Children's hearings training resource manual: volume 2
Volume 2 is a children's hearings handbook, focusing on the problems that some children face, the environment in which they live, their needs and their rights.
3 Children's Needs
Parents are responsible for creating an environment that enables their children to develop physically, intellectually and emotionally. Children are unlikely to fulfil their potential unless their needs are met.
Mia Keller Pringle ( The Needs of Children) identified clearly the needs that children have for love, security, new experiences, praise and recognition and responsibility. Although first published in 1975, the needs of children have not changed in the interim and the message is as true today as it was then.
For many of the children who come to hearings there has been failure to meet these needs at many levels.
Love and security
The need is met by the child experiencing from birth onwards a stable, continuous, dependable and loving relationship with his parents (or permanent parent-substitutes), who themselves enjoy a rewarding relationship with each other.
First and foremost, this need is met by giving the child the security of stable family relationships where attitudes and behaviour are consistent and dependable; the security of a familiar place; and the security of a known routine. All these make for continuity and predictability in a world in which the child has to meet and come to terms with so much that is new and changing.
When this need [for love and security] is not met adequately, then the consequences can be disastrous later on, both for the individual and for society.
Anger, hate and lack of concern for others are probably reactions to being unloved and rejected. Vandalism, violence and delinquency are not infrequently an outward expression of these feelings.
A child from a discordant home is liable himself to become emotionally disturbed or antisocial.
New experiences are a prerequisite for mental growth as essential to the mind's development as food is for the body.
Some adolescent escapades, which result in crime, are child's play conducted with adult means.
The urban environment is hostile to the young; there is little freedom or safety to explore or experiment, particularly without adult supervision. In seeking - legitimately- for the excitement of new experiences the forbidden, risky or dangerous are liable to acquire an aura of daring and excitement. What may start as a lark, giving vent to high spirits and the desire for adventure can all too easily turn into vandalism and mindless destruction.
Praise and Recognition
Because growing from a helpless baby into a self-reliant adult requires an enormous amount of emotional, social and intellectual learning . . . a strong incentive is needed. This is provided by the pleasure shown at success and by the praise given to achievement by adults who love the child and whom he in turn loves and wants to please.
If this need is inadequately met or remains unsatisfied, then in the long term the effects are destructive of self-respect and of confidence in tackling new situations, tasks or relationships.
How can responsibility be given to the immature and to the irresponsible? There is no way out of the dilemma that unless it is granted, the child cannot learn how to exercise it. Like every other skill, it needs to be practised under adult guidance, which then gradually diminishes during adolescence and adulthood.
The fact that during adolescence many youngsters rebel against parental standards and seek to find their own way of solving problems in no way changes the need for parents to make clear what they regard as desirable or acceptable standards.
The child who is denied opportunities to exercise responsibility will fail to develop a sense of responsibility for himself, for others or for material objects.
From: Pringle MK., The Needs of Children 3rd edition, London, Hutchinson, 1986
It is not the panel members' role to assess or diagnose attachment in hearings. The following notes are given to help understand the terms when used in reports by professionals
The current theories of attachment were largely developed by Mary Ainsworth.
Consequently the types of attachment are referred to as 'Ainsworth's Attachment Patterns'. These are categorised as:
- Secure attachment
- Ambivalent - insecure attachment
- Avoidant - insecure attachment
- Disorganised attachment.
A securely attached child will approach their carer confident of an unconditional response, certain that needs will be met and that they will be readily consoled. They will separate without anxiety and will respond positively to being reunited.
This type of attachment develops trust, self-esteem and confidence.
Many neglected children demonstrate patterns of insecure attachment behaviour. These are sub-categorised as:
- Ambivalent attachment, sometimes referred to as resistant attachment, results from a lack of certainty about how carers are going to respond, since they are experienced as unreliable, inconsistent and insensitive. This child both wants and fears intimacy. In order to make any kind of contact, extreme strategies are called for. The child uses angry, demanding, attention seeking behaviour in order to break through the emotional barriers that are being experienced.
- Avoidant, anxious or detached attachment results from the child discovering that if they become upset or distressed it gets them the opposite of what they want and need. They experience the carer as rejecting, interfering and controlling. The child's defensive strategy is to deny distress and strong feelings are blocked out. Consequently the child avoids intimacy and becomes unhealthily self-reliant.
- Disorganised attachment arises when it is the carers who are the cause of the original distress. They may have abused the child in some way or are emotionally totally unavailable, due to mental health problems or substance misuse. Whatever the child does, comfort is not forthcoming. As a result attachment behaviour becomes a confused mixture of angry approaches, indifference, avoidance, withdrawal, dazed behaviour - confusion. The child may also 'freeze physically or psychologically'.
LOSS AND CHANGE: EFFECT ON CHILDREN AND YOUNG PEOPLE
Loss or Change?
