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Children With Sexual Behavior Problems: Assessment and Treatment.

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

Year Published:  1999

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All data analyzed in connection with this final report are presented in Tables 1-12 which can be found in the Appendix. Selected results are presented and discussed in the following four sections. The first section describes the demographic data on a) the children with sexual behavior problems (CSBP; N=201) and the comparison group (CG; N=52) as completed by the 253 parents/caregivers, and b) demographic data on the biological parents of the two groups. The other three sections present information on the assessment, the development of the typology, and treatment outcome.

A. Demographic Data

1. Children*

The 201 children with sexual behavior problems referred for assessment included 126 (63%) boys and 75 (37%) girls. By age, this included 29 boys and 33 girls at age 6, 36 boys and 11 girls at age 7, 22 boys and 12 girls at age 8, 10 boys and 11 girls at age 9, 9 boys and 4 girls at age 10, and 20 boys and 4 girls at age 11. The average age of the children with sexual behavior problems was 7 years, 8 months.

The children's race reflected the populations of Oklahoma and King (WA) counties. The participants included 154 (76.6%) Caucasian children, 24 (12%) African-American children, and 10 (5%) Native American children. Another 11 (5%) children were Hispanic, Pacific Islander, or Asian, and 5 (3%) did not answer the item (See Table 1). Almost 60% (n=120) of the children had a history of receiving mental health counseling in the past.

*It should be noted that all totals do not equal 201 due to missing data on some items.

The children's history of abuse, including physical, sexual, emotional, and neglect, was primarily assessed through parental/caregiver or caseworker report. To check for additional incidents that were not known or reported by the parents, two additional measures were utilized: a) a subset of children was directly interviewed regarding possible incidents of abuse or neglect, and b) a review of Oklahoma Child Protective Services records was conducted. No additional reports of abuse were obtained from these sources.

Of the 201 children with sexual behavior problems, a total of 119 (59%) had a reported history of maltreatment, including physical abuse, sexual abuse, emotional abuse, and/or neglect; this included 64 (51%) of the 126 boys and 55 (73%) of the 75 girls. Of the total sample of 201 children, 64 (32%) had a reported a history of physical abuse, 97 (48%) sexual abuse, 70 (35%) emotional abuse, and 33 (16%) neglect. (These figures total more than 201 as 77 children were reported to have experienced multiple forms of abuse.) In this sample, 51 (25%) reported no history of abuse and 31 (16%) did not answer the item. In summary, of the 201 participants, 119 (59%) of the children (64 boys, 55 girls) with sexual behavior problems had experienced at least one form of abuse or neglect and 97 (48%; 49 boys, 48 girls) had a reported history of sexual abuse.

It should be noted that 104 (52%) of the 201 children with sexual behavior problems were not reported to have experienced sexual abuse, and 82 (41%) had no reports of any form of abuse or neglect. Only one child disclosed a history of abuse or neglect during the treatment phase of the project that was not known previously. This incident was reported by a member of the project staff and was investigated and substantiated by the Oklahoma Department of Human Services.

The comparison group (CG) (N=52) were children ages 6 to 12 with no reported sexual behavior problems. The group was comprised of 25 children (9 boys, 16 girls) who had reported histories of abuse or neglect and 27 children (15 boys, 12 girls) with no reported history of maltreatment. Overall, 48% of the comparison group had a reported or substantiated abuse or neglect history. Of this sample of 52 children, 10 (19%) had a reported history of physical abuse, 16 (31%) sexual abuse, 10 (19%) emotional abuse, and 8 (17%) neglect. The children's race was less reflective of Oklahoma (OK) and King (WA) counties, having 33 (63%) Caucasians, 11 (21%) African Americans, 2 (4%) Native Americans, and 5 (10%) Hispanic, Pacific Islander, or Asian. The average age of the comparison group was 8 years 5 months; this is statistically different from the CSBP group, although the average age is only six months more than the CSBP group.

The children with sexual behavior problems (CSBP; N=201) were compared on demographic items to the comparison group (CG; N=52) who had no reported sexual behavior problems. The significant differences between the groups are listed below. (For a complete review of the demographic data on the two groups as reported by the parents/caregivers, see Table 1 in the Appendix.)

