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The following article is based on research conducted on a sample of sexually assaultive children and adolescents between the ages of 6 and 17 at the Maryland Institute in College Park, Maryland . In this sample, which was evaluated over a five year period, 81% of the subjects were determined to have a prior or current diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). This incidence was found to be significantly greater than an 18% base rate diagnosis for all children and adolescents evaluated at the same location during the same time period, and the 5% base rate incidence of ADHD that has been consistently reported for the general population.

Background

The existing research on juvenile and adult sexual offenders has identified several factors that are positively correlated with sexual aggression and assault. These include (1) a history of sexual or other abuse to the offender (Barnard et al., 1985; Finkelhor, 1988; Freeman-Longo, 1985; Groth, 1979; Langevin,Wright & Handy, 1989; Petrovich & Templer, 1984; Pierce & Pierce, 1987; Seghorn et al., 1987; Smith, 1988), (2) a history of family dysfunction (Monastersky & Smith, 1985; Lewis et al., 1985; Smith, 1988), (3) deficits in the offender's personality, particularly in social and interpersonal competence (Blaske et al., 1989; Fehrenbach, et al., 1986; Figia, et al., 1987; Groth, 1977), (4) previous exposure to pornography and/or sexual violence (Becker & Stein, 1991; Candeon & Nutter, 1988; Carter et al., 1987; Ford & Linney, 1995; Pynoos & Nader, 1988), and (5) the offender's use of "cognitive distortions", i.e.. distortions in thinking and feeling that facilitate the sexually aggressive behavior (Hayashino, et. al., 1995). While some studies have noted the frequent presence of long-standing learning problems in sexual offender populations (Awad & Saunders, 1991; Lewis, et al., 1979; Pierce & Pierce, 1987; Tarter et al., 1983), almost none has described the possible role of Attention Deficit Hyperactivity Disorder (ADHD or ADD) in childhood sexual aggression, and none has specifically studied this relationship. Moreover, a recently published literature review (Hall & Barongan, 1997) of the causes of sexual aggression actually minimizes the importance of childhood learning problems or neurodevelopmental deficits as contributory factors to sexual aggression. Nevertheless, children and adolescents with ADHD are of special interest in this regard because (a) such youngsters frequently display co&endash;morbid antisocial-spectrum disorders (Hinshaw, 1987; Lynam, 1996), exceeding 50% in many samples (Biederman, Newcorn & Sprich, 1991), and (b) ADHD is, by itself, a strong predictor of delinquency and conduct disorders in adolescence and adulthood (Klein & Manuzza, 1991). The possible role of ADHD in sexual aggression is implicated further by a body of anecdotal, clinical information that associates ADHD in adulthood with episodes of hypersexuality and inappropriate sexual acting-out (Hallowell & Ratey, 1994). At the same time, Friedrich (1994), in research with the Child Sexual Behavior Inventory, has found that parents more frequently report "problems of interpersonal boundaries and increased masturbation" in their children with ADHD.

 

ADHD: A Neurodevelopmental Disorder

 

Of the three features identified as hallmarks of ADHD (impulsivity, distractibility/attention deficits, and hyperactivity; See APA, 1994 and Connors, 1994), impulsivity is thought to be the significant catalyst to antisocial behavior in the ADHD population (Hinshaw et al., 1995; White, et al., 1994). Recent brain-imaging studies (Zametkin, et al., 1990, 1993) have used positron emission tomography (PET) to establish a clear neurobiological process in ADHD. In these studies PET has been used to evaluate brain metabolism in children and adults with ADHD, with a finding of pronounced metabolic imbalance or insufficiency in crucial brain areas of subjects diagnosed with ADHD. One prominent theory (Barkley, 1994) states that the metabolic instability observed in ADHD leads to a problem of "inhibitory capacity", that is, a failure in the child's or adult's ability to inhibit behaviors, thoughts, actions, and emotions. As Hallowell & Ratey (1994) have described:

 

The social intrusiveness that is so characteristic of those who have ADD is the inability to stop at the other's boundaries. The failure to form intimate relationships is the inability to pause long enough even to listen to the other person, let alone to understand and respect the other's needs. The impulsivity, the lack of planning, and the outbursts [of emotion] are the inability to restrain the flow of action and feeling (p. 282) .

 

Children and adolescents with ADHD are known for their tendency to act impulsively, without considering possible outcomes or consequences, and without weighing the needs or feelings of others. This proclivity results in seemingly endless interpersonal wrangles for the ADHD child, as evidenced by frequent conflicts with family and at school. Later, in adulthood, these conflicts will often emerge with marital partners, employers and legal authorities.

