What happened to Eric? The derailment of sexual development.

This article was downloaded by: [Aston University] On: 04 October 2014, At: 16:14 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20

What Happened to Eric? The Derailment of Sexual Development Nirit Waisbrod

a b c

& Barbara Reicher

d

a

Zefat Academic College , Zefat , Israel

b

The University of Haifa , Haifa , Israel

c

Rimonim Center for Child Sexual Abuse , Hadera & Netanya , Israel

d

Private Practice , Kfar Saba , Israel Published online: 06 Jan 2014.

To cite this article: Nirit Waisbrod & Barbara Reicher (2014) What Happened to Eric? The Derailment of Sexual Development, Journal of Child Sexual Abuse, 23:1, 94-113, DOI: 10.1080/10538712.2014.864745 To link to this article: http://dx.doi.org/10.1080/10538712.2014.864745

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Journal of Child Sexual Abuse, 23:94–113, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.864745

What Happened to Eric? The Derailment of Sexual Development NIRIT WAISBROD Zefat Academic College, Zefat, Israel; the University of Haifa, Haifa, Israel; and Rimonim Center for Child Sexual Abuse, Hadera & Netanya, Israel

Downloaded by [Aston University] at 16:14 04 October 2014

BARBARA REICHER Private Practice, Kfar Saba, Israel

A variety of theoretical approaches, from the individual to ecological levels, was applied to the following clinical case in order to understand why a five-year-old boy demonstrated sexual behavior. Inappropriate sexual behavior in children is presented as symptomatic of problems in intrapersonal and interpersonal boundaries, relationship capabilities, and superego consolidation. The case material emphasizes that only when the child is helped to stop his sexual acting out can he access the sources of his emotional distress. The theoretical underpinnings that are relevant to this case will be shown as instrumental in the therapy of this child and his family. By integrating theory with practice, we hope to highlight this sensitive and prevalent issue as well as aid in the early identification and treatment of sexually problematic behavior. KEYWORDS CSBP, child sexual behavior problems, sexual development, treatment, child therapy, family therapy

In the past decade, the phenomenon of children under 12 with sexual behavior problems (SBP) has grown tremendously. Even among children of kindergarten age, this behavior has become increasingly widespread (Israeli Council for Children’s Rights, 2008). In the Association for the Treatment of Sexual Abusers (ATSA) Task Force report (2006), children with sexual behavior problems (CSBP) are defined as children ages 12 and younger who initiate Received 11 February 2012; revised 30 October 2012; accepted 15 December 2012. Address correspondence to Nirit Waisbrod, PO Box 171, Ein Sarid 40697, Israel. E-mail: [email protected] 94


The Derailment of Sexual Development

95

behaviors involving sexual body parts (genitals, anus, buttocks, or breasts) in a manner that is developmentally inappropriate or potentially harmful to themselves or others. ATSA’s report distinguishes SBP in children from sexual offending in adulthood (Chaffin et al., 2008). Studies show that sexually abusive behavior patterns evidenced in childhood do not necessarily continue into adulthood (Chaffin et al., 2008; Hershkowitz, 2011). Researchers have argued that sexually offensive behavior can be treated using a number of therapeutic modes (Amand, Bard, & Silovsky, 2008; Chaffin et al., 2008; Chaffin & Bonner, 1998; Rasmussen, & Miccio-Fonseca, 2007). Current research presents evidence that after receiving appropriate treatment, children with SBP have no greater long-term risk for committing future sexual offenses than other clinical child populations (Carpentier, Silovsky, & Chaffin, 2006). Literature focuses mainly on the efficacy of cognitive behavioral therapy (CBT) for children with SBP. A number of studies support the use of cognitive behavioral protocols in an individual or group format (Bonner, Walker, & Berliner, 1999; Carpentier et al., 2006; Cohen & Mannarino, 1997; Silovsky, Neic, Bard, & Hecht, 2007). Other sources have related to the need to improve parent–child relationships (Deblinger, Steer, & Lippmann, 1999). Friedrich (2007), in particular, proposes an attachment and relational perspective in treating children under 12 with SBP. The goal of this article is to organize existing knowledge and to present a comprehensive analysis of what can cause the derailment of natural sexual development in young children. Additional focus is on potential causes of subsequent, offensive, age-inappropriate sexual behavior. The article examines the influence of the parents, value system, and family climate, and it describes normative and deviant sexual behavior in children. The analysis is supported by models of child development and illustrated by the case history of 5-year-old Eric. Far from being a solitary symptom, SBP is often representative of difficulties in many domains of a child’s life. This article attempts to integrate a number of different perspectives in order to achieve a broader understanding of Eric’s problematic behavior. With the intention of building a consistent conceptual bridge between theory and practice, treatment efforts based on Friedrich (2007) are discussed as an alternative or complement to cognitive-behavior treatment plans.

THE ETIOLOGY OF SEXUAL BEHAVIOR IN EARLY CHILDHOOD Children are naturally curious about sex and sexuality (Johnson, 1990), and their behavior can be placed on a continuum from normative to inappropriate. Their sexual development consists of a process of information gathered by means of observation and contact. The young child begins to grasp a


