In appropriate sexual behaviors among children who were sexually abused have been observed in children as young as 2 years old (10, pp. 229-230). There are various factors that affect the emergence of sexualized behaviors. The most common variables that are associated with such behaviors in the children with sexual abuse history are poor parent-child relationships, lower emotional and social functioning of parents, psychological disorders such as depression, conduct disorder, and attention deficit-hyperactivity disorder, and a physical abuse hisotry of a child (1, 4, 6, 9). Due to these and other various types of associated factors, the treatment process for inappropriate sexual behaviors of sexually abused children need to be considered in relation to the diversity of a child's environment and problematical behavior characteristics.
One of the most common impact of child sexual abuse is child's inappropriate sexual behaviors (13). Although there are several theories behind the reasons for the emergence of such inappropriate sexual behaviors and a broad range of behaviors that should be included as "inappropriate," these behaviors commonly include public or excessive masterbations, repeatedly touching other children or adults, self-exposure, excessive sexual preoccupations, and sexually aggressive behaviors such as incest (1, 6 p.254, 10 p.227, 13, 15 pp.42-43, 16 pp.114-115). These behaviors shoudl be closely and specifically evaluated in the context of a child's environment and development stages (10 p.236). Even though sexually aggressive behaviors are considered as deviant and problematic which always require specialized treatment, other behaviors such as masturbation and self-exposure need to be carefully evaluated in comparison to child's normal development. Since it is normal and quite common for young children, especially between age 4 and 6, to exhibit sexual behaviors (6 p.255, 10 p.233), detailed knowledge of child development is needed in evaluation of such behaviors.
Classifications of Inappropriate Sexual Behaviors:
Although there are various classification systems of child's sexual behaviors, the most basic criteria seem to be whether a behavior is developmentally normal and whether a behavior involves physical force and coercion (1, 6 p.244, 9, 13). There are some researchers who classify children with sexual behavior problems not according to the behavior itself but rather, according to associated variables to those children, such as family characteristics, children's abuse histories, and psychological disorders (13). However, most use developmental appropriateness and physical force as criteria for classifications.
For example, Adams, McClellan, Douglass, McCurry, and Storck (1995) used three categories of child's sexual behaviors: (1) no offending, hypersexual (e.g., flirtatious and touching), (2) exposing (e.g., public masturbation and self-exposure), and (3) victimizing (e.g., molestation, incest, and rape). Similarly, Hall, Mathews, and Pearce (2002) used three groups and three clusters to categorize such behaviors: (1) developmentally expected, (2) developmentally problematic - self-focused, and (3) developmentally problematic - interpersonal, which includes clusters of (1) unplanned, non-coercive, (2) planned, non-coercive, and (3) planned, coercive. These categories are basically derived from clinical observations and theoretical standpoints, rather than empirical data, suggesting the importance of differentiating sexually reactive behaviors and sexually aggressive behaviors (7 p.110). According to literature, treatment process and techniques need to vary to some extent depending on the degree of physical force involvement and possible reasons for the sexual behaviors (7 p.110, 9, 13, 14).
Theories of Inappropriate Sexual Behaviors:
Behavioral perspective. According to behavioral perspective, sexually abused children exhibit sexualized behaviors due to modeling and paired-associate learning (2, 3, 6 p.251). Children who have experienced sexual abuse learn the sexual behaviors and model those behaviors. Then, their sexualized behaviors are mere reflection of their own abuse experiences (10 pp.229-230). They may also have associated sexualized behaviors with positive affects, such as pleasure, affection, and attention.
Psychodynamic perspective. Sexually abused children may have internalized the behaviors of abusers and experience identification with abusers (2, 6 p.252, 15 p.43). Those children feel the need to re-experience their abuse in the role of abusers in order to regain a sense of power and controll they have lost during thier abuse experience (6 p.252, 10 p.240, 11, 15 p.43).
Social learning perspective. Children who are sexually aggressive tend to have ODD as well as CD concurrently with sexual acting-out behaviors (1). Disrupted family systems and parents' poor child management and parenting skills, combined with an aggressive interaction patten among family members, may lead children to become more vulnerable to sexually aggressive behaviors (6 pp.246-247, 9). In this case, child's sexually aggressive behaviors are more of a disorder of conduct, rather than directly reacting to abuse experience (6 p.259).
