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Vol. XVIII, No. 4
Fall 2006
Treating Children: Results from a 10-year follow-up

10 Year Follow-up Supports Cognitive-Behavioral Treatment for  

Children with Sexual Behavior Problems:  

Implications for Services, Treatment Implementation, and Future Directions

 

Melissa Carpentier  

Oklahoma State University   

Jane Silovsky  

Mark Chaffin  

University of Oklahoma Health Sciences Center

  

Sexual assaults against children are often committed by other youth.  Crime statistics have shown that approximately 15-20% of all sexual offenses and up to 50% of all child molestations may be committed by youth under 18 years of age (Zolondek, Abel, Northey, & Jordan, 2002).  In a recent telephone survey of a nationally representative sample of over 2,000 youth, 72% of all sexual assaults against children were found to involve offenders who were under 18 years of age (Finkelhor, Ormrod, Turner, & Hamby, 2005).  Early adolescence appears to be the peak or modal age for committing sexual offenses against children (see Caldwell, 2002 for an analysis of NIBRS reports).  However, sexually aggressive behaviors have also been reported among school age children as well as children as young as 3 years (Bonner, Walker, & Berliner, 1999; Friedrich & Luecke, 1988; Johnson, 1988; Pithers, Gray, Busconi, & Houchens, 1998; Silovsky & Niec, 2002).

Treatment services and public policies addressing children (12 years and younger) with sexual behavior problems (SBP) have often mirrored conceptualizations of adult sexual offenders and have assumed a persistent trajectory of sexual offenses into adolescence and adulthood.  Adult sexual offender concepts of grooming, distorted thinking, cyclic behaviors, and limited victim empathy have been integral to some sexual behavior problem treatment for children (AACAP, 1999; Araji, 1997).  Public policies in some states assume that the children are legally culpable for their behaviors and at great risk for future sexual offenses.  Children who demonstrate sexual behavior problems may be expelled from school, segregated, restricted from certain services or placements, or in some states included on lifetime public sex offender registries and internet sites.  Many of these actions are predicated on the largely untested assumption that these children pose a long-term and difficult to modify risk for future sex offenses.

However, results of a 10 year follow-up of children with SBP question the assumptions about persistent or difficult to modify risk (Carpentier, Silovsky, & Chaffin, 2006).  Only 2% of children randomized to a 12-session group cognitive behavioral therapy were found to have any future sexual offenses, similar to the clinical comparison group with no sexual behavior problems (3%) and significantly lower than children with SBP who were randomized to group play therapy (10%).  If replicated, these follow-up results strongly suggest that childhood SBP are not typically developmental precursors of adolescent and adult sexual offending.  More importantly, the results suggest that long-term risk is low after appropriate treatment, and that the behavior is not difficult to modify in most cases. 

 Other results support conceptualizing children with SBP as qualitatively different from adolescent and adult sexual offenders.  For example, although adolescent and adult sex offenders are predominantly males, there are a substantial number of girls among children with SBP (Johnson, 1989; Pithers et al., 1998; Silovsky & Niec, 2002). Perceptions of high long-term risk for sexual offenses of children with SBP have been based on retrospective research indicating that a significant portion of paraphilic adult offenders report an adolescent- or even preadolescent-onset for their behavior or sexual interests (Abel et al., 1987).  However, the current state of research suggests that there are likely multiple trajectories, with the path of persistent sexually abusive behaviors being the exception rather then the rule (Chaffin, Letourneau, & Silovsky, 2002).  Further, the treatments for child SBP that have been found effective in the research literature are short-term cognitive-behavioral treatments (CBT) with a strong caregiver focus.  These treatments are substantially different in both content and intensity from CBT treatments for adolescent and adult sexual offenders. 

This article examines the research to date on treatment for children with SBP and provides guidelines for service providers.  We begin by providing a definition and clinical description of children with SBP.  Research on treatment of SBP in children is reviewed with a focus on the recent prospective investigation of children with SBP.  The cognitive-behavioral group treatment for children with SBP and their parents/caregivers found to significantly reduce risk is described followed by a discussion of important issues to consider in implementation, such as group versus individual formats, child age/development factors, mixed gender groups, and cultural considerations.  Finally, we provide suggestions for future directions in this area.    

Defining Children with SBP 

Children with SBP are defined as children ages 12 and younger who initiate behaviors involving sexual body parts (i.e., genitals, anus, buttocks, or breasts) that are developmentally inappropriate or potentially harmful to themselves or others (Silovsky & Bonner, 2003).  Although the term sexual is used, it is important to note that the intentions and motivations for these behaviors may or may not be related to sexual gratification or sexual stimulation.  Rather, these behaviors may simply be related to curiosity, anxiety, need for affection, imitation, attention-seeking, self-calming, or other reasons.   

Sexual behavior problems do not represent a specific diagnosable condition or syndrome (Chaffin et al., 2006).  Determination of SBP requires distinguishing the behavior from typical normative sex play in regards to type and frequency.  Normal childhood sexual play and exploration are behaviors that occurs spontaneously, intermittently, are mutual and non-coercive when it involves other children, and the behavior themselves do not cause emotional distress (Bonner et al., 1999a).  The Child Sexual Behavior Inventory (CSBI), a normed measure of child sexual behavior, can facilitate this assessment (Friedrich, 1997).  In addition, determination of SBP requires consideration of the behavior frequency, harm and potential harm, preoccupation, use of force, intimidation or coercion, and responsiveness to typical corrective efforts of caregivers (Araji, 1997; Hall, Mathews, & Pearce, 1998; Johnson, 2004).   

No population-based figures are available on the incidence or prevalence of sexual behavior problems in children.  Rates of sexual behavior problems among groups of traumatized youth are higher than the general population (Friedrich, 1998; Kendell-Tacket, Williams, & Finkelhor, 1993).  Although not limited to sexually abused children, child sexual behavior problems occur among as many as 1/3 of sexually abused preschool children.  Prevalence rates among children with other or multiple sources of trauma remains unclear.  Recent years have seen an increase in the number of children with SBP who have been referred to child protective services, juvenile services, and treatment in both outpatient and inpatient settings (Burton, Butts, & Snyder, 1997; Vermont Social and Rehabilitative Services, 1996 – cited in Gray et al., 1999).  It is not known whether this represents a true increase in the incidence of such behaviors, changing definitions of problematic sexual behavior, increased awareness and reporting of what has always existed, or some combination of these factors.   

