Effective interventions with children and young people who have been abused and with children and young people who have abused others Jon Brown Head of Development and Impact National Society for the Prevention of Cruelty to Children (NSPCC)

NSPCC Founded in 1884 UK’s foremost child protection NGO We provide services to children and families, two 24/7 helplines, policy development and advocacy, consultancy, training, evaluation and research 2,000 staff and 10,000 volunteers

NSPCC Vision and Strategy To end cruelty to children To answer key questions in child protection through a combination of service delivery, policy development and research We have 5 key goals: To prevent abuse in families where there are multiple adversities To prevent child sexual abuse To enable children and adults to speak out about abuse To ensure children who have been abused get the help they need To prevent child abuse online

Child sexual abuse – UK statistics 1 in 20 children below the age of 18 reported contact sexual abuse (NSPCC Prevalence study, Radford et al 2010) 1 in 12 young adults aged 18-25 reported contact sexual abuse when they were children (NSPCC Prevalence Study) During the two years up to March 2014 50,000 cases of child sexual abuse in the family environment were recorded by the police in England It has been estimated that during this period the real number of children sexually abused in the family environment is 450,000 (Office for the Children’s Commissioner for England , 2015) Only 1 in 8 cases of child sexual abuse in the family environment are known to the authorities

Child sexual abuse A hidden problem Victims often effectively silenced Many victims never disclose the abuse they have suffered Many victims do not disclose for many years Key impacts – shame, betrayal, stigmatisation, powerlessness, traumatic sexualisation Mental health problems – depression, alcohol and substance misuse, self harm, obesity, suicide Significant economic cost – latest estimate £3.2bn per annum to the UK economy

Child sexual abuse as a public health problem It is widespread The effects are damaging and long-lasting Some of its effects can spread to future generations Much of it can be prevented Primary prevention Treatment Deterrence to reduce opportunity Preventing Child Sexual Abuse – Towards a National Strategy NSPCC, Brown and Saied Tissier 2014

Statistics and child protection information relating to Latvians in the UK *A total of 61,440 Latvians live in Britain – or 3.2 per cent of the 1.9million anywhere in Europe *14th Aug 2015 https://www.theguardian.com/commentisfree/2015/aug/14/child-mother-court-of-appeal-latvian-girl-adoptive-parents-uk

Statistics and child protection information relating to Latvians in the UK * 9th March 2015 https://www.theguardian.com/uk-news/2015/mar/09/latvia-complains-to-uk-parliament-over-forced-adoptions * 29th March 2014 Kent County Council criticised over Latvian child in care : www.bbc.co.uk/news/uk-england-kent-26794840 Kent County Council has been criticised by the High Court for failing to give a Latvian father the right information when it took his young son into care.

Letting the Future In

Letting the Future In Letting the Future In (LTFI) is a structured guide to therapeutic intervention with children affected by sexual abuse Developed by the NSPCC. The guide has been implemented by 20 NSPCC teams across England, Wales and Northern Ireland since 2011.

Letting the Future In LTFI is available to children aged between four and 17 who have made a disclosure and live with a safe carer with no planned moves and have no diagnosed learning disability Grounded in an understanding of trauma, attachment and resilience. Largely psychodynamic in nature and emphasizes the therapeutic attunement of the practitioner to the child’s to the child’s emotional responses to abuse

Letting the Future In Children receive up to four therapeutic assessment sessions followed by up to 20 intervention sessions, extended up to 30 if necessary At the same time, their safe carer is offered up to eight sessions to help them process the impact of discovering that their child was sexually abused, and to support the child in their recovery.

Letting the Future In – research questions What are the outcomes for children and young people affected by sexual abuse of providing LTFI delivered by NSPCC service centres? What is the cost-effectiveness of this service? What is the effectiveness of the support intervention received by the ‘safe carers’? The cost effectiveness study is still proceeding and will be reported in a subsequent publication The largest RCT of its kind, globally

Letting the Future In – Methodology Standardised instruments - the Trauma Symptoms Checklist or Trauma Symptoms Checklist for Young Children (TSCC/TSCYC) Briere 1996; 2001) Secondary outcomes included the changed proportions of parents with clinical levels of parent/carer stress for safe carers (Parenting Stress Index (Abidin 1995)).

Letting the Future In – Process evaluation How is Letting the Future In delivered? What are children’s, safe carers’ and practitioners experiences and perceptions of the intervention? Investigated through case studies of eight NSPCC teams Family case studies were undertaken with 12 children and young people and 17 carers Evaluation also included a specific qualitative study to explore the nature and quality of the therapeutic relationship developed during LTFI

LTFI Results: Older children and Young People

Older children and young people: % with one or more ‘Clinical’ + ‘Significant Difficulty’ scores [McNemar Test – Intervention = .001, Waiting list = .581]

Statistically significant changes in % children with clinical + difficulty scores for Intervention group Reduction No difference Anxiety Post-traumatic stress Dissociation Depression (marginal) Anger Sexual concerns.

