Sexual abuse of two siblings under 6-years-old by an acquaintance of their mother. Both children were also subject to neglect by their mother. Learning includes: the importance of understanding the circumstances of parents or family members who are identified as having unmet and unassessed learning needs or learning difficulties; the need for a structured approach to identify and address child neglect; ensuring professionals are equipped when working in the area of child sexual abuse and improved awareness of the importance of clarity regarding risk; professionals balance intuitive reasoning with analytical reasoning; and a need for discussion in a multi-agency context about how to facilitate communication with a child and ensure their needs and voice are brought into focus, considering issues of disability, age and language. Makes recommendations to build a stronger, structured approach to neglect; and to remind practitioners that verbal or written communication is adapted to ensure accessibility during contact with families where there are potential learning needs.
      
 Title:  Wokingham child safeguarding practice review: Aisha and Ciara. LSCB: Berkshire West Safeguarding Children Partnership Author: Jane Wiffin Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1      Wokingham Child Safeguarding Practice Review Aisha & Ciara  Author: Jane Wiffin       2 Why this Child Practice Safeguarding Review (CSPR1) is being undertaken 1.1 This independently led Child Safeguarding Practice Review is about two siblings (Aisha and Ciara) who were both aged under 6 when they were found to have been sexually abused by Paul, who was known to their mother, but lived outside of the family home. A successful police investigation was undertaken; Paul was found guilty and has received a lengthy prison sentence. The police team who undertook the criminal investigation are to be commended for their hard work and diligence.  1.2 Berkshire West Safeguarding Children Partnership2 (SCP) undertook a Rapid Review3 of the contact agencies had with Aisha, Ciara and their family and agreed their circumstances met the criteria for a local child safeguarding practice review (CSPR) as set out in Working Together 20184.  Aisha and Ciara have moved to live permanently with members of their extended family.   Process of the review 1.3 All key agencies were asked to provide a chronology of their involvement with Aisha and Ciara. Interviews were conducted with all the professionals who played a role in supporting Aisha and Ciara. There was a professional’s event to discuss the key themes emerging from the review and a second event for those involved to feedback on the findings. All professionals have been open and reflective, with a willingness to share information and engage with the CSPR process. This is always a difficult process, but particularly so during COVID and I want to thank them for their contribution and generosity with their time.  1.4 The CSPR was overseen by a panel of local agency representatives (CSPR panel) who met regularly and contributed to the analysis, helped consider practice themes, and provided appropriate, robust and sensitive challenge. The CSPR was chaired effectively by a senior manager from the Quality Assurance Team at the council and managed by the SCP Partnership Manager and Coordinator. I would like to thank everyone for their hard work and commitment at what has been a challenging time, with all the restrictions and increased demands caused by the Covid-19 pandemic. The independent reviewer is Jane Wiffin; she is responsible for the writing of this report.   Family involvement 1.5 Interviews were conducted with mother, maternal grandparents and a brief discussion with father. They were open and reflective, and their views are incorporated into the findings section.  1 In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where abuse or neglect of a child is known or suspected https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (pg 84).  2 The Children and Social Work Act 2017 introduced the requirement that local safeguarding children boards be replaced with new local safeguarding partnerships led by three safeguarding partners – the Local Authority, Clinical Commissioning Group and Police; this is called the Safeguarding Children Partnership. 3 The safeguarding partners should promptly undertake a rapid review of the case https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (Chapter 4, pg 88). 4 Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf (Chapter 4, pg81). 3  Summary of the children’s journey through services 1.6 This summary provides a high-level overview of professional involvement with the family without analysis or commentary. This analysis is covered within the findings section that follows.  1.7 Aisha and Ciara were both under six when the review of their circumstances begins; they are White/British along with the rest of their extended family. They were living with their mother; their father had left the family home, but they still had contact with him. Aisha, Ciara and mother had been living with their maternal grandparents. This review starts during a period when mother was struggling to cope with looking after Aisha and Ciara and there were early signs of neglect and a poor understanding by mother of the children’s emotional needs; mother was a victim of domestic abuse from her new partner and there were heated incidents and conflicts with the extended family. Support was being provided through the local children’s centre and health visitor; mother was offered and declined help from specialist domestic abuse services.   1.8 Some months later there was an anonymous referral to children’s social services related to concerns for Aisha and Ciara and this led to an assessment and a child in need plan being initiated for a period of eight months. Mother was offered parenting support, help with child behaviour management, advice about the impact of domestic abuse on the children and practical support to improve the home circumstances. Aisha and Ciara started at a new nursery and their complex developmental needs were noted and they were linked in with the appropriate professionals, with appointments facilitated by the nursery.   1.9 A new social worker was allocated to oversee the child in need plan. There were concerns about a friend of mother’s called Paul, her partner Tony continued to domestically abuse her and conflicts with the family were ongoing; the likely negative impact of this on Aisha and Ciara was not sufficiently addressed and there was no discussion with mother about why she was reluctant to make use of specialist domestic abuse support. Volunteer support in the family home to improve parent-child relationships was provided from a third sector organisation. Mother made limited progress with improving the home circumstances, taking on board advice about parenting and behavioural management. There were concerns about the lack of developmental progress being made by Ciara and Aisha, the presence of adult men about whom little was known and a worry about Mother’s emotional availability to Aisha and Ciara.  There were concerns that mother did not always retain advice and information, but there was little discussion about what to do about this. Professionals were aware that mother might have some learning needs and that she did not always understand what was being asked of her.   1.10 A new social worker was allocated three months into the child in need plan and there emerged some professional disagreement about whether there was sufficient progress and improvement in mother’s care of the children.  This included whether there was sufficient change in the children’s developmental progress and whether there was stability in relationships, with a recognition by mother of the impact of Ciara both being introduced to new male partners and friends’ and their conflict and violence.  