Evidence Centre seminar: November 2020

Tena kotou katoa.  Ko Tangi-Te-Keo te māunga, Ko Te Whanganui-a-Tara te moana, nō Te Whanganui-A-Tara ahau, Kei Ōtautahi tōku kāinga ināianei, e mihi ana ki ngā tohu o nehe, o Te Whanganui-a-Tara e noho nei au.  Ko McClaverty Mather Harper rāua.  Ko Whitcombe tōku ingoa whānau.  Ko Sarah Whitcombe-Dobbs tōku ingoa.  No reira, ngā mihi mahana ki a whānau, whanaunga.  Kia ora.

So my motivation for working and researching in this field is personal and professional, and I've got this real drive to find out what and how we can do things better to reduce the actual harm occurring towards our tamariki.  I also just want to acknowledge the expertise in the room, so I'm talking from my perspective today, and I'm really aware that there's a lot of knowledge and expertise here and perhaps out in the web in the future, so I guess I'm offering my perspective which sits alongside your stuff.  So take what's useful.

Also, I should caveat, so I'm working for Oranga Tamariki now, but when I offered to give this talk, which is a chapter from my PHD research, it was under agreement from having partnered with Oranga Tamariki to conduct my doctoral research, so that was done as an independent researcher, not a within house organisational researcher, so my views today are not necessarily reflective of those of the organisation.

So, Duncan gave a really nice outline, so I won't spend too much time on that, but I just wanted to highlight again that focus on the particular population that I'm talking about today, I'm not talking about families who are high risk, I'm talking about families who have already had referrals of concern or notifications of harm that have been made to Oranga Tamariki but whose children remain in their day to day care.  So that's quite a specific population.

So I do want to briefly touch on what we currently do in Aotearoa and some of the implementation problems and then offer my thoughts on what might help in building an evidence base.

So, I started questioning the evidence around this, because during my training I was trained in a scientific and systematic approach to supporting children and adolescents and providing psychological interventions and treatment and so as part of that I was trained in Triple P, which is one of the best evidenced parenting intervention programmes in the world; there's a huge volume of articles on that and Incredible Years, of course, as well, is widely used.  My reality of implementing those with the families with whom I was working was really different from what it said in the textbook, it didn't touch the sides, actually, it was an inappropriate intervention for the needs of the parents and that was actually -- when I started talking about this and saying, "Look, am I doing it wrong?" My colleagues were saying the same thing.

I also had a real concern because I was picking up cases where families had had a lot of different interventions tried over several years with no fundamental change in the relationship dynamics between children and their parents and during that time, of course, incidents of abuse or chronic neglect was ongoing, and so I started going, "Well, hang on a sec, what are we using as markers for improvement here?"

So, I started thinking about soft markers versus hard markers of improvement, so by soft markers I mean things like perhaps scores on a parenting questionnaire or the parent using more frequent specific praise with a child or kind of improvement in other sorts of skills or behaviours, which are good and I guess a hard marker is are there more incidents of family violence or are the kids being left unsupervised for long periods of time, and so I came to believe that at this point, if we're talking broadly, then notifications of harm are currently the most reliable indicator of actual harm occurring towards children even though it's a blunt and not perfect indicator.

There's some evidence around improvements in those soft markers not actually co-occuring with improvements in the hard markers which is why I think it's really important we look at some of those more pointy indicators.

So, I'm just going to remind you guys around some of the known effects of child maltreatment, so children who have been exposed to child abuse and neglect during early childhood are at markedly increased risk for suicidal behaviour suicide and self-harm, involvement with the justice system, incarceration, learning difficulties and intellectual disabilities, being socially isolated, being lonely, being disconnected from whānau, from culture, from community, having poorer educational outcomes, having mental health problems, physical health problems such as immune disorders, even cancer, and neurodevelopmental differences and difficulties.

So, I would argue that if there was a medical condition or an event that led to an equivalent broad array of risk factors such as this in early childhood, then that would be considered a developmental emergency and we would be putting -- wrapping an intensive array of services around that child and their whānau.

So, the evidence review that I'm talking about today is the international published peer reviewed evidence, so I want to acknowledge that there is internal organisational evidence that is ongoing that might well be being used as well.  So, this is speaking internationally.

