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 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.


If it wasn’t for those pesky feminists…

This report argues that domestic abuse is a shocking and disturbingly prevalent hallmark of social breakdown – yet it exists inside every community.”

This sentence opens the executive summary of the Centre for Social Justice’s report on domestic abuse Beyond Violence, published, coincidentally, the day after my last post criticizing two previous CSJ publications for assuming that a correlation between two phenomena indicated a causal link between them. I was curious about the new report’s take on correlations and causality.

Correlations and causality

Beyond Violence, co-authored by a clinical psychologist and a policy expert, provides an overview of the legal, sociological and psychological aspects of domestic abuse from a public policy perspective. It recognizes the complex nature of domestic relationships and abuse and that perpetrators, as well as victims, need understanding and help. However, there’s an implicit assumption running through the paper, as in the CSJ’s papers about marriage and child development, that if A and B are positively correlated and A happens before B, then A must cause B.

That isn’t necessarily the case, of course. A and B might each have a different, independent cause, or both be caused by C – or the causes might be more complex. Take mental health for example. There’s no doubt that domestic abuse can cause mental health problems – for both victims and perpetrators. But mental health problems – in victims or perpetrators – can also be causal factors in abuse. Similarly, marriages might tend to result in stable relationships, or it might be that couples in stable relationships tend to get married. The social problems associated with poor attachment in infancy might not be caused by poor attachment; poor attachment and the associated social problems might have independent causes. What is certain is that interventions that make incorrect assumptions about causes run the risk of being ineffective.

Some other aspects of this report caught my eye and gave me cause for concern.

Domestic abuse and the law

The report deals at some length with the legislation relevant to domestic abuse and points out that

“…fundamentally the law and legal system were not designed with domestic abuse in mind and they still both misapply understandings of other sorts of crime to it.” (p.15).

In response, it recommends that a new crime of coercive control is recognized

“…whereby a prosecution can be brought on the basis of a ‘course of conduct’ in which a person has acted strategically to control, isolate, intimidate and/or degrade their victim.” (p.19)

and the report bemoans

the high standard of proof required before there is an acknowledgement of wrongdoing.” (p.15)

It’s quite likely that the law relating to domestic abuse might need to be changed; however, I have reservations about the direction in which this line of argument is moving. UK law puts the burden of proof on the plaintiff. This means that there’s a greater risk of criminals getting away with it than of innocent people being wrongly convicted. There are good reasons for that. It’s more difficult to prove that someone didn’t commit a crime than that they did, wrongful conviction causes long-term damage and reduces respect for the law, and if the burden of proof were on the defendant the courts would be full of vexatious litigants. UK law also requires evidence to show beyond reasonable doubt that someone committed a crime. A ‘high standard of proof’ is required for good reason. I couldn’t find any evidence that the report had tackled the thorny question of what sort of evidence would be required to prove that a course of conduct involving coercive control had taken place.

Involvement of public sector services

Understandably, the CSJ wants to prevent domestic abuse before it starts. In order to do so, it recommends a ‘skill-based module’ in schools ‘backed up by a supportive school culture and learning across other subjects’ (p.17).

It also recommends the involvement of health visitors, Sure Start Centres and GP surgeries and makes recommendations for the criteria used to commission interventions in domestic abuse cases. It’s clear that the authors envisage reallocating existing funding but since education, health and social care services are currently struggling to cope with a) demand b) reduced budgets and c) structural changes, these recommendations are likely to go on the ‘to do later’ list.

Payment by results

The report recommends several interventions funded by the creation of payment-by-results commissioning frameworks, including using social impact bonds for ‘domestic abuse services’(p.17). The report doesn’t explain what a social impact bond is, nor could I find any indication of what results would trigger payments. According to Wikipedia a social impact bond depends on

“…specified social outcomes being achieved and therefore in terms of investment risk Social Impact Bonds are more similar to that of a structured product or an equity investment.”

Social impact bonds have also been mooted in the USA and Australia, although there doesn’t appear to be any evidence yet for their efficacy. The idea is that the savings resulting from interventions pay for the interventions themselves. Of course until the interventions result in savings, there’s no money to pay to the agencies doing the intervening. That’s where the ‘investment’ of the social bond comes in. If my experience is anything to go by, this model would result in agencies focusing on meeting required outcomes, rather than on outcomes of maximum benefit to the client. It also assumes that the savings to the exchequer would be greater than the money needed to fund the agencies. But savings wouldn’t go back to the taxpayer – at least not during the life of the social impact bond – they would go to private investors. So much for limiting public sector borrowing.


