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Juvenile sex offender treatment outcome and conduct disorder diagnosis 1995

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. JUVENILE SEX OFFENDER TREATMENT OUTCOME AND CONDUCT DISORDER DIAGNOSIS by MICHAEL JAMES POND R.P.N., Alberta Hospital School of Nursing, 1978 B.S.W., The University of 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 thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1995 © Michael James Pond, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of 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 scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that 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 A b s t r a c t Using a d e s c r i p t i v e design, 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 outcomes between j u v e n i l e sex offenders who were diagnosed w i t h Conduct Disorder (according to DSM-III-R (APA, 1987) c l a s s i f i c a t i o n system c r i t e r i a ) and 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 c l i n i c a l records of 100 j u v e n i l e males convicted w i t h a sexual offense who were court ordered f o r a p s y c h i a t r i c / p s y c h o l o g i c a l / s o c i a l assessment and treatment at Youth Court Services/Out-patient C l i n i c between January 1, 1989 and January 1, 1993 were stud i e d . The r e s u l t s i n d i c a t e d that the youths diagnosed w i t h Conduct Disorder d i s p l a y e d a s i g n i f i c a n t l y higher p r o b a b i l i t y f o r unsuccessful treatment outcome as compared to those youths wi t h a non-conduct d i s o r d e r d i a g n o s i s . The f i n d i n g s suggest the j u v e n i l e sex offender who i s diagnosed as conduct disordered may be a subtype who i s at higher r i s k of u n s u c c e s s f u l l y completing treatment, and may r e q u i r e a more 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 . Furthermore, the f i n d i n g s suggest that there are l i m i t a t i o n s to 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 . I l l TABLE OF CONTENTS Page A b s t r a c t i i Table of Contents i i i L i s t of Tables v i i i Acknowledgements - i x CHAPTER ONE 1 INTRODUCTION 1 Statement of Purpose 1 Thesis Overview 2 Ju v e n i l e Sex Offenders Impact on So c i e t y 4 The Extent of the Problem 5 The J u v e n i l e Sex Offender and Offenses 7 Legal D e f i n i t i o n 7 Canadian Legal D e f i n i t i o n s 9 Meaning of Consent 11 Medical D e f i n i t i o n 12 The Modal J u v e n i l e Sex Offender.. 19 The Heterogeneity of J u v e n i l e Sex Offenders 22 S o c i o c u l t u r a l Factors 25 i v S o c i a l Competence 2 6 Sexual Adjustment.. 28 Cognit i v e Factors and Academic A b i l i t y 29 V i c t i m C h a r a c t e r i s t i c s 30 Level of Aggression and Violence 32 P s y c h i a t r i c Factors and Conduct Disorder 33 CHAPTER TWO 37 PSYCHIATRIC DIAGNOSIS AND SEXUAL OFFENDING IN ADOLESCENTS 37 In t r o d u c t i o n 37 H i s t o r y of 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 Ev a l u a t i o n of M u l t i a x i a l System 45 C r i t i c a l A n a l y s i s of DSM Revisions 49 C l i n i c a l Bias 51 Strengths and L i m i t a t i o n s of DSM 53 P a t h o l o g i z i n g C h i l d r e n 54 Changes i n DSM Categories and C r i t e r i a . . . 56 H i e r a r c h i c a l S t r u c t u r e 56 Diagnostic 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 of Conduct Disorder 63 V D i s r u p t i v e Behaviour Disorders 63 E v o l u t i o n of Conduct Disorder Subtypes 66 Ev 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 Disorder ...72 Diagnostic Thresholds 73 Conduct Disorder Symptoms 74 Treatment Outcome 77 Research Purpose and Hypotheses ..84 CHAPTER THREE 91 RESEARCH DESIGN 91 In t r o d u c t i o n 91 Method 92 Subjects 92 Measures 93 Diagnostic V a r i a b l e 93 A l t e r n a t e Diagnostic V a r i a b l e 93 Conduct Disorder Symptom V a r i a b l e 95 Previous Non-sexual Offense 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 v i CHAPTER FOUR 101 RESULTS 101 Treatment Outcome.... 101 P s y c h i a t r i c Conduct Disorder (PCD) 101 A l t e r n a t e Conduct Disorder (ACD) 102 A l t e r n a t e and P s y c h i a t r i c Diagnosis 104 Conduct Disorder Behavioral V a r i a b l e s 105 Previous Non-sexual Offenses 107 P s y c h i a t r i c Conduct Disorder 107 A l t e r n a t e Conduct Disorder 108 CHAPTER FIVE 110 DISCUSSION 110 Im p l i c a t i o n s 110 L i m i t a t i o n s 117 Conclusions 120 B i l i o g r a p h y 121 Appendices 153 Appendix 1: Youth Court Services L e t t e r of Approval 154 Appendix 2: UBC Request f o r E t h i c a l Review 155 v i i Appendix 3: UBC O f f i c e of Research Services 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 Admission Worksheet 165 Appendix 5: Forensic P s y c h i a t r i c Services Commission P r o v i s i o n a l Diagnosis 178 Appendix 6: Medical and Behavioral A l e r t s 179 Appendix 6: Forensic P s y c h i a t r i c Services Commission Admission Data 180 Appendix 8: Medical Procedures/Psychological Tests....183 Appendix 9: S o c i a l H i s t o r y Format .....184 Appendix 10: Nursing Assessment Guidelines 187 Appendix 11: P s y c h o l o g i c a l Interview 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 Diagnosis 203 LIST OF TABLES v m Table 1: Percentages of Conduct Disordered and Non-Conduct Disordered Subjects With Successful and Unsuccessful Treatment Outcomes 103 Table 2: I n d i v i d u a l Conduct Disorder Behaviours Diagnosis and Successful Treatment Outcome 106 Table 3: Percentages of Conduct Disordered Subjects and Non-Conduct Disordered Subjects With Previous Non-sexual Offenses 109 i x Ac knowledgements To my w i f e , Rhonda, who w i t h patience and love has continuously supported and endured a l l my e f f o r t s . To my sons, Taylor, Brennan, and Jonathan, who put up w i t h a f r e q u e n t l y absent f a t h e r . To Armond and Doreen, who supported and loved me i n more ways than they can imagine. To my mother, Merva, who was there when I needed her. To my advisor, Mary R u s s e l l , f o r always sharing her time and guiding me 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 process. To the s t a f f at Youth Court Services f o r t h e i r advise and access to the c l i n i c a l records. A l l of you gave me the strength to complete t h i s p r o j e c t . 1 CHAPTER ONE INTRODUCTION Statement of Purpose The purpose of t h i s t h e s i s i s to 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 diagnosis of Conduct Disorder and treatment outcomes of j u v e n i l e sex offenders. To achieve t h i s purpose, the c l i n i c a l records of a pop u l a t i o n of adolescent male sex offenders were s t u d i e d to determine i f the diagnosis has any impact on ou t - p a t i e n t treatment outcomes. The j u v e n i l e sex offender diagnosed w i t h Conduct Disorder possesses unique c h a r a c t e r i s t i c s that d i s c r i m i n a t e him from other adolescent sex offenders. As such, the p s y c h i a t r i c diagnosis of Conduct Disorder may be one way of i d e n t i f y i n g a s p e c i f i c subtype of j u v e n i l e sex offender who i s more l i k e l y to have unsuccessful treatment outcomes as compared to the offender who i s not diagnosed w i t h Conduct Disorder. Previous stud 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 f o r i d e n t i f y i n g subgroups w i t h i n the sex offender group have been devoted to the adult p o p u l a t i o n . The heterogeneity of adult sex offenders has been w e l l documented and recent s t u d i e s (eg. Knight & Prentky, 1990; Knight, 1992) have i d e n t i f i e d more 2 homogeneous subgroups f o r the purposes of improving p r e d i c t i o n and enhancing d i s p o s i t i o n a l accuracy. However, no comparable taxonomic studies have been undertaken f o r j u v e n i l e sex offenders (Knight & Prentky, 1993). Most of 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 offenders are l i m i t e d to simple 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 of these offenders and t h e i r offenses, such as,' t h e i r ages, the h i s t o r y of t h e i r previous sexual and non-sexual offending, the types of sexual crimes they have committed, and the ages and sexes of t h e i r v i c t i m s . The l i t e r a t u r e provides only weak speculations about the importance 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 dimensions. Thesis Overview This chapter w i l l discuss some of the more s i g n i f i c a n t dimensions that may act 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 offenders i n t o more homogenous subgroups. This provides a background to i n v e s t i g a t i n g Conduct Disorder diagnosis 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 of offender. The i n t e n t i o n of t h i s chapter i s to introduce the background and problem area of t h i s t h e s i s . To accomplish t h i s purpose, I s h a l l , 3 f i r s t , d efine and describe the problem i n terms of s o c i e t y ' s awareness and response to j u v e n i l e sexual 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 sexual 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 . T h i r d , I w i l l examine- offense and offender c h a r a c t e r i s t i c s i n an attempt to demonstrate the heterogeneity of t h i s p o p u l a t i o n . In so doing, I w i l l d iscuss c e r t a i n t y p o l o g i e s that may d i v i d e t h i s heterogeneous population i n t o meaningful 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 of the p s y c h i a t r i c diagnosis of Conduct Disorder as a subgroup c l a s s i f i c a t i o n and i t s relevance to the treatment outcomes of j u v e n i l e sex offenders. Chapter two provides a review of the e x i s t i n g l i t e r a t u r e i n terms of p s y c h i a t r i c diagnosis according to the various e d i t i o n s of the Diagnostic and S t a t i s t i c a l Manual of Mental 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 , chapter two provides a review of the l i t e r a t u r e on the diagnosis of Conduct Disorder and i t ' s relevance to the assessment and treatment of adolescent sex offenders. Chapter three o u t l i n e s the research design and Chapter four provides the r e s u l t s of t h i s study. Chapter f i v e discusses the research 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. 4 The J u v e n i l e Sex Offender's Impact on S o c i e t y Sexual a s s a u l t i s now recognized as one of the more severe problems i n modern western s o c i e t y , ranking w i t h nonsexual crime, poverty, environmental damage and substance abuse as a s o c i e t a l i l l . The prevention of sexual a s s a u l t w i l l depend on the extent to which i n d i v i d u a l s can be stopped from committing these crimes. A l a r g e body of research has i n d i c a t e d that a very high percentage of adult sex offenders began t h e i r o f fending career as adolescents (Davis & Leitenberg, 1987; Groth, 1977; Groth, Longo & McFadin, 1982; Longo, 1983; Longo & Groth, 1983) and i t i s imperative to concentrate on j u v e n i l e offenders i n order to detect the problem e a r l y and prevent or reduce l a t e r v i c t i m i z a t i o n . Ryan, Lane, Davis, and Isaac (1987) contend that 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 both f o r the prevention of m u l t i p l e v i c t i m i z a t i o n s and to i n t e r r u p t the r e i n f o r c i n g nature of deviant sexual behaviours. Furthermore, s e v e r a l s t u d i e s suggest that sex offenders may be more amenable to treatment during adolescence r a t h e r than during adulthood and that e a r l y i n t e r v e n t i o n may have pre v e n t a t i v e value (Abel, Mittleman, & Becker, 1985; Groth, et a l . , 1982; 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 that a high 5 percentage of sexual offenses are committed by p e r p e t r a t o r s under the age of 18 (Fehrenbach, Smith, Monastersky, & Deisher, 1986). In a d d i t i o n , a m a j o r i t y of adult sex offenders i n d i c a t e that the onset of t h e i r deviant sexual behavior occurred i n adolescence. The Extent of the Problem P r i o r to e a r l y 1980's, the predominant view of the sexual offenses committed by adolescents was that these were considered simply nuisance behaviours w i t h a discounted estimate of the s e v e r i t y of the harm produced. These behaviours 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 innocent. As such, i t was seen as the normal aggressiveness of s e x u a l l y maturing adolescents. Some s o c i a l s c i e n t i s t s viewed t h i s behaviour to be the r e s u l t of the marginal status of the adolescent male and the consequent r e s t r i c t i o n s of h i s permitted sexual o u t l e t s (Finklehor, 1979; Gagnon, 1965; Maclay, 1960; Markey, 1950; Reiss, 1960; Roberts et a l . , 1973). Others saw i t more as a r e f l e c t i o n of a general problem of a n t i s o c i a l behaviour. This tendency to minimize j u v e n i l e sex offending has reduced considerably over the l a s t 15 years, mainly because 6 there i s an increased awareness of the numbers of j u v e n i l e sex offenders. Twenty percent of a l l rapes and between 30% and 50% of a l l c h i l d molestations are perpetrated by adolescent males (Becker, Kaplan, Cunningham-Rathner, & Kavoussi, 1986; Brown, Flanagan, & McLeod, 1984; Deisher, Wenet, Paperney, Clark, & Fehrenbach, 1982; Groth, Longo, & McFadin, 1982). The U.S. 1986 a r r e s t s t a t i s t i c s report that approximately 20% of a l l s e x u a l l y aggressive crimes are committed by males under 19 years of age (Federal Bureau of I n v e s t i g a t i o n , 1987). Abel, Becker, Cunningham-Rathner, Rouleau, Kaplan, & Reich (1984) c l a i m that the average adolescent sex offender w i l l , without treatment, go on to commit 380 sexual crimes during h i s l i f e t i m e . Moreover, numerous studi e s suggest that approximately h a l f of a l l adult sex offenders report s e x u a l l y deviant behaviour i n adolescence (Abel et a l . , 1985; Becker, Kaplan, Cunningham-Rathner, & Kavoussi, 1986; Longo & Groth, 1983; Longo & McFadin, 1981; McConaghy, B l a s z c z y n s k i , Armstrong, & Kidson, 1989; Ryan, Lane, Davis, & Issac, 1987). Consequently, 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 before the behaviour becomes more entrenched i n adulthood (Green, 1987; Stenson & Anderson, 1987) 7 The J u v e n i l e Sex Offender and Offenses I n t r o d u c t i o n I t 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 offender and h i s offenses. I w i l l attempt to define these terms from both the l e g a l and the medical 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 of the l i m i t a t i o n s of 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 of j u v e n i l e court j u r i s d i c t i o n i n North America v a r i e s from 6 to 12, wit h many U.S. s t a t e s s e t t i n g 10 as the lowest age of 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 of 12. Depending upon the s t a t e or province, the maximum age of j u v e n i l e court j u r i s d i c t i o n runs from 15 to 17. In Canada adulthood begins f o r c r i m i n a l law purposes at the 18th b i r t h d a y , w i t h the reference date being the date of the commission of the a l l e g e d offense. J u v e n i l e s charged w i t h more serious sexual offenses may be subject to t r a n s f e r i n t o the adult system f o r t r i a l ; i f convicted there, they may face more severe adult sentences and can be i n c a r c e r a t e d i n adult f a c i l i t i e s . The l e g a l d e f i n i t i o n of what c o n s t i t u t e s a sexual offense 8 varies from one statute to another. Those seeking to invoke the criminal law i n th e i r work with adolescent sex offenders should be aware of 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 avoid r e l y i n g simply on c l i n i c a l or mor a l i s t i c notions of what constitutes appropriate or inappropriate behavior. In every j u r i s d i c t i o n , touching the g e n i t a l i a of another person for a sexual purpose, whether or not thi s involves intercourse, i s a criminal offense unless the other person f r e e l y consents. This would encompass such offenses as rape, sexual assault, and aggravated sexual assault. In some j u r i s d i c t i o n s of the United States, there i s a statutory minimum age for certain types of sexual offenses, such that a youth below a sp e c i f i e d age, such as 14, i s regarded as l e g a l l y incapable of committing such an offense. 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 that protects children and adolescents from sexual involvement with those who are l e g a l l y regarded as being i n a pos i t i o n to exploit the youthfulness of the victim. This l e g i s l a t i o n renders what would otherwise be consensual sexual relations a criminal offense. There i s substantial v a r i a t i o n i n how such "statutory rape" provisions are drafted, and some 9 j u r i s d i c t i o n s c r i m i n a l i z e what other j u r i s d i c t i o n s regard as l e g a l l y acceptable. For example, i t i s an offense f o r a 15- year - o l d to be i n v o l v e d i n a consensual sexual r e l a t i o n s h i p w i t h a 13-year-old 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 offense f o r a 16-year-old to be s e x u a l l y i n v o l v e d w i t h a 13-year-old. Canadian Legal D e f i n i t i o n s Under the Canadian C r i m i n a l Code there are s e v e r a l types of sexual offenses. I w i l l o f f e r a b r i e f overview of the most rel e v a n t types a p p l i c a b l e to j u v e n i l e sex offenders. Sexual i n t e r f e r e n c e . "Every person who, f o r sexual purpose, touches, d i r e c t l y or i n d i r e c t l y , w i t h a part of the body or wi t h an object, any part of the body of a person under the age of fourteen years..." (Martin's C r i m i n a l Code of Canada, 1994; p. CC/220). I n v i t a t i o n to sexual touching. "Every person who,•for sexual purpose, i n v i t e s , counsels or i n c i t e s a person under the age of fourteen years to touch, d i r e c t l y , or i n d i r e c t l y , w i t h a part of the body or wi t h an object, the body of any person, i n c l u d i n g the body of the person who so i n v i t e s , counsels or i n c i t e s and the body of the person under the age 10 of fourteen years..." (Martin's C r i m i n a l Code of Canada, 1994; p. CC/221). Incest. "Every one commits i n c e s t who, knowing that another person i s by blood r e l a t i o n s h i p h i s or her parent, c h i l d , brother, s i s t e r , grandparent or grandchild, as the case may be, has sexual i n t e r c o u r s e with that person" (Martin's C r i m i n a l Code of Canada, 1994, p.232) . Indecent a c t s . "Every one who w i l f u l l y does an indecent act (a) i n a p u b l i c place i n the presence of one or more persons, or (b) i n any place, w i t h i n t e n t thereby to i n s u l t or offend any person... Every person who, i n any place, f o r a sexual purpose, exposes h i s or her g e n i t a l organs to a person who under the age of fourteen years...." (Martins C r i m i n a l Code of Canada, 1994; p. CC/245). Sexual a s s a u l t . "Sexual a s s a u l t i s an a s s a u l t , which i s commited i n circumstances of a sexual nature such that the sexual i n t e g r i t y of the v i c t i m i s v i o l a t e d . . . . " (Martin's C r i m i n a l Code of Canada, 1994; p. CC/444). Sexual a s s a u l t with a weapon or causing bodiy harm. "Everyone who, i n commiting sexual a s s a u l t , (a) c a r r i e s , uses or threatens to use a weapon or an i m i t a t i o n thereof, (b) threatens to cause b o d i l y harm to a person other than the 11 complainant, (c) causes b o d i l y harm to the complainant...." (Martins C r i m i n a l Code of 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 or endangers the l i f e of the complainant" (Martin's C r i m i n a l Code of Canada, 1994, p. CC/447). Meaning of "Consent" "Consent means the volu n t a r y agreement of the complainant to engage i n the sexual a c t i v i t y i n question. No consent i s obtained where (a) the agreement i s expressed by the words or conduct of a person other than the complainant; (b) the complainant i s incapable of consenting to the a c t i v i t y ; (c) the accused induces the complainant to engage i n the a c t i v i t y by abusing a p o s i t i o n of t r u s t , power or a u t h o r i t y ; (d) the complainant expresses, by words or conduct, a l a c k of agreement to engage i n the a c t i v i t y ; or (e) the complainant, having consented to engage i n sexual a c t i v i t y , expresses, by words or conduct, a l a c k of agreement to continue to engage i n the a c t i v i t y . " (Martin's C r i m i n a l Code, 1994; p. CC/448) Consent no defence. Under s e c t i o n 150.1 of the C r i m i n a l 12 Code of Canada (1994) i t st a t e s that when the offender i s charged w i t h a sexual offense and the v i c t i m i s under the age of 14 i t i s not a defense that the v i c t i m consented. However, i f the v i c t i m i s 12 to 13 years of age i t i s not a defense that the v i c t i m consented unless the offender i s : (a) 12 to 15 years o l d ; (b) l e s s than two years o l d e r than the v i c t i m ; or (c) n e i t h e r i n a p o s i t i o n of t r u s t or a u t h o r i t y towards the v i c t i m nor i s the v i c t i m i n a r e l a t i o n s h i p of dependency wi t h the offender. In summary, i t i s apparent that the l e g a l d e f i n i t i o n of what c o n s t i t u t e s a sexual offense v a r i e s from one s t a t u t e to another. Furthermore, the l e g a l d e f i n t i o n alone i s inadequate i f the p r o f e s s i o n a l d e s i r e s a c l e a r understanding of j u v e n i l e sexual offending and the offender. 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 of t h i s - problem. Medical D e f i n i t i o n P a r a p h i l i a . " 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 of choice f o r s e x u a l l y deviant behaviour. The p a r a p h i l i a s described here inc l u d e E x h i b i t i o n i s m , Fetishism, Frotteurism, P e d o p h i l i a , Sexual Sadism, Voyeurism, T r a n s v e s t i c 13 Fetishism, and P a r a p h i l i a U n s p e c i f i e d . The Diagnostic and S t a t i s t i c a l of Mental Disorders (APA, 1994) describes the e s s e n t i a l feature of the p a r a p h i l i a s as "recurrent intense sexual urges and s e x u a l l y arousing f a n t a s i e s g e n e r a l l y i n v o l v i n g e i t h e r (1) nonhuman ob j e c t s , (2) the s u f f e r i n g or h u m i l i a t i o n of o n s e l f or one's partner, or (3) c h i l d r e n or nonconsenting persons (p. 552)". Therefore, obviously, a s i g n i f i c a n t number of sex offenders would be diagnosed a " p a r a p h i l i a c s . " According to Abel et a l . (1985), 100% of adult c h i l d molesters can be diagnosed 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 nerally age 13 years or younger) and the i n d i v i d u a l diagnosed w i t h P e d o p h i l i a must be age 16 years or o l d e r and at l e a s t 5 years o l d e r than the c h i l d (DSM-IV, APA, 1994). However, according to the DSM-IV (APA, 1994), "For i n d i v i d u a l s i n l a t e adolescence diagnosed 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; both the sexual m a t u r i t y of t h e - c h i l d and the age d i f f e r e n c e must be taken i n t o account" (p. 527). As such, those perpetrators, i n e a r l y and middle adolescence who offend against small c h i l d r e n do not q u a l i f y f o r t h i s d i a g n o s i s . Moreover, one must r e l y on the p r o f e s s i o n a l ' s c l i n i c a l 14 judgement when diagnosing those offenders i n l a t e adolescence. The 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 the exposure of one's g e n i t a l s to a stranger and sometimes the i n d i v i d u a l masturbates while exposing h i m s e l f . The p a r a p h i l i c focus i n Fet i s h i s m i n v o l v e s r e c u r r e n t , intense sexually- arousing f a n t a s i e s , sexual urges, or behaviors i n v o l v i n g the use of 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 touching and rubbing against a nonconsenting person. The i n d i v i d u a l rubs h i s g e n i t a l s against the v i c t i m ' s thighs and buttocks or fondles her g e n i t a l i a or breasts w i t h h i s hands. The behavior u s u a l l y occurs i n crowded palces from which the 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 . Voyeurism i n v o l v e s the act of observing unsuspecting i n d i v i d u a l s , u s u a l l y strangers, who are naked, i n the process of d i s r o b i n g , or engaging i n sexual a c t i v i t y . Among r a p i s t s , diagnosis i s not so s t r a i g h t f o r w a r d . The only 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 that r e l a t e s to rape i s Sexual Sadism, but i t would apply only to those r a p i s t s who appear to gain sexual pleasure from the 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 sexual abuse wit h j u v e n i l e offenders i s a complicated endeavour. The same 15 a p p l i c a t i o n as adult offenders i s appropriate w i t h respect to the degree of i n t r u s i v e n e s s and amount of coercion 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 of adequate knowledge as to what c o n s t i t u t e s "normal" adolescent sexual behaviour. I t seems more c o n s t r u c t i v e to examine the behaviours inv 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 of coercion and the issue of consent than to 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 c r i t e r i a (Barbaree, M a r s h a l l , & Hudson, 1993). As such, i t may be that p s y c h i a t r i c diagnoses f o r the j u v e n i l e sex offender are being made based on the behaviours i n v o l v e d and not the s t r i c t age c r i t e r i a as d i c t a t e d by the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. Therefore, I w i l l o f f e r another d e f i n i t i o n of j u v e n i l e sexual a s s a u l t i n terms of behaviours, 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 offender. Third, I w i l l present 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 features that do not f i t w i t h the modal p r o f i l e , thus suggesting the heterogeneity of the j u v e n i l e sex offender p o p u l a t i o n . 