CBT for children with problematic sexual behaviour

1. Introduction

Version followed: PSB-CBT-S (school-age, 7–12), the current University of Oklahoma Health Sciences Center (OUHSC) / National Center on the Sexual Behavior of Youth (NCSBY) group model: 18 weekly 60–90 minute concurrent child and caregiver groups with combined multi-family sessions about monthly, plus a family modality. Its manual lineage is Silovsky, Swisher & Widdifield (2010, 3rd ed.), adapted from Bonner, Walker & Berliner (1999). The current 2023 PSB-S curriculum was not available to open. Session-level child content below therefore comes from the original Bonner, Walker & Berliner child group manual (12 sessions), and the more recent components come from CEBC and NCSBY descriptions. Preschool (PSB-CBT-P, ages 3–6) and adolescent differences are noted where sources give them. [source: NCTSN fact sheet; CEBC school-age; Bonner, Walker & Berliner child manual]

PSB-CBT is a structured, manualised outpatient programme that combines group, psychoeducational, cognitive-behavioural and behavioural-parenting methods. It is not a single technique. Problematic sexual behaviour (PSB) means behaviour that a child initiates, that involves sexual body parts, and that is developmentally inappropriate or potentially harmful to the child or others. PSB is a behaviour, not a diagnosis or syndrome. [source: OU PSB-CBT clinical program page]

The theory of change has two parts. First, caregivers reduce opportunity and reinforce new behaviour: they run a family safety plan, supervise the child, set house rules and use behaviour-management and sex-education skills. Second, the child learns explicit sexual behaviour rules, acknowledges which rule they broke, and builds coping, self-control, decision-making and social skills so they can follow the rules without constant external control. The programme treats youth "as children first", able to learn, make safe decisions and build healthy relationships. [source: OU PSB-CBT clinical program page; CEBC school-age; NCTSN fact sheet]

2. Framework

Format by version [source: CEBC preschool; CEBC school-age; NCTSN fact sheet; Restoring the Sacred Circle 2024]

PSB-CBT-P (3–6 years): closed group, 12–14 weekly 90-minute sessions, 5–7 children per group, with a parallel caregiver group and a joint parent–child component. The model can be delivered to a single family when a group is not suitable.
PSB-CBT-S (7–12 years): 18 weekly 60–90 minute sessions with concurrent child and caregiver groups and monthly multi-family sessions. CEBC describes an open-ended group from which children graduate in about 4–5 months. Children's groups are split by age (6–9 and 10–12) with 5–8 children each. The 2006 randomised trial used a 12-session version. The Sacred Circle resource gives 18–22 sessions. [uncertain: session totals differ across sources; follow your training cohort's current curriculum]
Family modality (all ages): sessions with the caregiver alone, the child alone, or the family together. It can be delivered in the office or by telehealth.
Adolescent groups (13–18): adapted for family participation. Sacred Circle reports about 12 months for teens with no prior PSB treatment, or 6 months after residential treatment. OU also offers a separate advanced 13–14 track. [uncertain: no adolescent manual or OU adolescent page is drawn on]
Staffing: co-therapists for each child group and one therapist for the caregiver group. Programme staff also include a supervisor or director and staff who carry out intake assessments. Lead clinicians should be licensed and experienced with behaviour problems, maltreatment and caregivers. [source: CEBC]

Working phases. The sources describe components rather than named phases. The grouping below is [synthesis], built from the listed components and the OU learning objectives.

Phase	Goals	Typical timing	Move on when
0. Referral, assessment, immediate safety	Gather multi-informant assessment (written tools, interviews, observation, environmental screen). Put a family safety plan in place at once. Decide on placement and visitation with MDT partners.	Before group entry; 1–3 contacts [synthesis]	Safety plan agreed and supervisors identified; caregiver committed to weekly attendance
1. Orientation and rules	Group purpose and group rules. Teach the sexual behaviour rules, private parts and boundaries. Caregivers learn PSB psychoeducation and set up house rules.	Sessions 1–3 approx.	Child can state the rules; household rules posted and in use
2. Acknowledgment and skills	Child acknowledges the rule broken. Child learns feelings work, coping, self-control (Turtle Technique), problem-solving and social skills. Caregivers learn behaviour parent training and supervision refinements.	Middle sessions	Child shows skills in role-play and at home; weekly behaviour reports stable
3. Sex education, abuse prevention, amends	Developmentally matched sex education and abuse-prevention skills. Caregivers practise talking about sexual topics. Acknowledgment, apology and amends. Child's plan to keep the rules.	Later sessions	Plan written; caregiver able to talk about sex education with the child
4. Graduation and step-down	Review, graduation readiness check, gradual step-down of supervision toward a "new normal", and visitation or reunification steps where relevant.	Final sessions and after	Graduation criteria met (below)

Graduation. Completion is decided by clinical judgment together with the Assessment of Sexual Behavior – Child (ASB-C) and other standardised measures. Assessing graduation readiness is a trained competency. [source: OU PSB-CBT clinical program page; OU learning objectives] The exact OU criteria were not found [uncertain]. A defensible working set [synthesis]:

No new PSB over a sustained period, judged on weekly caregiver report and other sources.
The child can state the rules and the plan, and uses coping or self-control skills in role-play and at home.
Acknowledgment and apology work is complete.
The caregiver applies the safety plan and behaviour-management skills consistently and can talk with the child about sexual topics.
Standardised measures show improvement.

