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Case Study: Borderline Intellectual Functioning

Using said scenario students will respond to questions below in a minimum of 10 pages and maximum of 20 pages.

1. A robust description (APA format) of what are the key social, ethical, medical and psychological issues presenting in case scenario.

2. Assuming the role of the mental health professional outline what assessment tools would you use or recommend be used at this intercept of youth involvement in juvenile justice (in detention).

3. A brief description of what interventions, programs and services would be recommended for youth during detention as well as longer term recommendations that may be considered after detention stay.

4. Reflection on how the existing literature might be applied in practice (i.e., the clinical implications of the existing literature for child and adolescent forensic evaluations)

Case Scenario: 16 year old male detained on charges of sexual assault; incident: 16 YO is in inclusion class at his public school (based on his Individualized Education Plan which indicates borderline intellectual functioning along with other social and cognitive deficits). Student took hall pass to go to bathroom and while in bathroom sexual assaulted another male student a 14 year old male. Sexual assault (predominately voyeurism and intention to engage in petting/oral copulation) was interrupted by school staff person who immediately removed 14 year old and in verbally addressing 16 year old to get dressed and report to administrative office 16 year old attempted to charge staff and while staff was able to use approved physical tactics to contain 16 year old  staff did incur minor injuries (bruises mainly) until other staff responded and were able to support  during entire physical altercation with staff, while waiting for police to arrive, and during entire transport to juvenile detention facility 16 year old youth screamed, yelled and at times cried. Upon arrival at juvenile detention facility youth refused to answer basic safety questions (used in standard admission assessment to asses level of risk and inform placement & monitoring) including risk assessment for suicide, danger to others, and ability to perform independent living skills. Therefore, youth was placed on both suicide prevention monitoring (which restricted access to dangerous items and required 15 minute interval monitoring by staff 24/7) and was also placed on youth-contact restriction (youth was placed in staff office area to restrict contact with youth, but this facility does not have procedures or facility to isolate youth entirely.

When mental health professional arrives next day  staff advises that youth spent most of the night crying, yelling and at times sleeping, but no longer engaged in any physical or verbal aggression toward staff. When mental health professional attempted to contact family  staff advised that family has advised they do not wish to be contacted and are seeking guidance from Human Services/Social Services as they are concerned about youths risk toward other children in the home. Staff advises mental health professional that this is youths 2nd charge since age of 14 of sexual assault on a minor  no other details are available at this time. State of Colorado allows youth to consent at age of 15  staff is able to gain consent, and releases of information for family, public defender, juvenile detention center, school, and psychiatrist who has been seeing youth in community. Upon contact with psychiatrist mental health professional learns that youth began seeing psychiatrist after 1st sexual assault and was also at that time court ordered but positive engaged in sex offender treatment. This first assault was also the impetus that lead to psychological testing which indicated borderline intellectual functioning (rule out of fetal alcohol syndrome), Major Depressive Disorder, mild, recurrent, and significant impairment on Axis Four. Psychologist at that time recommended a psycho-sexual evaluation but psychiatrist and school were unable to find a copy of that evaluation on file and agency that provided that evaluation is no longer in business. Psychiatrist advises he has trialed youth on a few different types of mood stabilizers, anti-depressants and at times based on presenting symptoms of frustration & poor sleep brief trials on anti-anxiety but those prescriptions resulted in increased paranoia and aggression. Psychiatrist stated that anti-depressants appeared to have most positive benefit but he questioned family/youths ability to take prescriptions consistently as prescribed.

Introduction

The case indicates that sixteen-year-old is exhibiting extreme symptoms of a patient with borderline intellectual functioning (BIF). BIF is an intelligence categorization where individuals in the group have an intelligence quotient (IQ) of between 71 and 84, with individuals in this group exhibiting academic, social or vocational challenges (Esposito & Carotenuto, 2014). In the case, the unidentified youth has already been diagnosed with BIF and placed in an inclusion class at a public school. However, the youth is caught in the act of sexually assaulting a minor by a staff leading to a physical altercation between the staff and the youth. It is at the juvenile detention facility that a lot of details concerning the youth come into light including a past incidence of sexual assault against a minor. Moreover, the behavior of the youth when caught in the act of sexually assaulting a minor provides clinical symptoms that are essential in carrying out an assessment of the youth’s mental challenges.