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 the p s y c h i a t r i c diagnosis of Conduct Disorder as a subgroup c l a s s i f i c a t i o n and i t s relevance, to treatment outcomes of j u v e n i l e sex offenders. J u v e n i l e Sexual Offense. As i n d i c a t e d p r e v i o u s l y , j u v e n i l e sexual offenses may be c h a r a c t e r i z e d by one or more of a wide array of behaviours, and more than one type of deviancy may be seen i n a s i n g l e i n d i v i d u a l . M o l e s t a t i o n of younger c h i l d r e n or peers may i n v o l v e touching, rubbing, and/or p e n e t r a t i n g behaviours. Rape may i n c l u d e any sexual act perpetrated w i t h v i o l e n c e or f o r c e ; l e g a l d e f i n i t i o n s o f t e n i n c l u d e p e n e t r a t i o n . P e n e t r a t i o n may be o r a l , anal, or 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 . Hands-off offenses i n c l u d e exhibitionism, voyeurism, frottage, fetishism, and obscene communication (such as obscene phone c a l l s , and v e r b a l or w r i t t e n sexual harassment). In e v a l u a t i n g the sexual abuse of c h i l d r e n by a d u l t s , age d i f f e r e n t i a l and behaviours are adequate to define the problem. However, when concerns a r i s e regarding sexual 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 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 r e q u i r e d . Thus, i n any sexual i n t e r a c t i o n , the f a c t o r s that 17 are u s e f u l when assessing the presence or absence of e x p l o i t a t i o n are e q u a l i t y , consent, and coercion. The issue of e q u a l i t y addresses d i f f e r e n c e s i n p h y s i c a l , c o g n i t i v e , and emotional development, p a s s i v i t y and ass e r t i v e n e s s , 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 to assess, c o g n i t i v e and emotional 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 experience. That i s , regardless of age d i f f e r e n c e s , the act may be considered e x p l o i t i v e i f the two p a r t i e s are not developmentally equal. S i m i l a r l y , power and c o n t r o l issues and p a s s i v i t y and asse r t i v e n e s s may be used to define the r o l e s of 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 order to c l a r i f y the e q u a l i t y or i n e q u a l i t y of the two i n a p a r t i c u l a r s i t u a t i o n . In a d d i t i o n , a u t h o r i t y of one c h i l d over the other may e x i s t . For example, i n the case of an ol d e r c h i l d being put i n charge of 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 or when one c h i l d takes on the r o l e of "parent" or "teacher" i n a p l a y s i t u a t i o n . More su b t l e l e v e l s of a u t h o r i t y may incl u d e the i m p l i c a t i o n s of 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 , competence, t a l e n t s and success. 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 ol d e r adolescent. 18 The second f a c t o r i n d e f i n i n g sexual e x p l o i t a t i o n i s consent. Although a r b i t r a r y ages have been considered i n the l e g a l d e f i n i t i o n of the "age of consent", assessing consent demands more than a l e g a l d e f i n i t i o n or an age i d e n t i f i e r . The elements of consent have been defined as f o l l o w s : Agreement i n c l u d i n g a l l of the f o l l o w i n g : (1) understanding what i s proposed based on age, maturity, developmental l e v e l , f u n c t i o n i n g , and experience; (2) knowledge of s o c i e t a l standards f o r what i s being proposed; (3) awareness of p o t e n t i a l consequences and a l t e r n a t i v e s ; (4) assumption that agreements or disagreements w i l l be respected e q u a l l y ; (5) vol u n t a r y d e c i s i o n ; and, (6) mental competence (National Task Force on J u v e n i l e Sexual Offending, 1988). The assessment of consent may cause confusion, p a r t i c u l a r l y i n terms of the d i s t i n c t i o n s between compliance, cooperation, and consent. Consent i m p l i e s f u l l knowledge, understanding, and choice; whereas, cooperation i m p l i e s an a c t i v e p a r t i c i p a t i o n regardless of personal b e l i e f or d e s i r e and may occur without consent. Compliance may allow or p a s s i v e l y engage the v i c t i m without r e s i s t a n c e i n s p i t e of opposing b e l i e f s or d e s i r e s (Ryan, Lane, Davis, & Isaac, 1987) . 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 that deny the v i c t i m free choice. Once again, p h y s i c a l s i z e and/or perceptions of power or a u t h o r i t y are o f t e n e x p l o i t e d to coerce cooperation and compliance. Coercion can al s o i n v o l v e secondary gains or l o s s e s . For example, the offender w i l l use b r i b e r y i n the form of money, t r e a t s , favours, or f r i e n d s h i p i n r e t u r n f o r sexual involvements. Or, the offender may use more su b t l e and r e f i n e d forms of coercion w i t h i n the e x p l o i t i v e r e l a t i o n s h i p that are based upon h i s manipulative use of c a r i n g and nurturance of the v i c t i m . As such, the v i c t i m w i l l comply with the offender's wishes so as to avoid r e j e c t i o n or abandonment. F i n a l l y , the more b l a t a n t form of coercion l i e s i n the use of thr e a t s and v i o l e n c e . Although acts of v i o l e n c e are used, t h r e a t s of force or v i o l e n c e are more common. This form i s p a r t i c u l a r l y evident i n the sexual abuse of c h i l d r e n since a c h i l d i s more e a s i l y coerced without r e s o r t i n g to v i o l e n c e as compared to sexual a s s a u l t s against peers or a d u l t s . The Modal J u v e n i l e Sex Offender With the l e g a l and medical d e f i n i t i o n s i n mind, the 20 j u v e n i l e sex offender i s defined as a youth (age 12-17 i n Canada) who commits any sexual act with a person of any age against the v i c t i m ' s w i l l , without consent, or i n an aggressive, e x p l o i t i v e , or threatening- manner (Ryan & Lane, 1991). Although s t u d i e s i n d i c a t e that no one s i n g l e p r o f i l e can be a p p l i e d to every j u v e n i l e sex offender, i t i s p o s s i b l e to present what Ryan and Lane (1991) c a l l the modal (or most of t e n i d e n t i f i e d ) offender and offense as a composite. Using p a r t i c u l a r s t u d i e s of j u v e n i l e sex offenders as reference, one i s able to describe s e v e r a l features that are s i m i l a r i n most samples (Awad, Saunders, & Levene, 1984; Awad & Saunders, 1989; Becker, Kaplan, Cunningham-Rathner, Kavoussi, 198 6; Davis & Leitenberg, 1987; Fehrenbach, Smith, Monastersky, & Deisher, 1986; Knight & Prentky, 1993; Ryan et a l . , 1987; Wasserman & Kappel, 1985; Wheeler, 1986)). As such, the modal j u v e n i l e sex offender i s a fourteen year o l d white middle c l a s s male of average- i n t e l l i g e n c e with some form of l e a r n i n g d i f f i c u l t y . He would have been l i v i n g w i t h two parents at the time of h i s offense. Although he has had no previous c o n v i c t i o n s f o r sexual a s s a u l t , t h i s i s qu i t e 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 probably d i s c l o s e that he has been a v i c t i m of sexual abuse by some one he knows, 21 such as a neighbour or r e l a t i v e . His v i c t i m i s most l i k e l y a seven or eight year o l d female who i s not r e l a t e d to the offender by blood or marriage. The a s s a u l t i s coercive i n v o l v i n g g e n i t a l touching, 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 that he has been con v i c t e d of nonsexual delinquent behaviour p r i o r to t h i s a r r e s t . This b r i e f thumbnail sketch suggests that j u v e n i l e sex offenders are an homogeneous group. However, the f o l l o w i n g d i s c u s s i o n supports the contention that they are heterogeneous and present w i t h a wide range of c h a r a c t e r i s t i c s and dimensions. Moreover, i t i s argued that some of these c h a r a c t e r i s t i c s may be d i s c r i m i n a t e d to form more homogeneous subgroups. The dimensions featured 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 ; sexual 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 ; v i c t i m c h a r a c t e r i s t i c s ; l e v e l of aggression and v i o l e n c e ; b e h a v i o r a l disturbances; and p s y c h i a t r i c d i a g n o s i s . Although a l l these f a c t o r s can be l i n k e d to the assessment and treatment of j u v e n i l e sex offenders, 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 diagnosis of Conduct Disorder and i t s r e l a t e d b e h a v i o r a l symptoms as they r e l a t e to treatment outcome. Furthermore, I s h a l l suggest that Conduct Disorder 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 offender subtype who i s l e s s amenable to treatment, and may re q u i r e a h i g h l y s p e c i a l i z e d i n t e r v e n t i o n . The Heterogeneity of J u v e n i l e Sex Offenders The study of the heterogeneity of j u v e n i l e sex offenders i s i n i t s infancy. Knight and Prentky (1993) o f f e r three arguments to support the contention that j u v e n i l e offenders are at 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 of adult sex offenders have engaged i n s e x u a l l y coercive behaviour as j u v e n i l e s suggests that the heterogeneity found among adult offenders may e x i s t among j u v e n i l e offenders. Second, the low r e c i d i v i s m r ates reported f o r j u v e n i l e offenders i n d i c a t e that there may be a s u b s t a n t i a l subgroup of these offenders whose deviant behaviour does not p e r s i s t i n t o adulthood. T h i r d , j u v e n i l e offender samples t y p i c a l l y comprise both r a p i s t and c h i l d molester subgroups. Although degree of aggression was determined i n t h i s study, r a p i s t and c h i l d molester subgroups were not d i f f e r e n t i a t e d . Given that the subjects s t u d i e d f o r t h i s research were a l l o u t - p a t i e n t adolescent males, most were determined to be l e s s serious offenders, the m a j o r i t y being 23 c h i l d molesters. As many as 50% of adult sex offenders report that t h e i r f i r s t sexual a s s a u l t occurred during adolescence (eg., Abel, Mittleman, & Becker, 1985/ Becker & Abel, 1985; Groth, Longo, & McFadin, 1982; Smith, 1984). This i n d i c a t e s that a lar g e subsample of adult sex offenders were a l s o j u v e n i l e sex offenders and, as such could provide evidence f o r the heterogeneity of j u v e n i l e sex offenders. Knight and Prentky (1993) i n t h e i r study of 564 adult male sex offenders' c l i n i c a l records compared the 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 offenders and those who were not j u v e n i l e sex offenders. The j u v e n i l e sex offender group i n t h i s sample only i n c l u d e d those males whose s e x u a l l y coercive 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 lower than those of adult offenders (Furby, Weinrott, & Blackshaw, 1989; Smith, 1984; Smith & Monastersky, 1986). I t appears that there i s marked heterogeneity of the j u v e n i l e sex offender population, however, there i s l i t t l e concern f o r applying 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 of concern i s simply a consequence of the mistaken view that adolescents commit few 24 sexual offenses of serious consequence. Furthermore, i t may be a r e f e c t i o n of the general reluctance of c l i n i c i a n s to apply deviant l a b e l s to 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 negative consequences. However by r e f r a i n i n g from applying l a b e l s we may f o r f e i t our chances of d i s c e r n i n g causes, of designing i n t e r v e n t i o n programs that address the more s p e c i f i c needs of subgroups, of i d e n t i f y i n g v u lnerable i n d i v i d u a l s who might p r o f i t from primary prevention programs, and of improving our d i s p o s i t i o n a l d e c i s i o n s about s p e c i f i c subgroups of offenders. The a b i l i t y to gain an understanding of and make d e c i s i o n s about.these young offenders depends on the r e l i a b i l i t y and the v a l i d i t y of the c a t e g o r i c a l s t r u c t u r e s that are generated and a p p l i e d ' (Knight & Prentky, 1993). As mentioned p r e v i o u s l y , most of 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 offenders are l i m i t e d to t a b u l a t i o n 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 of these offenders and t h e i r offenses. To date only 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 offenders to delinquent 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 features are h e l p f u l f o r taxonomic purposes. 25 S o c i o c u l t u r a l Factors J u v e n i l e sex offenders 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 to these c h a r a c t e r i s t i c s i n the general p o p u l a t i o n . However, i n studies from the United States that report race as a demographic v a r i a b l e , between 33% and 55% of the subjects were black, 21-32% were Hispanic and 12-46% were white (Becker, Cunningham-Rathner, et a l . , 198 6; Becker, Kaplan, et a l . 198 6; Van Ness, 1984; Vinogradov, Dishotsky, Doty, & Tinklenberg, 1988). As such, these s t u d i e s appear to i n d i c a t e that non- white youth are over represented, p a r t i c u l a r l y i n terms of f o r c i b l e rape (Brown, et a l . , 1984). However, a r r e s t r a t e s are biased against these r a c i a l subgroups and the apprehensions of non-whites are greater as compared to whites. Although most j u v e n i l e sex offenders are l i v i n g i n two- parent homes at the time of discovery, over h a l f report some p a r e n t a l l o s s such as divorce, i l l n e s s , death of a parent, or permanent or temporary separations from the parents. 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 of d i s o r g a n i z a t i o n , sexual and p h y s i c a l abuse have been commonly observed as prevalent i n the h i s t o r i e s of j u v e n i l e offenders (Awad et a l . , 1984; Awad & Saunders, 1989; Becker, 26 Kaplan, et a l . , 1986; Becker, Cunningham-Rathner, & Kaplan, 1986; Deisher et a l . , 1982; Fehrenbach et a l . , 1986, Lewis et a l . , 1979; Longo, 1982; Robertson, 1990; Smith, 1988; Van Ness, 1984). Reported rates range from 19% to 47% of adolescents i n sample's of sexual aggressors who were themselves the v i c t i m s of sexual abuse (Becker, Kaplan, et a l . , 1986; Fehrenbach et a l . , 1986; Longo, 1982). In a study that i n c l u d e d i n c a r c e r a t e d adolescent homosexual pedophiles, 73% reported that 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 that the rates reported by j u v e n i l e sex offenders may a c t u a l l y underestimate the prevalence of sexual v i c t i m i z a t i o n i n these samples, because the r e p o r t i n g of sexual abuse o f t e n emerges only a f t e r the adolescent has been i n therapy. On the other hand, the estimates of the prevalence of t h i s v i c t i m i z a t i o n i s based on offenders' 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 that they seem to attenuate 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 Family 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 to 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 offender subtypes. M a r s h a l l (1989a) has o u t l i n e d the b a s i s of a theory l i n k i n g a l a c k of intimacy i n peer r e l a t i o n s to a p r o c l i v i t y to engage i n o f f e n s i v e sexual behaviours. This study i n d i c a t e d that a sample of adult sex offenders more f r e q u e n t l y f a i l e d to report intimacy i n t h e i r l i v e s and expressed greater f e e l i n g s of l o n e l i n e s s than d i d nonoffender c o n t r o l s . As such, l a c k of asse r t i v e n e s s 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 adolescent sex offenders (Becker & Abel, 1985; Fehrenbach et a l . , 1986). Attachment t h e o r i s t s argue that poor s o c i a l r e l a t i o n s are a f u n c t i o n of inadequate bonds with parents during i n f a n c y and e a r l y childhood (Bowlby, 1973; Grossman & Grossman, 1990; Weiss, 1982). Awad et a l . (1984) found that 88% of t h e i r sample of j u v e n i l e sex offenders had been separated from t h e i r parents f o r prolonged periods of time on at l e a s t one occasion. Furthermore, the parents of these boys lacked commitment to each other and had weak attachments to t h e i r c h i l d r e n . ' Fagan and Wexler (1988) found that 78% of the j u v e n i l e sex offenders 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 than 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 of r e l a t i o n s w i t h peer-aged females. Further s t u d i e s have found that j u v e n i l e e x h i b i t i o n i s t s , who 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 to have been r e j e c t i n g , have considerable d i f f i c u l t i e s w i t h intimacy and f e e l l o n e l y and i s o l a t e d from love r e l a t i o n s (Marshall et a l . , 1991) . However, c e r t a i n offender types may d i s p l a y a higher l e v e l of s o c i a l competence than others. A recent study (Awad & Saunders, 1989) found s i g n i f i c a n t l y greater s o c i a l i s o l a t i o n i n a sample of c o u r t - r e f e r r e d adolescent c h i l d molesters, compared to other male delinquents matched f o r age, socioeconomic s t a t u s , and time of r e f e r r a l . In a d d i t i o n , Saunders et a l . (1986) found that while 60% of the e x h i b i t i o n i s t s and 72% of the c h i l d molesters had no c l o s e f r i e n d s , only 32% of the r a p i s t s were so i s o l a t e d (Saunders et a l . , 1986). Thus, i t would appear that s o c i a l competence may p l a y an important 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 patterns of sexual arousal and of sexual f a n t a s i e s of adolescent sex 29 offenders have not been conducted. However, Becker (1988) proposed that there i s a d i s t i n c t i o n between j u v e n i l e offenders w i t h s e x u a l l y deviant recurrent 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 impulsive behaviour. This 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 of developing d i f f e r e n t offender subtypes. Co g n i t i v e Factors 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 are somewhat i n c o n s i s t e n t , o f f e r i n g c o n t r a s t i n g r e s u l t s . Although Awad et a l . (1984) found that t h e i r sample of adolescent sex offenders had s i g n i f i c a n t l y lower IQs than delinquent c o n t r o l s , Tarter, Hegedus, Alterman, 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 in 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 to report that over 80% of the sex offenders i n Awad et a l . ' s (1984) sample had experienced l e a r n i n g d i f f i c u l t i e s during some p a r t of t h e i r school career; and 71% had r e q u i r e d remedial education. A more recent study (Awad & Saunders, 1989) found a s i g n i f i c a n t l y greater degree of serious l e a r n i n g problems i n a sample of c o u r t - r e f e r r e d adolescent c h i l d 30 molesters, compared to other male delinquents matched f o r age, socioeconomic s t a t u s , and time of r e f e r r a l . Lewis et 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 offenders and delinquents, but no d i f f e r e n c e s on these dimensions between the sex offenders and v i o l e n t , non-sex j u v e n i l e offenders. Results from these and other s t u d i e s seem to suggest that the c o g n i t i v e impairments may be more ass o c i a t e d w i t h v i o l e n c e i n general r a t h e r than wi t h sexual v i o l e n c e i n p a r t i c u l a r . In f a c t , the hypothesis that j u v e n i l e sex offenders are c h a r a c t e r i z e d by a c l u s t e r of features that 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 behaviour, may only be true of more v i o l e n t sex offenders. In a d d i t i o n , one may suggest that the discr e p a n c i e s 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 offenders and nonsexual young offenders might be accounted f o r by the v a r i a t i o n s i n the frequency of v i o l e n t sex offenders i n d i f f e r e n t samples. V i c t i m C h a r a c t e r i s t i c s Fehrenbach et a l . (1986) found that 62% of the v i c t i m s of t h e i r sample of abusers were l e s s than 12 years of age, w i t h 44% l e s s than 6. In both Deisher et a l . ' s (1982) and 31 Wasserman and Kappel's samples, 50-60% of the v i c t i m s were under 10 years of age. The only exception seems to be w i t h non-contact offenders, 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 or adu l t s (Fehrenbach et a l . , 1986). As such, the v i c t i m s are t y p i c a l l y only 6-9 years of age, w i t h male v i c t i m s being younger than female v i c t i m s (Awad & Saunders, 1989; Becker, Cunningham- Rathner, & Kaplan, 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%) of the v i c t i m s of sexual 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 non-contact offenses (Awad et a l . , 1984; Groth, 1977; Fehrenbach et a l . , 1986; Longo, 1982; Van Ness, 1984; Wasserman & Kappel, 1985). However, studi e s seem to i n d i c a t e that as the age of the v i c t i m decreases, the v i c t i m i s more l i k e l y to be male, given that 45-63% of the c h i l d v i c t i m s of adolescent offenders are male (Awad & Saunders, 1989; Shoor et a l . , 1966; Van Ness, 1984). Generally, the c h i l d molester 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 of f r i e n d s of the parents, or c h i l d r e n the offender had been b a b y s i t t i n g (Awad & Saunders, 1989).. In c o n t r a s t , the adolescent r a p i s t tends to v i c t i m i z e strangers (Vinogradov, et a l . , 1988). Therefore, there appear to be subgroups w i t h i n the r a p i s t and c h i l d molester 32 categories i n terms of v i c t i m age and gender preference. Level of Aggression and Violence A wide range of coercion and v i o l e n c e has been reported i n the sexual a s s a u l t s committed by j u v e n i l e s , ranging from no i n t i m i d a t i o n or 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, et a l . , 1986; Groth> 1977; Lewis et a l . , 1981; Wasserman & Kappel,, 1985). In t h e i r study of the types of j u v e n i l e sex offender behaviour of 279 males, Fehrenbach et a l . (1986) found the 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 other non- contact offenses, 7%. In a s i m i l a r study of 161 male young offenders, 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 contact, 16% g e n i t a l f o n d l i n g and 12% non-contact offenses. I t appears as the offender age increases rape and more v i o l e n t sex offenses i n c r e a s e s . V i c t i m s report higher l e v e l s of coercion than offenders, and younger v i c t i m s seem to be subject to l e s s force (Davis & Leitenberg, 1987). These studi e s i n d i c a t e that one t h i r d of offenses perpetrated by adolescents r e s u l t i n p h y s i c a l i n j u r y . This v a r i a t i o n suggests that l e v e l of vi 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 offen d i n g . 