Children With Sexual Behavior Problems: Assessment and Treatment.

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Methodology - Assessment Measures

The 201 children with sexual behavior problems and the 52 children without sexual behavior problems and their parents/caregivers completed a battery of questionnaires and standardized tests in order to assess their affective and behavioral problems, cognitive ability, sexual behavior problems, and family functioning.

Data were also collected by child self-report, caregiver report, reports from the referral sources, and records obtained through the Oklahoma and Washington Department of Human Services. The test battery required 3.5 to 4.5 hours to complete; due to the length of administration and the sensitive nature of some questions, the children did not always complete the entire test battery. Breaks for refreshments and play were provided, as necessary, to ensure that the child was able to complete as many test items as possible. Children were not required to answer any questions that appeared to cause them distress; the instruments most frequently not completed included the Rorschach, the PTSD Symptom Scale, and the Family Environment Scale (see descriptions below).

The complete battery consisted of the following instruments:

1. Child Evaluation

1. General Intelligence
   
   The Kaufman Brief Intelligence Test (K-BIT) (Kaufman & Kaufman, 1990). The K-BIT is an individually administered screening device that provides three IQ scores: vocabulary (verbal), matrices (non-verbal), and composite (global) as well as a categorical descriptor (e.g., below average, average). This test was used to assess the child's intelligence level and was utilized as one indicator of his/her ability to participate in the group therapy sessions.
   
   
2. Overall Psychopathology and Adjustment
   
   The Child Assessment Scale (CAS) (Hodges, Stern, Cytryn, & McKnew, 1982). The CAS is a 226-item structured interview developed for the assessment of school-age children in clinical or research settings. The instrument is tied to the DSM-III-R and provides a standardized diagnosis. Abnormal responses are summed across the 226 items for a general pathology score and subscales are generated that provide assessments of depression, anxiety and fear, self-image, conduct disorders, and somatic complaints.
   
   The PTSD Symptom Scale, Interview Form (PTSD) (Dancu, Riggs, Rothbaum, & Foa, 1991). The PTSD is a 17-item self-report measure used to obtain or rule out a diagnosis of PTSD based on the DSM-III-R diagnostic criteria for PTSD. It was developed for use with adults but has been used with children; for this administration, it was added at the end of the CAS questionnaire.
   
   The Rorschach Inkblot Test (Rorschach, 1942). The Rorschach Inkblot Test is a standardized projective measure designed to explore an individual's personality by systematically studying the person's responses to a stimulus. All Rorschach test batteries were scored by one clinician trained in the Exner (1978,1986) scoring system.
   
   Draw a Person (DAP). Children were instructed to "draw a person" on a blank sheet of paper with no additional instructions. After the child completed the first drawing, the child was asked whether it was a boy or a girl. Then a clean sheet of paper was presented to the child and he/she was asked to draw a person of the opposite gender. The child was asked whom each picture represented and was asked to identify any unusual markings or depictions. The pictures were judged on two criteria: presence of sexual parts and immaturity of drawing by the Principal Investigator, Barbara L. Bonner, PhD.
   
   
3. Sexual Behavior
   
   The Child Sexual Behavior Inventory, Version 2 (CSBI-2) (Friedrich, Beilke, & Purcell, 1989). The CSBI-2 is a 35-item instrument completed by a parent or caregiver to determine the presence and intensity of a range of sexual behaviors in children ages 2 to 12 over a six-month period. The instrument assesses the child's sexual behaviors on a continuum ranging from mild to aggressive and provides separate clinical scores based on the child's age and gender. This instrument is the only checklist created to specifically assess sexual behavior problems in children ages 6 to 12. Studies conducted by Friedrich et al. (1991) have indicated that sexually abused children differ from non-abused children on critical items as well as on the total sexual behavior score, with sexually abused children showing significantly higher scores.
   
   
4. Behavior Problems and Social Competence
   
   Child Behavior Checklist-Parent Form (CBCL) (Achenbach, 1991). The CBCL is a 134 item standardized checklist of childhood behavior problems and social competence that is completed by the parents or caregivers. The CBCL measures factors such as depression, somatic complaints, hyperactivity, sexual behavior, aggressiveness, and delinquent behavior as reported by the parent. The CBCL also provides subscales for total, externalizing, and internalizing behavior problems. This instrument has been used in numerous studies of the effects of sexual abuse.
   
