Differentiating children with and without a history of repeated problematic sexual behavior.

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Differentiating Children with and without a History of Repeated Problematic Sexual Behavior a

b

c

Tracey Curwen , Jennifer M. Jenkins & James R. Worling a

Nipissing University, North Bay, Ontario, Canada

b

University of Toronto, Toronto, Ontario, Canada

c

Thistletown Regional Centre, Toronto, Ontario, Canada Published online: 12 May 2014.

Click for updates To cite this article: Tracey Curwen, Jennifer M. Jenkins & James R. Worling (2014) Differentiating Children with and without a History of Repeated Problematic Sexual Behavior, Journal of Child Sexual Abuse, 23:4, 462-480, DOI: 10.1080/10538712.2014.906529 To link to this article: http://dx.doi.org/10.1080/10538712.2014.906529

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Journal of Child Sexual Abuse, 23:462–480, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.906529

Differentiating Children with and without a History of Repeated Problematic Sexual Behavior TRACEY CURWEN Downloaded by [The Aga Khan University] at 04:01 25 December 2014

Nipissing University, North Bay, Ontario, Canada

JENNIFER M. JENKINS University of Toronto, Toronto, Ontario, Canada

JAMES R. WORLING Thistletown Regional Centre, Toronto, Ontario, Canada

Many adolescents who sexually offend commenced problematic sexual behaviors as children. There is little evidence to indicate which children may be at risk to continue problematic sexual behaviors and which children will desist once identified. The goal of this study was to determine variables that differentiate children who repeated problematic sexual behaviors following adult reprimand from those who did not. Predictive accuracy of 33 risk variables was investigated using 62 children assessed for problematic sexual behaviors. Eight individual variables were related to group membership, and a total score based on the combination of these variables was predictive of group membership. The results indicate variables that may assist in identifying children requiring intervention versus those likely to discontinue problematic sexual behaviors once they are identified and reprimanded. KEYWORDS child sexual behavior problems, problematic sexual behavior, risk assessment, risk prediction, receiver-operating characteristic curves

Received 13 December 2012; revised 31 May 2013; accepted 7 June 2013. Address correspondence to Tracey Curwen, Department of Psychology, Nipissing University, 100 College Drive, North Bay, Ontario, Canada P1B 8G5. E-mail: tcurwen@ nipissingu.ca 462


Risk of Repeated Sexual Behavior Problems

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In recent years, considerable attention has been paid to the characteristics of children who engage in inappropriate sexual behaviors. Much of this literature is based on etiology with little attempt to discriminate children who do and do not repeatedly engage in sexual behaviors. Although incidence rates of repeated sexual behaviors by children are unknown, researchers have demonstrated that many adolescents commenced their sexual aggression as children (Burton, 2000; Lane, 1991; Wieckowski, Hartsoe, Mayer, & Shortz, 1998), indicating that some children will repeatedly engage in problematic sexual behaviors (PSB) over time. Knowledge of the variables that differentiate children who repeatedly engage in PSBs from those children whose sexual behaviors stop following an adult reprimand would inform intervention efforts.

DIFFERENTIATING CHILDREN WHO CONTINUE FROM THOSE WHO DESIST The ultimate goal of treatment for children identified for PSB is to prevent the continuation of the behavior. However, without knowledge of the variables that contribute to the continuation of PSBs, intervention decisions will be based on treatment providers’ clinical judgment. As there is no empirical evidence to indicate specific risk variables for continued PSB, much of what is considered important is likely influenced by risk variables reported in adolescent sexual offending populations and anecdotal evidence in child populations. With the recent increase in publications on risk factors for adolescent sexual offending populations, it is important to note that the application of this knowledge to a younger population with sexual behavior problems could be detrimental to both identification and treatment efforts. Many have discussed the need to ensure that adult risk assessment protocols and variables are not used to assess risk of recidivism for adolescents (Rasmussen & Miccio-Fonseca, 2007; Rich, 2009; Worling, & Langstrom, 2006), and these same concerns are noted regarding using adolescent protocols to assess risk issues for children with PSB (Curwen & Costin, 2007; Rich, 2009). For example, a history of sexual abuse has not been linked to adolescent sexual offense recidivism (Kahn & Chambers, 1991; Langstrom & Grann, 2000; Rasmussen, 1999; Worling & Curwen, 2000) but is speculated to be a risk factor for children who continue PSB after identification (Curwen & Costin, 2010; Ray & English, 1995; Rich, 2002). Similarly, empirical evidence indicates that a nonsexual offending history is not related to adolescent sexual recidivism (Kahn & Chambers, 1991; Langstrom & Grann, 2000; Rasmussen, 1999; Sipe, Jensen, & Everett, 1998; Worling & Curwen, 2000) but is believed important for children who repeatedly engage in PSB (Gilgun, 2001; Johnson, 1993; Rich, 2002). Therefore, relying on adolescent protocols and risk variables to assess a child’s risk is


