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National Center on the Sexual Behavior of Youth
Title of Chapter:
Guidelines for Placement Within a Continuum of Care for Adolescent Sex
Offenders and Children with Sexual Behavior Problems
Duration:
1-2 hours
Target Audience:
Attorneys, Judges, Law Enforcement, Probation, Child Welfare Workers,
Mental Health Practitioners
Prepared by:
Mark Chaffin, Ph.D. & Robert Longo, MRC LPC
(NOTE: The following concepts are to be presented by the leader or co-leaders of the training
session. It is recommended that the presenter be a licensed mental health practitioner with
knowledge of the literature and experience in treating adolescent sex offenders)
Purpose: The purpose of this workshop is to provide guidance for decision-making in the type,
intensity, and location of interventions for adolescent sex offenders (ASOs) and children with
sexual behavior problems (CSBPs). Many ASOs and CSBPs can be appropriately treated through
community-based services. Others must be removed from their home in order to provide for their
individual treatment needs and to protect the safety of other family members and the communityat-large. Suggestions will be provided on how to structure the decision-making process when
determining the service needs of adolescents and youths who have engaged in illegal sexual
behaviors.
Materials:
 Handout 1: Levels of Care for Adolescent Sex Offenders and Children with Sexual
Behavior Problems
 Handout 2: Matching Youth Reoffense Risk to Levels of Restrictiveness
 Handout 3: Linking Case Factors and Treatment Program Types for Adolescent Sex
Offenders and Children with Sexual Behavior Problems
 NCSBY Fact Sheet: Risk Assessment of Adolescent Sex Offenders
 NCSBY Fact Sheet: Adolescent Sex Offenders: Common Misperceptions vs. Current
Evidence
 NCSBY Fact Sheet: Clinical Assessment of Children with Sexual Behavior Problems
 Overhead projector or Laptop computer and LCD projector if available
Resources: For additional help and information on this program you may contact The
National Center on Sexual Behavior of Youth, Center on Child Abuse and Neglect, Department
of Pediatrics University of Oklahoma Health Sciences Center 940 NE 13th St, Rm 3B-3406
Oklahoma City, OK 73104-5066. Phone: (405) 271-8858; Fax: (405) 271-2931.
Objectives:
At the conclusion of this session, participants will be able to:
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Identify the ten guiding principles for determining the placement needs of ASOs and CSBPs;
Describe the service Continuum of Care for ASOs and CSBPs;
Identify the methods of sexual reoffense risk assessment and describe how reoffense risk
factors influence placement decision-making;
Describe the importance of prioritizing intervention needs for ASOs and CSBPs and
incorporating this information into placement decision-making;
Identify common factors that drive sexually abusive behavior in ASOs and CSBPs and
describe their relevance to placement decision-making
Determine the relevance of such youth factors as personal strengths, sex, proximity to the
victim/potential victim, and developmental disabilities to placement decision-making.
Advanced Preparation:
 Review session material.
 Prepare adequate number of handouts and NCSBY fact sheets.
 Check availability and functioning of AV equipment
Outline:
I. Introduction
II. Ten Principles of Placement Triage Decisions for ASOs and CSBPs
A. General Principle I—Decisions should be made on a case-by-case basis.
B. General Principle II—The youth’s cultural identity should be considered in placement
decision-making.
C. General Principle III—The youth’s behavior, strengths, and problems are more
important than an administrative classification.
D. General Principle IV—The youth should be placed in the least restrictive level of care
that is consistent with community safety and victim welfare.
E. General Principle V—Placement decisions should be reassessed over time.
F. General Principle VI—Both sexual and co-morbid or non-sexual issues are important
considerations.
G. General Principle VII— Decision-makers should be knowledgeable about and have
expertise in child and adolescent development.
H. General Principle VIII—A group of professionals should be involved in the decisionmaking process.
I. General Principle IX—Decisions should be made with objectivity, fairness, and
candor, and should be based on current scientific knowledge.
J. General Principle X—Treatment services should meet high levels for standards of
care.
III. The Continuum of Care
A. Prevention Program Level
B. Outpatient Program Level
C. Intensive Community-Based Level
D. Foster Home and Independent Living Level
E. Day Treatment Level
F. Group Home Level
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G. Short-Term Intensive Inpatient Level
H. Unlocked, Staff-Secure Residential Level
I. High Security Lock-Down Level
IV. Five Questions to Ask in Making a Placement Decision, How to Answer Them and What
They Mean
A. What is the level of current risk for sexually harmful behavior in ASOs?
1. Risk Assessment Approaches
2. Using Risk Estimates
3. Matching Risk to Level of Restrictiveness
B. What are the intervention priorities?
C. What factors are driving the behavior?
D. What can realistically be expected to change?
E. What are the youth’s strengths to consider in placement decisions?
V. Additional Placement Issues
A. In-Home Victim or Potential Victim Situations
B. Special Needs Populations
C. Benevolent Triage
VI. Summary
Introduction
When adolescents have committed sexual offenses or children are discovered to have
highly inappropriate, aggressive, or victimizing sexual behaviors, decisions must be made.
Family members, child protection staff, juvenile justice personnel, judges, treatment providers,
and others often face decisions about the type, intensity, and location of intervention needed.
Often, these decisions involve choosing between different levels of care (e.g., community-based
or residential) and choosing among different types of intervention approaches.
These guidelines are intended to provide some structure and suggestions for the decisions.
Should be used to help those involved in the decision process think through the options. The
guidelines are not a replacement for case-by-case professional judgment or due process
procedure. The structure and many of the suggestions in these guidelines are based on inferences
drawn from clinical work and rigorous scientific study, these guidelines should be thought of as a
set of working assumptions that are subject to testing against emerging data. Because treatment
of ASOs and CSBPs is a rapidly developing field of study, decision makers should be aware of
the latest findings and research in this area.
These guidelines are designed to address questions about level of care, and placement, are
focused on the goals of meeting youth’s service needs. Preserving the safety of the community,
and respecting the welfare of the victim, and these goals are viewed as consistent with the main
priorities of the juvenile justice and child protection systems—rehabilitation and community
safety. Decisions about placement made in the service of other priorities, such as for punishment
purposes, cannot be well integrated into a services-oriented triage system. Although punishment
priorities exist and may be germane in some cases, these guidelines have focused on community
and victim safety, and service needs.
It is recommended that placement decisions for ASOs and CSBPs be guided by ten
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general principles:
General Principle I—Decisions should be made on a case-by-case basis.
It is well established that ASOs and CSBPs are diverse populations. That is, there is no
single profile or pattern of behavior or no single set of characteristics or background that describe
these youth, and consequently no single one-size-fits-all approach to intervention or case
disposition will be appropriate for all cases. Decisions about level of care, removal from the
home in cases of sibling abuse, placement options, treatment programs, and related matters
should be made on a case-by-case basis. This is the core rationale for the practice of placement
triage.
