Information

Supporting children and young people who may have experienced child sexual abuse - clinical pathway: consultation analysis

An analysis of the responses to the consultation on the draft Clinical Pathway for healthcare professionals working to support children and young people who may have experienced child sexual abuse.


Section 2: Context

Do you agree with the context given in the pathway document?
Yes 36 63.16%
No 8 14.04%
Not Answered 13 22.81%
Comments
ID. Consultation comment Clinical pathways subgroup response
641E-8 For children who are deemed to be at risk of Child Sexual Exploitation (CSE) they may not be adequately covered by the phrase “up to 18 years of age with vulnerabilities” so can you include the category of CSE here. The comment has been noted and the Pathway has been revised to include Child Sexual Exploitation.
641E-8 Potentially, inclusion of the need for translators should be included in this pathway in light of the increased number of trafficked children from overseas We would regard provision of a translator when required to be part of routine service delivery.
641N-H It would be useful for the guidance to include some case study examples so that practitioners can identify what it may look like in practice. This should be covered in training and education for practitioners.
64ME-4 It is a good attempt to clarify information about CSA – but the approach to interviewing and supporting children needs to be reviewed as a matter of urgency and a real commitment to helping children who are the most vulnerable should be made. These matters are out with the scope of the clinical pathway and are for the training of professionals involved in the interviews.
641T-Q Good context and background provided with a highlighted emphasis on the difficulties of estimating prevalence of sexual abuse in children. Noted.
6412-N The context and prevalence section raise awareness but as a toolkit it is unlikely to be revisited more than once. In its current format – how often are practitioners
expected to use this? Is it every time they receive a disclosure of abuse or is this information embedded in regular safeguarding training? As it stands it is not very
clear and as a result, we suggest it will probably not be looked at very often. To embed this, it will need to be very easy to use and not time onerous.
The Pathway is intended to assist practitioners by describing best practice in line with current relevant legislation and guidance with all the relevant information in one document.
6414-Q 4.5 Page 13 “where young people age 13 to 15 are involved in consensual sexual activity” is a comment that would benefit from some further clarity. If the “consensual” activity is with someone over 16 then it may require a CP response. Additionally interpreting what is “consensual” is complex e.g. many young people involved in Child Sexual Exploitation would believe they were consenting. The legal context section needs expanded in any future guidance. We are aware this is about developing a clinical pathway but clinicians should understand that evidence sufficient to satisfy the criminal standard of proof (beyond a reasonable doubt) does not mean there will be legal proceeding or that such proceedings will result in a conviction. Indeed, the chances are that there will be no conviction at the end of a trial and the impact of that in terms of the young person’s recovery and their continuing entitlement to criminal injuries compensation needs explained as clinicians have a role in this. CICA claims are awarded on a scale £1000 for loss of a thumb for example. Where harm is lingering or carries a lifelong risk (images on the internet of abuse) then the award may be higher but it will usually require input from a clinician to make the argument that the impact of abuse is likely to persist and will require therapeutic input. Reference to the legal framework has been reviewed.
Comments on CICA etc are out with the scope of the Pathway.
64SX-W Section 2 on Prevalence give a good overview of the subject. This issue with the section is about methodology used in surveys. For instance the Crime Survey for England and Wales is referred to, but the definition of sexual abuse excluded abuse by adolescents (sexual abuse was defined as something perpetrated by an adult). Most studies (such as the widely cited NSPCC 2011 Maltreatment study) have some kind of methodological flaw that leads to prevalence figures being presented as artificially low. You refer to the 2019 CSA Centre for Expertise report which is the best and most recent overview to draw on. The 15% of girls and 5% of boys figure is referred to in page 16 of this report. The next sentence of the report states 'The methods used and number of questions asked affect estimates; at the higher end, international estimates reach 30% for girls and 23% for boys.' This is a useful corrective and we would suggest this would be a helpful last sentence if added to the paragraph discussing the Centre for Expertise report on page 8 of the Clinical Pathway document. Noted
64SX-W Section 4.1 'Who is a child'. In cases involving abuse of a position of trust, the victim may be 16 or 17? Does this need to be referred to here? Similarly, if a vulnerable individual at age 17 was coerced into providing a sexual image of themselves, this would not be deemed to be child sexual abuse in the definition provided in the Clinical Pathway document. However, the viewing of a sexual image of a 17 year old would be a crime. Clearly the document should not needlessly complicate the issue of who is a child, but do these situations need to be referenced? These could be referred to in Appendix A. 3.) Section 4.2 describes sexual abuse are always caused by those in a position of responsibility, trust, or power of the victim. This is almost always true, but is there something more that could be usefully said about power? If a 15 year old girl breaks up with her boyfriend and he shares sexual images of her (obtained in a consensual context) with peers - is this sexual abuse? It would fall under the Abusive Behaviour and Sexual Harm (Scotland) Act 2016 and would be dealt with as a child protection matter. This section would be improved with a statement noting that sexual abuse can occur both online and offline and involve contact, non contact forms of abuse or both. Is peer on peer sexual abuse something that needs to be considered here more generally in the document? The power relationship may not be so obvious in such cases but it will often be present. A recent UNICEF report looking at international data on sexual violence stated that adolescent girls are at greatest risk of forced sex within the private sphere, in the context of intimate partner relationships (https://www.unicef.org/publications/files/Violence_in_the_lives_of_children_and_adolescents.pdf). It may be that we want to label these situations as sexual violence in childhood rather than abuse, but these situations can also be considered to be - and should be responded to as - sexual abuse. Such cases may be identified in sexual health settings and the utility of this document needs to be considered there. Further information about how health professionals can best respond to harmful sexual behaviour in adolescence (including peer on peer sexual violence and intimate partner sexual violence in adolescence) can be found at https://learning.nspcc.org.uk/health-safeguarding-child-protection/harmful-sexual-behaviour-guidance-health/ We anticipate that these complexities will be addressed during an IRD discussion as part of the Pathway.
