Children Problem Sexual Behaviours

Children who engage in
problem sexual behaviours:

context, characteristics and treatment
A review of the literature
Edited by Dr Petra Staiger

Deakin University
September 2005
Children who engage in problem sexual behaviours: context, characteristics and treatment
This document remains the intellectual property of the Australian Childhood Foundation.
No part of the document can be copied and/or distributed without the written consent of
the Australian Childhood Foundation.
2005, Copyright Australian Childhood Foundation and Deakin University
ISBN: 0 9580411 2 1
Australian Childhood Foundation

PO Box 525
Ringwood Vic 3134
T (03) 9874 3922
F (03) 9874 7922
www.childhood.org.au
Contributors
Dr Nicolas Kambouropoulos is a research staff member in the School of Psychology at Deakin University.His
research interests consist of the motivational processes underlying drug use, personality theory and child
psychology. He has presented at national and international conferences and published a number of papers in
refereed journals.
Janise Mitchell is the Manager of the Education and Prevention Programs for the Australian Childhood
Foundation. She is a social worker with extensive experience in statutory child protection, training and program
development. Janise was primarily responsible for the development of the Every Child is Important program and
its written material. She manages the Dimensions Program which seeks to assist children with a disability who
engage in problem sexual behaviour. She is currently completing a Master of Social Work examining the social
construction of children who hurt others. She can be contacted by email at jmitchell@childhood.org.au.
Dr Petra Staiger is a Senior Lecturer in the School of Psychology at Deakin University. She is a clinical
psychologist and has worked in the mental health sector (Royal Childrens Hospital) and the alcohol and drug
sector as a senior clinician. Her current research interests are developing parent training programs with high
risk families and development of early intervention programs with a range of young people e.g. tertiary students
engaging in harmful drinking, children with sexual behaviour problems and developing a model of risk factors
for young people who abuse substances. Dr. Staigers research has been presented at national and international
conferences and she has published extensively in refereed international journals. She is the coordinator of the
Addiction Studies Program at Deakin University and teaches extensively on the clinical doctoral program. She can
be contacted by email at pstaiger@deakin.edu.au.
Dr Joe Tucci is the Chief Executive Officer of the Australian Childhood Foundation. He is a social worker and
registered psychologist. He has extensive experience in child protection, child and family therapy and child welfare
research. He has recently completed his PhD on child emotional abuse. He is a guest lecturer in child abuse and
family therapy at Deakin and Monash University. He is a member of the Australian Council for Children and
Parenting, an advisory body to the Federal Minister for Family and Community Services. He can be contacted by
email at jtucci@childhood.org.au.
Additional contributions to the review:

Dr. Stephen Wallace, Dr. Jari Evertsz,
Ms Clare Shelton, Ms Catherine Acton.
Acknowledgements
In 1998, the then National Council on the Prevention of Child Abuse and Neglect identified the Childrens Sexual
Behaviour Program (recently renamed the Transformers Program) of the Australian Childhood Foundation as
a model child abuse prevention program. It provided a research grant to evaluate the program. This was an
essential element to the evolution of the program. This literature review is part of the background research that
informed the evaluation of the program.
The authors would like to gratefully acknowledge the assistance of the children and caregivers who participated in
the program for providing the additional time to take part in the evaluation. The authors would also like to thank
the ongoing support of Professor Chris Goddard from Child Abuse Prevention Research Australia at Monash
University for his focus on childrens rights and Dr. Stephen Wallace for his valuable input in developing the
evaluation protocol. The authors would also like to acknowledge the early work undertaken by Dr Jari Evertsz in
reviewing and providing feedback about this document.
More recently, the Australian Childhood Foundation received
a grant from Perpetual Trustees and the Telstra Foundation to
complete the two year follow up of the children who took part in
this evaluation of the Transformers Program. The support of the
Telstra Foundation, in particular, has enabled this report to become
part of one of the first opportunities in Australia to undertake a
long term analysis of the effectiveness of a program aimed at
reducing the number of children who have engaged in problem
sexual behaviour who develop even more problematic sexual
behaviour into their adolescence and adulthood.
Table of contents
Table of contents
Chapter 1. Introduction - Petra Staiger and Joe Tucci
Prevalence of children who engage in problem sexual behaviour
Definitions and language
Terminology used in this report
Chapter 2. Historical context of problem sexual behaviour in children - Janise Mitchell

Chapter 3. Understanding the background of children who engage in problem sexual
behaviour - Nicolas Kambouropoulos
9
14
Inclusion criteria for this review
15
Definition of problem sexual behaviour
23
Psychological characteristics
23
Behavioural problems
26
Demographics
27
Summary
31
Chapter 4. Theoretical models - Petra Staiger and Nicolas Kambouropoulos
32
Four related theories
32
Conclusion
36
Chapter 5. Treatment programs - Nicolas Kambouropoulos and Petra Staiger
37
Programs and agencies
37
Summary of programs
49
Chapter 6. Treatment programs and evaluation studies - Petra Staiger
50
Summary of evaluation studies
55
Chapter 7. Conclusion - Joe Tucci
56
References
58
Chapter 1. Introduction
Petra Staiger and Joe Tucci
In over a decade, the literature in relation to adolescent and adult sex offending has developed rapidly (Araji,
1997). In that time, there has been an increasing interest in building a framework for intervening to stop children
who engage in problem sexual behaviour from continuing to develop more harmful sexual behaviour into their
adolescence and adulthood. However, the development of this knowledge base has been fraught with a number
of hurdles.
Firstly, community responses towards children who engage in problem sexual behaviour are clearly diverse
and often dramatically so. Attitudes towards these children vary from denial and minimisation to outrage and
condemnation. Beliefs about the innocence of children are challenged by these problem behaviours.
Secondly, the responses by statutory services, the police and child welfare organisations have often added to
the confusion. At almost every level, children who engage in problem sexual behaviour have not been able to
access specialist services. There has been little public policy which covers their needs and there are few resources
allocated to programs specifically designed to support them and their families.
The academic literature has been equally varied and often unclear in its response to this issue. There has been a
distinct lack of research papers until 1980. Since then, the literature has been limited by an absence of empirical
data and an insensitivity to the ways in which children in this group can be further stigmatised through the use
of inappropriately strong language. It is only recently that there has been a recognition of the need for more
in-depth research that attempts to address critical practice debates, such as under reporting by professionals (Gil
and Johnson, 1993). The lack of clarity between what can be considered developmentally appropriate sexual
behaviour and problem sexual behaviour has also generated confusion.
Most of the work conducted in this area has arisen from the United States. Yet, it is clearly important to develop a
knowledge base and collect data on this topic within Australia.
The purpose of this review is to provide a comprehensive analysis of the current literature on the definitions,
characteristics, theories and treatment of children who engage in problem sexual behaviour. The review is written
with an emphasis on the Australian context despite the majority of published papers on this topic originating in
the United States. The review was originally commissioned by the National Council on the Prevention of Child
Abuse in Australia and is part of a larger joint initiative between the Australian Childhood Foundation and Deakin
University. The project has received subsequent funding from the Telstra Foundation and Perpetual Trustees. It
constitutes the first formal evaluation of a program for children who engage in problem sexual behaviour in
Australia (Staiger, Kambouropoulos, Evertzs, Mitchell and Tucci, 2005). The program (Transformers Program) has
been developed and implemented as part of the services offered by the Australian Childhood Foundation. This
review is a companion document to the evaluation report. It is hoped that this review will provide professionals
with the context and background to this complex area of work.
The review is structured in three sections. Section 1 (Chapters 1 and 2) includes a discussion of the social, legal
and historical context of the issue. Section 2 (Chapters 3 and 4) reviews the literature on the characteristics of
children who engage in problem sexual behaviour and examines proposed explanatory models which arise from
the data. Section 3 (Chapters 5, 6 and 7) discusses the current models of treatment and reviews the available
outcome studies, concluding with an agenda requiring urgent attention by researchers.
Prevalence of children who engage

in problem sexual behaviour
An accurate estimate of the prevalence of this problem in Australia is difficult to determine. There are very few
Australian studies about children under the age of 12 who engage in problem sexual behaviour. There is a
general absence of a clear definitions about how to define problem sexual behaviour. There is a reluctance of
parents, teachers and others to report to agencies any incidences of these behaviours in young children. Even if
reports are made, the service system often fails to acknowledge the significance of the problem and frequently
does not record reliable data.
There have been no attempts made to gauge the rates of children who engage in problem sexual behaviour
either in Australia or internationally. In contrast, it has been estimated that 2%-4% of adolescent males commit
sexual assaults (Ageton, 1983). Furthermore, Lane (1991) has reported that approximately 12% of adolescents
who commit sexual assaults are 11 and 12 years old and at least half of these children engaged in problem
sexual behaviour before 10 years of age. A report by the Childrens Protection Society in Victoria, estimated
that 20%-40% of child sexual assaults are the responsibility of those aged under 18 years (Flanagan and White,
1997).
Definitions and language

The lack of consensus about the use of language clearly highlights and reflects the confusion amongst
professionals and society, in general, about how to define these problems and respond to them. It is argued that
a fear of labelling children prevents many from recognising problematic sexual behaviours (National Childrens
Home, 1991; Johnson, 1993b; Araji, 1997). The lack of a conceptual frame for understanding childrens sexual
development results in the potential for a number of different interpretations to be made about the behaviour and
put into jeopardy an effective system response (National Childrens Home, 1991; Araji, 1997; Cantwell, 1988;
Gil and Johnson, 1993).
Children have been variously referred to as abuse-reactive (Johnson, 1993b; Cunningham and MacFarlane,
1991), victim-perpetrator (Jones, 1998), and trauma-reactive (Finkelhor and Browne, 1986). All these
terms imply that children have also been victims of sexual abuse. Whilst the presence of sexual abuse in the
backgrounds of these children is significant, not all children have been sexually abused and as such this
terminology is inaccurate.
The term sexualised children refers to very young children who appear very focussed and compulsively drawn
towards sexual matters when most of their peers are not (Gil, 1993c). These children may not necessarily involve
others in their sexual activity nor use coercion.
Becker (1998) argues that the field should be much more descriptive when discussing children and use
terminology such as children with sexual behaviour problems (Ray, 1995; Becker, 1998; Gray et al., 1999) or
children with touching problems (Becker, 1998). Whilst touching problems is too vague to be useful, the term
problematic sexual behaviours is a useful construct. Araji (1997) cites the model of Ryan and Blum (1994) in
which it is suggested there are three ways behaviour can be problematic. Firstly, the behaviour puts the child at
risk, interferes with his or her development and relationships, violates rules, is self-abusive and/or is defined by
the child as a problem. Secondly, the behaviour causes others to feel uncomfortable, occurs at the wrong time or
place, conflicts with family or community values, and is abusive. Thirdly, the behaviour can involve coercion and
unequal power. This construction has been adopted by this review as the most meaningful on the basis that the
child is positioned in relation to the behaviour rather than being totalised by it, the conceptualisation considers
the impact of social and cultural factors. Finally, there is acknowledgment that the behaviours may have an
adverse impact upon the child as well as others.
Terminology used in this report