General Principle II—The youth’s cultural identity should be considered in placement decisionmaking.
A good ‘fit’ between the service model, level of care, and the youth’s culture may be a
critical component of selecting the optimal case approach. Youth from some cultural groups may
not respond well to unfamiliar or culturally incompatible approaches. For many youth, culturally
based intervention practices may need to be considered as an alternative to or in combination
with standard treatment approaches. For example, traditionally oriented Native American youth
may benefit by including traditional healing practices or traditional practitioners in the overall
intervention plan. Treatment providers ideally should have some familiarity with the cultural
identities of their clients, and the traditions and belief systems of those cultures. It is important
to assess cultural identity on a case-by-case basis. Cultural identity is not always synonymous
with race or ethnicity. For example, a Hispanic youth’s cultural identity may derive from
Mexico, from Puerto Rico, or from Los Angeles, and each of these cultural identities might be
distinct from the others.
General Principle III—The youth’s behavior, strengths, and problems are more important than an
administrative classification.
Level of care and intervention decisions are most appropriately based on the youth’s
behavior, psychological make-up, and social ecology, and not on the youth’s administrative
classification. Because assessing behavior, psychological status, and social ecology are critical, it
is recommended that triage and placement decisions include information from professionals
qualified to assess these areas. Administrative classification alone (e.g., adjudicated offense
category, listing as a alleged perpetrator in a child maltreatment report) may be misleading.
Some youth might be administratively classified as sex offenders or abuse perpetrators, but might
not have any of the typical problems often targeted in specialized treatment programs. For
example, a youth who was adjudicated on the basis of participation in a group “mooning”
incident might share few issues or intervention needs in common with youth typically seen in sex
offender treatment programs. Conversely, just because a youth might be adjudicated for a nonsexual offense does not necessarily preclude the need for involvement in some level of sex
offender intervention. For example, a youth adjudicated for breaking and entering, where the
offense involved stealing undergarments for sexual purposes, might have clear needs for sex
offender specific services.
General Principle IV—The youth should be placed in the least restrictive level of care that is
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consistent with community safety and victim welfare.
Given a continuum of placement options, youth should receive services in the least
restrictive option available that is consistent with their needs and with community safety and
victim welfare. At present, there is some consensus among treatment professionals that most
ASOs and CSBPs can be served in community-based or outpatient programs (ATSA, 19). Youth
should be placed in more restrictive levels of care only when it is clear that the youth requires
this level of care or when a lower level of care would clearly compromise community safety or
victim welfare.
Level of care decisions should consider the potential risks and benefits inherent in more
restrictive placements. It is not recommended that decisions be made on a “better safe than
sorry” basis given that there are always risks involved in a decision to utilize a more restrictive
level of care. Placement in more restrictive levels of care has some intrinsic benefits. More
restrictive settings provide closer supervision, greater structure, more security, and intensive
services. Conversely, more restrictive placements may impair normal social and relationship
development, lead to subsequent institutionalization, run the risk of increasing future delinquent
behavior by socializing youth into delinquent subcultures, and compromise family ties. In within
family sexual abuse cases, children who were victims may have a variety of reactions to the
removal and placement of their sibling in a more restrictive level of care. In some cases, these
children may suffer distress if their abusive sibling remains in the home. In other cases, the
children may suffer distress related to their sibling’s removal from the home and the loss of a
sibling relationship. These issues need to be evaluated on an individual case-by-case basis and
not based on broad assumptions such as, “Perpetrators should never be left in the home with their
victims,” or “Families should always be preserved.”
The need for intensive services and secure containment, although often related, should be
evaluated separately in placement decisions. In some cases, a need for high-intensity services but
not for high-security containment may be met in high-intensity community programs. However,
when youth pose an acute, ongoing risk to the community, restrictive placements should always
be given strong consideration.
In addition, system-wide cost and cost-benefit factors must be considered, and decision
makers should consider the implications of their decisions for the overall service delivery system
as well as for the individual case. For example, over-utilization of more restrictive placements,
which are usually far more costly than lower levels of care, may deplete system-wide financial
resources and adversely affect the entire continuum of care. If the continuum of care fails to
provide services across various levels of restriction, professionals should advocate for the
development and efficient utilization of a full continuum of services rather than accepting service
levels that are not well matched to the youths’ needs and levels of risk.
General Principle V—Placement decisions should be reassessed over time.
The status of ASOs and CSBPs may change, either for the better or for the worse, over
time. Consequently, it is critical that triage decision-making be an ongoing process. Youth in
more restrictive levels of care can and should be moved into less restrictive settings as their
status improves and as they demonstrate competency. Conversely, youth in less restrictive levels
of care may require more intensive or more restrictive interventions if their condition deteriorates
or if their family or social ecology becomes problematic despite appropriate efforts to maintain
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the viability of a less restrictive level of care.
General Principle VI—Both sexual and co-morbid or non-sexual issues are important
considerations.
Placement decisions and service needs are determined by many factors. Sexual behavior
is an obvious and critical factor to be considered. However, in some cases, intervention
decisions should be based largely or even primarily on a set of non-sexual or co-morbid factors,
irrespective of the seriousness of the sexual behavior or sexual problems. In some cases, these
non-sexual factors are the first priority. For example, youth with acute psychosis may require
services that focus first on stabilization of their psychotic symptoms, and it could be
counterproductive to place these youth into a sex-offender program with little or no psychiatric
resources.
Some generally delinquent sex-offending adolescents may require services that focus
heavily on targets such as decreasing delinquent peer affiliations and promoting prosocial
affiliations, increasing school involvement, increasing general parental supervision, and
managing substance use. Vocational, educational, or recreational development may be important
to consider. CSBPs who have significant posttraumatic stress symptoms general childhood
behavior problems may primarily need services that focus on these problems.
It is important to take a holistic perspective of the youth’s needs and to balance sexual
and non-sexual issues on an individual case-by-case basis. Placement options should include,
but not be limited to, specialized sex-offender programming. The practice of excluding
adolescent sex offenders, as a broad group, from entire classes of services or requiring these
youth to be served exclusively in sex-offender specific programs is not supported by the available
evidence and should be actively discouraged. This is especially true for CSBPs.
General Principle VII— Decision-makers should be knowledgeable about and have expertise in
child and adolescent development.
Because ASOs and especially CSBPs are distinct from adult sex offenders, expertise
based on assessing and treating adult sex offenders does not qualify a decision-maker to deal
with the sexual, and especially non-sexual issues presented by teenagers and children. Placement
and intervention decisions should be based on a specific knowledge of ASOs and CSBPs and
specific expertise in general child, adolescent, and family work. With young CSBPs, primary
expertise in child or pediatric mental health is essential. Services to children and adolescents
should be in programs that are appropriate to their development and should not mix disparate
developmental levels. For example, with very few exceptions, preadolescent children should not
be placed in programs with older adolescents and adolescents should not be placed in programs
with adults. This is especially the case in residential programs where mixing disparate
developmental levels carries risk for victimization. Similar issues must be considered with
making residential placement decisions for developmentally challenged individuals.
