1. Sexual Behavior in Children: What you need to know
TNCAC Connecting for Children’s Justice Conference
November 19-20, 2014
Melissa L. Hoffmann, Ph.D.
University of Tennessee Health Science Center
UT Center of Excellence for Children in State Custody

2. Conflict of Interest Disclosures
1. I do not have any potential conflicts of interest to disclose, OR X
2. I wish to disclose the following potential conflicts of interest:
Type of Potential Conflict
Details of Potential Conflict
Grant/Research Support
Substance Abuse and Mental Health Services Administration (SAMHSA), National Child Traumatic Stress Initiative (NCTSI) Category III Grant #1U79SM
Consultant
Speakers’ Bureaus
Financial support
Other X
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
© 2010 American Academy of Sleep Medicine

3. Learning Objectives
Understand normal vs. problematic sexual behavior in children under 12
Understand possible causes and correlates of problematic sexual behavior in children
Gain basic knowledge of assessment and treatment of children with sexual behavior problems

4. Sexual Behavior & Sexuality in Children
Sexuality is a natural part of childhood development just like language, motor skills, cognitive development
Sexual behavior involves “sexual body parts” including
Touching
Looking
Talking
Some sexual behavior is a healthy, normal part of childhood development, while other behaviors are problematic

5. Sexual Behavior in Children
40-85% of children are expected to engage in at least some sexual behaviors or sex play before age 13
Most of these behaviors are never known by parents
These encounters are generally remembered as positive or neutral
Behaviors may occur between children of the same sex, but this is unrelated to adult sexual orientation

6. Typical Sexual Behaviors
Between children of similar age, size, and developmental status
All children involved agree to the behavior
Occurs in the context of exploration or play between children in an ongoing enjoyable relationship (friends, relatives)
Occurs over several periods of a child’s life

7. Typical Sexual Behaviors
Exploratory and spontaneous
Children have light-hearted feelings before, during, and after the behavior
Behavior ends when discovered and child is told to stop

8. Children Often: Ask sexual questions about
Bodies (theirs and others)
Conception/reproduction
Birth
Arousal
Marriage
Intercourse
Explore gender roles and behaviors

9. Children Often: Look at their own bodies and the bodies of others
observe others in the bathroom, dressing room, pool
look at own genitals while bathing or dressing
“you show me yours, I’ll show you mine” with peers
usually occurs in preschool and again at the onset of puberty
“No, you can’t touch it – you already broke yours off!”

10. Children May Touch their genitals to explore anatomy and sensations
Self-Stimulation or “Masturbation”
Rub genitals with a hand or against objects because it feels good
This may not be related to sexual thoughts or sexual gratification
Engage in mutual touching with similar aged friends or cousins
same or opposite sex friends

11. Children May
Tell sexual jokes and use sexual words/”potty words” with peers
either to evoke reactions in peers or adults, or in imitation of older role models
Do not assume that children are defining terms or understanding jokes in the same way adults do

12. Keep in Mind
Children engage in an array of sexual behaviors, the vast majority of which are not problematic or abusive

13. Concerning/Problematic Behavior

14. Sexual Behaviors Raise Concerns When:
They are causing complaints or are negatively affecting other children
They are directed at adults who feel uncomfortable receiving them
The child seems to have too much knowledge about sexuality and behaves in ways more consistent with adult sexual behavior
Note: Sexual behavior that raises concern does not automatically mean a child has sexual behavior problems – it means the child needs to be assessed to determine if there is a problem

15. Sexual Behaviors are Problematic When:
They continue in spite of consistent and clear requests to stop
They interfere with social or family relationships
They are out of balance with other aspects of the child’s life and interests
The child appears unable to stop him/herself from engaging in the behaviors
They progress in frequency, intensity, or intrusiveness over time
They are accompanied by or followed by aggression or verbal expressions of anger

16. Problematic Sexual Behaviors
Sexual behaviors which cause physical or emotional pain or discomfort to self or others
Sexual behavior toward much younger children
Planning how to sexually touch others
Forcing others (physically or through intimidation) to do sexual acts
Tricking others into sexual acts

17. Problematic Sexual Behaviors
Putting finger or object in another child’s vagina or rectum
Trying to have sexual intercourse with another child or adult
Putting mouth on sex parts
Manual stimulation or oral or genital contact with animals

