Child Abuse & Neglect xxx (xxxx) xxxx

Contents lists available at ScienceDirect

Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Preliminary findings of problematic sexual behavior-cognitive-

behavioral therapy for adolescents in an outpatient treatment
setting
Carrie S. Jenkinsa,*, Julia R. Grimma, Emily Knight Shierb, Simaya van Doorena,
Elizabeth R. Ciesara, Kathryn Reid-Quiñonesa
a
Dee Norton Child Advocacy Center, 1061 King Street, Charleston, SC 29403, United States
b
Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street,
Charleston, SC 29425, United States

A R T IC LE I N F O ABS TRA CT

Keywords: Background: The lack of empirical support for interventions commonly used to treat adolescents
Problematic sexual behavior with problematic sexual behaviors (PSB) has led to restrictive policies and interventions largely
Adolescent based on perceptions of these youth as younger versions of adult sex offenders, without con-
Treatment sideration for developmental and etiological differences between populations.
Juvenile
Objective: This study’s aim is to evaluate a low-intensity outpatient treatment regarding the re-
Sex offender
duction of internalizing symptoms and externalizing behaviors to include, PSB.
Cognitive-behavioral therapy
Participants & Setting: The study examined outcomes for 31 adolescents who completed
Problematic Sexual Behavior – Cognitive Behavioral Therapy for Adolescents (PSB-CBT-A) at a
Children’s Advocacy Center between 2013 and 2016.
Methods: Evaluation of PSB and other symptomology was conducted through pre- and post-
treatment administration of standardized instruments.
Results: Adolescent PSB-CBT-A treatment completers demonstrated a trend towards statistical
significance in reduction of PSB on the YSBPI from 5.33 (SD = 6.86) at pre-treatment to 0.17
(SD = 0.41) at completion. Additionally, significant reductions in caregiver-reported youth in-
ternalizing and externalizing problems were associated outcomes of completing PSB-CBT-A (t(13)
= 5.00, p < .001 and t(13) = 2.34, p = .036, respectively).
Conclusions: The promising results achieved in this study support further exploration of low-
intensity outpatient treatment interventions for adolescents with PSB.

What is known?

Youth initiated problematic sexual behaviors (PSB) are common (Finkelhor, Ormrod, & Chaffin, 2009). Youth with PSB are a
heterogeneous population for whom ecologically driven treatments are needed. Little research evaluating current treatment models
exists (Dopp, Borduin, Rothman, & Letourneau, 2017).

⁎
Corresponding author.
E-mail address: cjenkins@deenortoncenter.org (C.S. Jenkins).

https://doi.org/10.1016/j.chiabu.2020.104428
Received 12 November 2018; Received in revised form 8 January 2020; Accepted 10 February 2020
0145-2134/ © 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: Carrie S. Jenkins, et al., Child Abuse & Neglect, https://doi.org/10.1016/j.chiabu.2020.104428
C.S. Jenkins, et al. Child Abuse & Neglect xxx (xxxx) xxxx

What this study adds?

This study contributes promising preliminary findings of an outpatient group treatment for youth with PSB. We posit that
caregiver involvement and coordination among the treatment team and legal entities may contribute to treatment success.

