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11.3 Assessing Sexual Perpetrators with Learning Disabilities

It is becoming clearer about the issues that need to be considered when conducting or commissioning assessments in relation to perpetrators presenting with a learning disability. These focus on the assessment process and the differential nature of some of their behaviour.

Serious offences are less commonly recorded, with a greater proportion of 'non-contact' behaviours such as exhibitionism. Thomas and Singh (1995) found a relationship between the degree of disability and offences committed, with the most serious contact offences being committed by men assessed in the mild/borderline disability range. Opportunity appears more frequently to be the primary factor in shaping offence behaviour.

Thompson (1997) however, found a distinct pattern in which the more vulnerable and less able (children, women, more intellectually impaired service users) were targeted by sexually abusive men with learning disabilities.

Offence patterns of sexual abusers with learning disabilities have been reported as more frequently impulsive and with less attention to planning opportunities to offend. However, we should not discount that some individuals are capable of undertaking meticulous 'grooming' behaviours, particularly of children. They are seemingly able to move much more readily from situations which trigger arousal, into committing the abuse, in a very short space of time.

There are a number of relevant observations regarding the pathways to their behaviour. There is a prominence of medical factors including chromosone disorders, in particular Klinefelters syndrome, as a potential causal factor in the development of problematic sexual behaviours. Comprehensive multi-disciplinary assessments should be open to this aspect and ensure that appropriate professional assessments are undertaken to determine the possible impact of such physical influences on behaviour. The concept of "abuse without abuser" to describe sexual behaviours in which the initiator of an unwelcome sexual interaction does not understand the concept of consent or the impact of the behaviour on others is clearly relevant when conceptualising abuse perpetrated by individuals with a significant degree of learning disability.

It has been suggested that some adults or adolescents with learning disabilities may relate to children of similar developmental age. This appears a variation on the concept of 'emotional congruence' (Finkelhor, 1984), posited as a factor in the development of sexually abusive behaviour directed towards children.

The lack of opportunities for acceptable sexual expression is a situation common to many people with learning disabilities. The absence of private space, limited social networks and poor social skills may leave them with little direction for non-problematic sexual expression. "Abuse by design" refers to how the systems and physical structures of many care settings may increase the risk of sexual abuse. In addition, the feelings of rejection experienced when living in residential care linked to separation from the family of origin can contribute to offending by the individual seeking affection inappropriately.

The more placements and moves they have, the greater the impact. Children and adolescents with learning disabilities may be at increased risk of experiencing rejection and separation due to the additional strains in caring for a disabled child. The arrangement of respite care is an experience of separation and substitute carers common to many children/young people with disabilities. A chaotic or insecure attachment history is a feature of most learning disabled sexual perpetrators. 

There is evidence to suggest that incidence of physical and sexual abuse is higher amongst children and adults with a learning disability than in the general population. The learning disabled child's early childhood experiences in 'failing' within school and in relation to the achievements of peers as a predominant factor in the low self-esteem of many individuals with intellectual impairment. An assessment of cognitive functioning will provide assessors with crucial information as to memory, attention/concentration span, perception, language skills and ability to use conceptual thinking. When behaviour is overt and repetitive it may be of value to provide staff with structured formats to record behaviour in order to establish an objective baseline in terms of frequency, context and the nature of the behaviour itself

Evaluating whether a given behaviour is indeed sexually motivated can frequently be extremely complex. Behaviour may reflect a number of potential needs or responses, for example, attention seeking, distress, avoidance, control and stimulation.

There is a need to consider incidents and behaviour on a number of dimensions though the internal dimension (fantasy, thoughts, attribution) may be more difficult to access with individuals who have intellectual disabilities. It is helpful to make time at the outset of the assessment to provide information to them and allow them an opportunity to ask questions, for example concerning with whom the information gained in the assessment will be shared.

If there has been a history of professional interventions we need to ask them to share with us their view of these and what aspects they found helpful and less so. It is important to establish the reason for this assessment and any decisions which may be related to it. We need to allow clients the space to develop a working relationship based on trust and honesty. Many will have developed tried and tested tactics for keeping professionals at some distance. Attention spans are frequently poor with a need to structure sessions in such a way as to maintain participation and interest, for example, by constructing certain exercises as games, using pictures or building in breaks for alternative activities.

It is important to build into your assessment tactics to validate the assumptions you may have as to what the client is communicating. A frequent issue is that of sexual knowledge, and the use of words which may have a number of potential meanings. Many are likely to use either definitions given to them e.g. "I sexually abused... I did an indecent assault"; or rely on words heard from other people which they may or may not have a clear understanding of e.g. "I shagged..." Spending time prior to addressing the abusive behaviour in detail, considering their own sexual experiences and knowledge, and agreeing terminology (for parts of the body; types of sexual behaviour) will repay itself in aiding clarity subsequently.

There are a number of aspects to the intellectual functioning of individuals with a learning disability which may impact upon their participation in an assessment and will need consideration by assessors.

