This document summarizes a presentation on policies from conception to age 2 given by Sally Burlington of the Department for Education. The key points are: 1) The period from conception to age 2 is the most crucial phase of development, as this is when 80% of brain development occurs and early relationships shape lifelong outcomes. 2) Poor support during this early stage can have lifelong negative impacts on outcomes, including poor attachment, lower educational achievement, poorer health, and higher criminality. 3) Burlington reported on a recent government study of policies to better support families from conception to age 2, noting the importance of high-quality parenting support and early education programs during this critical window.

1. Primary Prevention –
cheaper than cure,
better outcomes for
children
June 13th 2012
Supported by

2. Welcome from the Chair
Christine Davies, CEO, Centre for
Excellence and Outcomes,
C4EO
Supported by

3. Keynote speaker: Early
Intervention agenda &
context setting
Sarah Teather, Children’s Minister,
Department for Education
Supported by

4. Why BIG Lottery has
given it’s support to
this agenda
Dharmendra Kanani
Director, England, BIG Lottery
Supported by

5. A local government
perspective on child
abuse and neglect
David Simmonds, Chairman LGA
Children and Young People Board
Supported by

6. Better fences - fewer
ambulances
Robin Millar
Programmes Director, Centre for Social
Justice
Supported by

7. The importance of a
local area prevention
strategy
George Hosking
CEO, WAVE Trust
Supported by

8. The importance of a local area prevention
strategy
George Hosking, WAVE Trust
Primary Prevention –
cheaper than cure, better outcomes for children
Central Hall, Westminster, 13th June 2012

9. The Barnet Graph of Doom
Without dramatic change, within 20 years the Council will be
unable to provide any services except adult social care and
children’s services
Irrespective of savings planned under One Barnet Transformation
Strategy, demographic change – more children, more elderly – will
soak up every available penny
‘In 5-7 years … it starts to restrict our ability to do anything very
much else. Over a 20-year period, unless there was really radical
corrective action, adult social care and children’s services would
need to take up the totality of our existing budget.’
Nick Walkley, Barnet CEO

10. The Barnet Graph of Doom

11. Current reality of budget cuts – 1
Matt Dunkley, Director of Children’s Services, East Sussex
2011-12 budget: £20m cuts to Children’s Services
– ‘We have done the best we can with the challenge we were set’
The challenge: deliver a heavy, frontloaded package of cuts
Ringfenced schools budgets off limits. Child protection and looked-
after children budgets insulated
Cuts fell disproportionately on preventive services inc. early years’
‘… not the way forward I would have ideally chosen.’

12. Current reality of budget cuts - 2
Matt Dunkley (continued)
East Sussex has put 600 more children (most under five years old)
on child protection plans in the past two years (2011)
Number of looked-after children has almost doubled to 560
Government’s Early Intervention grant cut, in effect, by 20%.
Soaring demand, little sign that trigger factors such as parental
substance abuse is falling
‘The pace at which we had to do this … led to missed opportunity
to do a smarter piece of work … to reshape those services.’

13. Fundamental choice
Continue on current path
or create a
Paradigm shift: Invest in primary prevention

14. Continue on current path?
Out of 12 million children under 16 in UK:
Severely maltreated 1 to 1.6 million
Physical neglect over 1 million
Alcoholic in household 1 million
Witnessing domestic violence ¾ million

15. Costs of continuing on current path
Annual waste from adverse early years estimated at over £200
billion, nationally
Includes cost of welfare benefits, crime, mental health, alcohol and drug
abuse, violence, family breakdown, domestic violence, NEETS,
prison service, looked after children, young offenders, special
education
doesn’t include...
Lost tax revenue and costs of poor physical health

16. The future: doom or hope?
What if, instead of doom and gloom, we could find a more up to
date way to set policy, using the latest scientific knowledge?
… which will produce far happier, healthier and more prosperous
communities…
Is there a safe and economically viable way to do this?