The language adopted in this report reflects the need to be sensitive to the way in key terms can shape responses
to children who engage in problem sexual behaviour. As a result, this report and all other documentation
associated with the Transformers Program has integrated the following key terms to define its framework.
Problem sexual behaviour is the preferred term to describe the array of behaviours for which a child can be
referred to the Transformers Program. Problem sexual behaviour indicates a behaviour which is both sexual
and problematic in nature. This phrase is preferred over other possible descriptors which include words such as
sexually offending behaviour or sexually abusive behaviour as these refer to adults. Sexualised behaviour may
be used as a descriptor but is not an effective defining term as it does not convey how problematic it is to children
who are the targets of such behaviour.
Similarly, children who engage in problem sexual behaviour is preferred over phrases which include
child offender or child perpetrator.
The key descriptive phrases acknowledge that the children referred to the Transformers Program
have not reached the age of criminal responsibility;
have experienced a range of disruptive and/or abusive experiences themselves; and,
are influenced heavily by the social, economic and familial conditions in which they live.
Children who are the target of the sexual behaviour is preferred over child victim of sexual abuse. This
term attempts to makes it clear that both the child who is the target and the child who exhibits such behaviour are
developmentally vulnerable and in need of support. Importantly, it does not seek to minimise the extent of trauma
experienced by the target child.
While other terms may be used in this document, they are referenced as the preferred terms of the relevant
author. Finally, as the majority of these children are male (Araji, 1997), they will be referred to in the masculine
gender within this report.
Chapter 2.
Historical context of problem sexual
behavior in children
Janise Mitchell
Throughout history and in contemporary Western society, children have been variously constructed as inherently
good and innocent or bad and evil. Whilst childhood innocence has dominated, the idea of the evil child has
continued to co-exist and has served as a useful other construct for children whose behaviour belies the notion
of innocence.
The notion of inherent innocence is derived from the idea that children were seen as nearest to God with the
process of maturation bringing a move away from original perfection (Archard, 1993). This view was challenged
in the seventeenth century when Christian Puritanism taught that children were born with Original Sin, an
inheritance of sin and wickedness (Archard, 1993).
The notion of childhood innocence flourished during the nineteenth century. For Victorian writers, children were
the guardians of virtue, their writings dedicated to assuring society that mischievous behaviour in children was not
indicative of a bad heart but rather demonstrative of the childs innocence by showing the child to be unconscious
of the effects of his or her actions. As one Victorian writer noted,
These actions may be quite destructive and may even endanger others, but the childs
remorse sets everything right. Honorable little hearts are hurt by the suspicion that they may
have been motivated by cruelty (p.206, Sommerville, 1982).
These ideas have continued to resonate in contemporary Western society. Children are attributed with more
qualities of innocence, purity, trust, beauty, and joy comparable to virtually no other social domain (Gittins, 1998;
Firestone, 1979; Gibson, 1998). Children have been perceived as the souls of a society through which adults
invest their hopes for the future (Gibson, 1998; James et al., 1998; Gittins, 1998; Daniel and Ivatts, 1998).
Adults, it is suggested, have identified these qualities as altogether lost to the adult world and therefore worthy of
preservation and protection at all costs. The perception that childhood is at risk is derived from a general sense
that the world is becoming less safe, stable and predictable with the breakdown of families and communities
(Jackson and Scott, 1999; James et al., 1998).
The dominance of the ideal purity of childhood has sat side by side with the image of the evil child in
contemporary literature (eg. Lord of the Flies, Golding, 1958), cinema (The Exorcist, Damian) and media (the
medias denomination of children who murder) (James et al., 1998; Gittins, 1998). James et al (1998) suggested
that ideas of the evil child continue today and positions the task of parenting as one of needing to constrain the
child with discipline and punishment. Mantras of spare the rod, spoil the child continue to echo throughout
Western societies. In 1968, Sir Rhodes Boyson, British Conservative MP declared that children are not born good,
they have to be disciplined, otherwise they are a threat to society (Holland, 1992).
10
Ten year old boys, Jon Venables and Robert Thompson abducted, beat up and murdered two year old James
Bulger. Though little was made of it in the trial, they also sexually interfered with him before he died (Gittins,
1998). In a trial that allowed the boys no concessions due to their age or backgrounds, both were given 8 year
sentences, later changed to 15 years following a public outcry as to their perceived leniency. This has since been
overruled by the European Court for Human Rights (Gittins, 1998; Sereny, 1998). The acts of the two boys defied
beliefs about what children are and what they can do (Gittins, 1998; Valentine, 1996).
The rage vented at the boys who killed James Bulger in 1992 was similar to that aimed, in 1968, at 11 year old
Mary Bell, also convicted of killing two small boys. The public focus in the Bulger trial was on punitive responses
rather than an examination of what underpinned the boys behaviour. The public outcry was essentially based
on the idea that the children had challenged the notion of childhood innocence and were deemed to be more
criminal because they had failed a fundamental test of childhood (Gibson, 1998). Daniel and Ivatts (1998) argue
that the level of concern raised over the Bulger murder was indicative of the level of anxiety over the state of
contemporary childhood in the United Kingdom and the extent to which children posed a threat to social order.
In neither the trial of Mary Bell, nor that of Jon Venables and Robert Thompson were assessments made and
testimony ever given as to why they did it or the childrens own backgrounds of abuse and severe disruption
(Gittins, 1998; Sereny, 1998). Psychiatric assessments undertaken were solely to assess criminal responsibility
(King, 1997; Sereny, 1998). In both cases, these children were labelled by both the court and the media as evil,
fiends, monstrous, vicious, cruel, terrifying, freaks of nature and bad seeds (Gittins, 1998; Sereny,
1998). Children who are violent or behave in ways that challenge ideas of innocence are readily defined as
pathological and unnatural, leading to their ejection from childhood altogether and considered non-children
(Gittins, 1998; Jackson and Scott, 1999; Jenks, 1992).
Clearly, the constructs of childhood innocence and evil rely on an interdependence of elements. With innocence
equated to the absence of evil, the onus has been placed on the naughty child to recapture the expectation of
innocence irrespective of their environment or lived experience. It is not surprising that children who betray the
ideal are routinely demonised and pathologised resulting in their active exclusion from childhood. Such themes
have been influential in contemporary literature on children who engage in problem sexual behaviour .
Despite the dominance of the notion of childhood innocence, this construct has never completely subsumed the
notion of the evil child (Jackson and Scott, 1999). As such, it is entirely plausible for parents to view their own
child as primarily innocent and other children as potentially threatening (Valentine, 1996; Jackson and Scott,
1999). The idea of bad children transgresses traditional constructions of childhood because it contravenes ideas
of innocence, vulnerability and powerlessness, accords children agency and independence and disassembles the
binary notion of childhood and adulthood (Gittins, 1998; Jenks, 1996; Gibson, 1998). The view of childhood as
special and children as the embodiment of innocence and dependence actually make the experience of children
who behave in ways that are sexual or sexually aggressive as particularly problematic.
The problem is further compounded when one considers the limited literature on what constitutes our
understanding of normal sexual behaviour of children. Some investigators believe that the paucity of research
on childhood sexual behaviour when compared to other areas of child development reflects a culture that is
profoundly ambivalent about human sexuality (Frayser, 1994) and in particular the sexuality of children. Frayser
(1994) further argues that the lack of balanced, comprehensive sex education programs which focus both on
positive and pleasurable sexuality reveals a culture at odds with the bulk of evolutionary, developmental and
cross-cultural evidence demonstrating that children are sexual beings, whose exploration of sexual knowledge
and play, is an integral part of their development as fully functioning human beings (p.210).
11
Three major lines of research have been adopted when investigating childrens sexual behaviour. One approach
has been to survey parents (e.g., Friedrich, 1990, 1993, 1995) and other caretakers (e.g., Lindblad, Gustafsson,
Larsson and Lundin, 1995) about their observation of childrens sexual activities; a second has been to gather
retrospective reports from adults of their memories of early childhood sexual experiences (e.g., Haugaard, 1996);
and, a third has been to study children who are brought to treatment for concerns about their sexual behaviors
(e.g., Gil and Johnson, 1993).
From this literature a number of similarities and conclusions have been drawn. According to Johnson (1998)
natural and healthy sexual exploration during childhood can be seen as an information gathering process where
children explore each others bodies, by looking and touching (e.g., playing doctor), and gender roles and
behaviours (e.g., play house). This exploration is an extension of regular play behaviour. Because most children
are aware of the taboo on openly sexual behaviour, they tend to play with other children who they know will keep
the secret. Whilst siblings engage in some form of mutual sexual exploration, most sexual play occurs between
children who have an ongoing mutually enjoyable play and/or school friendship. Children who are involved in
natural and healthy sexual play tend to be of a similar age, size, and stage of development. Although, children
who are developmentally delayed or have poor social skills may choose to play with younger children.
The frequency of natural, healthy sexual behaviour tends to be moderate and generally sporadic (Johnson,
1998). In healthy development, sexual expression and exploration is accompanied by positive emotions, and may
include teasing or daring. Childrens feelings about sexuality tend to be light-hearted, spontaneous, giggly, or silly.
Natural and healthy sexual exploration may result in embarrassment and guilt if discovered by an adult, but does
not usually leave children with deep feelings of anger, shame, fear, or anxiety. Children engage in healthy sexual
exploration with each other on a voluntary basis, and tend to agree directly or indirectly not to tell. Childrens
awareness of a taboo on openly sexual behaviour leads to most healthy exploration occurring outside the vision
and knowledge of others.
The childs interest in sexuality is generally balanced by curiosity about other aspects of his/her life (Johnson,
1998). Children have a natural curiosity about many aspects of their environment, and the topics of interest are
generally broad and tend to fluctuate. For example, one minute a child might be interested in how babies are
born, and the next about why stars twinkle. The knowledge that children gain about sex and sexuality tends to
be assimilated into their developing understanding of sex and sexuality, which translates into natural and healthy
sexual interest and curiosity (Johnson, 1998).
12
Araji (1997) has provided an excellent synthesis of the literature on childhood sexual development by providing
a list of commonly observed and non-problematic sexual behaviours followed by an analysis of those behaviours
which are considered problematic. Araji draws on a number of differing conceptualisations of problematic as
opposed to developmentally appropriate sexual behaviour. For example, Cunningham and MacFarlane (1991)
have offered a comprehensive list of behaviours across three age groups which can be identified as either
problematic or developmentally appropriate. Specifically, for children aged 0 - 5, developmentally appropriate
sexual behaviours include:
Masturbation as self-soothing behaviour
Touching self or others is exploratory or a result of curiosity
Sexual behaviours are done without inhibition
Intense interest in bathroom activities of others
In contrast, for the same age group problematic sexual behaviours include:
Curiosity about sexual behaviour becomes obsessive preoccupation
Exploration becomes reenactment of specific adult sexual activity
Behaviour involves injury to self
Childrens behaviour involves coercion, threats, secrecy, violence, aggression or developmentally
inappropriate acts.
For children aged 6-10, Cunningham and MacFarlane (1991) suggest that the following constitute
developmentally appropriate behaviours:
child continues to fondle and touch own genitals and masturbate;
child becomes more secretive about self-touching;
the interest in others bodies becomes more game playing than exploratory curiosity (e.g., Ill show you
mine if you show me yours);
boys may begin comparing size of penis;
an extreme interest in sex, sex words, and dirty jokes may develop;
child begins to seek information or pictures that explain bodily functions;
touching may involve stroking or rubbing.
Problematic sexual behaviour for this age group would involve:
sexual penetration;
genital kissing;
oral copulation;
simulated intercourse.
13
For children aged 10-12 Cunningham and MacFarlane (1991) have indicated that developmentally appropriate
sexual behaviour is characterised by:
the continuation of masturbation;
a focus on establishing relationships with peers;
sexual behaviour with peers; e.g., kissing and fondling;
primarily heterosexual activity but not exclusively;
an interest in others bodies particularly the opposite sex that may take the form of looking at photos or
other published material.
Problematic sexual behaviour for this age group primarily involves sexual play with younger children. According to
Cunningham and MacFarlane (1991) it is highly unusual and problematic for children of this age to be involved
in sex play with younger children.
Cunningham and MacFarlane (1991) stress that sexual activity between children of any age that involves
coercion, bribery, aggression or secrecy, or involve a substantial peer or age difference should be considered
problematic and warrant attention.
Conclusion
Despite researchers attempts to draw together available findings, the literature remains limited in a number of
critical areas. First, it is widely constrained by a limited conceptualisation of sexuality. Second, attempts to define
normal sexual development have occurred in the absence of a framework for considering childrens sexuality
within the wider and social and cultural context. Finally, there is the lack of research involving childrens views
about their sexuality and the forces that come to shape it.
14
Chapter 3.
Understanding the background of
children who engage in problem
sexual behaviour
Nicolas Kambouropoulos
Findings from studies aimed at identifying factors associated with the background of children who engage in
problem sexual behaviour have implications which directly impact on the development of treatment programs
(Pithers, Gray, Busconi and Houchens, 1998a). It has been noted (e.g., Ray and English, 1995) that the majority
of research in the area has focussed particularly on identifying characteristics associated with adolescents.
However, the recent increase in public awareness concerning children who engage in problem sexual behaviour
has resulted in the emergence of literature aimed at examining factors which may contribute to the development
of problematic sexual behaviour in children (e.g., Araji, 1997; Burton, Nesmith and Badten, 1997; Gray, Pithers,
Busconi and Houchens, 1999; Pithers et al., 1998a). In an excellent review of the literature regarding the
characteristics of such children, Araji (1997) identified six broad psychological and social factors that need to be
examined. These were abuser and victim characteristics, family characteristics and environments, victimisation
experiences, sexual and aggressive preoccupation, school performance, and social relationships and skills. The
following review will focus on these broad areas.
15
Inclusion criteria for this review

The following criteria needed to be fulfilled in order for a study to be included in this review. Specifically, the
sample for each study needed to involve children 12 years of age or younger who were identified as having
engaged in problem sexual behaviour. Studies which focussed on the effects of sexual abuse on children (e.g.,
psychological, social, emotional) were excluded. This review examined only published papers. Consequently,
unpublished manuscripts and raw data were not included.
Since Arajis review in 1997, ten additional papers have been published in relation to characteristics of children
who engage in problem sexual behaviour (Burton et al., 1997; Gray, Busconi, Houchens and Pithers, 1997; Gray
et al., 1999; Hall, Mathews and Pearce, 1998; Pithers et al., 1998a, 1998b; Ray and English, 1995). In total, 14
studies fulfilled the inclusion criteria and will be reviewed below.
Note that the same 2 groups of children have been referred to in two papers each, namely Gray, Pithers, Busconi
and Houchens (1999) and Pithers, Gray, Busconi and Houchens (1998b) in one instance, and Hall, Matthews and
Pearce (1998) and Hall, Matthews and Pearce (2002) in the other. Consequently these two pairs of studies will
each be subsumed under the same study heading in Table 1. However, important differences between each study
in relation to theoretical and treatment implications will be discussed in the review.
Table 1 summarises the findings in relation to 10 variables from each of these 14 studies. The variables examined
were sample size, age of children, family type, age of onset of sexual behaviour, gender, victimisation experiences
(sexual and physical), psychological characteristics, psychological/abuse characteristics of caregivers, and family/
environment characteristics. Other variables, for example, specific socioeconomic factors and education were not
included in Table 1. However, they are discussed in the text.
23
Definition of problem sexual behaviour