The authors are critical of what they describe as a ‘power, control and patriarchy’ model of domestic abuse (pp.15, 52ff) originating in feminist thinking (feminists get 24 mentions in this report). They are careful to acknowledge the part played by feminists in putting domestic abuse firmly on the political agenda. They also acknowledge that the model is oversimplified in government policy and in practice. But when they say;

However, as movements move from the margins to the mainstream, they need to confront and adapt to the nuances and complexities of the problems they are aiming to address. This has not happened in the domestic abuse field; the ‘patriarchy, power and control’ analysis remains more or less intact despite its incompatibility with emerging findings about domestic abuse” (p.54).

The implication is that the feminist model of domestic abuse is itself simplistic, lacks nuance and doesn’t recognize the complexities of the problem, despite Janice Haaken – ‘psychologist, feminist, activist and film-maker’ – being quoted as saying of domestic abuse;

‘There is something quite vital – and respectful – in acknowledging this complexity, and the challenges we face in bringing about a more humane world’” (p.23).

I wouldn’t describe myself as a feminist – I’ve always questioned the assumptions implicit in feminist thinking – and I’m quite sure many feminists do subscribe to a simplistic model of domestic abuse framed only in terms of power, control and patriarchy. But most of the feminist writers I’ve read (mainly academics) have been clear about their framework, explicit about their assumptions, and have understood the complexity of the phenomena they are dealing with. Their emphasis has been on power, control and patriarchy because of the extent to which such issues are taken for granted.

My experience with ‘marginal movements’ suggests that it’s when ideas rather than movements move to the mainstream that mainstream agencies such as governments and policy-makers adopt simplistic versions of the ideas that lack nuance and don’t recognize the complexities involved.

Underlying assumptions

What troubled me most about this report was something that wasn’t made explicit – its underlying assumptions. Let’s go back to the sentence that opens the executive summary. “This report argues that domestic abuse is a shocking and disturbingly prevalent hallmark of social breakdown – yet it exists inside every community.”

An accusation often leveled at researchers is that their writing is too dense and full of jargon, rendering it inaccessible to the average reader. There’s no reason why researchers’ writing should be impenetrable, but there are reasons for it being like it is. One is the space constraints of academic journals – authors often have to work within strict word limits and therefore use technical terminology for brevity. Another reason is that scientific research is about the objective evaluation of evidence. No one can be truly objective, of course, which is why, over the centuries, scientists have developed a toolbox of research methods that go a long way toward mitigating the effects of the errors and biases inherent in human thinking. A good academic paper will be grounded in evidence – authors will avoid personal opinion and emotive language because these could bias the conclusions of readers – or of the authors themselves.

Beyond Violence isn’t an academic journal paper, so it doesn’t have to conform to the same level of rigour. However, opening a report with personal opinion and emotive language makes it clear what the authors want readers to think. Some people, unfamiliar with domestic abuse or the full range of human behaviour might find the statistics on the prevalence of domestic abuse ‘shocking and disturbing’. Others, more familiar with both, might mutter about no one knowing about what goes on behind closed doors. The report refers to domestic abuse as a ‘hallmark of social breakdown’, but I couldn’t find any evidence to support this assertion. There have been times of social breakdown in English history; the Viking invasions, the wars of the roses, the civil war, the aftermath of the industrial revolution and the depression spring to mind. It’s quite likely that domestic abuse escalated during those periods, but they were characterized by far more obvious ‘hallmarks’ than domestic abuse.

Also, the authors of the report emphasise the fact that domestic abuse has only achieved widespread recognition as a social problem in the last few decades. The implication, coupled with historical evidence, is that the prevalence of domestic abuse is probably lower now than at any other time during our history. So what ‘social breakdown’ does it indicate? In the report’s Foreword, the CSJ’s Managing Director, Christian Guy, links ‘disadvantage’ to ‘family breakdown’.

