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Safeguarding Children Across Services
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Safeguarding Children
Across Services
Safeguarding Children
Across
Services
Messages from Research
Carolyn Davies and
Harriet Ward

Safeguarding Children Across Services
Safeguarding Children Across Services Series
Series editors: Carolyn Davies and Harriet Ward
Safeguarding children from abuse is of paramount importance. This series communicates messages
for practice from an extensive government-funded research programme designed to improve
early recognition of child abuse and neglect as well as service responses and interventions. The
series addresses a range of forms of abuse, including emotional and physical abuse and neglect,
and outlines strategies for effective interagency collaboration, successful intervention and best
practice. Titles in the series will be essential reading for practitioners with responsibility for
safeguarding children.
Carolyn Davies is Research Advisor at the Thomas Coram Research Unit at the Institute of
Education, University of London.
Harriet Ward is Director of the Centre for Child and Family Research and Research Professor
at Loughborough University.
other books in the series
Safeguarding Children from Emotional Maltreatment
What Works
Jane Barlow and Anita Schrader McMillan
ISBN 978 1 84905 053 1
Recognizing and Helping the Neglected Child
Evidence-Based Practice for Assessment and Intervention
Brigid Daniel, Julie Taylor and Jane Scott with David Derbyshire and Deanna Neilson
Foreword by Enid Hendry
ISBN 978 1 84905 093 7
Adolescent Neglect
Research, Policy and Practice
Gwyther Rees, Mike Stein, Leslie Hicks and Sarah Gorin
ISBN 978 1 84905 104 0
Caring for Abused and Neglected Children
Making the Right Decisions for Reunifcation or Long-Term Care
Jim Wade, Nina Biehal, Nicola Farrelly and Ian Sinclair
ISBN 978 1 84905 207 8
Safeguarding Babies and Very Young Children from Abuse and Neglect
Harriet Ward, Rebecca Brown and David Westlake
ISBN 978 1 84905 237 5
Safeguarding Children
Across Services
Messages from Research
Carolyn Davies and Harriet Ward
Jessica Kingsley Publishers
London and Philadelphia
First published in 2012
by Jessica Kingsley Publishers
116 Pentonville Road
London N1 9JB, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.jkp.com
Copyright © Carolyn Davies and Harriet Ward 2012
All rights reserved. No part of this publication may be reproduced in any material form (including
photocopying or storing it in any medium by electronic means and whether or not transiently
or incidentally to some other use of this publication) without the written permission of the
copyright owner except in accordance with the provisions of the Copyright, Designs and Patents
Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, Saffron
House, 6–10 Kirby Street, London EC1N 8TS. Applications for the copyright owner’s written
permission to reproduce any part of this publication should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work may
result in both a civil claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data
A CIP catalog record for this book is available from the Library of Congress
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84905 124 8
eISBN 978 0 85700 290 7
Printed and bound in Great Britain
Contents
PREFACE 9
1 Introduction 11
Introduction 11
The Safeguarding Children Research Initiative 12
Who should read this Overview? 12
The evolving policy context 13
How much maltreatment is there? 16
Introduction to the studies 21
The nature of the evidence 23
Conclusion 27
2 Identifcation and Initial Response 29
Introduction 29
Consequences of neglect and emotional abuse 30
Risk factors associated with neglect and emotional abuse 33
Child development indicators of emotional abuse or neglect 39
Assessing risk factors and indicators of maltreatment 42
Signalling the need for help: direct approaches 43
Recognition by professionals 45
Professional responses: to refer or not to refer 50
Response from the wider community 51
Conclusion 52
3 Universal and Targeted Services to Prevent the Occurrence of
Maltreatment 55
Introduction 55
A framework for intervention 56
Prevention before occurrence of maltreatment 57
Universal or population-based approaches to prevention in the UK 58
Targeted approaches to prevention 63
Conclusion 70
4 Social Work Interventions to Keep Children Safe 73
Introduction 73
Consequences of child maltreatment 74
Action following referral 78
Including parents 83
Identifying who can be safeguarded at home 84
Returning home from care or accommodation 85
Readmissions to care or accommodation 86
Who benefts from being looked after? 87
Outcomes of care and accommodation 88
Conclusion 90
5 Specifc Interventions for Children and Families with
Additional or Complex Needs 94

6 Providing a Context for Effective
Inter-Agency Practice 116

7 Overview: Principal Messages and their Implications 140
Introduction 140
Why is it important to identify neglect and emotional abuse early
and take action? 140
What can be done to prevent abuse and its recurrence? 142
How can we ensure that inter-agency working works well? 148
Conclusion 149
APPENDIx 1: IMPLEMENTATION AND ADvISORy GROUP 152
APPENDIx 2: DETAILS OF EvALUATIONS OF SPECIFIC INTERvENTIONS
DISCUSSED IN CHAPTER 5 154
APPENDIx 3: PROJECT SUMMARIES 165
ENDNOTES 195
REFERENCES 211
SUBJECT INDEx 219
AUTHOR INDEx 224
LIST OF TABLES AND FIGURES
Table 1.1: Studies included in the Safeguarding Children Research Initiative 22
Table 5.1: Hierarchy of levels of evidence 97
Table 6.1: Financial contributions to the operation of LSCBs by agency 135
Figure 3.1: Framework for intervention and prevention of child maltreatment 56
Figure 3.2: Extract from Neglect Matters: A Guide for young People about Neglect 60

Preface
Safeguarding Children Across Services: Messages from Research brings together a wideranging body of government-funded research on safeguarding children from
neglect and abuse in England and Wales. It provides a succinct Overview of 15
research projects and highlights the main implications for all professionals and
policymakers involved in the safeguarding process.
For many years non-technical summaries of research programmes and initiatives
in children’s social care, funded by the Department of Health and the Department
for Education, have been produced. The intention is to make the messages of
research useful and intelligible to practitioners, clinicians, service providers and
policymakers. There is a distinctive process through which these Overviews
are developed. They are written by academic experts with the support of an
outside advisory and implementation group, consisting of clinicians, practitioners,
managers and others with expertise in the subject area. Each Overview incorporates
the comments of practitioners, clinicians and policymakers on the projects and on
the draft text. Each Overview also tries to ensure that the individual researchers
agree with the synthesis produced, although the writers have the responsibility of
drawing out the messages that they think are warranted by the research.
The Advisory and Implementation Group saw the production of this Overview
as one key element in a rather larger exercise that would involve the various
stakeholders in safeguarding children, the research community and others
specifcally concerned with training and dissemination. The key aims have been
to bring to a wider audience material that is relevant, evidenced and accessible.
In order to ensure relevance, each study was read by two or more members of
the Advisory and Implementation Group who contributed both a summary and
an assessment of its main implications. In order to ensure accuracy, the researchers
involved in the core studies also read the resulting draft Overview to ensure
that their own work had been properly represented. They also contributed the
research summaries of their work. The authors, Carolyn Davies and Harriet Ward,
then took fnal responsibility for redrafting the Overview as a whole.
Thanks are due to the many people who have helped support both the
programme of research and the preparation of this publication.
We would like to extend our thanks to the Department for Education and the
Department of Health for their support in funding and overseeing the preparation
of this Overview and particularly Isabella Craig, Julie Wilkinson, Jenny Gray
9
10 | Safeguarding Children Across Services
(who chaired the Advisory and Implementation Group), Sandra Williams, Zoltan
Bozoky, Christine Humphrey and Alison Elderfeld.
Thanks are also due to the following members of the Thomas Coram Research
Unit (TCRU) at the Institute of Education and the Centre for Child and Family
Research (CCFR) at Loughborough University: Penny Mellor, who supported the
commissioning and progress of the Safeguarding Children Research Initiative
and developed and maintained the website; Suzanne Dexter and Debi MaskellGraham, who provided multi-faceted support in preparing the Overview; and
Harriet Lowe, who fnalized the presentation of the text.
We would also like to express our appreciation to the research teams who
conducted the studies on which this Overview is based. They have been very
committed and helpful throughout the process and their input is much appreciated.
We are very grateful for the support of our multi-disciplinary Advisory and
Implementation Group, whose names are listed in Appendix 1. The group were
exceptionally helpful in reading and commenting on drafts, advising on the
selection of key messages and providing wisdom from their respective disciplinary
perspectives. The Overview has been much improved by their contributions.
Finally the authors would like to extend their thanks to their husbands,
respectively Nigel Davies and Christopher Ward, for their patience and support
throughout the preparation of the publication.
1
Introduction
This chapter covers:
• the evolving policy context within which the research messages need to
be implemented
• prevalence of abuse and neglect
• issues concerning defnitions of emotional abuse and neglect and their
implications
• details of the studies in the Safeguarding Children Research Initiative
• the strengths and the weaknesses of the evidence they provide.
It can both be read as an introduction to the Overview as a whole and/or
be used as a resource by readers looking for more information about these
issues.
Introduction
Any society, any nation, is judged on the basis of how it treats its weakest
members – the last, the least, the littlest.1
On 25 February 2000 an eight-year-old child, victoria Climbié, died following
weeks of appalling maltreatment and neglect at the hands of the great-aunt who
had been entrusted with her care, and the man with whom she was living. On
3 August 2007, a 17-month-old boy, Peter Connelly, died following similarly
appalling treatment by his mother and two men who were living in her household.
victoria Climbié and Peter Connelly are by no means the only children to have
died in deeply troubling circumstances in England over the last decade or so.
However, these deaths both captured the public imagination and have served as
catalysts for change. Although all the adults who were directly involved served
prison sentences for murder or causing or allowing the death of a child, the
ensuing public outcries focused on the professionals who hold responsibilities
for preventing such tragedies. The reports that followed the deaths of both these
children2,3 called for an extensive programme of change in both the structure
and the delivery of services aimed at safeguarding and promoting the welfare of
children suffering, or likely to suffer, signifcant harm.
11
12 | Safeguarding Children Across Services
The Safeguarding Children Research Initiative
The Safeguarding Children Research Initiative4 is an important element in the
government response to the Inquiry following the death of victoria Climbié. Its
purpose is to provide a stronger evidence base for the development of policy and
practice to improve the protection of children in England in three specifc areas
that have been identifed as requiring particular attention:
• identifcation and initial response to abuse
• effective interventions after abuse or its likelihood have been identifed
• effective inter-agency and inter-disciplinary working to safeguard children.
In each of these areas the research has encompassed a specifc focus on neglect
and emotional abuse, signifcant elements in the maltreatment of victoria Climbié.
Research of the depth and quality covered by the Initiative takes time
to commission and to execute. During the period in which the studies were
undertaken, another signifcant tragedy, that of Peter Connelly, occurred. Regular
annual meetings between researchers and policymakers during the course of the
Initiative made it possible for emerging fndings to be fed into ongoing national
policy development, much of which has been shaped frst by Lord Laming’s
progress report5 following Peter Connelly’s death and more recently by Professor
Eileen Munro’s report on child protection.6
Before introducing the reader to the studies, this introductory chapter sets the
scene by examining some of the background issues against which they should
be understood. These include: the evolving policy context within which the
messages need to be implemented; the prevalence of abuse and its consequences;
issues concerning how maltreatment should be defned; the nature of the studies;
and the strengths and weaknesses of the evidence base they provide.
Who should read this Overview?
Safeguarding Children Across Services: Messages from Research provides an Overview of
the key messages from 15 studies, distilled to meet the needs of those professionals
who seek to utilize such research fndings to shape their day-to-day work. These
include strategic and operational managers and practitioners, commissioners and
providers of services, and policymakers in all those agencies that are required
to work together to safeguard children: although these are primarily those who
work in children’s and adults’ social care, health, education, the police and the
family justice system, the messages are relevant to staff in many other agencies in
both the statutory and independent sectors.
Introduction | 13
The evolving policy context
Initiatives to promote the welfare of children and to protect those likely to suffer
harm have been central elements in government policies for children and families
over many years. They form part of a wider agenda for improving outcomes for
all children, tackling child poverty and reducing social exclusion.
The inquiry following the death of victoria Climbié made it clear that a number
of long-standing problems, repeatedly raised by numerous child abuse inquiries
over the preceding 30 years, had still not been overcome. These included poor
co-ordination between services; a failure to share information between agencies;
the absence of anyone with a strong sense of accountability; and the numbers
of front-line workers trying to cope with staff vacancies, poor management and
inadequate training.7 These were not new issues,8 although the victoria Climbié
Inquiry brought them into sharper focus.
The Green Paper Every Child Matters9 that followed the inquiry accelerated
a number of strands of policy development that were already under way.10 It
covered four main areas: supporting parents and carers; early intervention and
effective protection; accountability and integration; and workforce reform. One
of its most signifcant features was the articulation of a set of fve outcomes which
all children should achieve: be healthy, stay safe, enjoy and achieve, make a
positive contribution and achieve economic wellbeing. This outcomes framework
set child protection within a wider agenda of improving the wellbeing of all
children. All children’s services would now be required to work together towards
the achievement of these outcomes and to provide evidence of progress across a
set of performance indicators for which they could be held accountable.
The Children Act 200411 delivered the legislative changes to support the new
agenda. These included the duty to promote co-operation between the children’s
services authority and its relevant partner agencies with a view to improving
the wellbeing of children in the authority’s area; provisions for integrating
education and children’s social services departments; and the introduction of
Local Safeguarding Children Boards, whose purpose is to co-ordinate and ensure
the effectiveness of member agencies in safeguarding and promoting the welfare
of children.
These structural changes were also reflected in the strengthening or introduction
of a number of programmes designed to improve practice. These included: more
widespread implementation of the existing, holistic Framework for the Assessment
of Children in Need and their Families;12 the development of a Common Assessment
Framework13 to be used by all agencies in identifying and assessing children’s
additional needs; the updating of statutory guidance for all professionals with
responsibilities to safeguard and promote the welfare of children;14 and the
development of practice and recording tools designed to support social work
practitioners and managers in undertaking the key tasks of assessment, planning,
intervention and review.15
14 | Safeguarding Children Across Services
The Every Child Matters: Change for Children agenda was reflected in the National
Service Framework for Children, Young People and Maternity Services, a ten-year
programme to stimulate long-term and sustained improvements in children’s health
and welfare, through setting standards to ensure fair, high-quality and integrated
children’s health and social care from pregnancy through to adulthood.16
Five years later, the recommendations for change made in the report triggered
by the death of Peter Connelly17 focused on many of the same issues. These
included a call for greater strategic co-ordination, improvements in the recruitment,
training, management and supervision of front-line social workers, reduced and
better managed caseloads and for all agencies with a safeguarding role to have
clear duties and responsibilities to work together and share information.
Emerging policy developments under the
Coalition Government and their implications
Many of these innovations remain key priorities for the current Coalition
Government. There is a continuing commitment to the principle of early
intervention to counter the adverse effects of socio-economic disadvantage and
diminished life chances.18,19 There is a renewed commitment to the reform of
social work and the strengthening of social work training.20 A number of major
new policy developments are also being introduced, the purpose of which is to
introduce greater autonomy and innovation at both the levels of professional
practice and strategic management and delivery of services. These are likely to
bring changes which will signifcantly impact on the manner in which the welfare
of children is safeguarded and promoted. Policies which at present appear most
likely to have such an impact are the substantial cuts to public services funding
set out in the 2010 Public Spending Review,21 the reshaping of local authority
responsibilities for partnership arrangements, the reforms to the delivery of NHS
services and the forthcoming changes to approaches to delivering child protection
services at the front line.
Cuts to public spending may be necessary to reduce the fnancial defcit but
they will inevitably have an impact on the manner and extent to which children are
safeguarded. They could produce incentives for positive and imaginative changes,
but they could also exacerbate existing tensions and reduce the availability of
high-quality services for families where there is a likelihood of maltreatment. For
instance, the evidence from the studies in this Overview indicates that already too
many children are left for too long in abusive families where there is insufcient
support, and that more, rather than fewer, would beneft by being looked after
away from home. yet budgetary pressures will make it hard to resist raising the
threshold for access to children’s social care and reducing the numbers of looked
after children even though, in the long run, these may be false economies.
Introduction | 15
Whilst the Coalition Government continues to support the need for local
partnerships as central to meeting the needs of children, it argues that the role
of central government should be reduced, that a one-size-fts-all approach will
not work and that co-operation will be better achieved by freeing local bodies
to adopt their own approaches to local problems than by defning partnership
arrangements.22 The previous requirement for local authorities to set up a
Children’s Trust Board and to produce an annual Children and young People’s
Plan has been withdrawn, on the grounds that:
Strong integration of services leads to better services for children, young
people and families – especially the vulnerable – and … the core principles
enshrined in the duty to cooperate on local strategic bodies remain as
important as ever, but Children’s Trusts are not critical to achieving this.23
However, it remains to be seen how such a duty to co-operate will be met under
these new arrangements, particularly as other reforms are increasingly pointing
towards greater fragmentation of services.
For instance, new policies to give local authorities greater freedoms and to
encourage more schools to become independent from their oversight by taking
Academy or Free School status have now been introduced.24 The duty placed on
schools to co-operate with the local authority through Children’s Trusts is also
being removed.25
Similarly, the main thrust of reforms to the NHS26 is to reduce central direction
and introduce more local autonomy in the delivery of services. The major
responsibility for commissioning health care will move to GP-led consortia. The
policy of ‘any qualifed provider’ is intended to introduce diversity of services and
service providers.
These new developments are intended to produce more opportunities for
innovation and creativity in local authorities and the NHS. There are, however,
plans to promote integration between the NHS and social care through the
establishment of Health and Wellbeing Boards, which will allow local authorities
to take a strategic approach across services including safeguarding children.
Although the new Health and Wellbeing Boards will have a duty to encourage
integrated working, it may nevertheless prove problematic to withstand the
challenges to inter-agency collaboration that increasing diversity may produce.
In times of economic stringency it is likely to be particularly difcult to promote
successful multi-agency practice and to share safeguarding responsibilities,
especially when these entail pooling budgets. A number of studies in the Research
Initiative show signifcant differences between authorities in the effectiveness of
measures to safeguard children, and these may increase as autonomy grows.
16 | Safeguarding Children Across Services
The Munro Review of Child Protection
The Munro Review of Child Protection has recommended extensive changes to the
day-to-day delivery of child protection services. Following the death of Peter
Connelly, concerns were raised by social workers and others about the nature
and amount of guidance and the potentially adverse impact of performance
indicators, both of which were thought potentially to stifle their ability to
exercise professional judgement or to prioritize time with children and families.
In addition, the public anger directed at social workers following the media furore
surrounding the deaths of victoria Climbié and Peter Connelly has been extreme;
one consequence has been an increasingly defensive professional culture that
may have further reinforced dependency on rules and processes at the expense
of professional judgement. The Munro Review adopted a systems approach to
analyse why the current problems have arisen, to set out the characteristics of an
effective child protection system and to outline the reforms that might help the
current system get closer to the ideal.27 The Government response28 has taken
forward many of its recommendations. Statutory guidance will be revised to
achieve a better balance between professional judgement and central prescription
and to make child protection services less procedurally driven. There will be
reductions in performance indicators as drivers of service quality and the use
of standardized formats and rigid timetables for assessment. There will be more
emphasis on supervision and professional support of social workers with new
senior professional roles at central and local level. There will be less emphasis
on adherence to procedures in the inspection process. There are also plans to
formalize shared responsibility with the NHS and public health services for ‘early
help’ services and to clarify the relationship between Local Safeguarding Children
Boards and Health and Wellbeing Boards which may well, in practice, come to
fulfl a similar role to that of Children’s Trust Boards.
These measures are intended to raise professional standards, promote shared
responsibility with health services, and give more time for direct work with
children. Their impact on day to day practice is not yet clear but they are likely
to address some of the issues identifed by the research covered by this Overview.
Emerging fndings from the Safeguarding Children Research Initiative have already
informed key policy areas such as social work training,29 and the organization and
responsibilities of Local Safeguarding Children Boards,30 identifed as central to
reform. They also informed the Munro Review of Child Protection, and will no doubt
continue to provide an evidence base for the development of policy in this area.
How much maltreatment is there?
It is not easy to fnd out how many children are subject to abuse and neglect. The
numbers vary substantially according to the sources of information, the time-span
over which it is collected and the ways in which maltreatment is defned. The
Introduction | 17
most recent government statistics show that, in 2009–10, 88,700 children and
young people aged under 18 were the subject of a Section 47 enquiry, but only
about half that number (44,300) were made the subjects of child protection plans.
Nevertheless, the numbers of children for whom child protection plans are made,
and are therefore considered to be suffering or likely to suffer signifcant harm,
have been rising annually since 2005, culminating in an increase of 30 per cent
over the two years following the furore when the circumstances surrounding the
death of Peter Connelly emerged in 2008–9.31,32
However, these fgures show the numbers of children assessed as being likely
to suffer signifcant harm in the future and therefore requiring a plan to protect
them. The numbers who are thought to be maltreated each year are much larger,
for many are not referred to children’s social care, and many referrals for abuse
or neglect are not substantiated.33 The most recent prevalence study in the UK,34
undertaken in 2009, found that 2.5 per cent of children aged under 11 and 6 per
cent of young people aged 11–17 had experienced some form of maltreatment
from a caregiver within the previous year. Experience of maltreatment at some
time during childhood is understandably higher: the same study found that 5 per
cent of children aged under 11, 13.5 per cent of young people aged 11–17 and
14.5 per cent of young adults aged 18–24 had experienced serious maltreatment
by a parent or caregiver at some time during their childhood. Evidence from
this study suggests, however, that since 1997 there has been a signifcant drop
in self-reported experiences of harsh emotional and physical treatment and in
experiences of physical and sexual violence. So it could be that, while increasing
awareness of maltreatment has meant that more children are referred to children’s
social care, in the population as a whole, fewer children are being abused. Such a
trend may well be an artefact, relating to the manner in which data were collected
rather than reflecting any true changes; however, it has been replicated in studies
from the US.35 Whatever the current trends, there is ample evidence that, in
England and Wales today, far too many children and young people are abused or
neglected by their parents and caregivers.
Uncertain defnitions and their consequences
One reason why it is not easy to calculate the prevalence of abuse and neglect
is that defnitions vary. For instance, in view of emerging evidence concerning
their long-term impact on children and young people’s welfare, it could be
argued that greater attention should be given to bullying by peers and siblings,
teenage intimate partner violence and neighbourhood violence.36 If the numbers
of children experiencing these types of maltreatment were routinely included
in calculations, the apparent prevalence would greatly increase, as the statistics
shown above only refer to abuse and neglect by parents and caregivers.
Defnitions also vary between cultures. In the UK, for instance, the physical
abuse of children was not recognized as a form of maltreatment until the 1880s,
18 | Safeguarding Children Across Services
and smacking was considered to be acceptable parental behaviour for at least
another century. It is still legal in this country, although it has been outlawed
in much of the rest of Europe. Witnessing intimate partner violence has only
relatively recently been recognized as a cause for concern. The parameters have
changed as the impact on children’s welfare has become better understood. In
some cultures both the physical abuse of children and intimate partner violence
are still regarded as normative adult behaviours, with the result that identifying
maltreatment and developing an appropriate response becomes a complex issue in
a multi-cultural society. Nevertheless, it is possible to make too much of cultural
differences: abuse is often defned as a failure to meet the child’s developmental
needs, and there is a very signifcant cross-cultural consensus about the basic
needs for healthy child development.37
Understanding how abuse and neglect should be defned is not simply an
academic issue. Maltreatment is known to have a negative impact on children’s
physical, cognitive, emotional and social development; it is linked with conduct
disorder, emotional disorders, delinquency and criminal behaviour, risk-taking
behaviours, addiction and suicide. The consequences may persist into adulthood
and be linked to adverse outcomes such as physical and mental health problems,
reduced employment opportunity, social exclusion, intimate partner violence
and abusive parenting.38 Abuse is therefore a public health issue, in that its
prevalence has a negative impact not only on the individuals concerned, but
also on the welfare of society as a whole. At a population level, understanding
what constitutes abuse is a prerequisite to frst calculating its prevalence and then
developing universal, targeted and specialist services that aim to reduce it. At an
individual or familial level, understanding what constitutes abuse is a necessary
step in identifying whether a child is being subject to maltreatment, and taking
appropriate action.
Focus on neglect and emotional abuse
The severity and persistence of neglect and emotional abuse were key factors
in the death of victoria Climbié. One of the questions raised by the subsequent
inquiry was how a large number of professionals from a range of disciplines
had been in contact with this child and yet failed to recognize the extent of her
maltreatment. This is why, although some cover a wider range of maltreatment,
many studies in the Research Initiative have a specifc focus on these two types
of abuse. Moreover, while there is considerable consensus both nationally and
in other Western societies concerning what constitutes physical and sexual
abuse, there is much less common agreement concerning the defnitions and the
thresholds for emotional abuse and neglect.39 Both the systematic reviews of
literature40,41 that explored the evidence in this area concluded that neglect and
emotional abuse are associated with the most damaging long-term consequences,
yet they are also the most difcult to identify. Studies in this Overview provide
Introduction | 19
evidence of the consequences of failing to understand these issues. However,
maltreatment is often multi-faceted, and there are many messages which apply
equally to the identifcation and response to physical and sexual abuse.
Defning neglect and emotional abuse
Government guidance provides descriptions of both emotional abuse and
neglect.42 Emotional abuse is described as:
The persistent emotional maltreatment of a child such as to cause severe
and persistent adverse effects on the child’s emotional development. It may
involve conveying to children that they are worthless or unloved, inadequate,
or valued only insofar as they meet the needs of another person. It may
include not giving the child opportunities to express their views, deliberately
silencing them or making fun of what they say or how they communicate.
It may feature age or developmentally inappropriate expectations being
imposed on children. These may include interactions that are beyond the
child’s developmental capability, as well as overprotection and limitation of
exploration and learning, or preventing the child participating in normal
social interaction. It may involve seeing or hearing the ill-treatment of
another. It may involve serious bullying (including cyber-bullying), causing
children frequently to feel frightened or in danger, or the exploitation or
corruption of children. Some level of emotional abuse is involved in all
types of maltreatment of a child, though it may occur alone.
Neglect is described as:
The persistent failure to meet a child’s basic physical and/or psychological
needs, likely to result in the serious impairment of the child’s health or
development. Neglect may occur during pregnancy as a result of maternal
substance abuse. Once a child is born, neglect may involve a parent or carer
failing to:
• provide adequate food, clothing or shelter (including exclusion from
home or abandonment)
• protect a child from physical and emotional harm or danger
• ensure adequate supervision (including the use of inadequate caregivers)
• ensure access to appropriate medical care or treatment.
It may also include neglect of, or unresponsiveness to, a child’s basic
emotional needs.
20 | Safeguarding Children Across Services
We have quoted these descriptions in full to demonstrate how comprehensive
and detailed they are. yet even with such precise guidelines, professionals fnd it
difcult to identify these types of abuse and to decide when a threshold for action
has been reached. The difculties arise for a number of reasons:
• Both types of maltreatment are heterogeneous classifcations that cover a
wide range of issues as is evident from the descriptions above.
• Both emotional abuse and neglect are chronic conditions that can persist
over months and years. Professionals can become accustomed to their
manifestations and accepting of the lack of positive change: the serious case
review into the death of Peter Connelly, for instance, found that professionals
were too accepting of low parenting standards.43 These can include poor
supervision resulting in numerous ‘falls’ and bruises; poor cleanliness of the
house and poorly cared-for animals; persistent and recurrent infestations
such as head lice; loss of weight and failure to thrive; poor dentition; skin
problems and nappy rashes; delayed motor and speech development; and
self-harm and running away in teenagers.
• Both types of maltreatment can persist for many years without leading to
the type of crisis that demands immediate, authoritative action. Without
such a crisis it can be difcult to argue that a threshold for a child protection
plan or court action has been reached.
• Both types of maltreatment are also closer to normative parental behaviour
patterns than physical or sexual abuse, in that most parents will, on occasion,
neglect or emotionally maltreat their children to a greater or lesser degree.
It is the persistence, the frequency, the enormity and the pervasiveness of
these behaviours that make them abusive. However, such factors are difcult
to pin down with any degree of clarity and this makes it difcult both
for practitioners and the courts to determine when a threshold has been
reached.
The neglect of adolescents is a major issue that frequently goes unnoticed.44
Adolescents can be neglected by services as well as by their families. Better
understanding of what constitutes adolescent neglect might lead to prompter
identifcation and service response.
It is clear that neglect is age-related, and as children grow older it is defned not
only by parental behaviours but also by the way in which young people experience
them. However, some of the fundamental questions have barely been considered.
For instance, there is little consensus as to what constitutes an acceptable level
of supervision as children grow older. At what ages can young people be safely
allowed out on their own? Be left alone for the day? Be left alone overnight?
When should a GP be worried about a request for contraceptives? When should
they ask the identity of the person accompanying the child? Although at a
Introduction | 21
familial level appropriate responses to such questions will be shaped by young
people’s levels of maturity and experience, nevertheless at a societal level neglect
would be better understood if there were some open discussion concerning what
is acceptable and what is not.
Introduction to the studies
Eleven studies were commissioned as part of the Safeguarding Children Research
Initiative. This Overview focuses on the fndings from these studies, but also refers
extensively to a further four important research studies that also reported during
the same time period. Brief resumés of all 15 studies are given in Appendix 3,
which also includes details of how the full reports can be accessed. In order to
make it easier for the reader to identify them – and to make this Overview more
readable – these studies are referred to by their abbreviated titles in the following
pages. The studies are listed in Table 1.1.
Training materials
The evidence from the studies has also been used as the basis for developing the
following training materials:
University of Stirling and Action for Children in collaboration with
University of Dundee and STRADA (2012) Childhood Neglect: Improving
Outcomes for Children. London: Department for Education.
Daniel, B., Taylor, J. and Scott, J. (forthcoming) Training Resources on Child
Neglect for a Multi-Agency Audience.
Hicks, L. and Stein, M. (2010) Neglect Matters: A Multi-Agency Guide for
Professionals Working Together on Behalf of Teenagers. London: Department for
Children, Schools and Families.
Hicks, L. and Stein, M. in collaboration with the Children’s Society and
the NSPCC (2010) Neglect Matters: A Guide for Young People about Neglect.
London: ChildLine.
Carpenter, J., Patsios, D., Szilassy, E. and Hackett, S. (2011) Connect, Share
and Learn: A Toolkit for Evaluating the Outcomes of Inter-Agency Training to
Safeguard Children. London: NSPCC.
22 | Safeguarding Children Across Services
Table 1.1: Studies included in the Safeguarding Children Research Initiative
(all available at www.education.gov.uk/researchandstatistics/research/scri)*
Study Full title Authors

Effective interventions after abuse or neglect has been recognized
4 Neglected Children
Reunifcation Study†
5 Home or Care? Study†
6 Signifcant Harm of
Infants Study‡
7 Emotional Abuse
Intervention Review†
8 Physical Abuse
Intervention Review†
Case Management and Outcomes for
Neglected Children Returned to their
Parents: A Five year Follow-Up Study
Maltreated Children in the Looked
After System: A Comparison of
Outcomes for Those Who Go Home
and Those Who Do Not
Infants Suffering, or Likely to Suffer,
Signifcant Harm: A Prospective
Longitudinal Study
Safeguarding Children from
Emotional Abuse: What Works?
Systematic Reviews of Interventions
Following Physical Abuse: Helping
Practitioners and Expert Witnesses
Improve the Outcomes of Child
Abuse
E. Farmer,
E. Lutman
J. Wade, N. Biehal,
N. Farrelly,
I. Sinclair
H. Ward, R. Brown,
D. Westlake,
E.R. Munro
J. Barlow,
A. Schrader
McMillan
P. Montgomery,
F. Gardner,
P. Ramchandani,
G. Bjornstad
Effective inter-agency and inter-disciplinary working to safeguard children
9 Inter-Agency Training
Evaluation Study†
10 Information Needs
of Parents at Early
Recognition Study†
Organisation, Outcomes and
Costs of Inter-Agency Training for
Safeguarding and Promoting the
Welfare of Children
Understanding Parents’ Information
Needs and Experiences where
Professional Concerns Regarding
Non-Accidental Injury were not
Substantiated
J. Carpenter,
S. Hackett,
D. Patsios,
E. Szilassy
S. Komulainen,
L. Haines
Introduction | 23

Effectiveness of the New Local
Safeguarding Children Boards in
England
Analysing Child Deaths and Serious
Injury through Abuse and Neglect:
What can we Learn? A Biennial
Analysis of Serious Case Reviews
2003–2005
Understanding Serious Case Reviews
and their Impact: A Biennial Analysis
of Serious Case Reviews 2005–07
Understanding the Contribution of
Sure Start Local Programmes to the
Task of Safeguarding Children’s
Welfare. Report of the National
Evaluation
H. Tompsett,
M. Ashworth,
C. Atkins, L. Bell,
A. Gallagher,
M. Morgan,
P. Wainwright
A. France,
E.R. Munro,
A. Waring
M. Brandon,
P. Belderson,
C. Warren,
D. Howe,
R. Gardner,
J. Dodsworth,
J. Black
M. Brandon,
S. Bailey,
P. Belderson,
R. Gardner,
P. Sidebotham,
J. Dodsworth,
C. Warren, J. Black
J. Tunstill,
D. Allnock

The nature of the evidence
What topics do the studies cover? How far do they complement one another?
All the studies covered by this Overview aim to identify how children might be
better safeguarded in the three key areas of recognition, effective intervention and
inter-agency working. However, within these areas they cover a wide range of
subjects and employ a number of different methodological designs:
24 | Safeguarding Children Across Services
• Two studies explore the question of how maltreatment might be recognized
and responded to more promptly and effectively. These are systematic reviews
of evidence gathered from other, primary, sources. The Recognition of Neglect
and the Recognition of Adolescent Neglect Reviews focus specifcally on neglect;
as well as exploring the effectiveness of interventions, these studies also
raise questions concerning defnitions and thresholds.
• The Sure Start Local Programmes Safeguarding Study focuses on the impact of
an initiative to provide targeted services to prevent abuse and maltreatment.
This is an issue that was also touched on by many other studies in the
Research Initiative. This is a mixed methods study utilizing qualitative data
from documents and interviews and quantitative data from a study of
referrals.
• Three longitudinal cohort studies explore the impact of general interventions
from social workers and their colleagues. The Neglected Children Reunifcation,
the Home or Care? and the Signifcant Harm of Infants Studies all use designs
that are mainly prospective. All three studies follow a mixed methods design,
making use of both quantitative and qualitative data.
• Two studies, the Emotional Abuse Intervention Review and the Physical Abuse
Intervention Review, focus on the impact of more specifc interventions. These
are systematic reviews of primary evidence.
• Two studies explore the impact of training: the Emotional Abuse Recognition
Training Evaluation Study utilizes a quasi-experimental design to assess the
impact of a new framework for the recognition, assessment and management
of emotional abuse on professional practice. The Inter-Agency Training
Evaluation Study assesses the impact of a number of training modules for
Local Safeguarding Children Boards, using a before and after design.
• The Local Safeguarding Children Boards Study is an evaluation of the impact of
new structures and processes for safeguarding and promoting the welfare
of children, utilizing a mixed methods approach that includes surveys, case
studies and social network analysis.
• Two other studies focus on specifc issues. The Information Needs of Parents
at Early Recognition Study is a small qualitative study that explores parents’
experiences following unsubstantiated professional concerns about nonaccidental injury to a child. The General Practitioner Tensions in Safeguarding
Study is a qualitative study that analyses the complex factors that come into
play when a GP has both a child and an alleged perpetrator as patients in
child protection cases.
• The two Analyses of Serious Case Reviews utilize the same transactional
ecological approach to analyse data from the reports of serious case reviews
(2003–5; 2005–7). A third study, exploring data from 2008–9, was not
Introduction | 25
published in time to be reviewed by the steering group, and is referenced,
but not formally included, in the Research Initiative.45
Although the studies focus on specifc topics, their subject matter overlaps and
intertwines. Putting them all together is like viewing a building through many
different windows, each showing a different perspective, but each shedding a
different light on the wider picture. While each of the chapters in this Overview
focuses on a selection of the studies, they are all informed by the full range of
messages from the Research Initiative.
While the studies provide a wide range of research messages on the topics they
cover, none of them focused specifcally on the role of fathers or on ethnic and
cultural diversity in relation to safeguarding issues. The studies provide a small
number of messages that shed some light on these issues, but these are clearly
areas where further research is required.
The Safeguarding Children Research Initiative focuses on government-funded
research, commissioned by the Department of Health and the Department for
Education. This type of research tends to be applied rather than theoretical, for
it is intended to provide evidence that can have a direct impact on policy and
practice. The studies inevitably reflect the government priorities for research, and
are by no means representative of all research in this feld in England and Wales,
or indeed further afeld. Where appropriate we have referenced the wider body
of research that provides a context for these studies.
Strengths and weaknesses of the evidence
How strong is the evidence? Are the messages transferable to other contexts
and settings? How valid are they? Can they be relied on?
Readers will want to understand what weight to give to the fndings from the
studies and how far they are relevant to a particular context. Both the research
proposals and the fnal reports for all studies included in this Overview were
subject to rigorous peer review. The messages drawn out from the reports were
then identifed and discussed by the Advisory and Implementation Group, whose
role was to ensure that the implications of the fndings were presented in such a
way as to be properly understood by the different professional groups to which
they apply. The reader should therefore regard this Overview as presenting
robust research fndings whose relevance to practice has already been extensively
scrutinized. The events that led to the Research Initiative raised a large number of
questions concerning the effectiveness of the full spectrum of structures, processes
and services in place to safeguard children from abuse and neglect. Numerous
26 | Safeguarding Children Across Services
questions were asked about the evidence base; as the preceding paragraphs show,
a wide variety of methodologies has been utilized in trying to answer them.
The four systematic reviews of evidence explored extensive secondary data on
trials and evaluations conducted on a variety of programmes to identify those
which appear to be most likely to promote change. They were commissioned in
the place of primary evaluations on the grounds that the Research Initiative would
provide a more useful evidence base if it included information on a wide range
of interventions rather than shedding an intense light on the effectiveness of
one or two. These reviews utilized an accepted hierarchy of evidence to identify
interventions that had been rigorously evaluated. This is discussed further in
Chapter 5.
The evidence from the reviews demonstrates that there has been, as yet,
very little methodologically sound evaluative research to identify ‘what works’
in safeguarding children from abuse and maltreatment. While such reviews
initially identify relatively large numbers of studies within the subject area, the
vast majority are of insufcient methodological rigour and are fltered out of
the fnal selection. For instance, the initial search strategy in the Recognition of
Neglect Review identifed a total of 20,480 studies that originally appeared to
meet the inclusion criteria, yet only 63 papers represented primary studies of
sufcient quality to merit further scrutiny. However, if the criteria for inclusion
are relaxed, less dependable evidence, that may be of limited validity, reliability
and generalizability, may be included.
Even those studies that are sufciently sound methodologically to merit
inclusion in the systematic reviews may still have their weaknesses. Some of the
best conducted randomized controlled trials are only able to recruit very small
numbers and/or suffer considerable attrition at follow-up. Many fail to clarify
their terms: neglect and emotional abuse are particularly poorly defned, and
are often conflated with other forms of maltreatment. There is also a tendency
for studies to use a range of proxy measures rather than directly observe the
most relevant outcomes, such as continuing maltreatment or its impact on the
child. Moreover, a vast array of different outcome measures are employed and
this can restrict attempts to compare fndings. Studies also generally focus on one
discipline, thereby ignoring the many factors at play as services become more
closely integrated.
The systematic reviews also demonstrate that even well-conducted interventions
which can be shown to produce positive changes do not necessarily have a lasting
impact. Those evaluations that include a later follow-up often fnd that initial
improvements are subsequently lost over the following six months or so. Thus
where the evidence base is sound, the data are not always encouraging.
While formal trials of specifc interventions are common in the area of health,
evaluations of broader interventions from social workers and their colleagues are
still very much in their infancy in the UK. At the time of writing, randomized
Introduction | 27
controlled trials of specifc interventions such as Multi-Dimensional Treatment
Foster Care46 and Multi-Systemic Therapy47 are under way, but interventions such
as returning children home from care or accommodation or placing infants for
adoption cannot be easily evaluated in this way. Randomly assigning children to
such interventions, which will have a far-reaching impact on the rest of their lives,
is difcult to justify ethically unless we are certain that we genuinely do not know
which are likely to be the most benefcial not just for one child but for the whole
group of potential participants. Moreover, there are substantial differences within
such interventions and between the children concerned, so that it is difcult to
compare like with like. Until relatively recently, studies in this area were largely
descriptive. However, the three empirical studies in the Initiative that focus on
these issues all improve on the existing evidence base and produce sophisticated,
robust fndings. The Home or Care? and the Signifcant Harm of Infants Studies both
introduce comparative elements, demonstrating how outcomes for children who
return home differ from those who remain looked after, or showing how infants
in families where there are different degrees of risk of signifcant harm follow
different life trajectories. The small sample in the latter study reflects the huge
ethical and practical obstacles to accessing the very vulnerable population studied;
the key fndings would merit further testing with a larger database.
Understanding effective inter-agency and inter-disciplinary working is a
multi-faceted issue, and research in this area is still under-developed. The mixed
methods and the small qualitative studies that explore this area either identify
themes that should be tested out with larger quantitative studies, or, as in the
Local Safeguarding Children Boards Study, use a variety of methods to explore several
different issues within a wide area of service development.
Conclusion
This Overview explores the messages from a programme of 15 research studies
and discusses their implications for the development of policy and practice in
identifying and responding to maltreatment (Chapter 2) and in the development
of: universal and targeted services to prevent its occurrence (Chapter 3); social
work interventions to keep children safe (Chapter 4); and specifc interventions
for children and families with additional or complex needs (Chapter 5). Policy and
practice for safeguarding children will only develop successfully within a context
of effective inter-agency working, an issue that runs through all the chapters, but
is explored in depth in Chapter 6.
28 | Safeguarding Children Across Services
Key messages from Chapter 1
• ‘Children’, as discussed here, means those unborn, babies, children
and young people under 18 years old, all of whom may be subject to
maltreatment. The group may also include maltreated young people and
their own children.
• Emotional abuse and neglect are far-reaching and malignant in their
effects, and may or may not accompany physical or sexual abuse. Early
detection and long-term support can make an enormous difference to
children’s developmental progress.
• Many more children are maltreated than come to the attention of statutory
services.
• Reduction of the role of central government and increased diversity at
local level will have implications for safeguarding children in the future.
• The 15 studies covered by the Overview cover a wide range of topics in
the themes of: identifcation and initial response to abuse and neglect;
effective interventions after maltreatment has been identifed; and effective
inter-agency and inter-disciplinary working to safeguard children.
• The range of different research methodologies reflects the diversity of the
questions they seek to answer.
2
Identifcation and Initial Response
• This chapter draws largely on the evidence from the Recognition of Neglect
Review,48 the Recognition of Adolescent Neglect Review49 and the two Analyses
of Serious Case Reviews (2003–5 and 2005–7).50,51
• This chapter has important messages for all those who have responsibility
for safeguarding and promoting the welfare of children.
• It also has specifc messages for the following professional groups:
ô Local Safeguarding Children Boards (all sections)
ô policymakers, commissioners and operational managers in adult
health and social care; children’s health and social care; the police;
and education (sections on consequences of neglect and emotional
abuse; risk factors associated with neglect and emotional abuse;
recognition by professionals; professional responses: to refer or not
to refer)
ô practitioners in adult health, mental health and social care; children’s
health, mental health and social care; education; the police; and the
family justice system (all sections).
Introduction
Chapter 1 explored some of the issues that make it difcult to defne both neglect
and emotional abuse. It is not always easy to distinguish between these two types
of maltreatment because they often overlap. Neglect cases almost always have an
element of emotional abuse because parents who ignore their children’s basic
needs for food, warmth and safety are also indicating that they do not understand
or care about them. However, emotional abuse can occur without neglect: children
who are singled out and rejected are sometimes physically well looked after.
There are two reasons why it is important to recognize emotional abuse and
neglect early and intervene appropriately. First, there is very robust evidence that
both types of maltreatment have serious long-term consequences across all areas
of children’s health and development. The effects appear to be cumulative and
pervasive, making early recognition and intervention necessary if the likelihood of
longer-term harm is to be minimized. The impact of emotional abuse and neglect
29
30 | Safeguarding Children Across Services
can be particularly severe when they occur during early childhood, because the frst
three years of life are critical to children’s later development. Emotional abuse in
a child’s early years is thought to have such a far-reaching adverse impact because
it compromises the infant’s ability to resolve the primary developmental tasks of
forming a secure attachment with an adult caregiver, learning to trust others and
developing a sense of self-worth. Success in completing later developmental tasks
in latency and adolescence is dependent on the extent to which the child has been
able to complete the earlier tasks of infancy and toddlerhood.52
Second, prevalence studies conducted in many countries, including Great
Britain and North America, suggest that the numbers of children and young
people experiencing these forms of abuse may be up to ten times as many as those
who come to the attention of professionals and receive services.53 The Analysis of
Serious Case Reviews (2003–5) found that only a small number (12%) of children
who die or are seriously injured as a result of neglect are the subjects of child
protection plans. Although the majority (83%) are known to them, little more
than half of these children are receiving services from children’s social care at the
time of the incident. Emotional abuse and neglect only rarely result in specifc
incidents which prompt attention from those outside the family group; this makes
it particularly important for practitioners in front-line services to be alert to the
signs and symptoms they need to look out for.
Neglect and emotional abuse have received limited attention in the past. Both
forms of maltreatment are particularly challenging for professionals to recognize
because of their pervasive and long-term nature and the lack of physical signs
and symptoms. But the long-term damage may be at least as serious as that from
physical and sexual abuse. In fact these may be the most damaging forms of
maltreatment because their consequences are the most far-reaching and difcult
to overcome.54 Before considering the evidence about how better recognition
by professionals can be promoted, we shall briefly consider what the studies say
about the impact of these forms of abuse on the child.
Consequences of neglect and emotional abuse
Why is it important for members of the community and professionals to
be alert to the possibility of neglect and emotional abuse and to respond in
appropriate ways? What do the studies tell us about the consequences and
impact of these types of maltreatment?
Neglect and its impact
The Neglected Children Reunifcation Study provides a valuable summary of the
impact of neglect on the child. We have drawn out the key points in the following
Identifcation and Initial Response | 31
paragraphs, but readers may wish to turn to the original for more comprehensive
information.55
Whilst the psychobiology of neglect is not yet fully understood, it is likely
that all forms result in serious, pervasive effects on a child’s neurological and
endocrine development. The neglected child’s system of response to stress,
through the hypothalamic-pituitary-adrenal axis (HPA), develops abnormally
and this in turn results in increased vulnerability to a range of psychological,
emotional and, probably, physical health problems throughout the lifespan. Both
structural and functional abnormalities are found in maltreated children’s brains.
Changes are seen in the prefrontal cortex, corpus callosum and hippocampus –
all areas concerned with emotional life and its regulation. Physical, behavioural,
emotional and attachment systems are dependent on these structures functioning
normally. There are therefore potentially highly damaging and long-term effects
for those suffering neglect.56
These changes are thought to represent adaptations to the extreme stress
of maltreatment, enabling the child to cope with an abusive and/or neglectful
parenting environment to some degree. However, such resilience is accompanied
by a greater likelihood of misperceiving and responding disproportionately to
everyday encounters in social situations and problems in managing emotions such
as fear and anger. Although research is still at an early stage, there is encouraging
evidence that some maltreatment effects can be modifed if the child’s caretaking
environment improves.57
Neglectful parenting
Neglectful parenting can also affect the essential processes of children’s early
attachment and subsequent development. Children who receive care which is
unpredictable, rejecting or insensitive are more likely to develop attachments
which are less secure.
Children who have experienced neglectful parenting may have poorer
emotional knowledge and be less able to discriminate between different kinds
of emotions. They may have lower self-esteem and higher levels of emotional
problems. Neglected children tend to be more aggressive than children who
are not neglected and are also more uncooperative and noncompliant. There is
also a related impact on children’s social development: the evidence suggests
that neglected children are more withdrawn and socially isolated and less
socially competent than their peers. Data from the large American longitudinal
LONGSCAN sample58 show that at the age of eight ‘general neglect’, as identifed
by child protection services, continues to be associated with behaviour problems,
impaired socialization and problems with daily living skills.
The stage of life at which a child experiences neglectful parenting is important,
as is the duration of the experience. Neglected children may experience a lack of
stimulation in early childhood, resulting in delayed speech and language problems.
32 | Safeguarding Children Across Services
This means that these children start school at a disadvantage, and may be one
reason why neglect has been shown to have a serious impact on educational
achievement and cognitive development.59
The Recognition of Adolescent Neglect Review found that neglect is most damaging
in both the early stages of life and in the teenage years. By adolescence ‘neglect
and/or neglectful parenting are associated with poorer physical and mental
health, risky health behaviours, risks to safety including running away, poorer
conduct and achievement at school, and negative behaviours such as offending
and anti-social behaviour’.60 Adolescents who have experienced neglect have
shown higher ratings on measures of depression and hopelessness.
Risk of fatalities
The risk of fatalities from neglect is by no means negligible, and may be as
high as that from physical abuse.61 The Analysis of Serious Case Reviews (2003–5)
found that neglect features in a third (52/161) of cases where children die or
are seriously injured, although it is not always identifed as the primary cause
and this fgure is likely to be a serious under-estimate.62 Although children die
from neglect primarily as a result of negligence (for instance from house fres,
accidentally ingesting poison or overlying), persistent neglect may also feature in
adolescent suicides.
Emotional abuse and its impact
Many authorities consider that emotional abuse is a component of all forms of child
maltreatment.63 There is powerful evidence of its harmful effects whether alone
or associated with other forms of maltreatment. The Emotional Abuse Intervention
Review provides a valuable summary of this evidence.64 Emotional abuse is known
to be particularly harmful when experienced in the frst three years of life. It
affects an infant’s ability to form a secure attachment with an adult caregiver
and to develop trust in others to provide a stable environment. Toddlers who
experience rejection of their bids for attention will have difculty in developing
a sense of self-worth and belief in the availability of others. Emotional abuse may
be the most damaging of all forms of maltreatment because it represents a direct
attack on the child’s needs for safety, love, belonging and wellbeing from their
primary carer – the person who should be responsible for nurturing them and
helping them to fulfl key developmental tasks. Children who are emotionally
abused show early signs of problems through a steep decline in performance from
as young as 9 to 18 months. One prospective study found that by 18 months of
age emotionally abused children were showing evidence of anxious attachments,
by 42 months they were observed to be ‘more angry, non-compliant, lacking in
persistence and displaying little positive affect’, and in early school they were
Identifcation and Initial Response | 33
‘more socially withdrawn, unpopular with peers and in general exhibiting more
problems of the internalizing type’.65
In adolescence emotionally abused children may display higher levels of social
problems, such as delinquency and aggression; they may also be more prone to
eating disorders. Retrospective studies have also identifed specifc and unique
types of problem associated with emotional abuse compared with other forms of
maltreatment, particularly aggression in later childhood and dissociation.
Emotionally abusive parenting
Emotional abuse results from the interplay of a variety of factors including
parental issues. These may include learned behaviours, psychopathology and/
or unmet emotional needs, and are often linked with mental health problems,
drug and alcohol misuse and domestic violence.66 Parents experiencing these
problems can be cold and insensitive, emotionally unavailable and even hostile.
The effect is harmful across all areas of children’s development, affecting security
of attachment, emotional development, behaviour, educational achievement and
social and physical development. Emotionally abusive parenting is associated
with a range of negative long-term outcomes for children such as anxiety and
depression, shame and anger/hostility.
Risk of fatalities
Whilst emotional abuse on its own may be less likely than other forms of
maltreatment to result in fatality as a result of carer action, it is known to be linked
with children attempting suicide and suffering multiple mental health problems.
One prospective follow-up study found that children who had been emotionally
abused in early childhood reported more attempted suicides by adolescence. The
majority received at least one diagnosis of mental illness and 73 per cent had two
or more disorders.67
Thus both emotional abuse and neglect have potentially highly damaging
consequences across all areas of children’s development. Professionals (and
members of the general public) need to be aware of them because they demonstrate
the importance of recognizing and responding early to indicators of these types
of maltreatment or the likelihood of their occurrence.
Risk factors associated with neglect and emotional abuse
What factors should alert practitioners to an increased likelihood of neglect
and emotional abuse?
