Putting the baby IN the bathwater, why attachment matters for all

Iriss.fm, episode 100
Published on 1 Oct 2014

We all believe in preventing harm to children and we know that attachment plays a key role in prevention, but how do we close the gap between what we know and what we do? Putting the baby IN the bathwater is a coalition of some 80 organisations and individuals committed to making Scotland the best place to grown up. The coalition recommended numerous amendments to the Children and Young People Bill, many of which were incorporated into the 2014 Act. Dr Jonathan Sher, Scotland Director of the WAVE Trust, talks to members of Scottish Attachment in Action about collaborating and the politics of making a difference.

Date of recording
Audio transcript

What follows is a direct transcription of the audio recording, made by Iriss specifically to assist people with hearing difficulties. Because of the differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

IRISS : SAIA – Jonathan Sher. Putting the baby IN the bathwater

I came here from the States, specifically from North Carolina, and I can talk like this all the live long day if it would amuse and please you, but it's not actually how I talk, so I will just sort of go with what I know and lapse into it every once in a while if it would please you. But in North Carolina, I had the pleasure of being Chief Executive of an organisation which was called the North Carolina Child Advocacy Institute, and part of what we did was to create a coalition of organisations called, 'the Covenant with North Carolina's Children.'

One of the things that we worked on for years, and it's one of those stories where it took 5 years to become an overnight success, was facing a dilemma in the 21st century in the wealthiest nation of the world, in which there were, in just this one state, more than 130,000 children who couldn't go to the doctor, couldn't get preventative care, couldn't get regular treatment, they had to be at the point of life and death in order to get medical care, which they could then get through an A&E at a hospital. 

Their parents were, what is called in the States, and I am sorry to say I increasingly see the term here, 'the working poor'. They were employed, but under the American system, they didn't earn enough to buy private health insurance and there is no obligation for employers to provide health insurance and the government doesn't provide a universal health service. And so there were 130,000 children who weren't getting the medical care that they needed, let alone the psychological and social and other kinds of care that they needed. 

And so we spent these years organising, working together for that one goal of figuring out what to do to help those particular children, and after years, and after a collective effort, we did get the governor of the State to call a specialist session of the legislature that had only one item on the agenda, which was to create the children's health insurance programme. Within the year, again through an enormous collective effort, which reminds me in some ways of the kind of community effort that's been happening around the [Scottish] referendum on both sides, it wasn't about politicians and it wasn't about only professionals, it was about everybody helping to get kids signed up to get the care they needed. And they did, virtually everybody, every child who wasn't being covered is now covered. 

Within the first year of this programme operating, there were 10,000 ... more than 10,000 children in North Carolina, in the 21st century, in the wealthiest nation in the world, who were able to get their first pair of prescription eye glasses, there were more than 1000 children in this one state who were able to get their first hearing aid: why weren't they doing well in school, was it because of the sort of whole language versus other methods of teaching language acquisition? I don't think so. I think the problem was that they couldn't see and they couldn't hear and they didn't have the medical conditions that they brought to school that they brought to their lives dealt with. And so those were being dealt with. 

And one way of looking at that is that that was a real triumph. On the other hand, it's also accurate to say that it is disgraceful that in the richest country in the world, in the 21st century, there could have been 10,000 children who needed eye glasses and had no way of getting them and more than 1000 children who needed a hearing aid and couldn't get it. And I say that by way of reminding you that there are differences and coming from a place that doesn't have an NHS, that doesn't have a universal service like that and like some of the others that exist here in Scotland, is the difference between night and day. There were lots of community clinics and there were lots of people trying in their own wee ways in their own back yards to try to help with health problems, but you couldn't ever patch together enough of these wee projects to add up to actually having something that's the equivalent of the NHS. 

And so when I came to Scotland, and I use that as an example, because you couldn't find 10 children in Scotland who had no access whatsoever, under any circumstance, to a hearing aid or to eye glasses. That just is unthinkable here. And so when I came here, part of the reason why I came here is having fought against a continuing stream of not very good things, that are essentially born inequalities ... I mean if you are healthy and wealthy in the States, it is a fabulous place. But unfortunately for too many people, if you are not, it's not. 

