Working with children and young people who have displayed harmful sexual behaviour: evidence based guidance for professionals working with children and young people

C) Sexually abusive and violent behaviour

Example 1:

Jerry is 15 and is going out with Dana who is 14. They attend the same high school. A couple of times a week they do not attend classes in the school and have sex in the boys’ toilets. One day Dana explains to her teacher that Jerry has filmed them having sex and shared the videos with peers. He has also asked her to perform various sexual acts that she does not want to do, and has said that he will send the videos to her friendship group if she doesn’t do them. The school escalate this as a child protection concern and an Interagency Referral Discussion (IRD) is held, agreeing that police should investigate and Joint Investigative Interviews (JII) should be held with Dana. Jerry is charged by the police and a Child Protection Planning Meeting decides to offer a placement at an alternative school where a robust safety plan is put in place. An assessment using a validated risk assessment tool is undertaken by a social worker who takes on a Lead Professional role and co-ordinates the Child’s Plan. A referral is made to a Children’s Hearing but there is agreement that the case can be discharged as there are insufficient welfare concerns in relation to Jerry because he has accepted his behaviour has caused harm and is willing to do something to ensure this does not happen again. On the back of the assessment Jerry undertakes 3 months of psycho-educational work about consent, emotional and sexual regulation, impact of pornography and his understanding of the law in relation to sexual behaviour.

Example 2:

Noah is 13 and his stepsister, Jade, is 6. They have lived together in the same household for the last year after their dad and mum met. Jade had been very withdrawn and prone to having tantrums over the last three months. When Jade’s mum asks about her about this, she tells her mum that Noah comes into her bedroom at night once a week, shows her videos of naked people and then asks her to touch his penis. He has told her that she must never tell anyone or she will need to leave the family. Jade’s mum contacts Noah’s mum, who is very distressed and contacts social work. Given the very serious concerns within Jade’s disclosures an Interagency Referral Discussion is held for both Jade and Noah. This offers key professionals in health, police and social work (education may also be involved) the opportunity to discuss how best to investigate Jade’s disclosure and agree an interim safety plan. The Interagency Referral Discussion will also discuss Noah, and what investigations may need to take place to investigate if he too is a victim of harm, what may have led to his behaviours and his wider needs and safety. This discussion will take account of any possible criminal procedures which may be initiated in respect of Noah. The Interagency Referral Discussion will also take a view on if care and risk management procedures are necessary to support Noah. Arrangements are made for Noah to live with his paternal aunt while an assessment of the situation takes place. Noah is charged with a sexual offence and is referred to a children’s hearing where he is placed on a compulsory supervision order. Some therapeutic work is undertaken with him further to a referral to a local third sector organisation who works with children who have displayed harmful sexual behaviour.

Where sexual abuse of a child or young person is alleged to have been carried out by another child or young person, such behaviour should always be treated seriously and be subject to a discussion between relevant agencies that covers both the victim and the perpetrator. In all cases where a child or young person acts in a sexually abusive fashion, immediate consideration should be given to whether action needs to be taken under child protection procedures, either in order to protect the victim or to tackle concerns about what has caused the child or young person to behave in such a way.

Risk Management

The Framework for Risk Assessment Management and Evaluation (FRAME) with children aged 12-17 sets out the process and principles of effective risk assessment and management through a child-centred lens. Professionals involved in this work must have the skills and competencies to manage the complexities inherent within it and where they do not have the appropriate level of competency, appropriate opportunities to develop these must be in place and all professionals should receive robust and meaningful support from their management structures and agencies.

CARM meetings ensure that a clear assessment of risk takes place and proportionate risk management measures are implemented subject to regular review to ensure further abuse does not occur.

