What are practitioners' views of how digital health interventions may play a role in online child sexual abuse service delivery?

Introduction: Online child sexual abuse (OCSA) affects considerable numbers of children globally and is associated with a variety of mental health problems. Existing practitioner studies suggest that young people are infrequently asked about online abuse and practitioners have a fragmented understanding of the problems experienced or how they might approach them. There are very few evidence-based interventions that guide clinical assessment or practice. Digital Health Interventions (DHIs) have the potential to be an effective option where children and young people's services are challenged, including accessibility and anonymity. The aim of this study was to explore mental health practitioners' views of how DHIs may play a role in supporting young people who have experienced OCSA, and the role they can play in healthcare delivery. Method: In-depth qualitative interviews and one focus group were conducted with 25 child mental health professionals across two sites (Manchester and Edinburgh). Data was analyzed using reflexive thematic analysis. Results: Three overarching themes and 9 sub-themes were identified: (1) feeling a little bit lost; (2) seeing potential problems; and (3) knowing what works. Practitioners expressed interest in a DHI to support this client group and saw it as a way of managing waiting lists and complementing existing therapies. They felt that many young people would see this as a preferred medium to in-person therapy, would be empowering, and offers new ways of learning how to stay safe online. However, there were concerns about how much time would be needed by staff to deliver a DHI, anxieties about safety issues in relation to content and data protection, some of which may be unique to this population of young people, and concerns about the absence of a therapeutic relationship with vulnerable children. Discussion: Our findings indicated that practitioners were uncertain about working with children subjected to OCSA but were receptive to the possibility of using a DHI to support their practice and to reduce waiting lists. Concerns were expressed about the time needed for staff training and support as well as concerns over patient safety and the lack of evidence about the effectiveness of an unsupported DHI.

Technical profiles of child sexual exploitation material offenders.

The idiographic technical profiles of child sexual exploitation material (CSEM) offenders provide insight into their behaviours and context for their interactions with technology, but minimal quantitative work has been done to evaluate their sociability, technical ability and technophilia compared to non-offenders. This work used an online survey to compare an offender group consisting of English-speaking adults previously convicted of CSEM offenses (N = 78) with a reference population of non-offenders (N = 254). The survey assessed sociability, technical ability and technophilia through self-rating and information on occupation, level of education and device ownership. The study found that CSEM offenders had slightly lower sociability than non-offenders, though not at a level of clinical interest. Additionally, CSEM offenders had no statistically significant difference in technical ability and lower overall technophilia when compared to non-offenders. This study fails to support popular perceptions of CSEM offenders being technically savvy loners who are early adopters of new technologies.

Experiences of a digital health intervention for young people exposed to technology assisted sexual abuse: a qualitative study.

BACKGROUND: There is growing evidence that Technology Assisted Sexual Abuse (TASA) represents a serious problem for large numbers of children. To date, there are very few evidence-based interventions available to young people (YP) after they have been exposed to this form of abuse, and access to support services remains a challenge. Digital tools such as smartphones have the potential to increase access to mental health support and may provide an opportunity for YP to both manage their distress and reduce the possibility of further victimization. The current study explores the acceptability of a digital health intervention (DHI; the i-Minds app) which is a theory-driven, co-produced, mentalization-based DHI designed for YP aged 12-18 who have experienced TASA. METHODS: Semi-structured interviews were conducted with 15 YP recruited through Child and Adolescent Mental Health Services, a Sexual Assault Referral Centre and an e-therapy provider who had access to the i-Minds app as part of a feasibility clinical trial. Interviews focused on the acceptability and usability of i-Minds and were coded to themes based on the Acceptability of Healthcare Interventions framework. RESULTS: All participants found the i-Minds app acceptable. Many aspects of the app were seen as enjoyable and useful in helping YP understand their abuse, manage feelings, and change behavior. The app was seen as usable and easy to navigate, but for some participants the level of text was problematic and aspects of the content was, at times, emotionally distressing at times. CONCLUSIONS: The i-Minds app is useful in the management of TASA and helping change some risk-related vulnerabilities. The app was designed, developed and evaluated with YP who had experienced TASA and this may account for the high levels of acceptability seen. TRIAL REGISTRATION: The trial was registered on the ISRCTN registry on the 12/04/2022 as i-Minds: a digital intervention for young people exposed to online sexual abuse (ISRCTN43130832).

