Welcome to NSPCC Learning, a series of podcasts that cover a range of child protection issues to inform, create debate, and tell you all about the work we do to keep children safe. At the heart of every podcast is the child's voice, and how what they tell us, informs the work we do.
Hi, and welcome to the latest NSPCC Learning Podcast. This episode focuses on the NSPCC’s thematic briefings, which pull out the learning from case reviews relating to particular issues or groups or sectors.
We’ve chosen to discuss the thematic briefing on infants, which highlights the challenges faced by professionals who are trying to find the balance between supporting new parents and recognising and addressing any risks posed to babies.
Wendy Noctor, who is one of the NSPCC’s Safeguarding Managers, sat down and had a chat with Liana Sanzone and Rachel Anslow, who are both Child Service Practitioners with the NSPCC.
Together they discuss their practice experiences as well as the vulnerabilities of infants and the importance of focusing on the baby’s day-to-day or “lived” experience and how to listen to the voice of even the youngest of children.
The NSPCC looks after the national collection of case reviews which has over 1,500 reports and related items such as the Triennial Analysis reports. The collection can be browsed or searched on NSPCC Learning, along with the thematic briefings – so do take a look.
Wendy began by asking Liana and Rachel what some of the concerns are for practitioners when working with very young children.
I think one of the main concerns is that because babies can't speak for themselves, we don’t know what's actually happening to them. So, if there’s domestic abuse within a family, the baby can't verbalise that abuse. We don't know what's actually happening to them.
So, there could be a baby that's being held in the mother's arms while there's an assault happening. There's drug and alcohol abuse or possibly mental health issues that may also impact on the care that's been given to the baby at any time by the parents.
It's about gathering and gaining the voice of all the children within the family. Sometimes children's voices, those under-two, are actually missed because there's too much going on within a house for practitioners to concentrate on that. And so, they concentrate on other areas within the family and sometimes miss the voices of the very, very young children.
And I think we all quite naturally think that because children maybe are pre-verbal, that then they don't understand maybe what they see or experience. So, we don't then talk to them about it or let them know that someone carries a safe narrative for them. They can try and help them - put into sort of more of a context of what's going on and help them through.
Well, I mean, it would be considered early trauma, the things Rachel had said - that would be experiences of trauma for a child. If those things don't get considered from that child's perspective and then thought about in terms of how it's impacted them and maybe the confusion that exists for them, how unsafe they have been, that these things were things that were what we would call in our team, “big people problems” and not the child's fault.
Then children are very likely to, even from a young age, internalise, and then start to blame themselves about these problems and carry that trauma if it's not addressed. So, I think it is important that we start to maybe think a bit differently about how we talk about trauma with very young children.
Can you tell us any more perhaps with examples of your experience around the sorts of things that have happened to babies and young children?
I mean, we know that some children, how they suffer from fetal damage from physical violence whilst in the womb, that there could be brain injury or organ damage.
With depressed parents, we may see them respond less frequently to babies’ cues, and then that baby isn't having its needs met by the parent. Again, they can't verbalise that to professionals around them.
Are you talking about examples potentially of neglect? So by what they're not doing rather than what they are doing - the parents?
I think it's also important for professionals to have a very clear understanding of developmental stages of babies and children and what we might go into a house and see with children that may not be meeting their milestones. So maybe at the age of one, if you've got a child that's not sitting, that may be a problem that's happened through the early years with the parenting.
We've seen children where they have had an inability to sort of walk and jump when you would developmentally be expecting them to. And then things like eating becomes a problem, they can't swallow properly. Yet all those expectations should have been met. And then it's impacting on how they're receiving basic nutrition, so they have to have other specialist inputs.
And then you're thinking, is it that the parents didn't know? Did they not get the right help? Was it neglect? What other issues have been going on? Sometimes you think, oh then the marital relationship maybe has been one with a lot of conflict or tension or they've been a very isolated family, haven't been able to reach out for help, or don't understand what the developmental needs for their child are and maybe having done work around that actually has caused some harm to that child even.
So, it's sort of trying to pull out where there's harm and where you can work with a parent to try and improve that or where you have to think there's been enough harm done, that there needs to be a different option for that child.
And we do have to be really careful, don't we? Because sometimes when there are physical or developmental issues for children, it isn't necessarily as a result of the care they're receiving from parents or carers. It can be for medical reasons.
