The importance of emotional development in the early years

1. The importance of emotional development in the early years George Hosking, CEO, WAVE Trust Mental Health Starts in the Womb The Pavilion, Reading, 9 November 2017

2. What are the causes of violence? Key finding: Two components to violence • The ‘propensity to be violent’ (personal factors) • The triggers of violence (social factors) • teenage alcohol consumption • media viewing, modelling violent behaviour • longer period between puberty and beginning work • many others • But generally social factors lead to violence ONLY when the propensity is present

3. Causes of violence: Deepest roots lie in the family International studies trace roots of violence to: • Parental competence and family control methods (e.g. McCord) • poor parental child rearing (e.g. Farrington) • unskilled parenting (e.g. Capaldi and Clark; Kazdin, Loeber, Dishion; Rutter & Giller) • harsh parental discipline (e.g. Patterson) • power-assertive punishment (e.g. Cohen)

4. Pathways to violence often laid down by age 3 Dunedin study of all children born in 1972 At age 3, an ‘at risk’ group identified by nurses • At age 21, ‘at risk’ males, compared with others: • 2.5 times as many with 2+ criminal convictions • 55% of their offences violent (18% others) • 47% abused their partners (9.5%)

5. Pathways to violence often laid down by age 3 Dunedin study • ‘At risk’ group offences much more serious • (e.g. robbery, rape, homicide) • Fewer females conduct disordered, but for those who were: • 30% of ‘at risk’ group had teenage births (vs. 0%) • 43% were in violent, abusive relationships “Immature mothers, with no strong parenting skills and violent partners have already borne the next generation of ‘at risk’ children”

6. Pathways to violence often laid down by age 3

7. Understanding the infant brain • Works via neurons (brain cells) & synapses (connections) • At birth: 10 trillion synapses - 200 trillion by age 3 • Too many to be specified by genes: formed by experience • Sculpted: Repeated use hard-wired; superfluous eliminated • Implies very rapid learning via early life experience

8. Understanding the infant brain • Critical windows of time during which brain hones particular skills or functions • Synapse formation in visual cortex • peaks at 3 months, finished by age 2 • Auditory map formed by 12 months • after this Japanese infant struggles to distinguish “L” and “R” • Emotional brain largely created in the first 18 months

9. Understanding the infant brain Brains of abused children significantly smaller • many areas dark on CAT scans (“black hole”) • limbic system (emotions), hippocampus (memory) smaller

10. Shaped by the carer’s interaction style Alan Schore - 10-year immersion in thousands of scientific papers in neurobiology, psychology, infant development “The child’s first relationship, the one with the mother, acts as a template … permanently moulds the individual’s capacity to enter into all later emotional relationships”

11. Shaped by the carer’s interaction style Infant brain needs time to mature, so … • Baby regulates inner world by aligning emotional state of mind with caregiver • Empathic attunement acts like emotional umbilical chord • Methods: Eye gaze, facial expressions, nonverbal signals

14. Keys: Attunementand Empathy • Attunement: parent and child emotionally in tune with each other • Not mimicking: rather a correspondence of behaviour to their feeling state • Responding to emotional needs leaving it feeling understood, cared for, valued • Empathy begins with sense of “oneness” with the other – coming from attunement

15. Keys: Attunementand Empathy Lack of attunement means empathy does not develop Low maternal responsiveness at 10-12 months predicted: • at 1.5 years: aggression, non-compliance, temper tantrums • at 2 years : lower compliance, attention getting, hitting • at 3 years : problems with other children • at 3.5 years: higher coercive behaviour • at 6 years : fighting, stealing

16. Keys: Attunementand Empathy • Empathy the single greatest inhibitor of propensity to violence • Established early by observation of parental reaction to suffering • Babies show empathy by one year old. Not all develop this • Abused toddlers react negatively or aggressively to signs of distress • Absence of empathy characteristic of violent criminals – worst psychopaths no emotion at all

17. London School of Economics(Carneiro et al, 2007) • Analysed consequences and determinants of cognitive and non-cognitive (social) skills at age 11 • Found non-cognitive skills important for a host of outcomes: • truancy before age 16 • smoking, age 16 • whether or not individual stays on at school beyond age16 • exclusion from school, teenage pregnancy • involvement with crime (ages 16 ,42) • work experience ages 23-42 • employment status, level of wages age 42 • health at age 42 • Self-discipline accounts for twice as much variance as IQ in explaining final grades (Duckworth et al, 2005, 2007)

18. Lifelong skills created very early(Research of Nobel Prize Winning Economist, James Heckman) • Skills needed for success in life multiple in nature • Soft skills very important • conscientiousness - perseverance • sociability - motivation • attention - self-regulation • self-esteem - ability to defer gratification • sociability (the ability to work with and cooperate with others) • These crucial skills mostly created in the family in early years • Largely neglected in devising policies to reduce inequality