34 | Safeguarding Children Across Services
There are now a number of well-recognized factors in both children themselves,
and their wider family and environment, that adversely impact on parental
capacity and make emotional abuse and neglect more likely. Such risk factors
do not mean that maltreatment is inevitable, but their presence, particularly
in combination, increases its probability and should alert practitioners to look
out for indicators that a child is suffering signifcant harm. There is common
agreement across the studies that an ecological model is relevant to assessing
both the likelihood of emotional abuse and neglect and the indicators that a
child may be suffering signifcant harm. This is because an ecological framework
encompasses a constellation of both positive and negative factors and therefore
offers a valuable methodology for helping professionals to recognize the interrelationship between them. The next section summarizes the evidence from the
studies concerning risk factors and indicators, using domains from one such
model: the Framework for the Assessment of Children in Need and their Families.68
Family and environmental factors
Family history and functioning
Parental problems such as mental illness, alcohol and drug misuse, domestic
violence and learning disability are all known to increase the likelihood of
children experiencing emotional abuse and neglect, particularly when they appear
in combination. Cleaver, Unell and Aldgate69 have brought together and analysed
a comprehensive body of evidence of the ways in which these factors adversely
affect parenting capacity. We have tried to draw together the key messages in
the following paragraphs, but readers may wish to turn to the original for more
detailed information. Several of the studies in the Research Initiative, notably the
Neglected Children Reunifcation Study, also summarize these issues.70
Parental mental health
Two thirds of adults who have been diagnosed with psychiatric disorders are
parents of children and young people who are less than 18 years old. However,
the research makes it clear that the risk of children being harmed is not inevitable
and that not all mentally ill parents neglect or emotionally abuse their children.71
Nevertheless, parental mental health problems can lead to a deterioration in
parenting capacity. For example, parents may become preoccupied and depressed
and be unresponsive to their children’s physical and emotional needs. Therefore
those offering adult mental health services should be highly alert to the possibility
of neglect and emotional abuse and be ready to ensure that children’s needs
are actively addressed. There is evidence that risk of harm can be mediated by
appropriate psychiatric treatment; it can also be reduced by protective factors in
the environment such as strong social and family support systems or the absence
of fnancial worries, as well as individual children’s coping skills. On the other
Identifcation and Initial Response | 35
hand, the absence of social and family support and the presence of fnancial
stressors and/or inter-partner conflict increase the likelihood of children being
harmed.
The ways in which parents’ mental health problems may impact on their
children also vary with age. The adverse effects of maternal caregiver depression on
the wellbeing of children, and in particular the under-fves, is well documented72
and has specifcally been shown to be linked to physical neglect, neglect more
generally and emotional abuse. On the other hand, adolescents may be more
likely to take on caring roles in addition to not always being adequately cared
for themselves, and may lack support and supervision at critical phases in their
development.
The Emotional Abuse Intervention Review provides more specifc information
about the impact of maternal depression, anxiety and psychotic disorders on
parenting behaviour in relation to emotional abuse.
Maternal depression
Maternal depression is associated with lower levels of maternal sensitivity and,
to a lesser degree, the mother’s disengagement with the child. Lower maternal
sensitivity may result in less empathetic understanding of toddlers, higher
intrusiveness, negative regard and harshness, lower warmth, more negative
perceptions of infants’ behaviour and more hostile feelings towards them. The
timing and severity of the depression is important. It affects all age groups but
seems to be most harmful in the frst fve years of a child’s life. However, the impact
on older children should not be under-estimated as maternal depression is also
associated with fewer positive and more negative behaviours toward adolescents.
Anxiety disorders
Amongst the most widespread mental health problems are anxiety disorders,
including panic disorder and phobias. Whilst there has been little research
specifcally on the effect of anxiety disorder on parenting behaviour, parents who
suffer from severe anxiety have been observed to display some behaviours which
may result in emotional abuse of their children. For instance, such parents have
been observed to be highly critical, to express less affection, smile less, be more
likely to over-react during interactions with their children, and appear to be less
likely to encourage emotional autonomy, by not soliciting their child’s views or
tolerating differences of opinion.
Psychotic disorders
At the most serious end of mental health problems, psychotic disorders which
involve distortions of thought, perception and communication, and signifcant
restrictions in the range and intensity of emotional expression, are associated
with greater difculties in fulflling daily parenting roles. Such disorders are
36 | Safeguarding Children Across Services
highly signifcantly associated with social services supervision and practitioners’
concerns about emotional responsiveness, practical baby care, and perceived risks
of harm to the baby.73
Substance and alcohol misuse
An estimated 250,000 to 350,000 children in the UK have parents who are
problematic drug users.74 About four times as many (1.3 million) children live
with parents who are thought to misuse alcohol. Drug and alcohol misuse are
widely recognized as serious risk factors in child maltreatment. They can impact
on children before birth, and in extreme cases result in foetal alcohol75 or neonatal
abstinence syndrome.76 Infants who have been exposed to drugs or alcohol in utero
may experience withdrawal symptoms and distressed behaviour after birth, as
well as possibly long-term consequences for their future health and wellbeing.77
Substance and alcohol misuse may have an adverse impact on parenting
capacity because parents become preoccupied with their own needs and are
unable to focus consistently on the needs of their children. Living standards can
be adversely affected if family income is used to sustain excessive alcohol or
drug consumption. In order to increase their income, substance-misusing parents
may also become involved in criminal activities such as shoplifting, drug dealing
and prostitution; as a result children may become exposed to violence and to
inappropriate sexual activity. Studies have shown an association between parental
substance misuse and neglect, for children’s basic needs for food, warmth and
hygiene may go unnoticed or unmet. Used needles and syringes may pose a risk of
harm to small children, and a lack of supervision may encourage experimentation.
There is some evidence that those parents whose ‘principal attachment is to a
substance’ may have difculty in forming attachments with their children.78 Older
children report the signifcant impact of parental substance misuse on their lives
and can often fnd themselves caring not only for themselves but also for their
parents.79 Unsurprisingly, substance misuse is prevalent in families who come
to the attention of services. Two thirds of the children in the Neglected Children
Reunifcation Study had parents who misused substances. Parents in this study who
misused alcohol often very severely neglected their children and supervised them
inadequately; there was also evidence of a considerable shortfall in services for
these parents, with only 16 per cent of those who needed it receiving help. Parental
substance misuse problems also feature in serious case reviews, highlighting that
these difculties can put children at risk of serious injury or death.
Substance misuse rarely occurs without other problems, such as those relating
to mental health, family relationships and socio-economic circumstances. Rather
than the drug use per se, it is the impact of inter-relationships between these risk
factors in families where substance misuse is an issue that should be regarded as
a signal of potential need for help.
Identifcation and Initial Response | 37
Parental learning disability
There is no foundation for assuming that parents with learning disabilities will
inevitably neglect or abuse their children. Most available research suggests that
the majority of learning-disabled parents can provide adequate care, and that,
with sufcient support, parental learning disability does not affect child outcomes.
Where care is inadequate it is often the product of a constellation of factors, of
which learning disability is just one among many others.
However, the presence of learning disability is a risk factor, especially when
it is associated with difculties such as a shortage of money, chronic housing
problems and fraught relationships. Many adults with learning disabilities will
have experienced difculties in their childhood, which have left them with a poor
sense of self-esteem and a low sense of their own worth. These may make them
vulnerable to being entrapped into relationships with child sex abusers.80 Learning
disability also affects opportunities to learn how to parent. Some learning-disabled
parents will have experienced poor parenting themselves or been brought up
in a very sheltered and protected environment. Their life experiences may also
have left them feeling powerless to deal effectively with negative attitudes and
prejudices.
Neglect is the most common form of concern raised about children cared for by
parents with learning disabilities. Neglect is more likely if the mother’s resources,
knowledge, skills and experiences are insufcient to meet the needs of her child
and if she receives inadequate support in overcoming these adversities. Parents
with learning disabilities may need long-term support over many years if they
are to provide adequate care for their children. These parents often experience
other problems such as mental ill health, social disadvantage and deprivation:
the inter-relationship between these factors may lie behind evidence that parents
with learning disabilities may be more likely than others to have their children
removed from their care.81
Domestic violence
Children are twice as likely to have neglect confrmed within their frst fve years
if there is domestic abuse in the household. Domestic violence has been found to
be present in the homes of just over half of those children who are identifed by
the NSPCC as child protection cases, or who are the subject of care proceedings
or become the subjects of serious case reviews.82
Domestic violence is rarely confned to physical assaults but includes a
mixture of physical and psychological violence. Female victims can be exposed
to emotional abuse, constant criticism, undermining and humiliation, all of
which can have a profound impact on their mental health. There is considerable
evidence that women exposed to domestic violence suffer a loss of confdence,
depression and feelings of degradation. They become isolated, suffer sleep loss
and use medication and alcohol more frequently.
38 | Safeguarding Children Across Services
Domestic violence also affects parenting skills. It is closely associated with
depression, and this can make parents irritable and angry with children and less
likely to be emotionally available and affectionate. They may have difculty in
organizing day-to-day living. When parents are preoccupied with their own
feelings they may experience greater difculty in responding to their child’s
needs. Cues are missed and the parent seems withdrawn and disengaged. In cases
of maternal depression, children may be perceived as having behaviour problems
that affect their parents’ capacity to provide adequate guidance and boundaries.
Feelings of inadequacy can affect parents’ interactions with their children.
There is also a relationship between domestic violence and physical abuse of
children. The Analysis of Serious Case Reviews 2003–5 found that seven out of eight
young children who are the subject of serious case reviews following physical
assault come from families where domestic violence is an issue. Such parents are
often known to probation, the police or adult services, but not to children’s social
care.
While the presence of domestic violence increases the risk of physical abuse
and neglect, witnessing domestic violence is, in itself, a form of emotional abuse.
Attacks on a parent almost always frighten children even if the child is not the
direct or indirect target, and a parent (most frequently, but not invariably, the male
partner) will sometimes exploit a mother’s or child’s fears for each other and use
threats or actual violence as part of a pattern of aggression. Witnessing domestic
violence undermines children’s emotional wellbeing and healthy development;
there is evidence that even babies are adversely affected by this particularly
harmful form of abuse.
Economic and neighbourhood factors
Widespread poverty, housing stress (e.g. residential instability, vacant housing),
and drug and alcohol availability are all known to add to the stresses of living
in a particular neighbourhood, and increase the likelihood of abuse and neglect.
Areas where these factors are prevalent are consistently shown to have higher
rates of child maltreatment, irrespective of the way this is measured.83
The Recognition of Neglect Review emphasizes the pervasive impact of poverty on
parents’ neglectful behaviour. Poverty is a stressor that makes neglect more likely,
but it is not, in itself, a causal factor: not all poor parents neglect their children,
but the majority of neglectful families who come to the attention of children’s
social care are poor.
The Recognition of Adolescent Neglect Review found that approximately 2 per cent
of the population of young people in England have been forced to leave home
for one night or more before their 16th birthdays.84 Poverty is one of the many
stressors identifed amongst young people running away or being forced to leave
home during the teenage years, for it can lead to or exacerbate tensions between
teenagers and birth parents or their partners.85
Identifcation and Initial Response | 39
Social isolation/informal support
Informal support from family, friends and neighbourhood networks is recognized
to be a protective factor in reducing the likelihood of maltreatment. The converse
– social isolation and lack of social support – is a further risk factor that makes
neglect, in particular, more likely. Neglectful mothers have been found to have
fewer members in their social networks and to perceive themselves as being
less supported (and more often excluded) than those who do not neglect their
children. These perceptions appear to be an accurate reflection of reality, and it
seems probable that neglectful parents are the most socially isolated of all types
of maltreating parents.86
The Signifcant Harm of Infants Study suggests that one reason why mothers
who have had previous experiences of care or accommodation may neglect their
children is that they lack informal support from either their birth families or from
substitutes such as previous foster carers. Many of the abusive or neglectful parents
in this study had been maltreated in their own childhood. They frequently had
dysfunctional relationships with their own parents, who in turn had often been
perpetrators or had failed to protect them from abuse. They also had diminished
opportunities for supportive relationships within their extended families, as
contact had been severed with other family members who had also sometimes
been perpetrators.
Child’s developmental needs: disabilities
Whilst factors within the child’s family and environment may increase the risk of
maltreatment, some children are also more likely to be abused or neglected than
others. All the studies draw attention to the greater likelihood of disabled children
being maltreated. The Recognition of Adolescent Neglect Review found that disabled
children are more vulnerable to abuse and neglect because inadequate or poorly coordinated services can leave their families unsupported and isolated. Maltreatment
of disabled children is also easier to conceal, as communication difculties may
prevent them from revealing what is happening and indicators of abuse or neglect
may be mistakenly attributed to their impairment.87 The associations identifed
between disability and maltreatment do not imply a one-directional causal link.
A US national incidence study indicates that, based on professional assessments,
disability can be both a risk factor for, and a consequence of, neglect.88
Child development indicators of emotional abuse or
neglect
While constellations of the risk factors discussed above should alert professionals
to an increased likelihood of emotional abuse or neglect, the studies also identify
several symptoms and signs that may indicate that maltreatment is taking place.
Indicators of maltreatment may be evident in all aspects of children’s development.
40 | Safeguarding Children Across Services
However, just as risk factors are not indicators or necessarily predictors of
emotional abuse and neglect, so indicators are often non-specifc and may be the
result of a wide range of underlying problems of which maltreatment is one
possibility;89 there is also some overlap between those indicators that suggest that
abuse is taking place and those discussed at the beginning of this chapter that
show the longer-term outcomes of maltreatment on children’s health and
development.
How may neglect and/or emotional abuse be indicated in children’s physical
development?
Faltering growth
Faltering growth was previously known as non-organic failure to thrive. It is
a complex issue and maltreatment is one of many potential causes. However,
it can be an indicator of emotional abuse or neglect. In such circumstances,
acts of omission, specifcally in terms of meeting a child’s emotional as well as
physical needs, may result in an infant falling to the bottom 5 per cent or lower
on established growth charts.90 In the months before his death Peter Connelly’s
weight plummeted from the 75th to the 9th centile. His dramatic weight loss was
noted on two separate occasions by the health visitor and by a school nurse, but
did not result in immediate action.91
very small children who are not fed eventually cease to cry, as did two of
the babies in the Signifcant Harm of Infants Study: this is probably a dissociative
reaction to anxiety, but may be falsely regarded as a sign of contentment.
Burns
Burns are an important physical indicator associated with neglect and maltreatment.
The Recognition of Neglect Review identifed two studies conducted by burns units,
respectively in the US and the UK, which offer a sobering perspective on ways
in which neglect may be signalled. The American evidence shows that burns due
to both abuse and neglect are likely to be scalds. The majority of the neglected
children who suffer burns have been identifed as at risk of harm before their
injuries, yet are returned to their original environments. Where children suffer
neglect, families often delay seeking help; neglected children are less likely than
other maltreated children to keep appointments or to receive adequate wound
care.92
The UK evidence corroborates these fndings, but also indicates that where
neglect is an issue it is more likely that:
• the child will not have been given frst aid at the time
Identifcation and Initial Response | 41
• the parents/carers will have put off seeking help for over 24 hours
• the burns will be deeper.93
How may neglect and/or emotional abuse be indicated in children’s
cognitive, emotional, behavioural and social development?
The evidence suggests that indicators of possible emotional abuse or neglect can
be manifest quite early in life. Problems with infant attachment behaviour can be
an early sign of emotional maltreatment. Disorganized/disoriented attachment
patterns in young children are revealed through odd behaviours, such as repeated
incomplete approaches to parents and failing to seek contact when very distressed.
These appear to reflect fear and confusion on the part of the infant.94 This pattern
of attachment is thought to occur when the person from whom the infant seeks
secutiry also becomes a source of fear.95
Neglect may be one of the many possible causes of delays in language and
communication, socio-emotional adjustment and behavioural problems. The
Recognition of Neglect Review suggests that neglect may be manifest in behavioural
patterns of children as young as three – a point corroborated by the Signifcant
Harm of Infants Study, which found that several children who had suffered neglect
since birth were showing signs of developmental delay and/or behavioural
problems by their third birthday. These factors are likely to compromise children’s
early experiences at nursery and school, as they will adversely impact on the
early stages of literacy and numeracy and on children’s acceptance by their peers.
However, the fndings from a range of studies suggest that there are opportunities
in the school setting for teachers to be alert to these possible indicators of neglect
and emotional abuse.
Drawings by maltreated children are also signifcantly different from those by
non-maltreated children. Although these differences are not sufciently distinctive
to provide a ‘diagnosis’, the evidence suggests that drawings could be usefully
included as part of an assessment of possible neglect.96
Adolescents signal neglect by behaviours which are harmful to them and are
considered anti-social. For example, there is strong evidence of a relationship
between neglectful parenting and the kinds of risk-taking behaviours that are likely
to affect young people’s health, such as drug and alcohol use in early adolescence,
although this is less evident as young people grow older.97 Maltreatment during
adolescence increases the chances of arrest, violent offending and drug use.
Neglect has the strongest association with violent behaviour in late adolescence,
although the impact dissipates somewhat in early adulthood. On the other hand
physical neglect at home is associated with children and young people being
stigmatized and bullied.
42 | Safeguarding Children Across Services
Assessing risk factors and indicators of maltreatment
Interplay of multiple factors
It is rare for there to be a single clear pathway leading to either emotional abuse
or neglect. If practitioners are to recognize the signs of both types of abuse, they
need to be alert to the interplay of the multiple risk and protective factors that
make such forms of maltreatment more – or less – likely. Practitioners should
therefore be cautious about making assumptions about the impact on children of
a single issue such as parental mental health or learning disability, because it is
the cumulative impact of combinations of factors that has been found to increase
the likelihood of harm for children.98 This makes the task of recognizing and
responding to these types of maltreatment particularly challenging, as does their
pervasive nature and the lack of clear signs or specifc incidents.
Frameworks and models for conceptualizing
neglect and emotional abuse
We have already seen that an ecological model is relevant in helping professionals
to make assessments of emotional abuse and neglect. The model provided in the
Framework for the Assessment of Children in Need and their Families99 offers practitioners
a conceptual framework which covers relevant multiple dimensions to assess
individual children’s and families’ cases. The dimensions of the assessment
are presented in the form of a triangle with three inter-related domains: the
developmental needs of children, the capacity of parents or caregivers to respond
appropriately to these needs and the impact of wider family and environmental
factors on both parenting capacity and the child’s development. The Core
Assessment Records intended to facilitate recordings from assessments using the
Assessment Framework offer a set of age-specifc indicators, covering a range of
dimensions relevant to all forms of maltreatment including neglect. These support
assessments of levels of care and of the extent to which children’s needs are met.
They thus offer the potential for a consistent method of defning neglect and
emotional maltreatment in relation to individual cases. They have been found to
be particularly useful in assessing neglect in adolescents. However, while the Core
Assessment Records offer a tool that should be valuable in identifying neglect, the
Signifcant Harm of Infants Study found that in practice they are often missing from
case fles or poorly completed.
Building on the ecological model underpinning the Assessment Framework,
the Analysis of Serious Case Reviews 2003–5 suggests that practitioners might adopt
an ‘ecological transactional’ perspective in analysing their assessments. This
approach permits an analysis of accumulating risks of harm.
Such an approach would involve:
• good-quality social and family history taking, including information about
parents’ childhood relationships and behavioural background
Identifcation and Initial Response | 43
• analysing the interactive effect of vulnerabilities and risks
• better understanding of the ecology of child abuse and neglect.
Their recommendations are as follows:
Information and evidence should be collected…based on clearly understood
developmental and psychosocial theories, including the relationship and
developmental histories that have shaped parents, families and children.
The ecological developmental framework should also provide a conceptual
structure and language for presenting a case formulation that should include
(i) a clear case summary and synthesis of knowledge brought together by
the assessment, (ii) a description of the problem/concern, (iii) a hypothesis
about the nature, origins and cause of the need/problem/concern, and (iv)
a plan of the proposed decisions and/or interventions.100
Two important training packs designed to help practitioners identify and respond
specifcally to neglect have been commissioned within this Initiative. Both Training
Resources on Child Neglect for a Multi-Agency Audience101 and Neglect Matters102 are
multi-agency resources for professionals working together on behalf of neglected
children and young people; Training Resources covers all aspects of neglect, while
Neglect Matters focuses specifcally on teenagers.
Signalling the need for help: direct approaches
In what ways do families directly and indirectly signal their need for help?
We know that emotional abuse and neglect (as well as other forms of maltreatment)
arise in families where there are multiple difculties that may not be recognized by
professionals until problems have accumulated and become severe. Some families
may be aware of their growing problems and signal their need for help either
directly or indirectly. This is an under-researched area.
The indicators of neglect and emotional abuse and their outcomes discussed
above are one way in which children indirectly signal a need for help. Direct
approaches are less common, for most children tend to protect their parents and do
not talk about their family affairs easily. However, professionals should be aware
that children often consult the school nurse more frequently when problems begin
to arise. young children often speak more openly than older age groups, and will
more readily respond to questioning, but there are great individual differences.103
The Recognition of Neglect Review found that we do not know whether neglectful
and emotionally abusive parents try and fail to seek help from professionals, or
44 | Safeguarding Children Across Services
whether they tend not to do so. Nor do we know if they want help, but not on the
terms in which it is offered. It is evident from the Signifcant Harm of Infants Study
that such parents may have few friends or family members to whom they can
turn for support, and may conceal their difculties from professionals for fear that
their children will be removed from their care – particularly if they have already
had such an experience with an older child. This corroborates other evidence
which suggests that, far from seeking help, neglectful families may be low users
of universal services. Persistent failure to attend appointments for routine services
such as immunization and hospital appointments should be seen by professionals
as a sign of potential neglect. More than a third of the children whose cases were
scrutinized in the Analysis of Serious Case Reviews 2005–7 had a history of missed
appointments for immunizations and developmental checks, while nearly half of
their mothers had only sporadically attended antenatal appointments if they had
gone at all.
The Signifcant Harm of Infants Study found that cases are often closed by social
workers in the expectation that parents will contact the local Sure Start children’s
centre if problems recur. However, interviews with parents show that many are
lacking in self-confdence and do not have the courage or the ability to make the
effort to attend support services such as play groups, and, as noted above, are more
likely to hide their difculties than ask for help. The Recognition of Neglect Review
found that, although the views of parents are important, this is another area
where we have little information. The evidence suggests that substance-misusing
parents, for example, understand how their addictive behaviour impacts on their
children. They are also aware of what good parenting is but feel unable to fulfl
this role adequately and may be unwilling to signal this to service providers.
Likewise the Emotional Abuse Intervention Review found that, contrary to what is
sometimes assumed, substance-misusing women often desire to be good mothers
and can be aware of what good parenting involves, but feel unable to fulfl this
role.104
The Signifcant Harm of Infants Study includes evidence from a group of parents
whose children were likely to suffer signifcant harm, often as a result of their
substance misuse. Many of these parents had been unable to acknowledge the
harm their actions were causing their children at the time of the abuse, but in
retrospect, after a child had been placed for adoption, some were able to accept
the reasons for the separation.
Practitioners must work to determine levels of risk of harm that parents
themselves can identify and use this information to inform their actions. A simple
chart that would graphically demonstrate to neglectful parents the reasons why a
child is considered to be likely to suffer signifcant harm and the actions they need
to take to reduce this likelihood might be useful here. However, more evidence is
needed to fnd out what kind of services such parents would be willing to access
Identifcation and Initial Response | 45
and what forms of help would enable them to move beyond having anxieties
about their children’s wellbeing to doing something about it.
Practitioners need to be alert to indicators which help them identify those
parents who have the capacity and motivation to overcome adverse behaviours
in order to meet the needs of their children. A useful model is provided by
Morrison105 who describes seven sequential elements of this process:
1. I accept that there is a problem.
2. I have some responsibility for the problem.
3. I have some discomfort about the impact, not only on myself, but also on
my children.
4. I believe things must change.
5. I can be part of the solution.
6. I can make choices about how I address the issues.
7. I can see the frst steps to making changes/can work with others to help me.
Recognition by professionals
How well equipped are professionals to recognize maltreatment and what
judgements do they make when deciding what action to take in relation
to concerns? What do we know about the ways professionals respond to
concerns about abuse and neglect? What action do they take? Does this
vary between professions? What seem to be the barriers and facilitators to
action?
We have seen from the above short review of the evidence how constellations
of risk factors as well as signs and symptoms from parents and children provide
indicators of both the likelihood and the presence of neglect and emotional abuse
that might be recognized by professionals. There is also some evidence about
how families signal their need for help. But how well equipped are practitioners
to recognize these factors? Do they act on their concerns and, if so, how? What
do the studies tell us about factors which inhibit or encourage recognition and
response?
46 | Safeguarding Children Across Services
Professional perspectives and a reluctance to act
It is evident from a number of the studies that professionals often have high
thresholds for recognizing emotional abuse and neglect and are reluctant to act in
response to suspicions in cases that are not clear cut.106 The Recognition of Neglect
Review identifed a number of studies which compared the views of professionals
about what constitutes neglectful parenting with those of the general public.
Two American studies asked subjects to rate neglectful behaviours in terms of
seriousness; in each case professionals indicated a higher threshold of concern
than members of the public.107,108 An English study also found that social workers
consistently rated statements indicating neglect as less serious than a group of
mothers.109
Absence of incidents
There are also other problems. We have already noted that clearly abusive
incidents which precipitate a crisis are rare in cases of emotional abuse and
neglect, making it difcult to decide when to take action. Moreover, neglected
and emotionally abused children may not attract attention in the same way as
those subject to physical or sexual abuse, so that despite the threats to their
wellbeing, the maltreatment they experience may often pass unnoticed. Even
when emotional abuse is suspected, workers often feel ‘impotent in the face of
problems which [unlike sexual abuse, physical violence or physical neglect] are
difcult to tabulate’.110 These difculties may be compounded by the tendency of
child protection services to focus on risks, rather than to assess children’s needs
and explore how parenting capacity might be strengthened.
Particular groups of children: adolescents
and disabled children
It is particularly difcult to recognize neglect and emotional abuse amongst certain
groups of children. For example, there is no common understanding concerning
what constitutes neglect of adolescents – especially what is appropriate supervision
at what age. This gives rise to obvious difculties in identifying when adolescents
are being neglected. Adolescents may also be neglected by services, as those
who are rejected by their own families may become disengaged and ignored
by professionals because their behaviour is challenging, and there are very few
interventions that meet their needs.
Agencies may fail to recognize indicators of neglect in disabled children, or
be reluctant to act in the face of concerns, as is powerfully illustrated by the
case study of a 12-year-old disabled boy in the Analysis of Serious Case Reviews
2003–5. This boy had articulate, well-qualifed, professional parents who severely
neglected him. He was fully dependent on his parents or others for all his selfcare needs and his appearance was described by professionals as grubby and
Identifcation and Initial Response | 47
unkempt. The house was clean and tidy except for his room, which was messy
and unhygienic. His parents did not take him to appointments at the Child
Development Centre; at the age of eight he was taken out of school and educated
at home where he became increasingly isolated. Several agencies assessed that this
child needed to be cared for outside the family home, but there was a year’s delay
before this happened. Finally, at the insistence of a senior health professional,
he was admitted to foster care, by which time his severely neglected state led to
a serious case review. It was evident that this child had been allowed to live in
conditions which, for any other child, would have been considered degrading
and unsuitable; however, his disability, rather than his unmet needs, was held
responsible for his state:
There was clear evidence of neglect in this case yet agencies failed to follow
these pointers consistently or effectively. The model of neglect used was
based on defning the concern in relation to parental action or omission
rather than viewing neglect as a set of needs for care and protection
regardless of the efforts of those caring for the child concerned.111
Recognition and response amongst
specifc professional groups
Different professional groups vary in their capacity to take note of the multiplicity
of risk factors and indicators that a child is suffering, or likely to suffer, signifcant
harm and respond to them. This section considers what the studies tell us about
the specifc issues they face.
Health visitors
The Recognition of Neglect Review found that health visitors stand out as one group
who are well equipped to recognize the parental characteristics associated with
neglect and the developmental signs in children. However, they fnd it difcult to
act on their concerns because they perceive that thresholds for access to services
are high. One UK study indicated that a high proportion of health visitors working
with vulnerable families see themselves as referral agents but many perceive the
lack of social services resources as a barrier to referral. They describe themselves
as:
…angry and frustrated over the lack of social services input with families,
particularly in those areas of ‘high concern’ often described as ‘grey areas’.112
These fndings from a literature review are corroborated by the evidence from
focus groups attended by health visitors in the Signifcant Harm of Infants Study.
There were numerous comments concerning the difculties of getting referrals
48 | Safeguarding Children Across Services
accepted by children’s social care, particularly if a case had been (prematurely)
closed.
Differences in thresholds and difculties in identifying likelihood of harm
in cases of chronic neglect can lead health visitors to feel frustrated that their
concerns are not adequately acknowledged:
‘We’ve got, I can think of three families on our caseload that we have got
grave concerns about, and we must make a referral probably every other
week…at least once a month. But because it’s little bits of things it just goes
“Oh, we’re not going to take it forward, the case is closed.”’ (Health visitor,
Local Authority A)113
Evidence about health visitors’ unwillingness to act on signs of neglect suggests
that they see their role as one of deciding whether or not to refer a case to
children’s social care rather than of considering alternative responses, such as
developing or arranging access to targeted services that might obviate the need
for referral.
Differences in the concept of response may relate to how practitioners perceive
their role in supporting and caring for families and children where there is abuse
or neglect. For instance, a Finnish study of 20 interviews with school nurses
identifed two operational modes: a passive and uninvolved mode and an active
and frm mode. Those nurses who adopted a passive and uninvolved mode equated
responding to family or child problems with referral to other professionals. These
nurses collaborated minimally with other professionals and viewed home visits
as unnecessary. In contrast, those nurses who adopted an active and frm mode
focused less on referral. Instead, they were confdent about their role in supporting
families, made home visits, were clear about their concerns and saw themselves as
active members of a collaborative network:
Active and frm school nurses were not afraid of interfering and did not wait
needlessly, expecting things to turn out right by themselves. They searched
for these families and supported them also by making home visits. Many
of the nurses sent a letter to the child’s home or telephoned the family
as problems arose. The school nurse might also ask the whole family to
visit him or her; they showed interest in their clients and cared for their
wellbeing.114
Schools
Schools are settings in which there are particular opportunities for practitioners to
be alert to constellations of problems. Indeed, in recent years national policy has
placed schools at the heart of early intervention, although it is at present unclear
whether this emphasis will remain as strong under the Coalition Government.
While practitioners in the law, social care and the health services are more likely
Identifcation and Initial Response | 49
to identify maltreatment that manifests itself in crises, people working in schools
tend to be more alert to chronic issues, a major factor in the identifcation of
neglect and emotional abuse.115
The Recognition of Neglect Review found that there is a paucity of evidence
concerning effective ways for schools to undertake such responsibilities, and a
striking absence of rigorous studies into the role of schools, teachers and also
the police in safeguarding children. However, one important study has shown
that, where teachers and educational psychologists are offered specifc training
in child protection, together with online support, guidance and consultation,
recognition improves and appropriate referrals increase. Training in this area may
be particularly effective if it addresses professionals’ fears and doubts about what
would be best for the child, and also their lack of confdence and knowledge
about the contribution they can make in safeguarding children.116
Adult mental health, substance misuse and
domestic violence services
The association between parental problems, such as poor mental health,
domestic violence and substance misuse, and emotional abuse and neglect is
well established.117 We might therefore expect that practitioners in these services
would be highly alert to risks of harm to the children of their clients/patients
who are parents. However, evidence of referral rates suggests that workers in all
three services are missing opportunities to recognize these risks or to respond to
concerns. For example, despite the high incidence of mental health and addiction
amongst their parents, only 1 of 50 children in the Signifcant Harm of Infants Study
was referred by drug and alcohol services, and none by adult mental health.
The Emotional Abuse Intervention Review considered that mental health
practitioners were chary of recognizing or acting on concerns:
Practitioners are perhaps understandably reluctant to describe the often
erratic, inconsistent and even frightening behaviours that can result as a
consequence of severe mental illness as emotional maltreatment, and there
is currently very little attention paid to the needs of children whose parents
have severe mental illness.118
The problems stem partly from understandable concerns about the wellbeing of
the parent as client/patient but also from a lack of collaboration and indeed some
hostility between, for example, mental health and child protection services. There
may be poor communication between those professionals who focus on the risks
to children posed by emotional maltreatment, and those who are more concerned
with treating the parental behaviour that gives rise to it. However, there is some
evidence that early recognition and intervention can influence such interaction
and improve outcomes for children.
50 | Safeguarding Children Across Services
The Emotional Abuse Intervention Review found that opportunities for recognizing
abuse that should be routinely considered as part of normal practice are missed
by practitioners working with adults. Children are at increased likelihood of
suffering emotional abuse where one parent, particularly if this is the main carer,
is experiencing mental health and drug/alcohol problems, and in families where
domestic violence is taking place. In the case of substance misuse, the dangers
also need to be recognized prenatally. The rate of substantiated maltreatment,
mostly neglect, is much greater in infants who have been exposed to drugs or
alcohol in utero.
Amongst all these services an assessment of the impact of parents’ problems on
child wellbeing should be a routine part of normal practice. Appropriate tools to
undertake such assessments include standardized psychological tests; assessments
of parent–child interactions; Goal Attainment Scaling; ongoing evaluations of the
impact of tailored interventions; and standardized tests showing progress over
time.119
Police
Many factors associated with neglect are also likely to entail police contact. The
Analysis of Serious Case Reviews 2003–5 found the police to be the agency most
involved with families in neglect cases, as the parents were often involved in
community and domestic violence. However, some branches of the police force
are insufciently aware of the link between domestic violence and the risk of
harm to children. The Recognition of Neglect Review found that the role of the police
in identifying and responding to neglect had not been researched.120
Professional responses: to refer or not to refer
What happens when professionals have concerns about maltreatment and
neglect? How do they respond and what action do they take?
The Recognition of Neglect Review explored how professionals other than social
workers respond to their own concerns about maltreatment. Response tends to be
conceptualized as ‘referral’ or ‘reporting’ and this is where the bulk of evidence
lies. Professionals outside social care are reluctant to take direct action other than
to refer to social care agencies. They appear to be frozen by the decision to refer
or not to refer rather than to consider what other forms of action might be useful
and appropriate.
There is far less evidence about the stages following recognition, or about
what universal services might be able to offer to support neglected children.
Identifcation and Initial Response | 51
However, there is evidence concerning those factors that make referral more
likely, although it comes from the US, and may not translate easily into a UK
context. These factors are:
• Family-related factors, including: the age of the child; whether they are at a
primary school where more children take free school meals and ‘perception
of maltreatment’ is high; whether there is strong evidence of concern for
safety; whether the child and parent are white rather than Afro-Caribbean.
• Practitioner factors, including: being white (Asian practitioners are least likely
to refer); having knowledge or personal experience of being abused.
• System factors, including: mandatory reporting; having fewer concerns about
the process of investigation; knowing that previous reporting has led to a
good outcome for a child; the absence of a range of system barriers.121
We have already seen that adolescents can be neglected by services. The Recognition
of Adolescent Neglect Review and the Analyses of Serious Case Reviews both found that
they are also the age group least likely to be referred.122
Response from the wider community
What happens when members of the wider community have concerns about
maltreatment and neglect? How do they respond and what action do they
take?
Although we know that the general public tends to have a lower threshold
for determining maltreatment, there is only minimal evidence about how
ordinary community members act when they have concerns about a child in
their neighbourhood. This comes from two studies undertaken with different
populations in different societies, and we do not know how far it would be
relevant in a UK context. Members of a South Asian Canadian community have
been shown to be quite able to identify neglect, but to be reluctant to approach
child protection services about their concerns.123 A general population survey in a
southern state in the US found that the majority of the general public would help
if they became aware of a child being abused or neglected as a result of substance
abuse; however, the help they would offer would be to contact child protection
agencies.124 We do not know the extent to which reported intention in this study
is translated into action if the occasion to refer arises.
52 | Safeguarding Children Across Services
Conclusion
The evidence discussed above carries a number of messages concerning how
maltreatment – and specifcally emotional abuse and neglect – can be better
identifed and responded to by all those who have responsibility for safeguarding
the welfare of children. While all of these have general relevance, some are of
specifc value to professionals from the numerous agencies involved.
Key messages for all who work together to safeguard
children
• Emotional abuse and neglect have long-term adverse consequences for
children’s future wellbeing.
• The risk of fatalities from neglect may be as high as that from physical
abuse.
• Ten times as many children experience emotional abuse and neglect as
come to the attention of child welfare services.
• Neglect and emotional abuse often manifest themselves early and have a
corrosive impact throughout childhood.
• The consequences of neglect and emotional abuse are particularly
severe in utero and in the frst three years of life because of the child’s
developmental stage.
• Adolescent emotional abuse and neglect are widespread and associated
with numerous adverse consequences, including suicide and death or
serious injury from risk-taking behaviours.
• Approximately 2 per cent of the population of England have been forced
to leave home for one night or more before their sixteenth birthdays.
• There is no common understanding of what constitutes supervisory
neglect of adolescents. However, there is much evidence that inadequate
supervision and monitoring is associated with adverse behaviour patterns.
• Assumptions about impairment, inadequacies in service provision and
impairment itself may all render disabled children more vulnerable to
abuse.
Key messages for front-line practitioners in education,
health, social care and the police
• Neglect and emotional abuse only rarely result in crises, so practitioners
need to look for evidence of long-term, chronic maltreatment.
Identifcation and Initial Response | 53
• Not all mentally ill parents neglect or emotionally abuse their children, but
parental mental health problems can lead to a deterioration in parenting
capacity and the failure to meet the child’s physical and emotional needs.
• Substance and alcohol misuse can be associated with severe neglect.
• When compounded with other parental difculties, learning disability
may be associated with neglect and emotional abuse.
• Police need to be aware that, not only is domestic violence harmful
to children, it is also often associated with physical abuse. Moreover
parents of neglected children may also often be involved in community
and domestic violence. Such parents may be known to the police and
probation, but not always to children’s social care.
What to look for
In adult health, mental health and social care
• The impact of parental problems such as poor mental health, alcohol and
substance misuse, or domestic violence on child wellbeing. This should be
routine practice where adult service users have parenting responsibilities.
In health and social care settings
• Persistent failure to attend appointments for routine services such as
immunization and hospital appointments.
• Disorganized/disoriented attachment patterns in young children, revealed
through odd behaviours, such as repeated incomplete approaches to
parents and failing to seek contact when very distressed.
• Frequent consultations with the school nurse.
• Passivity and sudden weight loss in very young children.
• Children who suffer burns or scalds who are not given frst aid
immediately; whose parents or carers have put off seeking help for over
24 hours; whose burns are unusually deep; who receive inadequate wound
care; whose parents fail to keep appointments.
In nursery, preschool and school
• Children who show a steep decline in performance (this can be from as
young as nine months).
• Children who become more socially withdrawn and unpopular with
peers as well as more aggressive and less attentive.
54 | Safeguarding Children Across Services
• Delays in language and communication, socio-emotional adjustment and
behavioural problems. These may be indicators of neglect in children as
young as three.
Response and referral
• Teachers are well placed to identify neglect and emotional abuse. Where
teachers and educational psychologists are offered specifc training in
child protection, together with support, recognition of maltreatment
improves and appropriate referrals increase.
• High thresholds for access to children’s social care may deter referrals.
Those front-line practitioners in universal/primary-level services who
adopt an active and frm mode of operating may be more confdent about
their role in supporting families and less likely to need to refer cases on.
• It is unrealistic to expect very vulnerable parents to refer or re-refer
themselves to children’s social care – or to access targeted services without
support.
• It is important for social workers and health professionals to assess
whether parents do or do not have the capacity to change: a number of
indicators, such as recognition of the impact their problems have on their
children, can be looked for as a basis for decision-making.
3
Universal and Targeted Services
to Prevent the Occurrence
of Maltreatment
• This chapter draws largely on the evidence from the Emotional Abuse
Intervention Review,125 the Recognition of Adolescent Neglect Review126 and the
Sure Start Local Programmes Safeguarding Study.127
• The chapter has important messages for all those who have responsibility
for safeguarding and promoting the welfare of children.
• It also has specifc messages for the following professional groups:
ô policymakers (section on prevention before occurrence)
ô strategic managers and commissioners of services (all sections)
ô operational managers (sections on targeted approaches to prevention;
assessment tools; parent-training programmes)
ô practitioners (sections on targeted approaches to prevention;
assessment tools; parent-training programmes).
Introduction
The last chapter explored the risk factors associated with maltreatment, and
considered how abuse and neglect can occur as a result of a complex interaction
between these and the positive factors in a child’s life. Emotional abuse and neglect
pose particular challenges to recognition because of their long-term nature and
the absence of specifc events or evidence of physical harm that might prompt
attention.
Programmes that prevent the occurrence of abuse are likely to be more
effective than those that aim to address its consequences. There is evidence of the
effectiveness of some well-designed, early intervention, preventive programmes.
This chapter explores what the studies have to say about these. However, frst
we shall briefly consider the different stages at which effective intervention is
possible.
55
56 | Safeguarding Children Across Services
A framework for intervention
A three-level model of prevention is often used to map both medical and social
interventions. In this model primary prevention covers universal approaches to
reduce the potential incidence of abuse and maltreatment; secondary prevention
covers targeted approaches towards families where there is a greater likelihood
of abuse and neglect, but before maltreatment has taken place; whilst tertiary
prevention is designed to prevent further deterioration in cases where abuse or
neglect has been identifed.
Another way to look at this is to distinguish conceptually between preventive
interventions, designed to reduce the likelihood of maltreatment, and therapeutic
interventions, designed to prevent its recurrence and/or address the often
extensive psychosocial consequences. This is shown in Figure 3.1. The diagram
provides a useful framework for considering the timing and types of intervention
which can be provided.
The left-hand side of Figure 3.1 maps preventive interventions before the
occurrence of maltreatment, and distinguishes between universal (primary) and
targeted (secondary) prevention. The right-hand side maps interventions which
take place after maltreatment (tertiary prevention). In including tertiary prevention,
the diagram demonstrates how interventions designed to prevent maltreatment
and its recurrence differ from those designed to prevent long-term impairment to
the child’s health and development.
Long-term
outcomes

Universal Targeted
Figure 3.1: Framework for intervention and prevention of child maltreatment128
In this chapter we focus on primary and secondary interventions designed to
prevent maltreatment before it has occurred. Many of these interventions are
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 57
introduced as part of public health programmes. Some are universally provided,
and aimed at a total population, while others are targeted towards families where
there is a greater likelihood of maltreatment. In Chapters 4 and 5 we look at both
long and short-term specifc or tertiary interventions, introduced at a familial or
individual level, after abuse (or a high risk of harm) has been identifed. Chapter 4
focuses on social casework, while Chapter 5 covers complementary specialist
interventions, designed to prevent the recurrence of maltreatment and to help
children overcome its consequences.
Prevention before occurrence of maltreatment
Why are universal or population-based interventions a good idea?
There are several reasons why it makes sense to adopt a universal or populationbased approach to prevention. The evidence from a number of populationbased surveys shows that the prevalence of both moderate and severe forms of
maltreatment is high. They indicate that every year 4–16 per cent of children
in high-income countries are physically abused, 10 per cent are neglected or
emotionally abused and at least 15 per cent are exposed to some form of sexual
abuse.129 We have already seen in Chapter 2 that the most recent UK populationbased survey shows that 2.5 per cent of children aged under 11 years and 6 per
cent of young people between the ages of 11 and 17 years had experienced some
form of maltreatment in the previous year.130 The proportion of children and
young people who are known to children’s social care, or are the subject of child
protection plans, is much lower. The latest statistical data for England indicate
that, in the year 2009–10, about 3.14 per cent were regarded as children in need
(i.e. requiring support from social services if they are to achieve a reasonable
standard of health and development), but only 0.32 per cent were the subjects
of child protection plans.131 In other words, the population-based surveys show
that well over ten times as many children may experience abuse or neglect as the
ofcial statistics would indicate.132
The contribution of population-based approaches may be to reach children
whose maltreatment has not yet been brought to the attention of services, or
whose situation does not meet the threshold for statutory intervention. By
reaching these families early, such approaches can reduce the number of parents
who might otherwise later abuse or neglect their children.
A second advantage of population-based approaches is that they are nonstigmatizing. Maltreating families are often low or inconsistent service users and
therefore hard to reach. They are more likely to be reached through programmes
58 | Safeguarding Children Across Services
that are provided through services that are accessible to all, such as health care,
education with a broad-based curriculum and public leisure and recreation facilities,
which offer a safe environment for older children and young people.133 In recent
years much effort has been directed at increasing the number of non-stigmatizing
access points through which potentially useful approaches such as parenting
programmes can be made more easily available. Other approaches include mass
media public education programmes; outreach services such as those provided by
health visitors; increased monitoring, surveillance and support through primary
health care; building up the school health provision; and support through Sure
Start children’s centres.
Many universal approaches aim to shift the norms of parenting behaviour
and thus change extreme patterns that are harmful to children. If we assume that
parenting behaviour follows a normal distribution pattern then the majority of
behaviour falls in the middle of the graph. The argument is that, by shifting the
normative behaviour of a whole population, extreme, abusive behaviour patterns
will also be influenced to change in the same positive direction.
Universal or population-based approaches to
prevention in the UK
What universal approaches in the UK can impact on maltreatment? How do
these apply to different age groups?
The studies in this Research Initiative did not explicitly review evidence evaluating
the effectiveness of population-based approaches. However, several comment on
their general applicability and suggest it is likely that they have an impact on
factors related to maltreatment. For example, the Emotional Abuse Intervention Review
found that the application of parenting programmes on a universal basis improves
many factors known to be associated with child maltreatment, such as family
functioning, parental depression, stress, conflict, efcacy and competence.134,135
The Healthy Child Programme and Inter-Disciplinary Framework (HCP) is a
nationally implemented health-based preventive initiative provided universally
under the NHS, designed to reach both children and their families.136 It comprises
a health promotion and surveillance programme that incorporates a range of
universal strategies which can be used by primary care professionals to promote
the type of sensitive and attuned parenting that is recognized to be important to
the wellbeing of young children. The programme includes screening, health and
development reviews, immunizations, and health promotion, all of which might
prompt a series of inter-disciplinary interventions critical to safeguarding the
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 59
child’s welfare: for example, a failed hearing test or detection of developmental
dysplasia of the hip will need urgent, preventive intervention. In addition, the
programme recommends the use of a range of interventions to support early
parenting including the use of media-based tools, books supplied to every mother
in a choice of languages,137,138 strategies such as promotional interviewing, and
group-based early interventions (e.g. infant massage and parenting programmes).
Every family is entitled to these services,139 which are offered in GP surgeries,
clinics and Sure Start children’s centres. Making these services available in a range
of settings maximizes opportunities for families who may be disengaged from
services to access them and for front-line practitioners to recognize and encourage
such families to make use of them.
Sure Start children’s centres are an example of a primary programme relevant
to the prevention of neglect.140 Their role is:
To help link services provided for fathers, mothers and their children from
the antenatal period through to when a child starts nursery school. They
are intended to help to provide a source of easily accessible advice about
how parents may help their child’s early learning development and mental
health. In doing so they can help with the early identifcation of children
with specifc developmental difculties.141
Sure Start has been designed as a broad-based, non-stigmatizing, universally
available service. The number of Sure Start children’s centres has increased in
recent years, and there were plans to make them available in every community
by 2010 as part of the national health promotion strategy.142 However, they also
have a particular focus on improving support to families who have been less
ready to access traditional services. In this sense they may also be seen to have
a targeted focus. This targeted approach may become more pronounced: under
current fnancial stringency plans, Sure Start centres may be reduced or charging
may be introduced for middle and higher-income parents.143
Many of the primary programmes are aimed at younger children. The Recognition
of Adolescent Neglect Review found that there are very few services available that
are relevant to the needs of neglected adolescents. Preventive interventions aimed
at improving parenting for this age group are particularly limited. A particular
issue for young people as they move towards independence is the extent to
which they should be supervised or monitored when not in school. One of the
key developmental issues for adolescents is the need to have the opportunity to
exercise autonomy in their transition to adulthood. Parents and carers may need
support in achieving the right balance between setting appropriate boundaries
and acknowledging young people’s increasing independence and potential for
self-determination.144
As Chapter 2 has shown, the relationship between levels of parental supervision
and monitoring and the likelihood of adolescents engaging in a range of risky or
60 | Safeguarding Children Across Services
anti-social behaviours is well established.145 There is some evidence that the most
effective mode of supervision for this age group is one in which young people keep
their parents informed of their activities through an open relationship, rather than
through one in which parents insist on being given detailed information about
the young person’s whereabouts at all times.146 However, there is little consensus
as to what might be appropriate levels of parental supervision for this age group.
There is a case for a national debate to be engendered through the media, and for
programmes to be introduced in Personal, Social and Health Education (PSHE)
classes in schools to take this issue forwards. The Neglect Matters guide for young
people147 (see Figure 3.2) has been produced as part of the Safeguarding Children
Research Initiative, and is already initiating such a debate, through its widespread
utilization in schools, youth clubs and health centres.
Figure 3.2: Extract from Neglect Matters: A Guide for Young People about Neglect
Preventive interventions might also be piloted and introduced as part of
parenting support programmes. Their purpose would be to change societal norms
about appropriate forms of parental monitoring and supervision of adolescents.
If successful, such approaches could play a similar role to those addressed at
the parenting of younger children, namely to change normative behaviour and
therefore shift extreme behaviour in a more positive direction.
The reviews have found no validated interventions aimed at the perpetrators of
intimate partner violence; the Signifcant Harm of Infants Study found that very few
services were available, and the common response was to exclude perpetrators from
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 61
the family home, with the result that many went on to abuse another family. One
way of beginning to address this issue might be to develop preventive, universal
programmes designed to raise awareness and change adolescent perceptions of
intimate partner violence and its consequences; this is another area where extreme
behaviour might well be shifted by a change in normative patterns.
Evaluated universal/population-based preventive
interventions
Which universal/population-based preventive interventions have been
shown to be effective?
Not all population-based interventions have been formally assessed. However, the
two approaches described below have been subject to rigorous evaluation, which
has shown them to be effective. The frst example shows how the introduction of
new legislation can provide an effective means of changing public attitudes and
reducing the maltreatment of children, while the second describes an effective,
universally introduced parenting programme.
An evaluation of the Swedish ban on physical chastisement
In 1979, Sweden became the frst nation to introduce legislation that banned
mild forms of physical chastisement including smacking. The ban’s aims were
threefold: to alter public attitudes; to increase early identifcation of children
likely to suffer signifcant harm; and to promote earlier and more supportive
interventions with families. It was accompanied by an associated national public
education campaign designed to change parenting behaviour. This included the
distribution of a public education brochure, and a two-month publicity campaign
that included printing information about the change in law on milk cartons.148
More than 15 years after the ban was introduced, its impact was evaluated. The
evaluation was based on an extensive examination of ofcially held statistics
in three key areas: public attitudes, crime prevention and child welfare. It also
drew on a series of cross-sectional studies of the use of physical punishment
by parents, including children’s reported experiences. The fndings showed that
public support for such punishment had declined. By 1994 only one third of
middle school children reported having received physical punishment from their
mother or father, and of these most had experienced only its mildest forms (arm
grabbing or mild slaps). Of the population surveyed, only 3 per cent had received
a harsh slap and 1 per cent had been hit with an object. young adults whose
own childhoods had largely been spent under the protection of this legislation
62 | Safeguarding Children Across Services
were also less likely to be suspected of physical abuse. Moreover, for a period of
11 years after the introduction of the ban, no child died as a result of physical
abuse in Sweden.
While it is difcult to be confdent about the extent to which these positive
shifts can be attributed to legislative reform, it seems likely that the ban will
have played some part in the changes witnessed not only in the attitudes and
behaviours of ‘average’ parents in the population, but also in a noted reduction
in the more extreme forms of those parenting behaviours that are the concerns of
child protection agencies.
The Triple P-Positive Parenting Programme: A
validated population-based approach
The Triple P-Positive Parenting Programme (Triple P) is a population-based
approach that has been rigorously and extensively evaluated. This is a multi-level
parenting and family support strategy that aims to prevent severe behavioural,
emotional and developmental problems in children by enhancing the knowledge,
skills and confdence of their parents.149
Triple P incorporates up to six levels of intervention of increasing strength
for parents of children from birth to 12. The preventive element consists of
three levels. These comprise a public health campaign linked to a more intensive
primary health intervention, which includes guidance and help to families with
children with mild behavioural problems. These frst three levels of intervention
can be summarized as follows:
• Level One: A universal parent information strategy provides access to
information about parenting through a co-ordinated promotional campaign,
using print and electronic media.
• Level Two: A brief one or two-session primary health care intervention
provides anticipatory developmental guidance to parents of children with
mild behavioural difculties, with the aid of user-friendly parenting advice
sheets and videotapes that demonstrate specifc parenting strategies.
• Level Three: A four-session primary care intervention targets children with
mild to moderate behavioural difculties and includes active skills training
for parents.
This programme has been formally evaluated in the US.150 The evaluation
consisted of a population trial in which 18 medium-sized counties in a southeastern state were randomly assigned to either dissemination of the Triple P
Programme or a services-as-usual control condition. The sample was controlled
for county population size, poverty rate and county child abuse rate. The
evaluation was undertaken after a two-year period of intervention and employed
a holistic approach, exploring the impact on a range of factors at the individual,
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 63
environmental and family level. It found that the dissemination of Triple P,
alongside the use of universal media and communication strategies, and professional
training to the relevant childcare workforce, was effective. When compared with
standard services, Triple P produced large changes in three independently derived
population-based predictors of child abuse: the number of substantiated ofcial
reports of child maltreatment; the number of out-of-home placements; and the
number of identifed child maltreatment injuries. The overall fndings appear to
be very promising; however, by public health standards, the evaluation used a
relatively small sample (an estimated 8883–13,560 families participated) and we
do not know whether Triple P is equally effective in a UK setting. However,
Triple P is currently being trialled on a population-wide basis in Glasgow, and
if successful, the results may further strengthen confdence in its effectiveness.151
Targeted approaches to prevention
Targeted approaches to prevention have a number of benefts. First, they facilitate
a more efcient and cost-effective delivery of services through their focus on
those sectors of the population which have the highest need. For example, the
evidence suggests that the long-term cost-effectiveness of one such approach,
home-visiting programmes, is dependent on careful targeting of the service to
socio-economically deprived, frst-time, teenage, parents.152
One of the most commonly used criteria to target interventions is that of
demographics or geography. This approach can be justifed in designing
interventions to prevent the occurrence of abuse, as this is more prevalent amongst
families living in highly stressed, socio-economically deprived, areas. While
this type of approach might be appropriate in terms of the delivery of broad,
preventive interventions, further criteria can be applied to identify families where
there is a greater likelihood of child maltreatment. In this way, more sharply
targeted interventions may be designed and delivered to meet the specifc needs
of small sectors of the population. However, it is necessary to have reliable ways
to recognize and target such families.