It was noted that health care appointments for the girls were missed, with mother choosing to seek advice from her local 4 GP surgery in a crisis. This meant some key developmental health issues went unassessed. Mother separated from Tony, and she asked Paul not to babysit because he refused to allow checks to be made about him; however, there was some evidence that he continued to fulfil childcare responsibilities.  The child in need plan was ceased because it was reported that mother had made some progress in her parenting skills and the relationship between mother, Ciara and Aisha was observed to have improved. Not all agencies agreed, believing that concerns remained about domestic abuse, missed health appointments and a new partner about whom little was known and who was in Aisha and Ciara’s life very quickly.   1.11 Six weeks after the child in need plan closed there was an anonymous referral to children’s social care expressing concerns about Paul and Tony providing care to Aisha and Ciara. Paul was said to be a “sex offender” and Tony a drug dealer. A home visit was undertaken immediately and both adults were present. Mother was asked to ensure they were not allowed in the home because they were not suitable to be around children; the exact reasons for this were not made clear but mother signed an agreement to say she would keep these adults away from Aisha and Ciara. A strategy discussion was undertaken, where information about Paul’s complex and abusive family history, his concerning interest in children and the safeguarding actions that had been put in place to ensure that he had no unsupervised contact with children were shared. The conclusion was that mother and the extended family needed to know about the nature of the concerns and to be supported to take the necessary action to keep the Aisha and Ciara safe. There were discussions with mother, and her parents, but the exact details of the concerns were not shared. They all reported as part of this review that information about Paul posing a sexual risk to children was not shared with them. Three weeks later a psychologist’s report was shared with children’s social care that confirmed Paul was assessed to pose a high risk of sexual abuse towards young children. This did not impact on the plan going forward.  1.12 A child protection enquiry/assessment was undertaken and concluded that Aisha and Ciara would become subject to a further period of a child in need plan. This child in need plan focussed on mother’s “choice of friends” and the need for ongoing support. The involved agencies were not informed of the exact nature of the concerns; these were described euphemistically as historical sexual exploitation issues. Some further information was provided to the GP surgery, but without clarity or context. The concerns focussed on parenting, mother’s choice of partners and domestic abuse.  1.13 There were further changes of social worker and the child in need plan focussed on issues of neglect. Mother had a new partner, Grieg. Over a 5-month period there were escalating concerns from school about the girls being unkempt and a lack of attendance at health appointments.  Ciara and Aisha had tummy upsets and mother told teachers that she believed that they were going through early puberty; this was shared with social workers. Maternal grandfather (MGF) reported that he thought Paul might have been in the home; MGF had been asked to check for the presence of both Paul and Tony. He reported as part of this review he did not know why and did not know what he was expected to do  1.14 The deteriorating situation for Aisha and Ciara led to an appropriate decision that child protection enquiries would be undertaken. This occurred at the point of the national lockdown for COVID and it was effective practice that this did not stop the assessment and the subsequent child protection conference from going ahead. The concerns about Paul did 5 not form part of the concerns raised, and an assumption was made that he was no longer in contact with mother or the children (see finding 3). Aisha and Ciara were made subject to child protection plans for neglect with a focus on mother managing Aisha and Ciara’s behaviour more successfully, supporting mother to risk assess males with whom she had friendships and relationships, and helping mother to make improvements to the home environment.  1.15 A month later children’s social care was told by the police that indecent images of Aisha and Ciara had been found on Paul’s devices. These images dated back to the year before. Extensive police inquiries were undertaken, and it is a credit to the team who went through all of Paul’s many electronic devices that there was a successful prosecution which led to a lengthy prison sentence for child sexual offences.  Analysis and findings 1.16 The purpose of any child safeguarding practice review is to identify any improvements that need to be made to safeguard and promote the welfare of children locally and nationally and to seek to prevent or reduce the risk of recurrence of similar incidents occurring5.  The critical incident which triggered this CSPR was the sexual abuse of Aisha and Ciara. The responsibility for this harm lies with Paul and not with those professionals who were in contact with Aisha and Ciara. However, in reviewing their circumstances several key practice themes or findings have emerged that had an impact on the effectiveness of the professional response to Aisha, Ciara and their family which are also likely to impact on the circumstances of other children locally in the future if not addressed.   1.17 The findings of this review were shared with the professionals who worked with the family, as well as senior managers from the multi-agency network at an on-line facilitated event. They were asked if the findings resonated with their experiences of working with this family and others, what the barriers were to effective practice and what would help.  A summary of people’s reflections is included under each finding.  Finding 1: The importance of establishing and understanding mother’s learning needs/borderline learning difficulty 1.18 The first significant issue that this review has identified is the importance of understanding the circumstances of parents/family members who are identified as having unmet and unassessed learning needs/learning difficulties. There is clear evidence across the timeframe of this review that professionals thought mother had some form of learning disability or difficulty, but they were unaware of the level of this need, and consequently there was a variable response by professionals. There were pockets of good practice, with the nursery for example, adapting their approach to communicating with mother, consistently checking that mother had understood and taking their meeting with her at her own pace; this was also true of those offering parenting support and support to enable Ciara and Aisha to communicate more effectively. Overall, though, there was a variable picture of professional understanding of what needed to be done to support mother and address her learning needs.   5 Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (Chapter 4, p84). 6  1.19 A learning disability is defined by the Department of Health6 as a “significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood and may be mild, moderate or severe in nature.  Many adults with a mild learning disability do not have a formal diagnosis or they fall just outside this definition, but they often struggle with similar issues. It is estimated (though it is hard to be exact about these numbers) that there are many parents who are in contact with specialist services who fit this profile. These parents often have difficulties with reading, understanding complex verbal communication and abstract concepts, telling the time, remembering appointments, retaining information, problem solving, decision making and organisational skills, struggles to understand other’s needs, including children and verbal reasoning. They may find it takes longer to acquire new skills, such as parenting and managing children’s behaviour, and to make use of mainstream approaches to teaching those skills.   