4 year Longitudinal evaluation of the Action for Children UK Neglect Project Outcomes for the children, families, Action for Children, and the UK
FINAL REPORT January 2012 Four year longitudinal evaluation of the Action for Children UK Neglect Project Outcomes for the children, families, Action for Children, and the UK
Tony Long Michael Murphy Debbie Fallon Joan Livesley Patric Devitt Moira McLoughlin Alison Cavanagh
January 2012
ISBN: 978-1-907842-30-6
THE PROJECT TEAM
Dr Tony Long is Professor of Child and Family Health. A Registered Child Health Nurse, his personal research programmes are in evaluation of early intervention in health and social care services for children and families, parental coping, and clinical research on quality of life outcomes for children and families after treatment for cancer.
Michael Murphy is Senior Lecturer in Social Work. A qualified social worker and counsellor, he has wide experience in dealing with substance misuse, looked after children, chaotic families, and safeguarding children, and has published widely in these areas. He acts as a training consultant to several training organisations, is Chair of Bolton Substance Misuse Research Group, and was an executive member of PIAT.
Dr Debbie Fallon is Senior Lecturer in Child Health and is the co-lead for CYP@salford taking the lead on research with young people. Her research interests span health (particularly sexual health) social care and education issues for young people, She is published in the field of teenage pregnancy and sexual health and is a Trustee at Brook (Manchester) and for The Association for Young People‟s Health.1
Dr Joan Livesley is a Senior Lecturer in Children‟s and Young People‟s Nursing and is published in the field of children in hospital, multi-agency working for children‟s services and evidence-based practice. She undertakes research in partnership with children and young people. She has a clinical background in services for children in hospital and the community, she has professional links with community children‟s services.
Patric Devitt is Senior Lecturer in Child Health with a clinical background in children‟s nursing working particularly with children with cancer and their families. He is a member of the steering group of the Royal College of Nursing‟s Research in Child Health Group. He researches the quality and effectiveness of services for children and families, and also investigates safety issues for children.
Alison Cavanagh is Lecturer in Child Health. Alison is a Registered Nurse in Child Health and Counsellor in training. Alison has a clinical background as a school health advisor/ nurse and wide experience working in the community, particularly in safeguarding services.
Moira McLoughlin is a Senior Lecturer in Children and Young People‟s Nursing. A registered children‟s nurse for over twenty years she is currently undertaking a PhD in a specific aspect of safeguarding and has developed and published teaching resources for both students and qualified staff in this area of practice.
http://www.salford.ac.uk/nmsw/research/children,-young-people-and-families
1 Now University of Manchester. [email protected]
CONTENTS Page EXECUTIVE SUMMARY 5 1 INTRODUCTION 7 2 REVIEW OF EXISTING EVIDENCE 8 Defining neglect 8 Understanding differing aspects of neglect 8 Effectiveness of responses to neglect 10 Why is neglect neglected? 10 What works? 12 3 THE EVALUATION STUDY 13 The stimulus for the evaluation 13 Evaluation objectives 13 Evaluation design 14 Selection of cases 14 Data collection and analysis 16 Ethical issues 18 Project Timetable 18 Ongoing dissemination 18 4 FINDINGS: eASPIRE CUSTOM FIELDS DATA 20 Presenting needs 20 Child-related factors 21 Parental factors 21 Environmental factors 22 Interventions 22 Summary 23 5 FINDINGS: ACTION FOR CHILDREN ASSESSMENT TOOL DATA 24 Removal of concern, remaining concern, or prevention of neglect 24 Removal of concern about neglect 25 Remaining concern about neglect 26 Prevention of neglect 26 Overall reduction in concern about neglect 27 Summary 27 6 FINDINGS: TEXTUAL DATA FROM CASE NOTES 29 The home 29
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The child 30 The parents 32 Summary 36 7 ANALYSIS AND DISCUSSION 37 Outcomes of Action for Children intervention 37 Key factors in achieving positive change 38 8 CONCLUSIONS 41 Summary 41 Key messages and questions for further research 41 9 REFERENCES 43 APPENDIX 1: Introducing parents to the neglect research project 45
LIST OF FIGURES Figure 1: Location of centres 15 Figure 2: Levels of need and problems 16 Figure 3: Removal of concern, remaining concern, or prevention of neglect 24 Figure 4: Change in total areas of serious concern (scores of 4 or 5) in the three 25 major areas of the Action for Children Assessment Tool Figure 5: Breakdown of cases where concern remained 26 Figure 6: Frequency of improvement in concern about neglect 27
LIST OF TABLES
Table 1: Items in the Action For Children Assessment Tool 17 Table 2: Cases recruited from each centre 18 Table 3: Evaluation timetable 18 Table 4: Presenting needs – frequency of recording 29 Table 5: Frequency of child health, education & emotional wellbeing indicators 21 Table 6: Frequency of parent/carer indicators 21 Table 7: Frequency of environmental indicators 22 Table 8: Frequency of interventions applied 22 Table 9: Frequency of parenting programmes applied 23
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EXECUTIVE SUMMARY
BACKGROUND TO THE EVALUATION 5) To identify worthwhile hypotheses During a 5-year intensive family support for further research. (IFS) programme to provide effective, lasting intervention for families and METHOD children most in need Action for Children The evaluation was based on quantitative created a redefined focus on neglect in a recording of the level of concern about selection of sites across the UK: the UK neglect in 14 areas at least on referral and Neglect Project. The intention was to on closure; electronic recording of key improve outcomes for children whose characteristics of the child, the parents developmental needs were being and the environment; and review of textual insufficiently met, placing them at risk of data in files for detail of issues on referral, poor educational, emotional and social specific interventions, and evidence of outcomes. An earlier evaluation2 reported outcome for the child. Serial review of the that IFS could “make a positive difference files and scores allowed for the to the lives of children and their families in longitudinal recording of progress, or lack even the most challenging circumstances”. of it, in each case. This evaluation was designed to establish the factors that made this possible. A four- An integral part of the project was to work year longitudinal evaluation was with Action for Children to enhance the commissioned which would allow quality of data through the introduction of a researchers to follow families from referral new assessment tool and development of to closure, and to pursue the work of additional elements of the standing in- individual sites over a period of house electronic database; and to improve development of working practices. practice and outcomes through shared
learning. EVALUATION OBJECTIVES
1) To gather detailed evidence on the The inclusion criteria were that children circumstances in which families are were under the age of eight years, and referred for intervention and the neglect had been identified explicitly by wide-ranging assessment of family the referring agency or on assessment. needs and problems; the The customised Action for Children interventions applied; and the Assessment Tool was employed with all outcomes for children. cases. Eighty-five cases were included 2) To correlate key factors at a from seven sites across the UK. population-level identified at the assessment phase with eventual OVERVIEW OF FINDINGS disposition on closure and The Action for Children Services that were outcomes for the child. (eAspire included in this evaluation demonstrated data) their ability to intervene successfully in most cases of neglect, even when neglect 3) To identify correlation between was a most serious concern (to the level of presenting factors, interventions, child protection intervention). In cases and outcomes from individual case where parents refused or were unable to file Action for Children Assessment respond positively, children benefited from Tool scores. an expedited move into care. 4) To secure illuminating detail from textual data in case files to explain Prevention of neglect or findings from quantitative data. improvement in the level of concern about neglect was shown 2 Tunstill J, Blewet J, Meadows P (2008) in 79% of cases. Only in 21% of Evaluating the delivery by Action for Children cases was no improvement made. of targeted family support. Synergy Research and Consulting Ltd. In 59% of cases, concern about neglect was removed completely.
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and domestic violence were also common In a further 9% of cases, factors. A combination of parenting intervention to prevent the programmes and home-visiting was the expected development of neglect mainstay of intervention. The ability and was successful. willingness on the part of parents to engage with services was a crucial factor In the remaining 32%, concern in deciding whether progress would be about neglect remained on closure made or children removed for of the case. Most of these resulted accommodation. in children being taken into care, though even among these a small The Action for Children Assessment Tool proportion showed some enabled practitioners to work with parents improvement. The remaining cases to establish a joint understanding of in which concern remained were problematic aspects of parenting and to returned to the referring agency for plan for staged improvements. It also continued work on the Action for provided a valuable source of evidence of Children action plan. objective assessment and review.
The most common problems identified as Further work is needed to investigate the serious causes for concern were chaotic impact (immediate and longer-term) on family lifestyles with absence of routines children. and poor home conditions. Poor hygiene
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1 INTRODUCTION
Public inquiries and other reviews repeatedly show that following early Such studies as have been completed identification of neglect, some children and have tended to be of short duration: families fail to receive adequate services, snapshots of activity and outcomes. A sometimes with tragic consequences. literature review for the former Department Since neglect is the most common for Children Schools and Families (DCSF) category for child protection registration in established that most research evidence the United Kingdom (Department for was retrospective, focused on proxy Education (DFE) 2011a), it is vital that measures of outcomes (rather than direct intervention is both timely and effective. observation), and were small in scale However, successful intervention to (Daniel et al 2009). improve parenting ability, to establish appropriate intra-family relationships, and During the course of this and other related to secure positive outcomes for children “is studies, it has become clear to the likely to be costly, requiring intensive, research team that in working with families long-term, multi-faceted work by a highly which operate in a multi-dimensional type skilled workforce” (Moran 2009). If these of chaos, child care teams and whole factors can be addressed, then positive systems can become drawn into outcomes are possible. There is recent “mirroring” parts of that family chaos. In evidence, too, that when neglect is the middle of this mirroring, it can become entrenched and timely assessment shows difficult to maintain focus, to measure that the family situation is unlikely to progress, or to measure decline in change, then intervening to take children functioning in the child or the family. This into care earlier rather than later improves may help to account for the “bulging outcomes in later (young adult) life thresholds” phenomenon, where levels of (Hannon et al 2010). Both in cases where intervention have not escalated despite neglect can be addressed successfully significant deterioration in the child‟s and in cases where there is no indication situation. This also has an impact on of likely improvement, skilled, early researching what works with neglectful intervention is the vital factor. families. The mirroring of chaos can lead to difficulty in obtaining clear and logical However, there is sparse research data to measure outcomes. In this study, evidence on the most effective means of the use of a problem-specific assessment preventing or reducing neglect and its instrument together with associated adverse outcomes. Reliance on studies training and ongoing support both centrally from the US risks basing practice on non- and locally helped to counteract this effect. transferable evidence which may not necessarily relate well to the political, legal Managing neglect is complex, and simple and socio-economic context of British approaches to intervention are likely to be services. Variation in the way in which insufficient. The chronic and multi-faceted neglect is defined, including the scope of nature of the problem necessitates a what is included in the definition, causes holistic, joined-up approach with a blend of additional difficulty in interpretation and services tailored to individual needs, often implementation of findings (Stein et al over a long period of time. Since the 2009). Failure to distinguish between nature of neglect often demands longer- neglect and other aspects of abuse further term intervention for sustained confuses the issue. Reports of improvement to be achieved, then a interventions with vulnerable families often longitudinal approach to evaluation is also fail to distinguish between cases where indicated. neglect is the concern and more generalised cases of abuse.
