2 Public health need and practice
Government policy puts a significant emphasis on early intervention services to ensure all children have the best possible start in life. The aim is to address the inequalities in health and life chances that exist between children living in disadvantaged circumstances and those in better-off families.
The importance of social and emotional wellbeing in relation to healthy child development is set out in a joint Department for Education and Department of Health publication, 'Supporting families in the foundation years' (2011). The primary aim of the foundation years (years 0–5) is defined as: 'promoting a child's physical, emotional, cognitive and social development so that all children have a fair chance to succeed at school and in later life'.
In addition the new 'Statutory framework for the early years foundation stage' (Department for Education 2012a) makes personal, social and emotional development a cornerstone of early years learning and education.
Other relevant policy documents and related reviews include:
'Fair society, healthy lives' (Marmot Review Team 2010).
'Healthy child programme: pregnancy and the first five years of life' (DH 2009).
'Healthy lives, healthy people: our strategy for public health in England' (DH 2010a).
'Healthy lives, healthy people: update and way forward' (DH 2011).
'No health without mental health: a cross-government mental health outcomes strategy for people of all ages' (HM Government 2011).
'Support and aspiration: a new approach to special educational needs' (Department for Education 2011a).
'The early years: foundations for life, health and learning' (Tickell 2011).
'The importance of teaching' (Department for Education 2010).
Social and emotional wellbeing is important in its own right, but it also provides the basis for future health and life chances.
Poor social and emotional capabilities increase the likelihood of antisocial behaviour and mental health problems, substance misuse, teenage pregnancy, poor educational attainment and involvement in criminal activity. For example, aggressive behaviour at the age of 8 is a predictor of criminal behaviour, arrests, convictions, traffic offences, spouse abuse and punitive treatment of their own children (Farrington et al. 2006).
The child's relationship with their mother (or main carer) has a major impact on social and emotional development. In turn, the mother's ability to provide a nurturing relationship is dependent on her own emotional and social wellbeing and intellectual development – and on her living circumstances. The latter includes family environment, social networks and employment status (Shonkoff and Phillips 2000).
Most parents living in poor social circumstances provide a loving and nurturing environment, despite many difficulties. However, children living in a disadvantaged family are more likely to be exposed to adverse factors such as parental substance misuse and mental illness, or neglect, abuse and domestic violence. Consequently, they are more likely to experience emotional and behavioural problems that can impact on their development and opportunities in life (Farrington et al. 2006; Shonkoff and Phillips 2000).
For example, measures of 'school readiness' show that the poorest 20% of children are more likely to display conduct problems at age 5, compared to children from more affluent backgrounds (Sabates and Dex 2012; Waldfogel and Washbrook 2008).
There are less opportunities after the preschool period to close the gap in behavioural, social and educational outcomes (Allen 2011; Field 2010).
Services that support families and children during their early years are generally not well coordinated and integrated either at the strategic or local level (Allen 2011a; Field 2010; Munro 2011; Tickell 2010).
The level and quality of early childcare and education services varies, with the most disadvantaged children likely to get the worse provision (Ofsted 2010). In addition, only an estimated 50% of children aged 2 and 2½ years in England are being assessed as part of the Healthy Child Programme – and not all women are being offered antenatal and parenting support services (Care Quality Commission 2010; DH 2010b).
The approaches and interventions used to address specific problems (such as abuse, maternal mental health problems and poor parenting) also vary widely and, while some interventions have been proven to be effective and cost effective, others have not. Where evidence-based interventions are used, they are not always being implemented effectively (Allen 2011a; Field 2010).
There is limited UK data on the indicators that provide an overall measure of the social and emotional wellbeing of children aged under 5 years. Independent reviews recommend that measures should be developed to assess children's cognitive, physical and emotional development at ages 3 and 5 years (Allen 2011b; Field 2010; Tickell 2011).
Early intervention can provide a good return on investment (Knapp et al. 2011). For example, an evaluation of the US-based Nurse-Family Partnership estimated that the programme made savings by the time the children of high-risk families had reached the age of 15. These savings, which were over five times the cost of the programme itself, resulted from reduced expenditure in the welfare and criminal justice systems, higher tax revenues and improved physical and mental health (Karoly et al. 2005). (The cost effectiveness of the UK Family Nurse Partnership (FNP) model is currently being investigated as part of the FNP trial.)
The cost of not intervening to ensure (or improve) the social and emotional wellbeing of children and their families are significant, for both them and wider society (Aked et al. 2009). For example, by the age of 28, the cumulative costs for public services are much higher when supporting someone with a conduct disorder, compared to providing services for someone with no such problems (Scott et al. 2001).