1.20 Good assessment and understanding can provide a strength-based approach to these differing cognitive styles and the reasonable adjustments needed in all these areas can be made as required by the Equalities Act 2010. So, professionals need to think about communication, verbal and nonverbal, written information, how to explain complex and abstract concepts, and how to check for understanding.  A different approach is required for teaching new skills.   1.21 The Good Practice Guidance7 regarding working with parents with learning difficulties makes clear what best practice looks like:   Appropriate communication: providing easy read versions of reports including visual aids and supplementing written information with clear and straightforward verbal explanations and not using font size 14 or below.   Provision of consistency; adults how are concrete thinkers do not need a multitude of advice from different professionals; there needs to be constancy in approach and advice; this could include the use of an advice diary when there are multiple professionals visiting the family home.   An approach which is focused on demonstrating what change looks like and straightforward explanations of concerns and why they are important, particularly in the context of child wellbeing.   Taking time; parents with learning difficulties need more time to build relationships, learn new skills and understand concerns; practice does not always allow this.  6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/250877/5086.pdf  7 Working Together with Parents Network (WTPN) update of the DoH/DfES Good practice guidance on working with parents with a learning disability (2007) https://www.bristol.ac.uk/media-library/sites/sps/documents/wtpn/2016%20WTPN%20UPDATE%20OF%20THE%20GPG%20-%20finalised%20with%20cover.pdf  7  Parenting with support; research suggests that parents with learning difficulties need longer term support. This means avoiding the “revolving door approach”   1.22 This outline of best practice was not evident in the professional response to mother. She told the review that she had been given reports and information in meetings to read which she could not understand; no one checked this with her. She described child in need meetings as overwhelming, with too many people, too many long words and jargon and she was not clear what the purpose was. She likened this to being at school, including feeling told off for not trying hard enough to make sense of things and being told what a bad mother she was.  Mother was not helped to understand the purpose of these meetings, she was not provided with an advocate or buddy and there was no debrief afterwards to check on her wellbeing and understanding.  Mother sometimes took a family member with her, who also reported a lack of clarity regarding purpose and a belief that they were intended to be a public telling off for mother. She also reported not understanding the working agreements she was asked to sign, or the verbal information provided about the risks posed by the men she saw as friends and the sexual risks Paul posed to children.  1.23 Alongside the importance of ensuring the needs of adults with learning needs are addressed and reasonable adjustments are made, there also needs to be a recognition of the targeting for exploitation of the population. There is considerable disquiet in policy, research, and serious case reviews about the vulnerability of parents with learning disabilities/leaning needs to disability hate crime, and exploitation by others to gain access to homes to deal drugs or engage in criminal activities such as sexual exploitation, children, money, or sex. This exploitation is known to be exacerbated by poor social networks and friendships, and co-existing vulnerabilities such as domestic abuse and poor mental and physical health. Adults with learning disabilities are more likely to have often experience physical, emotional, and sexual abuse and neglect in childhood, and this can have a long-term impact on their self-esteem and trust in professionals.  1.24 It is of concern that the role and place of adult males in mother’s life was not fully analysed or discussed. Mother was characterised as making her own choices about “friendships with men” and there was a lack of consideration of whether she had been chosen by those men to be exploited and coerced; this meant mother’s safety was not sufficiently addressed nor the safety of Ciara and Aisha.    1.25 This is a complex area of practice. It is not easy to get a formal assessment of whether an adult has a diagnosable learning disability and what their cognitive abilities are. There are assessment tools, such as the Parenting Assessment Manual Software (PAMS) which provides a functional assessment of an adult’s parenting ability, but these are resource intensive and difficult to access locally and nationally.  1.26 Despite this, it is important that professionals feel equipped to assess the specific needs of parent with learning needs and to make the reasonable adjustments necessary.     8 Feedback from the learning event to test the validity of the finding: Professionals recognised the complexity of working with parents with learning disability, both in these circumstances working with mother, but also more generally. Barriers to effective practice were identified as a lack of confidence, skill, and knowledge. Professionals considered there was a need for:   Multi-agency guidance about best practice in working with parents who have a learning disability, including where there is no formal diagnosis, but a professional assessment of need is required  Training for professionals   Access to easy read materials and ability/support/guidance about how to adapt existing reports into easy read versions  A parent’s/carers guide to early help, child in need and child protection meetings and plans   Access to advocacy and buddies for parents to assist with attending meetings    Routine signposting to organisations such as Family Rights Group which has an advice service, information sheets and explanations of common words and phrases used in child welfare services  Finding 2: A structured approach to child neglect 1.27 This finding looks at the extent to which there was a structured and analytical response to concerns about the ongoing neglect of Aisha and Ciara by mother and other adults who held a parental role. The neglect of children by their parent (primary caregivers) is a serious issue which has a significant and long-lasting negative effect on children’s developmental outcomes, their safety, their emotional wellbeing and the impact often lasts into adulthood8.   Child neglect is a complex area of practice which requires a structured and analytical response9. There are several key areas to be assessed and analysed. This was not apparent in trying to understand the neglect of Aisha and Ciara by mother.  