FIRST PRINCIPLE
People around the child talk to each other
Before we dismiss this as being too obvious, we should ask parents if the people supporting their child and family communicate with each other effectively. In my experience there is generally insufficient communication across disciplines and between agencies. The result can be added confusion for parents (sometimes with contradictory advice) and separate approaches to the child’s development and learning that might or might not fit together.
Do we need research into this situation? It would certainly be good to research the damaging effects on children, parents and families when people do not talk to each other, but I cannot imagine any research concluding that it is best practice for people not to talk to each other! If people are not talking to each other, or not doing so effectively, there must be reasons. If you are a practitioner, many reasons might already have occurred to you. If you are a parent or family member, then you will have your own insight into the situation. Here are some major reasons that occur to me:
No mechanism or protocols
While practitioners might feel the need to talk to the other practitioners around a child, there is no mechanism for it. This can be true both within a single agency (for example health, education, social care or voluntary agency) or across agencies. When there is no mechanism, it is almost certainly because there are no established multidisciplinary and multiagency (or multisectoral) protocols requiring people to talk to each other.
No time or place
The duplication, confusion and chaos that can happen when people do not talk to each other waste valuable time for children, families, practitioners and managers. Time is used more effectively in a team around the child system (TAC) with less time spent writing reports no one will read, rationalising how many people need to work with a child at the same time, and reducing the number of regular appointments child and parents are subjected to. Practitioners’ communications with each other can be face to face or virtual. Meetings can be in the child’s home or, if virtual, with parents fully engaged. (In my experience, virtual conversations with parents about a child should only happen once an effective face-to-face relationship is established.)
No trust or self-confidence
Practitioners are human beings and there can be emotions and attitudes involved in sharing their work with other practitioners. This is natural in all professions. The children and families we meet in early child and family support can be very challenging with few hard-and-fast answers and few ready-made solutions. Often we are working without certainty and this can make us wary of exposing ourselves to others in conversations around a child. I wonder if this is particularly true for newly-qualified practitioners? Practitioners need time with each other to grow confidence, trust and respect.
When people around a child do talk to each other, what will it achieve?
My list includes:
They will start relationships with each other in which respect and trust can grow
Anxious parents will be reassured to know their practitioners are talking to each other
They can share their observation about the child
They can tell each other what approach they are using and what goals they have for the child’s development and learning
They can easily remove any duplications and mismatches in what they are doing
They can start becoming a mutually-supportive team with shared aspirations
They can join their approaches togther to some extent.
You will see there is nothing weird, unprofessional or revolutionary in this first principle. But it can be very difficult to make it happen. Staying separate seems to be the default position of very many practitioners. What is the situation where you are?
Is there effective communication between the people around a child?
If not, what stops it happening?
What makes communication so difficult?
What problems does this lack of communication cause for children and families – and for practitioners?
SECOND PRINCIPLE
Parents are fully involved in the team around their child (TAC)
Parents have a rightful place in their child’s team. This is because the child belongs to the parents and no plans or decisions should be made without parents being fully involved. But there has to be room for flexibility in parent involvement: A parent might be accompanied by a grandparent, older sibling or trusted friend. Another family member might take the place of a parent if TAC discussion is beyond the capacity of a parent at that time.
Some parents might be nervous of the meeting situation and afraid to speak up. In this case, one of the practitioners who has a good relationship with the parent can offer support before, during and after the TAC meeting. It is strong rule in meetings that each person has an equal voice and each person’s views are respected. As the child belongs to the parents, then parents’ wishes are very important indeed.
When there are differences of view, perhaps about a course of action, there must be careful negotiation in which no one’s views are ignored or dismissed. Perhaps time is needed for more information to be gathered. Perhaps the parent and a practitioner can arrange to meet to go over the issues more thoroughly. Perhaps the discussion can wait till a later date. If a parent or another team member feels they are being ignored or bullied, then trust and partnership will be lost.
The venue chosen for meetings must suit the parents. Meetings can work well in the family home if that is what parents want. Other venues must be accessible, welcoming and non-intimidating. Pre-school siblings must be welcomed and catered for.
There needs to be some sort of very basic initial agreement between parents and practitioners at the beginning so parents will know what they can expect. It also means everyone can evaluate in three, six or nine months’ time whether or not people have held to the agreement and are working in the way they said they would. Obviously, it would be inappropriate for a practitioner to offer assurances to parents at this stage about what their baby or infant will achieve. But parents must be given some idea of what is on offer when they accept a support service.
