Conceptualizing and managing risk in pediatric OCD: Case examples.

It is not uncommon for patients with obsessive-compulsive disorder (OCD) to present with symptoms that suggest possible risk. This can include apparent risk, which reflects the content of obsessional fears, and genuine risk arising as the unintended consequence of compulsive behaviors. In both situations, risk can cause confusion in relation to diagnosis and treatment. The current article adds to the small existing literature on risk in OCD by presenting case examples illustrating different types of risk in the context of pediatric OCD, along with a discussion of their implications for management. The cases highlight that it is crucial that risk in OCD is considered carefully within the context of the phenomenology of the disorder. Guidance is offered to support clinical decision making and treatment planning.

Expectation of sexual images of adults and children elicits differential dorsal anterior cingulate cortex activation in pedophilic sexual offenders and healthy controls.

BACKGROUND: Pedophilic disorder is characterized by increased sexual interest towards children, with comparatively lesser interest towards adults. In real life, the behavior of subjects with pedophilic disorder is shaped by evaluative processes in response to sexually relevant cues. Therefore, brain activation during anticipation of sexually relevant cues is of potential interest. Whereas previous research demonstrated reduced activation when viewing adult (non-preferred) sexual stimuli in pedophilic sex offenders (PSOs), it is not known if anticipation of preferred versus unpreferred stimuli will elicit differential brain activation. METHODS: Two fMRI studies (1.5 and 7 Tesla) were conducted in separate samples, each with 26 subjects (13/13 PSOs/controls) to assess brain activity during expectancy of subsequent adult (non-preferred) sexual stimuli. In the second study (7 Tesla) additionally child (preferred) cues were presented. RESULTS: As predicted, expectancy of adult sexual stimuli generated smaller dorsal anterior cingulate cortex (dACC) activation in PSOs in both studies, driven by stronger activation during expectancy of adult erotic stimuli in non-pedophilic controls (HCs). In the second study, PSOs showed significantly increased activations in dACC during expectancy of child stimuli compared with expectancy of adult stimuli. This difference was significantly greater compared to the same contrast in HCs, thus demonstrating preference specificity of dACC activation. CONCLUSION: Our findings support the notion of decreased brain activation to adult cues in PSOs and preference specificity in neural response during expectancy of erotic stimuli. The localization of these cue reactivity differences in the salience network supports the interpretation that PSOs show abnormally increased preparatory activation even before relevant sexual stimuli are actually presented.

Empathy in pedophilia and sexual offending against children: A multifaceted approach.

Empathy is regarded as dynamic risk factor of child sexual offending. However, empathy research in the context of child sexual abuse suffers from various problems. First, prior studies failed to differentiate between pedophilic and nonpedophilic sexual offenders. Second, there is no distinction made between cognitive and affective empathy. Third, cognitive and affective empathy toward emotional states of specific age groups (children and adults) has not been adequately addressed. The current study tackles these shortcomings investigating offending and nonoffending pedophiles and multiple aspects of empathy using self-reports and objective behavioral measures. Participants included 85 pedophilic men who committed hands-on child sexual offenses (P+CSO), 72 pedophilic men who never committed hands-on child sexual offenses (P-CSO), and 128 nonoffending teleiophilic male controls (TC). Several affective and cognitive aspects of empathy were assessed using the Multifaceted Empathy Test (MET) and the Interpersonal Reactivity Index (IRI). Whereas in self-reports (IRI) P+CSO scored lower than TC (P-CSO intermediate) in cognitive perspective-taking abilities, a performance-based measure (MET) revealed evidence for a better differentiation of emotional states in P-CSO as compared with P+CSO (TC intermediate). In addition, P+CSO and P-CSO showed significantly higher affective resonance while observing children (MET), which was paralleled by higher self-reported levels of personal distress in social situations (IRI). The results indicate evidence for higher general affective empathic resonance to children in pedophilic men but superior cognitive empathy abilities in nonoffending pedophiles only, which may act as a protective factor in the prevention of sexual offending. Together, these findings underline the importance of accounting for multiple facets of empathy when targeting pedophilia and child sexual offending. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Child sexual offenders show prenatal and epigenetic alterations of the androgen system.

