Working Therapeutically with Children who have Exhibited Harmful Sexual Behaviour (HSB)

Harmful Sexual Behaviour can be defined as developmentally inappropriate sexualised behaviour exhibited by a child or young person, which is harmful or abusive to another child or young person.  Given that around one-third of child sexual abuse is perpetrated by those under the age of 18, it is vital that professionals working with this cohort develop a better understanding of the early indicators of those who both exhibit and fall victim to HSB, and how to effectively engage families in order to ensure safety and support reparation where appropriate.

However, whilst we must be careful not to minimise, the term HSB can be used to refer to a wide spectrum of sexualised behaviours and it is important to ensure a proportionate response which takes account of the young person’s age and stage of development.  Therapists who specialise in this area are tasked with striking the delicate balance between prioritising the safety of the victim/potential victims and addressing the behaviour proportionately, and in a way that facilitates real change, thus reducing risk for good.  They are also responsible for ensuring young people with HSB are not stigmatised and are safeguarded like any other child. 

Addressing HSB calls for a bespoke, needs-led multi-agency approach which endeavours to fully understand the context and sequence(s) of events which lead to the concerns; usually flagged by social care or CAMHS.  Given the nature and far-reaching impact of HSB, parents/ carers and often other family members should be involved for effective intervention to take place.  For parents, finding out that their child has exhibited HSB can be incredibly distressing, often causing feelings of anger, fear, shame and guilt, particularly when there is an identified victim.  Professionals should appreciate parents' tendency or temptation to deny or minimise HSB and the therapeutic relationship should be prioritised to ensure they feel able to be open and honest.  

Often parents will require psychoeducation to get them to a place where they are ready to engage in therapy.  Allocated clinicians should support concerned parents in understanding the contributing factors which may cause a child or young person to engage in HSB.  It is important for parents to understand that such factors are generally far removed from those which motivate adults to perpetrate sexual abuse.  HSB in young people tends to be precipitated by a combination of a number of factors including adverse childhood experiences, poor social skills, unmet emotional needs, a lack of same-age peer influences, and exposure to unhealthy sexual content/messages from other sources.  Children and young people with learning disabilities tend to be over-represented in those who exhibit HSB.

The priority for any specialist intervention is to develop a robust safety plan based on initial information, whereby all family members and professionals involved have a shared responsibility to ensure no further incidents of HSB for the duration of treatment.  It is important to understand the culture and dynamics of the family including what life is like in the family home, how family members communicate with each other, and what they would consider ‘normal’, inappropriate or concerning in terms of sexual behaviour.  Of course, any traumatic events which have occurred in the young person’s life should be explored.

The therapist should then work collaboratively with the young person, parents and family to develop a formulation which will form the basis of the therapeutic intervention.  Here, all systems and contributing factors should be considered to ensure a comprehensive conceptualisation.  This can be extremely cathartic, helping parents and family members to understand the child’s behaviour as a response to their environment and experiences as opposed to believing that there is something fundamentally wrong with their child.  Once the young person has a better understanding of their HSB, they may feel able to engage in reparation work with the victim, which should be facilitated where appropriate.  

Safety plans should always be reviewed and updated throughout therapy to ensure they are proportionate, and developmentally appropriate, and allow the young person to utilise and develop their newfound skills. Whilst any relaxation of the safety plan can be anxiety-provoking, it is vital that the longer term safety plan does not inadvertently isolate the young person or keep them from a normative trajectory, especially when this has often been a contributing factor to the HSB in the first place.  Education in particular provides young people with access to trusted adults and prosocial peers which may not otherwise be available, and continued engagement with education should always be a priority.