Bringing up baby: new hope for troubled teenage mothers

http://www.theguardian.com/society/2015/mar/29/teenage-mothers-and-family-nurse-programme

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Noon on a cold winter’s day in Manchester, and Emma, 19, sits deep in an armchair. She is dressed in a number of layers including her pyjamas, clutching a hot-water bottle in an effort to keep warm. The small terraced house, sparsely furnished, is colder inside than out. On the television The Real Housewives of New York spills out affluence. Upstairs, having her daily nap, is Tia, aged 10 months. Emma [not her real name] receives £145 a week in benefits – £45 of which goes to pay off debts for a mobile phone and clothing. So heating is a luxury.

Emma is in college, studying hard, and has ambitions to be a social worker. She is organised, calm and, in spite of what looks like insuperable odds, she is defying the negative stereotypes usually associated with teenage mothers. “I used to be in a bad place,” she says. “But not any more. I know where I’m going now.” Emma was in care for several years, attended a number of schools, spent time in a pupil referral unit for disruptive behaviour, and by 15 had a problem with alcohol. “My friend used to smash the bottle so I couldn’t drink any more,” she says. “I hardly bother at all now. That wouldn’t help Tia.”

By the age of seven she was caring for her three younger siblings. ‘The house was always full of strangers and mess’

The reasons for this positive turn in Emma’s life include her own resilience and the support of Dawn – the leaving care social worker – and, especially, Claire Reece, a former paediatric nurse and health visitor employed by the Family Nurse Partnership (FNP). The FNP is a voluntary programme offered to all first-time mothers under 20 (along with the dads) in England. A specially trained nurse visits regularly – 64 visits at a mother’s home – from pregnancy until the child is two. The aim is to ensure a healthy pregnancy, improve a child’s development and support a young woman to plan for the future and fulfil her aspirations.

The chemistry between the nurse and the teenager is crucial. The nurse encourages a young mother to exercise her own judgment and develop self-confidence – not easy for a person who may have been raised with the message that she is worth little. Ask Claire Reece what family nurses need most of all and she says: “Tenacity – and a love of young people. Humour helps, too.” Young women who themselves have been let down and rejected often do their best to push away the family nurse. “You have to treat ‘Fuck off!’ as a term of endearment,” remarks one family nurse drily.

A family nurse, over the weeks, teaches about pregnancy and child development as well as working with a teenager on her self-development through practical support and encouragement. The nurse and teenager together tackle, for instance, housing problems, acquiring furniture, finding baby clothes, sorting benefits, organising repayment of debts, arranging college courses, setting goals – but without crossing the line into unconditional friendship. Child protection is a prime concern, and young mothers are told that the safety of a baby or a toddler comes first. “But if there is a child-protection conference and we know a mum can manage, we say so,” says Claire. “In that respect we carry a lot of risk.”

In America the programme is called the Nurse Family Partnership. Professor David Olds, a developmental psychologist, established it in 1977, and is still in charge, based at the University of Colorado. Three major evaluations over 40 years have demonstrated not only startling success – and a huge saving to the taxpayer – but how much teenage parents with the right kind of support can achieve. This is in spite of challenges such as physical and mental ill health, poverty, homelessness and violent relationships. “The first pregnancy delivers a powerful motivation for a teenager to make a fresh start,” says Ailsa Swarbrick, director of the FNP national unit based in London.

My meeting with Emma is the first time a journalist has had extended access to observe how the FNP works. Over three months I visited teams in Manchester and Portsmouth, and the young women who are the FNP clients, to witness how this extraordinary intervention achieves little short of miracles. In Manchester Claire sits on the sofa next to Emma, a life-size doll on her lap, and a bag of leaflets, sheets of papers, toys and paraphernalia in a large bag at her feet. Claire, who fizzes with energy, began to visit Emma halfway through her pregnancy. If all goes well, in 14 months, when Tia is two, Emma will “graduate” with a testimonial and a celebration. “What’s really powerful is reiterating to the mum how far they’ve come,” Claire says. “What many of them achieve is phenomenal.”

