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A preliminary evaluation of the transformers program for children who engage in problem sexual behaviour

Petra Staiger Nicolas Kambouropoulos Deakin University Jari Evertsz Janise Mitchell Joe Tucci Australian Childhood Foundation September 2005

Evaluation of Transformers Program for children who engage in problem sexual behaviour

This document remains the intellectual property of the Australian Childhood Foundation. No part of the document can be copied and/or distributed without the written consent of the Australian Childhood Foundation. © 2005, Copyright Australian Childhood Foundation and Deakin University ISBN: 0 9580411 0 5

Australian Childhood Foundation PO Box 525 Ringwood Vic 3134 T (03) 9874 3922 F (03) 9874 7922 www.childhood.org.au

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Executive summary The identification of children who engage in problem sexual behaviour has a short history. In a little over a decade, the literature in relation to adolescent and adult sex offending has developed rapidly (Araji, 1997). In that time, there has been an increasing interest in building a framework for intervening to stop children who engage in problem sexual behaviour from continuing to develop more harmful sexual behaviour into their adolescence and adulthood. Most of the work conducted in this area has arisen from the United States. Yet, it is clearly important to develop a knowledge base and collect data on this topic within Australia. In the first part of this report, a summary of the literature review is presented. The complete literature review has been produced as an edited monograph by the Australian Childhood Foundation (Staiger, 2005). In the second part of this report, an evaluation of the Transformers Program is described in detail. This project constitutes one of the first formal evaluations of a program for children who engage in problem sexual behaviour in Australia. The Transformers Program (formerly known as the Children’s Sexual Behaviour Program) has been developed and implemented as one of the services offered by the Australian Childhood Foundation. The project aimed to: • conduct a comprehensive review of the literature about children who engage in problem sexual behaviour; and, • conduct a preliminary evaluation of the Transformers Program for children who engage in problem sexual behaviour run by the Australian Childhood Foundation in Victoria. All children 12 years of age and under, referred to the Australian Childhood Foundation for intervention regarding their problem sexual behaviour were eligible for participation in the study providing they did not fulfill the exclusion criteria. Those children who did not fulfill the criteria were offered support and therapeutic intervention through other programs provided by Australian Childhood Foundation. In the first part of this report, an analysis is presented of the 152 children referred to the Transformers Program who had engaged in problem sexual behaviour. It provides a background understanding about the experiences of these children and their parents/ caregivers. It also identifies a snapshot of the extent and severity of the problem behaviour for both children who engage in it and those who are the targets of it. The Transformers Program is primarily based on the principles of cognitive behavioural therapy and systems theory. It emphasises the importance of understanding children as part of a family system within the constraints of their developmental stage. It consists of three stages: assessment, intervention and follow up support. The intervention consists of two group therapy programs: one provided to the children and the other to parents/ caregivers.


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In the second part of this report, the outcomes of the evaluation of the Transformers program is detailed. Twentytwo children and their families agreed to participate in the evaluation of the program, six withdrew from the program due to clinical reasons or protective issues. The evaluation consisted of two groups: the first group (Group A) participated in the assessment phase of the intervention. The second group (Group B) participated in the assessment and treatment phases of the program. Due to ethical considerations, there was no control group comprising children who did not receive any treatment. The outcomes of the assessment group (Group A) were compared with the outcomes achieved by the intervention group (Group B). Data was collected prior to children entering the assessment phase for both groups and at the end of their participation in the program. Qualitative and quantitative data was collected, however only quantitative data is reported here. Questionnaires consisted of a collection of self-report measures completed by both the children and parents/caregivers. The findings of the evaluation suggested that the outcomes of the Transformers Program for children who engage in problem sexual behaviour are positive. Children in both groups showed a decrease in frequency of sexual behaviour and levels of anger. Those in the treatment group showed three times the frequency of the problem sexual behaviour compared to the assessment group prior to any intervention. Yet, following the intervention phase, the frequency of this behaviour in the intervention group (Group B) was substantially lower than the children in the assessment only group (Group A) who were still engaging in at least one or two problem sexual behaviour incidents a month. Program learning increased significantly for children who participated in the intervention. When compared to scores at pre-intervention, it is clear that the children improved considerably in levels of sexual knowledge, abilities in self-intervention and awareness of personal risk factors. This indicates that the intervention was effective in facilitating awareness and knowledge of problem sexual behaviours within this group of children. Both groups of parents/caregivers showed a significant increase in therapist-rated understanding about problem sexual behaviour. This measure included actual management responses, knowledge of risk issues, and understanding of the impact of their behaviour on their child. In contrast, only those parents/caregivers who participated in the intervention reported an increase in confidence to manage their child’s behaviour. Whilst only small in scale, the two year follow up data presented in this report also provided preliminary evidence to suggest that the positive outcomes of the Transformers program are able to be maintained. Many problems are encountered when conducting research in treatment settings. In this study, the difficulties were magnified by the fact that the subjects of the research were children who engaged in a complex and sometimes confronting behavioural problem. Due to the low numbers in the study, the conclusions should be considered as preliminary. The level of difficulties for both parents and children confirms the need for careful assessment and multi-level streamed treatment interventions which take account of each family’s particular needs. The level of problem sexual behaviour exhibited by children in the study implies the need for specialised intervention for this component of their problems. The complexity of children’s needs demonstrates that multiple agency and statutory involvement is often necessary. The results of the study highlight that it is appropriate and timely that the statutory child protection system consider the possibility of court prescribed treatment orders for children who have engaged in problem sexual behaviour. However, the focus of these treatment orders should not only be limited to children but also include mandated parental/caregiver participation in specialist programs to ensure that engagement is supported and facilitated.


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The report concludes with the following series of recommendations aimed at enhancing government and community responses to supporting children who engage in problem sexual behaviour.

Recommendation 1.

All State governments to ensure that relevant child protection policies and legislation actively support specialist programs for children who engage in problem sexual behaviour as an effective strategy for preventing child sexual abuse.

Recommendation 2.

All State governments adequately resource the implementation of specialist programs aimed at intervening with children under 12 years who have engaged in problem sexual behaviour with other children.

Recommendation 3.

All State and Commonwealth governments establish and resource a national strategy that delivers community and professional education to enhance understanding about the needs of children who engage in problem sexual behaviour and how to best respond to them and their families.

Recommendation 4.

All State and Commonwealth Governments establish and resource a research agenda to examine ways to prevent child sexual abuse through early intervention and treatment of children who engage in problem sexual behaviour.

Recommendation 5.

The Victorian Government ensure that the new treatment orders for children who engage in problem sexual behaviour proposed in the new Children’s Bill be expanded to include the option of mandating parents/caregivers to undertake specialist intervention themselves.


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Acknowledgements In 1998, the then National Council on the Prevention of Child Abuse and Neglect identified the Children’s Sexual Behaviour Program (recently renamed the Transformers Program) of the Australian Childhood Foundation as a model child abuse prevention program. It provided a research grant to evaluate the program. This was an essential element to the evolution of the program. The authors would like to gratefully acknowledge the assistance of the children and caregivers who participated in the program for providing the additional time to take part in the evaluation. The authors would also like to thank the ongoing support of Professor Chris Goddard from Child Abuse Prevention Research Australia at Monash University for his focus on children’s rights and Dr. Stephen Wallace for his valuable input in developing the evaluation protocol. More recently, the Australian Childhood Foundation received a grant from Perpetual Trustees and the Telstra Foundation to complete the two year follow up of the children who took part in this evaluation of the Transformers Program. The support of the Telstra Foundation, in particular, has enabled this report to become one of the first opportunities in Australia to undertake a long term analysis of the effectiveness of a program aimed at reducing the number of children who have engaged in problem sexual behaviour who develop even more problematic sexual behaviour into their adolescence and adulthood.

© 2005, Copyright Australian Childhood Foundation and Deakin University ISBN: 0 9580411 0 5


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About the authors

Petra Staiger is a Senior Lecturer in the School of Psychology at Deakin University. She is a clinical psychologist and has worked in the mental health sector (Royal Children’s Hospital) and the alcohol and drug sector as a senior clinician. Her current research interests are developing parent training programs with high risk families and development of early intervention programs with a range of young people e.g. tertiary students engaging in harmful drinking, children with sexual behaviour problems and developing a model of risk factors for young people who abuse substances. Dr. Staiger’s research has been presented at national and international conferences and she has published extensively in refereed international journals. She is the coordinator of the Addiction Studies Program at Deakin University and teaches extensively on the clinical doctoral program. She can be contacted by email at [email protected]. Nicolas Kambouropoulos formerly a Ph.D student at Deakin University, is currently a Lecturer in Psychology in the School of Social and Behavioural Sciences at Swinburne University. His research interests consist of the motivational processes underlying drug use, personality theory and child psychology. He has presented at national and international conferences and published a number of papers in refereed journals. Jari Evertsz is a Clinical Psychologist with special interests in children and in the development of abusive behaviour. She is the former Co-ordinator of the Children’s Sexual Behaviour Program at the Australian Childhood Foundation. She has been active in practice, theory and policy regarding violence prevention for several years. She has been the author of management and treatment programs for adult sexual offenders in prison systems, and a consultant to the State Government on offender management systems. Janise Mitchell is the Manager of the Education and Prevention Programs for the Australian Childhood Foundation. She is a social worker with extensive experience in statutory child protection, training and program development. Janise was primarily responsible for the development of the Every Child is Important program and its written material. She manages the Dimensions Program which seeks to assist children with a disability who engage in problem sexual behaviour. She is currently completing a Master of Social Work examining the social construction of children who hurt others. She can be contacted by email at [email protected]. Joe Tucci is the Chief Executive Officer of the Australian Childhood Foundation. He is a social worker and registered psychologist. He has extensive experience in child protection, child and family therapy and child welfare research. He has recently completed his PhD on child emotional abuse. He is a guest lecturer in child abuse and family therapy at Deakin and Monash University. He is a member of the Australian Council for Children and Parenting, an advisory body to the Federal Minister for Family and Community Services. He can be contacted by email at [email protected].


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Australian Childhood Foundation The Australian Childhood Foundation is an independent children’s charity working in a number of ways to prevent child abuse and reduce the harm it causes to children, families and the community. • Counselling. We provide a range of specialist counselling services for children and young people affected by abuse and for their families. • Advocacy for children. We speak out for effective protective and support services for children and young people. All our programs affirm the importance of children. • Education. We provide community and professional education, consultancy and debriefing programs. These programs aim to improve responses to children and young people who have experienced or are at risk of abuse, family violence and neglect. • Child abuse prevention programs. We run nationally recognised child abuse prevention programs that seek to decrease the incidence of child abuse and raise awareness about how to stop it even before it starts. • Inspiring and supporting parents. We provide ongoing parenting education seminars and easily accessible resources to strengthen the ability of parents to raise happy and confident children. • Research. In partnership with Monash University, we have established Child Abuse Prevention Research Australia to research the problem of child abuse and identify constructive solutions. The Australian Childhood Foundation won the 1998 National and State Violence Prevention Awards for its efforts to prevent child abuse. In 2005, it was awarded the National Child Protection Award by the Australian Government. The Australian Childhood Foundation relies on the support of the community to enable it to continue its programs and services.

