Harmful sexual behaviour among children and young people

Immediately inform your organisation's named safeguarding lead when a child or young person displays sexualised behaviour that is not appropriate for their age or developmental stage (for tools, see recommendation 1.3.4). Possible signs of problems include:

• using sexualised language such as adult slang to talk about sex

• sexualised behaviour such as sexting or sharing and sending sexual images using mobile or online technology

• viewing pornography that is inappropriate for age and developmental status (see the Brook Organisation information on pornography and the law).

Immediately inform your organisation's named safeguarding lead when a child or young person displays sexualised behaviour that is always inappropriate, regardless of age, such as public masturbation.

Named safeguarding leads should use locally agreed resources to assess concerns about the sexual behaviour of a child or young person. See recommendation 1.3.4.

Named safeguarding leads concerned about a child or young person's sexual behaviour should contact their local children's social services to discuss their concerns and determine whether a referral is appropriate.

Children's social services should refer children and young people who display inappropriate sexualised behaviour for an early help assessment, in line with local thresholds and referral procedures (see recommendation 1.1.5). Focus on the child or young person as an individual and not on the presenting behaviour.

At point of referral, early help professionals should identify a designated lead practitioner in the multi-agency, multidisciplinary team (see recommendation 1.1.6) who will:

• act as a single point of contact for the child or family

• coordinate early help and subsequent assessments and develop the care plan to avoid unnecessary or repetitious assessments that may be stigmatising

• coordinate delivery of the agreed actions

• involve children, young people and their families and carers in the design and delivery of early help services, as appropriate

• reduce overlap and inconsistency in services provided.

Early help professionals should be familiar with the child or young person's health and social care record and have access to neonatal and early health information, if necessary. This includes information on developmental delays or a diagnosis of autism spectrum condition, for example.

Use a locally agreed tool as part of the early help assessment that accounts for the severity of the behaviour, to avoid unnecessary and potentially stigmatising referrals. Examples of tools include:

• The Brook Sexual Behaviours Traffic Light Tool. This helps identify a range of sexual behaviours between infancy and adulthood and distinguishes between 3 levels, using a traffic light system to indicate the level of seriousness.

• Models that place a child or young person's sexual behaviour on a continuum indicating various levels of seriousness, such as Hackett's model (Hackett S [2010] Children and young people with harmful sexual behaviours, in Children behaving badly?: Peer violence between children and young people [eds Barter C and Berridge D]; John Wiley & Sons: Chichester).

Take account of the child or young person's age, developmental status and gender and, if relevant, any neurodevelopmental or learning disabilities.

Recognise that inappropriate sexualised behaviour is often an expression of a range of problems or underlying vulnerabilities.

Use the early help assessment to identify whether the child or young person has unmet needs that can be met by universal services. See Ofsted's Early help: whose responsibility? and Department for Education's Working together to safeguard children. Also:

• For preschool children, see the recommendations in NICE's guideline on social and emotional wellbeing: early years.

• For children and young people in primary and secondary education, see the recommendations in NICE's guideline on social, emotional and mental wellbeing in primary and secondary education.

Ensure services support children and young people of all ages. See the principles of care recommendations in NICE's guideline on children's attachment, NICE's guideline on looked-after children and young people, and:

• For children and young people who may have a conduct disorder, see NICE's guideline on antisocial behaviour and conduct disorders in children and young people.

• For children and young people who may have experienced trauma, see the sections on specific recognition issues for children and management of PTSD in children and young treatment in NICE's guideline on post-traumatic stress disorder.

If harmful sexual behaviour is displayed, refer to harmful sexual behaviour services, child protection services and the criminal justice system, if necessary.

Children's social care services and NHS England should identify services employing staff with the skills to undertake a specialist assessment of risk for children and young people displaying harmful sexual behaviour. This may include:

• child health services such as CAMHS

• children's social services

• voluntary sector organisations such as the NSPCC or Barnardo's

• organisations within the criminal justice system such as youth offender teams and youth justice boards.

Professionals responsible for specialist harmful sexual behaviour assessments should access any additional information they need. This includes incident reports of any behaviour that is causing concern. Get this information from the child or young person's:

• social care history

• educational records

• health records

• youth offending and youth justice records

• police records.

Consider the child or young person's developmental age, neurodevelopmental disabilities, learning disabilities and gender as part of the assessment. Do this in collaboration with other specialist services, if relevant.

