Themes Associated with Suicidal Ideation and Behavior Among People Attracted to Children.

Suicide represents a significant public health problem, with around 800,000 deaths per year worldwide and up to 20 times as many episodes of self-harm and suicide attempts. Members of stigmatized groups may experience increased risk of suicide due in part to stigma-related factors, such as expectations of rejection, internalization of negative stereotypes, or potential for greater social isolation. Research suggests that adults who are attracted to children face extreme stigma, even those who do not commit sexual crimes involving children. Adults who are attracted to children also experience significantly increased risk for suicidal ideation and behavior (SIB) compared to general population samples. The current study sought to explore experiences with SIB among adults attracted to children to better understand factors underlying suicidality in this population. The lead author conducted semi-structured interviews in a community sample of 15 adults attracted to children who self-reported some form of SIB in their lifetime. Using interpretative phenomenological analysis, the lead author explored and interpreted interview data to generate themes driven by respondents' characterizations of their SIB. Superordinate themes related to suicidality in this sample included low self-esteem or self-worth, cumulative impacts of the attraction and other stressors, and concerns about the ability to have a positive future due to the attraction. Findings underscore the importance of addressing internalized stigma, treating problems like depression and social isolation, and instilling hope for the future to promote mental health and prevent SIB among adults attracted to children.

Examining and Comparing the First Public Olympic and Competitive Sports Misconduct Registry with the National Sex Offense Registry.

In 2017, the U.S. Center for SafeSport launched the first public disciplinary sports registry listing individuals accused of engaging in harmful behavior against child and adult athletes. Our study reviews information from 1,161 individuals on SafeSport's sports registry. Of the individuals on the sports registry, 22% were concurrently listed on the national registry for sexual offenses. Relative to individuals listed only on the sports registry, those on both registries were 4.5 and 1.4 times more likely to have sexual misconduct allegations and allegations involving a child, respectively. Of those on both registries, 31% were on the national registry approximately seven years before appearing on the sports registry. We discuss whether and how public registries represent effective strategies for crime prevention.

No Check We Won't Write: A Report on the High Cost of Sex Offender Incarceration.

Child sexual abuse is a preventable public health problem that is addressed primarily via reactive criminal justice efforts. In this report, we focus on the cost of incarcerating adults convicted of sex crimes against children in the United States. Specifically, we summarize publicly available information on U.S. state and federal prison and sex offender civil commitment costs. Wherever possible, we used government data sources to inform cost estimates. Results indicate the annual cost to incarcerate adults convicted of sex crimes against children in the United States approaches $5.4 billion. This estimate does not include any costs incurred prior to incarceration (e.g., related to detection and prosecution) or post-release (e.g., related to supervision or registration). Nor does this estimate capture administrative and judicial costs associated with appeals, or administrative costs that cannot be extricated from other budgets, as is the case when costs per-prisoner are shared between prisons and civil commitment facilities. We believe information on the substantial funding dedicated to incarceration will be useful to U.S. federal, state, and local lawmakers and to international policymakers as they consider allocating resources to the development, evaluation and dissemination of effective prevention strategies aimed at keeping children safe from sexual abuse in the first place.

Self-Esteem, Perceived Social Support, and Suicidal Ideation and Behavior Among Adults Attracted to Children.

Introduction: People who are attracted to children may be at elevated risk for suicidal ideation and behavior compared to the general population. However, factors associated with suicidal ideation and behavior in this population represent a gap in the literature.Methods: The current study used multilinear regression to explore the impact of self-esteem and perceived social support on suicidal ideation and behavior in a sample of 154 adults attracted to children. Mediation analysis was conducted to investigate the role of lifetime major depressive disorder and hopelessness in these relationships.Results: Results showed high prevalence of past-year and lifetime suicidal ideation and behavior in the sample. Both self-esteem and perceived social support demonstrated significant, inverse relationships with suicidal ideation and behavior after adjustment for covariates. Mediation analyses provided support for the role of hopelessness, but not depression, in these relationships.Conclusion: Results demonstrate high rates of suicidal ideation and behavior among adults attracted to children and highlight important opportunities for prevention and intervention. Improving self-esteem, bolstering perceived social support, reducing hopelessness, and removing barriers to help-seeking may be targets for improving mental health and preventing suicidal ideation and behavior in this population.

