Written evidence submitted by Home-Start (CYP0053)
About Home-Start UK
Home-Start is a local community network of trained volunteers and expert support helping families with babies and young children through their challenging times. Home-Start works with families in communities across the UK. Starting in the home, our approach is as individual as the people we are helping. No judgement, it is just compassionate, confidential help and practical support. Across all four nations of the United Kingdom, home-visiting volunteers and groups for parents support over 27,000 families to transform their lives.
There are 187 local, independent Home-Starts working in the majority of local authority areas across the UK. Families struggling with perinatal mental health difficulties, isolation, physical health problems, bereavement and many other issues receive the support of a volunteer who will typically spend around two hours a week in a family’s home supporting them in the ways they need[i].
The Importance of mental health in the first years of life
The first 1,001 days are a vital stage in a child’s development, laying the foundations for lifelong physical and mental health[ii]. The years between 3 and 5 are a period of exploration and consolidation as attachment security underpins children’s widening horizons and understanding of themselves in the world. During this time, children need nurturing care from their parents and caregivers. Parents in turn need a facilitating and supportive environment to enable them and their child to thrive.
If we are to meet the ambitions set out in the Green Paper, to ensure that every baby and young child is given the opportunity to flourish, to improve the bond between parents and their children, and to support families at higher risk of developing a mental health problems, then the mental health needs of the youngest in society and their families must be at the heart of any policy approach.
We welcome the terms of reference for this inquiry including addressing the question of wider changes needed in the system as a whole, and the extent to which it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing. Our view is that this is essential for driving the change that is needed to support children and young people and reduce the burden of poor mental health.
Despite developments in understanding of the importance of early development and environment, this knowledge is not being leveraged effectively to inform new approaches to promoting whole-child development and preventing illness[iii]. To change this requires an ambitious cross-department strategy for improving outcomes for all children; improved and sustainable funding to support universal, targeted and specialised services; and a well trained workforce with the skills mix, capacity and capability to work with children and families.
In order to address the rising levels of poor mental health in children and young people a central message must be to start early, and that in order to address the needs of children we must also first address the needs of parents through:
The impact of the pandemic
The imperative to give all children the best start in life is all the more urgent as we address the already increasing levels of poor mental health seen before the pandemic. This has been exacerbated significantly over the past year with an anticipated increase in the need for services and support, with increased psychological morbidity evident in the UK and the already evident developmental disruption for young children.[iv] [v]
A report into Early Years provision from Ofsted[vi] noted that parents who needed to continue to work out of the home, and had less financial resources, were unable to offer their young children the same levels of support as wealthier parents and those working from home. They cited the stresses related to deteriorating family finances, poverty, larger family size and overcrowded households as impacting on parents’ capacity to support their young children.
Our own report, Babies in lockdown, also highlighted the particular strains felt by parents during lockdown and the resulting restrictions[vii], with our survey of 5,474 parents revealing the disproportionate impact of the pandemic on expectant parents and parents of young children.
As pandemic restrictions have continued further, research evidence has highlighted that the struggles of meeting competing demands of family, schooling and work have been felt particularly acutely by parents in low income families, those in single parent families, and those supporting children with special educational needs. These parents also report elevated mental health problems such as higher levels of stress, depression and anxiety. [viii]
Further, Ofsted have highlighted an alarming trend in cases of serious harm to, or deaths of, children under one from suspected abuse or neglect, amid a ‘toxic mix’ of poverty, isolation and family proximity during the pandemic[ix]. Concerns about the impact of the pandemic on domestic abuse[x] must also be viewed in relation to the impacts on the children exposed and the critical need for support for the victims and their children, including where needed for mental health.
As health is closely related to levels of deprivation and to the wider social determinants – conditions in the early years, education, employment and income, housing and environmental factors, it has been noted that the inequalities in mortality and morbidity from COVID-19 have mirrored these same levels of deprivation, as well as gender, age and ethnicity[xi].
All of these factors contribute to a ‘pile-up’ of family stressors contributing to poor mental health across all ages, and mitigating against resilience. Our network of local Home-Starts have witnessed this build-up, exacerbating the challenges already experienced by the families we serve, and opening up new constituencies of parents who previously would not have needed services. We believe that early identification, timely intervention and access to targeted support and where necessary to specialist mental health services is essential.
What progress has the Government made on children and young people’s mental health?
