Risks, rights and the role of the state: Early intervention

[Introduction]

The Research in Practice for Adults podcast, supporting evidence-informed practice with adults and families.

Dez: Welcome to the Research in Practice podcast. Over this series we're focussing on risk, rights, and the role of the state. I'm delighted to welcome Nick Axford here today, and you're going to be focussing particularly around early intervention in the context of risk, and rights, and the role of the state. Nick, do you want to start by introducing yourself, please?

Nick: Sure, yes, hi. So, I'm an associate professor down at Plymouth University, and a senior associate at the Dartington Service Design Lab, and worked at Dartington for about twenty years, focussing in particular on prevention and early intervention.

[The development of discussions and understanding around early intervention]

Dez: So, as I've said before, we're doing a series of interviews with various people on a range of topics, all under this overarching theme of risk, rights, and the role of the state. Now, you've been working in and around early intervention for many years, how have you seen the discussions and understanding change over that time?

Nick: Okay. Well, I started working at Dartington about twenty years ago, and I think it is fair to say at that time, the term 'early intervention' wasn't in common use, so we talked a lot about family support in particular. There was a lot of discussion and debate at the time about the needs of children, and this was particularly in light of the 1989 Children Act, and focussing on identifying and then serving children in need. I think it was in that context that we started to think particularly about risk, but we thought about it terms of risk and protective factors. So, risk factors being factors in children's lives that make it more likely that certain harmful outcomes might happen down the line, and protective factors of course being factors that, in the context of risk, might protect the child against the risks that they're facing. And I think thinking about it in terms of need is quite a helpful lens to think about it, because it shows that risk is not deterministic, it's probabilistic. And if you look at children in the round in terms of their living situation, their family situation, their school and so on, and you look at what the risk and protective factors are, it helps you to have a good holistic sense of what their needs might be. There was also a lot of discussion then around the rights of children and the rights of parents, and clearly that's still a very live discussion. I think one of the things that we are increasingly looking at in the context of early intervention is thinking about how to involve families and children in the design of interventions for them.

Dez: I'd like to just pick up, if I may, on a point that you made there about risks not being deterministic, but rather working with probabilities. That seems to me a really important point to interrogate. I think there seems to be, I would observe, a tendency, not just in early intervention, I'm thinking also of things like child sexual exploitation, a real desire to find neat mechanisms, neat solutions, risk assessment tool kits, indicators, which are then being treated as if they are predictive, not indicative. Can you tell us a little bit about your thoughts on that, what you meant there about determinism rather than…

Nick: Yes, well, I think we know at the aggregate level that certain factors are known to be strongly associated with other outcomes, and particularly as children grow up. So, things that children experienced in childhood, it could be family violence, it might be living in a poor neighbourhood, it might be having particular character traits, we know that children with some of these risks are more likely to develop certain problems later in life. That's not to say that they always will, and that's very important, as you say, it's probabilistic, and it depends on what else is going on in their life. And so I think, when applying these ideas at an individual child level, it's very important to think in the round, as I say, to look at not just the risk factors in their lives, but also some of the protective factors as well. Because we know that if certain things are present in children's lives, that even in a context of risk, their development can still be reasonably good, even very positive. So, when it comes to targeting early intervention, I think we need to think with that mindset. And checklists are very crude, obviously it needs to be, to my mind, it needs to be more careful, more holistic than that.

[The role of evidence in decision making around early intervention and risk]

Dez: Now of course not all early intervention is about reducing risk, or at least not a sense of risk of serious harm, and that's important to note because sometimes we can hear early intervention being talked about as if it only exists as a gatekeeper or step down function for social care, particularly child protection. Where early intervention is about reducing that risk of serious harm, where it is closely connected to social work, social care functions, what kind of evidence do we have that suggests it can be effective in reducing those risks?

Nick: Well, I think there's a lot of evidence around that, and of course a lot of that evidence comes in the form of systematic reviews, meta analyses. So, there's, kind of, the question of the type of evidence, say, from these kind of studies which look at a range of primary studies, so particularly randomised control trials, but also other evaluation designs, and they would look at the evidence from across these studies and try and synthesise them, sometimes in a narrative form, sometimes in a statistical form. But that gives us a good sense of what is and isn't effective, and also, to some extent, the factors that are associated with or predictive of things that are more effective. And there are a lot of systematic reviews and so on in various areas that are relevant to this subject, so obviously child abuse and neglect, sexual abuse, domestic violence, potentially things like gang violence as well, and bullying, of course, as well. So, we have a lot of evidence around those things. I think it's fair to say that often these systematic reviews conclude that effects are small to modest, so we have to accept that, and often they are short-term and they're not sustained, so that's an issue. Quite a lot of the research, probably the majority of the research, comes from outside of the UK, and in particular from North America, so we need to be aware of that. There are some challenges therefore around replication both of interventions, and also of their effects.

That said, I think there is a lot of evidence we should feel quite positive about, that there are tangible benefits of these kinds of interventions, and there are some things that are transportable, we know that. So, they might have been tested in different environments originally, but when they're tried elsewhere, they show that they're effective, so they have that transportability. I think it's fair to say that we tend to know, a lot of the research, particularly around child abuse and neglect, the outcome measures tend to be proxies for child abuse and neglect. So, the evidence might be more for reducing harsh parenting, let's say, than confirmed instances of child abuse and neglect, and that's partly to do with issues of measurement, which can be difficult. And sometimes it's because studies just haven't measured these things.

Dez: Is it heretical of me to suggest that some of this stuff we don't need an RCT to back it up, or quasi-experimental design, and we should be doing it because it's the right thing to do in some cases? And that might be true of various forms of early intervention. Is that a deeply anti-intellectual way to go about this?

Nick: No, I think it's a really fair point. I think there is a lot of stuff that, on the face of it, you look at it and you think, 'Firstly, it's important to do something about this. We don't need evidence to tell us, I don't think, that doing something about child abuse and neglect, or domestic violence… we don't act on that just because it causes harm to children down the line. We do it because it violates their rights and all that kind of stuff as well.' So, that's the first thing I'd say. Second thing I'd say is I think we have to be conscious, I think, that while we may have good intentions and we might think some things are good, it's good to test those things, but I think we need a degree of humility here. We know from other areas, youth justice is a good example, that things that people thought were good ideas weren't good ideas. Scared Straight is the classic example of a programme that took young kids who were on the verge of crime, getting into anti-social behaviour, took them to prison, the idea was it would scare them away from a path of crime. And multiple trials have now shown that far from doing that, it actually makes them more likely to get involved in crime. And there are various theories about why that is, one being that they're hanging out with other kids who are like them, and they, kind of, egg each other on, and they see that prison maybe isn't as bad as they thought, and so on and so forth. And there are other examples as well, but that's the best-known one.

There are studies that show that various interventions are effective in this area, but that they are more effective if those interventions have certain characteristics. So, for example, if they are of a certain length, or if they are delivered by certain people rather than other people, or if they contain certain content, maybe more on skills rather than just giving information. So, research helps us with that, I think, it helps us to not just to know that certain types of intervention are effective, but knowing how to make sure that they are more effective, and to try and make sure that we invest more of our time and money on those things that are more effective.

Dez: What you're describing there are common threads, or characteristics, or design features, which increase the probability that something will be effective for more people more often, which is a much less sexy, snappy expression than 'what works', but it's absolutely right that you are setting that out in a more nuanced way, I think.

Nick: I think that's right, and I completely buy that. I mean, I think the whole 'what works' thing, it's a convenient shorthand, it's no more than that. And I think most people, and I include myself, who work in that area, we understand that it is about things working in-, who does it work for, in what setting, in what context? And all that kind of stuff. It's a shorthand.

Dez: You've talked a little bit there about how we can access evidence around, we hope, more effective early intervention. What would you describe as the key characteristics, common threads, common factors? What type of thing tends to be important?

Nick: I think it various enormously depending on the… on one level it depends a lot on the area that we're looking at, so whether that's preventing child maltreatment, preventing youth crime, preventing bullying and so on. But I think there are some things that run across all of those. So, firstly, I think the more effective interventions tend to be very clear about what they're doing and why it's likely to be effective, so they tend to have a clear theory of change or logic model, or whatever, their assumptions about why intervening in a particular way will be effective, so that's the first thing. And secondly, I think they're very clear about who they're trying to reach, and they are deliberate about reaching those families and children, so they don't just assume that children and families will come to the door. They know who they want to find, and to some extent there's some outreach, they try to find them as well. I think another thing is that they tend to be implemented well. That doesn't necessarily mean that they are implemented exactly as it says in the intervention design, there's some degree of adaptation involved, but if they're implemented by people who are properly trained and supported and so on, then they will be more effective. I think in some areas, I mean, a good example would be child mental health. Again, you might say that this is self-evident and common sense, but we're learning that it probably makes sense to intervene in several settings. So, for example, there are school-based interventions around children's mental health, and for that matter, other aspects of their health and well-being, it might be obesity and so on, and there might be school lessons about some of these subjects. The evidence suggests that those interventions have limited effectiveness unless they are complemented by other things. So, for example, you don't just teach kids’ lessons about things, but you have a whole school environment that is reinforcing those messages, and you're engaging parents and potentially the wider community. So, kind of, more of a multi-component or even systemic approach to addressing some of those issues.

