Presentation on theme: "Pre-birth assessment and promoting attachment"— Presentation transcript:
1 Pre-birth assessment and promoting attachment Professor Jane Barlow, Director, Infant and Family Wellbeing Unit, Warwick UniversityClare Lushey, Research Associate, CCFR, Loughborough UniversityPre-birth assessment and promoting attachment
2 Structure of the paper Why is pregnancy important Where are we now and why do we need to be doing things differently?What does the science say about suboptimal environments in the first year; and in pregnancyLegal, ethical and practice issuesCurrent pre-birth assessment practiceNew Pre-birth pathwayFeasibility study
4 PSYCHOLOGICAL/BEHAVIOURAL PHYSIOLOGICALStress or TeratogensProgramming of foetus HPA axis/neurological damageCompromised physiological/emotional and behavioural functioningPSYCHOLOGICAL/BEHAVIOURALReflective Function in pregnancyAtypical parenting behavioursDisorganised attachmentPathways in pregnancy
5 Stress exposures associated with impact Maternal anxiety (O’Connor et al., 2002; Austin, 2005; Obel et al., 2003; Mennes et al., 2006; McMahon et al., 2013), and depression (O’Connor et al., 2002 ; Pawlby et al., 2011)Pregnancy specific anxiety and daily hassles (Huizink et al., 2003)Bereavement (Khashan et al., 2008) and stress due to a relationship problems with the partner (Bergman et al., 2007)Exposure to acute external disasters (Laplante et al., 2008), 9/11(Yehuda et al., 2005), Chernobyl (Huizink et al., 2008) a Louisiana hurricane (Kinney et al., 2008), and war (can Os and Selten, 1998)
6 Impact of stress on brain in-utero Altered diurnal pattern or altered function of the HPA axis (Glover et al 2010)Regional reductions in brain grey matter density (Buss et al 2010)Mechanisms – epigenetic; serotonin biosynthetic pathway; transplacental transfer (i.e. changes to barrier hormone changing cortisol to cortisone)
7 Physical and physiological outcomes Congenital malformations (Hansen et al 2000)Lower birth weight and reduced gestational age (Rice et al 2010; Wadhwa et al 1993)Altered sex ratio (Obel et al 2007; Peterka et al 2004)Stress caused by violence leads to epigenetic changes in DNA for this same receptor in the blood of the adolescent children (Radtke et al 2011)
8 Neurodevelopment – post birth Neurodevelopmental functioning of newborns (NBAS) (Diego et al 2004)Temperament (Austin et al 2005; Buitelaar et al 2003;Sleep problems (O’Connor et al 2007)Cognitive performance and fearfulness (Bergman et al 2007)
9 Neurodevelopment – childhood Increased emotional problems (anxiety and depression), ADHD and conduct disorder (O’Connor et al 2002; 2003; Keleinhaus et al 2013; Rice et al 2010; Van Den Bergh & Marcoen 2004; Rodriguez & Bohlin 2005; Beversdorf et al 2005)Reduced cognitive performance (Laplante et al 2008; Mennes et al 2006)
10 DV in pregnancyAround 30% of domestic abuse starts during pregnancy (DH 2010); around 9% of women being abused during pregnancy or after giving birth (Taft 2002)Associated with a wide range of compromised physical outcomes: late prenatal care; miscarriage, preterm and stillbirth; fetal injury (bruising, broken and fractured bones, stab wounds) (Mezey et al 1997)
11 DV in pregnancy Maternal depression and PTSD Significantly more negative representations of their infants and themselves;Babies were more likely to be insecurely attached(Huth-Bocks 2004)
12 PSYCHOLOGICAL/BEHAVIOURAL Pathways in pregnancyPHYSIOLOGICALStress or TeratogensProgramming of foetus HPA axis/neurological damageCompromised physiological/emotional and behavioural functioningPSYCHOLOGICAL/BEHAVIOURALReflective FunctionAtypical parenting behavioursDisorganised attachment
13 Foetal Alcohol Spectrum Disorders A range of effects (including physical, behavioral, and cognitive) can arise from prenatal alcohol exposurePrevalence of FASD (Ospina and Dennett 2013):FASD in community and population-based samples reported estimates ranged from 0.02% to 0.5% (i.e. rates of 0.2 to 5 per 1000 population)Foster care settings ranged from 30.5% to 52%Prisons ranged from 9.8% to 23.3%Children in special education – 2.1% to 8.8%
14 Substance misuse in pregnancy Around 15% of pregnant women used cannabis or other illicit substances with 1-2% using Heroin or Cocaine (Jones et al 2012)Strong association with intra-uterine growth retardation (IUGR), placental abruption and still birth (ibid); significantly higher risk of child protection proceedings post birth (Street et al 2004)Significant increase in the prevalence of NAS, from 1.20 per 1,000 U.S. hospital births in 2000 to 3.39 per 1,000 U.S. hospital births in 2009 (Patrick et al 2012)Alcohol withdrawal may include hyperactivity, crying, irritability, poor sucking, tremors, seizures, poor sleeping patterns, hyperphagia, and diaphoresis. Signs usually appear at birth and may continue until age 18 months.
