Etiological Pathways to the Emergence of Preteen Problematic Sexual Behavior: An Exploratory Mediational Model

Abstract

Studies examining the etiology of problematic sexual behavior (PSB) among pre-teen children often rely on identifying correlational relationships without examining potential causal mechanisms. This study describes an exploratory analysis of a potential mediational model where child sexual abuse (CSA) and child physical abuse (CPA) predict the onset of PSB through their impact on the emergence of posttraumatic stress (PTS) symptoms and self-dysregulation. The caregivers of 189 children between the ages of 3 and 11 years presenting for mental health treatment in the United States completed a battery of measures designed to assess each of the variables in the model. Cross-sectional, regression-based mediational analyses showed that the overall model performed adequately (R = 0.33, R² = 0.11, F = 3.07, p = .004). CSA exerted a direct effect on PSB that was not mediated through either PTS or self-dysregulation. However, no direct effect for CPA was found. Rather, CPA exerted a significant effect on the display of self-dysregulation, which in turn was associated with PSB. These results are discussed in light of clinical implications and directions for further research.

Keywords

problematic sexual behavior sexual abuse physical abuse posttraumatic stress self-regulation

Preteen children displaying problematic sexual behavior (PSB) are defined as “children ages 12 and younger who initiate behaviors involving sexual body parts (i.e., genitals, anus, buttocks, or breasts) that are developmentally inappropriate or potentially harmful to themselves or others.” (Chaffin et al., 2008, p. 200). The types of behaviors subsumed under this broad definition are diverse and include exhibitionistic and voyeuristic behaviors, self-focused behaviors, and those involving physical contact with another individual. Although epidemiological data are not available, estimates from large sample studies suggest that PSB may occur among 20%–25% of children (Allen, 2017; Friedrich et al., 2001; Friedrich et al., 1991). Estimates of the persistence of PSB over the course of 1–2 years range from 43% to 56.7% (Ensink et al., 2018; Lévesque et al., 2012), suggesting that these concerns are chronic in a large proportion of cases.

Initial attempts to understand the etiology of PSB focused on a presumed connection with the occurrence of childhood sexual abuse (CSA). For instance, Friedrich and colleagues (2001) compared a sample of children with CSA histories to normative and psychiatric comparison samples and found the highest prevalence of PSB among those experiencing CSA. Other early studies similarly found CSA predicted the occurrence of PSB (e.g., Gray et al., 1999; Hall et al., 2002). Postulations on the mechanisms connecting the two factors largely centered on the role of CSA-related posttraumatic stress symptoms (PTS; e.g., intrusive thoughts) that are inherently sexual in nature (e.g., Finkelhor & Browne, 1985; Rasmussen, 1999). Indeed, some evidence suggests that PSB is more prevalent among CSA survivors when they report higher levels of PTS (Allen et al., 2015; Friedrich et al., 2003; Wamser-Nanney & Campbell, 2020).

However, the CSA-related PTS model possesses significant limitations. For one, several studies suggest that the minority of children displaying PSB have a CSA history (Allen, 2017; Bonner et al., 1999; Silovsky et al., 2007). Even in those cases of PSB where CSA is present, PTS may not be a mediating mechanism. For instance, Silovsky and Niec (2002) found that, of 13 cases of preschool children displaying PSB and having a CSA history, only two met diagnostic criteria for PTSD. Using continuous measures, Allen (2017) observed only weak evidence linking PTS to the display of PSB among CSA survivors and Wamser-Nanney and Campbell (2022) found that PTS did not explain the connection between CSA and PSB. Data from Simon and Feiring (2008) suggested the opposite effect, that PTS, particularly posttraumatic avoidance of sexual topics, may predict lower rates of PSB among children with CSA histories.

One alternative etiological hypothesis utilizes a developmental psychopathology framework (see Elkovitch et al., 2009). From this perspective, any number of events and circumstances may result in the aberrant development of one’s ability to tolerate and effectively modulate behaviors and emotions (i.e., self-regulation; Cicchetti & Toth, 1995). This difficulty with self-regulation is presumed to underlie various forms of psychopathology (Cicchetti & Rogosch, 1996), which may include PSB. Seen through this lens, CSA may impact the development of PSB through its effect on the emergence of self-dysregulation; however, other untoward developmental experiences may also create a similar effect. The most commonly identified antecedent of PSB outside of CSA is the experience of childhood physical abuse (CPA; e.g., Allen, 2017; Lévesque et al., 2010; Merrick et al., 2008; Silovsky & Niec, 2002)

There is evidence that CPA may play an influential role in the development of PSB. Friedrich et al. (2003) showed that children experiencing CSA were more likely to develop PSB if they also had a history of CPA and Pithers et al. (1998) found that CPA predicted a quicker onset of PSB following CSA. For those cases without a history of CSA, the experience of CPA is found to increase the risk for developing PSB two- to three-fold (Lévesque et al., 2010; Merrick et al., 2008). However, this finding is not uniform as some studies fail to find a connection between CPA and PSB (Smith et al., 2019).

