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The sky is falling, the sky is falling – balance, and yes, more neuroscience

A lot of television and radio shows, particularly news or discussion shows, approach things on the principle of balance. You’ve got to show both sides of the debate and give them equal air-time.

So you get expert number one, Chicken Little, come on and say “The sky is falling, the sky is falling”

Expert number two, puts the counter position “The sky isn’t falling, the principles of gravity don’t work that way, and in the unlikely even that the sky was ever to fall, here would be some catastrophic signs and evidence that we would get”

And then the presenter wraps up, often with the expression “Well, the controversy rages on”

So the listener/viewer doesn’t learn much more than that some people think the sky is falling, others think it isn’t.  Some people think that Evolution is a load of nonsense and that the existence of bananas prove that*, others think it isn’t.  Some people think that the Holocaust is a fake Jewish conspiracy and it never happened, some people don’t. Some people think we should intervene militarily in Syria, some people think we shouldn’t.

[*Re – Bananas disprove evolution. I am not kidding, this is actually an argument]

The overwhelming message is that there are two sides to every story, there are no right or wrong answers.

What we don’t get is any analysis of whether Chicken Little is someone to be relied upon, or whether a detailed look at Chicken Little’s claims mean that almost anyone with an informed view would disagree.

And so you end up with Chicken Little’s views being just as much air time and weight as the counter-opinion, in order to have ‘balance’

I’m all for balanced debate when the issues are balanced – you can learn a hell of a lot from listening to people who have a contrary view. But it is helpful to know whether the debate is actually balanced (the Syria thing there are genuinely good and awful points on both sides, and though I might have views I wouldn’t say that the other camp is wholly wrong) or whether frankly one side is just wrong (The Holocaust really did happen, Evolution is not nonsense, the sky is not falling)

Long-term readers of the blog may well be aware that the Family Justice Board published some research on the neuroscience behind neglect – it’s all available and discussed here:-

http://suesspiciousminds.com/2012/11/05/taking-neglect-seriously/

And then Wastell and White published a critique of that research, essentially saying that it is being misused to make political decisions and justify a direction of travel that the individual studies simply don’t support

http://suesspiciousminds.com/2013/01/14/semantics-pedantics-and-neuro-mantics/

In very brief summary (the two articles tell you much much more, as do the source papers cited within them), there are two camps on what the neuroscience says. The FJB camp says that the neuroscience shows that there is hard evidence that neglect is very damaging to the underlying structure of children’s brains and that this neglect is difficult or not possible to recover from and that timely intervention and stopping the neglect early is thus vital. The Wastell/White camp say that the scientific evidence for these assertions is simply not there, that the studies the FJB camp rely on are either irrelevant or have been wildly overstated and that in particular, there is neuroscientific evidence that brains are more ‘plastic’ than the FJB camp claim – i.e that where damage occurs, the brain recovers and repairs that damage.

I candidly said in the second piece that not being a neuroscientist, I have no idea whether Wastell and White are correct in their demolition of the FJB research, or whether they are wrong.

I don’t know who “Chicken Little” is in this scenario, or whether either of the camps are “Chicken Little”, but that given that the FJB research has been an important underpinning “child-focussed” reason for the drive towards faster intervention and faster resolution of care proceedings, it is rather important that people who ARE in a position to say :-

(a)   The FJB camp are right

(b)   Wastell and White are right

(c)   One of them is probably more right than the other, but there are some real gray areas that need more studies and better evidence to be confident about deciding the issues

Are asked to say so.

If we are going to make policy decisions, or case decisions, we really do need to know if there is genuine doubt here and the extent to which that doubt impacts on how confident one can be about the research, or if one of the camps is a Chicken Little.      [For what it is worth, I really don’t believe that Wastell and White are Chicken-Littling here.  But I am no neuroscientist]

What I learn recently is that whilst the judiciary were all of course sent the FJB research (on the basis that finally, the Courts were going to be given some research on which decisions could safely and properly be taken)

they have now also been sent, without comment, the counter critique of Wastell and White.

Specifically, they were sent THIS document, which was produced for a conference organised by counsels chambers, 14 Grays Inn. As what I am doing here is linking to their website featuring it, and naming that 14 Grays Inn produced it and Wastell and White authored it, I don’t believe I am treading on anyone’s toes re authorship or copyright (but will take down the link if people object)

I think it is pretty important that people who are arguing cases in front of Judges know what research material the Court has been sent, and it may help to know that all Judges have been provided with access to both the FJB research AND this paper from 14 Grays Inn which critiques it.

http://www.14graysinnsquare.co.uk/The_childs_time_frame_%20a_neuro-scientific_perspective.pdf

What of course they DO NOT have, is any objective independent peer review of both documents, to answer the questions I have set out before. Which effectively makes the research fairly useless. We are left with the stereotypical TV presenter summary of “well, the controversy rages on”

I wonder if the same is going to be true once the FJB publish their research on the level of contact which is desirable for children (yes, it will), or the impact of drug misuse on family life and the ability of parents to recover from drug misuse (yes, probably)  and whether if all the Judges are getting are a set of controversial research papers and effectively being told that the science is controversial on all these issues, whether there is any value to it at all?

I was very supportive of the FJB producing some framework research which would answer some vital underpinning questions in child protection, but it seems to me that this has value only if the Courts who are potentially relying on that research have clear understanding of whether that research represents accurately the mainstream thinking of professionals within that field, and where any gaps are that  result in the need to be more cautious about certain aspects.

[The 14 Grays Inn paper is worth reading in any event, and I would urge you to do so, if you can find the time. A lot of the neuroscience is similar to already linked to on my earlier two blogs, but there is some new stuff. The “Error at the Door” piece about initial assessment is really very good]

“How safe are our children?”

The NSPCC report on child abuse and neglect.

 The report can be found here

http://www.nspcc.org.uk/Inform/research/findings/howsafe/how-safe-2013-report_wdf95435.pdf

 and is interesting and well worth a read. It is quite stat heavy, but there are decent graphs which make the points well, and they set out how the stats were arrived at. (One of their core ones, I have an issue with, but will deal with that a bit later on)

The latter bits of the report set out the risk indicators for children, nearly all of which are not likely to come to a shock to anyone working within the family justice system.

You are more likely, as a child, to be physically abused or neglected if these factors are present in your family :-

Domestic violence, substance misuse, parents with mental health problems, parents with learning difficulties, children with physical or mental impairments, children from certain ethnic or minority backgrounds,  parents who suffered abuse themselves as a child, and poverty.

 The poverty one is interesting, because it is the elephant in the room at the moment. Is part of our child protection system, as might be argued by John Hemming and perhaps Dr Dale, a punitive way of dealing with the poorest members of our society (and perhaps even a redistribution of children from those who have them, to those with greater means and income who would adopt them?)

 Also of course, from everything we know about the political climate of the country at present, poverty is only going to get worse over the next few years (unless you were on the Board of HBOS or are a stockholder in Vodafone, Starbucks, Google et al)

 Here’s what the report says about poverty as a risk factor [underlining is mine, as I think this is a VITAL point]

 Children living with poverty, debt and financial pressures

Why is this a risk factor?

Although there is no evidence to show that poverty causes child maltreatment, poverty and child maltreatment share many similar risk factors. Numerous explanations try to explain the relationship between poverty and child abuse and neglect. The impact of the stress associated with poverty and social deprivation on parenting is the most common explanation.

Researchers have found that parents with a low income are four times more likely to feel chronically stressed than parents with higher incomes. Stress levels of parents living in poorer neighbourhoods have been shown to be high. One study identified a “strong relationship between parents’ levels of stress and greater use of physical discipline”. Another associated being in a lower socio-economic group with a more significant level of physical discipline and abuse.

An analysis of women’s childhood experiences of abuse and neglect found evidence that women from poorer childhood homes were twice as likely to have suffered from abuse or neglect and three times as likely to have suffered from more than one form of abuse than those from more well-off childhood homes. Emerging findings from research in England highlight the impact of poor and inadequate housing on families and poor housing is a common characteristic of families in poverty. The unsafe environment and the impact of parental stress have been found to be factors in some SCRs and where children are subject to child protection plans.

 

This does not mean that parents who are poor will abuse or neglect their children. The relationship has been described as “circular and interdependent as opposed to linear and causal”.

 

What we know about prevalence

The Institute for Fiscal Studies estimates that the number of children living in relative poverty in the UK85 was around 2.5 million in 2012, rising to about 2.9 million in 2015.86

 

 Being poor doesn’t mean that you will neglect your children, but being poor of course means that you are much more likely to have to make difficult choices about budgeting and poor choices have a much more detrimental effect.  (If you are choosing between whether to spend £80 or £110 one week on food shopping for the next week, choosing the latter one week doesn’t massively affect your family, but if you are choosing between whether to spend £15 or £25 on shopping that week, and perhaps to spend the extra £10 means not having the heating on, those choices do make a proportionately greater difference to the wellbeing of the family.

 There is an interesting tack in the main body of the report. The NSPCC calculate that for every child known to the authorities to be suffering from abuse or neglect, there are another 8 who are not known.   [This is the statistic I am most cautious about, since it is drawn from an extrapolation of their 2011 study that showed children self-reported abuse or neglect  (6% of over 11s, and 2.5% of under 11s) and applied that to the population at large. For me, I would need the 2011 study to be much larger and more robust before you could start extrapolating it to the population at large – for example, if you are asking a 14 year old whether they have been seriously mistreated by their parents in the last year, that 14 year old’s idea of serious mistreatment might be very different to society’s idea of it. There might well be days when almost any 14 year old would say that his parents were mistreating him]

 But, setting aside my quibble about the number of children who are the bottom part of that iceberg, under the surface and unknown to professionals, the NSPCC say this

 The gap is unlikely to close

Could services ever reach all maltreated children? Even if this were desirable (and few would consider this level of state intrusion into family life appropriate) it is very unlikely in the current context. If children’s social services were to become aware of just one quarter of those children who were maltreated (but not currently known to them), we estimate the number of children subject to child protection plans or on registers in the UK would triple. The resources required for this would be significant: an estimated additional £360 million to £490 million in public spending. In today’s fiscal climate this kind of investment is unlikely; to close the gap altogether is highly improbable. Nor is this the most effective approach. While it is vital to support children and adults in speaking up about abuse, in order to stop abuse in its tracks, this will never be enough to prevent children from being harmed in the first place.

 

 

This seems to be a bold, if pragmatic, thing to say about child abuse. Particularly for an organisation has been campaigning for the last few years on the basis of ending child abuse.  Cruelty to children must end, FULL STOP (remember?)

They are now accepting that society simply can’t end it or stop it. There will always be child abuse and neglect.  And as they point out, even if you raised detection levels to a much higher point, that would have a huge and detrimental impact on freedom and privacy and family life, and the resourcing of the services would be utterly unmanageable for our society to fund.

 So, are the NSPCC throwing in the towel?  Unsurprisingly, not. What they instead posit is moving towards the very early period of child abuse and neglect and nipping that in the bud before it escalates into more serious problems.

 We need a different approach to child protection

 

Which is why a different approach to child protection is needed, one that does more to prevent abuse “upstream” rather than intervening to stop it once it has already happened. Most public spending goes towards picking up the pieces rather than into “upstream” prevention. The National Audit Office estimates that only 6 per cent of public expenditure is focused on stopping problems from emerging in the first place.

 

While intervening to address abuse once it is known will always be a moral and legal imperative, child abuse and neglect will never be substantially reduced unless we become smarter at preventing it from happening at all.

 

Understanding the circumstances in which children are at increased risk is essential for prevention. Research points to the personal characteristics, family circumstances and environments that place children at greater risk of abuse and neglect. In Part 3, we set out the available evidence on this, highlighting nine key risk factors. There is no direct causality between these factors and abuse; they are not predictive of maltreatment. But by recognising that children living in such circumstances are at heightened risk, greater support could be directed towards families to reduce the chances of abuse and neglect from occurring at all. While this support comes at a price, it is ultimately more cost-effective to prevent abuse from occurring than to meet the many costs that fall across society because of the damage caused to children who were abused or neglected in their childhood.

 

Wider society also has an important role to play. Abusive behaviour cannot be stamped out by the state alone; individuals, families and communities must also be responsible for the change. Most adults think parents, families, friends and neighbours have a responsibility to prevent child abuse – and that greater responsibility lies with these groups than with government.

 

So while government can do much to influence the conditions in which children live and while professionals play an important role in intervening to protect children and helping those who are at risk of abuse, wider society has a responsibility too. However, all too often people frame this responsibility in terms of being willing to act if worried about a child, rather than being willing to address faults in their own or others’ behaviour. Perhaps it is time to reassert our responsibilities to children as citizens.

 

 

I can’t say I’m sure how the NSPCC vision here gets translated into action, but I think it is a legitimate and interesting debate to have as a society.  I thought the report as a whole (although I don’t agree with every aspect) was a challenging and thought-provoking document.

 There are some very mind-boggling figures in it

 There were a total of 21,493 sexual offences against children recorded by police in the UK in 2011/12.*

 There were 4,991 rapes of children recorded by police in England and Wales in 2011/12.

 There were 7,812 cruelty and neglect offences recorded by police in the UK in 2011/12.

In England, justice is open to all, like the Ritz Hotel

Is there a difference in family justice provided to middle-class parents? A discussiony paranoidy rant…

As you may know, the title of this piece is drawn from a remark by an English Judge, Sir James Mathew and was made in the Victorian era. It is intentionally barbed.

It had quite a flurry of revival in popularity  last year, as the Government debated and then implemented legal aid cuts that removed free legal advice from large chunks of the most vulnerable in society.

Private law

In terms of private law dispute, my initial question is likely to be true, sadly, as we go past April 2013.  After that time, a parent who is denied contact is going to struggle to get their case off the ground and into court unless they are (a) literate (b) articulate or (c) a person of financial means.      One might be cynical and say that the three things are interwoven, and that having three possibilities isn’t much use if they mostly capture the same group.

Of course, a person can represent themselves in court proceedings and a great many people do very well at it.  (I’d recommend Lucy Reed’s book “Family Courts without a lawyer”  for anyone who wants to do this  http://www.amazon.co.uk/Family-Courts-without-Lawyer-Litigants/dp/0956777406/ref=sr_1_1?ie=UTF8&qid=1359383824&sr=8-1 )

But even then, the litigant in person will either need to pay the Court fee for a contact application, which will be £200, or (if they are of limited means) navigate the byzantine system by which you can avoid paying the Court fee if you can satisfy an unsatisfiable bureaucracy of your entitlement to do so, a task which exhausts many private law solicitors who are well accustomed to trying.

[A bit like the Groucho Marx line that banks will lend money to people who can prove beyond doubt that they don’t need it]

Moving beyond that, you will as a wealthy or moderately wealthy person, have an option, a choice, which is denied to the non-middle class.  You can decide whether to represent yourself or have a specialist used to navigating the courts, who speaks the same language as the judge, who can advise you.  That’s a choice that won’t be open to someone who is not middle-class.  [using middle-class as shorthand for someone who has a professional job which pays them average or better income, regardless of family background and such  - of course there are plenty of plasterers who earn more than bank clerks.   Perhaps the class debate is better expressed as ‘haves or have nots’ but is a shorthand for this piece]

If you are faced with allegations of violence or abuse, you won’t get a lawyer to represent you and defend you against them unless you have money. The other parent, the one making them, might well get a lawyer, even if the allegations are false.

More and more private law cases these days are descending into these sorts of allegations, and probably more and more will in the future, as the funding system says that making them gets you a lawyer, whereas defending yourself against allegations that you say are false, doesn’t. 

Care proceedings

What about care proceedings though? The law says that if you are a parent and the State might be intervening in the way you bring up your child and might be contemplating your child no longer living with you, you would be entitled to free legal advice.

Everyone is on a level playing field then.  Family justice is like the Ritz, it is open to everyone.

But how true is that, really?

Here are some names that you will have seen in care proceedings, often many times, if you work in this field  – Zac, Jordan, Chantelle, Destiny.

Here are some names you have probably NEVER seen in care proceedings, Oliver, Crispin, Sophia, Harriet.

You might well say, and you’d be partially right, that a large tranche of care proceedings relate to neglect, and neglect in part springs from poverty.  So, a middle-class family don’t face the same social problems as a poor family, since they have choices and options.

A middle-class parent who struggles with managing household tasks has an option to get a cleaner, or to have someone do the ironing, they don’t have to prioritise between food and electricity, or gas or a toy for their child.

I would argue that not all poor families end up neglecting their children, and that it is possible, and indeed the vast majority of poor families do it, to get their children brought up in clean, safe and loving environments despite a lack of resources.

But it is certainly true that you’re at far greater risk of living in neglect if money is very tight than if you are affluent.

 

[Subsequent to writing this, I came across an excellent blog post in Community Care on why more poverty does not mean more neglect :- http://www.communitycare.co.uk/blogs/childrens-services-blog/2013/01/poverty-does-not-equal-neglect-benefit-cuts-will-not-see-more-children-taken-into-care.html   and is an interesting counterpoint to this debate. I don't think we are miles apart, though I think if you increase the basic numbers of families in poverty, you may well increase the numbers of those families who don't manage that sort of poverty well enough]

[This is reminding me of one of my favourite books, George Orwell’s “Down and Out in Paris and London”

It is altogether curious, your first contact with poverty. You have
thought so much about poverty–it is the thing you have feared all your
life, the thing you knew would happen to you sooner or later; and it, is
all so utterly and prosaically different. You thought it would be quite
simple; it is extraordinarily complicated. You thought it would be
terrible; it is merely squalid and boring. It is the peculiar LOWNESS of
poverty that you discover first; the shifts that it puts you to, the
complicated meanness, the crust-wiping….