Measures (named only; do not reproduce items): Child Sexual Behavior Inventory, Youth Sexual Behavior Problems Inventory, ASB-C, and the Child Behavior Checklist. The preschool study also used the Parenting Stress Index-SF. Targeted outcomes are PSB, trauma symptoms, general behaviour problems, caregiver stress and caregiver supports. [source: NCTSN fact sheet; CEBC]

3. Guiding principles

[source: OU PSB-CBT clinical program page; CEBC; NCTSN fact sheet; Widdifield & Monroe 2024; Caregiver Partnership Board tip sheet; Bonner, Walker & Berliner child manual. Practical meanings are partly synthesis.]

Children first, strengths-based. Frame the child as a learner with a behaviour problem, not as a future offender; set goals around skills and relationships.
Behaviour, not identity. Say "problematic sexual behaviour" and never "offender", "perpetrator" or "abuser", in sessions or in reports.
Caregiver participation is required. Do not start a child in group without an active primary caregiver who attends weekly; change happens mainly through the caregiver.
Directive and structured. Run a set agenda, teach content explicitly and keep the group on task; this is not non-directive play.
Model, observe, correct. Every skill is demonstrated by the therapist, practised by the child or caregiver, and given specific constructive feedback in the session.
The manual is not a cookbook. Keep the core components but fit pace, examples and order of emphasis to each family.
Practise between sessions. Assign a weekly home activity to both child and caregiver, and review it at the start of the next session.
Safety plan is proportionate and active. Start it as soon as PSB is known. Match each identified vulnerability with a specific measure. Do not let it block normal activities or overburden caregivers. Update it as information arrives.
Least restrictive setting. Most children can be treated while staying at home, at school and in the community; consider out-of-home or residential care only when the criteria in 4.5 apply.
Collaborate across systems. Work with child protective services, juvenile court or probation, schools, and the recipient child's providers. Name one coordinator for the plan and put roles in writing.
Use data from several sources. Base step-down, visitation and graduation decisions on weekly behaviour reports, measures and reports from more than one person, not on one caregiver's impression.
Respond to lapses with curiosity. When the plan breaks or PSB recurs, find out why, solve the problem, and re-evaluate. Do not blame.
Do not coerce disclosure. Support acknowledgment with gentle structure. With children, avoid the words "abuse" and "victim" when describing their own behaviour.
Clear confidentiality. Children may share their own story but not other children's. Caregivers hear the topics covered, not the details. Therapists break confidentiality only to prevent harm.
Adults model the rules. Household modesty, privacy and respectful touch apply to everyone, not only the child with PSB.
Open communication about sex. Caregivers become the child's approachable source for sexual questions, and the long-term educator about sexual development.
Trauma-informed but not trauma-gated. Children with and without a trauma history are eligible. Address trauma alongside the PSB work (advanced TF-CBT-for-PSB pathway) rather than as a prerequisite.
Hold the recipient child's needs. Visitation and reunification decisions weigh the recipient child's reactions and their providers' views equally.
Cultural responsiveness. Use adapted materials where available (Restoring the Sacred Circle for American Indian/Alaska Native families; Spanish translations) and include extended family or elders where culturally appropriate.

4. Intervention inventory

The inventory has three parts: safety and caregiver interventions (4.1–4.10), child-group interventions (4.11–4.23), and joint, process and closing interventions (4.24–4.28). All example language is illustrative and my own wording unless it is quoted and cited. Manual worksheets and instruments are described, not reproduced.

4.1 Intake assessment and ongoing progress monitoring

Purpose: Confirm that the behaviour is PSB and not typical sexual development. Identify trauma, behavioural and family needs, gauge caregiver capacity and set baselines. Then track change each week so that decisions rest on data. [source: NCTSN fact sheet; OU clinical program page; OU learning objectives]
Steps:
- Interview the caregiver and the child separately. Cover what happened, frequency, planning, coercion or aggression, the ages of the children involved, and responses to adult correction so far. [synthesis]
- Add written tools: CSBI or YSBPI, the ASB-C, and a general behaviour checklist such as the CBCL. Add caregiver stress and support measures. [source: NCTSN fact sheet]
- Add behavioural observation and an environmental screen: sleeping and bathing arrangements, which children are in the home, access to devices and media, and exposure to sexual material or violence. [source: NCTSN fact sheet; Widdifield & Monroe 2024]
- Screen for trauma history and for current maltreatment. Make mandatory reports as your jurisdiction requires. [source: RSC rules handout notes jurisdictional variation; reporting steps are synthesis]
- Feed results back to the caregiver in plain, non-labelling terms and set measurable treatment goals.
- During treatment, have the caregiver complete a weekly behaviour report (or similar) and re-administer the measures at mid-point and at graduation. [source: Widdifield & Monroe 2024; OU clinical program page]
Example language (illustrative): "These questions help us see what's typical for your child's age and what isn't, so we can teach exactly the skills that will help."
Watch for: Caregiver minimising or catastrophising. Behaviour that is aggressive, coercive, persistent despite correction, or involves a much younger child (these call for tighter safety planning) [synthesis]. Signs of the child's own ongoing victimisation. Working when: weekly reports are returned regularly and show falling PSB, and the measures move toward the normal range.

