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Review of databases on social care, psychiatry, and psychology revealed various strategies for preventing sexual abuse in people with intellectual disabilities. These procedures generally seem to fall into one of three broad categories: therapeutic measures, designed to minimise the effects of abuse; education and training for staff, victims and/or family members (e.g. parents); and multi-agency information sharing.
Kroese and Thomas (2006) tested the value of Imagery Rehearsal Therapy (IRT) for treating sexual abuse trauma in learning disabled people experiencing recurring nightmares. The intervention produced a statistically significant reduction in distress. Furthermore, these positive effects seemed to endure even when participants were awake. Several studies have evaluated the merits of ‘support groups’ for victims of abuse (e.g. Singer, 1996; Barber et al, 2000). For example Singer (1996) organised ‘group work’ for adults living in a residential home. The aim was to teach these individuals how to respond assertively in situations of abuse. Assertiveness is an essential skill for victims who often fail to challenge authority, due to low self-esteem, fear, dependency and lack of awareness of their rights (MENCAP, 2001). Participants learned to respond more assertively when role-playing situations that involved sexual abuse. However, role-play scenarios often lack the stressful conditions of real-life that may prevent an individual from speaking out. Nevertheless, support groups may provide a valuable therapeutic resource for victims of abuse (Barber et al, 2000).
The National Association for the Protection from Sexual Abuse of Adults and Children with Learning Disabilities (NAPSAC[1]) identifies the sharing of information between protection agencies as a valuable prevention strategy (Ellis & Hendry, 1998). Based on data from a survey of individuals and organisations involved in social care, Ellis and Hendry (1998, p.362) emphasised the need for a “foundation level of awareness” between specialists in learning disability and those involved with child protection. Lesseliers and Madden (2005) report the establishment of a ‘knowledge centre’ to encourage systematic exchange of sexual abuse information, which is accessible to both victims and specialists (also see Stein, 1995). The problem with information sharing schemes is that they primarily benefit service providers (e.g. expanding their knowledge of available therapies), rather than the victims themselves. Finally, several studies have tested the efficacy of education and training programmes, targeted at staff, victims, and/or family members (e.g. Martorella & Portugues, 1998; Tichon, 1998; Bruder & Kroese, 2005). Bruder and Kroese (2005) reviewed clinical studies that evaluated the value of teaching protection skills to learning disabled adults and children. Findings revealed that adults could be successfully taught such skills, although the generality and longevity of these abilities was questionable. Martorella and Portugues (1998) conducted workshops with parents, based on the premise that prevention is best achieved by making family members aware of sexual issues concerning their children. Parents were provided with printed materials and videos on puberty, childhood sexual fantasies, and other related topics. Following these sessions many parents re-evaluated their children, and demonstrated a renewed urge to support and protect their children. Overall, training and education schemes seem to have immediate albeit short-lived psychological benefits, for both the victim and their families.
Discuss the Similarities in “Vulnerable Adult Sexual Abuse” and “Child Sexual Abuse”
There are similarities in terms of the reasons why disabled people are susceptible to abuse (MENCAP, 2001), psychopathological and social effects of abuse (Sequeira & Hollins, 2003), consent issues, and protection requirements (DOH, 2002a, 2002b). The MENCAP (2001) report identifies seven reasons for increased vulnerability in adults, most of which may equally apply to children; they include low self-esteem, long-term dependency on carers, lack of awareness, fear to challenge authority, powerlessness to consent to sexual relationships, inability to recognise abuse when it occurs, and fear of reporting incidents of abuse. These concerns are compatible with factors the National Society for the Prevention of Cruelty to Children (NSPCC, 2002) implicates in child vulnerability. They include: children’s lack of awareness and education; a learned reluctance to complain; dependency on carers, which can make it difficult for a child to avoid abuse; and general disempowerment. Whereas factors such as fear of authority and low self-esteem may be ambiguous, and hence difficult to detect, long-term dependency on a care giver is a much more tangible characteristic that increases susceptibility to abuse, in both adults and children. The risk may be higher in children because their level of dependence is usually more extreme. However, severely impaired adults may also be highly dependent on another person for their day-to-day care (MENCAP, 2001).