So part of the attraction of Scotland, for me, was that I see Scotland's glass as being more than half full, that there really are a lot of extraordinary things here that are good for people and especially good for children. Now I have been here long enough to know that neither the NHS, nor the children's hearing system are perfect, but again trust me, the difference between thinking about children in the way that Kilbrandon did and in the way that informs the children's hearing system, is the other side of the planet, literally, from a system that's known in the States as the 'Conveyor Belt from Cradle to Prison'. And has resulted in the United States unfortunately having the highest rate of incarcerated people anywhere in the world. 

There are more than 1 million people in prison in the States. This is not something to be proud of and one of the reasons that's not true here is that - well there are a lot of reasons why that's not true here - but one of them is to have a children's hearing system which starts from the premise, the children who do harm or who behave in ways which are not okay, are children who were very likely to have been harmed, or to have not been treated okay themselves. And that you have to understand them first and foremost as children who are people with needs as well as people defined by their deeds. 

And it is a wonderful thing. So I am kind of belabouring the point this morning because there already is an enormous amount upon which to build in Scotland, which is wonderful, it can be better, I live in the real Scotland, not in Brigadoon, but the glass is more than half full.  And your organisation is another example for me of that. The whole emphasis on attachment is not only laudable in some general sense, but day in and day out, makes a real difference in the real lives of real children, and the better we understand and act upon it, the more we do attachment in action to provide that kind of positive secure attachment. We are doing an extraordinarily wonderful thing in the world and that's true, no matter what the constitutional arrangement is, it's a wonderful thing to be doing.

I am not an expert on attachment, I am not a psychologist, this is not my own academic field of research, I know a wee bit about it, my guess is that many of you know more than me and some of you will know a lot more than me, so I wouldn't presume to tell you about things that you already know better than I could explain them to you. 

The reason I accepted the invitation, and I hope it's the reason that it was extended to me, is that I do know a wee bit about a few other things that are related. And the two that I want to particularly focus on are the issue of prevention and the issue of the small p, politics of making a difference. Since I have already talked about the Covenant with North Carolina's Children, I will start with the small p, politics. Because one of the things that is true here and true in every country I have ever worked in, is that there is a gap between what some people know are good things to have happening, what the aspirations are and what's really happening. And that gap between our aspirations and our realities, that gap between what we know and what we do is a problem, it's a problem here, it's a problem everywhere. But it's not a problem that cannot be solved. And one of the keys to solving it is to work together to engage in collective action. 

Nobody can do everything, but everybody can do something, and I think once you take seriously that as a political principle, that this isn't all down to you, or you, or you, or me, to make something happen, that we all have a contribution to make - however large or small, however local or regional or national, however confined to a particular neighbourhood, or more broadly in the community around you - that has a cumulative impact taking those small actions that make a difference. They add up to something that's absolutely crucial. 

Paul was very kind to say that the coalition that's developed around 'putting the baby in the bath water', has been guided by me. Frankly I wish. It's just not true. The reason why that has made a difference, and I will explain what the difference that it's made, is not because of what I have done, but because of what we have done, what this collective group of more than 80 signatories, and growing all the time ... one of the things that I am terribly proud of is that in the year we have been a coalition, no-one has left, and people keep joining, up until ... there were new people joining last week, new organisations and new distinguished individuals. 

I am old enough, so that I have learned over and over again, that government officials and politicians have no problem whatsoever in saying no to me. I may have a wonderful argument, I may know a lot about X or Y or Z, but that doesn't mean that because I say something which I know to be true based on my own experience or based on the research, that everybody is just going to do it. Saying no to me, or saying no to WAVE Trust, which is just a wee charity that most of you would have never even heard of before, it's not hard, nobody finds that difficult. But all of a sudden when you show up together with 6 royal colleges and your organisation and most of the children's charities, and a sort of A list of - well who are the Scottish experts on things related to early years? - all of a sudden it's a lot harder to say No to all of us than it is to say No to any one of us. 

And so I am delighted that Scottish Attachment Interaction is part of this coalition, because it magnifies your own power and creates, by you being part of it, it adds to the power of the whole group. That's how the real life of politics works, is people who are the decision makers, whether it's civil servants or elected politicians, are influenced by groups of people giving a clear consistent message to them, and the one that has to do with attachment, and the reason for bringing this all up today, is that there was ... as most of you will have known, the most important piece of children's legislation introduced earlier in this session, that was called the 'Children and Young People Bill.' 