So, I wanted to know, what are the research studies that have, as participants, parents who have involvement with child protection services as evidenced by more than one notification of harm to child protection services, where they received a parenting intervention of some description and where the outcome measure was notifications of harm within that family.

So, I did a systematic review starting with about 2,500 articles and screened them down for criteria for inclusion, so I did only include publications after 1990 because I considered that the child protection systems and reporting systems were so different prior to 1990 that they weren't probably quite so relevant.

Internationally, there are only nine studies that have been published that fit those criteria.  I was a bit shocked by that, I thought there would be more. 

Across those nine studies, what did we find?  There were about 3,500 participants and all of those participants had previous or current involvement with child protection services.  The recruitment rates within the studies varied hugely, so one was up to nearly 100% and one was as low as only 23% of that initial sample, so more than three quarters of the parents who were eligible to participate in that research study didn't.  So, potentially a bit of bias in that sample.

Most of those studies were randomised controlled trials with an average of 24 sessions, so weekly sessions, 24 sessions, that would be about six months which is a reasonably grunty intervention and so five of those nine studies showed no differences between the groups on the main outcome variable which was subsequent notification rates and the follow up periods were reasonably decent on those.  So by that I mean sort of around that 12 to 24 month period.

Three of those randomised controlled trials were home visiting interventions, so that's -- you might have heard of nurse family partnership or nurse home visiting which have -- there's some good evidence showing that they are effective as a preventative intervention for child abuse and neglect, but when it's implemented with families who already have involvement with child protection services, there is no evidence according to these studies anyway that they were effective.

One of those studies was an attachment based video feedback intervention, so if any of you guys have heard of VIG, Video Interactive Guidance, and there's various forms of it, those are quite popular and really interesting to me.

Four studies with two intervention approaches showed a difference.  These studies both had some -- all four studies had some methodological limitations, so the two interventions were Parent-Child Interaction Therapy and SafeCare.  So, the particular kind of approach of PCIT and SafeCare are that they used education, modelling and feedback, so that would be alongside the parent practising and implementing the particular skills you are wanting them to learn or they are wanting to learn and then providing some positive praise for the kinds of behaviours that are the more desired kind of behaviours, so like paying attention and engaging with children would be praised a lot.

I also note that PCIT had no effect on the rates of subsequent neglect, so the effectiveness was around the physical abuse only.  If you're familiar with PCIT, then that makes a bit of sense because it doesn't actually have a child neglect component to it, it teaches positive parenting strategies and child-directed play and child-led interaction and so it really helps with some of the positive parenting skills but SafeCare has a component that specifically targets supervisory neglect.

Some problems with even these studies.  So, across those nine studies, some of them didn’t include particular types of parents in the trial, so they were excluded from the study.  So, in four studies parents with intellectual disabilities were excluded.  Now, this is actually really common across the research base; people with disabilities are often excluded from studies meaning that the findings are not representative across the whole population.  Parents with severe mental health problems were excluded in one study, parents whose children had a development delay were excluded in two studies and parents with significant substance use were excluded in two studies.  For me, reading that, it's pretty frustrating because the parents with whom we work often have some, one, more, occasionally all of these things, and actually this is the target population, right, so we need an evidence base to support them. 

Retention rates were really low in some of those studies as well and I guess my question mark is around what happens with those parents who don’t engage with the intervention.

In conclusion to this point, I would argue that we lack robust evidence that existing parenting interventions, the off-the-shelf manualised parenting interventions are effective with maltreating parents but there are some, based on social learning theory and PCIT rooted in attachment theory that do show promising results.  Long-term home visiting programmes are ineffective when compared with treatment as usual, so that just means there's no difference on subsequent maltreatment rates.

The two components that seem to be common to effective interventions are coaching to mastery, so that means when you are teaching and learning a new skill, parents or participants learn it to a point of fluency so it's just automatic and easy, they don't have to think about it every time, and, of course, that including a specific component around child neglect.

So, I think we need to think about the families we serve as specific and different from other types of at risk populations in that they seem to be less responsive to intervention approaches that work for other people.  Programmes that might work as preventative shouldn't be considered as treatment for this particular group of parents.  There is the article if you want to go and download it -- I can send it to you if you don't want to pay for it.