This paper attempts to highlight the social, ethical, medical, and psychological issues presented in the case. Secondly, the paper will outline assessment tools recommended for the case. Thirdly, the paper will provide interventions, programs and services applicable to the youth under study. Finally, the paper reflects on the existing literature that applies to practice.

Social, Ethical, Medical and Psychological Issues Presenting in the Scenario

The social issues presented, in this case, are both behavioral and emotional. The youth is acting aggressively by attempting to fight a staff that is highly likely older and stronger than him. It takes the support of other colleagues to subdue the youth. Moreover, the youth sexually assaults a 14-year-old though voyeurism and potential oral copulation. The two examples indicate that the youth does not possess competence in certain social skills, especially those that pertain to interpersonal interaction. The youth likely used coercion to subdue his victim and based on past incidences, considers other youths as potential victims. Incompetence in social skills is brought out by the manner he reacts after getting caught in the act. He is violent and aggressive during the entire period that the staff tries to separate him from the victim. This provides an indication that the youth has a problem of remaining calm when criticized or prevented from achieving his goals. Emotionally, the youth portrays signs of anxiety as indicated by his behavior throughout the journey to the juvenile detention facility. He is crying, yelling, and screaming indicating his emotional instability. These characteristics are in harmony of attributes of adolescents with BIF since they normally exhibit emotional, behavioral and cognitive challenges (Nestler & Goldbeck, 2011).

The case presents some ethical considerations involving both offender and victim of the sexual assault committed in the case scenario. The first ethical issue is why an individual who has a sexual assault history was allowed to study in a public school that has students of all ages putting them at grave risk of assault the perpetrator. The second ethical issue is whether the administration of the public school has information about the youth’s history with regards to sexual assault. The third ethical issue is whether an individual who has gone through sexual offender treatment requires alienation from the community and whether that separation is ethical. The fourth ethical issue is whether it is ethical to deny an under-aged youth the right to education regardless of his past actions. The fifth ethical issue is whether the youth should undergo further sexual offend treatment or he needs a detention in a juvenile facility. The scenario presents a difficult situation to satisfy all parties, but it is recommended for mental health professionals to uphold the principles of beneficence and non-maleficence where they should do good and avoid harm at all times (Sarkar, 2013).

The case scenario presents medical concerns affecting the perpetrator of sexual offender and the victim considering that they are still minors. The victim requires intensive medical therapy to overcome the trauma of sexual assault experience. The 14-year-old boy may experience both short-term and long-term effects of the traumatic event ranging from losing self-esteem, poor academic performance to anxiety-related self-destructive behavior such as drug abuse. On the other hand, it is important that the perpetrator undergoes further sexual offender treatment to prevent the risk of him perpetrating such offenses in future. However, some analysts have criticized sexual offender treatment arguing that instead of having long-term benefits to the offender and community, the treatment increases the risk of recidivism while putting society at great risk of sexual violence (Bonnar-Kidd, 2010).

Psychological issues explicitly manifest in the case scenario with several symptoms from the youth indicating signs of anxiety and anger management challenges. The physical and verbal confrontation that the youth engages with staff members shows an individual unable to manage his anger. He is very angry because his actions are known and he expresses his anger first through physical aggression towards the staff that caught him in the act. The individual is very anxious and possibly depressed with the thought of facing detention in a juvenile facility. This anxiety is expressed through yelling, crying, and screaming. Additionally, the youth takes long to calm down considering that second day after spending the night in the facility. Reports indicate that the youth was still yelling and crying for most of the night albeit did not engage in any aggression toward staff. According to Alesi, Rappo & Pepi (2015), school children with BIF exhibit signs of anxiety, depression, and insecurity.

