From the Conwy and Denbighshire Local Safeguarding Children Board (LSCB) Conference, March 2012. www.conwy.gov.uk/lscb Shared with kind permission from Jane Barlow.

1. Safeguarding Children:
getting it right from the start
Jane Barlow
Professor of Public Health
in the Early Years

2. Structure of paper
 Where are we now – practice that needs
improving
 Why the very early years are important –
neurological and attachment research;
 What aspects of parenting are important during
this period?
 What should we be doing differently…?

3. Where are we now…

4. Significant Harm of Infants Study
 Prospective study in 10 LAs;
 Sample of 57 children who were the subject of a
core assessment, section 47 enquiry or became
looked after before their first birthdays;
 43 were followed until they were three
 http://www.lboro.ac.uk/research/ccfr/Publications
/DFE-RB053.pdf
(Ward et al 2010)

5. Identification
High prevalence of factors such as drug and alcohol
misuse, intimate partner violence and mental health
problems – few referrals to children’s social care were
received from any of these sources
About a third of the mothers and an unknown number of
fathers had already been separated from at least one older
child before the birth of the index child
Just under two-thirds (65%) of the infants were identified
before birth and almost all before they were six months old

6. Outcomes
By the time they were three, 28 (65%) children were living
with a birth parent and 15 (35%) were permanently placed
away from home.
Living with Birth Parents - 16/28 (57%) were living with
birth parents who had succeeded in overcoming their
problems and were now classified as low risk cases
At 3 years… twelve children (28%) were living with birth
parents who had shown little positive change; these infants
were now at medium, high or severe risk of suffering
significant harm.

7. Double jeopardy
 By three years of age:
- over half of the children were showing serious
developmental problems (poor speech) and significant
behavioural difficulties (aggression)
- many of the placements were approaching breakdown
 Long-term well-being of 60% of the permanently
separated children had been doubly jeopardised – by
late separation from an abusive birth family followed by
the disruption of a close attachment with an interim
carer when they entered a permanent placement;

8. Waiting for parents to
change…
 Developmental and behavioural difficulties were more
evident amongst children who had experienced some
form of maltreatment, often whilst professionals waited
fruitlessly for parents to change;
 All but one of the parents who made sufficient changes
did so before the baby was six months old.

9. Repeated Assessments
 Specialist parenting assessments made by psychologists,
psychiatrists or independent social workers were a major
cause of delay.
 All recommendations were followed; two thirds advised
that children should remain with birth parents, but in
over half of these cases the children eventually had to
be removed;
 Parenting assessments frequently repeated within very
short timeframes, during which parents have little
opportunity to overcome previously identified problems

10. Intervention
 Social work interventions were 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 child

11. Why are the
early years so
important?

12. Trauma in infancy:
‘Disorganised Attachment’
ensitised nervous system as brain adapts to emotional environment
Stress in child
reminders & experiences of trauma,
life events, etc.
Unbearably painful emotional states
Retreat: Self-destructive Destructive
isolation actions: actions:
dissociation substance abuse aggression
depression eating disorders violence
deliberate self-harm rage
suicidal actions
(Robin Balbernie 2011)

13. Aspects of Early
Development
Emotional/ Intellectual Behavioural
social Development development
development
Infancy Trust/attachment Alertness/curiosity Impulse control
AFFECT REGULATION
Toddlerhood Empathy Communication/ Coping
mastery motivation
Childhood Social Reasoning/problem Goal-directed
Relationships solving behaviour
Adolescence Supportive social Learning Social
network ability/achievement responsibility

14. Key points
 The first three years of life are VERY important
because:
- babies are born with immature brains that are shaped
by their early interaction with primary caregivers;
- early caregiving received influences their ‘attachment’
relationship with their primary caregiver and these
mediates the impact on the CNS

17. Nurturance/ Emotional and
Behavioural Regulation
Important aspects of the
parent-infant
relationship:
 Sensitivity/attunement
 Mirroring
 Reflective Function/Mind
Mindedness

