1.
Improving Decision-Making in
Pre-birth Assessment:
The OxPUP Project
Jane Barlow
Professor or Public Health
in the Early Years

2.
 What are the risks in pregnancy?
 OXPUP: Children’s Social Care Perinatal pathway
 Results of pilot study
Structure of Paper

3.
Parenting begins in
pregnancy…
Parenting begins in pregnancy with:
 Prenatal behaviours that are designed to
protect and promote the wellbeing of the
foetus;
 A process of ‘bonding’ with the foetus that
begins in the second trimester.

4.
PHYSIOLOGICAL
Stress or
Teratogens
Programming of
foetus HPA
axis/neurological
damage
Compromised
physiological/emotio
nal and behavioural
functioning
PSYCHOLOGICAL/BE
HAVIOURAL
Reflective
Function in
pregnancy
Atypical parenting
Behaviours
Disorganised
Attachment
Pathways in Pregnancy

5.
OxPUP: A Prebirth
Assessment Pathway

6.
OXPUP - Care Pathway
ANTENATAL
 Identify high risk families during pregnancy – pre-birth
assessments at 18 weeks
 PuP Intervention begins ante-natally for 3 months
BIRTH
 Assess parent-infant interaction; mother-baby foster
placements and concurrrent foster care where necessary
NEXT 8 MONTHS
 Continue time-limited intervention and clear goals to be
achieved; re-assess 2, 4, 6 months
 Remove infants where there is insufficient improvement
before 8 months

7.
PUP Programme
 Evidence-based programme with high risk families – eg.
Families referred from child protection services (Harnett
and Dawe 2008) parental substance abuse (Dawe and Harnett
2012; 2007) women leaving prison (Frye & Dawe 2008)
 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 and RF

8.
PUP evaluation
 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

9.
PUP
 Contains 12 modules, delivered across 20 calendar
weeks; sessions in home; 1-2 hours; parent workbook
 The selection and delivery of the modules is determined
by the assessment
 Additional case management occurs outside the
treatment session, according to individual family need
(e.g., housing, legal advice, school intervention)
 Day-to-day issues such as housing and finances provide
a therapeutic opportunity to put coping skills into
practise in a mindful and emotionally contained manner

10.
Capacity to Change
 Step 1: complete a cross-sectional assessment of the
family’s current functioning using a range of
standardised tools (Time 1)
 Step 2: define and agree measurable goals with the
family that address their unique situation specifying what
needs to change
 Step 3: delivery of evidence-based intervention (PUP)
 Step 4: re-administer the standardised tools that were
used previously (Time 2)

11.
PUP assessment
 Comprehensive assessment and individual case
formulation conducted collaboratively with the family
 Self-report measures supported by a purpose built data
base that is automatically scored and provides clinical
feedback on all key measures
 Specific targets for change are identified during the
assessment, as part of an assessment of capacity to
change; which then become the focus of treatment.
 12 modules - each module comprises a theme that
continues throughout treatment.

12.
Ante-natal Assessment Tools
 Pre-birth assessment
Standard pre-birth assessment
 3 monthly assessment of functioning
Mental health (DASS); Life events Scale (LES); Drug and
Alcohol screen; Domestic abuse screen (SARA)
 Reflective function – once during prenatal and once
postnatal
Pregnancy Interview and Parent Development Interview
(PDI)

13.
Postnatal Assessment
tools
 Parent-infant interaction – 3 minute videoclip
(CARE-Index)
 Home environment (HOME Inventory)
 Mothers feelings about relationship with baby
(Mother-Object relationship Scale)
 Parenting Stress – Parenting Stress Index (PSI)

14.
Level of expected
outcome
Goal 1
Decision making
Goal 2
Self esteem
Goal 3
Isolation
Review date:
Much more than
expected
(+2)
Makes plans, follows
through, modifies if
needed, and reaches
goal
Expresses realistic
positive feelings about
self
Actively participates in
group or social activities
More than expected
(+1)
Makes plans, follows
through without
assistance unless plan
needs changing
Expresses more positive
than negative feelings
about self
Attends activities,
sometimes initiates
contact with others
Most likely/expected
outcome
(0)
Makes plans and follows
through with
assistance/reminders
Expresses equally both
positive and negative
feelings about self
Leaves house and
attends community
centre. Responds if
approached
Less than expected
outcome
(-1)
Makes plans but does not
take any action to follow
through
Expresses more
negative than positive
feelings about self
Leaves house
occasionally, no social
contact
Much less than expected Can consider alternatives
but doesn't decide on a
plan
Expresses only negative
feelings about self
Spends most of time in
house except for formal
appointments