Recommended Assessment Tools

Admission of a juvenile into a detention facility incorporates risk assessment procedures that guide the facility on whether there is a need to put in place certain interventions aimed at reducing the risk of the juvenile harming self or others. The assessment includes taking cognizant of the likelihood of the juvenile continuing with his/her delinquent behaviors while still in the facility. In addition, mental health professionals should assess what areas in the juvenile should be targeted to reduce the risk of reoffending (Vincent, Guy & Grisso, 2012). It is clear from the case that no standard admission assessment was conducted on the youth as he frustrated the process by refusing to answer any basic safety questions. Consequently, staffs at the facility were unable to assess the youth’s level of risk to cause harm to self or others within the facility. The short-term strategy employed by the facility was to place the aggressive youth on both suicide prevention monitoring and the youth-contact restriction. However, since there was no any meaningful assessment conducted on the youth, there is a need to devise assessment tools that will provide long-term solutions to the prevailing situation.

A normative belief about aggression tool is an effective assessment tool applicable to the case scenario. The tool measures perception of a child, adolescent or youth on the level of acceptability towards aggressive behavior based on varying provocation conditions and unspecified conditions (Dahlberg, Toal, Swahn & Behrens, 2005). The assessment tool is easy to use and flexible since it is convenient to administer to individuals or groups. Furthermore, the use of the tool does not accrue any cost whatsoever. The respondents are only asked to choose an option out of several choices that are applicable to their ideas or experience. The tool has twenty constructs or questions that ultimately provide an indicator of the respondent’s self-control or impulsivity through a self-report questionnaire. The youth in the case needs time to calm down before subjecting him to the assessment. Once he cools, the assessment can be administered to him and retrieved data used to guide placement and monitoring procedures.

The normative belief about aggression tool has four grading scales that are used to measure general approval aggression and approval of retaliation. Grade four is “perfectly OK”, Grade three “OK”, Grade two “wrong”, and grade one “really wrong (Dahlberg, Toal, Swahn & Behrens, 2005). A grade four in the first subset indicates that the respondent is highly likely to aggress against others since it is acceptable to him/her. On the other hand, a grade one indicates that the respondent has a low risk of being aggressive towards others since it is unacceptable to him. In the second subset, a grade four indicates that the respondent will most likely retaliate back aggressively on provocation since it is acceptable to him/her to aggress against others when provoked. On the other hand, a grade one indicates that the respondent will least likely retaliate back upon provocation since to he/she is unacceptable to aggress against others upon provocation.

The youth in the case scenario exhibits violent conduct as shown by his involvement in a physical altercation with school staff. Therefore, an assessment tool that measures the violent behavior of a respondent is important in this case. The best assessment tool for the violent conduct is beliefs about aggression scale that is useful when measuring aggression in young adolescents with the intention of reducing violence (Meek, 2013). The grading of this tool is almost similar to normative belief about aggression with grade four indicating “strongly agree”, grade three “agree”, grade two “disagree”, and grade one “strongly disagree.” For one to ascertain the level of aggression of the respondent, the scores are usually summed up and divided by the number of items. Higher scores indicate that the respondent has more beliefs supporting aggressive behavior.

The third recommendable assessment tool for this case scenario is the attitude toward violence assessment tool. The tool measures a respondent’s attitude towards violence and whether they believe violence is acceptable, especially in relations to fighting. The tool has six questions that respondents are required to answer on whether they agree (strongly or somewhat) or disagree (strongly or somewhat) with violent behavior (Junger-Tas et al., 2011). The assessment tool has five grades; namely, grade five (strongly agree), grade four (agree), grade three (neither), grade two (disagree), and grade one (strongly agree). A respondent with high scores indicates that he/she has a positive attitude towards violent behavior thus has a high risk of choosing violent options. While the first two assessment tools were largely on aggression, this particular tool specifically focuses on violent conduct thus it would be very applicable to the youth in the case scenario.

