Attachment Theory and Sexual Offending: Making the Connection.

PURPOSE OF REVIEW: The purpose of this review is to discuss how attachment theory can be applied to explain sexual violence. Specifically, it discusses how the development of certain risk factors contributes to these behaviors and how attachment-based models can be used to address this issue through prevention and therapeutic interventions. RECENT FINDINGS: Recent research demonstrates that individuals who commit sexual offenses have higher rates of insecure attachment styles and that these styles are associated with a number of criminogenic risk factors associated with sexual offending. Such risk factors include cognitive processing difficulties, affect dysregulation, and challenges in interpersonal relationships, among others. Fortunately, treatment interventions have been shown to foster more secure attachment styles and reduce these risk factors. Attachment theory is a viable theory to both understand and intervene with those who have committed sexual violence to reduce the risk factors associated with sexual violence.

Patients' experience of incontinence and incontinence-associated dermatitis in hospital settings: a qualitative study.

OBJECTIVE: To explore the experience of patients with incontinence and incontinence-associated dermatitis (IAD) in acute care hospitals and their family caregivers, including their perceptions and management, as well as the impact on their wellbeing. METHOD: A qualitative exploratory study design was employed in 18 wards across six acute/subacute hospitals in New South Wales, Australia. Patients with incontinence (with or without IAD) were invited to participate. Where interviews were not possible with the patient, their family caregiver was invited to participate. Semi-structured interviews were conducted. RESULTS: There were 45 interviewees in the study; 41 were patients with incontinence (11 of whom had IAD) and four were family caregivers. The experience of incontinence was captured by three themes: 'incontinence interrupts every aspect of my life'; 'actively concealing and cloaking'; and 'perceived as irreversible'. Incontinence was expected by the patients at their age and did not come as a surprise. It was normalised and approached with stoicism. As such, patients self-managed their incontinence by developing strategies to ensure they avoided episodes of incontinence during their stay. Incontinence left patients feeling anxious, embarrassed and with a sense of shame, and they did not communicate these feelings, or engage with health professionals about their incontinence, nor did health professionals discuss their incontinence with them. There was a strong sense of resignation that incontinence was irreversible and nothing could be done to improve it. All participants displayed little knowledge of IAD. The experience of having IAD was characterised by the theme 'debilitating and desperate for relief' and was experienced as a particularly painful, itching and burning condition that left patients distressed and irritable. CONCLUSION: Patients with incontinence in acute settings required further education from health professionals to reduce the stigma of incontinence, and provide further support to manage their incontinence. Health professionals can also play a key role in educating patients about the risks of developing IAD and how it can be prevented.

Learning From Consumers of Mandated Sex-Offending Programs: "It's Not Treatment, I Wish It Was."

The purpose of this qualitative study was to explore clients' perceptions of sex-offending treatment. The sample included 291 people required to register as sex offenders in the U.S. who answered an open-ended question in an online survey asking them to describe their positive and negative experiences in mandated treatment. Using qualitative analysis, three overarching themes (with several subthemes) were identified: (1) positive and (2) negative treatment experiences and (3) the affiliation between the criminal justice system and clinical services. Experiences in sex offending treatment were viewed as positive when clients had opportunities to learn about themselves, experience group cohesion, build a positive alliance with a caring therapist, learn tools and skills for emotional health, explore the roots of offense behavior, and create healthy life plans to reduce risk for re-offending. Negative themes emerged when treatments were viewed as coercive, confrontational, or demeaning; when therapists seemed inexperienced or unqualified; and when seemingly outdated or unscientific methods were emphasized without explanation or dialogue. The entanglement between court-mandated treatment providers and the criminal justice system led to concerns about confidentiality, conflicts of interest, and role ambiguity. Drawing upon literature related to therapeutic alliance, trauma-informed care, and Risk-Need-Responsivity models, we offer suggestions for integrating client feedback to improve treatment responsivity and prevent re-offending.

Impact of an evidence-based bundle on incontinence-associated dermatitis prevalence in hospital patients: A quasi-experimental translational study.

