The important of early intervention
for disadvantaged families
Professor Jacqueline Barnes
Institute for the Study of Children, Families
and Social Issues, Birkbeck,
University of London
1
What will be covered
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Why early intervention/prevention
Some USA examples
National Evaluation of Sure Start
The Family Nurse Partnership
programme
2
Risk factors and poor outcomes
Wealth of data from life course studies
linking adversity in early life to:
o
Poor literacy
o
Anti-social and criminal behaviour
o
Substance abuse
o
Poor mental and physical health
o
Adult mortality
3
Need to intervene earlier
To divert trajectories related to disadvantage
there is a need for:
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Earlier and better identification of at risk families
Earlier and more effective intervention and
prevention
Ideally one should intervene prior to
conception and definitely during pregnancy in
order to promote optimal brain development
4
Prevent before problems emerge
If people keep falling off a cliff,
don’t worry about where you put
the ambulance at the bottom. Build
a fence at the top and stop them
falling off in the first place.
Source: Allen & Duncan-Smith, 2010
5
Experiences affect brain development
o Conditions in early life affect the differentiation and
function of synapses in the brain
o The more positive stimuli a baby is given, the
more brain cells and synapses it will be able to
develop but…
o
The brain of an abused or neglected child is
significantly smaller than the norm, with 20-30 per
cent fewer synapses in the limbic system (governs
emotion) and the hippocampus (responsible for
memory) is also smaller
6
Differences in brain development following
severe sensory neglect
7
Rates of return to human capital investment
(Heckman 2000)
Rate of
return to
investment
in human
capital
Preschool programs
Schooling
Job training
Preschool
0
School
Post-school
Age
8
 Brain Malleability
Spending on Health, Education, Income
Support, Social Services and Crime 
Public Expenditure
Intensity of Brain's Development
Brain Development – Opportunity and
Investment

Birth
1
3
10
Age
60
80
9
Early years interventions is effective
for disadvantaged populations
USA Examples
•Perry Preschool Project – structured
preschool 3+years
•Abecedarian Project – childcare/preschool 0-6
•Early Head Start – childcare/home visit 0-3
10
Perry Preschool Project
(Schweinhart and Weikart, 1997)
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Gains in IQ at school entry
Fewer in special education
More graduate from high school
Fewer on welfare
Higher average earnings in young
adulthood
Fewer arrests as adults
11
Perry preschool project return on
investment
Program Benefits
Versus Cost
$100,000
$80,000
Return on the
dollar
invested
$88,433
$60,000
$7.16
$40,000
$20,000
$0
$12,356
Benefit
Cost
1992 dollars, 3% annual discount rate
12
Abecedarian Project
(Ramey et al., 2000)
Intervention group by age 21 showed:
 Higher cognitive development from 18 months
upward
 Greater social competence in preschool
 Better school achievement
 More college attendance
 Delayed child bearing
 Better employment
 Less smoking and drug use
13
Early Head Start (0-3 years)
(Love et al, 2003, 2005)
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At age 3 intervention group had:
Improved Cognitive and Language
Development
More sustained attention
Less aggression
Improved parent-child interaction
Improved home environment (more
reading – less spanking)
Centre and home > centre > > homebased
14
UK, Sure Start Local Programmes
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Most disadvantaged neighbourhoods
From birth to fourth birthday
All families living in the area so nontargeted
Locally driven agenda allowing for
diversity
Enhancement of existing services
15
Some positive impacts by age 3
(Melhuish et al., 2008; 2010)
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Children in Sure Start areas had more
positive social behaviour, more
independence, better self regulation.
They received more immunisations and
had fewer accidental injuries.
Parents showed less negative (harsh)
parenting
In Sure Start areas there were more
stimulating home environments.
More use of child and family services.
16
Pregnancy- A ‘magic moment’ of opportunity?