Child sexual offending (CSO) places a serious burden on society and medicine and pedophilia (P) is considered a major risk factor for CSO. The androgen system is closely linked to sexual development and behavior. This study assessed markers of prenatal brain androgenization, genetic parameters of androgen receptor function, epigenetic regulation, and peripheral hormones in a 2 × 2 factorial design comprising the factors Offense (yes/no) and Pedophilia (yes/no) in analyzing blood samples from 194 subjects (57 P+CSO, 45 P-CSO, 20 CSO-P, and 72 controls) matched for age and intelligence. Subjects also received a comprehensive clinical screening. Independent of their sexual preference, child sexual offenders showed signs of elevated prenatal androgen exposure compared with non-offending pedophiles and controls. The methylation status of the androgen receptor gene was also higher in child sexual offenders, indicating lower functionality of the testosterone system, accompanied by lower peripheral testosterone levels. In addition, there was an interaction effect on methylation levels between offense status and androgen receptor functionality. Notably, markers of prenatal androgenization and the methylation status of the androgen receptor gene were correlated with the total number of sexual offenses committed. This study demonstrates alterations of the androgen system on a prenatal, epigenetic, and endocrine level. None of the major findings was specific for pedophilia, but they were for CSO. The findings support theories of testosterone-linked abnormalities in early brain development in delinquent behavior and suggest possible interactions of testosterone receptor gene methylation and plasma testosterone with environmental factors.

Attraction Versus Action in Pedophilic Desire: The Role of Personality Traits and Childhood Experience.

OBJECTIVE: Comparison of pedophilic individuals who do and do not refrain from sexually engaging with children may offer critically important information regarding the differential contributors to pedophilic attraction versus behavior. This study compared 5 traits that are potentially contributory to pedophilic attraction or behavior in both minor-attracted persons (MAPs) who refrain from sexually engaging with minors (nonacting MAPs) and those who have acted on pedophilic attractions and subsequently entered the criminal justice system (forensic MAPs). METHODS: Subjects included 195 nonacting MAPs, 50 forensic MAPs, and 60 healthy controls. Data on nonacting MAPs were drawn from an online survey, and data on the other 2 groups were based on prior in-person evaluations. Measures included the Millon Clinical Multiaxial Inventory-II (MCMI-II), Barratt Impulsiveness Scale (BIS-11), the MAP Questionnaire, and the Sexual History Questionnaire (SHQ). RESULTS: Both MAP groups scored higher than healthy controls on the domains of socially inhibited personality traits, propensity toward cognitive distortions, and subjects' own childhood sexual abuse (CSA). Forensic MAPs scored higher than nonacting MAPs on the CSA domain, but the 2 MAP groups differed little on the other 2 domains. Forensic MAPs also scored higher than the other 2 groups on the antisocial domain, whereas nonacting MAPs did not differ from controls on this measure. Nonacting MAPs scored higher than controls on impulsivity. CONCLUSIONS: Antisocial personality traits may be a primary driver of pedophilic behavior that is unrelated to pedophilic attraction. Socially inhibited personality traits and propensity toward cognitive distortions are associated with pedophilic attraction, although the direction of causation is not clear. CSA seems to increase the risk of both attraction and behavior.

Inhibition and attentional control in pedophilic child sexual offenders - An event-related potential study.

OBJECTIVE: Impaired response inhibition might play a role in child sexual offences. Recording of event-related potentials (ERPs) can help to clarify whether child sexual offenders (CSOs) show an altered processing of stop signals and commission errors. METHODS: In the current ERP study, we investigated these processes in a Go/Nogo task on two groups of CSOs, pedophilic contact CSOs and non-contact CSOs (child pornography offenders), as well as on non-offenders as controls. RESULTS: Behaviorally, CSOs showed a slight, but non-significant increase of the false alarm rate to Nogo cues, as compared to controls. The amplitudes of the ERP components N2 and P3 to Nogo cues followed by correctly withhold responses did not vary between CSOs and controls. The analysis of the ERPs to committed errors showed that the Ne amplitudes (reflecting error detection) did not differ between the groups either, whereas the Pe amplitudes (reflecting error evaluation and error awareness) were strongly diminished in CSOs. This diminishment was primarily found in contact CSOs. CONCLUSIONS: The findings suggest that response inhibition, processing of stop signals, and error detection are not necessarily impaired in CSOs. However, CSOs appear to dedicate less cognitive resources to the evaluation of committed errors. SIGNIFICANCE: This selective alteration could reflect a reduced sense of responsibility for misconduct in this offender group, which might contribute to their delinquent behavior.