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both counterproductive and unreliable; speculation and anecdotal evidence may result in unwarranted treatment or the decision that treatment is not necessary. To determine characteristics that best differentiate children who continue their sexual behaviors from those who desist, a prospective study of children assessed for PSB and then followed over time would provide insight. However, this design is both costly and time consuming, and it cannot be overlooked that so little research has been conducted on risk within this population. Therefore, it is important to ascertain variables with potential predictive utility that may be useful in future longitudinal investigations. Recently, a method to compare individuals who have and have not repeated PSBs has revealed important information. For example, by comparing those who were sanctioned (e.g., caught and reprimanded and reoffended—recidivists) with those who did not have a history of being sanctioned and reoffending, information has been gathered regarding variables that discriminate adult (Thornton, 2002) and adolescent (Kenny, Keogh, & Seidler, 2001; Worling, 2004) sexual recidivists from nonrecidivists. Importantly, this method of comparing recidivists and nonrecidivists is not an investigation of those who committed their first offense and those with multiple offenses; instead, it is a comparison of those with and without a history of reprimands for PSBs (Worling, 2004). A similar design could be used with a sample of children identified for PSB. In such a design, all children would be identified and reprimanded by an adult for their sexual behaviors and all brought to the attention of professionals. However, the children are expected to differ based on whether they were known to have previously been reprimanded for an earlier PSB and they reengaged in the behavior or there was no known history of prior reprimands (indicating that PSB desisted following the initial reprimand). By comparing children with and without a history of repeating PSB following a reprimand, it is possible to determine whether the groups differ on the presence of specific variables. Evidence of differences between the two groups of children could indicate variables that may contribute to repeated PSB. Knowledge of the risk factors for repeating PSB may assist in identifying (a) children who require additional intervention to reduce their risk to continue PSB and (b) children likely desist once identified.

Current Study The goal of the current study was to determine whether specific variables suggested to increase risk could differentiate children with and without a history of repeated sexual behaviors following an adult-imposed sanction. Following an extensive review of empirical and nonempirical evidence (Curwen, 2006; Curwen & Costin, 2007), 33 variables were identified as either empirically or clinically important to why some children repeat PSBs after being reprimanded. The goal of the current study was to investigate whether


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variables identified as potentially important do indeed differentiate children with and without a history of repeated sexual behaviors.

METHOD


Participants Participants in this study were 62 children who received an assessment specific to their PSBs. Data on 65 children were provided by clinicians who conduct assessments of children identified for PSB. Information was incomplete and therefore removed for one child. Two children were aged 14 years by the time they were assessed (even though their sexual behaviors had occurred under age 12) and, given the two-year age gap between the older children in the sample and these adolescents, they were not retained in the final analyses. A total of 13 individuals from seven agencies and two private practices in Canada, the United States, and Australia provided assessment information. Clinicians reported between 1.5 and 20 years (M = 8.87, SD = 5.8) of experience providing sexual behavior specific assessments, having assessed between 2 and 300 (M = 49.92, SD = 80.1) children, and having provided treatment to between 5 and 50 (M = 26.76, SD = 18.34) children with sexual behavior problems. Twelve of the 13 clinicians were female.

Inclusion and Exclusion Criteria Clinicians were informed that the child for whom they were completing the data collection forms must have been referred specifically for PSB and must meet the following criteria, as determined by the assessor: (a) the child is above borderline intellectual functioning and (b) the sexual behaviors must have been developmentally inappropriate and have warranted a sexual behavior assessment. Developmentally inappropriate criteria included: at least one victim who was three or more years younger, developmentally younger/developmentally delayed, physically smaller, or the child was in a position of responsibility (older sibling, babysitting). In addition, the child may have dominated, threatened, coerced, or used force against a victim. The child must also have been under 12 at the time of the PSB.

Measures DEMOGRAPHIC

INFORMATION

Demographic information was collected to describe the children in the study and included gender, age (in months) at the time of assessment, ethnic background, current residence, whether the family was involved in the assessment, primary caregivers for most of child’s life, special education,

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learning disability, type of reprimand for most recent sexual behavior, who reprimanded past sexual behaviors, pubertal status, and age (in months) of first and last inappropriate sexual behavior.