The Impact of a Public Health Campaign to Deter Viewing of Child Sexual Abuse Images Online: A Case Study of the UK Stop It Now! Campaign.

Public campaigns offer an opportunity to prevent child sexual abuse by raising awareness and promoting help available to bystanders, victims, and those at risk of perpetrating the abuse. This paper explores the impact of The Lucy Faithfull Foundation's 'Stop It Now!' campaign in the UK (2015-2018) on help-seeking. Helpline calls (11,190 unique callers), website analytics (109,432 new website visitors) and three website-hosted surveys (N = 252) provided data on help-seeking, awareness, and self-reported behavior. Results indicated that there were more visitors to the help website during active campaigning periods, and helpline callers and website visitors were more likely to seek help after viewing campaign materials during active than non-active campaign periods. Help-seekers were predominantly men concerned about their own behavior. Survey 2 respondents concerned about their own behavior (n = 53) indicated that their awareness of the law (75.5%), and legal and personal consequences (67.9%) had changed after hearing about the campaign, and 66% reported a change in behavior. Public health campaigns may be an effective way to promote help-seeking and prevent abuse.

A Digital Intervention to Improve Mental Health and Interpersonal Resilience in Young People Who Have Experienced Technology-Assisted Sexual Abuse: Protocol for a Nonrandomized Feasibility Clinical Trial and Nested Qualitative Study.

BACKGROUND: No evidence-based support has been offered to young people (YP) who have experienced technology-assisted sexual abuse (TASA). Interventions aimed at improving mentalization (the ability to understand the mental states of oneself and others) are increasingly being applied to treat YP with various clinical issues. Digital technology use among YP is now common. A digital intervention aimed at improving mentalization in YP who have experienced TASA may reduce the risk of revictimization and future harm and make YP more resilient and able to manage distress that might result from TASA experiences. OBJECTIVE: In this paper, we describe a protocol for determining the feasibility of the i-Minds trial and the acceptability, safety, and usability of the digital intervention (the i-Minds app) and explore how to best integrate i-Minds into existing routine care pathways. METHODS: This is a mixed methods nonrandomized study aimed to determine the feasibility, acceptability, safety, and usability of the intervention. Participants aged between 12 and 18 years who report distress associated with TASA exposure will be recruited from the United Kingdom from the National Health Service (NHS) Trust Child and Adolescent Mental Health Services, sexual assault referral centers, and a web-based e-therapy provider. All participants will receive the i-Minds app for 6 weeks. Coproduced with YP and a range of stakeholders, the i-Minds app focuses on 4 main topics: mentalization, TASA and its impact, emotional and mental health, and trauma. A daily prompt will encourage YP to use the app, which is designed to be used in a stand-alone manner alongside routine care. We will follow participants up after the intervention and conduct interviews with stakeholders to explore the acceptability of the app and trial procedures and identify areas for improvement. Informed by the normalization process theory, we will examine barriers and enablers relevant to the future integration of the intervention into existing care pathways, including traditional clinic-based NHS and NHS e-therapy providers. RESULTS: This study was approved by the Research Ethics Board of Scotland. We expect data to be collected from up to 60 YP. We expect to conduct approximately 20 qualitative interviews with participants and 20 health care professionals who referred YP to the study. The results of this study have been submitted for publication. CONCLUSIONS: This study will provide preliminary evidence on the feasibility of recruiting YP to a trial of this nature and on the acceptability, safety, and usability of the i-Minds app, including how to best integrate it into existing routine care. The findings will inform the decision to proceed with a powered efficacy trial. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Registry (ISRCTN) ISRCTN43130832; https://www.isrctn.com/ISRCTN43130832. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40539.

The experiences of practitioners working with young people exposed to online sexual abuse.

