This 2 hour webinar will explore normal sexualized behavior in children as well as when children display sexualized behaviors that are concerning and problematic. The webinar will highlight various factors associated with children's sexualized behaviors and assist clinicians in understanding appropriate assessment and disclosure processes involved when problematic symptoms are present.

1. Welcome to the
Military Families Learning Network Webinar:
Sexualized Behavior in Children
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This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

2. Welcome to the
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This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

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This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

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5. CE Credit Information
• Webinar participants who want to get 2.0 NASW CE Credits (or just
want proof of participation in this training) need to take the post-test
provided at the end of the webinar
» CE Certificates of completion will be automatically emailed to participants upon
completion of the evaluation & post-test.
» Questions/concerns surrounding the National Association of Social Workers
(NASW) CE credit certificates can be emailed to this address:
MFLNmilitaryfamilyadvocate@gmail.com
» Sometimes state/professional licensure boards for fields other than social work
recognize NASW CE Credits, however, you would have to check with your state
and/or professional boards if you need CE Credits for your field.
• To learn more about obtaining CE Credits, please visit this website:
http://blogs.extension.org/militaryfamilies/family-development/professional-development/
nasw-ce-credits/

6. Today’s Presenter:
Shelly Martin, M.D. Lt Col, USAF, MC, Child Abuse
Pediatrician
• Lt Col Shelly Martin M.D, United States Air Force, is presently assigned at the San
Antonio Military Medical Center, Ft Sam Houston, TX as a child maltreatment specialist.
She is an experienced child abuse pediatrician and provides consultation for all forms of
child abuse and neglect to all branches of the Armed Forces. Dr. Martin is an assistant
professor of Pediatrics at Uniformed Services University for the Health Sciences.
• Dr. Martin has extensive experience and training in the areas of child physical and sexual
abuse, child neglect, child fatalities, medical child abuse, child pornography, and child
interviewing. She completed fellowship in Forensic Pediatrics and is board certified in
both general Pediatrics and Child Abuse Pediatrics. Dr. Martin routinely lectures on all
aspects of child maltreatment to multi-disciplinary audiences. She is the medical
consultant for child abuse cases in the San Antonio area working closely with CPS and
local civilian experts. Dr. Martin is the primary consultant for Air Force child maltreatment
cases and also assists other branches of the military to include medical-legal case
reviews, training and education. She regularly consults and testifies as an expert witness
for both prosecution and defense in military courts martial.

7. Sexualized Behavior in
Children
Shelly Martin MD
Lt Col, USAF, MC
Child Abuse Pediatrician

8. Sexualized Behaviors
• Children often exhibit behaviors that are
deemed sexualized by the adults observing
them
• Can involve just one child or child on child
behaviors
• The question becomes
• What is normal and what is concerning???

9. Objectives
• Understand normal sexualized behaviors in
children
• Understand when sexualized behaviors are
concerning and problematic
• Understand the factors associated with
sexualized behaviors
• Understand the assessment of sexual behavior
problems
• Understand the concern for sexual abuse and the
disclosure process

10. Normal Sexual Behaviors
• Friedrich, W. Pediatrics 1991 and again in
1998
• Questionnaire- demographic information,
Child Sexual Behavior Inventory (CSBI),
and the Problem Behavior portion of the
Child Behavior Checklist (CBCL)

11. Normal Sexual Behaviors
• Many children exhibit behaviors of a sexual nature
• Often associated with
• Exploration and curiosity- by looking and touching
• May be part of exploring gender roles or pretend career
roles
• Most frequent behaviors:
• Self-stimulating behaviors
• Looking at people when nude or undressing
• Behaviors related to personal boundaries

12. Normal Sexual Behaviors
• Sexualized behaviors showed an inverse
relationship to age.
• Peaking at year 5 and dropping off over the next 7
years.
• A Child’s sexual behaviors are influenced by:
• Age
• Surrounding stresses
• Living Space
• Culture/Religion

13. Normal Sexual Behaviors
• Kids are:
• Friends
• Same age
• Same size
• Same developmental stage
• Participate voluntarily

14. Normal Sexual Behaviors
2-5 years old:
• Stands too close
• Kisses or hugs non family members
• Touches private parts in public and at home
• Masturbates with hand
• Tries to touch breasts
• Tries to look at people undressing
• Very interested in the opposite sex

15. Normal Sexual Behaviors
6-12 years old
• Similar actions as 2-5 yo, but not as high
percentages
• Increase in
• Interest in the opposite sex
• Knowledge about sex
• Wanting to watch TV nudity

