Tackling child neglect in Scotland 2: rapid review of intervention literature

Intervention Programmes and Approaches

66. Home visitation programmes typically involve regular contact between a family and a home visitor and can address a variety of issues including parenting skills, education about child development, the parent-child relationship, safety in the home, mental health issues, economic problems, education and employment, adequate health care, and lack of social support. The intervention is usually delivered by trained professionals or para-professionals with limited caseloads, who provide education counselling, and support for families until the child starts nursery (or kindergarten) or reaches 5 years old. In addition, families are directed to wider services and social activities outside the home (Boulatoff and Jump 2007; Asawa, Hansen and Flood 2008). There are a variety of programmes in place worldwide and many are aimed at preventing child abuse and neglect. These include the Early Head Start Program ( USA), Hawaii's Healthy Start Program ( USA), Healthy Families America ( USA).

67. Messages about the impact of home visitation programmes is mixed: RCTs and reviews have revealed significant differences in their impact. Across these programs, the most frequent positive outcomes included promoting healthy child development and school readiness, positive parenting practices, child and maternal health and decreased child abuse potential. Fewer programs documented evidence for reductions in child maltreatment (for most programs, this was not a strategic goal) (Asawa, Hansen and Flood 2008; Portwood 2006; Thompson 2015). Overall, these reviews suggest that early home visitation programmes are effective in reducing risk factors for child maltreatment, but whether they reduce direct measures is less clear-cut (Mikton and Butchart 2009). Unsuccessful programs tend to be implemented poorly with fewer weekly visits, lack intensity, are of short duration, and/or are insufficiently comprehensive (Portwood 2006).

68. Another study in Canada enrolled 163 families with a history of one index child being exposed to physical abuse or neglect in a randomised controlled trial to compare standard treatment (services from child protection agencies) with a programme of home visitation by nurses in addition to standard treatment. At 3-years’ follow-up, the recurrence of child physical abuse and neglect did not differ between groups. So, despite the positive results of home visitation by nurses as an early prevention strategy, this visit-based strategy did not seem to be effective in prevention of recidivism of physical abuse and neglect in families associated with the child protection system (MacMillan et al. 2005).

69. There are challenges to implementing such large-scale programmes: when programmes expand and are disseminated, the quality and scope of services may be affected and the original concept may be distorted. For some home visitation programs, several studies have revealed that families are receiving approximately half of the home visits they are scheduled to receive. This may be related to large caseloads, programme attrition, difficulty contacting the family, and characteristics of the visitor-family relationship (Asawa, Hansen and Flood 2008), large-scale programmes have shown limited commitment to research and program evaluation and there is a lack of controlled outcome research and that it is difficult to pinpoint an outcome to the home visitation programme as it is usually one of several supports and interventions for the family.

70. Among the factors that proved to be essential to the success of many home visitation programmes is the home visits and the relationship between parent and worker that had particular pertinence (Long et al. 2014). Gaining access to children, and relating effectively to them and their parents and carers in their homes, is a deeply complex practice. Parental engagement is a key issue for services working with families where children may be at risk of abuse or other significant welfare problems (Thompson 2015), but as has been discussed, engagement can be highly problematic. It is not uncommon for these parents to refuse admission to professionals on home visits, or, once in the home, to prevent professionals relating directly to the child (Long et al. 2014). The contact with families needs to be regular (weekly or fortnightly) and longer-term (one to two years and longer).

71. In their review of prevention programmes, MacMillan, MacMillan, Offord, Griffith and MacMillan (1994) concluded that programmes that included long-term home visitation (2 years or more) were more effective than programmes based solely on parental training or short-term home visitation. Since social isolation is one of the most frequently reported characteristics of maltreating families, the enhancement of social support is considered by many authors as an essential part of prevention strategies (Thompson 2015). The authors concluded that the most effective programmes for high-risk families were long-term, multidimensional and used an individual approach to address the problems of each member of the family. Findings such as this strike a chord with developments to health visiting in Scotland with the new Universal Health Visiting Pathway. The expectation of this new Health Visiting Pathway is that because of effective relationship building (underpinned by appropriately delivered training and ongoing Health Visitor assessment), the family remains at the centre of each home visit. Acknowledging that Health Visiting remains a specialist role that pivotally continues to involve ongoing assessment and professional judgement, the Health Visiting Pathway clearly emphasises the unique opportunity afforded by home visiting and its enhancement of the Health Visitor’s key role in assessing the wider context of family and community life and circumstances (Scottish Government 2015).

