Presentation on theme: "The Impact of Child Sexual Abuse- Is Polyvictimisation a Factor"— Presentation transcript:
1The Impact of Child Sexual Abuse- Is Polyvictimisation a Factor The Impact of Child Sexual Abuse- Is Polyvictimisation a Factor? The Challenge of Developing Effective Services for Sexually Victimised ChildrenDr Tara WeeramanthriConsultant Child & Adolescent PsychiatristSouth London & Maudsley NHS Foundation Trust
2Research into Practice How can we use research findings to help us develop effective services
3Research & Practice Guidance Polyvictimisation –FinkelhorTrauma –Organising Systems -BentovimTavistock- Maudsley CSA Treatment Outcome Study (Trowell et al)DoH Guidance -Jones & RamchandaniNICE Guidance
4Definitions of Child Sexual Abuse Schecter & Roberge (1976)The involvement of dependent developmentally immature children and adolescents in sexual activities that they do not fully comprehend, and to which they are unable to give informed consent, and that violate the social taboos of normal family roles..Finklehor & Korbin define sexual abuse as..any sexual contact between an adult and a sexually immature child (both in physical and social terms) for the purposes of the adult’s sexual gratification…
5Prevalence of Child Sexual Abuse Studies indicateRates of 6-62% in females3-31% in malesFemale:male ratio is 4 or 5:1Variation is due to differences in definitions (egif you include non- contact abuse that increasesrates) and in the way the study is carried out.
6Southwark StatisticsOf 234 children with a Child Protection Plan on 31/3/07, 23 (10%) were under the category of child sexual abuse.In 2006 all London rate was 6% and in England 9%In period April 06-March07 our CAMHS CSA service received 33 referrals of children and young people who were sexually victimised and 17 referrals of children and young people who showed sexually concerning or sexually abusive behaviours.
7Impact of Child Sexual Abuse (from Cotgrove & Kolvin) Psychological SymptomsDepression, anxiety, low self-esteem, guilt, sleep disturbance and dissociative phenomenaPsychiatric DisordersPost-traumatic stress disorder, depression, anxiety, eating disorders.Borderline personality disorder in adulthoodProblem BehavioursSelf-harm, drug use, sexual behaviour problems, running awaySocial Relationship ProblemsSocial withdrawal, sexual promiscuity and re-victimisation
8Impact of Child Sexual Abuse The child/young person may be affected by the abuse itself, the impact of disclosure and the consequences of disclosure. Families vary greatly in how they respond to a disclosure; some believe the child, are supportive and take protective steps; others are disbelieving and the child may end up distressed and isolated. Disbelief or lack of support or family pressure may result in a retraction of the allegation.
9Finkelhor 1985‘traumagenic dynamics’ in relation to child sexual abuseTraumatic sexualisationStigmatisationBetrayalPowerlessness
10‘Polyvictimisation’ Finkelhor, Ormrod & Turner2007 Telephone survey of community sample of 2030 children in USAAge 2-17Brief interview with adult carer re family demographic informationInterview with child if age 10-17Interview with carer if child 2-9
11Data Collected - Victimisation Victimisation data collected using Juvenile Victimisation Questionnaire (JVQ)Experiences of victimisation over previous year
12Data Collected – Mental Health Symptoms Three scales :anxietydepressive symptomsanger/aggressionof Trauma Symptom Checklist (children10-17)Trauma Symptom Checklist for Young Children( caregivers of children age 2-9)
13Kinds of Victimisation Violent and property crimesChild welfare violationsViolence of warfare and civil disturbancesBullying victimisation
14Victimisation Profile Any sexual victimisationAny maltreatmentAny property victimisationAny witnessing/indirect victimisationAny physical assaultAny peer/sibling victimisation
15Findings71 % had experienced victimisation in last year, majority more than one typeMean number of victimisation types was 3(range 0-15)Most common victimisations were peer and sibling assaults, witnessing non-weapon assaults, emotional bullying & theft
16DefinitionsPolyvictimisation - 4 or more types of victimisation in one year ( > mean)Chronic Victimisation – repeated victimisations of the same type
17Polyvictimisation- Findings Polyvictimisation or multiplevictimisation- four or more different kindsof victimisation in a single year – 22%Polyvictims disproportionately boys and older children
18Polyvictimisation - Findings More likely to be a polyvictim and experienced ahigh number of victimisation experiences in thefollowing types of victimisation:Exposure to war or ethnic conflictRapeFlashingWitnessing parental assault of a siblingKidnappingWitnessing a murderDating violence
19Polyvictimisation - Findings Poly-victimisation was highly predictive of trauma symptoms andwhen taken into account, greatly reduced or eliminated theassociation between individual victimisations (eg sexual abuse) andsymptomatology.Recontextualises impact of individual traumatic experiences.Need to assess for a broader range of victimisations intraumatised group not just presenting traumatic event.‘Work in Progress’
20Implications for Services A possible implication of this researchwould be whether having a dedicatedCSA service is the right focus or whetherfocusing services aroundtrauma/victimisation more broadly wouldbe more appropriate?