33 P s y c h i a t r i c Factors and Conduct Disorder The most common i n d i c a t o r s of behaviour 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 taken to be a h i s t o r y of delinquency, p r i o r a r r e s t s f o r both sexual and nonsexual crimes, and p s y c h i a t r i c diagnoses such as Conduct Disorder and O p p o s i t i o n a l Defiant Disorder (France & Hudson, 1993). Adolescent sex offenders f r e q u e n t l y have h i s t o r i e s of other c r i m i n a l a c t i v i t y (Saunders, et a l . , 1986). For example, a number of stud i e s found that 28-50% of the subjects committed at l e a s t one p r i o r nonsexual offense (Becker, Cunningham- Rathner, et a l . , 1986; Becker, Kaplan, et a l . , 1984; Becker, Kaplan et a l . , 1986; Fehrenbach et a l . , 1986). Several other r e l a t e d s t u d i e s put these f i g u r e s at 46-82% of the cases (Awad et a l . , 1984; Becker, Kaplan et a l . , 1986; P i e r c e & P i e r c e , 1987). Furthermore, aggressive acts and other a n t i s o c i a l behaviour were evident i n 50-8 6% of cases (Awad & Saunders, 1989; Shoor et a l . , 1966; Van Ness, 1984). Consequently, the presence of other nonsexual b e h a v i o r a l disturbances suggests that the sexual offense i s not n e c e s s a r i l y a sex crime, but i s simply one way of a c t i n g out (Davis & Leitenburg, 1987). On the other hand, a la r g e group, p a r t i c u l a r l y non-aggressive and 34 hands-off p e r p e t r a t o r s do not engage i n other a n t i s o c i a l behaviours. The range of rates f o r non-sexual offending found i n these s t u d i e s i s p a r t l y explained by the type of sex o f f e n d i n g . More serious and aggressive hands-on of f e n d i n g i s a s s o c i a t e d w i t h higher rates of non-sexual offending (Kavoussi et a l . , 1988; Lewis et a l . , 1979; Smith, 1988). Although 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 offending, i t looks at the relevance of the issue of previous non-sexual offenses. That i s , a h i s t o r y of non- sexual offenses may be one element of the Conduct Disorder subtype that has c l i n i c a l relevance i n terms of treatment outcome. Although a more thorough and extensive d i s c u s s i o n of > p s y c h i a t r i c diagnosis w i l l be discussed i n the next chapter, i t i s necessary to b r i e f l y address t h i s issue as i t r e l a t e s to e x p l o r i n g c h a r a c t e r i s t i c s f o r c l a s s i f y i n g j u v e n i l e sex offenders. In so doing, a b r i e f overview of the t h i r d r e v i s e d e d i t i o n of the Diagnostic and S t a t i s t i c a l Manual of Mental 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 , 1987) diagnosis of Conduct Disorder and i t s relevance to treatment w i l l be o f f e r e d as a t r a n s i t i o n to the next chapter. A p s y c h i a t r i c diagnosis i s f r e q u e n t l y given to the 35 j u v e n i l e sex offender i n 70-87% of t h i s p o p u l a t i o n (Awad & Saunders, 1989; Awad et a l . , 1984; Lewis et 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% of young sex offenders (Awad & Saunders, 1989). The DSM-III-R (APA, 1987) c l a s s i f i c a t i o n of Conduct Disorder was given i n 48% of young sex offenders, w i t h r a p i s t s (75%) being more l i k e l y than c h i l d molesters (38%) to rec e i v e t h i s diagnosis (Kavoussi, Kaplan, & Becker, 1988). The diagnosis of substance abuse was given i n over 10% of a sample i n Kavoussi et a l . ' s (1988) study of adolescent sex offenders. In a d d i t i o n , j u v e n i l e sex offenders appear to have e x h i b i t e d high r a t e s of emotional problems (Deisher et a l , 1982; Groth, 1977; Shoor et a l . , 1966; Van Ness, 1984). J u v e n i l e sex offenders d i s p l a y e d d i s t u r b e d emotional f u n c t i o n i n g and d i s r u p t e d peer r e l a t i o n s . In a d d i t i o n , they d i s p l a y e d greater a n x i e t y and estrangement and l e s s emotional bonding to peers than seen i n other j u v e n i l e s (Blaske et a l . , 1989). As a l l u d e d to e a r l i e r , s e v e r a l studies have sought to e s t a b l i s h the rates of nonsexual disturbances of conduct i n j u v e n i l e sex offenders by examining records of delinquency or through diagnoses of conduct d i s o r d e r based on p s y c h i a t r i c assessment. These stud i e s have e s t a b l i s h e d that approximately 36 h a l f of j u v e n i l e sex offenders have a h i s t o r y of nonsexual a r r e s t s and that the m a j o r i t y of these can be described as conduct disordered (Awad & Saunders, 1989; Becker, Kaplan et a l . , 1986; Kavoussi et a l . , 1988). Therefore, i t seems that the r e l a t i o n s h i p between nonsexual disturbances of conduct and j u v e n i l e sex offending i s r e l e v a n t given that a s i g n i f i c a n t number of j u v e n i l e sex offenders engage i n other c r i m i n a l acts and may be diagnosed as conduct disordered. Each c o n d i t i o n shares s e v e r a l important d i s t a l causative and prognostic f a c t o r s and there are s i m i l a r i t i e s i n the various attempts to s u b c l a s s i f y both. F i n a l l y , the coexistence of conduct d i s o r d e r and j u v e n i l e sex offending 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 sex offender as w e l l as f o r p r e d i c t i n g treatment outcome. 37 CHAPTER TWO PSYCHIATRIC DIAGNOSIS AND SEXUAL OFFENDING IN ADOLESCENTS In t r o d u c t i o n The purpose of t h i s chapter i s to describe and evaluate the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders i n general, and more s p e c i f i c a l l y , assess the u t i l i t y of p s y c h i a t r i c diagnosis as i t r e l a t e s to conduct d i s o r d e r and the sexual offending behaviour of adolescents. P s y c h i a t r i c diagnosis may be one way of i d e n t i f y i n g subtypes w i t h i n the j u v e n i l e sex offender 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 relevance of the p s y c h i a t r i c diagnosis of 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 of non- sexual offending as elements f o r p r e d i c t i n g treatment outcome. The Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (DSM) has been described 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, since that time and the recent p u b l i c a t i o n of DSM-IV i n 1994, the process has encountered c r i t i c i s m and created controversy 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 instances, the medical p r o f e s s i o n as w e l l . 38 F i r s t , a general review of the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders system and process 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 the e v o l u t i o n of 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. Second, a d i s c u s s i o n of the strengths and l i m i t a t i o n s of the DSM c l a s s i f i c a t i o n system w i l l be presented, 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 , i n terms of youth diagnosed as conduct disordered. T h i r d , the conduct d i s o r d e r diagnosis w i l l be described and analyzed i n terms of i t s v a l i d i t y , r e l i a b i l 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 . Fourth, an e v a l u a t i o n of the usefulness of t h i s diagnosis as i t r e l a t e s to treatment outcomes of j u v e n i l e sex offenders w i l l be presented. F i n a l l y , 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 the diagnosis w i l l conclude t h i s chapter. H i s t o r y of 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 to c l a s s i f y signs and symptoms of disease i n t o d i s c r e t e d i s o r d e r s has been an issue of contention f o r many years. This need to 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 to the c r e a t i o n , r e v i s i o n and demise of 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 of mental h e a l t h there are c u r r e n t l y two widely 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 of Diseases (ICD) and; second, the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (DSM). The ICD i s a worldwide s t a t i s t i c a l disease c l a s s i f i c a t i o n system f o r a l l medical 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, published by 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 o n s i s t s of a s e r i e s of Diagnostic and S t a t i s t i c a l Manuals of Mental Disorders, the l a t e s t of which i s the 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 of mental d i s o r d e r s i n North America was f i r s t attempted i n the 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 category, " i d i o c y / l u n a c y " . This was l a t e r expanded i n the 1880 census to i n c l u d e eight 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 (Williams, 1988). By the l a t e 1920's, n e a r l y every medical teaching 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 diverse nomenclature that t y p i c a l l y l e a d to 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 . In an attempt to b r i n g order to the terminology, the Standard C l a s s i f i e d Nomenclature of Disease (SCND) was published 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 terminology, as only 10% of the 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 could be c l a s s i f i e d using the SCND (American 40 P s y c h i a t r i c A s s o c i a t i o n , 1952). In a d d i t i o n , during the postwar p e r i o d , three separate U.S. nomenclatures e x i s t e d : the SCND, the Armed Forces nomenclature, and the Veterans A d m i n i s t r a t i o n system. Moreover, none of these was c o n s i s t e n t w i t h the I n t e r n a t i o n a l Diagnostic C l a s s i f i c a t i o n (IDC) system. The confusion over terminology r e s u l t e d i n the Committee on Nomenclature and S t a t i s t i c s of the American P s y c h i a t r i c A s s o c i a t i o n proposal of a r e v i s e d c l a s s i f i c a t i o n system. Subsequently, the f i r s t e d i t i o n of the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders was published i n 1952. When i t became apparent that r e v i s i o n s would be needed, the manual l a t e r became known as DSM-I. DSM-II was the r e s u l t of 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 that a l s o culminated i n the mental d i s o r d e r s s e c t i o n i n the Eighth R e v i s i o n of the 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 (ICD-8). 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 of ICD-9's 1979 scheduled p u b l i c a t i o n date, the development of DSM-III began i n 1974. However, the lac k of d e t a i l f o r research and c l i n i c a l a p p l i c a t i o n i n the 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 the American P s y c h i a t r i c A s s o c i a t i o n Task Force on Nomenclature and S t a t i s t i c s development of a new c l a s s i f i c a t i o n system. This development process included 14 advisory committees, 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 , conferences, and f i e l d t r i a l s . DSM-III was seen as a dramatic 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, Reid and Wise (1989) i d e n t i f y the major innovations of the DSM-III: 1 2 d i s o r d e r ; -system; 4 5 6 7 8 9 10 11 12 13 D e f i n i t i o n of the term mental disorder; 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 Diagnosis according to a m u l t i - a x i a l e v a l u a t i o n R e d e f i n i t i o n of major d i s o r d e r s ; A d d i t i o n of new d i a g n o s t i c c a t e g o r i e s ; 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 categories Systematic d e s c r i p t i o n of each d i s o r d e r ; D e c i s i o n trees f o r d i f f e r e n t i a l d i a g n o s i s ; Glossary of t e c h n i c a l terms; Annotated comparative l i s t i n g of DSM-II and DSM-II Disc u s s i o n of ICD-9 and ICD-9-CM; P u b l i c a t i o n of r e l i a b i l i t y data from f i e l d t r i a l s ; Indices of d i a g n o s t i c terms and symptoms (p. 5) The development and goals of the DSM-III-R were s i m i l a 42 to those of DSM-III. Twenty-six advisory committees were formed, each wi t h membership based on e x p e r t i s e i n a p a r t i c u l a r area. 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 c r i t e r i a , p a r t i c u l a r l y i n c e r t a i n research s t u d i e s , played a s i g n i f i c a n t r o l e i n proposed m o d i f i c a t i o n s . The f o l l o w i n g new appendices were added to DSM-III-R: Proposed d i a g n o s t i c categories needing f u r t h e r study (eg. l a t e l u t e a l phase dysphoric d i s o r d e r , s a d i s t i c p e r s o n a l i t y d i s o r d e r ; and s e l f - d e f e a t i n g p e r s o n a l i t y d i s o r d e r ) ; an al p h a b e t i c l i s t i n g of DSM-III-R diagnoses and codes; a numerical l i s t i n g of DSM-III-R diagnoses and codes; an index of s e l e c t e d symptoms (Reid & Wise, 1989, p.5) DSM-IV was f i r s t p ublished i n 1994 and demonstrated some s i g n i f i c a n t changes as compared to i t ' s predecessors. According to the DSM-IV Task Force, the t h r e s h o l d f o r making r e v i s i o n s in. DSM-IV was set higher than that f o r DSM-III and DSM-III-R. In a d d i t i o n , i n an e f f o r t to increase the c l i n i c a l u t i l i t y of DSM-IV, the c r i t e r i a sets were s i m p l i f i e d and 43 c l a r i f i e d . The American P s y c h i a t r i c A s s o c i a t i o n claimed commitment to " . . . 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, evidence 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 of f i e l d t r i a l s , and consensus of the 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 that t h e i r r e l i a n c e on data generated through s c i e n t i f i c research 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 to 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 the use of 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. 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 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 introduced i n DSM-III i n 1980, and wit 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 of DSM-IV. This 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 to a d i f f e r e n t domain of informat i o n that may help the c l i n i c i a n p l a n treatment and p r e d i c t outcome" (APA, 1994, p. 25). The f o l l o w i n g i s an overview of the f i v e axes i n DSM-IV: A x i s I C l i n i c a l Disorders 44 Other Conditions That May Be a Focus of C l i n i c a l A t t e n t i o n A x i s I I P e r s o n a l i t y Disorders Mental Retardation A x i s I I I General Medical Conditions A x i s IV Psychosocial and Environmental Problems A x i s V Global Assessment of Functioning A x i s I and A x i s I I are used to describe the c l i e n t ' s current c o n d i t i o n . When necessary, m u l t i p l e diagnoses, or diagnoses on both axes, are made. A x i s I l i s t s c l i n i c a l syndromes present or i f no mental d i s o r d e r i s present, reports the same. A x i s I I reports the P e r s o n a l i t y Disorders and Mental Retardation. A x i s I I can al s o be used to record prominent maladaptive p e r s o n a l i t y features that do not 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 Disorder and any r e p e t i t i v e defense mechanisms that impair the c l i e n t ' s a b i l i t y to f u n c t i o n . A x i s 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 that are re l e v a n t to the understanding or management of the i n d i v i d u a l ' s mental d i s o r d e r . For example, the p h y s i c a l c o n d i t i o n may be causative as i n the case of 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 and environmental problems that may a f f e c t the d i a g n o s i s , treatment, and prognosis of mental d i s o r d e r s . These problems are grouped together i n nine separate c a t e g o r i e s ; two examples being, "problems w i t h primary support group" and "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 Global Assessment of Functioning s c a l e (GAF). The GAF Scale i s a r a t i n g from 1 to 100 with respect only to p s y c h o l o g i c a l , s o c i a l and occupational f u n c t i o n i n g . According to the DSM-IV commentary on the m u l t i - a x i a l system, the GAF Scale i s u s e f u l i n planning treatment 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 to 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 Mental Retardation and Pervasive Developmental Disorders together with 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 during childhood. Rutter and Shaffer (1980) sev e r e l y c r i t i c i z e d the DSM-III f o r having-these d i s o r d e r s placed w i t h i n A x i s I because they d i d not perceive these as c l i n i c a l d i s o r d e r s i n need of a t t e n t i o n . However, i n the DSM-IV the developmental d i s o r d e r s have been rel e g a t e d to A x i s I because they are now considered to be a focus of 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 maintained as an A x i s I I d i s o r d e r . As such, Conduct Disorder i s placed 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 of a t t e n t i o n . This i s al s o the case f o r any of the P a r a p h i l i a s that a j u v e n i l e sex offender may be diagnosed w i t h . Many j u v e n i l e sex offenders receive m u l t i p l e diagnoses as they present w i t h a myriad of problems r e q u i r i n g a t t e n t i o n . For example, a 16 year o l d may be diagnosed w i t h P e d o p h i l i a , Developmental Disorder (eg. l e a r n i n g 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 Disorder a l l on A x i s I as co n d i t i o n s i n need of a t t e n t i o n . On occasion, a j u v e n i l e sex offender may al s o be diagnosed w i t h Mental Retardation which w i l l be entered on Ax i s I I . In terms of the use of A x i s I I I and the r e p o r t i n g of current medical c o n d i t i o n s r e l e v a n t to the i n d i v i d u a l ' s mental d i s o r d e r , youth diagnosed w i t h Conduct Disorder or a 47 P a r a p h i l i a w i l l on occasion r e c e i v e a diagnosis on t h i s A x i s . For example, severe cases of acne may have impact on the youth's self-esteem 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 include diabetes or asthma, each of which can have impact on the young person's behaviour. In DSM-III-R the c l i n i c i a n was asked to l i s t and r a t e on A x i s IV a l l the ps y c h o s o c i a l s t r e s s o r s judged to have c o n t r i b u t e d to the development or exacerbation of the current d i s o r d e r / s . Furthermore, i t added the comp l i c a t i o n (not incl u d e d i n DSM-III) that the c l i n i c i a n should s p e c i f y whether the s t r e s s o r s are "predominantly acute events" (l e s s than s i x months) or "enduring circumstances" (duration of more than s i x months). Studies (Rey, Stewart, Plapp, Bashir & Richards, 1987; 1988) suggest that A x i s IV r a t i n g s are u n r e l i a b l e ; that i d e n t i f i c a t i o n of s t r e s s f u l events ( p a r t i c u l a r l y the mi l d e r ones) during an unstructured 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 that r a t i n g s e v e r i t y of s t r e s s o r s decreases r e l i a b i l i t y even more. As such, i n DSM-IV the c l i n i c i a n i s no longer r e q u i r e d to ra t e or s p e c i f y whether the psy c h o s o c i a l s t r e s s o r s are acute or enduring. In terms of j u v e n i l e sex offenders and youth diagnosed w i t h Conduct Disorder, 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 introduced i n DSM-III, had the 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 completely new s c a l e , the Global Assessment of Functioning Scale or GAF s c a l e , to assess p s y c h o l o g i c a l , s o c i a l and occupational 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 of mental h e a l t h - i l l n e s s . C l i n i c i a n s are requested to rate 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 of seve r e l y h u r t i n g s e l f or others (eg. recurrent violence) OR p e r s i s t e n t i n a b i l i t y to maintain minimal personal hygiene OR serious s u i c i d a l act wi t h c l e a r expectation of death" t o : "90. Absent or minimal symptoms (eg. m i l d a n x i e t y before an exam), good f u n c t i o n i n g i n a l l areas, i n t e r e s t e d and i n v o l v e d i n wide range of a c t i v i t i e s , s o c i a l l y e f f e c t i v e , g e n e r a l l y s a t i s f i e d w i t h l i f e . . . " (p.22). In DSM- IV the r a t i n g i s now from 1 to 100, followed by the time p e r i o d r e f l e c t e d i n the r a t i n g i n parentheses; f o r example, " ( c u r r e n t ) , " "(highest l e v e l i n past y e a r ) , " " ( a t d i s c h a r g e ) . " L i t t l e research has been published on the subject of assessment of f u n c t i o n i n g to warrant the dramatic changes on A x i s V (Rey et a l . , 1988). The GAF sc 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 of 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 panic attacks) 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 , or school 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 to create c i r c u l a r i t y and spurious a s s o c i a t i o n s . DSM-IV has made an attempt to address these issues w i t h the I n t r o d u c t i o n of a proposed S o c i a l and Occupational Functioning Assessment Scale (SOFAS) i n Appendix B (APA, 1994, p. 7 60). Although the psyc h o s o c i a l axes are considered i n v a l u a b l e w i t h i n non- p 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 generated by the DSM Task Force (Williams, 1985; W i l l i a m s , S p i t z e r , & Skodol, 1985). Not one of the records of the subjects i n t h i s study i n c l u d e d data on e i t h e r A x i s IV or V. C r i t i c s of the use of DSM see t h i s as a s i g n i f i c a n t omission and misuse of the 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 of DSM Revisions Williams (1986) gives three reasons to j u s t i f y the r e v i s i o n s i n the DSM-III-R. F i r s t , i t had become apparent that statements i n the t e x t and c r i t e r i a were not 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 other statements i n the 50 manual since the p u b l i c a t i o n of DSM-III. Second, i t was a l s o suggested that a r e v i s i o n was necessary because new research had appeared w i t h novel information which could be incorporated i n the c l a s s i f i c a t i o n . This seems l e s s understandable, f o r DSM-III was published i n 1980 and the r e v i s i o n process was commenced i n 1983. Since a research p r o j e c t t y p i c a l l y takes about 3 to 4 years from the time of conception to the p o i n t of a c t u a l p u b l i c a t i o n , i t i s apparent that the bulk of the research r e f e r r i n g to the DSM-III c l a s s i f i c a t i o n could not have begun appearing u n t i l 1983 at 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 to be w e l l founded, p a r t i c u l a r l y when i n the i n t r o d u c t i o n of the DSM-III-R (APA, 1987) i t s t a t e s : " . . . 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 , or f o r adding new c a t e g o r i e s , the greatest weight was given to the presence of e m p i r i c a l support from w e l l conducted research s t u d i e s , though, f o r most proposals, data from e m p i r i c a l studies were l a c k i n g . Therefore, primary importance was u s u a l l y given to some other 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 having f i n a l l y been published i n 51 1994, a f t e r 14 years had elapsed between r e v i s i o n s , i n d i c a t e d a too long a p e r i o d . Any c l a s s i f i c a t i o n takes time to permeate through the medical, research, a d m i n i s t r a t i v e and teaching 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 to d i g e s t the changes and incorporate the ones that 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 . C l i n i c i a n Bias Numerous studi e s have r a i s e d concerns regarding 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 diagnoses and c r i t e r i a sets that were proposed or i n c l u d e d i n DSM-III and DSM-III-R (Achenbach, 1980; Bayer & S p i t z e r , 1982; Caplan, 1987; D e l l , 1988; Fenton, McGlashan, & Heinssen, 1988, Kaplan, 1983; K e n d e l l , 1988a; Quay, 1986; Rey, 1988; Rutter & Shaffer, 1980; Schacht, 1985; Tyrer, 1988; Zimmerman, 1988). I t has been suggested that 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 biases 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 of the s e t t i n g s and experiences i n which they p r a c t i c e d or researched (Gunderson, 1983; Kernberg, 1984; M i c h e l s , 1984; M i l l o n , 1981). As such, i t i s f e l t that d e c i s i o n s depend upon the personnel and the p e r s o n a l i t i e s who are on a committee and the c o n s t r u c t i o n of the DSM could s u f f e r from an u n r e l i a b i l i t y 52 i n i t s c o n s t r u c t i o n that i s comparable to the u n r e l i a b i l i t y of a c l i n i c a l d i a g n o s i s . The diagnoses and c r i t e r i a sets would r e f l e c t the committee membership ra 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 diagnosis r a t h e r than the syndromes being 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' given or has obtained 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 research l i t e r a t u r e f o r the DSM process i s not i n f a l l i b l e and i s o f t e n inadequate. S i m i l a r l y , a c l i n i c i a n who ignores the DSM-III-R c r i t e r i a may at times provide a more v a l i d diagnosis than would be provided i f the c r i t e r i a were followed b l i n d l y , given the l i m i t a t i o n s and f a l l i b i l i t y of any set of d i a g n o s t i c c r i t e r i a (Fenton, Mosher, & Mathews, 1981; Widiger et a l . , 1990). Research has i n d i c a t e d that a systematic assessment and adherence to 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 at times y i e l d eight or more p e r s o n a l i t y d i s o r d e r diagnoses (Skodol, Rosnick, Kellman, Oldman, & Hyler, 1988; Widiger, T r u l l , Hurt, C l a r k i n , & Frances, 1987). D e c i s i o n making i n the DSM i s considered by some to be an i m p l i c i t process having i n s u f f i c i e n t e m p i r i c a l b a s i s f o r p a r t i c u l a r d e c i s i o n s 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 process to i n d i c a t e otherwise (Achenbach, 1980; Caplan, 1987; D e l l , 1988; G a r f i e l d , 1986; Garmezy, 1978; Kaplan, 1983; Kocsis & Frances, 1987; Taylor, 1983; Tyrer, 1988; Walker, 1987). Strengths and L i m i t a t i o n s of DSM The use of- the DSM i s widespread among p s y c h i a t r i s t s , p s y c h o l o g i s t s , and s o c i a l workers employed i n a v a r i e t y of s e t t i n g s . 