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Adoption & Fostering
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DOI: 10.1177/030857590502900204
2005 29: 18 Adoption & Fostering
Sue Pollock and Elaine Farmer
Children in Substitute Care
A Hidden Population: Understanding the Needs of Sexually Abused and Abusing

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18 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
A hidden population Understanding the needs of
sexually abused and abusing children in substitute
care
1
Despite high levels of concern among professionals
about how best to manage sexually abused children
looked after in public care, there has been little re-
search on this subject. Sue Pollock and Elaine
Farmer report the findings from a study of a sample
of such children which shows that, as a group, they
share characteristics that make them significantly
more vulnerable to sexual risks and to emotional,
educational and behavioural difficulties than their
non-sexually abused counterparts in residential and
foster care. However, at the point of placement there
are rarely markers to alert carers to the multiple
deprivations and adversities in their backgrounds
and it is therefore likely that this group of children will
be denied the specific targeted therapeutic, educa-
tional and family support that they need. This study
highlights the importance of good record-keeping,
thorough assessments of need at the point of
placement, effective communication between social
workers and caregivers and joint planning between
social services, health and education to implement
comprehensive packages of care.
Introduction
Over the past 20 years the long-term
psychological and behavioural conse-
quences of sexual abuse in childhood
have been well documented. The psycho-
logical symptoms described include
depression, low self-esteem, self-blame,
fearfulness and anxiety, post-traumatic
stress disorder and dissociative reactions
(see, for example, Kendall-Tackett et al,
1993 for review; Briere and Elliott, 2003;
Cross et al, 2004; Goodman et al, 2003).
Among the behavioural difficulties iden-
tified are self-harm, attempted suicide,
age-inappropriate sexual behaviour, the
sexual abuse of other children and anti-
social behaviour (eg Finch, 1967; Burgess
Sue Pollock is
Lecturer in Social
Work, School for
Policy Studies,
University of Bristol
Elaine Farmer is
Professor of Social
Work in the same
department
Key words: sexual
abuse, substitute care,
adversities,
assessment
et al, 1987; Seghorn et al, 1987;
Fehrenbach and Monastersky, 1988;
Cinq-Mars et al, 2003). In particular,
sexualised behaviour in children is one of
the most robust and systematically
identified of the many behavioural
sequelae of sexual abuse (Friedrich,
1993).
However, sexual abuse does not stand
alone as the cause of subsequent disturb-
ance. A number of studies have suggested
that sexually abused children are more
likely to come from families with high
rates of problems such as prolonged
parental absence or conflict, parental
abuse and neglect and interactional dys-
function (eg, Alexander and Lupfer, 1987;
Madonna et al, 1991; Monck and New,
1996; Meyerson et al, 2002; Duane et al,
2003; Grossman et al, 2004), which in
themselves have been found to be associ-
ated with worse outcomes for children
(MacVicar 1979; Conte and Schuerman,
1987). Social and educational adversities
in the backgrounds of sexually abused
children have received less attention and,
to date, the cumulative impact of these
background factors, together with re-
moval from home and the likelihood of
repeated admissions to care, have not
been well researched. What is clear, how-
ever, is that children in the out-of-home
care system who have adverse sexual
histories are likely to be a particularly
vulnerable, testing and needy group
whose disturbed psychological function-
ing and behaviour cover a broad spectrum
of distress.
It follows from this that the placement
of sexually abused children poses particu-
lar challenges for all those involved.
Caring for them can be a demanding task
for residential workers, foster carers and
their families (eg Chop, 2003). At the
same time, caregivers have become
increasingly aware that they themselves
1
This research was funded by the Department of Health.
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 19
may be subject to allegations of abuse by
the children (eg National Foster Care
Association, 1988; Lowe and Verity,
1989; Nixon and Hicks, 1989; Levy and
Kahan, 1991; Williams and McCreadie,
1992; Kirkwood, 1993; Utting, 1997;
Hayes, 2002). Service providers, in their
turn, are beset by the task of trying to
maintain a stock of foster carers and
residential workers who have sufficient
training, experience and resilience to
cope with the demands of these children,
and by the difficulty of matching individ-
ual children with the availability of suit-
able placements (Utting, 1991; Rickford,
1992; Farmer and Pollock, 1999). There is
also concern about children who sexually
abuse others, and how they should be
managed in substitute care (Utting 1991;
National Childrens Home, 1992; Lindsay,
2001).
These challenges are heightened by
the fact that as a group sexually abused
children are rarely easily recognisable at
the point of placement, particularly when
the sexual abuse may have occurred
several years earlier, and therefore their
particular needs may often go unnoticed
and unmet. While the large body of prac-
tice literature on the subject suggests that
the task of looking after sexually abused
children is an important issue for practi-
tioners and caregivers (eg Roberts, 1989;
Devine and Tate, 1991; Calder, 2001;
Chop, 2003), there has been very little
systematic research on their management
and needs when they are taken into out-
of-home care.
