Publication - Advice and guidance

A Pathway of Care for Vulnerable Families (0-3)

Published: 22 March 2011
Topic: Health and social care
ISBN: 97817804509

Guidance to support the implementation of Getting it right for every child through continous assessment and a continuum of support.

Supporting documents

4. Guidance on approaches from the antenatal period to age 3

This section of the guidance presents the enhanced universal pathway from the antenatal phase to age 3, with suggestions for possible interactions at each core contact to support women, children and families where there is a concern about
the child's well-being.

It should be emphasised that these are not the only points where service providers will meet with the child or family, and local pathways should reflect flexible contact points in addition to these core contacts.

4.1 Guidance on approaches within the antenatal period to enhance the universal pathway

This is about equipping and supporting professionals to think about the kinds of issues that are important to women, children and families throughout their universal journey. The guidance presents prompts that will enable professionals to identify where women, children or families are at higher risk of poor outcomes. Professional judgement should then be used to decide how any needs can be met, working with the family and engaging other professionals as appropriate.

The antenatal period is a critical time to engage with women and their families to identify additional needs and to support them to achieve the best possible outcomes for their child and family.

Pregnant women with complex social factors may need additional support. Examples of high-risk groups are: ²⁷

women misusing substances (drugs and/or alcohol)
women experiencing domestic abuse
women under 20 years old
women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English.

Using the GIRFEC National Practice Model (see Figure 1) and placing the child at the centre of the assessment allows practitioners to consider their role in working with and supporting the family, whether through observation, practical support or involving other agencies as appropriate. The model focuses on key elements during the journey through consideration of the eight well-being indicators:

safe
healthy
achieving
nurtured
active
respected
responsible
included.

As Scottish Woman-Held Maternity Record ( SWHMR) is the national record for assessment used in maternity services, examples of strengths and needs have been mapped against the well-being indicators to show how the GIRFEC approach is reflected in the record.

Note that the examples are just that - examples that have been provided to support professionals to think about the kinds of issues they may want to address. Professionals and teams will also have to consider a wider range of issues, depending on individual needs.

4.1.2 Examples of questions to raise within SWHMR

Safe

Strengths/resources	Needs/worries
Mother/family has stable relationships Mother/family has good support network Mother/family has suitable housing Recognition and understanding of risks to the child No concerns regarding previous children	Abuse or neglect of previous children Previous children removed/on child protection register Poor impulse control Mother/family experienced abuse in childhood Domestic violence Drug or alcohol misuse Homeless and/or poor housing
Examples of questions to raise within SWHMR
When is your baby due? How sure are you of this date? Is this a planned pregnancy? Be respectful of the decision the woman has made in ensuring the progression of a safe and healthy pregnancy. Your previous pregnancy Is your current pregnancy with a new partner? Consider the safety and well-being of other siblings as this may impact on the unborn baby. Are you aware of any child protection concerns?

Strengths/resources

Needs/worries

Mother/family has stable relationships
Mother/family has good support network
Mother/family has suitable housing
Recognition and understanding of risks to the child
No concerns regarding previous children

Abuse or neglect of previous children
Previous children removed/on child protection register
Poor impulse control
Mother/family experienced abuse in childhood
Domestic violence
Drug or alcohol misuse
Homeless and/or poor housing

Examples of questions to raise within SWHMR

When is your baby due?

How sure are you of this date?

Is this a planned pregnancy? Be respectful of the decision the woman has made in ensuring the progression of a safe and healthy pregnancy.

Your previous pregnancy

Is your current pregnancy with a new partner?

Consider the safety and well-being of other siblings as this may impact on the unborn baby. Are you aware of any child protection concerns?