Interventions, Programs, and Services

The biggest challenge in juvenile delinquency justice system is coming up with effective intervention measures that are critical in reducing or minimizing recidivism. Reports indicate that about three out five previously arrested juvenile offenders released from the system will most likely offend before they attain the age of eighteen (18) (McDaniel, 2015). The offenders normally increase the rate of criminal behavior as their employability decreases. Primarily, they are unemployable due to several factors including non-completion of high school education and also having a criminal record. The youth in the case scenario is a case of recidivism though HE was not detained previously in a juvenile detention facility as the court ordered that he may undergo sexual offending treatment. Upon completion of the treatment, the youth was admitted to a public school where he reoffended.

The detention facility should develop interventions and strategies that will inculcate adaptive skills to the youth in a natural environment. He requires therapeutic services to address the emotional and psychological challenges that he is struggling with, especially aggression, anxiety, and emotional instability. Therapeutic services will also prove beneficial in addressing behavioral deficits that the youth exhibits. Moreover, the facility should develop education services and programs that address the academic or intellectual gap that the youth may be experiencing as a result of borderline intellectual functioning. The youth exhibits social skill incompetence, especially in relations to interpersonal skills. Consequently, it is prudent to come up with interactive programs that will address these interpersonal skills challenges eventually addressing the violence problem.

One of the most effective interventions applicable to the case is the Possible Selves self –determination intervention. The intervention consists of seven lessons that equip learners with certain personal skills such as self-determination, motivation, and goal setting (McDaniel, 2015). A test of the intervention on student athletes and middle school students has produced very positive results. Furthermore, it has been shown that the intervention is efficient concerning promoting self-regulation skills at the individual and interpersonal levels. The perpetrator’s behavior is likely to change positively if the intervention primarily on the juvenile’s strengths while addressing his/her fears with planning for the future. The youth in the case scenario has a problem of making right choices and self-regulating himself; therefore, it is advisable to motivate him to make right choices while helping him to overcome his weaknesses. Strategies that lead to the development of cognitively oriented skills have the ability to increase interpersonal competence that the youth in the case scenario largely struggles with (Clear, Reisig & Cole, 2015).

Several studies conducted in the recent past have shown that treatment programs are very effective when it comes to reducing recidivism even among serious delinquents (Helfgott, 2013).  Specific treatment programs that have been shown to have maximum benefits to juvenile delinquents include individual counseling and behavioral programs. Studies indicate that such intervention programs have the potential of mitigate recidivism by 30-40%. For maximum and effectiveness use of the programs, it is recommended that youths considered exhibiting a high risk for violent behavior to get special attention. Youths acting in a violent manner should undergo intensive treatment to improve recidivism reduction. The fact that the youth in the case scenario is in isolation from the rest indicates that probably has the highest risk of acting violently thus require intensive attention in order to reduce their risk of harming self and others.

Clinical Implications of the Existing Literature for Child and Adolescent Forensic Evaluations

The literature is of great clinical importance to the child and adolescent forensic evaluations. The literature addresses not only issues dealing with borderline intellectual functioning but also issues dealing with adolescent and teenage offenders. Therefore, the available literature has clinical implications in matters dealing largely with delinquency, aggression among children and adolescents, social skills competence, as well as the juvenile justice system. The literature provides an overview of how to conduct a forensic evaluation of an adolescent exhibiting delinquency characteristic. The evaluation can take several perspectives ranging from a social, ethical, medical or psychological angle. Mental health professionals working in juvenile detention facilities will find this literature helpful in developing assessment tools that will guide them in placement and monitoring procedures of the juveniles within the facility. Moreover, the literature will be useful in forensic evaluation as it provides data that can be used in the juvenile justice system to come up with treatment options for different offenders.

