Mandatory reporting on child abuse and neglect: the consultation

I’ve just responded to the government consultation Reporting and acting on child abuse and neglect which closes on 13 October. It’s prompted some thoughts;

The challenge

Preventing children being harmed. Obviously.   But that’s a pretty broad remit. Local authorities and the agencies they work with have a statutory duty to ‘make arrangements for ensuring that their functions are discharged having regard to the need to safeguard and promote the welfare of children’ (s. 11 Children Act 2004). Basically they should have appropriate procedures in place. That prompted this comment from Eileen Munro in her Review of Child Protection;

‘…instead of “doing things right” (i.e. following procedures) the system needed to be focused on doing the right thing (i.e. checking whether children and young people are being helped)’ (Consultation document para 5)

Since the 2004 Children Act, safeguarding children seems to have had an increasingly high profile; promoting the welfare of children appears to have taken a back seat. Here’s how the current government sees it;

“…Safeguarding children – the action we take to promote the welfare of children and protect them from harm…”(para 2)

In other words the broad duty to promote the welfare of children – with all that that entails – now boils down to protecting children from abuse and neglect.  And the child protection system doesn’t always work. Numerous people have pointed out that no system can guarantee the protection of all children; we don’t have, and never will have, the resources to do that.

The nation has been, understandably, shocked to the core by accounts of the appalling abuse some children have suffered. The news that one child each week is killed on our roads and over 2000 a year are seriously injured in contrast barely makes the headlines; child protection isn’t just about abuse and neglect.  But children are abused and neglected and recent high profile cases have been shocking partly because they’ve highlighted clear failings in the child protection system. The reporting and acting consultation is part of the government’s response.

What the consultation proposes is that reporting and acting on suspected child abuse and neglect is made mandatory for people working in certain organisations. If they don’t report and take appropriate action, they could face serious sanctions. The people include not only those working directly with children but support staff and senior officers. As the consultation document points out, the possibility of sanctions introduces a significant risk of unintended and unwanted outcomes, such as unwarranted intrusion into family life and even more problems with recruitment and retention of social workers.

The evidence

On the face of it, mandatory reporting and acting looks as if it makes sense; if everyone reported and acted on their concerns, surely children would be much safer. But the evidence doesn’t support that reasoning. The evidence shows that when mandatory reporting is introduced the number of referrals increases dramatically (in Australia it doubled), but the proportion of substantiated cases is low (around 20% in several jurisdictions).   As the consultation document itself says:

‘Overall, the literature seems to show that “there remains some question about the efficacy of reporting laws in achieving their ultimate goal: protecting children from harm”’(Annex D p.22).

The causes

Not only does the evidence demonstrate that mandatory reporting doesn’t help, but reporting and acting per se don’t play a major role in the failures of the child protection system to protect children, either. Serious case review after serious case review identifies complex decisions to which there is no obvious right answer, and not following existing procedures properly, as key factors in the failure to protect children from harm. SCRs are littered with accounts of novice social workers being assigned to difficult cases, agency staff unfamiliar with cases, inadequate supervision, lack of understanding of the law and poor communication between agencies – all signs of services that don’t have the capacity to meet demand. In the vast majority of cases, the problem wasn’t that no one had reported their suspicions or failed to act on them.

Given the lack of evidence for the effectiveness of mandatory reporting and acting, and the fact that reporting and acting weren’t the main causal factors of failure, why is the consultation happening at all?

Why consult?

The consultation appears to be have been prompted by some recent high profile cases where abuse and neglect was known about but ignored; the consultation document cites Jimmy Savile’s activities and the sexual exploitation cases in Rotherham, Rochdale and Oxfordshire. Mandatory reporting and acting has been suggested by “MPs, MPs, Peers, campaign groups and members of the public” (consultation document Foreword). But MPs, Peers, campaign groups and members of the public might not be familiar with the evidence for the efficacy of their suggestion.   The way the child protection system is designed isn’t a matter of opinion, it’s a matter of the evidence for what’s effective.

The only reason for consulting that I can think of that is that it’s politically advantageous; the government is seen to be doing something. As the consultation document says “… it is crucial that we do all that we can to strengthen our arrangements to minimise the risks as far as possible” (para 14). Yes, it is, but there’s no evidence to suggest this is the way to do it.

If there are problems with a system, the only way to address them effectively is to identify the root causes of those problems.   SCRs provide a wealth of evidence for those root causes. We need to be looking at them, not quick fixes that we know won’t work and could make things worse.

Invisible disability: Building Great Britons

A report was published on Wednesday by the All Party Parliamentary Group (APPG) for Conception to Age 2 – the First 1001 days. It’s called Building Great Britons.
The thrust of the report is similar to Early Intervention: Good Parents, Great Kids, Better Citizens (2008) and Early Intervention: The Next Steps (2011) from MPs Graham Allen and Iain Duncan Smith. Building Great Britons sets out a policy framework aimed at preventing the social problems believed to originate in adverse experiences between conception and a child’s second birthday.

Breaking the cycle

The conceptual model underpinning the report is a familiar one. Neglect, maltreatment and insecure relationships in early childhood are assumed to be a primary cause of mental health problems and antisocial and criminal behaviour. Parents who had such experiences during childhood tend to adopt the same child-rearing strategies as their parents, setting up a damaging (and costly) self-perpetuating intergenerational cycle.

Like the Early Intervention reports, Building Great Britons argues that preventing child neglect, maltreatment and insecure attachment will save money and result in a flourishing society due to the emergence of well-rounded citizens who are “physically and mentally healthy, well educated, empathic, prosocial, hardworking and contributing to the costs of society” (p.3). As Tim Loughton, Co-Chair of the APPG says “the economic value of breaking these cycles will be enormous” (p.4).

“This” it’s claimed, “is not ‘rocket science.’ Technically it is ‘neuro-science’” (p.3).
The basis for that claim seems to reside in repeated references to brain development, although there’s no detail about how brain development is involved. The association between early adverse experiences and long-term unwanted outcomes is well established, but there are some problems with the model.

what causes what?
The first is that just because two things are correlated, it’s not safe to assume that one causes the other. They might both be caused by something else, or be totally unrelated. So parents might neglect, maltreat or form poor attachments with their children because their parents did, or because the family has a genetic predisposition towards severe post-natal depression, or because they are grappling with challenging life circumstances.

multiple causes
The second problem is that even if we could predict with certainty that all neglected, maltreated, chaotically attached children will develop mental health problems or anti-social behaviour in later life, the causal chain doesn’t always hold in the opposite direction because mental health problems and anti-social behaviour have other causes such as poor physical health, adverse life events or peer pressure.

looking back vs looking forward
A third problem is that retrospective surveys linking adverse childhood experience with later health and social problems, such as the ACE study referred to in Building Great Britons (p.14), tend to rely on self-reports – not always the most reliable sources of information, especially about early life. Prospective assessments that track children through their life course such as the Dunedin and Cambridge studies tend to be more reliable. They have also found correlations between adverse childhood experiences and problems in later life but that the emerging patterns are quite complex.

When reading through the research findings, I was struck by how often researchers expressed surprise at the frequency of adverse childhood experiences. The ACE study was prompted by the unexpectedly high incidence of sexual abuse in childhood reported by people dropping out of a weight loss programme. The Dunedin study began as a small-scale follow-up assessment of perinatal risk. Its scope was broadened after researchers found a higher incidence than they expected of accidental injury and impairments to sensory function, development and behaviour in 4/5 year olds. The implication wasn’t that the children had been neglected or maltreated (although some might have been), but that developmental impairments in the general population were more frequent than had been previously thought.

children with disabilities: noticeable by their absence

This brings me to a glaring omission in Building Great Britons. One group of children is especially susceptible to social, emotional and behavioural problems and is at increased risk of poor physical and mental health in later life. They are children with disabilities. But the only mention of disability that I could find in Building Great Britons was of children with Foetal Alcohol Syndrome, caused by a mother’s excessive alcohol intake during pregnancy.

Childhood disabilities can be caused by neglect or maltreatment but they can also be caused by factors such as;

• inherited genetic conditions
• spontaneous genetic variations at or before conception
• mother’s illness during pregnancy
• environmental damage during gestation (e.g. exposure to toxins)
• childhood infections
• accidental injury.

Whether you think disability is caused by a ‘functional impairment’ or by the way society responds to that functional impairment, for administrative and legal purposes a clear-cut distinction is usually made between someone who’s deemed disabled and someone who isn’t. But from a biological perspective the boundary is rather blurred. As the Dunedin study found, a significant proportion of children has some sort of developmental impairment; currently in the USA it’s 15%. In the UK, only 6% of children are classified as disabled, but that figure rises with age. Around 16% of the working-age population has a disability.

