The aim of this assignment will be to critically explore recent Health and Social Care policies in relation to the family unit, and the implications of the policies for health and social care practitioners. The assignment will attempt to discuss relevant biopsychosocial theories which when impacted on the family, influence health status outcomes, including resilience factors. It will also highlight and focus on attributes of vulnerability within the family setting, using specialist assessments skills.

The family which the author will be discussing in this assignment (Appendix 1) is considered to be a vulnerable family, the family member which will be the main focus is the 14 year old teenage mother with a ten week old baby. For the purpose of this essay pseudonyms will be used, they will be called Jade and Billy, to protect the client's identity and for confidentiality purposes, this is in line with the Nursing and Midwifery Council Code of Conduct guidelines (Nursing and Midwifery Council 2008).

Every child and young person needs to be protected, feel secure and sheltered from abuse and harm in an environment which is safe and where their needs are met (Oliver and Pitt 2011). How children make sense of the world around them is formed by their early experiences as children, teenagers and our family life. Families nurture and build resilience and moral codes for children, this supports them in leading successful and fulfilling lives (Cabinet Office 2008). The family can be summarised as an institution which is exclusive for a vast range of functionality which it offers, this leads to outcomes for adults, children and the society in which they live. Family wellbeing does however depend upon the dedication and behaviours of its members (Hooper, Gorin, Cabral and Dyson 2007) and there are an extensive number of children within society who are born and live within families which are deemed ‘vulnerable’ (Howarth 2005). Arney & Scott (2010) describe vulnerable as meaning ‘Able to be hurt or injured; exposed to danger or criticism’. The Cabinet Office (2008) suggests that most families have the ability to function as a unit, providing support in relationships that are nurturing for children. There are however, some families which may experience occurrences which have an adverse effect on these relationships causing them to deteriorate, these families Arney & Scott (2010) state have the potential to become vulnerable. Vulnerable children as defined by the Department of Health (2004a) are those who are disadvantaged and could benefit from additional support from public groups to give them the best life chances.

There is currently a sound commitment, both nationally and locally, to ensure that the most vulnerable and underprivileged children in society receive the extra support from health and social care in order to guarantee they will have the chance to achieve in life (Cabinet Office 2008). The government has made a central theme to its policy, the emotional wellbeing of both children and young people, especially those who are deemed the most vulnerable, Ferguson, Bovaird & Mueller (2007 ) suggest that when children and young people experience positive mental health and emotional wellbeing, they are able to achieve in every way, and reach their optimal potential There has in recent years been an extensive development in provisions for family support services,. Because the beginning of life is such an important time for parents and children, the coalition government has invested in a commitment to resource an extra 4,200 health visitors to support families, in order for them to achieve a positive start in life (DH 2011). A well-resourced health visiting service can support this achievement when working in partnership with other agencies. Every Child Matters (Department for Education and Skills 2004) and then later the Children Act (England and Wales Statutes 2004) highlighted the government’s obligation to increasing these services. Allen (2011) discusses the shift of policy toward parents and its accompanying move towards early intervention and prevention. For parents to engage in mainstream preventative services has now become a key factor of policymakers and service providers.

The DH (2007) implies that teenage pregnancy is renowned for attributing to the cause of social exclusion and the consequence. In 2010 the teenage pregnancy strategy for England was published by the government, this was to support the needs of young parents and also to address teenage pregnancy prevention (DH 2011). ‘Teenage Pregnancy’ (The Stationary Office 1999), underpins the strategy, it highlights the fact that teenage parents with children are faced with an increased risk of poor social outcomes and poor health. Notwithstanding of these negative findings, it is clear that these poor outcomes were not potentially predictable if the young parents needs were met with dedicated support tailored to their needs (Arai 2009)

