Sexual behavior in infancy and early childhood
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Sexual Behavior in Infancy and Early Childhood. John S. Rozel, MD. Goals. The participant will understand what is and is not known about early sexual development (Ages 0-12) The participant will critically evaluate normal and abnormal sexual behaviors

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Sexual behavior in infancy and early childhood

Sexual Behavior inInfancy and Early Childhood

John S. Rozel, MD


Goals

Goals

  • The participant will understand what is and is not known about early sexual development (Ages 0-12)

  • The participant will critically evaluate normal and abnormal sexual behaviors

  • The participant will gain understanding of when and how to intervene and when and how to obtain further evaluation


Outline

Outline

  • Introduction

  • Normal development

  • What are and are not abnormal behaviors

  • Basic interventions

  • When and where to refer

  • Discussion


Introduction development

Introduction: Development

  • Childhood, sexuality, development, sexual abuse

  • Ancient phenomena but new concepts

  • Development is a process

    • Sequence set

    • Rate of progression variable

  • “Range of behavior” -- difficult to distinguish normal from abnormal at times


Introduction why study intervene

Introduction:Why study & intervene?

  • Part of development

  • Possible indicator of abuse

  • Behaviors are highly problematic to manage

  • Behaviors put the child and others at risk

  • Prevention of further victimization


Introduction context

Introduction:Context

  • Development strongly influenced by culture

    • Temporal

    • Social

  • Privacy

  • “Innocence”

  • Latency


Culture society

Culture & Society


Culture society1

Culture & Society


Introduction context1

Introduction:Context

  • Development strongly influenced by culture

    • Temporal

    • Social

  • Privacy

  • Children not protected until Victorian era

  • “Innocence”

  • Latency

Jackson, 1993


Freud latency

Freud & Latency

  • Early development: oral, anal, genital

  • Latency: ~5-12 yrs of age

  • Sexuality dormant?

  • No, sexuality hidden from adults

  • Cross cultural studies and historical documents

    • “adult” sexual behavior even in 6-8 year olds


Challenges in studying child sexual development

Challenges in studying child sexual development

  • New field

  • No money

  • Highly sensitive topic - parents unlikely to consent

  • Children learn to hide behaviors

  • Since children are “innocent” and “asexual,” most existing work is pathology-oriented


Sexual development

Sexual development

  • Children are born with the capacity for sexual arousal and function

  • Sexual behavior is learned

  • Sexual behaviors are likely to be repeated because they are very reinforcing

    • Intimacy

    • Arousal

    • Orgasm

    • Tension reduction

Ryan, 2000a


What is normal or abnormal

What is normal or abnormal?

  • Highly associated with culture and individual developmental trajectory

  • Primarily observational data

  • Friedrich (Mayo Clinic) & the Child Sexual Behavior Inventory

  • Extensively validated on thousands of children:

    • General population, known-abused, psychiatric

    • US & Europe

    • Parents best reporters


Sexual behavior in infancy and early childhood

CSBI

  • 35-item behavior checklist

  • Ages 2-12

  • Total score differentiates normative and sexually abused children

  • Three revisions

  • Yes/No or Frequency

    • never

    • less than once a month

    • one to three times a month

    • at least once a week

Friedrich 1992 and 2001


Csbi items

Puts mouth on sex parts

Asks to engage in sexual acts

Masturbates with objects

Inserts objects into vagina or anus

Imitates intercourse

Sexual sounds

French kisses

Undresses other people

Asks to watch explicit TV

Imitates sexual behavior with dolls

Wants to be opposite sex

Talks about sexual act

Touches other’s sexual parts

Rubs body against people

Hugs strange adults

Shows sex parts to other children

Uses sexual words

CSBI items

Friedrich, 1992


Csbi items1

Uses sexual words

Overly aggressive or passive

Talks flirtatiously

Masturbates with hand

Looks at nude pictures

Shows sex parts to adults

Interested in opposite sex

Tries to look at people undressing

Touches breasts

Touches sex parts at home

CSBI items

Friedrich, 1992


Csbi items nonsignificant

CSBI itemsnonsignificant

  • Dresses like opposite sex

  • Pretends to be opposite sex

  • Kisses nonfamily children

  • Kisses nonfamily adults

  • Sits with crotch exposed

  • Undresses in front of others

  • Scratches crotch

  • Uses opposite sex toys

Friedrich, 1992


Total scores age 2 6

Normative boys

Mean 10.60

SD 7.64

Normative girls

Mean 11.72

SD 8.32

Abused boys

Mean 20.51

SD 18.18

Abused girls

Mean 18.07

SD 11.97

Total scores: Age 2-6

Friedrich, 1992


Total scores age 7 12

Normative boys

Mean 5.56

SD 5.95

Normative girls

Mean 5.35

SD 6.14

Abused boys

Mean 16.69

SD 15.37

Abused girls

Mean 11.19

SD 12.92

Total scores: Age 7-12

Friedrich, 1992


Sexual behavior in infancy and early childhood

CSBI

  • Psychiatric patients “somewhere in between”