Developmental issues should also influence decisions about the duration, intensity, and
restrictiveness of care. For example, most CSBPs, will be placed in shorter-term and less
restrictive levels of care than ASOs.
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General Principle VIII—A group of professionals should be involved in the decision-making
process.
Using teams to make placement decisions has several advantages. Team members can
obtain information from a variety of sources that may not be fully available to a single individual
and will combine a range of perspectives and expertise. Teams may be structured as formal
organized multidisciplinary teams, or as ad hoc and informal working relationships. Although a
well-selected working team is useful for decision making, not all teams function or work together
well, and the potential for personal conflicts or domination by extreme agendas must be
recognized and managed in order for teams to function most effectively. Although placement
recommendations or decisions can be made by individuals with adequate expertise, involvement
in team decision-making, whether formal or informal, should be strongly considered.
General Principle IX—Decisions should be made with objectivity, fairness, and candor, and
should be based on current scientific knowledge.
Placement and intervention decisions should be strongly rooted in a clear understanding
of the available empirical scientific literature on ASOs and CSBPs. Objectivity and reliance
upon well-supported models and empirical data are the hallmarks of professional triage
assessment and decision-making. As in any forensically relevant assessment, professionals
should take care to avoid over-reliance on “clinical impressions,” “intuition” or other procedures
with limited predictive validity.
Professionals should make their triage decisions based on the most complete, objective,
behavioral history available, and minimize reliance on tests or measures with no demonstrated
predictive validity for placement purposes and with the population in question. It is
recommended that decision makers disregard information that may decrease accuracy. For
example, various projective personality tests might be used by some clinicians for generating
hypotheses for treatment, but would be of little use in making a good decision about the level of
care a youth needs.
Some estimate of re-offense risk is generally part of making placement decisions, and
these risk estimates should be made with a full understanding of the basic scientific principles of
risk prediction (e.g., influence of base rates, sensitivity and specificity on rates of false positive
and false negative prediction, etc.). The decision can be assisted by utilizing relevant actuarial
systems or empirically-based risk assessment instruments as these become available.
Assessments of risk should begin by referencing established research estimates of reoffense rates
among the group in question rather than relying on clinical impressions or untested assumptions
about reoffense rates.
Placement decisions should be fair. In other words, they should not be biased by
irrelevant personal factors which have no predictive validity and that might disadvantage
particular social or cultural groups. For example, it has been found that African-American youth
in the juvenile justice system are more likely than white youth to be placed in secure correctional
facilities rather than community-based programs even when their behaviors are comparable.
Placement recommendations and decisions should be made candidly. That is, the
objective facts supporting why one level of care is recommended and why another is not, should
be clearly stated to all concerned. Both corroborating facts and potentially contradictory facts
should be made explicit.
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General Principle X—Treatment services should meet high levels for standards of care.
Triage decision-makers should favor services with a) empirical support for effectiveness
(i.e., a body of well-controlled, rigorous, randomized clinical trials); b) an accepted theoretical
base; c) grounding in good clinical practices and ethical standards; and d) minimal demonstrated
or likely adverse effects. If rigorous empirical support for effectiveness is lacking (which is
currently the case for most standard ASO and CSBP interventions), decision-makers may select
treatments based on general professional consensus, provided these treatments meet criteria b),
c), and d). Triage decision-makers should be extremely cautious about recommending services,
treatments, or programs that are based on novel theories, that involve unusual or extreme
procedures, and that have potential for harm (e.g., “rebirthing” or “holding” therapies; memory
recovery therapies; shame-based interventions; aggressive and highly confrontational or punitive
interventions, etc.). At a minimum, treatment service providers should be licensed appropriate
for their discipline and treatment facilities should be accredited by an appropriate accrediting
body. It is desirable for treatment providers serving ASOs and CSBPs to maintain affiliations
with professional organizations designed to address this specialty area.
The Continuum of Care
In practice, triage requires that some continuum of care exists. Unless there is more than
one option from which to choose, there are no decisions to make, and the number of options
comprising the continuum directly contributes to the ease or difficulty of making placement
decisions. For example, if only outpatient group therapy or inpatient hospital levels of care are
available, then deciding can be very difficult for those youth where community-based group
therapy seems insufficient, but where inpatient hospitalization seems more restrictive than
necessary. A continuum that has two additional levels of care, such as intensive communitybased and therapeutic foster care, might make the decision far easier.
Given that less restrictive levels of care are appropriate for larger numbers of youth, a
continuum of care can be seen as a pyramid organized from least restrictive options at the bottom
to most restrictive options at the top. This is depicted in Handout 1, with corresponding
examples of continuum points on the right and corresponding costs of care on the left.
(NOTE: Distribute Handout 1: Levels of Care for Adolescent Sex Offenders and
Children with Sexual Behavior Problems.)
Examples of Continuum Levels of Care1 (beginning with least restrictive):
1) Prevention Level2
1
This continuum does not include all existing, necessary, or desirable levels of care. 2 It is not exhaustive
and the points along the continuum may not accurately characterize a particular individual facility. In this
continuum, the prevention level describes services which would be appropriate across a range of children
and adolescents, including some identified case populations as well as general populations of youth
(primary prevention levels) and at-risk populations (secondary prevention levels). 3 For example, there
may be group homes that provide a much higher level of security than that described, or a juvenile
correctional facility may provide far more services than described.
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a) Primary Prevention Programs
i) Example: Public and private school systems provide age-appropriate or educational
programs on human sexuality and human sexual behavior, including materials on
sexual assault and child sexual abuse prevention.
b) Secondary Prevention Programs
i) Example: For youth identified to be at-risk for sexual behavior problems,
community-based mental health or delinquency programs provide a short-term, age
appropriate, collateral psycho-educational module on human sexuality and human
sexual behavior, including detailed material on sexual assault and child sexual abuse
definitions, consequences, and strategies for identifying, avoiding, and coping with
risky sexual behavior situations.
ii) Example: Self-help and "hot-line” programs are public health model programs that
provide information and support to at-risk or undetected case populations; they
typically provide information, educational materials on self-management strategies,
anonymous call-in support, and linkage to intervention services (e.g., the StopItNow
model).
iii) Example: Big-Brothers/Big-Sisters programs; although not designed specifically to
prevent sexual behavior problems, these types of programs have been demonstrated to
broadly prevent behavior and delinquency problems among at-risk children and youth.