The study aimed to evaluate the effect of an intervention on the prevalence and severity of incontinence-associated dermatitis (IAD) in six hospitals in one state in Australia. This quasi-experimental pre-and post-study, conducted in 18 wards, was part of a larger implementation science study on incontinence-associated dermatitis. Skin and incontinence assessments were conducted on patients during February and March 2020 (pre-intervention) and July and August 2021 (post-intervention). The intervention comprised continence assessment and management, an education brochure for patients, family and caregivers on IAD, the Ghent Global IAD Categorisation Tool (GLOBIAD) and a skin care regime with patient skin protection measures (three-in-one barrier cream cloths, minimisation of bed protection layers, use of appropriate continence aid). A total of 1897 patients were assessed (pre-intervention = 964, post-intervention = 933). A total of 343 (35.6%) pre-intervention patients and 351 (37.6%) post-intervention patients had incontinence. The prevalence of hospital-acquired IAD was 6.71% in the pre-intervention group and 4.27% in the post-intervention group; a reduction of 36.3% (p = 0.159) despite higher patient acuity, prevalence of double incontinence and the COVID-19 pandemic in the post-intervention group compared with the pre-intervention group. Our multisite best practice IAD prevention and treatment intervention was able to reduce the prevalence and severity of hospital-acquired IAD, suggesting enduring effectiveness of the intervention.

Clinician Knowledge of Incontinence-Associated Dermatitis: A Multisite Survey of Healthcare Professionals in Acute and Subacute Settings.

PURPOSE: This study examined clinicians' knowledge of incontinence-associated dermatitis (IAD) using the Barakat-Johnson Incontinence-Associated Dermatitis Knowledge Tool (Know-IAD). DESIGN: A cross-sectional multicenter survey. SUBJECTS AND SETTING: The setting was 6 hospitals across 5 health districts in New South Wales, Australia. The participants were nurses (registered nurses and enrolled nurses), physicians, allied health (occupational therapists, dietitians, and physiotherapists), and students (nursing and allied health). METHODS: Data about IAD knowledge were collected from November 2019 to January 2020. The Know-IAD, an 18-item validated instrument that measures knowledge of IAD in 3 domains (etiology and risk, classification and diagnosis, and prevention and management), was administered to a cross section of eligible clinicians. The participants anonymously completed hard copy surveys. Descriptive and exploratory analyses were conducted to quantify clinicians' knowledge about the etiology and risk, classification and diagnosis, and prevention and management of IAD. A mean knowledge score of 70% was considered to be satisfactory. RESULTS: Four hundred twelve respondents completed the survey. One hundred twenty nine respondents (31.3%) achieved 70% correct responses and greater for the entire set of items. For the etiology and risk domain, 348 respondents (84.5%) obtained a score of 70% correct responses and greater, 67 respondents (16.3%) achieved 70% correct responses and greater for the classification and diagnosis domain, and 84 respondents (20.4%) achieved 70% correct responses and greater for the prevention and management domain. CONCLUSION: Clinicians tend to have low knowledge and recognition of IAD, particularly in the areas of classification and diagnosis along with prevention and management. They tend to have higher knowledge of how IAD is caused and the risk factors. This study has identified knowledge gaps for further education that can improve assessment, prevention, and management of IAD.

Implementing best available evidence into practice for incontinence-associated dermatitis in Australia: A multisite multimethod study protocol.

