Physical Contact and Intimate Care

This aspect of the care and treatment of children living away from home is important in itself, so that through good practice, children in our homes receive the care that they are entitled to and need. It is also an issue that concerns many people, because of the risk of betrayal and abuse of children (emotionally damaged children being particularly vulnerable). Staff must recognise the importance of appropriate touch and touching in caring for and communication with children.

These guidelines seek to set out what is expected of all staff acting responsibly, consistently, and maturely in this area, and what is not safe or acceptable. As guidelines they are the foundation and clear reference for practice which will serve to increase safety for children and adults at all homes. There will remain the need for discussion and further guidance through supervision and training.

We regard physical contact as a necessary ingredient in a child's learning, growth and healthy development. For it is to be a positive experience certain criteria must always be met:

1. Contact needs to “match” the relationship. Warm physical contact obviously belongs in a relationship that has warmth and consideration. Adults must be “in touch” with a child before touch can be of any positive benefit within the relationship;
2. Feelings which give rise to touch and which arise from it must be positive and mutual; that is, it must be “OK” for the receiver as well as the giver;
3. At all times in work with children who have suffered emotional hurt, it is essential that contact initiated by an adult is aimed to help and support the child by giving care, comfort or positive reinforcement. It must never be given or sought by adults for their own comfort or needs;
4. Contact must come from a position of respect for the child and must be experienced as respectful by the child.

Factors to recognise and keep in mind are:

1. Adults should never simply assume that they have the right to touch a child; in fact, children have the right to say no to touch;
2. Adults need to establish the significance of touch for a child, so that they can make good judgements in this sensitive aspect of care;
3. Therefore, children should be consulted about their views and wishes in this respect. Skilful observation of how and when a child seeks or avoids close contact will provide important information. In addition, a direct discussion with a child on these matters will permit the child to give an instinctive or informed response, either of which, again, will guide the adult and involve the child in establishing an appropriate approach. This is of particular importance for adults with whom children have established a good relationship. At a quiet time, and as part of the relationship building, adult and child should sit down together and discuss how it feels when touch is given, whether for care or comfort. In fact, for a child who had been abused and neglected it becomes an opportunity to reflect on this subject in a way which will give the child a greater understanding of the positive aspect of close contact in human relationships;
4. It is always the responsibility of the adults to ensure that any physical contact they are involved in with a child is safe, positive and healthy;
5. Most of the time it is best for touch to be accompanied by words to make clear the aims and methods of a worker and the safe, healthy nature of the contact;
6. Touch and contact should not proceed if it arouses sexual feelings in either adult or child, nor must it stem from such feelings. The sexual arousal of an adult by a child in these or any circumstances constitutes a cause for concern and must be communicated by the person to a manager in order that children's safety and welfare can be ensured;
7. It is often possible and best to allow the child to come to the grown up when s/he needs comfort or affection. Adults can readily indicate that they are available and willing to give this if it is sought, especially in a setting where healthy contact is a natural feature and within a child's control;
8. Never initiate close contact if you are not reasonably sure that it is appropriate and can be accepted by the child. If any contact is making an adult or child feel uncomfortable then the adult should disengage gently. This is an area that should be explored in supervision;
9. At all other times proceed slowly. The first steps in the development of a trusting relationship often may be signalled by a child as a simple desire to sit or be near to an adult without any closer contact such as an arm over the shoulder or a cuddle;
10. For cuddles or sitting on an adults lap for a reasonable period, children and adults should be dressed appropriately;
11. Closeness and cuddles often can be given genuinely and effectively by the adult standing side on to the child, thus reducing any unintentional introduction of a sexual element into the contact;
12. Comforting a child or exchanging affectionate hugs need not be done only in public, but it is safer for all concerned that demonstrations of physical affection are made in the vicinity of others;
13. At bedtimes it is entirely appropriate for an adult to sit on a child's bed and read or talk through the events of the day or a child's concerns. This should not be for a prolonged time, but within the agreed settling period. Staff should feel assured and confident that this is an important time for them to be with the children.

At all times by our approach and actions we can help children develop and strengthen a positive image of their own body. When children can feel that their body is their own and that they have proper control of the contact others make with it, they are far less vulnerable to sexual abuse or to a belief that the only value their body might have is as a commodity for others to use as they chooses without regard to the child's rights or needs.

Therefore, our attitude to contact with and intimate care of children is important. For the child our care should be enjoyable, relaxed and fun and it will be if these guidelines are followed and a child's right to say no is respected.

Recent investigations of abuse of children in residential establishments have identified a pattern of behaviours which were the hallmark of those adults establishing intimate contact with children in order to abuse them. Some features in this pattern are a worry to themselves. Others on their own may appear less so. It is the presence of many together in a regular and consistent pattern that gives the greatest cause for concern. Such a pattern has been termed “grooming” by police and social welfare officials involved in bringing it to light.

This pattern of “grooming” has these key features in close inter-relationship:

Adult carers who seek to abuse often display eccentric behaviours and involve children in a range of apparently harmless rituals that link the child ever more closely to them.

They gather cliques of favourite / favoured children around them and supply them with special favours or goodies denied the other children and outside the overall planned and agreed provision of the setting.

Children are used to perform tasks / jobs for the adult's own personal benefit, again often being rewarded by favours, treats and / or trips.

Complaints made about the person are not listened to properly, but are brushed aside by others as misperceptions arising from people's misunderstanding of the person's eccentricities / idiosyncrasies.

Not infrequently, visits and contact with the child by the parents are discouraged by a range of apparently innocent strategies which bring the child too often in solitary contact with the adult outside of (literally and figuratively) the work and the setting.

