National Center on the Sexual Behavior of Youth

What is the first step in the clinical decision making process with teens?

• Deciding whether the teen exhibits problematic sexual behavior is the initial consideration for clinical decision making and case plans.
• Teens may be referred because caregivers or guardians are worried about the youth’s sexual behaviors, such as masturbatory practices, pornography use, inappropriate nudity, “sexting,” or perceived promiscuity, behaviors that may not always be illegal (Social Media link Coming Soon).
• Other times, teens may have engaged in illegal sexual behavior with a willing partner close in age, but one or both of them have not obtained the age of consent in their state.
• Answering questions about whether the teen’s sexual behaviors are clinical problems requires knowledge of typical sexual development and behavior, relevant state and federal laws.  For more information, please see Sexual Behavior: Normative or Problematic?, Teens,and Assessment with Teens (Coming Soon).

 What if the assessment indicates the teen does not have problematic sexual behavior?

• Consultation or assessment may indicate a teen does not have problematic sexual behaviors and that further intervention to address sexual behavior is unwarranted.
• Assessment findings may not indicate problematic sexual behaviors but may reveal other difficulties including, other problem behaviors, untreated mental health disorders, or significant family conflict.
• If a teen’s problematic behaviors do not endanger others and are not illegal, mixing these teens with those who have violated the law may not be appropriate. Other types of treatment should be considered.

 What are some diagnostic considerations related to problematic sexual behavior?

• “Problematic sexual behavior” is not a diagnosable condition-these actions are clinically concerning behaviors. 
• At times, the problematic sexual behaviors represent an isolated or transitory problem of a teen who is otherwise functioning well. 
• Sexual behaviors may be part of a pattern of delinquent activities or one of a number of symptoms of a disruptive behavior disorder (Refer to the American Psychiatric Association Diagnostic and Statistical Manual V [DSM],(Coming Soon) for detailed diagnostic information).
• Problematic sexual behaviors involve breaking rules and violating other people’s physical boundaries, and thus, may represent behaviors consistent with other symptoms of disruptive behavior disorder(s), such as Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, or Disruptive Behavior Disorder Not Otherwise Specified (NOS). (Coming Soon) 

Do problematic sexual behaviors reflect atypical sexual interests?

• In rare cases, the problematic sexual behaviors may reflect atypical sexual interests involving much younger prepubescent children or coercive sexual activities. 
• Sometimes these atypical interests may resemble sexual traumas experienced by the youth, perhaps reinforced by multiple incidents or masturbatory activity, and physiological arousal responses involving pleasurable sensations or orgasms in pubertal youth. 

 When is appropriate to diagnose a teen with Pedophilia?

• Because sexual interests and patterns of sexual arousal are still developing in teens, a diagnosis of Pedophilia must only be used if the teen clearly meets the diagnostic criteria. As noted in the Diagnostic and Statistical Manual of the American Psychiatric Association – (DSM-V).
• Terms like “pedophilic traits” or “paraphilias not otherwise specified” with teens that are younger than 16 are inappropriate.

 What are some considerations for understanding teen behaviors and treatment/case planning decisions?

• Understanding how problematic sexual behaviors fit within the context of other behaviors, mental health difficulties, environment, and other risk and protective factors (Coming Soon) serves to inform treatment and case planning decisions.
• Consideration should be given to whether the teen: (1) evidences problematic sexual behaviors as a function of transitory personal, situational or contextual factors; (2) demonstrates problematic sexual behaviors as part of a larger pattern of conduct problems and delinquent behaviors; (3) has atypical sexual interests; or (4) has atypical sexual interests, antisocial attitudes, and delinquent behaviors.

 For more information, see Types of Youth with Problematic Sexual Behavior – Teens.  Also, for further information relevant your clinical or case management decision-making, link to Risk and Protective Factors in Understanding These Youths, Assessment and Intervention. (Coming Soon)

What situational or transitory factors are related to problematic sexual behaviors in teens?

For most teens, problematic sexual behaviors are related to situational transitory factors. Situational factors may include:

• Normative surge of adolescent onset sexual interest and impulses.
  • Lack of knowledge or misunderstandings about society’s rules regarding sexual behavior and not appreciating the wrongfulness of sexual misconduct.
• Insufficient adult monitoring.
• Substance use
• Exposure to sexual behavior through media or on the internet
• Obstacles to age appropriate peer relationships, e.g., social isolation.
• Negative peer influences. 

 Teens with Attention Deficit Hyperactivity Disorder (ADHD) (Coming Soon), in the absence of other delinquent behaviors, may also fall into this category.

Some teens may have other difficulties, learning disabilities, intellectual disability, or developmental disabilities, such as autism, Asperger’s Syndrome or fetal alcohol syndrome, and have difficulties with impulse control and decision making.  For these teens, interpersonal problems may be similar to children with ADHD, (Coming Soon) including impulsively touching others’ private parts or violating physical boundaries.  Click here for resources and further information Asperger’s Syndrome.

