n of how t h i s w i l l be accomplished.  ( X)  Statement  ( x)  D e t a i l s of monetary compensation, i f any, to be offered  ( )  An offer to answer any i n q u i r i e s concerning the procedures to ensure that they are f u l l y understood by the subject and to provide d e b r i e f i n g i f appropriate.  (  )  A statement of the s u b j e c t ' s right to refuse to p a r t i c i p a t e or withdraw at any time and a statement that withdrawal or refusal to p a r t i c i p a t e w i l l not jeopardize further treatment, medical care or influence c l a s s standing as a p p l i c a b l e . NOTE: This statement must a l s o appear on t e t t e r s of i n i t i a l contact. For research done i n the schools, indicate what happens to c h i l d r e n whose parents do not consent. Note: The procedure may be part of classroom work but the c o l l e c t i o n of data may be purely for research.  (  )  A statement acknowledging that the subject has received a copy of the consent form including a l l attachments for t h e i r own records.  (  )  A place for signature of subject CONSENTING to p a r t i c i p a t e study and a place for the date of the signature.  project.  of the t o t a l  amount of time that w i l l be required of a s u b j e c t .  to  subjects.  i n the research p r o j e c t ,  i n v e s t i g a t i o n or  ( )  Parental consent forms must contain a statement of choice providing an option for refusal to p a r t i c i p a t e , ( e . g . "I consent/I do not consent to my c h i l d ' s p a r t i c i p a t i o n i n t h i s study." A l s o , verbal assent must be obtained from the c h i l d , i f the parent has consented.  ( )  If  more than one page, number the pages of the consent,  i e page 1 of 3, 2 of 3, 3 of 3 e t c .  IE ST IONNA IRES (completed by subjects)  35  N/A  page 7  Questionnaires should contain an introductory paragraph which includes the f o l l o w i n g information.  each item i n the following l i s t  Please check  before submission of this form to insure that the i n t r o d u c t i o n contains a l l  necessary  items. (  )  UBC letterhead  (  )  T i t l e of  (  )  I d e n t i f i c a t i o n of investigators  (  )  A b r i e f summary that indicates the purpose of the project  (  )  The benefits  (  )  A f u l l d e s c r i p t i o n of the procedures to be c a r r i e d out i n which the subjects are  (  )  project  to be derived  A statement of the s u b j e c t ' s further  treatment,  explanatory  ( i n c l u d i n g a telephone number)  involved  right to refuse to p a r t i c i p a t e or withdraw at any time without j e o p a r d i z i n g  medical care or class standing as a p p l i c a b l e .  Note:  T h i s statment must a l s o appear on  l e t t e r s involving questionnaires  (  )  The amount of time required of the subject must be stated  (  )  The statement  (  )  that i f the questionnaire is completed i t w i l l be assumed that consent has been given  Assurance that i d e n t i t y of the subject w i l l be kept c o n f i d e n t i a l and d e s c r i p t i o n of how t h i s w i l l be accomplished  (  )  For surveys c i r c u l a t e d by mail submit a copy of the explanatory  l e t t e r as well as a copy of  the  quest ionnai re  TACHMENTS  36  Check items attached to t h i s submission i f a p p l i c a b l e . Letter of i n i t i a l contact (item  Incomplete submissions w i l l not be reviewed.  16)  Advertisement for volunteer subjects (item  16)  Subject consent form (item 34) Control group consent form ( i f d i f f e r e n t  from above)  Parent/guardian consent form ( i f different  (x  from above)  Agency consent (item 33) Questionnaires,  tests,  interviews,  e t c . (item 32)  Explanatory l e t t e r with questionnaire (item 35) Deception form ( i n c l u d i n g a copy or t r a n s c r i p t Telephone Contact form Other,  specify:  of written or verbal  debriefing)  DECEPTION FORM page 8 Deception undermines informed consent. Indicate (a) why you believe deception is necessary to achieve your research objectives, and (b) why you believe that the benefits of the research outweigh the cost to subjects.  N/A  Explain why you believe that there will be no permanent damage as a result of the deception. N/A  >  Describe how you will debrief subjects at the end of the study. N/A  162  TELEPHONE CONTACT FORM page 9  ' 1  Telephone contact makes it impossible for a signed record of consent to be kept. such contact is necessary to achieve your research objectives.  Indicate why you believe that  N/A  2  Include a copy of the proposed "front end" of your telephone interview. Please check each item on the following list before submission of request for review to ensure that the front end covers as much as possible of the normal consent procedures. (  )  identification of fieldwork agency, if applicable  (  )  identification of researcher  (  )  basic purpose of project  < )  3  nature of questions to be asked, especially if sensitive questions to be asked  (  )  guarantee.of anonymity and confidentiality  (  )  indication of right of refusal to answer any question  (  )  an offer to answer any questions before proceeding [see below, item 3]  (  )  a specific inquiry about willingness to proceed  Indicate how interviewers will be trained to answer respondents' questions. Investigators should prepare and submit "scripted replies", which may cover, but are not necessarily limited to: (a)  Means by which respondent was selected  (b)  An indication-of the estimated time to be required for the interview  (c)  The means by which guarantees of anonymity and confidentiality will be achieved .  (d)  An offer to provide the name and telephone number of a person who can verify the authenticity of the research project. This person shall not be the Research Administration Officer or any person in the Office of Research Administration. (Note: Investigators should be prepared, should potential respondents request it, to provide the name of a person outside the research group, as required by Section 9 of the SSHRCC guidelines.)  Sensitive Subject Matter: Respondents' should be forwarned of such questions. It is not always practical to do so as part of the interview's front end. Warnings can be placed later in the interview and can take a naturalistic form as long as their content specificially refers to the sensitive matter. Indicate how you propose to deal with sensitive items, if any, in your interview.  ^"6 3  165 Psychiatric Admission Assessment Worksheet Name: Residence: Date of Birth: Admission Date: Duty Doctor's Signature: CONFIDENTIALITY WARNINGS GIVEN CHARGES  PAST CHARGES  PENDING CHARGES  Y: •  N:  • PLEA  DISPOSITION  HISTORY OF CRIMINAL B E H A V I O U R  Medical History:  Functional Inquiry:  Alcohol and Drug Abuse:  Psychiatric History:  FAMILY HISTORY  CRIMINAL BEHAVIOUR F  Y: •  N:  •  M  Y: •  N:  •  Step P's.  Y: Q N:  •  Sibs  Y: •  •  N:  PSYCHIATRIC HISTORY F  Y: •  N:  •  M  Y: •  N:  •  Step P's  Y: •  N:  •  Sibs  Y: •  N:  •  A & D HISTORY F  Y: •  N:  •  M  Y: •  N:  •  Step P's  Y: •  N:  •  Sibs  Y: •  N:  •  General Attitude:  Mood: (sleep, appetite, energy, psychomotor)  Suicide: (thoughts, attempts)  Suicide Risk:  High: •  Moderate: •  Anxiety: (general, phobias, panic attacks)  Thought: (form and content)  Delusions:  Y: • N:  •  Hallucinations:  Y: Q N: Q  Low: •  DIAGNOSIS  Axis I:  Axis II:  Axis III:  Axis IV:  Axis V:  Comments:  PRIMARY THERAPIST COMPLETES SOCIAL HISTORY Primary Therapist Signature: Bio F:  Bio M:  Step P's:  Sibs:  Adoption:  Y: Q N:  Apprehension:  Y: • N: Q  Current Placement:  Past Placements:  •  Age: Reason:  172 DEVELOPMENT HISTORY Birth:  Normal •  Problems Q  Don't Know  •  Pre-School:  School History: Current School:  Academic:  Behaviour:  Susp: Y: •  N: Q  Exp: Y: •  N:  •  Occupational:  Peers:  Gang Affiliation: Y: Q  N:  Q  Delinquent Subculture: Y: Q  N:  Q  173  ABUSE HISTORY Physical Abuse:  Y: •  N: Q  Sexual Abuse:  Y: Q N: Q  If Abused: Recurrent Dreams: Y: •  N: •  Avoidance: Y: •  Memories: Y: Q N: •  N: •  Amnesia: Y: Q N: Q Arousal: Insomnia: Irritability: Startle:  Memories: Y: Q  Detachment: Y: Q  Y: Q N: Q Y: • N: Q Y: • N: Q  N: •  N: Q  Flashbacks: Y: •  Flashbacks: Y: •  N:  N: Q •  Restricted Affect: Y: •  Poor Concentration: Panic Attacks:  Y: Q N: Y: Q N:  N:  • •  •  DSM lll-R  174  ADHD 1.  Fidgeting in seat  Y: •  N:  •  2.  Difficulty remaining seated  Y: Q N: Q  3.  Easily distracted  Y: •  4.  Difficulty Awaiting Turn  Y: Q N:  •  5.  Answers questions before asked  Y: Q N:  •  6.  Fails to finish tasks  Y: •  •  7.  Difficulty sustaining attention  Y: Q N: Q  8.  Shifts from uncompleted activities  Y: Q N: Q  9.  Difficulty playing quietly  Y: Q N:  10.  Talks excessively  Y: Q N: Q  11.  Often interrupts  Y: •  N:  •  12.  Doesn't listen (often)  Y: •  N:  •  13.  Often loses necessary things  Y: Q N: Q  14.  Engages in physically dangerous activities  Y: •  N: Q  N:  •  N: Q  DSM lll-R  175  CONDUCT DISORDER CRITERIA Age of Onset 0-6 yrs. 6-12 yrs. 12-18 yrs. 1.  Stealing (more than once)  Y: •  N:  •  2.  Runaway overnight (at least twice)  Y: •  N:  3.  Frequent lying  Y: •  N:  • •  4.  Firesetting  Y: •  N:  5.  Truancy  Y: •  N:  6.  B&E (house, car, or building)  Y: •  N:  7.  Vandalism  Y: •  N:  8.  Cruel to animals  Y: •  N:  9.  Sexual Assault  Y: •  N:  10.  Use of weapon (more than one fight)  Y: •  N:  11.  Frequent fighting  Y: •  N:  12.  Stealing with confrontation  Y: •  N:  •  13.  Physically cruel to people  Y: •  N:  •  • • • • • • • •  176  O-H/A SCALES 1.  Verbally Hostile: shouts angrily, yells mild insults, makes loud noises, (age of onset 0 Never  2.  ) 2 1/Week  0 Never  ) 2 1/Week  4 1/Day  5  >1/Day  (age last 3 2-4/Week  )  4 1/Day  5  > 1/Day  Aggressive Posturing, aggression against objects: slam doors, make a mess, throw objects, hit walls, break things. (age of onset 0 Never  With Friends Q Peers Q  4.  3 2-4/Week  )  Verbally Aggressive: curses viciously, makes threats of violence toward self or others, (age of onset  3.  (age last  )  (age last  1 1-2/Month  2 1/Week  Siblings Q Parents •  Teachers Q Strangers •  )  3 2-4/Week  T o t a l  =  4 1/Day  5  > 1/Day  ( A P )  Aggressive against self:mild, tantrum-like behaviour without serious injury, scratch, hit self, pull hair, throw self on floor (age of onset 0 Never  With Friends Q Peers •  )  (age last  1 Once  2 2-3 Tims  Siblings • Parents •  Teachers Q Strangers •  )  3 4-6 Times T o t a l  =  4 7-10 times ( A S )  5  More Than 10 Times  177 Violence against self: significant self-injury, self-mutilation - deep cuts, bites that bleed, fractures, burns.  5.  (age of onset  )  0  1  Never With Friends Q Peers •  6.  2 2-3 Tims  Siblings Q Parents Q  Teachers Q Strangers •  With Friends • Peers Q  )  7-10 times  =  T o t a l  5 More Than 10 Times  ( V S )  (age last 2 1/Week  Siblings • Parents Q  Teachers • Strangers Q  )  3 2-4/Week  T o t a l  4 1/Day  =  (  P  H  O  5 > 1/Day  )  Physical violence toward others: attack others causing serious injury, heavy bruising, cuts, lacerations, fractures, internal injury  0  ) 1  ( a g e  ,  Never  1-2/Month  1/Week  Friends Q Peers Q  Siblings Q Parents Q  Teachers Q Strangers Q  Carry weapon:  gun  Y  Use weapon:  gun  Y  knife Y other Y  a s t  )  3 2-4/Week  2  knife Y other Y 9.  4-6 Times  1 1-2/Month  (age of onset _  8.  4  Physical hostility toward others: mild physical aggression - threatening gestures, grab clothes, push, hit without serious injury.  0 Never  With  ) 3  Once  (age of onset  7.  (age last  T o t a l  • • •  N N N;  • • •  • • •  N N N  • • •  =  4  1/Day  (PVO)  , > VDay  YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission • • ••• " . • PROVISIONAL DIAGNOSES ::::  ADMISSION DATA (Psychiatry)  CLIENT NUMBER [__ I _ J _ J — I — 1 _ } AGENCY:  WARD/PROGRAM/UNIT  CLIENT NAME DIAGNOSES: Primary Diagnoses:  . CODES DMSin-R  ICD9-CM  Secondary Diagnoses:  Other Diagnoses:  FORMULATION:  Signature  _ Pate (y/m/d):  _ /  /  File Name = A D M D A T A 3 . D O C " Admission/Assessment Screen 5 * * July 3. 1990 ** FORM YSIJ  Y O U T H SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission  179  M E D I C A L AND BEHAVIORAL ALERTS A D M I S S I O N / A S S E S S M E N T DATA DISPOSITION DATA  CLIENT NUMBER  (Ward/Unit Supervisors)  AGENCY:  (  1  1  1  1  1  WARD/PROGRAM/UNIT DATE (y/m/d):  /  /  CLIENT NAME T.—ADMISSION/ASSESSMENT DATA  2. DISPOSITION DATA  MEDICAL ALERTS:- ~ Alcohol/Drug Abuse:  DATE (y/m/d)  /  /  Personal Background:  DATE (y/m/d)  /  /  Criminal Record:  DATE (y/m/d)  /  /  Med- Complications: _  DATE (y/m/d)  /  Special Diets:  DATE (y/m/d)  /  . /  Family Characteristics:  DATE (y/m/d)  /  Other:  DATE (y/m/d)  / /  /  Other:  DATE (y/m/d)  /  /  Other:  DATE (y/m/d)  /  /  Other:  DATE (y/m/d)  ./--  /  DATE (y/m/d)  /  /  DATE  (y/m/d)  /  /  DATE (y/m/d")  /  /  DATE Cv/m/d)  /  /  DATE (y/m/d)  /  /  DATE (y/m/d)  /  /  7  BEHAVIORAL ALERTS (Table 42):  DESCRIBE SPECIFIC CIRCUMSTANCES:  Signature  !  180  RESPONSIBILITY OF INTAKE WORKER/CASE MANAGER Complete and return for data entry within 24 hrs of admission. Copy of this form must be placed In the Client Clinical Chart within 48 hrs. YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission ADMISSION DATA (Intake Worker/Case Manager)  CLIENT NUMBER t _ J _ L _ l _ J _ J _ J Old Client Number (if anv)  [_ f _ t _ l _ l _ l _ ] AGENCY:  WARD/PROGRAM/UNIT  CLIENT NAME ALSO KNOWN AS PERSONAL INFORMATION Sex (1 = Male, 2 = Female):  Education (Table 28):  Eye Colon  Handicaps:  Hair Colon  Height (###.# cm):  Distinguishing Marks:  Weight (##.# kg):  Date of Birth (y/m/d):  Ethnie Group (Table 51):  Birthplace (Table 25):  P.H.N:  Country  M.S.P:  Citizenship (Table 26):  Name on Card: Phone #/Notify (Y/N)  NAME and ADDRESS CLIENTS ADDRESS:  RELATIONSHIP  Postal Code: GUARDIAN OR PARENT:  Postal Code: EMERGENCY CONTACT:  Postal Code:  i  Postal Code: rr.i* K i , m . . i n M n 4 T i i  nnr  A ^ m l c d ™ / A e c « T T , » . n f <i<-r*+n< 1 1 anH 1 * • Tnlv4. 1000  Form YSI  001  YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission A D M I S S I O N DATA (Intake Worker)  CLIENT NUMBER ( AGENCY:  181 |  WARD/PROGRAM/UNIT DATE (y/m/d):  /  CLIENT NAME LEGAL AND OTHER INFORMATION:  Probable Expiry Date (T/A)  Legal Status (Table 38):  Court Location:  Effective Date (y/m/d):  /  /  Court Date (y/m/d):  Previous Convictions (Y/N):  Court Time (h:m):  Sex OfTense (current) (Y/N):  Stage of Proceedings (Table 56):  Child OfTense (current) (Y/N):  Region Code (Table 105):  Probation (Y/N):  Date of Legal Order (y/m/d):  Probation Length (mo):  O.I.C - Date Req'd (y/m/d):  Sentence Expiry Date (y/m/d):  /  /  /  /  /'.  /  /  / /  / /  Ward/Non-Ward (Table 54):  Criminal Charges (Table 53): Code:  Date:  Code:  Date:  Code:  Date:  / / /  CERTIFYING DOCTOR (Name and Address): Phone: Certifying Date (y/m/d):  Postal Code: CROWN COUNSEL (Name and Address): Phone:  Postal Code: LAWYER/DEFENCE COUNSEL (Name and Address): Phone: .  —  Postal Code: PROBATION/BAIL OFFICER (Name and Address}: Phone:  Postal Code:  /  /  / 7  / '  YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission ADMISSION DATA (Intake Worker) AGENCY:  CLIENT NUMBER ( FACILITY:  1 8 2  |  |  I I I  WARD/PROGRAM/UNIT DATE (y/m/d):  /  /  CLIENT NAME ADMISSION INFORMATION: Referral Type (Table 57): Referral Source (Table 37): Date of Referral (y/m/d):  /  /  Date of Admission/Registration (y/m/d):  /  /  /  /  Time of Admission/Registratioo (24hr dock): Type of Admission (Inpatient/Outpatlent/): Assessment or Treatment: Client Came With (Table 39): Mode of Admission: Projected Discharge Date (y/m/d): Referred by (Name and address): Phone:  Postal Code: Region:  Code:  CASE ASSIGNMENT INFORMATION Child Care Counsellor  Phone #  Nurse: Health Care Worken— Social Worker:  Phone #  Psychiatrist (Tbi lQ4fr  Primary (Y/K)  Psychologist (Tbl 104):  Primary (Y/K)  CTJENTS FAMILY PHYSICIAN: Phone  Postal Code  FJe_Namc •= ADM DATA2.DOC " Admission/Assessment Screens 4,6,11 " June 1, 1990 " FORM YSI002  YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission  183  PROCEDURES/PSYCHOLOGICAL TESTS  MEDICAL  CLIENT NUMBER [  DISPOSITION DATA (Medicine/Psychiatry/Psychology)  |  |  |  |  WARD/PROGRAM/UNTT I A U  AGENCY: YCS  CLIENT NAME  Code  Procedures (Table 47) Hematology:  Hemoglobin,  WBC, E S R , D i f f e r e n t i a l  Date  (y/m/d)  Morphology  Platelets Chemistry  #1:  Routine,  B i 1 i r u b i n - 1 o t a 1,  LDH Random Chemistry  #2:  Urinalysis:  Routine  AST (SGOT)  B/S  Thyroxine  (T4RIA)  Routine  Code  Psychological Tests (Table 46)  Date  (y/m/d)  MMPl  Je sne s s WISC-R/WAIS-R H.T.P.  (House,  Sentence  Person  Drawings)  Completion  Se1f—Ado1escent Self-Drug  Tree,  Use  Alcohol  Involvement  Scale  Screening  Date (y/m/d):  Signature  File Name = DISP06.DOC  Draft  /  /  Disposition Screen 6 ** February 23, 1990 ** FORM YSI010  | ]  184 SOCIAL HISTORY FORMAT ASSESSMENT OF YOUNG OFFENDERS  c  m  i  r  C  es  of  Information  s h o u l d be o u t l i n e d  in  opening paragraph. — ^ T ^ f c  1.  Relatives:  Both parents relatives.  2.  Guardians:  Foster-parents,  3.  Agencies:  MHR s o c i a l w o r k e r s , significant contact  4.  Written  Reason  for  reports:  the  where  2.  As e x p r e s s e d by  3.  As u n d e r s t o o d  or  4.  As u n d e r s t o o d  by t h e w r i t e r  of  can  group  uncles  or  by C o u r t  home p e r s o n n e l .  P r o b a t i o n O f f i c e r s , o r o t h e r who h a v e h a d w i t h t h e y o u n g p e r s o n , s-chc-ol c c w ^ s e l l c r the  referral  package, a l l  other  reports  ^\,<JL.  Order.  the  Probation Officer,  interpreted  w r i t t e n or  by p a r e n t s of  the  and  Social  verbal.  guardian.  History,  pU<^  a precis  Previous  2.  Difficulties  3.  C u r r e n t p r o b l e m s and t h e i r r e l a t i o n s h i p to the h i s t o r i c a l ( i . e . , e s c a l a t i n g , d i m i n i s h i n g , new e m p h a s i s . )  Developmental  charges,  of:.  1.  1.  significant  Difficulty  include  Early  other  Referral  As s t a t e d  History  possible, aunts,  Documents s e n t w i t h read or r e c e i v e d ,  1.  A.  .  - f U - x ^ ^ -  —  This  ,  at  home, s c h o o l ,  Ante-natal  (b) (c)  and o t h e r and i n  the  outcome. community.  iJv;^  zx^tr.difficulties,  History  Development:  (a)  dispositions  (Mothers  information  give  the  best  (some p r o b i n g  information; and j o g g i n g  P h y s i c a l and e m o t i o n a l c o n d i t i o n s of m o t h e r . taken, toxemia. L i f e s t y l e habits - d r i n k i n g , smoking, drugs. Pregnancy: duration.  of  memory  Illness,  is  often  necessary)  medications  185 " \  "  2  D e l i v e r y and Post-natal (a)  Type of b i r t h : n a t u r a l , breech, C-section, use of forceps, other complications. Condition of baby: blue, jaundiced, weight. Response of baby: contented vs agitated; c o l i c k y , eating and sleeping h a b i t s .  (b) (c)  3.  Birth  to 2 years  (a) (b) 4.  Milestones: walked, t a l k e d , t o i l e t - t r a i n e d ( i . e . , slow, f a s t , Traumas: i l l n e s s , h o s p i t a l i z a t i o n , separations from parents.  2 years  1.  Health, s o c i a l  (b)  Behavioural i n d i c a t o r s ,  i n t e r a c t i o n with other c h i l d r e n , speech  (b) (c) 2.  indicators of possible h y p e r a c t i v i t y ^  c*° <> r -S ~ < e  i  UOr  >  [  Development during those years:  (b) (c) (d) (e)  J  Academic performance, grades repeated, t e s t s done by school, and r e c o g n i t i o n . Behaviour as perceived by teachers and peers; suspensions. Sports and other involvementi  awards  High School. (a)  Academic performance,grades repeated, t e s t s done by school, and r e c o g n i t i o n . Behaviour as perceived by teachers and peers; suspensions. Sports and other involvement. Peer r e l a t i o n s h i p , and present grade. Ambitions and plans.  awards-  Other Concerns: . 2.  Health problems, f a l l s , head i n j u r i e s , e t c . Explore problems with (a) e n u r e s i s , and somnambulism. wti'ipr^M*' (b) f i r e - s e t t i n g , c r u e l t y to animals. (c~) aggressive behaviour^/* r«e<J*'"rt (fi) S^MA-cJ. JQ IA/>>_ / pJr^A^-cJ- QJOAJS**-'  ^>  t  ;  development.  