Letting the Future In

Tricia Jessiman, Research Associate in the School for Policy Studies, reports on a study of therapeutic support for children affected by sexual abuse.

It has at times felt difficult to keep up with overlapping high profile Child Sexual Abuse (CSA) scandals dominating the UK headlines in recent years. Jimmy Saville, Operation Yewtree, Rotherham, the ‘Westminster Paedophile Ring’ – the headlines have kept coming in. There has been rather less media coverage on the impact of sexual abuse on those children who experience it. The academic literature tells us that CSA is associated with a range of psychological and behavioural symptoms in both childhood and adulthood including post-traumatic stress (PTSD), depression, alcohol and drug misuse, suicide, and self-harming behaviour. Children who have been sexually abused need help – but it may not be readily available. The NSPCC’s current campaign, It’s Time, seeks to highlight the scarcity of therapeutic support in the UK for children who have experienced abuse.

Even were it more widely available, it is unclear ‘what works’. Research on the effectiveness of therapeutic support for CSA is limited. Colleagues in the School for Policy Studies have published two Cochrane systematic reviews of the effectiveness of therapeutic interventions. Geraldine McDonald led a review of cognitive-behavioural interventions (CBT), and concluded that “…CBT may have a positive impact on the sequelae of child sexual abuse, although most results were not statistically significant.” Most of the 10 studies in the review were American, and the most recent was published in 2004. William Turner’s review of psychoanalytic/psychodynamic psychotherapy for CSA failed to find a single study that met the inclusion criteria.

Hence we are delighted to see the publication today of our evaluation of ‘Letting the Future In’ (LTFI), a therapeutic service for children affected by sexual abuse. Led by Professor John Carpenter, the study was conducted with colleagues at Durham University and is the first impact evaluation of a therapeutic service for CSA published in over a decade. It’s also a rare example of the use of a randomised control trial in social work research with children and families in the UK (and we certainly learned just how much time, effort and goodwill is required to conduct one).

LTFI was developed by the NSPCC and at the time of the study delivered across 20 service centres in England, Wales and Northern Ireland. It is available to children aged between four and 17 without a diagnosed learning difficulty who have been affected by sexual abuse. Children are offered up to four therapeutic assessment sessions followed by up to 20 intervention sessions (extended up to 30 if necessary) with a children’s services practitioner (CSP). CSPs delivering the intervention vary in their background, training and experience but most commonly are qualified social workers with additional training in therapeutic work with children. At the same time, the child’s safe carer (typically the non-abusing parent, but sometimes a grandparent or foster carer) is offered up to eight sessions to help them process the impact of discovering that their child was sexually abused, and to support the child in their recovery.

We conducted a randomised control trial (RCT) with waiting-list control of LTFI, as well as a process evaluation of its implementation by NSPCC teams, and qualitative case studies with 15 children and young people who received the intervention. A total of 242 children took part in the RCT, making it the largest trial of a CSA intervention ever conducted. Three quarters of them were girls and most had experienced contact sexual abuse – inappropriate touching or penetration. Unlike the high profile headlines would have us believe, the children in our study were not abused by strangers or celebrities. They were almost twice as likely to have been abused by someone in their family as by someone outside it and in four out of ten cases where the perpetrator was known, they were also a child under 18 years of age.

The study confirms that children who have experienced CSA need support. When they were referred to LTFI, over half of the children and young people over eight years old in our study reported ‘clinical’ level scores on a standardized measure of psychological and behavioural symptoms, rising to 70% when one or more ‘significant difficulties’ were included. Parents/carers reported ‘clinical’ or ‘significant difficulty’ level scores for nine out of ten younger children under eight. Many of the children in our sample had also experienced three or more other types of victimization, such as physical and verbal abuse at home and bullying by other children, in addition to sexual abuse.

Did receiving LTFI help? We won’t give too much away, because the findings of the study are published today and we want you to read them. In short, the impact evaluation revealed that LTFI had a significant effect on older children and young people (broadly speaking, those aged eight years and older) after six months. The report provides a detailed account of the service delivered, the evaluation design and results, as well as details of how much it costs to deliver LTFI. It also has a strong service-user element; our qualitative research with children and their families who had received the intervention revealed that they valued it hugely, in particular the bond or ‘alliance’ that developed between NSPCC practitioners and the children. One of the young people we spoke who had this to say about LTFI:
“If you’re in a really bad place like I was, they will definitely bring you out of it and you’ll see there’s so much more to life. It’s probably one of the best decisions I made to do LTFI. Before I met them I was really quiet, withdrawn, wouldn’t really talk to anybody. Now since finishing with them, I’m such a more positive, outgoing person and I have a lot of confidence. They did their job.”

This blog post is based on Carpenter, J., Jessiman, T., Patsios, D., Hackett, S. & Phillips, J. (2016) Letting the Future In: a therapeutic intervention for children affected by sexual abuse and their carers: An evaluation of impact and implementation. NSPCC
https://www.nspcc.org.uk/services-and-resources/research-and-resources/2016/letting-the-future-in-evaluation

An engaging pilot study: How the PLAN-A study has been built on participant input.

Plan A logoDr Mark Edwards, from the Centre for Exercise, Nutrition and Health Sciences, discusses the value of participant inclusion in project implementation.

