Collaborative on Children with Sexual Behavior Problems: Public Policy and Planning

1. Collaborative on Children with Sexual Behavior Problems: Public Policy and Planning Sex Offender Treatment Board Conference, August 2009 Randal Lea, Assistant Commissioner, DCS Michael Myszka, PhD, TNCare

2. Formation of Workgroup ~ Children with Sexual Behavior Problems: • Steady numbers of children presenting with sexualized behavior at earlier and earlier ages • Lack of information in courts, state agencies, schools, and some provider groups about specific needs of these children • Treatment approaches vary by how providers or agencies “view the problem” • Group formed August 6, 2008 [At the end of last years TSOB Training!

3. Guiding Concept • It is a guiding concept that children 12 and under with sexual behavior problems have particular treatment needs that are as different as the needs of adolescents who act out sexually as those adolescents are different from adults who offend.

4. SCOPE OF EMERGING CONCERNS: CHILDREN 12 AND UNDER BY THE NUMBERS

5. Interesting Numbers! Part 1 Child Protective Investigative Team (CPIT) data: FY 2007-2008

6. Interesting Numbers! Part 2 253 Youth with substantiated sexual offenses in courts, by age for CY 2007 Source: AOC

7. Interesting Numbers! Part 3 An October 15, 2008 analysis of 1,701 children in state custody ages 5-12 who received a CANS assessment between February 18 and September 30, 2008, found that 161 of these 1701 children (or 9.5%) were identified as having sexually problematic behaviors. 161 or 9% of 1701 children Have an active or historical sexual behavior problem. [Source: Richard Epstein, PhD, Vanderbilt University Center of Excellence]

8. Link to Trauma This data also shows more than half the children this age with sexual aggression, and more than 80% of the sexually reactive children, also have a score indication difficulty adjusting to trauma.

9. WHY FORM A COLLABORATIVE?

10. Overview: Collaborative on CSBP • Purpose: to create an effective network with multiple levels of care that all use best practice to serve children 12 and under with sexual behavior problems. • Workgroup Structure: • Vision & Accountability • Best Practice • Service Array

11. Vision & Accountability workgroup • Goal: Synthesize the collaborative’s vision and principles. Create accountability mechanisms for inter-agency collaboration and completion of the deliverables • Create or adopt Vision & Values • Address sustainability of the effort • Trainings: (SOTB, TCSW), and interface with other state initiatives such as the Children’s Mental Health Council

12. Charge of Vision and Accountability • Develop a common vision for a comprehensive service system for children with sexual behavior problems • Challenge system partners to recognize early intervention opportunities • Promote treatment and services for younger children in the most normalized setting possible • Identify approaches which will encourage families to seek help by reducing stigma and the consequences of voluntary treatment

13. Results of Vision and Accountability Workgroup • Vision: • Tennessee will have a prevention, assessment and treatment network that promotes community safety while treating children with sexual behavior problems. Families, state agencies and treatment partners will partner with courts and advocates to provide accurate information, responsible recommendations, and timely and effective services.

14. Sample Values of the Workgroup • Assessment & treatment of children with sexual behavior problems involves specialized knowledge which requires ongoing training as new research emerges. Assessment takes into account the cause and seriousness of the identified behaviors as well as the developmental needs of the child. • Current evidence shows children with sexual behavior problems who receive appropriate treatment are less likely to continue exhibiting these sexually inappropriate behaviors. • We are committed to implementing evidence-based treatment approaches for children with sexual behavior problems. Stigma and punishment are ineffective in addressing the needs of children with sexual behavior problems. • Children with sexual behavior problems act out in different ways, for different reasons and with different levels of severity. Treatment must consider the seriousness of the behavior, the role of the family, and strengths of the community

15. Service array group commissioned to: • Conduct Survey/Inventory of Providers • To recommend new service in underserved area of State currently underserved

16. Achievements of Service Array group: • Survey Conducted • West TN likely candidate for increased services, but Tennessee has an emerging need for outpatient, community based appropriate services to address issues of sexually reactive youth throughout state

17. Work of Service Array Workgroup • Dialogue with EBP Group: exchange survey data and integrate Best Practices into Recommendation for new Services • Need to have services de-stigmatize and recognize that many of the individuals are actually reactive

18. Service Array Recommendations • Utilizing groups such as the Tennessee Sex Offender Training Board, professional groups such as TAMHO and Tennessee Alliance for Children and Families, TCCY and TCSW, workgroup participants will disseminate best practice information and ways to approach children with sexual behavior problems in developmentally appropriate and socially responsive ways. Child Advocacy Centers (CACs), COEs, and State Departmental Staff will conduct provider outreach and trainings to disseminate best practices and to encourage referrals to informed sources.

19. Service Array Recommendations 2. Departments of state government such as TennCare, DCS, and MHDD should include in their measurements and discussions with the Managed Care Organizations the capacity to serve children throughout their services areas with an adequate network utilizing age-appropriate practices.

20. Service Array Recommendations 3. CACs will work with COEs as subject matter experts and with the assistance of departments of state government in hosting an annual seminar or conference on the treatment needs of younger children with sexual behavior problems. Further, the departments of state government should, through their executive leadership, appoint such staff from each department to an ongoing collaborative to work with the CACs in carrying out this responsibility.