4.2 Family safety plan

Purpose: Reduce the opportunity for further PSB, and protect all children, while treatment builds skills. Start it immediately and keep it active. [source: Widdifield & Monroe 2024]
Steps: [source: Widdifield & Monroe 2024; RSC rules handout; NCSBY Family Safety Plan cited there]
1. Name one professional to coordinate the plan. This can be the clinician, a child protective services worker, a victim advocate or juvenile justice staff.
2. With the caregivers, list who is available to supervise. Check that each supervisor understands PSB, knows the children and has read the whole plan.
3. Map the child's day: play, school, after-school care, sleeping, bathing, car rides, visits, and online time. Mark each point where the child is with other, especially younger, children.
4. For each vulnerability, write one specific matching measure, then add the general common-sense rules (4.3 and 4.4).
5. Write "when help is needed" steps. The child talks to a caregiver before breaking a rule. Anyone who sees the plan broken tells an adult quickly. A caregiver who needs a break asks another informed adult to cover.
6. Add family agreements that apply to everyone: respect, appropriate dress, and regular private talk time between each child and a caregiver, including about bodies and relationships.
7. Decide who receives the plan (school, relatives, respite carers) and what each person needs to know. Share only what keeps children safe.
8. Review the plan every week against the behaviour report. If things go well, praise the family and reintroduce ordinary activities slowly. If there are barriers or new PSB, explore without judgement, solve the problem, tighten monitoring and re-evaluate.
Example language (illustrative): "This plan isn't a punishment. It's scaffolding while your son learns new skills, and we'll take it down step by step as he shows he can manage."
Watch for: Plans so restrictive that families quietly abandon them. Plans that rely on one exhausted caregiver. Gaps at transition times (mornings, bath time, sleepovers, car rides) [synthesis]. Working when: caregivers can say the plan from memory, report actual adherence (lapses included) honestly, and no new PSB occurs.

4.3 Supervision and household privacy rules

Purpose: Turn the safety plan into concrete household routines. [source: Widdifield & Monroe 2024; RSC rules handout]
Steps: Agree each rule explicitly with the caregiver and post it where useful.
- Continuous eyes-on supervision whenever the child is with other children. Arrange cover by another informed adult for breaks.
- The child sleeps alone, in their own bed, ideally in their own room. Siblings do not enter each other's bedrooms without an adult present.
- Hygiene, toileting, dressing and self-touch happen in private: a closed bathroom door or the child's own room. The child is never in the bathroom while a sibling is there. The child bathes and does personal care alone.
- Everyone is clothed except in their own room, a closed bathroom or bed. Adults and older teens model modesty and avoid nudity or sexual displays in front of children. Ordinary affection between adults and children is encouraged.
- Media: supervise and pre-approve phones, tablets, computers, gaming, TV, cameras and social media. Use parental controls. Minimise exposure to sexually explicit material in any form.
- Video cameras only as a last resort, after careful, informed decisions and professional consultation. Cameras can confuse children who are learning about privacy, and recording private activities can raise legal problems.
- Step supervision down gradually toward a "new normal" as progress is shown (Silovsky 2009, as cited in Widdifield & Monroe 2024).
Example language (illustrative): "When the kids are together, someone who knows the plan has eyes on them. If you need to cook or shower, who can cover, or where can the children be apart?"
Watch for: Plans that assume "in the next room" counts as supervision. Older siblings left in charge. Unsupervised device use at night [synthesis]. Working when: caregivers can describe a typical day with no unsupervised child-to-child contact.

4.4 Specific rules for the child who initiated PSB

Purpose: Give the child clear, behavioural limits that remove high-risk situations while keeping ordinary family life. [source: Widdifield & Monroe 2024]
Steps: Agree and review with the child and caregiver together. The child:
- does not babysit, supervise or discipline other children, and is not alone with a child;
- does not wrestle, tickle or play rough with siblings or young children;
- does not discuss or joke about sexual topics around children, and sends children who ask sexual questions to an adult;
- says no if invited into a sibling's bedroom;
- talks to a caregiver before doing anything that would break a sexual behaviour rule or the law.
Pair the restrictions with a list of things the child can do with supervision: TV, reading, music, games or sports with siblings when permitted, family meals, outings and car rides. Affection with a sibling is allowed only if the sibling starts it and a caregiver is present (hugs are acceptable, kisses are not).
Example language (illustrative): "These rules are about places where it's easy to make a mistake. There's still lots you can do, so let's write that list too."
Watch for: The child experiencing the rules as proof of being "bad". Siblings using the rules to provoke or tease [synthesis]. Working when: the child can name their rules and the "can do" list, and caregivers report few reminders needed.

4.5 Placement, visitation and reunification planning

Purpose: Decide where the child lives and how contact with the recipient child is managed, using the least restrictive safe option. [source: Widdifield & Monroe 2024]
Steps:
- Placement factors: the initiating child's self-control, response to intervention and acknowledgment of the PSB; how extensive the PSB was and what effects it had; the possible harm of removal; the recipient child's needs and strengths; and the caregivers' capacity to supervise and to take part in services.
- When separation is needed, moving the child who initiated the behaviour is typical, though occasionally other children must move. Treat reunification as a tentative goal, or plan for long-term non-reunification.
- Consider residential or inpatient care only if PSB recurs despite treatment, supervision and safety planning; if other severe behaviours or symptoms disrupt functioning; or if no placement can provide the needed supervision and treatment. Weigh the costs: less caregiver involvement, weakened family ties, peer grouping with high-need youth, and financial burden.
- Contraindications to visitation or reunification: in the child, ongoing or recent PSB, aggression, rule non-compliance or denial; in the caregiver, denial, blaming the recipient child, being overwhelmed by trauma symptoms, or inability to supervise; in the recipient child, strong adverse reactions or persistent symptoms.
- Five-step protocol: (1) planning sessions with caregivers and partners; (2) separate preparation sessions with each child; (3) first contact; (4) ongoing contacts and return home; (5) maintenance and closure. Keep the process collaborative and consent-based, set goals, move slowly, assess continuously and coordinate with the court. (Details of each step are in ATSA 2019 [uncertain].)
Example language (illustrative): "We'll only move to the next step when both children and their therapists say they're ready, and we'll go back a step if needed."
Watch for: Pressure from the court or family to speed things up. A recipient child who complies outwardly but shows distress. Working when: each step passes without new PSB or distress, as confirmed by the recipient child's provider.

