assessment of parental engagement and capacity … · web viewdevelopment of a practice model65...

2015

Assessment of Parental Engagement and Capacity to ChangePractice Handbook (Pilot Version)

Not to be copied or distributed in any form without the consent of the authors

Dendy Platt & Katie RichesSchool for Policy Studies, University of Bristol

With Bath & North-East Somerset Council, North Somerset Council, and Somerset County Council

Acknowledgements:The assessment approach presented in this guidance was developed as part of a collaboration between the University of Bristol and three local authorities in SW England: Bath & North-east Somerset, North Somerset, and Somerset.

Financial support for the project was provided by the Economic and Social Research Council’s Knowledge Exchange Opportunities Scheme, grant number ES/L001829/1. Ethical approval for the project was granted by the Ethics Committee of the Faculty of Social Sciences and Law, University of Bristol

We are particularly grateful to the following individuals:

Members of the project steering group:

Rob GreenJackie MiltonProfessor Julie SelwynPaul ShallcrossTrina ShaneDr Danielle TurneyKate Wilcox

Practice Consultant:

Hardey Barnett

Academic Reviewers:

Professor Judith MassonProfessor David ShemmingsProfessor John Carpenter

Colleagues from the three local authorities who took part in consultations and provided feedback:

Cathy AttfieldSarah BallAmy BarnardRichard DevineAnnabel GreggDawn MaskewKatrina McJannet

© Dendy Platt & Katie Riches, January 2015University of Bristol

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ContentsAcknowledgements:.............................................................................................................1

Navigating the Assessment Process – diagrammatic overview............................................7

1. Outline Approach.............................................................................................................9

Process.................................................................................................................................9

Diagrammatic summary of the approach...........................................................................11

Definitions of key terms.....................................................................................................12

Key Messages from Chapter 1............................................................................................13

Structure of this handbook.................................................................................................14

2. Factors affecting Capacity to Change.............................................................................15

Framework of factors affecting behaviour change.............................................................15

Table 2.1, Framework of Factors that affect Behaviour Change.....................................16

Priority and relevance........................................................................................................16

Knowledge and Skills..........................................................................................................17

Motivation and Intentions..................................................................................................17

Habits and Automatic Reactions........................................................................................20

Contextual Factors............................................................................................................. 20

Families where parents are experiencing additional difficulties.....................................21

Factors that suggest change is unlikely..........................................................................22

Key messages from chapter 2.............................................................................................23

3. How to assess factors affecting capacity to change.......................................................25

General Approaches...........................................................................................................25

Social history.................................................................................................................. 25

Standardised tools..........................................................................................................25

Observation....................................................................................................................27

Identifying Factors Affecting Capacity to Change...............................................................28

Priority and relevance........................................................................................................29

Knowledge and Skills..........................................................................................................30

Motivation and intentions..................................................................................................32

Habits and automatic responses........................................................................................35

Contextual Factors............................................................................................................. 36

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4. Methods of Gathering Evidence of Actual Change.........................................................39

Timescales..........................................................................................................................39

Setting objectives and measuring outcomes......................................................................40

Goal Attainment Scaling Chart...........................................................................................42

Standard tools to measure parenting behaviour etc. before and after intervention.........43

Observation........................................................................................................................44


5. Analysis and Conclusion of the Capacity to Change Assessment....................................47

Summarising and Analysing Factors Affecting Capacity to Change....................................47

a) Balance sheet..............................................................................................................48

Balance Sheet of Factors Affecting Capacity to Change.....................................................49

b) Pictorial Scale of Factors Affecting Change..................................................................51

c) Formal Written Summary............................................................................................54

Example Summary of a Capacity to Change Assessment...................................................55

Situations where change is looking unlikely: next steps.....................................................58


6. The Back Story and other Academic Stuff......................................................................63

Practice dilemmas and children’s vulnerabilities................................................................63

The legal and policy environment......................................................................................64

Development of a practice model......................................................................................65

Factors affecting capacity to change..................................................................................66

Assessment of Actual Change.............................................................................................68

Summary............................................................................................................................ 68

Appendices (contents)........................................................................................................... 69

Appendix 1 – How to assess Factors Affecting Change...........................................................71

Personal Aspirations and Concerns Inventory................................................................72

University of Rhode Island Change Assessment (URICA)................................................76

Treatment Motivation Questionnaire............................................................................76

Planning and Conducting Observations..............................................................................77

Observation tips.............................................................................................................77

Analysing observations...................................................................................................78

Impact of observation on parent and child....................................................................78

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A) Assessing Knowledge and Skills...............................................................................79

Reference....................................................................................................................... 81

B) Assessing Motivation and Intention.........................................................................83

Depression, Anxiety and Stress Scale.............................................................................83

Adult Well-Being Scale...................................................................................................85

Reference....................................................................................................................... 87

Guidance on developing eco-maps................................................................................88

Family Activity Scale.......................................................................................................89

The Parenting Sense of Competence Scale.....................................................................92

C) Habits and Automatic Responses.............................................................................95

Difficulties in Emotional Regulation Scale......................................................................95

D) Contextual Factors...................................................................................................99

Multidimensional Scale of Perceived Social Support......................................................99

Appendix 2 - Gathering Evidence of Actual Change.............................................................101

Goal Attainment Scaling Chart.........................................................................................102

Home Conditions Scale.................................................................................................103

Drug Abuse Screening Test...........................................................................................104

AUDIT........................................................................................................................... 106

T-ACE............................................................................................................................108

TWEAK..........................................................................................................................109

CHILD-PARENT RELATIONSHIP SCALE...........................................................................112

Appendix 3 – Analysing and Concluding...............................................................................118

Background information for the Case Study....................................................................118

Family members...........................................................................................................118

Key concerns................................................................................................................ 118

Strengths......................................................................................................................119

Actual harm to children................................................................................................119

BALANCE SHEET OF FACTORS AFFECTING CAPACITY TO CHANGE...................................121

Pictorial Scale of Factors Affecting Change.......................................................................122

References............................................................................................................................124

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Navigating the Assessment Process – diagrammatic overview

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Core / single assessment with need for a capacity to

change assessment

(Chapter 1)

Select target behaviours that parent needs to

change

Assess factors affecting capacity to change:

Priority & relevance Knowledge & skills Motivation &

intentions Habits & automatic

reactions Contextual factors

(Chapter 2 for background theory. Chapter 3 for practice guidance)

Provide intervention and observe outcomes:

Before & after measures if required Set goals and monitor changes (Goal Attainment Scaling )

(Chapter 4)

Summary and Conclusion

(Chapter 5)

1.Outline Approach

The approach proposed in this handbook is a method of assessing parents’ engagement with services, and capacity to change their behaviour, in a context where maltreatment is likely, or there are other welfare challenges affecting the children. The key to decisions about a child’s future often involves considering whether parents can make the necessary changes to promote the child’s well-being. Engagement with services is one part of a change process, but only a part: the proof of whether that engagement has been successful lies in whether relevant outcomes, in terms of parental behaviour change, can be achieved.

The approach has been designed to support local authority social work practice in England. It builds on existing processes including core / single assessments, parenting assessments, and routine practices of giving parents the opportunity to resolve their difficulties before considering more significant actions such as applications to the family court. It will be of particular interest in the following circumstances1:

Assessment of a child and family following a child protection conference. Assessment of a child and family following the issuing of a letter before proceedings

under the Public Law Outline [2, 3]. Preparation of a parenting assessment for the Family Court prior to or during Care

Proceedings. Assessment and planning for the potential return of a child from the care system to

its birth family or equivalent carers (reunification).

In this section, we set out key inter-related aspects of the assessment.

Process

The assessment of parental engagement and capacity to change (APECC) is not a free-standing assessment, and has been designed to be integrated within an existing assessment process, such as a core or single assessment. Such assessments, currently, would often be based on the Framework for the Assessment of Children in Need [4] or similar approaches.

1 It is acknowledged that processes vary between local authorities, and that a list of this kind may not describe precise aspects of standard practice in all authorities.

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The capacity to change assessment, thus, requires the following to be in place or planned:

Assessment of the child’s needs

Assessment of parenting capacity

Assessment of family and environmental factors

Identification of priority difficulties that the family should address to ensure the safety / well-being of the child

An evolving analysis that draws together the findings from all aspects of the assessment.

The model is comprised of two essential practice elements that must be integrated within the overall (core or single) assessment. They are:

1) How the parents are? Assessment of factors affecting the parents’ capacities to change their behaviour in order to safeguard the child, and

2) What the parents do? Offer parents an opportunity to resolve key difficulties, via provision of interventions to facilitate the process of change, alongside assessment of the extent to which change has been achieved within an agreed timescale.

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Diagrammatic summary of the approach

Core / Single Assessment

Assess factors affecting

capacity to change (How the

Summary & Conclusion

Time-limited Intervention,Agreed Goals

Observe engagement and change (What the

Includes parenting capacity, baseline data and identification of target difficulties

Analysis

Definitions of key terms

It is important to emphasise that parental capacity to change is different from parenting capacity. Parenting capacity refers to the parents’ overall ability to parent a child, across the range of needs the child may present. Capacity to change, in the social work context, refers to the range of attributes, capabilities, motivations etc that may enable a parent to turn their lives around for the benefit of the children, and to address critical difficulties that would otherwise have a severe impact on the child’s welfare.

Key to an appreciation of the approach is an understanding of its central concepts, engagement and capacity to change.

In the practice context, engagement is typically experienced in two ways. First are the observable, behavioural components of engagement, such as keeping appointments, allowing home visits, making sacrifices (e.g. of time, emotional commitment, money), and completing agreed tasks. Second is the working alliance between the parent and practitioner. The working alliance has been described [5] as involving the sense of a working bond between practitioner and parent (trust, respect, etc.), together with a commitment to working together to develop goals, and achieving agreement on and carrying out tasks.

As always with assessments that have the child’s welfare as paramount, the ability of the parent to make changes must be considered with regard to the child’s timescale. As indicated above, it should be assessed by examining the barriers and facilitators to behaviour change for the individual parent, and by observing actual change arising from appropriate intervention and support.

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Parental engagement is defined as

“The mutual, purposeful, behavioural and interactional participation of parent(s) and/or carers in services and interventions provided by social work and other relevant agencies with the aim of achieving

positive outcomes” [1] (pp.138-148).

Capacity to change, in the present context, is an estimate of the combined effect of personal psychological, family, social and

environmental factors in enabling a parent to make changes to his/her behaviour in order to safeguard their child and promote

his/her well-being.

The importance of these different concepts lies in understanding that mere engagement with services by a parent should not be mistaken for actual change. Engagement itself can be misunderstood by focusing merely on behavioural indicators, without considering the working alliance, or vice-versa. Similarly, behaviour change is often hard to sustain, and is subject to multiple influences, which may lead to failure to engage with the change process, or to relapses in commitment and failures to achieve the goals of change. Both aspects, factors affecting change, and the behavioural observation of change, are necessary for the most balanced assessment.

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Key Messages from Chapter 1

The fundamental principles behind the assessment model are:

1. To be able to make informed decisions about whether parents are capable of meeting their children’s needs in the future, a thorough assessment of parental capacity to change is needed;

2. The assessment of engagement and capacity to change should be integrated within existing assessments;

3. The approach in this handbook is not a free-standing assessment and should not be used on its own;

4. There are two essential elements of the assessment:a. Factors affecting the parents’ capacities to changeb. Offering intervention to address target difficulties, and

assessing extent of change.5. The child is central to the process, and planning the assessment

must be guided by the need to achieve change within the child’s timescales;

6. Co-operation or engagement should not be mistaken for actual change;

7. The model is intended to support analysis and reflective supervision

Structure of this handbook

The next four chapters set out ways of undertaking the assessment of engagement and capacity to change. Chapter two focuses on factors affecting capacity to change, and chapter three on ways of gathering information about these factors. Chapter four explores goal-setting and other methods of gathering evidence of actual change. Chapter five offers ways of drawing conclusions from the material collected, and Chapter six outlines the background academic work that lies behind the methods put forward.

The presentation of material is intended to offer an overall framework, which is the core of our approach, but within that to give a selection of materials to suit the needs of the child and family, and the style of the worker. Practitioners would be expected to use the overall framework as a basis for practice, and to select practice materials relevant to their particular context. This handbook is not, therefore, intended to be read at a single sitting, but to be used as a sourcebook, and as a back-up to practice. Chapter six may be of less interest to practitioners, but gives an account of the context behind the framework, and the practice methods selected.

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2.Factors affecting Capacity to Change

The approach to assessing factors affecting parents’ capacities to change is based on two particular academic developments that have sought to find common ground amongst a range of theories of behaviour change. The first comes from the United States where a range of well-evidenced and influential theories were brought together to develop a common framework for understanding behaviour change [6]. The second is work from an international collaboration that identified a framework of theoretical domains for use in behaviour change and associated research [7, 8]. Please see Chapter 6 for a fuller discussion of these various sources. We chose to base our approach primarily on the Jaccard et al model, as it has been applied in the context of family based services [9]. However, it was adapted to ensure consistency with Cane et al’s theoretical domains framework [7], and in the light of other relevant work . The terminology was also adjusted slightly to suit a UK audience. The result is an integrated categorisation of factors affecting behaviour. In this chapter we present the overall framework of five categories of factors that are considered to determine human behaviour change. We then explore each of these categories in depth, and present ways in which each factor may be assessed in the practice context. Research suggests that the precise factors affecting change may be different in relation to different potential changes [8], and therefore factors affecting each intended change should be analysed separately.

Framework of factors affecting behaviour change

The categories we have identified involve a combination of factors that affect whether a particular behaviour or behaviour change will take place. Considered together, they show how different things affect behaviour in different ways, and how one factor might help a person change their behaviour, but another factor may represent a barrier to change. It is important to recognise that different factors can operate in opposing directions. Thus, for example, someone may have great intentions to curb a tendency to anger, but, faced with certain triggers, an automatic reaction may take over, and override those good intentions. The framework of factors is set out in Table 2.1 below:

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Table 2.1, Framework of Factors that affect Behaviour Change

Factors affecting behaviour Explanation

Priority and relevance How much of a priority is the behaviour and how relevant is it in the context of the person’s life as a whole? This construct has also been summarised using the term ‘salience’.

Knowledge and skills Does the individual have the knowledge and skills – in other words, the capability - needed to change their behaviour in the ways identified?

Motivations and intentions What are the person’s intentions and how motivated are they to commit to the necessary changes?

Habits and automatic reactions How and when does the person respond to routine situations with an automatic behavioural response?

Contextual factors What is happening outside the parent-child relationship that may support change (or otherwise)? Perhaps there are environmental and social influences that affect the parent’s behaviour, some of which may be historical.

In the following pages, we present an outline of each of these categories in turn. Then we examine ways in which they may be incorporated into a social work assessment.

Priority and relevance

Assessing this factor involves examining key behavioural changes, and considering how those changes may fit within the lives of the people involved. Is it a priority for a particular parent to make specific changes in their behaviour, rather than to do other things that may

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seem more important? How relevant is the particular action in comparison to other pressures that parent may face?

For example, a parent who is asked to attend contact sessions with a child in foster care may have friendships that he/she wants to prioritise rather than seeing the child. Or similarly, where arrangements are being made for a parent to attend a support programme such as a parenting course or treatment for addiction, a parent may need to put work commitments etc. ahead of attending the particular programme, if there were a timing clash. In relation to changing behaviours towards a child, if a parent is being supported to spend more time playing with the child, such changes may not carry through to everyday life because the parent may believe that other responsibilities, such as managing other children in the household, have a higher priority.

Knowledge and Skills

A parent’s knowledge and skills may affect the success of an intervention in a variety of easily misunderstood ways. At the level of engagement with the practitioner, there is heavy reliance on communication skills. Also of importance under this heading is the parent’s capacity to make decisions (which may also be affected by the ability to remember and retain information, and the ability to focus attention on important issues). Similarly, a parent’s ability to regulate their own behaviour and emotions are skills that is important in this assessment.

Someone who is less articulate, with less well-developed oral communication skills, or whose difficulties are on the autistic spectrum, may experience difficulty from the start. Parents may also be hampered by lack of understanding of the child protection system, or lack of knowledge of child development. It is important that gaps in knowledge and skills are understood so that attempts can be made to address them as part of a package of intervention – or, if this is not possible, that there is a good assessment of why such gaps cannot be overcome. There is little point in engaging a parent with a group-based parenting programme, for example, if he/she does not have the necessary relationship skills to cope in a group setting. Or if a parent has trouble reading or writing, it would be unhelpful to give them educational materials in written form.

In considering changes that may be necessary to safeguard a child, the assessment should consider what skills and knowledge are required to underpin those changes, and whether any gaps can be addressed within the child’s timescale.

Motivation and Intentions

Motivation is a complex area with a variety of features. Here we have again adopted the approach of Jaccard and colleagues [6], and Olin and colleagues [9], adjusted for consistency

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with the Theoretical Domains Framework [7], as a basis for defining four aspects of motivation that an assessment should consider. They are as follows:

1) Needs and expectations . If a parent is considering certain behavioural changes, what are their goals, what is the expected value to them of those changes? Is the change likely to have a positive impact overall, do they consider the change worthwhile, and do they expect to be successful in achieving change? Similarly, how stable are the person’s intentions, or do they vary erratically from day to day? In the context of interventions, self-determination theory [10] focuses on specific needs that should be satisfied as part of a change process. One of these is the need for a sense of autonomy or control over what is happening, a factor that is fundamental to professional engagement with parents.

2) Attitudes, beliefs and feelings . Parents working with social work services will have a range of beliefs about key aspects of any work that is needed to safeguard a child. These may include attitudes and feelings about services, recognition or otherwise of problems, attitudes towards children and how they should be brought up, fear of what might happen, and so on. They will also include beliefs about the consequences of their own behaviour. It may not be possible to work through all these difficulties, but attempts to do so will help show whether they can be overcome sufficiently to enable the child’s needs to be met.

