By Udita Iyengar, project manager, BeST? Services Trial, King’s College London
How much do we know about outcomes for children subject to proceedings in the family justice system? Research in this area is relatively new and faces many challenges and unanswered questions. What do we actually mean by ‘good outcomes’? What should parenting assessments encompass, and who should deliver them? How are decisions about rehabilitating children to their parents or permanency reached and can we be sure they are best for the child long term?
Our research trial in East London (which is part of broader project started by Professor Helen Minnis in Glasgow in partnership with the NSPCC) is looking at a new question based on what we know about child brain development. We are following a cohort of young children (five years old and under) going into care to examine whether a service model that focuses on infant mental health brings benefits to children who enter care at a young age as they grow older – in terms of their social, emotional and mental wellbeing – compared to the existing social work model.
Why infant mental health?
Scientific studies have shown a strong link between adverse childhood experiences (such as domestic violence, emotional and sexual abuse, physical and emotional neglect), and physical and mental health.
This is particularly important in the first few years of life, when the brains of children are rapidly changing and developing, making young children highly vulnerable, but also highly resilient. Regardless of the severity of abuse and neglect, the negative effects of maltreatment can largely be reversed if children receive secure, loving care and are in a stable home environment, early enough.
The New Orleans Intervention Model (NIM) was developed by a team at Tulane University, Louisiana over 20 years ago to apply this research to practice when children come into care. NIM uses an infant mental health approach (see below), designed to improve the quality of the child’s permanent placement decisions.
However, we still do not know if an infant mental health model is more clinically and cost effective than the usual interventions for these children. This is the question our trial, run by the East London Family Court and King’s College London, is attempting to answer. The Best Services Trial (BeST?) is the first ever randomised controlled trial within the context of care proceedings. It is a longitudinal study, designed to evaluate the long-term impacts of different interventions.
The study started in Croydon in 2017. It has since extended to Tower Hamlets, Bromley, Sutton, and Barking & Dagenham and may expand into more east London boroughs.
BeST? aims to compare the outcomes of children and families receiving an intervention under an infant mental health service model delivered by the London Infant and Family Team (LIFT), and those receiving support under the existing model (we’ve referred to this as ‘services-as-usual’ or SAU).
What do the interventions involve?
LIFT teams are multidisciplinary, comprising of social workers, psychiatrist and psychologists all under one roof. The LIFT team conduct the initial assessment when proceedings are started and continue to work with the child and their family and carers during and after proceedings. They provide the evidence to court if orders are pursued.
Circle of Security and Video Interaction guidance are attachment based-interventions carried out by trained practitioners.In brief, CoS aims to increase awareness of and then shift the mental representations parents have of their own childhoods and the downstream effects they have on how they parent their child, and support parents to reflect upon parent-child interactions through video and/or group discussion. VIG aims to enhance communication and attunement in parent child relationships using a coaching approach to reflecting on the behaviour, feelings, thoughts, wishes and intentions in filmed interactions
The work carried out and techniques used depend on the specific contexts and needs of the individual child and family and carers but may include parent/infant psychotherapy, approaches based on attachment theory such as Circle of Security or and Video Interaction Guidance.
For those receiving ‘services as usual’, the service is led by the social work team, solicitors, and guardians following the procedures in that local authority and would typically include parenting assessments done in-house, or by independent social workers, or possibly external expert assessments – tailored to a family’s needs on a case by case basis.
It is a crucial part of this trial that children, birth families and foster carers are getting a high quality of service no matter which service they are allocated to.
Why a randomised controlled trial?
A randomised controlled trial (RCT) is seen as the ‘gold standard’ in research and is the fairest and clearest way to know which service is best for children long term. Random allocation to LIFT or SAU balances out, between the two groups, all of the complex factors that could influence outcomes for children.
While there are often ethical implications for a randomly allocated study, particularly in care proceedings, this trial has been through a rigorous ethical review board at the National Institute of Health Research (NIHR) and is supported by the East London Family Court. It is important to note that within the context of care proceedings, the jurisdiction of the court is to gather evidence on a welfare decision, and the ultimate decision maker is the court. Whichever service the family is allocated to, professionals will provide evidence for the courts to make a decision.
The only ‘random’ element is which service they are allocated to. All birth parents with children entering foster care (including mother and baby placements and kinship care) in the boroughs involved are informed about the study and asked if they want to participate. If they consent to take part, they are randomly allocated by computer to receive either LIFT or SAU. There is no random element in the decision making of the court.
The families receive the intervention they are allocated to during proceedings and continue to receive appropriate services following the outcome of care proceedings.
Researchers meet the children, birth parents, foster carers (and if the child is adopted, their adopters if they consent to taking part) three times over a two and a half-year period: roughly one month, 15 months and 30 months after the child enters care.
During these research visits we talk to parents, carers and children and assess the child’s development and wellbeing, mental health, and parent/carer and child relationship using a number of measures. Following the progress of children over a number of years is the only way to determine which services is better for children, as well as the costs associated with each service.
Separately, with the help of local authority, we are also doing an analysis of the cost for both services, to know long-term which is the most economical and beneficial service.
Ultimately, the trial aims to find out which service is best for children long term: a model led by social work experts or a model led by infant mental health experts. A key premise is that we know both models provide a quality service; no family participating in the study is being deprived of support. Birth parents, foster carers and adoptive parents, social work, legal teams and guardians all play a crucial part in in helping us to learn the best way to improve the mental health and placement stability of pre-school children who have come into care because of abuse and/or neglect. This study is the first of its kind, and if successful, could radically transform the way we implement social services for children and families. If you have any questions about it, please contact the research team.