June 18, 2010

New study on juvenile sex offender treatment

Efficacy claimed, but control group questionable

I previously reviewed forensic psychologist Frank DiCataldo's excellent book on juvenile sex offenders, in which he claims there is very little good research to show that sex offender-specific treatment is useful with adolescents. As DiCataldo points out, most of the studies (and the meta-analyses of studies) purporting to show a treatment effect have serious flaws. One big problem is the lack of control groups. This makes it impossible to know whether juveniles who did well after sex-offender treatment would have done equally well without treatment or with generic treatment not focused on sex offending.

But now, a study out of Canada (where else?!) is being trumpeted as methodologically sound proof that -- drum roll here -- treatment works. The study followed 148 adolescents for up to 20 years, which is a very long time for this type of research. Overall, only 17 of the subjects (about 11.5%) picked up a new sex offense as adults, with another 7 getting a new charge only in adolescence, for a total of 24 recidivists (16%). That's in line with a growing body of data on the very low recidivism rates of juvenile sex offenders, ranging from about 4% to 15%.

When they broke it down by those who underwent their specialized treatment, compared with a comparison group that did not, they found that only 9% (5 out of 58) of the youths who had gone through their program got charged with a new sex offense over the next 20 years, compared with 21% (19 out of 90) of those who had not. That's a significant difference.

But here's the rub. The participants were not randomly assigned to treatment (versus no treatment), which is how it's supposed to be done in psychotherapy treatment outcome research. Otherwise, you never know if there is something about the selection process that affected the results. Not only was assignment to groups not random, but the researchers put the kids who refused to undergo treatment, along with those who dropped out of treatment early, into their so-called "control" group! In fact, these bad boys comprised fully half of the non-treatment group. My guess is that these dropouts and refusers were probably a whole lot more delinquent than the other kids in the first place.

So it's possible that what the research really shows is not that treatment works, but that hardcore delinquents who refuse or drop out of treatment are likely to get into more trouble in their later teens and early 20s. It would be interesting to see if the control group still showed a higher recidivism rate if they removed the dropouts and refusers from the analyses. In fact, I would love to see some qualitative analyses of who those 19 recidivists (out of the total of 90 in the control group) are.

Another potential confounder I noticed was that many of the adolescents in the non-treatment control group were apparently in some different kind of treatment at the time. That treatment is not described, so perhaps this study is more of a between-treatments design, rather than a study of treatment versus no treatment.

Again, as I've discussed previously, part of the "problem" both with accurately predicting which juveniles will reoffend and also with designing treatment programs that work is the very low overall rate of recidivism among juveniles who have sexually offended. As DiCataldo and others have pointed out, if you just predict that no juvenile caught for a sex crime will reoffend, you will be correct in the broad majority of cases.

Flattening trajectory

The study, by psychologist James Worling and his colleagues at the Sexual Abuse: Family Education & Treatment Program (SAFE-T) program in Ontario, did have some other interesting findings. The researchers found that most recidivism -- both sexual and nonsexual -- happens within the first few years. Offending flattens out significantly at about the 10-year mark, when folks hit about the age of 25. This is consistent with the recent study by Lussier and colleagues of sex offender trajectories, as well as the general criminology literature on desistance. Crime, including sex offending, is a young man's game.

The finding that only 11.5% of the participants were charged with subsequent sexual offenses as adults is also in line with other research showing very low recidivism for juveniles. A strength of this study is its long course; it followed kids all the way up to an average age of 31.

The study is: Worling, J.R., Littlejohn, A., & Bookalam, D. (2010). 20-year prospective follow-up study of specialized treatment for adolescents who offended sexually. Behavioral Sciences and the Law, 28, 46-57.