4.6 Caregiver engagement and support

Purpose: Get and keep caregivers attending and active. Caregiver participation is required, and families often arrive in crisis, anxious and ashamed. [source: Caregiver Partnership Board tip sheet; CEBC; NCTSN fact sheet]
Steps:
- Give the caregiver space to tell their story before you teach. Validate how hard this is without trying to argue the feelings away.
- Separate the behaviour from the child, and avoid labels.
- Treat the caregiver as the expert on their child, ask how they are coping, and give practical tips without judgement.
- Build the safety plan with them, and protect supervised prosocial activities instead of removing everything.
- In group, use peer support. Families report feeling less alone and connected to other parents.
- Coordinate with other services so that legal and child-welfare processes do not swamp the family.
Example language (illustrative): "Many parents sitting in that chair have felt shocked, guilty or angry, sometimes all at once. Tell me how it's been for you."
Watch for: Judgemental facial expressions. Inconsistent messages across professionals. Holding legal meetings at school or in public. Working when: the caregiver attends every week and starts raising problems themselves.

4.7 Caregiver psychoeducation: sexual development and misconceptions

Purpose: Replace fear-driven beliefs with accurate knowledge, so that caregivers respond calmly and proportionately. [source: CEBC; Widdifield & Monroe 2024; OU learning objectives]
Steps:
1. Describe typical sexual behaviour at the child's age, then explain what makes behaviour problematic (frequency, age gap, coercion, persistence, distress) [synthesis on the dimensions].
2. Correct the common myths. It is untrue that a child with PSB has a psychopathology, will become a lifelong abuser, always needs long-term out-of-home care or can never live with other children. It is also untrue that the recipient child is permanently damaged.
3. Cover the outcome data in plain terms: low rates of later sexual offending after this treatment.
4. Cover moral and general child development so caregivers pitch expectations correctly.
Example language (illustrative): "Children who get this kind of help, with a parent involved, usually stop the behaviour. This is a learning problem, and you are the main teacher."
Watch for: A caregiver who swings from minimising to treating the child as dangerous. Working when: the caregiver can explain to a relative why the child is not "a predator" and why the safety plan is still needed.

4.8 Teaching and implementing household rules

Purpose: Build a predictable home structure in which the sexual behaviour rules and privacy rules sit alongside ordinary house rules. [source: CEBC; RSC rules handout]
Steps:
- Help the caregiver write a few clear, positively worded rules. Include the sexual behaviour rules (4.12) and the privacy rules (4.3).
- Have the caregiver go over the rules with every child in the household. Stay calm, explain each rule briefly, and invite questions.
- Set consequences in advance and agree how to praise rule-following.
- Rehearse in session how to deliver a rule calmly after a breach. [steps partly synthesis]
Example language (illustrative): "In our family, everyone keeps their private parts private, and everyone's body belongs to them."
Watch for: Rules applied only to the child with PSB, which signals blame. Working when: siblings can also state the rules.

4.9 Behaviour parent training

Purpose: Give caregivers behaviour-management skills to prevent and respond to PSB and to the general behaviour problems that often co-occur. [source: CEBC preschool and school-age]
Steps: The sources name this component but the session-by-session content is [uncertain]. The usual sequence in Oklahoma-lineage parent training is below [synthesis]:
1. Positive attention and specific praise for rule-following and skill use.
2. Planned ignoring of minor attention-seeking behaviour. This does not apply to PSB, which always gets a calm, direct response.
3. Effective instructions.
4. Consistent, brief, non-humiliating consequences (time-out for younger children, loss of privileges for older ones).
5. Rewards for using coping skills.
Teach each skill by didactic explanation, therapist modelling and caregiver rehearsal with feedback (role-play in the caregiver group, live practice in joint sessions), followed by a home assignment.
Example language (illustrative): "When you see him take a breath and walk away from his brother, catch it: 'Great job stopping and thinking.' That's the skill we want more of."
Watch for: Harsh, shaming responses to PSB, which can increase secrecy [synthesis]. Working when: general behaviour problems fall on the CBCL or weekly reports, and caregivers describe calm, consistent responses.

4.10 Caregiver communication about sex education and abuse prevention

Purpose: Make the caregiver the child's ongoing source of sexual health information and protection. [source: CEBC; NCTSN fact sheet; Caregiver Partnership Board tip sheet]
Steps:
1. In the caregiver group, preview what the children will learn (correct anatomical terms, body functions, puberty, where babies come from at an age-appropriate level, and abuse-prevention responses).
2. Explore the caregivers' own comfort and their family or cultural values.
3. Role-play answering a child's question briefly, accurately and calmly.
4. Agree a family "safe person" for sexual questions and a regular private talk time.
5. Practise with the child in a joint session.
Starter questions: Have you set private-parts rules? What does your child call private parts? Who is your child's safe person for questions? [source: Caregiver Partnership Board tip sheet]
Example language (illustrative): "If she asks you something that makes you blush, it's fine to say 'Good question, let me think and we'll talk tonight', and then follow through."
Watch for: Caregivers deferring all sexual topics to the therapist. Working when: the caregiver reports at least one sex-education conversation at home and the child names the caregiver as a person to ask.