19. Lifelong skills created very early Oxbridge study of children aged 1 to 12, Andhra Pradesh • Investigated determinants of children's cognitive and non-cognitive skills • Parental investment positive effect on skill levels for all ages • Child health at age 1 influenced by parental care from pregnancy to age 1 • Child health at age 1 influenced cognitive abilities at age 5

20. Lifelong skills created very early Mannheim Study of Children at Risk (MARS) • Individual differences in basic abilities amplify between 3 months and 11 years • Adverse consequences of initial risks cumulate and persist until adolescence • Basic abilities at preschool age significantly predict social competencies and school grades at age 8

22. ‘1. Conception to age 2 a crucial phase of human development. Focused attention can reap great dividends for society 2. How we treat 0-2 year-olds shapes their lives – and ultimately our society 3. Loving, secure and reliable relationships with parents + quality of home learning environment foster a child’s: emotional wellbeing (infant mental health); capacity to form and maintain positive relationships with others; brain development; language development; ability to learn.’ Conception to age 2 - The age of opportunity

23. Conception to 2: Ten recommendations • Increase breastfeeding and good antenatal nutrition • Promote language development • Reduce domestic violence; and stress in pregnancy • Achieve a major reduction in abuse and neglect • Set up an effective and comprehensive perinatal mental health service • Assess and identify where help is needed • Focus on improving attunement between parents and baby • Promote secure attachment • Ensure good, health-led multi-agency work • Ensure early years workforce has requisite skills

24. Child Maltreatment Cost to the UK Short to long term effects Causes Child maltreatment…£15bn pa Mental illness / depression Maternal mental and physical health Drug and alcohol use in families (1m) Poor physical health – heart / lung disease 1 in 5 Physical neglect (+1m children) Alcoholism / drug addiction Children severely maltreated Parental experience of maltreatment Poor work prospects Adverse early years… £200bn pa Witnessing Domestic Violence (.75m) Violence / aggression

25. Adverse Childhood Experience (ACE) Studies • Centerfor Disease Control and Prevention & Kaiser Permanente • One of largest investigations ever on links between childhood maltreatment and later-life health and well-being - 17,000 members at comprehensive physical examinations provided detailed information on:

26. ACE Studies

27. Californian ACE Studies Health risks which increase with 4 ACEs (17% of popn): (x 2) - liver disease, teenage pregnancy (x 3) - depression, COPD/chronic obstructive pulmonary disease, adult smoking, serious job problems, more than 50 sexual partners, sexually transmitted diseases (STDs) (x 4) - absenteeism from work, intercourse by 15 (x 6) - alcoholism and alcohol abuse (x11) - intravenous drug use (x14) - suicide attempts

28. Impact of ACEs: 2) Other ACEs • .

29. Impact of primary prevention over the life course Cost of intervention Welfare Reduced need for costly reactive interventions Justice System Primary Prevention – tackling the root causes at lower cost Acute healthcare Children in Care CAMHS Midwifery, Health visiting, GPs Children's Centres, Family Support 2 1 Support Support Drug / alcohol use Lack of affection Disruptive behaviour NEET Poor maternal diet Low school readiness Poor relation-ships Crime Risk factors Maternal stress / anxiety Parenting Domestic violence Mental illness Abusive partners Poor nutrition Special Education Unemp-loyment Reduced risk factors

30. The Pioneer Community ACE prevention project Pioneer Communities is a practical ACE prevention and reduction project, for the first 1001 days Tests a comprehensive primary preventive approach to ACEs based on scientific evidence and global best practice Prevents ACEs in children, addresses ACE-generation by parents: parental alcohol and drug abuse, domestic violence, mental health issues, potential inter-generational transmission of ACE damage

31. Pioneer Community Approach 5 Years

32. Pioneer Community Approach • Population level, preventive approach • Focussing on conception to age 2 • Population 50,000 • 3 components

33. Support Component

34. Assessment of Risk • Universal risk assessment at ante-natal stage • Key risks: Parents maltreated in childhood, domestic violence, drug or alcohol abuse, parental mental health issues • Carried out by trained midwives or health visitors (GP support) • Parental experience of child maltreatment: measure developed by Susan Pawlby at Kings College London • Other screening tools already available but need for special training and adequate resource

35. Assessment of Risk • Universal assessment at 3 – 6 months • Quality of interaction between mother and baby • Using Video Interaction Guidance/Parent Infant Interaction Observation Scale • Also possibility of universal PCPS model used very successfully in Dublin, and probably to be used in Derry/Londonderry • In Dublin: high participation rate by mothers, striking reductions in disorganised attachment