Introduction: This qualitative study explored healthcare professionals' current understanding of, and clinical practices related to, Online Child Sexual Abuse (OCSA). Methods: Data were collected across two UK sites (Manchester and Edinburgh). Interviews and one focus group were held with 25 practitioners working in services offering clinical support to young people who have experienced OCSA. Thematic analysis of the data identified three overarching themes and 10 subthemes related to the research questions: (1) the breadth of the problem; (2) working with OCSA; and (3) the emotionally charged nature of OCSA. Results: While practitioners recognized OCSA as problematic, they differed in how they conceptualized it. There was a heightened awareness of the role that sexual images played in OCSA and concerns about first-person-produced imagery by Children and Young People (CYP). Practitioners described a generational gap related to their technology use and that of the young people they worked with. Practitioners also described a paucity of referral pathways and concerns that there was no training available to them. Organizational barriers meant that questions about technology use were not routinely included in assessments and often there was reliance on young people making disclosures. Discussion: Novel findings from this study were the psychological impacts that such cases had on practitioners, which may indicate a need for organizational support for staff as well as further training needs. Existing frameworks that help conceptualize and assess the role of technology as part of the ecology of the child may have great utility for practitioners.

Self Perceptions and Cognitions of Child Sexual Exploitation Material Offenders.

Identifying the self-perceptions of child sexual exploitation material (CSEM) consumers compared to a reference population of non-consumers is critical in establishing distorted cognitions that may not be elucidated when comparison is made with groups who have committed other offenses. This exploratory work utilizes a quantitative approach toward identifying how individuals previously convicted of child pornography offenses view CSEM and CSEM offending, using a group of non-offenders as a baseline. The target group was selected based on their inclusion in two sex offender registries for child pornography offenses (n = 78). A reference group of non-offenders (n = 254) was gender-matched from a subset of a prior study evaluating the public perceptions of CSEM. Both groups were adults located within the United States and were asked questions using an online survey about their general perceptions of CSEM, their endorsement of CSEM beliefs, and their opinions related to the legality of various forms of CSEM and associated laws and sentencing guidelines. The study found that CSEM consumers more accurately assessed risks associated with CSEM offending, but that they exhibited potential minimization-based cognitive distortions related to severity and victimization and more strongly endorsed child erotica and virtual child pornography being legal. Additionally, they endorsed treatment over prison, and were strongly opposed to sex offender registration for child pornography offenses. The results provide potential treatment targets, including behavioral areas that may be pathways to CSEM offending.

Understanding online grooming: An interpretative phenomenological analysis of adolescents' offline meetings with adult perpetrators.

BACKGROUND: It is the norm for adolescents to form friendships online but connecting with strangers poses risks of online grooming. Adult perpetrators take advantage of the internet's anonymity and accessibility to befriend and groom young people for sexual abuse. Much of the existing research has focused on the offender's perspective and grooming tactics, while extensive studies on victim profiles have focused on risk factors and young people's vulnerabilities to online grooming. OBJECTIVE: This research takes an in-depth look into grooming processes from the perspective of the adolescent victim and explores how the relationships progressed online-to-offline, resulting in sexual abuse. It aims to understand young people's motivations and mindsets by exploring their lived experiences of offline meeting with adult perpetrators. PARTICIPANTS AND SETTING: The sample consisted of adolescents aged 14-21 in the UK and EU. METHODS: Using data from the Risk-taking Online Behavior Empowerment through Research and Training Project, six interviews were examined using an interpretative phenomenological analysis. RESULTS: Four themes emerged: 1) Varied interpretations of risk 2) Taking control 3) Seeking security and validation; and 4) Shifts in perspective. The subtleties of online grooming were masked by the adolescents' misplaced trust as they displayed agency in pursuing opportunities for online friendships or sexual activities. CONCLUSIONS: Findings suggest an insufficient knowledge of grooming and the need to more clearly define risks among adolescents. Safety guidelines should highlight the subtleties of grooming tactics and harmful behaviours that may not be readily perceived as abuse.

Suicidal ideation in offenders convicted of child sexual exploitation material offences.

Understanding the prevalence of suicidal ideation in Child Sexual Exploitation Material (CSEM) offenders and their psychological concerns provides the basis for early treatment and intervention. This research solicited responses (n = 78) via an anonymous, web-based survey from adults in the United States previously convicted of CSEM offences. Significant suicidal ideation was present in 73% of respondents (n = 57), and 19% (n = 15) reported attempting suicide after they were made aware of an investigation, with 41% (n = 32) stating they would have been likely to seek counselling if provided a contact. Most of the respondents felt they were not treated with fairness, understanding, and compassion by investigators, and that their primary psychological strains were going to jail and their families finding out. This research highlights the need for more empathetic investigative approaches, as well as the need for more rapid assessment and treatment of proximal suicide risk in this population.