The best way to target services may be for practitioners in universal services
to identify and assess need. For instance, The Healthy Child Programme 153 provides
for assessments to be undertaken routinely by primary care professionals, such as
midwives, health visitors and GPs, all of whom have regular contact with parents.
In addition, GPs see children under fve an average of fve times a year for minor
illnesses: these consultations can provide occasions for opportunistic surveillance,
especially for those who miss out on routine appointments. They also provide
opportunities to relate to the child and parent or caregiver and observe their
interaction, forming the basis of a more holistic assessment and reflection.
64 | Safeguarding Children Across Services
Assessment tools to identify families who might beneft from
targeted preventive interventions
What tools exist to help front-line workers to identify families whose
children are considered to be likely to be maltreated?
As Chapter 2 has shown, the coexistence of factors such as parental substance
misuse, intimate partner violence or severe mental health problems increases the
likelihood of maltreatment, particularly if protective factors such as the presence
of a supportive extended family or evidence of parents’ capacity to change
are absent.154 Parental problems such as these need to be assessed formally by
appropriate specialists. Such assessments need to be undertaken alongside
more broad-based assessments of parent–child factors including parent–child
interaction.
Good assessment may be as much part of an intervention as the intervention
itself; both require the same core practice skills of being able to interact and
communicate with parents and children, and utilizing knowledge and expertise
to promote relationships. This is an important point to bear in mind when
conducting any type of formal assessment or manualized intervention, as without
intelligent sensitivity and engagement, professionals risk falling into the trap of
allowing these to become mechanistic, and ultimately counter-productive, tickbox exercises.
A broad-based assessment tool: the Common Assessment
Framework
The Common Assessment Framework (CAF) has been developed to help target
preventive services towards children and families where there may be multiple
problems or an increased probability of maltreatment. This tool is designed to
help workers in universal services identify and assess children’s additional needs.
Government practice guidance explains that the CAF should be used where
children in ordinary settings have additional needs.155 The purpose of the CAF is
to help practitioners from a range of sectors assess children’s additional needs for
services earlier and more effectively; develop a common understanding of these
needs; and agree a plan for working together to address them.
Some common assessments might conclude with the identifcation of a lead
professional to co-ordinate the implementation of the plan. This is someone who
acts as a single point of contact for a child and their family when a range of
services is involved and an integrated response is required. The CAF process
has the advantage of being suitable for use with families with children of all
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 65
ages, from infants to adolescents. Needs are considered in consultation with the
family and/or young person and recorded on shared forms which may be held
electronically.
An evaluation of the implementation of CAF has been conducted, using a
mixed methods model.156 The fndings suggest that parents, young people and
practitioners are generally positive about the process. The role of lead professional
is found to be helpful in co-ordinating service inputs when needs have been
identifed. When supported by good multi-disciplinary training and support
systems, the process of implementation helps consolidate inter-agency and
inter-professional working. However, there are also some obstacles to effective
implementation. These only occur in some authorities and are related to poorly
conducted training, poor support systems for staff, and insufciently developed
or unsuitable IT systems. Some practitioners fnd the process time-consuming and
some fnd the role of lead professional stressful and are reluctant to take it on.
No evaluation of the outcomes of the CAF in terms of its possible contribution
to the prevention of maltreatment has yet been undertaken, although this would
obviously be valuable.
The challenges of effective implementation may inhibit the capacity of CAF
to deliver fully on its objectives. Initiatives to reduce the burden of recording by
practitioners157 may result in retrenchment and the rolling back of plans for the
national implementation. However, it would be regrettable if this were to result in
the jettisoning of a tool which can be used across disciplines and that provides a
valuable means of identifying and assessing the needs of families whose children
may not be achieving their optimal outcomes.
As we saw in Chapter 2, the quality of early parenting, including parent–child
interactions and the development of secure infant attachment, is fundamental to
a child’s early development. The task of assessing the parenting of very young
children is a more difcult and skilled undertaking. At a more specialist level than
the CAF, a number of tools are available to assess the quality of parent–child
interaction. Some examples are described below.
A sharply focused approach to assessment: tools to assess child–
parent interaction
Infants and toddlers
The Alarm Distress Baby Scale (ADBB)158 and the Crittenden CARE Index
(CARE-Index)159 are both valuable in assessing parent–baby and parent–toddler
interaction. Both scales can be utilized by social workers or health visitors who
have received specialist training, or by a specialist professional such as a parent–
infant psychotherapist. Training for using the Crittenden CARE Index is now
available in the UK.
The Alarm Distress Baby Scale (ADBB) is designed to assess social withdrawal
behaviour in infants under three years of age. It is undertaken by assessing the
66 | Safeguarding Children Across Services
infant’s social responses to the clinician (rather than the parent). Social withdrawal
behaviour is evident in infants from as young as two months old, and is indicated
by ‘a lack of either positive (for example, smiling, eye contact) or negative (for
example, vocal protestations) behaviours’.160 The scale requires practitioners to
assess eight items, with low ratings being considered as indicators of unusually
low social behaviour. This instrument is a useful resource in assessing social
withdrawal behaviour, which should alert practitioners to problems with the
infant’s environment. However, although this can be an indicator of emotional
abuse (see Chapter 2), there may be other reasons; the potential of the ADBB to
differentiate between abusing and non-abusing parents has not yet been tested.
However, the Crittenden CARE Index (CARE-Index)161 has been shown
to differentiate abusing from neglecting, abusing-and-neglecting, marginally
maltreating, and inadequate (i.e. providing seriously suboptimal parenting) dyads,
and is recommended for use as part of a broader assessment of functioning.
Using three minutes of videotape of parent–infant/toddler interaction, trained
practitioners analyse seven aspects of behaviour, assessing both parental actions
and infant responses. This enables the clinician to assess factors such as sensitivity,
control and unresponsiveness in parents, and co-operativeness, compulsiveness,
difcultness and passivity in infants and toddlers.162 This assessment provides the
practitioner with some indication of both the severity of the problems, and the
nature of the intervention required. Assessments are rated on a 14-point scale,
with low scores indicating negative behaviour patterns and the possibility of
maltreatment. The CARE-Index is short and can be used across a range of settings
including the home and clinic. It can also be used as an intervention to improve
maternal sensitivity.
The strength of tools such as the CARE-Index is that they can be used not
only to target or identify parents who show an increased likelihood of maltreating
very young children, but also to focus intervention. Recent research points to the
value of such tools when employed as part of a broader procedure for assessing
parents’ capacity for change.163
Older children
Assessments of parent–child interaction involving older children can be undertaken
using other structured methods including the Parent–Child Interaction Coding
System II.164 This records the frequency of discrete parent and child behaviours and
can distinguish abusive from non-abusive parenting. The Emotional Availability
Scales165 rate several dimensions of parenting for older children, including parental
sensitivity, parental non-intrusiveness, parental non-hostility, child responsiveness
and child involvement. As with the CARE-Index, such instruments can be
introduced both as part of a broader clinical assessment of functioning166 and to
identify actual maltreatment or seriously suboptimal parenting in order to target
costly interventions more effectively.
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 67
An actuarial approach to assessing risk
The Signifcant Harm of Infants Study used an inventory of risk and protective factors
that have been shown to be associated with a greater or lesser likelihood of
maltreatment or its recurrence167 to create an independent, four-level index of the
likelihood of the babies in the study suffering harm. Families were classifed both
at the time of identifcation, and also two to three years later, at the children’s
third birthdays. This proved to be a useful method of identifying, at a very early
stage, those families that would not be able to provide a nurturing home within a
child’s timescale – by the end of the study all but one of the children in the severe
risk category had been permanently removed, although there had been damaging
delays in making some of the decisions.
Such an actuarial approach has considerable value, and indeed there are plans
to pilot this methodology in a practice setting. However, its limitations should
be acknowledged. First, even using the best evidence we have, the current state
of knowledge does not allow for a reliable and accurate use of numerical scoring
of relative risk. Moreover the issues are more complex than can be reflected in a
numerical score or simple actuarial table. Individual cases will all have their own
idiosyncrasies and risk factors may interact with one another in different ways.
Even if valid estimates of the probability of future harm could be calculated for
groups of children, they will not necessarily be accurate for individual cases.
Decisions made about these children have permanent, life-changing consequences,
and it is not ethically defensible to make them on the basis of mathematical
probabilities without exploring the qualitative information about each child’s
individual circumstances. On the other hand, estimates of probability can be
extremely useful in providing a baseline against which decisions which ignore
them have to be justifed. Therefore, while actuarial approaches have considerable
potential as an aid to decision-making, there are dangers in introducing them in
place of professional judgement.168
Similar caveats hold for the use of validated inventories and assessment tools,
such as the CARE-Index: they have considerable potential to support decisionmaking, but should not be allowed to become tick-box exercises that replace
analysis and judgement. Findings from both the implementation of the Integrated
Children’s System,169 and the Assessment Framework170 that preceded it, suggest
that decision-makers need to develop the ability to analyse and understand the
implications of complex constellations of risk and protective factors and indicators
of maltreatment, supported by the practice tools available to them.
Notwithstanding these issues, validated tools are a valuable resource in helping
practitioners and clinicians assess the likelihood of a child being maltreated, or
the evidence that this may be happening, and make decisions about the delivery
of targeted interventions. In the next section we look at two examples of such
targeted interventions that have been shown to be effective.
68 | Safeguarding Children Across Services
What targeted approaches to prevention
have been shown to work?
Overall, the most effective targeted approaches to preventing child physical abuse
or neglect appear to be home-visiting schemes and multi-component interventions
of the type used in parent training.171
Home-visiting (or visitation) programmes
Home visiting for very young children and their parents through the health
visitor service has existed in the UK and most European countries for decades.
However, some more intensive home-visiting interventions have been developed
which are targeted at those children identifed as being at greatest risk of being
maltreated.172
Intensive programmes are very different in nature from those provided routinely
as part of a universal service. They vary both in terms of their nature and their
intensity. Some meta-analyses of evaluations of home-visiting programmes have
concluded that early childhood home-visiting schemes are effective in improving
a range of outcomes for children;173 however, they are not uniformly effective in
reducing child physical abuse, neglect and outcomes such as injuries.174 Moreover,
there are important differences both in the models of service delivery, content
and stafng, and in the design and methods, including outcome measures, used
in evaluations.
Nevertheless, one targeted home-visiting programme, the Nurse Family
Partnership (the Family Nurse Partnership (FNP) in the UK), has been the subject
of rigorous evaluations (including pilots in the UK) and shown signifcant benefts,
including reducing physical abuse.
The Nurse Family Partnership is a home-visiting programme provided by
nurses to low-income, frst-time mothers, commencing at the prenatal stage and
continuing during pregnancy. The aim is to improve pregnancy outcomes through
better health-related behaviours and to improve parenting both in the short and
long term by facilitating the development of better skills both in the care of the
child, planning and economic self-sufciency. The programme employs a model
based on theories of human ecology, self-efcacy and human attachment. Nurses
develop trusting relationships with mothers and other family members to review
their childhood experience of being parented, to help them decide how they
themselves want to parent, and to promote sensitive, empathetic care of their
children.
The Nurse Family Partnership was frst developed in the US, where it has
been shown to have lasting and wide-ranging impacts, including a reduction
in children’s injuries and in adolescent anti-social behaviour.175,176,177 Rigorous
evaluations have also shown that the programme reduces physical abuse and
neglect, as measured by ofcial child protection reports, and associated adverse
outcomes such as injuries to the children of frst-time, disadvantaged mothers.
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 69
A 15-year follow-up has found child abuse and neglect to have been identifed
signifcantly less often over this extended period in home-visited families, except
where there were moderate to high levels of reported intimate partner violence.178
Before considering whether such a programme should be implemented in the
UK, it is important to discover whether the results can be replicated. The model
is therefore being tested to see whether it can be delivered in a UK context in
a way that fts with NHS universal services. This is considered to be one of the
most important developments for vulnerable families.179 A formative evaluation of
Family Nurse Partnerships has now been undertaken in ten sites across England
with promising indications, and the programme is now being tested in 55 sites.
A randomized controlled trial is currently being carried out in 20 sites in the UK
and is due to report in 2013. The aims of this trial will be to test the effectiveness
of Family Nurse Partnerships in England compared with existing universal
services and consider costs, savings and any variations in impact between sites
and subpopulations.180 Further evaluations are also being undertaken in the
Netherlands181 and Canada.182
As many as two thirds of the babies in the Signifcant Harm of Infants Study
were identifed as suffering, or likely to suffer, signifcant harm before they were
born, and cases were frequently closed prematurely and later reopened. FNP is
delivered from pregnancy until the child is two years old; had it been available,
these infants and their parents would have benefted greatly from this type of
intensive, long-term intervention.
Parent-training programmes
The Triple P-Positive Parenting Programme was described earlier. This multilevel programme has modules of increasing intensity to be applied both as a
population-based approach and also on a targeted basis to families where there is
an increased likelihood of maltreatment. The frst three levels, designed to prevent
risk of maltreatment or other forms of harm, were described above. Further, more
intensive, levels are available to targeted families where there is a risk of their
children being maltreated or where maltreatment has been identifed. We shall
describe the more intensive programmes in Chapter 5.
The Webster-Stratton Incredible years programme has also been shown to be
effective in reducing problems associated with maltreatment. This is a series of
three interlocking training programmes for parents, children and teachers. The
parenting programme spans the age range of 0–12 years. It is based on cognitive
social learning theory. The training is based on principles of video modelling,
observation and experimental learning. Aims of the parenting programmes include
improving parent–child interactions, building positive parent–child relationships
and attachment, improving parental functioning, promoting less harsh and more
nurturing parenting and increasing parental social support and problem-solving.
The programme is delivered by group leaders drawn from professionals with
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qualifcations in psychology, psychiatry, social work or counselling and knowledge
of child development. The programmes have been recommended by Sure Start,
particularly for children under fve years, and there is training available for group
leaders in the UK. The Incredible years has been extensively and rigorously
evaluated and found to reduce harsh parenting, increase positive discipline and
nurturing parenting, reduce conduct problems and improve children’s social
competence. Programmes have been widely implemented in the UK in both
parenting and schools-based forms.183,184
Most parenting programmes are directed towards families with young children.
The Recognition of Adolescent Neglect Review found little material of direct relevance
to neglected adolescents; however, it did identify a number of interventions
with troubled adolescents that might be relevant to this group.185 For example,
some parenting programmes are designed to promote more vigilant approaches
to adolescent monitoring in order to protect troubled young people from selfharming behaviours.
The Informed Parents and Children Together (ImPACT) programme is
designed to promote increased parental monitoring as a means of reducing a
range of risky behaviours, including reducing substance misuse. It involves an
intervention with the parents to promote greater awareness and monitoring. A
rigorous evaluation of the ImPACT intervention utilized a randomized controlled
trial design with a sample of 817 African-American young people who had
already participated in a school-based risk reduction programme, and their
parents and carers.186 The intervention group and their parents received a single
session ImPACT intervention (a videotape and discussion), while the control
group received only a booster of the school-based programme with no parenting
element. The results indicated a reduced risk in 6 out of 16 behaviours for the
ImPACT intervention group. The reduction in risky behaviours included: days
suspended from school; substance abuse behaviour; and sexual risk behaviour,
as measured by completion of a self-report questionnaire at baseline and at 24
months follow-up. The evidence suggests that a parental monitoring intervention
can signifcantly broaden and sustain protection beyond that conferred by an
adolescent risk reduction programme.
Dangerous driving is another highly risky form of behaviour amongst
adolescents with time on their hands. A further initiative, the Checkpoints
Programme, encourages parents to play an active role in discussing driving risks
with older teenagers. Again, results are promising and show a positive impact on
trafc violations although not on driving accidents.187
Conclusion
A wide variety of universal and targeted approaches are available at both primary
and secondary level to prevent the occurrence of abuse and neglect. Universal
approaches include possible legislative changes and media campaigns, as well
Universal and Targeted Services to Prevent the Occurrence of Maltreatment | 71
as specifc programmes that can be introduced on a population basis. Targeted
approaches can address whole localities where indicators of poverty and deprivation
suggest that there may be a greater likelihood of maltreatment, as well as families
where children are at greater risk of suffering signifcant harm. Most of these
programmes originate from other countries (most frequently the US) and there
are questions as to how easily they can be transplanted into the UK. However,
the most successful are now being trialled in this country and, if effective, may
offer valuable approaches to the prevention of abuse and neglect. The fndings
from the many studies identifed in this chapter reinforce the message that early
interventions, accompanied by better integration of services, are necessary to
reduce the probability of maltreatment at a later stage.
Key messages for all who work together
to safeguard children
• Programmes that prevent the occurrence of abuse are likely to be more
effective than those that address its consequences.
• Well-designed interventions both at primary level (aimed at whole
populations) and at secondary level (targeted on at-risk populations) can
be effective.
• A population-based approach to prevention is non-stigmatizing, more
likely to reach families early and prevent escalation of abuse, and more
likely to reach those children whose maltreatment tends to pass unnoticed.
• Effective approaches include legislative changes, mass media public
education programmes and universally accessible parenting programmes.
Examples include the introduction of the Healthy Child Programme and
Sure Start children’s centres.
• By shifting the normative behaviour of a whole population, universal
approaches may influence extreme behaviour patterns to move in the
same, positive direction.
• The introduction of legislation banning physical punishment in Sweden
may have had this type of impact, in that it was followed by a decline
in public support for physical punishment, a noted reduction in extreme
forms of parenting behaviours, and a 15-year cessation of child deaths
from physical abuse.
• There is a strong case for developing and testing public education
programmes aimed at raising normative standards of parental monitoring
and supervision of adolescents outside of school to address neglect.
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Key messages for policymakers, strategic managers and
commissioners of services in health, education and
children’s social care
• The Triple P-Positive Parenting Programme has been shown to be effective
in the US in reducing the number of identifed child maltreatment injuries
as well as the number of substantiated reports of maltreatment and the
number of children placed away from home.
• The most effective targeted programmes to prevent maltreatment and
neglect are home-visiting schemes and multi-component schemes. Homevisiting schemes vary widely, both in terms of the nature and intensity of
service; effective targeted approaches need to be based on tested versions
with good models of practice.
• The Family Nurse Partnership now being trialled in the UK is a homevisiting programme offered by specially trained nurses. It has been
positively evaluated in the US. Early results from the UK evaluation are
promising.
• The Webster-Stratton Incredible years programme has been shown to be
effective in the US. It has been implemented in the UK in both a parenting
and schools-based format to tackle issues such as harsh parenting, child
conduct problems and early-onset anti-social behaviour.
Key messages for operational managers
and practitioners in health, education and
children’s social care
• The best way to target services may be for primary care professionals to
identify need by routinely assessing parents.
• The Common Assessment Framework has been shown to consolidate
inter-agency and inter-professional working, and to be acceptable
to service users and practitioners, but its possible contribution to the
prevention of maltreatment has not been evaluated.
• The Alarm Distress Baby Scale and the Crittenden CARE Index can be
used to assess parent–baby and parent–toddler interaction respectively.
For older children the Parent–Child Coding System II and Emotional
Availability Scales are recommended.
• Programmes such as ImPACT, which involve parents as well as adolescents
in initiatives to reduce risk-taking behaviours, are more effective than
those which only engage the young people.
4
Social Work Interventions
to Keep Children Safe
• This chapter draws largely on the evidence from the Neglected Children
Reunifcation Study,188 the Signifcant Harm of Infants Study189 and the Home
or Care? Study.190
• This chapter has important messages for all those who have responsibility
for safeguarding and promoting the welfare of children.
• It also has specifc messages for the following professional groups as
indicated:
ô policymakers (all sections, with reference to social work training,
ensuring children are safeguarded, benefts of local authority care or
accommodation)
ô Local Safeguarding Children Boards (all sections)
ô strategic managers and commissioners of services in children’s social
care (sections on services and outcomes of care)
ô practitioners and operational managers in children’s social care (all
sections)
ô judges, magistrates and local authority solicitors (sections on
assessments, plans, court involvement).
Introduction
The previous chapter focused on universal services, such as education and health
care, available to all families to improve the wellbeing of children, and targeted
services such as Sure Start children’s centres, available to all, but providing
additional support to more vulnerable families. However, some families will need
more intensive support if their children are to be safeguarded from harm. This
will include interventions from children’s social care such as the provision of
family support, social work casework and, for some children, placements away
from home, as well as a range of support from practitioners in partner agencies
including alcohol and substance misuse teams, psychologists, psychiatrists, health
73
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visitors and professionals in education. This chapter focuses on the more general
interventions from social workers and their colleagues, while the following chapter
explores the more specifc interventions that are often required to complement
them.
Consequences of child maltreatment
The Neglected Children Reunifcation, the Home or Care? and the Signifcant Harm of
Infants Studies all explored primary empirical data from social work case fles and
interviews with practitioners, parents and children that demonstrated the extent
of adversity facing some families and the consequences for their children. They
provide further evidence of the close relationship between child maltreatment
and parental problems such as mental ill health, substance and alcohol problems
and domestic violence, particularly when these occur in combination.191,192 Both
the Signifcant Harm of Infants and the Home or Care? Studies also found relationships
between child maltreatment and parents’ criminal convictions for violent offences,
often committed under the influence of alcohol. They both confrm that adults
who get involved in fghts or muggings are more likely to subject their children
both to physical abuse and to the emotional abuse of witnessing intimate partner
violence – evidence that corroborates the fndings from all three Analyses of Serious
Case Reviews 2003–9, and reinforces the point that the police need to be aware of
the link between domestic violence and children suffering harm.
Chapters 1 and 2 have discussed how child abuse and neglect impact on
children’s development and life chances; they have also shown how difcult it
is for professionals to identify that a child is being neglected or emotionally
abused and to take appropriate action. Other research that demonstrates that the
longer children experience maltreatment, the greater the risk to their long-term
wellbeing and the more entrenched are the adverse consequences, is confrmed by
all three of the empirical studies in the Research Initiative.
The Home or Care?, the Neglected Children Reunifcation and the Signifcant Harm
of Infants Studies all found extensive evidence of the consequences of abuse in
children’s delayed development, poor speech and language, poor school
performance, decayed teeth and untreated medical conditions, as well as in
numerous emotional and behavioural problems, particularly violence and
aggression.
Both the Home or Care? and the Neglected Children Reunifcation Studies found
that many maltreated and neglected children are identifed at a very early age.
Over half (56%) of the children in the latter study had been referred to children’s
social care before they were two, a third before they were born. The children in
the Signifcant Harm of Infants Study had been selected on the basis of their having
been identifed as suffering, or being likely to suffer, signifcant harm before their
Social Work Interventions to Keep Children Safe | 75
frst birthdays; nevertheless, it is noteworthy that 65 per cent of this sample had
also been identifed before birth.
It is therefore clear that swift and decisive interventions are of paramount
importance where children are thought to be at high risk of being maltreated or
where there is evidence that they are already being abused or neglected. So the
frst questions we need to ask are, how successful are such interventions, and how
could they be improved?
What do the studies tell us about social care interventions? What obstructs
and what facilitates prompt action when maltreatment has been identifed?
The studies identifed a number of instances where maltreatment, or a serious
likelihood of maltreatment, was identifed early and appropriate action taken.
For instance, a small number of infants, judged by the research team to be at
severe risk of suffering signifcant harm, were swiftly removed from potentially
damaging families and apparently never abused. However, such prompt and
decisive action is relatively rare. There are few cases where there is unequivocal
evidence right from the start to indicate that children either can or cannot be
adequately safeguarded at home; moreover, a number of other factors also tend to
get in the way of swift intervention when children are being maltreated.
First, there are a number of gaps in social workers’ knowledge and
understanding that mean that evidence of maltreatment, and particularly neglect,
can be overlooked or given too little attention. The implications of exposure to
alcohol or substance abuse in utero are particularly poorly recognized, and core
assessments often give only limited attention to the developmental needs of very
young children. Interviews with social workers reveal that child development
has often been only a small part of qualifying training – and one that is quickly
forgotten. Theories of attachment are sometimes misunderstood – for instance,
secure attachment to a birth parent is sometimes used as an argument in favour of
separation and adoption on the grounds that this can easily be transferred. Child
development, attachment and the impact of maltreatment and neglect should
obviously be core elements of training for all those who work with children
in need and their families. Moreover, new evidence is constantly emerging in
this feld – these issues should also form an essential component of continuing
professional development.193
Second, some practitioners do not appreciate the importance of reading case
fles and gaining a historical understanding of a child’s previous experience.
Simple chronologies showing, for instance, accumulating evidence of abuse
and neglect and mounting concerns expressed by referrals from neighbours and
other professionals are rarely compiled or used as a basis for action. Even where
76 | Safeguarding Children Across Services
accumulating evidence of chronic neglect is available and accessible, it is rarely
acted upon without a trigger incident, such as the discovery that a small child
is being locked up alone in the house. One problem is that local authority legal
departments are reluctant to act in neglect cases without such an incident. This
is a serious issue. For example, in the Peter Connelly case the legal team did not
feel able to make a decision as to whether the threshold had been met on the
basis of the (incomplete) evidence presented to them.194 Greater understanding
of the consequences of not acting might be of value both to local authority legal
departments and the courts.
The new empirical evidence also confrms fndings from earlier research
showing that practitioners can become desensitized to evidence of neglect
and uncritically accepting of poor parenting standards.195,196 There are some
disturbing examples of children who, as a result, are left unprotected in dangerous
and damaging situations. For instance, the Signifcant Harm of Infants Study found
a baby whose parents so persistently forgot to feed her that she ceased to cry, a
two-year-old left to forage in the waste bin for his food and a three-year-old who
could demonstrate how heroin is prepared. All of these children remained with
their birth parents for many months without being adequately safeguarded.
Neglect is not the only type of maltreatment to which practitioners can
become desensitized: the Neglected Children Reunifcation Study identifed ‘a number
of children [who] suffered continuing physical abuse, which social workers had
come to view as “acceptable” in some way, and even on occasions sexual abuse’;197
this study also has an example of a child who passed the social worker a note
saying ‘help me’ – which still did not elicit an adequate response.198
Third, the studies also confrm evidence found in earlier research199 that
children’s families can face such multi-faceted problems that practitioners can
fnd themselves overwhelmed in the face of so much adversity, to the point where
they are unable to take decisive action. The Analysis of Serious Case Reviews 2003–5
found that:
One common way of dealing with the overwhelming information and the
feelings of helplessness generated in workers by the families, was to put
aside knowledge of the past and focus on the present in what we have called
the ‘start again syndrome’. In this respect a new pregnancy or a new baby
would be seen to present a fresh start. In one case the child’s mother had
already experienced the removal of three children because of neglect, but
her history was not fully used in considering her and her partner’s capacity
to care for this child. Instead, agencies were more focused on supporting the
mother and the family to ‘start again’.200
There is ample evidence of the ‘start again syndrome’ in the three empirical
studies. Moreover, interviews with practitioners undertaken in the Signifcant
Harm of Infants Study found that this tendency to ‘start again’ could sometimes
Social Work Interventions to Keep Children Safe | 77
be underpinned by ethical concerns about not allowing their judgement to be
prejudiced by parents’ previous abusive behaviour. For instance, it was policy in
one team to reallocate the case to a different social worker if a mother became
pregnant after her older children had been placed for adoption. The new social
worker was deliberately kept in ignorance of the past.
All three studies of social work interventions found extensive evidence of
thresholds for access to children’s social care being too high and of professionals
giving parents ‘too many chances’ to demonstrate that they could look after a
child, often in the face of substantial evidence to the contrary and regardless of the
child’s timescales. The Neglected Children Reunifcation Study estimated that this had
happened in nearly two ffths (38%) of cases. This tendency was not only evident
in social workers’ decisions, but also in those made by psychologists, psychiatrists,
magistrates and judges. Decisions were informed by concepts of parental rights
and views about empowerment, so that the child’s welfare was not always the
paramount consideration. In a climate in which all decisions were made with the
expectation that children would remain at home, it was exceptionally difcult for
professionals to identify the few who could not safely do so. Some practitioners
appeared to consider that their role was to safeguard the family rather than the
individual children within it.
Both the Analyses of Serious Case Reviews demonstrate the serious consequences
of getting the threshold wrong for children living in families with multiple
problems. Some of the serious case reviews were of children who had been living
in overwhelmed families and were known to be neglected but whose circumstances
were not judged to reach the threshold for services to be provided by children’s
social care. Similarly, the Signifcant Harm of Infants Study raises questions about
how bad parenting has to become to be identifed as unacceptable. Judging by the
continued presence of recognized risk factors, just under half of the children in
this study who remained with birth parents were not considered to be safeguarded
at age three. The main issue was neglect, often as a result of parental alcohol or
substance misuse. Although none of the sample children died in the course of
the study, some of the cases might well have had a fatal outcome. However,
about half of the children for whom evidence was available were displaying
considerable developmental and behavioural problems by the time they were
three. These included delayed speech and language development, very aggressive
behaviour towards other children or pets, and destruction of property. One child
required one-to-one care at nursery, another had attacked the carer’s grandchild
and a third was considered so aggressive that she was not taken to the park for
fear that she would hurt another child. The children’s difculties were already
jeopardizing some placements, and were likely to cause major problems once they
started school. A further follow-up of this sample is currently exploring these
issues.201 There was evidence that almost all of these children had experienced
maltreatment in their frst few months of life, many of them in utero, because some
78 | Safeguarding Children Across Services
parents misused substances or alcohol throughout the pregnancy as well as after
they were born.
The fndings indicate that practitioners need much clearer guidance and
training as to what constitutes acceptable and unacceptable levels of parenting,
and that this should also be spelled out to parents – a point made by the parents
themselves in this study as well as by the Peter Connelly serious case review.202
What do the studies tell us about supporting maltreated children at home?
Are assessments adequate? Are plans viable? Do parents and children receive
appropriate help, for long enough to meet their needs? Is such support
effective?
Action following referral
Where children are suffering, or likely to suffer, signifcant harm, effective social
care interventions require careful assessment and planning, with clear articulation
of changes that need to be made, and specifc goals and timescales explicitly
agreed between families and professionals with safeguarding responsibilities.
Support has to include the provision of a package of services tailored to meet
the needs of children and their families. The complex issues facing such families
indicate that these services must address the multi-faceted needs of both adults
and children; careful co-ordination between several agencies will therefore be
necessary. The issues raised by such inter-agency working are discussed further in
Chapter 6. In this chapter we consider what the studies tell us about assessment,
planning and overall case management within children’s social care.
Assessments
The majority of assessments undertaken immediately following referral are
completed by social workers. Specialist assessments, undertaken by a range of
experts, may later be commissioned by local authority children’s social care
services, in preparation for legal proceedings, or by order of the courts.
There is some evidence that social work assessments sometimes fail to focus
sufciently on the core question – whether the child can safely remain in their
current circumstances. They also reveal some of the gaps in knowledge and
understanding, particularly around child development, attachment, and the signs
and consequences of maltreatment, discussed in this and earlier chapters. In some
authorities social work assessments are left undone, and there is little evidence of
any assessments being undertaken until a case comes to court.
However, most of the evidence from the studies concerns the use of specialist
assessments, and here the fndings are mixed. On the one hand, there appear
to be very few expert assessments of specifc issues such as the extent to which
Social Work Interventions to Keep Children Safe | 79
children will be likely to suffer signifcant harm if they remain with/return to
their families, of the likelihood of parents overcoming substance misuse within
a child’s timeframe, or of the impact of neglect or maltreatment on children’s
welfare.
On the other hand, large numbers of expert assessments of more general issues
such as the parent’s capacity to look after a child are undertaken by psychologists,
psychiatrists and specialist practitioners as part of the decision-making process.
There are a number of questions about the appropriate use of these assessments.
The Signifcant Harm of Infants Study found that they are frequently repeated within
very short timeframes, giving parents little opportunity to overcome previously
identifed problems. Many appear to have been commissioned in order to provide
evidence that parents’ rights are being duly acknowledged rather than to identify
whether adequate changes in parental behaviour have taken place. Both courts
and local authorities consider that too many specialist assessments are being
undertaken; there are long waiting lists for them, and there is substantial evidence
that they delay decision-making to the detriment of children’s welfare.
The majority of recommendations from expert parenting assessments are
in favour of parents retaining care of their children; these are virtually always
followed. All three studies found, however, that these recommendations can often
be unreliable. The Signifcant Harm of Infants Study found that over half of them
proved to be over-optimistic in that children, who, on the advice of experts,
remained at home, later had to be removed following further maltreatment. While
expert assessments are obviously valuable in some circumstances, careful thought
needs to go into how they could be better timed, and made more reliable.
Plans
Planning matters: where there is evidence of careful planning, outcomes for
children tend to be better. Conversely, where planning is weak, there is more
evidence of drift, so that children are left too long in abusive circumstances
without appropriate services to safeguard them; there is also more evidence of
children missing their chances of achieving permanence, of parents removing
children from placements at will, and of reunifcation occurring by default,
without clear arrangements for how children will be safeguarded in the future.
Planning can deteriorate – or come to a halt – when cases remain unallocated or
when practitioners become overwhelmed with the complexity of problems facing
families.
The quality of assessment and planning tends to vary signifcantly between
local authorities, and indeed between different teams within them. The Neglected
Children Reunifcation Study found that care planning had been inadequate for over
a third of all the children (36%) in its sample, and 81 per cent of those from one
authority. In ten cases there was very little planning of any sort. Wide variations
between authorities were also found in the Home or Care? Study. They suggest that
80 | Safeguarding Children Across Services
authorities have much to learn from one another, and that some of these issues
could be addressed by stronger management and supervision of front-line staff.
Where there is a likelihood of signifcant harm, the primary issue to explore is
how far children can be adequately safeguarded in different settings. Although
both the Signifcant Harm of Infants and the Home or Care? Studies found that
decisions were often informed by evidence that parental problems had improved
and that risks to the child’s safety were acceptable, there was also ample evidence
of children being left or returned to dangerous situations.
The Signifcant Harm of Infants Study found that social work interventions tend
towards the least intrusive option. Thus if the child protection conference considers
that a child can be adequately safeguarded through the provision of services
under Section 17a of the Children Act 1989, then a child protection plan is not
considered necessary. If a child can be accommodated successfully under Section
20 of the Children Act 1989, then a care order (and indeed court proceedings)
may be avoided. Although such decisions follow the spirit of the legislation, and
are consonant with the aims of empowering vulnerable parents and promoting
family cohesion, less intrusive measures do not always ensure that children are
adequately safeguarded. There are, for instance, signifcantly more social work
services provided for children who are the subjects of child protection plans203
than for those who are not. Children who have had some court involvement also
tend to receive a more robust overall service than those who have not.
Court involvement
Assessments, planning and case management are all usually more evident for
children who are the subject of care orders. Both the Neglected Children Reunifcation
and the Home or Care? Studies found that less rigorous work is undertaken with
children who are accommodated. Where children return from care through
placement with parents, every dimension of assessment and planning is stronger
than where they are discharged from accommodation. Abrupt and unplanned
reunifcations occurring as a result of a placement disruption, the lack of suitable
alternatives or running away are all more common with children who are
accommodated than with those who are the subject of care orders. The Home or
Care? Study found that, six months after the decision has been made, reunifcation
is judged to have been appropriate for less than half (47%) of the children who
return home after being looked after by the local authority. However, children
who are the subject of care orders and return home under placement with parents
regulations are more likely to re-enter care than those who return home from
being accommodated. This may be because care orders make it possible to
remove children quickly from unsatisfactory placements; they therefore give local
authorities sufcient security to attempt reunifcation where family circumstances
are more difcult and the prospects for a successful outcome less likely. Children
and young people who are the subject of care orders may also be more likely to
Social Work Interventions to Keep Children Safe | 81
re-enter care because they are under greater surveillance and there is therefore
a greater chance that maltreatment will be detected. Accommodated children in
the Neglected Children Reunifcation Study were also older than those placed on care
orders, another factor that may have had an impact on the extent to which they
were monitored following return.
However, although children may be better safeguarded when the courts have
been involved, their directions are not always carried out. The Neglected Children
Reunifcation Study found that 62 per cent of care plans made by the courts are
either not successful or not fully carried out. Moreover, those provisions that are
implemented are not always sufciently robust. Again in line with the tendency
to seek the least intrusive intervention, wherever it is thought that a child can be
adequately safeguarded through a supervision order, care orders are not made.
Where care orders are made, there is also a tendency to place children with their
parents at the earliest opportunity; indeed many of these children never leave
home. However, over three ffths (62%) of supervision orders fail as the situation
at home breaks down, as is also the case with 87 per cent of children who
are placed with their own parents. It would appear advisable for more robust
procedures to be developed whereby the courts routinely receive feedback on the
outcomes of their decisions.
Services
The sheer complexity of problems facing families where children are being, or
likely to be, maltreated makes it clear that they will not be adequately safeguarded
at home without intensive, well-coordinated support services. However, such
services are often unavailable. The Neglected Children Reunifcation Study found
that only 38 per cent of substance-misusing parents and as few as 16 per cent
of those who abuse alcohol receive support. Children and young people also
receive insufcient support: after they have returned home from care, only half
of those who need it have support with substance misuse, a quarter have help
with independent living skills or mental health problems, and only 8 per cent of
those who need it receive help with alcohol misuse. The scarcity of support for
alcohol-abusing adults and children is rarely acknowledged. There is also too
little help with critical issues such as parenting skills, parent–child relationships
and children’s behaviour problems. All these adversities make maltreatment more
likely – if children are to be adequately safeguarded in their homes, then much
more needs to be done to ensure that effective services are readily available.
Services also need to be provided at sufcient intensity and for a long enough
period. Most of the specifc validated interventions currently provided are on a
short-term basis, and end after six months. Social work support is also often of
relatively short duration – half the child protection plans for the babies in the
Signifcant Harm of Infants Study were for 32 weeks or less, and almost all for less
than a year.
82 | Safeguarding Children Across Services
There are diverse reasons for the short duration of service provision. Some
services may be most effective in the frst few months and then have increasingly
diminishing impact. The cost of provision is, and will increasingly be, a signifcant
consideration. There are also concerns about parents becoming too dependent
on services and evading their responsibilities towards their children. However,
withdrawing services in order to reduce dependency may well be at the expense
of children’s safety and welfare.
Even where parents apparently succeed in overcoming their difculties
sufciently to safeguard a child, there is a strong case to be made for continued
light-touch monitoring to ensure that their progress is maintained. Those parents
in the Signifcant Harm of Infants Study who had overcome substantial adversities
and were successfully parenting a child after others had been placed for adoption
were surprised that their cases were closed after just a few months. Some of them
asked for child protection plans to be extended in order to provide them with the
continuing support they felt they needed. Expectations that they would contact
social workers if they later ran into difculties were not fulflled because none of
them were prepared to run the risk of being separated from the new baby. Health
visitors appear to be seen as able to offer help with less threatening connotations;
their role could be expanded to offer continuing support in such circumstances. At
present, considerable thought is given to how the referral process, from universal
and targeted to specialist services, might be improved, but too little attention is
paid to processes by which children and families might be referred back to less
intensive services when social work cases are closed.
A major difculty is that many parents who maltreat their children have deepseated and entrenched problems that they are unable to overcome within a child’s
timeframe. These parents may not be able to safeguard their children adequately
without intensive long-term support, sometimes until the children are sufciently
independent to take care of themselves. If policy and practice aims, quite rightly,
to ensure that children are adequately safeguarded within their own families, then
the need for long-term dependency on services has to be acknowledged. Swift
withdrawal of services, and premature case closure, found in all three empirical
studies, is of concern.
There is also disturbing evidence of diminishing levels of social work services
as children grow older and their problems become more entrenched. The Neglected
Children Reunifcation Study found that case management is more proactive with
younger children, and tends to drop off as they grow older and there appears less
chance of them achieving permanence. The focus of intervention tends gradually
to shift from children’s experience of maltreatment to their difcult behaviour,
which is likely to become more challenging as they remain unprotected. This
study found a key turning point when children are as young as six. Those over
that age who return home unsuccessfully are less likely to settle, and have much
less chance of achieving a permanent placement in care or accommodation. This
Social Work Interventions to Keep Children Safe | 83
important fnding not only demonstrates how necessary it is to act swiftly to
ensure that children are properly safeguarded in stable homes as early in their
lives as possible. It also indicates the need for robust back-up procedures, such
as regular joint visits with senior practitioners, and routine case audits by senior
managers, to ensure that case management remains proactive and focused on the
child’s needs as they grow older.
The Recognition of Adolescent Neglect Review and the two Analyses of Serious Case
Reviews all identify how the process of disengagement continues, so that young
people at severe risk of suffering signifcant harm can become rejected by services
as well as by their families as they grow older. In the long run, diminished support,
passive case management and premature case closure are not cost-effective. The
Home or Care? Study provides convincing evidence to show how children who
are not safeguarded develop increasingly severe behavioural and emotional
problems, engage in risk-taking behaviours and become excluded from school
and mainstream society. All of these factors indicate future emotional costs to
children and families as well as fnancial costs to statutory services.204,205 Moreover,
if it later becomes evident that these young people need to be placed away from
home, their care episodes may be shorter, but they will be more unstable, and will
cost more than earlier intervention (including placement away from home) would
have done.206
Including parents
Written agreements
Although intensive, long-term packages of services may be necessary, parents
should not be supported indefnitely, with few incentives to overcome their
difculties and eventually safeguard their children independently. All the studies
identify a need for transparent and time-limited plans, to be agreed between
parents and children’s services, with clearly articulated goals and well-understood
consequences if these are not achieved. At present such plans exist in the form of
written agreements made between local authorities and parents. However, when,
as often happens, parents break the terms of these agreements, there are frequently
no consequences and they are given yet another chance to show that they can
safeguard the child. This is both damaging to children and also confusing to
parents, who may become resentful at a later date when action is fnally taken
to enforce agreements that have previously been ignored with impunity. There
is scope to develop written agreements further into more formal contracts which
both parties expect to see enforced.
Partnership with parents and its limits
Working in partnership with parents is one of the principles of the Children
Act 1989, and is seen as the hallmark of successful parenting support. However,
84 | Safeguarding Children Across Services
repeated failures to honour the terms of written agreements in high-risk families
may indicate that a more assertive approach to case management is required. The
evidence from serious case reviews and from the three studies of social work
interventions demonstrates that there may be some families and situations in
which parents cannot be treated as active partners if their children are to be
adequately safeguarded. This is an unwelcome fnding, but it should be noted that
the Neglected Children Reunifcation Study found that as many as two ffths of parents
may actively resist or attempt to sabotage interventions from professionals. Where
parents are uncooperative, extra vigilance is necessary to ensure that children are
adequately safeguarded.207
Parents’ views
Interviews with parents show that they appreciate social workers who not only
have the ability to listen, but are also ‘straight-talking’ and honest about their
problems and the threat that their children may be removed. Practitioners who
fnd it difcult to break bad news or who encourage parents to be over-optimistic
about their progress are not so highly valued:
‘The frst [social worker] didn’t like breaking bad news, and I said he shouldn’t
really be doing the job. yeah, he didn’t like saying that she [partner] wasn’t
going to get [child’s older sibling] back. He said she [partner] would have
[child’s older sibling] back at Christmas, he said, so that’s giving someone
false hope. But the next, like, two [social workers] we had were really on
the ball, they said, “There’s no chance,” and I found that more respectful
than being deceived all the time… I mean, if people aren’t there to break
bad news, they shouldn’t be doing the job… ’Cos that is a tough job, and I
mean decisions have to get made, on the spur of the moment, you can’t just
linger people along and get their hopes up.’ (Birth father)208
Identifying who can be safeguarded at home
The studies identifed a number of factors that make it more, or less, likely that
children will be adequately safeguarded while living with birth parents. virtually
all the parents in the Signifcant Harm of Infants Study were struggling with known
risk factors for maltreatment209 or its recurrence. About a third of them succeeded
in making sufcient changes to provide a nurturing home for an infant. Indicators
identifed by this study should be tested out with a larger database, but they
appear to point to a number of factors that distinguish between those parents
who are likely to overcome adversities sufciently to care for a new baby from
those who are not. Parents who succeed in making sufcient changes appear to
be less likely to have experienced abuse (particularly sexual abuse in childhood);
to have come to terms with the removal from home of older children and to
Social Work Interventions to Keep Children Safe | 85
have developed sufcient insight to acknowledge that their behaviour may have
played a part in such decisions; and to make use of the support that both social
work and more specialist services can provide. Engagement with services is often
regarded as a positive indicator, but the fndings from this study suggest that many
parents will go through the motions of, for instance, attending appointments and
support groups; it is only those who are genuinely motivated to change who will
participate thoroughly in the programmes they are offered. Parents appear to
fnd it easier to overcome external factors such as a relationship with a partner
who abuses them and/or their children than internal factors such as their own
addiction to drugs or alcohol.
Parents who are motivated to change often have a defning moment when
they realize that they will need to take substantial action if they are to meet
the new baby’s needs: for some parents this is the permanent separation from
an older child; for others it is the early death of a close relative from alcohol or
substance misuse; for others it is the realization that they will need to disengage
from an abusive partnership; and some parents become deeply attached to the
baby. Parents who do not make sufcient changes do not appear to experience
such wake-up calls.
A new baby appears to act as a catalyst for radical changes in parental behaviour
patterns; however, if these have not occurred within six months of the birth, then
any minor changes parents appear to have made are unlikely to persist or be
sufcient to meet the needs of the child within an appropriate timeframe.
Returning home from care or accommodation
The studies also identify a number of factors that make it more – or less – likely
that children who return home after a period spent in care or accommodation will
be adequately safeguarded and not require readmission.
Reunifcations are more likely to endure if children return to a different parent
from the one with whom they were living prior to becoming looked after. Children
who return early to the same parent are unlikely to do as well as those who return
after sufcient time has elapsed for the problems that led to the original admission
to have been addressed. For reunifcation to have some chance of success, there
needs to be some evidence that sufcient changes have taken place and that the
child will now be safe. For instance, reunifcation is unlikely to be successful if
there are ongoing concerns about parents’ substance misuse: the Home or Care?
Study found that 81 per cent of children who are reunited with parents who are
still misusing drugs subsequently re-enter care or accommodation.
younger children are more likely to return home successfully than those who
are older and perhaps have more entrenched experience of maltreatment and
instability. Children who return home with other looked after siblings appear
86 | Safeguarding Children Across Services
to fare better than those who return alone or are reunited with siblings who are
already in situ.
Looked after children who have experienced chronic and serious emotional
abuse and neglect do signifcantly worse than others if they return home, and
plans for their reunifcation should be considered with great caution. Reunifcation
for these children should not be undertaken unless there is strong evidence of
sufcient change in parenting capacity and appropriate long-term services are
available. Since one of the major factors that influence successful reunifcation is
the local authority in which the child resides, it would appear that proactive case
management plays a major role in the success or failure of reunifcation.
Readmissions to care or accommodation
The Home or Care? Study found that, when placements with own parents are
counted as reunifcations, the proportion of maltreated children who return home
is almost exactly the same as that of other children who have been looked after.
However, both the reunifcation studies found that about two thirds of maltreated
children who return home from care or accommodation are subsequently readmitted.
Both the Home or Care? and the Neglected Children Reunifcation Studies show that
many children experience repeated attempts at reunifcation. These should be
avoided. Children who move in and out of care or accommodation have the worst
overall outcomes. Not only are repeated attempts at reunifcation damaging to
children’s welfare, they also increase the risk of their losing the chance of fnding
an alternative pathway to permanence. Where parental progress is not sustained
or parents fail to comply with therapeutic programmes, an early assessment of
the impact of return for the child should be made to prevent drift and further
deterioration. Most difculties emerge within the frst few months of reunion.
The courts frequently insist on further trials at home before approving a
permanence plan – an issue that has been identifed as causing increasing instability
and delays for very young children, to the detriment of their welfare.210 Judges
and magistrates need to be aware of the frequency with which attempts at
reunifcation with birth families break down, and the detrimental consequences
for the children concerned.
What do the studies tell us about the looked after children system? Which
children beneft from being separated from their birth families? How do
outcomes compare with those for maltreated children who return home?
Social Work Interventions to Keep Children Safe | 87
Who benefts from being looked after?
Timing
Both child development research and the evidence from practice analysis
demonstrate the importance of taking early action when children are found to be
maltreated. Research on child development indicates that, in the frst six months
of life, having positive interactions appears to be more important than interacting
with specifc people.211,212 More preferential attachment behaviours and stranger
anxiety begin to set in at around seven months. From this age, maltreated children
may start to develop maladaptive attachments.213,214 Also at about this age, looked
after children in temporary placements may start to develop secure attachments to
carers, the loss of which, particularly in the early years, can be sources of enduring
distress. An important recent study of attachment in adopted children found that
those who were adopted before 12 months of age were as securely attached as their
non-adopted peers, whereas those adopted after their frst birthday showed less
attachment security than non-adopted children.215 Therefore if children cannot
live with their birth parents, early separation and speedy progression towards
permanence are likely to be the least damaging courses of action.
The Signifcant Harm of Infants Study also found that all the parents in the sample
who successfully overcame problems which represented signifcant risk factors for
maltreatment, and were able to provide a nurturing home for the index child, did
so before the baby was six months old – before birth if the problem was substance
abuse – an indicator that early action can be fair to parents as well as in the child’s
best interests.
However, this study also found that about one in fve babies identifed as
suffering, or likely to suffer, signifcant harm before their frst birthdays are doubly
jeopardized: both by being left too long in neglectful homes while professionals
wait in vain for parents to overcome their difculties, and then by remaining so
long with interim carers that they experience disrupted attachments when they
are fnally placed for adoption. Frequent references are made to meeting children’s
timescales, but professionals need to be more aware of what these actually are in
terms of children’s stages of development.
Based on the evidence of known risk and protective factors,216 researchers in
the Neglected Children Reunifcation Study considered that over a quarter of children
(28%) were left for too long in abusive homes before they were removed. This
was also true of about half the separated infants in the Signifcant Harm of Infants
Study, while it was also evident that the long-term wellbeing of about 50 per cent
of those who were still living with their birth parents at the age of three had been
compromised by persistent exposure to neglect and emotional maltreatment.
88 | Safeguarding Children Across Services
Outcomes of care and accommodation
The studies in the Research Initiative all focus on children who have been
identifed as suffering, or likely to suffer, signifcant harm or who have become
looked after because they are being abused or neglected by their birth families
or other carers. This is the primary reason for entry to care or accommodation
for about 60 per cent of looked after children in England, although many others
will also have experienced maltreatment. The studies provide incontrovertible
evidence that many of these children beneft from being placed away from home.
Stability
While constant moves from one placement to another are seen as a major problem
for children looked after away from home, the instability experienced by those
who remain with very vulnerable families is less well publicized.217,218 The Home
or Care? Study compared the progress and outcomes of a subset of 68 looked
after children who returned home at some point within the four-year followup period with a matched group of 81 children who did not. Six months after
the key decision, children in the care group were more settled than those who
had returned to their birth families. Although similar proportions had changed
placements, moves for the care group had largely been for positive reasons – for
instance, from short-term to long-term placements, or from strangers to kinship
carers after assessments had been completed. In contrast, moves for children in
the home group had been far less positive, resulting from disrupted arrangements
with relatives and/or returns to care or accommodation. About one in fve of
these children had never settled and had moved continually between relatives
and family friends before fnally returning to care. This pattern continued into
the fnal follow-up, by which time two thirds of the care group (65%) had been
settled for two or more years in their current placement, compared with two ffths
(41%) of those at home. The proportion of children who had found stability at
home is almost identical to that found in the Neglected Children Reunifcation Study
(43%).
Kinship care is, rightly, the placement of choice, but the Signifcant Harm
of Infants Study raises a number of caveats concerning its indiscriminate use.
Although such placements are often benefcial, and may produce better outcomes
than placements with strangers, they are sometimes selected with little regard
for the quality of care provided, the carers’ previous history of poor parenting,
their personal problems or their knowledge of the child. More attention needs
to be given to ensuring that children are only placed with relatives who can
genuinely offer both the benefts of belonging to a wider family network and the
commitment that makes such placements valuable. There are several indications
that relatives and friends may need specialist services to help children overcome
the consequences of maltreatment – and to manage the relationship with birth
Social Work Interventions to Keep Children Safe | 89
parents – but too little of this is forthcoming.219 Several family and friends carers
in the Signifcant Harm of Infants Study were receiving minimal support to cope with
the children’s often serious behavioural problems; by the time these children were
aged three, many of these placements were approaching breakdown.
Wellbeing
Notwithstanding such issues, children who remain looked after tend to do better
on measures of wellbeing than those who return home. The Home or Care? Study
found this to be true even when comparisons were made with those whose
reunions with birth families had stayed stable throughout the follow-up period.