Notably, children with SBP are quite diverse in the types of sexual behaviors performed and also with regard to personal demographics, familial factors, socio-economic status, maltreatment history, and mental health status (Chaffin et al., 2006).  Thus, no distinct SBP profile for children exists, nor is there a clear pattern of demographic, psychological, or social factors that distinguish children with SBP from other groups of children (Chaffin et al., 2002).   

Social context, individual characteristics, disruptive experiences, and the interactions of these factors impact the onset and course of sexual development (Araji, 1997).  Sexual abuse is one type of disruptive experience impacting the course of sexual development. Children who have been sexually abused are more likely to demonstrate SBP than children without such a history (Friedrich et al., 2001), particularly preschool age children (Kendall-Tackett, Williams, & Finkelhor, 1993).  However, many children with SBP have no known history of sexual abuse (Bonner & Fahey, 1998; Bonner, Walker, & Berliner, 1999a; Johnson, 1988; Silovsky & Niec, 2002) and the development of SBP appears to have multiple origins, including exposure to family violence, physical abuse, parenting practices, exposure to sexual material, absent or disrupted attachments, heredity, and the development of other disruptive behavior problems (Friedrich, 2002; Friedrich, Davies, Feher, & Wright, 2004; Gray, Pithers, Busconi, & Houchens, 1999).  

Regardless of the causal pathway, demonstrating SBP as a young child is associated with a variety of negative consequences in adjustment and development.  Children with SBP often exhibit other behavior problems (Bonner et al., 1999a; Friedrich & Luecke, 1988; Gray et al., 1999; Silovsky & Niec, 2002).  Poor impulse-control skills, aggressive behaviors, and inaccurate perceptions of social stimuli hinder social relationships and cause problems at school (Araji, 1997; Bonner et al., 1999; Friedrich & Luecke, 1988; Gil & Johnson, 1993; Horton, 1996).  Socialization difficulties and stigmatizing responses from peers and adults may impede developing self-concepts (Heiman, 2001).  Poor boundaries and indiscriminate friendliness may increase risk of future victimization (Pearce, 2003; Silovsky & Niec, 2002).  Further, children with SBP are at risk of separation from parents and of placement disruptions (Bonner et al., 1999a; Baker, Schneiderman, & Parker, 2001; McKenzie, English, & Henderson, 1987; Silovsky & Niec, 2002).  Further, for those children with a trauma history (sexual abuse as well as other trauma), co-morbid trauma symptoms complicate the clinical picture (Pithers et al., 1998; Silovsky & Niec, 2002) 

Treatment Outcomes for Children with SBP

Randomized clinical trials specifically on SBP treatment for children are limited to two studies (Bonner et al.,1993, 1999a; Pithers et al., 1998).  However, the field can also be informed by results of other research on SBP treatment, as well as outcome research on treatment for sexual abused children that includes components that address SBP and on treatment for disruptive behavior disorders in children.  A pattern of results is emerging supporting short-term, structured, family based, SBP-focused, cognitive-behavioral treatment (CBT) approaches.  The following provides a summary of the treatment-outcome research. 

Randomized Trials of SBP Specific Treatment 

The two randomized clinical trials examining treatment outcomes for children with SBP were both funded by National Center on Child Abuse and Neglect (now the Office of Child Abuse and Neglect).  One of the trials was in Vermont directed by Pithers, Gray, and colleagues (1993, 1998) in which they randomly assigned 115 school-aged children (i.e., ages 6 to 12) with inappropriate or aggressive sexual behavior to one of two treatment programs.  Each treatment consisted of 32 weeks of 90-minute parallel treatment groups for children with SBP and their caregivers.  One treatment arm consisted of an “expressive” approach which addressed sexual behavior rules, boundaries, emotional management, effects of sexual abuse, problem-solving, and social skills.  The second treatment arm consisted of a relapse prevention based approach which focused on risk factors and emphasized caregiver involvement as external monitors of the children's behavior.  Notably, both treatment arms were structured, psychoeducational, and cognitive-behaviorally focused (Araji, 1997). Although the “expressive” arm was the less focused of the two, descriptions of the expressive arm suggest that it was more similar in many ways to CBT treatments than to the play therapy or non-specific supportive therapies used as a comparison condition in other controlled studies.  Initial results suggested that both treatments yielded improvements, although a subset of children with serious traumatic stress symptoms demonstrated relatively greater improvement with relapse prevention treatment halfway through the program (Pithers, Gray, Busconi, & Houchens, 1998).  Ultimately, the gains observed in both conditions were similar (cited in Bonner & Fahey, 1998), which may not be surprising given that both were structured CBT type treatments and both included the parents or other caregivers.   

In the second randomized clinical trial of children with SBP, Bonner, Walker, and Berliner (1993, 1999a) randomly assigned school-aged children (i.e., ages 6 to 12) with SBP, and their parents, to one of two treatment approaches: 1) group cognitive-behavioral therapy (CBT), or 2) group play therapy (PT).  Each treatment approach consisted of 12 one-hour group sessions for the children with SBP followed by an hour long group for their caregivers.  The child CBT approach emphasized learning and implementing sexual behavior rules, learning basic sex education, improving impulse control, and preventing future abuse.  Similar topics were covered in the caregiver CBT group, along with discussion of developmentally expected sexual behaviors in children, supervision of children with sexual behavior problems, family rules about sexual behavior, talking about sexuality with children, and general behavioral management. In contrast, the child PT group was much less structured and utilized group play activities. The group was designed to promote a safe and positive atmosphere in which the children could express their thoughts and feelings, develop a better understanding of themselves and others, and interact appropriately with other children.  The caregiver PT group processed problems and issues that the caregivers brought up each week; therapists did not set the agenda and instead let the caregivers set the direction. Initial results from the study indicated significant reductions in SBP for children in both treatment conditions, but no differences between the treatments.  Similarly, one- and two-year follow-up caregiver phone interview of a small subsample of participants (i.e., 36% and 29%, respectively) yielded no statistically significant differences between the two treatments in the rate of future parent-reported behavior problems with sexual elements (17% for PT and 15% for the CBT group).  It is important to note that these rates are for any problematic behavior with a sexual element, most of which would not constitute a sex offense.     

