Written evidence submitted by the Blackpool Centre for Early Child Development (CYP0064)

Who are we? – Blackpool Centre for Early Child Development 

The Centre for Early Child Development (CECD) is the backbone organisation of Blackpool Better Start (BBS). ‘A Better Start’ is a ten-year programme consisting of a £215 million strategic investment that aims to use a test-and-learn approach to promote Early Childhood Development with a clear focus on prevention and early intervention.  

In Blackpool, mental and physical health outcomes are significantly worse than the rest of England. This includes the health of Blackpool’s children. Blackpool has the highest number of looked-after-children per 10,000 children in England and has some of the highest rates of children subject to child protection plans in England. Within this, intergenerational levels of trauma, abuse and adverse childhood experiences (ACEs) are extraordinarily high, including rates of depression, anxiety and substance misuse. Currently, approximately 26% of children are classed as living in poverty. There are also high levels of hospital admissions (including young people) due to self-harm, childhood obesity, teenage pregnancy, smoking in pregnancy and low breastfeeding rates (Blackpool JSNA, 2020). 

The provision of universal access to healthcare in the early years has the greatest potential to promote health and wellbeing and reduce health inequalities in later life (Marmot et al., 2008; Roberts, 2012). Without good-quality evidence based and innovative interventions, those living in Blackpool will continue to have lower than average life expectancy, high rates of intergenerational trauma and poor mental health.  

BBS aims to focus on primary prevention and early action to intervene timely with support that is accessible and suitable.  

Why Should We Think More About Infant and Young Children’s Mental Health? 

Whilst the CECD welcomes the inquiry into children and young people’s mental health, the evidence outlined in this submission relates to infants and very young children. It is essential that their voices are included in any Government review of child and adolescent mental health due to the potential impact of early intervention.  

There is currently an increasing focus on neuroscience, particularly brain development, in the early years of life; the first 1001 days of life, conception to age 2, is a time of unique opportunity and vulnerability and a period of particularly rapid growth, when the foundations for later development are laid. During this time, babies’ brains are shaped by the interactions they have with their parents and the world. There is compelling evidence to show that early relationships play an extremely important role in cognitive, emotional and social development and if these early relationships are compromised it can have a pervasive effect on physical and emotional health. This impacts children and young people’s mental health and has long-term costs to individuals, but to families, communities and society.  

The quality of the parent-infant interactions therefore is important for infant mental health. Blackpool, through the Better Start initiative, is taking a place-based approach to reducing the critical stressors experienced by families and increasing their capacity and capabilities. Where there are unresolved parent-infant relationship difficulties this can be passed on to future generations of parents leading to inter-generational distress and additional high costs to the public purse. As a result, there is a need for early intervention to prevent or intervene early. Through BBS the town is collectively supporting infant mental health which will have an impact on later child outcomes, therefore this submission will focus on our workforce development, systems and evidence-based approaches. 

Workforce Training 

We know that how services are delivered is as important as what is delivered and the quality of the relationships between practitioners and parents are central to achieving the objectives of the services (Centre for Child Health, 2016). Therefore, whilst it’s important to have diverse, evidence-based services on offer, the knowledge, competence and skills of the workforce is also key. 

BBS partners have been committed to the development of a Better Start Workforce. This has meant developing a shared vision and understanding of the importance of the first 1001 days of life; new knowledge and training in brain science; learning about the impact of negative early experiences on long term outcomes; developing shared communications tools and using a common language. This partnership has committed to ensuring that the range of interventions supporting mental health are based on science or evidence and are effective in reducing negative outcomes for children and families.  

Developing the workforce in evidence-based approaches

We know that during pregnancy there is opportunity to influence and interrupt intergenerational cycles of trauma and abuse. We also know that perinatal mental illnesses affect at least 10% of women and, if untreated, can have a devastating impact on them and their families. When mothers suffer from these illnesses it increases the likelihood that children will experience behavioural, social or learning difficulties and fail to fulfil their potential (Hogg, 2013).  

However, there is a tendency during pregnancy and the early years, to only focus on the mother. Communities and wider family members however play crucial roles. A ‘think-family’ approach considers the health, wellbeing and behaviour of children and their parents (carer givers) and recognises that they are all inter-related. Although there are numerous specialised services and programmes that support the empowerment of care givers and whole family effectively (e.g., Family Nurse Partnership), there have been global calls for family-centred health care and more child-centred approaches within health care and schools (e.g., United States, Australia, Finland). This is essential for those under-fives who are often missed by services.  

This requires workforces to be equipped with the skills to be able to work in such a way that understand this. To date, there has been little provision to undertake this work in a multi-site or area-wide manner; however, at the CECD, and through the Better Start partnership, we are testing and learning from new services and interventions, upskilling our workforce to use these evidence-based tools in their everyday practice; this ensures greater reach and less opportunity for families to fall through the gaps.  