Generally, studies have defined problem sexual behaviour as that which far exceeds the mutual exploratory
behaviour normally seen in young children (Friedrich and Luecke, 1988, p. 154) and is outside the normal
developmental sexual activity expected for children (Johnson, 1988, p. 222). For example, public masturbation,
forceful penetrative behaviour, excessive fondling and genital contact characterise children presenting with sexual
behaviour problems (Johnson, 1988; Gray et al., 1999). However, Pithers et al. (1998b) distinguished between
five distinct types of children who engage in problem sexual behaviour, each with substantially different defining
characteristics. Similarly, Hall et al (2002) found that by categorizing children with problem sexual behavior
according to the level of severity of their behavior, distinctly different clinical profiles also emerged between the
groups. Their rationale for doing so was that if there are distinct types of problem sexual behaviour and the
children presenting with such difficulties have differing clinical profiles, then this should directly impact on the
choice of treatment programs (Hall et al 2002; Pithers et al., 1998b).
Their analysis suggested five types of children (sexually aggressive, nonsymptomatic, highly traumatised, rule
breaker, abuse reactive) that differed on a range of behavioural and diagnostic variables. Sexually aggressive
children are characterised by: males, maltreatment history, conduct disorder, penetrative acts, clinical range on
Teacher Report Form for internalising/externalising problems. Nonsymptomatic children are characterised by:
females, mixed history of maltreatment, low use of force, normal range on internalising/externalising. Highly
traumatised children are characterised by: equal males and females, highest number of psychiatric diagnoses,
PTSD, extensive history of maltreatment, clinical range on Child Behaviour Check List total score and internalising.
Rule breaker children are characterised by: females, mixed psychiatric diagnoses (ADHD, ODD and CD present),
mixed history of maltreatment, clinical range (and highest group means) on nearly all psychological measures
(CBCL and TRF externalising and internalising problems). Abuse reactive children are characterised by: males,
Oppositional Defiant Disorder, high level of maltreatment, may penetrate victims, high-clinical range on all
psychological measures (CBCL and TRF internalising/externalising).
More importantly, Pithers et al. (1998b) reported that the efficacy of particular treatment methods differed among
the five groups of children. Specifically, cognitive-behavioural therapy was found to be significantly more effective
for the highly traumatised child, whereas expressive therapy was more beneficial for rule-breaking children
(Pithers et al., 1998b). These issues will be discussed further in the following section on treatment and assessment
considerations, however the manner in which the types of children identified by Pithers et al. (1998) differ on
important psychological and behavioural characteristics will be examined in the current section.
Psychological characteristics
In contrast to the large literature on adolescent sex offenders, there have only been a few studies which have
attempted to identify specific social and psychological competencies of children who engage in problem sexual
behaviour. Specifically, 9 of the 14 studies reported on the psychological characteristics of their sample (Friedrich
and Luecke, 1988; Gray et al., 1997; Gray et al., 1999; Hall et al, 2002; Hall et al., 1998; Johnson, 1988;
Pithers et al., 1998a; Pithers et al., 1998b; Ray and English, 1995). Each of these, except for Johnson (1988)
found significant levels of psychological problems with their sample.
Apart from the higher incidence of psychiatric diagnoses of behavioural disorders in children with problematic
sexual behaviour, other psychological problems such as lack of empathy, inadequate social skills, problematic
affect, and depression have also been reported (e.g., Friedrich and Luecke, 1988; Hall et al., 1998). Specifically,
24
Ray and English (1995) found that the children who exhibited problem sexual behaviours had difficulty in peer
relationships and lacked knowledge regarding social skills and their own sexuality. Moreover, depression (63%),
hyperactivity (30%) and substance use (20%) were also reported to be associated with heightened problematic
sexual behaviours (Ray and English, 1995).
Similarly, Hall et al. (1998) indicated that deficits in knowledge regarding non-sexual boundaries and a lack of
empathy and affective range characterised children with sexual behaviour problems. This study categorised their
sample into 3 groups; children who exhibit normal or developmentally expected sexual behaviour (group 1),
children who exhibit sexualised or developmentally problematic sexual behaviour (self-focused; group 2), and
children who exhibit developmentally problematic interpersonal sexual behaviour (group 3; Hall et al., 1998).
It was found that 47% of the children in group 3 exhibited a lack of warmth/empathy, compared to 7% of the
children in group 2 and 0% of the group 1 children (Hall et al., 1998). Similarly, 73% of the children in group
3 exhibited a restricted range of affective expression compared to 33% of the children in group 2 and 18% of
the children who exhibit developmentally expected sexual behaviour (Hall et al., 1998). In addition, Hall et al.
(1998) reported that 55% of the children who exhibited problematic interpersonal behaviour displayed were
characterised by depression and a sense of hopelessness, compared to 15% of the group 2 children and only 5%
of the children in group 1.
In their subsequent study on this group, Hall et al (2002) went on to further refine their categorization of children
with problematic interpersonal sexual behavior (group 3) into those who engaged in unplanned behaviors, those
who engaged in planned problem sexual behaviors but without use of coercion, and those engaging in planned,
coercive acts involving others. The trend towards greater problems among those with more severe sexual behavior
problems seen in their earlier study was continued. This data suggest a relationship between the extent of the
problematic sexual behaviour and levels of psychological problems. Specifically, it appears that higher levels of
psychological problems are associated with the more problematic types of sexual behaviour. In terms of Hall et
al.s study, children who exhibit problematic sexual behaviour toward other children were siginificantly more likely
to have psychological problems (i.e., lack of empathy, restricted affect, depression) than children who display selffocused problematic sexual behaviour and children who exhibit developmentally expected sexual behaviour.
Consistent with this, Friedrich and Luecke (1988) found that half of their sample of children who exhibited
problem sexual behaviours displayed age-inappropriate social skills. They concluded that the observed
socialisation problems reflected a distinct lack of empathy, whereby the children were unable to engage in
appropriate social interactions due to their dehumanising experiences (Friedrich and Luecke, 1988, p. 160).
This study also reported higher levels of anxiety and obsessiveness in the children who exhibited sexual behaviour
problems (Child Behaviour Checklist; CBCL). Specifically, the male and female children with sexual behaviour
problems were characterised as anxious and obsessive in that the mean scores for those groups exceeded the
clinical range. Similarly, the female children who exhibited problem sexual behaviour were found to also surpass
the clinical range for depression on the CBCL (Friedrich and Luecke, 1988).
Children who engage in problem sexual behaviour also have high levels of internalisation (i.e., anxiety,
withdrawal) and externalisation (i.e., behavioural) problems, with large percentages exceeding clinical cut-off
scores (Gray et al., 1997; Gray et al. 1999). Specifically, Gray et al. (1997) reported that 77.8% of children in
their study scored above the clinical criterion on the Full Scale of the CBCL, which provides a parental assessment
of a wide range of behavioural and emotional problems. Seventy-one percent of the children exceeded the
clinical criterion on internalising and 76% scored above clinical range on externalising (Gray et al., 1997). This
study also assessed internalising and externalising problems via teacher report. Interestingly, there were significant
differences between parents and teachers regarding the levels of internalising and externalising problems. Gray
25
et al. reported that the teachers rated fewer children as having behavioural and emotional problems (Total Score
on Teacher Report Form of the CBCL) than when the children were rated by their parents. Specifically, teachers
rated 60% of the children as surpassing clinical cut-off scores on the Total score (Gray et al., 1997). However,
on internalising problems, the teachers reported that 38% of the children exceeded clinical range, which is
substantially (but not significantly) less than the 71% reported by the parents. Thus, this study indicated that
parents rate their children as having more emotional and behavioural problems than when they are rated by
teachers (Gray et al., 1997).
Gray et al. (1997) also assessed self-reported externalising and internalising problems with the 11-12 year olds
in the sample using the Youth Self Report Form (YSR). It was found that 50% of the children exceeded clinical
range on the Total Score. Interestingly, teacher and parent ratings resulted in 80% of these children surpassing
the clinical cut-off region (Gray et al., 1997). In relation to internalising, 40% exceeded the clinical criterion
on the YSR, which is consistent with the 35% rated by the teachers. Interestingly, 75% of the parent completed
CBCL ratings on these children surpassed the clinical range, which is substantially more than that reported by the
children themselves (Gray et al., 1997). Similarly, on externalising problems 40% of the children rated themselves
as exceeding the clinical range, compared to 75% of the CBCL (parent) ratings and 90% of the TRF (teacher)
ratings. This data strongly indicated that parents and teachers rate children who engage in problem sexual
behaviour as having substantially more behavioural and emotional problems than do the children themselves.
This pattern of results was replicated by Gray et al. (1999). This study found that, compared to childrens own
ratings, teachers and parents rated significantly more children as exceeding clinical cut-off scores on internalising
and externalising problems. Specifically, 41% of children rated themselves as exceeding clinical cut-off scores
on the Full Scale of the YSR. In comparison, teachers rated 78% of the children as surpassing the same criterion
and parents rated 81% of the children as exceeding the clinical range (Gray et al., 1999). Similarly, in relation to
internalising, 35% of the children exceeded the clinical range on the YSR, compared to 41% on the TRF and 65%
on the CBCL. With regard to externalising, 35% of the children surpassed the clinical cut-off score on the YSR,
compared to 84% on the TRF and 76% on the CBCL. These differences between parents/teachers and children
were highly significant, indicating that parents and teachers rate the children as having considerably higher levels
of behavioural and emotional problems than do the children themselves (Gray et al., 1999), which is consistent
with findings reported by Gray et al. (1997).
Finally, Cosentino, Meyer-Bahlberg, Alpert and Weinberg (1995) in a study investigating the effects of sexual
abuse on children found that the sexually abused children with associated sex problems evidenced significantly
higher levels of depressive symptoms than a control group. Indeed, this study provided important insight into the
relationship between sexual abuse, subsequent problematic sexual behaviour, and psychopathology symptoms. It
was concluded (Cosentino et al., 1995) that sexually abused children manifest more sexual behaviour problems
and psychopathology symptoms than a group of non-sexualised, but psychiatric children. However, in contrast to
these findings Johnson (1988) in a sample of 47 children with sexual behaviour problems found no evidence of
major psychopathology. This indicates substantial variation in the psychological profiles of children who exhibit
sexual behaviour problems.
In summary, the studies reviewed indicate that children who engage in problem sexual behaviour are
characterised by high levels of externalising and internalising problems, low levels of empathy, restricted affective
experience and higher incidence of depressive symptoms.
26
Behavioural problems
Six of the 14 studies investigated behavioural problems associated with problematic sexual behaviour in children
(Friedrich and Luecke, 1988; Gray et al., 1997; Gray et al., 1999; Pithers et al., 1998a; Pithers et al., 1998b;
Ray and English, 1995). The studies reviewed indicate that a large percentage of children who engage in problem
sexual behaviour also exhibit high levels of other maladaptive behaviours. Four of these studies (Friedrich and
Luecke, 1988; Gray et al., 1997; Gray et al., 1999; Pithers et al., 1998b) assessed the relationship between
diagnosable behavioural disorders and sexual aggression.
Specifically, Gray et al. (1999) reported that 83% of male children and 62% of female children who exhibited
problem sexual behaviours in their sample (ages 6 - 12) met the diagnostic criteria for conduct disorder.
Pithers et al. (1998b) identified five types of children with sexual behaviour problems (sexually aggressive, nonsymptomatic, highly traumatised, rule-breaker and abusive reactive) and found differential relationships with
other behavioural problems. Specifically, it was reported that conduct disorder diagnoses were significantly higher
in sexually aggressive and abuse reactive children with sexual behaviour problems (see Pithers et al. 1998b).
Indeed, it was found that the sexually aggressive children evidenced the highest rates of conduct disorder
diagnoses (39%), suggesting that these type of children are more likely to display problematic behaviours.
Consistent with these findings, Friedrich and Luecke (1988) reported that 8 out of the 16 sexually aggressive
children in their sample satisfied criteria for a diagnosis of conduct disorder, and Gray et al. (1997) found that
73% of their sample fulfilled the diagnostic criteria for the disorder.
In relation to Attention Deficit/Hyperactivity Disorder (ADHD), Gray et al. (1999) found similar high rates of
diagnosis, with 49% of male and 22% of female children also meeting the criteria for the disorder. Qualifying
this, Pithers et al. (1998b) indicated that ADHD was significantly higher in highly traumatised and abuse reactive
children than in nonsymptomatic children (Pithers et al. 1998b).
These studies have also revealed increased diagnoses of Oppositional and Defiant Disorder in children who
engage in problem sexual behaviour . For example, Gray et al. (1999) found that a considerable percentage
of children (27%) also presented with behaviours consistent with Oppositional and Defiant Disorder (ODD).
In relation to the five child types, Pithers et al. (1998b) reported that 96% of abuse reactive children met the
diagnostic criteria for ODD. Additional support for high ODD rates comes from Friedrich and Lueckes (1988)
study which found that 4 of the 16 children who exhibited problem sexual behaviours satisfied criteria for the
disorder.
In relation to the other two studies (Ray and English, 1995; Pithers et al., 1998a) which examined more general
behavioral problems, high rates of disobedience, physical fights and property damage have also been reported
to be associated with sexual behaviour problems in children (Ray and English, 1995). Specifically, Ray and
English (1995) found that while attending a supervised mental health agency, high percentages of the children
who displayed problem sexual behaviours also engaged in physical fights (70%), property damage (60%) and
disobedience (84%). Similarly, Pithers et al. (1998a) reported that the sexually aggressive children displayed
heightened levels of hyperactivity, while Hall et al (2002) reported greater levels of hyperactivity, trickery on others,
and blaming of others for own misdeeds among children whose problematic sexual behavior was the most severe
(ie involved others, was planned, and coercive in nature). Thus, together these studies strongly indicate that
children who engage in problem sexual behaviour are likely to exhibit other socially deviant behaviours. Indeed,
Gray et al. (1999) found that in their sample of 127 children who displayed problem sexual behaviours, 123 met
the diagnostic criteria for at least one DSM-IV disorder related to problematic behaviour.
27
Demographics
Socioeconomic Factors
Of the 14 studies, 9 reported on the socioeconomic status of the families (Burton et al., 1997; Gray et al., 1997;
Gray et al., 1999; Hall et al., 1998; Johnson, 1988, 1989; Pithers et al., 1998a, 1998b; Ray and English, 1991)
and have found that children presenting with sexual behaviour problems often come from low income families,
with many living below the poverty level. More specifically, it is generally found that, on average, families of
children who exhibit sexual behaviour problems have very low levels of income (e.g., $14,000) to support four or
more individuals (e.g., Gray et al., 1999). Indeed, Pithers et al. (1998a) and Gray et al. (1997) reported that 72%