18. Children with Sexual Behavior Problems

19. Children with Sexual Behavior Problems
Child sexual behavior problems are a set of functional behaviors that fall outside acceptable societal norms. It is not a diagnostic category. Generally CSBP are defined as children 12 and younger who initiate behaviors involving sexual body parts that are developmentally inappropriate or potentially harmful. The intention and/or motivation of the behaviors may or may not be related to sexual gratification. These behaviors can be related to other factors such as curiosity, anxiety, imitation, attention seeking and/or self-soothing. Sexual behaviors can be self-focused or involve other children.
ATSA Report of the Task Force on Children with Sexual Behavior Problems, 2006

20. Children with Sexual Behavior Problems (CSBP)
Children with Sexual Behavior Problems is the preferred term in the field
Refers to youth 12 and younger
Separates children from adolescents with sexually abusive behaviors
Distinguishes between natural and problematic
Is developmentally sensitive
Focuses on the behavior
Although the term “sexual” is used, the motivations behind these behaviors may be unrelated to sexual gratification

21. Children with Sexual Behavior Problems
Occurs in boys and girls
Occurs across race, socioeconomic status, family composition
Many children with sexual behavior problems have other behavioral or emotional issues as well
Disruptive Behavior Disorders (ADHD, ODD, CD)
Trauma Related Disorders (PTSD, Adjustment)
Internalizing Disorders (Depression, Anxiety)
Learning and Language Delays

22. Children with Sexual Behavior Problems
In the past it was believed that most children with sexual behavior problems were victims of sexual abuse. But research shows that many children with SBP do not have a history of sexual abuse.
There are many possible reasons that a child’s sexual behaviors might move beyond natural and healthy.

23. Possible reasons for problematic sexual behaviors
Confusion regarding sexual behavior due to what the child has seen on TV, videos, magazines, or movies
Child has lived in a sexualized environment - a home or neighborhood where sexual talk and/or behavior occurs often
Child has lived in a home with little or no physical, sexual, or emotional privacy
Child has lived in a home where violence routinely occurs
Child has been exposed to sex routinely paired with aggression
Child has been physically, sexually, or emotionally abused and/or neglected
Child has been observed or photographed naked for the sexual stimulation of others
Note: Some children may not have any of these

24. Predictors of Sexual Behavior Problems
Research has identified four significant predictors of sexual behavior problems in children. Children who experience one or more of these factors may be more likely to exhibit sexual behavior problems.

25. Modeling of coercion has been found to be the strongest predictor of sexual behavior problems. Verbal and physical aggression and domestic violence are examples of coercive behavior that adults in the home may be modeling
Friedrich, Davies, et al. (2003)

26. Common Concerns and Questions

27. CONCERNS & QUESTIONS Do CSBP grow up to be sex offenders?
There is no current research that shows a clear link between sexual behavior problems in childhood and sexually abusive behavior as an adolescent or adult
Children with sexual behavior problems are different from adolescent and adult offenders in important ways
CSBP are even more diverse than adolescents who engage in sexually abusive behavior
The risks children under 12 present are very low
Brief structured treatments work well

28. CONCERNS & QUESTIONS Do CSBP need residential placement?
Most children with sexual behavior problems can be treated on an outpatient basis while living in the home/community
Residential/Inpatient placement should be reserved for the more severe cases
Interventions have not been successful in stopping behavior
Child appears unable to stop the behavior
Confounding psychiatric issues
Several incidents/several victims of sexually abusive behavior

29. CONCERNS & QUESTIONS
Can CSBP remain in their home/live with other children?
With appropriate treatment and supervision, children with sexual behavior problems can often remain in their home
If sexual behavior problems occurred with other children in the home, then the other child’s reactions and concerns must be considered
Children with intrusive or aggressive sexual behaviors that continue despite close supervision and appropriate treatment should not live with other young children until the problems are resolved
The welfare and safety of other children is always the main priority, including in the home setting

30. CONCERNS & QUESTIONS
Is it okay for CSBP to attend school?
Most children with sexual behavior problems can attend school and participate in school activities without jeopardizing the safety of other students
Do I need to always involve the school?
Not necessarily, especially if:
Sexual behavior has not occurred at school
Child is receiving appropriate treatment
Behavior is low frequency, not ongoing, etc.
Decisions should be made on a case-by-case basis, after discussion with the treatment provider

