Attack the roots

Case notes   

Practitioner: Dr Andrew Durham.  

Field: Young people with inappropriate sexualised behaviour. 

Location: Warwickshire. 

Client: Mark Morrell, who was aged nine when first referred to social services. 

CASEHISTORY: Mark’s parents separated when he was four. His father remarried and has two stepchildren, Stephen aged six and Jill aged four. Mark had considerable conflict with his stepmother, which meant that although he wanted to live with his father he could only stay for short periods. Mark’s mother had bouts of severe depression and alcohol problems and lived alone in temporary accommodation. Mark lived with his grandmother. It was reported to social services that at school Mark had put his hand down another boy’s trousers and touched his penis. There had been concerns at school about Mark touching the genitals (over the clothing) of a boy and a girl during a playground game. Two weeks later, police and social services investigated reports that Mark has sucked the penis of his stepbrother, and forced him to do the same to him. It was also reported that he forced Stephen to lie on top of Jill, both without clothes on. 

Dilemma: At first Mark was under the age of criminal responsibility but this wouldn’t be for long. 

Risk factor: Mark’s behaviour might be so deep-rooted that it is highly resistant to change. 

Outcome: Mark’s behaviour is now controlled and while he still lives with his grandmother, he has good relationships with both his parents.

Young children who abuse do not do so naturally; it is something that they learn to do. Such behaviour can be “un-learned” but the success of this depends on individual circumstances and how deep-rooted this behaviour has become.

When he was nine, Mark Morrell was investigated by police and social services for sexual abuse of his stepbrother and sister, and referred to the sexualised inappropriate behaviours service (Sibs).

“The therapeutic work carried out was aimed at the abusive behaviours,” says Dr Andrew Durham, consultant practitioner, Sibs. “We analysed their process, using cognitive behavioural techniques to explore them and sought to give Mark ways to avoid them in future.” It was essential first to understand why Mark acted the way he did. And this work had to begin immediately because Mark was only just under the age of criminal responsibility.

Mark’s parents divorced when he was four. Since then his mother – who has mental health and alcohol problems – had several unhappy relationships with men. “For 18 months she lived with a man who was physically and sexually violent towards her. She spent time in a woman’s refuge, twice taking Mark with her. This man was also physically violent towards Mark, often blaming him for their problems,” says Durham.

Mark – who wanted to live with his father – lived with his paternal grandmother but continually tested the boundaries of their relationship as if he believed it would not last. “Most of Mark’s attachments had been fragmentary and ultimately disrupted. He had little investment in letting himself become attached to others, as he believed he would be let down – this had been his experience. Mark felt nobody really liked him or wanted him apart from his grandmother,” Durham says. He was particularly angry about his father’s new family, whom he felt had taken his place.

Mark’s background manifested itself in his sexual behaviour. “He abused several children – each time putting himself in a powerful and controlling position. His behaviour became sexual because of what he has witnessed and because he learned that this behaviour generated a ‘buzz’ around him – drawing a great deal of attention,” says Durham.

It was recognised that because Mark’s behaviour was deep-rooted, multi-faceted and functional to his life, it would continue at first in the face of therapeutic work. “He was doing these things to address personal feelings of being out of control and to feel good about himself in a life where he often felt rejected. Some of the patterns of his behaviour were learned from the adult male role models he has had – sexual aggression, violence, and controlling attitudes. Also he wants to hurt the victims directly and others associated with the victims – his father and stepmother,” says Durham.

At this time Mark required full-time supervision and monitoring at home and at school. For this to work Durham believed that Mark needed consistency of care: “This was why we prioritised providing support to Mark’s grandmother – she was his only consistent attachment. There was also work on sex and relationships, on “being a boy” and images of masculinity, and work on making and keeping friendships and so on.

“Alongside this a lot of work was undertaken with Mark allowing him to explore his past experiences, his feelings of rejection and so on. We worked towards reconciliation with his father – eventually leading to closely supervised daytime visits. Mark also renewed contact with his mother. However, it was made clear to Mark that living with his mother or father was not an option – but that he could nonetheless continue to rebuild relationships with them,” he says.

The therapy – intensive for the first year and less so for the following six months – helped Mark not to feel responsible for his rejections and the bad things that had happened to him, but rather helped to understand the impact of his behaviour on others. It proved successful. However, when Mark was nearly 13, he returned for some further work – although this was predicted and planned for. “The ability to do this is an important part of our service,” says Durham. “Some children will only require one-off interventions; others will need more. This is an example of a complex and long term Sibs intervention involving many people – therapists, social workers, foster carers, teachers, his family – forming a team around Mark to help him avoid further abuse.” 

Arguments for risk

• Time would be needed to change his behaviour as there were so many root causes. “The one thing driving it was absolute rejection – a fear of not having anybody there for him. So to remove him from his grandmother – the one person still holding out for him – would have been a disaster. Mark would just have closed down,” says Durham.
• The team of people involved was crucial. The therapeutic work reframed the control needed positively. It helped Mark get used to all the people involved. It meant that he didn’t think that they were involved because nobody trusted him, but rather that they were aware of the risks but wanted to help him and keep him safe because they cared about him.
• Support for Mark’s grandmother was available – some holiday-type respite breaks and regular contact with a male worker engaging him in age-appropriate interests. Also respite foster carers were available who had attended Sibs training courses.

Arguments against risk

• There must be concerns about whether Mark could be managed safely within the community. He would need constant supervision which perhaps was guaranteed through therapists, care workers or foster carers but would be less secure when placed with his grandmother – who might not be able to survive the continual boundary-testing.
• An obvious and safer alternative would have been specialised residential care. This would have given Mark one-to-one intensive time to elearn appropriate behaviours, and digest new rules and relationships. However, such a move in sending Mark away from everybody could put him at risk given that other young people would be experiencing similar behaviour difficulties. There were also the cost implications and the fact that he would need to return at some stage.
• The plan for Mark’s rehabilitation in the community hinged on the grandmother – this was risky and might have put too much pressure on her to make it work.

Independent comment   

Work with young people who display sexually harmful behaviour is often hampered by misconceptions and misunderstandings, writes Patrick Ayre. In their work with Mark, Andrew Durham and his colleagues had to face several of the most important of these.  

Parents, carers and professionals may still find it difficult to admit to themselves that children below the age of criminal responsibility sometimes display aggressive and even predatory sexual behaviours. All too often it is suggested that “it was just a game” or that “they will grow out of it”. In reality, the self-reinforcing, almost addictive nature of some behaviour may mean that the children involved are much more likely to “grow into it” and early intervention is imperative. Here, the seriousness of the issue was recognised and responded to. 

Further alienation from his family through removal from his grandmother’s care would inevitably have made the work which needed to be done with Mark much more difficult.  

On the other hand, allowing him to remain involved substantial risk, not only to Mark and to children with whom he was in contact, but also to the professionals who sanctioned this approach. Balancing such risks is a key aspect of all decision-making in child protection. In this case it proved possible to invest sufficient resources to ensure that the balance of risks supported the option most favourable to Mark. 

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