4.11 Group orientation, group rules and the session routine

Purpose: Create a predictable, safe and motivating group in which children can talk about breaking a rule. [source: Bonner, Walker & Berliner child manual, session 1 and common structure]
Steps:
- Session 1: Children pair up and introduce each other to the group. State plainly that everyone here broke a sexual behaviour rule and is here to learn not to.
- Set the group rules. Confidentiality: share your own story, not other children's; parents hear topics, not details; therapists tell only to keep someone safe. Respect: no interrupting, hitting, name-calling or swearing, and stay in the room.
- Practise politely declining to answer a question.
- Standard session routine:
  - sign-in with an attendance sticker and a reward star;
  - a brief good-and-not-so-good check-in;
  - review of the group purpose and the rules;
  - the new topic;
  - a short knowledge check with immediate feedback;
  - mark the topic on a group progress chart;
  - an optional activity.
- Reinforcement: use tokens or stars for participation and rule-following, exchanged for small prizes.
- Records: keep an attendance and participation record (lateness, verbal participation and behaviour ratings, parent attendance).
Example language (illustrative): "Everyone in this room broke a rule about touching or private parts. That's why we're here, and nobody here is a bad kid. We're going to learn the rules and how to keep them."
Watch for: Children trading details of their behaviour (redirect at once), and children who are over-aroused or disruptive. Use the token system and seat them by a co-therapist. Working when: children follow the routine with little prompting.

4.12 Private parts and the sexual behaviour rules

Purpose: Give the child simple, memorable rules that are the yardstick for all later work. [source: Bonner, Walker & Berliner child manual, session 2; RSC rules handout; Widdifield & Monroe 2024]
Steps:
1. Define private parts simply. The original manual used the parts a bathing suit covers.
2. Teach the rules. The current NCSBY-derived list, paraphrased:
  - don't touch other people's private parts;
  - others don't touch yours, except a caregiver helping with hygiene or a doctor during a check-up;
  - don't show your private parts, and keep clothes on when others can see;
  - don't look at other people's private parts;
  - touching your own private parts is okay only in private and briefly;
  - don't use sexual talk or behaviour that makes others uncomfortable.
  The original 1990s manual taught four rules covering the same ground. [version note: follow your current OU curriculum's wording]
3. Have children apply the rules to picture or story cards ("Is this okay? Which rule?").
4. Review the rules at the start of every later session.
5. Send the rules home so caregivers can post and reinforce them.
Example language (illustrative): "Let's say rule two together. Now, in this picture, is anyone breaking a rule?"
Watch for: Rote recitation without application. Test with novel scenarios. Working when: the child correctly classifies new situations and caregivers hear the rules used at home.

4.13 Boundaries and personal space

Purpose: Extend the rules into general body boundaries and respectful touch. [source: CEBC lists "boundaries" as a child component; the specific methods below are synthesis]
Steps [synthesis]:
1. Demonstrate personal space (for example, an arm's length).
2. Role-play asking before hugging and accepting "no".
3. Sort touches into okay and not-okay, using everyday examples (a handshake, a hug from a relative, rough play).
4. Practise noticing other people's discomfort cues.
5. Link the skill to the child's "can do" and "don't" lists (4.4).
Example language (illustrative): "Before a hug, we ask. If they say no or step back, that's their answer."
Watch for: Boundary-testing in the group itself, which you can use as live practice. Working when: the child asks before touching in group and in joint sessions.

4.14 Feelings identification

Purpose: Build the emotional vocabulary that coping, self-control and acknowledgment depend on. [source: Bonner, Walker & Berliner child manual, session 3]
Steps:
1. Use a feelings "thermometer" sheet. The child rates how often they feel mad, sad, happy, scared and confused.
2. Each child gives one recent example.
3. Link feelings to body signals and to behaviour. [synthesis: body-signal step]
4. Use the thermometer again during acknowledgment work (4.15).
Example language (illustrative): "Where's your 'mad' on the thermometer this week? What happened that made it go up?"
Watch for: Children who name only "fine" or "happy". Offer choices and model your own examples. Working when: the child names feelings spontaneously in check-ins.

4.15 Acknowledging the rule broken

Purpose: Help the child state, in their own words, which rule they broke. This lowers secrecy and shame and anchors the rest of the work. The current model lists acknowledgment as a child component. [source: Bonner, Walker & Berliner child manual, session 4 onward; CEBC school-age]
Steps:
1. Each child names the rule they broke.
2. With gentle who, what, when and where prompts, the child gives a brief factual account. Keep it brief and factual: the goal is ownership, not detail.
3. Do not coerce, and avoid the words "abuse" and "victim" with the child.
4. The child rates how hard it was to tell (1–10) and how they feel about having broken the rule.
5. Praise the courage it took.
6. Continue across several sessions for children who are not ready. Revisit near the end (session 10 in the original manual).
Example language (illustrative): "Which rule did you break? ... Thank you. That was hard and you did it. How hard was it, from 1 to 10?"
Watch for: Flat denial, which is common early on. Keep the expectation open and do not argue. Over-detailed or excited telling: stop gently and redirect to the rule. Distress suggesting the child's own trauma: note it and link to trauma work (4.28). Working when: the child can state the broken rule without prompting and without excessive shame.

