Transcript Title slide - Coventry SCB

Safeguarding in the 21st Century:
Where to now?
Jane Barlow
Professor of Public Health
in the Early Years
Jane Scott
Research Fellow
Publications
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Barlow J, Scott J (2010). Safeguarding in the
21st Century: Where to Now? Dartington:
Research in Practice.
www.rip.org.uk
Barlow J, Schrader-McMillan A (2010).
Safeguarding Children from Emotional Abuse:
What Works? London: Jessica Kingsley.
Structure of paper
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Conceptual foundations for 21st century
model of safeguarding
Key aspects of the structural model
- Multidimensional evidence-based practice
- Relational theory
- Relationship-based practice
- Integrated approach
Conceptual Model
ORGANISATIONAL LEVEL
Service-based
Outcomes-based
Child protection focus
Child and family welfare approach
Tradition-based
Multidimensionally evidence-based
Multi-disciplinary
Transdisciplinary
Systems
Complexity
Social constructionist
Critical realist
PRACTITIONER LEVEL
Systemic
Relational
Solution-focused
Relationship-based
Expert
Partnership
Rule-Based/procedural
Reflective
Child-centred
Family-centred
Child or parent-focused
Dyadic
Deficit-based
Resilience/strengths-based
USER LEVEL
Isolationist
Transactional-ecological
Cognitive development
Social and emotional development
Non-participatory
Participatory
OUTCOMES FOCUS
Multi-Dimensional Evidence-Based Practice
Complexity
Child Welfare/Integrated Approach
•Standardised Tools
•Clinical Judgement
•What works
•Client preferences
Relational Theory
Ecological + Infant mental
health + Developmental
psychology + neuroscience +
psychoanalytic
Critical
realism
Relationship-based
Practice;
Reflective Practitioners;
Partnership;
Participatory; Family based;
Resilience/Strengths-based
Transdisciplinary
Parent-child relationship
and
Children’s Social and Emotional Development
Multi-dimensional
evidence-based practice
Multi-dimensional
evidence-based practice
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‘Best practices’ are defined as ‘those treatments or
interventions that have been shown to be effective
through rigorous scientific research’ (Petr 2009)
‘What works’ should not be defined narrowly as
‘quantitative evidence’ but should include data from a
range of sources including ‘qualitative data’
The need to move away from an assessment of ‘what
works’ using randomised controlled trials, to assessing
what ‘works, for whom, in which circumstances’
MEBP
1. identify the MEBP question
2-4. identify multiples sources of knowledge and
evidence pertaining to the MEBP question using the
following sources – consumers, professionals, and
research (both quantitative and qualitative)
5. summarise findings of best practices across all
three perspectives
6-7. critique current best practice in terms of their
‘potency’ and the application of ‘value criteria’
(Petr 2009)
Integrated approach to
assessment
Current Risk Assessment
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‘Assessments were only slightly better than
guessing’ Dorsey (2008)
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‘A complex picture of risk assessment in which
there are few patterns of risk factors (other than
prior reporting) that consistently are associated
with caseworker classification of risk and
subsequent report’.
