For Baby's Sake: Final Evaluation Report

Abstract

For Baby’s Sake is an intervention for expectant parents who want to break the cycle of domestic abuse and support their baby’s early emotional and social development. Both parents join For Baby’s Sake, whether together as a couple or not, and may be supported until their baby is aged two. The programme takes a whole-family approach that deals with the entire cycle and history of domestic violence and abuse, identifying and directly addressing the trauma or traumas that lie at the heart of the problem.

The Stefanou Foundation, a UK charity, designed and created For Baby’s Sake and commissioned King’s College London to conduct an independent evaluation of the programme’s operation during the prototype phase in two sites in Hertfordshire and London from 2015-2019.

For Baby’s Sake is the culmination of over ten years of investment, effort and continuous learning and the Stefanou Foundation is proud to publish its independent evaluation by a team of researchers from King’s College London, University of Warwick, University of Central Lancashire, University of Cambridge and McMaster University, Canada. The full report is available to download at www.forbabyssake.org.uk

The report is being launched in the context of COVID-19 and the creation of new domestic abuse legislation, so this joint summary by the Stefanou Foundation and the academic evaluation team provides some current context before outlining the key findings from the independent evaluation.

COVID-19 shines a spotlight on the challenges for those experiencing domestic violence and abuse (DVA) to come forward for support, as well as the physical, emotional and psychological risks and impact of the abuse. The pandemic is also raising questions about how best to support mental health and emotional regulation, especially for those with underlying needs caused by previous trauma. The welcome passage of the domestic abuse legislation through Parliament is drawing attention to the nature of domestic abuse and how best to address it. There are more calls to assist those who perpetrate abuse in changing their behaviour. There is growing recognition of the evidence that children are directly affected by domestic abuse and should be recognised as victims and not simply witnesses.

For Baby’s Sake makes a distinctive contribution on all of these points. It creates a different opportunity for families to seek and receive support, through allocating practitioners to work individually and separately with both parents. It takes a trauma-informed approach to address the mental health needs of parents and babies. It underlines that the call to recognise and support child victims of domestic abuse must include babies, who are particularly affected from pregnancy until the age of two. This is because of how domestic abuse can affect the development of babies’ brains, bodies and relationships with their parents over that timescale.

The academic evaluation report includes evidence from practitioners, stakeholders and a sample of parents who agreed to be interviewed up to three times during the course of the evaluation (2015 – 2019) and provides extensive data including validated research assessments. The four-year evaluation aimed to assess the feasibility, acceptability and impact of For Baby’s Sake as well as provide lessons for future research.

Having stated the extent and profound risks and impact of the experience of DVA for parents and children during the perinatal period (conception to age two) and beyond, and having conducted a systematic evidence review, the report recognises that For Baby’s Sake is the first programme to address key limitations of existing interventions. The programme is at the vanguard of the move towards whole-family, trauma-informed approaches.

For Baby’s Sake takes a unique approach, with practitioners working individually and separately with both parents, from pregnancy, combining evidence-based elements to break cycles of DVA, address the impact of parents’ own childhood trauma and improve adult mental health, alongside parenting interventions focused on infant mental health and parent-infant attachment.

Results of the evaluation show the successful embedding of For Baby’s Sake in its first two diverse prototype sites (Stevenage, North Herts and Welwyn Hatfield districts of Hertfordshire and London Three Boroughs - Westminster, Kensington & Chelsea and Hammersmith & Fulham). Across both sites, the programme received referrals, particularly from children’s social care, and attracted both co-parents to engage, demonstrating the feasibility of this novel aspect of the model, and sustained this engagement, with only 18% and 11% of all those referred disengaging following sign-up in Hertfordshire and London Three Boroughs respectively.

Those engaged in For Baby’s Sake, and recruited to the evaluation, had complex interpersonal abuse histories. There were challenges for service users in reporting on their experience and perpetration of domestic abuse, which included reports of bi-directional abuse in some relationships. The evaluation found that at their first, baseline interview, many service users did not acknowledge experiencing DVA or using DVA behaviours within the previous year, though they were much more likely to disclose that there had been domestic abuse at some time in the relationship. Almost all mothers also reported that they had experienced abuse at some stage from someone other than their co-parent. At the second interview, they were more likely to disclose experiencing abuse or using abusive behaviours. Evidence suggests that the initial low reports of abuse may be due to minimisation, to not recognising certain behaviours as abusive or to reluctance to disclose due to fear or shame. Qualitative data indicate how the therapeutic work could have affected disclosure of abuse, by enabling mothers to understand domestic abuse more clearly and link that knowledge to their experience.