Emma has said that she is fed up with Tia being so clingy and tearful whenever she leaves the room: “It’s getting on my nerves.” Claire begins to play peek-a-boo with the doll on her knee. She uses the doll to unravel a few of the mysteries of early attachment. “Around nine or 10 months, babies need to have you near them. Why do you reckon that is?” Claire asks chattily. “She needs me because she can’t do anything herself?” Emma suggests.

“Right! Very good. Tia thinks if you are out of the room, who’s going to feed her? So she screams until you come back. Peek-a-boo helps her to learn that even if she can’t see Mum, Mum will always look after her. She feels safe. What do you reckon to that?” Emma’s face lights up with pleasure. It’s a poignant moment, because later I learn that by the age of seven she was caring for her three younger siblings while her mother and older sister and brother partied and took drugs. “I made the little ones cheese on toast, got the baby a bottle and that,” Emma says. “The house was always full of strangers and mess. It was horrible.”

During the hour, Emma also discusses practical problems with Claire. She says she has lost the fob for the gas meter but she’s already applied for a new one. “That’s very good,” Claire says. Even when the gas isn’t being used, Emma has to pay a charge. That’s tough on a minimum income. Sam, Emma’s boyfriend and the father of Tia, in his 20s, visits often but contributes little financially. She and Claire discuss the next step in trying to get Emma into social housing that won’t stretch the budget so tight – and to provide proper heating. “When we say good-bye at the end of the programme we want our clients to know how to sort out issues for themselves,” Claire says, “and to know where to go for the right kind of help.”

“I used to sit and sulk when Claire visited at first. I was really suspicious,” Emma says. “But it’s helped me a lot. Now I know that I’m the one in the family who is going to do all right.”

In the 1970s David Olds worked with three- and four-year-olds with multiple problems in a day-care centre in New York. He concluded that some children were so troubled that by the age of four it was already too late to make a difference. Nearly 50% of a child’s learning may occur in the first four years of life. By kindergarten, a child from a disadvantaged family could have heard 32 million words less than a classmate from a professional family. In addition we have gradually become more aware of the negative impact of violence, alcohol and drugs on the unborn baby’s brain. Some young mothers themselves suffer from alcohol foetal syndrome, and as a result when they are adults they find it difficult to concentrate; academic ability is low and the self-regulation we acquire as we mature proves elusive. For a baby, that might mean a mother feeds only half a bottle before moving on distractedly to another activity and routines are difficult to establish.

In the US, the Nurse Family Partnership has had success with diverse urban and rural populations including white, Hispanic and African-American. Babies have been followed through to their teens and beyond, along with their mothers. The results are outstanding. They include, for instance, a 50% reduction in language delay at 21 months (compared with non-FNP programme children with similar backgrounds); a 67% reduction in behavioural and emotional problems and improved academic achievement at the age of six; a 67% reduction in 12-year-olds use of cigarettes, alcohol and marijuana; a 28% reduction in anxiety and depression in 12-year-olds; and a 59% reduction in arrests by the time the child is aged 15. Mothers do well, too: less smoking in pregnancy and more breastfeeding; greater maternal employment; reductions in the use of welfare and other state assistance; fewer subsequent pregnancies. Among the strongest gains are the prevention of child abuse, neglect and a reduction in childhood injury.

In Manchester, two teams led by Sheila Panton and Vanda Wellock explain some of the inherited attitudes to child-rearing that they need to find imaginative ways to correct. Ninety per cent of mothers stick with the programme. In pregnancy, a young woman is encouraged to write down positive thoughts about her unborn baby, and sing or play music to him or her. “We get a bit more rap than Mozart,” says one family nurse. “But when the baby recognises a tune after it’s born, the girls are delighted.” The nurses also gently bust popular myths: “An eight-month-old can be potty trained”; “He’s crying to wind me up”; “Babies love telly.”

