- Understand how risk factors impact sexual development and behavior.
- Understand developmentally appropriate intervention options, including counseling.
- Familiarize yourself with ways you may be asked to incorporate recommendations for children receiving intervention for sexual behavior challenges.
Variability of Causes for Sexual Behavior Challenges and Other Concerns
As you learned in Lesson Four, the reasons children and youth are affected with sexual behavior challenges are varied. These behaviors can be a result of sexual abuse; however, this may not always be the case. If you suspect sexual abuse, if a child or adolescent reports they have been sexually abused, or if a child or youth has been in contact with a known sexual abuser, it is important to make a mandatory report. For more information on mandatory reporting, see Lesson Three in the Virtual Lab School (VLS) Child Abuse: Identification & Reporting course.
As caregivers and educators, it is important to know the signs of sexual abuse in children and youth. However, it is also important to be aware of other potential causes for problematic or severe sexual behaviors. Children and youth who have not been sexually abused may also exhibit sexual behavior challenges. Consider a child with developmental delays who struggles with issues of personal space and inappropriately touches themselves or others. Or a child who mimics sexually explicit material they saw on TV after an older sibling left the TV on. Children may also display sexual behavior challenges to self-soothe through masturbation in response to traumatic events. These are all examples of paths to sexual behavior challenges that are not the result of sexual abuse. According to the National Child Traumatic Stress Network (2009), the following experiences and needs of children are risk factors for sexual behavior challenges:
- Exposure to traumatic experiences, such as abuse, natural disasters, or accidents
- Exposure to violence in the home
- Excessive exposure to adult sexual activity or nudity in the home (including media exposure through television or the internet)
- Inadequate rules about modesty or privacy in the home
- Inadequate supervision in the home, often as a result of parental factors such as depression, substance abuse, or frequent absences due to work
Other situational factors may contribute to sexual behavior challenges include:
- Playmates in the neighborhood
- Birth of a sibling
- Less privacy when dressing, going to the bathroom, or bathing
- Viewing another child or adult in the bathroom
- Seeing their mother breastfeeding
- Comorbid diagnoses such as conduct disorder, attention deficit hyperactive disorder, post-traumatic stress disorder, or oppositional defiant disorder (children often have more than one diagnosis)
- Developmental level of child or youth
Caregivers and educators working with children and youth experiencing sexual behavior challenges should be knowledgeable about the following social, emotional, and behavioral symptoms:
- Impulsiveness and a tendency to act before they think
- Difficulties following rules and listening to authority figures at home and in the community
- Problems making friends their own age and a tendency to play with much younger children
- A limited ability to self soothe (calm themselves down), so they may touch their own genitals as a way to release stress and calm down
If a child or youth experiences these challenges or needs, communicate your concerns with your program leadership. They will help decide what next steps you should take and communicate with the family about resources and supports. These can be challenging conversations primarily because of the myth that children with sexual behavior challenges have always been abused. If there is reported or suspected abuse, a mandatory report needs to be made. Communicating early and working as a team provides the family with options for support and can prevent a child with risk factors from developing sexual behavior challenges.
Potential Intervention Options
As caregivers and educators, it is beyond our training and skills to provide intervention for children and youth who exhibit sexual behavior challenges. However, we can educate ourselves on the intervention options available for families who have a child with sexual behavior challenges. It is important to be aware that different programs and schools refer to these resources by various names. At the Virtual Lab School, we think it is vital to familiarize yourself with the potential professional or job titles of those who may be working with a family that is experiencing sexual behavior challenges. For example, mental health professionals can include counselors, psychologists, psychiatrists, or social workers. These professionals may provide therapy, intervention, or treatment. Certain settings may also include specialists, such as, board certified behavior analysts, occupational therapists, and intervention specialists.
