Healthcare professionals - supporting children and young people who may have experienced child sexual abuse: clinical pathway

3 The wider child protection context in Scotland

The pathway is intended to inform the health care and recovery pathway for children and young people who may have experienced sexual abuse. The pathway sits within a wider policy and practice landscape which covers all forms of child abuse including physical abuse, sexual abuse and exploitation, emotional abuse, female genital mutilation (FGM), neglect and fabricated or induced illness.

FGM is an illegal practice and an extreme violation of human rights. FGM reflects deep-rooted inequality between the sexes and constitutes a severe form of discrimination against women and girls. FGM has been illegal in Scotland since 1985, when the Prohibition of Female Circumcision Act 1985 was passed. The Female Genital Mutilation (Protection and Guidance) (Scotland) Act 2020 was passed on 19 March 2020.

The term ‘gender-based violence’ is generically used to describe violence, predominantly against women and girls, in the context of gender inequality. Gender based violence encompasses:

• Domestic abuse including coercive control^[14]
• Rape and sexual assault
• Child sexual abuse
• Commercial sexual exploitation
• Sexual harassment and stalking
• Harmful traditions and practices including female genital mutilation

The wider policy context in Scotland includes:

• The Scottish Government’s intention to incorporate the United Nations Convention on the Rights of the Child (UNCRC) into Scots law. The convention includes a provision that everyone up to the age of 18 years is entitled to all the rights and protections provided for children
• A refresh of the GIRFEC national practice model for improving the wellbeing of children and young people
• The Promise Scotland which is responsible for implementing the change required by the findings of the Independent Care Review
• A Scottish Government commitment that all eligible children who are victims or witnesses to abuse or violence, as well as children under the age of criminal responsibility whose behaviour has caused significant harm or abuse will have access to a ‘Bairns’ Hoose’ (Scottish Barnahus) providing trauma informed recovery, support and justice by 2025
• The Vulnerable Witnesses (Criminal Evidence) (Scotland) Act 2019 which requires pre-recording of evidence of child witnesses (aged under 18 years) for certain types of case heard in a jury trial and increased use of pre-recorded evidence by vulnerable witnesses in other proceedings
• Embedding the implementation of the Scottish Child Interview Model of Joint Investigative Interview within the Bairns’ Hoose (Scottish Barnahus) model. Section 6.3 details the purpose of a Joint Investigative Interview (JII)

3.1 Adverse Childhood Experiences

We know that Adverse Childhood Experiences (ACEs)^[15] such as sexual abuse can create harmful levels of stress which can affect brain development, resulting in long term detrimental effects on learning, behaviour and health outcomes. It is not inevitable that ACEs will cause these negative outcomes and protective factors such as supportive relationships and appropriate care can mitigate their effects. The ideal is to prevent ACEs happening in the first place but once the traumatic events have occurred the aim is to ensure that children and young people affected by childhood adversity and trauma have the right support in place where and when needed to improve their health and life outcomes. Steps to achieve this aim include:

• Strengthening multi-agency and multi-disciplinary working across the children’s workforce to deliver integrated care for children and young people so they are experienced as coordinated by those who use the services
• Providing tailored support for families with the most complex needs to ensure children and young people can be safely cared for at home and in their communities, to prevent children and young people from entering the care system and/or experiencing multiple disadvantage
• Creating improved communication and coordination between child and adult services to enable adult services to better take account of and support the needs of affected children and enable children’s services to address the needs of non-abusing parent(s)/carer(s)

The care and support set out in the pathway should be delivered by a trauma-informed multi-agency workforce to help reduce the negative impact of ACEs on children and young people.

3.2 Serious harmful behaviour shown by children

Harmful behaviour in this context means behaving in a violent or dangerous way which causes or risks causing serious physical harm to another person, or sexually violent or sexually coercive behaviour, which has caused or risks causing harm (whether physical or not) to another person.

