Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The guidance complements, but does not replace, NICE guidance on: child maltreatment; pregnancy and complex social factors; antenatal and postnatal mental health; mental health disorders in children; looked-after children and young people; and the social and emotional wellbeing of children and young people.

The evidence statements underpinning the recommendations are listed in appendix C.

The Public Health Interventions Advisory Committee (PHIAC) considers that the recommended interventions are cost effective.

See also the recommendations for research and gaps in research and the evidence reviews, supporting evidence statements and economic modelling report.

Background: social and emotional development

A complex range of factors have an impact on social and emotional development. Knowledge of these factors may help encourage investment at a population level in early interventions to support health and wellbeing. This would ensure children (and families) who are most likely to experience the poorest outcomes get the help they need early on in their lives.

Knowledge of these factors, aside, practitioners' experience and expertise will be paramount in assessing the needs and risks of individual children and their families.

Home visiting, early education and childcare

The recommendations cover home visiting, early education and childcare for vulnerable children. The recommendations:

  • Adopt a 'life course perspective', recognising that disadvantage before birth and in a child's early years can have life-long, negative effects on their health and wellbeing.

  • Focus on the social and emotional wellbeing of vulnerable children as the foundation for their healthy development and to offset the risks relating to disadvantage. This is in line with the overarching goal of children's services, that is, to ensure all children have the best start in life.

  • Aim to ensure universal, as well as more targeted services, provide the additional support all vulnerable children need to ensure their mental and physical health and wellbeing. (Key services include maternity, child health, social care, early education and family welfare.)

  • Should be used in conjunction with local child safeguarding policies and the Children and Social Work Act 2017.

The term 'vulnerable' is used to describe children who are at risk of, or who are already experiencing, social and emotional problems and who need additional support. See vulnerable children in the glossary for factors likely to increase the risk of problems.

Whose health will benefit?

Vulnerable children aged under 5 years and their parents.

Recommendation 1 Strategy, commissioning and review

Who should take action?

All those responsible for planning and commissioning (including joint commissioning) services for children aged under 5 in local authorities, the NHS (primary, secondary and tertiary healthcare) and the voluntary, community and private sectors. This includes:

  • Clinical commissioning groups.

  • Health and wellbeing boards.

  • NHS Commissioning Board (the NHS Commissioning Board is responsible for commissioning health visiting services up to 2015; from 2015, local authorities will take over this responsibility).

  • Public health, children's services, education and social services within local authorities.

What action should they take?

Recommendation 2 Identifying vulnerable children and assessing their needs

Who should take action?

  • Early years settings (including children's centres and nurseries).

  • Primary schools (independent, maintained, private and voluntary) and school nursing services.

  • The NHS: general practice, health visiting services, maternity services, mental health services (perinatal, child and adolescent and adult) and paediatrics.

  • Voluntary and community sector organisations.

  • Child safeguarding services.

  • Police.

  • Local authority housing departments.

What action should they take?

  • All health and early years professionals should develop trusting relationships with vulnerable families and adopt a non-judgmental approach, while focusing on the child's needs. They should do this by:

    • identifying the strengths and capabilities of the family, as well as factors that pose a risk to the child's (or children's) social and emotional wellbeing

    • talking about the aspirations and expectations for the child

    • seeking to understand and respond to perceived needs and concerns

    • discussing any risk factors in a sensitive manner to ensure families do not feel criticised, judged or stigmatised (see vulnerable children for factors that may affect a child's social and emotional wellbeing).

  • Health professionals in antenatal and postnatal services should identify factors that may pose a risk to a child's social and emotional wellbeing. This includes factors that could affect the parents' capacity to provide a loving and nurturing environment. For example, they should discuss with the parents any problems they may have in relation to the father or mother's mental health, substance or alcohol misuse, family relationships or circumstances and networks of support.

  • Health visitors, school nurses and early years practitioners should identify factors that may pose a risk to a child's social and emotional wellbeing, as part of an ongoing assessment of their development. They should use the 'Early years foundation stage' assessment process to help identify and share any needs and concerns. Specifically, they should look for risk factors that were not evident at an earlier stage. For an infant or child, this could include:

    • being withdrawn

    • being unresponsive

    • showing signs of behavioural problems

    • delayed speech

    • poor language and communication skills.

      For parents, this could include indifference to the child or insensitive or harsh behaviour towards them.

  • Family welfare, housing, voluntary services, the police and others who are in contact with a vulnerable child and their family should be aware of factors that pose a risk to the child's social and emotional wellbeing. They should raise any concerns with the family GP or health visitor (working in the context of local safeguarding policies).

  • Health and early years professionals should ensure procedures are in place:

    • to make referrals to specialist services, based on an assessment of need

    • to collect, consistently record and share information as part of the common assessment framework (relevant child and adult datasets should be linked)

    • for integrated team working

    • for continuity of care

    • to avoid multiple assessments.

Recommendation 3 Antenatal and postnatal home visiting for vulnerable children and their families

Who should take action?

  • Maternity services.

  • Health visiting services.

  • Early years services.

What action should they take?

  • Health visitors or midwives should offer a series of intensive home visits by an appropriately trained nurse to parents assessed to be in need of additional support (see recommendation 2).

  • The trained nurse should visit families in need of additional support a set number of times over a sustained period of time (sufficient to establish trust and help make positive changes). Activities during each visit should be based on a set curriculum which aims to achieve specified goals in relation to:

    • maternal sensitivity (how sensitive the mother is to her child's needs)

    • the mother–child relationship

    • home learning (including speech, language and communication skills)

    • parenting skills and practice.