In all of our work with community-based organisations fighting poverty on the frontline, we are reminded of the close association between family breakdown and other drivers of disadvantage – particularly drug and alcohol addiction, welfare dependency, educational failure and serious personal debt.” (p.4)

The causal chain underpinning the CSJ’s view of social problems appears to look something like this;

individual behaviour
leads to
family breakdown
leads to
social problems/social breakdown

The CSJ appears to imagine that if all couples got married, engaged appropriately with their children and acted responsibly (and if the pesky feminists stopped propagating simplistic ideas) social problems would melt away. Certainly the behaviour of a small number of individuals can cause a disproportionate number of social problems, but the fact that individual behaviour results in those problems is a different issue from what causes the individual behaviour in the first place. Individuals are often severely constrained as to what they can do about their genes, physiological make-up, health problems, disabilities, learning difficulties, education, income, housing and family responsibilities. They can’t change national or international economic and social conditions, nor the quality of education, health or social care that’s available to them. That doesn’t absolve individuals of moral or legal responsibility for their own actions. What it does mean that locating the root cause of individual behaviour in individuals only is short-sighted and that interventions aimed at changing individual behaviour without addressing the complex causes of that behaviour are likely to fail.

Decades of research have shown that the causes of individual behaviour are complex. In order to change the behaviours that cause social problems, it’s necessary first to tease out the causes and then to address them all. Simultaneously. A rigorous review of several research literatures, some very careful planning and a great deal of joined-up working will be required. The task isn’t an impossible one, but it’s challenging. It might be a while before social impact bond investors get their money back. Taxpayers might need to wait a bit longer.

the big picture: do mothers cause social problems?

I’ve suggested Allen and Duncan Smith’s understanding of brain development and of data from large-scale studies isn’t as good as it might be. So what?

The role of evidence

It’s not clear why Allen and Duncan Smith feel compelled to use evidence from brain development to shore up their case for early intervention. We already know that maltreatment, neglect and poor attachment cause problems, often lasting ones; that’s why they’re called ‘maltreatment’, ‘neglect’ and ‘poor’ attachment. We’ve known for millennia that early intervention in children’s lives is more effective than late intervention. We can also demonstrate the effectiveness of an intervention without knowing how it works. The use of brain development as evidence is especially puzzling since Allen and Duncan Smith clearly don’t understand it well, and because people who understand it better suggest that the evidence linking maltreatment, neglect and attachment to abnormal brain development is still rather tenuous e.g. De Bellis (2005); Glaser (2000). Basing one’s case on unreliable evidence runs the risk of defeating one’s own aims.

Correlation and causality

Allen and Duncan Smith rely heavily on correlations to support their model. If I’ve understood it properly their model looks something like this:

Allen and Duncan Smith early intervention model

But all the causal connections implied in the model rely on correlations. Assuming that correlated variables must be causally linked – ie that one causes another – is a basic error in data analysis. It’s not the first time the Centre for Social Justice has made this mistake. Their paper on marriage published in December 2009, assumes that correlations between marriage and length of relationship, mental and physical health, violence and abuse and outcomes for children, mean that marriage itself results in more stable relationships, improved mental and physical health and a reduction in violence and abuse. Not that non-violent couples in stable relationships, with adequate parenting skills, who enjoy good mental and physical health might be more likely to get married and to stay together. As with the brain development data it’s clear that the error has been made by the authors of the reports, rather than in the research on which the reports are based. In order to change behaviour it’s essential to identify its causes accurately.

The causes of social problems

A name that keeps cropping up in the child development literature is that of Urie Bronfenbrenner, a psychologist renowned for his Ecological Systems Theory of child development, often depicted as a set of concentric circles representing nested systems as shown below.

external ecological systems affecting child development (after Bronfenbrenner)

The point made by Bronfenbrenner’s ecological systems model is that many external factors at different levels of complexity interact to influence a child’s development. The same point is made by Mareschal et al’s neuroconstructivist model, except that they include factors internal to the child (genetic, epigenetic and behavioural). In the diagram below I’ve integrated the neuroconstructivist framework with Bronfenbrenner’s and Allen’s and Duncan Smith’s models, taken a cross-section, and highlighted Allen and Duncan Smith’s causal pathway in red. Even though the diagram is sketchy (I’ve omitted many factors and their possible links to outcomes), it’s clear that Allen and Duncan Smith’s model of the links between poor attachment and social problems is a narrow one. Although there is little doubt that low levels of maternal ‘attunement’ and ‘empathy’ could result in the social problems referred to, there are clearly many other factors that could also cause them, not taken into account by Allen and Duncan Smith.

integrated outline of factors affecting child development

Of course there’s no reason why government shouldn’t focus on one particular cause of social problems. After all, water purification, sewage treatment, education, free healthcare and democracy have each resulted in major improvements to quality of life. The difference is that the evidence demonstrating the adverse effects from drinking polluted water, lack of access to sanitation, education, healthcare and living under an authoritarian regime, is robust. The evidence demonstrating a causal pathway between poor attachment, brain abnormalities and an array of ‘social problems’, isn’t.