Special journal issue on adolescent sex offenders

NOTE: It looks like this entire special issue of Behavioral Sciences and the Law is available online. Other interesting articles in the issue include:

Inter-rater reliability of the PCL-R total and factor scores among psychopathic sex offenders: are personality features more prone to disagreement than behavioral features?
John F. Edens, Marcus T. Boccaccini, Darryl W. Johnson

Searching for the developmental origins of sexual violence: examining the co-occurrence of physical aggression and sexual behaviors in early childhood
Patrick Lussier, Jay Healey

Assessing risk of sexually abusive behavior among youth in a child welfare sample
Robert A. Prentky, Nien-Chen Li, Sue Righthand, Ann Schuler, Deborah Cavanaugh, Austin F. Lee

Psychological mechanisms underlying support for juvenile sex offender registry laws: prototypes, moral outrage, and perceived threat
Jessica M. Salerno, Cynthia J. Najdowski, Margaret C. Stevenson, Tisha R. A. Wiley, Bette L. Bottoms, Roberto Vaca Jr., Pamela S. Pimentel

Legal, ethical, and methodological considerations in the Internet-based study of child pornography offenders (p 84-105)
James V. Ray, Eva R. Kimonis, Christine Donoghue

1 comment:

Andrew Burke said...

Hello Dr. Franklin.

Thanks very much for taking the time to review and comment on Dr. Worling’s recent article. It’s an important contribution to a growing body of evidence of what works with this population and the more people that know about it, the better. I do have a few comments regarding your review.

First, in regards to the methodological shortcomings you mention, Worling, Littlejohn, and Bookalam (2010) make no secret of these shortcomings in their approach. Indeed most everything you’ve said here is clearly spelled out in the discussion section of the paper and in its predecessor (see Worling & Curwen, 2000). You’re absolutely correct that true experimental research needs randomly assigned control and treatment groups to help mitigate the chances of any confounding variables that could influence the results. This approach was formalized by Fisher, an agriculturalist (see Hall, 2007). I’m sure you’re aware that it’s a lot easier to assign plants (or patients in short-term drug or treatment trials) to control and treatment groups than it is youth convicted of sexual offences, particularly for such a long follow-up period. Denying or delaying such youth treatment in order to have a more robust treatment methodology raises all sorts of ethical and social concerns (Marshall, Anderson, & Fernandez, 1999).

What Worling et al. have done is called a quasi-experimental design, and it’s a very common form of research in the social sciences. Although far from perfect, the authors have attempted to use a comparison group (not a control group) by accounting for factors that have been identified in the literature as associated with sexual and nonsexual recidivism. As you know, neither the treatment or comparison group showed significant differences in these factors and, as such, the authors felt comfortable using the comparison group. As noted, this approach is far from perfect, but it is the best that is available at this time given the constraints at hand.

Second, I am interested in your comment about Canada (“where else?!”). It’s worth pointing out that Worling & Curwen (2000) and the extension of that work have used the most methodologically sound approach to evaluating the effectiveness of adolescent sex offender treatment to date. Researchers who have performed reviews of available literature on the subject (e.g., Alexander, 1999; Caldwell, 2002; Vizard, Monck, & Misch, 1995) have identified common deficiencies, including: (a) small sample sizes; (b) limited-follow-up periods; (c) reliance on less stringent recidivism data, such as use of state records instead of national registries, or employ of a single database; and (d) use of single group follow-up designs that lack control or comparison groups. These deficiencies make conclusions about the effectiveness of therapy difficult. At the time, Worling and Curwen were the first to attempt address of all these short comings. It’s also worth noting that all the research that had these deficiencies was not from Canada (“where else”). Although slightly improved, a more recent review of the literature since 2000 shows similar trends in shortcomings (see Bourduin et al., 2008; Eastman, 2004; Hagen et al., 2001; Hendriks & Bijleveld, 2008; Miner, 2002; Seabloom et al., 2003; & Waite et al., 2005). Based on my understanding, it would appear the author’s still have the most methodologically sound, albeit quasi-experimental, study of this sort to date.

Thanks very much for your time Dr. Franklin. I hope you find these comments helpful.