Not all disabilities are obvious, and some are difficult to detect. The average age at which autism is diagnosed, for example, is 5.5 years, and diagnosis is often much later than that. Autistic children have unusual attachment patterns and autism is so frequently confused with attachment disorder that Heather Moran, a consultant clinical psychologist, devised the Coventry Grid to help professionals distinguish between them.

There’s little doubt that neglect, maltreatment or poor attachment in childhood can, and does, lead to social, emotional and behavioural problems and to impaired physical and mental health. But what Building Great Britons does is to frame the causes of those problems solely in terms of neglect, maltreatment or poor attachment, and more specifically in terms of the ‘troubled families’ who are deemed to be the source of these societal ills (pp.3-4).

When I was delving into the thinking behind the Early Intervention reports, I asked a few researchers who’d been actively involved how some obviously erroneous claims about brain function had crept in. None had had a say in the final content of the reports, but one told me that it was sometimes necessary to present data in a way that was most likely to persuade government to come up with funding. I take his point; but I couldn’t see how that justified presenting the data in a way that was misleading.

What the data on social, emotional, behavioural, physical and mental health problems tell us is that children by definition are vulnerable, and parenting by definition is challenging. They also tell us that we are all, at all times, at risk from unforseen life events that could trigger social, emotional, behavioural, physical or mental health problems that result in us needing help from the community. That’s why in the developed world we have education, health and social care services.

It’s true that a minority of families cause a disproportionate number of problems, for themselves and others. There are good reasons why early intervention is appropriate for them. But because all children are vulnerable and all parenting is challenging, there are good reasons why early intervention should be available to all families. We shouldn’t have to justify it in terms of ‘good citizenship’ or the financial costs for ‘society’ – which at one time we were told didn’t exist.

Nor should reports produced by Members of Parliament about vulnerable children and challenged parents look right past one of the most vulnerable groups of children and one of the most challenged groups of parents. In the total of 351 pages that make up the two Early Intervention reports and Building Great Britons, childhood disability is mentioned, in passing, only five times – and three of those references are to Foetal Alcohol Syndrome.

When I contacted @first1001days, the Twitter account for http://www.1001criticaldays.co.uk/ to point out the omission, I got a prompt response inviting me to write some supplementary material. Within an hour, another parent and I had responded with a paragraph summarising the main issues, and notified @first1001days. I wasn’t surprised not to get an immediate reply, as the report was being launched that morning. But we’re still waiting…

Disabled people are still invisible, it seems.

Martin Narey on social worker education

The tragic death of Victoria Climbie in 2000 focussed attention on the effectiveness of social services departments. The Laming reports published in 2003 and 2009 made recommendations for reform, and the 2011 Munro review of child protection referred to gaps in social workers’ expertise. A couple of weeks ago, Sir Martin Narey, fomer CEO of Barnardo’s and previously Director General of the prison service, published his review of the education of social workers. Although Narey recognises the high quality of some social work education, he is generally critical of the admissions criteria, content, quality and regulation of courses and makes a number of recommendations for improvement. What was striking about the report, I felt, was not so much what it said, but what it didn’t say.

Narey opens by directly addressing the fact that his inquiry was a one-man one, that evidence was gathered through private interviews, and says elsewhere that he didn’t have detailed terms of reference. Conducting an inquiry in this way has several advantages; it’s quicker and cheaper, reports are shorter, more focused, and more likely to be read and acted on – and as Narey points out, it encourages contributors to be more candid (p.3). There are also disadvantages; the opinion of a single reviewer is more likely to colour the inquiry’s conclusions and no one else can evaluate the evidence they’re derived from – with the best will in the world, people might misremember or misunderstand the evidence they present.

In addition, in complex systems like education health and social care, all elements of the system are connected, directly or indirectly. This means it’s often cost-effective in the long-term to remove the causes of problems, rather than to keep putting sticking plasters on the problems themselves. (Ten of Narey’s 18 recommendations involve increased regulation, rather than addressing the causes of what’s going wrong.) In an inquiry with narrow terms of reference the primary causes of problems the inquiry has been set up to investigate might actually fall outside its remit and not even get a mention. This is exactly what appears to have happened in the Narey review.

Narey makes it clear that some social workers are very able, are educated to a high standard and have no trouble getting a job when they graduate. But the rest of the picture he paints is a bit bleak. It suggests that school-leavers with low qualifications are being admitted to over-subscribed courses that offer insufficient teaching, inappropriate work placements and that lecturers and supervisors are sometimes under pressure not to fail inadequate students. In 2011 some local authorities had 20% of social worker posts vacant despite nationally almost 30% of Newly Qualified Social Workers (NQSWs) being unemployed; local authorities were clearly reluctant to employ NQSWs perceived as inadequately prepared for the job.

Why on earth would this situation arise? Narey locates the causes primarily in the calibre of applicants for social work courses, the content and quality of courses and the availability and quality of supervised work placements. And he makes a number of recommendations related to these factors. It’s apparent from his report, however, that the long-standing crisis in social worker recruitment might be driven by factors that Narey doesn’t explore in detail, such as the level of social worker qualifications, the reasons for the core content of courses, the regulation of social worker education, and university funding.

Level of qualifications

Throughout the 20th century, the level of qualification required to become a social worker rose steadily. In the 1970s Birmingham University offered a postgraduate diploma, a master’s level qualification and a four-year social work degree. In 1994, the national route to qualification became a postgraduate diploma involving partnership with employer, but during the 1990s there was a significant fall in applications. In response, in 2003 the government introduced a three-year social work BA – a sandwich course that included two work placements – or alternatively a two-year MA for graduates. This means that in the last decade the level of social worker qualification has fallen, something that is likely to have had an impact on the expertise of NQSWs and on the willingness of local authorities to employ them.

Core content of courses

Narey comments in some detail on the content of social worker courses. The original course offered by Birmingham University in 1908/9 consisted of 117 lectures covering topics as diverse as industrial history, law, statistics and sanitation & hygiene, as well as visits to a variety of institutions, and traditionally universities have continued to focus on the principles underpinning social work. But recent complaints from students and employers include challenges about the relevance of the courses including “weeks and weeks…looking at Plato, Socrates and Aristotle etc” rather than “skills relevant to social work” (p.9). Another student complained “ I have so far learned nothing concerning signs of abuse… There is not enough practical experience or theory related to its actual use in practice”(p.9). Narey adds “employers need to be more confident that students at every university will graduate with an adequate grasp of the basics necessary for them to develop into competent and confident children’s social workers.” (p.9)

Narey complains about the current focus of social work on ‘non-oppressive practice’ (or ‘anti-oppressive practice’ – he uses the terms interchangeably). He points out that there is a serious downside to a view that encourages working in partnership with, and the empowerment of, parents whose children are at risk. What he doesn’t seem to fully appreciate is that ‘non-oppressive practice’ is, and always has been, fundamental to the ethos of social work. Of course if anti-oppressive practice is the only theoretical framework presented to aspiring social workers, that does pose a problem that should be addressed. Narey entitles his critique of anti-oppressive practice the politics of social work teaching (p.10). Politics is about the distribution of power, so an anti-oppressive model of social work is in a sense ‘political’, but it’s not clear if Narey is using the term in that way, or if it’s because he suspects that this dominant conceptual model originates with the progressive Left (p.13).

Having debunked one core concept in social work teaching, Narey introduces another. In his own list of what he thinks social workers should understand he includes child development and attachment theory as two separate items (p.10). At first glance this looks like one of the conclusions of the Munro review that refers to social workers needing to know about ‘child development and attachment’ (Munro p.96). The difference is that Munro and the sources she cites could be construed as seeing attachment as one facet of child development, whereas Narey unambiguously presents them as distinct issues. My conclusion in previous posts about attachment theory is that there’s a serious risk of social workers seeing child development not as involving attachment, but solely in terms of attachment, rather than as a highly complex set of interacting biological, social and environmental factors of which attachment is only one. Narey’s suggestion is likely to perpetuate that over-simplification.

Intriguingly, given his focus on conceptual models in social work, Narey says he has never discussed the international definition of social work with the current Secretary of State for education or with any of his predecessors (p.13). It would be interesting to know why.

Narey isn’t the only one to take issue with the content of social worker education. There’s also disagreement between universities and employers, but much of it appears to centre on the difference between education and training. It seems fair to argue that social workers’ education should include statutory frameworks, but it’s debatable whether signs of abuse, a highly specialised skill, should be included in education or be approached via on-the-job training. My guess is that the problem actually boils down to who pays for what. The budgets of universities and local authorities have been under pressure for many years, and it’s understandable why local authorities might want social workers to emerge fully formed from their university courses, but that universities don’t want to broaden what they offer unless they have to. The ultimate losers are, tragically, the most vulnerable members of society that social workers are supposed to support.