The Pathway has been updated to include further information on CSA with additional clarification for younger and older children.
6413-P We believe that in the context of trauma informed services there should be recognition that some children and young people have a legal right to access independent advocacy. The Mental Health (Care & Treatment) (Scotland) Act 2003 gives anyone with a mental disorder a legal right to access independent advocacy. This means that any young person who has disclosed sexual abuse and has a mental health disorder which includes mental illness, autism, learning disability or related condition should be able to access independent advocacy. In situations where a child or young person is disclosing sexual abuse and they have support from independent advocacy then the independent advocate will ensure; - they know and understand their rights - they are able to understand what is happening - they are able to communicate their needs and wishes - they are able to participate effectively - they are understood by others - they can think through their choices - they can make informed decisions The Pathway emphasises the need for individualised care and support if concerns are raised about potential abuse.
64SM-J There is a large discrepancy between the number of sexual offenses against children and the number of people proceeded against for sexual crimes every year although two tables in section 2 not directly comparable. Is there any new research or analysis which we should be aware as to the reasons behind this and what can we do from a health prospective to improve these numbers (better forensic collection, documentation, etc.) How many convictions are recorded as a result of the prosecutions. The figures in the Pathway are provided for context only. The primary aim of the Pathway is to promote the delivery of consistent high quality care and support to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64SR-Q Not sure this is needed and if it stays will need to be updated annually in a 'live' version of the pathway The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SE-A The definition of a child is currently an issue due to a number of factors including current legislation. This can make procedures and decisions in child protection inconsistent and also confusing to practitioners. The clinical pathway is applicable to the care of children less than 16 years of age or up to 18 years of age for young people with vulnerabilities or additional support needs. A young person making a disclosure may present to the pathway having only reached 16 years of age and due to identifying factors may be categorised as an adult and would automatically fall would full under the remit of the adult pathway. It is however, important for practitioners who first engage with the young person to establish if they have previously been a victim of sexual abuse and the extent of the abuse. This will help determine the most suitable form of support. In addition, the practitioner must be alive to the emotional and physical development of the young person which may be more akin to that of a child rather than an adult, thus, consideration should be given to measures being put in place under the pathway for children rather than the pathway for adults. Police Scotland welcome the development of trauma-informed practice, which requires consistency to be delivered effectively. Therefore, we would appeal where possible, the same practitioners/professionals should be allocated to a child or young person in order to provide support and familiarity; promoting a safe comfortable environment for the child or young person. Giving consideration to the legal context core agencies must have a mutual understanding of legal obligations if a child or young person makes a disclosure of child abuse. Collectively, we have shared responsibilities under child protection procedures to assess and minimise risk to children and young people. The views of the child or young person should be taken into consideration, but should not detract or prevent us from following child protection procedures. In addition, there should be no conflict in relation to a duty to report to other agencies and patient confidentiality The Pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind. The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area. The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SN-K CSA in the context of the whole systems around the child needs to be addressed within the pathway, not just from a medical perspective. Assessment and recovery pathway needs to address attachment, resilience and familial context. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64SB-7

The issues in the context section are all important and relevant, however the concern identified in our answer to Section 1.3 applies. Much of the information in sections 4.1-4.5 is brief, introductory, and disconnected from the stated aims and purpose of the document. If the issues cannot be covered comprehensively within the document, it may be more beneficial to signpost to the National Guidance for Child Protection in Scotland (2014). This guidance is currently being reviewed, and utmost care should be taken to ensure the content of the Clinical Pathway document is aligned with the reviewed guidance to avoid the document quickly becoming out-of-date. Suggested specific amendments include:

  • 4.1 ‘Who is a Child’ –
    • Whilst we recognise the complex legal landscape in relation to defining the age of a age, to align with the Scottish Government’s commitment to the UNCRC, the Clinical Pathway should apply to all those under 18. This recognises the right of these individuals’ to a child-centred responsive approach, which takes into account their additional vulnerabilities as children and young people. Furthermore, extending the application of the Clinical Pathways to care experienced people up to the age of 26 should be considered, in line with corporate parenting duties and responsibilities.
  • 4.2 ‘Sexual Abuse’ –
    • Consistency with the definition of sexual abuse generally used in Scotland, taken from the National Guidance for Child Protection in Scotland (2014), is recommended.