• Pregnancy and the birth of a child is a
‘magic moment’ of opportunity when parents
are uniquely receptive to support
• In the UK Universal midwifery and health
visiting services are ideally placed to identify
children and families at risk
• It is possible to identify in pregnancy those
children at greatest risk for developmental
and behavioural problems
17
Risk factors potentially identifiable in
pregnancy, based on UK evidence
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Low socioeconomic status
Maternal school failure
Mother ever in care/looked after
Young mother
Single parent or non involved father
Resident in a deprived neighbourhood
Marital/parental discord
Ethnic minority status
Parental criminality
Substance abuse and/or other mental health
problems
Pregnancy unplanned or not happy about pregnancy
Mother continues to smoke in pregnancy
18
Nurse-Family Partnership (NFP)
programme (Olds, 2006)
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Manualised Nurse home-visiting
Starts early in pregnancy (16 weeks)
For first-time mothers
Continues until child is two
Supported by over 30 years of research
from three RCTs
Licensed programme with detailed nurse
training and fidelity objectives to ensure
replication of the original programme
19
Structured curriculum and specified
number of visits
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1/week first month
Every other week through pregnancy
1/week first 6 weeks after delivery
Every other week until 21 months
Once a month until age 2
Each visit has a range of materials and
activities designed to build self-efficacy,
change behaviour, promote attachment
20
The visits cover 6 domains
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Personal health – women’s health practices and mental
health
Environmental health – adequacy of home and
neighbourhood
Life course development – women’s future goals
Maternal role – skills and knowledge to promote health
and development of their child
Family and friends – helping to deal with relationship
issues and enhance social support
Health and human services – linking to other services
The relationship between the nurse and the family lies
at the heart of the programme
21
Findings consistent across at least 2 of
3 USA trials
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Improvement in women’s prenatal health
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Reduction in children’s injuries
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Fewer subsequent pregnancies
Greater interval between births
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Increase in fathers’ involvement
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Increase in maternal employment
Reduction in receipt of welfare and food
stamps (means tested)
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Improvement in school readiness
22
Mothers (USA) gaining most from the
Nurse Family Partnership programme
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Low income, at about the national poverty
level or below
Unmarried (or ‘no partner’)
Teenage at conception
Below average intellectual capacity
Mental health problems in pregnancy
Low self esteem/sense of mastery in
pregnancy
Smoker in pregnancy
23
Cumulative Cost Savings: Elmira
$30,000
Cumulative
dollars
per
child
Cumulative savings
$25,000
S
O
C
I
A
L
$20,000
$15,000
R
E
T
U
R
N
$10,000
$5,000
Cumulative Costs
$0
0
2
5
10 15 20 25 30 35 40 45 50 55 60 65
Age of child (years)
24
Testing in England (called FNP)
Small scale
testing 07-10
Large scale
testing 08-11
10 wave 1 sites
20 wave 2
Roll out?
2011-19
20 wave 3
20 wave 4
Evaluation
07/08 to 10/11
RCT 2b and
wave1
Testing:
Programme delivery, training, organisational and service context,
workforce, commissioning, eligibility, recruitment pathways, roll out
25
Who receives FNP in England
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In all sites under 20 and first-time
parent
In selected sites also clients with
ALL THREE of the following:
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Aged between 20 and 22 at their last
menstrual period (LMP)
Not currently in employment, education
or training (NEET)
No educational qualifications higher
than 4 A* to C GCSEs
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Recruitment in wave 1 identified
vulnerable population
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80% without 5 or more A*-C GCSEs
78% not employed
67% not living with partner
75% below poverty line
24% report physical abuse in past 12
months, 11% during pregnancy
50% BMI < or >recommended range
Indicates a simple selection system,
predominantly under 20 and first time
mother, will identify appropriate group
comparable to those in USA trials
27
Why using other criteria can be
problematic
Relevant data not available in midwifery
records (e.g. income, educational
qualifications, ever in care, mental health
problems)
 Nurses do not want clients to feel
stigmatised
BUT it has been suggested by
commissioners that FNP should be more
targeted.
The issue is the topic of ongoing evaluation.
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28
Implementation evaluation findings
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Nurses enjoy the materials and the
extended time with clients
When offered the majority accept the
programme
Clients continue to receive the
programme up to 24 months with only
the predicted level of attrition
Delivery of the programme is not quite at
the level specified in the ‘dosage’
objective (number of expected visits) but
good in coverage of domains
29
Some implications noted for the cycle of
disadvantage
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Many clients reported planning to return to
education
Closer involvement of fathers with infants
Clients more confident as parents, doing
activities with children likely to enhance
cognitive and social development
Health related changes should enhance child
health (e.g. smoking – asthma)
Mothers and fathers feel less judged and
excluded, are thinking about the future with
more optimism, gives them an expectation that
formal services could be helpful.
30
Full details of the formative evaluation:
Year 1 report (pregnancy and post-partum) available at:
http://publications.dcsf.gov.uk/eOrderingDownload/DCSF-RW051%20v2.pdf
Year 2 report (infancy) available at:
http://www.dcsf.gov.uk/pns/DisplayPN.cgi?pn_id=2009_0168
Reports due at the end of 2010
Refining eligibility criteria
Delivery through toddlerhood until children are 24 months
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Conclusions
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FNP appears to be an important
addition to the range of services within
the Healthy Child Programme, likely to
benefit the most disadvantaged
families
Further research evidence from the UK
trial will show what the impacts are in
the context of universal health care
provision
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