of the biological families of children with sexual behaviour problems were living below poverty level. Similarly,
Gray et al. (1999) found that 54% of the families fell below the federal poverty level (i.e., an annual income of
less than $15,000 and a family of four or more). Burton et al. (1997) also reported low levels of income among
families of children with sexual behaviour problems. The familial income in this study ranged between $5,000
and $20,000 per year (Burton et al., 1997).
Consistent with this, 47% of families in Johnsons (1988) study were from low socioeconomic backgrounds,
and 85% of the families in Johnsons (1989) study were identified as lower class. In an income comparison
of biological parents and nonbiological caregivers Pithers et al. (1998) indicated that foster families earned
significantly more than biological parents and consequently were significantly less likely to be living in poverty.
However, the study by Hall et al. (1998) found no significant differences between a group of normal children
(sexually abused but developmentally expected sexual behaviour) and children who exhibited sexual behaviour
problems, in relation to parental income. The fact that the normal group comprised of children with abuse
histories may explain the similarities in familial environment. Thus, evidence generally indicates that children who
engage in problem sexual behaviour come from relatively large families (biological) with low levels of income.
Gender
Eleven out of the 14 studies reported on the gender distribution of their samples (Burton et al., 1997; Cantwell,
1988; English and Ray, 1991; Friedrich and Luecke, 1988; Gray et al., 1997; Gray et al., 1999; Johnson, 1988,
1989; Pithers et al., 1998b; Ray and English, 1995). Almost all studies, apart from Johnson (1989) which only
examined female children reported an overrepresentation of males in their samples (e.g., Gray et al., 1999; Ray
and English, 1995). For example, Ray and English (1995) reported that in a sample of 271 children, 87.4% (237)
were male and only 12.5% (34) were female. Similarly, Gray et al. (1999) and Pithers et al. (1998b) found a
higher percentage of males (65%) than females (35%) in a sample of 127 children who exhibited problem sexual
behaviours. Further evidence for a male bias in such samples was reported by Burton et al. (1997) who found that
only 59 (20.6%) out of 287 children who displayed sexual behaviour problems were female, compared with 228
(79.4%) males. Consistent with this, Friedrich and Luecke (1988) found a higher proportion of males (77%) than
females (23%), and Burton et al. (1997) reported that 80% of their sample were male. The exception to this clear
trend is the study by Silovsky and Niec (2002) which found that 65% of all 3 to 7 year olds referred for treatment
for problem sexual behaviors were female. However overall, consistent with the adult literature on sexual abuse,
male children are much more likely to engage in problem sexual behaviour than females.
In relation to the five types of children with sexual behaviour problems, Pithers et al. (1998b) found that sexually
aggressive and abuse reactive children were more likely to be male, while nonsymptomatic and rule-breaking
children were represented most by females. Both males and females were equally likely to belong to the highly-
28
traumatised category. Thus, while in general males are overepresented in samples of children who engage
in problem sexual behaviour, the findings from Pithers et al. (1998b) suggest that female perpetrators differ
substantively from males in relation to behavioural and psychological characteristics. However, more data is
required before any concrete conclusions can be drawn.
Victimisation experiences
An examination of the literature in relation to the influence of the family on the child is relevant as a number of
family variables may strongly mediate childrens sexual behaviour. Studies have shown that children with sexually
abusive caregivers are more likely to develop problem sexual behaviours (Hall et al., 1998; Johnson, 1989;
Pithers et al., 1998b). In addition, high rates of physical and emotional abuse among such children have also
been reported (e.g., Hall et al 2002; Johnson, 1988; Ray and English, 1995; Silovsky and Niec, 2002). Of the
14 studies reviewed, 13 examined the victimisation histories of the children presenting with sexual behaviour
problems (Burton et al., 1997; English and Ray, 1991; Friedrich and Luecke, 1988; Gray et al., 1997; Gray et
al., 1999; Hall et al., 1998, 2002; Johnson, 1988, 1989; Pithers et al., 1998b, 1998a; Ray and English, 1995;
Silovsky and Niec, 2002). Each of these 13 studies reported on the number of children sexually abused and the
majority (10) reported that at least 50% of the sample were victims of sexual abuse. Eight papers also examined
other forms of abuse (e.g., physical, emotional), and 3 of these found that at least 50% of the children were
physically or emotionally abused.
Specifically, in a study of 13 female children (see Table 1), Johnson (1989) found that each girl had been sexually
abused and subjected to harsh physical punishment. Similarly, Friedrich and Luecke (1988) reported that 14
of the 16 children in their sample were themselves subjected to severe sexual abuse. In contrast, only 2 of the
6 children who did not display problem sexual behaviours were victims of sexual abuse (Friedrich and Luecke,
1988). Furthermore, Ray and English (1995) found that 86% of a sample of 271 children who displayed problem
sexual behaviour were victims of sexual abuse. Consistent with these findings, Burton et al. (1997) reported that
72% of 287 children were themselves sexually abused.
Seven of the 8 studies investigating other types of abuse have indicated that children who engage in problem
sexual behaviour are also more likely to be subjected to physical and/or emotional abuse (e.g., Gray et al.,
1997). For example, Gray et al. (1997) found that while 96% of the children were victims of sexual abuse, 61%
were subjected to multiple types of abuse (i.e., physical, emotional, neglect). Consistent with this, Hall et al.
(1998) reported that 72% of children identified as displaying interpersonal sexual behaviour (i.e., sexual contact
with other children) were victims of physical abuse, while 80% were subjected to high levels of emotional abuse.
Similarly, 85% of the children in Ray and Englishs (1995) study were victims of physical abuse, while Johnson
(1988) reported that 19% of children were subjected to harsh physical abuse. Pithers et al. (1998b) and Gray et
al. (1999) found that 48% of children in their sample were victims of physical abuse. Finally, Silovsky and Niec
(2002) found that 89% were either victims of sexual abuse, physical abuse, or had experienced domestic violence.
Caregiver characteristics
Almost each study (11) examined the characteristics of the parents of children who exhibited problem sexual
behaviours (Burton et al., 1997; Friedrich and Luecke, 1988; Gray et al., 1997; Gray et al., 1999; Hall et
al., 1998, 2002; Johnson, 1988, 1989; Pithers et al., 1998a, 1998b; Ray and English, 1995). In relation to
parenting practises, Johnson (1993a) in a review of three studies (Friedrich and Luecke, 1988; Johnson, 1988,
1989) indicated that child rearing in general is primarily based on an authoritarian model, whereby the parents
aim to obtain total obedience and exert extreme levels of control on the child. Indeed, Pithers et al., (1998b) and
Gray et al. (1999) revealed that biological parents of children who displayed problem sexual behaviour reported
29
significantly higher levels of anger and increased anger expression than the foster parents. Similarly, it was found
that biological parents also report significantly more state and trait anxiety than foster parents (Pithers et al.,
1998b). Consistent with this, Friedrich and Luecke (1988) found that parents evidence clinically high levels of
anger (MMPI). Thus, research indicates that parents of children who engage in problem sexual behaviour may
exhibit high levels of anger and anxiety.
Other important familial variables include the parents own history of abuse, chemical
dependency, criminality and parent-child relationships (Burton et al., 1997; Hall et al. 1998,
2002; Johnson, 1988). Five of the 11 studies examined parental history of drug dependence
and have found that at least 40% of parents to be chemically dependent (Burton et al., 1997;
Friedrich and Luecke, 1988; Gray et al., 1999; Johnson, 1988; Pithers et al., 1998b). For
example, Johnson (1988) reported that 73% of the parents had a history of drug dependence.
Similar high rates of substance abuse among parents were reported by Burton et al. (1997) and
Gray et al. (1999). Specifically, Gray et al. (1999) and Pithers et al. (1998b) found that 40% of
parents engaged in substance abuse, while Burton et al. (1997) reported that 70% of the parents
had a history of substance abuse. In addition, 8 of the 14 (57%) children in Friedrich and Lueckes
(1988) sample had chemically dependent mothers, while none of the mothers of the non-sexually
aggressive children were chemically dependent.
Four studies investigated parental victimisation histories and each have reported substantial levels of parental
history of abuse (Burton et al., 1997; Gray et al., 1997; Hall et al., 1998; Johnson, 1988). For example, Hall
et al. (1998) found that 68% of mothers were victims of childhood physical neglect, and Burton et al. (1997)
reported that 48% of children who engage in problem sexual behaviour had at least one parent (usually
the mothers) that had been sexually abused. Similarly, Johnson (1988) found that over 65% of parents were
themselves victims of sexual or physical abuse. Finally, Gray et al. (1997) indicated that 72% of the families
in their study contained at least one other victim of sexual abuse. The fact that one or more of the parents are
themselves likely to have been the subject of sexual abuse increases the chances of child sexual abuse (Johnson,
1994). The extent to which this is a causative factor in the child developing problem sexual behaviours is unclear,
however research does indicate a substantial relationship between a history of victimisation of the parent and the
incidence of problem sexual behaviours.
Each of the 11 studies investigating parental characteristics indicate that children who engage in problem sexual
behaviour mainly live with only one parent (e.g., Burton et al., 1998; Hall et al., 1998; Pithers et al., 1998b;
Ray and English, 1995), most likely the mother as the fathers are often unknown or absent (Johnson, 1994).
For example, Hall et al. (1998) found that fathers were more likely to be permanently absent in children who
displayed the most problematic interpersonal sexual behaviour. Specifically, 50% of these children compared to
5% of the children who displayed developmentally expected sexual behaviour had permanently lost their fathers.
Indeed, Friedrich and Luecke (1988) reported that 93% of the children lived with only one parent, usually the
mother. Similar high rates of single mother caregivers are reported across each of the 10 studies (e.g., Burton et
al., 1997; Gray et al., 1999; Pithers et al., 1998a, 1998b).
These findings are problematic, as mothers of children with sexual behaviour problems have been found to
exhibit problematic personality patterns including impulsivity and anger which were associated with impaired
interpersonal relationships (Friedrich and Lueke, 1988). Indeed, high levels of depression and isolation have been
reported among mothers of children who engage in problem sexual behaviour (Pithers et al., 1998a). Further,
Hall et al. (1998) found that 84% of the children who displayed the most problematic sexual behaviour (i.e.,
interpersonal) had mothers who were exhibiting chronic stress and post-traumatic stress disorder symptomatology.
30
Furthermore, Johnson (1994) in a summary of three studies (Friedrich and Luecke, 1988; Johnson, 1988, 1989)
reported that many of the mothers suffered from various personality disorders (e.g., Dependent Personality
Disorder, Narcissistic Personality Disorder, or Borderline Personality Disorder), and major depressive episodes
which can severely hinder the development of strong parent-child relationships. However, the manner in which
socioeconomic disadvantages (e.g., Burton et al., 1997; Gray et al., 1999; Pithers et al., 1998) and the difficulties
associated with being a single mother contribute to the development of psychological problems has not been
explored in the child sexual abuse literature.
Pithers et al. (1998b) also identified problems in parent-child relationships as an important factor in children
who engage in problem sexual behaviour. In particular, it was found that parents indicated high levels of
insecure attachment and extreme disappointment in the qualities of their child (Pithers et al., 1998b). This leads
to parents rejecting the child, which can disrupt identification with both societal and parental values, resulting in
the emergence of maladaptive or problematic behaviour patterns (Pithers et al., 1998b). Similarly, Friedrich and
Luecke (1988) reported that only 6% of mothers provided good emotional support to their children, compared
with 83% of mothers in a comparison group. Consistent with this Johnson (1989) found that families were
characterised by dysfunctional relationships and that parents were poor role models for their children. Parental
personality problems were also evident (Johnson 1989).
However, Friedrich and Luecke (1988) reported poor parent-child relationships in only 8 of the 16 children.
Nevertheless, according to Friedrich and Luecke (1988) problematic parent-child relationships also characterised
those described as having fair relationships. In total, only 1 of the 18 children who displayed problem sexual
behaviours was described as having a good relationship with his parent, compared with 5 of the 6 children who
did not display such behaviour (Friedrich and Luecke, 1988). Similarly, Hall et al. (1998) found that children who
engage in problem sexual behaviour have problematic relationships with their parents. It was reported that 81%
of the children in group 3 (children who exhibit problematic interpersonal sexual behaviour) were characterised
by inappropriate parent-child roles or role reversal, compared to 58% of the children in group 2 (problematic
self-focused sexual behaviour) and 21% of the children who display developmentally expected sexual behaviour.
Hall et al (2002) further noted that families of children with the most problematic interpersonal sexual behaviors
were characterized by greater levels of violence, sexualisation, and harsh/punitive parenting. Thus research
suggests that the combination of high levels of anger, anxiety, sexual and substance abuse, psychological
problems/disorders and parent-child relationship problems may be associated with the development of problem
sexual behaviours in their children.
Only 3 of the 14 studies examined caregiver education (Gray et al., 1997; Gray et al., 1999; Pithers et al.,
1998a). The findings in relation to the education of parents of children who engage in problem sexual behaviour
generally indicate high school levels of education (i.e., 12 years) in both mothers and fathers. An emerging trend
from these data is that mothers usually have attained higher levels of education than fathers. For example, Gray
et al. (1999) reported that mothers had received significantly more years of education than the fathers of children
who engage in problem sexual behaviour. Similarly, while not significant Pithers et al. (1998a) and Gray et al.
(1997) found that mothers had slightly more education than fathers.
31
Summary
Clearly, there are a wide range of differing characteristics associated with children who engage in problem sexual
behaviour . The most salient features include a history of sexual and physical abuse, behavioural problems, in
particular conduct disorder, and parental chemical dependency and clinical disorders (e.g., depression). It is
evident that the manner in which these factors interact influences their impact on the child. Theoretical models
provide a framework for conceptualising these influences and they can help identify the relative importance of
each feature in the development of problematic sexual behaviour. The following section will therefore describe
and discuss the major theoretical models of problematic sexual behaviour.
32
Chapter 4.
Theoretical models
Petra Staiger and Nicolas Kambouropoulos
Consideration of the various theoretical models of problematic sexual behaviour in children is important as they
help to explain the factors that contribute to such behaviour. Explanatory theories provide both researchers and
clinicians with a conceptual framework for understanding the reasons which motivate problem sexual behaviour
while also facilitating the development of appropriate intervention and treatment programs. However, there
has been little research addressing children who engage in problem sexual behaviour and consequently the
development of theoretical models is at a relatively early stage. The following discussion aims to provide an
overview of the major models in the area. It is important to note that the theories discussed do not represent
generally accepted explanatory accounts of children who engage in problem sexual behaviour but rather
provide a theoretical basis for understanding the correlates of problematic sexual behaviour and the factors that
contribute to its development and maintenance.
Four related theories