LTFI Results: Younger children

Young children: % Clinical scores [McNemar Test - Intervention = .687, Waiting list = 1.000, *small cell sizes]

Intervention group, young children: % clinical level scores (T1-T3) (N=36) [McNemar: T1-T2 p = .687 ; T2-T3 p = .063]

Children’s experiences of the intervention Children and young people were universally positive about the service they received They recalled a good relationship with their practitioner They valued being listened to, and the confidential nature of the relationship “I felt like I needed to talk to someone but not my mum because I didn’t want to upset my mum or have to put things more and more on her shoulders.” child aged 16

Therapeutic alliance study Practitioners were skilled at putting young people at ease in their initial meeting and this first contact was important in influencing young people’s willingness to take part. They described worker attributes as “reassuring”, “warm”, “friendly”, “honest” Young people valued the understanding that sessions would be private and confidential: “Like the way that she said that everything would be confidential, she wouldn’t say anything and to prove that I’d get to take everything home at the end which I did.”

Carer’s experiences of their child’s intervention Very positive about the support their child received And on the impact on their child. “I got my child back” – numerous carers

Impact on the child (reported by carers) Improved mood Reduction in anger Less withdrawn More confident Better sleep patterns Less anxious and stressed Knowing ‘right from wrong’ re sexual behaviour (younger children in particular) Improved mood – being in same room not upstairs, going out with friends, just being happier

Implications of the evaluation We have demonstrated for the first time that a “real world” RCT for a therapeutic intervention can be effectively delivered in a social care setting. We have contributed a well evaluated intervention to a market where there are currently few services compared to demand and need Challenges of testing a guided rather than manualised approach

Implications of the evaluation We can speak confidently about LTFI being effective with children aged 8 years and over. The great majority of children and young people who received the intervention experienced it as effective in addition to it being clinically effective as detailed above Therapeutic interventions with sexually abused children can be effectively delivered by trained social care professionals LTFI represents good value for money

Implications of the evaluation The evaluation points clearly to three key developments which would potentially further improve the effectiveness of the intervention: Children under the age of 8 require a longer “dosage” or period of intervention Protective parents and carers require more and more consistent support concurrent to the intervention with their child Ongoing post intervention support should be provided to help maintain improvements achieved as a result of the intervention

Children and Young People with Harmful Sexual Behaviour, including peer on peer abuse

Research project A UK multisite study to examine long term outcomes for young sexual abusers (ESRC grant reference RES-062023–0850) Research team at Durham University (Hackett and Phillips) and the University of Huddersfield (Masson and Balfe)

Overall aim To describe and analyse the experiences and life circumstances of adults who, in their childhoods, were subject to professional interventions because of their Harmful Sexual Behaviour (HSB) and to consider the implications of these experiences for policy and service delivery

Specific research questions What happens to children and young people after professional interventions to address their harmful sexual behaviour (HSB) has ended? What do they (as adults) make of the professional interventions offered to them (as children)? How do they understand their life narratives? What factors appear to contribute to successful outcomes where young people desist from HSB? What factors appear to contribute to poor outcomes where young people continue to present with psychosocial problems (both sexual and nonsexual) into adulthood?

What was done Retrospective study of 700 case files representing all referrals over a 9 year period across 9 sites in the UK Selected 117 cases to follow-up Managed to ‘trace’ 89 of these 117 cases to invite to take part in interview In-depth narrative interviews with 69 former service users (now adults), their carers, professionals focusing on long-term outcomes between 10 and 20 years after the original harmful sexual behaviours Complemented by some standardised measures, criminal reconviction data

Poor outcomes Individual Poor body image and poor health Inability to manage anger and aggression Personal vulnerability to exploitation Lack of understanding of 'sex offender' label on life Inability to offer a coherent narrative of the past Absence of planning- survives only day-to-day Learning disability and enduring mental health issues Relational Relationship instability- 'whirlwind romances' Violent partner relationships Persistent patterns of rejection (relationships, professional services, jobs) Social/ environmental Instability, chaotic, frantic lives Drug and alcohol problems Institutionalisation as adult (lack of autonomy) Unemployment Financial problems and poverty Loneliness Anti-social, criminal networks HSB related Physical violence as well as HSB

Good outcomes Individual Belief in self and in ability to make something of your life Sense of being in control of life (not being controlled by it) Optimism about the future, hope and personal ambition Ability to plan A good sense of humour and good communication skills Being ashamed of childhood behaviour and taking responsibility for it Ability to separate from the abuse "I'm no longer that person and I'm not a risk" Relational Stable partner relationships Becoming a parent (and wanting to) Positive carer and professional relationships that endure Social/ environmental Employment Pro-social friendship or colleague networks Interests and talents Decent housing HSB related Sexually victimised perpetrators?