A major change in a person's life can, and does, result in the same symptoms as loss. Consequently for the purposes of this section both terms are used.
What constitutes Loss?
Most adults will equate loss with bereavement, this being the major loss that people face in later life. However loss can take many forms both physical and emotional. The table below gives examples of both types. The lists are neither rated nor exhaustive. It is worthwhile contemplating one's own childhood to identify further examples.
|Physical Loss (change)||Emotional Loss (change)|
|parent or sibling dying||new baby or child in the house|
|grandparent dying||parent losing his/her job|
|separation or divorce||parent working away from home|
|moving house||parent misusing drugs and/or alcohol|
|moving to a new school||parent's mental health issues|
|health problems (child)||health problems ( parent or sibling)|
|leaving, or being removed from, home||sibling behaviour|
|parent in prison|
Given that bereavement is relatively rare for children, it is these other types of loss that are most likely to affect children and young people. In a recent survey of 10-14 year olds 1% had experienced the death of their mother and 3% the death of their father. This is therefore a small population and not one that will impact on many children's hearings. It is however useful to have some concept of a child's understanding of death and dying. Experience of a death or other major loss or change will trigger a reaction. It is important for panel members and others involved in the children's hearings system to be aware of the major reactions.
Children's Reaction to Loss
A child or young person's reaction to loss is in three distinct phases:
- Early Grief.
- Acute Grief.
- Integration of Loss.
Children's Needs in Times of Change
There are some general needs that should be met throughout the whole episode of loss. They are shown below:
|Help to express feelings||
|Help with secondary losses||
Children's day to day functioning and their development over time are shaped by the balance between harmful and protective factors in their lives. The association between poor quality insecure relationships in childhood and later social and behavioural difficulties is not inevitable, only more probable. However, there is growing evidence to show that some people who have experienced adverse environments and poor quality relationships in childhood develop reasonably integrated personality structures. This has led to the development of the concept of resilience.
"Successful children who do well despite adversity remind us that children grow up in multiple contexts - in families, schools, peer groups, sports teams, religious organisations, and many other groups - and each context is a potential source of protective as well as risk factors. These children demonstrate that children are protected not only by the self-righting nature of development, but also by the actions of adults, by their own actions, by the nurturing of their assets, by opportunities to succeed and by the experience of success".
[ Masten and Coatsworth 1998]
Resilience is associated with better long term outcomes.
To develop in a healthy way children need:
1 A secure base - this includes predictability of care over time and a coherent story of their own history.
3 Self efficacy.
Resilience can only be promoted if a child feels safe so this may, in some cases, mean removal from the risk environment. A child who feels unsafe will be expending all his/her emotional energy on strategies to keep safe (e.g. in engaging in behaviour which is aimed at mollifying a potential abuser). This may have the effect of delaying normal healthy development.
A resilience model should look first at the strengths within the child and the child's environment and aim to protect and build on them. It seems likely that children will be more resilient to adverse circumstances if they have:
- Supportive relationships with at least one parent.
- Supportive relationships with siblings and grandparents
- A committed adult other than a parent who takes a strong interest in the young person and serves as an ongoing mentor and role model.
- A capacity to develop and reflect on a coherent story about what has happened and is happening to them.
- Talents or interests which can be encouraged and developed.
- Positive experiences in school.
- Positive friendships.
- A capacity to think ahead and plan in their lives.
Children need to believe in themselves and their ability to transcend adversity. This comes in being supported as they negotiate the stages of development. The more they experience success, the more they will develop this self-belief.
Just one person who shows a consistent interest in a child can make a difference.
Panel Members - Tips for hearings
Some questions to consider in reaching decisions in child's best interests:
- What are the things that are going well in this child's life?
- To whom is this child important?
- Who is important to this child?
- Is there a concerned adult outside the home who has very regular contact with the child?
- Has the child a realistic way of contacting this adult when necessary?
- Does the child relate fairly easily to peers of his or her own age group?
- How does the child get on in school socially as well as academically?
- Has the school been briefed adequately on the child's home situation?
- Does the primary care-giver have people he or she trusts and can rely on for help in moments of stress and crisis?
If you do not find the answers to these questions in the reports or other information you receive prior to a hearing, you should be seeking answers during the hearing.
CHILDREN AND PARENTS
Panel members will have a limited role in assessing parents during a hearing, but an understanding of the process will help them to set in context the various reports received prior to the hearing.
The information shown below is based on materials provided by the late Professor Rudolph Schaffer, Emeritus Professor of Psychology, University of Strathclyde.
How Does One Assess A Parent?
Bear in mind:
- You are assessing that person in relation to the child - not in relation to yourself. The fact that you like him/her and get on well does not make him/her a "good" parent.
