Program Profile: Children with Problematic Sexual Behavior-Cognitive Behavioral Therapy (PSB-CBT)

This is a cognitive–behavioral therapy (CBT) program for children that is designed to eliminate problematic sexual behavior. The program is rated Effective. Children in the CBT treatment group who demonstrated problematic sexual behavior displayed no statistically significant differences, compared with control group children, in sexual and nonsexual offenses at the 10-year follow up, indicating that the treatment was effective at reducing these behaviors.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Children with Problematic Sexual Behavior–Cognitive Behavioral Therapy (PSB-CBT) is a short-term, outpatient group treatment program. The primary goal of PSB-CBT is to reduce and eliminate sexual behavior problems among school-age children. The program provides cognitive-behavioral, psychoeducational, and supportive services to children referred to the program for sexual behavior problems, and to their families. Intermediate goals are to increase awareness of sexual behavior rules and expectations, strengthen parent-management skills, improve parent-child communications and interactions, improve children’s self-management skills related to coping and self-control, improve children’s social skills, and decrease children’s internalizing and externalizing behaviors.

Target Population

PSB-CBT targets children 12 years of age and younger who exhibit intrusive sexual behaviors that are usually directed at other, often younger children.

Program Components

The PSB-CBT program for school-age children is typically implemented over 12 to 27 sessions, with each session lasting between 60 and 90 minutes. The program provides constructive and corrective feedback to teach children about appropriate and inappropriate sexual behaviors, and to teach their parents/caregivers how to communicate about sex education as well as how to implement appropriate sexual behavior rules in the home. In addition, caregivers are taught effective parenting strategies, and children are taught to develop plans on how they will follow appropriate sexual behavior rules and learn strategies to increase skills related to coping and self-control.

Session content for children includes (a) rules about sexual behavior, privacy, and boundaries; (b) sex education; (c) setting and respecting boundaries and other abuse-prevention skills; (d) emotional regulation and coping skills; (d) impulse-control strategies and problem-solving/decision-making skills; (e) social and peer-relationship skills; and (f) skills related to acknowledging and apologizing for inappropriate sexual behaviors, and making amends.

Session content for caregivers includes (a) how to respond to sexual behavior and other behavior problems; (b) sexual development, moral development, and child development in general; (c) misconceptions about problematic sexual behaviors among children, and their implications; (d) how to address sexual education topics with their children; (e) how to apply rules about sexual behaviors; (f) how to support abuse-prevention strategies and skills; and (g) how to improve the quality of their relationships with their children.

The PSB-CBT program includes a weekly group for caregivers and a parallel group for youths, with combined sessions for families to practice new skills. Group services for youths are typically delivered in two separate groups: (1) younger children, ages 7 to 9; and (2) older children, ages 10 to 12. Group sizes typically range from between five to eight children. Children and caregivers are encouraged to attend sessions regularly, actively participate in sessions, and complete skills rehearsal/homework between sessions. The program uses an open-ended format (i.e., families are able to enter the program at any time) and youths typically graduate any time between 4 to 6 months of treatment. The program may also be delivered to individual children and their parents/caregivers, when a group is not feasible.

Key Personnel

Lead therapists and supervisors should be licensed mental health practitioners with previous experience treating children with behavior problems and with children who have been maltreated. Staff should include a program director/supervisor and co-therapists for the children’s group; a therapist for the caregiver/parent group; and personnel to conduct the intake assessments.

Study

Carpentier, Silovsky, and Chaffin (2006) compared 10-year, follow-up data for three groups of children: two groups who had been referred to a mental health clinic for sexual behavior problems, and one group who had been referred to the same clinic for other (nonsexual) problematic behaviors such as aggressive or disruptive behavior.

Findings from this study were based on two sets of comparisons. The first set was drawn from a sample of youth with sexual behavior problems (n = 135), who had been recruited from child welfare, law enforcement, juvenile court, physicians, school personnel, and mental health centers between 1992 and 1995. As part of a clinical trial, 135 participants were randomized to receive a cognitive-behavioral treatment for sexual behavior problems (CBT-SBP, n = 64) or group play therapy (PT, n = 71). The control group consisted of children who had been referred to the clinic for nonsexual problematic behavior problems (n = 156). The treatment and control groups were predominantly white (84 percent in CBT-SBP, 83 percent in PT, and 78 percent in the control group) and male (63 percent in CBT-SBP, 60 percent in PT, and 78 percent in the control group). In the control group, most of whom were referred because of nonsexual problematic behavior, 64 percent had a diagnosis of attention deficit hyperactivity disorder,10 percent had an adjustment disorder, and 5 percent had an oppositional defiant disorder. The CrimeSolutions review of this study focused on the comparison between the CBT-SBP treatment group and the control group.