Australian Childhood Foundation PO Box 525 Ringwood Vic 3134 T (03) 9874 3922 F (03) 9874 7922 www.childhood.org.au


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Table of contents Executive summary

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Acknowledgements

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About the authors

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Australian Childhood Foundation

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Table of contents

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Section One: Introduction

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Project Aim

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Objectives

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The context of the evaluation

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Terminology

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Prevalence of children who engage in problem sexual behaviour

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Defining problem sexual behaviour

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How does the “system” respond to these children

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Section Two: Summary of the Literature Review

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Characteristics associated with children who engage in problem sexual behaviour

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Theoretical models for understanding problem sexual behaviour in children

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Treatment programs for children who engage in problem sexual behaviour

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Formal evaluation of treatment programs

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Section Three: Transformers Program description

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Aims of the Transformers Program

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Eligibility

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Program philosophy

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Core program Interventions

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Treatment

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Section Four: Evaluation of the Transformers Program

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Introduction

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Aims of the evaluation

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Components of the evaluation

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Evaluation period

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Methodology

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Method

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Measures

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Dependent measures - Children

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Dependent measures – Parents/Caregivers

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Data analyses

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Section Five: Results – Describing the profile of children referred to the Transformers Program and their parents/caregivers

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Section Six: Results – Evaluation of program outcomes

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Intervention evaluation

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Baseline differences

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Children

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Parents/caregivers

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Two year follow up assessment

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Children – 2 year follow up

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Parents/caregivers – 2 year follow up

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Analysing the results of the two year follow up

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Section Seven: Discussion – Program evaluation

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Characteristics of the children and parents/caregivers who participated in the Transformers Program

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Understanding the outcomes for children

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Understanding the program outcomes for parents/ caregivers

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Summarising the outcomes of the program evaluation

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Limitations and issues

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Implications for research and practice

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Section Eight: Conclusion and recommendations

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References

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Section One: Introduction In over a decade, the literature in relation to adolescent and adult sex offending has developed rapidly (Araji, 1997). In that time, there has been an increasing interest in building a framework for intervening to stop children who engage in problem sexual behaviour from continuing to develop more harmful sexual behaviour into their adolescence and adulthood. However, the development of this knowledge base has been fraught with a number of hurdles. Firstly, community responses towards children who engage in problem sexual behaviour are clearly diverse and often dramatically so. Attitudes towards these children vary from denial and minimisation to outrage and condemnation. Beliefs about the innocence of children are challenged by these problem behaviours. Secondly, the responses by statutory services, the police and child welfare organisations have often added to the confusion. At almost every level, children who engage in problem sexual behaviour have not been able to access specialist services. There has been little public policy which covers their needs and there are few resources allocated to programs specifically designed to support them and their families. The academic literature has been equally varied and often unclear in its response to this issue. There has been a distinct lack of research papers until 1980. Since then, the literature has been limited by an absence of empirical data and an insensitivity to the ways in which children in this group can be further stigmatised through the use of inappropriately strong language. It is only recently that there has been a recognition of the need for more in-depth research that attempts to address critical practice debates, such as under reporting by professionals (Gil and Johnson, 1993). The lack of clarity between what can be considered developmentally appropriate sexual behaviour and problem sexual behaviour has also generated confusion. Most of the work conducted in this area has arisen from the United States. Yet, it is clearly important to develop a knowledge base and collect data on this topic within Australia. This project constitutes the first formal evaluation of a program for children who engage in problem sexual behaviour in Australia. The Transformers Program (formerly known as the Children’s Sexual Behaviours Program) has been developed and implemented as one of the services offered by the Australian Childhood Foundation.

Project Aim The project aimed to • conduct a comprehensive review of the literature about children who engage in problem sexual behaviour; and, • evaluate the Transformers Program for children who engage in problem sexual behaviour run by the Australian Childhood Foundation in Victoria. In the first part of this report, a summary of the literature review is presented. The complete literature review has been produced as a separate monograph. In the second part of this report, an evaluation of the Transformers Program is described in detail.


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Objectives In broader terms, the objectives of the project were to • support the development of a treatment model of best practice when working with children who engage in problem sexual behaviour; • identify the psychological, family and social characteristics relevant to children who engage in problem sexual behaviour; • develop a theoretical and practice knowledge base for understanding the genesis of sexually aggressive behaviour in adolescents and adults; and, • increase professional awareness and understanding of the issues involved in the assessment and treatment of children who engage in problem sexual behaviour.

The context of the evaluation Conceptualising problem sexual behaviour in children As discussed in the introduction, the issue of children who engage in problem sexual behaviour has engendered a great deal of confusion in professional and community responses. It is clear that this is a sensitive and complex problem for children, their families and the service system. Mitchell (2001) has argued that current approaches to conceptualising the needs and experiences of children who engage in problem sexual behaviour have a number of limitations. In a lucid analysis of both academic and popular literature, she identified a number of issues which contributed to what she concluded is a poorly resourced vocabulary for assessment and intervention with children in this group and their families. Firstly, there is a need for practitioners and researchers alike to resist the influence of the tradition of intervention with adult sex offenders in which work with children who engage in problem sexual behaviour first found its origin. As Mitchell noted, “…In attempting to draw a distinction between children who display problematic sexual behaviour and adult sex offenders, Johnson (1998) argued that children are not ‘little’ adult offenders, lacking the reinforcing sexual pleasure and prominent fantasy life that accompanies older offending. Children’s values, attitudes and feelings are mainly shaped by the family in which they live. Their ability to differentiate from their family and mediate the impact of the family via the external world is more severely limited for children than is the case for adolescents or adults... (p.24)”. Secondly, Mitchell maintained that the cultural context itself shapes the way in which notions of childhood are interpreted and realised by individuals in a community. Children who engage in problem sexual behaviour fall within current discourses about children as polarised representations of “good” or “evil”. When perceived as “good”, children confirm a collectively idealised memory of the innocence and hope of childhood. Yet, when constructed as “evil”, children propose a challenge to the adult defined communal rules which require children to be passive and conform to expectations built on the theme of developmentalism. She argued that


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“…there is an intimate relationship between ‘the child’ and ideas of social order. Adults in general, have been constrained into social order whereas children represent the boundaries of and a challenge to that order (James and Prout, 1997)…the perceived threat to social order of children who flout ‘innocence’ often results in substantial public outcry for the punishment and control of these children and young people. The speed of change in our society, the escalation in family stress and breakdown and pessimism that exists in some about the future, invites adults to strengthen the investment in the idea of childhood innocence as the repository of our collective hope for a better set of social circumstances and relationships...(p.15)”.

Finally, by examining the construction of childhood sexuality, it is clear that this site of interest more than any other evokes the longest tradition of debate. Mitchell draws the parallel between the limited acknowledgement of sexual development in children with the denial of children who engage in problem sexual behaviour. “…Whilst childhood sexuality is not well tolerated by adults, children who display problematic sexual behaviour evoke feelings of discomfort, often leading to the denial or minimisation of the existence of the behaviour (Cunningham and MacFarlane, 1991; National Children’s Home, 1991; Masson and Erooga, 1999; Kikuchi, 1995; Johnson, 1988; Araji, 1997; Ray and English, 1995; Alpert, 1997; Adler and Schutz, 1995; Finkelhor and Browne, 1986; O’Brien, 1991; Allan, 1999). The rule of optimism invites adults to think the ‘best’ of children and minimise or deny behaviours that may challenge this view (Dingwall, 1992). Adults’ wish for sexual innocence in childhood, has manifested into ignoring sexual behaviour in children, whether consensual or exploitative (Cantwell, 1995; Gil and Johnson, 1993; Smith and Israel, 1987; Ryan, 1991a; National Children’s Home, 1991; Araji, 1997…(p.22)”. Mitchell’s analysis has served to highlight the continuing ideological turmoil and paradigm confusion which contexualises practice with and research about children who engage in problem sexual behaviour. Her work focused on the need to resist adopting sex offender language when describing the problem sexual behaviour of young children. In the next section, the terms used by the Transformers Program when working with this young group are described.

Terminology The language adopted by the Transformers Program is an important factor in shaping the responses to children who engage in problem sexual behaviour. As a result, the Transformers Program has integrated the following key terms to define its framework. Problem sexual behaviour is the preferred term to describe the array of behaviours for which a child can be referred to the Transformers Program. ‘Problem sexual behaviour’ indicates a behaviour which is both sexual and problematic in nature. This phrase is preferred over other possible descriptors which include words such as ‘sexually offending behaviour’ or ‘sexually abusive behaviour’ as these refer to adults. ‘Sexualised behaviour’ may be used as a descriptor but is not an effective defining term as it does not convey how problematic it is to children who are the targets of such behaviour. Similarly, children who engage in problem sexual behaviour is preferred over phrases which include ‘child offender’ or ‘child perpetrator’.


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The key descriptive phrases acknowledge that the children referred to the Transformers Program • have not reached the age of criminal responsibility; • have experienced a range of disruptive and/or abusive experiences themselves; and, • are influenced heavily by the social, economic and familial conditions in which they live. Children who are the target of the sexual behaviour is preferred over ‘child victim of sexual abuse’. This term attempts to makes it clear that both the child who is the target and the child who exhibits such behaviour are developmentally vulnerable and in need of support. Importantly, it does not seek to minimise the extent of trauma experienced by the target child. While other terms may be used in this document, they are referenced as the preferred terms of the relevant author.

Prevalence of children who engage in problem sexual behaviour An accurate estimate of the prevalence of this problem in Australia is difficult to determine. There are very few Australian studies about children under the age of 12 who engage in problem sexual behaviours. There is a general absence of a clear definitions about how to define problem sexual behaviour. There is a reluctance of parents, teachers and others to report to agencies any incidences of these behaviours in young children. Even if reports are made, the service system often fails to acknowledge the significance of the problem and frequently does not record reliable data. There have been no attempts made to gauge the rates of children who engage in problem sexual behaviour either in Australia or internationally. In contrast, it has been estimated that 2%-4% of adolescent males commit sexual assaults (Ageton, 1983). Furthermore, Lane (1991) has reported that approximately 12% of adolescents who commit sexual assaults are 11 and 12 years old and at least half of these children displayed problem sexual behaviour before 10 years of age. A report by the Children’s Protection Society in Victoria, estimated that 20%40% of child sexual assaults are the responsibility of those aged under 18 years (Flanagan and White, 1997).

Defining Problem Sexual Behaviour Generally, studies have defined problem sexual behaviour as that which “far exceeds the mutual exploratory behaviour normally seen in young children” (Friedrich and Luecke, 1988, p. 154) and is “outside the normal developmental sexual activity expected for children” (Johnson, 1988, p. 222). For example, public masturbation, forceful penetrative behaviour, excessive fondling and genital contact characterise children presenting with sexual behaviour problems (Johnson, 1988; Gray et al., 1999). Pithers et al. (1998b) distinguished between five distinct types of children who engage in problem sexual behaviour, each with substantially different defining characteristics. Their rationale was that if there are distinct types of problem sexual behaviour and the children presenting with such difficulties have differing clinical profiles, then this should directly impact on the choice of treatment programs (Pithers et al., 1998b). The analysis revealed five types of children (sexually aggressive, nonsymptomatic, highly traumatised, rule breaker, abuse reactive) that differed on a range of behavioural and diagnostic variables. As a group, sexually aggressive children were characterised by: males, maltreatment history, conduct disorder, penetrative acts, clinical range on Teacher Report Form for internalising/externalising problems. The nonsymptomatic group of children were characterised by: females, mixed history of maltreatment, low use of force, normal range on internalising/


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externalising. The highly traumatised group of children were characterised by: equal males and females, highest number of psychiatric diagnoses, PTSD, extensive history of maltreatment, clinical range on Child Behaviour Check List total score and internalising problems. The rule breaker group were characterised by: females, mixed psychiatric diagnoses (ADHD, ODD and CD present), mixed history of maltreatment, clinical range (and highest group means) on nearly all psychological measures. Finally, abuse reactive children were characterised by: males, Oppositional Defiant Disorder, high level of maltreatment, may penetrate victims, high-clinical range on all psychological measures. Importantly, Pithers et al. (1998b) reported that the efficacy of particular treatment methods differed among the five groups of children. Specifically, cognitive-behavioural therapy was found to be significantly more effective for the highly traumatised child, whereas expressive therapy was more beneficial for rule-breaking children (Pithers et al., 1998b).

