Inappropriate sexual behaviour: the risk factor. Andrew Durham and Patrick Ayre on the case of an adolescent whose behaviour is causing concern

Carl’s years of inappropriate sexual behaviour were causing distress to his peers and younger girls at school. Then Andrew Durham tried therapy and put Carl in a specialist boarding school. Graham Hopkins reports

Case notes
The name of the service user and his family has been changed

Practitioner: Dr Andrew Durham.
Field: Young people with inappropriate sexualised behaviour.
Location: Warwickshire.

Client: Carl Pitt, 14 at the time of referral, lives with his mother June and stepfather David, and his brothers Ian, 17, and Michael, 19. Carl’s disabilities have been diagnosed as dyspraxia (which affects his intellectual, emotional, physical, language, social, learning and sensory development), and which may overlap with aspects of Asperger’s syndrome.

Case History: Carl’s instinctive learning is poor he needs very specific and concrete instructions, which often have to be repeated. He is often impulsive and uninhibited in his behaviour. Carl attends mainstream school and receives special needs support. He has for many years presented significant management difficulties both at home and school. His challenging behaviour is only responsive to adult guidance in the here and now. He began to present inappropriate sexualised behaviour, exposing his penis, masturbating and inappropriate touching of others. Carl has difficulty in understanding why this causes concern.

Dilemma: Carl’s intellectual difficulties will obstruct his learning, understanding and management of his sexual behaviour and relationships.

Risk Factor: Carl’s sexualised behaviour makes him vulnerable as a victim or a perpetrator of sexual abuse.

Outcome: Following successful therapy, Carl continues to receive subtle supervision at home and school. There have been no reports of him committing sexual offences.

Young people with sexualised behaviour are vulnerable to becoming perpetrators of sexual abuse or victims or both. However, working intensively and therapeutically with such young people can help them control their behaviours and help them understand how to keep safe.

Carl Pitt, 14, has dyspraxia and borderline Asperger’s syndrome. From the age of six, Carl began to repeatedly fondle his genitals, both at home and in public. As he reached puberty, he began to masturbate publicly, and was reminded constantly that this was a private activity.

“At school, Carl began to expose his penis during lessons and in the playground, and attempt to touch girls on their breasts and genitals, leading to short-term school exclusions,” says senior practitioner, Andrew Durham, who works for the sexualised inappropriate behaviours service (Sibs) in Warwickshire.

“For the first six months at his secondary school, with the extra supervision in place, Carl’s behaviours were contained,” continues Durham. “However, from about 12, Carl’s inappropriate sexual behaviour began to re-emerge, and more frequently than before causing pupils and some staff to feel threatened.”

These behaviours included drawing attention to himself, pointing towards his groin whenever he had an erection, rubbing himself in class, asking girls if they wanted to touch his penis, and telling them he wanted to have sex with them.

Says Durham: “Carl was targeting his behaviour towards a particular group of girls in the year below him. He was also being bullied by some older boys in the school, making him feel unsafe. Carl received fixed-term exclusions sometimes these were after violent incidents where Carl had been the victim.” Teachers believed he invited the bullying.

It was at this point that Carl was referred to Sibs. “Carl’s behaviours appear to be quite entrenched,” explains Durham. “Their escalation was probably directly related to his sexual development. Sex had become one of his special and compulsive interests.”

Durham felt that some of the “mainstream” methods of working with Carl would fail given Carl’s limited capacity to maintain an understanding of the impact of his behaviour on others and his tendency to forget behavioural instructions: “Carl was likely to remain vulnerable to bullying and possible sexual abuse. He should have been referred for specialist help at a much earlier stage.”

Durham undertook 18 months of therapeutic work to support Carl and to assist him in developing a better understanding of his sexual behaviour and why they cause concern to others, and provided a comprehensive programme of sex and relationships education.

“Carl responded very well to his individual therapeutic plan saying that he had wanted ‘someone outside of everything to talk to’ for ages,” says Durham.