Sexual Desire Among an Online Sample of Men Sexually Attracted to Children.

Sexual attraction to children occurs in roughly 3 to 9 percent of the population. However, most knowledge about such desires comes from forensic samples, and most studies fail to assess preferred sexual activity and sexual partner. A new multimodal assessment of sexual desire was used to investigate interest in consensual and nonconsensual sex with adults and children in an online sample of men sexually attracted to children (n = 101). Desires were compared across history of sex offending behavior and preferred gender of child victim. Men who have and have not acted on their sexual attractions to children reported similar levels of sexual desire. Men primarily attracted to girls reported greater desire for sex with adults than did men primarily attracted to boys. Results highlight the heterogeneity of men sexually attracted to children as well as possible distinctions across gender of children to whom they are primarily attracted.

Executive Functioning in Pedophilia and Child Sexual Offending.

OBJECTIVES: Pedophilia (P) is a psychiatric disease associated with sexual attraction toward children and often accompanied by child sexual offending (CSO). Consequently, it is important to address the understanding of executive dysfunctions that may increase the probability of CSO. Moreover, this research field has been lacking to disentangle executive deficits associated with pedophilia (as a deviant sexual preference) from those associated with CSO (as a deviant sexual behavior). METHODS: The German multi-sided research network NeMUP offers the opportunity to overcome these limitations. By applying the Cambridge Automated Neuropsychological Test Battery in four carefully matched groups of men: (1) pedophiles with (N=45) and (2) without (N=45) a history of sexual offending against children; (3) child molesters without pedophilia (N=19), and (4) non-offending controls (N=49), we were able to analyze executive functioning in pedophilia and CSO independently. RESULTS: Both CSO groups as compared to both non-CSO groups exhibited worsened response inhibition ability. However, only non-pedophilic offenders showed additionally disabled strategy use ability. Regarding set-shifting abilities, the P+CSO group showed the best performance. We also found that performances were affected by age: only in pedophiles, response inhibition worsened with age, while age-related deficits in set-shifting abilities were restricted to non-pedophilic participants. The latter also differentiated between both sexual preference groups. CONCLUSIONS: Our results are the first to demonstrate that executive dysfunctions are related to offense status rather than pedophilic preference. Furthermore, there was evidence for differentiating age and performance correlations between pedophiles and non-pedophiles, which warrants further investigation. (JINS, 2017, 23, 460-470).

Inhibiting Sexual Arousal to Children: Correlates and Its Influence on the Validity of Penile Plethysmography.

The current study examined the extent to which 1136 men were able to inhibit their sexual arousal on a phallometric assessment, when instructed to do so. Although the observed changes between the two conditions (i.e., Normal and Suppression) were small to moderate in magnitude, the change was not more than what would be expected by measurement error for most participants (e.g., 83% of pedophilic sex offenders against children did not successfully inhibit their sexual arousal in the Suppression condition). There were very few variables that were associated with the ability to suppress. Higher Pedophilia Index scores in the Suppression condition predicted a greater likelihood of sexual recidivism among sex offenders (hazard ratio = 1.17, 95% CI [1.04, 1.32]), but the ability to suppress sexual arousal was not found to predict sexual recidivism. The current study highlights the importance of accounting for measurement error and found that, when doing so, most sex offenders against children are unable to successfully inhibit their sexual arousal to children when instructed to do so, and that the ability to suppress sexual arousal is not associated with recidivism.

Comparison of arousal and preference assessment outcomes for sex offenders with intellectual disabilities.

