BLOG PODS #49 - HSB Practice Lessons #2 - Lean in, Empathise & Be Kind
INTRODUCTION
In our last post we began looking at some practice lessons for working with harmful sexual behaviour (or HSB) in children and teenagers - this came off the back of a book chapter I co-authored with my fellow HSB specialist, Sharron Wareham.
The points we drew out in the first post were:
- Keep in mind that age is not the same as maturity
- Harmful sexual behaviour is often developmentally out of sequence
- The victim/perpetrator split is a false one, and…
- Behaviour has a function, even when it is harmful.
Here are the remaining 5 practice lessons. As always, please bear in mind that these are the things that came to mind when I was drafting these posts; they are by no means exhaustive - but I hope they’ll be helpful.
HSB Practice lessons (cont’d.)
5. Punishment rarely leads to safety or change
A strong theme in our chapter is the damage caused by punitive responses.
When it comes to punishment, the obvious candidate is the criminal justice system (CJS); that, at least in part, is its function - to meet out justice implies the victim is recognised as such and the offender punished. But other responses to HSB in children can be equally if not more punitive than prosecution.
I’ve lost count how many kids suffer what can only be described as ‘punishment’, but not from the CJS; for example:
- Being labelled inside and outside the family as some kind of weirdo, paedo or countless other pergoratives.
- Being made to leave their home in order to protect others, albeit that one or some of those same ‘others’ may have been abusing the child for years.
- Being kicked out of school and thus bereft of the routine, stability, friendships and positive adults it offers - again usually due to some malformed concept of ‘being risky’ to other kids.
…and on it goes. While we-the observing adults-may not see these things as punishments per se, that’s absolutely how children see them. Or certainly, it’s how they feel them. Some of the trickiest hurdles I’ve had to deal with in the treatment of HSB in children, are the complex grief, resentment, bemusement and/or utter rejection felt when these things happen.
Perhaps the greatest argument for the suspension (if not outright rejection) of the punishment paradigm, is the distraction it becomes to the treatment process itself. I’ve found myself spending weeks and weeks helping a child navigate the confusing vagaries and painful disruptions of things other than the behaviour itself. While these things happen because of the HSB, they also distract terribly from it - so the child’s focus moves from what really matters, the roots and meaning of the HSB, to the reactions of others to it. **
It’s worth noting, also:
- Most children with HSB do not go on to do so again once it’s been discovered and treated*
- Outcomes improve significantly when children receive timely, appropriate help and see treatment interventions through (rather than dropping out - this is a risk factor)
- Criminalisation often increases shame, isolation and distorted beliefs and adds nothing to the treatment process.
- But treatment doesn’t require criminal prosecution in order to happen (depending on the availability of local services to intervene effectively).
The worst case scenario is punishment without treatment or with off-the-shelf manualised programmes that don’t/can’t adapt to the individual needs of the child - again, as a developing human, every child HSB intervention is by definition unique as it has to address this child’s journey, no-one else’s (see lessons 1 & 2 in the previous post).
💡 Practice lesson summary: HSB in children should sit within safeguarding and welfare systems wherever possible, not criminal justice responses - which, overall, tend to do more harm than good. The development of countrywide effective, local, pre-court HSB services for children of all ages should be a policy and provision goal of national government, with resources to match. Breathy and meaningful oratory about addressing sexual violence needs to backed by robust legal processes and the cash to treat the abuse, not least in children - that would ensure we make quick and lasting strides towards a society free of sexual abuse.
6. Assumed ability is a serious blind spot
Professionals frequently overestimate what children understand about sex, consent and harm.
When I was helping to manage a secure children’s home, it never ceased to amaze me that an 16 year old child might not know how to tie their shoe laces. Or know how much shampoo to use on their hair. Or be able to use cutlery properly…
So I’m never surprised when children know a lot less about sex, sexuality and sexual behaviour than their age might suggest.
