Podcast: planning therapeutic sessions for children displaying harmful sexual behaviour

Last updated: 22 Nov 2021 Topics: Podcast Type: Podcast
Overview

What to consider when planning your sessions with children and young people

Following on from our first episode in this series, social workers and children’s practitioners, Katy Tomkinson and Rowan Wolfe, talk about planning therapeutic sessions and assessing children and young people who have displayed harmful sexual behaviour.

You’ll learn more about:

  • preparing therapeutic session plans and helping children explore their life experiences through the use of timelines, family trees and cartoons
  • addressing sensitive topics such as sex and HSB, and exploring children and young people’s understanding around consent.
This episode touches on our practitioners' experiences of working directly with children and young people. Although all experiences are generalised, they could be upsetting for some, and may cause distress. Listen to the first episode and third episode in the series.


Listen on YouTube

 


About the speakers

Katy Tomkinson is a qualified social worker who has worked at the NSPCC for over five years. She has undertaken assessments of therapeutic need and provided therapeutic interventions for young people who have been sexually harmed.

Rowan Wolfe has worked at the NSPCC for fifteen and a half years as a qualified social worker. She has worked with children and young people who have displayed harmful sexual behaviour by undertaking assessments and providing therapeutic interventions.

NSPCC Learning Podcast

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Related resources

> Browse our resources for understanding, preventing and responding to harmful sexual behaviour

> Listen to the first episode in this series on direct work with children

> Listen to the third episode in the series on technology-assisted harmful sexual behaviour

> Listen to our episode about harmful sexual behaviour in schools

Transcript

Podcast transcription

Introduction:
Welcome to the NSPCC Learning podcast, where we share learning and expertise in child protection from inside and outside of the organisation. We aim to create debate, encourage reflection and share good practice on how we can all work together to keep babies, children and young people safe.

Ali:
Hi and welcome to the latest NSPCC Learning podcast. This is the second of three episodes which are focusing on harmful sexual behaviour, also known as HSB. Back in January 2020, we published a series of podcasts on harmful sexual behaviour, and to date, these have been among our most well-received episodes, and so we've recorded three new podcasts on HSB.

Katy Tomkinson and Rowan Wolfe are social workers and children's practitioners at our Stoke Service Centre, and both have years of experience working on HSB services with children and young people. The second in the series focuses on some of the specific session plans and ideas that Katy and Rowan use to support their work with children and young people. For information, this episode was recorded in March 2021.

Katy:
This is part two of our direct work podcasts, and in this podcast we're going to talk a little bit more about some of those specific session plans and ideas that we might use to support our work with children and young people.

I think the first thing to think about — and we've talked more about it in podcast one — whilst we're going to offer you some session plans, it's really useful to have a couple that you might be able to use. Have a backup plan. Have a contingency.

Rowan:
There's nothing worse than going in and a session just falls flat and you get nowhere and you've not got a backup. And I think in this work, it's so sensitive, if you've not got that kind of plan in your back pocket to bring out you can just be left sitting feeling quite awkward. So I do like to have a contingency.

The more you do the work, the less you need to plan that contingency. I think when you first start you need to have a lot more prep time. I think what we wanted to think about was a combination of stuff. So how you might do some initial sessions, but also more HSB-specific examples of the sorts of sessions that we've done.

We talked about some of the initial stuff, the 'getting to know you' things that might be safer topics, but also what we wanted to do is think about how we could put a harmful sexual behaviour-specific change to that piece of work.

So, I think one of the things we talked about was timelines. You use timelines, Katy — how do you use them, just to do a timeline, and then how might you change that to develop that idea further?

Katy:
So I think helping them [children and young people] understand the concept of timelines is really useful because you can use them in so many different ways. So one of the initial sessions I might do with a child or young person is with a big piece of paper, if you can and have a room that sort of allows that. I would draw...

Rowan:
...wallpaper is quite good.

Katy:
Wallpaper's a really good one, back of wallpaper, lined paper... and some whiteboard markers, not sharpies, I would say, just because it doesn't wash out and families don't thank you for it.

But: [put a] big line down the middle and start off marking chronologically their age and ask them to think about the important things that happen to them chronologically in their age of marking off on the line. But the reason I do the line in the middle is that depending on whether the memory is a good memory or a bad memory, they might put it above for good memory and below for a bad memory.