The following are just three examples of items for such an agreement written by an agency after discussion and given to parents:
We respect your right and responsibility to bring up your child. We will offer you support in this when asked.
We will value and respect your child, treat them as a whole child and support you in giving them the best possible quality of life with freedom from discomfort and pain as far as possible.
We will work with you to make sure support for your child is properly organised to reduce tiredness, stress and strain on your child and on yourselves as parents.
An initial agreement of this sort is made before practitioners have detailed knowledge about the child’s strengths and needs, but the list should include some items that relate to what is already known about the child and family in their unique situation.
THIRD PRINCIPLE
There is a single, unified, holistic action plan for each child
Once TAC members have each acquired first knowledge of the child’s strengths and needs and of the family situation, they agree a single, unified, holistic action plan. The team around the child approach has a primary objective of preventing the fragmentation that occurs inevitably when the people around each child and family work separately from each other – and even, sometimes, in ignorance of who else is involved. The aim is for single comprehensive plan rather than a collection of separate ones. This reduces the potential confusion and overload when parents have a separate plan from each of the practitioners involved.
The actionplan is unified because it integrates everyone’s work into a coherent pattern in which all parts fit together harmoniously. Included here are parents’ approaches as well as those of practitioners. The plan is holistic because it considers all relevant parts of the child’s development and learning. Included here can be movement, communication, dexterity, cognition, posture, self-esteem, feeling, memory, listening, looking and more.
This teamwork is a learning process. When the informal agreement was made between the family and practitioners at the time when the family were accepting this support, very little was known about the child except that her or his needs fitted with what the support service could cater for. Practitioners’ first sessions with the child will bring their knowledge to a higher level so that they can roughly plan their future work and contribute to the action plan. As work progresses, each practitioner continues learning about the child using their preferred assessment processes.
The plan outlines how the team is going to operate in broad terms rather than giving details of separate programmes. The action plan can include:
The names and roles of practitioners who will be regularly and practically involved. Contact details included.
Where these people will do their work/play with the child – in hospital, clinic, centre or child’s home.
The particular elements of the child’s development and learning that will be prioritised in this phase.
Any sessions to be done jointly by practitioners, for instance with shared sessions or integrated programmes.
Regularity of the various sessions.
Plans for any at-a-distance conversations with phone or video communication.
Any plans for filming the child to aid discussion and observe progress.
The date of the meeting when the plan will be reviewed and refreshed.
As TAC practitioners learn more about the child, so will they learn more about the family’s situation, strengths and needs. Family needs can be extensive requiring much more time and skill than is available from TAC members. Where there is agreement about getting some outside help to the family, for instance about sleep, this can be put into the TAC Plan. The decision here might be to contact another professional or agency with parent’s permission.
The TAC Plan is an agreed outline of how support will be offered in the first phase and, broadly, of what the work will focus on. After an agreed period of time, the plan is refreshed or re-written for the next phase. Obviously, the Plan will be written and shared between TAC members. There may be a need for other people who are supporting the child and family on a less regular basis to see the Plan. This would be with the agreement of parents.
When a parent has spoken to a TAC member in confidence, this would not be discussed in TAC meetings and any agreed actions would not be written into the Plan. An example might be discussion of deteriorating relationships within the family or of private money matters.
FOURTH PRINCIPLE
Each child’s TAC (team around the child) is a mutually supportive team with a flat power structure
Each TAC comprises the small number of people who have the most regular and practical involvement with the child. Each member gets support from the others and everyone has an equal voice. This is horizontal collaborative teamwork.
There is no point in the TAC process if it does not support, inform and empower parents and other family members. Meetings are always in a positive mood even when there are very difficult issues to discuss. Practitioners have the professional and demanding task of being honest and sensitive at the same time. The aim is for each meeting of practitioners and parents together to be a positive experience in which parents feel listened to, feel they have an active part in planning support for the child and family and feel strengthened for the tasks that lie ahead today and tomorrow. Part of this is the very human process of people supporting each other. This can require personal qualities that are different from professional skills.
