Adverse childhood experices come in multiples. poverty, debt, financial pressures ■ child abuse/child protection concerns ■ family violence/domestic violence ■ parental illness/disability ■ parental substance abuse ■ parental mental illness ■ family separation/bereavement/ imprisonment ■ parental offending, anti-social behaviour. There is now compelling evidence that families whose children are involved with statutory child protection services have multiple and complex needs, and that the level of complexity increases across the spectrum from referral to placement in out of home care Multiples matter in relation to cumulative adversities. - There is now compelling evidence that families whose children are involved with statutory child protection services have multiple and complex needs, and that the level of complexity increases across the spectrum from referral to placement in out of home care In spite of signi fi cant public concern, professional efforts and fi nancial expenditure, there has been a perceived lack of progress in reducing the incidence of child abuse, and in improving the outcomes for children in both the short and longer term. In this article the authors re fl ect on recent policy developments in the United Kingdom relating to children and families experiencing multiple adversities, and argue that the current conceptualisation of child abuse is fl awed. In adopting a rational technical approach to the management of child abuse, there is a tendency to focus on shorter term outcomes for the child, such as immediate safety, that primarily re fl ect the outputs of the child protection system. However, by viewing child abuse as a wicked problem, that is complex and less amenable to being solved, then child welfare professionals can be supported to focus on achieving longer term outcomes for children that are more likely to meet their needs. The authors argue for an earlier identi fi cation of and intervention with children who are experiencing multiple adversity, such as those living with parents misusing substances and exposed to intimate partner violence. deveaney & spratt
What is cumulative harm? Cumulative harm refers to the effects of patterns of circumstances and events in a child’s life, which diminish a child’s sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or ‘layers’ of neglect. The unremitting daily impact on the child can be profound and exponential, covering multiple dimensions of the child’s life.
Adverse childhood experiences are the most basic cause of health related morbidity
Dr Rob- AndaThis slide is titled the influence of adverse childhood experiences throughout life and contains a pyramid of five levels from birth, at the bottom of the pyramid, to death, at the top of the pyramid. The first level at the base of the pyramid is labeled adverse childhood experiences. The next level up is labeled social, emotional, and cognitive impairment. The next level up is labeled adoption of health-risk behaviors. The next level up is labeled disease, disability. The last level, at the tip of the pyramid, is labeled early death.
34% of serious case reviews have dv, sub misuse and mental health
An ecological framework for prevention is based on the following assumptions: Children and families exist as part of an ecological system. This means that prevention strategies must target interventions at multiple levels: the individual, the family, the community, and society. Primary responsibility for the development and well-being of children lies within the family, and all segments of society must support families as they raise their children. Assuring the well-being of all families is the cornerstone of a healthy society and requires universal access to support programs and services.
New Learning from Serious case reviews 2009 to 11 Parental mental health problems featured in a majority of cases. Suicide or self harm particularly prominent Neglect a feature Some children who live in abusive situations may not stand out at school
2010 NSPCC prevalence survey indicates that – 3.3 percent of the under 11 year olds and 2.9 percent of the 11 to 17 year olds reported witnessing at least one type domestic violence in the last twelve months and 12 percent of under 11 year olds, 18.4 percent of 11 to 17 year olds and 24.8 percent of 18 to 24 year olds had witnessed at least one type of parental domestic violence at some time during their childhood Radford L, Corral S, Bradley C, Fisher H, Bassett C, Howat N, et al.(2010) The maltreatment and victimisation of children in the UK: NSPCC report on a national survey of young peoples’, young adults’ and caregivers’ experiences. London: NSPCC.
Child hood experiences underlie many instances of chronic depression (ACE) Patients as parents. Addressing the needs, including safety, of children whose parents are mentally ill CR105 June 2002 32 Mental illness in adulthood is thus one of a number of long-term outcomes associated with trauma and adversity in childhood. The fact that many childhood-onset psychiatric conditions show considerable continuity into adulthood lends additional weight to the preventive opportunities of earlier support and intervention for families in which mentally ill parents/carers live with dependant children. Promoting positive mental health across the lifespan and between generations will require broader approaches to assessment and treatment, an incorporation of a prevention perspective into daily practice, and good collaboration between The Psychiatrist (2003) 27: 117-118 doi: 10.1192/pb.27.3.117 »
A concentration on deficit models is not necessarily helpful. There is much evidence to suggest that bolstering protective factors can be productive.
