Treating Adolescents With Problematic Sexual Behaviors

Cases involving problematic sexual behavior are between a quarter and a third of all cases of child sexual abuse that come through Children’s Advocacy Centers. How do we understand this behavior in teens? What are risk factors and key opportunities to interrupt and disrupt this behavior? What do we know about evidence-supported treatment for these teens? And how may existing evidence-based treatments and approaches be shaped and applied? We speak with Dr. Melissa Grady at the School of Social Service at Catholic University and Dr. Jamie Yoder, assistant professor of social work at Colorado State University.

Topics:

01:50 – Origin story

08:37 – Trauma and childhood adversity

17:17 – Attachment

23:47 – Why TF-CBT?

32:09 – Findings

41:32 – What’s next?

48:32 – For more information

 Links:

Melissa Grady, Ph.D., professor, National Catholic School of Social Service at Catholic University

Jamie Yoder, Ph.D., assistant professor of social work, Colorado State University.

“Developing a trauma focused cognitive behavioral therapy application for adolescents with problematic sexual behaviors: A conceptual framework,” M. D. Grady, J. Yoder, E. Deblinger, A. P. Mannarino, Child Abuse & Neglect, Volume 140, 2023, 106139, doi.org/10.1016/j.chiabu.2023.106139

Jill Levenson, Ph.D., LCSW

Kevin Creeden, LMHC 

Elizabeth J. Letourneau, Ph.D.

Tony Ward, Ph.D.

William L. Marshall, Ph.D.

Michael Miner, Ph.D. 

“Sexual Behavior in Youth: What’s Normal? What’s Not? And What Can We Do About It?” with Jane Silovsky, Ph.D. (Season 3, episode 15)

“Understanding Kids With Problematic Sexual Behaviors,” with Geoff Sidoli, MSW, LCSW (Season 5, episode 21)

“Tony and Esther and Judy”

“TF-CBT: Helping Kids Get Better,” with Anthony Mannarino, Ph.D. (Season 5, episode 16)

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at NationalChildrensAlliance.org. Or visit our podcast website at OneInTenPodcast.org. And join us on Facebook at One in Ten podcast.

Transcript

Season 6, Episode 4

“Treating Adolescents With Problematic Sexual Behaviors,” with Melissa Grady, Ph.D., and Jamie Yoder, Ph.D.

[Intro music starts]

[Intro]

[00:09] Teresa Huizar:
 Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “Treating Adolescents With Problematic Sexual Behaviors,” I speak with Dr. Melissa Grady at the School of Social Service at Catholic University and Dr. Jamie Yoder, assistant professor of social work at Colorado State University.

Because cases involving problematic sexual behavior [PSB] comprise between a quarter and a third of all cases of child sexual abuse that come through Children’s Advocacy Centers, it’s important for us as child abuse professionals to know as much as possible about how to prevent and treat it. And One in Ten has touched on this topic numerous times before, but really focused on younger children. Today, we’re pivoting toward a more challenging aspect of this work and a more challenging population, which includes teens and adolescents, many of whom may be justice-system-involved.

How do we understand this behavior in teens? What are risk factors and key opportunities to interrupt and disrupt this behavior in teens? What do we know about evidence-supported treatment for these youth? And how may existing evidence-based treatments and approaches be shaped and applied to this specific population? 

As more and more child abuse professionals come to work with these youth, finding the answers to these questions becomes all the more critical. I know you’ll be as interested as I was in this important conversation. Please take a listen.

[Intro music begins to fade out]

[01:50] Teresa Huizar:
Hi, Melissa and Jamie. Welcome to One in Ten. 

Melissa Grady: 
Thank you. And thank you for inviting us to be here. We’re really excited to be able to talk about our work that we’ve been doing and where we’re going with it.

Jamie Yoder: 
Yeah, thanks for the invitation. 

[02:03] Teresa Huizar: 
How did you both come to this work, really looking at the way that TF-CPT [Trauma-Focused Cognitive Behavior Therapy] might be applied to youth with PSB?

Melissa Grady: 
So, Jamie and I met at a conference, a research conference, and I would say within the first five minutes of us meeting, we were, “bluh bluh bluh bluh bluh,” you know, just completely chatting, and we had already basically outlined an entire research agenda from, I would say, almost the minute we met. We went out to dinner, and we sat across from each other and we were just talking the whole time about all these different issues that we were both very interested in.

And although we came from different backgrounds, I would say that we really were seeing very similar gaps. What we were seeing in the field was around the role that trauma plays in the development of PSB, or problematic sexual behaviors. And not to say that we were the first people to ever talk about this because we stand absolutely on the shoulders of people who were already talking about this. Like Jill Levenson and Kevin Creeden and many, many others. 

