FINDING THE RIGHT TREATMENT

One of the most important supports for you, if your child has a problematic sexual behavior, is to have quality behavioral health treatments. Effective treatments do exist. When a child and his/her family can get this kind of treatment, it makes a big difference for all involved. The treatments can have positive results for a very long time. Consult a qualified treatment professional when

  • your child demonstrates a problematic sexual behavior as described earlier;
  • you are uncertain if the behavior was just “playing doctor” or was a problematic sexual behavior;
  • any child is distressed about the sexual behaviors of another child; or
  • you have other serious questions and concerns about your child.

The first steps of the behavioral health provider (therapist) should be to evaluate and assess the situation with your child and your family. This evaluation will help the provider determine if the behavior was a problematic sexual behavior, what other concerns or issues might need to be addressed, and what supports and protective factors are present in the family and community.

The evaluation will most likely involve an interview with you and your child (particularly if your child is 7 years old, or older). You and maybe your child’s teachers and your child, too, will have to complete an information checklist. Some other tests may have to be given to your child. If Child Protective Services or law enforcement is involved in the case, a summary of their findings will be helpful to the professionals. The professionals will often choose to postpone this evaluation until the completion of any Child Protection Services or law enforcement investigation, to prevent any interference with the process.

What makes a treatment program successful?

Different types of therapies for problematic sexual behaviors in children have been evaluated by researchers to determine just how effective each one is. Some of the research has examined therapy designed to help sexually abused children, with a goal of reducing the children’s problematic sexual behaviors. Other research has looked at treatments set up to focus specifically on problematic sexual behaviors. Looking at all the research to date, we have learned about what types of treatment are helpful for children with problematic sexual behaviors and their families. The main characteristics of effective therapy include

  • outpatient treatment (where the child stays in the home and community);
  • active and full participation in the treatment by parents and caregivers;
  • short-term treatment of approximately three to six months. Short-term treatment is possible if the family attends sessions regularly, actively participates in available services, and practices skills between sessions; and
  • Education for caregivers about how to:
  • apply rules about sexual behaviors;
  • improve the quality of their relationship with their children;
  • use parenting strategies that prevent and reduce behavior problems in general;
  • address sexual education topics with their children; and
  • support abuse-prevention strategies and skills.

“The concrete techniques taught gave my daughters new skills that have been useful in many situations. It reminded me to use praise more and to approach each situation with a calm attitude.”

—Parent of 10 and 8-year-old girls

“I now treat Houston like a 12-year-old child, instead of expecting him to always know the ‘right’ thing to do.”

—Parent of a 12-year-old boy

Other treatment characteristics that may be helpful include addressing the following topics with the children in age-appropriate ways:

  • Privacy rules, sexual behavior rules, and boundary rules
  • Abuse-prevention skills
  • The labeling and expressing of feelings and skills to reduce distress
  • Impulse-control strategies and decision-making skills
  • Social skills
  • Apologizing and extending empathy toward victims, when children are old enough to understand the value of such caring acts

These treatments have been found to be effective with children who have a wide range of problematic sexual behavior, including the types of problematic sexual behavior of the children in the examples provided in the introduction. Even kids who demonstrated aggressive sexual behaviors like Jerry Kastner have responded well to intervention.

Treatment for children with problematic sexual behavior is very different from treatments for adults with sex crimes. You should avoid adult sexual offender treatment models that appear punitive in nature, or that focus on sexual arousal and arousal reconditioning and that don’t involve caregivers. Information about teaching children Private Part or Sexual Behavior Rules can be found by clicking here. Strategies to teach abuse-prevention skills and impulse-control skills can be found below

“Both children benefited from learning alongside other children. The key areas of hula space, bubble breaths, and turtle technique became solid, basic family axioms. The children possess confidence and comfort in knowing what the rest of the group knows. This confidence and education has helped my children to understand and act appropriately.”

—Parent of a 6-year-old boy and a 5-year-old girl

“Johnny now is better at controlling himself and his sexual behavior. He is more comfortable with talking about and telling the truth.”

—Parent of an 11-year-old boy

Abuse-Prevention Skills

Adults who teach and take care of children are responsible for protecting all children from abuse. While most adults feel capable of watching out for strangers who might try to harm children, the reality is that most children are sexually abused by someone they know. Children with problematic sexual behavior are often considered more vulnerable to future sexual abuse victimization than other children. An important goal of treatment is to help you be able to recognize potentially risky behaviors and situations and have the skills to respond effectively.

“You should always have some trusted adult who will believe you. Never let any adult touch your private parts if they don’t have a good reason.”

