Healthy Child Programme and Child Programme and Age of Opportunity compared The Healthy Child Programme Age of Opportunity 1 Implementation Neurological Development It is disappointing

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Healthy Child Programme and Age of Opportunity compared

This project was funded by the Department of Health

Healthy Child Programme and Age of Opportunity compared

The Healthy Child Programme Age of Opportunity

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Implementation

Neurological Development

It is disappointing to hear that the HCP is given a low priority in some parts of the country. Health visiting and paediatric colleagues are reporting that it is proving difficult to provide a universal HCP. (p.2 HCP)

Implementation of the HCP is patchy and there is evidence that we are not getting early years’ intervention right. (p.6, p. 40 AoO)

A high quality HCP should be visible and accessible to families with children and delivered by integrated, community-based services. Working in partnership with other services, the HCP sits at the heart of services for children and families. (p.7, p.10 HCP)

A key priority is full implementation of the HCP which, over time, would give us a world class programme to reduce the need for additional support for young children and families. (p.9, AoO)

New information about neurological development, the impact of stress in pregnancy, and further recognition of the importance of attachment help to emphasise the importance of prevention and early intervention in the promotion of optimal social and emotional development. (p 6, p.23 HCP)

The 0-2 period is of fundamental importance in creating solid psychological and neurological foundations to optimise lifelong social, emotional and physical health, and educational and economic achievement. There is a clear case for prioritising earlier identification of need and provision of appropriate support for children and their families during this period. (p.3 AoO)

The HCP places a major emphasis on supporting mothers and fathers to provide sensitive and attuned parenting; supporting strong couple relationships; ensuring that contact with the family routinely involves and supports fathers; and supporting the transition to parenthood, especially for first-time mothers and fathers. (p.8 HCP). One of the core functions of the HCP is to support parenting using evidence-based programmes and practitioners who are appropriately trained and supervised. (p.23)

The nature of the day-to-day relationship between the child and primary caregiver is crucial. Parental mental health (before and after birth) is a key determinant of the quality of the relationships and of the ability to provide a number of other conditions for foetal and child development. It is also a key factor in safeguarding children from child abuse and neglect. (p.3 AoO) Midwives and health visitors should be resourced and trained to provide a level of support that promotes sensitive, responsive, loving, nurturing parenting and a good two-way relationship and communication between parents and children. (p.4 AoO)

HCP is a progressive universal programme that responds to different risk factors for children’s future life chances, including the effects of multiple parental risk factors. (p.9 HCP)

Policy debates have not given enough emphasis to the impact of multiple risk factors on the likelihood of really poor outcomes for children. (p.3 AoO)

Sensitive and Responsive Parenting

Risk Factors

One of the HCP’s key roles is to identify children with high risk and low protective factors and ensure that these families receive a service responsive to their needs (p.23 HCP). Poverty is one of the biggest risk factors linked to poor outcomes. (p.12 HCP)

Effective action to address the needs of parents and children who are most at risk of poor outcomes can be taken through the full delivery of the HCP and targeted work through Children’s Centres. (p.4 AoO)


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A range of predictors of risk in pregnancy are suggested alongside generic social and psychological indicators which confer risk or protection for particular outcomes. (p.16 HCP)

Risk Factors (contd.)

Pregnancy is a particularly important period during which the physical and mental well-being of the mother can have lifelong impacts on the child. Factors such as maternal stress, diet and alcohol or drug misuse can place a child’s future development at risk. (p.3 AoO)

HCP incorporates evidence from research and guidance from NICE into recommendations for interventions that promote behaviour change, improve health and build resilience to improve child health outcomes. (p.9 HCP)

Evidence-based and well-implemented preventive services and early intervention in the Foundation Years are likely to do more to reduce abuse and neglect than reactive services and deliver economic and social benefits. Policy emphasis needs to shift to take account of the numerous evidence-based approaches already in use, which support either improved early relationships or improved perinatal mental health. (p.3 AoO)

