Safeguarding Children:Safeguarding Children:getting it right from the startgetting it right from the start

Jane BarlowProfessor of Public Health

in the Early Years

Structure of paperStructure 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…?

Where are we now…Where are we now…

Significant Harm of Infants Study Significant Harm of Infants Study

Prospective study in 10 LAs; Prospective study in 10 LAs; Sample of 57 children who were the subject of a Sample of 57 children who were the subject of a

core assessment, section 47 enquiry or became core assessment, section 47 enquiry or became looked after before their first birthdays; looked after before their first birthdays;

43 were followed until they were three 43 were followed until they were three http://www.lboro.ac.uk/research/ccfr/http://www.lboro.ac.uk/research/ccfr/

Publications/DFE-RB053.pdfPublications/DFE-RB053.pdf (Ward et al 2010)(Ward et al 2010)

IdentificationIdentificationHigh prevalence of factors such as drug and alcohol High prevalence of factors such as drug and alcohol misuse, intimate partner violence and mental health misuse, intimate partner violence and mental health problems – few referrals to children’s social care were problems – few referrals to children’s social care were received from any of these sourcesreceived from any of these sourcesAbout a third of the mothers and an unknown number About a third of the mothers and an unknown number of fathers had already been separated from at least one of fathers had already been separated from at least one older child before the birth of the index childolder child before the birth of the index childJust under two-thirds (65%) of the infants were Just under two-thirds (65%) of the infants were identified before birth and almost all before they were identified before birth and almost all before they were six months oldsix months old

OutcomesOutcomes

By the time they were three, 28 (65%) children By the time they were three, 28 (65%) children were living with a birth parent and 15 (35%) were were living with a birth parent and 15 (35%) were permanently placed away from home. permanently placed away from home. Living with Birth Parents - 16/28 (57%) were living Living with Birth Parents - 16/28 (57%) were living with birth parents who had succeeded in with birth parents who had succeeded in overcoming their problems and were now classified overcoming their problems and were now classified as low risk casesas low risk casesAt 3 years… twelve children (28%) were living with At 3 years… twelve children (28%) were living with birth parents who had shown little positive change; birth parents who had shown little positive change; these infants were now at medium, high or severe these infants were now at medium, high or severe risk of suffering significant harm. risk of suffering significant harm.

Double jeopardyDouble jeopardy By three years of age:By three years of age:

- over half of the children were showing serious - over half of the children were showing serious developmental problems (poor speech) and significant developmental problems (poor speech) and significant behavioural difficulties (aggression)behavioural difficulties (aggression)

- many of the placements were approaching breakdown- many of the placements were approaching breakdown Long-term well-being of 60% of the permanently Long-term well-being of 60% of the permanently

separated children had been doubly jeopardised – by separated children had been doubly jeopardised – by late separation from an abusive birth family followed by late separation from an abusive birth family followed by the disruption of a close attachment with an interim the disruption of a close attachment with an interim carer when they entered a permanent placement;carer when they entered a permanent placement;

Waiting for parents to Waiting for parents to change…change…

Developmental and behavioural difficulties were Developmental and behavioural difficulties were more evident amongst children who had more evident amongst children who had experienced some form of maltreatment, often experienced some form of maltreatment, often whilst professionals waited fruitlessly for parents whilst professionals waited fruitlessly for parents to change;to change;

All but one of the parents who made sufficient All but one of the parents who made sufficient changes did so before the baby was six months changes did so before the baby was six months old. old.

Repeated AssessmentsRepeated Assessments

Specialist parenting assessments made by Specialist parenting assessments made by psychologists, psychiatrists or independent social psychologists, psychiatrists or independent social workers were a major cause of delay. workers were a major cause of delay.