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2 REVIEW OF EXISTING EVIDENCE
DEFINING NEGLECT Protect a child from physical and emotional In comparison with other forms of harm or danger; maltreatment of children, neglect is Ensure adequate complex and challenging to define (Moran supervision (including the 2009). The working definition provided in use of adequate care- “Working Together to Safeguard Children” givers); or is well known and had been retained and Ensure access to reaffirmed as central guidance for several appropriate medical care or years. treatment. “The persistent failure to meet a It may also include neglect of, or child‟s basic physical and/or unresponsiveness to, a child‟s psychological needs, likely to result basic emotional needs” (DCSF in the serious impairment of the 2010). child‟s health or development. It may involve a parent or carer failing to provide adequate food, UNDERSTANDING SOME DIFFERING shelter and clothing, failing to ASPECTS OF NEGLECT protect a child from physical harm or danger, or the failure to ensure Growing understanding of the complexity access to appropriate medical care of neglect and its contributing factors has or treatment. It may also include led to categorisation of types of neglect, neglect of, or unresponsiveness to, though the implication of some a child‟s basic emotional needs” classification has not always been clear. In (Department of Health 1999). a review of definitions of neglect, Horwarth (2007) identified the following domains. This definition was adopted by the project Medical neglect – minimising or and the evaluation as the basis for denial of a child‟s health needs decision-making. A rough rule-of-thumb Nutritional neglect – often version was also agreed: “Neglect occurs associated with failure to thrive or, when the basic needs of children are not more recently, obesity and lack of met, regardless of cause.” In an important exercise practical sense this was helpful to Emotional neglect – being practitioners. It brought attention squarely unresponsive to the child‟s basic onto the impact on the child and reinforced need for emotional interaction and the issue of parental fault or intention not support, perhaps causing damage being necessary for the child to suffer to the child‟s self-esteem neglect. Educational neglect – lack of normal stimulation in early years, The definition of neglect was revised in failing to ensure attendance at 2010. school and to support learning in “Neglect is the persistent failure to middle childhood meet a child‟s basic physical Physical neglect – failure to and/or psychological needs likely provide appropriate living to result in the serious impairment conditions, food, and clothing. of the child‟s health or Lack of supervision and guidance – development. Neglect may occur inadequate supervision to ensure during pregnancy as a result of the child‟s safety, and in later maternal substance misuse. Once childhood not providing essential a child is born, neglect may involve information and guidance about a parent or carer failing to: common risks (for example, Provide adequate food, alcohol misuse). clothing and shelter
(including exclusion from home or abandonment);
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These help to specify aspects of care that they demonstrate poor social relationships may be the focus of neglect, and all of with peers and with adults. It is not these featured in the referral, assessment uncommon, in due course, for children to and intervention reported in the cases in become carers of their parents. In doing the evaluation. so they may become strongly resistant to what is perceived as interference from A different approach was taken by services seeking to intervene to improve Crittenden (1999) in seminal work on the the parenting ability. causes and response to neglect. She considered both the cause and the Case management is directed at helping manifestation of neglect and offered the parents to learn to access other sources of following three common presentations. support and to reassert an appropriate parent-child relationship when necessary. Disorganised neglect It is often necessary to teach and coach Crittenden described this as occurring in parents to engage with their children multi-problem, disorganized, crisis-ridden emotionally. families, a common problem faced by family intervention projects. She noted that Depressed neglect parents often appear to recognise their Clinical depression in parents, with many need for help, and they welcome varied causes, can be disabling such that professional intervention. Evaluation of a parents may become unable to perceive raft of family intervention projects indicates their children‟s needs or to believe that that this welcome is dependent, however, any positive change is possible. They may upon a respectful approach from appear unable to understand what is practitioners, showing value for the required of them and clearly lack parents (Ravey et al 2008) and placing motivation. Parents may feed, change and equal priority on family-identified problems move children but rarely respond to (Livesley et al 2010). Parents‟ feelings signals from them. In the absence of dominate behaviour, leading to response to their prompts, children may inconsistent and unpredictable care of themselves become silent, limp, dull and children. In response, children become depressed. more demanding in order to gain their parents‟ attention, sometimes in Affected children benefit from access to increasingly dramatic behaviour. responsive and stimulating environments, so placements in day care are part of the Successful management of such cases solution. Building resilience in this way is relies upon developing trust and both key to their longer-term wellbeing. introducing and modelling consistent, Treatment of depression tends to take predictable care. Alternative strategies will much time, and little improvement may be be introduced to offer more effective and expected in the short term. Nevertheless, positive ways for parents to manage the coaching to practice simple interactive children‟s behaviour, and intensive, often strategies (smiling, soothing and so on) prolonged, coaching to set boundaries and may be effective with persistence. to provide structure to the family‟s day. Categorisation can be deceptive Emotional neglect Evidence about parental characteristics In emotional neglect, families might be associated with neglect has been found to seen to be materially relatively advantaged be particularly complex, and the types but the children suffer from their parents‟ identified above may appear deceptively failure to connect with them emotionally. clear-cut. Naturally, the diagnosis of Children know their roles, respond to clear depression is to be left to those qualified to rules, and often do well at school. Their undertake such a skilled activity, but physical needs are usually met, but their health visitors have been found to be well- emotional needs remain unfulfilled. In the equipped to recognise both the parental absence of empathic responses from characteristics associated with neglect and parents, children may appear falsely bright the signs in children of developmental and self-reliant, but on closer examination problems (Daniel et al 2009).
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EFFECTIVENESS OF RESPONSES TO move to a higher threshold, but sometimes NEGLECT it is the day-to-day neglectful interactions that lead to the most harm to the child Although most families can go through (Platt 2006). periods of relative neglect (Department of Health (DH) 1995), it is usual that the families which come to the notice of WHY IS NEGLECT NEGLECTED? safeguarding systems have shown signs of neglectful interaction between parents Assessment and children over a number of years. Assessing a family‟s private domain is Although there is some evidence to always difficult. The British safeguarding indicate that cognitive or behavioural system was originally established to approaches can be helpful within some measure acts of commission – particularly parenting programmes, there is little around physical or sexual violence. evidence to suppose that most short-term Assessing neglect involves measuring a intensive approaches work in the field of complex series of acts of parental neglect, thus longer-term interventions omission and their subsequent impact on seem to be more productive. However, the child‟s development and wellbeing. organising and resourcing longer-term This assessment attempts to measure interventions can be particularly collectively three areas of parental challenging to child care systems as most omission – provision, protection and interventions around physical and sexual emotional availability. abuse have a relatively short intervention period. Neglect is characterised by As part of the assessment, the assessors repeated need for intervention, and must decide if the interaction they are families require long-term support. If dealing with involves neglect, and at what families need to be in receipt of continuous threshold the child care system should services, this involves significant demand respond. As well as measuring parental on practitioner time, interagency omission, the assessment attempts to collaborative effort and emotional energy. measure the impact of that level of parenting on the child‟s development, In the face of families with complex, multi- safety, attachment and self-esteem. The faceted problems, child care systems have true impact of neglect may not be to develop multi-faceted plans, seeking to apparent immediately, but may take deal with more than one aspect of concern months to become clear. This demands an at a time. This leads to three different understanding of the concept of neglect in challenges. The first is that child care relation to child development and its interventions of all kinds seem to be less evidence base. It also requires an productive in the face of numerous appraisal of parenting capacity, and competing problems. The second is that parental capacity to change in relation to these different problems interact with each the developmental timetable of the child. If other to amplify child care difficulties within the impact of neglect is slow to become families. The third is that the complexity of apparent, and the system around neglect interwoven problems in families leads to is relatively reluctant to become involved great difficulty in measurement and in early stage interventions, the child can response by child care systems be many months old before the system gets to grips with the family situation These complex series of relative (Horwarth 2007, Platt 2006). judgements often lead to a lack of agreement on the threshold for Analysis intervention, particularly at safeguarding The analysis of the assessment of a and care stages of intervention (Platt neglectful family can also be difficult, if 2006, Stevenson 2007). The intent to analysis is taken to be the ability to apply a harm is not always present, but neglect collective meaning to gathered data. may overlap with other forms of Difficulties in definition, difficulties in maltreatment. The presence of physical or making judgements about highly complex sexual violence may lead to a decision to and chaotic family situations, and finally
8 the difficult task of making judgements the situation has really become much against changeable thresholds (Macrory & worse; to recognise whether or not Murphy 2011) can make the analysis and anything has changed significantly; and decision-making process especially whether there is sufficient evidence to complicated. respond differently. This phenomenon of „bulging thresholds‟ is particularly pertinent Neglect is not absolute. It is not to neglect. scientifically measureable. It is always relative and relies on a series of complex The intergenerational nature of neglect in interagency judgements about „normal‟ or many cases can mean that parents „average‟ levels of parenting in families. currently subject to professional concern The Children Act 1989 offers a wide band and supportive intervention can have of definition with „significant harm‟ and experienced seriously impaired levels of „reasonable parenting‟, which are matched parenting which, in the absence of better with the latest “Working Together” report knowledge and experience, they then (HM Government 2010) which offers replicate with their own children. Reder „persistent [parental] failure to meet a and Duncan (2001) note that, for some child‟s basic needs‟ and „serious parents, “care conflicts” can be played out impairment‟ of health or development with their own children in response to (p39). A series of extra tools, including the normal demands from the children for Home Inventory (Cox & Walker 2002) and levels of care which would be considered the Graded Care Profile (Pollnay & no more than minimally acceptable. One Srivastava 2001) have been developed, perspective on this intergenerational based loosely on Maslow‟s hierarchy of distress is the failure of attachment need, to assist in this process. Action for between parent and child that is sustained Children has used a modified version of and replicated from one generation to the the Graded Care Profile in its approach. next. However, all these tools depend on the practitioner‟s ability to analyse what they In just the same way that attachment see of the family‟s private domain and to difficulties between parents and children translate that into complex decisions about can be a significant consequence of what is and is not child neglect. neglect, there can also be attachment difficulties between practitioners and the Action family. Working over a period of years with If measuring and analysing a neglectful chaotic, unresponsive families can put family situation is beset with practice significant emotional strain on those in the difficulty, then the collective action field. With parents who are persistently required to help families to change is also neglectful, notably those with substance potentially problematic. The safeguarding misuse or domestic violence problems, system is set up to deal with the children and practitioners may be prone to collaborative „short sprint‟ between child feelings of disappointment and anger at protection inquiry, conference, core group the lack of progress and repeated relapses and review conference. Neglect involves (Hart & Powell 2006). This can be seen to an interagency „marathon‟ where be a manifestation of the emotional labour practitioners and systems have to act of working with neglectful parents, and the collectively and respond to families over a sustained effort and commitment required number of years. This poses ongoing to pursue matters to a satisfactory challenges to child care systems (Hallett & conclusion draws heavily upon Birchall 1992). professional emotional resilience (Social Work Reform Board 2010). Involvement with a family over a number of years can frequently find the practice Adult-orientation group „frozen‟ into a pattern of response In terms of child care systems, an adult- that is not productive. If action is delayed oriented issue is a problem with the adult to the end of the marathon it becomes parent that significantly impacts on their difficult to truly assess, analyse and ability to deliver a consistent parenting respond in a different way: to believe that service to the child. Substance misuse,
9 parental mental ill-health, domestic identified promising aspects of intervention violence and learning disability can often (Moran 2009). Home visiting, parent be present and significant in cases of training, school-based social worker neglect. In terms of the neglect itself these support and intervention, social network issues can make the parent less available support and therapeutic approaches with and responsive to the child. These issues parents and children are supported by can also intrude into the neglect response various degrees of evidence, though often in four ways. not so convincingly. The latest review of 1) Child care staff are not used to child neglect for Action for Children adds measuring these issues and more strategic dimensions to this (Burgess calculating their impact on the child et al 2012). In this report it is noted that (Cleaver et al 2007, McCarthy & the current structure of child protection Galvani 2010). systems in the UK can militate against effective action on neglect; that increasing 2) The adult-oriented issue can financial pressures are impacting more become the prime focus of severely on children‟s wellbeing; and that attention. commitment by UK and devolved 3) The family is often involved in administrations to a longer-term approach the adult-oriented practice system to intervention in neglect is essential. (eg mental health or substance Furthermore, improving clarity among misuse system) which makes professionals and the public over what interagency collaboration more constitutes neglect would help to ensure complex. earlier and more effective intervention. It is 4) The adult-oriented issue can clear that intervening in neglect is likely to become an obstacle to significant be costly in resources, requiring intensive, parental change. long-term, multi-faceted work, employing a highly skilled workforce. The challenges to achieving these requirements, particularly WHAT WORKS? in a persistently difficult financial context, A previous review of evidence to inform are enormous. practice for Action for Children has
“Provision of such services is likely to be hampered by the short-term nature of much funding available for new initiatives, and by a desire for quick results. Given that neglect is a problem characterised by multiple contributing factors at personal, interpersonal, social and societal levels, it is also important to remember the role of social policy in alleviating neglect.” Moran P (2009) Neglect: research evidence to inform practice. Action for Children.