15.
Cases to date
 CPT has taken 26 referrals. 3 pregnancies ended pre-term. 23
families have engaged fully with the programme
 CPT are case holders and have managed cases through from
referral to final hearing (in legal cases) and into the community for
those families who have remained intact
 6 cases have required legal proceedings - ICO applications made
and granted at birth in all cases
 Early full parenting assessments have been presented to Court
throughout proceedings by CPT team rather than this being seen as
a separate task
 17 families have been supported to care for their children at home
with on-going PUP intervention from CPT as well as appropriate
local support services

16.
CASE STUDY 1
 Mum 24 self referred 14 weeks pregnant requesting
help to keep her baby
 6 previous pregnancy’s 1st at age 14: 1 miscarriage;
2 abortions; 1 removed at 18 months due to chronic
neglect and non-accidental injury; 2 removed at birth
due to high-risk lifestyle
 4 fathers to the children all much older; all highly
aggressive and all with drug/alcohol dependencies
 Left area of her birth and severed links with family,
peer and previous abusive relationships
 Relocated and reporting at point of referral to be in a
loving relationship
17

17.
INTERVENTION
 Twice weekly sessions over period of 6 month
 View of self as parent: very emotional journey to explore her
own childhood traumas and to help her understand how to
love and be a parent
 Emotional Regulation: to help her to move away from guilt
and blame; journey through denial and recognition and into
responsibility in order to begin to forgive herself
 Connecting to your Child: helping her to view the world from
the eyes of her daughter; using her daughters cues and
behaviours to increase parental sensitivity; video feedback
 Building Relationships: to understand not just needs of
herself and her baby but how to be a good partner, and
what she should expect and accept from her partners
18

18.
OUTCOME
 Daughter remains in her parents care
 Connection between mother and daughter is beautiful;
mum is sensitive, caring and in total awe, not just of
her child, but her relationship with her
 Mum expresses that she cannot believe how good it
feels to be allowed to love and be loved back
 Mum and dad continue to parent together in a loving
and supportive relationship
19

19.
CASE STUDY 2
 Mum 22 in relationship with abusive man aged 24
 Extensive significant childhood trauma
 Parents relationship abusive; mum and siblings
chronically neglected and subjected to long-term
emotional abuse
 Mum continued into adulthood with no self-care skills;
dirty, unhealthy diet, and emotionally withdrawn
 1st Child removed due to neglect
20

20.
INTERVENTION
 Minimum 3 x a week over a 20 week period
 Independent housing secured, benefits reviewed and put in
place
 Life Skills: Personal Hygiene/self-care skills promoted to
increase self-esteem
 Emotional Regulation: and support to access GP for low
mood
 Relationship module: to help her to address dependency on
abuser identify and avoid abuse
 View of self as Parent: to look at positive parenting styles
and identify the kind of parent she would like to be
 And much more…
21

21.
OUTCOME
 Two weeks before birth of child she opted to leave the
accommodation and return to the abusive relationship
 Within days presented as dirty and unkempt
 Two admissions to A&E following fainting episodes due to
hunger
 Failure to attend appropriate ante-natal care
 Low Iron, urine infections, weight loss and other health
issues ignored, placing self and unborn child at risk
 Interim Care Order granted at birth and baby removed from
mothers care
22

22.
Care Proceedings
 Care proceedings for 6 CPT legal cases have all been
completed within 26 weeks; non-CPT cases all mostly
outside of the 26 week requirement
 Foster care costs for CPT cases are significantly less than
non-CPT cases because permanency planning for CPT
has been achieved more quickly - CPT cases is £58,490;
non-CPT cases cases is £99,272
 Court costs significantly less - CPT cases is £54,874; non
CPT cases is £91,119

23.
Risk
Assessment
Prebirth:
A Practice
Model
NSPCC
DfE

24.
Publications
 Barlow J, Hall D (2012). Systematic Review of Models of
analysing Significant Harm. London: DfE.
 Barlow J, Scott J (2010). Safeguarding in the 21st
Century: Where to Now? Dartington: Research in
Practice.
 Ward et al (2010). Infants suffering, or likely to suffer,
significant harm: A prospective longitudinal study.
London: DfE.
 Barlow J, Schrader-McMillan A (2010). Safeguarding
Children from Emotional Abuse: What Works? London:
Jessica Kingsley.