the new orleans intervention model · 2016-06-02 · 2 the new orleans intervention model: a case...

The New Orleans Intervention Model

Testing a new approach to looking after infant mental health through Infant and Family Teams

A case studY of practice

2 The New Orleans Intervention Model: A case study of practice

1. Introduction and context Page 3

2. Overview of the New Orleans Intervention Model and how it is being tested by NSPCC in the UK Page 4

3. Who this case study is for Page 4

4. Understanding the New Orleans Intervention Model Page 5

5. Evaluation of the original New Orleans Intervention Model Page 10

6. The New Orleans Intervention Model as a systemic and integrated intervention Page 11

7. Key themes addressed by the New Orleans Intervention Model Page 12

8. Developing and testing the New Orleans Intervention Model through Infant and Family Teams in the UK Page 14

9. Future plans and aspirations Page 16

Endnotes Page 16

Contents

Cover photography by Tom Hull. The people pictured are volunteers.

2 The New Orleans Intervention Model: A case study of practice 3

1.Introduction and context

For maltreated children, the most important intervention may be the provision of a safer and more nurturing home environment. Children who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout their lives, but the negative effects of these experiences can largely be reversed – if children are able to find safety and security early on. Mostly, this just doesn’t happen. Too many children experience uncertainty and upheaval, moving back and forth between birth parents and foster homes. This profoundly disrupts their development and effects their health and wellbeing for the rest of their lives.

Decisions about permanency and care-giving relationships for children who have been abused or neglected are momentous. We must find ways to make better decisions – and to check that we’ve made good decisions – that enable children to find loving and secure homes as early in life as possible. We have vastly under-estimated the importance of looking after infant mental health and must rethink the way we work together – across disciplines and agencies – to put the health and well-being of young children and the quality of their future life outcomes at the heart of decision-making.

‘The complexity of maltreatment in young children must be matched by the comprehensiveness of our efforts to minimise their suffering, reduce their developmental deviations, enhance their development and promote their competence.’ Charles H. Zeanah, Jr, MD, Executive Director, Institute of Infant and Early Childhood Mental Health, Director of Tulane Infant Team - Founder of the New Orleans Intervention Model

Looking after infant mental health – the headline case for change• Children who experience maltreatment

and grow up without positive and stable relationships, like children who end up in care, are at greater risk of mental health problems and other poor outcomes throughout their lives.

• Very young children are particularly vulnerable to abuse and neglect, and the negative effects of trauma on a young child’s development can be profound. The importance of looking after their mental health is well-evidenced.

• There is hope of recovery for maltreated babies and infants in care, but it needs to happen early.

• Stable relationships really matter, but many children who are in care get moved from one placement to the next, or returned to a home that can’t support them well.

• Foster carers need specialist support in order to give children the best care possible.

• And more needs to be done to help birth parents learn to care for their children – those they have now and any they may have in the future.

• Despite all the evidence, services designed to identify and look after the mental health of babies and infants in care are virtually non-existent.

• The effects of poor mental health are damaging not only for the child as they grow up, but also to society as a whole.

‘Children’s needs for stability, secure attachments and early permanency are not always, in reality, given priority.’1

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Read the full version of ‘Looking after infant mental health - our case for change. A summary of evidence’ on nspcc.org.uk/infantmentalhealth


2. Overview of the New Orleans Intervention Model and how it is being tested by NSPCC in the UK

3. Who this case study is for

For the past five years, NSPCC has been exploring a radically different approach to supporting young children who have been abused or neglected, and their caregivers. Our interest has focussed on a particular approach developed in the US and known here as the New Orleans Intervention Model.

In a systematic review by Helen Minnis and colleagues, the New Orleans Intervention Model was identified as the only evidence-based programme to use an infant mental health approach to improve the quality of permanent placement decisions so that children can experience appropriate nurturing care as early in life as possible.2 The New Orleans Intervention Model stood out for its comprehensive response to a complex problem and the promising results of early evaluations.