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3 THE EVALUATION STUDY
THE STIMULUS FOR THE EVALUATION conclude analysis and reporting, a four year evaluation was commissioned from The Intensive Family Support November 2008 to July 2012. Programme Action for Children embarked on a 5-year Intensive Family Support (IFS) programme EVALUATION OBJECTIVES in a determined effort to provide effective, lasting intervention with families and Evaluation Aim children most in need. As the lack of The end-product of this evaluation was to evidence to guide services in dealing with be research evidence to guide neglect became apparent a redefined practitioners in intervening in cases of focus was created to concentrate on neglect, establishing which interventions neglect in a selection of sites across the produce the best results in given sets of UK: the UK Neglect Project. Involved circumstances. projects adopted a whole-family approach and locally-appropriate resources to target The ultimate goal for Action for Children the IFS approach on selected families was to deliver better outcomes for where there was evidence of vulnerability vulnerable children, to develop an and unmet need relating to neglect. The improved service response that could be focus was on work to improve the rolled out across the organisation, and to outcomes for children whose improve co-working relationships with developmental needs were being Local Authority and other statutory insufficiently met, placing them at risk of agencies poor educational, emotional and social outcomes. Evaluation Objectives 1) To gather detailed evidence on the Early Evidence of Success circumstances in which families are As this evaluation was being planned, an referred for intervention and the earlier evaluation was reported (Tunstill et wide-ranging assessment of family al 2008). This provided clear indication needs and problems; the that IFS could “make a positive difference interventions applied; and the to the lives of children and their families in outcomes for children. even the most challenging circumstances”. 2) To correlate key factors at a Even as a short evaluation, this offered population-level identified at the both evidence of potential impact and assessment phase with eventual tantalising glimpses into the detail of the disposition on closure and mechanisms by which success might be outcomes for the child. (eAspire achieved. Action for Children then data) proceeded to set up a raft of further evaluations of specific elements of its 3) To identify correlation between portfolio, and this included the project presenting factors, interventions, reported here. and outcomes from individual case file Action for Children Assessment The Need for Longitudinal Evaluation Tool scores. Already cognisant of the limited results 4) To secure illuminating detail from achieved by short-term, snapshot reviews, textual data in case files to explain the commissioners planned for a findings from quantitative data. longitudinal approach which would allow researchers to follow families from referral 5) To identify worthwhile hypotheses to closure, and to pursue the work of for further research. individual centres over a period of development of working practices and improvement of data recording. Including time to set the evaluation up and to
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EVALUATION DESIGN order to focus on the effect of early intervention in reducing adverse Overview outcomes for children) The evaluation was based on quantitative • Neglect had been identified recording of the level of concern about explicitly by a referring agency at neglect in 14 areas at least on referral and the point of request for an Action on closure; electronic recording of key for Children service for a named characteristics of the child, the parents individual (an external referral) OR and the environment; and review of textual data in files for detail of issues on referral, • Neglect was identified as an specific interventions, and evidence of emerging concern relating to a outcome for the child. Serial review of the child attending one of the included files and scores allowed for the projects (an internal referral). longitudinal recording of progress, or lack • The Action for Children of it, in each case. Assessment Tool (or previously the
North East Lincolnshire An integral part of the project was to work Assessment Tool) would be used with Action for Children to enhance the and summary scores recorded. quality of data through the introduction of a new assessment tool and development of • From early 2010 it was also agreed additional elements of the standing in- that enhanced custom fields in house electronic database; and to improve eAspire (an Action for Children practice and outcomes through shared bespoke tracking system detailed learning. below under “Data Collection”) would be included as part of the Preparing and Supporting the study data. Managers and Practitioners Working closely with the Action for Children project managers, the project Recruitment of Services team planned to ensure thorough Identification, recruitment and preparation preparation by front-loading the project of selected sites for inclusion in the with careful preparation of sites, evaluation was the first step. Joint visits instruments and partnerships. This were made by the research team and the involved site visits, explanation of the Action for Children manager to all sites. evaluation objectives and required data, Staff at every site were enthusiastic and and relationship-building with project supportive, and plans for the evaluation managers and practitioners. were revised and improved as a result of observation, feedback and discussions. At A series of meetings for managers (six per each visit, where possible, a senior officer year) and workshops for project workers (2 from the Local Authority was invited to per year) was conducted to ensure meet the visitors and service managers to effective communication, cross-site discuss the value of the research project collaboration, and problem-solving as the to the Local Authority, and to elicit support project and the evaluation evolved. Much in the form of continuance of data effort was exerted by Action for Children, collection on outcomes for children after the research team and project staff to leaving Action for Children services. On develop appropriate and practical every occasion this was agreed, and, instruments for collecting and recording while the exact mechanism for the necessary data. transference of this data was still to be confirmed, it seemed likely that at least some ongoing data of the sustained SELECTION OF CASES impact on the child would be made available. However, as a result of budget Inclusion Criteria cuts, this arrangement has not proved The inclusion criteria were that: possible. Indeed, several commissions have since been cut, amended or lost. The family included at least one • child under the age of 8 years (in
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A UK-wide group of services was recruited Three of the initial sites were closed to (Figure 1). Initially (January 2009), these further recruitment to the evaluation included sites in Scotland, Wales and (though existing cases continued), and two England. It was found that cases from a new sites were added. These were site in the south of England would not selected on the basis of their dealing with meet the inclusion criteria, so this was cases where early intervention was more replaced in March 2009 by a site in central likely. An additional site in Derry was England. Following the interim reporting at brought in, completing the UK-wide focus. the midpoint in July 2010, where it was reported that the sample was heavily skewed towards cases of entrenched neglect, further adjustment was made.
Figure 1: Location of centres
Overall, then, the constituency of the Five services focused mostly on high-level evaluation was in a state of flux, but the neglect cases assessed at Hardiker level 3 longitudinal nature of the project allowed or 4 (Figure 2). Two sites also provided for changes to be exploited positively services at level 2, while one service rather than presenting limitations. The focussed entirely on level 4 cases, skewing of the sample was corrected, the undertaking intensive assessment for spread of cases across the UK was court reports. All seven services received widened, and additional explanatory direct referrals from the Local Authority, factors were uncovered. and two received self-referrals. Two sites
13 enjoyed particularly positive relationships observed, from an entirely outreach-based with health professionals, receiving service to regular group work in-house, but referrals from health visitors. Short-term most services engaged with families with contracts were common, often of around both approaches. three months. A continuum of focus was
Figure 2: Levels of need and problems (Hardiker et al 1991)
LEVEL 1: Universal , mainstream services provided for all children to secure overall well-being. May include services that are targeted at disadvantaged communities
LEVEL 2: Additional services targeted at vulnerable groups and children with additional needs, usually by referral.
LEVEL 3: Families may experience severe dysfunction and may be at risk of breakdown. Chronic, multiple or serious problems necessitate support through complex service plans.
LEVEL 4: Support for children and families when breakdown has occurred (possibly temporarily) . Children placed in care outside the family home.
DATA COLLECTION safety and supervision, and emotional care, each populated by a number of Action for Children Assessment Tool specific elements (14 in total). The items The North East Lincolnshire Assessment are scored from 1 to 5, higher scores Tool, which was based on the Graded indicating increasing levels of a concern. A Care Profile Scale, was trialled for some threshold was set at the boundary time but a number of items were identified between 3 and 4. Scores below this line by practitioners as being problematic. represented adequate care (though with These were reviewed internally by Action some concern at scores of 2 or 3). Scores for Children and the NELAT was revised to of 4 or 5 indicated inadequate care and such an extent that it seemed appropriate serious concern. This threshold was an to present this as an Action for Children essential element as it provided Assessment Tool. This was used for the practitioners with a means to gauge which rest of the project, and previous scores aspects of care were unacceptable (rather transferred into the new format by the than simply undesirable) and which to research team. This instrument was held prioritise for intervention. Each item bore to be an objective, comprehensive, child- descriptors at each level to assist the focused measure which promoted the use practitioner further. Serial scoring of items of common language and facilitated allowed for clear indicators of overall partnership assessments and planning progress and lowering of concern. with parents. Recording the number of scores of 4 or 5 offered the research team an additional The instrument is divided into three index of the degree of concern and the general areas of concern: physical care, direction of movement.
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Table 1: Items in the Action For Children Assessment Tool
PHYSICAL CARE AREA OF CARE & SAFETY EMOTIONAL CARE Nutrition Awareness Carer behaviour Housing Practice Mutual engagement Clothing Traffic Stimulation Hygiene Safety features Health eAspire The Strengths and Difficulties Action for Children maintains an internal Questionnaire4 included specific bespoke system which consists of four behavioural indicators. elements and tracks the child‟s progress The DCSF Child Well Being Group through the service from referral through offered examples on the quality of assessment, service plan and outcomes relationships.3 achieved at closure. It was recognised that elements of eAspire might serve to Frameworks such as the Scottish GIRFEC support and augment data collection. A (Getting It Right For Every Child)5 provided number of custom fields were designed examples of how outcomes review might and added to the system to collect be structured. A workshop on these issues electronic data at referral stage pertaining was held in July 2009 and followed up in to background characteristics of included October 2010. Accurate, valid observation children and their parents. Four areas of outcomes by project staff, with an were considered: acceptable degree of inter-rater reliability Child‟s health characteristics across and within projects was seen to be Child‟s education and emotional an essential precursor to similarly robust wellbeing recording and presentation of the findings. Parent/carer characteristics Environmental factors. Data Collection Visits This was amended in detail and Data from 1st April 2009 was collected. A supplemented in 2010 by the addition of first tranche of data collection was fields for presenting needs & interventions. completed between June and December The outputs from this data collection 2009. A second round of data collection support the population-based conclusions, visits was made in June 2010. Further helping to show which factors were most data collection visits were made to common, which commonly presented in individual centres until November 2011. A combination, and which were associated total of 85 cases made up the final with eventual dispositions of children. sample.
Outcome Measures Table 2: Cases taken from each centre Further guidance was needed for workers to recognise and record observed Centre Cases included outcomes robustly. In particular, the need 1 23 to provide evidence of impact on the child 2 14 was emphasised. A number of frameworks 3 7 and sources of outcome indicators for 4 23 aspects of the child‟s life were considered. 5 9 The Action for Children 6 3 Assessment Tool itself provided 7 6 specific family-based indicators. TOTAL 85 The National Healthy Schools Programme3 offered school- focused indicators. 4 www.sdqinfo.com/ 3 This site is no longer available following the 5 www.scotland.gov.uk/Topics/People/Young- dissolution of the DCSF People/gettingitright
ETHICAL ISSUES
Information and Consent forms were tailored to be locally specific As this was an evaluation of its own data, for each project when required by the local Action for Children already had authority manager. Formal approval was secured and permission to review this data for the from the University of Salford Research study. Information sheets and consent Governance and Ethics Committee.