There is no evidence that this fnding can be explained by greater difculties
among children who go home; it suggests that, overall, remaining in care or
accommodation is likely to enhance the welfare of maltreated children.
At the fnal follow-up, those in the Home or Care? Study who remained looked
after were less likely to have misused alcohol or drugs or to have committed
offences than those who returned home; they had signifcantly better mean scores
for health; they were more likely to have close adult ties; and they were considered
more likely to have a range of special skills, interests and hobbies. They were less
likely to be in pupil referral units, in alternative forms of education, without
a school place or to be persistent truants than those who had returned home,
although signifcant differences in school performance were not noted between
the two groups. The fndings are slightly less positive in the Neglected Children
Reunifcation Study, probably because different methodologies and defnitions were
used, although they point in a similar direction.
Neglected children who are returned prematurely to maltreating families fare
worse than those who have experienced other types of maltreatment. Where there
has been strong evidence of past neglect, even after taking account of other factors
that predict future wellbeing, these children do best if they remain looked after.
Amongst those who go home, the stability of the reunion appears to have little
impact on their overall wellbeing. Emotionally abused children who go home also
tend to fare worse than similarly maltreated children who remain looked after.
Local authority care can be rightly castigated for its low aspirations, lack of
stability and insensitivity to some children’s needs, and these are all issues that
need to be addressed.220 Nevertheless, the studies provide robust evidence of
its benefts. The poor outcomes of care and accommodation that have been so
widely publicized221 are largely the product of children’s long-term exposure to
abuse and neglect prior to entry, or following unsuccessful returns home. The
myth that care will have a negative impact on children’s wellbeing has meant
that professionals have tended to be reluctant to remove children from abusive
situations, to the detriment of their long-term life chances. When children are
looked after, placements need to provide more specialist interventions to help
overcome the consequences of abuse, but their potential to beneft maltreated
90 | Safeguarding Children Across Services
children should be better recognized. All the studies that utilized recent, primary
data found that, in the absence of intensive, effective packages of family support
services, provided on a long-term basis to meet parents’ and children’s needs,
more children should be placed away from home.
Conclusion
The messages from the studies that focus on interventions from children’s social
care point to the need for considerable improvement. They indicate that, for a
number of reasons, too many children are inadequately safeguarded while they
remain in the care of abusive and neglectful birth parents. Neglect and emotional
maltreatment are not sufciently recognized and acted upon in a timely manner.
Where parents succeed in overcoming signifcant difculties to care for a new
baby, services are often withdrawn abruptly, without robust arrangements for
future lower-level help being made. There is insufcient acknowledgement that
other parents, with entrenched problems, may be, at least temporarily, unreachable,
or need long-term, comprehensive and well-coordinated packages of services if
their children are to be adequately safeguarded. Case management tends to be
more active and effective for children who are supervised or placed under court
orders than for those who are not. When compared with those who are reunited
with their birth families, the majority of maltreated children do better in care
or accommodation. These are difcult messages to act on in times of economic
austerity. However, they do indicate that cutting back on early intervention and
Section 17 family support services could increase the levels of maltreatment and
its consequences, especially if this is accompanied by attempts to reduce the
numbers of children looked after away from home.
Key messages for all who work together to safeguard
children
• There is a need for proactive, not passive, practice.
• Greater attention should be given to ensuring that interventions for
maltreated children and their families are informed by evidence-based
assessments of need.
• Decisive and timely interventions are of vital importance. The evidence
of how quickly harm occurs, and how difcult it is to reverse, makes this
an imperative.
• There is a need to rebalance decision-making so it is driven by the
paramount interests of the child, rather than a concern for protecting
parents’ rights, regardless of their capacity to change. Children’s rights
demand this.
Social Work Interventions to Keep Children Safe | 91
• All involved need to be mindful that the purpose of the intervention is
not to safeguard the family but the individual children within it.
• Care can be the best option for some maltreated children and should not
be seen as a last resort. In the long run this may also prove to be the least
costly and most effective option.
• Attention should be given to referring children and families back to
targeted and universal services when children’s social care interventions
are completed.
• Expert knowledge of child development, attachment and the impact of
abuse and neglect is fundamental to the work of all those responsible
for safeguarding children. This should also form part of compulsory
continuing professional development to ensure practitioners are up to
date with new research evidence.
• About two thirds of maltreated children who return home from care
or accommodation are subsequently readmitted; this rises to 81 per
cent in the case of children whose parents are misusing drugs. Rates of
readmission to care or accommodation should be carefully monitored
and disseminated.
• Neglected and emotionally abused children who return home tend to fare
worse both on indicators of wellbeing and of stability than those who
remain looked after. There is incontrovertible evidence that in the absence
of intensive effective packages of family support services, provided on a
long-term basis, and tailored to both their and their parents’ needs, these
children beneft from being placed away from home.
Key messages for policymakers, strategic managers,
commissioners of services and lead members for
children’s services and the judiciary
• Both parents and practitioners need clear guidance on what constitutes
societally acceptable and unacceptable standards of parenting; initiating a
properly moderated public and professional conversation about this topic
should be a priority.
• There should be some formal agreement between chief executives of local
authorities, directors of children’s services and heads of legal services
departments and the courts concerning appropriate thresholds for taking
action when children are experiencing severe and chronic neglect. This
should lead to protocols for intervention that have been approved by
these senior managers.
92 | Safeguarding Children Across Services
• Sixty-two per cent of care plans made by the courts are either never
implemented or not fully carried out; 62 per cent of supervision orders
fail as the situation at home deteriorates; 87 per cent of placements with
own parents break down. Some discussion needs to be held by senior
managers at a strategic level concerning ways in which children can be
better protected through court involvement.
Key messages for operational managers and
practitioners in children’s social care
• Practitioners must fnd out about and analyse historical information about
the child and family including evidence about past family functioning,
particularly in cases of neglect.
• Attention should be given to ensuring proactive case management for
older as well as younger children suffering, or likely to suffer, signifcant
harm. At present the evidence suggests that this may start to diminish for
children as young as six.
• Repeated attempts at reunifcation with birth parents should be avoided.
These are damaging to children’s wellbeing and jeopardize their chances
of achieving permanence through alternative routes.
• Written agreements between parents and local authorities need to be
developed and made into more robust arrangements, with explicit plans
and timescales, and clearly spelled-out consequences for non-compliance.
• It is unrealistic to expect parents who have previously experienced the
removal of a child to re-refer themselves to children’s social care if they
run into difculties after a case has been closed.
• Practitioners need to be aware of children’s timeframes: if children need
to be permanently separated then it is important to do this as quickly as
possible. Those who are permanently placed by their frst birthday are
more likely to become securely attached to adoptive parents than those
who are older when placed.
• Parents who have not succeeded in overcoming complex problems
involving substance and alcohol misuse, mental ill health and intimate
partner violence by the time a baby is six months old are unlikely to do
so within an appropriate timeframe for that child, although they may
later make sufcient progress to parent subsequent children.
Social Work Interventions to Keep Children Safe | 93
Key messages for health professionals
• Health professionals need to be aware of delay and drift and their
consequences for children.
• GP evidence is well regarded and might be of critical importance if
brought before the courts.
Key messages for all those involved in the family justice
system
• The impact of delayed decisions on children’s subsequent life chances
should be widely disseminated, and timescales be formally discussed.
• Consideration should be given to the use of expert assessments of
parenting capacity. Assessments should be required to cover issues such
as how parenting problems are impacting on children’s health and
development. validated instruments such as the Crittenden CARE Index
should be used to assess parent–infant interaction.
• Consideration should be given to developing guidance for repeated
assessments: if there has been insufcient time for change to occur, then
further assessments introduce unnecessary delays, to the detriment of
children’s welfare.
• Feedback arrangements should be made to ensure that courts are aware of
the outcomes of their decisions. This should include the frequency with
which supervision orders or returns home to birth parents break down
and the impact of delays on children’s welfare.
5
Specifc Interventions for
Children and Families with
Additional or Complex Needs
• This chapter draws largely on the evidence from the Physical Abuse
Intervention Review222 and the Emotional Abuse Intervention Review.223
• This chapter has important messages for all those who have responsibility
for safeguarding and promoting the welfare of children.
• It also has specifc messages for the following professional groups:
ô policymakers (all sections)
ô Local Safeguarding Children Boards (all sections)
ô strategic managers and commissioners of services in health and
children’s social care (all sections)
ô practitioners and operational managers in health and children’s
social care (this chapter could be used as a resource when trying
to assess whether those specifc interventions that are available are
likely to be appropriate or successful)
ô practitioners and operational managers in education (the section
on child-focused interventions includes details of two school/
preschool-based interventions that are aimed at helping children
overcome the consequences of physical abuse and neglect).
Introduction
What focused, specifc programmes can be used to complement broader
interventions with children and families to help prevent further maltreatment
and mitigate its effects? What do we know about ‘what works’ and what
should be taken into account when considering the evidence?
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Specifc Interventions for Children and Families with Additional or Complex Needs | 95
In the last chapter we focused on broad interventions to safeguard children
including out-of-home placement and social work casework. This chapter
considers more focused specifc interventions, often designed to complement the
above. These interventions are usually rigorously time limited. They are offered
by professionals such as mental health workers and therapists or by trained social
workers, nurses or health visitors. In this context we use the term ‘intervention’
to refer to specifc therapeutic programmes that involve direct work with parents,
children and families. In many cases these do not stand in isolation, but might be
delivered as part of a planned inter-agency intervention with a child and family.
Most of the following evidence about ‘what works’ comes from two rigorously
conducted systematic reviews within the Research Initiative. The Physical Abuse
Intervention Review and the Emotional Abuse Intervention Review each focus on a
different form of maltreatment and its consequences. Where available, we have
supplemented the evidence with data from complementary sources; for instance,
the results of additional trials published since these studies were undertaken and
other major reviews224 which provide additional information about some of the
examples we have selected.
Chapter 3 introduced our adapted version of a conceptual map that has been
frequently used to illustrate the different stages of intervention. In this chapter we
will continue to use this framework to discuss what the evidence says about ‘what
works’ in terms of intervention programmes designed to be delivered in families
where there is a high risk of abuse or neglect, or after children have been exposed
to it. Specifcally we look at what the studies say about evaluated interventions
designed to:
• prevent the occurrence or recurrence of maltreatment in families where the
likelihood of abuse or neglect is high
• address the consequences of maltreatment (i.e. mitigate impairment).
Although we have categorized the various interventions in this way in order to
help commissioners and practitioners understand and make sense of the wide
variety that is available, in the real world it is not always so easy to make clear-cut
distinctions. For instance, it will often be necessary to try and prevent recurrence
of maltreatment, while at the same time attempting to mitigate the impairment to
a child’s health and development that has already resulted from the harm suffered.
Similarly, although programmes fall into groups according to the main ways
of achieving change (via parent, parent–child relationship, or whole family) as
indicated below, some are not so easily categorized. The focus of interventions
may be both on the parent and on the parent–child relationship or indeed the
whole family in parallel.
This chapter focuses on those specifc interventions which have been shown
to produce the best results for children and families who encounter the types
96 | Safeguarding Children Across Services
of adversity discussed in earlier chapters. Before considering them individually,
there are some key issues that need to be borne in mind.
Issues for commissioners and practitioners to consider in
choosing and utilizing a specifc intervention
Evidence of effectiveness
In choosing a specifc intervention, commissioners and practitioners frst need
to be sure that it is effective in addressing the issues for which it was designed.
Only interventions that have been rigorously evaluated should be selected. The
methodology used in the evaluation determines the weight given to the evidence
of effectiveness according to an established hierarchy, as shown in Table 5.1.
Table 5.1: Hierarchy of levels of evidence225

Specifc Interventions for Children and Families with Additional or Complex Needs | 97
The table ranks the evidence related to fve different types of evaluation. At the
top of this hierarchy (Level A) are randomized controlled trials (RCTs). When
rigorously implemented they produce the strongest evidence. Random allocation
minimizes the potential bias that might occur if participants are selected or selfselected to treatment conditions. Including a randomly allocated control group in
a study also allows the effects of an intervention to be compared with that of no
intervention or ‘treatment as usual’.
Because it is sometimes unethical or impractical to withhold an intervention
in order to obtain a control group, other ways have been developed of measuring
one treatment group against another. One common method is to compare two
active treatment groups (Level B). These evaluations offer information about the
relative effectiveness of two (or more) interventions but do not provide data about
the absolute effects of either. It could be the case that there is little difference
between the two options but we cannot determine whether either is particularly
useful.
In cases where it is not possible to offer an alternative programme (for instance,
where therapists are only trained to provide one service), a single-group study
can be used (Level C), measuring changes over time. These studies can be useful
in gaining information about the suitability and acceptability of an intervention
for a population, but should be considered in the light of the possibility that
any observed changes may be due to factors other than the treatment itself.
Retrospective quantitative studies (Level D) and case studies (Level E) are useful in
indicating factors to be taken into account in later studies, but are not evaluations
in themselves.
All the interventions introduced in this chapter have been shown to be effective
in addressing the issues for which they were designed. We have indicated the
place in this hierarchy for each of those discussed by showing the evidence level
of the evaluation. Those who are considering commissioning services may fnd
this a useful indicator of the strength of the current evidence of effectiveness.
In addition to considering the evidence level of any evaluation, commissioners
will also need to take into account the size of the sample participating and the
drop-out rate (which can be high, indicating that the intervention may have little
capacity to deliver change) as well as the data on outcomes. A sound evaluation
will have applied sensitive outcome measures before and after the intervention
and collected follow-up data to assess sustainability. However, there are also other
considerations to be borne in mind.
Transferability
First, many specifc interventions have been developed and evaluated outside the
UK. Services for children in other countries may be different and the context
in which they are delivered may have few similarities for all sorts of reasons.
Thresholds may also be set at varying levels so that the population who access
98 | Safeguarding Children Across Services
services may have very different needs. Thus we cannot be confdent that services
will produce the same level of beneft in a UK context. Nor can we automatically
assume that those interventions found to be effective in another country will
necessarily work in the same way in the UK. However, as we shall see, there are
grounds for thinking that some interventions are transferable from one country
to another. Some of the behavioural parenting interventions originally developed
in Australia and the US, and discussed later in this chapter, have now been
successfully trialled in the UK, with positive results.
Many specifc interventions have been standardized and documented in such
a way that they can be translated and used elsewhere by other service providers.
These manualized programmes are often available under a licence which usually
requires users to follow the guidance closely to ensure that the integrity of the
intervention is maintained. The process of adhering to the design as set down
in the manual is known as ‘programme fdelity’. Training and supervision are
frequently offered, and are often a requirement. However, there is usually scope
for some adaptation to local circumstances, as few programmes translate from one
context to another without the need for some change and modifcation.
Second, some promising interventions have been developed for ‘troubled’,
but not specifcally for maltreating or maltreated, populations. Again this raises
questions about transferability. There are some grounds for optimism. There is a
reasonable amount of evidence from randomized trials for the effectiveness of childfocused cognitive behavioural therapy in improving child outcomes, including
depression, anxiety and trauma, that are relevant to maltreatment.226,227,228 Wellstructured parenting interventions, such as parent training, have also been shown
to be effective with troubled but non-maltreating families; this should strengthen
our confdence in their likely effectiveness for maltreated children because they
have been shown to improve parenting per se.229,230,231 On the other hand, there is
ample evidence from studies in this Overview that parents with the most complex
and entrenched problems appear not to respond to routine services. They may
well not respond to these programmes either. Until such programmes have been
rigorously evaluated in families where children are suffering, or likely to suffer,
signifcant harm, their effectiveness remains unproven.
Implementation
Studies have consistently shown disappointingly high rates for re-abuse and poor
outcomes for those who receive specifc interventions.232,233 Risks to the child
are likely to remain high and things may start to go wrong if stresses within
the family build up. Taking account of the risk of further maltreatment and the
need for sustainability makes sense both in terms of the interests of the child and
family but also in terms of the return on social investment. Specifc programmes
are costly and it is crucial to ensure improvement gains are sustained over time.
Specifc Interventions for Children and Families with Additional or Complex Needs | 99
In a UK context, specifc intervention models may most usefully be applied
to families with complex needs as one of a range of Sure Start children’s centrebased interventions or alongside social casework or other services from a team
working with the child and family.234 Those commissioning specifc interventions
should ensure that ongoing support from the network of safeguarding services
is in place, bearing in mind that the follow-up is likely to be multi-disciplinary.
As a programme comes to an end, a health visitor, school, social worker or a
combination of all three may need to provide preventive services to ensure there
is no relapse.
The remainder of this chapter frst provides examples of ten specifc
interventions that have been shown to be effective in preventing maltreatment
and/or its consequences. They have been selected using the criteria indicated
above, and because of their appropriateness to the issues raised by other studies
in this Overview; examples of other validated interventions may be found in the
original reviews. We then conclude by introducing the reader to proposals for an
innovative ‘common elements’ approach, which has yet to be piloted, but which
could, potentially, provide more effective interventions for complex cases.
Parent-focused interventions to prevent the occurrence or
recurrence of maltreatment
Parent-focused interventions are designed to work on improving parental
skills and some aspect of the parent’s wellbeing or their parenting that is
thought to contribute to abusive interactions with the child.
As we have already seen in earlier chapters, it is now well established that children
growing up in families affected by parental substance misuse, domestic violence
and mental ill health are at an increased risk of being maltreated.235 The Signifcant
Harm of Infants Study demonstrates that many parents will be unlikely to beneft
from specifc interventions to improve their parenting skills unless some of these
and/or other underlying issues have also been addressed. The study shows that
even parents who have previously had several children placed for adoption can
change sufciently to provide a nurturing, non-abusive home for a subsequent
child. However, those who manage to do so will have reached a point at which
they realize they will need to make radical changes to their lifestyles if they
are to succeed. In order to engender sufcient change, such parents will need
support to overcome adversities that increase the likelihood of children being
maltreated. They may also need practical help, for instance to move away from a
100 | Safeguarding Children Across Services
drug-abusing network or to deal with debts that are adding to stresses that make
it difcult for them to maintain change.
Substance-misusing families
A number of innovative methods of working with families with multiple problems,
including substance misuse, have been developed in recent years. One example is
Parents Under Pressure (PUP),236,a a home-visiting programme designed principally
for substance-misusing parents that has since been extended to address wider
needs such as mental health problems. It has been evaluated with older children
in Australia in a randomized controlled trial,237 and is currently being piloted
with younger children in England.238
PUPtargets multiple domains of family functioning, including the psychological
functioning of individuals in the family, parent–child relationships and social
contextual factors. Its purpose is to help parents understand their own emotional
responses and the extent to which they may be influenced by substance misuse, with
the objective of improving affect regulation. Key features are a focus on parental
strengths and parental risk factors and on the introduction of ‘mindfulness-based
techniques’ (i.e. techniques for ‘refocusing the mind on the present moment and
letting go of negative thoughts in order to shift from a severely negative mood
state or feeling of anxiety, to one that is less overwhelming’) in terms of improving
parental affect.
This programme has been shown to be more successful in the treatment of
substance-misusing mothers than standard care by a substance abuse clinic or a
traditional parent-training intervention (Evidence Level A). Parents receiving the
PUP programme have shown signifcant reductions in stress, methadone dose,
and in indicators of the likelihood of child abuse. Their children have shown
signifcant reductions in child behaviour problems and improvements in prosocial scores. It seems likely that theoretically based interventions of this nature,
which address multiple domains in families’ lives, may be more effective than
those that adopt a single issue approach.
Parents involved in domestic violence
The Signifcant Harm of Infants Study found that in most cases the practice
solution to domestic violence is to exclude the (male) perpetrator rather than
to address the issues that engender it, with the result that many men are likely
to go on to abuse other women and children. Further research is needed into
the effectiveness of interventions for perpetrators,239 such as anger management
programmes, designed to reduce the risk of domestic violence. The systematic
reviews found few interventions for this population that were both relevant and
had been sufciently evaluated. One promising intervention, the South Tyneside
a See Example 1 in Appendix 2 for more details
Specifc Interventions for Children and Families with Additional or Complex Needs | 101
Domestic Abuse Perpetrator Programme, has so far only been evaluated as a case study
(Evidence Level E) with a very small sample.240
There may still be continuing issues for women who have been exposed
to domestic violence even after the perpetrator has been excluded. There is
considerable evidence that such women suffer a loss of confdence, depression
and feelings of degradation; this can result in their moving on to another
abusive relationship, as well as in difculties in organizing day-to-day living and
responding to the needs of children.241 Some interventions have been developed
to address these issues. The Post-Shelter Advocacy Programme 242,243 has been shown
signifcantly to reduce repeat violence and improve women’s quality of life at
two-year follow-up, although the effect was not sustained (Evidence Level A).
However, further trials are necessary to ascertain whether this intervention is
effective in safeguarding children.
Parenting problems amongst abusing parents
A parent’s own experience of maltreatment in childhood is known to be associated
with recurrent child abuse.244,245 We know that parents who have been physically
abused or neglected in childhood are more likely to maltreat their own children
in the same ways.246 Numerous studies have also demonstrated that parents who
maltreat tend to hold distorted beliefs and unrealistic expectations regarding
the developmental capabilities of children, the age-appropriateness of child
behaviours and their own behaviour when interacting with them. This can result
in misreading children’s intentions and behaviour and attributing hostile intent,
which in turn has been linked with over-reactive and coercive parenting, angry
feelings in parents, child behaviour problems, and the use of harsh punishment.247
Thus programmes which are designed to address adults’ own experiences of poor
parenting and/or the psychological consequences of abuse can make a valuable
contribution.
The Enhanced Triple P-Positive Parenting Programme 248,b is one such specifc
intervention that has been rigorously evaluated (Evidence Level A).249,250
Implementation of the core elements of Triple P as a targeted preventive
intervention has been discussed in Chapter 3. However, these core elements can
be complemented by an enhanced programme that includes elements designed
to reduce anger and misattribution in parents reported for, or at self-reported
risk of, emotionally abusing their children. A randomized controlled trial251
compared the effectiveness of the standard family intervention with the enhanced
version of Triple P; both are geared towards families in difculties. While at the
six-month follow-up both interventions showed similarly positive outcomes on
all measures of child abuse risk, parent practices, parental adjustment, and child
behaviour and adjustment, only those receiving the ‘enhanced’ version continued
b See Example 2 in Appendix 2 for more details
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to show greater change in negative parental attributions. The results point to the
benefts of delivering a less intensive intervention in the frst instance, followed
by reassessment to gauge whether there have been changes in the risk factors for
maltreatment, and then offering customized adjunctive interventions based on
this assessment.
This intervention has been comprehensively evaluated in different countries
and therefore demonstrated to be transferable to different national settings.252 It is
currently being implemented in the UK. In the absence of long-term effectiveness
studies, and in view of the evidence of recurrence of maltreatment noted above,
there still needs to be a continuing evaluation of those who have successfully
completed the programme to ascertain if their children are less likely to be reabused.
Cognitive behavioural approaches
Cognitive behavioural approaches aim to change the parents’ thoughts, beliefs and
behaviour in the present, rather than analysing the role of past influences. They
commonly focus on helping parents to change the way in which they perceive
children and supporting them to identify, confront and change their thinking and
develop better child management skills. Cognitive behavioural therapy (CBT) can
be provided in the home on a one-to-one basis or on a group basis away from
home.
The Emotional Abuse Intervention Review describes a study which compared CBTbased home-delivered parent training with an enhanced programme involving additional
group-based parent-training sessions.253,c The study showed the benefts of
appropriately delivered CBT with added components specifcally aimed at
addressing factors known to be associated with abusive parenting such as anger
and stress management. Participants showed signifcant reductions in stress and
anxiety levels and in emotionally abusive behaviour. The study also showed that
Summary: Parent interventions
A number of parent-focused interventions seem to hold promise for
reducing recurrence of abuse and improving outcomes for children,
including child mental health and parent–child relationships. It seems likely
that theoretically based interventions, which address multiple domains of
families’ lives, may be more effective than those that adopt a single issue
approach. It is also clear that unless continuing support services are offered
after a specifc, time-limited programme has been completed, many parents
will have difculties in maintaining the progress they have made.
c See Example 3 in Appendix 2 for more details
Specifc Interventions for Children and Families with Additional or Complex Needs | 103
the most effective results are achieved when home and group interventions are
combined.
Parents Under Pressure has been shown to be more successful in the
treatment of substance-abusing mothers than standard care by a substance
abuse clinic or additional parent training.
Few interventions for parents involved in domestic violence are
specifcally aimed at safeguarding children and/or have been sufciently
evaluated.
The evaluation of the Enhanced Triple P-Positive Parenting Programme
points to the potential benefts of providing CBT-based interventions to
maltreating families. The results showed reliable improvements in child
behaviour and in the management of problematic behaviours by parents,
though it should be noted that some of the parents participating were at the
less severe end of the spectrum.
When a one-to-one home-based CBT programme is compared with an
enhanced programme involving the addition of group-based sessions, the
benefts of appropriately delivered CBT with added components specifcally
aimed at addressing factors known to be associated with abusive parenting
such as anger and stress management are evident.
Combining one-to-one with group-based interventions appears to
achieve the most effective results.
Limitations of the evaluations were that some were conducted outside
the UK and were based on small samples.
Parent and child-focused interventions to prevent the
occurrence or recurrence of maltreatment in families
where children are suffering, or likely to suffer,
signifcant harm
Parent and child-focused interventions are intended to focus on the parent
and the parent–child relationship. They may work on aspects of parental
functioning and mental health at the same time as helping to reduce
parent–child conflict or child problem behaviour, which in some cases may
precipitate abuse.
Parent and child-focused interventions are intended to focus on the parent and
the parent–child relationship, targeting both parent and child with the aim of
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changing some aspect of parental functioning such as their attitudes, beliefs or
behaviour. At the same time the interventions may also seek to improve parental
wellbeing by working on mental health issues, such as anxiety, depression and
anger. A number of theoretical constructs underpin parent and child-focused
approaches; these include cognitive behavioural, psychoanalytic and attachmentbased approaches. Evaluated examples of all three types of intervention are given
below.
Parent–child psychotherapy to address emotional abuse
There is a growing body of evidence pointing to the effectiveness of parent–child
psychotherapy in addressing emotional abuse. Interventions are underpinned by
attachment theory, which argues that mother–child attachment relationships are
central to positive child outcomes; the aim is therefore to tackle aspects of parenting
representation but also to work simultaneously with both the parent and infant.
Preschooler–Parent Psychotherapy254,d is a specifc, clinic-based programme, provided
to mothers and preschoolers where there is a known history of abuse in the
family. Therapy focuses on helping the mother recognize how her past history is
re-enacted in the present and enabling her to change her representations. Other,
similar programmes have also produced positive outcomes.255,256 A randomized
controlled trial has shown this model of intervention to be more effective at
improving representations of self and of caregivers than a CBT-based model
directed at parenting skills.257 However, some evaluations have only focused
on factors likely to be changed by the therapy such as maternal and child
representations; further evaluations that explore a wider range of outcomes are
needed.
Attachment-based programmes for families where
there is a likelihood of abuse or neglect
video feedback interventions show statistically signifcant positive effects on
parenting behaviour, attitude of parents and the development of the child.258
Interaction Guidance 259,e is a promising example of an attachment-based
programme using this methodology, developed primarily for families where there
is a likelihood of abuse or neglect. It is designed specifcally for children with
faltering growth, and consists of videotaped interaction between mother and
infant, followed by discussion, education and feedback, geared towards promoting
improved communication. A two-group, non-randomized trial (Evidence Level
B)260 has shown this intervention to be more effective than a behavioural feeding
programme. However, the outcome measures were limited, and this should be
regarded as preliminary evidence. Further trials are being undertaken, including
one with maltreated infants and toddlers in foster care.261

Specifc Interventions for Children and Families with Additional or Complex Needs | 105
A cognitive behavioural approach to address physical abuse
Parent–Child Interaction Therapy 262,263,f is based on a cognitive behavioural model
and shows promise as a parent–child intervention that may be effective in reducing
physical abuse. The aim is to increase parental motivation and enhance skills and
to improve parent–child interaction through use of direct coaching and practice
of skills in didactic parent–child sessions in which parents are treated alongside
children. This behavioural management intervention has a strong evidence
base for helping child conduct problems, and is based on the Webster-Stratton
Incredible years programme, which has translated successfully to the UK.
A rigorous evaluation (Evidence Level A)264 with a sample of physically abused
children and their parents found that this intervention was more effective than a
standard community-based parenting group in improving parent–child interactions
and reducing the recurrence of physical abuse and the risks of further maltreatment.
It may therefore reduce referrals to children’s social care. However, it does not
appear to have a signifcant effect on child behaviour.
Summary: Parent–child interventions
We examined three interventions representing the three different approaches
to parent–child therapy, namely a psychotherapeutic approach: Preschooler–
Parent Psychotherapy (PPP); an attachment-based approach: Interaction
Guidance; and a cognitive behavioural model: Parent–Child Interaction
Therapy (PCIT). The frst two interventions are aimed at preschool children,
the frst being focused on parents diagnosed as emotionally abusing and the
second focused on infants with faltering growth. The third intervention is
directed at parents after physical abuse has been confrmed.
The strengths of the available evidence on the effectiveness of parent–
child-focused interventions are reflected in the innovative nature of many of
the methods of working and the clear theoretical approaches upon which
they are based.
The evidence from the two evaluations of programmes to address
emotional abuse is limited by the absence of adequate child outcome
measures. Furthermore, both studies used measures that were directly
related to the intervention (and thus likely to show improvement).
The third intervention, Parent–Child Interaction Therapy, has been
shown to be associated with reduced referrals to children’s social care. The
evaluation used a well-validated methodology and found medium effects in
both reduced negative behaviour towards the child and increased parental
positive behaviours. However, it did not show a signifcant impact on child
behaviour.
f See Example 6 in Appendix 2 for more details
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Family-focused interventions to prevent the occurrence or
recurrence of maltreatment in families where children are
suffering, or likely to suffer, signifcant harm
Family-focused interventions may aim both to prevent the occurrence or
recurrence of abuse and neglect to ensure better outcomes for the child,
because they concentrate on the interactions between all family members as
well as the mental health of each individual.
Although much of the attention on the causes and origins of maltreatment focuses
on the mother–child relationship, the problems may reside in the wider family
group. For example, we know that inter-parent conflict, especially when it results
in domestic violence, signifcantly increases the likelihood of maltreatment. In
some families one child may be singled out and treated differently from other
siblings. There may also be maladaptive relationships within and beyond the
immediate family, including with foster parents.265,266
Family-focused interventions are intended to work with the wider family group.
The family may be considered to include not just the members of a household,
but also the child’s larger family network, such as the biological parents, stepparents, siblings and step-siblings, and foster or respite carers. Family therapy may
be most effective in situations in which multiple problems are present, because it
takes into account the needs of the whole family at once; it may also be useful
for situations in which multiple services are involved, because of its ability to
incorporate people from outside the family into treatment.267
Family-focused interventions aim both to prevent recurrence of abuse and to
ensure better outcomes for the child because they concentrate on the interactions
between all family members as well as the mental health of each individual. Such
interventions seek to change maladaptive interactions between numerous family
members, rather than the behaviour of one or more individuals.
The term ‘family therapy’ is used to cover a wide range of methods for working
with families with various psycho-biological difculties. Indeed, there are several
major schools of family therapy and therapists often incorporate elements of more
than one method in practice. Nevertheless, the different schools of family therapy
all have some core features in common. All models prioritize interactions, notably
communication patterns, between family members in considering problems and
solutions in treatment. They also always take the whole family into account,
rather than prioritizing dyadic parent–child interactions.268 All members of at
least the immediate family are typically invited to treatment sessions, although
Specifc Interventions for Children and Families with Additional or Complex Needs | 107
some sessions may be individual and others may include people from outside the
family, such as teachers or social workers.
Family therapy is difcult to evaluate using rigorous trial-type designs. The
Emotional Abuse Intervention Review includes some interventions for children who
are being emotionally abused that have been evaluated using a case study design
(Evidence Level E), which indicates that the therapies are helpful. However, these
fndings are based on the lowest level of evidence. While it is therefore not possible
to conclude that family therapy has a positive impact on emotional abuse, reviews
have found strong evidence for its effectiveness in a range of relevant conditions.
These include conduct disorders in children and adolescents, eating disorders,
substance misuse and as a second-line treatment for depression.269 There is also an
extensive literature on the impact of family therapy in cases of child sexual abuse
and, to a lesser extent, parental violence,270 and examples of successful shortterm, intensive family therapy with families in which psychological maltreatment
is recognized as compounding other forms of abuse.271
The Physical Abuse Intervention Review was relatively sceptical of the value of
family therapy in treating child physical abuse. Their search only yielded two
randomized controlled trials, one of which compared it with CBT and found it
to be less effective for some outcomes and no different for others;272 the other
compared individual family therapy with multi-family group therapy and found
the latter to be more effective in reducing child abuse potential; however, there
was no control condition.273 They argued that the effectiveness of family therapy
is unclear and needs to be investigated further.
Multi-Systemic Therapy for Child Abuse and Neglect
However, since then, a randomized controlled trial of Multi-Systemic Therapy
for Child Abuse and Neglect (MST-CAN)274,g for physically abused young people
has been completed275 and shows promising results. A less rigorous (Evidence
Level E) study indicates that it may also be of value in families where neglect
is an issue.276 This form of therapy builds on three inter-related elements. First,
it adopts an ecological approach,277 which links the physical abuse of young
people with modifable factors within the individual young people, their parents
and family systems. Second, it builds on encouraging evidence from other
family-based interventions for child abuse and neglect, some of which have
been discussed above.278 Third, it is an adaptation of multi-systemic therapy, a
rigorously evaluated, evidence-based programme for young people displaying
serious anti-social and/or offending behaviour, developed over 30 years and now
being implemented or trialled across the world, including England.279
MST-CAN provides a social-ecological therapeutic framework to address the
multiple needs of families experiencing child abuse and neglect. It consists of an
g See Example 7 in Appendix 2 for more details
108 | Safeguarding Children Across Services
ongoing and extensive assessment process to conceptualize the case and establish
and prioritize target behaviours, followed by implementation of evidence-based
interventions.280 Interventions are tailored to meet the family’s clinical needs, and
may include, for instance, CBT for defcits in anger management; a CBT protocol
for families with low problem-solving skills or difculties in communicating
without conflict; and prolonged exposure therapy for parents experiencing post
traumatic stress disorder symptoms. When compared with enhanced outpatient
treatment for physically abused youths and their parents in the US, MST-CAN
has shown promising results in reducing young people’s mental health symptoms,
parent psychiatric distress and parenting behaviours associated with maltreatment,
and improving natural social support for parents.281 This form of therapy is
addressed to older children and would be relevant to those in the Home or Care?
and the Neglected Children Reunifcation Studies.
Summary: Family-focused interventions
Family-focused interventions may prove valuable both because they have
the potential to address multiple problems in a structured way, and because
the sustainability of treatment gains is highly contingent on the ecological
context. There have been few rigorous evaluations, and more research is
needed in this area. However, recent evidence suggests that an adapted form
of multi-systemic therapy may prove effective for families where physical
abuse or neglect of older children occurs.
Child-focused interventions to mitigate impairment
Child-focused interventions predominantly aim to help children cope with
the adverse effects of maltreatment such as stress, anxiety and low selfesteem, and address their immediate and long-term adjustment needs.
Child-focused interventions are designed to work specifcally on children’s
needs and to help them cope with the adverse effects of maltreatment such as
stress, anxiety, low self-esteem, aggressive or non-compliant behaviour and social
isolation. Therapy can be provided at different stages in life, from infancy to
teenage years. However, opportunities to intervene early are sometimes missed.
Both the Neglected Children Reunifcation and the Signifcant Harm of Infants Studies
found that a high proportion of children in their samples showed difculties that
could be attributed to long-standing neglect. These included children who had
Specifc Interventions for Children and Families with Additional or Complex Needs | 109
very delayed development or poor speech, did not put on weight, had missed a
great deal of school, and had decayed teeth or untreated medical conditions.
Child-focused interventions aim to work on both immediate and long-term
adjustment needs. The Physical Abuse Intervention Review found that there have
been surprisingly few previous reviews of child-focused interventions to mitigate
impairment from physical abuse or neglect.282 However, a number of effective
programmes have been identifed, including therapeutic day care, peer training
and treatment foster care. These examples have been selected to demonstrate
effective interventions for children at different ages.
Therapeutic Preschool 283,h provides medical, developmental, psychological and
educational services to promote healthy growth and development for infants aged
1–24 months who have been, or are at risk of being, maltreated. Interventions
are also offered to parents on a voluntary basis and include parenting education,
concrete services, support groups, counselling and referrals to other services.
A randomized controlled trial284 showed that this therapeutic preschool
intervention had a sustained and signifcant impact on parenting and child
behaviour. When compared with those offered routine services, children who
received the therapeutic preschool intervention showed less evidence of aggression,
delinquency and fewer serious offences; these results were maintained over a 12­
year follow-up. The trial used multiple sources for outcome measures, which
strengthens the reliability of these conclusions, although it should be noted that
only half the children were traced for the fnal follow-up.
Peer-Led Social Skills Training 285,i is aimed at slightly older children of three to
fve years with mixed maltreatment histories who are socially withdrawn. The
children are paired for play sessions with resilient peers who display high levels
of positive play, supported by a parent volunteer. A rigorous (Evidence Level A)
evaluation286 showed that the intervention had a positive impact on social skills in
socially withdrawn children, including those who have experienced maltreatment,
maintained at two-month follow-up. However, further investigation of the impact
on other aspects of the children’s mental health is needed to determine whether
this intervention might improve other outcomes, particularly in the longer term.
Peer training has been used in UK health promotion programmes in schools
to tackle substance abuse and promote healthy living.287 Therefore, although this
programme was developed in the US, there is relevant experience amongst public
health professionals which could inform its translation into a UK setting.
Multidimensional Treatment Foster Care
The Neglected Children Reunifcation, the Home or Care? and the Signifcant Harm
of Infants Studies all provided ample evidence that abused children placed with
foster parents may bring with them emotional, behavioural and developmental

110 | Safeguarding Children Across Services
problems. The latter study concluded that prolonged exposure to maltreatment
and delayed decision-making may jeopardize the life chances of about 60 per
cent of very young children who are eventually permanently placed apart from
their birth families. Multidimensional Treatment Foster Care (MTFC) is designed to
deliver intensive support to such children, their foster carers and birth or adoptive
parents. This therapeutic foster care programme is based on social learning
theory and incorporates parent training and consultation for foster parents,
parent training for birth parents and individual therapy for children who have
experienced maltreatment. Rigorous evaluations conducted in the US consistently
show positive outcomes, including improvements in children’s attachment to
caregivers, participation in school, foster parent stress levels, and likelihood of
achieving permanency (particularly marked for children who have had multiple
prior foster placement failures). They also show reductions in older children’s
delinquency and anti-social behaviour and subsequent time incarcerated.288
Further details of one of the MTFC programmes (MTFC-P) identifed by the
Physical Abuse Intervention Review and the results of a high-quality (Evidence Level
A) evaluation that provides evidence of its effectiveness when compared with
regular foster care are given in Appendix 2 (Example 10).289
There are currently three MTFC programmes being piloted or implemented
in the UK: MTFC-Adolescents; MTFC-Children of school age; and MTFCPrevention for young children aged three to six years. At the time of writing,
the MTFC-Adolescents programme is relatively well established. A pre and
post (Evidence Level C) evaluation undertaken by the project team showed
signifcant reductions in adolescent offending, self-harm, sexual behaviour
problems, absconding and fre setting and in foster carers’ stress levels. There
were also improvements in young people’s SDQ and IQ scores.290 The results of
a randomized controlled trial by independent evaluators are currently awaited.
The MTFC programmes for younger children are currently being piloted
in a number of sites in England. A related programme, KEEP (Keeping Foster
and Kinship Parents Supported and Trained), is also being introduced. This
utilizes the same principles as MTFC, and has been developed as a means of
skilling up mainstream foster carers, providing increased support to kinship
carers, improving placement stability and transferring the learning from the more
specialist programmes to a wider group of carers.291
This wide-ranging suite of programmes may prove cost-effective in the
long term if they promote better outcomes for children and prevent placement
disruptions. However, the many additional services that are provided to foster
families may initially appear to be expensive, and studies that measure costs
would clarify this issue. An exploration of the costs of one of the English pilots
showed that the monthly costs of maintaining MTFC placements were on a par
with placements in independent foster agencies outside the authority area, and
less costly when stability and length of stay are taken into account. Social care
Specifc Interventions for Children and Families with Additional or Complex Needs | 111
costs incurred by children in the frst six months of MTFC were about 15 per
cent less than those they had incurred in the six months prior to entry to the
programme.292
Future studies comparing MTFC with other treatments would provide more
information about its effectiveness. If the results of the English pilots prove
positive, this would be a useful approach to consider implementing.
Summary: Child-focused interventions
In this section we have looked at three child-focused interventions: a
therapeutic day treatment programme aimed at babies between one and two
years, a proportion of whom had documented histories of abuse; a peerled programme aimed at children of 3–5 years with mixed maltreatment
histories who were identifed as being socially withdrawn; and a treatment
foster care programme with a number of different modules, covering all age
ranges.
The evaluation of the therapeutic preschool programme showed
promising results in reducing anti-social behaviour in the long term and was
found to be more effective than standard child protection services. The trial
of the peer-led social skills training programme found the treatment group
exhibited more interactive play and less solitary play than a control group
but did not measure other aspects of child mental health or behaviour.
Rigorous evaluations have found that Multidimensional Treatment
Foster Care shows promising effects on the stability of foster placement,
children’s attachment and on cortisol levels, indicating that providing
both foster parents and children with extensive, specialist support and a
structured programme of intervention can help to improve child outcomes.
The way forward? The ‘common elements’ approach
As we have noted, many maltreating families suffer a multiplicity of problems and
may require a range of forms of help at the same time. It may be necessary for a
care plan to address a number of elements such as parental domestic violence and/
or drug and alcohol problems, as well as emotional and behavioural difculties
displayed by the child. Some of the interventions presented above address this
issue by adopting a comprehensive, multi-level approach.
However, diversity of goals has led to difculties in implementing evidencebased interventions in the real world. Although practitioners claim to be using
evidence-based interventions, audit and research into actual practice in the feld
have shown that, despite their stated intentions, this is generally not the case.
Practitioners tend not to use evidence-based practices and instead fall back on
112 | Safeguarding Children Across Services
their existing familiar patterns. Furthermore, attempts to change practice, in
mental health settings for instance, have met with mixed success.293
Appreciation of these obstacles to successful change has led to an innovative
‘common elements’ approach that takes on board concerns voiced by practitioners
about the diversity and complexity of their real-world cases.294 In this approach,
common elements are distilled from existing evidenced-based interventions for
a common problem, within four areas: treatment content, techniques, working
alliance, and treatment parameters.295 These common elements of intervention or
treatment are then agreed with the authors of individual evidence-based therapies.
The intention is that the common elements approach will be tried out in practice
as an innovative means of addressing these very diverse and complex cases. While
this holds promise for the feld of maltreated children and their families, it has not
yet been developed or trialled. Issues concerning programme fdelity, appropriate
training and the unlooked-for consequences of mixing elements that may come
from different theoretical backgrounds all need to be explored.296
So what can be suggested, based on the evidence reviewed above, for
commissioners and practitioners seeking the best interventions for maltreated
children and their families?
• Identify agreed principles and approaches to interventions, including ethical
and legal considerations. This has been done in the US, and consensus
reached between authors who had developed interventions with evidence
for effectiveness.297,298
• Use evidence-based interventions which are sufciently flexible to accept
adaptation or the introduction of additional modules to allow for case
diversity and complexity. For example, the Triple P Programme or Parents
Under Pressure, which do allow for such variation.
• Choose interventions which can be practised by a range of professionals,
and are not restricted to those from one profession.
• Use the above approach to agree the main intervention(s) that will be
supported in a geographical area, and only use other interventions, with a
less good evidence base, where the initial approach has proved unsuccessful,
and/or where a convincing case can be made for adopting an intervention
with less compelling evidence to support its use.
Conclusion
This chapter has reviewed a range of effective interventions and found that
there are several which are likely to provide real beneft for children and their
families where abuse and neglect has occurred. We have described ten specifc
interventions that have been proved to be effective in addressing the needs of
maltreated children and their families (and given further details in Appendix 2),
Specifc Interventions for Children and Families with Additional or Complex Needs | 113
in the expectation that all who consider using them will wish to have information
that will help them identify ‘what works’.
At the same time, however, there is a need for caution because the programmes
have limited success, and because there are signifcant rates of recurrence of
maltreatment and poor outcomes in the follow-up studies. Moreover, not all
interventions have been shown to be effective in addressing the multiplicity of
adversities faced by such families.
Key messages for all who work together to safeguard
children
• Reviews of evidence have identifed a number of specifc interventions
that have been proved to be effective in addressing the needs of maltreated
children and their families. Those highlighted in this chapter are examples
of what is available.
• Effective programmes for parents address alcohol and drug problems,
parenting problems arising from their own childhood experiences and
poor parenting practices. Better evidenced programmes for addressing
intimate partner violence in families where children are suffering, or
likely to suffer, signifcant harm are required.
• Effective programmes for parents and children address parent–child
relationships, conflict and parent–child interaction.
• Effective programmes for children address behavioural and emotional
issues arising from the consequences of abuse. They can be tailored to
different age groups and circumstances.
• There is a need for caution because the programmes only address aspects of
the multiple problems faced by families, and because all the interventions
have limited effectiveness and do not offer solutions for all families. For
example, there are signifcant rates of recurrence of maltreatment and in
some cases poor outcomes for children in the follow-up studies.
Key messages for strategic managers, commissioners of
services and operational managers in health, education
and children’s social care
• Those who commission specifc interventions should frst ask: whether
an evaluation has been undertaken and to what evidence level; whether
there is evidence of sustainability; whether there is evidence that the
fndings can be translated into a UK context; whether the intervention is
sufciently flexible to allow for extra modules to be added to accommodate
case diversity or complexity.
114 | Safeguarding Children Across Services
• Most specifc interventions are of short duration. Commissioners and
operational managers should be aware that maltreating parents and their
children will often need continuing support from social workers, health
visitors or other professionals after completing a programme in order to
maintain improvements and prevent relapse.
• Proposals to identify common elements of effective interventions in this
feld may offer a valuable way forward, but have not yet been trialled. In
the meantime the following programmes are examples of what has been
proven to be effective.
Programmes for parents
ô Parents Under Pressure (PUP) is an effective intervention for
substance-misusing parents and holds promise to parents who have
other problems too.
ô The Enhanced Triple P-Positive Parenting Programme is effective
in addressing adults’ own experiences of poor parenting and the
psychological consequences of abuse.
ô Cognitive Behavioural Therapy (CBT) can be effective in reducing
emotionally abusive parenting, particularly when individual sessions
are combined with group-based sessions.
Programmes for parents and children
ô Preschooler–Parent Psychotherapy is effective in improving maternal
and child representations where there is a known history of abuse in
the family.
ô Interaction Guidance may be an effective intervention in improving
parent–child relationships in infants with faltering growth, but
further evaluation would be valuable.
ô Parent–Child Interaction Therapy is a cognitive behavioural model
that has been shown to be effective in reducing physical abuse.
Programmes for families
ô Multi-Systemic Therapy for Child Abuse and Neglect has been
shown to be effective in reducing the likelihood and mitigating the
consequences of the physical abuse of adolescents.
Specifc Interventions for Children and Families with Additional or Complex Needs | 115
Programmes for children
ô Therapeutic Preschool is an effective intervention for children
aged 1–24 months who have been maltreated or are at risk of
maltreatment. It has a signifcant and lasting impact on parenting and
child behaviour.
ô Peer-Led Social Skills Training is an effective intervention for
3–5-year-olds with a history of maltreatment who are socially
withdrawn.
ô Multidimensional Treatment Foster Care is an effective intervention
for maltreated children in care or accommodation. Trials in the US
have produced promising results. A range of programmes have been
designed for adolescents, older children and preschoolers.
6
Providing a Context for Effective
Inter-Agency Practice
• This chapter draws largely on the evidence from the Local Safeguarding
Children Boards Study,299 the Inter-Agency Training Evaluation Study,300 the
Information Needs of Parents at Early Recognition Study301 and the General
Practitioner Tensions in Safeguarding Study.302
• The chapter has important messages for all those who have responsibility
for safeguarding and promoting the welfare of children.
• The chapter has specifc messages for the following professional groups:
ô policymakers, chairs and members of Local Safeguarding Children
Boards (all sections)
ô strategic managers and commissioners of services in health and
children’s social care (sections on inter-agency training; how
existing structures support both inter-agency and inter-disciplinary
working)
ô practitioners and operational managers in adult health, including
GPs, psychiatrists, psychologists and substance and alcohol
misuse teams, probation, police, education and children’s social
care (sections on what the studies tell us about inter-professional
working in day-to-day practice; improving co-operation through
inter-agency training).
Introduction: Why is inter-disciplinary/inter-agency work
needed?
Protecting children from harm requires alertness and effective interventions
from practitioners across a range of disciplines. How is this managed in an
inter-agency context? How is it supported at a local level and how effective
are mechanisms designed to promote joint working?
116
Providing a Context for Effective Inter-Agency Practice | 117
Evidence from high-profle reports into child deaths, including those of victoria
Climbié and Peter Connelly,303 provide compelling evidence about the need
for services to work together to protect children from harm. Findings from the
biennial Analyses of Serious Case Reviews further highlight and reinforce this.
Inquiries and serious case reviews focus on what happens when things go
wrong. However, evidence from other studies covered in the Research Initiative
also demonstrates the importance of inter-disciplinary working in routine
practice because of the multi-faceted nature of problems which beset families
for whom neglect and abuse is a concern. In Chapter 2 we saw the importance
of an integrated approach to referral and recognition. In Chapters 3, 4 and 5 we
saw the need for inter-agency working in the assessment of need and supply of
services.
Thus, inter-professional work is needed at all stages of the child protection
system. The studies demonstrate ways in which this works well, as well as times
when it appears to go wrong. In the frst part of this chapter we explore what
the studies tell us about how inter-disciplinary working operates in routine
practice. In the second part, we consider the evidence about the effectiveness
of arrangements designed to promote good practice in an inter-agency context.
However, we frst need to consider the likely impact of recent developments in
policy on the effectiveness of inter-agency working.
Recent developments in policy: the context for effective
inter-agency working
Lord Laming’s Inquiry into the tragic death of victoria Climbié304 found
serious problems in inter-agency and inter-disciplinary practice at a local level,
which needed urgent attention. These difculties involved poor working across
organizational boundaries and manifested themselves in a variety of ways. Senior
managers in relevant agencies did not see themselves as accountable for the
protection and welfare of children and appeared to refuse to take responsibility.
The quality of information exchanged between agencies was poor, in particular
between health and children’s social care, and there was reluctance amongst
some professionals to share it. The use of eligibility criteria by local authorities
to restrict access to social services was applied inappropriately, without proper
assessment of children’s needs or the likelihood of signifcant harm.
The challenge of developing new ways of working to promote a more
integrated approach across services lies at the heart of reforms since the victoria
Climbié Inquiry. A number of new structures were set up at a local level as part
of reforms introduced by the Children Act 2004.305 These include Children’s
Trusts and Sure Start children’s centres as well as Local Safeguarding Children
Boards (LSCBs). Whereas the Children’s Trust arrangements have a wider role in
planning and delivery of services, the LSCB objectives are about co-ordinating
118 | Safeguarding Children Across Services
and ensuring effectiveness of their member organizations both individually and
together.306
As Chapter 1 has shown, since the election of the Coalition Government in
May 2010, there has been a series of major policy developments which will have a
signifcant impact on the manner in which children are safeguarded from harm. One
particular reason for their anticipated impact is that they will change the context
in which inter-disciplinary practice takes place, and this will alter approaches
to inter-agency working. Reforms such as the reshaping of responsibilities for
partnership arrangements through relaxation of Children’s Trust requirements;307
policies designed to encourage more schools to take academy or free school
status;308 the introduction of greater diversity of services and service providers;
the reduction of joint targets and performance indicators as drivers of quality;
and the introduction of numerous incentives to increase local autonomy309 may
all provide opportunities for creative, positive change. On the other hand, greater
autonomy and increased diversity may make inter-agency collaboration more
problematic. It may prove particularly difcult to ensure that responsibilities for
safeguarding are genuinely shared, particularly when this brings a fnancial cost
at a time when budgets are being cut. As the evidence from the studies shows,
successful inter-agency working already poses considerable challenges.
What do the studies tell us about inter-agency working in
day-to-day practice on the ground?
Inter-agency and inter-disciplinary working are difcult to achieve for a variety
of reasons. Service sectors such as health, the police and education have different
structures, policies and priorities. There is evidence of distrust between some
professional groups and this can result in poor information sharing, insufcient
communication and reluctance to refer between services.
In the following sections we trace the process from recognition and referral
through different stages to intervention. However, it is important to note that,
rather than focusing specifcally on the recognized processes, the studies in the
Research Initiative give an insight into some of the challenges and dilemmas
faced by practitioners when engaging in them.
Recognition and referral: dilemmas
facing some front-line workers
The General Practitioner Tensions in Safeguarding Study examines the stresses faced
by general medical practitioners (GPs) in relation to child protection work. GPs
clearly face a dilemma about what action to take if they have concerns but are
unsure that this amounts to a likelihood of a child suffering signifcant harm.