 

And there is another feeling that is a great consolation in poverty. I
believe everyone who has been hard up has experienced it. It is a feeling
of relief, almost of pleasure, at knowing yourself at last genuinely down
and out. You have talked so often of going to the dogs–and well, here
are the dogs, and you have reached them, and you can stand it. It takes off
a lot of anxiety.

I have been, in case you doubt, exceedingly poor, as both a child, and as an adult, and recognise what Orwell says, particularly in his passages about how when you are truly truly hungry, nothing else in the world much exists than that hunger, that preoccupation with food and filling your belly with something.

So, perhaps the care proceedings net doesn’t cast over the “Haves” because neglect isn’t much of an issue in the “Haves” world.

But what about violence, what about sexual abuse, what about alcohol abuse?

I’m fairly certain that the disease of alcoholism, and the effect that it has on parenting, is not a class issue – it can take anyone.   In fact, I have worked, in the past, with people who drank a bottle of wine a night or more, and who would on that basis fail the sort of psychiatric examinations that we were sending parents to.

I have also encountered paedophiles from all walks of life – yes, very many were from damaged and impoverished backgrounds, but many others were teachers, professionals, doctors.

And I fail to believe that it is only poor people, only ‘common’ people, only ‘rough’ people, who reach the end of their tether, lose control and do something to a child that they should never have done.

There’s sort of a feeling, an unspoken one, in the Court rooms of this country, that child abuse is not done by people like us, that it belongs to a different world, another one, that we can look at, and judge, but not one that we truly belong in. There’s very little “there but for the grace of god” in child abuse cases.

As we know, and must remind ourselves, “The plural of anecdote is not data” and therefore it is of only  limited (or indeed no) evidential value that most of the times I have seen parents with middle-class jobs, accents, bearing and relations, facing allegations of physical mistreatment of children, a reason has been found as to why the medical evidence is wrong, and why they can be exonerated.

Efforts seem, again anecdotally to me, to be found by a mixture of professionals  (and again, I don’t claim that this is a conscious or deliberate action) to be more amenable to accepting that people like us couldn’t have done these dreadful things, than when similar things are alleged of people who live in a different sort of world to our own.

I don’t know how one could do the research on whether the outcomes for middle class parents are better for them than those for other parents – there’s no box on the application form for “Is the parent a bit posh?”    or “Do they shop at Asda or Waitrose?”   “Do they say napkin or serviette?”   but I’d like to see some, if someone wants to set out to do it.

So there is  at least the possibility of an unconscious bias of favouring or being more amenable to accepting the evidence given by people like us.

Can it go even further than that? To the overt stage, where actual cash, actual financial resources buys you a greater opportunity in a family case?

I don’t mind bribery, obviously. I don’t think that bribery plays any part in English justice. Call me naive if you want, I just honestly don’t believe that.

I had recently a conversation which prompted me to think about this piece, about a case (not one I was involved in, even tangentially and not necessarily a recent one) of suspected non-accidental injury, where the parents wanted to get a further piece of medical evidence, a fresh report. The Judge refused it, for good reasons about delay and proportionality.

The parents then pipe up that they could pay for the report themselves, rather than through legal aid, and lo and behold, there’s a reconsideration and the report is directed.

The justification, perhaps not unreasonably, is that the report is likely to be accelerated, expedited, on-time, if the expert knows that people are paying for it privately.  So the delay might not be so long, and the expert report will probably not hold the case up so much.  And of course, in the world we operate in, the Judge knows that the parents writing a cheque saves at least 2-3 weeks of messing around with the Legal Services Commission and prior authority, so the report probably will get done quicker.

Is that okay, or does that feel wrong?

It feels wrong to me that a person gets the chance to have a report not because of the merits of their case or the circumstances of the case, but because they, unlike someone else, can write a cheque and get it done.

[I couch all of this with the caveat that it wasn’t my case, I wasn’t there, I don’t know the detail – there may well have been very compelling reasons I am unaware of to have taken that course of action, but even just looking at it in the theoretical sense, would it be right in this hypothetical case below to allow the report?

 

Doctor says “I can do the report in 12 weeks, on public funding, but if it is paid for at my private rates, which are higher, I can do it in 5” 

 

If the Judge was going to refuse the report on basis that 12 weeks delay was too long, should she allow it in 5, if the parents are able to pay for it privately?    Or, is refusing it, if 5 weeks is considered reasonable delay, unfair just to preserve equality with some notional other parents who couldn’t pay the private fees?]

 

 

Can you go off and pay for your own expert without the Court’s permission?

Well, there have been some important decisions about that.  Firstly, you need leave of the Court to give the papers to the expert, and then  if you get leave of the court to instruct an expert, you have to cough up the report even if it is not favourable to you (unlike in crime)   [Re L : A Minor : Police Investigation : Privilege 1996 1 FLR 731 and then Re V (Care Proceedings : Human Rights Claims 2004 1 FLR 944]

 

If you don’t get leave of the Court and go off and get the report anyway, it still has to be disclosed.

[If there are ongoing criminal proceedings, the parent can keep those reports secret and even refuse to say if there are any expert reports and who has written them, and can keep legal privilege when discussing those reports with their care lawyer  S County Council v B 2000 2 FLR 161]

One clever way around this was tried in RE J (Application for shadow expert) 2008 1 FLR 1501

Where the applicant sought permission not to obtain a report that would have to be disclosed whether it was positive or negative, but instead an expert to basically advise the lawyer and formulate good questions for cross-examination and be a sounding board for the barrister’s theories. 

The Court felt that this was not appropriate and would not be granted. And of course, it would only have been a course open to someone paying for the report privately.

Can you get a better barrister by paying money?

A parent relying on a barrister who is being paid with public funding (or what all sane people call “Legal Aid”) will get proper advice, from someone who works hard and does their best and is bright.  All barristers who have experience in care proceedings do legal aid work, so you can’t get some better barrister, better advice by paying privately.  There’s not a Premier League of barristers who know about care but don’t do legal aid work.

I would NOT, for a second, suggest that the average barrister works harder or better on a case that they are earning more money on, I don’t think money comes into it. Honestly, I don’t.

But what you can get, potentially, is a QC.  If you are willing to pay for it, you can get a QC in a case that the LSC (legal services commission, or what sane people call the legal aid board) would not let you have one for free. 

That QC is the best of the best, and may give you an edge in the case.  Though some barristers who don’t have QC after their name are better advocates than some QCs, in general, a QC is going to be better.

It may well send a subliminal message to the Court about your case and the quality of it. Certainly there’s always an impression that the Court treats a QC with more respect than a run of the mill advocate.

Or you may not even need to go that far. Suppose you think about your barrister doing your case for public funding – they will work hard at your case, and put in effort. But they have another case the week before where they are doing that, and another the week after.

Might you get better representation from the same barrister, if you were willing to pay them to take two or three days off the week before your case to prepare?

We can’t know for certain, but I’d suggest that we all work better when we’re not shattered.

That’s an option available to those who have money that doesn’t exist for those who don’t.

Ring your solicitor up and say “I think my barrister should really only work on my case and nothing else the week before the hearing”, and you’ll get this answer if you have no money “That’s a nice idea, but I’m afraid it doesn’t work like that”   – and if you have lots of money, this answer  “They don’t normally do that, but we could see if they would – it would be very expensive though, you’d be paying for seven days of their time instead of five. Do you want me to speak to them about it?”

So, is English family justice really like the Ritz, or am I just crackers?

Neglecting neglect

 

The Parliamentary report on child protection, and a discussion of it.

One of the nice things about doing this blog is that some of my visitors will from time to time send me something that I might otherwise have missed.  I knew that this Parliamentary enquiry had been going on, but not that the report had yet been published.

 

You can find it here:-

 

http://www.publications.parliament.uk/pa/cm201213/cmselect/cmeduc/137/137.pdf 

 

 

They seem, on the whole, to be broadly supportive of the system, which is no doubt a disappointment to many of my readers.  They do recognise that there are serious problems within it, and make some recommendations.  They particularly felt, as the mainstream media picked up, that the child protection system isn’t a great fit for adolescents and that they get marginalised by the process.

 

 

One of the topics they looked at was neglect  (see also all of the blog posts I’ve done recently on the neglect and neuroscience issue)

 

Neglect

 

Neglect is the most common form of child abuse in England. Having looked at both the criminal and civil definitions of neglect, we recommend that the Government investigate thoroughly whether the narrow scope of the criminal definition contained in the Children and Young Persons Act 1933 is causing problems in bringing criminal cases of neglect, but we have seen no convincing evidence that the civil definition is insufficient.

 

To get a better picture of the scale of neglect, we recommend that the Government commission research to investigate whether similar situations and behaviours are being classified as neglect in different local authorities.

 

There is evidence that children have been left too long in neglectful situations. To tackle this, child protection guidance for all front-line professionals should include an understanding of the long-term developmental consequences of neglect and the urgency of early intervention. Securing positive outcomes and meeting the needs of the child should come before all other considerations, and there needs to be a continued shift in culture so that there is earlier protection and safeguarding of the long-term needs of children. The Government must be prepared to act if there are signs that improvement in the responsiveness of local authorities to neglect is not being sustained.

In cases of domestic violence, the focus should be on supporting the abused parent and helping them to protect their children, but the interests of the children must come first.

 

 

It did seem to me (subject to rigour in how the research is done) that a piece of research on how neglect is managed throughout the country, and whether there are fluctuations in what is considered to be neglect in different regions, is a valid and worthwhile exercise.  Child protection is a massively expensive and resource-intensive undertaking in this country, and if there are lessons that could be taken from the way certain local authorities tackle and overcome neglect, that would be useful information to share around.

 

 

They also looked at the issue of adoption, and in particular the competing current desires of the Government to speed up adoption and the campaigners against ‘forced adoption’

 

216. We endorse the Government’s current policy emphasis on increasing the number of children adopted, speeding up the process and facilitating foster-to-adopt arrangements. Adoption is clearly the preferred route to permanence and stability for some children. However, the same goal can be achieved by other means and it is vital that the Government and those in local authorities continue to concentrate effort and resources on prioritising stability in placements for all children, whether through longterm fostering, Special Guardianship or residential care. We would welcome greater debate on policies which might bring this about and greater encouragement from Government for these alternative solutions. In particular, while we recognise that an artificial limit on the number of times a child can be moved within the system would be unworkable, there should be increased emphasis in central guidance aimed at limiting the disruption and damage caused to vulnerable children by frequent changes.

 

217. We have listened with sympathy to concerns about widespread ‘forced adoption’, and to the very personal and moving stories that often lay behind them. It is evident that there are rogue misjudged cases with terrible consequences for those involved. This should not happen and those affected are right to fight against such injustice. Nevertheless, the weight of research evidence, matched by evidence to our inquiry, concluded that that the balance tended to lie with authorities not taking children into care or adoption early enough, rather than removing children from their parents without due cause.

 

We note that the Minister spoke of “work in progress” to look at “what further safeguards we might be able to institute whereby there is a sort of appeals mechanism”. This would have to be balanced against the further delay to a permanent solution for the child which would inevitably occur as a result.  An appeals mechanism against “forced” adoption is an interesting idea and we look forward to examining the Minister’s proposals when they are published.

 

 

As do I.

 

I’m rather surprised that the Minister spoke to them about introducing a ‘sort of appeals mechanism’ given that there is already an actual appeal mechanism.

 

So either :-

 

(a)   He doesn’t know that there is already  an appeal mechanism

(b)   He is planning to lower the test for appeals in Placement Order or adoption cases, from mistake in law or the Judge being plainly wrong to something lower

(c)   He is planning to introduce a mechanism whereby the Placement Order or adoption order can be appealed at a different stage in the process  (which would have to be later than at present)

OR even

(d)   That there is a plan for an appeal mechanism for Placement Orders which will sit outside of the legal appeal process, i.e that the appeal would be considered by a body outside the judiciary, and contemplating different principles than at present.

 

 

I’m not sure which of those possibilities I find most problematic, but any of them without a lot of proper thought first is worrying.  

 

 

I noted in the passage above that that the Committee touched upon the evidence of Martin Narey

 

215. The importance of permanence and stability is underlined by the shocking evidence we received of the number of times some children move in the course of their time in care.

 

It is clearly damaging to children to move from one form of care to another frequently; and yet we spoke to children who had moved multiple times—in one case up to 16. Martin Narey told us that he had “met countless children who have had 24 or 25 foster placements and 21 or 22 different schools”.396 He added: “We would never dream of doing this to our children and for some children the very best option for them is [...] high quality residential care”.397

 

 

 

Well, I agree with all of the principles set out there, and I am sure that the Committee really did speak to children who had moved up to 16 times, which is an awful and horrific tragedy. I am also sure, sadly, that there have been children in the care system who have had 24 or 25 foster placements.

 

I am somewhat sceptical, to put it mildly, that Mr Narey has met “countless” such children.  I think this is rather on a par with his comments about having asked to see a child’s social work files which were then literally brought into the room in a wheelbarrow.

 

I don’t think this sort of hyperbolae helps, when it comes from someone helping the Government form really important policy.

 

Every child who has multiple placements is a bloody tragedy. Those children who have had dozens or more are a huge tragedy. Every child who has had 24 foster placements is a disgrace   (there might well be really strong underpinning reasons, usually connected with the child’s damaged behaviour but that doesn’t stop the outcome being disgraceful)  and we really should learn as much as possible from it and stop this happening to any child in the future.  But to suggest that it is happening to so many children that Martin Narey has met “countless” is I think rather disingenuous.  

 

Or perhaps my concept of countless is more than Mr Narey’s – it depends on how good you are at counting, I suppose.

 

[All just my personal opinion, perhaps Mr Narey really has met over a thousand children, which would be around where I’d consider a number to be countless, who have had 25 placements.  I guess if he is disputing my suggestion that he hasn’t met ‘countless children’, he would need to show that he had met a significant number, which would mean him counting them, so they couldn’t then  be countless...]

 

Let me be plain, I consider that a single child who has 24 foster placements is a child too many. I just don’t care much for hyperbolae when giving evidence.

 

The Committee also talked about newer and more specialised forms of abuse and risk, they considered the technological side of things with paedophilia over the internet, child trafficking, child prostitution, forced marriage, and suggested that there was a need to build up specialist expertise in this area, and for those authorities who were encountering it to share their expertise with others

 

We recommend that the College of Social Work take a leading role in co-ordinating and promoting awareness of CPD training in specialised forms of abuse and in encouraging other disciplines to participate in relevant courses. For more general use, if the guidance on specialised forms of abuse is to be deleted from Working Together, the Government needs to make clear where such guidance will be found in future and how it will be updated and signposted to social workers and other professionals. (Paragraph 133)

 

17. We are also concerned that professionals faced with a specific type of abuse with which they are not familiar should have an identifiable source of expertise to consult in person. Local authorities should nominate a specialised child abuse practitioner to lead on such matters. Where an authority has a low incidence of a particular form of child abuse, they should be able to draw on the expertise of nominated practitioners in other authorities. (Paragraph 134)

 

 

 

I think the most controversial paragraph, and certainly the one which will provoke ire in some quarters, will be this one:-

 

 

We welcome the research by Cafcass into applications for care orders and recommend that this work be repeated on a regular basis. An assessment of the reasons behind the local variability in care applications is needed. We also believe that it is essential to promote a more positive picture of care to young people and to the public in general. The young people to whom we spoke were generally very positive about their experiences, including those who had spent time in children’s homes. This is backed by academic research on outcomes. Ministers should encourage public awareness of the fact that being taken into care can be of great benefit to children.

 

In the words of Bill Hicks – “it’s not a popular opinion, you don’t hear it very often”

 

 

Perhaps in that vein, the next Commons Committee will be on “Assessing the Costs and Benefits of using terminal ill people as stunt doubles.”

 

[And I know that makes no sense to you whatsoever if you’re not familiar with the work of Mr Hicks  “I know to a lot of you this might sound a little cruel… ‘Aw Bill, terminally ill stunt people? That’s cruel’…. Well hear me out..”]

Neurology, new neurology, old neurology, neurotic neurology… let’s have a heated debate!

Am beginning to think that I should move into the new field of paediatric neurology law blogging, as it seemed very popular last time.   [Although I am going to have to work harder on titles if I have to do a fourth, because I'm running dry]

This is my third post on this issue.

The last one was here:-

http://suesspiciousminds.com/2013/01/14/semantics-pedantics-and-neuro-mantics/

 

Which was about the Wastell and White report suggesting that too much political weight is being placed on headlines of neuroscience research when the actual research is more fragile than the headlines would suggest.

You may recall that the thrust of that was whether the impression that is being disseminated that neuroscience is at one on the principle that neglect in early childhood can cause longstanding harm to children, possibly even irreparable harm in the first years of life, is a genuine one on which important decisions can rightly be taken, or whether there is a schism within neuroscience which might need resolution before we start constructing metaphorical housing estates on those foundations.

The key debate seems to be about plasticity of the brain in an infant – is that damage long-lasting and irreparable, or does the brain form new structures and overcome it (obviously ideally with the neglect ceasing and positive parenting being in place) ?