Others. Children who have been sexually abused may also have heightened sensitivity to sexual issues and respond to them by becoming highly attracted to sexualized behaviors (16 p.145). Those children may also experience self-blame and sexually act out since they feel that they are already "bad" people (5). Other possible explanations for sexual acting out is that children who are sexually abused during young childhood do not go through healthy process of attachment and social learning; therefore, they may lack in empathy (6 p.253, 5 p.212). Due to this lack of empathy, they are unable to take perspectives of others and become sexually aggressive.
These various perspectives on child's inappropriate or aggressive sexual behaviors can give us an idea ofhow treatment process and techniques need to differ depending on the reasons behidn such behaviors. Since none of the sexually abused children go through exactly the same experience of abuse and develop exactly the same set of symptoms, treatment must be congruent to the individual child (9, 14). Further, the distinction between sexually aggressive children, who use physical forces or threat when engagin in sexual behaviors, and sexually reactive children, who exhibit inappropriate sexual behaviors as a direct response to their abuse experience, must be made before or during the process of treatment (7 p.110).
There are several issues that need to be assessed before treating children with sexualized behavior problems. First, inappropriate sexual behaviors themselves need to be assessed in detail. Objective measurements of child sexual behaviors may be used in addition to interview with parents and child him/herself since parents may not notice such sexualized behaviors of a child or may be too defensive to recognize the behaviors as a problem (7 p.145). The nature and frequency of inappropriate sexual behaviors should be assessed as well as time and place the child usually exhibits the behavior (6 p.255, 10 p.234). This detailed assessment of sexualized behaviors will help a therapist to distinguish sexually reactive behaviors from normal developmental sexual behaviors of a child.
Reactions of parents to theier child's abuse and sexualized behaviors also need to be assessed, as well as the meanings they attach to the sexualized behaviors of a child. Young children often do not have a enough experience and cognitive ability to understand the social meanings of sexual abuse and inappropriate sexual behaviors. They often learn what it means to be sexually abused by seeing their parents' reactions and responses to the event (10 p.229). Therefore, if parents react inappropriately to the disclosure of their child's abuse experience and following sexualized behavior problems, the child could be affected negatively by his/her parent's reactions, rather than the abuse experience itself (10 p.229).
Another important thing to assess is a relationship between parents and a child (6 p.255). Since parental attachment is a very important component of child development, receiving sufficient emotional support from parents or caregivers is almost critical in treating traumatized children of any kind, including sexual abuse (11, 13, 14). Reviews of research literature consistently agree that a positive relationship with parents or caregivers could be one of the indicators of positive prognosis of sexually abused children with inappropriate seuxal behaviors (11, 13, 14).
Furthermore, current parents' emotional functioning must be assessed. Parents of a child who was sexually abused probably need an individual or group supprot for themselves, too, in order to cope with it (11). Parents need to receive as much support as they need since they will play a very important role in a treatment process of their sexually abused child (8, 10 p.243, 13). Moreover, if a child is sexually aggressive, parents also need to set limits and supervise a child's behaviors very closely so that he/she will not victimize other children or even adults (6 p.255, p.260, 13). If parents or caregivers are not capable of appropriate supervision and a child is highly sexually aggressive, he/she may have to be treated in community-based or residential services at least temporarily (2, 6 p.260).
Treatment for Children With Inappropriate Sexual Behaviors and Related Issues
Treatment Issues: When a thearpist works with a sexually abused child who exhibits inappropriate sexual behaviors, there are several issues that need to be considered. These issues may interfere with a treatment process and hopefully, will be solved at the beginning of the process. However, even though they are addressed at the beginning, a therapist needs to keep them in mind throughout the treatment phases.
First, a child may exhibit a sign of transference, by which he/she projects his/her own issues of control, power, and autonomy onto a therapist. A child may experience negative feelings toward a therapist since a therapist is seen as an authority figure who was involved in the child's abuse experience, such as the abuser or his/her parents who were unable to protect the child. A child may try to control a therapist or boundaries in treatment becasuse a child may feel uncomfortable with a normal boundary (11).
Then, a therapist may experience countertransference by reacting to the child's sexualized behaviors with feelings of anger, fear, or disgust (6 p.242, 11). Parents or caregivers of a child often react to the child's sexualized behavior by avoidance or punishment. However, those reactions could be reinforcement to the child and thus, as a result, increasing the child's sexualized behaviors, as well as distancing a therapist from the child (6 p.242, 11).
