Professor Jane Barlow, Director, Infant and Family Wellbeing Unit,
Warwick University
Clare Lushey, Research Associate, CCFR, Loughborough University
PRE-BIRTH ASSESSMENT AND
PROMOTING ATTACHMENT
Structure of the paper
 Why is pregnancy important
 Where are we now and why do we need to be doing things
differently?
 What does the science say about suboptimal environments in
the first year; and in pregnancy
 Legal, ethical and practice issues
 Current pre-birth assessment practice
 New Pre-birth pathway
 Feasibility study
Pathways in pregnancy
PHYSIOLOGICAL
PSYCHOLOGICAL/BE
HAVIOURAL
Stress or
Teratogens
Reflective
Function in
pregnancy
Programming of
foetus HPA
axis/neurological
damage
Atypical parenting
behaviours
Compromised
physiological/emotio
nal and behavioural
functioning
Disorganised
attachment
Stress exposures associated with impact
 Maternal anxiety (O’Connor et al., 2002; Austin, 2005; Obel et al., 2003;
Mennes et al., 2006; McMahon et al., 2013), and depression (O’Connor et
al., 2002 ; Pawlby et al., 2011)
 Pregnancy specific anxiety and daily hassles (Huizink et al., 2003)
 Bereavement (Khashan et al., 2008) and stress due to a
relationship problems with the partner (Bergman et al., 2007)
 Exposure to acute external disasters (Laplante et al., 2008),
9/11(Yehuda et al., 2005), Chernobyl (Huizink et al., 2008) a
Louisiana hurricane (Kinney et al., 2008), and war (can Os and
Selten, 1998)
Impact of stress on brain in-utero
 Altered diurnal pattern or altered function of the HPA
axis (Glover et al 2010)
 Regional reductions in brain grey matter density (Buss
et al 2010)
 Mechanisms – epigenetic; serotonin biosynthetic
pathway; transplacental transfer (i.e. changes to
barrier hormone changing cortisol to cortisone)
Physical and physiological outcomes
 Congenital malformations (Hansen et al 2000)
 Lower birth weight and reduced gestational age (Rice
et al 2010; Wadhwa et al 1993)
 Altered sex ratio (Obel et al 2007; Peterka et al 2004)
 Stress caused by violence leads to epigenetic changes in DNA
for this same receptor in the blood of the adolescent children
(Radtke et al 2011)
Neurodevelopment –
post birth
 Neurodevelopmental functioning of newborns
(NBAS) (Diego et al 2004)
 Temperament (Austin et al 2005; Buitelaar et al 2003;
 Sleep problems (O’Connor et al 2007)
 Cognitive performance and fearfulness (Bergman et al
2007)
Neurodevelopment – childhood
 Increased emotional problems (anxiety and
depression), ADHD and conduct disorder (O’Connor
et al 2002; 2003; Keleinhaus et al 2013; Rice et al 2010; Van Den
Bergh & Marcoen 2004; Rodriguez & Bohlin 2005; Beversdorf et al
2005)
 Reduced cognitive performance (Laplante et al 2008;
Mennes et al 2006)
DV in pregnancy
 Around 30% of domestic abuse starts during pregnancy (DH
2010); around 9% of women being abused during pregnancy
or after giving birth (Taft 2002)
 Associated with a wide range of compromised physical
outcomes: late prenatal care; miscarriage, preterm and
stillbirth; fetal injury (bruising, broken and fractured bones,
stab wounds) (Mezey et al 1997)
DV in pregnancy
 Maternal depression and PTSD
 Significantly more negative representations of
their infants and themselves;
 Babies were more likely to be insecurely attached
(Huth-Bocks 2004)
Pathways in pregnancy
PHYSIOLOGICAL
Stress or
Teratogens
PSYCHOLOGICAL/BE
HAVIOURAL
Reflective
Function
Programming of
foetus HPA
axis/neurological
damage
Atypical parenting
behaviours
Compromised
physiological/emotio
nal and behavioural
