Assessing & Treating Sexual Behavior Problems in Children By Adam H. Benton, PhD

1. Assessing & Treating Sexual Behavior Problems in Children ByAdam H. Benton, PhD

2. Training: University of Oklahoma Health Sciences Center: Children & Adolescents- SBP/Child Maltreatment • Wichita, KS, Prairie View Center for Sexual Health: Children & Adol. & Adol with Dev. Disabilities with SBP’s • UAMS: Children/Adol. With ASD’s • Currently: Behavior Management Systems, Inc.: Child & Adol, with SBP’s and Child Maltreatment; PEERS Program for Adol Adam Benton, PhDBehavior Management Systems, Inc. www.arbms.com www.ahbentonphd.com

3. Outline • Normal Sexual Behavior in children • Origins of Problematic Sexual Behavior • Assessing Problematic Sexual Behavior • Treatment, Supervision, and Reintegration

4. Sexual Behavior in Childhood • Sexual development is best understood in the context of other aspects of development including language, social, motor, cognitive, and emotional development.

5. Children with Sexual Behavior Problems (CSBP) • Developmental sensitivity • Focuses on the behavior • Separates behavior of children from delinquent or criminal acts of adolescents and adults • Includes all children with sexual behavior problems, in which there appears to be multiple origins to the behaviors Terminology

6. Children with SBP are defined as youth 12 years and younger. • Although the term “sexual” is utilized, the intentions and motivations for these behaviors may be unrelated to sexual gratification. • Definition – not diagnostic criteria Terminology

7. Sexual development begins before puberty! • Educating other professionals as well as family members • What are normal developmental tasks for preschool and school age children? • What is the typical course of sexual development? Sexual Development

8. Cognitively Speech/Language Motor Socially Emotionally (Pre-Operational) Learning to use language & to represent objects with images and words Gross and fine motor coordination Social skills, roles, communication Initiative vs Guilt; Self-regulation Development of Children Ages 3 – 5 Years

9. Typical Development: Sexual Knowledge • Children 3 to 5 years old • Gender permanence is established • Gender differences are understood • Limited information about pregnancy and childbirth • Knows labels for sexual body parts, but uses slang • Sees elimination function for sexual parts

10. Typical Development: Sexual Behavior • Children 3 to 5 years old • Do not have a strong sense of modesty • Enjoy their own nudity • Are interested in toileting functions • Use elimination words with peers • Sexual and genital curiosity increased • May explore body differences between girls and boys

11. Typical Development: Sexual Behavior • Children 3 to 5 years old • Have gender role behaviors; observed by age 1 and well delineated by age 3 or 4 • Prefer same gender; develops earlier and more strongly in boys than girls • Exhibit sex play with peers and siblings • Experience pleasure from touching their genitals, and touch self, even in public • Can experience physical sexual reactions

12. Cognitively Speech/Language Motor Socially Emotionally Concrete Operational: Thinks logically about objects and events Growing vocabulary and language mastery Use of motor skills for achievement, such as sports Increased awareness of social norms & social self-awareness Industry Vs Inferiority Typical Development of Children Ages 6 to12

13. Typical Development: Sexual Knowledge • Children 6 to 12 years old • Aware of genital basis of gender • Aware of sexual aspects of pregnancy • Increasing knowledge of sexual behavior (e.g., masturbation, intercourse, etc.) • Knowledge of pubertal changes

14. Typical Development: Sexual Behavior • Children 6 to 12 years old • Boys & girls socialize with own gender. • Sexual activity more concealed • Documented increases in masturbation in boys: • 10% at age 7 • 14% at age 8 • 85% at age 13 • Caregiver attitudes, peers, and societal values influence child’s attitudes towards sex

15. Typical Development: Sexual Behavior • Children 6 to 12 years old • Sex games with peers and/or siblings • Show modesty & embarrassment; will hide sex games from adults • May fantasize or dream about sex (with older individuals) • Interested in sex in media (e.g., music, television, movies, Internet, print, etc.) • Use sexual language with peers