—12-year-old girl

The Stop It Now! organization has developed several useful pamphlets that address the prevention of child sexual abuse. The pamphlets, designed specifically for caregivers, can be found at www.stopitnow.org. The recommendations provided by Stop It Now! also support other parenting advice for children with problematic sexual behaviors. The pamphlets describe how to provide close supervision, monitor media and technology, have good physical boundaries, and address inappropriate talk and behavior. They also suggest that you have an open communication with your children about private parts, rules regarding sexual behaviors, relationships, and intimacy.

Teaching your child the Private Parts Rules or Sexual Behavior Rules allows him or her to learn information about appropriate and inappropriate touch. This information is an important foundation for your child because it teaches the child how to know when someone else is breaking a rule or when activities might hold the potential for abuse. Teaching your child how to respond if someone else attempts to break one of these rules provides abuse-prevention education. Strategies to include in this teaching process are how to get out of a dangerous situation and how to find and talk to an adult. At times the first adult a child tells may not understand or respond, so also teach your child to keep on telling, until someone believes and protects him or her. Teaching your child to tell an adult, even when the child has been told to keep the incident a secret, is important.

Impulse-Control Skills and Decision-Making Skills

Children can be taught helpful strategies to express their feelings, remain in control of their bodies, and follow home and school rules. Preschool children are impulsive by nature, but they can begin to learn to stop and think before acting. Older children with problematic sexual behavior may also be impulsive. A strategy called the STOP Steps can be taught to your child as a way to remain in control and to appropriately express anger and other feelings. The STOP Steps includes the following steps, which can be used when children have strong feelings or are about to do something that will get them in trouble:

Stop! relax, and calm down.
Think about what you should do.
Observe and explore choices for responses.
Plan your response.

First, children need to be taught how to recognize feelings and how to know when those feelings are especially intense or strong (such as very angry or scared). Once children recognize a strong feeling, before they say or do anything, they can tell themselves to stop and then can practice calming down. After they are calm, they can think better about what they should do in the situation. You can help your children practice these skills.

For younger children, it can be helpful to give them a story with animal characters to help them visualize the steps. One metaphor that has been useful is the image of a turtle that always carries a shell on his back to keep himself safe. You can use a story about turtles, with a wise old turtle who teaches the younger turtles to use their shells when they are feeling strong feelings or are about to get into trouble. The turtles can stop, go into their shell, take deep breaths to calm down, think about what they should do, and go do it! Puppets can help keep the children engaged in learning these steps.

You also can model this strategy for your children. If you are a little frustrated, you can say out loud, “I am beginning to feel frustrated. I need to calm down. I am going to take some deep breaths and count to 10. Then I will make a good decision.” Then you can do something that is constructive. You can also gently remind your child to use the STOP Steps or the Turtle Steps.

Hundreds of families have successfully learned and used these strategies. We find that not only do the children benefit from learning the strategies, but the parents do, too. Parents report that their children often remind them to use the STOP Steps, particularly when in the car during heavy traffic.

“After we learned the STOP method, instead of jumping angrily at the kids, I began using the STOP myself, which helped me deal with the situation.”

—Parent of two girls, ages 8 and 11 years old

“When he seems like he is going to ‘blow,’ I now catch him and tell him to, ‘Stop, relax, and think.’”

—Parent of a 9-year-old boy

“I now tell my son each day to do the next right thing. If he can just stop and think about what is the next right thing to do in this very situation, he will stay on the right path.”

—Parent of an 11-year-old boy

Apology and Empathy

Parents often comment about being concerned that their child may be a “psychopath,” because their child is not demonstrating strong remorse associated with various problematic sexual behavior. This is the case with Ms. Blackwood in the third story in the beginning of this website. Instead of having this worry, we want to assure you that children are naturally and normally self-focused. Young children do not readily understand and experience other people’s perspectives about situations and emotions. Young children follow rules to avoid punishment and receive benefits (rather than for the more altruistic reasons that adults may have).

Of the hundreds of children who received effective services for their problematic sexual behaviors, it has been rare that we have had any real concerns that a child was unable to be sensitive to others. More common, and of greater concern to us, are situations in which children have developed a strong sense of shame. In those situations, the children believe that they are worthless, damaged, or bad human beings.

While it is important for children to recognize that breaking the sexual behavior rule is a serious problem, they also need to recognize that they are valuable people who can learn how to follow the rules. A sense of guilt (such as, “I did something I should not have done, and I need to not do it again”) is healthy, but shame (such as, “I’m a horrible person who can never do any good”) is harmful. Caregivers need to provide and work with the other people in the child’s life to communicate the message that the child is loved and loveable; it’s the behavior and choice that was not acceptable.

Some therapies for children with problematic sexual behaviors may include the writing of a mock apology letter to the person with whom the child broke the sexual behavior rule. This letter is for therapeutic purposes only, and is not to be taken home or given to the other child. The letter helps the child to acknowledge that he or she has broken a specific rule, as well as to acknowledge the impact that that behavior has had on others. It also describes what the child has learned to be better able to follow the rules, and says what other people can do to stay safe. To provide support to a child through this process, we also ask the caregiver to write a supportive letter to the child about his or her progress.

