Child Sexual Exploitation Prevention Strategy for the NHS in Wales

Transcription

1 Child Sexual Exploitation Prevention Strategy for the NHS in Wales Alison Mott and Lorna Price Designated Doctors, National Safeguarding Team (NHS Wales)

2 Aims Present Child Sexual Exploitation (CSE) Prevention Strategy for the NHS in Wales Pick up key themes Health risk assessment tools Partnership working Engaging with young people What next?

3 Why CSE Prevention Strategy for the NHS in Wales? Focus on Police and Children's Services in guidance Clarify health role while working in partnership Major public health concern which requires systematic approach to prevention and intervention Agreed and developed at All Wales Safeguarding Children Network

4 Prevention 1 : Where are we now? Role of Health Professionals In promoting the young person s health which includes identification of immediate and ongoing health needs, In offering support, counselling, and information to enable young people to understand the risks and develop strategies for staying safe Recognition and Referral 1 : Health professionals to identify and act on concerns Familiar with SERAF Risk Assessment Framework and actions in relation to each level of risk Involvement in child protection process 1 Health boards to identify a lead officer for CSE 2 1. Child Sexual Exploitation Safeguarding Guidance All Wales Protocol 2013

5 Definition CSE Child sexual exploitation is the coercion or manipulation of children and young people into taking part in sexual activities. It is a form of sexual abuse involving an exchange of some form of payment which can include money, mobile phones and other items, drugs, alcohol, a place to stay, protection or affection. The vulnerability of the young person and grooming process employed by perpetrators renders them powerless to recognise the exploitative nature of relationships and unable to give informed consent. All Wales Child Protection Procedures 2008

6 Children and young people who are sexually exploited may not recognise that they are being abused as they perceive the perpetrator as giving them something they need or want. This may change over time as the perpetrator s behaviour becomes more coercive, but fear of consequences may stop them from disclosing. AOMRC Child sexual exploitation: improving recognition and response in health settings 2014

7 Charlotte (sexually exploited at 13, interviewed at 23) I was only 13 and he treated me like a queen. He told me that he loved me, he made me depend on him. He made me believe that if he wanted to he could turn the sky black and he could make the sun shine or make it rain. He could do anything for me and he made me believe it. I made the mistake of telling him that I d been abused, you know, and that things were bad at home and stuff and he like reached into that and drew it out of me and like pulled on strings. More than one chance - young people in prostitution speak out.

8 Prevalence CSE is hidden, rarely recognised or identified The Inquiry into Child Sexual Exploitation in Gangs and Groups CSEGG 2013 : estimated that at least 16,500 children were at risk of child sexual exploitation in 2011 in England Barnardo s report Cutting Them Free (2012) estimated 9% of vulnerable children in Wales are at significant risk of CSE

9 Correlation between ACEs and CSE and Sexually Harmful Behaviour Taith (SHB) Seraf (CSE) Child Protection Register Exposure to domestic abuse 62% 43% 21% Reported sexual abuse 40% 29% 7% Reported physical abuse 38% 32% 16% Reported emotional neglect 55% 51% 38% Gwella project, Barnado s Cymru and CASCADE, Cardiff University: develop toolkit of evidence based interventions

10 National Action Plan to Tackle Child Sexual Exploitation (Wales) 2015 Prepare: getting the strategic leadership and tools in place Prevent: ensure preventative services in place Protect: quality assurance of the child protection process Pursue: disruption and prosecution of perpetrators and support of victims with child centred approach

11 National Action Plan to Tackle Child Sexual Exploitation (Wales) 2015 Review of the statutory CSE guidance Evaluation of the SERAF (Sexual Exploitation Risk Assessment Framework) assessment tool National data set to capture the profile, prevalence and response to CSE in Wales NHS Wales strategy is consistent with the National Action Plan

12 Child Sexual Exploitation Prevention Strategy for the NHS in Wales

13 CSE Strategy Aims To provide a framework for the strategic response by the NHS in Wales to identify and reduce rates of child sexual exploitation in Wales. To ensure the NHS in Wales contributes to effective multiagency and partnership working to protect children and young people from this form of abuse at a national, regional and local level. To ensure the framework aligns with the National Action Plan to tackle child sexual exploitation (Wales) 2015