1. Introduction

PSB in youth are defined as youth-initiated sexualized behaviors which are developmentally inappropriate and/or potentially
harmful (Silovsky, 2012). Findings show adolescents who engage in PSB have greater levels of developmental trauma, family dys-
function, internalizing problems, and behavioral difficulties than the general population (Friedrich, Davies, Feher, & Wright, 2003;
Grant et al., 2009; Shields, 1995).
Much of the treatment available to this population has been distilled from treatments designed for adults who have sexually
offended and does not account for adolescent psychosocial needs, development and/or familial issues (Grant et al., 2009; Letourneau
& Miner, 2005). The majority of adolescents are referred to intensive, specialized residential programs which are costly, overly
restrictive, and utilize interventions that have not been subjected to empirical research with youth (Chaffin, 2008; Kettrey & Lipsey,
2018; Letourneau & Miner, 2005).
Interventions for treating PSB in adolescents are evolving into integrated approaches that are individualized according to youth
and family risk factors (ATSA, 2012). However, Dopp, Borduin, and Brown (2015) found that only two interventions have undergone
rigorous analysis related to efficacy in reducing PSB: Problematic Sexual Behavior - Cognitive Behavioral Therapy (PSB-CBT-S) for
children aged 7–12 (Carpentier, Silovsky, & Chaffin, 2006), and Multisystemic Therapy (MST) for adolescents aged 12–17 (Borduin,
Henggeler, Blaske, & Stein, 1990; Borduin, Schaeffer, & Heiblum, 2009; Letourneau et al., 2009). A 10 year follow up study of PSB-
CBT-S found participants exhibited lower rates of recidivism (2%) compared to the control group (10 %) who engaged in play therapy
(Carpentier et al., 2006). Furthermore, Silovsky, Hunter, and Taylor (2019) examined an adaptation of PSB-CBT-S for youth aged
10–14 and found reductions in PSB and internalizing, externalizing, and trauma symptoms. MST is an ecologically valid, intensive
community-based approach. MST is intended for youth with significant delinquent behaviors or severe clinical problems who are
often at risk for imminent out-of-home placement (Henggeler, 1999). As youth with PSB are a heterogeneous population, it stands to
reason that not all youth will require intensive intervention.
To date, there has not been an outcomes study published examining Problematic Sexual Behavior—Cognitive Behavioral Therapy
for Adolescents (PSB-CBT-A). This study hopes to build on the aforementioned research related to PSB-CBT-S by assessing the impact
of PSB-CBT-A. PSB-CBT-S and PSB-CBT-A have many similarities, including focus on caregiver engagement by requiring it for in-
clusion, sexual health, critical thinking, empathy development, and accountability. PSB-CBT-A focuses less on skill building and has a
stronger focus on the parent-child relationship and building insight related to decision making (Bonner et al., 2009; Swisher,
Widdifield, & Silovsky, 2013).
This study aims to evaluate a low intensity treatment option for adolescents with PSB in an outpatient setting. It is hypothesized
that those who successfully completed PSB-CBT-A would demonstrate statistically significant reductions in internalizing and ex-
ternalizing problems, including PSB.

2. Methods

2.1. Program description

Therapists at a Children’s Advocacy Center (CAC) in the Southeastern United States were trained in PSB-CBT-A (Bonner et al.,
2009). The curriculum is a six to 12 month, outpatient, single-gender cognitive-behavioral group therapy designed for adolescents
aged 13–18. The modules detailed in Table 1 are required components of this manualized intervention.
Standardly, PSB-CBT-A is comprised of approximately 44 90-minute weekly group therapy sessions conducted concurrently for

Table 1
PSB-CBT-A Curriculum.
Modules Standard Number of Sessions Required

Who to Tell and How to Respond 2–4

Monitoring Sexual Situations 4
Sexual Health 4
Principles of Healthy Sexual Behavior 2
Cognitive Behavioral ABC’s of Behavior 6
Juvenile Justice Guest Speaker 2
What Rules Should Caregivers Set 4
Caregiver-Teen Communication 4
Reasons for Illegal Sexual Behavior 4
Disclosure 8–12
Restitution and Apology 4–6
Total Sessions 44–48

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Table 2
Demographic information for initial sample seen for PSB-CBT-A assessment.
Variable N Percentage

Gender 130
Male 115 88 %
Female 15 12 %
Ethnicity 130
African American 54 42%
Caucasian 43 33 %
Hispanic 6 5%
Multiracial 7 5%
Unknown 20 15%
Referral Source
Law Enforcement, Department of Juvenile Justice, Courts 55 42%
Child Welfare 19 15%
Other (Mental health providers, Schools, Medical providers) 56 43 %

both youth and caregivers. PSB-CBT-A allows for adolescents and their caregiver(s) to start at any point in the curriculum. Younger
youth can be referred to PSB-CBT-A depending on the severity of the PSB and/or their developmental and cognitive abilities. Youth
who exceed allowable absences, refuse to participate, or who engage in subsequent illegal behaviors are considered unsuccessful and
are referred back to legal agencies who monitor community safety, when involved. Graduation from treatment occurs after sa-
tisfactory attendance and participation.