2) Out-patient Program Level
a) General Clinic-based Services
i) Example: Outpatient individual, group, or family therapy providing traditional
mental health services (variable focus, model, and duration)
ii) Example: Parent-training programs for child behavior problems (often around 16
sessions)
iii) Example: Cognitive-behavioral therapy for anxiety, depression, or traumatic stress
symptoms (often around 12-24 sessions)
b) ASO or CSBP Specific Outpatient Programs
i) Example: Outpatient ASO or CSBP group treatment programs. This is probably the
single most utilized mode of service and is one of the most common triage
dispositions. Program duration is usually a few months for CSBPs and from 12 to 18
months for ASOs. These programs may include individual and family sessions in
addition to group sessions. Many ASO or CSBP group programs are based on
cognitive-behavioral models and may include modules generally based upon relapseprevention theory; increasing self-monitoring of behavior; and understanding patterns,
consequences and strategies for managing inappropriate sexual behavior, etc. A
number of published manuals, workbooks, and guides are available for implementing
these programs. Parent or caretaker involvement is generally recommended or
required. Youth receiving outpatient services usually live at home, with other family
members, or in a foster home.
3) Intensive Community-Based Level
i) Example: Multi-systemic Therapy (MST) or Functional Family Therapy (FFT).
These are short-term (e.g., 4 months in some models), highly intensive (up to daily in9
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home contacts, small caseloads, and 24 hour interventionist availability) interventions
that are designed for seriously delinquent, multi-problem adolescents and their
families. Both approaches emphasize working with and through families, and both
focus on obtaining immediate and maximal behavior change on assessment-driven
goals. Youth receiving intensive community-based interventions usually live at home
or in a foster home. Both MST and FFT are based on empirically evaluated protocols
and both have been demonstrated to reliably reduce violent, delinquent, and substance
abusing behaviors and to have strong cost-benefit ratios. Specific training and
certification is involved for using these protocols. There is some specific evidence to
support the efficacy of MST with ASOs.
4) Foster Home and Independent Living Level
a) Foster Home
i) An actual home where the foster parent(s) normally reside which will accept a few
children or youth to live in the home. Foster homes are not facilities and do not have
staff. Foster parents are usually lay individuals who have been screened and provided
with brief basic training. Youth in foster care attend school in the community and
live a more normal family life. Foster homes are not physically secure and cannot
realistically provide constant supervision. Foster care services are usually supervised
by an agency that provides foster parent training, placement monitoring and case
management, and that assumes responsibility for youth in the agency’s foster homes.
Youth in foster homes often participate in outpatient or sometimes in intensive
community-level services. In general, foster parents accepting CSBPs and ASOs
should be aware of the potential sexual behavior problems these youth may have, and
not CSBPs and ASOs should not be placed in homes with vulnerable individuals
(e.g., younger children).
b) Therapeutic Foster Home or Specialized Community Home
i) Example: These are foster homes where the foster parent(s) have received more
extensive training, including specialized training in managing children with special
emotional or behavioral needs. In some cases, the training may include special
training in managing youth with sexual behavior problems. Agency supervision of
therapeutic foster homes may be closer, and there may be higher expectations for the
foster parent(s) to collaborate with other service providers or to be part of a treatment
team. Specialized community homes are similar to therapeutic foster homes, except
that they have a few more youth (perhaps 4-6) in a normal home environment with
foster parents, as distinct from group homes, which are generally larger and facilities
with staff.
c) Independent Living Home
i) Example: A small, semi-structured home-like facility, often in a residential
neighborhood, housing a small number of older adolescents under supervision. The
level of supervision and structure in independent living facilities may be less than that
of group homes. Residents of independent living facilities are often older teens who
do not have a viable family situation, but who are appropriate for a community level
disposition and who need to acquire basic independent living skills under some
supervision prior to living on their own. Some have previously been in more
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restrictive settings. Independent living facilities often emphasize youth completing
their education, obtaining employment, and learning basic household and money
management skills.
5) Day Treatment Level
i) Example: A program associated with or physically attached to a residential or
inpatient psychiatric program, where youth participate in the treatment milieu and
programming but live in the community and return home in the evenings and on
weekends. Day programs usually incorporate specialized classroom
schooling/vocational training and therapeutic components similar to those found in
residential programs. Day programs may have access to other inpatient or residential
treatment service components on site, such as access to psychiatric medication
management.
6) Group Home Level
a) Group Home
i) Example: A small, home-like facility, often in a residential neighborhood, housing a
group of delinquent adolescents with 24hour staff supervision. Group homes may be
locked at night and the activities of residents are highly structured and well
supervised; they are not physically secure facilities designed to contain youths;
provide constant supervision, or prevent escape. Group home residents may attend
school or hold jobs in the community, but typically there are rules that do not allow
them to move freely in and out of the facility. Group homes may provide on-site
counselors or offer on-site services such as group or family therapy or they may
arrange for those services off-site.
b) Sex-offender Specific Group Home
i) Example: A group home specifically for ASOs that includes specific sex offender
treatment programming. Sex-offender specific group homes may offer on-site sex
offender treatment groups and individual/family therapy, similar to that offered in
outpatient programs. Sex-offender specific group homes may supervise the
residents’ sexual behavior more closely and may have special rules related to
potentially sexual situations.
7) Short-term, Intensive Inpatient Level3.
a) General Psychiatric Inpatient Unit
i) Example: A locked psychiatric treatment unit in a hospital setting with 24-hour staff
coverage. Length of stay on these units can vary but is often a few weeks. These
units usually provide intensive, daily, multi-modal and multidisciplinary services
overseen by psychiatrists, including medical management of serious psychiatric
disorders such as severe depression, acute psychosis, or acute mania. Stabilization of
acute psychiatric symptoms is a common treatment goal for these facilities.
b) Sex-Offender Specific Short-Term Residential Unit
i) Example: A residential treatment facility with a short-term length of stay (e.g., 30
days) designed to stabilize sexual behavior problems, and other co-morbid problems,
3
These types of facilities are designated as less restrictive than residential treatment facilities based on
their shorter lengths of stay. However, the levels of security and restrictions on day-to-day freedom in
short-term, inpatient facilities may be greater than that found in residential type facilities.
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complete initial sex offender assessment and treatment, and then link the youth with a
less restrictive follow-up program to complete treatment. These units may be
physically attached to other less restrictive levels of care within an agency or facility.
For example, youth exiting the short-term residential program may continue in
outpatient treatment with the same providers or treatment team.
8) Unlocked, Staff-Secure Residential Level
a) Therapeutic Boarding Schools and Similar Programs
i) Example: A year-round structured program with staff-supervised dormitories or
cottages designed to provide therapeutic, educational, recreational, and behavior
management services to children and adolescents who have long-standing emotional
and/or behavioral difficulties, but who are not have acutely psychiatrically ill.