RISK

VARIABLES

Based on a review of the literature and feedback from specialists in the field who reviewed the identified risk variables, 33 risk variables were identified and classified into six categories: Sexual Behavior Characteristics (n = 12), Victimization (n = 7), Personal Characteristics (n = 3), Interpersonal Characteristics (n = 4), Family Characteristics (n = 5), and Intervention (n = 2). The selection of risk variables and coding information are discussed in detail (see Curwen, 2006; Curwen & Costin, 2007) and are available with the coding scheme (see Curwen, 2011). A three option coding scheme was used to indicate whether the variable was or was not present for each child. Each variable was coded with one of the following: Yes, indicating that the variable was definitely present; partially/possibly present (PP) to indicate that the variable is present to some extent (not meeting yes criteria) or may be present (no conclusive evidence); or no, indicating the variable is definitely not present (based on all available information). A similar coding scheme has been utilized in risk assessment protocols with sexually offending adolescents (Worling & Curwen, 2001) and to assess a child’s risk for involvement in general antisocial behaviors (Augimeri, Koegl, Webster, & Levene, 2001; Gilgun, 2001; Levene et al., 2001). All coding options were defined, and examples that would qualify for the presence or partial/possible presence of a variable were also provided. Table 1 provides an overview of the yes coding for a sample of the static and dynamic risk variables. TOTAL

RISK SCORE

To derive the Total Risk, each coding was assigned a score (i.e., no = 0, partially/possibly = 1, yes = 2), and the Total Risk Score was simply a sum of each assigned score. SEXUAL

BEHAVIOR WITH ANIMALS

Sexual contact with an animal was not originally identified through the literature; however, this behavior was subsequently hypothesized as possibly important by one of the specialist reviewers (E. Gil, personal communication, 2006) who reviewed the risk variables. Therefore, sexual contact with an animal was investigated as a behavior that could be unique to children with repeated sexual behavior problems. Dichotomous coding (yes = 1, no = 0) was used to indicate whether the child had ever engaged in sexual behavior toward an animal. Evidence must have been conclusive for the


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TABLE 1 Sample of Risk Variables and Yes Coding Criteria Sample risk variables Static Variables Use of Force/Threat/Violence


Witnessed Violence

Dynamic Variables Denial Family Instability

Impulsivity

Description of yes category During any sexual behavior or in an attempt to keep any of the sexual behaviors a secret, child has ever used: excessive force or violence, threatened to use force or violence, used intimidation against the victim, physical strength to gain compliance. Has witnessed, been exposed to, or been privy to violence as noted by but not limited to: family violence (seen or heard), witnessed violence between real people outside of the family, friends/peers have been harmed by violence. Currently denies: any involvement in sexual behaviors and/or any problem with sexual behaviors. Over the past 6 months, 2 or more indicators of family instability were present. Instability can include, but is not limited to: history of protective services, multiple parental figures, unexplained absent parent, family disruptions (e.g., divorce, out of home placements), strangers in and out of home, economic stressors, frequent residential moves, no sense of predictability/orderliness. Over the past 6 months, child has been impulsive/demonstrated poor self-control. Impulsivity and poor self-control can include, but are not limited to: acting before thinking, unable to wait turn, interrupting others.

child to be coded as yes on this variable; therefore, any speculation without confirmation was coded as no. PUBERTAL

STATUS

Pubertal status was not identified through the literature review as increasing a child’s risk of repeating his or her PSB; however, one specialist reviewer (C. Kamps, personal communication, 2006) noted its importance, resulting in pubertal status being included in this study. Therefore, assessors were asked to indicate whether, to their knowledge, the child had reached puberty. Clinicians investigated pubertal status for older children (9–12 years) through discussions with the child and parents. Groups were compared on the purported presence or absence of this variable.

REPEATER AND NONREPEATER GROUP MEMBERSHIP Two groups were formed based on whether the child had ever been reprimanded by an adult and then repeated PSB. All children were identified by an adult at least once for their sexual behaviors, which resulted in their


