Identifying and assisting adults affected by sexual abuse and exploitation Dr C. S. Mizen MBBS FRCPsych. Exeter
Covering: The presentation of child sexual exploitation in adulthood through a wide variety of health scenarios The importance of good communication and engagement skills with hard-to-reach adults The importance of information-sharing The duty to share information can be as important as the duty to protect patient confidentiality (Caldicott 2, principle 7) The need for knowledge of local safeguarding and referral and care pathways and for commitment to working within multi-agency approaches to tackling child sexual exploitation Support for provision of supervision and support to frontline staff in dealing with complex and distressing cases
Sexual abuse and exploitation and adult mental health: Stress and the developing brain Persistent Fear Response. (Perry, 2006). Chronic stress or repeated trauma. Persistent fear state activation of HPA axis- a cascade of changes Attention, impulse control, sleep, and fine motor control (Perry, 2000a; 2000b). Hippocampal damage impaired cognition and memory (Perry, 2000b, Putnam, 2006). Shape perception of and response to the environment. Hyper arousal and sensitivity to non-verbal cues
Adult Mental Health: Attachment Disrupted attachment may lead to impairments in three major areas for the developing child (Cook et al., 2005): Increased susceptibility to stress Excessive help-seeking and dependency or excessive social isolation Inability to regulate emotions Children with insecure or anxious attachments have more difficulties regulating their emotions and showing empathy for others' feelings (Applegate & Shapiro, 2005).
Adult Mental Health: Dissociation Victims may smother the memories of parental abuse to preserve attachment, resulting in amnesia for the abuse (Stien & Kendall, 2004). However implicit memories remain, triggering flashbacks or nightmares. Still controversial diagnosis of dissociative identity disorder. The more severe the abuse the greater the probability of psychiatric disorder in adulthood (Fergusson, Horwood and Lynskey, 1996, Mullen, Martin, Anderson, Romans and Herbison 1993.)
The long term effects of CSA/E Child abuse may have a causative role in the most severe psychiatric conditions. (Fergusson et al, 1996; Mullen et al, 1993). (Fergusson & Mullen, 1999; Walsh, Fortier, & DiLillo, 2010). Kendler et al. (2000), studied1,411 twin pairs, reported significant odds ratios for a range of psychiatric disorders in sexually abused women after controlling for family environment. The effects were strongest for drug and alcohol dependence and bulimia nervosa. As many as 80 per cent of abused young adults met the diagnostic criteria for at least one psychiatric disorder at 21. These included depression, anxiety, eating disorders, and suicide attempts. Silverman et al (1996), Around 50 per cent of adults receiving mental health services report abuse as children: 50 to 60 per cent of psychiatric inpatients 40 to 60 per cent of outpatients report childhood physical or sexual abuse or both. (Read, 1998).
CSA / CSE and Mental Illness Negative mental health effects consistently associated with child sexual abuse include: Post-traumatic symptoms (Canton-Cortes & Canton, 2010; O'Leary & Gould, 2009; Ullman,Filipas, Townsend, & Starzynski, 2007); Depression (Fergusson et al., 2008; Nelson et al., 2002); substance abuse (Lynskey & Fergusson, 1997; O'Leary & Gould, 2009); Helplessness, negative attributions, aggressive behaviours and conduct problems; eating disorders (Jonas et al., 2011); Anxiety (Banyard, Williams, & Siegel, 2001; Nelson et al., 2002). Personality disorders (Cutajar, 2010b, Zannarini). More recently CSA has been linked to psychotic disorders including schizophrenia and delusional disorders (Bendall, Jackson, Hulbert, & McGorry 2011; Lataster et al., 2006; Wurr & Partridge, 1996) Child sexual abuse involving penetration has, in particular, been identified as a risk factor for developing psychotic and schizophrenic syndromes (Cutajar et al., 2010a).
Personality Disorder and secure services 91% of patients with BPD report sexual abuse. (Zannarini et al 1997, 2000) Severe and complex PD: Severity (Risk) Complexity (ED, Substance misuse, Somatisation, ASD) Tier 4 PD estimated 400 3000 patients The Children s Commissioner If Only Someone had Listened. Young women(u18) in secure settings with emerging personality disorder correlated with sexual abuse and gang related activity and exploitation.