96

N. Waisbrod and B. Reicher

visual understanding of the body, notes gender differences, and associates body sensations in response to touch. In addition, the family context is cardinal to a child’s sexual development. Children are impacted by family dynamics, such as the way in which personal and physical boundaries are maintained and the degree of differentiation and polarity in gender roles. Children assimilate basic rules about touch according to the patterns of physical caregiving they experience from an early age. This information-gathering process can be supplemented by books, the Internet, and mass media exposure. Furthermore, the socialization process in children is continuous and is also impacted through play and the investigation of peer sexuality. In this way, children learn to distinguish between what is considered appropriate public and private behavior (Gordon & Schroeder, 1995; Johnson, 1990; Johnson, 2009). So how do we know if sexual behavior is inappropriate or normative in children? Silovsky and Hendrickson (2011) provide guidelines of typical sexual development: It is exploratory, spontaneous, intermittent, by mutual agreement, and among children of similar age, size, and development level who are familiar with one another. Typical sexual development is not accompanied by anger, fear, or strong anxiety. By contrast, problematic sexual behavior in children is intrusive, rare sexual behavior that occurs with greater frequency or duration than developmentally expected, is coercive or aggressive, and is potentially harmful to the individual and others concerned. The frequency of the sexual behavior excludes normal childhood activities, does not decrease with typically effective parenting strategies, occurs among youth of divergent ages or developmental levels, and elicits fear and anxiety in other children (Araji, 1997; Calder, 2001; Friedrich, 1991; Lamb & Coakley, 1993; Lewis, Loeb, Shaw, Rodriguez, & Rosado, 2000). Sexual behavior that continues even after the child has been reproached is also worrisome, particularly when the behavior arouses emotional distress in the child and the other children involved (Araji, 1997; Friedrich, 2007; Freidrich, Davies, Feher, & Wright, 2003; Silovsky & Niec, 2002). Studies indicate that a young child’s motivation for SBP is not sexual per se but a combination of curiosity, anxiety, imitation, attention seeking, self-soothing, and so on (Silovsky & Bonner 2003; Silovsky et al., 2007). Some studies have found that there is no uniform profile for children with SBP but that they form a heterogeneous group with varied personal traits (Elkovitch, Latzman, Hansen, & Flood, 2009). Other studies are based on an ecological approach that describes risk factors like attachment patterns, history of neglect or abuse, social or cultural isolation, poverty, and dysfunctional families. This includes families displaying skewed sexual attitudes and those exposed to sexuality in the media, such as pornography (Bonner et al., 1999; Burton, 2003 ; Calder, 2001; Friedrich, 2007; Friedrich et al., 2003; Friedrich et al., 2001; Gil & Johnson, 1993; Johnson, 1988; Johnson, 2009; Rasmussen, 2005; Silovsky & Bonner, 2003). Sexually inappropriate


97

behavior can also arise from deficient education, attention deficit disorders, poor regulatory ability, social problems, and more (Chaffin et al., 2008).


Interventions for Children with SBP Several factors emerge as important in the treatment of preschool children with SBP. Treatment needs to (a) directly address SBP using behavioral, CBT, and psychoeducational approaches; (b) address the child’s social problems, impulse control, coping strategies, boundary issues, and the caregiver–child relationship; (c) directly involve the parent/caregiver in treatment; and (d) include a behavior management training component. The treatment must be broad enough to address the needs of children with SBP who do not have a history of sexual abuse. Furthermore, treatment should be developmentally sensitive and consider the cognitive, emotional, and behavioral capacities of young children (Amand et al., 2008; Chaffin et al., 2006; Silovsky, 2009). A sizeable number of studies have examined the efficacy of therapy for children with SBP. The best efficacy was found in short-term outpatient treatment, especially CBT and psychoeducational interventions with caregiver involvement (Amand et al., 2008; Carpentier et al., 2006; Cohen & Mannarino, 1997; Deblinger, Stauffer, & Steer, 2001; Silovsky et al., 2007). CBT protocols focus directly on changing SBP and include elements such as teaching children clear sexual behavior rules and self-control skills. CBT also focuses on teaching caregivers basic behavioral parenting and supervision skills. The effect of CBT is specific to the treatment focus area (sexual behavior) rather than to a broad reduction in general delinquency (e.g., nonsexual arrests). CBT approaches demonstrated as effective in the studies mentioned previously should not be confused with the CBT approaches sometimes used with adolescent and adult sex offenders. Other approaches used in treating SBP include group CBT and group play therapy. These approaches were used in a study by Carpentier and colleagues (2006) in which the CBT group had significantly fewer future sex offenses than the play therapy group (2% versus 10%). Another group approach was that used by Silovsky and colleagues (2007) in the treatment of preschool children with interpersonal sexual behavior problems. In a single case study by Blunden and Nair (2010), of a young 6-year-old boy with sexual behavior and anxiety issues, a combination of systematic desensitization, token reward, and play therapy was used to reduce separation anxiety. This case study found that sexual behavior reduced considerably as anxiety reduced. Family and parent involvement is crucial in the treatment of children with SBP and can include individualized safety plans (Amand et al., 2008). Silovsky and Letourneau (2008) pay homage to Friedrich, long-time assessor of child abuse, particularly sexual abuse. Friedrich’s emphasis is on family reorganization to protect children from behaving in a sexually inappropriate

98


manner. A center for the prevention and treatment of sexual aggression among children used predominantly family therapy combined with individual therapy for children with SBP not based on sexual abuse (Etgar & Shulstain-Elrom, 2009). All these researchers maintain that many children with SBP can remain in the community, school, and home with suitable family support and monitoring. We are in agreement with this and feel that the treatment of children with SBP obviates a broad-minded approach similar to the methods mentioned.

CASE ILLUSTRATION


Presenting Problem The parents of 5-year-old Eric came to a regional center for the treatment of sexually abused children after their son began behaving in a sexually offensive and age-inappropriate manner at kindergarten. Eric had fondled some children and initiated oral sex using manipulation and secrecy. He “encouraged” a child to engage in touching behavior by bribing him with candy and then demanded that the child tell no one. This behavior occurred on a number of occasions over a period of several months. Eric’s parents experienced difficulty in seeing anything worrisome about their child’s behavior and considered it to be sexual curiosity. However, the kindergarten staff and parents of the other children saw Eric as an offender and asked to suspend him from the educational framework as a protective measure for the other children.

Background Information Eric comes from a family of six. He is the youngest of four children. He has two sisters aged 19 and 11 and a brother aged 17. The parents are of Ashkenazi (Western Jewish) background, and the family is secular. Both parents are academic professionals, and the family enjoys a comfortable, middle-class life in an affluent community. Eric’s parents are self-employed, their work schedules are erratic, and Eric is often cared for by his older siblings. Both parents were sexually abused—the mother as a child, and the father as a teen. Eric’s birth was regular, following an uneventful pregnancy. Eric was described by his parents as having a sensory processing disorder (SPD). He found it difficult to process, regulate, and organize the power and nature of behavioral responses following sensory stimulation. As such, Eric showed low sensitivity to touch and high stimulation tolerance, which was seen in his difficulty to register the intensity of pain and force of his interactions with others. Eric is an attractive boy. He is considered to be instinctual, with high physical capabilities, and had a tendency to endanger himself by initiating


99

risky behavior. His parents considered him to be a dominant child and in need of constant stimulation. They said that he often tested limits and tried to break rules, and although he functioned well, he gave a sense of being uptight and worried.