There is much discussion within social work practice regarding the importance of a parent having insight into the difficulties with their parenting, i.e. recognising that there is a problem. Received wisdom is that without such insight or recognition, change is unlikely. Research supports this position to a degree. For example, one of the factors common to parents who were able to change sufficiently to care for their children was insight into the part played by their own negative behaviours [11]. The structure for thinking about capacity to change through consideration of the five factors affecting change as proposed in this handbook aims to encourage deeper consideration of factors such as insight. There are numerous influences on motivation and intention to change, of which insight or problem recognition is one, but insight or acceptance of a problem is not necessarily straightforward. An apparent lack of insight or resistance to accepting there is a problem could be masking a parent’s fear about their ability to change, a resistance to intervention from services as a result of previous negative experiences, an assumption that workers cannot be trusted, shame over their behaviour, a lack of understanding or knowledge about what children need and so on [12, 13]. In some situations, where parents seem to have good insight into both the difficulty and their responsibility for it, change may not occur because of the numerous barriers to change within other areas of their lives. Although a very important factor, insight or problem acceptance alone is not an adequate predictor of capacity to change.

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3) Identity and social role . As with all the features of motivation, identity interacts with other factors. The obvious aspects of identity such as gender, race, disability, etc. lead to an emphasis on the importance of assessing capacity to change for each individual parent rather than treating the parents or carers together as a single unit. Forms of identity exist within a social context, and may be supported and bolstered by the social norms of those in the parent’s wider network. For example, in a situation involving domestic violence, the way a man treats his female partner may be bound up with his particular sense of identity as a man, and may be actively supported by the norms of other men around him. Similarly, attitudes to help-seeking may vary between different cultural groups. And the documented occurrence [11] of a ‘wake-up call’ for some parents (to address their difficulties) at the time of the arrival of a new baby is arguably linked, at least in part, to the change in identity when taking on the role of parent.

4) Confidence and self-efficacy . This heading is connected to the earlier factor of Knowledge and Skills as it highlights the parents’ perceptions of their own competence in terms of achieving the necessary changes; and their sense of their own ability to achieve success in relation to the range of difficulties facing them. How self-confident are they, do they have confidence in their own knowledge and abilities in terms of dealing with the services and making the necessary progress? Do they believe themselves to have control over their own behaviour and life events, or do they see other people as controlling them? Self-efficacy “is an individual’s assessment of his or her confidence in their ability to execute specific skills in a particular set of circumstances and thereby achieve a successful outcome” [14] (p.116). The concept comes from Bandura’s (1997) Social Cognitive Theory. Self-efficacy is enhanced by completing successively complex tasks, but decreased by failure in this respect. Bandura argued that beliefs concerning self-efficacy would influence how much effort an individual would devote to a task, their resilience when faced with difficulties (and consequently how much stress they experience), as well as their level of accomplishment [15].

There is much discussion of the influence of coercion (see also contextual factors) in facilitating change and whether motivation for change needs to be intrinsic if sustainable change is to occur [13] . The evidence available currently is inconclusive; the use of coercion alongside support within the Family Drug and Alcohol Court has produced encouraging results for facilitating change among substance misusing parents [16] and the formalisation of the pre-proceedings process has been effective in diverting cases from entering care-proceedings [13, 17]. Other research suggests that many parents who have been successful in making changes have experienced an internal ‘wake-up call’ or revelatory moment which has been the precursor to change, although this does sometimes occur after increasing levels of intervention from services [18].

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Behaviour change theories and qualitative research into the effectiveness of services in facilitating change suggest that for behaviour change to be successful, there is a need for the individual to retain a sense of autonomy over the decision to change as well as the process of change [10, 19]. Therefore, if coercion removes that sense of autonomy, sustained change is unlikely. Similarly, it has been found that parents who perceive social workers as using their power with parents rather than over them are more likely to develop a collaborative relationship with workers and services, thus enhancing the prospects for change [20].

Habits and Automatic Reactions

In this section we are concerned about automatic behaviours that are prompted by situational triggers. In other words, particular cues to behaviour occur in everyday life, and automatic responses may follow. If the same response occurs regularly over an extended period, that response may become deeply ingrained and habitual. Clearly, responses of this kind are of particular concern to social work services, if the response itself leads to some detrimental impact on a child. Strong habits may become so automatic that they override the best of intentions [21], but it is important to assess the strength of an automatic response, perhaps by exploring situations when the habitual response did not occur, or was weaker. In the context of an intervention, services may be able to find ways of replacing unhelpful habitual responses with more positive behaviours. Are there, for example, behaviours that can be reinforced through intervention, thus strengthening alternative, more beneficial habits?

Contextual Factors

It is acknowledged that there is a wide range of factors contextual to the family, that affect its functioning, and the ability of parents to make changes. They include income, class, education, culture and so forth, but the framework presented here aims to look at those factors that impinge most directly on parental capacity to change, and through which broader socio-structural effects may exert an influence. To this end, those contextual factors that can have a very considerable effect on the situation are identified here, and they deserve to be assessed in their own right.

Such factors include the circumstances surrounding the child’s difficulties (e.g. whether a particular type of abusive behaviour is involved; whether coercive measures are being used to manage the situation; whether difficulties such as ADHD may make the child more difficult to parent); what resources are available and what the barriers are to using them; whether there are any organisational problems such as the availability of staff time; what is the known effectiveness of a programme of intervention; and how are the practitioner’s skills impacting on the situation? In relation to skills, it is well accepted, for example, that

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workers should be clear about their roles, work in a collaborative way to help solve problems, reinforce strengths, and challenge parents without creating confrontation [22, 23].

There is one obvious difficulty in assessing the part played by contextual factors, that it partly involves organisations and individual practitioners in examining their own roles in facilitating (or otherwise) a change process. Our view is that openly addressing these factors is potentially positive and supportive in terms of working towards the best outcomes for the child. Our recommendation is that the best place for reflection on this aspect is in supervision, and that a safe supervision relationship is necessary for this discussion to be most productive.

Other contextual factors include the informal support that parents have from family or friends, support that may affect their beliefs and emotional responses to the situation. The social norms in the family and friendship networks of parents may serve, for example to bolster negative identity traits or roles played by the parent, or may conversely provide a source of support in achieving change. Having a friend who can support, cajole, persuade and encourage a parent to work through the difficulties he or she is experiencing can be a highly significant element in achieving change.

Families where parents are experiencing additional difficulties There is also a range of difficulties that have an impact on the capacity to change, and are part of the background circumstances of the parent(s) concerned. During a single assessment, or during an in depth parenting assessment, the needs of the children and the parents will have been identified. Research has consistently shown that a number of parental characteristics or behaviours pose a significant risk to the ability of such parents to be able to meet the needs of their children consistently and so to protect them from harm. These factors include

long-term substance abuse, extreme domestic abuse, mental illness, borderline personality disorder, unresolved childhood history of abuse or maltreatment, learning disability, physical health conditions.

[13, 24]

The combination of some of these characteristics, in particular poor mental health, substance abuse and domestic violence are considered especially harmful to children’s welfare.

For some families the changes will be relatively straightforward. For others, change will be required in a number of different, often inter-related areas and the process of change will be complicated by parental characteristics or behavioural issues. For example, parents

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affected by a combination of poor mental health, substance misuse or domestic violence are less likely to be able to sustain change [13]

The question for the capacity to change part of the parenting assessment, is what influence the parental characteristics or behaviours have on their capacity to make changes and thus improve their ability to meet their children’s needs? We recommend that such additional issues are considered under the heading of contextual factors, but that their influence on the other factors affecting change should also be explored. For example, it is likely that a parental history of childhood abuse or maltreatment will have resulted in habituated responses to children’s behaviour or to stressful situations. It will also affect parents responses to the type of approach or support offered by workers [25]. If the maltreatment remains unresolved in the parent’s mind then it can affect their knowledge and skills; both in terms of the parenting model they are following but they are also likely to struggle with empathy [26], a factor that is relevant in our knowledge and skills section. A level of learning disability is also likely to have an impact on the knowledge and skills a parent can draw on to be able to make changes, particularly with regard to the settings in which they will be able to learn new skills [13]. Their levels of motivation may be affected in that they may not have a clear understanding of the problem behaviour identified by social workers, or a belief in their ability to make changes. Support arrangements may consequently take on an additional significance. Substance misuse is likely to exert a strong influence on identity and social norms, and has a wide range of effects on health and wellbeing, including effects on cognitive functioning [24]. A victim of domestic violence is likely to feel low levels of self-confidence or self-efficacy, and this may impact negatively on their motivation for positive change [13, 24]. A parent experiencing a personality disorder may have automatic responses to attachment behaviours expressed by their child e.g. hostile or cold and unresponsive [27], and due to their personality traits may struggle to engage constructively in group settings. These are but a few examples, but they illustrate the idea that the specific difficulties parents face will influence the factors affecting change and thus have an impact on their overall capacity to change.

Factors that suggest change is unlikely Ward and colleagues’ review of literature suggested that clear-cut situations, where change is extremely unlikely, are very rare [13]. However, research has identified some particular issues, that are indicative of difficulties making changes within the child’s timeframe. In combination with serious child protection concerns and a parental failure to acknowledge the problem, these difficulties include extreme domestic violence involving significant disregard for others; serious substance abuse together with domestic violence, serious failures to protect children from perpetrators of sexual abuse and where deliberate abuse has been extensively and systematically covered up [13]. It is important to emphasise that these situations are rare, and no decisions should ever be made on the basis of the above characteristics alone. Clearly there will be rare circumstances, where the level of risk overall is so high that it would be too dangerous to place a child at home at all. However, the vast majority of cases are less obvious, and the assessment procedure proposed in this

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handbook should be followed carefully, in order to examine the process of change and gather sufficient evidence for a decision.

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Key messages from chapter 2

The framework for assessing factors affecting parental capacity to change consists of five key themes:

1. Priority / relevance of change2. Knowledge and skills to effect change3. Motivations and Intentions to change4. Habits and automatic reactions5. Contextual factors.

These five factors have been developed from theories of behaviour change, paying particular attention to models developed from research into parents making changes for the benefit of their children.

Gathering and analysing information on the factors affecting change will indicate what may help to facilitate change and what may be acting as a barrier to change.

For parents where a number of behavioural changes are required, each change should be considered individually in relation to the factors affecting that change.

In two-parent families, the factors affecting change need to be considered separately for each parent but with consideration of the dynamic between the couple and the influence of that dynamic on capacity for change.

3.How to assess factors affecting capacity to change

As discussed in chapter 1, an assessment of the child’s needs and parenting capacity is an essential pre-requisite to beginning a capacity to change assessment. In the course of completing the Children & Families Assessment, it is likely that information will have been gained which, when thought through, will be relevant to understanding the factors affecting change. There are approaches or techniques which will assist with the gathering of information across all of the factors affecting change, and these general techniques are discussed first. The chapter then considers each factor affecting change individually, to explore questions and tools more specific to each area. The suggested approaches, tools and questions are intended to support practice rather than direct it, and so this is not intended as a step-by-step process. Social work practitioners should select from the methods proposed in this chapter, with the aim of achieving a comprehensive assessment of factors affecting capacity to change, at the same time choosing approaches that are relevant to their working style and to the needs of the children and families they are working with.

General ApproachesSocial history Taking a social history or life narrative from a parent covering their childhood experiences, schooling, jobs, relationships with partners, pregnancies and their relationships with their children is a necessary starting point. With regard to capacity to change, a parent’s answers can provide information on the origins of habits, their perception of their identity, the views of their social network, the social norms of their community and their past experiences of services. The responses of a parent may also indicate their levels of self-efficacy and confidence, and the areas in which they would like to make changes.

Standardised tools Recent research literature suggests that using standardised tools to inform professional judgment is a more reliable method of assessing the risk within a family’s situation than clinical judgement alone [28]. The review of the literature for this project did not identify any standardised tools for assessing a parent’s capacity to change that cover all of the factors identified in this handbook. However, a semi-structured interview approach developed in the field of substance misuse and adapted for use with offenders could be used in support of obtaining information on several of the factors affecting capacity to change.

The Personal Aspirations and Concerns Inventory (PACI) is based on the Motivational Structure Questionnaire which is a reliable and validated instrument developed by Klinger and Cox [29]. It makes the assumption that most human behaviour is goal-oriented and that there is an interaction between the problem behaviour and the emotional satisfaction

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gained or lost through this behaviour. The PACI asks respondents to identify any concerns they have over seven life areas and then to formulate goals that correspond to each concern. The respondent is then asked to rate their goal from 0 (not at all) to 10 (the most I can imagine) on the following criteria; importance, likelihood, control, what to do, happiness, unhappiness, commitment and how long. This process and the conversation held to support it should provide plenty of information that can be included in the assessment of the factors affecting change. A more detailed explanation of how to use the PACI can be found in Appendix 1 (p71).

Standardised tools have been developed in areas other than child welfare, to assess different aspects of the level of motivation of a person to change a particular behaviour. In general, these are behaviours that relate to the self, e.g. smoking, drug use or offending. One example of these tools, which seems to capture information relevant to the factors affecting change, is the URICA (University of Rhode Island Change Assessment) [30].

The URICA is a 32 item self-completion questionnaire which was developed as part of research linked to the Transtheoretical, or Stages of Change Model [31]. It asks the respondent to rate statements between “strongly disagree” and “strongly agree.” The analysis of the scores provides an indication of which stage of change (pre-contemplation, contemplation, action, and maintenance) corresponds with the respondents answers. However, for our purposes, it may be useful in identifying factors affecting change rather than focusing on a single score. A link to the URICA can be found in appendix 1 (p.75).

The Treatment Motivation Questionnaire [32] aims to assess readiness for change through a 26 item self-completion questionnaire. The scores can be broken down into subscales which assess external reasons, internal reasons, help-seeking and confidence. The “confidence in treatment” subscale has been shown to be associated with engagement and treatment outcomes [33]. It does refer to attending ‘treatment’ which is not commonly used language within UK child welfare Services. However, the questions could provide some useful information on the parent’s motivation to engage as a means of achieving behavioural change.

When using tools or measures, thought should be given to selecting the most appropriate tool for the purpose. To be confident that the tools will provide helpful insights, where practical, information should be sought on their validity (do they measure what they claim to measure?), reliability (do they consistently measure what they are meant to measure?) and utility (what is the practical advantage of using it?). All the tools referred to in this handbook have been tested for reliability and validity; the important question to ask as practitioners considering the use of any of these tools is, therefore, how useful it will be. To answer this question you might think about the following:

Does the purpose of using the tool match the purpose for which it was developed? How direct is the tool? Direct measures straightforwardly measure feelings,

behaviours or thoughts. Indirect measures consider underlying dispositions that require interpretation of results.

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How easy is the tool to use? E.g. length of time taken to complete, score and interpret, how complicated / simple are the questions?

How suitable is the tool? E.g. for the person’s cognitive ability and emotional state, does the respondent see the tool as appropriate and acceptable? How would you deal with any literacy problems if the parent needs to read the questions? [34]

The tools suggested and included in this handbook are freely available for use and do not require specialist training. However, questions should be asked in the order and exactly as detailed in the measure. Particular care needs to be take over scoring (for example sometimes questions are reverse coded, so that a Yes response in one question scores 2 points, and in another question 0 points).

It is worth repeating that the use of tools is intended to contribute information to an assessment and the information gained from them should be discussed with parents and compared to information received from other sources. Tools rely on parental self-report and it is accepted that one person’s view of their ability to respond to their children, make changes, control their emotions etc. may not be the same as another person. Tools themselves, although tested for validity and reliability have rarely been subject to full testing of their psychometric properties and it is often unclear what a ‘normal’ score should be [35]. The tools referred to in this handbook were not developed as diagnostic tools but as screening tools or an alternative means of gaining information. If a parents’ score on a questionnaire indicates cause for concern then further specialist advice should be sought e.g. from mental health services, or from professionals trained in the relevant types of assessment.

There are a multitude of alternative tools that are valid and reliable, but have to be purchased or require training; their exclusion from this handbook is no comment on the utility of the tools, but we have taken a view that additional cost is likely to act as a barrier to the majority of social workers and that a more sustained use of tools will be likely if they are readily accessible.

Observation Observations provide a window into the actual situation within the family home, and help to identify how and why any difficulties’ in care-giving are occurring, as well as how this is being experienced by the child. Specifically, they offer practitioners the ability to witness the often complex dynamics in parent-child or parent-partner relationships. Observations are a means of gathering clear and detailed evidence of parental behaviour, interactions between parents and the effect on the child(ren). By being able to refer to specific, observed events as examples of positive or negative behaviours, parents may feel more accurately represented, rather than stereotyped or blamed which may facilitate the working relationship [36]. In terms of assessing factors that affect change, observations could be useful in understanding which behaviours or duties a parent is prioritising e.g. by helping to identify what is getting in the way of using the suggested behaviour management technique, attending the substance misuse appointment etc.? A parent’s approach to implementing

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new techniques may also provide clues as to their self-efficacy and belief in their own ability to make changes. Observing how a parent behaves towards their children during daily parenting tasks can provide a picture of their knowledge and skills and their manner of communicating. It can also be useful to observe patterns in the relationships between parents, for example power imbalances or whether one particular party tends to have the ‘final say’. Repeated observations may illuminate a parent’s pattern of responses to certain events or behaviours of children which would assist in identifying habitual or automatic responses that a parent may find difficult to verbalise. Gaining information on automatic responses and trigger / response situations is most likely to be observed through setting the parent(s) and children a task to complete together e.g. tidying toys away, building a lego model, playing a turn-taking game which involves losing and winning (snakes and ladders, ludo, card games).

For tips on planning and carrying out observation sessions as part of an assessment please see Appendix 1 and p43.

Identifying Factors Affecting Capacity to Change

In this section, we explore the factors affecting capacity to change that were set out in chapter 2 from a practice angle. We present key questions for which answers may be sought in individual assessments, together with pointers regarding the approach to the assessment and analysis of each factor. It is worth re-iterating that each target behaviour may be influenced by a different combination of factors, operating in different ways. Gathering the necessary information will involve common processes, but the analysis of that information should be adjusted in relation to each problem area and for each parent.