But where we were really seeing the gap is around trying to tie also attachment into this equation and how these early relationships get connected to a child’s trauma. And then how does that contribute to risk factors that are then associated with sexual abuse or sexual offending or PSB?

And so one of the things that I had done in a theoretical world is I had worked with Jill Levinson to develop a theoretical model, really trying to tie these pieces together. And when Jamie and I connected, it was a lot about, well, how can we test this? How can we really see if these relationships that in theory we think exist but do not necessarily have the empirical support where we can say, “Yes, this is connected to this, and this is connected to that”? So that was what was so exciting about our partnership, is that we were able to, right from the get-go, begin to really explore empirically the relationship between attachment, trauma, various types of traumas, and then the risk factors that are associated with PSB.

And then as we did that, and we could see the empirical support that was really there for these different relationships, we then started noticing that, okay, well, you know, we know this now, quote, unquote, but clinicians are really struggling to operationalize this knowledge then into practice. And in conversations with lots of clinicians, myself included, and other people that we knew, we were really struck with how many clinicians were saying, “Yeah, I know trauma is an issue, but I kind of put that over here to the side because I’m working on PSB.” And they don’t really have a strong sense as to how the two fit together in treatment. They understand the role that trauma can play in affect regulation, cognitive distortions, impulsivity, and some of the other struggles that these kids have, but they’re having a really hard time identifying how to integrate their clients’ own trauma histories along with the trauma that they’ve inflicted onto others. Or again, the broad term of PSB.

So our most recent kind of iterations of the work are: How do we take this knowledge that first was theoretical and then empirical, and now, how do we put this into the hands of practitioners that will allow them to work in a more holistic way with clients versus in the silos that we’ve been seeing? 

Because as Jamie and I say all the time, it feels like you can be, and we don’t like the, the term “victim” and “perpetrator,” but you can be a victim, in quotes, until you perpetrate. And then once you perpetrate, you become in this other box. It’s almost like the field forgets their own victimization histories and only wants to focus on the offending or the problematic behaviors. So what we’re hoping is that, in our work, we’re able to help clinicians to balance both of these identities along with all the other identities that these kids come into treatment with and provide a more holistic treatment to address the whole person.

And we’re social workers, too. So often we think holistically about people. And so it also fits really well with our own professional views of the importance of treating the whole person and all of the identities. Including what it means within their culture and how gender identity plays a role and how do different experiences of discrimination and social injustice, how do all of those come together to create this person sitting in front of you rather than just that they are an “offender,” again in quotes. 

Jamie Yoder: 
One thing I was going to add to that is that, you know, the system has largely ignored trauma as a key risk factor in PSB, largely because we’ve treated this problem so punitively.

Right? So we have very limited supports within our justice system or legal juvenile system to really handle the trauma impetus to this problem. And so when we see PSB manifesting, and whether it’s an interfamilial abuse or extrafamilial abuse, we know through a lot of the research that Melissa and I have done, and others in our field, that trauma is one of the most salient, biggest risk factors for the onset and the course of problem sexual behavior.

When we have justice systems and legal systems that, by and large, ignore that, we are faced with challenges with how do we clinically deal with this? And also, how do we deal with this from a supervision and, like, behavior maintenance standpoint? So, I think that’s part of this new challenge in our field is, how do we reconcile the need for this type of approach with the existing systems that are creating barriers to implementing this type of approach?

And we’ll talk more about the approach too. 

[08:37] Teresa Huizar: 
One of the things I want to do is level-set, because in terms of our listeners, it’s a wide audience of child abuse professionals. So, not just clinicians but Children’s Advocacy Center staff. True, there are clinical staff too, but also students and academic folks.

So one of the things that I want to do to level-set a little bit around this is to talk about the sort of roots in childhood adversity and trauma that you see around this issue. Because I think some folks, their first question, when you’re dealing with the general public or even an MDT [multidisciplinary team] that hasn’t really worked in this area before, the first thing is sort of like: Well, what causes this behavior? Why do some children and youth act out in this way? 

And so you hear lots of discussion about what some of those reasons are. But it’s interesting, because even on One in Ten I’ve interviewed a number of people talking about problematic sexual behaviors in youth. Your paper was one of the first that I had read that really talked in great depth about trauma and childhood adversity more broadly as key things we needed to pay more attention to.

So, for listeners who just may not be familiar with the literature, can you talk a little bit about that? 

Melissa Grady: 
Well, again, we stand on the shoulder of giants, so we are by far not the first people to talk about the role that trauma has played. And I remember Elizabeth Letourneau—who is a former president of ATSA [Association for Treatment of Sexual Abuse] and just an incredible researcher and contributor to the field—one of the things that she talked about is, just like cigarettes don’t cause lung cancer but it puts you at a much higher risk, as Jamie said, for subsequent problematic behavior. And I think one of the things that we both talk all about is, wouldn’t it be so lovely if it was a single causal pathway?