How does the “system” respond to these children Currently the age of criminal responsibility is set at 10 years in Victoria. As such, the juvenile justice system has no mandate over young children who engage in problem sexual behaviour. The grounds for statutory protective intervention with children who engage in problem sexual behaviour under the Children and Young Persons Act 1989 is unclear. In recognition of the lack of legislative provisions dealing with this group of children, the Crime Prevention Committee of the Parliament of Victoria (1995) made the following two specific recommendations for reform. Recommendation 102 … Children and Young Persons Act 1989 specifies grounds for protection be extended to include children displaying early signs of sexually offending behaviour. Recommendation 103 … Children under protection on the grounds of displaying early signs of sexually offending behaviour shall undergo immediate assessment and appropriate treatment. It has taken a decade for the Victorian Government to move to consider adopting these recommendations in legislation with the recently proposed review of the Children and Young Persons Act 1989 (Office for Children, 2005). As a consequence, children with these problems and their families have had limited access to support and intervention. Currently then, children who engage in problem sexual behaviour do not fall under the remit of the juvenile justice system, and often fall short of the current criteria for a response by the statutory child protection service. In the main, children who engage in problem sexual behaviour are referred to a range of mainstream health and welfare services or to a very small group of specialist service providers including the Australian Childhood Foundation, some Centres Against Sexual Assault and the Children’s Protection Society.


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Section Two: Summary of the literature review Documented below is a summary of the literature review conducted by Dr. Petra Staiger and Mr. Nicolas Kambouropoulos from the Faculty of Health and Behavioural Sciences at Deakin University. The complete version is published in a separate monograph by the Australian Childhood Foundation.

Characteristics associated with children who engage in problem sexual behaviour It has been noted (e.g., Ray and English, 1995) that the majority of research in the area has focused particularly on identifying characteristics associated with adolescents. However, the recent increase in public awareness concerning children who engage in problem sexual behaviour has resulted in the emergence of literature aimed at examining factors which may contribute to the development of problematic sexual behaviour in children (e.g., Araji, 1997; Burton, Nesmith and Badten, 1997; Gray, Pithers, Busconi and Houchens, 1999; Pithers et al., 1998a). Findings from studies aimed at identifying factors associated with children who engage in problem sexual behaviour have implications which directly impact on the development of treatment programs (Pithers, Gray, Busconi and Houchens, 1998a). In an excellent review of the literature regarding the characteristics of such children, Araji (1997) identified six broad psychological and social factors that need to be examined. These were: abuser and victim characteristics, family characteristics and environments, victimisation experiences, sexual and aggressive preoccupation, school performance, and social relationships and skills. The following summary of the literature will focus on these broad areas. Socioeconomic Factors Research has shown that children presenting with sexual behaviour problems often appear to come from low income families, with many living below the poverty level. More specifically, it is generally found that, on average, families of children who exhibit sexual behaviour problems have very low levels of income to support four or more individuals (e.g., Gray et al., 1999). Indeed, Pithers et al. (1998a) and Gray et al. (1997) reported that 72% of the biological families of children with sexual behaviour problems were living below poverty level. Gender In general, males are over-represented in samples of children who engage in problem sexual behaviour (approximately 70% are boys). Pithers et al. (1998b) suggest that females differ substantively from males in relation to behavioural and psychological characteristics. However, more data is required before any concrete conclusions can be drawn. Psychological characteristics of the children In contrast to the large literature on adolescent offenders, there have only been a few studies which have attempted to identify specific social and psychological competencies of children who engage in problem sexual behaviour. Johnson (1988) reported significant levels of psychological problems in these children. Apart from the higher incidence of psychiatric diagnoses of behavioural disorders in children with problematic sexual behaviour, other psychological problems such as lack of empathy, inadequate social skills, problematic affect, and depression have also been reported (e.g., Friedrich and Luecke, 1988; Hall et al., 1998). Specifically, Ray and English (1995) found that the children who engaged in problem sexual behaviour had difficulty in peer relationships and lacked knowledge regarding social skills and their own sexuality. Moreover, depression (63%), hyperactivity (30%) and substance use (20%) were also reported to be associated with heightened problematic sexual behaviour (Ray and English, 1995). Similarly, Hall et al. (1998) indicated that deficits in knowledge regarding non-sexual boundaries and a lack of empathy and affective range characterised children with sexual behaviour problems. In summary, the studies reviewed indicate that children who engage in problem sexual


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behaviour are characterised by high levels of behavioural and emotional problems, low levels of empathy, restricted affective experience and higher incidence of depressive symptoms. Victimisation experiences of the children An examination of the literature in relation to the influence of the family on the child is relevant as a number of family variables may strongly mediate children’s sexual behaviour. Studies have shown that children with sexually abusive caregivers are more likely to develop problem sexual behaviour (Hall et al., 1998; Johnson, 1989; Pithers et al., 1998b). In addition, high rates of physical and emotional abuse among such children have also been reported (e.g., Johnson, 1988; Ray and English, 1995). The majority of studies reported that between 50% and 70% of the sample were victims of sexual abuse and at least 50% of the children were physically or emotionally abused. Ray and English (1995) found that 86% of a sample of 271 children who engaged in problem sexual behaviour were victims of sexual abuse. Children who engage in problem sexual behaviour are also more likely to be subjected to physical and/or emotional abuse (e.g., Gray et al., 1997). For example, Gray et al. (1997) found that while 96% of the children were victims of sexual abuse, 61% were subjected to multiple types of abuse (i.e., physical, emotional, neglect). Caregiver characteristics In relation to parenting practices, Johnson (1988) indicated that child rearing in general is primarily based on an authoritarian model, whereby parents aim to obtain total obedience and exert extreme levels of control over their children. Research has suggested that parents of children who engage in problem sexual behaviour often exhibit high levels of anger and anxiety. Other important familial variables include the parents’ own history of abuse, chemical dependency and the quality of parent-child relationships (Burton et al., 1997; Hall et al. 1998; Johnson, 1988). Between 40-70% of parents are reported to be drug dependent (Burton et al., 1997). Studies have found that approximately two-thirds of mothers were victims of childhood physical neglect and/or had been sexually abused (Burton et al., 1997). The fact that one or more of the parents are themselves likely to have been the subject of sexual abuse increases the chances of child sexual abuse (Johnson, 1988). The extent to which this is a causative factor in the child developing problem sexual behaviour is unclear. However, research suggests that a substantial relationship between a history of victimisation of the parent and the incidence of problem sexual behaviour. Children who engage in problem sexual behaviour mainly live with only one parent (e.g., Burton et al., 1998), most likely the mother as the fathers are often unknown or absent (Johnson, 1988). Clearly, there are a wide range of differing characteristics associated with children who display problematic sexual behaviour. The most salient features include a history of sexual and physical abuse, behavioural problems, in particular conduct disorder, and parental/caregiver chemical dependency and clinical disorders (e.g., depression). The next section will briefly summarise the current theoretical models of attempts to explain problem sexual behaviours in children. This will be followed by a description of treatment programs developed for children who engage in problem sexual behaviour, It also includes a summary of the outcomes of any evaluations conducted in relation to these programs.


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Theoretical models for understanding problem sexual behaviour in children Explanatory theories of problem sexual behaviour in children are important as they provide both researchers and clinicians with a conceptual framework for understanding the reasons which motivate problem sexual behaviours, while also facilitating the development of appropriate intervention and treatment programs. In the following discussion the major theoretical models are outlined. A more detailed description can be found in the literature review published by the Australian Childhood Foundation. Trauma-based models (Cunningham and MacFarlane, 1996) focus primarily on the manner in which early trauma (e.g., physical/sexual abuse) facilitates the development of the symptoms associated with problematic sexual behaviour in children (e.g. negative feelings of isolation, anger/aggression, faulty cognitions). These models include posttraumatic stress disorder (PTSD) theory, the sexual abuse cycle model, and Finkelhor’s four preconditions of abuse. According to Posttraumatic Stress Disorder theory, a stressor (e.g. physical abuse, sexual abuse or the observation of violence or natural disasters, Eth and Pynoos, 1985) elicits significant symptoms in the child. The trauma is re-experienced by the child, inducing negative affective states that lead to a reduced involvement with the outside world, characterised by both internal and external withdrawal. In the sexual abuse cycle theory (developed by Lane and Zamora), problem sexual behaviour is conceptualised in terms of a cycle involving cognitive and behavioural components. For example, negative feelings may lead to isolation, resulting in maladaptive behaviour involving anger and power/control, which leads to negative sexual fantasies and problem sexual behaviours, which again lead to negative feelings. It is proposed that the cycle continues until an appropriate intervention is implemented (Isaac and Lane, 1990). The Four Preconditions of Abuse model, proposed by Finkelhor, is primarily concerned with the manner in which familial environments serve to facilitate the development of problematic sexual behaviour in children due to poorly defined, or nonexistent, boundaries and controls. It focuses on 1) the motivation to engage in problematic sexual behaviour as a reaction to the child’s own history of abuse; 2) internal problems which result in the child behaviourally expressing their sexualised and aggressive feelings; 3) external problems as a result of poorly defined boundaries and a lack of control in the family; and 4) overcoming the resistance of the target. Another ‘trauma-based’ model, which builds on the sexual abuse cycle model (Araji, 1995) is the comprehensive Trauma Outcome Process Approach, developed by Rasmussen, Burton and Christopherson (1992). This model focuses on the contribution of family characteristics, cognitive and emotional processes, and prior trauma to the development of problematic sexual behaviour in children. The trauma outcome process approach could be viewed as an integration of the models outlined above. Rasmussen et al. (1992) have identified five factors which are considered necessary for the development of problematic sexual behaviour in children - prior traumatisation, lack of empathy, social inadequacy, lack of accountability and impulsiveness. This approach draws on PTSD theory, psychodynamic theory, cognitive behavioural and humanistic approaches. Trauma based models emphasise the influence of prior victimisation on the development of problematic sexual behaviour. These approaches appear to have considerable validity as empirical studies have consistently found high rates of abuse in children who engage in problem sexual behaviour. Furthermore, studies have widely reported that children who engage in problem sexual behaviour also exhibit withdrawal and behavioural conduct problems. Importantly, some children who have been victimised do not develop problematic sexual behaviours, and these models discuss how certain cognitive processes combined with environmental factors facilitate the formation of problem behaviours in certain children. The theoretical models facilitate the identification of salient individual and environmental factors leading to problem sexual behaviours. Therefore, they have important


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implications for treatment programs as the symptoms critical to the development of problem sexual behaviour can be targeted in the hope of reducing the likelihood of the occurrence of such behaviour.

Treatment programs for children who engage in problem sexual behaviour A number of treatment programs based on these and other theoretical models, aimed at assisting children (up to 13 years) who engage in problem sexual behaviour, have been developed and are currently in operation (Araji 1997). These programs include: The STEP Program (Center for Prevention Services, Underhill Center, USA); the Harborview Sexual Assault Center program (Seattle, USA: Berliner and Rawlings, 1991); the Transformers Program (Australian Childhood Foundation, Victoria, Australia); the Valley Mental Health Adolescent Residential Treatment Education Center (ARTEC) and Primary Children’s Medical Center Child Protection Team programs; Redirecting Sexual Aggression, Incorporated (RSA); Jan Hindman’s program, It’s About Childhood: Children Who Sexually Act and Culpability; A Step Forward; Philly Kids Play it Safe (Philadelphia); William Friedrich’s program; Eliana Gil’s program; and the Support Program for Abuse Reactive Kids (SPARK) based at the Children’s Institute International in Los Angeles. The majority of programs which have been documented occur in the United States. The various treatment programs have a number of common components. Most programs utilise cognitive and behavioural approaches as their primary theoretical framework, with treatment interventions specifically targeting the problematic sexual behaviours. In all of the programs, parents or caregivers are considered to be an important part of the treatment process and are required to participate in treatment. The primary mode of treatment for children is group therapy, with individual and family therapy also frequently utilised, often as an adjunct to group treatment. It is important to note however that the effectiveness of many of these programs has not been empirically examined. A more detailed description of current programs can be found in Staiger (2005).