Parents of a child with inappropriate sexual behaviors may not recognize that their child has sexualized behavior problems. Some parents simply believe that young children are not sexual beings (2, 10 p.240, 15 p.168). Other may be defensive to admit that thier child has such problems since they feel guilty and blame themselves for their child's sexual abuse (2, 6 p.168). In either case, information and education about normal child development and sexuality and the impact of sexual abuse on a child chould be provided to parents (11). In addition, parents may benefit from their own coping-skill training and training on discussing about their child's sexuality (11).
Treatment for children with inappropriate sexual behaviors: Treatment of hypersexualized behaivors needs to be multidisciplinary, which involves people in various contexts in which a child lives, such as parents, teachers, and daycare worker (10 p.236, 16 p.145). Parents and the rest of family members of the child are especially important since a major component of the intervention with sexually inappropriate behaviros requiers consistent and continued attention to and management of behaviors of a child (8, 10 p.236, 13). Treatment of inappropriate sexual behaviors also need to cover a broad range of services, such as individual treatment, family therapy, group therapy, and residential services if necessary (2). A child may need to be in a residential treatment at least temporarily if he/she is highly sexually aggressive and his/her parents are not able to provide appropriate supervision to control and manage the child's seuxally aggressive behaviors. In such a case, since there is a high risk of further victimization of other children around the child, such as siblings, the child need to be away from home at elast for a while (6 p.260).
Cognitive Behavioral Therapy: Research on the treatment effectiveness for sexually abused chilren suggest that cognitive behavioral therapy (CBT) is generally more effective than other types of treatment, such as nondirective support therapy, in reduing the occurence of sexually inappropriate behaviors (3, 7 p.130, 12, 14). CBT addresses both cognitive and behavioral components of child's problems.
The cognitive components involve the relationship among feelings, thoughts, and behaviors. Children learn the relationship and how sexual abuse affects them (7 p.130). Through learning the self-monitoring skills of monitoring his/her own feelings and thoughts, a child will learn to recognize a trigger and feelings that are associated with sexulaized behaviors (7 p.130, 11). Then, a child and a therapist can work through finding alternative means to cope with these associated feelings, other than sexually acting out. If there is a situational trigger, such as seeing a naked person, then, external control of changing environment and situations can be administered (7 p.130). For example, if a child is likely to sexually act out after seeing a naked person, the child and his/her family members can work together not to expose the child to nudity, such as turning TV off when there is a naked person on a screen or stopping walking around in a living room half-naked (7 p.130).
Another cognitive component involves resuming paired-associate learning of sexual behaviors and positive affects. A therapist can help a child separate sexual feelings from his/her need for affect by helping the child find an alternative place where the child's emotional needs are met (10 p.243). Parents can also be educated on the importance of psychological attachment and how to be supportive and nurturing to a child (7 p.144, 10 p.243, 14).
Behavioral components of CBT involves setting clear rules and limits to the child's behaviors and access to other children (10 p.240, 16 p.146). A therapist can teach the child that he/she was taught the wrong rule of how to touch and relate to other people and since the child is now learning the new rules, he/she is expected to follow them. A therapist can put the child in charge of the rules, telling the child that he/she is now an expert of rules. By being in charge, a child feels a sense of power and control. This can shift a child's self-concept from a helpless victim to empowered expert who has a knowledge and control over the rules (10 p.241). After learning the new rules of interpersonal boundries and relationships, a child can role-play and practice it in either an individual or group setting (10 p.241, 16 p.146).
Achieving a sense of mastery and control can also be obtained through learning about a child's own body. A therapist can tell a child that he/she is in charge of his/her own body and, therefore, he/she is free to explore and touch own body; however, since there is a rule that has to be followed, a child can explore and touch his/her body only at a certain time and in a certain place (6 p.258, 7 p.145, 5, 10 p.242). This works well for a child with self-exposure and excessive and/or public masturbations. However, some parents have difficulty allowing thier child to touch him/herself even in a private place (10 p.242). A therapist, then, need to educate parents about the normal development of sexuality during childhood and the impact of sexual abuse on sexuality. A child's attempt to regain power and mastery through sexualized behaviors can also be controlled by redirecting his/her need for power to more prosocial activities, such as joining sports team and helping others (16 p.146).