Professionals involved

• A range of services are required for children and young people who display sexually abusive or sexually violent behaviours. These include:
• Support, case management and coordination in frontline settings supported by specialised services as needed.
• Community-based teams, including Forensic CAMHS (in NHS GGC) and the voluntary sector (such as the NSPCC or Barnardo’s) at local level, who can assess and offer interventions to children and young people (and their parents, carers and families) presenting with problematic and abusive sexual behaviours, supported where necessary with input from a regional specialist service with consultation and training. Community-based teams would be well-placed to provide consultation and advice to schools on children presenting with sexual behaviour problems in educational settings.
• A small number of therapeutic residential facilities for children and young people who have displayed HSB based around the UK to allow for intensive, supervised treatment of children whose needs cannot be met safely in the community.
• Provision in secure settings, for comprehensive assessments and interventions that address the young person’s risks and needs, linked to sentence planning (if they have been convicted), the Child’s Plan and transitions within the secure estate and to the community.
• Provision in young offenders institutes, although numbers are very low each year. Under 18s convicted of a sexual offence will be allocated to social work caseload and will be subject to Integrated Case Management (ICM) processes. If they have sufficient time they will be offered the opportunity to engage in assessment for intervention work. They will also have access to other services to meet their needs^[6].
• Interventions for Vulnerable Youth (IVY) is a national specialist psychological and social work service hosted by Kibble.
• IVY provides professional consultation and advice, psychological assessment and psychological intervention for those young people aged 12-18 who present a significant risk of harm to others by any sort of behaviour, including harmful sexual behaviour.

Specialist Assessment

Where behaviour has been abusive or violent, a more comprehensive assessment is required to consider the risk of harm to others within the context of the child’s broader welfare needs and any child protection concerns. The context within which this assessment takes place will differ depending on the child’s age and which system responds to their behaviour. Most public protection concerns will be managed by the CARM or Vulnerable Young Persons (VYP) processes depending on locality, but following conviction at court, a child may become subject to multi-agency public protection arrangements (MAPPA) and/or sexual offender notification requirements. The purpose of MAPPA is public protection and managing the risk of serious harm posed by certain categories of individuals (i.e. individuals subject to Sexual Offender Notification Requirements, Restricted Patients, or Other Risk of Serious Harm individuals). Where a child meets any of these criteria and becomes subject to MAPPA, robust connections must be in place to support the transition of any child in this situation. It is also critical to support and ensure their understanding of the expectations and implications of non-compliance or adherence with any additional requirements such as Sex Offender Notification Requirements which may also be in place.

Regardless of which system underpins the response of professionals to the child’s behaviour, the assessment will need to include an analysis of the harmful behaviour itself and the context within which it occurred to help determine the likelihood of future harm, those at risk of being harmed in the future, the severity of the potential harm and the imminence of any future harmful behaviour. Additionally, comprehensive assessments of harmful behaviour typically focus on examining the presence, and relevance, of risk factors or vulnerabilities known to be linked to the risk of future harmful behaviour as well as protective factors or strengths known to mitigate the risk of future harmful behaviour. The resulting comprehensive assessment and formulation (the process by which individual characteristics, experiences and behaviours interact) will be used to inform decision-making about proportionate measures to protect future potential victims; to identify risk factors or vulnerabilities to be addressed through interventions in order to reduce the level of risk presented; and build on protective factors and strengths to lay the foundations for supporting the child or young person’s ongoing social development in safe and healthy ways.

In short, comprehensive assessments need to answer the following questions:

• What happened?
• How did it happen? Was it planned or opportunistic? What environment did the behaviour take place in and were there factors related to the environment that created risks (e.g. poor supervision or monitoring).
• Who was harmed and how were they harmed? What do victim characteristics tells us about future risk?
• Why has the young person behaved in a harmful sexual manner?
• How likely are they to do so again, to whom and in what particular circumstances?
• What needs to be done in the short term to manage risks?
• What are the indicators of risk increasing or decreasing?
• What needs to be done in the longer term to reduce risks and to support prosocial development?
• How will progress be measured?