72. The Nurse Family Partnership ( US) and Family Nurse Partnership ( UK) is a voluntary home visiting programme for first time young mothers, aged 19 years or under. A specially trained family nurse visits the young mother regularly, from the early stages of pregnancy until their child is two. The FNP programme aims to enable young women to: have a healthy pregnancy; improve their child’s health and development; and plan their own futures and achieve their aspirations.

73. Several reviews single the Nurse Family Partnership in the USA as the only home visiting programme whose effectiveness has been unambiguously demonstrated. A randomized controlled trial showed a 48% reduction in actual child abuse at 15-year follow-up (Carr 2014). In 2009, the Family Nurse Partnership was introduced in England and subject to an RCT. Between June 2009 and June 2010, 1,618 young mothers were recruited from 18 sites across England. Of these, 50% were allocated to receive FNP support and 50% to receive usual care. Data was collected at intake, during the pregnancy an when the child was six, 12, 18 and 24 months old. The FNP programme appeared to improve early child development, particularly early language development at 24 months and may also help protect children from serious injury, abuse and neglect through early identification of safeguarding risks.

74. The study did help to highlight the high levels of vulnerability amongst first time teenage mothers and their children suggesting the case for additional support for this group remains strong. However, FNP did not have an impact across four outcome areas: pre-natal tobacco use, birth weight, subsequent pregnancy by 24 months, attendance at Accident and Emergency, and hospital admissions in first two years of life. However, some have suggested that the level of support offered to first-time mothers in the UK is greater than support for mothers in the US (Robling et al. 2016). In Scotland, the new Universal Health Visiting Pathway has built on the lessons learned from interventions such as Family Nurse Partnership ( FNP).

75. Strengthening Families Initiative is designed to reduce child abuse by enhancing the capacity of child care centres and early intervention programmes to offer families the support they need to avoid contact with the child welfare system. Strengthening Families also seeks to affect parent behaviour by using an existing service delivery system. Specifically, SFI uses focused assessments, technical assistance, and collaborative ventures to enhance the capacity of child care centres to promote five core protective factors among their program participants - parental resilience, social connections, knowledge of parenting and child development, critical support in times of need, and social and emotional competence of children. SFI is presented as problem solving rather than problem identification. At the time of publication, Daro and Dodge (2009) acknowledge that while anecdotal evidence support all of these assumptions, the ability of the SFI to achieve normative change within local child care and early care networks and to reduce maltreatment rates remained untested. There were no published reports of program efficacy using a rigorous design and no known trials under way.

76. Parent education programmes are usually centre-based and delivered in groups and aim to prevent child maltreatment by improving parents’ child-rearing skills, increasing parental knowledge of child development, and encouraging positive child management strategies. Seven of the 26 reviews summed up evidence relevant to this type of intervention from a total of 46 individual publications on outcome evaluation studies and from several other reviews. Two of the meta-analyses reported small and medium effect sizes for parent education programmes on the basis of both risk factors and direct measures of child maltreatment. Other reviews concluded, however, that while the evidence shows improvements in risk factors for child maltreatment, evidence of an effect on actual child maltreatment remains insufficient (Mikton and Butchart 2009).

77. Family Midwives, until recently, existed in Germany only in one area since the 1980s, but due to child death reports in the media, this approach has been given more attention. The goals of Family Midwives are to support and safeguard the physical and emotional health of infants who are born into psychosocially and health-related vulnerable families. This service offer care by continuously home-visiting the families depending on their needs beginning in pregnancy and following through up to the child’s first birthday. Visits comprise a ‘portfolio’ of various interventions which includes health promoting and preventive care, health-care measures for the child and the mother, as well as psychosocial and practical support, and counselling.