Notably, long-term treatment outcome differences for sex offense perpetration reports emerged in the follow-up study.  Carpentier, Silovsky, and Chaffin (2006) conducted a 10 year follow-up of children with SBP from Bonner and colleagues (1999) randomized clinical trial comparing group cognitive-behavioral therapy (CBT) with group play therapy (PT). This study tracked all the participants utilizing administrative across three surveillance systems all of which collect reports of sexual abuse perpetration and sex offenses—child welfare, juvenile justice and adult criminal justice. A clinic comparison group was included of 156 general clinic children with non-sexual behavior problems (most commonly ADHD, adjustment disorder, and learning problems) seen during the same time period. Results indicated that children in the CBT group had significantly fewer future sexual offenses than those children in the PT group (2% vs. 10%, respectively), and the children in the CBT group did not differ from the general clinic sample (3%). Given the low base rate of future sex offenses in this population and the moderate sample size, this longer term follow-up using the full sample was likely required in order for statistically significant treatment condition differences to emerge.  Results support the use of short-term CBT as an effective treatment for children with SBP, as well as question prevalent assumptions regarding persistent or difficult to modify risk among children with SBP (Carpentier et al., 2006).  

Other Treatment Outcome Studies  

Silovsky and colleagues (Silovsky, Niec, Bard, & Hecht, 2006) conducted a pilot study evaluating a 12-week group treatment program for preschool children with interpersonal sexual behavior problems (SBP), many of whom had co-occurring trauma symptoms and disruptive behaviors.  Time and treatment effects were assessed through weekly assessments of SBP during a wait period and treatment period.  An intent-to-treat analysis was conducted in which all participants, including those who did not complete treatment, were included to examine the impact of time and treatment separately.  By including all subjects, rather than just those who completed treatment, the results are more ecologically valid and generalizable.  The results of the intent-to-treat analysis revealed a significant linear reduction in SBP related to the number of treatment sessions attended, an effect that was independent of linear reductions affiliated with elapsed time for children with high frequencies of SBP.  Similar treatment effects findings emerged from semi-parametric growth mixture modeling.   

Sexual abuse focused treatments for children with trauma symptoms have often included components that directly address SBP, so this body of literature also is informative.  SBP are commonly found among children with sexual-abuse related trauma symptoms.  In a randomized controlled study with sexually abused preschoolers, Cohen and Mannarino (1996, 1997) found post-treatment SBP were lower with family based (not group) cognitive behavioral treatment (CBT) than non-directive supportive treatment (NST).  Moreover, CBT demonstrated significant within-group reductions of SBP from pre- to post-treatment, whereas NST did not.  Improvements with CBT were maintained at one-year follow-up (Cohen & Mannarino, 1997).  Pre- to post-treatment reductions in SBP have been found in evaluations of cognitive-behavioral (CBT) abuse-focused group therapy for sexually abused preschool children with concurrent treatment for non-offending parents (Hall-Marley & Damon, 1993; Stauffer & Deblinger, 1996).  Stauffer and Deblinger (1996) included a wait period, during which they did not find reductions in SBP, further supporting that treatment impacted SBP, beyond the simple passage of time.  Friedrich and colleagues (Friedrich, Luecke, Beilke, & Place, 1992) also found pre- to post-treatment SBP reductions in sexually abused boys with a multifaceted treatment that included individual, family, and parenting approaches.  In contrast to the above findings, sexual abuse treatments that do not include components addressing SBP have not been found to reduce SBP (Finkelhor & Berliner, 1995).   

One consistency across all effective interventions for reducing SBP has been the direct involvement of the caregivers in the treatment, particularly teaching caregivers how to use behavior management approaches.  Support for the involvement of parents in the treatment of children with SBP is also found in the related literature on disruptive behavior disorders.  SBP are similar to other behavior problems in a variety of ways: the behaviors involve behavioral disinhibition, problems with impulse or emotion regulation, social rule-breaking, and may include aggressive acts toward self or others (Silovsky, Niec, et al., 2006).  Further overlap is found in the factors that contribute to the development and maintenance of both non-sexual disruptive behavior problems and SBP (e.g., history of violence exposure, poor supervision, parent-child relationship).  Research on treatment for disruptive behaviors has consistently identified behavior management training with caregivers as an effective modality (see Brestan & Eyberg, 1998; Nixon, 2002).  This is one critical difference between effective treatments with childhood behavior problems, including SBP, and treatments often used with adolescent and adult offenders.  Effective treatments for childhood behavior problems focus strongly on parenting and behavior management skills, whereas many treatments for adolescent or adult sex offenders focus more on the individual’s psychological makeup.  

In summary, the existent literature suggests several factors as important for treatment for children with SBP: (1) treatments need to directly address SBP, (2) behavioral, family-focused, cognitive-behavioral, and psychoeducational approaches appear better than unstructured supportive therapy or unstructured play therapy approaches, (3) many effective treatments teach impulse-control skills, coping strategies, boundary issues, and work to improve caregiver-child relationships, (4) effective treatments directly involve the parent/caregiver in treatment, and (5) effective treatments teach caregivers to use behavior management skills.  Treatment needs to be developmentally sensitive, and consider the cognitive, emotional, and behavioral capacities of young children.  Further, treatment for children with SBP and trauma symptoms appears to benefit from blended CBT treatments targeting both traumatic stress symptoms and SBP, at least for sexual abuse trauma.   

The SBP specific CBT treatment and components of trauma-focused CBT addressing SBP are distinct in many ways from CBT treatment for adolescent and adult sexual offenders.  This distinction is important to make, particularly because CBT treatment based on adolescent or adult models (including treatment strategies to confront abuser’s denial, decrease deviant arousal, and teaching their sexual assault cycle) have been advocated for use with children with SBP (AACAP, 1999).  The CBT treatments for children found effective in reducing SBP are distinct from adult and adolescent sex offender treatment models and did not include elements such as confrontation, arousal management procedures, requirements for detailed admission of all behaviors, exploration of sexual fantasies, and most did not involve concepts such as cycles, grooming, compulsivity or predation.  Moreover, most of the childhood SBP treatments with demonstrated efficacy in the research literature have been short-term (as few as 12-sessions) whereas adult and adolescent sex offender treatment often lasts far longer.  Understanding of the CBT treatment components found effective for SBP in children and how they are distinct from treatment of adolescent and adult sexual offenders will be important in the dissemination of these findings.  The following provides a description of the treatment components of Bonner et al. (1999w) group SBP treatment and addresses implementation issues including treatment modality, composition of group, choice of therapists, and cultural issues. 