All recommendations were followed; two thirds All recommendations were followed; two thirds advised that children should remain with birth advised that children should remain with birth parents, but in over half of these cases the parents, but in over half of these cases the children eventually had to be removed;children eventually had to be removed;

Parenting assessments frequently repeated within very Parenting assessments frequently repeated within very short timeframes, during which parents have little short timeframes, during which parents have little opportunity to overcome previously identified problemsopportunity to overcome previously identified problems

InterventionIntervention Social work interventions were also often of relatively Social work interventions were also often of relatively

short duration – half the child protection plans for the short duration – half the child protection plans for the babies were for 32 weeks or less, and almost all for babies were for 32 weeks or less, and almost all for less than a year;less than a year;

Families successfully parenting children were given Families successfully parenting children were given little ongoing support and cases closed prematurelylittle ongoing support and cases closed prematurely

Kinship care sometimes selected with little regard for the Kinship care sometimes selected with little regard for the quality of care provided, the carersquality of care provided, the carers‟‟ previous history of poor previous history of poor parenting, their personal problems or their knowledge of the parenting, their personal problems or their knowledge of the childchild

Why are the Why are the

early years so early years so important?important?

Trauma in infancy:‘Disorganised Attachment’

Sensitised nervous system as brain adapts to emotional environment

Stress in childreminders & experiences of trauma,

life events, etc.

Unbearably painful emotional states

Self-destructive actions:substance abuseeating disordersdeliberate self-harmsuicidal actions

Destructiveactions:aggressionviolencerage

Retreat:isolationdissociationdepression

(Robin Balbernie 2011)

Aspects of Early Aspects of Early DevelopmentDevelopment

Emotional/Emotional/

social social developmentdevelopment

Intellectual Intellectual DevelopmentDevelopment

BehaviouralBehavioural

developmendevelopmentt

InfancyInfancy Trust/Trust/attachmentattachment

Alertness/Alertness/curiositycuriosity

Impulse Impulse controlcontrol

ToddlerhooToddlerhoodd

EmpathyEmpathy Communication/Communication/

mastery mastery motivationmotivation

CopingCoping

ChildhoodChildhood Social Social RelationshipsRelationships

Reasoning/Reasoning/problem solvingproblem solving

Goal-directed Goal-directed behaviourbehaviour

AdolescencAdolescencee

Supportive Supportive social networksocial network

Learning Learning ability/achievemeability/achievementnt

Social Social responsibilityresponsibility

AFFECT REGULATION

Key pointsKey points The first three years of life are VERY The first three years of life are VERY

important because:important because: - babies are born with immature brains that are - babies are born with immature brains that are

shaped by their early interaction with primary shaped by their early interaction with primary caregivers;caregivers;

- early caregiving received influences their - early caregiving received influences their ‘attachment’ relationship with their primary ‘attachment’ relationship with their primary caregiver and these mediates the impact on the caregiver and these mediates the impact on the CNSCNS

Nurturance/ Emotional and Behavioural Regulation

Important aspects of the parent-infant relationship:

Sensitivity/attunement Mirroring Reflective

Function/Mind Mindedness

By two months the mothers face is the By two months the mothers face is the primary source of visuo-affective primary source of visuo-affective communicationcommunication

Face-to-face interactions emerge which are Face-to-face interactions emerge which are high arousing, affect-laden and expose high arousing, affect-laden and expose infants to high levels of cognitive and social infants to high levels of cognitive and social information and stimulationinformation and stimulation

Regulation of emotional interaction: Regulation of emotional interaction: The dance: synchrony – rupture - repairThe dance: synchrony – rupture - repair Absolutely fundamental to healthy Absolutely fundamental to healthy

emotional development – prolonged emotional development – prolonged negative states are ‘toxic’ to infantsnegative states are ‘toxic’ to infants

Affect synchrony – Affect synchrony – the dancethe dance

‘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).

