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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 109-112

Exposure to pornography in a young boy: Diagnosis and management


Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission31-Jan-2021
Date of Decision22-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Prahbhjot Malhi
Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_38_21

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  Abstract 

Background: Child sexual abuse is highly prevalent in India, both among boys and girls; however, few studies have studied sexual abuse of male children. The present case report highlights the challenges of diagnosis and management of a young boy who presented with marked hyperactivity and sexual acting out behaviors subsequent to his repeated exposure to pornography. Clinical Description: H, a 5-year-old boy, presented with a 2 month history of hyperactivity, poor concentration, inappropriate touching, and self-stimulation. H also displayed sexual knowledge beyond that of what would be expected of his age and developmental level. The Child Sexual Behavior Inventory was administered that showed an unusually high score on the (sexual abuse specific items, sexual behaviors that are atypical for child's age and gender). Management and Outcome: The use of therapeutic interventions such as building a therapeutic relationship, environmental change, family counseling, and nondirective play therapy helped in remitting most of the child's behavioral difficulties. Conclusions: Parents need to be active participants in the digital lives of their children and exercise controls on what they view online. Since pediatricians are often the first points of contact for a child with aberrant behaviors, they need to be aware of the law on the protection of children against sexual offenses and the range of types of sexual offenses against children.

Keywords: Adverse childhood experiences, child sexual abuse, pornography, problem sexualized behaviors


How to cite this article:
Malhi P, Bharti B, Satya D. Exposure to pornography in a young boy: Diagnosis and management. Indian Pediatr Case Rep 2021;1:109-12

How to cite this URL:
Malhi P, Bharti B, Satya D. Exposure to pornography in a young boy: Diagnosis and management. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:109-12. Available from: http://www.ipcares.org/text.asp?2021/1/2/109/317356

A large majority of Indian children face chronic and multiple adverse childhood experiences including neglect, child maltreatment, loss of a parent, and sexual abuse.[1] The term “developmental trauma” is used as a way of conceptualizing the distress experienced by children exposed to early and chronic trauma, although it is not a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5. A recent review of 19 meta-analyses (559 studies, 28 outcomes, 4 million participants) reported that child sexual abuse (CSA) was associated with several long-term physical, psychiatric, and psychosocial health outcomes including conversion symptoms, anxiety, depression, substance abuse, and posttraumatic stress disorder.[2]

In India, the prevalence of CSA is extremely high, with many cases going unreported. A national-level study, conducted by the Ministry of women and child development, covering 13 Indian states and 12,447 participants (5–18 years) reported that nearly half had been exposed to some forms of sexual abuse. Out of the 21% who were exposed to extreme forms of sexual abuse, 57% were boys.[3] Sexual abuse includes both contact and noncontact abuse. Noncontact activities include involving children in looking at online sexual images and activities, using children in the production of sexual content, and encouraging children to behave in sexually aberrant ways. The protection of children against sexual offenses (POCSO) Act 2012 along with the Juvenile Justice Act 2015 serves as a legislative shield for the POCSO.[4] Although prevalence rates of CSA are high in India, there is limited published literature on effective management strategies. Hence, clinicians working with children have limited awareness and experience regarding the management of these challenging cases in a child-friendly and culturally sensitive way. In this case report, we discuss a case of a young boy who presented with marked hyperactivity and sexual acting out to highlight the challenges in making the diagnosis and management of problem sexualized behaviors (PSBs).


  Clinical Description Top


H, a 5-year-old boy, from an extended rural family was brought by his mother to the pediatric department of a tertiary care center, with a 2-month history of hyperactivity, poor concentration, inappropriate touching of his private parts, and self-stimulation. The history revealed that H was an easy to manage child but of late had become extremely hyperactive and displayed unremorseful disruptive behavior at school. On few occasions, H was observed to have touched his classmates inappropriately. The child also displayed sexual knowledge beyond what would be expected of his age and developmental level. He would use sexually graphic words, like “oral sex” and “intercourse.” These behaviors were a source of significant parental mortification and despite verbal warnings, reprimands, and physical punishment, the PSBs persisted. As a result of his atypical sexual behavior, the child was suspended from the school and advised to seek treatment. The parents sought several consultations with pediatricians and psychiatrists; however, the PSBs did not subside.

