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Infant mental health: health visitors as key partners.

INTRODUCTION

The field of infant mental health has grown dramatically over the past few decades and its increasing importance is now widely accepted. This is due in part to the supporting evidence in babies' neurological development that demonstrates how crucial early childhood experiences and the vital role of caregiving relationships are in shaping babies' brains. Secure attachment relationships have a positive effect on babies' emotional and social well-being and development resulting in fewer behavioural problems, better peer relationships and less affective disorders e.g. depression and anxiety. Where there are concerns in the attachment relationship, early intervention, even before the child is born, is known to prevent the development of mental health problems in later life. (Building Great Britons, 2015).

BACKGROUND

The Infant Mental Health Service (IMHS) began in South Leeds during 2002 as part of a local Sure Start programme. 'The Baby Bonding Early Attachment project' was aimed at first time parents with a risk of attachment difficulties. A Consultant Clinical Psychologist worked together with health visitors, (HVs) community midwives and other members of the Sure Start team to promote secure attachment relationships between infants and their primary carers. Various interventions were used from pregnancy up to the infant's first birthday focussing on maternal mood and wellbeing, attunement in interactions and emotional and social support. The 'Understanding your Baby' (UYB) booklet was developed as a city wide provision for parents and was handed out by HVs either during the antenatal period or at the birth visit.

Following the mainstreaming of Sure Start, the Clinical Psychologist together with a part time specialist health visitor, (HV) provided the IMHS which included a referral service plus training and consultation. A training day 'Supporting parents to understand their Baby: applying attachment theory' (UYB training) was developed predominantly for HVs supporting them to use the UYB booklet with families to establish sensitive and attuned parenting in the early weeks and months of a child's life.

From April 2012 Leeds IMHS was commissioned as a city wide service with a clear structure promoting awareness of Infant Mental Health across the city. With the emphasis on prevention and early intervention the aim is to achieve optimal mental health outcomes for children by providing advice and support to practitioners and parents in meeting their infants' emotional needs. Delivery of training and ongoing consultation works to underpin and improve the skills of the workforce in health and social care, including Early Start teams, (HVs, nursery nurses and children's centre staff) community midwifery and the Family Nurse Partnership. The Service operates at universal level, universal plus through to a targeted, and specialist level of care. Referrals are accepted where there is concern regarding the attachment relationship and direct work with families is offered from conception to the child's second birthday.

TRAINING

The 'Infant Mental Health : Babies, Brains and Bonding' training is a basic provision of the IMHS and was initially aimed at Early Start practitioners but continued to roll out across the city. Leeds children's social workers, foster carers and third sector workers have received the training and currently it is provided for Local Authority nursery staff and children's Guardians. The day includes infant neurodevelopment, attachment theory and how to support caregivers in understanding their babies. The emphasis is to link all three sections so that practitioners appreciate the importance of focussing on infant states and cues when supporting parents/carers to be attuned, sensitive and responsive in their caregiving. In turn this promotes secure attachment relationships with a positive impact on their babies' brain development and consequent healthier emotional and mental health outcomes.

All training sessions are evaluated and both quantitative and qualitative data is collected which inform the annual review where changes have been made. The training consistently evaluates positively, with 98% of participants reporting that their personal objectives were met, 99% that the training was relevant to their job and 99% that they would recommend the course to others. The IMHS provides a summarised version of the training for HV students at Leeds Beckett and Huddersfield Universities including a module on maternal mood for Leeds students.

The UYB training remains a core component of the IMHS and is offered to a range of professionals supporting families with babies and young children including professionals working outside Leeds. Currently it is expected that all Leeds HVs access this training and HVs new to Leeds access it as part of their induction.

REFERRAL SERVICE

The IMH referral service is for families where there are concerns about the quality of the attachment relationship between infant and caregiver from conception to the age of two. Currently referrals are accepted from health professionals, predominantly HVs and midwives of those families who may benefit from direct intensive therapeutic support. Intervention is provided as early as possible to enable formation of therapeutic relationships, provision of vital information about the importance of early relationships and promotion of attunement and sensitive caregiving.

