Hi, welcome everybody. We're going to be talking today about childhood sexual development and understanding child sexual behavior problems. So thank you for being here today. This is a very unusual topic so appreciate you taking the time to learn about this and to educate yourself on these very complex dynamics of young children. So my name is Ashley Cinelli-Matthews. I currently work at the Foothills Child Advocacy Center where I'm a forensic interviewer of children, which means when there's been an allegation of any kind of abuse, neglect or a crime committed against the child or teenager, they come and speak to me. So I talk with them and find out what has happened in as much detail as possible while also being developmentally sensitive, trauma informed and trying to ensure that the child only needs to tell their story one time to one person. So that's a little bit about me. I'm also a social worker and I have worked in child protective services as well. So kind of the spectrum of working with kids who have experienced trauma. All right. Thank you all for being here. I do need to share this disclosure. There are no conflicts of interest in this training. And so you have this information here for you to review. All right. So what we're going to talk about today is the continuum of child sexual development. So what that looks like when it's more typical and normative and what it looks like when we start to be concerned about it. And then we're also going to spend some time on how you can respond. So as a nurse and just, you know, as a person in the world, how you may respond if these situations come to your attention, who you need to involve or what the next steps might be if there is a concern about a child having sexual development problems, sexual behavior problems, and some information about treatment and intervention. So what helps these kids and families? I also want to let folks know this is, of course, a recorded training. And so, you know, you will have the power to to pause and to give yourself a break if you need it. So, you know, we're not going to be talking about a lot of specific or graphic details today, but we are going to be talking, you know, touching on the fact of sexual abuse of children. And so if at any point you need to take a break, you need to take a pause, step out, get some water, take a walk, anything that helps you to regroup, you know, I encourage you to do that. The other thing we're going to be doing today, because we're not together in the same room, what I would like for you to do is to grab yourself a piece of paper. And that's going to be kind of your to do list or your homework sheet. So as we go through today I'm going to pause from time to time and you're going to see this little image pop up. And that's going to be your flag to know that that's something for you to kind of write down on your cheat sheet or something for you to flag for yourself to look up and to find out. My goal is that by the end of our time together today you're going to have kind of a one page little cheat sheet that gives you those important bullets of like what do I do, who do I call, what are the numbers I need to know. What do I need to find out about these kinds of cases in my area. And so, some of it you may be able to put on your sheet while we're in our session today and some of them may be your homework for you to kind of find out that information and then again you'll have something so that if a situation involving a child pops up and you're like, Oh no, who do I call, you can pull out your cheat sheet and you'll know just what to do. So that's going to be our, our final outcome today of our training. Alright, so let's start talking about child sexual development. Starting with kind of what's natural what's healthy, what we typically see in most children. So the first question I always ask folks is, when does sexual development begin. Pause for a minute and let you think, and kind of picture in your own brain, the age of a child, the age of child is when sexual development begins. So many of you may already be picturing a baby at birth, because that's when sexual development begins right on children sexual organs organs are present in utero, as you know, genetic females are born with every egg they will ever have already inside and children are continuously developing sexually throughout their lives, right, just as they don't in every other way cognitively, emotionally, developmentally right, it's just part of the human body and part of development so you guys as nurses probably And I say this because sometimes when I do these trainings people are uncomfortable with that thought, and they think maybe doesn't have sexual development right it causes some anxiety or some discomfort. And so we want to recognize that that's kind of us as adults putting our own baggage and our own spin on to sexual development, sexual organs are part of the body and they're natural and healthy and they're there for for everybody, and they're there our whole lives. And so again we want to try to remove some of those stigma stigmas or discomfort that we may have around this, so we can, you know, respond in a calm and objective way, when we're working with kids. And so, what we see with children is that sexual behavior is a continuum. Right. And so what we see in kids when it's more typical, or more we would expect for young children is when any kind of sexual behaviors are exploratory meaning they're just curious they're trying to learn they're trying something they've never done before it's, it's a light and a curious attitude towards it. It's agreed upon. It's, you know, all any other kids or people who may be involved are kind of participating with consent and with no coercion. And so any kind of behaviors you might see would be kids who are near the same age, and you're the same age size development, not when there's a big gap in abilities between the kids, and then it happens from time to time. Right, so it's not something that they're preoccupied with or kind of engaging in sexualized behavior, all the time. Right. And so you guys have probably seen this if you have where you work with toddlers preschoolers elementary school kids right. They all go through that bathroom phase where those words are so funny. They're very curious about people's bodies maybe they're following people in the bathroom like, what do you have what do I have, why are they different what's going on here. All very normal. And so I don't want anybody to leave this training thinking, oh my god, everything is everything is a problem and I need to call CPS every time a kid peeks in the bathroom, right, because we don't want to become concerned about typical And so, you know, the first thing is just kind of understanding what is typical and that it's okay for kids to have some curiosity and some, you know, some behaviors that we as adults may term sexual, even though for a child, they're not experiencing that type of, you know, arousal or physical sensations that maybe as an adult we would, but the behavior itself may look or kind of be labeled as sexual. One resource that is at the end of the handout is this book here. That's called understanding children sexual behaviors you cannot see it because of my zooming there we go. So this is a little booklet by Tony Kavanaugh Johnson she's a PhD who has an extensive work with kids with sexualized behavior problems if you go to her website that's on the final slide of our presentation she has these little booklets, they're not very expensive the last time I checked and you can order them. She's got one on understanding children sexual behaviors and then she's got one on helping children with sexual behavior problems. So those are quick and easy you know they're, they're small little resources, but they are helpful if you if this is a type of child or a type of family that you're going to be working with or you just want to understand more about how to do that. She and her book has whole kind of charts for kids of different ages and different developmental stages of kind of what's typical and not something that we're normally too worried about what's something we want to keep an eye on. And what are the things that we probably need to start thinking about getting some professional help for. So she has some nice resources there that that you might find helpful. So again, just like I know we talked about preschoolers kind of being curious, wanting to, you know, look at other people or understand bodies and what they do. It's normal for preschoolers to touch their own private parts right again that's part of that curiosity and just in the same way they might scratch their elbow or pick their nose, they may touch their private parts right so again, that's not something that we would in and of itself be worried about. Kids get a little bit older into elementary school right again they still may have that curious curiosity around bathrooms and nudity. You know, they may start with that kind of boy girl stuff right boys are gross and girls have cooties you know these kinds of things that they're starting to learn. They start to want more privacy in the bathroom or in the bathtub. That's normal little kids don't always feel too modest but as they get a little bit older they start to want some privacy. And there may be some, you know, interest or again some passing behaviors of trying to look at or show their private parts, or, you know, touch other people's private parts again if it's kind of an exploratory and an occasional way that's able to be done by an adult, then again that's not not too out of the realm of what's what we would consider typical. So for preteens what we see is that there is some growing interest in sex. Very normal for them to want to seek out information about that certainly we may see them looking at things online, whether that's information videos, chatting those kinds of things. There's likely to be some masturbation. And so again, what I'm telling you now all these examples are things that are generally typical and that's something that we would, if there's no other risk factors, not really things that we would be worried about or be calling, calling for help for kids. Right. So moving on. We're also going to talk, of course about children with sexual behavior problems. So we've talked about what's typical. Now let's look at the things that we may be concerned about. I always want to start with a quick note about the language that we use for these kinds of children. We're not in this presentation I'm not going to say words like an offender, a predator. Those are not words we use to describe children and minors. What we're talking about is children who have problematic sexual behavior so you may see PSB or CSBP children with sexual behavior problems and those are the terms that we use here in our facility and we're working with children. We're going to talk in a little bit about the difference between kids who are acting out sexually versus adults, and why we don't want to confuse the two or think that children who have these behaviors would be the same as an adult who has those behaviors. Right. So we're always keeping in mind that this is a child who just has behavior problems just in the same way that we would think about a child who has other kinds of behavior problems right attention problems or acting out problems, or, you know, trouble focusing in school, things like that. And so I always like to pause about that. The other thing that I think people don't realize is that this is happening more and more. So, if we look at Children's Advocacy Centers across the nation. The, their most recent statistics that they had published was that they collected data on, you know, all the types of cases that come through a Children's Advocacy Center and receive forensic interviews and other types of abuse related services. So, pause for a minute and let you think, if I said you how many of the cases that come to a Child Advocacy Center across the United States. How many of those do you think involve somebody who's acting out or somebody who we would consider in the, I'm going to use the word even though we don't with children but in the offending role. What percentage of those would you think is a minor under the age of 18. Get that number in your brain. And then I'm going to tell you that the national statistics show that 20 to 25% of the cases where a child is coming to a Child Advocacy Center to have an interview. The person who is alleged to have offended against that child is a minor. Okay, so it's a lot. We get a lot of those cases and again I think that's something that maybe folks outside of this field might be surprised to learn. And we're going to talk in a minute about kind of what what leads to these behaviors and why that might be. I think part of what's happening is that across our communities and across the nation, more and more adults are starting to realize that this is a behavior that needs to be addressed and it is something that they need to get some outside help for. And so I think part of the reason we're getting more and more calls about these is that things that may be in past generations were kind of ignored or people pretended like they didn't happen or they just maybe thought it was okay. People are now starting to realize they need to reach out and get some help for the kids in these situations. And this is just my own opinion about maybe why these cases go up because just in my career I've definitely noticed a larger percentage of these cases coming in each year. All right. So what we're looking at now are, we're talking about children with sexual behavior problems. These are some of the patterns that we see and things that we would be concerned about and wanting to get some help for the kids. So if it happens a lot, right, it's not an occasional thing, it's happening very frequently. Any kind of sexualized behavior or sexual contact between children of very different ages or just very different developmental stages, different sizes, right, anything where it doesn't seem like it's an equal power balance is something for us to be looking at. When the sexual behaviors are initiated with strong and upset feelings. So I remember I said before, when things are kind of more typical or what we would expect for a young child, it's usually kind of light, curious, maybe even a little silly. If a child becomes very angry, and then that is linked for them to sexualized behaviors, that's something we want to look more carefully at. So that's definitely something to keep an eye out for. If it causes harm or even potential harm to another child, right, so anything that happens that one of the kids is not okay with, or feels upset about, feels that they've been victimized by, that was not a consenting interaction. That's something we want to look at. So again, for those of you who are listening to this, who are in a caregiving role for kids, right, just like with anything else, if we're seeing, you know, sexualized behaviors or just any kind of behaviors that we don't want to continue, we may say, right, hey, we don't do that here. Hey, let's stop that. Hey, go up to your room if you're going to do that. Hey, let's take a break. And again, if it's one of those common normative behaviors, most kids are going to be redirected just the same way they would be if you said, oh, we're not having any chocolate right now, put it down, right, they're able to be redirected from it. If people, parents, caregivers, or other adults are trying to stop the behavior, they're having those conversations, they're setting those limits and boundaries, and it continues to happen because the child just almost feels compulsive about it, or kind of can't stop, then again, that's something we want to look at. And anything that involves coercion, force, or aggression, that's a concerning behavior, right? So two kids who are kind of like, I'll show you yours if you show me mine, ha ha ha, how funny, and then they go on and play something else, that may be fairly typical, right? But when it turns into, hey, I'll give you a dollar if you show me, and the other kid kind of doesn't want to, but they feel a little bit forced into it, then we start to worry, right? So that's a very different feeling to what we're looking for. All right, so considering this and thinking about these behaviors, you know, those of you who spend time with kids or have your own kids, you may be starting to get a feel for kind of the difference or that continuum of what we see in, you know, a typically developing child and when we start to be worried. So as we move into any of these red flags, those are the times when you're going to be, as a nurse, thinking, I need to start pulling in my resources or making some of those phone calls. I also want to touch briefly on, you know, what may cause children to have these kinds of sexual behavior problems. What's the first thing you think of when I say, why would a child have sexual behavior problems? And if you're like most people, you're thinking, they were sexually abused themselves. And that may be, right, that's always, of course, something we're considering and that we're looking out for and that we're trying to check in with kids about. But that is not the only thing that may lead to a child having these behaviors. So we don't want to get so invested in looking for that, that we're not able to expand and consider other explanations for what has happened. That's why, as you'll see later, it's really important for these kids to have an interview, a forensic interview, if at all possible, so we can start to unpack that and kind of have more information about where this came from and not make assumptions. So other things that can lead to these types of behaviors are any type of abuse or neglect, so not just sexual. Actually, physical abuse is a really high, in some studies, even a higher predictor of sexual behavior problems than actually being sexually abused. So other types of abuse or neglect can kind of lead to kids acting out in this way. Lack of supervision. Of course, sometimes lack of supervision may come with some free time to get onto the internet, to get into their parents' stuff, to get into their older siblings' stuff, and find material that they're then viewing and that is impacting their behavior. Living in just a generally sexualized environment. Maybe there's a household or an environment with not good boundaries between adults and kids where kids are kind of being exposed to other people's sexual behavior or witnessing sexual contact between people, whether it's on purpose and somebody's allowing the child to see those things or even if it's kind of accidental. Kids peeking around into rooms, kids getting into other people's phones and computers, or just adults who are not keeping healthy boundaries between what kids are able to witness in the home. In general, if they're witnessing any kind of, you know, if there's domestic violence in the home, sexual violence towards other people in the home, maybe the child themselves hasn't experienced something but they've witnessed things, these can all impact how the child may work through what they've experienced, and sometimes it takes the form of them having sexualized behaviors. Let's see here. Okay, and so I had briefly touched on a moment ago that there is somewhat of a misconception that kids who are sexually abused are very likely to go on to sexually abuse others, whether it's as a child or as an adult. I was once conducting a forensic interview with a, I would say, a middle school-aged girl, and she was talking about, you know, being sexually abused by an adult, and when I said to her, tell me the worst thing about, you know, what he did, she said, well, now I can never have kids because I know that I would do the same thing to them because of what happened to me. This was a middle schooler, and this was so upsetting to her that she thought now she should never ever have her own kids as an adult because she thought she would automatically sexually abuse them. Of course, we made sure that that child got some therapy and that the therapist knew that that was a worry so that they could work through that in a therapeutic way, but these ideas are very common in our society, and so we want to, again, be thoughtful about this and kind of pull those apart and not make assumptions. We certainly don't want our child, children who've been victimized by sexual abuse to leave us with these kinds of ideas. That's very harmful to them. So there is, I was reviewing some research in preparation for this training. What I found is that there does not seem to be any evidence for a cycle of abuse for female children, and what the the study found was that, you know, one study found that of female children who had been sexually abused, 0.1, not 1%, 0.1% of them went on to sexually abuse another child, right? So that's a minuscule percentage, right? There was some different information related to boys who were sexually abused, and this was one of the first studies that had kind of pulled that apart, looking at the gender of the child and some of the other factors related to the abuse. So again, these are very complex situations that we need to really be looking at every situation individually and not making those large-scale assumptions. But that same study found that for boys who were under the age of 12 when they were sexually abused, 2.9% of them went on to sexually abuse another child in the future. Boys who were sexually abused when they were over the age of 12, so I guess between probably the ages of 12 and 18, 10% of those boys went on to be convicted of a sexual offense, right? So 10%, you know, that's a lot more than 0.1%, right? That's something we want to start looking at. Why was that? So additional research in that study found that there were four main factors that they're thinking, this is preliminary, but that they're thinking may be involved in kind of that connection between being abused over the age of 12 and then going on to offend. They found that it happened when boys were abused at the age of 12 or older, when they were subject to frequent sexual abuse or something that happened ongoing, not necessarily just one time, when they were subjected to serious sexual abuse, and by serious I think they meant more invasive acts that occurred, and when they were abused by somebody with whom they had a relationship of dependency. So kind of a father or a father figure type relationship seemed to be a risk factor for them going on to abuse others. So this is, I'm sharing this not because, again, we want to make assumptions or start treating any minor child who's been a victim as if they're automatically going to become an offender in the future. That's certainly not what we want to do, but I do want you to have these red flags and these risk factors in your brain because what this tells us is that we really need to make sure we get some support. And I don't know about you, but in my experience, preteen and teenage boys are not always the most open to saying they want to have therapy or that they want to talk to somebody or that they want to get support when something happens to them, right? I've heard many times from teenage boys like, no thanks, I don't want to talk about this ever again, but they need it, right? And even studies like this, they need it not only for themselves and their own healing, they need it in order to be healthy and safe for other people, right? So again, keep some of those risk factors in mind. And when you're seeing those kinds of child victims coming forward, we really do want to make sure they get connected to services to heal and to move forward in a healthy way. Make sure we're disconnecting from them, those ideas that may have been forced on them about power and control and the connection with that and sexuality. All right. So, whoops. All right. Pause and then let me get back to the correct screen. Here we go. Okay. All right. So now we're going to talk about what do we do, right? How do we respond when we're starting to see any of the behaviors we've been talking about today? How do we respond when we see natural and healthy things? Because for many adults, even if what the child is doing is natural and healthy, there may still be some discomfort or some hangups on our end, right? Because we all grew up and have all had the experiences that we have had in our own sexual development and in our own sexual lives. And sometimes seeing a child do something, even if now we know that it's natural and healthy, it may still be upsetting, triggering, or just confusing for us as adults. So I'm sharing this today not only in your role as nurses, but just in general, right? You may have your own kids. You may be helping out a neighbor. You may be, you know, doing other things and come upon a situation of a child acting out some sexual behavior. So what do you do, right? I think it's important for all adults to have some information about this. If a child's coming to you and asking questions, I think the most important, a helpful tip that I receive if they're asking you those very detailed questions, right? Like where do babies come from? Or what, you know, like they see something on TV, a sexual act, what are those people doing, right? So the first thing we want to do is breathe and pause. And we also don't want to assume that we know exactly what they're talking about. We don't want to launch into a super detailed explanation of, you know, fertilization of an egg when all they need to know is like, you know, there's a baby inside that person and it's going to come out, right? They may not need as much information that we think they need. We also want to be clear about what they're asking and the language we're using. I had a client once tell me that she had a, I think a four or five-year-old girl. They went to a family gathering and there was another woman there who was breastfeeding a baby. And the little girl looked over and said, what's that baby doing? And the mother said to her, the baby's eating. And the child got very upset because the child interpreted that as the baby is eating the mother, like ingesting, right? She didn't understand the milk. She didn't understand the breastfeeding. She heard the word eating and thought the baby was hurting the mother, right? And that caused a whole, the mom said she had to do a lot of correction of that to have the child calm back down and not be upset. So again, we want to be careful with our language and careful that we know what kids really want to know and only answer what they need to know. Sometimes when I get asked a very complex or what I feel like is maybe a tricky question, my first response is, what do you think? And then if they give, you know, then I can work with that, right? Because they may be asking something totally different than what I thought, or they may have some ideas that I can just say, well, it's not quite that. Here's something else. And we can move on together. I'd also encourage everybody to use the correct words for body parts with any child, right? We want to normalize in our society that an elbow is called an elbow and a finger is called a finger and a vagina is called a vagina or a vulva, right? And a penis is called a penis. These are the words we want to use with kids. We don't want there to be confusion. We don't want to cause shame or, you know, just, we want kids to be able to get help if they need it, right? So if a child goes to school and says, my uncle licked my cookie, their teacher is going to go, well, that was silly. All right, come on, let's do some math. Because they may not understand that the child uses the word cookie to mean their vagina, right? So we don't want to use those cutesy terms or those things that are, maybe increase our comfort, but they don't help keep kids safe. So that's important. Also, you know, considering just in general, enforcing those rules about consent and teaching consent to all kids, not just in relation to sex, but in general, right? Any kind of touching anything that is within your own body, you are in charge of that, right? You're in charge of your own body. You have the right to tell somebody no to something that's happening to your body. And you have the right to speak up if you're uncomfortable with something that's going on, right? These are all conversations we can have way before we're talking about sex, when we're just talking about hugs, kisses, bath time, you know, bathing, anything like that. All right. Another thing that I just want to, you know, I know this is probably a common suggestion these days, but just to be really mindful of what kids are having access to through media and particularly online. Just because a site says it's for children does not mean that everything on there, unfortunately, is going to be appropriate or safe for kids. And unfortunately, people who have an interest in children also know what those sites are, and they know how to get into them. And so, you know, we want to still be doing careful monitoring of what's happening online with our kids at all ages. And just, you know, try to keep those influences from accidentally coming through. But if it does happen, right, also giving kids the skills to know what to do. Hey, if something weird or creepy or gross or confusing ever pops up on the computer, here's what you do, right? We want to, if we're going to let kids have a phone or a computer, we have to also teach them how to keep themselves safe, right? So letting them know, turn it off, how to block people, how to come get a grown-up right away, how to, you know, stop the images or the things that are popping up to them. All right. When we're talking about sexual behavior problems, right, moving into what's more concerning or what are things that we would be more concerned with than the typical behaviors. Of course, we want to, so say, say you're in a situation where there's, you know, you're at the hospital and a couple of kids are out in the waiting room, right? And you go out to get the one that's coming back with you and you peek out and you look around the corner and they're engaged in some sort of sexual interaction, right? It's happening right here. Oh my gosh, what do I do? Right? Of course, the first thing we want to do is try to stay calm. Of course, we want to stop that behavior, but we don't want to do it in a hysterical way, in an angry way, or in a way that makes the kids feel like, oh, we're in big trouble now, right? That's really going to shut it down. It's going to make it hard for the kids to talk about what happened or to share where that behavior came from. So as best you can, keep it calm when you're interacting in these types of situations. You want to redirect, but in that positive, upbeat way, the same way as we direct for other things, right? Hey, you got to put your seatbelt on. Hey, we don't touch private parts in this room, right? Keep it light. Keep it positive. Keep those boundaries very clearly communicated to kids. You guys in your role as nurses, you may be in a situation where you are examining a child after there's been sexual abuse or sexual contact of some kind. So just be thoughtful about what you're asking, what you're not asking, how you're asking it. Those are things that you'll be working with your multidisciplinary teams or other partners who are bringing those kids to you to kind of know, of course you need to know what you need to know to keep the child medically safe, but to be careful about when you're crossing that line into getting into things that where maybe a child's going to have a forensic interview later or have a full interview of some kind, and you don't want to muddy the waters or make the child have to repeat things over and over. So just kind of be thoughtful about that and work with your team on where that line is and where you may need to stop finding out additional information. Let's see here. We're going to need to let the caregivers of these kids know, right? So if there's a child who's acting out sexually, having sexual behavior problems, the people who are in charge of that child are going to need to know about it, and that's something we're going to talk about in a minute. How do we have those conversations and what do we need to share? These are complex and they're really family cases. There's no way to address or to heal a child with these kind of behavior problems in isolation. We have to involve the whole environment where that child spends their time. If you aren't getting disclosures from kids, if they're telling you things that have happened to them, of course that documentation is crucial. So as best you can, as clearly as you can, and using the words the child uses, get that documented. That's going to be really crucial for the folks looking into it later on. All right. I do also like to mention that while we were careful about the language and the way we think about minors who are having sexual behavior problems and we don't want to label them as offenders, we do also want to keep in mind that a child who has been victimized by another minor is going to have the same needs and the same concerns and the same potential for trauma as any other victim. So we don't want to minimize the victims of another minor. They still need the same care and support that we would offer in any other situation. So we don't want to minimize what happened to them or think that they need fewer services because the person who did these things to them was another child or a minor. That's not necessarily the case. All right. I will tell you in my time as working in Child Protective Services and at the Child Advocacy Center, I've seen a lot of hard situations and a lot of caregivers and families who have very hard things going on. In my experience, being the parent of a situation where there are two kids in your family or household and one of them has acted out sexually against another one is pretty near the top of the list. Those parents are in such a difficult position. They're in between a rock and a hard place. They want to protect their child who maybe has been harmed. They also want to protect their child who maybe has acted out. It's really complex and really difficult for those families. We do want to approach these cases with some compassion and some sensitivity to what these parents and family members may be going through, especially when it's happened, particularly within a household or within a family unit where the caregivers are connected to both of the children who are involved. I once, when I worked in Child Protective Services, was working with a family and the elementary age girl came forward and said her teenage brother had been touching her. I called the mother and I said, can you come in? I have something to talk about with you regarding your children. We met one-on-one. We met in person so we could really have a good conversation. When I shared with her what had been disclosed, the mom stopped and she said, wow, if it's true, I'm so proud of her for telling. I really hope she's lying. She just didn't want it to be true, right? She didn't want that to be the case. She would rather have her daughter be lying and making something up for some reason than to have it be that her son had done this to her daughter. That's a very common reaction. We need to be mindful of that, to be compassionate with that, and to allow the caregivers some time to work through their feelings. We got to get those safety plans in right away. We got to make sure everybody's in right away. We got to make sure everybody's going to be kept safe, but we also need to understand that caregivers may take some time and may go back and forth in their feelings and their reactions a little bit over time as they try to juggle helping and protecting and healing all of the members of their family. It's very common, especially if you're on the front end of one of these situations or investigations involving a child acting out sexually, what you may see from the caregivers include disbelief. They may be angry at the child who acted out. They may be angry at the child who disclosed it. They may be angry at you. They may be angry at the system. They may be angry at all different reactions. Sometimes they withdraw from one or the other of the kids. They just can't have those interactions for a time. They may feel sad. They may feel shame. They may feel depressed. They may isolate, they may not want to tell anybody else that they know what's going on. They may have their own traumatic stress reactions, right? We need to remember that if one in 10 children is sexually abused, one in 10 of the caregivers that you're working with have that in their history. And to find out that this is happening now within their children may be very triggering, very upsetting, may recreate some feelings for those parents. So again, lots going on, very complex situations. So just consider how you would feel if something was happening within your own family of this nature. Use your compassion and use that child first language, right? So we're not going to say, your teenage son is a sex offender and he touched your little girl. That's not going to be helpful, right? We're going to say, you know, there's a disclosure of some sexual behavior problems. We want to help. We want to help all of the kids in this family to heal and to get better and to be safe, right? So thinking about how we explain things to the caregivers. We also, you know, because these situations are so complex and so difficult and because parents are so pulled in all the different directions, it usually helps to have some external accountability and some really strong boundaries and kind of monitoring while the family kind of regroups and moves into a safe, a more safe and a healing situation, right? So a lot of times we are going to need to pull in those resources and those other community agencies to really make sure there's close eyes on what's happening and that we're not allowing the situation to go back into denial, which is much more comfortable for most people, right? So helping those caregivers, you know, if you're in a situation where you're helping the caregiver, trying to help them understand what to do. Of course, you want to do our good active listening and kind of really understand their perspective. We can dispel some of those myths about children with sexual behavior problems, right? So use this information you've learned and share it with the parents. They don't know this stuff, right? No, most people, except for, you know, folks like me don't go into parenting thinking about what am I going to do if one of my kids acts out sexually against the other one, right? That's not a normal parenting skill that people are taught. So tell them that their child is not likely to go on to hurt other people, that kids are able to heal, that we have all these services and resources and some things are normal and, you know, let them know they need this information. You know, help them problem solve whatever barriers they may have to putting in a safety plan or getting the treatment that they need. Focus on wellness for the whole family, right? So not just the child who's been harmed, but a child who's acting out, we want wellness and healing for them as well. Emphasize how important the caregiver is to the process and that we really can't have a safe situation without the caregiver being actively involved and that they can do it. And don't sugarcoat the situation, right? Don't make them feel like they don't need to do anything, but do give them some help. Do let them know that most, by far, most kids who have these kinds of behavior problems do not continue to have them into adulthood and that there are lots of things we can do to help. I'm also going to, at the end, you're going to have a resource, the National Children's Alliance, which is the nationwide organization for child advocacy centers, has some wonderful resources on their website and we're going to give you the link to those. Some of them are specific, one of them is specifically for caregivers of children with sexual behavior problems. So, you know, these are things you can have with your cheat sheet and know where to find them if you need to share them with a parent. Okay. Who are we going to call? What are we going to do when these things pop up, right? The folks who are listening to this call, you are a nurse, you know that makes you a mandated reporter and then that means that any time you have reason to suspect possible sexual abuse or, of course, any type of abuse or neglect of a child that you need to call somebody. So, this is your first reminder for your homework and your cheat sheet page. Take a minute, pause if you need to, and add to your cheat sheet, who do I call if there's been an allegation, right? There may be a hotline that's going to be different for you depending on what state and what, you know, locality that you are in. So, you're going to want to know the numbers that are most helpful and most specific for you. Generally, you're going to be calling the place wherever the child lives or at least that's your first, your first best bet of who to call. So, you're going to want to call social services or child protective services, whatever it's called in your area and or law enforcement. So, as we're going to talk, different places handle these cases differently and so step one is who do I call if you don't know off the top of your head and that's your homework sheet to figure out as we finish up today. The other thing you're going to want to know is what is the process in my locality or my region. There is some variation across the country or even within states about how people handle these child on child sexual abuse situations because there are going to be some situations where two children, neither of them would be considered a caretaker of the other one. In some regions, social services or child protective services will say, well, we're not able to get involved because no caretaker harmed a child in this situation, right? They may not be allowed to open a case. So, in my area, what that means is that most of the time these cases get screened out by social services and they end up getting handled by law enforcement and that sounds a little funny to people because sometimes I literally get a police report that says this five-year-old touched this four-year-old on the private part. Here's the police report. I have never seen a situation where we're having five or seven or nine-year-olds carted off to juvie because of this, but because of the limitations of social services to my law enforcement is the only investigatory agency allowed to get involved that, you know, can kind of open a case. And in our area, their first call when they get those cases is to the Child Advocacy Center and they say, hey, we need these kids interviewed, right? None of us are there to get kids in trouble or to do anything that's going to be harmful to either of the kids, but we do need to make sure that there is a system response and that we're offering them both a chance to talk about what happened and for us to understand where the behavior came from as well as connecting them with healing and supportive services and that's what they get when they come to the Child Advocacy Center because they can access not only an interview but also victim advocacy, case management, connection to therapy, and other things that the family may need. So the second part of the next thing on your homework is to figure out is there a Child Advocacy Center that serves your area? Who are they? How do you reach them? How do you connect with them? So making sure that you kind of have that on your cheat sheet and then whether or not there is a Child Advocacy Center because not every locality in the United States is covered at this point in time. In general, know what's the process in my locality. Do I call social services? Do I call law enforcement? What are they going to do? These are really important conversations to be having within your multidisciplinary team if you have one in your area. So if you're having case staffing meetings, bring it up at the next one and say, hey, so if there's a case where it's two minors and one of them, you know, abuses or acts out against the other one, who should we call? Do we have a process for that? Do we have an MOU about this? Do we have a flow chart of what's going to happen that may already exist and you add that to your cheat sheet? And if it doesn't exist, now's the time to get it going because as I said, these cases are just coming more and more frequently. So every locality needs to know what to do when it happens. All right. I also want to share in terms of interviewing kids. Again, this may vary from place to place and it's part of finding out your own process. But in our area, some of the time we're interviewing not only the child that, you know, is listed in the report as a victim, but we may also be interviewing a child who is listed as the one who initiated the behavior, right? Because for certain behaviors, depending on how extensive they are or any other risk factors and red flags that we're noticing in the situation, we may be concerned that that child has been a victim of sexual abuse, or we may just want to rule it out and be on the safe side to make sure and give that child a chance to come in and talk about where they learned this behavior. Has anything else has this ever happened with somebody else? They know. Has this ever happened with an adult in their life, right? So in a lot of these situations, we're really looking at it as we might possibly have two or more victims, right? And so we want to, again, offer all of the kids a chance to tell anything that's happened to them and to be connected to healing and supportive services. So again, in our area, that's what our goal is, is to reach out and at the very least offer some outreach or some service connection to all of the kids and families involved, regardless of kind of their status on the report. Moving into our final sections, what helps these kids, right? What is it that's going to help kids with problematic sexual behaviors move forward, stop engaging in the behaviors and be healthy? So you can see in the blue box here, some examples of types of treatments that have been found, they're evidence supported, and they've been found to be effective. So one thing to do, I don't think I put a homework image on this page, but is this available in your area? Are there any therapy providers in your area providing any of these types of services? And if they are, get them on your cheat sheet. You want to know who they are and how to connect with them because you're going to be needing them. If nobody in your area is doing these treatments, use your connections. Maybe somebody could, right? If you're somebody who's helping make referrals or helping make recommendations for what's helpful for kids in your community, let your providers know these are the services we want, right? We want to have somebody to refer to who can help these particular types of situations. But in general, even if you don't have these exact services available, what we want for any kind of treatment is, of course, it needs to be developmentally appropriate, right? It needs to be geared toward the age and the development stage the child is in. We want things that are evidence supported, that have an evidence base to show that they work, trauma informed, of course, focus on the family. So again, not just having the kid come in for one hour a week and only talk to them, but really expanding to working with the parents and caregivers and other people. Maybe we need to work with the siblings who are in the home. Maybe we need to have some family time, some family therapy. So we really have to expand the focus and think of the whole family as kind of the client in these situations. We also want the therapy or the treatment to be as least restrictive as possible. I think that a lot of people think if a kid acts out this way, yank them out of the home tomorrow, that's it, right? But for most kids who have sexual behavior problems, other than the really, really severe ones, most of them can do treatment and move forward outpatient basis while living at home, right? Now there needs to be a really strong and a very strong safety plan and very careful monitoring and very close supervision, right? That's where working with the parents comes in, where they really need to be on board with making sure they're going to have that close monitoring for a while until we've really addressed the behaviors. But if the parents are willing and able to do that, then these kids can stay home while they get this treatment. We don't want to yank every kid out of the home. That's not only potentially more traumatic and harder for them to heal for the child who's yanked, but if you're dealing with a situation where the two kids were siblings or who lived in a home together and one child tells about what's happening and the other one gets pulled out of the house, how's that child going to feel, right? Because a lot of the kids that we're thinking of as victims, you know, they don't want their brother or sister or cousin to go away, right? And they would feel very guilty. And sometimes it can impact their healing if they feel like they're telling rip the family apart or cause somebody to get in trouble. So we want to, again, as I've said many times, these are very complex. They require a really close eye, but they can move forward and heal while being in the same home. Particularly considering how the child who's been victimized feels about it and if they feel safe and what they would want to see as part of their safety plan. All right. Okay. So I know that we had talked previously about that it's a misconception that all kids who are sexually abused are going to go on to harm others. And so I also want to share that even for kids who have acted out sexually against another child, even when they do do that, there's still a very low risk that they're going to persist in that behavior for a long time and that they're going to persist into that behavior into adulthood. So again, we do not want to have those assumptions in our brain that like, well, if a kid touched another kid when they were 10, they're going to be a pedophile when they're 25. Right? That is not what the research shows. So there was a study from a few years ago where they started looking more closely about the treatment that was provided to children with sexual behavior problems. They looked at kids who were between the ages of 5 and 12 who received the cognitive behavioral therapy to address this. And what they found that the kids who went through the cognitive behavioral therapy that was specific to dealing with their problematic sexual behaviors, their future sex offenses rate went down such that it was indistinguishable from other kids who were being treated in the clinic for any other type of thing, right? The kids who were there for ADHD and the kids who were there for depression and the kids who were there for any other kind of mental health or behavioral issue. Once the kids with problematic sexual behavior completed their cognitive behavioral therapy, they had the same rate of acting out as any other kid who was there. So again, the treatment really works. The treatment really helps. So we do want to make sure families know this is really, if you have those worries, if you're concerned about what's going to happen as your child grows, your best bet is to get them into some of this effective and supportive treatment. All right. The other important thing to remember is that cognitive behavioral therapy, particularly provided in this context, is very inclusive of the parents and the parents are being worked with almost as much as the kids are. So that also is what really helped those kids to move forward and to heal. All right. We are into our last couple minutes. So what I do want to share is the resources that I've mentioned. So you have websites here where you can find more information. The National Children's Alliance, if you go to that link here, you're going to see all of their helpful fact sheets. Like I said, there's one specifically for parents who are in this situation, but there's also some for providers and for how CACs can work with these cases. So all of that's available for free to download from their website. They even have additional webinars and other information about working with these types of situations. And that's a really helpful one-stop shop. There's also the National Child Traumatic Stress Network that has a lot of resources on their page. And then the Toni Kavanagh Johnson is the two little booklets that I had mentioned that have some helpful information. So her website is there. So your homework now is to, I would recommend, if nothing else, go to the National Children's Alliance site and grab these handouts and print them out or save them or however you'd like to keep your stuff and attach those to your cheat sheet. That way you're going to have all that information in one spot when you need it. And we're going to take a moment now, if you can, kind of check out your cheat sheet. If you remember, what we want to have on there is the hotline or the phone number for who you need to call if you are alerted to a child-on-child sexual behavior situation or a child with sexualized behavior problems. Who's your abuse neglect number that you need to call? You want to find out what's the protocol in your area? How are these cases handled? Is there a child advocacy center in your area and what are they doing for these cases? How do you need to connect with them? And then you're going to want to have also attached to your homework the handouts that you print out and the ones that you feel will be most helpful. Okay. So as we wrap up today, I just want to thank you for being here today. Thank you for being willing to learn about this very unique topic. I know as nurses, you guys do a lot of things and know a lot of things that maybe the general public doesn't think about very much. So I do appreciate you taking the time to be here for this. The information for my agency is here and my name. And I hope that this was helpful and that it helps you to kind of know what to do if you come across a situation involving children with sexual behavior problems. I also want to remind you to take a moment to care for yourself. So anything we talked about today caused some discomfort or some reminders or anything that you know was difficult to give yourself a moment to take a break, to pause, to take a walk, or to do what you need to do to re-regulate today. And I also want to share very heartfelt thanks to you all for working as nurses, staying in the healthcare field in this day and age, and working with this particularly vulnerable population that you do as forensic nurses. What you do is essential and I am very grateful to all that you do. So thank you for that. And with that, I will say thank you and have a great rest of your day.

childhood sexual development

child sexual behavior problems

forensic interviewer

social worker

sexual development

typical behaviors

consent education

child sexual abuse

risk factors

Ashley Cinelli-Matthews

Foothills Child Advocacy Center

continuum of child sexual development

intervention in child sexual behavior

developmentally sensitive approaches

trauma-informed care

child advocacy centers