Children with Problem Sexual Behaviours: Assessment & Treatment

Jane F. Gilgun, PhD, LICSW School of Social Work University of Minnesota, Twin Cities Issues at the Frontline of Sexual Abuse Melbourne, Australia 23 November 2011

Topics
A Kaleidoscope of Views on Sexuality
Varieties of Childrens Sexual Behaviours A Modified Gil & Johnson Typology NEATS Assessments

Sex in Australian Culture?

Taboo to talk aboutin some settings? Fascinatingin some settings?
Makes some people rich?

Sex in Australian Culture?

Sexual expressions linked to gender? Linked to violence? Rarely life-enhancing?

A Continuum of Child Sexual Behaviours

Developmentally Appropriate Inappropriate but Easily Correctable Abuse Reactive Extensive Mutual Sexual Behaviours Children Who Molest

Assessment For Each Type

Attachment Relationships Risk & Protective Processes NEATS Assessment

Developmentally Appropriate

Sexual Behaviours
Begin in womb
Continue over the life course

Sex is sweetwhen between generational equals and infused with respect and mutual understanding

Childhood Sexuality
Children naturally sexual The everydayness of sex education in childhood Appropriate & inappropriate sexual behaviours

Childhood Sexuality
What kinds of behaviours have you seen in young children who are growing up within the safety of secure relationships?

Sexual Socialization of Young People

Philia: Friendship Agape: Active Promotion of WellBeing of Others Lust: Deep, mindless ecstasy Erotic Love: combines the three above

Inappropriate & Easily Correctable Sexual Exploration

Case Scenario: Eddie

Sexually intrusive with two younger girls Girls told parents Girls parents told Eddies parents Parents talked to Eddie; Sought Professional Consult Eddie immediately remorseful Eddie apologized to little girls Parents opened up channels of sexual communication

Case Scenario: Charlie

Attachment Relationships Risk & Protective Processes NEATS Assessment Worst Case Scenario

Doing a NEATS Assessment

Neurobiology

Executive Function
Attachment

Trauma
Self-Regulation

A NEATS Assessment Is
Relational

Ecological
Developmental

Doing a NEATS Assessment: Neurobiology

What neurological issues are present? Parents Children Other family members Importance of genograms

Doing a NEATS Assessment: Executive Function

Whos in charge? Prefrontal cortex? Amygdala?

From LeDoux (1996)

NEATS Assessment: Attachment

Key Idea: Relationships Secure? Insecure? Dismissive? Preocupied? Disorganized?

Trauma
Complex Trauma

Centrality of Safety of Secure Relationships Trauma, managed or unmanaged, becomes encoded in brain circuits Experienced as emotions/thoughts/images, often connected to actions Activation of schemas automatic

The Effects of Protective Factors on Human Functioning After Trauma

Jane Gilgun, Ph.D., LICSW

emotion cognition memory sympathetic nervous system

Time

Self-Regulation
Connected to Neurobiology Executive Function Attachment Trauma Attended unattended

Stimulus, Dysregulation, Outcome

Stimuli Hot Buttons Dysregulation

Search for Coping Strategies

Human Agency/Automatic Activation of Schemas

Outcomes
Pro-social Anti-Social
i

Selfdestructive

Inappropriate

Indicators of NonProblematic Sexual Behaviours

Stop behaviours when asked Provided with guidelines about when & where behaviours are appropriate Receive positive recognition for appropriate behaviours

When Childrens Behaviours are Not Problematic

A NEATS assessment that identifies primarily positive processes indicates that in most situations children & families can cope with, adapt to, & overcome adversities.