Complexity Theory
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Complexity theory questions the appropriateness of such
systems and offers an alternative framework
‘Weather arises due to an interaction of factors and this
complex combination creates a complex adaptive system
able to undergo self-organisation. This means that while we
can know that a particular set of factors is likely to lead to a
hurricane, it is nevertheless not possible to predict when or
whether such hurricanes will occur’ (Stevens and Cox 2007)
Families are also complex adaptive systems - practitioners
can identify factors that contribute to the occurrence of
abuse, but will have great difficulty predicting whether or
when harm will occur
Complex Adaptive
Systems
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Linear approach to risk gives rise to a ‘blame
culture’
Criticism of this sort pushes the system toward
instability and then towards greater complexity
Implementation of more managerial and
proceduralist methods of working
Move away from reflective practice
Integrated, ‘Indicative’
Risk Assessment
Third generation approach involving:
 ‘empirically validated, structured decisionmaking’ (Douglas et al. 1999 cited in
White and Walsh 2006) or
 ‘structured clinical judgment’
 Clinical expertise + EB tools + client
preferences/choice + cultural factors etc
The Relational
4 Key points
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The first three years of life are VERY important because:
- Babies are born ready to interact and start mapping
early interactions;
- Babies are born with immature brains that are shaped
by their early interaction with primary caregivers;
- Early interactions with primary caregivers are central to
a) capacity for affect regulation; b) developing sense of
self
Current child protection procedures do not meet
children’s developmental needs
The Social Baby
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In first 15 hours baby’s distinguish the voice, smell and
face of their mother
By 2-3 weeks they remember specific details of a mobile
for up to 24 hours
They connect what they do with what happens
immediately after
Babies have a sophisticated understanding of facial
expressions – distinguish between surprise, fear,
sadness, anger and delight
By 10- months babies seek emotional information from
others to help them interpret things around them
By 10-months baby’s brain has developed according to
the type of emotions to which they have been exposed
(Beebe and Lachman, 2004)
Softwiring of the Infant’s Brain
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Babies are born with very immature brains (one-fifth of
full size)
By 3 years of age they have 80% of their full brain
capacity
Rapid proliferation and overproduction of synapses
followed by loss (pruning)
‘Use it or lose it’ – lost if not functionally confirmed
The role of early
relationships…
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Early relationship patterns are developed in interaction
with primary caregivers
These are internalised in the form of ‘internal working
models’ (IWM)
IWM are stored as procedural memories (i.e.
unconscious)
These IWMs strongly influence later relationship
patterns (Schore 2004)
‘Affect Synchrony’ –
the core building block
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By two months the mothers face is the primary source of
visuo-affective communication
Face-to-face interactions emerge which are high arousing,
affect-laden and expose infants to high levels of cognitive
and social information and stimulation
To regulate this infant and mothers regulate the intensity of
these interactions – ‘affect synchrony’ and repairs to
ruptures
Absolutely fundamental to healthy emotional development
– prolonged negative states are ‘toxic’ to infants
Adults that are incapable of ‘attunement’ i.e. intrusive;
depressed, cannot regulate appropriately (Schore, 2004)
Nurturance/ Emotional and
Behavioural Regulation
Important aspects of the
parent-infant
relationship:
 Sensitivity/attunement
 Mentalisation
 Marked mirroring
Videoclip One
For example…
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Looks and smiles help the brain to grow
Baby looks at mother; sees dilated pupils
(evidence that sympathetic nervous system
aroused and happy); own nervous system is
aroused - heart rate increases
Lead to a biochemical response - pleasure
neuropeptides (betaendorphin and dopamine)
released into brain and helps neurons grow
Families doting looks help brain to grow
Negative looks trigger a different biochemical
response (cortisol) stops these hormones and
related growth
(Gerhardt, 2004)
Affect synchrony in the face
of parental problems
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Infant’s emotional states can trigger profound
discomfort in the parent (e.g. where there is
unresolved loss/trauma, mental health problems,
drug/alcohol abuse, or where there is domestic violence
etc)
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Interaction becomes characterized by:
- withdrawal, distancing or neglect (i.e. omission)
- intrusion in the form of blaming, shaming, punishing
and attacking (i.e. commission)
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Babies of depressed mothers:
- nearly half show reduced brain activity
- much lower levels of left frontal brain activity
(joy; interest; anger)
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Early experiences of persistent neglect and
trauma:
- overdevelopment of neurophysiology of
brainstem and midbrain (anxiety; impulsivity;
poor affect regulation, hyperactivity)
- deficits in cortical functions (problem-solving)
and limbic function (empathy)
Videoclip two
Attachment: The dyadic
regulation of emotion
Attachment
What is it:?
