All parents who successfully overcame risk factors such as substance misuse or domestic violence and were able to provide a nurturing home for the index chil so before the baby was six months old Babies left for too long in abusive homes. By the time they were three, almost half the babies in the Significant Harm of Infants Study were displaying quite serious behavioural problems or developmental delay. Similarly, the Significant Harm of Infants Study raises questions about how bad parenting has to be to be identified as unacceptable. Judging by the continued presence of recognised risk factors, just under half of the children in this study who remained with birth parents were not considered to be safeguarded at age three. found a baby whose parents so persistently forgot to feed her that she ceased to cry, a two year old left to forage in the waste bin for his food and a three year old who could demonstrate how heroin is prepared. All of these children remained with their birth parents for many months without being adequately safeguarded.
These were children who, at the end of the study, either remained living at home amidst ongoing concerns or had experienced lengthy delays before eventual separation.
All parents who successfully overcame risk factors did so before the baby was six months old Parents who succeed in making sufficient changes appear to be less likely to have experienced abuse (particularly sexual abuse in childhood); to be able to come to terms with the removal from home of older children and to have developed sufficient insight to acknowledge that their behaviour may have played a part in such decisions; and to make use of the support that both social work and more specialist services can provide. A new baby appears to act as a catalyst for radical changes in parental behaviour patterns; however if these have not occurred within six months of the birth, then any minor changes parents appear to have made are unlikely to persist or be sufficient to meet the needs of the child within an appropriate timeframe. Social work interventions are also often of relatively short duration – half the child protection plans were for 32 weeks or less, and almost all for less than a year. Little ongoing support - cases are often closed by social workers in the expectation that parents will contact the local Sure Start children ‟ s centre if problems recur. However interviews with parents show that many are lacking in self confidence and do not have the courage or the ability to make the effort to attend support services such as play groups, and, as noted above, are more likely to hide their difficulties than ask for help. Those parents in the Significant Harm of Infants Study who had overcome substantial adversities and were successfully parenting a child after others had been placed for adoption were surprised that their cases were closed after just a few months. Some of them asked for child protection plans to be extended in order to provide them with the support they felt they needed to maintain their progress. Kinship care sometimes selected with little regard for the quality of care provided, the carers ‟ previous history of poor parenting, their personal problems or their knowledge of theSeveral family and friends carers in the Significant Harm of Infants Study were receiving minimal support to cope with the children ‟ s often serious behavioural problems; by the time the children were aged three many of these placements were approaching breakdown. Cases are often closed by social workers in the expectation that parents will contact the local Sure Start children ‟ s centre if problems recur. However interviews with parents show that many are lacking in self confidence and do not have the courage or the ability to make the effort to attend support services such as play groups, and, as noted above, are more likely to hide their difficulties than ask for help.
Babies are born with very immature brains By 3 years of age they have 85% of their full brain capacity Wiring takes place during prenatal period to school-entry – important first two years Influenced by genes and environment Rapid proliferation and overproduction of synapses followed by loss (pruning) ‘ Use it or lose it’ – lost if not functionally confirmed
Need for early intervention…
Initial reaction to overwhelming situation is for the child to become intensely aroused When this does not reduce the threat a sense of helplessness and hopelessness overwhelms them and his/her systems shut down Dissociation is enlisted as a primary defense Red line: child who has experienced trauma and neglect does not have the capacity to self regulate affect, Orange line: child how has developed ability to regulate affect through attuned interactions in childhood
Help infant to regulation his/her emotions
A comprehensive consultation service to professional and legal networks Integrated and individually tailored multi-disciplinary assessment programmes to assess severe parenting problems including child abuse and neglect The service is multi-disciplinary and includes a consultant nurse and child psychotherapist (clinical lead), clinical psychologist, psychotherapist, clinical co-ordinator/intervention worker, and has weekly consultations with a designated consultant psychiatrist. Expert professional and court reports including court appearance providing independent advice and recommendations to assist decision making regarding future placement and needs of children referred Community-based treatment programmes for children and their families following assessment and/or reunification.
Once children have been placed in out-of-home care, there is often an assumption that reunification is the optimum outcome.96–99 Although 50–75% of children placed in out-of-home care eventually reunify, between 20–40% of those reunified subsequently re-enter foster care.100–108 Studies have recorded better outcomes for children who were not reunified with their families of origin than those who were, including gains in intelligence scores,109 greater overall wellbeing,110 and less criminal recidivism.111 These studies, however, did not control for behavioural functioning at entry to foster care.