Residents typically receive weekly individual/group/family therapy and periodic
medical or psychiatric services. The youth are usually restricted to the campus, but
may have “grounds privileges” based on behavior and treatment plan progress.
Lengths of stays in these facilities are often quite long-term. Some of these facilities
have specialized sex offender programs and/or sex offender specific cottages or
campuses segregated from other youth.
9) Secure Residential Facility Level
a) Locked Residential Treatment Centers
i) Example: A freestanding, locked, controlled-access unit, or a more controlled unit
within an overall residential campus where resident activities and movements are
controlled or monitored by staff on a 24-hour basis and there is a strong emphasis on
structure, intensive behavior management, and containment. These facilities provide
on-site schooling and frequent, intensive psychological or psychiatric services
delivered by on-site professional staff. These facilities often have seclusion and
restraint capacity and rely on behavioral systems or level systems to gain compliance
from residents.
b) Sex Offender Specific Locked Residential Treatment Centers
i) Example: A facility similar to the one described above which but exclusively accepts
ASOs and where the treatment model is heavily focused on sexual behavior issues.
These facilities typically provide high levels of supervision of any circumstances
where there is a possibility of sexual behavior (e.g., bathrooms or shower restrictions,
supervision of sleeping facilities at all times during the night, etc.)
10) High Security Lock-Down Level
a) Juvenile Detention
i) Example: A short-term facility for youth, usually regimented, highly controlled, and
providing little or no treatment. These facilities are similar to correctional facilities,
except that they are designed to maintain youth for short periods of time (from a few
days to a month or so), either while waiting further processing, or as an “attention
getter” or sanction related to behavior or motivation problems.
b) Boot Camp Facility
i) Example: Boot camps are moderate-term (e.g., six month), highly structured
residential programs generally modeled after military basic training. They emphasize
rigorous physical exercise, regimented activities, strict supervision and discipline, and
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military drill. Some, but not all, boot camps emphasize aggressive confrontation, of
the youth. The level of physical security provided at boot camps can vary, although
many are highly secure facilities. Some boot camps are designed for sanction or “remotivation” purposes.
c) Juvenile Correctional Facility
i) Example: A juvenile facility with high security and multiple barriers preventing
escape. These facilities may provide some professional psychological or psychiatric
treatment services and may use a level system. Participation in school or GED
services usually is required for residents. Behavior change is often pursued via
control and application of sanctions. Staff members are typically security officers
rather than treatment or nursing staff.
d) Adult Correctional Institution
i) Example: An adult prison, which is similar in many ways to a juvenile correctional
facility. There is considerable variation among adult correctional institutions in both
their atmosphere and service availability. In general, however, adult correctional
institutions offer fewer rehabilitative services than juvenile correctional institutions,
house more serious and dangerous individuals, and have a greater emphasis on
physical security, containment, and control.
Five Questions to ask in Making a Placement Decision, How to Answer Them and What
They Mean
Question 1: What is the level of current risk for sexually harmful behaviors in ASOs?
There are currently three approaches to estimating risk for harmful behaviors: clinical
assessments, true actuarial systems, and empirically guided systems.
Clinical assessment relies on impressions from face-to-face interviews, reviews of basic
psychosocial history, and traditional psychological testing. This is the most common approach to
assessment, and is typical practice, in most psychological evaluations that are conducted in
forensic settings. Unfortunately, the predictive accuracy of clinical assessments has been widely
demonstrated to be quite poor (often no better than random chance). With ASOs in particular,
clinical assessments have been shown to over-predict risk relative to actual rates of sexual
recidivism. Clinical assessments may be valuable for answering other triage questions (i.e.,
identifying other severe mental health problems), but should not be used as the primarily tool for
estimating risk.
Actuarial systems are empirically derived and validated tools, usually based on objective
behavioral historical factors. True actuarial systems classify individuals into groups with known
probabilities for reoffense. For example, it would be possible to say, “a group of individuals with
a score of X on a particular actuarial system has an overall Y% chance of sexual recidivism over
the next 10 years.” Across a broad range of behaviors, actuarial systems are more accurate,
objective, and fair. True actuarial risk assessment systems exist and are the state-of-the-art for
adult sex offender risk assessment. Unfortunately, no comparable actuarial systems have yet
been developed for ASOs and CSBPs. However, the most basic of all actuarial systems is simply
to predict the mean risk for an overall group. For example, the overall detected sexual recidivism
risk for ASOs across studies is around 10%. Thus, without knowing anything else about an
ASO, the best initial estimate of his or her sexual recidivism risk would be 10% (given the usual
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structure, supervision, and services provided).
Empirically guided systems are midway between clinical assessments and true actuarial
systems. There are empirically guided systems available for ASOs and it is recommended that
decision-makers acquire and use these tools. Examples of empirically guided systems include
the Juvenile Sex Offender Assessment Protocol (J-SOAP-II; Prentky & Righthand), the Estimate
of Risk of Adolescent Sexual Offense Recidivism (ERASOR-2; Worling & Curwen, 2001) and
the Protective Factors Scale (PFS; Bremer, 2001). These are described below:
Empirically guided systems select potential objective risk factors from the empirical
outcome literature. They differ from true actuarial systems in that there currently is not an
empirically derived scoring system and there are no known sexual recidivism probabilities
associated with particular combinations of items or scores for ASOs or CSBPs. Therefore, it is
not recommended that scores from any of these instruments be used. Empirically guided systems
are valuable for directing attention toward factors that are important and away from factors that
have little predictive ability. They should be used as guidelines for conducting a risk assessment,
but the ultimate significance of any given item or combination of items still must be determined
by the evaluator. Consequently, it is recommended that empirically guided systems be used only
by professionals with adequate experience in the science of risk prediction and ASO or CSBP
assessment.
The first step in empirically guided risk assessment is to estimate the average risk for the
entire group (e.g., ASOs or CSBPs). Based on the current literature, that estimate would be
around 10% for ASOs and 15% for CSBPs. Some youth who reoffend may remain undetected,
so the actual number may be higher, although the extent to which that is true is unknown.
Because this rates is low, we could predict that 101% of ASOs will have further illegal sexual
behavior, (assuming the youth receives typical interventions and supervision conditions), and we
would be correct in that prediction 90% of the time. This is important to remember because it
suggests that there should be fairly persuasive evidence available before it can be legitimately
concluded that a given youngster is “high risk” to reoffend.