Videoclip –Videoclip –optimal optimal

M-I interactionM-I interaction

For example…For example… Looks and smilesLooks and smiles help the help the brain to growbrain to grow Baby looks at mother; sees dilated pupils Baby looks at mother; sees dilated pupils

(evidence that sympathetic nervous system (evidence that sympathetic nervous system aroused and happy); own nervous system is aroused and happy); own nervous system is aroused - heart rate increases aroused - heart rate increases

Lead to a biochemical response - pleasure Lead to a biochemical response - pleasure neuropeptides (betaendorphin and neuropeptides (betaendorphin and dopamine) released into brain and helps dopamine) released into brain and helps neurons grow neurons grow

Families doting looks help brain to growFamilies doting looks help brain to grow Negative looksNegative looks trigger a different trigger a different

biochemical response biochemical response (cortisol)(cortisol) stops these stops these hormones and related growth hormones and related growth (Gerhardt, 2004)(Gerhardt, 2004)

Babies of Babies of depressed depressed mothers:mothers: - nearly half show reduced brain activity- nearly half show reduced brain activity

- much lower levels of left frontal brain - much lower levels of left frontal brain activity (joy; interest; anger)activity (joy; interest; anger)

Early experiences of persistent Early experiences of persistent neglect and trauma:neglect and trauma:

- overdevelopment of neurophysiology of - overdevelopment of neurophysiology of brainstem and midbrain (anxiety; brainstem and midbrain (anxiety; impulsivity; poor affect regulation, impulsivity; poor affect regulation, hyperactivity)hyperactivity)

- deficits in cortical functions (problem-- deficits in cortical functions (problem-solving) and limbic function (empathy)solving) and limbic function (empathy)

Attachment What is it:?What is it:?- Affective bond between infant and caregiver - Affective bond between infant and caregiver

(Bowlby, 1969)(Bowlby, 1969)

What is its function?: What is its function?: - Dyadic regulation of infant emotion and - Dyadic regulation of infant emotion and

arousal (Sroufe, 1996)arousal (Sroufe, 1996)

Antecedants of attachment: Antecedants of attachment: Sensitive, emotionally responsive care during Sensitive, emotionally responsive care during

first year – secure attachmentfirst year – secure attachment Insensitive, inconsistent or unresponsive care Insensitive, inconsistent or unresponsive care

– insecure attachment– insecure attachment

Who is securely attached?Who is securely attached?SecureSecure (Group B) (Group B) – able to use caregiver as a – able to use caregiver as a secure base in times of stress and to obtain comfort secure base in times of stress and to obtain comfort (55-65%)(55-65%)

InsecureInsecureAnxious/resistant (Group C) – Anxious/resistant (Group C) – up-regulates in up-regulates in times of stress to maintain closeness (8-10%)times of stress to maintain closeness (8-10%)Avoidant (Group A) - Avoidant (Group A) - down-regulates in times of down-regulates in times of stress to maintain closeness (10-15%)stress to maintain closeness (10-15%)

DisorganisedDisorganised (Group D) – (Group D) – unable to establish a unable to establish a regular behavioural strategy (up to 15% in regular behavioural strategy (up to 15% in population sample; 80% in abused sample) population sample; 80% in abused sample) (Carlson, cicchetti et al 1989)(Carlson, cicchetti et al 1989)

Arousal in traumatic/disorganised Arousal in traumatic/disorganised attachmentsattachments

Hyper-arousal (aggression, impulsive behaviour, Hyper-arousal (aggression, impulsive behaviour, children emotional and behavioural problems – children emotional and behavioural problems – ‘Fight or flight’ response)‘Fight or flight’ response)

Window Window

ofof

ToleranceTolerance

Hypo-arousal (dissociation, depression, self harm Hypo-arousal (dissociation, depression, self harm etc)etc)

Disorganised/ControllingDisorganised/Controlling Attachment Attachment

Caregivers – unpredictable and rejecting; Caregivers – unpredictable and rejecting; source of comfort also source of distresssource of comfort also source of distress

Self represented as unlovable, unworthy, Self represented as unlovable, unworthy, capable of causing others to become capable of causing others to become angry, violent and uncaringangry, violent and uncaring

