What I mean to say: fit for purpose
10th January, 2012
Just before Christmas, UK Children’s Minister Tim Loughton commissioned a review of the adoption process. His advisor, Martin Narey, had become “exercised …. about (the) parental assessment process which is”, he said, “not fit for purpose”.
‘Not fit for purpose’ is, as far as I can work out, a recently invented cliché. I suppose a cliché by definition should have a certain vintage, maturing through over use from meaningful observation into banality. But some words and phrases are quicker to triteness than others, and ‘not fit for purpose’ has made the journey at the double.
Take away the negative, add a question mark and we are left with ‘fit for purpose?’ a routine quality assurance test. But whereas ‘fit for purpose?’ is asked of a specific part of a process, a cog in a system of wheels, ‘not fit for purpose’ is an adjective applied to the organisations on which society has come to rely.
Its intention is to shock. The Home Office, prior to its break up, was ‘not fit for purpose’. The European Union, say the eurosceptics, is ‘not fit for purpose’. The failure is not a part of the organisation, a department or leader, it is the whole damn system. ‘Blimey, I didn’t know that, thank goodness someone is going to put it right’ is the requisite response.
The riposte should be ‘what purpose’. The European Union seems to be implicated in near-on 70 years of peace in a continent that has specialised in war, so maybe it is suited to this purpose. On the economic front, capabilities are rightly being questioned.
The purpose in doubt with respect to adoption is its ability to supply middle class childless couples with healthy children from working class homes. As Minister Loughton put it,
"We cannot afford to sit back and lose potential adoptive parents when there are children who could benefit hugely from the loving home they can provide”.
Another purpose of children’s services is to ensure that working class parents are not deprived, because of temporary incapacity, from the opportunity of providing a warm supportive upbringing for their children. Another is to weigh the risks of things going wrong with the birth family against things going wrong with a foster or adoptive family. That middle class families are as vulnerable as working class families to incapacity or death, and as able to screw up their children, or to be screwed up by their children, is one of the great inconveniences of modernity.
Social workers are being asked to make life changing, in some cases, life saving decisions. I am sure I would, as Narey put it, ‘meander’, when faced with such huge choices. And I might slow to a complete halt if my decisions were constantly being questioned by unqualified people like me, the Minister or Narey.
What the high ups can do is to be clear about the purpose and to stop second guessing ‘fitness’. With a bit more clarity, maybe the practitioners would have more confidence to act.
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Finlandia: What’s essential and what’s optional in the quest to improve children’s lives?
22nd November 2011, Manchester
To the British liberal eye, Scandinavia is an idyll as perfect as that painted in Sibelius’s short symphony Finlandia.
Recent terrorism, the emergence of nationalism and the unsettling effects of Stieg Larsson and Henning Mankell scratch at the surface but the beautiful vista remains undimmed.
By most calculus, the Scandinavian states do more for their citizens than we do in the UK. The argument goes that doing more would make our children, our people, happier and healthier.
But it is interesting also to look at what apparently successful states omit.
Last week the Social Research Unit hosted a visit from anti-bullying expert Christina Salmivalli from Finland. Part of the story was about addition. She reported on how her well-crafted, rigorously evaluated bullying programme had been implemented, effectively so, and at scale. It is another Scandinavian success.
But the back story covered some of the things Finland does not do that the UK does. Finland does not have school inspectors. There is no equivalent to OFSTED.
Finland does not give parents or students choice about which school they attend. You go to your local school. It's not a command, it's just what you do. There is no testing. In fact the first real exam is at matriculation, when students are 16 years old. No SATS in primary school, and none in secondary school. Not that there is much primary school to speak of. Finnish students don’t really get around to learning how to read and write until they are seven years old.
And to round it all off, Finnish teachers are not told their raison d’être is to produce super smart graduates. The task is to prepare students for life. The product of this laid back approach to schooling is the smartest students in the world. Finland regularly tops the widely respected OECD PISA survey of scholastic performance.
In many ways I am resistant to these idylls. Sibelius is ok. Finlandia is quite nice and only seven minutes long. But most of the symphonies go on and on and are relentlessly uplifting or lovely.
But it did set me off wondering what would happen if we abandoned all inspection in a dozen or so local authorities. What if we gave OFSTED a school holiday and a social care break for a couple of years. Would the world come to a halt, and if it didn’t could we spend some of the savings on prevention or early intervention? And if we abandoned the commitment to choice in another handful of local authorities, would parents or pupils rise up and revolt, and would standards plummet as we have been led to believe?