In their review of the literature on the clinical effects of sexual abuse in intellectually disabled people, Sequeira and Hollins (2003) found that both children and adults exhibited behavioural problems, sexually inappropriate behaviours, and various forms of psychopathology. However, some evidence suggests that children may be more ‘overwhelmed’ by the experience of sexual abuse, often with long-term and harmful consequences for mental health (Green, 1995). Moreover the damaging effects of sexual abuse may be compounded in both adults and children when the abuser is known to the victim (e.g. family member). However, Sequeira and Hollins (2003) warn against drawing conclusive inferences regarding the clinical impact of abuse on disabled populations. Firstly many studies rely on ‘informants’ (e.g. family members) for their data, many of whom may be ignorant of the internal psychiatric and cognitive trauma that a disabled person might be experiencing. Thus, any apparent similarities between children and adults in how they respond to sexual abuse may not reflect less obvious discrepancies in psychopathology. Sequeira and Hollins (2003) emphasise the need for more reliable diagnostic criteria.
The MENCAP (2001) report stresses the issue of consent. Both children and adults often lack the ability to give consent albeit for different reasons. Children may simply not have any understanding of sexual activity, its consequences, and how to distinguish sexual behaviour from other forms of physical contact (e.g. hugging) and personal care (e.g. bathing). Although most adults will have a better grasp of sexuality, some may be unable to give consent if their learning disability is extremely severe. Regardless, adult and child sexual abuse denotes a lack of consent. Furthermore, both forms of abuse may require similar safeguards. There is a mutual need to create more awareness amongst the general public about the vulnerability of people with learning disabilities (NSPCC, 2002). Community building, staff training, and other protective measures will benefit both children and adults (Ellis & Hendry, 1998; Barter, 2001; Davies, 2004).
Can the “Keeping Safe” Child Protection Strategy Work with Adults with Learning Disabilities?
The Department of Health has made various recommendations for “keeping children safe” (DOH, 2002a). These include: having a sound statutory framework; encouraging professionals from different specialities/agencies to work together; assessing children’s needs and the range of support services provided by organisations and community groups; considering the impact of strategies designed for vulnerable adults on children; involving both children and family members in making decisions about what services the child needs; monitoring how well councils are delivering the system; and recruiting, training, and supervising adequate care staff. These proposals are a direct response to the Victoria Climbie Inquiry report. Overall they emphasise risk assessment, recognition of abuse, and information sharing, consistent with other published literature (e.g. Ellis & Hendry, 1998; Lesseliers & Madden, 2005). By contrast, the Department of Health prescribes a different set of guidelines for adults, referred to as the Protection of Vulnerable Adults Scheme, or POVA (DOH, 2004). Central to the scheme is the POVA list: “Through referrals to, and checks against the list, care workers who have harmed a vulnerable adult, or placed a vulnerable adult at risk of harm, (whether or not in the course of their employment) will be banned from working in a care position with vulnerable adults. As a result, the POVA scheme will significantly enhance the level of protection for vulnerable adults” (DOH, 2004, p.5). The POVA system is supposed to complement other schemes, such as MENCAPS “behind closed doors” plan (MENCAPS, 2001).
The child protection scheme can be adapted to work with adults. Many child safety measures focus on staff performance (e.g. working together, recruitment, training). For example, it is a requirement that staff are trained sufficiently to recognise “whether a child’s injury or illness might be the result of abuse or neglect” (DOH, 2004, p.7). By implication, it should be possible to modify training protocol so that staff can also identify sexual abuse in vulnerable adults. For example, Lunsky and Benson (2000) identify some issues to be considered when interviewing developmentally disabled adults about sexual abuse, notably the appropriateness of using detailed drawings and dolls used in assessing children (Martorella & Portugues, 1998). Proposals designed to help identify the need for protection and facilitate information sharing, such as community “neighbourhood watch” arrangements, can be extended to adults. What modifications would be required? MENCAPS (2001) highlights the need for a suitable mechanism for establishing consent between adults. Vulnerable adults have the same sexual rights and privileges as the general population, and these rights have to be accommodated within any protection strategy. Staff training on child protection can include guidelines for identifying adults who are able to give consent to sexual relations (e.g. suggesting appropriate tests to use), and protecting those who can’t. Additionally, MENCAPS (2001) emphasises the need to “tighten standards for people who work with adults” (p.16). The POVA scheme is set up precisely to address this issue, albeit retrospectively, after abuse has occurred (DOH, 2003). Improvements in staff recruitment, training, and monitoring can be implemented that benefit both children and adults.
Bibliography
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