This paper describes the character-
istics of a consecutive sample of sexually
abused and abusing children looked after
away from home (the sexual abuse
group) and compares them with a repre-
sentative population of children in sub-
stitute care who have no recorded adverse
sexual history. We were interested to
explore how far and in what ways the
sexual abuse group were significantly
different from their looked after counter-
parts. Do they constitute a hidden
population with particular needs or diffi-
culties in common that might not be
apparent to their caregivers?
Method
This was an exploratory study in an under-
researched area. Its purpose was system-
atically to compare the characteristics of
sexually abused and/or abusing children
in out-of-home care with those of the
wider population of looked after children.
Following from this the research aimed to
explore in more detail the childrens
behaviour, care and management in their
substitute care settings from the perspec-
tives of their carers, social workers and
the young people themselves.
The study was undertaken in two local
authorities with large multi-racial urban
populations as well as suburban and rural
areas. Both authorities had substantial
residential care sectors as well as estab-
lished fostering services. Two samples of
children and young people were selected
for study: the case file sample and the
interview sample (a sub-group of the case
file sample). This paper will report find-
ings from the case file sample. Findings
from the interview sample are reported
elsewhere (Farmer and Pollock, 1998)
The case file sample
The selection of an inclusive and repre-
sentative sample of young people entering
care with a history of sexual abuse or
abusing behaviour proved to be a task
beset with methodological difficulties.
First, sampling from among those child-
ren currently on the Child Protection
Register under the category of sexual
abuse or admitted to care because of
concerns about sexual abuse would ex-
clude those children who were not
currently thought to be at (or to present)
sexual risk, even if there had been con-
siderable risk in the past. Entry to care
itself can provoke de-registration.
Secondly, asking social workers or carers
to identify sexually abusing and abused
children on their caseloads or in their care
ran the risk of biased, selective or unin-
formed reporting.
In order to overcome these difficulties
it was decided to scrutinise the case files
of a consecutive group of all new admiss-
ions to care over a specific time period
(six months in local authority 1 and four
months in local authority 2). This pro-
cedure had the advantage of allowing
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20 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
comparisons to be made between young
people with a recorded history of sexual
abuse and/or abusing behaviour and those
with no such history on file. The case file
survey also provided contextual informa-
tion for the subsequent detailed interview
study.
Information was collected from the
young peoples files about their demo-
graphic and family background, abuse
and placement history and history of
other adversities as well as detailed
information on the reasons for the current
placement. Operational criteria defining
sexual abuse and abusing behaviour were
applied to the case file material (see
below) and the sample was divided into
those who met the criteria (the sexual
abuse group) and those who did not (the
non-sexual abuse group). Of course, it is
possible that the non-sexual abuse group
contained abused children whose sexual
history was not known or not recorded on
their case files. However, subsequent
statistical analysis of the data suggested
that the crossover between the groups was
unlikely to be significant or misleading.
In all, 250 case files were reviewed,
121 in local authority 1 and 129 in local
authority 2. Some sort of sexual abuse or
abusing behaviour had been an issue at
some point in their lives for almost two
out of five (38 per cent) of all the newly
looked after children. It was also clear
that there was a great deal of variation
within this group in terms of their hist-
ories of sexual abuse or abusing behav-
iour, levels of intervention by social
services and histories of other adversity.
Operational definition of child sexual
abuse and abusing behaviour
Child sexual abuse is a highly complex
and sensitive area to study. Accurate
descriptions of sexual behaviour and
events are often elusive and behaviours
are subject to variable definitions. For
this reason an inclusive definition was
needed which would include all those
young people whose involvement in
sexual abuse or abusing behaviour had
given rise to concern at some stage,
whether or not such behaviour was the
reason for their admission to out-of-home
care (Kelly, 1988). Therefore, for the
purposes of this study, sexual abuse or
abusing behaviour was operationally
defined as professional concern having
been noted on file about one or more
sexual incidents in a childs life. The
professional concern could have been
expressed by a medical professional or
teacher and noted by the social worker.
Alternatively, the social workers might
have been sufficiently worried themselves
to report the disquiet of a parent or other
adult about an incident or they might
have made a record of their own observa-
tions.
This approach had the advantage of
allowing the researchers to identify child-
ren whose abuse had taken place at some
time in the past and also to make their
own assessment of the probability of
abuse or abusing behaviour having occur-
red in the absence of disclosure, admiss-
ion of guilt or forensic evidence. The
definition was sufficiently broad to
include children who displayed a variety
of activities and behaviours ranging from
the sexually exploited to the sexually
exploitative end of the spectrum. In
making the assessments based on the file
data the researchers drew on their exten-
sive social work experience.
Degree of certainty that sexual abuse or
sexually abusive behaviour had
occurred
The childrens sexual histories were
diverse and the degree of certainty about
whether sexual abuse or abusing behaviour
had occurred was inevitably variable. The
different levels of certainty were therefore
recorded for all the relevant children.
Sexual abuse
There were 89 children in the case file
sample who had been or were suspected
of having been sexually abused. The first
and largest group (n = 53; 60 per cent)
comprised children where there was
consensus that sexual abuse had occurred,
usually because the child had made a
disclosure that had been believed or
because there was additional evidence or
corroboration for the abuse. For example:
At the age of nine David disclosed that a
family friend and another man had
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 21
sexually abused him. The family friend
was prosecuted and convicted.
