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The Impact of Child Sexual Abuse- Is Polyvictimisation a Factor? The Challenge of Developing Effective Services for Sexually Victimised Children. Dr Tara Weeramanthri Consultant Child & Adolescent Psychiatrist South London & Maudsley NHS Foundation Trust [email protected]

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The Impact of Child Sexual Abuse- Is Polyvictimisation a Factor? The Challenge of Developing Effective Services for Sexually Victimised Children

Dr Tara Weeramanthri

Consultant Child & Adolescent Psychiatrist

South London & Maudsley NHS Foundation Trust

[email protected]


Research into practice
Research into Practice

  • How can we use research findings to help us develop effective services


Research practice guidance
Research & Practice Guidance

  • Polyvictimisation –Finkelhor

  • Trauma –Organising Systems -Bentovim

  • Tavistock- Maudsley CSA Treatment Outcome Study (Trowell et al)

  • DoH Guidance -Jones & Ramchandani

  • NICE Guidance


Definitions of child sexual abuse
Definitions 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…


Prevalence of child sexual abuse
Prevalence of Child Sexual Abuse

Studies indicate

  • Rates of 6-62% in females

    3-31% in males

  • Female:male ratio is 4 or 5:1

    Variation is due to differences in definitions (eg

    if you include non- contact abuse that increases

    rates) and in the way the study is carried out.


Southwark statistics
Southwark Statistics

  • Of 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.


Impact of child sexual abuse from cotgrove kolvin
Impact of Child Sexual Abuse(from Cotgrove & Kolvin)

  • Psychological Symptoms

    Depression, anxiety, low self-esteem, guilt, sleep disturbance and dissociative phenomena

  • Psychiatric Disorders

    Post-traumatic stress disorder, depression, anxiety, eating disorders.

    Borderline personality disorder in adulthood

  • Problem Behaviours

    Self-harm, drug use, sexual behaviour problems, running away

  • Social Relationship Problems

    Social withdrawal, sexual promiscuity and re-victimisation


Impact of child sexual abuse
Impact 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.


Finkelhor 1985
Finkelhor 1985

‘traumagenic dynamics’ in relation to child sexual abuse

  • Traumatic sexualisation

  • Stigmatisation

  • Betrayal

  • Powerlessness


Polyvictimisation finkelhor ormrod turner2007
‘Polyvictimisation’Finkelhor, Ormrod & Turner2007

  • Telephone survey of community sample of 2030 children in USA

  • Age 2-17

  • Brief interview with adult carer re family demographic information

  • Interview with child if age 10-17

  • Interview with carer if child 2-9


Data collected victimisation
Data Collected - Victimisation

  • Victimisation data collected using Juvenile Victimisation Questionnaire (JVQ)

  • Experiences of victimisation over previous year


Data collected mental health symptoms
Data Collected – Mental Health Symptoms

Three scales :

  • anxiety

  • depressive symptoms

  • anger/aggression

    of Trauma Symptom Checklist (children10-17)

    Trauma Symptom Checklist for Young Children

    ( caregivers of children age 2-9)


Kinds of victimisation
Kinds of Victimisation

  • Violent and property crimes

  • Child welfare violations

  • Violence of warfare and civil disturbances

  • Bullying victimisation


Victimisation profile
Victimisation Profile

  • Any sexual victimisation

  • Any maltreatment

  • Any property victimisation

  • Any witnessing/indirect victimisation

  • Any physical assault

  • Any peer/sibling victimisation


Findings
Findings

  • 71 % had experienced victimisation in last year, majority more than one type

  • Mean number of victimisation types was 3

    (range 0-15)

  • Most common victimisations were peer and sibling assaults, witnessing non-weapon assaults, emotional bullying & theft


Definitions
Definitions

  • Polyvictimisation - 4 or more types of victimisation in one year ( > mean)

  • Chronic Victimisation – repeated victimisations of the same type


Polyvictimisation findings
Polyvictimisation- Findings

  • Polyvictimisation or multiple

    victimisation- four or more different kinds

    of victimisation in a single year – 22%

  • Polyvictims disproportionately boys and older children


Polyvictimisation findings1
Polyvictimisation - Findings

More likely to be a polyvictim and experienced a

high number of victimisation experiences in the

following types of victimisation:

  • Exposure to war or ethnic conflict

  • Rape

  • Flashing

  • Witnessing parental assault of a sibling

  • Kidnapping

  • Witnessing a murder

  • Dating violence


Polyvictimisation findings2
Polyvictimisation - Findings

Poly-victimisation was highly predictive of trauma symptoms and

when taken into account, greatly reduced or eliminated the

association between individual victimisations (eg sexual abuse) and

symptomatology.

Recontextualises impact of individual traumatic experiences.

Need to assess for a broader range of victimisations in

traumatised group not just presenting traumatic event.

‘Work in Progress’


Implications for services
Implications for Services

A possible implication of this research

would be whether having a dedicated

CSA service is the right focus or whether

focusing services around

trauma/victimisation more broadly would

be more appropriate?


Implications for practice
Implications for Practice

What kinds of victimisation should we screen for

in a child/young person presenting following

sexual assault?