- Parenting is an extremely complex business. It involves very many different things. To classify people simply as '"good" or "bad" is therefore of little help in arriving at some sort of judgment about them. For that matter, people can be perfectly adequate at one aspect of parenting but not at another.
- In arriving at some judgment about a parent, don't be swayed unduly by one piece of evidence. A mother may lose her temper with the child at the hearing, but that does not make her a "bad-tempered mother" - she may just be nervous in that situation.
- Beware of sweeping generalisations . For example, "all only children are spoilt", "all red-haired people are bad-tempered", or "all single parent families are incapable of coping". Assessing people is unfortunately not that easy - you need to start afresh with each individual case.
- Beware of imposing your own values on others. What is right for one person or one family may not be right for another. You may disapprove of working mothers/physical punishment/bottle-feeding a two-year old etc., etc., but normality is different things to different people and encompasses a vast range of differing circumstances.
- Where possible, don't make quick judgments. People are awfully complex, and the more we can see a parent on more than one occasion, and the more we can use evidence from others (social workers, teachers, etc.) the better
Some Aspects of Parenting to Look Out For
In assessing a parent it is useful to break down the relationship with the child into various components and to think about each of them. Three of the most important ones are mentioned below, but bear in mind that this is by no means a complete list - on the contrary, you may wish to add many others that you regard as just as important. The ones given here are only to start you thinking:
Does the parent love the child? Perhaps the most obvious thing to ask, but not easy to ascertain and especially so as people show love in many different ways (some are demonstrative, others not, etc.) Important for children because:-
- security comes from being loved
- children themselves learn to love because they are loved.
Remember: the mother is not necessarily the only - and may in some cases not be - the main source of love and security. Fathers, grandparents, aunts and other relatives - any one of them may be the most important person in the child's life, so all the child's relationships need to be explored if one is to get inside the child's skin and see the world from his or her point of view.
Young children can only absorb a limited amount: to have twenty parents would be quite impossible for them. They need consistent treatment:
- by not having too many different people looking after them
- by the two parents (or carers) being more or less in agreement about the child's care
- by each parent/carer being consistent in his/her demands.
Each child is an individual: what works with one does not necessarily work with another. One can't bring up children by recipe.
In addition, children change with age: what works at one stage of development does not necessarily work at another.
Parents, therefore, need to adapt to the individuality of their child. Their demands should be realistic in terms of the personality, ability and age of the child. Insensitive treatment leads to trouble.
Examples of questions to ask oneself about a parent:
- Does the parent feel love for this child?
- Can the parent act as a "haven of safety" for the child?
- Is the parent realistic in his/her appraisal of the child's needs for dependence on the one hand and independence on the other?
- Is the parent consistent in the demands made on the child?
- Do the parents agree, broadly speaking, on how to bring up the child?
- Can the parent adapt to the peculiarities of this particular child?
- Is the parent realistic in the demands made on the child?
The following are extracts from "Early Intervention: Good Parents, Great Kids, Better Citizens" by Graham Allen MP and Rt. Hon Iain Duncan Smith MP second edition, published May 2009 by The Centre for Social Justice.
There is only one criterion which endures: 'does your approach attack the intergenerational nature of underachievement?' Policies which do not meet that criterion, however well-intentioned or well-designed, are not Early Intervention.
What Dysfunction Costs
Speaking at the launch of 'Early Intervention City' in Nottingham, Paul Ennals, chief executive of the National Children's Bureau, said:
In some ways everyone knows Early Intervention is important. It's cheaper. It's more effective and it is less likely that things go wrong. It saves money in the long run. If you have a young man in drug rehabilitation it costs £250,000 a year, but the cost of family support that makes it less likely that he needs it costs only a fraction of that.'
A programme like this requires a 20-year perspective because for money invested today, while it will see some short-term gains, most of the gains will be in 10 to 15 years and that takes political courage.
He expected that for every £1 invested in such services, the Government would save £7 in the future.
Drunkenness and Drug Use
We are living through the death of civility …Today, it is commonplace to encounter road rage, muggings, street crime, drunkenness, lager louts, hoodies, yobbishness and laddishness. Teachers are attacked in the classroom. Nurses encounter violence from patients. …..the liberal revolution of the Sixties, which separated morality from law, is leading us to a new form of barbarism... The view that 'it's legal, so I can do it' is destroying the fabric of social harmony. Manners are disappearing, along with courtesy and shame. Sir Jonathan Sacks, Chief Rabbi
The Effects of Unresolved Trauma
Behind the drug and alcohol figures is the emergence and growth of a range of addictive behaviours and practices. One in fifteen children and adolescents now regularly self-harm e.g. by cutting and blood-letting. Bruce Perry provides a scientific explanation for the phenomenon of self-mutilation:
When they mutilate themselves, they can induce a dissociative state, similar to the adaptive response they had during the original trauma. Cutting can be soothing to them because it provides an escape from anxiety...people can become so disconnected from reality that they move into a dreamlike consciousness...linked with the release of high levels of opioids, the brain's natural heroin-like substances that kill pain and produce a calming sense of distance from one's troubles.
