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Early intervention, the Family Nurse Partnership programme, and father involvement

Professor Jacqueline BarnesBirkbeck, University of London

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What will be covered

Why early intervention/prevention Some examples Brief description of FNP FNP engaging with fathers

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Wealth of data from life course studies linking adversity in early life to:

o poor literacy

o anti-social and criminal behaviour

o substance abuse

o poor mental and physical health

o adult mortality

Risk factors and poor outcomes

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Need to intervene

Have been reductions in child poverty, unemployment and crime, but there are still families caught in a cycle of disadvantage and exclusion.

To divert trajectories related to disadvantage there is a need for: Earlier and better identification of at risk families Earlier and more effective intervention and

prevention

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Emerging knowledge on neurological development

Brain development depends on both genes and experiences

Rapid brain development takes place in the first year of life

Early interactions directly affect the way the brain is wired

Early relationships set the thermostat for later control of stress response

(Shore R, Rethinking the Brain, 1997)

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Experience affects Brain Development

o Conditions in early life affect the differentiation and function of billions of neurons and trillions of synapses in the brain

o Early experience sets up neurological and biological pathways in the brain that affect well being throughout life affecting health, learning and behaviour

o The more positive stimuli a baby is given, the more brain cells and synapses it will be able to develop.

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But - Brain vulnerability

The disadvantage of the human brain’s plasticity is that it renders it vulnerable to trauma.

The brain of an abused or neglected child is significantly smaller than the norm.

The limbic system (which governs emotions) is 20-30 per cent smaller with fewer synapses.

The hippocampus (responsible for memory) is also smaller.

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Differences in brain development following

severe sensory neglect

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Prevent before problems emerge

If people keep falling off a cliff, don’t worry about where you put the ambulance at the bottom. Build a fence at the top and stop them falling off in the first place.

Source: Allen & Duncan-Smith, 2010

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Small change early leads to large impact later

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Rates of return to human capital investment (Heckman 2000)

0

Preschool School Post-school

Rate of return to investment in human capital

Preschool programs

Schooling

Job training

Age

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Brain Development – Opportunity and Brain Development – Opportunity and Investment Investment

Spending on Health, Education, Income Support, Social Services and Crime

Brain Malleability

Conception

Pub

lic E

xpen

ditu

re

Inte

nsity

of B

rain

's D

evel

opm

ent

BirthAge

1 3 10 60 80

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Early years interventions for disadvantaged populations

Examples, USA•Nurse Family Partnership – home-visiting – pregnancy to 2 years

•Abecedarian Project – childcare/preschool 0-6

•Early Head Start – childcare/ home visit 0-3

•Perry Preschool Project – preschool 3+years

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Abecedarian Project (Ramey et al., 2000)Abecedarian Project (Ramey et al., 2000)

111 African-American disadvantaged children randomly assigned at age 3 months to:

• High quality centre-based provision

(day-care and preschool)

• Control group:

- Both groups followed into adulthood

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Abecedarian Project (Ramey et al., 2000)Abecedarian Project (Ramey et al., 2000)

Results up to age 21 years

- Intervention group showed

• Higher cognitive development from 18 months upward

• Greater social competence in preschool

• Better school achievement

• More college attendance

• Delayed child bearing

• Better employment

• Less smoking and drug use

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Early Head Start ------ 0-3year olds (Love et al, 2003, 2005)

3000 disadvantaged families studied from birth – randomly assigned: Home-based programme, Centre-based programme, Centre and home visits, Control group

At age 3 intervention improved Cognitive and Language Development, more sustained attention and reduced aggression

Improved parent-child interaction , Improved home environment (more reading – less spanking)• Centre and home > centre > > home-based• Better implementation overall better effects

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UK, Sure Start Local Programmes

Most disadvantaged neighbourhoods From birth to fourth birthday All families living in the area so non-

targeted Locally driven agenda allowing for

diversity Enhancement of existing services

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Some positive impacts

At 3 years children in Sure Start areas had better social development with: more positive social behaviour, more independence, better self regulation. They received more immunisations and fewer accidental injuries.

Parents showed less negative (harsh) parenting with more stimulating home environments.

More use of child and family services.

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Pregnancy- A ‘magic moment’ of opportunity?

“Like it or not, the most important mental and behavioural patterns, once established, are difficult to change once children enter school”

Nobel Laureate James Heckman (2005)

• Pregnancy and the first 3 years are vital to child development, life chances and future achievement

• Pregnancy and birth of a child is a ‘magic moment’ of opportunity when parents are uniquely receptive to support

• Universal midwifery and health visiting services are ideally placed to identify children and families at risk

• Embedding the principle of ‘progressive universalism’ into maternal services should be a priority to ensure that additional support is provided to those children and families at greatest risk

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The potential of the Family Nurse Partnership programme

To transform the life chances of the most disadvantaged children and families

A new professional role for nurses Transformation of universal services in

pregnancy and the first years of life Impact on ‘community parenting’ Strengthen the health contribution to child and

family services

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FNP approach

Builds on the strengths of existing universal health visiting and midwifery services

Builds on policy for children and families (Every Child Matters and the National Service Framework for maternity and children)

Multi-faceted risks need multi-faceted but integrated responses

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FNP

Nurses visit first time parents from pregnancy until child age two

Solid clinical & theoretical underpinnings

Has been rigorously tested over 30 years of development and 3 large scale randomised trials

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FNP GOALS

Connecting with families to:

1. Improve pregnancy outcomes

2. Improve child health and development and future school readiness and achievement

3. Improve parents’ economic self-sufficiency

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Visiting Schedule

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

Each visit covers 5 domains and uses materials and activities to build self-efficacy, change behaviour, promote attachment