Regulation of social worker education

Narey draws attention to the facts that social worker education is regulated by three different bodies and that universities need to consult at least five different source documents to shape the academic content of courses. He observes in respect of the Health and Care Professions Council (HCPC) that social work sits ‘very oddly’ with the list of other professions it regulates (p.21). Social work isn’t the only profession in this situation. In 2009, the HCPC replaced the Council for Professions Supplementary to Medicine (CPSM) set up in 1960, which regulated several professions that fall broadly under the umbrella of medicine. When the HCPC replaced it, the regulatory remit was broadened and practicing psychologists and social workers were added to the mix. This caused some consternation amongst psychologists, previously regulated by their own professional body, many of whom didn’t see themselves as working in professions related to either health or care. Only two of psychology’s protected titles – clinical and health psychology – could be clearly classified as involved in health or care whereas others covered fields as diverse as international educational systems and business management. Doubts were expressed as to whether the HCPC could have the range of expertise required in order to regulate effectively. From what Narey reports, it’s still a relevant question.

University funding

I mentioned earlier the three-year BA in social work introduced in 2003, following a fall in applications for social work courses. Narey doesn’t address the causes of the drop in applications, but it’s worth considering what it they might be.

Prior to 1945, some students from less well-off families could access a university education via much sought-after Board of Education grants, often on condition that they became teachers after graduation. In 1962 student funding by local education authorities became mandatory. A steady increase in student numbers coupled with a policy decision to increase the numbers of graduates and universities, led to the Dearing review of university funding in 1996, which recommended the introduction of an annual contribution of £1000 toward tuition fees, and in 1999 student loans were introduced. That meant that a four-year social work qualification was a relatively expensive way of getting a degree, so it’s hardly surprising that applications fell. In an attempt to boost social worker numbers, the three-year BA was introduced in 2003, accompanied by the offer of a bursary. The bursary, counterintuitively, appears to have had little impact on social worker recruitment, but does appear to have encouraged applicants wanting a low-cost route to a degree (p.28). Subsequent reductions in government funding have resulted in universities becoming increasingly reliant on student fees as a source of income; universities can now charge UK students up to £9000 p.a. and students from overseas usually pay much more. It appears that some universities have adopted a ‘pile ’em high’ approach to social work degrees, attracting large numbers of students but failing to provide them with the qualifications that employers are looking for.

Thinking outside the box

Times change, and social workers are no longer preoccupied by the impact of industrial injuries or poor sanitation as they were in 1908 (although hygiene is still an issue). But as far as I can see the social worker role is fundamentally unchanged; it still has to address the problems people encounter often as a result of societal factors over which they have little control. That doesn’t appear to be how social work is viewed by central or local government, however. In the last three decades, there’s been a noticeable shift from viewing social workers’ clients as people who are primarily victims of circumstance, to viewing their problems as the outcomes of individual choices. Both ways of framing people’s problems are over-simplifications and neither is helpful, because in reality everybody’s problems are due to a complex interaction of systems pressures and individual choices.

Another apparent shift is in respect of the focus of social work. Narey advocates not only restoring the option to specialise in adult or child social care following basic generic tuition, but also suggests the development of children’s social work degrees. Although specialisation seems justified, from the outside it looks as if social work is becoming increasingly polarised, toward care for the elderly at one end of the spectrum and toward children at risk at the other (p.37). In other words, adult social work will be about care of the elderly and children’s social work will be about child protection, as if adults and children had no other issues to deal with.

The location of the source of problems in the individual – or in individual organisations (universities and regulatory bodies in the case of the Narey report) – is an inevitable consequence of successive governments adopting a ‘market’ model for services. This is because the free market model rests on assumptions about the behaviour of individuals; that people make rational decisions, that they have free choices about the goods and services they purchase and that their free, rational choices ensure that competition between suppliers drives up quality. In reality none of these assumptions holds true.

The narrow terms of reference of the inquiry have resulted in the impact of some key systems issues being overlooked. These include; the underlying economic model chosen by government for the delivery of public sector services, the way context and individual behaviour are framed by government, the remit of regulatory bodies, the way the underlying purpose of social work is perceived, and how higher education is funded.

And a shift of the focus of social work from problems at all levels from the individual to the societal, is an inevitable consequence of shrinking the public sector; as a result there will be a tendency to focus on people most at risk, rather than in addressing the underlying systemic causes of a wide range of obstacles that people encounter when they are trying to get on with their lives.

the myth of the first three years

Reading John Bruer’s book The Myth of the First Three Years was like watching the past few months of my life flash before my eyes. That’s because, gratifyingly, Bruer comes to similar conclusions about the basis of child development theories currently influencing public policy. My one reservation about his book is its title and the repeated references to the ‘myth’ in the text. Technically Bruer is right to use this word for the cluster of popular ideas about the first three years because myths often have some basis in fact, but I think it’s a bit misleading because the word ‘myth’ is also widely used to mean something that has no basis in fact. The myth of the first three years conforms closely to the OECD definition of a ‘neuromyth’ – a “misconception generated by a misunderstanding, a misreading or a misquoting of facts scientifically established (by brain research) to make a case for the use of brain research in education and other contexts”. Other people have other reservations about Bruer’s work. One Amazon.com reviewer complained that the book jacket reveals he’s ‘not even a doctor!’ She obviously missed the significance of Bruer’s presidency of the James McConnell Foundation that awards grants for biomedical and educational research.

Bruer’s book deals with three aspects of what I’ll call the first three years model. He describes how the model migrated from research findings to public policy and the changes it underwent en route. He then explains what the research findings actually were, and what they mean for parents. Although the book was published over a decade ago, the first three years model has, as is traditional, taken a decade to cross the Atlantic, so is now very relevant to the coalition government’s social policy in the UK.

How the first three years model evolved

Bruer cites the developmental psychologist Jerome Kagan’s view that infant determinism – the idea that early experiences have a lasting effect on development – dates from a folk belief in 18th century Europe popularised by writers such as Rousseau. I think that the origins are more likely to be as old as parenthood. Like many of my contemporaries I was brought up on Biblical wisdom and was familiar with sayings such as; “Train up a child in the way he should go: and when he is old, he will not depart from it” (Proverbs 22:6). “He that spareth his rod hateth his son: but he that loveth him chasteneth him betimes” (Proverbs 13:24). The book of Proverbs dates from around 900 BC – the origins of the proverbs are likely to be much older.

Infant determinism was a theme explored by Freud and further developed by figures such as John Bowlby, Mary Ainsworth, Harry Harlow, Rene Spitz and Benjamin Bloom. During this period, as Bruer points out, the study of the brain and the study of behaviour, despite being seen as complementary in the late 19th century, have followed largely independent paths. It’s only since the implications of brain research for human behaviour have become clearer that the two paths have begun to cross more frequently. From the 1970s onwards, fields such as education and child development began to co-opt findings from neuroscience into their own theoretical models. Bruer traces the way neuroscience has been interwoven with child development theories from, for example, the Clinical Infant Development Project that began in the 1970s and developed into Zero to Three: The National Centre for Infants, Toddlers and Families. And from the 1979 book Education and the Brain, through to the I Am Your Child campaign that began in the mid-1990s, and on into public policy.

Research findings

Bruer identifies three key areas of neuroscience research that underpin the first three years model; neural connections, critical periods and the effects of enriched or complex environments. To illustrate how misconceptions about research have arisen, I’ll summarise the findings he discusses and what they might tell us about child development.

Neural connections Neurons are the cells in the brain that transmit information. They are formed – around 100 billion of them – by the second trimester of gestation, and soon after birth will have migrated to their final destinations in the brain. Neurons are nerve cells and in order to transmit information between each other, they need to be connected. The connections aren’t direct however, they are via synapses – points where the axon terminal of one neuron is close enough to the dendrite of another for chemical or electrical signals to pass from one to the other (see figure). In humans, synapse formation begins a couple of months before birth and peaks at 2-3 years after birth, when the number of synapses is many times greater than it is in adults.

synapse

At the same time, two other processes are going on – apoptosis and synaptic pruning. Apoptosis is cell death, and many neurons, like other cells in the body, do die off during normal development. During synaptic pruning the neurons don’t die, but the number of connections the neuron has with other neurons decreases. Between early childhood and puberty, the number of synapses in the brain gradually declines but remains above adult levels. Between puberty and adulthood, synaptic pruning increases rapidly.