How persistent and pervasive is the neglect and have services designed to create change been successful 1.28 There was a general reluctance across the professional network to “name” concerns about the care of Aisha and Ciara by their mother as neglect. This meant that the persistent and cumulative nature of it was not understood. This naming of neglect from its earliest manifestations is important to track the development of neglect over time and to be aware of both positive and negative changes in the outcomes of children. It is part of telling a child’s story, but also thinking about whether interventions designed to make a difference have helped. This can be an opportunity to think about the strengths of families to create change, despite how difficult this can be or to recognise that efforts to create change have been unsuccessful and need review both in terms of the appropriateness as well as a parent/caregiver’s capacity, ability and willingness to change  8  https://www.gov.uk/government/publications/childhood-neglect-and-abuse-comparing-placement-options 9 BRANDON, M. et al., 2014. Missed opportunities: indicators of neglect–what is ignored, why, and what can be done? London: Department for Education, DFE-RR404, 46pp. https://repository.lboro.ac.uk/articles/report/Missed_opportunities_indicators_of_neglect_what_is_ignored_why_and_what_can_be_done_/9580058    9 in the best interest of their child(ren). Mother reported feeling that she was unclear what the concerns were (see finding 1), but maternal grandfather also reported that what needed to change was not clear.  What type of neglect is occurring? 1.29 It is important to think beyond a child/young person physical environment and how they are physically cared for. Physical care is an important factor and there was evidence that there were problems associated with the physical environment in which the children were living and the physical care they received. This was however just part of the pattern of neglect.   1.30 There were unacknowledged concerns about the attachment relationship between Aisha, Ciara and their mother. A lack of an attachment relationship can make it hard for a parent to understand things from their child’s perspective. Mother does not appear to have considered the impact on Aisha and Ciara of introducing them to many new male adults as parental figures and how this might impact on them. Whatever the reason for this, including her potential learning needs, this needed acknowledging and addressing.   1.31 There were also concerns about the supervisory arrangements for Aisha and Ciara. Who was looking after them and when? Were these appropriate adults? Part of supervision is the creation of a safe environment for children. Aisha and Ciara witnessed significant amounts of violence, arguments and disputes by either family members or other adults. Support was offered to help mother make sense of the impact through specialist domestic abuse services, which she declined. This support was for mother, but also for Aisha and Ciara.  What is the impact on the child and what action is intended to address this? How will we know it is working to improve child outcomes? 1.32 It is important to be clear about what the impact of parental neglect is on children to ensure that services and support are addressing these and making an impact. Aisha and Ciara had significant developmental needs from birth and were receiving appropriate specialist support to address these. The impact of the neglect that they experienced was apparent in the lack of progress of their speech and language, despite this support. There were ongoing concerns around their behaviour at home, which was not managed by mother, though the sexual abuse they were experiencing will have had an impact. This behaviour was not seen in such an extreme way at nursery or school. Mother was provided with support and in the short term there were improvements seen for Aisha and Ciara. These did not last. The impact of the neglect, and the need for change was not part of the plan.   What is causing the neglect and have interventions been targeted in these areas? 1.33 It is critical in the professional response to neglect that there is an analysis of why the neglect is occurring to target interventions appropriately and be sure that change has occurred. There was a lack of analysis of what was behind mother’s neglect of Aisha and Ciara’s needs. This could have been her learning disability, her own emotional needs, the impact of abuse, violence and controlling behaviour from family and friends or her feelings about Aisha and Ciara. These primary causal factors would have required different responses, rather than a generic sense that teaching parenting would address 10 the issues. Mother reported that she struggled to understand what needed to be differ and that domestic abuse, and coercion and control impacted on her significantly, causing her to struggle.  Is the neglect passive or active: omission or commission? 1.34 Neglect is often seen as passive; parents unable to provide appropriate care to their children due to their own individual difficulties such as learning disability, poor mental health, substance misuse or being a survivor of domestic abuse and the attendant impact on self-esteem and wellbeing. There are occasions when neglect is an active process; the child is deliberately not cared for by a parent, seen as too difficult and problematic to be able to be parented, and then blamed for the lack of care they receive. This is a serious issue which causes long term harm to children.   1.35 As professionals we need to imagine what it is like not to receive the care that you need to grow and develop appropriately, and then for this to be characterised as your own fault because you are too difficult or too damaged. Child blame and a parental focus on the child as the problem to be fixed needs early professional attention. Where parents hold these beliefs, services designed to address neglect are often ineffective because the parent perceives the child to be the problem that needs fixing. It is hard to evaluate where mother was in the omission- commission continuum. There is evidence that mother was concerned about Aisha and Ciara and saw them as problematic and their behaviour as unmanageable. This led to Aisha and Ciara being seen as having unmanageable behaviour, rather than mother not consistently attending parenting classes or support sessions designed to help her provide structure and certainty which would support Aisha and Ciara and their behaviour. It is important as professionals to notice the extent to which we are persuaded by parents that their child is the problem, and our records can unwittingly reinforce this. So, do we record that a child’s behaviour is problematic or that their behaviour has not been contained by effective parenting? For children, such as Aisha and Ciara, it is important that for their sense of self-esteem and wellbeing we do not describe the impact of neglect as a child problem to be solved.  What other kinds of abuse is the neglect enabling? 1.36 The final area of concern or analysis to address is how does the neglect of children enable other forms of abuse to occur. There is a strong connection between neglect and child sexual abuse. This appears to be caused by factors such as poor supervision, lack of quality parent-child relationships, domestic abuse, coercion and control and adult needs dominating decision making by parents.   1.37 These were all important questions to ask about the circumstances of Aisha and Ciara. Neglect is multi-faceted. As professionals we need to move from a focus on the physical circumstances that the child lives in or the physical care, they are provided with to thinking about how all developmental needs are met, and the likely impact if they are not. Professionals must consider a parent’s understanding of the need for change, why it is necessary and commitment to change behaviours and unhelpful parenting approaches in the best interests of their child; in essence helping parents hold their child’s need in mind. Mother considered the discussions about the children’s needs as an attack on her. Mother was told that “her children might come into care” if she did not improve the home circumstances, and if there was no change, they might become subject to a child 11 protection plan. This approach characterises the child protection system as a threat rather than an important process which is intended to find proactive ways to keep children safe and support families. It feeds parental fear and reinforces the often negative view of social workers. It also focusses parental attention on pleasing professionals, making changes because of instructions by professionals, rather than as a demonstration of love and care and commitment to children.  