And a couple of other things I'll just say briefly, one is I think a lot of early intervention programmes are underpinned by quite similar theories, and we've tended to become a little bit obsessed in the field with what I think of as 'the wrappers'. So, there are a zillion parenting programmes, for example, and we tend to obsess a little bit about exactly which one is the most effective. And it's a little bit like obsessing, you know, is Twix better than Mars, better than whatever else? And what I think would be helpful, if we think more about what's the common underlying logic model? So, whether that's driven by social learning theory, or attachment theory, or in the case of youth crime, the social development model, which puts a big emphasis on children having opportunities to learn skills, to develop skills and so on, those things, it seems to me, are more important.

Dez: I couldn't agree more. When you said 'obsessed with wrappers', I thought you might be about to break out into some rap, but I see now you meant, sort of, the packaging.

Nick: I could do some rapping, if you like.

[The application of programmes and manuals]

Dez: Yes, we'll definitely have you rapping before the end of the podcast. And about the packaging almost being a bit distracting, and we might be better to focus on those, kind of, core elements, and the underpinning theoretical framework for it, that prompts another question for me around what we would sometimes call the balance between fidelity and context, and you touched on this earlier around adaptation. Why are we so utterly preoccupied with manualistic fidelity, and are we maturing from that? You can hear the hope in my question, perhaps, Nick.

Nick: That's a good question. Well, I guess in the first instance, a lot of these interventions were developed not necessarily as a product that would be widely disseminated, a lot of them were developed to test theories, and developed often in universities, in, kind of, almost laboratory-like conditions, I use that term broadly. And therefore, in order to test whether a certain theory works, it was necessary to develop manuals so that the people delivering the intervention delivered it as intended, so that they could test whether intervening in a particular way worked or was effective in improving outcomes. I think what's happened then is some of those programmes have then gone on to become commercial products, or sometimes freely disseminated, but sometimes commercial products. And I guess I think of that in a couple of ways, one is it's worth noting that often in these manuals, the intervention developers acknowledge the importance of adaptation, so the perception is that they are very, very rigid and they say, 'You absolutely must do this like it says on the tin. There's absolutely no room for manoeuvre.' In my experience, that's not entirely true. A lot of these programmes, interventions, the manual says, 'This is broadly the structure, this is the underlying theory, these are the lessons, or sessions,' or whatever. 'But you're dealing with people and you've got to relate it to them.' So, a good example would be something like the PATHS programme, which is a social and emotional programme that goes in to schools.

The developer, Mark Greenberg, is very clear that if you've got a lesson scheduled for that day, and just before the lesson a big fight breaks out at playtime, for example, don't ignore it, weave that into the lesson and make the lesson relevant to that situation. So, that's just a simple example. I think the other thing I'd say about manuals as well is that they are… where I think they potentially have strengths is in helping. I think they can help all practitioners, but arguably, some of the practitioners who are perhaps not as strong as others. And there's some evidence of practitioners saying, 'We found the manuals really helpful, they helped us to sharpen and hone our skills,' and so on. But I do think that, I don't have evidence of this, but I suspect that they could be more helpful for practitioners who are weaker, so I think we need to bear that in mind. In terms of 'are we maturing from that?', I think probably to some degree I think we're certainly becoming aware that there are these common underlying logic models or theories of change. The question is then what do to about that. So, for example, we could say, 'Well, let's identify what are some of the common features of these interventions,' and then we could train practitioners in using those. I think that's probably a healthy thing and a good idea. I worry slightly that what will then happen is people will say, 'Well, it would be really useful if we packaged these together in some way,' and we'll, kind of, come full circle and we'd be back at manuals.

I would say that I think it's slightly crazy we have so many programmes. I don't personally care, for example, Incredible Years is a very well-known parenting programme, it's one of the programmes that has good evidence of transportability, it seems to be effective in different contexts, and I don't really care terribly whether people do Incredible Years. What I do care about is are people who are delivering parenting programmes in children's centres, or schools, or community centres, or whatever, are they doing what the evidence suggests is highly effective and what we have learnt from Incredible Years? And it could be that Incredible Years is the best means of delivering those things, but there might be other things as well. And one of my interests is thinking about looking at how we can make practice that is already scaled and is already widely prevalent. How can we make that more evidence-based? So, there are people doing work on this, so looking at… a good example would be, let's say, mentoring programmes for young people who are getting involved in anti-social behaviour. There are lots of mentoring programmes around, what we could do is say, 'Well, instead of introducing a new mentoring programme into a local authority, why don't we look at the ones that exist and in some way, kind of, rate them or measure them against what we know to be the effective features of good mentoring programmes?' And then see if we can improve existing practice.

And, you know, maybe some of them are too short, or maybe they don't spend enough time matching the young person with a mentor, etc., etc., and we can improve things in situ. But certainly there is a push towards personalising some of these interventions. So, for example, I'm involved in some work at the moment with Family Nurse Partnership (FNP), which as you know, is a home visiting programme for young mothers, teenage mothers often from very disadvantaged backgrounds. A big trial in England showing no effect on the primary outcomes, and small effects on a handful of secondary outcomes. So, I think it obviously was very disappointing for everyone involved at the time. There was a little debate around the outcome measures, and that was captured in some journal articles, there was a bit of to-and-fro between the developers and some other experts in the field, questioning whether the outcome measures were the right ones. And I think that was probably a valid debate, but on outcomes where it was expected that FNP would have an impact, it didn't, and we need to be straight about that and not try and cover that up. So, the work that's happened since has had two elements, really. One is adapting the programme in terms of some clinical content. So, for example, adapting content around smoking cessation, breast feeding, domestic violence and so on, and trying to take on board the best, most recent evidence around those things, but also working with nurses and service users to try and co-design adaptations to the intervention.

And then second type of adaptation is more system-wide, and that's around personalising FNP. So, there was already some flexibility for nurses in terms of what they had to deliver over the 2.5 years, but there's even more flexibility now in the sites in which we're testing it, so they have freedom to adjust the content of sessions depending on the needs of the client. So, if it says in the manual, 'You're in visit twenty, and these are the things to cover,' but that's completely irrelevant to the person you're working with, then don't do it, do something else.

Dez: And that's interesting because you've touched on this already, the need for really good workforce development, support, ongoing skills development training, and supervision, I would argue, as being a key part of effective implementation. The more we move towards contextual adaptation rather than, sort of, slavish fidelity, my language, not yours, it seems to me the greater the need for that workforce development and support. Not so much just training you in how to deliver the programme, but critical thinking skills. Because the more adaptive the intervention, the more adaptive we need our colleagues to be.

Nick: Yes, I completely agree, and having tools to support that as well. So, for example, in the context of FNP, we've introduced a new tool to help nurses and the mothers to sit down and look at the needs in a more holistic way, like we were talking about earlier, and thinking about, 'Well, in different areas of their lives, where are there particular needs?' And in some ways trying to orientate the programme so that the content addresses those needs. And also, the other area of personalisation is adjusting the intensity of it.

Dez: There is an argument to be made that some of, or indeed most of, the work we do in early intervention locates the needs, risks, harms, problem, and strengths, in the parent. And when I say 'parent', we basically mean mothers, let's be honest about that, or with the child. So, we'll do behaviour work with the child, we'll do parenting programmes with the mum. How do we contextualise those, and what role can early intervention play in recognising and responding to those much bigger systemic pressures that children and families face?

Nick: Well, I think it's a fair comment. A couple of years ago I did a mapping exercise looking at a range of evidence-based programmes, probably 100 plus, and mapped them in terms of the risk and protective factors they were targeting, and then the different domains. And it's certainly true to say that the vast majority are focussing on individual-level factors, family-level factors, school to some extent, which of course is slightly wider context, but very, very little looking at the community or the economic context, so I think that's fair to say. I guess in its defence I'd say that's probably true of most front-line services generally anyway. So, with some exceptions, most social work is concerned with those kind of factors, most education is concerned with those kind of factors, because that's what they can do something about. To address things like poverty and housing difficulties to a large degree, not entirely, but to a large degree, requires policy-level responses, clearly, so I think from my perspective we have to accept that. I would also say there are some efforts to address some of these wider contextual factors, but there needs to be more. So, to give a couple of examples, there's a programme called Families and Schools Together, the FAST programme, which a lot of that's around, kind of, building social capital between families, I think that's an interesting idea. In other areas like drug abuse and substance misuse prevention, there's a lot of work around environmental prevention, so trying to change the way in which pubs are designed, or regulating drugs or alcohol, the price of these things, for example. So, that's taking a wider perspective, and maybe some of those ideas could be applied in other areas besides drug and alcohol misuse and so on.

I think another way of thinking about it is that we know from some studies, or maybe many studies in early intervention, that the children of families who benefit most are those who often, not always, often those who have the highest level of difficulty, so that's something to bear in mind. And we need to do more analysis of the effectiveness of programmes in terms of socioeconomic status. So, for example, what I mean by that is do children who come from poorer backgrounds benefit more than those who come from slightly less poor backgrounds? And I suspect the evidence will be very mixed, I suspect in some cases that will be the case, and others not. But if it is the case, it does suggest that these kind of interventions can be a vehicle for more mobility and for greater quality.

[Access to early intervention programmes]

Dez: And that raises a really interesting conundrum, if I put myself in the shoes of a local authority commissioner, for example. So, if I was made aware of evidence that suggested children living in poorer families, or those of particular socioeconomic disadvantage were likely to benefit more from early intervention programmes and interventions, I might then be encouraged to target very, very specifically. And of course your point earlier about what tends to enable things to work best is good targeting, and then I'm in to quite a tricky place, because I have almost immediately, I would argue, created a highly stigmatising approach. How do we help people to navigate that complexity? And it's okay if you need to come back for a second interview to muse on that one.

Nick: I guess a couple of things. The first thing I'd say is we shouldn't forget a lot of early interventions, even those that are not highly targeted, they're not targeting individuals but they might be targeting broad groups, are tested and found to be effective in very disadvantaged communities, with people who are, you know, disadvantaged in many ways. So, they have demonstrated effectiveness in such settings, so I think that's something we shouldn't lose sight of. And that families who've received these interventions, and Family Nurse Partnership is a good example, where a lot of the mothers who've received the Family Nurse Partnership speak very positively of it, including fathers. Some of whom, you know, FNP has tried and is trying more to do something with fathers, they speak quite positively of it. I think the second thing to say is that we've probably been less good than we should have been at reaching the families who often need these types of intervention most. So, I think there's sometimes this concern about stigmatisation, about targeting the poorest, the underclass, and so on. Part of me wants to say, 'If only,' in the sense that what, to my mind, happens more commonly, is we reach people who need the intervention less. And for me, a good example of this was some work we did in Birmingham with the Incredible Years parenting programme, where we went in to children's centres to… and it was for children with a certain level of behavioural difficulty, and it's a parenting programme.

And when we started off, the children's centre said, 'Well, we've got lots of children like that, no problem.' When the study started, it proved almost impossible to find these families, and what we realised was the children who the children's centre thought were really difficult actually weren't that difficult, the kids' behaviour wasn't that bad. We knew, because we had evidence from a city-wide survey, that the children with this level of difficulty did exist, but their families weren't coming to the children's centres. So, some concerted outreach was done to try and reach these families. And for me, that was a very useful lesson because the temptation was to say, 'Let's just work with the families we've got. Okay, they're not quite the right families, but let's just work with them anyway,' and the director of children's services at the time there was very strong and said, 'No, we know these families exist, we're going to find them.' And clearly, the argument would be that they would benefit the most. So, I think we need to be better at outreach. And the last thing I'll say here as well is I think we do need to balance the whole issue of universal and targeted, in the sense that the best way to engage some of the more disadvantaged children is of course to have a universal approach. But at the same time, we have to recognise some of these interventions are very expensive, and some children will frankly be wasting their time and their parents' time, which arguably is a bit of a rights issue as well, if we spend lots of time doing stuff with them that they frankly don't need and are unlikely to benefit from.

Dez: Are we potentially creating a risk which is we'll widen the net far enough, scrutinise every family long enough, and you'll find a reason to bring them in? And if you do agree, what kinds of things could we do to avoid that?

Nick: I think we need an approach that works across the spectrum. So, that we do have universal services, things that are going on, let's say in schools, that are around-, I think there should be interventions in schools that are helping parents hopefully to be better parents, helping children to develop their social and emotional learning, and so on. But then we need things that are more targeted as well, so we think it has to be progressive in that sense. I think my concern is that we already know that there are children, arguably children receiving help, who have less needs, or less serious needs, than some children who are not getting help. So, that concerns me, that yes, there's a danger of sucking in the wrong families, there's also a danger of not sucking in the right ones, which goes back to the previous point about making sure that we reach families who really need help. Sometimes they'd be referred to as so-called 'hard to reach', I think more in the sense of services are often just hard to access. I think in terms of unintended consequences, the other thing I'd say as well is that there is a growing awareness in the field of early intervention-, this comes back to the earlier point about good intentions, that the interventions or services that we design, they have the potential to do harm as well as to do good.

And Chris Bonell who's a professor at London School of Hygiene and Tropical Medicine, and some colleagues, a couple of years ago wrote a really interesting article called Dark Logic. And the idea of the article was when we develop interventions, we often develop a logic model, so, like, a little summary of why we think the intervention will be effective, or the mechanisms through which it will work. And he says 'that's fine, that's good, but we should also think about the mechanisms through which it might cause harm, and then reflect on, as we're designing an intervention, that might cause us to stop, it might cause us not to do something. It might cause us to say, 'Well, we don't know if that's going to happen or not, so we're going to test for that, see if that materialises'.' That seems to me a very sensible thing to do.

Dez: I think that's really important, but we don't… in health, there is language, there's iatrogenic, so where our treatment might make you more poorly, or worse. We don't have an equivalent word in social work, social care, early help, family support, and perhaps we need one.

Nick: Yes, I think that's fair, I think we do need to be aware of that. And it comes back to the earlier point I was making, really, about evaluation and that some things might seem good and helpful, but they're not necessarily. Some early intervention programmes have unintended or unanticipated positive effects that we don't necessarily pick up on. So, a good example would be, let's say, something like Family Nurse Partnership again, are we picking up the effect that it has on, say, the young women's self-esteem, on their general happiness with life? That they've got someone going in on a regular basis and spending time with them, being really supportive and so on. We obsess about public health outcomes, which of course are really important, birth weight, and smoking cessation and so on, but some of these other things, more relational things, arguably, we're sometimes not capturing, and perhaps those are important as well.

[The application of early intervention to grapple with systemic issues]

Dez: One of the concerns I can sometimes find myself feeling around early intervention is the… talk about location and responsibility, but also location of blame. So, if I'm a mum, because it's too much of a stretch for me to imagine being a dad, so if I'm a mum and I'm facing all sorts of difficulty with my child or children, and well-meaning professionals get me onto this course and that course, and blah, blah, blah, but in effect, they are training courses to make me a better mum. But if the reasons why I'm not enacting my parenting in the way that I would really want to is become I am structurally disadvantaged, experiencing all sorts of prejudice, oppression, experiencing poverty and abuse, there is a danger that I might come away with all sorts of fantastic new, you know, sticker charts and bedtime routines, and techniques like that, but I have potentially had it reinforced to me that I am the problem. Society can't change, the structures can't change, but you just need to make sure you're using the naughty step properly.

Nick: Yes, absolutely, and I think that's clearly very undesirable. And I think the thing I'd say about that is I think sometimes people who work in early intervention and develop and evaluate these kind of programmes, the criticism is levelled that there is this focus on these so-called more proximal factors of family environment, and parenting, and so on and so forth. It comes back to what I was saying earlier, I think that's partly because something can be done about those things by front-line practitioners, and we know from research that the effects of poverty, for example, are mediated parenting and so on. And the effects on child outcomes, child behaviour, are mediated through things like parenting. So, the parenting is something we can do something about. It's not to say we shouldn't do something about everything else as well, and certainly there's a line of criticism which is that people who work in early intervention are, kind of, part of this big neo-liberal enterprise, and it's all about investing in families because it's benefiting the economy and all that kind of stuff. And I think people I know, and I include myself in this, we care passionately about kids' well-being in the here and now, we want to improve it, and what we're looking for is the best means of doing that. And we also, many of us at least, think we need policy to address poverty, inequality, and so on and so forth, but, you know, what we're doing is we're doing something about what we can do something about in the here and now.

Dez: I do also wonder whether the discourse has helped. So, some of the very, very popular and widely spread messages around this include things like, 'You'll get an X% return on investment,' or, 'For every such-and-such spent, you'll save such-and-such,' and there's some really quite inhumane language about, you know, 'stock and flow' of families. And how can we challenge that?

Nick: I think there's a danger of that, for sure, and I think some people go in for that more than others. I think where it's been helpful is it's to some extent been a helpful, persuasive tool to get a cross-party political consensus on some of these issues. So, I think there are some who are more persuaded by that than others, so that could arguably be helpful. The second thing I think to say is that there is a danger of those kind of things being misused. The benefits are often over a long period of time, and benefits often don't come back to the organisation that made the initial investment. And also, not all of the benefits come to the tax payer, some of the benefits are potentially for the individual themselves. We need to use public money well.

Dez: We do. We also, it sounds to me, hearing you talk there, we need to educate local leaders, in particular I'm thinking local political leaders, to understand that, 'Well, it's not savings, it's potential cost avoidance. It might not happen in your lifetime, and it almost certainly won't come back to your budget.' So, something there around, kind of, evidence literacy for…

Nick: Yes, I think that runs through all of this. I think, you know, the point earlier, I think in terms of helping people think about how to apply early intervention, we just need, all of us, need a more sophisticated, nuanced understanding of these things.

[Creating the conditions for nuanced debate around early intervention]

Dez: It sometimes strikes me that we find it harder to be nuanced when we're under pressure. Now, the sector is under significant pressure, and I sometimes wonder whether that's feeding the, sort of, silver bullets rhetoric. How do we create the conditions for nuanced, sophisticated, values-driven debate in this territory?

Nick: A few things to say, and I think firstly we arguably need, in the sector, and across the sector, I mean, social care, education, health and so on, as you said earlier, greater research or evidence literacy. I think that's important to understand both the strengths and limitations of different methods of evaluating services, designing services and so on. I think that would help a lot, and when the whole evidence-based enterprise to me is… the danger of people assuming it's very deterministic. 'The evidence says this, therefore we must do that.' And everyone knows… well, not everyone, we know that it's much more nuanced than that, and you've got to take into account context and different types of knowledge and so on and so forth. So, I think a greater awareness of that would help. I think at a local level, I think we need a stronger what I think of as an intelligence function in local authorities. And by that, I mean a function that can serve several purposes. So, for example, I think we generally need a better sense than we do of the needs of children and families in a given jurisdiction. We actually don't tend to know very much about the needs of families at a, kind of, aggregate level, and that's not very helpful, because it means it's hard to then prioritise and hard to know where to focus, so we need a better sense of that. I think we need to help people to… this comes back to literacy, evidence literacy, I guess, make sense of things like databases of evidence-based programmes, how to use those, how to apply those, if you're a commissioner, how to make sense of those.

I think we probably need, at a local level, to be better at designing and developing our own interventions. So, we shouldn't just be looking to import things from other countries or other parts of the UK, but let's develop some things on the ground and test those in situ. And I think as well, we need to get systems, or system leaders, talking together so we develop a more rounded and holistic perspective in a given area.

[The role of neuroscience in early intervention]

Dez: One thing I'd be really interested in your view on is the role of neuroscience in early intervention. It's a very emerging field of course, and we forget that MRI imagery is actually quite a recent development for us. It seems to me, and I could be wrong, it seems to me that an increasing number of early intervention programmes and interventions purport to be rooted in neuroscience, and often its emerging nature is not always well recognised or advertised. And I think I might be right in saying, but do challenge me, that not all of that neuroscience is from human brains, which could lend itself to some quite interesting dilemmas, I think. I mean, if I think again about the people, if I was a struggling parent and I was offered a programme to make me be better at, you know, whatever issues I'm having, I would want to know it hadn't been tested on rats only. Why are we so seduced by neuroscience in this field, and are there any risks associated with it? That was a very leading question, do feel free to reframe it.

Nick: Sure. Well, it's interesting, a couple of years ago when I was working on the PATHS programme I mentioned earlier, I was invited to do an interview, and the interviewer was desperate for me to say something sensible about how the programme changed kids' brains. And I said, 'Look, I'm not a neuroscientist, and it probably does change their brains in some way, in the sense that doing other activities changes one's brain, but I'm not qualified to talk about it.' I know that there is evidence and… a lot of the programmes, when they talk about the neuroscience, some of it, and certainly in the case of PATHS, I think, is very much about this idea that there's a part of your brain that is, kind of, very much around fight or flight type reaction, and then there's the more thoughtful part of the brain. And these interventions are trying to help the more thoughtful part, more reflective part, overcome the fight or flight thing. Now, I know very little about that, it sounds plausible, I can't comment more than that because I'm not a neuroscientist. I think we are seduced by it, I definitely think there's been some unhelpful narrative around it, and there are the, the classic image of the healthy child brain and neglected child brain, and I think that's unhelpful. I think the narrative of damage to children's brains is unhelpful, and also any suggestion that those children's brains are not plastic and that they can't change in later life, I think that's unhelpful as well.

I think it's seductive probably because it's, kind of, coming from a more physical science, and probably because we don't know much about it as well, so I think that can be seductive. So, I think we have to be careful about how we use it. At the same time, we shouldn't throw it out and suggest that it's going to be of no use at all. And I think just going back to why it's seductive, I think one reason it's seductive is that those kind of images have suggested that, 'Look, if we abuse children, then look how bad it is, it damages their brain.' So, I think it's really important to say we don't need evidence of what abuse does to kids' brains to know that it's a terrible thing and we've got to do something about it. Some of what we know about brain science suggests that there's no point just teaching parents to do certain things with their kids if they live in really poor housing and really, to use the phrase they would use, toxic environments. So, in other words, pointing towards the more structural, economic, neighbourhood-based types of intervention that we talked about earlier. So, I think that's interesting that it might not always point in the directions we think it might.

Dez: So, some of the things that I think have come through really clearly in this conversation, this need for contextual adaptation, not just programmatic fidelity. This need to be evidence literate, lots of critical thinking, not just evidence compliant, which I think is a really important point. This intelligence function in local areas, so creating, building capacity locally for intelligence gathering use, rather than being passive recipients of some central body which releases the programmes which we must all then follow. You made an interesting point about having some broader measures of impact, not just what works, but how did it feel? What did it do for your self-esteem? What did it do for your social connectivity? Rather than just, 'Has your child now got better dental health?' Glorious notion of not just importing things from the US, we can and should be developing our own interventions here, and not least of course because the context is so different when you don't have a welfare state. I'm talking, in case you're listening to this in the future, about the US there, not Britain, in case it doesn't date very well. You know, it had huge implications for the Family Nurse Partnership. But lastly, that point about co-design, and this is not language I've heard very much of in early intervention, co-designing programmes, approaches, interventions, with families. Which, for me, starts to embody a sense of values-driven, rights-based perspectives.

Nick: I do think there is a shift in focus, and people are talking much more about co-design. So, I mean, the work I did…

Dez: With families receiving the support?

Nick: To some extent, yes, to some extent. I mean, we've been trying to do that in the context of Family Nurse Partnership. It's fair to say it's been a challenge, I think, and we have to reflect on why we have not been as good as we would like to have been at involving families, but some have been involved, and others are doing that in other areas as well. And I think the reasons these things are important, I mean, a whole range of reasons, but one is I think it will help us to understand better what's going on in people's lives, we'll have a better sense of what people are more likely to engage with. I mean, there's no point designing great interventions if no-one's going to come along, so that's really, really important.

Dez: What do you think are the, kind of, key pitfalls that a local authority colleague might face, or indeed someone working in the voluntary sector? I'm thinking particularly folks in commissioning roles, they have very limited resource to spend, and a range of issues they're trying to address for children and families. What do you think are the key pitfalls that they need to watch out for?

Nick: Well, I think certainly seeing discreet early intervention programmes as a silver bullet, I think that's… it would be nice if it was that easy, and I think we recognise it's not, so I think that's one. I think another one would be not thinking that you have to invest in good quality implementation and all the things that sit around that, so as we talked about earlier, about workforce understanding of evidence. A third pitfall would be not understanding that a lot of the problems that early intervention is trying to address are very complex. The systems that are trying to address those problems are also complex, and so we need to make sure that people who work in these systems are talking together more, and looking for more systematic responses to some problems.

Dez: That's really helpful. Nick, thank you very much indeed for such a broad ranging and really, I think, nuanced discussion around early intervention. Thank you very much indeed for your time.

Nick: Thank you.

[Outro]

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