Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Multi-agency approach

Multi-agency, multidisciplinary team

1.1.1 Ensure multi-agency, multidisciplinary teams promote continuity of care and, wherever possible, ensure the child or young person has contact with the same staff over time, so they can develop trust in their care team.

1.1.2 Ensure young people who are nearly 18 are prepared for the transition to adult services by developing links between child and adult services. See NICE's guideline on transition from child to adult services.

1.1.3 Ensure multi-agency, multidisciplinary teams:

  • have links to clinical and non-clinical services and can make prompt referrals

  • collaborate with specialists when children and young people have difficult or complex needs (for example, those with neurodevelopmental or learning disabilities or conduct disorders)

  • establish relationships with statutory, community and voluntary organisations that work with at-risk children and young people, to provide a broad range of support services

  • meet regularly to plan, implement and evaluate care pathways for the children and young people whose care they are overseeing

  • understand that the care plan is the responsibility of the whole multi-agency team and not individual practitioners.

Multi-agency, multidisciplinary working

1.1.4 Use established mechanisms, such as the local safeguarding children board, to develop local safeguarding policies and procedures and agree a harmful sexual behaviour operational framework between agencies. (See Department for Education's Working together to safeguard children, Ofsted's Early help: whose responsibility?, Children Act 1989 and Children Act 2004.)

1.1.5 Local safeguarding children boards should ensure:

  • Lead agencies are identified to commission specialist harmful sexual behaviour services.

  • Thresholds are established for when to refer a child or young person for an early help assessment or to specialist harmful sexual behaviour services.

  • Named safeguarding leads and practitioners working in relevant services are told what the referral thresholds are. This includes those working in education, children's social services, health and youth criminal justice (such as young offender teams and youth justice boards) and voluntary sector organisations.

  • Named safeguarding leads working in universal services use locally agreed resources as part of their policy and procedures to determine whether a child or young person should be referred for an early help assessment. (See recommendation 1.3.4 for examples of resources.)

  • Children's social services have access to policies and procedures for training staff to deal with concerns about a child or young person's sexualised behaviour.

1.1.6 The multi-agency team should agree which service is responsible when children and young people are referred for assessment. Consider one of the following for the lead role:

  • child health services such as child and adolescent mental health services (CAMHS)

  • children's social services

  • voluntary sector organisations such as Barnardos or the NSPCC.

1.1.7 Consider a range of care pathways based on the 5 core domains identified in the NSPCC harmful sexual behaviour framework.

1.1.8 The designated lead practitioner responsible for coordinating the care plan (see recommendation 1.3.2) should request a review of the care plan via the multi-agency, multidisciplinary team meeting if:

  • the child or young person's needs are not being met or

  • the referral and assessment procedure is unnecessarily delayed.

Information sharing

1.1.9 Agree a protocol for information sharing between all agencies. Base this on local safeguarding and child protection procedures and address legal and confidentiality issues.

1.1.10 Ensure the designated lead practitioner responsible for coordinating the care plan can access information on the child or young person's family situation and factors that may affect parenting capacity and attachment (see recommendation 1.4.2). Do this as part of the assessment process (See NICE's guideline on children's attachment and recommendations on sexualised behaviour in NICE's guideline on when to suspect child maltreatment.)

1.1.11 Ensure information is collected and shared in a sensitive and professional manner, as set out in the Caldicott Guardian information standards.

1.1.12 If there is a need to share information with other agencies and carers to inform risk management, do this in consultation with the multidisciplinary team.

1.2 Named safeguarding leads in universal services

1.2.1 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[1].

1.2.2 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.

1.2.3 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.

1.2.4 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.

1.3 Early help assessment

1.3.1 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.

1.3.2 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.

1.3.3 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.

1.3.4 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[2].

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

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

1.3.7 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:

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

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

1.4 Risk assessment for children and young people referred to harmful sexual behaviour services

1.4.1 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 Barnardos

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

1.4.2 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.

1.4.3 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.

1.4.4 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 and the Child Sexual Behaviour Inventory[3].

  • 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.

1.5 Engaging with families and carers before an intervention begins

1.5.1 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.

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

1.5.3 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[4].

1.5.4 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.

1.6 Developing and managing a care plan for children and young people displaying harmful sexual behaviour

General principles

1.6.1 Recognise that children and young people with learning and neurodevelopmental disabilities have specific needs. Consider providing short and more frequent sessions for them. Work with specialists in these areas to provide the intervention.