“Dear Sister, I am writing because I broke a sexual behavior rule. What I did was not okay because it is dangerous. It could hurt somebody really bad. When I think about what happened, I feel sad, scared, and embarrassed. I have learned some ways to control my behavior. They are the sexual behavior rules and the STOP method. I have been helping myself to not be so sad. If you ever feel uncomfortable around me, you could talk to someone.

—Sincerely, Leslie, 9 years old

“Dear Leslie, We want you to know how very proud of you we are. We know that there is so much that has happened and there have been a lot of changes that have taken place. We really feel that you are being strong and we are very proud of you. We appreciate that you listen and do what is asked. We have been pleased that you have opened up a little more each day and that you are talking about your feelings. We know things take time to feel more comfortable and natural, but you are putting in a really good effort. Thank you for your positive attitude. Always know that we will be here for you and loving you. You are very special and important.

—Mom and Dad

Trauma Symptoms in Children with Problematic Sexual Behaviors

Some children with problematic sexual behaviors have themselves been the victims of something deeply shocking or upsetting. Those children have sometimes been sexually abused, physically abused, or have witnessed violence. They have trauma symptoms, such as nightmares, separation anxiety, the inability to stop thinking about the trauma, or avoidance of things that remind them of the trauma. Both problematic sexual behaviors and trauma symptoms can be effectively treated with Trauma-Focused Cognitive-Behavioral Therapy. This treatment is similar to the one described above, in that it is often done on an outpatient basis with both the caregivers and the child, it is relatively short-term, and it teaches participants information and coping skills. Trauma-Focused Cognitive-Behavioral Therapy also provides education about the effects of traumatic events and addresses negative thinking that the child and parents may have. It encourages children to tell what happened in a way that reduces the trauma symptoms around the event (this is called the “trauma narrative”).  Parents can also go to www.nctsnet.org and click on For Parents and Caregivers. Information about TF-CBT and other treatments for trauma can be found here: www.cebc4cw.org

 

General Behavior Problems in Children with Problematic Sexual Behaviors

Often, but not always, children with problematic sexual behaviors have difficulty following rules in general and listening to their caregivers and other adults. They may have Attention Deficit Hyperactivity Disorder (ADHD) and as a result may be impulsive and active. Children with ADHD have difficulty sitting still and listening. They may talk in class, and have difficulties either sitting in their chairs or following the rules at home and at school.

Sometimes children with problematic sexual behaviors are more resistant, angry, or negative in general. They may yell a lot, argue, and get into fights. They may not listen to their parents or teachers without a good or clear reason. Parents’ and teachers’ efforts to have the children listen and follow rules just don’t seem to work with children who have a long pattern of being combative or argumentative. These children may be diagnosed with Oppositional Defiant Disorder or Conduct Disorder, such as Jerry in the fourth example in the introduction.

These types of behaviors—being impulsive, breaking serious rules, or displaying high levels of activity, anger, or resistance—come out in different amounts levels of intensity and extent to which problems are caused. In the milder stages, your family may benefit from using different parenting strategies.

Parenting strategies that can be helpful are as follows:

  • Schedule regular positive playtime with your child.
  • Provide consistency in your child’s daily routine.
  • Offer regular recognition of the positive behaviors
  • Give clear, concise messages.
  • Have clear, consistently applied rules, with clear consequences.
  • Provide opportunities for children to appropriately identify and express their feelings and to apply strategies to remain calm and make good decisions.
  • STAY CALM.

The parenting strategies listed above are important even with children with an abuse or trauma history. Caregivers often have a hard time requiring rules or consequences of children who have been abused, because they feel the children have been hurt enough already. This was the case in the example of Ms. Blackwood at the beginning of the website. Her granddaughter, Summer, had been sexually abused and Ms. Blackwood was worried that firm rules could upset Summer even more. Summer had been through a difficult time, and Ms. Blackwood wanted her to be happy. It is understandable that a parent will feel that way. Children will often cry and get upset when someone imposes consequences. But you can tell yourself that you are being a good parent if, through a structured and positive environment, you teach your child to make good decisions and follow rules. Treatments found especially helpful for sexually and physically abused children include the teaching of parenting strategies such as the ones above.

If you have told your child to do something, and she becomes upset, causing you to wonder if you are doing something harmful to her, ask yourself:

  • Is what I’m asking my child to do reasonable? Are most children her age capable of following this task?
  • Is my child choosing not to do what I say? That is, has she heard and understood the instruction and is she capable of doing it, yet is still not completing the task?
  • Is the consequence I have chosen reasonable (does it “fit the crime”)? That is, is the consequence appropriate, given what she is still choosing not to do?