Many of the babies and infants who get need early support have complex multifaceted conditions for which there are no ready-made programmes and many of the families are in very difficult and challenging situations. Practitioners who try bravely to support a child and family on their own might soon be overwhelmed. Meetings s are designed so that practitioners, as well as supporting parents, can support each other. No one has to feel they are struggling on their own. This means that practitioners need to be able to relate to each other with honesty, empathy, trust and respect – the same qualities they must aspire to in their relationships with parents and other family members. These relationships must be given time to develop.
Each TAC meeting will have people from a variety of disciplines and agencies. This means it cannot have a manger as if it were in a traditional vertical hierarchy. Instead it has the flat power structure of horizontal teamwork. Meetings have a horizontal structure because the child’s practitioners are temporarily removed from their hierarchical relationships and work with each other and with the parents as equals. Each meeting has a facilitator to help the meeting run well and arrive at an agreed action plan, rather than a team manager who exercises authority. This model works well with babies and infants and has been successfully modified for older children and young people with other needs. A strong appeal of the TAC approach for both families and practitioners is that it holds the solution to disorganisation and fragmentation and, in requiring people around the same child to talk to each other, accords with common sense.
This horizontal teamwork brings an awareness of the interconnectedness of all elements of the child’s situation and needs enabling each practitioner to contribute naturally and almost instinctively to a whole approach. While working with the child and family, practitioners have the reassurance that their work and the multiagency action plan of which their work is part has been discussed and agreed collectively in the child’s TAC meetings. In this way, the approach is an excellent training ground for practitioners who have not worked before with children with a multifaceted condition. Managers and practitioners will need to consider how far it is appropriate for newly qualified practitioners to work in horizontal teams before they have become confident in their practice and have developed a solid foundation for their work with these children.
FIFTH PRINCIPLE
Joint action plans are designed to reduce the child and family’s exhaustion and stress as much as possible
Action plans in the team around the child approach are designed to reduce the child and family’s exhaustion and stress as much as possible. Child and family are helped to have the best possible quality of life and bonds of attachment between the new child and significant adults are nurtured. In this, there is no assumption that parents and other close family members must accept long-term stress, strain and exhaustion. With stress and exhaustion marital relationships can falter, family members can suffer physical and psychological illness and some families can fall apart under the strain.
It is essential for the new child's family members to have a person they know and trust to discuss their upset, bewilderment, worry and confusion. There can be feelings of guilt if a parent feels responsible for the child’s condition, if one parent is blaming the other or if one side of the family blames the genetics of other side. A parent might need help with self-esteem and confidence if they feel disempowered in the face of so many expert practitioners and then feel inadequate to the task of caring properly for the child.
It will help if one person can learn from parents if life is too busy with repeated assessments, medical treatments, therapy sessions and case conferences in hospitals, clinics and centres. This must include learning about travel difficulties and costs and additional problems when there are pre-school siblings to cater for. It will be necessary to ask how many home visits are made by various professionals because these can be sources of stress, can make the family feel the home is no longer a private domain and even that they are being observed and judged.
Parents can be asked about any difficulties they are having with home programmes from one or more therapists and teachers. Home programmes can work well for some families but for others the work is difficult to fit into the available time and space and can add to parents’ stress and tiredness. Parents might blame themselves if they feel they are not doing the programmes well enough or often enough. Also, some parents do not easily modify the natural parental role to become a pretend therapist or teacher.
Parents must be asked about the child and family sleep routines. Many parents are struggling with all of the above issues while they are sleep deprived because of the child’s sleep patterns. Parents will be anxious if siblings are also sleep deprived and failing at school.
Parental tiredness, stress and general downheartedness will impact directly on the infant. But the child with a multifaceted condition has other threats to her or his wellbeing and quality of life, including:
busy days, busy weeks
perhaps sleeping badly and experiencing bodily discomforts, anxiety, fear and pain during days and nights
a growing throng of non-family people each expecting the child to relate to them and accept being handled by them
being trundled around to a variety of locations for appointments that are organised without proper regard for feeding, sleeping and play times. This makes it very difficult for parents to establish infant routines.
home-visiting professionals intruding on home life and natural home activities
home therapy programmes delivered by parents that might be experienced by the infant as unpleasant and unwelcome interruptions of the natural flow of infant and family activity.
Quality of life for the new child and family is enhanced for the present and future when there are good conditions for developing bonds of attachment. This is equally true for all children. The necessary good conditions include: child and adults being as free of stress and exhaustion as possible; adults having quality time to spend with the child in a calm atmosphere; the child being calm and pain free for these quality times.