Whilst they are familiar with the formal process of referral and understand what
Providing a Context for Effective Inter-Agency Practice | 119
to do when a case is clear cut, they are reluctant to approach children’s social care
when they have less immediate concerns. Their reluctance is based on a number
of factors. First, they are concerned about the high threshold for services which
means that a case referral can lead to no service being provided. Second, there
is the potential impact that referral to children’s social care might have on their
own relationship with the parents with whom they have a long-standing and
continuing relationship.
In clear-cut cases many GPs see their role primarily as referral agents, passing
on their concerns as they would for other issues which need a specialist view.
This is consistent with other aspects of the GP role, which involves referral to a
wide range of agencies. But it suggests a lesser engagement with child protection
services than is expected by other players or is recommended in statutory child
protection guidance.310,311 GPs are often frustrated because they are unable to
speak directly to a social work practitioner. Lack of feedback about progress and
actions following a referral are further causes of friction. Provided there is not a
very high level of concern, many GPs therefore prefer to keep the problem within
the health system by consulting a health visitor or another member of the health
team. However, both the Recognition of Neglect Review and the Signifcant Harm
of Infants Study found that health visitors also see themselves largely as referral
agents, and are equally frustrated when children’s social care does not routinely
provide feedback.
Slow responses by children’s social care to referrals arise for a number of
reasons. National statistics show a steady increase in numbers of referrals in
recent years, which social workers are fnding problematic to manage.312,313 In
addition, some practitioners argue that the reluctance of other agencies to share
safeguarding responsibility clogs the system up with inappropriate referrals.314
Other explanations for slow responses may lie in the way in which children’s social
care services are organized: the Munro report offers examples of good practice
in multi-disciplinary arrangements for dealing with enquiries and referrals.315
The Local Safeguarding Children Boards Study also found that the responsiveness
of the referral process is better in some areas than others. This study found that
specialized contact centres for referral may help improve accessibility for other
professionals, but there were some concerns about whether the staff who work
in them are adequately qualifed to respond appropriately. In one area the police
have a clear system for recording the details and times of feedback and this has
served to strengthen their working relationship with children’s social care.
Other evidence from the two Analyses of Serious Case Reviews and the two studies
of children returned home from care or accommodation indicate that the way in
which cases are seen by practitioners affects their response. Slow or inappropriate
action may arise because each incident is viewed in isolation; the threshold for
action is set too high; the ‘rule of optimism’ is being applied especially with
parents with whom workers are already engaged; the allegations are denied by
120 | Safeguarding Children Across Services
parents; or there are delays or stafng problems within children’s social care.
Referrals from neighbours or relatives may also be ignored. However, when
concerns are not adequately followed up, children are often left unprotected.
Over and above the shortcomings in response from children’s social care,
there are also concerns about sharing responsibility. Referrals should be about
continuing to work in a multi-disciplinary way;316 after a referral has been
accepted by children’s social care, inter-agency working remains important in
assessment, planning and intervention. For example, the assessment of neglect
requires attention from a range of agencies, as each may hold separate pieces of
information or knowledge that together show the whole picture.317,318 However,
referrals are sometimes seen as a means of handing over responsibility for the
child and family. The Signifcant Harm of Infants Study found little evidence that
responsibilities are equitably shared:
‘It’s frustrating when they won’t, they don’t recognize that they’ve got as
much responsibility as what you have…they’ve got as much of a duty to
protect, and support and nurture, as what you have, so you know again
that’s frustrating. And there are times when…they’ll phone you up and
make all these complaints and then you’ll get them into a meeting and
they’ll backtrack and they won’t say what they’ve said to you, as if, you
know, they’re scared to say it in front of a parent.’ (Social worker)319
The amount of time spent by health teams agonizing about whether a referral
should take place or not is also a cause for concern. Health professionals are often
frozen by the decision ‘to refer or not to refer’ and do not appear to consider
alternatives such as arranging access for children and families to therapeutic
and support services. Nevertheless, there are important opportunities for GPs
and health visitors to arrange for families to be assessed and be encouraged to
participate in preventive programmes, such as some of the parenting initiatives
described in Chapter 3. When health professionals are reluctant to refer, some
maltreated children inevitably fall through the net and do not receive the help
and protection they need. The Signifcant Harm of Infants Study confrms that this
happens in the case of very young children.
Different perspectives between providers
of adult and children’s services
Chapter 2 explored how some practitioners were reluctant to recognize or act on
concerns about maltreatment. The studies say more about how these issues impact
on effective inter-agency working.
General medical practitioners are reluctant to refer for a number of reasons,
including the fact that they treat the whole family. When there are concerns
about maltreatment there is sometimes confusion as to whether their loyalties lie
Providing a Context for Effective Inter-Agency Practice | 121
with the parents or the child,320 an issue that was noted in the General Practitioner
Tensions in Safeguarding Study. Providers of adult services, such as adult psychiatrists,
other mental health professionals and substance abuse workers, can be reluctant to
refer because they focus on adults and often do not appreciate how, for example,
parents’ mental health problems are impacting on their children. They often see
progress in terms of improvements in adult functioning and do not question
whether this is sufcient to meet the child’s timeframe. Parents may receive false
reassurances that all is going well, and then be surprised and angry when social
workers argue that children remain at risk of suffering signifcant harm.
As Chapter 2 has shown, practitioners in adult mental health services should
be particularly alert to the possibility that those of their patients who are parents
may maltreat their children, especially where mental ill health is linked with other
problems. However, adult services currently pay very little attention to the needs
of these children, and often fail to recognize the potential risks to their welfare.
There appears to be some reluctance on the part of substance misuse workers
to refer the children of their service users to social care; these practitioners often
give parents false reassurance that all is going well because they focus on parental
progress rather than on children’s needs. They:
‘…have a different perspective to social workers for children, in that they
will regard themselves as working for the adults and sometimes they will
struggle with the role that social workers have, in that they will want to
remain positive and supportive to parents’. (Team leader, children’s social
care)321
None of the studies were designed to address the question of how far those who
work with substance-misusing and/or violent adults recognize the risk of harm
to children or the actions they need to take in response. Nevertheless, it is clear
that opportunities for recognition of abuse or neglect are missed by practitioners
working with adults. Assessment of the impact of parents’ problems on child
welfare should be a routine part of normal practice in adult as well as children’s
services. These are important issues, indicating that further attempts need to be
made to better integrate adult and children’s services.
As we shall see below, the Inter-Agency Training Evaluation Study found that
drug and alcohol workers generally do not participate in inter-agency training
provided by Local Safeguarding Children Boards. An important opportunity to
develop greater understanding of children’s services is therefore being missed.
Without involvement in such opportunities for joint training these workers will
continue to have a poor understanding of the impact of parental substance and
alcohol misuse on children and the importance of sharing relevant information.
Lord Laming322 recommended strengthening channels between adult and
children’s services in social care and health. He also advised that feedback be
provided to those who make referrals, as a matter of course. The fndings of studies
122 | Safeguarding Children Across Services
in this Research Initiative would strongly endorse these recommendations, while
recognizing that, given high rates of referral, heavy caseloads and insufcient
stafng, the capacity to do so may be limited.323
How are thresholds applied on the ground?
The role given to LSCBs in developing local policy on thresholds demonstrates
the importance attributed to gaining agreements between agencies about what
these should be. The studies in this Research Initiative further emphasize this
issue, highlighting problems, particularly in relation to neglect and emotional
abuse. The Neglected Children Reunifcation Study, for example, found that, whilst
many social workers are able to comment on its impact on the child, they have
difculty in defning neglect. They consider that the concept is difcult to grasp,
particularly as there is no one clear indicator which signals that children are being
neglected. They fnd that neglect is less tangible than physical or sexual abuse,
but emotional abuse is an even more slippery concept than neglect.
The difculties in defning neglect and its chronic rather than acute nature
also feed into difculties of formulating protocols for agreeing thresholds. Social
workers interviewed in the Neglected Children Reunifcation Study commented on this
issue as follows:
‘To put together a threshold document based on neglect type issues is
incredibly difcult.’
‘Neglect is something which is very hard to determine the point at which [it
becomes] signifcant harm…when does it become a risk to their children?’
(Social workers)324
Similarly, neglect tends to be cumulative over a period of time, with the result
that it is not always easy to be aware when the threshold for signifcant harm has
been reached. Thus, ‘It’s easy I think for things to deteriorate gradually without
you noticing.’325
Moreover, the Local Safeguarding Children Boards Study shows that agencies do
not always perceive the likelihood of signifcant harm in the same way, so that
they hold different interpretations of thresholds:
‘It’s difcult because thresholds tend to differ and they’re different for
different agencies and different areas; it’s very inconsistent. There are issues
around how children’s services prioritise referrals but this often comes down
to perceptions of urgency. Often social care and mental health have different
views in terms of how anxious they are about a certain case.’ (Safeguarding
nurse)326
Providing a Context for Effective Inter-Agency Practice | 123
‘There are different views about how a case should be dealt with and as
a school nurse I don’t always agree with the level of priority given to
some cases. I feel that sometimes we are all on a different page.’ (Health
practitioner)327
Not only are there differences between agencies but also differences between teams
within them. For example, an assessment team can operate a threshold which is
‘much higher’ than that held by a looked after children’s team, with consequent
confusion about who is eligible to receive services. In the current economic
climate, agencies will need to be increasingly transparent about their thresholds,
both between themselves and with the general public. Greater clarifcation about
how thresholds are understood would be of beneft to all.
Further issues concerning the difculty of setting appropriate thresholds for
court involvement in cases of neglect have been discussed in Chapter 4.
What do the studies say about the response after
children’s social care has received a referral?
Evidence from the three empirical studies – the Home or Care? Study, the Neglected
Children Reunifcation Study and the Signifcant Harm of Infants Study – suggests
there may be some justifcation for the concerns expressed by health and other
professionals that children’s social care may be too slow to act, or offer too little
support in response to referrals.
For example, where children have been returned home after being looked after
by the local authority, one might expect re-referrals from other professionals,
neighbours or relatives to be followed up more fully than frst referrals because
these families are already known to children’s social care. However, the Neglected
Children Reunifcation Study found that insufcient action is taken in response to
more than half the re-referrals; either no action or a minimal response is made,
which does not appear to reflect the seriousness of the risks of harm to children,
and cases are sometimes closed shortly afterwards. The Signifcant Harm of Infants
Study also found that very small children who remain with their birth parents
but appear insufciently safeguarded frequently have their cases closed and then
are re-referred shortly afterwards. Both studies identifed cases where social
work staff had been so concerned about premature case closure that they had rereferred children themselves. It appears to be relatively common for concerns not
to be adequately followed up or appropriate action taken following a referral to
children’s social care.
The result is that children are often not sufciently protected from harm.
Some go on to experience further maltreatment, which might have been
prevented if different actions had been taken. Other children and families do not
access the intensive services they need to help them address the consequences
of maltreatment: in the case of older children this may result in deterioration
124 | Safeguarding Children Across Services
in behavioural patterns or in becoming increasingly involved in offending or
substance misuse. There is also substantial evidence that maltreated and neglected
children frequently return home from being looked after to situations that were
unchanged from those that existed when they were frst placed away. The Analysis
of Serious Case Reviews 2005–7 also found evidence of some children and families
‘bumping along the bottom’ with no services being offered at all.
Professionals from all agencies have to have confdence that referrals to
children’s social care will lead to suitable action. The Local Safeguarding Children
Boards Study found widespread sympathy amongst other professionals for the
work pressures on social workers. However, some give their uncertainty as to
whether a referral will lead to suitable action and the poor level of feedback about
the response as a reason for not referring cases.
Inter-agency working to supply support services
both prior to and after removal from home
Once referrals have been accepted, there is encouraging evidence of good interdisciplinary practice to support children and families, especially in the early
stages. For example, the Home or Care? Study found that there is clear evidence of
the provision of comprehensive support services for around two thirds of children
who return home from being looked after.
The Neglected Children Reunifcation Study found that, in the period from the frst
referral until fve years after reunifcation, about 80 per cent of families receive
some kind of additional service. Interventions may be aimed at the parent or
the child or can focus on the whole family. Such services include support for
parental mental health problems, help with parental substance misuse, parenting
programmes, help from a family centre, respite care, assistance from family support
workers, counselling, life story work, support from Child and Adolescent Mental
Health Services (CAMHS), play therapy, mentors and befrienders, play schemes,
keep safe work and help from the youth offending team. However, in about one
third of the cases in the Home or Care? Study sample, it was unclear what support
services (if any) had been offered.
Social workers refer many parents to specialist services dealing with substance
misuse or domestic violence and sometimes assist in negotiating alternative
accommodation with housing providers. The Signifcant Harm of Infants Study
found, as have other studies in this area,328 that housing is an important issue
for many families attempting to overcome problems such as substance misuse or
domestic violence, because it is easier to extract oneself from a drugs culture or
from an abusive relationship if one can change address. There is scope for closer
relationships and improved inter-agency working between housing agencies and
children’s social care.
The Sure Start Local Programmes Safeguarding Study noted that co-location of
health, social work and other practitioners facilitates improved inter-disciplinary
Providing a Context for Effective Inter-Agency Practice | 125
and inter-agency working and leads to better communication and delivery
of services to families at the front line. The benefts of co-location and/or
embedded health professionals for multi-disciplinary working have also been
demonstrated in related areas such as in work with disabled children and those
with special educational needs. More recently, the contribution and importance
of embedding health visitors and a range of practitioners in Sure Start children’s
centres, particularly in the protection and support of vulnerable families, has been
recognized by the Coalition Government.329 However, there is a danger that some
of this innovative work will be lost under new NHS arrangements if clinical
commissioning groups decide to opt out of commissioning such structures.
Whilst inter-agency working is shown to be strong in the provision of support
services, this does not mean they are always sufcient or fully meet all the families’
needs. Neither does it mean that families take up the services offered.
The Neglected Children Reunifcation Study explored the reasons why outcomes for
neglected children who return home from being looked after are so poor. In many
cases the level of support offered is limited and insufcient for the high level of
need amongst children and families. There are particular shortages of services for
parental alcohol misuse, the provision of direct help with children’s behavioural
problems and advice on behavioural management for their parents. Other services
that are insufcient to meet the needs of children and families where the likelihood
of maltreatment is high include: services for parental substance misuse; work on
parenting; services to address young people’s offending behaviour and their drug
and alcohol problems; psychotherapeutic support for children and young people;
respite care; material support; and help with children’s education. In some cases
support negotiated on an inter-agency basis, as part of a child protection plan, is
not forthcoming. However, caution should be exercised in noting these fndings,
because they are based on case records which have been shown in the past not to
be consistent in recording specialist interventions.
Even when support is readily available, families are not always willing to
engage with services. The following example is typical:
Mrs Jennings did not take up offers of therapeutic help for her three
children when they returned home to her, despite these being strongly
recommended. Mrs Jennings felt that the input would unsettle the children
and they themselves did not want to attend.330
The Home or Care? Study found that, in nearly one in ten cases, parents’ unwillingness
to engage with professionals, and with the services offered, contributed to the
decision to place children away from home.
Although engagement with services is sometimes regarded as a positive
indicator of parents’ attempts to overcome their difculties, it does not necessarily
distinguish between those families which will be successful in doing so, and those
which will not. Some parents interviewed in the Signifcant Harm of Infants Study
126 | Safeguarding Children Across Services
made it clear that they were aware that they had to appear to comply with plans
by keeping appointments, but had little intention of using the services offered
to address their problems. This issue has also been raised by both the Analyses of
Serious Case Reviews and needs to be taken into account in social work training and
supervision.
Even when interventions are acceptable and available, they may be too short to
facilitate lasting change. Specifc interventions are inevitably more focused than
those of children’s social care, and are often strictly time limited. This can be
problematic. For example, maltreating parents who receive time-limited substance
and alcohol misuse programmes may require support for much longer periods
than they are offered. Some specifc interventions achieve their greatest impact
within the frst few weeks or months, and there may be little value in extending
them; however, many families will still require more general ongoing support
after completing the programme.
The Home or Care? Study notes that in some cases social care interventions are, at
most, only limited, or short-lived, and the failure to change parenting behaviour
may result in a decision that the child’s needs will be best met through placement
away from home. However, the Signifcant Harm of Infants Study found no children
who were unnecessarily or prematurely removed from their birth parents.
Improving co-operation through inter-agency training
The new Local Safeguarding Children Boards should be required to ensure
training on an inter-agency basis is provided. Staff working in relevant
agencies should be required to demonstrate that their practice in interagency working is up to date by completing appropriate training courses.331
There is some evidence that inter-agency and inter-disciplinary working has
improved since the Victoria Climbié Inquiry Report in 2003.332 However, we have
also seen that many challenges remain and are manifest in working relationships
between different practitioner and professional groups that are characterized by
a lack of trust and reciprocity. One way to tackle the many cultural and practical
barriers which can act as obstacles to effective joint working is through interagency training, which LSCBs are mandated to arrange.
The Guidance on inter-agency working to safeguard children cites the InterAgency Training Evaluation Study, stating that:
Inter-agency training is highly effective in helping professionals understand
their respective roles and responsibilities, the procedures of each agency
Providing a Context for Effective Inter-Agency Practice | 127
involved in safeguarding children and in developing a shared understanding
of assessment and decision-making practices.333
Training for inter- and multi-agency work is defned as:
…training and education that equips people to work effectively with those
from other agencies to safeguard and promote the welfare of children.334
Introductory courses on identifying and responding to child protection concerns
are offered to a wide range of people in regular contact with children, including
nurses, teachers, librarians, fre ofcers and social workers. Some of these courses
are offered as e-learning programmes. More advanced courses are provided for
professionals working regularly with children and those who may be required
to contribute to assessments. These focus on effective, collaborative inter-agency
working, and on understanding roles and responsibilities. These courses, typically
over two days, include a focus on child protection conferences. Specialist courses
address a range of topics including safeguarding disabled children, safeguarding
children and domestic abuse, and safeguarding in the context of parental mental
illness and drug and alcohol misuse. Other specialist courses concern working with
young people with sexually harmful behaviours and female genital mutilation.
The Inter-Agency Training Evaluation Study investigated inter-agency training in
eight case study local authorities. The high-quality, time-series design incorporated
a pre-course baseline and a follow-up at three months. It was much more rigorous
than the standard “happy sheet” assessments that are routinely provided.
The project aimed to establish a substantial evidence base for inter-agency
training and set out to collect a large amount of data from a wide range of courses.
Training outcomes were measured using specially developed, validated scales
across a range of domains that included: attitudes to inter-professional learning;
knowledge of the topic (e.g. the effects of parental substance misuse on children)
and how to work together to safeguard children (i.e. inter-agency policies and
procedures); and attitudes to children and families in safeguarding situations and
to inter-professional working and self-efcacy (i.e. beliefs that you can work well
and effectively). There is substantial accumulated empirical evidence that selfefcacy is a powerful predictor of behaviour.335 An evaluation toolkit containing
all the materials is available on the Research Initiative website.336 The evidence
discussed below comes from this evaluation.337
Participation
The introductory courses are attracting much of the target audience of people
in contact with children, including support workers as well as nurses and social
workers. Social workers, teachers and nurses are well represented on at least some
of the advanced programmes. However, some groups including housing workers,
128 | Safeguarding Children Across Services
librarians and leisure staff are barely represented on any courses. There are also
three areas of particular concern:
• Alcohol and substance misuse workers do not generally attend inter-agency
training. Their attendance might do much to resolve the differences in
perspective and thresholds for action noted in earlier chapters.
• Hospital doctors and GPs are poorly represented on the advanced courses
on inter-professional working to safeguard children. Only 54 of the 96
GPs who responded to questionnaires in the General Practitioner Tensions
in Safeguarding Study had received any training in this feld in the previous
three years and only half of these had taken part in multi-agency events.338
This is both surprising and disappointing in the light of inter-collegiate
guidance which emphasizes flexible training and attendance for attainment
of competencies (including safeguarding) in the portfolio for revalidation.339
This is also a major concern in the context of evidence from government
reports, serious case reviews and the other studies in this Research Initiative
that suggests a continuing problem of trust and communication between
doctors and other practitioners in the child protection feld. Much training
of doctors is undertaken within the health system; in the absence of their
participation in LSCB courses, it is critically important that training should
deal effectively with child protection matters and the essential role of interagency working in protecting children.340
• Most of those who attend the advanced courses do so on a voluntary basis,
and the great majority are relatively inexperienced staff. Professionals with
more than fve years’ experience are generally not using these courses. It is
unclear whether they are not being put forward, or are given lower priority
by their employing agencies. Alternatively they may simply not be taking
opportunities to update their knowledge and skills. There was disturbing
evidence in the Signifcant Harm of Infants Study that some social workers did
not regard ongoing professional development as necessary once they were
qualifed.
Outcomes
The courses appear to be of a consistently high quality and they address the
learning needs of participants. Outcomes are remarkably consistent both across
different types of course and between LSCBs. They are encouraging. Attendance
brings substantial gains in knowledge of the topic (i.e. domestic violence and
child abuse; sexually abusing adolescents), and in self-confdence regarding
safeguarding policies and procedures. These positive outcomes are found
irrespective of the participants’ gender, age, ethnicity, service experience and the
compulsory or voluntary nature of their attendance.
Providing a Context for Effective Inter-Agency Practice | 129
The opportunity to learn and work together is also very highly valued, and
clearly promotes effective inter-agency working. Participants show very substantial
improvements in self-reported understanding of the roles of different professionals
who engage in work to safeguard and promote the welfare of children and in
confdence and comfort in working collaboratively. This has an important impact
on the self-confdence of social workers, and other professionals’ understanding
of their roles and responsibilities. Three months after the course these gains
appear to be maintained, although modest response rates at follow-up mean that
this evidence is relatively weak.
Inter-agency training courses, as provided by LSCBs, are therefore making an
important contribution to promoting better inter-disciplinary practice amongst
practitioners at local level. They are also cost-effective in that these one or twoday intensive courses produce signifcantly positive, lasting outcomes. However,
while this type of partnership working is mandated by central government, it
does not receive ring-fenced funding. Training relies very signifcantly on the
good will of partner agencies and the professional and personal relationships
developed locally. It is therefore particularly vulnerable to cuts, especially within a
context where changed responsibilities, greater diversity of service provision and
economic stringency may all re-ignite old tensions. It would be regrettable if the
strong platform of inter-agency training created in recent years were now allowed
to disintegrate and fall away.
How do existing structures support both inter-agency and
inter-disciplinary working?
This section focuses largely on fndings from the Local Safeguarding Children Boards
Study, the only one in the Research Initiative to focus on the structural context
of inter-agency working. The study involved a national mapping exercise and a
series of case studies of six Boards. Data from the mapping exercise were used to
inform Lord Laming’s Progress Report on The Protection of Children in England.341
Local Safeguarding Children Boards (LSCBs) were set up in 2006. They are
currently the key local strategic body responsible for co-ordinating and ensuring
the effectiveness of child protection and safeguarding services. The core objectives
of LSCBs, set out in the Children Act 2004, are as follows:

that purpose.342
The scope of the LSCB role falls into three categories:
130 | Safeguarding Children Across Services
First, activity that affects all children and aims to identify and prevent
maltreatment, or impairment of health or development, and ensure children
are growing up in circumstances consistent with safe and effective care…
Second, proactive work that aims to target particular groups…
Third, responsive work to protect children who are suffering, or likely to
suffer, signifcant harm…343
LSCBs were set up to address a number of weaknesses that had been identifed in
their predecessors, the Area Child Protection Committee (ACPC). These included
insufcient authority to deliver effective agreement on policies across a range of
service sectors; variations in levels of representation and membership, structure
and practice; poor leadership; and insufcient resources.344,345 The Boards also
have a wider role that is not only framed in terms of child protection but in
safeguarding and promoting the welfare of children.
The Munro Review346recognizes that LSCBs are uniquely positioned to monitor
how professionals and services are working together to safeguard and promote
the welfare of children. Recommendations to LSCBs to include an assessment of
effectiveness in their annual reports, and to ensure that these are submitted to the
most senior local leaders are designed both to strengthen their role and to ensure
that multi-agency accountability and partnership in safeguarding children is not
lost at a time of rapid change in public services.
Size matters
There are two ways in which the size of the strategic body matters: in the breadth
of its remit and in the representation of different professional groups.
Breadth of remit
It is not possible to separate the protection of children from wider support
to families. Indeed often the best protection for a child is achieved by timely
intervention of family support services.347
LSCBs currently have wide responsibilities, ranging from prevention of occurrence
of maltreatment to responsive work to protect children. While all Boards actively
seek to address the wider agenda and are signed up to its principles, those that
concentrate on the ‘core business’ of child protection and only expand into
prevention activities when resources permit are most successful.348 To be effective,
Boards need to set appropriate boundaries and determine what is feasible within
Providing a Context for Effective Inter-Agency Practice | 131
a given planning year, making allowances for resource-intensive activities such as
serious case reviews.
Board members from key sectors need to be involved to ensure their
commitment to plans. The role of Chair, as strategic lead, is central in ensuring
this takes place and in assisting the Board to determine and maintain its focus as
work programmes get under way.
Size, representation and shared responsibility
The future lies with those managers who can demonstrate the capacity to
work effectively across organizational boundaries.349
The Victoria Climbié Inquiry Report350 criticized senior managers and professionals
working in different agencies for refusing to share responsibility. Findings from
the Analyses of Serious Case Reviews also demonstrate that the problem of joint
responsibility has not yet been fully resolved. For example, the ‘silo’ working
mentality continues to be a repeated feature of cases which go seriously wrong.
Achieving cultural change and getting agencies to work together is extremely
challenging and requires cross-sector commitment.
As the key strategic bodies responsible for local co-ordination, LSCBs
need to have the appropriate composition, structure and leadership to gain
shared commitment across agencies. Active membership and participation by
representatives of partner agencies is of fundamental importance. However, whilst
all the core statutory agencies are meeting their membership obligations, there are
a number of practical issues that can hinder effective working. Many of these reflect
the sheer number of agencies with responsibilities for safeguarding children, and
the complexity of the task of ensuring their involvement in decision-making.
Securing the appropriate involvement of agencies within large structures such as
health and children’s services poses an ongoing challenge to Boards, both in terms
of identifying appropriate people to represent organizations and professional
groups and in getting consistent attendance. Levels of participation in meetings
may fluctuate; non-attendance by key partners impacts negatively on the work
programme of the LSCB and is very detrimental to progress. Membership of
the LSCB takes time, so some agencies, notably health and the police, operate
a system of member substitution which can impact on continuity, undermine
the collective identity of the Board, and lead to delays in the decision-making
process.
These problems are likely to intensify with the fragmentation of responsibility
for provision of local health and education services under new arrangements for
local GP-led commissioning and foundation trusts and free schools, independent
132 | Safeguarding Children Across Services
of the local authority. The Coalition Government has emphasized the continuing
importance of inter-sector co-operation in the interests of vulnerable children,
but it is yet to be seen how successful this will be at local level under new
arrangements.351
Managing communication within a complex structure
Poor inter-agency communication is a major feature of child protection tragedies.
The victoria Climbié Inquiry was highly critical of the narrow sectorial approach
adopted by front-line practitioners and their managers. The report found that
professionals construed their roles in compartmentalized terms and were too
focused on the narrow perspective of their own disciplinary interest to see whether
the wider welfare needs of the child were being met.
At a strategic level, leadership is needed to improve inter-agency communication.
There is some evidence that protocols aimed at facilitating information sharing,
developed by LSCBs, are clearer than they used to be and have increased trust,
thus promoting information exchange. However, concerns are still raised about
the speed of responses to requests for information and the unwillingness of certain
groups, particularly GPs, to share it.
Another way of improving inter-agency communication is through membership
of the Board. However, achieving appropriate involvement from professionals is
not without its difculties and has proved challenging. For example, while general
practitioners and head teachers do not necessarily need to sit on the LSCB,
mechanisms do need to be in place to input their views and to ensure that they
are fulflling their safeguarding responsibilities. The ‘quasi autonomous’ status of
these professionals can also raise challenges. It is difcult to fnd representatives
to become members of Board structures to gain effective involvement of these
professional groups. Some of these issues are being addressed for GPs in the Health
and Social Care Bill (2011) before Parliament at the time of writing, which will
make GP-led clinical commissioning groups statutory members of LSCBs.
One way to tackle insufcient involvement is through specialist subgroups.
The Local Safeguarding Children Boards Study showed that all Boards have developed
specialist subgroups to increase active participation and gain wider involvement
of professionals and relevant practitioners. The scale and focus of subgroups on
each Board varies considerably; there is an average of 6, but a range from 2 to 20.
An ‘inclusive model’ that engages as broad a membership of the LSCB as
possible, with a large number of subgroups, has the advantage of greater numbers
to promote greater awareness amongst professionals and direct links into
practice. However, it is unwieldy to manage and the contribution of subgroups to
planning and development is limited. Another problem is a relative lack of clarity
amongst subgroups about their role. By contrast an ‘exclusive’ model that restricts
membership of the Board and controls the composition of subgroups ensures that
all contribute directly to development and planning and engage in good joint
Providing a Context for Effective Inter-Agency Practice | 133
communications. However, in such a model there are no direct routes (apart from
representatives on the Board) into professional practice and information is not
always widely disseminated.
Leadership issues
The sheer size and complexity of the strategic partnership that forms the LSCB
means that strong leadership is required if it is to fulfl its functions.352 Moreover,
the two Laming Reports353,354 highlight the continuing signifcant issues of
accountability and challenge. Accountability requires managers in different
agencies to embrace their responsibilities and provide leadership to those at more
junior levels. A signifcant role of the LSCB is both to promote this style of
leadership amongst partner agencies and to encourage a culture of challenge,
without blame, between agencies and disciplines. A further important task is
to challenge agency managers about the quality of their service delivery when
concerns are identifed.
Leadership of the LSCB is therefore a very demanding role. LSCB Chairs need
to provide a sense of direction to ensure that the Board has an independent voice
and operates effectively. They also need to be of sufcient standing and expertise
to gain both respect and authority from Board members not only to manage
meetings and provide effective leadership, but also to act as a core representative
for the LSCB in external meetings with partners and other bodies.355
In the wake of the serious case review into the death of Peter Connelly356
and the subsequent Progress Report,357 Boards were instructed to work towards
appointing independent Chairs. The Local Safeguarding Children Boards Study found
that there were strengths and weaknesses to this arrangement. The advantages
of an independent Chair are to be found in the enhancement of the Board’s
independence and hence its capacity to challenge agency decision-making.
However, there are also attendant problems. For example, it is difcult for
independent Chairs to establish effective links to local networks and structures
because they are not routinely part of these.
In terms of accountability, there are also challenges since Chairs usually report
to the Director of Children’s Services. This can cause problems for independent
Chairs who may wish to challenge the operation of children’s services. Similar
difculties arose in relation to accountability to the Children’s Trust. The research
found that this ‘mutual accountability’ of being both accountable and ‘scrutinized’
by the Trust, especially when people can be members of both organizations, was
not appropriate. An alternative option, linking accountability to either (or both)
the chief executive’s ofce or political scrutiny, is recommended. This allows the
independence of the LSCB to remain, while also establishing a form of public
accountability.
Steps should also be taken to ensure the authority of the Chair and the
LSCB is acknowledged and respected by agencies, enabling them to engender
134 | Safeguarding Children Across Services
changes in policy and practice to safeguard and promote the welfare of children.
Independent Chairs can have difculty getting different partners to respond to
their requirements. In this case the chief executive can be involved and mechanisms
for resolving non-compliance should be agreed by agencies. It is important that
mechanisms for addressing such issues are transparent and that there is a shared
understanding of the actions that will be taken if agencies are perceived to have
failed to respond to issues raised by the LSCB.
In addition, the implications of non-compliance with Board recommendations
should be clarifed and systems should be put in place to support the resolution of
differences of opinion. The serious case review into the death of Peter Connelly358
found, for instance, that, in making decisions, equal weight was given to the
opinions of all members of the LSCB, regardless of their expertise in the issue
under discussion. More attention might need to be given to exploring how
decision-making can be better balanced.
Resource issues
To be effective the LSCB needs adequate resources to support its infrastructure
and business activities. Without adequate support, independent Chairs are unable
to operate effectively, independently from children’s social care services. The
Children Act 2004 made provision for payments to be made in connection with
an LSCB to provide stronger support.359
Two thirds of Boards have established an executive group to progress business
and separate strategic and executive matters. The majority have also appointed a
full-time business manager, a role that is seen as fundamental to their effective
functioning. However, staff turnover is a problem: every Board experienced a
change of business manager over the course of the Local Safeguarding Children
Boards Study.
As we have already seen, Boards have been active and successful in developing
inter-agency training. However, one area of particular concern is that insufcient
attention is given to the training (and career progression routes) for business
managers, given their high level of turnover. Access to training is also needed for
independent Chairs, but they are usually contracted for a relatively low number
of days so opportunities can be limited. There is a need for clear training plans to
be put in place to address these needs.
Without adequate funding and the release of staff to attend meetings and
undertake activities to take forward work, LSCBs are unable to operate effectively.
yet resourcing of the independent Chair post, and, in some cases, administrative
support, can be a problem. Fifty-four per cent of Chairs reported that their
budget was adequate for their LSCB to function effectively, but given funding
uncertainties and staff turnover, inadequate support may prove to be a continuing
constraint on the effective operation of Boards.
Providing a Context for Effective Inter-Agency Practice | 135
The sharing of fnancial responsibility across agencies has proved to be another
continuing challenge. Resource shortages and differences in funding mechanisms
are known to hinder inter-agency working.360 Key contributing agencies to
the funding of LSCBs are children’s services, health and the police. Bodies can
contribute fnance or staff, goods, services, accommodation or other resources.361
However, the levels of funding needed for effective operation and the relative
contributions of individual agencies are not prescribed. As a result, there are
considerable variations in LSCB budgets and expenditure, and the contributions
from agencies. The Local Safeguarding Children Boards Study collated data from 18
Boards and found that the local authority and children’s services made the largest
contribution to the operation of LSCBs, followed by health. Table 6.1 shows the
range of fnancial contributions by agency.
Table 6.1: Financial contributions to the operation of LSCBs by agency362

Analysis of the minutes of Board meetings also reveals considerable time is spent
discussing these issues. Annual negotiation of the various agencies’ fnancial
contributions to the LSCB and uncertainty concerning the budget from year to
year can limit the scope for effective strategic planning. A common complaint
is the absence of a funding formula to clarify the contributions from individual
agencies.
In the current fnancial climate there is a danger that funding contributions will
fall as agencies seek to reduce their budgets. This is likely to exacerbate existing
tensions between agencies, further limit the scope for effective strategic planning
and consequently limit the capacity of LSCBs to fulfl their responsibilities.
136 | Safeguarding Children Across Services
Conclusion
There is compelling evidence of the need for effective inter-disciplinary and
inter-agency working at all stages of child protection work. Evidence comes from
multiple ways of looking at service delivery including analyses of what happens
when things go wrong, and research on everyday routine practice. It is also clear
that joint working both at an inter-agency and front-line level is difcult and
involves overcoming cultural differences as well as organizational and cross-sector
boundaries. The challenge is to achieve continual improvement in the interests of
children and families.
In the last 20 years or so, many reforms have addressed efforts to promote
joint working at the local level. Reforms introduced by the Children Act 2004
sought to improve services to children both in terms of joint working of front-line
services, and co-ordination across agency boundaries at the strategic organizational
level.363 There is evidence of some success at both front-line and strategic levels
but much improvement is still needed, building on the developments of the past
to deliver an effective joined-up approach to children and families.
Many new changes are now on the horizon. These take the shape of reforms
to the confguration of local services which provide the context in which
safeguarding and child protection services are delivered. The reforms affect three
key areas: child protection service delivery; local health service delivery; and
new arrangements for greater independence of schools under academy and free
schools arrangements.
The impact of the Munro Review of Child Protection364 is likely to result in a
greater focus on promoting standards of professional practice by social workers and
professional judgement in work with children and families. The recommendations
are intended to improve the quality of practice, with a more confdent workforce
being able to develop better relationships with other professionals. Recording
systems are likely to be restructured, and it will be important to ensure that the
capacity for information sharing and exchange maintained. The recommendations
from the Munro review are also designed to ensure that an emphasis on multiagency accountability and partnership working are maintained throughout new
challenges and changes to the structure and delivery of services. They specifcally
identify the need to research the impact of health reorganization on effective
partnership arrangements.
The impact of NHS reforms is likely to pose challenges in terms both of
strategic thinking about safeguarding and of commissioning services. New clinical
commissioning may decide not to invest in multi-disciplinary services. This may
have negative consequences on innovative approaches to meeting the needs of
vulnerable children. The NHS White Paper, Equity and Excellence: Liberating the
NHS,365 and associated ofcial announcements provide reassurances that local
authorities, through Health and Wellbeing Boards, will have a duty to ensure
the supply of joint services to vulnerable groups, including greater flexibilities
Providing a Context for Effective Inter-Agency Practice | 137
in sharing NHS/local authority budgets. However, voluntary arrangements
have proved unsatisfactory in the past and, with GP-led consortia as the major
commissioners, as yet there is no evidence of how investment in these services
will be assured.
The impact of schools reform on protecting vulnerable children is as yet unclear.
More independent status for schools may lead to improved educational outcomes
for disadvantaged children and head teachers may increase their investment in
school nursing and education welfare/psychology services. However, it may prove
increasingly difcult to fnd ways to involve head teachers in Local Safeguarding
Children Boards or to achieve a strategic voice for education services in LSCB
arrangements.
The studies show that, though there have been some improvements, much still
needs to be done at both practitioner and organizational level to promote better
inter-agency working. Forthcoming changes will need to ensure that agencies
continue to work more closely together to ensure that children are properly
safeguarded from harm.
Key messages for all who work together to safeguard
children
• Inter-disciplinary and inter-agency working is vital at all stages of child
protection work. Evidence comes from multiple ways of looking at service
delivery, including analyses of what happens when things go wrong and
research on everyday routine practice.
• Important advances have been made in recent years at the practice
level through innovative approaches to service delivery such as mixed
disciplinary teams and co-location of workers.
• There are also slow but important advances in a shared sense of
responsibility between agencies and reductions in the silo mentality to
working. It is important to build upon these gains.
• Local Safeguarding Children Boards have played an important part in
building stronger relationships through providing high-quality interagency training and building networking arrangements between and
across disciplinary groups.
• There are risks that these advances could be lost as a result of radical
restructuring of services.
Key messages for policymakers
• Care needs to be taken to ensure that proposed reforms to the NHS and
to schools do not unintentionally impact on recent advances in interagency and inter-disciplinary working.
138 | Safeguarding Children Across Services
• Care needs to be taken to ensure that measures to restrict public
spending do not have a negative impact on initiatives to share fnancial
responsibility for maltreated children, and specifcally on the work of
Local Safeguarding Children Boards.
Key messages for practitioners
Health professionals
• GPs should give much greater priority to demonstrating safeguarding
children competencies as set out in the Safeguarding Children and Young
People: Roles and Competences for Health Care Staff 366 inter-collegiate
document.
• Members of the health team should take a more proactive role in cases
where they are uncertain whether a child is suffering signifcant harm and
so referral to children’s social care is required. There are many suitable
early interventions available which could be offered to families and
children (see Chapter 3).
• Referral should not be seen as absolving the referrer from further
involvement but rather as a step to protecting the child and safeguarding
the welfare of children and families.
Practitioners in adult services
• Practitioners in mental health, substance abuse and intimate partner
violence services need to establish better links with colleagues in children’s
social care to ensure that suspicions or concerns about possible risks of
children being maltreated are recognized and acted upon. These could be
initiated through attending inter-agency training.
Social workers
• The failure to respond with feedback to referrals is a signifcant difculty
in gaining co-operation and good working relationships with other
professionals such as those in health and education. Specifc efforts
should be made to improve responses to referrals, including those from
concerned members of the public, by adopting good practice methods for
ensuring feedback is given a high priority.
Providing a Context for Effective Inter-Agency Practice | 139
Strategic management of services at local authority
level
Directors of adult and children’s services
• Urgent arrangements need to be put in place to build systematic links
between adult services in mental health, substance abuse and intimate
partner violence with children’s social care services to ensure that
suspicions or concerns about possible risks of children being maltreated
are recognized and acted upon.
Clinical commissioning groups
• There are risks that as a result of the reconfguration of commissioning
arrangements some of the advances made in inter-agency practice may
be lost. Strenuous efforts need to be made to avoid the loss of valuable
multi-disciplinary working, including embedding practitioners in other
services.
Local Safeguarding Children Boards
• Inter-agency training is effective and highly valued by participants.
Courses are well run and of a high standard. Training committees should
be supported and properly resourced.
• Focusing on the core task of safeguarding children from harm and
keeping the number of subgroups to a manageable level may be the most
effective ways of working.
Chairs of Local Safeguarding Children Boards
• The opportunities for building cross-sector arrangements and joint
engagement in planning are valued and important. As well as dealing
with the business aspects of the task, efforts need to be redoubled to
improve networking both amongst and between disciplinary groups as
provided by subgroups and specialist groups.
7
Overview
Principal Messages and their Implications
Introduction
This Overview draws out the messages from 15 studies conducted following
the tragic deaths from abuse and neglect of victoria Climbié in 2000 and Peter
Connelly in 2007. The Inquiry which followed the death of victoria Climbié367
identifed three areas which required further research: identifcation and initial
responses to abuse and neglect; effective interventions after maltreatment or its
likelihood had been identifed; and effective inter-agency and inter-disciplinary
working to safeguard children. Similar issues were also raised by Peter Connelly’s
death. The 15 studies focus on these issues. The full list of studies has been
given in Chapter 1, Table 1.1, and short synopses are given in Appendix 3. Full
research briefs, reports and information concerning related publications can be
downloaded from the Safeguarding Children Research Initiative website at www.
education.gov.uk/researchandstatistics/research/scri.
Why is it important to identify neglect and emotional
abuse early and take action?
Many of the studies have focused specifcally on neglect and emotional abuse.
These were both key components in the deaths of victoria Climbié and Peter
Connelly, although both victoria and Peter were also physically abused. Despite
being the most prevalent forms of maltreatment, neglect and emotional abuse
have previously received less research attention in the UK.
Chapter 2 discussed both the causes and consequences of abuse and neglect.
There is compelling evidence to show that parents who maltreat their children
are frequently struggling with problems such as poor mental health, substance
and alcohol misuse, and domestic violence.368 Such difculties are particularly
conducive to abuse and neglect when they occur in combination and/or are
compounded by other stressors such as parental learning disability, fnancial or
housing problems and unsupportive or inadequate social and familial networks.369
A number of studies have explored the manner and extent to which such problems
impact on parents’ capacity to meet their children’s needs370 and increase the
likelihood of neglect and emotional abuse as well as other forms of maltreatment.
140
Principal Messages and their Implications | 141
One reason why it is so important to identify emotional abuse and neglect
early and take action is because they frequently frst occur in early childhood
(often before birth) when their impact can be particularly severe. What happens
in the frst three years of life is critical to children’s subsequent development,
because successful completion of the early developmental tasks of infancy and
toddlerhood impacts on the extent to which children are able to negotiate later
developmental stages.
A growing body of research has demonstrated the extent to which neglect
can impact on the neurological and endocrine development of infants, affecting
those parts of the brain that are concerned with emotional life and its regulation
and increasing children’s vulnerability to a range of psychological, emotional and
physical health problems.371,372
Emotional abuse is an element of all types of child abuse, although it can occur
on its own. It may be the most damaging type of child maltreatment, particularly
in the early years, because it represents the antithesis of a child’s need for safety,
love, belonging and wellbeing by the person responsible for meeting these needs –
their primary caregiver. It compromises children’s ability to negotiate the primary
tasks of infancy: forming a secure attachment with an adult caregiver, developing
trust in others to provide a stable environment and becoming confdent in their
own ability to solicit the care they need.
Early recognition is necessary if long-term damage is to be avoided, because
the effects of emotional abuse and neglect appear to be cumulative and pervasive.
Both these types of child abuse have serious adverse long-term consequences
across all aspects of development, including children’s social and emotional
wellbeing, cognitive development, physical health, mental health and behaviour.
Failure to recognize and address these forms of maltreatment may result in lifelong damage to the child and high costs to society through burdens on health
and other services.
While the frst three years are important, the impact of maltreatment is also
damaging at all stages of childhood, including the teenage years. By adolescence
‘neglect and/or neglectful parenting are associated with poorer physical and
mental health, risky health behaviours, risks to safety including running away,
poorer conduct and achievement at school and negative behaviours such as
offending and anti-social behaviour’.373 Emotional abuse is also associated with
teenage suicide.
However, although emotional abuse and neglect may be the most damaging
types of maltreatment, they are also the most difcult to recognize and respond
to. This is because they are long-term, corrosive conditions which rarely erupt
in the type of crisis that precipitates action. There are particular difculties in
determining when these types of abuse have reached a threshold for referral to
children’s social care or for action by the courts.
142 | Safeguarding Children Across Services
Early intervention is of key importance. All forms of maltreatment, including
emotional abuse and neglect, are most likely to be frst indicated to professionals
across a range of universal and targeted services: health professionals, the police,
nursery nurses, teachers and educational psychologists. Primary health care
professionals such as GPs, midwives and health visitors are in a unique position to
recognize early signs of parental and child difculties and to identify poor parent–
infant interaction. Teachers and nursery nurses see children on a daily basis and
are in the best position to identify chronic, slowly deteriorating situations.
Practitioners in adult services are likely to be well placed to consider the
potential impact of parents’ problems on children’s welfare and it should be
routine practice for them to do so. The police are often the frst agency to become
aware of domestic violence, often associated with community violence as well
as physical and emotional abuse of children. In order to recognize and respond
adequately to emotional abuse and neglect, all these practitioners, as well as those
who work in children’s social care, will need to be aware of:
• the growing body of research on child development which demonstrates
the consequences of maltreatment for children’s mental and physical health,
learning and education, socialization and life chances
• key signs and symptoms to look for in children, young people and in parents
that indicate the likelihood of maltreatment
• the damage that can derive through not taking action, or through delaying
decisions about intervention
• what steps to take as a practitioner, whether alone or in conjunction with
others.
Chapter 2 described in some detail a number of recognized signs and symptoms
that should alert professionals to consider whether maltreatment is likely. These
range from passivity, sudden weight loss and poor infant–parent interaction in
very young children to emotional and behavioural difculties and risk-taking
behaviours in adolescents. They may also be manifest in indicators such as
parents’ social isolation from their local community and from health, education
and children’s social care services; their failure to attend appointments for routine
medical services or delays in their seeking medical treatment for childhood
accidents such as burns and scalds; in their lack of attention to children’s education;
and in poor supervision or exclusion from the household of older children and
teenagers.
What can be done to prevent abuse and its recurrence?
Although maltreatment can have long-term adverse consequences for children,
there is increasing evidence as to how it can be prevented or its consequences
Principal Messages and their Implications | 143
mitigated. Knowledge about ‘what works’ is improving; it is important to use
existing evidence well, to ensure that interventions are selected on the basis of
their proven effectiveness and to evaluate them rigorously.
Population-based and targeted approaches
It is clear that early interventions are of paramount importance. Programmes
that prevent the occurrence of maltreatment are likely to be more effective
than those that address its consequences. They also require practitioners to be
proactive, rather than reactive, moving the focus from considering thresholds
for intervention to exploring how parenting can be improved in the population
as a whole, on a public health basis. A population approach is non-stigmatizing,
more likely to reach families early and prevent escalation of abuse, and more
likely to reach those children whose maltreatment tends to pass unnoticed. Such
an approach may be effective in shifting normative behaviour and so influencing
extreme behaviour patterns in a positive direction.
Effective population-based approaches include legislative change, mass media
public education programmes and universally accessible parenting programmes.
Examples include the introduction of legislation to ban physical punishment in
some countries, the Healthy Child Programme374 currently implemented across
the UK and the Triple P-Positive Parenting Programme being introduced on
a population-wide basis in Glasgow.375 There is a case for using a populationbased approach to address issues that are particularly pertinent to adolescents,
such as exploring normative standards of parental monitoring and supervision
outside school and reducing violence in early intimate partner relationships, both
of which might respond to mass media public education programmes.
There is also a place for targeted programmes to prevent abuse and neglect
amongst vulnerable populations. The most effective targeted programmes being
introduced in the UK at present are some (though not all) home-visiting programmes
such as Nurse Family Partnerships376 and validated parenting programmes such
as the Webster-Stratton Incredible years.377 Targeted approaches are valuable but
they need to be carefully piloted, adapted, if necessary, to a UK context and
thoroughly trialled before being implemented on a widespread basis.
Specialist interventions to safeguard children from harm
Where abuse has occurred or the likelihood is strong, families will need intensive
support to prevent its recurrence or to mitigate its impact on children. Some
parents can and do overcome extensive difculties and succeed in providing a
nurturing home for their children, sometimes after an older child has been placed
for adoption. Factors that indicate that parents may have the capacity to change
include the development of insight into how problems such as substance misuse
have affected their children and the part that their actions may have played in
144 | Safeguarding Children Across Services
previous separations; genuine rather than superfcial engagement with services;
and for many, a wake-up call when they have realized that they will need to take
substantial action if they are to meet their children’s needs. Parents who succeed
in making sufcient and sustained changes appear to have been less likely to have
experienced abuse in their own childhoods – an ominous indicator of the longterm, sometimes inter-generational consequences of maltreatment. We need more
research, however, to test out the reliability of these indicators, to understand
more about the causes and timing of positive change, and to learn more about
why some parents become more motivated to change than others.
A number of specifc, validated programmes are now available to support
parents in making necessary changes and help them sustain them. However, parents
need to be motivated to change before entering such programmes. Chapter 5
of this Overview offered ten examples of programmes that have been rigorously
evaluated and shown to promote positive change on the range of issues covered by
the studies.378 Those available include programmes that focus on parents; parents
and children together; wider families; and children alone. Selected examples of
programmes that focus on parents include effective interventions for: substancemisusing parents;379 and parents who have been exposed to harsh parenting and
abuse in their own childhoods.380 Those that focus on parents (and/or wider
family members) and children together include interventions to improve: maternal
and child representations where there is a known history of abuse in the family;381
parent–child relationships in infants with faltering growth;382 and interventions to
reduce physical abuse and parent–child conflict.383,384 Effective programmes that
focus on mitigating the consequences of abuse for children include a therapeutic
preschool for neglected infants;385 peer-led social skills training for maltreated
and socially withdrawn children;386 and interventions for maltreated children
who require placements away from home.387 Programmes such as these form part
of the increasing body of evidence about effective interventions in families where
child abuse and neglect are already evident or likely to occur.
When descriptions of these interventions are juxtaposed, as in the previous
paragraph, it is obvious that they address overlapping populations; most families
where abuse and neglect occur will experience multi-faceted problems that
impact on both parents and children. It is therefore difcult to select a specifc
intervention that addresses all their needs. Moreover, the interventions themselves
have numerous elements in common, and again treatment content, techniques and
parameters often overlap. It may be possible to develop an approach which distils
the common elements from existing evidence-based interventions to address
diverse and complex cases. Whether such an approach can be converted into
effective practice will need to be tested on a small scale initially.388
Care should be taken in commissioning specifc interventions as not all of
those available have been successfully evaluated.389 Commissioners should frst
consider whether, if developed elsewhere, an intervention has been successfully
Principal Messages and their Implications | 145
adapted for a UK context. In assessing the fndings of any evaluations, they will
also need to take account of the evidence level of the study design; the size of the
sample and the rate of attrition; whether there is evidence of sustained change
– and for how long. They will also need to consider whether the intervention
is sufciently flexible to be adapted to allow for complexity and diversity of
cases; and how to make good use of locally available practitioners’ expertise and
resources. Some existing interventions, that have no proven effectiveness, may
need to be dropped in favour of those where the evidence base is more robust.
Social work interventions to safeguard children from harm
Specifc, focused interventions may be offered as part of a package of intensive
support that will include more generic social work casework. Three studies in
the Research Initiative collected primary data from social work case fles and
interviews with professionals, parents and children, to explore the impact of these
interventions.390,391,392
Proactive social work can be very effective. Outcomes for children tend to
be better where there is evidence of careful assessment, thoughtful planning
and proactive case management. Children and families also receive a better
quality of service if social care involvement is the compulsory result of a child
protection plan or a care order than if it is offered on a less intrusive, voluntary
basis. However, the quality of assessment and planning tends to vary signifcantly
between different authorities and indeed between different teams within the same
authority, suggesting that supervision, culture, training and experience have a
major impact on effective case management.
Although some of these research messages are positive, there is also evidence
that many children are left for too long or returned prematurely to abusive or
neglectful families where their welfare is inadequately safeguarded. There are
numerous reasons why this happens. First, there is evidence that many social
work practitioners are insufciently aware of the impact of abuse and, particularly,
neglect on children’s long-term welfare or of the need to take swift and decisive
action when very young children, including those in utero, are suffering signifcant
harm. Theories of child development should be a central element in social
work training, but the subject is often quickly passed over and soon forgotten.
Practitioners are also often insufciently aware of the need to understand a family’s
previous history in order to make sense of present circumstances and to assess
any evidence of change. There is also evidence that practitioners can become
desensitized to evidence of neglect or so overwhelmed by parents’ difculties that
they are unable to see the situation clearly and, in particular, the child’s needs.