1.6.2 Help children and young people develop a strong sense of personal identity that does not include harmful sexual behaviour. This includes helping them to maintain their cultural and religious beliefs.

Developing and managing a care plan

1.6.3 Develop a care plan using an established risk assessment model, such as J‑SOAP‑II, ERASOR, AIM assessment for under‑12s, or AIM2, and a recognised treatment model such as the Good Lives Model, AIM or AIM2. The plan should:

  • recognise the needs and strengths of the child or young person and the risks they may pose

  • support them, their families and carers

  • include clearly defined therapeutic goals

  • include a safety plan that is agreed with the child or young person, their parents or carers and support network.

1.6.4 Ensure the care plan:

  • Encourages and supports children and young people to participate in a range of peer, school and community activities to help build a sense of belonging.

  • Includes supervised social activities that promote self-esteem, develop resilience and encourage socially appropriate behaviour.

1.6.5 Ensure the care plan is reviewed by the multidisciplinary team, and with the child or young person and their parent or carers at 3–6 monthly intervals, or if there is a significant change in circumstances.

1.7 Developing interventions for children and young people displaying harmful sexual behaviour

1.7.1 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.

1.7.2 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.

1.7.3 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.

1.7.4 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[5] 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.

1.7.5 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).

1.7.6 Consider 1 or more of the following modes of delivery:

  • individual therapy

  • group therapy

  • family therapy.

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

1.7.8 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.

1.7.9 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).

Children and young people not living with their birth parents

1.7.10 Ensure links with their family of origin or community are maintained if it is in the best interests of the child or young person. Maintain links with birth parents if safe and appropriate.

Children and young people who have been abused by a family member

1.7.11 If it is in the best interests of the child or young person, consider family reconciliation, re-integration and restorative approaches, if it is safe and appropriate.

Looked after children and young people

1.7.12 Ensure the intervention supports carers. This includes giving them advice on how to respond to the risks presented by children and young people in their care.

Working with parents and carers

1.7.13 Encourage caring relationships between the child or young person and their family and carer, if it is safe to do so. Recognise that looked after children and young people may have problems arising from insecure attachment, making the relationship with their carer very challenging (see NICE's guideline on children's attachment).

1.7.14 Help carers create a sense of belonging and trust to ensure the child or young person feels safe, valued and protected.

1.7.15 Consider including the following elements in the programme:

1.8 Supporting a return to the community for 'accommodated' children and young people

1.8.1 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.

Terms used in this guideline

This section defines terms that have been used in a specific way for this guideline. For general definitions, please see the glossary.

Children

In this guideline, 'children' refers to anyone under 10.

Harmful sexual behaviour

This guideline uses the NSPCC definition of harmful sexual behaviour: 'One or more children engaging in sexual discussions or acts that are inappropriate for their age or stage of development. These can range from using sexually explicit words and phrases to full penetrative sex with other children or adults.' (Harmful sexual behaviour: what is harmful sexual behaviour NSPCC).

Risk assessment tool

In this guideline, this term is used for tools that estimate the risk of sexual re‑offending or the level of supervision needed, and help users decide what action to take. It includes tools such as J‑SOAP‑II and ERASOR, which are North American tools designed to assess the risk of sexual reoffending. The AIM assessment model was developed in the UK and considers the level of management and supervision needed for people displaying harmful sexual behaviour.

Young people

In this guideline, 'young people' refers to those aged 10 to 18. It includes those on remand and those serving community or custodial sentences. The guideline also includes people aged up to 25 who display harmful sexual behaviour and have special educational needs or a disability. This age extension is in light of the Children and Families Act 2014.



[1] See Brook Organisation information on pornography and the law.

[2] 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.

[3] Achenbach T (1991) Manual for the Child Behaviour Checklist/4–18 and 1991 Profile. Burlington: University of Vermont.
Friedrich W (1997) Child Sexual Behaviour Inventory: professional manual. Odessa, Florida; Psychological Assessment Procedures.

[4] This is dealt with in NICE's child abuse and neglect guideline.

[5] McCrory E, Walker-Rhymes P (2011) A treatment manual for adolescents displaying harmful sexual behaviour: change for good. London: Jessica Kingsley.

  • National Institute for Health and Care Excellence (NICE)