16. Sexual Development

17. Research on Sexual Development • Self-touch behavior • Babies as young as 7 months touch their own genitalia (Ex. 14-month old toddler falling down) • Self-touch of preschoolers not same as adult masturbation • End of school age years, boys’ masturbation increases • Most 3 year olds knowledge of sexual behavior is limited to kissing; approx. 30% of 6 year olds know aboutmore explicit acts

18. Research on Sexual Development • Understanding of pregnancy and birth • Preschool: Vague and concrete • School-Age: Can understand, but knowledge depends on what is taught • Question: where did you believe babies came from? • Puberty is starting earlier; can start as early as 7 or 8 years (depends on nutrition, heredity, & other factors)

19. Sexual Behavior in Childhood • 40-85% of children will engage in at least some sexual behaviors before the age of 13 • In a sample of professionals who work with children: • 82% reported engaged in solitary sexual behaviors before age 13 • 76% engaged in sexual behavior with other children • 40% reported telling dirty jokes • 26% recalled showing their private parts to others • 10% humped or pretended to engage in intercourse • 5% reported feeling sexually aroused b/n 6-10 years old • 17% reported sexual arousal between 11 and 12 years of age

20. Sex play common (66 – 80%) • Most is never known by caregivers • Many encounters between children of the same gender • If it is true sex play (e.g., same age, no force and no aggression), then seen positive or neutral (inconsistent results with siblings) • Not related to adult sexual orientation Lamb & Coakley (1993), Larsson (2001); Reynolds, Herbenick, & Bancroft (2003); Friedrich, Whiteside, & Talley (2004); Greenwald & Leitenberg (1989); Okami, Olmstead, Abramson (1997) Long Term Implications of Sex Play: Retrospective Research

21. Sexual Behavior Problems in Childhood Sexual Behavior Problems (SBP) Child(ren)-initiated behaviors that involve sexual body parts (i.e., genitals, anus, buttocks, or breasts) in a manner that is developmentally inappropriate and potentially harmful to themselves or others. ~Silovsky & Bonner (2003)

22. Sexual Behavior in Children

23. Adaptive Caregiver Responses to Typical Sexual Behavior Calmly provide: • Accurate education about names and functions of all body parts; • Developmentally appropriate sexual education; • Information about social rules of behavior and privacy; • Information about respecting their own bodies; and • Information about friendships and relationships with others

24. Problematic Sexual Behaviors • Makes sexual sounds • Puts mouth on sex parts • Puts objects in rectum or vagina • Masturbates with objects • Touches others' sex parts after being told not to • Touches adults' sex parts • Asks to engage in sex acts • Imitates intercourse • Undresses other people • Asks to watch sexually explicit television

25. Effects of Problematic Sexual Behaviors • Psychological consequences can include internalizing disorders, externalizing disorders, cognitive difficulties, and/or social difficulties (Kaufman & Charney, 2001; Morrison, Frank, Holland, & Kates, 1999; Silverman, Reinherz, & Giaconia, 1996; Springer, Sheridan, Kuo, & Carnes, 2007; Teicher, 2000; U.S. Department of Health and Human Services, 2003; Watts-English, Fortson, Gibler, Hooper, & DeBellis, 2006) • Behavioral consequences can include juvenile delinquency, adult criminality, substance abuse, and/or abusive behavior (National Institute on Drug Abuse, 1998; Prevent Child Abuse America, 2001; Widom & Maxfield, 200; Widom, White, Czaja, & Marmorstein, 2007)

26. Development of Problematic Sexual Behavior • Curiosity • Exposure to overt sexuality • Coercive behavior • No model for healthy intimacy • Subtle family dynamics that support sexual acting out William Friedrich, 2007