Second, almost all decisions made by the wide range of practitioners involved,
from health, adult mental health, education and the family justice system as well
as by professionals in children’s social care, are made in the expectation that
children will fare best if looked after by their birth families. This is in keeping
146 | Safeguarding Children Across Services
with the Children Act 1989 and with human rights legislation, as well as with
social work values and theories of empowerment. However, it means that decisions
to separate children from their families go very much against the grain and are
particularly difcult to make. Expert assessments ordered by the courts tend to
follow this line, as do court decisions themselves, with the result that parents are
given numerous chances to demonstrate their capacity to look after a child; if
these efforts prove unsuccessful they delay the progress of a case to the detriment
of children’s welfare.
Practitioners are not always aware of the urgency of children’s timeframes.
very small children are more likely to develop secure attachments to permanent
carers if they are placed within their frst year. If they are left too long in abusive or
neglectful families pending a decision to separate them, their long-term wellbeing
may be compromised both by the far-reaching consequences of maltreatment, by
the later impact of rupturing secure attachments with temporary carers, and by
the difculties of fnding permanent placements as they grow older. There is also
evidence that, after children reach the age of six, proactive case management
tends to diminish as the chances of achieving permanency recede. In fact, parents’
timeframes also appear to be relatively short: there is some evidence, that needs
ratifcation, that the birth of a baby can serve as a catalyst, and those parents who
are able to make the often radical changes required to offer a nurturing home
will have done so by the time the child is six months old. Many such parents will
have begun the process of change before the baby is born. Those who have not
succeeded in making signifcant changes within this timeframe may be unlikely
to do so within the timescale of the child concerned, but may make sufcient
changes at a later date to care for subsequent children.
While all those involved may strive to keep children out of care or
accommodation or to return them swiftly to their birth families if separation
becomes necessary, the evidence suggests that maltreated children, and particularly
those who are neglected or emotionally abused, may beneft by being looked after
away from home. Where there has been evidence of past abuse, and particularly
neglect, maltreated children who remain looked after fnd greater stability and
achieve better wellbeing than those who return home. The Home or Care? Study
found that those who remain looked after are less likely to have misused alcohol
or drugs or to have committed offences than those who return home; they have
signifcantly better mean scores for health; they are more likely to have close
adult ties; and they are more likely to have a range of special skills, interests and
hobbies. They are less likely to be in pupil referral units, in alternative forms of
education, without a school place or to be persistent truants than those who
return home.393
We have quoted these fndings in full because concerns about the poor outcomes
of care are widespread. yet all three empirical studies in this Research Initiative,
as well as an increasing body of other research, demonstrate that the majority
Principal Messages and their Implications | 147
of children who become looked after in the UK today beneft from care.394,395,396
This is not to say that the concerns are unfounded: unstable placements, low
aspirations and insufcient support for young people as they move towards
independence are all long-standing problems that have not been sufciently
addressed.397,398,399 There is also evidence that some residential and foster homes
are at best insensitive to children’s needs and at worst openly abusive.400
Nevertheless, taken as a whole, when compared with their home circumstances,
care is often a positive alternative for children and young people who have been
maltreated. However, a major problem is that, though it may offer a safer and more
nurturing environment, care can, as yet, rarely compensate for past disadvantages.
We have seen how children and young people who have experienced maltreatment
may require intensive, specifc interventions to help mitigate the consequences of
abuse and neglect. Although, as previously indicated, the evidence about effective
interventions is growing, and some that have been validated elsewhere are now
being adapted and trialled in the UK, they are not widely available. Nor are many
carers sufciently trained to provide the intensive, specialist support required.
There is also a paucity of interventions that are tailored to the needs of neglected
adolescents. Moreover, there is often a loss of continuity: when children move
placement or return home from care or accommodation they may cease to access
a programme of support that was previously available.401 There is clearly a need
to develop this area further so that care becomes a more specialist service, offered
as one element in a package of specifc interventions aimed both at safeguarding
children and young people and helping them to overcome the consequences of
abuse and neglect.
One feature of both the generic interventions of social workers and the more
specifc interventions from psychologists, psychiatrists and other specially trained
professionals is that they may be offered for too short a period or withdrawn too
abruptly. Many of the parents and children who access such interventions have
entrenched and deep-seated problems that are unlikely to be overcome within a
few weeks or months. Most specifc interventions are strictly time-limited; if the
impact is to be sustained, ongoing, less intensive support and relapse prevention
needs to be offered for a longer period. However, more generic social work family
support is often also of very short duration. Half the child protection plans for
the babies in the Signifcant Harm of Infants Study were for 32 weeks or less, and
almost all for less than a year. Similarly, wherever possible the least intrusive
intervention is chosen, so that children who are placed on care orders tend to
be placed with their parents at the frst opportunity and, in fact, many of them
never leave home. Cases are also quickly closed; when parents have overcome
substantial adversities, there is little formal monitoring to check that change has
been sustained. Expectations that abusive parents will re-refer themselves if they
run into further difculties are unrealistic.
148 | Safeguarding Children Across Services
This tendency for specialist, tertiary, interventions to be offered on a short-term
basis and then prematurely withdrawn can be counter-productive and, in the long
term, costly.402,403 About two thirds of looked after children who return home are
subsequently readmitted, and those who experience repeated, failed, attempts at
reunifcation have the worst outcomes. Nevertheless pressures to close cases will be
exacerbated as services are reduced in response to the current economic situation.
If children are to be adequately safeguarded in such circumstances there is a
greater need for inter-agency co-operation. Where there is a risk of maltreatment
or its recurrence, children and families will continue to need transitional, and in
some cases long-term, multi-disciplinary support from cross-sector services such
as health, mental health, social work and education.
How can we ensure that inter-agency working works well?
The reports following the deaths of victoria Climbié and Peter Connelly both
stressed the importance of improving inter-agency and inter-disciplinary working
to ensure that maltreatment is recognized and responded to early and that the
multi-faceted needs of children and family members are addressed in a coordinated way. The consequences of not doing this are high, both to children
individually and to society. The studies in the Research Initiative found that there
have been improvements, but there are many issues that still need to be addressed.
Inter-agency working at practitioner level
At a practitioner level there are concerns about high thresholds for referrals to
children’s social care and about the lack of feedback when they are made. There
are also concerns about the limits of responsibility: at present there can be a hiatus
at the point of referral to children’s social care and at the point of case closure,
where children may be left in limbo, without adequate support. If specialist
services are unavailable or reduced then targeted services need to be made more
accessible to ensure that children are adequately safeguarded.
There are also concerns about different perceptions of risk of harm between
professionals. Where the role of professionals is to focus on parents, as is the case
with substance abuse workers, or both parents and children, as is the case with
GPs, there may also be divided loyalties. Better networking and communication
at practitioner level can help to dispel some of the misperceptions about the roles
of other professionals and resolve some of these difculties.
Developing multi-disciplinary teams and embedding practitioners in other
services is a valuable way of improving inter-agency working. Attendance
at LSCB inter-agency training events has also been shown to be an effective
means of forging links and fostering better understanding of shared roles and
responsibilities. However, at present those practitioners who are least engaged
in inter-agency working are also the least likely to attend. This is an issue that
Principal Messages and their Implications | 149
might be addressed as part of continued professional development for GPs and
professionals in adult services.
Inter-agency working at local and national level
LSCBs should note that the inter-agency training they provide is highly valued
and effective in terms of both impact and costs. The opportunities LSCBs offer
for building cross-sector arrangements and joint engagement in planning are also
important and have done much to break down silo mentalities. However, LSCBs
require adequate resources to support their infrastructure and business activities
if they are to be effective. LSCBs might restrict their role, and indeed there is
evidence that focusing on the core task of safeguarding children from harm and
keeping the numbers of subgroups to a manageable level may be the most effective
ways of working. However, for them to function properly, training subcommittees
should be supported and properly resourced, as should the post of the business
manager. At present LSCBs are jointly funded by the various agencies which
share responsibilities for safeguarding children, but there is no funding formula
to clarify their proportionate contributions. In the current fnancial climate these
may fall as agencies seek to reduce their budgets. There is a danger that this will
exacerbate tensions between agencies and limit the capacity of LSCBs to fulfl
their responsibilities for safeguarding children.
At a national level, there are concerns that proposed reforms to the NHS and
schools might unintentionally impact on recent advances in inter-agency and
inter-disciplinary working. The links that bind agencies together into partnerships
are fragile and easily destroyed; many are dependent on hard-won trust that can
swiftly be lost. New arrangements such as the proposed Health and Wellbeing
Boards need to be sufciently robust to ensure that greater diversity of provision
and increased freedom to innovate do not inadvertently lessen collaboration.
Conclusion
The purpose of this Overview is to distil the messages from a research programme
developed to strengthen the evidence base for the development of policies and
practice to improve the protection of children in England. Each chapter ends with
a resumé of the key messages from the research on the topic covered.
Many of these messages are not new: failure to attend to early warning signs,
lack of understanding of child development, delays in responding to children’s
timeframes, and unresolved professional tensions have all been identifed before
as key issues to address in improving the way that children are safeguarded. One
of the key questions for policymakers is how to ensure that these messages are
better implemented in the drive to improve services, and why it is so difcult to
do so.
150 | Safeguarding Children Across Services
In our view, the most important messages to be drawn from the Research
Initiative as a whole are as follows:
1. Efforts should be made to facilitate a closer alignment between targeted
services and GP as well as specialist services, so that families considered
to be at risk of harming their children are better supported when they fall
below the threshold for social care intervention, both prior to referral and
following case closure.
2. Social workers and social care agencies should ensure that feedback to
referrals is given a higher priority.
3. Better systematic links are needed between adult services in mental health,
substance misuse and intimate partner violence and GPs and children’s
services to ensure that risk factors for abuse and neglect are identifed and
concerns about children being maltreated are acted upon.
4. There is a strong case for developing public education campaigns aimed at
promoting good parenting supervision, reducing adolescent neglect and
reducing intimate partner violence in early adolescence.
5. The neglect of adolescents is too often unnoticed. Anti-social behaviour, risky
behaviour such as experimenting with drugs, and very poor performance in
school should be seen as possible signs of parental neglect of older children.
Targeted programmes to reduce risky behaviour amongst adolescents and
to promote positive models of parental supervision need to be developed
and tested in the UK.
6. Thresholds for referral to children’s social care and the family courts need to
be clearly articulated and agreed at the most senior managerial level. There
should be formal discussions between local authority senior managers, legal
departments and the judiciary concerning appropriate thresholds for taking
legal action. Post-order reviews of children’s progress would provide useful
feedback.
7. Child development should be given a very high priority in social work
training and continuing education. There is abundant evidence in the
studies of insufcient appreciation of fundamental child development
knowledge. Gaps in knowledge about the importance of simple
chronologies; understanding histories by reading case fles; the risk factors
related to parental problems; avoiding ‘start again’ syndrome; and becoming
desensitized to poor parenting standards need to be urgently addressed in
training and continuing professional development.
8. Key to effective intervention are interpersonal skills. All practitioners and
professionals who intervene with children and families need these skills.
Priority should be given to developing and consolidating interpersonal
Principal Messages and their Implications | 151
skills in all forms of training, supervision and professional development.
This should encompass work with non-compliant parents, and scepticism
about apparent compliance.
9. High-quality specifc interventions exist to address the multi-faceted needs
of both parents and children. These should be commissioned alongside
casework interventions by multi-disciplinary teams including social workers.
10. Commissioners of services need to evaluate the cost of premature case
closure or rigidly time-limited therapeutic interventions versus that of
ignoring long-term therapeutic and welfare needs.
11. All professionals with safeguarding responsibilities should be aware that the
majority of maltreated children who are looked after by local authorities do
better in terms of wellbeing and stability than those who remain at home.
Care works for these children, though there is an urgent need for more
specialist provision to help them overcome past adversities.
12. More services need to be developed, in particular for alcohol and substance
abuse, but also to improve aspects of parenting and addressing the needs of
children, after they have experienced maltreatment. Such interventions may
be home grown or adopted from tested versions from overseas but should
be subject to rigorous evaluation in the UK. Research funding bodies should
prioritize such evaluation.
13. There is a particular need for evidence-based services to address intimate
partner violence: for adult victims, affected children and for perpetrators.
14. Urgent action is needed at government level to ensure that advances in
inter-agency and inter-disciplinary working are not lost. Care needs to be
taken to ensure that proposed reforms to the NHS and schools do not
unintentionally impact on recent advances in inter-agency and interdisciplinary working. Measures to restrict public spending must not have a
negative impact on initiatives to share fnancial responsibility for maltreated
children, and specifcally on the work of Local Safeguarding Children
Boards. Funds should be ring-fenced for inter-agency training, which has
been shown to provide good value for money.
15. Further research is needed on particular support or access issues for
adolescents, fathers and families of diverse ethnicity.
Appendix 1
Implementation and Advisory Group
• Rosalyn Proops: Child Protection Coordinator, RCPCH, Norfolk and
Norwich NHS Trust
• Colin Green: Director of Children, Learning and young People’s Directorate,
Coventry City Council
• Martin Pratt: Corporate Director for Children and Learning, Luton Council
• Fiona Smith: Children and young People’s Adviser, Royal College of
Nursing
• Janice Allister: RCGP Child Safeguarding Lead
• Richard Stowe: Independent Chair, Dorset Safeguarding Children Board
• Malcolm Ward: Chair of Southwark LSCB
• Enid Hendry: NSPCC Head of Training, NSPCC National Training
• Jenny Gray (Chair): Professional Adviser, Department for Education
• Zoltan Bozoky: Head of Child Health Research, Policy Research Programme,
Department of Health
• Isabella Craig: Statistician, Department for Education
• Julie Wilkinson: Senior Research Ofcer, Department for Education
• Christine Humphrey: Safeguarding Adviser, Department of Health
• Jane Barlow: Professor of Public Health in the Early years, University of
Warwick
• Jan Horwath: Professor of Child Welfare, University of Shefeld
• Daryl Dougdale: Teaching Fellow in Social Work, University of Bristol
• Heather Brown: Divisional Manager, OFSTED
• Sue Eardley: Senior Policy Lead, NHS Review, Care Quality Commission
• Jane Lewis: Director, Research in Practice
• David Jones: Consultant Child Psychiatrist and Hon Senior Lecturer,
University of Oxford
• His Honour Judge Tony Mitchell: Nottingham Crown and County Courts
152
Appendix 1: Implementation and Advisory Group | 153
• Richard Bartholomew: Chief Research Ofcer, Department for Education
• Harriet Ward: Director, Centre for Child and Family Research, University
of Loughborough
• Carolyn Davies: Scientifc Coordinator, Safeguarding Children Research
Initiative, Thomas Coram Research Unit, IOE
Appendix 2
Details of Evaluations of Specifc
Interventions Discussed in Chapter 5
Example 1: Parents Under Pressure404
This programme has been rigorously evaluated (Evidence Level A).405
What is the programme?
Parents Under Pressure (PUP) comprises an intensive, manualized, home-based
intervention of ten modules conducted in the family home over 10–12 weeks,
with each session lasting between one and two hours. Modules include issues
such as: challenging the notion of an ideal parent; parenting under pressure;
encouraging good behaviour; mindful child management; coping with lapse and
relapse; extending social networks; and life skills and relationships. The programme
is delivered by an accredited trained therapist; training can be undertaken by
anyone with a commitment to working with multi-problem families.406
What has been evaluated?
This programme has been evaluated in an RCT407 comprising 64 methadonedependent primary carers, 86 per cent of whom were mothers with at least one
child aged between two and eight years in their full-time care. The Parents Under
Pressure (PUP) programme was compared with a brief (two-session) traditional
parent-training intervention and standard care (i.e. routine care by methadone
clinic staff involving three-monthly meetings with the prescribing doctor and
access to a caseworker to assist in housing, employment and benefts).
Results
Participants receiving the PUP programme showed signifcant reductions in
parental stress and in methadone dose. There was also a signifcant reduction
in the risk of child abuse as measured by the Child Abuse Potential Inventory
(CAPI). Children of parents in the brief intervention showed a modest reduction
in the risk of child abuse but no other changes. There was a signifcant increase in
the risk of child abuse in parents receiving standard care. Children of parents who
received PUP showed signifcant improvements in child behaviour problems and
154
Appendix 2: Details of Evaluations of Specifc Interventions Discussed in Chapter 5 | 155
an increase in child pro-social scores. There were no improvements in the children
of parents who received the brief intervention or standard care.
Issues for implementation
This programme was developed in Australia where it has been evaluated with
positive results: elements are now being used in the UK408 as part of the Helping
Families Programme.409 Information about training and supervision plus further
information about the programme is available on the PUP website: www.
pupprogramme.net.au.
Example 2: Enhanced Triple P-Positive Parenting
Programme410
This programme has been rigorously evaluated (Evidence Level A).411,412
What is the programme?
The enhanced Triple P-Positive Parenting Programme is based on a cognitive
behavioural approach involving a combination of social learning theory and
cognitive theory. The theoretical framework derives from evidence that children
are emotionally abused because parents have learned dysfunctional childmanagement practices.413
The Triple P-Positive Parenting Programme is ‘a multi-level, parenting and
family support strategy that aims to prevent severe behavioural, emotional
and developmental problems in children by enhancing the knowledge, skills and
confdence of parents’. It comprises a manualized programme that is provided by
fully trained practitioners who receive ongoing support and supervision during its
delivery. It incorporates succeeding levels of intervention of increasing strength
for children from birth to the age of 12.
The ‘standard’ family intervention (Triple P, Level Four) requires parents
to attend group sessions of parent training followed by individual telephone
consultations; they also receive a copy of Every Parent’s Group Workbook.414 Parents
are taught 17 core child-management strategies designed to promote children’s
competence and development; and help them manage misbehaviour. They are also
taught a planned activities routine to enhance the generalization and maintenance
of parenting skills.
The ‘enhanced’ version of the Triple P Programme (Level Five) comprises
an additional four sessions that are aimed explicitly at addressing cognitive
(attributional retraining) and affective (anger management) factors that have
been shown to differentiate between maltreating and other parents.415 In these
additional sessions, parents are taught ‘a variety of skills aiming to challenge the
beliefs they hold regarding their own behaviour and the behaviour of their child,
156 | Safeguarding Children Across Services
and to change any negative practices they currently use in line with these beliefs’.
Parents are also taught ‘a variety of physical, cognitive, and planning strategies
to manage their anger’ including the use of advanced planning for high-risk
situations.
What has been evaluated?
The study targeted 98 parents of children aged two to seven years, who had been
referred by child protection services for emotional abuse, or had self-referred
primarily because of concerns about their anger. The mean age of participating
parents was 34 years and that of their children 4.4 years. The level of disadvantage
of the parents was unspecifed, as were factors such as their ethnicity.
Results
Parents in both groups had improved levels of anxiety and depression following
the intervention. There was also a signifcant decrease in both groups in parental
distress and parental conflict, for both versions of the programme. At the six-month
follow-up, parents who had taken part in the enhanced programme continued to
improve at a greater rate in terms of anger management than those who had taken
part in the standard programme. The study also found reliable improvements in
child behaviour. Parents in both groups reported a signifcant decrease in the
number of parenting and childcare situations in which they experienced problem
behaviour both in the home and in the community. Signifcant improvements
were found in the management of problematic situations by parents in both
groups, with no differences between them at follow-up.
Issues for implementation
The programme is currently implemented in the UK under the auspices of the
NHS in at least two locations: frst, in North Staffordshire NHS Combined
Healthcare, where it is offered in a number of Sure Start children’s centres and
primary school locations; and second, in Glasgow under the Greater Glasgow
NHS Board Starting Well project, where it is the subject of a qualitative evaluation.
Example 3: Individual compared with enhanced individual
plus group-based cognitive behavioural therapy (CBT)416
This intervention has been evaluated to Evidence Level B.417
What is the programme?
The individual parent training comprises ten weekly sessions of two hours’
duration and involves the development of a collaborative partnership with parents
Appendix 2: Details of Evaluations of Specifc Interventions Discussed in Chapter 5 | 157
in terms of the arrangement and agreements made regarding the process and
content of weekly sessions. Topics covered include developmental counselling,
improving parent–child interactions and relationships through the exploration of
parental attitudes and feelings about the child, and putting them into interactional
contexts, and managing children’s and parents’ problematic behaviours. Frequent
telephone calls are made between sessions to support parents in the learning of
new skills, to provide advice, rehearse difcult tasks, and encourage and reinforce
their efforts. The enhanced programme provides additional ten weekly two-hour
sessions of group-based parent training including a play group for the children
and the transport of clients to sessions where appropriate. The programme focuses
on training in stress-management skills; self-control training; problem-solving
abilities; and the provision of a forum for mutual support, encouragement and
exchange of ideas.
What has been evaluated?
The evaluation was undertaken with 34 emotionally abusive and neglectful
parents with a median age of 25 years, referred by a paediatric assessment centre,
outpatient clinics, and local authority senior social workers. One sixth of the
sample were black and a similar proportion were single parents. Most families
were of a low socio-economic status.
Results
The results show signifcant reductions in the stress and anxiety levels of parents
receiving both home and combined home and group-based interventions.
Parents’ perceptions of the parent–child relationship before and after were
stronger in the combined group. Direct observations of parent–child behaviours
were undertaken by social workers to assess 22 forms of emotionally abusive
behaviour. These showed greater improvements in parents’ perceptions of the
parent–child relationship and statistically signifcant reductions in emotionally
abusive behaviours, with both changes more signifcant in the combined group.
Implications
Overall, the moderately rigorous evaluation of this programme suggests that both
formats produce a range of improvements in emotionally abusive parenting, but
that the additional group-based intervention results in signifcant improvements
in areas other than childcare.
158 | Safeguarding Children Across Services
Issues for implementation
This evaluation offers evidence that an appropriately delivered CBT programme
can have an impact in reducing emotionally abusive parenting. It could be
provided in the UK by appropriately trained therapists.
Example 4: Preschooler–Parent Psychotherapy (PPP)418
This intervention has been evaluated to Evidence Level A.419
What is the programme?
Preschooler–Parent Psychotherapy is a specifc programme, provided to mothers
and preschoolers who attend a clinic for weekly, hour-long sessions. Therapy
focuses on helping the mother recognize how her past history is re-enacted in the
present and enabling her to change her representations.
What has been evaluated?
This intervention has been compared with a CBT-based psycho-educational
home-visiting programme focused on parenting skills training (HvP), and a
standard community services programme (CS) for maltreated preschoolers and
their mothers, as well as with no treatment controls.
This high-quality evaluation explored the impact on parents, a large proportion
of whom were from minority ethnic groups. Eighty-seven mothers and their
infants took part. All the children had experienced a number of combinations
of different types of abuse. One third had been identifed as suffering emotional
abuse only or emotional abuse and neglect and 38 per cent had experienced
physical abuse.
Results: Parent outcomes
Parents were found to demonstrate signifcant improvement in their parental
representations post treatment in the PPP group compared with the other two
groups. The study also found a signifcant post-intervention difference in the
positive self-representations of children.
Issues for implementation
In terms of implementation, this form of therapy works well; regular supervision
is core to its delivery. Key groups of professionals, including social workers and
health visitors, could be appropriately trained to deliver this intervention.
Appendix 2: Details of Evaluations of Specifc Interventions Discussed in Chapter 5 | 159
Example 5: Interaction Guidance420
This intervention has been evaluated to Evidence Level B.421
What is the programme?
Interaction Guidance consists of videotaped interaction between mother and
infant followed by a lengthy session of discussion, education and feedback. It
includes an individually tailored information component on specifc problems
exhibited by the infant. The intervention is delivered in fve, weekly 90-minute
sessions in a clinical setting by therapists including one dietician trained in the
use of behavioural therapy, supervised by a clinical psychologist.
What has been evaluated?
This intervention has been evaluated using a two-group, non-randomized
model in which Interaction Guidance was compared with a behavioural feeding
programme. Twenty-eight infants diagnosed with faltering growth and their
mothers were included in each group. The median age of the mothers was 32
years and that of the infants was 18 months. Just under half of the sample was
from disadvantaged social groups. Ethnicity was not specifed.
Results: Parent outcomes
A signifcant decrease in disrupted communication was found between mothers
and infants in the Interaction Guidance group, in contrast with the feedingfocused group, which remained stable. Those in the Interaction Guidance group
were signifcantly more likely to attain a classifcation of ‘non-disrupted’ by the
end of the intervention than those in the feeding-focused group.
Example 6: Parent–Child Interaction Therapy (PCIT)422
This intervention has been evaluated to Evidence Level A.423
What is the programme?
The intervention is delivered over three modules: a six-session orientation
group aimed at increasing motivation by fostering understanding of negative
consequences of severe physical discipline, building confdence and self-efcacy
expectations; 12–14 sessions of clinic-based PCIT designed to enhance parent–
child relationship skills through clinic-based individual parent–child dyad sessions
aimed at developing discipline skills, following a protocol designed to promote
child compliance; and a four-session follow-up group programme with parents
to address any implementation problems, while the children attend a concurrent
social skills programme.
160 | Safeguarding Children Across Services
What has been evaluated?
PCIT was compared with PCIT plus individualized enhanced services and a
standard community-based parenting group in a randomized controlled trial. The
110 parents in the sample had been repeatedly referred to child protection services,
had displayed severe parent to child violence, had low household income and had
signifcant levels of depression, substance abuse and anti-social behaviour.
Results
The evaluation looked at recurrence of abuse and found a signifcant difference
between those given Parent-Child Interaction Therapy and those placed in
the standard community-based parenting group. The trial showed a signifcant
result favouring the PCIT group on reduced recurrence of physical abuse and
on improved parent–child interaction. There was also a small non-signifcant
difference favouring the PCIT group on a standardized measure of child abuse
risk (Child Abuse Potential Inventory (CAPI)).
Issues for implementation
The therapy can be delivered by trained therapists with Master-level qualifcations
in psychology, social work or a related feld. Further information, including
training and treatment guidelines, is available on the PCIT websites.424,425,426
Example 7: Multi-Systemic Therapy for Child Abuse and
Neglect (MST-CAN)427
This programme has been evaluated to Evidence Level A.428
What is the programme?
Multi-Systemic Therapy for Child Abuse and Neglect (MST-CAN) includes the
core components of standard multi-systemic therapy, as well as several adaptations
for treating maltreated young people and their families.
MST-CAN uses a recursive analytical process to identify, develop and prioritize
interventions. Stakeholders are interviewed to attain their views of desired
outcomes, and these become the over-arching goals of treatment. Following a
comprehensive assessment of the strengths and needs of individuals and systems
in the family’s social ecology, each target behaviour is assessed to determine
its ft or drivers (e.g. harsh discipline is associated with parental anxiety, youth
non-compliance, and low parenting skills). The ft factors that are the strongest
drivers to the target behaviours are prioritized for intervention. Evidence-based
interventions (e.g. CBT for defcits in anger management) are implemented with
the support of the family’s social ecology, and outcomes are assessed. Fit factors
Appendix 2: Details of Evaluations of Specifc Interventions Discussed in Chapter 5 | 161
and interventions are re-examined and modifed in a recursive process until
desired outcomes are achieved.
Adaptations to address serious child safety concerns include: the development
of a safety plan agreed by all family members; close working with child protection
agencies to promote positive relations and ensure that CPS decision-making is
based on clinical need or progress; and a clarifcation process on completion, to
help the parent address cognitions about the abuse incident, accept responsibility
and apologize to the child and family. In the trial, interventions, tailored to the
family’s needs, included CBT for defcits in anger management; a CBT protocol
with families who had low problem-solving skills or difculties communicating
without conflict; and prolonged exposure therapy for parents experiencing PTSD
symptoms.
What has been evaluated?
MST-CAN has been evaluated in an RCT comprising 86 physically abused
young people and their parents. MST-CAN was compared with standard services
(individual therapy, family therapy and parent and child sessions; referral to
outside agencies; and medication where deemed appropriate) and Enhanced
Outpatient Treatment (EOT) (standard services plus enhanced engagement and
parent-training interventions).
Results: Young people’s outcomes
young people in all three programmes showed improvements in self-reported
PTSD and depressive symptoms and parent-reported social skills. However,
the improvement in self-reported PTSD symptoms was signifcantly greater for
those in MST-CAN. MST-CAN, but not EOT young people, showed signifcant
decreases in parent-reported internalizing, PTSD, total symptoms and selfreported dissociative symptoms.
Parent outcomes
Parents across all three programmes reported signifcant decreases in global
psychiatric distress and a number of positive symptoms. Those who received MSTCAN, however, reported signifcantly greater decreases in psychiatric distress
than did counterparts in the EOT condition. MST-CAN was signifcantly more
effective than EOT at reducing neglect (youth and parent report), psychological
aggression (youth report), minor assault (youth report) and severe assault (parent
and youth report). Although use of non-violent discipline decreased signifcantly
for both groups over time, this decline was signifcantly less for MST-CAN.
MST-CAN parents also reported signifcant increases in total perceived support,
appraisal support (perceived ability of someone to talk about one’s problems) and
belonging support (perceived availability of people with whom to do things),
162 | Safeguarding Children Across Services
whereas EOT counterparts did not. The numbers for re-abuse were very small,
and group differences were not signifcant. Improvements were maintained at 16
months’ follow-up.
Example 8: Therapeutic Preschool (Childhaven)429
This intervention has been evaluated to Evidence Level A.430
What is the programme?
Childhaven is a therapeutic day treatment programme for infants aged 1–24
months who have been maltreated or are at risk of maltreatment. The treatment
programme is primarily directed towards the child, providing medical,
developmental, psychological and educational services to promote healthy growth
and development. Children are transported to and from the programme by staff.
Parent interventions are also offered on a voluntary basis and include parenting
education, concrete services, support groups, counselling and referrals to other
services as necessary.
What has been evaluated?
Participants in the trial were randomly allocated to Childhaven or standard
child protection services. Twelve years after the original intervention, 35 of the
participants were located and agreed to follow-up measures. These comprised
home observation and examinations of records including juvenile court fles;
parent, child and teacher reports were also obtained.
Results
While only about half the children were traced in the long-term follow-up,
multiple sources were used to inform the fndings. Results showed signifcant
improvements in terms of more than one type of outcome measure. At home, there
was a signifcantly more positive emotional climate and more responsiveness to
children on the part of Childhaven parents than the ‘treatment as usual’ families.
Juvenile court fles showed that participants from the ‘treatment as usual’ group
were frst arrested at an earlier age and were arrested for serious or violent crimes
(i.e. assault, arson, child abuse and robbery) signifcantly more often than those
in the Childhaven group. Children in the ‘treatment as usual’ group were also
reported by parents to show more aggressive behaviour on the Child Behavior
Checklist.
Issues for implementation
Implementation could be undertaken in the UK, supplied by appropriately trained
therapists in a preschool setting.
Appendix 2: Details of Evaluations of Specifc Interventions Discussed in Chapter 5 | 163
Example 9: Peer-led social skills training431
This programme has been evaluated to Evidence Level A.432
What is the programme?
Peer-led social skills training involves identifying children in the Head Start433
classrooms who display high levels of positive play and an ability to encourage
play in socially withdrawn children. A parent volunteer arranges an area in the
classroom in which pairs of resilient peers and socially withdrawn children may
play, and provides support. Play sessions occur three times per week for fve
weeks.
What has been evaluated?
The participants were 46 children in Head Start programmes who were rated
by teachers and classroom observers as socially withdrawn. All of the children
were African-American. Seven had documented histories of physical abuse,
11 had experienced physical neglect, and four had experienced both forms of
maltreatment. The remaining 24 children in the sample did not have documented
histories of maltreatment. The children were randomly assigned to receive peerled social skills training or to control conditions.
Results
The results are from blind observations of children’s social interactions post
treatment. Before treatment, maltreated children were signifcantly more isolated
and less interactive in peer play than non-maltreated children. The results show a
signifcant difference in children’s levels of interactive play between the treatment
group of children and the control group, with the treatment group exhibiting more
interactive play and less solitary play than the control group. These improvements
were evident in both maltreated and non-maltreated socially withdrawn children.
Treatment gains in social interactions were sustained at two months’ follow-up.
Observed teacher-rated skills were also more improved in the treatment group
than the control group, as were teacher-rated behavioural problems.
Example 10: Multi-Treatment Foster Care for Preschoolers
(MTFC-P) (Multidimensional Treatment Foster Care –
Prevention (MTFC-P) in UK)434
This intervention has been evaluated to Evidence Level A.435,436
164 | Safeguarding Children Across Services
What is the programme?
Multi-Treatment Foster Care for Preschoolers (MTFC-P) is a therapeutic foster
care programme for younger children that incorporates parent training and
consultation for foster parents, parent training for birth or adoptive parents
and individual therapy for children who have experienced maltreatment. The
programme consists of training for the foster parents before receiving the child
and daily telephone support and supervision, weekly group meetings and 24­
hour on-call crisis interventions when the child is in placement. In addition, the
children receive a behavioural treatment intervention in the foster home and
attend weekly therapeutic play groups. When children move from the foster
placement to a permanent placement, the new caregivers are trained in the same
techniques that the foster parents have been utilizing with the child. Most of the
intervention team have Bachelor’s or Master’s degrees and are supervised by a
licensed psychologist and supported by a psychiatrist for any medication needed
by the children.
What has been evaluated?
In one North American city all preschool children aged between three and six
years old entering new foster placements and expected to remain there for at
least three months were randomly assigned to MTFC-P or regular foster care.
Recruitment occurred continuously over three years. The two evaluations discussed
here covered one sample of 90 children (47 MTFC-P and 43 regular foster care)
and one of 117 (57 MTFC-P and 60 regular foster care).
Results
The frst evaluation437 explored whether the children were able to remain
successfully in adoptive placements or with their birth parents after treatment. The
results showed that there were permanent placement failures for 36 per cent of
children in the regular foster care group as opposed to 10 per cent of children in
the MTFC-P group (p<.05).438 The second evaluation showed that, at 12-month
follow-up, the morning–evening cortisol levels of children in the MTFC-P group
were signifcantly better than those of the regular foster care group, and were
more closely comparable to those of a non-maltreated community sample.439
This is important because raised cortisol levels are related to stress in children
who have experienced maltreatment or loss of a parent; they are associated with
anxiety and poor control of emotions. A further evaluation showed that children
in the MTFC-P group also displayed signifcantly more secure attachment
behaviours and signifcantly fewer avoidant attachment behaviours than children
in the regular foster care group.440 The intervention appears to increase fostered
toddlers’ ability to rely on their foster carers for comfort and to reduce their
insecure proximity-seeking behaviours.
Appendix 3
Project Summaries
Full details of all these studies, including unpublished reports, research briefs
and information about published papers and books, can be downloaded from
the Safeguarding Children Research Initiative website: www.education.gov.uk/
researchandstatistics/research/scri.
Safeguarding Children from Emotional Abuse: What Works?;
published as Safeguarding Children from Emotional Maltreatment
– What Works (The Emotional Abuse Intervention Review)
Jane Barlow and Anita Schrader McMillan
Introduction
Emotional maltreatment is an inadequately researched and poorly understood
concept, despite increasing awareness about the harm it can cause to children’s
lives. This review of the literature summarizes the evidence about what works to
prevent child emotional maltreatment before it occurs and also to prevent its recurrence
once it has taken place.
Aims
To identify studies that evaluate the effectiveness of interventions in the secondary
prevention and treatment of child emotional abuse involving the parents or
primary carers of children aged 0–19 years.
Methodology
A broad search strategy was developed to identify as many relevant studies
as possible. Studies were included if they involved any intervention directed
at emotionally abusive parenting, and that measured change in (i) emotional
unavailability; (ii) negative attributions; (iii) developmentally inappropriate
interactions; (iv) recognition of children’s boundaries; (v) inconsistency in the
parenting role; and (vi) mis-socialization or consistent failure to promote the
child’s social adaptation. The primary outcomes thus evaluated proxy measures of
a range of parent, family and child outcomes.
165
166 | Safeguarding Children Across Services
Key fndings
• A ‘one-approach-fts-all’ to the complex issues underlying emotional abuse
is unlikely to lead to sustained change.
• There is currently no research evaluating the use of population strategies in
reducing emotional abuse, although recent evidence suggests that the use
of population-level Triple P may be effective in reducing child abuse more
generally.
• A number of attachment-based interventions (including video-interaction
guidance and parent–infant psychotherapy) improved maternal sensitivity
and infant attachment security.
• The limited evidence suggests that some forms of emotionally abusive
parenting may respond to cognitive behavioural therapy. Parent–infant/
child psychotherapy also appears to hold promise.
• The Family Nurse Partnership programme is effective in reducing child
physical abuse, and is underpinned by a theoretical model which targets
parent–child attachment and parental sensitivity. Such an approach may
also reduce emotional abuse.
• Similarly, interventions underpinned by models of working that target
aspects of emotionally abusive parenting (e.g. misattributions and excessive
anger) may prove effective in treating emotional abuse.
• The evidence points to the value of implementing both population-based and
targeted interventions to prevent the occurrence of child emotional maltreatment,
alongside therapeutic-based interventions aimed at preventing its recurrence.
• Absence of evidence does not equal absence of efcacy. Practitioners and
commissioners of services should acknowledge the importance of research
to practice.
• There is a need for multi-level interventions that target not only parenting
practices but also aetiological factors affecting the parent.
• The effective reduction of child emotional maltreatment requires that
staff working at all service levels have the necessary skills to work more
‘therapeutically’ with families.
Appendix 3: Project Summaries | 167
Analysing Child Deaths and Serious Injury through Abuse and
Neglect: What can we Learn? A Biennial Analysis of Serious
Case Reviews 2003–2005 (The Analysis of Serious Case Reviews
2003–5)
Marian Brandon, Pippa Belderson, Catherine Warren, David
Howe, Ruth Gardner, Jane Dodsworth and Jane Black
Introduction
Serious case reviews are carried out when abuse or neglect are known or suspected
factors when a child dies (or is seriously injured or harmed). An overview analysis
of serious case reviews in England is conducted biennially so that lessons learnt
from these cases as a whole can inform both policy and practice. This is the third
such analysis.
Aims
1. To use the learning from serious case reviews to improve multi-agency
practice at all levels of intervention.
2. To analyse the ecological-transactional factors for children who became the
subject of serious case reviews.
Methodology
The study analysed a near total sample of serious case reviews undertaken during
the two-year period from April 2003 to March 2005. The ‘full sample’ of 161
cases included all of the available incidents of child fatality or serious injury
through abuse or neglect which were the subject of a serious case review. The
‘intensive sample’ is a subsample of 47 reviews drawn from the full sample where
fuller, more detailed information is available.
Key fndings
• Two thirds of the 161 children died and a third were seriously injured.
• A total of 47 per cent were aged under one, but 25 per cent were over 11
years, including 9 per cent who were over 16. Many older children were
‘hard to help’ and failed by agencies.
• Twelve per cent of children were named on the child protection register,
and 55 per cent were known to children’s social care at the time of the
incident.
168 | Safeguarding Children Across Services
• The families of very young children who were physically assaulted tended
to be in contact with universal or adult services rather than children’s social
care.
• In families where children suffered long-term neglect, children’s social care
often ignored past history and adopted the ‘start again syndrome’.
• Practitioners should be encouraged to think critically and systematically.
Being aware of the way in which separate factors can interact to protect or
cause increased risks of harm is a vital step in this process.
• A key test of the effectiveness of Local Safeguarding Children Boards will
be the extent to which they are able to rectify long-standing problems with
thresholds.
• Although domestic violence, parental mental ill health and substance
misuse were common, there were no clear causal relationships between
these potentially problematic parental behaviours and child death or serious
injury.
• More consistently reported minimum information would help build a more
rigorous knowledge base to provide better pointers to prevention of injury
or death where abuse or neglect is a factor.
Appendix 3: Project Summaries | 169
Understanding Serious Case Reviews and their Impact: A
Biennial Analysis of Serious Case Reviews 2005–07 (The Analysis
of Serious Case Reviews 2005–7)
Marian Brandon, Sue Bailey, Pippa Belderson, Ruth Gardner, Peter
Sidebotham, Jane Dodsworth, Catherine Warren and Jane Black
Introduction
Serious case reviews are local enquiries into the death or serious injury of a child,
where abuse or neglect are known or suspected. They are carried out under the
auspices of Local Safeguarding Children Boards so that lessons can be learnt
locally. An overview analysis of these reviews throughout England is undertaken
biennially so that the lessons learnt can inform both policy and practice. This is
the fourth such analysis.
Aims
1. To learn from the analysis of interacting risk factors present in the cases
under review.
2. To transfer this learning to everyday practice and to the process of serious
case reviews.
Methodology
The study analysed a sample of 189 reviews undertaken in 2005–7. It utilized
the same transactional ecological approach to make sense of interacting risk
factors as that employed in the previous biennial analysis of reviews. Results from
both studies (350 cases over four years) were compared and contrasted, and key
themes and trends and their implications for policy and practice were identifed.
The study also explored the way reviews are commissioned and scoped; how they
are published; and how key messages are disseminated and implemented locally.
Key fndings
• The two studies show similarities in: age profles of children; proportions
known to children’s social care; proportions subject to a child protection
plan; proportions of deaths and serious injuries; and high levels of current
or past domestic violence and/or parental mental ill health and/or parental
substance misuse, often in combination.
• The chaotic behaviour in families was often mirrored in professionals’
thinking and actions. Many families and professionals were overwhelmed by
170 | Safeguarding Children Across Services
having too many problems to face and too much to achieve, circumstances
which contributed to children becoming unseen. Good support, supervision
and a fully staffed workforce are crucially important for these practitioners.
• Reluctant parental co-operation and multiple moves meant that many
children went off the radar of professionals. However, good parental
engagement sometimes masked risks of harm to the child.
• Information about men and about the child was very often missing.
• Interviews with practitioners showed the profound impact of being involved
with such cases. None of those interviewed felt adequately involved in the
serious case review process or its subsequent learning.
• Many children not known to children’s social care are living with high levels
of vulnerability which can quickly tip into high risks of harm. Recognizing
these factors is an important step in helping and protecting children at all
levels of intervention.
Appendix 3: Project Summaries | 171
Organisation, Outcomes and Costs of Inter-Agency Training for
Safeguarding and Promoting the Welfare of Children (The InterAgency Training Evaluation Study)
John Carpenter, Simon Hackett, Demi Patsios and Eszter Szilassy
Introduction
It is the responsibility of Local Safeguarding Children Boards (LSCBs) to ensure
that single-agency and inter-agency (or multi-agency) training in safeguarding
and promoting welfare is provided in order to meet local needs.441 This study
investigated the training provided by eight LSCBs in England.
Aims
To develop an evidence base for inter-agency training to safeguard and promote
the welfare of children by asking how it is organized, what training is provided
and by whom, whether it is effective and how much it costs.
Methodology
The project was carried out collaboratively with the training co-ordinators in
eight LSCBs in four parts of England and with the support of an advisory group.
The research team observed meetings of LSCB training subgroups and carried
out 60 interviews with LSCB representatives to investigate the means by which
inter-agency training is planned and delivered. Specifc questionnaire measures
were developed to assess the outcomes of both generic and specialist courses,
and completed at course registration, the start and end of the course, and three
months later. Mean total scale ratings were compared at each time point. The
costs to LSCB partners of providing and participating in training were calculated,
based on staff time and use of resources.
Key fndings
• LSCB training subgroups generally offered good examples of effective
partnership working.
• The opportunity to learn together was very highly valued. However, doctors,
adult services staff and more experienced staff across agencies were underrepresented on specialist courses designed to update their knowledge and
skills. Professional bodies, especially in medicine, should review the reasons
for low participation. Consideration should be given to building LSCB
inter-agency courses into the post-qualifying professional development
frameworks for different groups of staff.
172 | Safeguarding Children Across Services
• Outcomes were remarkably consistent across types of course and LSCBs.
There were signifcant gains in knowledge of the substantive topic and
in self-confdence regarding safeguarding policies and procedures and
promoting the welfare of children.
• Some partner agencies were making substantial in-kind contributions to
the provision of training in addition to their ‘annual subscription’ to the
Board. The only explanation for the considerable variations in proportional
contributions between LSCBs was historical precedent.
• Inter-agency training is vulnerable to cuts in partner agencies’ fnancial
contributions and to changes in personnel.
• The costs were seen as very good value for money and compared favourably
to the fees charged by commercial organizations.
• Training co-ordinators and their support staff are critical in ensuring the
effective operation of the training programme.
• More generic and specialist trainers are needed. An expanded ‘training for
trainers’ should include standards and accreditation.
Appendix 3: Project Summaries | 173
Noticing and Helping the Neglected Child: Literature Review;
published as Recognizing and Helping the Neglected Child –
Evidence-Based Practice for Assessment and Intervention (The
Recognition of Neglect Review)
Brigid Daniel, Julie Taylor and Jane Scott
Introduction
Despite increased awareness of its impact on development, recognition of neglect
is inconsistent and referrals to services are often triggered by other events or
concerns about vulnerable children. This systematic review of the literature
examined the evidence on the extent to which practitioners are equipped to
recognize and respond to the indications that a child’s needs are likely to be, or
are being, neglected, whatever the cause.
Aims
The primary aim was to contribute to the evidence base that equips practitioners
and organizations with the information they need to consider themselves to
be part of a protective network around children, and to be able and willing to
recognize that a child’s needs are not being met, or are in danger of being unmet.
The study explored the following questions:
1. What is known about the ways in which children and families directly and
indirectly signal their need for help?
2. To what extent are practitioners equipped to recognize and respond to the
indications that a child’s needs are likely to be, or are being, neglected,
whatever the cause?
3. Does the evidence suggest that professional response could be swifter?
Methodology
The method was based on systematic review guidelines. The search strategy
yielded 20,480 possible items of which 63 were of sufcient quality for inclusion.
Key fndings
• There is considerable evidence to assist identifying how parents and children
indirectly signal their needs for help, but less on how they do this directly.
There is only limited evidence on whether parents try and fail to seek help
from professionals or whether they tend not to do so.
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• The overwhelming effect of poverty is strongly associated with neglect,
as is the corrosive power of an accumulation of adverse factors. Neglect
affects children’s development to an extent that signs should be apparent to
professionals. Indirect signs can be identifed in a range of settings.
• Professionals’ views of neglect differ from those of the general public, with
the latter setting higher standards for children’s care. Operational defnitions
can affect the number of children receiving a service, with variations
potentially contributing to concerns over different thresholds.
• The concerns of health staff were more about the most appropriate response
and access to resources than about their capacity to recognize neglect.
Studies of social workers tend to focus on responses to referrals.
• Some overseas studies suggest that earlier detection could be possible with
appropriate training, protocols for communication and provision of support
and guidance for practitioners.
• There is little research about children’s and parents’ views about how they
would seek help, what kind of support would be most helpful and what
factors hamper access to support services.
Appendix 3: Project Summaries | 175
Case Management and Outcomes for Neglected Children
Returned to their Parents: A Five Year Follow-Up Study; published
as Working Effectively with Neglected Children and their Families
– Understanding their Experiences and Long-Term Outcomes (The
Neglected Children Reunifcation Study)
Elaine Farmer and Eleanor Lutman
Introduction
Practitioners have very little research to inform them about which kinds of
case management or combinations of services keep neglected children safe and
contribute to improved outcomes.
Aims
1. To examine the case management, interventions and outcomes of a
consecutive sample of neglected children, from the point of frst referral
until fve years after they had returned home from care/accommodation.
2. To investigate which factors are related to outcomes for children fve years
after return.
3. To explore how far parents and children engage with professional
interventions and whether there are particular issues in cases of neglect.
Methodology
The sample consisted of 138 children who had been neglected from seven local
authorities. All had been looked after and returned to their parents during a
one-year period. The study followed the children up for fve years from this
return; data were collected from case fles and interviews with social workers,
team managers, leaving care workers and some parents and children.
Key fndings
• Three ffths of referrals about harm did not lead to sufcient action. Decisive
action often awaited a trigger incident of physical/sexual abuse or severe
domestic violence. Over time abuse and neglect were sometimes minimized.
• Outcomes were much better for younger children. The cut-off age was six at
the time of reunifcation, after which action to safeguard children and plan
for their future reduced and permanence outside the birth family was more
rarely achieved.
176 | Safeguarding Children Across Services
• Two ffths of children who were the subject of child protection plans were
not adequately safeguarded. Plans made during care proceedings did not
work out in three ffths of cases.
• Patterns of case management varied by local authority, with four patterns
evident: proactive throughout, initially proactive and later passive, initially
passive and later more proactive, and passive throughout.
• After fve years, 43 per cent of the children were stably at home, 29 per
cent had achieved permanence away from home, whilst 28 per cent had
had unstable experiences in care or at home. Those living stably away from
home were more likely to have good overall wellbeing (58%); wellbeing
was poor for 70 per cent of those with unstable outcomes, and for a third of
those at home. Children with the most returns had the poorest wellbeing:
38 per cent experienced two or more failed returns.
• Two years after return, 59 per cent of the children had been maltreated.
Returning to a changed or different household increased return stability.
• Children with poor wellbeing at follow-up and those subjected to the most
severe neglect were especially likely to have been living with parents with
alcohol misuse problems. There were signifcant gaps in services for these
parents as there were also for drug-misusing parents.
Appendix 3: Project Summaries | 177
Effectiveness of the New Local Safeguarding Children Boards in
England (The Local Safeguarding Children Boards Study)
Alan France, Emily R. Munro and Amanda Waring
Introduction
Local Safeguarding Children Boards (LSCBs) were intended to address the
weaknesses found in the Area Child Protection Committees that they superseded.
They were identifed as a potentially important means of ensuring an integrated
approach to service provision and enabling children to achieve their potential.
Aims
To examine whether the new structures and processes established by LSCBs
had overcome identifed weaknesses of ACPCs and promoted inter-agency cooperation.
Methodology
A mixed method approach was adopted, including a national survey and mapping
exercise of all LSCBs in England and in-depth case study work in six areas. Data
were collected from face-to-face interviews with six LSCB Chairs and business
managers and fve interviews with the directors of children’s services in each
area; 49 telephone interviews with board members; 132 telephone interviews
with front-line professionals (holding both managerial and non-managerial
responsibilities); content and thematic analysis of the minutes of board meetings;
examination of the relationships between individuals and groups within the LSCB
structure in two case study areas, utilizing social network analysis; and a detailed
analysis of costing of LSCB meetings in two case study areas.
Key fndings
• Across a range of conditions, LSCBs in case study areas were performing at
65 per cent effectiveness.
• LSCBs that have been able to determine their main priorities, that have been
realistic about what is feasible and that have maintained focus have been
more effective than those that have been overly ambitious.
• Professionals at the strategic and operational levels are embracing the
notion that safeguarding children is a shared responsibility. However, there
were different perspectives as to whether LSCBs should be embracing the
wider safeguarding agenda or concentrating their efforts more narrowly on
protecting children from harm.
178 | Safeguarding Children Across Services
• Local authorities have struggled to establish accountability mechanisms,
especially for Chairs. Governance arrangements generally remain weak.
• LSCB Chairs have provided strong leadership. Independent Chairs have
struggled to be active in the wide strategic framework within local areas.
• Demarcation of roles and responsibilities between the board and Children’s
Trust has not always been clear.
• Securing appropriate levels of participation by board members in LSCB
meetings remains a challenge.
• The most effective size for a LSCB appears to be between 20 and 25
members.
• LSCBs have struggled to fulfl all their functions. The time and resources
required to undertake serious case reviews, in particular, has inhibited
capacity to fulfl other responsibilities.
• Effective communication channels between the LSCB and partner agencies
are relatively weak.
• Although LSCBs are helping progress inter-agency work, developments
have also been influenced by wider changes. There has been progress in
inter-agency communication and the development of a shared language,
although a number of challenges remain.
Appendix 3: Project Summaries | 179
Does Training and Consultation in a Systematic Approach to
Emotional Abuse (FRAMEA) Improve the Quality of Children’s
Services? (The Emotional Abuse Recognition Training Evaluation
Study)
Danya Glaser, Vivien Prior, Katherine Auty and Susan Tilki
Introduction
Emotional abuse continues to pose difculties for professionals in its defnition,
recognition, thresholds and effective interventions. A conceptual framework has
been developed for the recognition, assessment and management of emotional
abuse (FRAMEA). It organizes factors pertinent to overall child maltreatment,
including specifcally emotional abuse and emotional neglect, into four tiers:
environmental and social circumstances; parental risk factors or attributes; illtreatment; domains of child functioning. Emotional abuse and neglect is defned
as persistent, harmful parent–child interactions; fve categories are distinguished
and defned. The framework also incorporates the necessary notion of a trial of
the family’s capacity to change.
Aims
To address some of the difculties encountered by professionals in dealing with
emotional abuse by exploring whether training and follow-up consultation
in FRAMEA would improve professional activity in terms of clarity of
conceptualization of concerns, recognition of emotional abuse and the nature of
professional response and intervention.
Methodology
Sixteen professional teams comprising health visitors, children’s social care (referral
and assessment and children in need) and child and adolescent mental health
services (CAMHS) in four ethnically diverse geographical areas participated. Data
were collected through specifcally designed questionnaires and semi-structured
interviews.
Professional practice concerning fve cohorts of children aged under 11 and
their families was tracked over time. Training was randomly distributed between
teams over four time points and followed by up to three consultations to each team,
during which FRAMEA was applied to actual cases brought by the professionals.