The bad news… Most of these positive outcome factors were not directly related to professional interventions offered to the young people and their families- complexity and unpredictability of life events Often, it was down to unplanned ‘developmental turning points’ Is it good enough for us to leave these to chance? (especially when only 26% had ‘good’ outcomes)

The good news… Relatively transient or small protective experiences could act as catalysts for future positive outcomes (in particular, the power of relationships- these could be, but often were not, professional relationships) The important concept of ‘protective chain effect’

So….how can we use these findings to design interventions to support positive outcomes: 5 simple ideas might be:

1) Helping people live with the legacy of the past “I do get bad thoughts, not bad thoughts like that [sexual thoughts] but they’re down thoughts, because I know what I’ve done is wrong, there’s nothing I can do to change it or anything, other than to get on with my life and try and make amends”. (Aged 33 years, mixed outcome) “Sometimes in dreams, I think about it, what I’ve done, I have flashbacks about what I’ve done and I don’t like it, I hate myself for it and I want to make things right. “ (Aged 26 years, good outcome) Aftercare (not just ‘follow-up’) Service transitions

2) Shift the intervention focus “Every time you go in there, they got you talking about the abuse, but they’re always referring back, to try to get you to understand more about what’s happened, but I found that, after they got me talking about it, it was just the same, going back, so when I’m trying to go forward .... then I come to puberty, it’s a big jump because it’s something new that I’ve never experienced before, it’s all emotions going up, and then to go back and it’s just the same, you’re going back and back, there’s no forward; it’s like it would have been better to probably, instead of going back and discussing what happened, maybe talking about how I felt in relation to my current situation in puberty, how I was feeling, how it was affecting me”. (Aged 21 years, good outcome) Longstanding focus on inward-looking interventions Even some approaches to YP’s ‘good lives’ are rather ‘abstract’ MST Employ as many or more outreach workers as therapists? Long-standing focus of inward-looking services (we all know why) Many approaches to the good lives YP are going to live are in the abstract (or passively monitored)

3) Support intimate partner success and parenting “I was frightened, it frightened me to death, but I wanted to be the one person in his life that didn’t let him down, that was always there for him.” (Partner of 28 year old M on knowing his past) It made me realise that, you know, I’m a pure adult now, I’ve got, I’ve just created the most amazing thing in the world, it’s the best feeling I’ve ever had in my life, it’s the greatest achievement I’ll ever have in my life. (Aged 28, mixed outcome) Young Fathers mentoring Specific parenting programme for YP with HSB? Project lead on ‘young fathers’? Couple work

4) Undertake (meaningful) family work “‘I think deep down, my mum still has regrets about what I did, which is understandable, but I don’t really think she wants to say, she doesn’t want to use the word ‘hate’, but sometimes I get the feeling that she does hate me for what happened, which is fair enough, it’s understandable, we do get along, I mean me and my mum do have a rough relationship, we really do”. (Aged 33 years, mixed outcome) “It was very important for me to sit down with my sister and talk about the issue, it really was, because I felt I hadn’t done that, I’d never have known how she felt towards me in that sort of sense.” (Aged 30 years, good outcome) Restorative family interventions 66% of the original sample of 700 were known to have experienced at least one form of familial abuse 31% of the males in the sample were known to have experienced sexual abuse in their family of origin (Hackett et al., 2013). As a result, many had been through their adolescence physically separated from other family members, some having unresolved histories of abuse themselves

5) Build intervention services that inspire BELONGING and LOYALTY “It’s like a family to you, you know, you have your daily meetings, you have your everything else, you have your workshops and things like that, you have your therapy...... (The home) to me will always have a place in my heart and may long it carry on doing the work it does.” (Aged 30, good outcome) Continuity of staffing Life long support?

Conclusions Many former service users appreciated the opportunity to tell their story. Few had other avenues to reflect on their past at 'critical periods' when issues about the HSB are raised (fragmentation of child v. adult welfare systems) Distancing and the ability to separate off from the child who committed the HSB (challenge the ‘once an offender, always an offender’ orthodoxy) For some, HSB remains an open wound, for others paled into relative insignificance against the catalogue of awful life events (system focus and balance) Developmental turning points- largely chance events (how can we plan for them?) The vital importance of 'social anchors' and relational stability- set against instability brought by professional systems (social development, not just a risk management approach)

Some Key Themes Evidence informing practice Understanding the dynamics and impacts of abuse Attachment Relationships Listening to children and young people Consistency of support Keeping a focus on prevention Maintaining an outward focus

Thanks for listening! I hope it was useful Jon Brown Head of Development and Impact National Society for the Prevention of Cruelty to Children (NSPCC)