Current UK data does not exist to reliably gauge the scale of difficulties presenting in under 5s, in terms of mental health problems. Routinely collected data however gives an indication of the proportion of children at risk. Data published in 2018/19 suggests that 7.5% of 2 year olds in England are not developing as expected in terms of personal and social skills, and in excess of one in ten (11.7%) of 5 year olds not achieving expected personal, social, and emotional learning goals. [xii]
How personal, social and emotional development are measured across the four nations differs, meaning a lack of comparable data. For England current prevalence data identifies that one in eighteen (5.5%) of 2-4 year olds have a diagnosable mental health issue, whilst only 0.8% are in contact with secondary mental health services pointing to a significant gap between need and provision.[xiii] As stated previously, this gap is only likely to have increased as a result of the coronavirus pandemic.
The ambitions laid out in the 2017 Green Paper
The 2017 Transforming Children and Young People’s Mental Health laid out ambitions for improving access to specialist services for all children and young people up to the age of 25. Despite the stated intention for a “fundamental shift” and moving towards “early intervention and prevention” the substantive focus remained on the role of schools and CAMHS services [xiv] predicating a lack of attention to the needs of babies and young children before school, and of the contexts within which good mental health arises.
The Government’s response to the Green Paper consultation acknowledged respondents concerns at the lack of scope in the paper to address issues such as support for early years, the role of the home environment and the needs of parents. Whilst the paper acknowledged the evidence linking early brain development with outcomes for children, the only commitment was “to considering further analysis in areas which may include supporting healthcare professionals to understand the importance of healthy, low stress pregnancies and healthy childhoods; and increasing the capability of midwives to support women with perinatal mental health issues.”[xv]
Our view is that this has perpetuated a ‘baby blind-spot’ in discussion of children’s mental health, and in the policies and services proposed[xvi]. The mental health of children in the early years, and of parents and infants in the first 1001 days too often is overlooked despite clear evidence that early years’ experiences play a unique role in shaping a child’s brain, with long-term consequences for health and well-being.
Providing specialist mental health services for all children, would necessitate providing services for children during the first years of life, and of course for their parents. This vision has been largely absent from Government policy to date and indeed we know that there is a paucity of mental health provision at all for children aged 2 and under, with 42% of CCG areas in England having CAMHS not accepting referrals for children aged 2 and under, and many more of those who could accept referrals for children aged 2 and under not doing so.[xvii]
In our local Home-Starts we work with families experiencing challenges, their circumstances often the crucible for emerging difficulties. We see families struggling to access specialist mental services in a timely way, experiencing long waiting times for assessment, and with high thresholds for referral. Our volunteers and staff offer appropriate relationship based support and where possible the containment and amelioration of difficulties. However, community based, non-specialised services like ours are not always viewed as an integral and valued part of the pathways of care or resourced so to be.
In order to meet the stated aims of the Long Term Plan there must be a focus starting earlier in the life course, well before children begin school, including a substantial focus on prevention and with clear pathways to step-up to or step-down from specialist support which must be available to all families who require it.
Addressing capacity and training issues in the mental health workforce
It is vital that Government sets out plans to ensure that there is a sufficiently well-trained workforce with the capacity, capability and skill mix to support children, parents and families during the early years. This strategy must set out to ensure that volunteers, practitioners, and professionals at all levels have the required training and supervision, knowledge and skills to understand early child development, support early relationships, promote nurturing care and deliver trauma-informed, non-judgemental services that are effective in improving outcomes.
Early mental health is shaped by the nature of relationships and practitioners and professionals must be equipped with an understanding and practical application of the knowledge base in building healthy early relationships, such as through the Association of Infant Mental Health competency framework[xviii].
The role of the voluntary sector and of well trained and supported volunteers in contributing to a continuum of mental health support that is inclusive and responsive must be recognised and effective volunteer home-visiting built on learning about the key factors which enhance and facilitate the engagement and effectiveness of volunteers[xix]
Improving access to mental health services
Improving access is not just about extending the reach of services, although of course this is important. It is also about shifting perceptions, reducing stigma and reducing the barriers to engagement with services.
The majority of parents believe the development of social and emotional skills in early childhood is essential. However, there are persisting misconceptions around mental health and mental illness in children. Amongst parents of 0 to 5-year-olds, recognition of the first five years as being the most important for laying the foundations for health and wellbeing is relatively low, with just 31% stating that this is the most important developmental period. This means that 7 in 10 parents of 0 to 5-year-olds (69%) are not aligned with the scientific consensus that the conception to age 5 period is crucial in providing the foundation of health and happiness[xx].
Alongside this we know that higher levels of parental knowledge about the importance of early relationships is associated with improved outcomes and positive parenting behaviours. In particular, increased levels of parental mentalization - the ability to understand the mental states (thoughts, wishes, beliefs, and feelings), and underlying behaviours of oneself or others) is associated with the ability to respond contingently to infants’ emotions and feelings.[xxi]
The alliances forged over time are just one of the ‘magic ingredients’ in being alongside parents as a volunteer. This relationship supports the engagement of parental mentalizing about the stressful situations associated with parenting, and in responding to the daily hassles in the home and in the parenting relationship. With this, parents are better able to cope, and better able to engage with specialist services where indicated.