15 PSYCHOLOGICAL/BEHAVIOURAL Pathways in pregnancyPHYSIOLOGICALStress or TeratogensProgramming of foetus HPA axis/neurological damageCompromised physiological/emotional and behavioural functioningPSYCHOLOGICAL/BEHAVIOURALReflective FunctionParenting behavioursInsecure/Disorganised attachment
16 RF in pregnancyAbility to think about the baby and what he/she may be like; indicative of parental bonding with the infantPregnancy Interview (Slade et al 1987; Slade 2001): Mother’s pre-natal representations of her fetus; Mother’s pre-natal representations of herself as a caregiver, focusing in particular on the mother’s capacity to identify with, respond to, and anticipate the needs of her fetus at present and her newborn in the near future.
17 RF in pregnancy and parenting behaviours High RF strongly associated with maternal parenting behaviours (e.g. flexibility and responsiveness)Low RF associated with emotionally unresponsive maternal behaviours (withdrawal, hostility, intrusiveness)(Slade et al 2001; Grienenberger et al 2001)
18 Long-term impact RF during pregnancy predicts: Infant security at 12 months;Children’s ToM skills at 5;Scholastic self-esteem at 12(Steele & Steele, 2008)
20 Legal & ethical issuesIn England the Children Act (1989) provides the legislative framework through which the state can intervene to safeguard and promote the welfare of children.The act does not provide for legal proceedings to protect a child before birth.Statutory guidance, Working Together to Safeguard Children (DfE. 2013) makes reference for to taking formal steps to protect and unborn child.A woman has control over her body.Restrictions on termination of pregnancy under the Abortion Act 1967.Can refuse medical treatment (exc. one who lacks mental capacity) even if doing so will put her unborn baby at risk of harm.Can refuse statutory interventions to safeguard her unborn child.Social workers can however make
21 Legal and ethical issues English (and Welsh) law provides very limited recognition of the foetus.It is not until birth that this right is superseded by the child’s right to be protected from harm.Legal proceedings for supervision and removal cannot be instigated until birth, but SWs can make plans for such actions during pregnancy.This present a slight predicament for social workers who have statutory responsibility to take steps to protect an unborn child.Working in partnership with the mother is therefore an essential way to secure the well-being of the child to be.
22 Practice issuesParents might be suspicious of/distrust social servicesParents could disappear, avoid ante-natal services, deliver the baby without medical care, or conceal or seek to terminate the pregnancy out of fear that their child might be removed at birth (Barker, 1997; Hart, 2010; Calder, 2000; Ward et al. 2012).Practitioners may not make referrals:Bond between mother and unborn child ‘sacrosanct’ (Hodson, 2011).Focusing on the parents rather than on the unborn child [adult services] (Ward et al. 2012; Hart, 2010; Ofsted, 2011).Under the impression that thresholds for CSC are too high (Davies and Ward, 2012).Reluctant to bond with the unborn baby and/or make preparations for the baby’s arrival due to uncertainties as to whether the child will be removed at birth (Ward et al., 2012).Role of the father absent from pre-birth assessments - ‘ignored’, ‘invisible’ and ‘the ghost in the equation’. Father may pose a risk to the unborn child or be a protective factor.There are practical issues of identifying and engaging parents.Other issues such as the impact the assessment might have on the expectant parent.