    • Relocate references to the legal context to section 4.5.
  • 4.3 ‘Trauma-Informed Services’ –
    • We strongly support a focus on trauma-informed services for children who have experienced sexual abuse. However, this section itself is brief, and a trauma-informed approach is not integrated into the document. The Clinical Pathway would be significantly strengthened by explicitly detailing the role of health practitioners in ensuring trauma-informed responses, in the multi-agency context, at every stage of the child’s journey, including future planning and recovery.
    • Replace ‘sexual violence’ with ‘sexual abuse’ in the opening sentence of this section. All experiences of sexual abuse require a trauma-informed response, not only experiences of sexual violence.
  • 4.4 ‘Adverse Childhood Experiences’ –
    • This section could be strengthened, it currently contains very limited detail.
    • The language used in this section is highly clinical, emphasising the diagnosable disorders which can result when child sexual abuse is not ‘treated’. This could be improved by taking a more holistic view of the child, the need to be trauma-informed, and attend to their overall wellbeing in responses to child sexual abuse.
  • 4.5 ‘Legal Context’ –
    • The focus of this section, particularly on responding to disclosures of sexual abuse by children, is potentially confusing. Firstly, there is not enough information to constitute comprehensive guidance. Secondly, the Clinical Pathway appears aimed at practitioners undertaking medical examinations, which will occur after disclosures have been made.
    • The lack of clear references to relevant law in this section is confusing. The statement that additional context is provided in Appendix B is noted, however this appendix is simply a list of Acts (plus a paragraph outlining some aspects of the Children and Young People’s (Scotland) Act 2014 which have not yet commenced) and as such the legal context is largely unexplained.
The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
There is now more information and context on trauma informed care and adverse childhood experiences.
64SZ-Y Page 11 the paper states: “ The dynamics of child sexual abuse differ from those of adult sexual abuse.” We are not clear what is meant by this? The paper goes on to say “It is more likely for a child to experience sexual abuse at the hands of a family member or another supposedly trustworthy adult.” This is the same for adults. For both it is about power and control, it is about silencing and blaming and putting barriers in the way of disclosure, whether internal within the person e.g. by making them feel responsible and to blame, or externally by threatening and isolating. With both, workers need to be aware of their own power, and work to build trust, utilising the trauma informed principles. Also the term 'adult sexual abuse' is referenced, what does this mean? We consider that people would read that as sexual abuse of a vulnerable adult. We consider this to be vague and unhelpful. If what the paper is trying to convey is it is important to consider the context of how children are abused and assaulted then this needs to be spelled out explicitly with practical considerations for practice. This phrase is used again later in the document on page 12, with the same feedback. On Page 11 the paper states: With childhood sexual abuse children are often too young to know how to express what is happening and seek out help. Again the use of CSA limits what kind of sexual assault this might be seen to apply to. This might not be the key barrier with older children, but with both there are significant barriers such as fear of not being believed, fear of being blamed, judged or of getting themselves or others into trouble. Also in this section the paper describes child sexual abuse of a child. We feel it is important to also highlight sexual assault of older children by peers/older children and to recognise coercion and the peer pressure at play which might be not about age but gender and status. In terms of health care responses it is important that this is given consideration and weight re training and staff responses. It would be useful to use the terms children and young people throughout the document and not just in the title to emphasise this. The term children and young people is now used throughout the document.
The Pathway has been revised to provide more clarity.
64SH-D In relation to the Crime Survey for England and Wales (2016), we assume that the wording should be clarified to explain that the percentages relate to any form of sexual abuse, not any form of abuse as currently drafted. It is important that the context given in this section reflects both contact and non-contact offences. The definitions of child sexual abuse explored later show that not all abuse involves physical contact with the child or young person (for example, online grooming), and it is vital that medical professionals both identify and respond to situations where any form of sexual abuse is taking place. The language in relation to the CSA Centre for Expertise paper could be simplified and clarified by referring to abuse by “adults and other children/young people” rather than adults and peers. The word ‘peer’ suggests someone of a similar age, when in reality abuse by another child or young person can encompass this, but can also include children/young people of different ages, and relationships between children/young people of the same age where a power imbalance creates an abusive context. The figures in the Pathway are provided for context only. The primary aim of the Pathway is to promote the delivery of consistent high quality care and support to Children and Young People who have experienced child sexual abuse and their non-abusing parent/carer(s).