21. Future Directions: • Partnerships with: • MCOs and their network, - and possibly a faith based aspect of network • University settings • COEs and Learning Collaborative Participants • Recruitment of new providers and re-tooling current providers:

22. Best Practice Workgroup • Evidence-based practices: Using the existing knowledge base of effective treatment paths for younger children from established literature • Understanding barriers & opportunities in implementing best practice • Recommending pathways to reduce or eliminate barriers • Dissemination plan for effective programming • Plan for embedding best practices in service delivery, including scopes of services for contracts

23. Best Practice Workgroup, ctd Goal: Focus on children 12 and under with sexual behavior problems to identify & develop plans for implementation of quality services utilizing evidence based practice, an understanding of the population & their needs and assessment of risk to the community. • Identification and assessment • Evidence-based treatment and interventions: • Management and risk in the community

24. Best Practice Workgroup • Addressing the tx needs of this group • Early identification and effective intervention • Treatment impacts of stigma and labelling • Individualizing treatment based on Risk, Need, and Responsivity • Engaging partners across systems for effective treatment coordination • Outcome tracking and adjustment

25. Healthy Sexual Behavior: Comes from a place of curiosity Is about exploration Is spontaneous and mutual Involves positive affect Is responsive to redirection Involves children in similar age/developmental range Low frequency Promotes social development Child engaging in healthy sexual behavior maintains healthy functioning Problematic Sexual Behavior: Seems to be a preoccupation Involves advanced sexual behavior or knowledge Seems planned/targeted or is coercive Is emotionally distressing Is unresponsive to redirection Inappropriate age/developmental range between children Is frequent or obsessive Interferes with social development Disrupts functioning Best Practice Workgroup

26. Best Practice Workgroup • Interviewers should be sensitive to developmental issues and past trauma when interviewing children. The atmosphere should be supportive and pressure to reveal information should not be applied. Interviewers should expect children to be reluctant to reveal the truth and details about events that may be upsetting to the child. • It is important to note that admission of engagement in the sexual behavior or lack thereof is not a factor that is related to risk. • Adult and adolescent assessment tools are inappropriate for children and should not be used. • While children who exhibit sexual behavior problems might have a history of sexual abuse, evidence suggests that there are other pathways to sexual behavior problems. Therefore, while it is appropriate to question whether or not the child has been sexually abused, it is inappropriate to assume that SBP definitively indicates past sexual abuse.

27. Recommendations • 1. Sustainability: Thatthe Tennessee Chapter of Children’s Advocacy Centers (CAC) provide ongoing leadership to the Collaborative on Children with Sexual Behavior Problems. It is recommended that the state CAC Director chair the collaborative, with a Commissioner-appointed DCS staff as the Co-Chair.

28. Administrative Offices of the Court Department of Children’s Services Department of Human Services Department of Education Department of Health Division of Mental Retardation Services Department of Mental Health and Developmental Disabilities Tennessee Commission on Children and Youth Providers Children’s Advocacy Centers Centers of Excellence District Attorney’s Council Managed Care Organizations Prevent Child Abuse Tennessee Tennessee Alliance for Children and Families Tennessee Foster and Adoptive Care Association Tennessee Chapter, American Academy of Pediatrics Other partners as identified Partners needed for sustainability

29. GOING FORWARD

30. Recommendations: • 2. Best Practices: We recommend that the Collaborative on Children with Sexual Behavior Problems develop and implement a plan to disseminate best practice information to those who are involved in the identification, assessment and treatment of children with sexual behavior problems.

31. How to steps on Recommendation #2: Dissemination of Findings • Use of Presentations at Boards, conferences such as this, and community forums • Specific Trainings of identified practioners through the Centers of Excellence for Children in State Custody in a learning Collaboratative Model (Janet Todd, UT~Boling Center in Memphis) and CAC staff

32. Recommendations, ctd. • 3. Public Policy and Data Collection: Quality data collection is critical to the development of evidence based practice. We recommend that agencies such as Department of Children’s Services, Child Advocacy Centers and the District Attorney’s Office develop and implement a protocol for the collection of data in child sexual abuse cases to ensure accuracy and consistency with guidance from the Collaborative on Children with Sexual Behavior Problems.

33. Considerations for Recommendation #3; • All Tennessee agencies and organizations refer to children 12 and under who meet appropriate criteria as children with sexual behavior problems, not perpetrators or offenders; [includes DCS] • Public policy should reflect the evidence showing that children with SBP are at a low risk for later sexual aggression, particularly if they receive appropriate treatment (Carpentier, Silovsky, & Chaffin, 2008).

34. Recommendations, ctd. • 4. Funding: We recommend that the Collaborative on CSBP continually seek funding opportunities, whether through grant dollars, state revenues, or existing department budgets to ensure ongoing training and education. A representative of the CSBP Collaborative should participate in the TCCY Resource Mapping initiative in order to identify funding opportunities.

35. Randal Lea DCS (615) 253-4360 Randal.M.Lea@tn.gov Kim Crane Mallory Gov’s Office of CCC Kim.Crane.Mallory@tn.gov Michael Myszka, PhD (615) 507-6916 Michael.Myszka@tn.gov Bonnie Beneke TN Child Advocacy Ctrs BBeneke@tncac.org Further Information