The second group (n = 15; 17 per cent)
contained children where there was a high
level of professional concern about sexual
abuse or the risk of abuse, often because
there was an accumulation of concerns
about the sexual risks in the childs en-
vironment or about the childs sexual
behaviour. For example:
Kevin, aged 11, was seen by professionals
as likely to have been abused. His younger
sister had disclosed that she had been
sexually abused by their father who was a
Schedule One offender and Kevin devel-
oped bulimia and had a fascination with
starting fires.
The third group (n = 20; 23 per cent)
included children where there were pro-
fessional suspicions that a child had been
sexually abused but the issue remained
uncertain in the absence of a disclosure
from the child or confirmatory evidence.
For instance:
The social services department had con-
cerns about Sam, aged 14, who together
with his brothers had shared his home for
over a year with a man who was a Sched-
ule One offender. This family friend had a
conviction for indecent assault on an
eight-year-old boy. The man had a great
deal of access to Sam and his brothers,
took a special interest in them and took
them away on holidays. Sams father
did not take seriously his friends convic-
tion for sexual assault and was pleased
to have his help in looking after the
boys.
Sexually abusing behaviour
What we have referred to as sexually
abusing behaviour covers a wide range of
activities. Using Cavanagh Johnsons
continuum of sexually abusing behaviour,
we categorised the young people as either
sexually reactive or as engaging in
extensive mutual sexual behaviours (n =
14; 58 per cent of the abusing group) or
as children who molest (n = 10; 42 per
cent of the abusing group) (Cavanagh
Johnson, 1993). The latter group was
considered to demonstrate a compulsive
quality to their abusing behaviour, to have
used coercion and to have exerted power
and control as a result of the considerable
age difference between the abuser and
victim. Many of the children in the
molesting category were nearing or had
reached adolescence. We grouped the 24
children who had shown sexually abusing
behaviour using similar criteria of cer-
tainty to the sexually abused children.
In comparison with the abused child-
ren, a much higher proportion of the
sexually abusing children fell into the
category of professional consensus that
the behaviour had occurred (n = 20; 83
per cent of the abusing young people).
This was largely because the abuse of
other children often came to light when it
was observed or discovered by an adult or
because of disclosure by the victim. For
example:
Donnas long-term sexual abuse of her
younger brother was discovered when he
disclosed to their mother. She was 14 by
then and he was nine.
Gavins sexual abuse of his younger bro-
ther was discovered by his foster mother
when she found them in bed together.
Gavin was eight and his brother was four.
The rape of a young woman by a group of
boys, including Wayne aged 15, was
reported by the victim to the police.
Charges were brought against the boys.
The second and only other group of
abusing children included those where
abusing behaviour seemed likely to have
occurred (n = 4; (17 per cent of the
abusing young people). We employed this
category when the information available
from the file was too sparse for us to be
completely confident about the behaviour
reported. Examples are:
Will, who had been sexually abused at the
age of five by a female cousin, was re-
ported at the age of six to have shown
inappropriate sexual behaviour at school
with a little girl.
Bens file records that he had sexually
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22 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
abused a younger boy at the age of six
when he was in foster care.
It was alleged that Paul had been
involved in sexual activities with a girl
when he was ten.
While the existence of reports on file
make it fairly likely that these events
occurred, the lack of detail serves to place
them in the less than certain category.
admission. Boys accounted for 57 per
cent and girls for 43 per cent of the
sample. Seventy-nine children (32 per
cent) had one or more siblings in the
sample.
Ninety-six children (38 per cent) met
the research criterion described above for
the abuse group (that is, that there had
been a professional concern noted on the
childs file about a sexual incident in the
childs life). Of these 96 children, the
information from the files suggested that
72 (75 per cent) had been sexually abused
only, 17 (18 per cent) had both sexually
abused another child and had themselves
been abused, while a small minority of
seven (seven per cent) were only known
to have sexually abused another child. In
the subsequent analysis these three groups
were treated as one sexual abuse group.
Nearly half of all the girls (48 per
cent) who were looked after in the case
file sample had raised professional
concerns abut a sexual incident in their
lives, as opposed to fewer than a third (31
per cent) of the boys. Girls therefore
tended to be over-represented in the sex-
ual abuse group (54 per cent compared
with 36 per cent in the non-sexual abuse
group) and boys under-represented, as
might be expected.
Eighty-seven per cent of children in
the sexual abuse group were white and 13
per cent black or of mixed parentage.
Twenty children in this group (21 per
cent) had a disability. Three children in
the sexual abuse group were physically
disabled, 14 had learning difficulties and
another three had severe learning difficul-
ties. The proportions of black and dis-
abled children in the sexual abuse and
non-sexual abuse group were very
similar.
