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

1. Early intervention, the Family Nurse Partnership programme, and father involvement Professor Jacqueline Barnes Birkbeck, University of London

2. What will be covered • Why early intervention/prevention • Some examples • Brief description of FNP • FNP engaging with fathers

3. Risk factors and poor outcomes • Wealth of data from life course studies linking adversity in early life to: • poor literacy • anti-social and criminal behaviour • substance abuse • poor mental and physical health • adult mortality

4. 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

5. Emerging knowledge on neurological development • Brain development depends on both genes and experiences • Rapid brain development takes place in thefirst year of life • Early interactions directly affect the way the brain is wired • Early relationships set the thermostat for later control ofstress response (Shore R, Rethinking the Brain, 1997)

6. Experience affects Brain Development • Conditions in early life affect the differentiation and function of billions of neurons and trillions of synapses in the brain • Early experience sets up neurological and biological pathways in the brain that affect well being throughout life affecting health, learning and behaviour • The more positive stimuli a baby is given, the more brain cells and synapses it will be able to develop.

7. 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.

8. Differences in brain development following severe sensory neglect

9. 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

10. Small change early leads to large impact later

11. Rate of return to investment in human capital Preschool programs Schooling Job training Preschool School Post-school 0 Age Rates of return to human capital investment (Heckman 2000)

12. Spending on Health, Education, Income Support, Social Services and Crime  Brain Development – Opportunity and Investment  Brain Malleability  Conception  Birth 1 3 10 60 80 Age

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. FNP GOALS Connecting with families to: Improve pregnancy outcomes Improve child health and development and future school readiness and achievement Improve parents’ economic self-sufficiency

24. 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

25. Programme domains • Personal health • Environmental health • Life Course Development • Maternal role • Family and Friends

26. THREE RANDOMISED TRIALS OF PROGRAMME Elmira, NY 1977 Memphis, TN 1987 Denver, CO 1994 N = 400 N = 1,138 N = 735 • Low-income whites • Semi-rural • Low-income • blacks • Urban • Large portion of Hispanics • Nurse versus paraprofessional visitors

27. 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

28. Cumulative Cost Savings: Elmira High-Risk Families Cumulative savings Cumulative dollars per child S O C I A L R E T U R N Cumulative Costs Age of child (years)

29. 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

30. 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

31. 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

32. 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

33. 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)

34. 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

35. 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.”

36. 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’.”

37. 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.”

38. 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.’”

39. 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.”

40. Learning, for both new and experienced fathers • “The Family Nursebrought 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.”

41. 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.

42. 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.”

43. 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.”

44. 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.