Personal Care and Relationships

The child may have had particular experiences which make it difficult to accept touch from an adult; or the child's experiences may lead to a need for more touch than is acceptable.

It is therefore important for carers to obtain information about the child's background before acting, in any way not just in terms of the use of touch.

If there are particular needs that the child has or if it appears that the child may respond more or less favourably to touch, this must be reflected in the planning process.

Dependent on the age and level of understanding of the child, s/he should be involved in this assessment and planning; and should be encouraged to consent to being touched; or to place conditions on it.

The culture or values of the household should be such that touch is encouraged; as a positive and safe way of communicating affection, warmth, acceptance and reassurance.

Carers/residential staff and children should be encouraged to use touch, positively and safely.

But it is important for carers and children to know if boundaries exist within the home or for individual children.

If boundaries or expectations exist for individual children they should be set out in their Care Plan and Placement Plan.

If boundaries or expectations exist for the home, they should be clear. For example, if carers are not expected to allow children to sit on their laps, or to carry children, this should be stated, preferably in writing.

In the absence of any plan or expectation, the following should be taking into consideration

1. When thinking about who is an appropriate person to touch a child, it is vital to consider what the adult represents to the particular child. Personal likes and dislikes will play a part in any relationship;
2. In addition, many factors influence the power relationship between adult and child, including gender, race, disability, age, sexual identity and role status;
3. The background of the child will also influence any decision about who represents a 'safe' adult in the eyes of the child;
4. Children from ethnic minority backgrounds may be used to different types of touch as part of the culture;
5. Children who have been subject to physical or sexual abuse may be suspicious or fearful of touch. This is not to say that children who have experienced abuse should not be touched, it may be beneficial for the child to know different, safer and more reliable adults who will not use touch as a form of abuse;
6. For each child, what constitutes an intimate part of the body will vary; but generally speaking it is acceptable to touch children's hands, arms, shoulders. It may be appropriate to hug or cuddle children, or carry or give them 'piggy backs';
7. Other parts of the body are less appropriate to be touched, by degrees. Some parts of the body are 'no go areas';
8. Therefore, it may be appropriate to touch a child's back, ears or stroke their hair or knees - if the child indicates such touch is acceptable. To go beyond this would be unacceptable, even if the child appeared to accept it;
9. In any case, no part of the body should be touched if it were likely to generate sexualised feelings on the part of the adult or child;
10. Also, no part of the body should be touched in a way which appeared patronising or otherwise intrusive;
11. Therefore, the context in which touch takes place is usually a decisive factor in determining the emotional and physical safety for both parties;
12. What message is being sent out to the child? If the intention is to positively and safely communicate affection, warmth, acceptance and reassurance it is likely to be acceptable;
13. A fleeting or clumsy touch may confuse a child or may feel uncomfortable or even cause distress. Carers should touch with confidence, and should verbalise their affection, reassurance and acceptance; by touching and making positive comments. For example, by touching a child's arm and saying "Well Done";
14. Where children indicate that touch is unwelcome carers should back off and apologise if necessary;
15. Carers should talk to colleagues and record their interactions with children. If particular strategies work, or not, colleagues should be informed so they can build on or avoid making the same mistake;
16. Touch of an equally positive and safe nature is acceptable between carers; demonstrating positive role models for children. Showing that adults can get along and use touch in non abusive or threatening ways;
17. It is also acceptable to talk about how touch feels, about acceptable boundaries and expectations; doing so in 'house meetings' or key worker sessions;
18. Play fighting is no alternative for this. It is unacceptable;
19. The key is for carers to help children experience and benefit from touch, positively and safely; as a way of communicating affection, warmth, acceptance and reassurance.

Carers/residential staff must have knowledge and understanding of the child and his or her background, and be able to recognise and respect any emotional 'barriers' the child has 'erected'.

Carers/residential staff should be sufficiently aware of their own feelings, so that they can recognise the dangers of a relationship with a child becoming sexualised and stop to consider what is happening and what they are doing.

Other people's feelings and views, of both adults and children, need to be taken into account. If there is any indication that a relationship could be viewed as inappropriate, the carers/residential staff should discuss the issues with their managers/supervisors and the child's social worker.

It is not a matter of carers never becoming involved in close one to one relationships with a child, it is a vital part of the 'caring' task, however, carers must be aware of the dangers, which this type of work can bring and be clear where the boundaries in such relationships lie.

Consideration should be given to the need for each child to have an Advocate or Independent Visitor - see Advocacy and Independent Visitors Procedure.

Appropriate support must be provided to all children including those who are refugees or asylum seekers, and those who are disabled children and with communication difficulties.

This addendum provides practice guidance for the personal care and sex education of children with learning disabilities and those with limited communication related to health difficulties.