And I might ask them to score it. You talked about scaling questions before, so I might say, "out of ten, how good was that memory? Out of ten, how bad was that memory?" That's not right for some children, so I think you use your professional judgment in that moment about whether that's going to be helpful for them. And I think generally to begin with, the children tend say, "I can't think of anything". So I asked them, "what was your first memory?", or "can you tell me about a Christmas that was really happy, or one of your birthdays?".

Rowan:
So I often do it with Post-it Notes because I think whenever you remember life events, often you forget the order and then you're like, "Oh, no, no, that happened before". So I find doing Post-it Notes quite helpful because you can move them up and down the timeline to get the order correct.

Katy:
I really liked doing it with the Post-it Notes, and that works really well for some children. I've had other children that have spent half the session creating and decorating their own timeline, and that's really important to them too so I don't really mind. For me, what's important is that engaging conversation with the child and whatever way we get from A-to-B, it doesn't really matter. But Post-its, you're right, is a good one because it means you can move those things around.

Rowan:
Sometimes I'll also write things that I know have happened to them, and it might be a really positive thing. Say, for example, it was the first time they played in the school football team and they were really proud of it. And that's just come out in general conversation. I might have that ready on a Post-it note, so that you're showing that you've listened to things that they've said before, but it also can give them a starting point of something to put on. And then you ask them about that experience.

Equally, sometimes when you know it's a negative experience that they're going to struggle to bring up themselves, that might be a way of introducing it.

Katy:
Yeah. And I think it's important if they do name negative experiences that, if this is an initial session, you don't want to explore that more. You maybe thank the child for being really brave and sharing that with you and sort of recognise that that wasn't nice and that you're sorry that that happened to them. It's better than saying nothing, isn't it? And also maybe reflecting, you know, "we can talk about that if you want to, but we don't have to. We can think about it in the sessions going forward", just so that you're acknowledging what you're saying. Because, sometimes, as people, we avoid the difficult.

Rowan:
Absolutely.

Katy:
I think it's important that we give them a response. But for some young people… Think about working with young people who've said that they understood timelines, they did it in history because I've said, "we're going to timeline next week", "oh yeah, I've done one of them in history" —great — and then we get to the session, I think, "no, no, this this concept is just not going to work for them." And then sometimes I've really pared it back and I've just done good and bad memories.

Rowan:
Yeah, keep it simple.

Katy:
Get rid of the chronology altogether, because for some children, that's a barrier to them being able to explore their life experiences.

Rowan:
So, you use timelines to look at the past. Do you ever use them to look at the future?

Katy:
Yes. So, like I say, I think that would be one that I would do initially as a 'getting to know you' session. And I think once they're comfortable with that in the session, and we're having a very positive session and might say, "Oh, can you just, sort of, put on your timeline where the harmful sexual behaviour happened?".

And I might not use harmful sexual behaviour as a language, I might say, "where the incident happened with your brother or sister" or whatever it may have been, and ask them to put it on [the timeline].

So it's just naming it and that gentle reminder that this is the purpose of the work. And if there's been more than one incident again, gently encourage them to plot all of those things on the timeline if they can.

Rowan:
You're looking for triggers and things. Are you matching that with life events?

Katy:
I think initially I just use it as a session to get them to get more comfortable in exploring it and talking about it. And then as the sessions go forward, I think what's really helpful is doing a really pared back timeline just about the day or the hour that the sexual behaviour took place.

You’re really paring back: "what were you thinking? What happened in that timeline, the events leading up to what happened and afterwards?", so you can really drill down into what was going on for them, what were they were thinking and feeling — but that would be a later session. And then also, I think future timelines as well. It might be something that you do later in the work when you're talking.

Rowan:
Might even be the intervention that you come on to, where you use the same timeline. That's the beauty of getting wallpaper or something because that piece of paper is going to keep you going and it can grow during your work.

Katy:
And it's quite empowering for young people as well, because it's helping them believe that they can choose the path that they want to. And that encouragement of "this can be your life. You can do this."

Rowan:
I often split mine into two. So, I stick with that positive negative theme that you've got, the line that goes through the middle, and I'll do the future timeline that's positive with no HSB and the future timeline if HSB occurs. And my aim would be to really get an understanding of their aspirations, what they want from their life and build that into the most vivid picture I can, this positive future.