16. Concerning Sexual Behaviors
• Sexual expression is more adult than child-like
• Other children complain
• Continues, despite requests to stop
• Children sexualize nonsexual things
• Genitals are prominent and persistent in
drawings

17. Behaviors that are Rarely Normal
• Developmentally inappropriate behavior
• Behavior involving children more than 4
years apart in age
• Intrusive or abusive behavior
• Behaviors that result in emotional distress or
physical pain

18. Behaviors that are Rarely Normal
• Behaviors associated with other physically
aggressive behavior
• Behaviors that involve coercion
• Behaviors that are persistent and the child
becomes angry if distracted

19. Concerning Sexual Behaviors
• Kids 2-12 yo rarely:
• Put mouth on sex parts
• Ask to engage in sex acts
• Masturbate with object or insert objects in
vagina
• Make sexual sounds
• Touch animal sex parts
• Imitate intercourse
• French kiss

20. Concerning Sexual Behaviors
• Drawing sexual body part on a picture
relatively uncommon
• Children less than 12 yo rarely draw sex parts.
• Girls do so slightly more than boys

22. Inappropriate Kid on Kid Sexual
Behavior – Why do we Care?
• Where is the children getting the behavior?
• Is there an aggressor?
• What is the nature of the behavior?
• Normal childhood exploration
• Abnormal sexual behavior

23. Possible Influencing Factors
• Sexual Abuse
• This is the big one we are worried about
• Exposure to pornography
• Magazines, movies, Internet
• Exposure to sexual material
• Movies, Internet
• Have seen parental sexual behavior
• Living in a highly sexualized environment

24. Other Factors
• Maltreatment
• Concerning parenting practices
• Parental supervision
• Family violence
• Playmates in the neighborhood

25. Important Considerations
• Age
• Variety and frequency of sexual behaviors
increases up to age 5 years then gradually
decreases
• Does not suggest the behaviors are more
common when younger , but younger children
less aware of personal space and how behaviors
are perceived
• Be concerned with an age difference of at least
4 years – distinct developmental differences

26. Important Considerations
• Situational Factors
• Preschool children are naturally inquisitive
• Recognition of gender differences
• Situations such as the birth of a sibling,
viewing another child or adult in the
bathroom, or seeing their mother breastfeed
can trigger or amplify sexual behaviors
• These behaviors are transient and diminish
when the child understands it isn’t appropriate
in public

27. Important Considerations
• Home life
• Kids more likely to engage in sexual
behaviors if reside in homes with
• Family nudity
• Cobathing
• Less privacy dressing, going to bathroom, or
bathing
• Sexual activity occurs more openly

28. Important Considerations
• Family dysfunction and stress
• Sexual behavior problems significantly related
to homes with disruptions due to poor health,
criminal activity, or violence
• The greater the number of life stresses
(domestic violence, death, incarceration,
illnesses) the greater the number and frequency
of sexual behaviors
• Because child abuse and neglect are more
frequent in these homes, a careful assessment of
the child is warranted.

29. Important Considerations
• Comorbid Diagnoses
• In one sample of children with sexual behavior
problems, 96% had additional psychiatric
diagnoses such as
• Conduct Disorder
• ADHD
• Oppositional Defiant Disorder
• Most children had more than one diagnosis

30. Important Considerations
• Children with developmental disabilities have
challenges with
• Social skills
• Personal boundaries
• Impulse control
• Understanding what is hurtful or uncomfortable
with others
• Have increased risk of sexual behavior problems
and sexual victimization
• Have to look at developmental level of child, not
chronological age

31. Considering Abuse
• Sexual and physical abuse are both
associated with sexual behavior problems
• A meta-analysis of 13 studies showed that
28% of sexually abused children had sexual
behavior problems
• Other studies show 38-48% of children with
sexual behavior problems were sexually
abused
• High rates of physical abuse (32%), emotional
abuse (35%) and neglect (16%) were also noted

32. Considering Abuse
• It is important to note that sexual behavior
problems are often latent
• Often see a lag of 2 to 4 years between sexual
abuse and manifestation of sexual behavior
problems.
• No one specific behavior is indicative of
sexual abuse

33. Considering Abuse
• Sexually abused children display a variety
of sexual behaviors with increased
frequency
• In sexually abused children, sexual behavior
problems correlate with
• Severity of abuse
• Number of perpetrators
• Family member perpetrators
• Use of force

34. What Should You Do?
• Approach the children and inquire about the
behavior
• Why they are doing that?
• Where did they learn that?
• Use open ended questions
• You have to decide if there are concerns
regarding the behavior
• Normal versus abnormal

35. Is the Behavior Normal Childhood
Exploration?
• Are the children acting out adult roles
within normal childhood development?
• Not beyond development level
• Not too sexual in nature (adult like)
• Playing house or doctor
• Are the children showing curiosity?
• Simple “I will show you mine if you show me
yours”

36. Is the Behavior Abnormal?
• Is there aggression, force, or coercion?
• Is the sexual behavior developmentally
appropriate for age?
• Is the play between same age peers with
same developmental level?

