Children With Sexual Behavior Problems: Assessment and Treatment.

Author(s): Bonner, B. L., Walker, C. E., Berliner, L.

Year Published: 1999

Problems and Obstacles

There are numerous problems that are encountered in conducting research on treatment outcome in clinical settings. These problems are typically magnified when the subjects a) are children, particularly when the children have been abused or neglected, b) are involved with the legal or Child Protection Services system (CPS), or c) have a serious behavior problem. This project dealt with children who met all three of the above criteria. This particular problem, i.e., a sexual behavior problem, is a highly sensitive one and the research project team had to be well trained in responding to the child, the caregivers, CPS workers, teachers, and other family members.

Subject Recruitment

One major problem encountered in conducting this project is one frequently found in research studies, that of adequate subject recruitment. While it is sometimes difficult to recruit adequate numbers of subjects from a broad clinical population, this study focused on a small subset of children in the clinical population, which increased the likelihood of problems. In addition, the study utilized a time-limited group format and it was necessary to have an adequate number of children available every 3 to 4 months in order to randomly assign them to the two treatment approaches.

It was initially planned that the majority of the children would be referred to the project by the Oklahoma and King County Child Protective Service agencies. This was true for King County for the assessment phase of the study. However, in Oklahoma County, the results indicated that only about 25% of the children were referred by CPS. This necessitated a great deal of unexpected work on the part of the project staff to advertise the program and increase the base of referral sources.

Subject recruitment was increased through a variety of techniques at the OUHSC site: (a) program announcements were sent to Oklahoma Child Protective Services (CPS) personnel on a regular basis; (b) the Principal Investigators (Bonner and Walker) described the research at CPS staff meetings and answered questions about the project; (c) announcements were published in the OUHSC Department of Psychiatry and Behavioral Sciences newsletter; (d) contact was established with the Special Services section of the Oklahoma City schools and the PIs met with elementary school counselors to describe the program; (e) the PIs spoke at local and state psychology and other mental health conferences to advertise the project; (f) an advertisement was placed in the Oklahoma City daily newspaper; and (g) flyers were placed around the OUHSC campus to recruit participants for the comparison group. At the UW site, the PI (Berliner) made regular, weekly visits to the CPS offices to speak directly to case workers and recruit subjects.

Subject History

It was frequently difficult to obtain adequate information on the children participating in the project. A sizable portion of the children were brought to the intake by adults other than their natural parents, i.e., foster parents, step-parents, or other family members. While these adults may have known the children for an extended period of time, they often did not have detailed knowledge of the child's behavioral, developmental, or academic history. Obtaining a complete history on the children from the CPS caseworker was often difficult as they lacked the information.

In addition, it was extremely difficult to obtain accurate, detailed information on the child's actual sexual behavior. What was reported by the adults at intake was sometimes what had been told to them by another adult, another child, or the child coming for treatment. Only in rare cases was an actual investigation conducted by CPS or the police. Without a formal investigation, it was hard to determine exactly who had done what to whom, how many times the behavior occurred, and the circumstances surrounding the behavior.

Subject Attrition

Another problem typically found in this type of research is that of subject attrition. Only one of these children was actually ordered by the juvenile court to attend while other children and caregivers/foster parents were encouraged to participate by their CPS caseworkers. But, in general, the caregivers were attending on a voluntary basis. While 147 were eligible to participate in the treatment program, only 110 (75%) chose to begin treatment, and of those 110, only 69 (63%) attended the required number of sessions (9 of 12) to be counted as research participants. Further attrition was found at follow-up when only 25 (36%) completed the one-year follow-up and 20 (29%) completed the two-year follow-up assessment.

Instruments

Another significant problem was the lack of standardized instruments to measure inappropriate or aggressive sexual behavior in children. While the study utilized the Child Sexual Behavior Inventory, a standardized instrument that measures the frequency of certain sexual behaviors in children, there were no items that assessed the level of inappropriate or aggressive sexual behavior found in this population of children.

Problems were also encountered in measuring treatment outcome as there are no instruments designed to measure the reduction of inappropriate or aggressive sexual behavior in children. Goal Attainment Scaling was initially used to document behavior to be decreased (sexual and other problematic behaviors). However, this technique proved to be problematic as the project PIs and consultants could not find a suitable scoring system to use for weighting the behaviors in a standardized format.