The HCP embraces new technologies and scientific developments to offer greater choice to parents in the ways that they can access information, guidance and support. (p.10 HCP)

Evidence Base

Assessment

The HCP advocates skilled assessment of family needs, strengths, risks and protective factors using validated tools to inform appropriate, responsive, evidence-based interventions and population statistics that can inform the commissioning process. (p.14)

High quality assessment, early years’ intervention and support are vital to giving children the best start in life and to tackling the underlying causes of ill-health and poor wellbeing throughout people’s lives. (p.4 AoO)

Technology

The most appropriate opportunities for screening, developmental surveillance, monitoring of growth, discussing social and emotional development and linking families with other services were considered to be by 12 weeks of pregnancy; the neonatal examination; the new baby review at 10 - 14 days; before the child’s first birthday and between two and two-and-a-half years old. (p.17 HCP)

Consider explicit use of social and emotional assessment; to continue to consider timing and frequency of assessments to follow NICE guidelines - i.e. including universal assessment by midwives during pregnancy (this should cover risk factors such as stress, domestic violence, antenatal depression, mental health issues and attitudes to baby) with potential modifications of timings immediately after birth and at around two years; to introduce a universal assessment at 3-4 months to assess the quality of parent-infant interaction and a targeted assessment of attachment at 12-15 months. (p.8 AoO)


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Workforce

Practitioners delivering the HCP programme are expected to have knowledge and understanding of child development; factors that affect health and well-being; and ways of working in partnership with parents that recognises their concerns, strengths and aspirations and enables them to set and achieve realistic goals and benefit from anticipatory guidance. (p.18 HCP)

A well-qualified and properly skilled workforce is a key factor in making a real difference to the quality of support that expectant parents and families with young children receive. (p.32 AoO)

Screening programmes, which form part of the HCP, should be associated with an agreed pathway which includes clear referral criteria and timely interventions delivered by suitably qualified personnel. (p.21 HCP)

There need to be motivated, qualified and confident leaders and professionals across health, early years’ and social care, committed to working closely together in the interests of children and families. (p.36 AoO)

A full health and social care assessment of needs, risks and choices by a midwife or maternity healthcare professional, by 12 weeks of pregnancy, represents the starting point of the HCP (p.14) and the opportunity to provide lifestyle advice, what to expect during pregnancy and beyond, preparation for parenthood (especially considering the needs of fathers); information about sources of support and services available; and referral to additional or specialist help, if required. (p.31 HCP) The comprehensive assessment should include identification of the following risk factors - young parenthood; educational problems; NEET, poverty; unsatisfactory accommodation; parents with mental health problems; unstable partner relationships; intimate partner abuse; parents with a history of anti-social or offending behaviour; families with low social capital; ambivalence about becoming a parent; stress in pregnancy; low self-esteem or low self-reliance; history of abuse, mental illness or alcoholism in mother’s own family. (p.15 HCP)

Midwives to be trained in the Family Partnership model to enable sensitive engagement with all clients. Social and emotional risk and resilience factors in the mother, father and wider social network should be explored. The purpose of the universal assessment is to evaluate any significant risk factors in the mother’s life such as mental illness, domestic violence and drug abuse as well as factors which represent a risk to the foetus such as drug abuse / smoking, antenatal anxiety or depression. Resilience factors may include evidence of coping, supportive family relationships and other social support (p.78 AoO). Vulnerable mothers-to-be to be identified using PREview. HADS to be used to identify women with additional mental health needs. Clinically indicated interventions to be offered to particularly vulnerable or high-risk families with complex needs including women in dangerous or threatening relationships and those disclosing past trauma or loss. (p.73 AoO)

Awareness of the fundamental importance of emotional intelligence (or competence) of the Early Years’ sector workforce, and that practitioners and managers possess the skills to form empathetic relationships with parents in a professional capacity. (p.35 AoO)