Children who behave in this way may themselves have been abused or neglected. Whether or not they have been maltreated, they are likely to have additional needs relating to their behaviour or the impact of their behaviour. While the police and statutory services will take action to protect the safety of those involved in the situation and attend to the needs of victims, all investigative and planning activity triggered by a child’s harmful behaviour must have regard for the child’s health and wellbeing as a primary consideration.

If child protection concerns arise in relation to the child who has behaved harmfully to others, then standard components of IRD processes apply (see section 6.2).

Further information, including wider IRD considerations, for children who show serious harmful behaviour can be found in the National Child Protection Guidance, Part 4.^[16]

3.3 Trauma-informed care

The Scottish Government’s ambition is for a trauma-informed and trauma-responsive workforce and services across Scotland, capable of recognising where children, young people and adults are affected by trauma and adversity, and able to respond in ways that prevent further harm, support recovery and improve life chances. Trauma-informed approaches are built on safe and trusted relationships which offer choice and empowerment, facilitated by:

• Active power sharing with people with lived experience of trauma
• Attention to embedding organisational support for staff wellbeing
• Data and evaluation feedback loops that confirm delivery of trauma-informed principles of care and inform positive change
• Leadership that is visibly trauma-informed in action and language
• A workforce that has access to quality education and training and support for implementation

This ambition is supported by a National Trauma Training Programme^[17], led by NHS Education for Scotland and is based on the Transforming Psychological Trauma: Knowledge and Skills Framework^[18]. This framework is designed to increase understanding of trauma and its impact, across all sectors of the Scottish workforce. Health boards and other agencies are responsible for ensuring that their employees are trained to the appropriate level in accordance with the framework.

The key components of the National Trauma Training Programme are:

• A Transforming Psychological Trauma Training Plan^[19], that provides essential guidance and planning tools to support workers, managers and organisations to identify their trauma training needs with reference to the Trauma Framework that will meet the aims and objectives set out in the Knowledge and Skills Framework
• On-line training resources^[20] to help increase awareness, knowledge, capacity and capability among all sectors of the workforce to understand the impact of trauma and embed trauma-informed practice and responses. These are available for free and accessible to everyone in the Scottish workforce and include the key principles of safety, trust, choice, empowerment and collaboration
• A network of Transforming Psychological Trauma Implementation Co-ordinators (TPTICs), based in each health board, providing their local areas with advice, support for training, and making connections with what is already happening on the ground locally
• Scottish Trauma Informed Leaders Training (STILT) supports leaders of organisations to implement and sustain trauma-informed systems, processes, environments and teams
• A Trauma Champions Network, consisting of senior leaders from Local Authorities, Health Boards, Health and Social Care Partnerships and other key community planning partners, is helping to progress trauma-informed practice in local areas and share learning across geographical and professional boundaries. The ‘Trauma Champions’ are supported in their role by the Improvement Service
• An online Community of Practice^[21], hosted by the Improvement Service, is available to all professionals across Scotland who are interested in finding out more about trauma-informed policy and practice and who would like to share learning
• A Leadership Pledge of Support^[22] for Trauma Informed Practice to help raise awareness and demonstrate the strength of commitment across Scotland
• Development of tailored trauma training and support for priority sectors including trauma-informed maternity services, justice services, and support for those contributing to the lives of care experienced babies, children, young people and families, aligning with The Promise^[23]

Since 2019, the right to trauma-informed care and practice has been embedded within the Charter of Patient Rights and Responsibilities^[24], as well as the guidance for local authorities and health boards on exercising the functions conferred by Part 3 of the Children and Young People (Scotland) Act 2014^[25].

The Forensic Medical Services (Victims of Sexual Offences) (Scotland) Act 2021 (“FMS Act”)^[26], creates a statutory duty requiring health boards to provide Forensic Medical Services (FMS) for victims of sexual offences. Once the FMS Act is commenced, those services will fall within the scope of the Patients’ Rights (Scotland) Act 2011, meaning that people who have experienced a sexual offence have the right to receive healthcare in a way that focuses on their needs – in these circumstances healthcare should be provided in a way which seeks to avoid re-traumatisation and is otherwise trauma-informed.