PROJECT TIMETABLE
Table 3: Evaluation timetable
Year 1 Year 2 Year 3 Year 4 ACTIVITY Nov 08 to Aug 09 to Aug 10 to Aug 11 to July 09 July10 July 11 July 12 Planning, scoping Construct & refine research tools Set data collection template Negotiate & establish sites Fieldwork Analysis Report
Planned activity Finish January 2012 Revised activity Revised intermittently
ONGOING DISSEMINATION October 2009: Neglect appeal – Bauer Radio (Key 103) media A joint approach to publicising and coverage. disseminating the project and the evaluation has been pursued, the research November 2009: Walsall team working closely with Maureen Nuttall Safeguarding Children Board and other Action for Children departments, Focus on neglect. and the university press and publicity February 2010: North West department. In addition to updates and Safeguarding Nurses Annual briefings, presentations were made at a Conference: Fit for Purpose. number of specific events. February 2010: Wirral Council Specific events: Children‟s Social Care Conference February 2009: National neglect Researching neglect: focusing on survey and associated media outcomes. coverage. July 2010: Kirklees Safeguarding March 2009: Keynote presentation Children Board Think Family at Government Office North West Conference. conference Understanding Neglect September 2010: British June 2009: Keynote presentation Association for Adoption and at Merseyside Local Safeguarding Fostering conference. Children‟s Boards (LSCBs) November 2010: Action for conference Learning Together. Children national conference Researching neglect: methods, problems and findings.
November 2010 Powys LSCB: November 2011 Action for Children Outcomes of the UK neglect Northern Ireland and Western project and impact on Health & Social Services Board: compromised parenting (Invited Neglect and Outcomes from plenary). Research (Invited keynote) Derry.
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4 FINDINGS: eASPIRE CUSTOM FIELDS DATA
Action for Children follows a bespoke PRESENTING NEEDS assessment and review system of practice A wide range of factors which had known as Aspire and record outcomes stimulated referral (“presenting needs”) from case on the database associated with were identified. The frequency of each of this system are known as e-Aspire. these is displayed in Table 4 below. eAspire was used with all cases. Each Chaotic lifestyles and home conditions child would be assigned a PIN, and were predominant in the presenting essential data was identified for each problems, and most often occurred case. Flexibility in this system allowed for together. Poor hygiene was also the addition of custom fields (specific to commonly associated with chaotic the sites engaged in the evaluation). lifestyles and home conditions. This was These were developed for presenting certainly borne out in the textual data. needs on referral; child, parent and However, other issues were also environmental factors on assessment; and widespread, with a significant degree of interventions. The selected factors were domestic violence (known to exert a known to exert on impact on the likelihood particularly negative impact on children‟s of neglect. wellbeing).
Table 4: Presenting needs – frequency of recording (n=85)
Alcohol abuse 8 (9%) Attachments 8 (9%) Behaviour management 25 (29%) Chaotic lifestyle/no routines 44 (52%) Domestic violence/abuse 29 (34%) Emotional abuse 13 (15%) Emotional development of child 22 (26%) Fail to attend medical appointments 21 (25%) Family dynamics 24 (28%) Home conditions 35 (41%) Lack of co-operation with services 11 (13%) Learning disability/difficulty 17 (20%) Mental health 15 (18%) Neglect identified by referrer 35 (41%) Parental supervision 29 (34%) Physical, emotional assessments 2 (2%) Poor hygiene 29 (34%) Primary safety – supervision 23 (27%) Relationship position 6 (7%) Risk /integrated assessment 5 (6%) School attendance 13 (15%) Substance misuse 12 (14%) Unmet health needs 19 (22%)
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CHILD-RELATED FACTORS
Failure to attend for health appointments which were more prevalent had already and poor hygiene were the most been identified on referral. The commonly reported factors in children‟s assessment process brought little more to health characteristics. One of the projects light. The higher incidence of emotional appeared to have a particularly positive and behavioural factors n the child reflects relationship with health professionals, the level of need that was present in many especially health visitors, and this seems cases. Multiple problems and complex to have boosted efforts at that centre to needs are characteristic of families address this issue. However, relatively requiring support at levels 3 or 4. The little focus was placed on factors relating problems identified in children could be to the child: an issue that was mirrored in either a contributing factor or a result of all aspects of the data. Those factors the chaotic family situation.
Table 5: Frequency of child health, education & emotional wellbeing indicators (n=85)
Child Health characteristics Complex health needs 10 (12%) Chronic health needs 7 (8%) Multiple hospital admissions 2 (2%) Frequent infections 2 (2%) Substance misuse 0 (0%) Disability 1 (1%) Injury due to poor supervision 8 (9%) Not registered with a GP 0 (0%) Failure to attend for health appointments 15 (18%) Separation in SCBU 1 (1%) Foetal alcohol syndrome 1 (1%) Poor hygiene 17 (20%)
Child’s Education & Emotional Wellbeing Emotional problems 24 (28%) Behavioural problems 20 (24%) School exclusions 6 (7%) Special educational support 7 (8%) Child is a carer 3 (4%)
PARENTAL FACTORS
The much greater prevalence of factors in mental health, substance misuse or parents was notable, and the bulk of learning disability is not clear. The effect of efforts made by workers was focused on domestic abuse on children is known to be parental behaviour. However, the degree significant (UNICEF 2006). to which these interventions address
Table 6: Frequency of parent/carer indicators (n=85)
Mental health problems 23 (27%) Learning disability 14 (16%) Domestic abuse 35 (41%) Substance abuse 23 (27%) Offending behaviour 12 (14%)
ENVIRONMENTAL FACTORS
Little was recorded to indicate that the this project. Child protection issues, either environmental factors considered in the in the form of a child protection plan in literature to be most relevant and frequent operation or court proceedings were were a particular influence in the cases in remarkably common (n=45, 53%).
Table 7: Frequency of environmental indicators (n=85)
Inconsistent residence 5 (6%) Single parent household 19 (22%) Living with relatives 5 (6%) More than 2 children under 5 11 (13%) Child protection multi-agency plan or Court 45 (53%) proceedings
INTERVENTIONS
The list of interventions commonly applied However, there was a notable was compiled through consultation with predominance of home visiting and practitioners and managers involved in the associated focus on routines and evaluation project. Some items were boundaries. Review of case files normally a required part of the service demonstrated that this was drastically commissioned (especially comprehensive under-reported in the custom fields. assessment and parenting programme).
Table 8: Frequency of interventions applied (n=85)
Attachment 9 0 (0%) Comprehensive assessments 24 (28%) Counselling/mediating work 7 (8%) Day care provided for child 3 (4%) Domestic abuse (Freedom programme) 7 (8%) Family group conferencing 4 (5%) Multi-agency planning 32 (38%) 1-to-1 parent/child relationship 24 (28%) One-to-one Webster Stratton 9 (11%) Parenting programme (see list) 47 (55%) Protective behaviours: ethnic minority 2 (2%) Supervised contacts 9 (11%) Home visiting/Outreach 47 (55%) Routines and boundaries 51 (60%)
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Commissioners would often specify a functioning or child problem behaviours specific parenting programme as part of between this programme and other group- the commission. This would usually be the based programmes (McConnell et al Positive Parenting Programme (PPP or 2011). A slightly smaller frequency was Triple P), perhaps because of perceived reported for use of the Webster Stratton rigour associated with this package. A (Incredible Years) programme. The recent independent evaluation of Triple P effectiveness of this programme has been found no significant difference in parenting supported in Sure Start centres (Hutchings stress, positive interaction, family et al 2007).
Table 9: Frequency of parenting programmes applied (n=85)
Intervene parenting support group 0 (0%) Triple P (PPP) 29 (34%) Family Links 3 (4%) Walter Barker: pictures 2 (2%) Webster Stratton 22 (26%) Parent line plus 4 (5%) Teenage antenatal group 2 (2%) Watch, wonder, wait 0 (0%)
SUMMARY
The eAspire data showed clearly that Domestic abuse stood out as an indicator chaotic lifestyles and concern about home in parents of concern, though mental conditions were by far the most prevalent health and substance misuse were also issues identified on referral that indicated important factors. Together, these provide neglectful parenting. Poor hygiene, a telling picture of the circumstances in emotional problems, and behavioural which neglect occurred and the complexity problems were the most commonly of the challenge to practitioners. identified characteristics identified about the children during the intervention, and The pattern of intervention was these obviously linked to issues identified predominantly comprehensive assessment on referral. Failure to take children to (usually an essential element of the health appointments (mostly for commission), followed by a parenting immunisation, but also for ongoing care for programme and an intensive course of enduring medical conditions) also caused home visiting to establish routines and concern in a significant number of cases. boundaries.
5 FINDINGS: THE ACTION FOR CHILDREN ASSESSMENT TOOL DATA
REMOVAL OF CONCERN ABOUT NEGLECT, REMAINING CONCERN ABOUT NEGLECT, OR PREVENTION OF NEGLECT
It is clear that Action for Children while a smaller number were “returned to interventions were largely successful in other services”. In some cases where addressing neglect. Success in this part of children were taken into care (removed), the analysis was gauged by the reduction no progress was made at all, but in some of concern so that no areas of the Action the degree of concern was at least for Children Assessment Tool were still reduced. scored at 4 or 5 (regardless of the number of areas scored at 4 or 5 on assessment). In a small number of cases, scores never This was based on the notion of a reached the threshold of neglect. These threshold integral to the Action For were cases in which neglect was Children Assessment Tool according to foreseeable and intervention was intended which a score of 1-3 indicates “good to prevent the otherwise inevitable enough care” (even if not desirable care), occurrence of neglect. In all cases, the and a child is considered to be subject to intervention was effective, and this was neglect if any aspect is scored at 4 or 5. termed “prevention of neglect”.
The reduction in all Action for Children In 50 (59%) cases the intervention was Assessment Tool scores to below 4 was successful in that the cases were returned termed “removal of concern about to lower-level concern and transitioned to neglect”. other support (removal of concern). In 27 (32%) cases there was remaining concern In some cases, the score in at least one about neglect (n=23, 27% of the total area remained above the threshold for number of cases). A significant proportion neglect – the boundary above the score of of these resulted in children being taken 3. This was termed “remaining concern into care. In the remaining 8 (9%) cases about neglect”. This group was itself there was never a score above 3, though formed by two elements. The larger concern about the potential for neglect number of cases resulted in children being required intervention (prevention of taken into care - “Children removed”, neglect).
Figure 3: Removal of concern about neglect, remaining concern about neglect, or prevention of neglect
8, 9%
Removal of Concern
27, 32%
50, 59% Remaining Concern
Prevention of neglect
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The areas of the Action for Children Assessment Tool in which serious concern was reported All areas of the Action for Children concern, but it was not uncommon for five Assessment Tool were implicated in or six items to be identified to be a serious practitioners‟ concern. Some cases concern (scored at 4 or 5 on the scale). showed only a single item of such
Figure 4: Change in total areas of serious concern (scores of 4 or 5) in the three major areas of the Action for Children Assessment Tool
250
On referral 200 On closure
150
100
5) or 4 of (score
50
0 concern of areas of number Total Physical Care Care and Safety Emotional Care Area of Concern
REMOVAL OF CONCERN ABOUT NEGLECT
Fifty cases (59%) resulted in transition to worker gained the trust of parents, the mainstream services with no remaining parents would divulge the presence of concern about neglect on closure. Most other problems, substance misuse, for cases transitioned into Child in Need or example. Alternatively, despite a trend of Targeted Services, though some were improvement in parenting and a reduction resolved to the extent that the families in scores, an untoward event could prompt were handed back to universal services for a sudden and significant increase in ongoing support. In all cases a clear concern. Often this would be the result of downward trajectory was recorded in the introduction of another adult into the reason for concern. Sometimes drastic household or crisis in relationship between changes were found, and even with no parents. In some cases it would be the remaining areas for concern, there was effect of violence or children getting into still a range of problems which required trouble. The worker would simply review intervention and support from other the assessment, revise the plan and services. priorities, and demonstrate to parents how to react positively and effectively to the When sequential records were kept over new problems. time of changes in the number of areas scoring 4 or 5, the pattern would often Typically, parents would have learned to indicate something of the complexity of the maintain a clean, tidy and hygienic house, cases in question. Some total scores and they would have established a more would increase as major risks were positive, stimulating relationship with the successfully addressed but additional, less child by the time of the final review. urgent items came to the fore. Not Boundaries would have been set in place uncommonly, as the Action for Children and maintained by the parents. Other
23 common indicators were better school have to be retraced and learning fostered attendance, more effective and again before moving back to the timetable appropriate communications between of progress. However, the persistence of parents and children, and greater the worker would tell, and parents would awareness of hazards to young children. often comment on the positive effect of The achievement of even a small change this persistence and stability on their own could take a great deal of intensive resolve to provide better parenting for their intervention, and frequently steps would children.