Reasons for admission to care
Even though as many as 96 (38 per cent)
of the young people in the file search
sample had a sexually adverse back-
ground, only a minority entered care for
this reason. In fact, the reasons for entry
to care were very similar in the sexual
abuse and non-sexual abuse group. The
stated grounds for admission at the time
of entry to care can be an important clue
to the ways in which that young persons
Table 1
Level of certainty of sexual abuse or sexually
abusive behaviour having occurred
Abused* Abusing*
Consensus 53 (60%) 20 (83%)
Concern 15 (17%) 4 (17%)
Suspicions 21 (23%) 0 (0%)
Total 89 (100%) 24 (100%)
*17 children fell into both abused and
abusing groups
Analysis
The case file material was coded and
entered on to a computer database and
analysed using SPSS for Windows. The
significance level for differences between
groups was set at p<0.05. The informa-
tion from this part of the study served two
purposes. Firstly, we were able to estab-
lish the prevalence of past sexual abuse or
abusing behaviour in a total population of
children newly entering out-of-home care.
This was an important exercise in an area
which has been prone to speculation, and
in which there have been guesstimates
but no solid research evidence (see, for
example, Utting, 1991). Secondly, this
hidden population could then be com-
pared with looked after children who had
no record of abuse or sexually abusing
behaviour. Bivariate analyses allowed us
to determine the variables that differen-
tiated the sexually abused and/or abusing
children from their non-abused peers in
out-of-home care.
Results
The 250 children in the case file study
came from 203 families. Just over half
(51 per cent) were under ten at the time of
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 23
care because they had been sexually
abused and four because of the childs
sexually abusing behaviour. Another 13
per cent of the abuse group entered care
because of concerns about their sexual
behaviour, which was seen as beyond
control and involving risks to them.
However, the majority of children in the
sexual abuse group (69 per cent) were
admitted for other reasons such as being
beyond their parents control or their
parent(s) being unable to care for them or
needing respite. These reasons were very
similar to the young people in the non-
sexual abuse group. At the time of entry
to out-of-home care, therefore, in most
cases the childrens experiences of sexual
abuse and/or abusing behaviour were not
obvious. Our subsequent interviews with
caregivers in the interview sample
confirmed that information about sexual
abuse or abusing behaviour was often not
given to them at the time of placement
(Farmer and Pollock, 1999). Thus, if there
were significant differences in the needs
of the children with adverse sexual hist-
ories, these might easily be disregarded.
Comparison of the abused and non-
abused children
When the children in the sexual abuse
and non-sexual abuse groups were
compared it soon became clear that there
were clear and significant differences
between them. The children in the sexual
abuse group tended to be older than those
in the non-sexual abuse group, with 59
per cent aged ten or over, compared to 42
per cent of the non-abused children in
this age group. They had also entered care
on this occasion at older ages (mean 10.8
years compared to eight years in the non-
abuse group).
Previous history of care
When we looked at the childrens pre-
vious contact with the care system it
became clear that children in the sexual
abuse group were significantly more
likely to have had a previous admission to
care than those in the non-sexual abuse
group (40 per cent as compared with 28
per cent).
2
While children in the sexual
Table 2
Primary reason for the children being looked after
Sexual abuse Non-sexual
group % abuse group %
Sexual abuse or abusing behaviour 18
Sexual behaviour put child at risk 13
Sexual abuse to another child of the
household 2
Break for parents 20 24
Parent hospitalised or unable to care 13 27
Beyond control, including non-
attendance at school and drug misuse
by the child 15 17
Physical abuse or neglect 6 14
Offending 3 3
Childs request 4 1
Poor home conditions 2 2
Drug or alcohol problems of parent 2 2
Other concerns about childs welfare 3 5
Not clear 1 3
100% N = 96 100% N = 154
needs have been perceived by the network
of professionals around them. This, in
turn, is likely to influence the care they
receive while other important aspects of
the young persons history or
circumstances may be overlooked.
Interestingly, children whose sexual abuse
or abusing behaviour was the immediate
reason for their entry to care accounted
for fewer than one in five (18 per cent) of
the admissions in the sexual abuse group
and this represented only seven per cent
of all of the 250 admissions. Since the
Cleveland Inquiry in the UK (Secretary of
State for Social Services, 1988) there has
been a clear expectation that when sexual
abuse is suspected the preferred course of
action is for the alleged abuser to leave
the household and in this way allow the
child to remain at home. The low pro-
portion of admissions for reasons of
sexual abuse suggest that local authorities
had heeded the recommendations of that
Inquiry.
Thirteen children were admitted to
2
p<0.01
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24 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
abuse and non-sexual abuse groups were
equally likely to have experienced respite
care, the sexual abuse group had more
previous admissions for other reasons
16 per cent had had four or more previous
care episodes compared with only five
per cent in the non-abuse group.
3
This
result is in line with Smith and Howards
finding of higher rates of placement
change in their sexually abused group
than in a non-sexual abused group (a
mean of 6.49 compared with a mean of
4.42 moves in the non-abused group)
(Smith and Howard, 1994). Children in
the sexual abuse group had also spent
significantly longer in care previously
than their non-sexually abused peers.
Fourteen per cent had spent more than a
year (compared with five per cent of the
others), and a quarter had spent more than
four months (compared with 11 per cent
of the others). The older age of the sexual
abuse group accounted for some but not
all of these differences.