Adverse childhood experiences and comorbidity in a cohort of people who have injected drugs.

BACKGROUND: Childhood adversity is associated with the onset of harmful adult substance use and related health problems, but most research on adversity has been conducted in general population samples. This study describes the prevalence of adverse childhood experiences in a cohort of people who have injected drugs and examines the association of these adverse experiences with medical comorbidities in adulthood. METHODS: Six hundred fifty three adults were recruited from a 30-year cohort study on the health of people who have injected drugs living in and around Baltimore, Maryland (Median age = 47.5, Interquartile Range = 42.3-52.3 years; 67.3% male, 81.1% Black). Adverse childhood experiences were assessed retrospectively in 2018 via self-report interview. Lifetime medical comorbidities were ascertained via self-report of a provider diagnosis. Multinomial logistic regression with generalized estimating equations was used to examine the association between adversity and comorbid conditions, controlling for potential confounders. RESULTS: Two hundred twelve participants (32.9%) reported 0-1 adverse childhood experiences, 215 (33.3%) reported 2-4, 145 (22.5%) reported 5-9, and 72 (11.1%) reported ≥10. Neighborhood violence was the most commonly reported adversity (48.5%). Individuals with ≥10 adverse childhood experiences had higher odds for reporting ≥3 comorbidities (Adjusted Odds Ratio = 2.9, 95% CI = 1.2 - 6.8, p = .01). CONCLUSIONS: Among people who have injected drugs, adverse childhood experiences were common and associated with increased occurrence of self-reported medical comorbidities. Findings highlight the persistent importance of adversity for physical health even in a population where all members have used drugs and there is a high burden of comorbidity.

Caregivers' Perceptions and Responses to a New Norm: The Missing Link in Addressing Adolescent Sexting Behaviors in the U.S.

Youth sharing of self- or peer-produced sexual content via electronic communications, dubbed by the media as "sexting" (i.e., sexting behaviors), has generated concern among a wide variety of adult stakeholders in the U.S. Experts recognize the need to integrate perspectives and knowledge about adolescents' sexting behaviors from individuals who interact with adolescents (e.g., their caregivers) to inform the development of prevention policy and practice. The present study fills this gap by interviewing 10 separate groups of caregivers in three different states, with the sole focus on adolescent sexting behaviors. Results indicated seven themes: (1) characteristics of adolescent sexting behaviors, (2) influences on sexting behaviors, (3) communication about sexting behaviors, (4) gender and sexting behaviors, (5) sociohistorical conditions and sexting behaviors, (6) consequences of sexting behaviors, and (7) ways to address sexting behaviors; multiple themes emerged within each of the seven parent codes. Findings inform the need to integrate adolescent sexting behaviors into comprehensive sexual education curricula and to develop educational content on adolescent sexting behaviors for adolescents and caregivers in online and printable handout formats. Clearly defining sexting and norms around sexting are of particular importance in such educational materials.

Responsible Behavior with Younger Children: Examining the Feasibility of a Classroom-Based Program to Prevent Child Sexual Abuse Perpetration by Adolescents.

Child sexual abuse (CSA) is a preventable public health problem typically addressed with either after-the-fact interventions or prevention programs focused on teaching children to protect themselves and report abuse. Such responses do little to prevent CSA victimization, leading to calls for prevention efforts targeting individuals most at risk of perpetrating CSA. These individuals include young adolescents, who are prone to making mistakes and bad decisions when it comes to their sexual behaviors. To begin to address this call to action, we developed Responsible Behavior with Younger Children (RBYC), a universal school-based prevention program to provide sixth and seventh grade students (and their parents and educators) with the knowledge, skills, and tools to prevent engaging younger children in sexual behaviors. School-based CSA prevention interventions are often met with feasibility and acceptability concerns including that (a) people at risk of offending are impervious to prevention efforts, (b) schools do not have the resources to take on additional programs, and (c) the content is too sensitive for educators, parents, and students. The goal of this article is to describe how the RBYC program was developed to address these concerns. We also summarize data on the feasibility of the RBYC program obtained from focus groups with educators, parents, and students during the development of the program and interviews with educators after a pilot randomized controlled trial (RCT). Feedback received during program development and after the pilot RCT suggests that RBYC is relevant, salient, palatable, and feasible for implementation in middle schools.