  • “Sexual behavior not unique to sexually abused children”

Friedrich, 2001


Spurwink study

Spurwink Study

  • Forensic referrals subjected to CSBI

  • Strong evidence of abuse: Diagnostic medical findings, credible and reliable statements made by child

  • No significant relationship between a diagnosis of sexual abuse and presence or absence of sexual behavior problems

Drach, 2000


Categorically abusive behavior

Categorically abusive behavior

  • CSBI not designed to delineate which children need intervention

  • Ryan, 2000a proposes “categorically abusive behavior” which requires clinical intervention

  • Sexual behavior between two children with

    • Lack of consent

    • Lack of equality

    • Coercion


Lack of consent

Lack of Consent

  • Not knowing what is proposed

  • Dissimilar knowledge of standards of behavior

  • Dissimilar knowledge of potential consequences

  • No ability to freely choose without repercussions

Ryan, 2000a


Lack of equality

Lack of Equality

  • Obvious differences in age, size, intellect, responsibility

  • Being in charge, baby-sitting

  • Subtle differences in strength, popularity, self image

  • Role differences: leader, boss, fantasy roles in play

Ryan, 2000a


Coercion

Coercion

  • Manipulation, trickery, peer pressure, bribes

  • Threats of lost relationships, privileges, or esteem

  • Threats of force or harm, intimidation

  • Physical restraint, force, weapons, violence

Ryan, 2000a


Prenatal behaviors

Prenatal behaviors

  • Oral: Thumb sucking

  • Genital: Erection


Masturbation

Masturbation

  • Frequently done by caregivers to children historically and, still, in some cultures

  • Seen in infants as young as 2-4 months


Distinguishing behaviors

Distinguishing behaviors

  • Normal

  • Of concern

  • Problematic


Preschool normal

Preschool - Normal

  • Touches genitals for exploration and pleasure, to relieve tension

  • Explores gender differences

  • Touches genitals and breasts of familiar adults and children

  • Looks at nude persons

  • Asks about genitals, breasts, intercourse, babies

  • Erections

Johnson, 1993 and Galenson, 1993


Preschool normal1

Preschool - Normal

  • Likes to be nude, may show others genitals

  • Uses dirty words

  • Investigates anal area in themselves, others, toys, etc.

  • Interested in watching people doing bathroom functions

  • Interested in having a baby

  • Interested in feces

Johnson, 1993


Preschool normal2

Preschool - Normal

  • Plays doctor

  • Puts something in genitals or rectum of self or other child owing to curiosity or exploration

  • Plays house, acts out roles of mommy and daddy

Johnson, 1993


Preschool of concern

Preschool - Of concern

  • Continues to touch or rub genitals in public place after being told no many times

  • Continuous questions about genital differences after they have been answered

  • Touches genitals, breasts of adults not in family

  • Asks to be touched himself/herself

  • Stares at nude persons even after seeing many people nude

Johnson, 1993


Preschool of concern1

Preschool - Of concern

  • Keeps asking about genitals, intercourse, breasts, babies even after parent has answered questions at age appropriate level

  • Continuous erections

  • Wants to be nude in public even after parents say no

  • Interest in watching bathroom functions that does not wane in days to weeks

Johnson, 1993


Preschool of concern2

Preschool - Of concern

  • Boys’ interest in having a baby does not wane after several days or weeks of play about babies

  • Uses dirty words at home even after parent says no

  • Smears feces on walls or floor more than one time

  • Frequently plays doctor even after being told no

Johnson, 1993


Preschool of concern3

Preschool - Of concern

  • Puts something in genitals or rectum of self or other child after being told no

  • Humping other children with clothes on

Johnson, 1993


Preschool problematic

Preschool - Problematic

  • Touches or rubs self in a masturbatory fashion, in public or private, to the exclusion of normal childhood activities

  • Plays male or female roles in an angry, sad, or aggressive manner

  • Hates own or other sex

  • Sneakily touches adults

  • Makes others allow touching

  • Demands touching of self

Johnson, 1993


Preschool problematic1

Preschool - Problematic

  • Asks people to take off clothes

  • Attempts to disrobe others forcibly

  • Aasks strangers about breasts, genitals, intercourse, babies after parent has answered

  • “Precocious” sexual knowledge

  • Painful erections (Could be medical)