78. A recent study (Ayerle, Makowsky and Schucking 2012) gathered data from 33 Family Midwives using a mostly standardized documentation sheet on a total of 814 vulnerable families from May 2006 to December 2008 and 757 cases (93%) were included based on the completeness of documentation. The study reported that the regular visit of the Family Midwife to the home over an extended period of time supports the conjecture that they were intimately familiar with the state of affairs of the families and thus enabled to make an expert assessment at the beginning and closure of care, acceptance of care and access to providers proved to be a key prerequisite in the supportive system for families and the availability of the FM by telephone, text and visits was highly appreciated by the mothers.

Summary points: Interventions and programmes

• Universal parenting programmes delivered as a universal or population wide service appear to have more success at engaging families more isolated in communities and where children may be experiencing neglect. These programmes have shown to be successful in improving the child’s circumstance, their relationship with parents and reducing the prevalence of conduct disorders and social behaviours in families where risks have been identified. There is less evidence in the preventative ability of such programmes at a population level. However, families may be more inclined to access services and neglect may more likely to be identified in families not previously known to services.
• Intensive family-based therapies, specifically for older children and teenagers who may have experienced neglect, have shown improvements in family relationships and a reduction in criminal behaviour and re-offending rates both in the short and long terms. Critical to their success are fidelity to the model and the solution-focussed approach. By nature these approaches are short and intense and some involved have felt that the intervention ends too soon or abruptly, and recommend a longer intervention for some young people or some follow-up sessions
• Family based therapies working with parents, particularly those with problematic substance use, are beginning to suggest that in many cases these approaches engage, stabilise, and effectively treat parents while promoting healthy parent-child attachment Some have shown that expected rates of neglect have reduced, but there is little longitudinal data to show if this is maintained over time.
• Messages about the impact of home visitation and parent education programmes are mixed. Overall, both approaches appear effective in reducing risk factors for child maltreatment, but it is less clear whether programmes prevent actual neglect or its recurrence long term. However, fidelity to the programme is critical, but not always achieved. Factors essential for success is gaining access to children and families and working with them in their homes, long-term home visitation (2 years or more) and the enhancement of social support. Use of technology in parent training programmes can be used to effectively engage parents and help model appropriate parenting behaviours.
• Parents with limited social support, high levels of poverty-related stress, and mental health problems derived the least benefit from behavioural parent training. In essence: the most effective interventions for high-risk families were long-term, multidimensional and used an individual approach to address the problems of each member of the family.

Working with communities

‘The neighbourhood is an important venue for child development and, more specifically, child welfare prevention efforts, given concentrated disadvantage that occurs among the child welfare-reported and investigated population. Understanding the risk factors that affect families reported into the child welfare system might be a way to help build place-based initiatives to better serve these families .’

[Abner 2014, p.133]

79. Bronfenbrenner’s seminal work in the 1970s argued that public policy focused on children must take into account the enduring environment of the child: the immediate surroundings of the child’s life; and also the supporting and surrounding layers. The immediate layer is embedded within the supporting and surrounding layer, which includes geographic surroundings as well as institutions that function in the social system around the child. Within this perspective, child abuse is considered a dysfunction of the social system and a sign of societal stress. Abner (2014) writes that sociological research has shown that neighbourhood characteristics shape social processes, including crime, attitudes, health, well-being, and child and adolescent development (Brooks-Gunn, Duncan, and Aber, 1997; Brooks-Gunn, Duncan, Klebanov, and Sealand, 1993; Kling, Liebman, and Katz, 2006; Samp- son, Morenoff, and Gannon-Rowley, 2002; Wilson, 1987 all cited in Abner 2014).