NSPCC is currently exploring whether and how the New Orleans Intervention Model might work in the UK context. Following a feasibility study in Glasgow,3 we are working in partnership with the University of Glasgow, Glasgow City Council and the NHS Greater Glasgow and Clyde to carry out a randomised control trial. This will report in 2020. A separate but linked study to develop and test the model has recently been established in South London and will also report in 2020.

This case study is for practitioners and other professionals across health, social care and the family justice system who work to improve infant mental health and support children in care and their families. The case study:

• Describes the New Orleans Intervention Model, its origins in the US, how it works and how it aims to affect change, and the results of early evaluations

• Identifies key features of the model and outlines how the model is different to what normally happens to young children in care due to abuse or neglect

• Outlines NSPCC’s work to bring the model to the UK and its current investment in testing the approach in two sites (Glasgow and South London)

4. Understanding the New Orleans Intervention Model

The New Orleans Intervention Model was developed in New Orleans in the 1990s by a group of clinicians and scientists (led by Professor Charley Zeanah and Dr Julie Larrieu) working as the Tulane Infant Team. The model aims to ensure appropriate and timely decisions about the permanent placement of children who are in care due to abuse and neglect. It puts a child’s attachment relationships at the heart of decision-making, so that they might experience a positive and secure care setting as early in life as possible, ultimately leading to improvements in their wellbeing and mental health.

In Jefferson Parish in Louisiana, every child under the age of five years who has been validated as having experienced maltreatment and placed in foster care is referred to the Tulane Infant Team for assessment and treatment. Following referral, the team embarks on a detailed attachment-based assessment process. The team starts their assessment by meeting with relevant people involved in a child’s life, including the child’s birth parents, social worker, and foster parents. They use a range of tools to gather information about the child and family’s history and current circumstances, which allows the team to understand the context and development of issues that led the child to come in to care. This leads to an intervention with the birth family aimed at maximising the chances of the child returning to their care. Focused support is simultaneously provided to the foster carer.4

Key aims of the New Orleans Intervention Model are to:• Improve decision making

about entry to care or parents’ capacity to support children safely at home

• Improve mental health, both for children who return home and those who remain in care

• Increase placement stability

• Reduce repeat maltreatment of children

• Reduce reunification breakdown

• Reduce the harm to subsequent children in a household


ASSESSMENT

Stage 2

REFERRAL

Stage 1

BESPOKE TREATMENT AND REVIEW

Stage 4

INITIAL PROFESSIONALS’ MEETING AND TREATMENT PLANNING

Stage 3

Otherprofessionals

Infant andFamily Team

Infant andFamily Team

Child’s socialworker

Social WorkLiaison Manager

Distinctively, the New Orleans Intervention Model offers assessment and treatment in almost every case. The Infant and Family Team brings together multi-disciplinary specialists in infant mental health and social care and typically works with a child and family over a 9-15-month period. It assesses each parent’s health and wellbeing, including mental health and any addiction issues, or their own exposure to trauma or violence. It then establishes explicit treatment goals and offers tailored therapeutic support to address problems and strengthen the parent-child relationship. Treatment might include one or more of a range of evidence-based interventions, including Video Interaction Guidance, Circle of Security and Parent-Infant Psychotherapy.

• Infant and Family Team liaises with the child’s social worker to gather information about the case.

• Any potential obstacles to Infant and Family Team involvement identified and resolved with the child’s social worker and his/her managers.

• Consent sought to Infant and Family Team involvement from the child’s birth parents.

• Case allocated to two primary clinicians who visit the child’s birth parents at home to discuss the Infant and Family Team programme.

• The two primary clinicians separately but simultaneously focus on assessment with the child and his/her foster parents, and with the child and his/her birth parents.