• Sometimes teens with such difficulties respond to normative sexual feelings inappropriately. 
• Sometimes, teens with developmental challenges may not have been taught or learned rules and laws regarding sexual behavior, or perhaps, because of difficulties with reading or understanding other’s feelings, may act in ways that are sexually inappropriate or even illegal. 
• Most youth with ADHD, developmental disabilities or other mental health challenges or disorders, do not engage in problematic sexual behaviors. 
• Treatment and case planning must account for the teen’s abilities, supports, and learning style. 

 Disruptive Behavior Disorder or Delinquency

What if the problematic sexual behavior is part of a larger pattern of disruptive behavior disorder or delinquency?

• Some teens engage in disruptive or aggressive behaviors that include violating laws or the rights of others. For these youth, problematic sexual behavior may be part of a larger repertoire of concerning activities. Youth who engage in antisocial and delinquent acts often meet criteria for Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Disruptive Behavior Disorder Not Otherwise Specified (NOS), or Attention Deficit Hyperactivity Disorder (ADHD).
• Common behavior patterns for youth with ODD or CD can include outbursts or aggression in response to limit setting or provocative behaviors intended to annoy or harass others. Problematic sexual behavior for these youth may follow similar triggers (e.g., being rejected by a romantic interest) or serve similar functions (e.g., harassing others). 
• Sometimes illegal sexual behaviors may be related to antisocial attitudes that justify these behaviors (e.g., that following a date, the youth is entitled to sex and, if the person unwilling, force is a required necessity).
• Some youth, for example, commit statutory offenses (i.e., have sex with a person close in age, who does not object, but is under the legal age to consent) or engage in sexual behaviors that do not include force, aggression, or even physical contact.
• Others may demonstrate severely nonsexual aggressive and dangerous conduct that has been ongoing from an early age, with intermittent sexual offenses. 

Most youth with delinquent behaviors do not exhibit problematic sexual behavior. A multisystemic intervention, such as Multisystemic Therapy for Problematic Sexual Behavior (MST-PSB) is an evidence based approach that could be considered for youth with conduct problems.

 Atypical Sexual Interests and Serious Delinquency

What if teens have problematic sexual behavior with atypical sexual interests?

• A small number of teens may evidence sexual preoccupation, excessive sexual behavior, and/or atypical sexual interests. For these teens the sexual behaviors are the main focus of treatment.
• They have difficulty managing their sexual arousal appropriately and may demonstrate problematic sexual behavior across a variety of contexts (e.g., school, home, etc.).
• Assessment and interventions must explore the meaning of these behaviors for the youth and develop appropriate interventions that facilitate healthy relationships and help them avoid hurtful or illegal sexual behaviors.
• Inaccurate and distorted beliefs about sexual behaviors (e.g., that the behavior is consensual, acceptable, not harmful) may be present; sometimes the youth may know the behavior is inappropriate, but persist anyway. 
• Occasionally, these teens experience persistent arousal associated with inappropriate sexual interests, such as sexual arousal involving significantly younger children, themes of violence, or coercion.

 What if the problematic sexual behavior is atypical and delinquent?

In rarer cases, teens may demonstrate significant, early onset, delinquent and aggressive behaviors and sexual preoccupation or deviant sexual interests. When identified, these teens often present with multiple, pressing treatment needs, frequently including co-occurring mental health challenges and disorders. 

• Interventions need to be prioritized to maximize the safety of all involved and reduce immediate risk factors related to offending.  Interventions may initially require short-term residential placement and intensive services.
• After a comprehensive assessment, interventions will need to target erroneous attitudes and beliefs related to the problematic sexual behaviors.
• Interventions that facilitate impulse management and other identified risk factors will be needed.
• Behavior management and collaborative, multisystemic safety plans involving parental and other adult supervision will be needed to facilitate safety upon re-entry to the community. 

 Other Diagnostic Considerations

Assessment sometimes reveals that a teen with problematic sexual behavior may have learning difficulties and mental health problems including or beyond those mentioned above, or a significant history of trauma or maltreatment. Determining how these difficulties affect problematic sexual behavior risk factors and treatment needs depends on how these factors interact with the problematic sexual behavior.

What are some diagnostic considerations for youth with learning problems?

• Teens with problematic sexual behavior often present with learning disorders or difficulties. In addition to learning problems, some teens may have developmental delays, intellectual disabilities, or pervasive developmental disorders that impact not only learning, but functioning across multiple domains. 
• It is essential that providers tailor interventions to match a teen’s learning styles and capabilities.
• Teens with memory difficulties will likely need opportunities to pre-learn material and have frequent repetition and practice. 
• Many teens could benefit from additional support and structure in their home environment, including cues by their caregivers to use their new skills. 

 What are some diagnostic considerations for teens with trauma exposure?