The intention outlined in the green paper, to understand how to give families the best support, and better understand the role of prevention were welcome. At Home-Start our ethos and approach recognises the importance of building community capacity through training and supporting volunteers and building trusted relationships with parents. We offer individualised support for parents to build parental capacity, promote wellbeing, support positive parent-child relationships and engage families with local universal and specialist provision where required. This kind of pro-active parental engagement promotes long-term community support networks and allows specialist resources to be used more appropriately.[xxii]
A recent review of the role of volunteering with vulnerable families[xxiii] found evidence of impacts of volunteering on improvements in mothers’ mental health, sense of well-being, parenting confidence, stress levels, relationships with their children and reduced social isolation, as well as overcoming reluctance or stigma to access services and/or address mental health needs. It was also noted that for some families, especially people from black and minority ethnic communities, volunteers sometimes compensated for the absence of wider family or community support and network.
Thus, the role of volunteers, and of Home-Visiting practices, offers the opportunity to enhance parental awareness and an understanding of children and young people’s mental health that is mediated by cultural, contextual and psychological factors.
The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing.
Young children develop in the context of relationships. The attachment relationship between baby and parents or caregivers is vital for healthy development. A secure, warm, responsive and predictable relationship with at least one caregiver influences the development of brain architecture and the building blocks for positive infant mental health. No other life stage depends more on the external environment for growth and development.
Secure attachment also positively affects the physiology of the young child, such as in the development of the systems which regulate stress. [xxiv] In this way we can see that early relationships between parents or caregiver and child are instrumental in setting children on a positive developmental trajectory for both mental and physical health.
Stated simply, nurturing and enabling relationships are the catalyst for the environment’s influence on healthy development. Conversely, early environmental adversity is associated with abnormalities in the areas of the brain responsible for memory, attention, impulsiveness and behavioural regulation and control, shaping physical cognitive and psychological functioning and increasing vulnerability to later physical and mental health conditions.[xxv]
The early years are an age of opportunity, which if not supported adequately can have long-term outcomes. Relationships between parents and their children hold within them the qualities that best promote competence, socio-emotional and self-regulation skills and well-being – responsiveness, interaction, and an emotional connection to another, which are the foundation stones for good physical and mental health and support the growth promoting challenges that are essential to build resilience.
Although children continue to develop throughout their lives, as children grow older it becomes ever more difficult to effect change. Developmental delays that arise in the early years tend to be compounded with age and to endure throughout life such that there is evidence that 40% of the socio-economic attainment gap at age 16 is already present at age 5[xxvi] (RF 5). For this reason we argue that whilst an important and welcome step, the focus on mental health provision in schools comes already too late.
The youngest children, whose brains are still extremely vulnerable to environmental stress, respond differently to external stressors. Early experience thus becomes encoded in our bodies and shapes the brain, affecting lifelong health, behaviour and learning.
If early relationships are highly stressful – through reduced parental capacities and the influence of stressors on the caregiving relationship as a result of unresolved trauma, domestic abuse, mental illness, absence, poverty, for example, it can be harder for parents’ to protect and promote their child’s development.
Home is where we start from. Families need a range of support including universal, targeted and specialist services that support early relationships, improve wellbeing and address the stressors impacting on family life. We believe that there should be continuum of care in each local area, which means that under-fives and their families can access the right support at the right time. Families benefit from effective public services in partnership with a strong voluntary sector, clearly defined pathways and integrated services. A mixed offer including professional services, informal drop-in groups and volunteer peer support makes the best use of appropriate skills and resources and ensure services are joined-up, accessible and non-stigmatising.
The wider determinants of health, including mental health, lie in the conditions in which babies are born, grow, live, work and age. Inequity in these conditions is driven by structural inequalities[xxvii] and the social gradients of many of the adversities experienced by parents are significant both in their breadth and depth.
In the context of environmental stressors secure attachment relationships can help buffer the impacts and mitigate developmental risk. In this way a strong social and emotional foundation, starting in the home, underpins all other development – the physical, motor and cognitive development that prepares children for school, for achievement and fulfilment throughout life, and for participation in communities as the productive citizens of the future.