Critical periods In early research into the functioning of the visual cortex of the cat, Torsten Hubel and David Wiesel found that if kittens were deprived of visual input from one eye during the first few weeks of life, they remained blind in that eye. It’s long been known that children with congenital cataracts usually develop normal vision if the cataract is removed within the first year after birth. If cataract removal is delayed, vision may never be normal. We know that children can learn to speak a second language like a native if they acquire that language before their teens – if not, the language can still be learned, but with a noticeable accent. So there are critical periods in child development when certain sensory input is necessary for typical development to take place.

Enriched or complex environments
Charles Darwin had noted that animals reared in the wild tended to have larger brains than their domesticated offspring. Harlow’s famous experiments demonstrated that baby monkeys reared in isolation showed severe behavioural abnormalities. And experiments in the 1970s conducted by Greenough and colleagues showed that rats reared in complex environments had a greater density of synapses than those raised in solitary conditions. It was clear that the environment has a significant impact on brain development.

Applying the research findings to child development

The model of the first three years has arisen partly because research findings have been misunderstood. Several factors need to be borne in mind before applying the findings to children.

1. Many of the research findings relate to animals, notably rats and monkeys that are often used in research because they are small, easy to handle and have relatively short life-cycles. Rats and monkeys are also social, problem-solving mammals, which means they have a lot in common with humans. Although their brains are very likely to function in similar ways to human brains, there might be species-specific differences. One of the differences is that they develop at different rates; rats are sexually mature by about six weeks of age, and macaques at around five years, so extrapolating findings to humans relies on estimates for the ages at which children reach similar developmental stages.

2. Many of the research findings are estimations. It’s impossible to count the number of synapses or neurons in a brain, so proxy measures are used such as the density of synapses in a small portion of the cortex. But different techniques have been used to arrive at those measures; one group of scientists calculated density of synapses in whole human cortical tissue and found that density peaked at three years of age; others used a different method to calculate the synaptic density in monkeys and estimated that density would peak at seven months in humans. These differences were resolved, but demonstrate that research findings need to be interpreted carefully.

3. Many research findings apply to specific locations in the brain. Huttenlocher, for example, has reported the density of synapses in the human brain peaking at around three months after birth in the auditory cortex, at 8-12 months in the visual cortex but not until 3.5 years in the frontal area. Similarly, synaptic pruning in auditory and visual areas reduces synapse densities to adult levels by 11-12 years of age, but not in frontal areas until several years later.

4. It’s not always clear whether developmental changes in the brain are determined by biological factors, by environmental factors, or by both. Clearly biology would have more influence than environment on the migration of brain cells before birth, but work on synapse formation suggests it is triggered by novel learning experiences. Novel experiences tend to diminish as children get older, and familiar experiences are by definition experienced repeatedly, suggesting a cause for synaptic pruning. However, the increased rate of synaptic pruning after puberty implies that some biological control might be involved.

Common misunderstandings

It’s easy to see how the first three years model came into being. There are differences between the brains of toddlers, older children and adults. It’s tempting to assume that the rapid synapse formation and rapid learning that take place during the first three years of life offer a now-or-never window of developmental opportunity. Synaptic pruning, viewed from a ‘use it or lose it’ perspective, makes it look as if this opportunity soon runs out, despite clear evidence that older children, adolescents and adults can learn a great many things that toddlers can’t. This misconception underpins the current vogue for early interventions. The idea of critical periods has resulted in a tendency for governments (at least in the US and UK) to front-load the education system because of an assumption that the earlier learning takes place the better. What the evidence indicates is that critical periods tend to involve low-level processing of sensory information and that broader ‘sensitive periods’ (e.g. for language acquistion) are not clear-cut. With regard to enriched or complex environments, the enriched environment enjoyed by Greenough’s lab rats was probably a lot less stimulating than the environment experienced by wild rats. Lab rats, however well cared for, tend not to lead a very exciting existence. In other words, children would need to be pretty deprived to experience the kind of environment that resulted in a reduced synapse density.

Chinese whispers

The transformation of a tentative conclusion based on findings from rats or monkeys into public policy that lacks a sound evidence-base appears to have begun in one of two ways;

• Journalists have accurately summarised research findings but their reports have been misinterpreted by some readers
• Journalists have misunderstood research findings and have inadvertently misled readers.

Casual readers of newspapers or magazines can be forgiven for getting hold of the wrong end of the stick; they often don’t have the time or inclination to check the original data. Policy-makers, in my view, have no such excuse. Governments have enormous resources at their disposal, and academics, however busy, are usually only too keen to explain their findings to willing listeners. There is no good reason why public policy shouldn’t be based on sound evidence.

The first three years model fits easily into our pre-existing mental models. Infant determinism has been seen as the key to solving problems such as poor educational and health outcomes, addiction, anti-social behaviour and criminal activity that preoccupy policy makers – it’s simpler to blame parents for bringing up their children badly than to trace back the complex causes of ‘problem’ behaviours and address them all. The model has also played to the anxieties of parents who understandably want to do the best for their children. The acceptance of the first three years model by parents and policy-makers has resulted in a proliferation of early interventions. So what effect have they had?

The outcomes of early interventions

Evidence from the evaluation of early interventions cited by Bruer, and from studies tracking changes in people’s lives over time suggests that;

• the best predictor of a child’s school performance is mother’s IQ or educational attainment
• good quality childcare improves school performance for children from ‘deprived’ environments (but not from less deprived ones)
• early interventions that focus on verbal skills improve children’s school performance up to about the age of eight – enough to reduce the number of children who repeat the first few school years
• early interventions that focus on verbal skills result in a marginal improvement in school performance, in the length of time spent in education, and in slightly later parenthood
• people tend to settle down as they get older
• chance events play a big part in lifetime achievement.

The pattern that emerges from these evaluations – and this speculative because I don’t have access to raw data – appears to centre on two factors; children’s language skills when they start school, and the way schools educate children. I think these factors have two implications for early interventions.

Firstly, children who are behind their peers with verbal skills when they start school are clearly at a disadvantage, but only because schools use language as the primary medium for education. Language is one of the things that distinguishes homo sapiens from other species. Spoken and written language allow us to communicate vast amounts of information to each other, so it’s obviously desirable that as many children as possible develop good skills in spoken and written language. But being skilled in spoken and written language is not synonymous with learning; children can also learn through practical experience, watching plays or listening to stories. Language skills, although an important component of the school curriculum, shouldn’t be made an obstacle to learning.

Secondly, although some early interventions have had positive outcomes, the effects have tended to be small. Politicians in favour of these programmes would doubtless argue that any positive outcomes are worth it, but given the importance of verbal skills, it might be more cost effective to improve access to speech and language therapy, especially since so many developmental disorders involve speech and language deficits.

What should parents do?

When I was expecting my first child, a friend gave me a book that advocated a ‘best odds’ approach to pregnancy – the author pointed out that nothing can guarantee that a baby will be completely healthy, but there are things that mothers can do that increase the odds in their baby’s favour. It’s a sensible and realistic approach. Bruer’s conclusion is that most parents are doing fine with their children and that we already know what children need and what’s bad for them. He advises parents to interact with their babies, fix known problems – especially visual, auditory and language ones – as soon as possible, and as neuroscientist Steve Petersen put it “Don’t raise your children in a closet, starve them or hit them in the head with a frying pan”.

References
Bruer, John T., (1999). The myth of the first three years, New York: The Free Press.

Green, E.J., Greenough, W.T. & Schlumpf, B.E. (1983). Effects of complex or isolated environments on cortical dendrites of middle-aged rats, Brain Research, 264,, 233–240.

Huttenlocher, P.R, de Courtena, C., Garey, L.J. & Van der Loosa, H. (1982). Synaptogenesis in human visual cortex — evidence for synapse elimination during normal development, Neuroscience Letters, 33, 247–252.

Organisation for Economic Co-operation and Development (2007) Understanding the brain: the birth of a learning science: The Birth of a New Learning Science: v. 2, OECD.

Image of synapses from Wikipedia.

back to Bowlby, briefly

John Bowlby

Two names that keep cropping up in the child protection literature (apart from Bowlby) are those of Bruce Perry and Allan Schore. Perry is a recognised expert in child mental health and is especially interested in the effects of trauma. Schore has been described as ‘the American Bowlby’ and as ‘the world’s leading expert in neuropsychoanalysis’. I want to focus on one paper by each of them. I’ve chosen the Perry paper because it tackles the nature/nurture debate head-on and is the source of the brain photograph on the cover of Graham Allen’s report Early Intervention: the Next Steps. The Schore paper “Attachment and the regulation of the right brain” seeks to map Bowlby’s attachment theory onto recently acquired knowledge about how the brain develops, and a shortened version of it forms the foreword to a recent edition of Bowlby’s classic book Attachment. Attachment is the first of three volumes dealing with attachment; the others are entitled Separation and Loss.