Implementation of Short-Term Group CBT Treatment for Children with SBP  

            Below is a brief description of the short-term group CBT treatment for children with SBP and their families. For professionals interested in obtaining Bonner and colleagues (1999b, 1999c) complete treatment manuals for the children and caregivers, these manuals can be obtained through the National Center on Sexual Behavior of Youth’s website at http://www.ncsby.org/pages/publications.htm
           

Cognitive Behavioral Group Treatment for SBP: Children’s Group 

            The Bonner and colleagues’ (1999a) group CBT treatment program for children with SBP is grounded in behavior modification principles for group management and emphasizes education, cognitive rules, decision making, and impulse control. The 12-session groups consisted of 6 to 8 boys and girls (seen together), ages 6 to 12, were highly structured, and utilized a teaching—learning model. The therapists, a male and female, assumed a directive, teaching role and the children were expected to follow the therapists’ lead. Five major topics were covered throughout the 12-session model; the topics include: 1) acknowledging inappropriate sexual behavior, 2) learning the sexual behavior rules, 3) improving impulse control, 4) receiving sexual education, and 5) preventing future abuse of self and others.  

            Child Session 1. The first child session commenced with introductions to allow children the opportunity to learn about one another, as well as about their therapists.  The purpose of the group program was clarified with the children. Therapists indicated all the children were there for the same reason—they had all broken a sexual behavior rule and were there to learn how to follow the sexual behavior rules. This session served as a model for how the rest of the sessions would be conducted and was utilized to help establish group responsibilities. Therapists emphasized the importance of maintaining confidentiality about topics discussed in the group, including the limits of such confidentiality (e.g., if not telling would hurt the child or someone else). Therapists also stressed the importance of respect (i.e., not interrupting, no hitting, no name calling, no swearing) in the group and encourage the children to think of additional rules on their own. Behavior modification strategies were used by the therapists to reinforce appropriate behavior and reduce the likelihood of misbehavior during group to prevent any unintended negative effects due to aggregating children with behavior problems. 

            Child Session 2. To ensure that children understand what the purpose of the group is and their group responsibilities, the second session began with a review of these concepts. The focus then shifted to defining what “private parts” are and how this definition fits into the sexual behavior rules. Once it appeared that the children understood this definition, the sexual behavior rules were introduced.  The sexual behavior rules are basic rules about our bodies such as (1) It’s not OK to touch other people’s private parts, (2) It’s not OK to show your private parts to others, (3) It’s not OK for other people to touch your private parts, unless that person has a very good reason (e.g., a doctor as part of a medical exam or a parent to keep the child clean), and (4) It’s OK to touch your own private parts when you are alone.  Discussion of the rules occurred with sensitivity to understanding abusive experiences of the children in the group.   

            Child Session 3 and 4. Sessions 3 and 4 provided a review of previous material, teaching of feeling identification skills, teaching of appropriate anatomical terms for private parts, and activities to facilitate learning these concepts.  In Session 4 the children were encouraged to self-disclose when they broke a sexual behavior rule without being coerced into discussion. Therapists asked helpful questions to stimulate disclosure, such as “Who did you break the rule with?” or “What did you do when you broke the rule?” Importantly, the words “abuse” and “victim” were not used in describing the child’s inappropriate sexual behavior; rather, the focus remained on breaking the rule and NOT on “abusing” someone else. Children were praised for disclosing which rule(s) they have broken, with acknowledgement that this indeed is something difficult to discuss with others. Activities were conducted to aid with making the association between sexual behavior rule-breaking and feelings.  

            Child Session 5. In addition to reviewing previous material, the goal of the fifth session was to teach an impulse control strategy called the Turtle Technique.  Using the symbol of a turtle and turtle shell therapists teach steps of impulse control (i.e., stop, go into shell and relax, think about options, evaluate and choose one, do it).  Therapists introduced the Turtle Technique by telling a short story using turtle puppets that had a head that may be pulled into its shell.  

            Child Sessions 6, 7, and 9. These sessions reviewed the earlier material, promoting acknowledgement of having broken a sexual behavior rule and applying the Turtle Technique to a variety of situations.  Games were played to reinforce learning and practicing the skills learned, including feeling identification, relaxation, the sexual behavior rules, and turtle techniques.   

            Child Session 8. The eighth session had two main objectives: 1) increasing children’s knowledge and understanding of private parts and their functions, and 2) clarifying when it is appropriate to talk about such things. To aid with the former, therapists utilized the book Where Did I Come From? (Mayle, 1973), a sex education book.  

            Child Session 10. This session had two main purposes: 1) provide a review of private parts, their functions, and puberty, and 2) teach abuse prevention principles. With regard to the former, visual aids (i.e., male and female diagrams) were utilized to help children name private parts and the functions of each. A review of what puberty is and when it occurs also took place at this time. The therapists encouraged the children to discuss the different changes that occur (for both males and females) during this time. To introduce abuse prevention principles, therapists highlighted the sexual behavior rule stating that it is not OK for other people to touch one’s private parts and encourage children to discuss what they should do if someone tries to break that rule. Children were taught abuse prevention skills.   

            Child Session 11. In this session, therapists reviewed important skills gained over the course of the group, including the sexual behavior rules, sex education information, abuse prevention skills, and steps of the turtle technique. Therapists presented different scenarios (ensuring that all of the sexual behavior rules were included in the different scenarios) and asked a child what he/she would do. The children took turns explaining what they would do in the given scenario in accordance with the steps of the Turtle Technique. 