Practice examples: 

•       Baby Steps was developed by the NSPCC and the University of Warwick and is now the only antenatal education programme delivered in Blackpool. A combination of Health Visitors, midwives and community nursery nurses engage mums and partners in this 9-week programme. It focuses on the transition to parenthood and the social and emotional impacts of this. In addition, it supports and encourages reflective function, which enables mums and dads to think what their baby may be like and promote early attachment. Through supporting parent infant relationships during pregnancy, this will support the later social and emotional development of children. 

•       Video Interaction Guidance (VIG), as well as other video-feedback interventions, is named in the Health Child Programme: Rapid Review of the Evidence (2015) and the NICE guidelines for Social Emotional Wellbeing: Early Years (2012) as an intervention to promote parental sensitivity and attachment security. Blackpool has committed to embedding this approach across antenatal, Health Visiting and Early Help services to ensure there is a consistent and evidence-based approach to supporting parent-child relationships. This will support positive mental health in babies and young children and has the potential the prevent problems. 

•       Behavioural Activation is an evidence-based approach to supporting mothers with postnatal depression is being integrated into the new Enhanced Health Visiting model. It is hoped that this will demonstrate positive outcomes for mothers with depression through a short intervention, which will be delivered by the parent’s HV, decreasing the need for referrals into other services and for mothers to fall through gaps. This will enable timely, evidence-based support for maternal mental health which is essential for babies to thrive. 

•       A specialised Parent-Infant Mental Health Service is being developed in Blackpool. This is a “specialised multi-disciplinary team with expertise in supporting and strengthening the important relationships between babies and their parents/carers” (Parent Infant Foundation, 2019). The service is early intervention service that will focuses on promotion, prevention, the development of the local workforce and treatment. The service will be the only service to work with carers and infants across the spectrum of mental health conditions. 

Developing the workforce with a shared understanding about the impact of adversity 

The CECD is working closely with the workforce and the community to mitigate the impact of early adversity, build resilience and improve the outcomes of communities for generations to come.  Trauma and Adverse Childhood Experiences (ACEs) can have a widespread and lasting impact and can lead to the development and exacerbation of poor mental and physical health that can pass down generations.  High quality and trauma-informed care is imperative for everyone, in order to ensure that the specific needs of those who have experienced adversity and trauma are addressed. Trauma-informed approaches to service delivery across sectors have been described as those which realise the widespread impact of trauma, recognise the signs and symptoms of trauma, respond by fully integrating such knowledge into service delivery at all levels, and seek to avoid, as far as possible, re-traumatising individuals during care. 

The CECD has developed an innovative suite of trauma focused interventions alongside more widespread trauma awareness training and community education approaches. It is therefore developing trauma informed systems which support and enhance the specific programmes being provided and ensure a consistent and seamless journey through services for families. This will ensure that there is extensive understanding of the importance of trauma and early adversity from all parts of society and community. Together the workforce and community will influence systems and culture change and reduce the stigma and taboo surrounding trauma and adversity.   

Reframing of Early Child Development  

BBS work with the FrameWorks Institute and the Palix Foundation in Alberta, Canada to test and embed the metaphors of Early Child Development within its communications, workforce development and community work. The metaphors were developed through strategic frame analysis, theories and methods which explain how people think about complex issues and are a tool that increases public understanding around the science of brain development using a common language between professionals and communities. After being tested in Blackpool the metaphors have been used extensively within communications, workforce development and practice. Through generating a shared language about the importance of early brain development, the town is generating collective impact in relation to increasing children’s social and emotional development. 

The Brain Game which was developed by the Centre on the Developing Child at Harvard University and Dr Judy Cameron at the University of Southern California. It is a quick and effective way to explain brain science, the impact of adversity, it explores how experiences influence child development and the support required for children to bear the weight of adversity to enable them to respond positively to life and challenges. It includes metaphors of Early Child Development and complements the delivery of other training relating to understanding the potential impact of trauma on children. Mechanisms such as this accessible game enable communities to understand how to prevent further exposure to adversity and how to promote positive mental health in their children and themselves 

Systems Change – A Focus on Early Intervention 

Intervening Early 

Of importance is the investment in infant mental health (IMH) and the recognition that currently there exists a ‘baby blind spot’; this has been highlighted by the first 1001 Days movement. CAMHS should be offering provision for those aged 0-18, however the reality is that many of these services do not have provision for under-fives (Parent Infant Foundation, 2018), with an estimated 42% unable to offer provision to those under five. There needs to be Government investment in IMH like the investment in perinatal mental health services. In addition to investment in IMH, there remains the need to highlight and address the specific competencies required to work with babies and their parents. 

Currently the NHS spends just £92 for every child compared to £225 for every adult (Children’s Commissioner, 2020); such late intervention costs significantly more over-time. Systems change is needed to develop a model that focuses on early intervention with prevention at the heart. This means taking early action to ensure services are in place when needed. Questions that are currently addressed relate primarily to school-aged children, despite stating that there is a commitment to early intervention. To generate a real shift towards prevention, we would recommend the Committee explores the following key areas in order to generate wider systemic and cultural change.  

