XVIth ISPCAN International Congress on Child Abuse and Neglect YORK, United Kingdom 36 September 06

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XVIth ISPCANInternational Congresson Child
Abuse and NeglectYORK, United Kingdom3-6
September 06
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Treatment and research center JANUS
Telephone [phone]
Website www. projekt-janus.dk e-mail
projekt-janus_at_projekt-janus.dk
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The JANUS Project

• Danish children/youth with sexual abusive
  behaviour 12-18 years and their families
• Overview and some results from assessment,
  treatment and research (03 06)
• Mimi Strange, Manager of The JANUS Project,
• Certified MSC in Psychology specialist in
  psychotherapy and supervision

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The JANUS Project
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• JANUS-head ca.230 b.c.
• The Roman God Janus is characterized by his
  double
• faced head that enables him to look forward and
  back at
• the same time.
• Janus is as well the God of all beginning and has
  given
• name to the month of January the first month of
  the
• year.
• The head of Janus has two faces. One turned to
  the
• past and one to the future.
• Janus has been chosen as logo of the project as
  it
• symbolizes the twofoldness Young people who
• sexually harm others have often also been victims
  of
• child neglect or/and abuse in their own
  childhood.
• Thus the Janus-head symbolizes as well victim-
  and
• perpetrator perspective as past- and future
  perspective.

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• Background
• The Danish Governments strategy and initiatives
  to prevent Child Sexual Abuse (publ. august 2003)
  by the Ministry of Social Affairs and the
  Ministry of Justice.
• The Ministry of Social Affairs has - as part of
  their strategy to prevent CSA - financed a
  project for a period of 3 years (03-06) to assess
  and treat children and youth (12-18 years) who
  sexually harm others.
• Center for Applied Social Psychology, Department
  of Psychology, University of Copenhagen has
  evaluated The JANUS Project 2005.
• The JANUS Project has been prolonged for 4 years
  (06-09) with extended tasks.

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Extend of the problem

• Approximately 1/3 of all known sexual assaults
  are reported to be committed by young people
  under the age of 18
• Approximately 50 of adult sexual offenders
  report about deviant sexual interests starting in
  early youth
• Adults who have been sexually abused in their
  childhood inform, that the abuse was committed by
  young people under the age of 18 in 50 of the
  cases

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Extend of the problemScandinavia

• A national survey in Sweden (2002) showed 200
  sexual abusive youth (12-18) (2 girls)
  (Cecilia Kjellgren)
• Denmark Rigshospitalet (Copenhagen University
  Hospital), Centre of Sexually Abused Children
• Status 2001-2006
• 435 sexually abused children
• 483 assumed perpetrators (98 male)
• 43 below 18, half of these below 15

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• Children and young people with problematic sexual
  behaviour/sexual abusive behaviour
• Prevent sexual abuse
• Prevent development of abusive behaviour and
  personality structure in adulthood
• Two foci
• Societal preventive interest (detect and prevent
  abuse)
• Careful interest (treatment of victims and young
  abusers)

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• Treatment and research centre for adolescents 12
  18 years old, with sexual abusive behaviour
  towards children
• Assessment of adolescents in order to evaluate
  need for treatment
• Treatment of adolescents and their families
• Co-operation with other professionals involved in
  the young persons case as well as coordination
• Counseling and supervision to professionals
• Developing treatment methods/ treatment models
  and education of professionals
• Research / knowledge gathering

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Clinical services

• Assessment
• Individual treatment
• Parental advicing
• Mediation between victims/perpetrators
• Group treatment of adolescents within the line of
  average intelligence
• Group treatment of mentally disabled adolescents
• Parent groups
• Individual supervision - professionals
• Group supervision - professionals
• Speaker at conferences lectures and education

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Data april 06 Gathered 03-06

• 58 clients and families
• Qualitative analysis of 28 interviews
• Psychological tests of 43 clients
• Analysis of treatment Individual -and
  grouptherapy Parentsgroup a.o.