            Child Session 12. The last child session consisted of another quick review of the skills learned over the course of group and then focused on the opportunity to say goodbye to their group. Specifically, children were encouraged to discuss their feelings regarding the group through completing sentence stems such as “I wish the group….” and “The thing I liked best about the group was…..” Children were presented with certificates that recognized their participation and achievement and allowed to choose a prize out of the prize basket.  

Cognitive Behavioral Group Treatment for SBP:  Parent—Caregiver Group 

            The group CBT treatment program for parents and caregivers of children with SBP also employs a 12-session format; the parent—caregiver group occurred immediately after the children’s group (child care was provided during that time). The focus of the caregiver group was to teach about sexual behavior problems and provide parents and caregivers with the skills necessary to reduce their children’s inappropriate sexual behavior.  The sessions often mirrored the content of the children’s sessions, but also provided education on differentiation of normal/expected sexual behavior from SBP and on parenting strategies to reinforce the children’s generalization of skills taught.  Close supervision of the children was emphasized with discussions of ways and barriers to implementation.  A couple of sessions focused specifically on behavioral management strategies, with particular emphasis is placed on setting good rules, natural and logical consequences, and use of praising, ignoring, and time-out. Application of these parenting strategies to the prevention and response to SBP was discussed.   

Clinical Modifications of CBT Treatment for SBP 

Overall, the treatment programs for children with SBP that have been found effective and successful reviewed here have included core components that teach rules about sexual behavior and physical boundaries, provide age appropriate sex education, and teach strategies that both support the children following and using these rules as well as address other concerns commonly found, such as other behavior problems, anxiety, poor coping skills, and difficulties in social relationships.  The skills addressed include feeling identification, coping, relaxation, impulse control, problem-solving, and abuse prevention skills.  In addition, for youth 7 years and older, treatment directly addresses identifying, recognizing the inappropriateness of, planning ways to prevent future acts, and apologizing for rule-violating sexual behaviors that occurred (Chaffin et al., 2002).   

Family involvement in treatment has been considered critical to the success of services for children with SBP (Bonner et al., 1999a; Friedrich, in press; Silovsky et al., 2006).  The importance of working on the quality of the parent(caregiver)-child relationship is particularly emphasized in Friedrich’s Attachment-Based Family Therapy model (Friedrich, in press).  Caregivers often benefit from information about sexual development, guidelines of how to differentiate typical sex play from sexual behavior problems, and ways to teach and enforce rules about sexual behavior and physical boundaries.  Caregivers are taught strategies to support their children’s use of the skills taught in session, and are also provided with parenting resources to prevent future SBP and respond to SBP in a manner to reduce the likelihood of future problems.  In addition, treatment addresses the emotional quality of the caregiver-child interaction, with a focus on enhancing supportive, positive and mutually enjoyable interactions.  The parenting practices taught are consistent with effective behavior parenting strategies, including close supervision, monitoring, good communication with teachers and other important adults in the child’s life, and the use of re-direction, clear directions, labeled praise, time-out and logical/natural consequences, and application of structure, consistent rules and discipline.  Many caregivers of children who have had inappropriate sexual behavior have high levels of parenting stress and limited support systems.  One advantage of the group approach is the opportunity to receive support from other parents, and to be able to discuss aspects of their child’s SBP frankly with a support group.   

After the completion of the randomized trial, the SBP treatment program has continued as a clinical program at the University of Oklahoma Health Sciences Center (OUHSC).  Modifications have been made to the original protocol to facilitate clinical implementation (e.g., open ended group rather than closed group protocol and concurrent rather than sequential child and caregiver group sessions) and in response to clinical practice and to caregivers’ and children’s responses to outcome questionnaires (CSBI, Friedrich, 1998; Behavior Assessment System for Children, Reynolds & Kamphaus, 1992; Parenting Stress Index – Short Form, Abidin, 1995) and post-services questionnaires on the social validity and satisfaction with the services. These modifications have not been systematically evaluated so it is unclear how they may or may not impact long-term outcome. 

One significant change implemented at OUHSC to the original protocol has been the integration of joint sessions, in which the children and caregivers are together for group family sessions where skills are practiced and facilitated by the therapist.  This change was initiated because direct practice of the skills by the family members was believed to enhance understanding and implementation of the skills outside of sessions.  On our social validity and satisfaction questionnaires, caregivers have repeatedly rated the joint sessions as an important component of treatment and requested increased time in session for these activities.  In addition to this modification, a module specifically on social skills was added due to deficits found in the children’s selecting, making, and maintaining age appropriate friendships.  Writing an apology letter that is used during the sessions was also formalized.  During this module, the caregivers write letters of support which are read to their child after hearing the apology letter in a joint session. We have found that the older children (10-12 years old) are more receptive to the STOP strategy (Stop and Relax, Think, Options, Plan) rather than the Turtle Technique.  The current protocol is approximately 18 sessions.  Due to the low base rate of future detected sexual offenses, the longer protocol will not likely reduce this further.  Potential deleterious effects are not expected but are unknown and the impact on adjustment and skills (e.g., increase social skills and number of appropriate friends) has not yet been examined. 

Providers may need to consider a range of issues for providing services for children with SBP including: 1) choosing the most appropriate treatment modality to fit your community and agency needs, 2) consideration of gender, age, and other factors that may affect treatment, and 3) awareness of cultural issues and needs related to implementation of treatment.  These implementation issues are briefly discussed in the following section.

Issues with Implementation 

Group Versus Individual Services  

            Both group and individual/family treatment modalities have been found effective in reducing SBP, and no study has systematically compared the two approaches for the treatment of children with sexual behavior problems.  A range of factors can impact providers’ and agencies’ decision and choice of treatment modality.  

            Advantages of Group Format.  The group-based format has several advantages for the family and agency.  The child has the opportunity to interact with other children who have had similar issues, thereby reducing feelings of isolation and stigma and decreasing negative self-perceptions related to the behaviors (Reeker, Ensing, & Elliott, 1997; Silovsky, Burris, McElroy, Bigfoot, & Bonner, 2006).  The group format also creates a social environment where children can learn and practice prosocial behaviors and social skills modeled by same-age peers.  Similarly, caregivers interact with other caregivers who are raising a child with SBP.  Caregivers have repeatedly expressed their appreciation for support and advice from other caregivers who have had similar experiences.  Due to the taboo nature of the topic, caregivers often feel isolated in their parenting efforts, which is the case even for caregivers with natural support systems.  The caregiver group provides a forum for discussion and feedback, and they acquire knowledge about their child’s sexual behaviors, child development, parenting, discipline, and the parent-child relationship. Further, the group can be an efficient use of resources, as many families can be served in a relatively short period of time.   