Supporting youngsters whose tragic early experiences have led them to find such extreme coping devices would not only help them lead better lives, it would also improve their likelihood of being good parents to their own children.
Unrecognised "Benefits" Of Some Dysfunctional Behaviour
What are the drivers behind the 'delinquent drinker' phenomenon? The ACE Study indicates that people who had high levels of adverse childhood experience are inclined to use such psychoactive substances as nicotine, alcohol, prescription and street drugs in attempts to improve how they feel, even though they know these things are bad for them. As Felitti states in his book:
it's hard to get enough of something that almost works
Nicotine, alcohol and street drugs (and even self-mutilation) can help people escape emotional pain arising from patterns that grew out of early adverse experience. In studying smokers, the study found a graded increase in the likelihood of children having suffered adverse child experience, amounting to a 250 per cent greater likelihood of smoking as adults in those with scores of six or more (adverse childhood experiences) compared with those who scored zero. For alcoholism the increased likelihood is 500 per cent and for injection of street drugs it is 4,600 per cent.
Dr Felitti stresses the profound implications of these figures in terms of the psychoactive benefits of the substances involved, when the user has suffered early damage and is carrying its effects to the extent that relief is sought in some other form. If we do not want people to feel compelled to turn to such ultimately destructive sources of comfort, their early years need to be sufficiently free of adverse experiences to protect them from the need.
This analysis is echoed by Bruce Perry in his book " The Boy who was raised as a Dog". There he says:
Research on addicts and alcoholics finds dramatically increased numbers of early traumatic events, as compared to those who have not suffered addictions... Brain scans of those who've experienced trauma often reveal abnormalities in areas that also show changes during addiction. It may be that these changes make them more vulnerable to getting hooked.
Detective Chief Superintendent John Carnochan, head of the Scottish Violence Reduction Unit described the strategy more graphically still:
If people keep falling off a cliff, don't worry about where you put the ambulance at the bottom. Build a fence at the top and stop them falling off in the first place.
The Visible Versus the Invisible Threat
The intergenerational nature of this is underlined by the estimate that 30 to 40 per cent of abused or neglected children (versus two to three per cent of the total population) go on to abuse or neglect their own children or, as Professor David Farrington puts it:
Antisocial children grow up to become antisocial adults who go on to raise antisocial children.
CLASSIC STUDY FOR EFFECTIVE INTERVENTION
The development of one thousand children born in Dunedin, New Zealand in 1972 was monitored from birth. When these children were three, nurses (who knew nothing about their backgrounds) assessed them, by watching them at play for 90 minutes, to identify those they judged could be at risk. At follow-up at age 21, it was found that the 'at risk' boys had two and a half times as many criminal convictions as the group deemed not to be at risk. In addition, 55 per cent of the offences were violent for the 'at risk' group, as opposed to 18 per cent of those not at risk, and 47 per cent of those in the 'at risk' group were abusing their partners, as opposed to under 10 per cent of the other group.
We urge the UK Government to commission a long-term study, similar to the Dunedin one, using cohorts of children with and without early intervention to inform the policy as it develops.
The Developing Brain 0-3 and What It Needs To Mature
The structure of the developing infant brain is a crucial factor in the creation (or not) of violent tendencies, because early patterns are established not only psychologically but at the physiological level of brain formation
Human infants arrive ready to be programmed by adults. From our first moments of life we are tuned into the facial expressions of those around us, as can be seen from the infant reflex to mimic. The problem is that this wonderful advantage turns into a disadvantage when it is met by the long term lack of positive expression on the nearest face, that of the primary caregiver. When this most basic need for a positive response is not met, and when a tiny child does not feel secure, attached and loved, the effect can be lifelong. Neuroscience can now explain why early conditions are so crucial: effectively, our brains are largely formed by what we experience in early life.
Bruce Perry records the case of a four-year-old girl who, despite massive medical attention and intervention, could not thrive and weighed just 26 lbs. As a child this girl's mother had been deprived of the early touch and affection necessary for the proper growth of her own brainstem, midbrain and limbic systems. She had been lacking in the 'natural' instinctual response to her infant as well as ignorant of the necessity of touch, eye-gaze and rocking. However, having been fostered in a stable, loving home from the age of five (during the growth of the cortical system of her brain) this woman was moral and dutiful towards her baby - which was fortunate because she constantly sought help. Sadly, until the infant was four, none of the doctors suspected a parenting reason for her failure to thrive and continued to seek a biomedical solution. When the truth eventually came out (after Perry observed parent/infant interaction), the child and mother did very well after moving in with a particularly 'motherly' fosterer, with whom they spent a year. On the same diet as in the hospital, the four-year-old's body weight increased by 35 per cent in the first month in the nurturing emotional environment.