And there are many, many people who experience different forms of child adversity who do not go on to commit sexual crimes. Or have problematic sexual behaviors. There are—and that’s the majority.

So it’s really important to remember this is a very heterogeneous group. It would be lovely if we could just have A plus B equals C. But we can’t do that. However—and again, lots of people who have more expertise in neurobiology have looked at the role that early childhood adversity, along with attachment, and we can talk about that relationship if that’s of interest, plays in developing some of the risk factors that are associated with sexual abuse.

So it’s, it’s really a combination. It’s a both/and, it’s multifaceted. But some of those things are certainly trauma because trauma we know changes the hormonal levels. We know it changes the neural pathways. It leads to and contributes to issues of impulsivity, affect regulation, Jamie’s looked especially a lot at executive functioning, cognitive patterns.

And none of those things in and of themselves alone are the thing. But when you look at what people talk about criminogenic needs, those are all related to risk factors that contribute then to sexual offending. So, there are many ways that trauma mimics other—I mean, like, sexual abuse and physical abuse mimics other forms of trauma, including attachment-based traumas, where people have an insecure attachment and struggle with relationship patterns. 

I wish I could tell your listeners, “It is this plus this equals trauma,” but we know that there are just so many different pathways that can contribute. And what we’re trying to do is sort of think about what might be one of the biggest bang for the buck. And of course, not everybody who commits sexual crime also has adversity. There are many people who don’t have this history of trauma.

So we, as a field, are still trying to understand what it is that contributes. For example, just really quickly—and then I’ll let Jamie chime in here—but one thing that’s coming up a lot in the literature in the last 10 years, I would say, is early exposure to pornography. Now, that is not listed in one of the traditional adverse childhood experiences, but there’s more and more research coming out about the impact of being exposed to sexual content when your brain is still developing.

So if you’re seeing pornography, and then that changes how you think sex is supposed to be, or a sexual encounter or a quote unquote relationship is supposed to be. It also creates surges in hormones and surges in different chemicals in your body. And then you have an arousal and then what do you do with that arousal? And if you’re managing your arousal as you’re watching porn, then you’re locking yourself into a cycle. And this could have been somebody with a loving family, with no other traumatic experiences, but they’ve developed these risk factors through exposure to pornography. That creates, or again, contributes to these risk factors associated with PSB.

Jamie Yoder: 
Yeah, and I think some of the ideological work that Melissa was referring to in terms of our, some of our early kind of discovery together is that we’ve seen trauma. And we’ve kind of operationalized trauma very broadly, right? To your point, Teresa, that we have different types of traumatic experiences and we know a lot of the research on trauma, that it’s a relative. That two people could be exposed to the same exact experience and have very different responses, internalization and responses to that experience.

But one of the things that we wanted to really nail down was: What are the differing ways in which trauma is experienced and internalized among these kids, and what are the differing pathways to the problem sexual behavior? And so it’s not just trauma alone, and it’s not just sexual abuse experiences or histories of sexual victimization that leads to the onset of problematic sexual behaviors. And that certainly has been discovered in other research studies as a really important risk factor that shows up time and time again. And it does show up in our studies many times, that sexual abuse is one of the more salient risk factors when we look at it compared to other types of abuse. 

But what we also have seen is that there’s many other interacting influences, right? So that when we look at abuse, there is usually a direct line or a direct association with a correlation with problem sexual behavior. But what we also see happening is that there’s things like deficits in cognitive processing, deficits in behavioral regulation problems within the family, and attachment issues.

And so these are part of the reasons why Melissa and I began to really dig deep into the nuances of: What are those pathways and how do those—how do those different risk factors connect to build into this greater propensity for problem sexual behavior? 

And some of our comparison groups are kids without problem sexual behavior but have justice involvement. So, kids that may have delinquent behaviors or arrests for other types of crimes that aren’t sexual in nature. 

Melissa Grady: 
I would also add the other piece that we’ve looked at is the role that parents play. 

Jamie Yoder: 
Yeah.

Melissa Grady: 
And I mean, not just attachment sort of in general, but the type of parenting. Whether they would classify their parents as cold or available or warm and nurturing. And how responsive they are to the child.

So, and we know from other research that we haven’t done, but that if a child experiences some sort of adversity, the parent’s response to that adversity and to that child has such a tremendous role on how that child will respond and process that trauma or adversity. There’s a lot of different complexities that go along with that.

Again, I wish I could just give a “Oh, it’s this.” 

Jamie Yoder: 
Mm-hmm.

Melissa Grady: 
But it’s such a heterogeneous population that it’s so difficult to be able to classify any one particular pathway. 

