A Comparison of Self-Reported Emotional and Trauma-Related Concerns Among Sexually Abused Children With and Without Sexual Behavior Problems

Abstract

Numerous studies document concomitant features of sexual behavior problems (SBPs) among children 12 years of age or younger, but rarely does research involve child self-report assessments. This study provides the most comprehensive examination to date of self-reported concerns among children with SBP, using a large sample (N = 392) of clinically referred participants who reported sexual abuse histories. Children between the ages of 8 and 12 were categorized as demonstrating SBP (n = 203) or not demonstrating SBP (n = 189) as determined by scores on the Child Sexual Behavior Inventory. Children completed the Trauma Symptom Checklist for Children, and caregivers completed the Child Behavior Checklist. Self-reports of children showed that those with SBP reported significantly greater concerns in all areas, including sexual preoccupation and sexual distress, than their peers not demonstrating SBP. Caregivers of children in the SBP group reported greater concerns of internalizing and externalizing problems than the caregivers of children who did not have SBP. Implications for clinical practice and future research are discussed. Specifically, it is recommended that future research improve on the manner in which sexual abuse and SBPs were defined and assessed.

Keywords

sexual behavior problems sexual abuse child abuse internalizing problems externalizing problems

Children with sexual behavior problems (SBPs) are a diverse group of individuals and relatively little research has examined the development of these behaviors. SBP is a broad term that encompasses developmentally inappropriate or potentially harmful interpersonal and/or non-interpersonal (e.g., self-focused and public demonstration) behaviors involving sexual body parts (Chaffin et al., 2008). Etiological factors may be complex and likely involve multiple influences at various systemic levels (Elkovitch, Latzman, Hansen, & Flood, 2009). One often reported risk factor for the development of SBP is the experience of sexual abuse (Friedrich et al., 2001; Kendall-Tackett, Williams, & Finkelhor, 1993). Some of the more prominent theories of SBP (e.g., social learning, manifestations of posttraumatic stress symptoms) are more plausible when sexual abuse has occurred (Finkelhor & Browne, 1985). However, some studies suggest that the majority of children with SBP do not have a sexual abuse history (Bonner, Walker, & Berliner, 1999; Silovsky & Niec, 2002), and these etiological theories may not be as applicable in these cases. Nevertheless, because sexual abuse is a risk factor for SBP, it makes sense to examine a sample with this history in order to gain a better understanding of the correlates of SBP in children.

A repeated finding is that children presenting with SBP display significantly elevated scores on measures of other externalizing and internalizing problems, and poorer social skills (Lévesque, Bigras, & Pauzé, 2012; Silovsky & Niec, 2002). One drawback to these studies is an almost universal reliance on caregiver-report measures, owing largely to the age of the population being studied. However, parent and child reports of emotional and behavioral concerns frequently differ, and children may be more accurate reporters of internalizing problems such as anxiety and posttraumatic stress (Choudhury, Pimentel, & Kendall, 2003; Stover, Hahn, Im, & Berkowitz, 2010). These results suggest the importance of obtaining reports from multiple informants, including the child.

Only two identified studies of children with SBP have included child-reported assessments of emotional and/or behavioral symptoms. Pithers, Gray, Busconi, and Houchens (1998) administered the State-Trait Anxiety Inventory for Children (STAIC) directly to children as part of a cluster analysis study examining potential typologies for children with SBP. Results suggested that children with more complex maltreatment histories scored higher on the STAIC than children who displayed greater levels of aggression during the commission of sexual acts. In a related study, Gray, Busconi, Hochens, and Pithers (1997) administered the Youth Self-Report measure to a small sample of children between the ages of 11 and 12 with SBP. Approximately 40% of the children reported clinically significant levels of internalizing (e.g., anxiety and depression) and externalizing (e.g., aggression and conduct problems) problems. These results suggest that the majority of children with SBP do not identify concerns with anxiety or other emotional or behavioral symptoms at a clinical level.