37. If this is not innocent play…..
• Make calls to the appropriate authorities –
FAP, OSI to initiate a proper investigation
• Know your resources
• Do not attempt to interview children beyond
your capabilities – Leave forensic interviewing
to those who are trained
• Employ increased supervision and address
safety concerns

38. Talk to Parents
• Ask if they know where the behavior may
have come from
• Ask about sexual material in the home –
computer, movies, cable

39. ATSA Task Force on Children with Sexual
Behavior Problems (SBP) – May 2008
• Looked at multiple factors related to SBP
• Definition
• Incidence and Prevalence
• Etiology
• Assessment Qualifications of Experts
• Assessment Contextual Factors
• Mandatory reporting
• Placement policies – removing a child

40. Definition of SBP
• Children < 12 years who initiate behaviors
involving sexual body parts that are
developmentally inappropriate or
potentially harmful to themselves or others

41. Incidence & Prevalence
• No population-based data
• Recent increase in cases referred to CPS,
juvenile services, and treatment settings
(inpatient and outpatient)
• Why the increase?
• Increased incidence?
• Changing definitions of SBP?
• Increased awareness and reporting?
• Combination of factors?

42. Assessment
• Those assessing SBP should have
knowledge about:
• Child development
• Differential Diagnosis – mental health and
other confounding behavior problems
• Should have specific knowledge of common
problems – ADHD, Bi-polar, etc
• Understand related factors
• Environment - Parenting – Family - Social Factors

43. Assessment Factors
• Quality of caregiver-child relationship
• Caregiver capacity to monitor and supervise
behavior
• Presence of positive/negative role models
and peers
• Types of discipline used – limits, structure,
consistency, and child’s response
• Emotional, physical, and sexual boundary
violations in the home

44. Assessment Factors
• Extent and degree of sexual and/or violent
stimulation
• Exposure to and protection from traumatic
situations
• Cultural factors – racial, ethnic, relious,
SES, etc
• Other factors – resilience, strengths,
resources

45. Assessment Issues
• Decisions on a case by case basis
• Respond well and quickly to treatment
• These children at low risk to commit future
acts if properly treated
• Use less restrictive means for child
• Long term residential treatment should be a last
resort
• Other efforts have failed
• Extreme circumstances – risk of harm

46. Assessment Issues
• This task force emphasized the importance of
identifying sexual behavior problems and
getting treatment for a child before the age of 12
• If treatment obtained before age 12 , these
children had a very low risk to commit future sex
offenses
• Children with SBP respond well and quickly to
treatment
• Children with SBP are a different population
than adult sex offenders

47. Understanding
Disclosures

48. Disclosures
• What was disclosed?
• In what context?
• What questions were asked that led to the disclosure?
• THE DISCLOSURE IS THE MOST
IMPORTANT PIECE OF EVIDENCE – The
Disclosure alone can make the diagnosis of
sexual abuse

49. Disclosures
• Need to be obtained appropriately without direct and
leading questions.
• Forensic interviews should be completed only by
qualified personnel.
• Open-ended questions, body language
• Know what is available in your community
• If you are not trained to do forensic interviewing,
then obtain minimal and do not attempt to obtain
more information than you are trained to get

50. Delayed Disclosure
• Common
• Analysis of retrospective studies show that
60-70% of adults do not recall disclosing
abuse as a child
• Studies of children show that delay of
disclosure is common and when they do
disclose it can take a long time

51. Delayed Disclosure
• Boys may be more reluctant to disclose than
girls
• Cultural differences effect disclosure
• Cultures with negative attitudes and taboos
about sexuality and cultures that place a high
value on preservation of family

52. Developmental Considerations
• Younger children more likely to disclose
accidentally
• Spontaneous statements about abuse not consistent
with the topic of discussion or current activity
• Witnessed abuse, medical examinations
• Older children more likely to report abuse to
an adult when asked
• No particular age cut-off

53. Developmental Considerations
• Younger children may not have the
linguistic skills to report abuse
• Younger children may not understand the
“meaning” of abuse