REMAINING CONCERN ABOUT NEGLECT
In 27 (32%) cases children remained case. These cases tended to relate to subject to concern about neglect on families in which neglect was already closure of the case. This could range from deeply embedded on referral. The cases a single lingering problem which would were severe and complex. Cases which require longer intervention than was resulted in children proceeding into care allowed in the commission to a complete would commonly show little or no change absence of change or even worsening of in the degree of concern about neglect, the situation. However, most of the cases sometimes with concern increasing as in this evaluation in which concern additional issues came to light. The most remained about neglect on closure of the common reason for closing a case was case resulted in complete absence of that the parent persistently failed to improvement. engage with intervention or was simply unable to make significant improvement in Twenty-three cases resulted in the child their care of the child. being taken into care on closure of the
Figure 5: Breakdown of cases where concern remained (n=27)
4, 15%
Children removed
Case returned to 23, 85% other services
In such cases, the strength of evidence parenting became acceptable or it became that the child was suffering neglect and even more apparent that the case needed that, despite intensive support and to be accepted as having crossed the intervention, parenting was not improving threshold into level 6 - care proceedings. was sufficiently convincing for the Local In this, Action for Children work ensured Authority to move directly into care that when the situation was found to be proceedings. When Action for Children irredeemable, children were taken into offered such an intensity of involvement, care more quickly. Hannon et al (2010) either families could change so that have demonstrated recently that children
24 who are taken into care sooner rather than lack of change in parenting behaviour. In later in such cases fare better in the long some cases the total score worsened, term. often as additional, previously hidden problems came to light or, as in more than Changes in total scores for those children one case, as a known child offender who continued into care on closure of the returned to the house. In five cases where case by Action for Children was also the children were removed, however, a mostly non-existent or minimal, indicating small improvement had been made.
PREVENTION OF NEGLECT
Eight cases (9%) were found to have no In one instance this related to the return of scores of 4 or 5 yet were included in the the children‟s father following his release project since it was agreed by a multi- from prison. The mother was unable to professional team that neglect would be cope and her care of the children was the inevitable outcome if preventive deficient in both knowledge and skill. The intervention were not provided. These commissioned brief for Action for Children were mostly cases of young parents, often with this family was to support the mother referred antenatally, whose ability to until the father‟s return to the household at provide adequate care was already of which point an acceptable level of care concern, and the intervention was aimed was expected to resume. Indeed, the case at keeping the baby safe while developing file showed that on his return he was seen the essential skills in the parent. In each to be cooking for the children and case the concern was underpinned by enforcing reasonable morning and evidence from careful assessment and bedtime routines. In all cases, the potential focused on specific deficiencies in neglect that was of concern was preparedness for parenting. prevented, and in six of these eight cases there was improvement in caring ability The remaining cases related to holding rather than merely stability below the actions in anticipation of a foreseeable threshold of neglect. improvement to the family circumstances.
OVERALL REDUCTION IN CONCERN ABOUT NEGLECT
Commissioners seek to achieve maximum improvement had been made, usually in service reach and avoidance of one or two areas out of five or six which dependency by the support of time-limited were of concern. periods of intervention, but the restriction caused by finite intervention periods Moreover, of the eight cases in which sometimes resulted in workers being intervention was aimed at prevention of unable to pursue clear improvement to the neglect, six demonstrated reduction in potential conclusion of complete removal actual scores and therefore lessening in of concern about neglect. In addition to the the cause for concern of anticipated 50 cases which improved to the point of neglect. removal of concern about neglect, a further nine which were counted as having Overall, the number of cases in which remaining concerns showed concern about neglect was prevented or improvement in scores and, therefore, reduced was 67 (79%). Even when no reduction in concern. Of the latter, four more serious concerns existed, a were cases which were returned to other controlled transition to previous services services, and five were cases in which the was established. children were taken into care but some
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Figure 6: Frequency of improvement in concern about neglect
Removal of Prevention Remaining concern concern of neglect about neglect
Returned to other services Improvement (n=4) or prevention Total = 67 (n=50) (n=8) of concern (79%) Children taken into care about neglect – some improvement (n=5)
Absence of improvement Children taken into care Total = 18 in concern – no improvement (n=18) (21%) about neglect
SUMMARY
Neglect was prevented or the level of allowance prevented completion of the concern reduced in 67 (79%) cases. Of process. However, for some cases the file these, 50 resulted in removal of concern indicated that the plan was for mainstream completely, nine had remaining concern, services to continue with the planned and eight were prevented from developing work, and it was clear in others that into neglect. referrals made by Action for Children to other specific agencies were to be Of the 27 cases where concern remained, maintained, too. In such circumstances it four were returned to other services for might be hoped that the improvement ongoing support while 23 resulted in the would be sustained. children being taken into care. In one centre, the commissioner was Eight cases were prevented from persuaded to extend funding for the Action deteriorating into neglect. for Children intervention in order to sustain adequate levels of parenting and safety for The change in financial circumstances of the children until the children became local authorities during the evaluation more able to be independent and to meant that the eventual outcome compensate for sub-optimal care by their remained unknown for many cases in mother who suffered from enduring mental which progress was being made but time health problems.
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6 FINDINGS: TEXTUAL DATA FROM CASE NOTES
The following outline of the textual data comments to indicate outcomes taken from the case notes is presented in successful or otherwise in terms of the three sections – The Home, The Parents condition of the house in the “home and The Child although it is acknowledged conditions” section. Similarly, there are that the issues for each are overlapping. few comments present for outcomes The narratives presented in these sections related to the children‟s personal hygiene add to the quantitative data, providing but many comments in terms of outcomes further illustration of the various issues about the relationship between the mother that indicated neglect as noted by the and the children. This may be because the Action for Children workers. This includes workers feel compelled to rationalise their data noted during the initial assessment quantitative scores in areas that are and during follow up visits before potentially open to interpretation. determining the final outcome of the interventions. Data related to the final It was common during data collection that outcome indicated a mixed picture, with gross issues would be identified during some success and some lack of progress. assessment (including on-going assessment), but that these would often It is notable that some of the issues have not be included in the comments on more qualitative commentary than others. outcomes. A decision would have been For example, there is little commentary to made that objectives had been met and reflect the outcomes of the section “living positive outcomes achieved, but the context”. In contrast, there are many evidence for this was not recorded.
THE HOME
Living Context Instability within the home also included On assessment differences in parenting or care offered to Qualitative data available in the notes individual children within the home, for reflected the living context of the children example: “Pattern of mother leaving home and their families on assessment. Here, with some children when relationship comments highlighted chaotic lifestyles in strained” “Younger children cared for at terms of housing, for example stating expense of neglect of older children”. “currently in temporary accommodation” Some of the children were looked after by “impending eviction - housing issues” the state, and comments related to this “Chaotic lifestyle – staying at multiple included “Other children in residential addresses” “Home conditions chaotic”. care” “Eldest daughter in residential care This included a lack of living space: but disruptive when home”. “Overcrowding” “Overcrowded house”. Workers also noted aspects of living Chaotic lifestyles also included instability context that included financial insecurity, in terms of personal relationships or the for example “problems with debt”. many and varied individuals living in the Problematic relationships with others also home at any one time: “Makeup of raised issues that ranged from lack of household – negative impact on support “Mother‟s father and brother also engagement” “Household deteriorated in home but not supportive” “Limited since mother‟s boyfriend arrived” “Child sources of support – with grandparents – mother living family/friends/neighbours” through to separately (associated with risky adults)” causes of conflict ”conflict with “Inconsistent family make-up”. neighbours” “difficulties with neighbours”.
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Outcomes noted reduced” “Home conditions seen to be “Chaotic household” was the only outcome clean and clutter-free “Home conditions recorded (though on many occasions). now „better than good enough”. Other comments indicated that improvement had Home Conditions included more than cleaning, for example On assessment “Dirty carpets have been removed and The workers made notes related to the decorating is in progress” “Children‟s upkeep of the home that indicated either a bedrooms have been overhauled”. lack of knowledge or lack of intent to provide a clean, safe and hygienic However, lack of success was noted by environment required for bringing up some workers, particularly reflecting lack children. Some notes were general of immediate personal attention to either comments related to lack of cleanliness: the child or pets rather than a simple “Home dirty / House not clean” “Poor neglect of daily house cleaning, for hygiene” “Dirty, squalid environment” example: “Faeces on windows, bedding “House untidy and dirty”. Other comments and walls in boy‟s bedroom” “Dog faeces related to specific aspects of hygiene that in child‟s bedroom again” “Child‟s bed were hazardous to the child‟s health: sheets soiled” “House cold and untidy” “Rubbish not removed” “Potty in hallway “Some concern about dogs in the house”. filled with stagnant urine”. Many comments indicated that dogs also lived in the homes Resources and that the parents did not ensure that On assessment the house was free of dog faeces, There were several comments related to presenting health risks: “Dog faeces in general lack of resources, particularly a living areas” “Faeces on floor in house” lack of basic furniture required for safe or “Dog faeces in children‟s play area” comfortable sleeping arrangements: “Hygiene problems – dog faeces in child‟s “Insufficient beds Child has no bed / no bedroom” “Faeces spread on walls and cot” “Insufficient beds” “Baby has no cot” skirting board in child‟s bedroom” “House “no bedclothes on children‟s beds”. In dirty with dog faeces”. The workers noted addition to lack of furniture, some of the the impact of the environment on the comments reflected lack of basic health of the child: “Child ill due to poor resources such as food or bedding, hygiene”. including “Lack of food, bedding and toys” “Little food in the house”. Outcomes noted Successful outcome scores were Outcomes noted supported by comments that reflected Successful outcomes made no mention of efforts made by the parents, including larger items such as furniture but did “Bedroom clean” “Home conditions mention improvements on a smaller scale maintained at satisfactory standard” such as “Food in cupboards”. Comments “Home conditions good enough” “Some indicating lack of progress mentioned both improvement in home conditions – cleaner lack of furniture “Despite provision of white and redecorated” “House clean and goods, still no furniture in child‟s bedroom, uncluttered” “Unplanned visit found house and no heating in house” “Sparse clean and child playing in doorframe bedroom furniture”, and lack of bouncer properly supervised by mother” improvement on a smaller scale “Fridge “Home condition improved. Smell of urine open, dirty and little food available”.