Family SMILES is a twin track programme working with children and their parents to reduce the risk of harm to children who live with parental mental ill health. Its core is an eight week group work programme for children. Each group will work with eight children. It is accompanied by individual work with parents over six sessions. The parent work is intended primarily to take place with the ill parent, however, this will be dependent on the parent ’s health at the time of the intervention and it may be that some of the work takes place with the well parent. In all cases, ‘safety planning’, which is part of the programme , will include the well parent Family SMILES was developed from the Australian SMILES programme established in 1997 by Erica Pitman. The original Australian SMILES was a young carers group work programme for children who live with parental mental illness. In contrast Family SMILES takes a child protection approach and aims to protect the child from harm, aims to help them avoid developing their own mental health challenges by enhancing resilience, bolstering protective factors, and providing children with life enhancing skills. The Family SMILES programme works with children to enhance protective factors in the child ’ s life, improve self-expression and creativity, increase self-esteem and reduce feelings of isolation. The programme also provides age-appropriate education about mental illness and life skills (e.g. what to do in an emergency) in order to improve children ’ s capacity to cope more effectively. Parents of children attending the group will be offered individual work, time limited to the life of the group, to strengthen the parent/child relationship and enhance the parent ’ s understanding of the impact of their illness on the child with a view to developing improved protective parenting. Throughout the course of the individual and group work, a bespoke safety plan will be developed for the child. This will be based on the premise that, in the event of a parental relapse, the child will be adequately protected; responsibility for the child ’ s safety will rest with adults; and the wishes of the child will be considered.
We are also using these tools ( except HoNOSCA and evaluation wheels) at the beginning, end and six months later The interim findings are based on very small numbers. We don ’ t have a comparison group so cant attribute these changes to participation in the programmes
The CAPI is a well validated evaluation tool that captures protective parenting across 6 domains: distress, rigidity, unhappiness, problems with child, problems with family, problems from others and has 2 special scales to examine the level of loneliness and the ego strength of the parent
Parents are reporting positive change on the above aspects on both programmes FED UP Parents liked: That the programme “ gave parenting strategies ” “ supported me to improve my family life ” and enabled them to “ see(ing) it through my child's eyes and how it affected him ” . Family SMILES Parents liked: Having the opportunity to “ relieve some concerns ” and “ learning to talk ” . Learning “ how to communicate with my children better ” and “ understanding (child ’ s name) more ” .
Children are reporting positive change on both programmes. FED UP Children liked: “ meeting people in a similar situation to me ” , feeling “ listened to ” and being able to “ tell people how I feel ” . Family SMILES Children liked: being able to “ find out more about mental health ” and “ talk about mental health ” as well as “ meeting new people ” and “ making friends ” Children learnt: about “ feelings ” , “ who to contact in an emergency ” and “ safety about mental health ” . Children learnt: “ to speak out ” and “ to tell people how I feel ” and how to deal with emergency situations.
Di Jerwood, March 2013. LSCB Conference
• Domestic Abuse• Substance Misuse• Parental Mental Ill Health
• Abuse & neglect are often a feature of a range of family difficulties and problems• Often compounded by poverty, house moves & eviction• Cumulative harm• A wicked problem• ReconceptualisationBunting & Toner (2012); Devaney & Spratt (2009)
• Adverse Childhood Experiences & their relationship to Adult Health and Well-Being – Child abuse & neglect – Growing up with domestic violence, substance abuse, mental illness, crime. – 18.000 participants – 10 year study Anda, R., & Felliti, V., (2010) The Adverse Childhood Experiences (ACE) Study: www.acestudy/org
Top 10 Risk Factors:•smoking,•severe obesity,•physical inactivity,•depression,•suicide attempt,•alcoholism,•illicit drug use,•injected drug use,•50+ sexual partners,•history of STD (sexually transmitted disease).
EarlyDeath Death Disease, Disability Adoption of Health-risk Behaviors Social, Emotional, & Cognitive ImpairmentBirth Adverse Childhood Experiences The Influence of Adverse Childhood Experiences Throughout Life
• Increased risk of lung cancer• More auto immune disease• Increased prescription drug use
• Importance of ecological frameworks• Mirroring: families and agencies• Exclusion of fathers• Fixed thinking• ‘Start again syndrome’• The rule of optimism• Silo practice• Disguised compliance• Vulnerability of older children and adolescents• Sidebotham, P., (2012) What do serious case review achieve? Arch Dis Child 97 (3): 189-192
• Family Characteristics• Minority previously known to CSC• The invisible child• Failure to interpret the information• Poor recording of information and decisions• Decision making• Relations with family• ThresholdsSidebotham, P., (2012) What do serious case review achieve? Arch Dis Child 97 (3): 189-192
Domestic Abuse•Domestic abuse is a major issue and accounts for 25% of allrecorded violent crime (police statistics)•On average 2 women a week are killed in England and Wales bypartners - ex partners ( home office)•24.8% 18 to 24 yr. olds witnessed DV at some time during childhood