functioning
Disorganised
attachment
Foetal Alcohol Spectrum Disorders
 A range of effects (including physical, behavioral, and
cognitive) can arise from prenatal alcohol exposure
Prevalence of FASD (Ospina and Dennett 2013):
 FASD in community and population-based samples reported
estimates ranged from 0.02% to 0.5% (i.e. rates of 0.2 to 5 per
1000 population)
 Foster care settings ranged from 30.5% to 52%
 Prisons ranged from 9.8% to 23.3%
 Children in special education – 2.1% to 8.8%
Substance misuse in pregnancy
 Around 15% of pregnant women used cannabis or other illicit substances with
1-2% using Heroin or Cocaine (Jones et al 2012)
 Strong association with intra-uterine growth retardation (IUGR), placental
abruption and still birth (ibid); significantly higher risk of child protection
proceedings post birth (Street et al 2004)
 Significant increase in the prevalence of NAS, from 1.20 per 1,000 U.S.
hospital births in 2000 to 3.39 per 1,000 U.S. hospital births in 2009 (Patrick et
al 2012)
 Alcohol withdrawal may include hyperactivity, crying, irritability, poor sucking,
tremors, seizures, poor sleeping patterns, hyperphagia, and diaphoresis. Signs
usually appear at birth and may continue until age 18 months.
Pathways in pregnancy
PHYSIOLOGICAL
PSYCHOLOGICA
L/BEHAVIOURAL
Stress or
Teratogens
Reflective
Function
Programming of
foetus HPA
axis/neurological
damage
Parenting
behaviours
Compromised
physiological/
emotional and
behavioural
functioning
Insecure/
Disorganised
attachment
RF in pregnancy
 Ability to think about the baby and what he/she may be like;
indicative of parental bonding with the infant
 Pregnancy Interview (Slade et al 1987; Slade 2001): Mother’s prenatal representations of her fetus; Mother’s pre-natal
representations of herself as a caregiver, focusing in
particular on the mother’s capacity to identify with, respond
to, and anticipate the needs of her fetus at present and her
newborn in the near future.
RF in pregnancy and parenting
behaviours
 High RF strongly associated with maternal
parenting behaviours (e.g. flexibility and
responsiveness)
 Low RF associated with emotionally unresponsive
maternal behaviours (withdrawal, hostility,
intrusiveness)
(Slade et al 2001; Grienenberger et al 2001)
Long-term impact
RF during pregnancy predicts:
 Infant security at 12 months;
 Children’s ToM skills at 5;
 Scholastic self-esteem at 12
(Steele & Steele, 2008)
19
Legal & ethical issues
 In England the Children Act (1989) provides the legislative framework
through which the state can intervene to safeguard and promote the
welfare of children.
 The act does not provide for legal proceedings to protect a child before birth.
 Statutory guidance, Working Together to Safeguard Children (DfE. 2013)
makes reference for to taking formal steps to protect and unborn child.
 A woman has control over her body.
 Restrictions on termination of pregnancy under the Abortion Act 1967.
 Can refuse medical treatment (exc. one who lacks mental capacity) even if
doing so will put her unborn baby at risk of harm.
 Can refuse statutory interventions to safeguard her unborn child.
Legal and ethical issues
 English (and Welsh) law provides very limited
recognition of the foetus.
 It is not until birth that this right is superseded by
the child’s right to be protected from harm.
 Legal proceedings for supervision and removal
cannot be instigated until birth, but SWs can
make plans for such actions during pregnancy.
21
Practice issues