Stages of the New Orleans Intervention Model

Powerful professional collaboration through the New Orleans Intervention ModelSystematic, intensive, child-focused support from a consistent team of multi-disciplinary professionals

Open and inclusive approach to case management and treatment planning, within and beyond the team

Respect for the essential role of both birth and foster parents, and processes to ensure their full involvement

Participation in local authority agency meetings as needed

Liaison with other services that can support the needs of parents and/or children

Decision-making about permanent entry to care for each child is made only after the treatment programme and is based on the parents’ capacity to change their behaviour and strengthen their care-giving relationship with the child. The Infant and Family Team must agree that goals of becoming a “safe and effective parent” have been met. One crucially important change is whether a parent is able to accept responsibility for their maltreatment of the child.

• Infant and Family Team findings and treatment plan for the family is shared with the wider professional group (e.g. social work team, guardian and educational psychologists).

• Infant and Family Team professionals provide recommendations for use by the courts.

• Infant and Family Team report is completed, outlining the recommended treatment plan.

• Treatment tailored to individual needs of parents.

• Focus of treatment is parent-child relationship, but may include interventions with foster parents in order to enhance the child’s mental health and wellbeing.

• Social work staff and Infant and Family Team make joint recommendations about the child’s care plan based on the best interests of the child.

Through the assessment and treatment process, the Infant and Family Team undertakes ‘concurrent planning’ with foster carers, so that children whom the judiciary has decided should remain in care might stay with the same family have the best chance of a successful placement while they are in care. Alongside work with parents to repair relationships, the New Orleans Intervention Model also works to support good quality attachments between the child and the foster carer.

Where parents can achieve significant change, children are rehabilitated back into their birth family. If nothing changes, then the recommendation is for adoption. Members of the Infant and Family Team attend relevant legal proceedings to explain the detail of the work and the implications for any requested conditions in respect of contact arrangements or child assessments. The assessment and treatment process is intensive, but it generates detailed evidence from a range of perspectives so that the family court can make better decisions about the best care setting for the child.


Circle of SecurityCircle of Security is an evidence-based early intervention which uses attachment theory as a basis to develop better parent-child relationships. The core idea of Circle of Security is that caregivers have more freedom to change their behaviour than their children, but they can influence their child’s behaviour by improving their own.

The Circle of Security model starts with an assessment which is used to develop individualised treatment plans for a family. The number of sessions varies but treatment generally takes place over 12 months. Videos of parents and children interacting are used to educate parents about the different cues children use to get nurturing and support from parents. This helps parents look at their own behaviour from the outside, giving a critical perspective. It allows children’s cues for particular kinds of attention to be highlighted, so the next time parents are cued they are more likely to respond appropriately. It also allows parents and therapists to explore different potential interactions with children, and take part in an educational and therapeutic dialogue.5

Parent-Infant PsychotherapyParent-Infant Psychotherapy is an evidence-based intervention that has developed in response to the seriousness of infant mental health problems. It is based on developmental and clinical research, specifically targeting the infant-parent relationship. By improving the ability of parents to reflect on their child’s needs, the relationship security of infants improves and better mental health follows.

A psychotherapist works directly with a parent-infant pair, or in some cases both parents and their infant. This may take place at home, in a clinic, or in a hospital. Parent-infant psychotherapy interventions have evolved over time, from representational therapy in the 1980s to more behavioural approaches.6

Assessment measures used in the New Orleans Intervention ModelAges & Stages Questionnaire, Beck Depression Inventory, Behavior Screening Questionnaire, Child Behavior Checklist, Circle of Security Interview, Crowell procedure, Davidson Trauma Scale, Disturbances of Attachment Interview, Genogram, Infant and Family Team intake interview, Life Stressor Checklist, Parenting Stress Index – short form, Partner Violence Interview, Still Face procedure, Trauma-Related Dissociation Scale, Traumatic Events Screening Inventory – Parent Report Revised (TESI-PRR) and Working Model of the Child Interview.

Treatment interventions used in the New Orleans Intervention ModelTreatment could include a range of therapeutic interventions, such as: Visit Coaching, Dyadic Psychotherapy (Circle of Security, Infant-Parent Psychotherapy, Attachment and Biobehavioral Catch-Up, Parent Child Interaction Therapy), Individual Psychotherapy (TF-CBT) and Couples Psychotherapy.