The frequent mention of the same few names isn’t unusual in a specialist field, and what I expected to find when I read Perry’s and Schore’s work was the painstaking, step-by-step hypothesis testing typical of researchers working in a little-explored area. That wasn’t quite what I found. Before tackling either of the papers, I need to re-visit Bowlby’s attachment theory because Schore’s paper starts where Bowlby leaves off, and Perry’s paper opens with a discussion about the evolution of human behavioural characteristics – a topic central to Bowlby’s thesis.

The title of this post refers to a brief return to Bowlby’s theory, not to the length of the post. I’ve evaluated Bowlby’s ideas in some detail because later interpretations of his ideas are many and varied and sometimes haven’t taken into account Bowlby’s often meticulous reasoning.

Schore and Bowlby

Schore begins by summarising Bowlby’s view of the biological systems underpinning attachment, and then shows how recent findings about the development of regulator systems in the brain’s right hemisphere support Bowlby’s predictions. In the abstract to his paper Schore summarises Bowlby’s model of attachment like this:

“… attachment is instinctive behavior with a biological function, that emotional processes lie at the foundation of a model of instinctive behavior, and that a biological control system in the brain regulates affectively driven instinctive behavior”.

The first thing that struck me about Schore’s paper is that he doesn’t define terms such as attachment, instinct and emotion. Biologically speaking, none of these constructs is straightforward and Bowlby discusses their definitions at length. It’s a pity Schore doesn’t explore these terms, because re-reading Bowlby’s explanations half a century after publication (revisions in the second edition of the book in 1983 notwithstanding) suggests that there are some implicit assumptions in his thinking that are open to question. And anyone unfamiliar with either Bowlby or the animal behaviour literature might be unaware of the complexity of the issues involved.

Let’s start with some of the key concepts that underpin Bowlby’s theory of attachment – first, psychoanalysis.

Psychoanalysis

Bowlby opens Attachment with a chapter called “Point of View” in which he explains the basis for his model. He begins with a quote from Freud, and takes as his starting point an underlying principle of psychoanalysis; that personality, both healthy and pathological, is shaped by events that occur in childhood. But Bowlby differs from Freud on several key points;

Despite these differences, Bowlby assumes that personality (one construct that he doesn’t attempt to define) is shaped by childhood events and that pathologies of personality originate in traumatic experiences in childhood, observations suggesting that a significant trauma is separation from, or loss of, the mother. In the two later volumes of his Attachment trilogy Bowlby suggests that separation is an underlying cause of anxiety and that loss is a cause of sadness and depression. Bowlby points out that his model’s underlying mechanism involves biological processes rather than psychical energy. A central biological process is evolution.

Evolution

Bowlby’s theory is rooted firmly in the Darwinian model of evolution. Darwin’s theory is based on two main concepts, inherited characteristics and natural selection. Neither of these concepts was new when Darwin proposed his theory. People had known for millennia that offspring inherit physical and behavioural characteristics from their parents and that plants and animals thrive in a particular environment only if their characteristics are well adapted to it. Farmers had been using artificial selection for centuries to breed characteristics into or out of plants and animals to suit a specific purpose or environment. What was new about Darwin’s theory was the idea that environmental factors acting on inherited characteristics could result in changes to a species, or in new species arising. What was missing from his theory was the mechanism by which characteristics were passed on to subsequent generations. Although DNA had been discovered in the mid-19th century, its structure and function were unknown and it wasn’t until the turn of the 20th century and the re-discovery of Gregor Mendel’s work showing that characteristics were inherited via discrete units of heritability, that the concept of genes was developed.

Genes

Bowlby sees ‘instinctive’ behaviours like attachment as emerging from the interaction between genetic endowment and environment, but essentially limits his comments on genes to the following paragraph:

The basic concept of the genetical theory of natural selection is that the unit central to the whole process is the individual gene and that all evolutionary change is due to the fact that certain genes increase in number over time whereas alternative genes decrease or die out. What this means in practice is that, through the process of differential breeding success, individuals that are carrying certain genes increase in numbers whilst individuals that are carrying others diminish. A corollary is that the adaptedness of any particular organism comes to be defined in terms of its ability to contribute more than the average number of genes to future generations. Not only, therefore, does it have to be designed so that it is capable of individual survival but so that it is capable also of promoting the survival of the genes it is carrying. This is commonly done through reproducing and promoting the survival of offspring.” (pp.55-56)

Although what Bowlby says is true at one level, his comments don’t give any indication of the complexity of genetic variation in a population. This is despite de novo (spontaneous) mutations having been discovered in fruit flies by the 1920s, and by the time Bowlby published Attachment in 1969 population genetics was a well-established field. The second edition of Attachment came out in 1983, only five years before the commencement of the Human Genome Project.

Bowlby is clear that a debate about whether development is primarily a matter of nature or nurture is meaningless because individual development is a product of an interaction between genes and the environment (pp.38, 296). Nonetheless Bowlby plays down the likelihood of genetic causes of behavioural anomalies in favour of environmental causes;

There are many reasons why, in the course of development, one or another feature of an animal’s diverse biological equipment may fail to develop satisfactorily… Though occasionally one or more genes are responsible for the failure, more often some anomaly of the embryo’s environment is the cause – a virus, a chemical, a mechanical trauma and so on. It is probably the same with failures in development of behavioural systems. Whilst genes may well account for some forms and cases of failure, anomalies of a juvenile’s environment beyond those to which behavioural equipment is adapted are likely to be the cause of most of them.” (pp. 129, my emphasis).

Bowlby couldn’t have known about the frequency of de novo mutations in humans and he was studying a behavioural interaction that’s highly susceptible to environmental factors, but his speculative ruling out of genetic causes is rather surprising. His emphasis leads to a detailed discussion of environments.

Environment

A central concept in Bowlby’s model is what he calls the environment of adaptedness. Although human beings occupy a wide range of environments, all those environments fall within limits outside which human beings can’t function efficiently. Bowlby argues that each biological system of each species has its own environment of adaptedness; the one to which it is evolutionarily adapted and the one in which it functions best. He points out that cardio-vascular systems work only within certain limits of oxygen and carbon dioxide, and that those limits vary for different species. So, he concludes, the behavioural systems responsible for maternal behaviour will work within certain limits of the physical and social environment, but not outside them. In short, the environment of adaptedness produced instinctive behaviour so instinctive behaviour will work effectively only within the environment of adaptedness.

Instinctive behaviour

Bowlby presents the traditional definition of instinctive behaviour as;

• species-typical
• a sequence of behaviours running a predictable course
• having obvious survival value for the individual and/or the species
• arising in the absence of opportunities for learning the behaviour.

During the heyday of research into instinctive behaviours there was considerable debate about whether they were innate (inborn) or acquired (learned). Bowlby thinks this is a pointless distinction, because all the characteristics of biological organisms are products of an interaction between genetic endowment and environment (p.38). He follows zoologist Robert Hinde in suggesting that instinctive behaviour forms a continuum ranging from characteristics that remain stable regardless of environment such as nest-building behaviour, to those that are labile and environmentally dependent, such as show jumping or piano playing. Although he wouldn’t include reflexes as instinctive behaviour, Bowlby’s continuum could be seen as extending from reflexes and simple stimulus-response reactions at the stable end, to complex chains or hierarchies of behaviour that include both innate and acquired behaviours, at the labile end. Although ‘instinctive’ might be a more useful concept than ‘innate’ or ‘acquired’ for researchers studying behaviour, for those investigating the biological mechanisms underpinning behaviour, a distinction between innate and acquired behaviours might be more useful than the umbrella term ‘instinctive’.

Emotion

Schore’s summary of the concept of attachment says ‘that emotional processes lie at the foundation of a model of instinctive behavior’. Bowlby devotes an entire chapter to emotion, which is well worth reading if you’re interested in behavioural theory. In it, he opts to use the term ‘feeling’ rather than ‘emotion’ because ‘feeling’ can be applied to a wide range of… well, feelings, but ‘emotion’ tends to have a more restricted use. (And one that’s proved notoriously difficult to define.) Essentially Bowlby sees feeling, not as a stand-alone biological phenomenon, but as having an important role in an organism’s appraisal of its internal and external state. The appraisal process involves;

• assigning a value (e.g. nice/nasty) to current sensory input
• comparing the current situation with previous ones
• selecting an appropriate behavioural response
• evaluating the behavioural response in terms of the organism’s goals

Bowlby shares the view of philosopher Susanne Langer that ‘being felt is a phase of the process itself’ (p.108). In other words, feelings are a phase of the process of appraisal.

