Practice Exchange Workshop: Pre-birth planning, Assessment and “Getting it right from the start”

celcis.org @CELCISTweets
Thursday 15th November 2018
CELCIS
Practice Exchange Workshop
Pre-birth planning, Assessment and “Getting it right from the start”

WELCOME
Carol Wassell
Permanence & Care Team Lead, CELCIS

Linda Davidson
Permanence Consultant, CELCIS
A national conversation about what we
know, what we do and what we could
improve?
10 years on from the Early Years Framework

What do we know?
• Babies
25.7%

All behaviour is communication

The System
• Culture and language – “judges who
whip them away without terribly much ado?” Tickle
Guardian 2018
• Policy and Guidance – The Early
Years Framework – The key themes?
• Legal system

Service Landscape
• Wordle?

“Keeping the main thing the main thing”
Fullan 2017
• Aspirations are good - We repeat ourselves?
• What we can predict, we can prevent.
• We need every part of the system to understand
child development and be trauma informed.
• Responsive, well resourced and flexible services.
• We need to both support and challenge parents
to change.
• “Stand by parents from the start” – Alan Sinclair

Coffee Break

Alan Sinclair
Author of “Getting it Right from the Start”
Keynote Speaker

Right from the Start
Investing in Parents and Babies

Self-control in childhood is more important
than socio-economic status or IQ in predicting
adults’ physical health, wealth, life
satisfaction, addiction, crime, and the
parenting of the next generation

Aged 38, 22% of the children as adults:
• 81% crime
• 78% prescriptions
• 77% fatherless child rearing
• 66% of welfare benefits
• 57% of hospital nights
• 54% cigarettes smoked
• 40% excess kilograms

Budget items 2017/18
• Concession fares and bus service £254m
• Motorway and trunk Roads £967m
• Rail services £775m
• Prisons £361m

Group Discussion
What have we achieved?
Where are the gaps?

Lunch

Examples from Practice
What Works?
And what have we learned?

Shona Irvine
Dumfries & Galloway

SPECIALIST PRE-
BIRTH TEAM FOR
VULNERABILITY
Natalie Potts,
Specialist Midwife for
Vulnerability
Shona Irvine, Senior
Social Worker

BACKGROUND
Team became operational in 2014, following a
request from the Children’s Services Executive
Group;
Joint Inspection / Significant Case Reviews /
Audit of all activity, in relation to vulnerable
pregnancies, across Dumfries & Galloway;
Areas of deficit identified in relation to
partnership working, information sharing and
recording, thresholds, timescales, Child’s Plans
and provision of support for vulnerable
pregnant women and their families.

INITIAL AIMS
• Earlier identification of additional need and risk in
pregnancy;
• Improved communication between Health, Social Work
and other agencies;
• Intensive supports in place where required;
• Oversight to improve consistency of thresholds of risk /
completion of Pre-Birth Assessment reports.
Every baby nurtured & thriving; every parent
prepared and supported.

TEAM
STRUCTURE
• Specialist Midwife for Vulnerability (full time –
NHS);
• Senior Social Worker (full time);
• Acting Senior Social Worker (full time);
• Social Worker (1 full time);
• Social Work Assistants (1 full time & 2 part time);
• Parenting Support Officer (part time);
• Admin Support (part time).
The team are co-located at The Willows – Children,
Young People & Family Centre, Dumfries.

ROLES &
RESPONSIBILITIES
• Region wide accountability;
• Oversight of all concerns received in relation
to vulnerable pregnancies / initial Risk
Assessment;
• Screening – advice and signposting support to
Health, Social Work & Police colleagues;
• Information Sharing;
• Facilitation of tripartite Pre-Birth Referral
Discussion (commenced January 2015);
• Decisions / Recommendations…

ROLES & RESPONSIBILITIES
CONTINUED…
• Multi Agency Clinic – illicit substance use;
• Mellow Bumps;
• Quality Assurance – review of continued activity
including adherence to timescales;
• Strategic Pre-Birth Group reporting to and attendance
at.

ACTIVITY – AUGUST 2017
TO AUGUST 2018
Between 1st August 2017 and 1st August 2018, in excess of
15 Requests for Assistance were received by the Specialist
Pre-Birth Team, relating to vulnerable pregnancies from
across Dumfries & Galloway.
All (but a small few) were discussed within either the Pre-
Birth Referral Discussion / Initial Referral Discussion forum,
depending on stage of pregnancy.
Over 80% progressed to Pre-Birth Assessment / Child
Protection Investigation.
During this period, 120 Pre-Birth Assessments were due for
completion.

TIMESCALES
Within Dumfries & Galloway it is our aim to have all Pre-
Birth Assessments completed by the 26th week of a
woman’s pregnancy, referred to Social Work Services at
or before 23 weeks.
In order to achieve this aim, early identification of
vulnerability in pregnancy and notification / referral to
Social Work Services is essential. For all referred at or
before 14 weeks gestation, it is our aim to facilitate multi
agency information sharing and discussion (Pre-Birth
Referral Discussion) at or before 16 weeks gestation.

