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

Evidence Rating: Effective - One study Effective - One study

Date: This profile was posted on February 04, 2015

Program Summary

This outpatient treatment program’s primary goal is to reduce sexual behavior problems among school-age children, through the provision of cognitive-behavioral therapy (CBT), psychoeducational, and supportive services to children and families. This program is rated Effective. Compared to youths in play therapy, youths in the CBT for sexual behavior problems group had significantly fewer sexual offenses. There was no significant difference in the rate of non-sexual offenses between these groups.

Program Description

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.

Evaluation Outcomes

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Study 1
Comparison Group 1
Sexual Offenses
Results from the first comparison of the Carpentier, Silovsky, and Chaffin (2006) study indicated that youths who had been randomized to the cognitive behavioral treatment for sexual behavior problems (CBT-SBP) group had significantly fewer sexual offenses than those who had been randomized to the play therapy (PT) group (2 percent versus 10 percent).

Nonsexual Offenses
However, there were no significant differences in the rates of nonsexual offenses between youths who had been randomized to the CBT-SBP group and those who had been randomized to the PT group.

Comparison Group 2
Sexual Offenses
Results from the second comparison of the Carpentier, Silovsky, and Chaffin (2006) study indicated that youths who had been referred for sexual behavior problems and treated with CBT-SBP were no more likely to commit sexual offenses than a comparison group of youths with disruptive behavior problems (2 percent versus 3 percent). This finding suggests that the program reduced the problem sexual behavior of the treated youths to a level consistent with other youths with disruptive behaviors.

Nonsexual Offenses
Similarly, no significant differences were found between youths in the CBT-SBP group and those in the no-treatment comparison group in the rates of nonsexual (criminal and juvenile justice) offenses.

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Evaluation Methodology

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Study 1
Comparison Group 1
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 comparison was drawn from a sample of youths 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.Youths were randomized, as part of a clinical trial, to receive a cognitive behavioral treatment for sexual behavior problems (CBT-SBP, n=64) or group play therapy (PT) (PT, n=71). The treatment and control groups were predominantly white (84 percent in CBT-SBP, and 83 percent in PT) and male (63 percent in CBT-SBP, and 60 percent in PT).

Cases referred for sexual behavior problems were included if (a) the referred child had clinically significant SBP, and not simply developmentally normal sexual behavior;(b) the child was between 5 and 12 years of age; and (c) the child and caregiver were fluent in English. Cases were excluded if (a) the referred child’s performance on an IQ test was too low; (b) the child’s behavior was judged by a clinician as too severe for outpatient treatment; or (c) the child’s parents withdrew study consent. 

Like the CBT-SBP group, the PT group also followed manualized, treatment protocols for twelve 60-minute sessions, but was much less structured and directive. Instead, therapists led common PT activities and offered reflections, probed into feelings, and interpreted patterns of play using client-centered and psychodynamic PT principles. Discussion themes were similar for both caregiver groups.

Data on nonsexual and sexual offenses was collected at the 10-year follow-up. Data for future juvenile and adult arrests was obtained from juvenile justice and criminal justice databases, and data for child-welfare perpetration reports was 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 PT control group for future sexual offense arrests or reports, were tested.

Comparison Group 2
In the same article by Carpentier, Silovsky, and Chaffin (2006), findings were described for a second comparison. The 64 children from the clinical trial who received CBT-SBP were also compared with 156 disruptive children who had been treated at the same mental health outpatient clinic within the same time frame, but did not exhibit sexual behavior problems. Inclusion criteria for the comparison group included the following: (a) the child was seen during the same time frame; (b) the child was between 5 and 12 years of age; (c) the presenting problem was disruptive behavior; (d) the child had no reported history of SBP (because the SBP trial was ongoing at the clinic, inquiry into SBP was routine); and (e) there were no indications in the child’s file of a diagnosis of autism, pervasive developmental disorder, or childhood psychosis.

The treatment and comparison groups were predominantly white (84 percent in CBT-SBP, and 87 percent in the no-treatment comparison group) and male (63 percent in CBT-SBP, and 78 percent in the no-treatment comparison group). Most of the comparison group (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 same data sources and instruments were used to collect data on future sexual and nonsexual offenses.

Cox proportional hazards survival models, comparing the CBT-SBP group with the clinic comparison group for future sexual offense arrests or reports, were tested.

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Cost

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There is no cost information available for this program.
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Implementation Information

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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 Web site 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 with sexual behavior problems and adolescent sex offenders.

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Evidence-Base (Studies Reviewed)

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

Study 1
Carpentier, Melissa Y., Jane F. Silovsky, and Mark Chaffin. 2006. “Randomized Trial of Treatment for Children with Sexual Behavior Problems: Ten Year Follow-Up.”  Journal of Consulting and Clinical Psychology 74(3):482-488.
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Additional References

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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.
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Program Snapshot

Age: 7 - 12

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, White, Other

Geography: Urban

Setting (Delivery): Inpatient/Outpatient

Program Type: Cognitive Behavioral Treatment, Group Therapy, Parent Training

Current Program Status: Active

Listed by Other Directories: Model Programs Guide

Program Developer:
Barbara Bonner
CMRI/Jean Gumerson Endowed Chair, Director, Center on Child Abuse and Neglect, and Director, Adolescents with Illegal Sexual Behavior Treatment Progra
University of Oklahoma Health Sciences Center
940 NE 13th Street, Nicholson Tower, Suite 4900
Oklahoma City OK 73104
Phone: 405.271.8858
Fax: 405.271.2931
Website
Email

Program Director:
Jane Silovsky
Director, Preschool and School-age Children with Problematic Sexual Behavior-Cognitive Behavioral Therapy Treatment Programs
University of Oklahoma Health Sciences Center
940 NE 13th Street, Nicholson Tower, Suite 4900
Oklahoma City OK 73104
Phone: 405.271.8858
Fax: 405.271.2931
Website
Email

Training and TA Provider:
Elizabeth Bard
Co-Director, School-age Children with Problematic Sexual Behavior-Cognitive Behavioral Therapy Treatment Program (PSB-CBT)
University of Oklahoma Health Sciences Center
1100 NE 13th Street
Oklahoma City OK 73117
Phone: 405.271.8858
Fax: .271.2931
Website
Email

Training and TA Provider:
Jimmy Widdifield
Co-Director, School-age Children with Problematic Sexual Behavior-Cognitive Behavioral Therapy Treatment Program (PSB-CBT)
University of Oklahoma Health Sciences Center
1100 NE 13th Street
Oklahoma City OK 73117
Phone: 405.271.8858
Fax: 405.271.2931
Website
Email

Training and TA Provider:
Carrie Schwab
PSB T/TA Project Coordinator
University of Oklahoma Health Sciences Center
940 NE 13th Street, Nicholson Tower, Suite 4900
Oklahoma City OK 73104
Phone: 405.271.8858
Fax: 405.271.2931
Website
Email