Improving Decision-Making in Pre-birth Assessment:

The OxPUP Project

Jane BarlowProfessor or Public Health

in the Early Years

What are the risks in pregnancy?

OXPUP: Children’s Social Care Perinatal pathway

Results of pilot study

Structure of Paper

Parenting begins in pregnancy…

Parenting begins in pregnancy with: Prenatal behaviours that are

designed to protect and promote the wellbeing of the foetus;

A process of ‘bonding’ with the foetus that begins in the second trimester.

PHYSIOLOGICAL

Stress or Teratogen

s

Programming of foetus HPA

axis/neurological damage

Compromised physiological/emot

ional and behavioural functioning

PSYCHOLOGICAL/BEHAVIOURAL

Reflective Function in pregnancy

Atypical parenting

Behaviours

Disorganised Attachment

Pathways in Pregnancy

OxPUP: A Prebirth Assessment Pathway

OXPUP - Care PathwayANTENATAL Identify high risk families during pregnancy – pre-

birth assessments at 18 weeks PuP Intervention begins ante-natally for 3 months BIRTH Assess parent-infant interaction; mother-baby foster

placements and concurrrent foster care where necessary

NEXT 8 MONTHS Continue time-limited intervention and clear goals

to be achieved; re-assess 2, 4, 6 months Remove infants where there is insufficient

improvement before 8 months

PUP Programme Evidence-based programme with high risk

families – eg. Families referred from child protection services (Harnett and Dawe 2008) parental substance abuse (Dawe and Harnett 2012; 2007) women leaving prison (Frye & Dawe 2008)

PUP is underpinned by an ecological model of child development and targets multiple domains of family functioning, including the psychological functioning of individuals in the family, parent–child relationships, and social contextual factors

Incorporates ‘mindfulness’ skills that are aimed at improving parental affect regulation and RF

PUP evaluation RCT with substance abusing parents of children

aged 2-8 years (Dawe and Harnett 2007)

Compared PUP with standard parenting programme

Significant reductions in parental stress; methadone dose and child abuse potential (significant worsening in the child abuse potential of parents receiving standard care); improved child behaviour problems

PUP Contains 12 modules, delivered across 20

calendar weeks; sessions in home; 1-2 hours; parent workbook

The selection and delivery of the modules is determined by the assessment

Additional case management occurs outside the treatment session, according to individual family need (e.g., housing, legal advice, school intervention)

Day-to-day issues such as housing and finances provide a therapeutic opportunity to put coping skills into practise in a mindful and emotionally contained manner

Capacity to Change Step 1: complete a cross-sectional assessment of

the family’s current functioning using a range of standardised tools (Time 1)

Step 2: define and agree measurable goals with the family that address their unique situation specifying what needs to change

Step 3: delivery of evidence-based intervention (PUP)

Step 4: re-administer the standardised tools that were used previously (Time 2)

PUP assessment Comprehensive assessment and individual case

formulation conducted collaboratively with the family

Self-report measures supported by a purpose built data base that is automatically scored and provides clinical feedback on all key measures

Specific targets for change are identified during the assessment, as part of an assessment of capacity to change; which then become the focus of treatment.

12 modules - each module comprises a theme that continues throughout treatment.

Ante-natal Assessment Tools Pre-birth assessment Standard pre-birth assessment

3 monthly assessment of functioning Mental health (DASS); Life events Scale (LES); Drug

and Alcohol screen; Domestic abuse screen (SARA)

Reflective function – once during prenatal and once postnatal

Pregnancy Interview and Parent Development Interview (PDI)

Postnatal Assessment tools

Parent-infant interaction – 3 minute videoclip (CARE-Index)

Home environment (HOME Inventory)

Mothers feelings about relationship with baby (Mother-Object relationship Scale)

Parenting Stress – Parenting Stress Index (PSI)

Level of expected outcome

Goal 1Decision making

Goal 2Self esteem

Goal 3Isolation

Review date:Much more than

expected

(+2)

Makes plans, follows through, modifies if

needed, and reaches goal

Expresses realistic positive feelings about

self

Actively participates in group or social activities

More than expected

(+1)

Makes plans, follows through without

assistance unless plan needs changing

Expresses more positive than negative

feelings about self

Attends activities, sometimes initiates contact with others

Most likely/expected outcome

(0)

Makes plans and follows through with

assistance/reminders

Expresses equally both positive and negative

feelings about self

Leaves house and attends community centre. Responds if

approached

Less than expected outcome

(-1)

Makes plans but does not take any action to

follow through

Expresses more negative than positive

feelings about self

Leaves house occasionally, no social

contact

Much less than expected

(-2)

Can consider alternatives but doesn't decide on a

plan

Expresses only negative feelings about self

Spends most of time in house except for formal

appointments

Cases to date CPT has taken 26 referrals. 3 pregnancies ended pre-term.

