Working with Children with Sexual Behavior Problems

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 Also from Eliana Gil

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The Healing Power of Play:

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Helping Abused and Traumatized Children:

Integrating Directive and Nondirective Approaches
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Play in Family Therapy

Eliana Gil

Treating Abused Adolescents

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Working with Children to Heal Interpersonal Trauma:

The Power of Play
Eliana Gil

DVDs
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Play Therapy for Severe Psychological Trauma

Eliana Gil
Working with Children
with Sexual Behavior
Problems

Eliana Gil
Jennifer A. Shaw

The Guilford Press

New York London
© 2013 The Guilford Press
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or use with individual clients. This license does not grant the right to reproduce these
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The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that
are accepted at the time of publication. However, in view of the possibility of human error
or changes in behavioral, mental health, or medical sciences, neither the authors, nor the
editor and publisher, nor any other party who has been involved in the preparation or
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Library of Congress Cataloging-in-Publication Data

Gil, Eliana.
Working with children with sexual behavior problems / by Eliana Gil and
Jennifer A. Shaw.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4625-1197-6 (cloth : alk. paper)
1. Psychosexual disorders in children. 2. Children and sex. 3. Children—Sexual
behavior. 4. Child sexual abuse. I. Shaw, Jennifer A. II. Title.
RJ506.P72G553 2013
618.92´8583—dc23
2013016494
 To my big brother, Peter,
whose steady presence in my life
has been a source of stability, guidance, and comfort
                      —E. G.

To the children and families who invite me

to participate in their journey of repair and recovery;
I continue to be awed by your courage and resilience
and inspired by the trust and commitment
of your parents or caretakers,
who can see your behaviors as expressions of pain
and who respond to you with compassion and nurturance.
                        —J. A. S.
 About the Authors

Eliana Gil, PhD, is senior partner in a private group practice, the Gil
Institute for Trauma Recovery and Education in Fairfax, Virginia, which
provides therapy, consulting, and training services. She is also Director
of Starbright Training Institute for Child and Family Play Therapy in
northern Virginia, where she provides multiple-day trainings on family
play therapy and specialized therapy with youth (and their families) who
have experienced childhood trauma. Dr. Gil has worked in the field of
child abuse prevention and treatment for almost 40 years. In the last two
decades she has directed two child sexual abuse treatment programs in
northern Virginia (at Inova Kellar Center and Childhelp Children’s Cen-
ter of Virginia). She is a licensed marriage, family, and child counselor;
an approved marriage and family therapy supervisor; a registered play
therapist; and a registered play therapy supervisor. Dr. Gil also consults
and trains across the United States and is an adjunct faculty member
in Virginia Tech’s Marriage and Family Therapy Department. She has
served on the Board of Directors of the American Professional Society
on the Abuse of Children and the National Resource Center on Child
Sexual Abuse; she is also a former president of the Association for Play
Therapy. Dr. Gil is the author of The Healing Power of Play: Work-
ing with Abused Children; Play in Family Therapy; Treating Abused
Adolescents; Helping Abused and Traumatized Children: Integrating
Directive and Nondirective Approaches; and other acclaimed books and
video programs on child abuse and related topics. Many of her books
have been translated into other languages, including Spanish. Originally
from Guayaquil, Ecuador, Dr. Gil is bilingual and bicultural. She has
three grandchildren under the age of 6.

vii
viii About the Authors

Jennifer A. Shaw, PsyD, is a founding partner of the Gil Institute for

Trauma Recovery and Education, and has worked in a number of clini-
cal settings and capacities in metropolitan Washington, D.C. She pro-
vides individual, family, and group therapy to children and adolescents
presenting with sexual behavior problems; with symptoms of depression,
anxiety, and adjustment problems; and with complex trauma. She has
been the coordinator of the specialized family-based program described
in this book, the Boundary Project, in two clinical settings—at Child-
help Children’s Center of Virginia and the Gil Institute for Trauma
Recovery and Education. Dr. Shaw has also acquired specialized train-
ing and certification in conducting psychosexual risk assessments and
treating sexual offending behaviors in adolescents and adults, and is cur-
rently working toward certification as a registered play therapist. She
provides trainings at the local, regional, and state level for professionals
who work with families of children with sexual behavior problems. Dr.
Shaw has coauthored two book chapters with Dr. Gil. Their latest col-
laboration is a children’s book entitled A Book for Kids about Private
Parts, Touching, Touching Problems, and Other Stuff.
 Preface