It's the most significant piece of children's legislation since devolution. And when it first came out, it was accompanied by something called a 'Policy Memorandum'. A policy memorandum is the government making its case about what this is for, why it should be done, it gives the reasons and the justification for what's in the bill. The Policy Memorandum, I have to say, credit where credit is due, was pretty wonderful. When you read through it, you know I was reading through it, and if you will excuse my North Carolina, I was going, 'Amen, Amen, yes', you know there was a lot of really good rhetoric in there, fine aspirations, good knowledge, it had a lot to say about how important it is to prevent harm, rather than simply intervene after the fact, although that's always important. It had a lot to say about how important the very earliest years of life are, and I was delighted to read it, and then I read the actual legislation. Wait a minute: what happened to all of that argument about the importance of prevention, what happened to the importance of the earliest years of life? It simply wasn't there. And as I have learned to say in Scotland, 'that's no right!', and it's not. 

Happily, I wasn't the only person who had that reaction to it. A fair number of colleagues, individual colleagues and organisations read it and had the same reaction: that there's this most curious gap, between why this legislation is happening and what the legislation actually says. More happily still, we actually decided to talk with each other about it and have some discussions to see if there was common ground we could agree on, and that's one of the things that I have found over the decades, is the secret of successfully organising politically. 

We started with 2 basic premises, 1 is that everybody involved check their ego and their agenda at the door, this isn't an opportunity to show off, everybody has got those opportunities, who needs it, it doesn't help. Second thing is that we only tried to find the areas on which we agreed, because being clever people and clever organisations, we could always find things to disagree about, inevitably, and in all kinds of areas. And so we said, right, take that as a given, there are going to be things we disagree about. What do we all share? Where is the common ground? What can we all agree on? And that's what's worked well with the North Carolina organisation? (which is still around and going strong). And it's what has worked thus far with putting the baby IN the bath water. In other words, putting back into the legislation what the government itself said was truly important. You know there's nothing here about disagreeing with the government, it's all about saying, you know you were right, why don't we actually do it, and so that's where the common ground was created.

Three things have happened as a result of the coalitions work on this, and I do feel great pleasure and pride to have been part of this collective effort, and it has been a collective effort. The first is that when the bill was passed, there is now in the Children and Young People Act, which passed in the Spring of this year, got Royal Assent in the spring of this year, there is now a provision that says that prevention has to be part of all children services planning. Up until this time, prevention was on the nice to do list. Trust me there's no coalition of people who are against prevention, there's nobody lobbying to say, no, no, no, please don't prevent the harm: you know that doesn't happen. But there doesn't have to be a coalition in favour of not preventing, for prevention to fail to happen. And so what has happened is that now prevention is part of the 'have to do' list, not just the 'nice to do' list. It's not just a good idea, it's the law, and we are very hopeful that that will make a difference in how health boards and local authorities and community planning partnerships approach the whole issue of children's services, because there's now a statutory duty and an obligation to make prevention a part of every plan. 

The second thing that happened is that there was a part of the original bill that was called 'Counselling Services to Parents of Looked After Children'. Let me say that's a good idea, you know if ... I know that there are some parents of looked after children in the room, and for those of you who want and need counselling, that absolutely ought to be available, helpful, a good thing. But it wasn't about prevention and it wasn't early enough. And so the way the legislation now reads, because of the work of putting the baby in the bath water, because of that coalition, is it now says ... 'relevant services to parents of children at risk of becoming looked after from pregnancy, etc'. It's much broader in who is covers, in what it covers. And again this isn't just a sort of chit chat memo or a guideline which says, wouldn't it be wonderful and wouldn't it just be good practice to do this. It is now part of the law, which says there have to now be relevant services of a variety, from pregnancy, that will help to prevent children from the need to be looked after in the first place.

So those are the 2 things which were actually in the bill. There were a number of other things that we went for as a coalition and they didn't happen, but in almost all cases when they didn't happen, the minister said, 'well, we agree with the policy intent of this' - which well they should: it was in their policy memorandum; hard to argue with yourself – 'but we will deal with this later. It doesn't need to be in the legislation itself, we will deal with it through regulation and statutory guidance and other policy things'. 

And there was a ministerial commitment to work with our coalition, which includes SAIA, in the development of the statutory guidance of the different elements which will lead to implementation, and so even though the Act has passed, the coalition's work is not over, because words on paper, words in an Act don't mean they are going to happen in the real world. The next stage is making sure that the regulations and guidance and all the other stuff that government does is right, and isn't just trivialised or sloughed off into some corner. And so we are part of that, and it's the WE that made that happen, not the ME.

