Age Confusion and Counterfeit Deviance in ID: Rethinking Risk Through Behavior Analysis and Sexual Education
Dr. Meaghan McCollow, PhD, BCBA-D, LBA

1 Hour
1 BACB Learning CEU 

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Session Description:

Comprehensive sexuality education (CSE) is inconsistently implemented across the United States (Grasso & Trumbull, 2023). And for youth with intellectual disabilities (ID) access to CSE becomes even more elusive. However, it is an important aspect of the development of healthy individuals. Without explicit instruction, individuals with ID are at risk of lack of information regarding sexual development, sexual and reproductive health, interpersonal relationships, affection, intimacy, body image, and gender expression. This lack of information can lead to misinformation about sexuality, lack of development of sexual and gender identities, and leaves these individuals open to abuse, or to becoming an offender, a less discussed issue, later in life. In this session, the presenter will overview concepts and topics related to offenders with ID and provide a framework for addressing concerns preemptively and in rehabilitative contexts from a behavior analytic perspective.

While there is extensive evidence that individuals with ID are at increased risk of being sexually assaulted and/or abused, a concern that has been highlighted in media (NPR, 2018), the evidence related to offenders, or those at-risk of offending, with ID is less easily obtained. While some individuals with ID will come into contact with the criminal justice system due to offending, many are also “diverted away from the criminal justice system for hospital or community treatment, rather than receiving a conviction” (Heppell et al., 2022). Because of this, it can be difficult to identify the prevalence of offending-type behaviors, however, the impact of either conviction or diversion to hospital or community settings has a similar result: a victim of the offense, and a rights restriction to the individual with ID. 

A study of men with ID who offended against women and who offended against minors (Lindsay et al., 2011) compared results of group treatment, which included cognitive behavior therapy and sexuality education, on cognitive distortions pre and post treatment. Treatment reduced attitudes as assessed by QACSO (Questionnaire on Attitudes Consistent with Sex Offense) including attitudes related to rape, voyeurism, stalking, exhibitionism, and offenses against children. The QACSO is an assessment tool developed for the ID population to assess for cognitive distortions, assess treatment needs, and track treatment progress (Gray, 2020; Lindsey et al., 2004). A more recent meta-analysis (Heppell et al., 2022) reviewed the effectiveness of cognitive behavioral treatment on sex offenders with ID. One highlight from this meta-analysis was the inconsistency in how sexually abusive behaviors are reported for this population. 

Identifying a course of education or treatment, depending on whether the individual with ID has offended or is displaying the potential for offense (i.e., risky sexual behaviors), is imperative to reducing risk and addressing lack of socio-sexual knowledge. An early study focused on men with ID who offended (Lunsky et al., 2009) found variability amongst sub-categories of offender groups (i.e., those with more serious offenses such as rape and sexual misconduct with minors, those with offenses categorized as inappropriate behavior) and differences in knowledge and attitudes related to socio-sexual education. 

Because of the convergence of lack of CSE (whether through insufficient, inaccessible, or simply not available information) and the potential for offending sexual behaviors due to lack of information or misconceptions (i.e., cognitive distortions), it is imperative that treatment be focused on knowledge and skill building that also addresses attitudes and perceptions. 

As practitioners plan for treatment, there are considerations to be made regarding where misinformation or misperceptions may occur for the ID population. Specific concepts for consideration include: counterfeit deviance and age confusion. 

Counterfeit deviance. The term “counterfeit deviance” was first introduced by Hingsburger, Griffiths, and Quinsey in 1991 and is meant as a means of differentiating between individuals with ID “whose behaviors appeared like paraphilia but served a function that was not related to paraphilia sexual urges or fantasies” (Griffiths et al., 2013). Of importance for practitioners is recognizing the theoretical concept of counterfeit deviance versus offenses that serves a different function as the treatment approaches must differ. Determining function of behavior, regardless of topography of that behavior, is critical in teh assessment process. Practitioners should consistently consider counterfeit deviance, particularly in the face of behaviors that may be taboo in broader society. 

Age confusion. The ability to distinguish between lifespan stages, such as childhood and adulthood, is important for functioning in the broader community. While making this distinction is an assumption across society (i.e., it is assumed that an adult can distinguish between a same-age or similar age peer and someone much younger), for individuals with ID, there may be a blurred distinction. And when an individual has difficulty with this distinction and engages in behavior that looks inappropriate (e.g., approaching children to play as an adult), this can lead to rejection from the community or more serious outcomes. 
While there is more dated literature on the concept of age confusion, a recent study synthesized the existent literature and explored skills of adults with ID related to life stage recognition (Straccia et al., 2020). Results determined there is variability in results depending on cognitive abilities and materials used, however, the implications for determining skill-building tasks and generalization are provided.

The purpose of this presentation is to overview the context of individuals with ID who have offended or are at-risk for offending and to overview the concepts of counterfeit deviance and age confusion. Suggestions for framing these concepts and the treatment of individuals with ID with a history of harmful sexual behaviors in a behavior analytic framework will be provided, while specific treatments (i.e., a “how-to”) for these will be avoided. At the core of the presentation will be reinforcing the importance of determining function of behavior, regardless of topography of the behavior. Based on the presenter’s clinical experience, recommendations will be made, including the importance of supervision in development of SME and of referral when practitioner is not comfortable with history of behaviors or is not trained.

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Learning Objectives:

By the end of this session participants will be able to:

1. Describe the concepts of counterfeit deviance and age confusion in individuals with intellectual disabilities, and explain their implications for assessment and treatment planning within a behavior analytic framework.
2. Identify risk factors associated with harmful sexual behavior in individuals with intellectual disabilities and outline strategies for addressing these risks through socio-sexual education.