64SU-T The context itself is what is failing the proposed system. A great part of the system despite its recommendation of abortion and my objection to it is in fact, very well intended and if other advanced qualities were added could be very effective indeed but I will tell you now its no were near the other systems I have examined from other nations. Even if such advancements were to be made in the Scottish system the legal context of Scotland will lead to the system ultimately not achieving its objective to be just in regards victims and the falsely accused in terms of objective reality. It is incapable in that respect because as stated by the UKSC in regards some child protection measures in Scotland, the measures and the laws the system will be governed by in terms of protecting children are themselves incompetent and thus actually potentially dangerous to the wellbeing of children. Now that irrespective of the abortion issue may have been completely avoided if it was designed only to tackle issues of rape regarding children 0-15 regardless of any gender or sexuality without mixing in those who are 16-17 in the same "young persons" bracket. This is not England. The 16-17 year old age bracket should have been dealt with in the adult pathway or the age raised for all rights and freedoms to 18 by a referendum. Before a system like this is ever put in place there needs to be three things already present in Scotland: A) A fundamental change in the attitude of Scottish adults towards Scottish children and Scottish children towards Scottish adults. B) A fundamental change in the laws in Scotland that define when a child is a child and when they are not, when rape is rape and when it is not. C) Proper selection, training and allocation in regards the people on the ground operating such a system like this. There should also be: I) A clear understanding of what police can and can not do. II) A clear understanding of what social work can and can not do. III) A clear understanding of what medical personnel can and can not do. And ultimately there should be a management for the modus operandi that the system will work by that is: 1. Responsible to the public. 2. Accountable to the public. 3. Transparent to the public All within an atmosphere that yes constantly offers the alleged victim collaboration and control, power and support, trust and safety as proposed by the Scottish Government. I want to say something on collaboration - the government should only collaborate on matters of fact and fact only in these cases facts as to those established or facts as to those witnessed by the civil service. I find the legal context that will be the backdrop to this rather bizarre as evidenced in such statements as: "A child and an older child" Now there is either a child or an adult, there is no such thing as an older child or younger adult in regards child protection. The line between an adult and child needs to be stark and evident. Or that a child of the age of 13-15 needs to have there statement of consent to sex interrogated by the state to verify there consent is "truly genuine" well no - they don't because a child under 16 can not give there consent. Period. End of argument. If a child therefore at 13-15 purports to give consent then they have not given anything of the sort there's no need for an interrogation to verify any genuineness about it because there is none it's not consent in anyway shape or form a child can not consent to sex to any person older, the same age or younger. Full stop. If the child has given it to somebody of the same age at 13-15 then the parents of both partners should be given social work support as a mandatory requirement. If it is true that a person at 13-15 can give valid consent in some incidences if the state deem it "true consent" then who decides that ? Them, criminal law enforcement or the assessor of such genuineness and why ? Perhaps this system should be more interested in its creators and proponents than innocent families - a case of deflection perhaps ? Furthermore, if the state deems a person at 13-15 can in some incidences give true consent then whom can they give it too other persons of 13-15 or a 60 year old ? Finally, if the state can justify incidences were a 13-15 year old can give "True consent" then what are we doing maintaining a statutory age of consent at 16 ! It should be lowered to 13 then should it not ? Perhaps that's the ultimate aim of those making such bad statements - No ! Clearly, clearly Scotland that is not the correct answer, the correct answer is to not interrogate a 13-15 year old to verify if there consent is genuine the correct answer hear is to regard all and any giving of consent by any person at 13-15 in regards sex to anyone regardless of sexuality or gender as automatically invalid in every case no matter who they give it to without exception whatsoever. As stated there needs to be a change in law and in context as well as adults attitudes to children before the pathway can bring any change to Scottish society in this area. The Pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind.
64SD-9 The context provided would benefit from additional resources to support practitioners in understanding the impact of adverse childhood experiences. A link to the NHS Health Scotland Gender Based Violence resource is suggested http://www.healthscotland.scot/health-topics/gender-based-violence The section on adverse childhood experiences in the Pathway has been reviewed and enhanced.
64SP-N We have concerns over the definition of a child, primarily in the differentiation of 16 and 17 year olds with “vulnerabilities and additional support needs”. Introducing the concept of ‘vulnerability’ as a qualifier risks a lack of clarity and certainty in the application of the pathway, and may not result in the best outcomes for the individual concerned. In addition, it is unclear how the assessment of vulnerability will be made, who will make that assessment, and what criteria will be applied. Being defined as a child attracts specific protections in law. For instance, the Vulnerable Witness (Criminal Evidence) (Scotland) Act 2019 (2019 Act) provides for safeguards as to how the child should give evidence in serious cases which include those of sexual abuse. This provides for all those under the age of 18 to be treated as vulnerable witnesses. In addition, the United Nations Convention on the Rights of the Child, which the Scottish Government has stated its intention to incorporate into Scots law, applies to all those up to the age of 18, which is also reflected in the Children and Young People (Scotland) Act 2014. However, we also note that the definition of child varies across different pieces of legislation, for example the Sexual Offences (Scotland) Act 2009 uses the ages of 13 and 16 when framing sexual offences against children. It would be helpful to maintain consistency of approach across the range of relevant legislation regarding children that have been affected by sexual abuse. Clarity and certainty in how the application of the clinical pathway is to operate should be the objective taking into account what provides the best outcomes for the individual concerned. We would recommend that the pathway applies to all up to the age of 18, with regard to the different needs of different age groups. The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SP-N The description of the law in this area could be more nuanced. Paragraph 4.2 of the consultation briefly highlights the Sexual Offences (Scotland) Act 2009 Act and the distinctions made in that Act between different age groups. More could be done to set out the legal context clearly and more comprehensively. It may also be worth noting that in limited circumstances, consensual sexual activity involving older children is not illegal (e.g. where both parties are aged 13-15 and the behaviour does not involve penile penetration or genital contact; or where a party is over 16 but the difference between A's age and B's age does not exceed 2 years and the behaviour does not involve penile penetration or oro-genital contact). However, while such conduct is not covered by an age-based offence, it would of course be covered by the general sexual offences, for example sexual assault if consent is not present The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SQ-P While we agree with the overall context of the pathway document, we suggest the following amendments: We question whether the definition of “children and young people with vulnerabilities and additional support needs” is clear enough and suggest that this is likely to be too open to interpretation. We suggest that, in line with UNCRC that all children and young people under 18 years of age would be entitled to this clinical pathway. Para 4.1: The term ‘accommodated’ should be removed from ‘looked after and accommodated’ so as not to exclude those children and young people looked after at home, in kinship care or on a permanence order. Para 4.2: We suggest it may be helpful to include in section 4.2 a definition of child sexual exploitation as a form of sexual abuse Para 4.3: Trauma informed care should also underpin work with the child’s family and professionals already working with the child e.g. teachers, bearing in mind recovery is most likely to take place through the enduring relationships within the child’s network. Para 4.5: the phrase “passed on” implies a shifting of responsibility for child protection and such language should be avoided in line with the principles of GIRFEC – it may be more appropriate to say “should be considered as part of local child protection procedures” The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
A definition of CSE is now included in the pathway.