  • Poor memory: Given that a psychological defence and tactic for people, reluctant to discuss sensitive or embarrassing matters, is to respond with "I don't remember", this will need careful evaluation.
  • We thus need to check with carers as to their general ability to recall past events.
  • In the context of assessment sessions, time can be spent on considering less threatening aspects of their life and evaluating their response.
  • Psychological assessment can also provide guidance on their functional ability.
  • It is important not to take the initial response at face value or to categorise it as 'denial'. Many people present with an initial statement of not being able to remember events, but with time and the space to work, the development of trust and the use of motivational approaches and imaginative communication techniques, are able to develop a fairly full account of their behaviours and associated feelings.

It has been found that respondents with a learning disability have a greater likelihood to find open-ended questions confusing; a bias to answer closed (yes/no) questions in the affirmative and increased vulnerability to a suggestible response to leading questions.

It is important to work methodically through responses, and frequently return to issues to ensure our understanding of their response is accurate. It is often helpful to offer them some choices, including a 'none of these' or 'not true for me'. Language and tone is important to ensure they do not feel a particular response is the most desired. Pictorial or graphic formats to allow the young person to locate themselves along a continuum, or use size, colour etc to communicate meaning.

In the assessment and evaluation of sexual offending, psychometric testing (the use of written questionnaires) is much used and considered by some to have advantages over direct questioning for generating certain types of information. Psychometric tests may be able to provide 'normed' samples to offer a statistical comparison of the individual with a certain group and offer an important evaluation of change pre and post -intervention.

Most questionnaires however are designed for those with an average literacy and frequently ask the respondent to analyse a number of choices. Basic literacy and sexual knowledge may also impede responses to questionnaires designed to explore sexual attitudes, interests and preferences.

A number of factors may mean that the timescale for undertaking the assessment may need to be extended in the case of those presenting with learning difficulties. These may include:

  • A need to interview others or review documentation to establish a clear understanding of the behaviour as presented by the perpetrator
  • Establishing the degree of intellectual impairment. This may involve reviewing available documentation or in certain cases negotiating a specific psychological assessment.
  • Planning interviews with the individual and negotiating appropriate co-working arrangements
  • The need to ensure that interviews are conducted at a pace that is suitable for the individual - this may require extra sessions. 

O'Callaghan (2002) set out a useful template for the conduct of assessments with this group:

  1. Family of Origin
    • Parents level of intellectual functioning
    • Development and functioning of siblings
    • Family attitudes to sexuality, particularly in respect of child with intellectual disability
    • Current family relationships and contact
  2. Personal Health History
    • Birth history e.g. "blue" baby
    • Specific known genetic conditions e.g. fragile X; Downs syndrome; Autism/Asperger's,
    • Other medical factors impacting on development e.g. brain trauma
    • Use of medication
    • Impact of other physical conditions is present
  3. Developmental History
    • Point at which developmental delay identified
    • Other behavioural problems
  4. Care History
    • Attachment concerns e.g. unwanted pregnancy
    • Loss or separation e.g. respite, substitute or hospital care.
    • Care concerns e.g. neglect/lack of stimulation; abuse; supervision, etc.
    • Response of parents to child being identified with intellectual disability
  5. Educational history
    • Balance of mainstream or special schooling
    • Point at which Education, Health and Care Plans drafted.
    • Experience of schooling to date (academically; socially)
    • Behaviour within school setting
  6. Assessment of cognitive intellectual functioning
    • Memory/retention of information and skills
    • Attention/concentration span
    • Problem solving
    • Language/communication/literacy skills
    • Conceptual thinking
    • Ability to transfer and generalise known solutions.
  7. Social functioning
    • Networks/activities/opportunities
    • Relationships with peers
    • Independence skills e.g. mobility within the community, use of public transport
    • How supervised is the young person in the community
    • Assertion skills
  8. Sexual Development
    • Known information on sexual maturity e.g. onset of puberty; physical development; masturbation
    • Known information on young persons sexual experiences
    • Known negative experiences e.g. exposure to pornography; sexual victimisation
  9. History of Problematic Sexual Behaviour
    • Range of behaviours demonstrated e.g. exposure; hands on offences
    • At whom has the behaviour been targeted to date e.g. children; adults; gender specific or not
    • Relationship to those victimised e.g. familial; fellow student; fellow service user; neighbour
    • How has the young person gained access/made contact with those victimised
    • Settings and circumstances i.e. community; home; school; respite care.
    • Evidence of planning/targeting specific vulnerable others e.g. children; less able peers; certain care staff
    • What responses have adults/agencies made to problematic sexual behaviours to date e.g. ignore; attempt to distract; sanction/restriction; move child/young person; police involvement; legal sanction.
    • Any previous attempt interventions e.g. sanctions; sex education; behavioural programmes.

References

Finkelhor D (1984) Child Sexual Abuse: Theory and Research. NY: The Free Press.

O'Callaghan D (2002) A framework for undertaking initial assessments of young people with intellectual disabilities who present problematic/harmful sexual behaviours. Manchester: G-MAP.

Thomas DH and Singh TH (1995) Offenders Referred to a Learning Disability Service: A Retrospective Study from One County.  British Journal of Learning Disability 23: 24-27.

Thompson D (1997) Men with intellectual disabilities who abuse: A review of the literature. Journal of Applied Research in Intellectual Disabilities 10(2): 140-158.

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