A lthough our interest in children with sexual behavior problems

has spanned two decades, the questions remain the same: What is nor-
mative sexual play? What prompts children to develop sexual preoccu-
pations? How do we know when such children need professional help?
And, finally, in what circumstances is child-to-child sexual activity abu-
sive or harmful?
In spite of myriad resources to help parents or other primary caregiv-
ers and professionals sort out these questions to their satisfaction, some-
thing still seems to get in the way. For some reason, accessible informa-
tion is either dismissed or misunderstood. Even after parents, caregivers,
and professionals search the Internet, locate the available information on
this topic, and read voraciously, confusion can still persist. The reason
for this, we believe, is that sexuality in general, and childhood sexuality
in particular, still elicit a range of rational and irrational thoughts that
often produce uncomfortable feelings; these thoughts and feelings then
complicate the taking in and processing of information. When anxiety
or fear enter the mix, primary caregivers and professionals alike can
struggle to make sense of what is going on and how to respond.
This book was written to help professionals choose a variety of
interventions when they are asked to evaluate a specific situation or
make recommendations to parents and other caregivers. The first three
chapters of the book discuss sexual behavior problems and note the
progress that has been made in understanding the origins of these
problems and contributing factors. Issues such as prior victimization,
exposure to various media, the influence of social pressure, and factors

ix
x Preface

influencing the merging of sex and aggression are explored. In Chapter

Four, we discuss a child-friendly assessment process for helping chil-
dren engage in honest conversations about their thoughts and feelings;
in Chapter Five, we describe consensus-based areas for treatment and
discuss our approaches to working with parents. In Chapter Six, we
describe the Boundary Project—a program that Eliana Gil developed
many years ago and that has since been implemented in a variety of
treatment settings. Jennifer A. Shaw has spearheaded the Boundary
Project since 2003 and has contributed greatly to its current form and
shape. Pre- and posttreatment testing of this model shows a decrease in
sexual behavior problems and an increase in healthier social function-
ing, according to parental reports, and other preliminary findings are
likewise optimistic. In addition, the early chapters review many treat-
ment efforts across the United States that also indicate positive treat-
ment outcomes in programs with a cognitive-behavioral foundation. It
appears that for children with sexual behavior problems, a combina-
tion of approaches to help them get better control of their impulses,
thoughts, and feelings, along with assistance to parents in monitoring
and supervising their children’s behaviors, can be quite successful.
Chapters Seven through Ten are case studies that highlight how
theory and practice inform our work. These case examples illustrate the
high priority we give to eliciting the cooperation of parents or other
caregivers in successfully implementing the treatment model and helping
their children. Without this support, our work is much more challeng-
ing, and we encourage families to understand the critical contribution
they make. These chapters also illustrate our integrated approach to
working with young children with sexual behavior problems, demon-
strating aspects of both assessment and treatment.
 Contents

1. Children with Sexual Behavior Problems: An Introduction 1

Defining Sexual Behavior Problems 3
Synopsis of Research on Treatment and Predictive Factors 5
The Role of Caregivers in Treatment 9
Summary 11

2. Differentiating Normative Childhood Sexuality 13

from Sexual Behavior Problems
Normative Sexual Behaviors 15
Problematic Sexual Behaviors 20
Summary 24

3. The Climate of Childhood Sexualization 25

Where We Are with Marketing to Children—
and How We Got Here 29
The Scope of the Media Challenge: How Often
Are Children Getting These Messages? 31
Sexualization of Girls 33
The Special Problem of Pornography 36
What Can Parents/Caregivers Do? 37
What Else Can Be Done to Combat Media Influences? 39
Summary 41

xi
xii Contents

4. Assessment of Young Children with Sexual Behavior Problems 43

Our Specialized Assessment Process 44
Features of the ASBPC 45
Directive Tasks Utilized in the ASBPC 51
Summary 62

5. Consensus-Based Treatment Areas and Suggestions for Work 66

with Primary Caregivers
Consensus-Based Areas for Treatment 67
Suggestions for Working with Parents/Caregivers 79
Summary 89

6. The Boundary Project Model 100

Special Features of the Boundary Project 100
Treatment Formats 102
Treatment Phases and Goals 103
Parental/Caregiver Groups and Integration
of Education 103
Activities for Transitions in/out of Sessions 104
Treatment Objectives: The Lessons
of the Boundary Project 106
Challenges and Responses 109
Gauging Progress Objectively 111
Summary 112