1.38 As well as the lack of a structured approach to identifying and addressing child neglect, the child in need meetings, designed to address concerns and to develop a plan about neglect were not sufficiently effective. Mother reported that she did not understand the purpose or process of child in need meetings and plans; she also felt bullied within them, reminding of her of experiences of domestic abuse. Professionals working with this family also reported a lack of clarity about the purpose and process of child in need meetings. For some professionals working in universal services, this was their first experience. This meant that this important forum was not as helpful as it could have been in addressing neglect. It is essential that all professionals feel equipped to work effectively to address the neglect of children and young people.  There was a lack of a structured approach to making sense of the neglect experienced by Ciara and Aisha.   Feedback from the learning event to test the validity of the finding: Professionals recognised that there needed to be a more structured approach to working with neglect because of inconsistency in the professional response, caused by different values and understanding of what constituted the neglect of children.  Professionals reflected that getting the balance right between being clear with parents about concerns regarding parenting and addressing children’s needs and enabling parents to feel supported and not “got at” was difficult to achieve. This was even more challenging when parents had known learning needs.   There was professional agreement that the child in need process was not well understood by parents and that they often felt out of their depth and isolated in these meetings. This was in comparison to child protection processes where the clear role of the chair to explain to adults and children what the meeting was about, what was going to happen and to explain the information that would be shared. A similar approach is needed within child in need meetings.  Professionals thought there needed to be:  Agreement about tools and frameworks used locally to identify and address neglect  Multi-agency information about the purpose and process of child in need meetings, including clarity about roles and responsibilities (including the need for an update report for each meeting, who would record the meeting and how parents/family members learning needs were to be addressed and how they were to be made comfortable)  A leaflet for families (and children) about child in need meetings, including an outline of the purpose and process, their right to bring a report, in what circumstances advocacy or a buddy would be provided and how to feel comfortable as often the only non-professional in the meeting   There needs to be a multi-agency discussion about how information is shared relating to families either moving back and forth across the continuum of need; recognising that saying “if 12 things don’t change, we will have to refer to children’s services/get a social worker” feels like a threat, rather than a child focused requirement to change in the best interests of a child and feeds distrust of social workers and statutory processes  Finding 3: Working effectively to address child sexual abuse 1.39 This CSPR was initiated because Aisha and Ciara have been sexually abused by Paul.  It is important to reiterate that the responsibility for the harm lies with Paul, but this review raises important questions about the extent to which professionals feel equipped to work in this area of practice. Prevalence studies for England and Wales suggest that some 15% of girls and 5% of boys experience some form of sexual abuse before the age of 1610.  However, sexual abuse is a hidden crime and many of those who experience it do not report their experiences.  Only around 1 in 8 cases of child sexual abuse (CSA) reach the attention of statutory services, which means far more children are being sexually abused than we are currently identifying or safeguarding.   The impact of CSA on children and young people’s development and wellbeing is serious and can last throughout childhood and into adulthood11.   1.40 Effective practice in working to address child sexual abuse should take a whole family approach to understanding, assessment and intervention. There has been too much focus and emphasis on the necessity of children telling professionals they have been sexually abused, as opposed to understanding the child’s contextual circumstances and building a picture of concern. There is much more emphasis on this in the context of neglect (see finding 2), but less so on child sexual abuse. Professionals need to:   Provide children and young people with the best opportunity to seek help from professionals when they are being sexually abused by either being facilitated to tell someone or for someone to notice through changes in their behaviour or other indicators of concern.  Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people  Think about how to understand the needs and circumstances of a non-abusing parent/family.  Providing children and young people with the best opportunity to seek help from professionals when they are being sexually abused by either being facilitated to tell someone or for someone to notice through changes in their behaviour or other indicators of concern. 1.41 Research suggests there are many barriers to children feeling able to tell someone that they are being sexually abused12. This includes feelings of shame and embarrassment, fear that they may not be believed, or they may not have the language or the capacity to communicate verbally. Children may also not recognise the experience as abusive or are being threatened or manipulated by the person who has abused them. These barriers to talking about sexual abuse are compounded by professionals worries about supporting  10https://www.csacentre.org.uk/our-research/the-scale-and-nature-of-csa/     11 Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice.  12 Allnock D. et al (2019). Key messages from research on identifying and responding to disclosures of child sexual abuse The International Centre (University of Bedfordshire) and NSPCC for the Centre of Expertise for Child Sexual Abuse  https://www.csacentre.org.uk/resources/key-messages/disclosures-csa/    13 children to speak out. This includes lacking confidence and skills and worries about saying the wrong thing or fears about contaminating evidence in any future criminal proceedings.   1.42 Aisha and Ciara did not have the necessary language skills to be able to tell a family member or professional that they were being sexually abused by Paul. In these circumstances’ children are dependent on adults and professionals noticing the signs and indicators of child sexual abuse. There is a clear evidence base regarding these signs and indicators. For Aisha and Ciara these included tummy aches and escalating behavioural concerns. Mother also asked professionals whether Aisha could be going through the early stages of puberty (she was aged under 5 at the time). Professionals were unaware that there were concerns that Paul posed a sexual risk to children and so were unable to contextualise any concerns about an escalation of Aisha and Ciara’s distressed behaviours. There was a particular incident in February 2020 where Aisha said she had been hit by another child on the leg but put an icepack on her groin area. This was noticed as an incident of concern and recorded as such; Aisha was not asked about it. This is the sort of incident where it is important for the child to know that an adult has noticed and to demonstrate to the child that they have noticed, by saying what they have seen and providing an opportunity for the child to communicate any concerns or worries. Children will not always take the first opportunity to communicate concerns, but research suggest that this communication is a process.   