The family nurses teach how to read baby cues and the value of getting down on the floor to play. “What we are not is the breastfeeding police,” Claire says. “That won’t work. If a young woman prefers to feed her baby with a bottle, we explore that idea together and support the decision she comes to.”

Sheila Panton says young women are “remarkably forthcoming” about smoking in pregnancy, drugs, alcohol and sexual behaviour – but they are much more reticent on the issue of domestic violence. “Sometimes it’s because they don’t recognise a boyfriend’s behaviour as abuse,” she points out. Marie Livesley, formerly a specialist health visitor in HMP Styal, says: “Abuse is sometimes seen as love.”

I’d see friends on Facebook going out. I shouldn’t say it, but it was a struggle. I’m a young girl – I need a life

In Portsmouth, the Family Nurse Partnership was established in 2011, so it has just seen its first group of teenage mothers graduate. The office is garlanded with thank-you cards. Around 160 first-time mothers are eligible for the programme, and the youngest client is 13. Enthusiastic Mia Wren, 48, a former nurse and health visitor for 30 years, heads the family nurse team. Family nurses come from professions such as community nursing, midwifery and health visiting. They undergo intensive training, refresher courses and weekly supervision and have meetings to discuss safeguarding issues. While the rate of teenage pregnancy in the UK has plummeted to its lowest level since 1969, Portsmouth currently has triple the national rate of pregnancies of girls aged 14 and under.

Mia tells me about Sarah [not her real name]. Aged 15, she was living in the garden shed of her mother’s friend. Sarah was pregnant with twins and diagnosed with multiple sclerosis. Her father had hanged himself when she was nine, and her mother, a prostitute, had died of an Aids-related disease when Sarah was 13. She had been in and out of care. Sarah had a badly scarred face from a dog bite and her boyfriend, a user of drugs, was in prison.

“Two years on, Sarah has done beautifully,” Mia says. “She had twin girls; she breastfed. She dumped the boyfriend. She had her scars fixed, so her self-esteem has risen, she is at college and has a part-time job and her own tenancy. Her two little girls are doing so well. We tell our girls again and again: ‘You can be different if you choose to be.’”

Jacquie Nurse, 47, a health visitor and midwife for 16 years before joining FNP, is quietly spoken but brims over with innovative ideas. She raids charity shops for props – a road map painted on an old pillowcase, for instance, with toy cars and bricks illustrating the roadblocks to a baby’s learning.

Jacquie has been visiting Leah for 21 months. Leah is 19 and was at college throughout her pregnancy, earning a merit in her BTEC. Her son, Layton, was born by Caesarean section, weighing 9lb 3 oz. Leah is living with her disabled boyfriend Ben, 24, who has no job and is Layton’s dad.

Unlike many mothers, Leah has the strong support of her parents, although her mum, Janice, didn’t speak to Leah for a week after being told the news. “But we wouldn’t be without him now,” Janice adds, smiling at Layton, an inquisitive, happy boy.

“I was horrible growing up,” Leah says. “The child from hell. I was always out, drinking under age.” Her midwife referred Leah to Jacquie. “I was a worrier, and Jacquie has been brilliant,” she says. “I text her all the time. I had postnatal depression. I’d see my friends on Facebook going out. I shouldn’t say it, but it was a struggle. I’m a young girl. I need a life, too.” Jacquie helped with GP appointments and medication. At the time the couple’s income was erratic. Now Leah has a job in B&Q and works 16 hours a week.

A few weeks later, when Jacquie and I make a second visit, life has changed, as it often does with teenage mothers. Leah and Ben have split up. Leah is living with her parents, sharing a room with Layton. “He’s had his own room since he was six months old, but now he’s with me again,” she says, upset that her son’s routine is disturbed. The cap on housing benefit means that she can’t afford a two-bedroom flat. But Leah tells me that she now likes the job at B&Q. “It helps my confidence,” she says. She plans to go to college, become a prison officer, move to the Isle of Wight for work.