Finally, inter-agency meetings were held in each of the four geographical areas.
180 | Safeguarding Children Across Services
Key fndings
• Fifty per cent of referrals to CAMHS and 69 per cent of referrals to social
care children in need teams included emotional abuse.
• Health visitors were unable to refer 21 per cent, and social workers 13 per
cent, of emotionally abusive or neglectful families for further intervention
because services were unavailable. Lack of clarity about the respective roles
and responsibilities in service provision in relation to emotional abuse across
the three agencies and the absence of a shared threshold were major issues
raised by professionals.
• Eighty-nine per cent of participants rated the FRAMEA training as excellent
or very good, but some effects were not sustained in post-consultation
cohorts.
• There was signifcantly more recognition of emotional abuse following
training.
• Health visitors showed a signifcant increase, and social workers a very signifcant
decrease, in separation of tiers following training. CAMHS teams showed a
signifcant increase in separation of tiers post-training with consultation.
• Following training, all professional groups reported signifcantly more
harmful parent–child interactions when certain parental risk factors were
present.
• All professional groups showed signifcant improvements in some areas of
service provision following training.
Appendix 3: Project Summaries | 181
Understanding Parents’ Information Needs and Experiences
where Professional Concerns Regarding Non-Accidental Injury
were not Substantiated (The Information Needs of Parents at Early
Recognition Study)
Sirkka Komulainen and Linda Haines
Introduction
Determining whether or not a presenting sign is a non-accidental injury (NAI) is
a difcult area for health professionals; poor communication triggers complaints
from parents.
Aims
1. To explore parents’ experiences of situations where concerns of nonaccidental injury were raised, with a particular focus on communication
processes.
2. To generate data on parents’ experiences and set these in context.
3. To identify what information participants wished to receive and describe
how they remembered and reflected on their experiences.
4. To increase the awareness of health professionals of what parents perceive
as helpful and less helpful practice.
5. To make suggestions for paediatric training to improve communication.
Methodology
Ten pilot and 12 formal interviews were conducted with consenting parents/
carers. Participants were recruited through parents’ support groups and NHS
Trusts. A narrative interview method was adopted for this sensitive topic to allow
participants to express themselves in their own words, with additional probing
to address particular paediatric training in communication and public information
needs. Interviews were recorded, transcribed, anonymized and analysed with a
specialist software package designed to manage qualitative data (NvIvO).
Key fndings
• Concerns were usually articulated to parents/carers by consultant
paediatricians.
182 | Safeguarding Children Across Services
• Most parents had sought help because they were worried about their child’s
health; they needed to be kept informed about their child’s medical care
and progress throughout the investigation.
• Many reported feeling they had been treated less courteously once concerns
of NAI were raised. Participants were dissatisfed when their concerns and
explanations were not listened to or when not enough time was allowed for
communication. Participants were particularly dissatisfed where concerns
of NAI were raised in a public place.
• Parents understand the professional duty to investigate further if there are
concerns. They prefer honest, clear and early face-to-face communication
on what a child protection enquiry means; what referral to social services or
the police means; who else (including schools and other family members)
will be involved; whether emergency proceedings are taking place; what
the child protection medical examination involves; how long the child has
to stay in hospital; what different tests involve; whether further tests are
needed; and how long it will take to receive results. Written information
leaflets were of uncertain value.
• Participants expected clear, written communication that their case was
closed. years later some were uncertain whether they were ‘still being
monitored’.
• Being subject to child protection investigations – however briefly – left
many parents distressed and had a long-lasting effect on the whole family.
Disappointment with the ‘system’ and anxieties about future contacts with
health professionals were expressed.
• Awareness of media reports where child protection cases had ‘gone wrong’
contributed to parents’ anxieties.
Appendix 3: Project Summaries | 183
Systematic Reviews of Interventions Following Physical Abuse:
Helping Practitioners and Expert Witnesses Improve the
Outcomes of Child Abuse (The Physical Abuse Intervention Review)
Paul Montgomery, Frances Gardner, Paul Ramchandani and Gretchen Bjornstad
Introduction
Physical abuse is highly prevalent across the world and is frequently a component
of broader maltreatment. The focus of this study is on secondary prevention of
adverse child outcomes and recurrence of abuse in children who have experienced
maltreatment.
Aims
1. To conduct three reviews that synthesize the published grey literature for
interventions for children who have experienced physical abuse, in order to
present a complete picture of all the available evidence.
2. To draw out the implications of this evidence for policy, practice and future
research.
Methodology
Three separate electronic search strategies were conducted for each of three
categories of child-focused, parent-focused or family-focused intervention. These
searches aimed to identify all studies investigating interventions for children who
have experienced physical abuse. The search included efforts to fnd studies in the
grey literature and contacts with experts in the feld. All evidence was reviewed so
as to capture a complete picture; methodological quality is indicated in discussion
of the results, as research shortcomings may produce a biased picture.
Key fndings
• There is evidence to support well-structured, manualized parenting and
treatment foster care interventions. Training and supervision for practitioners
to be able to deliver such interventions would have positive benefts for
many children and families where a child has experienced physical abuse.
• However, family preservation services, home visiting, psychodrama,
therapeutic day treatment, individual child psychotherapy and art therapy
do not yet have sufcient evidence to support their effectiveness. Residential
treatment and play therapy were not found to be effective, with comparison
treatments showing better outcomes.
184 | Safeguarding Children Across Services
• However, fdelity to treatment protocols would be crucial for practitioners
who wish to replicate results in their own practices. Systems need to be in
place for ongoing supervision and quality control. Few of the reviewed
studies provided details about the settings in which they delivered
treatment. Practitioners will have to consider the effects that compulsory
or non-compulsory interventions might have on participant retention and
motivation, and to know about the types of children or families for whom
interventions are effective.
• In general, the evidence pointed to the value of parenting and cognitive
behavioural approaches as having a stronger evidence base than other
interventions and thus worthy of further investigation.
• Funding for research that includes measures of recurrence of abuse as a
primary outcome is needed to determine the effects of parent and familyfocused interventions.
• There is insufcient information about the costs of interventions, although
we need to know whether these are justifed by their benefts.
Appendix 3: Project Summaries | 185
Neglected Adolescents: A Literature Review; published as
Adolescent Neglect – Research, Policy and Practice, with Rees as
frst author (The Recognition of Adolescent Neglect Review)
Mike Stein, Gwyther Rees, Leslie Hicks and Sarah Gorin
Introduction
‘Neglect’ as it applies to adolescents is a signifcant under-explored area in the
UK. This literature review considers the research, policy and practice implications
of international research in this area. It has also informed: a multi-agency guide
for teams who work with young people and a guide for young people about
neglect.
Aims
1. To provide an accessible summary of relevant literature on adolescent neglect
and to draw out the implications for further developments on this topic.
2. To inform the preparation of guides for multi-agency teams and for young
people.
Methodology
The method was based on systematic review guidelines. The searches covered
the years 1997–2006 and initially yielded 450 potentially relevant items. Focus
groups were carried out with young people and members of two LSCBs to inform
the guides for young people and multi-agency workers.
Key fndings
• There is a need for more age-sensitive defnitions of neglect for both research
and practice purposes. These should reflect differences in the way neglect is
conceptualized as children grow older.
• Neglect is the most common form of maltreatment across all age groups,
including adolescence. Relatively little is known about the distinctive
background factors associated with adolescent neglect. However, experiences
of neglect in adolescence are associated with a range of negative outcomes.
• No effective interventions aimed specifcally at adolescent neglect were
identifed; however, some more generic approaches, based on an ecological
or multi-systemic approach, may be of relevance.
186 | Safeguarding Children Across Services
• There is a need to raise awareness among young people about the meaning
and potential consequences of neglect, so that they may feel able to
seek appropriate support. Similarly, there is a need to raise professional
awareness of defnitional issues and of the scale and outcomes of adolescent
neglect, in order to promote more effective responses to the needs of these
young people. The guide for young people and the multi-agency guide
for professionals, produced as part of this project, will contribute to these
objectives.
• At a management and policy level, the review suggests a need for additional
documentation to support age-specifc assessments in cases of potential
neglect; potential improvements to ofcial defnitions and measurement
of maltreatment; and the need for more dedicated funding to undertake
further research and to pilot new interventions in this area.
• The fndings present a major challenge to the research community to pay
more attention to neglect and to issues affecting adolescents within the feld
of maltreatment research.
Appendix 3: Project Summaries | 187
The Child, the Family and the GP: Tensions and Conflicts of
Interest in Safeguarding Children (The General Practitioner
Tensions in Safeguarding Study)
Hilary Tompsett, Mark Ashworth, Christine Atkins, Lorna Bell,
Ann Gallagher, Maggie Morgan and Paul Wainwright
Introduction
The role of GPs in safeguarding children is vital to inter-agency collaboration
in child protection processes and to promoting early intervention in families.
However, potential conflicts of interest may constrain their engagement.
Aims
1. To explore the nature and consequences of tensions and conflicts of interest
for GPs in safeguarding children.
2. To evaluate how these are seen and responded to from a range of professional,
parent and child perspectives.
3. To consider ways of managing these issues to promote best practice.
4. To explore the complexity of relationships between GPs, parents and
children and other professionals (added in response to initial piloting).
Methodology
This exploratory mixed methods study focused particularly on GPs in two
contrasting Primary Care Trusts (PCTs) and groups of GPs accessed through
training events. It included interviews with Local Safeguarding Children Board
(LSCB) key stakeholders and drew on a panel of 25 independent experts, who
used the Delphi structured communication technique to guide their discussions,
and three focus groups of parents, young people and a minority ethnic group.
It was supported by a literature and policy review and demographic and child
protection statistics in the PCTs. Data were collected through 96 questionnaire
responses and 14 interviews with GPs.
Key fndings
• GPs saw their role as referring patients/families on, while key stakeholders
expected fuller engagement in all stages of child protection processes.
• GPs see supporting parents as the best way to support children and families.
188 | Safeguarding Children Across Services
• Although GPs are clear about ‘what to do’ when the situation clearly
warrants referral to children’s social care services, they would frst seek
advice and support from a paediatrician or a health visitor in more complex
cases.
• Not being able to speak directly to social workers in children’s services,
over or under-response to concerns, lack of feedback when referrals were
made and potential impact on families of intervention were reasons for
hesitance in referral and dilemmas in confdentiality.
• Most GPs (and key stakeholders) did not refer to the views and wishes of
children.
• The health visitor’s important role in safeguarding children, both for parents
and as a key fellow professional for the GP, was confrmed.
• GPs perceived that child protection work is not as valued as other activities
rewarded under the Quality and Outcomes Framework.
• GPs reported low attendance at child protection conferences, though
provision of reports was higher than expected. Conferences may be better
informed by other/health professionals who may hold more relevant
information.
• Changing policies, structures and guidance emerging since this study was
initiated will provide a new framework in which these tensions can be
addressed.
Appendix 3: Project Summaries | 189
Understanding the Contribution of Sure Start Local Programmes
to the Task of Safeguarding Children’s Welfare. Report of the
National Evaluation (The Sure Start Local Programmes Safeguarding
Study)
Jane Tunstill and Debra Allnock
Introduction
The initial 524 community-based Sure Start Local Programmes (SSLPs, now Sure
Start children’s centres) were rolled out from 2000; each supported an average
population of between 400 and 800 children under four years old. This study
formed part of the Implementation Module of the National Evaluation of Sure Start
(NESS).
Aims
1. To explore ways in which SSLPs and children’s social care can work in
collaboration.
2. To ascertain if, and how, SSLPs are represented in local structures such as
LSCBs.
3. To explore the nature of concerns likely to trigger referrals between
children’s social care and SSLPs and vice versa.
4. To identify the range of supports requested and provided.
5. To explore the SSLP contribution to positive outcomes for children.
6. To identify and describe examples of good practice.
Methodology
The study comprised: (a) an exploration of the safeguarding policy and practice
of eight local programmes, identifed as exemplifying ‘relatively good practice’;
(b) an in-depth study of four local authorities, to enable the fuller exploration
of wider partnerships and networking activity across a ‘whole local authority’.
A conceptual framework was developed for studying existing arrangements
and identifying key challenges. Data were collected through: an analysis of
documentation; interviews with key stakeholders; and a study of referrals from
SSLPs to children’s social care.
190 | Safeguarding Children Across Services
Key fndings
• Collaboration reflected ongoing tensions between services designed to
support families and those designed to protect children.
• Inter-professional and inter-agency collaboration requires a shared
understanding/acceptance of thresholds; confdence in informationsharing; and systematic recording systems.
• Staff reluctance to collaborate in safeguarding activity was minimized
by establishing operational linkages between child protection and family
support and having managers who helped staff see support in terms of
packages rather than isolated services.
• Regular contact and access to informal advice from other professionals can
improve service provision and lead to more appropriate referrals between
organizations. Having social workers co-located within the centre develops
confdence and competence around child protection for other staff members.
• The Common Assessment Framework (CAF) can provide a bridge for
communication about individual children between members of the
workforce and underpin the provision of a seamless service at Tiers Two
and Three (targeted and specialist levels).
• Co-location of multi-disciplinary teams has both strengths and limitations
– the consequences for different groups of families should be carefully
thought through, so practitioners can offer a choice of routes to services for
parents in different circumstances.
• The ongoing debate around the balance to be struck between the targeted
and universal provision within children’s services ensures the continuing
relevance of study fndings for policy and practice in and around children’s
centres.
Appendix 3: Project Summaries | 191
Maltreated Children in the Looked After System: A Comparison
of Outcomes for Those Who Go Home and Those Who Do Not;
published as Caring for Abused and Neglected Children – Making
the Right Decisions for Reunifcation or Long-Term Care (The Home
or Care? Study)
Jim Wade, Nina Biehal, Nicola Farrelly and Ian Sinclair
Introduction
Around six in ten children enter the looked after system for reasons of abuse or
neglect. Many subsequently return home. This study set out to strengthen the
evidence base about the long-term consequences of decisions to reunify or not
reunify maltreated children.
Aims
1. To compare the care pathways of maltreated children with those of children
looked after for other reasons and account for any differences identifed.
2. To investigate which maltreated children are more, or less, likely to go home
and why this may be the case.
3. To examine how the decision concerning return was made; to identify
the main factors that were taken into account and how this decision was
supported over the next six months.
4. To compare the progress of children in relation to their safety, stability and
psychosocial wellbeing up to four years (on average) after this ‘effective
decision’ was made.
Methodology
The research design comprised:
1. A census study of all 3872 children who were looked after by seven
local authorities at some point in 2003–04. Information primarily from
administrative systems was used to track their pathways for up to three
years and to compare those for maltreated and other looked after children.
2. A survey of 149 of these children, all of whom had been maltreated and of
whom 68 returned home and 81 remained continuously looked after. Data
were collected from case records, interviews with a small number of birth
parents and children, and survey responses from current social workers and
teachers who assessed progress and outcomes at fnal follow-up.
192 | Safeguarding Children Across Services
Key fndings
• Maltreated children were less likely than children looked after for other
reasons to leave the care system within the study timeframe. Placement with
parents was an important pathway, although breakdowns were higher for
this group.
• Outcomes for maltreated children who remained looked after were better
than for those who went home, with respect to stability and wellbeing.
Even those whose home placements had endured had lower wellbeing than
those who had not gone home.
• Careful assessment of risks, evidence of parenting change, slow and wellmanaged returns and provision of services to support them were associated
with home placements that endured.
• Although services helped placements to last, they were not sufcient to
help improve children’s overall wellbeing at home. Intensive, long-term
provision of services will be needed to support home placements.
• Where reunifcation failed, there were often early signs. Over one third of
children (35%) had returned to care within six months.
Appendix 3: Project Summaries | 193
Infants Suffering, or Likely to Suffer, Signifcant Harm: A
Prospective Longitudinal Study; published as Safeguarding Babies
and Very Young Children from Abuse and Neglect (The Signifcant
Harm of Infants Study)
Harriet Ward, Rebecca Brown, David Westlake and Emily R. Munro
Introduction
Decisions made by practitioners to protect and promote the welfare of infants
suffering, or likely to suffer, signifcant harm will have long-term consequences
for their life chances. It is therefore important to know how such decisions are
made and whether they can be improved.
Aims
To trace the decision-making process influencing the life pathways of a sample of
very young children who had been identifed as suffering, or being likely to suffer,
signifcant harm in order to: improve understanding about how such decisions are
reached and their consequences; the weight given to risk and protective factors;
and the role participants, including birth parents, play in the decision-making
process.
Methodology
This mixed methods study took place in ten local authorities and focused on a
sample of 57 children who were the subject of a core assessment, Section 47
enquiry or became looked after before their frst birthdays; 43 were followed until
they were three. Quantitative data concerning children’s life experiences, evidence
of need, reasons for referral and changes of circumstances were collected from
case fles; qualitative data came from interviews with birth parents, carers, social
workers, team leaders, children’s guardians, senior managers, judges, magistrates
and local authority solicitors, and focus groups with health visitors.
Key fndings
• Parents showed a high prevalence of factors known to be associated with
an increased risk of children suffering signifcant harm.
• About a third of the mothers had already been separated from at least one
older child before the birth of the index child. Nearly two thirds of the
infants were identifed before birth.
• About a third of the children were maltreated in utero. However, at age three
44 per cent of the sample had apparently never been maltreated.
194 | Safeguarding Children Across Services
• The long-term wellbeing of over half of the children who were permanently
separated had been doubly jeopardized – by late separation from an abusive
birth family followed by the disruption of a close attachment with an
interim carer on entering a permanent placement. There is no evidence that
any child was unnecessarily separated.
• At age three, 43 per cent of those children remaining with their birth parents
were considered to be at continuing risk of signifcant harm.
• All but one of the 16 (37%) parents who made sufcient changes to provide
good enough care did so before the baby was six months old.
• By their third birthdays over half the children were displaying developmental
problems or signifcant behavioural difculties. These were more evident
amongst children who had experienced maltreatment, often whilst
professionals waited fruitlessly for parents to change.
• Decisions to separate children permanently from birth parents go against the
grain for all those involved. However, if such children are to be adequately
safeguarded within their birth families, then much greater consideration
needs to be given to the development of effective policies and practices to
engage potentially abusive parents and to support them in reducing those
factors that place their children at risk of being maltreated.
5
10
15
20
25
Endnotes
Chapter 1
1 Mahony, Cardinal R. (1998) Creating a Culture of Life (unpublished letter).
2 Laming, Lord (Cm 5730) (2003) The Victoria Climbié Inquiry: Report of an Inquiry by Lord Laming. London: The
Stationery Ofce.
3 Laming, Lord (HC 330) (2009) The Protection of Children in England: A Progress Report. London: The Stationery
Ofce.
4 See www.education.gov.uk/researchandstatistics/research/scri.
Laming, Lord (HC 330) (2009) op. cit.
6 Munro, E. (2011b) The Munro Review of Child Protection: Final Report. A Child-Centred System. London:
Department for Education.
7 Laming, Lord (Cm 5730) (2003) op. cit.
8 See for instance Chief Inspector of Social Services, Commission for Health Improvement, HM Chief Inspector
of Constabulary, HM Chief Inspector of the Crown Prosecution Service, HM Chief Inspector of Schools and
HM Chief Inspector of Prisons (2002) Safeguarding Children: A Joint Chief Inspectors’ Report on Arrangements to
Safeguard Children. London: Department of Health.
9 Department for Education (Cm 5860) (2003) Every Child Matters. London: The Stationery Ofce.
Ward, H. and Jones, H. (2009) ‘Le système de protection en Angleterre.’ Santé, Societé et Solidarité 1, 181–192.
11 Children Act (2004) London: HMSO.
12 Department of Health, Department for Education and Skills and Home Ofce (2000) Framework for the
Assessment of Children in Need and their Families. London: The Stationery Ofce.
13 See Department for Children, Schools and Families (2011) Common Assessment Framework. Accessed on 15
April 2011 at: www.education.gov.uk/childrenandyoungpeople/strategy/integratedworking/caf.
14 HM Government (2010) Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and
Promote the Welfare of Children. London: Department for Children, Schools and Families.
Cleaver, H., Walker, S., Scott, J., Cleaver, D., Rose, W., Ward, H. and Pithouse, A. (2008) The Integrated
Children’s System: Enhancing Social Work and Inter-Agency Practice. London: Jessica Kingsley Publishers.
16 Department of Health and Department for Education and Skills (2004) National Service Framework for Children,
Young People and Maternity Services. London: Department for Education and Skills and Department of Health.
17 Laming, Lord (HC 330) (2009) op. cit.
18 Field, F. (2010) The Foundation Years: Preventing Poor Children from Becoming Poor Adults. London: HM
Government.
19 Allen, G. (2011) Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government.
London: HM Government.
Social Work Reform Board (2010) Building a Safe and Confdent Future: One Year On. London: HM Government.
21 HM Treasury (Cm 7942) (2010) Spending Review. London: The Stationery Ofce.
22 Department for Education (2010a) Reform of Children’s Trusts Safeguarding and Social Work Reform. News release:
22 July 2010. Accessed on 26 January 2011 at: www.education.gov.uk/children and young people/.
23 Department for Education (2010b) More Freedom and Flexibility: A New Approach for Children’s Trust Boards,
Children and Young People’s Plans, and the ‘Duty to Cooperate’. News release, 3 November 2010. London:
Department for Education.
24 Department for Education (2010c) Secretary of State for Education’s Letter to Local Authorities: 4 November 2010.
London: Department for Education.
Department for Education (2010b) op. cit.
26 Department of Health (2010) (cm 7881) Equity and Excellence: Liberating the NHS. London: The Stationery
Ofce.
195
196 | Safeguarding Children Across Services
27 Munro, E. (2011a) The Munro Review of Child Protection: Interim Report. A Child’s Journey. London: Department
for Education, p.14. See also Munro, E. (2010) The Munro Review of Child Protection. Part One: A Systems Analysis.
London: Department for Education.
28 Department for Education (2011) A Child-Centred System: The Government’s Response to the Munro Review of Child
Protection. London: Department for Education
29 Department for Children, Schools and Families (2009a) Building a Safe, Confdent Future: The Final Report of the
Social Work Taskforce. London: Department for Children, Schools and Families.
30 HM Government (2010) op. cit.
31 Department for Education (2010d) Children in Need in England, including their Characteristics and Further
Information on Children who were the Subject of a Child Protection Plan (2009–2010 Children in Need Census, Final).
London: Department for Education.
32 Department for Children, Schools and Families (2009b) Referrals, Assessment and Children and Young People who
are the Subject of a Child Protection Plan, England – Year Ending March 31 2009. Accessed 3 August 2011 at: www.
data.gov.uk/dataset/referrals.
33 See Gilbert, R.E., Widom, C., Browne, K., Fergusson, D., Webb, E. and Janson, S. (2009) ‘Child maltreatment
1: Burden and consequence of child maltreatment in high income countries.’ The Lancet 373, 68–81.
34 Radford, L., Corral, S., Bradley, C., Fisher, H., Bassett, C., Howat, N. with Collishaw, S. (2011) The
Maltreatment and Victimisation of Children in the UK: NSPCC Report on a National Survey of Young People’s, Young
Adults’ and Caregivers’ Experiences. London: NSPCC.
35 See Finkelhor, D. (2008) Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People. Oxford:
Oxford University Press, Chapter 7, pp.122–147.
36 See Radford et al. (2011) op. cit.
37 Stevenson, O. (2007) Neglected Children and their Families (Second Edition). Oxford: Blackwell Publishing.
38 For an overview of the evidence see for instance Jones, D.P.H. (2008) ‘Child Maltreatment.’ In M. Rutter, D.
Bishop, D. Pine, S. Scott, J. Stevenson, E.Taylor and A.Thapar (eds) Rutter’s Child and Adolescent Psychiatry (Fifth
Edition). Oxford: Blackwell Publishing, pp.421–439; Cleaver, H., Unell, I. and Aldgate, J. (2011) Children’s
Needs – Parenting Capacity. The Impact of Parental Mental Illness, Learning Disability, Problem Alcohol and Drug Use
and Domestic Violence on Children’s Safety (2nd Edition). London: The Stationery Ofce, pp. 95–193.
39 Munro, E.R., Brown, R., Sempik, J. and Ward, H. with Owen, C. (2011) Scoping Review to Draw Together Data
on Child Injury and Safeguarding and to Compare the Position of England with that in Other Countries. Research Report
DfE-RR083. London: Department for Education.
40 Daniel, B., Taylor, J. and Scott, J. (2011) Recognizing and Helping the Neglected Child: Evidence-Based Practice for
Assessment and Intervention. London: Jessica Kingsley Publishers.
41 Rees, G., Stein, M., Hicks, L. and Gorin, S. (2011) Adolescent Neglect: Research, Policy and Practice. London:
Jessica Kingsley Publishers.
42 HM Government (2010) op. cit. pp.38–39.
43 Haringey Local Safeguarding Children Board (2010) Serious Case Review: Child A, March 2009. London:
Department for Education.
44 Rees, Stein, Hicks and Gorin (2011) op. cit., passim.
45 Brandon, M., Bailey, S. and Belderson, P. (2010) Building on the Learning from Serious Case Reviews: A Two-Year
Analysis of Child Protection Database Notifcations 2007–2009. London: Department for Education.
46 Holmes, L., Westlake, D. and Ward, H. (2009) Calculating and Comparing the Costs of Multidimensional Treatment
Foster Care, England (MTFCE). Report to the Department of Children, Schools and Families. Loughborough:
Centre for Child and Family Research, Loughborough University.
47 See National Mental Health Development Unit. Accessed on 24 January 2011 at: www.nmhdu.org.uk/news/
multi-systemic-therapy-new-therapy-brings-results-for-troubled-young-people/.
Chapter 2
48 Daniel, B., Taylor, J. and Scott, J. (2011) Recognizing and Helping the Neglected Child: Evidence-Based Practice for
Assessment and Intervention. London: Jessica Kingsley Publishers.
49 Rees, G., Stein, M., Hicks, L. and Gorin, S. (2011) Adolescent Neglect: Research, Policy and Practice. Jessica
Kingsley Publishers.
50 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J. and Black, J. (2008) Analysing
Child Deaths and Serious Injury through Abuse and Neglect: What can we Learn? A Biennial Analysis of Serious Case
Reviews 2003–2005. DCSF-RR023. London: Department for Children, Schools and Families.
Endnotes | 197
51 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C. and Black, J.
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52 For further information see Barlow, J. and Schrader McMillan, A. (2010) Safeguarding Children from Emotional
Maltreatment: What Works. London: Jessica Kingsley Publishers, pp.30–34.
53 Gilbert, R., Widom, C., Browne, K., Fergusson, D., Webb, E. and Janson, S. (2009) ‘Child Maltreatment 1:
Burden and consequences of child maltreatment in high income countries.’ The Lancet 373, 68–81.
54 Ibid. p.68.
53 Farmer, E. and Lutman, E. (forthcoming) Working Effectively with Neglected Children and their Families –
Understanding their Experiences and Long-Tern Outcomes. London: Jessica Kingsley Publishers.
56 De Bellis, M.D. (2005) ‘Psychobiology of neglect.’ Child Maltreatment 10, 2, 150–172.
57 See Twardosz, S. and Lutzker, J.R. (2010) ‘Child maltreatment and the developing brain: A review of
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58 Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) Accessed on 3 August 2011 at: www.iprc.
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59 See O’Hagan, K. (2006) Identifying Emotional and Psychological Abuse. Maidenhead: Open University Press.
60 Rees, Stein, Hicks and Gorin (2011) op. cit. p.51
61 The Bridge Consultancy (1995) Paul: Death through Neglect. The Bridge Consultancy.
62 Brandon, M., personal communication concerning further analysis of SCR data.
63 HM Government (2010) Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and
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64 See Barlow and Schrader McMillan (2010) op. cit. pp. 30–35.
65 Egeland, B. (2009) ‘Taking stock: Child emotional maltreatment and developmental psychology.’ Child Abuse
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66 Cleaver, H., Unell, I. and Aldgate, J. (2011) Children’s Needs – Parenting Capacity. The Impact of Parental Mental
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67 Egeland (2009) op. cit. p.23.
68 Department of Health, Department for Education and Employment and Home Ofce (2000) Framework for the
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69 Cleaver, Unell and Aldgate (2011) op. cit.
70 See Farmer and Lutman (2009) op. cit. pp. 10–14.
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72 Cleaver, Unell and Aldgate (2011) op. cit.
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82 Kroll and Taylor, (2003) op .cit., pp.163–191.
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110 Boulton, S. and Hindle, D. (2000) ‘Emotional abuse: The work of a multi-disciplinary consultation group in a
child psychiatric service.’ Clinical Child Psychology and Psychiatry 5, 3, 439–452, p.440.
111 Brandon, Belderson, Warren, Howe, Gardner, Dodsworth and Black (2008) op. cit. p.135.
Endnotes | 199
112 Appleton, J.v. (1996) ‘Working with vulnerable families: A health visiting perspective.’ Journal of Advanced
Nursing 23, 5, 912–918, (see p.8).
113 Ward, H., Brown, R., Westlake, D. and Munro, R. (forthcoming) Safeguarding Babies and Very Young Children from
Abuse and Neglect. London: Jessica Kingsley Publishers.
114 See Paavilainen, Astedt-Kurki and Panounen (2000) op. cit.
115 Gilbert, R., Kemp, A., Thoburn, J., Sidebotham, P., Radford, L., Glaser, D. and MacMillan, H. (2009) ‘Child
maltreatment 2: Recognising and responding to child maltreatment.’ The Lancet 10, 373, 167–180.
116 Angeles Cerezo, M. and Pons-Salvador, G. (2004) ‘Improving child maltreatment detection systems: A largescale case study involving health, social services, and school professionals.’ Child Abuse and Neglect 28, 1153–
1170.
117 See Cleaver, Unell and Aldgate (2011) op. cit.
118 Barlow and Schrader McMillan (2010) op. cit. p.28.
119 See Harnett, P. (2007) ‘A procedure for assessing parents’ capacity for change in child protection cases.’
Children and Youth Services Review 29, 1179–1188.
120 Daniel, Taylor and Scott (2011) op. cit. p.45.
121 Ibid.
122 See also Gilbert, Kemp, Thoburn, Sidebotham, Radford, Glaser and MacMillan (2009) op. cit.
123 Maiter, S., Alaggia, R. and Trocme, N. (2004) ‘Perceptions of maltreatment by parents from the Indian subcontinent: Challenging myths about culturally based abusive parenting practices.’ Child Maltreatment 9, 3,
309–324.
124 Andrews, A.B. (1996) ‘Public opinions about what a citizen can do to help abused and neglected children in
addictive families.’ Journal of Community Practice 3, 1, 19–33, p.25.
Chapter 3
125 Barlow, J. and Schrader McMillan, A. (2010) Safeguarding Children from Emotional Maltreatment: What Works.
London: Jessica Kingsley Publishers.
126 Rees, G., Stein, M., Hicks, L. and Gorin, S. (2011) Adolescent Neglect: Research, Policy and Practice. London:
Jessica Kingsley Publishers.
127 Tunstill, J., Allnock, D. and The National Evaluation of Sure Start Team (2007) Understanding the Contribution of
Sure Start Local Programmes to the Task of Safeguarding Children’s Welfare. London: HMSO.
128 After Barlow and Schrader McMillan (2010) op. cit. p.15
129 Gilbert, R., Widom, C.S., Browne, K., Fergusson, D., Webb, E. and Janson, S. (2009) ‘Child maltreatment 1:
Burden and consequences of child maltreatment in high income countries.’ The Lancet 373, 68–81.
130 Radford, L., Corral, S., Bradley, C., Fisher, H., Bassett, C., Howat, N. and Collishaw, S. (2011) The
Maltreatment and Victimisation of Children in the UK: NSPCC Report on a National Survey of Young People’s, Young
Adults’ and Caregivers’ Experiences. London: NSPCC.
131 Department for Education (2010d) Children in Need in England, including their Characteristics and Further
Information on Children who were the Subject of a Child Protection Plan (2009–2010 Children in Need Census, Final).
London: Department for Education; see also Munro, E. (2011a) The Munro Review of Child Protection: Interim
Report. A Child’s Journey. London: Department for Education.
132 See also Gilbert, Widom, Browne, Fergusson, Webb and Janson (2009) op. cit.
133 Gaudin, J.M. (1993) ‘Effective intervention with neglectful families.’ Criminal Justice and Behaviour 20, 1, 66–
89.
134 Sanders, M.R. (2008) ‘The Triple P-Positive Parenting Programme: A public health approach to parenting
support.’ Journal of Family Psychology 22, 506–517.
135 Prinz, R.J., Sanders, M.R., Shapiro, C.J., Whitaker, D.J. and Lutzker, J.R. (2009) ‘Population-based prevention
of child maltreatment: The US Triple P system population trial.’ Prevention Science 10, 1, 1–12.
136 Department of Health (2009) Healthy Lives, Brighter Futures: The Strategy for Children and Young People’s Health.
London: Department of Health and Department for Children, Schools and Families.
137 Department of Health (2009, updated 2010a) The Pregnancy Book. London: Department of Health.
138 Department of Health (2009, updated 2010b) Birth to Five. London: Department of Health.
139 Department of Health (2009) op. cit.
140 Tanner, K. and Turney, D. (2006) ‘Therapeutic Interventions with Children who have Experienced Neglect
and their Families in the UK.’ In C. McAuley, P. Pecora and W. Rose (eds) Enhancing the Well-Being of Children
through Effective Interventions: International Evidence for Practice. London: Jessica Kingsley Publishers.
200 | Safeguarding Children Across Services
141 Department of Health (2009) op. cit. p.25.
142 Ibid.
143 Asthana, A. (Policy Editor) (2001) ‘Sure Start children centres told to charge for some services.’ The Observer,
14 November.
144 See Rees, Stein, Hicks and Gorin (2011) pp. 28-29; 61–63
145 vazsonyi, A.T., Hibbert, J.R. and Snider, J.B. (2003) ‘Exotic enterprise no more? Adolescent reports of family
and parenting processes from youth in four countries.’ Journal of Research on Adolescence 13, 2, 197–207.
146 Stanton, B., Cole, M., Galbraith, J., Li, x., Pendleton, S., Cottrel, L., Marshall, S., Wu, y. and Kaljee, L. (2004)
‘Randomized trial of a parenting intervention.’ Archives of Pediatrics and Adolescent Medicine 158, 947–955.
147 Hicks, L. and Stein, M. in collaboration with the Children’s Society and the NSPCC (2010) Neglect Matters: A
Guide for Young People about Neglect. London: ChildLine.
148 Durrant, J.E. (1999) ‘Evaluating the success of Sweden’s corporal punishment ban.’ Child Abuse and Neglect 23,
5, 435–448.
149 Triple P Programme. Accessed on 24 January 2011 at: www.triplep.net/.
150 Prinz, Sanders, Shapiro, Whitaker and Lutzker (2009) op. cit.
151 See Health Scotland. Starting Well? What is Triple P? Accessed on 24 January 2011 at: www.healthscotland.
com/uploads/documents/swsection%208.pdf.
152 Morrell, C.J., Spiby, H., Stewart, P., Walters, S. and Morgan, A. (2000) ‘Costs and effectiveness of community
postnatal support workers: Randomised controlled trial.’ British Medical Journal 321, 593–598.
153 Department of Health (2009) op. cit.
154 Hindley, N., Ramchandani, P.G. and Jones, D.P.H. (2006) ‘Risk factors for recurrence of maltreatment: A
systematic review.’ Archives of Disease in Childhood 91, 9, 744–752.
155 Department for Education and Skills (2006) Common Assessment Framework for Children and Young People:
Practitioners’ Guide for Service Managers and Practitioners. London: The Stationery Ofce.
156 Brandon, M., Howe, A., Dagley, v., Salter, C. and Warren, C. (2006) ‘What appears to be helping or hindering
practitioners in implementing the Common Assessment Framework and lead professional working?’ Child
Abuse Review 15, 390–413.
157 Munro, E. (2006) ‘What tools do we need to improve identifcation of child abuse?’ Child Abuse Review 14,
374–388.
158 Alarm Distress Baby Scale (2004) Accessed on 1 December 2010 at: www.adbb.net/gb-intro.html.
159 Crittenden Care Index: Family Relations Institute. Accessed on 24 January 2011 at: www.patcrittenden.com/
include/care_index.htm.
160 Guedeney, A. and Fermanian, J. (2001) ‘A validity and reliability study of assessment and screening for
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559–575.
161 Crittenden, P.M. (1981) ‘Abusing, neglecting, problematic and adequate dyads: Differentiating by patterns of
interaction.’ Merril-Palmer Quarterly 27, 1–18.
162 Ibid.
163 Barlow, J. and Scott, J. (2010) Safeguarding Children in the 21st Century: Where to Now? Totnes: Research in
Practice.
164 Eyberg, S.M., Besmear, J., Edwards, D. and Robinson, E. (1994) ‘Manual for the dyadic Parent–Child
Interaction Coding System II.’ Social and Behavioural Sciences Documents (MS no: 2898).
165 Biringen, Z. (2000) ‘Emotional availability: Conceptualization and research fndings.’ American Journal of
Orthopsychiatry 70, 104–114.
166 Harnett, P. and Dawe, S. (2008) ‘Reducing child abuse potential for child abuse among families: Implications
for assessment and treatment.’ Brief Treatment and Crisis Intervention 8, 226–235.
167 Ibid.
168 See Jones, D., Hindley, N. and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and
Evaluating Outcomes.’ In J. Aldgate, D. Jones and C. Jeffery (eds) The Developing World of the Child. London:
Jessica Kingsley Publishers, pp.278–279. for further discussion.
169 Cleaver, H., Walker, S., Scott, J., Cleaver, D., Rose, W., Ward, H. and Pithouse, A. (2008) The Integrated
Children’s System: Enhancing Social Work and Inter-Agency Practice. London: Jessica Kingsley Publishers.
170 Cleaver, H. and Walker, S. (2004) ‘From policy to practice: The implementation of a new framework for social
work assessments of children and families.’ Child and Family Social Work 9, 1, 81–90.
171 Barlow, J., Simkiss, D. and Stewart-Brown, S. (2006) ‘Interventions to prevent or ameliorate child physical
abuse and neglect: Findings from a systematic review.’ Journal of Children’s Services 1, 6–28.
Endnotes | 201
172 Barlow, J. (2006) ‘Home visiting Programmes for Parents of Pre-School Children: The UK Experience.’ In C.
McAuley, P. Pecora and W. Rose (eds) Effective Interventions for Children and Families. London: Jessica Kingsley
Publishers.
173 Bull, J., McCormick, G., Swann, C. and Mulivihill, C. (2004) Ante-Natal and Post-Natal Home-Visiting
Programmes: A Review of Reviews. Evidence Briefng (First Edition). London: Health Development Agency.
174 MacMillan, H.L., Wathen, C.N., Barlow, J., Fergusson, D.M., Leventhal, D.M. and Taussig, H.N. (2009) ‘Child
maltreatment 3: Interventions to prevent maltreatment and associated impairment.’ The Lancet 373, 9659,
250–266.
175 Olds, D.L., Henderson, C.R. and Kitzman, H. (1994) ‘Does prenatal and infancy nurse home visitation have
enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life?’ Pediatrics 93,
89–98.
176 Olds, D.L., Henderson, C.R., Cole, R.C., Eckenrode, J., Kitzman, H., Luckey, D., Sidora, K., Pettitt, L., Morris,
P. and Powers, J. (1998) ‘Long-term effects of home visitation on children’s criminal and anti social behaviour:
15-year follow up of a randomized trial.’ Journal of the American Medical Association 280, 14, 1238–1244.
177 Olds, D.L., Robinson, J., O’Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., Ng, R.N., Korfmacher, J.,
Hiatt, S. and Talmi, A. (2002) ‘Home visiting by nurses and by paraprofessionals: A randomized controlled
trial.’ Pediatrics 110, 3, 486–496.
178 Olds, D., Eckenrode, J., Henderson, C.R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt,
L. and Luckey, D. (1997) ‘Long-term effects of home visitation on maternal life course and child abuse and
neglect: 15-year follow up of a randomized trial.’ Journal of the American Medical Association 278, 637–643.
179 Department of Health (2009) op. cit.
180 Barnes, J., Ball, M., Meadows, P., Belsky, J. and the FNP Implementation Research Team (2009) Nurse–Family
Partnership Programme, Second Year Pilot Sites Implementation in England: The Infancy Period. London: Department
for Children, Schools and Families and Department of Health.
181 MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op. cit.
182 See Nurse Family Partnership (2008) Accessed on 24 January 2011 at: http://cbpp-pcpe.phac-aspc.gc.ca/
intervention_pdf/en/600.pdf.
183 See for instance Hutchings, J., Bywater, T., Williams, M.E., Shakespeare, M.K. and Whitaker, C. (2009)
Evidence for the Extended School Aged Incredible Years Parent Programme with Parents of High-Risk 8 to 16 Year olds.
Bangor: School of Psychology, Bangor University.
184 Webster-Stratton, C. and Reid, J. (2010) ‘Adapting the Incredible years, an evidence-based parenting
programme, for families involved in the child welfare system.’ Journal of Children’s Services 5, 1, 25–42.
185 Devore, E.R. and Ginsburg, K.R. (2005) ‘The protective effects of good parenting on adolescents.’ Current
Opinion in Pediatrics 17, 4, 460–465.
186 Stanton, B., Cole, M., Galbraith, J., Li, x., Pendleton, S., Cottrel, L., Marshall, S., Wu, y. and Kaljee, L. (2004)
‘Randomized trial of a parenting intervention.’ Archives of Pediatrics and Adolescent Medicine 158, 947–955.
187 Simons-Morton, B.G., Hartos, J., Leaf, W. and Preusser, D. (2006) ‘The effect on teen driving outcomes of the
Checkpoints Programme in a state-wide trial.’ Accident Analysis and Prevention 38, 907–912.
Chapter 4
188 Farmer, E. and Lutman, E. (forthcoming) Working Effectively with Neglected Children and their Families –
Understanding their Experiences and Long-Term Outcomes. London: Jessica Kingsley Publishers.
189 Ward, H., Brown, R., Westlake, D. and Munro, E.R. (forthcoming) Safeguarding Babies and Very Young Children
from Abuse and Neglect. London: Jessica Kingsley Publishers.
190 Wade, J., Biehal, N., Farrelly, N. and Sinclair, I. (2011) Caring for Abused and Neglected Children: Making the Right
Decisions for Reunifcation or Long-Term Care. London: Jessica Kingsley Publishers.
191 Cleaver, H., Unell, I. and Aldgate, J. (2011) Children’s Needs – Parenting Capacity. The Impact of Parental Mental
Illness, Learning Disability, Problem Alcohol and Drug Use and Domestic Violence on Children’s Safety (2nd Edition).
London: The Stationery Ofce.
192 Hindley, N., Ramchandani, P.G. and Jones, D.P.H. (2006) ‘Risk factors for recurrence of maltreatment: A
systematic review.’ Archives of Disease in Childhood 91, 9, 744–752.
193 See also Brandon, M., Sidebotham, P., Ellis, C., Bailey, S. and Belderson, P. (forthcoming) Child and Family
Practitioners’ Understanding of Child Development: Lessons Learnt from a Small Sample of Serious Case Reviews. London:
Department for Education.
194 Haringey Local Safeguarding Children Board (2010) Serious Case Review: Child A, March 2009. London:
Department for Education, p.39.
202 | Safeguarding Children Across Services
195 Ayre, P. (1998) ‘Assessment of signifcant harm: Improving professional practice.’ British Journal of Nursing 7, 1,
31–36.
196 Stephenson, O. (1996) ‘Emotional abuse and neglect: A time for reappraisal.’ Child and Family Social Work 1, 1,
13–18.
197 Farmer and Lutman (2009) op. cit. p.105.
198 Ibid. p.113.
199 Mattinson, J. (1975) The Reflection Process in Case Work Supervision. London: Institute of Marital Studies.
200 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J. and Black, J. (2008) Analysing
Child Deaths and Serious Injury through Abuse and Neglect: What can we Learn? A Biennial Analysis of Serious Case
Reviews 2003–2005. DCSF-RR023. London: Department for Children, Schools and Families, pp.72–73.
201 Ward, H., Brown, R. and Maskell-Graham, D. (forthcoming) Young Children Suffering, or Likely to Suffer,
Signifcant Harm: Experiences on Entering Education. Loughborough: Centre for Child and Family Research,
Loughborough University.
202 Haringey Local Safeguarding Children Board (2010) op. cit.
203 Holmes, L. and McDermid, S. (forthcoming) Understanding the Costs of Child Welfare. London: Jessica Kingsley
Publishers.
204 Hannon, C., Wood, C. and Bazalgette, L. (2010) In Loco Parentis. London: DEMOS.
205 Scott, S., Knapp, M., Henderson, J. and Maugham, B. (2001) ‘Financial cost of social exclusion: Follow up
study of antisocial children into adulthood.’ British Medical Journal 323, 191–196.
206 Ward, H., Holmes, L. and Soper, J. (2008) Costs and Consequences of Placing Children in Care. London: Jessica
Kingsley Publishers.
207 See also Fauth, R., Jelecic, H., Hart, D., Burton, S. and Shemmings, D. (2010) Effective Practice to Protect Children
Living in ‘Highly Resistant’ Families. London: C4EO.
208 Ward, Brown, Westlake and Munro (forthcoming) op. cit.
209 See Jones, D., Hindley, N. and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and
Evaluating Outcomes.’ In J. Aldgate, D. Jones and C. Jeffery (eds) The Developing World of the Child. London:
Jessica Kingsley Publishers.
210 Ward, H., Munro, E.R. and Dearden, C. (2006) Babies and Young Children in Care: Life Pathways, Decision-Making
and Practice. London: Jessica Kingsley Publishers.
211 Tannenbaum, L. and Forehand, R. (1994) ‘Maternal depressive mood: The role of the father in preventing
adolescent problem behaviours.’ Behaviour Research and Therapy 32, 321–325.
212 van den Dries, L., Juffer, F., van IJzendoorn, M.H. and Bakermans-Kranenburg, M.J. (2009) ‘Fostering
security? A meta-analysis of attachment in adopted children.’ Children and Youth Services Review 31, 410–421.
213 Howe, D. (2005) Child Abuse and Neglect: Attachment, Development and Intervention. Basingstoke: Palgrave
Macmillan.
214 Schore, A. (2010) ‘Relational Trauma and the Developing Right Brain: The Neurobiology of Broken
Attachment Bonds.’ In T. Baradon (ed.) Relational Trauma in Infancy: Psychoanalytic, Attachment and
Neuropsychological Contributions to Parent–Infant Psychotherapy. New york: Routledge.
215 van den Dries, Juffer, van IJzendoorn and Bakermans-Kranenburg (2009) op. cit.
216 Jones, Hindley and Ramchandani (2006) op. cit.
217 Skuse, T. and Ward, H. (2003) Outcomes for Looked After Children: Children’s Views, the Importance of Listening.
An Interim Report to the Department of Health. Loughborough: Centre for Child and Family Research,
Loughborough University.
218 Ward, H. (2009) ‘Patterns of instability. Moves within the English care system: Their reasons, contexts and
consequences.’ Children and Youth Services Review 31, 1113–1118.
219 See also Hunt, J., Waterhouse, S. and Lutman, E. (2008) Keeping Them in the Family: Outcomes for Abused and
Neglected Children Placed with Family and Friends Carers through Care Proceedings. London: BAAF; and Farmer, E.
and Moyers, S. (2008) Kinship Care: Fostering Effective Family and Friends Placements. London: Jessica Kingsley
Publishers.
220 Hannon, Wood and Bazalgette (2010) op. cit.
221 Sergeant, H. (2006) Handle with Care. London: Centre for Policy Studies.
Chapter 5
222 Montgomery, P., Gardner, F., Ramchandani, P. and Bjornstad, G. (2009) Systematic Reviews of Interventions
following Physical Abuse: Helping Practitioners and Expert Witnesses Improve the Outcomes of Child Abuse. Report to
the Department for Children, Schools and Families. Oxford: University of Oxford.
Endnotes | 203
223 Barlow, J. and Schrader McMillan, A. (2010) Safeguarding Children from Emotional Maltreatment: What Works.
London: Jessica Kingsley Publishers.
224 For instance, MacMillan, H.L., Wathen, C.N., Barlow, J., Fergusson, D.M., Leventhal, D.M. and Taussig, H.N.
(2009) ‘Child maltreatment 3: Interventions to prevent maltreatment and associated impairment.’ The Lancet
373, 9659, 250–266.
225 Compiled from Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.12–15.
226 Compton, S.N., March, J.S., Brent, D., Albano, A.M.v., Weersing, R. and Curry, J. (2004) ‘Cognitive-behavioral
psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine
review.’ Journal of the American Academy of Child and Adolescent Psychiatry 43, 930–959.
227 March, J.S., Amaya-Jackson, L., Murray, M.C. and Schulte, A. (1998) ‘Cognitive-behavioral psychotherapy
for children and adolescents with posttraumatic stress disorder after a single-incident stressor.’ Journal of the
American Academy of Child and Adolescent Psychiatry 37, 585–593.
228 Webster-Stratton, C., Reid, J. and Hammond, M. (2001) ‘Social skills and problem-solving training for
children with early-onset conduct problems: Who benefts?’ Journal of Child Psychology and Psychiatry 42, 943–
952.
229 Dretzke, J., Frew, E., Davenport, C., Barlow, J., Stewart-Brown, S., Sandercock, J., Bayliss, S., Raftery, J., Hyde,
C. and Taylor, R. (2005) ‘The effectiveness and cost-effectiveness of parent training/education programmes
for the treatment of conduct disorder, including oppositional defant disorder, in children.’ Health Technology
Assessment 9, 50, 50.
230 Gardner, F., Burton, J. and Klimes, I. (2006) ‘Randomised controlled trial of a parenting intervention in the
voluntary sector for reducing child conduct problems: Outcomes and mechanisms for change.’ Journal of Child
Psychology and Psychiatry 47, 1123–1132.
231 Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., Eames, C. and Edwards, R.T. (2007)
‘Parenting intervention in Sure Start services for children at risk of developing conduct disorder: Pragmatic
randomised controlled trial.’ British Medical Journal 334, 678–682.
232 Fluke, J. (2008) ‘Child protective services rereporting and recurrence: Context and considerations regarding
research.’ Child Abuse and Neglect 32, 8, 749–751.
233 Hindley, N., Ramchandani, P. and Jones, D.P.H. (2006) ‘Risk factors for recurrence of maltreatment: A
systematic review.’ Archives of Disease in Childhood 91, 9, 744–752.
234 Thoburn, J. and members of the Making Research Count Consortium (2009) Effective Interventions for Complex
Families where there are Concerns About, or Evidence of, a Child Suffering Signifcant Harm. Safeguarding Briefng 1.
London: Centre for Excellence and Outcomes in Children and young People’s Services (C4EO).
235 See for instance Cleaver, H., Unell, I. and Aldgate, J. (2011) Children’s Needs – Parenting Capacity. The Impact of
Parental Mental Illness, Learning Disability, Problem Alcohol and Drug Use and Domestic Violence on Children’s Safety
(2nd Edition). London: The Stationery Ofce; Cleaver, H., Nicholson, D., Tarr, S. and Cleaver, D. (2007) Child
Protection, Domestic Violence and Parental Substance Misuse: Family Experiences and Effective Practice. London: Jessica
Kingsley Publishers; Kroll, B. and Taylor, A. (2003) Parental Substance Misuse and Child Welfare. London: Jessica
Kingsley Publishers; and Tunnard, J. (2002) Parental Problem Drinking and its Impact on Children. Dartington:
Research in Practice.
236 Parents Under Pressure. Accessed on 24 January 2011 at: www.pupprogramme.net.au.
237 Dawe, S. and Harnett, P. (2007a) ‘Reducing potential for child abuse among methadone-maintained parents:
Results from a randomized controlled trial.’ Journal of Substance Abuse Treatment 32, 4, 381–390.
238 Parents Under Pressure. op. cit.
239 See also MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op. cit. p.255.
240 Williamson, E. and Hester, M. (2009) Evaluation of the South Tyneside Domestic Abuse Perpetrator 2006–8. Final
Report. Bristol: University of Bristol.
241 Cleaver, Unell and Aldgate (2011) op. cit.
242 For further information see MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op. cit.
p.259.
243 Sullivan, C.M. and Bybee, D. (1999) ‘Reducing violence using community based advocacy for women with
abusive partners.’ Journal of Consulting and Clinical Psychology 67, 1, 43–53.
244 Hindley, Ramchandani and Jones (2006) op. cit.
245 WHO (2007) The Cycles of Violence: The Relationship Between Childhood Maltreatment and the Risk of Later Becoming
a Victim or Perpetrator of Violence. Copenhagen: World Health Organization.
246 Kim, J. (2009) ‘Type-specifc intergenerational transmission of neglectful and physically abusive parenting
behaviours among young parents.’ Children and Youth Services Review 31, 7, 761–767.
204 | Safeguarding Children Across Services
247 For summary see Jones, D.P.H. (2008) ‘Child Maltreatment.’ In M. Rutter, D. Bishop, D. Pine, S. Scott, J.
Stevenson, E. Taylor and A. Thapar (eds) Rutter’s Child and Adolescent Psychiatry (Fifth Edition). Oxford: Blackwell
Publishing.