17. Implication for optimum investment
Source: Heckman, James J. (2008). "Schools, Skills and Synapses," Economic Inquiry, 46(3): 289-324.

18. Pattern of public spending on education in England
& Wales over the life cycle, 2002/2003

19. A new paradigm
National and local strategies of primary prevention, rather than
reaction
Transformation of the quality of parenting – through changed
attitudes and better preparation for parenting
Respect for children’s right not to be abused or neglected
Understanding and adoption of early years interventions that work

20. Lifelong skills created very early
Research of Nobel Prize Winner, James Heckman
An open and persevering child learns more
– early success fosters later success, advantages cumulate
– young children more flexible and adaptable
– much easier to prevent deficits from arising in early years than
to remediate later
Mannheim Study of Children at Risk (MARS)
Individual differences in basic abilities increase between 3 months
and 11 years

21. Lifelong skills created very early
Research of Nobel Prize Winner, James Heckman
Achievement gaps between children primarily due to gaps in skills
Hard and Soft skills very important for success in life
– conscientiousness - perseverance
– motivation - attention
– emotional self-regulation - self-esteem
– ability to defer gratification
– sociability (ability to work with and cooperate with others)
These crucial skills mostly created in early years, in the family
Gaps in skills emerge early, before pre-school, and persist

22. Causes and consequences:
Californian ACE Study
Major investigation on links between childhood maltreatment
and later-life health and well-being
17,000 Kaiser Permanente members at comprehensive physical
examinations provided detailed information on their childhood
experiences of physical and emotional abuse, including being
reared in households with domestic violence, drug and alcohol
abuse.
WHO now conducting its own international (including UK)
ACE study

23. Californian ACE Study
Health risks which increase with 4 ACEs (17% of popn):
liver disease (x 2)
lung disease (x 3)
adult smoking, depression, serious job problems (x 3)
intercourse by 15, absenteeism from work (x 4)
alcoholism and alcohol abuse (x 6)
intravenous drug use (x 11)
suicide attempts (x 14)

24. Pathways to violence by age 3

25. Pathways to crime often set by age 3
Dunedin study of all
Violent offences
children born in 1972, Abused partners
to age 21
Number with 2+
criminal convictions
55%
47%
2.5x
18%
1x
9.5%
At risk Normal At risk Normal At risk Normal

26. Key: understand infant brain
Works via neurons (brain cells) & synapses (connections)
At birth: 10 trillion synapses - 200 trillion (or more) by age 3
Emotional brain largely created by experience in first 18
months; acutely vulnerable to trauma
Brains of abused children significantly smaller, less developed

27. Understand the infant brain

28. Understand the infant brain
Alan Schore - 10-year immersion in thousands of scientific
papers in neurobiology, psychology, infant development
‘The child’s first relationship, the one with the mother,
acts as a template … permanently moulds the individual’s capacity
to enter into all later emotional relationships’

31. Key factors: Attunement and Empathy
Attunement between mother and infant develops empathy.
Lack of attunement means empathy does not develop.
Low maternal responsiveness at 10-12 months predicted:
– at 1.5 years: aggression, non-compliance, temper tantrums
– at 2 years : lower compliance, attention getting, hitting
– at 3 years : problems with other children
– at 3.5 years: higher coercive behaviour
– at 6 years : fighting, stealing
Absence of empathy characteristic of violent criminals
– worst psychopaths no emotion at all

32. Primary Prevention does work

33. Successful Primary Prevention

34. Successful Primary Prevention

35. Need for Primary Prevention
?

36. Early years prevention saves money - 1
Expert opinion USA:
Dr Bruce Perry
James Heckman (Nobel Prize winning economist)
RAND Research Institute / Karoly, Kilburn, and Cannon (2005)
Felitti and Californian ACE studies
Washington State Institute for Public Policy (WSIPP)
Expert opinion UK:
Government Office for Science
London School of Economics
Action for Children / New Economics Foundation
Croydon Prevention Strategy
WAVE Trust

