1. Barnahús – The Children´s House · www.bvs.is Child sexual behavior, sibling abuse, prevention and treatment Ólöf Ásta Farestveit Þorbjörg Sveinsdóttir Tallinn December 2014

2. Barnahús – The Children´s House · www.bvs.is Children´s house Mission and basic function

3. Barnahús – The Children´s House · www.bvs.is

4. Mission of Barnahus To facilitate collaboration and coordination of the CPS, Police, Prosecution and the Medical profession in the investigation of child sexual abuse To provide a child friendly settings for joint investigative interviews and medical examination To ensure professional implementation of investigative interviews

5. Barnahús – The Children´s House · www.bvs.is Mission of Barnahus To ensure that the child victim and his/her family receives appropriate assessment, treatment and support To establish professional work practices and guidelines by interdisciplinary cooperation To enhance specialized knowledge on child sexual abuse and to mediate that knowledge as appropriate to professionals and the public alike Not to harm the child

6. Barnahús – The Children´s House · www.bvs.is Referral to Barnahus Child tells about sexual abuse Reported to the police Reported to CPS Vitness debriefing Court The child´s testimony Preliminary interview Treatment in Barnahus

7. Barnahús – The Children´s House · www.bvs.is Basic functions Child sexual abuse from ages 3 ½ - 18 years. Joint forensic interviews CPS preliminary forensic interviews Medical examination Victim therapy and family counselling and support Instructions to other professionals

8. Barnahús – The Children´s House · www.bvs.is

9. After 15 years of experience Efficient, professional and child-friendly work procedures and case management re-victimization of the child victim minimized Appropriate therapeutic services secured Mutual professional trust among the different agencies Assimilation of knowledge and experience Increased public awareness and confidence in the authorities Increased „rate of discovery“ Role model for other Children´s houses in Europe

10. Barnahús – The Children´s House · www.bvs.is Barnahus in 15 years 1. nov. 1998-31.dec 2013 Number of children Average “Forensic interviews” 2815201 Treatment1502107 Medical examination 33224

11. Barnahús – The Children´s House · www.bvs.is Total forensic interviews

12. Barnahús – The Children´s House · www.bvs.is Child-friendly environment Environment for testifying (%)

13. Barnahús – The Children´s House · www.bvs.is Child-friendly testimony Giving testimony (%)

14. Barnahús – The Children´s House · www.bvs.is Child sexual behavior

15. Barnahús – The Children´s House · www.bvs.is Understanding children´s sexual behavior Age of the child Sibilings Access to computer Family form

16. Barnahús – The Children´s House · www.bvs.is Children are curius about their own body and other peoples body and sometimes they act out on this curiosity with sexual play and behavior This interest can vary alot between children and is very individualized

17. Barnahús – The Children´s House · www.bvs.is Sexual behavior Natural and healthy Of Concern Seek professional help

18. Barnahús – The Children´s House · www.bvs.is Natural behavior - pre-school Touches own genitals Differences between boys and girls Touches private parts of familiar adults Looking at nude people Asks about genitals, breasts etc Erections Like to be nude and show others Watching people doing bathroom functions Interested in having a baby Use „dirty“ words Play doctor and inspecting privat parts Interested in own feces Put something in own genitals Plays roles of mommy and daddy

19. Barnahús – The Children´s House · www.bvs.is Behavior of concern - pre-school Continues to touch privat parts in public but has been told not to Ask continuous question about genital parts Touches private parts of adults not in family Stares at nude people Keeps asking after their parents answer Continuous erections Wants to be nude in public Interest in watching bathroom functions for weeks Continue the behavior said before even though parents have told them everything or after being told “no”

20. Barnahús – The Children´s House · www.bvs.is Seek professional help – pre-school Hurts own genital parts when rubbing Plays male or female role in angry/aggressive way Sneakily touches adults – ask for them to touch Ask people to take of their clothes Ask unfamiliar people about sexual knowledge Painful erections Refuses to put on clothes Refuses to leave people alone in bathroom Display fair or angry about babies Use dirty words in public Repeatedly play with feces Force children to play sexual play Pain putting others genital parts Real intercourse without clothes, oral contact