Devon out of area patients Number of patients 60 CSA within the family 32 (CSE 6) CSA extra-familial 7 No CSA 5 Don t know 7
CSA/CSE and Suicide Sexual victimisation, both in childhood and beyond, is a significant risk factor for suicide attempts and for (accidental) fatal overdoses. (Briere & Zaidi, 1989; Fondacaro & Butler, 1995) More recent studies using large-scale data sources or longitudinal designs, reported significant links between CSA and later suicidal behaviour or ideation (Dube, Anda, & Whitefield 2005; Fergusson et al., 2008; Molnar, Berkman, & Buka, 2001). Mental health disorders, including suicidality, 2.4 times higher in children exposed to CSA involving attempted or completed sexual penetration than in those of children not exposed.
Exceptions Not all victims of child sexual abuse develop mental health problems in adulthood. Lynskey and Fergusson (1997), reported one-quarter of those exposed to child sexual abuse in their cohort study, did not meet the criteria for any psychiatric diagnoses or adjustment difficulties in early adulthood. However, it is important to be alert to sleeper effects, problems emerging later in life or triggered by significant life events. McLaughlin et al. (2010) found, for example, that both men and women with such adversities in childhood were more likely to have psychiatric disorders when exposed to stressful life events in adulthood than those without such early adversities.
CSE/CSA impact in physical health in adulthood. Negative effects arising from physical trauma Adults, maltreated as children show increased, heart disease, cancer, chronic lung disease, and liver disease. 74- to 100-percent higher risk of hospital treatment (Lanier, Jonson-Reid, Stahlschmidt, Drake, & Constantino Journal of Pediatric Psychology, 2009) Increased high-risk behaviour such as smoking, substance abuse, overeating, and sexual risk-taking.
Summary: Impact on adult mental health The whole person is affected, not PTSD alone Those effected more severely are likely to come into contact with MH services and require whole system intervention They present MH services with particular challenges: Addressing their mental health needs Providing therapy Dealing with disclosure Assessing capacity
Addressing mental health needs
Evidence Simple Trauma (PTSD Nice Guidance CG26 (2005)) Trauma Focussed CBT and EMDR Medication second line 50% have comorbid affective disorder, anxiety and substance misuse Complex Trauma (dissociative subtype in DSM 5) ISTSS Expert consensus Treatment Guidelines for Complex PTSD in adults. 2012 Nine studies, No RCTs Phase 1 Phase 2 Ensuring safety, reducing symptoms, psycho-education Skills based interventions and mindfulness Focus on unresolved trauma. Individual and group therapy. Verbal and art therapy For severely impaired patients treatment of several years may be needed. 3-6 m 3-6 m Phase 3 consolidation and transition 9-12 m
Pathways Tier 1 Primary Care and Community services Family interventions and IAPT (See Case Study 1 Trowell 2002) Work with offenders (See Case Study 2 Vizard 2009) Tier 2 Secondary Mental Health KUF and trauma training for mental health professionals Timely access to a range of trauma focussed therapies Tier 3 Specialist Complex trauma services and PD services Interventions up to 3 years Tiers >4 Locked and secure services.
Funding PD and trauma pathways 40 35 30 25 20 15 10 Repatriations Total placements Repatriations New placements Repatriations Discharges 5 0 Fig. 2
Dealing with Disclosure
Communication and engagement: Dealing with the consequences of disclosure External anxieties Threats from abusers Loss of family relationships Loyalty to abusers within and outside the family Loss of control Likelihood of prosecution Training of professionals Internal anxieties Exacerbating dysregulation Exacerbating PTSD Internalised abusive figures Auditory Hallucinations Pathological Organisations
Supporting teams
Supporting Teams: Psychodynamic Formulation and reflective practice
Dilemmas in confidentiality and information sharing The duty to share information can be as important as the duty to protect patient confidentiality (Caldicott 2, principle 7) Fantasy, impaired reality testing, attachment and disclosure Miss A
Dilemmas regarding capacity Miss B