37. Early years prevention saves money - 2
RAND Research Institute / Karoly, Kilburn, and Cannon
Cost benefit analyses or meta-analyses of early years’ programmes
showed payoffs per dollar invested from $1.80 to $17.07
Estimated net benefits from $1,400 to nearly $240,000 per child
Chicago Child-Parent Center Program / Reynolds
Benefits > $80,000 per child - $10.80 of benefits per $1 invested
Children with four or more family risk factors yielded almost
double the benefits of those with fewer ($12.8 vs. $7.2)
Children from highest poverty neighbourhoods had returns more
than four times higher than those from less disadvantaged areas

38. Early years prevention saves money - 3
Federal Reserve Bank of Minneapolis/Rolnick & Grunewald
Internal rates of return for early years programmes exceed returns
from both stock market and typical public policy investments
[would also significantly exceed returns from many UK large-scale
public investments, including high speed HS2 rail link]
Washington State Institute for Public Policy (WSIPP)
Rigorously conservative approach to programme evaluation
– $1.75 per $1 for Parents as Teachers
– $3.23 per $1 for Nurse Family Partnership
– $7.00 per $1 for Parent Child Interaction Therapy
– $10.32 per $1 for Level 4 Group Triple P

39. WAVE’s Core Recommendation
Implement a committed primary prevention strategy
for children from conception to age 3
US Surgeon General:
‘Preventing an illness from occurring is inherently better
than having to treat the illness after its onset. The classic
public health definition of primary prevention refers to
interventions which ward off the initial onset of a
disorder’

40. Strategies of prevention
National strategies
Infancy and Early Childhood in Sweden
Every Opportunity for Every Child, Netherlands
Scotland – new Preventive Strategy
Local strategies
Croydon Prevention Strategy (joint local authority & PCT)
Derry, Fermanagh and Tyrone
Ballymun, Dublin

41. A National Strategy of Prevention
Approach to Infancy and Early Childhood in Sweden
99% of pregnant women access maternity healthcare services, 99%
of families use child healthcare services, avg. 20 contacts
98% of maternity services offer group parenting education to first
time mothers, specialist support to teen mums, single mums
Parent education c10% of midwives time; Parents invited to join
parent groups when child 1-2 months (61% attended 5+, Stockholm)
65% of midwives receive regular professional training on parenting
education, 72% instructed by a psychologist

42. A National Strategy of Prevention
Approach to Infancy and Early Childhood in Sweden
100% of hospitals have BFHI (baby-friendly) status (UK<10%)
Long periods of paternal and maternal leave to support baby
Breastfeeding:
98% of Swedish mums begin breastfeeding (79% UK)
72% breastfeeding at 6 months (22% UK)
15% exclusive breastfeeding at 6 months (less than 1% UK)

43. A National Strategy of Prevention
SWEDEN UK
% Live Births to teen mothers 1.6 7.1
Infant Mortality (per 1,000 live) 2.5 5.1
Smoking (% per day aged 15+) 16 25
Alcohol (litres per person p.a.) 7 11
Adult Obesity (% of population) 11 23
Smoking Related Deaths (per 100,000 popn) 196 245
Chronic Liver Disease Deaths, < 65 yrs (per 4 9
100,000)
Cancer Deaths, < 65 yrs (per 100,000) 56 67
Circulatory Disease Deaths, Under 65 32 43

44. Infant Mental Health Strategy:
Derry, Fermanagh and Tyrone
Vision for the Infant Mental Health Strategy:
WHSCT committed to supporting families to provide secure
attachments children need to make best possible start in life
Every child has a right to a supportive environment to create and
support positive mental health and emotional wellbeing
Investment in early years’ child development and positive infant
mental health, contributing to lifelong health, social and economic
outcomes

45. Infant Mental Health Strategy:
Derry, Fermanagh and Tyrone
Whole Child Approach: a holistic systems-based model of Early
Intervention
Collective Responsibility:
• 1) Women and Children’s Services plays a primary delivery role
• 2) Ante-natal and perinatal services a core universal service
• 3) Every Directorate actively supporting delivery of the strategy
Quality Service Standards:
• All delivery based on timely access to services based on need
• Evidence-based best practice and innovation at core of all services

46. Infant Mental Health Strategy:
Derry, Fermanagh and Tyrone
Specific Initiatives:
Hidden Harm Action Plan for Northern Ireland and Think Child
/Think Parent/Think Family project
A universal perinatal mental health pathway
Leading on Roots of Empathy Programme
NI Regional Healthy Futures strategy principles: health visitors
supporting children & families during formative early years
Leading on Family Nurse Partnership

47. Ballymun, Dublin: Ready, Steady, Grow
Service aims:
Improve positive pregnancy and birth experiences
Strengthen adaptive protective systems in infancy and toddlerhood
Increase confidence and competence of parents
Promote healthy infant and child development
Reduce childrearing problems

48. Ballymun, Dublin: Ready, Steady, Grow
Initiatives:
– Amplify range & increase uptake of ante natal support in
collaboration with primary health care team, maternity services
– Enhanced baby development clinic in partnership with Public
Health Nurse team
– Increased emphasis on infant social and emotional development
– Direct support to families and onward referral as appropriate
– Build capacity of statutory/community services to understand
and respond to infant mental health need

49. Ballymun, Dublin: Ready, Steady, Grow
Strand I - Preparing for Parenthood
Focus on pregnancy and Infant Mental Health incl. systematic
strategy for engaging expectant mothers and partners
Support adaptation to pregnancy & relationship with unborn child
Better meet ante natal needs of women and their families
Increase capacity of ante natal care

50. Ballymun, Dublin: Ready, Steady, Grow
Strand II - Parent-child Psychological Support Programme
Promote strong parent-child relationships, parental wellbeing and
adaptive systems in children
Provide parents with information on child development
Check baby’s progress and changing needs
Empower parents to solve conflict

51. Ballymun, Dublin: Ready, Steady, Grow
Strand III - Infant Mental Health Promotion
Focus on promoting social & emotional development in children
Build service capacity to respond to infant social and emotional
need
– capacity building for staff, families, programmes, systems
– identify, treat, reduce mental health problems birth to 3 years
– direct observation of children and care-giving environment
– interventions designed to change behaviour

52. Early intervention programmes - 1
Excellent Parenting programmes
Nurse Family Partnership
Roots of Empathy
First Steps in Parenting
Leksand Model, Sweden
SKIP (Strategies for Kids, Information for Parents)

53. Early intervention programmes - 2
Fostering attunement, breast-feeding, secure attachment
Attunement
Video Interactive Guidance
Breast-feeding
Breastfeeding Initiative, Blackpool
Secure Attachment
Circle of Security, Sunderland Infant Programme
Reducing teen pregnancy
Enfield

54. .
.

55. Report on recent study of
policies from conception
to age 2
Sally Burlington
Deputy Director, Sure Start and Early
Intervention Division, Department for
Education
Supported by

56. Special Interest Group:
Pregnancy to 2
Sally Burlington
Department for Education
13 June 2012
Supported by

57. Conception to 2 is the most crucial
phase of development
The first 2 years of life are critical to a child’s development.
How we treat 0-2 yr olds shapes their lives… and ultimately our
society.
• Period of fastest development
– 80% of all brain volume development is complete
by age 3; and is fundamentally affected by early
relationships and interactions
• Lays foundations for all later development
Supported by

58. Poor support at this stage can have life-
long impact on outcomes
• Poor attachment in infancy is associated with
behaviour problems later on (and the effect
doesn’t reduce over time)
• It can affect anyone: the effects are not less
for higher socio-economic groups
• Early childhood abuse and neglect affects
physical and mental health and life-time
outcomes; and the next generation
Supported by

59. Key factors
• Health in pregnancy (including maternal stress)
• Maternal health and mental health post-birth
• Quality of relationship (attachment) with main carer
has impact on:
– emotional wellbeing (and infant mental health);
– capacity to form and maintain positive relationships with
others;
– brain development;
– language development; and
– the quality of the home learning environment.
Supported by

60. Early childhood programmes have been shown
to have substantial net benefits and social
gains
• … and net savings to the public purse
particularly through better long term health
and crime reduction
• Cost-benefit analyses show a range of net
benefits, up to 1000 x initial costs
• James Heckman: highest returns for earliest
interventions (0-3)
• Best effects are delivered when long-term
follow-up
Supported by

61. But care is needed in interpreting
this….
• American evidence does not necessarily translate
directly to the UK
• In the UK we already have universal maternity and
perinatal health provision: Healthy Child Programme,
and Family Nurse Partnership
• People tend to quote the most positive effects rather
than the most likely
• Most striking effects are for groups with a large
number of risk factors
Supported by

62. Nevertheless, some key conclusions:
• Full implementation of the Healthy Child Programme
(supported by 4200 new health visitors by 2015) will give us a
world class service (more like Sweden than USA?)
• Opportunity to “join up” services for infants and their families
when responsibility for public health moves to local
authorities from 2015
• Implementation – what you do and how you do it – is key
• Early findings from FNP evaluation are very positive
(suggesting some of the success of American schemes can be
replicated here): doubling of capacity is very welcome
Supported by

63. Wider policy developments
• 4,200 new health visitors
• Doubling of Family Nurse Partnerships
• Prof Cathy Nutbrown review of early years workforce
• Free early education for disadvantaged 2 year olds
• Digital Advice Service for parents just launched
• New Early Years Foundation Stage: new focus on very young
children; identifying prime areas of Communication and
Language; Social and Emotional Development; Physical
Development;
• New requirement for all EY settings to undertake a progress
check for 2 year olds, and to provide a report to parents. This
will help to identify development needs – to be integrated
with the healthy child review
Supported by

64. Some lessons from evidence can be used
to influence ongoing practice
• “Spread the word” to all practitioners: understand
what very early child development looks like, and
importance of secure attachment: do people in
childcare settings understand babies’ behaviour?
• Publicise good sources of advice
• Early years workforce: importance of a key worker;
emotionally intelligent staff; effective supervision –
role of reflective supervision
Supported by

65. Other Implications
• How to target? Stigma vs “deadweight”
• Therefore make best use of universal provision, and stop
people falling through the net by
– Early identification and early help systems (HV, social work and strong
multi-disciplinary approaches)
– Effective information sharing between professionals
– Sure Start Children’s Centres and outreach working effectively to
identify and support the most vulnerable families very early in a
child’s life
– Staff in other EY settings (especially 2YO and earlier childcare) having
a good understanding of child development and how to spot and
tackle problems appropriately and quickly.
• Continue to improve our understanding of what evidence
based intensive support can be commissioned: who it works
for; what it costs; timescales and management. Supported by

66. Resources
• Pregnancy Book
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107
302
• Birth to Five
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107
303
• The NHS Choices website also provides a wealth of information relating to pregnancy, maternity and the
early years, including an interactive Pregnancy Care Planner (based on ‘The Pregnancy Book’) and Birth to
Five guide (based on the ‘Birth to Five’ book) and a range of videos on issues relating to pregnancy, babies
and children. http://www.nhs.uk
• Start4Life http://www.nhs.uk/start4life/Pages/healthy-pregnancy-baby-advice.aspx
• Healthy Start http://www.healthystart.nhs.uk/
• Information Service for Parents http://www.nhs.uk/InformationServiceForParents/pages/home.aspx
• Age specific downloadable handouts: http://www.zerotothree.org/about-us/areas-of-expertise/free-
parent-brochures-and-guides/
http://community.fpg.unc.edu/connect-modules/learners and http://community.fpg.unc.edu/connect-
modules/5-step-learning-cycle for an explanation.
Supported by

67. Lunch
with Social Investment Business
models showcased
Supported by