Early intervention in the spotlight – Nick Axford

Dr Nick Axford, Associate Professor, Community and Primary Care Research Group, University of Plymouth

Early intervention has been in the policy spotlight in the UK recently thanks to an inquiry by the House of Commons Select Committee for Science and Culture broadcast on Parliament Live TV.

The first session, on 20th February, offered some insight into contrasting perspectives in the field as regards the desirability of early intervention as it is currently construed.

Specifically, two authors of recent critiques of early intervention – Sue White and Rosalind Edwards – appeared alongside academics who are arguably more closely associated with early intervention. One MP on the committee astutely asked whether they were witnessing a ‘turf war’.

Last month the British of Journal of Social Work published my response with Vashti Berry to the award-winning article by Sue White and colleagues entitled ‘A marriage made in hell: early intervention meets child protection’, and earlier this week Adoption & Fostering published my review of a book co-authored by Rosalind Edwards called ‘Challenging the Politics of Early Intervention: Who’s Saving Children and Why’.

The critiques tend to cluster around a handful of themes:

  • that early intervention is concerned with ‘fixing’ families quickly rather than offering longer-term relational support
  • that by focusing on individual and family factors and ignoring structural inequalities it perpetuates a moral underclass discourse in which families are blamed for their predicament
  • that early intervention programmes adopt a deficit model, focusing on risk, and are unduly rigid, manifested in an obsession with fidelity to the manual
  • that early intervention rests on incorrect assertions about neuroscience which ignore the brain’s long-term plasticity
  • that randomised controlled trials (RCTs) are erroneously deemed to offer unbiased objectivity and are not really suitable for complex psychosocial interventions
  • that the evidence base for early intervention is weaker than its proponents claim, since effects are often exaggerated, short-term, equivocal and difficult to replicate
  • that it regards children as future human capital to be invested in and is motivated primarily by a desire to reduce government funding for services

I am sympathetic to at least some of these concerns: neuroscience has unquestionably been misrepresented; poverty is often given insufficient attention; authors of evaluations have sometimes cherry-picked favourable findings from otherwise unimpressive data; effects are often smaller than any of us would like; RCTs have their limitations. More on some of these later.

But before that it is important to say that, in my view at least, the authors of these critiques tend to mispresent the field and ignore evidence that runs counter to their views. As such, while the debate is important, their perspective is very partial.

For example, in response to some of the points above I would argue that:

  • intensive and long-term support is a feature of some interventions, notably those that use home visiting, where building strong relationships with service user is fundamental
  • interventions often seek to boost protective factors in families’ lives (i.e. as well as reduce risk factors), and developers have often encouraged some adaptation in response to services users’ needs
  • neuroscience has been less influential in intervention development than the fanfare around it might suggest, and used well it could help make intervention more effective (ironically, it may point to the central importance of addressing material and environmental factors)
  • RCTs are adept at controlling for extraneous factors that might influence the outcomes of interest, and the increasing use of standards for reporting and assessing trial results seeks to guard against malpractice and over-egged claims
  • some interventions and classes of intervention do produce tangible benefits for children and families, and do transport well in terms of implementation and effectiveness: they should be used more widely than they are
  • it is possible to respect empirical evidence that early intervention is able to yield economic benefits for individuals (by boosting their earning potential) and society (by reducing the need for ‘heavy-end’ services) while also being an advocate of improving children’s well-being in the here-and-now

In my view, critics of early intervention have also failed to recognise that the field is dynamic, and that the people who work in it are constantly innovating and testing new ideas to address perceived weaknesses. This is exemplified by changes to how we intervene, and changes to how we evaluate those interventions.

Taking the first of these, it is noticeable that interventions are increasingly multifaceted in recognition of the often disappointing effects of discrete individual interventions. For instance, school-based curricula on subjects such as mental health promotion and drug misuse prevention are increasingly complemented by activities to develop a whole school ethos and engage parents and the wider community. Efforts to create whole system place-based approaches, in which various agencies and civic society work together synergistically to affect specified outcomes, represent an exciting new avenue for the field. There are also innovative approaches to making evidence-based programmes more person-centred so that they better meet the needs of different individuals and respond to their preferences.

As for evaluation, mixed methods and realist trials are a response, in part, to the challenge of finding out what works for whom, when and where – in other words, recognising the importance of context and implementation. Others are using rapid cycle testing methods to develop or ‘co-produce’ prototype interventions with service users in context and then make refinements iteratively subject to what the quantitative and qualitative data show. I declare an interest here because I’m involved in work with the Family Nurse Partnership programme to do just this (and for that matter to personalise it).

For me, the criticism of early intervention that resonates most strongly, because it is the one where to my knowledge we have made least progress, concerns the alleged blind spot on poverty. In my experience, most advocates of early intervention want to see greater economic equality and are frustrated at how interventions struggle in the face of deprivation. I also think that policy responses are ultimately best placed to address child poverty. But we could arguably do more to test whether interventions benefit poorer families disproportionately and promote social mobility. And, though I may be wrong, I can’t help but think that there must scope to develop forms of early intervention where the theory of change somehow integrates activity to address issues with housing, benefits, debt, low income and the like rather than simply taking deprivation as a given.

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