professor jane barlow, director, infant and family wellbeing unit, warwick university clare lushey,...

Professor Jane Barlow, Director, Infant and Family Wellbeing Unit, Warwick University Clare Lushey, Research Associate, CCFR, Loughborough University PRE-BIRTH ASSESSMENT AND PROMOTING ATTACHMENT

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 pregnancy Legal, ethical and practice issues Current pre-birth assessment practice New Pre-birth pathway Feasibility study Structure of the paper

PHYSIOLOGICAL Stress or Teratogens Programming of foetus HPA axis/neurological damage Compromised physiological/emotion al and behavioural functioning PSYCHOLOGICAL / BE HAVIOURA L Reflective Function in pregnancy Atypical parenting behaviours Disorganised attachment Pathways in pregnancy

Stress exposures associated with impact Maternal anxiety (OConnor et al., 2002; Austin, 2005; Obel et al., 2003; Mennes et al., 2006; McMahon et al., 2013), and depression (OConnor 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)

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)

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)

Neurodevelopment post birth Neurodevelopmental functioning of newborns (NBAS) (Diego et al 2004) Temperament (Austin et al 2005; Buitelaar et al 2003; Sleep problems (OConnor et al 2007) Cognitive performance and fearfulness (Bergman et al 2007)

Neurodevelopment childhood Increased emotional problems (anxiety and depression), ADHD and conduct disorder (OConnor 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)

DV in pregnancy Around 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)

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)

PHYSIOLOGICAL Stress or Teratogens Programming of foetus HPA axis/neurological damage Compromised physiological/emotion al and behavioural functioning PSYCHOLOGICAL / BE HAVIOURA L Reflective Function Atypical parenting behaviours Disorganised attachment Pathways in pregnancy

Foetal Alcohol Spectrum Disorders A range of effects (including physical, behavioral, and cognitive) can arise from prenatal alcohol exposure Prevalence 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%

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.

PHYSIOLOGICAL Stress or Teratogens Programming of foetus HPA axis/neurological damage Compromised physiological/ emotional and behavioural functioning PSYCHOLOGICA L / BEHAVIOURA L Reflective Function Parenting behaviours Insecure/ Disorganised attachment Pathways in pregnancy

RF in pregnancy Ability to think about the baby and what he/she may be like; indicative of parental bonding with the infant Pregnancy Interview (Slade et al 1987; Slade 2001) : Mothers prenatal representations of her fetus; Mothers pre-natal representations of herself as a caregiver, focusing in particular on the mothers capacity to identify with, respond to, and anticipate the needs of her fetus at present and her newborn in the near future.

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)

Long-term impact RF during pregnancy predicts: Infant security at 12 months; Childrens ToM skills at 5; Scholastic self-esteem at 12 (Steele & Steele, 2008)

Legal & ethical issues In 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.

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 childs 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. 21

Practice issues Parents might be suspicious of/distrust social services Parents 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 babys 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.

Review: models for pre-birth assessment where there is high likelihood of significant harm to an unborn child Pre-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 outdated Pre-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 assessment The 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.

Pre-birth assessment: Current practice 24

25 LSCB: Pre-birth assessment guidance All 147 LSCBs in England made reference to pre-birth assessments in their procedures (2012-13). Only one third (33%/n=48) acknowledged the lack of legal status of a foetus. Just one quarter (25%/n=36) referenced a pregnant womans 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.

Interviews with practitioners Existing pre-birth assessment practice Telephone interviews with 18 practitioners from 9 localities Main 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 harm Routine 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.

Interviews with practitioners Working with parents Parents 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.

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.

Implications for model development Guidance for social work assessments during the pre-birth period is minimal Few practitioners use standardised tools to aid decision-making and found them difficult to access Legal issues Presents difficulties for practitioners with a statutory responsibility to undertake pre-birth assessments 29

New Model of Pre-birth Assessment 30

Underpinning concepts Partnership working and promoting attachment and reflective function Structured professional judgment and use of standardised tools Capacity to Change 31

Stages of the Model 32

Initial referral Who should refer midwives at booking-in Timing of referral 16 weeks gestations Reasons for referral A 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 child Previous children have been removed because they have suffered or been deemed likely to suffer significant harm A child in the household is the subject of a child protection plan. A child under the age of 16 is pregnant Other DV; Substance-dependency; SMI: Learning problems; parental history of LAC etc. 33

Stage 1 cross sectional assessment: Core assessment tools HITS a domestic violence screening tool Substance use risk profile-pregnancy scale Primary care PTSD screen Multi-dimensional scale of perceived social support (MSPSS) and the support scale North Carolina family assessment scale (NCFAS-G) Depression, anxiety and stress scale (DASS) Relationship questionnaire (RQ) 34

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 scale Brief child abuse parenting (BCAP) inventory form VI Adult-adolescent parenting inventory (AAPI) form Pregnancy interview - revised 35

Stage 1 Core cross-sectional assessment: Optional assessment tools Addiction severity index (ASI) psychiatric status Conflict tactics scale Addiction severity scale (ASI) - drug and alcohol section Alcohol use disorders identification test (AUDIT) C The Needs Jigsaw 36

Stage 2 Case conceptualisation Case formulation involves three stages: Learning about the issues (gather assessment data) Organising the information into patterns or themes Explaining these patterns or themes using a theoretical framework 37

Stage 2 Discrepancy Matrix 38

Stage 3 Goal setting (GAS) 39

Stage 4 - Working therapeutically Core methods Partnership Model; Motivational Interviewing Promoting affect regulation: urge surging techniques; mindfulness techniques etc. Promoting the relationship with the baby: media based tools Getting to Know your Baby app Evidence based programmes: Parents under Pressure; Minding the Baby; Baby Steps; Circle of Security; VIG; Parent-infant psychotherapy etc. 40

Stage 5 Monitoring change 36 weeks gestation Re-administer baseline tools Outcomes of GAS Observations Multiagency reports 41

Stage 6 Analysis and decision-making 42

Classification of risk Severe risk of harm: Families showing risk factors, no protective factors and no evidence of capacity to change High risk of harm: Families showing risk factors and at least one protective factor but no evidence of capacity to change Medium risk of harm: Families showing risk factors and at least one protective factor including evidence of capacity to change Low 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 43

Feasibility study The 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 model Administered by social workers 44

Feasibility study Face-to-face interviews with eight social work managers Focus groups with a maximum of 40 social workers Face-to-face interviews with a maximum of 40 parents; includes those receiving the new model of pre-birth assessment and those receiving the standard Telephone interviews with 12 practitioners who make referrals for pre-birth assessments, e.g. midwives, drug and alcohol workers Collation 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). 45

professor jane barlow, director, infant and family wellbeing unit, warwick university clare lushey,...

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