Disadvantages of Group Format.  Despite the benefits of group treatment, there are also unique considerations and potential barriers.  Systematic behavior modification during the children’s group is needed to prevent behavioral problems during group, which could inadvertently be a negative model of behavior.  Children who have frequent aggressive outbursts that are not readily modified with behavior modification would not be appropriate for this group format.  Confidentiality is another issue that arises in a group format. Understandably, confidentiality in group therapy is handled differently from individual or family therapy and is of greater concern for small communities. The number of appropriate referrals for SBP treatment impacts the choice to use a group format, such that in some smaller communities there may be a limited number of children who are in need of the service at the same time.  SBP treatment can be provided to a couple of families at a time, rather than a larger group (Friedrich, in press).  In some communities, group programs may also be challenging due to difficulty openly discussing these topics, which may be considered taboo or inappropriate (Silovsky, Burris, et al., 2006).  Individual and family approaches may be preferable for children with significant and pronounced co-morbid conditions, family problems, or other concerns (Chaffin et al., 2006). 

Closed versus Open-Ended Groups.  The original Cognitive-Behavioral Group Treatment Program evaluated by Bonner et al. (1999) was provided as closed groups of 12 sessions.  This format is beneficial in assisting the group members to develop trust amongst themselves, but requires families to wait a period of time before the next group to begin. Thus, a closed group format will require consideration and planning on how to manage children in need of services referred after the initiation of the group, and may include providing periodic individual/family sessions until the next group begins. Conversely, an open-ended group allows for children to join the group once they are deemed appropriate to participate (and there is an opening).  The children remain in treatment until they have successfully completed services and meet other graduation criteria (such as no SBP for a period of time).  This format allows for children to enter without a wait and for children who are close to graduating to act as role models of adaptive behaviors for the newer group members.  Using a closed- or open-ended group format will likely be reliant on the number of referrals for children with SBP, the agency resources dedicated to the treatment program, and the availability of the service providers. For developmental reasons described below, we have recommended an open-ended group format for school-age children and a closed group format for preschool children.   

Age/Developmental Considerations 

Consideration of the child’s development level is vital in determining the grouping of children.  To facilitate learning and reduce frustration, it is preferable to have some limitations on the age range for the group.  Consideration of maturity, verbal skills, and social skills are needed in addition to the chronological age of the child.   

Preschool-Aged Children. It is suggested that preschool children, children ages 3 to 6, are grouped together due to their cognitive and social development (Silovsky, Burris, et al., 2006). Preschool children do not have the maturity or mental reasoning abilities to learn the material provided in treatment at the same level as school-age children. Preschool children are not expected to directly talk about their own history of inappropriate sexual behavior in the group for developmental reasons.  Because of their concrete thinking, there is significant concern that making them talk about past sexual behavior each week may actually have a detrimental impact on their developing self-concept (Silovsky & Niec, 1996).  Moreover, preschool children are less able to use thoughts about mistakes made in the past and subsequently make plans to change their future behavior.  Thus, the purposes of talking about the history of behaviors are not applicable and potentially harmful for this age group. (It should be noted, however, that if the preschool child has Posttraumatic Stress Disorder, directly addressing their trauma history and perhaps their past inappropriate behavior may occur in the context of trauma-focused therapy to reduce the negative effects of the trauma, e.g., re-experiencing symptoms). 

Preschool children are concrete, have developing self-concepts, need active learning, require activities that can be completed in short period of time, and need consistency in routines and expectations from adults in order to minimize their anxiety and enhance learning.  Due to their need for structure, predictability, and routine, a closed group format having the same routine each session may be beneficial.  

School-Aged Children.  The initial implementation and evaluation of the original group treatment model (Bonner et al., 1999) included children ages 6 to 12 together in the same group.  However, we have found it useful to include the six year olds with the preschool group and to separate the 7- to 9-year old olds and the 10- to 12-year olds, due to developmental and social reasons.  The age limits are not strict, such that a child who has recently turned 10 and is quite immature may benefit more from the 7- to 9-year-old group.  One of the goals for treatment is to encourage the children to learn to interact and play with same age children, thus it is better that those with whom they are practicing are same-aged peers.  In addition, taking into account the cognitive, emotional, social, and physical changes that occur across the 10- to 12-year age span, it stands to reason that these youth are beginning to understand and process more complex and abstract information, develop a higher level of empathy and moral development, and may be experiencing related changes due to puberty.  

School-age children tend to be peer-focused, require active learning, can sustain attention for longer periods of time, can engage in more complex activities, and learn through games and rule-based activities.  Unlike younger children, school-age children are able to separate past behavior from whom they are as a person, if presented correctly, and can learn from past behavior to change future behavior.  For these reasons, school-age children are expected to talk about past breaking of private part rules, with focus on preventing future acts and moral development.  An open-ended group format has been helpful, as youth near graduation provide important positive peer modeling for the children starting the program. 

Gender Considerations 

Gender of Children in Groups.  Having a mixed-group of boys and girls has advantages and disadvantages.  The children’s natural school and community environment typically includes children of both genders, thus a mixed gender group is reflective of the everyday life of the youth.  Teaching appropriate boundaries and behavior in this group facilitates generalization to everyday life (Silovsky, Burris, et al., 2006).  A mixed-group format also assists children in learning social skills in a structured environment with supervised interaction.  Positive peer interactions are helpful for children who may have experienced social problems. Importantly, some particularly sensitive topics (such as sex education) can be done separately with each gender group if this appears warranted and more culturally appropriate.  Logistically and financially, mixed gender groups are typically more manageable for agencies, as separate gender groups would require considerably more resources in personnel, space, etc.   

