PHYSICAL DEVELOPMENT

Even as infants, children are capable of sexual arousal; newborn boys have penile erections, and baby girls are capable of vaginal lubrication.^14–16 Otherwise, until puberty, there is limited change in physical sexual development (including hormonal and gonad changes) during early childhood.³

SEXUAL KNOWLEDGE

Children as young as 3 years of age can identify their own sex and, soon after, identify the sex of others.^17,18 Initially distinctions between the sexes are based on visual factors found in the culture (such as hair), although by age 3 or 4 years, many children are aware of genital differences.^18,19 Both girls and boys have been found to be more likely to know labels of male than of female genitalia.^20–22

Much of the research on sexual knowledge of preschool children was conducted before 1997.^{19,20,23–26} Interestingly, the same pattern of results for toddlers and preschoolers have been found in a more recent study on knowledge of genital differences, pregnancy, birth, procreation, sexual activities, and sexual abuse.¹⁸ Preschool children’s understanding of pregnancy and birth tends to be vague until age 6, when most report knowledge of intrauterine growth, a third know about the concept of fertilization, and most know about birth by cesarean or vaginal delivery. Knowledge of adult sexual behavior was most often limited to behaviors such as kissing and cuddling; only 9% of 3-year-olds mention explicit sexual behaviors, increasing to 21% for the 6-year-olds, and another 8% of 6-year-olds can give detailed descriptions of the acts. The rate of this behavior is affected by abuse: Sexually abused 2- to 5-year-olds have been found to talk more about sex than do preschool-aged children in normative samples of (33% and 2%, respectively).²⁷

SEXUAL BEHAVIOR

Preschool-aged children are curious in general and tend to actively learn about the world through listening, looking, touching, and imitating. Children as young as 7 months have been found to touch and play with their own genitalia; this behavior is found in both sexes but is more common in boys.^15,16 Infants’ and young children’s self-touch appear largely related to curiosity and pleasure seeking.³ Children aged 2 to 5 years look at others when they are nude, intrude on others’ physical boundaries (e.g., stand too close to others), touch their own genitalia even in public, and touch women’s breasts (occurring in at least 25% of normative samples^27,28). Preschool-aged children’s general curiosity about the world manifests with questions and exploratory and imitative behaviors concerning sexual body parts.³ Although gender role behavior is seen as early as age 1, dressing like the opposite sex is also not unusual throughout this developmental period (14% of boys and 10% of girls).^27,28 Boys demonstrate strong same-sex preferences early in the preschool years that increase in strength over time, whereas girls’ same-sex preferences, strong in the preschool years, wanes in later years.¹⁶

Nonintrusive sexual play of showing sex parts to other children was found in 9% of preschoolers, and 4.5% were reported to have touched another child’s sexual body parts (reported by mothers).²⁷ Sexual play is discussed in more details in the next section. Culture and social context affects the incidence of these typical behaviors, inasmuch as frequencies of these behaviors have been found to differ by the population and the situation studied.^29–32 Cultural effects are described in more detail later in this chapter.

Intrusive (putting finger or objects in another child’s vagina or rectum), planned, and aggressive sexual acts were not reported by anyone in a normative sample of mothers of preschool children.³³ Other rare behaviors include putting objects in vagina/rectum, putting the mouth on sexual body parts, and pretending toys are having sex.^29,27,32

PHYSICAL DEVELOPMENT

Pubertal development on average begins around 10 years of age, with girls starting earlier then boys, and can begin as early as 7 or 8 years of age. For girls, early puberty starts with a growth spurt in height, followed by a growth spurt in weight. Boys’ growth spurts are often later than girls,² and occurs with acceleration of the growth of the testes and scrotum, enlargement of the larynx, and deepening of the voice.¹⁶ There is wide variation, affected by a variety of factors (e.g., nutrition, heredity, race), in the onset and course of puberty, including a 4- to 5-year age range for the onset of puberty.¹⁶ This variability can have significant effects on social adjustment of youth. Further information about puberty is provided later in the section on adolescent sexual development.

SEXUAL KNOWLEDGE

Knowledge of pregnancy, birth, and adult sexual activity increases during the school-age period. By age 10, most children have basic and more realistic understanding of puberty, reproductive processes, and birth.³ Accuracy of knowledge depends in part on the child’s exposure to correct informal and formal educational material.