4.16 The Turtle Technique (stop, relax, think, do)

Purpose: The core self-control and problem-solving routine in the original child manual, used for impulses to break sexual behaviour rules and other rules. (The "turtle" self-control method predates PSB-CBT and was incorporated into the manual. [uncertain: original attribution not verified]) [source: Bonner, Walker & Berliner child manual, sessions 5–7, 9, 11]
Steps:
1. Introduce the four steps with a turtle puppet story:
  - Stop and wait;
  - go into your shell and relax, using slow breaths or letting the body go floppy;
  - think: is this okay? What would happen? What else could I do? Include options that would have bad consequences, and say why they would;
  - do the chosen action.
2. The child may draw a reminder picture.
3. Practice game: children act out the steps with the puppet while peers judge accuracy with thumbs-up or thumbs-down cards. Award tokens and prizes.
4. Board game: a floor or board game in which squares trigger tasks: name a feeling and when it happened, encourage someone, compliment a peer, keep a straight face while others try to make you laugh (impulse control), or plan a response to a scenario.
5. Review: each child recites the steps, and the group runs the sequence twice.
6. Generalise: split into small groups to role-play scenarios, narrating each step aloud.
7. Send the steps home so caregivers can prompt and praise their use.
Example language (illustrative): "You feel like doing something that breaks a rule. What does turtle do first? ... Right, stop. Now into the shell: three slow breaths."
Watch for: Children who can recite the steps but skip "think" in role-play. Slow them down and ask for two alternatives. Working when: caregivers report the child pausing or using the steps at home, and role-plays show all four steps.

4.17 Emotional regulation and coping skills

Purpose: Broader coping for the anger, anxiety, shame or sadness that can precede rule-breaking. [source: CEBC lists emotional regulation and coping as child components; techniques beyond the Turtle Technique are synthesis]
Steps [synthesis]:
1. Teach slow breathing and simple muscle relaxation.
2. Help each child build a personal coping list of three to five safe actions (go to a caregiver, draw, physical activity in sight of an adult).
3. Practise positive self-talk.
4. Rehearse using the list in feelings scenarios.
5. Caregivers prompt and reinforce at home.
Example language (illustrative): "When your worry thermometer goes up, pick one thing from your coping list and show me how you'd do it."
Watch for: Coping items that are unsupervised or isolating, which conflicts with the safety plan. Working when: the child chooses a coping action in role-play without prompting.

4.18 Impulse control, problem-solving and decision-making

Purpose: Strengthen thinking through consequences and alternatives before acting. [source: CEBC (impulse control and problem-solving); OU clinical program page (decision-making); method extends 4.16]
Steps: Use the "think" step as a structured problem-solving routine:
1. Name the problem.
2. Generate several options.
3. Predict the consequences of each, for self and for others.
4. Choose one.
5. Review how it went.
Use rule-related and everyday scenarios (teasing, losing a game, a peer suggesting a game involving undressing). [synthesis: scenario examples]
Example language (illustrative): "What are three things you could do? What would happen after each one? Which would keep you and everyone else safe?"
Watch for: Generating only one option, or options that break the safety plan. Working when: the child produces safe alternatives quickly.

4.19 Social skills and peer relationships

Purpose: Build appropriate ways to make and keep friends, and reduce isolation and unsupervised or unsafe peer contact. [source: CEBC; RSC 2024 lists social skills and empathy, including understanding effects on others]
Steps: Practise the skills in the board game and in role-play: compliments, joining play, sharing, handling teasing and conflict, and recognising how one's actions make others feel. Caregivers arrange supervised prosocial activities. [method partly synthesis]
Example language (illustrative): "Give a real compliment to the person on your left, something about what they did, not what they look like."
Watch for: Peer rejection at school that pushes the child toward younger children. Working when: there are more same-age supervised friendships.

4.20 Sex education for the child

Purpose: Replace confusion or misinformation with accurate, age-matched knowledge, and teach the child whom to ask. [source: Bonner, Walker & Berliner child manual, sessions 3, 8 and 10; CEBC]
Steps:
1. Teach correct anatomical names and functions using simple diagrams.
2. Teach the basics of puberty for older children.
3. Give an age-appropriate explanation of reproduction. The original manual used a published children's picture book.
4. Teach when, where and with whom to ask questions: trusted adults such as caregivers, at a private, quiet time, generally not peers.
5. Coordinate content with caregivers beforehand (4.10).
6. Keep all content clinical and developmentally matched. Separate the age groups (6–9 and 10–12) for this content.
Example language (illustrative): "Questions about bodies and babies are normal. The best people to ask are your mom or dad or another grown-up you trust, at a quiet time."
Watch for: Giggling or over-excitement, which you can contain with the token system and matter-of-fact tone. Questions that reveal exposure to sexual media: note them and follow up with the caregiver. Working when: the child uses correct terms and names a trusted adult to ask.

4.21 Abuse prevention skills

Purpose: Teach the child to protect themselves. Many children with PSB have their own victimisation risk. [source: Bonner, Walker & Berliner child manual, session 10; CEBC]
Steps:
1. Read a body-safety story. The original manual used a published body-safety book.
2. Generate responses to unwanted touch:
  - adults need a good reason to touch private parts;
  - you can say you will do it yourself;
  - say no;
  - shout;
  - tell, and never keep it secret;
  - keep telling until someone believes you.
3. Use cards to sort acceptable touch (a doctor's exam, an infant's nappy change) from unacceptable touch.
4. Role-play saying no and telling.
5. Close by restating the rule the child themselves broke, linking self-protection with respecting others.
Example language (illustrative): "If someone tries to touch your private parts and there's no good reason, what can you do? ... And if the first grown-up doesn't listen?"
Watch for: New disclosures of the child's own abuse. Follow reporting duties and the trauma pathway. Working when: the child can role-play all the responses.

