Tricia O'Donnell, NSPCC Tricia Jessiman, John Carpenter, University of Bristol

1. BASPCAN 2015
'Letting the Future In' an
intervention for child sexual
abuse: from practice model to
RCT
Trish O’Donnell, NSPCC
Tricia Jessiman, John Carpenter, University of Bristol
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2. Aims of Presentation
• Tell the story of a partnership between a practice
organisation with a commitment to research and
evaluation and two universities.
• Describe the evolution of a model of therapeutic
intervention for child sexual abuse developed by
practitioners (Letting the Future In)
• Focus on the external evaluation of LTFI and the
development of a pragmatic RCT
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3. About the NSPCC
• National Society for the
Prevention of Cruelty to
Children
• UK-wide child protection
organisation
• Founded in 1884, now has
over 2000 employees in over
40 centres across the UK
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4. ‘Gap between provision and need’:
Therapeutic services for children affected
by sexual abuse in the UK
• 2009 NSPCC study estimating need for therapeutic
services for children affected by SA in the UK
• Compared existing estimates of prevalence of CSA
with mapping of available services:
– estimate of need over 70,000
– 508 services identified across the UK: approx
16,000 children and young people in receipt of a
service in 2006/7
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5. Scoping the evidence base
• NSPCC 2011 literature review of
– impacts of sexual abuse
– therapeutic interventions
– what children and young people say
about therapy
• Online survey of adult survivors
of CSA and their experience of
services
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6. Implications of NSPCC studies for the
development of a practice guide for
therapy
• Importance of high quality initial
assessment
• Child-centred therapeutic approach
• Draw on elements of different therapeutic
approaches to enable practitioners to
respond to individual need and
preferences
• Importance of establishing a strong
therapeutic alliance
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7. Creation of therapeutic practice guide
• Literature review
• Practitioner-led working group + researcher and
consultant/writer (6 months)
• Draft guide (March 2011) included theory +
research + assessment protocols + intervention
guidelines
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8. Pilot and Stress Test
• One team…
• …then 6 teams
• ….then training and roll out
(within 9 months)
• BUT piloting helped with
future delivery continuous
challenges
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9. Letting the Future In – the model
• Structured assessment and intervention based on
Regenerative Model (Bannister, 2003)
• Child: up to 20 weekly therapeutic sessions (and
further 10 if required). Flexible: play therapy, CBT,
social-education, use of creative arts
• Safe carer – up to eight sessions, possibly 3 joint
sessions
• A new model, with no empirical evidence.
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10. 10 Commissioning an independent, external
evaluation
• Impact evaluation
– To what extent is the intervention Letting the
Future In more or less successful in meeting the
needs of children who have experienced sexual
abuse and their safe carer in comparison to a
comparison group?
• Process evaluation
• Economic evaluation

11. Evaluation Team
Outcome evaluation
Cost-effectiveness
Process evaluation
• Implementation
• Case studies
• Therapeutic alliance
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12. What do we know about the effectiveness
of interventions? Cochrane Reviews
CBT interventions (2012). 10 RCTs:
• CBT may have an effect on depression, PTSD,
anxiety but most studies too small and results not
statistically significant.
Psychoanalytic/psychodynamic psychotherapy
• (2013) NO eligible RCTs
Recommendation: quality of studies should be
improved (allocation bias, outcome measures,
reporting, sample sizes)
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13. Outcomes evaluation: What comparison
group?
• Treatment as usual e.g. child welfare?
– too difficult to collect data from non-NSPCC
families
• Children and Adolescent Mental Health Service
– But why would they cooperate? Could not
randomise.
• Cluster randomisation (at team level)
– but NSPCC are committed to the roll out of the
intervention in all teams
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14. RCT with waiting list control
• By December 2011, agreed that an RCT with
waiting list control
• Once teams have reached capacity, new cases
randomised to immediate intervention OR 6 month
waiting list
• But still some issues to resolve with practitioners
and managers…
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15. Setting up the study
• Convincing senior management (service delivery)
• Regional workshops
– Existing research on interventions for CSA
– Rationale for RCT and design
– Outcome measures
• Evaluation handbook (13 iterations!)
• Team visits
– Evaluation training and support
– More than once…
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16. Responding to practitioners’ and
managers’ concerns
• Of course the intervention will work – so we must
give it to all children who need it without delay.
– but we don’t know this, so ethically it’s
responsible to evaluate rigorously.
• You can’t make children wait
– Better a waiting list than closing to new referrals
• You can’t have practitioners doing nothing
– Only teams at capacity will enter the trial