The higher rates of previous care
admissions in the sexual abuse group
reflect the higher levels of family and
educational disruption and rejection in
this group, which are detailed below. In
addition, the number of moves in care
may be viewed as both a contributor to
and an indicator of the level of emotional
disturbance experienced by children who
are removed from their family. Children
who have higher levels of emotional and
behavioural disturbance, particularly if
this involves an element of sexual acting
out, may be more likely to be ejected
from foster and residential placements
(see, for example, Fanshel et al, 1990),
thereby causing a repetition of family
patterns of disruption and rejection.
At the time of these previous periods
in care, 19 per cent of the sexual abuse
group had been subject to a care order,
interim care order or wardship, ordered
by the courts (as compared with only six
per cent of the non-sexual abuse group).
This suggests that not only were there
more frequent and longer experiences of
care in the sexual abuse group but that the
circumstances surrounding the
admissions were also charged with more
risk and conflict. Ten per cent of the
sexual abuse group had previously been
looked after because of the discovery that
they had been sexually abused, while
none had previously been looked after
because of their abusing behaviour. The
low rates of admission for the reason of
sexual abuse imply high levels of other
disruption in these childrens family
backgrounds.
Previous child protection registration
The Child Protection Register is a list,
held by the local authority, of children
resident in the area who are considered to
be at continuing risk of significant harm
and for whom there is a child protection
plan following an inter-agency case
conference to discuss child protection
concerns (Department of Health, 1999).
Children in the sexual abuse group had
significantly more often been subject to
child protection registration at some time
previously (54 per cent) as compared with
those in the non-sexual abuse group (34
per cent). However, registration was under
several categories besides sexual abuse.
Children in the sexual abuse group were
as likely as children in the non-sexual
abuse group to have been registered under
the category of physical abuse, emotional
abuse or neglect. Nonetheless, in spite of
the greater use of the register in relation
to the sexual abuse group, 40 per cent of
them had never been on the register (in
six per cent of the cases the childs
registration history was unclear). Clearly,
in spite of the level of professional con-
cern about many of these children,
registration was not always seen as an
appropriate intervention.
Previous adversities
Quite clearly the children in the sexual
abuse group had been subject to signifi-
cantly higher levels of professional con-
cern and intervention than the children in
the non-sexual abuse group. This led us to
explore whether there were other under-
lying differences in the personal or
domestic histories of the young people in
3
p<0.001
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 25
the two groups that might tell us more
about the reasons for this professional
interest and, through this, generate
helpful ways of thinking about these
childrens future care.
During the scrutiny of case files we
collected information on a range of 33
other concerns relating to the childs
previous behaviour and family circum-
stances. These included first, adversities
or data describing deficiencies in the
young persons caretaking environment
(for instance, violence in the home,
offending or drug and alcohol misuse by
the parent, multiple changes of house or
parental partner, psychiatric and physical
illness in a parent, sexual and physical
abuse and neglect of the children). Sec-
ond were behaviour problems or data
about behavioural difficulties shown by
the young people themselves (for in-
stance, non-attendance at school, bully-
ing, self-harm, criminal activity and drug
and solvent misuse).
In both the sexual abuse and non-
sexual abuse groups, as might be ex-
pected, the levels of previous adversity
and behaviour problems were high.
Ninety-seven per cent of the total sample
had suffered at least one prior adversity or
behaviour problem, 53 per cent had
suffered one to five, 35 per cent had
suffered six to ten and 12 children (five
per cent of the total) had been exposed to
extremely high rates of previous adversity
or had demonstrated a number of behav-
iour problems, having experienced 14 to
17 major difficulties or disruptions as
they grew up.
However, there were significantly
more prior concerns about the children in
the sexual abuse group than about the
others, with a mean of 7.8 for the children
with histories of sexual adversity and 4.1
for the non-sexual abuse group. This still
held true after excluding those concerns
that dealt with sexual abuse or abusing
behaviour, with a mean number of con-
cerns of 5.7 recorded for the sexual abuse
group and 4.1 for the non-sexual abuse
group. Overall, half of the children in the
sexual abuse group had five or more such
prior concerns as compared with only 30
per cent of the children in the non-sexual
abuse group. These differences were
highly statistically significant (p<0.001).
Some adversities and problems were
common in both sexual abuse and non-
sexual abuse groups, with no significant
differences between them. As Table 3
shows, a substantial proportion of both
groups of children had lived in families
where there was violence between their
parents, mainly violence by the man to
the mother but also occasionally violence
by the mother to the father figure or
violence on both sides. Physical abuse to
the child was high in both groups and
parental psychiatric illness and misuse of
drugs and alcohol were an issue in the
background of a substantial proportion of
children in both groups.