Understandably, mixed gender groups may not be appropriate for some communities.  Thus, community standards regarding mixed gender groups should be considered prior to establishing the program, and may be included in assessing the needs of the community (Silovsky, Burris, et al., 2006).  Moreover, some families may feel uncomfortable with children being in mixed groups, which could impact their subsequent participation in treatment.  Service providers should plan in advance how to handle potential situations that may arise during treatment, such as a given family’s discomfort or cultural beliefs about males and females discussing potentially sensitive topics.  Further, the fit of individual group members with the other group participants will need to be considered when determining if the mixed gender group format is appropriate.  For example, a mature 12 year old girl may not fit well if the rest of the group are immature 10 year old boys, and family services may be more suitable. 

Gender of Therapists in Groups.  Co-therapists are advantageous when conducting a group therapy for children with SBP.  Therapists can be more flexible and actively involved by using the support and shared leadership.  Choosing co-therapists who balance each other’s strengths enhances the group, such as selecting one therapist who is enthusiastic and engaging and another who is well-organized and calming (Trounson-Chaiken, 1996).  With co-therapists, the children's behavior, reactions, and social interactions are more readily observed and behavior problems can be more efficiently monitored and managed, which in turn reduces the feeling of a loss of control (Lynn, 1989).  An additional advantage of co-therapists, is that sessions can continue to occur regularly and not be interrupted by absence of one of the therapists, such as due to illness, and important factor for youth who benefit from routine and consistency.  

Consideration of the gender of the co-therapists may be made when developing the group and after completing the initial assessment of the children.  Notably, a mixed-gender combination models nonviolent male-female communication, which is particularly important for children who have been exposed to intimate partner violence.  Children with abuse histories who demonstrate high levels of fear towards those who are the same gender as the perpetrator (such as fearing men) may not respond well to group leaders of that gender initially, but may benefit from positive interactions with group therapists in future groups.  Again, careful consideration of gender issues should be made both prior to the group’s onset, and should also continue to be monitored along the length of the group.   

Cultural Considerations.  Consideration of the child and family’s cultural values, beliefs, and norms are of foremost importance in the provision of any mental health and social services.  Race, ethnicity, religion, spirituality, socioeconomic factors, and other cultural factors can strongly impact individuals’ and families’ receptivity and response to treatment of child sexual behavior problems.  Due to the sensitive nature of the topic, clinicians must become knowledgeable about the family’s and community’s beliefs, values, traditions, and practices concerning sex, including the spoken and unspoken rules about public and private behavior, relationships, intimacy, and modesty.  For example, discussions on sexual behavior with children may be considered appropriate for some individuals (e.g., aunts teaching nieces) but taboo for others (e.g., fathers talking with daughters).  Beliefs about the appropriateness of children touching their own private parts and about masturbation tend to be strongly held and directly impact receptiveness to treatment.  Understanding and respecting the cultural beliefs and values of families and providing services to enhance the family’s ability to accept and receive the services is critical for not only outcome, but also to initiation and retention of families in services. 

A culturally adapted treatment program for American Indian and Alaska Native children with SBP and their families, Honoring Children, Respectful Ways (Silovsky, Burris, et al., 2006), is being developed through the Indian Country Child Trauma Center (ICCTC), which is part of the National Child Traumatic Stress Network (NCTSN) funded by the Substance Abuse Mental Health Services Administration (SAMHSA) under the National Child Traumatic Stress Initiative.  The ICCTC was established to develop trauma-related treatment protocols, outreach materials, and service delivery guidelines specifically adapted and designed for American Indian and Alaska Native children and their families.  ICCTC is working with Native American cultural experts to adapt the original treatment model to integrate Native teachings, world view, and practices, and develop a service and training approach that is sufficiently flexible to engage communities at their level of readiness and to accommodate a range of tribal cultures as well as individual variations in cultural identity and affiliation. 

Traditional Native healing and cultural practices are congruent with the central beliefs, components, and approach of the original group treatment program for children with SBP (Silovsky, Burris, et al., 2006).  Traditional Native values hold children as sacred and to be honored and the children’s behaviors are seen as reflecting the teachings of the family.  Acts of inappropriate SBP are viewed as changeable behaviors, not as reflecting ingrained personality features.  Children are to be nurtured and guided through childhood into adulthood by the extended family network.  The family focused approach and foundational philosophy of the original SBP treatment program compliments these beliefs.  Further, integral in both the caregiver group curriculum and Traditional Native teaching is the importance of supervision, of shared responsibility with the other caregivers in the child’s life, and of modeling and encouraging self-respect, modesty, respect of others’ boundaries, and positive friendships. Traditional Native teachings are based on an observational style of learning which includes listening, watching, and doing guided by relatives or someone connected with the person who is learning.  This learning style is consistent with the cognitive-behavioral treatment approaches (LaFromboise & Bigfoot, 1988).  Honoring Children, Respectful Ways encourages the use and integration, with appropriate permission, of Tribal language, stories, dances, activities, healing practices, and traditional child rearing practices throughout the program.  Collaboration with Traditional Healers may be particularly important for some families. The themes of honoring children and of respect have been integrated in the original program.  Thus, Honoring Children, Respectful Ways is a treatment program designed for American Indian and Alaska Native children and their families to learn about how to utilize their cultural values, ways and practices to develop positive beliefs about themselves and healthy values and behaviors in their relationships with others.  More information about ICCTC and the adapted treatments can be found at www.icctc.org

Summary and Future Directions 

In summary, children under age 12, including children as young as 3 years, can demonstrate clinically significant sexual behavior problems, including those involving intrusive acts against other children.  Although many children with sexual behavior problems have a history of child sexual abuse, the origins of SBP appear to be multifaceted, involving individual, biological, social, and familial factors.  Initial treatment outcome research suggests that SBP are responsive to short-term outpatient services that are cognitive-behavioral based, directly involve the caregivers, and teach self-control skills to children and behavior management skills to caregivers.  Notably, few youth continue to demonstrate SBP into late adolescence and early adulthood based on the results of a 10 year follow up (Carpentier et al., 2006).  In fact, given effective short-term treatment, it appears that these children pose no greater long-term sex offense risk than groups of children with non-sexual disruptive behavior problems. 