A comprehensive psychosocial evaluation by the social pediatrics and child psychology team was undertaken including in-depth interviews of parents and evaluation of the child using standardized measures. The parental interview revealed a history of marital conflict and spousal abuse. On evaluation, H was a cooperative child and participated in all tasks with enthusiasm. The child was given the task of drawing a person and house-tree-person (HTP) test. The use of drawings is an ideal tool for evaluation of young verbally immature children as they can reveal critical information regarding development and emotional issues. H told the treating team that his cousin had showed him “pictures of nude men and women” on his smartphone. In view of the child's sexual acting out, the Child Sexual Behavior Inventory (CSBI) was administered. The CSBI indicates the overall level of sexual behavior in children (2–12 years). It provides scores on 9 sub-domain scores including self-stimulation, sexual interest, sexual intrusiveness, sexual knowledge, voyeuristic behavior, boundary problems, exhibitionism, gender role behavior, and sexual anxiety. The CSBI yields several scores including a total score which indicates the overall level of PSBs the child exhibits, (developmentally related sexual behavior, sexual behaviors that are developmentally normal), and sexual abuse specific items (SASI, sexual behaviors that are atypical for child's age and gender).[5] The child's narrative of sexual abuse was further corroborated by the unusually high score on SASI (score >6 standard deviation above the mean) and his drawings which showed several signs of sexual abuse on the draw-a-person test (missing pupils, emphasized hair, phallic symbol, and sharp elongated lines) and HTP test (missing person, circuitous pathways leading nowhere) [Figure 1].[6] Since the child also displayed easy distractibility and hyperactivity, the Vanderbilt attention-deficit hyperactivity disorder (ADHD) diagnostic rating scale forms (parent and teacher) to the parents and class teacher, respectively, were also administered to assess for symptoms of ADHD. The teacher's responses suggested concerns in attention and academics, while the mothers' responses suggested concerns in hyperactivity, oppositional, and defiant behaviors. However, the number of symptoms endorsed fell short of the ADHD criteria. The final diagnosis was adjustment disorder to developmental trauma. The case was initially reported to the child welfare committee who further referred it to the District Child Protection Unit for management as per the POCSO and Juvenile Justice Act.
Figure 1: Drawings of the child (draw-a-person and house-tree-person)

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Management and outcome

A comprehensive management plan was drawn out. To ensure that the boy had no contact with the alleged perpetrator, an environmental change was suggested, and the family moved in with the maternal grandparents. Parents were counseled regarding the need for fostering stable and respectful relationships within the family and work together as a team to support the child. Several sessions of nondirective play therapy along with the mother were conducted. The initial symbolic play themes reflected aggressive actions possibly re-enactment of sexual scenes that had been witnessed. However, over time H worked out his hostile impulses and his play became more constructive. The symbolic theme of “rescue from monsters” emerged consistently in the child's play. Follow-up, 18 months after the initiation of therapy, revealed that except for some occasional hyperactivity and inattention, the aberrant sexual behaviors had resolved completely [Figure 2].
Figure 2: Schematically presents the timeline of the case presentation and management