However, some previous adversities
and behaviour problems were
considerably more common in the sexual
abuse group (Table 4). The sexually
abused or abusing children were signifi-
cantly more likely than the others to have
had severe educational problems, ie non-
attendance and school exclusion, serious
behaviour problems at school and to have
been bullied (see also Beitchman et al,
1991, 1992; Kendall-Tackett et al, 1993;
Smith and Bentovim, 1994). They were
also significantly more likely to have
experienced disrupted parenting, ie multi-
ple separations from their main parent, a
parent who had many partners or care
which adversely affected their emotional
development, or a parent figure who
Table 3
Previous adversities and behaviour problems that were common in
both the sexual abuse and the non-sexual abuse groups*
Adversity Sexual abuse Non-sexual
group % abuse group %
Physical abuse to child 45 42
Domestic violence 38 39
Child offending 22 14
Psychiatric illness of parent 19 25
Alcohol or drug misuse by parent
or parents partner 19 25
Alcohol or drug misuse by the child 16 9
Child bullying others 10 7
Physical illness of parent 7 12
*Differences are not statistically significant
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26 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
offended; and to have been seen as
troublesome, ie having displayed serious
behaviour problems at school or being
beyond control at home. In addition, the
girls were more likely than others to have
become pregnant.
When previous adversities and behav-
iour problems were differentiated, the
analysis demonstrated that the children in
the sexual abuse group were particularly
characterised by their high level of pre-
vious behaviour problems (2.4 compared
with 1.4). Interestingly, there was no
difference between boys and girls on this
measure.
It is also worth noting that over twice
as many sexually abused or abusing child-
ren harmed themselves (nine per cent as
compared with four per cent) and a higher
proportion experienced neglect (42 per
cent as compared with 31 per cent),
although these differences, unlike the
others, did not reach statistical signifi-
cance. The only adversity that was sig-
nificantly more likely to occur in the
non-sexual abuse group was violence
between non-parental figures, such as
lodgers, and children (29 per cent v 16
per cent).
Discussion
The greater prevalence of adversities and
behaviour problems in the sexual abuse
group is in accord with our earlier evi-
dence about their higher number of
previous admissions to care, the longer
periods of time children had previously
been looked after away from home and
the larger proportion who had been on
court orders. Certainly the difference was
not simply due to the extent to which the
two groups of children were known to
professionals, since similar proportions
had had previous involvement with social
services departments (81 per cent of the
sexual abuse and 78 per cent of the non-
sexual abuse group). Furthermore, the
higher levels of difficulty and disadvant-
age in the sexual abuse group should be
seen in the context of the high levels of
disadvantage already prevailing in the
whole population of children looked after.
What the data appear to suggest is that
sexual abuse or sexually abusing behav-
iour when combined with placement in
care may often be a marker for parenting
environments which, in a variety of ways,
fall far short of those which are optimal
for childrens development.
These results demonstrate that sexually
abused and abusing children entering care
have significantly more difficulties in
their early history than non-sexually
abused children. These are problems not
only directly connected with the abuse
itself but also with the abusive and
neglectful context within which the abuse
occurred (see also Livingstone Smith and
Howard, 1994; Stevenson, 1999). This
highlights the complex relationship of
sexual abuse to other early difficulties, in
particular those poor parenting environ-
ments that resulted in childrens exposure
to sexual risk and removal to the care
system. These children should be seen not
only as suffering from the compounding
effects of multiple layers of stress which
interact as they move from family to care
and from placement to placement, but
also from the subsequently compromised
capacity to recover from the trauma to
which they have been exposed. The
significantly higher levels of behaviour
problems of children in the sexual abuse
group are the result. These emotional and
behavioural difficulties were potentially
likely to have long-term effects on these
childrens lives, particularly in terms of
Table 4
Previous concerns and adversities which occurred significantly more
frequently in the sexual abuse group than in the non-sexual abuse
group*
Events prior to Sexual abuse Non-sexual Level of
entry to care group % abuse group % significance
School exclusion 17 8 p<0.04
Non-attendance at
school 29 13 p<0.001
Severe behaviour
problems at school 35 20 p<0.007
Child bullied 9 3 p<0.04
Multiple separations
from main parent 34 14 p<0.0001
Psychological/emotional
distress of child 40 20 p<0.0008
Beyond control at home 59 40 p<0.003
*All differences significant at p<0.05
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 27
their educational attainment and social
functioning. They were also likely to have
implications for their care and manage-
ment. Strategies for managing the
challenging behaviour of sexually abused
and abusing behaviour of children in
substitute care therefore needs careful
thought and reference to its complex
development.
Care and management in placement
Although there are interrelationships
between the multiple problems in these
childrens backgrounds which may not be
apparent when they enter care, it is clear
that there are particular areas of difficulty
for this group that need to be addressed.
We would suggest that these fall into four
areas. Firstly, young people with a back-
ground of sexual abuse or abusing behav-
iour need work on the impact of the
sexual abuse per se. Secondly, they need
therapeutic interventions aimed at
addressing their multiple separations and
rejections and their current behavioural
disturbance; thirdly, good educational
interventions are a vital part of their
recovery and, finally, they need protection
from sexual risks or their own risky
behaviour in the care system.
Help with the direct consequences of
sexual abuse
Lifelong deficits in functioning as a result
of sexual abuse in childhood have been
demonstrated in a number of clinical
studies of survivors (eg Bagley and
Ramsay, 1986; Goodwin et al, 1990). The
emotional and behavioural difficulties
demonstrated by the young people in the
abuse group, both at home and at school,
were likely to have long-term effects on
the childrens lives because of the
implications for their care and
management, particularly their educa-
tional attainment and social functioning.
