Evidence and Impact: Improving infant mental health

The NSPCC works with children, young people and families who need help across the UK. Its services aim to protect children today, prevent abuse tomorrow and support wider efforts to make child cruelty a thing of the past. To improve understanding of best safeguarding practice, the NSPCC publishes evaluations of its services and interventions, and undertakes research and literature reviews. These are published on the NSPCC website (www.nspcc.org.uk/evidence) to contribute to the evidence on what works to protect children and families.

The first two years of a child's life are a particularly important developmental phase, primarily because of the impact of early parent-infant interaction on the infant's developing neurological and attachment systems. Children who grow up without positive and stable relationships are at greater risk of mental health problems.

The lives of families facing adversities, such as substance misuse, domestic abuse and mental health problems, are often complex. Parents themselves may be experiencing other challenges, such as feeling socially isolated or struggling to deal with their own traumatic childhood experiences. It is not surprising that for many, managing the day-to-day business of parenting is challenging.

Not all parents who face adversity find it difficult to care for their children. But we know that, when combined, these are significant risk factors for child abuse and neglect. Very young children are particularly vulnerable to the impact of abuse and neglect. Babies don't exhibit the classic symptoms of mental illness or disorder, but research has shown infants can experience depression as early as four months old. Research shows they can also experience serious psychiatric disorders related to attachment and traumatic stress.

The most important relationship is the relationship between a child and their parents, but other relationships between practitioners and parents, and between local services are also key. The NSPCC has developed evidence-based approaches that have been found to strengthen the relationships between couples and between parents and practitioners, which can have an impact on the mental health of very young children.

Learning points
Parent-infant relationship

In 2011 the NSPCC, in collaboration with the University of Warwick developed Baby Steps, a perinatal education programme for vulnerable parents based on the latest science, theory and research. Delivered to groups of mothers and fathers over nine group sessions and two home visits starting at the beginning of the third trimester of pregnancy and including three post-birth sessions, the programme aims to support parents through the transition to parenthood with a particular focus on the relationship between parents and the development of positive parent-infant relationships.

During the programme, parents learn about the development of their growing baby. They are encouraged to talk and sing to their baby and to spend time imagining what he or she might be like. In the post-natal period, practitioners provide parents with information about how to interact with babies at different stages. Practitioners offer positive feedback about how parents are responding to their infants' cues, and model the positive interactions they hope to see between parent and infant.

A pre- and post-measures evaluation found that both mothers and fathers reported an increase in their attachment to their unborn baby between the beginning of the programme and just before the birth. Parents also reported an increase in the warmth they felt towards their babies between the birth and the end of the post-natal part of the programme. Evaluation findings also suggested that parents had experienced changes which NSPCC would expect to enhance their ability to provide supportive care to their baby:

• A reduction in levels of parental anxiety and depression
• An increase in self-esteem
• An improvement in the quality of the relationship between parents (for those whose relationships were struggling) due to better conflict management and communication skills.

Therapeutic relationship

Minding the Baby (MTB) is an intensive home-visiting programme for disadvantaged mothers under the age of 25. The programme aims to promote secure parent-child attachment relationships by working with mothers from the third trimester of pregnancy until the child is two years old. Visits are carried out by health practitioners and social workers.

A large part of MTB is reflective work which encourages mothers to think about their or other people's mental states and how that influences their or other people's behaviour. The qualitative evaluation of MTB (Grayton et al, 2017) found the therapeutic relationships between mothers and practitioners were really important for being able to engage mothers in reflective work. Given that mothers on the programme faced a number of challenges such as a history of attachment disruption or negative experiences of professional involvement, it is impressive that practitioners were able to build trust and openness with the mothers and engage them in this work. Practitioners and mothers felt that the practitioner showing the mother they were consistently there for them, no matter what, was also important to this relationship. A randomised controlled trial is due out in 2019.

Using film to strengthen the parent-infant relationship

Parental attunement (or sensitivity) is core to building strength in the parent-infant relationship. A consistent understanding of parental sensitivity is "the ability to accurately perceive the child's signals and to respond to these signals in a prompt and adequate way" (Ainsworth et al, 1978). When signals are regularly missed by a parent or responded to in a discordant way the challenges to relationship building are heightened.

Research tells us that the use of video, particularly where it is used in strengths-based and parent-led ways, enables parents to identify for themselves when they are responding in attuned ways thereby supporting them to build on those responses with a particular infant and to apply that to their parenting of other children.

Professional relationships

Baby Steps is a service the NSPCC is scaling up.

Six early-adopter organisations delivered the programme and the NSPCC then evaluated how it was implemented. One of the factors that paved the way for successful implementation was about establishing strong referral pathways. This involved building good working relationships with referring bodies and continuing to be proactive about promoting the programme to referrers.

While one of the strengths of Baby Steps is its multi-agency approach - it is designed to be delivered by two practitioners from different backgrounds in health and social care - cross-agency co-delivery can be complicated. For example, anxiety about different working styles, logistics of cross-agency working and perceptions about the hierarchy of different professions. This challenge tended to diminish once delivery had started, however, because facilitators saw the strength of the cross-agency model.

Baby Steps is designed to sit alongside mainstream provision, and to be co-delivered by health and social care practitioners. If organisations are interested in delivering this service, the NSPCC offers an implementation support package through the Scale-up unit.

Increasing mental health provision for babies

Where infants have experienced maltreatment, the evidence shows that recovery can be rapid if safe nurturing care is achieved early enough, ideally in the first year of life. The benefits of this can be intergenerational. Increased awareness of the consequences of early adversity, generated by adverse childhood experiences (ACE) research, can drive a culture change by creating a common language and understanding of what children need to thrive.

Evidence shows that childhood adversity is associated with increased risk of mental health problems in adulthood and this can shorten lives. Experiencing multiple or severe traumatic events in childhood dramatically increases the odds of suffering mental health problems as an adult. Mental health services targeted at babies, young children and their families are one of the most cost-effective ways of making a positive impact on these problems. Yet, currently, most Child and Adolescent Mental Health Services CAMHS teams do not provide a service to children aged under five. Nor do they work with children where there is a live child protection concern which means our most vulnerable children, whose mental health may already be compromised or at risk, are unable to access support.

Any attempt to effectively address poor mental health must acknowledge that in many cases mental health issues can arise in infancy. Early childhood adversity and associated disorders carry a heavy social cost. The renewed focus generated by ACEs should be supported by a continuum of provision for children and families, from universal services through to targeted support for those who need it.

Investing to prepare and support new parents to care and interact with their babies, and to form strong healthy attachments is the fundamental building block in reducing adverse childhood experiences. Infant mental health care, comprising primary, secondary and tertiary interventions, should be an essential part of the current drive to reduce adverse childhood experiences.

FURTHER READING

• How a Child's Brain Develops Through Early Experiences https://www.youtube.com/watch?v=hMyDFYSkZSU
• Implementation Evaluation of Baby Steps Scale-up, Johnson and Andersson, 2018
• Minding the Baby: Qualitative Findings on Implementation, Grayton et al, 2017
• Baby Steps: Evidence From a Relationships-based Perinatal Education Programme, Hogg, Coster and Brookes, 2015