In contexts where parents are unable to access the support they need in a timely way, to overcome challenges and parent in the ways they would like to, then the possibility is that in the baby and young child neuronal pathways more attuned to reactivity are laid down. This poorer foundation puts children at greater risk for challenges as they grow older, including school failure and social difficulties. [xxviii] An intergenerational cycle can then be perpetuated as a child’s own experience influences how in adulthood they go on to parent their children.
While interventions later in childhood and in adolescence are effective and essential, the return on investment is greatest in the earliest years and supporting early relationships can pay dividends for generations to come.[xxix]
Every program, sector, and policy that affects the lives of young children and their families, as well as expectant mothers and fathers before and during pregnancy, presents opportunities to build resilience and protect developing biological systems from the disruptive effects of excessive adversity and concommitant mental health sequelae.
Giving babies and young children the best start in life, and reducing the mental health challenges faced by children and young people thus requires a dual approach which both addresses adversity and supports early relationships, recognising the crucial role of the home environment in the early years of life and the challenges facing parents.
[i] Sugarman, P, and Chadasama, K. Volunteer-led family intervention: the UK Home-Start programme. 2019
[ii] House of Commons Health and Social Care Committee First 1000 days of life: Thirteenth Report of Session 2017–19. 2019
[iii] Leveraging the Biology of Adversity and Resilience to Transform Pediatric Practice. Jack P. Shonkoff, W.Thomas Boyce, Pat Levitt, Fernando D. Martinez, Bruce McEwen. Pediatrics Feb 2021, 147 (2) e20193845; DOI: 10.1542/peds.2019-3845
[iv] Jia R, Ayling K, Chalder T, et al. Mental health in the UK during the COVID-19 pandemic: cross-sectional analyses from a community cohort study. BMJ Open 2020;10:e040620. doi: 10.1136/bmjopen-2020-040620
[v] OFSTED. COVID-19 series: briefing on early years, November 2020
[vii] Babies in Lockdown: listening to parents to build back better (2020). Best Beginnings, Home-Start UK, and
the Parent-Infant Foundation
[viii] Oxford University-led COVID-19 Supporting Parents, Adolescents, and Children in Epidemics (Co-SPACE) study
[ix] Amanda Spielman Speech to the National Children and Adults Services Conference (NCASC)
[x] Domestic abuse during the coronavirus (COVID-19) pandemic, England and Wales: ONS. November 2020
[xi] Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Herd, Joana Morrison (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity
[xii] Nurturing healthy minds together: Exploring how services and parents can work in partnership to support the social and emotional development of under fives. Full Report - June 2020 Authors: Dr Stephanie Smith with Sarah-Jane James, Keith Clements, Ava Berry, Claire Dorris and Dr Gayle Munro
[xiv] NHS England (2019) Long Term Plan. P50.
[xv] DHSC and DfE (2018) Government Response to the Children and Young People’s Mental Health Green Paper
[xvi] Working for babies -Lockdown lessons from local systems. Reed, J., Parish, N. ISOS Partnership for 1001 Days Movement. Jan 2021
[xvii] Rare Jewels. Parent Infant Foundation
[xix] Volunteering with vulnerable families - A rapid review of the literature. Dr Louca-Mai Brady and Berni Graham. NSPCC Learning. January 2021
[xx] Royal Foundation report. State of the Nation: Understanding public attitudes to the early years. IPSOS MORI November 2020
[xxi] Nurturing healthy minds together: Exploring how services and parents can work in partnership to support the social and emotional development of under fives. Full Report - June 2020 Authors: Dr Stephanie Smith with Sarah-Jane James, Keith Clements, Ava Berry, Claire Dorris and Dr Gayle Munro
[xxii] Enhancing the parent-infant relationship through training volunteers. Lee, P., Cook, S. and Mee, C. Community practitioner: the journal of the Community Practitioners' & Health Visitors' Association.
[xxiii] Volunteering with vulnerable families - A rapid review of the literature. Dr Louca-Mai Brady and Berni Graham. NSPCC Learning. January 2021
[xxiv] National Scientific Council on the Developing Child The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper 12. 2012. www.developingchild.harvard.edu
[xxv] Hart, H., & Rubia, K. Neuroimaging of child abuse: a critical review. Frontiers in Human Neuroscience. 6. 2012 www.frontiersin.org/article/10.3389/fnhum.2012.00052
[xxvi] Royal Foundation report. State of the Nation: Understanding public attitudes to the early years. IPSOS MORI November 2020
[xxvii] Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Herd, Joana Morrison (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity
[xxviii] National Scientific Council on the Developing Child 2005/2014. Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. www.developingchild.harvard.edu
[xxix] Fraiberg, S., Adelson, E., & Shapiro, V. (2003). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Parent-infant psychodynamics: Wild things, mirrors and ghosts, 87, 117.