So, do they see themselves with a family or a partner? What job do they want to be doing? And for some kids, they have such low self-esteem, they don't see any future. And then that's our job to look at how can we build that over the course of the work. You don't have to do it in that one session. You don't fix everything. But it might be something we need to really think about; about how we can develop their talents and get them to start to see that there's a future.

But equally, also, I'm saying... I want to check that they understand the consequences of further behaviour and how that might impact their future. So what I try and do is never tell the children that because they've displayed this behaviour their life's over. I think some of them think, especially if they've ended up with a conviction of some sort, "that's it, my life's over." And it could be that some of their career opportunities have changed because of that conviction, and that's really difficult, and you might have to support them with that. But also, there's lots of things that are still open to them that are positive career opportunities.

I spend less time on the negative, but I spend some time thinking about, well, if there was further behaviours, how might that impact on your life, your relationships, your career options? And then you're basically saying to them, which path do you want to choose? Very few are going to say, "well, I definitely want to choose the negative path". They're going to want the positive. And then it's like, well, this work is how you commit to that. This work is how you start to make steps towards that positive future. You're always trying to bring them back to "life can change".

Katy:
In a positive way. And that support: “it's my job to help you on that path, isn't it?”. So they don't feel like they're overwhelmed and on their own with it as well. In terms of some of the initial sessions, the 'getting to know' you sessions, do you do genograms, family trees?

Rowan:
It varies. Sometimes what I'll do if it's what I call a 'littley', so primary school, I might try and do it in a much more fun way. For example, I know that they're really into football and there's a particular team that they've got, I've gone and downloaded the little shirts of a particular football team, and I'll print loads and loads of them off, and then they can put their family football team out rather than their family tree. And then that means that each member of the family gets their own football shirt. But it just brings a bit more engagement.

And others, I might make an actual tree and the leaves are [family members]. Others, I just draw out simply on a piece of paper. Don't be afraid to draw it for them. This isn't a class exercise at school where they have to have completed the work themselves. If all they can do is mumble some responses, that's a win. That's good. I'm happy to do the drawing for them.

Katy:
I would say give them a choice. "Do you want to do it or you want me to do it?". And it doesn't matter either way.

Rowan:
And if they want to do it great. And let them decorate it and all the rest. It's quite useful, I think, when we do family trees, genograms, however you do that, is to think about how you can then bring the HSB in later. So, initially, it's just to find out who's in their family.

Sometimes we'll use things like 'feelings bear' cards and say which bear represents each member of the family. So you get in a sense of whether they have a happy bear, a safe bear, an angry looking bear. And that can be quite telling about how they see those people in the family.

Or objects to represent [family]. An example would be someone who had a scouring pad with a spongy bit on one side, picking that for somebody because you never know what you're going to get, whether you get the rough side or the smooth side, which is quite insightful.

Katy:
I quite like doing family Top Trumps.

Rowan:
Oh yeah, nice.

Katy:
So they score the family members. And sometimes they want to draw them, or sometimes they find little character pictures. You have a set of questions like, how safe they make you feel? How happy do they make you feel? How angry? And I think if kids like the game of Top Trumps, then that's quite a fun way to explore their family.

Rowan:
I like that one. I've not used Top Trumps. That's good. The other things I think about is, you might look at, "well, who knows about your sexual behaviour?" Circle all the people in the family that know. Is there anybody that isn't on that family tree that knows about the behaviour? Because you get some young people and half the street know.

And then you've also got to think about their safety, about people knowing and how they've reacted to it and if there's a risk from the community. It might tell you that parents are actually sharing a lot of this information with lots of people, and how would that feel for a child knowing that "Tina at number seven knows about what I've done".

I think that can be quite useful to find out how they know, how they reacted, because they might have had a lot of rejections in their lives. So that's quite useful. Or anyone you didn't want to know. So you can explore it in lots of different ways.

Katy:
I quite like in the 'Three Islands' as well, which is really good for lots of ages of children, generally younger ones where you might have an island of 'Always', 'Sometimes' and 'Never'. And I would physically, or they would physically, cut out paper to represent each of the islands and stick it on a paper sea. And they are always on the 'Always' island, because they're always with themselves, and then you ask them to populate the islands with the people that they want to have with them always, that they want to have with them just some of the time, and the people that they never want to have them.