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 they would stop using the DSM i f i t were not r e q u i r e d and fewer than 50% used three or more of the axes to record a d i a g n o s i s . The authors concluded that 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 that "...there i s a danger that complex d i a g n o s t i c systems, even i f v a l i d and r e l i a b l e , might evolve i n the course of time to be mere ex e r c i s e s on paper that are o f t e n p r a i s e d but seldom p r a c t i c e d " (p.23). Kutchins & K i r k (1988) i n t h e i r study of the DSM-III and 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 and disadvantages to the system. They s t a t e that the DSM i n c l u d e s 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 , that these c r i t e r i a increase 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 f a c i l i t a t e 54 communication and enhance d i a g n o s t i c s k i l l s . However, Kutchins & K i r k ' s (1988) conclude that the disadvantages f a r out weigh the advantages. F i r s t , they report that very l i t t l e a t t e n t i o n i s given to a l l 5 axes. This was evident i n t h i s study as none of the records included reports on A x i s IV or V. Second, there e x i s t s an overuse of c e r t a i n diagnoses because of 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 . This may be evident i n the diagnosis of j u v e n i l e sex offenders who do not meet the diagnosis f o r P e d o p h i l i a given t h e i r r e l a t i v e age, p a r t i c u l a r l y the youth i n e a r l y adolescence. T h i r d , i t i s not s e n s i t i v e to 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 . Fourth, the DSM 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 c l i n i c a l t o o l . F i n a l l y , Kutchins & K i r k suggest i t does not adequately r e f l e c t i n t e r a c t i o n a l problems. P a t h o l o g i z i n g C h i l d r e n Kutchins & K i r k (1988) found that 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 of mental d i s o r d e r s and thought that DSM- I I I placed medical 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 of childhood as p a t h o l o g i c a l . Furthermore, the DSM has increased the number 55 of childhood d i s o r d e r s to include many behaviours which are troublesome but not, i n t h e i r opinion, p a t h o l o g i c a l . However, s o c i e t y has a tendency to minimize and normalize childhood and adolescent sexual behaviour, which i n f a c t may be sexual 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 d i a g n o s t i c c r i t e r i a of Conduct Disorder the behaviours "often l i e s " , "truancy", and "running away" q u a l i f y the i n d i v i d u a l to rece i v e t h i s d i a g n o s i s . In some c i r c l e s these c r i t e r i a may be perceived as normal a c t i n g out or r e b e l l i o u s adolescent behaviour. On the other hand, the 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 relevance i n terms of p r e d i c t i n g treatment outcomes as i s hypothesized i n t h i s study. In t h e i r study, Kutchins & K i r k (1988) found that many p s y c h i a t r i s t s approach diagnosis i n an i n d i v i d u a l and unsystematic way and not i n conformity w i t h DSM c r i t e r i a . Diagnosis should be i n t i m a t e l y r e l a t e d to treatment but only 33% of the p s y c h i a t r i s t s surveyed found DSM h e l p f u l i n treatment planning and that i t 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 (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 the l e a s t favourably endorsed d i a g n o s t i c option and r e j e c t e d the idea that mental d i s o r d e r i s a subset of medical d i s o r d e r , and 56 concluded that too 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 to DSM-III (Smith & K r a f t , 1983). They s t a t e d that the DSM l a b e l s c l i e n t s and i s not h e l p f u l i n treatment planning (Raffoul & Holmes, 1986). They go on to s t a t e that the 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 higher than was the case f o r DSM- I I I and DSM-III-R, u t i l i z i n g : "comprehensive, systematic, and consensus reviews of the published l i t e r a t u r e ; r e a n a l y s i s of rel e v a n t c o l l e c t e d data s e t s ; and f i e l d . t r i a l s (Francis et a l . , 1991). They a l s o c l a i m that i t i s more d i f f i c u l t to remove something that was already included i n DSM-III-R than to introduce something new that has been suggested f o r DSM-IV (Frances et 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 necessary to avoid frequent and a r b i t r a r y d i a g n o s t i c changes that impede c l i n i c a l d iscourse, t r a i n i n g , and research. There has to be a f a i r l y compelling reason to change the c l a s s i f i c a t i o n " (Frances et a l . , 1991, p. 172). Changes i n DSM Categories and C r i t e r i a H i e r a r c h i c a l S t r u c t u r e One of the main changes i n the c r i t e r i a f o r diagnosis 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 of the 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 h i e r a r c h i c a l s t r u c t u r e . That i s , the d i f f e r e n t d i s o r d e r s are organized i n l e v e l s i n such a way that each l e v e l of pathology i s allowed to e x h i b i t the c h a r a c t e r i s t i c features of a l l lower l e v e l s but not any of a higher l e v e l . This approach makes p o s s i b l e the use of a s i n g l e diagnosis despite the f a c t that 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 appear at any given time. The DSM-III-R has l a r g e l y done away wi t h those p r i n c i p l e s which are maintained only i n two areas: the organic mental d i s o r d e r s , which r u l e out a diagnosis of almost any other d i s o r d e r , and schizophrenia 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 diagnosis of A n x i e t y Disorder or Major Depression can be made despite a concurrent diagnosis 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 Disorder or Conduct Disorder. These changes appear to be a response to 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 of DSM-III and of the h i e r a r c h i c a l hypothesis on e m p i r i c a l grounds, and that 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 stronger than when they were s p e c i f i e d (Robbins & Helzer, 1986). Furthermore, the r e l a x a t i o n of 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 increase of the number of i n d i v i d u a l s w i t h m u l t i p l e diagnoses. 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 et a l . , 1994; Russo et a l . , 1994) support the 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 behaviour d i s o r d e r s i n c h i l d r e n . That i s , Conduct- Disorder i s perceived as an advanced and more severe form of Opp o s i t i o n a l Defiant Disorder. This issue w i l l be discussed i n more depth i n the f o l l o w i n g s e c t i o n s of t h i s chapter. Diagnostic Rules Most of the 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 of symptoms, minimum length of time during which symptom should be present, etc.) have never been t e s t e d e m p i r i c a l l y (Rutter & Shaffer, 1980; Eysenck, Wakefield, & Friedman, 1983). Moreover, the "Chinese menu system" (Klerman, 1978), i n which symptoms are assorted i n t o groups with the requirement that symptoms from a l l groups be present to be able to make a diagnosis, 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 longer l i s t s of symptoms. These "laundry l i s t s " (Klerman, V a i l l a n t , S p i t z e r , & Mic h e l s , 1984) which make l i t t l e sense, are impossible to 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 without having been subjected to psychometric a n a l y s i s . An example of that i s Conduct Disorder i n the DSM-III-R wi t h a l i s t of 13 symptoms, 3 i f which must be present to 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 to t h i s issue by adding two more symptoms. In a d d i t i o n , as i f to compromise, the 15 symptoms are now d i v i d e d i n 4 groups, however the 3 necessary c r i t e r i a need not come from every group to make a d i a g n o s i s . As such, d i a g n o s t i c c r i t e r i a continue to seem more s u i t e d f o r use w i t h standardised i n t e r v i e w schedules and computer a l g o r i t h i s m s , than f o r a p p l i c a t i o n i n every 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 . C l i n i c i a n s are encouraged to 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 remission and i n f u l l remission. 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 Disorder diagnosis, as the c l i n i c i a n i s asked to make a d i s t i n c t i o n i n the l e v e l s of s e v e r i t y . In f a c t , to present 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 Options Book (APA, 1991) i n c l u d e d an attempt to i n t e g r a t e O p p o s i t i o n a l Defiant Disorder and Conduct Disorder 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 behaviour syndrome wi t h three 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 (MODD), and intermediate l e v e l of Conduct Disorder (ICD), and an advanced l e v e l of Conduct Disorder (ACD) (Russo, et 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 With 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 predecessors because "a much broader, more re p r e s e n t a t i v e array of d i a g n o s t i c and research e x p e r t i s e was brought to bear on these versions of the Diagnostic and Statistical Manual" (Nathan, 1994, p. 103). Nathan goes on to s t a t e that " 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 primary 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 to the development of DSM-IV were markedly d i f f e r e n t from those who developed the previous four e d i t i o n s " (p. 103). Only a small number of se 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 of p s y c h i a t r y were i n v o l v e d i n the development of DSM-I and DSM- I I i n 1952 and 1968 r e s p e c t i v e l y . However, a much l a r g e r number of p s y c h i a t r i s t s with a broader scope of e x p e r t i s e , 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. According to Nathan (1994) t h i s process of 61 broadening the base of c o n t r i b u t o r s a c c e l e r a t e d p r o g r e s s i v e l y during 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 involvement of a l a r g e and d i v e r s e group of mental h e a l t h p r o f e s s i o n a l s that 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 other 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 served as a d v i s o r s . 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 f a c u l t y . 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 conspicuously, been absent i n the DSM development process. Several s t u d i e s 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 informed e i t h e r the DSM-I or DSM-II processes ( G a r f i e l d , 1986; Michels, 1984; Skodol et a l . 1988; Widiger et a l , 1990). Moreover, although both DSM-III and DSM-III-R were considered f a r more grounded i n s c i e n t i f i c research than t h e i r predecessors, i n r e a l i t y only 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 research. Nathan (1994) co n t r a s t s t h i s , s t a t i n g that the c r i t e r i o n sets i n n e a r l y 62 every major d i a g n o s t i c category 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 reviews, and the r e s u l t s of both the analyses of e x i s t i n g data and extensive f i e l d t r i a l s . Furthermore, i n con t r a s t to previous e d i t i o n s where research f i n d i n g s were i n f r e q u e n t l y published, the r e s u l t s of Work Groups' analyses of e x i s t i n g data sets 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 the s e v e r a l volume's of DSM-IV Sourcebooks of published r e p o r t s . Several s t u d i e s show that DSM-III was constructed through d e c i s i o n s based on expert consensus, as research on the diagnosis of mental d i s o r d e r s was o f t e n l i m i t e d (Kendell, 1988b; Robins & Helzer, 1986; S p i t z e r , 1985). The development of DSM-IV b e n e f i t s from the s u b s t a n t i a l increase i n research and i n t e r e s t i n diagnosis generated i n part by DSM-III. The diagnosis of mental d i s o r d e r s p r i o r to DSM-III was u n r e l i a b l e to the po i n t that t h e i r v a l i d i t y was suspect ( B l a s h f i e l d & Draguns, 1976; Rosenhan, 1975; S p i t z e r & F l e i s s , 1974). The major innovation of DSM-III wi t h respect to the improvement of r e l i a b i l i t y was to provide 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 hat made diagnosis more systematic and r e p l i c a b l e ( S p i t z e r et a l . , 1980) . The most recent studies s t a t e that the DSM-IV i s much 63 b e t t e r informed by e m p i r i c a l data than any of i t s predecessors and that 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 f u l l y from e m p i r i c a l f i n d i n g s as have others (Frances, Davis & K l i n e , 1994; Frances, Pincus, & Widiger, 1994; Pincus, Frances, Davis, Widiger, & F i r s t , 1994). For example, i n the D i s r u p t i v e Behaviour Disorders grouping, a number of overlapping c r i t e r i a are shared by the various diagnoses and are l e s s s p e c i f i c than other DSM diagnoses, such as Schizophrenia. According to Nathan (1994) t h i s dual 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 process from those of i t s predecessors. In a d d i t i o n , he s t a t e s that t h i s dual emphasis should ensure that 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 w i l l be higher than i n the previous instruments. DSM C l a s s i f i c a t i o n of Conduct Disorder D i s r u p t i v e Behaviour Disorders The Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (DSM-IV, APA, 1994) i s the most widely used c a t e g o r i c a l d i a g n o s t i c system of childhood disorders.. Major A x i s I diagnoses d e s c r i b i n g childhood and adolescent disturbances of 64 conduct are grouped as a subclass c a l l e d D i s r u p t i v e Behaviour Disorders. These d i s o r d e r s are 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 to others than to 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 are 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 Disorder, O p p o s i t i o n a l Defiant Disorder, and Conduct Disorder. The d i a g n o s t i c term Conduct Disorder from the t h i r d r e v i s e d e d i t i o n of the Diagnostic and S t a t i s t i c a l Manual of Mental 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 , 1987) includes the f o l l o w i n g set of behaviours l i s t e d i n descending order of d i s c r i m i n a t i n g power: (1) has s t o l e n without c o n f r o n t a t i o n of a v i c t i m on more than one occasion ( i n c l u d i n g forgery) (2) has run away from home overnight at l e a s t twice while l i v i n g i n p a r e n t a l or p a r e n t a l surrogate home (3) o f t e n l i e s (other than to avoid p h y s i c a l or sexual 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 of t e n truant from school (6) has broken i n t o someone el s e ' s house, b u i l d i n g , or car 65 (7) has d e l i b e r a t e l y destroyed others' property (8) has been p h y s i c a l l y c r u e l to animals (9) has forced someone i n t o sexual a c t i v i t y w i t h him or her (10) has used a weapon i n more than 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 of 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 to people, (p. 58) Conduct Disorder i s considered the most severe of the D i s r u p t i v e Behaviour disturbances, having as i t s e s s e n t i a l feature "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 behaviour i n which the b a s i c r i g h t s of others or major age-appropriate s o c i e t a l norms are v i o l a t e d " (APA, 1994, p.53). This e s s e n t i a l feature i s l i t e r a l l y unchanged since DSM-III, other than the use of 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 of the word "behaviour" i n s t e a d of "conduct" .in the DSM-IV . This behaviour i s t y p i c a l l y observed to occur across s i t u a t i o n s (at home, at school, and i n the community), across persons (parents, peers, and s t r a n g e r s ) , and across time. The DSM-III-R s p e c i f i e s a d u r a t i o n of at l e a s t s i x months, during which at l e a s t three of the of the b e h a v i o r a l symptoms are present. This symptom t h r e s h o l d was increased from only one 66 b e h a v i o r a l c r i t e r i a as per the DSM-III to make a d i a g n o s i s . The DSM-IV changed the time t h r e s h o l d to s t a t e : "...the presence of three (or more) of the f o l l o w i n g c r i t e r i a i n the past 12 months, w i t h at l e a s t one c r i t e r i o n present i n the past s i x months" (APA, 1994, p.90). In a d d i t i o n , as mentioned e a r l i e r , the number of a p p l i c a b l e d i a g n o s t i c items have been increased from 13 to 15 d i s c r i m i n a n t b e h a v i o r a l items. These two new items are: "often b u l l i e s , threatens, or i n t i m i d a t e s others", and "often stays out at night despite p a r e n t a l p r o h i b i t i o n s , beginning before age 13 years" (APA, 1994, p. 90) . S t e a l i n g and p h y s i c a l aggression are primary to the diag n o s i s , although other behaviours such as running away from home and l y i n g were reported to be high i n d i s c r i m i n a t i n g power based on the r e s u l t s of a n a t i o n a l f i e l d t r i a l of DSM- III - R c r i t e r i a (APA, 1987). E v o l u t i o n of Conduct Disorder (CD) Subtypes I t i s c l e a r to a l l who study a n t i s o c i a l behaviour i n youths that CD i s a heterogeneous d i a g n o s t i c category (Farrington, 1987; Kazdin, 1987; Loeber, 1988). Therefore, subtypes have been proposed i n an e f f o r t to capture 67 d i f f e r e n c e s i n behaviour, developmental t r a j e c t o r i e s , and assumed e t i o l o g y . 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 the DSM 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 the c a p a c i t y of the youth f o r maintaining s o c i a l r e l a t i o n s h i p s , the presence or absence of aggression, age of onset, and the presence or absence of comorbid di a g n o s i s . S o c i a l i z a t i o n and aggression. 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 st 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 i n c a r c e r a t e d j u v e n i l e delinquents beginning with the p i o n e e r i n g s t u d i e s of Jenkins (Jenkins & Hewitt, 1944; Jenkins and Glickman, 1947). These studi e s i n d i c a t e d that youths w i t h u n d e r - s o c i a l i z e d CD are more aggressive, adjust l e s s w e l l to j u v e n i l e detention f a c i l i t i e s , are l e s s l i k e l y to v i o l a t e probation and be r e a r r e s t e d a f t e r release than youth w i t h s o c i a l i z e d CD (Henn et a l . , Quay, 1986b, 1987). However, e x p l i c i t o p e r a t i o n a l c r i t e r i a i s necessary i n order to make a meaningful 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. 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 CD d i s t i n g u i s h e d i n DSM-III were each subdivided i n t o aggressive and non-aggressive subtypes. There i s evidence to support the b e l i e f that youths w i t h CD who are p h y s i c a l l y aggressive 68 should be d i s t i n g u i s h e d from those who are not (Olweus, 1979; Henn et a l . , 1980). Studies have shown that high l e v e l s of aggression as e a r l y as age 10 are h i g h l y p r e d i c t i v e of p e r s i s t e n t adult 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 et a l . , 1980; S t a t t i n & Magnusson, 1989) . The symmetrical subtyping of CD i n DSM-III along both the 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 the aggressive-non-aggressive dimensions was dropped i n DSM-III-R i n favour of two subtypes that captured some aspects of these d i s t i n c t i o n s . A solitary- aggressive type was d i s t i n g u i s h e d , but no s o l i t a r y non- aggressive subtype was provided on the assumption that few such cases of CD would be i d e n t i f i e d . The group type can incl u d e both aggressive and non-aggressive youths, but no d i s t i n c t i o n was made on the b a s i s of aggression i n t h i s subtype. In support of t h i s d i f f e r e n t i a t i o n of subtypes, poor peer r e l a t i o n s h i p s have been demonstrated to be p r e d i c t i v e of l a t e r maladjustment i n t h i s p o p u l a t i o n (Roff & Wirt, 1984). I t may be p o s s i b l e to d i f f e r e n t i a t e subtypes w i t h i n the j u v e n i l e sex offender population who are conduct disordered based on t h e i r l e v e l of aggression and s o c i a l i z a t i o n . That i s , the more aggressive, u n d e r - s o c i a l i z e d sex offender may be 69 one subtype of Conduct Disorder who i s more l i k e l y to have poor treatment outcome. In the DSM-III-R, the j u v e n i l e sex offender diagnosed as "Conduct Disorder: s o l i t a r y aggressive type" may f i t i n t o t h i s category. A study by Rogeness et a l . (1983) i s c o n s i s t e n t w i t h the DSM-III-R approach to subtypes of 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 adolescents given a DSM-III diagnosis of CD, 46% were given the diagnosis of s o c i a l i z e d aggressive CD, and 38% were given the diagnosis of u n d e r - s o c i a l i z e d aggressive CD. Fourteen percent r e c e i v e d a diagnosis of s o c i a l i z e d non-aggressive CD, but only 2% of the youths w i t h CD r e c e i v e d a diagnosis of u n d e r - s o c i a l i z e d non-aggressive CD. However, these r e s u l t s are questionable 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 of a l l c l i n i c - r e f e r r e d youths w i t h CD. Age of onset. C e r t a i n s t u d i e s have been able 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 that l a t e onset delinquents tend.to be l e s s severe i n t h e i r offending, p a r t i c u l a r y i n e x h i b i t i n g l e s s aggression, and have a b e t t e r prognosis f o r desistance i n offending (Farrington, 1987; Loeber, 1982, 1988). S i m i l a r l y , Robins (1966) found that youths whose CD onset before age 11 70 were twice as l i k e l y to re c e i v e a diagnosis of A n t i s o c i a l P e r s o n a l i t y Disorder (sociopathy) i n adulthood as those w i t h an onset a f t e r age 11. McGee et a l . (1992) i d e n t i f i e d a very l a r g e group of male and female youths who e x h i b i t e d DSM-III CD fo r the 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 to be aggressive, and e x h i b i t e d higher v e r b a l a b i l i t y and reading scores. An important goal of the DSM-IV f i e l d t r i a l s was to assess the u t i l i t y of subtyping CD. Thus, the subgroups were compared to see i f they d i f f e r e d i n terms of impairment, f a m i l y h i s t o r y , comorbidity, and other c l i n i c a l l y important v a r i a b l e s . Although a s i g n i f i c a n t body of research suggests that meaningfully d i s t i n c t subtypes of CD should 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 that d i s t i n c t i o n s of s o c i a l i z a t i o n and aggression were redundant and i d e n t i f i e d the same subgroups of youths w i t h CD ( F r i c k et a l . , 1994; Loeber et a l . , 1993; Lahey et a l . , 1994). However, t h i s same research determined that i t was u s e f u l to d i s t i n g u i s h between two developmentally staged l e v e l s of s e v e r i t y w i t h i n CD. As such, DSM-IV o f f e r s two subtypes based on age of onset: "childhood-onset type: onset of at 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 of Conduct Disorder 71 p r i o r to 10 years" and "adolescent-onset type: absence of any c r i t e r i a c h a r a c t e r i s t i c of conduct d i s o r d e r p r i o r to age 10 years" (APA, 1994, p.91). Thus, i t may be p o s s i b l e to i d e n t i f y subtypes of j u v e n i l e sex offenders diagnosed w i t h Conduct Disorder based on age of onset. This would have c l i n i c a l relevance i n terms of p r e d i c t i n g treatment outcome i n that those j u v e n i l e sex offenders diagnosed w i t h e a r l y onset Conduct Disorder are more l i k e l y to have poor treatment outcome. Comorbidity. There i s some evidence that youths w i t h CD and comorbid A t t e n t i o n D e f i c i t Hyperactive Disorder (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 alone (Offord et a l , 1979; Schachar et a l . , 1981; Walker et a l . , 1987; Werry et a l . , 1987). Furthermore, they concluded that only the greater 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 the greater s o c i a l impairment a s s o c i a t e d w i t h Conduct Disorder d i f f e r e n t i a t e d the two groups across the m a j o r i t y of studies reviewed. However, given the previous research f i n d i n g s one would expect that those j u v e n i l e sex offenders w i t h both CD and ADHD would have poorer treatment 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 Disorder 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 c l a s s i f i c a t i o n systems were o u t l i n e d by Quay (1986a). The f i r s t r e q u i r e s that features be o p e r a t i o n a l l y defined and covary. The second i s r e l a t e d to the r e l i a b i l i t y of the observations. The r a t i n g scales commonly used i n these i n v e s t i g a t i o n s have been reported to 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 (eg. between parents; Achenbach & Edelbrock, 1983). F i n a l l y , the c l a s s i f i c a t i o n must be v a l i d . According to Baum (1989) dimensions defined 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 other and provide an e m p i r i c a l b a s i s f o r 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 , course, outcome, and response to treatment. However, the extensiveness of the behaviours assessed and the c o m p a r a b i l i t y of dimensions across s t u d i e s are v a l i d c r i t i c i s m s of these approaches (Quay, 1986a). Using Quay's c r i t e r i a (1986a) to evaluate the DSM-III-R, t h i s r e v i s i o n appears to o f f e r improvements over previous versions 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 observable behaviours. 