27. Other Factors Found to Influence Children's Sexual Behavior • Confused about sexuality in media • Inadequate supervision • Highly sexualized neighborhoods • Little physical, emotional, or sexual privacy in home • Child being used to meet parental needs • Parents who act in sexual ways while intoxicated • Observing of sexuality paired with aggression, such as domestic violence, sexually aggressive language etc • Physical or emotional abuse • Sexual abuse • Forced to be photographed naked for stimulation of adults

28. Continuum of Sexual Behaviors • Natural and healthy • Sexually reactive • Often in view of adults. • May be self or other directed • Usually no coercion or force • Confusion, fear or anxiety about sex, stemming from history of sexual abuse, typical drive the behavior • Some report arousal, others do not • This is the most common of the three groups

29. Continuum of Sexual Behaviors • C) Children who engage in extensive mutual sexual behavior • Often frequent or habitual • May include adult-like behaviors • May have a hx of broken attachments with adults • Sexual behavior may be a way of coping with feelings • SBP may be more difficult to stop • May use persuasion but not likely to coerce or force • Like find other children who will collude with them to avoid being caught • The second largest group

30. Continuum of Sexual Behaviors D) Children who molest • Frequent and pervasive sexual behaviors • A growing patter of SBP's is evident in hx • Intense sexual confusion • Sexuality and aggression are closely linked • Generally use coercion, bribery, an/or force • May select vulnerable individuals to victimize • SBP's may have impulsive and aggressive qualities • Smallest group, but in need of specialized help

31. A grandmother went upstairs to get her grandsons down for dinner. When she walked into the bedroom the two boys, ages 8 and 9, only had their shirts on and were touching each other’s penises. After talking with them, both denied any coercion and indicated they were curious. Case Study

32. Myths About CSBP’s • Only males engage in inappropriate sexual behavior • Sexual aggression reflects “deeply rooted pathology” • (Ex. “Referral to treat a “little Perp.”) • Children with SBP’s need for restrictive placement • Utilization of adolescent and adult sex offender treatment approaches • Children who have SBP’s will grow up to be adult perpetrators

33. Truths about CSBP’s • Sexually acting out Children can be helped • Problematic sexual behaviors are learned and can be unlearned • There are no “deeply rooted patterns” of sexual behavior in children • They are malleable and can absorb healthy attitudes, behaviors, and feelings about sexuality. • After receiving short-term tx, CSBP's are of no greater risk for SBP's than the typical outpatient client (2-3%). (Carpentier, Silovsky, & Chaffin 2006)‏

34. There is no current research that shows a clear link between sexual behavior problems in childhood and illegal sexual behavior in adolescents or adulthood. Truths About CSBP’s

35. With appropriate treatment and careful supervision, most children can live safely with other children. • Children with highly aggressive or intrusive sexual behavior, despite treatment and close supervision, should not live with other young children until this behavior is resolved • If SBP occurred with other children in the home, their reaction must be considered. • Most children with SBP can be treated on an outpatient basis while living at home. • Residential and inpatient treatment should be reserved for most severe cases, such as children with other psychiatric disorders and/or highly aggressive sexual behavior which recurs despite appropriate outpatient treatment and close supervision. Truths About CSBP’s

36. Boys and Girls have SBP • Preschool Girls 65% • School Age Girls 33% • Co-Occurring diagnoses Disruptive Behavior Disorders: • ADHD, ODD, & CD Trauma Related Disorders: • PTSD & Adjustment • Other Internalizing Disorder: Depression Learning and Language delays Summary of Children with SBP: Characteristics

37. Relationship issues • Parenting/Caregiver stress • Caregiver perception of youth • Peer relationship problems Summary of Children with SBP: Characteristics

38. Historical assumption – “All children with sexual behavior problems have been sexually abused” • Kendall-Tackett, Williams, & Finkelhor (1991) • 36% of preschoolers • 6% of school-age children • Hall, Mathews, & Pearce (1998, 2002) • Cohen & Mannarino (1996, 1997) Characteristic of Children with SBP’s

39. Assessment of Children with SBP’S In many cases necessary assessment information can be gathered through a thorough clinical interview and administration of a few simple assessment instruments. (ATSA Task Force Report on Children with Sexual Behavior Problems)‏