Blaming the parents

Decades of research have demonstrated that the causes of Allen and Duncan Smith’s ‘social problems’ are many, varied and often interact in complex ways. Identifying what interventions might be most successful in reducing social problems is a challenging task. And some potentially effective interventions, such as de-criminalising drug use or adopting alternatives to custodial sentences, are deeply unpopular politically. It’s much easier, and more intuitive, to allocate the blame for social problems to factors at Bronfenbrenner’s microsystems level than to tackle the complex, expensive and potentially embarrassing task of identifying possible causes at the economic, legislative or historical level. In locating the primary cause of social problems with parents – notably mothers – Allen and Duncan Smith are conveniently overlooking other possible causes at the level of the child (genetics, epigenetics, disease, diet, environmental toxins); the microsystems level (churches, schools, communities, quality of education, health and social care); the exosystems level (employment, economics, legislation, government policy); the macrosystems level (cultural assumptions, global trends) and the chronosystems level (constraints and affordances that have arisen historically). Again there is no doubt that bad mothering could cause abnormal brain development and could lead to social problems, but there is considerable doubt over whether it’s the main cause of either. In short, what Allen and Duncan Smith don’t say is as important as what they do say.

The real world is an uncompromising place

Concerned about the poor quality of evidence in the chapters on the brain in these two papers, I contacted Graham Allen. A member of his research team called me back. He assured me that the material on the brain in the Allen report had been approved prior to publication by a neuroscientist, Professor A. I contacted Professor A – who incidentally isn’t a neuroscientist. He said his role was to check the evidence on parenting programmes; the scientific advisor was Dr B. I contacted Dr B – also not a neuroscientist. No, he worked on the chapters on standards, what works and cost-benefit. Both Professor A and Dr B said they had questioned the use of the report’s cover image and had pointed out that it might be counterproductive.

This brings us back to the issues of expertise and use of evidence I highlighted in relation to Kanner and Bettelheim. The chapter on brain development in Allen’s Next Steps report doesn’t appear to have been written or checked by someone with expertise in the field – despite there being a number of high profile neuroscientists with excellent international reputations working in universities in the UK. It also raises questions about the role of ‘think tanks’. Despite inevitable shortcomings, universities have acquired a reputation for producing reasonably reliable, valid research findings; that is, research findings that reflect consistently and accurately the situation in the real world. Government policies based on a rigorous analysis of reliable, valid data are likely to be effective. Unfortunately politics tends to be not so much about the real world as about beliefs about the real world. Successful political campaigning involves persuading people that you are right and that those with opposing beliefs are wrong. It doesn’t matter, politically, if you haven’t understood the evidence or if you’ve misinterpreted the data, as long as you make a persuasive case for your policies. Of course for the people who benefit (or otherwise) from those policies, it’s quite important what evidence you are using, because if the evidence doesn’t reflect the situation in the real world, your policies won’t work. The adult social world might be open to manipulation and compromise, but as anyone who works with children, animals or materials will tell you, the real world is a pretty uncompromising place. The increasing reliance by politicians on material from think tanks founded by, or with strong links to politicians (as is the case with both the Centre for Social Justice and the Smith Institute who jointly published Early Intervention: Good Parents, Great Kids, Better Citizens) suggests we might see increasing amounts of policy-based evidence as distinct from evidence-based policy. It remains to be seen how the real world will respond.


De Bellis, M.D. (2005). The psychobiology of neglect, Child Maltreatment, 10, 150-172.
Glaser, D. (2000). Child abuse and neglect and the brain – a review, Journal of Child Psychology and Psychiatry, 41, 97-116.
Mareschal, D., Johnson, M., Sirois, S., Spratling, M.W., Thomas, M.S.C. & Westermann, G. (2007). Neuroconstructivism: How the brain constructs cognition, Oxford University Press.