      It is not clear from current evidence how many home visits are needed. The Family Nurse Partnership, an evidence-based, intensive home visiting programme, provides weekly or fortnightly home visits for 60–90 minutes throughout most stages of the programme - with more in the early stages and less later.

  • The nurse should, where possible, focus on developing the father–child relationship as part of an approach that involves the whole family. This includes getting the father involved in any curriculum activities.

  • Health visitors or midwives should regularly check the parents' level of involvement in the intensive home visiting programme. If necessary, they should offer them a break, to reduce the risk that they will stop participating. If the parents do decide to have a break, the nurse should continue to communicate with them on a regular basis.

  • Managers of intensive home-visiting programmes should conduct regular audits to ensure consistency and quality of delivery.

  • Health visitors or midwives should explain to parents that home visits aim to ensure the healthy development of the child (see recommendation 2). They should take into account the parents' first language and make provision for those who do not speak English. They should also be sensitive to a wide range of attitudes, expectations and approaches in relation to parenting.

  • Health visitors or midwives should try to ensure both parents can fully participate in home visits, by taking into account their domestic and working priorities and commitments. They should also try to involve other family members, if appropriate and acceptable to the parents.

  • Health visitors and midwives should consider evidence-based interventions, such as baby massage and video interaction guidance, to improve maternal sensitivity and mother–infant attachment. For example, this approach might be effective when the mother has depression or the infant shows signs of behaviourial difficulties.

  • Health visitors and midwives should encourage parents to participate in other services delivered by children's centres and as part of the Department of Health and Social Care's Healthy Child Programme.

  • Health visitors and midwives should work in partnership with other early years practitioners to ensure families receive coordinated support. This includes psychologists, therapists, family support workers and other professionals who deliver services provided by children's centres and as part of the Healthy Child Programme.

Recommendation 4 Early education and childcare

Who should take action?

  • All those involved in providing early education and childcare services. This includes childminders and those working in children's centres, nurseries and primary schools (maintained, private, independent and voluntary).

  • Health visiting services.

  • Local authority children's services.

  • School nursing services.

What action should they take?

  • Local authority children's services should ensure all vulnerable children can benefit from high quality childcare outside the home on a part- or full-time basis and can take up their entitlement to early childhood education, where appropriate. The aim is to give them the support they need to fulfill their potential. Childcare and education services should:

    • offer flexible attendance times, so that parents or carers can take up education, training or employment opportunities

    • address any barriers that may hinder participation by vulnerable children such as geographical access, the cost of transport or a sense of discrimination and stigma

    • be run by well-trained qualified staff, including graduates and qualified teachers

    • be based on an ethos of openness and inclusion.

  • Managers and providers of early education and childcare services should ensure all vulnerable children can benefit from high quality services which aim to enhance their social and emotional wellbeing and build their capacity to learn. Services should:

    • promote the development of positive, interactive relationships between staff and children

    • ensure individual staff get to know, and develop an understanding of, particular children's needs (continuity of care is particularly important for younger children)

    • focus on social and emotional, as well as educational, development.

  • In line with the Department for Education's statutory framework for the early years foundation stage, managers and providers of early education and childcare services should:

    • provide a structured, daily schedule comprising a balance of adult-led and child-initiated activities

    • ensure parents and other family members are fully involved (for example, by contributing to decisions about service provision, or by participating in learning or other activities, as appropriate)

    • ensure the indoor and outdoor environment is spacious, well maintained and pleasant.

Recommendation 5 Delivering services

  • Who should take action?

  • Early years settings (including children's centres and nurseries).

  • Primary schools (independent, maintained, private and voluntary) and school nursing services.

  • The NHS: general practice, health visiting services, maternity services, mental health services (perinatal, child and adolescent and adult) and paediatrics.

  • Voluntary and community sector organisations.

  • Child safeguarding services.

What action should they take?

  • Health and early years providers should put systems in place to deliver integrated universal and targeted services that support vulnerable children's social and emotional wellbeing. This should include systems for sharing information and for multidisciplinary training and development.

  • Health and early years providers should ensure a process is in place to systematically involve parents and families in reviewing services and suggesting how they can be improved. As part of this process, vulnerable parents and families should be asked about their needs and concerns – and their experiences of the services on offer.

  • Health and early years practitioners should be clear about their responsibility for improving the social and emotional wellbeing of vulnerable children and their families. This involves developing and agreeing pathways and referral routes that define how practitioners will work together, as a multidisciplinary team, across different services within a given locality.

  • Health and early years practitioners should be systematic and persistent in their efforts to encourage vulnerable parents to use early years services. (This includes parents who do not use universal services such as primary care.) Activities should include:

    • targeted publicity campaigns

    • making contact by using key workers and referral partners

    • encouraging other parents to help get them involved

    • sending out repeat invitations

    • using local community venues, such as places of worship and play centres to encourage them to participate and to address any concerns about discrimination and stigma

    • home visits by family support workers.

  • Health and early years practitioners should use outreach methods to maintain or improve the participation of vulnerable parents and children in programmes and activities. Parents who may lack confidence or are isolated will require particular encouragement. (This includes those with drug or alcohol problems and those who are experiencing domestic violence.)

  • Health and early years practitioners should work with community and voluntary organisations to help vulnerable parents who may find it difficult to use health and early years services. The difficulties may be due to their social circumstances, language, culture or lifestyle.