Formal evaluation of treatment programs The literature on evaluating interventions for children who engage in problem sexual behaviour is extremely sparse. It is possible that many of the programs described above have conducted their own evaluations but have not formally published them. This report however focuses only on the published literature. To date, there have been only three published outcome evaluation studies (Bonner, Walker and Berliner, 1999; Pithers, Gray, Busconi, and Houchens, 1998; Ray, Smith, Peterson, Gray, Schaffner and Houff, 1995). Ray et al. (1995) evaluated the Sexually Reactive Youth Program (based in Spokane, Washington), which provides treatment for children who are in therapeutic foster care. The program utilises a holistic therapeutic approach and the stabilisation of the child in a foster home is a priority. The length of treatment is approximately 18 months. Each child has a treatment team including a social worker who provides case management and therapy, therapeutic foster parents who deliver behavioural interventions in the home, psychiatric aides, and the biological parents are provided with education and support. The treatment program consists of assessment, individual therapy, group therapy, family support/therapy, and educational groups. The evaluation of the program included fifteen children (11 boys, 4 girls), and evaluation measures included a Risk Assessment Matrix and a mental health measure. The authors reported that no children were displaying inappropriate sexual behaviour at the completion of therapy, although one year later two children had incidents of inappropriate sexual behaviours. From intake assessment to the one year evaluation, there were significant decreases in clinician-rated aggression, sophistication, coercion, escalation and resistance. Children’s knowledge of age appropriate sexual behaviours improved significantly as did their social skills, and the children exhibited significantly more empathy toward their victims. There was no significant change in levels of denial. Significant


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improvements in behavioural and emotional adjustment, social functioning, family relationships and overall adjustment rating were observed, although the program had no significant effect on life skills and educational adjustment in these children. As discussed in an earlier section, Pithers et. al. (1998) identified five types of children with sexual behaviour problems (sexually aggressive, abuse reactive, nonsymptomatic, rule-breaking, highly traumatised) and compared the efficacy of expressive therapy with structured cognitive behavioural (relapse prevention) treatment for these children. Their study consisted of the families of 127 children (ranging in age from 6 to 12) who had engaged in problem sexual behaviour. Ninety-three of these families completed treatment and were included in the analysis. The treatment consisted of 32 weekly sessions. Families were randomly assigned to one of two treatment conditions. Expressive therapy involved an unstructured, spontaneous approach to treatment, with ideas and concepts communicated indirectly through metaphor, symbols and creative activities. The cognitive behavioural relapse prevention program, on the other hand, was a highly structured approach which aimed to identify and prevent precursors to sexual acting out. In this treatment condition, coping strategies were taught using a didactic approach. Families were also encouraged to seek the assistance of friends or acquaintances in order to facilitate skill acquisition and the generalisation of these skills. In both treatment conditions, groups were simultaneously run for parents and children. Treatment outcome was assessed in terms of the change between intake and week 16 of the treatment program, in scores on the Child Sexual Behaviour Inventory -Third Edition (CSBI-3) (Friedrich, 1995). Overall, both the expressive and cognitive behavioural interventions were found to be effective in reducing problem sexual behaviour. Pithers et. al. (1998) also found that for one subtype, highly traumatised children, the modified relapse prevention was more effective than expressive therapy. They concluded that the identification of different types of children with sexual behaviour problems may be relevant in selecting a treatment approach for these children. However, these conclusions were based on data collected after the first 16 weeks of a 32 week program (data collected at the end of the treatment and during follow-up have not yet been published). Furthermore, in a recent review article, Chaffin et. al (2002) reported that the differences in responsiveness to the two treatments were not maintained over time, and that there was little evidence to support one treatment approach over another for the treatment of different types of children. The third study which was conducted by Bonner et. al. (1999) compared the efficacy of dynamic play treatment (DPT) and cognitive behavioural treatment (CBT) approaches for children who had engaged in problem sexual behaviour. A group treatment approach was used. No further information on the treatment program was provided in their report Children aged 6-12 and their caregivers participated in the study. One hundred and ten children referred for sexual behaviour problems began treatment, and 69 completed treatment and were included in the analysis. Fifty-two children who had no known sexual behaviour problems served as a comparison group. The children with sexual behaviour problems were randomly assigned to one of the two treatment conditions. Treatment consisted of 12 weekly one-hour group sessions for both the children and caregivers (the caregiver’s session followed the children’s session). Assessment measures were collected at intake, immediately posttreatment and one-year and two-year follow up. Treatment outcome was assessed by calculating the difference between the children’s pre and post treatment scores on the Child Sexual Behavior Inventory (Version 2: CSBI-2, Friedrich, Beilke, and Purcell, 1989) and the Child Behavior Checklist - Parent Form (CBCL) (Achenbach, 1991), and by a structured interview at one and two year follow up assessing sexual behaviour problems.


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Both treatment approaches were found to be equally effective in increasing the children’s social competencies, and reducing their behavioural, affective and sexual behaviour problems. Follow up data indicated that 85% of the cognitive-behavioural group and 83% of the dynamic play group did not engage in problem sexual behaviour following treatment. Each of the treatment outcome studies is limited by methodological problems. Only one study had a comparison group, this means that changes in test scores from pre-treatment to post-treatment cannot be attributed with certainty to the impact of the treatment. The study by Ray et al. (1995) was hampered by small sample size and did not include self report data from the children themselves. Despite methodological limitations, these treatment outcome studies provide preliminary evidence to support the efficacy of structured cognitive behavioural and dynamic/expressive therapy for children who engage in problem sexual behaviour. It also appears that a number of important components are inherent in most programs, including family involvement, group therapy, education and cognitive-behavioural therapy. The relationship between different types of children with sexual behaviour problems, and treatment outcome, is yet to be established. It is highly likely that different types of therapy might be needed for different types of children and family circumstances. In this respect programs will need to remain responsive to the individuals needs of the child and the family. The next section describes the Transformers Program developed by the Australian Childhood Foundation over the last eight years. The program is currently under review and further funding has enabled a larger study to be undertaken over a three year period beginning mid 2004. After the description of the Transformers Program, the methodology used to evaluate the program is outlined. The findings and discussion of the evaluation then follow.


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Section Three: Transformers Program description The next section outlines a summary of the Transformers Program (formerly known as the Children’s Sexual Behaviour Program) based on the original program document written by Jari Evertsz as conceptualised at the time of the evaluation. It has since been re-written and extended to take into account more recent research findings.

Aims of the Transformers Program The Transformers Program is an early intervention program which aims to reduce the number of child victims of sexual assault by preventing children, who have engaged in problem sexual behaviour from developing further problematic sexual behaviour into adolescence and adulthood. The aims of the Transformers Program are to: • provide effective assessment, treatment and management for children who have engaged in problem sexual behaviour; • provide interventions which are helpful and supportive to children and their families; • develop a theoretical and practice knowledge base for understanding the genesis of sexually aggressive and abusive behaviour in adults; and, • increase professional awareness and understanding of the issues involved in the assessment and treatment of children who have engaged in problem sexual behaviour.

Eligibility All children 12 years and under referred to the Australian Childhood Foundation for intervention regarding their problem sexual behaviour were eligible for participation in the study providing they did not fulfill the exclusion criteria. Exclusion criteria included: lack of stable living arrangements; unwillingness for parents/caregivers to participate in the program; the child has a major developmental delay or intellectual disability. Those children who did not fulfill the criteria were offered support and therapeutic intervention through other programs provided by Australian Childhood Foundation.

Program Philosophy The Transformers Program is primarily based on the principles of cognitive behavioural therapy and systems theory. It emphasises the importance of understanding children as part of a family system within the constraints of their developmental stage.


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Core Program Interventions Assessment An assessment takes place after a child has been confirmed as eligible for the Transformers Program. Over 4 – 6 sessions, the assessment evaluates the systems issues and problems for the child; the impact of parenting/family factors; the onset, duration, triggers, and risk level for the sexual behaviour; the full range of the child’s emotional and learning needs; and, the ability of the child to engage with program materials. Although not a treatment intervention, assessment incorporates many therapeutic features for the child. These include having a safe and knowledgeable person to talk to about difficult issues, the opportunity to reduce anxiety around the sexual behaviour and the family’s response to them via increased understanding of their context. Parents/caregivers obtain extensive advice and support in regard to the child’s sexual behaviour and emotional wellbeing, and in relation to the adults’ own fears and anxieties. An analysis of clinical records in the Transformers Program have shown that children’s behaviour often stabilises during this period, and anxiety and depression seem to improve. Thus, these factors may show measurable improvement over the assessment period. At the conclusion of the assessment, a treatment plan is devised for each child client and their family. As described in the summary above, both children and families often need a period where factors generating significant distress, are stabilised. Common experiences include adverse parental/caregiver circumstances, poor parental/caregiver mental health, unstable living arrangements, imminent court process, grief and loss, recent victimisation, or an unstable case plan. When these issues were resolved, the child and their caregivers were able to proceed to the treatment phase of the Program.

Treatment As is indicated by the treatment literature, multiple aetiological and maintaining factors in the young person’s problematic sexual behaviour must be addressed (Lane, 1991). A child assessed as requiring intervention was either able to participate in the group program or receive individually based interventions that follow the same guidelines as the group program. The program is based on a schedule incorporating activities which: • Develop personal responsibility for behaviour; • Identify triggers to sexual behaviour; • Provide alternative methods of dealing with difficult feelings; • Increase awareness of personal risk patterns; • Promote empathy for other’s experiences and feelings; • Enhance self-intervention skills; • Develop and maintain an appropriate support network; • Improve children’s self-esteem and self-confidence.


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Due to the young age of the children in the Transformers Program, involvement of the children’s parents/ caregivers is an important component of treatment of the children. A parent/caregiver group is run in parallel with the children’s group to assist in their ability to: • Understand, prioritise and respond to the needs of the child; • Identify and respond appropriately to the protective needs of the child; • Appropriately and consistently discipline; • Understand the issues regarding sexually aggressive behaviours in children; • Cope with their own anger and denial; • Appropriately respond to the child’s sexually aggressive behaviours; • Support better models of coping in the child; • Identify and change familial initiating/maintaining factors to the child’s behaviour; • Use professional support networks.

Involvement in the parents/caregivers group was not a prerequisite for the child to receive treatment but participation was encouraged. Throughout the treatment program, staff from the Transformers Program continued to liaise with, support and provide consultation to the professional network involved with the child and his family to promote their continued ability to fully understand, effectively support and contain the child’s behaviours. Following the treatment phase, additional individual and family therapy was provided to children and their families if other difficulties were evident. For example, children with significant histories of abuse related trauma were provided with individually tailored psychotherapy. For some families, family therapy was offered in relation to enhancing patterns of communication and resolving long standing points of tension or conflict.


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Section Four: Evaluation of the Transformers Program Introduction This next section of the document reports on the evaluation of the effectiveness of the Transformers Program. It assesses the extent to which the program achieved its stated aims in responding to the complex needs of children who engage in problem sexual behaviour.

Aims of the evaluation The specific aims of the evaluation were to • describe the characteristics of children and families where a child has engaged in problem sexual behaviour; • assess the efficacy of the Transformers Program of the Australian Childhood Foundation; and, • provide directions on public policy development about how to best meet the needs of children in the client group and minimise the risk they pose to other children.

Components of the evaluation The evaluation included the following components: • an international review on the characteristics of families and children of the client group (presented as a separate document); • an international review on the current models of intervention for children who engage in problem sexual behaviour and a review of any evaluations of these interventions (presented as a separate document); • the development of an extensive literature reference list; • documentation of the Transformers program, as well as client characteristics; • the analysis of quantitative data relating to the evaluation of the program and, • a discussion of the findings and the development of a list of recommendations for future directions in providing interventions to children and caregivers.

Evaluation Period The period in which this evaluation relates is October 1999 to December 2001. A two year follow up of all children in Group B was conducted in mid 2004.


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Methodology Formal evaluation An evaluation of the Transformers Program was conducted which included the collecting of information via questionnaires and interviews. Two groups were included in the evaluation. The first group (Group A) participated in the assessment phase of the intervention. The second group (Group B) participated in the assessment and treatment phases of the program. Due to ethical considerations, there was no control group comprising children who did not receive any treatment. The outcomes of the assessment group (Group A) was compared with the outcomes achieved by the intervention group (Group B). Data was collected prior to children entering the assessment phase for both groups and at the end of their participation in the program. All children in Group B were followed up two years after their completion of the program. Ethics approval was obtained from the Standing Committee on Ethics in Research with Humans at Monash University.