Despite teenage pregnancy being associated with a variety of adverse outcomes, Trivedi, Burn, Graham and Wentz (2007) suggest that this is not merely related to early motherhood alone. This is because teenage parents are not thought to happen indiscriminately among the population, but mainly as a result of the experience that the mother herself has experienced, they are more likely to have originated from a disadvantaged background, with a lone parent. Hooper, Gorin, Cabral & Dyson (2007) state that like Jade, many teenage mothers have spent a great deal of their own childhood in poverty, possibly living in an impoverished community which is characterised by access to poor education, public services and limited career opportunities. The extent to which a parent has influence on adolescent behaviour purely depends on the relationship quality between adolescent and parent (Di Clemente, Santelli, & Crosby 2009). McDermott & Graham (2005) believe that the higher the level of family conflict, the more that risk taking behaviour is increased. Family unity on the other hand as suggested by (Sawtell et al 2005) is more likely to reduce sexual activity and substance misuse among the adolescent group. Erikson’s (1963) psychosocial stages of development, explores the concept that what happens to us through life, being dependent upon what has been done to us in the past, thus the way we then develop mainly comes from what we do (Learning Theories Knowledgebase 2012). What is clear from Daniel and Wassell (2005) is that at the adolescence stage the teenage is neither child nor adult, and life becomes more complex as they endeavour to seek their own identity.

Jade had been born and raised by a mother who herself had spent most of her life in and out of the social care system, been involved with the criminal justice system, and indulged in substance misuse and alcohol abuse. Jade’s mother’s first child had been born to her at the age of 14, this may have contributed to the poor outcomes for Jade, as for the whole of her childhood, poverty has prevailed. Childhood poverty according to Hooper, Gorin, Cabral and Dyson (2007), if experienced during the life course, may be conveyed through generations.

Intergenerational transmission according to Gonzales & Dodge (2010) occurs through health-related and maternal health before and at the time of pregnancy. If the mother herself was of low birth weight, shaped by the socio-economic position of her family, this will have a direct effect on her child’s birth weight (Swann et al 2003). The family unit was fragmented by her mother’s risk taking behaviour with illicit substances and alcohol abuse, a positive role model was unavailable for most of her childhood, and Jades father was absent. Research has recognised that teenage pregnancy and early sexual activity is a key risk factor when the young person’s biological father is absent from the home (Boothroyd and Perrett 2008). This confirms the outcomes of Ellis et al (2009) who suggest that life stages adversity models of early sexual activity and teenage pregnancy are indicative of a family’s life history and environment induced stress, these factors are thought to incite earlier onset of sexual activity and reproduction.

The impact of strong parenting on physical and emotional health and wellbeing during someone’s life, to say is crucial. Arney & Scott (2010) highlight this, stating that a child needs positive, resilient and confident parenting which commences at birth. Hobcraft & Kiernan (1999) imply that young people becoming pregnant are extremely likely to have experienced a past of difficulty with poor parenting experiences, or even having been in the care system, they continue to say that the teenage parents are more likely to lack strong emotional or social skills which form the basis for self-esteem, self-efficacy feelings, or the ability to create in depth relationships than teenagers who have a positive parenting experience. Arai (2009) focusses on the fact that the teenage parents may have experienced weak attachment patterns with their own parents, which would put them at high risk of repeating these patterns with their own child.

The significance of good parenting is acknowledged within recent policy. The National Service Framework for Children, Young People and Maternity Services (DH 2004b) requires practitioners to provide an exemplary class services in order to meet the needs of children and young people to guarantee amalgamated health and social care from confinement through to adulthood. Provisions for pregnant teenagers and young parents remain central to the government’s policy development. The Children Act (England and Wales Statute 2004) is the legislative framework which restructured Child and Young Peoples Services in order to link the Every Child Matters (Department for Children, Schools and Families 2008) five outcomes. The Children Act (England and Wales Statute 2004) requires that local authorities and their key partners make provisions one Children and Young Peoples plan in order to meet the outcome. Arial (2009) states that to be healthy and to achieve economic wellbeing, are the main outcomes to be addressed when supporting the needs of teenage parents and their children. As the child of a teenager mother, Ferguson, Bovaird & Mueller (2007) suggest that Billy’s vulnerability already prevails. It is further suggested by Sawtell et al (2005) that children born to teenage mums have already been identified as having worst health outcomes than children born to older women, they are more likely to have a low birth rate or be premature, are 60% more likely to die in the first year of life, and twice as likely to be admitted to hospital for accident or incidents of gastroenteritis (Bosley 2009). A child’s development begins before birth, therefore the mother and wider family’s health and wellbeing are able to impact upon the child’s mental health and brain development according to Howarth (2005). Evidence suggests that babies develop best when parents relate to them in stimulating warm and constant ways, as they need to form a secure attachment, which is important for the development of trust, wellbeing and empathy (Allen 2011).