But I do have to make sure for some children, I have to say this isn't real and it won't come true. So you might want to put someone on the Never Island, and also that safe space reminds me about confidentiality, we're not going to share this with anybody. So if your mum or dad or your nan needs to go on the Never Island because you really don't have a good relationship with them, that's okay. We're not going to tell them.

And I always think that brings out some really interesting information about who might be the most important one. So, I encourage them to put pets on, because sometimes with some young people that the only people they want with them all the time is their dog. And that's really helpful to think about the strengths and resilience that that child may or may not have.

Rowan:
I think sometimes as well, some of the young people we see might be quite anxious, or they might find it really hard to sit still. So sometimes you could use different pieces of paper at different points in the room so the child can physically go and move things to that, rather than just a piece of paper in front of you. And that can be a way to help them deal with those feelings of anxiety or the need to move around.

And I think that's the thing, you have to give permission. You're not encouraging children to be running around the room or anything, you're trying to do it in a contained way. But recognising that kids struggle to sit still, especially when they're feeling really awkward and embarrassed.

Katy:
I think a proper formal family tree as well is a really useful assessment tool that we should be including in our assessment reports anyway. It's helpful sometimes where we've got lots and lots of safeguarding issues for a family, or lots of abuse, to colour code those and sometimes you might colour code all of those who have maybe experienced abuse, all of those who've displayed abusive behaviours. Sometimes you need to colour in both, because people have done both. That's a really good visual tool to highlight safeguarding concerns as well.

Rowan:
Would you do that with the child, or would that be something you did more when you're back in the office and you're looking at the case?

Katy:
It would depend on the child. I think for some young people, they're able to do that piece of work, and it's a really helpful, cathartic thing to do. And for some young people, it absolutely isn't and it needs to be done away from them and shared with the professional network in terms of a safeguarding response.

Rowan:
So in terms of... You're talking about the general family — and I suppose what we should say as well is that for some children, what is actually the most painful thing to talk about isn't the HSB, it's the family. So we need to be sensitive with that. Talking about family trees and creating things like that can actually bring a lot of difficult feelings for children, so it's being sensitive about that.

The more you know about a child, the more you can talk to professionals and family members or carers about what their background's like, the easier it is to be sensitive about those issues. And also, we don't know who might not be safe people in their family. So we might think talking about somebody, a specific family member's fine. But actually, to them, that's really painful.

Katy:
So I guess it's never forcing them, is it, never pushing them. And in every bit of work we do, it's about trying to be mindful and read their body language and reflect back to them. So, "I'm wondering if you're feeling a bit uncomfortable about doing this? You don't have to do it. It's fine." I guess that's important in terms of, again, that therapeutic relationship we talked about previously.

Rowan:
Some children we work with have never, maybe, had a lot of family members regulating their emotions. So actually, the process of reflecting back what you're observing in the changes of their body, they might not be in tune with how they feel. Especially young people who get very angry, very quickly, but they didn't see the warning signs as they started to build. But we, as professionals might start to notice that they're starting to breathe heavier or look uncomfortable or tense their jaw, and their opportunities aren't they, to name that for them before it gets to the point that they pop. And then they feel angry and they can no longer engage.

In terms of moving the conversation on: you've started that conversation of getting to know them, find out about their background, you're then starting to move really to talking about sex. It might be more generically, rather than straight into harmful sexual behaviour. What are some of the ways that you could approach talking about sex with young people?

Katy:
I think it's really helpful when you're having — prior to having your sessions that are going to directly explore the HSB — that you've had other sessions with them that are more explicitly about sex because it's about gradually building that up, isn't it? It's going to be more difficult to talk about their own sexual behaviour than sex in general. And it's really helpful to understand what their sexual knowledge is and whether it's appropriate or not for their age.

I think it's helpful, where possible, to do that in line with whatever PSHE (personal, social, health and economic education) or RSE (relationships and sex education) that they're getting in school so that you're giving the message in the same way and reinforcing it in that positive way. Working with your professional partners is helpful.

I'd really want to explore their understanding around consent. One of the ways I might do that is create a series of vignettes, really short narratives — and once you've created them once you can use them in lots of different ways, so it's not a waste of time in that respect — that describe some sexual interactions and encounters and ask them to say whether or not they think that scenario shows consent or not. And then spend a bit of time unpicking why they think that and supporting them with the law, what the law says, you have to be over 16, you have to be free to consent and you have to have the capacity or understanding to what you're consenting to.