Healthy

Strengths/resources	Needs/worries
Mother keeps antenatal appointments Mother develops and sustains good working relationship with professionals Good self-care skills Expresses an awareness of the unborn baby's needs and a desire for the baby Ability to prioritise the baby's needs Mother/family has good support network	Drug/alcohol misuse Domestic violence Mental ill health History of postnatal depression Poor engagement with professionals Learning disability Very young parent/immature Stressful relationships Limited support Unwanted/concealed pregnancy
Examples of questions to raise within SWHMR
Mother's health The woman can make a significant difference to the unborn baby's/child's health by giving them the best start in life through, for instance, having adequate nourishment, sleep and physical activity. Other health-related questions Do you go to the dentist regularly? Consider referring the women to a dentist as part of the "Childsmile" programme if appropriate. How many units of alcohol a week are you drinking now? Consider the impact of all substance misuse on the unborn baby, as well as the health and safety of the woman. Current smokers: cigarettes smoked per day Consider the targets to reduce smoking and the programmes of local support available. Substances used Is the well-being of the woman and unborn baby/child being compromised due to substance misuse? There is a need for skilled and sensitive enquiry to elicit information and to establish the additional support needed from other practitioner and partner agencies as appropriate. Medication Is the woman compliant with prescribed medication and getting any additional help with problems?

Strengths/resources

Needs/worries

Mother keeps antenatal appointments
Mother develops and sustains good working relationship with professionals
Good self-care skills
Expresses an awareness of the unborn baby's needs and a desire for the baby
Ability to prioritise the baby's needs
Mother/family has good support network

Drug/alcohol misuse
Domestic violence
Mental ill health
History of postnatal depression
Poor engagement with professionals
Learning disability
Very young parent/immature
Stressful relationships
Limited support
Unwanted/concealed pregnancy

Examples of questions to raise within SWHMR

Mother's health

The woman can make a significant difference to the unborn baby's/child's health by giving them the best start in life through, for instance, having adequate nourishment, sleep and physical activity.

Other health-related questions

Do you go to the dentist regularly?

Consider referring the women to a dentist as part of the "Childsmile" programme if appropriate.

How many units of alcohol a week are you drinking now?

Consider the impact of all substance misuse on the unborn baby, as well as the health and safety of the woman.

Current smokers: cigarettes smoked per day

Consider the targets to reduce smoking and the programmes of local support available.

Substances used

Is the well-being of the woman and unborn baby/child being compromised due to substance misuse? There is a need for skilled and sensitive enquiry to elicit information and to establish the additional support needed from other practitioner and partner agencies as appropriate.

Medication

Is the woman compliant with prescribed medication and getting any additional help with problems?

Achieving

Strengths/resources	Needs/worries
Mother demonstrates understanding of the developmental needs of a baby Good early childhood experiences Positive experience of professional relationships	Lack of awareness of baby's needs Unrealistic expectations Poor physical and/or mental health Learning disability Poor experience of professional relationships
Examples of questions to raise within SWHMR
Information for mother The named person (midwife) will be establishing the relationship with the pregnant woman and should support understanding of the desired outcomes and their shared responsibility to work with practitioners to make this happen. Plan of care for pregnancy The plan for care should be documented following the assessment undertaken using the pregnancy record. The pathways for maternity care (green/amber/red) will support the identification of the Health Plan Indicator appropriate for the unborn baby/child and family as part of the continuum of support. Postnatal record Problems identified during pregnancy, labour/birth Problems in the postnatal period/referrals, investigations or results pending Transition from antenatal to early years care will require that the assessment and plan for the unborn baby needs to be refreshed by the named person when the baby is born. Postnatal care Transfer of the relationship-based care from, and to, a named person/lead professional as appropriate will need to be managed sensitively to achieve the best outcome for the child and family. Feeling confident with the baby The support a child and family needs to achieve the desired outcomes can be developed through the well-being indicators of safe, healthy, achieving, nurtured, active, respected, responsible and included.
Examples of questions to raise within SWHMRcontinued
Formula feeding the baby Sensitivities around supporting informed decision-making to bottle feed may impact on the mother's bonding with the baby and create potential concerns regarding mental health issues and attachment as a result of feelings of failure/rejection. This will inform assessment and planning to support early intervention and prevention of problems. Thinking about the pregnancy, labour and birth Sensitive enquiry should be considered to elicit health and social care needs which may affect the woman's decision to have another pregnancy or come to terms with the current pregnancy.