We compared outcomes of arousal and preference assessments for five adult male alleged sexual offenders with intellectual disabilities. Arousal assessments involved the use of the penile plethysmograph to measure changes in penile circumference to both deviant (males and females under the age of 18) and nondeviant (males and females over the age of 18) video clips. Paired-stimulus preference assessments were arranged to present still images from the video clips used in the arousal assessments. Results showed correspondence between the assessments for four out of the five participants. Implications are discussed for the use of preference assessment methodology as a less intrusive assessment approach for sexual offender assessments.

Evidence for superior neurobiological and behavioral inhibitory control abilities in non-offending as compared to offending pedophiles.

Neurobehavioral models of pedophilia and child sexual offending suggest a pattern of temporal and in particular prefrontal disturbances leading to inappropriate behavioral control and subsequently an increased propensity to sexually offend against children. However, clear empirical evidence for such mechanisms is still missing. Using a go/nogo paradigm in combination with functional magnetic resonance imaging (fMRI) we compared behavioral performance and neural response patterns among three groups of men matched for age and IQ: pedophiles with (N = 40) and without (N = 37) a history of hands-on sexual offences against children as well as healthy non-offending controls (N = 40). As compared to offending pedophiles, non-offending pedophiles exhibited superior inhibitory control as reflected by significantly lower rate of commission errors. Group-by-condition interaction analysis also revealed inhibition-related activation in the left posterior cingulate and the left superior frontal cortex that distinguished between offending and non-offending pedophiles, while no significant differences were found between pedophiles and healthy controls. Both areas showing distinct activation pattern among pedophiles play a critical role in linking neural networks that relate to effective cognitive functioning. Data therefore suggest that heightened inhibition-related recruitment of these areas as well as decreased amount of commission errors is related to better inhibitory control in pedophiles who successfully avoid committing hands-on sexual offences against children. Hum Brain Mapp 38:1092-1104, 2017. © 2016 Wiley Periodicals, Inc.

Pedophilic brain potential responses to adult erotic stimuli.

Cognitive mechanisms associated with the relative lack of sexual interest in adults by pedophiles are poorly understood and may benefit from investigations examining how the brain processes adult erotic stimuli. The current study used event-related brain potentials (ERP) to investigate the time course of the explicit processing of erotic, emotional, and neutral pictures in 22 pedophilic patients and 22 healthy controls. Consistent with previous studies, early latency anterior ERP components were highly selective for erotic pictures. Although the ERPs elicited by emotional stimuli were similar in patients and controls, an early frontal positive (P2) component starting as early as 185 ms was significantly attenuated and slow to onset in pedophilia, and correlated with a clinical measure of cognitive distortions. Failure of rapid attentional capture by erotic stimuli suggests a relative reduction in early processing in pedophilic patients which may be associated with relatively diminished sexual interest in adults.

Diffusion Tensor Imaging of Pedophilia.

Pedophilia is a principal motivator of child molestation, incurring great emotional and financial burdens on victims and society. Even among pedophiles who never commit any offense,the condition requires lifelong suppression and control. Previous comparison using voxel-based morphometry (VBM)of MR images from a large sample of pedophiles and controls revealed group differences in white matter. The present study therefore sought to verify and characterize white matter involvement using diffusion tensor imaging (DTI), which better captures the microstructure of white matter than does VBM. Pedophilics ex offenders (n=24) were compared with healthy, age-matched controls with no criminal record and no indication of pedophilia (n=32). White matter microstructure was analyzed with Tract-Based Spatial Statistics, and the trajectories of implicated fiber bundles were identified by probabilistic tractography. Groups showed significant, highly focused differences in DTI parameters which related to participants' genital responses to sexual depictions of children, but not to measures of psychopathy or to childhood histories of physical abuse, sexual abuse, or neglect. Some previously reported gray matter differences were suggested under highly liberal statistical conditions (p(uncorrected)<.005), but did not survive ordinary statistical correction (whole brain per voxel false discovery rate of 5%). These results confirm that pedophilia is characterized by neuroanatomical differences in white matter microstructure, over and above any neural characteristics attributable to psychopathy and childhood adversity, which show neuroanatomic footprints of their own. Although some gray matter structures were implicated previously, only few have emerged reliably.

Connectivity and functional profiling of abnormal brain structures in pedophilia.