80. Understanding how social capital - relationship between tangible (public spaces, property) and intangible (neighbours, social networks) resources - or the structural determinants of communities may impact on child abuse and neglect is growing. Children who live in neighbourhoods characterised by poverty, a high ratio of children to adults, high population turnover, and a high concentration of female-headed families are, not unexpectedly, at highest risk for maltreatment (Daro and Dodge 2009). A study of residents views on their community by Abner (2014) revealed that in addition to traditional notions of community being at low risk - if high or medium social order and high or medium social capital is identified - or at high risk - if low social order and low social capital is identified - there was third category where a community may have high social order, but low social capital.

81. Abner (2014) concludes that these results show that classifying families based on either “high” or “low” risk may not fully capture the story for families at risk for child maltreatment. Families who reside in communities that might appear to be lower risk based on social order might have a lack of social capital; social capital being an important factor in preventing child maltreatment. Daro and Dodge (2009) conclude that both individual responsibility and a strong formal service infrastructure are important to prevent child abuse and promote child protection. The challenge, however, is how to develop a community strategy that strikes the appropriate balance between individual responsibility and public investment.

82. Durham Family Initiative is a population-wide effort to expand the consistency and scope of universal assessments designed to identify families needing prevention services and to link them with appropriate community-based resources. It aims to enhance community social and professional capital and improve community capacity to provide evidence-based resources and increase families’ ability to access these resources. Its activities fall into four main areas. First, it fosters local interagency cooperation regarding adoption of a coordinated and consistent preventive system of care. Second, it increases social capital within a number of communities through the targeted use of outreach workers and community engagement. Third, it develops and tests innovative direct service models to improve outcomes with high-risk families and increase supports for high-risk new parents. Finally, it reforms county and state policies affecting the availability and quality of child welfare and child protection services.

83. As part of an evaluation of the initiative, anonymous surveys were completed with 1,741 family-serving professionals in Durham and one comparison site in 2004 and 2006. Professionals’ estimates of the proportion of children who had been neglected decreased 18 percent in Durham but only 3 percent in the comparison site. Repeated population-based surveys also found significant reductions in parental stress and improvements in parental efficacy over time. These data, however, did not reveal any significant changes in parental self-reports of positive or potentially abusive interactions with their children, changes in observed acts of potential abuse in other families in the community, or any changes in resident interactions, collective efficacy, or neighbourhood satisfaction (Daro and Dodge 2009).

84. Strong Communities places emphasis on changing residential attitudes and expectations regarding collective responsibility for child safety and mutual reciprocity. Its aim is to help the general public and local service providers within those communities understand how their individual and collective efforts can directly address the complex and often destructive web of interactions contributing to child maltreatment. Its premise is that once residents feel their neighbourhood is a place where families help each other and where it is expected that individuals will ask for and offer help, public demand will drive service improvement.

85. Daro and Dodge (2009) report that the success of these community engagement efforts is reflected in improved parent-child interactions as measured by repeated surveys of randomly selected parents of young children in both the intervention and matched comparison areas. The surveys found significant improvement over time in parent self-reports of positive interactions with their children and a corresponding reduction in parent reports of acts suggestive of neglect. Local administrative records, however, revealed no significant declines in child abuse reports, substantiation rates, or hospitalisations related to injuries suggestive of maltreatment when compared with similar records in the comparison community.

86. Personal, Family and Community Help Programme ( PFCHP) addresses multiple dimensions of child neglect and aims to enhance parental competencies, and the family environment. The programme includes four aspects: home-visiting family assistance; group meetings for parents that focused on parental competency issues (meetings were held weekly for 44 weeks and were conducted by an experienced therapist); stimulation of the children through educational activities aimed at enhancing their language, cognitive and social skills; and individual counselling offered by the social worker assigned to each family. The entire programme lasted 18 months.

87. In 2000, Ethier and colleagues published their evaluation of the effects of this programme applied to families at risk for child neglect. Twenty-nine families were recruited assigned either to the Personal, Family and Community Help Programme or to the local community centre for support and intervention. The study found that both types of intervention are equally associated with improved family situation and satisfaction with the social network increased significantly at the end of the intervention period, but the impact on social support networks varied noticeably. PFCHP participants sought less help from professionals and less support from their children. They relied more on friends and members of their family for support. In summary, the results of the quantitative analyses therefore suggest that both types of intervention were equally effective in decreasing the risk of child neglect but that the PFCHP was superior regarding the mother’s relationship with her environment, which is key to sustained improvements.

