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CASE REPORT
The importance of multidisciplinary evaluation for differentiating between mental retardation and antisocial behavior in sex offenders: a case study
Paula Approbato de OliveiraI,
Corresponding author
paula.approbato@usp.br

Tel.: 55 11 3392-5624
, Christian César Cândido de OliveiraI, Cristiana Castanho de Almeida RoccaII, Ana Paula Gonzaga CostaI, Sandra ScivolettoI
I Equilibrium Project, Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo/SP, Brazil.
II Psychology and Neuropsychology Unit - Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo/SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">The World Health Organization considers sexual abuse in childhood to be a growing public health problem worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> The psychological and behavioral profile of sex offenders is a topic that has been widely investigated in the literature<a class="elsevierStyleCrossRefs" href="#bib2">2&#8211;6</a> because the appropriate treatment of such individuals can prevent them from becoming repeat sex offenders&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">One important aspect of the aggressor profile is cognitive functioning&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#44;6</a> In some cases&#44; sexual assaults are committed by individuals with intellectual disabilities that impair their capacity to critically analyze their actions&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> In other cases&#44; sexual assaults can represent sadistic behavior related to antisocial personality disorder&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p><p id="para30" class="elsevierStylePara elsevierViewall">The objective of this case report is to analyze the case of a teenager who was accused of sexually abusing a child and to determine whether the teenager should be diagnosed with mental retardation or early-onset antisocial behavior&#46; This case exemplifies the need for multidisciplinary evaluation to establish a diagnosis and to develop appropriate treatments to prevent the recurrence of violence&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para40" class="elsevierStylePara elsevierViewall">The patient &#40;W&#46;&#44; a black male&#41; was 16 years old and in the eighth grade&#46; He had been a resident of a supervised shelter for two years due to inadequate family support after his father&#39;s death in a car accident and his mother&#39;s arrest for shoplifting&#46; Before entering the shelter&#44; W&#46; often witnessed physical aggression between his parents and was neglected in terms of basic health care&#46; He had seven siblings&#44; of whom two had been adopted and five were living in shelters&#46; He was in the process of being adopted&#44; but he was not accepted because he sexually assaulted an 8-year-old girl who was living with the prospective parents&#46; Sexual abuse was not substantiated by medical examination&#46; Therefore&#44; it was suspected that the assault involved fondling and sexual acts other than penetration&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">The shelter team referred W&#46; to the Equilibrium Program &#40;Programa Equil&#237;brio&#41;&#44; a multidisciplinary program that specializes in socially vulnerable children and at-risk adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> One complaint was that W&#46; had difficulty studying the materials because he could not read or write properly&#46; Although he rarely exhibited behavioral difficulties at the shelter&#44; once he inappropriately approached a female caregiver&#44; attempting to grope her and using profane language regarding his body parts&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Before entering the Equilibrium Program&#44; the teenager was followed at a health program&#44; where his sexual misconduct was attributed to early-onset antisocial behavior&#46; These types of adolescents should be referred to the Social and Educational Services for Adolescents Foundation Center &#40;Funda&#231;&#227;o Casa&#41;&#44; which focuses on implementing court-ordered educational measures for adolescent offenders between 12 and 21 years of age&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">During the evaluation process&#44; the shelter staff expressed uncertainty about how to handle W&#46;&#39;s case&#46; They indicated that all possible interventions would be ineffective in improving his conduct&#46; However&#44; the multidisciplinary assessment differed from the assessment provided by the shelter staff&#46; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a> presents the results of the multidisciplinary assessment&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para80" class="elsevierStylePara elsevierViewall">This report addresses a case of diagnostic uncertainty&#46; In such cases&#44; a careful multidisciplinary assessment should be performed to establish treatment strategies and approaches that improve quality of life and preserve the dignity of patients and other people within their social environment&#46; Sexual abuse results in biopsychosocial damage to the victim&#44; and treatment of the abuser is an important strategy for preventing such violence&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">One