I think one of the particular challenges for under-twos are their increased vulnerability because of their absolute level of dependency.
Can you tell us anymore about some of the impacts that different issues can have on children?
I think it's about key inter-agency working - working with all the professionals to ensure that there's a really robust assessment for the family, of the family's needs. And that every person within the family's needs are looked at.
So as you say, the under-twos are extremely vulnerable because they can't verbalise what's actually happening for them. It may be that we have to look at other people within the families to get the voice of the child, to understand what that lived experience is.
It may be that there's grandparents within the family that support and look after the child. We need to acknowledge that and bring them into the assessment to ensure that we hear what they have to say because it might be very different from what the parent is saying.
And also, all the professionals that are working with the baby or the child, so that we can make sure that… we know what is going on in that family, what is going on specifically for that child.
I guess in our team, in our experiences, we're working with children who've already experienced harm and being separated from their parents. So, they're in foster care or they're in kinship care with grandparents, an aunt or something like that.
The way we work is quite systemic around the child, so we'll work with the parent and the foster carer with a focus on the child and the professional system. We've got a benefit in some way of trying to draw everyone in and understanding how that child maybe has had the impact of harm and what has happened in that family. But then how they're changing, developmental catch up, or how they're responding differently to a foster carer and understanding how they're forming adaptive attachment patterns from their birth parents to then their foster carers.
And something we talk about where children maybe learn to miscue because they've not had a need met in a particular way. So then what lays down is a template of them studying to hide that need.
If they want to directly come to their parent for cuddles and comfort, but then have worked out - which they can work out from around about the age of 11 months - that that puts discomfort into that parent, they start to adjust to their cuing for that need for comfort and maybe go off and play with a soft toy or go off and play with something else that occupies them and they learn to miscue.
So that child might look like, oh, gosh, they just get on with play. They're okay. They look like nothing bothers them. But it might actually be that they're miscuing a need for coming in for comfort when they actually are showing like they're coping. So, trying to unpick what has that child's history been and what's their behaviour now? Does it match or not? And then trying to work out how to override that miscue.
Other things that we do see in children are things like sleep disturbances, emotional distress, aggressive behaviour or withdrawn behaviour, possibly uncertainty and new fears and a lack of basic trust in adults.
Children can also lose those skills that they have developed - toileting skills or eating skills - and then they actually can regress to an early stage or they can become attuned to aggressive stimuli. So where they're seeing aggressive behaviour in the adults, they become more attuned to that and actually will then possibly seek out to undertake that behaviour with other children within the families and mimicking that behaviour.
In my experience, one of the other challenges around certainly the case review learning, is around not necessarily knowing who is in the household, who is in the child's lived experience.
Also parents saying things like “she's doing it on purpose”. They've been up all-night crying, hungry, maybe not very well, “they're doing it on purpose” and getting really frustrated and feeling like the baby's crying is almost a personal attack on themselves and feeling completely overwhelmed.
So, it is tricky isn’t it? In terms of at what point do you intervene? How do you do it? Which of those cases say have to come for a pre-birth assessment because you know that the history indicates a higher risk for any unborn baby?
I think going back to your first point, it is really difficult when you're only getting a snapshot of a family in that moment to sometimes get the voices of other people that are within the family unit. Especially if you are being told that a partner isn't around or you're not being given information about that person. And it's about maintaining professional curiosity around that understanding of who is in this baby's life.
As professionals, we need to be able to challenge or to actually have that confidence to ask parents them questions to ensure that we are keeping these babies safe, these children safe and safeguarding them and ensuring that all risk is being monitored and met.
I'd be really interested to know bit more about the child's lived experience and the voice of the child. Certainly when I was a child protection chairperson, I would regularly have social workers coming to me at conferences having done their reports, and the child's voice section would be blank because maybe it was a child of nine months old or eighteen months old or three months old. And having to really unpick, you know, they're pre-verbal, they can't tell us what's wrong, so what sorts of things would we be looking for, so that we can advocate what the child may be experiencing?
I think maybe that's about building that narrative and actually talking from the child's perspective. Putting ourselves in the position of the baby and what that baby would need, what it would feel like to be scared, what it would feel like to not receive care from a parent.
And then you can actually build that into the assessment, how that child feels and that would give a really clear snapshot of what would be going on for that child. I think that it's important to gather as much information as you can. So, from all people within the family to understand the lived experience, but it's about us acknowledging what it would feel like for a child to have those fears or to not have its needs met.