After beginning with the overall group risk estimate (ASO=10%), this estimate can be
adjusted up or down depending on the number and importance of the risk factors identified using
a tool such as the JSOAP-II, ERASOR-2, or PFS. Note that adjustments up or down should be
made from what would be expected for an “average” ASO on these instruments. An average
ASO would be expected to have some number of risk factors. Finally, it is important to note any
dramatic or exceptional factors that might dictate an increase from the overall average risk or the
tools. Very rare factors, such as a statement of intent to re-offend, often are not included on risk
instruments. However, if an adolescent made a credible statement of intent to re-offend or was
showing clearly out-of-control sexual behavior, this would indicate high-risk status regardless of
a low score on a risk assessment tool. It is important to note that risk assessments for ASOs and
particularly for CSBPs must focus on the youth’s family and social ecology and not be limited to
individual child or adolescent characteristics. Youth who might be higher risk in one
environment (e.g., no supervision, no appropriate adult involvement or support, easy access to
potential victims) might be lower risk in another setting (e.g., high supervision, involved and
capable adults, etc.).
Using Risk Estimates—Immediate Steps That Might Reduce Risk. Risk is particularly
important for determining how restrictive a level of care is needed. Before deciding, it is first
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important to look for any immediate steps that might be taken to modify the assessed risk. For
example, if a youngster is assessed as high risk partially on the basis of poor parental supervision,
the first question to ask is, “Are there any alternative adults who can step in to provide adequate
supervision?” Or, if a youngster is assessed as high risk partially on the basis of having a
potential victim living in the same home, the first question to ask is, “Are there immediate steps
that can be taken to control unsupervised assess to the potential victim?” If a youngster is
assessed as high risk partially on the basis of significant ADHD symptoms, the first question to
ask is, “Can these symptoms be immediately reduced by treatment?” In many cases, the answer
to these kind of questions is “Yes,” and there may be immediate steps that will reduce the initial
risk estimate. If so, these steps should be recommended as clear prerequisites and the
recommended level of care can be based on how much risk is expected after the prerequisite
steps are taken and evaluated.
In other cases, the factors contributing to high risk may be difficult to modify or may not
be amenable to immediate interventions. Or, despite all immediate steps that might be taken, a
youngster may remain at high risk. In these cases, recommendations for a more restrictive level
of care are appropriate.
Matching Youth Reoffense Risk to Level of Restrictiveness
Handout 2 is a rough guide for matching levels of current risk (adjusted for any
prerequisite steps taken) and levels of restrictiveness.
(NOTE: Distribute Handout 2: Matching Youth Reoffense Risk to Levels of Restrictiveness.)
Question 2: What are the intervention priorities?
In addition to risk, triage decisions should be based on an evaluation of intervention
priorities. Some intervention or treatment needs are simply more important than others. ASOs
and CSBPs may be multi-problem youth or come from multi-problem families or environments.
In these cases, the number and variety of problems, may appear overwhelming and or to over
array of interventions may be prescribed in an effort to be comprehensive or intensive. This is
seldom a good idea. In general, interventions and treatments that focus on a limited number of
major, important target areas are as effective, or more effective, than attempts to provide an
intervention for every problem. Unfocused, over-prescribed approaches to intervention are not
only unproductive; they impose burdens on both clients and the service delivery system. It is
important to address major problems first and not everything at once.
Some paramount priorities are fairly obvious. For example, youngsters who are acutely
suicidal or who have acute medical needs require immediate intervention to insure their health
and safety, and this would clearly take priority over other issues and needs. Similarly, youth who
are homeless or who lack adequate nutrition or shelter require attention to these matters
immediately.
Serious mental health problems may be a high priority. For example, youngsters who
have serious psychotic symptoms, are severely depressed or manic, are clearly suicidal, or who
have continuous out of control explosive behavior may be unable to meaningfully participate in
ASO or CSBP treatment until these problems are treated and brought into some reasonable
remission. In these cases it makes little sense to pursue primary treatment for sexual behavior
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problems until these other problems are managed. It is important to note that some facilities or
placements may not be equipped to manage serious mental health problems. For example, some
group homes or correctional facilities may have limited on-site expertise or resources to deal
with these problems and would not be good choices for acutely psychiatrically ill youth. In cases
where there are high-priority serious mental health problems, the triage decision should be
guided first by the availability of resources and expertise needed to deal with these problems
rather than the availability of specific treatment for sexual behavior problems, provided that
sexual behavior risk can be managed adequately in the psychiatric setting. Other sex-offender
programs (e.g., short-term inpatient programs) may have excellent resources for managing both
serious acute mental health problems and sexual behavior problems and may be good choices in
many of these cases. In making triage decisions about seriously psychiatrically ill youth, it is
critical that the placement decision-maker know specifically what psychiatric expertise and
services are available along their local continuum of care.
Sexual behavior is usually a significant priority in almost all ASO and CSBP cases, and
there is consensus in the practice field that the intervention plan should focus specifically on the
sexual behavior problem at some point. Specific services targeting sexual behavior will be a
component of most triage decisions and will usually be a major priority, although not the top
priority or the first-step recommendation in all cases. The exact format of these services and
programs can vary considerably. Group-based programs are very common. However, there are
no data to suggest that group-based programming is any better or worse than other approaches
(individual, family, ecological). Whether or not a program is sex-offender specific is
independent of its level of care or restrictiveness. Sex-offender specific or sexual behavior
specific services are adaptable across a range of levels of care, from outpatient clinic services to
maximum security facilities, and there may be more similarities than differences in the actual
content of these sex-offender services across the various levels of care.
Non-sexual behavior problems, including oppositional defiant or aggressive behavior
problems among CSBPs and or delinquency among ASOs, are also a high priority. Major
substance use disorders may be included in this category (or even higher in the event they reach
life-or-death severity). In general, the prevalence or recurrence rates for sexual problems.
Consequently, these problems are also a significant priority in many cases. Many of the most
effective interventions for childhood behavior problems and adolescent delinquency emphasize
strong family or family surrogate involvement. For example, behavioral parent training
programs such as Parent-Child Interaction Therapy are among the more effective interventions
for childhood behavior problems, and interventions such as Multi-systemic Therapy or
Functional Family Therapy are among the more effective interventions for adolescent
delinquency.
Many other problems might be moderate priorities or relatively low priorities. For
example, parent-child relationship problems might be considered as a moderate priority to target
at some point. Lower priority intervention needs might reflect life-enhancement goals, such as
self-understanding or improved self-esteem. Although these might be worthwhile goals to
pursue at some point, they will seldom be high priorities in making a placement decision.
Question 3: What factors are driving the behavior?
Decisions about level of care and type of intervention may depend on some assessment of
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the etiology and driving factors involved in the sexual behavior. This is an area of triage
decision-making that is currently not well defined and is certainly not well standardized. There
are many theories and models of the factors that drive aggressive or victimizing sexual behavior
among CSBPs and ASOs, and consequently there may be variation in how intervention programs
approach the problem with any individual child. Finkelhor (1984) described a set of factors that
motivate sexually abusive behavior, and Johnson (1988) described a range of childhood patterns.
Typologies of ASOs have been described by Becker (1998), O’Brien and Bera (1986), and
others, many of which classify youth by their motivational pattern, and in some instances
prescribe intervention modes corresponding to the particular motivational pattern or subtype.