14 What can we do to prevent CSE? Universal Primary Prevention for example, adolescent friendly health services, encouraging healthy relationships Selective Primary Prevention focusing on groups at higher than average risk, for example, support services to teenage mothers Secondary Prevention responding quickly when low-level problems arise to prevent them from getting worse, for example working with looked after children, sharing information Tertiary Help/Prevention responding when the problem has become serious, for example, child protection process, criminal justice Quaternary Help/Prevention providing therapy to victims so that they do not suffer long-term harm, for example, therapy for victims of sexual exploitation or therapeutic help for looked after children. Munro Review of Child Protection 2011

15 CSE Objectives and Action Plan Identified 8 objectives Linked action plan Priority action How we will do it Who will do it By when How will we know

16 Priority CYP Looked After Children Children with sexually transmitted infections Children who are pregnant Children with poor school attendance Children who self harm/have suicidal thoughts Children who abuse alcohol or substances Children with behavioural issues Children with learning disabilities Priority services General Practice Midwifery Health Visiting School Health Nursing Sexual Health Services Advice and Counselling Services Child and Adolescent Mental Health Services (CAMHS) Paediatric Services Substance Misuse Services Looked After Children (LAC) Teams Accident and Emergency Services Learning Disability Services

17 CSE Strategy Objectives PREPARE OBJECTIVE 1: The NHS in Wales will ensure that a range of organisational arrangements with strategic leadership and clear lines of accountability are put in place to evidence the effectiveness of the strategy and inform perpetual improvement Health Boards and NHS Trusts will have an identified CSE Lead within their safeguarding structure CSE outcomes incorporated into Safeguarding Children Quality Outcomes Framework

18 CSE Strategy Objectives PREPARE OBJECTIVE 2: The NHS in Wales will use existing local partnership arrangements including RSCBs (with social care, education, local business, housing, the police and criminal justice system, transport and the Third sector) to ensure activity on child sexual exploitation prevention is prioritised RSCB CSE/risky behaviour protocols implemented in Health Boards and NHS Trusts Health contribute to the evaluation of the effectiveness of RSCB action plans

19 CSE Strategy Objectives PREPARE OBJECTIVE 3: The NHS in Wales will continue to promote and support learning, information and monitoring systems and research to improve our understanding of child sexual exploitation and guide action Identification of best available risk assessment framework to be used in health

20 CSE Strategy Objectives PREVENT OBJECTIVE 4: Health professionals in Wales who work with families, children and young people will promote healthy interpersonal relationships to ensure children attain their health and developmental potential Delivery of effective universal and selective primary prevention in relation to CSE Provision of Emotional and Wellbeing services for young people with risky behaviours to provide early intervention and support

21 CSE Strategy Objectives PREVENT OBJECTIVE 5: Health professionals in Wales will have improved awareness, knowledge and understanding of child sexual exploitation through training Training for CSE is incorporated into existing safeguarding training for the NHS in Wales Update Level 1 and 2 Safeguarding Children E- Learning programmes to include CSE

22 CSE Strategy Objectives PROTECT OBJECTIVE 6: Health professionals in Wales will identify children and young people who are at risk of sexual exploitation and act to protect them Network involvement in Welsh Government review of SERAF Implement use of risk assessment framework in clinical practice

23 CSE Strategy Objectives PROTECT OBJECTIVE 7: Health professionals in Wales will provide support and treatment to children and young people affected by child sexual exploitation according to their needs with the aim of preventing consequent morbidity and re-victimisation

24 CSE Strategy Objectives PROTECT OBJECTIVE 8: Health professionals will work with police, social services and others by appropriately sharing information and contributing to a proactive, co-ordinated, multi-agency approach which will be effective in safeguarding children and young people at risk of sexual exploitation Contribute to the development of CSE information sharing systems

25 Key themes

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27 Risk assessment of CSE in health Dr Louise Cook Sexual Reproductive Health ABHB

28 Development of Health CSE risk assessment tool: why? SERAF assessment usually forms part of a multiagency response to a child protection referral. It can include information from different agencies e.g. Social services, education, police etc. In sexual health settings any risk assessment relies almost entirely on information provided by the young person themselves. A modified version of the SERAF comprising 28 items assessing CSE vulnerabilities and risk factors has been in routine use since The modified SERAF omitted items that clinicians working in health would be unable to answer. Even so, its wider use across other health settings has been limited due to consultation time constraints. A research project determined which of the 28 items best predict a young person, aged years, is at high risk of CSE.