  • Previous physical or sexual assault

  • History of physical or sexual assault in other family members/friends

  • Bullying

  • Mobile phone theft

  • Mugging

  • Witnessing an assault

  • Burglaries


Clinical example
Clinical Example

  • Case example of ‘Maria’


Developing post traumatic stress disorder
Developing post-traumatic stress disorder

Factors influencing aetiology & course of PTSD in childhood

(from Yule, Smith & Perrin):

  • Developmental stage

  • Pre-exposure history

  • Temperament

  • Family functioning

  • Objective trauma severity

  • Post-trauma coping style

  • Social support

  • Nature of the trauma memory laid down

  • Attributional style and misappraisals of the event

  • Appraisals of the symptoms

  • Thought control strategies

  • Reactions to secondary adversity


Understanding trauma
Understanding Trauma

Arnon Bentovim:

Trauma –Organised Systems looking at physical and sexual abuse in families

drawing on David Finklehor’s concept of

‘traumagenic dynamics’ in relation to child sexual abuse ( traumatic sexualisation, stigmatisation, betrayal, powerlessness)


Powerlessness

invasion of the body,

vulnerability, absence of protection,

repeated fear , and helplessness

fear, anxiety

inability to control events

learning difficulty , need to control,

despair, dominate,

depression aggressive,

low efficacy abusive


Tavistock maudsley csa treatment study
Tavistock – Maudsley CSA Treatment Study

  • This study showed high levels of PTSD in symptomatic sexually abused girls

  • Internalising problems are easily missed

  • Importance of comprehensive assessment


Tavistock maudsley csa treatment study1
Tavistock – 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 study

  • 73% PTSD

    57% Clinical Depression

    58% Separation Anxiety

    37% General Anxiety

    High levels of co-morbidity

  • Carers

    Some had of physical or sexual abuse in their own families.

    Some had previous domestic violence.

    Some had current mental health problems.


Tavistock maudsley csa treatment study2
Tavistock – Maudsley CSA Treatment Study

  • 71 girls entered treatment, randomly allocated to group or individual therapy

  • Support for carers, individually tailored according to need

  • Outcomes

    -reduction in psychiatric disorders

    -improvement on dimensions of PTSD

    -reduction in impairment

    -few differences between two treatment modalities


Tavistock maudsley csa treatment study implications for practice
Tavistock – Maudsley CSA Treatment StudyImplications 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.


Child sexual abuse informing practice from research 1 jones ramchandani doh
Child Sexual Abuse Informing Practice from Research(1)Jones & Ramchandani (DoH)

DESIRED OUTCOMES

  • Keeping the child safe

  • Ensuring or improving general caretaking and parenting

  • Treating symptoms of psychological disorder in children and/or adults

  • Containing sexually aggressive, violent or exploitative behaviour


Child sexual abuse informing practice from research 2 jones ramchandani doh
Child Sexual Abuse Informing Practice from Research (2)Jones & Ramchandani (DoH)

PROFESSIONAL INPUTS

  • Child protection work

  • Direct social work and support

  • Child health surveillance

  • ‘Psychoeducation’

  • Psychological treatments


What are nice guidelines
What are NICE guidelines

  • Attempt to base clinical practice on available evidence

  • NICE recommendations are based on a hierarchy of evidence, so different strength of evidence for different recommendations

  • NICE 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


Nice grading of recommendations
NICE: 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 authorities

  • GPP Good practice point based on the clinical experience of the guideline development group.


Post traumatic stress disorder nice
Post-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 measure

  • Importance of talking to child/young person on their own

  • Trauma-focused cognitive behavioural therapy


Model service
Model 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 & 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 and to get information on what is helpful.


Assessment phase
Assessment Phase

  • Specific assessment of impact of abuse needs to be within framework of a broader assessment

  • It should include:

    Direct interview with the child

    Use of screening/ self-report measures

    Information from parents/family & school


Assessment
Assessment

  • Assessments are therapeutic

  • Dealing with fears

  • Use of play and drawings


Assessment of parents family function
Assessment of parents/family function

  • Parents as informants about the child’s current

    state, pre-trauma behaviour and coping behaviours

  • Assessment of parent’s state eg parents with

    PTSD or depression. Helping parent access help if necessary

  • Psychoeducation and advice to parents on management of child’s behaviours.


Screening outcome measures
Screening/Outcome Measures

  • Screening/outcome measures at baseline and review

  • Mood & Feelings Questionnaire – broad range of emotional symptoms

  • CPSS (PTSD)

  • Victimisation Profile


Psychoeducation
Psychoeducation

  • Use of psychoeducational material

    eg Royal College of Psychiatrists leaflets (which are free

    and can be accessed via website.)

    - as part of assessment

    explanation of disorder & help,

    containment of anxiety.


Model service1
Model 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).


Model service post assessment intervention
Model ServicePost-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.


Model service post assessment intervention1
Model ServicePost-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.


Real life opportunities obstacles southwark camhs csa team experience
Real 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 plans

  • Therapy 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 abuse

  • Team 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).


Southwark service next steps
Southwark Service: Next Steps Team Experience

  • 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 team

  • Re-audit engagement and treatment compliance (in a year).


Cbt for csa tonge king
CBT for CSA (Tonge & King) Team Experience

  • Groundwork

  • Addressing feelings

  • Learning coping skills

  • Exposure to memories of abuse experience

  • Dealing with disclosure

  • Body awareness & sexuality

  • Prevention training & termination


Back to model service
(Back to) Model Service Team Experience

ASSESSMENT

1.Importance of good assessment - high levels of co-morbidity in some symptomatic children/YP eg depression, PTSD, anxiety

Disorders. 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 and

To get information on what is helpful.

POST-ASSESSMENT INTERVENTION

3.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).

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.


References
References Team Experience

  • Post-traumatic stress disorders, Yule,W, Smith,P, & Perrin,S, in

    Cognitive 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 & Neglect

    31(2007) 7-26.

  • Child Sexual Abuse. Informing Practice from Research. Jones, DPH,

    & Ramchandani, P. Radcliffe Medical Press 1999.

  • Psychotherapy for sexually abused girls: psychopathological

    outcome findings and patterns of change, Trowell,J, Kolvin,I,

    Weeramanthri,T, Sadowski,H, Berelowitz,M, Glaser,D, & Leitch,I,

    British J of Psychiatry(2002), 234-247.


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