Ann Rowe

1

Preventing social exclusion The Health-led
Parenting Project

• Ann Rowe
• Implementation lead
• Family nurse partnership
• DfES/DH

2
The starting point Reaching Out

• We have seen reductions in child poverty,
  unemployment and crime, we now need to help those
  families caught in a cycle of disadvantage and
  exclusion by
• Earlier and better identification of at risk
  families
• Earlier and more effective intervention and
  prevention
• Building on the strengths of existing universal
  health visiting and midwifery services
• Builds on policy successes for children and
  families (Every Child Matters and the National
  Service Framework for maternity and children)
• Multi-faceted risks need multi-faceted but
  integrated responses

3
Progressive impacts but concerns about the tail

• Faster income growth for poorer families since
  1997 particularly compared to 1979 - 1997

poorer families
richer families
Source Institute for Fiscal Studies
4
A magic moment of opportunity
Like it or not, the most important mental and
behavioural patterns, once established, are
difficult to change once children enter
school Nobel Laureate James Heckman (2005)

• Pregnancy and the first 3 years are vital to
  child development, life chances and future
  achievement
• Pregnancy and birth of a child is a magic
  moment of opportunity when parents are uniquely
  receptive to support
• Universal midwifery and health visiting services
  are ideally placed to identify children and
  families at risk
• Embedding the principle of progressive
  universalism into maternal services should be a
  priority to ensure that additional support is
  provided to those children and families at
  greatest risk

5
How we are delivering the SEAP

• Refining the identification, assessment and
  engagement process
• Testing and evaluating the Nurse Family
  Partnership Programme in 10 sites
• Promoting sustainability through
• Commissioning
• Workforce development
• Wider service redesign
• Sharing learning

6
Long term effects of maternal antenatal stress on
the child

• Lower cognitive development
• ADHD and conduct disorder
• Anxiety and depression
• Lower birth weight, earlier delivery

7
What causes stress?

• Anxiety and depression/ mental illness
• Abusive relationship with partner (emotional or
  physical abuse)
• Lack of social support-little supportive contact
  with family or friends
• Recent immigrant/ethnic minority, especially
  Pakistani/ Bangaldeshi
• Poverty/poor housing

8
Parenting is at the heart of a range of public
health issues
9
Parenting and later outcomes
Attachment
Smoking/drugs
Self-esteem
Promiscuity
Mental health Education Poverty Unemployment Etc
Parenting
Behaviour
School failure
Emotional Regulation
Delinquency
Relationships
Obesity
Communication
10
Emerging knowledge on neurological development

• Brain development depends on both genes and
  experiences
• Rapid brain development takes place in the first
  year of life
• Early interactions directly affect the way the
  brain is wired use it or lose it
• Early relationships set the thermostat for later
  control of stress response
• (Shore R, Rethinking the Brain, 1997)

11
Why love matters

• Looks and smiles help the brain to grow
• Baby looks at mother sees dilated pupils
  (evidence that sympathetic nervous system aroused
  and happy) own nervous system is aroused - heart
  rate increases
• Lead to a biochemical response - pleasure
  neuropeptides (betaendorphin and dopamine)
  released into brain and helps neurons grow
• Negative looks trigger a different biochemical
  response (cortisol) stops these hormones and
  related growth
• 
  (Gerhardt, 2004)

12
Differences in brain development following
sensory neglect
13
THE NURSE FAMILY PARTNERSHIP

• Program with power
• Nurses visit first time parents from pregnancy
  until child age two
• Makes sense to parents
• Solid clinical theoretical underpinnings
• Rigorously tested
• 30 years of development and 3 large scale trials
• Synergy of science and service

14
FAMILIES SERVED

• Low income pregnant women
• Usually young
• First-time parents
• From early pregnancy until the child is 2 years
  old

15
NURSE FAMILY PARTNERSHIPSTHREE GOALS

• Improve pregnancy outcomes
• Improve child health and development and future
  school readiness and achievement
• Improve parents economic self-sufficiency

16
TRIALS OF PROGRAM
Elmira, NY 1977
Memphis, TN 1987
Denver, CO 1994
N 400
N 1,138
N 735

• Low-income whites
• Semi-rural

• Low-income
• blacks
• Urban

• Large portion of Hispanics
• Nurse versus paraprofessional visitors

17
CONSISTENT RESULTS ACROSS TRIALS

• Improvements in womens prenatal health
• Reductions in childrens injuries
• Fewer subsequent pregnancies
• Greater intervals between births
• Increases in fathers involvement
• Increases in employment
• Reductions in welfare and food stamps
• Improvements in school readiness

18
Memphis Program Effects on Childhood Injuries (0
- 2 Years)

• 39 Reduction in Health-Care Encounters for
  Injuries Ingestions (Low-Resource Mothers)
• 78 Reduction in Days Hospitalized for Injuries
  Ingestions (Low-Resource Mothers, p.07)

19
Growing Effects on Child Development Memphis
6-Year

• Higher IQs
• Better language development
• Better school readiness in Math
• Fewer mental health problems

20
ELMIRA SUSTAINABLE RESULTS Benefits to Children

Based upon family-court records of 116 children
who remained in study-community for 13-year
period following end of program.
15-YEAR FOLLOW-UP
21
Benefits Minus Costs of Child Welfare Home
Visiting Programs

• Nurse Family Partnership
• Home Visiting for at-risk mothers/children
• Parent-child interaction therapy
• System of care/wrap around programs
• Family Preservation Services Programs
• Healthy Families America
• Comprehensive Child Development Program
• Infant Health and Development Program
• Summary Report
• http//www.wsipp.wa.gov/rptfiles/04-07-3901.pdf

• 17,180
• 6,197
• 3,427
• -1,914
• -2,531
• -4,569
• -37,397
• -49,021

22
Cumulative Cost Savings Elmira High-Risk
Families
Cumulative savings
Cumulative dollars per child
S O C I A L R E T U R N
Cumulative Costs
Age of child (years)
23
The 10 PCT / LA sites

• Somerset
• Manchester
• Slough
• Tower Hamlets
• Derby
• Walsall
• Southwark
• County Durham/Darlington
• SE Essex
• Barnsley

24
What is different?

• New systems and conversations to identify and
  engage at risk clients
• Starts early - parenting begins at conception
• Multi-dimensional intervention
• Programme ethos strengths and goals not needs
  and problems
• Continuity of practitioner
• The intensity of the intervention (relationship
  and contact)
• Using a licensed research based programme
• Role and level of supervision

25
The content of the visits cover 6 domains

• Personal health womens health practices and
  mental health
• Environmental health home and neighbourhood
• Life course development womens future goals
• Maternal role skills and knowledge to promote
  health and development of their child
• Family and friends helping to deal with
  relationship issues and enhance social support
• Health and human services linking to other
  services
• The relationship between the home visitor and the
  family lies at the heart of the programme.

26
Visiting Schedule

• 1/week first month
• Every other week through pregnancy
• 1/week first 6 weeks after delivery
• Every other week until 21 months
• Once a month until age 2

27

Opportunities for practitioners

• Work with evidence based programme prescribed
  structure, materials, monitoring.
• Develop advanced skills, using materials
  creatively in the moment
• Develop client centred therapeutic relationships
• Strengths based, solution focused with an
  expectation of behaviour change
• Building on existing skills and knowledge base
• Skills for advanced level practice with most
  challenging families
• Applying theories and principles integral to NFP
  model

28
What is exciting?

• Passion and commitment to make a difference
• Level of interest and support
• Our learning
• Catalyst for wider change
• Building a 21st century service for families
• Developing professional practice for the future