64S1-P

[Our organisation] believes further development is required within the context section of the pathway document. In particular, [our organisation] welcomes attention being given to the increased risk of sexual exploitation to children and young people with learning disabilities (please refer to Recommendation 1). This was discussed in detail in [our organisation] submission to ‘Equally Safe: A consultation on legislation to improve forensic medical services for victims of rape and sexual assault’ (2019, p.3-5) . This outlined the risk present to adults as well as children and young people with learning disabilities and the barriers they experience in accessing justice. In addressing the context regarding the risks to children and young people with learning disabilities to sexual assault and rape, [our organisation] points to a range of relevant literature spanning across the twentieth century, including but not limited to Wescott (1991) and Hershkowitz et al (2010) . In particular, [our organisation] welcomes the pathway drawing from ‘Underprotected, Overprotected’ (2015) which highlighted an increased risk to children and young people with learning disabilities due to a number of complex factors including:

  • The challenges for children and young people with learning disabilities in identifying risk
  • The overprotection and isolation of children and young people with learning disabilities
  • The limited awareness of the sexual exploitation of children and young people with learning disabilities among professionals.

A full list of contributing elements to increased risk found in this study is discussed in more detail in ‘Overprotected, Underprotected’ (2015,p.41). In addressing the risks to children and young people with learning disabilities, the pathway should also highlight the rights of this group to romantic relationships as well as friendships. [Our organisation] believes that in addressing this the Scottish Government can work towards the achievement of the recommendation made in ‘Overprotected, Underprotected’ (2015) which said: "The Scottish Government must ensure the development, revision, and implementation of legislation, policy, and guidance to meet the needs of young people who experience, or are at risk of, CSE." (Franklin et al; 2015, p.144)

In anticipation of the revised National Guidance for Child Protection in Scotland which addresses these issues in depth, the Pathway stresses general principles that underpin the consideration and conduct of investigative activities in relation to children and young people who may be harmed and those who may cause harm to others.
64SK-G Page 11--the document mentions children up until 16-18 depending on vulnerabilities then on page 11 mentioned care experienced young people... we have a corporate parenting responsibility until age 26 in the CYP act to this needs explained and context added to clarify. Pg 12 would be helpful to include align with the definition of trauma-informed care as explained in the NES psychological trauma framework... trauma informed is much wider and would support all those involved with this pathway to use a trauma informed lens on the child's journey p 12 the 4 rs are good but be helpful to use the trauma informed organisations diagram by NES which frames it in the context of trust, safety, empowerment, choice, collaboration and relationships 0 12 4.4 would change the title to childhood adversity as opposed to ACEs The vulnerability of care experienced young people up to age 25 has been emphasised in the Pathway.
There is an enhanced section on trauma informed care.
64S7-V 4 and 4.3.1.3 Trauma Informed Services and 4.3.1 Trauma Informed Child and Family Centred Care Could “Sowing Seeds: Trauma Informed Practice for Anyone Working with Children and Young People” https://vimeo.com/334642616 be included as a resource instead of or as well as Opening Doors in Useful resources. To also highlight that in trauma informed practice with children it also important to consider the age and stage of the child, to understand the potential impact of trauma and also how they might present and communicate. There is now more information and context on trauma informed care and adverse childhood experiences.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64S7-V Section 4.4 Understanding the Impact of Adverse Childhood Experiences Should be clearer in stating, adverse, stressful and traumatic experiences. Currently does not state traumatic. Also inaccurate and overstated impact. “When not properly treated, child sexual abuse can result in a lifetime of Post Traumatic Stress Disorder (PTSD), depression and anxiety.” Would advise rewording to something more general such as “When childhood sexual abuse is not responded to with trauma informed principles and specific interventions where required, it could result in poorer outcomes in terms of mental health, physical health and social outcomes” There is now more information and context on trauma informed care and adverse childhood experiences.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64S7-V Other resources to refer to in terms of Trauma Informed Practice are the Forensic Medical Examination Guidance. NES Forensics updated and developed resources following the CMO request in 2018 that all doctors working in sexual offences have accessed training in trauma informed principles of practice. Collaboration with NES Trauma ensured that the resulting emanual, video walk through of a forensic examination and two days of face to face training had trauma informed principles embedded throughout. These resources remain accessible to those who have attended training. Also the Joint Investigative Interview Training which is currently being revised by Social Work and Police staff, in line with a new protocol. Again NES Trauma have provided input in developing this training and highlight the importance of child development and impact of trauma. Both of these areas would be relevant to this pathway There is now more information and context on trauma informed care in the Pathway.