Despite its 0.5-1% lifetime prevalence in men and its general societal relevance, neuroimaging investigations in pedophilia are scarce. Preliminary findings indicate abnormal brain structure and function. However, no study has yet linked structural alterations in pedophiles to both connectional and functional properties of the aberrant hotspots. The relationship between morphological alterations and brain function in pedophilia as well as their contribution to its psychopathology thus remain unclear. First, we assessed bimodal connectivity of structurally altered candidate regions using meta-analytic connectivity modeling (MACM) and resting-state correlations employing openly accessible data. We compared the ensuing connectivity maps to the activation likelihood estimation (ALE) maps of a recent quantitative meta-analysis of brain activity during processing of sexual stimuli. Second, we functionally characterized the structurally altered regions employing meta-data of a large-scale neuroimaging database. Candidate regions were functionally connected to key areas for processing of sexual stimuli. Moreover, we found that the functional role of structurally altered brain regions in pedophilia relates to nonsexual emotional as well as neurocognitive and executive functions, previously reported to be impaired in pedophiles. Our results suggest that structural brain alterations affect neural networks for sexual processing by way of disrupted functional connectivity, which may entail abnormal sexual arousal patterns. The findings moreover indicate that structural alterations account for common affective and neurocognitive impairments in pedophilia. The present multimodal integration of brain structure and function analyses links sexual and nonsexual psychopathology in pedophilia.

Brain alterations in paedophilia: a critical review.

Psychosocial and biological factors have been implicated in paedophilia, such as alterations in brain structure and function. The purpose of this paper is to review the expanding body of literature on this topic including brain abnormality case reports, as well as structural and functional neuroimaging studies. Case studies of men who have committed sexual offences against children implicate frontal and temporal abnormalities that may be associated with impaired impulse inhibition. Structural neuroimaging investigations show volume reductions in paedophilic men. Although the findings have been heterogeneous, smaller amygdala volume has been replicated repeatedly. Functional neuroimaging investigations demonstrate an overlap between paedophiles and teleiophiles during sexual arousal processing. While it is controversial among studies regarding group differences, reliable discrimination between paedophilic and teleiophilic men may be achieved using functional activation patterns. Nevertheless, the heterogeneous findings published so far suggest further research is necessary to disentangle the neurobiological mechanisms of paedophilic preference. A number of methodological confounds have been identified, which may account for the inconsistent results that could prove to be beneficial for future investigations.

Changed processing of visual sexual stimuli under GnRH-therapy--a single case study in pedophilia using eye tracking and fMRI.

BACKGROUND: Antiandrogen therapy (ADT) has been used for 30 years to treat pedophilic patients. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism. Yet the therapeutic success of antiandrogens is uncertain especially regarding recidivism. Meta-analyses and reviews report only moderate and often mutually inconsistent effects. CASE PRESENTATION: Based on the case of a 47 year old exclusively pedophilic forensic inpatient, we examined the effectiveness of a new eye tracking method and a new functional magnetic resonance imaging (fMRI)-design in regard to the evaluation of ADT in pedophiles. We analyzed the potential of these methods in exploring the impact of ADT on automatic and controlled attentional processes in pedophiles. Eye tracking and fMRI measures were conducted before the initial ADT as well as four months after the onset of ADT. The patient simultaneously viewed an image of a child and an image of an adult while eye movements were measured. During the fMRI-measure the same stimuli were presented subliminally. Eye movements demonstrated that controlled attentional processes change under ADT, whereas automatic processes remained mostly unchanged. We assume that these results reflect either the increased ability of the patient to control his eye movements while viewing prepubertal stimuli or his better ability to manipulate his answer in a socially desirable manner. Unchanged automatic attentional processes could reflect the stable pedophilic preference of the patient. Using fMRI, the subliminal presentation of sexually relevant stimuli led to changed activation patterns under the influence of ADT in occipital and parietal brain regions, the hippocampus, and also in the orbitofrontal cortex. We suggest that even at an unconscious level ADT can lead to changed processing of sexually relevant stimuli, reflecting changes of cognitive and perceptive automatic processes. CONCLUSION: We are convinced that our experimental designs using eye tracking and fMRI could prospectively add additional and valuable information in the evaluation of ADT in paraphilic patients and sex offenders. But with respect to the limited significance of this single case study, these first results are preliminary and further studies have to be conducted with healthy subjects and patients.