The disadvantage of the human brain's plasticity mentioned earlier is that it renders it acutely vulnerable to trauma. If a child's early experience is predominantly characterised by fear and stress, then the neurochemical responses to fear and stress become the primary architects of the brain, for the simple reason that these are the responses most frequently triggered. The stress hormones, such as cortisol, that are elevated during trauma, flood the brain like acid. One result is the formation of significantly fewer synapses (connections). Specialists viewing computed axial tomography ( CAT) scans of the key emotional areas in the brains of abused or neglected children have likened the experience to looking into a black hole.
The brain of an abused or neglected child is significantly smaller than the norm: the limbic system (which governs emotions) is 20-30 per cent smaller and tends to have fewer synapses; the hippocampus (responsible for memory) is also smaller. Both of these stunted developments are due to decreased cell growth, synaptic and dendrite density - all of which are the direct result of much less stimulation (e.g. sight, sound, touch) than is required for normal development of the brain. The images shown on the next page have been taken from studies conducted by researchers from the Child Trauma Academy ( www.ChildTrauma.org ) led by Bruce Perry. They illustrate the negative impact of neglect on the developing brain. The CAT scan on the left is from a healthy three year old child with an average head size. The image on the right is from a three year old child following severe sensory deprivation neglect in early childhood whose brain is significantly smaller than average and has abnormal development of cortex (cortical atrophy) and other abnormalities suggesting abnormal development of the brain.
Even if actual abuse is not present, the combined stressors of poverty appear to have a significant impact. A study of educational achievements from infancy to age 26 found significantly different development scores in the three socio-economic status ( SES) groups studied.
At the start of the study, when the participants were 22 months old on a scale of one to 70:
High SES infants averaged approximately 57
Medium SES group averaged approximately 48
Low SES group approximately 43.
This snapshot provides a chilling glimpse of the handicap suffered by our most deprived children in the lowest socio-economic group.
Significance of "Sensitive Windows"
During the first three years of life there are sensitive windows of time when specific learning takes place and the brain hones particular skills or functions. Certain elements of human capability including vision, language and emotional development, occur in maturity 'spurts' during these sensitive times. If the opportunity to practise a skill is missed during the window relating to that skill, a child may either never learn it or its learning may be impaired.
To the best of current knowledge, the sensitive window for emotional sensitivity and empathy lies within the first 18 months of life, and these 'skills' are shaped by the prime caregiver.
The 18-month theory is reflected in Bruce Perry's story of a boy who was routinely abandoned by his nanny from morning to night for the first 18 months of his life before his working parents found out. By age 14, despite having been well cared for in the interim and a great deal of money spent on trying to treat his various disorders, he was:
rocking and humming to himself, friendless and desperately lonely and depressed: a boy who didn't make eye contact with other people, who still had the screaming, violent temper tantrums of a three or four-year-old; a boy who desperately needed the stimulation that his brain had missed during the first months of life.
He responded very well to the physical touch and rhythm-building treatment appropriate to the age he was when the neglect took place.
The Crucial Elements of Early Attunement and Empathy
The child's first relationship, the one with the primary caregiver, normally the mother, acts as a template that permanently moulds the individual's capacity to enter into all later emotional relationships
Attunement takes place when the parent and child are emotionally functioning in tune with each other and where the child's emotional needs for love, acceptance and security are met. Without satisfactory early attunement to the primary caregiver, the development of empathy can be greatly impaired.
Empathy entails the ability to step outside oneself emotionally and be able to suppress temporarily one's own perspective on events to take another's. It is present when the observed experiences of others come to affect our own thoughts and feelings in a caring fashion. When a parent consistently fails to show any empathy with the child's expression of particular emotions, the child can drop those emotions from his or her repertoire. Empathy is also perceived as a prime requirement for a citizen to be of the law-abiding 'self-regulator' type. Empathy is a powerful inhibitor of the development of propensity to violence. Empathy fails to develop when the prime caregiver fails to attune with an infant. Absence of parental attunement combined with harsh discipline is a recipe for violent, anti-social offspring.
A large part of the difference in the empathic capabilities which children develop comes from the way they are disciplined. Children are more empathic when discipline includes clearly drawing attention to the distress their behaviour causes to someone else. Empathy is shaped by how children see others responding to distress. By imitating the adult response, children develop a repertoire of empathy - or its absence.
More child abuse occurs in the first year of life than in any other. UK rates of abuse are over three times the average for Norway, Sweden and Denmark and ten times the reported average for Spain, Greece and Italy. Research shows that the worst single trigger for abuse is parental overestimation of what infants can understand. It is not unusual for infants to be expected to respond and perform at levels appropriate for those months beyond their age, and to be punished for their 'perversity' when they disappoint these expectations.