If we went about this exorcism of choice randomly, we could find out, and potentially save a few bob. Or is this just another idyll, a fantasia maybe?
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Family Nurse Partnership Annual Study Day
22nd November 2011, Manchester
In today's Family Nurse Partnership Annual Study, I addressed the audience with the following talk:
"It is a great privilege to be invited to speak at the FNP National Study Day. I suppose I would count myself as FNP’s number one fan, except that many others will be vying for that position.
There are lots of things I want to say, but I only have 20 minutes. So I will just draw out some highlights.
Achievements
We are having the toughest of times for over a century. You work with people who feel the economic downturn most. But your achievements are significant. Over 6,000 families receive FNP. That is a market penetration of 10 per cent. In the US I reckon that after about 30 years they have reached 15 per cent. So you are really motoring.
More importantly, the replication of the model has been strong. We know this from the Birkbeck research. For the most part -there is always room for improvement- FNP has been implemented as it should be implemented. That is crucial for delivery of better outcomes for mother and child.
By now, so skilled are you at this work, you probably do not think this is such a big deal. But I can remember the host of other government initiatives that broke all the rules:
- For example, those that had no evidence base
- Those that lumped together several evidence-based programmes willy-nilly
- Or where volume was put ahead of fidelity.
With one or two notable exceptions, nearly all of these efforts resulted in zero impact on child or family outcomes, and most are long gone and forgotten.
Even now we are not supposed to talk about these huge errors of government. Millions of pounds were wasted by taking perfectly good products, dismantling them and then re-assembling them badly.
It was FNP’s good fortune that it fell into the hands of sensible people who put what was right ahead of political expediency.
Money
We can argue about the figures but roughly speaking the state spends about £5,000 per child per annum. It doesn’t sound like a lot, but nationwide it adds up to about £55 billion.
And at FNP you are asking that we blow £6,000 on a single intervention. It is a big ask. It is a credit to those of you seeking commissioning that you have made the case. Your job must have been difficult, and it has been getting more difficult, and it will be more difficult still as the recession continues to bite.
If we were informed gamblers, we would see FNP as a safe bet. Yes it's a reasonably big outlay, but the returns are significant. The econometric model that Dartington has been developing for the UK calculates that each £6,000 chip is going to bring in about £16,000 of returns.
Why? Because FNP mums are more likely to go back to work. Because child protection concerns are decreased by over a half. Because in the long run the children are more likely to do well at school and less likely to bother youth justice services. Because mother and child are healthier and make fewer demands on the NHS.
Since we are cautious souls, we run what we call a ‘Monte Carlo Simulation’ in our models. This is like saying, 'I know I might get lucky on the casino tables one or two nights in a row, but what would happen if I played for 1,000 nights, including those times when everything was going wrong'. And it turns out that 99 times out of 100 FNP will always pay off.
These kinds of calculations have led to different ways of thinking about commissioning. We have helped local authorities to make investments that not only improve child outcomes but also generate an economic return. Social finance organisations are bringing private finance into the equation. Payment by Results turns the outcomes into pounds and pence.
FNP is a slam-dunk, home-run, and every other type of cliche you want to apply to an investment that is bound to pay-off. I would put my money into FNP tomorrow if the mechanism existed. The commissioners in the room will be exploiting these opportunities, and getting social care, schools, and youth justice to invest as much as the health service has invested, knowing that they are going to be primary beneficiaries.
Culture
What helps FNP is your sober approach to evidence. There is a culture of not over-claiming. Don’t lose this.
Recently I went with a venture philanthropist to a large UK city to reflect on potential investment opportunities. Each programme we saw claimed, in the absence of any credible evidence, to be 70 per cent successful. Whenever I hear the words ‘my programme is 70 per cent successful I zone out since I have never encountered anything that was 70 per cent successful.
When we got to FNP, we were told that although FNP had been subjected to three experimental trials, all showing significant effects on child outcomes, the UK evaluation was still underway. When the venture philanthropist asked about Group-FNP, he was told this was still very experimental, under development and some way from being ready for prime-time.
It was a breath of fresh air. And for a venture philanthropist today and I suspect for public sector investors in the future, it injected some predictability into a series of conversations that have been marked by guesswork. The need for honesty, predictability, transparency is going to feature strongly in future commissioning conversations and I urge you to hold on to your values.