21. Barnahús – The Children´s House · www.bvs.is Natural behavior – school age Asks more direct questions Shows others his/hers privat parts Interst in urination and defecation Rubs own genitals when going to sleep, tense or afraid Draws genitals on human figures Pretends to be opposite gender Kisses familiar adults and children Thinks other gender children are „gross“ Talks about sex with friends Want´s privacy when in bathroom Likes „dirty“ jokes Makes few sexual sounds Compares genitals with peers Interested in touching privat parts of peers or vice versa Looks at nude pictures

22. Barnahús – The Children´s House · www.bvs.is Behavior of concern – school age Shows fear or anxiety about sexual topics Keeps getting cought watching others doing bathroom functions Uses „dirty“ words with adults after told not to Frequently plays „doctor“ after being told no Shows privat parts in public after being told no Plays with fecis, urinates outside of toilet bowl Rubs genitials in public after beinig told no Rubs genitials on furniture Humps other children with clothes on Repeatedly imitates sexual behavior with dolls Uses „dirty“ language with other children after they have complained Sex talk gets child in trouble Keeps getting cought telling „dirty“ jokes or making sex sounds

23. Barnahús – The Children´s House · www.bvs.is Behavior of concern – school age Plays games related to sex and sexuality with younger children Stares at nude people after being told no Wants to compare genitals with much older or much younger people Makes others uncomfortable by request to touch their privat parts or vice versa Kisses unfamiliar adult or child Fearful of hugs and kisses by adults Continuous fascination with nude pictures Frequently puts something in own privat parts or other children´s privat parts Touching genitals of animals French kissing

24. Barnahús – The Children´s House · www.bvs.is Seek professional help – school age Endless questions about sex Sexual knowledge much too great for age Refuses to leave people alone in bathroom Continues use of „dirty“ words even after exclusion from school/activities Repeatedly plays or smears feces Forces child to take off clothes and play „doctor“ Force and pain in putting something in own privat parts and others Drawings of intercourse, group sex, sex with animals Tries to forcibly undress children and adults Demands to see other´s privat parts Coerces unwilling child to touch his/hers privat parts or vice versa, Forced or mutual oral, anal or vaginal sex Want´s to masturbate to nude pictures or display them Any coercion or force in putting something in privat pars of other child Sexual behavior with animals

25. Barnahús – The Children´s House · www.bvs.is Research show that children that have been sexual abuse show more sexual behavior than other children That doe´s not mean that sexual behavior is always an indicator of abuse Strong connections between sexual behavior and other problematic behavior in children such as ADHD, obsessive-compulsive, Asperger Many children that show sexual behavior have seen pornographic material of some sort

26. Barnahús – The Children´s House · www.bvs.is Sibling sexual abuse

27. Barnahús – The Children´s House · www.bvs.is Definition “Siblings” refers to children growing up in the same family Can occur between siblings of same gender or not –Older brother – younger sister most common Difference between sibling abuse and siblings involved in sexual play –Abuse when the older child is 12 years or older

28. Barnahús – The Children´s House · www.bvs.is The older sibling usually wins the trust of the younger sibling first May use force, bribe, threat –More common than with older offenders Offer special attention or a gift to keep the abuse secret

29. Barnahús – The Children´s House · www.bvs.is Can involve all kinds of sexual acts as in other forms of sexual abuse Does not necessarily involve sexual touching –May force two or more other children to engage in sexual activity –May force the child to watch porn –May repeatedly watch their sibling dress, shower or use the toilet

30. Barnahús – The Children´s House · www.bvs.is Consequences Most often siblings live together under the same roof or meet very regularly The abused sibling can feel pressured and trapped long period of time physical abuse and threats Isolation from other family members

31. Barnahús – The Children´s House · www.bvs.is The abused child feels betrayed –Someone they expect to love and care for them is hurting them The abused child feels powerless –Feel like they can´t stop the abuser Bigger, older, stronger, may have threatened them –Feel like no one would believe them if they would tell Feelings of shame –They take the blame and are made to feel responsible

32. Barnahús – The Children´s House · www.bvs.is Studies of convicted teenagers show that sibling offenders commit more serious abuse, over longer period of time than other teenage offenders. Their victims are more readily available and the abuse is protected by family secrecy