The current study is an archival analysis that examined the self-reported characteristics of children with sexual abuse histories to determine any potential differences between those who did and did not demonstrate SBP. In addition, caregiver reports of emotional and behavioral concerns were compared between those caring for children with SBP and those caring for children without SBP to ascertain whether our data reflect the larger body of research suggesting greater levels of problems among children with SBP. Given the current literature, it was hypothesized that children with SBP, and their caregivers, would report greater levels of symptomatology than the children and caregivers with no significant concerns related to sexual behavior.

Method

Participants

All participant children in this study presented to a hospital-based outpatient mental health clinic serving maltreated children and children 12 years of age or younger with SBP. During the admission and intake process, caregivers completed a clinic-specific questionnaire asking about the child’s experience of various events. Only children whose caregivers endorsed the child previously disclosed sexual abuse were included in this study. It was not possible to verify these reports as a result of the archival nature of the study and confidentiality concerns. All children were between the ages of 8 and 12, as these ages constitute the lower bound of the self-report measure (i.e., Trauma Symptom Checklist for Children [TSCC]) and the upper bound of the caregiver-report measure of SBP (i.e., Child Sexual Behavior Inventory [CSBI]).

All data for this study were obtained between December 1997 and September 2010. Children and caregivers completed a battery of psychological testing instruments as part of the intake process prior to beginning treatment. Prior to 2002, the CSBI was only administered if SBP was a concern during the initial intake interview; afterward, it was a core component of the assessment battery. In addition, until 2007, the clinic ran a state-sanctioned specialized outpatient treatment program for children with SBP. These factors resulted in a sample with a larger proportion of children presenting with SBP than might be typical in general clinical settings. During the study period, 603 children with reported sexual abuse histories and within the defined age range presented for treatment. Only children with complete data in the archive (n = 392) were included in this study. The data most often missing from the archive were the CSBI (n = 134). No differences were found between the children included and those not included for age, gender, or ethnicity. This project was approved by an Institutional Review Board.

All participants meeting inclusion criteria were categorized as either No SBP (n = 189) or SBP (n = 203) based on CSBI scores (see subsequently). The sample was overwhelmingly of European descent (n = 325, 82.9%) and was approximately 9.8 (SD = 1.4) years of age. No significant differences were found between the groups on ethnicity or age. However, gender distribution was significantly different between the groups, χ²(1, N = 392) = 9.8, p = .002, with the SBP group containing a greater proportion of males (n = 83, 40.9%) than the No SBP group (n = 49, 25.9%). A series of between-group analyses were performed to determine whether gender differences existed for the emotional and behavioral variables under examination, and no significant findings were observed. This is most likely due to the separate gender norms used for scoring the measures. No demographic information was collected for the caregivers and was therefore not available for analysis.

Measures

CSBI

The CSBI (Friedrich, 1997) is a widely used caregiver-report measure of sexual behavior among children between ages of 2 and 12. The 38-item measure assesses the frequency of developmentally normative and abnormal sexual behaviors. T-score conversions use norms specific to the age and gender of the child. We used the CSBI Total Scale score, which includes all items on the measure, and the Sexual-Abuse Specific Items (SASI) scale, which includes only those items that are unusual for a child of a specific age and gender. The CSBI demonstrates acceptable reliability and validity (Friedrich, 1997). Children who received clinically significant scores (T = 65 or greater) on the CSBI Total and/or SASI scales were classified as demonstrating SBP. Children not receiving a clinically significant score on either scale were assigned to the No SBP group.

Child behavior checklist (CBCL)

The CBCL (Achenbach, 1991) is a widely used caregiver-report broadband measure of emotional and behavioral concerns in children. We used the Internalizing and Externalizing composite scores of the CBCL. T-scores of 70 or greater are considered in the clinically significant range. Reliability and validity of the CBCL is demonstrated in numerous studies and summarized in Achenbach (1991).