Within the first 12 weeks of pregnancy

Recommended schedule of contacts


All parents should be offered the opportunity to attend antenatal classes with content based on Pregnancy, Birth and Beyond which not only provides information about the birth but also explores the transition to parenthood. (p. 22 HCP)

After 28 weeks of pregnancy

Midwives to take action to facilitate a ‘secure’ birth by providing emotional and psychological preparation for delivery and early postnatal care. Evidence-based antenatal classes to be offered as both a universal and a targeted intervention: e.g. Preparation for Pregnancy, Birth and Beyond, group version of FNP for young mothers, First Steps into Parenting, Mellow Bumps. The FNP is a good example of an intensive support programme with proven long-term impacts. It is a licensed, preventive programme offering intensive and structured home visiting, delivered by specially trained nurses, from pregnancy until the child is aged 2. (p.74 AoO)

After 28 weeks, during the course of an antenatal review, the HCP team should use promotional interviewing techniques to explore emotional preparation for parenthood; perceptions and expectations of carer-infant relationships; physical and emotional needs of babies; neurobiology and attachment; sources of information about infant development and parenting; explanations about the HCP and Sure Start. (p.33/34 HCP)

Health visitors to use the antenatal promotional guide to initiate a parent-led exploration of feelings about the pregnancy, the developing relationship with the foetus, and the impact of the pregnancy on the couple relationship. The guide should facilitate the identification of mothers and/or their partners who need Universal Plus interventions (medium level of need e.g. ambivalence about the pregnancy, mild to moderate anxiety or depression) or universal partnership plus services (high level of need e.g. serious mental health problems, domestic violence, drug abuse) with referral to other services according to local pathways of care. The Antenatal Attachment Questionnaire can be used at this point if the health visitor is concerned about the mother’s relationship with her unborn baby. (p.80 AoO)

At any time during the pregnancy


All mothers and their partners should be offered 24 hour rooming-in; continuing skin-to-skin mother-baby contact; on-going sensitive, expert support to promote breastfeeding or safe bottle-feeding; information on sources of information and support; anticipatory guidance on the reality of the early days with a baby; sensitive responses to parental concerns; the amazing capacities of the newborn and how to promote closeness and sensitive, attuned parenting. (p.35) Validated tools such as ‘The Social Baby’ book/video, the Brazelton NBAS or NBO or the NCAST parent-child interaction feeding and teaching scales can be used by practitioners to foster sensitive parenting. (p.35 HCP)

Birth to 1 week

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Birth to 1 week (contd.)

10 – 14 days

14 – 21 days


Techniques to promote a trusting relationship and develop problem-solving abilities within the family, e.g. promotional / motivational interviewing; Family Partnership model: The Solihull Approach; One Plus One Brief Encounters should be used to establish parental support needs, provide 1 - 2 structured listening support visits and work in partnership with families to develop problem-solving skills. (p.37 HCP)

New baby review by health visitor

Women should be asked about their mental health within 10 - 14 days of birth and if additional mental health issues identified, offered a choice of options including listening visits by the health visitor or referral for brief CBT, psychotherapy or referral to a perinatal mental health specialist. (p.40, p.42, p.43 HCP)

The primary care PTSD screen could be used. (p.80 AoO)

Where there are concerns about parental mental health or parent-infant interactions, a range of postnatal parent-infant groups should be offered which should include specific components to address the needs of fathers, e.g. Mellow Parenting, PIPPIN or infant massage group. Parents should be encouraged to attend local groups that provide an opportunity for interactive and supportive activities for parents and babies. (p.42 HCP).

