What About the Children? Conference Report October 2022

Our Families, Our Future: An Investment

Since the first coronavirus lockdown in 2020, all WATCh? conferences have been held on Zoom. In 2022 the charity introduced a further innovation, swapping an intense single-day conference for two half days, one in the spring and one in the autumn. The first of these, in March, focused on the need to build ‘critical connections’ between the youngest children and their caregivers. The autumn meeting, held on Monday, 17 October, took a rather wider perspective, looking at the importance of investing in young children and their families. Two distinguished speakers, Graham Music and Sally Hogg, brought different perspectives to this issue and, as always with WATCh? meetings, the talks were followed by a lively and engaged discussion.

The Urgency of Creating a Nurturing and Compassionate World

Graham Music

Graham Music is a child and adolescent psychiatrist who has worked privately and for the NHS in the Tavistock and Portland clinics in London for over 15 years. He is also an internationally respected lecturer, trainer and author, and he has previously worked as a psychotherapist and counsellor with adults, children and families.

He began his talk with an introduction to the human brain as a machine that predicts the future and adapts to fit that prediction. It is an extraordinarily complex machine, made up of about 100 billion neurons (nerve cells). Brain function, however, is not derived from those neurons alone but from the way they connect. Each neuron has axons and dendrites, which contact other neurons at synapses and send messages to them; there are far more synapses than neurons. A piece of brain tissue the size of a grain of sand will contain about 100,000 neurons, two million axons and a billion synapses. When a baby is born, his or her brain will contain more neurons than an adult brain needs, but few connections; if neurons (and their axons and synapses) are not used they simply die off. These unused synapses have been compared to bus routes that go out of business if they have no customers. Conversely, the neural patterns that a baby uses will stay and be reinforced as the child grows.

If we are to survive and (hopefully) thrive, we need to be able to predict what will happen based on what has already happened, and for that we need continuity. Babies and small children need to make sense of the relationships with the adults in their lives by making predictions about how they will behave. We all imagine the future by making sense of the present through our past experiences, and abused children will have vey different past experiences to process than secure ones.

Therefore, it is not surprising that what babies experience is a critical factor in determining how their brains develop. This is the basis of the theory of Adverse Childhood Experiences (ACEs): children, who experience neglect, abuse, poverty or other adversities, are more likely than their fortunate peers to suffer from social, emotional and cognitive impairment, leading to risky behaviours in adolescence and adulthood and greater risks of disease and even premature death. The effect of these experiences is cumulative: one study of over 18,000 people found that, for example, a male child with six ACEs is about 46 times as likely to become an intravenous drug user than one with none.

Exposure to trauma at an early age can produce lasting alterations in the nervous system, affecting the structure of brain regions involved in emotional processing, stress response and memory. It is not surprising, therefore, that effects are longest lasting and most severe if the trauma occurs very early in life, and children who were maltreated as babies and toddlers can experience problems in adulthood, even if their later childhoods were happy and secure. DNA changes have been observed in the brains of holocaust survivors and adult victims of child abuse, and even in babies whose mothers experienced domestic violence or other types of severe stress during pregnancy. Other studies have shown that babies, whose mothers witnessed the 9/11 attacks or lived through hurricanes, had enhanced stress responses, and that those, whose mothers had been close to starvation, developed metabolisms that were pre-set for food shortages. If food is plentiful when these babies become adults, they will be at greater risk of developing diabetes, heart disease and other conditions.

With such a lot hanging on childhood experiences, it is not surprising to learn that early parenthood is a particularly stressful and worrying time. Professionals need to work through these issues with parents, but always in a supportive manner. It is important to remember that babies are automatically ‘wired’ to interact with their caregivers, and vice versa, and that caregivers do not necessarily need to be parents. The ‘affectional bonds’ described by John Bowlby can form with any consistent, loving, supportive caregiver.

Bowlby defined three different types of attachment that children will develop, depending on how they are treated. Consistent, loving care leads to secure attachment in which children have the confidence to explore their environment, knowing that they can return to the safety of an attachment figure. Ambivalently attached children learn to watch their caregiver closely as they cannot predict how they will react, and avoidant children learn to limit their expression of emotion as they believe their emotional needs will not be met. Secure children are more likely to engage with others spontaneously.

One of the factors affected by abuse and neglect in babyhood is emotional regulation, and here there is a difference between the two types of experience. Abused babies are unable to respond to pain in the way that older children or adults do, through the ‘fight or flight’ response, so they enter a state of ‘learned helplessness’, and freeze emotionally. Conversely, babies who are deprived of interaction, such as some of those in orphanages or with severely depressed mothers, learn to avoid emotional responses.

ACEs have a cumulative effect, with, on average, the ‘response’ – the prevalence of a particular physical or mental health condition – proportional to the ‘dose’, or the number of ACEs. One particularly stark example is with sexually transmitted diseases, which are, of course, behavioural as well as physical: one study in 1998 found that over 16% of a population who had experienced at least four different ACEs were affected by these diseases, compared to about 5% with none. Another study found that those with multiple ACEs may develop common diseases decades earlier than those with one or none. This is not only a neurological effect: many other physiological processes are involved, including DNA expression, inflammation, and gut function. Environmental and socio-economic adversity in childhood has been associated with increased inflammation throughout the lifespan; the telomeres, regions of DNA at the ends of chromosomes that protect against DNA damage, are also shorter and, therefore, more fragile, in people with chronic stress.

Some of the studies quoted here have highlighted the fact that adverse experiences can be social and political as well as individual. Telomere shortening in African Americans has also been associated with race bias. However, the presence of a supportive community at all levels (family, local and national) can develop a child’s resilience and improve outcomes, even in the face of adverse experiences. A second set of ‘ACEs’ – Adverse Community Environments - or issues, such as poverty, discrimination, and poor housing, can be defined alongside the first one.

Both these types of adverse experience – or the reverse – can combine to produce a vicious, or a virtuous, circle. Everyone has a ‘window of tolerance’ in which they can stay calm, focused and alert, but too much arousal will put them in a ‘fight or flight’ state and too little in a sluggish or even frozen one. ACEs, of both kinds, can shrink an individual’s window of tolerance, so they are less often ‘in balance’, but therapy can expand it. The result can be either a virtuous or a vicious circle: cooperation and attunement leading to health and care, or fear and anxiety leading to isolation, in individuals, families and communities. Or, in the words of the American author, Manitonquat, “It is clear that the way to heal society of its violence . . . and lack of love is to replace the pyramid of domination with the circle of equality and respect".

Being and Becoming:

The economic arguments for investing in childhood and why we should use them with caution

Sally Hogg

Introducing Sally, Jacqueline Barnes described her as ‘a champion of the earliest years of life’. Her long and varied career has included posts with the Maternal Mental Health Alliance and the NSPCC, and as deputy CEO of the Parent-Infant Foundation. She is now a senior policy fellow at PEDAL (Play in Education, Development and Learning), based in the Department of Education at Cambridge University. She was, therefore, following directly in the footsteps of her colleague, Professor Paul Ramchandani, who gave one of the talks at WATCh?’s March 2022 conference.

She introduced her talk on the economic arguments of investing in early childhood by saying that it would address both why these are important and necessary, and why they cannot be used alone. This economic argument certainly has distinguished supporters. It has been summed up in the Nurturing Care Framework, produced by the WHO, UNICEF and the World Bank, which states that ‘Investing in this period [from pregnancy to age 3] is one of the most efficient and effective ways to help eliminate extreme poverty and inequality, boost shared prosperity, and create the human capital for economies to… grow’. This direct link between child wellbeing and economic growth derives from the malleability of babies’ and young children’s brains. Ensuring that children can thrive at this stage lays the foundations for optimal brain development, which will have lasting benefits for the adolescents and adults they will become. Skills beget skills: children who master the cognitive, social and emotional competences required to learn will be more likely to make a positive contribution to the economy, through working in a high-skilled job and paying taxes.