According to Cunningham and MacFarlane (1996) clinicians and researchers need to be aware of and familiar
with four related theories of behaviour when providing treatment to children who engage in problem sexual
behaviour . These theories can be termed trauma-based models as they focus primarily on the manner in
which early trauma (e.g., physical/ sexual abuse) facilitates the development of the symptoms associated with
problematic sexual behaviour in children. The models emphasised by Cunningham and MacFarlane (1996)
include: posttraumatic stress disorder (PTSD) theory; the sexual abuse cycle model; the addiction model, and
Finkelhors four preconditions of abuse. For the purposes of this review, PTSD, the sexual abuse cycle and the four
preconditions of abuse will be discussed as these appear to be most relevant to the issue of problematic sexual
behaviour in children.
Posttraumatic Stress Disorder

In the context of problematic sexual behaviour, Cunningham and MacFarlane (1996) emphasise that the model
applies to children who have been traumatised (e.g., abused) at an early age. Specifically, the theory requires
there to be a stressor that elicits significant symptoms in the child. Such stressors may include physical abuse,
sexual abuse and the observation of violence or natural disasters (Eth and Pynoos, 1985). Secondly, the trauma
is reexperienced by the child through either recurrent recollections, recurrent dreams or nightmares, or through
an association having formed between the traumatic event and an external stimulus. The negative affective
states induced by the recollections lead to a reduced involvement with the outside world, characterised by both
internal and external withdrawal. Finally, various symptoms not present prior to the abuse may result including
hyperalertness, sleep disturbance, concentration difficulties and avoidance behaviour (Cunnningam and
MacFarlane, 1996).
33
The focus on early traumatic experiences in a model of problematic sexual behaviour is an important component
as studies have consistently found that over 80% of children who engage in problem sexual behaviour were
themselves victims of physical and/or sexual abuse at young ages (see Chapter 3). In addition, the model
emphasises withdrawal type symptomatology in children who have experienced early trauma which is also
consistent with the literature reviewed in the previous section. Specifically, it was noted that a number of studies
have found elevated levels of internalising problems in children who engage in problem sexual behaviour . Thus,
the inclusion of PTSD theory in a model of problematic sexual behaviour appears to be valid due to research
that has emphasised withdrawal symptoms and heightened incidences of early trauma in the form of frequent
physical and sexual abuse. However, it is clear that not all children who have been abused engage in problematic
sexual behaviour. Thus, the model may not be applicable to all children with sexual behaviour difficulties.
Indeed, as Finkelhor (1987) notes PTSD should not be regarded as a theoretical model and rather it represents a
diagnostic category which is therefore only relevant to a particular subsample of children. Thus, Cunningham and
MacFarlane (1996) have also drawn on the sexual abuse cycle in order to more fully conceptualise problematic
sexual behaviour in children.
Sexual Abuse Cycle Theory

The sexual abuse cycle theory, or the concept of a sexual abuse cycle was developed by Lane and Zamora at the
Closed Adolescent Treatment Center of the Division of Youth Services in Colorado. Both behavioural and cognitive
processes leading up to, during and following the problem sexual behaviour are described in the model which
views the process as a repeating cycle (Araji, 1997; see Figure x). In their treatment manual, Cunningham and
MacFarlane (1996) adopted the modified version of the sexual abuse cycle (Isaac and Lane, 1990) which was
adapted for use with preadolescents. The sexual abuse cycle is described below:
The cycle begins with a:
negative experience or feeling, which leads to:
negative or wrong expectations (e.g., expecting to get into trouble, expecting bad things to happen), which
results in:
nognitive and/or behavioural isolation (e.g., feeling alone, withdrawal symptoms), which is followed by,
behaviours involving anger and power/control (e.g., rebelliousness, quick temper, starting fights), which
lead to,
negative fantasies (e.g., thinking about sex with other children, imagining control over other children),
resulting in,
negative behaviours (e.g., creating opportunity, selecting victim, planning, engaging in problematic sexual
behaviours), which again lead to,
negative feelings (point 1, e.g., feeling bad, hating yourself), resulting finally in,
rationalisation/cognitive distortions about the experience (e.g., they wanted it, I couldnt help it)
The model is conceptualised in terms of a cycle as it is proposed that these processes continue until an
appropriate intervention is implemented (Isaac and Lane, 1990). For example, the negative feelings which result
from the performance of the problematic sexual behaviour serve to again initiate the sexual abuse cycle. For
example, negative feelings as to the consequences of the behaviour (e.g., fear of getting caught) lead to cognitive
distortions which rationalise and minimise the problem sexual behaviour. These faulty cognitions are eventually
overcome resulting in additional negative feelings about the problem sexual behaviour result and the cycle is
thus reinitiated. Importantly, the sexual abuse cycle model incorporates a number of the correlates of problematic
34
sexual behaviour identified in the previous section. Specifically, behavioural isolation (point 3) is generally
reported in studies of children who engage in problem sexual behaviour as these children typically report elevated
internalisation problems. Similarly, many studies have found that such children display externalised problems
such as conduct disorder and other behavioural excesses and the manner in which this influences subsequent
problem sexual behaviours is also described within the model (point 4). Finally, it is important to note that the
model conceptualises problematic sexual behaviour in children as exercises in power and control rather than
impulsive, spur-of-the-moment acts. In this way, children who engage in problem sexual behaviour, it is argued
have planned the behaviour in order to express feelings of control and power.
Four Preconditions of Abuse

Another approach adopted by Cunningham and MacFarlane (1996) is Finkelhors four preconditions of abuse.
This model focuses on 1) the motivation to engage in problematic sexual behaviour; 2) internal problems; 3)
external problems; and 4) the resistance of the target. The theory is primarily concerned with the manner in which
familial environments serve to facilitate the development of problematic sexual behaviour in children due to
poorly defined, or nonexistent, boundaries and controls.
According to the model, the motivation to engage in problematic sexual behaviours is most likely a consequence
(reaction) to the childs own history of abuse, which is subsequently reinforced sexually during an important
period of sexual development. It is argued that the problem sexual behaviour may provide the child with feelings
of control and power over the target child. However, as previously noted it is clear that not all children who
engage in problem sexual behaviour have been sexually abused themselves. Thus, the second condition of the
model focuses on the manner in which children who have been abused develop problematic sexual behaviours
by overcoming internal inhibitors. Specifically, the model proposes that abuse-reactive children (i.e., children who
engage in problem sexual behaviour as a reaction to their own abuse) develop problematic cognitions including
heightened sexual, aggressive and self-destructive thinking. These cognitive problems, combined with the fact
that such children often come from familial environments where there are poor role models lacking self-control
facilitates the development of problematic sexual behaviour due to inadequately developed moral values and a
consequent lack of empathy (Araji, 1997).
The third condition of the model focuses on the processes involved in overcoming external inhibitors. Specifically,
as the childs family often lacks well-defined external boundaries and controls, the child is placed at greater risk of
developing problem behaviours. Cunningham and MacFarlane (1996) suggest that the family may inadvertently
place the child in particular situations which may facilitate problem sexual behaviours. It was argued that this may
occur if family members have themselves been victims of abuse and need the child to become the identified
patient for the whole family (Araji, 1997, p.135). The final condition relates to the target of the problem sexual
behaviour and specifically the processes by which their resistance is overcome by the child exhibiting the problem
behaviour. In particular this condition argues that the children often choose targets who are less powerful than
themselves (e.g., smaller and younger) and overcome their resistance by means of trickery, bribery and coercion.
Thus, in summary the model emphasises the manner in which poorly defined boundaries and a lack of control
in the family (third condition) allow the child to behaviourally express their sexualised and aggressive feelings
(second condition) which have resulted from their own history of abuse (first condition). It was noted how the
problematic sexual behaviour is most often directed at less powerful targets in order to decrease the possibility of
resistance (fourth condition).
Overall, the models adopted by Cunningham and MacFarlane (1996) focus primarily on the abuse histories
of the child in promoting negative feelings of isolation, anger/aggression, faulty cognitions, and consequently
35
problematic sexual behaviour. These approaches appear to have considerable validity as empirical studies
have consistently found high rates of abuse in children who engage in problem sexual behaviour. Furthermore,
studies have widely reported that children who engage in problem sexual behaviour also exhibit withdrawal and
behavioural conduct problems (see Chapter 3). Indeed, as previously noted, the development of these symptoms
is explained within the models discussed, thus further strengthening their empirical and theoretical validity.
Another trauma-based model, which builds on the sexual abuse cycle model (Araji, 1997) is the comprehensive
Trauma Outcome Process Approach, developed by Rasmussen, Burton and Christopherson (1992). This model
focuses on the contribution of family characteristics, cognitive and emotional processes, and prior trauma to the
development of problematic sexual behaviour in children.
Trauma Outcome Process Approach

The trauma outcome process approach could be viewed as an integration of the models outlined above.
Rasmussen et al. (1992) have identified five factors which are considered necessary for the development of
problematic sexual behaviour in children. Specifically, the model focuses on prior traumatisation, lack of empathy,
social inadequacy, lack of accountability and impulsiveness.
The model holds that while prior victimisation increases the risk of developing problem sexual behaviours it is
not a sufficient condition as there are three possible responses to traumatic experiences (Rasmussen, 1999).
In the present context, children who have been victimised may: a) internalise their emotions and become
self-destructive, b) externalise their emotions and become abusive, and c) express their emotions and come to
understand and integrate the traumatic experience with their other life experiences (Rasmussen, 1999, p. 15).
Thus, the trauma outcome process approach distinguishes between abusive and self-destructive behavioural
patterns which represents an extension over the sexual abuse cycle theory.
According to Rasmussen (1999) the second tenet of the model is that traumatised children have a choice in
relation to which of the three outcomes to pursue. This premise follows a cognitive-behavioural approach whereby
children who have been victimised need to recognise and rectify cognitive distortions and display responsible
thinking. This will allow healthy decisions to be made resulting in recovery from the traumatic experiences
(Rasmussen, 1999). The model further indicates that the ability to make healthy choices is mediated by levels
of self-awareness which includes: feelings, motivations, thoughts, physical sensations and actions. Thus, each
choice made regarding behavioural outcomes resulting from the traumatic experience is a product of levels of
self-awareness (Rasmussen, 1999). Importantly, Rasmussen (1999) stresses that recovery from victimisation is
a dynamic process and that children may choose all three behavioural outcomes at different times during the
recovery process.
Consistent with the PTSD theory and psychodynamic perspectives, the trauma outcome process approach
emphasises the role of internal conflicts and unresolved feelings related to past traumatic experiences in
facilitating the development of problem behaviours. In addition to this however the model also focuses on the
influence of distorted thinking processes on current behaviour and draws on aspects of cognitive behavioural
theory. The humanistic approach is also adopted as it emphasises self-awareness and choice as powerful
motivators of responses to traumatic experiences.
Thus, the first contributing factor, prior traumatisation is an essential component of the trauma outcome process
approach. The second of these factors relates to problems in social skills whereby children have difficulty
interacting effectively with their peers and inadequate social groups from which to draw support (Araji, 1997).
Lack of empathy is the next contributing factor identified by Rassmussen et al. (1992) and relates to children who
use others for personal gain. Moreover this factor emphasises the inability of children to relate to others on more
36
than a superficial basis and consequently feelings of loneliness develop as deep relationships cannot be formed
or maintained. Impulsivity is also considered to be an important factor and Rasumussen et al. (1992) argue
that extreme levels of impulsivity characterise children who engage in problem sexual behaviour . Specifically,
low levels of behavioural inhibition combined with intense fantasies about the sexual act were found in large
numbers of these children (Araji, 1997). For example, a number of studies have reported that children who
engage in problem sexual behaviour also lack impulse control in stealing, conduct disorder and ADHD. The
final contributing factors relates to a lack of accountability and specifically a denial of personal responsibility
for actions (Araji, 1997, p. 140). Consistent with the sexual abuse cycle theory, this factor emphasises cognitive
distortions or rationalisations in relation to the problem sexual behaviour which result in the denial of its
seriousness.
As noted by Araji (1997) the trauma outcome process approach provides considerable insight into how children
develop problem sexual behaviours. As with PTSD theory and the sexual abuse cycle model it emphasises the
role of prior trauma (e.g., victimisation) in facilitating the development of such behaviours. It is important to note
that prior trauma is not a sufficient factor for the formation of problem sexual behaviours and self-awareness
is considered to be influential. Specifically, levels of self-awareness serve to mediate the type of choice made in
relation to behavioural outcomes. Thus, as discussed the child can either work through and recover from the
traumatic event, internalise the problem (i.e., self-destructive behaviours) or externalise the problem (i.e., problem
sexual behaviours toward others). Moreover, the model describes the manner in which various other important
factors interact and contribute to the development of problematic sexual behaviour in children (e.g., impulsivity,
lack of empathy and social skills, and accountability).
Conclusion
While there are other explanatory accounts of children who engage in problem sexual behaviour, the models
reviewed here appear to be the most representative of the literature to date. However, it is important to note
there has been very little research in the area and this statement reflects a conclusion drawn only from the limited
available literature.
Each approach emphasises the influence of prior victimisation on the development of problematic sexual
behaviour and it was noted that this approach appears to hold considerable validity as almost every study
investigating children who engage in problem sexual behaviour report high rates (over 80% on average) of
prior sexual victimisation. In addition, these models, to various degrees, describe the manner in which prior
trauma leads to symptoms which contribute to problem sexual behaviour. Importantly, some children who have
been victimised do not develop problematic sexual behaviours and these models discuss how certain cognitive
processes combined with environmental factors facilitate the formation of problem behaviours in certain children.
Thus, the theoretical models reviewed provide clinicians and researchers with a conceptual framework for
understanding why children engage in such behaviour (Araji, 1997). Indeed, the identification of salient individual
and environmental factors has important implications for treatment programs as the symptoms critical to the
development of problem sexual behaviours can be targeted thus reducing the likelihood of its occurrence.
37
Chapter 5.
Treatment programs
Nicolas Kambouropoulos and Petra Staiger
This chapter describes current treatment programs aimed at assisting children who engage in problem sexual
behaviour. While there have been few published papers of treatment programs there are a number of treatment
programs which have been developed and are currently in operation (see Sirles, Araji and Bosek, 1997).
However, the effectiveness of many of these programs has not been empirically examined.
This section will first provide a description of the various programs by drawing primarily on Sirles et al. (1997)
who provide a comprehensive discussion of a range of treatment programs, the majority of which occur in the
United States. The three published papers will then be discussed and preliminary conclusions drawn regarding
the effectiveness of the programs reviewed. Components common to the various treatment programs will be
highlighted.
Programs and agencies

