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Growing Support
14. Key points and concluding remarks
Summary of key points
We have indicated at the beginning of this review that the early years are crucial in developing healthy developmental outcomes in later life. The term vulnerability can be interpreted in various ways, as it can refer to material deprivation, family malfunctioning or a combination of the two. Evidence indicates that children most at risk of ill-treatment, neglect or separation are in families where both poverty and some kind of serious parental or family difficulties co-exist, but of course children can also suffer in households with no material disadvantage.
Four holistic frameworks were described in section 2. These help clarify principles, aims and targets for intervention:
- cumulative risk, protective and resilience factors;
- attachment theory;
- ecological models; and
- social construction approaches to parenting and childhood.
Children living in vulnerable families are more at risk from poor parenting and therefore have a more than average chance of incurring negative biological, emotional and psychological consequences. They are less likely to form positive attachments while protective factors (such as family stability, good education) are less likely to feature in their lives, so they will be less resilient in later years. From a broader perspective the ecological approach to child development has sought to place more emphasis on the wider environment and the availability and extent of support networks as an important factor in contributing to the wellbeing of the parent and child. Social construction theories indicate that a critical and open approach should be adopted to assumptions about children's needs and family relationships.
With these issues in mind, it is apparent that some families will need support from specialist or targeted services, though many will benefit from services universally available in the community. In providing these services it is important to ascertain the effectiveness of the interventions. This review has drawn on some of the available literature in this area to try and provide evidence of what is effective in supporting vulnerable families with very young children. However, this has not been a simple task as the availability of rigorous outcome research has been lacking in several areas and often we have quoted research carried out in the US as opposed to the UK. This is not to say that lessons cannot be learnt from this research and in some cases similar programmes have been imported and implemented. Due to the lack of experimental studies we have included a number of different designs in this review, but have warned where necessary that caution may need to be taken when interpreting certain results. In addition the limited time scale has meant that we have been unable to carry out in depth literature searches, so there are gaps in some of the areas in this review.
Family centres and early educational interventions
Family centres provide a large amount of support to vulnerable families with children under 3 and most commentators favour a non-stigmatising universal support service. However, it would appear from a national survey (Warren 1990) that most largely provide child protection services to families who are referred by statutory services. Critics of this targeted model of provision argue that by adopting a universal approach a more preventative service can be implemented that reduces stigma and encourages usage. On the other hand, engaging the most vulnerable without a referral process is problematic. It was also found that drop-in users do not like being associated with those who have been referred. Thus there is no conclusive evidence regarding the most effective or even preferable models of family centres, although the studies reviewed in this work do advocate open access, non-stigmatising services.
A number of studies provided evidence that indicated positive gains for mothers and their children as a result of attending family centres. These studies were based on the views of staff and users. This is a valid method of investigation, but without external assessments or comparisons it is difficult to be certain that any gains can be attributed to the family centres. Evidence from a range of sources does suggest that in order to provide effective early years provision, both child and parent need to be actively involved in a range of activities over a sustained period of time. Centres can help mothers' self-esteem and prospects for increased family income by promoting skills and contacts that can lead on to employment. Concerted efforts and adapted activities are needed to encourage men to engage with family centres.
More rigorous studies were available from the US regarding early educational interventions and findings from these studies showed that there were positive social, economic and educational gains in later years. Vital elements appear to be structured programmes, intensive help, parental inclusion and sustained involvement.
Professional early parenting support and training
There is limited evidence from the UK to indicate the effectiveness of parent education and evidence from the US has largely focused on the parents of children with behavioural problems. Most studies carried out in the UK seem to have included mainly affluent individuals. Although they may include some with serious parenting difficulties, it appears that services are not targeted to the needs of vulnerable families and are not made accessible to them. However, the limited research in this area, which used non-experimental methods of evaluation, did report sustained benefits to parents. They appeared to experience improved levels of confidence, less reported stress and isolation, greater understanding and better management of their children's behaviour.
Unlike education programmes there is considerably more information regarding the effectiveness of support for vulnerable families. A number of studies using experimental designs have reported positive results for a range of interventions for particularly vulnerable groups of mothers and parents in the community.