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Priority and relevance

In the course of completing the Children & Families Assessment it is likely that information will have been gained which will give an indication of the parent’s priorities. For example, which worries do the parent(s) regularly discuss? What are their main topics of conversation?

One way of understanding a parent(s) priorities could be to work with the parent(s) to assist them in identifying their own goals for their life. This would illuminate areas they see as a priority and most relevant to improving their situation, and that of their child. It can be achieved through existing approaches such as Signs of Safety [37], or by using a method such as the Personal Aspirations and Concerns Inventory [29] which is described above (p.24) and can be found in Appendix 1.

There may be clues to priorities from the interventions which the parents have been offered; which programmes are they fully (i.e. behaviourally and attitudinally) engaged with? Whose appointments are they prioritising? Which worker’s suggestions are they attempting to implement (as evidenced through observations)?

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Key questions to ask parents:

Do you think any change is needed?....If yes, what?

What do you think is the most important change for you to make to improve your child’s life?

What would be the good things that would happen if you made this change?

What would be the not so good things?

What do you think are the least important changes being asked of you?

How important do you think the changes are that Social Care are asking you to make?

How much time have we got to make these changes before the child is too old for it to make a difference?

Use scaling questions e.g. If you’re thinking about …..(issue of concern), where 10 is a priority and 0 is bottom of the list, how would you rate yourself?

If 10 is ‘change this immediately’ and 0 is ‘it can wait for months’ how would you rate the different changes you’re being asked to make / you want to make?

Miracle question type questions e.g. If you could improve life by one point, what would it be that changed?

If you could change one aspect of your life what would it be?


At the beginning of the work it can be useful to ask parents what sort of worker style (e.g. more direct, less direct) they feel most comfortable with, when giving or receiving information. You might describe your personal style and the type of work you are intending to do, and ask whether that will be OK for them. Ask whether group settings assist in their learning or do they prefer a one-to-one situation? Explore the parents’ educational experiences as a way of uncovering whether there may be any issues with cognitive ability or whether their ability to learn was disrupted during formal education. Techniques may also have to be used to explore whether a parent has understood questions – such as reflecting back and checking you have understood their meaning, asking them to explain what they think the concerns are and considering whether they are using their own words (which suggest they have processed the information) or are parroting what they have been told by workers.

Using a variety of assessment methods such as pictorial cartoons that depict everyday parenting scenarios to provoke discussion, video clips of common issues that affect parenting, questions and answers and observations will help to gain a picture of the parents’

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Do you need any extra knowledge or skills to be able to make these changes?

Check for literacy levels e.g. how would you like me to give you the information that is needed? Is English readily understood by the parents or would an interpreter be beneficial? Literacy is easily over-estimated where verbal communication is good.

What will help us to communicate well?

Would you like information on an advocacy service e.g. Family Rights Group?

Would you like to have an advocate with you during sessions or meetings?

How do you understand these issues / concern?

Describe / explain to me what you think the concerns / worries are?

Can you tell me about one part of parenting that you feel you do well, or you feel most comfortable with? Describe a specific situation where this happened and how you felt.

Can you tell me about one part of parenting that you find the most difficult? Describe a specific situation where this happened and how you felt/

Explore reflective ability e.g. what (happened), so what (was the consequence), now what (needs to happen)?

knowledge and communication skills. Child development knowledge can be assessed through responses to questions about typical child behaviours or parenting situations. The Parenting Daily Hassles questionnaire [38], Appendix 1) could be useful in providing an indication of whether parents perceive ‘normal’ parenting issues as an expected part of parenting or as a negative characteristic of their child(ren). Aspects of these methods may well be used in a standard single or core assessment, and will often yield information about knowledge and skills at the same time.

Research is increasingly highlighting the importance of mentalisation and reflective function as a parenting skill [39]. Parents with low mentalisation are likely to struggle to understand that others have different thoughts and feelings to their own thoughts and feelings. In the context of parent-child interactions, this difficulty will present itself as poor reflective function such as the imposition of the parent’s needs or feelings onto the child. An example might be a parent saying “she’s not tired” when actually it is the parent who isn’t tired. Identifying these skills or the lack of them is important as there are links between low mentalisation and the development of disorganised attachments. In the context of capacity to change, parents without these skills are likely to find empathy very difficult and thus struggle on several levels. Firstly it will influence their understanding of why their child may need them to make any changes and secondly, it will influence their ability to listen and respond to the concerns of professionals and thus to develop an effective working relationship [26]. The ability of parents to mentalise can be assessed through asking parents to describe their children simply by talking about each child for a period of five minutes. Parents who struggle to mentalise will tend to make negative statements, will often be externally descriptive e.g. “he’s funny”, “she’s cute”, “he’s naughty” but make little reference to the internal workings of their child’s mind e.g. “he likes to watch before he joins in so he knows what’s going on”, “she likes to play with dolls”. There are a number of programmes available that support parents to explore their own states of mind in relation to parenting. An example is “Minding the Baby” which is being used by the NSPCC in the UK, originally developed by Mayes and colleagues [40].

Observation is a powerful tool to gain information on actual knowledge as evidenced through parents’ actions and behaviour rather than relying on their ability to express their knowledge. It would be particularly useful for parents who struggle with verbal communication skills or have a level of learning disability. Videoing observations can also be used as an intervention to promote change through the use of video-clips in feedback sessions. This can be particularly useful in helping parents to develop their empathic skills and increase their mentalisation abilities, ultimately improving the parent-child interactions [26].

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Motivation and intentions

Our discussion of motivation and intentions is divided up under the four key headings introduced in chapter two.

Needs and expectations: It is important to understand from parents what they are fearful of losing, as a result of making changes, as well as what they hope to gain. The Personal Aspirations and Concerns Inventory (PACI, Appendix 1) asks about how happy / unhappy the person will be if they are successful in achieving their goals, and these ideas could be adapted into exploratory questions. The possibility that parents may fear being unhappy after making changes as well as the possibility of increased happiness if the changes are achieved needs to be explored. It is also worth considering whether the goals, process and changes are compatible with the parent’s sense of autonomy, and their connectedness with those in their social network.

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Key question to ask parents:

What has been your experience of working with social care and other services?

Tell me about your expectations of Social Care’s involvement?

Tell me what you think Social Care’s concerns are?

How do you see yourself and how would others describe you?

What do you think about what is happening, and what do others around you think about what is happening?

Do you believe you can deal with the social work system?

Do you believe you have the knowledge and skills to make changes in your life?

What kind of difficulties have you faced in the past?

Who or what has helped you to address those difficulties?

What has helped you make changes at other times of your life?

What hasn’t helped you to make changes at other times of your life?

Which is your main reason for considering making the changes? Consider whether answer corresponds closely with any of the following: because I’m told to, because I want to, because my children need me to.

Who will benefit from you making these changes? Who is the change for?

Tell me about your interests?

Plus the impact of contextual factors… Would the people close to you support you in changing?

Beliefs and feelings: the ability of the parent’s to recognise the problems and concerns regarding their ability to parent is an important aspect to understand. Information on this is likely to come from the completed Children and Families Assessment or through work to identify shared concerns using approaches such as Signs of Safety.

If there are historical problems around the parents’ experiences of working with Social Care or other agencies, or if the parents hold strong views, then these will need to be acknowledged. To avoid the conversation getting stuck on previous experiences, groundrules can be agreed between the parents and worker for the current period of intervention.

Levels of anxiety, stress and depression can influence a person’s motivation and using a standard questionnaire to consider this can be useful. Two options are the Depression Anxiety and Stress scale (DASS), [41] and the Adult Well-being scale [38] which can both be found in Appendix 1.

The DASS assesses depression, anxiety, tension/ stress, the levels of which are important in terms of the factors affecting change but also because of the effect of parental psychological functioning on the emotional responses to their children. The DASS has proven validity and reliability and indicates when there is likely to be a clinical level of psychological distress. The Adult Well-being Scale is easy to administer and useful as a starting point for discussion, and as an indicator of overall psychological distress which may have an influence on capacity to change.

Identity and Social roles: Some information on the identity and social norms of a parent should come from understanding their social history and from the development of a working relationship. A tool that can be used to explore these further is the completion of an Eco-map (Appendix 1) with a focus on the views of friends / family members rather than practical ability to help (see also p.36). Asking parents to complete the Family Activity Scale [38] may also provide an indication of ‘normal’ leisure behaviour for that family.

The ways in which a parent’s identity interacts with their approach to the child were highlighted some time ago by Reder and colleagues’ [42] exploration of the meaning of the child. The idea is that parents may see the child in a particular kind of way that is bound up with their own unmet needs. Questions such as ‘What is the importance of the child to you?’ may help elicit the meaning invested in a child, positive or negative. The meaning of the child may also come to the fore in a family tree, showing, perhaps that a first name of a child has particular significance. Similarly, the Signs of Safety approach [37] draws attention to what is described as the “position” of the parent in relation to the particular problem. The authors advocate questions such as “From the report, you can see how others view things. What is your perspective on this situation?” (p.55). Questions such as these are likely to help identifying deeply held beliefs etc. that may be linked to identity and the parent’s social role.

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Self-efficacy: A parent’s sense of self-efficacy or competence can be ascertained through comments made, observations of their confidence in trying new techniques or by asking more direct questions along the following lines:

How confident do you feel in your ability to….?

How capable do you feel of handling / learning….?

How able do you feel to do / achieve…?

How able do you feel to meet the challenge of….?

[10]

There are some standard tools which have been developed to consider self-efficacy beliefs relating to parenting. The Parenting Sense of Competence Scale [43] is a 17-item self-report scale used to measure satisfaction / comfort with being a parent and parental self-efficacy i.e. perception of knowledge and skills. If positive, these two factors represent important protective factors and would also indicate positive capacity for change. This questionnaire can be found in the Appendix 1.

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Habits and automatic responses

Assessment may address what a parent’s automatic reactions are, what triggers these reactions, and whether there are regular repeated triggers that are maintaining existing patterns. It is important to assess the strength of an automatic response, perhaps by exploring situations when the habitual response did not occur, or was weaker.

Day in the life type questions may assist in identifying automatic or habitual response. Triggers to these responses may then be sought out by working backwards from the automatic behaviour– what happened immediately before that behaviour within the environment, and what was the consequence of the behaviour that may be acting as reinforcement of the habit. Signs of Safety, and Solution-focused brief therapy [37] encourage us to ask about “exceptions”, and these may be useful in determining the strength of a habitual response. Parents would be asked about situations where the trigger factors were the same, but the habitual response did not occur. Responses to this may help in identifying ways of overcoming habitual responses.

There are tools which can help with identifying particular types of habitual behaviour, one of which is the Difficulties in Emotional Regulation Scale (DERS) [44]. The scale assesses difficulties in emotional regulation for adults between 18 and 60. Higher scores suggest greater difficulty with emotional regulation. Scores are broken down into subscales that indicate difficulties with accepting emotional responses, engaging in goal directed

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How do you cope with stressful situations?

Can you give me an example of a regular stressful time related to parenting? How do you respond?

When your child behaves in a certain way (use an example the parent has given previously), how do you react?

Can you remember whether you think about how to react before you react?

When does the habit kick in?

How long have you been behaving like this?

When did it start?

Why did it start?

When don’t you behave in this way? What are the exceptions?

Can you see yourself as being different in the future?

How would you / your life look if this behaviour / habit was no longer there?

behaviour, controlling impulses, being emotionally aware, regulating emotions and having emotional clarity. The DERS can be found in Appendix 1 (p.94).

Contextual Factors

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Would you make any of these changes without pressure from Social Care?

Do you feel you have any control over the changes you are being asked to make and how you are being asked to make them?

Are there any practical or financial issues that are preventing you from accessing the support that is being offered e.g. timing, distance from home, childcare, clashes with work

What would / do your family and friends think or say about the changes you are being asked to make?

Do the worker and I have a good enough working relationship so we can work towards change together?

What professional support do you think you need to help make positive changes?

What support from family and friends do you think you need to help you make positive changes?

How do friends and family describe you as a parent?

Key questions for practitioners:

Are we working to support the parents’ senses of autonomy (as far as is feasible), their connectedness with formal and informal support networks, and their self-belief (in their own abilities to change)?

Are we working collaboratively to help the parent(s) identify goals, and give them the means to achieve the necessary changes?

Are we using the right types of interventions for the identified needs?

Where are the points of difficulty in the relationships between parents and services, and what can be done to address them?

Is the parent’s (or worker’s) attachment style affecting our working relationship?

How can I adapt or modify my style to acknowledge the parent’s style of relating, and improve our working relationship?

What is the current situation regarding the practical engagement of the parent(s) e.g. are they attending sessions, at home for visits, working towards goals?

Social support is often explored within Child and Family Assessments through the use of genograms and, once the PLO process has commenced parents are formally asked to nominate any family members or friends as potential carers for their children. Using an Eco map in comparison with a genogram can be an illuminating way to understand the emotional support or stresses within the parent’s network of family, friends and acquaintances (see Appendix 1 for tips).

There are many questionnaires that can be used to gain a parent’s views on the support available to them, one that is freely available and simple to administer s the Multidimensional Scale of Perceived Social Support [45]. The MSPSS is a 12-item self-report questionnaire that takes less than 5 minutes to complete and measures the perceived adequacy of social support. The tool can be found in Appendix 1 (p.96).

In the field of child welfare, the worker – parent relationship is an important factor in facilitating change and deserves consideration. The dynamics of the worker-parent relationship could be usefully explored within safe, reflective supervision asking the types of questions suggested above. Expanding the discussion into areas of worker - parent agreement on goals, shared understanding of changes that would be beneficial or necessary, and confidence in usefulness of current support or interventions would provide further information on the role of the worker and services in facilitating change.

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Much of the information needed to consider the factors affecting change will have been gathered during the process of completing a thorough children and families or parenting assessment.

There are some techniques, tools or approaches that can be used to elicit further information across the factors affecting change, or specifically for each factor

Standard tools should be used in context, be appropriate for purpose and aimed at supporting professional judgement, not replacing it.

Observation is a powerful tool for understanding the dynamics within families and the habits or automatic responses that occur without conscious thought.

Information needs to be collected on all of the factors affecting change to enable a balanced analysis

4.Methods of Gathering Evidence of Actual Change

There are currently two complementary, and sometimes overlapping methods, of gathering evidence of actual changes achieved by parents. Both involve creating an opportunity for parents to address the relevant difficulties and then examining whether they have been able to do so. The first is to set up goals/objectives with the parent(s), and then establish whether they have been achieved. The second is to use standard tools to measure parenting behaviour before the intervention, and then to repeat the same measures after the parents have had the opportunity to work on the necessary changes. Measures alone may not be enough, as in most cases there needs to be observable change as well.

Timescales In the context of child welfare practice in the UK (see Ch 1), the timescales within which these processes would have to be carried out are necessarily short. There may, for example, be a need for formal responses (court proceedings and permanency arrangements) to be put in place within a time frame that best meets the child’s needs, even if this may not necessarily meet the parents’ needs.

It is not possible to predict how long it will take for parents to acknowledge the need for change and to genuinely engage with the process of change [13]. It is known that behaviour changes are susceptible to relapse, particularly within the first six months of making the change. Harnett suggests that four to six months is needed to assess capacity to change adequately, including offering an appropriate intervention and gathering evidence of change following that intervention [46]. This recommendation is comparable with the 26 week time limit on care proceedings, but in most cases will clearly not be the end of a period of change. Others have drawn attention to the fact that some changes, such as recovery from alcohol or substance dependency, can take 5-10 years or more to become fully stable. Readers should bear in mind that we are only addressing social work assessments in this handbook. If a parent is assessed as likely to be able to make changes and sustain them, this will only be the start of a process, and the parent may need support into the future to maintain and improve on the changes achieved.

To assess thoroughly a parent’s capacity to change and to sustain those changes, the process should ideally start before care proceedings are initiated. Our recommendation is that consideration be given to a parent’s capacity to change during the Child Protection process (i.e. following an initial child protection conference), or in situations where a child in need might be on the edge of care. Capacity to change should be thoroughly explored, following the suggestions in this handbook, once the Public Law Outline Process has begun (i.e. beginning if possible before issuing a letter before proceedings, but if not, then immediately after issuing this letter). In this way, there should be sufficient time to gather

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information on the factors affecting change and to allow for evidence of actual change to be obtained.

The reality of practice is that it will sometimes be necessary to conduct the assessments once court proceedings have been initiated. If there is insufficient time to develop feasible goals against which to intervene and monitor progress, then capacity to change can be considered by using information from the most recent historical assessment and comparing it to the present situation, alongside an analysis of the factors affecting change.

The over-riding consideration, regarding timings for assessment and decision-making, is the timescales of the individual child and how quickly they require change to occur. For detailed discussion of child development in the context of timescales, please see Brown and Ward [47], available at http://www.cwrc.ac.uk/resources/documents/Decision_making_within_a_childs_timeframe_Feb_2013_CWRC_WP_16.pdf Figures 5.1 (p.90) and 5.2 (p.94) set out key considerations regarding the child’s timescales, in relation to the different ages and stages of childhood.

Setting objectives and measuring outcomes

The approach put forward in this handbook is derived from the work of Paul Harnett [46]. Fundamental to it are the following steps (adapted from Harnett, 2007):

When agreeing the goals in step 3, a collaborative approach should be taken. Ideally, a social worker and parents could negotiate the goals together, each listening to the other’s suggestions but always with a clear ‘bottom line’ regarding the need for a healthy and safe environment for the child. Approaches that seek and respect parental views and involve a basic level of agreement about the changes that need to happen have a better chance of

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Steps in setting objectives and measuring outcomes:

1. Use appropriate assessments/tools/measures to establish a baseline. This would often be the standard, in-house assessment used by the agency, generally based on the Framework for the Assessment of Children in Need, and perhaps incorporating other approaches such as Signs of Safety.