Parents might be suspicious of/distrust social services
Parents could disappear, avoid ante-natal services, deliver the baby without medical
care, or conceal or seek to terminate the pregnancy out of fear that their child might be
removed at birth (Barker, 1997; Hart, 2010; Calder, 2000; Ward et al. 2012).
Practitioners may not make referrals:





Bond between mother and unborn child ‘sacrosanct’ (Hodson, 2011).
Focusing on the parents rather than on the unborn child [adult services] (Ward et al. 2012;
Hart, 2010; Ofsted, 2011).
Under the impression that thresholds for CSC are too high (Davies and Ward, 2012).
Reluctant to bond with the unborn baby and/or make preparations for the baby’s arrival
due to uncertainties as to whether the child will be removed at birth (Ward et al., 2012).
Role of the father absent from pre-birth assessments - ‘ignored’, ‘invisible’ and ‘the ghost
in the equation’. Father may pose a risk to the unborn child or be a protective factor.
Review: models for pre-birth assessment where there is
high likelihood of significant harm to an unborn child

Pre-birth assessment tools designed to screen for potential maltreatment in
the general population (detect parents whose unborn baby is at risk of
significant harm):
 Limited number of screening tools identified (n=4)
 Many outdated

Pre-birth assessment tools designed to screen for the presence of
maltreatment in cases being assessed by CSC practitioners (families referred
to, or already identified, by CSC).
 Pre-birth assessment (Corner, 1997)
 Pre-birth assessment (Calder, 2003)
 Core assessment

The core assessment recommends the use of other standardised assessment
tools to aid decision-making , e.g. the parenting daily hassles tool, however
the others do not.
Pre-birth assessment:
Current practice
24
LSCB: Pre-birth assessment guidance
 All 147 LSCBs in England made reference to pre-birth assessments in their
procedures (2012-13) .
 Only one third (33%/n=48) acknowledged the lack of legal status of a foetus.
 Just one quarter (25%/n=36) referenced a pregnant woman’s right to
autonomy over her body.
 The majority (96%) contained information additional to Working Together
(2010, 2013):
 Referral protocols, e.g. when to make a referral, timescales for referral.
 Purpose of a pre-birth assessment.
 The type of information that requires collecting during a pre-birth assessment.
25
Interviews with practitioners




Existing pre-birth assessment practice
Telephone interviews with 18 practitioners from 9 localities
Main findings/implications for model development:
Guidance and tools:
 Limited guidance. Reliance on guidance from more experienced social workers and
previous pre-birth assessments. Additional guidance welcomed.
 Difficulty keeping up-to-date with new findings and accessing standardised
assessment tools.

Identification of unborn children at risk of harm
 Routine ante-natal booking interviews, are the main source of referrals to CSC.
Opportunities to disclose DV and asking whether older children are living with
birth parents will increase opportunities for identifying unborn children at risk of
harm.
 Automatic referrals to CSC of pregnant women with problematic substance or
alcohol use.
Interviews with practitioners
 Working with parents





Parents generally willing to participate but more suspicious and distrusting of
social workers in comparison with other workers.
Presentation is important – opportunity for parents to show they are able to
overcome their difficulties and meet the needs of their child.
Not concerned about parents disappearing. They will seek some form of support.
Attention needs to be given to processes for assessing and working with parents
whose older children are living at home (there is a likelihood that the focus will be
on the older children and the needs of the unborn child overlooked).
Contrary to previous research involvement of fathers was encouraged.
Interviews with practitioners
 Timescales:
 Referral and assessment early in the pregnancy
deemed important to prevent delay/drift and the
likelihood of a rushed assessment at the end of the
pregnancy .
 Time to undertake a robust assessment and provide
early support for parents that might succeed in
effecting change and prevent the need to remove the
child.
28
Implications for model development
 Guidance for social work assessments during the
pre-birth period is minimal
 Few practitioners use standardised tools to aid
decision-making and found them difficult to
access
 Legal issues
 Presents difficulties for practitioners with a
statutory responsibility to undertake pre-birth
assessments
29
New Model
of Pre-birth
Assessment
30
Underpinning concepts
 Partnership working and promoting attachment
and reflective function
 Structured professional judgment and use of
standardised tools
 Capacity to Change
31
Stages of the Model
32
Initial referral