2.2. Participants

Table 2 details demographics of the initial sample, which included 130 adolescents (88 % male) who ranged in age from 11 to 18
(M = 14.24; SD = 1.49) who completed a pre-treatment assessment from 2013 to 2016. Female adolescents (12 %) who completed a
pre-treatment assessment were referred to other family-based services and, therefore, were not included in subsequent analyses. Of
those assessed, 38 % (n = 49) were referred to PSB-CBT-A. Criteria for inclusion were acknowledgement of incidents of PSB and the
ability to engage in outpatient treatment (i.e., caregivers were willing to abide by a safety plan and engage in treatment, low level-
risk to the community). Conversely, 62 % (n = 81) were not considered appropriate for PSB-CBT-A and were referred to more
appropriate alternative services (i.e., TF-CBT, CBT, or residential treatment) if indicated. Reasons for ineligibility included youth’s
lack of acknowledgement of PSB and/or limited caregiver support. Of those who engaged in PSB-CBT-A treatment, 31 completed
treatment. Adolescents who completed PSB-CBT-A and who completed pre- and post-treatment measures with a consistent caregiver
were included in the treatment outcome analyses (n = 22). Fig. 1 displays the flow of clients through the referral process.

2.3. Assessment measures

Assessment for PSB-CBT-A consisted of a semi-structured clinical interview and the administration of a battery of standardized
instruments for all adolescents and caregivers. The following standardized instruments, included in this study, were part of a larger
battery administered at pre- and post- treatment: The Achenbach System of Empirically Based Assessment (ASEBA; Achenbach &
Rescorla, 2001) and the Youth Sexual Behavior Problems Inventory (YSBPI; Silovsky, Chaffin, Swisher, & Pierce, 2011).
The ASEBA is a battery of standardized assessments used to measure emotional/behavioral problems and overall functioning in
children and adolescents (Achenbach & Rescorla, 2001). The ASEBA includes a 118-item caregiver report version (Child Behavior
Checklist, CBCL/6–18: 6–18 years) and a 112-item youth report version (Youth Self-Report, YSR; 11–18 years), both measuring

Fig. 1. Demographic information for initial sample seen for PSB-CBT-A assessment.

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externalizing and internalizing problems. The CBCL and YSR have internal consistencies of 1.00 and .95 (p < 0.001, for both),
respectively. Additionally, test-retest reliability for the CBCL subscales varies between subscales range from .82 (α = .84) to .94
(α = .97) and ranges from .74 (α = .74) to .89 (α = .90) for the YSR subscales (Achenbach & Rescorla, 2001). The YSR was added to
the battery of instruments in February of 2015.
The YSBPI is a 34-item caregiver questionnaire that assesses both the youth’s history of PSB and frequency of PSB over a six-week
time period. Thirty items assess a range of sexual behaviors on a three-point Likert scale; four items assess general behavior problems
and rule-following. The baseline administration of the YSBPI includes an additional option of reporting whether the PSB ever
happened and subsequent administrations focuses only on the six weeks between administrations. Research supports the internal
consistency of the YSBPI (α = 0.88; Silovsky et al., 2011). The YSBPI became available in December of 2014 and was added to the
battery of assessments at that time. For the current study, the YSBPI was recoded to reflect whether adolescents had ever engaged in
the specified behavior. Prior to the inclusion of the YSBPI, assessment of ongoing PSB during treatment was based on caregiver and
youth report.