Service user interviews pointed to their multiple, complex needs, indicating the success of For Baby’s Sake in reaching its target population. A substantial proportion of men and women had symptoms of depression, anxiety and post-traumatic stress disorder (PTSD), as well as high numbers of disordered personality traits. As expected, the majority of parents reported adverse childhood experiences (ACEs), with many experiencing various forms of abuse and trauma and over half reporting that they experienced DVA as children.

These childhood experiences link directly to one of the key reasons for expectant co-parents to engage in For Baby’s Sake. Many of the mothers and fathers explained how their motivation for change stemmed from their desire to provide a better life for their children and to be different kinds of parents in order to prevent their children having the same upbringing as they did. Similarly, practitioners reflected that the central emphasis on the baby is crucial in engaging service users and in facilitating healthy parenting behaviours, leading to secure attachments.

The voluntary nature of For Baby’s Sake, and the contrast with service users’ previous experience of interventions, also acted as a motivating factor. Parents felt that the voluntary approach meant they did not feel coerced into participating and found interactions with the For Baby’s Sake teams to be non- judgemental, inviting and welcoming.

Mothers and fathers engaging in For Baby’s Sake were positive about the programme, with many describing how ithad exceeded their expectations. They were able to identify the impacts for them, their relationships and their children, and to explore their successes, including gaining confidence and recognising and challenging abusive behaviours. These learnings were perceived to resonate particularly among some women from minority ethnic backgrounds who described how certain cultural expectations could create barriers to recognising domestic abuse and to speaking out against certain behaviours.

The evaluation finds merit in the For Baby’s Sake approach ofsupporting parents whether together as a couple or not and making it clear that the programme has no goal in principle about parents staying together or separating. Each service user is supported and empowered to recognise and acton their own goals in this respect. The evaluation noted how these goals changed for some service users who expected to stay in the relationship but found personal growth instead.

Over two thirds of women and all of the men interviewed for the evaluation were in a relationship with their co-parentatbaseline interviews. This reduced across time, with only a third of both men and women remaining in this relationship at the two-year follow-up. The researchers suggested that changes in the intimate relationship status with the co-parent can represent a useful assessment of the outcome of the programme.

Mothers and fathers described how For Baby’s Sake had facilitated step- changes in their relationships with their babies and in their understanding of what parenting input babies need to develop. For the babies, birth and child developmentoutcomesatoneandtwoyears(includingbabies’ social, emotional and behavioural development) were largely in the normal range and only a third of families had any social care input at the two-year stage. This contrasted with 70% at baseline, of which 56% were either under a Child Protection Plan or Child in Need processes.

Throughout the evaluation report, consistent messages about the mechanisms for change enabled by For Baby’s Sake were reflected by service users and practitioners alike. Parents talked about the value of the whole-family therapeutic approach, which provides support for the needs of the individual, within intimate and/or co-parenting relationships, and for the needs of the children. Parents are provided with tools and strategies to manage and improve their situations and feelings, including learning about visualisation and mindfulness, practising time-outs and using an anger scale. Many fathers, in particular, reflected on how the therapeutic model allowed them space to acknowledge their own emotions and to use tools and develop methods to instil healthy coping mechanisms.

Another key mechanism for change was identified as the ability to develop a close therapeutic relationship with a highly skilled practitioner over a long period of time. Practitioners reflected that they were able to focus in a detailed way on a specific member of the family, while working with their colleagues to develop a holistic picture of the issues for all members of the family and understand much better any risks and safeguarding issues.

Many parents specifically identified the Inner Child module, the therapeutic core of For Baby’s Sake, as particularly beneficial, building trust and working therapeutically with practitioners to examine their childhoods through a trauma-informed lens. For mothers, the Inner Child module was reported as giving them time and space to explore different aspects of their lives, process their childhood experiences and their experience of DVA as adults and build self-esteem and a sense of empowerment. For fathers, benefits were described in helping them to understand that what happened to them as a child was not their fault but that they were responsible for the behaviours and actions they engaged in as adults. This led to greater awareness among some fathers of the impact of their behaviour, a willingness to take responsibility for their actions, the commitment to no longer use violence and abuse and the desire to put the needs of their co-parents and children first.