Others – frightening, dangerous, Others – frightening, dangerous, unavailableunavailable

Predominant feelings – fear and angerPredominant feelings – fear and anger Little time for exploration or social learningLittle time for exploration or social learning

Compulsive StrategiesCompulsive Strategies

Compulsive compliance (where parent is Compulsive compliance (where parent is threatening) – watchful; vigilant and compliant threatening) – watchful; vigilant and compliant

Compulsive caregiving (where parent is needy) Compulsive caregiving (where parent is needy) – role reversal; parentification; children deny – role reversal; parentification; children deny own developmental needsown developmental needs

Coercive – combination of threatening and Coercive – combination of threatening and placatory behavioursplacatory behaviours

Controlling strategies (abusive and neglectful) – Controlling strategies (abusive and neglectful) – self is strong and powerful but also dangerous self is strong and powerful but also dangerous and bad; avoidance and aggression; completely and bad; avoidance and aggression; completely ‘out of control’ and ‘fearless’‘out of control’ and ‘fearless’

Compulsive caregiving ‘ ‘Caroline is 18 months old. She lives with her Caroline is 18 months old. She lives with her

mother, who is chronically depressed. The mother, who is chronically depressed. The mother describes the household as ‘noxious to mother describes the household as ‘noxious to the soul’. She cannot tolerate the idea that her the soul’. She cannot tolerate the idea that her depression is affecting Caroline. She says: depression is affecting Caroline. She says: “Caroline is the only one who makes me laugh.” “Caroline is the only one who makes me laugh.”

It is observed that Caroline silently enacts the It is observed that Caroline silently enacts the role of a clown. She disappears into her room and role of a clown. She disappears into her room and comes out wearing increasingly more comes out wearing increasingly more preposterous costumes. Caroline makes her preposterous costumes. Caroline makes her mother laugh, but she herself never laughs…’ mother laugh, but she herself never laughs…’ (Howe, 1999)(Howe, 1999)

Vulnerable ParentsVulnerable Parents

Parent-infant relationship in the Parent-infant relationship in the face of parental problemsface of parental problems

Infant’s emotional states trigger profound Infant’s emotional states trigger profound discomfort in vulnerable and ‘unresolved’ discomfort in vulnerable and ‘unresolved’ parent sparent s(e.g. where there is unresolved (e.g. where there is unresolved loss/trauma, mental health problems, loss/trauma, mental health problems, drug/alcohol abuse, or where there is domestic drug/alcohol abuse, or where there is domestic violence etc)violence etc)

Interaction becomes characterized by: Interaction becomes characterized by: - withdrawal, distancing or neglect (i.e. omission)- withdrawal, distancing or neglect (i.e. omission) - intrusion in the form of blaming, shaming, - intrusion in the form of blaming, shaming,

punishing and attacking (i.e. commission) punishing and attacking (i.e. commission)

‘‘Atypical’ parenting Atypical’ parenting behavioursbehaviours

Fr-behaviour – frightened AND frightening; Fr-behaviour – frightened AND frightening;

Frightening, threatening (looming); Frightening, threatening (looming); dissociative (haunted voice; deferential/timid); dissociative (haunted voice; deferential/timid); disrupted (failure to repair, lack of response, disrupted (failure to repair, lack of response, insensitive/communication error.insensitive/communication error.