Further evidence for the developmental psychopathology perspective comes from the multitude of studies showing a significant correlation between PSB and broader externalizing behavioral problems (e.g., Allen, 2017; Friedrich et al., 2003; Gray et al., 1999; Smith et al., 2019; Wamser-Nanney & Campbell, 2022). In addition, deficits in social competence also are well-established for children displaying PSB (e.g., Allen, 2017; Wamser-Nanney & Campbell, 2019), which may exacerbate anomalous developmental trajectories. These findings suggest that the concomitant display of broader externalizing/social problems and PSB are the result of a general etiological construct, presumably self-dysregulation.

Although these two etiological models (i.e., CSA-related PTS, developmental psychopathology) are commonly discussed in the literature, rarely are they examined in tandem. Rather, studies commonly test one perspective or the other and give little consideration to how the two perspectives relate. For instance, CSA may disrupt the development of adaptive self-regulation capabilities as well as cause the onset of PTS. As such, CSA may predict PSB through its effect on self-dysregulation regardless of whether PTS is present. Considering a developmental model such as this allows for the inclusion of other indicated developmental experiences, particularly CPA. One may hypothesize that CPA yields significant self-dysregulation, which may result in PSB in the absence of CSA or CSA-related PTS.

This study provides an initial test of this proposed developmental approach. Figure 1 graphically depicts the full mediational model, where experiences of CPA and CSA are hypothesized to predict the development of both self-dysregulation and PTS, and these mediating mechanisms, in turn, predict the emergence of PSB. Of course, there are likely other ways that CSA and CPA may cause PSB and these are accounted for by the direct effect pathways linking these variables. It should be noted prior to describing the method of this analysis that the data are cross-sectional in nature. As such, although the variables are arranged in a theoretically defensible manner in the model, the data were not collected in a longitudinal design. It is best to consider this analysis as an exploratory model testing the potentiality that the variables may be related in the manner specified.

Figure 1.

Full Mediation Model for Problematic Sexual Behavior.

An additional issue deserves mention. It is not uncommon in studies of PSB for (a) the sample to consist exclusively of children with known PSB and for analyses to examine differences in severity or frequency, or (2) compare children with PSB to normative samples. Relatively few studies compare children with PSB to a suitable treatment-seeking sample not displaying PSB, which might explicate factors unique to the display of PSB. For example, one may expect to find higher rates of CPA, CSA, self-dysregulation, and PTS in children with PSB when compared to a normative sample, not because these factors relate necessarily to PSB, but because they relate to a mechanism common to various presenting concerns largely absent within the normative sample. This study employed a sample of children displaying PSB and/or with known maltreatment histories, which yields a sample comprised entirely of treatment-seeking cases.

Method

Participants

Participants were the primary caregivers of children between the ages of 3 and 11 who were assessed for services at a specialized, hospital-based outpatient treatment program for children with maltreatment histories (e.g., CSA, CPA, exposure to inter-partner violence, neglect) within the United States. The clinic also admits children presenting with PSB, regardless of maltreatment history, meaning that either a maltreatment history or concerns of PSB was sufficient for admission and subsequent inclusion in this study, although the presentations often overlap. This resulted in 189 cases for the current study. During an intake evaluation, caregivers completed multiple psychometric assessment measures to aid in determining the most appropriate treatment program. Because of the age limits for the measures included in this study, all children were between the ages of 3 and 11 and were assessed between July, 2015, and March, 2020. The children on whom the caregivers reported were predominantly of White/European (55.6%), non-Hispanic (78.8%) racial and ethnic backgrounds and qualified for government-supported medical insurance (i.e., Medicaid; 73.5%). Gender was more evenly represented (54% male; 46% female) and the average child was 5.5 years of age (SD = 1.6). Given the nature of the sample, the majority were residing with a non-biological/surrogate caregiver (e.g., foster, adoptive, or kin; 62.3%) and the vast majority of caregivers were female (92.6%). Demographic information and abuse history are reported in Table 1. Examination of these archival data were approved by the Penn State College of Medicine Institutional Review Board.

Table 1.

Demographic Characteristics.