Families should receive intervention from providers who are knowledgeable about sexual development, childhood and adolescent development, and research-based interventions (NTCSN, 2009). Mental health professionals will consider alternative conditions and look holistically at the child or youth, taking into consideration their environment, parenting style, family, and social factors. Each assessment is unique and treatment decisions are made on a case-by-case basis aiming for the least restrictive treatment option (Martin, 2019). Two main research-based practices for sexual behavior challenges are Trauma-Focused-Cognitive Behavioral Therapy (TF-CBT) and Problematic Sexual Behavior-Cognitive Behavioral Therapy (PSB-CBT).
TF-CBT is implemented by mental health professionals for children and youth recovering from trauma. TF-CBT also effectively addresses many other trauma impacts, including (Trauma- Focused Cognitive Behavioral Therapy, 2019):
- Cognitive and behavioral problems
- Improving the participating parent’s or caregiver’s personal distress about the child’s traumatic experience
- Effective parenting skills
- Supportive interactions with the child
PSB-CBT is also provided by a trained mental health professional. This model includes:
- Rules about sexual behavior and boundaries
- Abuse prevention skills and safety planning
- Emotional regulation and coping skills
- Impulse-control and problem-solving skills for children
- Developmentally appropriate sexual education
- Social skills and peer relationship
- Acknowledgment of sexual behavior, apology, and making amends
Additional key clinical components for caregivers include (NCTSN, 2016):
- Behavior parent training to prevent and respond to problematic sexual behavior and other behavior problems
- General child development with emphasis on psychological and emotional changes
- Dispelling misconceptions regarding problematic sexual behavior and implications for the child
- Communicating with children about sexual behavior and development
- Supporting children’s use of coping and decision-making skills
During the child or youth’s initial assessment, the mental health provider may ask that you as the caregiver or educator contribute to the assessment of the child. Often, you will be provided with a questionnaire or checklist to complete. In addition to other assessment materials, your information helps the mental health professional make a recommendation for outpatient or more intensive therapy, such as inpatient or residential care, depending on the severity of the problematic sexual behavior, the presence of additional mental health concerns, or previous unsuccessful treatment.
As intervention progresses, the mental health provider will work with the child or youth and with the family, possibly in individual and or group/family therapy formats, to create a developmentally appropriate intervention plan. Often times, counseling will consist of, but is not limited to, learning to identify and establish healthy boundaries, self-regulation skills, and parent management training. The following are examples of what intervention for sexual behavior challenges may look like based on the recommendation of a mental health professional:
- The child who mimicked sexually explicit acts when their older sibling left the TV on may be recommended to have weekly outpatient intervention including all of the family members to establish healthy boundaries and support improved parental oversight.
- The child with developmental delays who used inappropriate touch may benefit from outpatient counseling two to three times a week to help both parents and the child establish healthy boundaries and address other areas of need for the child.
- The child who self-soothed through masturbation due to traumatic events may be best served in a half-day outpatient setting to learn coping skills for their traumatic stress responses and appropriate times of when to explore their sexuality. If, in that intensive outpatient setting, the mental health professional identifies that the child’s home life is more of a risk factor or that trauma is more intense than originally diagnosed, the child can be moved into an inpatient or residential care facility. Depending on the facility, the child may have limited interaction with their family and increased daily structure with regular therapeutic interventions that can include individual and group counseling. While the child or youth intervention plan is confidential, it is crucial to be aware of what you as a caregiver or educator can do to help the child or adolescent, especially if and when they reintegrate back into your program.
Incorporating Intervention Strategies
In addition to receiving intervention, children with sexual behavior challenges who will continue to attend your program may be asked to follow recommendations. Mental health specialists may request that you incorporate strategies into your daily routines to reinforce what the child learned during intervention. According to Mitten, Sigel, and Silovsky (2017), discussing rules about sexual behavior is a strategy that can prevent sexual behavior challenges. It is also appropriate to communicate with families before such information is discussed with children so that families will not be caught off guard in case questions or comments occur at home after the information is presented. Presenting information in a calm manner helps children and youth to be more open in discussing these sensitive, challenging topics. Interventions are important to consider as preventive--before learning of a child or adolescent with sexual behavior challenges or in response to a presenting sexual behavior concern).