[17:17] Teresa Huizar: 
Well, I don’t think your answers are surprising in that way, right? In child abuse, there are lots of complexities. So this just happens to be one other aspect of that.

So talk a little bit, if you would, you both have mentioned attachment as something that both interested you in looking at further on this issue and something that where you had not really seen much work done prior or not in the way that you wanted to approach it. So can you talk a little bit about that?

Melissa Grady: 
Sure, I would say the two people in the field that have done the most work are Tony Ward and Bill Marshall. They— 

Jamie Yoder: 
Michael Miner has also done a lot on attachment.

Melissa Grady: 
And Mike Miner, actually. 

Jamie Yoder: 
Yes.

Melissa Grady: 
Thank you, yeah. Those are some individuals who really did a lot of the groundwork in attachment. And just—I’m assuming your listeners understand attachment theory, but just super briefly—that basically the underlying theory is that the early relational experiences that children have, right from birth, kind of set the stage for future relationship patterns as they age. And there are different attachment styles. There’s one secure and then there are three that are called insecure, and there are different subsets of those. If it’s helpful, I can go into that, but if not, it’s not a big deal. 

But one of the things that I started to notice as I was looking at insecure attachments—again, the bigger category—is that they were associated with all the same risk factors that were being targeted in problematic sexual behavior treatments. So, everything, again, that I’ve already mentioned: affect regulation, impulsivity, cognitive distortions, difficulties with interpersonal relationships. So, when—and in fact, we have slides that we presented where we list the risk factors or list the consequences or behaviors associated with an insecure attachment. And we line those up next to the risk factors that we know empirically are associated with sexual abuse. And they’re the same risk factors. The lists are almost identical. 

And so that became a focus, because if we can think about prevention, and really think about it on—you know, the CDC talks about three levels of prevention. There’s primary universal prevention. Then there’s prevention around those at risk. And then there’s tertiary prevention around those that have already done it, but we want to provide better treatment. Well, we also know that we can do things on that primary and secondary level with trying to work with families with early intervention. And if we know a child has been exposed to some sort of adversity, how can we get in there with the parents and do a lot of work with them as caregivers? 

But on the tertiary level, even when we know that people have committed sexual crimes, and I’ve done some research looking at even adults who have committed sexual crimes and what their attachment styles are. And I’ve also done some research that looks to see what changes happen in the course of treatment, and their attachments become more secure if they’re in a very good relational experience. So we know that we can improve attachments. There’s lots of research now that shows it’s not static. While it is a constant in the context of a therapeutic and corrective, emotional, relational experience, we can improve attachment styles. And with that risk factors do go down. 

So at every level of prevention, we have an opportunity to work in a relational way to create more secure attachments that then will reduce risk levels that are associated with sexual abuse while simultaneously targeting more directly those risk factors.

In sexual abuse, we have a principle called risk-need-responsivity. And I think attachment theory actually fits really well with that because you can be looking at what are the risk factors that an individual has? What are their needs? And how do we respond to those? And by thinking in an attachment lens, we are able to still do that across these different levels of intervention.

So that’s a little bit of where attachment comes in. And I don’t know, Jamie, if you want to say anything else.

Jamie Yoder: 
Yeah. And I was just going to say, too, I think part of what we’ve discovered is that we have kind of a reciprocal relationship between trauma and attachment, right? Where kids with greater trauma exposures early in life have also more insecure attachments, and those things mutually influence each other.

And one of the things we really wanted to do as part of our work with Tony [Mannarino] and Esther [Deblinger] and Judy Cohen, who are the model developers of TF-CBT, is really think through, conceptualize, how do we take this evidence-based approach and use it towards and with knowing these existing risk factors are part of the reason we’re seeing—and again, I say, part of the reason we’re seeing—the emergence of PSB? But how do we take this already evidence proven model to work and bring it into the world of PSB and begin to think about the relational connection between a caregiver and the youth as well as the trauma elements in the context of the larger problem sexual behavior work?

And so we can talk more about that too, but I think that that’s also what has led to really, I guess, putting our brains together as we began to do the ideology work and thinking through, okay, so this model already exists. What does it mean when we apply it to this different group of kids who maybe are presenting with some greater risks in certain ways? And can we test it and see if it works equally as well here as it does with just kids that have experiences with trauma. 

So, yeah, I think that the attachment lens has been really, really critical in our thinking and conceptualization of where do we go from here? And so, like we said, all of these things are working together. When it comes to the intervention and evidence-based approach, how can we bring all of those risk factors in and begin to develop or think about a model that works best for the kids? 

[23:47] Teresa Huizar: 
One of the things I appreciated about your paper is that you really laid out, I think, in a detailed way, sort of the lack of a variety of evidence-based interventions for this population.

