Preventing sexually harmful behaviour in children Sarah Andrews

Preventing sexually harmful behaviour in children Sarah Andrews Anglesey & Gwynedd LPHT sarah. andrews@nphs. wales. nhs. uk

What is the problem? Sexual abuse has affected around a third of the population, damaging physical & mental health: a prevalent problem A third of sexual offences are committed by under-18 s Children and young people with learning disabilities are more likely than other children to become: • Victims of sexual abuse/harmful behaviour • Perpetrators of sexually harmful behaviour Interventions have focussed on work with victims/potential victims, and have not been very effective

Self-portrait by a teenage pupil at a special school in Wales Laxton, J Sex education for children with disabilities. FPA Cymru 1995

15 case studies of sexually harmful behaviour by children with LD Mean age 14, oldest 21 (invited up to age 24) 14 male perpetrators, one female Harmful behaviour ranged from indecent exposure (n=4) to rape (n=1). Most involved sexual assault (n=10). Most cases included more than one incident. Schoolmates/peers were the most common victims (n=9), and school was the most common setting (n=8), especially in the toilets (n=6)

15 cases: problem behaviour A Ahmed Touched fellow pupils at school, boys at first then girls B Alan Got younger children to touch him, public masturbation C Andrew Touched girls at school D Clive Undressed and lay on top of his disabled sister in her bedroom E Daniel Befriended girls in a pub, touched them inappropriately F Fred Touched fellow pupil’s genitals; repeated stripping off own clothes G James Undressed & simulated rape of fellow pupil in school toilets H Joe Exposing himself on a housing estate, stealing underwear I Jon Raped lone-working care worker in individual care home J Kevin Touched younger boys at school and in the community K Martin Public masturbation at school L Mary Exposing herself, public masturbation, touching inappropriately M Neil Attempted rape of daughter of respite carer N Peter Took younger girl to his room in a respite unit, undressed her O William Had oral sex with much younger boy in shared school bedroom

Case examples Andrew (who has Asperger’s Syndrome and additional learning disabilities) was excluded from school at the age of 14 when he was accused of touching a female pupil inappropriately. Case study B: Andrew William (17) indecently assaulted an 8 year old boy John. William performed oral sex on John and forced John to do the same to him. They and two other boys were sharing a room in a residential school. William is now on the sex offenders register. Case study O: William

Analysis of case studies 3 types of analysis to identify types and location of potential prevention work: Beattie’s model of health promotion Tannahill’s model of health promotion (both to identify what kind of work might have prevented the harmful behaviour) Finkelhor’s concept of barriers to abuse (to point to where/with whom the work could have been done)

Analysis using Beattie framework Arena of health Relevant examples promotion activity (in Beattie model) Case A: Ahmed Prevention: what could have helped? 1 Health persuasion Individual authoritative intervention Objective knowledge Health education about appropriate behaviour rules SRE in general Ahmed needed all this, and much earlier: he was deaf and in a mainstream school 2 Legislative action Collective authoritative intervention Objective knowledge Sexual Offences Act 2003 Child protection legislation Education legislation SRE curriculum guidance Policies and procedures SRE curriculum needs to spell out the need for extra work with children like Ahmed who have difficulty understanding 3 Personal counselling Individual negotiated intervention Participatory, subjective knowledge Work on developing empathy Self esteem work Therapy on relapse prevention This was needed for Ahmed, but only because routine education was ineffective 4 Community development Collective negotiated intervention Participatory subjective knowledge Work with groups of YP and parents on how to meet needs for good education, services and protection, and seek help Community-based support work for BME parents of disabled children could have helped

Tannahill: Health Promotion activity types Type Relevant examples 1 Preventive services Child health services Care of looked-after children 2 Preventive health education Education for children and young people about: a) keeping safe and disclosing abuse b) consent rules 3 4 Preventive health protection Child protection services Health education for preventive health protection Staff training on child protection 5 Positive health education Lifeskills and relationships work with children and young people Sex and relationships education (SRE) 6 Positive health protection Policies and procedures to keep children safe from abusers 7 Health education for positive health protection Lobbying for good policies and procedures Staff training on healthy sexuality Prevention campaigns that encourage parents to seek help for children & YP with problem behaviour

Analysis using Tannahill framework Type of health Prevention possibilities for Ahmed promotion activity 1 Preventive services Earlier support on communication difficulties, both his deafness and not having a common language with his mother 2 Preventive health education Education about consent and keeping safe seems to have been missing for Ahmed. The victims seem clear on this though and report Ahmed’s assaults 3 Preventive health protection Child protection staff could explore concerns about Ahmed sharing a bed with his father 4 Health education for preventive health protection Staff child protection training should be sure to include cultural and disability issues 5 Positive health education Appropriate and understandable sex and relationships education is needed for Ahmed 6 Positive health protection Safety policies and procedures would not have helped much here 7 Health education for positive health protection Cultural issues could be a barrier to prevention work with Ahmed’s parents

Perpetrator Victim Adapted from Finkelhor (1984)

Analysis using Finkelhor model Locus of barrier Prevention possibilities identified The perpetrator: These elements were nearly all missing Internal inhibitors Such as: Protection from physical/domestic violence Knowing the rules of social and sexual behaviour Education to develop impulse control and victim empathy External inhibitors Such as: Family, friends, neighbours and professionals keeping watch Social pressure for acceptable behaviour The victim: Limited effectiveness in most cases studied here External protectors Such as: Family, friends, neighbours and professionals keeping watch Buildings and organisational structures designed for safety Internal protectors Such as: Knowing what is sexual abuse, that it is wrong and what to do if it happens Feeling confident about how to stop it or to get help

Results of the study Most sexually harmful behaviour carried out by these young people could have been prevented Prevention efforts should focus on potential perpetrators – work with victims alone would rarely have been effective (and these populations overlap) All types of health promotion can contribute Preventing domestic violence is important Sex and relationships education, especially on appropriate public and private touching, is urgently required in this population and is usually lacking Circles of support models look promising: supportive vigilance in communities around perpetrators

Wider conclusions Conclusions can be extended to – sexually harmful behaviour by non-disabled children – all sexually harmful behaviour – other types of crime prevention Valid to include levels of sex crime in local sexual health targets alongside STIs and teenage pregnancy

Dealing with sexually harmful behaviour What is needed by the child or young person now? Start with what provoked the behaviour: Lack of information? –About bodies & sex –About social rules Give information/education –Include social skills Distorted perceptions of sex? Awareness education Sexual frustration? Educate about masturbation Educate about & enable relationships Experience of abuse? Therapy What work can be done with other young people so this does not happen again?

Summary: levels of prevention Level Focus Primary prevention Secondary prevention Tertiary prevention Relevant examples Create healthy social conditions for all Target high risk groups Catch health problems early Limit the damage Respectful relationships Universal broad sex and relationships education (SRE). Universal protective legislation and action against abuse. Vulnerable people have extra education and protection to meet their particular needs. Disclosures of abuse made easy Community awareness of prevalence and seriousness of abuse and participation in safeguarding Careful enforcement of abuse legislation Extra education where gaps identified Appropriate therapy and support: prevent relapse