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current assessment. Participants were asked to indicate whether any other reprimands for sexual behavior had been given prior to the most recent one. Reprimands must have been given by an adult, must have been specific to the sexual behavior, and must have been done in such a way as to indicate to the child that his or her sexual behavior was unacceptable. Clinicians used interview information and prior documentation to determine whether there were any prior reprimands. If the child was reprimanded for inappropriate sexual behaviors on one occasion only (the reprimand that resulted in the current referral for an assessment) and the child was not known to have repeated the sexual behaviors following this reprimand, the child was categorized as a “nonrepeater.” If the child was reprimanded for inappropriate sexual behaviors on more than one occasion (had been reprimanded and repeated PSB), the child was placed in the “repeater” group. Children in the repeater group were known to have continued their PSB following between 1 and 5 (M = 2.43, SD = 1.17) prior reprimands. In fact, 43% of children in this group had been reprimanded between 3 and 5 times and, regardless of the reprimands, continued to engage in PSB. Prior reprimands included: parental warning (87.1%), school warning (32.3%), child protection warning (25.8%), agency referral (25.8%), school suspension (12.9%), and police warning (3.2%). Other (32.3%) prior reprimands included removal from residence, residential/treatment staff warning, and foster parent warning.

Procedure RISK

VARIABLE CODING

Once an assessment was finished, the clinician completed the demographic information and coded the risk variables. Participants were instructed to complete the data collection forms only after the completion of a comprehensive assessment. Responses were based on information collected from all sources of information (child, parent, other family member, school personnel, prior clinical reports) provided during the assessment. No formal training to code the risk variables was provided as the categories and coding criteria were self-explanatory. PILOT

TESTING RISK VARIABLES

Prior to investigating the variables with the current sample, interrater agreement was examined to ensure reliability in assessing the presence of the variables. Dual ratings were provided for 12 children during pilot testing. Overall, seven assessors provided dual coding for the recently assessed children. The intraclass correlation coefficient (ICC) was used to investigate interrater agreement. Variables that attained an ICC of .61 or higher were retained for investigation; the minimum acceptable ICC of .61 was selected

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TABLE 2 Risk Variables, Intraclass Correlation Coefficient (ICC) for All Variables, Missing Data


Assessment variables 1.0 Sexual Behaviors Characteristics Force/Threat/Violence Coercion/Manipulation Pattern of Sexual Behaviors Multiple Types of Sexual Behaviors Penetration Sexual Thoughts/Fantasies Distorted Sexual Beliefs Lack Understanding Sophisticated Sexual beliefs Denial Victim Selection Opportunities for Sexual Behaviors 2.0 Victimization Victim of Sexual Abuse Trauma From Own Sexual Victimization Arousal During Sexual Victimization Arousal to Memories of Sexual Victimization Multiple Offenders Impact of Nonsexual Abuse Witness Violence 3.0 Interpersonal Characteristics Impulsivity History of Nonsexual Aggression Aggressive Thoughts/Fantasies Power-Based Beliefs 4.0 Personal Characteristics Social Skill Deficits Affective Coping Skill Deficit Poor Self-Esteem 5.0 Family Environment Family in Denial Poor Family Sexual Boundaries Negative Home Environment Family Instability Guardian Rejection 6.0 Intervention No Response to Treatment/Intervention No Guardian Treatment Involvement

ICC (n = 12)

Included in final analyses

1.0 .96 .94 .94 .94 .78 .78 .83 .94 .65 .91 .53

∗

1.0 .92 1.0 1.0 .97 .85 .91

∗

.86 .81 .43 .32

∗

1.0 −.29 .96

∗

0

∗

0

∗

0 0 0 0

.59 .79 .86 .71 .74 .78 .52

∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗

∗ ∗ ∗ ∗ ∗

∗

∗ ∗ ∗ ∗

n missing 0 3.2 0 0 0 8.1 0 0 0 0 0 0 3.1 6.3 12.5 6.3 3.2 3.2 0 0

0

as this reflects moderate consistency (Shrout, 1998). As can be seen in Table 2, 27 variables achieved acceptable ICCs and were retained for further analysis.

Analytic Plan To ensure that the groups were similar on a number of demographic variables, the groups (repeater and nonrepeater) were compared using χ 2 for

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categorical variables and t-tests for continuous variables. Cramer’s V was used to investigate the relationship between group membership (repeater and nonrepeater) and the presence of each variable (yes, PP, no). Where a significant association was found, the area under the Receiver Operating Characteristic Curve (AUC) was used to investigate predictive accuracy of group membership based on the presence or absence of each variable. Analyse-it Statistical Software (http://www.analyse-it.com/) was used to compute and compare all AUCs. To determine whether individual variables or a combination of variables (Total Score) most accurately identified group membership, each individual variable with a significant AUC was compared to the AUC for the Total Score.