I don’t think anyone would argue that children suffering neglect is BAD, the issue here is whether science is now showing that it is FAR MORE BAD than we had previously believed. 

As a result, a kind subscriber has sent me this new report “The Foundations of Life” compiled by Harvard University, which is firmly in the Family Justice Review camp, of neglect causing much greater and more irreparable harm than had earlier been understood.

My initial reading suggests that this is not new research, or commenting on fresh experiments or studies, but again a drawing together of existing research and formulating conclusions from it.

That report can be found here: -

http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/foundations-of-lifelong-health/

There is a summary of essential findings, which I shall set out here.

(The analysis of whether those findings are made out from the research is a task beyond me, but some of my new readers who have lovely neurosciency brains will probably set to work on considering that).

Advances in molecular biology, and genomics have converged on three compelling conclusions:

Early experiences are built into our bodies.

Significant adversity can produce physiological disruptions or biological “memories” that undermine the development of the body’s stress response systems and affect the developing brain, cardiovascular system, immune system, and metabolic regulatory controls.

These physiological disruptions can persist far into adulthood and lead to lifelong impairments in both physical and mental health.

Messages for Decision-Makers

The biological sciences have two clear and powerful messages for leaders who are searching for more effective ways to improve the health of the nation.

First, current health promotion and disease prevention policies focused on adults would be more effective if evidence-based investments were also made to strengthen the foundations of health in the prenatal and early childhood periods.

Second, significant reductions in chronic disease could be achieved across the life course by decreasing the number and severity of adverse experiences that threaten the wellbeing of young children and by strengthening the protective relationships that help mitigate the harmful effects of toxic stress.

A New Framework for Early Childhood Policy and Practice

The following four interrelated dimensions offer a promising framework for innovative approaches to improving physical and mental well-being. The biology of health explains how experiences and environmental influences “get under the skin” and interact with genetic predispositions, which then result in various combinations of physiological adaptation and disruption that affect lifelong outcomes in learning, behavior, and both physical and mental well-being.

These findings call for us to augment adult-focused approaches to health promotion and disease prevention by addressing the early childhood origins of lifelong illness and disability.

From the report itself, this is interesting – the suggestion that child abuse should start being treated as a public health issue, and treatment programmes designed and delivered.

Child Welfare.

For more than a century, child protective services have focused on issues re¬lated to physical safety, reduction of repeated injury, and child custody.

Now, recent scientific advances are increasing our understanding of the extent to which the toxic stress of abuse, neglect, or exposure to family or community violence can produce physiological changes in young children that increase the likelihood of mental health problems and physical disease throughout their lives.

Based on this heightened risk of stress-related illness, science suggests that all investigations of suspected child abuse or neglect should include a comprehensive assessment of the child’s cognitive, language, emo¬tional, social, and physical development, followed by the provision of effective therapeutic services as needed. This could be accomplished through regularized referrals from the child welfare system (which is a mandated service in each state) to the early intervention system for children with developmental delays or dis¬abilities (which provides services under an en¬titlement established by federal law).

Although the most recent federal reauthorizations of the Keeping Children and Families Safe Act and the Individuals with Disabilities Education Act both included requirements for establishing such linkages, sufficient funding has not been provided, and the implementation of these requirements has moved slowly.

The availability of new, evidence-based interventions that have been shown to improve outcomes for children in the child welfare system168 underscores the compelling need to transform “child protection” from its traditional concern with physical safety and custody to a broader, more science-based focus on health promotion and disease prevention.

The Centers for Disease Control and Prevention has taken an important step in advancing this issue by promoting the prevention of child maltreatment as a public health concern.169,170

I remain in the dark as to whether the current path we are on, of policy decisions being taken, and perhaps individual ones too, on the basis of neglect being irreparably harmful to infants and that our timeframe for making decisions is much more narrow than previously believed, is the right one and that we have some mavericks suggesting otherwise, or whether the current trendy thinking on that is wrong and the naysayers are actually pointing out that this emperor has no clothes on.

I would like someone to find out. Or perhaps we lawyers just have an over-optimistic view of the social sciences, and think that there is a definitive answer out there to be found out (like there really is a definite number for the co-efficient of the expansion of brass and that every scientist in the field would agree on what the number is, and how you could prove it). Maybe there isn’t.

Perhaps the truth of the world of neuroscience is that we are still stumbling in the dark and that every theory is going to have its proponents and opponents.

In which case, we perhaps ought to know THAT, and not be treating the findings and theories of neuroscience as though they represent the final word on any given subject.

Semantics, pedantics and Neuro-mantics

A discussion of the  fascinating “Blinded by neuroscience – social policy, the family and the infant brain”  paper by David Wastell and Sue White

I was sent this compelling and interesting paper by a colleague, and it makes an interesting companion piece to the official family justice research paper on neglect, which I blogged about here :-

http://suesspiciousminds.com/2012/11/05/taking-neglect-seriously/

The paper can be found here :  –    (you need to click on the PDF to read it, but it is free)

http://www.ingentaconnect.com/content/tpp/frs/2012/00000001/00000003/art00008?token=005015070f39b6e58654624315142576b7921766b3c252e5e4e2663433b393f6a333f256698c60b5

Now, why this is interesting generally, rather than just specifically because it is an interesting paper, is because the authors are positing that the Government is about to go in a direction based on scientific research that neglect :-

(a)   causes much more long-standing damage on children than previously understood

(b)   that poor quality of care in the early years of a child’s life causes damage to the structure of the brain which is hard to overcome

(c)   and that as a result, earlier intervention, and where necessary removal is the way to tackle this

And of course, the very first piece of research published by the Family Justice Review team is on these very issues, and although it doesn’t advance as far as (c) explicitly, it certainly comes up to the shoreline and says that speed of decision making is critical and that children under two can’t wait for decisions. It certainly endorses unequivocally the viewpoint that science has demonstrated (a) and (b)

What this article does, is question the scientific studies and research that lead to (a) and (b) and suggests that a careful analysis of the source material suggests that it is not so concrete as the FJR research suggests. And if (a) and (b) are not solid foundations, moving to (c) as the public policy seems to be doing at present may be even more risky than it appears.

[As a sidebar, this argument of if (a) and (b) are right, is (c) right, reminds me of Lewis Carroll's dialogue between Achilles and the Tortoise, and you can find that here, and shows that you simply can't prove anything at all with logic, if you are arguing with a smart-arse :-   ]

http://www.ditext.com/carroll/tortoise.html

achilles

In detail, the authors of this paper suggest that the thinking the Government are working on, that the infant brain is readily susceptible to permanent and irreversible damage from poor care, is wrong and that the truth is rather that the infant brain is resilient and has a plasticity  (by which they mean it is flexible and can adjust and will recover from early delays)

Initial caveat  –  I was concerned by the strident tone of this paper, and I was also concerned that neither of the authors (eminent and smart as they obviously are) are actually neuroscientists.   [That will teach me to judge by the titles that people give at the end, have been contacted by one of the authors, who very politely tells me that he is indeed a neuroscientist - ignore every other time I say that in the piece]

I would be terribly interested to learn whether this is a genuine schism in the field of neuroscience as it relates to children, neglect and brain development in infants, or whether one side or the other is cherrypicking data and quotes.  I simply don’t know. I’m not a neuroscientist, and though I can make sense of what is said by both sides, I am in no position to weigh up who is right.

Having critiqued the strident tone, I suppose that if the authors are right, and the Government is about to lurch into a public policy on neglect, child protection and quick adoptions based on ‘hard science’ when what they believe the ‘hard science’ says is wrong, I might be pretty forceful in my tone too.

Let’s have a look at some detail

We argue that the neuroscientific claims supporting current policy initiatives have receivedlittle critical commentary. They appear to be operating as powerful ‘trump cards’ in what is actually very contentious terrain, suppressing vital moral debate regarding the shape of state intervention in the lives of children and families.

 

In this article, we interrogate the nature of the scientific claims made in key documents and the ideological thrust of policy that they have engendered. We examine Allen’s first report in detail first, before developing a more general critique of what Tallis and others have dubbed neuromania: ‘the appeal to the brain, as revealed through the latest science, to explain our behaviour’ (Tallis, 2011: 5; Legrenzi and

Umilta, 2011). Bruer’s (1999) deconstruction of the ‘myth of the first three years’ will feature prominently in our argument, paving the way for a broader critical analysis of the ‘new’ brain science and its influence on policy. We contend that neuroscience is re-presenting an older ideological argument about the role of the state in family life in terms of a biologically privileged worldview. We suggest that there is a great

deal of difference between ‘early intervention’ as defined in the Allen report and what Munro (2011: 69) refers to as ‘early help’, which includes a much wider range of family support activities. Neuromania, we conclude, is the latest of modernity’s juggernauts reifying human relations into ‘technical objects’ to be fixed by the state (Smith, 2002), which always ‘asks nothing better than to intervene’ (Ellul, 1964: 228).

 

 

Strong words there, and the phrase at the end that the State generally seeks reasons to intervene is resonant.  I feel personally that the State has moved much more towards a paternalistic approach to the lives of its citizens and away from a broad principle that people are autonomous and best placed to make decisions for themselves save in very narrow circumstances, and that the law has done the same in recent years.  People’s freedom to make bad, foolish and downright idiotic decisions for themselves has to an extent been eroded.

Criticising Allen’s report, on which a lot of the foundation of the neglect causes irreversible damage in infants is based, the authors say   (their quotes from Allen are in italics)

The importance of secure attachment is invoked:

 

“Children develop in an environment of relationships.… From early infancy, they naturally reach out to create bonds, and they develop best when     caring adults respond in warm, stimulating and consistent ways. This secure attachment with those close to them leads to the development of empathy, trust and well-being. (2011a: 13)”

 

Predictive claims quickly follow regarding the long-term effects of such early attachment patterns, especially the beneficial effects of secure attachment and the dire impact of the failure to cement such bonds:

 

“Recent research also shows insecure attachment is linked to a higher risk for a number of health conditions, including strokes, heart attacks … people with secure attachment show more healthy behaviours such as taking exercise, not smoking, not using substances and alcohol, and driving at ordinary speed.

(2011a: 15)”

 

Two studies are cited as the basis for these ominous claims. But again the evidence cited is perplexing. These are not studies of children, but adults; both use ‘attachment style’ as a way of measuring the adult personality with self-report questionnaires. Neither study shows, nor purports to show, any link between early childhood experiences and

problems later in life. In subsequent paragraphs, damaged emotionality and damaged brains are soon united, and the perpetrator of all this devastation is unflinchingly denounced.

 

Parents are to blame:

 

“Parents who are neglectful or who are drunk, drugged or violent, will have impaired capacity to provide this social and emotional stability, and will create the likelihood that adverse experiences might have a negative impact on their children’s development … the worst and deepest damage is done to children when their brains are being formed during their earliest months

and years. (2011a: 15)”

 

 

If the authors here are right about the studies of attachment and impact on later life, and the flaws that they claim, my faith in the FJR research does wobble.  Again, I am not a neuroscientist, and neither are the authors, but if we are going to be taking the FJR research as agreed research on which the judiciary can base conclusions and decisions, we need to know whether the foundations are solid or built on sand.

Returning to Allen’s report, the following excerpt summarises the final

step of his neurobiological argument:

 

Different parts of the brain develop in different sensitive windows of time. The estimated prime window for emotional development is up to 18 months, by which time the foundation of this has been shaped by the way in which the prime carer interacts with the child…. Infants of severely depressed mothers show reduced left lobe activity (associated with being happy, joyful and interested) and increased right lobe activity (associated with negative feelings).

 

If the predominant early experience is fear and stress, the neurochemical responses to those experiences become the primary architects of the brain.

 

Trauma elevates stress hormones, such as cortisol. One result is significantly fewer synapses. Specialists viewing CAT scans of the brains of abused or neglected children have likened the experience to looking at a black hole.

 

In extreme cases the brains of abused children are significantly smaller than the norm. (Allen, 2011a: 16)

 

Those damaged brains again. For the claim of lasting damage from fear, stress and trauma, Allen cites no specific scientific support. A significant body of work does, however, exist on the possible damage caused by post-traumatic stress disorder, reviewed by Wang and Xiao (2010). Although there is evidence of reduced volume in one brainstem structure (the hippocampus), the seminal research involves war

veterans, not children; follow-up studies have not shown lasting hippocampal damage, and the scant imaging research on children has failed to find such impact. A recent authoritative review (McCrory et al, 2012) comes to much the same conclusion regarding the hippocampus, and another much-mentioned brainstem structure, the amygdala; only under conditions of prolonged rearing in orphanages is diminished

brain size evident (see below).

 

Digging into the specific (frontal) lobe evidence invoked by Allen, he cites a paper by Dawson et al (1994), which reviews psychophysiological studies of the children of depressed mothers. Dawson’s evidence, however, actually goes in the opposite

direction to that claimed in the Allen report. Referring to a study on the reactions of children when mothers left the room: ‘the infants of symptomatic mothers exhibited an unexpected pattern of greater left than right activation during the maternal separation condition’ (Dawson et al, 1994: 772). More ‘positive’ emotion it would seem. In truth, there is a vast gallimauphry of neuroscience research, but little settled knowledge. Evidence for policy making does not simply repose in journals ‘ready to be harvested’ (Greenhalgh and Russell, 2006: 36). Rather, it is ‘rhetorically constructed on the social stage so as to achieve particular ends’ (Greenhalgh and Russell, 2006: 37). This seems an apt enough description of Allen’s modus operandi.

 

Although ‘journal science’ is invoked, he seems not much interested in what it actually says. This is ‘prejudice masquerading as research’ (Furedi, 2001: 155), of science being enrolled to legitimate an a priori ideological position favouring a larger arena for public intervention in the lives of families.

 

(and later)

 

It should now be clear that neuroscientific knowledge is at an early and provisional stage. As Bruer (1999: 98) avers, after more than a century of research we are still ‘closer to the beginning than the end of this quest’.

 

This point was reinforced recently by Belsky and de Haan (2011: 409–10): although the brain ‘packs a punch’ for policy makers, they conclude that ‘the study of parenting and brain development is not even yet in its infancy; it would be more appropriate to conclude that it is still in the

embryonic stage’. Neuroscientists may know the limitations of their research, but such caveats are not what politicians and proselytisers wish to hear;

Again, I am in no position to judge whether what the author’s say of Allen’s report is accurate, fair comment, or a scurrilous attack. I simply don’t know and can’t say.  But what does seem clear to me is that simply ignoring the counter arguments and pressing ahead on the basis that there is clear research with firm conclusions on which future plans can be built is problematic unless that research addresses the criticisms of it head on.

We have much the same problem with the vexed issue of contact levels for infants in care.  I have blogged before about this being presented in the Family Justice Review research as being strong, almost overwhelming views about how high levels of contact are detrimental to infants, and this underpinned entirely the Government consultation on contact, and how there is a contrary view out there and criticism that the research just isn’t robust enough to bear the weight that is being placed upon its branches.  Particularly Dr Peter Dale’s critique of the original research

[See http://suesspiciousminds.com/2012/09/11/family-preservation-versus-child-rescue/                            ]

Again, I am not a scientist or researcher practising in this field, so I can’t resolve those debates and come to a firm conclusion about who is right. But that may well be the problem – neither are the politicians who are setting the course, or the Judges who will be deciding individual cases.

We need clarity as to whether the science on infant brain development is as claimed in the Family Justice Research, or as claimed here, or whether it is simply too early to tell, likewise with the impact of contact on children.

It also raises broader and deeper questions  – when, as the Family Justice Review intends, we collect research with a view to identifying the current state of play in a particular area and what that means for us, how are we, as lawyers, social workers, judges, politicians, in a position to assess whether that research actually shows what the headlines suggest ?   Do we have to get under the bonnet of the individual studies to realise that what was being tested was NOT the central hypothesis, but some ancillary matters from which large extrapolations are being drawn?

I don’t think it is controversial to say that neglect is harmful to children, but if we are working on the basis that science has proven that neglect is not only harmful to children but that such harm carries on into adult life and that harm caused by neglect in the first two years is irreparable, so decisions have to be made very quickly, then we had better be confident about that proof.

I’m not at all saying that the authors here have overturned the research – they are, as I have emphasised a lot, not neuroscientists. But what they have certainly done is gone up to the duvet and said “are you sure that’s someone asleep under there, rather than just some pillows?”

If you do happen to be a neuroscientist, I’d love to have a discussion about this, though it will need to be taken slowly – I’m strictly an amateur.

I’ll conclude with some wise philosophical words, from Descartes via 1980s Manchester

Does the body rule the mind, or does the mind rule the body? I dunno

Take my breath away

A discussion of A Local Authority v A mother and others 2012    (which has to be the most anonymous of anonymisations I have seen to date… I  almost wish they had called it  Some organisation versus Someone 2012  – or  Applicant versus Respondent 2012, you can’t get much more anonymous than that)   – let’s call it “the Asthma case” so that we can remember it.