Jacquie chats to Leah about reading to Layton. “I don’t do it a lot,” Leah says. “I don’t see the point; he doesn’t understand.” Over the next 20 minutes Jacquie runs through the value of turning off the telly and looking at picture books to promote language, share sounds and rhymes, and prepare a toddler for bed. “I used to love being read to,” Leah concedes. “I will try. If Layton’s happy then I’m happy and Jacquie is happy, so we’re all happy,” she says.

Jacquie takes me to meet Alice Roses, with her aubergine hair, tattoos and shy, warm smile. She became pregnant with Daxton, now 10 months old, when she was 16. Daxton’s father said he had been in a bit of trouble for street crime. When he appeared in court it emerged he had 46 convictions. He was in prison during much of Alice’s pregnancy: “He missed all the scans, everything.” Alice is in a new relationship now. He treats the baby and Alice well. Alice laughs. “Jacquie came here at 9am one day and the first thing she talked about is contraception and have I asked my new boyfriend if he’s had a test for STDs – at 9am!” “And she did ask,” Jacquie says approvingly. Alice nods: “I wouldn’t have had the confidence to do that a few months ago.”

Alice is an only child. Both parents have had mental-health issues since she was very young. Her father, Pete, suffers from schizophrenia, initially triggered by drug use, and he is bipolar. Alice’s mother, Holly, made several suicide attempts. “But I’ve been better for quite a while now,” Holly says, doting on her grandson. Alice suffered from depression, anxiety and had poor school attendance. She was in care and had several foster placements as well as living with relatives for a time. During her pregnancy, Alice was again moved several times in foster care and into a hostel. A family nurse provides the constancy often missing in the usual support system provided. For instance, one teenage mother and her baby, both of them on the child-protection register, were allocated seven social workers in six months. “So much that we achieve is about trust,” Jacquie says. “Alice is doing beautifully.”

“When all the professionals were telling us what we could and couldn’t do,” says grandmother Holly, “Jacquie was the only one who asked if we were OK.” Alice aims to go to college and become a beautician. “Before Daxton was born, I was scared I wouldn’t be able to give him good attachment,” she says. “Then I saw him and thought: Wow – he’s my baby!”

It costs around £3,000 a year for each young woman in the FNP. This month the scheme expands to 16,000 places, meeting 25% of the need from first-time teenage mothers. In October funding for the FNP will transfer from the NHS to local authorities. Funding isn’t ring-fenced, so there are concerns about cuts. Mia Wren offers the sums. If five emergency hospital admissions for a child are avoided as a result of FNP, £3,750 is saved. If five children no longer have to go into foster care, the savings are £135,000 a year.

For my final visit, I return with Claire to see Emma in Manchester. Tia wakes from her nap and comes to say hello. “She’s really bright,” Emma says proudly of her daughter. She talks a little more about her own upbringing. Her mother, Vicky, stopped drinking when she met her new partner, then moved the family away from drug dealers, but the children stopped going to school. “She was sorting things out,” Emma says. “Then early one morning, the police and social workers all piled into the house. It was horrible; we were screaming. The neighbours saw it all. They took us children away.” Intervention has come at a price. One brother is in prison, a sister is in secure accommodation, another lives with her stepfather; a fourth sibling is “off on one”, and there is Emma.

“My mum’s a workaholic now,” Emma says. “She never drinks. She has two jobs. She hasn’t celebrated Christmas since they took her children away. They should have given her a chance to put things right.”

A history of suspicion and hostility towards social services makes the relationship that Claire has forged with Emma all the more remarkable. “Your college tutor told me you’re doing really well,” Claire tells Emma. It’s hard to tell who is the prouder of the two.

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