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 how f r e q u e n t l y a behaviour must occur to meet the c r i t e r i a . 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 Disorder have been found to load on separate f a c t o r s i n m u l t i v a r i a t e research (Baum, 1989) . For example, although " s t e a l i n g without 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 highest i n d i s c r i m i n a t i n g power and " s t e a l i n g with c o n f r o n t a t i o n " i s 12th of the 13 DSM-III-R c r i t e r i a (APA, p. 5 5 ) , t h e f t i s commonly ass 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 aggressive type p a t t e r n . TV,. Diagnostic Thresholds The d i a g n o s t i c thresholds f o r both 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 milder symptoms and i n c r e a s i n g the number of symptoms re q u i r e d f o r each di a g n o s i s , r e s u l t i n g i n decreased prevalence of the two d i s o r d e r s (Lahey, et a l . , 1994). The changing c r i t e r i a of DSM-III and DSM-III-R c r i t e r i a f o r Conduct Disorder have been c o n t r o v e r s i a l f o r two main reasons. F i r s t , some researchers have challenged r a i s i n g the d i a g n o s t i c t h r e s h o l d f o r Conduct Disorder to three symptoms i n DSM-III-R because some evidence suggests that even one or two conduct d i s o r d e r symptoms i n childhood p r e d i c t adverse adult 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, others have suggested that 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 merely a milder form of Conduct Disorder and should not be considered as a separate d i s o r d e r ( F r i c k , Lahey, Applegate, 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, Barkley, McBurnett, Newcorn, & Waldman, 1991; Lahey et a l . , 1994). Lahey et a l . (1994) reviewed e x i s t i n g research i n an attempt to evaluate the v a l i d i t y of the DSM approach to. the 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 evidence of a strong 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 that a high percentage of youths who meet c r i t e r i a f o r conduct d i s o r d e r before the age of puberty met c r i t e r i a , f o r O p p o s i t i o n a l Defiant Disorder at an e a r l i e r age (Lahey et a l . , 1994) . Conduct Disorder Symptoms There have been no research s t u d i e s forthcoming to 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 Disorder. Ongoing extensive research i s needed to assess 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 behaviour d i s o r d e r s . Lahey et a l . (1992) c l a i m 75 that t h i s can be done i n three general ways. F i r s t , the conditional p r o b a b i l i t y that i f a youth exhibits symptom X the youth w i l l also exhibit symptom Y may be so high that symptom Y i s redundant and adds l i t t l e or nothing to the diagnostic c r i t e r i a . Thus, i t may be possible to drop one or more redundant diagnostic c r i t e r i a that simplify the diagnostic c r i t e r i a without s a c r i f i c i n g diagnostic precision. Second, using a strategy developed by Loeber et a l . (1993), the power of each symptom to predict the f u l l diagnosis can be compared. This strategy may allow the elimination of 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 associated with the diagnosis. Third, when symptoms are i d e n t i f i e d for possible deletion i n these ways, the prevalence, r e l i a b i l i t y , and v a l i d i t y of the diagnosis can be assessed before and after the deletion of the symptoms to be sure that they have not changed. As mentioned e a r l i e r , previous evidence suggested that some of the more prevalent DSM-III and DSM-III-R symptoms of conduct disorder might more accurate symptoms of Conduct Disorder (CD) than of Oppositional Defiant Disorder (ODD). Therefore, a new alternative for the d e f i n i t i o n of oppositional defiant disorder and conduct disorder was 76 presented i n the DSM-IV Options Book (APA, 1991) .' In t h i s d e f i n i t i o n the symptoms of 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 to 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 . This o p t i o n was r e j e c t e d on the b a s i s of reanalyses - of e x i s t i n g data sets ( F r i c k et a l . , 1994; Loeber, et a l . , 1993; Russo, et a l . , 1994) and symptom u t i l i t y analyses of the f i e l d t r i a l s sample (APA, 1991) . F r i c k et a l . ' s (1994) analyses of CD symptoms i n the DSM- IV revealed that the two symptoms not inc l u d e d i n DSM-III-R c r i t e r i a , "often b u l l i e s , threatens, or i n t i m i d a t e s others" and "often stays out a f t e r dark without permission, beginning before 13 years of age" were h i g h l y p r e d i c t i v e of the di a g n o s i s . This study a l s o i n d i c a t e d that a l t e r i n g the d e f i n i t i o n s of two symptoms increased 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 the d e f i n i t i o n of l y i n g was a l t e r e d to i n c l u d e only l y i n g to "con others" ("often l i e s or breaks promises to o b t a i n goods or favours") and the d e f i n i t i o n of truancy was a l t e r e d to l i m i t i t to truancy beginning before age 13, the d i a g n o s t i c e f f i c i e n c y of the symptoms was increased. 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 of " l y i n g " and "truancy" replaced the DSM-III-R versions of these CD symptoms. The d e c i s i o n to l i m i t 77 "truancy" to youths i n which the truancy began before the age of 13 was made to avoid m i s a t t r i b u t i n g t h i s symptom to normal adolescents, i n whom truancy i s common. Given that these changes i n the DSM have increased the p r e d i c t i v e v a l i d i t y of Conduct Disorder diagnosis, one could speculate that these changes would a l s o have s i g n i f i c a n t c l i n i c a l relevance i n terms of p r e d i c t i n g treatment outcomes f o r j u v e n i l e sex offenders r e c e i v i n g t h i s d i a g n o s i s . Treatment Outcome There i s wide agreement that j u v e n i l e sex offenders are extremely noncompliant and unmotivated toward treatment. As such, i t i s commonly f e l t that court-mandated treatment i s necessary. However, even wi t h the pressure of the 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 offenders f a i l to 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. For example, se v e r a l of these reasons i n c l u d e : unmanageable due to be h a v i o r a l disturbance; v i o l a t i o n of agency r u l e s ; • and/or, reoffense 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 behaviours found i n conduct disordered youth. However, are those j u v e n i l e sex offenders who are more r e s i s t a n t to treatment a d i s c r e e t subtype who al s o meet the c r i t e r i a f o r 78 Conduct Disorder. As such, one may speculate that those i n d i v i d u a l s diagnosed w i t h Conduct Disorder would be more noncompliant and as .a r e s u l t more prone to not s u c c e s s f u l l y completing treatment as compared to those w i t h a non-conduct disordered d i a g n o s i s . For t h i s study, treatment outcome, was determined based on whether the youth s u c c e s s f u l l y or 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 treatment program. This was determined from the c l i n i c a l r e c o rd notes on f i l e that i n c l u d e d a discharge report w r i t t e n by the primary t h e r a p i s t . The youth was considered to have s u c c e s s f u l treatment outcome i f he completed the program and re c e i v e d b e n e f i t from the program. In a d d i t i o n , the youth was considered unsuccessful i f he was evaluated as at high r i s k to reoffend based on a p h a l l o m e t r i c measure of deviant arousal p r i o r to discharge from the program. In summary, the treatment outcome v a r i a b l e was determined based on c l i n i c a l judgement and the 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. In p h a l l o m e t r i c assessment, changes i n p e n i l e tumescence are assessed while the subject i s exposed to a v a r i e t y of sexual and nonsexual s t i m u l i ( e i t h e r s l i d e s or audiotapes). C o g n i t i v e - b e h a v i o r a l l y o r i e n t e d 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 of sexual 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 that 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 considerable 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 offenders but there i s sparse research on i t s use w i t h a j u v e n i l e p o p u l a t i o n . Studies have shown that adult c h i l d molesters 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 offenders based on degree of response to 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 that high indexes of deviant arousal are a s s o c i a t e d w i t h a greater l e v e l of sexual offending ( i . e . , more v i c t i m s ) (Barbaree & M a r s h a l l , 1989; E a r l s & Quinsey, 1985). I t i s estimated that over 175 j u v e n i l e sex offender treatment programs i n the United States and Canada report using 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 p o p u l a t i o n (Knopp, Freeman-Longo, & Stevenson, 1992). Becker, Hunter, Goodwin, Kaplan, and Martinez (1992) assessed the t e s t - r e t e s t r e l i a b i l i t y of audiotaped s t i m u l i developed s p e c i f i c a l l y f o r an adolescent sexual offender p o p u l a t i o n . S t a t i s t i c a l l y s i g n i f i c a n t t e s t - r e t e s t r e l i a b i l i t y 80 was. demonstrated f o r 15 of the 19 audiotaped v i g n e t t e s . The highest c o r r e l a t i o n s were found f o r those sexual behaviours i n which the adolescent 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 ranging from .48 to .83. Schram, M i l l o y , and Rowe (1991) examined deviant sexual arousal i n r e l a t i o n s h i p to 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 followed 197 male adolescent sexual offenders an average of 6.8 years f o l l o w i n g completion of treatment. Sexual r e c i d i v i s t s were found to be more l i k e l y to have deviant sexual arousal patterns as w e l l as a h i s t o r y of truancy, 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. Instead, 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 of deviant arousal and response to 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 of p h a l l o m e t r i c assessment of j u v e n i l e sexual offenders i s growing. However, there i s growing evidence that j u v e n i l e s may be more g l o b a l i n t h e i r sexual i n t e r e s t and arousal patterns than adult offenders, and that p h a l l o m e t r i c data should 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 to that of a d u l t offenders (Hunter & Becker, 1994). Methodological Issues. The u t i l i t y of the c l i n i c a l 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 of j u v e n i l e sex offenders appears to be w e l l e s t a b l i s h e d (Hunter & Becker, 1994). Although some studie s have not been supportive (eg. Hanson, S t e f f y , & Gauthier, 1993; Rice, Quinsey, & H a r r i s , 1991) of programs (such as the one i n t h i s study) of a multicomponent, c o g n i t i v e - b e h a v i o r a l nature, many have produced promising r e s u l t s , e s p e c i a l l y w i t h c h i l d molesters (see M a r s h a l l & Barbaree, 1990). I t i s important to note that some of these studies 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, using designs that i n c l u d e comparison groups, adequate follow-up p e r i o d s , and m u l t i p l e outcome measures. Marques, Day, Nelson, & West (1994) i d e n t i f y important methodological requirements f o r sound outcome research w i t h sex offenders based on s e v e r a l previous s t u d i e s (eg. Furby, Weinrott, and Blackshaw, 1989; Grossman, 1985). These requirements in c l u d e comparison groups, r e c i d i v i s m measures, a t t r i t i o n , c l i n i c a l judgement and s t a t i s t i c a l methods. One of the most d i f f i c u l t obstacles i n e v a l u a t i n g treatment programs f o r sex offenders 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 impossible to t r u l y determine how e f f e c t i v e treatment i s without a 82 comparison group of s i m i l a r offenders who d i d not r e c e i v e the i n t e r v e n t i o n . An i d e a l comparison group would be s i m i l a r offenders randomly assigned to an untreated c o n t r o l group (Furby et a l . , 1989; M a r s h a l l & Barbaree, 1990). I t has been argued that such designs are u n e t h i c a l because they r e q u i r e w i t h h o l d i n g treatment from offenders who may d e s i r e and/or need therapy (Becker & Hunter, 1992; M a r s h a l l & Barbaree, 1990; M a r s h a l l et a l . , 1991). Although there i s no consensus on the best c r i t e r i o n f o r treatment f a i l u r e , most researchers use the recommission of a sex offense (e.g., M a r s h a l l & Barbaree, 1988), w i t h some (e.g., Rice et a l . , 1991) c o n s i d e r i n g other crimes against persons as w e l l . However, there i s also considerable v a r i a b i l i t y across s t u d i e s regarding the use of o f f i c i a l data (such as records of a r r e s t or c o n v i c t i o n s ) and u n o f f i c i a l 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 reported numbers of sex offenses are widely recognized to be gross underestimates of the true number of crimes that have been committed (Repucci & Clingempeel, 1978; R u s s e l l , 1982). Marques et a l . (1994) s t a t e that the types of l e g a l charges and c o n v i c t i o n s that are recorded are a r e s u l t not only of the acts committed but a l s o of the p o l i c i e s and 83 p r a c t i c e s of l o c a l law enforcement, prosecutors, and c o u r t s . S e l f - r e p o r t s by sex offenders are considered very u n r e l i a b l e given t h e i r high degree of 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 fending behaviours. However, when absolute c o n f i d e n t i a l i t y i s provided, offender s e l f - r e p o r t s have revealed l a r g e numbers of crimes that have not r e s u l t e d i n a r r e s t (Abel et a l . , 1987; Weinrott & Saylor, 1991). In terms of a t t r i t i o n , r a tes of treatment withdrawal and ter m i n a t i o n vary widely depending on a number of f a c t o r s (eg. offender m o t i v a t i o n , program requirements, l e g a l consequences). In 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 offender who d i d not complete treatment was considered unsuccessful. However, other s t u d i e s have excluded treatment dropouts (e.g., Abel et a l . , 1988; M a r s h a l l & Barbaree, 1990). In Abel 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% of those e n t e r i n g the program f a i l i n g to complete i t . In terms of c l i n i c a l judgement, Foa and Emmelkamp (1983) s t a t e that a treatment program's value i s measured not only by the success of those who complete i t but a l s o by the number who refuse the i n t e r v e n t i o n s or drop out a f t e r beginning treatment. In e v a l u a t i n g treatment outcomes, schemes must be 84 devised to account f o r these offenders 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 . This study accounted f o r treatment dropouts and f a i l u r e s and i n c l u d e d them as unsuccessful s u b j e c t s . With respect to s t a t i s t i c a l methods, the usefulness 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 to 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 , reoffense, which re 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 & Nelson, 1984). The e v a l u a t i o n of treatment 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 rigorous and comprehensive research designs p o s s i b l e . Although 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 that c o n t r o l f o r discrepant a t - r i s k periods, i t d i d i n c l u d e a t t r i t i o n f a c t o r s , 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 Hypotheses The o v e r a l l purpose of t h i s t h e s i s i s to 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 diagnosis of Conduct Disorder treatment outcomes of j u v e n i l e sex offenders. The uniqueness of t h i s study l i e s w i t h the f a c t that t h i s 85 diagnosis has never been evaluated w i t h t h i s p o p u l a t i o n i n terms of treatment outcomes. However, as mentioned p r e v i o u s l y , there are c e r t a i n l i m i t a t i o n s to the DSM 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 process, p a r t i c u l a r l y w i t h t h i s p o p u l a t i o n . Notwithstanding these l i m i t a t i o n s , t h i s study attempts to demonstrate that j u v e n i l e sex offenders diagnosed w i t h Conduct Disorder (according to DSM-III-R c r i t e r i a ) have a higher p r o b a b i l i t y of unsuccessful treatment outcome and those not diagnosed w i t h Conduct Disorder are more l i k e l y demonstrate s u c c e s s f u l treatment outcome i n an o u t - p a t i e n t treatment program. Link to Hypotheses As mentioned p r e v i o u s l y , the DSM s t a t e s that "the e s s e n t i a l feature of Conduct Disorder 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 behaviour i n which the b a s i c r i g h t s of others or major age-appropriate s o c i e t a l norms or r u l e s are v i o l a t e d " (APA, 1994, p. 85). 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 to argue that a l l j u v e n i l e sex offenders are conduct disordered. However, the c l i n i c i a n must determine i f the sexual misbehaviour i s a •86 one time event, or "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 task i n a pop u l a t i o n renowned f o r i t ' s high degree of d e n i a l and mi n i m i z a t i o n . Through the examination of records of delinquency and/or through the diagnoses of Conduct Disorder based on p s y c h i a t r i c assessment, stud i e s have attempted to e s t a b l i s h the rates of nonsexual disturbances of conduct i n j u v e n i l e sex offenders w i t h a view of diagnosing them as Conduct Disordered. Becker, Kaplan, Cunningham-Rathner, and Kavoussi (1986) found that 50% of t h e i r sample of j u v e n i l e male p e r p e t r a t o r s had a record of previous non-sexual a r r e s t s , and that 63% of those a v a i l a b l e f o r p s y c h i a t r i c assessment could be diagnosed as Conduct Disordered. This r a t e of nonsexual a r r e s t s i s higher than the 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 of j u v e n i l e sex offenders s t u d i e d by Becker et a l . (1986), but i s s i m i l a r to f i g u r e s f o r non-sexual delinquencies reported i n other samples of j u v e n i l e sex offenders (Awad & Saunders, 1989; Awad, Saunders, & Levene, 1984; Fehrenbach, Smith, Monastersky, & Deishner, 1986; Kavoussi, Kaplan, & Becker, 1988; P i e r c e & P i e r c e , 1987). Adult sex offenders 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 Disorder (considered the adult counterpart of Conduct Disorder) i n conjunction w i t h 87 t h e i r s e x u a l l y abusive behaviours were more l i k e l y to r e o f f e n d both s e x u a l l y and nonsexually (Bard, Carter, Cerce, Knight, Rosenberg, & Schneider, 1987; H a l l , Mauiro, V i t a l i a n o , & Proctor, 1986; Henn, J e r j a n i c , & Vanderpearl, 1976). Moreover, s t u d i e s i n d i c a t e that those offenders who f a i l to complete treatment are more l i k e l y to reoffend e i t h e r s e x u a l l y or nonsexually (Abel, Mittleman, & Becker, 1985; M a r s h a l l , Jones, Ward, Johnston, & Barbaree, 1991). Thus, i t would make sense to speculate from these s t u d i e s that youth diagnosed w i t h Conduct Disorder would have poor treatment outcomes. However, given the questionable r e l i a b i l i t y and v a l i d i t y of the DSM process i n general; and more s p e c i f i c a l l y , the i n s t a b i l i t y 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 debatable a p p l i c a t i o n of the Conduct Disorder d i a g n o s t i c process, does t h i s p a r t i c u l a r diagnosis have c l i n i c a l relevance' i n the assessment and treatment of j u v e n i l e sex offenders. Conduct Disorder diagnosis i n the DSM-III-R (APA, 1987) l a c k s p r e c i s i o n and the presence of r a t h e r " s o f t " d i a g n o s t i c b e h a v i o r a l c r i t e r i a , such as " l y i n g " and "truancy" may create the over-diagnosis of youth who are. convicted of sexual offending. On the other hand, i s i t p o s s i b l e that assessment and treatment formulations f o r Conduct Disorder has 88 u s e f u l explanatory power f o r at l e a s t some types of j u v e n i l e sex o f f e n d i n g . France and Hudson (1993) suggest that a s i g n i f i c a n t number of j u v e n i l e sex offenders engage i n other c r i m i n a l acts or may be diagnosed as conduct disordered and that the coexistence of disturbances of conduct and j u v e n i l e sex offending may be 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 r e o f f e n d i n g . However, studie s on the importance of Conduct Disorder as a p rognostic i n d i c a t o r i n j u v e n i l e sex o f f e n d i n g are few and show c o n f l i c t i n g r e s u l t s . Henderson, E n g l i s h , and MacKenzie (1988) s t a t e d that 50% of the youths i n t h e i r treatment program, who had v i c t i m r e l a t e d c r i m i n a l h i s t o r i e s p r i o r to the sex offense, continued to e x h i b i t s e x u a l l y a s s a u l t i v e behaviour a f t e r treatment. However, Smith and Monastersky (1986) found only a s l i g h t trend between a h i s t o r y of aggressive and d e s t r u c t i v e behaviour 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 , there appears to be only one study that 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 j u v e n i l e sex offenders who s u c c e s s f u l l y complete treatment to those who f a i l to complete treatment. Based on c l i n i c i a n assessment and s u b j e c t i v e judgment, Joseph Randazzo (1992) found that 89 offenders who s e l e c t e d v i c t i m s near i n age to themselves, who blamed t h e i r acts on a l c o h o l and/or drugs and who had school truancy problems were d i s t i n g u i s h e d as being at highest r i s k of treatment drop-out or f a i l u r e . Furthermore, Randazzo (1992) suggests that non-completers were perceived by t h e i r t h e r a p i s t s to be more aggressive, more a n t i - s o c i a l , and more dangerous than other s u b j e c t s . This suggests that those j u v e n i l e sex offenders who f a i l e d to complete treatment d i s p l a y e d many of the behaviours found i n Conduct Disorder and may have been so diagnosed. Given the previous r a t i o n a l e , s p e c i f i c hypotheses regarding treatment outcome are st a t e d as f o l l o w s : 1) J u v e n i l e sex offenders who have been given a p s y c h i a t r i c diagnosis of Conduct Disorder 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 offenders who meet the c r i t e r i a according to the DSM-III-R c l a s s i f i c a t i o n of Conduct Disorder 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 diagnosis of Conduct Disorder i s ass 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 according to the DSM-III-R c r i t e r i a . This hypothesis was t e s t e d to determine i f the subjects d i d indeed meet the f u l l c r i t e r i a 90 f o r Conduct Disorder. In a d d i t i o n , t h i s hypothesis sought to t e s t whether these youth were being over-diagnosed. 