If you can answer yes to all of the above, then know that you are being a good caregiver by giving your child this consequence. You are teaching your child the importance of listening to you and following your instructions. You are teaching your child to respect others and to learn self-control.

For children with the most difficult attention problems—impulsiveness, hostility, or poor conduct—professional support is a must. What can help is a treatment called Behavioral Parent Training, which can be provided by a psychologist, social worker, or other licensed mental-health specialist. This treatment teaches you parenting strategies proven effective with children who are combative or impulsive, and who do not follow important rules at home, at school, or in the community. A number of different types of Behavioral Parent Training have been found effective, including Parent-Child Interaction Therapy, Incredible Years, and Parent Management Training. The therapist will work with you directly to help you apply these parenting strategies to your child.

Consult with your child’s pediatrician about your child’s behavior. That doctor may, in turn, refer your child to a developmental pediatrician (a pediatrician who specializes in behavior and developmental problems) or a psychiatrist. If your child has ADHD, a number of medication choices can be used as well. The medication you use should help your child focus his attention and help reduce his need to act impulsively. Medication should not change your child’s core personality or make him or her “zombie”-like. If these changes occur, the dose is likely too high. In that case, you should immediately contact your child’s prescribing physician.

Should We Have Family Therapy or Group Treatment?

Therapy with individual families and group-treatment approaches have both been found helpful in reducing problematic sexual behaviors in children. Treatments that work only with the child (and do not directly involve the caregivers) are not useful in reducing problematic sexual behaviors. Family therapy and group treatment have different advantages and disadvantages.

Family therapy
  • can address complex, concurrent issues;
  • can provide individualized treatment;
  • may more readily address crises when they occur; and
  • may be the only thing available, particularly in small, rural communities where therapy in a group would feel too threatening and too exposing to group members.

“Having a child with problematic sexual behaviors can feel very isolating. While parents can often talk with other parents about things like poor grades, stealing, and fighting, sexual matters and problematic sexual behaviors are topics other parents just don’t know how to take. It has been helpful to be with a group of parents who know the road I’ve been walking.”

——Parent of a 12-year-old boy

“The group helped me know that other kids have the same problems and that there are people willing to help. I’m not alone.”

—Parent oF 4-, 5-, and 6-year-old girls

Group therapy
  • is the most common format for directly addressing problematic sexual behaviors;
  • provides children with the opportunity to practice good skills with other children;
  • provides an opportunity to be accountable to other children, since school-age children tend to look to other children for guidance;
  • provides important support for the caregivers; and
  • requires that the therapist maintains good control of the children’s group. If the group is out of control, the benefits to the group are lessened.
When Do Children with Problematic Sexual Behaviors Require Inpatient or Residential Treatment?

Most children with problematic sexual behaviors can be treated on an outpatient basis while living at home. When children have sexually acted out with their younger brother or sister, they may temporarily need to live with a relative or in another home. Most of the time, children can be successfully raised at home with outpatient treatment, and without the removal of any children from the home. This option is discussed in more detail here. Residential and inpatient treatment has downsides including cost, difficulty of maintaining caregiver involvement in treatment (due to transportation/distance issues), exposure to other children with severe problems, labeling, and stigma. These concerns have to be weighed against the potential benefits of residential care. Residential and inpatient treatment should be reserved for the most severe cases, such as children with

  • intense psychiatric disorders, such as psychotic symptoms (like hearing voices);
  • highly aggressive or coercive sexual behavior that recurs despite appropriate outpatient treatment and close supervision;
  • suicidal tendencies that include specific plans; and
  • specific plans to physically harm others.

Children with any of the above characteristics should be evaluated by a qualified mental health professional to determine the need for a higher level of care, such as inpatient or residential placement.

Qualifications of Therapists

Children with problematic sexual behaviors should be seen by a licensed mental health professional who has

  • child development expertise (including sexual development expertise);
  • knowledge of the different types of childhood mental health disorders;
  • familiarity with children who have multiple diagnoses, which is often the case with children with problematic sexual behaviors. The professional should be trained in the topics of ADHD, child
  • maltreatment, child trauma, and conditions that affect self-control;
  • an understanding that larger social problems have an impact on children’s behavior, including their sexual behavior;
  • knowledge of current research and effective approaches for treating childhood mental health disorders and problematic sexual behavior; and
  • knowledge of the many cultural variations that exist in parenting and childhood sexual behavior.
Tips to Remember
1 Effective treatment actively involves the parents and other caregivers.
2 Most children with problematic sexual behavior can remain in the community and receive treatment.
3 Inpatient or residential treatment should be reserved for children with serious mental health issues or whose sexual behaviors are not responsive to adult supervision and guidance.
4 Ask therapists about their qualifications and experience serving children with problematic sexual behavior.
Resources