RESULTS Clinical ratings were provided for nine girls and 53 boys. At the time of the assessment, the children ranged in age from 5 to 12 years (M = 10, SD = 1.6), with similar ages for males (M = 10.11, SD = 1.57) and females (M = 10.59, SD = 1.60), t = –.91 (2, 60), p > .05. There were three male children who had turned 12 during their assessment; however, none was known to have engaged in any inappropriate sexual behavior since turning 12, and they were retained. Based on the clinicians’ knowledge, most children had not reached puberty at the time of assessment (n = 48, 77.4%), and this information was not known for 3 (4.8%) children. There was no significant gender association for pubertal status (77.4% males and 77.8% females not reaching puberty), χ 2 = (2, 62) = .63, p > .05. Males and females were combined to investigate clinical coding trends. For clarity, all variable names are presented in italics. MISSING

DATA

The percentage of children coded in each of the three coding options as well as the percentage of children with missing information is presented for all 27 variables in Table 2. In order to retain as many variables as possible, those variables with no more than five missing data points were retained resulting in the removal of one additional variable.

Differentiating Repeater from Nonrepeater Children DEMOGRAPHIC

DATA

The groups were compared on those demographics that were not tapped through any of the 26 risk variables. As the purpose of the study was

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to identify whether specific risk variables discriminated the two groups, any information that could be used to code a variable was not explored separately. Demographics that were investigated included residential location, family involvement in assessment, primary family members, educational issues, reasons for most recent reprimand, who reprimanded the child for the most recent sexual behavior, and age of first and last known inappropriate sexual behavior (in months; see Table 3). The only significant difference between the groups was the age of first inappropriate sexual behavior. Children in the repeater group started their sexual behaviors at a younger age (72.4 versus 101.25 months), t (2, 53) = 3.59, p < .001, and had engaged in sexual behaviors over a longer period of time (M = 45.0 months, SD = 26.13) compared to those in the nonrepeater group (M = 23.89 months, SD = 23.80), t (2, 53) = 3.13, p < .01.

TABLE 3 Nominal Demographic Data for the Repeated and Nonrepeated Groups Demographic

N

Repeated % (n)

Nonrepeated % (n)

Caucasian Current residence Parental home Group home Foster home Relatives Othera Family involved in assessmentb Primarily reared by: Biological parents only At least 1 biological parentc Education Special education (yes) Learning disabilities (yes) Average (90–109) intellectual functioningd Most recent reprimand was for contact sexual behavior Reprimand for most recent behaviorse School suspension Referral to agency Police warning Conviction Parental warning School warning Child protection warning Other adult warningf

58 59

71.4 (20)

63.3 (19)

37.9 31.0 24.1 3.4 3.4 70.8

50.0 20.0 10.0 6.7 13.3 88.5

a

50 58

(11) (9) (7) (1) (1) (17)

(15) (6) (3) (2) (4) (23)

40.7 (11) 41.9 (13)

51.6 (16) 44.4 (12)

57 56 55

42.8 (12) 25.0 (7) 58.6 (17)

44.8 (13) 21.4 (6) 65.3 (17)

49

96.1 (25)

91.3 (21)

13.7 (4) 48.3 (14) 10.3 (3) 0 62.1 (18) 17.2 (5) 62.1 (18) 37.9 (11)

6.4 35.5 12.9 3.2 48.3 3.2 74.1 32.2

60 (2) (11) (4) (1) (15) (1) (23) (10)

residential treatment, friends. b both biological parents attended the assessment for 14 children. c includes involvement from step, foster parents, grandparents, single parent. d this information was documented for 43.6% and suspected for others: 2 children (3.2%; one in the repeated and one in nonrepeated group) had reported intelligence in the superior range. e a total of 17 (27.4%) children received 1 reprimand, 20 (32.3%) received 2 reprimands, and 22 (35.5%) had 3 or more reprimands that precipitated the current assessment. f includes treatment center staff, residential staff, foster home, and doctor (16.1%).

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INITIAL

T. Curwen et al. GROUP COMPARISON ON VARIABLES


The relationship between group membership and presence of a risk variable revealed significant associations for eight variables (see Table 4: Force/Threat, Pattern of Sexual Behaviors, Multiple Types of Sexual Behaviors, Sexual Thoughts/Fantasies, Victim of Sexual Abuse, Impact of Nonsexual Abuse, History of Nonsexual Aggression, Poor Family Sexual Boundaries). Two variables had marginal relationships with group membership (Impulsivity, p = .052 and Social Skill Deficits, p = .08); however, given the sample size and the number of analyses conducted, only those eight variables that resulted in statistically significant group associations (p < .05) were retained. ACCURACY