Providers familiar with conceptualizations and services for adult sexual offenders are cautioned to avoid applying these models to children.  The current state of research suggests that children with SBP should be viewed as distinct from adult sexual offenders.  This point may be particularly important for providers whose backgrounds are in adult or adolescent models, but who may be less familiar with models designed to work with child behavior problems.  While it appears that a specific treatment focus on SBP is important, it does not appear that only a specialized SBP treatment program can be effective.  It appears that SBP focused elements can be effectively incorporated into other treatments.  For example, studies have demonstrated that young children with trauma histories and associated trauma symptoms have responded to trauma-focused treatments that incorporate child and caregiver SBP focused components.  

Research on children with sexual behavior problems is a relatively new area of research, but one which has advanced rapidly.  It is important to note that in many ways the treatment outcome research on children with SBP is more advanced than the research literature on adolescent and adult sex offender treatment outcomes.  Two randomized clinical trials have been conducted thus far on SBP-specific treatment with school-age children, one with long-term follow-up.  SBP specific treatment for preschool children includes one wait-list control study.  Two additional randomized trials and one wait-list trial have been conducted with sexually abused children, examining SBP outcomes.  In contrast, only a single modern randomized trial has been conducted with adult sex offenders, and only MultiSystemic Therapy (MST) has amassed any controlled trial data with adolescents.  Nonetheless, many questions remain.  Additional research examining such service factors as group vs. individual/family services, use of direct practice of skills with families in session, and need of specific components of treatment (such as, acknowledging past SBP) would advance the field.  Given the low base rates of subsequent SBP or sexual offenses, it is unlikely that refined services would significantly lower this rate any further, but research could examine improvements in receptivity of services by families, reduced treatment burden, treatment attrition, co-morbid symptom relief, and gains in coping skills and resiliency factors.  Most of the treatment outcome research reviewed focused on outpatient populations.  Research is needed on services in more restrictive settings (i.e., inpatient and residential interventions) for children with persistent, aggressive SBP who are also more likely to have severe trauma histories, co-morbid conditions, and problematic family histories and situations (e.g., mental illness, substance abuse, maltreatment, community and domestic violence, etc.).  Many youth with SBP have co-morbid conditions of PTSD, separation anxiety, and/or disruptive behavior disorders (including oppositional defiant disorder, attention deficit hyperactivity disorder, and conduct disorder).  While evidence-based treatments exist for each of these conditions, research on the most efficacious and efficient manner to integrate these services for children with co-morbid conditions such that it is also palatable for families is needed.   

There is considerable research to be done in the area of clinical assessment of children with sexual behavior problems.  The CSBI (Friedrich, 1998) is the only normed measure of sexual behaviors of youth and is quite useful for clinical assessment as well as monitoring treatment progress.  The published version of the measure does not include items to assess aggressive or coercive sexual behaviors, however, and clinicians are advised to add items later developed by Friedrich (see Friedrich, 2002).  Another clinically useful measure is the Child Sexual Behavior Checklist (CSBCL – 2nd Revision, Johnson & Friend, 1995).  The CSBCL includes items that assess broad issues such as environmental factors, in addition to asking about specifics about the types and other details regarding sexual behavior problems.  While clinically useful, the measure does not yet have published norms.  An untapped area of measurement is in regards to the caregivers’ knowledge, reaction, and perception of their child and the sexual acts.  Mothers’ emotional reaction and support has been found to mediate treatment outcomes for preschool and school-aged sexually abused children (Cohen & Mannarino, 1996b, 1998, 2000).  Clinically, the perceptions caregivers’ hold of their children who have demonstrated sexual behavior problems appear to strongly impact their willingness to support the child, engage in services, and respond to intervention.  Psychometrically supported measures of caregiver’s emotional reaction, support, and perceptions for this specific population would facilitate research in this area. 

Finally, the results of this initial prospective study of 10 years are encouraging.  Given the length of follow up and that multiple data sources were combined (child protective services, juvenile services, and criminal data bases), the likelihood of missing acts is greatly reduced.  However, youth have been found to self-disclose delinquent acts (when assured anonymity) at rates greater than detected through administrative means.  Thus, longitudinal research including self- and caregiver-disclosed rates of sexual behavior problems, other delinquent acts, as well as victimization and trauma experiences is warranted.  Preschool children with sexual behavior problems have been found to have much more frequent SBP, more severe co-morbid conditions, and greater rates of placement disruptions than school age children with SBP (Silovsky & Niec, 1998).  Trajectories of other disruptive behaviors (particularly physical aggression) have been found to be distinct, depending in part on age of onset, with a younger onset related to more severe and pervasive problems (e.g., Broidy et al., 2003).  Longitudinal research with preschool as well as school age onset of SBP would facilitate examining whether SBP has a similar pattern as other disruptive behaviors. 

In summary, initial results in this relatively new area of research are encouraging, but further research is warranted for assessment, treatment mediators and outcome, and longitudinal trajectories.

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 Author Note

            Melissa Y. Carpentier, Department of Psychology, Oklahoma State University; Jane Silovsky and Mark Chaffin, Center on Child Abuse and Neglect, Department of Pediatrics, University of Oklahoma Health Sciences Center. 

            This manuscripts and the results presented were supported by a grant from the Association for the Treatment of Sexual Abusers (ATSA), in conjunction with the Falconer and Felix Foundations, to Melissa Y. Carpentier, M.S., by a grant from the National Center on Child Abuse and Neglect (90-CA –1469) to Barbara L. Bonner, Ph.D., and by a grant from the Substance Abuse and Mental Health Services Administration SAMHSA 1 UD1 SM56113-01) to Dolores Subia Bigfoot, Ph.D. and Barbara L. Bonner, Ph.D. The authors wish to acknowledge the contributions of Barbara L. Bonner, C. Eugene Walker, Lucy Berliner, William N. Friedrich, Lorena Burris, Erika McElroy, Larissa Niec, Debra Hecht, Lisa Swisher, and Dolores Subia Bigfoot to this project. The authors also wish to express our sincere thanks to the families involved and to the Oklahoma Department of Human Services, the Oklahoma Office of Juvenile Affairs, and the Oklahoma State Bureau of Investigation for their assistance with this project.

            Correspondence concerning this article should be addressed to Jane F. Silovsky, Ph.D., Department of Pediatrics, University of Oklahoma Health Sciences Center, P.O. Box 26901, Oklahoma City, Oklahoma 73190. E-mail: jane-silovsky@ouhsc.edu.

 

 

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