Elementary school. (a)  C.  to 5 years  (a)  Education,  time).  Family R e l a t i o n s h i p s  _^  ^  .  ^ ^  J  ^  ,  ^  tvhc-n -i  1. ^ P a r e n t s : marriage, strength of relationship*.- Inquire about:(a) Disagreements and fights between parents - causes. (b) A l c o h o l or drug problems. (c) If separated or divorced - cause of marriage breakdown. (d) Work of parents or means of f i n a n c i a l support. (e) R e l a t i o n s h i p of patient to parents.  £Asj\y\JVA^  CUJM// -^ 5  2.  Siblings:  significant  information about each.  3.  Extended family:  4.  Other important information about the family dynamics.  5  Friendships. Close friends of patient; duration of f r i e n d s h i p s ; to make and keep friends, ( y v ^ ^ C L ^ ^ l t ^ )  patient's  Patient's  r e l a t i o n s h i p with  relationship with family members.  ability  D i s c i p l i n e and Control 1.  Explore parents' methods and attitudes  2.  C h i l d ' s e a r l i e r response to d i s c i p l i n e .  3.  Patient's  4,  P a t i e n t ' s involvement in discipline-forming organizations Demolay, the church or synagogue, sport c l u b s ) .  present  towards d i s c i p l i n e .  1  .lA-<"-^v~pLe.V  response to d i s c i p l i n e and c o n t r o l . (e.g.,  Cadets,  Future Plans 1.  Parents' point of view as to what they would l i k e to see happen w i t h / f o r the patient.  . \^^K  <TA  T-  • •' \  • '  c»Tf\AAAX4«.tt*«-. Z. . . . .  2.  Involved agencies' plans for patient.  3.  W r i t e r ' s impression of what might be helpful to patient based on information gathered. , fx  pry/rtt-.v.r„. ^.ja^JcJJj_  Summary and Evaluation Summarize s a l i e n t points of history, and interpret t h e i r psycho-social meaning based on the gathered information, as well as the affect and emphasis given to the facts by the parents and other sources of information. Recommendat ions may be made subject to the p s y c h i a t r i c / p s y c h o l o g i c a l  Signature of Writer T i t l e of W r i t e r .  ,  -V , ,,  findings.  ^ \ u -  ,  [  i I 1~ rL  \ 1 . 11 (L-h SMV-l*  187  YOUTH COURT SERVICES NURSING ASSESSMENT GUIDELINES 1.  IDENTIFYING DATA Name: D.o.b: Age: Status:  2. REASON FOR  REFERRAL  R e c o r d l e g a l s t a t u s , i n c l u d i n g Young o f f e n d e r s A c t C r i m i n a l Code S e c t i o n i f known.Record o f f e n c e s .  and  3. LEGAL HISTORY E n t e r f o r each c r i m e o r group o f (a) Date (b) Type (c) Disposition 4.  crimes.  MTDTCAT. HISTORY  E n t e r f o r each major i l l n e s s , i n c l u d i n g o p e r a t i o n s injuries (a) (b) (c) (d) (e) 5.  6.  Nature of i l l n e s s ( d i a g n o s i s i f a v a i l a b l e ) Place of treatment Attending p h i s i c i a n Nature of treatment Response t o t r e a t m e n t  PAST MENTAL HEALTH ( i n c l u d e i n p a t i e n t , o u t p a t i e n t (psychiatrist-) (a) (b) (c) (d) (e) (f)  Date Place of treatment Attending physician Symptoms o r d i a g n o s i s Treatment Response t o t r e a t m e n t  FAMILY HISTORY (1) (a) (b) (c) (d) (e)  and  P a r e n t s ; (2) S i b l i n g s ; (3) F o s t e r o r a d o p t i v e p a r e n t s . R e c o r d t h e f o l l o w i n g f o r each. Age Occupation M a r i t a l status Any major i l l n e s s ( p h y s i c a l and mental) Any h i s t o r y o f a l c o h o l , d r u g s , s u i c i d e attemps, diabetes,epilepsy,etc.  and  private  188  (f) (g)  I f member deceased,record cause and age at death. Quality of r e l a t i o n s h i p with p a t i e n t .  7 . PERSONAL HISTORY (a) (b) (c) (d) (e) (f)  (g) (h)  8.  Date and place of b i r t h Ethnicity Complication of pregnancy/delivery and b i r t h weight. Early development,include h i s t o r y of aggressive behaviour. Home atmosphere: r e l a t i o n s h i p s i n childwood with parents, s i b l i n g s , q u a l i t y of family l i f e . Education:include grade level,grade f a i l u r e s , f u r t h e r education,reason for leaving s c h o o l , s p e c i a l a b i l i t i e s , s p e c i a l problems,special/recreational/academic achievements,peer group r e l a t i o n s h i p s . Work h i s t o r y : i n c l u d e age started work,jobs i n chronological order and length job held,reason f o r change, present job. Sexual H i s t o r y : E a r l y sexual development,masturbation (including fantasy),sexual adequacy,present o u t l e t and performance,sexual orientation,abnormal sexual interests. LIFESTYLE PRIOR TO REFERRAL  (a) (b) (c) (d) 9.  Social relationships/friends/school. H a b i t s : i l l i c i t drugs/alcohol/,amount and on l i f e s t y l e . Religion:church attendance,moral values. A c t i v i t i e s and i n t e r e s t .  frequency,effects  CIRCUMSTANCES LEADING TO ARREST AND REFERRAL (a)  10.  Record i n d e t a i l s d and chronological o r d e r , p a t i e n t * s account of events ( i . e . , s u b j e c t i v e f o r m ) . P s y c h i a t r i s t may also include t h i s information.However,a second opinion can be invaluable. CURRENT MENTAL STATUS  (a)  General behaviour and appearance/degree of. cooperation. Contact with surrounding.  (b)  CLINICAL TESTING OF SENSORIUM (i)  Orientation,time/date/month/year,place,person. Awareness of l e g a l s i t u a t i o n and charges. Understanding the nature and purpose of interview.  (ii)  Attention and concentration (comment on person's a b i l i t y to attend to relevant matters).Always include s e r i a l 7 ' s or s e r i a l 3 ' . Month r e v e r s a l .  (iii)  Memory,recent and remote.Comment on person's  ability  189 to r e c a l l events a t the t i n e of the a l l e g e d offence. Ask p a t i e n t t o g i v e name and a d d r e s s , t o r e p e a t immediately and a g a i n i n t h r e e m i n u t e s . (iv)  (v)  General information:Always i n c l u d e the following. Six l a r g e c i t i e s i n Canada,Capital o f Canada,Capital of England,Name o f t h e Prime M i n i s t e r , r u l i n g p o l i t i c a l p a r t y ( P r o v i n c i a l and F e d e r a l ) . I n t e l l i g e n c e : m a k e a g e n e r a l assessment based on the p a t i e n t ' s e d u c a t i o n , g e n e r a l knowledge,use o f language,understanding of c o n c e p t s , e t c .  (c)  Mood- e l e v a t i o n , d e p r e s s i o n , f l a t n e s s , i n c o n g r u i t y , s u s p i c i o n , p e r p l e x i t y , f e a r , a n x i e t y , s l e e p , energy, libido,appetite.  (d)  T h i n k i n g and Speech- s p o n t a n e i t y o f c o n v e r s a t i o n , r a t e , pressure,poverty,possession-(when a person's t h i n k i n g i s c o n t r o l l e d from e l s e w h e r e ) . Thought b l o c k i n g - p e r s e v e r a t i o n - . t h e a b i l i t y t o s w i t c h words o r i d e a s ) , c i r c u m s t a n t i a l i t y , i n t e r p r e t a t i o n - t h e interweaving of two o r more t h o u g h t sequences a t one time),other thought d i s o r d e r , a b i l i t y t o a b s t r a c t - ( r e c o r d f o l l o w i n g responses " s t i t c h i n time...'', " o u t of a f r y i n g pan... ' ', " p e o p l e i n g l a s s houses....''.  (e)  Perceptual disorders. Hallucinations-visual,auditory,etc. Derealisation/Depersonalisation.  (f)  (g)  11.  Special Information, ( i f f i t n e s s i s required). Pleas available t o patient. Nature of evidence Meaning o f Oath Function of Judge,jury,prosecutor, d e f e n c e lawyer. I n s i g h t and judgement. Attitude to present situation, i n c l u d i n g c o u r t case,lawyer, offences,etc. U n d e r s t a n d i n g o f i l l n e s s ( i f present) and need f o r t r e a t m e n t , a b i l i t y t o p l a n ahead.  PROBLEM FORMULATION OR  S.O Rev.-1992.03.05  IMPRESSION.  PSYCHOLOGICAL INTERVIEW  DATE: D.O.B.: CHRONOLOGICAL AGE: Inform o f l i m i t s o f c o n f i d e n t i a l i t y PRESENT CHARGE -  pled g u i l t y current offense  (with whom, when and where)  justification family criminal  history  remorseful f e e l i n g PREVIOUS CHARGE offense  & sentences  outstanding  received  charges  FAMILY CONSTELLATION  r e l a t i o n s h i p w i t h mother r e l a t i o n s h i p with  father  r e l a t i o n s h i p with s i b l i n g s r e l a t i o n s h i p between mother and f a t h e r  191 -  2 -  problem i n t h e f a m i l y : t i o n , work problems  a l c o h o l i s m , drugs,  separa-  LIVING SITUATION p r e s e n t l y l i v i n g where h i s t o r y o f f o s t e r placement h i s t o r y o f r u n n i n g away SCHOOL -  present  school  grade favorite subject l i k e or d i s l i k e grade  school  failures  suspension  i n school  h i s t o r y of f i g h t i n g numbers o f s c h o o l s a t t e n d e d  since kindergarten  FRIENDS numbers o f f r i e n d s degree o f i n t i m a c y and independence w i t h f r i e n d s t y p e s o f a c t i v i t i e s enjoyed best friends existed  (how  long  with f r i e n d s this  relationship  ALCOHOL AND DRUG HISTORY o n s e t o f u s i n g a l c o h o l and/or drugs  has  192 - 3 -  what k i n d s o f drugs q u a n t i t y p e r day, week o r month SEXUAL HISTORY p u b e r t a l experience ( i n c l u d i n g raphy, exposure t o s e x u a l i t y ) first -  sexual experience  numbers o f s e x u a l  fantasy  masturbation prostitution pregnancy HEALTH -  hospitalizations high  fever  head  injury  health i n general allergies FUTURE PLANS BEST MOMENT IN LIFE WORST MOMENT IN LIFE  pornog-  and type  partners  i f charge i s s e x u a l i n nature, sexual  sex abuse,  the d e t a i l s o f i t  193 -  4  -  ANGER MANAGEMENT frustration tolerance sensitivity to criticism response t o a u t h o r i t y emotional verbally  figures  control abusive  physically  abusive  abuse towards inanimate o b j e c t s -  abuse towards animals o r people s e l f d e s t r u c t i o n tendencies  THREE WISHES, PSYCHOLOGICAL HISTORY therapists  (how many, frequency, where, and when)  HISTORY OF SEXUAL ABUSE HISTORY OF PHYSICAL ABUSE MENTAL STATUS EXAMINATION g e n e r a l p r e s e n t a t i o n ( h e i g h t , weight, h a i r , g e n e r a l appearance, d r e s s ) rapport verbal expression eye c o n t a c t  color  of  194 -  5  -  credibility cooperation behaviour during interview (aggressive, alert, apathetic, bizarre, h o s t i l e , f l a t , bland, passive) mood (1 t o 10) stable - labile affect etc.)  (e.g.,  hallucination  at  assessment  anxious,  flat  time,  in  depressed,  general: euphoric  ( a u d i t o r y and/or v i s u a l )  delusions i n s i g h t and eating  judgement  disturbance  r e c e n t l o s s o f weight  (general e a t i n g patterns)  general eating patterns sleep  disturbance  initial  insomnia  intermittent terminal  insomnia  insomnia  h i s t o r y of nightmares somatization paranoid ideation s i g n s of  depression  low energy crying  level  spells  w i t h d r a w a l from r e g u l a r a c t i v i t y  195 - 6 -  -  apathy  -  dysthymic t e n d e n c i e s signs of psychosis  -  anxiety  level  ADOLESCENT'S CHOICE OF DISPOSITION IMPRESSIONS RECOMMENDATIONS  196  Weschler I n t e l l i g e n c e scale f o r Children  - Revised  (WISC-R)  The WISC-R i s an i n t e l l i g e n c e t e s t c o m p r i s e d o f t e n s u b - s c a l e s which p e r m i t s an e v a l u a t i o n of various cognitive abilities, i n c l u d i n g a number o f b o t h v e r b a l and v i s u a l - s p a t i a l a b i l i t i e s . In addition to indicating how a child i s functioning i n t e l l e c t u a l l y i n comparison w i t h same-age p e e r s , t h e WISC-R a l s o yields clues t o the c h i l d ' s self-perception, frustrationt o l e r a n c e , and a number o f performance c h a r a c t e r i s t i c s .  P r o j e c t i v e Drawings T e s t s P r o j e c t i v e drawing t e s t s (e.g. House-Tree-Person T e s t ) p e r m i t an evaluation o f a c h i l d ' s f i n e motor c o o r d i n a t i o n and g e n e r a l d e v e l o p m e n t a l l e v e l , and a l s o y i e l d i n s i g h t i n t o t h e c h i l d ' s s e l f - p e r c e p t i o n and view o f h i s o r h e r e n v i r o n m e n t . In addition, they provide clues t o the c h i l d ' s p e r s o n a l i t y and e m o t i o n a l state.  Minnesota Multiphasic  Personality  Inventory  (MMPI)  The MMPI i s a s e l f - r e f e r r a l q u e s t i o n n a i r e which i s u s e f u l i n assessing an i n d i v i d u a l ' s p e r s o n a l i t y , a f f e c t , a n d i n t e r a c t i v e style. E s s e n t i a l l y , i t i s an o b j e c t i v e instrument used t o identify t h e major p e r s o n a l i t y c h a r a c t e r i s t i c s which a f f e c t p e r s o n a l and s o c i a l adjustment.  Jesness Personality  Inventory  The J e s n e s s i s a l s o a s e l f - r e f e r r a l q u e s t i o n n a i r e , but i t i s s p e c i f i c a l l y t a i l o r e d t o adolescents. I t provides information r e g a r d i n g an a d o l e s c e n t ' s a f f e c t i v e s t a t e , v a l u e o r i e n t a t i o n and s o c i a l adjustment, as w e l l a s h i s o r h e r p e r s o n a l i t y and a c t i n g out p o t e n t i a l .  197  Incomplete Sentences Blank Form This t e s t helps i l l u m i n a t e the i n d i v i d u a l ' s emotional s t a t e and a t t i t u d e s , how he or she perceives the s o c i a l environment, and what h i s or her hopes and fears are for the f u t u r e .  Rorschach Inkblot Test I n d i v i d u a l s ' perceptions of ambiguous s t i m u l i ( i . e . inkblots) reveal a great deal about t h e i r p e r s o n a l i t y organization, i n t e r r e l a t i o n s h i p s and areas of c o n f l i c t . In a d d i t i o n , t h i s t e s t permits an e v a l u a t i o n of c o g n i t i v e d i s t o r t i o n s and c r e a t i v e abilities.  Thematic Apperception T e s t (TAT) The TAT r e q u i r e s the i n d i v i d u a l t o create s t o r i e s i n response t o p i c t u r e s d e p i c t i n g ambiguous scenes. The ways i n which t h e i n d i v i d u a l i n t e r p r e t s the p i c t u r e s y i e l d c l u e s t o the ways i n which he or she perceives h i s or her own s o c i a l environment, arid i s often i n d i c a t i v e of c o n f l i c t s , s t r e s s o r s , r e l a t i o n s h i p s and other important features of the i n d i v i d u a l ' s l i f e .  198  Province O f British Columbia  Ministry of- . Health  Forensic Psychiatric Services Commission 3405 Willingdon Avenue Burnaby  i n  V  T u ^ « « ^  E  S  TO THE COURTS  B n , i s h  Columbia  Telephone: (604)  660-5788  91.02.26 DOCUMENT FORENSIC PSYCHOLOGICAL REPORT PRIVATE AND  CONFIDENTIAL  H i s or Her Honour t h e P r e s i d i n g Judge, Youth Court o f B r i t i s h Columbia, c/o The Court R e g i s t r y , Then t h e address o f t h e court* Your Honour, re:  Name o f t h e a d o l e s c e n t Date o f B i r t h  REASON FOR  REFERRAL  V  R e f e r r e d by P r o b a t i o n O f f i c e r / C o u r t . A l s o i n d i c a t e where t h e a d o l e s c e n t has many t i m e s . SOURCE OF  been seen  and  how  call  and  INFORMATION:  P s y c h i a t r i s t p r o g r e s s note. S o c i a l Worker p r o g r e s s note. Nursing f i l e . PO - Youth Workers r e p o r t . I n f o r m a t i o n from p a r e n t s i n t e r v i e w o r case conference.  