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Cases

• 58 cases referred, adolescents and families
• Assessment and treatment
• All boys except 2
• Largest group 13-15 years old (36 cases)
• In 7 cases no victim
• Most of the boys are danish
• ½ of the clients live at home and ½ out of home
  (fosterfamily, recidental care)

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Age of clients 2003-2006 (58 clients)
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Victims

• 58 victims
• Age 3-15
• 37 girls, 21 boys
• Age 4-5 (16 cases)
• Age 8-10 (17 cases)
• Age 11-12 (8 cases)
• Most cases one victim and one perpetrator

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The gender of victims, 2003-2006 (58 cases, 58
victims)
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The age of victims from 2003-2006 (58 victims)
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The number of victims per client from 2003-2006
(58 cases, 58 victims)
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Relationship between victim and offender

• They know each other in all cases except 3
• Siblings 1/4(14 cases)
• Schoolmates 1/3 (17 cases)
• Residental care/fosterfamily 1/7 (8 cases)
• The rest Other known victims Cousins, friend,
  nabour etc.

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Survey of the relationship between offender and
victim/victims (58 cases, 58
victims)
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Abusive acts

• Most cases hands on
• A few cases hands off
• Continuum from indecent exposure, pawing etc to
  grossly sexual abuse
• ½ of the cases penetration (vaginal, anal, oral)
  or attempt to
• frottage, masturbation, pawing etc.

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Characteristics of the sexual abuse from
2003-2006 (58 cases, 58 victims)
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Victims gender, age and relation to perpetrator
and his/her age

• Victims who are siblings, other familymember or
  child in fosterfamily Age 4-7
• Siblingincest 1/3 victims are boys, 2/3 girls.
• ½ of the victims below 6 years, average 7
• The perpetrators average age is 13
• All cases except 3 are anal, vaginal or oral
  penetration or attempt to
• In most cases of siblingincest Several abuses
  over a period of time

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Family pattern of the clients in ongoing
assessment and treatment cases (27 cases)
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• Schoolmates victim average age 11 and perpetrator
  14 1/3 boys, 2/3 girls
• Victims who are friends, schoolmates or
  residental care Age 10-14 perpetrator 14 years
• Abuse in fosterfamilies victims age 4-5
• Residentalcare between 12-14 equal boys and
  girls
• Friends most boyvictims age 10 and offender age
  12-13

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• Length of treatment Average approx. 1 year
• 8 cases 13-15 months
• 7 cases 7-9 months
• 6 cases 19-21 months
• 5 cases More than 22 months
• ½ of the cases 7-15 months

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Duration in treatment referrals 01.09.03
01-03-06(32 cases)
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• In 1/3 of the cases More severe or more
  incidents of sexual offending than reported at
  the time of referral as well in victim as
  offender position

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Contacts in 58 cases

• 259 professionals, 94 socialworkers/social
  service system
• Fosterfamilies/recidental care 71 professionals
• Others professionals Psychologists, child
  guidance centers etc.
• Family 113 family members 98 adults and 15
  children

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Professionals in contact with The JANUS Project
(259 professionals) 01.09.03 01.03.06.
(assessment and treatment cases in total 58
cases).
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Family-members (113 all together ) in contact
with The JANUS Project in cliniccases
(assessment- and treatmentcases, 58 cases all
together) from 01.09.03 01.03.06
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AssessmentInterview

• Semi-structured qualitative interview users
  perspective (same questionnaire as used in a
  qualitative interview study, National Institute
  of social research, Strange 2002)
• Clinical purpose
• increase knowledge of the young offenders
  upbringing, insight of role in sexual abuse,
  empathy level etc. to optimate treatment, make
  risk assessment etc
• Research purpose
• increase knowledge of young offenders own
  understanding of their abusive behaviour,
  thoughts, feelings etc. to optimate prevention
  and treatment

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Social function (mainly based on assessment
sessions and interviews)

• The young people describe themselves as lonely,
  as having difficulties with social relations and
  a majority point out that they have been bullied
  in school. The lives of the young people seem
  characterised by a lack of relations with peers,
  by a certain degree of social isolation and by a
  low self-esteem partly as a result of the
  above.They have at the time of referal no
  explanation what so ever to their abusive
  behaviour

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Qualitative interview study

• Attention problems
• Behaviour problems
• Learning difficulties
• Lack of ability to identify, differentiate or
  verbalize feelings in them selves and others or
• Lack of exercise in doing so