31. Assessment & Treatment

32. Professional Assessment of CSBP
An assessment will usually cover
social and family factors
broad psychological and behavioral status
sexual behavior and contributing factors
An assessment for a child under the age of 13 is not the same as a psychosexual evaluation for an adolescent or adult
Phallometry, polygraph are not appropriate
Assessing for grooming behaviors or victim empathy is not relevant to children
Recommendations should be time-limited or tied to specific goals or conditions

33. Treatment of CSBP
Treatment is effective in reducing sexual behavior problems as well as non-sexual behavior problems
Cognitive-behavioral treatment is most effective
Caregivers must be integrally involved for treatment to be successful
Group and individual therapies are equally effective as long as caregivers are involved
Treatment is generally short term: 3-6 months
Most children can be treated in an outpatient setting and live in a family

34. Treatment of CSBP Treatment for CSBP includes:
Behavior Parent Training
Teaching rules about sexual behavior
Age appropriate sex education
Abuse prevention skills
Behavior Parent Training has been found to be the treatment element most strongly related to reduction of sexual behavior problems

35. Treatment of CSBP
Effective treatments for CSBP do not include elements that are common in treatment of adult or adolescent sex offenders such as confrontation, arousal reconditioning, or interventions targeting grooming behavior and offense cycles

36. Caregiver Components of Treatment
Education about healthy sexual development and how it differs from SBP
Developing privacy and sexual behavior rules for the child
Education about factors that contribute to and maintain SBP
Sex education and how to discuss with children
Parenting strategies to improve the relationship with the child

37. Caregiver Components of Treatment
Supporting child’s use of self-control strategies
Modeling appropriate physical affection and building relationship
Guiding the child toward positive peer groups
Developing and implementing a safety plan, which includes:
A supervision and monitoring plan
Communicating the plan with other adults in the child’s life
Modifying the plan over time as needed

38. Recommendations for Families of CSBP
The adults should communicate clear rules and expectations about privacy and appropriate sexual behavior to the child. It is important that all members of the family know and observe these rules.
Close supervision is important when the child is playing with other children. Initially, CSBP should be watched at all times when playing with other children. Do not allow them to play in a room with the door closed.

39. Recommendations for Families of CSBP
The child should bathe alone and should not sleep in the same bed with other children. Also, if possible, the child should sleep in a room alone
The child should not be given any opportunities for assuming a role of authority over younger or more vulnerable children
Sexually explicit materials should not be available in the home

40. Recommendations for Families of CSBP
The adults should enforce privacy in their bedroom and in the bathrooms
The adults should use appropriate modesty in the child’s presence
It is, however, appropriate for adults to show normal affection to each other and the children
The child should not be permitted to sleep or bathe with the parent

41. Child Components of Treatment
Child’s recognition of the inappropriateness of the sexual behavior and apologizing for that behavior as appropriate for their age
Education and practice of boundaries and rules about sexual behavior
Age-appropriate sex education
Coping skills and self-control strategies
Sex abuse prevention and safety skills
Improving social skills

42. SEXUAL BEHAVIOR RULES
It's not OK to show your private parts to other people.
It’s not OK to look at other people’s private parts.
It's not OK to touch other people's private parts.
It's not OK for other people to touch your private parts.
It's OK to touch your own private parts when you are alone.

43. Treatment Effectiveness
Research has shown that over 10 years most children have significantly fewer sexual behavior problems after short-term outpatient treatment that is sexual behavior specific and has a significant caregiver involvement component
There is no research showing a clear link between sexual behavior problems in childhood and illegal sexual behavior in adolescence or adulthood after children have received outpatient treatment
Carpentier, Silovsky, & Chaffin, 2006

44. Reunification
If a child has had to leave the home due to sexual behavior problems, reunification back into the home may be appropriate
Reunification may not be appropriate if:
Child and/or caregiver deny that aggressive sexual behavior has occurred despite clear evidence that it has
Significant discomfort from siblings is evident
Siblings are experiencing PTSD or trauma symptoms, have high levels of anxiety about CSBP returning to the home, exhibit concerning behaviors after contact with CSBP, etc.
Evidence exists that siblings are being pressured to endorse reunification
Recent aggressive episodes by the child have occurred