Scale
My current passion in this work is helping to take some proven models to scale. In the UK we have many many interventions, few of them proven, some of them harmful, a handful like FNP backed by strong evidence, and none of them scaled.
In the same UK city I visited with the venture philanthropist, there were 100 FNP places to meet potential demand of 350. Scaling up in that city meant finding another £1.5 million. Another big ask.
But the advantages of scale are huge. Not only are more children and parent served but a public health effect is produced. Parents who don’t come anywhere near FNP begin to behave like FNP parents. A contagion is produced.
So, to my mind, I am asking, instead of funding 10 things, nine of which have at best a dubious evidence base, why not scale two or three things in which we have most confidence.
So whereas Kate and Ann rightly have their eye on the prize of 60,000 places England wide, I am hoping you have your eye on scale in your locality. That might be just 50 places, or three to five hundred in a big city. If you can do it, you will be the first people in the world, to take an evidence-based programme to scale, and to bring all the benefits for families that this promises.
The challenge of scale is huge. As a general rule of thumb, most things proven to work have not been scaled, and most things taken to scale have not been proven. I recently helped to convene a major conference on the subject at the Gates Foundation in Seattle and here are some of the things I have learned.
First, scaled products are personal products. So while evidence-based programmes like FNP demand fidelity, scaled programmes will require adaptability to suit the user. We can do both, but it takes a little extra thought to work out how.
Second, people don’t want to know how something works, they just want to know what it will do for them.
The iPhone is a good illustrator of these two points. We don’t want to know how it works, just that it will make calls, link to the internet, play music etc. We make an iPhone our own. We personalise it.
People don’t need to know how FNP works, just what it will do for them. And your secret weapon is the relationship between nurse and parent and child. This is the personal bit.
For those of you responsible for managing FNP, similar personal connections are needed with systems folk commissioning FNP. They need to feel they are bringing something specific to meet local needs, something that preserves the fidelity of the core but allows adaptability around the edges. Something that allows an added dimension designed with Manchester, or Newcastle, or Preston in mind. Context is king in the world of scale.
Third, stories matter. Numbers, trials, effect sizes etc matter. They really matter. But once we know the evidence, we can engage hearts and minds by telling the stories to which human beings, parents, relatives, social workers, general practitioners, relate. This, in my experience, has been a strength of FNP in the UK, and you can use it to greater effect in the scaling process.
Fourth, most successful scale-up links a product with a process.
The combine harvester, that transformed the US from a largely agricultural to a largely industrial nation, was linked to the invention of hire purchase. The Ford Model-T was linked to mass production.
Toyota, the worlds most successful motor car company, 60 years ago a sewing machine producer, is linked to ‘Just in Time’ technology.
Microsoft, the world’s greatest scale up triumph, is a product of two big bets paying off at the same time. Bill Gates bet on Windows software. His colleagues bet on packaging that software so that it could be licensed and sold with any computer, meaning they did not have to be computer manufacturers. FNP is the world beating product. What process is going to help us scale it?
Messages for the Workshops
I will close with some messages for the workshops that follow. I cannot comment on the organisational aspects of the work since that is well outside my expertise, but there are some messages from research that might be relevant for the other groups.
Quality improvement is going to be a recurring theme in the next decade. It is intrinsically tied to the question of scale. Public expenditure will get progressively tighter. We can cut or we can get better at what we do well. Scaling evidence based programmes like FNP is on the getting better at what we do well side of the equation.
I have urged commissioning strategies that seek local scale up of FNP. The first person in this room to meet the needs of every high risk, young prospective mother will be the first person in the world to scale an evidence based programme. I am betting that the returns will be much greater than the benefits that accrue to the mothers who are supported, that there will be a contagious effect. If you are on this journey to local scale, give me a call because I want to be on the journey with you. Its the next big frontier.
Your achievements over the last four years have been remarkable, and this makes sharing the learning difficult. We don’t embrace success in this country. But your sober approach to implementation, respectful of evidence but putting the child and family first, should be hugely instructive to the children’s services workforce. To me this is more than sharing ‘top tips’, its about making the best practice routine practice. I really hope there may be some investment in this task.
On data collection, you have, unlike most children’s services operations, good data. You probably have too much. The challenge is reduce it to the information that the nurse and the mother really need to know in order to achieve the best outcome for the child. This will be a defining challenge in children’s services in the next decade since we collect too much data and do too little with it. Its draining our resources that could be better invested in kids.