Professionals responsible for assessing risk should use risk assessment tools suitable for the child or young person's developmental age and gender. For example, when assessing:

• Pre-adolescent children or those aged under 12, consider psychometric measures and questionnaires such as the Child Behaviour Checklist (Achenbach T [1991] Manual for the Child Behaviour Checklist/4–18 and 1991 Profile; Burlington: University of Vermont) and the Child Sexual Behaviour Inventory (Friedrich W [1997] Child Sexual Behaviour Inventory: professional manual; Odessa, Florida; Psychological Assessment Procedures).

• Children under 12 who have not been charged with a sexual offence, consider the relevant elements of AIM plus clinical judgement.

• Children aged 10 to 12 who have been charged with an offence, consider the relevant elements of AIM plus clinical judgement.

• Adolescent boys, consider tools such as J‑SOAP‑II, ERASOR or AIM2, plus clinical judgement.

Consider family or social factors that may contribute to the child or young person's harmful sexual behaviour, particularly if there is evidence of abuse within the family. See NICE's guideline on child maltreatment.

Think about the impact a child or young person's harmful sexual behaviour may have on all family members.

If the person at the receiving end of the harmful sexual behaviour is another child within the family, provide support for the family or a referral as needed (see NICE's guideline on child abuse and neglect).

Consider the following before providing an intervention:

• Meeting families and carers to discuss any concerns they may have, including any potential barriers to attendance.

• Providing families and carers with information about the intervention and including them, when appropriate.

• Adopting a flexible approach to accommodate the child or young person's social activities.

Structure interventions, but make them flexible enough to meet changing needs and the developmental status and age of the child or young person. Include regular progress reviews by practitioners delivering the intervention.

Base interventions on:

• A comprehensive assessment of the child or young person's family and social context. This includes: their placement (for example, home, foster care, residential care, secure children's home or other custodial settings).

• Developmental stage, gender, learning ability, culture and religion.

• Factors that may have contributed to the harmful sexual behaviour, such as their background, past care or any trauma they may have experienced.

• The harmful sexual behaviour itself.

Consider including the following elements:

• safety planning to reduce the risk they pose to others and themselves

• engagement and working that takes account of their denial of the behaviour

• sex and relationships education including consent, boundaries and social and moral considerations

• empathy development

• how to make good choices to keep themselves and others safe sexually

• emotional and self-regulation

• life story work

• understanding of their harmful sexual behaviour

• victimisation

• peer and social relationships

• community reintegration for those who have spent time in residential or secure units

• support to make future plans.

Use recognised treatment resources or guided interventions such as:

• AIM assessment and intervention model for boys and girls. This includes components for:

  • children aged under 12 who have not committed a criminal offence, and

  • children aged 10 to 12 who have committed an offence (10 is the age of criminal responsibility in England).

• AIM2 assessment and intervention model for boys aged 12 to 18 within or outside the criminal justice system. This also has a component aimed at girls in the same age group and for those with learning disabilities. But note: the 'level of supervision' scale for young females (12 to 18 years) is likely to misrepresent the level of risk. A degree of caution is also advised when using it to predict sexual reoffending in young people with learning disabilities.

• Barnardo's Cymru Taith project for girls – assessment and treatment workbook.

• The California Evidence-Based Clearinghouse for Child Welfare Children with problematic sexual behaviour cognitive-behavioural treatment program: preschool program and school-age program.

• Good Lives Model, a strengths-based programme.

• NSPCC manualised treatment programme Change for good (McCrory E, Walker-Rhymes P [2011] A treatment manual for adolescents displaying harmful sexual behaviour: change for good; London: Jessica Kingsley) aimed at boys aged 12 to 18 in residential care.

• NSPCC harmful sexual behaviour programme Turn the page, a guided intervention that follows certain key principles for boys and girls aged 5 to 18 and those with learning disabilities. This is suitable as a community-based approach.

Use therapeutic approaches such as:

• cognitive behavioural therapy

• multisystemic therapy for problematic sexual behaviour

• psychotherapeutic approaches

• strengths-based approaches

• systemic therapy (a type of family therapy).

Consider 1 or more of the following modes of delivery:

• individual therapy

• group therapy

• family therapy.

Deliver interventions in community and family settings, if it has been assessed as safe to do so.

Work alongside care staff when delivering interventions in residential, secure or custodial settings. Ensure the care plan includes safety planning to reduce the risk the child or young person may pose to others in the same environment.

Consider including family members when delivering interventions in residential, secure or custodial settings. Do this only if it is safe and has been agreed as part of the care plan (see recommendation 1.6.4).

Provide ongoing support when children and young people in residential homes, secure children homes or young offenders' institutions move back into the community or return to the family home. This includes continuity of care for those who need this type of support.