I wanted to talk a little bit about the parenting programmes that we currently use in Aotearoa.  So, these are off the top of my head.  Triple P, Incredible Years, Theraplay, Toolbox parenting, various home visiting approaches, individualised sessions and counselling and many others that are locally created which may well be effective but I certainly haven't got access to robust research evaluations of those.  When I say they may well be effective, I was talking to one of our data guys down in our regional office in Canterbury and he had done a research study in conjunction with a local NGO looking at the effectiveness of their work and found some really good results, but that was an internal report so obviously not disseminated and published, so unfortunately not available to the international audience either.  Because I really want to emphasise that this is not just a New Zealand problem, this is internationally doing research in this field is really, really hard, and it's not just us who are kind of looking around for ways that we can do things better, so that’s where New Zealand has that opportunity to contribute to the international problem around child maltreatment.

I think that -- the implementation of parenting programmes, it's not like giving a prescription from the doctor.  Citalopram costs the government something like $3 a month, parenting interventions are much more expensive than that and even when a social worker makes a referral for a partnered response, they don't necessarily know whether the parent has gone along, has engaged, whether it's an appropriate fit for that particular parent, even if they do go along, how many sessions they might have attended, and also -- earlier this year, I was involved in an assessment around a family who had a significant ongoing involvement with Oranga Tamariki and one of the parenting programmes that was used, the standard administration according to their information is between 19 and 28 sessions, so that's for children without any kind of extra developmental problems. 

So, this family had been involved with the service delivering the outcome for over a year, so I thought, great, they would have actually received this intervention.  So, when I asked the therapist how many sessions were delivered to that child and parent together as per protocol, the answer was five sessions in a year.  So, that's just -- and I would like to say that that's an anomaly and we've had COVID and there's been a lot of disruptions, but my hunch is that it's not actually that unusual.

I also wanted to say that client satisfaction outcomes are very different from reduction in abuse and neglect, but we do need to be looking at complementing the hard markers with meaningful soft markers, and those soft markers might also be markers that are meaningful to the whānau, so they could be things generated and decided upon collaboratively.  For example, there are lots of models from te ao Māori, there's Whānau Ora models where there are areas to look at in terms of improvement, so for example, the Meihana model, Te Wheke, Tapa Whā. 

The other thing you might be seeing is a change in parent attitude or insight, but a really key one to look for is a child, the child or the children in the whānau starting to develop well, so the language, the learning, the play, the social skills all coming along and starting to improve, that's a really good sign that their needs are beginning to be met, and, of course, stronger daily routines.  There are lots of others, those are just ones that I think are pretty important and meaningful.

So, where to from here?  I think that we need the adequate investment in a research programme that goes alongside our implementation across the board is necessary and that this needs to be a bicultural research approach as a bicultural organisation.  There are many Māori academics researching in this field using Kaupapa Māori approaches and other types of methodologies that include western paradigms as well as other forms of methodologies.  I think, obviously, the best, the most robust science includes and upholds indigenous methodologies. 

RCTs are great, but also they are so hard to do and they are not the only way to do research.  There is pre-post trials, there is site randomisation, I have a hunch -- this is my personal opinion, not from the research -- that individualised co-designed intervention approaches are a better fit for the families that we serve, just because of the heterogeneity of the difficulties.  There is such a variation in what people are coming with and people's difficulties are really unique and I think that those can still be evaluated in a systematic and scientific way.  A good example of this is MST which has quite a strong process but the individual intervention, of course, is variable and fits with the needs of the family.

We do need to record attrition rates in our intervention.  So, who is not engaging or how many people aren't engaging, what are the parenting interventions that we're running where they seem to be able to keep people engaged and keep them coming because whatever they are doing, we should be trying to replicate that because that engagement is massive, and I think we need to be collecting referrals of concern as standard practice for parents who have received intervention and include, as well, some intent-to-treat analyses if you are going to be looking at particular programmes.

I think that it can be really painful sometimes to hold up a mirror to what we're doing to see whether or not it's effective, I know that it's always a scary question because we all want to think that we're really good, effective practitioners, and I'm speaking from a practitioner point there, but if we don't know whether or not what we're doing is effective, we can't start doing it better.