Program 1: STEP Program, Center for Prevention Services, Underhill Center, Vermont USA
The STEP program integrates cognitive and behavioural theories, child development and child sexual abuse
theory, models of sexual offense cycles, and in particular relapse prevention theories. STEP represents a
prevention-focused program with a particular emphasis on cognitive and behavioural models aimed at directly
addressing children who engage in problem sexual behaviour .
Admission to Program
This program provides services for children aged between 6 and 12 and their parents.
Treatment
The STEP program focuses on a number of treatment goals for the children, including; forming agreements,
improving safety, learning and self-management, making healthy decisions, gaining self-esteem, developing
sexual attitudes consistent with age, making choices that contribute to abuse prevention, and developing positive
friendships. Parents are also considered to be an important part of treatment and are encouraged to participate
as part of the prevention team. Specifically, goals for parents include, reducing isolation, gaining support,
developing stress-management skills, increasing parenting skills, furthering personal knowledge of childhood
sexual behaviour problems, and learning to take care of personal needs.
Two specific treatment approaches are utilised, and research is currently examining their relative effectiveness
(Sirles et al., 1997). Sex abuse specific treatment (SAST) focuses on a relapse prevention approach. Abuse
prevention treatment (APT) is a more broad approach which focuses on assertiveness, self-esteem, decisionmaking, healthy sexuality, and building positive relationships. Children are randomly assigned to treatment
groups and separate sessions are conducted for children aged 6-9 and 10-12 (Sirles et al., 1997). The two
approaches will be briefly outlined below.
The curricula included in the SAST program is as follows:
Orientation-Introductions/Setting boundaries/Setting group rules.
What is a sexual behaviour problem? Part one: Setting up Sexual Safety Rules, and Part two: Setting up
Sexual Safety Rules: Rewards and Consequences.
Emotional Risk-Management
Positive Self-Image
Giving up Sticky Thinking
Cycles and Steps
Managing Risky Factors: Recollections, Urges, Lapses (Slides), and Relapses (Act Outs)
Positive Power
Building a Prevention Team
Responding to Body Arousal (Fear, Anger, and Sexual)
Nurturing Healthy Sexual Development
Loss and Trauma (History, Effects, Compensatory Behaviour)
Loss and Trust (Stages of Grief, Practice good-byes, Self-Trust)
Respecting Sex Abuse Consequences and Victim Impact, Moral Development and Stages to Empathy,
Amends to Others
Prevention Plans Where we started and Where we are now, Review Accomplishments and Surprises, Reset
Goals, Good-Byes.
A 30 minute group session is conducted weekly in order for parents and children to review progress by
completing a checklist and reporting on any lapses or relapses from the previous week. Additional time is
provided for setting goals. The program allows 55 minutes for the childrens group which is split up into four
areas:
Review last week and report on problems or lapses with peers (20 minutes)
Lesson or activity or homework (20 minutes)
Snack and clean up activities (10 minutes)
Weekly evaluation (5 minutes)
38
39
Finally, a closing session is conducted which involves children and parents in which both identify one thing I like;
one think I am thankful for; and one thing I learned (Sirles et al., 1997).
The curricula included in the APT program are as follows:
Introductions/Safety Boundaries/Group Rules/Goals
Touching Rules
Appropriate Sexual Behaviour (Definitions and Respectful Language)
Emotional Management (Being Brave with Feelings)
Sorting out Effects of Sexual Abuse (Tough Stuff Speak Out)
Self-Esteem and Shame (Being My Own Best Friend)
Anger Management (Letting go of Stuffing, Storming and Cheating)
Decision Making (Using Assertiveness in Decision Making)
Taking Perspective (How Do I Feel and How Do You Feel?)
Choosing Friends (Safe Friends)
Healthy Sexual Information I (Getting Clear)
Healthy Sexual Information II (Getting Clear)
Values and Roles (Brave Beliefs Can Strengthen Safety)
Best Safety Problem Solving
Safety Success and Assertiveness
Celebration and Good-byes.
The format for children in the APT program involves therapeutic play and expressive therapies such as clay,
puppetry, games, and art therapies in workbook form (Sirles et al., 1997). Activities designed to improve selfesteem, decision making, and problem solving are implemented, in addition to theme-based sessions aimed at
facilitating socialisation and attachment development. The group begins with interpretive storytelling followed by a
weekly self-report on safety rules.
Another aspect of the program is designed to aid parents by providing weekly support in a group session of
1.5 hours. These sessions are facilitated by a therapist and the approach focuses on empowerment. Individual
goals are set each week and progress, problem solving, and other issues are discussed in an atmosphere of peer
support (Sirles et al., 1997). The therapist encourages group and individual problem solving and the individual
identifies their own areas of change.
Parents learn to identify characteristics of abuse and the effects of abuse within a group context. Rule-setting
and nurturing is also discussed. Nurturing parent experiences are considered essential to obtaining adaptive
reattachment skills. Sexual reactivity in children is described and the therapist encourages relationships with
children which build self-esteem and facilitate secure attachment.
According to Sirles et al. (1997) the STEP program represents highly specific interventions that provide an effective
guide to developing a system-based treatment approach to problematic sexual behaviour. The inclusion of the
prevention team concept is a primary factor the STEP program and this appears to facilitate its usefulness in this
regard (Sirles et al., 1997). As noted, research is currently evaluating the effectiveness of both the SAST and the
APT programs.
Program 2: Harborview Sexual Assault Center, Seattle, Washington USA (Berliner and Rawlings,
1991)
This program is based on a literature review and clinical experiences with children who engage in problem
sexual behaviour and their families. The program assumes that problematic sexual behaviours are learned
and therefore treatment must include a cognitive and behavioural component which focuses specifically on the
problem behaviours.
Sessions are conducted for children aged between 6 and 12 who exhibit problematic sexual behaviours.
Treatment
Individual therapy is the primary mode of treatment and goals include:
The elimination of the problematic sexual behaviour
Obtaining sexual information that is developmentally appropriate
Learning acceptable sexual behaviour,
The internalistion of healthy values about appropriate sexual behaviour
Developing strategies that decrease the opportunities to display problematic sexual behaviours
Understanding the consequences for misbehaviour.
According to Sirles et al. (1997) further treatment may include increasing personal responsibility, selfcontrol,victim empathy, and prevention of reoffense. Children attend individual sessions in order to increase
internal control and sessions for parents focus on increasing external control over the child.
This program is primarily concerned with behavioural change for children who engage in problem sexual
behaviour . Thus, therapists focus on facilitating prosocial behaviours thereby minimising the risk for future
problematic behaviour. As noted, the approach adopts a cognitive and behavioural model of intervention with
precisely defined outcome goals and little attention paid to etiology.
Program 3: The Transformers Program, Australian Childhood Foundation, Victoria, Australia

The Transformers Program is an early intervention program which aims to reduce the number of child victims of
sexual assault by preventing children, who have engaged in problem sexual behaviour from developing further
problematic sexual behaviour into adolescence and adulthood.
The aims of the Transformers Program are to:
provide effective assessment, treatment and management for children who have engaged in problem
sexual behaviour;
provide interventions which are helpful and supportive to children and their families;
develop a theoretical and practice knowledge base for understanding the genesis of sexually aggressive
and abusive behaviour in adults; and,
increase professional awareness and understanding of the issues involved in the assessment and treatment
of children who have engaged in problem sexual behaviour.
40
41
Eligibility criteria for the Transformers Program requires children to be aged under 11 years of age and to have
engaged in problem sexual behaviour.
Program Design
The Transformers Program is primarily based on the principles of cognitive behavioural therapy and systems
theory. It emphasises the importance of understanding children as part of a family system within the constraints of
their developmental stage.
An assessment takes place after a child has been confirmed as eligible for the Transformers Program. Over 4 6
sessions, the assessment evaluates the systems issues and problems for the child; the impact of parenting/family
factors; the onset, duration, triggers, and risk level for the sexual behaviour; the full range of the childs emotional
and learning needs; and, the ability of the child to engage with program materials.
Although not a treatment intervention, assessment incorporates many therapeutic features for the child. These
include having a safe and knowledgeable person to talk to about difficult issues, the opportunity to reduce anxiety
around the sexual behaviour and the familys response to them via increased understanding of their context.
Parents/caregivers obtain extensive advice and support in regard to the childs sexual behaviour and emotional
wellbeing, and in relation to the adults own fears and anxieties.
At the conclusion of the assessment, a treatment plan is devised for each child and their family. As described in
the summary above, both children and families often need a period where factors generating significant distress,
are stabilised. Common experiences include adverse parental/caregiver circumstances, poor parental/caregiver
mental health, unstable living arrangements, imminent court process, grief and loss, recent victimisation, or an
unstable case plan. When these issues are resolved, the child and their caregivers are able to proceed to the
treatment phase of the Program.
The treatment program is based on a schedule incorporating activities which:
Develop personal responsibility for behaviour;
Identify triggers to sexual behaviour;
Provide alternative methods of dealing with difficult feelings;
Increase awareness of personal risk patterns;
Promote empathy for others experiences and feelings;
Enhance self-intervention skills;
Develop and maintain an appropriate support network;
Improve childrens self-esteem and self-confidence.
42
Due to the young age of the children in the Transformers Program, involvement of the childrens parents/
caregivers is an important component of treatment of the children. A parent/caregiver group is run in parallel
with the childrens group to assist in their ability to:
Understand, prioritise and respond to the needs of the child;
Identify and respond appropriately to the protective needs of the child;
Appropriately and consistently discipline;
Understand the issues regarding sexually aggressive behaviours in children;
Cope with their own anger and denial;
Appropriately respond to the childs sexually aggressive behaviours;
Support better models of coping in the child;
Identify and change familial initiating/maintaining factors to the childs behaviour;
Use professional support networks.
Involvement in the parents/caregivers group is a prerequisite for the child to receive treatment.
Throughout the treatment program, staff from the Transformers Program continue to liaise with, support and
provide consultation to the professional network involved with the child and his family to promote their continued
ability to fully understand, effectively support and contain the childs behaviour.
Following the treatment phase, additional individual and family therapy is provided to children and their families
if other difficulties were evident. For example, children with significant histories of abuse related trauma are
provided with individually tailored psychotherapy. For some families, family therapy is offered in relation to
enhancing patterns of communication and resolving long standing points of tension or conflict.
43
Program 4: Valley Mental Health: Adolescent Residential Treatment Education Center (ARTEC) and
Primary Childrens Medical Center Child Protection Team, Salt Lake City, Utah USA
These two programs adopt a number of theories which were discussed in section 2 including the four
preconditions of abuse (e.g., Araji and Finkelhor ,1986) sexual assault cycles, and trauma theory. The programs
are focused on cognitive and behavioural therapy but also includes a systems approach as parents are
considered important in the process (Sirles et al., 1997).
Admission
The program provides services to children aged between 4 and 12 who display problematic sexual behaviour.
Groups are divided for 4.5 to 8 year old children and those aged 8 to 12. Parents also attend joint sessions which
are held occasionally. Individual and family sessions are held for children as well as their own group therapy.
Treatment
Treatment goals depend primarily on the age and developmental level of the child and include:
Accountability
Empathy
Boundaries
Social Skills
Sex Education
Anger Management
Trust
Assertiveness.
Other treatments include:
Eliminating sexually abusive behaviour
Eliminating self-destructive
Using the trauma outcome process to assist in recovery from trauma
Dealing with feelings related to trauma
Improving social skills
Establishing empathy with others
Impulse control and making healthy choices
Personal accountability.
Parent and family sessions cover topics relating to: identifying factors that contribute to childrens sexually abusive
behaviour; identifying factors that contribute to childrens sexually reactive behaviour; setting boundaries;
increasing supervision; setting up the environment to decrease opportunities for sexual reoffence and open
communication (Sirles et al., 1997).
Program 5:
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Redirecting Sexual Aggression (RSA), Colorado USA
This program was founded in 1983 as a community-based outpatient treatment program for adolescents
and adults who displayed problem sexual behaviours. The child program originated when several adolescent
clients informed therapists that they had begun their problematic behaviour at age 9 or 10. Thus, the program
developed and focuses now on providing services to children ages 12 and under. Clinicians at RSA conceptualise
problematic sexual behaviour as a learned behaviour that most likely begins in childhood and continues into
adolescence and adulthood.
Admission
Children aged 12 and under who display problematic sexual behaviour are admitted into the program. For
children aged between 7 and 12, the primary mode of treatment is group therapy and the children are grouped
according to age and developmental level. Groups are held separately for children between 7 and 10 and for
children 11 12.
Treatment
The major theoretical focus of RSA is cognitive and behavioural in nature. Thus, treatment interventions
specifically target the problematic sexual behaviours. The treatment program also focuses on the sexual abuse
cycle (see section 2) and aims to help children in recognising the cycle and learning new, adaptive methods of
coping. Lane (1991) highlights that treatment goals are specific to the problematic behaviour and include:
Eliminating sexual aggression
Changing distorted thought patterns
Learning how to manage and control sexual thoughts and arousal associated with sexual aggression
Increasing social and coping skills
Developing a greater understanding of the effects of sexual abuse on the victim
Gaining and increased awareness of the ramifications of committing sexual offenses.
As with the majority of the other programs reviewed parents are considered an integral part of treatment and
are required to attend 10 to 12 hours of education focusing on; increasing knowledge about problematic sexual
behaviours; understanding forthcoming treatment interventions; and, learning ways to assist the treatment
process. Parents complete weekly risk monitoring forms and are required to know their childs treatment
homework assignments, and assist their child in maintaining treatment gains between sessions (Sirles et al.,
1997).
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Program 6: Its About Childhood, The Hindman Foundation, Baker City, Oregon USA.
Cognitive and behavioural approaches are the primary theoretical framework utilised by this program and
models of sexual abuse and perpetrator prevention are also drawn on in the development of treatment.
Admission
Children from preschool to 12 years of age who exhibit problematic sexual behaviour are eligible for inclusion.
Treatment
Children are allocated to one of four treatment conditions based on information obtained from a culpability
assessment (Juvenile Culpability Assessment; Sirles et al., 1997). Culpability is operationalised as knowledge
that a particular sexual behaviour is unacceptable and that there are consequences for the behaviour. Treatment
conditions I and II contain children termed sex offenders; children in condition III are termed sexually actingout children without criminal culpability; and condition IV contains children considered at risk for becoming
sex offenders. The program defined goals aimed at facilitating understanding of the behaviour and its
consequences. Treatment contracts relating to specific expectations for the child and their parents are defined and
goals and plans are also clearly specified. The two general goals for all children are
to stop the problematic sexual behaviour; and
to learn adaptive, healthy sexual behaviour.
Specific issues addressed in each condition include:
Treatment condition I:
The control of criminal thinking and behaviour
Treatment conditions II, III, IV:
Society and sexual offending
Criminal thinking
Sexual history
Positive sexuality
Victim empathy and restitution
Problem solving
Specific interventions based on the particular needs of the child are also incorporated into the program. In
addition, treatment goals for parents are also specified as they are seen to be an integral part of the process.
46
Program 7: A Step Forward