The Course of Therapy Based on the ecological approach espoused by Amand and colleagues (2008), we built a systemic working model relating to Eric, his parents, his kindergarten teacher, the educational framework, and the parents of Eric’s peers. The model took Eric’s developmental stage into account. We began by attempting to identify the elements that increased the risk for offensive behavior, as well as delineate the reasons for Eric’s SBP. In the wake of this assessment, we built a treatment plan with the emphasis on helping the child prevent further offensive behavior by modeling a corrective attachment relationship. For example, issues such as proper limits, empathy, and defective skills (self-regulation, self-control, and so on) were practiced in the therapy sessions. Work with the parents and kindergarten teacher was based on these same issues. At the onset of therapy, Eric denied behaving sexually. He claimed that nothing like that had ever happened or that the other kid did it to him. He saw nothing wrong with his behavior and became enraged with his kindergarten teacher for mentioning it. In keeping with his age, Eric took an egocentric stance, which made it difficult for him to connect with the emotional situation of the children he offended against. Eric had difficulty accepting his teacher’s authority and was ambivalent toward the therapeutic relationship. Whenever he felt uncomfortable, he would opt to disregard. Because he was not able to deal with uncomfortable emotions or unfamiliar situations, he denied his actions and took the stance that “I don’t do bad things like that.” In Eric’s narrative, he was the victim and not the perpetrator. The issue of control played a central part during the course of therapy. During the initial play therapy sessions, Eric would say things like “I’ll get you” or “I’m going to win.” When it appeared that he might lose a game, he would get aggressive and start shouting. Eric was preoccupied with his genitals over a number of sessions. He spoke about the fact that his “penis gets small and it’s uncomfortable when it moves around,” noting that “[he wants] it to be strong and hard.” Eric’s parents said that he believed his genitals had been cut and that this was a “punishment.” This is a classic Oedipal and age-appropriate fantasy. In response to directives that Eric received as to what is acceptable and where, he asked, “What do I do when it bothers me in public?” The therapist encouraged Eric to air his concerns about his genitals, responding with psychoeducational answers and direct and indirect reflections aimed at assuaging any anxiety or guilt Eric alluded.


100


During therapy, the therapist explained Eric’s behavior and thinking processes to his parents so that they could respond with optimal understanding and sensitivity. Concrete intervention was used during treatment. The therapist directed the parents to work out an agreed-on signal for Eric when he forgot his touching rules in public. Eric’s parents initially displayed a collaborative persona. However, it became evident during therapy that they were not being entirely candid about themselves and the family dynamics. They began to disclose a sexual philosophy espousing a need for open sexual expression, both for adults and children, which they said evolved from their experiences of having been sexually abused. The therapist did not relate to the parental philosophy from a reference point of values but rather examined with them whether their stance suited their son’s developmental needs. For example, Eric’s parents participated in a nudist festival that Eric also attended, and that caused him stress. The therapist also brought up intergenerational issues, such as the parents themselves having been abused as children, the way their own parents dealt with this, and their unique place in Eric’s world. Besides precluding parental monitoring and intervention, their way of life allowed for a sexually open marriage. As such, Eric witnessed sexual acts between his parents and other adults, mutual bathing and sleeping arrangements with his adolescent siblings, and other vestiges of a sexualized home environment. Initially, Eric’s parents did not see the connection between their son’s sexual acting out and their own sexualized behavior.

THEORETICAL ANALYSIS OF ERIC AND HIS FAMILY Literature offers a number of different theoretical approaches to explain a case like Eric’s. We chose to focus on three central theories that we believe are particularly relevant to understanding Eric’s case: psychosexual theory, cognitive-behavioral theory, and family theory. However, we have no doubt that additional developmental and social factors like culture, gender roles, and sexual abuse history, among others (Elkovitch et al., 2009) can contribute immensely to understanding this case. Developmentally, 5-year-old Eric was at a stage of increased physical growth and maturation of his nervous system. At this age, children have more control over their physical actions, their coordination improves, and there is an increase in the speed of their reactions (Apter, Hatab, Tyano, & Weizman, 1999). We believe that Eric’s physiological state impaired many of his coping abilities. As mentioned, Eric suffered from problematic sensory regulation that caused difficulties in concentration and intense reactions visà-vis interactions with others. This constellation of symptoms made Eric feel easily threatened and caused him to react aggressively (Ayers, 1994). His



101

need for constant movement, stimuli, and physical contact with little to no awareness of pain seemed to be related to his offensive behavior (Gomez, Baird, & Jung, 2004). Eric’s physical development was as expected for his age. He showed a need for strong stimulation, which could be connected to his tactile dysregulation. It is also probable that this need developed as a result of inadequate mirroring and a consequent desire to feel that he exists. On the one hand, Eric tended to push off any attempt by adults to hug or touch him; on the other hand, his constant need for stimulation and excitement would result in his running around the house naked, breaking rules and limitations. He would also occasionally have temper outbursts. Parents of children with tactile disorders like Eric’s can have difficulty finding the optimal level of contact their child needs, and the child can feel that his or her needs are not being met. The child may feel that his or her parents are not strong enough or available enough, and are, therefore, unreliable. In some cases a child can compensate for this situation by developing a “grandiose self,” characterized by difficulty in empathizing and, as in Eric’s case, a tendency to be demanding and expecting all needs to be met.

Aspects of Cognitive Development Eric was at a stage characterized by egocentric thinking, or the preoperational stage (Piaget & Inhelder, 1969). This theoretical material sheds light on Eric’s reactions. It is possible that Eric was unable to conceptualize the intentions behind his behavior and did not have the ability to recognize his mental state and to see his mental state as separate from his actions. However, he was preoccupied with the kindergarten teacher drawing attention to him. He viewed her as that of a bad person who wouldn’t let him do what he wanted. It was evident that Eric was not cognizant of the effects of his behavior on other children in light of his egocentric outlook. At the time of these incidents, Eric was in the Oedipal or phallic stage (ages 3 to 6) of psychosexual development (Freud, 1924). The erotogenic focus of the phallic stage is the genital area. Satisfaction is autoerotic and not provided by mutual sexual activities. The child becomes aware that his parents are different and is preoccupied and interested in discovering these gender differences and how they relate to him. He begins to grasp that, in comparison to adults, there are things he does not have. Eric, who had been exposed to nudity at the nudist festival, in his home environment, and via pornographic films, was both preoccupied with gender differences and intolerably distressed by them. According to theory, during the Oedipal or phallic stage, the child is attracted to the parent of the opposite sex and views the same-sex parent as a rival who can potentially get rid of the child. Eric had seen his mother with other men, which both reinforced his fears that she was not “his” while