36. Targeted Support • Range of programmes In WAVE’s original blueprint we identified a number of evidence- and science-based programmes which would support parents and families where there is: • a parent who suffered ACEs in childhood • domestic violence risk • substance abuse • mental health issues and poor attunement • need for improved parenting capability These included Family Foundations, IRIS, For Baby’s Sake, Brazelton, Steps to Safety, Solihull Approach, Mellow Bumps, Video Interaction Guidance, Parent-Infant Psychotherapy, Specialist Perinatal Mental Health Support, Circle of Security, Watch, Wait and Wonder • These will not be imposed on Pioneer Communities • Ultimate choice lies with Pioneer Community Partnership • Does need to fit within research protocol – i.e. preventative

37. Community Engagement - 1 • Community mobilisation a crucial part of the blueprint • Based on a blend of two effective community mobilisation models of which we have close knowledge: • ABCD (Asset Based Community Development), and • ACE-aware, trauma informed (‘Resilient’) communities • Goal: community engagement and ownership of commitment to creating healthy, successful lives for children, happy relationships in families • Community mobilised via an inspiring vision which they have helped to create

38. Community Engagement - 2 • Asset Based Community Development – proven results with Nurture Development • Training ‘Community Builders’, who then work through volunteer Community Connectors • Unlock the potential of the community to mobilise for good • Local assets (people, organisations) primary building blocks of sustainable community development • Communities active co-producers in design, planning and implementation of Pioneer Community approach • Work done with communities not to them • Building resilience a potential focus

39. Community Engagement - 3 • ACE (i.e. Adverse Childhood Experiences)-aware, Trauma-responsive communities – proven results in Washington, Wisconsin in USA • WAVE working with Scottish, Welsh and N Ireland governments on implementing this model in the UK ‘Building resilient communities’ • Creates positive shift in delivery of Health, Social Care, Education, Criminal Justice, Police • Potential for significant savings in service costs (this still being tested but indications very positive – e.g. in South Wales)

40. Research & Evaluation • Measures likely to include • Parental Sensitivity • Disconnected Parenting • Child Aggression • Key measure Disorganised Attachment at 15 – 18 months • Measuring this is an integral part of PCPS • Use of existing local data • Data from child health profiles, other local data where relevant

41. Disorganised Attachment Mental Illness 15% of children Children into Care Disorganised Attachment Poor Relationships Disruptive Behaviour in Pre-School Aggression Violence

42. Pioneer Community Criteria • Commitment to taking a whole system, preventive approach to ACEs for children aged 0 – 2 over 5 years • Either in selected wards or whole area basis (minimum 800 live births) • Following principle of primary prevention with evidence or science-based support programmes • With sign up from Local Authority, Health Board, Councillors • Willingness to participate in research and evaluation • Sharing and reporting relevant measurement data

43. Potential Outcomes • Major reduction in child maltreatment and related ACEs for 0 – 2 years olds in the Pioneer Communities • Thousands of children rescued from severely damaged lives • Widespread community improvement in child outcomes, health, wellbeing, school readiness • Fewer children in care or needing special support • Reduced inequalities These are not ‘one-off’ benefits They break the intergenerational cycle of violence and abuse

44. 70/30 Prevention Campaign It’s possible to reduce child maltreatment in the UK by at least 70% by 2030. We have developed a strategy, based primarily on prevention, to make this a reality, we call it 70/30.

45. 70/30 Prevention Campaign "I do not view 70/30 as either wishful thinking or an unachievable goal. On the contrary, reducing child maltreatment by 70% in the next fifteen years is the minimum acceptable outcome in responding to this unacceptable (and profoundly costly) harm to our youngest children." Sir Harry Burns (Former Chief Medical Officer, Scotland, 2015) “WAVE's visionary 70/30 strategy has my full backing. It tackles the roots of the problems in our society where so many address the symptoms.” Iain Duncan Smith(Former Secretary of State for Work and Pensions, 2011)

46. 70/30 Prevention Campaign "I have long been a supporter of the argument for putting prevention first. WAVE Trust have been leaders in promoting prevention for the past decade. Their 70/30 strategy to prevent child abuse and neglect before they happen has my full backing, and will deliver significant social, health and economic benefits to the country." Andy Burnham, (former Secretary of State for Health, now Mayor of Greater Manchester, 2017)

49. Become an Ambassador forthe Grass Roots 70/30 Campaign • Commitment • 1 hour per month listening to a conference call • 1 evening per month co-ordinating a meeting of people in your area who care • 1 letter or meeting with an MP or councillor every month • Guidance and training provided by WAVE • Become part of a movement to transform childhood in the UK • Contact Sam Lawes - slawes@wavetrust.org