Nurtured

Strengths/resources	Needs/worries
Positive childhood experiences Stable relationships developed and maintained Mother shows maturity Mother/family has good support network Empathy and the ability to keep the unborn child in mind Safe and secure family environment Expectant mother happy about pregnancy	Conflict and hostility in the family environment Very young parent/immature Poor relationship history Poor physical and/or mental health Lack of social supports Inability to focus on the needs of the unborn child
Examples of questions to raise within SWHMR
Questions or concerns Consider the impact on the child's health and development as a result of: living in a poor physical environment family tensions social and family networks.

Strengths/resources

Needs/worries

Positive childhood experiences
Stable relationships developed and maintained
Mother shows maturity
Mother/family has good support network
Empathy and the ability to keep the unborn child in mind
Safe and secure family environment
Expectant mother happy about pregnancy

Conflict and hostility in the family environment
Very young parent/immature
Poor relationship history
Poor physical and/or mental health
Lack of social supports
Inability to focus on the needs of the unborn child

Examples of questions to raise within SWHMR

Questions or concerns

Consider the impact on the child's health and development as a result of:

living in a poor physical environment
family tensions
social and family networks.

Active

Strengths/resources	Needs/worries
Keeping active during pregnancy Taking advantage of local activities Prepared for the baby's arrival Attending antenatal education classes	Social isolation Physical or mental health problems that inhibit social activity Inability to prepare for the baby's arrival
Examples of questions to raise within SWHMR
Breastfeeding the baby Raise topic of breastfeeding. Consider local community planning initiatives in relation to infant nutrition/healthy start food cooperatives and peer support groups to support ongoing breastfeeding.

Strengths/resources

Needs/worries

Keeping active during pregnancy
Taking advantage of local activities
Prepared for the baby's arrival
Attending antenatal education classes

Social isolation
Physical or mental health problems that inhibit social activity
Inability to prepare for the baby's arrival

Examples of questions to raise within SWHMR

Breastfeeding the baby

Raise topic of breastfeeding.
Consider local community planning initiatives in relation to infant nutrition/healthy start food cooperatives and peer support groups to support ongoing breastfeeding.

Respected

Strengths/resources	Needs/worries
Good self esteem Positive relationships Involved in decision-making Makes positive choices	Poor self care Poor self esteem Poor relationship history Domestic violence
Examples of questions to raise within SWHMR
Postnatal record Mother's progress Ensure that needs are systematically assessed universally for all children and, for a small proportion of children with additional needs, on a multi-agency and/or multidisciplinary basis. Mother's health after the birth Managing transitions from the woman and unborn baby being at the centre to the child and family being at the centre by ensuring that the woman does not feel excluded and remains central to the well-being of the child.

Strengths/resources

Needs/worries

Good self esteem
Positive relationships
Involved in decision-making
Makes positive choices

Poor self care
Poor self esteem
Poor relationship history
Domestic violence

Examples of questions to raise within SWHMR

Postnatal record

Mother's progress

Ensure that needs are systematically assessed universally for all children and, for a small proportion of children with additional needs, on a multi-agency and/or multidisciplinary basis.

Mother's health after the birth

Managing transitions from the woman and unborn baby being at the centre to the child and family being at the centre by ensuring that the woman does not feel excluded and remains central to the well-being of the child.

Responsible

Strengths/resources	Needs/worries
Able to make positive choices in pregnancy Keeps all appointments and is proactive in self care Acknowledges concerns Able to prioritise the well-being of the unborn child Able to budget - good practical skills	Chaotic lifestyle Unable to focus on, or prepare for, the baby Poor antenatal care Prioritising own and partner's wants above well-being of baby History of offending
Examples of questions to raise within SWHMR
Mother's age If the mother is a young woman, consider if she is actively playing a responsible part at home and in school. Is she a confident individual? Postnatal care Consider the transition from named person (midwife) to named person (public health nurse/health visitor). What aspects of well-being do you need to consider. How will the transfer of the relationship-based care to another practitioner impact on the woman? What process will you use if there are additional needs and a lead professional is responsible for coordinating the care?