• Some teens with problematic sexual behavior have experienced some type of maltreatment, abuse, or traumatic event (e.g., sexual or physical abuse, witnessing domestic or community violence). Only a portion of youth will go on to develop symptoms consistent with a trauma –related disorder. 
• Specifically, possible diagnoses related to trauma may include Post-Traumatic Stress Disorder (PTSD), Acute Stress Disorder, or Adjustment Disorder. Several evidenced based treatment interventions exist for trauma disorders.
• Some teens are able to work successfully on goals in sexual behavior treatment and address their trauma symptoms concurrently, or after sexual behavior treatment is completed. Other teens might become anxious, agitated or angry when treatment discussions focus on sexual behavior, as these discussions offer vivid reminders of their own abuse history.
• Initial treatment for trauma may be necessary before a teen with such trauma reactions would be able to engage in treatment effectively.
• It is important, however, to recognize that these teens may require a “trauma-informed” approach to their treatment. Evidence based interventions include Trauma Focused-Cognitive Behavior Therapy. (See Trauma Interventions (Coming Soon) in Resources for additional evidence based interventions).

For more information about youth responses to traumatic life experiences, visit the National Child Traumatic Stress Network.  

 Treatment Planning and Interventions

What are some considerations for effective treatment planning and interventions?

Effective treatment planning requires an initial assessment (Coming Soon) to ensure safety and identify risk and protective factors, interventions needs, and treatment responsivity requirements.  Interventions are most likely to be effective when individual and family treatment needs are matched with high quality services in a seamless and flexible continuum of care. Ongoing and timely reassessments are necessary to facilitate effective treatment plans over time.

The continuum of treatment interventions (Coming Soon):

• Brief psycho-educational interventions.
• Outpatient therapy (6-16 months).
• Intensive outpatient therapy (clinic or home-based).
• Intensive multisystemic treatments
  • Day Treatment.
  • Staff-secure residential treatment.
  • Intensive treatment in locked facilities (e.g., juvenile correctional facilities or hospital settings).

Community-based treatment interventions can vary in intensity depending on the individual and family’s needs.  Most teens with problematic sexual behavior, who have few risk factors associated with reoffending and strong protective factors, may only require weekly outpatient treatment sessions. Research suggests treatment is likely to be more effective when caregivers and teens are involved in treatment concurrently and together, practice new skills in sessions.

How can I tailor the intervention to address multiple risk factors?

• Youth and families with more risk factors and needs may require multiple weekly outpatient treatment sessions, home based services, or multisystemic services.
• Home based interventions are appropriate for youth with significant needs across multiple domains, especially ongoing problematic behaviors in their home environment.
• Home based programs often address parenting strategies, youth problem behaviors, and sometimes include additional community support and coordination with other providers and settings, such as schools.
• One intervention with empirical support is Multisystemic Therapy (MST) for Problematic Sexual Behaviors. 

 What if families and individual family members have multiple needs?

• Multidisciplinary teams or intensive case management services, such as High Fidelity Wraparound, may be useful in addressing multiple needs. 
• Case managers and team facilitators must be knowledgeable about youth with problematic sexual behavior, their risks and needs. 
• Multidisciplinary teams and clinicians are cautioned against attempting to address all needs of the families with a variety of interventions provided by multiple agencies. 

 How can foster care placements help teens with problematic sexual behavior?

For teens who are unable to remain at home, foster care placements offer another alternative.

• Foster parents, especially when highly trained to manage problem behaviors, may coordinate and work closely with treatment providers and safety teams to help youth resolve difficulties and develop pro-social skills and behaviors.
• Therapeutic foster care or foster homes with services such as MST-PSB may be good alternatives for youth who may be at increased risk for negative peer influence in residential care, such as younger adolescents or those with less severe delinquent behavior.

 When should I consider in-patient treatment?

Teens with the highest level of risks and needs may require residential, hospital, or correctional placements with appropriate treatment programs.

Research suggests that while youth in some residential programs demonstrate positive gains, these gains often are lost once youth re-enter the community.  Studies suggest, however, that the effectiveness of residential treatment may be enhanced and improvements may be maintained by:

• Use of intensive, evidence based interventions.
• Family involvement and participation in services.
• Interpersonal and pro-social skill development.
• Stable aftercare settings.
  • Ongoing supports following discharge (outpatient treatment, school supports, and so forth).
  • Treatment components of juvenile corrections programs should incorporate   components of evidence-based, effective interventions.

 How can I involve caregivers in the treatment process?

Although teens are at a time in their lives when they are beginning to separate from their parents and caregivers, these adults remain very important to them.  Research shows that involving parents or caregivers with has positive outcomes.  Parents benefit from learning:

• Effective parenting strategies that promote positive behaviors and prevent misbehaviors.
• Information about sexual development and guidelines for distinguishing more common sexual behaviors from those that are problematic or illegal.
• Acquiring knowledge about the origins of these problematic behaviors.
• Developmentally appropriate sex education and how to promote open communication about sexual knowledge and behavior.
•  How to help their teens understand relevant laws and legal consequences for illegal sexual behavior.
• How to address relationship building skills and intimacy, and ensure consenting relationships.
• Abuse prevention skills, with an emphasis placed on how the caregivers’ plan to protect all of their children.

 For information about the research support for a range of treatments for teens with problematic sexual behavior and more information about specific intervention strategies, link to Treatment Outcome Research Results – Teens and Intervention with teens (Coming Soon). Additional relevant information for decision-making may be found in Qualifications, Guidelines and Standards of Care and Intervention-Program Evaluation (Coming Soon).

Clinical Decision-Making