This is particularly the case, in my experience anyway, when it comes to teenagers. Younger children attract a more consistent ‘benefit of the doubt’ approach from most adults. But it’s different with teens. There’s a tendency to assume that because they’re out there in the world and have access to the internet that somehow they can assimilate all that into a coherent sense of how this stuff works.
They can’t. Not necessarily, anyway.
Most abused and developmentally troubled kids will get by and make do and not harm anyone else along the way; but many won’t. And when that journey includes sexual abuse of some kind, we shouldn’t be surprised when a child’s presentation and behaviour goes awry in the sexual domain. After all, how do you safely, consistently and realistically get good information about the nuances, vagaries and subtleties of safe sexual exploration, reciprocity and informed consent when your only counsel is t’internet?
I dread to think!
Some things to remember:
- Sexual abuse can fundamentally distort a child’s internal rulebook. What most kids imbibe and infer from years and years living and observing loving, prosocial adults in the family home, these kids miss out on. So they end up with a deficient (on a good day) or distorted (on a bad day) script about how to conduct themselves sexually.
- If the wider context of family relationships is dysfunctional, then the far more complex and granular intricacies of emerging sexuality will remain opaque, too. So even kids who haven’t been sexually abused, but may have endured poor attachments in early development, will struggle to grapple successfully with their burgeoning adolescent selves - including their sexual selves
- Learning disabilities, ADHD, autism (and other ND conditions) and trauma all affect judgement and impulse control. Taking account of the broader functional and developmental picture must be a primary focus of any treatment program.
💡 Practice lesson summary: Understanding must never be assumed. It must be assessed, supported and reviewed. I try to make it a rule of thumb not only to ask the right questions, but to dig deeper to ensure that I and the child understand their answers. Children, particularly troubled children, quickly learn how to parrot things adults around them say. Some of them can do this brilliantly as they’re able to fit the words to the context. BUT, we have to ensure they understand the words themselves, lest we fall foul of assumed knowledge that isn’t really there.
7. Gender shapes how children are responded to by systems - and by individuals
Responses to HSB are not gender-neutral.
I’ve worked in two places in my life that illustrate this point well:
- the criminal justice system and
- the mental health system.
Where I live, in Wales, there are no prison beds for women and girls; there are hundreds for men and boys, though. In the low secure mental health unit downstairs from my office, it’s rare to see boys; but girls proliferate.
I realise this is an over-simplification, but the point stands, I think: we tend to categorise boys’ aberrant behaviour as criminal and girls’ as health related; ergo, one is punished (or at least dealt with in a more punitive system) and one is treated.
Think about that. Boys are much more likely to end up in prison for sexual behaviour, whereas girls are more often dealt with in hospital or community-based services. In truth, for most children displaying HSB, neither of these places is ideal for helping them process what’s happened to them and move forward to better days.
In short:
Boys may be more likely to be viewed as dangerous and therefore get punished or, at the very least, get made subject to a more punitive system.
Girls’ HSB may be minimised, mislabelled and perhaps seen as something ‘in them’ that needs fixing (though there are significant outliers where girls’ HSB gets an even more punitive response than boys’. There’s a detailed case example of exactly this point in our book chapter)
Gender stereotypes, particularly in the sexual domain, can obscure both vulnerability and risk in boys and girls equally.
This connects to the point made in section 3 above - the victim/perpetrator split. Boys are more often tagged as a offenders (forgive the phrase but it reflects the system vernacular and helps for brevity!) and girls as victims. Whilst the offender stats around prevalence and gender attributes support this broad bifurcation, both these terms are a little odious to me as they bring to mind toxic generalities of predation and paralysis respectively - neither of which does anything like justice to the complex nature of the HSB problem.
💡 Practice lesson summary: Professionals must actively reflect on how gendered assumptions shape assessment and intervention, resisting the enmeshed in-built biases of male/female and victim/offender which are so ingrained in our systems.
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8. Culture matters, but it must never excuse harm
Children develop within family and community cultures that influence beliefs about sex, power, gender roles and relationships. For the purposes of this post, I’m thinking about wider cultural parameters like nationality, ethnicity, language, sex and religion as well as the practical, lived-experience of these in an individual family home.