OF VARIABLES IN IDENTIFYING GROUP MEMBERSHIP

To investigate the accuracy of the eight variables in identifying group membership, the AUC was investigated. As noted, there was missing data for five children (8%) on the Sexual Thoughts and Fantasies variable and two children (3%) on the Impact of Nonsexual Victimization variable. A code of no (not present) was substituted for these missing variables. To ensure that substituting the no code did not influence the results, the AUCs for the two variables with missing data were investigated twice, once using the full sample with the no code substituted and again on a reduced sample with the missing data cases removed. The AUC was significant for both samples (with and without missing data); therefore, the substitution of a no code was utilized to maintain the larger sample for final investigation. As can be seen in Table 5, all AUCs ranged between .60 and .75, with a Pattern of Sexual Behaviors having the highest predictive accuracy (AUC = .75). The next step was to determine whether a combination of the eight variables had better predictive accuracy than any one variable. A Total Risk Score (see “Analytic Plan” section) was computed and examined. Item-total correlations indicated that all variables contributed significantly to the Total Risk Score (p < .01) and all were above r = .61, except Force, Threat, or Violence, Victim of Sexual Abuse, and Poor Family Sexual Boundaries (see Table 5). Internal consistency for the eight variables combined was α = .70 (n = 55). The Total Score AUC was .86 (95% CI = .77–.95, p < .0001), suggesting moderate accuracy in predicting group membership. In other words, 86% of the time, a randomly selected child from the repeater group would have a higher eight-item Total Score than a randomly selected child from the nonrepeater group. The differential predictive accuracy between the Total Score and the eight individual assessment variables was investigated by comparing the AUCs (see Table 5). The Total Risk Score had significantly better predictive accuracy than all individual variables (all z s = .17 to .26, all ps
.05). Removal of the Pattern of Sexual Behaviors variable does not alter the AUC for the seven-variable Total Risk Score. As noted, sexual behavior toward an animal was not included in the original risk variables but was investigated separately. Sexual contact with an animal was a behavior that contributed to the referral for assessment for five (8.1%) children; however, it is important to note that none of these children had only ever engaged in sexual behaviors with an animal, but this was one of the various sexual acts that contributed to identifying them as having PSB. All five children who had sexual contact with an animal were in the repeater group.

DISCUSSION The goal of the study was to determine whether specific risk variables could differentiate children who had repeated PSB following an adult reprimand from those who did not have this history. The results indicated that eight individual variables were present to a greater extent for children who repeated their PSBs following adult reprimand compared to those without this history. In addition, a combination of the eight variables was shown to be superior to most individual risk variables in accurately identifying children known to have repeated their PSBs following adult reprimand. The eight risk variables identified for predictive accuracy included: the use of force, threat, or violence during sexual behaviors; having demonstrated a pattern of sexual behaviors; having engaged in multiple types of sexual behaviors; currently having age inappropriate sexual thoughts or fantasies; being a victim of sexual abuse; currently experiencing negative impact



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from a nonsexual victimization experience; having a history of nonsexual aggression; and having ever resided in a family with poor sexual boundaries. These may be important issues for assessors to focus on when attempting to determine whether a reprimand may be enough to deter a child from continuing PSB. Of note, two factors (having demonstrated a pattern of sexual behaviors and having engaged in multiple types of sexual behaviors) could be considered synonymous with the repeated sexual behavior group as, by definition, both involve multiple incidences of PSB. However, multiple issues in various incidents could have occurred prior to ever being caught and reprimanded; therefore, a nonrepeater may have engaged in various acts against multiple victims over a number of years without identification but once identified and reprimanded their behavior stopped. It is important to keep in mind that this study was not an investigation comparing children who engaged in PSBs for the first time to those with a history of PSB. Both groups had, on average, more than two years of involvement in PSBs. The difference between the groups was whether PSB was repeated following an adult reprimand; therefore, these seemingly confounding variables suggest that more diversity in sexual behaviors and/or establishing a pattern of sexual behavior may be linked to children who, once identified, have difficulty ceasing PSB. In fact, the group of children who repeated the behaviors had, in most cases, been reprimanded on multiple occasions, and, regardless of these warnings, their PSBs did not stop. Variable coding and missing data indicate the need for more consistency in assessments of children with PSB. Most of the missing data were on dynamic variables. In order to establish whether a dynamic variable is present, the assessor must have obtained the necessary information to make a determination. Similarly, indicating that a variable was partially or possibly present suggests some uncertainty as to its presence (Worling, 2004). In situations where an assessment did not produce adequate or accurate information, determining the presence of all variables would be difficult. In some cases, the study was introduced to clinicians only after they had completed their assessment, and it is possible that some of the variables being investigated were not actually assessed. For example, no child with a known sexual abuse history was reported to currently experience physical pleasure from memories of his or her abuse, and, in fact, this information was often missing. Certainly there may have been children who were experiencing these feelings, but the assessor did not gather the information necessary to make this determination. Continued investigation of all the issues identified for this study should be undertaken with clinicians who are already familiar with the variables. The results demonstrated eight risk variables that differentiated children who repeated their PSBs following at least one adult reprimand from those without this history. Given that this was the first study of its kind, it would be premature to disregard any of the 33 variables initially proposed. Utilizing all


