Despite the growing number of specialized treatment options for children with sexually problematic behaviour, the scientific literature is striking in its scarcity of treatment efficacy research. Moreover, the studies which do exist are riddled with methodological pitfalls that limit the scope of their results.
Nevertheless, a review of the literature has uncovered important and useful information about the treatment of children with sexually problematic behaviour, illustrating the complex, multidimensional nature of the problem itself and of carrying out clinical research among these children. Our review revealed only one unique case study and two randomized control trials of treatment programs for children with sexually problematic behaviour.Kolko (1986) carried out a unique case study in a hospital environment describing the social skills training of an 11-year-old boy with sexually problematic behaviour.
Kolko developed a social skills training program based on a functional analysis of socially problematic behaviour; the program targeted four behaviours: tone of voice, eye contact, physical gestures, and verbal content. The results showed clinical improvements (i.e., without a statistical analysis) when comparing pre- and post-training tests of social adjustment (score on the Weekly Global Social Adjustment Ratings – WGSAR) and of relationships with peers (score on the Matson Evaluation of Social Skills of Youngsters – MESSY). In addition, the improvements were maintained during the 12-month period following the boy's participation in the program.
Finally, a significant improvement between the pre-treatment test and the follow-up was observed with respect to both behavioural problems and sexually problematic behaviour (score on the Child Behavior Checklist – CBCL). While the scope of these results is limited because of the nature of the study (unique case study), the author concluded that social skills training had a positive effect in reducing inappropriate sexual behaviour. According to Brown and Kolko (1998), the results also raised the question of whether or not treatment specific to sexually problematic behaviour is necessary.
In another study, Pithers and his colleagues (Pithers & Gray, 1993; Pithers, Gray, Busconi & Houchens, 1998) compared the effectiveness of group cognitive-behavioural therapy with group expressive therapy. They studied 127 children aged 6 to 12 years with sexually problematic behaviour and their parents. Subjects were randomly assigned to one of the two treatment methods. The cognitive-behavioural therapy employed an approach that focused on relapse prevention and that included external supervision and a relapse prevention team.
This team – created to support the development of a preventative lifestyle – consisted of the child, the parents, therapists, and selected people from the child's and parent's circle. The expressive therapy used a variety of techniques to deal with assertiveness, self-esteem, decision-making, sexuality, and social skills, but it did not include a relapse prevention team. Both treatments took place over 32 weeks (90-minute sessions for the children, with simultaneous sessions for the parents). In addition, the groups of children were divided according to age – one group for 6-to-9-year-olds and another for 10-to-12-year-olds.
The overall program results showed a significant reduction in sexually problematic behaviour among 30 percent of the children after 16 weeks of treatment (score obtained on the Child Sexual Behavior Inventory – CSBI). Of these children, participants in the cognitive-behavioural group showed a significantly greater reduction in sexually problematic behaviour than participants in the expressive therapy group. However, 3.2 percent of the children showed an increase in sexually problematic behaviour. The unified data showed that after one year, behavioural problems had diminished (assessed using the CBCL, CSBI, and the Eyberg Child Behavior Inventory – ECBI). The authors attributed the persistence of these improvements to the ability of the families to develop and maintain a healthy family environment and to post-program support by other families who participated in the group sessions. The authors felt that even though certain stress factors may remain in the family environment, it is possible for families to maintain a preventative lifestyle. This finding is indicative of parents' and children's potential to change when they have access to treatment programs that make use of their strengths to promote a preventative lifestyle rather than those that focus only on the elimination of the sexually problematic behaviour (Pithers & Gray, 1993).
In addition, Pithers and his colleagues (1998) observed that irrespective of the type of treatment (i.e., group cognitive-behavioural therapy or group expressive therapy), children with sexually problematic behaviour of an aggressive nature demonstrated less change than children with unaggressive sexual behaviour. They also stressed the importance of parental participation in the treatment to maximize program effectiveness and to present positive models. More recently, a study by Bonner et al. (1999) compared the respective effectiveness of cognitive-behavioural therapy and psychodynamic therapy on 201 children and their parents.
The subjects, 6 to 12 years old, were randomly assigned to one of the two methods and took part in 12 group sessions. Cognitive-behavioural therapy is a structured approach aimed at behaviour modification by helping subjects to recognize inappropriate sexual gestures, to abide by certain rules, to improve their self-control, to learn about sexuality, and to prevent relapses. Psychodynamic therapy, based on play therapy, focuses on the expression of emotions, increasing self-awareness (insight), transference, and limit setting. The children's behaviour was assessed by their caregivers at the beginning of the treatment, at the end, as well as one and two years post-treatment. The authors reported significant post-test improvements on the CSBI and the CBCL for both groups of children (cognitive-behavioural and psychodynamic therapy) and with respect to sexual behaviour, social skills, and behavioural and affective problems (score on CBCL and CSBI).
The authors pointed out that there was no relationship between the results obtained and the type of treatment, i.e., neither treatment was significantly more effective than the other. Results from the two-year post-treatment telephone follow-up indicated that roughly the same number of children from each group (15 percent from the cognitive-behavioural therapy group and 17 percent from the psychodynamic therapy group) had made inappropriate sexual gestures after participating in the program. Of note, however, is the program withdrawal rate: 63 percent of participants completed 9 of the 12 sessions, 56 percent responded to the post-test, and only 29 percent of parents completed the two-year follow up. In short, Bonner et al. (1999) concluded that both therapeutic approaches appeared to be effective in reducing sexually problematic behaviour in children, though they stressed that without a control group, it was impossible to determine with certainty if the improvements were attributable to the treatment program.
Bonner, B.L., Walker, C.E., & Berliner, L. (1999). Final report on children with sexual behaviour problems: assessment and treatment. Washington, DC: Office of Child Abuse and Neglect, Department of Health and Human Services.
Brown, E.L., & Kolko, D.J., (1998). Treatment efficacy and program evaluation with juvenile sexual abusers: A critique with directions for service delivery and research. Child Maltreatment, 3(4), pp.362-373
Kolko, D.J., (1986), Social-cognitive skills training with a sexually abused and abusive child psychiatric inpatient. Training, generalization and follow-up. Journal of Family Violence, 1(2), 149-165
Pithers, W.D., & Gray, A., Cunningham, C., & Lane, S. (1993). From trauma to understanding: A guide for parents of children with sexual behaviour problems. Orwell, VT: Safer Society Press.
Pithers, W.D., Gray, A., Busconi, A, & Houchens, P. (1998) Children with sexual behaviour problems: Identification of five distinct child types and related treatment considerations. Child Maltreatment, 3(4), pp.384-406
Gagnon, M.M, Bégin, H & Tremblay, C. (2004), Treatment programs for children with sexually problematic behaviour. International Journal of Child & Family Welfare, 4(1) pp.50-52