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Programme domains

Personal health Environmental health Life Course Development Maternal role Family and Friends

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THREE RANDOMISED TRIALS OF PROGRAMME

• Low-income whites

• Semi-rural

• Low-income blacks

• Urban

• Large portion of Hispanics

• Nurse versus paraprofessional visitors

Elmira, NY1977

N = 400

Memphis, TN1987

N = 1,138

Denver, CO1994

N = 735

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Findings across at least two trials Improvements in women’s prenatal health

Reductions in children’s injuries

Fewer subsequent pregnancies Greater intervals between births

Increases in fathers’ involvement

Increases in employment Reductions in welfare and food stamps

Improvements in school readiness

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Cumulative Cost Savings: Elmira High-Risk Families

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

0 2 5 10 15 20 25 30 35 40 45 50 55 60 65

Cumulative dollars

perchild

Age of child (years)

Cumulative Costs

Cumulative savings

SOCIAL

RETURN

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FNP at the heart of current government policy

Health Inequalities – progress and next steps

The Children’s Plan Healthy Child Programme Think Family Excellence and Fairness: achieving world

class services Youth Crime Action Plan Child Health Strategy

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Testing the NFP in England 10 PCT/LA sites Somerset, Manchester, Slough, Tower

Hamlets, Derby City, Walsall, Southwark, County Durham/Darlington, SE Essex, Barnsley

Teams drawn from health visiting and midwifery

100-150 clients per site Approximately half have reached 2

years

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Aims of the implementation research To examine the feasibility of implementing the

Nurse-Family Partnership model in England To determine the most effective method of

presenting the model to prospective clients To estimate the cost To illuminate the experience of practitioners,

the wider service community, and children and families

To determine short-term impacts on practitioners, the wider service community, children and families

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FNP Identified vulnerable population

80% without 5 or more A*-C GCSEs 78% not employed 67% not living with partner 75% below poverty line 24% report physical abuse in past 12 months,

11% during pregnancy 50% BMI < or >recommended range

Indicates simple selection system, under 20 and first time mother will identify appropriate group cf. those in USA trials

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Father involvement high

Young fathers show great interest in FNP, and many want to be present for visits or complete the activities

Pregnancy, 51% father present for at least one visit, on average 24% of all visits (2220/9270)

Infancy, 57% father present for at least one visit, on average 24% of all visits (2213/9236)

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Fathers rated well in understanding, slightly lower in involvement

Mean understanding during visit Mothers 4.5, 4,.6 Fathers 4.1, 4.1

Mean involvement during visit Mothers 4.7, 4.7 Fathers 3.9, 3.8

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Fathers do not expect to be involved

“I liked that she [FN] wasn’t just involving [client], she was involving me as well.”

“I did not expect to be involved I thought it would be more for my girlfriend’s benefit but when I turned up she said she would help me as well. I have learned about being a parent and that has helped a lot. I don’t mind doing the worksheets; I find them really useful.”

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Proud to be a Dad?

FN was first one who asked this young father “Am I proud that I’m going to be a Dad, am I getting ready for everything” and he concluded his interview by saying

“I would say, ‘Come to the visits it is a good thing to do’.”

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Strength based, not intrusive

“When I first heard about it I thought it would have been all about [client] being a teenage mother, not giving information but trying to check up, prying into our pregnancy, but it hasn’t been like that.”

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Unsure at first, broad coverage attracts

“It’s been better than what I thought it might be. I wasn’t very sure at first….”

“I was a bit wary at the beginning, and when she went through one or two things I thought ‘well, its not for me really, its just for [client]’ but then after a couple of sessions I started to get a bit more involved. When she started saying stuff like about the finance and what the baby needs, how to look after the baby properly, I thought ‘right, I haven’t really got much of a clue so maybe I’ll stick it out.’”

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Getting involved in the activities

[Father who has children from previous relationship] “Sometimes we all get carried away and we’re chatting for ages. [FN] gets loads of questionnaires each time. Like try to remember how you feel, or something like, she’ll give one to her [client] and one to me and see if we get the same sort of answers. Last time it was how many babies would you like to have.”

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Learning, for both new and experienced fathers

“The Family Nurse brought a little baby to show us how the baby is actually born. I’ve never seen a birth before and it was quite interesting.”

“First off I thought ‘this is going to be boring’ and I did think I knew everything [had child already with another mother] but when she [FN] did come there is so much more that I have found out and so much more that I can still find out from her.”

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Helping behaviour change for fathers

[Father with three teenage children from a previous relationship]

“The FN has updated me on certain information and refreshed me on others, and she is going to be helping me with stopping smoking”

thought he went on to say that he usually stayed in a separate room during the visits.

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Keeping a bit distant is OK

“When she visits I am not always in the same room. Because I feel like if I am needed to be spoken to obviously my girlfriend will come and get me. Sometimes I am in there sometimes I am out of the way. [In the future] I’ll probably just go along with everything. Like when I go and leave my girlfriend and the nurse to it. If I am needed I will be there.”

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FNP and parental relationship

“We used to do nothing but argue but we have both calmed down, we don’t argue because we know the baby can hear everything.” (mother)

“It’s like she cares about my situation [partner in prison]; she’s doing her job but she actually goes a step further.”

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Conclusions

FNP initiated during pregnancy, to have maximum potential impact for mother, father and child

Received well by families Father involvement is good and

sustains beyond the pregnancy phase Potential to reduce inequality for

children born in disadvantaged circumstances, and enhance the life course of parents.