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the variables to guide assessments would help to establish some consistency in the information collected across various assessors. Until further empirical evidence of risk variables is provided, no single variable should be considered more or less important. Furthermore, investigation into the function of a child’s current thoughts and feelings on repeated sexual behaviors must be undertaken; without evidence as to the role of the child’s subjective experiences, the contribution of current thoughts and feelings to repeat PSBs remains purely speculative. This study was an exploration of those variables specifically outlined in the literature as being important to understanding children who repeated PSB regardless of adult intervention. However, this investigation revealed a number of other variables not outlined in the literature, but potentially important. One such behavior was a reported history of sexual contact with an animal. In this study, those children who engaged in sexual behavior with an animal were all in the repeater group. Sexual contact with an animal is uncommon in community samples of children (Friedrich, Grambsch, Broughton, Kuiper, & Beilke, 1991) and is, therefore, viewed with concern. In prior samples of children with sexual behavior problems, sexual contact with an animal appears to be more prevalent in male children (Gardner, 1997); however, both males (n = 3) and females (n = 2) in this study engaged in the behavior. As this was the first study to consider the sexual touching of an animal as a behavior linked to a child at risk to continue PSB, further investigation is necessary to elucidate the relationship between this atypical behavior and repeated PSB. Other issues important to note include the age of first sexual behavior and gender of the child with PSB. Both groups were involved in PSB over multiple years; however, children in the repeater group started engaging in PSB at a younger age and over a longer time frame than the children in the nonrepeater group. The longer duration could suggest entrenched behaviors that may be more difficult to change or other early difficulties (e.g., Poor Family Sexual Boundaries) that may have contributed to and then maintained PSB. Regardless of possible explanations, this study identified the age of initial PSB, the duration of the sexual behaviors, and influences on early sexual behaviors as issues important to repeated PSBs, and future investigations of risk should include these variables. The small number of females precluded gender-specific exploration, even though similar numbers of males and females are reported in PSB samples (Friedrich, Davies, Feher, & Wright, 2003). It appears, therefore, that females were underrepresented in this study, which highlights the need for further consideration of gender specific discriminative variables. This study was an important first step toward understanding the characteristics of children who repeatedly engage in PSBs despite being reprimanded for these by an adult. However, there are a number of limitations that must be considered when interpreting the results. One major limitation



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is the method used to group children into the repeater and nonrepeater groups. Knowledge of involvement (victim report) is required to accurately classify individuals involved in PSB. It is well known that many victims do not disclose sexual abuse and that many sexual offences are never detected; these same detection problems will exist for children with PSB. Another design limitation of this study is inherent in test development. The risk variables were both identified and then validated on the same sample; therefore, shrinkage in predictive accuracy is likely when replicated on another sample. As such, the risk variables outlined should be considered a starting point for future research, and using these results to assign a risk level to a specific child would be unjustified until further research is conducted. Other limitations include the small sample size, especially given the number of analyses conducted; however, given the exploratory nature of the study it provides information that further research may validate. Finally, it was the participants’ responsibility to ensure that the child being assessed was of at least borderline intelligence and that the sexual behavior met criteria for being inappropriate. Certainly, in cases where there was an absence of documentation regarding the child’s intelligence level, clinicians would have been required to speculate about the child’s level of functioning. It is recognized that certain inclusion criteria were left to the judgment of the clinicians, but given that most clinicians had been working with this population for many years, it is likely that they were appropriately identified as meeting study criteria. This study is the first known empirical investigation into variables outlined in the literature as potentially important to a child’s risk of ongoing PSBs. Until further investigations of these or other potential risk related variables are conducted, it is necessary to stress the need for caution in interpreting these results. Without more empirical evidence on these variables, clinicians must balance the limitations of current knowledge of risk variables with Ryan’s (2000) caution of the “lure of a quick answer” (p. 54). Specific behaviors or thoughts and feelings should not be viewed in isolation when assessing a child’s potential for continued PSBs. The goal of conducting any risk assessment should be the accurate identification of those children who may benefit from additional intervention; the purpose should not be to make simple risk statements or the segregation of children with sexual behavior problems.