45. Reunification
When reunification occurs, it should be done gradually while the child is still in treatment. The reunification process includes:
Family therapy sessions
Safety plans and reviews
Visits of increasing length and frequency
Assessment of emotional reactions by family members
Treatment should continue after the child is returned home to provide support to all family members

46. Promoting Healthy Sexuality

47. Sexual behavior is a natural part of child development
Age appropriate sex education does not encourage sexual behavior
Children are more likely to engage in responsible sexual behavior if they have positive models, correct knowledge, and clear values

48. TALKING ABOUT SEX & SEXUALITY Adapted from T.C. Johnson/NCSBY
If you are going to talk with your child about sexuality, make certain that you have correct information.
Pay attention to your child’s questions and answer the questions at the level he/she can comprehend.
Remember how your parents discussed or did not discuss sexuality with you and decide whether you want to change how you talk to your child.
If some children are not ready to discuss sexual behavior, let them know you will talk with them when they are ready.

49. TALKING ABOUT SEX & SEXUALITY Adapted from T.C. Johnson/NCSBY
Find a time to bring up the topic of sexuality.
Have age appropriate books on sexuality available for your children and read these books together.
Use the generally accepted terms for body parts (breasts, penis, vagina, etc.), particularly with children ages 6 to 12.
Remember that your own sexual values will be conveyed to your child.

50. TALKING ABOUT SEX & SEXUALITY Adapted from T.C. Johnson/NCSBY
It is important for children to know that changes will occur to their bodies during puberty before these changes begin to occur.
A way to encourage communication about sexuality with children is to ask what the dirty jokes are that are going around their school or what sexual slang words are being used.
When your child uses a dirty word, you may want to ask what the word means.

51. GOALS FOR HEALTHY SEXUAL DEVELOPMENT IN CHILDREN
Healthy Communication
Using words to talk about thoughts, feelings, and behaviors
Using correct words (i.e., penis, vagina, private parts, masturbation)
Having a “No secrets” rule: secrets in childhood prevent parents from knowing what a child is experiencing. This is different from privacy:
“WE DON’T KEEP SECRETS BECAUSE I CAN’T BE SURE YOU’RE SAFE”

52. GOALS FOR HEALTHY SEXUAL DEVELOPMENT
Empathy
Helping children become aware of their feelings and the feelings of others
Adults being aware of the differences in our feelings and the child’s feelings
Accountability
Helping children feel responsible for their behavior and the impact it has on others

53. SEXUALLY HEALTHY CHILDREN
Feel good about their bodies
Are respectful of family members, other children, and other adults
Understand the concept of privacy
Make age-appropriate decisions
Feel comfortable asking their parents questions about sexuality
Are prepared for the changes of puberty

54. RESOURCES
Taskforce Report on Children with Sexual Behavior Problems – Association for the Treatment of Sexual Abusers
National Child Traumatic Stress Network – Publications regarding trauma in children
National Center on the Sexual Behavior of Youth - Fact Sheets

55. SELECT REFERENCES
Carpentier, M., Silovsky, J.F., & Chaffin, M. (2006). Randomized trial of treatment for children with sexual behavior problems: Ten year follow-up. Journal of Consulting and Clinical Psychology, 74(3),
Chaffin, Berliner, L., Block, R., Johnson, T.C., Friedrich, W., Louis, D., Lyon, T.D., Page, J., Prescott, D., & Silovsky, J.F. (2008). Association for the Treatment of Sexual Abusers Task Force Report on Children with Sexual Behavior Problems. Child Maltreatment, 13,
Chaffin, M. (2008). Our Minds Are Made Up – Don’t Confuse Us with the Facts: Commentary on Policies Concerning Teen and Preteen Juvenile Sex Offenders. Child Maltreatment, 13,

56. SELECT REFERENCES
Friedrich, W.N. (2007). Children with sexual behavior problems: Family-based attachment- focused therapy. NYC: Norton.
Johnson, T.C. (2007). Understanding Children’s Sexual Behaviors: What’s Natural and Healthy.
Silovsky, J.F. (2009). Taking Action: Support for Families of Children with Sexual Behavior Problems. Safer Society Press.
Swisher, L.M., Silovsky, J.F., Stuart, R.H., & Pierce, K. (2008). Children with Sexual Behavior Problems. Juvenile and Family Court Journal, 59,