102


also intensifying his competitiveness. This situation was played out in the therapy room with his therapist and in the kindergarten with his friends. Eric was anxious that his father would discover the fantasies that caused him to feel guilty and worthy of punishment. Young boys of this age tend to have an unconscious fear that their father will castrate them. As such, Eric felt he had to be strong and keep his penis erect. Eric’s mother was fearful that his sexuality would become externalized. Such forbidden impulses arouse strong anxiety, which Eric tried to repress or rechannel by sexual physical contact with his peers. During the Oedipal or phallic stage, the attraction to the parent of the opposite sex can be anxiety-provoking for the child, as the parents are a couple and eroticism is supposed to be their prerogative alone. At ages five to seven, children are supposed to solve their Oedipus complex. A boy identifies with his father instead of competing with him and adopts his father’s values and behavior. At the end of the process, the child becomes socialized by internalizing paternal values and norms, including ethical rules of society. However, when the environment is too stressful for the child or not containing enough, the child is not able to solve his Oedipus complex, and this can cause a variety of sexual problems as well as neurotic behaviors (Freud, 1924). In this case, Eric’s father was a weak figure, and in order for Eric to solve his Oedipus complex, his father had to be a significant part of the therapy as a meaningful model for identity in the Oedipal triangle. Eric demonstrated castration anxiety. Like other children of his age, he was preoccupied with his genitals. However, due to the sexualized environment present at home, Eric felt anxious about his body size. He was concerned about his penis being erect so that it would look big, like those of the adults he was exposed to. This situation was accompanied by normative castration anxiety in the form of a fantasy that his penis had been cut off as punishment for something he did. It is possible that Eric performed oral sex to check that his penis was not severed and castrated. Eric grew up in a family in which relationships were confusing. Fantasies were acted out at an almost concrete level. Eric bore witness to a variety of male figures sexually interacting with his mother, and Eric’s frequent exposure to nudity created an experience that intensified castration anxiety. Eric’s father did not offer a stable paternal figure signifying law and order, and this situation led Eric to imagine that his fantasies (sleeping with his mother or being castrated) could actually materialize. The culture of what was permitted and forbidden in this family was skewed, and sexuality was unbridled. These factors inhibited the proper development of Eric’s superego and led to a “leakage” of sexual behaviors outside of the home with his peers. According to the cognitive-behavioral approach (Skinner, 1974), this particular situation created various conditioning responses. For instance, in classical conditioning, where a neutral (conditioned) stimulus becomes



103

connected with another (reflexive, unconditioned) stimulus by repetitive association between the two stimuli, Eric learned that sexual behavior is connected to lack of boundaries. If we relate to operant conditioning, whereby learning is a function of behavioral consequences that lead to positive recompense and reinforcement, then we can say that Eric’s family maintained an openly sexual atmosphere with quite a few reinforcements for sexual expression. Other conditioning occurs by observing an emulated model (Bandura, 1977). This occurs by means of a cognitive script. We can assume that Eric’s exposure to sexuality in his home created confusing and contradictory models for him. On the one hand, he could feel omnipotent; on the other hand, impotent. His omnipotence could have arisen from the lack of limits placed on him, and the sense that he controlled his life and did whatever he wanted. Possible consequences of this is behavior that hurts others, impulsivity, power struggles with adults (parents, teachers), refusal to accept rules, and a low frustration tolerance (screaming and crying if he doesn’t get his way). Cognitively, Eric was preoccupied with thoughts of power: “Who is stronger?” and “Who has a bigger penis?” He showed difficulty in seeing others’ needs. He tended to force his will (including in his sexual behavior) on other children. His feeling of lack of power was expressed in his sense that no one looked out for him, and he was worried about what would happen to him. Eric was anxious, and his self-esteem was hurt as he tended to polarize his sense of self to an all-or-nothing stance. From the perspective of impotence, it is possible to see Eric’s sexual behavior as perhaps a misguided attempt to feel closeness, self-value, and vitality. However, the motivation behind this same behavior could also be a reflection of his feeling alone in a chaotic environment. His sexual offending against other children through the use of power and coercion may have been Eric’s way of vacating similar feelings of powerlessness onto the victim. It is also possible to understand Eric’s sexual behavior problems as a function of problems in his family system dynamics. We can therefore assume that any family member’s behavior reflects issues in the family system. As such, a person is impacted by social relationships and also impacts them (Minuchin, 1982). The formation of Eric’s symptoms was often an indication of a need for change, which the family system had difficulty accommodating. During the therapeutic process, we could see how strongly Eric personified the family system. It appears likely that the symptom—his sexual behavior— served as both an indication of the inappropriate sexual climate existing in the household and a reflection of the undifferentiated way the parents related to their children and their children’s various developmental stages. Based on the model of Cunningham and MacFarlane (1991), it was apparent that Eric’s parents initially displayed a rather rigid boundary


104


between the family and the outside world, as evidenced in their secretiveness and withholding information. Within the family, relationship boundaries were blurred. The sexualized environment enabled inappropriate behaviors with no sensitivity to the children’s developmental needs. The parental subsystem also showed signs of dysfunction. Eric’s father exhibited childish behavior, and his relationship with his wife often played out like a mother– child dyad. The parent’s executive functioning was inconsistent, and the overall lack of behavioral limits on the children left them with a sense of noncontainment and a weak sense of belonging. Eric and his siblings could function autonomously, but this is independence without containment. These children were not able to display mutual dependency or ask for support, and this could explain why Eric needed to develop offending behavior outside of the family in order to draw attention to his distress. By sexually offending, Eric could both control and punish his parents for not seeing him (Kolko, 1996). The inconsistent hierarchy and ineffectual authority between the parents and their children left Eric with the feeling that he needed to run his own life because he had no one to rely on. Eric tried to bind his anxiety and defend himself by taking a stance of pseudomaturity, whereby he insisted he could act like a grown-up. By denying and/or refraining from feelings of distress, Eric demonstrated behavior that relied on extreme self-reliance, while taking risks and testing limits. This kept him alone with his instincts and fostered a sense of “internal chaos” (Fonagy, 1999; Fonagy & Target, 2002). Friedrich (2007) makes reference to the impact of parent–child relations when the parent has a history of sexual abuse. In Eric’s case, his parents’ “sexual ghosts” were apparent in their inability to see their son’s needs and in the insecure attachment they created with him. It took a while for Eric’s parents to disclose their sexual philosophy to the therapist, which we can assume stems from the parents’ individual personal histories, including the sexual abuse they experienced and their reaction formation to this. Both parents hid the emotional consequences of their abuse experiences by denying them and unconsciously repressing their vulnerability. On the other hand, the parents’ behavior was often a direct and authentic expression of their inner life, demonstrated by the fact that Eric’s mother showed her need for control or her rigid tenacity in espousing open sexuality in the home. Eric’s mother disclosed very little about her own abuse, and tended to speak cryptically about it, while Eric’s father spoke openly about his difficulties with sexuality, including his heightened interest in sex and the fact that he still dreams about his abuse. Other relevant dynamics in this case were Eric’s parents’ inability to be aware of the influence of their past on their present relationships with their children and their failure to be cognizant of their provocative behavior.