1. Age: The CSBP group was significantly younger than the CG group (p =.05).
   
   
2. Gender: There were significantly more males in the CSBP group (p =.05).
   
   
3. Race: The CSBP group had significantly more Caucasians and fewer African Americans (p =.05).
   
   
4. History of sexual abuse: More children in the CSBP group had a history of sexual abuse (p =.001).
   
   
5. Age at which emotional abuse and neglect occurred: The CSBP group was significantly older when both forms of abuse were reported to have occurred (p=.05).
   
   
6. Behavior problems at school: Children in the CSBP had significantly more problems at school (p =.05).
   
   
7. Witnessing human sexual behavior: Significantly more children in the CSBP group had witnessed human sexual behavior (p =.05).
   
   
8. Parental divorce: Parents of CSBP children had higher rates of divorce (p = .05).
   
   
9. Experiencing death in family: CSBP children were significantly more likely to have had a member of their immediate family die (p = .05).
   
   

1. Number of years known child: The CG parents had known the child significantly longer as the children in this group were significantly older (8.4 years vs. 7.7 years) than the children in the CSBP group (p =.05).
   
   
2. Marital status: The CG is significantly more likely to be married to their first spouse than the CSBP group (p =.05).
   
   
3. Family income: The CG group has significantly more parents in the $40,000+ range than the CSBP group (p = .05).
   
   

B. Assessment Results

1. Child Reported Information

The 253 children were given a battery of instruments to assess their current level of intelligence, behavior, affect, self-perception, and view of the family environment (See Table 4). There were no significant differences in the CSBP and CG on intelligence or self-esteem measures; both groups scored in the normal range of intelligence and reported mid-to-high levels of self-esteem.

Other measures indicated significant differences between the two groups of children. Children with sexual behavior problems reported significantly higher levels of anxiety, post-traumatic stress, ADHD, oppositional and conduct disorder, depression, and dysthymia. In general, the CSBP children reported significantly more problems with school, friend, activities, physical complaints, and in their families.

There were also significant differences between the two groups of children on the Rorschach. (It should be noted that this was the most frequently refused instrument in the battery.) The differences were generally consistent with and reflective of the groups of children that were evaluated. The CSBP group showed higher levels of intensity and lack of modulation in their outbursts, were less interested in people, more avoidant of affect, less likely to anticipate that people would be cooperative, and more likely to view the world as aggressive.

2. Biological Parent Reported Information

The biological parents of the two groups completed two instruments that provided information on the child's behavior, affect, social and school competence, personal living skills, and level of sexual behavior. There were numerous significant differences between the two groups that are similar to those reported by the children themselves (see Table 5). The CSBP children were found to be significantly higher in levels of overall problems in behavior, affect, and sexual behavior. (It should be noted that the CSBP children's average scores on the CBCL fell into the at-risk as opposed to the clinical range.)

In addition, the parents completed instruments assessing their own current symptomology, the family environment, the level of their stress related to parenting and their life in general, and their attitude toward the child (See Table 6). The results indicate that there were no significant differences between the groups of parents in current symptoms or their views of their families. There were, however, numerous differences in their levels of stress. Parents of CSBP children reported significantly more stress in 11 of the 17 categories assessed. It appears that parenting a child with sexual behavior problems causes significant stress to the adult. This difficulty is also reflected in the parental attitude toward the child as parents of CSBP children reported significantly less positive attitudes toward their children.

C. Typology Development

The original data analysis strategy called for developing clinically useful subcategories of children with sexual behavior problems by subjecting data gathered on the children in this experiment to cluster analysis. Using the SPSS Cluster procedure, several attempts were made to derive clusters from the data from the 201 children referred for sexual behavior problems.

Various combinations of scales and demographic data were employed in these clustering attempts. In keeping with the goals of the project, data selected for the cluster analyses concentrated primarily on measures of inappropriate and aggressive behavior, particularly with respect to sexual behavior. None of the cluster analyses yielded stable clusters that appeared to have clinical relevance or utility.

Examination of the variables available for use in generating the clusters revealed that there were very few variables dealing explicitly with the children's sexual behavior and virtually none that dealt with aggressive sexual behavior in children. Therefore, the failure to obtain useful clusters was thought to be due to the fact that suitable scales for assessing this behavior were not available. (It should be noted that although the Child Sexual Behavior Inventory (CSBI-Version 2) measures sexual behaviors and differentiates sexually abused children from non-sexually children, this version does not contain highly aggressive sexual behavior items and, thus, did not subtype children in this study based on the severity of their sexual behavior.)