Both extra specialist input from health visitors or midwives and support from experienced volunteers has been shown to help mothers in the early stages of parenthood. Improvements have been documented in parent-child interaction, rate of immunisations, nutrition and mothers' mental health. The routine service provided by health visitors is generally valued by mothers as helpful, but many are unclear about health visitors roles and some single mothers feel judged and stigmatised.
Community networking models and volunteer befriending schemes
Peers are very important for young children and centre-based interventions help promote social skills and confidence. On the other hand, both centre and neighbourhood approaches have been shown to help isolated parents (mainly mothers) develop their links to existing community networks (Kirk 1999). The development of community networks can also provide flexible and acceptable support in ways that more formal support cannot. Some evidence indicates that workers who understand and engage with informal networks can reduce child abuse (Fuchs 1995; Henderson 1999).
Studies carried out in the UK have pointed to the benefits parents report from being befriended by a volunteer, in such programmes as Home Start and NEWPIN, sometimes alongside others kinds of support. However, some schemes have high non-engagement or drop-out rates, so arguable those most in need may not be assisted.
Child protection
This review has looked at the effectiveness of interventions aimed at prevention of child abuse/ maltreatment as well as the prevention of the reoccurrence of abuse/maltreatment.
Studies into secondary prevention have identified long-term home visiting for women pre- and post-natally by professionals, lay professionals or volunteers as most effective, although evidence on the effectiveness of shor-term programmes was inconclusive. It was reported that there is limited reliable evidence regarding the effectiveness of tertiary prevention in legal and administrative interventions (Oates and Bross 1995). The multiple and often compulsory nature of responses make quasi-experimental studies difficult. More evidence is available regarding therapeutic interventions, although this is largely from the US. Rigorous studies using good outcome measures have reported a decrease in the recurrence of abuse as a result of programmes, especially those with a cognitive-behavioural orientation.
There is also evidence to suggest that social network intervention is also effective in preventing the reoccurrence of abuse/maltreatment. Evidence from work carried out in the US (Gaudin 1990) showed that significant improvements were found in several aspects for families who were subjected to intensive case management which included the development of supportive social contacts.
Social work and inter-agency activities
Parents want social workers to be clear and honest about their intentions and respect their viewpoints, especially when there is a conflict of perspective about what is best for the child. Both practical help and emotional support is valued. Similarly, well structured multiple interventions have been shown to work well. Social and cognitive learning approaches are effective.
Both in relation to child protection and family support, this indicates that often a 'package' of services is beneficial which tackles individual, family, neighbourhood and practical issues, in accordance with ecological principles.
Inter-professional co-operation has been examined most closely in relation to child protection. Most of those involved are reasonably satisfied with the type and degree of collaboration.
Fostering and adoption
If young children are placed in foster care, this is normally for a short period and the experience is usually a brief and satisfactory experience unless it is a prelude to multiple placements away from home. Adoptions of children under 2 have very low risks of breakdown. Children from disadvantaged backgrounds who are adopted soon reach or exceed normal physical and cognitive achievements, but a minority develop psycho-social difficulties.
Concluding comments
This report was prepared in eight weeks and so is inevitably partial and provisional. Nevertheless, from the limited evidence provided in this review it seems there are a number of options and methods for enhancing the healthy development of children. Their success has been demonstrated to varying degrees, but certain key messages emerge from the most systematic research or are supported by several studies. These are set out below:
- multi-level and multi-method approaches have most impact;
- nurseries and family centres have long-term benefits for children and parents from vulnerable families when they are well structured, involve mothers and continue for some time;
- intensive home visiting by professionals or experienced befrienders is helpful, though attitudes are more clearly affected than behaviour;
- parenting is helped when professionals seek to enhance informal network support;
- skills-based and social or cognitive learning approaches are valuable in work with both individual parents and groups;
- interventions mainly focus on mothers: concerted efforts are needed to engage fathers and male partners;
- usually input needs to last months, if not years, to have lasting effects on families with serious multiple difficulties; and
- much care is required to access families with the most serious difficulties or alienation and to keep them involved.
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