Child Sexual Abuse

Informing Practice from Research

David Jones, Paul Ramchandani

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9781315348445
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Child sexual abuse is widespread and often an element of many other social difficulties. This book outlines a number of different ways professionals can help, particularly focusing on the role of social workers and mental health professionals. It describes how professional intervention can improve the outcome for sexually abused children and their families. It is based on extensive evidence-based research and includes summaries of the implications for practice. Funded by a grant from the Department of Health and reviewed by an expert advisory group, this book covers the child protection process and psychological treatments in a clear and accessible format.

Chapter 1

Introduction

In this book we identify and summarise selected key research findings on intervening with sexually abused children, their family members and alternative carers. These have implications for practitioners, their managers, and planners and commissioners of services. Throughout, we have emphasised an evidence based approach to this crucial work. Research should support practice, not dictate it, and the hope is that this review will aid practitioners in their work. The best use of research is to examine it critically for oneself and take out the messages that are most helpful to practice. We hope that this review will facilitate this process for practitioners and their managers.

When a child is identified as having been sexually abused it is rarely found to be the sole problem, and a range of coexisting family based difficulties is a common finding. Problems such as domestic violence, parental mental illness, substance abuse, and parenting problems including physical abuse and neglect, pose additional challenges for effective intervention. However, not all child victims are abused within families, many being abused by known but trusted figures within the neighbourhood or in out-of-home care. In these circumstances too, coexisting difficulties abound. The cost of not intervening is great in terms of damaged development, personal difficulties for the abused child in adult life and, for some, the move to being an abuser of other vulnerable children.

There is no simple theory or model with which to explain either the occurrence or the consequences of child sexual abuse. However, there are frameworks that can prove helpful. The ‘developmental ecological’ perspective, widely accepted, is particularly useful. It is explained in detail elsewhere, but briefly it has two broad themes, developmental and ecological, as follows.^{1, 2 and 3}

The first is the developmental one, which stresses that the child becomes increasingly organised, integrated, yet more complex as an individual as he or she grows up.⁴ There are many influences on this process, amongst them genetic, physical, psychological, and family influences, as well as wider neighbourhood and cultural influences. Traumatic events, such as child sexual abuse, can lead to disruption and derailment of the process of normal development. Subsequent influences on the child can either be ameliorating or further potentiate the effect of early damage.

The second theme in this model is the ecological one. This considers the child within their environment surrounded by layers of successively larger and more complex social groupings, which have an influence on him or her. These include the family and extended family, friendship networks, school, neighbourhood, and work influences, and the family’s place within the community. Still wider is the influence of the culture within which the family live. These are shown in Figure 1. As well as this, both the child and their parent influence the outcome of events via their personalities and social functioning.⁵ In fact, parents have one of the greatest relative influences within this model.

Several important implications flow from this perspective. One is that dissimilar pathways can arrive at similar destinations in terms of the effect upon the developing child, and conversely similar pathways can have quite diverse outcomes. Secondly, the perspective reflects the understanding that development is a process which involves interactions between the growing child and his or her social environment. Thirdly, while the experience of a phenomenon such as child sexual abuse can damage a child’s development, change is still possible in many different ways. Therefore, the range of positive and negative influences are important to consider when examining the occurrence, or looking at the outcome, of an influence upon children, such as sexual abuse.

Figure 1 A developmental and ecological perspective on child maltreatment.

Once abuse has occurred, there are a number of intervening factors which influence outcome. These include the individual child’s coping skills and strategies, parental and family support, and societal influences including the impact of child protection procedures and, where offered, psychological treatments. Each of these factors may have a beneficial effect or may worsen outcome for the child and their family. It is these intervening factors, and particularly the child protection process and psychological treatments, that we focus on in this book, with the aim of helping practitioners and their managers achieve the best outcome for sexually abused children and their families.

Methodology

Our aim has been to gather together the currently available research (both published and unpublished) and to draw out those key findings which have relevance to those professionals working with children and families where a child has been sexually abused.

In deciding how far to search for evidence we divided the area up into two (see Figure 2). The first covers broad issues in child protection, including the formal child protection process, and the contextual setting within which this operates. The second area focuses particularly on psychological treatments. We have adopted a differing approach to the way in which we have searched for and included studies in the two areas.

1 The child protection process

The system of child protection practice varies from country to country around the world. Whilst some similarities exist, the differences can be large. As a consequence, we have focused on literature from the United Kingdom when considering this area, as this seemed of most relevance to UK practitioners. In this we have drawn largely on the research initiated and funded by the Department of Health as part of the ‘Studies in Child Protection’ series.^{6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17} Good quality research into the UK system of child protection has been sparse, and the included studies constitute a large proportion of this. Not all of these studies focus exclusively on sexual abuse, but where possible we have drawn out those findings that pertain particularly to this form of abuse.

Figure 2 Methodology: dividing the process.

2 Psychological treatments

In recent years there have been notable trials conducted examining therapeutic help for children and families following disclosure of child sexual abuse. These have predominantly been conducted in the United States, although there have been some UK based trials. In searching for trials in this area we have attempted to include all the treatment studies which are of a randomised controlled or controlled design. As a starting point we have used the excellent review of Finkelhor and Berliner.¹⁸

From there we have searched Medline and other bibliographic databases using standard searching methods in collaboration with librarians in Oxford.¹⁹ We have retrieved references from papers and books and contacted principal researchers and experts, both in the United Kingdom and the United States. We have examined abstract books from recent international conferences. From these efforts we have gathered and read a wide range of material.

Appraising the evidence

We have critically appraised each individual study for its methodological strengths and limitations in order to be able to place appropriate weight and confidence on its findings. To do this we have used standard critical appraisal formats, the exact one depending on the study design. For quantitative studies we have used the ‘Users’ Guides’ developed at McMaster University,²⁰ and for qualitative studies we have used the guidelines prepared for the Journal of Evidence-Based Mental Health.^{21, 22} This has given us a firm basis for extracting key relevant findings for this publication.

Strengths and limitations of this book

As we have critically appraised the research, it seems only fair that we should be explicit about the strengths and weaknesses of our own work in this book.

This is not a summary based on all the available evidence. Given a time limit, choices have had to be made about the most fruitful sources of information. In our writing about treatment options we feel we have overcome this as far as is possible by searching thoroughly for all available controlled trials. However, there are other areas of practice which we have not been able to address fully, either because the research evidence is lacking, or because of limitations of space. One area we have excluded is the important field of work with abusing adults and juveniles, as this fell outside the remit of our study. Another important omission is a consequence of the way in which issues such as ethnicity, culture and learning disability are not addressed thoroughly by the bulk of the research. This means that within this review we are unable to discuss these issues as fully as they warrant given their key importance within the context of child protection.

Any research, particularly in the qualitative field, must consider issues of bias. We are both medical practitioners, and inevitably this will influence the topic areas of particular interest to us. We have tried to overcome this by using standardised selection and appraisal criteria for the projects we have studied, and by checking our criteria and appraisals with the authors of the original research studies. In addition, we have looked particularly for findings that are consistent across studies.

The review ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Acknowledgements
• 1 Introduction
• 2 Background (family) factors in child sexual abuse
• 3 Associated problems for a child who has been sexually abused
• 4 Referral and early planning
• 5 Investigation and initial assessment
• 6 Child protection conference
• 7 Comprehensive assessment and planning
• 8 Implementation, review and deregistration
• 9 Psychological treatments
• 10 Measuring outcome
• 11 Conclusions
• 12 Implications for practitioners
• References
• Appendix A: Department of Health funded projects
• Appendix B: Summaries of studies
• Appendix C: Glossary of terms
• Index