33
Who should refer – midwives at booking-in
Timing of referral – 16 weeks gestations
Reasons for referral
A parent or other adult in the household has been convicted of an
offence against a child, or is believed by child protection professionals
to have abused a child
Previous children have been removed because they have suffered or
been deemed likely to suffer significant harm
A child in the household is the subject of a child protection plan.
A child under the age of 16 is pregnant
Other – DV; Substance-dependency; SMI: Learning problems;
parental history of LAC etc.
Stage 1 cross sectional assessment:
Core assessment tools




“HITS” a domestic violence screening tool
Substance use risk profile-pregnancy scale
Primary care PTSD screen
Multi-dimensional scale of perceived social support (MSPSS) and
the support scale
 North Carolina family assessment scale (NCFAS-G)
 Depression, anxiety and stress scale (DASS)
 Relationship questionnaire (RQ)
34
Stage 1 cross sectional assessment:
Core assessment tools
 Emotion regulation questionnaire (ERQ)
 Maternal/paternal antenatal attachment scale
(MAAS/PAAS)
 Pictorial representation of attachment measure (PRAM)
 Parenting stress index 4 short form (PSI – 4- SF)
 Parenting daily hassles scale
 Brief child abuse parenting (BCAP) inventory form VI
 Adult-adolescent parenting inventory (AAPI) – form
 Pregnancy interview - revised
35
Stage 1 Core cross-sectional
assessment: Optional assessment tools
 Addiction severity index (ASI) – psychiatric status
 Conflict tactics scale
 Addiction severity scale (ASI) - drug and alcohol
section
 Alcohol use disorders identification test (AUDIT) – C
 The Needs Jigsaw
36
Stage 2 – Case conceptualisation
Case formulation involves three stages:
 Learning about the issues (gather assessment
data)
 Organising the information into patterns or
themes
 Explaining these patterns or themes using a
theoretical framework
37
Stage 2 – Discrepancy Matrix
38
Stage 3 – Goal setting (GAS)
39
Stage 4 - Working therapeutically
 Core methods – Partnership Model; Motivational
Interviewing
 Promoting affect regulation: urge surging techniques;
mindfulness techniques etc.
 Promoting the relationship with the baby: media
based tools – Getting to Know your Baby app
 Evidence based programmes: Parents under
Pressure; Minding the Baby; Baby Steps; Circle of Security;
VIG; Parent-infant psychotherapy etc.
40
Stage 5 – Monitoring change
36 weeks gestation
 Re-administer baseline tools
 Outcomes of GAS
 Observations
 Multiagency reports
41
Stage 6 – Analysis and decision-making
42
Classification of risk
 Severe risk of harm: Families showing risk factors, no protective
factors and no evidence of capacity to change
 High risk of harm: Families showing risk factors and at least one
protective factor but no evidence of capacity to change
 Medium risk of harm: Families showing risk factors and at least one
protective factor including evidence of capacity to change
 Low risk of harm: Families showing no or few risk factors (or families
whose earlier risk factors had now been addressed), and protective
factors including evidence of capacity to change
43
Feasibility study
 The overall purpose is to assess the acceptability
and feasibility of implementing the new pre-birth
assessment model, prior to large-scale testing.
 Four local authorities testing the new pre-birth
assessment model
 Administered by social workers
44
Feasibility study
 Face-to-face interviews with eight social work managers
 Focus groups with a maximum of 40 social workers
 Face-to-face interviews with a maximum of 40 parents; includes
those receiving the new model of pre-birth assessment and those
receiving the standard
 Telephone interviews with 12 practitioners who make referrals for
pre-birth assessments, e.g. midwives, drug and alcohol workers
 Collation and collection of social work case file data from 40 families
that have received the new pre-birth assessment model, and from a
matched group of 40 families who have received standard care (=80).
45