Pre-birth child protection

Ariane Critchley (University of Edinburgh)

May 2018

Acknowledgements

This Insight was reviewed by Helen Allbutt and Lesley O’Donnell (NHS Education for Scotland), Sue Brunton (Barnardo’s Scotland), Linda Davidson and Vicki Welch (Centre for Excellence for Looked After Children in Scotland), Neil MacLeod (Scottish Social Services Council) and colleagues from Scottish Government. Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and comment on this publication.

Key points

- Pre-birth involvement forms a small but increasing part of child protection work in Scotland

- Social workers have the task of protecting the unborn baby from current risk and making a plan for predicted risks, at the same time as making good working relationships with expectant parents

- Pre-birth work remains under-researched and under-theorised

- Various models of good practice exist and further opportunities for shared learning from these would be positive to support social workers in developing best practice

- There is a need for scoping the national picture and a consideration of whether detailed guidance, specific to pre-birth child protection, could create a more consistent evidence-based approach across Scotland

- Practitioners need support for skilled relationship-based practice with parents and recognition of their high level of responsibility in child protection processes

- Case conference chairpersons are integral to the current pre-birth child protection process; their approach can enable participation by expectant parents and good multidisciplinary planning for the unborn child

Introduction

Pre-birth child protection processes involve social workers and allied professionals in assessing the risk of harm to children who are as yet unborn. Existing child protection processes have been applied to babies in utero, recognising the high vulnerability of newborns. The national guidance on child protection has made reference to unborn babies since 2014, and clearly indicates the timescales for case conferences within a pregnancy and the responsibilities of relevant agencies (Scottish Government, 2014, 100-101).

The focus of this Insight is pre-birth child protection assessment and care planning, and more specifically, the lead social work role within this work. However, it is recognised that the work of midwives, health visitors, early years workers and allied professionals is crucial to good pre-birth child protection assessment and intervention.

This Insight’s aim is to present the limited research evidence available around pre-birth child protection, and relevant studies concerning infants at risk and recurrent care proceedings. Some of the tensions of this work are also explored. Social workers must act in the present to protect the child in the future, but must also consider the long-term implications of intervention. This is challenging, as research and critical scholarship can appear to pull in opposite directions. It remains a contested area of practice which could benefit from more attention and support, in order to secure best outcomes for families.

The scale of pre-birth child protection in the UK

Statistics on the numbers of unborn babies placed on Scottish child protection registers pre-birth have been routinely collected since 2011. In 2017, 126 unborn babies were registered nationally. This means that 5% of registered children were recorded as unborn and represents a 1% increase on the previous year’s numbers. Since 2011, ‘unborn children … have been a small but increasing proportion of the total number of registrations’ (Scottish Government, 2018, 15).

In England, a study by Masson and colleagues (2008) included a relatively large, random sample of care proceedings cases of which 23% were for newborn babies. Masson and Dickens’ (2015, 109-110) claim that in England, ‘a substantial proportion of child protection work relates to unborn and newborn babies’ may be reflected in the practice of those working in child protection in Scotland, however, there has been no specific research to support this.

Small-scale data from the Scottish Children’s Reporter Administration (SCRA) (2011a, 2011b) suggests that children who ultimately require permanent alternative care are often identified prior to birth. SCRA’s research attempted to draw on a representative sample of children in Scotland whose journey through the Children’s Hearing system led them to permanency out-with their immediate birth family (SCRA, 2011a, 15). A supplementary report focusing on the children from the original sample who were subsequently ‘freed and/or adopted’, showed that 30% (n=13) had been placed on the child protection register before birth (SCRA, 2011b, 2).

Characteristics of parents

Professional concern about the risks to babies before and soon after birth is not new. Ferguson (2004, 46–47) refers to the ‘inebriate reformatories for mothers’ of the late 19th and early 20th century, designed to correct alcohol problems in the maternal population. Since the 1970s, there have been concerns raised about the practice of ‘removing of babies at birth’, particularly in the context of substance misuse (Tredinnick and Fairburn, 1980a, 1980b, 1980c).

No profiling has been undertaken on pre-birth referrals or the characteristics of parents. However, doctoral studies undertaken in England (Hodson, 2011; Hart, 2002) suggest that families referred for social work assessment during a pregnancy have similar difficulties to those subject to any child protection proceedings in Scotland (Scottish Government, 2018). Substance misuse, domestic abuse and parental mental health problems dominate, with unborn babies being understood as at risk of neglect, or emotional or physical abuse as a result of parental issues.