Method Participants and procedure During a 2-year period, all children who engaged in problem sexual behaviour under the age of 12 years who were referred to the Transformers Program of the Australian Childhood Foundation were asked to participate in the study. Children were excluded if there were protection issues pending, no parental/caregiver consent and/or no stable living environment. In total, 152 children were referred to the program and 41 were eligible to participate. Due to limited resources, the numbers eligible to participate were smaller than initially anticipated. Twenty-two families gave consent to take part and 6 of these withdrew from the program due to clinical reasons, protective and placement issues. Children who were eligible and agreed to participate were firstly assessed for sexual behaviour problems and were administered the instruments described below at the assessment phase. Those children continuing on to treatment took part in the intervention program described in the preceding section. Measures obtained during the assessment phase were again completed post intervention. The following section provides a description of the instruments used in the evaluation. The mean age of the children was 9.27 (SD = 1.74). For Group A (assessment phase only) the mean age was 9.61 (SD = 1.70) while for Group B (treatment phase) the mean age was 8.83 (SD = 1.82). Group A was comprised of 7 boys and 2 girls, and Group B consisted of 6 boys and 1 girl.


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Measures Profile of children and their parents/caregivers Background characteristics of the children who were referred to the transformers program and their parents or caregivers, were recorded through a comprehensive file audit process. The file audit was conducted at the first point of contact for all children referred to the program. For those children who then went onto take part in the program itself, additional file audits were undertaken at the conclusion of the Assessment Phase (Group A) and Treatment Phase (Group B). The file audits examined the following factors: • characteristics of children including abuse history, school problems, social problems, existence of psychiatric diagnosis, • the problematic sexual behaviour, including nature, history, number of children known to be subject to the behaviours and how the behaviours were detected, • the characteristics of the children subject to the problematic sexual behaviour including age, relationship to child who engaged in problem sexual behaviour and age difference to the child showing the behaviours, and, • the characteristics of parents/family including known substance abuse, history of abuse in parental/ caregiver background, isolation, and history of involvement with other treatment/support services.

Dependent Measures - Children Depression Children in Groups A and B were administered the Birleson Depression Scale (Birleson, Hudson, Buchanan and Wolff, 1987) to assess for the magnitude of depressed feelings. This scale was specifically designed for use with children and adolescents. The questionnaire comprised 18 items with children asked to rate the degree to which each item applied to them during the previous week. Items include “I have lots of energy” and “I sleep very well”, and are rated as either mostly, sometimes or never. Generally, a cut-off score of 15 and above is suggested as a sensitive index of clinical levels of depression. Frequency of problem sexual behaviour Behaviour report forms were completed by teachers, parents/caregivers, and statutory child protection workers to provide an approximation of the frequency of problem sexual behaviours. The questionnaires were used as structured interview items. They elicited information on the type, risk level, and frequency of sexualised behaviours. These interviews were conducted via telephone by the therapist and incorporated into the standard intake and discharge process. For the purposes of this report, the number of occurrences per month was taken as the index of frequency of sexual behaviours. Anger An illustration of a thermometer was presented to the children who were asked to “show me on the anger thermometer how angry you are feeling now?” Children pointed to or marked a position on the thermometer which ranged from 0 to 100. The score was then noted by the therapist.


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Responsibility taking A “Blame Cake” was presented to children with the explanation about the cake representing the degree of responsibility for the sexual behaviour. Children were asked to divide the cake into proportions according to whom they believe should accept responsibility for the problem sexual behaviour. The proportion of blame which the child allocated to themselves was used as the measure of responsibility taking (0-100 expressed as a proportion). Empathy In order to provide a measure of empathy, children were asked “How do you think (name of target child) felt about the behaviours?” The expectation that the children would be able to generate three possible feelings resulted in the score range of 0 – 3. Program Learning Program learning was assessed using three measures targeting sexual knowledge, awareness of personal risk factors and self-intervention abilities. The Sexual Knowledge Scale, based on the Sexual Knowledge, Experience, and Needs Scale for people with Intellectual Disability (McCabe, 1994) was utilised. As there are no specifically designed sexual knowledge questionnaires for children, the use of one designed for adults with an intellectual disability was considered to be developmentally appropriate for children. Awareness of Personal Risk Factors was measured using 5 subscales collapsed into one variable, which shows a mean of the proportion correct for each child. The degree to children were able to prevent themselves from engaging in the behaviour was evaluated using a three point questionnaire collapsed into one score (0-100).

Dependent Measures – Parents/Caregivers Self-rated confidence A single item was used to assess parental/caregiver confidence in managing their child’s problem sexual behaviours. Parents/caregivers were asked “How confident do you feel in your ability to effectively manage these behaviours?” A scale from 0 – 4 is presented with 0 = not at all confident and 4 = extremely confident. For the purposes of this report, scores were computed a percentage of scale maximum. For example, a score of 4 would equal 100 (%) whilst a score of 2 translated to 50 (%). Understanding Parental/caregiver knowledge and management of their child’s problem sexual behaviours was rated by therapists on a 39 item questionnaire. This measure was divided into three sections each comprising 13 items. These were actual management responses; knowledge of risk issues; and understanding of own impact upon the child. Therapists were required to identify whether parents/caregivers explicitly recognised or described each item. For example, relevant management responses included appropriate setting of limits for the child and consistency in applying discipline to the child. Every question endorsed by the therapist was given a value of 1, resulting in a possible score range of 0-39.


Data Analyses Wilcoxon signed-ranks tests were used to evaluate the impact of intervention for the Assessment and Treatment groups. The Wilcoxon was chosen as it is more reliable than a t-test for small samples. The nonparametric nature of the Wilcoxon test means that strict assumptions of normality usually required do not need to be met which is particularly relevant for the small sample sizes reported here.

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Section Five: Results – describing the profile of children referred to the Transformers Program and their parents/caregivers In the first section examining the results of the project, a detailed description of the total population of children referred to the Transformers Program between October 1999 to December 2001 is outlined. This analysis provides a background understanding about the experiences of children who engaged in problem sexual behaviour and their parents/ caregivers. It also identifies a snapshot of the extent and severity of the problem behaviour for both children who engage in it and those who are the targets of it.

Profile of children who engaged in problem sexual behaviour referred to the Transformers Program The majority of children (73%) referred to the program met the inclusion criteria for age. In Table 1, 35% of children were aged between six and eight years of age and 38% were aged between nine and eleven years. A total of 27% were too old for the program and were referred to more appropriate external welfare organizations. Table 1. A ge of children who engaged in problem sexual behaviour referred to the Transformers Program.

Number of children

Proportion of total

6 – 8 years

53

35%

9 – 11 years

58

38%

12 – 14 years

34

22%

15 years and over

7

5%

152

100%

Age

Total

As indicated in Table 2, the majority of children (85%) referred to the Transformers Program who engaged in problem sexual behaviour were male. Table 2. G ender of children who engaged in problem sexual behaviour referred to the Transformers Program.

Number of children

Proportion of total

Male

129

85%

Female

23

15%

152

100%

Gender

Total

Only a quarter of children referred to the program came from an intact family unit with both biological parents still caring for them (Table 3). The majority had experienced changes in their parental/caregiver arrangements. Importantly, almost 1 in 5 (18%) were living away from their parents due to ongoing risk of abuse and family violence.


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Table 3. F amily composition of children who engaged in problem sexual behaviour referred to the Transformers Program.

Family type

Number of children in this family grouping

Proportion of total

Single parent

41

27%

Two biological parent

38

25%

Step-family

45

30%

Foster care

23

15%

Other

5

3%

Total

152

100%

Referral information As indicated in Table 4, the largest single referral source was school personnel, accounting for 28% of the total number of children referred to the program, highlighting the extent to which such behaviour poses challenges to teachers and others in the school environment. Statutory child protection staff represented the second largest referral source. It is important to note that according to the file audit, almost all of the parents who referred their own children to the program had done so at the request of statutory child protection workers. Interestingly, the combined number of referrals from child mental health services, private therapists and other welfare organizations reflects a possible perception in the mind of these referrers that the treatment of problem sexual behaviour in children requires specialist resources and understanding. In Table 5, the period of time since the first incident of problem sexual behaviour occurred and referral to the Transformers Program is described. Only 18% were referred within a reasonable short time line (1-3 months). The majority (77%) were referred after 4 months of the first incident of problem sexual behaviour.


Table 4. S ources of referral for children who engaged in problem sexual behaviour who were referred to the Transformers Program.

Number of children

Proportion of total

Schools

42

28%

Statutory child protection

29

19%

Welfare organisation

26

17%

Child Mental Health Service

12

8%

Private therapist

15

10%

Police

12

8%

Parents/Caregivers

16

11%

152

100%

Referral Sources

Total

Table 5. P eriod of time since first known incident of problem sexual behaviour and referral to Transformers Program.

Period of time since first known incident of problem sexual behaviour and referral to Transformers Program

Number of children

Proportion of total

1 - 3 months

28

18%

4 - 6 months

63

41%

7 - 9 months

23

15%

10 - 12 months

22

14%

13 - 15 months

11

7%

Unknown

5

3%

152

100%

Total

This time lag in referral reflects a range of possible issues, including the capacity of the child to keep the behaviour secret, the minimization by the child’s network about the seriousness of the behaviour, a lack of understanding from the child’s network about how to best respond, and a lack of protocols between agencies. It is also important to note that that many children only make further disclosures about earlier incidents previously unknown to adults during assessment and treatment. As such, it is likely that these behaviours have a longer history than these figures indicate.

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A description of the problem sexual behaviour An analysis of the figures in Table 6 demonstrates that the 152 children referred to the program targeted a total of 277 children, leading to an average of 1.8 children affected by experiences of problem sexual behaviour per child referred. Two thirds (66%) of children referred to the program had targeted 2 – 3 children with their behaviour. In practice, many children do not disclose the full extent of their behaviours and as such these figures may underestimate the real numbers of children who were targeted. Table 6. N umber of children known to have been targeted by child who had engaged in problem sexual behaviour and referred to the Transformers Program.

Total number of children targeted 52 children referred to the Transformers Program had targeted 1 child

52

75 children referred to the Transformers Program had targeted 2 children

150

25 children referred to the Transformers Program had targeted 3 children

75

Total

277

In Table 7, the age range of children who were the targets of problem sexual behaviour is described. The majority of children who were the targets of the behaviour were younger or of similar age compared to the children who engaged in the problem sexual behaviour (Table 1). This reflects a tendency for children engaging in the behaviour to target children who are developmentally less mature than themselves. Table 7. Age of children who were the targets of the problem sexual behaviour.

Number of children

Proportion of total

3–5

66

24%

6–8

95

34%

9 – 11

79

29%

12 – 15

37

13%

277

100%

Age of target children (years)

Total


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Table 8 provides a breakdown of the relationship between the targeted child and the child who engaged in the problem sexual behaviour. The majority of children (71%) are reported to have a close relationship being siblings, cousins or friends. The remaining 21% were also known to each other prior to the incident or incidents of the problem sexual behaviour occurring. Table 8. Relationship between target child and child who engaged in problem sexual behaviour.

Relationship between target child and child who engaged in problem sexual behaviour

Number of children

Proportion of total

Siblings

64

23%

Friends

89

32%

Cousins

45

16%

Attended same school

52

19%

Lived in neighborhood

27

10%

277

100%

Total

Clearly, the results in Table 9 highlight that the majority of the problem sexual behaviour occurred within the home environment of the target child and/or the child who engaged in the problem sexual behaviour. Almost a quarter (23%) occurred at school or in the environment in which the child was participating in an organized activity (after care, camp, holiday program). Table 9. Analysis of the place that first incident of sexual behaviour took place.

