Education CommitteeWritten evidence submitted by the NSPCC

The importance of pregnancy to two years old

1. It is important to be clear that children’s centres have a remit to support families from pregnancy until a child is five. Whilst the “Foundation Years” are an important time to support child development and ensure children are ready for school, the evidence set out below shows that the real foundations are laid earlier—during pregnancy and infancy. Furthermore, babies are disproportionately vulnerable to neglect and abuse1. Children’s centres have a key role to play in bringing together a comprehensive offer of support that begins in pregnancy, and lasts until children are ready to start school.

2. There is now compelling evidence which demonstrates the critical importance of pregnancy and the first two years of life in laying the foundations for a child’s development2. Parents have a profound influence on children’s outcomes. Parental adversity and capacity for sensitive caregiving matter enormously during these formative years. Early infant experiences and infant-parent relationship shape the way their brains develop and a child’s capacity to cope with the challenges life puts in their way. Disorganised attachment in infancy has been clearly linked to poor outcomes throughout childhood. Babies who are not well cared for are more likely to struggle at school and to have behaviour, relationship and health problems in later life3. Children’s centres need to do more to engage and work with families during pregnancy and the first two years.

3. This early period is also a time when parents are particularly receptive to help and advice as they seek to adjust to drastic changes in family life and relationships. It provides an opportunity to help parents get off on the right foot, and crucially to help set the pattern for effective parenting later on. It is also a time when families expect to have contact with professionals such as health visitors and midwives, and this contact offers an opportunity to engage families constructively in change.

4. Furthermore, intervention at this early stage has been shown to deliver good value for money. Programmes such as the Family Nurse Partnership have demonstrated that well-crafted and evaluated interventions can deliver substantial savings4.

Identifying and addressing additional needs

5. In England, babies are seven times more likely to be killed than older children5. They account for 6% of the child population and yet 36% of serious case reviews between 2009–11 involved a child under one6. Although there is no single cause which leads to child abuse, it is crucial to acknowledge that babies living within complex family situations are at a heightened risk of neglect or maltreatment. In particular, our studies have found that around 26% of babies (198,000) in the UK are estimated to be affected by parental risks factors of domestic abuse, substance misuse or mental illness7. We need to ensure timely access to services which can both address parental problems and help them bond with their babies and provide good parenting. There is currently a lack of support for parents with additional needs, and where services do exist, they often don’t consider the needs of children in their household.

6. It is important to be clear what is meant by disadvantaged families within the core purpose for children’s centres. This should include all families where there is an increased risk of poor child outcomes and not just those who live in economic poverty. It is particularly important that children’s centres (working alongside other agencies) play an increased role in identifying and addressing the needs of parents suffering from mental health problems, substance misuse and/or domestic abuse through the provision of evidence-based programmes.

Focus on parental and infant mental health

7. Parental and infant mental health are major public health concerns. Supporting parents experiencing mental illness and promoting sensitive parenting and secure attachment between a baby and their caregiver can have a profound impact on developmental outcomes for children and on the wider wellbeing of families. These approaches enable parents to understand their baby’s communication and behaviours in light of their emotional states and stages of development. Services have the opportunity to shape the way parents care for their children, which can have long term positive effects. It is therefore really important that children’s centres support families during pregnancy and infancy in this way. Promising service models exist in some children’s centres but provision is very patchy across the country as a whole. We need to ensure that all children’s centres have good quality parental and infant mental health services and strong links to specialist provision where necessary.

8. The following examples are of evidence-based infant mental health programmes which can be run in children’s centres and promote attuned parenting:

Service	Evidence of impacts
Oxford Parent Infant Project (OXPIP)—OXPIP aims to help parents and their babies by providing them with therapeutic support and intervention as soon as any difficulties are recognized, either by families themselves or the professionals working with them. Parent-infant psychotherapy involves specialists working with both mother and baby using psychotherapeutic methods to a range of problems including faltering growth, attachment difficulties and abusive parenting, by focusing on the relationship between the parent and infant and mothers’ representations and parenting practices.	Outcomes for the service included: 72% of parents were moderately depressed at the outset of their treatment with OXPIP, whereas only 23% were at the time the work finished. 60% of parents were at least moderately anxious at the beginning of their therapy, whereas only 25% were at the end. In terms of attachment 40% of the families were in the top end of the range (well adapted or adapted) at the end of their sessions, which had increased from 7%.8
Secure Start, Gloucestershire An infant mental health team, working in conjunction with local SureStart Children’s Centres. The aim is to embed early intervention in inter-agency working; the project has contact with many families who are already accessing statutory and voluntary services, with the aim of preventing maltreatment by working on the relationship between parents and their babies.	The Ages and Stages Questionnaire for Social and Emotional Development (ASQ: SE) is used as a guide to measure development, and all the babies seen on the programme are at the age appropriate stage, which is valuable, given that the families referred to the programme are deemed “at risk”
Mellow Babies Group based intervention for vulnerable parents and their children under one year. Aims to improve parent mental health and infant mental health by promoting positive attachment relationships. Targets mothers with mental health problems such as post-natal depression or anxiety and families where there are child protection concerns.	In a waiting list controlled group, Mellow Babies has been shown to reduce maternal depression, enhance positive parent child interaction and reduce negative parent child interaction9.