 

 

Theoretical Considerations

 

A possible etiological pathway between ADHD and the emergence of sexually aggressive and assaultive behaviors is intuitively compelling for several reasons. First, many children, adolescents and adults with ADHD and co-morbid conduct disorders share multiple characteristics with individuals who commit sexual aggression; these include (1) a frequent lack of interpersonal sensitivity and empathy, more generally demonstrated by emotional immaturity, (2) a vulnerability to chemical dependency and addictive behavior, (3) an attraction to dangerous, high- stimulation and high-risk behavior, (4) a tendency, in some, toward hypersexuality, and (5) a difficulty or deficit in imposing limits, structure and direction on their own behavior. The presence of ADHD may also explain the occurrence of sexual acting-out in children who have never been abused - sexually or otherwise - and have not been exposed to sexual violence or severe family dysfunction. ADHD, when coupled with exposure to sexual stimulation, may be sufficient to evoke an imitative response that results in sexual aggression and misconduct in young children. Youngsters with ADHD are well-known for impulsively reenacting dangerous and highly stimulating behavior that they have observed elsewhere. Although impulsivity may be instrumental to a child's initial forays into sexual misconduct, particularly when other traumatic influences are absent, it is not likely to be the factor that propels this sexual behavior into a lifelong, adulthood pattern. In fact, impulsivity may be a key variable in differentiating episodic, thoughtless acting-out from calculated, remorseless psychopathy (Hinshaw, 1994). This formulation also is consistent with Groth's (1982) original distinction between chronic, "fixated" pedophiles (who are known to carefully plan their offenses and "groom" their victims) and the more episodic, "regressed" offender, who seems more often to be driven by thoughtless or unconscious impulses. What may be necessary for impulsive episodes to develop into chronic patterns of planned behavior is the co-morbid presence of interpersonal and social deficits, referred to by some as a deficit in "emotional intelligence" (Goleman, 1995). If a child or adolescent is severely lacking in interpersonal and emotional understanding and skills, it is unlikely that more appropriate and mature forms of sexual expression will be developed. Instead, it may be more likely that existing forms of sexual expression - however primitive or maladaptive - will become fixed. It is therefore also useful to note the well-established finding that some children with ADHD also have major deficits in social skills and in processing social information (Moffett, 1990; Milrich & Dodge, 1984). It is certainly reasonable that such deficits, if not ameliorated, could contribute to lifelong problems with sexual intimacy and healthy sexual expression. In fact, the presence of cognitive deficits associated with the processing of social and emotional information may be instrumental to the creation of "cognitive distortions" that maintain a chronic pattern of sexual misconduct. Hence, children with ADHD, by virtue of their impulsivity, may be more vulnerable to reenacting inappropriate sexual behavior during childhood and adolescence, and may be more likely to continue this antisocial behavior into adulthood when they also lack the cognitive skills essential to their social and emotional development. In fact, this paradigm is particularly congruent with existing research which has shown that children with both ADHD and verbal learning disabilities/ social skill deficits present a more serious risk for sustaining their antisocial behavior through adolescence and into adulthood (Moffett, 1990).

 

 

Implications for Evaluation and Treatment

 

Because sexually aggressive and assaultive behavior in children and adolescents may be symptomatic of a more fundamental attention-deficit hyperactivity disorder, it may be essential that clinical evaluations of child and adolescent sexual offenders also include screenings for ADHD. Presently, many professionals who perform offender evaluations are not trained in the evaluation and treatment of ADHD, and may lack an understanding of the disorder's potential contribution to the child's sexual aggression, as well as its' implications for the child's long-term adjustment and predisposition to antisocial behavior. Without adequate evaluation, a significant component of these children's' behavioral difficulties could go undetected, resulting in insufficient treatment and enhanced risk of continued anti-social behavior.

 

When ADHD is detected in sexually aggressive children, it is imperative that it be treated clinically, using the same comprehensive strategies that are indicated for attention-deficit disorders in general. These strategies generally include (1) various school interventions, (2) parent education and training, (3) individual and/or group counseling for the child, (4) cognitive training strategies, and (5) medication, most commonly a CNS stimulant, antidepressant, or other mood stabilizer. Education and counseling for the child and family are typically included in offender treatment, as is some type of cognitive retraining. These interventions can be easily supplemented to include information and counseling related to ADHD. Also, it may be important for clinicians to recognize ADHD's potentially profound effect on academic performance, and its subsequent influence on long-term social and emotional adjustment. These effects may require clinicians to act as advocates at school and with teachers, to ensure that the child receives all of the academic services and supports that are appropriate and necessary for the child's success. Finally, the important role of medication must not be overlooked. Although considerable misinformation and misunderstanding about drug treatment for ADHD persistently appears in the media, a sizable body of research (see for example Hinshaw, et al., 1989) has demonstrated the significant positive effects of stimulant medication on multiple target symptoms of ADHD, including aggressive behavior. Hence, it is also important for clinicians to be familiar with the various pharmaceutical treatments for ADHD and to be able to consult with pediatricians and psychiatric physicians concerning the sexually aggressive child's medication needs. In short, it may become essential for clinicians to broaden their assessment and treatment repertoire so they can provide truly comprehensive and effective services for sexually aggressive and assaultive children and their families.

 

References

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