The first task is for practitoners to listen to parents and other family members to learn what their situation is, what is causing exhaustion and what is causing stress. The second task is to be imaginative and creative in making a comprehensive and unified action plan that reduces exhaustion and stress as much as possible.
SIXTH PRINCIPLE
It is the responsibility of parents to bring up their child. It is the responsibility of early support practitioners to support them when they ask for help
Effective early child and family support offers respectful partnership rather than authoritative intervention and helps parents find an evolving balance between the needs of the child and the needs of the family.
Human society in its infinite variety of cultures recognises that parents have the right, the responsibility and the skills to bring up their children without interference. This is early supports respectful starting point and, ideally, practitioners do not move in to help with the child’s development and learning until they are asked to do so. After that, the helping relationship begins by acknowledging the family’s knowledge, strengths and skills.
Local cultures determine broadly how families bring up children and, within their culture, each family has their individual way of doing things. Support cannot be effective unless this is explored. understood and respected. Practitioners, who might come from a different culture and might have different levels of education, social status and income, will fail to establish a helping relationship with parents if they try to impose their own way of doing things. The task is to start with what parents know about their child and with the skills they already have in helping their child develop and learn.
While this work in the past has been called early childhood intervention, any insensitive attempt to intervene between the child and the family or between the parents and their natural skills will be disempowering and result in a loss of trust. Parents of babies and infants who have some sort of special needs often report that practitioners have moved in on them, sensitively or insensitively, in a way that would not happen in other families. Parents of typically developing infants are left largely to their own devices with freedom to use their natural parenting skills and learn as they go along. If parents stay within the very broad limits set by their culture and society, they are not checked or taught or challenged.
Parents might lose this freedom when their baby or infant has difference, delay or disability. From the first hours or days of the child’s life, there can be an expanding host of experts telling parents what to do and how to do it. The assumption is that practitioners know best and that new parents know little or nothing. There is an unspoken message to parents that bringing up the child must now be a group effort led by experts. Few parents at this difficult time can resist this takeover and will take to heart the message that they are not up to the task of bringing up their new child. The result can then be a very dangerous mix of an infant with complex needs and parent or parents who are undermined, deskilled and feeling out of control.
An important part of the child- and family-centred approach is to help parents achieve a working balance between the needs of the child and the needs of the family as a whole. The balance will change as the whole situation changes. A new baby might have to be the focus of attention for weeks or months at the expense of family relationships and the needs of siblings. But this is not sustainable and parents might welcome support in finding a balance in which the family increasingly has some quality of life and avoids breaking apart. In early support, this will be an on-going process in which parents and other family members have opportunities with a trusted practitioner to discuss such topics as development, inclusion, anxieties, aspirations, future prospects and, for some, life and death.
Just as practitioners in the team around the child can support families with their child’s development and learning, so can they offer to support staff members when the child enters a nursery or first school. These staff members will almost certainly value the special knowledge and skills held by members of the child’s TAC. The family will value some continuity in the child’s opportunities for development and learning.
SEVENTH PRINCIPLE
Activities to support the child’s learning, development and quality of life are integrated into the child and family’s natural activities
All new children develop their understanding of the world and learn their first skills in manipulating it during the natural activities of taking food and drink, relating to parents and other family members, being washed / bathed / dressed, getting ready for bed, in playing with toys and moving around the house. This starts from the very first days as bonds of attachment are forming. Development and learning in these basic tasks begin in the family home and then perhaps continue outside in a play group, nursery or first school.
When asked to do so, early support ractitioners can support parents in learning how to manage these activities as pleasurable learning or educational experiences. Parents can decide which activities they want to focus on rather than trying to tackle them all at once. Some parents will choose those everyday activities that are presenting difficulties at the moment, for instance, managing clothes. Working with the child and family in this way: avoids discipline-specific programmes; ensures new learning is relevant to the child and family’s situation, routines and culture; provides daily opportunities to practice new skills. While fun and games are part of these activities as much as possible, children are learning to take their part in the life of the family.
All natural activities provide opportunities to develop understanding and skills in all interconnected and interdepenedent aspects of child development; posture, movement, dexterity, communication, cognition, seeing, hearing, touching, etc. They also provide early learning about relationships, emotions, consequences, sequences and purpose. As an example, all of this can happen in the activity of getting a child dressed at the start of the day. Practitioners can offer guidance in this when a parent is finding difficulties because of the child’s physical, cognitive or sensory challenges.
There is no suggestion here that parents should turn every natural activity into a lengthy education session. This would only add to their tiredness and stress and detract from the child’s enjoyment of life. Each parent must come to a balance that suits them and the child, that offers appropriate opportunities for development and learning, that fits with the child’s interest and capacities and that uses the time available to the best advantage. Providing early education in this natural and relaxed way will enhance quality of life by giving the child opportunities to be fully involved and succeed and by enhancing parent’s self-esteem as they increase their competence and confidence in bringing up their child.
EIGHTH PRINCIPLE
For the child’s development and learning, practitioners do not use the term multiple disabilities and think instead of a single unique multifaceted condition
In effective joined-up early child and famly support, practitioners do not use the term multiple or complex disabilities and think instead of a single unique multifaceted condition. Their task then is to integrate all their work into a unique, individualised multifaceted response for each unique child.
These old terms about multiples assume that challenges to a young child’s movement, dexterity, seeing, hearing, cognition, etc. are existing separately from each other. This cannot be true. For example, when a baby has cerebral palsy and impaired vision, each challenge will impinge on the other and jointly influence hand-eye co-ordination. Similarly, when there are challenges for a child in hearing and also in the development of relationships, the two challenges will interact with each other as the child learns first skills in relating to and communicating with parents and siblings.
The ill-considered medical approach to these children in countries with high economies has usually been to provide a separate practitioner for each diagnosis or condition. This overloads babies and infants, exhausts parents and creates confusion and contradictions. It offers the child no help in internally integrating the work in each area of development.
The positive side of challenges interacting with each other rather than staying separate is that progress in one area of child development, for instance hearing, will support progress in another, for instance developing social relationships. We come to see that the traditional separate areas of child development are not so separate after all and that, in supporting their development and learning, there is merit in seeing each new baby and infant in the whole – and then seeing all their challenges and diagnoses as a single unique multifaceted condition.
This brings us to the desirability of a joined-up multifaceted response. In this, practitioners move away from discipline-specific programmes and exercises towards relevant, functional and purposeful play/work activity. For instance, an exercise of rolling on the floor is replaced with the challenge of getting to the toy box or biscuit tin and arriving with one hand in a good position for reaching the biscuits. The presence of an encouraging parent, sibling or practitioner adds social and communication elements. The baby or infant now has opportunities to develop purpose, sequential activity and a sense of achievement in real life.
All natural baby and infant activities are opportunities for multifaceted support to promote development and learning. Suppose a parent has asked for help in teaching her child to sit at a table or tray and drink from a cup. The starting point is to observe the present approach, understanding and skills in this activity and then agree collectively how to move forward. This discussion will very likely include chair, posture, grasp, choice of appropriate cup and drink, hand-eye co-ordination, support at elbow / wrist, understanding of the task, listening to verbal prompts, pleasure when the task is achieved and so on. Each practitioner will have a valuable professional contribution to the plan.
This is collective activity in which TAC practitioners and parent learn skills from each other rather than having all of them around the child at drinks time. This achieves collective competence, the end product of which can be allocation of just one practitioner to support the child and parent for a period of time as the primary worker. This is an opt if it is felt necessary for the child and family's wellbeing. All the necessary expertise, knowledge and skills for teaching these multifaceted activities reside not in the child’s primary worker, but in the whole TAC team – practitioners and parents together. TAC practitioners support the worker to become competent in supporting parent and child in the chosen activity.
This multifaceted response in early support, perhaps witha primary worker, can reduce the number of practitioners around the child and reduce busyness for child, parents and practitioners. This supports the family in keeping family life as normal as possible.
NINTH PRINCIPAL
Joined-up support for a new child’s development and learning is much more an education issue than a health issue
In a team arond the child approach, a baby and infant’s first learning in posture, movement, dexterity, communication, cognition, social skills, vision, hearing, confidence, emotions, etc. come under the umbrella of education – which I define as the acquisition of new understanding and skills with or without teaching and instruction.
