Around 1 in 1000 adolescents aged 12 to 17 years old display problematic or harmful sexual behaviour (HSB). Examples include behaviours occurring more frequently than would be considered developmentally appropriate; accompanied by coercion; involving children of different ages or stages of development; or associated with emotional distress. Some, but not all, young people engaging in HSB come to the attention of authorities for investigation, prosecution or treatment. Depending on policy context, young people with HSB are those whose behaviour has resulted in a formal reprimand or warning, conviction for a sexual offence, or civil measures. Cognitive‐behavioural therapy (CBT) interventions are based on the idea that by changing the way a person thinks, and helping them to develop new coping skills, it is possible to change behaviour.
To evaluate the effects of CBT for young people aged 10 to 18 years who have exhibited HSB.
In June 2019, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also examined relevant websites, checked reference lists and contacted authors of relevant articles.
We included all relevant randomised controlled trials (RCTs) using parallel groups. We evaluated CBT treatments compared with no treatment, waiting list or standard care, irrespective of mode of delivery or setting, given to young people aged 10 to 18 years, who had been convicted of a sexual offence or who exhibited HSB.
Data collection and analysis
We used standard methodological procedures expected by Cochrane.
We found four eligible RCTs (115 participants). Participants in two studies were adolescent males aged 12 to 18 years old. In two studies participants were males simply described as "adolescents."
Three studies took place in the USA and one in South Africa. The four studies were of short duration: one lasted two months; two lasted three months; and one lasted six months. No information was available on funding sources.
Two studies compared group‐based CBT respectively to no treatment (18 participants) or treatment as usual (21 participants). The third compared CBT with sexual education (16 participants). The fourth compared CBT (19 participants) with mode‐deactivation therapy (21 participants) and social skills training (20 participants). Three interventions delivered treatment in a residential setting by someone working there, and one in a community setting by licensed therapist undertaking a PhD.
CBT compared with no treatment or treatment as usual
No study in this comparison reported the impact of CBT on any measure of primary outcomes (recidivism, and adverse events such as self‐harm or suicidal behaviour).
There was little to no difference between CBT and treatment as usual on cognitive distortions in general (mean difference (MD) 1.56, 95% confidence interval (CI) ‐11.54 to 14.66, 1 study, 18 participants; very low‐certainty evidence), assessed with Abel and Becker Cognition Scale (higher scores indicate more problematic distortions); and specific cognitive distortions about rape (MD 8.75, 95% CI 2.83 to 14.67, 1 study, 21 participants; very low‐certainty evidence), measured with the Bumby Cardsort Rape Scale (higher scores indicate more justifications, minimisations, rationalisations and excuses for HSB).
One study (18 participants) reported very low‐certainty evidence that CBT may result in greater improvements in victim empathy (MD 5.56, 95% CI 0.94 to 10.18), measured with the Attitudes Towards Women Scale, compared with no treatment. One additional study also measured this, but provided no usable data.
CBT compared with alternative interventions
One study (59 participants) found little to no difference between CBT and alternative treatments on post‐treatment sexual aggression scores (MD 0.09, 95% CI ‐0.18 to 0.37, very low‐certainty evidence), assessed using Daily Behaviour Reports and Behaviour Incidence Report Forms. No study in this comparison reported the impact of CBT on any measure of our remaining primary outcomes.
One study (16 participants) provided very low‐certainty evidence that, compared to sexual education, mean cognitive distortions pertaining to justification or taking responsibility for actions (MD 3.27, 95% CI
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