40. Assessment of CSBP’s Biological • IQ; Neurological conditions, like ADHD, NVLD, ASD... Psychological • Hx. of Maltreatment, PTSD; Personality assessment; Reading ability Sociological • Family environment...Relationships, Conflict, etc; Family sexuality; Poverty; Association with negative peers; Parental support and attachment; Parental sexual abuse history; Neighborhood; Education

41. Risk and Protective FactorsWilliam Friedrich, 2007 Variable Protective Factor Potentiating Factor Sexual Abuse No hx History Sex. Behavior Self-Focused Other Focused Mutual Coercive Spontaneous Premeditative No contact Penetration Same age Age difference Single victim Multiple victims No status diff Status difference Not arousal focused Arousal and genital focus Family No other maltreatment Hx of maltreatment Secure attachment Insecure attachment No parent abuse hx Parental sex abuse hx No domestic violence Witnessed domestic violence Family Stability Family instability Child Internalizing Oppositional Defiant Disorder Positive peer relationsNo positive peer relations

42. Assessment Instruments • Cognitive & Reading: An estimate of cognitive and reading ability is helpful for treatment, especially group treatment, but is not necessary in all cases. • KBIT, *WASI, SB5 • Impulse Control and Behavioral Functioning: To assess overall behavior, teacher and parent report • *Behavior Assessment System for Children, II • Child Behavior Checklist

43. Assessment Instruments Psychosocial / Sexual • Social Functioning • Social Responsiveness Scale (ASD Children) • Various social skill questionnaires • Sexual Behaviors • *Child Sexual Behavior Inventory • Traumatic Stress • Trauma Symptom Checklist for Children / Young Children • *UCLA PTSD Reaction Index • *Trust Events Survey

44. Assessment Instruments Family Environment • *Family Sexuality Index (Friedrich, 2007) • Parenting Stress Index • Family Adaptability & Cohesion Evaluation Scale • *Family Environment Scale • Children’s Version, Family Environment Scale • *Parenting Relationship Questionnaire

45. Clinical Interview Behavior Assessment System for Children Child Sexual Behavior Inventory Trauma Symptom Checklist for Children (as needed) Family Environment Scale Parenting Relationship Questionnaire Example Assessment Battery

46. Assessment of Children with SBP’S Assessment Should Ask... • Is the child safe from maltreatment? • Do other children need protection? • Is there reason to think that sexual abuse or exposure to adult sexuality is a contributing factor? • What is the nature of the parent-child relationship and family environment? • Remember: This is a developmental problem, so where did this child get off track?

47. Assessment of Children with SBP’S • Are other behavioral, emotional, or medical problems present? • How open is the family to treatment? • What barriers to treatment exist? • What was the nature and severity of sexual behavior problems...where do they fall on the continuum? • In what situations does the SBP seem to occur? • Are the behaviors self-focused, other-focused, planned aggressive, coercive? • How does the child interact with others? • What purpose did the sexual behavior serve for the child?

48. Cindy Lou, a six-year-old girl, has her hands in her panties much of the time, including while watching television and eating dinner. Her mother has repeatedly told her to stop, but she does not stop. Case Study

49. Treatment Randomized Trial of Treatment for Children with Sexual Behavior Problems: Ten-year Follow-up (Carpentier, Silovsky, & Chaffin, 2006)‏ • 135 children 5-12 years of age • 12 session CBT tx Vs Play Therapy • At 10-year Follow-up • The CBT group had significantly fewer sex offenses than Play Therapy (2% vs10%) and did not differ from the general clinic comparison (3%)‏ • There were no group differences in terms of non-sexual offenses (21%)‏

50. Research on treatment outcome for CSBP concludes that... CSBP improve over time... That focused treatment helps... Some treatments are more effective than others in both short and long-term That parent involvement should be emphasized... And that blended CBT treatments targeting both traumatic stress symptoms and SBP can be successful in helping both problems Treatment