1.43 In recognition of the need to improve professional’s skills in talking to children/young people about abuse, signalling to them that we have noticed their distress and identifying the signs and indicators of CSA, the Centre for Expertise in Child Sexual Abuse has been commissioned to produce several resources in these areas, communicating with children about CSA and a signs and indicators toolkit.   Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people. 1.44 Understanding the motivations, needs and behaviours of adults about whom we have professional concerns they may/or have sexually abuse a child is critical to keeping children/young people safe, managing risks, addressing the impact on the whole family and create change in offending behaviour. Understanding this behaviour is often viewed as a specialist task, which can only happen once an adult is known to have offended.   1.45 It is critical that safeguarding professionals are familiar with the evidence base around adult sexual abuse13. The most often use framework is Finkelhors (1984) 4 preconditions model14. This suggests that there is a process that adults who pose a sexual risk to children go through. The first precondition is motivation to abuse. This can include emotional loneliness, intimacy and relationship problems, hostility and anger towards women, a desire for power and control, poor impulse control, using sex as a coping mechanism and a possible sexual attraction to children. Adults are using sex to get these needs met. The second stage is overcoming Internal Inhibitors. An adults need to  13 Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice.  14 Finkelhor et all (2016) The Four Preconditions Model: An Assessment. https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118574003.wattso002  14 overcome internal inhibitors such as knowing what they are doing is wrong. Professionals need to understand factors that disinhibit behaviour. This can include the use of alcohol or drugs and the development of cognitive distortions to validate behaviour. The third stage is overcoming external inhibitors, finding opportunities to offend, but gaining access to children. The final stage is finding ways of abusing the child, overcoming their resistance. This is achieved through grooming, exploiting vulnerabilities such as a young age, disability, need for a special relationship as well as threats and coercion.   1.46 These were all factors that needed to be considered regarding Paul. This should have formed part of an assessment by children’s services. There was clear evidence of Paul’s emotional vulnerabilities; he was abused as a child and required ongoing support. It is not known how he overcame his internal inhibitors but is clear that he actively sought to be in situations where he had access to children. This was first recognised when he joined a local church. When the church became aware of concerns regarding his behaviour, they took steps to address this, and it is good practice that this led to Paul’s social worker seeking an assessment of him and ensuring that police action was taken. He had not offended against a child, but there were indications that he might, and so action was taken to address that he was not suitable to work with/volunteer with children through the DBS process. When there was an anonymous referral of concern to children’s services, all appropriate information was shared. Including the psychologists report which made clear the risk he could pose. Mother was asked to not allow him into the family home. This approach assumed that mother had the capacity and willingness to stop contact, or that he would accept this without engaging in grooming behaviour. The grooming process is such that it is likely that Paul actively undermined children’s services role.   1.47 Each agency sought to limit Paul’s contact with children, without an active discussion about the likelihood that he would actively seek other opportunities and that they needed to be alert to this. There was a strategy meeting and LADO meetings where it could have been considered whether Paul’s behaviour met the criteria for a Sexual Risk Order15. A Sexual Risk Order is an order made by the Court which imposes restrictions on a persons’ behaviour that the Court deems necessary for the purposes of protecting the public from risk of sexual harm. An order can be made in respect of any person who the police consider poses a risk of sexual harm to the public, where they have not been convicted of a sexual offence. Sexual Risk Orders prohibit the subject from doing anything contained in the order, they can prohibit anything from foreign travel and internet use to preventing a person from being in the company of children. To impose a Sexual Risk Order, the Court must find that a person has: done an act of a sexual nature; and because of which, there is reasonable cause to believe that it is necessary to make an order to protect the public from harm. It must be proved, beyond reasonable doubt that a person has done an act of a sexual nature, however, it must only be proven on the balance of probabilities (that it is more likely than not) that there is reasonable cause to believe that is necessary to make an order to protect the public from harm.     15https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/755142/11.18guidanceonpart2ofthesexualoffencesact2003.pdf  15 Understanding the needs and circumstances of a non-abusing parent/family. 1.48 The third factor in addressing the possible/actual sexual abuse of children is to consider the role of a non-abusing parent or extended family. It is critical that there is an assessment of the non-abusing parents’ ability to protect and believe children. Research indicates that feeling believed by your main care giver is one of the strongest mediators of the long-term mental health issues caused by sexual abuse. This parent/caregiver will need to play a central role in protecting their children from the person of concern, implementing safety plans and managing risks; they will need to support their child with the immediate and longer-term impacts of their abuse16.   1.49 It is also important to understand any vulnerabilities that can be exploited by an adult to make sexual abuse possible. Non abusing parents may be groomed, making use of unmet needs for financial and emotional support or they may be being coerced and controlled through domestic abuse. It is important that the non-abusing parent has all the relevant information and that they understand the process of likely adult sexual offending to be equipped to address it. Adults who pose a sexual risk to children often undermine the non-abusing parents parenting capacity, seeking to make use of any difficulties they have such as mental ill health, depression and low self-esteem. They can try to become a better substitute parent figure whose role is essential to family life. This requires a good assessment of these factors; understanding the needs and circumstances of the non-abusing parent, considering what of their needs are being met by the adult who poses a sexual risk being in their life, what role that adult plays in family life, financial contribution and looking after children. There is likely also to be a process whereby these adults who pose a risk undermine non-abusing parent/child relationships as well as other family relationships.  1.50 It is not known how Paul met mother; she reports that this was due to the coercion from Tony, he insisted that Paul play a part in family life, particularly babysitting so they could go out.  It is known that mother was vulnerable because of her learning needs, her experience of violence and conflict with her partners and extended family.  