  • Refuses to put on clothes

Johnson, 1993


Preschool problematic2

Preschool - Problematic

  • Secret exposes self in public after many scoldings

  • Refuses to leave people alone in bathroom

  • Displays fear or anger about babies, birthing, or intercourse

  • Uses dirty words in public or at home after numerous scoldings

  • Repeatedly plays or smears feces after scolding

Johnson, 1993


Preschool problematic3

Preschool - Problematic

  • Forces child to play doctor or take off clothing

  • Any coercion or force in putting something in rectum or genitals of other child

  • Simulated or real sex without clothes on

Johnson, 1993


School aged children

School aged children

  • Have robust sexual imagination

  • Many questions

  • Emerging modesty

  • “School yard mythology”

  • Gender solidification

  • Gender separation

Rosenfeld, 1993


School aged normal

School aged - Normal

  • Interest in urination and defecation

  • Touches or rubs own genitals when going to sleep, when tense, excited, or afraid

  • Plays house, may simulate all roles of mommy and daddy

  • Thinks other-sex children are gross, have cooties, and chases them

  • Talks about sex with friends,

Johnson, 1993


School aged normal1

School aged - Normal

  • Talks about having a girlfriend or boyfriend

  • Wants privacy in bathroom or when changing clothes

  • Likes to hear and tell dirty jokes

  • Looks at nude pictures

  • Plays games with same-aged children related to sex and sexuality

  • Draws genitals on human figures

Johnson, 1993


School aged normal2

School aged - Normal

  • Explores differences between males and females

  • Takes advantage of an opportunity to look at nude child or adult

  • Pretends to be opposite sex

  • Wants to compare genitals with same-aged friends

  • Kissing familiar adults and children

Johnson, 1993


School aged normal3

School aged - Normal

  • Wants to touch genitals, breasts, buttocks, of other same-aged child or have child ouch him or her

  • Allowing kissing by familiar adults or children

  • Looks at genitals, buttocks, breasts of adults

  • Erections

  • Outs something in own genitals or rectum

  • Interest in breeding behaviors of animals

Johnson, 1993


School aged of concern

School aged - Of concern

  • Continues to touch or rub genitals in public after being told no

  • Masturbates on furniture or with objects

  • Humping other children with clothes on

  • Imitates sexual behavior with a doll or stuffed toy

  • Uses dirty language when other children really complain

Johnson, 1993


School aged of concern1

School aged - Of concern

  • Sex talk gets child in trouble

  • Romanticizes all relationships

  • Becomes very upset when seen changing clothes

  • Keeps getting caught telling dirty jokes

  • Makes sexual sounds

  • Continuous fascination with nude pictures

  • Wants to play sex-related games with much younger or older children

Johnson, 1993


School aged of concern2

School aged - Of concern

  • Draws genitalia on only certain figures

  • Genitals disproportionate to size of body in drawings

  • Remains confused about gender differences even after questions answered

  • Stares at or sneaks looks at nude persons after having seen many nude people -- beyond exploration

  • Wants to be opposite sex

Johnson, 1993


School aged of concern3

School aged - Of concern

  • Wants to compare genitals with much older or younger children or adults

  • Continuously wants to touch genitals, breasts or buttocks of other child or children

  • Tries to engage in oral, anal or vaginal sex

  • French kissing

  • Talks in sexualized manner with others

Johnson, 1993


School aged of concern4

School aged - Of concern

  • Fearful of hugs and kisses by adults

  • Fearful of public displays of affection

  • Touches or stares at breasts, buttocks, genitals of adults

  • Asks adults to touch them on genitals

  • Continuous erections

  • Touches genitals of animals

Johnson, 1993


School aged problematic

School aged - Problematic

  • Touches or rubs self in public or private to the exclusion of normal childhood activities

  • Humping other children naked

  • Intercourse with another child

  • Forcing sex on another child

  • Uses bad language against other child’s family

  • Targets other-sex children for violence

Johnson, 1993


School aged problematic1

School aged - Problematic

  • Talks about sex and sexual acts frequently

  • Repeatedly in trouble because of sexual behavior

  • Aggressive or tearful demand for privacy when in bathroom or changing clothes

  • Persists in telling dirty jokes even after negative social or disciplinary consequences

  • Wants to display nude pictures or masturbates with them

Johnson, 1993


School aged problematic2

School aged - Problematic

  • Forces others to play games related to sexuality

  • Group forcing of sexual play or behavior

  • Genitals stand out as most prominent feature in drawings

  • Drawings of intercourse or group sex

  • Plays male or female roles in sad, angry, or aggressive manner

Johnson, 1993


School aged problematic3

School aged - Problematic

  • Hates own or opposite gender

  • Hates being own gender

  • Hates genitals

  • Demands to see the genitals, buttocks, breasts of other children or adults

  • Manipulates or forces other children to allow touching of genitals, breasts, buttocks

  • Mutual or forced oral, anal, vaginal sex

Johnson, 1993


School aged problematic4

School aged - Problematic

  • Overly familiar with strangers

  • Talks or acts in a sexualized manner with unknown adults

  • Physical contact with adult causes extreme anxiety

  • Tries to manipulate adults into touching the child’s genitals, breasts, or buttocks

  • Sneakily or forcibly touches genitals, breast, buttocks of an adult or other child

Johnson, 1993


School aged problematic5

School aged - Problematic

  • Painful erections

  • Any coercion or force in putting something in genitals or rectum

  • Causing harm to others or own genitals or rectum

  • Sexual behaviors with animals

Johnson, 1993


So its abnormal what now

So its abnormal, what now?