AIMS: Incontinence-associated dermatitis (IAD) is an insidious and under-reported hospital-acquired complication which substantially impacts on patients' quality of life. A published international guideline and the Ghent Global IAD Categorisation Tool (GLOBIAD) outline the best available evidence for the optimal management of IAD. This study aims to implement theguideline and the GLOBIAD tool and evaluate the effect on IAD occurrences and sacral pressure injuries as well as patient, clinician and cost-effectiveness outcomes. MATERIALS AND METHODS: The study will employ a multi-method design across six hospitals in five health districts in Australia, and will be conducted in three phases (pre-implementation, implementation and post-implementation) over 19 months. Data collection will involve IAD and pressure injury prevalence audits for patient hospital admissions, focus groups with, and surveys of, clinicians, patient interviews, and collection of the cost of IAD hospital care and patient-related outcomes including quality of life. Eligible participants will be hospitalised adults over 18 years of age experiencing incontinence, and clinicians working in the study wards will be invited to participate in focus groups and surveys. CONCLUSION: The implementation of health district-wide evidence-based practices for IAD using a translational research approach that engages key stakeholders will allow the standardisation of IAD care that can potentially be applicable to a range of settings. Knowledge gained will inform future practice change in patient care and health service delivery and improve the quality of care for patients with IAD. Support at the hospital, state and national levels, coupled with a refined stakeholder-inclusive strategy, will enhance this project's success, sustainability and scalability beyond this existing project.

Criminogenic Needs as Intervening Factors in the Relation Between Insecure Attachments and Youth Sexual Violence.

There is a strong theoretical and research base demonstrating the link between attachment styles and adolescent sexual offending. However, this relationship may be best explained by deficit-based mediational pathways including criminogenic needs such as emotional or affect regulation and callousness. Grady, Levenson, and Bolder propose a framework that details criminogenic needs as intermediary variables in the attachment-sexual offending relationship. Using data on adolescents adjudicated of sexual and nonsexual crimes in a Western state (N = 200), two structural equation models (SEM) tested direct and indirect relationships between ambivalent and avoidant attachment styles (in separate models), dysregulation including cognitive and behavioral transitions, emotional control, and inhibited/impulsive behaviors, callousness, delinquency, and offending type (sexual or nonsexual offending). Results revealed statistically significant direct pathways between variables of interest and a multimediational effect of dysregulation and callousness in the relationship between insecure attachments and sexual offending. Treatment, policy, and research implications are discussed.

Maternal Caregiving Practices and Child Abuse Experiences as Developmental Antecedents to Insecure Attachments: Differential Pathways Between Adolescents Who Commit Sexual and Non-Sexual Crimes.

Grady, Levenson, and Bolder's etiological framework contextualizes sexual offending behaviors through a trauma and attachment lens to suggest child abuse experiences (CAE) are associated with attachment problems that contribute to sexual offending. To empirically test a portion of this theory, this cross-sectional study employed a structural equation mediated-moderated model on a sample of juvenile justice-involved youth (N = 505) who committed sexual (n = 355) and non-sexual (n = 150) offenses. Results revealed a good model fit and statistically significant direct effects between maternal harsh and indifferent caregiving styles and insecure attachment. However, CEAs did not mediate the relationship between caregiving styles and insecure attachment. Results also revealed a moderation effect whereby youth who commit sexual crimes who report harsher and more indifferent maternal caregiving styles were more likely to have higher CAEs relative to youth who commit non-sexual crimes. Implications are discussed using a public health perspective of prevention.

Preventing Sexual Abuse: Perspectives of Minor-Attracted Persons About Seeking Help.

The primary aim of this exploratory research was to gain information from minor-attracted persons (MAPs) about their (a) formal and informal experiences with help-seeking for minor attraction, (b) perceived barriers to seeking help for concerns about minor attraction, and (c) treatment priorities as identified by consumers of these services. A nonrandom, purposive sample of MAPs (n = 293, 154 completed all questions) was recruited via an online survey. Results show that 75% of participants did seek formal help from a professional; however, just less than half of them found the experience to be helpful. Characteristics of helpful therapeutic encounters included nonjudgmental attitudes, knowledge about minor attraction, and viewing clients in a person-centered and holistic way. Barriers to help seeking included uncertainty about confidentiality, fear of negative reaction or judgment, difficulties finding a therapist knowledgeable about MAPs, and financial constraints. Understanding or reducing attraction to minors were common treatment goals, but participants also prioritized addressing general mental health and well-being related to depression, anxiety, loneliness, and low self-esteem. Implications for effective and ethical counseling and preventive interventions for MAPs are discussed.

Relationships between Early Life Victimization, Antisocial Traits, and Sexual Violence: Executive Functioning as a Mediator.