ACKNOWLEDGMENTS Aspects of this manuscript were based on Tracey Curwen’s doctoral dissertation, University of Toronto. We thank Dana Costin for editorial comments; William Friedrich, Eliana Gil, and Toni Cavenaugh-Johnson for reviewing the factors; and Phil Rich for his contributions. Thank you to D. Bozzato, T.

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Elliot, S. Enright, N. Falls, S. Frankle, K. Hasentus, K. Holz, C. Kamps, K. Madden, P. Ohm, L. Reese, B. Rodgers, and S. Strickland for participating.


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AUTHOR NOTES


Tracey Curwen, PhD, is an Associate Professor of Psychology at Nipissing University, in North Bay, Ontario, Canada. She has worked in the sexual abuse field since 1995 and, during this time, has completed conference and workshop presentations, book chapters, and articles regarding sexual offending during adolescence and children engaging in concerning sexual behaviour. Her primary interests involve risk assessment and prediction of continued concerning sexual behaviour during childhood. She has developed a risk assessment protocol for children identified for concerning sexual behaviour, which is based on the results of this study and other research. Jennifer M. Jenkins, PhD, is the Atkinson Chair of Early Child Development and Education and Director of the Atkinson Centre at the University of Toronto. She is a clinical and developmental psychologist and has worked with children and families in hospital and academic settings since 1980. Her research has examined the influence of marital, parental and sibling relationships on social understanding, early learning and mental health. She studies why some children are more resilient than others when growing up in highrisk environments and is particularly interested in within family differences in development. She is the director of Kids, Families, Places, a birth-cohort, longitudinal study of 500 families that have been followed up for seven years. She is the author of two books, including Understanding Emotions which is in its third edition. She collaborates with the Centre for Multilevel Modeling in the UK on the development of new statistical methods in the analysis of family data. James R. Worling, PhD, is a clinical and forensic psychologist who has worked extensively with adolescents who sexually offend, and their families, since 1988. During this time, he has presented many workshops internationally, and he has written a number of articles and book chapters regarding the etiology, assessment, and treatment of adolescent sexual aggression. In addition to his full-time consulting and clinical practice, he is presently an associate faculty member at the University of Toronto, and he serves as an Associate Editor for Sexual Abuse: A Journal of Research & Treatment.

Affect and Sexual Responsivity in Men With and Without a History of Sexual Aggression.

A comparison of self-reported emotional and trauma-related concerns among sexually abused children with and without sexual behavior problems.

Neural Substrates of Sexual Desire in Individuals with Problematic Hypersexual Behavior.

Access to and use of sexual health care services among young Canadians with and without a history of sexual coercion.

Mediators of sexual functioning and marital quality in chronically depressed adults with and without a history of childhood sexual abuse.

Dissociation during sex and sexual arousal in women with and without a history of childhood sexual abuse.

Executive functioning and suicidal behavior among veterans with and without a history of traumatic brain injury.

Language ability of children with and without a history of stuttering: a longitudinal cohort study.

Problematic sexual behavior in young adults: Associations across clinical, behavioral, and neurocognitive variables.

Vesicoureteral reflux in children with and without a history of urinary tract infection: a comparative analysis.

Catecholamines and the initiation of sexual behavior in male rats without sexual experience.

Dorsal Anterior Cingulate Cortex Responses to Repeated Social Evaluative Feedback in Young Women with and without a History of Depression.

Craniofacial shape in children with and without a positive otitis media history.

A population-based survey of the characteristics of high school students with and without a history of suicidal behavior.

Fresh onion juice enhanced copulatory behavior in male rats with and without paroxetine-induced sexual dysfunction.

Role of Body Esteem in the Sexual Excitation and Inhibition Responses of Women With and Without a History of Childhood Sexual Abuse.

Bulimia nervosa with and without a history of overweight.

Bulimia nervosa with and without a history of anorexia nervosa.

Repeated threat (without harm) in a living environment potentiates defensive behavior.

The woman without a history.

The Relationship of Sexual Abuse with Self-Esteem, Depression, and Problematic Internet Use in Korean Adolescents.

Comparison of Sexual Experience and Behavior between Bipolar Outpatients and Outpatients without Mood Disorders.

Oxytocin and sexual behavior.

Sleep disturbances and behavior problems in children with and without arthritis.