All comprehensive assessments tend to follow a similar process:

• Collecting data, and identifying historical and current factors about the child, their life circumstances, family, peer group and environment as well as the context of the behaviour that supports further harmful sexual behaviour (risk factors) or desistance (strengths). This will include summary of patterns of behaviour, as well as nature and seriousness.
• Applying professional knowledge to undertake an analysis of known risks and strengths to consider the pattern, seriousness, nature and likelihood of future harmful behaviour to produce an understanding of the risk of harm (including likelihood and imminence of future harmful sexual behaviour), and the future risk of non-sexual offending.
• Use of relevant appropriate tools or psychometrics. This might include risk assessment tools but could also be things like learning, personality or intelligence measures.
• Make professional judgements about relationships, risks, safety and potential for change for the child, family and environment.
• Recommending the measures required to facilitate safety and change. This will typically include type and intensity of intervention tailored to individual, family and community characteristics and consideration of how progress will be measured.
• Ensuring meaningful communication of the assessment to those who need to act upon it.

In some cases involving sexually abusive or violent behaviour, a Care and Risk Management (CARM) meeting should co- ordinate the assessment, setting a timeline and expectations. Assessment will typically be a social work role with the social worker taking on the role of Lead Professional and co-ordinating the multi-agency assessment and response

There are various assessment tools and frameworks (including for children under the age of 12) that can helpfully guide the assessment, some of which are detailed in the Risk Management Authority’s Risk Assessment Tools Evaluation Directory. Crucially, when working with children any tools or frameworks used to help inform the assessment should be developmentally appropriate, support a structured professional judgment approach, and be in line with best practice guidelines and standards (Scottish Government, 2021; 2021a). Standard 7 of the Scottish Government’s Standards for those working with children in conflict with the law 2021 states that:

Risk assessment and formulation is a crucial step to identify which children require services, the type and intensity of service provision required and in guiding appropriate care planning. Undertaking proportionate assessment to understand and reduce the risk of harm posed by aspects of a child’s behaviour is essential and must actively include the child and their views.

Assessments should be undertaken by suitably qualified and experienced professionals who have completed relevant training in child protection, harmful sexual behaviour and trauma-informed practices, and who receive relevant support and supervision.

AIM3 is the most widely used assessment tool in social work contexts in Scotland. The PROFESOR tool is also used. Young people who have displayed harmful sexual behaviour may also be at risk of other kinds of offending in the future including violent offending. Use of an assessment tool such as Short-Term Assessment of Risk & Treatability: Adolescent Version (START:AV) or Structured Assessment of Violence Risk in Youth (SAVRY) may also be appropriate. For extremely complex cases a psychosexual assessment (a comprehensive psychological assessment combined with an assessment of the harmful sexual behaviour) may be beneficial.

The standards also highlight that practice must be underpinned by the Framework for Risk Assessment Management and Evaluation (FRAME) for children aged 12-17 when assessing, and managing the risk of harm that might be posed by aspects of a child’s behaviour. The FRAME Standards, Guidance and Operational Requirements for risk practice require that a proportionate approach to risk practice is taken which recognises children’s rights and their inclusion in the decision-making process.

Assessments of children and young people should involve their parents and / or carers whenever possible and appropriate. An understanding of family functioning and family strengths and challenges will be necessary in helping to understand the background to the child or young person’s behaviour, as well as developing any potential Child’s Plan to support the child or young person. When engagement is not possible or appropriate, the reasons for not involving families should be clearly communicated in the assessment.

Interventions

It is important that the key focus of organisations providing interventions to children who have harmed others is on recovery and reintegration into society, as well as protecting others from future harm, in line with the UNCRC.

Interventions may take place in the community, but also in custodial, secure and specialist residential settings.

Over the past few decades, when children have engaged in sexually abusive or sexually violent behaviours, the approach taken to intervention has tended to be a cognitive behavioural approach. Such interventions tend to involve analysis of the behaviour; modifying unhealthy thinking and attitudes; developing victim empathy; educating about healthy sexual relationships; managing emotions; developing coping strategies; social skills training; modifying unhealthy sexual arousal; and risk management strategies (Hackett, 2014). There is evidence-based research demonstrating that certain core principles in interventions can lead to the effectiveness of interventions with adolescents. These include the following:

1. Integrity – The most effective structured cognitive behavioural interventions are those that are delivered in the way they were intended and where their delivery is regularly supervised and quality assured.

2. Management / Staff – Interventions are most effective when staff are well trained and receive good support from the management within their organisations.

