1. 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)

6. 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

7. 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

8. 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 reported contact sexual abuse when they were children (NSPCC Prevalence Study)
During the two years up to March ,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

9. 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

10. 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

11. 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

12. Statistics and child protection information relating to Latvians in the UK * 9th March * 29th March 2014 Kent County Council criticised over Latvian child in care : 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.

13. Letting the Future In

14. 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.

15. 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

16. 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.

17. 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

18. 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)).

19. 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

20. LTFI Results: Older children and Young People

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

22. 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.

23. LTFI Results: Younger children

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

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

26. 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

27. 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.”

28. 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

29. 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

30. 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

31. 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

32. 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

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

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

35. 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

36. 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?

37. 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

38. 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

39. 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?

40. 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)

41. 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’

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

43. 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

44. 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)

45. 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

46. 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

47. 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?

48. 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)

49. 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

50. 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)