Higher rates of fostering breakdown have
been shown to be associated with earlier
sexual abuse (Livingstone Smith and
Howard, 1994).
Previous research suggests that some
at least of the higher rates of previous
disturbance in the sexual abuse group
could be directly connected with the
incidents of sexual abuse which the child-
ren had experienced (Beitchman et al,
1991, 1992; Kendall-Tackett et al, 1993;
Smith and Bentovim, 1994), although it
has been suggested that there is no dis-
tinctive set of symptoms associated with
this experience (Kendall-Tackett et al,
1993). Two main processes have been
suggested to account for the trauma of
abuse. The first of these is a general
formulation of post-traumatic stress dis-
order and the second suggests a damaging
impact on self-esteem and self-concept
(Stevenson, 1999). Although we cannot
be certain about the relative contribution
of previous sexual abuse per se to these
young peoples emotional and behavioural
difficulties, there are clearly arguments
for their being given the opportunity to
talk about their abusive experiences in a
therapeutic environment in order to assist
in their recovery.
Research evaluating different types of
therapeutic intervention for sexually
abused children suggests that psycholo-
gical treatment is associated with
improvement for the majority of children.
Short-term, focused cognitive behavioural
therapy has been shown to be particularly
successful with younger, symptomatic
children, although it has been more diffi-
cult to establish effective methods in
treating more persistent symptoms of
psychological distress (Stevenson, 1999;
Jones and Ramchandani, 1999).
To date, there has been little research
on the complexity of providing effective
therapeutic interventions for sexually
abused and abusing young people living
away from home. We would suggest that
therapeutic intervention for these young
people should embrace several different
approaches. Firstly, creating time and
space for the young people to talk about
traumatic and disturbing events in their
past lives in order to help them start to
make sense of what happened, with a
clear emphasis on placing the blame for
the abuse elsewhere. Secondly, work on
self-esteem is important if the young
people are to learn how to keep them-
selves safe from sexual and other risks
and learn the fundamental principles of
treating others with respect. Thirdly, it is
clear from the interview sample in the
second part of our study that a number of
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28 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
these young people have inappropriate
sexual behaviour that needs attention in
its own right. We would suggest that
behavioural interventions specifically
targeted at the young peoples inappro-
priate sexual behaviours are crucial in
minimising risks to other children (and to
the young people themselves) and in-
creasing the young persons social accept-
ability. Lastly, other non-sexual behaviour
problems arising in the placement and at
school need focused attention, including
direct disciplinary firmness and boundary
setting. We would suggest, however, that
behavioural interventions on their own
are unlikely to be effective if the young
persons underlying emotional needs are
not addressed (see Farmer and Pollock,
1998). Finally, we would endorse Jones
and Ramchandanis (1999) suggestion
that therapeutic intervention needs to be
part of a combined package of care that
involves the young persons caregiver and
social worker in the therapeutic process
(see also Macaskill, 1991).
How therapeutic interventions should
be delivered to abused children in care is
a complex area and will be reported else-
where. What is clear is that there is a
necessity for a good assessment of the
need for therapeutic intervention in order
specifically to deal with the direct conse-
quences of sexual abuse at the point of
placement for all children entering care or
changing placement. This ought to be
subject to regular review.
Attention to difficulties in family
environments
Our findings suggest that, while the
sexual abuse is important, its existence
seems to be linked to a particularly poor
spectrum of parenting. In this study,
children in the sexual abuse group suf-
fered significantly higher rates of pro-
blems internal to their families (multiple
separations from main carer, parents with
multiple partners, parental management
damaging to childs emotional develop-
ment, child beyond control at home) than
children in the non-sexual abuse group.
These findings are in accord with other
research that focuses on relationships
between family members where there has
been sexual abuse. For instance, Leifer
and colleagues (1993) reported a relation-
ship between low maternal support, poor
child functioning and placement in foster
care for children who had been sexually
abused. Other research confirms that the
parents of sexually abused children in
care are twice as likely to suffer from
deficits in parenting skills as parents of
non-sexually abused children in care
(Gwat-Yong et al, 1991). Conte and
Schuerman (1987) demonstrated that poor
family functioning was strongly related to
the impact of sexual abuse on children,
while Santry and McCarthy (2001)
discuss the impact of poor early attach-
ment relationships on later social func-
tioning in sexually abusing children.
Sexually abused children coming into
the care system are therefore likely to
have profound unmet needs for good,
secure parenting and unresolved difficul-
ties in their relationships with their own
families. Social workers, foster carers and
residential workers who have responsi-
bility for sexually abused children living
away from home need to think about how
to work either directly or indirectly with
these profound family difficulties. Care-
givers may need to demonstrate parenting
styles that are particularly competent and
consistent and are likely to need increased
levels of support and training to manage
this. Issues around contact may need
scrupulous planning and management and
work towards reunification may be part-
icularly complex.