TSCC

The TSCC (Briere, 1996) is a self-report measure for children between the ages of 8 and 16 and was used to assess anxiety, depression, anger, posttraumatic stress, and dissociation as well as sexual preoccupation (the child’s frequency of thinking about sexual behaviors and topics) and sexual distress (anxiety toward sexual topics). The 54-item measure asks children to identify the frequency of concerns on a scale from 0 (never) to 3 (almost all of the time). T-scores of 65 or greater are considered clinically significant on all scales, except the two assessing sexual concerns, which require a T-score of 70 to reach clinical significance. Briere (1996) reports on the results of multiple validation studies documenting the measure’s acceptable psychometric properties.

Analytic Plan

Prior to beginning parametric analyses (including demographic analyses), screening of data occurred. Examinations of the normality of distributions found that both scales of the CBCL were normally distributed; however, all scales of the TSCC demonstrated significant positive skew. Based on examinations of the shape of the distributions, the anxiety, anger, posttraumatic stress, and dissociation scales underwent square root transformations, the depression scale was transformed using logarithmic procedures and the sexual preoccupation and sexual distress scales were transformed using inverse properties. All transformations were used for the purposes of data analyses; however, to assist with data interpretation and clinical utility, T-score means and standard deviations are provided in Table 1. Next, a series of multivariate analyses of variance (MANOVAs) were calculated to examine the relatively large number of dependent variables jointly in an effort to reduce test-wise alpha inflation. The dependent variables were grouped according to similarity within source of report (child, caregiver), that is, child self-reported emotional problems (anxiety, depression, and anger) and trauma-related problems (posttraumatic stress, dissociation, sexual preoccupation, and sexual distress), and caregiver-reported concerns (internalizing and externalizing scales). When the resulting MANOVA was significant, univariate analyses of variance (ANOVAs) were used to examine group differences on specific variables.

Table 1.

Descriptive Statistics and Univariate Tests.

	No SBP		SBP
	(n = 189)		(n = 203)
Variable	M (SD)	95% CI	M (SD)	95% CI	F(1, 390)	η²
TSCC: Anxiety	51.9 (12.5)	[50.1, 53.7]	58.0 (15.2)	[55.9, 60.1]	18.56**	.05
TSCC: Depression	50.7 (11.5)	[49.1, 52.4]	56.7 (13.9)	[54.8, 58.6]	21.23**	.05
TSCC: Anger	48.8 (10.5)	[47.3, 50.3]	53.2 (11.8)	[51.5, 54.8]	15.04**	.04
TSCC: Posttraumatic stress	51.0 (10.9)	[49.4, 52.5]	56.0 (12.0)	[54.3, 57.7]	18.73**	.05
TSCC: Dissociation	50.6 (11.3)	[49.0, 52.2]	54.9 (11.8)	[53.3, 56.6]	14.64**	.04
TSCC: Sexual preoccupation	53.9 (15.2)	[51.7, 56.1]	61.6 (21.2)	[58.6, 64.5]	18.04**	.04
TSCC: Sexual distress	60.6 (19.5)	[57.8, 63.4]	67.1 (23.0)	[63.9, 70.3]	8.58*	.02
CBCL: Internalizing	57.8 (11.7)	[56.2, 59.5]	65.8 (10.9)	[64.3, 67.3]	48.14***	.11
CBCL: Externalizing	55.4 (10.1)	[53.9, 56.8]	66.4 (9.6)	[65.1, 67.8]	122.48***	.24

Note. SBP = sexual behavior problems; CI = confidence interval; TSCC = trauma symptom checklist for children; CBCL = child behavior checklist.

*p < .01, **p < .001.