Cases referred for sexual behavior problems were included if 1) the referred child had clinically significant SBP, and not simply developmentally normal sexual behavior, 2) the child was between 5 and 12 years of age, and 3) the child and caregiver were fluent in English. Cases were excluded if 1) the referred child’s performance on an IQ test was too low, 2) the child’s behavior was judged by a clinician as too severe for outpatient treatment, or 3) the child’s parents withdrew study consent. Inclusion criteria for the control group included the following: 1) the child was seen during the same time frame, 2) the child was between 5 and 12 years of age, 3) the child’s presenting problem was disruptive behavior, 4) the child had no reported history of SBP (because the SBP trial was ongoing at the clinic, inquiry into SBP was routine), and 4) there were no indications in the child’s file of a diagnosis of autism, pervasive developmental disorder, or childhood psychosis.

The outcomes of interest were nonsexual and sexual offenses, and data were collected at the 10-year follow up. Data for future juvenile and adult arrests were obtained from juvenile justice and criminal justice databases, and data for child-welfare perpetration reports were obtained from child welfare databases. The most common nonsexual offenses included property offenses, drug or alcohol offenses, and probation or procedural violations. Cox proportional hazards survival models, comparing the CBT-SBP group with the control group for future sexual offense arrests or reports, were tested. No subgroup analyses were conducted.

The number of training days and hours depends on the training and experience of the staff. Typically, there are 4 days of initial training for teams of providers; ongoing consultation (preferred live observation of program); and at least one booster training visit in the subsequent 12 months. A team meeting with community stakeholders (e.g., juvenile justice, child welfare, child advocacy, schools, etc.) is recommended with follow up regular calls with senior leaders to facilitate administration and sustainment of the program.

During biweekly consultation calls, trainers review recorded sessions with trainees. Program administrators advise that supervisors and lead therapists should be licensed mental health practitioners with previous experience in treating children with behavior problems and children who have been maltreated by adults.

The National Center on Sexual Behavior of Youth (NCSBY; the website is http://www.ncsby.org) is a national training and technical assistance center developed by the Office of Juvenile Justice and Delinquency Prevention and the Center on Child Abuse and Neglect, University of Oklahoma Health Sciences Center. NCSBY is designed to provide states, territories, and the District of Columbia with information and support through national training and technical assistance in the management of both children and adolescents with sexual behavior problems.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Bonner, Barbara L., C. Eugene Walker, and Lucy Berliner. 1999a. Children with Sexual Behavior Problems: Assessment and Treatment. Final Report. Grant No. 90-CA-1469. Washington, D.C.: National Clearinghouse on Child Abuse and Neglect, U.S. Department of Health and Human Services, Administration of Children, Youth, and Families.

Bonner, Barbara L., C. Eugene Walker, and Lucy Berliner. 1999b. Treatment Manual for Cognitive Behavioral Group Therapy for Children with Sexual Behavior Problems.  Washington, D.C.: U.S. Department of Health and Human Services, Administration of Children, Youth, and Families.

Bonner, Barbara L., C. Eugene Walker, and Lucy Berliner. 1999c. Treatment Manual for Cognitive Behavioral Group Treatment for Parents/Caregivers of Children with Sexual Behavior Problems. Washington, D.C.: U.S. Department of Health and Human Services, Administration of Children, Youth, and Families.

Silovsky, Jane F., and Larissa Niec. 2002. “Characteristics of Young Children with Sexual Behavior Problems: A Pilot Study.” Child Maltreatment 7(3):187-197.

Silovsky, Jane F., Larissa Niec, David E. Bard, and Debra B. Hecht. 2007. “Treatment for Preschool Children with Interpersonal Sexual Behavior Problems: Pilot Study.” Journal of Clinical Child and Adolescent Psychology 36(3):378-391.

Swisher, Lisa M., Jane F. Silovsky, Roger H. Stuart, and Keri Pierce. 2008. “Children with Sexual Behavior Problems.” Juvenile and Family Court Journal 59(4):49-69.

St. Amand, Annick., David E. Bard, and Jane F. Silovsky. 2008. “Meta-Analysis of Child Sexual Behavior Problems: Practice Elements and Outcomes.” Child Maltreatment 13(2):145-166.