21Implications for Practice What kinds of victimisation should we screen forin a child/young person presenting followingsexual assault?Previous physical or sexual assaultHistory of physical or sexual assault in other family members/friendsBullyingMobile phone theftMuggingWitnessing an assaultBurglaries
23Developing post-traumatic stress disorder Factors influencing aetiology & course of PTSD in childhood(from Yule, Smith & Perrin):Developmental stagePre-exposure historyTemperamentFamily functioningObjective trauma severityPost-trauma coping styleSocial supportNature of the trauma memory laid downAttributional style and misappraisals of the eventAppraisals of the symptomsThought control strategiesReactions to secondary adversity
24Understanding Trauma Arnon Bentovim: Trauma –Organised Systems looking at physical and sexual abuse in familiesdrawing on David Finklehor’s concept of‘traumagenic dynamics’ in relation to child sexual abuse ( traumatic sexualisation, stigmatisation, betrayal, powerlessness)
25Powerlessnessinvasion of the body,vulnerability, absence of protection,repeated fear , and helplessnessfear, anxietyinability to control eventslearning difficulty , need to control,despair, dominate,depression aggressive,low efficacy abusive
26Tavistock – Maudsley CSA Treatment Study This study showed high levels of PTSD in symptomatic sexually abused girlsInternalising problems are easily missedImportance of comprehensive assessment
27Tavistock – Maudsley CSA Treatment Study 81 girls, aged 6-14, assessed at baseline. They had to be symptomatic and to have experienced contact abuse to enter the study73% PTSD57% Clinical Depression58% Separation Anxiety37% General AnxietyHigh levels of co-morbidityCarersSome had of physical or sexual abuse in their own families.Some had previous domestic violence.Some had current mental health problems.
28Tavistock – Maudsley CSA Treatment Study 71 girls entered treatment, randomly allocated to group or individual therapySupport for carers, individually tailored according to needOutcomes-reduction in psychiatric disorders-improvement on dimensions of PTSD-reduction in impairment-few differences between two treatment modalities
29Tavistock – Maudsley CSA Treatment Study Implications for Practice Sexually abused girls who are symptomatic require careful assessment to gauge the full extent of their symptoms and disorders.Many parents and families are likely to be struggling and the importance of support work for parents/carers is relation to engagement and facilitating their child’s improvement is emphasised.Time-limited focused work helps. Individual and group work are equally effective.Follow up and review are essential as a significant proportion may need further help from CAMHS.Children may need additional help in school for an extended period.
30Ensuring or improving general caretaking and parenting Child Sexual Abuse Informing Practice from Research(1) Jones & Ramchandani (DoH)DESIRED OUTCOMESKeeping the child safeEnsuring or improving general caretaking and parentingTreating symptoms of psychological disorder in children and/or adultsContaining sexually aggressive, violent or exploitative behaviour
31Child Sexual Abuse Informing Practice from Research (2) Jones & Ramchandani (DoH) PROFESSIONAL INPUTSChild protection workDirect social work and supportChild health surveillance‘Psychoeducation’Psychological treatments
32What are NICE guidelines Attempt to base clinical practice on available evidenceNICE recommendations are based on a hierarchy of evidence, so different strength of evidence for different recommendationsNICE guidelines will be periodically reviewed as evidence base changes over time and so they reflect an evolving consensus on good clinical practice.‘Stepped care’ model of help
33NICE: Grading of recommendations A At least one randomised controlled trial as part of a body of literature of overall good quality and consistency adressing the specific recommendation.B Well conducted clinical studies but no randomised clinical trials on the topic of recommendation.C Expert committee reports or opinions or clinical experiences of respected authoritiesGPP Good practice point based on the clinical experience of the guideline development group.
34Post-Traumatic Stress Disorder (NICE) Timing of any intervention, ‘watchful waiting’ for first four weeks.Training staff in assessment of post-traumatic stress disorder. Possible use of a screening measureImportance of talking to child/young person on their ownTrauma-focused cognitive behavioural therapy
35Model Service ASSESSMENT 1. Importance of good assessment - high levels of co-morbidity in some symptomatic children/YP eg depression, PTSD, anxiety disorders.Screen for PTSD, depression & anxiety2. Use of leaflets in assessment phase eg Young Minds on CSA , Royal College of Psychiatrists on trauma, depression (on RCPsych website) in assessment to help child and family understand range of impact of sexual abuse, to feel less alone and to get information on what is helpful.
36Assessment PhaseSpecific assessment of impact of abuse needs to be within framework of a broader assessmentIt should include:Direct interview with the childUse of screening/ self-report measuresInformation from parents/family & school
37Assessment Assessments are therapeutic Dealing with fears Use of play and drawings
38Assessment of parents/family function Parents as informants about the child’s currentstate, pre-trauma behaviour and coping behavioursAssessment of parent’s state eg parents withPTSD or depression. Helping parent access help if necessaryPsychoeducation and advice to parents on management of child’s behaviours.