3. Risk / Needs / Responsivity – Interventions are most effective when the level of intervention is proportionate to the level of risk and need presented, with those who have the highest needs being able to access more intensive supports; when they focus on the underlying needs that led to the harmful behaviour; and when they are delivered in various formats that are responsive to individuals learning styles.

4. Therapeutic style – The therapeutic style of those delivering Interventions is critical to engagement and the development of positive therapeutic relationships which is one of the key contributors to the effectiveness of interventions.

5. Community Focussed – Interventions that are delivered as ‘close to home’ as possible have the highest chance of effectiveness.

6. Evaluation – Effective interventions often include a focus on ongoing evaluation and research focused on whether the intended aims and outcomes are being achieved, and if not, what can be done to improve this.

There are, however, limitations to structured cognitive behavioural interventions. One of the key limitations is that they tend to focus on changing the individual’s behaviour, whereas research tells us that wider family and societal factors can also contribute to sexually abusive and violent behaviours. This emphasis on individual change can be demotivating, especially for children who often have little control over the circumstances and contexts in which they are growing up. It is therefore increasingly recognised that for changes in behaviour to be effective and sustained, interventions should also be strengths-based and focused on understanding and providing support to families, schools, peers, and the wider community. A good example of this is the Good Lives model discussed on page 17.

Whichever intervention approach is taken, it is essential that it is developmentally appropriate, individualised, holistic and trauma informed.

The focus on harmful sexual behaviour generates powerful feelings and responses which often obscure seeing the child/young person in the context of their everyday life and future. This is seen when direct work focuses only on the harmful behaviour(s) and risk (which is fundamental), while unmet needs such as social isolation and vulnerability remain. Messages from research paint a compelling picture of young people with complex life experiences and vulnerabilities, at times displaying other forms of violence or harmful behaviours including towards themselves, and navigating many of the challenges associated with different developmental stages of childhood, adolescence and young adulthood. It is important that interventions are responsive to different aspects of individuals’ lives – including social, educational and emotional development – and ‘focus unrelentingly on the future’ (Hackett et al, 2022). This includes building on strengths, positive relationships, sexual literacy, educational achievements and social inclusion. Consideration of the United Nations Rights of the Child (UNCRC), particularly the three ‘pillars’ of protection, participation and provision, offer important guiding principles for developing right’s respecting responses that recognise individual lives more holistically.

Working Systemically

Engaging with the child and young person’s family / carers are recognised as an important aspect of effective interventions (NICE 2016). The shape and focus of the intervention should be informed by an assessment and will depend on factors such as the circumstances of the child and the type of behaviour engaged in.

For example, for children it is recommended the parent / carer is either directly involved in the child’s session or work is undertaken with them in tandem with the child’s interventions. In cases where there has been sibling sexual abuse, where the behaviour emerges in the context of family dynamics, interventions should focus holistically on the family (Allardyce & Yates 2018). In general, there is an acceptance that engaging parents in work alongside any interventions being undertaken with children and young people is recommended to enhance parents’ and carers’ capacity to manage and support their child. However, given the impact of harmful sexual behaviours can be so overwhelming and negative, it should not be assumed that parents will want to be involved in the interventions and they may need to be motivated and encouraged to see the value of engaging for them and their child.

Role of schools

Research to date has shown the treatment success, measured by both treatment completion and specific outcomes are positively associated with school-based protective factors. Schools have a significant contribution to make to positive outcomes for young people who have displayed abusive sexual behaviour. Safety planning and risk management is key and specific resources are available to support this.

Inform Young People’s Programme

The Lucy Faithfull Foundation developed the ‘Inform Young People’ Programme for young people who have used the internet or new media in a way that may be harmful to themselves or others. It is an educative programme for 14 to 21-yearolds in contact with the police or other professionals following inappropriate use of technology, such as sending intimate images of themselves or the possession or distribution of indecent images of children, as well as other risky online behaviours. It aims to provide information, advice and support to young people and their parents, to help them devise strategies to prevent reoccurrence of concerning behaviours, and to promote safe and responsible use of technology. Referrals can be made directly by phoning or emailing The Lucy Faithfull Foundation. They can also provide training for professionals so they can deliver the programme.