And what sorts of things will we be looking out for? What would we be wanting to observe?
At certain developmental points for children, you can see where they're going to choose or preference one carer over the other or one adult in the family over the other and how they do that.
We've had experience of children who come through our service, where they say hello to everyone, they blow kisses to everyone, and what you're seeing is some indiscriminate behaviours from that child which do not feel protective, and then you think what's been that child's lived experience where they feel like they can be open and welcome everyone in. How have they learned that and what have they been exposed to?
Where actually what's more appropriate is a child would shy away, go to their preferred carer, seek some protection or wait for that carer to introduce a new person and not be very open. So, I think when you're doing a lot of behavioural observations, think about what development that child is at because there are key stages for those sorts of things that children should be around the mark of.
And certainly, I think where children are either very withdrawn or whether they are very much acting out. I think we've talked a lot about different behaviours that we can see in children.
Children might have certain indicators maybe for a social communication or autistic type trait behaviour, but sometimes that has to be looked at through a lens of trauma as well, because I think where children have experienced traumas, there can be some of those social communication behaviours that seem, what we observe as odd, or not right, or there's something about that that I want to look more into or have someone else look at, because I'm not sure.
You have to think, where's that come from? Is it indicating something in a learning profile or is it about trauma? What have they experienced in the home that might show this type of maladapted type of behaviour? So, I think observation really is key.
Absolutely. And some of the things I guess I would be looking out for and wanting to hear about would be things like, with a very young baby, are they thriving? Are they putting on weight? Are they clean? Is their nappy regularly changed? Have they got severe nappy rash? That might be a bit of an indicator that they're sitting in a wet or dirty nappy for long periods of time. Are they responding appropriately to stimuli? How does the carer, or the siblings even, how do they respond?
Because even with young babies, you can see, approaching them as an adult, they're very honed in to recognising faces, little eyes can light up. There can be babies that have suffered from neglect that look thin, pale, a bit docile.
One of the things you look out for if there are issues and concerns about putting on weight and thriving is just touching the top of the baby's head to see the fontanel is inverted or is it full, because that could be an indicator of dehydration.
There's lots of things that you can tell both from understanding a child's development and what's right for them because in a premature baby, for example, you wouldn't be expecting them to necessarily hit the same milestones that you would have if they’re a child the same age. It's got to be within a context.
I think one of the other concerns for the professionals is that you go out in a small window of time and sometimes the baby may be asleep. So, when you get there and the parents tell you the baby's asleep and they don't want to wake the baby up. Maybe professionals don't feel that they can do that, don't feel confident enough to actually wake the baby up.
So, it may be about the professional visiting at different times of the day to ensure that they see the baby awake. And then if the baby isn't awake, to ask parents to get the baby up and we shouldn't feel anxious about doing that. We should actually want to see the baby. And it may be that within that, we can see how the child interacts with the parent, how the parent soothes the baby and if they are able to contain the baby at that time.
I think that's a really important thing that we need to do as social workers, to actually address issues like when children are asleep or in another room or in different parts of the house, because that keeps them invisible. And we need to make invisible children very visible within our work.
And it is very easy to become parent focused. If you've got a parent in difficult situations, lots of different issues going on, it's very easy to get drawn into their agenda. They may be deliberately doing that or not, just doing it because their needs are great and they are in a lot of crisis and very easy to get drawn into that and perhaps not keep focus on what's going on for the child. Because you can empathise with parents, can't you? But as professionals, and other carers, other family members, you have to keep focused on what is going on for the baby, for the young child.
I think also an approach with parents is thinking about how they talk about their child. So I think there are certain questions with the mindset of adult-attachment style questions where you can ask parents about… We will ask certain questions about “what's the meaning of the child's name?”, “where did you get that from?”, “what's your favourite story about the child?”, “can you please describe your child using words about their personality?”, or “how was your experience of pregnancy and labour?”, “who was with you when this happened?”, “how do your family respond to the child?”, “what would be something they say about your child?”.
So trying to get to the idea of what the meaning of the child is in the parent's mind. Because sometimes I think where parents have had intergenerational issues, where they've had their own experiences of maybe trauma or abuse in their own families, then they don't have a template to give to that child from what they've learned. What they've learned is something that is distorted and quite naturally they're going to pass it on.