2. Identify target difficulties affecting the children3. Agree goal(s), related to each target difficulty, that are

• Negotiated with parents• Meaningful (to both parties)• Manageable

4. Provide intervention(s) aimed at addressing target difficulties5. Assess observable changes

http://www.cwrc.ac.uk/resources/documents/Decision_making_within_a_childs_timeframe_Feb_2013_CWRC_WP_16.pdf

http://www.cwrc.ac.uk/resources/documents/Decision_making_within_a_childs_timeframe_Feb_2013_CWRC_WP_16.pdf

facilitating change than those where goals are imposed [13]. It is equally important that the child’s voice is heard with regard to understanding the changes they would like their parents to make and the benefit this would have for their wellbeing. There are numerous techniques for working directly with children that could be useful here such as the miracle question, Three houses [37] or three islands [48]. If using techniques such as these to work with children, they can be re-visited at a later date as a means of understanding whether the child feels that there has been any actual change in their experience.

Harnett proposed a method of assessing observable changes based on Goal Attainment Scaling, an approach that has been used in a wide range of clinical contexts. Its application in the social work context is represented, using a fictitious case example, the chart below. It should be noted that the scores are not intended to be added up across a number of target behaviours to give an overall total. The method overall has been found to be effective, but research suggests that the adding up of scores is not valid or reliable.

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Date: …3rd March 2014…………

Goal: …Rob and Penny’s drinking decreases to a level where the children are not affected.Importance for children ……John, Steph and Ella will be physically and emotionally safer if they are not cared for by their parents when drunk.

Description of situation at start(2nd December 2013)

Level of Outcome Score Description of levels: Evidence of change at follow-up(date: 3rd March 2014………)

Rob and Penny are drinking alcohol to a point where Children’s services believe they are not able to function well enough to provide safe or appropriate care to their children. All children have been at significant risk of harm both while Rob and Penny are drinking and while they are recovering the following day.Rob and Penny are drinking to this level on average once every two weeks and are not arranging alternative care for their children while they are drinking.

Much more successful than expected

5 Parents do not drink more than one unit of alcohol on any occasion involving drinking

Somewhat more successful than expected

4 Parents engage in social drinking but drink no more than 3 units in any one day, once a fortnight. Children cared for by reliable babysitters while parents drinking.

Successful 3 Parents drink to excess no more than once every two months, and have another adult to look after children until they recover

Penny and Rob have reported drinking to excess on two occasions since Dec. On both occasions the children were looked after by an appropriate family friend until lunchtime the following day (confirmed through calls to friend).

Somewhat less successful than expected

2 Parents drink to excess no more than once every two months, and have the children in their own care whilst recovering

Much less successful than expected

1 Parents drink to excess once a month or more, without appropriate babysitting arrangements

Note any difference in opinion between parents and social worker:

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Goal Attainment Scaling Chart

Setting up goals with the parents involves agreeing the wording of a stated goal and devising a chart for each goal. The goal is written along the line headed “goal”. Then descriptions are agreed of the different levels of potential achievement of the goal. These descriptions are inserted into the boxes beneath the heading “description of levels”, and correspond to the degrees of success indicated by “Levels of Outcome”. The goals set should follow the SMART formula (specific, measurable, agreed, realistic, timely) involving concrete descriptions of behaviours. In this way, parents should be able to understand clearly what is expected of them and be able to form their own view about which level they have achieved after a specified time period.

The actual outcome at follow-up can be recorded in the final column, including a description of the source of the evidence of the change e.g. self-report, drug screens, police reports, professional observation, childs view. It is important that the services have a view about the level of outcome that would be acceptable in terms of keeping the child at home in his/her parents’ care and that this is understood by the parents. Goal Attainment Scaling can be used flexibly in a variety of contexts. If used at the beginning of the Child Protection Process then the levels of success may be set in terms of small steps towards the goal with the expectation that the levels will be adjusted at the review conference if progress is made but further progress is required. The outcomes may then be used to back up a decision to take a child of a child protection plan. If used to gather evidence of change during the PLO process then reaching the ‘successful’ level across all goals would normally be enough to prevent the Local Authority from initiating care proceedings (assuming no additional risks have presented themselves).

Standard tools to measure parenting behaviour etc. before and after intervention

The tools selected to use to measure the behaviour of parents will depend on the type of change that is promoted and expected. Tools should always be used in context and explanations given to the parents about why they are being asked to complete them. For example, the TWEAK or T-ACE should be used within the context of a conversation about a parent’s health and possible substance misuse; the Parental Daily Hassles [38] or Mother Object Relationship Scale [49] as part of a discussion about the highs and lows of parenting.

The following tools are some suggestions, all of which have been tested for reliability and validity, are free to access and use, and are relatively simple to administer and analyse. Links to or copies of all of these tools can be found in Appendices 1 and 2.

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Tool Used to measure?Home Conditions Scale(11 items)[38]

State of home environment

Parental Daily Hassles( items)[38]

Levels of pressure the parent is feeling in meeting child’s needs; helpful in identifying whether the child’s behaviour is troublesome or whether the parent is struggling to meet legitimate needs of the child.

Family Activity Scale[38]

Explores the environment that parent’s provide for their children through joint activities or support for independent activities.

DAST[50]

Level of substance use

TWEAK [51] T-ACE [52, 53]AUDIT [54]

Level of alcohol use

Child-Parent Relationship Scale (15 items)[55]

Parent’s perceptions of the relationship between themselves and their child. For use with parents of children aged 3 – 12.

Mother-Object Relation Scale. (14 items)[49]

Maternal perceptions of warmth and invasiveness with regard to their baby; brief screen of potential attachment difficulties. Can be used for infants from 0 – 4.

Parenting Sense of Competence (17 items)[43]

Self-report. Two scales, satisfaction with parenting and efficacy of parenting skills.

Observation Research has shown that information gained from independent observation is more reliable and sensitive than self-report from parents, particularly when trying to assess change following an intervention [56]. If using observations as a means of gathering evidence of change then at least two observations will need to be carried out, in similar circumstances at the beginning and end of a period of intervention [46]. Standard coding schemes for use during observations have been developed, and several of these have been validated and found to be reliable. The complexity of these schemes means that training is required and handbooks need to be purchased. They have not therefore been reproduced here. The use of such schemes in gathering evidence of change through observation does highlight the importance of using the same criteria, structure and environment for the before and after observations [57]. For some tips on conducting observations as part of the process of assessing change please see Appendix 1 and p26.

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Parents need to be given a time-limited opportunity to evidence their ability to make the required changes

Change should be measured in either or both of two ways:

1. Through the use of standard tools to take baseline and follow-up measures

2. Through setting meaningful and manageable goals in collaboration between parents and social workers and gathering evidence of the level of achievement of the goals.

One systematic way of setting goals and measuring change is to use Goal Attainment Scaling

The assessment of parental capacity to change fits within existing assessments and thus within the court timescales. However, the assessment will be at its most thorough if started as soon as the PLO process is initiated, or earlier. This will allow for the opportunity to set goals, measure change and begin to form a view about the sustainability of that change

The most important timescale is that of the child and

5.Analysis and Conclusion of the Capacity to Change Assessment

There are several fundamental principles involved in drawing conclusions from this assessment:

1) The analysis should weigh up the results of both aspects of the assessment, the assessment of factors affecting capacity to change, and the assessment of evidence of actual change. The two aspects provide complementary methods of assessment, and the overall conclusion would be incomplete without considering both.

2) The capacity to change assessment does not stand on its own as implying a particular decision about a child’s future. It must be incorporated into an overall analysis of the assessment of the child and his or her family. This assessment balances the nature of the target difficulties, the harm the child is experiencing as a result of these difficulties, and the parent’s potential for change within the child’s timescale.

3) Once the factors that are currently hindering change are understood, consideration should be given to how to address these factors, and the support the family will need to make progress towards change.

Summarising and Analysing Factors Affecting Capacity to Change

In this chapter, we suggest a number of ways of sorting and weighing up the information gained through the Capacity to Change assessment. None of these methods are essential to use, and the practitioner should choose the most appropriate method for the situation, and may use them in combination if relevant. They aim to help present the information gained on the factors affecting capacity to change in a systematic manner, thus avoiding bias towards the most recently gained information, or information that supports the prevailing view of the parent’s situation. The three alternatives are

a) A balance sheet, b) A pictorial scale, c) Guidance for completing a formal written summary of capacity to change, e.g. for

use in Child Protection reports, court statements.

In the following pages, we provide examples of how these different means of analysing information may look if completed in relation to a family. In order to do so, we have developed a fictitious case, the background information on which can be found in Appendix 3. Blank templates of all the completed forms can also be found in Appendix 3 so they can be readily printed or copied for use.

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a) Balance sheet

The purpose of this template is to set out clearly the different factors affecting change, and how they may be weighed up. When completing it, information on all the five factors affecting change should be considered (Priority / Relevance, Knowledge and Skills, Motivation and Intention, Habits / Automatic Reactions, and Contextual factors). It is intended that, by setting them out in clear language, the sheet could be shared with the parents to enable better understanding, on their part, of the reasons Social Care believe that change is possible (or not) within the timescales of their child(ren). The approach also lends itself to use in supervision, group case reflection, to aid discussion and case management.

If completed at an early point in the process of intervention, work can then be done with the parents to address some of the factors hindering change, and in so doing provide every possible chance for change to be achieved. Towards the end of the intervention when a decision is necessary about future plans for the child(ren), the balance sheet could be completed again, and compared with the original to ascertain whether the parents have made progress in their capacity to change. If completed at the end of an intervention, or for inclusion in an assessment, report or statement, evidence gained from processes of assessing actual change (GAS, before / after measures) could also be incorporated.

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Balance Sheet of Factors Affecting Capacity to ChangeWhat needs to change: Rob and Penny need to reduce their alcohol use to a point where it is no longer harming their children

Why is this change necessary for Jon, Steph and Ella? So they can live safely with their Mum and Dad

What is helping to achieve change? What is acting against change? Next steps e.g. What action can be taken to promote change

Rob has been able to make changes before to improve his life

Penny can explain what Jon, Steph and Ella need from her as a Mum and Rob as a Dad to feel safe and content.

Rob and Penny have been able to make positive changes in their relationship with help from professionals

Both Rob and Penny are able to understand the support offered to them, to take part in groups and to practice the skills that they gain from groups or 1:1 work.

Rob and Penny have made some suggestions about their own goals and ways to improve the current situation

× Rob and Penny want to be able to drink alcohol in the future, as an important part of their life

× Rob and Penny believe that drinking alcohol is an important and positive part of who they are, both as individuals and as part of their group of friends

× Rob and Penny feel they will lose a lot by stopping drinking

× Rob and Penny (particularly Penny) do not trust Social Care: this makes it hard for Penny and social workers to be able to make real agreements and plans

× Penny does not always believe that she is able to change the amount she drinks

× Penny partly blames her parents for her drinking but has not talked about this with her parents or talked to professionals in detail. This means that Penny thinks her parents are

Both Rob and Penny and Social Care need to compromise on goals so that agreement can be reached on goals to be worked towards which will keep Jon, Steph and Ella safer.

Rob and Penny to be supported to think about, plan and do family activities that do not involve any alcohol to reinforce that children are the reason for change

Get together Rob, Penny, Social Care and Substance misuse to agree how best Rob and Penny can reduce their use of alcohol.

Any work done by substance misuse or any further relationship work should acknowledge the important interplay between their identity as a couple and problematic alcohol use

Look back at the records of previous social work involvement and talk Penny and Rob through the decisions that were made, being ready to

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critical and unsupportive.× Rob and Penny are only listening to

the views from their friends and family that agree with their wish to drink; they dismiss other views as wrong or unfair

× Rob and Penny sometimes say that they think they drink too much and want to stop, and sometimes say that they do not need to cut down, that there is no problem.

× Substance misuse professionals have not been able to make agreements with Rob and Penny about the goals of the work or how/ where the work should begin

× Rob and Penny’s priorities seem to be about themselves individually or as a couple e.g. work, mental health, having fun together rather than about their children

× Little opportunity for case hypothesising / reflection in supervision

accept if practice was not as good as it could have been.

Use methods / techniques like the miracle question or motivational interviewing to try and support Rob and Penny to reach their own decision that change in their drinking habits is necessary

Discuss Rob’s own goals with him, assisting him to think about how his goals affect Penny, Jon, Steph and Ella and how positive changes might improve life for everyone in the family

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b) Pictorial Scale of Factors Affecting Change

The purpose of this chart is to set out which of the factors affecting change are supporting change in the desired direction, and which are hindering change. It is likely that it will be most useful as a tool to aid gathering thoughts and case discussion in supervision.

With regard to Rob and Penny’s use of alcohol (behaviour that requires change), we have marked the influence we think each factor has in supporting change and noted some of the evidence for this decision.

Seriously hinders change No effect Fully supports change


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Priority/Relevance


Rob and Penny enjoy alcohol and wish for it to remain part of their life in the future, though they recognise the current levels of drinking aren’t ok for the children.

Rob has good communication skills, can work in groups but little understanding of child development / emotional needs. Is able to reflect.

Penny has improved her knowledge of her children’s needs and can implement some of it. Is able to form relationships with workers on 1:1 basis. Can reflect on childhood and empathise with children but struggling to understand why she drinks excessively.

Struggling to accept level of drinking is problematic – compare themselves similarly to peer group. Alcohol important part of identity – for both separately and as a couple.Assume Social Care are trying to catch them out and want to remove children.Penny not convinced she can change.

Rob has strong self-belief and been able to make significant changes previously.

Both have changed behaviour towards each other.



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Motivation and Intention

Habits and Automatic Responses

Alcohol seems to be the response to various triggers ; feel they’ve done well – have a drink;feel stressed – want a release, have a drink;don’t like being told what to do – want to prove their point, have a drink.Need to develop new responses!!

Support from social network either encourages continued drinking or if encourages them to drink less is perceived as negative support which is overly critical.

Worker empathetic, collaborative approach but difference of opinion between SC and parents over ‘bottom line’ of what is needed to keep children safe


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Contextual Factors

Not been a genuine working relationship between Penny and subs misuse – intervention needs to be looked at again.

c) Formal Written Summary

Templates for court statements or parenting assessments will often provide guidance on what to consider when forming a view on a parent’s capacity to change. In this section, we give a list of key elements of what to include in such a report, and a fictitious example of a section in a parenting assessment that concerns capacity to change.

Key points to consider when writing a summary on a parent’s capacity to change are:

State clearly the areas in which change is required to secure the children’s safety Address separately each area of behaviour that requires change. There are likely

to be links between behaviours and the changes or lack of changes in those behaviours but these can be considered at the end of the analysis. The comparison of progress towards change in the different behaviours will also provide further evidence of the parent’s priorities.

In relation to each target behavior, comment on the five factors affecting change (Priority/ Relevance, Knowledge and Skills, Motivation and Intention, Habit and Contextual factors) in a way that shows which factors are supportive of change and which are acting as barriers to change.

Consider the balance between the factors that support change and those that hinder change; where has there been progress? Which factors appear to be the most resistant to interventions? Which factors appear to have the most influence over this parent’s response to the need for behaviour change?

Summarise evidence of changes that have been gathered during the process of assessment and intervention. This evidence might include goals achieved, or the difference between the scores in baseline and follow-up questionnaires.

Using the information gained from the analysis of factors affecting change, and evidence of observable changes to behaviour, it is possible to form a view on the parent’s overall capacity to change. This part of the analysis may include an estimate of the parents’ positions in relation to the Stages of Change model [31].

It is a matter of personal style as to whether the five factors affecting change are addressed separately. There are likely to be a number of behaviours or examples which provide information on several of the factors affecting change, and it may therefore make sense to describe these behaviours and what they mean for the likelihood of change. It is not necessary explicitly to name the five factors each time they are referred to; rather the important point is to be considering them all and the impact they are having on the parent’s capacity for change.

Below is an example of the summary of a (fictitious) capacity to change assessment. We have used speech bubbles to indicate which of the above bullet points is being addressed, and have used brackets and underlining to illustrate which of the factors affecting change I am referring to. Obviously this commentary would be omitted from a real life report.

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Please note that this section is additional to the main assessment report, and full details of the problem areas would be given elsewhere in the relevant section.

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Set out any evidence of observable behaviour change.

Comment on how the five factors affecting change have facilitated or hindered change.

Use the information given to form a view on the parent’s position relative to the Stages of Change54

Give an opinion on the balance of factors affecting change.

Form an opinion on the parent’s position in relation to the Stages of Change.

How does this relate to the children’s welfare?

Example Summary of a Capacity to Change AssessmentThe areas where change is most required in this situation are the parental relationship and the parent’s misuse of alcohol. It is Mr. and Mrs. A’s actions in these areas that are exposing their children to significant risk of harm.

Parents’ relationship

Both Mr and Mrs A have provided evidence of an ability to make changes within their relationship. The majority of the time they are better able to listen to the others’ views, and they respect that these may be different without escalation into a volatile argument. The police have not been called as a result of domestic abuse during the last six months and there has been no suggestion of physical assault against Mrs A. The eldest child has worked with a therapist and is now able to alert his parents when he is beginning to feel scared by the tone of their communication. They are responsive to his anxiety and are able to de-escalate the situation.

In my view, these changes have been facilitated and supported by a number of factors known to affect change. Maintaining their relationship as a couple is a priority for both Mr and Mrs A; they have consistently expressed their desire to remain together as being part of the couple is an important part of their identity. Both believe that they have more to gain from staying together with an improved relationship than to lose by not making changes [Motivation and Intention]. Mr and Mrs A perceive Mr A’s family as supportive of the couple staying together, as are their friends. Mrs A’s family would prefer to see the relationship end but for Mr and Mrs A this acts as additional motivation to improve their relationship and show that they can stay together happily [External factors – social networks]. Mr and Mrs A addressed issues of minimisation and denial in the work they did with the Domestic Abuse Service. They were able to speak openly and honestly [knowledge and skills] to workers, and by the end of the programme, to each other. [External factors – programme of work]. Mr A has learnt alternative strategies [knowledge and skills] to deal with his feelings of anger or annoyance that arise during arguments and as such is beginning to change his habits. Mrs A presents as more able to express her opinions to Mr A, at least when professionals are present and not to act to appease him in all situations and so is also beginning to change her automatic reactions in this context.