THE CHILD
Physical Health highlighted health issues that had arisen On assessment for the child as a direct result of a lack of Some of the comments highlighted non- knowledge, ability or intent to perform specific concerns related to physical basic age-appropriate child care in the health: “Child‟s appearance suggests home. For example, this included issues neglect”. However, several comments about nutrition and stimulation “Child
28 failing to thrive”, inadequate attention to personal hygiene “Child has genital sores Clothing and children’s personal from inadequate wiping after toilet”, and hygiene prolonged failure to intervene “Worst ever On assessment nit infestation”. In addition to the hygiene and cleanliness problems with the immediate environment, The comments also made note of staff the workers noted issues related to lack of recognition of developmental delay in basic personal hygiene and care for the many of the children that may have child. General comments included resulted from an underlying physical “Personal hygiene of concern – not always problem but may also have resulted from a clean clothing” “Child sometimes unkempt” lack of cognitive or emotional stimulation “Children dirty and unkempt”. Other of the child in the home environment. Such comments pointed to a lack of knowledge, comments included “Developmental delay” ability or intent to perform basic age- “Children all global developmental delay”. appropriate child care in the home, for example, in terms of hygiene: “Child left to Several staff noted that the parents had manage toilet-wiping alone at 1 year”. failed to take the children to scheduled health appointments for general health Comments were related to lack of clean or promotion or preventative health care, for appropriate clothing both in and out of the example “Immunisations outstanding and home, for example, “Children seen to be limited engagement with health services” inappropriately dressed” “Child appears at “Missed health appointments” “Children school dishevelled and in stained clothes” not taken for health appointments”. This “Child inappropriately dressed for weather included preventative health care that is conditions”. Sometimes it was noted that not automatically scheduled or monitored the children were not dressed at all: such as dental care “Mother avoids dental “Children naked in house, mother asleep” care for self and children (anxiety)” that “Children seen naked at bedroom can also have consequences for the window”. child‟s future health “Dentist reluctant to agree further appointments due to number Outcomes noted missed”. Comments on outcomes were minimal, but included “Children presented well” Failure of parents to act appropriately was “Children‟s appearance unkempt” “Child also noted when the child exhibited signs sent to school in mouldy T-shirt”. of illness “Appropriate health advice not sought for baby” or when the child needed Attendance at school and nursery continued health support at home from On assessment parents, for example, “Repeat Impact on the child‟s education was noted, prescriptions of asthma drugs not ordered for example in terms of attendance: and drug not available at home” “Child‟s “Attending school only for short periods / health needs not being met – essential irregularly” “School attendance poor” food supplements, control of fluid intake” “Removed from school by mother” “Child “Mother ignoring health professional persuades mother to keep her off school”, advice on bedwetting”. or in terms of achievement “Child‟s attendance good but achievement is low”. On occasions where children had been When children attended education admitted to hospital, staff noted that their services, comments were made if the parents had effectively abandoned them to parent failed to collect the child at the care of the institution: “Child with appropriate times, for example “Mother medical problem (diaphragmatic hernia, late picking up from nursery and not O2 dependant, peg fed). Not been home contactable”. from hospital” “Parents do not visit“ “Becoming institutionalised”. Outcomes noted Success was noted here: “No further Outcomes noted problems with school attendance or Nothing was noted about outcomes. punctuality” “No issues at school now”
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“Attending nursery regularly” “Attending each other. Both hurting younger sibling” cubs” “Attending nursery placement” “Child kicking others, spitting and running “Mother managing relationship with school off” “Aggressive to mother and sister. better – reported child‟s illness”. In Kicking and biting” “Child physically contrast, improvement was not always aggressive to children, adults and pets”. seen: “Attendance at school sporadic” Other comments indicated access to “Children still not attending school” “Still inappropriate equipment and associated not attending all available nursery aggression towards service providers: placement sessions”. “Child fired airgun at worker”. There were also comments that potentially pointed to Child Behaviour problems with mental wellbeing: “Child On assessment soiling and smearing at home” “Child has Comments were also made on threatened to self-harm” “Sexualised assessment that highlighted inadequate behaviour towards sibling”. parental management of the child‟s behaviour: “Ineffective management of Outcomes noted children‟s behaviour” “Mother unable to Positive remarks were made about manage son‟s aggressive behaviour”. progress: “Aggressive behaviour reduced” There were also many comments related “Behaviour is calmer” “Reduced number of to the children‟s behaviour in the home incidents” “Child interacts positively with that indicated a lack of adequate parenting siblings and other family members” “Using including parental guidance or boundary toilet to defecate” “Children happy and at setting. Some of the comments were non- ease” “Some evidence of less aggression specific: “Child shows challenging from child”. behaviour at home” “Children‟s behaviour not controlled”. Other comments described Lack of progress was noted by a variety of problems that were associated with behaviours exhibited by the children, for parenting problems or chaotic family example “Sexualised behaviour not situations such as aggressive behaviour resolved” “Child over-eating at nursery and towards other individuals including family hiding food” “Child hid from mother at members: “Brothers fighting and hurting home time at nursery”.
THE PARENTS Many comments were also related to The presence and health of the substance abuse in the home: “Cannabis mother and cocaine use” “Mother has chaotic On assessment lifestyle – crack-cocaine + methadone The health of the mother was commented programme” “Mother staying with heroine- upon, and sometimes this related to using parents” “History of alcohol abuse” physical health and the impact that this “Smell of cannabis noted by worker”. may have exerted on parenting: “Mother has slipped disc and is on anti- Young parents and associated issues depressants” “Mother suspected to have were also noted, for example “Young learning difficulties. Unable to understand mother, socially isolated” “Young mother” and undertake parenting”. However, more “Immature teenage mother – unborn child, often they related to mental health: needs support with general parenting “Mother has suicidal thoughts” “Maternal skills” “Prenatal referral. Teenage mother depression” “Mother‟s mental health and father residing together”. unstable leading to inability to offer consistent and responsive care” “Mother There were also comments that illustrated diagnosed with personality disorder” inappropriate communications between “Mother has history of depression” “Mother the mother and children that had the exhibiting psychotic symptoms – but no potential to cause the child distress: medical risk to children” “Mother has “Mother tells children that they need to go history of depression”. into care because she is a bad mother”.
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Outcomes noted children” “Worker witnessed aggression Nothing was noted about outcomes of and lack of warmth” “Little opportunity for these issues. child to play and learn” “Many missed appointments” “Mother failed to empathise The relationship between the children with child‟s experience.” “Persistent lack of and the mother and the impact on the emotional availability”. child’s psychological or emotional health and bonding The presence and health of the father On assessment Factors relating to fathers are often During the assessment the workers also ignored or omitted from research into noted aspects of the relationship between neglect and parenting capacity (Moran et the mother and children that were likely to al 2004). The positive or negative effects impact on the child‟s emotional wellbeing: that can be exerted by fathers or father “Mother prioritises her own needs over figures in neglectful households was made those of her children” “Mother struggling to apparent by the workers in this evaluation. show emotional warmth” “Mother able to The notion of both risks and opportunities provide physical care but no emotional being attached to fathers and other male bond or warmth” “Little emotional warmth family figures has been recognised by between mother and child”. Lifestyle Daniel and Taylor (2005). The need issues that were likely to have a negative actively to seek fathers‟ involvement in impact on the child‟s emotional welfare parenting or simply to enable this has were also noted, for example “Over-use of been reported, too (Long et al 2008). social networking leading to emotional neglect of child”. On assessment The role of the father in the child‟s life was Outcomes noted noted, in particular whether the father was A considerable amount of evidence was present in the home. This was mainly a provided for outcomes in this area. comment related to custodial sentences: “Acceptance of child” “Acceptance of new “Father is in prison” or “Father in prison – baby” “Accepting of new baby. Uses then home on curfew. Support needed baby‟s name and points baby out to while he was in prison”. The impact of the visitors” “Child receives positive praise and father‟s health, particularly mental ill health attention from mother” “Mother spends or substance abuse, was also commented quality time with child” “Seen to be playing, upon “Father diagnosed with bipolar cuddling and interacting in a positive and disorder and ADHD” “Substance misuse enjoyable manner” “Improved emotional by father (alcohol)” including any impact wellbeing” “Mother communicating with on his behaviour: “Child‟s father is alcohol baby/children” “Improved emotional abuser and violent”. Violent behaviour wellbeing – mother has quality time with exhibited by the father was also children” “No professional concern commented upon in the notes “Child‟s identified. Baby breast-fed and consistent father is unpredictable and violent” “Father physical care on all visits”. had tried to strangle mother” including the impact that this may have had on the care When improvement was either slow or of the child: “Mother scared of father and absent, a similar degree of detail was would not check his care of the child”. noted. This was mostly in cases where strong professional relationships were in Outcomes noted evidence with health professionals. Success in this area was noted in terms of “Medical advice not sought when children general improvement or mood: “Return of were ill” “Child‟s weight remains of great mother‟s partner raised mother‟s mood” th concern. >98 centile” “Immunisation “Situation improved on father‟s release undertaken – but only because HV made from prison” “Mother stated clearly that home visit” “Mother routinely placed her things would not revert to previous own needs above the welfare and safety unsatisfactory state when children‟s father of her child” “Child hides from mother at due to be released from prison” “Children nursery” “Little opportunity to play and are thriving in father‟s care (HV report)”, learn” “Parent aggressive towards and in terms of actions taken by the
31 parents to improve living standards: “Consistent boundaries in place and child “Parents decorating house together” feels secure” “Routines established” “Couple working together on decorating “Mother has a routine for washing clothes” house”. “Routines and home organisation learned and maintained” “Routines and boundaries Commentary on lack of progress revolved much improved” “Mother reports that she around violence and abusive relationships has the kids in a bedtime routine”. rather than neglectful behaviour: “Father of sibling under review for safety with child” Other qualitative data that indicated “Inconsistent handling by father” “Mother success related to more confident had violent, abusive outburst at parenting: “Mother is more confident” grandparents. Police involved” “Some evidence of greater parental “Relationship between parents is volatile confidence after parenting programme”, and non-trusting”. while other comments pointed to increased parenting skills: “Mother able to Parenting Ability provide physical care without prompting” On assessment “Baby back in care of mother. Able to Workers noted that some parents lacked undertake care with support” “Observed to basic skills necessary for maintaining a have coped with daughter‟s minor illness home environment or for provision of basic (pyrexia)”. needs for children. Comments included “Basic home-making skills lacking” “Needs However, comments also noted less help with organisational skills” “Needs help success in terms of boundary setting for with nutrition. Does not cook” “Unable to example “Child allowed to play DVDs in maintain hygiene”. Other comments early hours of the morning” “Children go to pointed to a lack of knowledge, ability or bed when they want to do. No routines”. intent to provide a basic diet or feeding Other comments indicated a more general conditions necessary for growth lack of improvement e.g. “Mother has little “Inappropriate diet for toddler” “Prop- insight into child‟s needs” “Home visits feeding” “Child eating ice lolly for repeatedly showed lapses in care and breakfast”. inconsistent improvement”
Some comments made in the notes by Parents’ ability to keep the child safe workers identified problems with more On Assessment specific parenting skills particularly in One of the most significant aspects of the terms of developing routines or boundary qualitative commentary related to the setting for example “Lacking routines and safety of children in the home. Some of structure in home life” “Mother needs help the comments related to hazardous with routines and boundaries” “Struggling situations through poor repair of the with bedtime routines” “Routines with property: “Cot unsafe – one side missing” household inadequate” “Routines “Exposed to hazards in the home” “Light inadequate or absent”. switch hanging off and wires uncovered”, or lack of parental insight or ability to Outcomes noted maintain safety: “Poor parental awareness Several comments highlighted success in of danger and risks” “Safety issues – fire in terms of visible efforts by parents to apply kitchen”. Many of the entries related to the parenting techniques to which they lack of appropriate adult supervision which had been exposed: “Mother has changed in some cases had resulted in injury to the parenting strategies” “Mother reports child: “Children left alone for extended applying techniques to share time with periods” “Children left unattended” “Lack child and offer praise”, or a general of supervision” “Little supervision indoors change in attitude, for example “Evidence or outdoors” “Lack of supervision caused of mother taking responsibility seriously”. physical injury” “Children seen leaning out of windows”. Some comments indicated There were many comments to indicate that other dangerous actions were taken success in terms of boundary-setting by parents in the place of appropriate following the intervention, for example supervision: “Lock on child‟s bedroom