Florida's Opioid Crackdown and Mortality From Drug Overdose, Motor Vehicle Crashes, and Suicide: A Bayesian Interrupted Time-Series Analysis.

In 2011, Florida established a prescription drug monitoring program and adopted new regulations for independent pain-management clinics. We examined the association of those reforms with drug overdose deaths and other injury fatalities. Florida's postreform monthly mortality rates-for drug-involved deaths, motor vehicle crashes, and suicide by means other than poisoning-were compared with a counterfactual estimate of what those rates would have been absent reform. The counterfactual was estimated using a Bayesian structural time-series model based on mortality trends in similar states. By December 2013, drug overdose deaths were down 17% (95% credible interval: -21, -12), motor vehicle crash deaths were down 9% (95% credible interval: -14, -4), and suicide deaths were unchanged compared with what would be expected in the absence of reform. Florida's opioid prescribing reform substantially reduced drug overdose deaths. Reforms may also have reduced motor vehicle crash deaths but were not associated with a change in suicides. More research is needed to understand these patterns. Bayesian structural time-series modeling is a promising new approach to interrupted time-series studies.

Child Sexual Abuse: The Need for a Perpetration Prevention Focus.

In the evolution of efforts to reduce child sexual abuse (CSA) rates in the United States, there has been a gradual shift to add preventive measures to after-the-fact interventions (i.e., interventions and policies implemented after the abuse has already happened, such as services and treatment for victims and punishment, treatment, and management of offenders). Prevention of CSA perpetration, however, is often missing from these efforts, despite decades of experts calling for broader prevention solutions. The current paper describes the scope of the problem of CSA, highlights problems with an over-reliance on after-the-fact interventions, and describes promising perpetration-focused CSA prevention interventions. While most existing preventive efforts focus on teaching children to protect themselves from incurring sexual harm, perpetration prevention efforts may hold more promise by addressing the onset of harmful behavior. As such, perpetration prevention efforts can contribute to a more robust and comprehensive approach to CSA - an approach that focuses on prevention of harm from occurring in the first place, as well as responding once harm has occurred.

Factors promoting and impeding HIV testing among adolescents in juvenile drug court.

A randomized pilot study compared Risk Reduction Therapy for Adolescents (RRTA) to treatment as usual (TAU); the present study examined whether intervention condition influenced HIV testing, barriers to HIV testing, and HIV communication among adolescents involved in juvenile drug courts overall and by sexual experience. Of 105 participants, 13.3% had HIV pre-treatment testing, whereas 27.2% (of 92 participants) indicated follow-up HIV testing. Sexually active youth in RRTA (but not in TAU) reported a significant increase in HIV testing over time. RRTA demonstrated the greatest increase in HIV testing (8% pre-treatment to 44% follow-up), but not significantly more than TAU. Prevalence of barriers to HIV testing were observed at consistent rates among adolescents who did not get tested for HIV within either treatment condition. Adolescents in both conditions reported increased communication about HIV at follow-up. HIV testing was positively associated with perceived need for testing and testing resource accessibility. Stigma remained a barrier to testing at follow-up for RRTA (22%) and TAU (21%) participants. The RRTA intervention increased HIV testing and both interventions increased adolescents' communication about HIV; however, barriers persisted, warranting treatment modification.

Association of Mental Health Symptoms and Peer Behaviors with Risk for Substance Use and Condomless Sex among Youth in Juvenile Drug Court.

Juvenile drug courts are a growing response to adolescent substance use, but a better understanding of modifiable risk factors is needed to improve program outcomes. Youth's mental health symptoms and peers' activities may impede the effectiveness of these "therapeutic" courts. In a unique longitudinal sample of 105 adolescents involved in juvenile drug court, we find elevated internalizing symptoms and deviant behavior of peers were each associated with increased risk of alcohol and marijuana use. Similar effects were seen on risk for condomless sex. Mental health and peer behaviors should be intervention targets for evidence-based juvenile drug court programming.

Evidence-Based Treatments for Youths Who Engage in Illegal Sexual Behaviors.