CBT requires intensive involvement of parents in the treatment process since majority of intervention and behavior management is conducted at home by parents. Therefore, parents need to go through behavioral management and parenting skills training (7 p.145, 11, 14). In this training, parents learn how to set an enforce clear limits (6 p.145, 14), reinforce nonsexual behaviors with verbal reinforcement (6 p.257, 7 p.145, 11), redirect and reframe their child's sexual behaviors by simply telling him/her to stop and, if developmentally appropriate, explain why the behavior is not acceptable (10 p.241), and be a good observant and monitor theri child's behaviros closely (7 p.144, 14). In addition, parental supervision is very important for a child with a high level of sexually aggressive behviors in order to provide a safe environment to the child's siblings and to prevent future victimization (6 p.255, 7 p.144, 13).
Education; Children with sexualized behavior problem can learn about adult molesters who sexually abuse children (5, 10 p.240, 11). By learning this, a child can resolve self-blame and correct distorted self-image of being responsible for the abuse. For sexually aggressive children, this can teach them that they are not responsible for their experience of being sexually abused but they are responsible for breaking the cycle of being an abuser (5).
Sexually abused children can also benefit from receiving sex education. Education about sexuality must be developmentally appropriate and it focuses on any damamge that was done to the child's sexuality and perceptions of sex (2, 15 p.168, 16 p.145). This can laso be taught in a group setting.
Therapy for Parents: Since parents of sexually abused children are often overwhelmed and experience a significant level of distress of their child's sexual abuse, additional therapy for them to cope with their own distress may be needed (11). Moreover, since sexually aggressive children tend ot come from dysfunctional families with substance abuse problems and coerceive interaction styles, coping-skills training and general supportive therapy may also be appropriate for parents. In addition, sexually aggressive children are likely to have more negative attachment to their parents (11, 13, 15). Since parental support and secure attachment to parents are important for a child in order to work through the sexual abuse issues and decrease the seuxal behaviors, teaching parents to interact and communicate with thier child in more nurturing manner is also important (7 p.144, 15). If a child exhibits only a milder sexualized behavior problems, the behaviors are likely to extinguish with time in a supportive environment (6 p.259).
A therapist can help parents to be more supportive of their child by normalizing the sexualized behaviors (6 p.258, 7 p.145, 10 p.230). Parents may be told that it is natural for a child to have sexualized behavior problems after experiencing sexual abuse and that this is a way of a child to express his/her distress and pain of the sexual abuse.
Sexually Aggressive Children: Sexually aggressive children need some more interventions and techniques to address their aggressions, in addition to the issues stated above. Treatment process for sexually aggressive children can be lengthy since unlike sexually reactive behaviors such as self-exposure, excessive masturbasion, and inappropriate touching of other people's private parts without using physical power, sexually aggressive behaviors, such as rape, tend ot be resistant to treatment (6 p.262, 13). Sexually aggressive behaviors also involve victimization of others and, therefore, safety contract may be made between a therapist and a child at the beginning of the treatment process (11).
First, a child need to understand that he/she should take a full responsibility for his/her abusive behavior (2, 5 p.212). A therapist should never take the child's sexual abuse experience as an excuse for his/her own abusive behaviors. Through this, a therapist can emphasize the seriousness of the negative impact of sexual abuse on a child (5). Then, a child will also be told that he/she need to take a full responsibility for resolving his/her sexual abuse experience and conflict (2, 5 p.212). By this, a child may be able to develop empathy through his/her own victimization experience (5 p.212, 10 p.231, 11).
Second, a child must be told that he/she has a control over his/her own behaviors. A therapist can explain to the child that since the child is able to control and stop sexually abusing others, he/she is different from the abuse who has abused the child. A child also can expand his/her worldview to include other choices thatn being either victim or an abuser (5 p.211).
Third, since sexually aggressive children tend to have unresolved issues about their own sexual abuse experience, a therapist can direct them to go back to those issues (6 p.258, 7 p.110, p.145, 5 p.211). Prognosis of sexually aggressive children is likely to be poor if their own sexual abuse history remains in the child unresolved (5 p.211, 11).
Although sexually abused children in general receive a broad range of common treatment and intervention, such as resolving self-blame, correcting distorted thinking, improving parent-child relationships and sex education, there are several features that are especially important in the treatment for children with inappropriate sexual behaviors. They include: managing transference and countertransference, reducing parents' defensiveness on a child's sexuality, behavioral techniques which focus on managing a child's sexualized behaviors, behavior management training for parents, and clear responsibility for the child's own actions as an abuser. These issues may be difficult to deal with since we usually feel somewhat uncomfortable thinking about sexulaity of young chilren. However, it is important to handle their sexualized behavior problems appropriately because unresolved issues of sexual abuse and sexuality, combined with aggression, could become very powerful tool for further victimization of other children.