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Case notes  

Practitioner: Jamie Schofield, residential team manager, Behaviour Resource Service. 

Field: Assessment of children and young people with complex mental health needs and behavioural difficulties. 

Location: Southampton. 

Client: David Crystal, a 16-year-old who had been sexually abused and who was also an abuser. 

Case history: David had been in secure accommodation for some time, primarily because there was no other place to send him. He openly stated that he would offend again. He had been in foster care but had put himself further at risk by being involved in prostitution. Although not aggressive, David was quite predatory and would focus on individuals. His siblings - three sisters and two brothers - are all in care. However, they are all settled in foster care, thus leaving David, the oldest sibling, isolated. Realising that secure accommodation was not the best option for David, but unsure where else to place him, he was referred to the Behaviour Resource Service for a six-week assessment.  

Dilemma: David's placement in a secure unit is inappropriate but the alternatives - foster care and children's homes - would be unable to provide a service that would keep David safe.  

Risk factor: David's predatory behaviour makes him a risk to others, but his age and emotional complexity makes him similarly at risk of harm also.  Outcome: David has been placed in a specialist unit where he is happy, his behaviour is improving and he has been able to do some work experience.

Twenty-three per cent of all child sexual abuse is carried out by other children, according to Home Office statistics. Despite growing professional concern, until recently little research had been carried out into children who abuse, and who may have considerable unmet developmental needs, as well as specific needs arising from their behaviour. Such a young person is David Crystal.

David is both an abused child and abuser. He was referred to the Behaviour Resource Service (BRS), a partnership between health, education and social services. The BRS is made up of two teams: the residential team running a four-bedded unit for 13-16 year olds, and the community team for children aged five to 18 years old. Managed as one service, it can draw on psychiatry, clinical psychology, educational psychology, teaching, social work, occupational therapy, community support and nursing.

David was referred to the residential team, managed by Jamie Schofield. The residential unit, although an open unit, is well-staffed and could manage David. "The original plan was that he should be in a long-term care unit," says Schofield, "but they wanted to look at whether there were enough safety nets that could be put around him so he could be placed in a local authority children's home."

David was clear from the start that he felt he was a risk to other people as well as at risk himself. "He identified himself as being gay and had already been involved with a gay men's health project in the area. They had a really good link with him, so we involved them as part of his network. We also involved his children's guardian as she had known him from the secure unit," says Schofield.

"In terms of risk assessment we wanted to give David the opportunity to be outside but feel safe," he continues. "We needed a sort of halfway house."

Important for the team was David's understanding of himself being a risk. The team make use of a behaviour management programme. However, as David did not exhibit aggression at all, Schofield worked the programme around David's sexual offending. "The first week he wasn't allowed out," he says. "We knew that we'd never get to the point where he'd be allowed out on his own, but when we got to know him we began working with him day-by-day allowing him differing levels of freedom." Eventually, he was allowed out most days but always accompanied by staff.

Also David's family was an important factor. His five siblings were aged from three to 10 years. "We organised contact," Schofield recalls, "but standard social services contact - where you're accompanied all the time and everyone sits in a room for an hour wondering what to do - can be very boring and stale. So we thought about how to make that more interesting. We have another building down the road which has toys and things to play with."

The team's outcome target was to identify an appropriate placement. "He didn't need a secure environment," says Schofield, "he needed somewhere that would challenge his behaviour and belief systems. He needed somewhere to allow him to test himself out safely."

This ruled out any possible move to a children's home: he would be too high a risk with a changing group. Also education was a major concern. David had no educational placement because the school felt that he would need to have someone with him all the time. At the end of the six-week assessment a suitable placement had still to be identified. So, unusually, Schofield decided to keep him longer and do a thorough search for a placement. "We visited about seven different places up and down the country that worked with young people who sexually offend. We narrowed it down to three and took David to see them," he says. "Although we counselled him through the decision, he did choose the place that we would have chosen."

And it has proved a good decision. David is doing "fantastically well". He's once again receiving education and his individual and group therapeutic work is producing excellent results. He's now on work experience in offices and he's managing his behaviour. As for the future, Schofield says that David will stay at the unit: "It's where he wants to be."


Arguments for risk

• David is bright and understands himself very well. On referral he clearly felt he could harm other people. He was very open about this giving professionals something they could work with to help him make sense of and control his behaviour.
• Secure accommodation was inappropriate for David. Even without intervention from the BRS he would have had to leave with an exit plan. This more than likely would have resulted in a children's home placement which would, believes Schofield, inevitably lead to David offending again and thus ending up in prison.
• David showed signs of community participation through his involvement with the local gay men's health project. He had also displayed maturity with an understanding of his sexuality.
• It was important to re-engage David with his education, which he had missed out on but not through any animosity or indifference on his part.

Arguments against risk

• Although at times showing ability and understanding beyond his years, he is also very young in some of his attitudes. He is clearly a complex person and with such stark contradictions, combined with an underlying belief that he is a risk to others in his predatory and abusive nature, would suggest that a community presence could be damaging. Similarly, his complexity and youth make him vulnerable to others.
• As it seems inevitable that it will always be too much of a risk for David to be permitted freedom to come and go, there must be a question mark over the possibility of always having staff or the funding available to accompany him out.
• With no suitable resources available within the local area, this will inevitably mean David being placed a great distance from his family. David is alienated enough owing to his behaviour. The younger sisters and brothers are being denied opportunities to know him.

Independent comment  

Managing a young person who states very clearly that he believes himself to be a sexual risk to others is a very challenging and potentially daunting task, writes Andrew Durham. Jamie Schofield has done well to find an appropriate resource for David. I agree with him that a standard children's home placement would be a high risk for all, including David. It is important for those involved with David's current intervention not to lose sight of the fact that at some point in his future, David will be living in the community. If, by being in a residential placement, he is kept too much out of the community, he will be hindered in developing life skills.  One should also bear in mind David's age and family history, and remember that he is essentially a victim. David's experience of being sexually abused needs to be explored with him fully, looking at how he has interpreted it, and the influence it is likely to have had on his subsequent beliefs and feelings about himself.    The issues of being sexually abused, sexually abusing others and being gay, need to be disentangled, as part of a full programme of specialist therapeutic intervention. 

David is clearly prepared to engage in the therapeutic process, but his co-operation should not be allowed to result in any complacency. He needs to be challenged about the impact of his sexually abusive behaviour on others. 

Andrew Durham is consultant practitioner, sexualised inappropriate behaviours service, Warwickshire social services.