A Step Forward draws on information from models of relapse prevention, directed play therapy and the assault
cycle to develop interventions which consider developmental influences but with a primary emphasis on cognitive
and behavioural processes.
Admission
The program provides services to children aged 4 to 12 who exhibit problematic sexual behaviours and individual
therapy is the main treatment modality.
Treatment
Goals for children include:
Eliminating problematic sexual behaviour
Creating a behaviour management plan that emphasises self-control
Learning alternative coping strategies
Developing competencies to cope with situations that previously resulted in problematic sexual behaviour
Incorporating a sense of healthy sexuality
While individual therapy is the primary approach, group sessions are also conducted which focuses on
cooperation, containment of problematic sexual behaviour, developing interpersonal boundaries, and creating
safer interpersonal relationships. As with the majority of programs discussed, parents are considered important
and joint sessions with both children and their parents are also held (Sirles et al., 1997).
Program 8: Philly Kids Play it Safe, Philadelphia USA

Description and Admission
This small program focuses on helping children (3-12) in foster care who display problematic sexual behaviour.
According to Sirles et al. (1997) this program is primarily aimed at the facilitating the formation of strong and
safe relationships between the child and their foster parent. A number of theoretical approaches are adopted
including cognitive, behavioural, and psychodynamic models.
Treatment
Children are allocated to different groups according to age. Specifically, groups are formed for 3-4 year olds,
5-6 year olds and 7-11 year olds. Children 12 years of age participate in adolescent treatment groups. All
groups meet for 2 hours each week and treatment can continue for up to 30 weeks. Goals are developed in
consideration of developmental levels and include:
Eradicating problematic sexual behaviour
Preventing future problematic sexual behaviour
Learning to set boundaries
Increasing empathy
Dealing with family of origin issues
Resolving personal victimisation
Expressing grief and loss
47
Developing trust
Building a sense of self
Gaining hope for future families.
As noted foster parents are included in this program and separate goals for this group are also defined. Foster
parent groups focus primarily on: developing an understanding of problematic sexual behaviour and the assault
cycle; examining personal histories to understand how foster children trigger old issues; decreasing the tendency
to self-victimise; strengthening parenting skills; learning to set healthy boundaries and rules in the foster home;
and, improving overall communication.
Program 9: Programs developed by William Friedrich

Description and admission
Friedrich draws on psychodynamic, behavioural, cognitive, sexual abuse, developmental and attachment theories
in his approach to treatment. Particular focus is on the behavioural management of the child in the context of
the system in which he or she developed. Services are provided for children under 13 years of age who exhibit
sexually abusive or reactive behaviours.
Treatment
Family, group and individual therapy are utilised as required and the particular goals for individual therapy
depend on the requirements of the child. Goals may include:
Developing a therapeutic relationship
Dealing with a history of personal sexual abuse
Eliminating the problem sexual behaviour
Learning alternatives to problem sexual behaviour
Dealing with feelings
Developing empathy.
Family therapy sessions are also conducted and issues covered during these include: developing a therapeutic
relationship; improving parent-child attachments; increasing positive reinforcement; developing mutual empathy;
conflict resolution; and behaviour management. Individual therapy is also sometimes offered to parents.
According to Sirles et al. (1997) the emphasis is primarily on building healthy parent-child relationships, teaching
social and coping skills to both parents and children, and facilitating safe and nurturing environments.
Program 10:
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Programs developed by Eliana Gil, Private Practice, Fairfax, Virginia USA
Description and admission

Through her private practice, Eliana Gil has worked with children who display a range of problem sexual
behaviours. According to Sirles et al. (1997) her treatment approach draws on a range of theories and
approaches including: psychodynamic, systems, trauma, attachment, development, cognitive, and behavioural.
The primary focus is on the problematic sexual behaviour but emphasis is also placed on the underlying areas of
concern. Gil provides services to children under 13 years of age who display problematic sexual behaviours.
Treatment
Treatment involves combined individual, group, family, two-peers, or pair therapies (Sirles et al., 1997). According
to Gil (1993) individual therapy is considered a vital component and is particularly beneficial for a number of
reasons. Specifically, individual therapy can prepare the child for group therapy by addressing concerns which
may arise in the group setting, and provides a safe environment for those children who cannot be treated with
others. Gil (1993) describes in detail several specific primary goals for individual therapy, including:
Establishing a working therapeutic relationship with children
Assessing childrens readiness and preparing them for group therapy
Obtaining specificity about the problem sexual behaviours
Obtaining information about risk factors across settings
Stopping the problem sexual behaviours
Assessing a history of victimisation or other issues
Understanding childrens perceptions of family dynamics
Process material generated in group therapy.
In addition to these primary goals a number of secondary goals of individual therapy were also identified and
discussed: improving childrens self-concept and self-esteem; decreasing childrens feelings of helplessness and
vulnerability; exploring issues of relatedness (attachment, dependency); teaching children appropriate social skills;
helping children identify and get needs met; encouraging childrens realistic view of family and family roles; and
helping children become future oriented (Gil, 1993, p. 200-206).
Thus, according to Gil (1993) children who engage in problem sexual behaviour can benefit primarily from
individual therapy and/or education with parents. Gil suggests that placing children with problematic sexual
behaviours in a context where there are other children with similar difficulties may heighten their interests. Even
though individual therapy is the major focus, Gil emphasises that cooperation between individual, group and
family therapists is integral to the effectiveness of the treatment program.
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Summary of programs
It is clear that the majority of the programs described focus primarily on cognitive and behavioural approaches
and emphasise the role of the parents in the treatment process. It is important to note however that either the
effectiveness of these programs has not been empirically examined, or possibly this may have occurred but
has not been published. Indeed, there is a distinct lack of research investigating the effectiveness of treatment
programs for children who engage in problem sexual behaviour. The following section will review three published
studies, one which included an empirical evaluation of treatment effectiveness.
50
Chapter 6.
Treatment programs and evaluation
studies
Petra Staiger
To date, the published literature on evaluating interventions for children who sexually abuse other children is
extremely sparse. In 1993, Johnson estimated that only 12 specialised treatment programs existed throughout
the US, UK and Canada. However our review of the literature in 2005 revealed only three published treatment
studies. These three articles (Ray, Smith, Peterson, Gray, Schaffner and Houff, 1995, Pithers, Gray, Busconi and
Houchens, 1998c; Bonner, Walker and Berliner, 1999) provide evaluations of programs whilst another paper
describes a description of a program but with no evaluation of outcome (Johnson and Berry, 1989). We include in
the current review this latter article in light of the limited data available, as it provides a comparison with respect
to program type.
Evaluation 1. Support Program for Abuse Reactive Kids (SPARK), Los Angeles USA
The first documented program began in 1985 and was developed by Kee MacFarlane. It is termed the Support
Program for Abuse Reactive Kids (SPARK) and is based at the Childrens Institute International in Los Angeles.
Johnson and Berry (1989) describe the main components of the program, however no evaluation of the program
has been completed. This is surprising considering its excellent reputation and level of funding.
Admission to program
Children 13 years of age and younger who have committed sexual offences against other children are referred
and accepted into the program. The typical types of offenses are exhibitionism, fondling, vaginal penetration, oral
copulation, and anal penetration.
A comprehensive evaluation and screening process is undertaken before admission into the program. Specifically,
the child, the parents and selected siblings are required to participate in various interviews (5 hours in total). The
interviews are conducted with the child alone, each sibling alone, the parents, and the family together.
A battery of tests is also administered: Roberts Apperception Test, Peabody Picture Vocabulary Test, Purdue
Measure of Self Concept, and the Nowicki Test of Locus of Control.
As described earlier a court mandate is required in order to ensure family participation and a comprehensive
family interview is conducted in order to ensure family participation.
Treatment
The main theoretical framework is cognitive-behavioural therapy and the primary modality is group therapy. A
number of groups are conducted which cater for the children who abuse, their siblings, and parents.
51
Group treatment is emphasised due to the nature of the childrens problem. Since the children have chosen to
act out in an interpersonal manner, the problems need to be addressed in the context of persons acting together.
However, the aim is not to have the child be able to interact on a one-to-one basis with an adult but to be able to
be with other children without engaging in sexually inappropriate behaviours. Sexual issues that stimulate children
are discussed so that they can identify these feelings and prevent themselves from acting on them
Individual and family therapy is often utilised as an adjunct to the group treatment and is provided when the level
of disturbance is high, the internal and external conflicts are substantial and the individual is highly defended.
Johnson and Berry (1989) argue that family therapy is essential for this population as families often have many
and complex difficulties.
Conclusions
Johnson and Berry (1989) do not provide outcome data on this program despite saying that they have collected
some data on this population. It will be important in the next decade to begin to assimilate outcome data on the
effectiveness of these programs.
Evaluation 2. The Sexually Reactive Youth Program, Spokane, Washington USA