18. Affect synchrony –
the dance
 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
 Regulation of emotional interaction:
The dance: synchrony – rupture - repair
 Absolutely fundamental to healthy emotional
development – prolonged negative states are
‘toxic’ to infants

19. ‘Attuned mutual co-ordination between mother
and infant occurs when the infant’s squeal of
delight is matched by the mother’s excited
clapping and sparkling eyes. The baby then
becomes overstimulated, arches its back and
looks away from the mother. A disruption has
occurred and there is a mis-coordination: the
mother, still excited, is leaning forward, while the
baby, now serious, pulls away. However, the
mother then picks up the cue and begins the
repair: she stops laughing and, with a little sigh,
quietens down. The baby comes back and
makes eye contact again. Mother and baby
gently smile. They are back in sync again, in
attunement with each other (Fosha, 2003 in
Walker 2008, p. 6).

20. Videoclip –
optimal
M-I interaction

21. For example…
 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)

22.  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)

25. 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

26. Who is securely
attached?
Secure (Group B) – able to use caregiver as a secure
base in times of stress and to obtain comfort (55-65%)
Insecure
Anxious/resistant (Group C) – up-regulates in times of
stress to maintain closeness (8-10%)
Avoidant (Group A) - down-regulates in times of stress
to maintain closeness (10-15%)
Disorganised (Group D) – unable to establish a regular
behavioural strategy (up to 15% in population sample;
80% in abused sample) (Carlson, cicchetti et al 1989)

27. Arousal in traumatic/disorganised
attachments
Hyper-arousal (aggression, impulsive behaviour, children
emotional and behavioural problems – ‘Fight or flight’
response)
Window
of
Tolerance
Hypo-arousal (dissociation, depression, self harm etc)

28. Disorganised/Controlling
Attachment
 Caregivers – unpredictable and rejecting; source
of comfort also source of distress
 Self represented as unlovable, unworthy,
capable of causing others to become angry,
violent and uncaring
 Others – frightening, dangerous, unavailable
 Predominant feelings – fear and anger
 Little time for exploration or social learning

29. Compulsive Strategies
 Compulsive compliance (where parent is
threatening) – watchful; vigilant and compliant
 Compulsive caregiving (where parent is needy) –
role reversal; parentification; children deny own
developmental needs
 Coercive – combination of threatening and
placatory behaviours
 Controlling strategies (abusive and neglectful) –
self is strong and powerful but also dangerous
and bad; avoidance and aggression; completely
‘out of control’ and ‘fearless’

30. Compulsive caregiving
‘Caroline is 18 months old. She lives with her
mother, who is chronically depressed. The mother
describes the household as ‘noxious to the soul’.
She cannot tolerate the idea that her depression is
affecting Caroline. She says: “Caroline is the only
one who makes me laugh.”
It is observed that Caroline silently enacts the role
of a clown. She disappears into her room and
comes out wearing increasingly more preposterous
costumes. Caroline makes her mother laugh, but
she herself never laughs…’ (Howe, 1999)

31. Vulnerable Parents

32. Parent-infant relationship in the
face of parental problems
 Infant’s emotional states trigger profound
discomfort in vulnerable and ‘unresolved’ parent
s(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)

33. ‘Atypical’ parenting
behaviours
 Fr-behaviour – frightened AND frightening;
 Frightening, threatening (looming); dissociative
(haunted voice; deferential/timid); disrupted
(failure to repair, lack of response,
insensitive/communication error.
 Systematic review of 12 studies found strong
association between ‘atypical’ parenting at 12/18
months and disorganised attachment

34. Videoclip –
Severely suboptimal
M-I interaction

35. Getting it right, first
time…

36. Working to the developmental
timelines of children
 ANTEANTAL - Identify high risk families during
pregnancy – pre-birth assessments at 18 weeks
 Intervention provided ante-natally
 BIRTH - Assess parent-infant interaction;
concurrrent foster care where necessary
 Provide time-limited EB intervention and clear
goals to be achieved; re-assess
 Remove infants where there is insufficient
improvement before 8 months ideally, end of
first year at worst