The early years are so critically important to the child's later social development that pathways to violence are often laid down by the age of two or three. Three-quarters of aggressive two-year-olds are still aggressive at age five. Untreated early-onset aggression can establish a lifelong tendency to be aggressive and the earlier aggression is established, the worse the long-term outcome tends to be. Discouraging aggression in schoolchildren requires that corrective action begin long before they are in school.
Lack of Attunement
Regrettably, for many parents attunement either does not come 'naturally' (because they did not receive the benefit of it themselves), or is disrupted by postnatal depression, domestic violence or other severe stresses. If a child does not experience attunement, their development is retarded, and they may lack empathy altogether.
Bruce Perry records the history of a 'cold-hearted' 16-year-old boy who raped, murdered then viciously kicked two young girls (It was the blood on his boots that made a family member suspicious enough to call in the police.) The mystery in the case was that both parents were very respectable and decent and his older brother well-adjusted. Investigation of the murderer's past uncovered the fact that his mother (who was of low intelligence) had found it difficult to cope with a demanding infant without the extended family support she had received with her first child (because the family had moved between the births of her two sons). She had coped by taking her four-year-old out all day, every day and leaving the baby unattended apart from the bare minimum involved in feeding and changing him. No bond of attunement was ever formed between them and this accounted for how two small boys in the same family could turn out so differently. The callousness of the post-mortem kicking is a chilling portrayal of the boy's lack of empathy. No sign of remorse was ever given: when he was asked two years later what he would do differently, if he had the time over again, his answer was:
I don't know. Maybe throw away those boots.
THE RATIONALE FOR INTERVENTION: TO MAKE EVERY CHILD'S FIRST THREE YEARS THE BEST POSSIBLE
The subject of intervention is sensitive because it goes against our cultural tendencies. Our historic approach has been that pre-school child-rearing is the exclusive province of the parents (or other carers), unless there is a highly visible level of neglect or maltreatment.
Just as medical research into the effects of smoking paved the way for a cleaner and safer public environment, similar effects should flow from the body of sound research we are drawing from here. It shows that the way children are treated in their first three years has a direct bearing on whether they grow up to be pro- or anti-social, adjusted or dysfunctional, peaceable or violent, healthy or unhealthy. In addition to our legal, ethical and moral obligations to our helpless young, we now know that 'minding one's own business' and 'turning a blind eye' to all but the worst of parental failings is likely to carry a high price later - both for the children and for society. We also know that providing infants with what they need will make society not only safer and more functional, it will also produce happier, healthier citizens with higher IQs who are consequently more likely to be assets than liabilities. This new knowledge must make giving our infants the best possible experience a social imperative rather than the luxury or desirable option it has previously been seen to be.
A report by the Institute of Psychiatry contrasted the estimated £70,000 per head direct cost to the public of children with severe conduct disorder with a £600 per child cost of parent training programmes. To include indirect costs such as impact of crimes or the costs to victims would multiply this £70,000 an estimated seven-fold . The financial case for Early Intervention is becoming overwhelming and as we show later, even if a government were unconcerned about breaking the intergenerational cycle of underachievement, it is highly likely to find the massive savings of Early Intervention irresistible.
Early Intervention investment is massively cheaper than late intervention, as well as being much more effective. For example, the costs of comprehensive drug and alcohol education for every 11-year-old in Nottingham would be seriously lower than meeting the costs of a dozen people on drug rehabilitation, each of which costs around £200,000 per year and most of whom will re-offend. Or suppose that we help a young mother and a toddler with a £1000 worth of health visiting at the time she and her baby need it most: that makes more sense than waiting 16 years in order to pay £230,000 to incarcerate that baby in a young offenders' secure unit for a year when he has gone astray.
Conclusion so far
We are clear that while 0-3 may be the ultimate target, it is the 0-18 who are the agents through which we reach that target. Social and emotional capabilities, especially for empathy, are a significant antidote to anti-social behaviour, including violence. By far the most effective way to develop this is by receiving it from parents, especially in the first three years of life. Yet parents who did not receive effective social, emotional and empathic behaviour themselves can find it impossible or very difficult to pass this on to their children. This explains our emphasis on ensuring that 0-18s are 'child ready' rather than narrowly focusing on remedial action alone for the 0-3s.
However, we have focused on a significant and effective intervention point for stemming the 'flow' of dysfunction. It has emphasised the need for young children to be in relationships characterised by attunement and in environments fostering empathy. Achieving this requires reaching into the most private realm of a citizen's life, the emotional world they share with those around them and especially with their very young children. We must face up to this problematic aspect of relevant and effective interventions, if we believe that every child matters and that the welfare of children is paramount.