• Children with learning disabilities and those with limited communication related to health difficulties and those with limited communication related to health difficulties should have the same basic rights as other children, including the right to protection from abuse and to have their views sought and taken account of in decisions regarding their care;
• Each child should have an individual programme based on their individual abilities and understanding;
• Individual programmes should take account of children's needs arising from their ethnicity, gender, culture and religious background;
• Individual programmes should be devised, developed and implemented in consultation with parents and other carers and other involved agencies;
• Children with learning disabilities and those with limited communication related to health difficulties have a right to appropriate sex education.

Individual programmes should be devised for each child in residential care, using the tools of Residential Action Plans (and Support Plans) and Risk Assessments. The contents of these will be devised and implemented using a multi-agency approach with input and agreement from Parents/Carers.

Gender Appropriateness

Gender appropriate care needs to be discussed with the young person (and appropriate communication methods used to ascertain views where necessary) and their parents/carers. In common practice we would always attempt to provide same gender personal and intimate care (which could range from assisting female children with sanitary hygiene and help with bathing/showering, to tasks such as brushing hair). However, this assumption should not be made in all cases as a young person may have a preference for someone they know, trust and feel safe with who is of the opposite gender. Plus, due to unforeseen circumstances with staffing resources it may be impossible to provide gender specific care at certain times. This should not prevent different gender staff ensuring that young person’s need for cleanliness and hygiene is met. If it is agreed that same gender care is an absolute (such as cultural/religious reasons) then both parents and the young person must be made aware of the potential for non-adherence in the circumstance above. Such provision should be regularly reviewed in line with the young person's age and level of development.

Individual Routines

Prior to admission information should be gathered to determine the capabilities of young people in relation to their self-care and what support they may require (if any). All staff need to be fully aware of any established routine that a young person may have that will ensure continuity and hopefully security for them whilst away from home. Any lack of consistency in routines may cause major anxiety and distress for young people.

All young people should be consulted with sensitivity regarding their preferences regarding bathing, teeth cleaning, shaving, toileting etc. It must be recognised that these are private times and that dignity and sensitivity are paramount. Staff training in disability awareness is important in this respect. If staff or young people feel uncomfortable with this type of support it is essential that they share it with colleagues and managers.

Privacy

People with learning disabilities and those with limited communication related to health difficulties are often denied privacy. Having the experience and knowledge that there is a place that is exclusively their own is a major factor in reducing anxiety and creating an environment where they feel safe. To this end young people should be encouraged to close and lock their bedroom (and toilet) doors (where appropriate/safe).

Staff should be committed to knocking on doors before entering rooms and respect the right of young people to deny them entry.

Only one member of staff should enter a bathroom at any one time (save for safeguarding reasons or when it is part of an agreed plan).

Young people should be given the space and opportunity to express themselves sexually in the same way as a non-disabled person in the privacy of their bedrooms.

Independence

Young people should be encouraged to undertake as much personal care as is possible and whilst supporting them, it is important to recognise that development of independence in this area will enable them to grow in other areas by celebrating achievement.

Protection

Young people with learning disabilities and those with limited communication related to health difficulties are often vulnerable through their inability to effectively communicate. It is vital that the personal background and history of all young people is known to enable any possible triggers to be avoided in personal care routines.

It is important to recognise that sexuality is an individual manifestation of a person's feelings and a highly personal expression. Before we embark on any sex education, particularly with young people with learning disabilities and those with limited communication related to health difficulties, we have to question our own moral and behavioural codes and practices. Our own personal value systems should not be imposed on others.

Sex education should be an integral part of the learning process beginning in childhood and continuing into adult life. It is important for all young people, including those with learning disabilities and those with limited communication related to health difficulties to begin to understand their rights in relation to sex and sexuality. Sex education in residential care should dovetail; with similar programmes at school and at home where exploration of personal relationships and development of communication and the ability to make informed judgements should be encouraged.

An integral part of sex education should be the fostering of positive self-esteem, self-awareness, as sense of moral responsibility and the skills and knowledge to resist unwanted sexual experience.

Acceptable Physical Contact

Those working with the child prior to puberty should consider if the physical contact they initiate with the child is an acceptable model for the child to carry through into adulthood. There is no point in the parent or care worker teaching the child to hug and kiss if they, or their successors, are going to have to stop the adolescent doing precisely that, with minimal discrimination, later in life.

The pattern of physical contact with people outside the immediate family group should be changed. A pat on the back, or a handshake accompanied by warm, verbal praise, is more relevant to the adult life that the child is about to enter. This might also help us to change the style of address that we use, the 'good boy' and 'good girl' that is often inappropriately carried over into the adult years.

Rights to Say No

It is important for young people to understand that nothing they do makes someone abuse them. It is the perpetrator who makes the decision to sexual abuse. Therefore, when teaching young people with learning disabilities and those with limited communication related to health difficulties (or any children) about how to say "No" to unwanted sexual contact, we must be sure to avoid giving the impression that they are responsible if they are abused.

Modesty

Young people with developmental delays may need help in understanding when it is permissible to touch your own body and the bodies of other people, when being naked is ok, choosing the correct toilets and remembering to close the cubicle door.

