Transcript Slide 1

The Impact of Child Sexual AbuseIs 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
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How can we use research findings to
help us develop effective services
Research & Practice Guidance
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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
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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
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
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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)
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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
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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
‘traumagenic dynamics’ in relation to
child sexual abuse
 Traumatic sexualisation
 Stigmatisation
 Betrayal
 Powerlessness
‘Polyvictimisation’
Finkelhor, Ormrod & Turner2007
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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
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Victimisation data collected using
Juvenile Victimisation Questionnaire
(JVQ)
Experiences of victimisation over
previous year
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
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Violent and property crimes
Child welfare violations
Violence of warfare and civil
disturbances
Bullying victimisation
Victimisation Profile
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Any
Any
Any
Any
Any
Any
sexual victimisation
maltreatment
property victimisation
witnessing/indirect victimisation
physical assault
peer/sibling victimisation
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
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Definitions
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Polyvictimisation - 4 or more types of
victimisation in one year ( > mean)
Chronic Victimisation – repeated
victimisations of the same type
Polyvictimisation- Findings
Polyvictimisation or multiple
victimisation- four or more different kinds
of victimisation in a single year – 22%
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Polyvictims disproportionately boys and
older children
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 - 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
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
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
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Case example of ‘Maria’
Developing post-traumatic stress disorder
Factors influencing aetiology & course of PTSD in childhood
(from Yule, Smith & Perrin):
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Developmental stage
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Pre-exposure history
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Temperament
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Family functioning
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Objective trauma severity
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Post-trauma coping style
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Social support
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Nature of the trauma memory laid down
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Attributional style and misappraisals of the event
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Appraisals of the symptoms
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Thought control strategies
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Reactions to secondary adversity
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 ,
despair,
depression
low efficacy
need to control,
dominate,
aggressive,
abusive
Tavistock – Maudsley CSA Treatment Study
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This study showed high levels of PTSD in
symptomatic sexually abused girls
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Internalising problems are easily missed
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Importance of comprehensive assessment
Tavistock – Maudsley CSA Treatment Study
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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 Study
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71 girls entered treatment, randomly allocated to
group or individual therapy
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Support for carers, individually tailored according to
need
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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
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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)
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)
PROFESSIONAL INPUTS
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Child protection work
Direct social work and support
Child health surveillance
‘Psychoeducation’
Psychological treatments
What are NICE guidelines
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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
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A At least one randomised controlled trial as part
of a body of literature of overall good quality and
consistency adressing the specific recommendation.
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B Well conducted clinical studies but no randomised
clinical trials on the topic of recommendation.
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C Expert committee reports or opinions or clinical
experiences of respected authorities
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GPP Good practice point based on the clinical
experience of the guideline development group.
Post-Traumatic Stress Disorder
(NICE)
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Timing of any intervention, ‘watchful waiting’
for first four weeks.
Training staff in assessment of posttraumatic 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
ASSESSMENT
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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
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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
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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
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Assessments are therapeutic
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Dealing with fears
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Use of play and drawings
Assessment of parents/family function
Parents as informants about the child’s current
state, pre-trauma behaviour and coping behaviours
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Assessment of parent’s state eg parents with
PTSD or depression. Helping parent access help if
necessary
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Psychoeducation and advice to parents on
management of child’s behaviours.
Screening/Outcome Measures
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Screening/outcome measures at
baseline and review
Mood & Feelings Questionnaire – broad
range of emotional symptoms
CPSS (PTSD)
Victimisation Profile
Psychoeducation
Use of psychoeducational material
eg Royal College of Psychiatrists leaflets (which are free
and can be accessed via website.)
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- as part of assessment
explanation of disorder & help,
containment of anxiety.
Model Service
POST-ASSESSMENT INTERVENTION
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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
If symptomatic then:
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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 longerterm therapy.
Model Service
Post-Assessment Intervention
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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
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Enthusiastic committed small team but spread too thin2.4 WTE staff for about 50 cases a year(33 CSA victims, 17
sexually harmful behaviours)
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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
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Looking at experiences of victimisation in assessment.
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Use of screening instruments where appropriate (MFQ,CPSS).
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Explicit agreement of treatment goals with patient and family during
assessment.
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All parents to be offered at least one ‘psychoeducational’ session and
consideration of whether parallel work for parents/family work is
needed.
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Developing CBT skills in the team
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Re-audit engagement and treatment compliance (in a year).
CBT for CSA (Tonge & King)
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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
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:
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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.
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c) Follow-up and review post intervention to see if any further help required.
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d)If the child does not respond to CBT, consider need for longer-term therapy.
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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
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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.