Talk to me a little bit about why you thought—I mean, there had to be this aha moment, right? You didn’t pick—

Jamie Yoder: 
Mm-hmm.

Teresa Huizar: 
—TF-CBT out of a hat. So talk to me a little bit about what made you think, as you were talking together and brainstorming—I see the energy between you, so I can only imagine what it was like at conference—

[Laughter]

—but what made you think, “Okay. You know, we’re dealing with trauma. We’re dealing with attachment issues. Why don’t we try to see if we can create a conceptual framework by which it would make sense for there to be an application of TF-CBT with this population?”

Melissa Grady: 
I actually remember the exact conversation that we had about this. I don’t know, Jamie—

Jamie Yoder: 
I’m glad.

Melissa Grady: 
I don’t know if you do but—

Jamie Yoder: 
I’m glad you remember because I don’t. [Laughter]

Melissa Grady: 
I remember the exact conversation because we were saying—we had done this empirical work about looking at these connections and really demonstrating these connections. And then it was like, you know, we just—what do we do with this? We need to figure out a way to operationalize this.

And then it was like, well, do we need to develop a trauma treatment? Do we like—because we’ve got to figure out a way to integrate. And then, I don’t remember which of us said it, but we’re like, well, what about TF-CBT? Because I did want to say that we’re not the first people to think about this. Because TF-CBT—and Esther Deblinger has been using TF-CBT to work with younger kids, and then there’s a whole group out of University of Oklahoma working on PSB with TF-CBT for the younger kids. So, again, we stand on the shoulder of giants. I want to give credit where credit’s due. 

But what we were finding when we started looking for adolescents, is there was virtually nothing being published out there. And when we contacted different people, again, Oklahoma, and when we initially started having conversations with the developers of TF-CBT, they were, “Yeah … we haven’t gone there.” 

Jamie Yoder: 
Yeah.

Melissa Grady: 
And Jamie and I had, we felt like we were kind of circling around this for a while. And then it just made sense that we already have this empirically driven intervention, but it really hasn’t been moved over or used with this other population. 

The other thing that’s really appealing about this in relation to your question about attachment is while it is not an attachment-based therapy, there is a very clear role for the caregiver. 

Jamie Yoder:
Yes.

Melissa Grady: 
This is not a child-only intervention. Everything that’s been done with TF-CBT is done with the caregiver. Now, that’s not to say there aren’t a lot of challenges around getting caregiver engagement. And we’re experiencing that firsthand in the study that Jamie’s running right now. It is because of our interest in attachment and because of our other research about the role that caregivers play in this issue, that was also a super appealing part of it.

And so it was really this: You know what? They’ve already done it with the younger kids, 12 and under, but nobody is doing it with the adolescent—people might be doing it, but they’re not studying it. And they’re not doing it in a systematic, really integrated, intentional way. The developers call it an enhanced model.

Jamie Yoder:
Yeah.

Melissa Grady: 
Because we are still using the basis, the practice outline of TF-CPT, but we’re enhancing it by really including this integrative piece of PSB. So that plus the caregiver component, those were really the driving forces behind our: Let’s kind of full force go into this. And while there had been work with just CBT and adolescence, the trauma piece was not as fully integrated into that work.

And given our experience, with this population, we just felt like they’re needed to—and clinicians have been asking, asking for this. How do we do both of these at the same time? 

Jamie Yoder: 
So, I also just want to state that when Melissa and I contacted the developers, Dr. Mannarino, Deblinger, and Cohen, all three of them were very receptive, and we have been very lucky to be able to partner with them and conceptualize—

Melissa Grady: 
Absolutely.

Jamie Yoder: 
—the way this can look. And being really true to the way that they developed the model in this enhancement.

So we’ve really thought about, you know, how do we, how do we ground these clinicians in TF-CBT in a way where we also harness their knowledge and really a lot of experience, right, field experience in PSB work. So a lot of the people that we are working with now have in-depth experience with working with kids with problem sexual behaviors in various different capacities. Whether it’s justice-involved kids or child-welfare-involved kids, they have had the experience with PSB. 

So our thought process was, how do we train clinicians that are rooted and grounded in this work into a new way of kind of a new paradigm shift, into thinking about trauma as part of this work? 

And that’s part of where we are now. And I’m happy to talk more about the pilot study that we’re conducting. But I do want to say that the work with the developers and with the training team out of Oklahoma has been instrumental towards where we are now and where we’ve gotten to be with using the model, applying the model, and seeing how it works. 