2.4. Statistical analysis

Descriptive statistics were used to examine baseline demographics as well as chi square analyses and independent samples t-tests
to examine difference between groups (e.g., treatment completers vs. non-completers). Two-tailed paired t-tests were used to com-
pare adolescents’ symptoms before and after treatment. Cohen’s effect size d was calculated by the formula: (Mean pre-treatment –
Mean post-treatment)/SD pre-treatment. The within effect sizes were interpreted as follows: < 0.50: weak or no effect; 0.50-0.80:
moderate effect; > 0.80: large clinically meaningful effect (Cohen, 1992). Listwise deletion was used to handle missing data.

3. Results

3.1. Comparisons based on treatment referral status

Given that the group format is single-gender and few treatment referrals for females were received, only males were included in
subsequent analyses. Chi square analyses and independent samples t-tests were conducted to determine whether youth referred to
treatment differed on demographic characteristics or initial referral source from those who were excluded (see Table 3). There were
not statistically significant differences in referral status based on race/ethnicity; however, chi square analyses revealed that there
were significant differences in referral status based on the initial referral source. As displayed in Table 3, adolescents with legal
involvement were recommended to PSB-CBT-A at higher rates than youth referred from other sources. There was not a significant
difference in age when comparing adolescents referred for group treatment (M = 14.29; SD = 1.72) to those not referred for
treatment (M = 14.21; SD = 1.34); t(128) = -.281, p = .779.

3.2. Treatment dosage and completion

Of those referred for treatment (n = 49), the majority (n = 31; 63 %) completed the full course of treatment. The average number
of attended sessions for all those who began treatment was 24.29 (SD = 13.62; Range 1–45). However, independent samples t-test
indicated a statistically significant difference when comparing treatment completers (M = 32.16; SD = 9.17) and treatment non-
completers (M = 10.24; SD = 9.15) on the number of attended sessions, t(46) = 7.93, p = .000. Additionally, one adolescent was
terminated from treatment prematurely due to engaging in a sexual contact offense.
Chi square and independent samples t-test analyses revealed that relationships between treatment completion and race/ethnicity,

Table 3
Bivariate Predictors of referral to PSB-CBT-A Group after Assessment.
Variable N Referred to PSB-CBT-A (%) χ² p

Race/Ethnicity 115 3.34 .503

Black/African American 48 17 (35 %)
White/Caucasian 39 20 (51 %)
Hispanic 5 3 (60 %)
Biracial 6 3 (50 %)
Unknown 17 6 (35 %)

Referral Source 115 13.45 .036

Legal (i.e., Law Enforcement, Juvenile Justice, Courts) 52 30 (58 %)
Child Welfare 15 3 (20 %)
Mental Health Provider/Agency 18 3 (17 %)
Children’s Advocacy Center 14 7 (50 %)
Caregiver 8 3 (38 %)
School 5 2 (40 %)
Medical Provider 3 1 (33 %)

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Table 4
Bivariate Predictors of PSB-CBT-A Treatment Completion.
Variable N Completed PSB-CBT-A (%) χ² p

Race/Ethnicity 49 4.75 .314

Black/African American 17 13 (77 %)
White/Caucasian 20 12 (60 %)
Hispanic 3 3 (100 %)
Biracial 3 1 (33 %)
Unknown 6 3 (50 %)
Referral Source 49 6.86 .334
Legal (i.e., Law Enforcement, Juvenile Justice, Courts) 30 20 (67 %)
Child Welfare 3 3 (100 %)
Mental Health Provider/Agency 3 3 (100 %)
Children’s Advocacy Center 7 3 (43 %)
Caregiver 3 2 (66 %)
School 2 1 (50 %)
Medical Provider 1 0 (0%)
Legal Involvement during Treatment 49 11.77 .001
Yes 41 31 (76 %)
No 8 1 (13 %)

age, and referral source were not statistically significant (see Table 4). However, the association between legal involvement during
treatment and treatment completion was significant. Adolescents who experienced any type of involvement with the legal system
(including child welfare) during treatment successfully completed PSB-CBT-A at higher rates (74 %) than those without such legal
involvement (13 %) regardless of whether they were initially referred by a legal entity. Additionally, there were not statistically
significant differences between treatment non-completers and treatment completers on baseline symptom measures.