Mr. A still presents as the controlling force within the relationship and Mrs. A’s behaviour suggests that she is ready to modify her opinions if Mr. A reacts with displeasure. For this reason, I believe Mrs. A retains some fear that the potential for violence remains and would not say that the changes made are as yet clinically significant for the children’s safety and wellbeing. This is partly because of the relationship between the parents’ misuse of alcohol and the dynamics of their relationship, to which I will return below.

It would be fair then to assess Mr. and Mrs. A as having made positive changes to their relationship which are compatible with the transition between the preparation and action stages of the change cycle.

Address each behaviour that requires change separately; in this summary the relationship issues are covered first, followed by the alcohol misuse.

How significant are the changes for the welfare of the children?

Comment on the factors affecting change in relation to the next

Situations where change is looking unlikely: next steps

The issue of timescales is crucial when change appears unlikely; if, in the early stages of an intervention, the balance appears to be more against change, then (assuming the child is safe) there is time to focus the work on addressing the main barriers to change so preparing the parents to begin a process of change. Techniques from Motivational Interviewing have been shown to be successful in assisting parents to explore their ambivalence to change and to progress to a position where they are more receptive to targeted interventions [13]. Goals could then be agreed which focus on addressing the barriers to change and increasing the factors which could facilitate change. The parent’s progress could be measured using Goal Attainment Scaling or similar. A Family Group Conference can also be useful in supporting parents to overcome resistance to working with service-led goals, as it can provide an opportunity to set their own goals within a safe limit agreed by Social Care. It also provides an opportunity to harness support from the parent’s network [13]

If attempts have been made to address barriers to change, and appropriate interventions have been offered to parents to support them in changing their behaviours, but little evidence of change has been gathered and the interventions have been in place for between four and six months, then some evidence suggests that change within the child’s timescales is unlikely [46]. However, it should be noted that Department for Education Guidance advises that cases should be reviewed only six weeks after a letter before proceedings has been issued, at least to ensure that sufficient progress is being made. Where the assessment of factors affecting capacity to change is pessimistic, and there are no indications of parent’s making any necessary changes, then an earlier decision is arguably worth taking.

If the evidence of change is inadequate, the decision then becomes one of whether the parenting that the child is currently receiving is ‘good enough’ to protect them from significant emotional and / or physical harm. The analysis required here returns to the central point of the impact on the child of the parenting they are receiving. The impact on the child(ren) may be so harmful to their welfare that the unlikelihood of significant change to their parents behaviour within their timescales means that separation from their parents is the only option. Alternatively, small changes could improve the situation to a point where it is ‘good enough’, especially if there is positive support available from the informal network or universal services. The services would have to monitor the situation to ensure change is sustained and the risk of significant harm does not re-emerge.

Parents with learning disabilities or chronic mental health conditions are unlikely to be seen as able to make significant changes if their parenting difficulties are related to their

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Comment on the factors affecting change in relation to the next

impairment. If the focus shifts to providing appropriate ‘parent-training’ and /or practical support equipment, and there is a recognition that ongoing support may be necessary to enable them to adapt to new challenges faced as their children grow and develop, then the possibility of change increases [58]. The structure of Children’s Services and resource constraints mean that social workers face a difficult task when an assessment suggests that parenting can be ‘good enough’ but only with continued support and funding from Children’s Services.

The Care Act 2014 places statutory responsibilities on Local Authorities to actively promote the wellbeing of adults and to work in a preventative manner i.e. to prevent needs from escalating by intervening early and helping people retain or regain their skills and confidence [59]. This duty applies to both adults who are assessed as being eligible for support from the Local Authority as well as to those who are assessed as not eligible. The Care Act 2014 introduces national eligibility criteria which are based on how the needs of a person impact on their ability to achieve at least two specified outcomes and the consequence of this for their wellbeing. One of the specified outcomes is “carrying out any caring responsibilities the adult has for a child” [59]. It is therefore increasingly important that children’s social workers take all possible steps to provide appropriate support to prevent needs connected to parenting from escalating, to promote the welfare and wellbeing of both parent and child. Key messages for practitioners about how to best to assess and support parents with Learning Disabilities, or arguably any parent with additional needs such as long-term physical or mental health conditions are:

Treat the parents as parents first – do not assume the difficulty results from their condition, consider the impact of social isolation, poverty, childhood experience, domestic violence etc.

Empower parents to be fully involved – use advocates, have shorter meetings or breaks within meetings.

Work jointly with other services so that parents have as few workers as possible but benefit from specialist knowledge

‘Tell it as it is’ – use straightforward language, make one point at a time and ensure your body language and facial expression matches the information you are giving

Explain what you mean in simple terms – what does tidying up mean? Model the behaviour you want the parents to copy, be creative in techniques.

Provide parents with enough time to learn and practise the techniques you want them to implement, this is best done in their home

Provide accessible information – use pictures, videos, jargon-free language Accept that support may be needed on a long-term basis to promote ‘good enough’

parenting and plan with the parents what this should look like

Working Together with Parents Network [60]

Further information on positive practice during parenting assessments with parents with learning difficulties is available via the Working Together with Parents Network at http://www.bristol.ac.uk/sps/wtpn/ and resources to use in parenting assessments can be

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http://www.bristol.ac.uk/sps/wtpn/

accessed through Change at http://www.changepeople.org/ and Raising Children at http://raisingchildren.net.au/parenting_in_pictures/pip_landing_page.html

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Analysis should weigh up the results of both aspects of the assessment, the assessment of factors affecting capacity to change, and the assessment of evidence of actual change.

The conclusion regarding a parent’s capacity to change does not indicate any particular decision about the child’s future. It must be incorporated into the overall assessment about the parent’s capability to meet their child’s needs.

This chapter suggests three different ways of gathering together the information gained on capacity to change. They aim to help present the information in a systematic manner so avoiding any bias towards the most recently gained information, or information that supports the prevailing view of the parent’s situation.

The three alternatives are1. A balance sheet, 2. A pictorial scale, 3. Guidance for completing a formal written

summary of capacity to change, e.g. for use in Child Protection reports, court statements.

http://raisingchildren.net.au/parenting_in_pictures/pip_landing_page.html

http://www.changepeople.org/

6.The Back Story and other Academic Stuff

Where a child has been abused or is suffering harm in a family context, the parents’ potential to address the identified problems is critical to that child’s future wellbeing. However, methods of assessing a parent’s capacity to engage with services, and to change their behaviour for the benefit of their children, are underdeveloped in social work in the UK. Here we present a brief overview of the background to the practice approach proposed in this handbook, and we show how the methods relate to the theoretical, research and policy base.

Practice dilemmas and children’s vulnerabilities

The focus of this handbook, the capacity of parents to change their behaviour where there are risks to the children, lies at the heart of significant tensions in social work practice. When working with abused and neglected children, social workers are expected, on the one hand, to support them to remain in the care of their own parents if it is safe to do so. On the other hand, they must initiate action if the child would be unsafe remaining in his or her parents’ care. To keep a child in his or her own family safely, it is necessary for the parents to be engaged with services, and to work towards overcoming whatever problems led to the children being at risk in the first instance. However, there have been a number of children’s deaths from abuse or neglect where social workers seem to have over-estimated parents’ co-operation, or have taken an over-optimistic approach [61]. The high profile case of Baby Peter [62] provides an example of the risks of over-estimating parental engagement ; and over-optimism about changes parents are making was highlighted in the South West of England in the case of Child K [63]. Problems of engagement and capacity to change are similarly evident in the research literature. Harder [64], for example, showed that parents who exhibited more ‘resistance’ were more likely to re-abuse their children. And Brandon et al [61], in their analysis of reviews into child deaths, also found that a lack of parental engagement was linked to recurring abuse.

In most helping processes related to individual psychological and social problems, there are two aspects of particular importance, engagement of the therapist with the client, and the processes of change needed to address the problem [37, 65]. The underlying dilemma is that, in the context of social work with vulnerable children, engagement with the parents is fundamental to working towards change, but, where parents are unable to achieve changes in their behaviour, engaging them with services risks masking that lack of progress. A particular research study confirms one implication of this, that social workers may sometimes mistake superficial engagement by parents for a genuine desire to change [18].

There is growing research evidence that parental cooperation makes a significant contribution to decisions regarding coercive actions, such as taking children into care,

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initiating child protection investigations, or placing children on a child protection plan [66-70]. This relationship, however, is not one-dimensional. Thus, a lack of parental cooperation may make care proceedings more likely in many cases, but there are also instances of the opposite effect. That is, there are occasions where lack of engagement by parents with services means that the information available to social workers is so limited that the evidence would not be sufficient for legal action [69, 71]. Indeed, Farmer and Lutman’s [71] study of neglect, found that around two-fifths of parents in their sample actively resisted, or attempted to sabotage work. For this handbook, our argument is that better practitioner understanding of engagement and change ought, in principle, to help maintain the focus of practice on the welfare of the child, enable more objective exploration of the parents’ abilities to meet their child’s needs in the future, and thereby lead to better decision-making.

The legal and policy environment

At both policy level, and amongst the judiciary, there is growing support for the development of practice in this area. A recent set of developments, were initiated following an Appeal Court ruling in the case of Re B-S (Children) (Adoption Order: Leave to Oppose) [2013] EWCA Civ 1146, which drew on a number of other relevant judgments, and highlighted the requirements for good analysis in social work assessments. It also emphasised that the court’s assessment of the parents’ capacity to care for the child should include an analysis of the support available to them to do so. The implication of this is that the parents’ response to that support should be assessed in terms of achieving change that would improve the welfare of the children, so that they can remain in, or be returned to their parents’ care.

A revision of the Public Law Outline, providing guidance on care proceedings and pre-proceedings work [2, 3], was introduced in 2014, and is supported by the provisions of the Children and Families Act 2014. Included under these provisions is a 26 week time limit for the completion of Care Proceedings, and an expectation that careful and focused work needs to be undertaken prior to initiating proceedings, to ensure that cases can be completed without delay. The Public Law Outline not only gives detailed guidance regarding the timely management of proceedings, but also includes the requirement, where possible, for local authorities to issue to parents a letter before proceedings. This letter, in effect, warns the parents that Care Proceedings are being considered, and gives them the opportunity to make specified improvements aimed at securing the welfare of the child(ren), thus, if successful, avoiding the need for subsequent court action. Further details about the Pre-proceedings Process are included in the Department for Education statutory guidance on court orders and pre-proceedings [3].

The letter before proceedings provides an obvious, and formalised, opportunity to build in to practice an assessment of the parents’ capacity to change. However this assessment is managed, the courts now also require a more analytical approach to report writing, (as

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indicated above, following Re B-S). The approach we are proposing to assessing parental capacity to change, will support the necessary analysis in court statements. In relation to Bristol Courts, a parenting assessment template has now been developed, which includes a section on parental capacity to change. At national level, a proforma developed by CAFCASS and the ADCS (and endorsed by the President of the Family Law Division) includes the expectation that social workers analyse any gaps in the parents’ capabilities, and whether these can be overcome within the timetable for the child [72].

Interest amongst policy makers led recently to the Department for Education commissioning a review of research evidence related to parental capacity to change when children are on the edge of care [13]. They are also funding research into improving practice in returning children home from the care system, including the development and testing of practice guidance by the NSPCC and University of Bristol [73]. The direction of policy in relation to reunification appears to involve ensuring that assessments take place prior to returning a child, and that they take account of whether improvements made by the parents are sufficient to ensure the child’s safety.

Development of a practice model

Moving from the policy to the practice context, our starting point is linked to previous work on social work assessment [74], which identified some particular features of practice that are important for the present context. A holistic assessment of the child’s needs, parent’s capacities and family/environmental factors is fundamental. Such an assessment should lead to an identification of the priority aspects of parenting that need to be addressed, in the individual case, in order to ensure the child is safeguarded. This clarity about target problems, which, as Turney and colleagues’ review [74] identified, should be based in sound analysis, will provide the basis for assessing a parent’s capacity to change. Identifying target problems enables the parents’ capacities to change their behaviour to be assessed in relation to meeting the particular needs of their particular child.

Evidence for the approach proposed in this handbook was drawn from (1) an international review of literature in the child welfare and associated fields, focused on parental engagement and readiness to change [1]; (2) a detailed examination of the recent UK based review commissioned by the Department for Education [13]; (3) a review of frameworks of theoretical models of behaviour change, and (4) a review of standardised tools relevant to the context.

Central to this was the work on theories of behaviour change. There is a large number of such theories, and our work aimed to identify categorisations of key factors affecting behaviour change rather than to review all theoretical models. Because of the variety of individual difficulties presented by parents involved with social work services, we were seeking an integrated, or ecological, framework that drew upon a range of relevant theoretical models. Not only would such a framework present a range of factors worthy of assessment by social workers in individual cases, but it would also support existing strengths

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within the profession, where assessment using an ecological framework is accepted as a fundamental aspect of practice.

Our examination of the available material led to a number of conclusions. Our overview of a range of research studies suggested that the most comprehensive picture of engagement and readiness to change was achieved in those studies that included data on factors affecting engagement and change (barriers and facilitators), as well as data drawn from observable actions such as actual engagement or actual changes in behaviour. Studies that considered one aspect or the other aspect of these sources of data can be shown to present a more partial picture than studies that cover both. This insight was reflected in the conceptual model of engagement presented in Platt [1], and is now presented as one of the fundamental principles of the present approach to assessment. Our position is that social workers, in making their assessments, should BOTH examine the factors affecting capacity to change, AND observe the effects of parents being offered supported opportunities to make actual changes.

This position is further supported by two other key findings from relevant research. The first is the importance of utilising more than one method in assessing parenting [74]. Our approach does just that. The second is the widespread evidence that enabling people (in this instance, parents) to undergo a process of change requires an approach whereby their voices are heard, and they are involved actively. Our model engages the worker in understanding the parents’ positions, albeit within a framework of constraints that are intended to ensure the safety of the child.

Factors affecting capacity to change

Models of behaviour change were a significant source of information for the method of assessing factors affecting capacity to change. An important line of development in identifying and categorising key factors affecting behaviour change can be traced back to a workshop organised by the National Institute of Mental Health in the United States in 1991. The workshop brought together a group of behaviour change theorists from different theoretical traditions, who, despite theoretical differences, were able to agree on a framework of factors influencing behaviour and behaviour change [75]. This framework has been influential in relation to further academic developments, including the Unified Theory of Behaviour [6], the Theoretical Domains Framework [7, 8], and subsequent work by Fishbein and colleagues [76].

The work of Susan Michie and colleagues is of particular interest because it arises from several decades of research on behavioural change interventions, many of them in the health promotion field [8]. Their Behaviour Change Wheel, and Theoretical Domains Framework were developed from a review of 19 frameworks of behaviour change interventions, and an international collaboration of theorists and researchers which identified and subsequently validated key constructs in understanding factors affecting behaviour change [7]. The constructs are thus based on a very considerable body of

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research and analysis. The Theoretical Domains Framework, as it stands currently, is comprised of 14 domains, located under three headings, capability, opportunity and motivation.

The Unified Theory of Behaviour [6] was helpful to us because their framework was adapted (slightly) by Olin and colleagues [9] in New York for work with parents of children with mental health problems. It was evaluated in that context with positive results, although further evaluation would be desirable. Given its common theoretical roots, this framework maps very closely to the Theoretical Domains Framework.

In developing the current approach to assessing factors affecting behaviour change, we decided to use the Unified Theory of Behaviour as our basic framework, as it had been used successfully with a similar target group (i.e. parents with children experiencing mental health difficulties). We compared this framework to ensure consistency with other models in child welfare and related fields [1, 12, 77-79], as well as with the Theoretical Domains Framework. The result was some slight adjustment to ensure adequate coverage of relevant constructs, and is presented as the Factors Affecting Parental Capacity to Change in this handbook. Consultation with social work colleagues during the preparation of the handbook also contributed to some refinements (without compromising theoretical integrity). Please refer to back to chapters 2 & 3 for full details of the framework we adopted.

Regarding practice methods for assessing factors affecting capacity to change, we focused particularly on the types of routine questions social workers would need to ask to gain information on these factors in individual case. We also explored tools which purported to explore a person’s readiness for change or intent to engage with an aspect of the change process e.g. a form of treatment. We reviewed the content of eight tools, seven of which were in questionnaire format and one of which was a semi-structured interview which included rating questions relating to different aspects of capacity to change. The tools were developed in a variety of disciplines including health promotion, offending, substance misuse and child welfare services in the USA. Our brief analysis of the questions in the tools suggested that although no tool covered all aspects of the factors Affecting Capacity to Change as described in this model, the themes mapped well onto the factor concerning Motivation and Intention. All of the tools also included questions aiming to understand how relevant or how much of a priority the behaviour change was for the respondent. Six of the tools included questions referring to another of the factors affecting change; contextual factors and these related to coercion, feelings about the working relationship and feelings about the intervention / treatment programme that was being offered. The majority of tools had been shown to be valid and reliable to a satisfactory level, but it was rare to find one that had been subject to full psychometric testing. This lack of psychometric testing appears to be a general feature of measures in the field of parenting assessment [35].

Assessment of Actual Change

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With regard to assessment of actual changes achieved by parents, it is relatively commonplace for social workers to provide support or interventions to families as an opportunity to ‘turn things around’. However, less well developed is the means of agreeing specific goals and of identifying whether and how those goals are achieved. Research, for example, in the context of reunification work has identified variable practice in relation to the purposefulness of planning, and in the handling of shortcomings in the achievement of planned goals by parents [80, 81]. The practice need, thus, would appear to include further development of knowledge and skills in relation to setting objectives and goals, and in monitoring the outcomes of parents’ attempts to change.

Our search for practice methods, in relation to these professional needs, identified concurrent work [82, 83] involving goal setting and the use of before and after measures. The work of Paul Harnett [46] using goal attainment scaling is generating considerable interest in the UK, and offers a tested approach which has potential credibility with social work practitioners. Our view about its potential is based on our consultation over the development of the present materials. Consequently, we developed a format for specifying goals and levels of achievement based on Harnett’s model.