Upcoming NSPCC review of “Pregnancy to two years old”

9. The NSPCC has been carrying out an innovative review of local service provision and spending from pregnancy to two years old across universal, targeted and specialist provision delivered by health services, children’s services (including children’s centres) and other service providers. We decided to undertake this work as despite the compelling case for investing in services for babies, there is a lack of understanding about the levels of spending and service provision during pregnancy and the first two years of life at a local level across England. By the end of the project we will have completed “deep dives” within differing local areas and have run in-depth workshops with, and interviewed staff from, approximately 20 local authorities, speaking to a range of people in different roles including commissioners, children’s centre managers and practitioners, local leaders, local MPs, heads of midwifery, community midwives and specialist midwives. Through this work we will have gained a more comprehensive understanding of sufficiency of services for vulnerable families during the perinatal period, which will include exploring the role and purpose of children’s centres.

10. Our final report is due to be published in January 2013. Early findings suggest that at a local level:

a compelling argument for focussing on pregnancy and babies has not yet been made:

vulnerable families are not consistently identified and targeted;

there are gaps in preventative and targeted services;

and commissioning is not yet sufficiently joined up.

The NSPCC would welcome the opportunity to share the findings of our review, in particular our findings relating to children’s centres, during an oral evidence session in early 2013 should that be helpful to the Committee’s inquiry.

Multiagency working

11. Children’s outcomes are heavily influenced by the circumstances of their parents and families, therefore it is important that services are tailored around the needs of the whole family. Children’s centres need to have strong links with other agencies—particularly adults’ services such as maternity, health visiting, primary care, mental health, social care and welfare in order to maximise the opportunities to identify and engage with parents, particularly those who may need further support.

12. Early findings from the NSPCC’s Pregnancy to Two review suggest a lack of systematic coordination between different agencies or practitioners supporting families during this life stage. For example, whilst children’s centres now receive the information about live births in their localities, they do not receive information about Children in Need. One children’s centre manager told us, “We know which children are on Child Protection plans, but we don’t know the Children in Need who live in the area. If we did we could offer support.” Colocation of different services within a children’s centre can help professionals to learn from each other and share information easily. However co-location is neither necessary nor sufficient to ensure that information is shared in an effective and timely way. It is important that there are good area-wide systems to enable all services working with families to share information and coordinate their work. Having named social workers attached to children’s centres could also improve the early identification of families with additional needs.

13. Having midwife and health visitor clinics run out of children’s centres is also effective in making other services more accessible to many parents and enabling parents to access a range of other relevant information, advice and support at the same time. Through our review we have found some really promising practice occurring in children’s centres, supported by family support workers, health visitors and midwives and many practitioners told us that relationships between children centre staff and health professionals are consistently good. Our review has also found varied levels of commitment to providing outreach services. Whilst some centres have a targeted approach to engagement, others have less outreach services available. Children’s centres must use assertive outreach techniques such as children’s centre staff delivering services in other venues or accompanying midwives and health visitors into homes of vulnerable families in order to raise awareness of services on offer.

Evidence-based interventions

14. There is a growing body of evidence about effective interventions during pregnancy and infancy which are highlighted in the NSPCC’s All babies count report10. Children’s centres should offer services for families which promote sensitive and attuned parenting, and need to do more to ensure that scarce resources are invested in programmes which have been demonstrated to be cost effective. There needs to be continuous investment in developing and evaluating new interventions to address gaps in knowledge and practice. Bodies like the proposed Early Intervention Foundation have an important role to play in improving this evidence base and sharing learning.

15. We are interested to see whether initiatives like “payment by results” help encourage providers to focus their attention and resources on inventions that are known to be effective. However, it is important to acknowledge that the current measures are for trial purposes only. While these measures are spread across the 0–5 age range, and do encourage a focus on disadvantage, they don’t focus on the most hard to reach and vulnerable families nor do they encourage centres to focus on the social and emotional development of younger children and their early interactions with parents. The lives and wellbeing of parents are important determinants of how well children do. Professor Marmot’s report on Improving Outcomes in Children’s Centres argues that “further investment should be focused to fill the measurement gaps around the most important aspects of parenting”11

16. The NSPCC has significant expertise in the design, delivery and evaluation of evidence-based services. In the past year alone, we have invested £47.8 million in delivery of 24 new services in 40 locations across the UK. These include new services designed to protect children under one, promote effective parenting and improve outcomes in pregnancy and infancy, which might in the future be offered in children’s centres. This includes Pregnancy, Birth & Beyond which is a new eight session programme working with vulnerable and high risk expectant parents. Jointly delivered by health and children’s services practitioners, this programme covers the social and emotional aspects of parenthood as well as the medical content of traditional antenatal education. In doing so it helps parents to prepare for the transition to parenthood and sets a template for effective parenting. The NSPCC is beginning an impact evaluation in 2013. A formative evaluation for has already shown the programme is positively received by parents.

December 2012