Scotland’s independent think tank
Scotland’s independent think tank

Early Intervention & Pastoral Care Key to Addressing Adverse Childhood Experiences – Rhona McLeman

From the moment of birth a million connections are made within a baby’s brain every second; beginning to hard wire everything from how that wee person experiences the world to learning about relationships through the connections made with the faces that swim into focus.  Early childhood is a time of exponential growth and developmental progress and as a Health Visitor, it is a privilege to walk alongside families as they experience all the joys and challenges this can bring.

Health Visiting is a unique profession, working in a strength-based, salutogenic (health-creating) way, we visit families in their homes, building trusting relationships and playing a significant role in providing support to overcome adversity. The role is complex and at its foundation is the quality of the connections which are formed with families; knowing when to offer containment, knowing how to empower and when to advocate. Health Visitors must work on suspending their nursing ‘fixing’ skills, instead walking alongside parents to reduce the barriers that prevent them being the best they can be.  Of course not every family requires the same level of support and the power of Health Visiting comes in its universal proportionalism, the way in which our service is resourced and delivered as a universal service for all but with an intensity proportionate to the degree of need. Through this approach Health Visitors get to know the needs of their individual communities and the challenges of disrupting intergenerational trauma and preventing Adverse Childhood Experiences (ACEs) from occurring.

The link between adversity experienced in childhood and its impact on health in adulthood was first made in the late 1990s. Since then the knowledge base around ACEs has grown considerably. We know that ACEs are stressful and potentially traumatic experiences that occur in childhood or adolescence and that they influence a child’s development making them more likely to engage in risk taking behaviours and experience increased physical and mental ill health in adulthood. Research tells us that there is a higher risk of experiencing ACEs if you are born into a family experiencing poverty. Compared with those with no ACEs, those with four or more ACEs are twelve times more likely to experience alcoholism, drug use, depression and suicide attempts. Strikingly, if we could prevent ACEs occurring in childhood it is estimated we could reduce the numbers of adults suffering with depression by as much as 44%.  

In coproduction with colleagues across the local Health Visiting teams, we undertook a project to transform record keeping. As in many areas of health care, Health Visitors were documenting rich detail in patient’s records about families’ experiences and the challenges they faced however in a format that was uncollectable and therefore prevented any further analysis from occurring. We sought to change this and are now able to capture data and view it interactively through a dashboard that allows for analysis. Our early ACEs data provides evidence that the greatest adversity facing children in our communities is having a parent living with a mental health condition. For these children the impact can be wide ranging; from poor attachment affecting their own ability to form connections, to not managing within the classroom to being socially isolated and lacking the opportunities to make friends. As a Health Visiting service, we plan to use our new found knowledge to inform our early intervention work in specific areas but also to work alongside our Public Health colleagues to consider how this new data can be best used to influence policy and direct funding.

The project described above is just one example of innovation within Health Visiting practice aimed at putting the focus firmly on early intervention and prevention of adversity and there are many more. Health Visitors often look creatively at the public health challenges within their communities and will work with people locally to find solutions. Undoubtedly, across the country there will be Health Visitors working hard on their own areas of service development in response to gaps encountered or issues raised, after all the Nursing and Midwifery Council Spheres of Practice for the profession indicate this a key area of our practice. What does not exist however is a specific professional and strategic lead at national level … a Chief Health Visitor.

Whilst we have a Chief Nursing Officer and a Chief Allied Health Professions Officer sitting within the Chief Nursing Officer Directorate at Scottish Government level the responsibility for oversight of early years and children sits under the Chief Midwifery Officer’s remit. These senior roles are necessary and in many ways achieve their aims of providing policy advice to ministers and delivering strategic and professional leadership. However, in order to be effective in leading the kind of reform that will impact on reducing ACEs and intergenerational trauma through investment in early intervention across childhood and adolescence I would argue that a further specialist Chief Officer role is needed.

If we are serious about health and education reform, we must look towards a model which promotes and provides early invention in families where adversity exists. At present Health Visitors provide specialist pastoral support (care provided to ensure physical and emotional wellbeing) to parents until their child goes into Primary One. From this pivotal moment, forwards families must negotiate the challenges of parenthood without this intensive professional input. Many families have circles of support to call upon and due to their resilience weather the storms that parenting can sometimes bring. However, other families have little resilience promoting factors in their lives and have often needed regular Health Visiting support to keep them afloat. Every year from August onwards, we continue to have families who reach out for support after their child has started school. They know they have been discharged from our care but are accustomed to being able to ‘check in’ with a trusted professional for advice and support. These families have had home visits where the Health Visitor has had time to listen, to contain, to signpost and advocate for them allowing them to overcome some of the barriers and wider stressors affecting family life and without this, they begin to flounder.

In my experience, it is not that primary schools do not wish to provide this type of support to families most in need but the current system and resources available are not designed with this in mind. There is little in the way of home visits, which would allow education staff to understand the complex needs of vulnerable families. Nor is there the capacity for staff within schools to have time to focus on building relationships with parents to understand the barriers faced and then work alongside families to reduce these. The School Nursing Service, which could be well placed to provide pastoral care is currently a referral only service and it relies on these referrals to highlight families otherwise they go unseen. The current capacity of School Nursing is such their work is dominated by supporting families who are experiencing the greatest adversity due to this there is little scope to focus on early intervention public health approaches which would go some way to alleviating adversity occurring. When pastoral care is more present again in secondary school for many families this comes as too little, too late. The work done in the early years has now lost momentum and the challenges facing some families have become insurmountable.

If we are serious about reducing health inequalities and adversity experienced in childhood I believe we must look to provide proportionate pastoral support to parents throughout childhood not just the early years. We must do this through reform that chooses to prioritise delivering models of care which promote and provide early intervention through strategic national focus on leadership in this area.

Rhona McLeman is Health Visitor and Queen’s Nurse.

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