Longitudinal studies that examined the effect of reunification, controlling for functioning assessed pre-reunification, have reported that reunified youth showed worse outcomes in internalising and externalising problems, risky behaviours, competencies, grades, school dropout, involvement in the criminal justice system, adverse life events, and witnessing physical violence.
A large US study noted that enhanced foster care (which included better trained caseworkers and greater access to services, and supports for youth and foster families) led to fewer mental and physical health problems for foster care alumni than did traditional foster care.88 Other uncontrolled studies have reported that young children’s adaptive behaviour improved after placement in foster care89
Concurrent planning is a form of fostering and adoption that removes children aged up to six years old from parents with severe difficulties in their lives and places them with specially trained prospective adoptive parents, who act as foster carers for six to nine months. If the birth-family, who are given intensive support, can overcome their problems, the child is returned to them otherwise, they will be adopted by the foster carers. Prospective adoptive parents have to be prepared to give a child back if the birth-parents are able to alter their behaviour.
the effectiveness of the Parents under Pressure (PUP) programme compared with a brief (two-session) traditional parent-training intervention and standard care (i.e. routine care by methadone clinic staff involving three-monthly meetings with the prescribing doctor and access to a case worker to assist in housing, employment and benefits). PUP is underpinned by an ecological model of child development and targets multiple domains of family functioning, including the psychological functioning of individuals in the family, parent–child relationships, and social contextual factors. The programme also incorporates ‘ mindfulness’ skills that are aimed at improving parental affect regulation. PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in the family home over 10 to 12 weeks, and each session lasting between one and two hours
Safeguarding Children:getting it right from the start Jane Barlow Professor of Public Health in the Early Years
Structure of paper Where are we now – practice that needs improving Why the very early years are important – neurological and attachment research; What aspects of parenting are important during this period? What should we be doing differently…?
Significant Harm of Infants Study Prospective study in 10 LAs; Sample of 57 children who were the subject of a core assessment, section 47 enquiry or became looked after before their first birthdays; 43 were followed until they were three http://www.lboro.ac.uk/research/ccfr/Publications /DFE-RB053.pdf (Ward et al 2010)
IdentificationHigh prevalence of factors such as drug and alcoholmisuse, intimate partner violence and mental healthproblems – few referrals to children’s social care werereceived from any of these sourcesAbout a third of the mothers and an unknown number offathers had already been separated from at least one olderchild before the birth of the index childJust under two-thirds (65%) of the infants were identifiedbefore birth and almost all before they were six months old
OutcomesBy the time they were three, 28 (65%) children were livingwith a birth parent and 15 (35%) were permanently placedaway from home.Living with Birth Parents - 16/28 (57%) were living withbirth parents who had succeeded in overcoming theirproblems and were now classified as low risk casesAt 3 years… twelve children (28%) were living with birthparents who had shown little positive change; these infantswere now at medium, high or severe risk of sufferingsignificant harm.
Double jeopardy By three years of age: - over half of the children were showing serious developmental problems (poor speech) and significant behavioural difficulties (aggression) - many of the placements were approaching breakdown Long-term well-being of 60% of the permanently separated children had been doubly jeopardised – by late separation from an abusive birth family followed by the disruption of a close attachment with an interim carer when they entered a permanent placement;
Waiting for parents to change… Developmental and behavioural difficulties were more evident amongst children who had experienced some form of maltreatment, often whilst professionals waited fruitlessly for parents to change; All but one of the parents who made sufficient changes did so before the baby was six months old.