This shift ‘from being me-centred to child-centred’ describes practitioners’ and service users’ views thatplacing the baby atthe centre ofthe work and adopting a whole-family and co-parenting approach provide the best opportunity to affect change in parents’ lives and improve children’s outcomes and safety. Many families spoke of the value in receiving psychoeducation on how DVA impacts on children and in receiving general parenting support. Parents identified their learning about child brain development and how attachments form as contributing to them becoming more confident in their parenting and improving communication in their family. Building on this, mothers and fathers who took part in Video Interaction Guidance (VIG) within the programme perceived it had helped them to focus on attachment and sensitive, attuned parenting, allowing them to see the bonds they had developed with their child and providing reassurance about their parenting abilities.

The researchers interviewed multi-agency professionals in Hertfordshire and London who reported on their views of For Baby’s Sake and their experience of working with the teams. They valued the holistic, whole family approach, endorsed the programme for being evidence-based and reported that the For Baby’s Sake teams were highly trained, skilled and responsive. Stakeholders described effective joint working practices and communication, with children’s social care and health in particular, citing how this would result in collaborative working around the safeguarding of children and families.

The evaluation also described how dialogue between For Baby’s Sake and local stakeholders helped to build and strengthen understanding of the programme and encouraged this dialogue to continue at local and national levels.

The evaluation report also provides valuable learning about the research process itself, concluding that it is feasible and acceptable to collect quantitative and qualitative data through a range of self-report, observational, staff and researcher-administered measures. These data can be collected from all family members among this cohort of families with multiple complex needs and intergenerational trauma histories, although data collection, from fathers in particular, across multiple time points can be challenging. Realist research methodologies that use qualitative and quantitative techniques to examine what works best for whom, when and in what context, are suggested for use in future evaluation, to suit the holistic and continuously developing nature of For Baby’s Sake. Undertaking longer-term follow-up of those engaged in prototype For Baby’s Sake sites and the introduction of a comparator group who receive standard support are encouraged for consideration in any future evaluation of the effectiveness of For Baby’s Sake. The evaluation team suggests further research is required with a larger sample in order to undertake a full economic evaluation of the programme.

Finally, the report includes many insights and ideas to consider as the Stefanou Foundation and its partners continue to develop and roll-out For Baby’s Sake beyond its (now four) delivery sites. These include:

• Development of an assessment of fidelity using key principles of For Baby’s Sake rather than adherence to specific elements of the programme manual, to reflect the flexibility now embedded within the programme that enables the match with service users’ needs and circumstances

• Drawing on feedback about language and messaging to ensure the programme’s approach is well understood. For example, guarding against ‘victim’ and ‘perpetrator’ terminology which fathers found to be blaming, providing assurance to mothers about the programme’s approach to supporting one parent when the other parent disengages, and clarifying to stakeholders that the programme is not prescriptive about models of co- parenting

• Developing a new outcome assessment to measure changes to the relationship status of co-parents throughout the programme, alongside indicators regarding not only practitioners’ assessment of risk but also parents’ perceptions of safety and risk of harm, both for themselves and for their children, to indicate the success of the programme

• Providing training to local authorities and sharing learning from For Baby’s Sake more widely, including on adopting trauma-informed approaches to all of the factors (individual, family/personal relationships, communities and societal) that can contribute to domestic abuse and make it challenging to break the cycle

• Finding new ways to examine the full range of outcomes achieved by families, reflecting the difficulty of applying quantitative measures to assess outcomes for families and longer-term outcomes for children. This would build on the Foundation’s move to incorporate more qualitative approaches that describe families’ journeys through For Baby’s Sake as a way to ‘show the true impact’ in addition to quantitative measures

The evaluation has confirmed that For Baby’s Sake is the first programme to fill an important gap in provision through its unique approach. This early research evaluation into the prototype phase found that the majority of individuals who engaged in the evaluation and remained in the programme over time reported a positive experience, were able to identify specific ways that they had changed their behaviour and related these to aspects of the programme. These findings, alongside the recognition by the evaluation team of the importance of the innovation and the careful, evidence-based approach of the Foundation in creating and operating the programme, support the creation of two new sites in Cambridgeshire and Blackpool in 2019 and early 2020 respectively, and will contribute to the case for further expansion of For Baby’s Sake. The Stefanou Foundation is keen to work with partners to achieve this expansion, to reach more families, break the cycle of domestic abuse and give babies the best start in life.