Systematic review of 12 studies found strong Systematic review of 12 studies found strong association between ‘atypical’ parenting at association between ‘atypical’ parenting at 12/18 months and disorganised attachment12/18 months and disorganised attachment

Videoclip –Videoclip –Severely suboptimal Severely suboptimal

M-I interactionM-I interaction

Getting it right, first time…Getting it right, first time…

Working to the developmental Working to the developmental timelines of childrentimelines of children

ANTEANTAL - Identify high risk families during ANTEANTAL - Identify high risk families during pregnancy – pregnancy – pre-birth assessments at 18 weekspre-birth assessments at 18 weeks

Intervention provided ante-natally Intervention provided ante-natally BIRTH - Assess parent-infant interaction; BIRTH - Assess parent-infant interaction;

concurrrent foster care where necessaryconcurrrent foster care where necessary Provide time-limited EB intervention and clear Provide time-limited EB intervention and clear

goals to be achieved; re-assess goals to be achieved; re-assess Remove infants where there is insufficient Remove infants where there is insufficient

improvement before 8 months ideally, end of improvement before 8 months ideally, end of first year at worstfirst year at worst

FASS – Family Assessment and FASS – Family Assessment and Safeguarding ServiceSafeguarding Service

Specialist multi-disciplinary service provided Specialist multi-disciplinary service provided by Oxford Health NHS Foundation Trust;by Oxford Health NHS Foundation Trust;

Integrated and individually tailored multi-disciplinary Integrated and individually tailored multi-disciplinary assessment programmes to assess severe parenting assessment programmes to assess severe parenting problems including child abuse and neglect;problems including child abuse and neglect;

Expert professional and court reports including court Expert professional and court reports including court appearance providing independent advice and appearance providing independent advice and recommendations to assist decision making recommendations to assist decision making regarding future placement and needs of children regarding future placement and needs of children referredreferred

Is home the best place Is home the best place to be…?to be…?

Once children have been placed in out-of-home Once children have been placed in out-of-home care, there is often an assumption that reunification care, there is often an assumption that reunification is the optimum outcome.is the optimum outcome.

Although 50–75% of children placed in out-of-home Although 50–75% of children placed in out-of-home care eventually reunify, between 20–40% of those care eventually reunify, between 20–40% of those reunified subsequently re-enter foster care; reunified subsequently re-enter foster care;

Studies have recorded better outcomes for children Studies have recorded better outcomes for children who were NOT reunified with their families of origin who were NOT reunified with their families of origin than those who were, including gains in intelligence than those who were, including gains in intelligence scores, greater overall wellbeing, and less criminal scores, greater overall wellbeing, and less criminal recidivism (Lancet 2009).recidivism (Lancet 2009).

Cont…Cont…Longitudinal studies found that reunified youth Longitudinal studies found that reunified youth

showed worse outcomes for: internalising and showed worse outcomes for: internalising and externalising problems;externalising problems;

risky behavioursrisky behaviours Competencies; grades; school dropoutCompetencies; grades; school dropout involvement in the criminal justice systeminvolvement in the criminal justice system adverse life eventsadverse life events witnessing physical violence witnessing physical violence more likely to receive physical violence as part of more likely to receive physical violence as part of

discipline; discipline; less likely to receive mental health treatment(ibid)less likely to receive mental health treatment(ibid)

Cont…Cont… Children who were formerly in foster care Children who were formerly in foster care

were 1.5 times more likely to die from a were 1.5 times more likely to die from a violent death than were children who violent death than were children who remained in foster care;remained in foster care;

Three times more likely to die from violent Three times more likely to die from violent causes than were children in the general causes than were children in the general population.population.

Does foster care improve Does foster care improve outcomes?outcomes?

Children placed in care fared better than maltreated Children placed in care fared better than maltreated children who remained at home:children who remained at home:

antisocial behaviour; sexual activity; school antisocial behaviour; sexual activity; school attendance and academic achievement; social attendance and academic achievement; social behaviour and quality of life;behaviour and quality of life;

Enhanced foster care (better trained caseworkers Enhanced foster care (better trained caseworkers and greater access to services, and supports for and greater access to services, and supports for youth and foster families) fewer mental and youth and foster families) fewer mental and physical health problemsphysical health problems

Concurrent Planning in Concurrent Planning in Foster CareFoster Care

‘‘Concurrent planning is a form of fostering and Concurrent planning is a form of fostering and adoption that removes children aged up to six years old adoption that removes children aged up to six years old from parents with severe difficulties in their lives and from parents with severe difficulties in their lives and places them with specially trained prospective adoptive places them with specially trained prospective adoptive parents, who act as foster carers for six to nine months.parents, who act as foster carers for six to nine months.