In our practice, there are some basic principles it’s useful to have in mind - they are i basic but no less important for it:
Cultural humility is essential - it’s easy to slip into assuming we know everything we need to know about someone else’s culture; we certainly don’t. In fact, even if we share the same culture, we grew up in a different home at a different time with different people - these factors alone make cultural humility a necessary prerequisite for our work.
Cultural stereotyping is dangerous. Following on from the previous point, if we flagrantly assume we understand the broad range and granular nuances of how another culture may have impacted a child, not only are we open to major mistakes and misunderstandings, we’ll almost certainly never be able to help to optimal effect.
Harmful experiences must never be minimised in the name of culture. The question is not one of excuses but of explanations. Examining the influence of wide and narrow cultural drivers on the emergence of HSB in a child is necessary in order to understand it better and treat it more effectively. It is never OK to minimise, play down or some how excuse it.
In our poly-cultural societies, those of us haling from hegemonic groups have grown used to tailoring our language and assumptions so as not to offend. Such social complexities and allowances are helpful and respectful as well as, in my view, ensuring we enjoy and benefit from the delightful and multifaceted cultural traditions around us - the total is far greater than the sum of the individual parts.
But, we must never allow politeness, sensitivity or the eagerness not to offend others to lull us into ducking the very real issues in play. While it can be tricky to navigate the space between honesty and openness about what’s going on and differing cultural experiences and viewpoints, navigate it we must. Better to confront the issue/s and find oneself on the receiving end of an angry service user or worse still a complaint, than to balk at the challenge, be distracted or diluted in our practice and find that we missed something. Or worse, find that a child was not kept safe, that HSB wasn’t assessed and treated properly and/or an adult abuser went unchallenged.
When religion and gender expectations converge, things can be very hard. But I think returning to our practice principles can help us here. Asking about things with a genuinely open desire to learn and understand, can really promote trust in situations where people in the cultural minority will not expect humility or respect. Demonstrating both in spadefuls can be a bulwark against knee-jerk reactions from all concerned and help relationships coalesce into something that can promote healing.
💡 Practice lesson summary: Something can be culturally familiar and still harmful. Not assuming we know enough and instead taking time to ask about things in a firm but gentle way, will help us to understand more and to practice better. In the end, though, safeguarding responsibilities always come first. First and foremost this is not a deaf child, a christian child, a same-sex parented child, or a Sikh child (for example); above all they are a child and they may well be in need of our protection, regardless of cultural heritage, preference or choice.
9. Early warning signs are often missed
Many children show indicators of distress long before behaviour escalates.
Sexualised behaviour in younger children is often silenced or redirected: Parental discomfort to notice and address sexual play that is out of sync developmentally or resistant to correction can prolong the behaviour, intrenching it and increasing treatment resistance later on.
Systems frequently wait until harm to others occurs before intervening. Again, I’ve lost count how many kids have had to precipitate numerous incidents before someone decides to ask the ‘why’ question. Schools, social workers and others often do not call a strategy meeting or even consider whether they should look more closely - which they should.
Opportunities for early recovery are lost. Most so-called HSB will never develop into that if we’re prepared to talk more openly, intervene more readily and do so earlier. The earlier the better, too, as children’s problematic conduct is most effectively resolved if it’s brought out into the open and addressed honestly, with kindness at the first opportunity - we do not need a pattern of HSB before we can justify getting involved; if fact, the opposite is true.
Many local authority areas have good systems in place - partnerships with specialist services that can advise-formally or informally-those with a statutory duty of child protection. But many do not, so practitioners, teachers, social workers, foster carers and others are left to flounder for information and guidance about what to do and how to do it. Early intervention is key.