105


IMPLICATIONS This chapter highlights the therapeutic interventions in Eric’s treatment through a multisystem approach that took place over one year. Each course of treatment was influenced by and based on different theories, studies, and reviews. We concluded that clinical studies were not sufficient, and the therapeutic model in this case consisted of three levels of intervention: individual work with the child, varying levels of parental guidance, and systemic work with the kindergarten staff and parents of the other children involved. When Eric was referred for treatment, we determined the level of inappropriate sexual behavior and made an assessment based on his developmental stage, physiological condition, sensory regulation, cognitive development, moral development, responsibility for behavior, level of damage, lack of support, the fact that it was repetitive, and other issues. This assisted us in making a determination as to the severity of the sexual abuse and the type of therapy most appropriate. In Eric’s case, his problematic sexual behavior was a symptom that expressed itself in various forms— difficulties regarding limits, social relations, and dealing with authority as well as anxiety, loneliness, poor self-image, lack of sense of security, and SPD. According to ATSA (2006), Eric’s treatment needed to address the different needs and situations that he was faced with, primarily the need for more family involvement and psychoeducational components that have proved to be successful for children with SBP. Based on several studies (Engel-Yeger, 2008; Lane, Miller, & Hanft, 2000; Miller, Anzalone, Lane, Cermak, & Osten, 2007), we know that there are a number of therapeutic models for children with SPD including: sensory integration treatment, sensory diet, the Alert Program, therapeutic listening (TL), and more. Due to the fact that we were unable to accommodate all these issues in this article and that our focus was more on emotional and behavioral aspects, we chose not to expand on the various interventions for children with SPD. Although Eric was referred for occupational therapy for his SPD, we made use of CBT tools in the therapy room to teach self-regulation, and we used the Alert Program to help Eric identify and understand arousal level and how to change it. Eric’s difficulty in stimulus regulation was explained to him. He was made aware of the possibility that he may feel a greater need for touch than other children, including the need to touch genitals, but that this is not acceptable behavior. It doesn’t respect other people’s boundaries and makes them uncomfortable. Regarding Eric’s exposure to adult sexuality, the therapist initiated sessions in which she would raise an issue and Eric would often opt to relate by writing a brief answer. Dynamic theory, particularly psychosexual theory, serves primarily as a background to understand Eric’s behavior as our reference to what happens in the consulting room, especially through using transference,


106


countertransference, and play therapy. For example, Eric would throw himself on the ground shouting, “I’m being pulled. I’m being swallowed up,” until the therapist extended her hand and “saved” him. The therapist sensed that Eric wanted desperately to feel needed and to share his distress through verbalization and symbolization rather than sexual acting out but that he was wary of how others around him would react. This session was significant in enabling the therapist to get close to Eric and serve as a nurturing figure. Information on Freud’s psychosexual development theory and the Oedipus complex helped in understanding Eric’s preoccupation with his penis and his need to be strong and big rather than small and weak. Eric was in a continuous struggle to be big, because big people can do what children can’t, including have sex with others. The therapist decided to relate to this issue by means of an externalization technique whereby Eric dialogued or drew pictures for his little and big self. The big self was asked to relate to what little Eric wanted to do. This served to encourage the development of a responsible and reflective image. Based on various literature (Amand et al., 2008; Carpentier et al., 2006; Cohen & Mannarino, 1997; Silovsky et al., 2007), most of our work was influenced by CBT and psychoeducational components, even if the technique was applied through playing. Eric and the therapist discussed how to determine what is right and wrong. Eric was encouraged to think about what sexual behavior is acceptable and to distinguish this from behavior that is considered off limits. Gender differences and age-appropriate sex education, self-protection, identifying dangerous situations, dynamics of secrecy, and other topics were discussed. These issues were presented as universal, and this served to lower Eric’s anxiety level and sense of shame or blame. The therapist expressed a strong and clear stand regarding inappropriate contact, and this appeared to help Eric contain some of his negativism and gradually let go of his need for denial. Through trials and losses during play therapy, the therapist helped Eric work on coping skills as well as self-control strategies and social skills. This included teaching him relaxation skills, problem solving skills, and techniques to encourage him to stop and think before acting. In the early stages of therapy, Eric tried to establish his own rules regarding the therapeutic setting and games he wanted to play. He would often say things to the therapist like, “I’ll rip you to pieces,” or “You really piss me off.” The therapist made use of the emotions this aroused to steer the conversation in the direction of the children Eric had offended against. In the parental guidance meetings, the therapist worked with the parents on how to “see” Eric in a more realistic way: as a 5-year-old boy with specific developmental needs and not as a small adult. Another therapeutic goal was to help Eric develop his own inner “compass” whereby he could determine for himself how he should behave. Instead of blaming others for his sexual acting out, the therapist helped