4.22 Apology and amends

Purpose: Help the child take responsibility, show understanding of the effect on others, and repair relationships where safe. [source: CEBC school-age lists "acknowledgment, apology and amends"; procedure not described in the sources [uncertain]; steps below are synthesis]
Steps [synthesis]:
1. Build on acknowledgment (4.15) and empathy work.
2. Help the child draft an apology in their own words. It names the rule broken, takes responsibility without excuses, recognises the other child's possible feelings and states what they will do differently.
3. Review the draft with the caregiver.
4. Deliver it to the recipient child only with that child's caregiver and therapist agreeing and preparing them, usually within the visitation or reunification steps (4.5). Otherwise keep it as a therapeutic exercise.
5. Agree on amends: concrete, age-appropriate acts of repair.
Example language (illustrative): "An apology says what I did, that it was wrong, and what I'll do now. It doesn't say 'but'."
Watch for: A forced or scripted apology, apologies that place blame on the other child, or recipient-child distress. Working when: the apology is in the child's own words and is accepted by the adults involved as genuine.

4.23 The child's plan to keep the rules

Purpose: Consolidate the work into a personal plan the child and caregiver can use after graduation. [source: CEBC school-age ("developing a plan to keep sexual behavior rules"); format is synthesis]
Steps [synthesis]:
1. With the child, list their rules, their warning signs (feelings and situations), their Turtle steps and coping list, and their safe adults.
2. Review the plan with the caregiver in a joint session.
3. Give copies to the child and caregiver.
4. Link it to the family safety plan's step-down schedule.
Example language (illustrative): "This is your plan. Let's write down what you'll do if you're ever in a situation like before."
Watch for: Plans that are too long to remember. Working when: the child can explain the plan unaided.

4.24 Joint caregiver–child and multi-family sessions

Purpose: Transfer skills from the separate groups into the caregiver–child relationship and give caregivers live coached practice. [source: NCTSN fact sheet and OU page (combined multi-family sessions about monthly; prepared in advance per RSC 2024); CEBC (one room for all families)]
Steps: The specific joint-session agendas are not described in the sources [uncertain]. A typical structure [synthesis]:
1. Prepare caregivers and children separately beforehand.
2. In the joint room, children demonstrate a skill they have learned (sexual behaviour rules, the Turtle Technique, the coping list).
3. Caregivers practise praising the skill and, where relevant, rehearse a brief sex-education or rules conversation.
4. Therapists coach live and give specific feedback.
5. Close with a shared positive activity.
Example language (illustrative): To the caregiver: "He just did all four turtle steps. Tell him exactly what you liked."
Watch for: Caregivers criticising the child in front of other families; set a praise-only norm for the joint room. Working when: caregivers use the skills unprompted in the joint session.

4.25 Weekly home practice

Purpose: Generalise skills to daily life. [source: CEBC preschool and school-age]
Steps:
- Each week, give the child and the caregiver a short activity that applies that session's skill (for example, practising the Turtle Technique once a day, posting the rules, or one praise per day for rule-following [examples synthesis]).
- Caregivers monitor and support the child's skill use.
- Review the home practice at the start of the next session, and problem-solve non-completion.
Example language (illustrative): "What got in the way? What would make it doable this week?"
Watch for: Tasks too big for families in crisis; scale down rather than drop them. Working when: completion rises and caregivers report the child using skills spontaneously.

4.26 Knowledge checks and progress records

Purpose: Check that each child has learned the content, and track participation. [source: Bonner, Walker & Berliner child manual]
Steps:
- Give a brief yes/no/don't-know check (about five items) at the end of each session, with immediate corrective feedback, and a longer check at termination. Write your own items matched to your curriculum.
- Record attendance, participation and behaviour each week.
- Combine these with the weekly caregiver behaviour report (4.1).
Watch for: Consistently wrong items, which show you what to reteach. Working when: scores approach ceiling.

4.27 Graduation and termination

Purpose: Mark achievement, consolidate learning and hand the safety plan's step-down over to the family. [source: Bonner, Walker & Berliner child manual, session 12; OU clinical program page and learning objectives]
Steps:
1. Assess graduation readiness (Section 2 criteria) using the ASB-C, standardised measures and clinical judgment.
2. In the child group, the child completes a reflection sheet: feelings about the group, the hardest thing they did, what they would change if they ran it.
3. Give the final knowledge check, a certificate, and prizes in order of stars earned.
4. The child takes home their folder. The clinic retains selected materials in the case file.
5. Hold a final caregiver review of the safety plan step-down and the child's plan (4.23).
6. Agree booster contact options [synthesis].
In an open-ended group, graduations happen individually as each child meets the criteria.
Example language (illustrative): "You learned the rules, you told the truth about what happened, and you've shown you can stop and think. That's what this certificate is for."
Watch for: Graduating on time served rather than on criteria. Working when: gains hold at any follow-up contact.

4.28 Version-specific and adjunct components

Preschool (PSB-CBT-P): private-part rules and abuse prevention taught within safety rules and boundaries, plus assertiveness, emotion regulation, impulse control, social skills, and sexual and moral development. Heavier caregiver focus on supervision, house rules and behaviour parent training. Use concrete materials (puppets, books, crayons, stickers). OU also offers advanced training in PCIT for PSB (PCIT-PSB). [source: CEBC preschool; RSC 2024; OU site links] Session-level preschool content is not drawn on here [uncertain].
Trauma integration: an advanced "TF-CBT for PSB" pathway exists for preschool and school-age children (prior TF-CBT training is required). The trauma narrative can address cases where the child also acted out with another child. [source: RSC 2024; OU site links] Procedures are not drawn on here [uncertain].
Cultural adaptation: Restoring the Sacred Circle toolkit for American Indian/Alaska Native families (protective factors, elders and tribal history in family sessions, healing practices); Spanish materials. [source: NCTSN fact sheet; RSC 2024]

5. Handling problems

Sources address contraindications, lapses in the safety plan and engagement. Most specific responses below are [synthesis] unless tagged.