  • Further Assessment

  • Intervention

  • Degree of behavior

    • Normal exploration

    • Sexually preoccupied

    • Consensual sexual behavior

    • Nonconsensual sexual behavior


Comprehensive assessment

Comprehensive assessment

  • Evaluation of number and types of sexual behavior

  • History of any sexual behavior problems

  • Is sexual behavior alone or with others

  • What is the motivation of the behavior

  • Other child or children’s description, response, and feelings regarding the behavior


Comprehensive assessment1

Comprehensive assessment

  • Child’s emotional, psychological, and social relationship with other person involved in behavior

  • Use of trickery, bribery or coercion

  • Affect of child regarding sexuality

  • Thorough developmental history

  • Sexual and physical abuse history

  • Custody history


Comprehensive assessment2

Comprehensive assessment

  • School reports, peer behavior, home behavior, day-care behavior

  • Family History focusing on emotional, physical, sexual abuse, substance use disorders, psychiatric disorders, divorce, incarceration, violence

  • Emotional and sexual climate of home

  • Psychiatric evaluation of child

  • Medical / forensic evaluation of the child


Secondary tertiary prevention

Secondary/Tertiary Prevention

  • If there is abuse, make the appropriate interventions

  • Be alert to possibility of the identified child as being aggressive towards other children


Basic interventions for behaviors

Basic Interventions for Behaviors

  • Behaviors, Interventions, Response, Prognosis: All proportional

  • Moderate amount of empirical data

  • Limited clinical resources

  • Goals (Ryan, 2000a)

    • Communication

    • Empathy

    • Accountability


Functional analysis of behavior

Functional Analysis of Behavior

  • What is the purpose of the behavior?

  • What are the positive reinforcers?

  • What are alternative reinforcers?


Psychoeducation

Psychoeducation

  • Parent and parent-child education


Group therapy

Group Therapy

  • Older, school-aged children

  • Normalization of abnormal experience and validation of emotional responses


Play therapy

Play Therapy

  • Catharsis of a traumatic event

  • Role playing

  • Socialization


Pharmacotherapy

Pharmacotherapy

  • Comorbid or contributing disorders?

  • SSRIs


Understanding and responding to the sexual behaviors of children

Understanding and responding to the sexual behaviors of children.

Ryan, Blum, Sandau-Christopher, Law et al, 1993. Denver, CO: Kempe National Center, University of Colorado Health Sciences Center

303-864-5252www.kempe.org


Why refer

Why Refer?

  • Problematic sexual behavior interfering in normal psychosocial development

  • Sexual behavior is suspected to be attributable to sexual abuse


Why refer1

Why Refer?

  • Problematic sexual behavior interfering in normal psychosocial development

    • Child development specialist, psychologist or therapist


Why refer2

Why Refer?

  • Sexual behavior is suspected to be attributable to sexual abuse

    • CYF?

    • Child Advocacy Center, CHP

    • Any local ER, pediatrician, or family practitioner


49 pa code 16 102

49 PA Code § 16.102

“Board regulated practitioners who, in the course of their employment, occupation or practice of their profession, come into contact with children shall report or cause a report to be made to the Department of Public Welfare when the Board regulated practitioners have reasonable cause to suspect on the basis of their professional or other training or experience, that a child coming before them in their professional or official capacity is a victim of child abuse.”


49 pa code 16 1021

49 PA Code § 16.102

Board regulated practitioners who are staff members of a medical or other public or private institution, school, facility or agency, and who, in the course of their employment, occupation or practice of their profession, come into contact with children shall immediately notify the person in charge … when they have reasonable cause to suspect … that a child coming before them in their professional or official capacity is a victim of child abuse … The person in charge or the designated agent shall assume the responsibility … to report


Websites for professionals

Websites for Professionals

  • The Kempe Center

    • www.kempe.org

  • AACAP

    • www.aacap.org

  • National Network for Child Care

    • www.nncc.org

  • SIECUS

    • www.siecus.org


Websites for families

Websites for Families

  • AACAP

    • www.aacap.org

  • American Academy of Pediatrics

    • www.aap.org


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