The Best Services Trial (BeST?)

We spoke to Dr. Udita Iyengar, Project Manager for BeST? at King's College London, about the New Orleans Intervention Model and adapting the PLO guidelines to trial new ways of working.

The Best Services Trial (BeST?) is an ongoing trial which is researching the clinical and cost effectiveness of the New Orleans Intervention Model (NIM) in care-proceedings in the UK, in partnership with the NHS, third sector and social care.

The model has been piloted via a Randomised Control Trial (RCT) in Glasgow since 2011 and in the London Boroughs of Croydon since 2017, expanding more recently into Tower Hamlets, Bromley, Sutton, and Barking & Dagenham. In the UK, the NSPCC delivers the service through multi-disciplinary teams known as Infant and Family Teams.

The New Orleans Intervention Model

The NIM is a mental health assessment and treatment service designed using attachment theory. The model was developed in 1998 by Dr. Charles Zeanah, a professor of child and adolescent psychiatry, at Tulane University in Louisiana, United States. Its key aim is to improve the long-term mental health and placement stability of infants who are in foster care. Family reunification is not a primary objective of the model. Rather it seeks to remedy the fact that many children who come into foster care return home, only to be subject to further child protection inquiries in the future.

NIM is aimed at children aged 0-5 years who are living away from their parents, either in foster or kinship care placements, and who are subject to court processes due to concerns about their treatment at home. The intervention undertakes relational assessments, exploring the quality and particularities of the child’s key attachments to care-givers. The assessments and intensive treatment are delivered using structured clinical tools. The model has been rolled-out in some parts of the US and South Australia, but implementation has not always been faithful to Zeanah’s original model.

An early evaluation of the model in Louisiana indicates that children who received NIM were more likely to be adopted, and less likely to be reunified with their birth family, than in service as usual.

At the same time, the research suggested that over time, NIM reduced future maltreatment of the child subject to proceedings and other subsequent children in the family, as well as improving mental health in middle childhood.

It is important to emphasise that this research cannot be taken as a definitive judgement on the model, as it evaluated NIM operating in a significantly different context, and not in RCT conditions. It is possible that some major changes to the family law system in Louisiana during the study period biased the outcomes.

From Louisiana to Glasgow

Interest in trialling the model in the UK was first initiated by a group of social work and child mental health practitioners in 2008 and the Glasgow Infant and Family Team (GIFT) has been operating in Glasgow since 2011. It is hosted and funded by the NSPCC, though most of the team are child mental health and social work practitioners seconded from NHS Greater Glasgow and Clyde and Glasgow City Council. The work of the team is being evaluated under the Best Services Trial, led by Professor Helen Minnis of the University of Glasgow.

Since 2011, around two-thirds of all children in Glasgow aged 0 to 5 years who are coming into  care due to concerns about abuse or neglect have been recruited to the trial. Half of these families have been randomly selected to receive NIM and the other half to receive social work services as usual, which would incorporate a parenting capacity assessment There are usually about 20 or 30 families in touch with GIFT at any one time and families may be in contact with the service for up to a year.

NIM cases last longer than standard cases, as GIFT undertakes a three- month assessment, which is similar timescale to services-as-usual, but then delivers a six- to nine-month treatment phase which normal services do not offer. The treatment model is tailored to families’ specific needs, but may include child/parent psychotherapy, contact guidance, Video Interaction Guidance, narrative work, and Circle of Security therapeutic group work.  

And Glasgow to London

In 2015, the NSPCC applied to the Department for Education Children’s Social Care Innovation Fund to extend the trial to the London Borough of Croydon.

The London and Infant Family Team (LIFT) is a collaboration with the South London and Maudsley NHS Foundation Trust and comprises of a multi-disciplinary team: a consultant child and adolescent psychiatrist, a consultant clinical psychologist, a social work team manager, 3 clinical psychologists, 3 social workers, 2 family liaison workers and an administrator.

Exclusion from the Public Law Outline

To set up the NIM service in London is was necessary to adapt it to operate within the English legal context, which differs significantly from the Scottish system of children’s hearings. In conversation with the judiciary, it was agreed that families should be randomised after the case had been issued, placing it firmly within the court arena. In England, therefore, the LIFT team is specifically a court assessment and treatment service, which an equivalent status to a FDAC specialist team.

However, unlike within the FDAC process, the NSPCC have agreed a significant change to the court timetable so that NIM cases can sit outside the Public Law Outline’s 26-week timetable, and are therefore excluded from the data reporting conditions attached to it. Cases are expected to last instead for up to 40 weeks, allowing a 12-week assessment with the intervention period starting at week 16. Towards the end of the intervention period, LIFT provide a final report and recommendation of whether the child should be reunited with their parents or adopted. 

Longitudinal Study

BeST?’s interest in children’s placement stability means it is key to follow up on the infants concerned for a period after proceedings have concluded, in order to assess which provides the best long-term outcomes. Academics from King's College London will continue to monitor the progress of all children involved in the study – both those on the LIFT programme and those receiving service-as-usual – for three years.

Conclusion

There is much of interest to justice innovators in the implementation of NIM in the United Kingdom, not least the final research which is due in 2021. Ultimately, this should be able to report with some certainty which service is best for children long term: a model led by social work experts or a model led by infant mental health experts. A key premise is that we know both models provide a quality service; no family participating in the study is being deprived of support. 

Whatever the outcome, the trial will have an important legacy, as it has been significant in adapting the PLO guidelines to trial a new way of working. It has also set a methodological precedent as the first study to undertake a Randomised Control Trial within Public Law Proceedings in UK.

If you would like to learn more about the Best Services Trial, please contact Udita on udita.iyengar@kcl.ac.uk.