Surveying the wider literature, maternal mental ill health is highlighted as of particular concern in the perinatal period (Hart, 2002; Senervirante and colleagues, 2003). Parental learning disability can be a reason for assessment pre-birth, and specific issues with agency responses to this population of parents have been raised (Booth and Booth, 2005; Booth and colleagues, 2006; McConnell and Llewellyn, 2000; Tarleton, 2009). Intimate partner violence is known to increase during pregnancy, creating risk factors for mothers and babies (Cottrell, 2009; Levondosky and colleagues, 2011).

Related research into babies in need of alternative care

Related indications of the difficulties resulting in care proceedings at birth come from Ward and colleagues’ research (2006; 2012). This followed the care paths of babies and young children accommodated before their first birthdays across a number of English local authority areas. The study found that families with long-standing and entrenched problems, which are identified early in a child’s life, were unlikely to be able to care for that child in the longer-term (2006, 57-58).

Ward and colleagues’ work wrestles with the tensions of working within a legislative and policy landscape, which both prioritises attachment to birth family and asks professionals to make decisions about the care of babies within realistic timeframes. The findings are cautionary in terms of the impact of drift in permanency planning for infants. They also highlight the importance of open, honest working relationships between social workers and parents.

Research into pre-birth child protection

Empirical research into this area of social work practice has been surprisingly limited given the level of responsibility and complexity social workers encounter. In England, Hart’s PhD thesis on the subject (2002) was followed by Hodson’s (2011), which found that the significant ethical questions raised by pre-birth assessment work were not sufficiently answered by policy or agency guidance. Both Hart and Hodson focused on the challenge for practitioners working with and assessing risk to an unborn child. Hart (2010) and Calder (2003) provide constructive practice guidance and advice for social work assessment.

The parental perspective has been absent from research into pre-birth child protection, apart from Corner’s (1997) small-scale study, which gathered evidence from one family. The author’s doctoral research, currently in progress, represents an attempt to contribute to addressing the gap in evidence in this area and to include the perspectives of families, as well as practitioners and chairs of case conferences. Within the current Scottish model for addressing risk through pre-birth case conferences, the skill of chairpersons in managing these meetings is integral.

Child protection and care proceedings in early years

Although specific research into pre-birth involvement may be limited, it is clear that the practice is part of a wider child protection trend across the UK (Bunting and colleagues, 2017, 16-17). In Scotland, over half (53%) of children whose names were placed on the child protection register in 2017 were under five years of age (Scottish Government, 2018). When we consider looked after children, similar trends of increasing involvement with, and accommodation of, young children can be seen. Albeit, in light of a slight decline in child welfare involvement overall.

Wider policy context

Early years policy is comprehensive due to the emphasis that both Scottish and UK governments have placed on this part of the life cycle. A strong focus on early intervention has informed the development of the Early Years Collaborative (Scottish Government, 2008) and the overarching Getting It Right for Every Child (GIRFEC) agenda (Scottish Government, 2012).

Policy aimed at developing good public services in the area of maternity, neonatal and early years is also under development in Scotland (Scottish Government, 2017). However, challenges remain for constructive work with families when separation of the unborn child from parents soon after birth is being considered. Discussions around the child’s future cannot take place without involving parents, and particularly expectant mothers, in highly stressful processes. The concept of ‘trauma informed care’ now often considered in terms of ACES (Adverse Childhood Experiences) (Aces Too High, 2017), applies not just to children, but can be very important for work with young people and adults whose own life experiences have been adverse.

Many women who come to the attention of social work in pregnancy have experienced multiple traumas (Broadhurst and colleagues, 2017). In midwifery, the case for trauma-informed maternity care, particularly for women who have experienced abuse and sexual violence, has been established (Seng and colleagues, 2002; 2009; 2010). The comprehensive Scottish Maternity Review (Scottish Government, 2017) is working towards more personalised, consistent care for mothers and babies. It recognises that perinatal care pathways need to be adapted for the specific health and social care needs of families.

Further work is necessary to ensure that social work and health share an evidence base in pre-birth child protection work. Models of working together are also required to ensure expectant mothers, who may be experiencing extreme difficulties in their lives, also experience supportive maternity care.

Models for best practice and multidisciplinary collaboration

There have been a number of very positive examples of multidisciplinary teams within Scotland for vulnerable families. It is important to acknowledge the models of good practice that have been developed (NHS Lothian, 2007; NHS Scotland, 2010) and evaluated (Galloway, 2012; Gadda and colleagues, 2015). However, there is no consistent provision of a national early intervention multidisciplinary team approach.

Following a successful pilot, the Family Nurse Partnership (Scottish Government, 2016) for young first-time mothers has been rolled out across Scotland. This provides a model for voluntary engagement with intensive support. However valuable, it is only relevant to a small proportion of child protection work, characterised as much by recurrent care proceedings as by the needs of new young mothers.