Human face processing is tuned to sexual age preferences.

Human faces can motivate nurturing behaviour or sexual behaviour when adults see a child or an adult face, respectively. This suggests that face processing is tuned to detecting age cues of sexual maturity to stimulate the appropriate reproductive behaviour: either caretaking or mating. In paedophilia, sexual attraction is directed to sexually immature children. Therefore, we hypothesized that brain networks that normally are tuned to mature faces of the preferred gender show an abnormal tuning to sexual immature faces in paedophilia. Here, we use functional magnetic resonance imaging (fMRI) to test directly for the existence of a network which is tuned to face cues of sexual maturity. During fMRI, participants sexually attracted to either adults or children were exposed to various face images. In individuals attracted to adults, adult faces activated several brain regions significantly more than child faces. These brain regions comprised areas known to be implicated in face processing, and sexual processing, including occipital areas, the ventrolateral prefrontal cortex and, subcortically, the putamen and nucleus caudatus. The same regions were activated in paedophiles, but with a reversed preferential response pattern.

Elevated rates of atypical handedness in paedophilia: theory and implications.

Multiple factors determine handedness including genetics, prenatal stress and post-natal environmental conditions. Atypical handedness, whether manifest as increased sinistrality or decreased strength of lateral preference, has been noted in a wide variety of populations with neuropathology. Those with atypical sexual preferences, specifically paedophilia, also manifest reduced rates of right-handedness. This paper uses the largest sample of phallometrically assessed men to date to establish the pattern of atypical handedness in paedophilia. Specifically, whereas prior research has largely characterized participants dichotomously as right-handed or non-right-handed and/or used self-report of writing hand, this paper expands upon such reports by using the Edinburgh Handedness Inventory's laterality quotient. Participants' handedness and phallometrically assessed sexual preference were analyzed both as continuous and categorical variables, and the responses of those scoring in the range of ambiguous-handedness were evaluated to ascertain whether they were ambiguously handed or more accurately described as mixed-handed. Results indicated those producing scores in the range of ambiguous-handedness demonstrated response patterns consistent with ambiguous-handedness, rather than mixed-handedness. Paedophiles demonstrated high rates of non-right-handedness primarily manifested as sinistrality, whereas those who had a sexual preference for pubescent children evidenced increased ambiguous-handedness. Results support a view of ambiguous-handedness as less pathological than previously hypothesized, and of a neurodevelopmental origin of paraphilic sexual preferences.

Response inhibition in pedophilia: an FMRI pilot study.

BACKGROUND: The failure to inhibit pleasurable but inappropriate urges is associated with frontal lobe pathology and has been suggested as a possible cause of pedophilic behavior. However, imaging and neuropsychological findings about frontal pathology in pedophilia are heterogeneous. In our study we therefore address inhibition behaviorally and by means of functional imaging, aiming to assess how inhibition in pedophilia is related to a differential recruitment of frontal brain areas. METHOD: Eleven pedophilic subjects and 7 nonpedophilic controls underwent fMRI while performing a go/no-go task composed of neutral letters. RESULTS: Pedophilic subjects showed a slower reaction time and less accurate visual target discrimination. fMRI voxel-level ANOVA revealed as a main effect of the go/no-go task an activation of prefrontal and parietal brain regions in the no-go condition, while the left anterior cingulate, precuneus and gyrus angularis became more activated in the go condition. In addition, a group × task interaction was found in the left precuneus and gyrus angularis. This interaction was based on an attenuated deactivation of these brain regions in the pedophilic group during performance of the no-go condition. The positive correlation between blood oxygen level-dependent imaging signal and reaction time in these brain areas indicates that attenuated deactivation is related to the behavioral findings. CONCLUSION: Slower reaction time and less accurate visual target discrimination in pedophilia was accompanied by attenuated deactivation of brain areas belonging to the default mode network. Our findings thus support the notion that behavioral differences might also derive from self-related processes and not necessarily from frontal lobe pathology.