Variable	f (%)
Child gender
Male	102 (54.0)
Female	87 (46.0)
Race
White/European-American	105 (55.6)
Black/African-American	31 (16.4)
Multiple races reported	14 (7.4)
Other races reported	28 (14.8)
Not reported	11 (5.8)
Ethnicity
Not Hispanic/Latino	149 (78.8)
Hispanic/Latino	29 (15.3)
Not reported	11 (5.8)
Medicaid Eligible
No	50 (26.5)
Yes	139 (73.5)
Caregiver relationship
Biological caregiver	71 (37.6)
Surrogate caregiver	118 (62.3)
Caregiver gender
Male	14 (7.4)
Female	175 (92.6)
Physical abuse history
No	108 (57.1)
Yes	81 (42.9)
Sexual abuse history
No	115 (60.8)
Yes	74 (39.2)

Measures

Trauma History Screen (THS)

The THS is a 19-item screening measure for various forms of trauma and adversity (Lang & Franks, 2007). All caregivers were administered the THS in an interview format as part of the child’s initial evaluation and responded to each item in a yes/no format (coded: 0 = No, 1 = Yes). In cases of surrogate caregivers, the assessment interview was often supplemented with information provided by the child protective services (CPS) worker and incorporated into responses. The two items specifically assessing the child’s prior experience of sexual abuse and physical abuse were utilized for this study. Although a number of children presented for treatment with histories of other forms of maltreatment (e.g., physical neglect, exposure to inter-partner violence), these other forms of maltreatment are not consistently shown to predict the onset of PSB and, when they are indicated, the effect is often weak (Allen, 2017; Merrick et al., 2008). As such, these forms of maltreatment are not included in the specified models although children presenting with only these types of maltreatment are included in the total sample.

Trauma Symptom Checklist for Young Children (TSCYC)

The TSCYC is a widely-used 90-item caregiver-report measure of a child’s trauma-related symptomatology (Briere, 2005). It was developed for children between the ages of 3 and 12 years. Caregivers report how often each symptom occurred in the past month on a 4-point Likert-type scale ranging from 1 (not at all) to 4 (very often). For the current study, the TSCYC was administered at intake and the total score of the Posttraumatic Stress (PTS) subscale was used as an index of PTS. The TSCYC PTS subscale is repeatedly demonstrated to display acceptable internal consistency and to correlate strongly with other measures of childhood PTS (see Briere, 2005, for the results of multiple psychometric analyses). Internal consistency of the measure was excellent in the current sample (Cronbach’s α = .93).

Strengths and Difficulties Questionnaire (SDQ)

The SDQ (Goodman, 1997) is a widely used measure of youth emotional and behavioral concerns. It is a 25-item questionnaire where the caregiver is asked to identify whether each item is Not True (0), Somewhat True (1), or Certainly True (2) for the youth. The psychometric properties of the SDQ are well-established, including repeatedly demonstrated strong correlations between the SDQ and the Child Behavior Checklist (see Stone et al., 2010, for a meta-analytic review). Five subscales are derived from the SDQ items; the summation of three of these subscales (i.e., Conduct Problems, Emotional Problems, Hyperactivity) is generally considered a composite index of self-dysregulation (Deutz et al., 2018). This index was used for the current study and internal consistency within the present sample was strong (α = .84).

Child Sexual Behavior Inventory (CSBI)

The CSBI is the current “gold standard” measure for assessing PSB among preteen children (Friedrich, 1997). However, many of the items are considered objectionable in contemporary practice (e.g., “Dresses like the opposite sex.”) or ask about behaviors that are not captured by contemporary definitions of PSB. For these reasons, a modified form of the CSBI was employed that eliminated questions designed to assess transgender behaviors, non-sexual boundary violations (e.g., “Stands too close to people”), and subjective caregiver opinions of normality (e.g., “Knows more about sex than other children their age”). The final measure included 28 items assessing exhibitionistic, voyeuristic, self-focused, and intrusive/interpersonal forms of sexual behavior. Modification of the CSBI is common in developmental research (e.g., Allen, 2017; Lussier et al., 2018) largely because of the issues discussed here. In addition, the norms for the CSBI were collected over 30 years ago and are generally considered out-of-date. This precludes identifying clinical cutoffs or utilizing T-score conversations. For this reason, raw scores were used for the current study. Higher scores inherently reflect the display of a greater number of discrete behaviors and/or a greater frequency of exhibiting the endorsed behaviors. As such, while lower scores may reflect non-clinical forms of sexual behavior, higher scores suggest an increasing likelihood that a child is displaying PSB. The internal consistency of the measure was strong in the current sample (α = .89).