Women identified with other risk factors such as learning difficulties, drug or alcohol abuse or domestic violence, which are likely to have a profound impact on their health and well-being or the safety and health of their baby should receive more intensive support from the appropriate specialist service. At risk first-time young mothers should be able to benefit from multimodal support combining home visiting, life skills training and integration with social networks such as that provided by the Family Nurse Partnership. (p.43 HCP)

Use NBAS or NBO to undertake an evaluation of the baby’s reactivity and habituation to external stimuli to increase the parents understanding of the baby’s reactions. This assessment should be focused on more vulnerable parents or parents with more complex problems and is not envisaged as a universal service (p.78 AoO)

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6 – 8 weeks

3 – 4 months


At 6 - 8 weeks, as well as a comprehensive physical examination and review of progress, all parents should be given advice about parenting, health, development, behaviour and safety particularly in the context of sensitive, responsive parent-infant interactions. (p.44 HCP)

Another opportunity to assess risk and resilience - possibly using the Gloucester risk factor checklist. (p.78, p.81, p.89 AoO)

Assessment of maternal mental health should be offered at 6 - 8 weeks (p.40 HCP) by asking the questions recommended in the NICE guideline for antenatal and postnatal mental health (currently under review), followed by the use of an appropriate assessment tool if the mother answers ‘yes’ to either of the two screening questions. If additional mental health issues are identified, a range of options should be offered including listening visits by the health visitor or referral for brief CBT or referral to a mental health / perinatal mental health specialist.(p.47 HCP)

The HADS can also be used postnatally to establish early significant levels of psychological distress or anxiety likely to impact on the relationship with the infant. The Kessler-10 questionnaire may also be used for this purpose. (p.86 AoO)

As well as using promotional/motivational interviewing, etc. to establish support needs and promote problem-solving skills, practitioners should promote closeness and sensitive, attuned parenting. Opportunities for temperament based anticipatory guidance and listening to parents concerns about child development, behaviour and child-rearing practices should be provided. The use of media-based material (e.g baby express newsletters), The Social Baby and NCAST or NBAS/ NBO can be used to foster sensitive parenting where there are concerns about insensitive parenting interactions. (p.47 HCP). If seriously inadequate parent-infant interaction or child protection concerns are identified, referrals should be made to specialist attachment-oriented or parent-infant psychotherapy interventions. (p.47 HCP)

It is recommended that one of the following tools are used to assess mothers’ perception of her infant - ASQ - 2 months; maternal attitude scale; post-partum bonding questionnaire; the maternal object relations short form. (p. 81 AoO)

Assessment of maternal mental health should be offered at 3-4 months by asking the questions recommended in the NICE guideline for antenatal and postnatal mental health (currently under review), followed by the use of an appropriate assessment tool if the mother answers ‘yes’ to either of the two screening questions. If additional mental health issues are identified, a range of options should be offered including listening visits by the health visitor or referral for brief CBT or referral to a mental health /perinatal mental health specialist. (p.47 HCP)

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3 – 4 months (contd.)

By 1 year


Techniques to promote a trusting relationship and develop problem-solving abilities within the family e.g. promotional / motivational interviewing; Family Partnership model: The Solihull Approach; One Plus One Brief Encounters should be used to establish parental support needs, provide 1- 2 structured listening support visits and work in partnership with families to develop problem-solving skills. (p 47 HCP)

As well as using promotional/motivational interviewing etc. (detailed above) to establish support needs and promote problem-solving skills, practitioners should promote closeness and sensitive, attuned, parenting. Opportunities for temperament based anticipatory guidance and listening to parents concerns about child development, behaviour and child-rearing practices should be provided. The use of media-based material ( e.g baby express newsletters), The Social Baby and NCAST or NBAS/ NBO can be used to foster sensitive parenting where there are concerns about insensitive parenting interactions .(p.47 HCP). If seriously inadequate parent-infant interaction or child protection concerns are identified, referrals should be made to specialist attachment-oriented or parent-infant psychotherapy interventions.(p.47 HCP)