Safeguarding. There is a simple message here. FNP is, to date, the best proven model for preventing child abuse. By far. It is fantastic that the Health Service has invested so heavily in FNP but I am hoping that social care will become the major purchaser since your product is the best on the market for reducing avoidable harm to children. Yes, you have to get your safeguarding right, and you will talk about this in your groups, but don’t lose sight about the intrinsic safeguarding capabilities of FNP.
And let me finish on relationships and encouraging positive, sensitive parenting. Conflict in families in ubiquitous. Living with other people is not easy. About five per cent of families resolve this conflict using violence. Not minor violence, severe violence. Most of these families are unknown to children’s services, and the damage to children in terms of clinical disorders is considerable.
Most of us resolve conflict badly. We resort to psychological aggression, we use minor physical violence, for example slapping our kids. This is the norm but it is not healthy. It elevates the risk of conduct disorder for children three-fold. This is not a problem for other people’s children, it is a problem for most of us in this room.
So for me, another scale challenge, is how do we take the components that have made a programme like FNP so successful, changing the behaviour of the most at risk new parent, and translate them into a form that we can reach every new parent. How do we spread the idea that ordinary conflict in the home can be resolved with a little more awareness, more mindfulness and little less angst, and getting our own way and hitting.
This public health approach to child protection, changing what all of us do at home, has the potential to radically improve the well-being of UK children.
Conclusion
I hope those remarks were of some value to you. FNP is arguably the best evidence based programme available. The implementation in the UK has been exemplary. Its a success story. So lets break the habit of a lifetime and celebrate. But more importantly, lets use the success as a platform for the next challenge. For me that is scale. Not so much 60,000 places, which seems unattainable at the moment. But achieving scale in a number of significant places, say here in Manchester, or Birmingham, Nottingham maybe. The place doesn’t matter as much as achieving this more modest goal and estimating the value added by virtue of the contagion and other public health effects produced. I very much hope some of you will make that important journey."
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We Can Work it Out
11th November 2011
Bill Gates stares out of a Rotary International poster and tells us ‘We are this close to ending Polio.’ His thumb and forefinger are placed either side of the words ‘this close.’
Gates is making a huge contribution to this dream. As, no doubt, are Rotary International. But it was the pronoun ‘We’ that caught my eye. Eradicating Polio demands that a lot of people do something different.
The poster caught my eye at the airport as I returned from the convening on Achieving Lasting Impact at Scale organized by the Bill and Melinda Gates Foundation in Seattle.
We had been reminded that we know how to reduce infant mortality but we haven’t figured out how to get the solutions widely taken up. Exclusive breast feeding in the first two years of life saves lives but few mothers start never mind persist in nursing their own children. Chlorhexidine kills the infection that spreads from the umbilical chord to the new born child. But how do we get this simple, inexpensive, antiseptic to every birth place?
There was an impressive ‘We’ at the Gates convening. Experts in child health sat alongside business leaders. Politicians and policy makers shared the platform with media experts. Most branches of academia were represented, and participants came from all corners of the globe.
Most will have left reflecting on the need to collaborate and to think anew. Experts like to think they have the solution, when in fact most solutions are the product of several experts.
We know that telling people what to do in order that they and their children will lead healthier lives seldom works. So how do we change our habits with a view to tracking down innovative ways of getting people to demand health enhancing products and practices?
We learned that the personal approach pays dividends. But how do we mass produce the personal so that we can help recipients of innovation to be determinedly individualistic whilst adhering to emerging health enhancing norms?
I cannot work out the solutions to these problems. And nor could the participants at the Gates convening in the short amount of time allocated. But with more time and more collective effort progress should be possible.
We know what works and we continue to invent new ways of improving global family health. But preventing eight million under five deaths each year requires a new expertise, the scaling of proven products and practices. We don’t yet know how to do this. But We can work it out.
Michael Little is co-Director of the Social Research Unit at Dartington, an independent foundation dedicated to bringing science to bear on better child development. Dr Little assisted in the facilitation of the Achieving Lasting Impact at Scale convening organized by the Bill and Melinda Gates Foundation in Seattle in November 2011.
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Separate but connected?
10th August 2011
"There are pockets of our society that are not just broken, but frankly sick," said David Cameron on his return from Tuscany. Like the Prime Minister I have a strong belief in the power of communities to improve human development, and child development in particular.
But the condemnation of young looters, echoed by Ed Milliband as he took his photo opportunity in front of a group of broom bearing youngsters in Manchester, only serves to disconnect those who are already unhinged.