Practice and patterns of behaviour which accentuate a highly personalised approach to children and put into question the professional position of adults should be a legitimate subject of challenge and questioning by colleagues. All members of a team have a responsibility to monitor their own and their colleague's behaviour, it is not so much “whistleblowing” but good practice to raise concerns with appropriate Senior Managers if any doubt about the wisdom of some practices or the intentions of an adult carrying them out. It is sometimes painful for a person to be challenged about matters of their practice, however, for everyone else it is safer done openly and respected as part of professional practice and safety for all.

Parents / carers and the child's Social Worker should always be made aware of how intimate care for the child will be managed. These guidelines should be viewed as expectations upon staff, which are designed to protect both children and staff alike. In situations where a member of staff potentially breaches these expectations, other staff should be able to question this in a constructive manner.

Details of the way the intimate care of a child is to be handled must be incorporated in the child's care plan and respect the individual needs of each child in our care. Any query about the interpretation of the child's care plan by a member of staff must be raised with the shift leader and/or the home's managers.

The following guidelines are to be followed derived from the Norfolk Local Safeguarding Children Board (Norfolk LSCB) policy on intimate care.

Guidelines for good practice (adapted from the Chailey Heritage centre)

1. Treat every child with dignity and respect and ensure privacy appropriate to the child's age and the situation. Privacy is an important issue. Much intimate care is carried out by one staff member alone with one child. Norfolk LSCB believes this practice should be actively supported unless the task requires two people. Having people working alone does increase the opportunity for possible abuse. However, this is balanced by the loss of privacy and lack of trust implied if two people have to be present – quite apart from the practical difficulties. It should also be noted that the presence of two people does not guarantee the safety of the child or young person – organised abuse by several perpetrators can, and does, take place. Therefore, staff should be supported in carrying out the intimate care of children alone unless the task requires the presence of two people. Norfolk LSCB recognise that there are partner agencies that recommend two carers in specific circumstances. Where possible, the member of staff carrying out intimate care should be someone chosen by the child or young person. For older children it is preferable if the member of staff is the same gender as the young person. However, this is not always possible in practice. Agencies should consider the implications of using a single named member of staff for intimate care or a rota system in terms of risks of abuse;
2. Involve the child as far as possible in his or her own intimate care. Try to avoid doing things for a child that s/he can do alone, and if a child is able to help ensure that s/he is given the chance to do so. This is as important for tasks such as removing underclothes as it is for washing the private parts of a child's body. Support children in doing all that they can themselves. If a child is fully dependent on you, talk with her or him about what you are doing and give choices where possible;
3. Be responsive to a child's reactions. It is appropriate to “check” your practice by asking the child – particularly a child you have not previously cared for – “Is it OK to do it this way?”; “Can you wash there?; “How does mummy do that?”. If a child expresses dislike of a certain person carrying out her or his intimate care, try and find out why. Conversely, if a child has a “grudge” against you or dislikes you for some reason, ensure your line manager is aware of this;
4. Make sure practice in intimate care is as consistent as possible. Line managers have a responsibility for ensuring their staff have a consistent approach. This does not mean that everyone has to do things in an identical fashion, but it is important that approaches to intimate care are not markedly different between individuals. For example, do you use a flannel to wash a child's private parts rather than bare hands? Do you pull back a child's foreskin as part of daily washing? Is care during menstruation consistent across different staff?
5. Never do something unless you know how to do it. If you are not sure how to do something, ask. If you need to be shown more than once, ask again. Certain intimate care or treatment procedures, such as rectal examinations, must only be carried out by nursing or medical staff. Other procedures, such as giving rectal valium, suppositories or intermittent catheterisation, must only be carried out by staff who have been formally trained and assessed as competent;
6. If you are concerned that during the intimate care of a child:
   • You accidentally hurt the child;
   • The child seems sore or unusually tender in the genital area;
   • The child appears to be sexually aroused by your actions;
   • The child misunderstands or misinterprets something;
   • The child has a very emotional reaction without apparent cause (sudden crying or shouting).
   Report any such incident as soon as possible to another person working with you and make a brief written note of it. This is for two reasons: first, because some of these could be cause for concern, and secondly, because the child or another adult might possibly misconstrue something you have done.
   
   Additionally, if you are a member of staff who has noticed that a child's demeanour has changed directly following intimate care, e.g. sudden distress or withdrawal, this should be noted in writing and discussed with your designated person for child protection;
7. Encourage the child to have a positive image of her or his own body. Confident, assertive children who feel their body belongs to them are less vulnerable to abuse. As well as the basics like privacy, the approach you take to a child's intimate care can convey lots of messages about what her or his body is “worth”. Your attitude to the child's intimate care is important. As far as appropriate and keeping in mind the child's age, routine care of a child should be enjoyable, relaxed and fun. Intimate care is to some extent individually defined, and varies according to personal experience, cultural expectations and gender. Norfolk LSCB recognise that children who experience intimate care may be more vulnerable to abuse:
   • Children with additional needs are sometimes taught to do as they are told to a greater degree than other children. This can continue into later years. Children who are dependent or over-protected may have fewer opportunities to take decisions for themselves and may have limited choices. The child may come to believe they are passive and powerless;
   • Increased numbers of adult carers may increase the vulnerability of the child, either by increasing the possibility of a carer harming them, or by adding to their sense of lack of attachment to a trusted adult;
   • Physical dependency in basic core needs, for example toileting, bathing, dressing, may increase the accessibility and opportunity for some carers to exploit being alone with and justify touching the child inappropriately;
   • Repeated “invasion” of body space for physical or medical care may result in the child feeling ownership of their bodies has been taken from them;
   • Children with additional needs can be isolated from knowledge and information about alternative sources of care and residence. This means, for example, that a child who is physically dependent on daily care may be more reluctant to disclose abuse, since they fear the loss of these needs being met. Their fear may also include who might replace their abusive carer.