Data Analysis

Initial analyses examined the normality of the distributions of continuous data and applied necessary transformations to allow for valid parametric analyses. Next, several demographic factors were examined for their potential relationship to model variables using t-tests, ANOVAs, Pearson product-moment correlations, and X² tests, depending on the structure of the data. Demographic variables identified as significantly related to at least one model variable were subsequently entered as covariates during estimation of the mediational model. Lastly, the full hypothesized mediational model was tested using the PROCESS macro (v. 4.0) for SPSS v. 28, which utilizes ordinary least squares regression (Hayes, 2022). The statistical significance of each direct pathway was determined using t-tests and the overall model was evaluated as any other multiple regression model. It should be noted that the model evaluated was prespecified based on theoretical grounds and prior research, and was not constructed after preliminary analyses suggested the nature of relationships within the data.

PROCESS evaluates indirect effects using a percentile bootstrap method that generates 95% confidence intervals derived from 5000 bootstrap samples. Using this method, if the calculated confidence interval includes 0, the indirect/mediational pathway is not statistically significant. According to a simulation study conducted by Fritz and Mackinnon (2007), a sample size of 162 is required to detect statistically significant mediational effects using percentile bootstrap methods when the effect sizes of the involved pathways are halfway between the coefficients customarily considered small and medium in strength. However, only 78 cases are required when the effect sizes are medium in strength. Given these estimates, the current sample size of 189 appears more than sufficient to detect statistical significance given medium effect sizes, and it is likely that power is sufficient to detect effects of a lesser magnitude as well. The author takes responsibility for the integrity of the data, the accuracy of the data analyses, and has made every effort to avoid inflating statistically significant results.

Results

Preliminary Analyses

Normality checks showed that one of the continuous variables, PSB, exhibited extreme positive skew (Kolmogorov-Smirnov = 0.27, p < .001; Shapiro-Wilk = 0.66, p < .001) given the high proportion of cases who received the lowest possible score of 0 (n = 78, 41.3%). As a result, the variable was inverse transformed with the addition of a constant (+1). All reported parametric analyses utilized this transformed variable in calculations. However, given that coefficients related to transformed variables are difficult to interpret, all coefficients reported were calculated with raw, untransformed data for the PSB variable.

Using indicated parametric and non-parametric methods, the following statistically significant relationships were found between demographic and model variables: physical abuse experience was more prevalent among children qualifying for Medicaid (X² = 6.13, p = .013); biological caregivers reported higher levels of PTS (t = 3.78, p < .001) than surrogate caregivers; an older age was weakly associated with lower scores for PSB (r = 0.20, p = .007). As such, Medicaid eligibility, caregiver relationship, and age were included as covariates in model estimates.

It should also be noted that of the 189 cases included in this analysis, only 31 endorsed a history of both CSA and CPA, yielding extremely limited power to detect an interactive effect. However, significant concerns are noted in contemporary child maltreatment research regarding the contamination of studies when one fails to control for the impact of other forms of maltreatment (e.g., CPA) that may co-occur with the primary subject of the study (e.g., CSA; see Shenk et al., 2022). The use of multiple regression analyses in the current study results in the statistical controlling of the impact of one type of abuse while deriving coefficients for the effect of the other type of abuse, thus addressing this concern. In other words, although the interactive effect of the two forms of abuse could not be effectively evaluated, the impact of CSA is controlled when estimating the effects for CPA, and vice versa.

The Mediational Model

The full mediational model is depicted in Figure 1 and bivariate correlations amongst all variables entered in the model, as well as gender, are displayed in Table 2. As expected, sexual abuse was associated with increased concerns of PTS (ß = 6.92, t = 3.42, p < .001), but was not associated with self-dysregulation (ß = 1.72, t = 1.92, p = .057). The experience of physical abuse was correlated with higher scores for PTS (ß = 8.58, t = 4.25, p < .001) and self-dysregulation (ß = 2.0, t = 2.23, p = .027). However, while self-dysregulation correlated with PSB (ß = 0.36, t = 2.45, p = .015), PTS did not (ß = −0.04, t = 1.50, p = .137).

Table 2.

Bivariate Correlations.

Variable	1	2	3	4	5	6	7	8
1. Gender	—
2. Age	0.02	—
3. Medicaid eligible (0 = No, 1 = Yes)	0.07	0.04	—
4. Caregiver relation (0 = Bio., 1= Surrogate)	0.04	0.05	0.35**	—
5. Physical abuse (0 = No, 1 = Yes)	0.02	0.03	0.18*	0.01	—
6. Sexual abuse (0 = No, 1 = Yes)	0.11	0.03	0.04	−0.09	−0.02	—
7. Self-dysregulation (SDQ)	0.11	0.01	0.02	−0.13	0.17*	0.15*	—
8. Posttraumatic stress (TSCYC)	0.13	0.06	0.09	−0.27**	0.30**	0.25**	0.70**	—
9. Sexual behavior (CSBI; transformed)	−0.12	−0.20**	−0.02	−0.07	−0.04	0.18*	0.16*	0.05

*p < .05, **p < .01.