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  Discussion Top


This case report highlights the establishment of diagnosis and management of a child who developed PSBs after exposure to online pornographic viewing. In recent years, easy accessibility and availability of mobile devices have substantially expanded child and adolescent access to pornography, regardless of age, gender, and geographical location. This may occur either intentionally or unintentionally. Several socioeconomic, demographic, and family factors are linked to increased exposure to pornography, including male sex, lower socioeconomic status, traumatic negative life experiences, lower level of caregiver supervision, and poor emotional bonding with caregivers.[7] Exposure to sexually explicit content viewing in young children increases the risk for early initiation of PSBs, sexual offending, unsafe sexual health practices, unhealthy attitudes supportive of sexual violence against women, and stronger beliefs in gender stereotypes.[8] The national child abuse study revealed that nearly one-fourth of children surveyed (5–12 years) had been exposed to pornographic material.[3] Given the magnitude of this problem, pediatricians need to be sensitized and have a high index of suspicion when they encounter young children with symptoms of inappropriate sexual behaviors, knowledge of sexual topics, regressive behaviors such as thumb sucking or bedwetting, nightmares, overly compliant behavior, and excessive fearfulness.

Research on treatment modalities has found trauma-focused behavioral therapy and nondirective play therapy as useful therapeutic tools for victims of sexual abuse.[9],[10] Abused children can therapeutically correct their traumas in fantasy and through their actions in play, creative artwork, and stories. For example, the use of water in play symbolically indicates cleansing of thoughts and actions, and the use of “weapons” to chase away “bad guys” in imaginative play may indicate increasing feelings of empowerment. The themes of play change from negative to positive as the child gains mastery over his trauma.[9] It is important to co-opt parents as co-therapists as they can aid in treatment with filial sessions at home. Moreover, since most intrafamilial sexual abuse occurs in the context of a dysfunctional family, clinicians need to counsel parents regarding the importance of fostering stable relationships within the family.

Recent research has focused on primary prevention programs such as parent education, the involvement of school teachers, and community health workers to prevent sexual abuse.[7] Since many children and adolescents are digitally connected for prolonged periods, especially post the pandemic, the range of online risks such as inadvertent exposure to sexually explicit images and materials, sexting, sharing of explicit images, cyberbullying, and exploitative relationships are bound to increase. Parents need to be active participants in the digital lives of their children and exercise controls on what they view on the internet. Critical viewing of digital content can help viewers to reflect on the messages contained in visual content including pornography. Since pediatricians are often the first point of contact for children with behavioral and emotional problems, they are uniquely placed to provide anticipatory counseling to parents and children alike.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health 2017;2:e356-66.  Back to cited text no. 1
    
2.
Hailes HP, Yu R, Danese A, et al. Long-term outcomes of childhood sexual abuse: An umbrella review. Lancet Psychiatry 2019;6:830-9.  Back to cited text no. 2
    
3.
Study on Child Abuse: India. Ministry of Women and Child Development, Government of India; 2007. Available from: www.wcd.nic.in/childabuse.pdf. [Last accessed on 2021 Jan 19].  Back to cited text no. 3
    
4.
Seth R, Srivastava RN. Child sexual abuse: Management and prevention, and protection of children from sexual offences (POCSO) act. Indian Pediatr 2017;54:949-53.  Back to cited text no. 4
    
5.
Friedrich WN. Child Sexual Behavior Inventory: Professional Manual. Odessa, FL: Psychological Assessment Resources; 1997.  Back to cited text no. 5
    
6.
Lisi A, Valentina S, Giovanna TM, et al. Child abuse: The human figure drawing test in evaluating minors. Int J Criminol Sociol 2013;2:109-17.  Back to cited text no. 6
    
7.
Hornor G. Child and adolescent pornography exposure. J Pediatr Health Care 2020;34:191-9.  Back to cited text no. 7
    
8.
Raine G, Khouja C, Scott R, et al. Pornography use and sexting amongst children and young people: A systematic overview of reviews. Syst Rev 2020;9:283.  Back to cited text no. 8
    
9.
Ryan V, Edge A. The role of play themes in non-directive play therapy. Clin Child Psychol Psychiatry 2012;17:354-69.  Back to cited text no. 9
    
10.
Tal R, Tal K, Green O. Child-parent relationship therapy with extra-familial abused children. J Child Sex Abus 2018;27:386-402.  Back to cited text no. 10
    


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