Physical activity is a big problem in the UK. We’re not doing enough of it. Lots of evidence suggests that when people are more active they are also healthier, have a greater sense of wellbeing, and help reduce their risk of future disease. So, why isn’t everybody active? This is a difficult question. We could ask why some people still smoke or why we don’t all eat a healthy diet. The potential answers to these questions are complex and multifaceted.

We do know a few things about physical activity however; firstly, females are less active than males at all ages. Secondly, adolescence is a key time when females become less active and the divide between males’ and females’ activity widens; around the beginning of secondary school. Thirdly, when adolescents stop being active, it becomes even more difficult to (re-)engage them. Fourth, being physically active is not a simple as it seems: the choice and ability to be active is wrapped in myriad social and psychological factors.

The PLAN-A team, led by Dr Simon Sebire at the University of Bristol’s Centre for Exercise, Nutrition & Health Sciences, hope to advance our understanding of how we can increase the physical activity of girls during early adolescence. We are testing the feasibility of increasing the activity levels of Year 8 girls (aged 12-13) through a ‘peer-led’ concept that has proved successful in reducing adolescent smoking rates (www.decipher-impact.com/). The basic concept of PLAN-A is: 1) ask all Year 8 girls in a school to nominate who they think are the most influential girls in their year, 2) recruit the top 15% of the girls nominated to attend a training course to be a peer-supporter, 3) train peer-supporters to recognise the importance of being active, how they can overcome barriers commonly faced by teenage girls and incorporate more activity into their friends’ lives, and how to communicate effectively, and 4) send the girls  back to their peer groups to informally encourage their peers to be more active.

A central belief that underpins PLAN-A is that the people taking part – the girls whose behaviour we are trying to change and, to a lesser extent, the trainers who will train the girls – are best placed to know what will work for them. Despite having a diverse range of experience in our team, we are not Year 8 girls, and as such can only go so far to develop an educational experience that meets their expectations. If the PLAN-A intervention is to help increase the physical activity levels of Year 8 girls, it needs to reflect what they find important, speak their language, engage and enthuse and inspire them to encourage their friends to be active. As such, we have continuously engaged our “end users” in the design of the PLAN-A study, as can be seen in the following narrative.

Our stakeholder engagement started when the grant application was being written. A group of adolescent girls from the DECIPHer ALPHA (Advise Leading to Public Health Advancement) group took part in a focus group and gave valuable feedback on the design of a peer-led activity intervention. The intervention we designed expressly adhered to the girls’ suggestions that the training should focus on health, vitality and enjoyment. The girls also wanted the training to equip them with practical skills. We took what the girls said and edited the training and recruitment materials in light of this.

Before we conducted the ‘feasibility’ study we wanted to explore the materials and training we had developed in light of the DECIPHer ALPHA group’s suggestions with more year 8 girls. We hoped that this would provide a further opportunity to tailor the intervention to their preferences. A school in Wiltshire kindly allowed us to pilot the whole of the PLAN-A intervention with their Year 8 girls. As such, we tested the recruitment, peer nomination, pupil briefings and training with these girls. The process was interesting, a little reassuring, and hugely constructive. Children can be good critics!

In total we conducted six focus groups with the Year 8 girls. The first two focus groups sought feedback on our proposed peer-supporter recruitment and training materials, including the study logo. We mainly wanted to know if what we were proposing appealed to Year 8 girls. Although we weren’t too far off, we redesigned elements of the intervention and then invited the girls to two more focus groups to check whether we had done what they asked. Following a few more revisions based on their input, we felt we were ready to rehearse the intervention.

We ran a pilot recruitment drive, which entailed a presentation to all Year 8 girls and an information pack for themselves and their parents. This went well and 95.7 % of girls in the year wanted to take part. We then conducted the peer nomination with the year group. This provided the chance to test the nomination process out. Again, this went smoothly and a few days later we invited the girls who had been nominated as peer supporters to a briefing session. As they suggested in the earlier focus groups, the girls were reminded of the kudos of being identified as one of the most influential people in their year group. Of the 14 girls who were nominated, 12 attended the training.

In the meantime we trained our PLAN-A trainers – the two people who would be training the peer supporters. The trainers received a training course (run by study staff) and then delivered the peer supporter training. We had an experienced observer sit in and watch the training to help identify any issues that may not be apparent to the trainers (and to also check that everything flowed as planned). Immediately after the training, we interviewed each trainer and conducted two focus groups with the girls who took part. We wanted a ‘warts and all’ account of their experience with PLAN-A, and that’s what we got!

In general the girls loved the training (and their trainers). The biggest issue was that there was too much writing and not enough moving. The trainers largely agreed with the girls and raised similar issues. We took this feedback and used it to change as many activities as possible to reflect what the girls wanted. We revised the activities and now have a “final” intervention package that targets the intended learning outcomes using much more activity, less writing and sitting, and more role play. We will be delivering the intervention over the next few months and will, once again, seek detailed feedback on how this was received by the people taking part.

 

This project is funded by the National Institute for Health Research [Public Health Research Programme] (project number 13/90/16). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR PHR Programme or the Department of Health.