107

Eric learn to take responsibility for his actions by identifying his feelings, paying attention to sensations, and grasping the essence of cause and effect. This process was actualized by using play therapy, in which Eric could dysregulate and project his disappointment. For example, if the therapist began to win a game, Eric would react strongly with verbal threats or attempts to change the rules. The therapist reflected on Eric’s disappointment but also consistently adhered to the rules of the game and disregarded Eric’s attempts to manipulate her. Gradually, Eric began to show an ability to play calmly, coping with both winning and losing. The interaction itself began to take precedence over his need to control the situation. Eric’s increased regulation and inner direction helped him problem solve in a more normative fashion. One particular technique that seemed to help Eric organize his experiences was the “traffic light”. He learned how to determine which situations are red (dangerous, volatile), yellow (be prepared, potential problem), and green (go ahead). The therapist was constantly aware of the need to increase Eric’s empathic ability. As such, she interspersed empathy-arousing questions in the therapy sessions, such as, “How does your teacher feel when you don’t listen to her?” or “How does your friend feel when you try to touch his genitals?” and so on. Family therapy approaches and the results of many studies (Friedrich, 2007; Friedrich et al., 2001; Silovsky et al., 2007), in particular the ATSA report (Chaffin et al., 2008), emphasize that the primary agent of change for SBP appears to be the parent or caregiver. Eric’s parents were preoccupied with the external implications of Eric’s sexual acting out, and they expressed anxiety about how the various systems and authorities might react and possibly retaliate if Eric continued his behavior. Our first area of focus was therefore on developing and implementing a safety plan that included supervision and monitoring, especially monitoring Eric’s interaction with other children. The therapist’s emphasis was on providing information about sexual development, normal sexual play and exploration, and how these differ from SBP as well as strategies to encourage children to follow privacy and sexual behavior rules. After helping Eric’s parents contain their anxiety, the therapist began drawing their attention to their individual life histories. Their parenting styles were discussed, including boundary issues, intimacy dynamics, and the functioning of the various subsystems in the family. In a transferential mode, Eric’s father tried to personalize his relationship with the therapist, who made use of this tendency to help both parents work through the need for limits between each other and their children. Each parent played significantly different roles in the family: Eric’s father displayed a more affect-laden behavior (a “being” approach) while Eric’s mother was more instrumental (a “doing” approach). There was much dialogue on accepting and respecting these differences while drawing connections to the importance of relating to their children according to their


108


developmental age and needs. If at the outset the parents were convinced that everything on the home front was fine, they gradually came to view family interactions in a more differential manner, and as they made changes in their behavior, this had an almost immediate impact on the children. Eric’s behavior became a sharper-focused lens through which the parents could observe family dynamics. Eric’s parents began to understand that their son’s need to present himself as a little adult was a reflection of the powerlessness he felt as a child—a child who was not being attended to by his parents. The therapist spent a lot of time discussing how their childhood experiences had impacted or negated what they thought was right for Eric. Attention was paid to the subject of boundaries, and Eric’s father expressly asked for instructions on how to concretely apply limits. The therapist initiated a continuous discussion aimed at identifying parental attitudes regarding open sexual relations, communal bathing in the family, and the exposure of young minors to pornography. It became apparent that Eric’s parents were in need of a direct, concrete, and psychoeducational approach regarding acceptable behavior. Many aspects of family life were assessed, and with each directive, the therapist offered the parents the rationale behind it and how it was relevant to Eric’s developmental abilities. The parents were made aware of the potential damage to Eric from inappropriate exposure to adult sexuality and how it contributed to his acting out. They were coached on the importance of creating a safe environment for Eric. The therapist brought up a psychodynamic issue due to its relevance to some of Eric’s behavior. She briefed the parents about the dynamics of castration anxiety and how this could have been exacerbated in Eric due to his exposure to adult nudity at home. This both heightened the parents’ awareness of the developmental aspects of sexuality and presented Eric’s behavior in a normative framework. Eric and the therapist spoke openly about his genitals. Eric was told that his penis need not be erect for him to feel “whole,” and that there is a time and place to make use of his genitals. After much work on normative sexuality, Eric’s parents began to express anxiety about his future, specifically if he could develop some kind of perversion like pedophilia. These anxieties were both psychoeducational and emotional (their newly aroused guilt). The therapist also discussed Eric’s sensory regulation issues with his parents and its implications. While Eric’s sensitivity is a given trait, the rationale presented to the parents was that a heightened awareness of the problem and how to deal with it would bring about a positive reaction both at home and in extrafamilial frameworks. The parents were coached on assessing how much stimulus is optimal for Eric and on how to sublimate his tactile needs through sports, gardening, and so on. On a social level, children with contact problems present a complex dilemma to relevant systems. It was necessary to present a psychoeducational outlook to Eric’s parents and the kindergarten staff, which maintains that



109

children can express myriad problems via inappropriate sexual touching. The staff received training on how to deal with the parents of the children who had been exposed to Eric’s inappropriate behavior. We advocated a developmentally sensitive and nonpunitive approach while helping the staff to contain some extreme responses shown by other parents. It was important to ensure Eric’s privacy, both to avoid his being labeled and scapegoated and also to be consistent with the emphasis of the therapy in dealing with proper boundaries. On a behavioral level, we advised the kindergarten staff in the initial stages of therapy to monitor Eric closely. This served the multiple purposes of preventing reoffense, offering Eric a sense of being “seen,” and calming the parents of the other children. It is important to note that once Eric was able to cease his sexual contact behavior, a ripple effect occurred, and many other areas of his life improved. Relations at home between Eric’s parents and siblings were more organized and satisfying. Eric’s academic functioning rose, and he was no longer preoccupied with authority, rules, and how to disobey. His demeanor was calmer, and he became a blatantly happier boy. With respect to the literature presented in this article, intervention included (a) directly addressing SBP using behavioral, CBT, and psychoeducational approaches; (b) addressing the child’s social problems, impulse control, coping strategies, boundary issues, and caregiver–child relationship; (c) directly involving the parent/caregiver in treatment; and (d) a behavior management training component.