   Behavior Change Rating Scale (BCRS). This instrument was based on Goal Attainment Scaling and was completed by the parent or caregiver. The parent reported the three specific misbehaviors that were of greatest concern to them, with at least one misbehavior being sexual in nature. The parents reported the date the misbehavior was first observed as well as the frequency of the behavior on a weekly basis. The parents were also asked to report three specific prosocial behaviors that they would like their child to exhibit on a weekly basis and the current frequency of that behavior. These indices were to be used as baseline rates of behavior for the immediate, one-year, and two-year follow-up assessments conducted after the conclusion of the treatment program. However, this proved to be problematic as the project PIs and consultants were not able to find a suitable scoring system to weight the behaviors in a standardized manner. Analysis of these data, therefore, are not included in the present report but will be addressed in future reports.
   
   
5. Affective Problems
   
   Revised Children's Manifest Anxiety Scale (RCMAS) (Reynolds & Richmond, 1985). The RCMAS is a 37-item inventory that assesses a variety of anxiety symptoms. Three factor scores and a validity score are obtained to detect a social desirability response bias. Reliability and validity studies indicate that the instrument may act as a satisfactory measure of chronic anxiety.
   
   
6. Self-Concept
   
   The Self-Perception Profile for Children (SPPC) (Harter, 1985). The SPPC is a 36-item structured alternative format measure of self-concept including competence and self-adequacy for children ages 8 through 13. The instrument provides subscales of scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, and global self-worth.
   
   The Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (PSPC) (Harter & Pike, 1983). The PSPC is a 24 pictorial assessment of self-reported self-concept for children ages 5 through 7. This assessment provides subscales of cognitive competence, physical competence, peer acceptance, and maternal acceptance.
   
   
7. Family Functioning
   
   The Child Version of the Family Environment Scale (CVFES-C) (Pino, Simmons, & Slowksi, 1984). The CVFES contains 30 items with 3 items for each of 10 dimensions. Children's perceptions of family functioning are assessed through pictorial representations of three differing interactions between mother, father, and children. Children rate their families on subscales encompassing cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural orientation, active-recreational orientation, moral-religious emphasis, organization, and control. The subscale t-scores are used to obtain a categorical description of the child's perception of the family based on a hierarchical system. These criteria should be able to characterize approximately 90% of families.

Parent/Caregiver Evaluation

1. Psychological Status
   
   The Brief Symptom Inventory (BSI) (Derogatis, 1991). The BSI is a shortened version of the Symptom Checklist 90-Revised (Derogatis, 1983). This 53-item self-report measure provides nine primary symptom dimensions and three global indices of distress. T-scores equal to or greater than 70 are considered clinical. Scores obtained on the BSI correlate significantly with the clinical and content scales of the MMPI.
   
   
2. Level of Stress
   
   The Parenting Stress Index (PSI) (Abidin, 1983). The PSI is a 120-item self-report instrument designed to measure the relative degree of stress in a parent-child system and to identify the sources of distress. Three major sources of stress, characteristics of the child, characteristics of the parent, and situational-demographic life stress, are assessed by the instrument.
   
   
3. Attitude Toward the Child
   
   The Index of Parental Attitudes (IPA) (Hudson, 1982). The IPA is a 25 item self-report instrument that measures the degree of contentment that the parent or caregiver has regarding the relationship with their child. The parent or caregiver rated each item on a 7-point Likert-type scale indicating the frequency of their subjective feelings about the child.
   
   
4. Family Functioning
   
   The Family Environment Scale Form R (FES-R) (Moos & Moos, 1981). The FES-R is a 90-item true-false instrument that measures the social-environmental attributes of various kinds of families or the perception of family members about their family. The FES assesses three dimensions of family functioning: relationships, personal growth, and system maintenance based on ten different subscales. The subscales assess levels of: cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural orientation, active recreation, moral-religious emphasis, organization, and control. Subscale t-scores are used to obtain a categorical description of the adult's perception of the family based on a hierarchical system. These criteria should be able to characterize approximately 90% of families.
   
   
5. The Demographic Questionnaire (Bonner, Walker, & Berliner, 1991). This measure was developed for this study and assesses the demographics, employment status, income, substance abuse and use, adult and child abuse histories, as well as behaviors observed in the child before and after the target date (the date at which the inappropriate sexual behavior was first observed).

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