Repeated Assessments Specialist parenting assessments made by psychologists, psychiatrists or independent social workers were a major cause of delay. All recommendations were followed; two thirds advised that children should remain with birth parents, but in over half of these cases the children eventually had to be removed; Parenting assessments frequently repeated within very short timeframes, during which parents have little opportunity to overcome previously identified problems
Intervention Social work interventions were also often of relatively short duration – half the child protection plans for the babies were for 32 weeks or less, and almost all for less than a year; Families successfully parenting children were given little ongoing support and cases closed prematurely Kinship care sometimes selected with little regard for the quality of care provided, the carers‟ previous history of poor parenting, their personal problems or their knowledge of the child
Trauma in infancy: ‘Disorganised Attachment’ensitised nervous system as brain adapts to emotional environment Stress in child reminders & experiences of trauma, life events, etc. Unbearably painful emotional states Retreat: Self-destructive Destructive isolation actions: actions: dissociation substance abuse aggression depression eating disorders violence deliberate self-harm rage suicidal actions (Robin Balbernie 2011)
Aspects of Early Development Emotional/ Intellectual Behavioural social Development development developmentInfancy Trust/attachment Alertness/curiosity Impulse control AFFECT REGULATIONToddlerhood Empathy Communication/ Coping mastery motivationChildhood Social Reasoning/problem Goal-directed Relationships solving behaviourAdolescence Supportive social Learning Social network ability/achievement responsibility
Key points The first three years of life are VERY important because: - babies are born with immature brains that are shaped by their early interaction with primary caregivers; - early caregiving received influences their ‘attachment’ relationship with their primary caregiver and these mediates the impact on the CNS
Nurturance/ Emotional and Behavioural RegulationImportant aspects of the parent-infant relationship: Sensitivity/attunement Mirroring Reflective Function/Mind Mindedness
Affect synchrony – the dance By two months the mothers face is the primary source of visuo-affective communication Face-to-face interactions emerge which are high arousing, affect-laden and expose infants to high levels of cognitive and social information and stimulation Regulation of emotional interaction: The dance: synchrony – rupture - repair Absolutely fundamental to healthy emotional development – prolonged negative states are ‘toxic’ to infants
‘Attuned mutual co-ordination between mother and infant occurs when the infant’s squeal of delight is matched by the mother’s excited clapping and sparkling eyes. The baby then becomes overstimulated, arches its back and looks away from the mother. A disruption has occurred and there is a mis-coordination: the mother, still excited, is leaning forward, while the baby, now serious, pulls away. However, the mother then picks up the cue and begins the repair: she stops laughing and, with a little sigh, quietens down. The baby comes back and makes eye contact again. Mother and baby gently smile. They are back in sync again, in attunement with each other (Fosha, 2003 in Walker 2008, p. 6).
For example… Looks and smiles help the brain to grow Baby looks at mother; sees dilated pupils (evidence that sympathetic nervous system aroused and happy); own nervous system is aroused - heart rate increases Lead to a biochemical response - pleasure neuropeptides (betaendorphin and dopamine) released into brain and helps neurons grow Families doting looks help brain to grow Negative looks trigger a different biochemical response (cortisol) stops these hormones and related growth (Gerhardt, 2004)
Babies of depressed mothers: - nearly half show reduced brain activity - much lower levels of left frontal brain activity (joy; interest; anger) Early experiences of persistent neglect and trauma: - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation, hyperactivity) - deficits in cortical functions (problem-solving) and limbic function (empathy)
AttachmentWhat is it:?- Affective bond between infant and caregiver (Bowlby, 1969)What is its function?:- Dyadic regulation of infant emotion and arousal (Sroufe, 1996)Antecedants of attachment: Sensitive, emotionally responsive care during first year – secure attachment Insensitive, inconsistent or unresponsive care – insecure attachment
Who is securely attached?Secure (Group B) – able to use caregiver as a securebase in times of stress and to obtain comfort (55-65%)InsecureAnxious/resistant (Group C) – up-regulates in times ofstress to maintain closeness (8-10%)Avoidant (Group A) - down-regulates in times of stressto maintain closeness (10-15%)Disorganised (Group D) – unable to establish a regularbehavioural strategy (up to 15% in population sample;80% in abused sample) (Carlson, cicchetti et al 1989)
Arousal in traumatic/disorganised attachmentsHyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – ‘Fight or flight’ response)WindowofToleranceHypo-arousal (dissociation, depression, self harm etc)
Disorganised/Controlling Attachment Caregivers – unpredictable and rejecting; source of comfort also source of distress Self represented as unlovable, unworthy, capable of causing others to become angry, violent and uncaring Others – frightening, dangerous, unavailable Predominant feelings – fear and anger Little time for exploration or social learning
Compulsive Strategies Compulsive compliance (where parent is threatening) – watchful; vigilant and compliant Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny own developmental needs Coercive – combination of threatening and placatory behaviours Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’