Results

Table 1 provides descriptive data for all scales, as well as the results of univariate ANOVAs for all variables. The MANOVA for self-reported emotional concerns was significant (λ = .94, F = 7.73, p < .001) with significant differences for anxiety, depression, and anger. The effect sizes were small to moderate (Cohen, 1992), and the mean T-scores for the SBP group were roughly half a standard deviation higher on all three variables when compared to the No SBP group. The MANOVA for the self-report scales of post-sexual abuse symptomatology was significant (λ = .94, F = 6.27, p < .001) with significant differences for each type of concern by SBP group. The SBP group scored significantly higher than the No SBP group, with small to moderate effect sizes and T-score differences of approximately 5 to 10 points. The final MANOVA for caregiver-reported concerns was significant (λ = .76, F = 62.3, p < .001) with group differences on the internalizing and externalizing scales. As expected, the SBP group scored higher than the No SBP group with medium to large effect sizes.

Discussion

The results of the current study were consistent with the hypotheses that sexually abused children with SBP, and their caregivers, would report greater levels of concern than children without SBP and their caregivers. There are three primary findings of the current study. First, sexually abused children with SBP consistently reported higher levels of emotional and trauma-related concerns than the control group of sexually abused children without SBP. Second, caregiver report mirrored the findings of the child self-report scales, with caregivers of children with SBP reporting greater levels of internalizing and externalizing concerns than parents of children without SBP. Finally, children with SBP did not, on average, self-report clinically significant levels of concern. Similarly, caregivers of these children did not report clinically significant levels of concern on the two scales of the CBCL. Collectively, these findings suggest that sexually abused children with SBP may self-report greater emotional and trauma-related concerns than other sexually abused children, but these concerns do not rise to the level of clinical significance, reflecting findings noted elsewhere (Gray, Busconi, Hochens, & Pithers, 1997). Similarly, a pattern is noted for caregivers that confirms previous findings of increased concerns related to multiple emotional and behavioral problems among children with SBP (Lévesque et al., 2012; Silovsky & Niec, 2002), even though these increases do not reach the level of clinical significance.

This study should be viewed in light of its limitations. First, the study employed a cross-sectional design, and the nature of the design involved assessing emotional and behavioral characteristics concurrent with SBP. Common method variance cannot be ruled out. Second, the sample was inherently biased as only children presenting for mental health assessment and treatment were involved. Lacking children who were not referred for services (e.g., asymptomatic children, children with unidentified sexual abuse or SBP) may have skewed the obtained results. In addition, it was not possible to verify claims of sexual abuse disclosure as provided by the parents. The possibility that some parents endorsed a previous sexual abuse allegation based solely on the child’s presentation of SBP cannot be ruled out. Greater confidence in the sexual abuse status of the children would have improved the quality of this study. Third, the archival data used for the current study did not allow for an examination of single items on the CSBI, which would have yielded greater information about the nature of the SBP displayed. Such information holds the potential for answering more sophisticated questions, such as whether differences exist between children with interpersonal SBP and non-interpersonal SBP. In addition, the lack of item-level data resulted in the use of the CSBI’s T-scores, which are a function of number and frequency of problems. As such, single event “critical incidents” that would qualify as an SBP were not captured. Finally, data about the caregivers of the children were not available in the archival data set employed. Therefore, it was not possible to evaluate caregiver demographics as possible influences on the outcomes.

Despite these limitations, our findings support the importance of obtaining standardized psychological test data related to SBP. In this study, children actively demonstrating clinically significant levels of SBP obtained normative scores on both a child self-report measure and a caregiver broadband measure. Unfortunately, neither of these measures (i.e., CBCL and TSCC) directly assesses problematic sexual behavior in a valid and reliable way. Thus, the likelihood of failing to accurately identify and treat SBP is high. Given the relatively high rate of sexually abused children with SBP, this lack of direct assessment of SBP may result in poor identification and treatment of such concerns with these children. It may be useful for clinics treating sexually abused children to routinely assess problematic sexual behavior using the CSBI or another instrument. However, routine assessment and identification of SBPs may result in the more frequent need to notify appropriate protective services or investigatory agencies depending on the mandated reporting laws in effect.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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