A MENU FOR HELPING THE EARLY INTERVENERS: 0-18
After reviewing and identifying programmes that fulfil most standard criteria and score highly on delivery, we believe that a small number - we suggest six - must be specified as the foundational elements of an Early Intervention strategy. In other words, these are the minimum requirements for a policy framework for those aged 0-18 aimed at interrupting the intergenerational cycle of disadvantage.
Our suggested foundational programmes are:
1. A prenatal package.
2. Postnatal (Family/Nurse Partnership).
3. Sure Start Children's Centres.
4. Primary school follow-on programmes, focusing on parenting support, language, numeracy and literacy, and the development of children's social competences.
5. Anti-drug and alcohol programmes.
6. Secondary school pre-parenting (i.e. pre-conception) skilling.
1. A Prenatal Package
The inspiration for a prenatal package comes from Sweden but also from our own experience in the UK with the involvement of midwives in prenatal care. Sweden has long been regarded as an exemplar of prenatal practice. This is wholly separate from the help given to the mother once the child is born. Sweden has an extensive 'Mothercare' system in which public health organisations interact with the expectant mother from the moment pregnancy is confirmed. The objective is to provide the fullest support to all expectant mothers with extra emphasis on those who need additional support. This is a critical intervention, not least since many of the hard-to-reach individuals who are, at any other time, most resistant to public authority will respond when pregnant to a friendly and helpful midwife or health visitor who can then open the door to others later who may help, for example, with training or education. To put it in economic terms, it is the best investment opportunity in our human capital: all later investments are more expensive, riskier and give diminishing returns.
2. Postnatal (Family/Nurse Partnership)
The Nurse Family Partnership Home Visiting programme ( NFP) was set up by Professor David Olds at the University of Colorado to replicate programmes for low-income mothers having first babies. The programme is committed to producing enduring improvements in the health and wellbeing of low-income, first-time parents and their children. It bridges the period of pregnancy and up to two-years old. Pregnancy outcomes are ameliorated by helping women practice sound health-related behaviours, prenatal care, improving diet, and reducing the use of cigarettes, alcohol and substance abuse. Children's health and development are improved by helping parents provide responsible and competent care for their children. Families' economic self-sufficiency is improved by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find jobs.
Home visitors are highly educated registered nurses, who receive more than 60 hours of professional training from the NFP Professional Development team. Nurse Home Visitors and families make a 30-month commitment to each other, following which an average of 33 visits are made per family. Visits begin during pregnancy (no later than at 28 weeks of gestation) and continue through the first two years of the child's life. The programme is targeted to support 'at risk' families and specific training is given in supporting parental behaviour to foster emotional attunement and confident, non-violent parenting. The visits last, on average, 75-90 minutes per family and there is a case load of about 25 families per nurse.
By contrast, typical UK health visitors are rarely able to afford more than 20-30 minutes per visit because their case loads are as high as 240 families.
The Nurse Family Partnership is the most rigorously tested programme of its kind. Olds conducted randomised controlled trials in Elmira, New York (1977); Memphis (1987) and Denver (1994). Research demonstrated that NFP mothers are less likely to abuse or neglect their children, have subsequent unintended pregnancies, or misuse alcohol or drugs; and they are more likely to stop needing welfare support and to maintain stable employment.
This US-inspired initiative which helps young parents give their children a healthier start in life is to be introduced in a further five health board areas, including Glasgow, by 2013.
Health Secretary Nicola Sturgeon has asked NHS boards to identify further localities that would likely benefit from the Family Nurse Partnership ( FNP) programme, which provides support for first-time mums under the age of 20. Under the initiative - which is already supporting 440 clients in NHS Lothian and NHS Tayside - family nurses visit expectant mums every one or two weeks during pregnancy and throughout the first two years of their baby's life, offering guidance on child development, preventative health measures, parenting skills, breastfeeding, better diet information and support for mothers looking to continue in education and employment.
Ms Sturgeon said:
Intervening at the earliest possible opportunity to support those in our society who are most in need is the key to improving Scotland's health. That's why the Family Nurse Partnership is an exciting opportunity for health boards in Scotland.
I have seen for myself how the FNP is making a valuable difference to the lives of families. The programme is helping to give children healthier and happier futures, working with young families to improve prenatal health and reduce child neglect.
We want to see the kind of support that the FNP provides expanded in Scotland ... put the resources in place to support implementation of the FNP in five new boards, including Scotland's largest city Glasgow, between now and the end of 2013.
3. Sure Start and Children's Centres
The pre-school years are the next stage of the intergenerational cycle. Sure Start Children's Centres are a one-stop shop for families and children under five years of age. They offer easy access to a range of services including early years learning, childcare, family health services, and advice and support for parents. They help to promote parents' ability to play with their children and develop their language and readiness to learn. This helps address the issues referred to in Iain's [ Iain Duncan Smith] introduction on 'children who are not stimulated and sit in front of the TV interminably'. A recent independent evaluation report found that Sure Start was having a positive impact on the lives of children and families. 2,906 Children's Centres had opened in England as of the end of March 2008. By 2010 there will be 3,500 Children's Centres, one for every community.