Rules for Younger Children
- It is not OK to touch other people’s private parts
- It is not OK for other people to touch your private parts.
- It is not OK to show your private parts to other people.
- It is not OK to look at other people’s private parts.
- Touching your own private parts when you are alone is OK.
Rules for School-Age Children & Youth
- It is not OK to look at other people’s private parts.
- It is not OK to show other people your private parts.
- It is not OK to touch other people’s private parts.
- It is not OK to use sexual language.
- It is not OK to make other people feel uncomfortable with your sexual behavior.
- It is OK to touch your private parts as long as you are in private and it does not interfere with your daily routines and activities.
Programs are charged with keeping all children safe while in care. With this in mind, caregivers need to consider ways all children and youth stay safe. To address this concern, you may be asked to provide additional supervision for children receiving intervention for sexual behavior challenges. This may mean you will want to create a supervision or safety plan with the child or youth’s parents or caregivers and program administrators to ensure the safety of all children. This is especially important if the child or youth who exhibited sexual behavior challenges toward other children or youth.
Supervision plans can include:
- Adult-only supervision of child or youth.
- Supervision of the child or youth upon arrival, during recess and lunch, and upon departure.
- Supervision of the child or youth during other times of the day that are less structured or have reduced supervision.
- Designated play areas.
- Supervision of the child’s or youth’s use of the washroom.
- Supervision for sports, including changing areas (e.g., at a pool).
- Procedures for the child or youth to check in with a designated adult throughout the day.
- A plan to respond to subsequent inappropriate sexual behavior, which may include a set of escalating consequences.
- Specific behavior-management strategies including a plan to reinforce appropriate behavior.
- A plan to involve the child in positive activities with peers.
- A communication plan that specifies how and with whom information will be shared.
- A designated case manager (preferably or program administrator).
- A scheduled review and update of the plan and clear communication of rules.
- Implementation of coping or calming skills, including those for the caregiver or educator similar to the CAPPD model in Lesson One and the self-care strategies in Lesson Four of the VLS Focused Topics Trauma-Informed Care in Child Care Settings course.
It is important that the safety and supervision plan is periodically reviewed as the child or adolescent progresses in their intervention (Responding to Children’s Problem Sexual Behavior in Elementary Schools, 1999).
Programs can implement policies and preventive measures to address sexual behavior development and be a supportive factor for children or youth with problematic sexual behavior or sexual behavior challenges. These can include:
- Reviewing policies regarding communication about sex education, promoting abuse prevention, and working with families affected by sexual behavior challenges.
- Offering sex education for families to incorporate the entire support system to engage in healthy communication about appropriate sexual development.
- Employing school counselors or collaboration with clinical counselors to implement classroom developmental lessons on healthy boundaries, self-regulation skills, and safe touch. School and clinical counselors can also meet individually with children and youth or with families to assist with supervision plans and discuss counseling referrals.
With intervention, supportive parents or guardians, and on-going monitoring, the likelihood of reoccurrence is reduced, according to the National Children’s Alliance. It is a common misconception that children and youth with sexual behavior challenges will become sexual offenders. This is not true. With early identification of behavior as non-normative, guidance from a mental health professional, and having a supportive network of parents, guardians, caregivers and educators, children and youth can learn to self-regulate and control their challenging sexual behavior.
Children with sexual behavior challenges benefit most from research-based interventions. First, Sharon (Shell) Millington, Licensed Professional Counselor at the University of Oklahoma Health Sciences Center, describes Problematic Sexual Behavior-Cognitive Behavioral Therapy (PSB-CBT) and Trauma-Focused-Cognitive Behavioral Therapy (TF-CBT). These interventions are provided by a trained mental health professional. Then, Amanda Mitten, also a Licensed Professional Counselor at the University of Oklahoma Health Sciences Center, shares examples of recommendations that a mental health professional may request of a child care program.