3.4 National Guidance for Child Protection in Scotland 2021

The National guidance for child protection Scotland 2021 provides additional detail about multi-agency child protection assessment and about the need to assess intersecting risks arising from different forms of abuse (including child sexual abuse, exploitation, trafficking, internet-enabled sexual abuse and harmful sexual behaviour by children and young people). It recognises that children and young people who cause harm to others may themselves have experienced abuse.

Following publication of the guidance, this pathway stresses general principles that underpin the consideration and conduct of investigative activities in relation to children and young people who may be harmed and those who may cause harm to others. These are summarised below:

Rights: The child’s present feelings, views and future rights are respected and protected at every stage.

Safety: Processes are both careful and robust, promoting the safety of those involved by discovering the truth within the most harmful circumstances.

Wellbeing: The wellbeing of the child is the lens through which all decisions and actions are taken.

Preparation: Processes include early discussion between the lead agencies, co-ordination and partnership with those responsible for the child’s care.

Understanding: Each stage and any change or decision is explained in a way that makes sense to each child and those responsible for their safe care, taking in to account culture, capacity, age and stage.

Support: Support will be provided for children and families involved in these processes.

Skill: Professionals involved are afforded the training and supervision that ensures a coordinated and child-centered process.

Pace: Preparation and pace of exploration is patient and attuned to the impact of trauma upon the needs and feelings of each child.

Place: Investigative processes are conducted in an environment which is child-friendly and amenable to those attending for the child’s support.

Improvement: Processes are evaluated and improved to ensure adherence to standards.

Useful resources

NHS Education Scotland (2017): Transforming Psychological Trauma: A knowledge and skills Framework for the Scottish Workforce^[27]

NHS Health Scotland (2018): Gender Based Violence^[28]

NHS Lanarkshire: Trauma and the Brain: Understanding Abuse Survivors Responses^[29]

NHS Education Scotland (2018): Opening Doors: Trauma-Informed Practice for the Workforce^[30]

NHS Health Scotland (2018): Adverse Childhood Experiences (ACEs)^[31]

3.5 Care experienced young people

Young people who have experience of the care system are at a significantly greater risk of suffering abuse. A young person with a history of experiencing sexual abuse will therefore need any new incident or report to be assessed within the context of a chronology of adverse childhood events. As in all cases, they will need a comprehensive and holistic assessment of their needs to inform the offer/plan for trauma-informed support. Particular attention should be paid to considering any ongoing risks to their safety and assessing general wellbeing concerns.

3.6 Corporate parents

The term corporate parenting is defined as: ‘An organisation’s performance of actions necessary to uphold the rights and safeguard the wellbeing of a looked after child or care leaver, and through which physical, emotional, spiritual, social and educational development is promoted’ (Statutory Guidance on Corporate Parenting, 2015)^[32].

The Children and Young People (Scotland) Act 2014^[33] (“the 2014 Act”; part 9 which relates to Corporate Parenting) came into effect on 1 April 2015. The Act names 26 public bodies^[34] and groups of bodies as corporate parents. Under the 2014 Act, corporate parents have a duty to promote the wellbeing of looked after children and care leavers to the age of 26.

As for all children and young people, for those who have a corporate parent, it will be necessary to consider whether the GIRFEC approach should be used to provide support or augment support already in place for the child or young person. When required, the GIRFEC approach will provide a holistic assessment of support needs for the child or young person and a personalised support plan when the child or young person needs a range of extra support to be planned, delivered and coordinated. This plan will explain what should improve for the child or young person, the actions to be taken and why the plan has been created. The plan is managed by a 'lead professional'; someone with the right skills and experience to make sure the plan is managed properly. The child or young person and parent/carer(s) will know what information is being shared, with whom and for what purpose, and that their views will be taken into account.

The 2014 Act also supports the provision of continuing care, meaning that an eligible young person can remain in their foster care, residential care, formal kinship care or an equivalent placement until their 21^st birthday. Corporate parenting duties for the 26 public bodies also apply to these young people.