Specific interventions used within the New Orleans Intervention ModelThe New Orleans Intervention Model offers intensive treatment in every case, tailored to the individual needs of parents and drawing on attachment-informed, relationship-focused interventions.

Video Interaction Guidance (VIG)Video Interaction Guidance (VIG) is an evidence based intervention used to improve communication and understanding in a range of relationships, from parent-child to teacher-student and client-practitioner.

VIG is delivered by trained guiders who videotape interactions between pairs or groups who have experienced problems in their relationship. The guider then edits the video to find examples of positive interaction, which they analyse with the people involved. Reflecting on positive behaviours they have already exhibited encourages people to repeat them, and to notice the patterns in their behaviour. Guiders will normally take three or four videos at different points and run separate discussion sessions on each video. This allows different aspects of relationships to be highlighted.

In the case of parent-child VIG, guiders view videos with the parent and sometimes the child if they are old enough. The NSPCC has been testing VIG as a means of reducing neglect through helping parents of children aged between 2 and 12 develop a better bond with their child and understand what they need. Levels of emotional and behavioural difficulties experienced by their children were significantly reduced by the end of the programme and parents reported that VIG had helped them understand their child’s needs and change their parenting style.

‘The decision about whether to return a child to a family in which s/he has previously been maltreated or to place him or her permanently in an adoptive family is a momentous one. We must find ways to make timely informed decisions and to test whether or not we make the right ones.’7

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Evaluation of the New Orleans Intervention Model in the U.S.A. has shown promising results in terms of the difference it aimed to make in the lives of children.8

Zeanah and his colleagues evaluated the New Orleans Intervention Model by comparing routine child protection data in the four years before and after the programme began. They found that the programme resulted in a significant reduction in the repeat maltreatment of children who returned home from care, and a significantly lower risk of harm to subsequent children in the same family.

5. Evaluation of the New Orleans Intervention Model in the U.S.A.

Key evaluation findings:Significant reduction in the repeat maltreatment of children who returned home from care.9

Between 53% and 68% reduction:

Significantly lower risk of harm for subsequent children in a household, irrespective of whether the first child entered care or returned home.10

Between 63% and 75% reduction:

A recent seven year follow-up of children supported by the New Orleans Intervention Model found that their mental health was comparable to the general population.11

This is remarkable when the high rates of mental health difficulties among children in care are considered.

6.The New Orleans Intervention Model as a systemic and integrated intervention

The New Orleans Intervention Model is a way of working across systems, to build capacity and offer holistic support to children, families and foster carers.

The family courts The model ensures the family courts are provided with robust evidence from a multi-disciplinary team, so that they are able to make timely decisions about children’s permanent care.

Child and adolescent mental health services The model advocates for mental health services for all children in care who are under 5, to support their development and mitigate the impact of maltreatment on their young brains. It brings together health and social care practitioners to work together to assess and treat child-caregiver relationships.

Children’s social care The model offers local authorities reliable evidence on which to build children’s care plans, and make safe decisions about returning children home. Regular contact with social workers and other professionals involved with the family enable everyone to monitor parents’ progress towards positive outcomes.

Foster carers are supported to build and maintain good quality attachment relationships with children, and are given support to respond to children’s needs.


There are a number of key characteristics of the New Orleans Intervention Model which, in combination, present a unique intervention from which the wider system can learn.

7.Key characteristics of the New Orleans Intervention Model

Early intervention and investment in prevention

The New Orleans Intervention Model is truly an early intervention with a focus on infants (under 5s)

Specialists working within multi-disciplinary teams

Combined mental health and social work expertise and capacity supports real integration

Focused on child-caregiver relationships

Holistic assessment and support is provided for all relationships around the child

The New Orleans Intervention Model is an approach for under 5s in care, their birth parents and their foster carers. Central to the approach is offering assessment and treatment as soon as children are taken into care, to mitigate the impact of abuse on their development. Similarly, the model advocates working intensively with birth parents to prevent maltreatment from re-occuring in the family.