CONCLUSION The case described here reinforces the findings of various studies (Friedrich & Luecke, 1988; Gray, Pithers, Busconi, & Houchens, 1999; Johnson, 1998) that found a relationship between sexually abused children and sexual behavior problems. In Eric’s case, we can see that sometimes a sexual atmosphere and problematic family dynamics lead to consequences and situations in which there is sexual abuse. In this case we can see how Eric’s age-inappropriate sexual behavior was impacted by a type of noncontact sexual abuse: exposure to sexuality at home and through the media. Eric was confused about sex and sexuality after witnessing stimuli beyond his comprehension and emotional maturity. He was anxious about the size of his genitals, and his repetitive sexualized behavior was a misguided attempt to connect with his peers. Additional factors impacting Eric were his sensory regulation issues, his sense of being unprotected and alone, his parents’ sexual abuse history, and their difficulty in seeing their child’s developmental needs. This article is not a research article. It is a case of a young child with problematic sexual behavior and is based on different elements that were


110


effective in field trials. Although literature talks about the effectiveness of CBT, we found that we had to also draw on other theories, such as Freud’s psychosexual theory and family theories, in order to conceptualize and effectively treat this case. Eric’s case illustrates how dealing with a young child’s SBP necessitates multiple levels of intervention. The context of the child’s life experience, especially within his family milieu, was cardinal in understanding Eric’s symptomatic behavior. We believe that in these cases it is important for the analyst to be familiar with theoretical approaches and different treatment options and to adjust the treatment to each specific child. We are of the opinion that existing treatment models afford only a partial understanding of children with SBP, and each child necessitates a unique and individual integration of these models. While we understand that it may not be possible to create one overarching theory, we feel that more needs to be done in the area of dyadic developmental therapy in treating these cases. Developmental models should be expanded to include more situational, social, familial, and moral variables in the treatment of children with SBP. However, having said that, we can currently make good use of several theoretical modes of thought to comprehend different types of SBP in children and the treatment thereof.

REFERENCES Amand, A., Bard, D., & Silovsky, J. (2008). Meta-analysis of treatment for child sexual behavior problems: Practice elements. Child Maltreatment, 13, 145–166. doi:10.1177/1077559508315353 Apter, A., Hatab, J., Tyano, S., & Weizman, A. (1999). Child and adolescent psychiatry (2nd ed.). Dyonon, Israel: Tel Aviv University. Araji, S. K. (1997). Sexually aggressive children: Coming to understand them. Thousand Oaks, CA: Sage. Association for the Treatment of Sexual Abusers. (2006). ATSA task force on children with sexual behavior problems. Beaverton, OR: Author. Ayers, A. J. (1994). Sensory integration and the child. Los Angeles, CA: Western Psychological Services. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Blunden, S., & Nair., D. (2010). An unusual clinical phenomenon: A case of bedtime with apparent sexual overtones. Clinical Child Psychology and Psychiatry, 15, 55–64. doi:10.1177/1359104509339090 Bonner, B. L., Walker, C. E., & Berliner, L. (1999). Children with sexual behavior problems: Assessment and treatment-final Report (Grant No. 90-CA-1469). Washington, DC: U.S. Department of Health and Human Services, National Clearinghouse on Child Abuse and Neglect. Burton, D. L. (2003). Male adolescents: Sexual victimization and subsequent sexual abuse. Child and Adolescent Social Work Journal, 20, 277–296. Calder, M. C. (2001). Juveniles and children who sexually abuse: Frameworks for assessment. (2nd ed.). Dorset, England: Russell House.



111

Carpentier, M., Silovsky, J. F., & Chaffin, M. (2006). A randomized trial of treatment for children with sexual behavior problems: Ten year follow-up. Journal of Consulting and Clinical Psychology, 74, 482–488. doi:10.1037/002206X.74.3.482 Chaffin, M., Berliner, L., Block, R., Johnson, T. C., Friedrich, W., Louis, D., . . . Silovskey, J. F. (2008). Report of the ATSA Task Force on Children with Sexual Behavior Problems. Child Maltreatment,13, 199–218. doi:10.1177/ 1077559507306718 Chaffin, M., & Bonner, B. L. (1998). Don’t shoot, we’re your children: Have we gone too far in our response to adolescent sex abusers and children with sexual behavior problems? Child Maltreatment, 3, 314–316. Cohen, J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1228–1235. doi:10.1097/00004583-199709000-00015 Cunningham, C., & MacFarlane, K. (1991). When children molest children: Group treatment strategies for young sexual offenders. Orvell, VT: Safer Society Program and Press. Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6, 332–343. Deblinger, E., Steer, R. A., & Lippmann, J. (1999). Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress of health and human services. National Clearinghouse on Child Abuse and Neglect, 23, 1371–1378. Elkovitch, N., Latzman, R. D., Hansen, D. J., & Flood, M. F. (2009). Understanding child sexual behavior problems: A developmental psychopathology framework. Clinical Psychology Review, 29, 586–598. doi:10.1016/j.cpr.2009.06.006 Engel-Yeger, B. (2008). Sensory processing patterns and daily activity preferences of Israeli children. Canadian Journal of Occupational Therapy, 75, 220–229. Etgar, T., & Shulstain-Elrom, H. (2009). A combined therapy model (individual and family) for children with sexual behavior problems. International Journal of Offender Therapy and Comparative Criminology, 53, 574–595. doi:10.1177/0306624X08319914 Fonagy, P. (1999). Points of contact and divergence between psychoanalytic and attachment theories: Is psychoanalytic theory truly different. Psychoanalytic Inquiry, 19, 448–480. doi:10.1080/07351699909534264 Fonagy, P., & Target, M. (2002). Early intervention and the development of self-regulation Psychoanalytic Inquiry, 22, 307–335. doi:10.1080/ 07351692209348990 Friedrich, W. N. (1991). Casebook of sexual abuse treatment. New York, NY: Norton. Friedrich, W. N. (2007). Children with sexual behavior problems: Family-based, attachment-focused therapy. New York, NY: W. W. Norton & Company. Freidrich, W. N., Davies, W. H., Feher, E., & Wright, J. (2003). Sexual behavior problems in preteen children: Developmental, ecological, and behavioral correlates.