Number of children

Proportion of total

Family home of target child and child who engaged in problem sexual behaviour

42

28%

Home of target child

42

28%

Home of child who engage in problem sexual behaviour

33

22%

School

21

14%

Organised children’s activity

14

9%

152

100%

Place that first incident of sexual behaviour occurred

Total


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In Table 10, the nature of the problem sexual behaviour reported at the time of the referral to the Transformers Program is described. Almost half of the children (49%) referred to the program were reported to have engaged in some kind of penetrative behaviour involving the targeted child. This included examples of • target children who were digitally penetrated in their anus or vagina, • target children who were forced to digitally penetrate another child’s vagina or anus, • target children who were forced to undertake oral sex with the child who was engaging in the problem sexual behaviour. A third of children referred to the program engaged in sexualized touching of a targeted child that did not involve penetration. Finally, almost 1 in 5 of children (18%) were referred for exposing their genitalia in public and/or masturbating in public. Table 10. A nalysis of the kinds of problem sexual behaviour exhibited by children referred to the program.

Number of children

Proportion of total

Self exposure

15

10%

Self exposure and public masturbation

12

8%

Self exposure and sexualised touching of another

14

9%

Self exposure, sexualised touching and penetration of another

26

17%

Sexualised touching of another

36

24%

Sexualised touching of another and penetration of another

49

32%

152

100%

Type of problem sexual behaviour

Total

Identifying the prior disruptive and/or abuse experiences of children who engaged in problem sexual behaviour and their parents/caregivers In Table 11, the background experiences of abuse and trauma of the children who had engaged in problem sexual behaviour is described. Clearly, the majority of children (73%) were known at the time of referral to have experienced at least one form of child abuse or neglect. A total of 33% of children who had engaged in problem sexual behaviour were victims of sexual abuse. Just over 1 in 5 were victims of physical abuse (22%). A total of 64% had experienced emotional and psychological abuse within their family. The background experiences of a substantial proportion of children referred to the Transformers Program involves serious trauma and developmental disruption. The results highlight the complexities of their emotional, social and cognitive needs. In particular, it highlights the requirement for therapeutic intervention which addresses the children’s own experiences of violation and disempowerment. In addition, the analysis of the parental/caregiver background in Table 12 also suggests that children referred to the Transformers program have experienced compounding stressors arising from the high proportion of parents/ caregivers who themselves have histories of substance and alcohol misuse, mental illness and/or criminal activity.


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Children who engage in problem sexual behaviour appeared to be rendered developmentally vulnerable by their experiences of abuse, neglect and poor relational environments within their family. Table 11. H istories of abuse and neglect experienced by children who engaged in problem sexual behaviour.

Abuse histories of children who engaged in problem sexual behaviour

Number of children

Proportion of total

Sexual abuse and emotional/psychological abuse

34

22%

Physical abuse and emotional/psychological abuse

16

11%

Sexual abuse, physical abuse and emotional/psychological abuse

16

11%

Emotional/Psychological Abuse

31

20%

Neglect

14

9%

No reported histories of abuse at time of referral

41

27%

152

100%

Total Table 12. Analysis of parental/caregiver backgrounds.

Parental/Caregiver background factors

Proportion of total number of parents/caregivers who were reported with factor in background

History of illicit drug use

35%

History of alcohol problems

28%

History of mental illness

18%

Experienced domestic violence

24%

Engaged in criminal activity

14%

History of childhood abuse

42%


Concluding summary Children who engage in problem sexual behaviour present with a complex interplay of experiences including abuse related trauma, disadvantage and disruption within their primary care environments. Not withstanding their backgrounds, this study also highlights the reality that young children are engaging in high tariff problem sexual behaviours including penetrative acts that must be addressed with effective and timely treatment. Rendered developmentally vulnerable by their experiences of abuse, neglect and poor relational environments within their family, these children pose a range of challenges for the existing service system, in particular schools and statutory child protection services. As a result, there is an increasing reliance on specialist services and interventions to address the matrix of interdependent needs and risks with which these children present. Traditional therapeutic approaches have often been limited in their effectiveness by focusing either exclusively on the child’s vulnerabilities with no targeted intervention for the problem sexual behaviours, or alternatively, concentrated on the problem sexual behaviours without giving due regard to the child’s context and history. Effective intervention with these children must incorporate activities that address both domains.

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Section Six: Results – evaluation of program outcomes Sample Characteristics In total, data from 16 children with sexual behaviour problems were included in the following analysis of program outcomes. Nine children completed the clinical assessment phase only (Group A) and 7 children completed the assessment phase and participated in treatment for problem sexual behaviour (Group B). In Group A, children lived at home with both parents/caregivers, a natural parent and a defacto, in foster care or in residential units. Four of the 7 children in Group B lived at home with both parents/caregivers and 3 were in foster care or placed with extended family members. Table 13 contains summary data relating to children’s experiences of abuse and neglect. Of the 16 children, 7 were victims of physical abuse, 6 were exposed to emotional abuse, and 4 children had been sexually abused. Four of the 16 children had been exposed to family violence and 4 had been victims of neglect.

Table 13. Abuse history of the children who engaged in problem sexual behaviour.

GROUP A (N = 9)

GROUP B (N = 7)

Physical Abuse

4

3

Sexual Abuse

1

3

Emotional Abuse

3

3

Neglect

3

1

Exposure to family violence

2

2

Details of the problem sexual behaviour are described in Table 14. Table 14. Description of frequency and seriousness of problem sexual behaviour.

GROUP A (N = 9)

GROUP B (N = 7)

1.3

2.2

High Tariff

8

7

Medium Tariff

1

0

Low Tariff

0

0

Mean number of children targeted


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Table 15 provides a brief overview of the psychiatric characteristics of the sample. Of the 16 children, 4 were diagnosed with ADHD, 2 with a learning difficulty, 2 with anxiety disorders and 1 with enuresis/encopresis. Six of the 16 children did not meet criteria for a psychiatric diagnosis. Table 15. Psychiatric diagnoses of children who engaged in problem sexual behaviour.

GROUP A (N = 9)

GROUP B (N = 7)

ADHD

2

2

Enuresis/Encopresis

0

1

Specific Learning Difficulty

0

2

Anxiety Disorder

0

2

No Psychiatric Diagnosis

4

2

Note: ADHD = Attention Deficit/Hyperactivity Disorder

Characteristics of the parent/caregiver sample are provided in Table 16. A large proportion of the parent/ caregivers were diagnosed with personality disorders (33% - 57%) and psychological disorders (28% - 44%). In Group B, 85% of caregivers were engaged in substance abuse and the same percentage had a poor history in engaging with support services. Over half the sample of parent/caregivers were themselves victims of some form of physical and/or sexual abuse. Table 16. Parent/Caregiver Characteristics.

GROUP A (N = 9)

GROUP B (N = 7)

Personality Disorder

33%

57%

Psychological Disorder

44%

28%

Substance Abuse

44%

85%

History of Abuse

55%

57%

Criminal History

22%

28%

Domestic Violence

22%

14%

History of not engaging with support services

77%

85%


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Intervention Evaluation The evaluation examined the efficacy of the Transformers Program to stop children engaging in problem sexual behaviour. It did so by gathering data on a range of dependent measure for children and their parents/ caregivers. Means and standard deviations for the dependent measures are displayed in Tables 18 (children) and 19 (parents/caregivers). Due to the small sample size, individual Wilcoxon signed-ranks tests were conducted to examine changes in these variables from pre to post intervention.

Baseline Differences An examination of Table 17 indicates that children in Group B (treatment) were considerably higher than those in Group A on frequency of sexual behaviour problems. As is often the case in intervention programs those with more serious problems continue on to treatment. Table 17. Means and standard deviations for pre and post assessments for children.

GROUP A (N = 9) Pre

GROUP B (N = 7)

Post

Pre

Post

M

SD

M

SD

M

SD

M

SD

Sexual Behaviour

4.25

4.61

1.61

2.57

12.43

16.95

0.64

1.49

Depression

8.25

4.02

8.75

6.22

7.42

4.61

6.57

2.69

Anger

46.87

27.63

20.25

21.62

44.28

21.49

9.00

9.14

Responsibility – taking

25.00

43.42

48.13

42.92

20.00

36.51

59.29

24.56

Empathy

0.03

0.08

0.18

0.22

0.03

0.09

0.35

0.33

Personal Risk

-

-

-

-

29.14

5.75

55.57

8.79

Self-Intervention

-

-

-

-

53.57

13.03

78.57

11.88

Sexual Knowledge

-

-

-

-

84.14

15.98

96.71

13.75

Program Learning

-

-

-

-

59.81

10.20

76.95

7.06

Note: Responsibility taking expressed as percentages and Personal Risk = Awareness of personal risk factors.


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Children Sexual behaviour Using the Wilcoxon signed-ranks test, analysis of pre-post data indicated that children in Group A demonstrated a significant decrease in frequency of sexual behaviour (p = 0.02). Group B children also displayed a significant reduction in sexual behaviour from pre-post intervention (p < 0.02). Scores on sexual behaviour at preintervention ranged between 0.25 – 50. Post-intervention scores ranged between 0 – 8. The changes in scores for this measure are represented diagrammatically in Figure 1. Even though there are differences at baseline between the two groups, it should be noted that as opposed to Group A, the degree of improvement was of a greater magnitude for the children who received treatment in Group B (see Figure 1).

Figure 1. Sexual behaviour at pre and post intervention.


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Depression Analysis of the pre-post data of Group A children indicated that scores on depression did not change significantly (p = 0.72). For Group B, there was also no significant change in depression (p = 0.75). For Group A, scores on depression ranged between 3 – 15 pre-intervention and between 2 – 17 post assessment. For Group B children, depression scores ranged between 2 – 14 pre-intervention and between 2 – 9 post-intervention. This difference in score range indicates that depression in Group B children reduced whilst for Group A, there were 3 children scoring above the clinical cut-off at post-assessment. The changes in scores for this measure are represented diagrammatically in Figure 2.

Figure 2. Depression scores at pre and post intervention


Anger Wilcoxon analysis of the scores on anger indicated that for children in Group A the decrease in subjective anger was significant (p = 0.03). A similar significant decrease in anger was also found for children in Group B (p = 0.02). The changes in scores for this measure are represented diagrammatically in Figure 3.

Figure 3. Anger ratings at pre and post intervention.

43


44

Empathy Analysis of empathy ratings revealed no significant changes for children in Group A (p = 0.10). Children in Group B displayed a significant increase in empathy from pre-post intervention (p = 0.04).

Responsibility Taking There were no statistically significant changes in responsibility taking from pre-post intervention for either Group A (p = 0.17) or Group B (p = 0.07). The increase in responsibility taking for Group B approached statistical significance. The changes in scores for this measure are represented diagrammatically in Figure 4.

Figure 4. Responsibility taking at pre and post intervention.

Program Learning Statistically significant increases in program learning (average of awareness of personal risk factors, selfintervention ability and sexual knowledge) were found for children involved in the treatment program (Group B, p = 0.02).


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Parents/Caregivers The changes in parental/caregiver ratings of understanding about problem sexual behaviour and their confidence in responding to such behaviour is presented in Table 18. Table 18. Means and standard deviations for pre and post parental assessments.

GROUP A (N = 9) Pre

GROUP B (N = 7)

Post

Pre

Post

M

SD

M

SD

M

SD

M

SD

Understanding

20.18

6.76

23.75

9.08

18.01

6.21

25.28

10.19

Confidence

54.32

5.89

76.21

8.36

21.01

10.17

70.87

7.72

Understanding Wilcoxon analysis of self-rated understanding scores for parents/caregivers in Group A revealed a significant increase from pre-post intervention (p = 0.04). For parents/caregivers in Group B, the increase in self-rated understanding was also statistically significant (p = 0.03). The changes in scores for this measure are represented diagrammatically in Figure 5.

Figure 5. Understanding (parents/caregivers) at pre and post intervention.


46

Confidence The analysis of confidence ratings indicated no significant changes for parents/caregivers in Group A (p = 0.07). For Group B, parents/caregivers reported significant increases in confidence from pre-post intervention (p = 0.02). The changes in scores for this measure are represented diagrammatically in Figure 6.

Figure 6. Self-rated confidence (parents/caregivers) at pre and post intervention.