4) Conduct Disorder symptoms are as 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 , stu d i e s have shown that s i n g l e Conduct Disorder '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 the d i a g n o s i s . This hypotheses was t e s t e d to determine i f s i n g l e Conduct Disorder behaviours are a s s o c i a t e d w i t h unsuccessful treatment outcome. 5) Adolescent sex offenders w i t h previous non-sexual offenses w i l l be l e s s l i k e l y to s u c c e s s f u l l y complete treatment. 6) . Adolescent sex offenders w i t h previous non-sexual offenses are more l i k e l y to be given a p s y c h i a t r i c diagnosis of Conduct Disorder. 7) Adolescent sex offenders w i t h previous non-sexual offenses are more l i k e l y to meet the f u l l DSM-III-R c r i t e r i a f o r a diagnosis of Conduct Disorder. 91 CHAPTER THREE RESEARCH DESIGN In t r o d u c t i o n 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 the c l i n i c a l records of j u v e n i l e sex offenders to determine i f those diagnosed with Conduct Disorder were more l i k e l y to be unsuccessful at completing treatment then those who were not diagnosed w i t h Conduct Disorder. The outcome measure was the treatment 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 offender treatment program as determined and recorded by the primary c l i n i c i a n . The primary 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 or a p s y c h i a t r i c nurse who was i n charge of that p a r t i c u l a r subject's case. The discharge s t a t u s was determined from m u l t i d i s c i p l i n a r y treatment team review of the subject's progress. In a d d i t i o n , I attempted to provide 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 of each subject, independent of the p s y c h i a t r i c diagnosis given on the c l i n i c a l record, i n an e f f o r t to determine i f the subject d i d indeed meet the f u l l d i a g n o s t i c c r i t e r i a according to the DSM-III-R (APA, 1987). 92 Method Subjects C l i n i c a l records of one hundred adolescent males, aged 12-18 at the time of admission, who had completed a c o u r t - ordered p s y c h o s o c i a l assessment and were admitted to the Adolescent Sex Offender Treatment Program at Youth Court Services/Outpatient Department, Burnaby, B.C. were pi c k e d randomly from the time frame between January 1, 198 8 and December 31, 1992. Mean subject age was 15 years, the youngest i n the sample was 12 and the o l d e s t was 18. Twenty-four percent of the subjects had a grade 7 education or l e s s , 63% had between grade 8 and 10, whereas 13 percent achieved grade 11 or higher. Seventy-three percent of the subjects had Caucasian e t h n i c background, 23% were of F i r s t Nations h e r i t a g e , and 4% were considered other. At the time of the offense 41% of the subjects l i v e d w i t h t h e i r n a t u r a l mother and her partner, 8% 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% l i v e d 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 partner, 5% l i v e d w i t h adult r e l a t i v e s , 7% l i v e d w i t h adoptive parents, and 30% l i v e d w i t h f o s t e r parents or i n a group home. 93 Measures Diagn o s t i c v a r i a b l e . The d i a g n o s t i c (independent) v a r i a b l e was measured by the c l i n i c a l diagnosis (PCD) provided by the assessing p r o f e s s i o n a l 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 the w r i t t e n report to court. This diagnosis 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 nurse. This assessment i n c l u d e s : a face to 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 of 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 that includes an i n t e r v i e w w i t h the young person's care g i v e r s , s o c i a l workers, teachers, probation o f f i c e r s , extended f a m i l y and any other s i g n i f i c a n t people 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 independently by t h i s researcher to assess i f the subject d i d indeed meet the f u l l c r i t e r i a according to the DSM-III-R C l a s s i f i c a t i o n Manual (APA, 1987). C l i n i c a l records were analyzed and coded to ensure that the c l i n i c a l d iagnosis on record met the minimum 3 b e h a v i o r a l c r i t e r i a necessary 94 w i t h i n the minimum 6 months time frame. The 13 b e h a v i o r a l symptoms of Conduct Disorder i n c l u d e d the f o l l o w i n g items: . (1) has s t o l e n without c o n f r o n t a t i o n of a v i c t i m on more than one occasion ( i n c l u d i n g forgery) (2) has run away from home overnight at l e a s t twice while l i v i n g i n p a r e n t a l or p a r e n t a l surrogate home (3) o f t e n l i e s (other than to avoid p h y s i c a l or sexual 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 truant from school (6) has broken i n t o someone e l s e ' s house, b u i l d i n g , or car (7) has d e l i b e r a t e l y destroyed others' property (8) has been p h y s i c a l l y c r u e l to animals (9) has forced someone i n t o sexual a c t i v i t y w i t h him or her (10) has used a weapon i n more than 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 of 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 to people. (APA, 1987, p. 58) 95 I f the c l i n i c a l records i n d i c a t e d that the subject met the minimum 3 c r i t e r i a i n the minimum 6 month time frame he was given an A l t e r n a t e Conduct Disorder (ACD) c l a s s i f i c a t i o n . However, i f he met l e s s than 3 c r i t e r i a he was given an A l t e r n a t e Non-conduct Disorder (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 Disorder (ACD)and P s y c h i a t r i c Conduct Disorder (PCD). The a l t e r n a t e conduct d i s o r d e r diagnosis v a r i a b l e was then recoded to include 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); or, a l t e r n a t e non-conduct d i s o r d e r (AN-CD). Conduct Disorder symptom v a r i a b l e . A yes/no response was given f o r each of the 13 b e h a v i o r a l symptoms of Conduct Disorder according to the data on f i l e . Furthermore, each of these items had to meet the DSM-III-R c r i t e r i a i n terms of the 6 month time frame. Previous non-sexual offense v a r i a b l e . The previous non- sexual offense v a r i a b l e was determined from the c l i n i c a l records which report a l l p r i o r c r i m i n a l charges and c o n v i c t i o n s of a sexual or non-sexual nature. Treatment outcome v a r i a b l e . The treatment completion (dependent) v a r i a b l e was measured according to the c l i n i c a l 96 records on f i l e recorded by the primary t h e r a p i s t s i n charge of the subject's case. This v a r i a b l e was coded i n t o ' f o u r c ategories of completion status that included: terminated due to noncompliance w i t h program r u l e s and/or c r i m i n a l charges; probation ended and d e c l i n e d f u r t h e r treatment; 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 treatment completion v a r i a b l e was then recoded to inc l u d e the dichotomous c a t e g o r i e s : (1) terminated due to 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 ; or, (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 simply completed treatment 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 offenders complete treatment, but were s t i l l considered to be of high r i s k to reoffend. Therefore, treatment completion may be more the r e s u l t of a combination of pressure from the c r i m i n a l j u s t i c e system and other supervisory supports and the degree of compliance i n the i n d i v i d u a l offender. The subject was determined s u c c e s s f u l , i f the discharge report i n d i c a t e d that he re c e i v e d maximum b e n e f i t from the program and was considered at low r i s k to reoffend. The subject was determined unsuccessful i f he had 97 zero to minimal b e n e f i t from the program and was considered at moderate to high r i s k to reoffend a f t e r completion of the program. R e l i a b i l i t y and V a l i d i t y I n t e r r a t e r r e l i a b i l i t y of the previous 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 Disorder symptom v a r i a b l e s was performed by the researcher and a Master of S o c i a l Work student at Youth Court Services who was i n s t r u c t e d on the coding of v a r i a b l e s and r a t i n g ; procedures. Twelve cases were picked randomly from the t o t a l , sample. The degree of agreement on a l l 15 v a r i a b l e s of 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 according to 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 and the extensive p r o f e s s i o n a l c l i n i c a l notes on f i l e . As p a r t of the i n t e r r a t e r r e l i a b i l i t y measure, f o r the a l t e r n a t e diagnosis (ACD) the contents of the notes were analyzed to determine which of the 13 Conduct Disorder c r i t e r i a were met. Of the 12 c l i n i c a l records p i c k e d randomly and analyzed, 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 of agreement between the two r a t e r s . 98 V a l i d i t y of the P s y c h i a t r i c Diagnosis was augmented by m u l t i p l e sources of informat i o n gathered by various members of 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. The s o c i a l worker and/or p s y c h i a t r i c nurse gathered i n f o r m a t i o n from the f a m i l y , teachers, probation o f f i c e r s and other s i g n i f i c a n t people, based on questions d i r e c t l y r e l a t e d to the presence or absence of the Conduct Disorder 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 subject s e l f reports of the presence or absence of the Conduct Disorder b e h a v i o r a l 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 of psychometric t e s t i n g and a one- to-one p s y c h o l o g i c a l assessment. These members then c o l l a b o r a t e d to 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, the p s y c h i a t r i s t , given h i s / h e r medical 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 determination to make the d i a g n o s i s . V a l i d i t y of outcome measures was obtained by a s i m i l a r c o l l a b o r a t i v e process to determine treatment status upon discharge from the program. The primary t h e r a p i s t would then complete a standardized discharge report i n d i c a t i n g the subject's progress i n treatment and treatment completion status based on b e n e f i t received, degree of deviant a r o u s a l , a b i l i t y to suppress deviant a r o u s a l , and subsequent r i s k to 99 reoffend. Data A n a l y s i s Hypothesis 1. To t e s t the hypothesis that i n a pop u l a t i o n of j u v e n i l e sex offenders a p s y c h i a t r i c diagnosis of Conduct Disorder i s a s s o c i a t e d w i t h outcome of o u t - p a t i e n t treatment, a chi-square and Phi were computed between these two v a r i a b l e s . Hypothesis 2 . To t e s t the hypothesis that i n a pop u l a t i o n of j u v e n i l e sex offenders an a l t e r n a t e conduct d i s o r d e r diagnosis (ACD) i s a s s o c i a t e d w i t h outcome of out- p a t i e n t treatment, a Chi-square and Phi were computed between these two v a r i a b l e s . Hypothesis 3 . To t e s t the hypothesis that i n a pop u l a t i o n of j u v e n i l e sex offenders a p s y c h i a t r i c diagnosis of Conduct Disorder (PCD) i s as s o c i a t e d w i t h an a l t e r n a t e Conduct Disorder c l a s s i f i c a t i o n (ACD) a Chi-square and Phi were computed between these two v a r i a b l e s . Hypothesis 4 . To t e s t the hypothesis that a s i n g l e Conduct Disorder behaviours i s as s o c i a t e d w i t h treatment outcome a Chi-square and Phi were computed between these two v a r i a b l e s . 100 Hypothesis 5. To t e s t the hypothesis that previous non- sexual offenses are a s s o c i a t e d w i t h treatment outcome i n a pop u l a t i o n of j u v e n i l e sex offenders i n o u t - p a t i e n t treatment, a Chi-squre and Phi were computed between these two v a r i a b l e s . Hypothesis 6 . A Chi-squre and P h i were computed to measure a s s o c i a t i o n between previous non-sexual and p s y c h i a t r i c diagnosis of Conduct Disorder (PCD). Hypothesis 7. A Chi-square and Phi were computed to measure a s s o c i a t i o n between previous non-sexual offenses and A l t e r n a t e Conduct Disorder c l a s s i f i c a t i o n (ACD). 101 CHAPTER FOUR RESULTS Treatment Outcome P s y c h i a t r i c Conduct Disorder (PCD) Hypothesis 1. In the present sample of j u v e n i l e sex offenders 50% of subjects were diagnosed as conduct disordered by the p s y c h i a t r i s t (PCD). Tabulations of data revealed that 45% percent of subjects had s u c c e s s f u l treatment outcome. In assessing whether there 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 negative % c o r r e l a t i o n was observed, [X = 37.1, Phi = -.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) adolescent sex offenders (71%) were s i g n i f i c a n t l y more l i k e l y to have s u c c e s s f u l treatment outcome than not (29%). In c o n t r a s t , p s y c h i a t r i c conduct d i s o r d e r (PCD) subjects (67%) were more l i k e l y to have unsuccessful treatment outcome that not (33%). Table 1 provides f u r t h e r r e s u l t s of the 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 unsuccessful outcomes wi t h or without a p s y c h i a t r i c conduct d i s o r d e r diagnosis (PCD). 102 A l t e r n a t e Conduct Disorder (ACD) Hypothesis 2. From the t o t a l sample of 100, a higher percentage (68%) of subjects were given an a l t e r n a t e conduct d i s o r d e r diagnosis (ACD) when diagnosis was dependent upon the DSM-III-R c r i t e r i a as compared to 50% f o r the p s y c h i a t r i c conduct d i s o r d e r diagnosis (PCD). A negative a s s o c i a t i o n was observed between a l t e r n a t e conduct d i s o r d e r diagnosis (ACD) and s u c c e s s f u l treatment outcome, [X = 37.0, Phi = -.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 diagnosed (AC-ND) j u v e n i l e sex offenders (88%) were s i g n i f i c a n t l y more l i k e l y to have s u c c e s s f u l treatment outcome than not. In con t r a s t , a l t e r n a t e conduct d i s o r d e r diagnosis (ACD) subjects were s i g n i f i c a n t l y more l i k e l y to have unsuccessful treatment outcome (75%) than not (25%) (see the bottom h a l f of Table 1 f o r f u l l r e s u l t s of these d i s t r i b u t i o n s ) . 103 Table 1 / Percentages of Conduct Disordered and Non-conduct Disordered Subjects With Successful and Unsuccessful Treatment Outcomes ASSESSMENT OUTCOME Successful n Unsuccessful n P s y c h i a t r i c Conduct Disorder (PCD) Non-conduct Disorder (PN-CD) 13 32 26% 64% 37 74% 36% A l t e r n a t e Conduct Disorder (PCD) Non-conduct Disorder (PN-CD) 17 28 25% 51 75% 4 12% To t a l 45 45 55 55% 104 A l t e r n a t e (ACD) and P s y c h i a t r i c Diagnosis (PCD) Hypothesis 3. 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 diagnosis and t h i s researcher's a l t e r n a t i v e assessment was s i g n i f i c a n t , [X = 19.4, Phi = .43, p < .0001]. E i g h t y - e i g h t percent of those subjects given a conduct disordered diagnosis by the p s y c h i a t r i s t were given the same c l a s s i f i c a t i o n by the a l t e r n a t e assessment. Although the t o t a l degree of agreement was 70%, 80% of the j u v e n i l e s who were not diagnosed as conduct disordered by the p s y c h i a t r i s t were considered conduct disordered by the a l t e r n a t e assessment. 105 Conduct Disorder Behavioral V a r i a b l e s Hypothesis 4. A Chi-square and Phi were computed to measure a s s o c i a t i o n between each of the 13 b e h a v i o r a l v a r i a b l e s l i s t e d f o r DSM-III-R Conduct Disorder diagnosis and the dependent v a r i a b l e , s u c c e s s f u l treatment outcome. Table 2 shows the values 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 completion of treatment and the s e v e r a l of the behavior v a r i a b l e s . 106 Table 2 I n d i v i d u a l Conduct Disorder Behaviours and Successful Treatment Outcome Behaviour Successful Outcome 2 % . x o f t e n l i e s 49 24.1 s t e a l s 59 15.4 truant 61 17.5 runs away 70 18.2 c r u e l to people 72 17.7 p h y s i c a l f i g h t s 74 15.1 property d e s t r u c t i o n 75 16.1 f i r e - s e t t i n g 77 — break and enter 82 — c r u e l to animals 3 — robbery 7 — weapon use 5 — forced sex 97 — Note. d e p i c t s i n s i g n i f i c a n t values, p < .001 on a l l s i g n i f i c a n t values. 107 Previous Non-sexual Offenses Hypothesis 5. F i f t y - f o u r percent of subjects had previous non-sexual 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 previous non-sexual charges and s u c c e s s f u l treatment outcome, [X = 14.1, Phi = -.38, p < .001]. The j u v e n i l e s w i t h no previous non-sexual charges were somewhat more l i k e l y to have s u c c e s s f u l treatment outcome (67%). Table 3 provides the f u l l r e s u l t s 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 unsuccessful outcomes f o r those w i t h and without previous non-sexual offenses. P s y c h i a t r i c Conduct Disorder (PCD) Hypothesis 6. 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 j u v e n i l e s having previous non-sexual offenses and having a p s y c h i a t r i c conduct d i s o r d e r diagnosis (PCD), [X = 16.1, Phi = p < .001]. The j u v e n i l e s w i t h no previous non- sexual charges were more l i k e l y to not have a p s y c h i a t r i c conduct d i s o r d e r diagnosis (72%). Table 3 provides f u l l r e s u l t s of the d i s t r i b u t i o n of previous non-sexual charges and 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 . 108 A l t e r n a t e Conduct Disorder (ACD) Hypothesis 7. A p o s i t i v e c o r r e l a t i o n was observed between j u v e n i l e s having previous non-sexual charges and having an a l t e r n a t e conduct d i s o r d e r diagnosis (ACD), [X = 32.6, Phi = .57, p < .0001]. Those j u v e n i l e s w i t h previous non-sexual charges were more l i k e l y to have an a l t e r n a t e conduct d i s o r d e r diagnosis (74%) than not. Those j u v e n i l e s w i t h no previous non-sexual charges were more l i k e l y to not have an a l t e r n a t e conduct d i s o r d e r diagnosis (88%) . Table 3 shows f u l l d i s t r i b u t i o n s of these r e s u l t s . 109 Table 3 Percentages of Conduct Disordered Subjects and Non-conduct Disordered Subjects With Previous Non-sexual Offenses Offenses No offenses Assessment ' n % n % P s y c h i a t r i c Conduct Disorder (PCD) 37 74 13 26 Non-conduct Disorder (PN-CD) 17 34 33 66 A l t e r n a t e Conduct Disorder (ACD) Non-conduct Disorder (AN-CD) 50 74 4 12 18 26 28 88 110 CHAPTER FIVE DISCUSSION Im p l i c a t i o n s The o v e r a l l purpose of t h i s study was to examine and more c l e a r l y understand the relevance of Conduct Disorder diagnosis i n the assessment and treatment of j u v e n i l e sex offenders i n order to 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 of 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 to the purpose of the study. Hypothesis 1 The study suggests that i n a p o p u l a t i o n of j u v e n i l e sex offenders i n o u t - p a t i e n t treatment, those who are given a p s y c h i a t r i c diagnosis of Conduct Disorder are more l i k e l y to have unsuccessful treatment outcomes. Furthermore, those j u v e n i l e sex offenders who are not c l a s s i f i e d as Conduct Disorder are more l i k e l y to have s u c c e s s f u l treatment outcomes. Although t h i s , i n and of i t s e l f , may not be a r e v e l a t i o n to 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 (given the non-compliant, a n t i - s o c i a l nature of I. I l l t h i s p o p u l a t i o n ) , i t suggests that there may be a sub-group of j u v e n i l e sex offenders who are l e s s amenable to treatment. At the same time,, i t suggests that j u v e n i l e sex offenders who are not considered conduct disordered may a l s o be a sub-group wi t h unique c h a r a c t e r i s t i c s making them more amenable to treatment approaches. Hypothesis 2 This study suggests that those j u v e n i l e sex offenders who meet the c r i t e r i a f o r a diagnosis of Conduct Disorder, according to the DSM-III-R (APA, 1987), are s i g n i f i c a n t l y more l i k e l y to have unsuccessful treatment outcomes and those who do not meet the c r i t e r i a are s i g n i f i c a n t l y more l i k e l y to 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 of the study r e i n f o r c e s the suggestion that Conduct Disorder i s a s s o c i a t e d w i t h treatment outcome. Moreover, i f given an accurate diagnosis of Conduct Disorder, there i s even stronger 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 treatment outcome and the d i a g n o s i s . The degree of 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 higher than most previous comparative stud i e s on p s y c h i a t r i c d i a g n o s i s . However, given that 80% of the subjects who were 112 not given a p s y c h i a t r i c diagnosis of Conduct Disorder 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 to consider t h i s a r a t h e r low degree of agreement i n terms of underdiagnosing. Thus, t h i s study suggests that Conduct Disordered j u v e n i l e sex offenders are being under-diagnosed 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 to the po p u l a t i o n from which t h i s sample was taken. Hypothesis 3 The f i n d i n g s suggest that the p s y c h i a t r i c assessment and 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 . However, as mentioned i n the previous paragraph, the variance i n the.two assessments suggests that 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 of g i v i n g a diagnosis of Conduct Disorder. Although the r e s u l t s show that j u v e n i l e sex offenders are being a c c u r a t e l y diagnosed as conduct disordered, a s i g n i f i c a n t percentage of 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 being diagnosed as conduct disordered by the assessing p s y c h i a t r i s t . Several p o s s i b l e explanations can be put forward here. One, the p s y c h i a t r i s t may not be diagnosing conduct d i s o r d e r unless the 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 already be diagnosed 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 Hyperactive Disorder (and/or some other disorder) and there i s a r e s i s t a n c e to.give m u l t i p l e diagnoses. Thus, although the offender does meet the c r i t e r i a of Conduct Disorder, the diagnosis i s not given f o r fear of overdiagnosing. Or, three, the diagnosis i s simply not reported on the p s y c h i a t r i c assessment. Another explanation may be that the c l i n i c i a n who works wi 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 long p e r i o d of time, may become d e s e n s i t i z e d to the youth who presents w i t h Conduct Disorder behaviors. That i s , the youth may demonstrate a l l the behaviors necessary to meet the dia g n o s i s , but the c l i n i c i a n may not perceive him as "that bad" r e l a t i v e to the youth who demonstrates the more aggressive and v i o l e n t behaviours against others. In any event, the discrepancy between p s y c h i a t r i c diagnosis (PCD) and a l t e r n a t e diagnosis (ACD) i n t h i s study i s minimal, w i t h the a l t e r n a t e (ACD) f i n d i n g s being s i m i l a r except somewhat stronger on most v a r i a b l e s . Hypothesis 4 An observation of the a s s o c i a t i o n between the i n d i v i d u a l 114 behaviours of conduct d i s o r d e r and s u c c e s s f u l treatment outcome suggests that the d i s c r i m i n a t i v e u t i l i t y of i n d i v i d u a l symptoms are 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 treatment outcomes. P a r t i c u l a r y , behaviours such as "often l i e s " , "running away", "truancy", and " p h y s i c a l c r u e l t y to humans" are a s s o c i a t e d w i t h unsuccessful treatment outcome. That i s , j u v e n i l e sex offenders i n ou t - p a t i e n t treatment who e x h i b i t any of these behaviours and even more so these behaviours i n combination are more l i k e l y to have unsuccessful treatment outcomes. However, each