He explores the role of feelings in communication – via facial expressions, for example, and whether feelings cause behaviours. Bowlby’s analysis is very thorough. So although feelings clearly play an important role in the interaction between mother and infant, I find it difficult to understand how Schore can conclude that Bowlby sees emotional processes as at the root of attachment, especially as Bowlby warns repeatedly about the danger of reifying feelings and emotions as if they can exist apart from the process of appraisal of the internal and external environment.

Strengths and weaknesses of Bowlby’s model

This is my understanding of Bowlby’s model of attachment;

Over time, human beings have evolved instinctive, biologically regulated behaviours that increase the likelihood of the survival of the individual and the species. Mating, parenting and attachment behaviours are critically important (p.179). Attachment involves infants seeking proximity to a primary caregiver, usually the mother. Separation from the attachment figure causes anxiety, and loss of the attachment figure causes depression.

Elsewhere I’ve been quite critical of attachment theory so it might be worth highlighting in more detail where I think Bowlby is wrong – and where he’s right.

There are some aspects of Bowlby’s model I wouldn’t question. It’s clear that childhood experiences affect development and adult behaviour. Some behaviour fits Bowlby’s definition of instinctive, and it’s valid to describe the proximity-seeking behaviour of young children toward a caregiver as ‘attachment’. Attachment behaviours would generally improve an infant’s chances of survival. And there’s no question that there’s usually an emotional bond between infants and their mothers and that separation from the mother can have lasting effects.

What I am questioning is some of Bowlby’s underlying assumptions about nature and nurture. I think there are four questionable assumptions – about genetic endowment, the environment of adaptedness, typical development and what causes developmental differences. Bowlby sees the nature/nurture debate as pointless because development – of the species and the individual – is the outcome of interactions between genetic endowment and environment. Yet he sees individual development as being influenced predominantly by environmental factors. How does he come to what appears to be a contradictory conclusion?

genetic endowment

As far as I can tell, the contradiction originates in his first implicit assumption about genetic endowment; that the human genome has already evolved and is unlikely to evolve further. In Bowlby’s model, instinctive behaviour has evolved once and for all in its environment of adaptedness. It’s as if human beings, like all other species, have ended up in a kind of evolutionary cul-de-sac. That’s true in the sense that past genetic changes limit future ones, but it doesn’t preclude the minute de novo changes in genetic material between generations that are now believed to be involved in many developmental disorders.

The interaction between genes and environment can occur at a molecular level. A small genetic variation can result in changes to levels of a specific protein that can in turn trigger a cascade of developmental abnormalities, including abnormal social interaction, with variations between individuals resulting from interacting developmental and environmental factors interacting in different ways; this is what occurs in Williams syndrome, for example.

environment of adaptedness

The second assumption involves the environment of adaptedness – the environment that shaped the genetic endowment and the instinctive behaviour of a species. Bowlby says;

So long as the environment is kept within certain limits, it seems likely that much of the variation in the behaviour of different children is attributable to genetic differences. Once environmental variation is increased, however, the effects to which such variation gives rise are plain to see”. (p.296)

The problem with this view is that although the limits of the environment of adaptedness are clear for something like the cardiovascular system – if they are exceeded the system stops functioning and the organism dies – we don’t actually know for sure what those limits are for various behavioural systems. We can only speculate by observing the points at which behaviour begins to depart from typical patterns. And typical behaviour varies not only between individuals, but also within individuals – over time and in different environments. Although some behaviour patterns can be described as typical of a species, the typicality itself isn’t clear-cut; all we can say is that a species has a tendency to behave in particular ways in particular circumstances.

typical development

Although he doesn’t say so explicitly, Bowlby appears to be moving towards a normative view of child development. So a third assumption is that not only are some patterns of behaviour typical of human beings, those are also patterns that healthy human beings should be showing.

causes of developmental differences

The fourth assumption is that psychoanalysis is correct in locating the root of many pathologies in attachment patterns;

If the satisfactory development of attachment is as important for mental health as is claimed [by Freud], there is an urgent need to be able to distinguish favourable development from unfavourable and also to know what conditions promote one or the other.” (p.331)

Bowlby explains Freud’s view of separation anxiety as follows;

“… we try at times to withdraw or escape from a situation or object that we find alarming, and … we try to go towards or remain with some person or in some place that makes us feel secure. … So long as the required proximity to the attachment-figure can be maintained, no unpleasant feeling is experienced. When, however, proximity cannot be maintained … The consequent searching and striving are accompanied by a sense of disquiet … and the same is true when loss is threatened. In this disquiet at separation and at threat of separation Freud in his later work came to see ‘the key to an understanding of anxiety’.” (p.330)

Bowlby supports this thesis by referring to studies that show typical attachment patterns in infants. I think this is where his theory runs into problems because the studies also show a great deal of variation in behaviour in both babies and mothers. Despite this, Bowlby focuses on the correlation between infant and maternal behaviour and concludes;

Whatever the causes of a mother’s behaving in one way or another towards her infant, there is much evidence suggesting that whatever that way is plays a leading part in determining the pattern of attachment he ultimately develops.” (p.345)

At one level Bowlby understands the importance of the interaction between genetic endowment and environment in behaviour and that genetic endowment and environment can vary. But because of his underlying assumptions about the human genome, the environment in which it evolved, the nature of instinctive behaviours and a psychoanalytic model that locates the source of mental health in childhood experiences, it’s almost inevitable that Bowlby ends up placing a disproportionate emphasis on environmental factors – especially on the mother’s behaviour.

Does the nature/nurture debate really matter?

Despite child development theorists from Darwin onwards espousing the idea that behaviour develops from an interaction between genetic make up and environment, child development theory has throughout its history swung between an overemphasis on genes and an overemphasis on environment. An overemphasis one way or another isn’t just an obscure theoretical issue. Overemphasising the role of genes resulted in the eugenics movement that had catastrophic outcomes for minority groups worldwide. Overemphasising environmental factors (coupled with a misunderstanding of probability) led to the relatively recent imprisonment in the UK of several mothers wrongfully convicted of murdering their children – with tragic consequences.

Attachment theory has experienced something of a resurgence in recent years, but professionals using it don’t necessarily have sufficient biological knowledge to critique it. In the publications on child development referred to by the Munro review of child protection Bowlby’s ideas were generally presented as givens, with little discussion. In other words, there appears to be an assumption implicit in the child protection literature – and amongst politicians – that the most likely cause of abnormal behaviour in children is parental behaviour. The problem with an overemphasis on parental behaviour is that there’s a serious risk of genetic and medical disorders and alternative environmental factors being overlooked. I’ve lost count of the number of accounts I’ve read from parents who have been puzzled as to why their child refusing to go to school is attributed by teachers and social workers to a child having a problem with attachment (rather than a problem with school), or where problems with attachment have transformed into a diagnosis of autism or ADHD once practitioners who are specialists in those fields get involved.

My fundamental problem with attachment theory is not that I think attachment behaviours don’t exist – they clearly do. It’s that Bowlby’s theory consists of a number of phenomena over which there’s little disagreement, held together by a series of assumptions. Those assumptions implicitly rule out a host of other possible causes for mothers and children behaving in the ways they do. In the next post, I’ll look at what Allan Schore makes of Bowlby’s model.

Edited for clarity 11/7/15.

Image of Bowlby from http://tinyfootprints.wikispaces.com/John+Bowlby

protecting disabled children: systems maltreatment and neglect

Ofsted’s assumptions in their report Protecting disabled children: thematic inspection that “risks to disabled children are not well identified or that support effectively reduces risks and helps to keep them safe” appear to be based on some rather unreliable data. That doesn’t mean Ofsted wasted its time doing an inspection. But what concerned me about the report – in addition to the statistical analysis that triggered it – wasn’t so much what was said, as what wasn’t said about the risks to disabled children and support for them.

If we had robust data I’d be surprised if they didn’t show disabled children to be at an increased risk of maltreatment or neglect. That’s because of the risk factors involved. Many disabilities have a genetic component, meaning that other family members are more likely to have health or disability issues. Add to that the challenge of looking after a disabled child, the impact on siblings, the likelihood of a reduced income with increased expenditure and you have a situation where all those directly involved are likely to be vulnerable. But some protection from those risks can be offered by the community. Appropriate support from relatives, friends, neighbours and the local authority can make a big difference to families’ quality of life and thus reduce the risk of maltreatment or neglect.

Ofsted’s inspection focused on safeguarding and looked after children services in relation to disabled children. Nothing wrong with that focus, per se. But Ofsted also refers to more general support services that could have an impact on the safety and wellbeing of disabled children. In this post I want to examine some of the wider issues relating to child protection and support services for disabled children.

