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Two boys being fostered together display inappropriate sexual behaviour but have no history of abuse. The first task for consultant practitioner Andrew Durham was to establish who was telling the truth. Graham Hopkins reports

CASE NOTES

PRACTITIONER: Dr Andrew Durham.
FIELD: Young people with inappropriate sexualised behaviour.
LOCATION: Warwickshire.
CLIENTS: Stephen Ross is nine and Paul McNamara, who has moderate learning difficulties, is 14.
CASE HISTORY: Stephen had for some time been disruptive and aggressive at school. He had also been reported for putting his hand in between the legs of two girls in his class, and had been heard asking girls to "touch him". Paul had been on the child protection register for neglect and was often under-nourished and poorly clothed. Both boys had been placed with the same foster carers. Recently, the carers reported that one night Stephen had taken his pyjamas off and gone into Paul's bedroom waking Paul and asking him to show him his penis. Stephen became distraught and blamed Paul. However, the carers believed Paul's claim that he was fast asleep before Stephen entered his room. After a while, Stephen withdrew his allegation.

DILEMMA: Stephen's recent history suggested he was the more likely initiator of abuse. But there are often sound reasons why children make statements about being sexually abused and then withdraw them.
RISK FACTOR: Even if Stephen and Paul are placed apart, they are still vulnerable and remain at risk of being either victims or perpetrators of abuse.
OUTCOME: Paul is now living in semi-independent accommodation, has a job and has not re-offended. Stephen has retained his foster and school placements and his life has settled down.

Mention perpetrators of child sex abuse and we tend to think of adults, usually men. We probably wouldn't immediately think the perpetrator to be another young person.

However, this appeared to be the case involving two young people fostered in the same home: Stephen Ross, nine, and Paul McNamara, 14. "Stephen had been exhibiting inappropriate sexual behaviours at school," says Andrew Durham, consultant practitioner for Sexualised Inappropriate Behaviours Service (Sibs) in Warwickshire, and author of Young Men Who Have Sexually Abused - A Case Study Guide (John Wiley, 2006).

Having been discovered without his pyjamas in Paul's bedroom late at night, Stephen claimed it was all Paul's fault but Paul argued plausibly that he had been asleep when Stephen came in. "Stephen later admitted that during that incident Paul did not do anything to him," says Durham. 

A multi-agency meeting between social services, the foster carers, police and school representatives, agreed that Stephen should receive some therapeutic work to help him with his behaviour. Durham adds: "Paul was also offered an opportunity to discuss and explore his feelings about the incident."

During the investigation, Stephen changed back his explanation. "He told his social worker that on several occasions Paul had gone into his bedroom and played 'games' with him," says Durham. "Stephen said that Paul had told him that he needed to play these 'games' so that he could learn about sex and practice what to do for when he gets a girlfriend. Stephen said Paul also told him not to tell anyone and that Stephen would be taken away if anybody found out."

Following this disclosure Stephen confirmed the account during a video interview. Paul was then interviewed by police. "He admitted that he had touched and kissed Stephen's penis on several occasions, and that Stephen had done the same to him," says Durham. "Paul explained that when Stephen first came to live with him, he would sometimes take his trousers down and expose his penis, asking Paul to do the same. He had asked to leave the placement and did so because he knew eventually he would get caught and that he wanted to stop."

Paul received a final warning from police for sexual assault and he agreed to undertake specialist therapeutic work to explore his sexual offending behaviour.

According to Durham this case shows how having sexualised behaviours can make children vulnerable to sexual abuse, and how this behaviour allows the person abusing to make the victim feel responsible. "It appears likely that for Paul, these behaviours triggered sexual arousal and thoughts that led to him involving Stephen in sexual activity," he says.

All parties agreed that the two boys could no longer remain in the same placement. "As Paul had committed the sexual offence, the initial thinking was that he should move out, and that Stephen should not have to move, as he was the victim," explains Durham.  "However, Stephen could not get over initially being blamed for what had happened, and began to say that he no longer wanted to stay." Stephen moved to another foster home.

It became crucial to secure Stephen's safe engagement in therapeutic work, to ensure he understood that what happened to him was not his fault. "But Stephen was showing sexualised behaviour before Paul abused him, so there may be issues to consider from his past. It will nonetheless be important to explore the patterns of his behaviour, and give him techniques to divert his 'touching' thoughts, and develop alternative and positive ways to relate to his friends and peers," says Durham.

As well as assisting Stephen with his school difficulties, work also centred on raising his self-esteem by encouraging him to make new friends, take part in leisure activities and to develop new hobbies and interests. This work enabled Stephen to retain both his foster and school placements.

Paul's 16-month therapeutic programme was also holistic, covering many of the difficulties in his life, including developing relapse prevention techniques. "Because of Paul's learning difficulties we adapted our approach," says Durham. "For example, we made extensive use of role play and graphic materials, cartooning scenarios using simple language and repetition of main learning points." Paul now lives semi-independently and has a full-time job. There have been no reports of re-offending.

Arguments for risk
As the therapeutic work progressed, Paul again became more in touch with the impact of this sexual abuse, and this helped him to appreciate the extent of the harm he had inflicted upon Stephen. "From this, Paul was able to recognise that he presents future risks that needed to be managed," says Durham.
For Stephen, similar behaviour management strategies were employed at home and school, and were discussed regularly with Stephen during the therapeutic sessions. This plan worked, and Stephen was able to hold on to both his school and his foster care placement.
Importantly, the foster carers received support and training, and liaised regularly with those involved with the therapeutic work. The carers were considered important members of each team of professionals formed to help either Stephen or Paul resolve not to commit further harmful sexual behaviours.

Arguments against risk
It is difficult to make appropriate placements in foster care when carers are offering more than one placement. Says Durham: "Paul was well established in the placement, there was no evidence to suggest that he needed to be placed on his own, or that he presented any risk to other children. Nor was there any evidence of Stephen showing sexualised behaviour."
However, given there was serious neglect in Paul's past care, there may have been overlooked experiences that will have influenced his current harmful sexual behaviour. 
In managing Stephen and Paul in their respective foster homes, it can often happen that specialist placement agreements are not completed. These should give details of the harmful sexual behaviour that have been committed and what the professional response has been and will continue to be, alongside details of what is needed in terms of supervision and risk management.

Independent comment
This case provides us with excellent evidence of the complexity of the dilemmas facing those working with young people who display harmful sexual behaviour, writes Patrick Ayre.

Common sense can be dangerously unhelpful when working to safeguard children. Common sense would tell us that, since there had been previous reported concerns about Stephen's sexual behaviour but no such concerns about Paul, Paul's account of the incident in the bedroom must, surely, be true.

Common sense would also suggest that if someone displays sexually harmful behaviour, they have probably been sexually abused. Research, however, tells us that there is no such neat connection.

Furthermore, we have a convenient rule of thumb that when someone significantly older, more mature or more powerful is involved in sexual contact with a child or young person, the responsibility lies solely and exclusively with the older person. 

However, from a therapeutic perspective, there is a danger that it may lead us to ignore some of the victim's needs.

While Paul must accept the blame, it may be important to assess the extent to which what occurred was interactive, arising from the interaction between Stephen's vulnerability and Paul's motivation to exploit that vulnerability.

Too often we may be so keen to reassure the victim that the blame lies elsewhere that we may be insufficiently thorough in exploring the victim's own risky or inappropriate behaviour, its origins and how to amend it.

Patrick Ayre is senior lecturer at the University of Luton and an independent child welfare consultant