The full mediational model significantly predicted PSB and with a medium size effect (R = 0.33, R² = 0.11, F = 3.07, p = .004). Results examining the direct and indirect effects for CSA and CPA on PSB provided interesting results. The estimate for CSA exerting a direct effect on PSB was significant (ß = 3.79, t = 2.54, p = .012); however, there was no evidence of an indirect effect for CSA through self-dysregulation (ß = 0.027, 95% CI = −0.002–0.072). Meanwhile, results pertaining to CPA provided a contrasting picture. The direct effect of CPA on PSB was not significant (ß = −0.35, t = −0.29, p = .77), although CPA was observed to exert an indirect effect on PSB through its influence on self-dysregulation (ß = 0.032, 95% CI = 0.001–0.077).

Discussion

In many cases, the etiology of PSB is likely a complex interplay between multiple factors. This study tested the combined contribution of two different hypotheses regarding the emergence of PSB: posttraumatic stress symptoms secondary to CSA and the development of self-dysregulation. In addition, this study incorporated two experiences most frequently associated with PSB, CSA and CPA.

Results of the mediational model suggested that CSA did exert a significant direct effect on the display of PSB, but was not mediated through PTS or self-dysregulation. This finding is not unique to the literature as Wamser-Nanney and Campbell (2019) similarly found that CSA continued to predict PSB after controlling for PTS. Such findings require the incorporation of other etiological perspectives to explain such a relationship. The most likely explanation utilizes a social learning perspective, which suggests that the sexual nature of the abuse provided a modeling experience which influenced the development of PSB. Consider Cale and Lussier’s (2017) sample of preschool children exposed to inter-partner violence (IPV). Children exposed to sexual coercion occurring within the IPV were more than twice as likely to development PSB as those children whose IPV exposure did not involve sexual coercion. More directly as it pertains to CSA, Friedrich et al. (2003) initially found that CSA predicted PSB, but this relationship no longer held after controlling for the child’s exposure to various forms of expressed sexuality within home. In other words, after accounting for a form of non-CSA social modeling of sexual behavior, CSA was no longer connected to PSB. These studies suggest that CSA may increase the likelihood of PSB largely as a result of the social modeling provided to the child.

CPA, on the other hand, was not directly related to the display of PSB. Rather, there was evidence that the experience of CPA played a role in the development of self-dysregulation, which in turn was associated with the display of PSB. Indeed, the formative experience of CPA on dysregulated emotions and behaviors is well-established (Kim & Cicchetti, 2010; Kim et al., 2023) and it is likely this factor accounts for the often-cited association between PSB and others forms of externalizing psychopathology (e.g., Allen, 2017; Smith et al., 2019; Wamser-Nanney & Campbell, 2022). In this view, the emergence of PSB is more related to aberrant development as opposed to a specific stressor or event.

The regression-based methodology of the current study provides an important strength for the study: the collective influence of other model variables was statistically controlled when determining whether a specific variable was associated with the outcome. In other words, the direct effect of sexual abuse on PSB remained after controlling for CPA, self-dysregulation, PTS, and the demographic covariates. Similarly, the indirect effect of CPA on PSB through self-dysregulation was significant after controlling for CSA and the rest of the entered variables. This suggests that each of the two identified pathways (i.e., CSA, developmental psychopathology) may operate independently and constitute two distinct avenues through which PSB may arise.

These results have clear clinical implications. Given the finding that PTS did not mediate the impact of CSA on PSB, there is little suggestion that a trauma-focused intervention specifically targeting post-CSA PTS may improve PSB. Although PSB is frequently included as a secondary outcome in clinical trials of interventions targeting CSA-related PTS (e.g., Allen & Hoskowitz, 2017; Cohen et al., 2004), no trials test the effectiveness of a trauma-focused intervention for children displaying clinically elevated levels of PSB. Rather, a developmental psychopathology perspective argues for the importance of an intervention that can improve self-regulation as a means of reducing PSB. Much like the research on treatment for other forms of externalizing problems (see Kaminski & Claussen, 2017), behavioral parent-training models appear worthy of study. There is evidence that such programs not only improve self-regulation (e.g., Lieneman et al., 2020), but may also reduce harsh physical discipline practices that may promote and maintain poor regulatory ability (Chaffin et al., 2004). As it relates specifically to PSB, there is preliminary evidence that such behavioral parent-training interventions may be effective (Allen et al., 2016; St. Amand et al., 2008). In addition, those interventions designed specifically to treat PSB teach caregivers behavioral child management skills (Allen et al., 2018; Silovsky et al., 2007).

It should be reiterated that the data for the current study were cross-sectional in nature, which prevents demonstrating that the variables examined relate in the developmental nature presented. Longitudinal studies of the onset and trajectory of PSB are necessary to push the field forward and may confirm the model specified here or identify necessary modifications. It must also be remembered that PSB is a broad concept that subsumes a diversity of phenomenologies (e.g., self-focused, intrusive/interpersonal). Future studies may examine specific subtypes of PSB to determine how etiological factors might differentiate between them. In addition, while the current study examined mediational pathways, it did not examine potential moderation of effects. Determining whether demographic factors moderate the relationship between a mediator and the outcome of PSB or whether two mediators may combine to enhance vulnerability for the development of PSB (e.g., the combination of PTS and self-dysregulation) are suitable next steps. In addition, the inclusion of techniques designed to assess the contribution of social learning mechanisms may help in determining how CSA fosters the development of PSB. By identifying the underlying etiological mechanisms of PSB, it may be possible to more effectively design and test appropriate interventions.

Footnotes

Authors’ Note

The author takes responsibility for the integrity of the data, the accuracy of the data analyses, and has made every effort to avoid inflating statistically significant results.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Allen is supported by grants R01HD097707 and P50HD089922 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD). The views expressed in this paper are solely those of the author and do not necessarily reflect the views of NICHD or the National Institutes of Health (NIH).

ORCID iD

Brian Allen

References

Allen

(2017). Children with sexual behavior problems: Clinical characteristics and relationship to child maltreatment. Child Psychiatry and Human Development, 48(2), 189–199. https://doi.org/10.1007/s10578-016-0633-8

Allen

Berliner

Shenk

C. E.

Bendixsen

Zellhoefer

Dickmann

C. R.

Arnold

Chen

M. J.

(2018). Development and pilot testing of a phase-based treatment for preteen children with problematic sexual behavior. Evidence-based Practice in Child and Adolescent Mental Health, 3(4), 274–285. https://doi.org/10.1080/23794925.2018.1515580

Allen

Hoskowitz

N. A.

(2017). Structured trauma-focused CBT and unstructured play/experiential techniques in the treatment of sexually abused children: A field study with practicing clinicians. Child Maltreatment, 22(2), 112–120. https://doi.org/10.1177/1077559516681866

Allen

Thorn

B. L.

Gully

K. J.

(2015). A comparison of self-reported emotional and trauma-related concerns among sexually abused children with and without sexual behavior problems. Child Maltreatment, 20(2), 136–140. https://doi.org/10.1177/1077559514566864

Allen

Timmer

S. G.

Urquiza

A. J.

(2016). Parent-child interaction therapy for sexual concerns of maltreated children: A preliminary investigation. Child Abuse & Neglect, 56, 80-88. https://doi.org/10.1016/j.chiabu.2016.04.008.

Bonner

B. L.

Walker

C. E.

Berliner

(1999). Children with sexual behavior problems: Assessment and treatment-final report (Grant No. 90-CA-1469). U.S. Department of Health and Human Services. National Clearinghouse on Child Abuse and Neglect.

Briere

(2005). Trauma symptom checklist for young children: Professional manual. Psychological Assessment Resources.

Cale

Lussier

(2017). Sexual behaviour in preschool children in the context of intra-parental violence and sexual coercion. Criminal Behaviour and Mental Health, 27, 176-190. DOI:10.1002/cbm.1996.

Chaffin

Berliner

Block

Johnson

T. C.

Friedrich

W. N.

Louis

D. G.

Lyon

J. F.

Page

Prescott

Silovsky

Madden

(2008). Report of the ATSA task force on children with sexual behavior problems. Child Maltreatment, 13(2), 199–218. https://doi.org/10.1177/1077559507306718

10.

Chaffin

Silovsky

J. F.

Funderburk

Valle

L. A.

Brestan

E. V.

Balachova

Jackson

B. L.

Lensgraf

Bonner

(2004). Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72(3), 500–510. https://doi.org/10.1037/0022-006X.72.3.500

11.

Cicchetti

Rogosch

F. A.

(1996). Equifinality and multifinality in developmental psychopathology. Development and Psychopathology, 8(4), 597–600. https://doi.org/10.1017/S0954579400007318

12.