248 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.68–70 and MacMillan, Wathen,
Barlow, Fergusson, Leventhal and Taussig (2009) op. cit. p.253.
249 Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S. and young, R.W. (2004) ‘Does
parental attributional retraining and anger management enhance the effects of the Triple P-Positive Parenting
Programme with parents at risk of child maltreatment?’ Behavioural Therapy 35, 513–535.
250 Prinz, R.J., Sanders, M.R., Shapiro, C.J., Whitaker, D.J. and Lutzker, J.R. (2009) ‘Population-based prevention
of child maltreatment: The US Triple P system population trial.’ Prevention Science 10, 1, 1–12.
251 Sanders, Pidgeon, Gravestock, Connors, Brown and young (2004) op. cit.
252 Triple P Programme. Accessed on 24 January 2011 at: www.triplep.net/.
253 Barlow and Schrader McMillan (2010) op. cit. pp.70–73; Iwaniec, D. (1997) ‘Evaluating parent training for
emotionally abusive and neglectful parents: Comparing individual versus individual and group intervention.’
Research in Social Work Practice 7, 3, 329–349.
254 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.93–94 and Montgomery,
Gardner, Ramchandani and Bjornstadt (2009) op. cit.
255 Cicchetti, D., Rogosch, F. and Toth, S. (2006) ‘Fostering secure attachment in infants in maltreating families
through preventive interventions.’ Development and Psychopathology 18, 623–649.
256 Toth, S.L., Rogosch, F.A., Cicchetti, D. and Manly, J.T. (2006) ‘The efcacy of toddler–parent psychotherapy
to reorganise attachment in the young offspring of mothers with major depressive disorder: A randomised
preventive trial.’ Journal of Consulting and Clinical Psychology 74, 6, 1006–16.
257 Toth, S., Maughan, A., Todd Manly, J., Spagnola, M. and Cicchetti, C. (2002) ‘The relative efcacy of two
interventions in altering maltreated preschool children’s representational models: Implications for attachment
theory.’ Development and Psychopathology 14, 887–908.
258 Fukkink, R. (2008) ‘video feedback in widescreen: A meta-analysis of family programmes.’ Clinical Psychology
Review 28, 6, 904–916.
259 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.98–99.
260 Benoit, D., Madigan, S., Lecce, S., Shea, B. and Goldberg, S. (2001) ‘Atypical maternal behaviour toward
feeding-disordered infants before and after intervention.’ Infant Mental Health Journal 22, 6, 611–626.
261 Ibid.
262 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.31–32.
263 See also MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op cit p.255
264 Chafn, M., Silovsky, J.F., Funderburk, B., valle, L.A., Brestan, E.v., Balachova, T. et al. (2004) ‘Parent–Child
Interaction Therapy with physically abusive parents: Efcacy for reducing future abuse reports.’ Journal of
Consulting and Clinical Psychology 72, 3, 500–510.
265 See Stith, S.M., Ting Lui, L., Davies, C., Boykin, E.L., Alder, M.C., Harris, J.M., Som, A., McPherson, M.
and Dees, J.E.M.E.G. (2009) ‘Risk factors in child maltreatment: A meta-analytic review of the literature.’
Aggression and Violent Behaviour 14, 3–29.
266 Binggeli, N., Hart, S.N. and Brassard, M.R. (2001) Psychological Maltreatment of Children. London: Sage.
267 Stratton, P. (2005) Report on the Evidence Base of Systemic Family Therapy. Warrington: Association for Family
Therapy.
268 Carr, A. (2000) Family Therapy: Concepts, Process and Practice. Chichester: John Wiley & Sons Ltd.
269 Asen, E. (2002) ‘Outcome research in family therapy.’ Advances in Psychiatric Treatment 8, 3, 230–238.
270 Carr, A. (2006) ‘Thematic review of family therapy journals in 2005.’ Journal of Family Therapy 28, 4, 420–
439.
271 Fraser, L. (1995) ‘Eastfeld Ming Quong: Multiple-Impact In-Home Treatment Model.’ In L. CombrickGraham (ed.) Children and Families at Risk. New york, Ny: Guilford Press.
272 Kolko, D.J. (1996) ‘Individual cognitive behavioural treatment and family therapy for physically abused
children and their offending parents: A comparison of clinical outcomes.’ Child Maltreatment 1, 322–342.
273 Meezan, W. and O’Keefe, M. (1998) ‘Evaluating the effectiveness of multifamily group therapy in child abuse
and neglect.’ Research on Social Work Practice 8, 330–353.
274 This randomized controlled trial reported after completion of the scientifc reviews but it builds on studies
that were identifed by Montgomery and colleagues.
275 Swenson, C., Schaeffer, C., Henggeler, S., Faldowski, R. and Mayhew, A. (2010) ‘Multi-Systemic Therapy for
Child Abuse and Neglect: A randomised controlled effectiveness trial.’ Journal of Family Psychology 24, 497–
507.
Endnotes | 205
276 Stallman, H., Walmsley, K., Bor, W., Collerson, M.E., Swenson, C. and McDermott, B. (2010) ‘New directions
in the treatment of child physical abuse and neglect in Australia: MST-CAN, a case study.’ Advances in Mental
Health 9, 148–161.
277 Bronfenbrenner, U. (1979) The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA:
Harvard University Press.
278 See Kolko (1996) op. cit.; Meezan and O’Keefe (1998) op. cit.
279 Swenson, Schaeffer, Henggeler, Faldowski and Mayhew (2010) op. cit.
280 Stallman, Walmsley, Bor, Collerson, Swenson and McDermott (2010) op. cit.
281 See Swenson, Schaeffer, Henggeler, Faldowski and Mayhew (2010) op. cit.
282 But see Wiggins, C., Fenichel, E. and Mann, T. (2007) Literature Review: Developmental Problems of Maltreated
Children and Early Intervention Options for Maltreated Children. Report to Ofce of the Assistant Secretary for
Planning and Evaluation, US Department of Health and Human Services; Macdonald, G.M. (2001) Effective
Interventions for Child Abuse and Neglect: An Evidence-Based Approach to Evaluating and Planning Interventions.
Chichester: John Wiley & Sons Ltd.
283 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.25–26.
284 Moore, E., Armsden, G. and Gogerty, P.L. (1998) ‘A twelve-year follow up study of maltreated and at-risk
children who received early therapeutic child care.’ Child Maltreatment 3, 3–16.
285 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.24–25.
286 Fantuzzo, J., Sutton-Smith, B., Atkins, M., Meyers, R., Stevenson, H., Coolahan, K., Weiss, A. and Manz, P.
(1996) ‘Community-based resilient peer treatment of withdrawn maltreated preschool children.’ Journal of
Consulting and Clinical Psychology 64, 1377–1386.
287 See for example Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., Hughes, R.
and Moore, L. (2008) ‘An informal school-based peer-led intervention for smoking prevention in adolescence
(ASSIST): A cluster randomised trial.’ The Lancet 371, 1595–1602; and Cuijpers, P. (2002) ‘Peer-led and
adult-led school drug prevention: A meta-analytic comparison.’ Journal of Drug Education 32, 2, 107–119.
288 See for instance Leve, L., Fisher, P. and Chamberlain, P. (2009) ‘Multidimensional Treatment Foster Care as a
preventive intervention to promote resiliency among youth in the child welfare System.’ Journal of Personality
77, 6 1869–1902; and Fisher, P., Chamberlain, P. and Leve, L. (2009) ‘Improving the lives of foster children
through evidence-based interventions.’ Vulnerable Children and Youth Studies 4, 2, 122–127.
289 Fisher, P.A., Burraston, B. and Pears, K. (2005) ‘The Early Intervention Foster Care Programme: Permanent
placement outcomes from a randomized trial.’ Child Maltreatment 10, 61–71; and Fisher, P.A. and Kim, H.K.
(2007) ‘Intervention effects on foster preschoolers’ attachment-related behaviours from a randomized trial.’
Prevention Science 8, 161–170. The evaluation given in Appendix 2 (Example 10) is the only MTFC evaluation
identifed by the scientifc reviews, presumably because it met the criteria by referring explicitly to physical
abuse, while others do not. Strictly speaking our discussion should therefore be restricted to this study, but it
seems pointless to withhold, in the interests of academic purity, information about the wider programme that
is of potential value to readers.
290 National Implementation Team (2010) Multi-Dimensional Treatment Foster Care in England: Annual Project Report.
London: Department for Children, Schools and Families.
291 Ibid. p.1.
292 Holmes, L., Westlake, D. and Ward, H. (2009) Calculating and Comparing the Costs of Multidimensional Treatment
Foster Care, England (MTFCE). Report to the Department for Children, Schools and Families. Loughborough:
Centre for Child and Family Research, Loughborough University.
293 Garland, A.F., Bickman, L. and Chorpita, B.F. (2010) ‘Change what? Identifying quality improvement targets
by investigating usual mental health care.’ Administration in Policy and Mental Health 37, 15–26.
294 Chorpita, B.F. and Daleidin, E.L. (2009) ‘Mapping evidence-based treatments for children and adolescents:
Application of the distillation and matching model to 615 treatments from 322 randomized trials.’ Journal of
Consulting and Clinical Psychology 77, 3, 566–579.
295 Garland, A.F., Hawley, K.M., Brookman-Frazee, L. and Hurlburt, M.S. (2008) ‘Identifying common elements
of evidence-based psychosocial treatments for children’s disruptive behaviour problems.’ Journal of the American
Academy of Child and Adolescent Psychiatry 47, 5, 505–514.
296 Jones, D.P.H., personal communication.
297 For example, see summaries based upon these by Jones, D.P.H. (2008) ‘Child Maltreatment.’ In M. Rutter, D.
Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor and A.Thapar (eds) Rutter’s Child and Adolescent Psychiatry (Fifth
Edition). Oxford: Blackwell Publishing, pp.431–433.
298 Jones, D.P.H. (2009) ‘Child Abuse and Neglect.’ In M. Gelder, J. Lopez-Ibor and N. Andreasen (eds) The New
Oxford Textbook of Psychiatry (Second Edition). Oxford: Oxford University Press, pp.1738–1739.
206 | Safeguarding Children Across Services
Chapter 6
299 France, A., Munro, E.R. and Waring, A. (2010) The Evaluation of Arrangements for Effective Operation of the New
Local Safeguarding Children Boards in England – Final Report. London: Department for Education.
300 Carpenter, J., Hackett, S., Patsios, D. and Szilassy, E. (2010) Outcomes of Inter-Agency Training to Safeguard
Children. Research Report DCSF-RR209. London: Department for Children, Schools and Families.
301 Komulainen, S. and Haines, L. (2009) Understanding Parent’s Information Needs and Experiences where Professional
Concerns Regarding Non-Accidental Injury were not Substantiated. Research Report. London: Royal College of
Paediatrics and Child Health.
302 Tompsett, H., Ashworth, M., Atkins, C., Bell, L., Gallagher, A., Morgan, M. and Wainwright, P. (2009) The
Child, the Family and the GP: Tensions and Conflicts of Interest in Safeguarding Children. DCSF-RBx-09-05-ES.
London: Department for Children, Schools and Families.
303 Laming, Lord (Cm 5730) (2003) The Victoria Climbié Inquiry: Report of an Inquiry by Lord Laming. London: The
Stationery Ofce; and Haringey Local Safeguarding Children Board (2010) Serious Case Review: Child A, March
2009. London: Department for Education.
304 Laming, Lord (Cm 5730) (2003) op. cit.
305 Children Art (2004) London: HMSO.
306 HM Government (2010) Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and
Promote the Welfare of Children. London: Department for Children, Schools and Families.
307 Department for Education (2010b) More Freedom and Flexibility: A New Approach for Children’s Trust Boards,
Children and Young People’s Plans, and the ‘Duty to Cooperate’. News release, 3 November 2010. London:
Department for Education.
308 Department for Education (Cm 7980) (2010f ) The Importance of Teaching: The Schools White Paper. London:
The Stationery Ofce.
309 See Department for Communities and Local Government: Newsroom, 14 October 2010. Ministerial
Statement by Rt Hon Eric Pickles: Local Government Accountability; and HM Treasury (Cm 7942) (2010)
Spending Review. London: The Stationery Ofce.
310 HM Government (2010) op. cit. pp.60–62.
311 Royal College of General Practitioners (2009) Safeguarding Children and Young People: A Toolkit for General
Practice. London: RCGP.
312 See Department for Children, Schools and Families (2009) Referrals, Assessments and Children and Young People
who are the Subject of a Child Protection Plan, England – Year Ending March 31 2009 (www.data.gov.uk/dataset/
referrals) and Department for Education (2010d) Children in Need in England, including their Characteristics and
Further Information on Children who were the Subject of a Child Protection Plan (2009–2010 Children in Need Census,
Final). London: Department for Education.
313 Munro, E. (2010) The Munro Review of Child Protection. Part One: A Systems Analysis. London: Department for
Education.
314 Holmes, L., Munro, E.R. and Soper, J. (2010) Calculating the Cost and Capacity Implications for Local Authorities
Implementing the Laming (2009) Recommendations. London: LGA.
315 Munro (2010) op. cit.
316 HM Government (2010) op. cit.
317 Sanders, R., Colton, M. and Roberts, S. (1999) ‘Child abuse fatalities and cases of extreme concern: Lessons
from reviews.’ Child Abuse and Neglect 23, 3, 257–268.
318 Munro, E. (1999) ‘Common errors of reasoning in child protection work.’ Child Abuse and Neglect 23, 8, 745–
758.
319 Ward, H., Brown, R., Westlake, D. and Munro, E.R. (forthcoming) Safeguarding Babies and Very Young Children
from Abuse and Neglect. London: Jessica Kingsley Publishers.
320 Ward, H., Holmes, L., Moyers, S., Munro, E.R. and Poursanidou, D. (2004) Safeguarding Children: A Scoping
Study of Research in Three Areas. Loughborough: Centre for Child and Family Research, Loughborough
University.
321 Ward, Brown, Westlake and Munro (forthcoming) op. cit.
322 Laming, Lord (HC 330) (2009) The Protection of Children in England: A Progress Report. London: The Stationery
Ofce.
323 Holmes, Munro and Soper (2010) op. cit.
324 Farmer, E. and Lutman, E. (forthcoming) Working Effectively with Neglected Children and their Families –
Understanding their Experiences and Long-Term Outcomes. London: Jessica Kingsley Publishers.
325 Ibid. p.185.
326 France, Munro and Waring (2010) op. cit. p.177.
Endnotes | 207
327 Ibid. p.177.
328 See Leslie, B. (2005) ‘Housing Issues in Child Welfare: A Practice Response with Service and Policy
Implications.’ In J. Scott and H. Ward (eds) Safeguarding and Promoting the Well-Being of Children, Families and
Communities. London: Jessica Kingsley Publishers.
329 Department for Education (2010e) Response to Public Comments on Coalition Agreement on Families and Children.
London: Department for Education.
330 Farmer and Lutman (2009) op. cit. p.77.
331 Laming, Lord (Cm 5730) (2003) op. cit. p.367.
332 Ibid.
333 HM Government (2010) op. cit. Section 4.3.
334 Ibid. Section 4.2.
335 Salas, E. and Cannon-Bowers, J. (2001) ‘The science of training: A decade review of progress.’ Annual Review
of Psychology 52, 471–499.
336 See www.education.gov.uk/researchandstatistics/research/scri Carpenter, J., Patsios, D., Szilassy, E. and
Hackett, S. (2011) Connect, Share and Learn: A Toolkit for Evaluating the Outcomes of Inter-Agency Training to
Safeguard Children. London: NSPCC.
337 Carpenter, Hackett, Patsios and Szilassy (2010) op. cit.
338 Tompsett, Ashworth, Atkins, Bell, Gallagher, Morgan and Wainwright (2009) op. cit.
339 Royal College of Paediatrics and Child Health (2010) Safeguarding Children and Young People: Roles and
Competences for Health Care Staff. Intercollegiate Document. London: Royal College of Paediatrics and Child
Health.
340 Ibid.
341 Laming, Lord (HC 330) (2009) op. cit.
342 Children Act (2004) op. cit.
343 HM Government (2010) op. cit. Sections 3.8–3.10.
344 Chief Inspector of Social Services, Director for Health Improvement, Commission for Health Improvement
and HM Chief Inspector of Constabulary (2002) Safeguarding Children: A Joint Chief Inspectors’ Report on
Arrangements to Safeguard Children. London: Department of Health.
345 Narducci, T. (2003) Increasing the Effectiveness of the ACPC. London: NSPCC.
346 Munro, E. (2011b) The Munro Review of Child Protection: Final Report. A Child-Centred System. London:
Department for Education; Department for Education (2011) A Child-Centred System: The Government’s Response
to the Munro Review of Child Protection. London: Department for Education.
347 Laming, Lord (Cm 5730) (2003) op. cit. p.6.
348 Munro (2010) op. cit.
349 Laming, Lord (Cm 5730) (2003) op. cit. p.8.
350 Ibid. pp.5–6.
351 Department for Education (2010e) op. cit.
352 Percy-Smith, J. (2006) ‘What works in strategic partnerships for children: A research review.’ Children and
Society 20, 4, 313–323.
353 Laming, Lord (Cm 5730) (2003) op. cit.
354 Laming, Lord (HC 330) (2009) op. cit.
355 HM Government (2010) op. cit. Paras 3.52–3.32, p.99.
356 Haringey Local Safeguarding Children Board (2010) op. cit.
357 Laming, Lord (HC 330) (2009) op. cit.
358 Haringey Local Safeguarding Children Board (2010) op. cit.
359 Children Act (2004) op. cit.
360 Hardy, B., Turrell, A. and Wistow, G. (1992) Innovations in Community Care Management. Aldershot: Avebury.
361 HM Government (2010) op. cit. Para. 3.97, p.109.
362 France, Munor and Waring (2010) op. cit.
363 Children Act (2004) op. cit.
364 Munro (2010) op. cit.; Munro, E. (2011a) The Munro Review of Child Protection: Interim Report. A Child’s Journey.
London: Department for Education.
365 Department of Health (2010) (cm 7881) Equity and Excellence: Liberating the NHS. London: The Stationery
Ofce.
366 Royal College of Paediatrics and Child Health (2010) op. cit.
208 | Safeguarding Children Across Services
Chapter 7
367 Laming, Lord (Cm 5730) (2003) The Victoria Climbié Inquiry: Report of an Inquiry by Lord Laming. London: The
Stationery Ofce.
368 Jones, D.P.H. (2008) ‘Child Maltreatment.’ In M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor
and A. Thapar (eds) Rutter’s Child and Adolescent Psychiatry (Fifth Edition). Oxford: Blackwell Publishing.
369 Hindley, N., Ramchandani, P.G. and Jones, D.P.H. (2006) ‘Risk factors for recurrence of maltreatment: A
systematic review.’ Archives of Disease in Childhood 91, 9, 744–752.
370 For a comprehensive overview see Cleaver, H., Unell, I. and Aldgate, A. (2011) Children’s Needs – Parenting
Capacity. The Impact of Parental Mental Illness, Learning Disability, Problem Alcohol and Drug Use and Domestic
Violence on Children’s Safety (2nd Edition). London: The Stationery Ofce.
371 See De Bellis, M. (2005) ‘Psychobiology of neglect.’ Child Maltreatment 10, 2, 150–172.
372 See Glaser, D. (2000) ‘Child abuse and neglect and the brain: A review.’ The Journal of Child Psychiatry and
Psychology 41, 1, 97–116.
373 Rees, G., Stein, M., Hicks, L. and Gorin, S. (2011) Adolescent Neglect: Research, Policy and Practice. London:
Jessica Kingsley Publishers.
374 Department of Health (2009) Healthy Lives, Brighter Futures: The Strategy for Children and Young People’s Health.
London: Department of Health and Department for Children, Schools and Families.
375 See Health Scotland. Starting Well? What is Triple P? Accessed on 24 January 2011 at: www.healthscotland.
com/uploads/documents/swsection%208.pdf; see also the Institute for Applied Health. Accessed on 24
January 2011 at: www.gcu.ac.uk/iahr/globalprojects/triplep/.
376 Barnes, J., Ball, M., Meadows, P., Belsky, J. and the FNP Implementation Research Team (2009) Nurse–Family
Partnership Programme, Second Year Pilot Sites Implementation in England: The Infancy Period. London: Department
for Children, Schools and Families and Department of Health.
377 See for instance Hutchings, J., Bywater, T., Williams, M.E., Shakespeare, M.K. and Whitaker, C. (2009)
Evidence for the Extended School Aged Incredible Years Parent Programme with Parents of High-Risk 8 to 16 Year Olds.
Bangor: School of Psychology, Bangor University. Also see Webster-Stratton, C. and Reid, J. (2010) ‘Adapting
the Incredible years, an evidence-based parenting programme, for families involved in the child welfare
system.’ Journal of Children’s Services 5, 1, 25–42.
378 Further information about such programmes can be found in the two reviews of evidence: Barlow, J. and
Schrader McMillan, A. (2010) Safeguarding Children from Emotional Maltreatment: What Works. London: Jessica
Kingsley Publishers; Montgomery, P., Gardner, F., Ramchandani, P. and Bjornstad, G. (2009) Systematic Reviews
of Interventions following Physical Abuse: Helping Practitioners and Expert Witnesses Improve the Outcomes of Child
Abuse. Report to Department for Children, Schools and Families. Oxford: University of Oxford.
379 Parents Under Pressure: see Barlow and Schrader McMillan (2010) op. cit. pp.79–80.
380 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.68–70 and MacMillan, H.L.,
Wathen, C.N., Barlow, J., Fergusson, D.M., Leventhal, D.M., and Taussig, H.N. (2009) ‘Child maltreatment
3: Interventions to prevent child maltreatment and associated impairment.’ The Lancet 373, 9659, 250–266,
p.253.
381 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.93–94 and Montgomery,
Gardner, Ramchandani and Bjornstad (2009) op. cit.
382 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.98–99.
383 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.31–32 and
MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op. cit. pp.250–266.
384 Swenson, C., Schaeffer, C., Henggeler, S., Faldowski, R. and Mayhew, A. (2010) ‘Multi-Systemic Therapy for
Child Abuse and Neglect: A randomised controlled effectiveness trial.’ Journal of Family Psychology 24, 497–
507.
385 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.25–26.
386 Ibid. pp.24–25.
387 Ibid. pp.23–24.
388 Garland, A.F., Hawley, K.M., Brookman-Frazee, L. and Hurlburt, M.S. (2008) ‘Identifying common elements
of evidence-based psychosocial treatments for children’s disruptive behaviour problems.’ Journal of the American
Academy of Child and Adolescent Psychiatry 47, 5, 505–514.
389 See, for instance, Becker, S., Sempik, J. and McCrossen, v. (2003) Mapping Therapeutic Service Provision and
Approaches Used by Learning Support Units in Nottingham City Secondary Schools: First Report – LSU Managers’
Perceptions. Loughborough: Centre for Child and Family Research, Loughborough University, and Nottingham
City Education Department.
Endnotes | 209
390 Farmer, E. and Lutman, E. (forthcoming) Working Effectively with Neglected Children and their Families –
Understanding their Experiences and Long-Term Outcomes. London: Jessica Kingsley Publishers.
391 Wade, J., Biehal, N., Farrelly, N. and Sinclair, I. (2011) Caring for Abused and Neglected Children: Making the Right
Decisions for Reunifcation or Long-Term Care. London: Jessica Kingsley Publishers.
392 Ward, H., Brown, R., Westlake, D. and Munro, E.R. (forthcoming) Safeguarding Babies and Very Young Children
from Abuse and Neglect. London: Jessica Kingsley Publishers.
393 Wade, Biehal, Farrelly and Sinclair (2011) op. cit.
394 Forrester, D. and Harwin, J. (2008) ‘Parental substance misuse and child welfare: Outcomes for children two
years after referral.’ British Journal of Social Work 38, 1518–1535.
395 Ward, H., Skuse, T. and Munro, E.R. (2005) ‘The best of times, the worst of times: young people’s views of
care and accommodation.’ Adoption and Fostering 29, 1, 8–17.
396 Skuse, T. and Ward, H. (2003) Outcomes for Looked After Children: Children’s Views, the Importance of Listening. An
Interim Report to the Department of Health. Loughborough: Centre for Child and Family Research, Loughborough
University.
397 Sinclair, I., Baker, C., Lee, J. and Gibbs, I. (2007) The Pursuit of Permanence: A Study of the English Child Care
System. London: Jessica Kingsley Publishers.
398 Ward, H. (2009) ‘Patterns of instability. Moves within the English care system: Their reasons, contexts and
consequences.’ Child and Youth Services Review 31, 1113–1118.
399 Stein, M. and Munro, E.R. (eds) (2008) Young People’s Transitions from Care to Adulthood: International Research and
Practice. London: Jessica Kingsley Publishers.
400 See Skuse and Ward (2003) op cit.
401 Ibidem
402 Scott, S., Knapp, M., Henderson, J. and Maugham, B. (2001) ‘Financial cost of social exclusion: Follow up
study of antisocial children into adulthood.’ British Medical Journal 323, 191–196.
403 Ward, H., Holmes, L. and Soper, J. (2008) Costs and Consequences of Placing Children in Care. London: Jessica
Kingsley Publishers.
Appendices
404 For further information see Barlow, J. and Schrader McMillan, A. (2010) Safeguarding Children from Emotional
Maltreatment: What Works. London: Jessica Kingsley Publishers, pp.79–80.
405 See Dawe, S. and Harnett, P.H. (2007) ‘Reducing potential for child abuse among methadone-maintained
parents: Results from a randomized controlled trial.’ Journal of Substance Abuse Treatment 32, 381–390.
406 Parents Under Pressure. Accessed on 24 January 2011 at: www.pupprogramme.net.au.
407 Dawe and Harnett (2007) op. cit.
408 Personal communication from steering group members.
409 See National Academy for Parenting Research. Accessed on 24 January 2011 at: www.parentingresearch.org.
uk/Projects.aspx?ID=3.
410 For further information see Barlow and Schrader McMillan (2010) op. cit. pp. 68–70 and MacMillan, H.L.,
Wathen, C.N., Barlow, J., Fergusson, D.M., Leventhal, D.M. and Taussig, H.N. (2009) ‘Child maltreatment
3: Interventions to prevent child maltreatment and associated impairment.’ The Lancet 373, 9659, 250–266,
p.253.
411 Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S. and young, R.W. (2004) ‘Does
parental attributional retraining and anger management enhance the effects of the Triple P-Positive Parenting
Programme with parents at risk of child maltreatment?’ Behavioural Therapy 35, 513–535.
412 Prinz, R.J., Sanders, M.R., Shapiro, C.J., Whitaker, D.J. and Lutzker, J.R. (2009) ‘Population-based prevention
of child maltreatment: The US Triple P system population trial.’ Prevention Science 10, 1, 1–12.
413 Iwaniec, D. (2007) The Emotionally Abused and Neglected Child: Identifcation, Assessment and Intervention.
Chichester: John Wiley and Sons.
414 See Triple P Programme. Accessed on 24 January 2011 at: www.triplep.net/.
415 Stern, S.B. and Azar, S.T. (1998) ‘Integrating cognitive strategies into behavioural treatment for abusive
parents and families with aggressive adolescents.’ Clinical Child Psychology and Psychiatry 3, 387–403.
416 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.70–73.
417 Iwaniec, D. (1997) ‘Evaluating parent training for emotionally abusive and neglectful parents: Comparing
individual versus individual and group intervention.’ Research in Social Work Practice 7, 3, 329–349.
210 | Safeguarding Children Across Services
418 For further information see Barlow and Schrader McMillan (2010) op. cit. pp.93–94 and Montgomery, P.,
Gardner, F., Ramchandani, P. and Bjornstad, G. (2009) Systematic Reviews of Interventions following Physical
Abuse: Helping Practitioners and Expert Witnesses Improve the Outcomes of Child Abuse. Unpublished report to DCSF.
Oxford: University of Oxford.
419 Toth, S., Maughan, A., Todd Manly, J., Spagnola, M. and Cicchetti, C. (2002) ‘The relative efcacy of two
interventions in altering maltreated preschool children’s representational models: Implications for attachment
theory.’ Development and Psychopathology 14, 887–908.
420 For further information see Barlow and Schrader McMillan (2010) op.cit. pp.98–9.
421 Benoit, D., Madigan, S., Lecce, S., Shea, B. and Goldberg, S. (2001) ‘Atypical maternal behaviour toward
feeding-disordered infants before and after intervention.’ Infant Mental Health Journal 22, 6, 611–626.
422 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.31–32 and
MacMillan, Wathen, Barlow, Fergusson, Leventhal and Taussig (2009) op. cit.
423 Chafn, M., Silovsky, J.F., Funderburk, B., valle, L.A., Brestan, E.v., Balachova, T. et al. (2004) ‘Parent–Child
Interaction Therapy with physically abusive parents: Efcacy for reducing future abuse reports.’ Journal of
Consulting and Clinical Psychology 72, 3, 500–510.
424 Parent–Child Interaction Therapy (PCIT). Accessed on 24 January 2011 at: http://pcit.phhp.ufl.edu.
425 Parent–Child Interaction Therapy International (PCIT International). Accessed on 24 January 2011 at: www.
pcit.org.
426 Child Welfare Information Gateway: Protecting children, strengthening families. Accessed on 1 December
2010 at www.childwelfare.gov.
427 Swenson, C., Penman, J., Henggeler, S. and Rowland, M. (2010) Multisystemic Therapy for Child Abuse and
Neglect. Charleston, SC: Family Services Research Center, MUSC.
428 Swenson, C., Schaeffer, C., Henggeler, S., Faldowski, R. and Mayhew, A. (2010) ‘Multi-Systemic Therapy for
Child Abuse and Neglect: A randomised controlled effectiveness trial.’ Journal of Family Psychology 24, 497–
507.
429 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.25–26.
430 Moore, E., Armsden, G. and Gogerty, P.L. (1998) ‘A twelve-year follow up study of maltreated and at-risk
children who received early therapeutic child care.’ Child Maltreatment 3, 3–16.
431 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.24–25.
432 Fantuzzo, J., Sutton-Smith, B., Atkins, M., Meyers, R., Stevenson, H., Coolahan, K., Weiss, A. and Manz, P.
(1996) ‘Community-based resilient peer treatment of withdrawn maltreated preschool children.’ Journal of
Consulting and Clinical Psychology 64, 1377–1386.
433 Head Start is a programme implemented in the US that provides comprehensive education, health, nutrition
and parent involvement services to low-income children and their families. Education includes preschool
education to national standards that have become de facto standards for all US preschools. Health services
include screenings, health check-ups and dental check-ups. Social services provide family advocates to work
with parents and assist them in accessing community resources for low-income families.
434 For further information see Montgomery, Gardner, Ramchandani and Bjornstad (2009) op. cit. pp.23–24.
435 Fisher, P.A., Burraston, B. and Pears, K. (2005) ‘The Early Intervention Foster Care Programme: Permanent
placement outcomes from a randomized trial.’ Child Maltreatment 10, 61–71.
436 Fisher, P.A. and Kim, H.K. (2007) ‘Intervention effects on foster preschoolers’ attachment-related behaviours
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437 Fisher, Burraston and Pears (2005) op. cit.
438 That is, the probability of this happening by chance is less than 5 per cent.
439 Fisher, P.A., Stoomiller, M., Gunner, M.R. and Burraston, B.O. (2007) ‘Effects of a therapeutic intervention for
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440 Fisher and Kim (2007) op. cit.
441 Department for Children, Schools and Families (2010) Working Together to Safeguard Children. London:
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Subject Index
absence of ‘incidents’ (reporting of
maltreatment) 46
abuse
defnitions and terminology 17–18
epidemiology and prevalence
trends 17
actuarial approaches to risk assessment
67
adolescents
‘identifcation of neglect or abuse’
studies 22
maltreatment concerns 20–1
parenting programmes 70
recognising abuse 46–7, 150
risk-taking behaviours 70
service provisions and availability
59–60
supervision 59–60
adult mental health services,
professional perspectives 49–50
Alarm Distress Baby Scale (ADBB)
65–6
alcohol abuse, parental 36
Analysis of Serious Case Reviews [2003–
2005] (Brandon, M., Belderson,
P., Warren, C. et al.) 23, 24–5
fndings
abuse amongst adolescent and
disabled children 46–7
domestic violence 38
frameworks and concept
models 42–3
police contacts 50
professional stress responses
76
project summary 167–8
Analysis of Serious Case Reviews [2005–
2007] (Brandon, M., Bailey, S.,
Belderson, P. et al.) 23, 24–5
fndings
families seeking help 44
post-referral service responses
124
project summary 169–70
anxiety disorders, parental 35
assessment
to identify families who might
beneft from interventions
64–7
see also risk assessment
assessment tools
Alarm Distress Baby Scale (ADBB)
65–6
Common Assessment Framework
(CAF) 13–14, 64–5
Crittenden CARE–Index 65–6
Emotional Availability Scales 66
attachment theories 75
attachment–based programmes for
families 104
behavioural indicators of abuse 41
bullying by peers/siblings 17
burn injuries 40–1
CAF see Common Assessment
Framework (CAF)
care orders 80–1
care planning 79–80
child abuse data see abuse
epidemiology
child development indicators of
abuse/neglect 39–40
child development needs
children with disabilities 39
importance in safeguarding work
145, 150
child protection plans
duration 81
recent increases 17
child-focused interventions to mitigate
impairment 108–11
Multidimensional Treatment Foster
Care (MTFC) 109–11
Children Act–1989 80
Children Act–2004 13
children with disabilities, recognising
abuse 46–7
Children’s Trust Boards, disbanding 15
Climbié, victoria 11–13
cognitive behavioural approaches
to address physical abuse 105
to change parental belief systems
and abuse behaviours 102–3
cognitive development indicators of
abuse 41
commissioning of care 96–9, 144–5,
151
decentralisation initiatives 15
Common Assessment Framework
(CAF) 13–14, 64–5
‘common elements’ approach 111–12
communications management 132–3,
150–1
Connect, Share and Learn: A Toolkit for
Evaluating the Outcomes of Inter–
Agency Training to Safeguard Children
(Carpenter, J. et al. 2011) 21
Connelly, Peter 11–12, 14
consequences of neglect and
emotional abuse 30–3, 74–8
Core Assessment Records 42
Court involvement 80–1
Crittenden CARE Index 65–6
cultural differences 18
cycles of abuse 101–2
deaths, risk factors 32
decentralisation initiatives 15
defnitions and terminology 17–18
Department for Education,
commissioning evidence studies
25
Department of Health, commissioning
evidence studies 25
domestic violence 37–8, 100–1, 151
driving dangerously 70
‘early help’ services 16
early interventions, importance of
141–3
ecological model for neglect and
abuse 42–3
economic factors 38
emotional abuse
consequences 30–3
defnitions and terminology 19–21
importance of identifying 140–2
indicators of 41
parents 33
Emotional Abuse Intervention Review
(Barlow, J., Schrader McMillan,
A.)
brief resumé 22, 24
fndings 55–70, 94–112
cognitive behavioural
approaches 102–3
families seeking help 44
family–focused interventions
to prevent maltreatment
107
impact of abuse 32
parental mental health 34–6
parenting programmes 58
preventing the occurrence of
maltreatment 55–70
recognition of parents with
mental health problems
49–50
project summary 165–6
Emotional Abuse Recognition Training
Evaluation Study (Glaser, D., Prior,
v., Auty, K. and Tilki, S.)
basic resumé 22, 24
project summary 179–80
Emotional Availability Scales 66
219
220 | Safeguarding Children Across Services
environmental factors 38
evaluating evidence–based research
96–9
identifying concerns and problems
75–7, 88–90, 129–35,
145–7
Every Child Matters (DfE 2003) 13–14
evidence studies on safeguarding
children see research
methodologies; The
Safeguarding Children Research
Initiative
failure to thrive 40
faltering growth 40
families seeking help see signalling the
need for help
family functioning 34
family history 34
Family Nurse Partnership (FNP)
68–9, 143
family-focused prevention
interventions 106–8
Multi-Systemic Therapy for Child
Abuse and Neglect 107–8
fatalities, risk factors 32
father’s role, lack of evidence–base 25
foster care provisions 109–11
Framework for the Assessment of Children
in Need and their Families (DH/
DfES/HO 2000) 13–14
frameworks and models
for conceptualizing neglect and
emotional abuse 42–3
for interventions 56–7
‘fresh start’ attitudes 76–7
funding cuts 14–15
General Practitioner Tensions in
Safeguarding Study (Tomsett, H.,
Ashworth, M., Atkins, C., Bell,
L. et al.) 23, 24
fndings 116–37
differences in adults–
children’s service
perspectives 120–1
participation on courses 128
recognition and referral
dilemmas 118–19
project summary 187–8
government policies see policy
contexts; policy development
(post–2003)
GP-led commissioning 125, 131–2
GP-led consortia 15
health visitors 47–8
Health and Wellbeing Boards 15
Healthy Child Programme and InterDisciplinary Framework (HCP)
58–9, 143
help-seeking behaviours see signalling
the need for help
hierarchy of evidence 96
Home or Care? study (Wade, J., Biehal,
N., Farrelly, N. and Sinclair, I.)
brief resumé 22, 24, 27
fndings 73–90
care planning 79–80
consequences of maltreatment
74
inter-agency working 124–6
involvement of the Courts
80–1
multi-systemic therapy for
child abuse and neglect
107
multidimensional treatment
foster care 109–11
placement stability 87
post-care family reunifcation
85–6
post-referral responses 123
readmissions to care 86
social work interventions 146
wellbeing outcomes 89
fndings provision of services 83
project summary 191–2
home-based support for maltreated
children
identifcation of families 84–5
monitoring arrangements 82
outcomes and benefts 87–8,
89–90
overview of key concerns 73–8
readmissions to care and
breakdowns 86
returning post-care /
accommodation 85–6
stability concerns 88–9
timing issues 87
welfare issues 89–90
working with parents 83–4
home-visiting programmes 68–9
‘identifcation of neglect or abuse’
studies, brief outlines 22
ImPACT programme see Informed
Parents and Children Together
(ImPACT) programme
indicators of neglect / emotional
abuse 39–40
cognitive, behavioural and social
development 41
physical signs 40–1
infants and toddlers, assessment tools
for parent–child interactions
65–6
informal support 39
Information Needs of Parents at Early
Recognition Study (Komulainen, S.
and Haines, L.)
brief resumé 22, 24
fndings, inter-agency practice
116–37
project summary 181–2
Informed Parents and Children
Together (ImPACT) programme
70
Inter–Agency Training Evaluation
Study (Carpenter, J., Hackett, S.,
Patsios, D. and Szilassy, E.)
brief resumé 22, 24
fndings 116–37
adult–children services divide
120–1
improving co-operation
through training 126–9
practitioners working in adult
services 138
resource requirements 134
project summary 171–2
‘inter-disciplinary working to
safeguard children’ studies, brief
outlines 22–3
inter-disciplinary/inter-agency work
116–39, 148–9, 151
aims and rationale 116–17
contexts and recent policy changes
117–18
feedback from evaluation studies
118–26
post-referral service responses
123–4
professional differences in
perspectives 120–2
recognition and referrals
118–20
support service supply prior/
after removal from home
124–6
threshold applications in
practice 122–3
improving co-operation through
training 126–9
role and effectiveness of existing
support structures 129–33
interpersonal skills 132–3, 150–1
intervention frameworks 56–7
‘intervention on identifed neglect or
abuse’ studies, brief outlines 22
kinship care 88–9
Laming, Lord 12
leadership issues 133–4
legislative frameworks 13
influence on 16
Local Authorities, funding cuts (post–
2010) 14
Local Safeguarding Children Boards
(LSCBs) 13, 24, 129–35,
148–9, 151
aims and scope 129–30
communications management
132–3
leadership issues 133–4
resource issues 134–5
size matters 130–2
training initiatives 148–9
Subject Index | 221
Local Safeguarding Children Boards Study
(France, A., Munro, E.R. and
Waring, A.)
brief resumé 23, 24, 27
fndings 116–37
leadership issues 133
managing communications
within complex
structures 132
post-referral responses 124
recognition and referral
dilemmas 119
resource issues 134–5
structural contexts of
inter–agency and inter–
disciplinary work 129
threshold application criteria
122
project summary 177–8
longitudinal cohort studies 24
looked after children, outcomes
88–90, 146–7, 151
maltreatment
defnitions and scope 19–21
importance of early intervention
140–3
long-term consequences 18
prevalence 16–17
recognition and identifcation
140–3
maternal depression 35
Multi-Systemic Therapy for Child
Abuse and Neglect (MST–CAN)
107–8
Multidimensional Treatment Foster
Care (MTFC) 109–11
Munro Review of Child Protection (DfE
2010/2011a) 16
National Service Framework for
Children, young People and
Maternity Services (DH/DfES
2000) 14
neglect
consequences 30–3
defnitions and terminology 17–18,
19–21
importance of identifying 140–2
severity and persistence 18–19
Neglect Matters: A Guide for Young People
about Neglect (Hicks, L., Stein, M.
and Children’s Society/NSPCC)
21, 60
Neglect Matters: A Multi-Agency Guide
for Professionals Working Together
on Behalf of Teenagers (DfCSF
2010) 21
Neglected Children Reunifcation Study
(Farmer, E. and Lutman, E.) 22
fndings 73–90
application of threshold
criteria 122–3
care planning considerations
79–80
child-focused interventions
to mitigate impairment
108–9
consequences of maltreatment
74–7
family history and functioning
34
impact of neglect 30–1
inter-agency working 124–5
involvement of the courts
80–1
multidimensional treatment
foster care 109–10
post-referral responses 123
readmissions to care 86
scope of service provisions
82–3
stability of placements 88
substance and alcohol misuse
36
timing of interventions 87
wellbeing outcomes 89
working with parents 83–4
project summary 175–6
neglectful parenting 31–2
neighbourhood influences 38
NHS-social services integration
initiatives 15
Nurse Family Partnership 68–9, 143
older children, assessment tools for
parent–child interactions 66
parent and child-focused prevention
interventions 103–4
attachment-based programmes for
families 104
cognitive behavioural approaches
105
psychotherapy to address emotional
abuse 104
Parent–Child Interaction Coding
System–II 66
parent-focused prevention
interventions 99–103
parents involved in domestic
violence 100–1
parent’s own experiences of
maltreatment 101–2
substance-misusing families 100
parent-training programmes 69–70
parental involvement 83–4
limits of 83–4
written agreements 83
parental learning disability 37
parental mental health 34–5
anxiety disorders 35
maternal depression 35
psychotic disorders 35–6
substance and alcohol abuse 36
parental supervision 59–60
parental views 84
parenting
emotionally abusive 33
neglectful 31–2
partner violence 18
partnership working
parental involvement 83–4
structural arrangements 15
Physical Abuse Intervention Review
(Montgomery, P., Gardner, F.,
Ramchandani, P. and Bjornstad,
G.)
brief resumé 22, 24
fndings 94–112
family-focused interventions
to prevent recurrence
107
impairment mitigation childfocused interventions
109
specifc interventions
(overview) 94–6
project summary 183–4
physical chastisement studies 61–2
police 142
professional perspectives 50
policy contexts 11–12, 13–14
policy development (post-2003) 12
evidence-base initiatives 12–14
legislative initiatives 13
recent government changes (post–
2010) 14–16
population surveys, attitudes to
maltreatment 51
population-based prevention measures
58–61, 143
evaluated interventions 61–3
‘positive parenting’ programmes 62–3
predictors of abuse, population–wide
trials 62–3
prevention measures 57–8, 142–3
population-based measures 58–61,
61–3, 143
targeted approaches 63–70, 143
see also specialist interventions
Prior, v. 22, 24, 179–80
professional perspectives
amongst adult mental health
services 49–50
amongst health visitors 47–8
amongst school staff 48–9
recognising maltreatment 45–50
reluctance to act 46
psychotherapy programmes, parent–
child sessions 104
psychotic disorders, parents 35–6
public concerns 51
public education campaigns 150
public service measures see
population–based prevention
measures
public spending cuts 14–15
222 | Safeguarding Children Across Services
Recognition of Adolescent Neglect Review
(Stein, M., Rees, G., Hicks, L.
and Gorin, S.)
basic resumé 22, 24
fndings 29–51, 55–70
development needs of children
with disabilities 39
disengagement from services
83
economic and neighbourhood
factors 38
neglectful parenting 31–2
parent-training programmes
70
referral practices 50–1
universal approaches to
prevention 59–60
project summary 185–6
recognition of maltreatment 45–50,
140–3
absence of incidents 46
identifcation in adolescents 46–7
identifcation in children with
disabilities 46–7
professional perspectives 46
reluctance to act 46
Recognition of Neglect Review (Daniel,
B., Taylor, J. and Scott, J.) 24, 26
basic resumé 22
fndings 29–51
approaches for help 43–4
burn injuries 40–1
economic and neighbourhood
factors 38
health visitor’s approaches
47, 119
police attitudes and practices
50
professional approaches and
attitudes 46
referral practices 50
school attitudes 48–9
project summary 173–4
Rees, G. 22, 24, 29–51, 55–70,
185–6
referral practices 50–1, 119–20
key messages 150
thresholds and criteria 122–3, 150
research methodologies 96–7
hierarchies of evidence 96
research studies on safeguarding
children see The Safeguarding
Children Research Initiative
resource issues 134–5
returning home from care/
accommodation 85–6
risk assessment, actuarial approaches
67
risk factors 42
for fatalities 33
for neglect and emotional abuse
33–8
risk-taking behaviours 70
safeguarding children at home
see home–based support for
maltreated children
The Safeguarding Children Research
Initiative 12
applications overview 16, 21, 60
brief resumes of main studies 21,
22–5
key messages 12, 150–1
overview 140–51
strengths and weaknesses of
evidence 25–7
school-based professionals 48–9, 142
Section–47 enquiries 17
seeking help behaviours see signalling
the need for help
self-reported experiences 17
service provisions 81–3
durations 81–2
gaps and defcits 81
signalling the need for help 43–5
Signifcant Harm of Infants study (Ward,
H., Brown, R., Westlake, D. and
Munro, E.R.)
brief resumé 22, 24, 27
fndings 73–90
assessments 79
burns 41
care planning 80
consequences of maltreatment
74–7
drug and alcohol service
referrals 49
faltering growth 40
families seeking help 44
frameworks and concepts of
neglect and emotional
abuse 42
front-line worker’s concerns
119–20
health visitor responses 47
home safeguarding criteria 84
home-visiting programmes 69
impairment mitigation childfocused interventions
108–9
inter-agency working 124–6
multidimensional treatment
foster care 109–10
parent-focused interventions
99
parents involved in domestic
violence 100
perpetrators of violence 60–1
placement stability 88–9
post-referral responses 123
recognition and referral
dilemmas 119–20
risk assessment approaches 67
services 81–2
social isolation and informal
support 39
social work interventions 147
timing of interventions 87
universal approaches to
prevention 60
inter-agency training participation
128
project summary 193–4
smacking 18, 61–2
social development indicators of
abuse 41
social isolation 39
social withdrawal, in infants 65–6
social work interventions 73–93,
145–8
actions following referral 78–80
court involvement 80–1
existing concerns and problems
75–7, 88–90, 129–35,
145–7
identifying who can be safeguarded
at home 84–5
importance of child development
theories 39, 145
inclusion of parents 83–4
intervention services 81–3
planning matters 79–80
prevention measures (overview)
57–8, 142–3
referral issues and concerns 50–1,
119–20, 122–3, 150
returning home from care /
accommodation 85–6
see also specialist interventions
social workers
knowledge and training needs 75
‘start again’ attitudes to difcult
cases 76–7
specialist interventions 143–5
child-focused interventions to
mitigate impairment
108–11
family-focused prevention
interventions 106–8
parent and child–focused
prevention interventions
103–4, 105
parent-focused prevention
interventions 103–4, 144
speech and language delays 77
stability issues, of home–based care
88
‘start again’ syndrome 76–7
stress responses, children 31
studies on Safeguarding Children see
The Safeguarding Children Research
Initiative
substance abuse, parental 36, 100
substance misuse services, professional
perspectives 49–50
supervision needs, of adolescents
20–1
Sure Start children’s services 59
Subject Index | 223
Sure Start Local Programmes Safeguarding
Study (Tunstill, J. and Allnock, D.)
23–4
fndings 55–70
inter-agency working to
supply services 124–5
project summary 189–90
Sweden, bans on physical
chastisement 61–2
targeted prevention approaches
63–70, 143
actuarial approaches to assessing
risk 67
assessment tools to identify families
64–7
assessment tools to identify older
children 66
evaluated programmes 68–70
thresholds and referral criteria 122–3,
150
training impact studies 24, 148
training materials 21
Training Resources on Child Neglect for a
Multi-Agency Audience (Daniel, B.
et al.) 21
transferability of research studies
97–8
Triple P-Positive Parenting
Programme 62–3, 69, 143
violence see partner violence; physical
abuse of children
Webster-Stratton Incredible years
programme 69, 143
weight loss in children 40
wellbeing studies, looked-after
children vs. home-based care
arrangements 89–90, 151
wider community responses 51
Author Index
Allnock, D. 23, 23–4, 55–70, 124–5,
189–90
Ashworth, M. 23, 24, 116–37,
187–8
Atkins, C. 23, 24, 116–37, 187–8
Auty, K. 22, 24, 179–80
Bailey, S. 23, 24–5, 44, 124, 169–70
Barlow, J. 22, 24, 32, 34–6, 44, 49–
50, 55–70, 94–112, 165–6
Belderson, P. 23, 24–5, 38, 42–4,
46–7, 50, 76, 167–8, 169–70
Bell, L. 23, 24, 116–37, 187–8
Biehal, N. 22, 24, 27, 73–90, 107,
109–11, 123, 124–6, 146,
191–2
Bjornstad, G. 22, 24, 94–112, 183–4
Black, J. 23, 24–5, 38, 42–3, 46–7,
50, 76, 167–8, 169–70
Brandon, M. 23, 24–5, 38, 42–4,
46–7, 50, 76, 124, 167–8,
169–70
Brown, D. 22
Brown, R. 22, 24, 27, 40–2, 47,
49, 60–1, 67, 69, 73–90, 99,
108–10, 119–20, 124–6, 128,
193–4
Carpenter, J. 22, 24, 116–38, 171–2
Daniel, B. 22, 24, 26, 29–51, 173–4
Dodsworth, J. 23, 24–5, 38, 42–3,
46–7, 50, 76, 167–8
Farmer, E. 22, 30–1, 34, 36, 73–90,
82–4, 86–9, 108–10, 122–5,
175–6
Farrelly, N. 22, 24, 27, 73–90, 107,
109–11, 123, 124–6, 146,
191–2
France, A. 23, 24, 27, 116–37,
177–8
Gallagher, A. 23, 24, 116–37, 187–8
Gardner, F. 22, 24, 94–112, 183–4
Gardner, R. 23, 24–5, 38, 42–4,
46–7, 50, 76, 167–8, 169–70
Glaser, D. 22, 24, 179–80
Gorin, S. 22, 24, 29–51, 55–70,
185–6
Hackett, S. 22, 24, 116–38, 171–2
Haines, L. 22, 24, 116–37, 171–2
Hicks, L. 22, 24, 29–51, 55–70,
185–6
Howe, D. 23, 24–5, 38, 42–3, 46–7,
50, 76, 167–8
Komulainen, S. 22, 24, 116–37,
171–2
Laming, Lord 11
Lutman, E. 22, 30–1, 34, 36, 73–90,
82–4, 86–9, 108–10, 122–5,
175–6
Montgomery, P. 22, 24, 94–112,
183–4
Morgan, M. 23, 24, 116–37, 187–8
Munro, E.R. 12, 16, 22–4, 27, 40–2,
47, 49, 60–1, 67, 69, 73–90,
99, 108–10, 116–37, 177–8,
193–4
Patsios, D. 22, 24, 116–38, 171–2
Prior, v. 22, 24, 179–80
Ramchandani, P. 22, 24, 94–112,
183–4
Rees, G. 22, 24, 29–51, 55–70,
185–6
Schrader McMillan, A. 22, 24, 32,
34–6, 44, 49–50, 55–70,
94–112, 165–6
Scott, J. 22, 24, 26, 29–51, 173–4
Sidebotham, P. 23, 24–5, 44, 124,
169–70
Sinclair, I. 22, 24, 27, 73–90, 107,
109–11, 123, 124–6, 146,
191–2
Stein, M. 22, 24, 29–51, 55–70,
185–6
Szilassy, E. 22, 24, 116–38, 171–2
Taylor, J. 22, 24, 26, 29–51, 173–4
Tilki, S. 22, 24, 179–80
Tompsett, H. 23, 24, 116–37, 187–8
Tunstill, J. 23, 23–4, 55–70, 124–5,
189–90
Wade, J. 22, 24, 27, 73–90, 107,
109–11, 123, 124–6, 146,
191–2
Wainwright, P. 23, 24, 116–37,
187–8
Ward, H. 22, 24, 27, 40–2, 47,
49, 60–1, 67, 69, 73–90, 99,
108–10, 119–20, 124–6, 128,
193–4
Waring, A. 23, 24, 27, 116–37,
177–8
Warren, C. 23, 24–5, 38, 42–3, 46–
7, 50, 76, 167–8, 169–70
Westlake, D. 22, 24, 27, 40–2, 47,
49, 60–1, 67, 69, 73–90, 99,
108–10, 119–20, 124–6, 128,
193–4
224
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