In order to further clarify the nature of the behavior for which children were referred, the referral behaviors were rated on two scales by five selected mental health professionals who were experts in child behavior and had considerable experience in working with children with sexual behavior problems (Mark Chaffin, PhD, Eliana Gil, PhD, Laura Merchant, MSW, Robert Wheeler, PhD, and Anthony Urquiza, PhD). The referral behaviors for each child were typed on a separate sheet of paper, along with the child's sex and age. These were submitted to the experts who were asked to rate each case on two 7-point Likert scales. One scale dealt with the degree of appropriateness vs. inappropriateness of the behavior. The other scale was constructed to determine the degree of aggression in the behaviors reported. Reliability of these ratings was determined to be adequate. A reliability coefficient of .91 was obtained for the overall reliability of the ratings using the Cronbach Alpha technique. However, inclusion of these scales in additional attempts at cluster analysis was unsuccessful.

While the attempts at cluster analysis were unsuccessful due to the lack of reliable and valid scales measuring the dimensions of behavior necessary to produce meaningful clusters, familiarity with the data suggested that there were distinctions to be made among the children in this study. This led to an attempt to classify the subjects based on the manifest behavior present in the referral information given at the time they entered the project. This is very similar to strategies used by other sex researchers including Kinsey and his colleagues. Examination of the content of the referral behaviors indicated that they could be divided into three groups:

Group I, Sexually Inappropriate Children, represented behaviors in which there was inappropriate sexual behavior but no contact with another person. These behaviors included making sexual remarks, gestures, touching or exposing one's self, and so forth.

Group II, Sexually Intrusive Children, was composed of behaviors in which the child made sexual contact with another person in an inappropriate manner, but did so only briefly. Behaviors in this group included individuals who ran up to another child and grabbed the child's genitals after which they would retreat and run away; rubbing against another person in a sexually provocative manner; briefly fondling another person but stopping when the other person indicated displeasure; and similar behaviors.

Group III, Sexually Aggressive Children, involved behaviors in which there was significant or prolonged contact resulting in completion of a sexual act such as oral sex, vaginal or anal penetration, mutual masturbation, and similar behaviors. In most instances, the behaviors in Group III were implicitly and/or explicitly coercive or aggressive.

Two of the Principal Investigators (BLB & CEW) served as expert judges and independently sorted the actual cases in the sample into the three predetermined categories based on the referral behaviors. Examination of these sorts indicated an initial agreement rate of 88% regarding classification of subjects into one of the three groups. At this point, the two judges met to examine and discuss those cases in which there was disagreement. This led to clarification of the criteria as to what constituted minimal contact versus full contact. Following this, the cases in question were independently resorted by each of the judges. There was 98% agreement on classification of the cases following clarification. Cases in which disagreement continued to exist following clarification were classified by discussion and consensus by the two judges. At the completion of this classification process, it was found that Group I, Sexually Inappropriate children, contained 40 cases, 23 males and 17 females; Group II, Sexually Intrusive children, contained 74 cases, 39 males and 35 females; and Group III, Sexually Aggressive children, contained 87 cases, 64 males and 23 females. These three groups are briefly described below.

Group I, (n=40), Sexually Inappropriate Children, was made up of 23 boys and 17 girls which is a similar distribution between the genders. These children were rated the lowest on inappropriate and aggressive behavior on the Likert Scales by the five experts. In fact, these two scales showed a step-wise progression from Group I to Group III. The Sexually Intrusive Children (Group II) were higher on these two variables than the Sexually Inappropriate Children (Group I), and the Sexually Aggressive Children (Group III) were higher than both Group I and Group II children on these two measures. In addition, Group I had higher sexual content on the Rorschach than the other groups, indicating a significant degree of preoccupation internally with sexual matters. Group I had the lowest scores on the Child Sexual Behavior Inventory, indicating the least overt sexual behavior.

These results indicate that the children in Group I are somewhat less disturbed and less sexually aggressive in their behavior as opposed to the other two groups. However, they are quite preoccupied with sexual thoughts and behave inappropriately when compared to normal children. The biological parents (n=23) reported that in general, the children have not experienced high levels of physical abuse (17%) or neglect (9%), but 57% of them have a reported history of sexual abuse and 30% experienced emotional abuse.