37. FASS – Family Assessment
and Safeguarding Service
 Specialist multi-disciplinary service provided by Oxford
Health NHS Foundation Trust;
 Integrated and individually tailored multi-disciplinary
assessment programmes to assess severe parenting
problems including child abuse and neglect;
 Expert professional and court reports including court
appearance providing independent advice and
recommendations to assist decision making regarding
future placement and needs of children referred

38. Is home the best place
to be…?
 Once children have been placed in out-of-home care,
there is often an assumption that reunification is the
optimum outcome.
 Although 50–75% of children placed in out-of-home care
eventually reunify, between 20–40% of those reunified
subsequently re-enter foster care;
 Studies have recorded better outcomes for children who
were NOT reunified with their families of origin than
those who were, including gains in intelligence scores,
greater overall wellbeing, and less criminal recidivism
(Lancet 2009).

39. Cont…
Longitudinal studies found that reunified youth
showed worse outcomes for: internalising and
externalising problems;
 risky behaviours
 Competencies; grades; school dropout
 involvement in the criminal justice system
 adverse life events
 witnessing physical violence
 more likely to receive physical violence as part of
discipline;
 less likely to receive mental health treatment(ibid)

40. Cont…
 Children who were formerly in foster care were
1.5 times more likely to die from a violent death
than were children who remained in foster care;
 Three times more likely to die from violent
causes than were children in the general
population.

41. Does foster care improve
outcomes?
 Children placed in care fared better than maltreated
children who remained at home:
antisocial behaviour; sexual activity; school attendance and
academic achievement; social behaviour and quality of life;
 Enhanced foster care (better trained caseworkers and
greater access to services, and supports for youth and
foster families) fewer mental and physical health problems

42. Concurrent Planning in
Foster Care
 ‘Concurrent planning is a form of fostering and adoption
that removes children aged up to six years old from
parents with severe difficulties in their lives and places
them with specially trained prospective adoptive parents,
who act as foster carers for six to nine months.
 If the birth-family, who are given intensive support, can
overcome their problems, the child is returned to them
otherwise, they will be adopted by the foster carers’.
 www.communitycare.co.uk
 Must stop moving children through foster placements
because it TRAUMATISES them!!

43. Evidence-Based
Interventions
 Sensitivity/attachment-based: Video-
interaction Guidance; Family Nurse Partnership;
 Psychotherapeutic: Parent-infant
psychotherapy
 Family Drug and Alcohol Courts (FDAC)
 Parenting programmes – Parents under
Pressure; Parent-Child Interaction Therapy

44. PUP Programme
 PUP is underpinned by an ecological model of child
development and targets multiple domains of family
functioning, including the psychological functioning of
individuals in the family, parent–child relationships, and
social contextual factors.
 Incorporates ‘mindfulness’ skills that are aimed at
improving parental affect regulation;
 PUP comprises an intensive, manualized, home-based
intervention of ten modules conducted in the family
home over 10 to 12 weeks, each session lasting between
one and two hours

45. PUP evaluation
 Parents Under Pressure
 RCT with substance abusing parents of children
aged 2-8 years (Dawe and Harnett 2007)
 Compared PUP with standard parenting
programme
 Significant reductions in parental stress;
methadone dose and child abuse potential
(significant worsening in the child abuse potential
of parents receiving standard care); improved
child behaviour problems

46. Summary
 First three years of life are foundational in
terms of neurological and developmental
outcomes;
 Considerable scope for prevention of serious
problems if we work to the developmental
timelines of the children, not the parent;
 Innovative models of working show good
outcomes

47. Publications
 Barlow J, Scott J (2010). Safeguarding in the 21st
Century: Where to Now? Dartington: Research in
Practice. www.rip.org.uk
 Ward et al (2011). Infants suffering, or likely to suffer,
significant harm: A prospective longitudinal study.
London: DfE.
www.lboro.ac.uk/research/ccfr/Publications/DFE-RB053.pdf
 Barlow J, Schrader-McMillan A (2010). Safeguarding
Children from Emotional Abuse: What Works? London:
Jessica Kingsley.