Title: The Best Services Trial (BeST?): Effectiveness and cost-effectiveness of the New Orleans Intervention Model for Infant Mental Health
Funder: Chief Scientist Office, Scotland

Abstract: The negative effects of child maltreatment on mental and physical health amplify across the lifespan and costs to society are enormous. Regardless of the extent of early life maltreatment, placement in a nurturing family is associated with rapid development of secure attachment and improved mental health – but only if that nurturing placement is achieved early enough in life. The best type of placement is not yet clear: randomised controlled trial (RCT) evidence has shown that placement of maltreated children in substitute family care (i.e. adoption or fostering) is associated with significant developmental catch-up, but other studies suggest that placement within the birth or extended family may be even better than substitute care. Efforts to improve the mental health of maltreated children in birth families or foster placements have had mixed success and researchers have recommended that far more intensive approaches are required. We are conducting a two-arm UK-based RCT of such an intensive approach. The programme we are evaluating, the New Orleans Intervention Model (NIM), is currently the only one that is well evidenced, although only in a US setting. NIM offers families whose child enters care due to maltreatment a structured attachment-based assessment followed by an intensive intervention aiming to improve family functioning and child mental health. If adequate change is achieved a recommendation is made for the child to return home but, if not, the recommendation is for adoption. US pilot research suggests that NIM is associated with a reduction in future maltreatment of both the index child and other siblings as well as improved mental health in middle childhood. Our control intervention, Case Management (CM), comprises standardised social work contact and referral to other services where necessary. In order to translate NIM for the Scottish context, we conducted extensive mapping and modelling in both New Orleans and Glasgow to understand how best to develop NIM to take account of the differing healthcare and legal context. Since beginning our feasibility RCT, in December 2011, we have recruited 65% of all maltreated children aged 6 months to 5 years coming into an episode of care. Preliminary findings suggest that the intervention is acceptable to parents, foster carers, social workers and legal professionals, but this study will not be large enough to say definitively what impact NIM has on the health of the children involved or how much it will cost in the long term. We are currently conducting similar detailed mapping and modelling work in South London, and a NIM team is going to be launched there in 2015. We now want to test whether NIM is clinically and cost-effective in the different legal jurisdictions across England and Scotland. We propose a multi-centre RCT of NIM involving a continuation of our current Glasgow RCT, including a further 2 sites in Scotland and 1 site in London, England. We plan to involve 462 families in total across these sites, including those recruited in our current Glasgow study. This will allow us to test, definitively, whether NIM is clinically effective and cost effective in the UK.

Lay abstract: Children who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout life. This places an enormous burden on individuals, families and society. Regardless of the severity of this abuse and neglect, these negative effects can largely be reversed if children are placed in secure, loving homes early enough in life. Placing children in nurturing foster placements can help them recover rapidly, but it is not known whether it is better for children’s long term development to place them with substitute (foster or adoptive) families or return them to birth or extended families. Efforts to improve the mental health of maltreated children in birth families or foster placements have had mixed success and researchers have recommended that far more intensive approaches are required. We have carried out careful exploratory research, in Glasgow, on an intensive approach developed in the United States. We have called this the New Orleans Intervention Model (NIM). NIM offers families who have a child entering care due to abuse or neglect a structured assessment followed by an intensive treatment that aims to improve family functioning and child mental health. If adequate change is achieved a recommendation is made for the child to return home but, if not, the recommendation is for adoption. Preliminary research from the US suggests that NIM might reduce future maltreatment of the child and other children in the family, and improve mental health in later childhood. We are currently conducting a preliminary study in which, since December 2011, we have managed to recruit around two-thirds of all maltreated children aged 6 months to 5 years coming into an episode of care in Glasgow. Half of the families who are taking part receive NIM, which is delivered by a multidisciplinary team comprising health and social care professionals. The remaining half of families receive usual services, which is delivered by social workers. Preliminary findings suggest that NIM is acceptable to parents, foster carers, social workers and legal professionals. We are currently conducting detailed exploratory work in South London and a NIM team is going to be launched there in 2015. We now need to test whether NIM is effective, in terms of both clinical outcomes and cost, in the different legal systems across England and Scotland. We, therefore, propose a study of NIM involving a continuation of our current Glasgow work including a further 2 sites in Scotland, Fife and Tayside, that are fully committed to the study. When the exploratory work carried out in London has been completed we plan to include this site in the randomised trial, allowing us to have a number of recruiting sites across the UK. We plan to involve 462 families in total across all sites, including those recruited in our current Glasgow study. This will allow us to determine whether or not NIM is effective in the UK.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH