Looking after infant mental health: our case for change A summary of research evidence
When a young child experiences abuse or neglect and ends up in care they are at greater risk of mental health problems and other poor outcomes throughout their lives.
If they are given safety, stability and the right support early on they can recover from this trauma and get back on track.
Our case for change emphasises the fundamental importance of looking after infant mental health. Drawing on evidence from research and practice it builds a compelling case for rethinking how we work together to put the health and well-being of young children in care and the quality of their future life outcomes at the heart of decision-making.
Children who experience abuse and neglect, like children who end up in care, are at greater risk of mental health problems and poorer outcomes later in life
- Children in care are 4 times more likely than their peers to have a mental health difficulty and 6 to 7 times more likely to have conduct disorders. Children with the poor self-control associated with these disorders are more likely to be involved in crime as adults.
- At age 19, care leavers are more than twice as likely as their peers not to be in education, employment or training (41% compared to 15% of their age peers) (National Audit Office, 2015).
- Adults who were maltreated as children are at increased risk of physical health problems, including cardiovascular disease, and mental health issues such as substance abuse and suicide (Deans et al, 2009; Dube et al, 2001).
Very young children are particularly vulnerable to abuse and neglect, and trauma can have a profoundly negative effect on their development
- 20% of children in care and over 40% of children subject to a child protection plan in England are under 5 years old (Department for Education, 2015).
- In England and Wales, babies are more than 7 times more likely to be killed than older children (Office for National Statistics, 2015).
- The first months and years are critical to a child's development, laying the foundation for future learning, behaviour and health (Center on the Developing Child, 2009).
- 'Toxic stress' caused by trauma, abuse and neglect disrupt the developing brain's architecture and chemistry, which can lead to severe damage and lifelong consequences for the child (Scannapiecco et al, 2005).
- Research shows babies as young as 4 months can experience depression as well as serious psychiatric disorders related to attachment and traumatic stress (Luby, 2000).
There is hope of recovery for maltreated babies and infants in care, but it needs to happen early
- Positive experiences and good relationships between children and carergivers form the basis of lifelong mental health (Dozier et al, 2006).
- Stability, loving attachments and nurturing have an exceptional effect on the recovery of the developing brain. When infants who have suffered abuse or neglect are placed with loving carers, whether family or not, they demonstrate rapid, healthy brain development comparable to peers who aren't in care (Rubin et al, 2004; James et al, 2004).
- Evidence suggests that when high quality caregiving is combined with added interventions this can also improve a child's wellbeing (Luke et al, 2014).
- But this needs to happen in infancy – when neural connections are still being made at a rapid rate and the effects of traumatic stress can be undone, giving children the chance to catch up with their peers on social, emotional and intellectual development.
- There is a small window of opportunity for this kind of recovery so early identification and focused intervention are imperative (Department of Health, 2012).
Stable relationships really matter, but many children who are in care get moved from one placement to the next, or returned to a home that can't support them well
- One of the most robust predictors of poor outcomes for children and infants who have been abused is placement instability whilst they are in care (Rubin et al, 2004; James et al, 2004). In England, in 2014-15, nearly a quarter of children in care moved placements 2 or more times (Action for Children, 2015).
- Children with poor mental health when they enter care are most likely to experience this placement instability, creating a damaging multiplier effect as their experiences of instability make their mental health worse (Bazalgette et al, 2015).
- Placements often end prematurely when foster carers cannot cope with a child's behaviour or are unable to meet their needs. Foster carers can struggle to understand and respond if a child has challenging emotional and behavioural needs. A lack of professional support for foster carers can leave them feeling isolated and helpless (Schofield and Beek, 2005).
- For some children, returning home from care is the best possible outcome. But research shows that for many others this can result in further abuse and neglect, with many children ending up back in care (DFE, 2013; Farmer, 2011; Wade, 2011).
Foster carers need specialist support to give children the best care possible
- The 2 most common causes of placements breaking down are children's challenging behaviour and foster carers' lack of confidence in managing the behaviour (Sinclair et al, 2005).
- Foster carers often look after children with significant emotional and behavioural challenges whilst balancing the needs of the rest of their family.
- Due to a national shortage of foster carers, some local authorities overburden carers, asking them to care for children with needs they are not equipped to deal with and not giving them adequate support even in difficult circumstances (Pearlman, 2010).
- It is vital foster carers receive advice and support to develop the enhanced parenting skills needed to meet the behavioural, developmental and therapeutic needs of children in their care.
- Foster carers need to be attuned and responsive to every child they care for. They need a good theoretical understanding of attachment development and the impact of trauma, separation and loss. Crucially they need to be able to translate this theory into practice (Schofield, 2009; Golding, 2008).
And more needs to be done to help birth parents to care for their children – those they have now and any they may have in the future
- Vulnerable parents need support to develop nurturing relationships with their children.
- A successful return home is one of the best steps for children in care, but unfortunately it is very common for children to return home and face the same neglect and abuse which led to them being taken into care in the first place.
- Children are often returned home to parents having difficulties with alcohol and drug misuse and ongoing relationships with violent partners. A lack of support for parents is a key factor in the breakdown of reunions between children in care and their parents (Wade et al, 2011; Farmer et al, 2011).
- Abuse or neglect are recurring problems within families – research indicates that a quarter of children in care proceedings in England have mothers who have had a previous child removed (Broadhurst et al, 2015).
- Many of the women who have their children removed had difficult childhoods themselves and are severely emotionally damaged. When a child is removed from her care, a mother is unlikely to receive the level of support she needs to overcome her problems because agencies do not have a statutory duty to provide comprehensive post removal support.
- The result is a devastating cycle of family court proceedings for these mothers. Almost 1 in 4 women return to the family court (1 in 3 young mothers). Many of these women become pregnant shortly after, or even during, care proceedings involving their previous children (Broadhurst et al, 2015).
Despite all the evidence, services designed to identify and look after the mental health of babies and infants are virtually non-existent
- The mental health needs of young children are largely overlooked in the current system. They are not routinely assessed and most local services only start mental health provision for children from the age of 5 (Hardy and Murphy, 2014; Joint Commissioning Panel for Mental Health, 2013).
- Research shows that when screening and assessment programmes are introduced, the proportion of under-5's in care identified as having social, emotional or mental health difficulties rises significantly (Southwark Child and Adolescent Mental Health Service for Looked After Children, 2012).
- Therapeutic support is vital if children who have been abused and neglected are to recover from their experiences and rebuild their lives.
- 98% of professionals working with children who have experienced abuse or neglect report a lack of therapeutic support. Services are often only available to children with chronic problems, or those who are suicidal or self-harming. Priority is not given to children who have been abused who have no obvious signs of mental health difficulties (NSPCC, 2016).
- Despite commissioners of health and social care services acknowledging the benefits of early intervention, and government calling for greater focus on mental health, children's mental health services have suffered significant budget cuts in recent years (Gander, 2016).
- Under financial pressure, children's social care providers act as emergency services rather than intervening early with children and families to prevent problems developing in the first place (House of Commons Health Committee, 2014).
The effects of not intervening early are damaging not only for the child as they grow up, but also to society as a whole
- Local authority spending on children in care in England rose to £3.4 billion in 2012/13, £1 billion of which was spent on residential care placements for children with the most severe needs (at an average cost of £131-£135K per child) (Comptroller and Auditor General & Department for Education, 2014).
- Total annual costs for failed reunifications amount to £300 million, or £61,614 annually for each child who returns back to care from home (Holmes, 2014).
- Children's early experiences can have long-term impacts on their emotional and physical health, social development, education and future employment – which can lead to significant long-term costs to the public purse (Comptroller and Auditor General & Department for Education, 2014).
- Rather than directing money into preventing problems occurring in the first place, we mostly spend money on costly 'late interventions' for children and families. In England and Wales, late intervention costs the state £17 billion a year. The costliest interventions are taking children into care, dealing with the consequences of domestic violence, and welfare benefits for 18-24-year-olds not in education, employment or training (Early Intervention Foundation, 2015).
- Between 2010-11 and 2015-16, local authority spending on early intervention services for children and families fell by 31% in real terms. In the same period, central government early intervention allocation fell by 55% in real terms. Over the next 3 years, central government allocation will fall by a further 29% in real terms (Action for Children, NCB and the Children's Society, 2016).
- Yet the research evidence is clear: intervening early to improve the mental health of young children is one of the most cost-effective ways of improving mental and physical health, and national productivity as a whole (Olds, et al, 1998; Stewart-Brown, et al, 2004; Heckman and Masterov, 2007).
Looking after the mental health of every infant in care means comprehensively understanding their individual needs, ensuring they experience sensitive and nurturing care as quickly as possible, and supporting them to recover from trauma through effective, evidence-based treatments (Woolgar, 2013).
More resources and information
Mapping mental health services for looked after children in London aged 0-5 years
We commissioned King’s College London to complete a short mapping review of mental health services for young children in care in London.
Process evaluation of the New Orleans Intervention Model for infant mental health in Glasgow
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Action for Children (2015) Thousands of foster children move home several times of year.
Action for Children, NCB and The Children's Society (2016) Losing in the long run: trends in early intervention funding.
Bazalgette, L., Rahilly, T. Trevelyan, G. (2015) Achieving emotional wellbeing for looked after children. NSPCC.
Broadhurst, K. et al. (2015) Connecting events in time to identify a hidden population: birth mothers and their children in recurrent care proceedings in England. (British journal of social work, Vol.45, No.8) pp 2241-2260.
Center on the Developing Child (2009) Five numbers to remember about the developing child. Harvard: Center on the Developing Child.
Comptroller and Auditor General & Department for Education (2014) Children in Care. London: National Audit Office.
Deans, K. A., Bezlyak, V., Ford, I., Batty, G., Burns, H., Cavanagh, J., et al. (2009) Differences in atherosclerosis according to area level socioeconomic deprivation: cross sectional population based study. British Medical Journal. 339, b4170.
Department for Education (2015) Characteristics of Children in Need, 2015-2015: national tables. London: Department for Education.
Department for Education (DfE) (2013) Data pack: improving permanence for looked after children (PDF). [London]: Department for Education (DfE).
Department of Health (2012) Report of the children and young people's health outcomes forum. London: Department of Health.
Dozier, M., Manni, M., Gordon, M.K., Peloso, E., Gunnar, M.R., Stovall-McClough K.C. (2006) Foster children's diurnal production of cortisol: An exploratory study. Child Maltreatment. 11,189–197.
Dube, S. R., Anda, R., Felitti, V., Chapman, D., Williamson, D., Giles, W. (2001) Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: finding from the Adverse Childhood Experiences Study. Journal of the American Medical Association, 286, 3089–3096.
Early Intervention Foundation (2015) Spending on late intervention: how we can do better for less (PDF). [London]: Early Intervention Foundation.
Farmer, E. et al. (2011) Achieving successful returns from care: what makes reunification work. London: British Association for Adoption and Fostering (BAAF).
Gander, K. (2016, January 27) 'Inadequate' mental health services leave children 'languishing without support', NSPCC warns. The Independent.
Golding K.S. (2008) Nurturing Attachments. Supporting Children who are Fostered or Adopted. London: Jessica Kingsley Publishers.
Hardy, C., Murphy, E. (2014) Social-emotional screening for 0-4 year old children entering care. In Tarren-Sweeney, M., Vetere, A. (Eds.), Mental health services for children and young people. Abingdon: Routledge.
Heckman J. J., Masterov D. V. (2007) The productivity argument for investing in young children. Review of Agricultural Economics, 29, 446–493.
Holmes, L. (2014) Supporting children and families returning home from care: counting the costs. London: NSPCC
House of Commons Health Committee (2014) Childrens’ and adolescents’ mental health and CAMHS: Third report of session 2014-2015. London: House of Commons.
James, S., Landsverk, J., Slymen, D. J., Leslie, L. K. (2004) Predictors of outpatient mental health service use: the role of foster care placement change. Mental Health Services Research, 6(3):127-4.
Joint Commissioning Panel for Mental Health (2013) Guidance for commissioners of child and adolescent mental health services.
Luby, J. (2000) Depression. In C. Zeanah (ed.) Handbook of Infant Mental Health (pp. 296- 382).
Luke, N., Sinclair, I., Woolgar, M., Sebba, J. (2014) What works in preventing and treating poor mental health in looked after children? Oxford: Rees Centre, NSPCC.
National Audit Office (2015) Care leavers' transition to adulthood.
NSPCC (2016) 96% say support for children after abuse 'inadequate'.
Office for National Statistics (2015) Focus on violent crime and sexual offences, 2013/14. Newport: ONS
Olds D., Henderson C.R., Cole R., Eckenrode J., Kitzman H., Luckey D., et al. (1998) Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280, 1238–1244.
Pearlman, D. (2010) Independent Review Mechanism (Adoption and Fostering) Annual Report 2009/10. London: BAAF/Independent Review Mechanism/Department for Education.
Rubin, D. M., Alessandrini, E. A., Feudtner, C., Mandell, D. S., Localio, A. R., Hadley, T. (2004) Placement stability and mental health costs for children in foster care. Pediatrics, vol. 113 no. 5 1336-1341.
Scannapieco, M. and Connell-Carrick, K. (2005) Understanding child maltreatment: an ecological and developmental perspective. Oxford: Oxford University Press.
Schofield, G. (2009) Permanence in Foster Care in Schofield, G. and Simmonds, J (eds) The Child Placement Handbook: Policy, research and practice. London: BAAF.
Schofield, G., Beek, M. (2005) Risk and resilience in long-term foster-care. British Journal of Social Work 35, 8: 1283-1301.
Sinclair, I., Wilson, K., and Gibbs, I. (2005). Foster placements: Why they succeed and why they fail. London: Jessica Kingsley Publishers.
Southwark Child and Adolescent Mental Health Service for Looked After Children (2012) Annual report 2011-2012.
Stewart-Brown S., In Morgan A., Swann C., eds. (2004) Social Capital for Health: Issues of Definition, Measurement and Links to Health. NHS, Health Development Agency, London.
Wade, J. et al. (2011) Caring for abused and neglected children: making the right decisions for reunification or long-term care. London: Jessica Kingsley.
Woolgar, M. (2013) The practical implications of the emerging findings in the neurobiology of maltreatment for looked after and adopted children: recognising the diversity of outcomes. Adoption & Fostering, 37(3), 237-252.