17. Responding to concerns
• Randomising isn’t fair.
– But fairer than closing the door to all children
referred after service reaches capacity. In this
model, all children have a 50:50 chance of receiving
the service immediately
• What about children who need the service immediately?
– Limited exceptions from RCT, and additional
safeguards
• What if children on the waiting list can’t cope?
– Waiting list safeguards

18. REFERRAL ASSESSMENT
(ELIGIBILITY)
CONSENT
Safe carer and child: baseline
RESEARCH ASSESSMENT
RANDOMISATION
THERAPEUTIC ASSESSMENT
and INTERVENTION
6 months –T2
reassessment
Intervention
ends
Follow-up: 12
months T3
Intervention
continues
(max 30 sessions)
Follow-up: 12
months T3
WAITING LIST +
SAFEGUARDS
6 months – T2
Re-Assessment
THERAPEUTIC
ASSESSMENT &
INTERVENTION
12-month T3
re-assessment
Crisis: receive
intervention-
opt-out of trial
Not eligible or other
abuse issues for CYPS
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19. Practitioners’ key role in RCT
• Information and consent
• Decisions about (rare) exemptions from trial
• Dealing with outcome of randomisation
• Data collection and management
• Managing waiting list caseloads
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20. Making it work
NSPCC
• Shared vision across
practitioners, team
managers and senior
managers that there was
a need to generate
evidence about what
worked for children
affected by sexual abuse
Bristol & Durham
• Establishing credibility
and commitment
• Listening to concerns
• Flexibility
• Persuading not imposing
• Support to teams +
regional phone meetings
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21. RCT progress
• Recruitment closed Oct
2014
• Largest trial of this type
of intervention
• 242 valid randomisations
• 18 of 20 teams involved
• Study to report to funders
end 2015
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22. References
Allnock, D. & Hynes, P. (2011) Therapeutic Services for Sexually Abused Children and Young People:
Scoping the Evidence Base. Summary report. NSPCC
Allnock, D., Bunting, L., Price, A., Morgan- Klein, N/. Ellis, J., Radford, L. & Stafford, A. (2009) Sexual abuse
and therapeutic services for children and young people. NSPCC
Allnock, D., Radford, L., Bunting, L., Price, A., Morgan- Klein, N., Ellis, J. & Stafford, A. (2012) In demand:
Therapeutic Services for Children and Young People Who Have Experienced Sexual Abuse. Child Abuse
Review 21:318-334
Bannister, A. (2003) Creative Therapies with Traumatized Children. Jessica Kingsley Publishers
Dixon, J., Biehal, N., Green, J., Sinclair, I., Kay, C. & Parry, E. (2013) Trials and Tribulations: Challenges
and Prospects for Randomised Control Trials of Social Work with Children. British Journal of Social Work 1-
19
Parker, B & Turner, W 2013, ‘Psychoanalytic/psychodynamic psychotherapy for children and adolescents
who have been sexually abused’. Cochrane Database of Systematic Reviews, vol 7.
Macdonald G, Higgins JPT, Ramchandani P, Valentine JC, Bronger LP, Klein P, O’Daniel R, Pickering M,
Rademaker B, Richardson G, Taylor M. Cognitive-behavioural interventions for children who have been
sexually abused. Campbell Systematic Reviews 2012:14
Saunders, B.E., Berliner, L. and Hanson, R.F. (eds) (2003) Child Physical and Sexual Abuse: Guidelines for
Treatment (Final Report: January 15, 2003). Charleston, National Crime Victims Research and Treatment
Center
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