Naming of Body Parts

We work with children with learning disabilities and those with limited communication related to health difficulties who often have a fragmented comprehension of their physical identity and need to be taught that arms and legs etc. belong to, and are part of, them. However, we often avoid giving the correct name, or any name at all to the child's sex organs. We talk in embarrassed euphemisms or use one of the multitudes of slang names.

Whilst it can be embarrassing to talk to a young child about their penis or their vagina, we have to remember that the embarrassment is ours; if presented with the correct word in a matter of fact manner, the child will take it in as just another name for just another part of the body. The importance of this is obvious. People with learning disabilities and those with limited communication related to health difficulties can have difficulty with concepts, often finding it difficult to link word sound with idea. Use of the wide variety of names given to the sexual zones of the body cannot help their understanding.

Menstruation

The onset of menstruation should be addressed as a routine, with a regular pattern for changing sanitary protection. Eventually leading to the young woman being self-sufficient. The issue should be discussed in an open and matter of fact way, but some degree of discretion should be taught to avoid embarrassment and that it would be best to discuss the issue with parents or carers.

Appropriate Masturbation

Our support is needed in accepting the reality of the expression of sexual needs amongst people with learning disabilities and those with limited communication related to health difficulties. In addition to understanding their right to express their sexuality through solo masturbation, in the dignity of privacy, we have to accept that it is our task to teach them to use those rights responsibly, teaching the relevance of time and place.

In addition to training in the appropriate expression of sexuality through masturbation, people with learning disabilities and those with limited communication related to health difficulties need training to help them behave appropriately in a society that is tightly constrained by unspoken rules that govern the behaviour of people whose bodies are sexually mature.

They need, at the very least, sufficient skills to enable them to behave acceptably in open society, without triggering inappropriate or disapproving responses. It is our responsibility to find training methods that are helpful, realistic and specifically tailored to the understanding of people with learning disabilities and those with limited communication related to health difficulties.

Inappropriate Masturbation

Ranging from the socially embarrassing repeated touching of the genital area through the clothing to the more emotive issue of public masturbation. Over-reaction must be avoided as it is likely to make matters worse; disapproving of the behaviour carries the risk of generating anxiety, or of suppressing the behaviour, leaving the individual with no release for sexual energy.

The first positive step is to ensure that the individual does not have a health problem. Often the discomfort of a tight foreskin or a vaginal or urinary tract infection results in behaviour that people assume to be masturbatory. If a health check finds no physical irritation, then a programme of behaviour modification should be set up. If the behaviour is a severe problem, then the help of a psychologist should be sought in designing the modification programme. The aim of the programme will not be to stop masturbation, but to approve of it where and when it is done appropriately.

Excessive Masturbation

It is difficult for any individual to pass judgement on the sexual drive of another. Many of us take our own level of need as a norm and assume that others have the same need. Masturbation can be judged to be excessive when the individual is making the genital region sore from repeated friction, or where the need to masturbate intrudes into his or her ability to take part in training or recreational activities.

Staff groups can be helped in dealing with excessive masturbation if they become involved in training the individual to use an appropriate place for the act. Once this is established, staff can deal with the less emotive problem that he or she is spending too much time in that place.

Setting times when the individual is free to go to bedroom or toilet to masturbate is a successful strategy. This can be very frequently at first, followed by a slow process of lengthening the periods between bedroom sessions. Staff will work on other favourite activities and use these to lengthen the time between bedroom sessions and to encourage the individual to leave their bedroom after a period.

Inappropriate Touching of Other People

Over-reaction to this should be avoided. It is not known for a person with learning disabilities and those with limited communication related to health difficulties who has a hand flapping mannerism to be accused of touching the breasts of female staff in corridors. This has more to do with the height of hands and the narrowness of corridors than it has to do with sex.

In cases of definite and deliberate touching, the motivation of the person with learning disabilities and those with limited communication related to health difficulties should be assessed. It is common for their interest to be based on watching (and hearing!) the resulting upset rather than on sexual interest. A calm response may, over time, reduce and stop the behaviour, as it becomes less interesting.

Exposing Self

This should not be confused with lack of modesty and lack of understanding of social rules. The man with learning disabilities and those with limited communication related to health difficulties who turns away from the urinal with his penis showing is not sexually exposing himself. He lacks modesty and understanding and needs training. It is common for males to awake from a night's sleep with an erection. This is not cause by sexual excitement but by the physical reaction to an overfull bladder. Again this is a modesty issue rather than a sexual matter and it is important that it is dealt with calmly and professionally.

There is a range of issues at stake when attempting to standardise a policy that will encompass all children, in all residential settings. However, of fundamental importance is the principle that all children are treated as individuals, and that their needs in whatever area, in this case their intimate care needs, are recognised and planned for in all circumstances, and that due regard is given to their needs, wants, dignity, privacy, independence and protection.