WHY?
Completion of a robust assessment, by the 26th week of
a pregnancy enables timely and informed decision
making, planning and intervention – with the formulation
of a Child’s Plan at or before 28 weeks gestation (within
a Pre-Birth Initial Child Protection Case Conference /
Child’s Plan Meeting).
A preventative assessment – completed as early as is
appropriate in a pregnancy – should be considered the
ultimate early intervention. Calder (2003) advises that
this should enable a movement from reactive, crisis led
responses to a more considered, proactive and needs led
response.

ACHIEVEMENTS
• First point of contact for advice;
• Co-located team – enhanced relationships /
understanding of roles & responsibilities of
colleagues;
• Communication, information sharing, recording of
information & partnership working;
• Improved timescales & Child’s Plans – Pre-Birth
Referral Discussions / allocation of assessments;
• Identification / provision of supports available for
vulnerable pregnant women and their families –
Mellow Bumps;
• Data / statistics.

FUTURE
DEVELOPMENTS
• Joint Home Visits prior to Pre-Birth Referral
Discussion (work in progress);
• Continued education in relation to vulnerability;
• Consistency of thresholds / timescales;
• Development of Vulnerability Teams within
Midwifery;
• Supports in relation to Perinatal Mental Health;
• Mellow Bumps / Mellow Babies;
• Intensive Family Support;
• Working alongside Family Nurse Partnership.

Helen Runciman
South Lanarkshire

Social Work Resources
caring about people
Social Work Resource
caring about people
PACT Team
Introduction to the Service – Helen
Runciman, Team Leader

Scope of Service
 To support decision making
 To assist in a child’s journey towards permanence
where ever that may be (with birth parents, with
kin or in an adoptive placement)
 To minimize drift and delay

Criteria for referral to PACT
 All unborn babies for whom plan is to be
accommodated in foster care at birth
 Where there is capacity within the PACT team, to
carry out assessments of parents of children aged
two and under, who are in foster care

Assessment process
 x3 two hour assessed parenting sessions
 Individual sessions
 Usually completed in 12 weeks though extended
where necessary – usually most complex cases

Assessment framework
 Jeff Fowler, DoH, NRA Framework
 Donald and Juredini (2004) – parental capacity,
parentability of the child, scaffolding for parenting
 Knowledge base – child development and close
knowledge of developmental history of that
individual child well as comprehensive
assessment skills.

Training plan
 Team development – external support and
development sessions x4/year
 Training in Infant Observation and Infant
Mental Health from CAMHS
 Introduction to Adult Attachment and the
DDM (Dynamic Maturational Model)

Review process
 Six week
 Twelve week (doubles up as PPM)
 Where adoption the recommendation, all
paperwork completed within 4 weeks of end of
assessment

Pathway in cases going for
adoption
 Referral to EYMAS
 Early identification of high risk pregnancies
 Alert to PACT
 Comprehensive support package to mother
 Referral to local office for pre-birth assessment
 Referral to PACT if appropriate
 PACT pre assessment meeting
 Early engagement to get PACT “ready”
 x3 meetings prior to birth if possible
 Assessment commences soon as appropriate post birth
 12 week assessment
 PCA completed within 4 weeks of date completion, permanence reports 2
weeks thereafter
 Linking meeting
 Adoption and Permanence Panel
 Final Placement

Contribution to permanence planning
 Links with Family Placement Team (FPT)
 With team leaders of adoption service – 6 weekly
meetings
 With foster carers

Where rehabilitation is the plan:
 Planning will take a different direction usually from
the 6 week review.
 Identification at that point what the focus of work
should be for the next 6 weeks, areas of concern
still to be covered.
 12 week review - multi agency agreement of plan
for rehabilitation, focus being on build up of contact
and what multi agency support plan should look
like. Engagement with family.

What works
 Early identification of pregnancy
 Consistent ante-natal support
 Relevant interventions to promote positive change
 Close communication with local office
 Pro-active multi agency work
 Early exploration of kin

Challenges
 Complexity of cases being presented
 Need to strengthen Early Years supports and
intervention
 Difficulties in accessing clinical adult assessment
services
 Maintaining a relationship if outcome is not to
rehabilitate and losing opportunity to provide
ongoing support
 Prevalence of trauma – limited resources to
address this to promote sustainable change

Outcomes
 2017/2018 – 21 assessments
 51% Adoption
 24% Home (two re-accommodated within a
fortnight of returning, adoption plans now being
progressed)
 12% Kin
 12% TBC

Julia Donaldson
Glasgow Infant & Family Team (GIFT)

49
Julia Donaldson
Clinical Director GIFT
Consultant Clinical Psychologist
15th November 2018
Glasgow Infant and Family Team
GIFT

Rationale: the earlier the better
• Mental health problems much
more common amongst children
in care than their peers
• Early adversity contributes but
effects compounded by placement
instability and change
• Children are most vulnerable to
effects of poor care and most
responsive to intervention during
the early years of life