32 door” “Chair seen placed against child‟s in the house” “Child taken back to violent bedroom door handle”. situation” “Child accompanying strangers on request.” “Child exposed to unsafe Many of the comments related to the situations” “Mother return to house with emotional wellbeing of the child with child when violent father still there. Left particular reference to witnessing or child with him while she worked a double experiencing violence in the home: “Child shift” “Mother denies knowledge of witnessed domestic violence” “Concerns physical abuse but evidence was clear”. about effect on children of parental domestic violence” “Child witnessed Abuse domestic violence between parents” On assessment “Children exposed to domestic violence” In addition, workers noted abusive rather “History of serious domestic violence in than neglectful situations in the home. This grandparents. Same for child‟s parents” included verbal abuse by parents: “Mother “History of domestic violence and alcohol shouts at children” “Parents seen using misuse with previous partner”. Other abusive language to children and shouting comments highlighted safety issues at them”, and by others: “Other family related to danger posed by individuals who members shout and swear at children”. were not family members: “Mother unable Physical abuse by parents and others was to protect child from inappropriate adults” also noted: “Father had punched one child “Unknown male arrived in house” “Subject in the face” “Mother swearing, shouting at to sexualised behaviour by another child and hitting children” “Physical abuse of (outside family)”. child by father” “Inappropriate punishment” “Maternal uncle hit child with plastic Outcomes noted spatula” “Marks of physical abuse found Successful outcomes reflected raised on skin by health professional” “Physical awareness of danger: “Parent shows injuries to child on more than one increased awareness of risks to safety” occasion”. “Increased awareness of safety issues and risks to children”, and that parents had Outcomes noted taken action to remove dangers: “Hazards Outcome statements were sparse, have been removed” “Dangerous however: “Sexualised behaviour modelling tools put away” “Doors and continues”. windows locked to secure the house”. Attitude to Services Lack of success was highlighted by On assessment recognition of lack of parental awareness: Qualitative commentary highlighted the “Father has poor awareness of immediate difficulties arising from reluctance of dangers” or of parental failure to make the service users to engage with services, for environment safe or secure: “Electrical example “Distrust of social worker – wires exposed – sockets and light reluctant to engage” “Mother failing to switches” “Broken glass not repaired” engage with housing and other services”. “House still dirty and unsafe – planks of This included attendance for scheduled wood propped up against wardrobe”. Lack appointments or availability for planned of action in terms of adequate supervision visits: “Mother does not implement of children was also noted in this section: proffered advice” “Mother failing to engage “Children play outside with no supervision” with services or attend for appointments or “Young children left to supervise younger admit workers for planned visits”. siblings” “Allowed to go with strangers” “Children not supervised when playing Outcomes noted outside” “Young children left to supervise In terms of attitudes to services, workers even younger siblings outside” “Children noted an improvement in some parents‟ playing in street unsupervised. Mother no attitudes: “Mother and partner open to insight into danger”. Workers also made working with Action for Children” note here of dangerous, violent or “Expressed appreciation for worker‟s help potentially violent situations to which the with improvement in parenting”. child was exposed: “Risky adults allowed
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However, lack of progress was noted “Mother persistently demonstrated no particularly in terms of the worker‟s ability interest, capacity or willingness to work to access the home: “Access denied” with agency to bring about change in “Access achieved only when not expected” neglectful parenting” “Mother not engaging “Refused entry to house”. Parents‟ failure purposefully with the service” “Only to engage with services was also noted: superficial engagement with services”. “Parent shows no interest or capacity to These were often the summarising change”. statement in cases where no progress was made and children were taken into care.
SUMMARY
In all three areas in which textual data was reluctant to express judgement in detail recorded, information about assessment about outcomes. In contrast, issues of was usually provided in detail. However, personal hygiene were central to many recording of outcomes was sometimes cases, yet comments on outcomes were lacking, notably about children. With minimal. The general focus on parental regard to issues about children‟s physical action rather than impact on children that health (sometimes including serious is seen across both health and social care medical problems), it might be services may be a factor that contributed understandable that workers would be to this.
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7 ANALYSIS AND DISCUSSION
OUTCOMES OF ACTION FOR CHILDREN INTERVENTION
Change in the level of concern about with the intensive support that the Action neglect for Children service was able to offer, the Overall, there was a significant evidence of the poor likelihood of future improvement in the level of concern about change was seen to be compelling by neglect in the total of 85 cases considered. commissioners and by the courts. For most cases, discernible improvement was recorded, but two fairly distinct groups There was concern, however, among the of cases were discerned. research team and Action for Children managers that, while Action for Children Expediting the move into care had played a vital role in ensuring that The first group was characterised by these decisions were finally taken in families in which no change was achieved confidence and with due evidence of need, and the children were subject to care such cases allowed for only limited proceedings. The complexity of this evidence of the potential for early grouping requires further consideration. intervention in guiding families back from the threshold of proceedings and into The scores and narrative outcomes for targeted services. some children showed that some parents were unwilling or unable to make the Improvement in the level of concern required changes to lifestyle and parenting about neglect behaviour, and the result was that the Once the sampling frame was altered to children were taken into care. These include project sites at which early cases tended to be already on the intervention was possible, even though threshold of care proceedings on referral sometimes with families in which neglect to Action for Children, and successful was a particularly serious concern transition to lower level services was (sometimes scoring as many areas at 4 or predictably rare. However, Action for 5 in the Action For Children Assessment Children services clearly assisted statutory Tool instrument as the cases above), it agencies to reach earlier conclusions was noted that the possibility of returning about the need for children to enter some families to a much lower level of alternative care whether with agreement of concern was realised. parents or through securing care orders. Families in the second group showed This was most evident when Action for engagement with project workers, made Children presented the results of changes in carefully planned stages, often comprehensive assessment to a multi- relapsed temporarily, and disclosed agency forum to enable that forum to additional problems during engagement, make a clear decision about the well-being but tended to transition successfully into of the child or young person. The targeted services. These families were not assessment from Action for Children in usually on the threshold of care (though these cases was influential for two main this was not always the case), and “early reasons. First, the family was seen intervention” more readily described the through “fresh eyes” and with a renewed practice activity. The lowering of concern chance of providing evidence of the resulting from these early interventions family‟s ability to change. Some families prevented neglect deteriorating to the will engage more easily with staff from the point where children would have to live voluntary sector than with those from the with alternative carers. The importance of statutory sector, so one of the barriers to workers establishing effective, trusting change may have been removed. The relationships with families and gaining second strength was that if the families access to homes should not be were shown to be unable to change even understated. Similarly, the provision of
35 multi-faceted approaches which combined area of concern which required extended practical assistance with support for intervention beyond the limit of the vulnerable parents to confront painful commission Even in these cases where issues about their parenting were crucial some concern remained on closure, huge to success. improvements were often seen, with an obvious trajectory towards complete Most of these transitioned to less intensive resolution.. In these cases, families were services with no remaining areas of transferred with well-developed action concern. However, concern remained in plans to the referring agency for other cases, often with a single lingering completion of the work.
KEY FACTORS IN ACHIEVING POSITIVE CHANGE
Five factors proved to be essential to the The age of children was not found to be an success recognised by the evaluation. influence on whether or not the result was These related to early intervention, home a return to targeted (or even universal) visits and the relationship between parent services or entry into care. In almost all and worker, explicit acknowledgement of cases in which neglect was so severe and neglect as a problem, addressing the improvement so inadequate as to require complexity of the problem, and the utility of entry into care, all of the children were the Action for Children Assessment tool. made subject to care proceedings. The whole family situation was the key, with Early intervention the focus mostly on parental response and The notion of early intervention repeatedly ability such that the risk to all of the requires clarification, particularly whether children was too great to be managed at this refers to intervention at an early age of home. The context of family chaos and the child or intervention at an early stage multiple gaps in parenting were clearly of the descent into neglectful parenting. interwoven with this.
Early age Early stage Since neglect can become an issue at any Intervening when neglectful parenting is at stage of a child‟s life (Horwarth 2007), an early stage was a key factor in the early age was not the prime factor in this evaluation and became more vital as the evaluation. Neglect might develop preliminary analysis was completed. Early because of multiple stimuli that start to intervention was, in most cases, taken to affect parenting only when one child is in mean intervention with the smallest middle childhood. The birth of an possible delay after neglect had been additional child, changes in parental identified as a concern. There may be a relationships, the admittance to the house concern that early intervention could slide of a „risky‟ adult, the onset of substance into intervention at such an early stage misuse, and many other factors might tip that neglect is neither present nor likely, the balance and transform what was yet the application of the Action for previously acceptable parenting into Children Assessment Tool was helpful in clearly neglectful parenting. Neglect may ensuring that there was actual concern occur in early infancy for one child but in about the level of parenting in cases middle-childhood for an older sibling. recruited to the evaluation. There were cases in the evaluation in which older children were neglected as There was an exception to this which attention was focused on young siblings. applied to eight cases. These related However, the neurodevelopmental mostly to young, inexperienced parents, evidence is clear that for infants who are sometimes with a learning disability or with subject to neglect in the early months, little other support, in which it was rapid intervention is vital HM Government foreseen that neglectful parenting would 2011, Howe 2005). be inevitable. This was sometimes recognised before the birth. In these cases, the target was to keep the baby
36 safe and appropriately cared-for while Explicit acknowledgement of neglect as working with parents to increase skills and a problem general parenting ability. In all cases this Before being able to address inadequate was seen to be successful and families and neglectful parenting effectively, it was were successfully transitioned to universal vital to establish an explicit understanding services. with parents that the problem was neglect. Without this overt acknowledgement it Home visits and the relationship would have been impossible to identify the between parent and worker improvements that were essential or to Workers reported establishing effective verify that the required changes had relationships with parents and children, occurred. While in most cases the gaining trust and therefore access to commissioner had already declared the challenge failings, offer guidance, and to concern about neglect to the parents, provide reassurance and moral support. practitioners also spoke of many instances This was often accomplished with parents of parents being shocked to discover that who were hostile or clinically depressed, their parenting was considered to be or holding deep suspicion of agencies and neglectful. The broaching of the subject their intentions. It was clear from letters was clearly a difficult matter for some. The and case conference minutes that workers research team engaged with managers gained access to houses and information from the sites to develop a template script which was sometimes not available to for briefing staff on how to broach the other workers and professionals. In this, subject of inclusion in the neglect project Action for Children staff sometimes to parents when this was necessary. became the only workers with meaningful (Appendix A) access, opportunity to observe the children and work with the parents. Addressing the complexity of the problem To achieve this access and to sustain an Another aspect of successful home visiting effective working relationship the was the workers‟ ability to identify (with practitioners had to demonstrate parents) the wide range of problems that persistence and determination to engage were stimulating or aggravating the parents, to work through repeated rebuffs, neglect, to hold these and keep them all in and to retain the motivation to succeed. mind, but then to prioritise those which The notion of parents having had chances, needed to be addressed first, usually missed them and therefore being prioritising those that would immediately considered impossible could not be bring most benefit to the child. Often the accepted, so workers persisted and pursuit of a single problem would involve a pestered until objectives were achieved. raft of activities, each of which might need to be taught and demonstrated, and then a The findings of the interim report of this sustained programme of coaching, evaluation prompted Action for Children to reminding and motivating parents until a develop its Family Partners initiative, routine was established. For example, to informed specifically by the experiences of achieve the outcome of children eating a Action for Children staff in the UK Neglect nourishing evening meal, the practitioner Project. The Family Partners project might need to start with recognition of actively sought out early neglect and basic food groups and planning a meal, intervened in an informed manner, then shopping for the food, cooking the exploiting, in particular, the new learning meal, supervising children in eating the about the importance of the practitioner- meal, cleaning up after the meal, and so parent relationship. This Family Partners on. Practitioners talked of having to model is being delivered in several physically demonstrate how to clean a services in Action for Children and is being toilet such was the lack of experience of presented to commissioners as an some parents. Consequently, while each effective and efficient way to engage individual aspect of care might require a families where there are early signs or detailed programme for progress to be emerging concerns and to achieve positive achieved, the sum of these facets of care outcomes for children. could be seemingly overwhelming – the
37 reaction experienced by many of the professional groups and to parents. Skill was needed to break this commissioners. Its stable, objective nature chaotic mass of difficulties down into and simple scoring system engendered manageable units of learning and then confidence in the assessment of problems gradually building the whole picture back and evaluation of outcomes. The revised up again into the full skills set required for Action For Children Assessment Tool has adequate parenting. been reviewed by the original author of the Graded Care Profile,6 and agreement has The utility of the Action for Children been secured for Action for Children to Assessment Tool use the revised instrument. It now forms The use of the Action for Children part of an Action for Children practitioners‟ assessment tool proved to be a key factor toolkit. Care is taken to ensure that the in enabling practitioners to measure and instrument remains a supplement to improve progress in each case. judgement rather than a substitute for it Practitioners reported that they used the (Munro 2010). instrument with parents (rather than applying it to them). They would use the items to score jointly with the parent according to the state of the situation. This might involve a tour round the house, including children‟s bedrooms. This access was often unprecedented and would uncover more evidence of problems.