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Qualitative interview study

• Lack of well-rooted biography
• Lack of experience of control and influence in
  own life
• Child abuse and neglect fysical and emotional
  victim of or wittnes to domestic violence sexual
  abuse
• Problems with attachment and social competence
  loneliness
• Lack in empathy

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The Results of the psychological tests

• 43 young men testet with WISC III,
• TOVA and Rorschach.
• August 2003 December 2005

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General intellectual functioning

• 1 (2) IQ gt 110 (above average).
• 13 (30) IQ 90-110 (average).
• 3 (7) IQ 90-85 (less able).
• 13 (30 ) IQ 85-70 (Inferioritas
  Intellectualis).
• 8 (19) 70-50 (Mild Mental Retardation).
• 5 (12) IQ lt 50 (Moderate Mental Retardation.

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Abstract/hypothetical reasoning

• 15 (35 ) were able to reflect and reason
  abstract/hypothetically.
• 28 (65) had limited ability to reflection and
  abstract/hypothetical reasoning.
• Only 1/3 were able to profit from traditional
  psychotherapy.
• 2/3 should have other treatment E.g. cognitive
  behavioral therapy, social training, individually
  or in groups.

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Perceptual organisation

• 9 (21 ) Above average.
• 11 (26) Average.
• 12 (28) 2-4 years retarded.
• 11 (26) Mentally retarded.
• The ability of perceptual organisation was
  generally better developed than the verbal skills.

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Attention and Processing time

• 8 (19 ) Problems with attention focusing.
• 24 (56) Problems with processing time.
• Problems with attention focusing and processing
  time could be symptoms of ADHD.

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TOVA(Test of Variables of Attention)

• 1 (2 ) Diagnosed and treatet for ADHD.
• 13 (30) No symptoms of ADHD.
• 10 (23) Symptoms of ADHD,
• pedagogical treatment/perhaps medicine.
• 7 (16) Severe symptoms of ADHD,
• referral to youth psychiatrist medicine.
• 8 (19 ) Atypical symptoms of ADHD, ½ referral
  to youth psychiatrist medicine.

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RorschachGeneral maturity

• 32 (74) Generally immature.
• 7 (16) Narcissistic personality.
• 4 (9) Pseudo-mature personality.
• Nobody showed a personality development according
  to age.
• 25 showed symptoms of disturbed personality
  development.

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Stress

• 7 (16) Good tolerance for stress.
• 4 (9) High level of stress.
• 28 (65) No symptoms of stress, but weak
  tolerance for stress.
• 4 (9) Stressed by emotional inhibition.

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Coping strategies

• 18 (42) According to age.
• 24 (58) weak coping-strategies.
• 58 had insufficient social competence
  because of weak coping-strategies.

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Social maturity

• 5 (12) No problems with self-knowledge and
  empathy.
• 36 (84) had insufficient self-knowledge and
  insufficient empathy.
• All showed signs of weak social competence, e.g.
  because of emotional immaturity, egocentricity,
  social anxiety, oppositionality, submissive
  behavior or bad reality testning.

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Attachment

• 5 (12) Normal attachment.
• 38 (88) Problems with attachment.
• 6 (14) Severe problems with attachment
  (Attachement Disorder).
• 88 had difficulties concerning basic trust and
  ability to commit and attach emotionally to other
  persons.

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Summary

• 61 Intellectually retarded.
• 70 ADHD or atypical ADHD difficulties.
• 75 Immature personality.
• 25 Disturbed personality development.
• All showed weak social competence.
• 88 Problems with attachment.

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Essential treatment principles

• Holistic perspective
• Ecological perspective
• Network involving
• Family involving
• Cooperation and coordination with professionals
  involved

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Group treatment adolescents

• Holistical approach (including all areas of the
  young persons life/ factors)
• Ecological approach (use several kinds of
  theoretical approaches and ways of understanding)
• Focused treatment approach method more than
  avoidance method.
• Take responsibility for creating healthy
  development including a non abusive sexuality
• Psychological as well as psychotherapeutic
  assessment comes previous to group treatment