Group II, (n=74), Sexually Intrusive Children, was composed of 39 boys and 35 girls, again basically equivalent in terms of gender. This group was seen to have higher self-concept scores on the Harter than the children in Group III, but lower than Group I. As noted previously, these children were intermediate in the ratings of their inappropriateness and aggressiveness with respect to sexual behaviors, being higher than those in Group I but not as high as Group III. As reported by the biological parents (n=47), they had similar scores on the Child Sexual Behavior Inventory as Group III, indicating high levels of sexual behavior, although not specifically highly aggressive sexual behavior. The biological parents reported higher levels of physical abuse (35%) and neglect (15%) than Group I, but similar rates of sexual abuse (58%) and emotional abuse (38%).

Group III, (n=87), Sexually Aggressive Children, is composed of children who are significantly older and significantly more likely to be male (64 boys vs. 23 girls). They were rated as the most aggressive and most inappropriate by the five experts reviewing their referral sexual behaviors. The biological parents in this group (n=63) reported similar levels of physical abuse (35%), neglect (17%), and emotional abuse (40%) as Group II, but somewhat lower levels of sexual abuse (48%) than both of the other groups.

Scores on the assessment instruments for children in each of these three groups are presented by group in Table 7. It is interesting that there are few significant differences among the three groups based on data obtained by the children's self-reports. This lack of differences by group is also reflected in the biological parents' reports on the children shown in Table 8. In addition, there was only one significant difference reflected on the parents' reports of their own current status (See Table 9). Significant differences are shown among the three groups, however, in Table 10; these figures show the levels of appropriateness and aggressiveness of the children's sexual behaviors as rated by the five experts. The groups are significantly different from each other in both appropriateness and aggressiveness in the expected direction, that is, the groups are increasingly less appropriate and more aggressive from Group I to Group III.

All of the variables available for the subjects, including demographic characteristics and test scale scores, were analyzed using Chi Square for frequency data and analysis of variance for other data. Statistically significant differences among the three groups were found for age; gender; history of physical abuse; inappropriateness and aggressiveness of sexual behavior; Rorschach sexual content, white space, and cooperation scores; and Child Assessment Schedule scores on Conduct Disorder, Total Primary Diagnosis, and Expression of Anger.

D. Treatment Outcome

Of the 147 children eligible for group treatment at the OUHSC site, 110 (75%) agreed to participate in the treatment groups. Sixty-nine (63%) of these participants were considered to have completed treatment, in that they attended at least 9 of the 12 treatment sessions. Thirty-nine caregivers (56%) completed the follow-up assessment immediately following the twelfth treatment session, 25 caregivers (36%) completed the one-year telephone follow-up assessment, and 20 caregivers (29%) completed the two-year telephone follow-up assessment.

There were no significant differences in abuse history, age, or overall assessment scores for the children who completed and those who did not complete the treatment program. Parents who had previously received mental health counseling were significantly less likely to complete the treatment program. There were no other significant differences in demographic or assessment variables for the two groups of parents.

The 110 children were randomly assigned to one of two treatment approaches, dynamic play (n = 59) or cognitive-behavioral therapy (n = 51). Thirty-five of the 59 children enrolled in the dynamic-play group completed at least nine of the twelve sessions (59%), while 34 of the 51 children enrolled in the cognitive-behavioral group completed a minimum of nine sessions (67%).

Treatment outcome was measured in two ways: a) by administering two of the tests at the beginning and at the end of treatment; and (b) by a structured interview assessing the incidence of additional sexual behavior problems at one and two years following treatment. Data were obtained on the 69 children who completed treatment in one of the two group therapy approaches at the end of treatment. The tests readministered at the end of treatment were the Child Sexual Behavior Inventory and the Child Behavior Checklist. One indication of the overall effectiveness of the program is the significant difference between the children's pre and post test scores on the CBCL and the CSBI (See Table 11). Behaviorally, affectively, in social competence, and in their sexual behavior, the children showed significant changes in a positive direction over the course of therapy. This finding is further reflected in a significant decrease in their level of sexual behavior problems.

An indication that both approaches were effective in increasing the children's social competencies while reducing their behavioral, affective, and sexual behavior problems is shown in Table 12. Examination of these data indicates no significant differences between the two treatments, thus, one treatment cannot be considered to be more effective than the other.

Data were gathered through a structured phone interview at one-and two-year follow-up periods. At one year, 36% of the caregivers were located and participated in the follow-up interview and 29% at the two-year follow-up. The data indicated that there were no significant differences in the rates of subsequent inappropriate or aggressive sexual behavior between the two treatment approaches, with 15% of the cognitive-behavioral group and 17% of the dynamic play group reporting additional sexual behavior problems.

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Updated on March 1, 2010