Understanding & Healing Children Who Act Out Sexually Second Edition

Understanding & Healing Children Who Act Out Sexually

Copyright © 2019 by Daria Shewchuk.

Second Edition

All rights reserved under International, Universal, and Pan-American Copyright Conventions. No part of this book may be reproduced, stored in a retrieval system, transmitted in any form by an electronic, mechanical, photocopying, recording means or otherwise, without prior written permission from the author. The one exception is listed on page 284.

Published in Canada

Library and Archives Canada

Publisher: Shewchuk-Dann & Associates

Author: Daria Shewchuk

Graphic Designer: Amy Mraze

Includes bibliographical references and index

ISBN: 978-1-9994777-2-1

ISBN: 978-1-9994777-3-8 (e-book)

1. Psychology, Child Psychology, Child Treatment, Post-Traumatic Stress Disorder, Treatment, Sexual Abuse, Sexual Acting Out, Sexual Offending, Play Therapy, Trauma-Informed Interventions, Self and Professional Sustainability, Intersection Between Legal and Psychological Needs

To contact the Publisher, visit the websites below:

http://understandingandhealing.com

http://www.shewchuk-dann.com

The Internet addresses listed are accurate as of the this printing.

10 9 8 7 6 5 4 3 2

Dedication

Dedicated to the souls of the world and their ability to grow, heal, challenge, and teach others. I marvel at most individuals’ ability to address and transcend the challenges in their lives. Heartfelt thanks to all the clients from whom I have learned so much over the years.

Acknowledgments

I am grateful to many people for their support and encouragement to write this book, the idea of which started over 20 years ago.

Conversations and questions from my graduate students and colleagues through the years helped inform the topics included in this book. I thank all of you.

I also wish to thank:

Sonya Dann, my daughter, who encouraged me to be patient and take my time. She read and edited many of the chapters. Her suggestions were always helpful.

Sara Bennett, my friend and colleague, for reading multiple drafts, for making suggestions, and editing. She reviewed the book in its entirety more than once!

Harleen Cheema, my psychological assistant, who helped with editing and the hundreds of references I reviewed while writing this book.

Amy Mraze, graphic designer and friend, who designed the layout of the book and provided help in editing and publishing, as well as moral support.

Thank you to the many others who read parts of the book or commented on certain chapters. All of you made useful suggestions to help me convey complex theory and ideas more clearly.

Special thanks to Viviane Wingerak, Reinette van Schalkwyk, and others (you know who you are).

Thank you to all of my clients, teachers, researchers, and skilled clinicians who have taught me in my career.

Table of Contents

ACKNOWLEDGMENTS

ILLUSTRATIONS

INTRODUCTION

PART ONE

Case Examples to Help Explain Why – An Introduction To Working with Children Who Sexually Act Out

CHAPTER 1 - THE GIRL WHO CAUSED AN EPIDEMIC

CHAPTER 2 - CHILDREN TELL THEIR EXPERIENCE THROUGH PLAY (GREG)

Play Therapy Theme: Need for Protection

Play Therapy Theme: Hiding

Play Therapy Theme: Being Hurt

Play Therapy Theme: Wanting to Live at Mom’s House

Play Therapy Theme: Greg’s InappropriateSexual Behavior

The Jumping Game

What Happened to Greg?

CHAPTER 3 - SEXUALIZED CHILDREN (BRIAN AND SAM)

The Sexualized Child in Adulthood

CHAPTER 4 - CHILD SEXUAL EXPLOITATION: THE GIRL WHO SOUGHT REWARD (DAISY)

Play Therapy Reveals Daisy’s Story

CHAPTER 5 - WHEN A CHILD CAN’T TELL (APRIL)

Using a Safety Scale

CHAPTER 6 - THE IMPORTANCE OF HEALTHY BONDING (ADAM)

CHAPTER 7 - TRAUMATIZED OR NOT? (CLARA)

CHAPTER 8 - THE IMPORTANCE OF FOSTERING SAFETY (VINCE AND RICK)

Case Example: Vince Was Taught Safety Skills

Case Example: Rick Was Made Fearful

Why a Gentle Approach Is Important

PART TWO

A Practical Guide for Caregivers, Teachers,

and Social Workers

CHAPTER 9 - HOW TO HELP CHILDREN EXPRESS THEIR FEELINGS

Safety

How to Help a Child Feel Safer

The Care Wheel

CHAPTER 10 - GUIDELINES FOR ASSESSING SEXUAL BEHAVIOR

Developmentally-Appropriate Sexual Behavior

CHAPTER 11 - HOW TO HELP A CHILD WHO ACTS OUT SEXUALLY

A Practical Guide for Caregivers

Managing the Child’s Behavior

Supervision

Decrease Opportunity to Reoffend

PART THREE

Theoretical Research Considerations for Professionals

CHAPTER 12 - FOUNDATIONS FOR THERAPY WITH CHILDREN

A Child-Focused Approach

Dynamics of Abuse

Knowledge Around Sexual Abuse

Understanding the Architecture of the Problem

CHAPTER 13 - CHILD DEVELOPMENT: A FOUNDATION FOR WORKING WITH CHILDREN

Typical Developmental Stages

Horticulture and Growth/Plant Metaphor

Fostering/Aiding Optimal Brain Development

Healthy Attachment

Assessing Attachment

Disruption of Development

Brain Development

CHAPTER 14 - THE EFFECTS OF NEGLECT, TOXIC STRESS, AND TRAUMA ON THE DEVELOPING BRAIN

Neglect

Toxic Stress and Traumatic Stress

Hormonal and Nervous System Changes

Potential Responses to Trauma

Physiological Adaptations and Neurobiological Impacts of Trauma

Neuroimaging Studies

Three Types of PTSD?

CHAPTER 15 - ASSESSMENT: TRAUMA-SPECIFIC VARIABLES TO CONSIDER

What Is Trauma?

Treatment Must Be Assessment Driven

Medication Can Be Helpful but Is Rarely Curative

Why Some People Become Traumatized and Others Do Not

Victim-Specific Variables

Social Environment

Stressor Characteristics

Single-Event Trauma

Polyvictimization

Childhood Trauma

Protective Variables

The Impact of Retraumatization

Trauma in Infancy and Childhood

Diagnosis

How Does Diagnosis of PTSD in Preschoolers Differ?

Untreated Trauma and Comorbidity

How Can We Help Children?

CHAPTER 16 - TRAUMA-INFORMED AND TRAUMA-SPECIFIC INTERVENTIONS

Principles of Trauma-Informed Services

Principle 1: Safety

Principle 2: Do Not Retraumatize Clients

Principle 3: Respect, Connection, Collaboration

Principle 4: Building Resiliency

Principle 5: Therapeutic Attitudes

Principle 6: Understanding Trauma

Principle 7: Strengths-Based Interventions

Principle 8: Empowerment and Choice

Principle 9: Cultural, Historical, and Gender Issues

The Use of Language

Trauma-Specific Interventions

CHAPTER 17 - THERAPEUTIC ENVIRONMENT AND TREATMENT MILIEU

Creating a Treatment Milieu

Safety Is Protective

Timing of Therapy

Therapy Must Be Developmentally Appropriate

Assessing the Child

Research into Effectiveness of Therapy

Common Factors Theory

A Variety of Therapies

Evidence-Based Therapy

Other Models of Therapeutic Change

The Architecture of the Problem

Trauma and Trauma Treatment

Stage 1: Safety and Stabilization

Stabilization of the Client

Stage 2: Working Stage of Therapy

Stage 3: Integration of Trauma

Developing a New Sense of Self

Stage 4: Consolidation of Gains

Future Pacing

Ending Counseling and Future Counseling

CHAPTER 18 - TYPES OF TREATMENT

Suitable Treatment Modalities and Therapies

CHAPTER 19 - PLAY THERAPY AND THE COUNSELING PROCESS

Why Play Therapy?

Approaches to Play Therapy

Choice Points

The Play Therapy Room

Investigative Interviewing vs. Therapeutic Assessment

Observations During Play Therapy

The Counseling Process

The First Stage of Therapy

Encouraging Exploration

Setting Limits, Structure, and Boundaries

Establishing the Purpose

Case Example of Disruption of Emotional Trust

Middle or Working Stage of Therapy

Paraphrasing vs. Interpreting

Examples of Interpretations

Final Stage

Consolidating the Learning From Therapy

Addressing Endings

Anticipating How the Child’s Life Will Continue to Improve and Grow

Impacting Self Concept in Positive Ways

Assessing Progress in Play Therapy

Themes in Play Therapy

Themes Clients Present in Therapy

The Personalized/Symbolic Role of Toys

Has the Child Been Traumatized?

Posttraumatic Play and Posttraumatic Reenactment

When to Intervene

How to Intervene

CHAPTER 20 - MEMORY AND CHILDREN

Implicit Learning vs. Explicit Learning

Memory

Process of Memory

Verbal vs. Nonverbal Memory

Working with Memories in Therapy

Interviewing to Elicit Certain Types of Memory

Declarative and Episodic Memory

Script Memory

Autobiographical Memory and Belief

Self-Concept

Is Traumatic Memory Different from Ordinary Memory?...

State-Dependent Memory

Therapeutically Working with Memory Systems and Self-Concepts

Dissociation

Amnesia

Depersonalization

Dissociation in Children

Recognizing Dissociation in Children

Factors that Can Impact Memory

Factors that Can Impact Episodic or Declarative Memory

Trustworthy vs. Nontrustworthy Information

Interviewing Children

Tips and Information on Interviewing Children

How Well Do Children Remember?

Don’t Mix the Research

CHAPTER 21 - THE INTERSECTION BETWEEN LEGAL AND PSYCHOLOGICAL NEEDS

The Importance of Prompt Treatment

Child Welfare Involvement

The Child’s Perspective

Resolution

Case Example 1: Contact (With Therapeutic Support)

Regression

Case Example 2: Contact (Without Therapeutic Support)

Case Example 3: The Importance of Inoculation

Legal Requirements vs. Psychological Needs

Supporting the Child Through the Legal Process

Recommended Resources

Additional Readings

CHAPTER 22 - SELF SUSTAINABILITY, PROFESSIONAL SUSTAINABILITY, AND SELF-CARE

Burnout, Vicarious Traumatization, and

Compassion Fatigue

How to Sustain Self-Care

Recommended Readings

CHAPTER 23 - HELPFUL TOOLS FOR TREATMENT

Integration of Treatment Components

Variables to Consider in Treatment

Tracking Outcomes

Tracking Themes

CHAPTER 24 - CONCLUSION

Main Points

Summary

APPENDIX I - GLOSSARY OF TERMS

APPENDIX II - CHARTS AND DIAGRAMS

APPENDIX III - RECOMMENDED BOOKS

APPENDIX IV - RECOMMENDED RESOURCES

REFERENCES

INDEX

ABOUT THE AUTHOR

Charts & Illustrations

Figure 1: Interventions at Various Levels

Figure 2: Example of Play Therapy Houses

Figure 3: Feeling Sheet (6 faces)

Figure 4: Sand Tray with Many People

Figure 5: Sand Tray of Adults Interacting with Children

Figure 6: Safety Scale

Figure 7: Feeling Sheet (12 faces)

Figure 8: Feeling Sheet for Ages Birth to Two

Figure 9: Feeling Sheet for Ages Two to Four

Figure 10: Feeling Sheet for Ages Five and Up

Figure 11: The Care Wheel

Figure 12: Four Guidelines for Assessing Sexual Behavior

Figure 13: Sexual Behavior - Birth to Age Five

Figure 14: Sexual Behavior - Age Six to Ten

Figure 15: Sexual Behavior - Age Ten to Twelve

Figure 16: Functional MRI Images of Patients with PTSD

Figure 17: Variables to Consider in Treatment

Figure 18: Implementation of Trauma-Specific Treatment

Figure 19: Recommended Play Therapy Supplies

Figure 20: Integrative Treatment Chart

Figure 21: Symptoms Tracking Chart

Figure 22: Safety Tracking Chart

Preface

It has taken decades of study, keeping up on the research, combined with practice, to consolidate the learnings summarized in this book.

In order to have the text in this book flow easily and not break up the rhythm of reading, I have minimized the in-text citations. However, I have summarized descriptions of the research that is available. The references used are at the back of the book. Some chapters also include recommended readings.

I hope you will find the book useful for:

• Better understanding of how to work with children in general

• Information about conducting child therapy

• Information about play therapy

• Understanding psychological trauma and how to work with traumatized children

• How to work with children who have been sexually abused and who may also sexually act out

I have created handouts over the years, some of which can be used for individual purposes (use only as noted on page 284).

Dr. Daria Shewchuk

Registered Psychologist

British Columbia, Canada

Introduction

Some cases weigh on us therapists. Many years ago, while working as a young social worker in a hospital psychiatric ward, I encountered a number of children who sexually abused other children. They included a 5-year-old boy who performed fellatio on a 3-year-old; a 9-year-old girl who masturbated boys and attempted to pull off their penises; and a 12-year-old boy who violently raped his two younger sisters and continually made obscene gestures and shouted obscenities at adult women.

How does a child develop such behavior? What is the impact of such behavior on the perpetrating child and on the other children involved? How can a therapist, or a parent for that matter, differentiate between what is age-appropriate exploratory play and behavior that is seriously problematic? Why is it important to provide therapy to these children, and how should the therapist plan and execute that treatment? These questions will be addressed.

One case was particularly disturbing to me. It involved a 14-year-old boy who was already branded a sadistic sex offender. How does a child so young get labeled a sadistic rapist who must be locked up? How could so many of my colleagues consider him untreatable?

This book pulls together a plethora of relevant research and combines it with my many years of experience in working with such cases. The impact of violence, oppression, trauma, bonding to inappropriate role models, and traumatic events at crucial stages and ages of development are all explored.

Some of the information presented here can be found in articles of professional journals and in numerous specialized books. However, these sources are widely dispersed, and many are not easily available to the practicing clinician, let alone to teachers and laypeople. Even if one were to read all the theory available, only by combining it with experience can effective help be offered to a particular child.

The case examples in this book are either composites of cases I learned of from other therapists or of my own child-clients seen across a 35-year period. All identifying information has been altered to maintain anonymity. I am using the terms they and them to refer to both multiple children or an individual child because these terms are more gender-neutral.

People often feel anxious or even afraid of what they do not understand, and therefore a stigma might exist around this topic. No child endeavors to grow up to be a sex offender. We can help these children.

This book is for therapists, social workers, doctors, child care workers, teachers, parents, caregivers of children, family lawyers, judges, policy makers, and adults who wish to heal their past. The overarching aim of this book is to help everyone better understand the underlying causes of why children act out sexually, as well as the critical importance of providing timely, developmentally appropriate treatment and helpful interventions.

It is important for children and their caregivers to work with nonjudgemental, knowledgeable professionals who can assist them with the difficulties that children who sexually act out might present with. It is important that these professionals know how to assess the child in a helpful, non-traumatizing way and come to understand the motivations and inner dynamics of which the child is usually unaware. These inner dynamics are actually more important than focusing on the details of the sexual-acting-out behavior.

More specifically, the goals of the book are to assist the reader to:

• Understand why a child may act out sexually.

• Differentiate between what is age-appropriate exploratory play and problematic behavior that requires intervention.

• Provide examples of assessment and therapeutic treatments delivered by trained child therapists to help children heal and learn healthy behavior.

• Provide a summary of relevant research findings on various topics related to working with these children.

The book is divided into three parts.

Part One (Chapters 1–8) presents case examples of children acting out sexually in which each example illustrates a different reason for the sexual acting out behavior. As well, each case illustrates different psychological dynamics.

Part Two (Chapters 9–11) considers the assessment of child sexual behavior as developmentally appropriate or inappropriate. It also provides practical guidelines for caregivers on how to manage a child’s sexual acting out behavior.

Part Three (Chapters 12–24) provides theory, research, information, and resources related to working with children. Information regarding: trauma, trauma-informed interventions, working with children who sexually abuse others, related themes such as memory impacts, dissociation, and issues related to interviewing children are also included. In short, the book is about what we need to know in order to help children heal and move forward in their lives in a healthy and appropriate way.

Parents, daycare staff, and other caregivers might want to read only Parts One and Two. Therapists, students, or professionals working with children will find more research-based information in Part Three.

I urge each of us to remember that all interventions with a child should, at a minimum:

• Create an atmosphere of safety for the child and those around the child

• Address the issues at hand

• Be helpful

• Above all, do no harm

Throughout the book, the reader will also see grey boxes highlighting clinical, or otherwise, notable information.

The reader will learn that typically young children who act out sexually were sexually abused themselves. However, the psychological dynamics (i.e., the psychological forces that underlie human behavior, feelings, and emotions) can be different in different situations. Understanding these differences and the reason any particular child sexually acts out is important because then the underlying issues can be assessed and treated more appropriately. (Please note that childhood sexual abuse does not mean that the individual will offend as an adult.) Assessment is the key.

PART ONE

Case Examples to Help Explain Why

An Introduction to Working With

Children Who Sexually Act Out

The case examples in this book are

either composites of cases or scenarios heard

about or based on child clients seen across

a 35-year period. All identifying information

has been altered to maintain anonymity. Any

resemblance to a known person is

purely coincidental.

Chapter 1

The Girl Who Caused an Epidemic

One day, child welfare investigators called the office to solicit our help with events at an elementary school (Kindergarten through Grade 6) in an upper-middle-class neighborhood. In March of that year, school staff discovered what they called a ‘sex ring’ at their school. To their horror, they realized, that children in Kindergarten, Grade 1, and Grade 2 were regularly sexually molesting each other in corners of the playground, in the washrooms, and in empty classrooms during lunch and recess breaks.

Administrators at the school and child welfare representatives felt overwhelmed. More than 120 children were in those grades. Each one would need to be interviewed! It was a massive task. They wanted suggestions on how to proceed. They also wanted to keep it quiet.

After extensive investigation of more than 100 individuals by the police and child protection authorities, the details of the situation were finally pieced together. Three years previously, a particular girl had entered Kindergarten at this school. Unbeknownst to anyone, she was being regularly sexually abused by her father.

This abuse continued on a regular basis as she progressed to her current grade (Grade 2). She did what many young children do in her situation: she reenacted her sexual abuse onto other children. In turn, many of those she abused reenacted and abused other children. As a result, multiple children were sexually acting out with each other on the school premises. School personnel labeled it a ‘sex ring.’ This is what led to the phone call to the office.

The magnitude of the situation became apparent to school officials, the police, and parents. Some parents figured out that their child was not the only one exhibiting sexual acting-out behaviors, and started demanding answers. The school district wanted to keep things quiet and, not surprisingly, out of the media. Parents were adamant that they wanted answers and help for their children.

No community is really set up to deal with this type of situation. Resolving it included providing education and counseling, as well as developing a safety plan. As a first step in dealing with the situation, we, along with social workers, recommended a group meeting, first with school officials and then with parents. This meeting involved an honest discussion of what had happened, information known to date, and an offer to assist their children. We provided information on how to proceed in assisting their children, counseling, and a plan for future safety of their children.

Education was provided to school staff on how to implement safety plans as well as how and why to be vigilant during this implementation. The plan’s preventative measures included more adult supervision in the bathrooms, extra supervision on the playground, and ensuring that all children were accounted for at all times.

The adults were carefully selected to ensure the children were not only safe with them but also felt safe (with a person who was kind and approachable).

While this situation was eventually controlled and resolved, it provided a shocking example of how psychological trauma can be very infectious in a community.

A variety of terms are used to refer to sexual acting out behaviors of children. Some call them:

• Posttraumatic play

• Sexual acting out

• Sexual reactivity

• Abuse-reactive behavior

• Secondary abuse

• Traumatic reenactment

• Secondary traumatization

The glossary of terms at the end of the book includes the definitions of the terms listed here.

It’s a sad fact that whole communities can be affected by one traumatized child. Furthermore, most of the communities to which this happens are wholly unprepared.

Figure 1: Interventions at Various Levels

It is important to be able to support the child both individually and in all of their different environments.

The child is involved with their family, school, daycare (or other caregivers), and their larger community. The child is impacted by whether they live in a big city or a small town, and what services are available. In addition, the child can be impacted by their culture, race, social economic status, and policies and politics of the area in which they live.

The child therapist needs to be aware of these various influences and might need to intervene with the child or with those involved with the child in each of the above variables.

Part Three of the book discusses in more detail intervention and implementing support at the various levels.

Chapter 2

Children Tell Their Experiences Through Play

(Greg)

Greg, a three-year-old boy, was brought in to my office by his concerned mother. She and her husband had separated six months prior when Greg was two and a half. She stated that he reacted badly to the separation. He acted out, slept poorly, experienced frequent nightmares, talked about monsters, his heart being broken, and dying and going to heaven. (Even very young children can wish to die and feel suicidal.)

Greg also exhibited behaviors from an earlier developmental stage, or regressed behaviors. An example of this is when a toilet-trained child reverts to wetting or soiling themself again.

In addition, over the previous few months, daycare staff had expressed concerns about Greg’s aggression and inappropriate sexual behavior toward other children. Other caregivers also reported to Greg’s mother that Greg sexually acted out with other children.

Greg’s mother finally brought him in after she personally witnessed his inappropriate sexual behavior while she was babysitting another child. The other child did not like Greg pulling down his pants and touching his bum. She was particularly distressed, as she told Greg to stop but later caught him doing the same thing again.

When I spoke with Greg’s father, he reluctantly admitted that he did see Greg engage in ‘sexual’ behavior, but he thought it was exploratory. He