In contrast, Hooper, Gorin, Cabral and Dyson (2007) identifies that when a child is exposed to a neglectful, impoverished or abusive environment, they are at risk of not learning regulation of emotions, not developing social skills or developing empathy. Mental health problems, anti-social behaviour and crime are all risk factors of this type of environment (Swann et al 2005). The threat of this is significant as a considerable amount of children are not securely attached (Daniel and Wassell 2005). However, with effective early childhood interventions, youth development programmes and home visiting, positive outcomes can be achieved, especially among socially disadvantaged groups. Sound antenatal care can benefit both mother and child in terms of health outcomes, and has proven to be cost-effective. The main aim of the government’s Healthy Child Programme (HCP) (DH 2009) is to provide early intervention to children and families to attempt to challenge health inequalities. There is an emphasis on the most vulnerable families and children, and the need to distribute capital suitably. A key role of the HCP (DH 2009) is to highlight the children who may be at high risk with little or no protective factors, and ensure that these children and their families obtain a custom-made service. The relationships between poverty and health inequalities are very clear. The necessity of working with families with young children is emphasised, because inequalities commence very early on (DH 2009)

It has been suggested by Katz, Placa & Hunter (2007) that working in partnership with and engaging families such as Jades can be very challenging. Marginalised, dysfunctional families where there are concerns in relation to substance misuse, domestic violence or mental health problems are usually linked to non-engagement (Oliver and Pitt 2011). Poor engagement, as highlighted by Howarth (2005) more than likely means poor outcomes for children. In order, to maximise the best possible outcomes for Jade and Billy, the health practitioner must ensure that she works in complete partnership with other agencies and the family to complete thorough holistic assessments to offer services which have meaning for the family and be easy to access. Howarth (2005) identifies that the consequence of a family not engaging with services, increases the risk to the child. An important area of intervention for the practitioner to concentrate on is building a therapeutic relationship with Jade and her family, based on trust and respect. The therapeutic relationship involves adopting a positive relationship between the client and the practitioner, where the latter is recognised as being supportive and helpful. Luker, Orr and McHugh (2012) suggest that there are numerous qualities of an effective therapeutic relationship such as attentiveness, responsiveness sensitivity and warmth, being attuned, empathic, open and honest. Working with Jade has proven to be sporadic and challenging, due to several factors, (see Appendix 1) but first and foremost, home visiting presented difficulties due to her drive to access education by attendance at a pupil referral unit for pregnant and school age mothers. Despite all Jades adversities, she has remained consistent in her approach to the care of her child, engagement with services at school and in the community; she attends school regularly and is actively seeking a more positive and more secure future for her son and herself. Hooper et al (2007) state that warm, unified families are amongst the most vital factors for resilience in young people, they further suggest that resilience promotes great self-esteem and a positive social orientation. Resilience is someone’s capability of surviving and recovering from threatening life events. Bowlby’s (1988) attachment theory gives assurance that a secure base in childhood makes a great deal of difference on how people internalise the effects of trauma and abuse and is therefore closely related to the development of resilience. According to Barrett (2006) attachment is a bond between two people that endures space and time and joins the two parties together emotionally. As highlighted by
Holmes (2001) a secure attachment creates a secure base from which the child is able to feel safe and thus explore their surroundings. For children whose primary attachment figures have been unpredictable and unsupportive, they are able to identify other attachment figures. Barrett (2001) states that a sign of resilience in a child is their ability to recruit supportive adults who actively take an interest in them. This could be a neighbour, teacher, foster carer, mentor or residential worker. In Jade’s case, she appeared to find her attachment figure from her family support worker/mentor at the teenage pregnancy unit, this relationship appeared to enable her to develop skills and knowledge in preparation for life.