Effective treatments for youths who have engaged in illegal sexual behaviors are needed to reduce the societal impact of sexual crimes. This article reviews the state of the evidence base for treatments that target this clinical population. We conducted a comprehensive literature review to identify studies that evaluated outcomes of treatments for youths who have engaged in illegal sexual behaviors. Based on the results of our review, we characterized each treatment using established criteria for five evidence-based treatment classifications. We identified 10 treatment studies that met inclusion criteria. We classified one treatment-multisystemic therapy for problem sexual behaviors-as Probably Efficacious (Level 2), and two treatments-cognitive-behavioral therapy and behavior management through adventure-as Experimental (Level 4). Cognitive-behavioral therapy has limited research support with youths who have engaged in illegal sexual behaviors, but it is widely used in the United States and Canada. In contrast, multisystemic therapy for problem sexual behaviors had the highest level of research support but is used much less extensively with this population. We discuss implications of the present findings for treatment providers, policymakers, and researchers who seek to improve clinical services in this area.

Parent and Youth Engagement in Court-Mandated Substance Use Disorder Treatment.

While juvenile drug courts (JDCs) require treatment participation, youth and parent engagement in treatment cannot be mandated. We compared youths' and parents' self-reports of engagement in Risk Reduction Therapy for Adolescents (RRTA) and Treatment as Usual (TAU) in JDCs. Parents and youth receiving RRTA were more likely than those receiving TAU to report high engagement in treatment. High parent engagement in RRTA early in treatment predicted fewer missed appointments and lower youth substance use at 3 months. Emphasizing therapeutic techniques that increase parent engagement, as utilized in RRTA, could lead to improved participation and clinical outcomes in court-mandated treatment settings.

Collateral Consequences of Juvenile Sex Offender Registration and Notification: Results From a Survey of Treatment Providers.

Among many in the research, policy, and practice communities, the application of sex offender registration and notification (SORN) to juveniles who sexually offend (JSO) has raised ongoing concerns regarding the potential collateral impacts on youths' social, mental health, and academic adjustment. To date, however, no published research has systematically examined these types of collateral consequences of juvenile SORN. Based on a survey of a national sample of treatment providers in the United States, this study investigates the perceived impact of registration and notification on JSO across five key domains: mental health, harassment and unfair treatment, school problems, living instability, and risk of reoffending. Results indicate that treatment providers overwhelmingly perceive negative consequences associated with registration with an incremental effect of notification indicating even greater concern across all five domains. Providers' demographics, treatment modalities, and client profile did not influence their perceptions of the collateral consequences suggesting that provider concern about the potential harm of SORN applied to juveniles is robust. Policy implications are discussed.

Commercial sexual exploitation of children and the emergence of safe harbor legislation: implications for policy and practice.

Commercial sexual exploitation of children is an enduring social problem that has recently become the focus of numerous legislative initiatives. In particular, recent federal- and state-level legislation have sought to reclassify youth involved in commercial sexual exploitation as victims rather than as offenders. So-called Safe Harbor laws have been developed and centered on decriminalization of "juvenile prostitution." In addition to or instead of decriminalization, Safe Harbor policies also include diversion, law enforcement training, and increased penalties for adults seeking sexual contact with minors. The purpose of this paper is to review the underlying rationale of Safe Harbor laws, examine specific policy responses currently enacted by the states, and consider the effects of policy variations. Directions for future research and policy are addressed.

Parent-Focused Prevention of Child Sexual Abuse.

Child sexual abuse (CSA) is a serious public health issue. Current after-the-fact approaches to treating victims and punishing offenders are not adequate to address a problem of this magnitude; development and rigorous evaluation of CSA prevention strategies are critical. We propose that CSA prevention efforts should target parents of young children. Parents have been neglected as a focus of CSA prevention; they merit attention given their potential to improve children's safety via effective communication and monitoring. This paper provides an overview of current strategies for reducing CSA prevalence and their limitations, presents a rationale for parent-focused CSA prevention, and discusses considerations pertinent to development of an effective parent-focused approach. Parent-focused CSA prevention offers potential as a public health approach to prevention of CSA, and it is time that we devote resources toward developing and studying this important area.

ADHD and risky sexual behavior in adolescents: conduct problems and substance use as mediators of risk.