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Two year follow up assessment Follow up assessment interviews were conducted two years after the children and parents/caregivers completed the program. It was only possible to conduct interviews with those who had attended both the assessment and intervention (i.e., Group B). Of the seven families in Group B, six participated in the follow-up assessment with one family not providing child measures. The follow up data provides an indication of whether the outcomes of the Transformers Program for children who engage in problem sexual behaviour are maintained over time. Measures Dependent measures used at pre and post intervention were also completed at follow-up. Children were administered measures of depression, frequency of problem sexual behaviour, anger, responsibility taking, empathy and program learning. Parents/caregivers were administered measures of self-rated confidence and understanding of child’s problem sexual behaviour. Results Means and standard deviations for the dependent measures at follow up assessment are displayed in Tables 19 (children) and 20 (parents/caregivers). Pre and post intervention assessment results are also displayed in Tables 19 (children) and 20 (parents/caregivers) for purposes of comparison. Statistical comparisons are not made due to the small numbers in the sample. Instead, the reader’s attention is drawn to group means as the basis for providing an insight into the stability of the changes following the intervention. Table 19. Means and standard deviations for pre, post and two year assessments for children.

GROUP A (N = 9) Pre

GROUP B (N = 7)

Post

Pre

Post

Follow up

M

SD

M

SD

M

SD

M

SD

M

SD

Sexual Behaviour

4.25

4.61

1.61

2.57

12.43

16.95

0.64

1.49

0.17

0.41

Depression

8.25

4.02

8.75

6.22

7.42

4.61

6.57

2.69

3.40

1.14

Anger

46.87

27.63

20.25

21.62

44.28

21.49

9.00

9.14

8.00

8.37

Responsibility – taking

25.00

43.42

48.13

42.92

20.00

36.51

59.29

24.56

60.00

41.83

Empathy

0.03

0.08

0.18

0.22

0.03

0.09

0.35

0.33

1.00

1.00

Personal Risk

-

-

-

-

29.14

5.75

55.57

8.79

Self-Intervention

-

-

-

-

53.57

13.03

78.57

11.88

Sexual Knowledge

-

-

-

-

84.14

15.98

96.71

13.75

Program Learning

-

-

-

-

59.81

10.20

76.95

7.06

Note: Responsibility taking expressed as percentages; Personal Risk = Awareness of personal risk factors.


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Children – 2 year follow up Sexual Behaviour Frequency of problem sexual behaviour decreased from post-intervention to two-year follow up. Since completing the intervention program, only one of the six children had displayed any form of problem sexual behaviour. This child had also reported sexual behaviour at post intervention. He is currently attending the Australian Childhood Foundation for further therapy. Depression Scores on Depression decreased even further from post-intervention to two-year follow up. All children scored below the clinical cutoff (similar to non-clinical levels reported at pre and post intervention). Scores on Depression ranged between 2-5. Anger From post-intervention to two-year follow up, scores on Anger remained stable at a low level. Responsibility Taking The increased levels of responsibility taking by children were maintained at follow up. Empathy Overall, there was a substantial increase in empathy from post intervention to follow up assessment. However, only two children were able to provide a response to the question “How do you think (name of target child) felt about the behaviours?” It is unclear as to whether this is due to the length of time passed since the problem sexual behaviour occurred or difficulties with empathy. Program Learning All children were able to identify at least three appropriate self-intervention strategies when given a hypothetical scenario of a child who felt upset and wanted to engage in sexual behaviour with another child. Table 20. Means and standard deviations for pre and post parental/caregiver assessments.

GROUP A (N = 9) Pre

GROUP B (N = 7)

Post

Pre

Post

Follow up

M

SD

M

SD

M

SD

M

SD

M

SD

Understanding

20.18

6.76

23.75

9.08

18.01

6.21

25.28

10.19

27.00

10.56

Confidence

54.32

5.89

76.21

8.36

21.01

10.17

70.87

7.72

87.5

13.69


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Parents/caregivers – 2 year follow up Understanding Therapist rated parental/caregiver knowledge and management of their child’s problem sexual behaviours remained stable from post-intervention to follow-up. Scores ranged from 12-37 (out of 39). Confidence Self-rated parental/caregiver confidence to manage behaviours of the child increased from post-intervention to follow-up assessment. As a percentage of the scale maximum, scores ranged from 75-100%.

Analysing the results of the two year follow up The follow up results suggest that the outcomes of the Transformers program for children who engage in problem sexual behaviour are maintained or enhanced over a period of two years. Specifically, the decreases in frequency of problem sexual behaviour and anger, and the increases in responsibility taking and empathy at post intervention, were maintained at follow up. Levels of depression remained within the normal range. Further improvement since post intervention was evident for frequency of problem sexual behaviour, depression and empathy. The increase in parental/caregiver understanding of their child’s problem sexual behaviours from pre to post intervention was maintained at follow up, while parental/caregiver confidence to manage behaviours of the child further improved from post-intervention to follow-up. The follow-up data indicates that the therapeutic effects of participating in the Transformers program are enduring over a period of two years. Thus the Transformers Program can be considered successful in the medium term in reducing the risk of children who engage in problem sexual behaviour continuing to develop even more problematic and potentially aggressive sexual behaviour into their adolescence. Due to the lack of follow up data for the children who participated in assessment only, it is not possible to determine whether the positive outcomes reported by Group B is unique to that group. It is important that further work is carried out in this area. For example, studies utilising larger sample sizes and standardised measures will enable a more confident analysis of the program. It is clear however that the Transformers Program is addressing the needs of these children and their parents/caregivers and further funding is required to ensure those in need have access to this program.


50

Section Seven: Discussion – program evaluation The findings of the program evaluation will be discussed in three sections. The first section describes a summary of the key background characteristics of the children and parents/caregivers who took part in the assessment and intervention components of the Transformers Program. The second section examines the findings of the evaluation in relation to the effectiveness of the Transformers program. The last section explores the limitations of the evaluation.

Characteristics of the children and parents/caregivers who participated in the Transformers Program Approximately 50% of the children in the sample who actually undertook the program had experienced some form of abuse in their lives. This is consistent with the numbers reported in the recent large scale study conducted by Bonner, Walker and Berliner (2003) in the USA. Interestingly, previous smaller scale studies have reported higher levels of experienced abuse (around 80%) in the backgrounds of children in this group. From these results, it is reasonable to conclude that previous experiences of child maltreatment increases the probability of children engaging in problem sexual behaviour. However, as a contributing factor, a history of child abuse is not sufficient to completely explain the genesis of the behaviour. Almost two-thirds of the children in the sample who undertook the program had psychiatric diagnoses. A similar proportion was found in previous studies (Gray et al., 1997; Pithers et al., 1998b). In particular, children who engage in problem sexual behaviour tend to display greater behavioral problems and more symptoms of anxiety and trauma. The parents/caregivers in the sample who undertook the program showed high rates of psychological difficulties, substance abuse and histories of abuse. These findings are again consistent with prior research (Burton et. al., 1997). Overall, it suggests that the sample of children and their parents/ caregivers who took part in the intervention program are representative, or at least similar to, those reported in the literature so far. The high degree of distress and disadvantage experienced by the children and parents/ caregivers in the study have a number of implications. Firstly, the relational context for the children is poor, with parents/caregivers experiencing multiple concurrent personal problems and/or difficulties with parenting. As a result, a significant proportion of children referred to the program were in foster care or residential units. For the children who were in out of home care, placement disruption was common. Secondly, the findings also highlighted the fact that this group of children have complex and multidimensional needs requiring careful assessment and intervention. Thirdly, it is clear that the parents/caregivers of these children found it difficult to engage in services which encouraged them to reflect on the impact of their behaviour on their children’s development. In the context of competing emotional and psychological needs, these parents/caregivers also appear to struggle to understand their children’s behaviour or how to respond to it. Finally, the capacity of parents/caregivers to support their children through a long and complex therapy program is likely to be challenged.


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Understanding the outcomes for children Problem sexual behaviour and levels of anger Children in both groups showed a decrease in frequency of sexual behaviour and levels of anger. Those in the treatment group showed three times the frequency of the problem sexual behaviour compared to the assessment group prior to any intervention. Yet, following the intervention phase, the frequency of this behaviour in Group B was lower with less than an average of one incident per month whilst the assessment only group (Group A) was still engaging in at least one or two problem sexual behaviour incidents a month. The fact that problem sexual behaviour and levels of anger decreased significantly following the assessment phase is not that surprising. Considerable effort was made during assessment to contain the family and resource the wider social network of the children. In such poorly resourced families, even this initial degree of support can result in important benefits for children. Depression At the beginning of the assessment phase, children in both groups reported similar nonclinical levels of depression which were more consistent with “normal” levels expected in the population. These levels did not change significantly after assessment or intervention. Based on previous studies, it would have been expected that children reported higher levels of depression prior to treatment. The Birleson Depression Scale is a standardised questionnaire with good discriminant validity and is appropriate for that age group. Empathy and responsibility taking Empathy was measured by asking children who took part in the assessment and intervention phases to identify the feelings the target child may have had resulting from his/her experience of the problem sexual behaviour. Only the group who participated in the intervention reported an improvement in their ability to identify these feelings. It is clear that these children have particular difficulties in being aware of their own feelings, let alone understanding the nature of other’s experiences of them. It should be noted that despite the statistically significant increase reported the actual change in mean level of empathy was very small. The clinical significance of these results is therefore questionable. Whilst empathy is considered an important prognostic indicator in the adult offender field, it is unclear how predictive it is with children who engage in problem sexual behaviour. Once again the importance of the developmental stage of the child is vital in understanding the meaning of these findings. It is highly likely that many children of this age would have difficulties in identifying the feelings of another child. It is critical then that greater emphasis be placed on encouraging children to understand empathy not only in relation to the consequences of their problem sexual behaviour but in other facets of interpersonal relations. There was no statistically significant increase in responsibility taking in those who participated in the assessment phase only. Those in Group B who received the intervention showed a trend towards an increase in responsibility taking which almost approached significance. A closer inspection of the means and standard deviations in Table 6 suggests that there was considerable variability in the response to this question. Despite not reaching significance, responsibility taking did increase from 25% to around 50% for the assessment group and 20% to 60% for the intervention group.


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Program Learning As noted, program learning increased significantly for Group B children. When compared to scores at preintervention, it is clear that the children improved considerably in levels of sexual knowledge, abilities in selfintervention and awareness of personal risk factors. This indicates that the intervention was effective in facilitating awareness and knowledge of problem sexual behaviours within this group of children.

Understanding the program outcomes for parents/ caregivers Both groups of parents/caregivers showed a significant increase in therapist-rated understanding about problem sexual behaviour. This measure included actual management responses, knowledge of risk issues, and understanding of the impact of their behaviour on their child. Therapists were required to identify whether parents/caregivers explicitly recognised or described each item. In contrast, only those parents/caregivers who participated in the intervention reported an increase in confidence to manage their child’s behaviour. It should be noted that the higher level of confidence pre-assessment in Group A could have been because half of them were in foster care or residential units and the caregivers would have had more professional support.