New Orleans Model
• Potential fit
– For young children in foster care because of maltreatment
– Comprehensive relationship-focused intervention
– Aim of re-unification, where safe and in child’s best
interest
• Relevant research outcomes
– Reduced risk of parental recidivism
– More children were adopted
– Better outcomes for children

• Primary caregiving relationships are the most
important predictor of children’s social and
psychological outcomes
• Quality of caregiving experiences is critical and key
to child well-being – moderate risks
• Stability is crucial; minimising harm of disruptions
• Caregivers support the child’s mental health when
they:
• Provide sensitive and attuned care
• Know and value the child as an individual
• Put the child’s needs ahead of their own
Essence of infant mental health

The BeST? Study
• Local authority decision as context
– All maltreated children 0 - 60 months entering
foster care will receive a family-based
intervention
• BeST?
– Importance of equipoise
– A randomised control study of children entering
foster care
– Compares the GIFT with the Family Assessment
and Contact Service - FACS
– Trial will report in 2020’s……

Glasgow Infant + Family Team
• Set up specifically to deliver New Orleans intervention
• Delivered by NSPCC as part of a partnership between
Glasgow City Council, NHSGCC and the NSPCC
– 6 social workers, 6 psychologists, 1 child psychiatrist,
1 co-ordinator, 2 family liaison workers
• Works with birth families, foster carers and wider
system
• Offers evidenced recommendations about permanence
• Usually after intervention, recommends either
rehabilitation or adoption.

Parents agree to BeST
Child randomised to GIFT
Initial assessment:
foster carer(s)
Developmental
assessment
(ASQ)
Initial mental
health
assessment
(CBCL, BSQ)
Assess “fit“
between child and
foster carer
Working model
of child
interview
Crowell
procedure
GIFT: stage1

Screening
questionnaires
with each parent
Intake interview
with each biological
parent
Arrange assessments
WMCI with
each parent
about each child
Home visit to parent(s) to seek consent
GIFT: stage 2
Appropriate
referrals for parent
Crowell procedure
with each parent
with each child

Stage 3: planning treatment
• Conference (around week 12)
– GIFT hosts professional network meeting including
• Child’s social worker
• Foster carers’ social worker
• Social work liaison manager
– Distil evidence from assessment into formulation
– Set out a treatment plan
– Clarity about agreement and points of difference
• Summary report sent to SW and Reporter

Stage 4: delivering treatment
• Treatment phase
– Most families are offered treatment
– Importance of attending to both the wider system
and to care-giving relationships
– Tailored, typically intensive treatment package
• Ensuring birth parent is offered appropriate help
• Therapeutic work: relationship based therapy is
a key model
• Overall intervention runs for up to 9 months
• Reviewed 3 monthly
• Then make recommendation about permanence

Birth parent relationship:
Circle of Security
Video Interaction
Guidance
Contact Guidance
Child-Parent
Psychotherapy
Trauma
Informed CBT
Foster parent:
 Consultation
Formulation of child’s
needs
Video Feedback
Circle of Security
GIFT Interventions

Goals of Treatment with Birth Parents
• Accept responsibility for child’s maltreatment and
need to change their own behavior
• Acknowledge longstanding psychiatric, substance
use and/or relationship difficulties
• Place needs of child ahead of their own needs
• Capacity for change and willingness to try different
approaches within a reasonable time frame
• Work constructively with involved professionals
• Make use of available community resources

A multi-systemic intervention
• The intervention process involves
• The children
• Their families
• The foster families
• The social and health workers involved with
them
• Those who recruit foster and adoptive
parents
• Those who make decisions about
their care

GIFT Infants
• Have experienced multiple life
stressors/traumas
• More than half have developmental
delay
• Show disturbances in their
relationships
• Miscue their needs

Learning so far
• The therapeutic multidisciplinary approach
fits with the needs of children and families
were there is intergenerational trauma
• Intervention is indicated with majority of
foster parents
• Respite and ‘taxi’ to contact
• Translating the model to Scottish legal and
social care context - timescales

Euser et al (2015):
• Interventions effective with maltreating
families
– programs with a focus on intervention
more effective than programs that
solely provide support
– interventions with a moderate number
of sessions (16-30) more effective
compared to those with fewer
– interventions lasting 6–12 months
yielded significant effects, unlike those
<6/12 or >12/12

Conclusion
The complexity of maltreatment in young
children must be matched by the
comprehensiveness of our efforts to:
• minimize their suffering
• reduce their developmental deviations
• enhance their development
• promote their competence
Zeanah (2005)

Group Task
Making Connections
Opportunities & Challenges

Next Steps

Carol Wassell
Permanence & Care Team Lead, CELCIS
Summary & Closing Comments
Linda Davidson
Permanence Consultant, CELCIS

Practice Exchange Workshop: Pre-birth planning, Assessment and “Getting it right from the start”

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