final- sexual behavior

Interventions for Inappropriate Sexual Behavior (ISB) in Individuals with Intellectual and Developmental Disabilities (IDDs)

Introduction

Individuals with intellectual or developmental disabilities (IDDs) may exhibit inappropriate sexual behavior (ISB), ranging from public masturbation to sexually aggressive acts. Prevalence rates estimate that 6% to 28% of individuals with IDDs engage in ISB. Such behaviors can lead to negative social consequences, restricted community access, barriers to independence, involvement with the criminal justice system, and counter-therapeutic outcomes.

This note reviews recent, effective behavior-analytic treatments for ISB in individuals with IDDs, while also addressing ethical considerations and suggesting areas for future research. This extends the work of Davis et al. (2016) by including contemporary studies on differential reinforcement and self-management procedures, while also adding relevant information pertaining to the assessment of ISB.

Defining Inappropriate Sexual Behavior (ISB)

ISB is defined as sexual behavior that is developmentally and socially inappropriate or potentially harmful or distressing to others (Tarren-Sweeney, 2008). Examples include: nonconsensual sexual contact, public masturbation, removing clothes in public, looking down others’ shirts or up skirts, sexual behavior with inappropriate objects, and sexually explicit talk.

Prevalence estimates suggest that many forms of ISB, such as removing clothing in public, masturbating in public, or other inappropriate touching, are relatively common, occurring in 18%-28% of individuals with IDDs (Ruble & Dalrymple, 1993). These behaviors increase the risk of involvement with the criminal justice system and can lead to negative social consequences, restricted community access, and barriers to independence (Hutchinson et al., 2012).

Differential Reinforcement Interventions

Differential reinforcement interventions may include differential reinforcement of alternative behavior (DRA) or differential reinforcement of other behavior (DRO). These reinforcement-based procedures can be combined with punishment procedures, such as response cost, response blocking, or overcorrection.

Examples of Differential Reinforcement

  • LeBlanc et al. (2000): Used a DRO token economy with response cost to decrease ISB (touching genitals over clothing) in a 26-year-old male with an intellectual disability. While effective, the necessity of the response cost component was not determined.

  • Dufrene et al. (2005): Assessed DRA alone and DRA with punishment (response blocking and guided compliance for a handwriting task) to decrease public masturbatory behavior in a 7-year-old female with an intellectual disability. DRA alone was ineffective, but DRA with punishment decreased the behavior.

  • Pritchard et al. (2018): Successfully used a DRA token economy (without punishment) to decrease severe ISB for five of six teenagers with IDD.

  • Fyffe et al. (2004): Used functional communication training (FCT) and extinction to reduce ISB (touching others’ private areas) maintained by adult attention with a 9-year-old male with traumatic brain injury, and increased an appropriate communicative response for attention (handing an “attention” card to an experimenter).

Response Interruption/Time-Out (RI/TO)

More recent research suggests that punishment procedures in the absence of differential reinforcement may also effectively reduce ISB. For example, during response-interruption/time-out (RI/TO), the therapist or caregiver physically interrupts the initiation of ISB and implements a brief time-out.

  • Dozier et al. (2011): Used RI/TO with an adult male diagnosed with autism and a profound intellectual disability to decrease inappropriate masturbatory behavior (flopping to a prone position near other’s feet and grinding his pelvis on the floor). The therapist interrupted masturbatory behavior by pulling up on the backpack straps and implemented a 1-min time-out. RI/TO eliminated the client’s inappropriate sexual behavior and the backpack was systematically faded.

Self-Management

Few recent studies have assessed the ability of individuals with IDDs to suppress inappropriate sexual arousal. However, several self-management tactics have been examined within the literature, such as:

  • Bringing sexual arousal under instructional control.

  • Engaging in tasks or activities which compete with arousal (i.e., counting backwards).

  • Altering relevant establishing operations which decrease sexual arousal.

Examples of Self-Management Strategies

  • Reyes et al. (2011): Evaluated self-management strategies during conditions in which either neutral or evocative visual stimuli were shown to two adult male sex offenders with IDDs. Therapists instructed participants to inhibit their arousal without providing any specific suppression instructions. If participants did not suppress arousal, therapists instructed them to vocally count backwards from 100. One participant suppressed arousal towards the evocative stimuli using instructional control, and the other participant successfully used a combination of instructional control and backwards counting.

  • Walker et al. (2014): Replicated Reyes et al., demonstrating that offenders with IDDs may be able to differentially suppress arousal in the presence of appropriate (adult) and inappropriate (child) visual stimuli.

  • Brogan et al. (2020): Replicated and extended the procedures used by Reyes et al., demonstrating the generality and clinical utility of these procedures with adjudicated adolescents.