Children are affectedChildren who live with domestic abuse are significantly affected and this can be manifest in a number of ways, including,• Physical injury• Disruptive behaviour• Difficulties at school• Depression, resentment, anger• Sleep disturbances• Sense of loss• Bed wetting and nightmares• Guilt, confusion, sadness, self blame• PTSD
• 300,000 children in the UK (Scotland 59,600)• Conflation of ‘substances’• 1100 children pa die as a direct result• Children four times more likely to develop a dependency• Prevalent in cases of DA and child protection• Strong links between alcohol and violence• Little evidence that substance use alone is a risk factor• SG Statistics (2011); Best (2011) Scottish Drug Recovery Consortium; ACMD 2007; Forrester and• Harwin (2008)
• Effects on Parents• Physical Ailments (e.g. infections, injuries)• Psychological impairments – Withdrawal symptoms – Psychoses – Serious memory lapses Most short lived Manifestation: mental health; psychological impact of drug; self- expectations; personality; type, dosage, admin method
• Neglect• Physical abuse, sexual abuse etc• Exposure to dodgy adults• Unstable and violent environment• Feel second to drugs• Exposure to noxious hazards• Criminality• Health issues
• About on in four adults is affected by mental illness• Most cases will be mild or short lived• Sometimes severe (e.g. schizophrenia or manic depression)• Many more live with long term personality disorder or long term depression• 40-60% of people with a severe mental illness have children• Around a third of children subject to CPP (CPR NI & Scotland)• The Psychiatrist (2003) 27: 117-118 doi: 10.1192/pb.27.3.117
• Effects on ParentsEmploymentIncomeRelationship strainLinks to substance misuse ad violence
Children’s Voices • What children say about living with parental substance misuse
FEDUP (Family Environment Drugusing Parents)• A family approach to supporting children who live with parental substance misuse• Group work programme with children• Individual work with parents• Come together for safety planning
• Based on the Erica Pitman Programme• Twin track programme working with children and their parents to reduce the risk of harm to children who live with parental mental ill health.
EvaluationFED UP & Family SMILES : Summary of findings so far
Overview of the evaluation tools Overall aim: To improve the well-being of children and young people and reduce isolationSpecific aim Tool PerspectiveTo enhance parents’ protective Child Abuse Potential Inventory Parentparenting/ to improve the (CAPI) &safeguarding of children & young Evaluation Wheelpeople.To enable children and young Self Esteem Scale Childpeople to feel better about (based on Rosenberg)themselves.To reduce children and young Goodman’s Strengths and Child/ Parentpeople’s emotional & behavioural Difficulties Questionnaireproblems. (SDQ) HoNOSCA PractitionerTo enable children and young Evaluation wheel Childrenpeople to process their thoughtsand feelings.
Interim Findings ( October ‘11 to February ‘13) To enhance parents’ protective parenting/ to improve the safeguarding of children & young people.• For both FED UP and Family SMILES there has been a decrease in total CAPI score between T1 and T2 which is statistically significant for both programmes. This indicates that for both programmes parents are reporting a positive change in their parenting behaviours related to improving the safeguarding of their children.• The change in five out of seven subscales on the CAPI was statistically significant for FED UP suggesting that parents’ levels of distress, unhappiness, problems with the family, loneliness and ego strength have all improved. For Family SMILES , the distress, unhappiness and ego strength subscale are statistically significant Note: For both FED UP and Family SMILES number of Time 1 and Time =19, Statistical significance at 95% confidence levels using a one
To enhance parents’ protective parenting/ to improve the safeguarding ofchildren & young people: Evaluation wheels with parents FED UP Note: The rating of 1 to 5 where 1 is low and 5 is high
To enable children and young people to feel better about themselves Levels of self esteem amongst children as reported on the adapted Rosenberg scale increases on both programmes. In Family SMILES, this change is statistically significant.FED UP Family SMILESN = 28 (T1 and T2) N = 20 (T1 and T2)Mean at T1 = 19.6, Mean at T2 = 20.8 Mean at T1 = 19.05, Mean at T2 = 21.5P value = 0.102 (one tailed t-test) P value = 0.009 (one tailed t-test)The change is not statistically significant The change is statistically significant
To reduce children and young people’s emotional & behavioural problems.At present the evaluation is not showing any statistically significant change inreducing emotional and behavioural problems as reported on the SDQ on either theFED UP or the Family SMILES programmes. Practioners on FED UP have reportedchange that is statistically significant using the HoNOSCA FED UP Family SMILES Self Report SDQ No statistical No statistical significance significance between T1 and T2 between T1 and T2 (n=27) (n=29) Parent completed No statistical No statistical SDQ significance significance between T1 and T2 between T1 and T2 (n=18) (n=9) HoNOSCA Statistically No statistical significant change difference ( completed by from Time 1 and 2
To enable children and young people to process their thoughts andfeelings: Children’s evaluation wheels FED UP Family SMILES
The world is a dangerous place to live. Notbecause of the people who are evil, butbecause of the people who don’t do anythingabout it(Albert Einstein)
Thank You for ListeningDi Jerwooddjerwood@nspcc.org.ukAcknowledgements Professor Julie Taylor Dr. Prakash Fernandes