Home visiting, and parental support can improve health and welfare outcomes for teenage mothers and their children, The HCP (DH 2009) recognises incorporating risk reduction interventions into routine care, comprehensive care, by integrating clinical and social services to teens and their infants, education and career development may prevent adverse outcomes, including repeat pregnancy in teenage parents. Working in partnership with others, general practitioners (GPs), nurses, health visitors and midwives in preventing pregnancy and supporting young parents to improve their social, educational attainment is an integral requirement of early intervention.
Due to concerns over areas of her family life which Jade had raised to her family support worker at school, a Common Assessment Framework (CAF)(Department for Education and Skills 2004) was commenced involving the multi-professionals involved in her care, the CAF has been constructed to offer complete, holistic combined assessment of the child and their circumstances, this according to Howarth (2005) reduces any duplication enabling earlier intervention. A CAF is used for any young person or child with extra needs, which facilitates partnership working.
Jade’s needs were assessed by the lead professional in conjunction with Jade and her mother. Luker, Orr and McHugh (2012) state that partnership working with the family is an important part of information gathering. Naidoo and Willis (2010) explore the different ways in which information can be gained, family history, observation of interactions. Collins and McCray (2010) state that it is important if like Jade the child is living at home, to ensure that the initial meeting involves the whole family. Howarth (2005) further suggests that parents/carers need to be seen together and individually to determine the impact their own history and relationships impact upon the needs of their child. The practitioner should meet with the child to determine their perception of needs, their relationship with their family and the wider community. It is very important to observe the adults and children together, in order to assess the quality of their relationship and the child’s attachment to the parent. On meeting with Jade at the birth visit, it was evident of the weak attachment that she had with her mother, who did not show any care or affection to Jade and on occasions she spoke negatively about Jade, her siblings also undermined her, and were quite critical of her care of Billy. These observations can prove quite crucial when information gathering. Katz, La Placa & Hunter (2007) stipulate the need for practitioners to be realistic about both what they can offer, and for how long they can offer it, noting previous professional involvement and how the family responded to this, as this will influence the way the family will relate to current professionals.
To summarise, Daniel & Wassell (2005) discuss how health and social policies impact upon vulnerable families, they explore ways in which various factors can contribute to family life to make a child vulnerable, and oddly enough, how these same factors can contribute to resilience. Teenage parents are not exempt from this, as it is apparent that this results in poor outcomes in major areas such as socio-economics and health and wellbeing (Arai 2009). By working in partnership with other agencies, health professionals can support teenage mothers to achieve positive outcomes for health and wellbeing, and also provide thorough reviews of the physical, emotional and social development of their baby through systematic assessments (DH 2004b).

On-going assessment of recognised family issues is vital and helps to provide the vulnerable family with the opportunity to integrate back into society ,and thus improve their health and social outcomes (Hooper, Gorin, Cabral and Dyson 2007), whether they be generic interventions or targeted issues. Robust assessment skills are important in the drive to promote healthy child development.

Identifying risk is an intrinsic factor of assessment, and needs to be addressed sensitively and with high levels of skill and knowledge (Robotham & Sheldrake 2003). Evidenced based practice, rooted in robust knowledge and professional judgement is the basis for successful practice with vulnerable children and families.

The HCP (DH 2009) reminds us that as health professionals, there is an emphasis on the importance of early intervention, preventative care and health promotion work for children and their families, this cannot be stressed enough. This area is where the health visiting role has the greatest impact. The Munro Review (2011) reinforces the impact that early interventions can have on a child’s life, it discusses how having access to services in the early years, brings about benefits in abundance. Practitioners need to be able to pre-empt action, which will break down the patterns of dysfunction which is passed down from one generation to the other (Griffiths 2010).