Those are all goods things and one of the other things we pushed for was, they are going to be adding 500 new health visitors, which was one of the things we called for collectively. You know that actually was 2 coalitions working together, ours combined with the one led by the Royal College of Nursing. So this is not abstract, this is not intangible blah, blah, blah, this is about changing what government has to do and in a time of financial constraint, which we are in, and will continue to be in, it's really important. At local government level there is an awful lot of attention to paid to what's on the 'have to do' list, and if you are not on the 'have to do' list, chances are good that enough if people like the idea, believe in the concept, things it's a good thing, if they don't have to do it, the resources are going to go to what they have to do. And those 2 things are now on the have to do list. So I regard that as a big accomplishment. So if you didn't know that you were part of that accomplishment, you just pat yourselves on the back, because that's a good thing to have had happen, and we are going to continue to stick with this until it is actually implemented in real life, in real communities and makes a difference in children's lives, because otherwise it's just a futile effort. And so one of the other laws of coalitions, is that they need to stay together and be strong together until the job is done, and understand that the job is not done with words on paper. The job is done when children's lives and parents health and wellbeing are actually changed for the better.

Now, the second thing I wanted to talk to you about is prevention. Wave Trust is just a tiny charity. Our whole reason for being is to focus on the prevention side. Specifically our interest is on the prevention of child maltreatment, because years of research, looking at the best available evidence from around the world, kept coming back to 2 conclusions. One was that the root cause of most of our social ills can be found in child maltreatment, in what happens during those first thousand and one days of life, from pre-birth to pre-school. What I can tell you for sure and what the research absolutely documents, all over the world in all kinds of ways, is that what happens in early childhood never just stays in early childhood. That what happens during those crucial one thousand and one days continues to shape or misshape, continues to inform or misinform what we think, how we are wired, what our stress levels are, how we see the world, how we react to the world, throughout our lives, in ways large and small, in ways we can understand and in other ways which are largely imperceptible to ourselves, but which are no less powerful in influencing our lives. We need to get that right, but we are not set up as a society to get that right.

In Scotland today, and in the rest of the UK and in the States, and in most other places around the world, the emphasis for perfectly understandable reasons is to wait around until children are harmed and then to respond. The effort in child protection, the effort of our systems is to try to be ever better, ever quicker, ever more effective at reacting after a child has been harmed. You are probably the last group of people in the world who I need to say this to, but that's a very good thing. If a child has in fact been harmed, we owe that child, as a society, our very best, quickest, most effective efforts to stop the harm, to start the healing, to do what we can do to improve that child's life and circumstances that is absolutely a good thing to do. It's just not the only thing to do. 

And what we are missing is a correct balance between reaction and prevention, because I don't know anybody who I have ever worked with, who is in the reaction, the responding world, and I would be surprised if there was anybody in this room who didn't believe it was better if the harm had never happened in the first place. If the harm had been prevented. So that we are not lining up to try to fix children who have been harmed, but to make sure they have never been harmed in the first place. That's not where the investment is. We had some influence with the Scottish Parliament's Finance Committee, in coming out in their enquiry in preventative spending, and preventative spending is now officially the policy of the Scottish Parliament and the Scottish Government, and that's a crucial good step in the right direction, but it's another perfect example of it's not enough to say it, you have to actually do it. And the investment hasn't been there, the resources haven't shift, human and financial, to make that happen. 

Some of you will have heard of something called the Christie Commission, here in Scotland, a very few years ago. And to make a very long story very short, one of their findings was that right now, 40% of public spending in Scotland goes to fixing problems and cleaning up messes that could have been prevented. Now think about that for a minute, 40% of the whole public budget. It doesn't take 40% to do the prevention side, it takes a tiny fraction of that, but if you do the prevention side, you don't have to spend the money on the clean up effort, on the fixing effort, because the problem was stopped before it ever started.  And so our work is about how you do that, and attachment is an absolutely crucial part of this, promoting secure, positive attachment, and trying wherever possible to prevent especially disorganised attachment, which affects about 15% of the population and is incredibly damaging in their lives and there is a big connection between disorganised attachment and child maltreatment. Maltreatment meaning abuse, neglect, living with domestic violence. And the children for whom disorganised attachment is a reality, are the ones most likely to need to be looked after, to end up having damaged lives, to end up needing extra resources spent to them, whether it's through the education system, the health system or the criminal justice system. 