64S3-R Further context in relation to the new child protection guidance should be given, in addition to information on corporate parenting duty and the additional context of adult support and protection. GIRFEC is initially referenced, but not weaved throughout the document to emphasise the child rights and wellbeing context, especially in relation to new work around child protection. Further information on the legal context of the children's hearing system needs to be added. Additional legal context in relation to vulnerable witnesses is also needed. The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
Further information on the Children’s Hearing system is now included in the Pathway.
64S3-R The figures outlined in the introduction do not highlight the experience of children and young people as it refers solely to police date. SRCA have data on concerns raised and child protection concerns within the children's hearing system The figures in the Pathway are provided for context only. The primary aim of the Pathway is to promote the delivery of consistent high quality care and support to Children and Young People who have experienced child sexual abuse and their non-abusing parent/carer(s).
64S4-S Have to get to paragraph 4 before the discussion of child sexual abuse. This has been brought forward after the introduction and wider child protection context.
64MX-Q Information sharing across agencies. Someone to link in and share. Need a co-ordinator. Each health board has different opinions on what they want to receive (information). Under 16years there shouldn’t be difficulty as they should be in child protection. Whose responsibility is it is to share information written into the pathway. Nothing explicit about after care, inclusion team would do that. All within young person service. Support worker who would follow up within 48hours and refer to Sandyford. SLA is for forensic examination, can also include follow up. The choice should be the child’s. We cannot force that on the child. Number 12 missed out – something about after care, co-ordinator. Make sure we are all working to same specification – consistency. Small numbers for children – high quality for small number of children Lack of consistent nursing support. Peripatetic nursing? Co-ordinator role? Help to drive the standards. Implementation of the pathway – resource, model and governance. Custody care nurses all work under standard setting/training/data/competencies for custody care we could apply those. Pre and post exam. Clinical pathways as a rule – depends on implementation, governance and monitored. Need processes around that. Something not in the control of the servicers – i.e. test results. Also admin support for reports etc. – need resources. Monitoring – sense of improvement. We have numbers from the police, clinical numbers? Not sexual offences, number of examinations should be noted. Number of children seen by SARC. Maintaining skills. Other guidance exists in non-health setting. Adapting this pathway (another version) for other agencies to use. The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area.
The revised Pathway now includes a section on the roles and responsibilities of the professionals involved.
Hyperlinks are provided throughout the pathways for all resources referenced or referred to in the document.
64M5-M It is helpful for the draft pathway to contain a section on the prevalence of CSA. The lack of robust prevalence data at both national and local level may at least in part contribute towards the low priority given to the planning and delivery of therapeutic services for children who have experienced sexual abuse, particularly younger children. The section would be very helpfully strengthened by containing clear evidence on the proportion of children experiencing sexual abuse who are likely to come to the attention of statutory services. For example, a report by the Children’s Commissioner for England found that as few as 1 in 8 children are estimated to come to the attention of statutory agencies. 2 Children whose abuse does come to light during childhood must be understood as the ‘tip of the iceberg’ of a much larger number who are sexually abused whilst growing up and this should be clearly articulated in the Pathway. We would also strongly welcome the section being fleshed out to further clarify the difference between the data on the population prevalence of child sexual abuse and the administrative data recorded by agencies, for example police and social work. Recent UK and Scotland specific reports in this area are referenced and linked below . Lastly, it might flow better if the prevalence section was contained at section 4, immediately following the definition of CSA (for example; what is CSA; how prevalent is it?) It is helpful for the draft pathway to contain a section on the prevalence of CSA. The lack of robust prevalence data at both national and local level may at least in part contribute towards the low priority given to the planning and delivery of therapeutic services for children who have experienced sexual abuse, particularly younger children. The figures in the Pathway are provided for context only. The primary aim of the Pathway is to promote the delivery of consistent high quality care and support to Children and Young People who have experienced child sexual abuse and their non-abusing parent/carer(s).