So, my final point is we would not accept poor standards of evidence for our medical system, so why should we accept them for our children?

Kia ora.

DUNCAN McCANN:   I was just wondering, with those nine studies you looked at, were those international ones or were they -- so there weren't any New Zealand based context ones?

SARAH WHITCOMBE-DOBBS:  No, none of them were New Zealand ones.  None of them fit the inclusion criteria unfortunately.  The closest would have been the Early Start trial but not published.

DUNCAN McCANN:     Yeah.  That is always the real pity, so much of the international evidence doesn't really consider a lot of the New Zealand cultural context that we have.

SARAH WHITCOMBE-DOBBS:  Hugely, yes.  Absolutely, I totally agree, that's why we need to generate our own, right?

DUNCAN McCANN:     And as you were saying, it was a really unfortunate thing that that excludes so many parents with various challenging conditions and things like that because it is very prevalent in some of the populations that we deal with.

SARAH WHITCOMBE-DOBBS:  Yes.  The other point I didn't make that I wanted to make is that if we're talking about participation in research and informed consent, I think there is a perception that people don't want to participate, and what I found during my PHD research was -- so, all my participants were parents with ongoing involvement with Oranga Tamariki, so that's not the study that I'm talking about today, so parents were told about the study and they could just say yes or no to me giving them a call, but every single person when I met with them face to face and explained the nature and the purpose of the study, there wasn't a single parent who said no. 

The reason they said yes to participating in research was for the same reasons that I might participate in research which is to make things better for families in the future.  They -- parents knew in my research study that they wouldn't be benefitting directly themselves, this was for other families in the future and people -- I think that we sometimes underestimate people and don't ask the question.  So, I just wanted to say, you know, don't expect a "no".

FEMALE SPEAKER:    How did you make contact with people?  So, the process before you asked them that question?

SARAH WHITCOMBE-DOBBS:  So, I had a very brief one-pager that included a photo of me, as suggested by one of the NGOs that I partnered with and the social worker or the family engagement worker who was -- so this was all through NGOs working in partnered response type ways, would say, "Look, there's this lady from the University of Canterbury doing this study, are you okay with her contacting you and asking to meet to explain what the study is and what participating might involve?" And so then if they said a verbal yes to that, they would pass on their name and contact and I would follow up directly with the person.

So, my biggest challenge was the workers, the family workers asking the question, and I really understood that because I think when your rapport and engagement with someone is really tenuous, the last thing you want to do is ask them another "can you" question, so that was really hard, that was probably my bottleneck, yes.

FEMALE SPEAKER:    Thanks, Sarah.  I'm from Barnardos New Zealand, so we're one of the partnering organisations that these come through, and I guess what immediately sticks out to me is the schism between what you're saying and what the contracting system of Oranga Tamariki provides for.  So, you know, in particular, our funding doesn't include any cost to do any evaluation, so it's all very well, these are great things, but unless we literally find another charity that will offer their services to evaluate, we can't do the robust evaluation of this.

SARAH WHITCOMBE-DOBBS:  That's a really, really good point, and that's where this is up front investment, like financial investment, right?

FEMALE SPEAKER:    Yes.  And the other one for us really is that we struggle to get funded for ideas, innovations…

SARAH WHITCOMBE-DOBBS:  Piloting.

FEMALE SPEAKER:    …true fantasticness that is not a programme.  So, there is amazing things going on out there, probably more responsive to the trauma of the parents which is something that all of this kind of social learning theory, we're going, yes, once you know how to communicate, social learning theory to play is great, but if someone has never actually valued you.  So, that kind of looser attuned relational social work, we cannot get funded for unless you have the particular young person or child that Oranga Tamariki goes, "You're on the top ten list so we'll pull one out of the bag", so it's -- I absolutely agree, but the system is not actually allowing for what you are telling us is viable.

SARAH WHITCOMBE-DOBBS:  I think there's that -- and I may be wrong because things might have changed, but there's an idea that we need to be funding evidence-based programmes, and that's a real push if you're going to be spending government money, there has to be some evidence behind it.  I guess my point is, actually, there isn't.  The one Triple P study where they claim that it's effective for parents involved with child protection services, when you look at the methods and the participant sample, 95% of those parents were not involved with child protection services, and so it's not a study that actually contributes towards this evidence.