The work with Carl used methods to repeat and develop crucial messages – reading materials, films, web-sites, CD-Rom, making video diaries, and discussing and cartooning life scenarios. As the work progressed there was evidence of a reduction in the frequency and intensity of Carl’s sexualised behaviour.

As Carl approached 15, he showed an improved understanding of appropriate sexual relationships, and spoke in terms of wanting to have a “serious” relationship with a girl the same age as him.

Finally, Carl’s inappropriate contact behaviour stopped. “He said that the main reason he stopped was because of the trouble he would be in, and that he knew it made him unpopular, and that he would therefore never be able to get a girlfriend.”

However his sexualised language and explicit sexual comments continued, and he was threatened with permanent exclusion from school. Says Durham: “His reputation at school deteriorated and the school felt unable to protect him from being bullied. Carl also felt scared at school. He was offered a weekly boarding place at a residential school for young people with dyspraxia and Asperger’s syndrome.”

The move proved successful and he very quickly received a series of positive and encouraging reports. “He thrived in a small group-teaching environment, and really began to enjoy his schooling,” says Durham.

At his request, he attended occasional therapeutic sessions during the first two sets of school holidays, before the work with him came to a final close, since when there have been no reports of him committing sexual offences.

Arguments for risk
● Carl’s sexualised behaviour rendered him and others vulnerable to sexual abuse.
● Professionals and family members needed to be aware of the fine balance that will need to be drawn between effective and protective supervision, and oppressive over-control and containment, which will prevent Carl from having positive social experiences, and will therefore further hinder his development.
● Carl’s interest in collecting and developing information about sex could lead positively to good co-operation with a comprehensive programme of sex and relationships education work.
● Much of the long-term outcome for Carl depends on how he is able to manage his transition into adulthood. There is an indication that Carl is able to manage adult company better than peer relationships. He may therefore find the adult world less threatening, and more helpful, than his school and neighbourhood peer groups.

Arguments against risk
● Because of Carl’s limited capacity to understand the impact of his behaviour on others, he will require continuous reminders of what he has learned – which may not be readily available if he remains in a mainstream, community setting.
● Carl’s impulsive behaviour is a key feature of his intellectual disability and he will therefore respond less well to cognitive behavioural techniques.
● Carl will need continuing close support and supervision. Professionals are likely to experience a sense of failure and may become disillusioned or impatient in their approach and management of Carl.
● Carl’s difficulties would be no excuse if he committed sexual assaults.
● There is also the added danger of setting targets or expectations for Carl that he will simply be unable to achieve. This could create a sense of failure for him, and put him at risk of being charged with sexual offences.

Independent comment
Carl’s situation provides an excellent illustration of the dilemmas associated with our desire to “normalise” the life experiences of young people whose behaviour presents significant challenges, writes Patrick Ayre.

That Carl should attend school alongside his peers from the local community would generally be regarded as likely to enhance his social and emotional development. However, this case shows us clearly the need for individual assessment and for specialist provision in certain cases.

The change to weekly boarding seems to have had several very beneficial outcomes. But in many ways, the most meaningful test of the success of specialist residential provision cannot really be applied until after the young people have left. I call this the “test of transferability”.

Local authorities will often spend very large sums of money to enable troubled young people to attend facilities, which have very high staff-student ratios and in which life is conducted according to carefully constructed therapeutic regimes. Frequently, there is considerable improvement in the young people’s behaviour. However, if one’s object is to go beyond the short-term containment of the resident’s problematical behaviour, the key question is whether the improvement can be maintained in the outside world. “Going home” may sometimes mean replacing a predictable, supportive, structured environment with one which is chaotic, unsupportive and relatively unskilled in responding to problematical behaviour.

Patrick Ayre is an independent child care consultant and senior social work lecturer at the University of Bedfordshire

Contact the author
Graham Hopkins

This article appeared in the 25 January issue under the headline “Threatening behaviour”