Public Perceptions of Child Pornography and Child Pornography Consumers.

Understanding the public's perceptions of child pornography helps identify gaps in awareness and knowledge, impacts legislative decision making, quantifies stigmatization, and provides a baseline for identifying differences between lay and offender populations for clinical purposes. This research provides a comprehensive public survey assessing these issues. An Internet-based sample of 524 adults (mean age = 47 years, 51% female) within the USA were asked about their understanding and beliefs related to child pornography and individuals who view child pornography. The questions covered three topic areas-general perceptions of child pornography, endorsement of child pornography beliefs, and opinions related to the legality of various forms of child pornography as well as the decision making related to sentencing and sex offender registration for child pornography consumers. The research found that the public viewed these offenses as more severe than most other crimes and that there was an overestimation by the public of risks related to recidivism and contact offending. Additionally, the research found that there was support for most of the current sentencing guidelines in the USA, including sex offender registration, and that there was limited support for treatment over incarceration.

Predicting Risk of Reoffending in Persons with Child Sexual Exploitation Material Offense Histories: The Use of Child Pornography Offender Risk Tool in a Scottish Population.

In the past decade, there has been an increase in child sexual exploitation material (CSEM) offenses and convictions. Although research shows that individuals with CSEM offence histories generally are at low risk of reoffending, certain factors do increase in CSEM convictions, in order to assist with case prioritization, management and supervision, risk assessment is helpful across agencies. The Child Pornography Offender Risk Tool (CPORT) was created specifically for this population and shows significant predictive validity for various outcomes. This study aimed to validate the use of the CPORT in a Scottish sample of 141 adult males who were convicted of CSEM offenses. Receiver Operating Characteristic (ROC) and logistic regression analyses indicated that the CPORT significantly predicted any recidivism (Area Under the Curve = .81), any sexual recidivism (AUC = .78) and CSEM recidivism (AUC = .74), suggesting that it is a valid risk assessment tool for Scottish populations. Recommendations for further research and clinical implications are discussed.

Relationship between Early Maladaptive Schemas and Anxiety in Adolescence and Young Adulthood: A systematic review and meta-analysis.

BACKGROUND: Early maladaptive schemas (EMS) are self-perpetuating dysfunctional cognitive structures that have been linked with youth psychological health and play a significant role in developing and maintaining psychological distress, including anxiety symptoms. METHOD: The present meta-analysis synthesises the existing literature to evaluate the strength of association between EMS and anxiety symptoms among adolescents and young adults (aged 10-29 years). The systematic literature search was carried out in October 2019 using six different databases. RESULTS: Our systematic search has identified 15 studies, comprising of 9515 participants (Mean age = 18.95, SD = 5.30). All the studies assessed were either cross-sectional or longitudinally designed. The random effect estimate for overall EMS with anxiety was r = 0.59 (95% Cl = 0.50 to 0.68, Z = 9.69, p < 0.0001), indicating a strong association between EMS and anxiety. When different schema domains were investigated separately, anxiety was shown to have significantly stronger associations with the schema domains of disconnection/rejection (r = 0.50), impaired autonomy/performance (r = 0.47) and other-directedness (r = 0.49). Further, females were found to have higher schemas of hypervigilance and other-directedness and associated anxiety symptoms compared to males. LIMITATIONS: Meta-analytical results were limited to articles published in peer-reviewed journals in English language, inducing an upward publication bias and limiting the generalizability of the findings. CONCLUSIONS: The findings highlight schemas related to disconnection/rejection, impaired autonomy/performance and other-directedness as particularly salient precursors of anxiety symptoms, providing evidence for clinicians to target these particular schemas during prevention, intervention, and management of anxiety disorder.

Online sexual harassment and depression in Chilean adolescents: Variations based on gender and age of the offenders.