Cicchetti

Toth

S. L.

(1995). A developmental psychopathology perspective on child abuse and neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 34(5), 541–565. https://doi.org/10.1097/00004583-199505000-00008

13.

Cohen

J. A.

Deblinger

Mannarino

A. P.

Steer

R. A.

(2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393–402. https://doi.org/10.1097/00004583-200404000-00005

14.

Deutz

M. H. F.

Shi

Vossen

H. G. M.

Huijding

Prinzie

Deković

van Baar

Woltering

(2018). Evaluation of the strengths and Difficulties questionnaire-dysregulation profile (SDQ-DP). Psychological Assessment, 30(9), 1174–1185. https://doi.org/10.1037/pas0000564

15.

Elkovitch

Latzman

R. D.

Hansen

D. J.

Flood

M. F.

(2009). Understanding child sexual behavior problems: A developmental psychopathology framework. Clinical Psychology Review, 29(7), 586–598. https://doi.org/10.1016/j.cpr.2009.06.006

16.

Ensink

Godbout

Bigras

Lampron

Sabourin

Normandin

(2018). Persistent and transitory sexualized behavior problems in children. Child Psychiatry and Human Development, 49(4), 621–631. https://doi.org/10.1007/s10578-017-0778-0

17.

Finkelhor

Browne

(1985). The traumatic impact of sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55(4), 530–541. https://doi.org/10.1111/j.1939-0025.1985.tb02703.x

18.

Friedrich

W. N.

Davies

W. H.

Feher

Wright

(2003). Sexual behavior problems in preteen children: Developmental, ecological, and behavioral correlates. Annals of the New York Academy of Sciences, 989(1), 95-104. https://doi.org/10.1111/j.1749-6632.2003.tb07296.x

19.

Friedrich

W. N.

Fisher

J. L.

Dittner

C. A.

Acton

Berliner

Butler

Damon

Davies

Gray

Wright

(2001). Child sexual behavior Inventory: Normative, psychiatric, and sexual abuse comparisons. Child Maltreatment, 6(1), 37–49. https://doi.org/10.1177/1077559501006001004

20.

Friedrich

W. N.

Grambsch

Broughton

Kuiper

Beilke

R. L.

(1991). Normative sexual behavior in children. Pediatrics, 88(3), 456–464. https://doi.org/10.1542/peds.88.3.456

21.

Friedrich

W. N.

Grambsch

Damon

Hewitt

S. K.

Koverola

Lang

R. A.

Wolfe

Broughton

(2011). Child sexual behavior inventory: Professional manual. Psychological Assessment Resources, Inc. https://doi.org/10.1037/t00814-000

22.

Fritz

M. S.

Mackinnon

D. P.

(2007). Required sample size to detect a mediated effect. Psychological Science, 18(3), 233–239. https://doi.org/10.1111/j.1467-9280.2007.01882.x

23.

Goodman

(1997). The strengths and Difficulties questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38(5), 581–586. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x

24.

Gray

Pithers

W. D.

Busconi

Houchens

(1999). Developmental and etiological characteristics of children with sexual behavior problems: Treatment implications. Child Abuse & Neglect, 23(6), 601–621. https://doi.org/10.1016/S0145-2134(99)00027-7

25.

Hall

D. K.

Mathews

Pearce

(2002). Sexual behavior problems in sexually abused children: A preliminary typology. Child Abuse & Neglect, 26(3), 289–312. https://doi.org/10.1016/S0145-2134(01)00326-X

26.

Hayes

A. F.

(2022). Introduction to mediation, moderation, and conditional process analysis (3rd ed.). Guilford Press.

27.

Kaminski

J. W.

Claussen

A. H.

(2017). Evidence base update for psychosocial treatments for disruptive behaviors in children. Journal of Clinical Child and Adolescent Psychology, 46(4), 477–499. https://doi.org/10.1080/15374416.2017.1310044

28.

Kim

Cicchetti

(2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. Journal of Child Psychology & Psychiatry, 51(6), 706–716. https://doi.org/10.1111/j.1469-7610.2009.02202.x

29.

Kim

S. G.

Weissman

D. G.

Sheridan

M. A.

McLaughlin

K. A.

(2023). Child abuse and automatic emotion regulation in children and adolescents. Development & Psychopathology, 35(1), 157–167. https://doi.org/10.1017/S0954579421000663

30.

Lang

J. M.

Franks

(2007). Trauma history screen. Connecticut Center for Effective Practice.

31.

Lévesque

Bigras

Pauzé

(2010). Externalizing problems and problematic sexual behaviors: Same etiology? Aggressive Behavior, 36(6), 358–370. https://doi.org/10.1002/ab.20362

32.

