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

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 #1U79SM061152-01 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

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

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

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

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

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

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

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!”

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

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

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

Concerning/Problematic Behavior

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

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

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

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

Children with Sexual Behavior Problems

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

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

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

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.

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

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.

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)

Common Concerns and Questions

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

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

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

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

Assessment & Treatment

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

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

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

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

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

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

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.

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

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

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

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.

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

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

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

Promoting Healthy Sexuality

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

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.

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.

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.

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”

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

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

RESOURCES Taskforce Report on Children with Sexual Behavior Problems – Association for the Treatment of Sexual Abusers http://www.atsa.com.pubRpt.html National Child Traumatic Stress Network – Publications regarding trauma in children www.nctsn.org National Center on the Sexual Behavior of Youth - Fact Sheets www.ncsby.org

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), 482-488. 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, 199-218. 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, 110-121.

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, 49-69.