💡 Practice lesson summary: Early, curious and developmentally informed responses reduce harm and prevent escalation. HSB responses and system expectations should form part of all worker inductions, particularly in social work, foster care and residential care, but also for health visitors, youth workers, YOT teams, support staff, as well as those running sports clubs, Sunday schools, play and youth groups and many more. Know the signs and do something straight away - there’s no better intervention than an early intervention.
For information on this see the excellent resources produced by the CSA Centre for Expertise.
What good HSB practice with children looks like
Across the book chapter, and more so in these two posts, I’ve tried to summarise what effective HSB practice consistently involves if it’s to avoid a legion of pitfalls and optimise our service to the child and, through them, to their family and the wider community. Here’s a bullet-point distillation:
- Avoid punishment and advocate for it’s avoidance wherever possible
- Never assume a child has the knowledge or ability their age might suggest
- Sex and sexuality are inseparable from gender - always consider it
- In formulation and assessment generally, ask how culture might have contributed
- Intervene as early as possible and train others to do so
Useful treatment foci
In their qualitative systematic review of HSB teenagers (all boys unfortunately!) Campbell et al (2020) identified 5 key themes as critical components of successful intervention for these kids.
Here they are in brief - there’s a link to the full paper below**):
- The key role played by the relationships between the young person and the practitioner
- The significance of the role played by the parents and carers
- The importance of taking account of the wider context in which the HSB took place
- The role of disclosure during the intervention process
- Children need to be equipped with skills as well as knowledge
Time and space won’t allow me to unpack these in more depth here (may be there’s another post in this for later?), but you’ll be able to see that there’s some crossover with the content outlined above and in last week’s post.
As I look back over this now before hitting ‘publish’ I’m struck by how much more could be said on each point, as well as a number of others that could be made. But I’ll stop there…for now.
FINAL THOUGHTS
Children and young people who display harmful sexual behaviour are, obviously, children and young people first. Their episode/s of HSB should not be allowed-either by us or by the system-to define them - they are so much more than that!
But when HSB takes place someone nearly always suffers detriment or harm. As practitioners, therefore, we have a duty to maintain the complex and sensitive balancing act that involves promoting safety for all while providing treatment that will avert future recurrence. This is often referred to (including by me sometimes) as ‘risk management’ and ‘treatment provision.’ This is not a binary choice that demands we choose which child to manage and which to treat; along with the victim/perpetrator split mentioned previously, this is spectacularly unhelpful - but it still happens.
All HSB kids have suffered, usually some form of sexual abuse, but not always. Implicitly they are all victims in some form or another. If they have gone on to display HSB later on, then they have all in some way or another put others in harm’s way. So, let’s do away with stigmatising tag lines and unhelpful tropes in favour of seeing the child in the big picture of their lives so we can help them make changes and learn lessons that improve their life chances moving forward.
For me, it helps to keep these things in mind, so I don’t become part of the problem, adding to the iatrogenic systems around us all.
As always, when in doubt and not sure what to do, I revert to my tried and tested maxim: lean in, empathise and be kind!
See you in the next one.
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More information:
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- BOOK: For a great book covering the range of issues around HSB in much more depth, see the excellent: Allardyce, S. & Yates, P. (2018) Working with Children and Young People Who Have Displayed Harmful Sexual Behaviour (Protecting Children and Young People). Dunedin Academic Press. (Link)
- BOOK: Cultural Responsivity Book 1: Treatment of Sexual Violence (Ours is chapter 4 - link)
- WEBSITE: Child Sexual Abuse Centre for expertise - brillaint website with tons of useful resources and information (link)
- BOOK: Children as ‘Risk’ - Sexual Exploitation and Abuse by Children and Young People by Anne-Marie McAlinden (link)
- PREVIOUS POST: For more on moral development see Theory Bites 6a - Lawrence Kohlberg’s theory of moral development (link)
- *PAPER: A meta-analysis of trends in general, sexual, and violent recidivism among youth with histories of sex offending by Lussier et al (2024 - link)
- **PAPER: Young people who display harmful sexual behaviors and their families. A qualitative systematic review of their experiences of professional interventions - Campbell et al (2020 - link)
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