Something like what would be a ghost-in-the-nursery type of experience where you're looking at intergenerational trauma and thinking about what template of parenting is that parent carrying in their mind that they're going to apply to that child? Are there things that they're challenging themselves? Do they have the insight to understand that that's been a problem for them? And so, then they might be able to identify and change it or want to change it for their child? Or is that not been explored before? And it's something they carry that hasn't been resolved? Or, just looked at enough and understood? And so actually, they're going to pass it on, and how risky is that?
Are there any particular cues or sorts of comments that might be a bit of a flag for you in terms of, okay that's something I perhaps need to explore with mum or dad, in terms of how that might impact on a child?
I certainly think sometimes you can hear where things might be a bit distorted or not very balanced about a parent describing their child for instance. So, something might come across as very superficial, so everything's loving, smiley, playful, easy. Whereas that's quite unrealistic. And the expectation of a child to be those things all the time is also unrealistic and doesn't show you that there's a response to or room for a child to be grumpy or tired or have needs, or where sometimes parents have described their child or their relationship with their child but actually what they're talking about is just themselves.
What I'll take from that is thinking that in their mind, they can't think of their child as a separate person with their own separate needs. They're really thinking about how that child fulfils their needs. And then you wonder about would that then show in the relationship, something like role reversal or an idea of this child being a prize or some type of commodity, and wonder about how then that impacts on the value of that child being their own person, seeing them with their own needs being met.
So I think that things like that sometimes come through in these interviews we would do and then we would also follow that up with a very particular type of structural observation. Often what we see is a match to what the parents told us and what we formed from that, whether it's something that's balanced or something that's distorted or something that's quite superficial or narcissistic. And then when we see the observation, we can see some of that in the behaviour. It's like testing it out in a way, but it's understanding where does the parent come from in this relationship and then what's the child showing us in this relationship?
And having the opportunity to do that is, of course, is good. It's helpful for assessment and understanding where this child is in this relationship, how they’re used in that relationship, and where maybe the parent has some stumbling blocks or what areas we might need to try and work on for that relationship to improve and hopefully recover.
So we've explored quite a bit really in terms of what's going on for children, what we might observe, what the impact is on them, what sorts of difficulties they might find themselves facing.
Can we just explore a little bit about what we can do in our organisation to help practitioners be fully aware of some of the vulnerabilities and what they need to do in order to make practice as good as it can possibly be with the child's best interest in mind?
Using play-based therapeutic tools to actually get to the heart of what the child's voice is. Practitioners need to be able to feel that they can interact with the child as well as a parent. And a lot practitioners maybe feel that they are nervous about interacting with very, very young children and may stick to interacting with a parent.
But I think actually we need to build skills where we have that capability to go and do that and to actually get down on the level of the child. That the child doesn't have to come to us, that we will get down and we will play with the child, that we’ll take out dolls, we will take out sand trays, we’ll take out work to the child that is at the child's level and at their developmental needs and actually make the work that we do about interacting with that child on that level, rather than interacting with the parent and with the child through the parent.
Some of the messages that I would really hope that would get out to our practitioners, people on the front line actually engaging with families and doing the work would be, how there is such an increased vulnerability for children under-two. We know that they're over representative in serious incidents and case reviews because of that.
That we absolutely need and want practitioners to always think 'child first’, so be child-centred and not get drawn into an adult agenda. And the third thing would be really knowing who is in the child's world. Who is in the household? Who is in the family? Who's the child having contact with?
I think it's also about keeping robust inter-agency working practices. Ensuring that we work with children's services, with health visitors, with midwives, with the police and other agencies that may be working with these families, so that they're not getting lost through a net and disappearing so that then they become serious case reviews. I think that's really key.
I think as an organisation as well, this is probably a little bit wider maybe in terms of thinking of who and where we're learning from. Because there is quite an agenda on things like infant mental health and thinking about children, young children and their safety.
I think it's also important that we get in there early and we start at the beginning and we don't let this get to the point where it's becoming a serious case review. We work with families at the first point when we see something going wrong.
So more preventative type intervention. And because research tell us that that works, it works better than coming at a later date.
Thank you for your contributions. That's really helpful and you've illustrated some points really clearly. So, thank you very much for your time.
"Thank you for listening to this NSPCC Learning podcast. If you're looking for more safeguarding and child protection training, information or resources, please visit our website for professionals at nspcc.org.uk/learning."