Few research studies examine how the relationship between trauma and executive functioning can influence sexual violence among youth. Knight and Sims-Knight (2004) proposed a Developmental Etiological Theory (DET) connecting early life physical and sexual victimization to sexual violence via antisocial traits. Drawing from research that identifies a link between early life victimization and executive functioning, this study tests an adaptation to the DET by including executive functioning as an intervening factor. Using data on adolescents adjudicated of sexual and non-sexual crimes in a western state (N = 200), multiple structural equation models tested direct and indirect relationships between early life sexual, physical victimization, and other adversity, four differential forms of executive functioning, callousness, and sexual violence. Results revealed statistically significant direct pathways between variables of interest and a multi-meditational effect of certain forms of executive functioning and callousness in the relationship between victimization and sexual violence. Treatment and research implications are discussed.

A Descriptive Study of Psychosocial Characteristics and Offense Patterns in Females with Online Child Pornography Offenses.

Despite a growing body of literature on females who sexually offend, there is a dearth of research on online sexual offending in women. This study collected descriptive psychosocial and offense conduct data on 98 females convicted of online sexual offenses housed in United States federal prisons. Psychosocial history results demonstrated that 60% of the subjects reported a history of sexual abuse (n = 59), while 46% reported physical abuse (n = 45). In addition, 47% reported a history of outpatient mental health treatment (n = 46), and 15% reported prior inpatient mental health treatment (n = 15). The majority (n = 70) of the women's offenses involved the victimization of accessible minors to produce child pornography for distribution on the Internet, most often in association with a male co-offender. Typically, the subject's child was the victim and the focus of the child pornography. Contact offending frequently (n = 39) occurred in the context of the production of child pornography. The implications of these findings, especially regarding the role that women play in the creation and distribution of child pornography, are discussed as well as important directions for future research.

Evaluating the Use of Plain Language in a Cancer Clinical Trial Website/App.

Medically complex titles and descriptions found on clinical trial websites and online applications present a barrier to comprehension for users from the general public. In this study, we examine the effectiveness of plain language trial descriptions for user comprehension of basic trial details. Two hundred seventeen volunteers recruited from patient waiting areas completed 441 user tests of ten plain language trial descriptions. The majority of volunteers adequately comprehended the cancer type and basic inclusion/exclusion criteria from plain language trial descriptions. Difficulty comprehending the treatment being studied was seen in seven of ten descriptions tested. Revision and retesting of the seven trial descriptions showed continued user challenges in comprehending the treatment being studied. Plain language clinical trial descriptions integrated into a website/app allowed users to understand basic inclusion/exclusion criteria. Despite plain language used, discerning the treatment being studied may be difficult for some users. Integration of plain language descriptions into clinical trial online applications can help users understand trial basics. Further research regarding effective use of plain language to communicate the treatment being studied is needed.

A Longitudinal Outcome Evaluation of a Prison-Based Sex Offender Treatment Program.

Sex offender outcome studies continue to produce mixed results. A common critique of these studies is their lack of methodological rigor. This study attempts to address this critique by adhering to the standards established by the Collaborative Outcome Data Committee (CODC) aimed at increasing the quality and confidence in outcome studies. We examined recidivism outcomes for a sample of formerly incarcerated sex offenders who participated in a state prison-based cognitive-behavioral-skills-based treatment program. We used propensity score analysis to compare treatment participants with a matched sample of non-participants. The final sample post-matching ( n = 512) was observed for a minimum of 4 years and a maximum of 14 years. Using survival analysis, findings indicate that there were no differences in recidivism rates between treatment participants and non-participants in sexual or violent crimes. However, participants demonstrated significantly lower rates of recidivism for non-violent crimes. We discuss strengths, limitations of the study, and implications of these findings.

Seeking an Integrated Approach to Trauma and Problematic Sexual Behaviors in Adolescents: Learning from Practitioners.