3.3. Treatment outcomes

Based on analyses of YSBPI data (among the small subsample for which this data was available; n = 6), caregiver-reported
frequency of adolescent PSB decreased from pre-treatment to post-treatment, t(5) = 1.87, p = .120, while not statistically significant
is a trend towards significance. As shown in Table 5, adolescents improved with regard to caregiver-reported internalizing problems
on the CBCL/6–18 from pre-treatment to post-treatment, t(13) = 5.00, p < .001, which also demonstrated a large effect size (Cohen d
= 1.34). When examining the subscales that comprise the Internalizing Problems scale, significant reductions were reported by
caregivers on the Anxious/Depressed, Withdrawn/Depressed and Somatic Complaints subscales with large effect sizes across all
subscales (above 0.80). Significant reductions were also reported by caregivers on the CBLC/6–18 externalizing problems scale from
pre-treatment to post-treatment, t(13) = 2.34, p = .036, with a moderate effect size. Of the two subscales that comprise the Ex-
ternalizing Problems Scale, the Aggressive Behaviors subscale demonstrated significant reductions from pre-treatment to post-
treatment, t(13) = 3.18, p = .007) and a large effect size. Conversely, statistically significant reductions were not demonstrated on
the Rule Breaking Behavior subscale, t(13) = 1.71, p = .111. While statistically significant reductions in internalizing problems or
externalizing symptoms from pre-treatment to post-treatment were not identified on youth-report on the YSR, there was a statistical
trend toward reductions on these symptom scales from pre-treatment to post-treatment in the small sub-sample (n = 7) for whom

Table 5
Clinical Ratings at Pre-treatment and Post-treatment for Adolescents with PSB.
Pre Post Pre-Post

N Mean SD Mean SD Cohen’s d t p

YSBPI 6 5.33 6.86 0.17 0.41 0.72 1.87 0.120

CBCL Externalizing Problems 14 54.21 9.63 47.43 7.84 0.62 2.34 0.036
CBCL Rule Breaking 14 56.93 6.41 53.64 4.99 0.24 1.71 0.111
CBCL Aggressive Behaviors 14 55.86 6.07 51.79 2.97 0.85 3.18 0.007
CBCL Internalizing Problems 14 57.14 11.93 46.29 7.98 1.34 5.00 0.000
CBCL Anxious/Depressed 14 57.36 6.93 51.71 2.16 0.89 3.32 0.006
CBCL Withdrawn/Depressed 14 62.71 11.02 53.50 4.33 1.02 3.83 0.002
CBCL Somatic Complaints 14 56.00 6.26 51.14 2.45 0.82 3.08 0.009
YSR Externalizing Problems 7 54.71 6.65 49.14 8.15 0.87 2.41 0.061
YSR Rule Breaking 7 55.14 4.74 52.71 2.56 0.75 2.00 0.092
YSR Aggressive Behaviors 7 55.86 5.79 53.86 5.49 0.48 1.27 0.251
YSR Internalizing Problems 7 56.14 8.57 44.41 13.47 0.81 1.45 0.076
YSR Anxious/Depressed 7 55.29 6.92 51.57 1.81 0.63 1.29 0.244
YSR Withdrawn/Depressed 7 58.00 6.38 53.43 5.03 0.49 1.66 0.148
YSR Somatic Complaints 7 57.00 5.83 54.43 5.86 0.30 0.80 0.457

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pre- and post-treatment youth-report data was available. Similarly, statistically significant reductions in the subscales that comprise
the internalizing and externalizing problems scales were not detected.