Summarising the outcomes of the program evaluation The two groups participating in the study received a comprehensive assessment which included: regular support from a therapist, containment of the problematic behaviours, systems intervention and a formulation of the problem with a recommended treatment plan. The assessment phase did not address the specific factors underlying the problem sexual behaviour, the level of emotional disturbance experienced by the children or the background problems of the parents/caregivers. The treatment phase involved a 20 week program primarily in group format for both the children and their caregivers. The group program for children involved developing personal responsibility for behaviour; identifying triggers to sexual behaviour; providing alternative methods of dealing with difficult feelings; increasing awareness of personal risk patterns; promoting empathy for other’s experiences and feelings; enhancing self-intervention skills; developing and maintaining an appropriate support network; improving children’s self-esteem and self-confidence. The group program for parents/caregivers involved assisting them to understand, prioritise and respond to the needs of the child; identify and respond appropriately to the protective needs of the child; appropriately and consistently discipline; understand the issues regarding problematic sexual behaviours in children; cope with their own anger and denial; appropriately respond to the child’s problem sexual behaviours; support better models of coping in the child; identify and change familial maintaining factors to the child’s behaviour; using support networks. The findings of the evaluation suggested that the outcomes of the Transformers program for children who engage in problem sexual behaviour are positive. More specifically, there was a general decrease in frequency of problem sexual behaviours for children in both groups. However, those in the treatment group showed a greater magnitude of change compared to those who only participated in the assessment phase. Levels of anger reported by the children were also found to reduce significantly for both groups. Children’s level of depression remained the same following the intervention although Group B seemed to display slightly greater improvement


53

than Group A. Children who participated in treatment showed an almost significant (significant trend) increase in responsibility taking whilst no change was observed for those in the assessment only group. It appears that taking part in the assessment phase only was as equally effective as taking part in both assessment and intervention phases in decreasing problem sexual behaviour and levels of anger in children. However, it should be noted that the magnitude in decrease for the intervention group was much greater. In contrast, participating in the intervention program was more effective than participating only in the assessment process in increasing responsibility taking and empathy for children who engaged in problem sexual behaviour. Interestingly no change was reported in either group on level of depression, although it should be noted that pre assessment levels of depression were within normal range. For parents, understanding and management of their child’s sexual behaviour problems improved significantly for both groups. This indicates that assessment may be just as effective as treatment in addressing parental/ caregiver ‘knowledge’ issues pertaining to sexual behaviour problems. However, parental/caregiver confidence in managing the child’s sexual behaviour problems only improved significantly for those who received the intervention. This reflects the additional time and resources required to assist parents/carergivers to integrate their new knowledge into new strategies for understanding and responding to their child’s needs. The results also indicate that the program learning improved considerably (and significantly) from pre to post intervention. Individually, scores on each of the three measures increased demonstrating that, compared to preintervention, the children in Group B became more aware of personal risk factors, more competent in engaging in self-intervention and possessed a higher level of sexual knowledge following completion of the intervention program. Whilst only small in scale, the two year follow up data presented in this report has also provided preliminary evidence to suggest that the positive outcomes of the Transformers program are able to be maintained.

Limitations and issues Many problems are encountered when conducting research in treatment settings. In this study, the difficulties were magnified by the fact that the subjects of the research were children who engaged in a complex and sometimes confronting behavioural problem. Due to the small numbers in the study, the conclusions should only be considered preliminary. Care was taken not to exceed the number of participants by the number of statistical tests applied. Even so, the ratio was somewhat high. There was no formal control group in this study, that is there was no group who did not receive assessment or treatment. This was based on the ethical concerns for the children of withholding or delaying treatment particularly in the light of the behaviours of this group. The assessment group who themselves chose to not continue into treatment provided a unique comparison group to allow an examination of how effective the treatment was over and above the comprehensive assessment phase. Previous studies have not been able to provide this information as they have had either only one treatment group or two different types of treatments. The methodological limitation of the comparison group is that they were self-selected and hence random assignment to groups did not occur. Considering the vulnerable nature of this group random assignment would have been ethically inappropriate.


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Hence, the current study suggests that treatment provided through the Transformers Program can result in therapeutic change for children who engage in problem sexual behaviour.

Implications for research and practice Despite the small numbers, this study suggests that the treatment offered by the Transformers program provides additional therapeutic change compared to children who participated in an assessment alone. Future studies would benefit from a larger sample size and data on whether changes in behaviour remained stable. Even though conducting empirically based research on such complex clients groups has its limitations, the process has provided important insights and much valuable information. In conjunction with the literature review, it offers the field an important information base from which to develop models of best practice when working with children who engage in problem sexual behaviour. Recognising the need for specialist intervention The level of difficulties for both parents/caregivers and children confirms the need for careful assessment and multi-level streamed treatment interventions which take account of each family’s particular needs. The level of problem sexual behaviour exhibited by children in the study implies the need for specialised intervention for this component of their problems. The complexity of children’s needs highlights that multiple agency involvement is often necessary. Establishing best practice principles Below are ten key principles that should be considered in the development of intervention programs for children who engage in problem sexual behaviour. The principles are drawn from the literature (primarily Araji, 1997), the Transformers program and the findings from this study. • It is vital that children who engage in problem sexual behaviour are not treated as sex offenders but rather understood within the context of their history, living situation and developmental age. • The most effective treatment model will incorporate an understanding of child development, sexual abuse, trauma, learning models, relapse prevention, and systems theories. • It is essential that a family therapy component is integrated into treatment models to address the family dynamics which support and often maintain the problem sexual behaviour in children. • Group, peer, or pair therapy are useful methods for working with children who engage in problem sexual behaviour. Children are best managed and treated in developmentally separate age groups. • Treatment that is individually tailored offers the greatest likelihood for success. • In order for families to remain engaged in treatment, it is important that there is an identifiable individual or organisation which assumes case management and case co-ordination responsibility. • Some families may require mandated attendance by a statutory body to facilitate their retention in the program. • When appropriate, treatment needs to address the history of victimisation of the child who has engaged in the problem sexual behaviour. • Children who engage in problem sexual behaviour will need support to be able to identify, understand and manage strong feelings of anger and disempowerment. • Parental/caregiver support activities are a crucial component in assisting them to build the skills and knowledge necessary to prevent further problem behaviours.


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The need for urgent resourcing As an early intervention model, the Transformers Program appears successful in the short and medium term in reducing the risk of children who engage in problem sexual behaviour continuing to develop even more problematic and potentially aggressive sexual behaviour into their adolescents. The Transformers Program remains under-resourced. It has only recently received additional funding from the state government. It is expected that even with the additional resources made available to the Foundation, there will be a shortfall in the number of children who can be offered a service in the coming year. The pressure for additional resources will be even greater if the recommended changes to the Children and Young Persons Act 1989 proceed leading to the introduction of specifically targetted treatment orders for children aged between 10 and 14 years who engage in problem sexual behaviour. It is essential that the program itself not be compromised because of a lack of funds. Children who engage in problem sexual behaviour are clearly at highest risk of developing a series of extremely damaging behavioural and emotional conditions without access to specialist support and therapy. As equally urgent is the need for a comprehensive research agenda to be developed which examines in a methodical manner the genesis of problem sexual behaviour and continues to build a locally relevant knowledge base about the effectiveness of strategies designed to stop such behaviour in children, adolescents and adults. Once established the research agenda should drive the commitment of government and philanthropic resources to ensure that it delivers positive outcomes for children. The need for legislative review The proportion of children who commenced taking part in an assessment but did not continue with the remainder of the program highlights just how difficult it is for them and their families to believe, acknowledge and know how to make changes in relation to problem sexual behaviour. Parental/caregiver involvement in the Transformers Program is critical to beneficial outcomes for children. However, the shame and embarrassment for many parents/caregivers of being made aware of their child’s problem sexual behaviour is a considerable obstacle to their positive engagement with a specialist clinical program for this specific problem behaviour. The results of the study highlight that it is appropriate and indeed timely for the statutory child protection system to be considering the possibility of court prescribed treatment orders for children who have engaged in problem sexual behaviour. However, the focus of these treatment orders should not only be limited to children but also include mandated parental/caregiver participation in specialist programs to ensure that engagement is supported and facilitated. This has been highlighted by a number of overseas researchers as being integral to the success of these early interventions (see Araji, 1997). It is also clear that for children, their family context and in particular their experiences of abuse and neglect are significant contributing factors to the development of the problem sexual behaviour in the first place. As such, it is insufficient, and clearly ineffective, to mandate treatment only for children who engage in the behaviour. The findings of this evaluation highlight just how critical it is to target intervention at parent and/or caregivers in order to ensure that change occurs and is maintained. Effective intervention for children who engage in problem sexual behaviour begins with the children themselves being provided with positive, safe and nurturing relationships.


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The need for more professional training Given the complexity of the needs of children who engage in problem sexual behaviour and their families, it is essential that professionals who work with them are provided with training and consultation programs that enhance their confidence and competence. Children in this group often come into contact with professional from a variety of networks and disciplines, including child protection, out of home care, police, homelessness services, disability programs and education system. There is an urgent need for the resourcing of opportunities for professional education that can disseminate up to date research outcomes about practice in working with children who engage in problem sexual behaviour and their families.


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Section Eight: Conclusion and recommendations Children who engage in problem sexual behaviour experience a number of significant difficulties. Firstly, the large majority of them have experienced trauma and disruption in their life. A significant proportion have experienced physical and sexual abuse. A number of them have been affected by family violence. Some have been involved in environments in which their parents/caregivers are seriously affected by illicit drugs and an abuse of alcohol. For these children, their early childhood experiences are filled with anger, confusion, sadness and fear. Their relationships with significant adults in their lives are plagued with loss, violence and most of all a sense of alienation and lack of attunement. For a range of reasons, these children translate these early experiences into behavioural and emotional patterns that include sexual behaviour with other children. Often, the sexual behaviour has elements of threats, intimidation and, almost always, secrecy. It should not be surprising that this is the outcome. Acclaimed neurobiologist, Bruce Perry has argued for some time now that the actions of parents/caregivers and the community as a whole are generating increasing ways to incubate children in terror (Perry, 2002; Perry, Colwell and Schick, 2002). In this context, problem sexual behaviour is an extremely challenging outward manifestation of what a child is feeling internally. The behaviour itself has consequences for the child who has engaged in it as well as the child who is the target of the behaviour. For the child who has engaged in it, the problem sexual behaviour can serve to become a central focus that is repeated and repeated as a way of relieving internalised stress. It can act as a block to other areas of their development. They can struggle to form positive relationships with peers. They may find it difficult to respect limits. They do not learn empathy and feel heightened levels of anger and depression. Once the problem sexual behaviour is discovered, they are frequently stigmatised and humiliated at home, school and amongst their friends. For children who are the targets of the sexual behaviour, they experience confusion and often anxiety. They can feel manipulated and violated. They may also feel worried that they might be implicated in their behaviour. They are embarrassed and frequently traumatised. For parents/caregivers of children who have engaged in problem sexual behaviour, their experience often mirrors their children. They feel humiliated. Their friendship circle dramatically reduces. Other parents/caregivers are frightened to have their children play together. Their own family may turn on them and withdraw any support. They worry about their child growing up to be a sex offender. They either blame themselves or totally abdicate any responsibility for their child, preferring to blame him for the suffering brought down on the family. It is a complex interplay of competing needs and experiences. The Transformers Program has been shown to address these needs and turn around children’s day to day experiences. It has done so successfully because it has not fallen into the trap of providing intervention aimed only at children with the problem. It has been effective in the large part because it has also focused on engaging parents/caregivers in the process of counselling. It has done so by emphasising the responsibility of parents/caregivers to provide an environment of safety, stability and support for their children. It is clear that the Transformers Program is uniquely positioned to provide constructive treatment and hope to children who engage in problem sexual behaviour and their families. It will do so only if it is not compromised by a lack of funding or the continuation of a public policy context that does not support child centred and family focused intervention.


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As such, the following recommendations are made as the basis for enhancing government policy and legislation in relation to supporting children who engage in problem sexual behaviour.

Recommendation 1.

All State governments to ensure that relevant child protection policies and legislation actively support specialist programs for children who engage in problem sexual behaviour as an effective strategy for preventing child sexual abuse.

Recommendation 2.

All State governments adequately resource the implementation of specialist programs aimed at intervening with children under 12 years who have engaged in problem sexual behaviour with other children.

Recommendation 3.

All State and Commonwealth governments establish and resource a national strategy that delivers community and professional education to enhance understanding about the needs of children who engage in problem sexual behaviour and how best to respond to them and their families.

Recommendation 4.

All State and Commonwealth Governments establish and resource a research agenda to examine ways to prevent child sexual abuse through early intervention and treatment of children who engage in problem sexual behaviour.

Recommendation 5.

The Victorian Government ensure that the new treatment orders for children who engage in problem sexual behaviour proposed in the new Children’s Bill be expanded to include the option of mandating parents/caregivers to undertake specialist intervention themselves.


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