The program evaluated by Ray, Smith, Peterson, Gray, Schaffnerand Houff, (1995) is termed The Sexually Reactive
Youth Program and is based in Spokane, Washington.
Admission to program
Similar to Johnson and Berry (1989) children 13 years of age or younger are accepted although older youths that
are intellectually disabled have been accepted. Each child in the program has engaged in inappropriate sexual
acts against other children.
Treatment
The program utilises a holistic therapeutic approach and the stabilisation of the child in a foster home is a priority.
The child appears to receive individual therapy although it is unclear how long this is and whether it occurs in
conjunction with the group and family therapy. The content of the individual sessions appears similar to Johnson
and Berry (1989) in that it includes focussing on issues such as denial, cognitive distortion, sexual identity,
empathy, and childrens own experience of abuse and trauma. There is less emphasis on group therapy and
sibling groups in this treatment program compared to Johnson and Berrys program.
Evaluation
The evaluation of the program included fifteen children (11 boys, 4 girls). The children ranged in age from 7
15 with a mean age of 10.5 and all had been victims of sexual abuse themselves. Seven children had been
hospitalised for psychiatric problems prior to entry to program.
Measures included a Risk Assessment Matrix which consisted of the following nine risk factors: level of aggression,
sophistication, coercion, empathy, escalation, resistance, denial, social skills, knowledge of age appropriate
sexual behaviours. A further measure was a mental health measure, which included 7 dimensions related to
adjustment. These included: behaviour, emotions, practical skills, social network, education, family, overall level of
functioning.
The authors reported that no children were displaying inappropriate sexual behaviour at the completion of
therapy. Post interviews one year later however revealed that 2 children had incidents of inappropriate sexual
behaviours. In relation to the Risk Assessment Matrix, 8 of the 9 items changed significantly from Intake
52
assessment to the 1 year evaluation. Specifically, there were significant decreases in clinician-rated aggression,
sophistication, coercion, escalation and resistance. Furthermore, the childrens knowledge of age appropriate
sexual behaviours improved significantly as did their social skills. Similarly, the children exhibited significantly
more empathy toward their victims. There was no significant change in levels of denial. With respect to the Mental
Health Adjustment, five of the seven dimensions improved significantly from intake assessment to the 1 year
evaluation. Specifically, significant improvements in behavioural and emotional adjustment, social functioning,
family relationships and overall adjustment rating were observed. The program had no significant effect on life
skills and educational adjustment in these children.
Conclusions
The results of this evaluation are fairly positive, although there are a number of weaknesses in this study. First,
there is no self-report data from the parents or the children. Second, the sample size is fairly small. Third, the
instruments utilised are not standardised instruments. It is also needs to be emphasised that the latter program is
more individually tailored than the program described by Johnson and Berry (1989).
Evaluation 3. Pithers, Gray, Busconi and Houchens (1998c) Treatment Outcome Study
Participants
Pithers et al (1998c) compared the efficacy of expressive therapy with structured cognitive behavioural (relapse
prevention) treatment, for the five identified types of children with sexual behavior problems (sexually aggressive,
abuse reactive, nonsymptomatic, rule-breaking, highly traumatized) discussed in an earlier section of this review.
Their study consisted of the families of 127 children (ranging in age from 6 to 12) who had engaged in problem
sexual behaviour. Ninety-three of these families completed treatment and were included in the analysis. The
location or agency setting of the study is not disclosed.
Treatment
The treatment consisted of 32 weekly sessions. Families were randomly assigned to one of two treatment
conditions. Expressive therapy involved an unstructured, spontaneous approach to treatment, with ideas and
concepts communicated indirectly through metaphor, symbols and creative activities. The cognitive behavioural
relapse prevention program, on the other hand, was a highly structured approach which aimed to identify and
prevent precursors to sexual acting out. In this treatment condition, coping strategies were taught using a didactic
approach.
Families were also encouraged to seek the assistance of friends or acquaintances in order to facilitate skill
acquisition and the generalisation of these skills. In both treatment conditions, groups were simultaneously run for
parents and children. Treatment outcome was assessed in terms of the change between intake and week 16 of the
treatment program, according to scores on the Child Sexual Behaviour Inventory-Third Edition (CSBI-3) (Friedrich,
1995).
Evaluation
Overall, both the expressive and cognitive behavioural interventions were found to be effective in reducing
problem sexual behaviour. Pithers et. al. (1998c) also found that for one subtype, highly traumatised children, the
modified relapse prevention was more effective than expressive therapy. They concluded that the identification
of different types of children with sexual behaviour problems may be relevant in selecting a treatment approach
for these children. However, these conclusions were based on data collected after the first 16 weeks of a 32
week program (data collected at the end of the treatment and during follow-up have not yet been published).
53
Furthermore, in a recent review, Chaffin, Letourneau and Silovsky (2002) reported that the differences in
responsiveness to the two treatments were not maintained over time, and that there was little evidence to support
one treatment approach over another for the treatment of different types of children.
Evaluation 4. Bonner, Walker and Berliner (1999) Treatment Outcome Study, Washington /
Oklahoma, USA
Based across two sites, Bonner et. al. (1999) compared the efficacy of dynamic play treatment (DPT) and cognitive
behavioural treatment (CBT) approaches for children who had engaged in problem sexual behaviour. A group
treatment approach was used. No further information on the treatment program was provided in their report,
though the programs occurred at both the Harborview Medical Center, Washington USA (whose standard
program is described earlier in this section), and the Department of Paediatrics, University of Oklahoma, USA.
Participants
Children aged 6-12 and their caregivers participated in the study. One hundred and ten children referred for
sexual behaviour problems began treatment, and 69 completed treatment and were included in the analysis.
Fifty-two children who had no known sexual behaviour problems served as a comparison group.
Treatment
The children with sexual behaviour problems were randomly assigned to one of the two treatment conditions.
Treatment consisted of 12 weekly one-hour group sessions for both the children and caregivers (the caregivers
session followed the childrens session). Assessment measures were collected at intake, immediately posttreatment and one-year and two-year follow up. Treatment outcome was assessed by calculating the difference
between the childrens pre and post treatment scores on the Child Sexual Behavior Inventory (Version 2: CSBI-2,
Friedrich, Beilke and Purcell, 1989) and the Child Behavior Checklist - Parent Form (CBCL) (Achenbach, 1991),
and by a structured interview at one and two year follow up assessing sexual behaviour problems.
Evaluation
Both treatment approaches were found to be equally effective in increasing the childrens social competencies,
and reducing their behavioural, affective and sexual behaviour problems. Follow up data indicated that 85% of
the cognitive-behavioural group and 83% of the dynamic play group did not engage in problem sexual behaviour
following treatment.
54
Evaluation 5. Professional Parenting Intensive Program, Morganton, North Carolina USA

Ownbey, Jones, Judkins, Everidge and Timbers (2001) evaluated the outcome of a new multimodal residential
treatment program for its first six clients, in North Carolina USA.
Admission
All six clients were 8 to 12 years of age, had documented histories of serious sexual behavior problems directed
toward others, and had been removed from their biological parents due to neglect and or abuse.
Treatment
Treatment was based within a foster care program, with specially recruited and trained foster families, weekly
professional family support including in-home consults, crisis response, and a 24 hour telephone consultation
support. Safety planning included the extended system. Parent support group meetings occurred fortnightly, while
client educational groups occurred weekly. Although most clients were in individual counseling, this occurred
outside of the program and was not a formal component of the intervention. Assessment measures were collected
retrospectively at intake for the 12 months prior to admission to the program at intake, then at three monthly
intervals after commencement of treatment, up until 24 months. These consisted of information from interviews of
caregivers, program families, or prior foster families and social workers for pre-treatment measures where family
reports were unavailable or considered unreliable, describing the nature and frequency of childrens problem
sexual behaviour. It also concerned the informants judgement of the childs propensity to engage in such
behavior in the future.
Evaluation
Substantial variability was noted between individuals on the two outcome dimensions of frequency of and
propensity for problem sexual behaviour. This is unsurprising considering the small sample size. However, overall
frequency data showed that behaviours were rapidly contained during the first few months of the program. Only
one child relapsed after the initial three month evaluation, and one child with particularly serious problems
continued to exhibit problematic behaviors to some degree throughout the treatment. Propensity measures
decreased more gradually. The study presumes that the non-standardised measures used for assessment were
valid, and from these it concludes that the treatment package was overall an effective means of containing
problem sexual behaviour whilst cautioning that children with particularly severe sexual behaviour problems
cannot be deemed safe without the intensive supervision even after 24 months of treatment. Note that the effect
of individual counseling was not controlled for and is thus uncertain. Follow up data is being gathered on this
cohort.
55
Summary of evaluation studies

Overall conclusions based on the available data must be made with caution. Each of the treatment outcome
studies is limited by methodological problems. Only one study had a comparison group. As a result, changes in
test scores from pre-treatment to post-treatment cannot be attributed with certainty to the impact of the treatment.
The study by Ray et al. (1995) was hampered by small sample size and did not include self report data from the
children themselves. Despite methodological limitations, these treatment outcome studies provide preliminary
evidence to support the efficacy of structured cognitive behavioural and dynamic/expressive therapy for children
who engage in problem sexual behaviour.
The general lack of evaluation studies is not surprising when one considers the nature of the problem. Most of
the authors in the field have described the disbelief they encounter when presenting papers about children who
sexually abuse other children (Araji, 1997; Gil and Johnson, 1993, Friedrich, 1990). This disbelief is widespread
and in particular many of the parents of such children have enormous difficulty in accepting the reality of their
childs behaviour.
Developing programs for children who engage in problem sexual behaviour is further hindered by a number of
important factors. Firstly, intervention programs have been developed to treat adult perpetrators of sexual abuse
and more recently adolescents. It is not developmentally appropriate to simply adapt that program to children
(Gil and Johnson, 1993). For example, many of the educational concepts of programs are too complex for young
children. Also, treatment programs need to focus considerable attention on the ongoing effects of the caregivers
on the childs behaviour. In this respect an important component of treatment is the caregivers attendance in
therapy (Araji, 1997). Johnson and Berry (1989) argue that court jurisdiction and/or mandate is sought in all
cases in order to provide the authoritative incentive that is often needed to involve families (p.192). This of
course poses problems when states do not have such statutory rulings. Finally, as Araji (1997) describes treatment
for these children often involves numerous groups of people and involving a number of different therapists. A
clear commitment is required on the part of the agency as well as the family and the referring agency. This does
not always happen.
In conclusion, there is a great deal of research to be undertaken to identify which programs are effective in
supporting children who engage in problem sexual behaviour and their families. It appears that a number of
important components are inherent in most programs. These are: families need to stay involved, group therapy
needs to be part of the treatment, education and cognitive-behavioural therapy is an important therapeutic
ingredient and family therapy is vital. The relationship between different categories of children who engage in
problem sexual behaviour and treatment outcome is yet to be established. It is highly likely that different types of
therapy might be needed for different groupings of children and family circumstances.
56
Chapter 7. Conclusion
Joe Tucci
In a comprehensive history of sex offender treatment, Marshall and Laws (2003) made the interesting observation
that
although many clinicians often fail to see the relevance of theories, the fact is all
practitioners have a perspective on how sexual offending develops and what maintains it; it is
simply that most clinicians rarely make their theories explicit although these theories influence
what they do in assessment and treatment(p. 102).
The study of children who engage in problem sexual behaviour presents a unique opportunity to understand more
about an important aetiological trace of adolescent and adult sex offending behaviour.
Yet, the knowledge base about children who engage in problem sexual behaviour to date remains patchy. The
preceding literature review has highlighted that there are an extensive number of issues requiring the urgent
attention of researchers.
There is little real understanding of the prevalence of the problem in children of primary school age, in
particular in the Australian context.
There is little real understanding of how to best define problem sexual behaviour within a developmentally
sensitive framework that accounts for the socio-political construction of childhood sexuality.
There is little real understanding about the familial and parenting experiences which may have contributed
to the emergence of problem sexual behaviour in children.
There is little real understanding of how experiences of traumatisation and victimization shape the attitude,
beliefs and emotional functioning of children who engage in problem sexual behaviour.
There is little real understanding of the experiences of the children who are the targets of the behaviour.
There is little real understanding of how children who experience problem sexual behaviour experiences
themselves, their relationships and their development.
There is little real understanding of what is effective in helping children who engage in problem sexual
behaviour to stop.
There is little real understanding of the kind of public policy and legislation requirements that would be
helpful to health, education, welfare and legal professionals in responding to the needs of children who
engage in problem sexual behaviour and their families.
There is little real understanding of the most prominent obstacles to providing adequate services to this
group of children and their families.
There is little real understanding about how to resource local communities and networks to be able to
identify and positively respond to children who engage in problem sexual behaviour in a way that strives to
find a balance between over-tolerance and over-reaction.
57
Conclusion continued
The lack of a solid knowledge base leaves clinicians and policy makers without a blueprint about how to best
answer critical practice questions. They are forced to make decisions about this group of extremely vulnerable
children which at best reflect their own personal value base and at worst tap directly into a social discourse aimed
at decontexualising children and punishing them for not matching community expectations about childhood
innocence.
There is a need for greater resourcing of a research agenda in Australia that builds understanding about the
background experiences of children who engage in problem sexual behaviour and their families. There is also
a critical need to develop and evaluate intervention approaches which aim to support these children and their
networks to change.
Allocating funds for research into children who engage in problem sexual behaviour is not an easy option.
Funding an issue that many would prefer to ignore takes courage and a longer term commitment to building an
evolutionary knowledge base. For governments, such an investment is imperative even though it is unlikely to offer
many public rewards. For philanthropic organizations, such an investment would generate the impetus for the
possibility of transforming the experiences and vulnerability of children who engage in problem sexual behaviour,
the children who are the targets of the behaviour and all of their families.
Ultimately, this research provides a credible hope that a strategy can be developed which will prevent child sexual
abuse. Effective early intervention with children who engage in problem sexual behaviour and their families will
reduce the number of adolescents and adults who go onto to develop more difficult, aggressive and abusive
behaviour as they grow older. It will, by definition, decrease the number of children who experience sexual abuse.
It will reduce the trauma and pain of these children and their families. It will minimize the enormous cost to the
community of down stream consequences of child sexual abuse.
It is such a simple equation and worthy of government and community recognition.
58
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Children Problem Sexual Behaviours

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Children who engage in

problem sexual behaviours:

Edited by Dr Petra Staiger

Australian Childhood Foundation

Additional contributions to the review:

Chapter 1. Introduction - Petra Staiger and Joe Tucci

Prevalence of children who engage in problem sexual behaviour

Definitions and language

Terminology used in this report

Chapter 2. Historical context of problem sexual behaviour in children - Janise Mitchell

Inclusion criteria for this review

Definition of problem sexual behaviour

Chapter 4. Theoretical models - Petra Staiger and Nicolas Kambouropoulos

Four related theories

Chapter 5. Treatment programs - Nicolas Kambouropoulos and Petra Staiger

Programs and agencies

Chapter 6. Treatment programs and evaluation studies - Petra Staiger

Summary of evaluation studies

Chapter 7. Conclusion - Joe Tucci

Prevalence of children who engage

Definitions and language

Terminology used in this report

Inclusion criteria for this review

Definition of problem sexual behaviour

Four related theories

Posttraumatic Stress Disorder

Sexual Abuse Cycle Theory

Four Preconditions of Abuse

Trauma Outcome Process Approach

Programs and agencies

Program 3: The Transformers Program, Australian Childhood Foundation, Victoria, Australia

Redirecting Sexual Aggression (RSA), Colorado USA

The control of criminal thinking and behaviour

Treatment conditions II, III, IV:

Society and sexual offending

Victim empathy and restitution

Program 7: A Step Forward

Program 8: Philly Kids Play it Safe, Philadelphia USA

Program 9: Programs developed by William Friedrich

Programs developed by Eliana Gil, Private Practice, Fairfax, Virginia USA

Description and admission

Evaluation 2. The Sexually Reactive Youth Program, Spokane, Washington USA

Evaluation 5. Professional Parenting Intensive Program, Morganton, North Carolina USA

Summary of evaluation studies

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