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Group treatment - themes

• Identity and lifestory (genogram, network a.o.)
• The sexual offences (externalization)
• Relationships (friendships,girlfriend/boyfriend)
• Feelings (identification,differentiating,verbalizi
  ng)
• Social competences (establishing relationships)
• Sexuality (education, focus on healthy sex.)
• Future (visions, goals, means)
• Recidivprevention (4 steps, cycle of abuse)

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8 treatment areas/adolescent perpetrators

• Motivation
• Consequenses of sexual abusive behaviour
• Abusive patterns
• Empathy with victim
• Feeling of self and selfunderstanding
• Sexual education
• Relapse prevention
• 
  (Nymann, 2003)

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• The 4 pre-conditions according to David Finkelhor
  
• 1) Motivation to sexually abuse
• 2) Internal inhibitors
• 3) External inhibitors
• 4) Ressistance of child

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Motivation to sexually abuse
1
2 internal inhibitors
3 external inhibitors
4 resistance by child
Emotional congruence
Sexual arousal
Blockage
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step 1 wanting to
(OCallaghan, David G-MAP 2003)
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step 2 making excuses
(OCallaghan, David G-MAP 2003)
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step 3 getting the chance
(OCallaghan, David G-MAP 2003)
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step 4 doing it
(OCallaghan, David G-MAP 2003)
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Abuse which increases helplessness and poor self
image
Early experience and perception influences
understanding
Negative expectations
Reinterpretation
Avoiding behaviour
abuse
Compensation through sexual power/
Control, behaviour or thoughts
Grooming
Arousal such as masturbation
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Mediation

• Meeting between victim and offender
• In as many cases as possible
• In cases of sibling incest where the siblings
  live in the same family
• But also in cases with less close bonding
• Focus on healing the wounds of the victims, but
  also important to the sexual abusive person as
  part of taking responsibility of his actions

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Mediation

• Method development
• Not only the directly involved persons
  (victim/perpetrator) but also
• Parents from victim/perpetrators families who are
  befriended
• Divorced parents with new partners/children (new
  partners anger towards the offender who is the
  child of the spouse)
• The young offender has himself been sexually
  abused as a child Meeting with the perpetrator
  (parents a.o.)

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Future areasfor the next 4 years 06-09

• Integrate knowledge to establish nationwide
  treatment centres
• Increase education of professionals
• Include children under 12 (6-18)
• Continue research and knowledge-gathering
• Continue development of treatment-methods

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(No Transcript)
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Children with sexual behaviour problems (SBP)

• Intention and motivation may be unrelated to
  sexual gratification (Children lt 12 with SBP)
• Children with SBP more diverse than adolescent
  and adult sex offenders
• No profil of children with SBP
• Many children who have been sexually abused do
  not have sexual behaviour problems
• Many children with SBP do not have a sex.abuse
  history

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• Early adolescent is high-risk peak at 14-15
  years
• Fewer victims
• Different motives More experimental or curiosity
  driven behaviour
• Peerrapists differ from childmolesters, who are
  less delinquent, immature etc.
• 
  (Bonner)

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Perpetrator and victim

• The first prevalence studies dealt with a man as
  the perpetrator and a girl as the victim
• There has been a development in the view of who
  the perpetrator and the victim is
• the perspective of the helping professionals had
  progressed from blind to one-eyed with respect to
  sexual abuse (Mendel, 95)

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• Today we also discuss the male victim and the
  female perpetrator
• The same can be said about awareness of
  adolescent abusive youth and children with
  sexually worying behaviour
• The sexual component in sexual abuse of children.
  It is time to recognize more than aggression,
  hostility and revenge

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Theoretical vaccuum conc. sexuality and CSA

• Various theories claim that sexual abuse is not
  primarily an act of sexuality.
• Instead sexual abuse is motivated by aggression,
  hostility, revenge and a need to gain power and
  control.
• 
  
• (Tidefors Drougge
  2006)

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• The concept of an existing erotic component
  does not exclude the existence of other aspects.
  Several emotional states may be active
  simultaneously during the sexual abuse towards a
  child, but there is almost a theoretical vaccum
  surrounding sexuality and eroticism
• 
  (Tidefors Drougge 2006)
• International Journal of
  Qualitative studies on health and well-being, 1-10