64M5-M We welcome the inclusion of a definition of child sexual abuse. In order to increase ownership of the Pathway across the services/ agencies to which it pertains, it might be helpful to use the Scottish Government definitions of CSA and CSE, contained in National Guidance Child Protection. As mentioned, the guidance is currently under review; liaison with the review team will be important to ensure consistency. More information about the context of CSA/ CSE would also be extremely helpful to clarify the dynamics of child sexual abuse. For example, from The Right to Recover: This broad (Scottish Government) definition encompasses the many different contexts and situations in which sexual abuse occurs. This includes within the child’s family, circle or community; peer to peer abuse perpetrated by other children, including within teenage intimate relationships. It includes sexual abuse and exploitation conducted online, a new platform for abuse both by peers and adults which includes, for example, causing or coercing a child to watch a sexual act, and grooming a child online. Child sexual exploitation (CSE) is a type of abuse which is recognised as taking a variety of different forms and takes place in a variety of contexts including organised crime. The Scottish Government definition of CSE is a form of child sexual abuse in which a person(s), of any age takes advantage of a power imbalance to force or entice a child into engaging in sexual activity in return for something received by the child and/or those perpetrating or facilitating the abuse. As with other forms of child sexual abuse, the presence of perceived consent does not undermine the abusive nature of the act. Explicit in these definitions is the misuse of power. The social position of children involves not only their reliance upon adults for all their basic material and emotional needs, but subordination to adult authority, a relationship often reproduced in dynamics between older and younger children. Additionally, inequality between the sexes and therefore the social position of women, and not only children, shapes the context for sexual abuse. Globally CSA is recognised as a form of gendered violence rooted in sexual inequality.12,13 Evidence overwhelmingly points to child sexual abuse as a problem affecting a significant minority of the population, both female and male, but with a higher prevalence (2-3 times higher) amongst females. Over 90% of all sexual abuse is perpetrated by males, with around one third involving physical force. Approximately two thirds of CSA is extra-familial, with young people’s intimate partner relationships, and therefore socialised gender relationships, forming a key context The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, which is currently out for public consultation.
64M5-M Missing Section - Impacts of child sexual abuse on children and families […] regards it as imperative that the care pathway outlining the stages in the joined-up health response to children following sexual abuse raises practitioner’s awareness of the potential impacts of sexual abuse on the health and wellbeing of children and young people, and families, during childhood and at later stages in life. This information underlines the critical importance of the pathway in supporting practitioners/ services to meet the holistic health needs of all children and young people experiencing sexual abuse, minimising preventable harm to health and wellbeing in the short and long term. There is extensive research literature on impact to draw on. A recent rapid evidence assessment of the impacts of CSA, published by the Independent Inquiry into Child Sexual Abuse, provides a very helpful summary. It also includes vital information about identified risks and protective factors which may impact on a child’s experience of recovery, including the response of health services and other agencies. https://www.cypnow.co.uk/digital_assets/7fc18fa4-5745-48e6-bb02-b0e3157061f6/IICSA-Impacts-of-CSA-REA-English-summary-report-FINAL.pdf It is critical that health practitioners, and all practitioners, understand the potential impact of their response to a child, on the child’s journey to recovery. It is also of fundamental importance that the pathway outlines the potential impacts of child sexual abuse on families/ non-abusing carer. Health practitioners in West of Scotland described sexual abuse – in particular familial – as ‘like a bomb going off on the family’ . Impacts experienced by non-abusing parents as a result of their child’s abuse can mirror the outcomes experienced by victims107 and can affect all aspects of parents’ lives, including their physical health, personal relationships, employment and financial stability. 108 Crucially, parents can find it very difficult to support a child who has experienced abuse, at a time when they are trying to cope with acute emotional upheaval, which can have a critical impact on the child’s chances of recovery. Understanding the potential impact on carers helps underline the necessity of a supportive carer response. Support for non-abusing carers, on a case by case basis, will range from providing information and support at each stage, to facilitating access to therapeutic support, where required. The document references current work being undertaken by the CMO Taskforce to explore enhanced provision of family support services (5.1, pg. 14). Further information on the nature of enhanced provision would be extremely helpful in order that we can comment. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64M5-M 4.3 Trauma informed Services 'The core experience of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based on the empowerment of the survivors and the creations of new connections' Herman (1992) Trauma and Recovery pg. 133 This section could very helpfully be expanded to include some brief text around the fundamental characteristics of child sexual abuse in order to make information about trauma informed practice really meaningful to practitioners. For example, understanding the nature of the ‘relationship’ between child and abuser – where all power and control resides entirely with the abuser, helps underline why it is critical for services to help children and young people feel in control of the processes they are going through, with trusted support, information and choice being given at every stage of the journey. We would also stress the need for a paragraph which indicates that a central reason for the pathway – and indeed a trauma informed response - is to ensure that the child, young person and non-abusing carer/ family are supported towards recovery, including support to access therapeutic services, where indicated. It might also be helpful to include some brief information to de-bunk what may be a common assumption: that if children are not displaying overt symptoms of what adults consider distress, there may be no need to intervene. The evidence around ACES provides clinical evidence to support the moral imperative that a) children have a fundamental right to recover from sexual abuse and access therapeutic services and b) a trauma informed response to a child is based on the principle of addressing preventable harm and minismising negative outcomes in the short and long term. Useful resources describing a trauma informed approach to working with people who have experienced CSA include ‘Yes You Can: Working with Survivors of Child Sexual Abuse’. (Scottish Executive, 2005). There is now more information and context on trauma informed care and adverse childhood experiences.