BACKGROUND: Recent studies have linked attention-deficit/hyperactivity disorder (ADHD) to elevated rates of risky sexual behavior (RSB) in adult samples. The current study tested whether ADHD symptoms were associated with RSB among adolescents, and examined comorbid conduct problems and problematic substance use as joint mediators of this association. METHODS: ADHD symptoms, conduct problems (oppositional defiant disorder/conduct disorder symptoms), problematic alcohol use (alcohol use disorder symptoms, alcohol use frequency), problematic marijuana use (marijuana use disorder symptoms, marijuana use frequency), and RSB were assessed among an ethnically diverse cross-sectional sample of adolescents (N = 115; mean age = 14.9 years) involved in the juvenile justice system. RESULTS: Bootstrapped mediation models revealed an initial association between ADHD symptoms and RSB that was accounted for fully by the influence of problematic alcohol and marijuana use, but not conduct problems. A follow-up multiple groups mediation analysis demonstrated that the relationship between ADHD symptoms and RSB emerged only among youth with clinically elevated conduct problems, and that problematic marijuana use fully accounted for this relationship. Hyperactive/impulsive, but not inattentive, symptoms were related to RSB, although the pattern of indirect effects was consistent with the multiple groups analysis. CONCLUSIONS: The association between ADHD and adolescent RSB is restricted to youth with elevated comorbid conduct problems and reflects the contributions of comorbid marijuana use problems, and to a lesser extent alcohol use problems. Early identification and treatment of these comorbid conditions may be important for the prevention of negative sexual health outcomes among youth with ADHD.

Keep testing the waters: Fanniff and Letourneau reply.

Hecker raises a number of important considerations in interpreting the review of literature and empirical research presented in Fanniff and Letourneau's article "Another Piece of the Puzzle: Psychometric Properties of the J-SOAP-II." Despite these considerations and the publication of new research in the interim, the current authors continue to urge caution in the interpretation of Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) scores in disposition evaluations, largely due to the serious consequences that youth face in this context.

Risk Reduction Therapy for Adolescents: Targeting Substance Use and HIV/STI-Risk Behaviors.

This paper describes a family-based intervention for addressing both substance use and unprotected sexual behavior in adolescents presenting for outpatient substance use treatment. The intervention combines contingency management (CM) for adolescent substance use, which is a behavioral intervention modeled on the Community Reinforcement Approach, with a sexual risk reduction protocol that mirrors aspects of the CM model. As a family-based intervention, caregivers attend every session and actively collaborate with the therapist to address their youth's behavior problems. The treatment is criterion-based with treatment duration determined by the youth's achievement of reduced substance use and unprotected sexual behavior goals. A case study describes the implementation of this treatment with an adolescent presenting a history of polysubstance use and unprotected sexual intercourse. Following the adolescent and caregiver's participation in weekly sessions, the adolescent demonstrated improvements in substance use, unprotected sexual behavior, and other behavior problems. Clinical summary data from two outpatient clinics reveal similar positive outcomes for youth receiving the intervention. This paper illustrates the potential utility of an integrated treatment approach targeting substance use and unprotected sexual behavior in an adolescent population.

Responsible Behavior With Younger Children: Results From a Pilot Randomized Evaluation of a School-Based Child Sexual Abuse Perpetration Prevention Program.

Many efforts to prevent child sexual abuse (CSA) aim to teach children strategies for recognizing, resisting, and reporting victimization. There is limited evidence that victimization-focused efforts actually prevent CSA. Moreover, these efforts often overlook the fact that many children and adolescents engage in problem sexual behavior against younger children. Responsible Behavior with Younger Children (RBYC) is a novel universal school-based perpetration-focused intervention that aims to prevent the onset of inappropriate, harmful, or illegal sexual behavior by adolescents against younger children.1 Responsible behavior with younger children was designed to provide adolescents and their parents with the knowledge and tools to help adolescents interact appropriately with younger children and avoid CSA behaviors. In this paper we describe intervention development, summarize lessons learned from implementing RBYC in four urban schools, and report results from our pilot randomized waitlist-controlled trial (RCT) with 160 6th and 7th grade students. Results indicate RBYC was associated with increased accuracy in youth knowledge about CSA and CSA-related laws, and with increased behavioral intention to avoid or prevent CSA with younger children and peer sexual harassment. Although the sample was small and the effects were relatively modest, the findings do suggest that RBYC holds promise for preventing the onset of problem sexual behavior.