 

 

The case can be found here

 

http://www.bailii.org/ew/cases/EWHC/Fam/2012/2969.html

 

 

It is a High Court case, dealt with by the Honourable Mr Justice Peter Jackson (of whom regular readers of this blog will know that I have something of a brain-crush on)

It is an interesting one  – the child in question is nine, and has had an extensive history of medical treatment and interventions arising from her asthma

 

  1. The circumstances relating to J are highly unusual. She suffers from asthma, which has since her removal from her parents been well controlled by common basic inhaled steroid medication (Seretide) and occasional use of an inhaled bronchodilator (Salbutomol). Her asthma does not currently impinge on her daily life to any significant extent, although she had one hospital admission for two days in March 2012 for exacerbation of asthma following an infection. She does not suffer from any other life-limiting conditions. Her regular clinical reviews are all clear. Her attendance at school has been excellent and her participation has been full, in the physical and social aspects of school life as well academically. She is currently a well child physically, and there are soundly-based professional hopes that her current medication can progressively be reduced. Asked how she was in July 2012 by the jointly-instructed medical expert Dr H, J said she was ‘much better now’.
  1. A year ago, before her removal from her parents, J’s apparent health status could hardly have been more different. Her asthma was uncontrolled, despite receiving the most extreme treatments available. She was on intensive treatment to combat reported nocturnal desaturations (reduction in blood-oxygen levels). She had also suffered a number of reported Apparent Life-Threatening Events (ALTEs) while in the care of her parents.
  1. J, aged just 8, then described herself as ‘a very poorly little girl’. This is not surprising, because since she was under a year old she had been under continuous medical care and her condition had baffled and defeated the efforts of the country’s leading specialists, despite every conceivable strategy to control her asthma and to diagnose the cause of desaturations and ALTEs. None of the three specialists who gave evidence had encountered a child who has had more varied or intensive treatment.
  1. J’s medical records spanning 8 years run to over 4500 pages (12 lever arch files). The history is set out in full and uncontested detail in the reports of Dr H, referred to above, and Dr C, referred to below. Any summary is bound to be incomplete, but it must include:

A Specialist care

J has had the following care:

  • Primary: her GP
  • Secondary: her local hospital, under Dr O, since September 2004
  • Tertiary: the leading regional hospital, under Dr C, since October 2006
  • Quaternary: the leading national hospital, under Professor B, since January 2007.

B Hospital admissions

Between 2005 and 2011, in addition to countless routine hospital appointments

  • J was admitted to hospital over 50 times, ranging from overnight to a three-month admission in April 2010.
  • these admissions included 22 by ambulance, frequently at night.

C Medical examinations

J has been assessed or examined during planned reviews or emergency admissions by

  • her GP
  • a Paediatric Dietician
  • a Consultant Paediatric Cardiologist
  • a Consultant Child & Adolescent Psychiatrist
  • a Consultant Paediatric Neurologist
  • a Consultant Community Paediatrician (Dr O)
  • a Clinical Psychologist
  • a Consultant Ear, Nose & Throat Surgeon
  • specialist Respiratory Nurses
  • a Consultant in Paediatric Respiratory Medicine (Dr C)
  • two further Consultants in Paediatric Respiratory Medicine at leading specialist hospitals
  • a Professor in Paediatric Respirology (Professor B)
  • a Consultant in Paediatric Intensive Care, Respiratory and Sleep Medicine (Dr H, providing an independent overview for these proceedings)
  • many specialist Registrars locally and across the country
  • numerous other doctors not listed above

D Intensive medical treatment

For her asthma, J’s treatment progressed rapidly through the recognised stages of asthma treatment, in accordance with the British Guidelines on the Management of Asthma, and then beyond those guidelines. The following are prominent among the many drugs that she has been given:

  • inhaled bronchodilators (Salbutomol)
  • inhaled steroids (Seretide)
  • oral steroids (Prednisolone)
  • eventually, unlicensed drug treatments for a child of her age:
    • Omalizumab (Xolair) by highly distressing monthly intramuscular injection
    • Triamcinoline, an intramuscular steroid
    • Methotrexate, an oral steroid to suppress her immune system
    • Terbutaline (Bricanyl), delivered subcutaneously via an infusion pump visibly attached to the body for four months prior to her removal from the parents

For her reported desaturations, J had since 2006

  • slept wearing a positive airway pressure face mask (BIPAP)
  • slept with an oximeter (blood/oxygen level monitor) attached to her toe
  • had a large oxygen concentrator at her bedside

E Tests

J has had

  • sleep studies at three hospitals
  • blood tests and sweat tests
  • an echocardiogram, an ECG and a CT scan (whilst sedated)
  • a barium swallow
  • a bronchoscopy (under general anaesthetic)
  • an ENT investigation, leading to removal of her adenoids

F Side effects

The physical risks from this escalating treatment were substantial. For example:

  • Steroids can cause weight gain and change in facial appearance, slowing of growth, adrenal suppression, and in the long term high blood pressure and diabetes
  • Methotraxate is used in chemotherapy. It carries the risk of nausea, severe infection, liver or renal damage, gastro-intestinal upset and suppression of bone marrow; it requires weekly hospital blood testing to check blood count
  • General anaesthetics carry their own risks

Fortunately there is no evidence that J has suffered lasting physical side-effects, but it cannot be known that she has not been affected in some way in the longer term.

G Pain and suffering

J’s overall treatment is described by Professor B as having been invasive and unpleasant. She was often extremely frightened and sometimes had to be held down. She developed needle phobia. The distress caused to J by the Xolair injections was such that the nursing staff became so concerned that they asked for the treatment to be discontinued, which it was.

H Emotional, psychological and social consequences

J has been profoundly affected by her experiences. Writing this year, an educational psychologist describes her as ‘a youngster who is the product of her life’s experiences which until very recently have been those of a child with a life threatening condition requiring considerable accommodation to her medical needs by J herself and all those in contact with her.’ During each of her three years at Infant School her attendance record was just 55-60%. A child with no apparent learning difficulty, her spelling and reading is delayed by two years or more. Her social development has also suffered severely. She adopts an adult style of conversation, speaking with knowledge and fluency about her medical condition, which until recently has been a fixation for her. She does not relate well to other children, and has had no friends. Dr H described the amount of medical intervention as being comparable to that with a child with leukaemia. He said that J has had ‘a very, very stressful life’.

  1. In the light of the above, it is sad and indeed shocking to record that there is now a firm medical consensus, ostensibly accepted by the parents during the course of this hearing, that most of the treatment that J has received down the years has been unnecessary.

 

 

 

What happened, eventually, is that one of the doctors in the case alerted the Local Authority and recommended that J be placed in foster care, because he was of the view that the extreme treatments this young girl was having were not required by her condition and that her being away from the parents might demonstrate that.

 

To an extent, they did – in foster care, her asthma condition was entirely controlled by the same twice-daily administration of steroids through an inhaler as the parents had been told to give the child.

 

On the face of it, this looked like it might be a factitious illness case (we don’t call them Munchausen’s Syndrome any more, that being rather tainted, and we never did call it the correct name which was Raspe’s Syndrome  – as Munchausen was invented by Raspe and is a fictional character, although actually there’s some doubt as to whether it is a syndrome at all, rather than just being a small subset of behaviour… end of sidetrack)

 

But the thrust of the case and the medical evidence  rather than being whether the girls symptoms were being faked, eventually turned on whether the parents were actually giving this very poorly young girl the twice a day inhaler that she needed. Straightforward, though particularly unusual, neglect

 

  1. The LA’s case, in reliance on unanimous medical opinion, is that the parents failed to administer J’s steroid medication (Seretide and possibly also Prednisolone) to her, either properly or at all, and that this explains why her asthma remained uncontrolled for so long. It also alleges that the parents have misrepresented and exaggerated descriptions of J’s desaturations and ALTEs.
  1. In their written evidence, the parents denied any shortcomings in the way they have managed J’s care. Faced with her statement about not having a purple inhaler, they said that they administered the Seretide to her morning and night while she was asleep. During the hearing, they then admitted that on a significant number of occasions (a quarter, M thought, though F thought fewer) they did not administer steroids and that there were other times when they did try but when J would not accept her medicine. They also stated on the first day of the hearing that they were giving half the prescribed dose of Seretide (i.e. one puff twice a day rather than two puffs), saying that this was as a result of a misunderstanding. They now say that they accept the medical opinion that their failure to administer the correct doses regularly was the cause of J’s uncontrolled asthma.
  1. As to the desaturations and ALTEs, the parents say that these were real and frightening events. Insofar as they may ever have mishandled them, they point to the huge stress of looking after such a sick child, latterly with a new baby in the household. M in particular is described as having been permanently exhausted.

 

 

 

On this key issue, the Judge determined that the parents had not been giving their daughter her medication and that this is what had led to her asthma being so uncontrolled and problematic

 

  1. The evidence in relation to J’s apparently intractable asthma is clear. Over 95% of sufferers have their asthma readily controlled by the use of common safe and effective remedies such as Salbutomol (a reliever of symptoms) and Seretide (a preventer of symptoms). In the remaining number, half are resolved by ensuring compliance with the drug regime and improving inhaler technique.
  1. The probable explanation for J’s uncontrolled asthma is simple. As Professor B put it, there is a strong argument that very little steroids of any kind were being given, in the light of the fact that her asthma has for the last year been controlled by two puffs of Seretide twice a day, and little else.
  1. Dr H considers that lack of adequate Seretide led to poor asthmatic control, and that it was tantamount to no anti-inflammatory drug being delivered to J. Had it been delivered, the escalation of treatment that took place over the years would not have been expected. There has been no change in environmental factors to explain the change in J’s health. The only other explanation for her presentation now is that she has severe asthma that is coincidentally in remission, a prospect that cannot absolutely be dismissed but is remote.
  1. Dr C considers that J cannot have been given her oral Prednisolone either, as this would in her view have delivered a substantial dose of steroid, which J cannot have been getting. In this she differs from Dr H. I do not find it possible or necessary to resolve this issue.
  1. The parents’ account is that they did their best to give J her Seretide (which she did not like) by giving it when asleep, and her Prednisolone by dissolving the tablet and administering it orally by syringe, rewarding J with chocolate for taking it. They missed some occasions, and J sometimes refused, but they honestly thought they were doing what was required and using the required doses.
  1. It was at first thought, including by Professor B, that evidence about prescription uptake strongly demonstrated a gross underuse of Seretide and Prednisolone. On closer inspection, it shows an overuse of Salbutomol and a somewhat lower uptake of the steroids than would be expected, but not such as might lead to any definite conclusion. Likewise, the amount of drugs discovered in the home after the children’s removal does not suggest hoarding.
  1. There are a number of possibilities in relation to the prescription evidence. It is on the face of it not inconsistent with the parents’ evidence that they were giving J the quantities that were dispensed, at the level they thought was being prescribed. Alternatively, the parents may have disposed of unused medication, something that they deny.
  1. Taking the evidence as a whole, I accept the unanimous medical evidence that J was not receiving any Seretide. My findings go further than the parents’ concessions:

(i) I reject their case that they were routinely giving J Seretide while J was asleep, a convoluted and inconvenient procedure.

(ii) I do not accept that they genuinely believed that administration of Seretide to a sleeping child would be effective. Any reasonably competent parent would realise that this could not possibly be so, and M, as a nurse, would know that it was absurd. I do not accept that the parents learned to do it by watching nurses administer a different drug (Salbutomol) during sleep, or that they were encouraged or allowed to do so themselves; if that happened, it can have been on no more than an insignificant handful of occasions.

(iii) The fact that the parents never spoke to anyone about a practice of administering drugs to J in her sleep, even remaining silent when J’s inhaler technique was being checked, makes it highly improbable that they were in fact doing it.

(iv) I accept the evidence of Dr C that both she and the nurses would repeatedly reinforce the need for good inhaler technique to M and that the parents knew that J needed a good dose of steroids every day.

(v) I do not accept that the parents genuinely thought J should be on one puff of Seretide twice a day, when she had been prescribed two puffs for more than two years. The fact that some letters and labels described the dosage in different ways did not in my view mislead the parents; they are now relying on it after the event. If there was any doubt about whether the parents know the correct dosage, it is firmly dispelled by Mrs H’s evidence about her conversation with M on 10 November 2011.

(vi) M is unlikely to make careless mistakes about J’s prescriptions. She was punctilious with the school about J’s medication, and took a zero tolerance approach to any stepping out of line on their part.

  1. My view of the parents’ evidence about Seretide causes me to doubt that they administered Prednisolone in the way that they described (orally by syringe, rather than simply dissolving it in J’s breakfast), but I can reach no clear conclusion about this. At all events, I find that she was probably receiving considerably less Prednisolone than was being prescribed:

(i) M understandably did not like the use of steroids.

(ii) J did not like taking her medication, and the parents are both notably ready to defer to her.

  1. Insofar as the prescription records show an inflow of steroidal medication into the home, I conclude that it cannot have been effectively administered to J. The medical opinion is to this effect, and I accept it.
  1. My assessment of the parents is therefore that they are not reliable witnesses in matters relating to J’s health, either in relation to the administration of medication, or in relation to the management of J’s acute episodes. Their evidence about asthma treatment has evolved in response to the case as it has developed. The concession that ‘only one puff’ of Seretide was being given was made on the opening day of the hearing. Their evidence about J’s supposed ALTEs is, I find, exaggerated and unreliable in its detail. They have both given unreliable descriptions of J’s condition to the school and to the emergency services.

 

 

The final part is what lifts the case from being very fact specific  (I’ve done an insane amount of care proceedings in twenty years of practice, but have never come across one that arose from parents not giving their child asthma medicine  – some that come close on children with naso-gastric tubes for feeding perhaps) to one of broader interest.   (the underlining is my own, for emphasis)

 

  1. My final observation is that each of the doctors recognised that there are lessons to be learned from J’s case. Paediatricians are conditioned to trust parents, particularly where a child has a genuine medical condition. That instinct was strong in this case, despite indications that it needed to be examined. Dr C had concerns about the reliability of these parents as long ago as 2008 but, having taken advice from her child protection lead, she did not pursue her doubts, a decision she regrets. The doctors will form their own conclusions, but those may include the following:

(1) Faced with a possible conflict of interest in circumstances involving serious consequences, the preservation of a working relationship with parents cannot take precedence over the interests of the child.

(2) The principle of diagnostic parsimony (c.f. Occam’s Razor) proposes that simple explanations for medical conditions are exhausted before complex and unusual treatments are attempted.

(3) Fragmentation of responsibility between different hospitals carries the risk that the whole picture is not seen and understood by anyone – in J’s case, no proper meeting was held until November 2011, and even that did not involve the LA.

(4) Where dilemmas of this kind arise, involving social as well as medical issues, doctors and schools should not be reluctant to call for a comprehensive assessment that can only be carried out by the ordinary child protection services.

Taking neglect seriously

 

 

Some interesting research about children’s timescales and the Court process, which has been conducted by the Childhood Wellbeing Research Council. It is the first piece of the research that was commissioned under the Family Justice Review, and therefore worthy of attention.  (More attention than it has received)

 

It is heavy, and I can’t say yet whether its conclusions will necessarily be unchallenged, but it is, I think, for the first time, a proper drawing together of all of the important research on delay, decision-making, impact of neglect on children and attachment issues.  If the other pieces of FJR research are going to be as important as this, I will be a very happy law geek.

 

 

http://www.cwrc.ac.uk/news/documents/Decision_making_within_a_childs_timeframe_Oct_2012_CWRC_WP_16.pdf

 

 

It is long and detailed, so my cursory summary of it is absolutely no substitute for reading it.  It also contains some important research about the impact of child abuse, particularly neglect, on children.  A lot of it is pulling together of research that is already out there, but might be less widely known than it should be.

 

 

 

1.1 This overview of research evidence has been commissioned in response to the Family Justice Review recommendation for consistent training and development for family justice professionals, including a greater emphasis on child development. It aims to bring together key research evidence to facilitate understanding among professionals working in the family justice system in areas relating to:

  • · neuroscience perspectives on children’s cognitive, social and emotional development;
  • · the implications of maltreatment on childhood and adulthood wellbeing;
  • · evidence concerning the outcomes of interventions by the courts and children’s social care; and
  • · timeframes for intervening and why they are out of kilter with those for children.

 

 

I am hoping to whet your appetite to read the research, because this is some big important stuff.  (I will stop nudging you in the ribs at some point, but really, this needs to be read)

 

 1.19 While the issues covered in this chapter are intended to help the reader develop a critical approach to the understanding of research findings they should not detract from the value of the research itself. The following chapters consider robust findings from a number of well received research studies into parents’ problems and the impact of abuse on early childhood development; family justice professionals need to be aware of this research, particularly because it points to the importance of making timely decisions when children are suffering, or likely to suffer, significant harm.

 

 

We start with some basic principles  (the first few are of the “no-s*** Sherlock variety, but the last two are perhaps startling to see in such stark form)

 

 

Summary points

  • · Children growing up with parents who experience problems such as mental illness, learning disability, substance misuse and domestic violence are at greater risk of being maltreated.

 

  • · Not all parents with these problems will abuse or neglect their children; however these factors interlock in complex combinations which substantially increase the likelihood of maltreatment.

 

  • · Protective factors such as the presence of a non-abusive partner and/or a supportive extended family, parents’ ability to understand and overcome the consequences of their own experiences of childhood abuse, their recognition that their adverse behaviour patterns constitute a problem and their willingness to engage with services can substantially reduce the likelihood of maltreatment.

 

  • · Where insufficient protective factors are present, parents’ problems can undermine their ability to meet the needs of their children and inhibit the child’s capacity to form secure attachments.

 

  • · Healthy child development depends on the child’s relationships, and particularly their attachment to the primary caregiver.

