Abstract
I
Ryan, Hunter, and Murrie are all experienced experts in the field, and their expertise shows. They address a highly emotionally fraught issue with balance and objectivity. They utilize a general systems approach to the problem, with an equal emphasis on biology, psychology, and environmental influences. The authors cite Uri Bronfenbrenner at one point, and Dante Cicchetti at another, both of whom have written extensively about ecological explanations of normal development as well as psychopathology. The chapters are uniformly well written and accessible, and I found little variation in the high quality of exposition, despite the fact that there are three authors.
The book begins by placing sexual offending in a social and legal context. It notes that between one third and one half of adult sex offenders began their sexual offending as adolescents, and individuals <18 years of age may commit up to 50% of all child molestations. (As a bonus, the first chapter has a very nice discussion of the concept of consent, which is relevant in a wide variety of clinical contexts.) The authors note that although the risk of sexual recidivism for juveniles is relatively low, it is often difficult to predict risk on an individual basis. Nevertheless, transferring juvenile offenders to adult criminal court actually increases the risk of recidivism. The point here is that “getting tough on crime” often does not achieve the goal of decreasing future risk.
The second chapter of the book addresses normal sexual behavior in childhood. I found it somewhat frustrating, not because it was poorly written; rather, there simply is not a lot of good information on this topic. I came away with the idea that children of all ages are sexual, but as they get older, they tend to hide their sexual behaviors from adults.
Chapters Three and Four specifically address risk factors for juvenile offending, patterns of this behavior, and the complex interaction between psychopathology and sexuality. The authors note that the study of risk factors is in its infancy, but that there are certain “endogenous” risk factors including psychopathy, deviant sexual interests, and distorted sexual cognitions. This is one of two places in the book where the authors discuss psychopathy. These discussions are of general interest to both forensic psychiatrists and mental health practitioners in general. There are also a number of “exogenous” risk factors, including having been the victim of sexual abuse. The risk conferred by victimhood, however, is complicated. Having been a victim increases the risk for the emergence of sexually abusive behavior, but it is not a very strong predictor of sexual recidivism. Other “exogenous” factors include exposure to violence and/or pornography, which the authors note is now ubiquitous, and negative peer influences. The chapter on psychopathology includes five case examples, which were somewhat sparse, but nevertheless interesting. The chapter itself contains detailed discussions of developmental issues, mood and anxiety disorders, substance abuse, posttraumatic stress disorder (PTSD), and personality disorders. The authors emphasize, once again, “that having been sexually abused as a child does not de facto place one at risk for sexually abusing others. Most sexually abused children do not offend against others.”
Chapters Five, Six, and Seven address evaluation. The chapter on forensic versus clinical evaluation was, for me, the highlight of the book. Ryan identifies the ways in which these two types of evaluations differ, and this chapter highlights all the mistakes that naïve clinicians make when they get sucked into the world of litigation. The next chapter, on specific interview and evaluation techniques for juvenile sexual offenders, addresses the difference between clinical judgment and actuarial assessment. Ryan states that although actuarial assessment might be ideal, there are no instruments currently available to conduct such an assessment. Rather, mental health practitioners should attend to empirically validated risk factors, do a careful and relevant literature review, and conduct skilled interviews with alleged offenders, their families, and collateral sources. The chapter on structured assessment instruments focuses more on their weaknesses than on their strengths. It points out that there are no diagnostic shortcuts, and it highlights the inappropriateness of using instruments designed to evaluate adults when assessing children and adolescents.
The last two chapters of the book focus on treatment interventions. There is a brief discussion of psychophysiological assessment, but Hunter notes that because the majority of adolescent sexual offenders are not motivated by deviant sexual interests, such evaluations are typically unhelpful. He then describes a variety of interventions, the most interesting of which is a cognitive behavioral therapy (CBT)-based treatment called “prolonged exposure.” The final chapter is an excellent discussion of pharmacologically based treatments, with a detailed explanation of the relevant endocrinology, as well as a caution against using hormonal treatments in children and adolescents.
The authors succeed in their goal of creating a practical guide for mental health professionals who confront these types of problems. The book is easy to read, and comprehensive enough to serve as a reference. It serves as a tonic against diagnostic oversimplification, therapeutic grandiosity, and overreaching assumptions regarding this clinical population. As a forensic child and adolescent psychiatrist, I have been involved in a number of cases related to sexual offenses committed by children and adolescents. After reading Juvenile Sexual Offenders, I am, on the one hand, confident that I arrived at the right conclusions in those cases, but on the other, struck by the lack of specific knowledge that went into my reasoning. Now that I have read this book, I will feel much more confident in my assessment techniques as well as my diagnostic and therapeutic opinions in these types of situations. Even nonforensic child and adolescent clinicians regularly confront questions related to the sexual behaviors of their patients. Juvenile Sexual Offenders is an accessible resource, with excellent references that they can confidently turn to when assessing the significance of such behavior.
Footnotes
Disclosures
No competing financial interests exist.