BACKGROUND: Online sexual harassment in adolescence is associated with depressive symptoms. There is, however, a dearth of research investigating variability of symptom profiles in this population in relation to offender gender and age. OBJECTIVE: To identify the proportion of adolescents reporting online harassment by different types of offenders and compare their levels of depression. PARTICIPANTS AND SETTING: Participants were 18,872 Chilean students aged 12 to 17 years (3.063 of them online sexually harassed). METHODS: The study involved a secondary analysis of self-report data on online sexual harassment, poly-victimization, and depression collected as part of the National Poly-victimization Survey. RESULTS: In 37.6% of the cases the offender was male under 18, in 22.4% an adult male, in 14.5% a female under 18, and in 2.9% an adult female. In 22.5% of cases the offender could not be identified. An ANCOVA demonstrated levels of poly-victimization across the lifespan and frequency of online sexual harassment in the last year to predict depressive symptomatology. In females, higher levels of depressive symptoms were observed among those sexually harassed by either a female under 18, an offender whose age and gender the victim could not identify, or an adult male. In males, higher levels of depression were observed among those harassed by either an adult male, an offender whose age and gender the victim could not identify, or a male under 18. CONCLUSIONS: The current study highlights the importance of offender's age and gender in predicting depression levels in adolescent victims of online sexual harassment.

Collecting and viewing behaviors of child sexual exploitation material offenders.

BACKGROUND: The collecting behaviors of child sexual exploitation material (CSEM) offenders provide insight into their cognitions and motivations that have clinical applications. OBJECTIVE: This study analyzed the CSEM collecting and viewing behaviors of previously convicted offenders. PARTICIPANTS AND SETTINGS: A postal letter soliciting participation in an online survey was sent to adults previously convicted of CSEM offenses in the United States. Comparison information from a non-offending population of adults within the United States (N = 524) was collected and compared to the CSEM respondents (N = 78). METHOD: A mixed-methods approach was utilized. The CSEM group was compared to a gender-matched sample from the non-offending group for general adult sexual exploitation material (SEM) viewing. Exploratory analyses of CSEM offender behaviors related to collecting, collection diversity, and recidivism were conducted. RESULTS: The majority (78%) of the offenders did not organize their content and 74% deleted their entire collection on at least one occasion. Offenders viewed more diverse categories of adult SEM than non-offenders, including more bestiality, hentai, teen, and nudist/naturist material. None of the offenders viewed CSEM exclusively, and 74% viewed more adult SEM than CSEM. The age range of CSEM content viewed did not support highly preferential viewing but did support general novelty seeking. The self-reported recidivism rate was 10%, with infrequent post-conviction CSEM activity. CONCLUSION: Treatment professionals should not assume that pedophilic interests are the sole or even primary motivator for CSEM behavior. Problematic Internet usage, general pornography consumption, coping issues, or novelty seeking may be more appropriate targets for some offenders.

Prevalence and correlates of individuals with sexual interest in children: A systematic review.

BACKGROUND: Despite debates on what should constitute sexual interest in children in terms of definition and diagnostic criteria and its strong association with individuals who commit sexual offences against children, research in this area has shown that sexual interest in children is also commonly seen in the general population. Studies in this field have investigated its prevalence and its correlates. However, most research on this topic has focused on men and most particularly sex offender populations. When investigating the general population, again the vast majority of studies used male samples and students. OBJECTIVE: This systematic review aimed to critically evaluate previous research on the prevalence of sexual interest in children across populations and to examine its correlates. METHODS: A search of relevant databases was conducted as well as a hand search of selected journals to identify eligible papers. Studies meeting the inclusion criteria had their data extracted and were assessed for risk of bias, with a second rater to establish inter-rater reliability. RESULTS: A total of 30 studies were reviewed and results indicated a mean prevalence rate of sexual interest in children between 2 %-24 %. Findings also indicated correlates such as the presence of mental health problems and adverse childhood experiences. Most studies showed poor external validity, with the majority of them scoring high on risk of bias. CONCLUSION: Overall, the findings indicate inconsistencies in terms of methodology and definition/diagnostic criteria of sexual interest in children. Further research in this area using recommended methodology to avoid biases is recommended.

Secondary attachment and mental health in Pakistani and Scottish adolescents: A moderated mediation model.