33. Barnahús – The Children´s House · www.bvs.is Why telling is so difficult Don´t understand that what is happening is „abuse“ Think it´s just what sibling´s do Need for attention and physical pleasure Don´t want their siblings to get to trouble Don´t want to upset their parents Scared of their sibling Don´t want anyone to know that their sibling did this to them

34. Barnahús – The Children´s House · www.bvs.is Prevention

35. Barnahús – The Children´s House · www.bvs.is Young children Develope children´s body safety skills –Right to say no (body ownership) –Assertiveness –Identification/recognition of „red flags“ –Safe people/safe places –Telling what happens –Secrets – good and bad –Ok/Not ok touch –Risk behaviors

36. Barnahús – The Children´s House · www.bvs.is Teenagers Education about healthy sexual relationships Education about self-esteem, self-awareness, self-respect Education about sexual abuse, what is rape Education about pornography –Difference between porn and reality Get a yes!

37. Barnahús – The Children´s House · www.bvs.is Treatment for children

38. Barnahús – The Children´s House · www.bvs.is Victim Therapy and family counselling Victim therapy can start soon after the interview For children who disclose sexual abuse Based on individual needs Age appropriate The DVD recorded child´s disclosure is used for initial assessment and treatment plan Therapy is practiced in the child´s hometown The therapist is most often important witness in court proceedings

39. Barnahús – The Children´s House · www.bvs.is Type of therapy According to WHO (world health organisation) TF-CBT (Trauma-focused cognitive-behavioral therapy) http://tfcbt.musc.edu/http://tfcbt.musc.edu/ CPT (cognitive-processing therapy) EMDR (eye movement desensitization and reprocessing) Other forms of therapy we use Psycho-education Sand-therapy CBT (cognitive-behavioral therapy) Behavioral-modification Mindfullness Building self esteem /self respect

40. Barnahús – The Children´s House · www.bvs.is Therapist´s Role Structure –Agenda setting and kid´s choice –Homework Assignment and Review –Watch for and manage COWS (crises of the week) Directive Active Supportive Fun!

41. Barnahús – The Children´s House · www.bvs.is Assessment Provides a picture of what´s going on with the child Helps to determine –Presenting symptoms –The need for treatment –What type of treatment is best fit? Helps in development of treatment plan Enables therapist to assess treatment progress Methods: –Formal, Standardized Measures –Clinical interview –Clinical observations

42. Barnahús – The Children´s House · www.bvs.is Psychoeducation Provide information about the impact of trauma and hope for recovery Facts about trauma/abuse (prevalence, who offends, why don´t children tell…) Informations about child´s symptoms and reactions Normalize emotional and behavioral reactions Educate family about the benefits of treatment Sometimes importance of psychoeducation is overlooked because we want to move on to the other parts of treatment!!

43. Barnahús – The Children´s House · www.bvs.is What is TF-CBT? An evidence-based treatment for children experiencing trauma related difficulties Adresses wide range of traumas Developed for youth ages 3-18 years Components-based treatment protocol Time limited, structured (12-20 sessions) Parents are an integral part of treatment

44. Barnahús – The Children´s House · www.bvs.is TF-CBT Components Assessment Psychoeducation and Parenting skills Relaxation Affective Modulation Cognitive Processing Trauma Narrative Conjoint parent-child sessions Enhanching safety and social skills

45. Barnahús – The Children´s House · www.bvs.is What is CPT A short term evidence based treatment for PTSD A specific protocol With or without written account Can be conducted in groups and individually 12 sessions

46. Barnahús – The Children´s House · www.bvs.is CPT components Education regarding PTSD, thoughts and emotions Processing the trauma Learning to challenge thoughts Trauma themes Facing the future

47. Barnahús – The Children´s House · www.bvs.is What is EMDR An evidence-based treatment for children experiencing trauma related difficulties Re-processing of traumatic memories Standardized protocol For all ages of people One to four sessions –Complicated trauma needs more sessions

48. Barnahús – The Children´s House · www.bvs.is EMDR components History and treatment planning Preparation Assessment Desensitization Installation Body Scan Closure Re-evaluation

49. Barnahús – The Children´s House · www.bvs.is We must think of The child´s best interest !