And I think that that the training team, you know, they struggled a little bit, I think—even in the child side, when our conversations began to happen, a lot of them were saying, “You know, we’ve been doing this with young children. We’ve trained a lot of clinicians who have TF-CBT experience. And they’re coming to us and saying, “We have questions about how do we apply this with kiddos that are demonstrating problem sexual behavior? But we don’t necessarily know enough about the adolescent side to move this into a more developmentally appropriate, age 12, maybe, to 18, context.” So in our conversations with them, it was, how do we also take some of what they’ve done, with their permission, and apply it to that adolescent framework? 

Because it’s such a different developmental stage, right? It’s a lot. You’re dealing with the kids who are going through a little bit more of a precarious developmental experience. It’s evolving and there’s a lot of hormonal developments happening at the time. So we had to be really careful about: What does this mean when we’re talking about a different age bracket? And how do we adapt it? Because these aren’t yet adults, right? We’re still dealing with adolescents. So we’re happy to talk about all of that. 

Melissa Grady: 
Yeah. And two other quick things about that, too, is that part of it is that the relationship between the caregiver and the child is so different in adolescence. And so making sure that we’re cognizant of that piece.

And then the other thing that’s really different about the adolescent population that, even in our conversations that we’ve been having in these early stages of developing this manual and doing the feasibility study, is the justice piece. 

Jamie Yoder: 
Mm-hmm.

Melissa Grady: 
It’s, usually with kids 12 and under, you know, you don’t have a probation officer. They’re not in court. You don’t have these correctional contextual factors that are playing a role. And with a lot of the adolescents, you do. And that is a whole other layer of complexity and also trauma. 

Jamie Yoder: 
Yeah.

Melissa Grady: 
That has to be talked about within the treatment that when you’re 9 isn’t really a factor in that treatment.

Those were two really big standouts that, for us, we really had to be thinking about in the development of this. 

Jamie Yoder: 
Mm-hmm.

[32:09] Teresa Huizar: 
So you were mentioning that, you know, you now have an active trial really looking at how this is playing out clinically with a pool of kids. And what are you finding? What is surprising to you as you’ve been doing this work under this conceptual framework? What is an “Aha!” moment or, you know, “Oh, no!” or whatever it might be?

Jamie Yoder: 
I think it’s interesting, right? Because we’ve had a lot of different challenges as we’ve started to pilot this. And one of the challenges we’ve found is that Melissa and I always talk about that we have people kind of at different starting points. We’ve got clinicians we’re training now with PSB experience. And we know that clinicians exist with TF-CBT experience and are beginning to see kiddos manifesting problem sexual behaviors. And so we decided to kind of put that side of the equation on pause for a minute and just look at the PSB clinicians because we really wanted to see whether this works and we can train possibly these new clinicians in this new model.

And so one of the things we’ve been seeing is that we have a wonderful group of partners in Georgia. It’s the Department of Juvenile Justice in the state of Georgia, and we have a community partner agency there as well. And as part of our pilot, we’re seeing how it works in both settings, right?

And we just had a consultation call this morning, and one of the things we talked about in both settings was the different barriers that they’re facing in the community-based setting. One of the biggest barriers to implementation is that we have client or clinicians that are getting paid by the hour. So they’re not salaried employees, and they have a 9 to 5 schedule maybe, and they’re having a difficult time getting cases past five o’clock in the afternoon. Or parents can’t be involved for whatever reason, because they work at two o’clock and they don’t want to pull the kids out of school.

Another challenge we’re seeing on the other side is caregiver involvement altogether. Because if you’ve got kids involved in the justice system, a lot of times, and many times, especially when it comes to kids who are engaging in problem sexual behavior, there’s a lot of stigma, a lot of shame, and a lot of blame that goes alongside of that.

So when caregivers are being asked to be involved in a treatment, a lot of times they’re saying, “I don’t want to do this,” or “I want to relinquish my rights.” And so that’s been a challenge for the. justice side. So we’re seeing a lot of these different challenges come up, but the tenacity that our clinicians are showing up with and their willingness to really engage has been one of the driving forces of this work. And the kids’ willingness.

And so I think that’s been a big surprise for me to see, as we’re going through our consultation calls, the clinicians are saying time and again, that with every new kid that they’re enrolling in the study, they’re saying the kid wants this. They want to be able to overcome their trauma. They want to be able to talk about what happened to them. And they want to be able to talk about the harm that they caused to somebody else—within the full context. One of the clinicians this morning on the call said that the kiddo kept saying, “I just don’t want to be like my dad. And I want to grow up to be a different person and a different human.” And so you hear those narratives from the kids directly. 

And we know that the studies show through TF-CBT that, irrespective of whether or not the caregivers are involved, that it can be really, really successful and really, really effective for the kid. And so, if we consider that, and we use that as kind of our baseline, we know that if the youth is showing motivation, that is going to drive a lot of success and bring a lot of success.