Caregiver denies the PSB or blames the recipient child.
- Denial and blame are contraindications to visitation and reunification, so do not progress those steps. [source: Widdifield & Monroe 2024]
- Respond with validation first: "It's hard to believe this of your child." Then share the facts, separate the behaviour from the child's worth, and use other caregivers in the group who have moved past denial. [synthesis; tip sheet on validation]
- Keep the safety plan non-negotiable even while denial continues. [synthesis]
Caregiver overreacts or rejects the child (sees the child as a "predator", demands removal, uses harsh punishment).
- Teach the misconceptions content early (4.7), give outcome data, and acknowledge the caregiver's fear. [source: Widdifield & Monroe 2024 (misconceptions)]
- Coach calm, brief responses to rule breaking. [synthesis]
- If harsh punishment is occurring, address it directly and report it if it meets thresholds. [synthesis]
Caregiver does not attend. Attendance is required. [source: CEBC; NCTSN]
- Problem-solve the practical barriers: transport, work, childcare for siblings, or telehealth. [source: NCTSN fact sheet (telehealth)]
- Offer the family modality if the group schedule is impossible. [source: OU page]
- Involve the referring agency, and pause the child's group place if the caregiver stays absent. [synthesis]
Child denies or minimises.
- Do not argue or coerce. Keep acknowledgment as a standing invitation, and let peers' acknowledgments normalise it. [source: Bonner, Walker & Berliner manual (no coercion)]
- Use the 1–10 "how hard" scale, and praise partial steps. [synthesis]
- Persistent denial argues against reunification steps. [source: Widdifield & Monroe 2024]
Sexualised, disruptive or contagious behaviour in group.
- Hold a strict no-details rule and stop and redirect immediately.
- Use the token system, seat the child next to a co-therapist, and supervise toilet breaks and transitions.
- Give separate brief individual coaching. If the behaviour persists, move the child to the family modality.
- Tell the caregivers about in-group incidents, at topic level. [synthesis]
New PSB during treatment.
- Take a non-judgemental, curious approach. Find out why the plan was not followed, try out solutions, step up monitoring and re-evaluate. [source: Widdifield & Monroe 2024]
- Report as required. [synthesis]
- Consider a higher level of care only if PSB recurs despite treatment, supervision and the safety plan. [source: Widdifield & Monroe 2024]
Safety plan fatigue.
- Check that the plan is not overly burdensome. Build in relief supervisors, and step down supervision gradually as data allow. [source: Widdifield & Monroe 2024]
- Normalise fatigue and praise any adherence. [synthesis]
Child or caregiver overwhelmed; trauma reactivation.
- Slow the pace and use coping skills in session. [synthesis]
- For a child's trauma symptoms, add or sequence trauma-focused work (TF-CBT for PSB). [source: RSC 2024]
- A caregiver with their own history of sexual abuse may need their own therapy. Offer a referral without making it a condition of the child's treatment. [synthesis]
- Caregiver trauma reactions to the PSB are a contraindication to reunification. [source: Widdifield & Monroe 2024]
Rupture after a mandatory report or a court decision.
- Explain the limits of confidentiality at intake and in session 1. [source: Bonner, Walker & Berliner manual]
- After a report, say what you did and why, and reaffirm that you are working for the whole family. Repair before teaching new content. [synthesis]
System pressure (court, child protective services or family wanting fast reunification or rapid closure).
- Present data from several sources and the contraindication list. Keep roles written down, and insist on a slow, step-by-step protocol that responds to the recipient child. [source: Widdifield & Monroe 2024]
Stigma and labelling (school exclusion, neighbours, relatives). This is the main known risk.
- Share information on a need-to-know basis and describe PSB in non-labelling terms. [source: Widdifield & Monroe 2024; tip sheet]
- Help the school build a proportionate supervision plan instead of exclusion. [synthesis; a school-specific safety plan was not found in sources [uncertain]]
Recipient child lives in the same home.
- Coordinate with the recipient child's own therapist. Apply the privacy, sleeping and supervision rules strictly. Never use the recipient child as part of the initiating child's treatment without their own provider's agreement. [synthesis consistent with Widdifield & Monroe 2024]
Developmental delay or low verbal ability.
- Simplify the rules, use visual supports and more repetition, and move to the family modality if needed. [synthesis] Sacred Circle notes that assessing developmental level is recommended but still experimental. [source: RSC 2024]
Cultural or religious discomfort with sex education.
- Preview the content with caregivers, explore their values, and agree wording and scope. Keep accurate anatomical terms and the abuse-prevention content as the core minimum. [synthesis] Use the cultural adaptations where they fit. [source: NCTSN; RSC 2024]
Not enough referrals for a group. Run the family modality, which is an approved format. [source: OU page; CEBC]
Adolescents with court involvement. Sources state that adolescent PSB is more often illegal and probation is often involved. [source: OU page] The adolescent protocol is not drawn on here [uncertain]. Coordinate closely with probation, and do not use the school-age materials unadapted. [synthesis]
Clinician discomfort. OU names comfort discussing sexual development, a directive style and skill at managing a group as provider prerequisites. [source: OU page] Use the consultation calls and recorded-session feedback to build these. [source: OU page]

Sources

Sources: