Ensuring safe and nurturing care

Matt Forde argues that the child protection system is failing many children who desperately need help and looks at how the national parenting strategy can provide a radical rethink.

Declan Hainey, Brandon Muir, Caleb Ness. Looking at the appalling circumstances of each of these tiny children's short lives we want assurances that such a tragedy will never happen again. Consider that nearly one in five of all children across the UK aged 11-17 has been abused or maltreated at some point in their life (Radford et al. 2011) and a harsh truth becomes clear: despite the hard work and dedication of those working within it, our child protection system is failing many children who desperately need help.

Parenting is fundamentally about providing the safe, nurturing care a child needs to grow to their full potential. Surely then, the main ambition of the proposed national parenting strategy should be ensuring such care for every child in Scotland.

Addressing hidden damage

Death or physical injury from child abuse has the greatest power to shock. The hidden damage child abuse causes attracts less attention despite its long-lasting effects. Abused or neglected children are at increased risk of mental health problems such as conduct disorder (Meltzer et al. 2003). Delinquent adolescents have a nine-fold increase in all types of mortality (Coffey et al. 2003). By the time they reach adulthood, aggssive children commit more than 50% of violent offences. Early childhood adversity and associated disorders impose a massive financial burden on individuals, families and society (Scott et al. 2001).

By placing infant mental health at its heart, the national parenting strategy can address this.

Secure attachment to an adult caregiver, especially in the first year of life is one of the biggest protective factors against abuse (Shonkoff and Philips 2002). Abused children who receive safe nurturing care quickly enough, can make remarkable recoveries (Dozier et al. 2008). By giving parents the right support to provide the safe nurturing care their children need, the national parenting strategy can have a significant impact on levels of child abuse and mental ill-health.

The importance of early intervention, preventative spend and focusing on what prevents professionals from being able to properly help and protect children is already part of Scottish Government thinking. The challenge for the parenting strategy is translating that policy into practice. The government has clearly stated that the strategy should encompass all parents. But, in our constrained economic circumstances, investment must be directed to getting the best results and the biggest impact. Universalist approaches must be supplemented by intervention for children most at risk. Without some targeting, action will come too late for too many children to ever recover from the damage of abuse.

Drink, drugs, mental health problems and domestic abuse are often the key indicators of potential parenting problems. That's not to say all parents with these problems are a risk to their children but there is significant evidence that children in these families are at a greater risk of abuse or neglect. The NSPCC estimates that 4,700 babies in Scotland live in families where their father or mother's partner reports hazardous levels of drinking; over 12,300 live in a family where one or either parent/caretaker is at a high risk of depression or serious anxiety; and over 1,300 babies' mothers report that their current partner has used force against them*. There are no clear figures for the number of babies being cared for by drug abusers in Scotland. Declan Hainey, Brandon Muir and Caleb Ness all lived with parents who were struggling with one or more of these issues. Yet, according to the 2008 Early Years Taskforce, infancy is rarely a primary focus for parenting support (The Scottish Government 2008).

Models of support

Some of the best child protection models from around the world, such as the New Orleans Intervention Model show that, with the right support at the right time, families in high-risk circumstances can often give their children the nurturing care they need.

In New Orleans, the Tulane Infant Team provides assessment and individual programmes of intervention for families of children under four in foster care. The team assesses the relationship between the child and their birth family and provides intensive support to the family for a set time. At the end of the programme, the team's work informs court decisions about whether a child will be safe and nurtured if they return to their parents. The New Orleans Intervention Model prevents the yo-yoing between foster care and home that is so disruptive and damaging to a young child's sense of stability and mental health.

The NSPCC, Glasgow City Council and NHS Greater Glasgow and Clyde are so impressed by the model's results that we are working together to trial a similar model in Glasgow. By investing in work with families when their child first enters care we want to see if we can increase their child's chance of having a happy and successful life while reducing the long-term burden on care and other support services.

The New Orleans model is one of a number of evidence-based early intervention programmes that the NSPCC believes could lead to a substantial reduction in levels of child abuse. Most of these focus on families where the risk of abuse is greatest, but others are targeted at all parents, because in some types of child abuse, for example non- accidental head injuries, there are no recognisable risk factors.

Jane Barlow, professor of public health in the early years, believes it is practitioners in primary and secondary care - midwives, health visitors, community nurses, GPs - who are the critical workers for infants and toddlers at risk (Barlow 2011). Many early intervention models, such as our own Non-Accidental Head Injuries programme (NAHI) which aims to educate all new parents about the risk of shaking their baby, and how to cope with stress and tiredness, rely on the skills of already hard-pressed professionals, such as midwives, to be successful.

The results that the NAHI programme could potentially achieve are significant. The original programme, in Buffalo, USA, led to a 47% drop in non-accidental head injuries in babies (Dias et al. 2005). A holistic policy approach should recognise that, as recommended by the Munro Review in England, professionals should share responsibility for providing early help to children and their families (Munro 2011). As well as thinking about the skills of professionals who regularly come into contact with children, the national parenting strategy should consider the role of adult-facing services working with domestic abuse, mental ill-health and substance abuse. With training and access to social work expertise, these services can be critical in child protection, by supporting their clients not just as individuals, but as parents. This shared approach to child protection should be integral to the strategy, along with recognition of the investment in professionals and training such an approach requires.

This makes economic sense. Reducing child abuse and improving children's mental health will free up money spent on dealing with the damage caused by abuse. One project we are replicating in Scotland is saving £4 for every £1 spent.

For this approach to work however, we need to be upfront about whose responsibility it is to protect, even to parent our children. Children need everybody to look out for them. If professionals do not know that parents are struggling, then however skilled or early interventionist they are, they cannot help. If no one tells social services, the police, or another agency, the situation will continue. So, alongside early intervention, the parenting strategy needs to encourage us all to be there for those around us who struggle with a newborn baby or to pick up the phone to report anything serious.

Putting infant mental health at the heart of the strategy

Putting infant mental health at the heart of the national parenting strategy by supporting early interventions will take time, money and a radical rethink of who is responsible for child protection. The results will be transformational - for children, their families and for Scotland.

*Statistics generated from analysis of the Millennium Cohort Study, Wave 1, and Scottish population figures for 2010.