What does child protection mean?

‘Child protection’ is a term commonly used to refer to the protection of children from maltreatment and neglect by people they know well, like family members. There’s no doubt that children are most at risk from people they know well. That’s not because people who know children well are inherently more evil than people who don’t; it’s partly because not everyone who brings up a child is good at doing so, but also because children spend a great deal more time with people they know well, as distinct from with people they don’t. When that situation is reversed, historical evidence from children’s institutions suggests that the main source of risk to children changes accordingly.

‘Child protection’ can also refer to protection from people who work with children (hence Criminal Record Bureau checks), from strangers (hence ‘stranger danger’ warnings), and sometimes from other children (hence anti-bullying policies in schools). But ‘child protection’ is rarely used in the context of what the Australian government calls ‘systems abuse’, defined as:

preventable harm [that] is done to children in the context of policies or programs which are designed to provide care or protection. The child’s welfare, development or security are undermined by the actions of individuals or by the lack of suitable policies, practices or procedures within systems or institutions.

I’d broaden this definition by omitting the words ‘which are designed to provide care or protection’, since children can experience collateral damage from policies of any sort.

An example of what I mean was featured in a recent documentary shown on BBC 4 (unfortunately not currently viewable) entitled ‘Growing children: autism’. The last part of the programme shows footage of two young brothers, Jake and Zaine, both on the autistic spectrum. Their behaviour results in their mother spending much of her time protecting her shins. Zaine explains very clearly and persuasively why he doesn’t want to attend school (the people, the noise) but it’s no use, he has to go to school. (I’m not blaming his mother, incidentally, because her options might have been limited.) If a child had behaved like that at the end of the school day, rather than at the beginning, and said those things about going home, my guess is that social services would have been contacted. But despite much rhetoric about listening to the voice of the child (and s.17. 4(A) of the Children Act 1989 requiring the wishes and feelings of children in need to be ascertained in respect of service provision), the impact of some policies and programmes on children is simply ignored regardless of the distress and harm it causes, as many parents of children with disabilities and those children themselves can testify.

This is what Bronfenbrenner’s ecological systems theory highlighted; that children are most strongly influenced by people they come into direct contact with (for obvious reasons), but that the actions of people they never meet, such as decision-makers in organizations and national and international governments, can have a significant influence too – for good or ill. This brings me to the point about support services.

Support services

The Ofsted inspection involved 12 local authorities – that’s fewer than 10% of the total in England. Of the 12, seven had been judged ‘good’ and five ‘satisfactory’ in previous inspections of safeguarding and looked after children services (p.9). Ofsted wanted to look in detail at the ‘child’s journey through the system’, so it made sense to investigate authorities that were following procedures fairly closely, in order to identify shortcomings resulting from the design of the system rather than because of failures in implementation. Inspectors also met with “18 parents, 10 of whom had disabled children with child in need plans and eight of whom had children subject to child protection plans” (p.9). I couldn’t discover how many families were represented, but at best it was obviously a very small sample, an average of 1.5 per local authority inspected.

Ofsted’s focus is on safeguarding and looked after children services but several references are made to universal services. The introduction (p.7) begins:

When the national Aiming High for Disabled Children programme was being developed in 2007 by the previous government it was estimated that there were 570,000 disabled children in England. This programme put in place a range of support for disabled children and their families.”

Aiming high for disabled children

Let’s take a closer look at the Aiming High programme, as described in Aiming high for disabled children: better support for families, published jointly by HM Treasury and the Department of Education and Skills in May 2007 and signed off by Ed Balls, then Economic Secretary to HM Treasury and Andrew Adonis, then Parliamentary Under-Secretary of State for Schools. The Aiming High programme was the outcome of the Disabled Children Review, one strand of a Review of Children and Young People, in turn part of a Comprehensive Spending Review (CSR), undertaken by the previous Labour government. The CSR set government departmental spending plans and priorities for 2008-2011. (Aiming High p.10)

So what is the ‘range of support for disabled children and their families’ that the Aiming High programme put in place? The Aiming High report identifies three core areas, which I’ve summarized for brevity. You can read them in full on pp. 6-8 of the document.

Empowering disabled children, young people and their families

• a “core offer“ to make it clear what entitlements and services disabled children, young people and their families can expect

• piloting individual budgets

• spreading good practice on engagement such as parents’ forums

Promoting more responsive services and timely support

• a national disabled children indicator

• evaluation and benchmarking good practice on early intervention

• Local Authorities and PCTs will improve their data collection

• continuing the Early Support Programme

• a Transition Support Programme

Boosting provision of vital public services

• provision of short breaks for disabled children

• a childcare accessibility project

• a radical reform of community equipment and wheelchair provision and

• research the skills and behaviours required by the workforce and to identify gaps.

Funding was allocated to some of these areas and funding for short breaks and parent forums, for example, has been maintained by the coalition government. But how much of this actually constitutes ‘support’? And how much support is on offer? Feedback from parent groups and voluntary sector organisations suggests that parents who can access short breaks, specialist childcare and individual budgets value these services, but that provision varies and access is often limited. And although the Aiming High document repeatedly refers to improvements in educational provision, the Education and Skills Select Committee report on Special Educational Needs, published less than a year earlier, had described the SEN system as ‘not fit for purpose’. Little mention is made in the Aiming High document of medical provision except in the context of improving workforce skills and behaviours. More recent reports on the state of healthcare (Kennedy), social care (Munro) and education (Lamb) suggest that there is still considerable scope for improvement in terms of universal services for children with disabilities. This is somewhat at odds with the overall impression I got from the Ofsted report that despite some weaknesses in the system around prevention of maltreatment and neglect by parents and carers (paras. 104-8), most local authorities had good information about disabled children, a high level of commitment to supporting them, and offered a wide range of early support services (para. 15).

Clearly the quality of healthcare, social care and education services has a disproportionate effect on the development of children with disabilities and the functioning of their families. But the home is not the only source of child maltreatment and neglect. It could be argued that disabled children in England have always been subject to systems maltreatment and neglect because they have never had access to consistently high quality support that’s timely, appropriate and effective. Ofsted’s focus was on safeguarding and looked after children services. But a narrow view of what constitutes child protection, overlooking concerns about universal services raised in recent high-profile reports, and basing statistical analyses on assumptions and unreliable data doesn’t help to paint an accurate picture of the real level of risk to disabled children.

A fundamental principle of democracy is that everyone matters. A key indicator of the health of a democratic society is how it treats its most vulnerable members, and disabled children constitute one of the most vulnerable groups in our society. Disability can strike anyone at any time, which is why it’s so important to have timely, appropriate and effective interventions available. Such interventions can optimise the quality of life of disabled people and their families as well as increasing the likelihood that the disabled person and their carers will be able to work and reducing the cost of support and the interventions that are too little too late – outcomes dear to the heart of the current government.

Despite its obvious concerns about the wellbeing of disabled children, I felt the Ofsted report perpetuated their marginalisation by failing to consider the wider failings of systems that are supposed to offer support.

what is it about child protection plans and statistics?

Ofsted warns of abuse risks to disabled children” says the BBC headline about the report entitled Protecting disabled children; thematic inspection published last week. And indeed the report opens by reminding us that research “indicates that disabled children are more at risk of being abused than non-disabled children”. It goes on:

However, they are less likely than other children in need to become the subject of child protection plans. This suggests either that risks to disabled children are not well identified or that support effectively reduces risks and helps to keep them safe.

The thematic inspection was undertaken to find out more. I’ll come back to the findings later, but in this post I want to take a closer look at the data about risk that appear to have prompted Ofsted’s interest. The research cited in support of Ofsted’s opening claim consists of one paper (Sullivan and Knutson, 2000) describing a large-scale study of children in Omaha, Nebraska during 1994-95. Disabled children were found to be 3.4 times more likely to have experienced maltreatment than non-disabled children.

By contrast, Ofsted points out;

The children in need census as at 31 March 2011 showed that there were 382,400 children in need in England of whom 54,100 (14.2%) were recorded as having a disability. At that time 42,700 (11%) children were subject to a child protection plan of whom 1,600 (3.8%) were recorded as having a disability. Children with a recorded disability were therefore less likely to be the subject of a child protection plan than other children in need.” (p.8)

If I’ve understood this correctly, it’s saying that if disabled children are at a higher risk of maltreatment than non-disabled children, you’d expect to see a higher rate of child protection plans (CPPs) amongst disabled children. But the frequency of CPPs amongst disabled children is lower (3.8% as compared to 11%), prompting concerns about children falling through the net.