There are a number of common features across these typologies and models, and these features
are summarized below, as they may be relevant to making triage decisions.
Strong and recurrent sexual interests in unusual partners or unusual activities may be one
factor driving sexual misbehavior. For example, some ASOs may have emerging or established
sexual interest patterns focused on young children. Although this is a clear motivational factor
among some subgroups of adult sex offenders (i.e., adults with paraphilias), it remains unclear
and questionable how prevalent or important this is among ASOs. Some ASO treatment
programs are strongly based on this sexual deviancy model. Because concerns have been raised
that these types of programs might be counterproductive or even harmful for those youth who do
not have sexual deviancies, it is suggested that placement in these programs be limited to youth
where there is some independent assessment that the youth has significant problems with
recurrent and strong paraphilia-like interests and behaviors. These may include older adolescents
who have established patterns of behavior with unusual sexual targets (i.e., young children), or
who are assessed as having clear, strong, recurrent sexual arousal to young children. In cases
where there is clear-cut evidence of sexual deviancy, specific intervention for this problem is
recommended.
General delinquency is a common pattern among ASOs and most typologies include
some reference to youth who commit sex crimes as part of an overall delinquent behavior
pattern. Norm violating and victimizing sexual behavior has long been noted among the general
population of delinquent adolescent. Although some generally delinquent sex offenders also may
have recurrent sexual deviancy, many do not, and these predominantly delinquent youth may
engage in abusive sexual behaviors due to more general factors (impulsivity, poor judgment,
delinquent peer influences, etc.) that are unrelated to sexual deviancy. Other ASO programs are
more focused on general competency development, family involvement, peer relationship
development, decision-making, general behavior modification, and related factors. These
programs may be better choices for youth who do not have strong sexual deviancies. In other
cases, where the level of non-sexual delinquency is high and there is not evidence of strong
sexual deviancy, more intensive delinquency oriented models, such as MST or FFT should be
considered.
Other youth, particularly young, immature adolescents, may engage in sexually abusive
behavior motivated by sexual curiosity or experimentation. Some of these youth may not have
acquired a habitual interest in sexually abusive behavior and may be otherwise non-delinquent.
Although these youth may have a range of less severe identified problems (e.g., learning or
attention problems, social skills problems, family problems), they often do not have any serious
mental health disorders. Programs focused on competency development and decision-making
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and sexual behavior management might be considered for many of these youth.
A few youth may participate in sexually abusive behavior under coercion from an older
person or as a direct consequence of a major mental illness. For example, a young adolescent
boy may be coerced by an abusive parent to perform sexual acts on a younger sibling, or an
adolescent may commit a sex crime during an acute psychotic episode. In these cases, the
primary driving factors for the behavior may be so unique that the intervention plan will not
include sex-offender specific treatment at all. Related to this, there are some youth whose
behavior is strongly influenced by peer pressure (e.g., a young adolescent who is persuaded by a
group of peer to engage in a single incident of sexually inappropriate behavior), and intervention
in these cases may focus more on assertiveness and education about sexual behavior, potential
consequences, and coping with peer pressure.
It is generally accepted that some CSBPs are responding to recent personal experiences
with sexual abuse or exposure to explicit sexuality. Some CSBPs present with significant sexual
trauma symptoms, and others exhibit behavior that reflects sexual experiences they have had. In
many of these cases, triage may favor interventions that, while having a sexual behavior focus,
provide considerable emphasis on reducing sexual trauma symptoms. More structured
treatments have been found to be somewhat better for more highly traumatized CSBPs. General
behavior problems also are common among CSBPs, and in these cases triage decisions may favor
interventions that include a focus on teaching parents effective child management skills. Again,
in general, triage for CSBPs will typically favor interventions that are shorter-term and less
restrictive than interventions for ASOs. Parent/caretaker involvement, which is important in
ASO intervention, is seen as critical for CSBP intervention and should be a high priority.
Consequently, it is suggested that triage decision-makers strongly favor levels of care for CSBPs
where parent/caretaker involvement is an integral part of the intervention.
Handout 3 depicts some possible triage linkages between possible case factors and
treatment program types.
(NOTE: Distribute Handout 3: Linking Case Factors and Treatment Program Types for
Adolescent Sex Offenders and Children with Sexual Behavior Problems.)
Question 4: What can realistically be expected to change?
Prognosis is an important factor in placement and service decisions. Simply put, some
problems or factors are more amenable to change, modification, or compensation and others are
far less pliable. Triage decision makers select interventions based on a reasonable expectation of
benefit and favor priorities that are amenable to rapid and substantial change over similar
priorities that are not. Some priorities and factors may not be amenable to change, but they may
be amenable to compensation. For example, a youngster may have dyslexia that impairs his
ability to participate in a treatment program with written assignments, but modifying the format
of the curriculum or providing a reading coach may compensate this for this.
There are a number of common coexisting problems that have a favorable prognosis for
prompt change, assuming they are matched to the correct intervention. For example, ADHD
often responds rapidly and favorably to stimulant medication. PTSD symptoms respond rapidly
to short-term, structured cognitive-behavioral protocols. Childhood oppositional and defiant
behavior responds substantially and rapidly to behavioral parent training approaches.
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Other problems may require sustained intervention and have unpredictable success. For
example, drug or alcohol dependency responds to treatment but the response may require time
and there may be significant lapses over time. Serious delinquency problems may be reduced but
not always eliminated, and chronic family dysfunction may be improved but deteriorate later.
Other problems, despite their importance, may not respond well to the typical services
offered or may be intrinsically stable. For example, chronic poverty, mental retardation, or broad
social-environmental problems may be difficult or impossible to change through any
intervention. In these cases, triage decisions can focus on compensation and averting the worst
outcomes of these problems rather than attempting to eliminate them.
Question 5: What are the youth’s strengths to consider in placement decisions?
In addition to considering risk, problem priorities, driving factors, and prognosis, it is
important to base placement decisions to some extent on the available strengths present in a
youngster and his or her family. For example, the presence of a committed and motivated parent
or parent substitute may compensate for any number of problems. A youngster who has friends
and a commitment to academic success may be able to overcome obstacles despite other
disadvantages.
Finally, it is important to consider motivational strengths. For example, a youth with few
problems but who denies his or her sex offense and has no interest in treatment despite
overwhelming evidence of guilt and need, may do worse in a lower level of care than a youth
with more problems but who admits and is motivated to participate in treatment.