These provisions sit alongside the entitlement to a free nursery place for every three- and four-year-old from which children are today benefiting.
This is one obvious area where we need to achieve and embed an all-party consensus on Early Intervention and it is important that all parties commit to maintaining spending on Sure Start at its current level in real terms while subjecting such spending to rigorous review to ensure value for money. [ Note: in Scotland Sure Start has been replaced by the Early Years Framework]
4. A Primary School Package
A statutory framework about the early years from birth to five (Early Years Foundation Stage) is now in force, but because the UK uses an age-based, rather than a grade-based system, many children start off failing from the first day at school.
This situation has to be addressed by an earlier intervention in UK primary schools for those children who need it. Other countries recognise this problem: for example in the USA, 14 per cent of children were a year older than their class mates on starting school. In areas of chronic school unreadiness this concept should now be seriously considered and piloted in the UK. It is commonplace in Switzerland, Hungary, Germany, USA, Australia and Sweden. In Switzerland, an additional year may be spent in kindergarten, or in a 'double' first year primary class, with a smaller class size. One of the Swiss kindergarten's prime functions is precisely this early diagnosis of incapability and a decision on its optimum resolution.
In the UK local education authorities should be allowed to choose to operate such a system so those areas with lower than average school attainment and poor social/emotional capabilities resulting from inadequate preparation in the early years of life can put this right at the very beginning of eleven, soon to be thirteen, years of education, rather than seeking ever more desperate and expensive remedies as school years proceed. School-entry tests of a child's speech abilities, perception, skills, ability to understand numbers, quantities, motor skills, attitude to work, concentration, memory and social conduct are normally carried out in Germany, for example, by a school doctor.
To imagine that a central diktat pushing children into school when they are not ready is in any way of helping the child exemplifies a 'one size fits all' attitude, which fails to recognise the depth of some children's incapability. This must be put right at the easiest time in a child's life to do so, ideally before school starts.
If every child really does matter, then every three or four year old child should have a professional assessment to ensure that they are 'school ready'. If they are not, then help should be given at that point, including waiting a year to start school, in order to save years of remedialism at school.
As with all other interventions it is part of the package and not a one-off remedy. There is considerable evidence, to show that the benefits of early support provided in the 0-5 age range can fade if they are not consolidated in the primary school years. Getting the basics of language, literacy and numeracy right in these years is essential, as is ongoing support for parents and educational measures to further develop children's social and emotional competences.
The actions taken by a school to welcome and engage its parents can significantly improve the home learning environment, and it is important to supplement any literacy and numeracy strategies with parental involvement. We know that parents typically feel a stronger sense of connection with primary schools that they do with their child's secondary school. If we want parents to get involved in their child's education, it is important to start early. However, it can be incredibly difficult to engage hard to reach families in areas of high social deprivation. That is why the full circle of interventions is a key factor in breaking the cycle of disadvantage and underachievement.
5. Anti-Drug and Alcohol Programme
Even if primary school and any Early Interventions have been successful, the key care and maintenance issue which requires serious intervention concerns drugs and alcohol. There are a great number of schemes around to rehabilitate substance abusers and the overwhelming majority of funding goes into rehabilitation rather than preventative education. Once again, the big public bureaucracies have enormous budgets to intervene late in the 'stock' of problems and little or nothing to choke off the 'flow'. We need a much wider and deeper educational effort to stop the supply of young people into drug and alcohol abuse in the first place. There are dozens of education schemes and the Government should now agree one model scheme, which should be adapted for use everywhere.
6. Secondary School Pre-Parenting Skills
Just as being 'school-ready' is a milestone for a pre-schooler, so being 'child-ready' is vital for the teenage years, especially in areas of disadvantage where parents may not pass such knowledge on. The SEAL [Social and Emotional Aspects of Learning] programme now developing in secondary schools is also intended to make a significant contribution to pre-parenting skills, in this case for teenagers. In order to become the good parents of the future, young people need to develop a set of skills that include how to make and sustain relationships, tolerate frustration, communicate effectively, manage conflict, and demonstrate empathy. These skills and qualities are as important as knowing about the technical aspects of reproduction, contraception and caring for infants that have traditionally formed the officially transmitted body of knowledge in this area.
Young people also need to develop an understanding of what it is like to build and sustain a relationship, to have a family and look after a small child, of how babies and children grow and develop, and how parents can best promote this development. This learning is particularly critical, as for those who may not have been able to internalise role models of effective parenting as a result of their own upbringing.
"There are no quick fixes, no "one size fits all"; we need an integrated approach that is shared by people across the political divide."
Iain Duncan Smith
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