There was something that didn’t look quite right about Ofsted’s analysis and I think I’ve figured out what it is. (I should point out that statistical analysis isn’t my forte, so please let me know if I’ve got it wrong.) I think there are three problems with Ofsted’s data;

– the level of risk to disabled children is based on an assumption
– the figures for children in need and disabled children are unreliable
– the level of risk and level of CPPs are derived from qualitatively different populations.

Assumptions about disabled children and the risk of maltreatment

First, let’s look at the figures for the risk of maltreatment. Little relevant research has been undertaken. Sullivan and Knutson’s study did indeed find that disabled children were 3.4 times more likely than non-disabled children to experience maltreatment. But they also cite an earlier finding that the risk was 1.7 times higher (p.1258). It’s clear from previous research that determining the prevalence of maltreatment is dependent on factors such as the quality of available data, quality of support services, definitions of disability and maltreatment, and whether disability has led to maltreatment or maltreatment has led to disability. This means that the prevalence of maltreatment is likely to vary widely between communities. The figure Ofsted took as its baseline for England was one that emerged from data gathered almost 20 years ago and 5,000 miles away in a community with a very different healthcare system. We don’t actually know the risk of maltreatment for disabled children in England.

Who qualifies as a child in need or a disabled child?

Let’s assume for the moment that disabled children are at a higher risk of maltreatment than non-disabled children. Whatever the level of increased risk, we’re still left with the question of the lower proportion of disabled children with a CPP.

Sullivan and Knutson’s sample consisted of 50,278 children enrolled in the Public (OPS) and Archdiocese schools of Omaha, Nebraska during the 1994–95 school year. It included children in other educational programmes and therefore covered an age range between 0-21. So the sample represented almost all children in a specific geographical area. But the sample Ofsted refers to consists, not of all children in a geographical area (in this case England), but of children in need in that location.

Section 17 (10) of the 1989 Children Act defines children in need as follows:

“For the purposes of this Part a child shall be taken to be in need if—
(a) he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this Part;
(b) his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or
(c) he is disabled”

and s. 17 (11) defines ‘disabled’ as;

For the purposes of this Part, a child is disabled if he is blind, deaf or dumb or suffers from mental disorder of any kind or is substantially and permanently handicapped by illness, injury or congenital deformity or such other disability as may be prescribed; and in this Part—
* “development” means physical, intellectual, emotional, social or behavioural development; and
* “health” means physical or mental health.”

The first problem that arises is one of classification. The Children Act appears to class all disabled children as ‘children in need’, whether or not they are considered to be otherwise at risk. But local authorities don’t necessarily do that. DirectGov site says ‘local councils must identify the extent of need in their area and make decisions about levels of service they provide’, and it’s clear from local authority websites that their criteria for ‘children in need’ and criteria for ‘disabled children’ vary somewhat. One local authority officer told me that her LA classifies all disabled children as children in need whereas Cheshire East, for example, carries out an assessment to determine whether a disabled child qualifies as a child in need.

Then there’s the issue of the reliability of local authority records. The Citizen’s Advice Bureau tells us that ‘the local authority must keep a register of children with disabilities in its area but does not have to keep a register of all children in need’. Local authorities might be required to keep a register of children with disabilities, but that doesn’t mean that all children with disabilities will be registered. A recurring complaint from my own local authority is that although they have a register, it’s perpetually out of date and incomplete. In short, if LAs are unclear about how many disabled children and how many children in need are living in their area, the census data cited by Ofsted might not be entirely reliable. I did try to find out what data were collected by the census, but failed. If you can figure it out, let me know.

Qualitatively different populations

A key problem with Ofsted’s data is that if some LAs are treating all disabled children as children in need, but are treating non-disabled children as children in need only if their health or development is at risk, this would result in non-disabled-children-in-need being at a higher risk of maltreatment than non-disabled children-in-the-general-population. Ofsted is comparing data drawn from two qualitatively different populations – the general population vs children in need.

Child protection plans

What difference does that make to Ofsted’s concern about CPPs? It means that you’d expect non-disabled-children-in-need to have a disproportionately high level of CPPs compared to non-disabled-children-overall. That would widen the gap between CPPs for non-disabled children and CPPs for disabled children, making the proportion of CPPs for disabled children look disproportionately low. Some calculations might clarify the point:

Sullivan and Knutson set out their data (for all children) in a 2 x 2 matrix as shown below:

If Ofsted’s data (for children in need) are set out in the same way, they look like this:

In Table 2, the proportion of non-disabled children with CPPs is 4 times the proportion of disabled children with CPPs, exactly the opposite of Sullivan and Knutson’s trend, and that’s what Ofsted is concerned about.

But Sullivan and Knutson’s finding was based on data from all children in a location, not just children in need. If we put Ofsted’s figures into the context of all children in a location (in this case, England), a different picture emerges. (The total figures for all children and for all disabled children are estimates – the figure for disabled children is the Aiming High estimate).

If my calculations are correct, the proportion of non-disabled children with CPPs in the whole population of non-disabled children is only 0.39%, whereas the proportion of disabled children with CPPs in the whole population of disabled children is slightly lower at 0.28%, considerably less than the 4-fold ratio if children in need only are taken into consideration. When the population differences are corrected for (as far as is possible with the data provided), the discrepancy between CPP rates for disabled and non-disabled children almost disappears.

*********

There’s something about child protection plans that seems to have an adverse effect on statistical analysis. UK readers who were home-educating their children during the Badman review in 2009 will probably recall the disagreement between Graham Badman and Graham Stuart (later to become Chair of the Education Select Committee) about the proportion of home-educated children subject to CPPs. The central issue was that the total number of home-educated children in the UK was unknown; estimates had varied between 20,000 and 150,000. You can read the full account here, but I thought it was worth reproducing some of the exchange in full:

Graham Badman: I reflected a great deal on our exchange of views, I promise you. I did go back and look at the figures and I came up with exactly the same conclusion. In fact, if you want me to qualify it, when surveying the number of child protection plans in the authorities that we covered in the last survey, we came up with a figure of 0.4 per cent., which is double that within the normal population. In fact, that figure could be fractionally higher, because we discounted any child protection plan that was there as a consequence of disability. I know you argued that because I did not know about the other half, that therefore negated it and made it even again. My argument in return, as you will recall, was that because we did not know about the other half, that did not mean to say that they were all safe either. It could be exactly the same figure or more.

Q 86Mr. Stuart: May I interrupt you there? The question was not about the letter to the Select Committee in which you suggested that I had said that any child who was not known about was automatically safe. I said no such thing, so you have your facts wrong there—again. What we were establishing was the rate of child protection plans in the home-educating community. We went through it slowly, and you want to rehearse it, so I will rehearse it.

If you have a child protection plan, automatically you are known to the local authority, so children previously not known to the local authority who become subject to a child protection plan are then known to the local authority. It does not by any means guarantee that children who are not known to the local authority and do not have a child protection plan are necessarily safe. But what you do know is that every child with a child protection plan is known to the local authority, and you claimed, completely erroneously—and although you have been corrected, here you are months later still getting it wrong, which is pretty frightening—that the percentage of children who are home educated who have a child protection plan is double the national average, when your own report suggests that the numbers are at least double the 20,000, which is the number registered with the local authority, and the Secretary of State said on Second Reading that the Government estimated the number was 70,000. They do not know for sure, but they think it is 70,000.

If you take the number of home-educated children with a child protection plan and you see that as a percentage of 70,000, it comes out at a great deal less than the average for the population, and that I believe is the definitive statement of what we know. It does not tell us everything we need to know, which is why I would not overstate my reliance on it. Could you please comment on whether you believe that we can truly say, as you have repeatedly said, that there is double the rate of the most serious level of child protection plan among children who are home educated?

Graham Badman: I fear we are in danger of going round in the same circle. I am afraid I fundamentally disagree with you. You think I am wrong; I think you are wrong.

Mr. Stuart: It is maths.

Graham Badman: Well, fine; we might want to debate that later—perhaps you went to a better school than me. The fact remains that I do not agree with your assumptions. On the basis of the data collected from the local authorities and from two surveys that have been validated by DCSF statisticians, I believe that we are quite safe in saying that on the basis of the child protection plan analysis that they carried out, there are twice as many young people on a child protection plan known to local authorities within that population as are within the general population. That is a fact. I am sorry that you do not agree with me, but we could go on for ever disagreeing.

I also have concerns about other aspects of the report, which I’ll discuss in the next post.

Reference

Sullivan, P.M & Knutson, J.F (2000). Maltreatment and disabilities: A population based epidemiological study. Child Abuse & Neglect, 24, 1257–1273,