54. Developmental Considerations
• Adolescents have a greater appreciation of
the consequences of disclosing intra-familial
abuse and may withhold
information
• They may also not disclose extra-familial
abuse because they think it is a “personal”
issue or they have already disclosed to peers

55. Other Considerations
• Children with a supportive parent
(especially the mother) are more likely to
disclose than children whose parents do not
support or believe them

56. Behavioral Disclosure
• Younger children may exhibit sexually
inappropriate behaviors
• Older children may exhibit behaviors that they
hope will tell someone something is wrong
• Trying to avoid going home by hanging out at
school
• Angry outbursts with hopes that people will
wonder what is wrong
• Asking Mom to come home early or asking if
she has to go work
• Substance abuse (“blank out the abuse”)

57. Recantations
• Rates vary, likely lower than once thought
• Often influenced by the perpetrator, but
more often influenced by the “non-offending”
family members.
• The child is made to feel guilty
• The child is told to lie to protect another family
member
• The child feels the repercussions are their fault

58. Fantastical Disclosures
• Children will often provide a detailed disclosure,
but add fantastical parts
• Then I hit him and knocked him out and ran
• Superman arrived and saved me
• You have to keep in mind the developmental level
of the child as well as coping mechanisms
• Sometimes children don’t have all the words to
explain the detail or focus on specific details

59. Why Children Don’t Disclose
• Psychological manipulation- abusers may
threaten, or “bribe” the child
• Shame from guilt- blame themselves
• If the child discloses incest the family will “fall
apart”
• Do not want to be responsible for putting the
perpetrator “in jail” or getting them in trouble
• Dissociation and repression
• Didn’t know the behavior was wrong

60. Why Children Don’t Disclose
• Relationship to the perpetrator
• The more closely victims are related to the
perpetrator the less likely they are to disclose
sexual abuse
• Significant caregiver, attachment issues, child’s
need to protect the family

61. Impetus for Disclosure
• Exposure to the perpetrator
• Planning visit to where perpetrator is
• Safety
• Disclose after moving or when perpetrator no
longer close
• Influence of peers
• Educational awareness
• Anger

62. Disclosure Types
• Active
• Ready to give detailed disclosure to the best of their
ability
• Tentative
• Partial disclosure of events
• Vague, vacillating
• Testing the waters (will they be believed)
• Minimizing
• Testing threats by the perpetrator

63. What do you do if a child discloses
sexual abuse?
• Believe them
• Ensure them that it was not their fault
• Listen carefully
• Tell them they did the right thing in
disclosing
• Be very careful of your reaction – don’t act
shocked or emotional – Keep composed
and help the child

64. Documentation
• Document everything the child reports to
you.
• In quotes if possible
• Document what is reported to you by the
parents
• Again use quotes to document what the parents
report the child saying

65. How Can We Help Parents
• Computer safety
• Keep computer in an open area
• Monitor children’s use
• Use parental controls
• Don’t allow potentially dangerous activities (like
chat rooms)
• Teach kids to never give out personal
information
• Do not send pictures over the internet

66. How Can We Help Parents
• Encourage parents to provide education
appropriate for age
• Teach preschool children appropriate names
for body parts and private parts
• Teach preschool children about who can and
cannot touch private parts
• Advance sexual knowledge as children get
older
• Repeat safety education
• Maintain open communication with your child

67. How Can We Help Parents
• Know who your children play with
• What ages, what games are being played
• Don’t be afraid to be involved and monitor
your children

68. CE Credit Information
• Webinar participants who want to get 2.0 NASW CE Credits (or just
want proof of participation in this training) need to take the post-test
provided here:
https://vte.co1.qualtrics.com/SE/?SID=SV_b95UC5DHIlcj34V
» CE Certificates of completion will be automatically emailed to participants upon
completion of the evaluation & post-test.
» Questions/concerns surrounding the National Association of Social Workers
(NASW) CE credit certificates can be emailed to this address:
MFLNmilitaryfamilyadvocate@gmail.com
» Sometimes state/professional licensure boards for fields other than social work
recognize NASW CE Credits, however, you would have to check with your state
and/or professional boards if you need CE Credits for your field.
• To learn more about obtaining CE Credits, please visit this website:
http://blogs.extension.org/militaryfamilies/family-development/professional-development/
nasw-ce-credits/

69. Next Webinar:
Thursday, December 11, 2014 @ 11:00 am EST
Using Protective Factors to Inform
Work with Child Maltreatment
https://learn.extension.org/events/1797#.VFAL4b7yOzA
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

70. Military Families Learning Network
Find all upcoming and recorded webinars
covering:
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http://www.extension.org/62581
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.