Recognising the importance of Health Visiting services 

The Enhanced Health Visiting Service (EHVS) is a key universal public health service for improving the health and wellbeing of young children, the use of health and development reviews, health promotion, parenting support, screening and immunisation programmes. Inherent in the principles of health visiting are prevention, early intervention to reduce inequalities and progressive universalism, which can support engagement without stigma. Evidence of acceptability to families is described in a poll by the Early Intervention Foundation (2015) which found that HVs are the most common source of guidance on children’s health and development. Parents look for support, advice and guidance from their HV twice as often as they would from children centres.  

Given the poor early health and wellbeing outcomes the EHVS offers more opportunity for contact and relationship building with children and families in Blackpool with a HV to identify need, and address issues and problems earlier. Evidence from 1001 critical day’s enquiry highlighted the impact that HVs make to early child outcomes.  

In Blackpool, there has been an extensive review, with professionals and the community, of its Health Visiting service. This has resulted in an increase in HV visits, the introduction of new assessments and a redesign of tools used during visits. Blackpool families now receive at >8 visits compared with the statutory five that the rest of the country receives. The increased one-to-one visits ensure parents receive more support, as well as giving them the opportunity to discuss issues at a deeper level. This builds a trusting relationship and encourages families to be more open to discuss sensitive issues and supports HVs to identify concerns earlier and refer to additional services where needed.   

Additional assessment tools have been introduced enabling the service to be better tailored to the needs of local families. HVs now explore parents’ own experiences of adverse childhood experiences (ACEs) and trauma. This supports the health visitor’s relationship with parents and enables parents to think about how to reduce their unborn child’s exposure to ACEs and build their resilience.  

Involving dads 

Over the last twenty years there has been increasing interest on the impact of the dads’ roles in the perinatal and early year’s period on child outcomes. Secure father-child attachment can positively impact child development in many ways (Barker et al. 2017). The psychological and emotional aspects of paternal involvement in a child’s infancy are the most powerful in influencing child’s later behaviours (Opondo et al., 2016). For example, numerous studies highlight the importance of dads in early years play, suggesting that this can contribute children’s social, emotional and cognitive outcomes (Amodia-Bidakowska et al., 2020), with such positive interactions impacting a child’s cognitive development (Sethna et al., 2017).   

NHS England and Improvement however have made some steps in including mental health checks for dads during the perinatal period in instances where the mother has poor mental health.  This recognises the important role of dads in supporting the mother and potential impact of the partner’s mental health on themselves. However, routine checks taking place for all dads are required (Baldwin et al., 2019). Additionally, whilst the desire from frontline staff to ask dad about his mental health or experiences of trauma may be there, the systems are not in place to support this and can result in practitioners being unable to record and provide support. 

Change is required that thinks holistically about systems, the workforce and community. 

Systems: 

•       Encourage the routine collection of data of both parents 
•       Support services to ensure that communications are aimed at both parents 
• Support the inclusion of ‘touch points’ for dads throughout the perinatal and early years period 
• Encourage joined up systems that recognise the role of dads, i.e. Perinatal Mental Health Service 

Workforce: 

•       Develop and deliver co-created training material on the roles of dads in the perinatal period and the early years 
•       Support for the workforce to integrate learning about the role of dads and perinatal mental health into their practice, enhancing the care that is provided to families 
•       Support and enable the workforce to ensure equal access for dads into their services 

Community: 

•       Develop opportunities for dad/child learning through play activities, to educate and support    

bonding and relationships 

•       Develop co-created targeted campaigns for dads in relation to their role in the early years 

In Blackpool, we have developed a Dads’ Strategy ensuring the town is committed to the above-mentioned points, with a Dads’ engagement team driving the work forward.  

Social determinants of health  

Whilst the increase in focus on children’s mental health is welcome, there needs to be a policy shift to recognising the wider social determinants of health such as social isolation and poverty which impact the well-being of our communities. It has been suggested that by providing influential individual interactions in a social network that the interaction can lead to behaviour change (e.g., Shakya et al., 2017). With many meaningful social interactions, there can be sustainable change across a community.  

In Blackpool, we have invested in multiple community-based approaches including our Community Connector service. Community Connectors are employed as members of the local community who have lived experience and in depth understanding of the challenges of being a parent in Blackpool. As local champions, Connectors are best placed to work alongside families to maximise community participation and engagement exposing communities to opportunities to learn and achieve change together. They work alongside the community to embed key messages about early child development, engage parents in programmes and activities with their children and support pathways into and out of services. By being better connected, parents understand their own needs more and will subsequently feel better supported and more confident as a parent, promoting good mental health of themselves and their children.  

 Conclusion 

Supporting children’s mental health starts from conception. It requires a whole systems approach involving all parts of communities. It also requires a skills and supportive workforce that are unified in a vision and ambition to recognise and improve infant and child mental health, and that understand the role they play. Through place based approaches focused on the earliest intervention, there is huge opportunity to break the intergenerational cycle of poor mental health and poor outcomes and make an embedded and sustainable cultural shift.

March 2021