Presession Masturbation

Reyes et al. (2011) examined the effect of presession masturbation as an abolishing operation for sexual arousal. Masturbation decreased subsequent arousal to deviant stimuli, suggesting masturbation may decrease arousal levels in situations where an establishing operation for inappropriate sexual behavior is typically present. Self-management procedures may be enhanced by teaching individuals with IDDs to masturbate prior to engaging in activities or entering situations that are typically arousing. Individuals may learn to inhibit or manage their arousal by counting backwards, they may also learn to engage in appropriate sexual behavior as an antecedent strategy to reduce subsequent arousal.

Ethical Issues and Future Research

Issues related to sexuality and sexual behavior problems are generally considered taboo, which may explain the limited research on treatment of ISB among individuals with IDDs. Researchers and clinicians face the difficult task of identifying and assessing topographies of ISB (with a primary focus on dangerous or socially unacceptable topographies), decreasing ISB through evidence-based behavioral interventions, and promoting contextually appropriate, healthy sexual behavior while fully balancing clients’ habilitative goals and rights to privacy and autonomy.

Parents and caregivers may lack the prerequisite skills to provide adequate sex education to individuals with IDDs without specific training, education, or support (Kok & Akyuz, 2015). Parents should receive education and training on appropriate supervision strategies (e.g., no unsupervised contact with young children or at-risk persons) for individuals with ISB. Individuals with IDDs may also benefit from training in which they learn to differentially respond to situations in which engaging in sexual behavior is (e.g., private area) and is not (e.g., public area) appropriate. Behavioral skills training could be useful to teach relevant interpersonal and sexual skills (e.g., appropriate courtship behavior and obtaining consent) for individuals with IDDs and ISB (e.g., Sala et al., 2019). These social skills interventions may be implemented alone or be adjunctive components of comprehensive treatment packages targeting ISB—regardless, such skills are likely crucial for promoting generalization and continued maintenance of treatment effects and facilitating appropriate social interactions with others.

Assessment Techniques

Prior to intervention, clinicians should use evidence-based assessment techniques when possible to identify eliciting stimuli, contextual conditions, or consequent events associated with the occurrence of ISB. Such procedures might include:

  • Antecedent-only functional analyses (Dozier et al., 2011)

  • Precursor functional analyses (e.g., Najdowski et al., 2008)

  • Functional analyses with extended no-interaction conditions (Querim et al., 2013)

  • Traditional consequent-based functional analyses (Fyffe et al., 2004).

In clinical contexts in which such assessments cannot be conducted, a combination of direct and indirect assessment measures or clinical inventories (e.g., Child Sexual Behavior Inventory; Friedrich, 1997) may suggest potential contextual variables associated with the occurrence of ISB. Future research should identify and compare different assessment procedures for ISB which yield clinically meaningful data, are feasible to implement, and are minimally intrusive.

Measurement Challenges

Accurate measurement and data collection for ISB may be particularly challenging given:

  • Ethical considerations and constraints due to the private, socially conspicuous nature of sexual behavior.

  • The intrusiveness and social acceptability of data measurement and collection procedures.

  • Measurement difficulties associated with discrete and/or potentially covert behaviors.

Any measurement techniques used during assessment and treatment procedures should yield data which accurately reflect and quantify the behavioral products of ISB during assessment and/or treatment. To the extent that we develop behavior-analytic technologies that accomplish this measurement goal (and can be adopted programmatically; Brogan et al., 2018) while simultaneously maximizing our clients’ privacy and autonomy, we advance the science of human behavior in a manner consistent with the goals and values of applied behavior analysis.

Future research should evaluate factors that may moderate the effectiveness of these interventions, such as:

  • Topography of the behavior (e.g., self-stimulation, person-directed).

  • Severity of the behavior.

  • Treatment fidelity issues (e.g., intermittent reinforcement during extinction, addressing covert behaviors).

For example, automatically maintained self-stimulatory ISB (as opposed to socially maintained, person-directed ISB) may be more difficult to assess and modify as it may be more likely to occur discretely/privately, may not reliably be occasioned by stimulus changes in the environment, and produce intermittent reinforcement.

Self-management procedures warrant additional examination, as the putative behavioral mechanisms that underlie these procedures are largely unknown. Moreover, the boundaries of the generality for these strategies must be examined (i.e., under what conditions, and for whom, do self-management procedures work or not work? what behavioral repertoires are needed for these strategies to be effective?).

Ultimately, future research and clinical attention within these domains will serve to decrease inappropriate sexual behavior and support safe sexual practices to promote safety, autonomy, and quality of life for individuals with IDDs.