Using genograms, assessment focusses on family history, childhood experiences, emotional history, significant relationships, obstetric history and the caregiver's thoughts and feelings about their infant. Observation of the caregiver and infant interaction is crucial in providing vital information not only regarding the caregiver's ability to meet their infant's needs but more importantly regarding the infant's response. Close observation using an NCAST parent/child interaction assessment scale reveals caregiver's sensitivity, promotion of social, emotional and cognitive growth and response to their infant's distress together with the infant's responsiveness to their caregiver and environment providing necessary detail of their emotional wellbeing.

A diverse range of therapy options are offered to improve the quality of the parent- infant relationship, including psycho education, parent-infant psychotherapy, cognitive analytical therapy and cognitive behavioural therapy. Owing to the mix of skills and modalities within the team, families can benefit from team members coworking, which can be particularly beneficial when parental mental health difficulties are present.

The majority of referrals into the service are appropriate, suggesting that referrers are skilled in identifying concerns around attachment relationships and have a good understanding of the service. Quantative outcome measures are routinely collected using validated self-report questionnaires such as the Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder scale (GAD-7) and MORS, (Mother's Object Relation Scale, Short Form). More qualitative outcomes are obtained by verbal report, observation and Child and Adolescent Mental Health routine 'Experience of Service' questionnaires administered on discharge.

Results are positive, demonstrating visible and often significant improvements in parental mental health, parent-infant relationships and the wellbeing of infants.

CONSULTATION/REFLECTIVE CASE DISCUSSION

Working intensely with infants and their families in addition to the complexity of attachment relationships evokes strong emotions. The IMHS offers Consultation to teams, groups and individuals either face to face or by telephone. Early Start teams are provided with regular on-going support from the IMHS in the form of 'Reflective Case Discussion' (RCD) sessions.

Reflective supervision in IMH and early intervention supports best practice (The Wave Report 2013) and issues around confidentiality are negotiated in advance. A practitioner, typically a health visitor or children's centre outreach worker, will have a family in mind to bring for discussion having thought about key issues. The family is presented using a genogram. This provides a focal point to aid understanding when families are typically complex.

The same IMH practitioner facilitates the discussion at regular intervals and times to suit team members but usually every 6-8 weeks for 1hr-1 1/2hrs.

Cases brought for discussion are the complex families that practitioners worry about; families with chaotic life styles, relationship problems and where parents express concerns regarding their children's behaviour. The aim is to:

* Provide a safe, reflective space for practitioners to think about their work with families focussing on early attachment relationships.

* Hold in mind the importance of the infant's emotional experience

* Improve understanding and increase confidence

* Improve practice

* Relieve stress and anxiety

* Help build team cohesion and positive working relationships

A brief evaluation questionnaire measures the effectiveness of the RCD's which are found to:

* be helpful in reflecting about families,

* improve understanding of the infant/ child/family's experience

* improve practitioners' confidence when working with families.

DEVELOPING THE SERVICE

Additional investment into the IMHS has allowed the Service to develop by increasing the number of consultant clinical psychologist sessions and appointing new team members bringing the total number of health visitors in a team of six permanent practitioners to three. Health visiting is very much a core component of the IMHS and plans are underway to introduce a city wide universal screening by HVs for attachment concerns at the 6-8 week contact, alongside maternal mood.

ANNE CHITTY

Specialist health visitor, infant mental health, Parkside community health centre

References

Building Great Britons (2015) Conception to Age 2: First 1001 Days. All Party Parliamentary Group.

Oxford, M. L. & Findlay, D. M. (2013) NCAST Caregiver/Parent-Child Interaction Teaching Manual, Seattle: NCAST Programs, University of Washington, School of Nursing.

WAVE Trust (2013) Conception to age 2--the age of opportunity. Supporting Families in the Foundation Years. Department for Education
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Title Annotation:CLINICAL FEATURE
Author:Chitty, Anne
Publication:Community Practitioner
Geographic Code:4EUUK
Date:Oct 1, 2015
Words:1491
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