 

  • · The process of attachment formation begins at birth. The four basic attachment styles: secure, insecure ambivalent, insecure avoidant and disorganised illustrate different adaptive strategies in response to different types of caregiving.

 

  • · Up to 80% of children brought up in neglectful or abusive environments develop disorganised attachment styles. These children behave unpredictably and have difficulty regulating their emotions.

 

  • · Disorganised attachment is strongly associated with later psychopathology.

 

 

 

 

 

This is interesting :-

 

 

The risk of recurrence (of child abuse) was reduced when medical and/or legal services were involved.

 

So the PLO may have been onto something, when they wanted to draw lawyers for parents into the process earlier – it is just a shame that the funding system means that they really can’t come in until proceedings are almost inevitable, rather than at the Initial Assessment process, when legal advice could make a real difference.

 

  

The mitigating value of protective factors

2.10 There is substantial evidence that certain protective factors can interact positively with parental problems to mitigate their impact, thus reducing the likelihood of maltreatment and improving the chances of better long-term outcomes for children. Jones and colleaguesidentified the following factors to be particularly pertinent: the presence of a non-abusive partner; the presence of a supportive extended family; parents’ adaptation to their own experience of childhood abuse; parents’ recognition that there is a problem and their willingness to take responsibility for it; and parents’ willingness to engage with services.

 

 

Whilst these are all things that we intuitively look at in care proceedings, it is helpful to see that the things we take for granted as common sense protective factors actually are.  And the phrase ‘insight’, which we hear so often, really is instrinsically bundled up in this.

 

 

[I do wonder, on a 26 week timetable, how the “Ostriches”  - those parents who bury their heads in the sand and pretend none of this awful situation is happening to them, before finally realising, will fare.  I suspect that there will no longer be enough time to turn the Ostrich cases around to a positive outcome]

 

2.11 Cleaver and colleagues40 have provided a comprehensive analysis of the manner in which, where there are insufficient protective factors, parents’ problems can impact on parenting capacity and trigger maltreatment and poor child outcomes. To summarise:

 

  • · Parental mental illness can seriously affect functioning. For example someone suffering from schizophrenia can experience delusions and hallucinations and be preoccupied with a private world. A person who is depressed can have feelings of gloom, worthlessness and hopelessness, which may mean that everyday activities are not carried out. Mental illness can blunt parents’ emotions and feelings towards their children, cause them to be emotionally unavailable or behave unpredictably, or occasionally cause them to be violent.

 

  • · Learning disability can affect parents’ capacity to learn and retain the new skills that are necessary to parent a child. Parents with a learning disability may also have had a negative experience of their own childhood which can leave them with low self-esteem and a poor sense of self-worth. Consequently, parents with learning disabilities and their children are vulnerable to financial and sexual exploitation, domestic violence, harassment and bullying.

 

  • · Parents who abuse drugs and/or alcohol can be subject to erratic mood swings, paranoia and hallucinations, or feelings of elation and calm, diminished concentration, memory impairment and a loss of consciousness. This can leave them unable to: meet the basic needs of their children, be emotionally available to them or at times keep them safe.

 

  • · Being the victim of domestic violence is likely to undermine parents’ self-esteem and confidence in their parenting skills. Such parents may have their attention focussed on the necessity to placate the perpetrator rather than on their children’s needs. They may not be able to protect those of their children who get caught up in or witness an attack from physical abuse and emotional trauma. Perpetrators of domestic violence are likely to cause physical and emotional harm to their children as well as to their partners.

 

2.12 Behaviour patterns such as these undermine a parent’s ability to meet their children’s needs. They have a particularly damaging impact on the child’s emerging capacity to form attachments.

 

 

The report then goes on to specifically look at attachment issues – I think lawyers (and perhaps some others in the family justice system) are often a bit muddled about attachment, and what the significance or otherwise of it is.  I often see it being conflated with an concept of whether the parent loves the child and vice versa. If you know a bit about attachment theory, not much of this is new, but it is helpful to have it pulled into one place and be able to take the Courts to this one document.

 

 

The importance of a secure attachment base for healthy child Development

 

Young children experience their world as an environment of relationships, and these relationships affect virtually all aspects of their development – intellectual, social, emotional, physical, behavioural, and moral.

 

 

2.13 Healthy child development depends on the establishment of these relationships. Early secure attachments contribute to the growth of a broad range of competencies, which can include: a love of learning; a comfortable sense of oneself; positive social skills; multiple successful relationships at later ages; and a sophisticated understanding of emotions, commitment, morality, and other aspects of human relationships.

 

2.14 Howe asserts that, biologically, attachment is a means of survival. It is defined as proximity seeking behaviour to an attachment figure, the primary caregiver, by a baby or child when he or she experiences discomfort such as pain, fear, cold or hunger.This behaviour is instinctive and is based on the assumption that the primary caregiver will be able to reduce the discomfort.

 

The baby gradually constructs an internal working model of themselves and of their primary caregiver on the basis of their caregiver’s responses to their attachment needs:

These mental representations refer to the kind of memories, experiences, outcomes, feelings and knowledge about what tends to happen in relationships, particularly with attachment figures at times of need.

 

2.15 Thus, the primary purpose of an internal working model is to help regulate the negative emotions of fear, distress and anxiety triggered when a child feels insecure.

 

2.16 The process of attachment formation begins at birth. A newborn infant seeks care and protection through proximity to their attachment figures. Following birth, a baby is instantly alert to messages they receive about the world around them, such as those reflected in the face of their caregiver(s) and the way in which their urgent needs are met. From about the age of three months a baby is increasingly selective and begins to smile less readily for strangers, tending to target their attachment behaviours more accurately towards their significant carers. By the age of six to seven months, an infant can generally show a clear cut attachment to their primary caregiver(s), and will show distress and anxiety about being separated from them. For instance, infants of this age become less likely to tolerate being held by strangers. However, from this point onwards a securely attached infant is able to use their caregiver as a secure base for exploration.

 

2.17 During toddler and pre-school years children learn to define themselves and others in increasingly sophisticated ways. They develop their locomotive skills, their cognitive capacity, their communicating and negotiating abilities, and increase their knowledge and understanding of the perspectives of others. A child’s secure foundations from infancy help them to achieve these developments.

 

2.18 Researchers have identified four basic attachment styles, each relating to the type of caregiving received. These are: secure, insecure ambivalent, insecure avoidant and disorganised. Each of these styles of attachment illustrates different adaptive strategies in response to different types of caregiving, and are developed by children to enable them to ‘stay close and connected to their attachment figures at times of intense negative arousal’.

 

Whilst these categories are very useful in facilitating understanding of different attachment styles, it should be noted that in real life they are not entirely discrete entities; whilst some children will fall exclusively into one category, many children will show a mixed pattern of attachment behaviours, with elements of several styles present.

 

2.19 Children who are securely attached to their caregiver(s) have a relationship that is characterised by sensitive, loving, responsive, attuned, consistent, available and accepting care.51 Securely attached children have the ability to regulate their distress, either by themselves or by the knowledge that they can get help from their attachment figure should they need it.

 

2.20 These children develop internal working models in which they see other people as positively available and themselves as loved and likeable, valued and socially effective.Secure attachment styles are found in about 55% of a non-clinical population.

 

2.21 Conversely, insecurely attached children experience anxiety about the location of their caregiver at times of need, as well as uncertainty about the type and sensitivity of the response they will receive.55 There are three types of insecure attachment patterns, the avoidant, the ambivalent and the disorganised.

 

2.22 Children who develop an insecure, ambivalent pattern of  Attachment experience inconsistent caregiving. Their caregiver(s) tend to be preoccupied with their own emotional needs and uncertainties, and can be unreliable and emotionally neglectful. These children will exaggerate their attachment behaviour in an attempt to be noticed; in this they are not always successful, and their ambivalence reflects their simultaneous need for and anger with their attachment figures.56 About 8% of children in a non-clinical population display insecure ambivalent attachments.

 

2.23 About 23% of children develop insecure, avoidant attachment patterns.These children tend to experience parenting that is hostile, rejecting andcontrolling. They come to see themselves as neither loved nor loveable.They adapt to their caregivers’ rejection by over-regulating their emotions,and are anxious that any display of need, longing, vulnerability or emotionmight drive their caregiver(s) away.59

 

2.24 Some caregivers cannot regulate their child’s responses to stressful circumstances; as a result, their children experience feelings of danger and psychological abandonment.60 Children who are cared for by people who are frightening, dangerous and/or frightened develop disorganised attachments.61 These children may be fearful of approaching their caregivers because they cannot predict the response: sometimes they may be picked up and cuddled, but at other times they may be shouted at or smacked. As a result, these children are not able to ‘organise’ their own behaviour, and have difficulty regulating their emotions. Like their parents they may behave unpredictably. They develop highly negative and inconsistent internal working models in which they see other people as not to be trusted.

 

Disorganised attachment is strongly associated with later psychopathology.

 

There is consistent evidence that up to 80% of children brought up in neglectful or abusive environments develop disorganised attachments, although these are evident in only 15% of a non-clinical population.The effects of maltreatment on attachment behaviour will be discussed further in Chapters Three and Four.

 

 

 

Chapter 3 gets stuck into the neuroscience – what is happening with a child’s brain during early years and what are the effects of neglect upon child development?     I’ve felt for a while now that neglect is the poor cousin of child abuse  – it is really easy to understand and grasp the risks of sexual abuse, or a fractured skull, but neglect is so easy to minimise and belittle and so hard to get a firm grasp on  ‘what will happen to the child if this situation persists rather than improves?’

 

A lot of the neuroscience bit may be a bit fresher than the attachment theory previously discussed, and I think it is very important in the way we look at neglect. It may help Courts take neglect as seriously as it needs to be taken.

 

How the child’s relationships shape the development of the brain and the stress response system

Summary points

  • · Much of the development of the brain and central nervous system takes place after a child is born, within the first three years of life.

 

  • · The child’s environment of relationships – and in particular the relationship with the primary caregiver – plays a critical role in shaping the development of the overall brain architecture.

 

  • · Negative experiences, and in particular insufficient stimulation, adversely impact on the construction of neural connections which form the basis for cognitive and social development.

 

  • · By the time children are two, the foundations for their ability to speak and understand language, to reason and make plans have already been laid.

 

  • · Executive function skills, necessary for both learning and social interaction, begin to develop shortly after birth, with dramatic growth occurring between the ages of three and five years.

 

  • · There is a short window of opportunity for certain types of development. If the types of experience upon which they depend do not occur within a predetermined timeframe, children will not move on to the next stage of development and their long-term wellbeing will be compromised.

 

  • · Early interactions between the primary caregiver and the baby play a significant role in establishing the normal range of emotional arousal and in setting the thermostat for later control of the stress response.

 

  • · Both very high and very low levels of cortisol are indicative of abnormal development of the stress response and can cause long-term physiological and psychological damage.

 

 

[This last one is interesting, because it raises the possiblility of a biological/chemical test for neglect, that there’s a chemical which can be measured and considered whether it is in normal parameters - and I suspect Trimega and Trichotech are already contemplating the marketing for their Cortisol tests…  Are we ready for neglect to be determined by science?  There’s an entire blog post all on its own, I think]

 

3.14 The process of creating and strengthening or discarding synapses is the brain’s means of learning and the way in which a child responds to their environment. This process is often referred to as ‘plasticity’, a term that indicates the brain’s ability to change in response to repeated stimulation.

 

These repeated adaptations are made in response to a combination of genetics and experience. The brain is genetically pre-programmed to expect certain experiences and forms certain neural pathways to respond to them; the more the child is exposed to these experiences, the stronger the pathways become. For example, a baby’s brain is genetically preprogrammed to respond to voices. When a baby is spoken to the neural systems which are responsible for their speech and language receive the necessary stimulation to strengthen. If, however, they are not exposed to adequate stimulation through exposure to speech, the pathways which have been developed in anticipation of this exposure will be discarded:

 

All children need stimulation and nurturance for healthy development. If these are lacking – if a child’s caretakers are indifferent or hostile – the child’s brain development may be impaired. Because the brain adapts to its environment, it will adapt to a negative environment just as readily as it will adapt to a positive one.83

 

3.15 A child’s experiences greatly shape the quality of the architecture of the developing brain. Positive experiences, particularly in the first year of life, produce more richly networked brains. More neuronal connections produce better performance and more ability to use particular areas of the brain.

 

Conversely, as Chapter Four shows, negative experiences, and in particular insufficient stimulation, adversely affect the development of neural connections and have a negative impact on children’s cognitive and social development, their speech development and their learning and memory.

 

3.18 The sequence of brain development follows a logical pattern. Development of the higher regions does not commence before the connections in the lower regions have been completed.92 This is because the higher levels in the hierarchy depend on reliable information from the lower levels in order to accomplish their functions.93 Impaired development in the lower regions of the brain will therefore have a negative impact on the development of the functions of the higher regions, such as language, empathy, regulation of emotions and reasoning.

 

 

This, for me, is a big deal.  The research establishes that a major part of the formation of basic brain structure happens in the first few years of life, that positive experiences enhance this and negative ones hinder it, and that higher brain functions don’t get formed until the basic ones are completed.  So a baby that is being understimulated or mistreated will have serious consequences on that emotional development in later life.

 

This next bit also interested me

 

3.24 There are specific periods when the development of a child’s brain is more strongly affected by a certain type of experience than at other times. These periods are widely referred to as sensitive periods. At certain times the impact of experience on development can be irreversible: these are a special class of sensitive period known as critical periods.

 

 

This is then the pulling together of research on the impact of stress and how it affects children. It is sciency but important

 

 

3.34 Everyday life involves responding and reacting to varying degrees of stress.

 

When an individual experiences stressful events, their body responds physiologically to restore a condition of equilibrium, or homeostasis.114 The body’s stress response activates several interlocking biological systems designed to prepare an individual for events that may threaten their wellbeing.The hypothalamus, which is located in the centre of the brain, is involved in maintaining homeostasis, including responding to stressful events which upset regulatory rhythms. The amygdala reacts to social situations that generate uncertainty or fear by releasing chemical messages in various directions. The hypothalamus is activated by these messages, and in turn triggers the hypothalamus-pituitary-adrenal (HPA) axis: the core stress response system.

 

3.35 The stress response involves activation of the pituitary, which in turn triggers the adrenal glands to produce extra cortisol. This allows the body to generate extra energy to focus on the stress and to put other bodily systems ‘on hold’ while this is being dealt with.

 

3.36 Chronically high levels of cortisol have detrimental effects on health. Therefore feedback loops are present to modulate the responsiveness of the HPA axis which returns the system to homeostasis. This feedback loop is mediated by receptors located, in the main, in the hippocampus. The purpose of this regulation is to produce adaptive responses to social and psychological stressors. These prepare the body to anticipate and respond optimally to threat but return efficiently to a homeostatic balance once the body is no longer challenged.

 

3.37 The stress response system is not fully mature at birth. It requires an extended period of development whereby experience plays a crucial role.

 

An important component of this development is a baby’s attachment to their caregivers.When babies express feelings of distress or discomfort, they are dependent on their caregivers to notice these signals and to respond by providing the type of care which maintains their equilibrium, such as sensitive touch, feeding and rocking.122 A baby’s stress response system is unstable and reactive; it will produce high levels of cortisol if the baby’s needs are not being met, or if the baby is in an environment which is aggressive or hostile. Persistent and unrelieved chronic stress in infancy results in the baby’s brain being flooded by cortisol for prolonged periods.

This can have a toxic effect on the developing brain, with detrimental consequences for future health and behaviour. Please see Chapter Four paragraphs 4.38 to 4.44 for further discussion relating to the toxic consequences of chronic stress.

 

3.38 In some children, however, prolonged exposure to stress may be linked to abnormally low levels of cortisol. This is particularly evident in those who have experienced low-grade, frequent emotional (and sometimes physical) abuse and neglect in very early childhood and is associated with early indications of anti-social behaviour in boys.

 

3.39 Both very high and very low levels of cortisol are indicative of abnormal development of the stress response, and cause long-term physiological and psychological damage.

3.40 A normal adult pattern of cortisol production is highest in the morning, and then gradually declines through the day to be at its lowest in the evening.

Babies who have secure attachments to their caregiver(s) will begin to form this pattern between three to six months old; however it takes until about the age of four years before it is fully established.126 Early interactions between primary caregiver and baby therefore play a significant role in how a child develops the capacity to respond appropriately to stressful circumstances and the ability to regulate their own negative emotions if and when these occur, such as following an immunisation injection, an injury, or on the first day at school.

 

3.41 This chapter has shown how the brain and stress response systems develop in early childhood and are shaped by the relationship with the primary caregiver. There are indications that when the caregiver does not respond appropriately to the child’s needs, development can be impaired

 

 

 

Chapter Four then gets heavily stuck into the impact of child abuse on children and their development. Traditionally, this has been a difficult area, because there are obvious ethical reasons why you can’t get a bunch of children and mistreat them under scientific conditions to see what happens, and you can never be certain when looking at children you suspect have been neglected exactly what did happen to them. But there was a group of children who we knew exactly how neglected they were, and those were the babies who grew up in Romanian orphanages that were effectively given very minimal care and no stimulation.

 

So some of the research is drawn from that. I haven’t really discussed any of that, because it involves palpably worse neglect than we are used to seeing in a family court environment  – the Romanian orphanages had a staffing ratio of 1 carer to every 20 children, and it is clear that one twentieth of a carers time (or 1 hour 12 mins per child per day), even if they are very dedicated and devoted and hardworking, isn’t going to be enough for a baby, and even the worst of our neglectful parents must spend more than an hour and twelve minutes a day interacting with their baby.

 

Here is the summary for chapter four – note the last point about the correlation between childhood neglect and adult dysfunction.  [To be balanced, no doubt a parallel could be drawn about children in the care system and adult dysfunction…]

 

 

Summary points

  • · Exposure to domestic violence and/or parental substance misuse in utero can have a long-term negative impact on the unborn child.
  • · High quality care can determine the extent to which children who are genetically predisposed to mental illness or learning disability, or who are exposed to abusive or neglectful parental behaviours, are affected.
  • · Chronic exposure to trauma through aggressive, hostile or neglectful parenting can lead to stress system deregulation. Exposure to toxic stress in early childhood can cause permanent damage to the brain and have severe and long-term consequences for all aspects of future learning, behaviour and health.
  • · Neglected children may experience chronic exposure to toxic stress as their needs fail to be met. This is compounded by a lack of stimulation and social deprivation.
  • · Severe global neglect (i.e. severe neglect in more than one domain) during the first three years of life stunts the growth of the brain.
  • · Adults who have been physically abused in childhood show poorer physical and intellectual development, more difficult and aggressive behaviour, poorer social relationships and are more frequently arrested for violent crimes than their peers.
  • · Children who have been sexually abused may experience sleep problems, bedwetting or soiling, problems with school work or missing school, and risk taking behaviour in adolescence including multiple sexual relationships.
  • · Adolescents who have experienced abusive or neglectful parenting in childhood are more likely to engage in risk-taking behaviours such as substance misuse and criminal activity.

 

 

 

There’s a discussion on emotional abuse which (perhaps appositely) is the most emotive form of reasons for State intervention in family life and the one which gets people hot under the collar, and is the one which opponents of the Family Justice system consider to be a trivial and unwarranted justification for State intervention.   Note my underlining.

 

Emotional abuse and neglect

4.17 Emotional abuse is described as:

The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or making fun of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber-bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

 

4.18 Emotional abuse is often considered to be the most damaging of all forms of maltreatment in early childhood because the perpetrator is almost always the primary caregiver, and their abusive behaviour represents a direct negation of the child’s ‘need for safety, love, belonging and self esteem’.

The chapter discusses the professional difficulties in determining when neglect or emotional abuse reaches the stage when intervention is required. There are some big strong statements in here, which I have underlined.

 

 

4.20 Findings from the studies in the Safeguarding Research Initiative154 showed that practitioners found it difficult to identify emotional abuse and neglect and to decide when a threshold for action had been reached. These difficulties arose for a number of reasons:

• Both types of maltreatment are heterogeneous classifications that cover a wide range of issues.

• Both emotional abuse and neglect are chronic conditions that can persist over months and years. Professionals can become accustomed to their manifestations and accepting of the lack of positive change.

Both types of maltreatment can persist for many years without leading to the type of crisis that demands immediate, authoritative action.

Without such a crisis it can be difficult to argue that a threshold for a child protection plan or court action has been reached.

• Both types of maltreatment are also closer to normative parental behaviour patterns than physical or sexual abuse, in that most parents will, on occasion, neglect or emotionally maltreat their children to a greater or lesser degree. It is the persistence, the frequency, the enormity and the pervasiveness of these behaviours that make them abusive.

 

4.21 Two systematic reviews of literaturethat explored the evidence in relation to neglect and emotional abuse concluded that these types of abuse are associated with the most damaging long-term consequences, yet they are also the most difficult to identify. Furthermore, relative to physically abused children, neglected children have more severe cognitive and academic deficits, social withdrawal and limited peer interactions, and internalising (as opposed to externalising) problems.

 

4.22 Child maltreatment is a public health issue, in that its prevalence has a negative impact not only on the individuals concerned, but also on the welfare of society as a whole. The consequences of child maltreatment can last over the course of a life time and negatively affect parenting capacity, with detrimental consequences for the next generation.

 

A consideration of when changes would be made is the next discussion

 

4.30 Ward and colleaguesstudied the life pathways of 43 infants who had been identified as likely to suffer significant harm before their first birthdays; two thirds of them had been identified before birth. This study found that those parents who were able to overcome issues affecting parenting capacity, such as substance misuse and domestic violence, had begun to address these during the pregnancy. This was often as a result of a revelatory moment when they realised they needed to make substantial changes to their lifestyles in order to protect their unborn child, and indeed to prevent the local authority from removing the baby from their care immediately following the birth. Those parents who were able to address all of their difficulties before their child was six months old were able to maintain these changes in the longer term – up to at least their child’s third birthday. Parents who were interviewed as part of the evaluation of the Family Drug and Alcohol Court pilot also identified the birth of a child as a catalyst for overcoming adverse behaviour patterns.176 The findings from these studies suggest that there is a window of opportunity for social work and legal interventions during pregnancy and in the first few months following birth when parents may be more open to address adverse behaviour patterns.

The portions on “Toxic Stress” are interesting  – this is a new term to me, and I suspect I will be hearing it more in the future.   I’m starting to wonder whether paediatric neuroscience is going to be an expert discipline which has much more to tell us about neglect than the traditional psychological assessment that tells you nothing at great expense and delay.

 

 

Toxic stress

4.38 In addition, if inadequate or damaging parent-infant interactions persist, a child’s stress response system can be activated over prolonged periods, producing chronically high levels of the stress hormone cortisol. Brief periods of moderate, predictable stress are not problematic. In fact, they are protective and essential for survival. However excessively high levels of stress and prolonged exposure to raised cortisol levels are harmful and have toxic consequences for the developing child’s brain.186 A child’s stress response system can be activated over prolonged periods if they continually feel threatened by aggressive or hostile parenting, including witnessing or hearing violence between caregivers, or if, as a result of neglectful parenting, their basic needs for food, warmth, nurture, care and affection are not met.

The stress response system starts to self-regulate at around six months, and persistent maltreatment may lead to poor emotional regulation and a maladaptive response to stress. 

Toxic stress can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive adult relationship.

 

4.39 Brain development can be altered by this type of stress, resulting in negativeconsequences for children’s physical, cognitive, emotional, and socialgrowth.The ability of a child’s brain to adapt to its environment,particularly during the first three years of life (and especially during the firstyear) makes it particularly sensitive to chemical changes. Therefore,persistently high levels of stress hormones, such as cortisol, can disrupt itsdeveloping architecture.190 Because the brain develops in certain setsequences (see paragraphs 3.16 to 3.18) early development impacts uponlater brain development. Therefore stress exposure early in life has thehighest potential for long-term dysfunction in neurobehavioral systems that mediate emotional responses, abstract thinking, and social interaction.

 

4.40 As Chapter Three has shown, the amygdala, hippocampus and prefrontal cortex regions of the brain are particularly sensitive to chronic stress (see paragraphs 3.34 to 3.41). This is because they contain an abundance of stress hormone receptors.Exposure to high levels of cortisol can cause cell damage which is reversible when exposure is brief, however when exposure is prolonged it can lead to cell death. Therefore permanent damage can be caused to these areas of the brain when a child is exposed to toxic stress.

 

4.41 Damage to the hippocampus can lead to impairments in memory and mood related functions, and limit the ability of the hippocampus to promote contextual learning, ‘making it more difficult to discriminate conditions for which there may be danger versus safety, as is common in post-traumatic stress disorder’.It can also lead to problems in the development of linguistic, cognitive and social-emotional skills.

 

4.42 Chronic stress is also associated with over activity in the amygdala which then activates the stress response system. This can result in an increase in the potential for fear and anxiety. One task of the prefrontal cortex is to suppress amygdala activity, allowing for more adaptive responses to threatening or stressful experiences. However exposure to chronically elevated cortisol levels can damage the neural pathways between the prefrontal cortex and amygdala, limiting the ability of the prefrontal cortex to inhibit amygdala activity. As a result, children may appear, ‘to be both more reactive to even mildly adverse experiences and less capable of effectively coping with future stress’.

 

 

 

The brain scans comparing a neglected child with a non-neglected child are staggering. I can’t reproduce them here, but go and look at them.

 

The last sentence of this next section is also staggering. I had never contemplated childhood neglect having a correlation with the  serious adult illnesses described here

 

Impact of maltreatment in later childhood and adolescence

4.50 Child abuse and neglect typically begin early in childhood; however the damage these experiences cause to all areas of development can have a cumulative effect on subsequent behaviour and health in later childhood and adolescence. Unsurprisingly, socially, emotionally and behaviourally impeded development attributed to abuse and neglect in the early years continues into middle and later childhood. Maltreated children may experience difficulties in coping with the social and academic demands of school and neglected children in particular may fall behind in their language and reading skills.Because subsequent development builds on previous milestones, abused and neglected children can continue to be challenged by normal developmental tasks.

 

4.51 During middle to late childhood caregiver(s) need to be good role-models and actively encourage sociable behaviour alongside firm and calm limit setting to promote good adjustment.212 Parenting which is harsh, rejecting or inconsistent is associated with poorer outcomes.213

 

4.52 Adolescence is a period of preparation for adulthood, when several key developmental tasks are encountered. These include physical and sexual maturation; movement towards social and economic independence; the development of identity; the acquisition of skills needed to carry out adult relationships and roles; and the capacity for abstract reasoning.

 

Adolescence can be a time of tremendous emotional, social and physical growth and potential, however for young people who have experienced abuse and neglect either in their past or present, this is a time of particular vulnerability.

 

4.53 The neglect of adolescents is a major issue that frequently goes unnoticed.Adolescents can be neglected by services as well as by their families. It is clear that neglect is age-related, and as children grow older it is defined not only by parental behaviours but also by the way in which young people experience them. Davies and Ward216 argue that some fundamental questions have barely been considered. For instance, there is little public debate or consensus as to what constitutes an acceptable level of supervision as children grow older. Furthermore, teenagers are the second most likely group of children to be the subject of a serious case review.

 

4.54 As children grow and develop into young adults, the cumulative effects of child abuse and neglect can have detrimental consequences for their health and welfare. Growth in the frontal lobe of the brain may be under developed in young people who have experienced abusive or neglectful parenting during their childhood. This may mean that they are more likely to engage in risk taking behaviour and live a generally unhealthy life style (see paragraph 3.17). For instance, abused and neglected adolescents are more likely to start drinking alcohol at a younger age and more likely to use alcohol as a way of coping with stress than for other social reasons.Exposure to maltreatment during childhood is also associated with tobacco use, illicit drug use, obesity and promiscuity in adolescence.

 

4.55 Young people who have been maltreated in childhood are also more likely to have trouble maintaining supportive social networks and are at a higher risk of school failure, gang membership, unemployment, poverty, homelessness, violent crime, incarceration, and becoming single parents.Additionally, if they become parents themselves, they are less likely to be able to provide a stable and supportive environment for their children. This creates an intergenerational cycle of adversity.221

 

4.56 There may also be physiological disruptions in later life as a consequence of abuse and neglect during childhood. For example, the manifestations of toxic stress can cause alterations to the body’s immune system and increases in inflammatory markers which are known to be linked to poor health outcomes.These include cardiovascular disease; viral hepatitis; liver cancer; asthma; chronic obstructive pulmonary disease; autoimmune disease; poor dental health; and depression.

 

 

The fifth chapter deals with Timely decision-making.  This is the first time that the Pro 26 week evidence has been properly set out, and in this context, it becomes more compelling  (I remain troubled by what it means for justice – I think Judges should decide on what the right timeframe for decision-making is, based on the case before them)

 

Summary points

  • · One of the most important issues to confront in promoting better outcomes for abused and neglected children is a mismatch between three timeframes: those of the developing child; those of the courts and those of the local authority.
  • · The birth of a baby is often a catalyst for change. Children who remain with parents who have not made substantial progress in overcoming adverse behaviour patterns and providing a nurturing home within a few months of their birth may continue to experience maltreatment for lengthy periods.

 

  • · Social work decisions concerning permanence are made after lengthy and meticulous deliberations. There is a tendency for delays to occur once a temporary solution has been found and the pressure to resolve a crisis has been relaxed.

 

  • · The Children Act 1989 embodies the principle enshrined in human rights legislation and policy that children are best brought up by their own families. Identifying the very few children whose parents will not be able to meet their needs within an appropriate timeframe requires professionals to set aside much of the culture of their training and practice.

 

  • · On average, care proceedings take a year to complete; data collected between 2008 and 2011 indicate that courts in only eleven local authority areas meet the previous target of 40 weeks.

 

  • · Factors that contribute to delays in completing care proceedings include: resource issues; waiting for parenting assessments and the results of attempted placements with parents; resolution of disputes and changes of plan.

 

  • · Repeated assessments of birth parents are a major source of delay, as are sequential assessments of different groups of relatives. These are sometimes undertaken in spite of obvious contraindications. There is a stark contrast between the frequency of parenting assessments and the paucity of paediatric assessments to ascertain the impact of abuse and neglect on children’s development.

 

  • · The more complex the case, the greater the proliferation of expert assessments and the longer the delay.

 

  • · Professionals encounter numerous difficulties in trying to retain a focus on the best interests of the child: attempts to ensure that parents’ rights and needs are respected can conflict with those of their children.

 

  • · Most children placed for adoption are aged two or older before they reach their adoptive families. This timeframe is at odds with research evidence that indicates that babies who are placed early for adoption are most likely to form secure attachments with new carers.

 

  • · Delayed decisions mean that children experience the cumulative jeopardy of lengthy exposure to abuse and neglect; disruption of attachments with temporary carers; unstable placements at home or in care; and prolonged uncertainty about their future.

 

  • · There is a relatively short window of opportunity in which decisive actions should be taken to ensure that children at risk of future harm are adequately safeguarded. Delays close off those opportunities

 

 

 

This is interesting, gathering some research on when and how interventions work  – the importance of gripping neglect cases early and avoiding drift is really apparent from this  – the longer the neglect has gone on, the less chance there is on intervention making a difference.

 

 

In families where children are abused or neglected, social work interventions can be effective if they are decisive and proactive and if they fit in with children’s developmental timescales.230 Actions reinforced by court orders can be more effective than those that are less intrusive, particularly where parents are reluctant to engage with support services or social workers have competing priorities.231 Where parents do not have the capacity to overcome entrenched, adverse behaviour patterns that damage their children’s welfare, placement in the care of the local authority is generally more beneficial for children than remaining at home (or returning there),232 and adoption is likely to lead to the best outcomes for very young children.233 A number of intensive, evidence-based interventions have been shown to be effective in other countries and the results of some UK pilots look promising.234

  However one of the key messages from this wide body of research is that the longer that children experience abuse and neglect without sufficient action being taken, the less effective are even the most intensive and intrusive interventions in promoting their long-term wellbeing.

 

 

 

 

5.7 The prospective study of infants suffering significant harm also showed that 93% (13/14) of the parents who were able to overcome adverse behaviour patterns sufficiently to provide a nurturing home did so within the first six months of the birth. Where children remained with birth parents who had not made substantial progress within this timeframe (12 cases), concerns about maltreatment persisted and were still evident at the child’s third birthday.

 

 This finding has obvious implications for timescales for decision-making and for intensive interventions. However it is drawn from the experiences of a very small number of children in what is already a relatively small study. It needs testing out with a larger sample

 

 

 

The research is interested in a concept called Cumulative jeopardy, where the child development, already harmed by poor parenting, is compounded by the legal process aimed at protecting them

 

Conclusion: Cumulative jeopardy

5.26 There is a complex interaction between child development timeframes and delayed actions by local authorities and the courts. Firstly, research on child development and the consequences of abuse shows that the longer children are left inadequately protected from all forms of maltreatment (emotional abuse and neglect, as well as physical and sexual abuse) the greater the chance that their long-term wellbeing will be compromised. Three recent English studies that explored the consequences of professional decision making in neglectful and/or abusive families all found that a high proportion of maltreated children are left in very damaging circumstances with inadequate action being taken to safeguard them, and with adverse consequences for their health and development.

 

Intensive interventions such as the Family Drug and Alcohol Courtscan make a difference in families, prevent recurrence of abuse and neglect and enable children to remain safely at home. They are also able to show where parents are not able to change within a child’s timeframe, so that decisions concerning alternative routes to permanence can be made in a timely fashion. However such interventions are not yet widely available in this country.

 

5.27 Secondly, a number of studies have shown that, once children are removed from abusive families they often spend lengthy periods in temporary placements before long-term plans are made for their future.Young children can become closely attached to interim carers, only to experience further loss when this attachment is disrupted as they move to a permanent home. Ward, Brown and Maskell Grahamfound that infants who had experienced this double jeopardy (six months or more in an abusive environment followed by a short period of stability and then a disrupted attachment) were showing severe developmental and behavioural difficulties by the time they were three, and that these persisted as they entered formal education. Again, evidence based interventions were not available for these children, and indeed some carers had difficulty in accessing any psychotherapeutic or behavioural support for them.

 

5.28 The long-term wellbeing of abused and neglected children can be jeopardised in other ways. Frequent changes of placements are one of the most problematic aspects of the current care system in England, as each change can have a negative impact on children’s developmental progress, and particularly their capacity to form secure attachments. Studies by Masson and colleagues284 and Ward, Munro and Deardenboth identified a relationship between delayed decisions and placement instability when children are looked after away from home. Masson and colleagues found that ‘the longer the case lasted the more likely it was that the child would move’:children moved during the proceedings in over 80% of the cases in this study. Ward, Munro and Deardenfound that very young children move at least as frequently as teenagers, and that instability is closely related to the provisional nature of decisions, as children move back and forwards between temporary, short-term foster homes and placements with own parents or new carers while they wait for permanence plans to be made.

 

5.29 Finally, there is also a relatively short window of opportunity in which decisive actions can be taken to ensure that children are adequately safeguarded. Delays close off these opportunities. If children are to remain at home, proactive engagement with social workers needs to begin early, particularly in view of evidence that case management becomes less active after they reach their sixth birthdays. There is a body of research evidence to show that if abuse and neglect are not adequately addressed at an early stage, as children grow older they may benefit less both from specialist interventions to address its consequences and from separation to prevent its recurrence.Early intervention is also urgently necessary where there are concerns that a child might need to be placed for adoption, for not only do children become increasingly difficult to place as the consequences of long-term exposure to abuse and neglect become more entrenched, but also adoptive carers are harder to find for older children.

 

 

5.30 The following timeline, showing best and worst case scenarios related to child development timescales where children remain with their birth parents and where adoption is the conclusion illustrates how these issues intertwine.

 

 

[I can’t reproduce that timeline, but it is well worth seeing, and probably having a copy at Court for most hearings. It has the potential to be extremely helpful and might actually start making that god-awful phrase “The timetable for the child” have some actual meaning]

 

and said ‘oh oh, smother me mother’

Tasteless title, for which I apologise, but it is a Smiths song.  (the passing of time, and all of its sickening crimes, is making me sad again)

A consideration of AA (A Child) 2012 EWHC 2647 (Fam)  – especially for John Bolch, as I am now taking requests  (other than of the ‘why don’t you just eff off’ variety)

http://www.bailii.org/ew/cases/EWHC/Fam/2012/2647.html

Firstly, either Justice Baker has had the most difficult caseload of all time, or (more likely) he’s had a pile of published judgments in his in-tray waiting to be signed off for a while and has done about six in a week, because this is him again.

Secondly, its another in the developing body of High Court caselaw where Judges who might have been accepting of medical evidence (particularly if it stood up to cross-examination) are now setting it in a broader judicial context of the totality of the evidence to be assessed, and recognition that today’s medical dogma might well be tomorrow’s “well, we USED to think”  – I have been told today of a very interesting judgment forthcoming on this topic where the conclusion is that an earlier fact finding on very serious injuries resulted in a miscarriage of justice.

But anyway, onto RE AA.

Here is the opening background, and one can tell immediately that the mother is going to be under pressure in the finding of fact hearing

    1. This is a tragic and extremely difficult case. On 6th January 2011, a little boy, whom I shall refer to as J, died while in the sole care of his mother. Twelve weeks later, on 1st April 2011, his older brother, whom I shall refer to as B, then aged four, was found in a state of acute collapse, also whilst in the sole care of his mother, and died three days later in hospital.

 

  1. Police began an extensive investigation, which is still ongoing, into the causes of those deaths. The local authority started care proceedings in respect of the surviving younger sister of the boys, whom I shall refer to as A, now aged two. The local authority contends that the threshold under section 31 of the Children Act for the making of care orders is crossed in this case and seeks findings, first, that the mother neglected her children and, secondly and more seriously, that she was responsible for the deaths of the two boys by asphyxiation. The proceedings were transferred to the High Court and listed before me for a fact-finding hearing held in Portsmouth. This judgment is delivered at the conclusion of that hearing.

Regardless of how things play out, it is plain to see that professionals are going to have high levels of anxiety about this case.  Particularly given the existence of a third child.

And here’s a warning that idle remarks, made without any malice, can take on horrible significance when looked at through the cold microscope of forensic analysis

On another occasion in November, the mother became drunk when caring for the children, who were taken round to DA’s house. There is evidence that on occasions the mother expressed frustration about the demands for caring for the children. She was a regular user of text-messaging and the internet MSN message service and, when chatting to friends by these means, she would on occasions grumble about the children. One example, on the evening prior to J’s death, contains the statement that she could have “fucking killed” B, because he had made J cry and been disobedient, and added an additional remark: “I wish I didn’t have fucking kids.”

The case sets out the detailed medical history, which I won’t go into – I couldn’t summarise it better than the Judge has already done, and if you want to read it, I would go to the source.

The Judge sets out the legal position on reliance on medical experts, with the Cannings case unsurprisingly looming large in that regard.

The approach to expert evidence

    1. It is particularly important to bear in mind the point just made above where, as is invariably the case in cases of suspected physical abuse, the evidence adduced includes the opinion of the medical experts. As Ryder J observed in A County Council v A Mother and others [2005] EWHC Fam. 31,

 

“A factual decision must be based on all available materials, i.e. be judged in context and not just upon medical or scientific materials, no matter how cogent they may in isolation seem to be.”

    1. Whilst appropriate attention must be paid to the opinion of the medical experts, their opinions need to be considered in the context of all the circumstances. In A County Council v K D & L [2005] EWHC 144 (Fam) at paragraphs 39 and 44, Charles J observed,

 

“It is important to remember (1) that the roles of the court and the expert are distinct and (2) it is the court that is in the position to weigh up the expert evidence against its findings on the other evidence. The judge must always remember that he or she is the person who makes the final decision.”

Later in the same judgment, Charles J added at paragraph 49,

“In a case where the medical evidence is to the effect that the likely cause is non-accidental and thus  human agency, a court can reach a finding on the totality of the evidence either (a) that on the balance of probability an injury has a natural cause, or is not a non-accidental injury, or (b) that a local authority has not established the existence of the threshold to the civil standard of proof … The other side of the coin is that in a case where the medical evidence is that there is nothing diagnostic of a non-accidental injury or human agency and the clinical observations of the child, although consistent with non-accidental injury or human agency, are the type asserted is more usually associated with accidental injury or infection, a court can reach a finding on the totality of the evidence that, on the balance of probability there has been a non-accidental injury or human agency as asserted and the threshold is established.”

    1. In assessing the expert evidence, I bear in mind that cases involving an allegation of smothering involve a multi-disciplinary analysis of the medical information conducted by a group of specialists, each bringing their own expertise to bear on the problem. The court must be careful to ensure that each expert keeps within the bounds of their own expertise and defers where appropriate to the expertise of others (see the observations of Mrs Justice Eleanor King in Re S [2009] EWHC 2115 (Fam).

 

    1. On behalf of the mother, Miss Judd and Miss Pine-Coffin invite me to bear in mind the decision of the Court of Appeal in the criminal case of R v Cannings [2004] EWCA 1 Crim. In that case a mother had been convicted of the murder of her two children who had simply stopped breathing. The mother’s two other children had experienced apparent life-threatening events taking a similar form. The Court of Appeal Criminal Division quashed the convictions. There was no evidence other than repeated incidents of breathing having ceased. There was serious disagreement between experts as to the cause of death. There was fresh evidence as to hereditary factors pointing to a possible genetic cause. In those circumstances, the Court of Appeal held that it could not be said that a natural cause could be excluded as a reasonable possible explanation.

 

    1. The impact of the Cannings decision on care proceedings was considered by the Court of Appeal in Re U, Re B, supra. Dame Elizabeth Butler-Sloss P identified the following considerations arising from the Cannings decision as being of direct application in care proceedings:

 

“(1) The cause of an injury or an episode that cannot be explained scientifically remains equivocal.

(2) Recurrence is not in itself prohibitive.

(3) Particular caution is necessary in any case where the medical experts disagree, one opinion declined to exclude a reasonable possibility of natural cause.

(4) The court must always be on the guard against the over-dogmatic expert, the expert whose reputation is at stake or the expert who has developed a scientific prejudice.

(5) The judge in care proceedings must never forget that today’s medical certainty may be discarded by the next generation of experts or that scientific research would throw a light into corners that are at present dark.”

    1. Usually, it is unnecessary for the Family Court to go further into the analysis by the Court of Appeal in Cannings, but in this case Miss Judd invites the court to have regard to the whole of that decision. I remind myself that it was a criminal case involving the deaths of infants under the age of six months, whereas these are family proceedings involving the deaths of two children aged two and four. Nevertheless, I find the analysis by the Court of Appeal of what Judge LJ, as he then was, described as two critical problems, as relevant to the current case.

 

    1. First, I note the paragraphs specifically cited by Miss Judd, in particular paragraphs 10 to 13 of the judgment in Cannings, which amplify point 2 in Butler-Sloss P’s summary in Re U, Re B cited above.

 

“(10) It would probably be helpful at the outset to encapsulate different possible approaches to cases where three infant deaths have occurred in the same family, each apparently unexplained and for each of which there is no evidence extraneous to the expert evidence that harm was or must have been inflicted, for example, indications of or admissions of violence or a pattern of ill-treatment. Nowadays such events in the same family are rare, very rare. One approach is to examine each death to see whether it is possible to identify one or other of the known natural causes of infant death. If this cannot be done, the rarity of such incidents in the same family is thought to raise a very powerful inference that the deaths must have resulted from deliberate harm. The alternative approach is to start with the same fact, that three unexplained deaths in the same family are indeed rare, but thereafter to proceed on the basis that if there is nothing to explain them, in our current state of knowledge at any rate, they remain unexplained and still, despite the known fact that some parents do smother their infant children, possible natural deaths.

(11) It would immediately be apparent that much depends on the starting point which is adopted. The first approach is, putting it colloquially, that lightning does not strike three times in the same place. If so, the route to a finding of guilt is wide open. Almost any other piece of evidence can reasonably be interpreted to fit this conclusion. For example, if a mother who has lost three babies behaved or responded oddly or strangely or not in accordance with some theoretically “normal” way of behaving when faced with such a disaster, her behaviour might be thought to confirm the conclusion that lightning could not indeed have struck three times. If, however, the deaths were natural, virtually everything done by the mother on discovering such shattering and repeated disasters would be readily understandable as personal manifestations of profound natural shock and grief.”

Later at (13):

“Reverting to the two possible approaches to the problems posed in a case like this, in a criminal prosecution we have no doubt that what we have described as the second approach is correct. Whether there are one, two or even three deaths, the exclusion of currently known natural causes of infant death does not establish that the death or deaths resulted from the deliberate infliction of harm. That represents not only the legal principle, which must be applied in any event, but, in addition, as we shall see, at the very least, it appears to us to coincide with the views of a reputable body of expert medical opinion.”

    1. Secondly, in considering the Cannings judgment, I note the observations of Judge LJ at paragraph 22, which amplifies point 5 in Butler-Sloss P’s summary in Re U, Re B cited above.

 

“We have read bundles of reports from numerous experts of great distinction in this field, together with transcripts of their evidence. If we have derived an overwhelming and abiding impression from studying this material, it is that a great deal about death in infancy, and its causes, remains as yet unknown and undiscovered. That impression is confirmed by counsel on both sides. Much work by dedicated men and women is devoted to this problem. No doubt one urgent objective is to reduce to an irreducible minimum the tragic waste of life and consequent life-scarring grief suffered by parents. In the process however much will also be learned about those deaths which are not natural, and are indeed the consequence of harmful parental activity. We cannot avoid the thought that some of the honest views expressed with reasonable confidence in the present case (on both sides of the argument) will have to be revised in years to come, when the fruits of continuing medical research, both here and internationally, become available. What may be unexplained today may be perfectly well understood tomorrow. Until then, any tendency to dogmatise should be met with an answering challenge.”

    1. With regard to this latter point, recent case law has emphasised the importance of taking into account, to the extent that it is appropriate in any case, the possibility of the unknown cause. The possibility was articulated by Moses LJ in R v Henderson-Butler and Oyediran [2010] EWCA Crim. 126 at paragraph 1:

 

“Where the prosecution is able, by advancing an array of experts, to identify a non-accidental injury and the defence can identify no alternative cause, it is tempting to conclude that the prosecution has proved its case. Such a temptation must be resisted. In this, as in so many fields of medicine, the evidence may be insufficient to exclude, beyond reasonable doubt, an unknown cause. As Cannings teaches, even where, on examination of all the evidence, every possible known cause has been excluded, the cause may still remain unknown.”

    1. In Re R, Care Proceedings Causation [2011] EWHC 1715 (Fam), Hedley J, who had been part of the constitution of the Court of Appeal in the Henderson case, developed this point further. At paragraph 10, he observed,

 

“A temptation there described is ever present in Family proceedings too and, in my judgment, should be as firmly resisted there as the courts are required to resist it in criminal law. In other words, there has to be factored into every case which concerns a discrete aetiology giving rise to significant harm, a consideration as to whether the cause is unknown. That affects neither the burden nor the standard of proof. It is simply a factor to be taken into account in deciding whether the causation advanced by the one shouldering the burden

of proof is established on the balance of probabilities.”

    1. Later in the judgment, at paragraph 19, Hedley J added this observation:

 

“In my judgment a conclusion of unknown aetiology in respect of an infant represents neither professional nor forensic failure. It simply recognises that we still have much to learn and it also recognises that it is dangerous and wrong to infer non-accidental injury, merely from the absence of any other understood mechanism. Maybe it simply represents a general acknowledgment that we are fearfully and wonderfully made.”

Long term readers of this blog will know that I am a huge admirer of Hedley J, and this observation is very well made. I think on shaking cases we are getting very close, judicially speaking, to a conclusion that we simply cannot be sure until all of the evidence is tested forensically whether a child is likely to have been shaken or not, and as a result, I suspect that we may relatively soon get an appeal on an interlocutory decision to place in foster care,  a child suspected of having been shaken.

The Local Authority had run their threshold in parallel – on neglect, and on the far more serious allegations that the mother had smothered and killed two children. The Judge found that they had proved the neglect allegations.

    1. The local authority alleges that the mother is culpable of serious and repeated acts of neglect of her children and has set out this allegation in the schedule of findings filed in these proceedings. In their response on behalf of their client, the mother’s representatives have very substantially accepted the allegations. Some issues, however, remained and they have formed part of the hearing before me.

 

    1. Having considered the evidence, written and oral, I make the following findings on this aspect of the case:

 

(1) There is evidence that the mother struggled to cope with all of the children. In the early days after B was born, she was unable to cope with his care and often left him in the care of other people, including DA. On one occasion, feeling unable to manage, she left him at the social project where she was receiving support. Later she found it difficult to care for J and A together. As a result she did not always provide adequate attention, stimulation or boundaries for the children.

(2) The mother failed to prioritise her children’s physical and emotional needs, on occasions putting her own needs and interests first. She spent significant periods of time on the internet, including extensive periods communicating with friends via internet chat rooms. The children were expected to fit around the mother’s own wishes and needs. This was a particular concern for the experienced health visitor who gave evidence before me.

(3)On occasions the mother was emotionally neglectful towards the children. On one occasion she announced that she was placing the children in care and packed their bags before being talked out of this by support and social workers.

(4)The home conditions in which the children lived were frequently poor. The mother struggled to keep her home clean and tidy, despite repeated reminders from others, including DA. The home was often left cluttered with rubbish.

(5)On a number of occasions the mother failed to protect and supervise the children so that their safety was at risk. In September 2009, B covered himself in bleach. In October 2009, he was found sitting in bleach. In October 2009, J was taking to hospital having ingested Sudocrem. Stair-gates were fitted but on occasions left open. On other occasions dangerous items were left within the reach of the children, cans of spray, loose wall sockets, paracetamol, scissors, cleaning fluid and medication. On one occasion, J was observed by a health visitor to be in a position to turn a fire on and off. The mother failed on occasion to supervise the children in the street, on one occasion allowing J to walk so far ahead that he was able to cross a road by himself.

(6)The mother struggled to manage the care of the children so as to ensure that they were kept clean and had their nappies changed with sufficient regularity. J was noted on occasions to have a very dirty nappy and to be dressed in dirty, wet and sometimes inadequate clothing. As a result on occasions J and A had very sore bottoms and nappy rashes.

(7)The mother struggled to provide the children with appropriate food. She delayed starting B on solid food. She would give the children inappropriate food on occasions and rely excessively on junk food. J would be fed chocolate biscuits for breakfast. The mother struggled to manage A’s feeding regime as a baby and did not always follow advice on this topic. She told the health visitor that she could on occasions put J straight to bed without giving him any meal if they were late arriving home.

(8)The mother found it difficult to manage the children’s behaviour. She resorted on occasions to harsh chastisement of the children that was both inappropriate for their age and generally excessive. She would smack the children, perceiving their behaviour as “naughty,” not realising that it was often simple normal conduct to be expected of a lively, inquisitive toddler. She would shout at B when he was a baby in a vain effort to keep him quiet. She would resort to corporal punishment to an inappropriate and excessive extent. In October 2010 she was observed to slap B on the legs. She would threaten to smack the children by raising her hand. On occasions she put J in his room for excessive periods and sent him to bed at inappropriate times. On one occasion, as I find, she slapped B on the back of the head after he had run off.

(9)In November 2010 the mother was found drunk in charge of J and A. There is no evidence that this was anything other than an isolated incident; nonetheless it is a matter for considerable concern and jeopardised the safety of the children.

(10)The mother was provided with considerable support throughout the intervention of Social Services. Whilst there is some reason to question the level of support provided, the mother was not always as cooperative with the support workers who asked to assist her. The health visitor felt that her failure to take her advice was wilful. I bear in mind, however, that this mother suffers from a learning disability and I am unsure about the extent to which this was taken into account by the professionals who were trying to help her.