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64MV-N The context gives a useful overview of the issues that need to be considered before discussing the pathway, but need to be revised to ensure the link with child protection approaches The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, which is currently out for public consultation.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MV-N The WHO definition quoted on page 11 defines child sexual abuse in very general terms, and does not give clarity on issues of consent. A more helpful definition of child sexual abuse can be found in Para 36 of the National Child Protection Guidance. 36. Sexual abuse is any act that involves the child in any activity for the sexual gratification of another person, whether or not it is claimed that the child either consented or assented. Sexual abuse involves forcing or enticing a child to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of indecent images or in watching sexual activities, using sexual language towards a child or encouraging children to behave in sexually inappropriate ways (see also section on child sexual exploitation). The NCPG definition makes that sexual abuse is any act that involves the child in any activity for the sexual gratification of another person, whether or not it is claimed that the child either consented or assented The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, which is currently out for public consultation
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MV-N The final paragraph on page 11 also needs to be clarified. While it is true that the 2009 Act does create a separate “offence of engaging an older child in sexual conduct with or towards another older child”, and in these circumstances child protection risk assessment is appropriate, even if a child “engages by consent in the conduct in question” an offence has still been committed and, according to the National Child Protection Guidance, child sexual abuse has taken place. However, the final paragraph on page 11 could be read as implying that situations where older children are involved, ‘consent’ is apparently given and no immediate child protection concerns raised do not come within the ambit of child sexual abuse and therefore the pathway does not need to deal with children in these situations. [Our organisation] believes the pathway must be flexible enough to meet the needs of any child who has disclosed child sexual abuse under the terms of the NCPG References to legislation in the Pathway have been updated in line with additional comments from COPFS.
64MV-N It would also be worth citing the description of child sexual exploitation set out in paras 572 -575 of the National Child Protection Guidance. As with all sexual abuse the sexual exploitation of children and young people is a hidden form of child abuse, with distinctive and insidious elements of exploitation and exchange. In some cases consent may appear to have been given, and the sexual activity may be may just take place between one young person and a peer, but nonetheless sexual exploitation is abuse and should be treated accordingly. The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, which is currently out for public consultation.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MV-N These issues around consent and definition of abuse highlight the necessity of the pathway being designed to work within wider child protection process. Whilst we recognise that all age services and parallel pathways for adults and children might have been identified by the options appraisal process as the best approach, any response to disclosures of child sexual abuse needs to take account of the very different needs, rights and issues for children and young people. This journey, from disclosure to recovery, should also be the core remit of the Barnahus standards development group. We recognise and welcome the speed of movement on the development of Barnahus by Scottish Government in recent months. It is very likely that had that development started sooner, the pathway for adults and children and young people would have been addressed separately from the outset. [We] believe that the Barnahus development work so far can help develop clarity about what a good response for children and young people looks like in relation to this pathway. Alongside that links to the pathway can be included in the discussion and planning for Barnahus standards for Scotland The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, which is currently out for public consultation.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MV-N We would also like to see a stronger and more complete section on adverse childhood experiences. The current section is very limited, and some of the language used – such as “When not properly treated, child sexual abuse can result in a lifetime of Post Traumatic Stress Disorder (PTSD), depression and anxiety” does not fully reflect the current Scottish government approach to ACEs. We have therefore, as a suggestion, drafted a longer and more detailed section 4.4, which we hope is a useful starter for a longer and more detailed coverage of ACEs. It is largely drawn from the Scottish Public Health Network (ScotPHN) publication 'Polishing the Diamonds, Addressing Adverse Childhood Experiences in Scotland’ by Sarah Couper and Phil Mackie and published in May 2016: 4.4 Understanding the Impact of Adverse Childhood Experiences It is recognised that sexual abuse is one of the Adverse Childhood Experiences that can impact the health and wellbeing of individuals throughout their life. In particular the dynamics of child sexual abuse and the associated grooming process and/or coercive aspect of the abuse can affect all aspects of a child’s life and therefore addressing these is also a necessary part of the recovery process. Young people who are victims of sexual abuse can experience issues like difficulty in concentrating in school, challenges in their interpersonal relationships and places themselves at repeated risk as a result of the complex feelings and response to abuse. For some they find that the consequence of disclosing abuse is that they are taken from their family in order to remain safe, or some find themselves in a conflicted situation where family, friends and peers can choose to believe either their story or that of the accused. The importance of being listened to and heard in a non-judgemental environment cannot be underestimated, as it is through the process of sharing their thoughts and feelings that young people can be supported to make sense of their experiences and begin to understand why they may feel and act in certain ways. Children and young people can be helped to cope with the impact that being sexually abused has had on their sense of sense and the way in which they relate to the world around them, through being offered respectful, relationship based therapeutic support. Conversely if young people are not offered the support they need to recover from the impact of sexual abuse, we know from adult survivors that some will go on to develop symptoms of mental ill health such as depression and anxiety or may be given diagnosis of Post Traumatic Stress Disorder (PTSD or other mental health diagnosis. Many will also have an increased likelihood of developing a chronic physical illness There is now more information and context on trauma informed care and adverse childhood experiences.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).

Contact

Email: CMOtaskforce.secretariat@gov.scot

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