It is, of course, possible for a child who has a difficult start to ‘catch up’ later and make a success of his or her life, but the later an intervention occurs, the more it will cost. The Nobel-winning American economist, James Heckman, turned this into a mathematical relationship, the ‘Heckman Curve’, illustrating how the return on investment in children’s development is highest for the youngest children (and investment in pre-natal care has even higher returns).  Several studies have attempted to quantify the economic cost of late or inadequate intervention in expenditure on (e.g.) benefits and the criminal justice system, and quoted annual figures in tens of billions. A UK study suggested that extending free school meals to all children in poverty would return £1.38 on every £1 invested, and, even more dramatically, one from the US found that a Nurse-Family Partnership project returned over $34,000 to the state from increased tax revenues and lower spending on social services. The greatest benefits arose from targeting the programme to those mothers who had the fewest resources.

One problem with these figures, however, is that the economic benefits they measure cannot be counted for many years, until the children in the families helped have become adolescents or adults. It is possible to measure benefit to families earlier, as in an Oxford study that showed that parents who had taken part in Sure Start local programmes were able to move into paid employment earlier than those who had not. This did beg the question often raised by WATCh? of whether having both parents in paid employment would always be the most appropriate setup for young children, but at least those families are financially better off. Another study suggested that at-risk children who experienced ‘good parent-child interaction’ had used 12 times less public money by the age of 12 than those whose relationships were more troubled.

Despite Heckman’s work and the evidence from studies like these, the UK continues to invest far more in the later stages of a young person’s development – in further and higher education, and skills – than in the early years (and even in primary schooling). The World Bank takes a different approach. Its YouTube channel includes an engaging short video making the economic case for investing in young children to increase their productivity as adults and, therefore, the wealth of their countries[1].

This, therefore, is the economic case for intervention in babies and young children, and it is a compelling one. Sally used the second half of her talk to argue that it must nevertheless be used with caution. This is an extremely complex area and it is simplistic to suggest that one argument, however compelling on the surface, will be enough to force a change in policy. While there is an appetite for ‘fast results and clear returns’, we are asking for investment and patience. In the UK, policymakers look for results that will be clear before the next spending review (in a timetable of perhaps 3 years), but the economic arguments alone cannot make this case directly. Although the current cost of untreated maternal mental illness has been estimated at over £8 billion for each year’s births, this only accrues in the long term. Policy change is most likely to come about if a case is combined with specific policy proposals and supported with both research evidence and lived experience stories.

Adverse outcomes cannot necessarily be avoided by making investments, although there should be reduced risk. Also, any savings will not necessarily accrue to those individuals and agencies who make the investment; they will be picked up by different departments and authorities, and over periods of time considerably longer than political cycles.  Any quoted figures can only be estimates, and these are notoriously difficult; for example, the level of return in a small, highly controlled clinical trial of an intervention may well be more than would be achieved if the same intervention was scaled up. It is hard to judge which of several suggested interventions might be the most effective use of resources. And is there, in any case, any money to invest? Not, it seems, in the UK at present where the talk is only of cuts.

The economic basis for early childhood interventions is firmly focused on their likely effect on gross national product (GNP), which politicians in many countries have stressed for decades. But this relentless focus on the ‘bottom line’ is not the only approach. Over 50 years ago, a famous speech by then US Presidential candidate, Bobby Kennedy, included an eloquent promotion of a better way: “Gross national product does not allow for the health of our children, the quality of their education or the joy of their play…” The list goes on, but it is interesting that Kennedy puts children first. 

If you ask parents what they most desire for their children, they invariably pick happiness – or perhaps wellbeing – over wealth. This priority is matched in only a few countries: New Zealand’s ‘wellbeing budget’ with one of five objectives explicitly focused on children is a good, but rare example of what is possible. Focusing on economic benefits is invariably future-focused; focusing on children first involves focusing on the here and now. Successful policy change is not impossible in the UK, as campaigns by Jamie Oliver against junk food and Marcus Rashford for free school meals, and the Blair-Brown governments’ commitment to Sure Start have shown.

Sally concluded that children must be treated as  children first, and not economic units; as Nelson Mandela has said, “There can be no keener revelation of a society’s soul than the way in which it treats its children”. That, and not just some projected future hike in GDP, should provide all the motivation we need for investment in our youngest children.

·         Dr Clare Sansom, November 2022