Early investment in looked after children’s mental health equates to significant cost savings across the care, education, justice and health systems.

The New Orleans Intervention Model brings together specialists from different fields within a dedicated team (the Infant and Family Team) to undertake assessments, provide treatment and make recommendations about the best support and arrangements for a child and family.

Infant and Family Teams are made up of a combination of infant mental health and social work expertise, and include: psychiatrists, psychologists, social workers, family support workers and psychotherapists. Working together, they are able to offer a robust and holistic assessment and treatment service to children and families.

The New Orleans Intervention Model puts a child’s attachment relationships at the heart of decision-making. The Infant and Family Team undertakes a detailed, holistic assessment of the child and its context. It looks at all the child’s care-giving and potential care-giving relationships. Beginning with each foster carer, the process goes on to include each member of the child’s family who is involved in care-giving.

Other case studies

Capacity-building

Focuses on parents’ capacity to change, and the provision of associated support

Personalised and intensive treatment and intervention

A tailored/bespoke treatment model, with intensive intervention offered in every case

Focused on evidence

Designed to gather evidence for better decision-making across the system

The New Orleans Intervention Model focuses on a parent’s capacity to change, with assessment and intervention offered to parents to address problems, rebuild relationships and maximise their chances of the child returning to their care. This work with birth parents can improve things even if the decision is to remove a child, for example in the quality of relationships and a reduction in maltreatment of subsequent children.

The New Orleans Intervention Model offers intensive treatment, tailored to the individual needs of parents and drawing on attachment-informed, relationship-focused interventions.

Treatment could include a range of therapeutic interventions, such as: Dyadic Psychotherapy (Circle of Security, Parent-Infant Psychotherapy, Attachment and Biobehavioral Catch-Up, Parent Child Interaction Therapy), Individual Psychotherapy (TF-CBT) and Couples Psychotherapy.

The New Orleans Intervention Modal uses integrated infant mental health and social work to generate robust evidence to inform decisions about a child’s permanent placement, so that children experience stable nurturing care as early in life as possible. Decisions about permanence are informed by changes in the strength of the child-parent attachment relationship following detailed assessment and treatment, rather than based on a static assessment of risk. Standardised measures are used to determine parental capacity to change and where there is evidence for parental capacity to change, a treatment plan is that draws on evidence based attachment focused interventions is is offered. • The Family Drug and

Alcohol Court • Pause• The Child House model• Parents Under Pressure

Download the full set of case studies at nspcc.org.uk/infantmentalhealth

As part of NSPCC’s focus on looking after infant mental health, we have developed a set of case studies which further explore and illuminate these characteristics. The case studies share UK-based and international examples of relevant, evidence-based approaches and programmes, including:


8. Developing and testing the New Orleans Intervention Model through Infant and Family Teams in the UK NSPCC’s long-term goal is to support the transformation of child health and social care policy and practice so that it recognises the fundamental importance of infant mental health for looked after children’s outcomes; and the importance of working intensively with birth parents to prevent repeat removals and placement instability. We want to help create a culture change across the whole system, so that the very earliest years are prioritised in both health and social care commissioning budgets for looked after children.

We believe that the New Orleans Intervention Model offers the potential to radically improve the mental health and life outcomes of children who have been abused or neglected in the UK.

Excited by the promising early results in the US, NSPCC has been exploring the feasibility of the New Orleans Intervention Model in the UK and has begun rigorous testing of the model in this context to see whether and how it might make a difference for young children and their families. In order to deliver the New Orleans Intervention Model, NSPCC has established specialist, multidisciplinary Infant and Family Teams in Glasgow and South London.

NSPCC, University of Glasgow, Glasgow City Council and the NHS Greater Glasgow & Clyde are currently running a randomised control trial to test the New Orleans Intervention Model against current practice in Glasgow. The National Institute of Health

Research (NIHR) is funding an evaluation of the trial, which will report in 2020.12

NSPCC is also running a linked study in South London, with Croydon Council and the South London and Maudsley NHS Foundation Trust.