29 School attended Sexual history Sexual behaviour Vulnerabilities Moderate risk indicators Action: when to refer Significant risk indicators Action: when to refer (AWC SERAF)

30 Child Sexual Exploitation Risk Questionnaire (CSERQ) Research Project Analysis of data from All Wales Clinical SERAF (13-17yr olds) used in sexual health 1595 female; 204 male Validating results Staff Survey ABUHB SRH Focus group with young people

31 AWC SERAF: Risk Level Figure 1: Risk level classification for female sample Not at risk Low risk Moderate risk Significant risk 1% 6% 43% 50% Figure 2: Risk level classification for male sample Not at risk Moderate risk 56% 1% 3% Low risk Significant risk 40% Females, n=1595 Males, n=204

32 Number ABUHB SRH Significant risk: age at referral yrs 12yrs 13 year 14yrs 15yrs 16yrs 17yrs

33 ABHB SRH Cumulative CSE referrals:

34 Top 3 items (88.7%) 1. Have you ever run away from home or gone missing over night or longer? 2. Does client have an older boyfriend /relationship with controlling adult? 3. Does client frequent areas known for on/off street sexual exploitation?

35 11 good predictors items 4. Disclosure of sexual/physical assault followed by withdrawal of allegation? 5. Have you ever met anyone you met on the internet? 6. Expressions of despair? (self-harm, OD, eating disorder, challenging behaviour, aggression) 7. Do you drink alcohol more than once a week or binge drink? 8. Does the client have low self-esteem? 9. Exclusion from school or not engaged in, unexplained absences from school? 10. Previous STI/pregnancy/termination of pregnancy? 11. Do you live with your trusted adult? 12. Do you have friends your own age and go out with them? 13. Do you have counselling or have extra help at school or elsewhere? 14. Does the person responsible for you have mental health/drug/alcohol problem?

36 Sensitivity and Specificity % 3 items 14 items Sensitivity (at risk) Specificity (not at risk)

37 External validation Analysis one Further sample 1645 AWC SERAF forms Top 3 and best 14 items performed well Analysis two 882 SERAF assessments completed by Barnardo's Cymru between 1 st April 2010 to 31 st July % high risk Top 3 and 13/14 best items performed well

38 Staff survey Percentage (%) Training helpful AWC SERAF: helps identify those at risk 2 7 Benefits outweigh time taken to complete 16 Phrasing of items difficult Difficult to decide whether to refer Clients reluctant to engage SERAF: detrimental effect on clinician/pt relationship Disagree/ Strongly disagree Strongly agree/ Agree

39 Focus Group 11 young people from Merthyr Tydfil Borough Wide Youth Forum August 2014 Caught in Traffick DVD Awareness/knowledge of CSE/supported Understanding of items How to phrase questions to make them user friendly

40 Have you ever run away from home or gone missing over night or longer? Have you ever stayed out overnight without permission (from parents or guardian)?

41 Does client have an older boyfriend / relationship with controlling adult? Are you in a (sexual) relationship with someone older than you? Does your partner stop you from doing things?

42 CSERQ4 questions CSERQ1 CSERQ2 CSERQ3 CSERQ4 CSERQ4 questions Yes / No Have you ever stayed out overnight or longer without permission from your parent(s) or guardian? How old is your partner or the person(s) you have sex with? Age of partner Age of client/patient Age difference If age difference is 4 or more years then answer YES Does your partner stop you from doing things you want to do? Thinking about where you go to hang out, or to have sex. Do you feel unsafe there, or are your parent(s) or guardian worried about your safety? ACTION: If one or more of CSERQ4 questions is answered in the affirmative then a child protection referral is indicated.