There should be a formal universal assessment at 3-4 months of the quality of parent-infant interaction in terms of parental sensitive responsiveness and parental perceptions and attributions. This is a crucial stage on the pathway to secure, or insecure, attachment, and without assessing every mother-infant dyad, attachment difficulties would be missed at this crucial early stage. This also presents an ideal opportunity to explore factors that get in the way of sensitive attunement, and provide guidance on how to foster enjoyable and reciprocal interactions. (p.32, p.79 AoO) The most salient dimension of the early years is the parent-infant relationship. It has been very clearly established as the best predictor of the child’s future wellbeing. Video Interactive Guidance is recommended to assess the parent-infant relationship; however other interactional assessments could also be used - keys to interactive parenting scale; parent-infant interaction observation screen; emotional availability scales (infancy to early childhood version); The CARE index; NCAST. ASQ SE - could be used with vulnerable families to identify social and emotional issues for the baby. The Adult-Adolescent Parenting Inventory is recommended when there are parenting concerns. (p.82 AoO)

The physical, social and emotional needs of the baby should be assessed taking into account the family context. Parents should be provided with information about attachment, particularly with regard to separation anxiety.

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By 1 year (contd.)

12 – 15 months


Techniques to promote a trusting relationship and develop problem-solving abilities within the family, e.g promotional / motivational interviewing; Family Partnership model: The Solihull Approach; One Plus One Brief Encounters should be used to establish parental support needs, provide 1 - 2 structured listening support visits and work in partnership with families to develop problem-solving skills. (p 50 HCP) As well as using promotional/motivational interviewing, etc. (detailed above) to establish support needs and promote problem-solving skills, practitioners should promote closeness and sensitive, attuned parenting. Opportunities for temperament based anticipatory guidance and listening to parents concerns about child development, behaviour and child-rearing practices should be provided. If seriously inadequate parent-infant interaction or child protection concerns are identified, referrals should be made to specialist attachment-oriented or parent-infant psychotherapy interventions. (p.51 HCP) At risk first-time young mothers should be able to benefit from multimodal support combining home visiting, life skills training and integration with social networks such as that provided by the Family Nurse Partnership. (p.51 HCP)

An additional assessment to assess attachment behaviour for those families where there are concerns about the parent-infant interaction or the child’s behaviour (Universal Plus / Universal Partnership Plus) (p.8 AoO) At this age the infant will have developed clear attachment behaviours as well as strategies to regulate emotionally, or not. This age therefore offers the first opportunity to assess for risk and resilience in the infant and is also early enough for targeted or indicated interventions to help change a possible pathway to insecure attachment and/or pathology. Once the proposed assessment method is established in England, it is proposed this additional assessment opportunity is added to the HCP at 12 - 15 months. (p.32, p.79 AoO) If the facilities were available, it would be preferable to use the Strange Situation to assess attachment behaviours in toddlers at this age. However, where this is not possible, a variant such as TAS-45, The Crowell Procedure or the Attachment Q Sort could be used. It is recommended that the infant’s social and emotional well-being is assessed using the Brief Infant and Toddler Social and Emotional Assessment (BITSEA). Additionally, the ASQ - 12 months can be used. (p.82 AoO)

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2 – 2,5 year review


Integrated review with early years’ professional. Review of the child’s social, emotional, behavioural and language development; responses to parental concerns; guidance on health, development and behaviour especially nutrition, physical exercise and the promotion of language development (p.52 HCP). Signposting to appropriate services if required, including parenting programmes.

Integrated health and early education review between the age of two and two-and-a-half will help ensure early identification of any developmental delay or additional needs, and will inform support from providers, parents and other practitioners to address those needs (p.31 AoO). However, the AoO proposes moving the 2/2.5 year review forward to 22 - 24 months to allow for any problems to be identified and help given priority to vulnerable children accessing free early education at age 2 (p.32, p.8 AoO) A number of assessment tools have been proposed to assess various aspects of social and emotional development at this age - e.g. ASEBA CBCL. (p.83 AoO)

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This project was funded by the Department of Health

Documents

Healthy Child Programme and Child Programme and Age of Opportunity compared The Healthy Child Programme Age of Opportunity 1 Implementation Neurological Development It is disappointing