Additional Triage Issues
In-home Victim or Potential Victim Situations. In cases of sibling or other in-home abuse, there
is considerable controversy surrounding the issue of removing ASOs or CSBPs from the home or
returning them to the home. There are those in favor of always removing abusive youth in these
cases (or alternately and less desirably, removing the victim child), and those never permitting
the reunification of abusive and victimized children, and those who make recommendations on a
case-by-case basis and favor reunification in most cases. Unfortunately, there is little empirical
data to guide decision making in these cases. It appears that the diversity of the ASO and CSBP
populations, the diversity of family environments involved, and the diversity of victim feelings
and needs in these cases is so great that a single approach to making decisions about removal and
reunification is not the best approach. In cases where risk is low, the family environment is
adequate, and the victim is emotionally intact and would be distressed by the loss of a sibling
relationship, it may be desirable for the family to remain intact with appropriate supervision and
treatment intervention. The value of preserving the integrity of family connections and family
living may be especially important to consider for CSBPs. In other cases, considerations of risk
and the welfare of the victim may be so acute that family preservation or reunification is simply
not viable. Regardless, it is suggested that these decisions be made on a case-by-case basis and
based on a thorough assessment of the entire circumstances. In some cases, it may be necessary
for abusive youth to be removed in the interim while this assessment is being conducted.
Special Needs Populations. Certain populations, such as female ASOs or developmentally
disabled ASOs, may not be adequately served within an existing continuum of care simply
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because the population is comparatively small. Often placement decision-makers must choose
between a specialized program that is more restrictive than needed and/or located at a great
distance from the youngster’s home and family, and a non-specialized alternative. If risk is high
and a more restrictive level of care would be the first choice regardless of availability, then
distance from home may be less important than the need for appropriate containment and
provision of specialized treatment. However, risk will probably not be this high in the majority
of these cases, and it may be counterproductive to remove a child to a more restrictive level of
care than is needed, especially if it is located at a great distance from home, simply in order to
provide a particular intervention. In these cases, a generally qualified local provider might be
identified and arrangements made for that provider to obtain remote consultation or mentoring
from an experienced expert or program serving the special needs population. In addition, it is
important to note that some intervention programs, especially those that do not rely on group or
aggregate treatment approaches, may be more readily adaptable to diverse populations. For
example, intensive community based ecological models may be especially adaptable to the
individualized needs of these cases.
Benevolent Triage. On occasion, there may be unique circumstances that dictate a triage
recommendation that would not otherwise be appropriate. ASO or CSBPs may occasionally be
controversial in their neighborhoods, communities or schools and may be subject to social
stigma, threats or violence. On occasion, placement decision-makers may opt to recommend a
more distant or restrictive placement than would be dictated solely by the youngster’s assessed
status, simply in order to remove the youngster from a bad situation and allow some time and
space for circumstances to improve. Or there may be cases where a youngster might be linked
with an unnecessary service or program simply because the consequences of not accepting the
youngster would clearly be worse than any risks from unnecessary treatment. For example, a
youngster might be accepted into an outpatient sex-offender program on the basis of behavior
that normally would not meet the threshold for requiring sex-offender treatment if it was clear
and unavoidable that the youngster would otherwise be sent to an even more inappropriate
placement.
Summary
These guidelines are offered to assist professionals in the triage decision-making process.
Triage is viewed as an individualized, case-by-case process where risks, problems, driving
factors, prognosis, strengths, and the context of a case are combined and weighed in order to
arrive at a dispositional recommendation that balances the needs for rehabilitation, community
safety, victim welfare, and family integrity. Although empirically tested placement guidelines
and specific protocols may be available in the future, considerable work remains to be done
before any standardized or well-supported system is available. These guidelines are intended to
serve as a starting point for framing these decisions. Alternative frameworks, embodying
alternative assumptions, may be equally viable, and it is anticipated that, as knowledge develops,
some of the suggestions made in these guidelines will be supported and others will change over
time.
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References
Association for the Treatment of Sexual Abusers (ATSA). (2000). The effective legal
management of juvenile sex offenders.
Becker, J. (1998). What we know about the characteristics and treatment of adolescents who
have committed sexual offenses. Child Maltreatment, 3, 317-329.
Bremer, J. (2001). Protective Factors Scale. St. Paul, MN: Project Pathfinder, Inc.
Finkelhor, D. (1984) Child sexual abuse: New theory and research. New York: Free Press.
Johnson, T. C. (1988). Child perpetrators – children who molest other children: Preliminary
findings. Child Abuse & Neglect, 12, 219-229.
O’Brien, M. & Bera, W. (1986). Adolescent sexual offenders: A descriptive typology. Preventing
Sexual Abuse, 1, (3), 1-4.
Prentky, R., & Righthand, S. (Undated). Juvenile Sex Offender Assessment Protocol II (JSOAPII) Manual.
Worling, J. & Curwin, T. (2001). The “ERASOR”: Estimate of Risk of Adolescent Sexual Offense
Recidivism, Version 2.0. Toronto, Canada: Sexual Abuse Family Education & Treatment
(SAFE-T) Program, Thistletown Regional Centre for Children and Adolescents.
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Handout 1. Levels of Care for Adolescent Sex Offenders and
Children with Sexual Behavior Problems
•Locked Secure Facility
•Secure Residential Program
(more restrictive)
•Unlocked Staff Secure Level
•Group Homes
•Day Programs
•Foster Homes, Mentor
Homes or Independent Living
•Intensive Community-Based
Ecological Models (e.g., MST)
More Youth
(less restrictive)
•Outpatient Programs
•Prevention Programs
$$$$$ COST PER CASE $
Fewer Youth
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Handout 2. Matching Youth Reoffense Risk to Levels of
Restrictiveness
•Extreme Risk-security or
flight risk, possibly
predatory
•Locked Secure Facility
Fewer Youth
(more restrictive)
•High Risk-can’t be in
community
•Secure Residential
Program
•Unlocked Staff Secure
Level
•Group Homes
•Day Programs
•Moderate Risk or Risk Due
Primarily to Environmental
(e.g. supervision)
•Some Risk
•Minimal Risk (perhaps not a
legal offense) or Prevention
Population
More Youth
(less restrictive)
•Foster Homes, Mentor
Homes or Independent
Living
•Intensive CommunityBased Ecological Models
(e.g., MST)
•Outpatient Programs
•Prevention Programs
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Handout 3. Linking Case Factors and Treatment Program
Types for Adolescent Sex Offenders and
Children with Sexual Behavior Problems
Case Factors
•Younger ASO, Limited
Sexual Problem
•Most CSBPs
•Limited Sexual Problem
•Judgment and competency
problems, but non-delinquent
Treatment Program
Shorter-Term
Outpatient Program
With Some
S.O. Focus
Outpatient
Competency Oriented
Sex-Offender
Program
•Limited Sexual Problem
•Generally Delinquent
Delinquency
Oriented
Program with Some
S.O. Focus
•Extensive Sexual Problem
(i.e. sexual deviancy)
More Extensive
Sexual Interest and
Sexual Behavior
S.O. Program
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