    1. There is a further allegation which concerns the father of the two younger children, GM. The mother reported that she had seen him poke J’s genitals with his finger. Despite her concern about this alleged behaviour, the mother continued to allow GM contact with the children. She states that she found it difficult to say no to him and still had feelings for him. The father has played no part in these proceedings. There has been no oral evidence about this matter and I am not in a position to make a finding about whether he did behave in a sexually inappropriate way towards J. I find however that the mother, knowing of the allegation that the father had behaved in that way, failed to protect J from further contact with him.

 

  1. Taken together, these findings about the mother’s treatment amount to serious and chronic neglect at a time when she was receiving considerable support through Social Services, as well as from her own mother, DA, and from friends and neighbours. Miss Davis and Miss Dewhurst, on behalf of the local authority, have rightly taken the view that it would be disproportionate to conduct an enquiry into each and every allegation about which there is documentary evidence that the mother was unable to cope, but I have heard enough to reach a clear conclusion. I conclude that this mother was simply unable to cope with the demands for caring for her children.

But on the major allegations, that the two children had been smothered (even in the context of those findings that the mother was unable to cope), the Judge did not agree that this was proven.

There were several clinical features which the experts explored . This is the passage of the judgment specifically on the expert evidence as to whether there was evidence of smothering (as opposed to any other possible cause of death)

Evidence of smothering

    1. So far as B is concerned, Dr Cartlidge found no evidence of any general health problems, nor any developmental problems. B was a previously healthy child who died suddenly and unexpectedly at the age of four and a half. Dr Cartlidge described this as “very unusual.” J died suddenly and unexpectedly, aged 28 months. Dr Cartlidge described this also as “very unusual.”

 

    1. Dr. Cartlidge considered that the evidence of a possible intentional airway obstruction in B’s case included: the fact that B was a healthy child; the fact that he had been well no more than half an hour before his collapse; the fact that he had collapsed suddenly without explanation; and the fact that his brother, J, had also collapsed and died suddenly without explanation. On the basis (which I have rejected above), that the petechiae were present on B on arrival at hospital, Dr Cartlidge concluded that they were consistent with, rather than diagnostic of asphyxiation, but stressed that his conclusion did not turn on the presence of the petechiae. Dr Cartlidge concluded that it is most likely that B died unnaturally and “smothering is probable.” He added, however, that “the medical evidence for smothering is not specific and relies quite heavily on the exclusion of other causes and an assessment of the case as a whole.”

 

    1. So far as J is concerned, again Dr Cartlidge found no evidence of any general health problems, nor any developmental problems. Like his brother, J was a previously healthy child who died suddenly and unexpectedly, in his case at the age of 28 months. Once again Dr Cartlidge described this as “very unusual.”

 

    1. Dr Cartlidge considered J’s earlier hospital admissions on two occasions to be significant. On 1st January, J had been well when he went to bed, but two hours later found unresponsive and jerky, with blue hands, feet and face. On admission to hospital some 50 minutes later, he was fully conscious and afebrile, but with petechiae over his chest and upper neck. In Dr Cartlidge’s opinion, this episode considered in isolation would support a diagnosis of a fit, although he noted that the evidence of a fever was weak and the temperature taken in hospital over 37.9 degrees Celsius was not usually sufficient to trigger a febrile fit. So far as J’s second admission to hospital was concerned on 3rd January, Dr Cartlidge noted that once again J had been well or reasonably well at the time he went to bed. Several hours later, he was found pale with staring eyes and possibly twitching of his hands. On admission to hospital, J was found to be suffering from chicken pox, but was very energetic and afebrile. In those circumstances, Dr Cartlidge ruled out the possibility that he had suffered from chicken pox encephalitis on this occasion. Once again Dr Cartlidge considered that this episode, taken in isolation, would not be of significance. However, when considered in the light of the later events, he considers that the admissions to hospital on 1st and 3rd January were concerning. The events that are said to have taken place on those occasions were similar to later events in J’s and B’s lives that resulted in their deaths. However, J’s clinical features on both 1st and 3rd January were not typical of a cardiac arrhythmia. Dr Cartlidge thought that smothering could have caused the clinical features in J on both 1st and 3rd January, as well as those described in both children immediately prior to their deaths. He therefore concluded that smothering was a plausible explanation for J’s death, but added again that medical evidence of smothering “is not specific and relies quite heavily on the exclusion of other causes and the assessment of the case as a whole.”

 

    1. In his oral evidence, Dr Cartlidge said that in his clinical practice he had only come across two cases of children of this age dying without any known cause. He had no experience of two children from the same family dying in such circumstances and he was unaware of any epidemiological study of childhood deaths involving this age group. He was asked to consider a paper produced by counsel for the mother entitled, “Smothering children older than one year of age, diagnostic significance of morphological findings,” by Banaschak and Others (2003) published by Forensic Science International. This paper led Dr Cartlidge to reflect on how B, at the age of four and a half, would have been expected to struggle quite vigorously if an attempt was made to smother him. Cross-examined by Miss Judd, he acknowledged that it was more surprising that there were no marks on the four-year-old child.

 

    1. In his oral evidence, Dr White said that the presence of physical signs of smothering would depend on the size and strength of the victim, the size and strength of the assailant and the method by which smothering was inflicted. In the case of child victims, the older the child, the more likely he or she was to struggle and the greater the likelihood of physical signs. Dr White considered that it was possible that B would have scratched himself in an attempt to prevent suffocation, but the fact that there were no scratch marks observed on B did not rule out suffocation as an explanation.

 

    1. In passing, I remind myself that Dr White noted two small marks, bruises, on the top of B’s head during his post-mortem examination. He did not, however, suggest that they were indicative of a physical assault. The local authority did not ask the mother about these bruises, nor did they feature at all in the local authority’s case.

 

    1. The striking picture provided by the consultant in emergency care, Dr Beardsall, was that B looked like he was sleeping, rather than suffering a life-threatening event.

 

  1. Having found, as explained above, that the petechiae on B’s face were not present when he was admitted to hospital, I conclude that there is no clinical evidence of asphyxiation other than the fact that two children died suddenly with cardiac failure, for which no cause had been identified.

So, the Judge concluded that although the deaths had unusual features, there was not clinical evidence to show that they had been asphyxiated, other than that the deaths had no identified cause.  He reminded himself of the other evidence, the number of genetic factors that were particular to this family and the mother’s evidence (particularly that her emphatic denials were convincing) and that whilst he had found her culpable of neglect such that the threshold was made out, there was still a marked difference between that neglect and deliberate murder of two children.

    1. Miss Judd rightly points out that, whilst the various experts have pointed to the lack of evidence of any disease or condition that could have caused the death of either J or B, there is equally no evidence of smothering. She submits that it is no more likely that this mother smothered each child without leaving any signs, than that the child died of an unknown, probably as yet unrecognised, cardiac cause.

 

    1. This mother has a variety of conditions which are likely to be genetic in origin. Dr Newbury-Ecob accepted that the new variant found in the KCNH2 gene, whilst not a cause of LQTS, might lead to a susceptibility or risk of arrhythmia in the presence of other factors, either genetic or environmental and might be associated with his death in some unknown way. Dr Martin noted that “there are quite possibly a whole host of genetic conditions we know nothing about.” The clear impression from his evidence is that the genetic understanding of cardiac disorders is still evolving.

 

    1. I recall again the observations of Judge LJ in Canningsquoted above, in particular that “where there are one, two or even three deaths, the exclusion of currently known natural causes of infant death does not establish that the death or deaths resulted from the deliberate infliction of harm” and that “a great deal about death in infancy and its causes remain as yet unknown and undiscovered.” I also have in mind the observation of Butler-Sloss P in Re U, Re B cited above: “The cause of an injury or episode that cannot be scientifically explained remains equivocal. Recurrence in itself is not prohibitive. The judge in care proceedings must never forget that today’s medical certainty may be discarded by the next generation of experts or that scientific research would throw light into corners that are at present dark.” Finally, I remember the wise words of Hedley J in Re R, also quoted above: “there has to be factored into every case which concerns a discrete aetiology giving rise to significant harm, a consideration as to whether the cause is unknown …. a conclusion of unknown aetiology in respect of an infant represents neither professional nor forensic failure. It simply recognises that we still have much to learn and it also recognises that it is dangerous and wrong to infer non-accidental injury, merely from the absence of any other understood mechanism.”

 

    1. I have given extremely careful attention to the opinions of all the experts and Dr Cartlidge in particular. I acknowledge that there is a significant possibility that this mother was responsible for the deaths of the boys and my mind has fluctuated during the course of this hearing and in my subsequent deliberations. There may be in due course other evidence that bears upon this issue. Having considered all the evidence put before me, however, I find that the local authority has not proved on a balance of probabilities that this mother smothered either J or B.

 

  1. The consequence of my finding is that, for the purposes of these proceedings, the court and the parties will proceed on the basis that the mother did not smother the boys. For the reasons explained above, however, I have found that the mother was responsible for significant acts of neglect of all the children and on that basis the threshold conditions under Section 31 of the Children Act are satisfied.

This body of caselaw may very well be a watershed moment in care proceedings, where the Courts began taking a stance that the presentation of the parents in evidence can be as pivotal as the seemingly damning medical evidence laid against them, and that mere lack of an alternative plausible explanation than non-accidental injury does not necessarily equate to NAI.  It is liable to lead to the job of Local Authorities in such complex medical cases to be more akin to marshalling and testing the evidence rather than the quasi-prosecutor role that traditionally accompanies trying to prove threshold at a finding of fact hearing.  It is also liable to make senior figures in Local Authorities very nervous about fact finding hearings where the outcomes are now so hard to predict, and the costs so vast.

“Returning home from care” – an analysis of the NSPCC research on rehabilitation of looked after children

The NSPCC have published their research into outcomes for looked after children who are rehabilitated to the care of their parents. The report can be found here: -

http://www.nspcc.org.uk/Inform/resourcesforprofessionals/lookedafterchildren/returning-home-from-care_wdf88986.pdf

Their big headline figure is that over 70% of the children in that situation they surveyed said that they weren’t ready to go home.

That initially made me blink, and wonder why the children had said that to the NSPCC but hadn’t said it to their Guardians, but then I realised that the pool of children concerned were probably the older children who were going home from s20 care rather than care proceedings.

There are still some startling figures in the report, however. In 2011, 90,000 children were looked after in England. 39% returned home (about 10,000 children, compared to the 3,050 who were adopted) Of the children who return home, between a third and a half come back into local authority care because the rehab breaks down, and around half suffer further abuse at home.

The NSPCC suggest that variance in Local Authority practice plays more of a part in whether a child is rehabilitated and whether that rehabilitation is successful than the child’s needs.

The report is quite critical of whether the family Courts have skewed the protection of children as against parental rights and article 6 too much in favour of parents.

“For children on care orders, family courts play a central role in assessing whether a child should return home. Their involvement can lead to improved planning and service provision26. However, courts have been shown to favour parents’ rights over those of the child27,28. Interviewees told the NSPCC that courts often instructed reunification, even when it was not in the best interests of the child, with decision making tipped in favour of the parents rather than the child.”

The tiny footnote there is referring to the Farmer research published in 2011, which is also worth a read.

The NSPCC recommendation in this regard is :-

Action must be taken to ensure that court decisions are always based on the child’s best interests. The new Family Justice Service must ensure that members of the judiciary specialising in family law receive training in child development and the implications of returning home from care. Information made available to the courts must enable members of the judiciary to receive better feedback on the outcome of their decisions.

To an extent, this strikes a chord with the Justice Ryder modernisation campaign, with its suggestion that the Family justice system should commission and take notice of some agreed research, rather than operating in a vacuum. I have to say, that for many years, my default reaction to seeing research quoted in a social work report is to reach for the red pen (or now, the ‘strikethrough’ button) as I know how unpopular it can be with the bench or judiciary to have a lot of research spouted to them -it tends to be either a statement of the bleeding obvious, in which case, why bother, or something which supports a proposition which is controversial (such as – the odds are that this child you’re thinking of sending home is 50-50 to suffer abuse at home as a result, or having five sessions of contact with a parent per week isn’t actually good for a baby) in which case nobody trusts it.

But you know, if all of the time and money we spend in trying to reach the right outcomes for children is resulting in half of the children we send home after that exhaustive process being abused, then we might want to recalibrate.

(of course, from the other side of the coin,  there’s something of a paucity of research as to the number of children who get long-term fostered or adopted when the Court and professionals were wrong and they could  successfully have gone home – that’s probably a harder piece of research to work out – probably working on the parents who go onto have another child and successfully care for that later child)

It is a bit hard to totally trust research commissioned by the NSPCC – I’m not questioning their integrity in the slightest, but when it comes down to working out where they stand on the “Keep children safe at all costs” versus “keep families together at all costs” spectrum (or the Cleveland-Haringey axis, if one is being unkind) it doesn’t take long to spot that they come with an agenda.

(Not necessarily a bad agenda – I wouldn’t claim to be precisely on the fulcrum of that particular see-saw myself – but it makes it harder to rely on their research as probative. It’s like seeing a report from Benson and Hedges about passive smoking – you sort of suspect there’s a starting point there)

 I liked this quote from a senior social work manager, though :- “Support is crucial. [But] we have to take a pragmatic approach as often the support that has been suggested by the courts or experts is simply not available.”

 Very true – an awful lot of expert reports which recommend that the door to rehab is not shut do so in complete absence of context about just how feasible it is that the parents GP will commission six months of therapy for them, and that that can start without delay.

The first bit of this next quote is blindingly obvious, the second part much less so.

Poor parenting, drug or alcohol misuse, domestic violence, and parental mental health problems, all increase the chance of harm when the child returns home. Farmer et al found that 78 per cent of substance-misusing parents abused or neglected their children after they returned from care, compared to 29 per cent of parents without substance misuse problems29

 

78% of rehabs involving substance-misusing parents result in further abuse or neglect. Being a maths guy, that suggests to me that rehab to parents who misuse substances is more likely than not to result in the child being abused or neglected if rehabilitated to their care. (of course, what you argue in any individual case is that for this particular parent, these are the factors that mean the Court can be confident that they are one of the 22% who won’t abuse their child; but that context of how prevalent the risks are to that subject-group remains important.)

 The challenge of rehab to a substance-misusing parent is significant – on the one hand, if you can resolve the drug problems there’s often a good parent underneath, but on the other it is so easy to be over-optimistic about an upward curve on a graph of peaks and troughs being a sign of a genuine change – being too close to the graph to see the pattern as being anything other than up, up and up)

From a bit more of a parental perspective, I think this is probably a valid and fair criticism of LA support.

Where support is provided it is often removed after a short period of time, before a problem has been sustainably addressed. Alongside resource constraints, support can be removed due to a belief that parents need to be able to shoulder their responsibilities and not become dependent on services33. Support is often discontinued once a child returns home without any assessment of whether the families’ problems have diminished. This results in further instability and an increased risk of harm to the child. Parents also report concerns about the short-term nature of interventions designed to support them.

Some more recommendations – all of which make sense to me

Decisions about whether a child should return home must always be led by what is in their best interests.   [Of course, it already is, it is just that what one body thinks is in the child's best interests isn't necessarily the same as what another body thinks]

Support for children and their families prior to and following reunification must improve. 

 The government should ensure there is sufficient support for parents who abuse drugs and alcohol, who are victims of domestic violence, who have mental health difficulties or who have other issues which could affect their ability to parent effectively when their child returns from care. Local services must be incentivised to provide sufficient support for these parents. 

 Local authorities must ensure that the support provided to children and families matches the needs identified in a child’s risk assessment. This information should be used to inform local commissioning and investment decisions. •

Local authorities must ensure that foster carers and residential care workers are involved in the process of a child returning home from care and are supported to help the child prepare for a return home, where that is in their best interests. 

 Guidance on designated teachers for looked after children should be revised to include children who return home from care, even if they cease to be looked after on their return. The support provided by the school can play an effective part in successful returns home.

The very last bit of the report sets out a new method of classifying risk, which the NSPCC are working with 8 local authorities on. To my cynical eye, it looks somewhat simplistic given how complex the variables are in child protection cases, but it’s not bad as a benchmarking exercise. I’m not sure I’d place quite as much weight on them as the child’s wish to return home being an element that allows you to consider the risk is lower. (It seems to be about a third of the factors in weighing the risk, which appears to my untrained eye to be far, far, far, far, too high)

Classifying the risk of reunification – a tool to support decision making about children returning home from care, adapted from Safeguarding Babies and Very Young Children from Abuse and Neglect (Ward, Brown and Westlake, 2012) 

 Severe risk

 • Risk factors apparent and not being addressed, no protective factors apparent.

 • No evidence of parental capacity to change and ambivalence or opposition to return home by child or parent.

High risk

 • Risk factors apparent, and not being addressed. At least one protective factor apparent.

• No or limited evidence of parental capacity to change and ambivalence or opposition to return home by child or parent.

Medium risk

• Risk factors apparent or not all risk factors addressed. At least one protective factor apparent.

 • Evidence of parental capacity to sustain change. Parents and child both want return home to take place. 

 Low risk

 • No risk factors apparent, or previous risk factors fully addressed, and protective factors apparent.

• Evidence of parental capacity to sustain change. Parents and child both want return home to take place.

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