Hoodies and their tattoo bearing, cigarette smoking, borderline obese, single mothers are an easy target for a moral majority. But these young people and their families also constitute a community. They hold often unpalatable views, not least the aggressive, unrepentant, young man captured on television news this afternoon putting it all down to the ‘Poles taking our jobs’.
Progress will come not from denouncing these communities but by forging connections. The most remarkable contribution today came from Tariq Jahan whose son Haroon was last night murdered during unrest in Birmingham. Tariq called for an end to violence that threatened to escalate into racial strife between neighbourhoods.
There is a power in communities that can be unleashed for good and for bad. A healthy community will understand that we are separate but connected to a broader society to which we hold obligations.
Parts of our society must change. But none, whether they be bankers who broke the bank or young thugs who want to break into the bank are going to be told what to do. We must provide incentive to change.
In the days that come, our political leadership might remember its responsibilities to those who Cameron labels as ‘sick’. Inequalities in wealth. The failure to sponsor social mobility. The narrowly drawn political elite. These are among the many symptoms of the illness that lays low our society. The remedies are hard pills to swallow.
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Response to the response
19th July 2011
Four reviews. One response. Two more reviews promised. There has been a lot of reflection on how to better support child development since the Coalition Government was formed 12 months ago.
Today, Education and Health Ministers Sarah Teather and Anne Milton published their reaction to the reviews commissioned from Labour MPs Frank Field and Graham Allen, Action for Children Chief Clare Tickell and LSE Professor Eileen Munro (the 19th of July, 2011). The detail is set out in Supporting Families in the Foundation Years http://www.education.gov.uk/home/childrenandyoungpeople/earlylearningandchildcare/early.
Perhaps the most significant aspect of the publication is its’ authors. The drive for change has been coming from Treasury, Number 10 and the Department of Work and Pensions. But it is the owners of children’s policy, Education and Health that have provided the primary reaction. This may or may not signal future priorities.
The four reviews produced a lot of requests for action and it is impossible for Government to respond favourably to all of them. The initial reaction is broad. Inevitably it backs the things to which Government is already committed, the expansion of Family Nurse Partnership for example. There is strong backing for more information for parents, a better trained workforce and a shift of resources towards the most disadvantaged.
There is nothing here to argue against. But the aspirations may be too broad to be useful, and some of the things that matter most may get shunted down the list of priorities.
My contribution to these reviews, a lot with Allen and a little with Munro and Field, has been a call for a higher standard of evidence. The Government response indicates a shift in the right direction. But it is far from all embracing perhaps reflecting the anti-body reaction that this injection of science has produced.
Maybe Teather and Milton have judged this right. Interventions selected by a high standard of evidence are potentially part of the solution to impairments to children’s health and development. They are not the entire solution. And we have to further test the potential. As long as evidence-based programmes and policies are not being kicked into the long grass, to borrow a favourite Whitehall phrase, then we are doing well.
The test will be the extent to which Government backs or at least does not impede the creation of an Early Intervention Foundation to provide independent standards of evidence, identify programmes and policies that pass muster and support new financing arrangements to see if the potential benefit to children can be realised.
One recognises in Teather and Milton’s report the cleft that Government must stand over. One line takes us away from telling local authorities what to do. The other line demands that we all do one or two things to improve the lot of England’s children.
The join requires proper experimentation at a local level, and an honest sharing of results so that others can pick up what is successful. Science, truth and embracing failure are necessary ingredients to make this work.
The cleft also highlights the need to develop a social contract regarding child development. Little is to be gained by telling people what to do. Nobody has ‘a’ solution to the ills visited upon our children. We still lack consensus about what we agree on, what we need to learn and how we can test innovation.
The glaring gap in both the reviews and the government response is innovation through subtraction. Everyone wants to add (in a time of economic adversity). Nobody wants to acknowledge that some progress depends on taking away that which is harmful (and testing the extent of its harm along the way).
The great triumph of this process, the reviews and the response, has been the way it has crossed party political interests. Child development is not going to be enhanced by voting left, right or middle. The political parties can help by approaching child development in a non-partisan manner. That reviews were commissioned from two Labour MPs and the response came from the Coalition parties is a significant step in the right direction.