behaviour must be examined more f u l l y to get a c l e a r e r understanding of i t ' s relevance. "Often l i e s " may suggest that the i n d i v i d u a l e x h i b i t s a higher degree of d e n i a l than h i s counterparts and i s u n w i l l i n g to accept he has a problem and thus, be more r e s i s t a n t to treatment. The youth who i s o f t e n " t r u a n t " from school may be more l i k e l y to al s o be truant from the treatment program. As such, he i s e x p e l l e d from the program f o r breaking the r u l e of compulsory attendance. The behaviour " p h y s i c a l c r u e l t y to others" may suggest that t h i s i n d i v i d u a l i s a more serious offender and i s more aggressive and engages i n a higher l e v e l of offense s e v e r i t y . For example, the r a p i s t or offender who uses p h y s i c a l force as compared to the offender who i s not 115 aggressive or engages i n hands-off offenses. As such, the more serious offender may be a more a n t i - s o c i a l and/or a more aggressive conduct disordered j u v e n i l e sex offender, making •him much l e s s amenable to treatment. Hypothesis 5 The f i n d i n g s show that i n a po p u l a t i o n of j u v e n i l e sex offenders i n ou t - p a t i e n t treatment those who have previous non-sexual a r r e s t s are more l i k e l y to have unsuccessful treatment outcome as compared to those who have no h i s t o r y of non-sexual offenses. This suggests that these subjects may be a d i s c r e e t subgroup who are more a n t i - s o c i a l , more delinquent, and consequently more severely conduct disordered. L o g i c a l l y , t h i s would make them l e s s amenable to treatment. Hypothesis 6 and 7 These f i n d i n g s show that a pop u l a t i o n of o u t - p a t i e n t j u v e n i l e sex offenders w i t h a h i s t o r y of non-sexual offenses are more l i k e l y to be diagnosed w i t h Conduct Disorder than those w i t h no h i s t o r y non-sexual offenses. Once again, these f i n d i n g may suggest the existence of a d i s c r e e t subgroup that i s at higher r i s k of unsuccessful treatment outcome. On the 116 other hand, i t may a l s o suggest a d i s c r i m i n a t e subtype of j u v e n i l e sex offender 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 of aggression. However, the presence or absence of non-sexual offenses may simply be a broad i n d i c a t o r of the Conduct Disorder behaviours that are c r i m i n a l a c t s . For example, the DSM-III-R Conduct Disorder non-sexual behaviours, such as " t h e f t " , "robbery", " f i r e - s e t t i n g " , "break and enter", " d e s t r u c t i o n of property", " p h y s i c a l f i g h t s " , and "weapon use" are a l l c r i m i n a l offenses. As such, non-sexual offenses simply increase the l i k e l i h o o d of the j u v e n i l e sex offender w i t h a h i s t o r y of non-sexual a r r e s t as being diagnosed as Conduct Disordered. Thus, once again, the question must be asked; i s t h i s a d i s c r i m i n a t e subtype of sex offender, or i s "forced sex" j u s t another behaviour of a Conduct Disordered j u v e n i l e . However, i t i s s i g n i f i c a n t to report that the r e s u l t s of 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 Disorder (ACD) was assessed independent of the "forced sex" DSM b e h a v i o r a l item. At the same time, how does the researcher define the behaviour "forced sex". I f the j u v e n i l e sex offender i s not 117 aggressive and uses no form of overt coercion, does he meet t h i s b e h a v i o r a l 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 issues discussed i n the f i r s t chapter of t h i s paper; such as, the l e v e l of e q u a l i t y , consent, coercion and aggression between the offender and the v i c t i m . Taken together these f i n d i n g s suggest that there i s a j u v e n i l e sex offender subtype that can be d i f f e r e n t i a t e d who i s l e s s amenable to o u t - p a t i e n t treatment. This subtype i s c h a r a c t e r i z e d by having a h i s t o r y of non-sexual offenses and by meeting the f u l l c r i t e r i a f o r Conduct Disorder 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 truant and i s p h y s i c a l l y c r u e l to others. As such, the f i n d i n g s suggest that the more severe and aggressive Conduct Disordered j u v e n i l e sex offender i s l e s s amenable to treatment. L i m i t a t i o n s This 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 . F i r s t , the data c o l l e c t i o n and c o m p i l a t i o n was based on the a v a i l a b l e c l i n i c a l record documentation on f i l e . As such, I r e l i e d on the premise that the c l i n i c i a n s ' gathering and recording of 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 accurate. Second, the p o p u l a t i o n I sampled from were considered by the p r o f e s s i o n a l s t a f f to be the more serious and r e s i s t a n t j u v e n i l e sex offenders r e c e i v i n g o u t - p a t i e n t treatment i n the province of B.C. That i s , a s i g n i f i c a n t percentage of the youth r e f e r r e d f o r treatment to the Youth Court Services/Out-patient Department i n Burnaby, B.C. could 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 province where there was a l a c k support 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 offenders. However, a s i g n i f i c a n t percentage (89%) of the subjects i n t h i s study were housed i n s p e c i a l i z e d residences f o r adolescent sex offenders, and were considered as more serious offenders. As such, t h i s data then may not be r e p r e s e n t a t i v e of the t y p i c a l o u t - p a t i e n t j u v e n i l e sex offender who i s u s u a l l y considered as l e s s serious an offender, as at l e s s r i s k to reoffend, and as more amenable to treatment. There may be an over- r e p r e s e n t a t i o n of conduct disordered subjects r e l a t i v e to the general p o p u l a t i o n of j u v e n i l e sex offenders r e c e i v i n g out- p a t i e n t treatment. On the other hand, the f i n d i n g s of t h i s study are c o n s i s t e n t w i t h previous s t u d i e s on the incidence of Conduct Disorder f o r t h i s p o p u l a t i o n . Third, t h i s study 1 119 lacked r e c i d i v i s m data. . Although a j u v e n i l e sex offender may s u c c e s s f u l l y complete treatment, there i s no guarantee that he w i l l not reoffend. Furthermore, although s t u d i e s report that offenders who s u c c e s s f u l l y complete treatment are at lower r i s k to reoffend, many offenders who complete treatment do i n f a c t go on to reoffend. A f o u r t h l i m i t a t i o n , was that t h i s study was d e s c r i p t i v e i n nature, summarizing frequencies and measures of a s s o c i a t i o n between v a r i a b l e s . Although the 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 c a u t i o n . Without a c o n t r o l group, or at the very l e a s t a comparison sample of j u v e n i l e non-sexual offenders diagnosed w i t h and without Conduct Disorder, one can only speculate on the s i g n i f i c a n c e of 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 that although the frequencies of other diagnoses were examined, the i m p l i c a t i o n s of any diagnoses other than Conduct Disorder, and/or the impact of m u l t i p l e diagnosis on treatment outcome was not examined. For example, many youth diagnosed w i t h Conduct Disorder are al s o diagnosed w i t h A t t e n t i o n D e f i c i t Disorder (27% i n t h i s sample). This may have a serious impact on the i n d i v i d u a l ' s a b i l i t y to s u c c e s s f u l l y complete treatment. A f i n a l l i m i t a t i o n , was the f a c t that 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 of e x i s t i n g 120 a r c h i v a l data. The data 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 records and, as mentioned e a r l i e r , I r e l i e d completely on the various c l i n i c i a n s ' accurate i n f o r m a t i o n gathering and recording of the data. A more robust study would have the 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 the Diagnostic Interview Scale f o r C h i l d r e n (DISC-2) (Shaffer et a l . , 1992). This would i n v o l v e extensive i n t e r v i e w s w i t h the youth, c a r e g i v e r s , and teachers, pre and post treatment. Such an endeavour w i t h the same sample s i z e would take approximately 2 years of concentrated e f f o r t on data c o l l e c t i o n alone. Conclusions.. This study's f i n d i n g s suggest that there i s a Conduct Disorder subtype of j u v e n i l e sex offender who i s l e s s l i k e l y to have s u c c e s s f u l treatment outcome. At the same time, i t suggests that there may be a subtype of j u v e n i l e sex offender who i s not Conduct Disordered and who i s more amenable to treatment. As such, i t may be necessary to provide more s p e c i a l i z e d treatment f o r these subtypes based on t h i s d i a g n o s t i c assessment. For example, the Conduct Disorder j u v e n i l e sex offender may not be s u i t e d f o r the t y p i c a l out- 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. Perhaps a more i n t e n s i v e , process 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 appropriate. This study suggests that there are subtypes w i t h i n the j u v e n i l e sex offender p o p u l a t i o n that are l e s s or more amenable to treatment based on Conduct Disorder diagnosis and i t s b e h a v i o r a l c r i t e r i a . This may mean that 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 are i n d i c a t i v e of poor prognosis i n terms of s u c c e s s f u l treatment outcomes. With t h i s i n mind, studie s comparing subgroups of j u v e n i l e sex offenders are needed, p a r t i c u l a r l y w i t h respect to Conduct Disorder and r e c i d i v i s m i n response to s p e c i f i c treatment i n t e r v e n t i o n s . This study a l s o suggests that the p s y c h i a t r i c diagnosis of Conduct Disorder i s underdiagnosed f o r t h i s p o p u l a t i o n . As such,-more rigorous and exact diagnosing may enhance the c l a s s i f i c a t i o n of Conduct Disorder j u v e n i e l sexual offenders and subsequently, more a c c u r a t e l y i d e n t i f y those youth who are more or l e s s l i k e l y to be s u c c e s s f u l i n treatment. Factors such as l e v e l of i n t e l l e c t u a l f u n c t i o n i n g , presence of l e a r n i n g d i s a b i l i t i e s , degree of s o c i a l s k i l l s , and l e v e l of impulse c o n t r o l must be considered when studying treatment outcomes wi 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 , given that s t u d i e s show that a s i g n i f i a n t number of adolescent sex offenders s u f f e r from d e f i c i t s i n a l l these areas. Treatment success might be a f f e c t e d by the a b i l i t y to l e a r n that which i s o f f e r e d i n therapy. This i s important when c o n s i d e r i n g that c o g n i t i v e - b e h a v i o r a l therapy has a strong "teaching" component, as i s the case f o r the program accessed f o r t h i s study. In outcome studi e s of j u v e n i l e sex offenders, numerous extenuating f a c t o r s must be considered. 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 treatment team and c a r e g i v e r s i s necessary to compel a very r e s i s t a n t population to engage i n and remain i n out- p a t i e n t treatment f o r the d u r a t i o n . Furthermore, stud 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 to i n - p a t i e n t treatment 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 adolescent Conduct Disordered sex offender are necessary. F i n a l l y , future s t u d i e s are needed to address the i s s u e of the increased r e l i a b i l i t y and v a l i d i t y of the DSM-IV as compared to i t ' s predecessors. Of p a r t i c u l a r relevance i s an analyses of the CD behaviors not i n c l u d e d i n the DSM-III-R c r i t e r i a , "often b u l l i e s , threatens, or i n t i m i d a t e s others" 123 and "often stays out a f t e r dark without permission, beginning before 13 years of age". These are h i g h l y p r e d i c t i v e of CD diagnosis (eg. F r i c k , et a l . , 1994) and may have p r e d i c t i v e u t i l i t y f o r treatment and r e c i d i v i s m outcomes. Studies a l s o i n d i c a t e that a l t e r i n g the d e f i n i t i o n of l y i n g to "cons others" and the d e f i n i t i o n of truancy to " truancy beginning before age 13" has increased the d i a g n o s t i c e f f i c i e n c y of these behaviours, 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 value ( F r i c k , et a l . , 1994). In a d d i t i o n , the increase i n the time window f o r DSM Conduct Disorder behaviors from 6 months to one year (APA, 1994) may 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 offender p o p u l a t i o n . The s i g n i f i c a n c e of the presence of conduct d i s o r d e r behaviours i n j u v e n i l e sex offenders w i l l depend on research that overcomes methodological and conceptual problems that were evident i n t h i s study and previous r e l a t e d research. The c l i n i c i a n and researcher a l i k e must contemplate what Kazdin (1989) s t a t e s i s the most important c o n s i d e r a t i o n i n the diagnosis of Conduct Disorder: the s t a b i l i t y , breadth, and i n t e n s i t y of the behaviours, rather than simply the presence of any p a r t i c u l a r behaviour. As such, c a r e f u l c o n s i d e r a t i o n must be taken to determine i f the s i g n i f i c a n t behaviours have 124 been i n evidence f o r the minimum 12 month time window. This i s important, p a r t i c u l a r l y when assessing the degree of s e v e r i t y of the d i s o r d e r . Furthermore, the "age of onset" subtype c r i t e r i a f o r Conduct Disorder (DSM-IV, APA, 1994) must be assessed c a r e f u l l y . 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 of treatment outcome, given that e a r l y onset Conduct Disorder youth have been found to be much l e s s amenable to i n t e r v e n t i o n as compared to the l a t e onset subtype. Furthermore, there i s a need f o r diagnosis to expand along 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 o r i e n t a t i o n of c l i n i c a l diagnosis i s on the "problem of the c h i l d " . The behaviour must be viewed i n the context of a l t e r n a t i v e systems, p a r t i c u l a r l y that of the f a m i l y . The e m p i r i c a l 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 to 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 behaviour and as a p r e d i c t o r of long- term course (Kazdin, 1987). 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DSM- I I I i n residency t r a i n i n g : Results of a n a t i o n a l survey. American Journal of Ps y c h i a t r y , 142, 755-758. Wi l l i a m s , J.B.W. (1986). DSM-III-R: What's a l l the fuss 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 are we rushing to p u b l i s h DSM-IV?. Archives of General 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 y o u r study involves deception, you must also complete page 8, the "Deception F o r m " . Data will be obtained from the medical records (archival data) at Youth Court Services/Out-Patient Treatment Program for adolescent sex offenders. Subjects will be selected via individual medical files of out-patient adolescent males who completed a ful l court-ordered biopsychosocial assessment and who were recommended for and court-ordered to complete the treatment program. All the subjects are males who were charged with sexual offences and consequently evaluated between Jan. 1/90 - Dec.31/92 will be included (n••= 156) in this study. All files will be separated based on completers vs. non-completers according to psychology/psychiatric reports. Each record will 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? 156 How many in the control group? 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 part icipat ion? Nil 16 How are the subjects being recruited? (If i n i t i a l contact is by le t ter or i f a recruitment notice is to be posted, attach a copy.) NOTE that UBC pol icy discourages i n i t i a l contact by telephone. However, surveys which use random d i g i t d ia l ing may be allowed. If your study involves such contact, you must also complete page 9, the "Telephone Contact form". Retrieval of medical/clinical records. 17 If a control group is involved, and i f their se lect ion and/or recruitment d i f fers from the above, provide de ta i l s . No control group. ROJECT DETAILS - 18 Where wi l l the project be conducted? (room or area) Youth Court Services/Out-Patient Program Burnaby, B.C. 19 Who w i l l actual ly conduct the study and what are their qual i f icat ions? Michael J. Pond, RPN, BSW 20 Wi l l the group of subjects have any problems giving informed consent on their own behalf? Consider physical or mental condition, age, language, or other barr iers . - 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 wi l l consent on their behalf? N/A 22 What is known about the r isks and benefits of the proposed research? Do you have additional opinions on this issue? 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 ke l y to endure as a result of the experimental procedures? None-confidentiality is ensured„ IU If monetary compensation is to be offered the subjects, provide deta i l s of amounts and payment schedules. None >5 How much time wi l l a subject have to dedicate to the project? None >6 How much time wi l l a member of the control 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 conf ident ia l i ty of the data be maintained? - A l l files will remain on site. - A l l files will be numerically coded to maintain confidentiality 29 What are the plans for future use of the raw data (beyond that described in this protocol)? How and when w i l l the data be destroyed? None 50 Wi l l any data which identi f ies individuals be available to persons or agencies outside the University? No individuals will be identified 31 Are there any plans for feedback to the subject? NO 158 CHECKLISTS Wil l your project use: (check) ( ) Questionnaires (submit a copy) ( ) Interviews (submit a sample of questions) ( X ) Observations (submit a br ief description) ( ) Tests (submit a br ief description) - indirect observation of archival data in Medical Records. FORMED CONSENT 33 Who wi l l consent? (check) ( ) Subject ( ) Parent/Guardian (Written parental consent is always required for research in the schools and an opportunity must be presented either verbal ly or in writing to the students to refuse to par t ic ipate or withdraw. A copy of what is written or sa id to the students should be provided for review by the Committee.) ( x) Agency O f f i c i a l ( s ) ln the case of projects carr ied out at other ins t i tu t ions , the Committee requires written proof that agency consent has been received. Please specify below: ( ) Research carr ied out in a hospital - approval of hospital research or ethics committee. ( ) Research carr ied out in a school - approval of School Board and/or P r i n c i p a l . (Exact requirements depend on individual school boards: check with Faculty of. Education Committee members for d e t a i l s . ) ( ) Research carr ied out in a Provincia l Health Agency - approval of Deputy Minister ( x > other, specify: Dr. Roy 01 Shaughnessy, Clinical Director Youth Court Services/Out-Patient Department Burnaby, B.C. page 6 34 UBC Pol icy requires written subject consent in a l l cases other than questionnaires which are completed by the subject (see item #35 for consent requirements). Please check each item in the following l i s t before submission of th is form to ensure that the written 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 this sect ion. ( ) Consent form must be prepared on UBC Department letterhead ( x) T i t l e of project . ( x) Ident i f icat ion of investigators (including a telephone number). Research for a graduate thesis should be ident i f i ed as such and the name and telephone number of the Faculty Advisor included. ( X) Brief but complete descr ipt ion IN LAY LANGUAGE of the purpose of the project and of a l l procedures to be carr ied out in which the subjects are involved. Indicate i f the project involves a new or non-traditional procedure whose eff icacy has not been proven in control led studies. ( x) Assurance that ident i ty of the subject w i l l be kept confidential and descr ipt ion of how this wi l l be accomplished. ( X) Statement of the tota l amount of time that wi l l be required of a subject. ( x) Detai ls of monetary compensation, i f any, to be offered to subjects. ( ) An offer to answer any inquir ies concerning the procedures to ensure that they are f u l l y understood by the subject and to provide debriefing i f appropriate. ( ) A statement of the subject's right to refuse to par t ic ipate or withdraw at any time and a statement that withdrawal or refusal to part ic ipate w i l l not jeopardize further treatment, medical care or influence class standing as appl icable . NOTE: This statement must also appear on tetters of i n i t i a l contact. For research done in the schools, indicate what happens to chi ldren whose parents do not consent. Note: The procedure may be part of classroom work but the co l l ec t ion 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 their own records. ( ) A place for signature of subject CONSENTING to par t ic ipate in the research project , investigation or study and a place for the date of the signature. ( ) Parental consent forms must contain a statement of choice providing an option for refusal to par t ic ipate , (e .g . "I consent/I do not consent to my c h i l d ' s par t ic ipat ion in th is study." Also, 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, ie page 1 of 3, 2 of 3, 3 of 3 e tc . IE ST IONNA IRES (completed by subjects) N/A page 7 35 Questionnaires should contain an introductory paragraph which includes the following information. Please check each item in the following l i s t before submission of this form to insure that the introduction contains a l l necessary items. ( ) UBC letterhead ( ) T i t l e of project ( ) Identi f icat ion of investigators (including a telephone number) ( ) A br ief summary that indicates the purpose of the project ( ) The benefits to be derived ( ) A f u l l descript ion of the procedures to be carried out in which the subjects are involved ( ) A statement of the subject's right to refuse to part ic ipate or withdraw at any time without jeopardizing further treatment, medical care or class standing as appl icable . Note: This statment must also appear on explanatory letters involving questionnaires ( ) The amount of time required of the subject must be stated ( ) The statement that i f the questionnaire is completed i t wi l l be assumed that consent has been given ( ) Assurance that identity of the subject wi l l be kept confidential and descr ipt ion of how this w i l l be accomplished ( ) For surveys circulated by mail submit a copy of the explanatory le t ter as well as a copy of the quest ionnai re TACHMENTS 36 Check items attached to this submission i f applicable. Incomplete submissions w i l l not be reviewed. (x Letter of i n i t i a l contact (item 16) Advertisement for volunteer subjects (item 16) Subject consent form (item 34) Control group consent form ( i f different from above) Parent/guardian consent form ( i f different from above) Agency consent (item 33) Questionnaires, tests, interviews, etc. (item 32) Explanatory let ter with questionnaire (item 35) Deception form (including a copy or transcript of written or verbal debriefing) Telephone Contact form Other, specify: 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. 162 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 TELEPHONE CONTACT FORM ' page 9 "̂6 3 1 Telephone contact makes it impossible for a signed record of consent to be kept. Indicate why you believe that such contact is necessary to achieve your research objectives. 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 < ) 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 3 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. 