23 families have engaged fully with the programme CPT are case holders and have managed cases through

from referral to final hearing (in legal cases) and into the community for those families who have remained intact

6 cases have required legal proceedings - ICO applications made and granted at birth in all cases

Early full parenting assessments have been presented to Court throughout proceedings by CPT team rather than this being seen as a separate task

17 families have been supported to care for their children at home with on-going PUP intervention from CPT as well as appropriate local support services

CASE STUDY 1

Mum 24 self referred 14 weeks pregnant requesting help to keep her baby

6 previous pregnancy’s 1st at age 14: 1 miscarriage; 2 abortions; 1 removed at 18 months due to chronic neglect and non-accidental injury; 2 removed at birth due to high-risk lifestyle

4 fathers to the children all much older; all highly aggressive and all with drug/alcohol dependencies

Left area of her birth and severed links with family, peer and previous abusive relationships

Relocated and reporting at point of referral to be in a loving relationship

17

INTERVENTION Twice weekly sessions over period of 6 month View of self as parent: very emotional journey to explore her

own childhood traumas and to help her understand how to love and be a parent

Emotional Regulation: to help her to move away from guilt and blame; journey through denial and recognition and into responsibility in order to begin to forgive herself

Connecting to your Child: helping her to view the world from the eyes of her daughter; using her daughters cues and behaviours to increase parental sensitivity; video feedback

Building Relationships: to understand not just needs of herself and her baby but how to be a good partner, and what she should expect and accept from her partners

18

OUTCOME

Daughter remains in her parents care Connection between mother and daughter is

beautiful; mum is sensitive, caring and in total awe, not just of her child, but her relationship with her

Mum expresses that she cannot believe how good it feels to be allowed to love and be loved back

Mum and dad continue to parent together in a loving and supportive relationship

19

CASE STUDY 2

Mum 22 in relationship with abusive man aged 24 Extensive significant childhood trauma Parents relationship abusive; mum and siblings

chronically neglected and subjected to long-term emotional abuse

Mum continued into adulthood with no self-care skills; dirty, unhealthy diet, and emotionally withdrawn

1st Child removed due to neglect

20

INTERVENTION

Minimum 3 x a week over a 20 week period Independent housing secured, benefits reviewed and put in

place Life Skills: Personal Hygiene/self-care skills promoted to

increase self-esteem Emotional Regulation: and support to access GP for low mood Relationship module: to help her to address dependency on

abuser identify and avoid abuse View of self as Parent: to look at positive parenting styles and

identify the kind of parent she would like to be And much more…

21

OUTCOME

Two weeks before birth of child she opted to leave the accommodation and return to the abusive relationship

Within days presented as dirty and unkempt Two admissions to A&E following fainting episodes due

to hunger Failure to attend appropriate ante-natal care Low Iron, urine infections, weight loss and other

health issues ignored, placing self and unborn child at risk

Interim Care Order granted at birth and baby removed from mothers care

22

Care Proceedings Care proceedings for 6 CPT legal cases have all

been completed within 26 weeks; non-CPT cases all mostly outside of the 26 week requirement

Foster care costs for CPT cases are significantly less than non-CPT cases because permanency planning for CPT has been achieved more quickly - CPT cases is £58,490; non-CPT cases cases is £99,272

Court costs significantly less - CPT cases is £54,874; non CPT cases is £91,119

Risk Assessment

Prebirth: A Practice

Model

NSPCCDfE

Publications Barlow J, Hall D (2012). Systematic Review of

Models of analysing Significant Harm. London: DfE.

Barlow J, Scott J (2010). Safeguarding in the 21st Century: Where to Now? Dartington: Research in Practice.

Ward et al (2010). Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study. London: DfE.

Barlow J, Schrader-McMillan A (2010). Safeguarding Children from Emotional Abuse: What Works? London: Jessica Kingsley.