MALE SPEAKER:    Just echoing back further that point from Duncan.  Are you saying that none of the nine studies you looked at were of current New Zealand home visiting or parenting programmes?

SARAH WHITCOMBE-DOBBS:  Yes, that is the international research, that is not local New Zealand research, simply because it hasn't been published.  There were none that are published.  That's the caveat; there may well be reports that I'm unaware of or internal studies.

MALE SPEAKER:    There are two big programmes that OT funds: Family Start and Early Start --

SARAH WHITCOMBE-DOBBS:  Yes.

MALE SPEAKER:  -- which are home visiting.  But they've got a very strong parenting component embedded in them, and they are targeted at children who often have contact with social (overspeaking 30.44) --

SARAH WHITCOMBE-DOBBS:  Yes, most of their clients are, in my experience, yes.

MALE SPEAKER:  -- services.  And they have -- but they are not evaluated, there are various evaluations floating around there, soft and hard, as you would say.  There is quite a lot of information around, in New Zealand (overspeaking 31.01).

SARAH WHITCOMBE-DOBBS:  Yes, David Fergusson led a study on the subsequent hospital admission looking and it did reduce the non-accidental injury -- yes, that was several years ago, yes.

MALE SPEAKER:    Now, Family Start did a quasi-experimental study a few years ago that I think also showed that reduced hospitalisations.

SARAH WHITCOMBE-DOBBS:  Yes, but not reduced notifications in general?

MALE SPEAKER:   Yes, that's right.

SARAH WHITCOMBE-DOBBS:  That is my understanding, yes.  So, when I looked at the kind of treatment content and protocol of the three home visiting studies, they were all slightly different but broadly really similar in terms of including that parenting component, but they're not what we've got here, so it's a really interesting question.

DUNCAN McCANN:    Family Start is in the IDI now, I believe, actually, so it might be possible to have a sort of further research and just sort of a longer term outcomes for those involved in Family Start.

SARAH WHITCOMBE-DOBBS:  That would be --

MALE SPEAKER:    It's been in for about two years.

SARAH WHITCOMBE-DOBBS:  That would be amazing.

MALE SPEAKER:    You've got the Rebstock report in your bibliography there.  It's been a while since I've read it, but presumably there's material in there that's relevant to what you're doing.  Reflecting back five years later, what do you think of that report and what is there about it which is relevant to what seems frankly like an astonishing lack of research underpinning a very large amount of public money. 

SARAH WHITCOMBE-DOBBS:  That's a really good question.  So, what I heard you ask was around reflecting back five years after that interim report, what do I see as the progress or, sorry, what was that second part?

MALE SPEAKER:    Well, it's just something in the report is obviously relevant to what you're doing, I'm sorry, because I haven't read it for a long time, I can't remember, but did it say something about the evidence base and investigative clinical sort of --

SARAH WHITCOMBE-DOBBS:  Yes, but I think the specific thought that I had around that was looking at that cumulative harm, so that average number of notifications before children get to FGC being quite high and so what we know is that the longer a period of time goes on before there's intervention to support change, and I am not necessarily talking about uplift at all, I'm just talking about even whānau-led decision making and naming the problem that, you know, if there are four notifications over several years that occur before it's decided to be reaching some kind of threshold, then actually a child's development during that elapsed period of time has serious consequences.  So, there is an appendix to the Rebstock report that contains some of that data on the number of notifications at various different stages for Māori and non-Māori as well, so that was my link, but that was more an implicit link.

In terms of where those numbers are now, I just don't know.  I think maybe you guys would know the answer to that?  Number of notifications on average before FGC?  Has that gone up or down?

DUNCAN McCANN:    I wouldn't know the number off the top of my head, I have a feeling it's something in the realm of -- I couldn't say for sure, seven is in my mind, but I don't know exactly -- it might be for very specific circumstances.  We can certainly find that information out.