If the birth-family, who are given intensive support, can If the birth-family, who are given intensive support, can overcome their problems, the child is returned to them overcome their problems, the child is returned to them otherwise, they will be adopted by the foster carers’.otherwise, they will be adopted by the foster carers’.

www.communitycare.co.uk Must stop moving children through foster placements Must stop moving children through foster placements

because it TRAUMATISES them!!because it TRAUMATISES them!!

Evidence-Based InterventionsEvidence-Based Interventions

Sensitivity/attachment-based: Sensitivity/attachment-based: Video-Video-interaction Guidance; Family Nurse interaction Guidance; Family Nurse Partnership;Partnership;

Psychotherapeutic: Psychotherapeutic: Parent-infant Parent-infant psychotherapypsychotherapy

Family Drug and Alcohol Courts (FDAC)Family Drug and Alcohol Courts (FDAC) Parenting programmes Parenting programmes – Parents under – Parents under

Pressure; Parent-Child Interaction TherapyPressure; Parent-Child Interaction Therapy

PUP ProgrammePUP Programme PUP is underpinned by an ecological model of PUP is underpinned by an ecological model of

child development and targets multiple domains child development and targets multiple domains of family functioning, including the psychological of family functioning, including the psychological functioning of individuals in the family, parent–functioning of individuals in the family, parent–child relationships, and social contextual factors. child relationships, and social contextual factors.

Incorporates ‘mindfulness’ skills that are aimed at Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation;improving parental affect regulation;

PUP comprises an intensive, manualized, home-PUP comprises an intensive, manualized, home-based intervention of ten modules conducted in based intervention of ten modules conducted in the family home over 10 to 12 weeks, each the family home over 10 to 12 weeks, each session lasting between one and two hours session lasting between one and two hours

PUP evaluationPUP evaluation Parents Under PressureParents Under Pressure RCT with substance abusing parents of children RCT with substance abusing parents of children

aged 2-8 years (Dawe and Harnett 2007) aged 2-8 years (Dawe and Harnett 2007) Compared PUP with standard parenting Compared PUP with standard parenting

programmeprogramme Significant reductions in parental stress; Significant reductions in parental stress;

methadone dose and child abuse potential methadone dose and child abuse potential (significant worsening in the child abuse (significant worsening in the child abuse potential of parents receiving standard care); potential of parents receiving standard care); improved child behaviour problemsimproved child behaviour problems

SummarySummary

First three years of life are foundational in First three years of life are foundational in terms of neurological and developmental terms of neurological and developmental outcomes;outcomes;

Considerable scope for prevention of Considerable scope for prevention of serious problems if we work to the serious problems if we work to the developmental timelines of the children, developmental timelines of the children, not the parent;not the parent;

Innovative models of working show good Innovative models of working show good outcomesoutcomes

PublicationsPublications Barlow J, Scott J (2010). Barlow J, Scott J (2010). Safeguarding in the 21Safeguarding in the 21stst

Century: Where to NowCentury: Where to Now? Dartington: Research in ? Dartington: Research in Practice. Practice. www.rip.org.uk

Ward et al (2011). Infants suffering, or likely to suffer, Ward et al (2011). Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study. significant harm: A prospective longitudinal study. London: DfE.London: DfE. www.lboro.ac.uk/research/ccfr/Publications/DFE-RB053.pdf

Barlow J, Schrader-McMillan A (2010). Barlow J, Schrader-McMillan A (2010). Safeguarding Safeguarding Children from Emotional Abuse: What Works? Children from Emotional Abuse: What Works? London: Jessica Kingsley.London: Jessica Kingsley.