With regard to the use of standardised tools to measure parents behaviours at base-line and follow-up stages, we undertook a review of available tools that have been developed to measure behaviours that parents are often asked to change. The tools are therefore issue specific e.g. designed to measure alcohol or drug use, home conditions or parent-child relationships. We reviewed the individual questions of each tool to estimate their usability in social work practice in the UK by considering their clinical utility i.e. acceptability of format, timescale and skills needed for completion and analysis, likelihood of providing clinically useful information and level of ease of use with parents [84]. Thereafter, pragmatically, we included only those tools that are readily available in the public domain and would be unlikely to present local authorities using them with problems of copyright or licensing.

Summary

The package of materials presented in this handbook, as a result of the work described above, is intended to support a coherent approach to the assessment of parental capacity to change. This assessment, we propose, has two essential components, the assessment of factors affecting capacity to change, and the assessment of whether parents can make actual changes in reality. The approach offers a method of assessing factors affecting capacity to change that is based on the Unified Theory of Behaviour [6]. And the assessment of actual change is achieved using goal attainment scaling, and, where appropriate, standardised tools as before and after measures.

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Appendices (contents)

1. Tips and tools relating to Chapter 3 – How to Assess Factors Affecting Capacity to Changea) General Approaches

- Personal Aspirations and Concerns Inventory- URICA- Treatment Motivation Questionnaire- Planning and Conducting Observations

b) Priority and Relevancec) Knowledge and Skills

- Parenting Daily Hasslesd) Motivation and Intention

- Depression, Anxiety and Stress Scale- Adult Well-Being Scale- Guidance on developing Eco-Maps- Family Activity Scale- The Parenting Sense of Competence Scale

e) Habits and Automatic Reactions- Difficulties in Emotional Regulation Scale

f) Contextual Factors- Multidimensional Scale of Perceived Social Support

2. Tips and tools relating to Chapter 4 – Methods of Gathering Evidence of Actual Changea) Goal Attainment Scaling Proformab) Tools to measure behaviour before and after intervention

- Home Conditions Scale- Drug Abuse Screening Test- Alcohol use scales; AUDIT, T-ACE, TWEAK- Child-Parent Relationship Scale- Mother Object Relations Scale

c) Case Study Summaryd) Balance Sheet Proformae) Pictorial Scale proforma

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3. Analysing and Concluding – background materials supporting the analysis and conclusiona) Background Information for the case studyb) Balance sheet (blank version)c) Pictorial Scale (blank version)

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Appendix 1 – How to assess Factors Affecting Change

General Approaches

- Personal Aspirations and Concerns Inventory- URICA- Treatment Motivation Questionnaire- Planning and Conducting Observations

Priority and Relevance


- Parenting Daily Hassles


- Depression, Anxiety and Stress Scale- Adult Well-Being Scale- Guidance on developing Eco-Maps- Family Activity Scale- The Parenting Sense of Competence Scale

Habits and Automatic Reactions

- Difficulties in Emotional Regulation Scale

Contextual Factors

- Multidimensional Scale of Perceived Social Support

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Personal Aspirations and Concerns Inventory

How to use the Personal Aspirations and Concerns Inventory

Introduce the seven different life areas to the parent:

1. Past, current and future living arrangements; 2. Close personal relationships; 3. Physical or mental health issues; 4. Recreation; 5. Self changes and personal improvement (including issues with violence or anger); 6. Employment, training and financial situation; 7. Other.

Prompts or examples may be needed to support the parent(s) in identifying concerns. Below are some descriptors that may be useful. The life areas are not exclusive and concerns will inevitably overlap. It is not important in terms of the use of this method for the concerns to be identified in the ‘correct’ area, rather it is important to understand the current concerns of the parent.

Past, current and future living arrangements e.g. housing size, housing condition, make-up of the household, security of housing (threats of eviction, mortgage / rent payments), neighbourhood, complaints from neighbours / housing association

Close personal relationships e.g. with parents, siblings, partner, children, friends Physical or mental health issues e.g. physical ill health connected to substance

misuse, emotional wellbeing, stress levels, managing mental health conditions Recreation e.g. how do they/ would they like to spend their ‘leisure time’ (goals in

this area could relate to developing alternatives to use of substances, spending constructive time with their children etc)

Self-changes and personal improvement e.g. appearance, self-confidence, personality issues, controlling anger, being kinder

Employment, training and financial situation e.g. keeping / gaining employment, related childcare costs, debt levels, ability to manage finances to maintain household

Ask the parent to identify which areas they have concerns in; concerns can be positive i.e. something the person wants to do, to achieve, to accomplish or negative i.e. something that person wants to avoid, get rid of or prevent.

The discussion about identifying concerns could be conducted in a variety of ways, depending on personal style, the characteristics of the parent and the stage of the work. For example:

A) Free flow e.g. give no direction so the purpose is to ascertain the parent’s perception of the concerns / goals in their life. If parents are not identifying any areas of concern that are similar to those social care hold then this would indicate a lack of

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acceptance of those concerns and would require further exploration. If parents identify concerns not directly related to the child welfare concerns, it may highlight additional areas of need that are influencing the child’s situation or it may suggest that the parents do not share the priorities of Social Care.

B) Boundaried e.g. asking parent to consider each area in relation to the concerns that have been raised with them by Social Care.

C) Directive e.g. making suggestions of the concerns that Social Care hold in each area and asking the parent to respond with their perception of the concern, identify goals in relation to those concerns and then rate their goals.

Identifying goals

Goals can be established based on the identified concerns e.g. if that’s the current situation, how would you like things to be? / what would you like to happen? What you would like to achieve that will help with this worry?

Once goals have been identifed the parents can be asked to rate each goal from 0 – 10 along the rating scales in Box 1. Rating is important as it can identify differences in motivation that are not apparent in verbal responses. It can also provide a measure of progress.

Box 1

Importance: How important is it to me for things to turn out the way I want?

Likelihood: How likely is it that things will turn out the way I want?

Control: How much control do I have in causing things to turn out the way I want?

What to do: Do I know what steps to take to make things turn out the way I want?

Happiness: How much happiness would I get if things turn out the way I want?

Unhappiness: Sometimes we feel unhappy, even if things turn out the way we want. How unhappy would I feel if things turn out the way I want?

Commitment: How committed do I feel to make things turn out the way I want?

When will it happen?: How long will it take for things to turn out the way I want?

0 meaning (none at all) to 10 (the most that I can imagine).

Box 2 suggests two additional questions which can be asked if there is an issue of particular risk within the parents situation e.g. substance use, mental health, domestic violence, non-engagement with services etc.

Box 2

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Will using alcohol or drugs / not managing my mental health / the relationship with my partner / working with Social Care help things to turn out the way I want?

Will using alcohol or drugs / not managing my mental health / the relationship with my partner / working with Social Care interfere with things turning out the way I want?

0 meaning (none at all) to 10 (the most that I can imagine).

The rating given to each goal can be discussed further to understand the thinking behind the number – what is it provides the person with the belief that they know (or don’t know) ‘what to do’, what are the barriers they see in affecting the likelihood or the control they have.

Using the information to consider factors affecting change

The concerns and goals identified by the parent and the discussion held during the process should provide information on several of the factors affecting a person’s capacity for change.

Verbal information from the parent should hopefully provide information on their motivation and intention e.g. needs / expectancies (happiness/unhappiness), problem recognition, self-efficacy (control, likelihood), identity (from discussion, particularly in relation to self-changes). Information shared in living arrangements, personal relationships, recreation and self-changes may provide clues to the external factors acting on the parent and on their identity and social norms.

During the rating process, information should be gained on the priority / relevance of the different concerns for a parent by considering how important or committed they are to the various goals. The rating given to ‘what to do’ should help indicate whether a parent believes they have the necessary knowledge and skills to affect change. Scores of control and likelihood could indicate levels of self-efficacy.

With regard to the relative influence of the different factors in the rating scales; likelihood, happiness and commitment have regularly been shown to be associated with an adaptive motivational profile (and better treatment outcomes). One research study also identified knowledge of what to do as influential [85].

Bringing it back to the child

If the parent(s) are not relating the concerns and goals to their children, such a conversation can be introduced.

Once the concerns / goals have been identified and discussed initially, it may be useful to ask the parent(s) what affect they think their concerns have on their child (or their relationship with their child), and what potential improvement achieving the goals could have for their child (or their relationship with their child).

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Although untested in terms of assessing motivation, useful insights into the child-centredness of a parent’s thinking could be gained by asking them to use the rating scales in relation to their child’s perception of importance, likelihood, control etc.

Alternatively, if the child(ren) are old enough to understand the concepts, the rating scales could be used with them to discuss the concerns / goals identified by their parents. The identification of concerns / goals could also be used with older children though there are already more child-friendly methods of eliciting children’s aspirations and concerns.

Reference

The above information on the PACI is taken from:

Campbell, J., et al. (2010). "Personal Aspirations and Concerns Inventory for Offenders: Developments in the measurement of offenders’ motivation." Criminal Behaviour and Mental Health 20: 144-157.

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University of Rhode Island Change Assessment (URICA)

Accessible via:

http://www.uri.edu/research/cprc/Measures/Smoking04urica.htm

ReferencesMcConnaughy, E.N., Prochaska, J.O., & Velicer, W.F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375.

Treatment Motivation Questionnaire

Accessible via:

www.selfdeterminationtheory.org

Reference

Ryan, R., et al. (1995). "Initial motivations for alcohol treatment: relations with patient characteristics, treatment involvement, and dropout." Addictive Behaviour 20(3): 279-297.

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http://www.selfdeterminationtheory.org/

http://www.uri.edu/research/cprc/Measures/Smoking04urica.htm

Planning and Conducting Observations

Observation tips Choose the following carefully as these will have implications for the utility of the

information gained;o task, o setting o duration of the observations

Ensure that the behaviours identified are common enough to be observed during a brief session or that the session is long enough to see the behaviour of interest.

Observing mildly stressful events can be useful e.g. mealtimes, tidying-up, times when the parent is busy and the child is unoccupied.

Observations can include setting tasks e.g. structured play like completing a jigsaw together, building something specific with lego or free play.

Observations in the home are likely to be more closely representative of the ‘normal’ environment.

Try not to become actively engaged with the parents or children but maintain an ‘attentive presence’

Try not to take notes during the observation; this allows for full engagement with the interactions occurring.

Immediately after the observation, write a detailed record of what has been seen and experienced.

If intending to use the information gained from the observation as part of the measurement of actual change, then the circumstances of both before and after observations need to be similar to allow for realistic comparison e.g. same environment, same task or event.

Depending on individual circumstances, it may be useful to look for the number, regularity, or examples of the following types of behaviour during an observation session:

- Parents responsiveness to non-verbal or verbal ‘seeking’ behaviour from the child

- Child-centred verbalisations e.g. praise, acknowledgements- Child directive verbalisations e.g. commands- Parental engagement in play – commentary, encouragement, silence- Parent’s recognition of child’s internal emotional state by using language of

emotions e.g. tired, bored, happy, excited- Providing supportive assistance when the child is stuck in their play e.g.

following through on what the child was trying to do, not imposing own ideas.

- Promoting child’s autonomy

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- Expressions of warmth, pleasure in child’s company either verbally or physically.

- Parental intrusiveness e.g. interrupting flow of play by attempting to control / dominate, pace not appropriate for child’s level of development

- Criticisms through verbalisations e.g. negating a child’s statement without explanation, imposing adult ideas over child’s enjoyment e.g. if a child is colouring in some grass pink a statement like “grass can’t be pink, it has to be green, colour it green!”

- Criticisms through action e.g. taking some toys for self and playing with them differently – the ‘correct’ way or not allowing the child enough time to finish a task e.g. finishing building a model without child’s permission.

Analysing observations It might be useful to refer to Crittenden’s model of parental information-processing. Crittenden identified four levels of parental response to the needs of children: perception, interpretation, selection of a response, implementation of the response. (Tanner and Turney, 2000). By observing a parent and child together, it may become clear at which stage (if any) the parent is experiencing difficulties in responding to their child’s needs.

Impact of observation on parent and child Being observed can affect a person’s behaviour (reactivity) which can affect the generalizability of the information gathered from observations. However, studies have found that parents in clinical samples were unable to alter their own behaviour during observations (Apsland and Gardner, 2003).

Reactivity can be decreased by reducing how conspicuous the process of observation is, allowing the people being observed to get used to the presence of the observer, those being observed having a clear understanding of why they are being observed and the demands and setting of the observation.

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A) Assessing Knowledge and Skills

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GUIDANCE ON USING PARENTING DAILY HASSLES SCALE

Background

1. This scale aims to assess the frequency and intensity/impact of 20 experiences that can be a ‘hassle’ to parents.

2. It has been used in a wide variety of research concerned with children and families. The research in which it has been used includes a parenting programme with families who had major difficulties in raising young children.

3. Parents/Caregivers enjoy completing the scale, because it touches on aspects of being a parent that are very familiar. It helps them express what it feels like to be a parent.

4. During piloting, social workers reported that it depicted concisely areas of pressure felt by the carer. This helped identify areas where assistance could be provided either by the social services department or other agencies.

5. It is seen by parents as a way for them to express their needs for help with parenting.

The Scale

6. The caregiver is asked to score each of the 20 potential Hassles in two different ways for frequency and intensity.

7. The frequency of each type of happening provides an ‘objective’ marker of how often it occurs.

8. The intensity or impact score indicates the caregiver’s ‘subjective’ appraisal of how much those events affect or ‘hassle’ them.

9. The time frame for this scale can be varied according to the focus of the assessment. For example, if a family is thought to have been under particular pressure in the last 2 months the parent can be asked to consider how matters have been during that period. However, if it is intended to assess progress, the same time frame should be used on each occasion. Periods of less than one month are probably too short to give a useful picture.

Use

10. The caregiver should understand the aim of filling out the questionnaire, and how it will contribute to the overall assessment.

11. The scale is probably most useful with families that are not well-known. In piloting it was found to highlight areas for future discussion, and help prioritise which parenting issues should be addressed first.

12. It can also be used to monitor change.

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Administration

13. It should be given to the parent/caregiver to fill out themselves.

14. It can be read out if necessary.

15. It takes about 10 minutes to complete.

16. The scale should always be used as a basis for discussion. In general this is best kept until the parent has finished, but there will be occasions when it is vital to acknowledge, or immediately follow up comments made while it is being filled out.

Scoring

17. The scale can be used in two distinct ways: (a) the totals of the frequency and intensity scales can be obtained, or (b) scores for challenging behaviour and parenting tasks can be derived from the intensity scale.

18. To obtain frequency and intensity total scores

(a) The frequency scale is scored: rarely = 1, sometimes = 2, a lot = 3, and constantly = 4. If the parent says that an event never occurs, never = 0.

Scoring

19. (a) The challenging behaviour total score is obtained by adding the intensity scale scores for items: 2, 4, 8, 9, 11, 12, 16. Range: 0–35.

(b) The parenting tasks total score is obtained by adding the intensity scale scores for items: 1, 6, 7, 10, 13,14, 17, 20. Range: 0–40.

20. There is no cut off for any of the scales but total scores above 50 on the frequency scale or above 70 on the intensity scale indicate on the one hand a high frequency of potentially hassling happenings, and on the other that the parent is experiencing significant pressure over parenting.

21. Events occurring with frequency 3 or 4, or intensity 4 or 5, particularly those where the parent rates high intensity or impact, should be discussed to clarify the extent of need.

22. The total score on the challenging behaviour and parenting tasks scales may be useful in indicating how the parent/caregiver sees the situation, whether difficulties lie in the troublesome behaviour of the children, or the burden of meeting the ‘expected’ or ‘legitimate’ needs of the children. The subscores may also be useful in monitoring change.

Reference Reproduced from Cox and Bentovim, 2000, The Family Assessment Pack of Questionnaires and Scales, The Stationery Office, London

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B) Assessing Motivation and Intention

Depression, Anxiety and Stress Scale

DAS S 21 Name: Date:

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time

2 Applied to me to a considerable degree, or a good part of time

3 Applied to me very much, or most of the time

1 I found it hard to wind down 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn't seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (eg, excessively rapid breathing,breathlessness in the absence of physical exertion)

0 1 2 3

5 I found it difficult to work up the initiative to do things 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I experienced trembling (eg, in the hands) 0 1 2 3

8 I felt that I was using a lot of nervous energy 0 1 2 3

9 I was worried about situations in which I might panic and makea fool of myself

0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting agitated 0 1 2 3

12 I found it difficult to relax 0 1 2 3

13 I felt down-hearted and blue 0 1 2 3

14 I was intolerant of anything that kept me from getting on withwhat I was doing

0 1 2 3

15 I felt I was close to panic 0 1 2 3

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16 I was unable to become enthusiastic about anything 0 1 2 3

17 I felt I wasn't worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat)

0 1 2 3

20 I felt scared without any good reason 0 1 2 3

21 I felt that life was meaningless 0 1 2 3

Scoring the DASS

Sum scores overall and also in the following subscales:

Stress: 1, 6, 8, 11, 12, 14, 18

Anxiety: 2, 4, 7, 9, 15, 19, 20

Depression: 3, 5, 10, 13, 16, 17, 21

A score of 60 overall is the clinical cut off.

Reference

Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney: Psychology Foundation

The DASS is in the public domain and can be downloaded from http://www2.psy.unsw.edu.au/groups/dass/

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Adult Well-Being Scale

This form has been designed so that you can show how you have been feeling in the past few days.

Read each item in turn and UNDERLINE the response which shows best how you are feeling or have been

feeling in the last few days.

Please complete all of the questionnaire.