23 Review: models for pre-birth assessment where there is high likelihood of significant harm to an unborn childPre-birth assessment tools designed to screen for potential maltreatment in the general population (detect parents whose unborn baby is at risk of significant harm):Limited number of screening tools identified (n=4)Many outdatedPre-birth assessment tools designed to screen for the presence of maltreatment in cases being assessed by CSC practitioners (families referred to, or already identified, by CSC).Pre-birth assessment (Corner, 1997)Pre-birth assessment (Calder, 2003)Core assessmentThe core assessment recommends the use of other standardised assessment tools to aid decision-making , e.g. the parenting daily hassles tool, however the others do not.Following exploration of the ethical, legal and practical issues we needed to consider when developing our pre-birth assessment model. we undertook a review to identify pre-birth assessments designed to screen for maltreatment in the general population and for cases referred to CSC.A wide range of electronic databases were searched.Assessments included if they had been developed, brought into use, or their effectiveness researched, betweenA limited number of tools were identified.Four screens for detecting in the general population and three for use by cases referred to social workers.Brigid Collins Risk Screen (Weberling et al., 2003)Child Abuse Potential Inventory (CAP) (Zelenko et al., 2001)Maternal History Interview – 2 combined (MHI-2) (Brayden, 1993)Adolescent-Adult Parenting Inventory (AAPI) (Hasket et al., 1994)DON’T GO INTO BUT THERE IF ATTENDEES WANT TO KNOW MORE.We were particularly interested in those tools being used social workers. Of which we identified two plus we have the core assessment for use during the pre-birth period.Therefore whilst they provide advice on when to undertaken a pre-birth assessment and information to collect they do not provide advice or tools to assist in the collection of information and analysis/decisions.
25 LSCB: Pre-birth assessment guidance All 147 LSCBs in England made reference to pre-birth assessments in their procedures ( ) .Only one third (33%/n=48) acknowledged the lack of legal status of a foetus.Just one quarter (25%/n=36) referenced a pregnant woman’s right to autonomy over her body.The majority (96%) contained information additional to Working Together (2010, 2013):Referral protocols, e.g. when to make a referral, timescales for referral.Purpose of a pre-birth assessment.The type of information that requires collecting during a pre-birth assessment.This means that they didn’t just state that procedures and timescales in Working Together should be followed when there are concerns about an unborn child etc.. However, again they did not provide advice on how to gather information, what tools to use or how to analysis and make sense of the information gathered to inform decisions making.We can really see where the gap is. Limited guidance and virtually no advice on what tools to use during the pre-birth assessment period to aid decision making. Ethical and moral issues that require some thought and make social workers cautious about undertaking pre-birth assessments. However, there is limited data on what current pre-birth practice is so we interviewed practitioners involved in such assessments to find out if on the ground tools were be used and whether ethics and practicalities impacted on pre-birth assessment work.
26 Interviews with practitioners Existing pre-birth assessment practiceTelephone interviews with 18 practitioners from 9 localitiesMain findings/implications for model development:Guidance and tools:Limited guidance. Reliance on guidance from more experienced social workers and previous pre-birth assessments. Additional guidance welcomed.Difficulty keeping up-to-date with new findings and accessing standardised assessment tools.Identification of unborn children at risk of harmRoutine ante-natal booking interviews, are the main source of referrals to CSC. Opportunities to disclose DV and asking whether older children are living with birth parents will increase opportunities for identifying unborn children at risk of harm.Automatic referrals to CSC of pregnant women with problematic substance or alcohol use.Explored: existing pre-birth assessment practice, barriers and how these can be overcome, the ideal time to undertake pre-birth assessments, practitioners that should ideally be involved, and training and supervision requirements.Use of guidance and standardised tools during pre-birth assessments were limitedStandardised assessment tools identified:Attachment style interview; maternal and paternal antenatal attachment scale (Condon, 1993); PHQ7/GAD9 assessments; depression, anxiety and stress scale (DASS); alcohol use disorders identification test audit-C; pregnancy interview; support scale; and life events.Two sites had developed their own local pre-birth assessment measures:First: focus on previous children that have been removed, the meaning of the unborn child and preparation for parenting.Second: constructed around the Framework for the Assessment of Children in Need (Department of Health, Department for Education and Employment, Home Office, 2000).