- Affective bond between infant and caregiver
(Bowlby, 1969)
What is its function?:
- Dyadic regulation of infant emotion and arousal
(Sroufe, 1996)
Antecedants of attachment:
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Sensitive, emotionally responsive care during first
year – secure attachment
Insensitive, inconsistent or unresponsive care –
insecure attachment
The Importance of
Attachment
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Secure base – to explore the world
Prototype for later relations – internal
working model is a ‘representational
model’ of self and self with other
Provide child with expectations in relation
to self and others
Child abuse and attachment
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Up to 80% of children who are abused have a ‘disorganised
attachment’
In maltreating families parent-child interactions
characterised by hostility; low levels of reciprocity,
engagement and synchrony, unpredictability (ignoring plus
intrusive hostility)
Disorganised attachment predicts very poor outcomes
including a range of social and cognitive difficulties, and
psychopathology
Safeguarding practitioners MUST have this developmental
model at the core of their practice
Significant Harm of Infants Study –
Key findings
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2/3s of the babies were identified as being at risk of
significant harm before they were born
Only 1/3 were classified as ‘safe from harm’ at 3 years of
age
By the time they were three, almost half the babies were
displaying quite serious behavioural problems or
developmental delay;
By the time the children were aged three many of the
placements were approaching breakdown
(Ward et al, forthcoming)
cont…Assessment
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75% identified during antenatal period - almost no
referrals from drug/alcohol or adult mental health services
Parenting assessments frequently repeated within very
short timeframes, during which parents have little
opportunity to overcome previously identified problems.
Over half of expert assessments proved to be overoptimistic in that children who, on the advice of experts,
remained at home, later had to be removed following
further maltreatment
“Start again‟ syndrome common – often underpinned by
ethical concerns about not allowing their judgment to be
prejudiced by parents‟ previous abusive behaviour
cont…Intervention
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All parents who successfully overcame risk factors did so
before the baby was six months old
Social work interventions are also often of relatively
short duration – half the child protection plans for the
babies were for 32 weeks or less, and almost all for less
than a year
Families successfully parenting children were given little
ongoing support and cases closed prematurely
Kinship care sometimes selected with little regard for the
quality of care provided, the carers‟ previous history of
poor parenting, their personal problems or their
knowledge of the
Relationship-based
Practice
Effective therapeutic
working?
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Many abusive parents have experienced early
care-giving that was characterised by a lack of
attunement and an absence of repair to ruptures
Such parents experience intense feelings of
anger, fear and shame when disruption occurs
relationships in adult life, and why they are also
highly vulnerable to feeling misunderstood and
not listened to (Walker 2008).
What Works?
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Recent reviews have pointed to the importance of longterm ‘relationship-based practice’ with complex and
resistant families;
Some evidence about the effectiveness of manualised
programmes;
Effective intervention during the first 3-4 years of life
involves dyadic interventions including parentinginfant/child psychotherapy, and should be provided by
specialist practitioners
The team around the child model appears to offer
benefits in terms of both families and professionals
Relationship-based
practice cont.
i) a supportive therapeutic stance based on principles of
acceptance, empathy, genuineness and trust, all of
which are essential to fostering a strong alliance
between client and worker and to meeting some of the
parent’s unmet developmental needs
ii) a focus on interpersonal and relational issues with the
aim of giving parents an opportunity to reflect on the
parenting they are providing in the light of their own
experiences of being parented and to improve their
parenting skills
Reflective practice
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‘holistically reflective’ practitioners adopted more
‘relationship-based’ and ‘risk-taking’ approaches
to their practice
‘technically reflective’ practitioners more inclined
to focus on ‘what they did and how, with a view
to doing it better next time’.
latter group less inclined to ask ‘why’ questions
and more inclined to ‘exhibit more restrictive and
prescriptive responses to practice situations, and
find it more difficult to establish responsive,
relationship-based approaches’ (Ruch 2005)
Its wider relevance…
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Key to the functioning of child welfare
organisations (Mandin 2007)
e.g. effective communication between
professionals - rupture followed by a lack
of repair characterised much of the miscommunication referred to in the Climbié
Inquiry
Summary
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Need for new conceptual model to underpin 21st
century model of safeguarding
Need for new ways of working with regard to
assessment and intervention
- Relationship-based and reflective practice
- Evidence-based attachment and dyadic
interventions
Need for better organisational structures to
support such practice