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• A deeper understanding of the dynamics behind
  sexual abuse of children will hopefully result in
  (yet) more efficient treatment methods with the
  aim of reducing the risk of new perpetrations
• New knowledge is needed as well concerning adult
  perpetrators as adolescents and sexual abusive
  children

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Network

• ISPCAN (International Society for Preventing
  Child Abuse and Neglect
• ESSAY (European Society working with Sexual
  Abusive Youth)
• IATS0 (International Association for the
  Treatment of Sexual Offenders)
• Nordic/ Scandinavian Society (Nordic Association
  against Child Abuse and Neglect).
• Nordic Society working with Sexual Abusive Youth
  (Denmark, Sweden, Norway, Island)
• National networks (research and treatment)
• to gather knowledge across countries in order to
  increase early finding and treatment of young
  people who sexually harm others before they
  develop a history of sexual abuse.

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Multidisciplinary cooperation

• Social service system (social-workers,
  psychologists, youth-workers, advicers (youth
  contracts a.o.)
• Special institutions lt 15 treatment and research
  centers for mentally deficit young people
• Child Guidance Centers (psychologists, social
  workers, and other victim treatment centers)
• School system (teachers, spec. advicers, school
  psychologists a.o.)
• After-school system (social educators, pedagogues)

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Criteria for treatment

• Acknowledge of (some kind of) offending behaviour
• A certain degree of denial is accepted at the
  time of referral
• Initially the boy/girl will often have a more
  external than internal motivation for change
• Increase cognitiv dissonans and egodyston approach

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Criteria for treatment

• As low self confidence, lack of social
  competences, low degree of empathy and
  understanding the damage of CSA are important
  factors, based on research results, these factors
  are part of focus in treatment
• Satisfactorial development is important criteria
  for ending treatment

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Criteria for treatment

• Relevant support from parents and/or others
• Assessment of vulnerability, risk- and resilience
  factors
• Increased insight in background and motivation of
  abusive behaviour
• Increased insight alternatives in risk situations
• Increased insight in own sexuality
• Increased insight in the damage of CSA as well
  for victim as perpetrator

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Criteria for treatment

• Realistic plans of a future without sexual abuse
• Reduced risk of recidiv
• Increased social life with peers and adults
• Increased social skills/competences ability to
  relate to others
• Increased thrive/growth/feeling of well being in
  general and in school

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• 3 factors indicate increased risk for becoming an
  abuser
• Victim of intrafamiliar violence
• Witness to intrafamiliar violence
• Discontinuity of care
• Risk for becoming an abuser is not attached to
  the degree of in the original sexual abuse, but
  mostly to the part of being witness to violence
  followed up with being victim to violence

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Risk factors for developing sexual abusive
behavior

• The risk for sexually abused boys even in their
  early youth abuses others children may be
  understood in relation to experiences in early
  childhood, which is not directly related to the
  sexual victimization
• Exposure to continuous violence in the family
  considers to be a particular risk faktor.
  Intrafamiliar violence includes being witness to
  violence as well as offer for violence
• (Skuse
  et al, 2000)

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Exclusion criteria 1.9.03

• The treatment is not aimed at children/ young
  people
• with af heavy criminal background
• with heavy intellectual disabilities/deficits
• with sexual abuse of adults

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3 groups

• Adolescents with experiences of child abuse and
  neglect, obvious signs/symptoms of neglect, lack
  in social competences, school difficulties, peer
  problems etc..
• Adolescents with less obvious signs/symptoms of
  neglect such as loneliness, lack in social
  competences etc.
• Adolescents with intellectual deficits.

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Evaluation of Project JANUS

• ASSESSMENT
• Young people assessment was a good experience
  due to the establishment of a secure setting and
  relation. It was experienced as safe to talk
  with project workers - also about difficult
  issues such as the sexual assault itself ( the
  importance of trained professionals)
• Parents information and verbal feed-back from
  the assessment has been very good and useful
  especially in those cases where the assessment
  points to possible neuropsychological
  difficulties (ADHD) till now undiagnosed. A
  possible explanation for difficulties that
  parents and young people may have experienced for
  several years.
• Collaborators assessment-process has been very
  thorough and encompassing, and in some cases has
  contributed with new, important and relevant
  knowledge about the young person, for the direct
  use for the caseworkers continued work with
  regard to the young person.