SARAH WHITCOMBE-DOBBS:  So, one thing that I seem to have noticed or I've noticed in the last -- I've only been within Oranga Tamariki for the last five weeks or so -- is the hui ā-whānau process is occurring earlier, so there is that hui ā‑whānau before FGC and pushing for that to happen earlier, and that seems like a really good idea to me, because that's the point at which you are getting people around the table saying, "Hang on, there's something not okay here, what are we going to do?" and I don't know when the hui ā-whānau process was brought in, so for how long that's been going, somebody here might know.  So, that's the pre-FGC meeting, so it's not a mandated process, it's the non-mandated, whānau-led decision making collaboration stuff, and that's the point, I guess, at which I think if you are at that point, this is when every kind of support and access to services and funding for the social work stuff that you need to do, that's the point at which we need to be getting involved, because that's when kids are first brought to the attention of Oranga Tamariki.

FEMALE SPEAKER:   You will be pleased hear perhaps that I've been charged with doing a bit of work to look at do hui ā-whānau make a difference (overspeaking 36.26).

SARAH WHITCOMBE-DOBBS:  Fascinating.

FEMALE SPEAKER:   We actually do have a lot of evaluative activities going on at different phases in the --

SARAH WHITCOMBE-DOBBS:  Within the Evidence Centre.

FEMALE SPEAKER:    Within Oranga Tamariki, so I'm from the Oranga Tamariki Evidence Centre (overspeaking 36.43).  So that is happening, and we are -- I hesitate to say final stages, but late stages in a study of Family Start and what impacts it is having, so next March, maybe, published on our website with the findings from that.  You know how long it takes to move from your nearly final report into the final report and getting it published.

SARAH WHITCOMBE-DOBBS:  Public access.

FEMALE SPEAKER:    It can take a while.

SARAH WHITCOMBE-DOBBS:  Yes.  I do wonder whether internationally every country is publishing reports that don't make it into the international sphere where some of these things can be put into a meta-analysis, because that would be good.

FEMALE SPEAKER:    I was just going to ask out of interest, when you were talking about things that do work, could you give me an example of one of the coaching to mastery bits you were talking about?

SARAH WHITCOMBE-DOBBS:  Okay, so I've used PCIT, so I'm more familiar with that one.  The SafeCare one, as far as I am aware, has not ever been used in New Zealand, that's a US one.  And how they randomised the SafeCare one was by site, so they randomised sites to treatment rather than families, so that was quite a -- that is a way around randomising.

The coaching to mastery, for example, the first component of PCIT is child-directed play and child-led integration, and so that's, you know, you have got toys, this is -- most high fidelity is clinic base but you can do PCIT within the home, and so there are kind of five skills that you are explicitly teaching, so that is praise, specific praise, like, "Oh, I love the way you came and sat down so quickly, that was amazing", or reflection, so, you're reflecting back what the child said, so the child might say, "My turn", "Oh, you want it to be your turn?", so, reflection. 

Imitation is copying what the child does, description, describing what the child's doing.  "Oh, I see you're stacking those blocks all up", and the E is for enthusiasm, and so those five skills are gone through one-by-one and modelled.

And then parent has a go, PCIT has an earpiece where you are actually in another room and the parent is engaging with their child and you're going, "Oh, I love how you just did that.  I saw -- how you just copied that child bringing the toy cup to their lips, they just -- you saw their face light up", so you're drawing attention to what the parent is doing live that's getting that response from that child and so the parents starts to see how that tamariki is more engaged, they always increase their language use during that time, so all of those things support that oral communication and you actually want -- when I say coaching to mastery fluency into PCIT is ten instances of that within a five minute period, so it’s pretty high.  So, you keep doing that.

FEMALE SPEAKER:    Kia ora, Sarah.  I'm Carla Kamo and I'm one of the National Educators from Plunket, so I lead the PTC programme for child health, and I just wanted to talk about the engagement part of it, and I think that's, as a practitioner, that has been an area that we've sort of been lacking in because the contractual requirements is actually underpinning that in terms of doing the tick box --

SARAH WHITCOMBE-DOBBS:  So, you're coming in with a bit of paper.

FEMALE SPEAKER:    Well, it's a laptop now.

SARAH WHITCOMBE-DOBBS:  Things have moved on since my kids were little.