OBJECTIVES: Research into adolescent mental health has tended to focus on primary attachment relationships. However, the effect of secondary attachment relationships and the role of culture remain under-explored. This study examined the associations between primary attachment, secondary attachment, and coping strategies (task-focused, emotion-focused, and avoidant coping) with psychological well-being and psychological distress in adolescents across two cultural settings. DESIGN: A cross-sectional study. METHOD: An identical test battery was used across two geographic sites in Pakistan (N = 510; 12-18 years; 51.5% male; mean age = 14.50) and Scotland (N = 610; 12-18 years; 53.6% male; mean age = 13.97). Associations were tested separately in each sample using moderated mediation modelling for the outcome variables: psychological well-being and psychological distress. RESULTS: For psychological well-being, all three coping strategies were significant partial mediators and secondary attachment was a significant moderator in both samples. Secondary attachment moderated the association between emotion-focused coping and psychological well-being in the Pakistani sample only. For psychological distress, task-focused coping was a significant full mediator in the Pakistani sample only. In contrast, for the Scottish sample, task-focused coping and emotion-focused coping were significant partial mediators. Secondary attachment's direct effect on psychological distress was significant in both samples. Secondary attachment also moderated the association between emotion-focused coping and psychological distress in the Pakistani sample only. CONCLUSIONS: The cross-cultural evidence suggests that alongside primary attachment, it is important to target secondary attachment through coping strategies, in order to enhance psychological well-being and lessen psychological distress in adolescents. PRACTITIONER POINTS: Secondary attachment plays a different role from primary attachment in adolescents. Therefore, it is important to target both primary attachment and secondary attachment security to enhance psychological well-being and lessen psychological distress. Cross-cultural differences in coping suggest that differential strategies to target different coping dimensions may enhance adolescent well-being across cultures. These cross-cultural differences highlight the ethical importance of cultural sensitivity among clinicians working with adolescents globally.

Management of non-consensually shared youth-produced sexual images: A Delphi study with adolescents as experts.

There is an increased availability of online child abuse images, a proportion of which is created by young people in coercive and non- coercive relationships (sexting). OBJECTIVES: This Delphi study with adolescents as "experts" who had taken and shared sexual images, was conducted to identify appropriate responses to sexting where images are shared without consent and identify indicators of distress and ways to facilitate disclosure when the sharing of images causes anxiety or is associated with further victimization. PARTICIPANTS AND SETTING: 124 adolescents from the United Kingdom completed an online survey. All self-identified as taking and sharing sexual images of themselves. 45 provided full survey responses (73% female; mean age 16.24) and of these 23 completed the second round. Recruitment was through social media and local schools. METHODS: An online two-round Delphi method was completed using a vignettes-based questionnaire. To assess consensus, a defined average percentage agreement (80% cut-off) was used. Qualitative content analysis identified relevant themes in responses to Round 1 which informed the Round 2 items. RESULTS: In the first round 60 items were identified that endorsed views of problem identification, facilitation of disclosure, proportionate responding, and problem management. Overall, participants agreed that the clear majority of statements identified in Round 2 were important and thus achieved consensus. CONCLUSIONS: This study represents a novel and inclusive approach through the formation of an expert panel of young people. These views may inform appropriate victim-centered management of cases where images have been shared without permission.

Professionals' Perspectives on Viewing Child Sexual Abuse Images to Improve Response to Victims.

The complexity of the phenomenon of child sexual abuse images online (CSAIO) benefits from cross-disciplinary collaboration across law enforcement, child protection, and children's mental health. Through focus groups with professionals working in these fields, this article focuses on when and whether professionals who work with child sexual abuse cases should be exposed to viewing CSAIO and if so under what circumstances doing so would benefit investigations and support services for victims. In a broader sense, this article is about professional experience, decision making, training, and collaboration around a particularly difficult professional experience, namely exposure to viewing CSAIO.

Transition from school to adult services for young people with severe or profound intellectual disability: A systematic review utilizing framework synthesis.

BACKGROUND: The transition to adulthood has been described as a difficult time in the lives of young people with intellectual disability. There has been little emphasis on young people with severe or profound intellectual disability specifically, even though their pathways may differ, due to greater support needs across the life course. METHODS: A systematic review was conducted utilising Bronfenbrenner's ecological model to inform framework analysis to synthesise qualitative findings. RESULTS: Taking an ecological perspective proved valuable. The transition process was described as stressful and barriers were identified across the ecological levels. Parents accounted for the majority of participants in studies, and the needs of young people and their parents emerged as highly interdependent. CONCLUSION: Themes reflect the complex nature of the question what adulthood should look like for individuals with severe or profound intellectual disability. There is a lack of involvement of multiple stakeholders and young people themselves within studies.