88. Communities That Care ( CTC) engages all community members who have a stake in healthy futures and sets priorities for action based on community challenges and strengths. It is a community prevention system that addresses factors suggested as essential for community coalition success. The premise underlying CTC is that a reduction in the prevalence of problem behaviours in a community can be achieved by identifying risk and protective factors and then implementing interventions that will help. In a randomized controlled trial of CTC in 12 pairs of communities across seven states, CTC has shown positive effects at reducing the initiation of mental, emotional and behavioural disorders, specifically, drug use and delinquent behaviour (Hawkins et al., 2008; Hawkins, Oesterle, Brown, Abbott and Catalano, 2014; Hawkins et al., 2009, 2012 cited in Salazer et al. 2016).

89. Keeping Families Together Initiative ( KFT) has adapted the Communities that Care approach to address prevention of abuse and neglect in families with children aged 0 to 10. Keeping Families Together brings together housing providers and child welfare agencies to strengthen vulnerable families and protect children. It recognises that poverty and housing instability are often linked to child neglect, child welfare involvement and family separation uses supportive housing to offer stability to families with children who are at risk of abuse and neglect. Preliminary evaluation findings regarding the adoption by communities of a science-based approach to prevention look promising (Salazer et. al. 2016).

90. Salazer and colleague (2016) conclude:

‘As attention to the prevention of mental, emotional and behavioural disorders increases and input is needed from community and key leaders, frameworks are needed to help communities with their strategic planning. Communities That Care provides communities with an approach that has demonstrated outcomes in youth problem behaviors and can be applied to preventing child abuse and neglect and promoting child well-being across the community .’

(Salazar et al. 2016, p.153).

Summary points: Working with communities

• Classifying communities as ‘high’ or ‘low’ risk may not fully capture the story for children at risk of abuse and neglect. Families who reside in communities that might appear to be lower risk based on social order might have a lack of social capital; social capital being an important factor in preventing recurring neglect.
• Individual responsibility and a strong formal service infrastructure are important to prevent child abuse and protect children. The challenge, however, is how to develop a community strategy that strikes the appropriate balance between individual responsibility and public investment.
• Interventions with a focus on the community and social networks can be effective in decreasing the risk of neglect and improving a parent’s (mother) relationship with the environment: key to sustaining improvements.
• Community approaches in the US have shown to have some impact on the risk factors associated with abuse and neglect: mental health, emotional and behavioural disorders, drug use and delinquent behaviour.

Relationships: Direct support to children and families

91. Throughout this background paper, the important role of relationships to engage neglecting families in services is apparent, however, the issues and processes relating to building working relationships with these families, in particular, remain complex. In her review of relationship-based practice, Reimer (2013) found the development of a relationship that is collaborative and authentic to be important when working with families where neglect is an issue and it is important to balance empathy with objective distance along with linking clients to a range of community and social supports.

92. Reimer notes that in building trust some have argued for the worker as seen confidant, because this helps reduce client resistance and hopelessness. The relationship is a useful tool to model relationship and conflict resolution skills. Building a relationship is assisted when workers calm clients’ anxiety by being clear about worker and client roles, boundaries, and expectations and includes approaching family members from a position of respect, equality, mutuality, and reciprocity. Clients may also come to the relationship with barriers to developing effective relationships and a history of poor relationships and communication difficulties.

93. In drawing on the findings from one case study, Reimer identified perceived factors as reported by parents and workers at the point of building relationships:

• Parents’ desperation and ambivalence is characterised by parents feeling vulnerable, desperate and ambivalent with some feelings of unfamiliarity, anger or fear, and a pressure to engage. Previous poor experiences impacted negatively on the early part of the relationship. The parents were often unwilling, commonly making it difficult for the workers to engage them. This was resolved by parents putting aside their fear and becoming sufficiently motivated, or willing, to give their worker a chance to prove why the parent would want to engage. It was also common for workers to feel apprehensive as some were concerned the parent would not be willing to engage or work on the identified issues.