Attachment, I think, has grown as a field, because it wasn't very many decades ago, in fact it wasn't even a decade ago, when anybody, well almost anybody, talked about attachment, what they meant was the psychiatric condition of attachment, or the lack of attachment which had gone horribly wrong and was to the point of it being a clinical psychiatric problem. Now, we are slowly but surely moving toward a much better day in which we are figuring out that the best thing to do is to promote health, to promote wellness, to promote good attachment, so that we are not waiting around until it happens and correcting it, we are making sure that the people understand and know and can do the things they can do, to help make positive attachment a reality. 

Who could be more important than those of you gathered in this room, to that happening, you get this. The question and the challenge that I am going to leave with you is essentially you know all of this, and you also know that it isn't happening as fully and well as universally and powerfully as it could and should in the world. Why is that and what can we collectively and individually do about that? 

But we still live in a world that doesn't get attachment, that doesn't get it, especially in the terminology that's medicalised and highly professionalised and therefore inaccessible to a lot of people who very much need to get it, understand it, know how to do it.

So how do we go about that task, how do we take the knowledge that you all have, how do we take your understanding, your passion, your professionalism, your caring, and make sure that that becomes something which spreads? 

It seems to me that that the whole idea of, on the one hand preventing child maltreatment, is that we believe that it is entirely feasible to reduce child maltreatment by at least 70% by the year 2030, and we call that the '70/30 initiative'. Which is a call for an all hands on deck effort. For the kinds of discussions that have been happening around the referendum, to move into the positive world of a conversation about, well, how do we actually make Scotland the best place in the world to grow up, what do we actually do? We all agreed to the aspiration. There's complete cross party support for Scotland being the best place to grow up. But how do we do it, how do we make that actually happen? 

And it seems to me that you guys are in a privileged and powerful position, individually and collectively, to be part of that solution, because the way of getting rid of child maltreatment, of abuse and neglect and growing up with domestic violence is not just to keep exposing its horrors: there's been plenty of that. We all get that child maltreatment is a terrible thing, what we need to do now is to shift to the positive side and the way we talk about that is that we need to together seek 4 goals.
1. Every baby nurtured, both emotionally nurtured and physically nurtured,
2. every child thriving,
3. every parent prepared and
4. every parent supported. 

And if we lived in a world in which every baby was nurtured, every child was thriving, every parent was prepared and supported, child maltreatment would drop like the proverbial stone. The number of children who would need to be looked after would decline dramatically and we would be so much better off as communities, as families, as individuals, as an economy, were that to happen. And the way to get there is by doing what each of us can do positively, toward any of those 4 things. What you can do as an association, what you can do as an individual, what we can do collectively to make it happen in a thousand different little ways that all add up to being something extraordinary. 

And there are precedents for this, there are big public health precedents for it, like the fact that it wasn't very long ago, it was within our lifetimes that there were 350,000 people every year who developed smallpox: last year nobody developed smallpox, in the world. It was not a million years ago when cholera epidemics were part of life on this island. Not any more. The steps that have been taken through an amazing number of collective actions. And even on the not so clinical - this is just a jab in the back seat - but on the social side the same is true, when I first started coming to Scotland, which was in the 1970s, if somebody had said, 'oh well, in your lifetime, in the day, Scotland is going to have no smoking in pubs or clubs or anywhere indoors; it's like 'aye, right'. You'd have been laughed out of the place ... And yet, here we are, and that happened. 25 years ago, how many of you were recycling or dealing with alternative energy or doing something to make this a greener planet? Not me for sure. And not many other people. And yet now it's just part of what we all do. That didn't happen because of an injection and it didn't happen because a powerful person said you must do this, it's because we figured out that was a win, win situation that everybody benefitted, by us doing our part toward that common good. 

The last one I will cite, just by way of encouragement, is that again, when I moved to Scotland, and certainly when I was first coming here, there was a real problem with drink driving. It's not that it doesn't exist any more, but the whole attitude toward it is completely different, and the incidence of it has dramatically declined. 

These are things we can do. Spreading the word about the importance of attachment, so that it isn't just knowledge you have, but really putting it in action. Doing what we can do individually and collectively toward 'every baby nurtured, every child thriving, every parent prepared and supported' is within our grasp. And the way it's going to happen is not just by governments doing it (although governments have a crucial role to play) and not just by professionals doing it (although professionals have an important role to play), but by a genuine all hands on deck effort, in which everyone in this room and everyone in a thousand other rooms across Scotland, all say,

'you know, we want this for ourselves and for our children and for our communities and for our society, and this is something that we can accomplish.'

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