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Related Topics
Children with Sexual Behavior ProblemsReview - Children with Sexual Behavior Problems
Family-Based, Attachment-Focused Therapy
by William N. Friedrich
W. W. Norton, 2007
Review by Ryan R. Lindsay, LCSW
Mar 30th 2010 (Volume 14, Issue 13)

If you are a clinician and work with children and families, it is almost certainly that you have encountered a child in your office or in the community that the parent/s is highly concerned about their son or daughter's sexual acting out behaviors.  Many of these behaviors, in my experience, have ranged from benign and completely developmentally appropriate to behaviors that are surely symptoms needing to be targeted and raise questions about inherent "assumptions" that these behaviors must be learned from somewhere.  In American society, sex and sexuality continue to be subjects that are feared, ignored, silenced, or simply brushed to the side.  With these cultural and societal influences, there is no wonder why many clinicians don't feel prepared to answer such questions from parents.  Many clinicians simply refer clients to "experts" in the community in order to avoid having to make a decision about how to appropriately intervene.  Frankly, training around sexual behavior problems in children, adolescents and even adults are quite lacking in the mental health field.  Moreover, unless you attend a specialized training program that targets these issues, it is hard to find worthy training at all around sexual behavior issues.  Given the relative commonality of expressions of sex and sexuality in addition to the relative common histories of chaotic home environments, physical abuse and neglect, and sexual abuse histories, a focus in educating current and future clinicians seems obvious.  Yet, as a society, we are behind in the research targeting sexual behavior problems, particularly the pathogenesis of sexual behavior problems.  To date, there are very few large sample studies that target normative versus pathological sexual behavior problems.  Fortunately, for the mental health and research fields, William N. Friedrich has written a book that not only addresses normative versus pathological sexual behaviors in children and adolescents, it goes the most important step further and describes a treatment approach that targets the influence and role of the family as well as the role attachment plays in these behaviors.  As Friedrich writes, "sexual behavior problems are relational and should be treated as such." 

Friedrich's book, from start to finish, is clearly articulated and well-focused.  He takes the reader from the overview of the book, through the research and rationale for this type of an approach, to a sequenced assessment and treatment manual of sexual behavior problems.  If one is a part of the therapeutic community, then one is acutely aware of the intense debates that take place regarding the role of attachment in the treatment of children who come from chaotic backgrounds and have lacked the stability and predictability that help children develop the appropriate skills to regulate their affects, understand and maintain healthy and safe relationships, develop solid sense-of-self, and help individuals develop behavioral control mechanisms.  The undisputed fact is that attachment is a very real part of human development and is correlated with healthy development.  What is constantly being debated is how does one utilize this knowledge to create appropriate and data supported treatments for children who have chaotic and disrupted backgrounds and develop maladaptive coping strategies to manage life's daily challenges. 

There is an abundance of "theorists" touting how to approach children who have "attachment disorders" that have actually been proven to be harmful, however Friedrich takes his emphasis on "relational" and integrates a model of treatment that holds significant support for its efficacy.  Parent-Child Interaction Therapy is a model of therapy that focuses on increasing a parent's ability to respond to the needs of their child, integrates behavioral approaches to parenting, and emphasizes nurturing the parent-child relationship.  The idea being that improved parenting skill, improved awareness of the needs of a child by a parent, improved consistency and behavioral approaches, provides the stability and structure that helps the child to develop a closer relationship with parents and, in turn, allows the parent to begin to improve positive feelings about and see their child in more loving ways. 

Friedrich has taken the view that sexual behavior problems in children and adolescents have particular risk factors making it more likely that one will develop sexual behavior problem, one being a history of chaotic homes and the lack of a child's needs being met.  Furthermore, he claims that due to the histories of the "culture" around sex and sexuality a family brings to the existence and more importantly maintenance of sexual behavior problems, targeting families is a key aspect to improving targeted behaviors.  Friedrich suggest that a targeted intervention promoting effective and behaviorally driven parenting skills, increasing awareness and response to a child's needs, targeting psycho-education and skill development within the child, and emphasizing nurturing environments, will lead to better and sustainable outcomes for these individuals and families.  As an evidenced driven therapist, I can appreciate a Family-Based, Attachment-Oriented approach to working with families with children that express sexual behavior problems.  What this approach does, is allows for the normalization of sexual behavior, provides the needed psycho-education on appropriate sexual development, provides an emphasis on families to solve their problems and increase their ability to effectively parent, and gives the child skills to manage their life without resorting to sexualized behaviors as a coping strategy.  

Overall, Friedrich's book Children with Sexual Behavior Problems: Family-Based, Attachment-Focused Therapy, is a thorough overview and practical treatment guide for treating children with sexual behavior issues.  Given that much of his data that was presented in this book came from his own studies, additional research and data are  needed to fully test the validity of a Family-Centered, Attachment-Focused approach utilizing Parent-Child Interaction Therapy as a major means of increasing parenting skills of children with sexual behavior problems.  Furthermore, aside from the anecdotal evidence presented, further investigation into understanding the mechanisms of change, and isolating the strategies that are most helpful with this type of approach would be extremely helpful for the therapeutic community.  I would recommend this book for any practitioner that focuses their practice on treating children, adolescents and families.  


© 2010 Ryan R. Lindsay


Ryan R. Lindsay, LCSW, St. Louis Center for Family Development, LLC, Clinical Director/Co-Founder,  Ryan Lindsay is the Clinical Director and co-founder of the St. Louis Center for Family Development, LLC, a mental health and social service agency that provides in-home, trauma-informed, evidenced-based interventions to individuals in the St. Louis, MO community.  Prior to his current position, he was the co-founder of the Ann Arbor DBT Center and worked to develop and help lead an Adolescent DBT Program for Washtenaw County Community Support and Treatment Services in Ann Arbor, MI.  Ryan works daily to improve the lives of those individuals who suffer from emotional pain as a result of trauma. 



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