Lévesque

Bigras

Pauzé

(2012). Persistence of problematic sexual behaviors in children. Journal of Clinical Child and Adolescent Psychology, 41(2), 239–245. https://doi.org/10.1080/15374416.2012.651991

33.

Lieneman

C. C.

Girard

E. I.

Quetsch

L. B.

McNeil

C. B.

(2020). Emotion regulation and attrition in parent-child interaction therapy. Journal of Child and Family Studies, 29(4), 978–996. https://doi.org/10.1007/s10826-019-01674-4

34.

Lussier

McCuish

Mathesius

Corrado

Nadeau

(2018). Developmental trajectories of child sexual behaviors on the path of sexual behavioral problems: Evidence from a prospective longitudinal study. Sexual Abuse: Journal of Research and Treatment, 30(6), 622–658. https://doi.org/10.1177/1079063217691963

35.

Merrick

M. T.

Litrownik

A. J.

Everson

M. D.

Cox

C. E.

(2008). Beyond sexual abuse: The impact of other maltreatment experiences on sexualized behaviors. Child Maltreatment, 13(2), 122–132. https://doi.org/10.1177/1077559507306715

36.

Pithers

W. D.

Gray

Busconi

Houchens

(1998). Children with sexual behavior problems: Identification of five distinct child types and related treatment considerations. Child Maltreatment, 3(4), 384–406. https://doi.org/10.1177/1077559598003004010

37.

Rasmussen

L. A.

(2000). The Trauma Outcome Process: An integrated model for guiding clinical practice with children with sexually abusive behavior problems. Journal of Child Sexual Abuse, 8(4), 3–33. https://doi.org/10.1300/J070v08n04_02

38.

Shenk

C. E.

Rausch

J. R.

Shores

K. A.

Allen

E. K.

Olson

A. E.

(2022). Controlling contamination in child maltreatment research: Impact on effect size estimates for child behavior problems measured throughout childhood and adolescence. Development and Psychopathology, 34(4), 1287–1299. https://doi.org/10.1017/S0954579420002242

39.

Silovsky

J. F.

Niec

(2002). Characteristics of young children with sexual behavior problems: A pilot study. Child Maltreatment, 7(3), 187–197. https://doi.org/10.1177/1077559502007003002

40.

Silovsky

J. F.

Niec

Bard

Hecht

D. B.

(2007). Treatment for preschool children with interpersonal sexual behavior problems: A pilot study. Journal of Clinical Child and Adolescent Psychology, 36(3), 378–391. https://doi.org/10.1080/15374410701444330

41.

Simon

V. A.

Feiring

(2008). Sexual anxiety and eroticism predict the development of sexual problems of youth with a history of sexual abuse. Child Maltreatment, 13(2), 167–181. https://doi.org/10.1177/1077559508315602

42.

Smith

T. J.

Lindsey

R. A.

Bohora

Silovsky

J. F.

(2019). Predictors of intrusive sexual behaviors in preschool-aged children. The Journal of Sex Research, 56(2), 229–238. https://doi.org/10.1080/00224499.2018.1447639

43.

St. Amand

Bard

D. E.

Silovsky

J. F.

(2008). Meta-analysis of treatment for child sexual behavior problems: Practice elements and outcomes. Child Maltreatment, 13(2), 145–166. https://doi.org/10.1177/1077559508315353

44.

Stone

L. L.

Otten

Engels

R. C. M. E.

Vermulst

A. A.

Janssens

J. M. A. M.

(2010). Psychometric properties of the parent and teacher versions of the strengths and Difficulties questionnaire for 4- to 12-year-olds: A review. Clinical Child and Family Psychology Review, 13(3), 254–274. https://doi.org/10.1007/s10567-010-0071-2

45.

Wamser-Nanney

Campbell

C. L.

(2020). Childhood sexual abuse characteristics, abuse stress, and PTSS: Ties to sexual behavior problems. Child Abuse & Neglect, 105(2), Article 104290. https://doi.org/10.1016/j.chiabu.2019.104290

46.

Wamser-Nanney

Campbell

C. L.

(2019). Children’s sexual behavior problems: An ecological model using the LONGSCAN data. Child Abuse & Neglect, 96(2), Article 104085. https://doi.org/10.1016/j.chiabu.2019.104085

47.

Wamser-Nanney

Campbell

C. L.

(2022). Sexual behavior problems among sexually abused children: Associations with co-occurring symptoms. Child Maltreatment, 27(1), 78–87. https://doi.org/10.1177/1077559520971362