I'd really want to drill down on how much they understand about what the law says. Using consent scenarios is a really helpful way. And again, talking about it in a third-party way is less challenging. At the end of that session, I might then ask the question of, "do you think, when you think about what happened with whoever, whatever the HSB was, do you think that there was consent in that?" So it's then asking them to reflect on their own behaviour.

Rowan:
We also might look at where they've got sexual knowledge from. So just asking them to say every place that they might have got sexual knowledge and you can prompt them a bit can't you? And then whether they think they're good places to get accurate information, and that's a good place where talking about peers telling them things or viewing pornography — it's a good, gentle way in, isn't it, to start that conversation and say, "do you think pornography is an accurate way to depict what sex is like? What consent is like? What healthy relationships are like?" But it's not going straight into "do you watch pornography?" where they can feel quite confronted.

Katy:
And if they can't verbally discuss it there are lots of other things you can do. You could print off bullet points — all the different ways that children might learn about sex — and then ask them to just move those pieces of paper with those bullet points onto a 'safe way', 'unsafe' or 'not sure'. So there’s less requirement on them to verbalise it. And if they can't do stuff about consent verbally, you could do the same about good and bad touch, so give them lots and lots of different examples of touch, including not just sexual touch, like it could be punching someone, hitting someone, brushing someone's hair and asking them put in a 'good' column, 'bad' column, 'not sure', or 'both', because again, it's less pressurising for that child.

Rowan:
There's lots of ways to talk about sex, and I know, if we had a longer podcast, we could go on for quite a long time. So we've talked about the general 'getting to know you'. We've talked a little bit about starting to explore sex. What about approaching talking about the harmful sexual behaviour? I think we've got two that we particularly want to talk about, which was 'cartooning' and 'Finkelhor'. Can you talk a little bit about cartooning?

Katy:
When we talked about the timeline we said one of the things you can do is then create a much shorter timeline that really drills down on the events of that specific day or week of whatever timeframe is relevant. And another way of doing that is to 'cartoon out' the sexual behaviour. And let's be clear, we don't need to be expert drawers, I'm talking about stick figures here.

Rowan:
My cartoons are dreadful but they find it funny, they laugh at my artistic skills.

Katy:
And actually, it makes for a more light-hearted session because I'll say I am clearly very rubbish at drawing, and what I will do is create these cartoon slides and cut them out individually, prior to the session, but I also bring a bunch of blank ones as well. And that's based on the information that we have about the harmful sexual behaviour incident, so it's really important we have as much information as we can prior to doing the session so that we can challenge and bring what we already know. And then all I will ask the young person to do is to put those slides in order, initially. That kind of circumnavigates denial, because I'm not asking them directly if it happened, I'm just asking to put it in order. Fill out any slides where there are gaps.

And once we've got them in order, then I might start to ask them to think about how they were feeling. We might use feeling cards if they can't name it. And then we might go, "so how were you feeling just before? So in slide three, where you're just walking home from school, how were you feeling? And then when you walked through the door and then an hour later you were looking at pornography, how were you feeling? And then half an hour before the sexual behaviour happened, how were you feeling?" So really drilling down and then helping that young person identify, when did the thought come into their head? When did they start to plan it? Because a lot of young people will say, "I didn't plan it. It just happened". And what we know is nothing ever "just happens".

Rowan:
Cartooning's really good to slow it down, isn't it? When you get down to: "so you were thinking about that, but then how did you end up in such-and-such-a-body's bedroom? So how did you get from the point of having that thought, lying in your bedroom, watching porn, getting to that bedroom? There's a process. There's a physical barrier of the door that you had to kind of open it."

It's breaking that down into really small, bite-sized things for them to start to reflect. Ultimately, what you're looking for is where were these points that they could have stopped? So if they're in a situation in the future where they start to get these thoughts and feelings again, what are their warning signs? How could they stop themselves at different points? And that could be part of their strategy then for their safety plan.

Katy:
Exactly. I think when you've done that first layer of cartooning, then you can start to add the thoughts and feelings that were happening at various points. And then you could take it a step further and ask them to think about what they think the children impacted by their behaviour might have been thinking and feeling and recognising, because a lot of children say, "Well, I don't know, I'm not them" but you say, "I just want you to think about it. How do you imagine they might have been?".