4. Discussion

This study contributes promising findings in support of PSB-CBT-A delivered in an outpatient setting. Analyses of the YSBPI
indicate a statistical trend toward reductions in PSB from pre- to post-treatment and a moderate effect size for the small sub-sample
for whom this data was available (n = 6). This, however, should be interpreted with caution due to the instrument’s reliance on
caregiver awareness and accurate reporting of PSB. 63 % of youth referred to engage in PSB-CBT-A completed a full course of
treatment and had no additional reported incidents of PSB. Of the 37 % of youth referred to treatment who did not successfully
complete, only one of those youth was terminated due to a subsequent contact sexual behavior. Additional examination of all
contributing variables (i.e. legal involvement) is needed to account for other possible explanations of this finding; however, it does
indicate promise that PSB-CBT-A can reduce PSB in youth. Additional research is needed to draw conclusions about the long-term
sustainability of treatment effects.
The finding of a 37 % attrition rate is in contrast with existing attrition research which suggests that roughly 80 % of youth
engaged in outpatient psychotherapy disengage prematurely and only 9% remain engaged after three months (De Haan, Boon, De
Jong, Hoeve, & Vermeiren, 2013). One important treatment completion factor identified in this study is the involvement of a legal
entity capable of mandating engagement in services. While initial referral from a legal source did not seem to predict treatment
completion, some adolescents (regardless of initial referral source) experienced continued involvement of a legal entity throughout
the duration of treatment. This involvement appeared to have a significant relationship to treatment completion with 74 % of legally-
involved youth completing treatment compared to only 13 % of youth who completed treatment without legal involvement. The
treatment completion rate demonstrated in this study indicates legally-involved youth can successfully and safely complete treatment
in an outpatient setting.
One notable possible contributing factor to treatment completion is the concurrent involvement of the caregiver. The notion that
caregiver engagement is pivotal in contributing to treatment completion and the subsequent reduction of PSB is consistent with
existing research highlighting the importance of caregiver involvement in creating sustainable change in child and adolescent be-
havior and family functioning (Letourneau et al., 2009; Shields et al., 2018). This should be a focus of future research as it applies
specifically to youth with PSB.
Researchers have noted that youth with PSB sometimes display a pattern of problematic behaviors and antisocial tendencies akin
to youth who commit nonsexual offenses (Seto & Lalumière, 2010). Findings from the current study indicate that caregivers reported
statistically significant reductions in externalizing behaviors. This finding supports recommendations in existing research that youth
who have engaged in offending behavior should be placed in the least-restrictive environment possible and can participate in out-
patient treatment with success. Christiansen and Vincent (2013) note, “…placement of low-level offenders with offenders of higher
delinquency oftentimes results in negative effects” (p. 512). Future research is warranted to examine PSB-CBT-A outcomes related to
nonsexual delinquency as compared to other established treatment options (i.e. MST).
Caregiver reports of perceived internalizing symptoms in their youth showed statistically significant reduction from pre- to post-
treatment, while youth self-report indicated a statistical trend toward reduction. The difference in youth-reported and caregiver
reported internalizing symptoms may be a construct of the small sample for whom YSR data was available (n = 7). It is also possible
that caregivers at pre-treatment may project their own emotional climate onto their youth in the weeks following discovery of the
PSB. Given the negative social stigmatization that can accompany PSB, it stands to reason youth who engage in PSB and their families
may experience isolation, family separation, and feelings of shame, distress, fear, anger, and confusion. Youth with PSB also often
have co-morbid anxiety, depression, and other mental health diagnoses (Hunter, Figueredo, Malamuth, & Becker, 2003). As such, the
cohesion and shared experience of group treatment for this population has been reported to be uniquely suited to address these
internalizing symptoms, alleviate shame, and reduce isolation by providing a sense of community and peer support (Shields et al.,
2018). The statistical trend toward youth self-reported reductions in internalizing problems in the current study suggests youth self-
report should be a focus of future research with a larger sample.
Taken together, these findings have important implications for both treatment and policy for adolescents with PSB and their
families. Trends toward statistically significant reductions of PSB during treatment and statistically significant reductions in non-
sexual externalizing behaviors indicate that PSB-CBT-A is a promising outpatient treatment option for adolescent males with PSB.
Statistically significant reductions in internalizing symptoms indicate that PSB-CBT-A could also improve adolescent emotional
functioning overall. This is an important finding when common drivers of adolescent PSB (e.g., social skills deficits, difficulty with
impulse control, and comorbid mental health diagnoses such as anxiety and depression) are considered (Chaffin, 2008). Treatment
completion rates indicate that PSB-CBT-A delivered in an outpatient setting, such as a CAC, can be successful. Future research should
explore the feasibility PSB-CBT-A dissemination in a CAC setting. Perhaps most salient for policy making is the finding that legally
involved youth completed treatment at a rate of nearly five times that of youth without legal involvement. This is important when
considering the adoption of holistic community responses that include partnerships among multi-disciplinary agencies that can
mandate engagement in treatment in the least restrictive environment. While additional research is needed, these findings posit that
PSB-CBT-A may be well-suited as a mandated diversion program for youth with PSB, thereby ensuring community safety and cur-
tailing ineffective and potentially harmful life-long consequences.

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5. Limitations

Our sample was exclusively male due to the nature of the group being delivered in single-gender fashion, limiting generalizability
to female adolescents with PSB. The overall sample was small and the sub-samples of youth for whom YSBPI and YSR data were
smaller due to those instruments being implemented later in the data collection time frame. Due to omission in the administration of
standardized assessment measures or changes in caregiver/placement, complete pre- and post-treatment data were not available for
the full treatment sample. There was no treatment comparison group, thus outcomes as compared to other established treatment
modalities have yet to be determined.

6. Conclusion

In this study, youth with PSB were treated successfully in the community. PSB-CBT-A is a promising outpatient intervention for
youth with PSB and can improve other internalizing symptoms as well as nonsexual externalizing behaviors.

Funding

The United States Department of Justice, Office of Justice Programs [grant number 2014-AW-BX-K012] informed the selection of
some of the measures used within the clinical service delivery. In addition, the clinical services, from which the data were obtained,
were partially supported by the United States Department of Health and Human Services Substance Abuse and Mental Health Services
Administration [grant number 1U79SM059480-01] and the United States Department of Justice, Office of Justice Programs [grant
number 2014-AW-BX-K012].

Acknowledgements

Contributing authors would like to thank the treatment developers and trainers of the PSB-CBT-A program, namely Drs. Barbara
Bonner, Jane Silovsky, and Mr. Jimmy Widdifield Jr., LPC for their dedication to training and continued consultation with the Dee
Norton clinical staff, without which this project would not have been possible. Authors would also like to thank current clinicians,
former clinicians, and clinical interns, too many to name individually, without whom program sustainability would not have been
possible.

