Safeguarding in the 21 st Century: Where to now? Jane Barlow Professor of Public Health

1. Safeguarding in the 21st Century: Where to now? Jane Barlow Professor of Public Health in the Early Years Jane Scott Research Fellow

2. Publications • 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.

3. Structure of paper • 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

4. Conceptual Model

6. OUTCOMES FOCUS Relational Theory Ecological + Infant mental health + Developmental psychology + neuroscience + psychoanalytic Relationship-based Practice; Reflective Practitioners; Partnership; Participatory; Family based; Resilience/Strengths-based Transdisciplinary Multi-Dimensional Evidence-Based Practice • Child Welfare/Integrated Approach • Standardised Tools • Clinical Judgement • What works • Client preferences Critical realism Parent-child relationship and Children’s Social and Emotional Development Complexity

7. Multi-dimensional evidence-based practice

8. Multi-dimensional evidence-based practice • ‘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’

9. 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)

10. Integrated approach to assessment

11. Current Risk Assessment • ‘Assessments were only slightly better than guessing’ Dorsey (2008) • ‘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’.

12. Complexity Theory • 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

13. Complex Adaptive Systems • 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

14. Integrated, ‘Indicative’ Risk Assessment Third generation approach involving: • ‘empirically validated, structured decision-making’ (Douglas et al. 1999 cited in White and Walsh 2006) or • ‘structured clinical judgment’ • Clinical expertise + EB tools + client preferences/choice + cultural factors etc

16. The Relational

17. 4 Key points • 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

18. The Social Baby • 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)

19. Softwiring of the Infant’s Brain • 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

22. The role of early relationships… • 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 proceduralmemories (i.e. unconscious) • These IWMs strongly influence later relationship patterns (Schore 2004)

23. 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) ‘Affect Synchrony’ – the core building block

24. Nurturance/ Emotional and Behavioural Regulation Important aspects of the parent-infant relationship: • Sensitivity/attunement • Mentalisation • Marked mirroring

25. Videoclip One

26. For example… • Looks and smileshelp 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 lookstrigger a different biochemical response (cortisol)stops these hormones and related growth (Gerhardt, 2004)

27. Affect synchrony in the face of parental problems • 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) • Interaction becomes characterized by: - withdrawal, distancing or neglect (i.e. omission) - intrusion in the form of blaming, shaming, punishing and attacking (i.e. commission)

28. Babies of depressed mothers: - nearly half show reduced brain activity - much lower levels of left frontal brain activity (joy; interest; anger) • 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)

31. Videoclip two

32. Attachment: The dyadic regulation of emotion

33. 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: • Sensitive, emotionally responsive care during first year – secure attachment • Insensitive, inconsistent or unresponsive care – insecure attachment

34. The Importance of Attachment 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

35. Child abuse and attachment 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

36. Significant Harm of Infants Study – Key findings • 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)

37. cont…Assessment • 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 over-optimistic 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

38. cont…Intervention • 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

39. Relationship-based Practice

40. Effective therapeutic working? • 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).

41. What Works? • Recent reviews have pointed to the importance of long-term‘relationship-based practice’ with complex and resistant families; • Some evidence about the effectiveness of manualisedprogrammes; • Effective intervention during the first 3-4 years of life involves dyadic interventions including parenting-infant/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

42. 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

43. Reflective practice • ‘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)

44. Its wider relevance… • 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 mis-communication referred to in the Climbié Inquiry

45. Summary 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