Rowan:
Or, "what did their face show? How was their face at the time? Or what emotion do you think they were feeling then if their face looked like that?".

Katy:
And it's also a helpful tool to think about whether or not the response of other children is sufficient barrier for them to stop. Did they stop at the point that they recognised this child was uncomfortable, not consenting? Or did they see that they were uncomfortable and not consenting but carry on? And that changes our risk assessment slightly.

You were going to talk a little bit about Finkelhor model…

Rowan:
Finkelhor's a bit of a contentious one. I think people have different feelings over it because ultimately it is a model that was written for work with adult sex offenders, and I think we need to be really, really clear, these are children. Whether they're children or they're young people, these are not adults, they're not mini sex offenders, they're children, and they need to be treated and talked to in a nurturing way. They're not sophisticated in terms of their offenses and thought processes and we need to be clear about that.

Despite that, I actually still find Finklehor's [model] a really useful way of helping young people understand. And again, I think we do have to think about children's levels of understanding, so there might be some children that this is a bit too complicated for. They might find this a bit challenging, so you do need to get to know your child and their learning style.

So, if you're going to use Finklehor, you do need to read around it, understand it, decide if it's suitable for that child. But basically, you're looking at… the first thing is having a sexual motivation. It's the thinking stage. It's that impulse to do the behaviour. It's around the feelings and fantasies of a child. Then you've got to overcome internal inhibitions, so it's giving yourself permission. So most young people know that behaviour is wrong, but they do something to convince themselves that it's not that bad. Sort of minimise it. They then need to overcome all the external barriers, like creating the opportunity. So, like we talked about in using cartooning, if the door was shut they had to go through the door, there's certain things that they need to do.

And then it's overcoming victim resistance. Now, that can sound like that's going to be a very threatening thing that they might have to do but actually, sometimes, it's just that that person trusted them, because it might have been a sibling. And that's really sad. But it doesn't mean that they have actually done something very forceful. It might be that they have.

It's understanding that because, again, each of these steps offer an opportunity to look at what allowed them to get to the next step. But also, what things do we need to put in place? If you imagine it like hurdles, or a brick wall, they've got to climb over that wall to get over the first step how can we make that wall bigger in the future for them? How can we make it harder for them to get over it? Because we start to work on those internal thought processes that will help them think differently in the future.

I think you can do that on paper, but there are other ways you can do it, things like having four chairs. I don't know if you ever done it with four chairs?

Katy:
No, sounds really good.

Rowan:
Sometimes we put four chairs out and then for each of the stages we ask the child to sit in that seat as though they're at that point of the process of thinking. So in that moment, they haven't got to think about all the stages, just that one stage, and that can sometimes help them. It's also that physical movement, makes them feel a bit more comfortable. But it is one where I think you do need to spend time thinking about how you're going to approach it. But I have had some of my most successful sessions using it because they've really got down to what they were thinking and feeling at such a deep level that that is been the thing that's really enabled me to help create a realistic safety plan.

Katy:
Yeah, I really like it as a strategy. I think, like you say, for the right child it can be a really fantastic way of helping them understand their behaviour. I do think it's helpful when you're introducing it to use a non-sexual story, like stealing from a sweet shop, in order to introduce the idea that you can 'role play it out' is likely to less threatening.

Rowan:
Eating cream cakes is quite a good one.

Katy:
Yeah, smoking, that kind of thing. But yeah, a really good strategy.

Rowan:
I think in general, what I suppose our message would be is that doing this work, you need to develop a toolkit. You can't go into this work and think you can just sit down and have a chat, with a piece of flip chart. You will need to spend time to prepare, time to create stuff, so that when you go, you're confident and clear, and you can make it as easy for the child to engage in that process as possible.

Ali:
We hope you've enjoyed this podcast. The third episode, which will be released next week, will look at technology-assisted harmful sexual behaviour.

(Outro)

Thanks for listening to this NSPCC Learning podcast. At the time of recording, this episode’s content was up to date but the world of safeguarding and child protection is ever changing – so, if you're looking for the most current safeguarding and child protection training, information or resources, please visit our website for professionals at nspcc.org.uk/learning.