Dr Tara Weeramanthri Consultant Child & Adolescent Psychiatrist South London & Maudsley NHS Foundation Trust Tar

1. 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 Tara.Weeramanthri@slam.nhs.uk

2. Research into Practice • How can we use research findings to help us develop effective services

3. Research & Practice Guidance • Polyvictimisation –Finkelhor • Trauma –Organising Systems -Bentovim • Tavistock- Maudsley CSA Treatment Outcome Study (Trowell et al) • DoH Guidance -Jones & Ramchandani • NICE Guidance

4. 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…

5. 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.

6. 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.

7. 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

8. 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.

9. Finkelhor 1985 ‘traumagenic dynamics’ in relation to child sexual abuse • Traumatic sexualisation • Stigmatisation • Betrayal • Powerlessness

10. ‘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

11. Data Collected - Victimisation • Victimisation data collected using Juvenile Victimisation Questionnaire (JVQ) • Experiences of victimisation over previous year

12. 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)

13. Kinds of Victimisation • Violent and property crimes • Child welfare violations • Violence of warfare and civil disturbances • Bullying victimisation

14. Victimisation Profile • Any sexual victimisation • Any maltreatment • Any property victimisation • Any witnessing/indirect victimisation • Any physical assault • Any peer/sibling victimisation

15. 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

16. Definitions • Polyvictimisation - 4 or more types of victimisation in one year ( > mean) • Chronic Victimisation – repeated victimisations of the same type

17. Polyvictimisation- Findings • Polyvictimisation or multiple victimisation- four or more different kinds of victimisation in a single year – 22% • Polyvictims disproportionately boys and older children

18. 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

19. 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’

20. 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?

21. 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

22. Clinical Example • Case example of ‘Maria’

23. 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

24. 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)

25. 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

26. 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

27. 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.

28. 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

29. 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.

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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.

36. 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

37. Assessment • Assessments are therapeutic • Dealing with fears • Use of play and drawings

38. 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.

39. Screening/Outcome Measures • Screening/outcome measures at baseline and review • Mood & Feelings Questionnaire – broad range of emotional symptoms • CPSS (PTSD) • Victimisation Profile

40. 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.

41. 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).

42. 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.

43. 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.

44. 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).

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

46. CBT for CSA (Tonge & King) • Groundwork • Addressing feelings • Learning coping skills • Exposure to memories of abuse experience • Dealing with disclosure • Body awareness & sexuality • Prevention training & termination

47. (Back to) Model Service 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.

48. References • 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.