References

Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children,
Youth, & Families.
Association for the Treatment of Sexual Abusers (2012). Adolescents who have engaged in sexually abusive behavior: Effective policies and practices. Adopted by the ATSA
Executive Board on October 30, 2012. Retrieved from:http://www.atsa.com/pdfs/Policy/AdolescentsEngagedSexuallyAbusiveBehavior.pdf.
Bonner, B. L., Chaffin, M. C., Pierce, K., Swisher, L., Schmidt, S., & Walker, C. E. (2009). Treatment manual for adolescent sexual offenders. Oklahoma City, OK: Authors.
Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stein, R. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and
Comparative Criminology, 34, 105–113.
Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of multisystemic therapy with juvenile sexual offenders: Effects on youth social
ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77(1), 26–37.
Carpentier, M., Silovsky, J., & Chaffin, M. (2006). Randomized trial of treatment for children with sexual behavior problems: Ten-year follow up. Journal of Consulting
and Clinical Psychology, 74, 482–488.
Chaffin, M. (2008). Our minds are made up-don’t confuse us with the facts: Commentary on policies concerning children with sexual behavior problems and juvenile
sex offenders. Child Maltreatment, 13(2), 110–121.
Christiansen, A. K., & Vincent, J. P. (2013). Characterization and prediction of sexual and nonsexual recidivism among adjudicated juvenile sex offenders. Behavioral
Sciences & the Law, 31(4), 506–529.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159.
De Haan, A. M., Boon, A. E., De Jong, J. T. V. M., Hoeve, M., & Vermeiren, R. R. J. M. (2013). A meta-analytic review on treatment dropout in child and adolescent
outpatient mental health care. Clinical Psychology Review, 33, 698–711.
Dopp, A. R., Borduin, C. M., & Brown, C. E. (2015). Evidence-based treatments for juvenile sexual offenders: Review and recommendations. Journal of Aggression,
Conflict and Peace Research, 7(4), 223–236.
Dopp, A. R., Borduin, C. M., Rothman, D. B., & Letourneau, E. J. (2017). Evidence-based treatments for youth who engage in illegal sexual behaviors. Journal of Clinical
Child and Adolescent Psychology: the Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 46(5),
631–645.
Finkelhor, D., Ormrod, R., & Chaffin, M. (2009). Juveniles who commit sex offenses against minors. [Juvenile Justice Bulletin]. Retrieved fromWashington, DC: U.S.
Department of Justice Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://www.ojjdp.gov/publications/PubAbstract.asp?
pubi=249770.
Friedrich, W. N., Davies, W. H., Feher, E., & Wright, J. (2003). Sexual behavior problems in preteen children: Developmental, ecological, and behavioral correlates.
Annals New York Academy of Science, 989, 95–104.
Grant, J., Indermaur, D., Thornton, J., Stevens, G., Chamarette, C., & Halse, A. (2009). Intrafamilial adolescent sex offenders: Psychological profile and treatment.
Trends & Issues in Crime and Criminal Justice, 375, 1–6.
Henggeler, S. (1999). Multisystemic Therapy: An overview of clinical procedures, outcomes, and policy implications. Child Psychology and Psychiatry Review, 4(1),
2–10.
Hunter, J. A., Figueredo, A. J., Malamuth, N. M., & Becker, J. V. (2003). Juvenile sex offenders: Toward the development of a typology. Sexual Abuse A Journal of
Research and Treatment, 15, 27–48.
Kettrey, H. H., & Lipsey, M. W. (2018). The effects of specialized treatment on the recidivism of juvenile sex offenders: A systemic review and meta-analysis. Journal of
Experimental Criminology, 14(3), 361–387.
Letourneau, E. J., & Miner, M. H. (2005). Juvenile sex offenders: A case against the legal and clinical status quo. Sexual Abuse A Journal of Research and Treatment,

7
C.S. Jenkins, et al. Child Abuse & Neglect xxx (xxxx) xxxx

17(3), 293–312.
Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E., et al. (2009). Multisystemic therapy for juvenile sexual offenders: 1-
year results from a randomized effectiveness trial. Journal of Family Psychology, 23(1), 89–102.
Seto, M. C., & Lalumière, M. L. (2010). What is so special about male adolescent sexual offending? A review and test of explanations through meta-analysis.
Psychological Bulletin, 136(4), 526–575.
Shields, I. W. (1995). Young sex offenders: A comparison with a control group of non-sex offenders. Forum on Corrections Research, 7(1), 17–19.
Shields, J. D., Klinkebiel, C. M., Taylor, E. K., Espeleta, H. C., Beasley, L. O., & Silovsky, J. F. (2018). A qualitative analysis of family perspective on treatment services
for youths with problematic sexual behavior. Victims & Offenders, 13(7), 955–973.
Silovsky, J. F. (2012). Problematic sexual behavior. Retrieved fromhttp://ncsby.org/content/problematic-sexual-behavior.
Silovsky, J. F., Chaffin, M. C., Swisher, L. M., & Pierce, K. (2011). Youth sexual behavior problems inventory. Unpublished measure.
Silovsky, J. F., Hunter, M. D., & Taylor, E. M. (2019). Impact of early intervention on youth with problematic sexual behaviors and their caregivers. The Journal of
Sexual Aggression, 25(1), 4–15.
Swisher, L. M., Widdifield, J. L., Jr., & Silovsky, J. F. (2013). Problematic sexual behavior – Cognitive-behavioral therapy: Treatment for children ages 7-12 with problematic
sexual behavior and their families, supplemented for youth ages 13-14 (4th ed.). Training and Treatment Manual.