As noted in Lesson Two, promotion and prevention are common terms used in the Virtual Lab School. As you think about your role as a professional working with infants, toddlers, preschool children, or school-age children and youth, reflect on what you can do to be a part of a supportive team. Consider these guidelines and standards of care for professionals working with children and youth with sexual behavior challenges, provided by the National Center on the Sexual Behavior of Youth:
- Recognize the importance of your work for promoting community and family safety.
- Be aware of the potential for significant impact and life-altering consequences your practices may have on youth and their families.
- Inform children, youth, and their families that professionals are mandated reporters of child abuse.
- Ensure that the child or youth is fully informed in developmentally and cognitively appropriate language.
- With the consent of families, collaborate with outside specialists and agencies so children’s intervention feels like a team effort.
- Follow relevant practice guidelines and ethical standards (e.g., Association for the Intervention of Sexual Abusers’ standards and guidelines, as well as those of your profession).
Revisit the expanded Case Study you read in Lesson Four below, and review the accompanying sample supervision plan. Supervision plans may be recommendations based on the evaluation of specialists or created by program leadership to bridge the gap between when an incident occurs and when a specialist can consult or make recommendations. Brainstorm how you would implement the plan with a coach, trainer, or administrator.
Case Study - Supervision Plan - Infant Toddler: Jasmin
Case Study - Supervision Plan - Preschool - Henry
Review the documents on Types of Touch and Guidelines for Documentation of Sexual Behavior Challenges. Discuss your thoughts with a trusted colleague.
This course has introduced many strategies to support children’s sexual development and behavior. Use the Sexual Development and Behavior in Children & Youth: Direct Care Practice Inventory to think more deeply about the practices that you use to understand and support children’s sexual development and behavior. After completing this inventory, talk with your trainer, coach, or administrator if you need more support. Training & Curriculum Specialist may also use this inventory to observe direct care staff’s practices.
Guidelines for Documentation of Sexual Behavior Challenges
Guidelines and Standards of Care. (n.d.) National Center on the Sexual Behavior of Youth. Retrieved from http://www.ncsby.org/content/guidelines-and-standards-care
Martin, S. (2019). Sexualized behaviors in children and youth. Retrieved from militaryfamilieslearningnetwork.org/event/29419
Ministry of Education, British Columbia. (1999). Responding to children’s problem sexual behaviour in elementary schools: A resource for educators. https://www.icmec.org/wp-content/uploads/2015/10/Responding-to-Improper-Touching-CA.pdf
Mitten, A., Sigel, B.A., Silovsky, J.F. (2017). Birds do it, bees do it…Even the TF-CBTers do it: Addressing sexual behavior in trauma intervention. National Children’s Alliance. Retrieved from http://www.nationalchildrensalliance.org/wp-content/uploads/2018/03/08242017-TF-CBT-PSB-Webinar-Presentation.pdf
National Child Traumatic Stress Network. (2009). Understanding and coping with sexual behavior challenges in children. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress. Retrieved from https://www.nctsn.org/sites/default/files/resources//understanding_coping_with_sexual_behavior_problems.pdf
National Child Traumatic Stress Network. (2016). PSB-CBT-S: Problematic sexual behavior – cognitive-behavioral therapy for school-age children. Retrieved from https://www.nctsn.org/sites/default/files/interventions/psbcbt_fact_sheet.pdf
National Children’s Alliance. (2017). What we can do. http://www.nrcac.org/wp-content/uploads/2018/01/2017-PSB-Fact-Sheet-Overview-3.pdf
Trauma-Focused Cognitive Behavioral Therapy. (2019) About trauma-focused cognitive behavior therapy (TF-CBT). Retrieved from https://tfcbt.org/about-tfcbt/