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Evidence Based Programmes, Child Protection and Munro
Blog entry: May 11, 2011
Eileen Munro today published the third and final part of her review of child protection for UK Government. She writes about the value and challenges associated with evidence based programmes, and is cautious about their value. The report includes a large quote to some notes that I prepared with my colleagues David Jodrell and Seden Karakurt about evidence based programmes in the context of child protection. I thought it might be useful to blog that submission in full. Here it is.
Evidence Based Programmes in Child Protection
Much attention has been given in recent years to the place of evidence based programmes in children’s services. These are prevention, early intervention or treatments that are proven at a high standard of evidence to improve children’s health or development.
What counts as an ‘evidence based programme?’ For the purposes of this brief overview, the same standards of evidence applied in the Allen Review of Early Intervention have been adopted. These standards, developed by an international team of experts, are not written in stone. But they provide a ready tool to assess the variety of potentially evidence based programmes relevant to the task of protecting children from maltreatment.
This process selected programmes that were supported by at least two robust evaluations in which the effects on those receiving the intervention were compared to a control group. One of the evaluations for each programme included was a randomised controlled trial[1].
The search focused on prevention, early intervention and treatment programmes that have the potential to:
• reduce the risks of child maltreatment
• reduce maltreatment.
The list did not extend to programmes that reduced the effects of maltreatment, such as emotional and conduct disorders, or other mental health problems consequent upon maltreatment. (There are many examples of evidence based programmes in this category).
The following summary also drew on meta-analyses or systematic reviews that bring together many rigorous evaluations. The paper by Christopher Mikton and Alexander Butchart for the World Health Organization is an exemplar[2].
What types of evidence based programmes exist?
The following attached table summarises the types of programmes that exist, and whether there is evidence of impact on risks of maltreatment or the level of abuse.
*Intensive parenting programmes focused on child protection reduce maltreatment
1) Community/Public health strategies
Two programmes exemplify this category. Much attention has been given to the delivery of all five levels of the Triple-P parenting programme in South Carolina in the United States. This begins with media strategies to change parenting behaviour in the general population but also provides intensive group based training for parents of children who are known to child protection agencies. This strategy has produced significant reductions in abusive behaviour and referrals to child protection.
The Safe Environment for Every Kid programme better prepares people living in disadvantaged communities to identify and respond to child maltreatment, and to work more closely with public agencies such as social work.
2) Health visiting programmes
The class of evidenced based programme with the greatest impact on child maltreatment involve intensive and enduring work by health visitors with parents whose newborns are at most risk of poor outcomes. Family Nurse Partnership, being delivered in the UK with fidelity to 6,000, soon to rise to 12,000, vulnerable, mostly teenage lone mothers, has the strongest pedigree. Among a long list of benefits to child and mother is a reduction in reported child abuse and neglect of 48% by the time the child is 15 years old.
3) Early Years support
There has been relatively little attention given to the contribution played by early years provision, for example Sure Start Children’s Centres, to reducing child maltreatment. Evaluations of an early version of this approach, the Chicago Child Parent Center, report positive findings. For example, the lower incidence of child abuse leading to higher parental involvement in the child’s development explained about a quarter of the variance in reductions high school completion and juvenile arrest attributed to the CCPC programme.
4) Parenting programmes
There is good evidence that proven parenting programmes like Incredible Years and Triple-P, both widely applied in the UK, reduces the risks of maltreatment, and some evidence of reductions in actual maltreatment. The Triple-P universal programme, for example, applied in a community of 100,000 people would result in nearly 700 fewer child maltreatment cases, 240 fewer children coming into foster or residential care and 60 fewer injuries.
These generic parenting programmes are generally delivered to families with a child experiencing impairments to health or development, a conduct disorder for example. More specialised programmes, such as Parent-Child Interactive Therapy, have been delivered to families known to have abused their children, and with good results. For example, in a US evaluation, more than two years after intervention, less than a fifth of families in the child protection system receiving PCIT had been re-reported for maltreatment compared to nearly half receiving services as normal.
5) Therapeutic models
A wide range of therapeutic models have been evaluated and shown to have some impact on child abuse outcomes. For example, the Infant-parent Psychotherapy and Psycho-educational Parenting programmes have proven impact on attachment in families where the parent is known to have abused their child. Trauma-focused Cognitive Behaviour Therapy (CBT) has been used with some effect with children who have been badly maltreated.
What does not work?
The same high quality evaluations used to find out whether or not an intervention works can be used to indicate what does not work. That is to say, some programmes, designed with good intentions, result in negative effects, such as more children being abused or reported to child protection agencies.