So we’re hopeful so far. We are still enrolling a few kids. We’ve got about 15 right now, which is really great. And we’re starting with, the case consultation calls are all about psychoeducation and affect regulation and starting the beginning parts of the practice. And so as we continue forward, I really look forward to seeing, like, how this evolves and what kind of outcomes we’re going to be getting. 

But it’s been a big lift from the research side of things, because it’s not only the training element. So we had to go through a pretty extensive training, but also learning about the differing systems in order to recruit effectively the youth and the families. And so we have the dyads, the caregiver involvement, and the consent process that goes along with it as well.

Melissa Grady: 
I would add another piece, and Jamie’s really the leader on this project, but another piece that we’ve been talking about as a research team around this study is that there’s a lot of variation in the PSB work. And so Jamie talked about sort of two different sets of or pockets of clinicians. Those with extensive PSB work, and those with TFC work. Well, TF-CBT is standardized. It’s, you know, there’s set training, there are protocols. There’s the practice that everybody follows. There’s, you know, the developers of have done a fantastic job in ensuring that there’s fidelity and there’s clarity and there’s consistency in how it’s being trained and rolled out to different clinicians. 

We don’t have the same on the PSB side. There isn’t a gold standard. There isn’t a way that people do it. It is incredible, actually, the range that you will see in how clinicians provide PSB services. 

So, that is another challenge that I would say, when we’re talking about what is treatment as usual or what’s the gold standard in PSB work. That’s a great question that we cannot answer. And I would love for somebody to be able to answer that. Jamie and I are both on a task force throughout the Association for the Prevention and Treatment of Sexual Abuse, and it’s updating the adolescent treatment guidelines right now. And so that’ll be interesting to see what comes out of that committee’s work and what we can all agree on in terms of what constitutes a gold standard.

But it’s really difficult right now. If you ask 50 adolescent practitioners who work in the PSB world what they do, I bet you would get 50 different versions of what PSB work looks like. So that’s another whole challenge because you’re not, even though we’ve got these two groups, we’re not necessarily all starting on the same part of the starting line.

Jamie Yoder: 
I had a chance to listen a bit to what Dr Mannarino’s podcast was in October. And one of the things he mentioned was that, you know, there’s 25 randomized control trials and there’s been a lot of research around TF-CBT, which is just wonderful. And I think one of our challenges in this work is that our control group is so varied, right?

So to the extent possible, we need to make sure our control group is controlled and tight. And we have a very standardized approach to what PSB work is, is looking like. And so this feasibility study we’re doing is answering a lot of these questions of: Where do we go next? And how do we go there? Because it is varied, and we are seeing these are the barriers here, these are the barriers here. But in what ways can we work around those barriers to effectively deliver this in a way that makes the most sense and with practitioners and clinicians that need it the most? So that’s kind of our long-term goal is to think about an RCT [randomized controlled trial] with a control group that has enough of that standardization across the way they’re delivering PSB.

And we know there’s some evidence-based approaches like PSB-CBT out there for younger kids, and we know that some of these, like, Good Lives Model has been talked about and touted as a really wonderful approach. And so we know that there’s a lot of approaches that are being used that are really useful to the extent that they’ve been rigorously studied. We know PSB-CBT has but, like, to the extent that others have been is somewhat of a question. 

[40:38] Teresa Huizar: 
One of the things I was thinking as you guys were talking is that so many Children’s Advocacy Centers wind up working with both children and youth with PSB in part because no one’s working with them.

And so it’s interesting to hear you talk about sort of like the wide variety of practice. Which I’m sure is true and exists because so many CACs basically report that nothing in their community happens unless you have a child who’s justice-involved, and then that may be inpatient someplace, and they may or may not get treatment at all, and all of those things. So I think that there’s real promise here. And I think it’s going to be interesting to see not only the work that’s done with providers who are already trained in some sort of treatment for youth with problematic sexual behaviors but also in all of those who’ve been trained in TF-CBT already. 

Jamie Yoder: 
Mm-hmm.

[41:32] Teresa Huizar: 
What do you think’s next for you beyond, you know, sort of moving beyond this pilot to hopefully, knock on wood, you’ll get good funding for a randomized control trial with this? What else is next?

Jamie Yoder: 
Yeah, I think our next step is just that. It’s a randomized control trial. We really hope to bring this out and to the full to really bring evidence behind this. Because the feasibility study gives us this much information, and it gives us really important information. A lot of it’s qualitative, and a lot of it’s going to be useful in terms of guiding where we go next.

But we’ve had conversations recently about developing partnerships where we have clinicians that are trained in a similar approach or some of a standardized approach in PSB and then randomizing the clinicians to be trained in TF-CBT. So we have the treatment group and then the control group who are doing treatment as usual, which is the standardized PSB.