165 Psychiatric Admission Assessment Worksheet Name: Residence: Date of Birth: Admission Date: Duty Doctor's Signature: CONFIDENTIALITY WARNINGS GIVEN Y: • N: • CHARGES PLEA PAST CHARGES DISPOSITION PENDING CHARGES HISTORY OF CRIMINAL BEHAVIOUR 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: • Low: • Anxiety: (general, phobias, panic attacks) Thought: (form and content) Delusions: Y: • N: • Hallucinations: Y: Q N: Q Axis I: Axis II: Axis III: Axis IV: Axis V: Comments: D I A G N O S I S 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 Affi l iation: Y: Q N: Q Delinquent Subculture: Y: Q N: Q ABUSE HISTORY Physical Abuse: Y: • N: Q 173 Sexual Abuse: Y: Q N: Q If Abused: Recurrent Dreams: Y: • N: • Memories: Y: Q N: Q Flashbacks: Y: • N: Q Avoidance: Y: • N: • Memories: Y: Q N: • Flashbacks: Y: • N: • Amnesia: Y: Q N: Q Detachment: Y: Q N: • Restricted Affect: Y: • N: • Arousal: Insomnia: Y: Q N: Q Irritability: Y: • N: Q Startle: Y: • N: Q Poor Concentration: Y: Q N: Panic Attacks: Y: Q N: • • DSM lll-R ADHD 174 1. Fidgeting in seat Y: • N: • 2. Difficulty remaining seated Y: Q N: Q 3. Easily distracted Y: • N: Q 4. Difficulty Awaiting Turn Y: Q N: • 5. Answers questions before asked Y: Q N: • 6. Fails to finish tasks Y: • N: • 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 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: • O-H/A SCALES 176 1. Verbally Hostile: shouts angrily, yells mild insults, makes loud noises, (age of onset ) (age last ) 0 2 3 4 5 Never 1/Week 2-4/Week 1/Day >1/Day 2. Verbally Aggressive: curses viciously, makes threats of violence toward self or others, (age of onset ) (age last ) 0 2 3 4 5 Never 1/Week 2-4/Week 1/Day > 1/Day 3. Aggressive Posturing, aggression against objects: slam doors, make a mess, throw objects, hit walls, break things. (age of onset ) (age last ) 0 1 2 3 4 5 Never 1-2/Month 1/Week 2-4/Week 1/Day > 1/Day With Friends Q Siblings Q Teachers Q Peers Q Parents • Strangers • T o t a l = ( A P ) 4. Aggressive against self:mild, tantrum-like behaviour without serious injury, scratch, hit self, pull hair, throw self on floor (age of onset ) (age last ) 0 1 2 3 4 5 Never Once 2-3 Tims 4-6 Times 7-10 times More Than 10 Times With Friends Q Siblings • Teachers Q Peers • Parents • Strangers • T o t a l = ( A S ) 177 5. Violence against self: significant self-injury, self-mutilation - deep cuts, bites that bleed, fractures, burns. (age of onset ) (age last ) 0 1 2 3 4 5 Never Once 2-3 Tims 4-6 Times 7-10 times More Than 10 Times With Friends Q Siblings Q Teachers Q Peers • Parents Q Strangers • T o t a l = ( V S ) 6. Physical hostility toward others: mild physical aggression - threatening gestures, grab clothes, push, hit without serious injury. (age of onset ) (age last ) 0 1 2 3 4 5 Never 1-2/Month 1/Week 2-4/Week 1/Day > 1/Day With Friends • Siblings • Teachers • Peers Q Parents Q Strangers Q T o t a l = ( P H O ) 7. Physical violence toward others: attack others causing serious injury, heavy bruising, cuts, lacerations, fractures, internal injury (age of onset _ ) ( a g e , a s t ) 0 1 2 3 4 , Never 1-2/Month 1/Week 2-4/Week 1/Day > VDay With Friends Q Siblings Q Teachers Q Peers Q Parents Q Strangers Q T o t a l = (PVO) 8. Carry weapon: gun Y knife Y other Y 9. Use weapon: gun Y knife Y other Y • N • N • N; • N • N • N • • • • • • YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission • • • • • " . : : : : • PROVISIONAL DIAGNOSES ADMISSION DATA CLIENT NUMBER [_ _I_J_J—I—1_} (Psychiatry) AGENCY: WARD/PROGRAM/UNIT CLIENT NAME . DIAGNOSES: CODES Primary Diagnoses: 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 YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission 179 M E D I C A L A N D B E H A V I O R A L A L E R T S A D M I S S I O N / A S S E S S M E N T DATA DISPOSITION DATA (Ward/Unit Supervisors) AGENCY: CLIENT NUMBER WARD/PROGRAM/UNIT ( 1 1 1 1 1 ! 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) / 7 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) ./-- / BEHAVIORAL ALERTS (Table 42): DATE (y/m/d) / / DATE (y/m/d) / / DATE (y/m/d") / / DATE Cv/m/d) / / DATE (y/m/d) / / DATE (y/m/d) / / 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) AGENCY: CLIENT NUMBER WARD/PROGRAM/UNIT t _ J _ L _ l _ J _ J _ J Old Client Number (if anv) [_ f _ t _ l _ l _ l _ ] CLIENT NAME ALSO KNOWN AS PERSONAL INFORMATION Sex (1 = Male, 2 = Female): Eye Colon Hair Colon Distinguishing Marks: Date of Birth (y/m/d): Birthplace (Table 25): Country Education (Table 28): Handicaps: Citizenship (Table 26): Height (###.# cm): Weight (##.# kg): Ethnie Group (Table 51): P.H.N: M.S.P: Name on Card: NAME and ADDRESS CLIENTS ADDRESS: Phone #/Notify (Y/N) 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 n n r A ^ m l c d ™ / A e c « T T , » . n f <i<-r*+n< 1 1 anH 1 * • Tnlv4. 1000 F o r m YSI 001 YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission 1 8 1 A D M I S S I O N D A T A ( In take W o r k e r ) AGENCY: CLIENT NUMBER ( | WARD/PROGRAM/UNIT C L I E N T N A M E DATE (y/m/d): / / 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: / 7 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: YOUTH SERVICES INFORMATION SYSTEM Forensic Psychiatric Services Commission 1 8 2 ADMISSION DATA (Intake Worker) AGENCY: FACILITY: CLIENT NUMBER ( | | 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 M E D I C A L PROCEDURES/PSYCHOLOGICAL TESTS DISPOSITION DATA (Medicine/Psychiatry/Psychology) AGENCY: YCS CLIENT NUMBER [ | | | | | ] WARD/PROGRAM/UNTT IAU C L I E N T N A M E Procedures (Table 47) Code Date (y/m/d) Hematology: Hemog lob in , WBC, ESR, D i f f e r e n t i a l Morphology P l a t e l e t s C h e m i s t r y #1 : R o u t i n e , B i 1 i r u b i n - 1 o t a 1, AST (SGOT) LDH Random B/S C h e m i s t r y #2: R o u t i n e T h y r o x i n e (T4RIA) U r i n a l y s i s : R o u t i n e Psychological Tests (Table 46) Code Date (y/m/d) MMPl Je sne s s WISC-R/WAIS-R H . T . P . (House , T r e e , Person Drawings) Sentence C o m p l e t i o n Se1f—Ado1escent A l c o h o l Involvement S c a l e S e l f - D r u g Use S c r e e n i n g Signature Date (y/m/d): / / 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 e s o f I n f o r m a t i o n s h o u l d be o u t l i n e d i n o p e n i n g p a r a g r a p h . — ^ T ^ f c , . — - f U - x ^ ^ - 1 . R e l a t i v e s : B o t h p a r e n t s where p o s s i b l e , a u n t s , u n c l e s o r o t h e r s i g n i f i c a n t r e l a t i v e s . 2. G u a r d i a n s : 3. A g e n c i e s : F o s t e r - p a r e n t s , g r o u p home p e r s o n n e l . MHR s o c i a l w o r k e r s , 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 have had s i g n i f i c a n t c o n t a c t w i t h the young p e r s o n , s-chc-ol ccw^se l lc r 4 . W r i t t e n r e p o r t s : Documents s e n t w i t h t he r e f e r r a l p a c k a g e , a l l o t h e r r e p o r t s r e a d o r r e c e i v e d , ^\,<JL. R e a s o n f o r t h e R e f e r r a l 1. A s s t a t e d by C o u r t O r d e r . 2 . As e x p r e s s e d by t he P r o b a t i o n O f f i c e r , w r i t t e n o r v e r b a l . 3. A s u n d e r s t o o d o r i n t e r p r e t e d by p a r e n t s and g u a r d i a n . 4 . As u n d e r s t o o d by t h e w r i t e r o f t he S o c i a l H i s t o r y , pU<^ H i s t o r y o f D i f f i c u l t y T h i s c a n i n c l u d e a p r e c i s o f : . 1. P r e v i o u s c h a r g e s , d i s p o s i t i o n s and o t h e r o u t c o m e . 2 . D i f f i c u l t i e s a t home, s c h o o l , and i n t he c o m m u n i t y . i J v ; ^ zx^tr.- 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 t o t he h i s t o r i c a l d i f f i c u l t i e s , ( 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 . ) D e v e l o p m e n t a l H i s t o r y A . E a r l y D e v e l o p m e n t : ( M o t h e r s g i v e t he b e s t i n f o r m a t i o n ; 1. A n t e - n a t a l i n f o r m a t i o n (some p r o b i n g and j o g g i n g o f memory i s o f t e n n e c e s s a r y ) ( a ) 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 o f m o t h e r . I l l n e s s , m e d i c a t i o n s t a k e n , t o x e m i a . ( b ) L i f e s t y l e h a b i t s - d r i n k i n g , s m o k i n g , d r u g s . ( c ) P r e g n a n c y : d u r a t i o n . 185 " \ 2 " Delivery and Post-natal (a) Type of b i r t h : natural , breech, C-section, use of forceps, other complications. (b) Condition of baby: blue, jaundiced, weight. (c) Response of baby: contented vs agitated; co l icky, eating and sleeping habits. 3. B i r t h to 2 years (a) Milestones: walked, talked, to i le t - trained ( i . e . , slow, fast, time). (b) Traumas: i l lness , hospital izat ion, separations from parents. 4. 2 years to 5 years (a) Health, social interaction with other chi ldren, speech development. (b) Behavioural indicators, indicators of possible hyperactivity^ c*°i<>[re-SUOr~>< Education, Development during those years: 1. Elementary school. (a) Academic performance, grades repeated, tests done by school, awards and recognition. (b) Behaviour as perceived by teachers and peers; suspensions. (c) Sports and other involvementi 2. High School. (a) Academic performance,grades repeated, tests done by school, awards- and recognition. (b) Behaviour as perceived by teachers and peers; suspensions. J (c) Sports and other involvement. (d) Peer relat ionship, and present grade. (e) Ambitions and plans. C. Other Concerns: . Health problems, f a l l s , head injuries , etc. ^ > £Asj\y\JVA^ CUJM// 5 -^ 2. Explore problems with (a) enuresis, and somnambulism. wt i ' ipr^M*' (b) f i r e - se t t ing , cruelty to animals. (c~) aggressive behaviour^/* tr«e<J*'"rt ; (fi) S^MA-cJ. JQ IA/>>_ / pJr^A^-cJ- QJOAJS**-' Family Relationships _ ^ ^ . ^ ^ J ^ , ^ tvhc-n -i 1. ^Parents: marriage, strength of relationship*.- Inquire about:- (a) Disagreements and fights between parents - causes. (b) Alcohol or drug problems. (c) If separated or divorced - cause of marriage breakdown. (d) Work of parents or means of f inancial support. (e) Relationship of patient to parents. 5 2. S ib l ings : significant information about each. Patient's re lat ionship with 3. Extended family: patient's relationship with family members. 4 . Other important information about the family dynamics. Friendships. Close friends of patient; duration of friendships; a b i l i t y to make and keep friends, ( y v ^ ^ C L ^ ^ l t ^ ) Disc ip l ine and Control 1. Explore parents' methods and attitudes towards d i sc ip l ine . 1 .lA-<"-^v~pLe.V 2. C h i l d ' s e a r l i e r response to d i sc ip l ine . 3. Pat ient's present response to disc ipl ine and control . 4, Patient 's involvement in discipline-forming organizations ( e . g . , Cadets, Demolay, the church or synagogue, sport clubs) . Future Plans 1. Parents' point of view as to what they would l ike to see happen wi th / for the patient . . \^^K <TA T- • •' \ • ' c»Tf\AAAX4«.tt*«-. Z. . . . . 2. Involved agencies' plans for patient. 3. Writer's impression of what might be helpful to patient based on information gathered. , f x pry/rtt-.v.r„. ^.ja^JcJJj_ Summary and Evaluation Summarize sal ient points of history, and interpret their 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 psychiatric/psychological f ind ings . Signature of Writer -V ^ \ 1 . 11 T i t l e of Writer . , , , , \ u - , [ i I 1~ rL (L-h SMV-l* 187 YOUTH COURT SERVICES NURSING ASSESSMENT GUIDELINES 1. IDENTIFYING DATA Name: D.o.b: Age: Status: 2. REASON FOR REFERRAL Record l e g a l s t a t u s , i n c l u d i n g Young offenders Act and Criminal Code Section i f known.Record offences. 3. LEGAL HISTORY Enter f o r each crime or group of crimes. (a) Date (b) Type (c) D i s p o s i t i o n 4 . MTDTCAT. HISTORY Enter f o r each major i l l n e s s , i n c l u d i n g operations and i n j u r i e s (a) Nature of i l l n e s s ( d i a g n o s i s i f available) (b) Place of treatment (c) Attending p h i s i c i a n (d) Nature of treatment (e) Response to treatment 5. PAST MENTAL HEALTH (include inpatient,outpatient and p r i v a t e ( p s y c h i a t r i s t - ) (a) Date (b) Place of treatment (c) Attending p h y s i c i a n (d) Symptoms or diagnosis (e) Treatment (f) Response to treatment 6. FAMILY HISTORY (1) Parents; (2) S i b l i n g s ; (3) Foster or adoptive parents.Record the f o l l o w i n g f o r each. (a) Age (b) Occupation (c) M a r i t a l status (d) Any major i l l n e s s (physical and mental) (e) Any h i s t o r y of alcohol,drugs,suicide attemps, diabetes,epilepsy,etc. 188 (f) I f member deceased,record cause and age at death. (g) Quality of relationship with patient. 7 . PERSONAL HISTORY (a) Date and place of b ir th (b) Ethnicity (c) Complication of pregnancy/delivery and b ir th weight. (d) Early development,include history of aggressive behaviour. (e) Home atmosphere: relationships in childwood with parents, s ib l ings ,qual i ty of family l i f e . (f) Education:include grade level,grade fa i lures , further education,reason for leaving school,special a b i l i t i e s , special problems,special/recreational/academic achievements,peer group relationships. (g) Work history:include age started work,jobs in chronological order and length job held,reason for change, present job. (h) Sexual History:Early sexual development,masturbation (including fantasy),sexual adequacy,present outlet and performance,sexual orientation,abnormal sexual interests . 8 . LIFESTYLE PRIOR TO REFERRAL (a) Social relat ionships/friends/school . (b) H a b i t s : i l l i c i t drugs/alcohol/,amount and frequency,effects on l i f e s t y l e . (c) Religion:church attendance,moral values. (d) Ac t iv i t i e s and interest. 9 . CIRCUMSTANCES LEADING TO ARREST AND REFERRAL (a) Record in detai lsd and chronological order,patient*s account of events ( i . e . , subject ive form).Psychiatrist may also include this information.However,a second opinion can be invaluable. 10. 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 legal s i tuat ion and charges. Understanding the nature and purpose of interview. ( i i ) 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 reversal . ( i i i ) Memory,recent and remote.Comment on person's a b i l i t y 189 to r e c a l l events at the t i n e of the alleged offence. Ask p a t i e n t t o give name and address,to repeat immediately and again i n three minutes. (iv) General information:Always include the following. Six large c i t i e s i n Canada,Capital of Canada,Capital of England,Name of the Prime M i n i s t e r , r u l i n g p o l i t i c a l party ( P r o v i n c i a l and Federal). (v) Intelligence:make a general assessment based on the patient's education, general knowledge,use of language,understanding of concepts,etc. (c) Mood- elevation,depression,flatness,incongruity, suspicion, p e r p l e x i t y , fear, anxiety, sleep, energy, l i b i d o , a p p e t i t e . (d) Thinking and Speech- spontaneity of conversation,rate, 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 elsewhere). Thought blocking-perseveration-.the a b i l i t y t o switch words or 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 or more thought sequences at one time),other thought d i s o r d e r , a b i l i t y to abstract-(record 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 glass houses....''. (e) Perceptual d i s o r d e r s . H a l l u c i n a t i o n s - v i s u a l , a u d i t o r y , e t c . Derealisation/Depersonalisation. (f) S p e c i a l Information, ( i f f i t n e s s i s r e q u i r e d ) . Pleas a v a i l a b l e t o p a t i e n t . Nature of evidence Meaning of Oath Function of Judge,jury,prosecutor, defence lawyer. (g) Insight and judgement. A t t i t u d e to present s i t u a t i o n , i n c l u d i n g court case,lawyer, offences,etc. Understanding of 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 to plan ahead. 11. PROBLEM FORMULATION OR IMPRESSION. S.O Rev.-1992.03.05 PSYCHOLOGICAL INTERVIEW DATE: D.O.B.: CHRONOLOGICAL AGE: Inform of l i m i t s of 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) j u s t i f i c a t i o n family criminal h i s t o r y remorseful f e e l i n g PREVIOUS CHARGE offense & sentences received outstanding charges FAMILY CONSTELLATION r e l a t i o n s h i p with 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 father 191 - 2 - problem i n the family: alcoholism, drugs, separa- t i o n , work problems LIVING SITUATION presently l i v i n g where h i s t o r y of f o s t e r placement h i s t o r y of running away SCHOOL - present school grade f a v o r i t e subject l i k e or d i s l i k e school grade f a i l u r e s suspension i n school h i s t o r y of f i g h t i n g numbers of schools attended since kindergarten FRIENDS numbers of fr i e n d s degree of intimacy and independence with f r i e n d s types of a c t i v i t i e s enjoyed with f r i e n d s best friends (how long t h i s r e l a t i o n s h i p has existed ALCOHOL AND DRUG HISTORY onset of using alcohol and/or drugs 192 - 3 - what kinds of drugs quantity per day, week or month SEXUAL HISTORY pubertal experience (including sex abuse, pornog- raphy, exposure to sexuality) f i r s t sexual experience and type - numbers of sexual partners i f charge i s sexual i n nature, the d e t a i l s of i t sexual fantasy masturbation p r o s t i t u t i o n pregnancy HEALTH - h o s p i t a l i z a t i o n s high fever head i n j u r y health i n general a l l e r g i e s FUTURE PLANS BEST MOMENT IN LIFE WORST MOMENT IN LIFE 193 - 4 - ANGER MANAGEMENT f r u s t r a t i o n tolerance s e n s i t i v i t y to c r i t i c i s m response to authority figures emotional control v e r b a l l y abusive p h y s i c a l l y abusive abuse towards inanimate objects - abuse towards animals or people s e l f destruction tendencies THREE WISHES, PSYCHOLOGICAL HISTORY thera p i s t s (how many, frequency, where, and when) HISTORY OF SEXUAL ABUSE HISTORY OF PHYSICAL ABUSE MENTAL STATUS EXAMINATION general presentation (height, weight, c o l o r of hai r , general appearance, dress) rapport verbal expression eye contact 194 - 5 - c r e d i b i l i t y cooperation behaviour during interview (aggressive, a l e r t , apathetic, bizarre, h o s t i l e , f l a t , bland, passive) mood (1 to 10) at assessment time, i n general: stable - l a b i l e a f f e c t (e.g., anxious, f l a t depressed, euphoric etc.) h a l l u c i n a t i o n (auditory and/or visual) delusions i n s i g h t and judgement eating disturbance recent loss of weight (general eating patterns) general eating patterns sleep disturbance i n i t i a l insomnia intermittent insomnia terminal insomnia h i s t o r y of nightmares somatization paranoid ideation signs of depression low energy l e v e l c r y i n g s p e l l s withdrawal from regular a c t i v i t y 195 - 6 - - apathy - dysthymic tendencies signs of psychosis - anxiety l e v e l ADOLESCENT'S CHOICE OF DISPOSITION IMPRESSIONS RECOMMENDATIONS 196 Weschler I n t e l l i g e n c e s c a l e 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 comprised of ten sub-scales which permits an evaluation of various c o g n i t i v e a b i l i t i e s , i n c l u d i n g a number of both verbal and v i s u a l - s p a t i a l a b i l i t i e s . In a d d i t i o n to i n d i c a t i n g how a c h i l d i s f u n c t i o n i n g i n t e l l e c t u a l l y i n comparison with same-age peers, the WISC-R a l s o y i e l d s clues to the c h i l d ' s s e l f - p e r c e p t i o n , f r u s t r a t i o n - t o l e r a n c e , and a number of 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 Tests P r o j e c t i v e drawing t e s t s (e.g. House-Tree-Person Test) permit an ev a l u a t i o n of 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 general developmental l e v e l , and also y i e l d i n s i g h t i n t o the c h i l d ' s s e l f - p e r c e p t i o n and view of h i s or her environment. In a d d i t i o n , they provide clues to the c h i l d ' s p e r s o n a l i t y and emotional s t a t e . Minnesota Multiphasic P e r s o n a l i t y Inventory (MMPI) The MMPI i s a s e l f - r e f e r r a l questionnaire which i s u s e f u l i n asse s s i n g 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 , and i n t e r a c t i v e s t y l e . E s s e n t i a l l y , i t i s an objec t i v e instrument used t o i d e n t i f y the 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 personal and s o c i a l adjustment. Jesness Personality Inventory The Jesness i s also 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 to adolescents. I t p r o v i d e s information regarding an adolescent's a f f e c t i v e s t a t e , value o r i e n t a t i o n and s o c i a l adjustment, as we l l as h i s or her 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 tes t helps i l luminate the indiv idual ' s emotional state and at t i tudes , how he or she perceives the soc ia l environment, and what h i s or her hopes and fears are for the future. Rorschach Inkblot Test Indiv iduals ' perceptions of ambiguous s t imul i ( i . e . inkblots) reveal a great deal about the i r personal i ty organizat ion, interre lat ionships and areas of c o n f l i c t . In addi t ion , t h i s tes t permits an evaluation of cognitive d i s tor t ions and creat ive a b i l i t i e s . Thematic Apperception Test (TAT) The TAT requires the ind iv idua l to create s tor ies i n response to pictures depicting ambiguous scenes. The ways i n which the ind iv idua l interprets the pictures y i e l d clues to 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 indicat ive of conf l i c t s , stressors, re la t ionsh ips and other important features of the indiv idual ' s l i f e . 198 Province O f Ministry of- . Forensic Psychiatric British Columbia Health Services Commission 3405 Willingdon Avenue Burnaby i n V T u ^ « « ^ E S B n , i s h Columbia TO THE COURTS Telephone: (604) 660-5788 91.02.26 DOCUMENT FORENSIC PSYCHOLOGICAL REPORT PRIVATE AND CONFIDENTIAL His or Her Honour the Presiding Judge, Youth Court of B r i t i s h Columbia, c/o The Court Registry, Then the address of the court* Your Honour, r e : Name of the adolescent Date of B i r t h REASON FOR REFERRAL V Referred by Probation O f f i c e r / C o u r t . A l s o indicate where the adolescent has been seen and how many times. SOURCE OF INFORMATION: P s y c h i a t r i s t progress note. S o c i a l Worker progress note. Nursing f i l e . PO - Youth Workers report. Information from parents interview or telephone c a l l and case conference. BACKGROUND INFORMATION - SUMMARY Summarize the most s a l i e n t moment of the adolescent. Longstanding h i s t o r y of delinquency. Recent placement. Attendance i n school. B r i e f summary of the family s i t u a t i o n . Number of times he appears before the court. INTERVIEW WITH THE PATIENT Information of l i m i t e d c o n f i d e n t i a l i t y . 199 2 - CRIMINAL HISTORY Present charge/ past criminal history/outstanding charge. Involvement with community hours. Probation time done. Rationale f o r the patient to ex p l a i n misconduct. Remorseful f e e l i n g , reaction towards v i c t i m s . Onset of misconduct behavior. FAMILY HISTORY Where i s the c h i l d l i v i n g at the time of the assessment. Relationship with each member of the family i n c l u d i n g stepbrother, stepfather, and stepmother. H i s t o r y of f o s t e r placement. Problem at home. Alcohol and drugs, separation, work problem, and f i n a n c i a l problem. Family consultation and number of s i b l i n g s and step family involved. SOCIAL ENVIRONMENT Friends, doing crime or not doing crime. Alcohol and drug abuse. HEALTH I n j u r i e s , a l l e r g i e s , and broken bones. H i s t o r y of h o s p i t a l i z a t i o n s . SEXUAL HISTORY Onset of s e x u a l i t y . Homosexual tendencies. Pregnancies. Contact with pornographic material. Promiscuous behavior. Inappropriate dressing code. SCHOOL School performance. H i s t o r y of school attendance. H i s t o r y of f i g h t s at school. Suspension from school. A t t i t u d e toward school work. 200 - 3 - Major problem i n school. TEST RESULTS Psyc h o l o g i c a l t e s t i n g . Behavioral t e s t i n g . R e s u l t from the 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. Result from the MMPI. Result from the Jesness Personality Inventory. Result from the House-Tree-Person. Result from the 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. A f f e c t . E a t i n g disturbance. S l e e p i n g disturbance. S u i c i d a l ideation - s u i c i d a l attempt - s u i c i d a l plan. H a l l u c i n a t i o n : auditory or v i s u a l . V erbal expression: amount, flow, and syntax. Sign of depression. Sign of psychosis. Thought disorder. Anxiety l e v e l and somatization. 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 since most of the time t h i s i s the only part that the judge w i l l read, before the k i d appears i n court. We, therefore, have to summarize the main point of the report even i f i t seems redundant to repeat them. Summary: the age of the patient, i n t e l l e c t u a l f u n c t i o n i n g of the patient, h i s numbers of appearance before the court previous to t h i s charge, his a t t i t u d e s i n the interview and i n the t e s t i n g . The main D.S.M. - III diagnostic colon would be: conduct d i s o r d e r , psychotic disorder, C l i n i c a l A f f e c t i v e Disorder, anxiety disorder, and Attention D e f i c i t Disorder. 201 r - 4 - Prognosis and explanation of why we proceed the prognosis guarded or not. Recommendations: time f o r probation, access to c h i l d r e n , curfew, attendance i n school, work placement, c h i l d care 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. Identifying Data; Name: D.O.B: Address: Status: 2. Reason for Activation: Record legal status, offences,. and referring agency. 3. Reason for Termination: Record expiry of b a i l , probation, and rescindment of O.I.C. or termination by patient. 4. Mental State at Time of 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 psychiatrist. 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) AGENCY: CLIENT NUMBER WARD/PROG RAM/UNIT I l _ l I I * 1 CLIENT NAME DIAGNOSES: Primary Diagnoses: Secondary Diagnoses: Other Diagnoses: CODES DMSIII-R ICD9-CM FORMULATION: \ Signature Date (y/m/d):

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