Just as a positive evaluation does not imply a programme must be used, a negative finding does not indicate that a programme must be axed. The findings suggest a direction of travel or encourage further testing and exploration.
Generally speaking, there are less than promising results from interventions that focus on keeping together families where there is high risk of child maltreatment. (This is not to say that such efforts should cease, just that impacts on child maltreatment are, at best, likely to be mixed).
For example, Homebuilders, an intensive family preservation service delivered in several US states, produced impacts on child maltreatment and placement away from home that were initially promising but soon tailed off.
Family Group Conferences also deserve a mention in this category. There have been many studies of family group conferences, but only two that met the exacting standards applied by the Allen Review Team. These evaluations show, at best, mixed results but also evidence of iatrogenic effects on child abuse and maltreatment that correspond with the findings from intensive family preservation. Again, these results do not definitively say that Family Group Conferences are damaging. However, more reflection and evaluation is required.
The Problem with Evidence Based Programmes
Any rapid review of evidence based programmes runs the danger of selecting a short list of interventions and giving the impression that they have the potential to eradicate the problem in hand. Evidence based programmes are not a cure-all for child maltreatment or any other aspect of child development. The list of challenges is long, but a few points are sufficient to inject caution.
First, because other countries put a higher value on experimental evaluation methods in the context of children’s social needs, many of the proven models come from outside the UK. This does not invalidate them any more than Microsoft computers should be invalidated because they were invented in the US. But it does urge caution and re-testing to ensure that the ideas travel well. (Most partnerships doing this work in the UK are finding that, so far, the programmes do travel well).
Second, the relative absence of rigorous evaluation in the UK means that it is simply not known whether home-grown interventions are effective. It may be that UK boasts many more effective responses to child maltreatment than North America, Australasia or Scandinavia.
Third, if evidence based programmes are not delivered with fidelity, that is to say if they are not delivered as they were intended to be delivered, with the correct levels of training, coaching and adherence to the manuals, they seldom achieve their intended benefits. Moreover, a proven model can be damaging when delivered badly. Getting the right staff, to deliver the right programmes, to the right people in the right way has proven elusive for some UK agencies.
Fourth, there is a difference between proving an intervention in trial conditions and seeing the effects at scale with several tens of thousands of children. Most evidence based programmes have little market penetration. It is for this reason that results from interventions like Family Nurse Partnership that is reaching seven per cent of eligible children within three years of its introduction to the UK are attracting so much attention.
Fifth, mainstream systems, such as social care and the police, have little experience of delivering evidence based programmes, most of which depend on short-term, marginal funding. Getting systems ready for evidence based programmes and evidence based programmes ready for systems is fundamental to any progress in this area[3].
Evidence based programmes and child protection
Evidence based programmes will never be a panacea for problems of child maltreatment. As this brief review demonstrates, there are strategies known to reduce risks of child abuse but implementing those strategies is challenging. Moreover, supposing nothing was known to work, in the context of child abuse it would still be necessary to act.
It would, however, seem sensible for managers of resources to have more access to information about what works in the context of child maltreatment, much as argued by the Allen Review in the context of early intervention. This information would never tell managers or practitioners what to do. But it would be an important point of reference during the allocation of scarce resources.
Second, more could be done to test promising innovations in the UK to see if they deliver similar results to those rigorously evaluated in the US, Australasia, and Scandinavia. Many of the interventions referenced in the Munro Review, Re-claiming Social Work for example, would be expected to have child protection benefits and deserve to rigorous evaluation.
Third, where evidence based programmes are being implemented, there should be the proper attention to fidelity necessary to make them work.
[1] With the exception of Chicago Child Parent Centers, where a robust quasi-experimental design gives indications of impact of Children’s Centre type provision on child maltreatment outcomes.
[2] Mikton, C. & Butchart, A., ‘Child maltreatment prevention: a systematic review of reviews’, Bulletin of the World Health Organization, 2009, 87, 353-361
[3] See Little, M., Proof Positive, Demos, 2010 for full exposition of this challenge
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Orchid in the woods
Blog entry: April 1st, 2011
Every now and then, ambling through the woods of scientific orthodoxy that populate a conference like SRCD, one comes across a beautiful orchid. They are rare finds.
Jane Costello’s natural experiment to test the effect of higher family income on the mental health of children in the Smoky Mountain Longitudinal Study was a great example. It is many years old now, but it stays in the mind.