27 Interviews with practitioners Working with parentsParents generally willing to participate but more suspicious and distrusting of social workers in comparison with other workers.Presentation is important – opportunity for parents to show they are able to overcome their difficulties and meet the needs of their child.Not concerned about parents disappearing. They will seek some form of support.Attention needs to be given to processes for assessing and working with parents whose older children are living at home (there is a likelihood that the focus will be on the older children and the needs of the unborn child overlooked).Contrary to previous research involvement of fathers was encouraged.Important in light of previous findings that indicated that pre-birth assessments were of low priority in the face of other competing demands.Hostility not an issue, but some parents could be resistant.However, there can be difficulties involving fathers. If they are separated consent from the mother is required but this can be overridden if there are significant concerns.
28 Interviews with practitioners Timescales:Referral and assessment early in the pregnancy deemed important to prevent delay/drift and the likelihood of a rushed assessment at the end of the pregnancy .Time to undertake a robust assessment and provide early support for parents that might succeed in effecting change and prevent the need to remove the child.
29 Implications for model development Guidance for social work assessments during the pre-birth period is minimalFew practitioners use standardised tools to aid decision-making and found them difficult to accessLegal issuesPresents difficulties for practitioners with a statutory responsibility to undertake pre-birth assessments
33 Initial referral Who should refer – midwives at booking-in Timing of referral – 16 weeks gestationsReasons for referralA parent or other adult in the household has been convicted of an offence against a child, or is believed by child protection professionals to have abused a childPrevious children have been removed because they have suffered or been deemed likely to suffer significant harmA child in the household is the subject of a child protection plan.A child under the age of 16 is pregnantOther – DV; Substance-dependency; SMI: Learning problems; parental history of LAC etc.
34 Stage 1 cross sectional assessment: Core assessment tools “HITS” a domestic violence screening toolSubstance use risk profile-pregnancy scalePrimary care PTSD screenMulti-dimensional scale of perceived social support (MSPSS) and the support scaleNorth Carolina family assessment scale (NCFAS-G)Depression, anxiety and stress scale (DASS)Relationship questionnaire (RQ)
35 Stage 1 cross sectional assessment: Core assessment tools Emotion regulation questionnaire (ERQ)Maternal/paternal antenatal attachment scale (MAAS/PAAS)Pictorial representation of attachment measure (PRAM)Parenting stress index 4 short form (PSI – 4- SF)Parenting daily hassles scaleBrief child abuse parenting (BCAP) inventory form VIAdult-adolescent parenting inventory (AAPI) – formPregnancy interview - revised
36 Stage 1 Core cross-sectional assessment: Optional assessment tools Addiction severity index (ASI) – psychiatric statusConflict tactics scaleAddiction severity scale (ASI) - drug and alcohol sectionAlcohol use disorders identification test (AUDIT) – CThe Needs Jigsaw
37 Stage 2 – Case conceptualisation Case formulation involves three stages:Learning about the issues (gather assessment data)Organising the information into patterns or themesExplaining these patterns or themes using a theoretical framework
40 Stage 4 - Working therapeutically Core methods – Partnership Model; Motivational InterviewingPromoting affect regulation: urge surging techniques; mindfulness techniques etc.Promoting the relationship with the baby: media based tools – Getting to Know your Baby appEvidence based programmes: Parents under Pressure; Minding the Baby; Baby Steps; Circle of Security; VIG; Parent-infant psychotherapy etc.
43 Classification of risk Severe risk of harm: Families showing risk factors, no protective factors and no evidence of capacity to changeHigh risk of harm: Families showing risk factors and at least one protective factor but no evidence of capacity to changeMedium risk of harm: Families showing risk factors and at least one protective factor including evidence of capacity to changeLow risk of harm: Families showing no or few risk factors (or families whose earlier risk factors had now been addressed), and protective factors including evidence of capacity to change
44 Feasibility studyThe overall purpose is to assess the acceptability and feasibility of implementing the new pre-birth assessment model, prior to large-scale testing.Four local authorities testing the new pre-birth assessment modelAdministered by social workers
45 Feasibility studyFace-to-face interviews with eight social work managersFocus groups with a maximum of 40 social workersFace-to-face interviews with a maximum of 40 parents; includes those receiving the new model of pre-birth assessment and those receiving the standardTelephone interviews with 12 practitioners who make referrals for pre-birth assessments, e.g. midwives, drug and alcohol workersCollation and collection of social work case file data from 40 families that have received the new pre-birth assessment model, and from a matched group of 40 families who have received standard care (=80).Aim is to look at their views and experiences of the new model in particular the tools, quality of data collected, timescales, actions taken and outcomes.