When concerns were raised about Paul, there was a child protection enquiry and assessment completed. This did not consider mother’s vulnerabilities, the needs that were being met for her by Paul’s presence or consider his likely and active grooming behaviour. Mother and the extended family were not given the right information to evaluate the risks that Paul posed to Aisha and Ciara. The capacity and willingness of mother to be able to ensure that Paul did not have access to Aisha and Ciara was not questioned, and assumptions made that a working agreement would provide appropriate motivation.   1.51 The recent Ofsted thematic review of sexual abuse in the family environment17 has highlighted that there is not enough attention paid, or assessments completed regarding the needs and circumstances of a non-abusing parents or an evaluation of how to understand their willingness and capacity to keep children safe from sexual abuse and  16 Still, J (2016) Assessment and Intervention with Mothers and Partners Following Child Sexual Abuse: Empowering to Protect 17 Ofsted (2020) The multi-agency response to child sexual abuse in the family environment Prevention, identification, protection and support https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/862454/Multi_agency_response_to_child_sexual_abuse_in_the_family_environment_joint_targeted_area_inspections_JTAIs.pdf  16 their vulnerability to grooming and exploitation which can undermine that safety. Work is being undertaken by the Centre of Expertise on Child Sexual Abuse to support professionals to assess and understand the needs of non-abusing parents to increase safety for children.  1.52 This Finding highlights the complexities of working with child sexual abuse and the importance of clarity regarding risk and need. When the concerns about Paul became known to children’s services, appropriate child protection processes were followed, with a strategy discussion and a child protection enquiry started. This concluded that Aisha and Ciara should be subject to child in need plans which focussed on previous concerns, not current risks. The threshold criteria are clear that where children are at risk of likely or actual significant harm, they should be subject to an initial child protection conference to evaluate all the risks to them. The circumstances of Aisha and Ciara met those criteria, but the focus moved away from the likely source of the risk, which was Paul.   Feedback from the learning event to test the validity of the finding: Most of the professionals working with Ciara and Aisha were unaware of the concerns about Paul, and that there was any possibility that sexual abuse was a concern. It was a great shock to them all when this abuse was discovered.  These professionals said that working with child sexual abuse was not a routine part of their work and so it felt overwhelming, complex and people said they lacked both skills and knowledge in this work. For those working in universal services there was a recognition that their role was different from those in specialist safeguarding roles who worked more routinely with child sexual abuse. However, those in specialist roles such as social workers also acknowledged a lack of confidence and the need to enhance their skills in this area.   Professionals who were in non-specialist roles wanted:  Awareness raising training  Information about signs and indicators (a tool is being published by the Centre for Expertise on Child Sexual Abuse in September 2021)  Information about talking to children and being curious about behaviour that are of concern and indicate sexual abuse may be an issue (a guide is being published by the Centre for Expertise on Child Sexual Abuse in October 2021  Those with more direct roles in safeguarding wanted information and training about:  Communicating with children  Assessing and working with non-abusing parents (a guide is being published by the Centre for Expertise on Child Sexual Abuse in October 2021)  Working with adults who pose a sexual risk to children  Finding 4: The importance of Child Focussed Practice  “Everyone involved in safeguarding and support should pursue child-centred working and recognise children and young people as individuals with rights, including their right to participation in decisions about them” Munro 201118   18Munro, E (2011) The Munro Review of Child Protection: Final Report A child-centred system Professor Eileen Munro https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf  17 1.53 Working Together 201819 and local safeguarding procedures make clear that one of the core principles of effective safeguarding practice is a child centred approach which is focused on understanding the lived experience of children and seeking their own views about their lives and circumstances. This is reinforced by the United Nations Convention on the Rights of the Child20, which recognises a child’s right to expression and to receive information. This right is also reinforced by Article 10 of the Human Rights Act 199821 and the Children Act 198922, which requires a local authority to ascertain the ‘wishes and feelings’ of children and to consider these when determining what services to provide, or what action to take (considering the child’s age and understanding). The Assessment Framework (2000)23 also clearly states that direct work with children is an essential part of the assessment process because children are a key source of information about their lives and the impact any problems are having on them. This is particularly true where children have disabilities and/or complex communication needs.   1.54 Despite this mandate, evidence shows that children are not being routinely fully included in safeguarding and support work. The consistent finding from serious case reviews is that professionals do not speak to the children enough, that children are not seen frequently enough by the professionals involved in their lives, professionals focused too much on the needs of the parents and overlooked the implications for the child. This appears to be caused in part by workload pressures, parental resistance, undeveloped skills and differing views about at what age a child can participate.   1.55 Aisha and Ciara were both young and they had limited verbal skills. It is notable that in most of the assessments and child in need process their views were not sought or addressed and their lived experience not outlined. This was despite there being significant knowledge about their circumstances. They witnessed violence and conflict; they were often looked after by adult men they barely knew and were introduced to new father figures on a regular basis. They were not developing as well as they should, and they came to school and nursery looking unkempt. The sections in the assessments and child in need plans to outline their views were left blank. The social workers responsible could have sought advice from the many professionals who worked directly with Aisha and Ciara including nursery, school, speech and language therapist and a specialist deaf teacher. These professionals knew the children well and could have helped with communication or be asked to be an advocate for their voice and lived experience.   1.56 There is evidence that some professionals felt they lacked the specialist skills to communicate with Aisha and Ciara.     19 Working Together to. Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf  20 https://www.unicef.org/child-rights-convention  21 https://www.legislation.gov.uk/ukpga/1998/42/schedule/1  22https://www.legislation.gov.uk/ukpga/1989/41/contents  23 DoH (2000) Framework for the Assessment of Children in Need and their Families. https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014430.pdf  18 Feedback from the learning event to test the validity of the finding: Communicating with children was seen as something extremely important to all professionals, and for most they felt they lacked the skills to know how best to do this when children had limited verbal skills and communicated in other ways.   