Jane’s colleague at Duke University Ken Dodge provided another on the first day of the SRCD Conference in Montreal, Canada today.
Dodge has been experimenting with a series of community wide interventions to reduce child maltreatment. I think of this kind of initiative as the future of child protection. The story in Prevention Action describes the details.
The orchid in the woods is the evaluation strategy used by Dodge and his colleagues. It is commonplace to have insufficient resource to provide every family with additional, largely unproven interventions. Faced with this problem, and looking for a fair way to proceed, Dodge got the communities in which his interventions would be tested to agree that babies born on birth dates with an even number would get extra help, while those born on a birth date with an odd number got services as usual.
Later, a team asks the parent of one child born on each day of the year to participate in a descriptive child development study. Of course, half will have been offered extra help, and half will not.
In this form of random allocation, the date becomes the identifying factor. One does not need a name. That means that in say 10, 20 or 30 years, if researchers or policy makers want to examine administrative data to find out if the extra help translates into better school outcomes, or less incarceration or delayed parenting, they need only know the birth date of the study participants. Not their names.
Beautiful.
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Graham Allen is a heavy man
Blog entry: January 17th, 2011
Many leaders of children’s services in the UK will glance at the Allen Review on Early Intervention published today and dismiss it as important but soft. They will be making a big mistake.
The Review is all about evidence based early intervention. It is about nipping problems in the bud and not waiting until they bloom in the gardens of child protection, youth justice, mental health and special education.
Children’s services and their employees are usually described with strong adjectives. Foster care and juvenile detention is about the heavy end. There is the hefty burden of responsibility on those who make the tough decisions about child maltreatment. There are the intractable problems of young people in trouble, in care or in need of treatment from mental health professionals.
Few people disagree with the idea of intervening early to stop these problems occurring in the first place. But that ‘soft’ work, engaging, some time in the future, with a much broader range of potentially needy children, it is argued, should not detract from the ‘hard’ job of responding to the very needy who are knocking on the doors of children’s services as we speak.
True? I do not think so. Every person with an interest in the future of children’s services will find the Allen Review directly relevant to their work. Let me give some indications about the weight of his recommendations.
Allen talks about giving every child the social and emotional bedrock for a healthy life. Motherhood and apple pie? More platitudes about emotions and minor misbehaviours?
As the report indicates, a social and emotional bedrock for children translates into fewer conduct and emotional disorders and better school performance. The PATHS early intervention curriculum for all primary school children in Birmingham has the potential to reduce conduct disorders by two per cent in the City. That means less demand for ‘heavy-end’ services. Since happier and better behaved pupils learn more, it also has the prospect of improving school performance by over ten percentage points.
Allen clearly brings out the economic potential of evidence based early intervention. Readers will rightly raise an eyebrow and question the veracity of the data. There have been many false claims in the last three decades. But the technology to predict costs and benefits of competing investment decisions is now arriving at the door of children’s services leaders. My organisation is delivering it, free of charge. Only the fool hardy will ignore it. Early intervention really can make you money. It will also improve the well-being of children into the bargain.
Many of the programmes that Allen recommends are targeted at the same families that child protection, social care and youth justice target. Family Nurse Partnership is directly relevant to the task of reducing child maltreatment by high risk often teenage mothers. When I talk to the parents of three and four year olds with conduct disorders attending the Incredible Years programme in Birmingham children’s centres I can feel their reduced anxiety and need for additional help. (I have also rigorously measured it). People watching the videos of parents and adolescents participating in Functional Family Therapy will see the clients that keep social workers and youth justice professionals awake at night.
So Graham Allen’s business -showing how evidence based early intervention programmes can reverse the down trend in child well-being in this country and make us some money along the way- is everybody’s business. It is not the soft end. It is the heavy end. It is child protection. It is mental health. It is about the young people we fail in foster and residential care. It is about students with special educational needs. And it is youth justice.
So people reading Allen’s Review may disagree with it. But they should not dismiss it as peripheral. It is core to the future of children’s services. And our children.
The first report of the review by Graham Allen MP into early intervention was published on the 19th of January. Michael Little is co-director of the Social Research Unit and contributed to the Review.
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Innovation Through Subtraction blog
Over the next few months, the Social Research Unit will be contributing ideas about how to get the best for children with less resources in a series of blogs. My contribution to the blog will be posted here, on the main page of my site.
To view all contributions to the blog, please visit the Social Research Unit website at: www.dartington.org.uk |