112


Annuals of New York Academy of Science, 989, 95–104. doi:10.1111/j.17496632.2003.tb07296.x Friedrich, W. N., Fisher, J., Dittner, C., Acton, R., Berliner, L., Butler, J., . . . Wright, J. (2001). Child Sexual Behavior Inventory: Normative, psychiatric and sexual abuse comparisons. Child Maltreatment, 6, 37–49. doi:10.1177/ 1077559501006001004 Friedrich, W. N., & Luecke, W. J. (1988). Young school-age sexually aggressive children. Professional Psychology Research and Practice, 19, 155–164. doi:10.1037/ 0735-7028.19.2.155 Freud, S. (1924). The dissolution of the Oedipus Complex (standard ed.). London, England: Hogarth Press. Gil, E., & Johnson, T. C. (1993). Sexualized children: Assessment and treatment of sexualized children and children who molest. Rockville, MD: Launch Press. Gomez, C. R., Baird, S., & Jung, L. A. (2004). Regulatory disorder identification, diagnosis and intervention planning: Untapped resources for facilitating development. Infants & Young Children, 17, 327–339. Gordon, B. B., & Schroeder, C. (1995). Sexuality. New York, NY: Plenum. Gray, A. S., Pithers, W. D., Busconi, A., & Houchens, P. (1999). Developmental and etiological characteristics of children with sexual behavior problems: Treatment implications. Child Abuse & Neglect, 23, 601–621. Hershkowitz, I. (2011). The effects of abuse on sexually intrusive behavior by children: An analysis of child justice records. Child Abuse & Neglect, 35, 40–49. Israeli Council for Children’s Rights. (2008, November 23). Information regarding the scope of sexual harm to minors. Retrieved from http://www.amanim. israelnow.co.il/levin/a241144 Johnson, T. C. (1988). Child perpetrators—Children who molest other children: Preliminary findings. Child Abuse & Neglect, 12, 219–229. Johnson, T. C. (1990). Curriculum in human sexuality for parents and children in troubled families. Los Angeles, CA: Children’s Institute International. Johnson, T. C. (1998). Children who molest. In W. Marshall, S. Hudson, T. Ward, & Y. Fernandez (Eds.), Sourcebook of treatment programs for sexual offenders (pp. 337–352). New York, NY: Plenum Press. Johnson, T. C. (2009). Understanding children’s sexual behaviors, what’s natural and healthy. South Pasadena, CA: New Harbinger Publications. Kolko, D. J. (1996). Clinical monitoring of treatment-course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse & Neglect, 20, 23–43. Lamb, S., & Coakley, M. (1993). “Normal” childhood sexual play and games: Differentiating play from abuse. Child Abuse and Neglect, 17, 515–526. Lane, S. J., Miller, L. J., & Hanft, B. E. (2000). Toward a consensus in terminology in sensory integration theory and practice: Part 2: Sensory integration patterns of function and dysfunction. Sensory Integration Special Interest Section Quarterly, 23, 1–3. Lewis, J. E., Loeb, J., Shaw, J. A., Rodriguez, R. A., & Rosado, J. (2000). Child on child sexual abuse: Psychological perspectives. Child Abuse & Neglect, 24, 1591–1600. doi:10.1016/S0145-2134(00)00212-X



113

Miller, L. J., Anzalone, M. E., Lane, S. L., Cermak, S. A., & Osten, E. T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61, 135–140. Minuchin, S. (1982). Reflections on bounderies. American Journal of Orthopsychiatry, 52, 655–663. Piaget, J., & Inhelder, B. (1969). The psychology of the child. London, England: Routledge & Kegan. Rasmussen, L. A. (2005). Differentiating youth with sexual behavior problems: Applying a multidimensional framework when assessing and treating subtypes. Journal of Child Sexual Abuse, 13, 57–82. doi:10.1300/j070v13n03_04 Rasmussen, L. A., & Miccio-Fonseca, L. C. (2007). Paradigm shift: Implementing MEGA, a new tool proposed to define and assess sexually abusive dynamics in youth ages 19 and under. Journal of Child Sexual Abuse, 16, 85–106. doi:10.1300/j070v16n01_05 Skinner, B. F. (1974). About behaviorism, New York, NY: Vintage. Silovsky, J. F. (2009). Taking action: Support for families of children with sexual behavior problems. Brandon, VT: The Safer Society Press. Silovsky, J., & Bonner, B. L. (2003). Sexual behavior problems. In T. H. Ollendick & C. S. Schroeder (Eds.), Encyclopedia of clinical child and pediatric psychology (pp. 589–591). New York, NY: Kluwer Press. Silovsky, J. F., & Hendrickson, P. (2011, September). Children’s sexual behavior: What’s common, what’s concerning, and what to do (slide 3). Powerpoint presentation at Through the Eyes of the Child Initiative Regional Conferences, Sidney, NE. Silovsky, J. F., & Letourneau, E. J. (2008). Introduction to special issue on children with sexual behavior problems. Child Maltreat, 13, 107–109. doi:10.1177/10775595083-15354 Silovsky, J., & Niec, L. N. (2002). Characteristics of young children with sexual behavior problems: A pilot study. Child Maltreatment, 7, 187–197. doi:10.1177/1077559502007003002 Silovsky, J. F., Niec, L., Bard, D., & Hecht, D. (2007). Treatment for preschool children with interpersonal sexual behavior problems: A pilot study. Journal of Clinical Child and Adolescent Psychology, 36, 378–391. doi:10.1080/15374410701444330

AUTHOR NOTES Nirit Waisbrod, PhD, is a lecturer at the School of Social Work at Zefat Academic College and the University of Haifa in Israel. She also founded and manages the Rimonim Center for Child Sexual Abuse, two centers dealing with sexually abused children and their families. Her current research interest focuses on the treatment of child sexual abuse, young children with sexual behavior problems, and the perceptions and experiences of all those affected. Barbara Reicher, MSW, is a family therapist who focuses on treating children with sexual behavior problems.

What happened to you?

What Happened to Software Metrics?

What happened to growth monitoring?

What has happened tothe myocardial sinusoids?

What happened to my Valeant shares?

What actually happened.

Tumor metastasis: what happened to the invading cancer cells?

What happened to the modeling and simulation revolution?

Flint Water Crisis: What Happened and Why?

Eric Davidson: Steps to a gene regulatory network for development.

[Resuscitation between the guidelines -- what has happened since 2010].

Staff response to inpatient and outpatient suicide: what happened and what do we do?

What ever happened to the "cool" kids? Long-term sequelae of early adolescent pseudomature behavior.

Whatever happened to EPSDT?

Asbestos and cancer 1934-1965: and what happened thereafter?

Opportunity cost calculations only determine justified effort--or, what happened to the resource conservation principle?

A melanoma trend forecast from 2002 - What happened then?

What Happened to Self-Actualization? Commentary on Kenrick et al. (2010).

Whatever happened to the clinical DNP?

Secular trends in invasive meningococcal disease, Massachusetts, 1988-2011: what happened to invasive disease?

Whatever Happened to Broad Perspective?

Can adults with autism spectrum disorders infer what happened to someone from their emotional response?

It finally happened to me.

"I need you to listen to what happened to me": personal narratives of social trauma in research and peace-building.