1. Commissioning Specialist Provision for Young People with Harmful Sexual Behaviour: Using Assessment and Theory in Practice to Ensure Value for Money 1

2. Introductions Kevin Gallagher – Social Worker (Residential Care) – Psychodynamic organisational consultant – Managing Director Michelle Russell – Forensic Psychologist – Therapeutic Community Specialist Amberleigh Care – 2 x residential intervention services (Therapeutic Communities) – 2 x fully registered schools – In house, multi-discpilinary clinical team. – Specialists in/ focussed on Harmful Sexualised Behaviour – Males, 11-18 on admission 2

3. Aims for Today Understanding Harmful Sexualised Behaviour Prevalence and trends Assessment Model Intervention Framework Example in practice Questions 3

4. Definition 4 “Harmful sexual behaviour involves one or more children engaging in sexual discussion or acts that are inappropriate for their age or stage of development. These can range from using sexually explicit words and phrases through to full penetrative sex with other children or adults” (Rich,2011)

5. Residential Care 5 Residential care is not a single entity – is a segmented sector: a continuum of different shapes and sizes of placements, with different features and structures, using different theoretical models to respond to specific child needs. Use of residential placements is now on the increase after several years of decline but the complexity of use has increased There is a spread of fees/costs – so value has to be determined on the input, model, interventions and effectiveness for the specific client group

6. Referral Context 6 Young people displaying inappropriate, problematic or harmful behaviour – often surfaced in younger years Breakdown in family, foster care, residential placement or residential school. Problematic behaviours, but no justice interventions Offending – referral pre and post court processes We contribute to pre-sentence assessments and reports We provide a non-custodial sentence placement and we also provide placement for young people released on licence from a custodial sentence

7. Prevalence 7 30-35% of sexual assaults are committed by under 18s (Home Office). Note: this only counts those in the criminal justice arena No under 10’s are counted (age of criminal responsibility) Significant under reporting, missed or not recognised 5% of children have experienced sexual contact (Radford et al, 2011) 90%+ were abused by someone they knew 34% of victims of adults did not tell – 83% of peer victims did not tell

8. Local Authority Placement Demands 8 Almost without exception, Local authorities are experiencing an increase in demand for care placements for children over 13 years with complex needs including sexualised behaviours. (DfE June 2015) 22.1% of residential placements across 4Cs (Wales) authorities were for HSB (Data 31 st March 2015) Of which – 66% SEN, 47% self harm, 38% mental health needs, 26% CSE – these are young people with multiple needs Residential care should be categorised in 3 ways: standards services commissioned locally, more specialised care, likely to be commissioned regionally, complex needs and specialist intervention – high acuity/ low volume, to be commissioned regionally or nationally. (What Work in Residential Care, 2012) This required a standardised “audit” of need across the UK. “all consortia admitted they had struggled to establish a regional needs analysis” (DfE June 2015) Commissioners felt they had good local knowledge of services in their area, but there is virtually no communication between regions so that specialist services can be more widely known about

9. Initial Checklist 9 Type of behaviour Context Young persons response Response of others Relationship between parties/ young people Persistence Other behavioural problems History and background

10. Harmful Problematic Healthy/ OK Small Group Exercise

11. Scaling Summary 11 HEALTHYPROBLEMATICHARMFUL Mutual Consensual Choice Exploratory No harmful intent Fun No power differentials Not age appropriate One-off incident or low key touching over clothes Peer pressure Spontaneous rather than planned Other balancing factors: level of understanding, acceptance of responsibility, no harmful intent Other children irritated/ uncomfortable but not scared….no secrecy Not age appropriate Elements of planning, secrecy, coercion etc Power differentials – age, size, strength, status Blames others Frequent incidents, increasing escalation Not easily dissuaded, entrenched, compulsive Other difficult behaviours – conduct, anger, poor peer relationships

12. Healthy 12 Mutual Consensual Choice Exploratory No harmful intent Fun No power differentials

13. Problematic 13 Not age appropriate One-off incident or low key touching over clothes Peer pressure Spontaneous rather than planned Other balancing factors: level of understanding, acceptance of responsibility, no harmful intent Other children irritated/ uncomfortable but not scared….no secrecy

14. Harmful 14 Not age appropriate Elements of planning, secrecy, coercion etc Power differentials – age, size, strength, status Blames others Frequent incidents, increasing escalation Not easily dissuaded, entrenched, compulsive Other difficult behaviours – conduct, anger, poor peer relationships

15. The Key Local Authority Questions: 15 Why has this happened? How can we reduce the risk of this happening again? The answer to both questions is the same – HSB is a dysfunctional response and coping mechanism to a combination of underlying trauma, abuse, poor parenting, domestic violence, poor self image and esteem, poor emotional regulation Each individual history explains WHY and informs the intervention required to address needs to REDUCE RISK These intervention needs will often be layered and require a systemic approach

16. Myth Busting 16 Most adolescent males who sexually abuse have NOT been sexually abused However they are 5x more likely to have been sexually abused (Seto and Lalumiere, 2010) The vast majority of adolescent abusers have been victims of physical abuse, emotional abuse, poor parenting, loss, trauma, rejection etc ( Yates, 2012) Children under 12 who abuse are 2x as likely to have been sexually abused or live in environments with poor sexual boundaries. Female abusers – the majority if not all have experienced sexual abuse – this is likely to have been more repetitive and severe than young males (Kubik et al, 2002) There can be an over/ higher representation of adolescents with LD – lack of sex education, lack of sophistication, more impulsive, more likely to admit, higher supervision (and detection) – warning: reduced research in this area, social and professional resistance to acknowledge

17. Assessment 17 Assessment is a dynamic process, it need to use a range of tools for different purposes – baseline, profile of needs, intervention targets. What are you measuring and why? They need to be developmentally appropriate and selected for suitability to client group Some are for large data collection trends, some are for progress measurement over time, some are pre/post specific intervention – understand how you will use what the data tells you

18. Amberleigh Assessment 18 We use a selection of tools and risk assessments which follows the Independent Childrens Homes Assoc (ICHA) recommended approach to assessment – capturing data in 3 strands. TSCC Trauma Checklist WISC Becks Youth Inventory HoNOScA AAB Educational SAVRY Resiliency Scales AIM2 SDQ Locus of Control BROADPROFILE SPECIFIC ACA Assessment Checklist (Adolescents)

19. Intervention Framework 19 The Good Lives Model is the most researched and supported intervention framework for adolescents with HSB. Developed from adult treatment it has been adapted for adolescent intervention and can be used in residential, fostering and field settings (Ward et al 2007) Resilience, strengths based and built on positive psychology and psych-social approaches.

20. GLM - Overview 20 Offending is a dysfunctional way of meeting emotional and psychological needs. Building pro-social strengths and capabilities reduces risk. Multi-tool assessment, including AIM2 gives a detailed profile of strengths (to use as protective factors) and deficits to work on. Specific therapies then deal with individual defence mechanisms or specific areas of need (e.g. distorted thinking, anger management) The framework considers the young persons risk, strengths and needs ( in the context of their history) through 6 PRIMARY NEEDS Being Healthy Having fun and achieving Being my own person Having a purpose/ making a difference Having people in my life Staying safe

21. Models in Practice We operate the GLM as a framework to understand sexualised behaviour and deliver interventions in a formal group living environment – a Therapeutic Community (TC) The TC is itself a relationship based approach to living and learning that offers containment and boundaries and the support to develop resilience and pro-social skills through structured interaction with others. This is a systemic mix of Care, Education and Therapy – but the TC itself is part of the therapy within which specific intervention work is undertaken Specific therapeutic input consists of:  1:1 Therapy  Group work  Daily community meetings 21  Staff team consultation  Staff dynamics/ group supervision  Staff Training

22. 22 Golfa Hall

23. 23 A Systemic Structure of Theory to Practice Good Lives Model Formal Therapeutic Community Quarterly Intervention review: Refinement, measurement & progression 12 Week Assessment Care Education Therapy Psychosocial CBT Psychotherapy EMDR Schema Focussed Family work Staff Consultation Staff Training

24. Audit and QA 24 A therapeutic community is a formalised environment in which psycho- social interventions can be applied. We follow external Therapeutic Service Standards (Children and Young People) which are overseen by the Royal College of Psychiatry We develop a portfolio of our TC records and activities which looks at all aspects of our functioning and we are externally reviewed/ audited each year

25. Does it work? 25 Glebe House (The only other TC for this client group in the UK) has a 10 year research study which adopts Randomised Control Study methodology. This demonstrates effectiveness. Young people typically stay 2-2½ years, depending on their age at admission. This is usually about finishing their education and developing independence skills. Move on: – 1/3 rd of young people return to family – 1/3 rd move to independence – 1/3 rd transition to adult services (LD) In 11 years of operation we are not aware and have not been contacted for follow up information in relation to any young person committing sexual offences after placement.

26. Measuring Effectiveness 26 We are now engaging with a university partner to undertake a formal follow up study of previous placements N = 37 One way we regularly monitor and track a young person’s progress is using the Outcome Rating Scale (ORS). We use the Session rating Scale (SRS) to measure the therapeutic alliance. The ORS and SRS were introduced in 2000. Research demonstrates impressive internal consistency and test re-test reliability (Campbell and Hemsley 2009) ORS and SRS are a natural fit for collaborative clinical practice. Gives young people a voice in their intervention.

27. 27 Case Study

28. Overview 28 Understanding Harmful Sexualised Behaviour Prevalence of sexual offending and behaviours and placement trends and requirements Assessment Model – how to use a defined selection of tools and assessments to inform intervention and placement tracking. Intervention Framework – The Good Lives Model Applying this in a Therapeutic Community setting using a systemic approach. QA and effectiveness

29. References and Links 29 “The Good Lives Model for Adolescents Who Sexually Harm”, Ed. Bobby Print, The Safer Society, Vermont, 2013 www.goodlivesmodel.com “Children and Young People with Harmful Sexual Behaviours – Research Review), Prof. Simon Hackett, Research in Practice, Dartington, 2014 National Organisation for the Treatment of Abusers – www.nota.co.ukwww.nota.co.uk Training in Good Lives Model and AIM2 assessment: www.g-map.orgwww.g-map.org Information on the evidence base for Therapeutic Communities: www.therapeuticcommunities.org www.therapeuticcommunities.org Glebe House Research: http://www.ftctrust.org.uk/research.php http://www.ftctrust.org.uk/research.php Information on the quality audit and standards for Therapeutic Communities: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditati on/therapeuticcommunities/communityofcommunities.aspx http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditati on/therapeuticcommunities/communityofcommunities.aspx