University of Copenhagen, Departement of
psychology, Center for applied social psychology,
81

• In sum
• It is the evaluation of the different people
  involved, that the assessment both gets hold of
  all relevant aspects of the young person and his
  family network and life, and that it thereby
  creates a good fundament for the following
  planning of the individual treatment process.

University of Copenhagen, Departement of
psychology, Center for applied social psychology,
82
Evaluation of Project JANUS

• TREATMENT
• Young peoplehave experienced being listened to,
  having influence on topics discussed, and feel
  that they have been treated as whole persons
  because the treatment offers have included many
  aspects of their lives. The young people mention
  that the treatment has resulted in that it will
  not happen again and they are more able to
  formulate why this is so.
• Parents obvious changes and developments have
  taken place The young person seems to thrive
  more, has become more mature, more independent,
  has become more extroverted and has established
  new contacts with peers. Parents mention that the
  project has been extremely helpful in supporting
  them in coping with feelings and reactions, and
  in rebuilding a bridge of trust toward the young
  person.
• Collaborators consider the treatment-offers as
  both relevant and effective and as necessary and
  sufficient. Several case-workers emphasize the
  projects family- and network approach as
  especially useful, and some mention that the
  project has been very helpful in re-establishing
  a good relationship between the family and the
  social system.

University of Copenhagen, Departement of
psychology, Center for applied social psychology,
83

• In sum
• It is concluded that the JANUS-project has
  developed a clear and purposive treatment offer,
  which is assessed as both relevant and effective
  in relation to the intended goals of prevention
  and support for general personality development.
  Both parents and young people mention already
  attained results from the treatment Development
  of social competencies and a beginning attachment
  to peers factors which are both considered
  signs of the young peoples increased well-being
  and development.

University of Copenhagen, Departement of
psychology, Center for applied social psychology,
84
Evaluation of Project JANUS

• Counselling, knowledge transmission and
  cooperation with relevant parties
• Collaborators evaluate the type and extent of the
  cooperation with and the received services from
  the JANUS-project as very positive. Some
  professionals point out that there is a good and
  close contact with the project, that they receive
  good advice and that the project workers offer
  counselling and help when needed.
• The project has to a large extend also given
  priority to the task of transmitting and
  communication knowledge about young sexual
  offenders, through lectures and teaching
  seminars, and through establishing
  supervision-groups for professionals.
• Additional important knowledge will be developed
  as a result of the project having referred 4
  mentally disabled young people for assessment and
  treatment. Development of which general and
  special conditions constitute risk-factors for
  the development of sexually abusive behaviour.

University of Copenhagen, Departement of
psychology, Center for applied social psychology,
85
Risc factors for developing sexual abusive
behavior in young people with average
intelligence

• Neglect (physical, emotional and sexual)
• Empathy (reduced, resting, selective, context
  dependent, non existance)
• Low self esteem
• Loneliness
• Experiences of defeat
• Social events

86
Risc factors for developing sexual abusive
behavior in young people with average
intelligence

• School difficulties
• Learning disabilities
• Peer problems
• Lack of emotional and social competence
• Lack of or tvisted knowledge of sex

87

• Definitions
• A sexually abusive person
• Have commited a sexual aggressive act, which
  breaks social laws and moral/ ethical codes and
  result in physical or emotional damage and breaks
  laws and orders.
• A sexual abuse
• Sexual behaviour which is exploisive, affrontive
  or offensive and breaks social laws, moral/
  ethical codes result in physical / emotional
  damage, breaks laws.
• A young molester
• Young person from puberty to full age, who commit
  a sexual act against another person, regardless
  of age, against the other persons will, without
  consent or in an aggressive or threatening way.

88
Including most worrying group, likely to have
significant needs across a range of areas high
level of specialist intensive treatment, high
needs for management and supervision
High level of needs, but may be managed safely in
the community, maybe placement away from home
need for range of disciplines incl. Specialist
workers, carers, family workers, teachers and
other support staff
high concern (professional)
Low strength (Young person/ enviroment)
High strenght (Young person/ enviroment)
Limited intervention work through parents
Require help in meeting a range of needs
increasing resilience factors, family work,
family support.
Low concern (professional)
Bobbie Print G-MAP, UK