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 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

• 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.

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But - Brain vulnerability

• The disadvantage of the human brains 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, dont
  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
11
Rates of return to human capital investment
(Heckman 2000)
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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 3years

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

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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 gt centre gt gt 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

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

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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
• Improve pregnancy outcomes
• Improve child health and development and future
  school readiness and achievement
• 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
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

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Findings across at least two trials

• Improvements in womens prenatal health
• Reductions in childrens 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
Cumulative savings
Cumulative dollars per child
S O C I A L R E T U R N
Cumulative Costs
Age of child (years)
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FNP at the heart of current government policy

• Health Inequalities progress and next steps
• The Childrens 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 lt or gtrecommended 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 wasnt just involving
  client, she was involving me as well.
• I did not expect to be involved I thought it
  would be more for my girlfriends 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 dont 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 Im 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
  hasnt been like that.

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Unsure at first, broad coverage attracts

• Its been better than what I thought it might
  be. I wasnt 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 havent really got much of a
  clue so maybe Ill 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 were chatting for ages. FN gets loads of
  questionnaires each time. Like try to remember
  how you feel, or something like, shell 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. Ive 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 Ill 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 dont argue because we know the
  baby can hear everything. (mother)
• Its like she cares about my situation
  partner in prison shes 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.