FEMALE SPEAKER:    Absolutely, so it's moved on from paper to technology.  So, it’s really getting our practitioners to remember how to be with whānau, which has been quite a journey in terms of our students in particular, and I think it's, when you talk about engagement, it can take a minute or two, whether you make it or break it and you're either out of there or not.  And when we talk about those who are not engaging, it's actually, "Do they want to engage with us?" Is it about the practitioner -- because I guess what I'm trying to say is for us to -- we need to be attuned to the whānau and there's not enough in that in our undergraduate programme on what that looks like, and postgraduate when we get them, we almost have to start all over again on what that looks like, and in terms of mental health for our parents, but it's also looking at infant health as well, because you can't have one without the other.

SARAH WHITCOMBE-DOBBS:  I agree fully.

FEMALE SPEAKER:    So, we've sort of been working with our students and talking about (inaudible 42.42), so talking to parents about what has it been like for you when you were growing up, how were you parented, and so we're trying to put in a place, tie in that space to have reflection in their visits, but it's really constricted because of that contractual requirement.  There's a lot of other things I'd like to add into that, but that's what we're finding at the moment.

SARAH WHITCOMBE-DOBBS:  And that upfront investment and rapport and listening, in my experience, that is necessary to effective practice, so if you've got the luxury to walk in and say it doesn't matter, I don't need to fill in my laptop today, all I am doing is meeting this mum or this couple and just getting to know them, then that's your foundation, right, to your ongoing relationship, so is that not allowed for within the timeframes within the contract?

FEMALE SPEAKER:    I think we don't do it very well.  I think our art of caring has been put to the sidelines (inaudible 44.09) and now it's all about KPIs and meeting your numbers and so forth, so I think that's where we're having to come in and start all over again so we can have that time for whanaungatanga and to make that connection right at the beginning, but it's been quite a challenge.

SARAH WHITCOMBE-DOBBS:  Hugely, and especially I guess with more novice practitioners perhaps who are going in with a mental agenda who want to get that stuff done.

FEMALE SPEAKER:    Well, that's why we come in with our own constructs and especially with culture, we always seem to think that our families are the ones with the (inaudible 44.55) cultures, but we're actually the (inaudible 44.57) cultures as practitioners.  So we're having to, you know, really think that through with our nurses and say you need to go in there and focus, see from mum and baby's eyes, and when baby sees mum, it's telling mum what baby sees in you is how he sees in himself.

And so it's having these conversations with them. 

SARAH WHITCOMBE-DOBBS:  It's slow.

FEMALE SPEAKER:    It's slow progress.  It's really slow progress, and working in collaboration, the Triple P we use, the Triple P, but we've now moved on to more of a strength-based because we seem to think in a deficit paradigm that we actually, we need to look at the strength-base, what's working well and, yeah.

SARAH WHITCOMBE-DOBBS:  Thank you for that, yes, kia ora, it's really interesting to hear your perspective.  I do think about the economic argument as being really flawed because there's many, many things that are invisible in a cross-sectional economic kind of transaction that occurs around that stuff and the hundreds and thousands of dollars and millions of dollars we are happy to spend in corrections and all of these other areas that cost, you know, astronomical amounts, and so what, ideally, we're shifting some of that funding, a good proportion of it, we should have that reversal in terms of that early intervention being, trying to pump that investment into that end. 

But that cultural engagement stuff is, again, where is that in the KPIs?

MALE SPEAKER:   Sarah, I'm John Zonnevylle from Pathways and Real.  I'm just wondering, why are we even fantasising that manualised approaches are going to work in this area when, if we don't pair it with addressing poverty of these families, living situations, mental health appearance, substitutes of the issues appearance, support network appearance, all of those things need to go together otherwise we're just doing something and then sending them back into the environment that's creating everything that is negative to these families, I just --

SARAH WHITCOMBE-DOBBS:  So like a whānau ora approach perhaps might be better?

MAKE SPEAKER:    A much more, all-encompassing wraparound intervention.  I just don't see how -- I think it's fantasy land to think that a manualised approach is going to work in many of these situations.

SARAH WHITCOMBE-DOBBS:  Yes, but components from the manualised approaches might be appropriately drawn in at various points as needed, which means that you need an incredibly skilled workforce.  Now, that is really challenging, we have massive shortages around workforce staff as well, so, yes, I completely agree, and, again, that investment stuff is in research and in workforce, yes. 

Thank you.