There was recognition that there had been a lack of understanding across the professional network about those professionals who were routinely communicating with Aisha and Ciara and their expertise could have been called upon.  It was agreed there needed to be more discussion in a multi-agency context of the team around a child (across the child welfare continuum from early help to child protection) about how communication with a child could be facilitated, considering issues of disability, age and language. There was also reflection that those professionals meeting Aisha and Ciara’s developmental and disability needs were not invited to contribute to meetings (not necessarily by attending but providing information) which could have brought their needs and voice into focus.  Professionals wanted more training about communicating with children who have different communication styles and who are young.   Finding 5. Recognizing and acting upon “gut” feelings  “Intuition is the process by which we come to know something ‘without being able to explain how we know’. It has been defined as a form of nonconscious holistic information processing’ (Sinclair 2010, p.37824). It is sometimes described as a sixth sense, or gut feeling, that is later proven correct.  1.57 Many of those professionals who met Tony and Paul were concerned about them and how they behaved around mother, Aisha and Ciara as well as other parents. They shared this with other professionals but there remained uncertainty about whether this was legitimate information and what weight they should apply to it.   1.58 Making professional judgements and decisions about the needs and circumstances of children/young people in a safeguarding context is complex. There has been much reflection and research regarding this and consideration about how to help professionals build effective critical reasoning skills. There has been debate about the role of “gut” instincts in professional practice, and a focus on objective, fact driven practice to avoid errors and mistakes which have led to several high-profile public inquiries into the death and harm of children nationally.   1.59 More recent debates suggest that because of the complexity of the safeguarding task, professionals need to use the full range of human reasoning skills. Munro (2018)25 refers to this as using intuitive and analytical reasoning. Intuitive reasoning, or gut instinct is an unconscious process that occurs automatically as response to perceptions and emotions, integrating a wide range of immediate data to come to a judgement in a quick and  24 Sinclair, M (2010) Misconceptions About Intuition. Psychological inquiry. Vol.21(4), p.378-386 https://web.archive.org/web/20200320195127id_/http://www.msjkeeler.com/uploads/1/4/0/6/1406968/intuition.pdf  25 Munro (2019) Effective Child Protection. 3rd Edition Sage Publishers  19 relatively effective way. The intuitive judgment process has been associated with several errors including biased and fixed thinking, forming judgements which do not change despite contradictory information. Analytical reasoning is conscious and controlled, using formal reasoning and explicit evidence-based data and rules to make judgements and decisions. This is time consuming and effortful and lacks an acknowledgement of the emotional and person-centred nature of much of the work of safeguarding. The Munro review highlighted that professionals need to use formal knowledge, practice wisdom, emotional wisdom, ethics and values.  1.60 Professionals in their work need to balance intuitive reasoning (gut feelings, practice wisdom, emotional responses) with analytical reasoning (formal processes, research findings, guidance, hard facts).   Feedback from the learning event to test the validity of the finding: Professionals recognised this as a dilemma that they routinely faced. Despite evidence that training and many supervisory processes, professionals felt they could only use what they saw “as hard facts” in making sense of children and their family’s lives. Senior managers felt that this myth had been dispelled over time, and the professional task was to interrogate information using analytical skills. There was a real sense that there are mixed messages locally and nationally about the use of intuitive reasoning.  Professionals were not clear what exactly could help, beyond the provision of effective supervision which enabled a discussion of intuitive and analytical reasoning.  It was noted that the designated leads in school do not receive supervision and relied on peer support.   Professionals felt there needed to be clearer guidance to them about providing professional opinions about children and families, and there was a clear sense of the importance of the role and expertise. There was agreement that all professionals needed to move beyond “flat information sharing” to providing meaning based on their expertise and understanding. A simple example given was that there were concerns about mother not putting in Aisha’s hearing aid; there was discussion if this was an indicator of neglect. The specialist professional was not asked about this and could have shared her view on this.  20 Recommendations: Each core agency involved with Ciara and Aisha has considered the findings from this review and agreed that action that is needed.  These actions are being progressed.  In addition, the Berkshire West Child Safeguarding Partnership (BWSCP) is asked to consider what action is necessary to address the core issues raised in this report:  Stronger/structured approach to neglect 1. BWSCP to convene a multi-agency neglect working group which will look at developing a position statement and reviewing tools and frameworks for a structured approach to neglect.   The importance of establishing and understanding mother’s learning needs/ borderline learning difficulty 2. BWSCP to produce local information, support and guidance to remind practitioners that all contact with families where there are potential/additional learning needs, that all verbal or written communication is adapted to ensure they are accessible.  Child in Need 3. Building on existing audit and review work in relation to the Child in Need process, BWSCP will produce good practice guidance which will facilitate effective multi-agency involvement in Child in Need meetings.    Working effectively to address child sexual abuse 4. As an outcome of this review, BWSCP will share the best practice resources being developed by the Centre of Expertise on Child Sexual Abuse26 across the safeguarding network.  Plus, the Local learning regarding working to address child sexual abuse that has emerged in early years and school settings involved in the review will be shared anonymously with the wider school Designated Safeguarding Lead network. 5. BWSCP to ask Wokingham Children’s Services to review the use of working agreements in terms of appropriateness, ability to keep children safe and understandability for families.  Supporting practitioners through up-to-date and clear safeguarding procedures 6. BWSCP to work with colleagues across Berkshire, and the procedures provider, to review the following Pan Berkshire Child Protection Procedures and raise awareness of the revised procedure across the local agency network:  Neglect;   Children of Parents with Learning Disabilities, with a specific focus on those parents who do not have a formal diagnosis, in line with the Equalities Act 2010;  Child Sexual Abuse in Family Environment.  26 The Centre of Expertise on Child Sexual Abuse is funded by the Home Office, with the aim of reducing the impact of child sexual abuse through improved prevention and better response.  Home - CSA Centre 