Recurrent care proceedings and birth parents

The issue of recurrent care proceedings and the potential for women to lose multiple children through state removal at birth has been highlighted by Broadhurst and colleagues (2013; 2015a; 2015b; 2017), following Cox’s (2012) persuasive identification of the problem. Localised initiatives have aimed to support birth mothers (Welch and colleagues, 2015), but arguably a larger-scale response is needed to prevent the harm and cost of repeated removal of children (Broadhurst and colleagues, 2017). There is no strategy for preventative work with women in Scotland who have lost children through care proceedings and who may go on to have further pregnancies.

Despite frequent calls for social work to include fathers more fully, as helpfully summarised by Clapton (2017), a problem of marginalisation of birth fathers in pre-birth proceedings remains (Masson and Dickens, 2015, 114). Ward and colleagues (2006, 58) advise that careful assessment of fathers should be undertaken as to whether they may pose a risk to a child, or act as a protective factor in a child being able to remain with birth family.

Contested truths: early intervention and neuroscience

A difficulty in developing work around pre-birth is the contested nature of available evidence and its application. The early years policy focus in Scotland (described earlier) has been much informed by neuroscience, and neuroscientific evidence has heavily influenced social work practice with families for at least a decade (Perry and Szalavitz, 2006; Zeedyck, 2014).

Work informed by neuroscientific understandings of brain development has emphasised the lifelong consequences of failing to intervene early to protect children. It has helped demonstrate the developmental challenge for children whose needs for care, consistency and stimulation in their early life are not well met. It has also suggested constructive ways for enhancing the care of very young children. However, critical scholars have sought to question the application of neuroscience to social policy and practice, and raise the following points:

1. The findings of neuroscientific studies of the impact of extreme deprivation, where children have had barely any of their needs met, have been misapplied to the wider population of children where deprivation is much less severe (Wastell and White, 2012).

2. Complex scientific findings are liable to over-simplification and there is a danger that they can be over-simplified to the point of ‘misuse’ within social policy, a critique given balanced consideration by Broer and Pickersgill’s (2015) analysis of a broad range of policy documents.

3. A major finding of neuroscience has been the lifelong plasticity of neural development. However, this has not always been made clear in early intervention approaches that emphasise the significance of the first three years of life (MacVarish and colleagues, 2014).

4. Plasticity is not a straightforward concept. It may be that some human and animal capacities may have more flexible ‘critical windows’ than others (Pitts-Taylor, 2016).

5. Science is not value-free. On conducting experiments into the links between brains, hormones and behaviour, animal studies can be critiqued for adopting a heteronormative perspective in the ‘biological stories about kinship’ they have emphasised (Pitts-Taylor, 2016, 17).

6. Scientific findings are only ever part of the story for health and social policy development. The ethical dimension has to be another part, and the absence of public debate around the implications of neuroscientific discoveries for state intervention in the early years has been questioned (Featherstone and colleagues, 2014; Wastell and White, 2012).

Early intervention and outcomes for children

The final critique of the translation of neuroscientific findings into policy and practice highlights two components of ethical policy development (McGavock and Spratt, 2017, 1141):

1. Good evidence is needed to support early state intervention.

2. Where this evidence exists, a further case needs to be made for the efficacy of proposed intervention strategies.

Meaning that we need to be confident that interventions are based on solid evidence, but also that they are likely to be effective. Within social work, academics and practitioners are often mindful of their professional history in this. Children who have entered the care system through child protection measures have not always experienced the positive outcomes intended by state interventions (Lonne and colleagues, 2009).

Rutter (2002) has cautioned against the temptation to rush to apparently scientifically sanctioned solutions, as the problems for children are so pressing. Rutter argues that rigour in assessing and applying science to real-world problems is needed in order to guard against reductionism.

Further resolution of this debate would be very helpful to professionals dealing with frontline dilemmas around intervening with unborn children in adverse family situations. The tension between intervening in order to protect children ‘in time’ (Ferguson, 2004) and the need to support parents and acknowledge their rights is not new. However, the ‘now or never’ imperative and the extension of the need to intervene in the pre-birth period have heightened pressure on practitioners to move early and quickly to prevent risk. This places a heavy burden on social workers and there is a need for greater clarity around the defensible implications of neuroscience for child protection practice, particularly with unborn babies.

Conclusion

Pre-birth child protection is a growing part of social work practice, but remains underdeveloped. Despite promising examples of best practice and multidisciplinary models, there has not been a consistent approach nationally. This can leave social workers carrying out very skilled assessment and planning work with parents in what remains a contested field. Practitioner focus must always be on the unborn child, but good working relationships with parents are essential to securing positive outcomes, whether or not the baby can go home. Further research, sharing of best practice and policy development is needed to support social work practitioners in this demanding area of work.

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