The UK evaluations are investigating:

• Impact on infant mental health

• The quality of the child’s relationship with their birth parent and with their foster carer

• The impact of the model on early decisions about a child’s placement

• The cost-benefit of the intervention

The purpose of this testing is to establish the extent to which results of the New Orleans Intervention Model might be replicable in a UK context. The New Orleans Intervention Model is the only programme we have come across that uses an infant mental health approach aiming to improve the quality of permanent placement decisions so that children can experience appropriate nurturing care as early in life as possible.. An important outstanding question is therefore whether this approach to early intervention with maltreated children can improve decision-making and health outcomes in a UK context.

9. Future plans and aspirations

Across the wider health and social care system we have vastly under-estimated the importance of looking after infant mental health. We must rethink the way we work together – across disciplines and agencies – to put the health and well-being of young children in care and the quality of their future life outcomes at the heart of decision-making.

We have created this case study along with a wider set which describe Pause, The Family Drug and Alcohol Court (FDAC), The Child House model and Parents Under Pressure.

Download the set of case studies at nspcc.org.uk/infantmentalhealth

This case study forms part of a set of materials NSPCC is developing which focus on the importance of looking after infant mental health. This is part of our goal to help abused children get back on track and prevent abuse in families facing adversity.

We have published a ‘case for change’ for looking after infant mental health, which brings together a wide range of evidence from research and from practice, from the UK and internationally, in order to tell what we hope is a compelling story.

That story is not simple or straightforward: it has many different, interconnected parts which highlight a wide range of complex issues. These are issues facing young children and babies in care, their parents and foster carers, as well as other professionals working with children, the family courts and decision-makers in the wider health and social care system.


Endnotes1. Wolfson, R. (2010) The Coram Concurrent Planning Project: A Review

of Ten Years’ Experience. Seen and Heard 20, p. 492. Jamieson, M. (2015) Therapeutic Interventions with Birth Parents

and Foster Carers of Maltreated Children: A Systematic Review (Unpublished)

3. nspcc.org.uk/services-and-resources/research-and-resourc-es/2016/evaluation-new-orleans-intervention-model-infant-mental-health-glasgow

4. Zeanah, C., Larrieu, J., Heller, S., Valliere, J., Hinshaw-Fuselier, S., Aoki, Y., Drilling, M. (2001) Evaluation of a preventive intervention for maltreated infants and toddlers in foster care. Journal of American Academy of Child and Adolescent Psychiatry Feb 40(2), pp. 214-21.

5. http://circleofsecuritynetwork.org/evidence-based.html http://www.psychology.sunysb.edu/attachment/online/online_2/CircleOfSecu-rit2002bw.pdf

6. http://www.pipuk.org.uk/sites/default/files/parent-infant_psy-chotherapy.pdf http://www.campbellcollaboration.org/lib/down-load/3726/Barlow_Psychotherapy_Review.pdf

7. Minnis, H., Bryce, G., Phin, L., and Wilson, P. (2010) ‘The ‘’Spirit of New Orleans’’: Translating a model of intervention with maltreated children and their families for the Glasgow context.’ Clinical Child Psychology and Psychiatry. 15 (4), p. 502.

8. Zeanah, et.al. 9. Zeanah, et.al. 10. Zeanah, et.al.11. Robinson L. R., Boris N., Heller S. S., Rice J., Zeanah C. H., Clark C., et al.

(2012) The good enough home? Home environment and outcomes of young maltreated children. Child Youth Care Forum, 41, 73–88.

12. nspcc.org.uk/services-and-resources/research-and-resourc-es/2016/evaluation-new-orleans-intervention-model-infant-mental-health-glasgow

18 The New Orleans Intervention Model: A case study of practice

© NSPCC 2016. Registered charity England and Wales 216401. Scotland SC037717.

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the new orleans intervention model · 2016-06-02 · 2 the new orleans intervention model: a case...

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