1. I feel cheerful

Yes, definitely Yes, sometimes No, not much No, not at all

2. I can sit down and relax quite easily


3. My appetite is

Very poor Fairly poor Quite good Very good

4. I lose my temper and shout and snap at others


5. I can laugh and feel amused


6. I feel I might lose control and hit or hurt someone

Sometimes Occasionally Rarely Never

7. I have an uncomfortable feeling like butterflies in the stomach

Yes, definitely Yes, sometimes Not very often Not at all

8. The thought of hurting myself occurs to me

Sometimes Not very often Hardly ever Not at all

9. I’m awake before I need to get up

For 2 hours For about 1 hour For less than 1 hour Not at all. I sleep

until it is time to get up

10. I feel tense or ‘wound up’


11. I feel like harming myself


12. I’ve kept up my old interests

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Yes, most of them Yes, some of them No, not many of them No, none of them

13. I am patient with other people

All the time Most of the time Some of the time Hardly ever

14. I get scared or panicky for no very good reason


15. I get angry with myself or call myself names

Yes, definitely Yes, sometimes Not often No, not at all

16. People upset me so that I feel like slamming doors or banging about

Yes, often Yes, sometimes Only occasionally Not at all

17. I can go out on my own without feeling anxious

Yes, always Yes, sometimes No, not often No, I never can

18. Lately I have been getting annoyed with myself

Very much so Rather a lot Not much Not at all

SCORING THE ADULT WELLBEING SCALE

The possible response scores that are shown below run from the left to the right – i.e. for question 1 ‘I feel cheerful’, the scores would be looked at from ‘yes, definitely’ (0), ‘yes, sometimes’ (1), ‘no, not at all’ (3).

1. Depression – Questions 1,3,5,9 and 12 look at depression. A score of 4–6 is borderline in this scale and a score above this may indicate a problem.

QU1: 0,1,2,3 QU3: 3,2,1,0 QU5: 0,1,2,3 QU9: 3,2,1,0 QU12: 0,1,2,3

2. Anxiety – Questions 2,7,10,14 and 17 look at anxiety. A score of 6–8 is borderline, above this level may indicate a problem in this area.

QU2: 0,1,2,3 QU7: 3,2,1,0 QU10: 3,2,1,0 QU14: 3,2,1,0 QU17: 0,1,2,3

3. Outward directed irritability – Questions 4,6,13 and 16 look at outward directed irritability. A score of 5–7 is borderline for this scale, and a score above this may indicate a problem in this area.

QU4: 3,2,1,0 QU6: 3,2,1,0 QU13: 0,1,2,3 QU16: 3,2,1,0

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4. Inward directed irritability – Questions 8,11,15 and 18 look at inward directed irritability. A score of 4–6 is borderline, a higher score may indicate a problem.

QU8: 3,2,1,0 QU11: 3,2,1,0 QU15: 3,2,1,0 QU18: 3,2,1,0

Use of cut-off scores gives indicators of significant care needs with respect to depression, anxiety, and inwardly and outwardly directed irritability. Inward irritability can point to the possibility of selfharm. Outward irritability raises the possibility of angry actions towards the child(ren).

As with any screening instrument, interpretation must be in the context of other information. Some respondents will underreport distress, others exaggerate it. A high or low score on any scale does not guarantee that a significant level of need is present.

Most value is obtained by using the scale as a springboard for discussion.

Reference Snaith RP, Constantopoulos AA, Jardine MY & McGuffin P (1978) A clinical scale for the self-assessment of irritability. British Journal of Psychiatry. 132: 163–71.

Reproduced from Cox and Bentovim, 2000, The Family Assessment Pack of Questionnaires and Scales, The Stationery Office, London

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Guidance on developing eco-maps

An Eco-map is a diagram of a person’s important relationships with people, groups and organisations. By using different symbols the relationships can be shown as sources of support or stress and can be useful to consider which people or groups are likely to facilitate or hinder change.

General practice is to use the following types of symbols in Eco-Maps:

Female =

Male =

Supportive or positive relationship =

Neutral relationship =

Stressful relationship =

Tenuous relationship =

Direction of energy / resources =

Compiling Eco-Maps should be a collaborative process with parents, aimed at understanding who is significant in their network. The people placed in the Eco-Map should therefore be the parent’s decision but practitioners can add to the process by asking questions to elicit important people or groups who may have been forgotten e.g.

Who would you call for help if you were ill and the children needed to get to school?

Who would you send a birthday or Christmas card / email / text to? Who do you speak to regularly over text / on the phone / on Facebook? Who asks you for help? Who do you give help to? Who would you speak to if you were feeling sad / stressed? Are there any groups you go to regularly e.g. more than once a month? Are there any organisations involved in your life e.g. employer, Social Care, GP

There is an excellent and interactive example of the information to be gained from Eco-Maps available at: http://routledgesw.com/sanchez/engage/mappingTheCase

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Family Activity Scale

SCALE FOR CHILDREN AGED 2 TO 6

Could you let me know the sort of things you do as a family, or with your child/children both regularly and in the last year. Below are some examples of activities you may have done.

If you have done any of these activities within the timescale written in bold, please tick in the box provided. You may also like to mention other activities you have done. You ca do this by filling in the lines at the end of this sheet.

Activity If YES, please tick

Have you read a story to your child in the last week?

Has your child eaten with you and other family members at least once in the last week?

Did you do anything special for your child on their last birthday, such as a cake, party, trip to the park etc.?

Have you gone with your child/family to the park, playground, farm or similar in the last month?

Have you gone with your child/family to a local event, such as county show, fete, in the last 6 months?

Have you ever belonged to a mother/toddler baby group of any kind for at least 3 months?

Have you and your child/family visited friends who have young children in the last month?

Has the family been away for the day out to somewhere different in the last 6 months (town/into town/to the seaside/day trip)?

Has your child had a friend to visit in the last 6 months?

Has your child been to visit relatives or friends as a treat for her/him in the last 6 months?

Are there any other things you have done as a family/with your child in the last:

Week:

Month:

Last 6 months:

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SCALE FOR CHILDREN AGED 7 TO 12

Could you let me know the sort of things you do as a family, or with your child/children both regularly and in the last year. Some examples of the kind of activities you may have done are listed below.

If you have done any of these activities within the time-scale written in bold, please tick in the box provided.

You may also like to mention other activities you have done in the space provided at the bottom of the page.

Activity If YES ,please tick

Had a friend of your child to visit – in the last month?

Had a birthday celebration (i.e. party/cake)?

Been to the cinema/museum/zoo/panto/local event – in the last 3 months?

Been swimming/skating/other (participant) sport – in the last 3 months?

Been away on holiday with the family/to the seaside – in the past year?

Been to the park/for a picnic/local farm – in the last 3 months?

Has – or had – any pets in the past year?

Attended any special classes/clubs i.e. football, dance – in the last 3 months?

Been to stay with relatives or friends (without parents) – in the last year?

Visited own friends (i.e. for a meal/for the day) – in the last 3 months?

Belongs to a children’s library?

Are there any other things you have done as a family/with your child in the last:

Week:

Month:

Six months:

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(Reproduced from Cox and Bentovim, 2000, The Family Assessment Pack of Questionnaires and Scales, The Stationery Office, London)

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The Parenting Sense of Competence Scale

INSTRUCTIONS:

Listed below are a number of statements. Please respond to each item, indicating your agreement or disagreement with each statement in the following manner:

If you strongly agree, circle the letters SA

If you agree, circle the letter A

If you mildly agree, circle the letters MA

If you mildly disagree, circle the letters MD

If you disagree, circle the letter D

If you strongly disagree, circle the letters SD

1. The problems of taking care of a baby/child are easy to solve once you know how your actions affect your baby/child, an understanding I have acquired

SA A MA MD D SD

2. Even though being a parent could be rewarding I am frustrated now whilst my child is at his / her present age

SA A MA MD D SD

3. I go to bed the same way I wake up in the morning – feeling I have not accomplished a whole lot

SA A MA MD D SD

4. I do not know what it is, but sometimes when I’m supposed to be in control, I feel more like the one being manipulated

SA A MA MD D SD

5. My mother / father was better prepared to be a good mother / father than I am

SA A MA MD D SD

6. I would make a fine model for a new mother / father to follow in order to learn what she would need to know in order to be a good parent

SA A MA MD D SD

7. Being a parent is manageable and any problems are easily solved

SA A MA MD D SD

8. A difficult problem in being a parent is not knowing whether you are doing a good job or a bad one

SA A MA MD D SD

9. Sometimes I feel like I am not getting anything done

SA A MA MD D SD

10. I meet my own personal expectations for expertise in caring for my baby / child

SA A MA MD D SD

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11. If anyone can find the answer to what is troubling my baby/child, I am the one

SA A MA MD D SD

12. My talents and interests are in other areas, not in being a parent

SA A MA MD D SD

13. Considering how long I’ve been a mother, I feel thoroughly familiar with this role

SA A MA MD D SD

14. If being a mother or father of an infant/a child were only more interesting, I would be motivated to do a better job as a parent

SA A MA MD D SD

15. I honestly believe I have all the skills necessary to be a good mother / father to my baby / child

SA A MA MD D SD

16. Being a parent makes me tense and anxious

SA A MA MD D SD

17. Being a good mother / father is a reward in itself

SA A MA MD D SD

Scoring

Items are scored on a 6 point scale from 1 (strongly agree) to 6 (strongly disagree). The total is the sum of all 17 items.

Subscale scores are available for parental satisfaction and parental self-efficacy (all scores need to be reverse coded for this scale e.g. 1 (strongly disagree) to 6 (strongly agree).

Parental satisfaction scale: 2, 3, 4, 5, 8, 9, 12, 14, 16, 17

Parental Efficacy Scale: 1, 6, 7, 10, 11, 13, 15

Reference

Gibaud-Wallston, J, 1978, Self-Esteem and Situational Stress: Factors related to sense of competence in new parents. Dissertation Abstracts International, 39 (1-B)

Reproduced with kind permission from Ken Wallston.

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C) Habits and Automatic Responses

Difficulties in Emotional Regulation Scale

Name Date

Please indicate how often the following 36 statements apply to you by writing the appropriate number from the scale below (1 – 5) alongside each item.

1= almost never (0-10% of the time)

2= sometimes (11-35%)

3 = about half the time (36-65%)

4 = most of the time (66-90%)

5 = almost always (91-100%)

Scale:

1. I am clear about my feelings.

2. I pay attention to how I feel.

3. I experience my emotions as overwhelming and out of control.

4. I have no idea how I am feeling.

5. I have difficulty making sense out of my feelings.

6. I am attentive to my feelings.

7. I know exactly how I am feeling.

8. I care about what I am feeling.

9. I am confused about how I feel.

10. When I’m upset, I acknowledge my emotions.

11. When I’m upset, I become angry with myself for feeling that way.

12. When I’m upset, I become embarrassed for feeling that way.

13. When I’m upset, I have difficulty getting work done.

14. When I’m upset, I become out of control.

15. When I'm upset, I believe that I will remain that way for a long time.

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16. When I'm upset, I believe that I'll end up feeling very depressed.

17. When I'm upset, I believe that my feelings are valid and important.

18. When I'm upset, I have difficulty focusing on other things.

19. When I'm upset, I feel out of control..

20. When I'm upset, I can still get things done.

21. When I'm upset, I feel ashamed with myself for feeling that way.

22. When I'm upset, I know that I can find a way to eventually feel better.

23. When I'm upset, I feel like I am weak.

24. When I'm upset, I feel like I can remain in control of my behaviours.

25. When I'm upset, I feel guilty for feeling that way.

26. When I'm upset, I have difficulty concentrating.

27. When I'm upset, I have difficulty controlling my behaviours.

28. When I'm upset, I believe there is nothing I can do to make myself feel better.

29. When I'm upset, I become irritated with myself for feeling that way.

30. When I'm upset, I start to feel very bad about myself.

31. When I'm upset, I believe that wallowing in it is all I can do.

32. When I'm upset, I lose control over my behaviours.

33. When I'm upset, I have difficulty thinking about anything else.

34. When I'm upset, I take time to figure out what I'm really feeling.

35. When I'm upset, it takes me a long time to feel better.

36. When I'm upset, my emotions feel overwhelming.

Scoring

The DERS is a brief, 36-item self-report questionnaire designed to assess multiple aspects of emotional dysregulation.

Reverse-scored items are numbered 1, 2, 6, 7, 8, 10, 17, 20, 22, 24 and 34.

Higher scores suggest greater problems with emotion regulation. The suggested norm is 78 for females and 80 for males.

The measure also yields scores on six sub-scales:

Difficulties engaging in goal directed behaviour (GOALS ) Impulse control difficulties (IMPULSE)

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Lack of emotional awareness (AWARE) Limited access to emotion regulation strategies (STRATEGIES) Lack of emotional clarity (CLARITY)

Nonacceptance of Emotional Responses (NONACCEPT)

25) When I’m upset, I feel guilty for feeling that way

21) When I’m upset, I feel ashamed with myself for feeling that way

12) When I’m upset, I become embarrassed for feeling that way

11) When I’m upset, I become angry with myself for feeling that way

29) When I’m upset, I become irritated with myself for feeling that way

23) When I’m upset, I feel like I am weak

Norms: 12 for both sexes

Difficulties Engaging in Goal-Directed (GOALS)

26) When I’m upset, I have difficulty concentrating

18) When I’m upset, I have difficulty focusing on other things

13) When I’m upset, I have difficulty getting work done

33) When I’m upset, I have difficulty thinking about anything else

20) When I’m upset, I can still get things done (R)


Impulse Control Difficulties (IMPULSE)

32) When I’m upset, I lose control over my behaviours

27) When I’m upset, I have difficulty controlling my behaviours

14) When I’m upset, I become out of control

19) When I’m upset, I feel out of control

3) I experience my emotions as overwhelming and out of control

24) When I’m upset, I feel like I can remain in control of my behaviours (R)

Norms: 11 females, 12 males

Lack of Emotional Awareness (AWARE)

6) I am attentive to my feelings (R)

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2) I pay attention to how I feel (R)

10) When I’m upset, I acknowledge my emotions (R)

17) When I’m upset, I believe that my feelings are valid and important (R)

8) I care about what I am feeling (R)

34) When I’m upset, I take time to figure out what I’m really feeling (R)

Norms: 14 females, 16 males

Limited Access to Emotion Regulation Strategies (STRATEGIES)

16) When I’m upset, I believe that I’ll end up feeling very depressed

15) When I’m upset, I believe that I will remain that way for a long time

31) When I’m upset, I believe that wallowing in it is all I can do

35) When I’m upset, it takes me a long time to feel better

28) When I’m upset, I believe that there is nothing I can do to make myself feel better

22) When I’m upset, I know that I can find a way to eventually feel better (R)

36) When I’m upset, my emotions feel overwhelming

30) When I’m upset, I start to feel very bad about myself


Lack of Emotional Clarity (CLARITY)

5) I have difficulty making sense out of my feelings

4) I have no idea how I am feeling

9) I am confused about how I feel

7) I know exactly how I am feeling (R)

1) I am clear about my feelings (R)


Reference

Gratz & Roemer, 2004, Multidimensional Assessment of Emotion Regulation and Dysregulation: Development, Factor Structure and Initial Validation of the Difficulties in Emotion Regulation Scale, Journal of Psychopathology and Behavioral Assessment, Vol. 26, No. 1

Reproduced with kind permission of Kim Gratz.

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D)Contextual Factors

Multidimensional Scale of Perceived Social Support

Instructions: We are interested in how you feel about the following statements. Read each statement carefully. Indicate how you feel about each statement.

Circle the “1” if you Very Strongly Disagree

Circle the “2” if you Strongly Disagree

Circle the “3” if you Mildly Disagree

Circle the “4” if you are Neutral

Circle the “5” if you Mildly Agree

Circle the “6” if you Strongly Agree

Circle the “7” if you Very Strongly Agree

1. There is a special person who is around when I am in need.

1 2 3 4 5 6 7 SO

2. There is a special person with whom I can share my joys and sorrows.

1 2 3 4 5 6 7 SO

3. My family really tries to help me. 1 2 3 4 5 6 7 Fam

4. I get the emotional help and support I need from my family.

1 2 3 4 5 6 7 Fam

5. I have a special person who is a real source of comfort to me.

1 2 3 4 5 6 7 SO

6. My friends really try to help me. 1 2 3 4 5 6 7 Fri

7. I can count on my friends when things go wrong.

1 2 3 4 5 6 7 Fri

8. I can talk about my problems with my family.

1 2 3 4 5 6 7 Fam

9. I have friends with whom I can share my joys and sorrows.

1 2 3 4 5 6 7 Fri

10. There is a special person in my life who cares about my feelings.

1 2 3 4 5 6 7 SO

11. My family is willing to help me make decisions.

1 2 3 4 5 6 7 Fam

12. I can talk about my problems with my 1 2 3 4 5 6 7 Fri

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friends.

Consider the responses in groups relating to the source of the social support, namely family (Fam), friends (Fri) or significant other (SO).

To calculate mean scores:

Significant Other Subscale: Sum across items 1, 2, 5, & 10, then divide by 4.

Family Subscale: Sum across items 3, 4, 8, & 11, then divide by 4.

Friends Subscale: Sum across items 6, 7, 9, & 12, then divide by 4.

Total Scale: Sum across all 12 items, then divide by 12.

Any mean scale score ranging from 1 to 2.9 could be considered low support; a score of 3 to 5 could be considered moderate support; a score from 5.1 to 7 could be considered high support. However there are no established population norms for this tool so it may be better used as the basis of a discussion about how the person perceives the social support they have available to them, and how this could be enhanced if necessary.

More information at:

http://gzimet.wix.com/mspss

Reference

Zimet, Dahlem, Zimet and Farley, 1988, The Multidimensional Scale of Perceived Social Support, Journal of Personality Assessment, 52, 30-41

Reproduced with kind permission of Dr. G Zimet.

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http://gzimet.wix.com/mspss

Appendix 2 - Gathering Evidence of Actual Change

Goal Attainment Scaling Proforma

Tools to measure behaviour before and after intervention:

Home Conditions Scale Drug Abuse Screening Test Alcohol use scales; AUDIT, T-ACE, TWEAK Child-Parent Relationship Scale Mother Object Relations Scale

97

Date: ……………………………………………………………………..