Using the instrument allowed parents to come to their own understanding of what was lacking in their parenting: a powerful means to promote resolve to make the necessary improvements and changes. At this point, it would be hoped that the impact of this on the children would then be pointed out by the worker. The lack of recorded evidence means that this cannot be verified. Nonetheless, the joint agreement between parent and worker of deficiencies in parenting was a much more effective foundation for moving on to planning and action than the imposition of the view of an external agency.
The instrument was often completed sequentially in stages so as not to overwhelm the parent. As one prioritised issue was sent to be coming under control, another would be introduced, again often by agreement between worker and parent. Parents, then, were presented with challenging but manageable targets. The whole complexity of the case was held by the worker while the parent was encouraged to focus on improving selected aspects of care.
The Action For Children Assessment Tool 6 was also found useful by practitioners in Dr Om Prakash Srivastava, Consultant presenting the evidence of a case to multi- Community Paediatrician, NHS Luton Community Services.
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8 CONCLUSIONS
SUMMARY
There was little pattern to see in the of removing concern to below the declared characteristics of parents or children who threshold, the best results were clearly to were involved with the services in the be seen when intervention began early in evaluation. A number of different issues the family‟s decline in neglectful parenting. were present in most cases but the When cases were identified in a timely combination of specific issues differed manner, and skilled, intensive intervention from one case to another. However, the and support were instigated, significant most common presenting problems were success could usually be expected. often linked: chaotic lifestyle with no routines, and home conditions which Establishing a positive relationship was presented health, hygiene or safety crucial, as was home-visiting. hazards to children. The most common responses to neglect involved a key worker forming a close In 79% of cases, the Action for Children working relationship with the parents and, intervention succeeded in reducing the commonly, coordinating interagency level of concern about neglectful services. Home-visiting was almost parenting or preventing neglect from universal across sites, usually focused on developing. establishing routines and boundaries, and This reduction was sometimes minor when improving hygiene and safety in the home. linked to a sustained overall high level of Group-based parenting programmes, most concern in cases which resulted in commonly the Positive Parenting accommodation of children, but was most Programme or the Webster-Stratton often indicative of major improvement at Programme formed the second arm of least to the point of moving the level of intervention. For both elements of concern below the threshold of neglectful intervention, a crucial issue was the parenting. willingness and ability of parents to engage with the service on offer. In 50 cases (59%), concern about neglect was removed completely. The Action for Children Assessment Twenty-three (27%) cases resulted in Tool was a successful innovation. the children being taken into care, but It proved to be useful both in identifying the Action for Children service also key areas of neglect together with achieved an improvement for the example descriptors and in promoting children concerned since this action shared identification of failings and routes was taken in a timely manner as a to improvement with parents. Regular result of detailed and convincing workshops for service staff and feedback evidence of intractable neglect. from managers and researchers were designed in this project to promote this In eight cases (9%) otherwise inevitable thoughtful use of the Action for Children neglect was successfully averted by Assessment Tool as a guide and an the intervention. instrument rather than as a complete In six of these, the existing signs of assessment in itself. potential for neglect were reduced to a point further from the threshold of concern. A high level of skill was required by Early intervention was vital. practitioners. While determined and persistent efforts by Both the focus on home-visiting and the Action for Children staff often secured complexity of assessing, addressing and improvement in cases of entrenched evaluating neglect demanded a high neglect, though less commonly to the point
39 degree of knowledge, skill, and experience reflecting on what the assessment tool of the practitioner. was indicating and then supporting them to share the findings with confidence with Complex circumstances, vulnerable more qualified colleagues. families, and the breadth of factors to include in decision-making provide a Many of the workers in the project challenge to any worker. In this study, the acknowledged the role of this support in best practice across all of the services was enhancing their confidence in assessment evidenced when the manager or lead skills and presenting their findings to other practitioner engaged all the staff in colleagues and agencies.
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KEY MESSAGES AND QUESTIONS FOR FURTHER RESEARCH
The Action for Children Services that the constituent elements in order to inform were included in this evaluation training and mentorship. demonstrated their ability to intervene successfully in most cases of neglect, The Action for Children Assessment even when neglect was a most serious Tool enabled practitioners to work with concern (to the level of child protection parents to establish a joint intervention). In cases where parents understanding of problematic aspects refused or were unable to respond of parenting and to plan for staged positively, children benefited from an improvements. It also provided a expedited move into care. valuable source of evidence of objective assessment and review. The instrument, while valued, was too The ability and willingness on the part large and cumbersome. Further work is of parents to engage with services was being undertaken by Action for Children to a crucial factor in deciding whether reduce the size of the instrument but progress would be made or children without damaging its effectiveness. removed for accommodation. Testing for continued effectiveness and Specific contributing factors were retention of both objectivity and specificity identified, but mostly relating to the will be necessary. worker‟s approach and ability. Further research is needed to investigate the factors in parents that support or militate Acknowledging that most neglected against a positive response to offers of children remain in the care of their help for efficiency in the approach to parents, it is vital that efforts are made borderline cases to be enhanced. to provide services directly to the child and not just to parents. Where a twin- track approach has been used in other The work undertaken in outreach or services it has proved to be successful. home-visiting by often unqualified The degree to which the intervention support workers with especially impacted specifically on children‟s health difficult cases requires a high level of and wellbeing could not be fully skill as well as experience. established in this evaluation. A focused Research is required to establish the effort to address this should made with a means by which practitioners achieve this moderate but carefully monitored sample level of skill and expertise, and to isolate using the methods developed in the evaluation.
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42 medication in pregnancy. London: UNICEF (2008)Behid closed doors. The MacKeith. impact of domestic violence on children. New York: UNICEF. Available at McCarthy T, Galvani S (2010) Alcohol and http://www.unicef.org/protection/files/Behin other drugs. London: BASW. dClosedDoors.pdf McConnell D, Breitkreuz R, Savage A www.actionforchildren.org.uk/media/14398 (2011) Independent evaluation of the 3/evaluating_targeted_family_support.pdf Triple P Positive Parenting program in family support service settings. Child and www.barnardos.org.uk/what_we_do/camp Family Social Work aigns/campaigns_children_in_care.htm doi: 10.1111/j.1365-2206.2011.00771.x (accessed 12.7.10) Moran P (2009) Neglect: research www.childwelfare.gov/pubs/usermanuals/n evidence to inform practice. Action for eglect/neglect.pdf Children. www.education.gov.uk/rsgateway/DB/STR Moran P, Ghate D, van der Merwe A /d001041/index.shtml (Accessed (2004) What works in parenting support? 03.01.12). An international review of the literature. www.scotland.gov.uk/Topics/People/Youn London: DfES. g-People/gettingitright Munro E (2010) The Munro Review of www.sdqinfo.com/ child protection. Interim report: the child‟s journey. London: DfE. Available at http://www.education.gov.uk/publications. Platt D (2006) Threshold decisions: how social workers prioritise referrals of child concern. Child Abuse Review 15: 4-18. Pollnay L, Srivastava O (2001) The Graded Care Profile. Luton: Bedfordshire and Luton PCT. Ravey M, Murphy M, Long T, Fallon D (2008) Evaluation of the Blackpool Springboard Project. University of Salford. ISBN: 978-1-905732-53-1. Available at www.nursing.salford.ac.uk/research/n&m- research/childrenandyoungpeople/ Reder P, Duncan S (2001) Abusive relationships, care and control conflicts and insecure attachments. Child Abuse Review 10:411-427. Social Work Reform Board (2010) Building a safe and confident future: One year on. www.education.gov.uk/swrb Stein M, Rees G, Hicks L, Gorin S (2009) Neglected adolescents - literature review. London: DCSF. Stevenson O (2007) Neglected children and their families. Oxford: Blackwell. Tunstill J, Blewet J, Meadows P (2008) Evaluating the delivery by Action for Children of targeted family support. Synergy Research and Consulting Ltd.
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APPENDIX A: Introducing “level 2 parents” to the neglect research project
Key points
You have problems that are affecting your child(ren), and we want to help you with them. (Indicate the impact on the child(ren) of struggling in these areas.)
The problems that I see now are the sort of thing that can lead to children receiving care that falls below government-defined standards.
If things got to that point, the level of care is defined as being neglect.
So, if things go on like this you will find people getting involved in your life to protect the children because they will be at risk of neglect. It can even end up in children being taken into care.
That’s why Action for Children wants to help you now, while the problems can be fixed.
You can work with us now to tackle the problems and ensure that they don’t escalate into needing more intrusive intervention. We can agree on what needs to be done differently, and I can help you to make the changes that are needed. You can stay in control and, hopefully, you will all see the benefits. (Examples from the specific case of what could be achieved for the family.)
So, there it is. It’s not a demand: it’s an offer to help you to help yourself.
(The research)
We are currently trying to find out what works best in the way that we help families with these sorts of problems. Some researchers from the University of Salford are working with us to do this.
They especially want to see if helping at an early stage like this is more effective than waiting until the problems have really taken over.
They are looking at family case files (but not collecting personal details like names or addresses) to see what works best in different circumstances.
If you agree they might want to see your case file and include some information anonymously along with other families like yours - and also some that are in much more difficulty. They may ask to interview you to ask how you found the service that we offer and if anything could be done better.
We would do this only if you agree, though your names or address or other details that might identify you wouldn’t ever be recorded or divulged to anyone outside the Action for Children service. Long T, Murphy M, Fallon D, Livesley J, Devitt P, McLoughlin M, Cavanagh A (2012) Evaluation of the Action for Children UK Neglect Project: Outcomes for the children, families, Action for Children, and the UK. University of Salford.
CYP@Salford
ISBN: 978-1-907842-30-6
© University of Salford 2012
© Front cover image - Action for Children
Available online at: actionforchildren.org.uk/media/2760817/childneglectin2011.pdf and www.salford.ac.uk/nmsw/research/children,-young-people-and-families /key-project-reports