7. The Case of Kayla 115

Referral Information 115
Psychosocial Background 116
Assessment Process 119
Assessment Results 129
Treatment Goals 130
Treatment Plan and Process 131
Summary and Conclusions 134

8. The Case of Thomas 136

Referral Information 136
Psychosocial Background 138
Assessment Process 140
Assessment Results 149
Treatment Goals 152
Treatment Process 153
Summary and Conclusions 153
 Contents xiii

9. The Case of Jenna 156

Referral Information 156
Psychosocial Background 157
Assessment Process 161
Treatment Plan, Goals, and Process 171
Summary and Conclusions 175

10. The Case of Lorenzo 178

Referral Information 178
Psychosocial Background 179
Assessment Process 184
Assessment Results 189
Treatment Plan, Goals, and Process 190
Summary and Conclusions 192

Epilogue 201

Resources 205

References 209

Index 217
 Chapter One

Children with Sexual Behavior Problems

An Introduction

M ental health professionals tasked with identifying, assessing, and

addressing sexual behavior problems in young children (i.e., those below
school age) and school-age children face unique and complex challenges,
which have been increasingly recognized over the past two decades. Chil-
dren with sexual behavior problems appear to be sexually preoccupied
and overstimulated, and the behavioral manifestations are diverse and
vary significantly in frequency, scope, and intensity. These manifesta-
tions can include both self-directed behaviors (such as excessive mastur-
bation, disinhibited masturbation in public, and/or self-exposure) and
other-directed behaviors (ranging from fondling to coercive sexual play
to aggressive sexual abuse of other children). Many parents and other
caregivers, and even many professionals, are uncomfortable with open
discussions of childhood sexuality—especially overt sexual behaviors.
Such behaviors are particularly distressing when they are observable
outside the home. Adults’ discomfort not only can interfere with accu-
rate reporting of these children’s behaviors over time, but may contrib-
ute to inappropriate and ineffective responses to the children, including
rigid, extreme interventions focused on the safety of others. As Friedrich
(2007) has noted,

the automatic response to childhood sexuality is that it is problem-

atic and reflective of a sexually abusive experience . . . and while it is
true in some cases, it only explains a small percentage of children’s

1
2 WORKING WITH CHILDREN WITH SEXUAL BEHAVIOR PROBLEMS

sexual behaviors. An option to our uncertainty is to step back, ana-

lyze whether our perspective is appropriate, and then create a sensitive
response. (p. 8)

Unfortunately for families of children with sexual behavior prob-

lems, stereotypes often serve as reference points: The children are viewed
as either victims of sexual abuse or future sex offenders. Neither stereo-
type is accurate for the majority of these children, but such assump-
tions can lead to repercussions that do not correspond to the children’s
actions (Friedrich, 2007). In the absence of an informed, individualized,
and sensitive approach, many children are inaccurately labeled, stigma-
tized at school, marginalized in community settings, and socially iso-
lated, particularly in cases where more intrusive sexual behavior prob-
lems place other children at risk. Misconceptions regarding etiology and
prognosis can result in labeling young children as “juvenile offenders,”
which can provoke fear-based responses from parents or other caregiv-
ers, as well as school personnel and after-school care providers. Inap-
propriate, exaggerated, or generalized responses to behavioral problems
alone can prohibit or delay interventions that address a child’s or fam-
ily’s underlying conflicts. A misguided, limited, or exclusive focus on the
sexual behavior problems can leave the child alone to cope with his or
her internal conflicts, and the familial factors unexamined. Too often,
children with sexual behavior problems are left untreated, and caregiv-
ers are left without adequate support and appropriate guidance.
Sexual preoccupation and sexualized behaviors associated with
overstimulation can be diminished when caregivers learn to use tools
that are now known to address sexual behavior problems effectively,
while also addressing the caregivers’ and/or family’s emotional needs. As
research has increasingly confirmed, sexual behavior problems in young
and school-age children can be successfully treated in a relatively short
time by correcting misinformation and misperceptions through psy-
choeducation for both caregivers and children, in combination with an
integrative, family-focused approach by therapists trained to work with
children and their families. With correct information, proven strategies
to redirect behaviors, and consistent responses across a child’s care set-
tings, caregivers can confidently advocate for their child’s mental health
needs; compassionately respond to the child’s unique emotional life;
effectively address underlying familial issues that may have contributed
to the emergence or maintenance of sexual behavior problems; and build
or rebuild a healthy family system.