More than a third of all sexual crimes are committed by adolescents. In addition, many adolescents struggle with problematic sexual behaviors (PSB) that may not rise to a criminal offense, but cause harm to themselves and those around them. A significant number of these adolescents also have histories of their own trauma; yet there are no treatment models that integrate both PSB and trauma into one comprehensive treatment for this population. This qualitative study's aim was to use the expertise of clinicians who work with adolescents with PSB as well as clients and their caregivers who had completed PSB treatment to understand what they believe are the necessary components and elements needed for an integrated model that seeks to simultaneously address both PSB and the consequences of traumatic experiences. Twenty-six mental health professionals and one former client and his caregiver participated in focus groups (three with clinicians and one with the caregiver and former client) to share their experiences and expertise regarding an integrated model. The thematic analysis procedure yielded six major themes: family, external systems, treatment structure, therapeutic themes, specialized PSB targets, and trauma and PSB integration. Each of these major themes was comprised of subthemes that are presented as well. Implications for practice and future research are discussed, including that clinicians could benefit from guidance and structure to assist them in structuring their interventions to address the multiple needs of their clients that seek to reduce their risk of reoffending while simultaneously enhancing the quality of their lives.

Does volunteering for sex offender treatment matter? Using propensity score analysis to understand the effects of volunteerism and treatment on recidivism.

A common critique of program evaluations of prison-based sex offender treatment holds that the samples inherently show selection bias because the participants typically volunteer for treatment. To address this critique, we used propensity score analysis to assess the influence of volunteerism on treatment effects. We examined recidivism outcomes for a sample of participants who volunteered for treatment, of whom some participated in treatment (n = 161) and some did not (n = 282) and compared these outcomes to the recidivism rate of a matched sample of nonvolunteers for treatment (n = 443). The primary finding is that offenders who volunteered for treatment did not demonstrate any differences in recidivism rates when matched with and compared to inmates who did not volunteer to participate in treatment. Furthermore, our results revealed that there were a number of significant differences between unmatched volunteers and unmatched nonvolunteers, perhaps most importantly in their risk for future recidivism as measured by the STATIC-99 risk assessment. We discuss study strengths and limitations and present the implications of the findings for policy, practice, and research.

Developing a trauma focused cognitive behavioral therapy application for adolescents with problematic sexual behaviors: A conceptual framework.

Sexual abuse (SA) perpetration is a significant public health problem; SA perpetration is most likely to emerge during adolescence and youth ages 13 to 17 account for a significant portion of all child sexual abuse. While research shows that these youth have high rates of adversity, once they have engaged in problem sexual behavior (PSB), their own trauma histories are often ignored with treatment primarily focused on reducing risk for reoffending. Although sexual re-offense rates among adolescents with PSB are very low, the rates of non-sexual recidivism are considerably higher; with almost half of known youth have reoffended non-sexually, requiring development, implementation, and testing of therapeutic interventions responsive to the indicated risks and unmet needs of adolescents who have engaged in a range of problematic sexual behaviors (PSB-A) and their families. Yet, there are no empirically supported interventions designed specifically to address PSB-A with trauma histories. This article introduces how Trauma-Focused Cognitive Behavioral Therapy can be applied to PSB-A and provides implications for practice and future research.

Positive Caregiving Styles Attenuating Effects of Cumulative Trauma Among Youth Who Commit Sexual Crimes.

Among youth who commit sexual crimes, childhood trauma experiences have been linked to a host of outcomes including trauma symptom expression. Furthermore, research has begun assessing differential rates of cumulative adverse childhood experiences (ACEs) between youth who commit sexual and non-sexual crimes. Yet, few studies have comparatively examined rates of cumulative traumatic events using more robust measures of adversity. There is scant research on outcomes associated cumulative trauma among youth who commit sexual crimes including linkages to trauma symptoms and how positive parenting styles (PCSs) can attenuate in this relationship. This study aims to compare cumulative trauma experiences between youth who commit sexual (n = 112) and non-sexual crimes (n = 224). Among youth who commit sexual crimes, we test how PCSs mitigate or moderate the effects of cumulative trauma on trauma symptoms. Results from independent samples t-tests revealed significant group differences on singular and cumulative traumatic experiences, and trauma symptomatology, where youth who commit sexual crimes had higher rates of all. Stepwise linear regressions revealed mitigating effects of maternal PCSs and tests of moderation revealed main and interaction effects, where intermediate positive maternal caregiving styles for youth with higher cumulative trauma were associated with greater trauma symptomatology. Implications and limitations are discussed.