SEXUAL BEHAVIOR

School-age children’s behaviors become more guided by societal rules, which restrict the types of sexual behavior demonstrated in public. Sexual behavior continues to occur throughout the school-age period, but it is more concealed, and thus caregivers may not be directly aware of the behavior. In contrast to younger children, school-aged children are much less likely to touch their private parts in public or women’s breasts.²⁷ However, they are more interested in media and are more likely to seek out television and pictures that include nudity.²⁷ Masturbatory behaviors occur, with an increase in frequency in boys during this developmental period.¹⁶ Modesty emerges during this developmental period, particularly in girls, who become more shy and private about undressing and hygiene activities.³⁴

During the early school years, children tend to seek out and interact with children of the same sex.³⁵ Interest in the opposite sex increases near the end of this developmental period with puberty, and interactive behaviors initiates with playful teasing of others. A small but substantial portion is involved in more explicit sexual activity, including sexual intercourse, at the end of this developmental period.³⁶

SEXUAL PLAY

Sexual play is distinguished from problematic behaviors in that childhood sexual play involves behaviors that occur spontaneously and intermittently, are mutual and noncoercive when they involve other children, and do not cause emotional distress.^1,8 Sexual play typically occurs among children of similar age and ability who know and play with each other, rather than between strangers. Interpersonal sexual play often occurs between children of the same sex and can include siblings.^16,37,38 Experiencing sexual play at least once during childhood appears prevalent (reported by more than 66% to 80% of adults in retrospective research) and can occur in children as young as 2 or 3 years. Many incidents of sexual play in school-aged children may be unknown by caregivers, because the behaviors are more likely to be hidden with increased awareness of social norms.^37–39 Some degree of behavior focused on sexual body parts, curiosity about sexual behavior, and interest in sexual stimulation are a normal part of child development. This type of exploratory sexual play (periodic and without coercion or force and between children of similar age/abilities) has not been found to negatively affect long-term adjustment,^37,40–42 although inconsistent results have been found with sibling involvement.⁴³

Childhood sexual play and exploration are not a preoccupation and usually do not involve advanced sexual behaviors such as intercourse or oral sex. Intrusive, planned, coerced, and aggressive sexual acts are not part of typical or normative sexual play of school-aged children; rather, they are perceived as problematic.³³ SBPs are discussed more extensively later in the chapter.

PHYSIOLOGICAL DEVELOPMENT

During adolescence, changes associated with puberty continue, including enlargement and maturation of the genitalia and secondary sex characteristics.⁴⁴ Most girls by age 16 have begun to menstruate; the average age at onset is 12 years.^3,45,46 Current research indicates that Caucasian girls enter puberty approximately 1 year earlier and African-American girls approximately 2 years earlier than previous studies have shown. The mean age for the beginning of breast development (sexual maturation rating stage 2) in African-American girls has been found to be 8.87 years, and that for white girls, 9.96 years.⁴⁷ By age 15, most boys are capable of ejaculation.³ About 2 years after pubic hair growth begins, there is development of axillary and facial hair, as well as an acceleration of muscular strength. Hormonal changes that occur during puberty affect sexual interest, behavior, and fantasies.^48–50

SEXUAL KNOWLEDGE AND BEHAVIOR

It is expected that adolescents have knowledge about sexual intercourse, contraception, and sexually transmitted diseases.³ However, the quality of the knowledge they possess varies greatly across individuals. Evaluations of a variety of sex education programs (e.g., sex education, human immunodeficiency virus [HIV] education, teen pregnancy prevention) targeted at adolescents suggest that such programs do not lead to earlier onset of sex, more frequent sex, or more sexual partners. Many programs have been found to be associated with better outcomes for youths, including delay in the onset of sexual intercourse, increase in the use of contraceptives, and reduction in the number of sex partners. Programs more likely to affect teenagers’ behavior contain several common characteristics, including having and reinforcing messages about abstinence and/or use of contraception, focusing on reducing at least one sexual behavior that leads to pregnancy or HIV infection and sexually transmitted diseases, and providing information about the risks of adolescent sexual activity.^51,52

Many studies indicate that increases in sexual behavior during adolescence are not only influenced by hormones but are also affected by social factors, including parental supervision, peer influences, and community characteristics.^53–55 Several factors have been identified as being associated with the onset of sexual activity in adolescents: (1) less educated mothers; (2) having a boyfriend or girlfriend; (3) lower educational expectations (i.e., no intention of going to college); (4) authoritarian parenting; (5) poor communication with parents about sexuality; and (6) older siblings who are sexually active.⁴⁵

The majority of teenagers engage in some form of sexual activity, whether masturbation or sexual intercourse. Studies have shown that 25% to 40% of adolescent girls and 45% to 90% of adolescent boys masturbate.^49,56 Sexual activity rates in adolescents have increased more than 79% since 1970.⁵⁷ In 2003, 47% of students in grades 9 to 12 reported that they had had sexual intercourse. Of these high school students, 14% reported having had sexual intercourse with four or more partners.⁵⁸ Research studies have revealed that 10% to 49% of adolescents have engaged in oral-genital contact, and the incidence is increasing.^59–61 Sexual experimentation and exploration is normative and may include behaviors with same-sex peers.

Risks associated with increased and early-onset sexual activity are notable, including sexually transmitted diseases, pregnancy, substance use, and exposure to and experiences of assault and unwanted sexual experiences. Although condom use has increased, it is not consistent, and approximately 25% of sexually active youths have been found to contract sexually transmitted diseases each year.³⁶ Furthermore, use of substances before sexual activity has increased.⁶² Youths are at risk for experiences of sexual assault, force, coercion, and violence.² Other youths are often the offenders in these assaults, and information about management of adolescent sexual offenders is provided later in the chapter.

A summary of sexual development information by age group is provided in Table 25A-2.

TABLE 25A-2 Sexual Development by Age

ORIGINS OF SEXUAL BEHAVIOR PROBLEMS IN CHILDREN

Social context, individual characteristics, disruptive experiences, and the interactions of these factors affect the course of sexual development.⁹ Sexual abuse is one type of disruptive experience affecting sexual development. Children, particularly preschool age children,⁷⁰ who have been sexually abused are more likely to demonstrate SBPs than are children without such a history.²⁸ However, many children with SBPs have no known history of sexual abuse.^76,78,79,82 The development of SBPs appears to have multiple origins, including exposure to family violence, physical abuse, parenting practices, exposure to sexual material, absence of or disruption in attachments, heredity, and the development of other disruptive behavior problems.^33,83–85 For some children, SBPs may be one part of an overall pattern of disruptive behavior problems,^83,86,87 rather than an isolated or specialized behavioral disturbance.

RISKS AND COMORBIDITY OF SEXUAL BEHAVIOR PROBLEMS

Regardless of the causal pathway, a young child’s demonstration of SBPs is associated with a variety of negative consequences in adjustment and development. Trauma histories and related trauma symptoms are common, particularly in young children with SBPs.^78,87 Children with SBPs often exhibit other behavior problems and disruptive behavior disorders.^{78,79,84,87,88} Poor impulse-control skills, aggressive behaviors, and inaccurate perceptions of social stimuli hinder social relationships and cause problems at school.^9,79,88–90 Socialization difficulties and stigmatizing responses from peers and adults may impede developing self-concepts.⁹¹ Poor boundaries and indiscriminate friendliness may increase risk of future victimization.^78,92 Furthermore, children with SBPs are at risk of separation from parents and of placement disruptions.^78,79,93,94

CLASSIFICATION

There is much to be learned about subtypes of SBPs, because the research in this area is limited to a few studies. Youths with more frequent and more intrusive SBPs are more likely to have other behavior and emotional problems, to have caregivers with histories of trauma, and to have learning difficulties than are children with less frequent or nonintrusive sexual behaviors.^95,96 Typological examinations of comorbidity have suggested the differential effects of trauma and disruptive behavior, as well as gender’s effect on rate of sexual behaviors.⁸⁷ Otherwise, how types of SBPs affect the functioning of the children demonstrating the behavior, the trajectory of SBPs and related concerns, and responsiveness to interventions are unknown.

EFFECT OF SEXUAL BEHAVIOR PROBLEMS ON OTHER CHILDREN

When children experience sexual behaviors initiated by other children, there can be a range of effects. The literature is scant but appears to suggest that sexual behaviors between children of similar age and ability that was of mutual agreement and without intrusive or aggressive behaviors is retrospectively viewed as neutral or positive. However, when the sexual behavior experienced is considered to be an SBP as previously defined, the experience can have potentially negative effects, perhaps similar to those of sexual abuse perpetrated by adolescents or adults. The research on the effect of child sexual abuse indicates that the level and severity of the effect are influenced by the duration; frequency; relationship with the initiator of the sexual acts; use of aggression, coercion, or force; the child’s previous functioning; and the response and support by the caregivers.⁹⁷ Response can range from no or limited discernible symptoms to the development of trauma symptoms, other internalizing symptoms, behavior problems, sexual behaviors themselves, and/or social and peer problems.

ASSESSMENT OF SEXUAL BEHAVIOR PROBLEMS (AGES 3 TO 12 YEARS)

When caregivers report concern about the sexual behavior of children, an initial screening can facilitate the need for further clinical assessment. Gathering information about the type, frequency, duration, level of intrusiveness, harm, use of coercion, and course of behaviors can facilitate distinguishing typical from problematic sexual behaviors. The Child Sexual Behavior Inventory (CSBI)²⁷ is the only norm-based parental report measure of child sexual behavior with gender and age norms for ages 2 to 12 years. It is a 38-item measure used to assess boundary issues, showing of private parts, self-stimulation, sexual anxiety, sexual interest, sexual knowledge, interpersonal and intrusive sexual behavior, and looking at others’ private parts. It is easy to administer and score; the Total Scale Score provides a T-score and a percentile that are based on age and gender norms. The published manual recommends that the CSBI be administered by mental health professionals with training in psychological assessments. It is important to note that this published version does not include any items concerning sexual aggression. Friedrich³³ evaluated four such items and found none of them to be endorsed by mothers in a normative sample. Friedrich also provided a checklist to assess exposure to sexualized material, supervision, and privacy, which facilitates developing a safety plan with the family.³³

Assessment of the situations or circumstances under which SBPs seem to occur, the social ecology, exposure to sexualized materials, and success of attempts made to correct the behaviors can guide identifying points of intervention and treatment recommendations. The Child Sexual Behavior Checklist, 2nd revision, can help assess contributing factors and identify environmental intervention area, as it lists 150 behaviors related to sex and sexuality in children, asks about environmental issues that can increase problematic sexual behaviors in children, gathers details of children’s sexual behaviors with other children, and lists 26 problematic characteristics of children’s sexual behaviors.⁹⁸ However, the no norms have been published for the Child Sexual Behavior Checklist.

Comorbid disruptive behavior disorders, affective disorders, trauma-related symptoms, and learning deficits are not uncommon in children with SBPs.78–80,^84,87 Thus, a broad assessment is warranted and may include such measures as the Child Behavior Checklist (which includes items on sexual behavior),^99,100 or the Behavior Assessment System for Children.¹⁰¹ To specifically assess trauma symptoms, the Trauma Symptom Checklist for Children (child report) and the Trauma Symptom Checklist for Young Children (caregiver report) are useful instruments that include subscales related to sexual concerns.^102,103 For preschool children, the Weekly Behavior Report¹⁰⁴ is useful in assessing a wide range of emotional and behavior problems, including SBPs, and in tracking progress over time.

A common misunderstanding is that if a child has SBPs, he or she must have a history of sexual victimization. Although a history of previous or ongoing sexual abuse increases the risk for developing SBPs,^70,72 there appear to be multiple pathways to the development of SBPs, and the presence of SBPs should not be presumed sufficient evidence of sexual abuse. However, when a child exhibits SBPs, it is appropriate for assessors to make direct inquiries into whether the child has been or is being sexually abused.⁸ Suspected sexual abuse that had not been previously investigated by Child Protective Services necessitates responses consistent with state and regional child abuse reporting statutes. Additional information on management of suspected child sexual abuse is available in The APSAC Handbook on Child Maltreatment (2ed) by Myers JEB, Berliner L, Briere J, et al, 2002.

CASE EXAMPLE

A description of the application of these measures and assessment procedures to a case may facilitate application of the information. An example case of a young child follows:

TREATMENT FOR SEXUAL BEHAVIOR PROBLEMS (AGES 3 TO 12 YEARS)

SBPs have been successfully treated with SBP-specific therapy services for school-age children and preschool children.^8,79,105,106 Further, Trauma-Focused Cognitive Behavior Therapy as a treatment for the effects child sexual abuse that includes SBP-specific elements effectively reduces SBPs in sexually abused preschool-aged children.^107–110 These treatments have been found to be more effective than time (wait periods), play therapy, and nondirective supportive treatment approaches. The types of SBPs found in the children involved in the studies have been wide ranging, with most children demonstrating interpersonal sexual behaviors, and include aggressive sexual behaviors.

One study provided results from a 10-year follow-up on children with SBPs who had been randomly assigned to receive group cognitive-behavioral treatment (CBT) or group play therapy. The study included a clinic comparison group of children with disruptive behavior problems but no SBPs.¹⁰⁵ Child welfare, juvenile justice, and criminal administrative data on all the children were collected and were aggregated. The CBT recipients were found to have had significantly fewer future sex offenses than the play therapy recipients (2% vs. 10%) and did not differ from the general clinic comparison (3%).¹⁰⁵ The overall rate of future sexual offenses not only was quite low with short-term outpatient CBT that involved families but also was indistinguishable from that of the comparison sample.

Common elements of the effective treatments are outpatient, short-term, cognitive-behavioral and educational approaches; caregiver direct involvement; teaching of rules about sexual behaviors and skills to facilitate maintaining these rules (such as feeling identification, impulse control, and problem-solving skills); sex education; and teaching caregivers efficacious behavior management strategies (such as praise, reinforcement, timeout, and logical consequences). This treatment should be distinguished from CBT approaches to treating adolescent and adult sexual offenders. Efficacious treatment for childhood SBPs have not included components more characteristic of treatment of adults, such as concepts of grooming, offense cycles, predation, or use of techniques such as confrontation or arousal reconditioning.¹⁰⁵ For children who have histories of sexual abuse and trauma-related symptoms, a trauma-focused CBT approach that includes SBP-specific strategies has been successful.^111–113

For some children, the SBP may be part of a general pattern of disruptive and oppositional behaviors. Research on treatment for disruptive behaviors has consistently identified behavior management training as an effective modality.^114,115 Integrating SBP-specific treatment components with well-supported treatment models for early disruptive behavior disorders (such as Parent-Child Interaction Therapy,¹¹⁴ The Incredible Years,¹¹⁶ Barkley’s Defiant Child protocol,¹¹⁷ or the Triple P program¹¹⁸) might be considered; however, this approach has yet to be tested in regard to reducing SBPs.

The presence of attention-deficit-hyperactivity disorder is not uncommon in these youth,¹⁰⁶ and appropriate treatment is warranted to facilitate control of impulsive behaviors (see Chapter 16). In cases of neglectful, conflicted, or chaotic family environments, interventions focused on creating a safe, healthy, stable, and predictable environment may be the top priority.¹¹⁹ For cases in which insecure attachment is a major concern, short-term interventions emphasizing parental sensitivity have been found to be the most effective.¹²⁰ Family-based attachment-based treatment may be considered for complex cases involving significant family relationship concerns, as well as comorbid conditions,⁸⁶ although this approach has yet to be empirically validated.

ORIGINS OF SEXUAL BEHAVIOR PROBLEMS IN ADOLESCENTS

Adolescents with SBPs are a heterogeneous population.^125,126 Although it is commonly believed that adolescent sexual offenders were sexually abused themselves, most in fact were not childhood sexual abuse victims.^127,128 Some differences in maltreatment history between adolescent boys and girls with SBPs have been found. Adolescent girls with SBPs have been shown to have more severe physical and sexual abuse histories than have adolescent boys with SBPs. For adolescents with SBPs and who have been sexually abused, the girls tended to be sexually abused at younger ages and were more likely to have been abused by multiple perpetrators.^127–131 There appears to be multiple origins, including abuse history, family stability, and psychiatric disturbances in the development of SBPs in adolescence; however, for many adolescents, there is no known cause.¹⁰

RISKS, COMORBIDITY, AND TYPOLOGY

Although professionals have proposed subtypes of adolescent sexual offenders, these subtypes have not yet been confirmed in the literature. What is known is that adolescent sexual offenders are diverse. There are adolescent sexual offenders with few other behavioral or psychological problems and those with many nonsexual behavior problems or other (nonsexual) delinquent offenses. Some have psychiatric disorders. Some adolescent sexual offenders come from well-functioning families; others come from poorly functioning or abusive families.¹⁰ Adolescents with SBPs tend to have poorer social skills, more behavior problems, learning disabilities, depression, and impulse control problems in comparison with nonoffending adolescents (see Becker¹²⁵ for a review). Some differences have been found between adolescents who rape peers and those whose sexual behavior is with younger children. Adolescents whose sexual behavior is with younger children have been found to be younger, to be less socially competent, to have less same-age sexual activity, to be more withdrawn, and to have fewer nonsexual behavior problems than do adolescents who rape peers.^132,133 Risk predictors that have been identified for sexual and nonsexual repeated offending, include antisocial tendencies, psychopathy, and larger numbers of victims.¹³⁴

CONTRASTING ADOLESCENTS WITH SEXUAL BEHAVIOR PROBLEMS WITH ADULT SEXUAL OFFENDERS

Adolescents are different from adult sexual offenders in several important ways: (1) Adolescents are considered more responsive to treatment than are adults¹³⁵; (2) of sexual offenders who receive treatment, adolescents have a lower sexual recidivism rate than do adults¹³⁶; (3) adolescents have fewer victims and tend to engage in less aggressive behaviors than do adults¹³⁷; and (4) most adolescents do not meet the criteria for pedophilia.¹³⁸ With regard to recidivism, adolescent sexual offenders are less likely to have sexual repeated offenses and are more likely to have nonsexual repeated offenses than are adults.¹³⁹

ASSESSMENT OF ADOLESCENTS

There are no psychological tests available that can establish guilt or innocence of committing a sexual offense. However, there are some measures under development to assess the risk of future sexual offenses of adolescent sexual offenses. The National Center on Sexual Behavior of Youth (www.ncsby.org) provides more guidelines about assessment of adolescent sexual offenders.

For adolescents with histories (e.g., maltreatment, life stressors, behavior problems) that make it more likely that they will engage in high-risk sexual behaviors or have sexual concerns, it is important for clinicians to assess their sexual practices and concerns to guide intervention. The Adolescent Clinical Sexual Behavior Inventory (ACSBI) can be used as a screening tool with such adolescent clinical samples. The ACSBI has parent- and self-report versions (45 items each), responses to which can provide information about adolescent’s high-risk sexual behavior and help determine appropriate interventions. The ACSBI measures a range of sexual behaviors and yields five factors: sexual knowledge/interest, divergent sexual interest, sexual risk/misuse, fear/discomfort, and concerns about appearance.¹⁴⁰

TREATMENT FOR ADOLESCENT SEXUAL OFFENDERS (AGED 13 TO 17 YEARS)

Rigorous research regarding treatment of adolescent sexual offenders is lacking. However, there is some evidence to support the use of sex offender–specific treatment for adolescent sexual offenders. Two randomized clinical trials with small sample sizes yielded results in support of the use of multisystemic therapy with adolescent sexual offenders. Multisystemic therapy is a home-based treatment intervention that targets the systems in which youth are embedded, as well as the factors that are associated with delinquency. Results from these studies indicated that youths who received multisystemic therapy had lower rates of sexual and nonsexual recidivism than did youths who received the usual services (e.g., individual or group treatment).^139,141,142 On the basis of what is known about juvenile sex offenders, state-of-the-art treatment recipients should include caregivers, so that relevant factors (e.g., parental monitoring and engagement) associated with delinquent behavior can be addressed.¹³⁹ Because of the low rates of pedophilia among adolescent sexual offenders, it is generally inappropriate to apply adult sexual reconditioning techniques to adolescent sexual offenders. The widely held belief that most adolescent sexual offenders will become adult sex offenders is not supported by research.¹³⁵