study of sex offenders has suggested that sex offenders with an average or above-average intelligence quotient are more likely to have deviant sexual preferences and exhibit coercive behaviors&#44; whereas those with intellectual disabilities choose children due to a cognitive lack of sexual knowledge and understanding of social rules&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> Reviews of the literature support this hypothesis and classify sex offenders who suffer from some type of psychiatric disorder&#44; including mental retardation&#44; as &#8220;inadequate situational molesters&#8221;&#46; These individuals engage in nonaggressive sexual caressing and touching without perceiving the criminal nature of their acts&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Based on the aforementioned studies&#44; we assumed that the sexual abuse committed by W&#46; was associated with intellectual disability and an impaired perception of reality&#46; The victim did not report coercion or aggression&#44; nor was there any physical evidence of these types of behaviors&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The expression of sexuality in adolescents with mental disabilities is thought to be similar to that observed in adolescents with preserved intellectual ability&#58; intense desire and curiosity&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> For individuals with mental disabilities&#44; the environment plays an extremely important role in providing models of healthy behavior&#46; Communication must be adapted to the cognitive capacity of the individual&#44; and it is necessary to provide concrete illustrations of social norms&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a></p><p id="para110" class="elsevierStylePara elsevierViewall">W&#46;&#39;s biological family did not provide appropriate models of social behavior and dignity&#44; which is a risk factor for the development of behavioral problems&#46;<a class="elsevierStyleCrossRef" href="#bib10">10</a> In addition&#44; W&#46; was not encouraged to exercise his capacity for empathy&#46; His sexual misconduct appeared to be related to the models that he observed in his social and family environment&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Risk factors for the development of inappropriate behavior in people with intellectual disabilities include problems in language acquisition<a class="elsevierStyleCrossRef" href="#bib9">9</a> and deficits in cognitive functioning and nonverbal executive functioning&#44;<a class="elsevierStyleCrossRef" href="#bib11">11</a> which were observed in the multidisciplinary assessment of W&#46; Because language and cognition are important for adapting to reality&#44; these deficits should be treated by specialists&#46; After treatment&#44; individuals such as W&#46; will be able to properly analyze their social environment and plan their actions in a healthy manner&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">The shelter team evaluated the episode of sexual abuse without considering W&#46;&#39;s environment or other aspects of his overall development &#40;such as cognitive and communication deficits&#41;&#46; This unilateral approach may result in hasty diagnoses that stigmatize patients and hinder their rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib12">12</a></p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION</span><p id="para140" class="elsevierStylePara elsevierViewall">A multidisciplinary assessment of the patient&#44; which included an analysis of environmental factors and evidence from previous studies&#44; indicated that the sexual abuse committed by W&#46; was associated with mental retardation&#46; A misdiagnosis &#40;such as antisocial personality disorder&#41; would have further victimized the patient&#44; who might have been stigmatized and&#44; more importantly&#44; would have had little chance of receiving appropriate treatment and adapting to reality&#46; In addition&#44; without appropriate guidance and treatment&#44; W&#46; may have become a repeat sex offender&#44; which would have increased the number of individuals at risk for psychiatric and emotional problems&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">This case exemplifies how a multidisciplinary approach can be helpful in the event of diagnostic uncertainty in complex psychiatric cases&#46; Many patients can benefit from appropriate treatment of their symptoms after the underlying cause of those symptoms has been clarified&#46;</p></span></span>"
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                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">&#8226; Estimated IQ &#61; 62 &#40;mild mental retardation&#41;<a class="elsevierStyleCrossRef" href="#tfn1">&#42;</a>&#8226; Unsatisfactory performance on verbal test &#40;Vocabulary Subtest - WISC-III&#41; - Percentile &#61; 0&#46;1&#8226; Unsatisfactory performance on non-verbal test &#40;Block Design - WISC-III&#41; - Percentile &#61; 9&#8226; Unsatisfactory performance on tests assessing executive function by <span class="elsevierStyleItalic">Frontal assessment battery&#58;</span><a class="elsevierStyleCrossRef" href="#bib8">8</a> mental flexibility&#44; planning&#44; and selective attention&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos