The information in this program outline is provided by the program representative and edited by the CEBC staff. The When Children Abuse program has been reviewed by the CEBC in the area of: Sexual Behavior Problems in Children, Treatment of, but lacks the necessary research evidence to be given a Scientific Rating.

• Types of Maltreatment: Physical Abuse, Sexual Abuse, Physical Neglect, Emotional Abuse, Exposure to Domestic Violence
• Target Population: Children from 5 to 12 years of age who have been identified by any number of sources for exhibiting inappropriate sexual behavior that involves the exploitation of other children.

When Children Abuse is a structured, cognitive behavioral program that addresses the dynamics and behavior of children with sexual behavior problems. The types of sexual behavior addressed include a broad spectrum, ranging from socially inappropriate behavior to aggressive sexual assault involving force or coercion.

It was developed with issue-related modules that can be tailored to address the child, the behavior and the circumstances presented at intake and as treatment progresses. Its guidelines include intake criteria, client assessment, and two types of progress and evaluation tools which can be applied during and following treatment.

It is a “Parallel” treatment program because it includes simultaneous educational/ treatment groups for the caretakers of its child clients, due to the degree of dysfunction, unresolved personal issues and/or emotional reactions of the parents.

The program is based on the belief that a child, regardless of the specificity of the referral or severity of the behavior, must be seen and addressed as a whole child. If there are multiple diagnoses or abuse issues, cognitive/developmental issues, complex family circumstances, etc., these should be addressed as part of treatment.

The goals of When Children Abuse include:

• The client will develop the tools to stop inappropriate sexual behavior.
• The client will gain skills to develop positive relationships with peers and younger children.
• The client who has been abused will be able to resolve the trauma in such a way that it will not be used as a primitive defense mechanism (i.e., as a projective identification with the aggressor).
• Upon completion of treatment, the client will be able to develop positive attachments to caregivers and significant others.
• The family will develop an understanding of the issues that brought them into treatment and gain an understanding of the reasons behind the behavior.
• Other impulsivity issues and co-morbid diagnoses will be addressed, and symptoms will be reduced.
• The client who feels shamed or unworthy will gain a more positive sense of him or herself.

The essential components of When Children Abuse include:

• Structured groups (with individual treatment as needed) which addresses the issues, behaviors and needs of children who exhibit sexually abusive behavior.
• One-on-one approaches often resulted in defensiveness; traditional group treatment challenged limited coping skills and increased anxiety and acting-out behavior, non-directive play therapy offered no way to bind anxiety. Structuring the program around key behavioral issues and activities reduced impulsivity and sexual acting out.
• The philosophy, program components and treatment approaches are available in the form of a soft cover book entitled: When Children Abuse, Cunningham & MacFarlane, 1991. (This is an updated version of their prior book, When Children Molest.) This expanded version includes the importance of attachment issues, medication alternatives (if the child has an impulsive behavior that is not responding to therapy), individual treatment approaches (i.e., sand tray therapy), as well as fire-setting and animal cruelty.

Three Program Components

• Planning and Intervention:
• Intake and Assessment: assessing normal vs. inappropriate sexual behavior, and following progress weekly and monthly using progress evaluation tools and assessment tools including:
• Child Behavior Checklist for 6-18 Years of Age (CBCL/6-18)
  
• Piers-Harris Children's Self-Concept Scale
  
• Connors Rating Scale (particularly if ADHD symptoms are demonstrated)
• Roberts Apperception Test for Children
• Child Sexual Behavior Inventory III (CSBI)
  
• Trauma Symptom Checklist for Children (TSCC)
  
• Test of Problem Solving - Elementary (TOPS-E)
  
• Management of Group Behavior: This component includes a module for group management techniques with focus on tools to help clinicians conduct groups that contain impulsive, acting-out children.
• Working with Parent Groups: The parallel parents’ treatment group is an essential component of the program, so the curriculum also includes guidelines on conducting parents’ groups.
• Teaching Skills and Competencies:
• This component has seven issue-based modules which include developmentally appropriate activities in the following areas:
• Building self esteem
• Managing anger
• Problem solving skills
• Victimization/Trauma Issues
• Perpetration Issues
• Building Empathy
• Sexuality; Sex role stereotyping
• Examples of other issues addressed include: identifying feelings, attachment and loss, and relapse prevention. There are specific goals for each module.
• It is important to note that not all child clients need exposure to each module or to all aspects of every module (i.e., some may not need to address prior trauma, for others, it may be a core component of their treatment.) Some children may need to focus primarily on anger management and its expression via inappropriate sexual behavior. However, many have co-morbid factors, including diagnoses of ADHD, Conduct or Attachment Disorder, Asperger’s, etc. For these children, regardless of their identified sexual behavior, the modules such as empathy training and social skills can aid in behavior management even as deeper issues are being explored. In addition, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) can be used for children with abuse histories. Again, the goal is to treat the whole child with the best tools available.
• Treatment Approaches:
• Children’s groups are generally divided by age and sex. There are a wide range of issue-related activities; clinicians can pick the activities that are most developmentally appropriate for their groups
• Most aspects of the curriculum can readily be adapted for use in individual therapy. It includes a chapter on sand- tray therapy with victims of abuse.
  
• Smaller, companion manuals on related aspects of treatment are also available to supplement the curriculum. For example: From Trauma to Understanding and Steps to Healthy Touching, by the same authors are both available from Safer Society Press.

Other Essential Books Used by Clinicians, Parents, and Clients (included in reference section below)

All clinicians that are working with this population should have access to the book: Children with Sexual Behavior by William Friedrich. Dr. Friedrich was the pioneer in this field, and this publication states all of the research that he and others compiled related to children with sexual behavior problems, as well as suggested hands-on treatment techniques. His philosophy of treating the whole child and not just the sexual acting out behavior is important when treating these children, as often there are other family issues, attachment issues, and other problems with which these children present. From Trauma to Understanding is a book by Pithers, Stickrod-Gray, Lane, and Cunningham that helps parents understand the issues in simple terms, in a supportive manner. Steps to Healthy Touching by MacFarlane and Cunningham, has homework assignments and can be a companion workbook for older children.

When Children Abuse was designed with a child component that addresses the following presenting problems and symptoms:

• Inappropriate sexual behaviors toward younger children, such as fondling, compulsive masturbation, oral copulation, sexual or physical coercion, and sexual acting out that is so compulsive that it is affecting the child’s life and the family’s functioning. If the child has been a victim of or witnessed a trauma, that also is addressed. If the child is particularly sexually aggressive, the program includes assessment and treatment tools for that. It also includes modules that address other impulsive behaviors that may associated with sexual acting out.

Age range: 5 – 12

Developmental Delays:

This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

Treatment Involves Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: It is important that parents be involved since they can be sexual victims themselves, they are overwhelmed that they are in the system, there are child victims in the family, they are angry at the child perpetrator, etc. If they don’t address those issues, treatment will be undermined and the behavior may continue. If they don’t understand their child’s treatment, they may sabotage it. If there is an attachment disorder, that also needs to be addressed as a crucial part of treatment.

When Children Abuse was not designed with a parent/caregiver component.

When Children Abuse was designed to be conducted in a group setting; but has not been tested for use in a group setting.

Recommended group size:

Six children

Testing References:

Recommended Intensity:

One contact per week, 90 minutes in length. Note: If the particular client is in extreme crisis, individual therapy also may be warranted.

Recommended Duration:

If the child was involved in a minor incident, is responding to the program, and has an adequate support system, duration may be as short as 3 months. If the family is extremely dysfunctional, the child has an additional diagnosis, or the sexual behavior is aggressive, coercive, or extremely compulsive, 6 to 9 months is more likely.

This program is typically conducted in a(n):

• Adoptive Home
• Birth Family Home
• Community Agency
• Foster Home
• Group Home
• Hospital
• Outpatient Clinic
• Residential Care Facility
• School

This program does not include a homework component.

When Children Abuse does not have materials available in a language other than English.

The typical resources for implementing the program are:

In a group setting environment, two therapists per group, rooms large enough for 6-8 children, and a separate, larger group room for the parents. Children and parents do not need manuals but clinicians will need a Xerox machine to copy some of the materials. They also need crayons, some puppets, and other play therapy tools that may be necessary. The parents group needs at least one therapist, but two are preferable. In addition, pre/post-testing measurements will need to be purchased by the agency.

Licensed supervisors should who have knowledge of the sexual abuse field and in the area of children with sexual behavior problems. It is be important for there to be a PhD available to the agency to do the pre and post testing, as well as any other psychological testing that may be necessary. Clinicians should have at least a Bachelor’s Degree, and knowledge of child development and sexual abuse. Preferably, they would be in a program to become licensed.

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contacts:

• Carolyn Cunningham, PhD
  playshrink@gmail.com
  phone: (818) 845-5679
• Kee MacFarlane, MSW
  phone: (619) 723-6305

Training is obtained:

it can be provided onsite, or at a mutually agreed site, where multiple agencies may come.

Number of days/hours:

3 days- 5-7 hours per day

Additional Resources:

There currently are additional qualified resources for training:

• Jessica Card, PhD, and Linda Damon, PhD, from the San Fernando Valley Child Guidance Clinic-Family Stress Center.
• Dr. Toni Cavanagh Johnson is in private practice in Pasadena and has a set of materials for this population.

This program has been reviewed and it was determined that this program lacks the type of published, peer-reviewed research that meets the CEBC criteria for a scientific rating of 1 – 5. Therefore, the program has been given the classification of "NR - Not able to be Rated." It was reviewed because it was identified by the topic expert as a program being used in the field, or it is being marketed and/or used in California with children receiving services from child welfare or related systems and their parents/caregivers. Some programs that are not rated may have published, peer-reviewed research that does not meet the above stated criteria or may have eligible studies that have not yet been published in the peer-reviewed literature. For more information on the "NR - Not able to be Rated" classification, please see the Scientific Rating Scale.

Child Welfare Outcomes: Not Specified

Currently, there are no published, peer-reviewed research studies for When Children Abuse.