It is a hangover from the last century that in some places early support has been thought of as a health concern and made the responsibility of practitioners allied to health in hospitals and clinics. These practitioners are often trained in an aspect of child development and have an important contribution to make but are not trained in the discipline of how babies and infants learn and, in very many cases, are not trained to see the whole interconnected child. The consequence of this historical anomaly is that new children and their parents might have months or years of regular visits to hospitals, centres and clinics for some sort of therapy. This will probably mean:
A continual drain on family time, energy, spirit and money
Disruption of child’s essential daily routines with unnecessary stress and anxiety
Reinforcement of the medical idea of a problematic disability to be treated (if not cured)
Loss of opportunities for inclusion in more natural baby and infant social / educational environments.
Paediatric therapists can have a dual role with babies and infants: Firstly, they support the acquisition of new understanding and skills. This is an educational role; Secondly, they offer essential treatments to do with drinking, eating, respiration, muscles, joints, etc. This is a medical role and for this it might be necessary for the child to attend hospitals and clinics. In effective child and family support though, education and learning is best supported in the family home and then in play groups, nurseries and first schools - going to where the child is.
When a new child has a multifaceted condition, the ideal support system will bring the understanding and skills of parents, play workers, teachers and therapists into a collective effort to support development and learning. All of these people have separate competencies that can be brought together to create collective competence in whatever new learning is being focussed on. This brings paediatric therapists out of their hospitals, centres and clinics to work / play with the child where they are – at home or in nursery or school.
Following these basic early support principles, a large part of therapists' role is to join others in helping parents acquire new understanding and skills as they bring up their child. When there is agreement in support of the wellbeing of the busy family to reduce the number of practitioners around the child, some practitioners will act as advisors / consultants to the others and, for a period of time, reduce their direct contact.
We can go further in this and try more generally to demedicalise early child and family support in an effort to adjust the balance between health supports and education supports. This can include reducing children’s visits to hospitals and other health centres as much as sensibly possible and thinkig of each child as a learning child moving our mind-sets away from the negatives of disability, dysfunction, etc. While recognising the good work that happens in hospitals and health centres around the world, and acknowledging the high levels of practitioners’ caring and competence, I believe placing early child and family support in these medical institutions has happened by default with no conscious decision making. I also believe that early support has been unhelpfully flavoured now with negative medical terms while education terms tend to be about growth. I see a great need and great opportunities now for a radical redesign.
TENTH PRINCIPLE
Parents are not treated as passive and powerless recipients. They can work at the grassroots to help improve or create a local effective early support system
Parents of all children have a right to be fully involved in decisions about the health, education and wellbeing of their children. It is logical and natural for parents to be included in their child’s team as genuinely equal partners. It is equally appropriate for representative parents and family members to be involved in promoting, evaluating and improving early child and family support in their city, region or country. The involvement of parents and other family members will surely help counter outdated institutional attitudes.
This is not common practice in my experience. Instead parents, siblings and grandparents can be organisationally discounted and generally treated as lesser beings by some practitioners with elements of professional snobbery. They can be thought incompetent to contribute in any real way to discussions about how early child and family support is provided and then excluded by default from important meetings about service provision. The injustice of this becomes clearer when we imagine keeping black people out of discussions about racial equality or excluding women from discussions of supposed male superiority. With this context, I am presenting the children and families I am talking about as an oppressed, neglected and marginalised minority.
For parents and other family members to have their rightful place in developing early child and family support, it is necessary to counter out-dated institutional attitudes that are often strongest in more highly paid people and more common in medical services than in nurseries and schools. I am using the word institutional to characterise provision that is impersonal, inflexible, meeting the needs of agencies rather than of children and families, neglectful of human rights, and persisting only because it is the cheapest and easiest option. My description of outdated support is meant as a comment on how some agencies operate and is not meant to characterise the practitioners working in them.
During the last one hundred years in the UK, disabled women and men and members of their families and friends have been very powerful in changing how disability is thought about. New national or local organisations have been established to campaign for rights and to provide support. This has greatly influenced how public services operate – with much still to be done. In the same way, parents and other family members can be very powerful when they get together to enact change in early child and family support. This must include parents and family members whose children have grown beyond infancy and willing parents whose child has died. I advocate family members and practitioners getting together at the grass roots to take power with each other to influence how effective integrated early child and family support is created, managed and resourced in their city, region or country. Parents do not have to wait for the initiative to come from service managers.