Compulsive caregiving‘Caroline is 18 months old. She lives with hermother, who is chronically depressed. The motherdescribes the household as ‘noxious to the soul’.She cannot tolerate the idea that her depression isaffecting Caroline. She says: “Caroline is the onlyone who makes me laugh.” It is observed that Caroline silently enacts the roleof a clown. She disappears into her room andcomes out wearing increasingly more preposterouscostumes. Caroline makes her mother laugh, butshe herself never laughs…’ (Howe, 1999)
Parent-infant relationship in the face of parental problems Infant’s emotional states trigger profound discomfort in vulnerable and ‘unresolved’ parent s(e.g. where there is unresolved loss/trauma, mental health problems, drug/alcohol abuse, or where there is domestic violence etc) Interaction becomes characterized by: - withdrawal, distancing or neglect (i.e. omission) - intrusion in the form of blaming, shaming, punishing and attacking (i.e. commission)
‘Atypical’ parenting behaviours Fr-behaviour – frightened AND frightening; Frightening, threatening (looming); dissociative (haunted voice; deferential/timid); disrupted (failure to repair, lack of response, insensitive/communication error. Systematic review of 12 studies found strong association between ‘atypical’ parenting at 12/18 months and disorganised attachment
Working to the developmental timelines of children ANTEANTAL - Identify high risk families during pregnancy – pre-birth assessments at 18 weeks Intervention provided ante-natally BIRTH - Assess parent-infant interaction; concurrrent foster care where necessary Provide time-limited EB intervention and clear goals to be achieved; re-assess Remove infants where there is insufficient improvement before 8 months ideally, end of first year at worst
FASS – Family Assessment and Safeguarding Service Specialist multi-disciplinary service provided by Oxford Health NHS Foundation Trust; Integrated and individually tailored multi-disciplinary assessment programmes to assess severe parenting problems including child abuse and neglect; Expert professional and court reports including court appearance providing independent advice and recommendations to assist decision making regarding future placement and needs of children referred
Is home the best place to be…? Once children have been placed in out-of-home care, there is often an assumption that reunification is the optimum outcome. Although 50–75% of children placed in out-of-home care eventually reunify, between 20–40% of those reunified subsequently re-enter foster care; Studies have recorded better outcomes for children who were NOT reunified with their families of origin than those who were, including gains in intelligence scores, greater overall wellbeing, and less criminal recidivism (Lancet 2009).
Cont…Longitudinal studies found that reunified youth showed worse outcomes for: internalising and externalising problems; risky behaviours Competencies; grades; school dropout involvement in the criminal justice system adverse life events witnessing physical violence more likely to receive physical violence as part of discipline; less likely to receive mental health treatment(ibid)
Cont… Children who were formerly in foster care were 1.5 times more likely to die from a violent death than were children who remained in foster care; Three times more likely to die from violent causes than were children in the general population.
Does foster care improve outcomes? Children placed in care fared better than maltreated children who remained at home: antisocial behaviour; sexual activity; school attendance and academic achievement; social behaviour and quality of life; Enhanced foster care (better trained caseworkers and greater access to services, and supports for youth and foster families) fewer mental and physical health problems
Concurrent Planning in Foster Care ‘Concurrent planning is a form of fostering and adoption that removes children aged up to six years old from parents with severe difficulties in their lives and places them with specially trained prospective adoptive parents, who act as foster carers for six to nine months. If the birth-family, who are given intensive support, can overcome their problems, the child is returned to them otherwise, they will be adopted by the foster carers’. www.communitycare.co.uk Must stop moving children through foster placements because it TRAUMATISES them!!
Evidence-Based Interventions Sensitivity/attachment-based: Video- interaction Guidance; Family Nurse Partnership; Psychotherapeutic: Parent-infant psychotherapy Family Drug and Alcohol Courts (FDAC) Parenting programmes – Parents under Pressure; Parent-Child Interaction Therapy
PUP Programme PUP is underpinned by an ecological model of child development and targets multiple domains of family functioning, including the psychological functioning of individuals in the family, parent–child relationships, and social contextual factors. Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation; PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in the family home over 10 to 12 weeks, each session lasting between one and two hours
PUP evaluation Parents Under Pressure RCT with substance abusing parents of children aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting programme Significant reductions in parental stress; methadone dose and child abuse potential (significant worsening in the child abuse potential of parents receiving standard care); improved child behaviour problems
Summary First three years of life are foundational in terms of neurological and developmental outcomes; Considerable scope for prevention of serious problems if we work to the developmental timelines of the children, not the parent; Innovative models of working show good outcomes
Publications Barlow J, Scott J (2010). Safeguarding in the 21st Century: Where to Now? Dartington: Research in Practice. www.rip.org.uk Ward et al (2011). Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study. London: DfE. www.lboro.ac.uk/research/ccfr/Publications/DFE-RB053.pdf Barlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Abuse: What Works? London: Jessica Kingsley.