And the hope is that once we randomize the clinicians, that we will be able to determine with greater control some of the effects of TF-CBT. And we know that, even if we didn’t integrate—largely, if we didn’t integrate PSB into this TF-CBT in the way we’ve written about it in the paper, we may still see some really great effects of TF-CBT just by and large because we are talking about trauma.

And we know that that trauma narrative piece of this approach is one of the biggest parts of the work that is the most effective. But at the end of the day, we are still obligated because it’s a public safety issue to do the PSB work. So we can’t ignore it and we have to integrate it in a way that makes the most sense.

And if we can think about it through almost a restorative justice lens, how do we work with both the victim and the kid who has problematic sexual behavior, we think we’re going to see better outcomes. Or at least that’s the hope. So the next step will be a randomized control trial. And Melissa and I are putting our brains together now about what that funding is going to look like and what mechanism we want to go for.

That would be the best fit for this. Because it would still be a smaller group of initial kids we’d be recruiting for the study, but it has to be powered enough to be able to see some outcomes. 

Melissa Grady: 
And then I would just say, you know, our long-term goal is to create better treatments so that we really help this population. Whenever we write anything together, we’re always talking about prevention on the primary, secondary, and tertiary level. We have a colleague in England who’s writing now about the quaternary level—and I don’t know if I’m saying that right— but the fourth level. Which is how do we also create treatments or interventions that don’t make things worse? Like Elizabeth Latourneau’s. A lot of her work is on the registry for adolescents and the negative impact.

So, I feel like that we have so much work to do on all four levels of trying to address sexual abuse in our society as a whole. Thank you. And this. While we all would love to focus in on doing everything to eradicate sexual abuse, this is sort of our niche that we’re hoping that with these kids, we can think about some of these principles. Especially on the secondary, when we know kids have experienced sexual abuse, can we get in with empirically supported interventions like TF-CBT early—

Jamie Yoder:
Mm-hmm.

Melissa Grady:
—and help disrupt those potential pathways that we talked about earlier? And then for kids who already are there, how can we make sure that they come through this experience? As Jamie gave the example of not like the person who hurt them before, but as a person who wants to contribute, as a person who wants to give back, as a person who wants to live in the world in a different way and hopefully have a much higher quality of life as a result of that.

So ultimately yeah, that’s the bigger picture goal that we would love to be able to do, is reduce sexual crime across the board. And then for those who have experienced it, try and create a different outcome for them as we think about how to treat the whole person and think about all of their needs. 

Jamie Yoder: 
Yeah, I really see this approach as being a secondary prevention approach where we have a targeted group of kiddos that we’re working with, and while they may have displayed some problematic behaviors—and some of them may be very serious, and so we can’t discount that, right? Like, we can’t discount the impact that this has on the victims. 

Melissa Grady:
Absolutely. 

Jamie Yoder: 
We certainly can’t minimize the impact that it has on families and all those affected in the community. And we also can work with the youth who has committed the behavior or the crime, however, we want to think about it, to really begin to develop skills and internalize the why behind the reason they’re doing it. And in order to motivate them and deter them from doing it in the future. 

So that’s the goal, right? And if we continue just to focus on victims in this world, then I think we’re missing an entire group of kiddos that we really can begin to rehabilitate and work with. 

And the reason I was always drawn to working with adolescents is because I’ve always considered them to be amenable. And they have a lot of skills and resources, and we can empower them to overcome these difficulties and have a really successful, positive development as they move forward. But we can only do that if we work with them directly. So I think that’s our goal. And I’m super, super, just super grateful to be able to partner with Melissa and everyone else who’s part of this team because it’s such profound, exciting work. 

[47:38] Teresa Huizar: 
You know, I really appreciate so much the work that you both are doing on this along with other colleagues. I think it’s just critically important and that in many ways too long we’ve expected victims to sort of carry the whole burden of community safety on their backs.

And in some ways, what this really does is, you know, more fairly distribute the responsibility for community safety. And, you know, it’s gratifying to hear that there are youth who really want to live better, healthier lives, you know—

Jamie Yoder:
Yeah.

Teresa Huizar:
—into their adulthood. And whatever we can do to make that possible I think can only be good for victims, honestly, who really want better, safer communities.

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So thank you for your work. We appreciate you. And we look forward to your continued research and hope you’ll come back to talk about it when it’s finished.

Melissa Grady: 
We hope to be invited back and thank you so much for the opportunity. 

Jamie Yoder: 
Yeah, this has been lovely. Thank you so much.

[Outro]

[48:32] Teresa Huizar:
Thanks for listening to One in Ten. If you like this episode, please share it with a friend or colleague. And if you’re a fan of this show, please rate us in the Apple Podcasts store or wherever you listen. For more information about this episode or any of our others, please visit our podcast website at OneInTenPodcast.org.

[Outro music fades out]