Abuse-Reactive

Abuse Reactive Sexual Behaviours

Trauma Related to sexual trauma Not related to sexual trauma but other to kinds of trauma

Abuse Reactive Sexual Behaviours

Use of sexual stimulation to cope with effects of trauma

Sexual preoccupations
May act out with other

Abuse Reactive Sexual Behaviours

Absence of safe havens Parents psychologically unavailable/dismissive/p reoccupied Children afraid to talk to parents

Case Study: Josie

Sexually abused at age three or younger Sexualized behaviours Mother asked her to stop

She did

Case Study: Josie

High protective factors & lower risks NEATS Assessment of Josie & Family Josie as adult: Sought therapy

Case Study: Marty

No history of sexual abuse

Sexualized behaviours
Experienced complex trauma that was unattended

Case Scenario: Marty

Assessment of Risk & Protective Factors NEATS Assessment Long-Term Outcomes

Advantages of Early Interventions

Extensive Mutual Sexual Behaviours

General Observations
Sexualized Many risks & few protective processes NEATS
N: May have neurological issues E: Difficulties with executive function A: Disorganized attachments T: Complex unattended trauma

Services Required
Many & long-term Parental willngness crucial Coordinated services Appropriate services 24/7 supervision of children Treatment foster care

Ideal Living Situations

Supervision Structure Affirmation of prosocial actions Safety of secure relationships Adults emotionally available Psychoeducation Everything is on the table Humour

Typical Treatment Plans

Psychoeducation

Peer groups for children

Family therapy

Individual therapy
Couple therapy

Respite
Other medical/psychological

Case Scenarios
Share cases you have had Do a risk & protective factors assessment Do a NEATS assessment

Children Who Molest

General Description

Force & trick

Unable to stop, much of the time

If do stop, its temporary

Case Scenario: Tonio

Tonio: Complex Trauma

Mother Stella: Complex, Untreated Trauma Dismissive/Disorganized Attachment Styles

Case Scenario: Tonio

Risk & Protective Factors Assessment NEATS Assessment

Case Scenario: Tonio

Stella: Forced choice for ACE program Refused to participate in day treatment Refused sex-specific treatment for Tonio

Case Scenario: Tonio

Case outcome so far?

Case Scenario: Tonio

What will change the likely outcome?

Case Scenario: Tonio

What will change the likely outcome? What do you think are major barriers?

Case Scenario: Rakim

Parents did not believe 3 year-old Lavinia that 6 y.o. Rakim had molested her

Mother: treated incest survivor Father: busy with work

Fairly well-put together family

Case Scenario: Rakim

Case turned out fairly well What do you think happened? What factors led to good outcomes? Risks/Protective Factors NEATS Assessment

Some Therapeutic Issues

Presenting Family & Child Affect

Emotionally Expressive
Angry

Anxious
Hollow

Disorganized
Blaming

Indicators that Children are Learning to Manage Their Sexual Behaviours

Children show assertiveness Previous taboo topics are on the table

Indicators that Children are Learning to Manage Their Sexual Behaviours Children can ask questions that they were too ashamed to ask in the past Children tell on themselves Humor

Indicators that Children are Learning to Manage Their Sexual Behaviours Signs of attachment to others Affect becomes more animated.

Language becomes more concrete, specific, clear, and pictorial

Indicators that Children are Learning to Manage Their Sexual Behaviours

Takes responsibility for their Behaviours Empathy for victims

Parents set limits

A Continuum of Response to Childrens Sexual Behaviours

Highly sexualized Permissive Authoritative Authoritarian Repressive

Some Therapeutic Issues

Importance of Neutrality What does the term mean?

Lot of case management

Need for on-going consultation

Some Therapeutic Issues

Were good at soothing and comforting How much training do we have in dealing with clients who sexualize us? manipulate us? Use us? trigger anger, fear, dread in us?

Service User Responses to Us

Appropriate

Were rescuers/will solve their problems Can get us stuff

Persecutors/judges Sexual objects

Responses to the Work

Sometimes called countertransference How do we handle transference reactions?