Goal: …………………………………………………………………………………………………………………………………………………………..Importance for children …………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

PLEASE NOTE ANY AREAS OF DISAGREEMENT WITH PARENTS:

98

Goal Attainment Scaling Chart

Home Conditions Scale

Instructions:

Record on the basis of what is observed. Why the conditions are as they are is not taken into account. The worker needs to understand why matters are as they are to take appropriate action but that is not part of this scale. The scale charts the child environment as it is.

Score 0 if the condition is not present, 1 if it is present.

1. Smell (e.g. stale cigarette smoke, rotting food) 01

2. Kitchen floor soiled, covered in bits, crumbs etc. 01

3. Floor covering in any other room soiled as above. 01

4. General decorative order poor – obviously in need of attention (e.g. badly

stained wallpaper, broken windows) 01

5. Kitchen sink, draining board, work surfaces or cupboard door have not been

washed for a considerable period of time 01

6. Other surfaces in the house have not been dusted for a considerable period of time 01

7. Cooking implements, cutlery or crockery showing ingrained dirt and or

these items remain unwashed until they are needed again. 01

8. Lavatory, bath or basin showing ingrained dirt. 01

9. Furnishings or furniture soiled 01

10. Informant’s or children’s, clothing clearly unwashed, or hair matted

and unbrushed 0 1

11. Garden or yard uncared for and strewn with rubbish 0 1

Scoring:

The scale has no cut off. Depending on the age of the children different items may give more or less concern, but in general the higher the score the greater the concern.

Reference:

Reproduced from Cox and Bentovim, 2000, The Family Assessment Pack of Questionnaires and Scales, The Stationery Office, London

99

Drug Abuse Screening Test

Available from

http://www.projectcork.org/clinical_tools

Instructions: Circle either yes or no to the right of the question to indicate your answer.

1. Have you used drugs other than those required for medical reasons? Yes No2. Have you abused prescription drugs? Yes No3. Do you abuse more than one drug at a time? Yes No4. Can you get through the week without using drugs (other than those Yes Norequired for medical reasons)?5. Are you always able to stop using drugs when you want to? Yes No6. Do you abuse drugs on a continuous basis? Yes No7. Do you try to limit your drug use to certain situations? Yes No8. Have you had "blackouts" or "flashbacks" as a result of drug use? Yes No9. Do you ever feel bad about your drug abuse? Yes No10. Does your spouse (or parents) ever complain about your Yes Noinvolvement with drugs?11. Do your friends or relatives know or suspect you abuse drugs? Yes No12. Has drug abuse ever created problems between you and your spouse? Yes No13. Has any family member ever sought help for problems related to your Yes Nodrug use?14. Have you ever lost friends because of your use of drugs? Yes No15. Have you ever neglected your family or missed work because of Yes Noyour use of drugs?16. Have you ever been in trouble at work because of drug abuse? Yes No17. Have you ever lost a job because of drug abuse? Yes No18. Have you gotten into fights when under the influence of drugs? Yes No19. Have you ever been arrested because of unusual behavior while Yes Nounder the influence of drugs?20. Have you ever been arrested for driving while under the influence Yes Noof drugs?21. Have you engaged in illegal activities to obtain drugs? Yes No22. Have you ever been arrested for possession of illegal drugs? Yes No23. Have you ever experienced withdrawal symptoms as a result of Yes Noheavy drug intake?24. Have you had medical problems as a result of your drug use Yes No(e.g., memory loss, hepatitis, convulsions, or bleeding)?25. Have you ever gone to anyone for help for a drug problem? Yes No26. Have you ever been in hospital for medical problems related to Yes Noyour drug use?27. Have you ever been involved in a treatment program specifically Yes Norelated to drug use?28. Have you been treated as an outpatient for problems related to drug abuse? Yes No

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Scoring:

Yes = 1 point except for questions 4 and 5 where No = 1 point.6 or more = substance use problem (abuse or dependence)

Reference

Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7(4),363–371.

Used with permission, copyright 1982 Centre for Addiction and Mental Health

101

AUDIT

Instructions: Place a checkmark on the response that is most applicable:

How often do you have a drink containing alcohol?

Never 0

Monthly or less 1

2 - 4 times a month 2

2 - 3 times a week 3

4 or more times a week 4

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 drinks 0

3 or 4 drinks 1

5 or 6 drinks 2

7 or 9 drinks 3

10 or more 4

3. How often do you have six or more drinks on one occasion?

Never 0

Monthly or less 1

2 - 4 times a month 2

2 - 3 times a week 3

4 or more times a week 4

Scoring:

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The number following each response is the number of points. Answers for each question range from 0 to 4.

There are a total of 12 possible points.

The cut-off score for hazardous alcohol use for men is 4 or more; for women, 3 or more

The AUDIT can also be downloaded from


Reference

Babor et al, 2001, AUDIT; The Alcohol Use Disorders Idenitification Test, WHO

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T-ACE (Designed for use with pregnant woman)

Name_______

Date_______

Score_______

Yes No

1. Does it take more than it used to for you to get high? [Tolerance] 2 -

2.Have you become Angry or Annoyed when others express concern about your use?

1 -

3. Have you tried to Cut down or quit? 1 -

4. Have you had an Eye opener? 1 -

Scoring:

Three or more points or more indicates high-risk alcohol use

Also available from:


References

SOKOL, R. J. ; MARTIER, S. S. ; AND AGER, J. W. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 160: 863 871, 1989.

Chiodo, L M, Delaney-Black, V, Sokol, R J, Janisse J, Pardo Y, and Hannigan J H, 2014, Increased cut-point of the TACER-3 screen reduces false positives without losing sensitivity in predicting risk alcohol drinking in pregnancy, Alcoholism: Clinical and Experimental Research 38 (5) 1401-1408

Reproduced with kind permission from Dr R J Sokol.

TWEAK

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TWEAKHOLD: Version recommended for populations with high levels of binge drinking.

To determine whether to administer the TWEAK, ask: Do you sometimes drink alcohol beverages, that is, beer, wine, or liquor?

Yes (Continue)

No (End TWEAK, or ask about drinking in the past)

1. How many drinks can you hold?[1]

Record number of drinks______.

If 6 or more, circle 2 at right………………………………………………………………………………………..2

Don’t know =>If alcohol never made client sick, pass out, or fall asleep, ask:

What’s the largest number of drinks you have?

Record largest number of drinks______.

If 6 or more, circle 2 at right............................................................................................2

2. Have close friends or relatives Worried or complained about your drinking in the past year?

If yes, circle 2 at right......................................................................................................2

3. Do you sometimes take a drink in the morning when you first get up? (Eyeopener)

If yes, circle 1 at right.....................................................................................................1

4. Are there times when you drink and afterwards you can’t remember what you said or did? (Amnesia or blackouts)


5. Do you sometimes feel the need to Kut down on your drinking?


___________________________________________________________________________

105

Add numbers that were circled........................................................................Total_______

[1]How many drinks can you hold before the alcohol makes you sick, pass out, or fall asleep? A drink is a 12 oz. beer, a 5 oz. glass of wine, or a drink containing 1 1/2 oz. liquor.

TWEAKHIGH: Version recommended for populations with low levels of binge drinking.

To determine whether to administer the TWEAK, ask:

Do you sometimes drink alcohol beverages, that is, beer, wine, or liquor?

Yes (Continue)

No (End TWEAK, or ask about drinking in the past)

Tolerance

1. How many drinks[1] does it take before you begin to feel the first effects of the alcohol?

Record number of drinks______.

If 3 or more, circle 2 at right........................................................................................2

2. Have close friends or relatives Worried or complained about your drinking in the past year?


3. Do you sometimes take a drink in the morning when you first get up? (Eyeopener)


4. Are there times when you drink and afterwards you can’t remember what you said or did? (Amnesia or blackouts)


5. Do you sometimes feel the need to Kut down on your drinking?


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______________________________________________________________________

Add numbers that were circled..................................................................Total_______

[1] A drink is a 12oz beer, a 5oz glass of wine, or a drink containing 1 1/2 oz of liquor.

Scoring:

To score the test, a sevenpoint scale is used.

The Tolerance and Worry questions each contribute two points, and the other three items contribute one point each.

The Tolerancehigh question scores two points if it is reported that three or more drinks are needed to feel high. The Tolerancehold question scores two points if a respondent reports being able to hold six or more drinks.

When screening for alcohol abuse or dependence a cutpoint of 3 or more appears to optimize the balance between sensitivity and specificity among males, whereas a cutpoint of 2 is needed to achieve comparable sensitivity levels among women (Cherpitel, 1995) and adolescents (Chung et al., 2000).

Also available from:


Reference:

Russell, M. (1994). New assessment tools for drinking in pregnancy: TACE, TWEAK, and others. Alcohol Health and Research World, 18(1): 5561.

Both versions of the TWEAK and the scoring information are reproduced with kind permission from Dr Marcia Russell.

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CHILD-PARENT RELATIONSHIP SCALE

Child:____________________________________ Age:__________ Parent:_____________________________________

Please reflect on the degree to which each of the following statements currently applies to your relationship with your child. Using the scale below, circle the appropriate number for each item.

Definitely does not apply

1

Not

really

2

Neutral,

not sure

3

Applies somewhat

4

Definitely applies

5

1. I share an affectionate, warm relationship with my child. 1 2 3 4 5

2. My child and I always seem to be struggling with each other. 1 2 3 4 5

3. If upset, my child will seek comfort from me. 1 2 3 4 5

4. My child is uncomfortable with physical affection or touch from me. 1 2 3 4 5

5. My child values his/her relationship with me. 1 2 3 4 5

6. When I praise my child, he/she beams with pride. 1 2 3 4 5

7. My child spontaneously shares information about himself/herself. 1 2 3 4 5

8. My child easily becomes angry at me. 1 2 3 4 5

9. It is easy to be in tune with what my child is feeling. 1 2 3 4 5

10. My child remains angry or is resistant after being disciplined. 1 2 3 4 5

11. Dealing with my child drains my energy. 1 2 3 4 5

12. When my child is in a bad mood, I know we're in for a long and difficult day. 1 2 3 4 5

13. My child's feelings toward me can be unpredictable or can change suddenly. 1 2 3 4 5

14. My child is sneaky or manipulative with me. 1 2 3 4 5

15. My child openly shares his/her feelings and experiences with me. 1 2 3 4 5

©1992 Pianta, University of Virginia.

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Scoring:

Sum the items as per the following subscales:

Conflicts: 2, 4, 8, 10, 11, 12, 13, 14

Closeness: 1, 3, 5, 6, 7, 9, 15

Reference:

Reproduced with kind permission of Dr Robert Pianta.

Pianta, R. (1992). "Child-Parent Relationship Scale." Retrieved December, 2014.

109

Mother-Object Relations Scale

Please underline one of the choices for each of the questions below. There are no ‘right’ or ‘wrong’ answers; many of these are true of all babies at times.

1. My baby smiles at me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

2. My baby annoys me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

3. My baby likes doing things with me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

4. My baby ‘talks’ to me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

5. My baby irritates me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

6. My baby likes me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

7. My baby wants too much attention - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely

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0 Never8. My baby laughs - 5 Always

4 Very often3 Quite often2 Sometimes1 Rarely0 Never

9 My baby gets moody - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

10. My baby dominates me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

11. My baby likes to please me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

12. My baby cries for no obvious reason - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

13. My baby is affectionate towards me - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

14. My baby winds me up - 5 Always4 Very often3 Quite often2 Sometimes1 Rarely0 Never

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Scoring:

Warmth items Score Invasion items Score1. smiles at me

3. likes doing things with me

4. 'talks' to me

6. likes me

8. laughs

11. likes to please me

13. is affectionate towards me

2. annoys me

5. irritates me

7. wants too much attention

9. gets moody

10. dominates me

12. cries for no obvious reason

14. winds me upWarmth total Invasion total

Mean scores from the original data sets were 29 for Warmth and 11 for Invasion based on a sample of ‘normal’ mothers. Scores that are significantly higher than these means may indicate some dysfunction in the mother-infant relationship and require further observation and assessment.

Reproduced with kind permission of John Oates.

Reference

Oates JM, Gervai J: Mothers’ Object Relational Scales. Poster presented at the XIth European Conference on Developmental Psychology. Milan, Italy: 2003.

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Appendix 3 – Analysing and Concluding

Background Information for the case study

Balance sheet

Pictorial Scale

Background information for the Case StudyFamily members Penny – Mother and wife

Rob – Father and Husband

Jon – son, aged 9

Steph – daughter, aged 3

Ella – daughter, aged 10mths

Key concerns Previous physical violence from Rob to Penny. Police were regularly called and it was this issue that originally triggered the current referral to Social Care. Their relationship improved after attending a Domestic Abuse service but lower level concerns remain around issues of control and possible financial abuse perpetrated by Rob over Penny.

Incidents of physical violence almost always occurred when either or both Rob and Penny had been drinking heavily. Although the actual physical violence is no longer being reported, volatile arguments remain common when the parents have been drinking. Penny and Rob seem to drink to incapacitation e.g. incoherent, not able to function, cannot be roused in the morning, at least once a week though there have been periods of up to 3 weeks with no alcohol use.

Penny’s mother and siblings live locally but after Rob had an extra-marital affair last year, Penny’s extended family actively dislike him and are stating that Penny’s excessive alcohol use is Rob’s fault. They have taken the stance of withdrawing babysitting support in the evenings/ overnight in an attempt to ‘force’ Penny to stop drinking and to end the relationship. However, the actual effect has been that Penny and Rob have continued to binge drink while the two youngest children are in their care and so they are now experiencing harmful neglect whereas before they were protected from the direct impact of their parents’ drinking. The maternal grandmother will take care of the youngest two children in crisis situations e.g. when the police are called and decide that Penny and Rob are incapable of providing adequate care. The oldest child chooses to split his time and residence between parents and local uncle so is often not present when his parents drink.

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There has been longstanding social care involvement at various levels since the oldest child was born because of alcohol / substance misuse.

Rob and Penny’s engagement with substance misuse services is patchy. Rob was engaging well and attending group sessions. He ‘finished’ the treatment group and began attending a recovery support group but this folded due to staff shortages. Penny attended a preparatory group about 5 years ago but did not move on to the ‘treatment’ group. She is currently offered key work sessions but there are significant practical barriers to her attending these.

Strengths When not drinking, parenting is ‘good enough’. Children present as attached to Penny and comfortable in Rob’s presence. Local family provide a safe haven for children during drinking crises.

Has been some change over time i.e. reduction in regularity of binges, parents no longer using substances other than alcohol.

Jon able to express his emotions to parents and extended family.

Penny perceived by professionals as responsive and willing but struggles to act. Rob seen as ambivalent.

Actual harm to children Jon has been open about his experiences of being in his parents care when they have been drinking. He describes being left to fend for himself and having to be responsive to the needs of his younger sisters. On waking up in the morning after his parents have been drinking there is rarely any food that he can prepare to eat for himself or his sisters and neither is there any money to buy any. In these situations Jon does not call his grandmother or uncle as he does not wish to make the relationship between his parents and his Mum’s family worse as he is frightened he will be forced to ‘choose a side’. He does not attend school on these mornings as he stays to look after his sisters.

January 2013: Steph seen crossing the road outside her house alone at 2p.m. Car driver stopped as concerned she would have hit her had she been going any faster. Tried to talk to Steph but Steph did not respond to questions about where her parents or house were, though did give her name. Car driver called the police who attended and recognised Steph. On arrival at the house they found the door ajar and Penny and Ella asleep on the sofa with the TV on. Large amount of alcoholic cans and bottles on the kitchen surfaces. Police woke Penny who presented as coherent but severely hungover and exhausted. Penny could provide no explanation for how the door had been opened. Police waited until Penny fully awake and then informed Social Care.

March 2013: Police called to loud argument between Rob and Penny at family home at 11.30p.m. Both parents intoxicated, Penny presented as extremely distressed. All three children upstairs and awake, Jon had gone into his sisters’ bedroom to be with them. Police decided Rob and Penny not functional and situation inflammatory; removed Rob to police station and took children to maternal grandmother.

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May 2013: Ella fell off the double bed where she had been sleeping with her parents. Her cries did not awaken her parents and Jon was at his grandmother. Her sustained cries alerted a neighbour/ friend who came to knock on the door and found it unlocked. She went in, picked Ella up and tried to rouse Penny and Rob but had no success. She then called Penny’s mother. Ella sustained a bruise to her forehead but no serious injuries. Steph was sleeping upstairs and woke to found the neighbour holding Ella and her parents not responding. She became very frightened and started to cry also. The incident was reported to the social worker later that day by Penny and Rob.

June 2013: Steph found wandering up and down the pavement outside the house at 9p.m. She did not appear distressed but a passerby was concerned and stopped to ask where she lived. Steph pointed at her house, from which loud music was coming. The door was wide open. Penny then came out of the door, saw Steph and the man talking, swept Steph into her arms, accused the man of paedophilia and went back into the house closing the door. The passerby observed Penny to be unsteady on her feet and he could smell alcohol on her breath. He called the police when he got home to register his concerns. The police made a home visit at 10.30 by which time the music was off and they observed Steph and Ella to both be asleep in their beds. In the opinion of the police both Penny and Rob had been drinking but both were functioning. This information was passed to Social Care the next day. Penny and Rob deny that Steph was outside for more than a minute or two and say she has learnt to open a locked door herself.

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BALANCE SHEET OF FACTORS AFFECTING CAPACITY TO CHANGEWhat needs to change:

Why is this change necessary for (insert children’s names)?

What is helping to achieve change? What is acting against change? Next steps e.g. What action can be taken to promote change

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Pictorial Scale of Factors Affecting ChangeThe purpose of this chart is to set out which of the factors affecting change are supporting change in the desired direction, and which are hindering change.

With regard to ………………………………….(behaviour that requires change), mark the influence you think each factor has in SUPPORTING CHANGE and note some of the evidence you have for your decision.






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Priority/Relevance



Habits and Automatic Responses

Contextual Factors

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