• Parents assessed worker qualities or tested workers during this phase such as testing the character of the worker to decide whether or not they were trustworthy, judgemental, and if the parent felt comfortable with the worker. It required getting to know the worker, but at the same time not revealing too much about themselves until they decided the worker was ‘‘right’’. It also involved being guarded when discussing their issues, telling varied accounts of situations, remaining silent and avoiding contact, or making contact randomly and intermittently. Knowing a worker was ‘‘right’’ was also promoted through discovering some similarity with the worker, for example a common experience of parenting. Parent identification with the worker seemed to mark a turning point in the building relationship.

• Worker actions and attributes included workers providing a first impression that they were genuine/authentic, active in their attention to the parent, willing to help, focused on capacities, empathic, non-judgemental, patient, flexible, collaborative, and confident in their dealings with the parent. Underpinning all of this was a perception of worker respect for the parents. Being attentive and responsive remained important throughout the entire relationship. It involved providing solutions to parents’ concrete and emotional needs, but not in such a way that they felt disempowered. Worker empathy was important; parents needed to feel that workers understood what they experiencing to some degree and workers showing that they cared about the parent. It was considered important that workers were interested in more than just the professional issues. Worker patience and flexibility, along with being available as needs arose helped form strong foundations.

• Collaboration was characterised by open and honest communication and negotiation, particularly about the parents’ needs, what the workers could offer, and the relationship parameters. It also involved the parents feeling some sense of choice and power regarding the process. Some parents noted that it was important to perceive the workers as confident or competent. They described the workers as resourceful, knowledgeable about a range of areas of professional expertise and life in general, able to respond to the parents’ changing needs, and able to connect with people from a variety of backgrounds.

• Trust for the workers had strong practical implications. Parents described becoming more attentive and responsive to what the worker was saying once trust was built, and both described parents progressing from unwillingness to willingness as they got to the point of connection and feeling comfortable, the lynchpin of which was trust.

94. Reimer (2013) concludes that it could be argued that parental resistance could actually be a reasonable and protective response to new individuals coming into their lives, rather than a sign that such families are difficult or unwilling to engage.

Relationships: Social support for children and families

95. Another emerging message is that sustained change will only be brought about if attention is given to a family’s social support and networks in addition to more individualised interventions. Thirty years after experiencing childhood adversities, individuals can still experience significantly lower levels of social support impacting in terms of perceptions of lower tangible support and lower levels of self-esteem (Sperry and Widom 2013). Social support was found to mediate the relationship between abuse and neglect, and anxiety and depression, although specific types of social support were important. The introduction of total social support, which included having someone to talk to, people with whom one can do things, others with whom one feels they compare favourably and the availability of help, reduced the direct effect of child neglect on anxiety and depression.

96. Thompson’s (2014) review of the two decades since publication of a review of research on social support and the prevention of child maltreatment conducted in the US in 1994 summarised the lessons learned:

• Social support and risk for child maltreatment is not simply about families isolated from the community networks. Some parents feel isolated in neighbourhoods, but others are embedded in community networks that afford considerable affirmation and mutual assistance or may support the parents’ concerning behaviour. The reasons for social isolation can vary: some parents have heightened distrust of others that contributes to their social marginality; some parents actively avoid detection of family or personal practices including substance abuse and domestic violence as well as neglect; and some parents may be so exhausted by personal difficulties that they do not extend the time and energy to make contacts with others in their social networks, even if they desire greater social contact. Indeed, their network associates may also be drained by the same stressors and have little capacity for providing support. Different parents have different social support needs, requiring a fine-tuned appraisal of social support and social networks as a foundation for intervention efficacy.
• Social support and the prevention of child maltreatment consists of social relationships that provide (or can potentially provide) material and personal resources that are of value to an individual, such as access to information and services and sharing tasks and responsibilities. These elements provide important social, emotional, and material resources and, in doing so, can enhance social engagement, reduce isolation, and promote child protection goals by integrating social norms into parenting practices. Some parents enjoy the emotional support afforded by their social networks without altering harmful parental conduct, in part because family or friends justify or rationalise harmful practices rather than challenging them. Thompson (2014) comments on an additional function of social monitoring, which can be friends noticing signs of depression and supporting an individual to seek help, however, this can be interpreted as meddling and intrusive; balancing child-centered monitoring with efforts to socialise parenting and maintain strong connections to parents is a difficult challenge.