The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review.

BACKGROUND: Incontinence-associated dermatitis is a common, under-recognized painful skin condition associated with poorer quality of life, increased nurse workloads, and costs. OBJECTIVE: To systematically review economic evidence for the prevention and treatment of incontinence-associated dermatitis. DESIGN: Systematic review of quantitative research. DATA SOURCES: PubMed, MEDLINE, EMBASE, Cochrane Library, York Centre for Reviews and Dissemination database, Econlit, Tufts' Cost-Effectiveness Analysis Registry, and Web of Science. REVIEW METHODS: A comprehensive search for studies on resource use (costs), health outcomes, and cost-effectiveness of interventions for incontinence-associated dermatitis was conducted. Screening, data extraction, and initial quality assessment were conducted independently by two reviewers, with disagreements/queries regarding quality settled through consensus with the larger team. Quality evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist and results narratively arranged. FINDINGS: Seventeen studies (10 for prevention, one for treatment and six for both prevention and treatment) included. All studies measured resource use from a healthcare provider perspective; 14 quantified resources in monetary terms. Considerable variation existed in the resource use data primarily due to differences in the type of resources counted, selected time horizons, valuation methods, and reporting approaches. Ten studies provided evidence of their intervention to be cost saving (or at least cost avoiding). Five studies on barrier products provided evidence to be cost saving: three for prevention, one for treatment, and one for both prevention and treatment. Two studies of cleanser and barrier products provided evidence to be cost saving for the prevention and treatment of incontinence-associated dermatitis. One study found a cleanser to be a cost saving preventative intervention. One bowel management system was found to be cost saving over time only, and one nurse education intervention was found to be cost saving for preventing and treating incontinence-associated dermatitis. One barrier product was found to be cost-effective for preventing and treating the condition. Finally, one study found a cleanser and barrier product was time saving for prevention. None of the studies incorporated a multi-attribute quality of life measure; however, two studies included person-reported outcome measures for pain. A narrow range of resources (mainly products) were considered, and there was limited information on how they were counted and valued. Analyses relating to heterogeneity among patients/hospital wards or health facilities and uncertainty were lacking. CONCLUSIONS: Barrier products are possibly a more cost-effective treatment than others; however, this evidence lacks certainty. Structured health economic evaluations are required for a reliable evidence-base on the interventions for incontinence-associated dermatitis. TWEETABLE ABSTRACT: Most incontinence-associated dermatitis studies lack person-reported outcomes, costs beyond product/staff time, and economic evaluation.

Do children with developmental disabilities and mental health conditions have greater difficulty using health services than children with physical disorders?

The objective of this study is to determine whether achievement of the Maternal and Child Health Bureau core outcome ease of use of health services differs between children with developmental disabilities, mental health conditions and physical disorders. We analyzed data from the 2005 National Survey of Children with Special Health Care Needs. Children with special health care needs were classified into 4 health condition groups: developmental disabilities (DD), mental health conditions (MH), physical disorders (PD) and multiple conditions. The outcome measure was 'difficulty using services'. We conducted bivariate and multivariate analyses to determine the associations between the health condition groups and the outcome. Of the CSHCN included in the study, 2.6% had DD, 12.9% had MH, 49.9% had PD and 34.6% belonged to multiple conditions group. Four percent of CSHCN with PD, 17% of those with DD, 13% of those with MH and 20% of those in the multiple conditions group had difficulty using services. In multivariate analyses, CSHCN with DD had 2.3 times and MH conditions had 2.6 times the odds of having difficulty using services compared to those with PD. Existing programs for CSHCN should be evaluated for the adequacy of services provided to children with DD and MH. Future studies should evaluate how developmental disabilities and mental health policies affect navigating the health care system for this population.