43 Difference in age (Female, n=1107; male n=83) Male Female n=71 (6%)

44 CSERQ15 CSERQ4 and 11 good predictor questions comprise the CSERQ15 assessment. The questions have been phrased to allow busy clinicians, particularly those who are less confident about assessing CSE risk, to be able to read straight from the page. This will enable a more systematic approach to question asking and lead to more consistent responses from the young people themselves. The format of the CSERQ15 has simplified both its incorporation into electronic records and its auditability. It is anticipated that child protection referrals will include responses to CSERQ4 questions together with remaining positive CSERQ15 questions plus other relevant issues.

45 Ongoing issues CSERQ based on SERAF which was validated in non health settings with high risk group Will CSERQ4/15 miss young people at risk? Young people decide what responses to give Feedback from referrals rarely received Service evaluation to check YP subject to CSE strategy meetings and attendance at SRH Feedback from young people CSERQ4 Potential for use in other services e.g. Primary care, A&E etc

46 CSERQ4/15 future plans Publication Complete service evaluation Target use to vulnerable young people It has been used successfully on pilot basis in maternity, ED and paediatric ward with YP who have self harmed Ensure Children s services informed

47 In summary The Child Sexual Exploitation Risk Questionnaire (CSERQ15), derived and validated in a sexual health setting in Wales, provides a pragmatic approach to assessment of a young person's risk of exploitation in Health settings The CSERQ4 has potential use in other services e.g. primary care, where there are often considerable constraints on consultation times.

48 Partnership working Operational Multiagency CSE teams including health Common standards Peer review Influences strategic group

49 Components of a good service Proactive RSCB Risk assessment tool Recording and information sharing Flagging of victims and perpetrators Daily governance of high risk cases Missing from home return interviews Close links with SARC Access to counselling/ therapeutic support Support during court process Children receive support post 18 Commitment to training Links to other partnerships

50 Young people hate being assessed: assessment needs to be a collaborative activity Current procedures/ services are not YP friendly

51 Health risk assessment The young people said that they wanted someone to notice that something was wrong and to be asked direct questions NSPCC report No one noticed, no one heard - a study of disclosures of childhood abuse (2013)

52 Bristol SCR feedback: messages from children to professionals Recognise that we don t see ourselves as victims, so we won t want to tell you or work with you. Don t see troublesome, see troubled, and stick with us. Don t be scared of breaking confidentiality, even if we tell you not to, if you think we could be at risk, but be aware that we are scared that if the information gets back to the perpetrators they will hurt us or our families. Examine us when we come asking for contraception at age 13/14, especially if it s an emergency appointment Don t be embarrassed to talk to us about sex, ask the difficult questions and keep asking if you suspect we may not be telling the truth think the unthinkable, not just underage sex.

53 Bristol SCR feedback: messages from children to professionals Bristol BASE (Barnardo's Against Sexual Exploitation) Hub and Spokes Project knows how to work with us, we can do things there and that makes it easier to talk. CAMHS just want us to sit and talk about what s happened which is too difficult. Our families need advice quickly about what to do if we go missing. If you don t trust us or don t think we re telling you the truth when we go missing, follow us. Don t pass us on or stop seeing us when we reach 18, we are often still vulnerable, and everyone changes over or stops at the same time. Give us help out of hours.

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55 Take home messages Young people must be at the centre CSE is complex, therefore the response cannot be simple or linear No agency can address CSE in isolation; collaboration is essential Effective services require resilient practitioners Action the strategy and share with partners

56 Future steps CSE Strategy Implementation Group 20 th July CSE Roundtable discussion chaired by Sally Holland 9 th June

57 Acknowledgements Dr Lorna Price Dr Louise Cook Damien Dallimore, Project Phoenix Dr Maria Bredow, Bristol All Wales Safeguarding Children NHS Network (Nigel Farr, Gaynor Johnson, Linda Brown, Janet Edmunds, Lisa Humphrey, Jean Beard, Sarah Russell, Lindsay Groves, Donna Newell, Jane Randall, Pauline Gallucio, Mary Morton)

58 Legislative context Children Acts 1989 and 2004 Underpinned by UNCRC Sexual Offences Act 2003 Social Services and Well-being (Wales) Act 2014 Violence against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015 Well-being of Future Generations (Wales) Act 2015