Gil & Johnson on Responses of SP Caretakers/rescuers Fear as a response to rage Children/adults need a secure base

Responses to the Work

Dismissive therapist So detached children/families do not feel safe

Overinvolved
Preoccupied

Collude in avoiding sensitive topics

Responses to the Work

Embarrassment Anger Helplessness/hopelessness Cant be of help Systems issues overwhelming

Self-Reflection
Memories related to sexuality Early Funny Confusing Evokes strong emotions How did you learn differences between sex as a way of getting rocks off and communicating desire and intimacy What are the multiple meanings of

Summary & Discussion

A wide range of childhood sexual behaviours Significance of the safety of secure relationships

Summary & Discussion

A wide range of childhood sexual behaviours Significance of the safety of secure relationships Primacy of parents
Emotional availability Deal with own issues

Children require love, safe havens, structure, guidance, appropriate modeling, predictability, recognition of prosocial behaviours

Summary & Discussion: Service Providers

We need to be safe havens Emotionally available Collaborative: Can build relationships

References
Friedrich, William N. (2007). Children with sexual Behavior problems: Family-based attachment-focused therapy. New York: Norton.

Gil, Eliana & Toni Cavanagh Johnson (l993). Sexualized children: Assessment and treatment of sexualized children and children who molest. Rockville, MD: Launch Press.
Gilgun, Jane F. (2011). Child sexual abuse: From harsh realities to hope. http://www.scribd.com/doc/16484981/Child-SexualAbuse-From-Harsh-Realities-to-Hope Gilgun, Jane F. (2010). Do abused children become abusers? In Jane F. Gilgun, Shame, blame, and child sexual abuse: From harsh reality to hope (pp. 132-140). Available at http://www.scribd.com/doc/16484981/Child-Sexual-AbuseFrom-Harsh-Realities-to-Hope

References
Gilgun, Jane F. (2011). The NEATS: A child and family assessment. Available at http://www.scribd.com/doc/16496944/The-NEATS-AChild-Family-Assessment

Gilgun, Jane F. (2006). Children and adolescents with problematic sexual behaviors: Lessons from research on risk and resilience. In Robert Longo (Ed), Work with children and adolescents with sexual behavior issues (pp. 383-394). Holyoke, MA: Neari Press. Available at http://www.scribd.com/doc/21896410/Children-With-ProblematicSexual-Behaviors-Lessons-From-Research-on-Resilience Gilgun, Jane F., Kay Rice, & Danette Jones (2005). Emotion-focused therapy and children with problematic sexual behaviors. In Martin C. Calder (Ed.), Children and young people who sexually abuse: New theory, research, and practice developments (pp. 231-244). Dorset, England: Russell House. Available at http://www.scribd.com/doc/56713865/Emotion-Focused-Therapy-andChildren-with-Problematic-Sexual-Behaviors

References
Hindman, Jan (1998). A very touching book...for little people and big people (rev. ed.) Baker City, OR: Alexandria Associates. Hoyle, Sally G. (2000). The sexualized child in foster care: A guide for foster parents and other professionals. Washington, D.C.: Child Welfare League of America. Johnson, Toni Cavanagh (2009). Helping children with sexual behavior problems: A guidebook for parents and substitute caregivers (4th ed.). www.TCavJohn.com Johnson, Toni Cavanagh (2009). Understanding childrens sexual behaviors: Whats natural and healthy. www.TCavJohn.com

Lieberman, Alicia F. (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4), 336-351.
Lieberman, Alicia F. (2007). Ghosts and angels: Intergenerational patterns in the transmission and treatment of the traumatic sequelae of domestic violence. Infant Mental Health Journal, 28(4), 422-439.

References
Schechter, Daniel set al (2006). Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributions. Infant Mental Health Journal, 27(5), 429447 Van der Kolk, Bessel A. (2005). Developmental Trauma Disorder: A new, rational diagnosis for children with complex trauma histories. Psychiatric Annals 35(5), 390398. Weatherston, Deborah J., Melissa Kaplan-Estrin, & Sheryl Goldberg (2007). Strengthening and recognizing knowledge, skills, and reflective practice: The Michigan Association for Infant Mental Health competency guidelines and endorsement process. Infant Mental Health Journal, 30(6), 648-663.