Strengths/resources

Needs/worries

Able to make positive choices in pregnancy
Keeps all appointments and is proactive in self care
Acknowledges concerns
Able to prioritise the well-being of the unborn child
Able to budget - good practical skills

Chaotic lifestyle
Unable to focus on, or prepare for, the baby
Poor antenatal care
Prioritising own and partner's wants above well-being of baby
History of offending

Examples of questions to raise within SWHMR

Mother's age

If the mother is a young woman, consider if she is actively playing a responsible part at home and in school. Is she a confident individual?

Postnatal care

Consider the transition from named person (midwife) to named person (public health nurse/health visitor). What aspects of well-being do you need to consider. How will the transfer of the relationship-based care to another practitioner impact on the woman? What process will you use if there are additional needs and a lead professional is responsible for coordinating the care?

Included

Strengths/resources	Needs/worries
Good support from family and/or friends Makes use of community resources	Socially isolated family Mother/family has poor social supports Negative childhood experiences by mother/family Housing and financial problems being experienced by the mother/family
Examples of questions to raise within SWHMR
Mother's partner/supporter for this pregnancy Have all contact details for any health or social care agency the woman is in contact with been gathered? Sensitive enquiry to elicit wider health and social care needs. Ethnic origin Is the woman and her family accepted into the community without prejudice or tension and included in local supports and resources? Referral needed Consider if anyone else is involved with the care of the pregnant woman. Care and intervention may be required from other practitioners and agencies to determine the extent of the additional needs. Additional needs identified here may require discussion with practitioners and partner agencies. An integrated assessment and core planning meeting may need to be called. Are you confident that you understand how this happens?

Strengths/resources

Needs/worries

Good support from family and/or friends
Makes use of community resources

Socially isolated family
Mother/family has poor social supports
Negative childhood experiences by mother/family
Housing and financial problems being experienced by the mother/family

Examples of questions to raise within SWHMR

Mother's partner/supporter for this pregnancy

Have all contact details for any health or social care agency the woman is in contact with been gathered? Sensitive enquiry to elicit wider health and social care needs.

Ethnic origin

Is the woman and her family accepted into the community without prejudice or tension and included in local supports and resources?

Referral needed

Consider if anyone else is involved with the care of the pregnant woman. Care and intervention may be required from other practitioners and agencies to determine the extent of the additional needs.

Additional needs identified here may require discussion with practitioners and partner agencies. An integrated assessment and core planning meeting may need to be called. Are you confident that you understand how this happens?

4.2 Guidance on approaches to enhancing the universal pathway in the immediate postnatal period up to age 3

The well-being of children and young people and their "well becoming" are at the heart of Getting it Right for Every Child. The eight indicators of well-being (safe, healthy, achieving, nurtured, active, respected, responsible and included) are the basic requirements for all children and young people to grow, develop and reach their full potential. Children and young people will progress differently depending on their circumstances, but every child and young person has the right to expect appropriate support from adults to allow them to develop as fully as possible across each of the well-being indicators.

Family circumstances may change over time. The additional needs that arose in the antenatal period will impact differently in the immediate postnatal period and beyond.

Families with additional needs may be able to manage their circumstances with little or no intervention from universal or specialist services. However, continuous assessment of need, at every contact, will enable the right level of support, in agreement with the family and other professionals, to be given at the earliest opportunity.

Examples of families at higher risk of poor outcomes include:

first-time young mothers
parents misusing substances
those experiencing domestic abuse
those with emotional or mental well-being issues
parent or child with disabilities.

4.3 Protective and risk factors ²⁸

Protective factors are behaviours or characteristics for which there is research evidence that shows they make a difference in outcomes for children with complex or multiple needs. In addition to generic social and psychological indicators, there are specific risk and protective factors for particular outcomes.

4.3.1 Protective factors

Include:

authoritative parenting combined with warmth, with an affectionate bond of attachment being built between the child and the primary caregiver from infancy
parental involvement in learning
protective health behaviours, such as smoking cessation in pregnancy
breastfeeding
psychological resources, including self esteem.

The parent/carer may show evidence of understanding and appropriate action in some areas. These should be considered strengths and a measure of where to start building parental capacity, rather than focusing on areas that are not being met.