These findings highlight the import-
ance of addressing both the particular need
for secure attachments to carers for child-
ren in the abuse group and the need for
attention to the childrens relationships
with their own families of origin. Oates
and colleagues (1994) found that improve-
ment in childrens depression, self-esteem
and problem behaviour was closely related
to improvement in family functioning.
Substitute carers of children in the abuse
group will need support in maintaining
resilience in the face of the childrens
particular attachment difficulties and anger.
Attention to education problems
While educational deficits are prevalent
in populations of looked after children
(Ward, 1995), children in the sexual abuse
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ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005 29
group suffered particularly high rates of
educational problems, typified by being
bullied, behaviour problems at school,
non-attendance at school and school
exclusion. Educational attainment is an
important end in its own right and we
would argue that work with looked after
children who have been sexually abused
needs to place a strong emphasis on their
return to mainstream school where
possible and making serious efforts to
help them to recover and maintain educa-
tional progress. The high rates of school
exclusion among the sexually abused and
abusing children suggest that many of
these children are not being maintained in
mainstream school and need special
educational interventions in order to
address current and earlier deficits in
their learning. Thorough and speedy
assessments are needed in order to gauge
which children are able to resume main-
stream education and which children are
in need of special educational provision,
thereby avoiding delay in accessing
appropriate education.
When we looked at these educational
problems they had frequently been
evident very early on in the childs school
career, often at the primary school stage.
Early indications frequently presented as
florid behavioural disturbance, often
involving aggressive attacks on others and
behaviour that could not be contained in
an ordinary school environment. This
highlights the importance of early inter-
vention that might pre-empt later behav-
ioural difficulties and alert professionals
to the profound difficulties in these
childrens backgrounds.
Apart from poor educational and
social effects, non-attendance at school
also entails daily hazards of criminal and
sexual risk due to lack of adult super-
vision. In our interview sample, foster
carers in particular emphasised the stress
entailed in having to be responsible for
the young people in their care on a 24-
hour basis when attendance at school was
problematic (see also Berridge and
Brodie, 1998). In their study of young
people going missing from care, Wade
and his colleagues (1998) suggest that
detachment from school, through exclu-
sion or non-attendance, was likely to be
related to absconding from placement,
with attendant risks. Absconding from
placement is also associated with place-
ment instability, particularly for adoles-
cents (Berridge and Cleaver, 1987; Rowe
et al, 1989).
Sexual abuse and risk of pregnancy
Our interview study shows that sexually
abused and abusing young people have
poor levels of knowledge about sex and
contraception, partly due to missing the
sex education curriculum because of non-
attendance and exclusion from school and
partly because of the cognitive distortions
arising from the sexual abuse (Farmer and
Pollock, 1998). Disturbed family relation-
ships and dislocated peer relationships
may also mean that other channels of
information and knowledge about sexual
health are disrupted. When this is coupled
with the low self-esteem of sexually
abused girls, their tendency to show self-
destructive behaviour and the likelihood
of sexualised behaviour, these young
women in care are likely to have few
strategies for keeping themselves safe
from sexual risks. This underlines the
importance of considering who can
discuss sex education and development
with looked after young people and of
continuous attention to protection from
sexual risk for girls, both inside and
outside the placement. Our interview
study also suggests that while boys are, of
course, not at risk of pregnancy they may
be equally sexually active and vulnerable
to early fatherhood and a variety of sexual
risks.
Recognition of this particularly disad-
vantaged group poses particular problems
for caregivers, as the reasons for place-
ment are unlikely to make them easily
identifiable as sexually abused when they
are placed. Even close scrutiny of the
young peoples case files may not yield
sufficient information to formulate effec-
tive plans. We were surprised to find that
there was no information on file about the
nature of abuse inflicted in relation to 46
per cent of the sexually abused children,
about the frequency of abuse in relation to
50 per cent of children and its duration in
69 per cent of cases. As a result, informa-
tion that could be passed on to caregivers
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30 ADOPTION & FOSTERING VOLUME 29 NUMBER 2 2005
when the children entered care is very
likely to be incomplete.
This finding highlights the importance
of good record-keeping by social workers
in order for key facts about previous
sexual abuse and abusing behaviour to be
easily available to all those involved in
making and maintaining placements.
Good transfer of information at the point
of placement is also vital if caregivers are
to be given a reasonable chance of mini-
mising sexual risk in placement and
responding appropriately to disturbed or
unacceptable behaviour.
Conclusion
Sexually abused children entering care
are clearly at a significant disadvantage,
even when compared to their disadvant-
aged contemporaries living in substitute
care. As a group, they share specific
characteristics which make them more
vulnerable to sexual risks and emotional,
educational and behavioural difficulties
while in placement. At the point of place-
ment there are rarely markers to alert
carers to the multiple deprivations and
adversities in their backgrounds; it is
therefore possible or even likely that they
will be denied the specific targeted thera-
peutic, educational and family support
that they need. This study highlights the
importance of a well-informed under-
standing by social workers of the specific
disadvantages in the backgrounds of
sexually abused and abusing young
people entering care, thorough assess-
ments of need at the point of placement,
good communication between social
workers and caregivers and joint planning
between social services, health and
education to implement packages of care
to meet the young peoples complex
needs.
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