Forensic evaluators offer expert testimony in courts that is useful in resolving legal disputes. This literature will prove useful to adolescent forensic evaluators in guiding the courts to determine the best judicial decision that will be in the interest of the adolescent without appearing to defeat justice in the process. Primarily, forensic evaluators can use this literature in advocating for rehabilitation programs that are intended to help children and adolescents detained in a detention facility. This literature highlights recidivism as a big challenge among young offenders. The literature provides program interventions and services that are applicable in reducing recidivism significantly. Therefore, the clinical implication of this literature is that it provides forensic evaluators with information on why due diligence is necessary before releasing a juvenile sexual offender into the community. Releasing such offenders into the community may expose the community to offending behavior of the offender while increasing the risk of the offender to reoffending.

Conclusion

The youth in the case scenario exhibits social, ethical, medical, and psychological issues based on his behavior. The social issues brought out through the offenders behavioral are emotional and cognitive challenges. He has anxiety, unable to stay calm and seems to be emotionally unstable. Ethically, the scenario presents a case of a victim taken advantage by a sexual offender that the court only asks him to undergo sexual offending treatment. On the other hand, the perpetrator has been accepted in a public school to assimilate him into the community as well help in addressing his borderline intellectual functioning. Both the victim and perpetrator require medical attention with the victim in a dire need of therapeutic services while the perpetrator requires further sexual offending treatment. The psychological issues manifest themselves through the youth’s physical and verbal aggression.

The assessment tools recommended for this case includes a normative belief about aggression and attitude towards violence. The tool is critical in assessing the risk of aggression of the youth to prevent him from harming self or others. Interventions recommended for the case scenario include therapeutic services for the youth, Possible Selves self –determination, and intensive treatment programs.

 

References

Alesi, M., Rappo, G. & Pepi, A. (2015). “Emotional Profile and Intellectual Functioning: A Comparison among Children with Borderline Intellectual Functioning, Average Intellectual Functioning, and Gifted Intellectual Functioning.” SAGE Open, 5(3), 1-9

Bonnar-Kidd, K. K. (2010). “Sexual Offender Laws and Prevention of Sexual Violence or Recidivism.” American Journal of Public Health, 100(3), 412-419

Clear, T., Reisig, M. & Cole, G. (2015). American Corrections. Boston: Cengage Learning

Dahlberg, L. L., Toal, S. B., Swahn, M. & Behrens, C. B. (2005). Measuring Violence-Related Attitudes, Behaviors, and Influences Among Youths: A Compendium of Assessment Tools, 2nd ed. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Esposito, M. & Carotenuto, M. (2014). “Intellectual disabilities and power spectra analysis during sleep: a new perspective on borderline intellectual functioning.” Journal of Intellectual Disability Research, 58(5), 421-429

Helfgott, J. B. (Ed.) (2013). Criminal Psychology. Santa-Barbara: ABC-CLIO

Junger-Tas, J. et al. (2011). The Many Faces of Youth Crime: Contrasting Theoretical Perspectives on Juvenile Delinquency across Countries and Cultures. Berlin: Springer Science & Business Media.

McDaniel, S. (2015). “A Self-Determination Intervention for Youth Placed in a Short-Term Juvenile Detention Facility.” Journal of Correctional Education, 66(3), 5-15

Meek, R. (2013). Sport in Prison: Exploring the Role of Physical Activity in Correctional Settings. London & New York: Routledge

Nestler, J. & Goldbeck, L. (2011). “A pilot study of social competence group training for adolescents with borderline intellectual functioning and emotional and behavioral problems (SCT-ABI).” Journal of Intellectual Disability Research, 55(2), 231-241

Sarkar, J. (2013). “Mental health assessment of rape offenders.” Indian Journal of Psychiatry, 55(3), 235-243

Vincent, G. M., Guy, L.S. & Grisso, T. (2012). “Risk Assessment in Juvenile Justice: A Guidebook for Implementation.” National Youth Screening & Assessment Project. Retrieved December 7, 2015 from http://www.nysap.us/Risk%20Guidebook.pdf

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