4.3.2 Risk factors

Include:

an underlying medical or developmental disorder and temperamental characteristics, some of which may be genetic
low birth weight and prematurity
obesity in parents (a child is at greater risk of becoming obese if one or both of the parents is obese)
poor attachment and cold, critical or inconsistent care (this can result in emotional and behavioural problems)
smoking in pregnancy (this has multiple short and long-term adverse effects on both the foetus and child, and can be a wider indicator of a pregnant woman's self esteem)
smoking by partners (this also has both a direct and indirect impact on children and is the most powerful influence on the mother's smoking habit).

Some of the indicators listed above are more difficult to identify than others. Health professionals need to be skilled at establishing a trusting relationship with families to enable them to build a holistic view.

4.4 What questions to ask

Within the National Practice Model, the "My World Triangle" questions should prompt users about key areas to focus on, following identification of a need. Probing questions on areas that impact on "How I grow and develop" and that relate to "What I need from people who look after me" and "My wider world" are found within the GIRFEC guidance. ²⁹

Table 2 provides examples of families who may need additional support. The list is not exhaustive, but can be used as a guide to considering what the population-level needs might be within your local area. ³⁰

Table 2. Universal pathway (enhanced) - birth up to age 3

Example of family need*		Evidence of strength/asset in ³¹ relation to (or knowledge of):
Birth to around 10 days	First-time parents Mother recovering from a difficult delivery New babies up to eight weeks All children in neonatal unit until completion of SOGS assessment Breastfeeding mothers depending on need	Pram and cot safety Sleeping pattern, bed sharing, position, temperature Feeding preparation safety SIDS (sudden infant death syndrome) Animal safety Carer's routine/lifestyle
Around 10-28 days (handover from midwife to public health nurse/health visitor)	Families new to area Children whose main carer is isolated, unsupported partner Previous history of child bereavement Serious illness of parent/child Children isolated from services due to geography, resources or parenting capacity Children recently removed from child protection register	Skin care - bathed and nappy changed regularly Smoke-free home Parent/carer expresses love and emotional warmth towards the baby Parent/carer seeks appropriate help and advice if experiencing difficulties managing baby Parent/carer calm and consistent when dealing with baby's distress
From handover - 6 months	Parents with complex needs Significant life events, such as bereavement or homelessness Children with disabilities, including communication disorders Children with complex care needs, chronic ill health or terminal illness Chronology frequent no access	Baby is calm and comfortable with parent/carer Siblings show obvious love and affection towards the baby Physical needs of baby attended to by parent/carer Appropriate play (singing, talking, reading, floor play etc.) Parent/carer may attend local groups Taken out to visit family/friends/shops/local community A limited number of safe adults deliver intimate care Feeding appropriate for age and stage Appropriate sleeping pattern
6 months to 1 year	Children with emotional, behavioural, developmental or mental health issues Families with literacy issues Children whose development may be affected by a succession of carers Specific behavioural problems such as sleep difficulties Children in families where there is poor hygiene Children subject to supervision requirement Chronology indicating high mobility Chronology failed health appointments	Appropriate home safety precautions Infant is normally well Developmental milestones reached Appropriate use of language and tone of voice (by parent/carer) Taking cues and responding appropriately Support from family and friends Gross motor skills age appropriate Vision and fine motor skills age appropriate Development of secure attachment Child understands simple commands
1 year to 3 years	Obesity and/or other weight issues (with parent/carer and/or child) Children experiencing a crisis likely to result in a breakdown of care arrangements Parents who self refer for additional support Looked after and looked after and accommodated children Young carers in the family unit Children involved in contact/residence disputes Failure to thrive/developmental delay Children on child protection register	Parent/carer ensures child has plenty of opportunity and encouragement to develop motor skills Appropriate modelling of behaviour Child expects to be liked by parents/carers Child is outgoing, smiles and "talks" - responds appropriately to parents/carers Child's sense of self begins to develop Child explores their environment with parent/carer in close proximity Child has a range of safe toys to play with Accidental injuries appropriately dealt with by parent/carer Parent/carer responds appropriately to any symptoms of illness Infant has age-appropriate diet

* Examples of HPI additional categories from a number of NHS Boards

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4. Guidance on approaches from the antenatal period to age 3

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