39Screening/Outcome Measures Screening/outcome measures at baseline and reviewMood & Feelings Questionnaire – broad range of emotional symptomsCPSS (PTSD)Victimisation Profile
40Psychoeducation Use of psychoeducational material eg Royal College of Psychiatrists leaflets (which are freeand can be accessed via website.)- as part of assessmentexplanation of disorder & help,containment of anxiety.
41Model Service POST-ASSESSMENT INTERVENTION All benefit from some psychoeducational work re parts of body, touching what's ok, what's not, who to tell if harassed (lines of communication etc).
42Model Service Post-Assessment Intervention If symptomatic then:a) Interventions for child/YP - time-limited cognitive-behavioural work.b) Plus parallel work with parents/carers (helps overall engagement and helps the parents to understand and respond appropriately to the child's behaviour.) Parents may themselves have experienced abuse or subject to other risk factors such as domestic violence that are affecting their response to the child.c) Follow-up and review post intervention to see if any further help required.d)If the child does not respond to CBT, consider need for longer-term therapy.
43Model Service Post-Assessment Intervention e) Risk of acting out such as deliberate self-harm during treatment. Service needs to have facility to respond to crises and manage risk.f) Assess need for educational help. Children with internalising disorders may be underachieving but not picked up. Liaison with schools in relation to the needs of such children. Children can also be bullied by peers post-disclosure.f) Workers need skilled supervision. This group can present with a lot of negative feelings and this needs to be understood in terms of how abuse has impacted on how they see the world.
44Real life: Opportunities & Obstacles – Southwark CAMHS CSA Team Experience Enthusiastic committed small team but spread too thin-2.4 WTE staff for about 50 cases a year(33 CSA victims, 17 sexually harmful behaviours)Difficulty in getting effective multi-agency working if children are not in receipt of child protection plansTherapy is only a component of a broader plan encompassing child protection, care , education , leisure but can often be seen as a ‘magic solution’ with a lack of focus on other components.Children and parents are ambivalent about thinking about the abuseTeam audit of CSA victim cases showed that only around 20% of those referred engaged fully in treatment ( in contrast to research group which had overall high engagement and treatment completion rates).
45Southwark Service: Next Steps Looking at experiences of victimisation in assessment.Use of screening instruments where appropriate (MFQ,CPSS).Explicit agreement of treatment goals with patient and family during assessment.All parents to be offered at least one ‘psychoeducational’ session and consideration of whether parallel work for parents/family work is needed.Developing CBT skills in the teamRe-audit engagement and treatment compliance (in a year).
46CBT for CSA (Tonge & King) GroundworkAddressing feelingsLearning coping skillsExposure to memories of abuse experienceDealing with disclosureBody awareness & sexualityPrevention training & termination
47(Back to) Model Service ASSESSMENT1.Importance of good assessment - high levels of co-morbidity in some symptomatic children/YP eg depression, PTSD, anxietyDisorders. Assessment should include information on number and range of victimisation experiences.Screen for PTSD, depression & anxiety.2. Use of leaflets in assessment phase eg Young Minds on CSA , Royal College of Psychiatrists on trauma, depression(on RCPsych website) in assessment to help child and family understand range of impact of sexual abuse, to feel less alone andTo get information on what is helpful.POST-ASSESSMENT INTERVENTION3.All benefit from some psychoeducational work re parts of body, touching what's ok, what's not, who to tell if harassed (lines ofcommunication etc).4. If symptomatic then:a) Interventions for child/YP - time-limited cognitive-behavioural work.b) Plus parallel work with parents/carers (helps overall engagement and helps the parents to understand and respond appropriately to the child's behaviour. )Parents may themselves have experienced abuse or subject to other risk factors such as domestic violence that are affecting their response to the child.c) Follow-up and review post intervention to see if any further help required.d)If the child does not respond to CBT, consider need for longer-term therapy.e) Risk of acting out such as deliberate self-harm during treatment. Service needs to have facility to respond to crises and manage risk.f) Assess need for educational help. Children with internalising disorders may be underachieving but not picked up. Liaison with schools in relation to the needs of such children. Children can also be bullied by peers post-disclosure.f) Workers need skilled supervision. This group can present with a lot of negative feelings and this needs to be understood in terms of how abuse has impacted on how they see the world.
48ReferencesPost-traumatic stress disorders, Yule,W, Smith,P, & Perrin,S, inCognitive Behaviour therapy for Children & Families, Ed, Philip Graham.Cognitive behavioural treatment of the emotional and behavioural consequences of sexual abuse, Tonge B & King N in above book.Trauma Organised Systems, Physical & Sexual Abuse in Families,Bentovim, A.Poly-victimisation: A neglected component in child victimisation,Finkelhor,D, Omrod, R,K & Turner, H,A, Child Abuse & Neglect31(2007) 7-26.Child Sexual Abuse. Informing Practice from Research. Jones, DPH,& Ramchandani, P. Radcliffe Medical Press 1999.Psychotherapy for sexually abused girls: psychopathologicaloutcome findings and patterns of change, Trowell,J, Kolvin,I,Weeramanthri,T, Sadowski,H, Berelowitz,M, Glaser,D, & Leitch,I,British J of Psychiatry(2002),