• Social networks for informal support from family, friends and neighbours have the benefits of being readily accessible, and non-stigmatising. However, informal helpers are likely to lack the skill and knowledge to provide meaningful assistance that can address serious psychological problems. Formal social support can offer more intensive services when needed and referrals to other services or resources, although formal social support tends to more limited. The challenges of coordinating formal and informal helpers should not be underestimated. Differences in values and goals, and mutual distrust in many communities can undermine the effort to create partnerships of this kind.

97. Thompson (2014) reflects that receiving social support can result in feelings of vulnerability, humiliation, and resentment, whether aid comes from formal or informal sources. When support is normalised for the recipient’s neighbourhood or community, provided in places that avoid stigma and when it is broadly available rather than targeted, it is more likely that received support will be perceived as beneficial. Stress is also a factor that can undermine access to social support through erosion of social networks as distressed individuals withdraw because of pain, shock, or humiliation, or potential helpers withdraw because the individual’s needs are emotionally taxing or their conduct repels. Intervention programs might distinguish different kinds of stress in the design of social support.

98. Many would argue that the most beneficial and comprehensive form of social support is through direct relationships, however, the internet is one means of increasing social support without direct face-to-face contact with individuals or groups. Two distinct social networks are emerging: networks of individuals who are known and seen on a regular basis; and networks which consist of individuals who are only known online, such as through chat rooms, virtual gaming and blog posts. Research findings suggest higher rates of self-reported depressive symptoms for adolescents and adults in online communication with strangers compared with lower depression scores for those communicating online with friends (Thompson 2014).

Summary points: Relationships

• The important role of relationships between the parent and child, family and worker, and family with the community for sustaining change cannot be underestimated. Relationships need to be collaborative and authentic.
• Parental anger, ambivalence and testing of relationships may be part of a process of building trust, and a worker’s action to find solutions to immediate difficulties may be the building blocks for tackling more entrenched behaviours. Trust is practical as well as emotional.
• Parental resistance to support initially could be a protective response rather than an unwillingness to engage.
• Sustained change in families will only be brought about if attention is given to social support as well as direct interventions. Social support for parents included having someone to talk to, people with whom one can do things, others with whom one feels they compare favourably and the availability of help. Together this reduced the direct effect of child neglect on adult wellbeing.
• Social networks and supports are unique to individual families: some feel isolated; some are embedded in networks that may support concerning behaviours; some withdraw from communities to avoid challenge; and some may too exhausted by personal difficulties. Indeed, their network associates may also be drained by the same stressors and have little capacity for providing support.
• Different parents have different social support needs, requiring a fine-tuned appraisal of social support and social networks as a foundation for intervention efficacy.
• Balancing child-centred monitoring with efforts to socialise parenting and maintain strong connections to parents is challenging.
• When support is normalised for the recipient’s neighbourhood or community, provided in places that avoid stigma and when it is broadly available rather than targeted, it is more likely that received support will be perceived as beneficial.
• Virtual social networks are emerging with mixed results: networks online of known individuals can be supportive, but networks of individuals who are only known online are less so. When support is normalised for the recipient’s neighbourhood or community, provided in places that avoid stigma and when it is broadly available rather than targeted, it is more likely that received support will be perceived as beneficial.
• Virtual social networks are emerging with mixed results: networks online of known individuals can be supportive, but networks of individuals who are only known online are less so.