telephone  BACKGROUND INFORMATION - SUMMARY Summarize the most s a l i e n t moment o f t h e a d o l e s c e n t . Longstanding h i s t o r y of delinquency. Recent placement. Attendance i n s c h o o l . B r i e f summary o f the f a m i l y s i t u a t i o n . Number o f times he appears b e f o r e t h e c o u r t . INTERVIEW WITH THE  PATIENT  I n f o r m a t i o n of l i m i t e d  confidentiality.  199 2  -  CRIMINAL HISTORY P r e s e n t charge/ p a s t c r i m i n a l h i s t o r y / o u t s t a n d i n g c h a r g e . Involvement w i t h community h o u r s . P r o b a t i o n time done. R a t i o n a l e f o r the p a t i e n t t o e x p l a i n misconduct. R e m o r s e f u l f e e l i n g , r e a c t i o n towards v i c t i m s . Onset o f misconduct b e h a v i o r . FAMILY HISTORY Where i s t h e c h i l d l i v i n g a t t h e t i m e o f t h e assessment. R e l a t i o n s h i p w i t h each member o f t h e f a m i l y including s t e p b r o t h e r , s t e p f a t h e r , and stepmother. H i s t o r y o f f o s t e r placement. Problem a t home. A l c o h o l and drugs, s e p a r a t i o n , work problem, and f i n a n c i a l problem. F a m i l y c o n s u l t a t i o n and number o f s i b l i n g s and s t e p f a m i l y involved. SOCIAL ENVIRONMENT F r i e n d s , d o i n g crime o r not d o i n g c r i m e . A l c o h o l and drug abuse. HEALTH I n j u r i e s , a l l e r g i e s , and broken History of h o s p i t a l i z a t i o n s .  bones.  SEXUAL HISTORY Onset o f s e x u a l i t y . Homosexual t e n d e n c i e s . Pregnancies. Contact with pornographic material. Promiscuous b e h a v i o r . I n a p p r o p r i a t e d r e s s i n g code. SCHOOL S c h o o l performance. H i s t o r y o f school attendance. History of f i g h t s at school. S u s p e n s i o n from s c h o o l . A t t i t u d e toward s c h o o l work.  200  -  3 -  M a j o r problem i n s c h o o l . TEST RESULTS Psychological testing. Behavioral testing. R e s u l t from t h e t e s t i n g . Cognitive a b i l i t i e s . P e r s o n a l i t y Inventory. R e s u l t from t h e MMPI. R e s u l t from t h e J e s n e s s P e r s o n a l i t y I n v e n t o r y . R e s u l t from t h e House-Tree-Person. R e s u l t from t h e Incomplete Sentences Blank. MENTAL STATUS EXAMINATION General d e s c r i p t i o n of the patient. S t y l e and appearance. Rapport. Affect. E a t i n g disturbance. Sleeping disturbance. S u i c i d a l i d e a t i o n - s u i c i d a l attempt - s u i c i d a l Hallucination: auditory or v i s u a l . Verbal expression: amount, flow, and s y n t a x . Sign o f depression. Sign o f psychosis. Thought d i s o r d e r . A n x i e t y l e v e l and s o m a t i z a t i o n .  plan.  IMPRESSION AND RECOMMENDATION T h i s s e c t i o n i s extremely e s s e n t i a l s i n c e most o f t h e t i m e t h i s i s t h e o n l y p a r t t h a t the judge w i l l read, b e f o r e t h e k i d appears i n court. We, t h e r e f o r e , have t o summarize t h e main p o i n t o f t h e r e p o r t even i f i t seems redundant t o r e p e a t them. Summary: t h e age o f t h e p a t i e n t , i n t e l l e c t u a l f u n c t i o n i n g o f t h e p a t i e n t , h i s numbers of appearance b e f o r e t h e c o u r t p r e v i o u s t o t h i s charge, h i s a t t i t u d e s i n t h e i n t e r v i e w and i n t h e t e s t i n g . The main D.S.M. - I I I d i a g n o s t i c c o l o n would be: c o n d u c t disorder, psychotic disorder, C l i n i c a l A f f e c t i v e Disorder, a n x i e t y d i s o r d e r , and A t t e n t i o n D e f i c i t D i s o r d e r .  201  r  -  4 -  P r o g n o s i s and e x p l a n a t i o n of why guarded o r not.  we  proceed  the  prognosis  Recommendations: time f o r p r o b a t i o n , a c c e s s t o c h i l d r e n , curfew, attendance i n s c h o o l , work placement, c h i l d c a r e worker, and D.A.R.E. worker. Treatment:  group, i n d i v i d u a l , and  follow-up of  treatment.  202  CLOSING SUMMARY 1.  I d e n t i f y i n g Data; Name: D.O.B: Address: Status:  2.  Reason f o r Activation: Record l e g a l status, offences,. and r e f e r r i n g agency.  3.  Reason f o r Termination: Record expiry of b a i l , probation, and rescindment of O.I.C. or termination by patient.  4. Mental State at Time o f Termination: B r i e f l y give patient's mental state, how stable he/she i s . b.  Treatment Provided: Example - chemotherapy, supportive psychotherapy.  6.  Medication: L i s t a l l medication patient has been on and current medication.  7.  Diagnosis: As per p s y c h i a t r i s t .  8.  Reccrrrnendation: Any future treatment and rnanagement plan.  SO/cm  YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission  203  DISCHARGE/DISPOSITION DIAGNOSES ADMISSION DATA (Psychiatry)  CLIENT NUMBER AGENCY:  I  l _ l  I  I  WARD/PROG RAM/UNIT  CLIENT NAME CODES  DIAGNOSES: Primary Diagnoses:  DMSIII-R  Secondary Diagnoses:  Other Diagnoses:  FORMULATION:  \  Signature  Date (y/m/d):  ICD9-CM  *  1  

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