Holding the future: The importance of health visitors

from an infant mental health perspective.

robin.balbernie@gmail.com © R. Balbernie.

I’m really not sure here! – I could be teaching

…

The viewpoint – from the Mental Health

Task Force of Zero to Three.

“Infant mental health is the developing

capacity of the child from birth to three

to: experience, regulate, and express

emotions; form close interpersonal

relationships; and explore the

environment and learn – all in the

context of family, community and

mental health expectations for young children. Infant

mental health is synonymous with healthy social and

emotional development.” So the task for early years

workers should be more preventative than reactive.

So how do we achieve this?

1818 – 1895

The starting point: The first relationships are

the most important.Positive predictable interactions

with nurturing caregivers

profoundly stimulate and

organize young minds.

The quality of early caregiving

has a long lasting impact on

how children develop, their

ability to learn, and their

capacity to both regulate their

own emotions and form

satisfying relationships. But

relationships can also have a

negative influence.

Health visitors are central to

infant mental health.

Health visitors are the

professional group at the frontline

for supporting vulnerable families

and babies by delivering a

universal service designed to

promote the healthy development

of small children. Top of the range health visiting

aims to promote all aspects of child health. It should

be preventative, relationship-based, containing,

developmentally informed and help connect families

to other specialized resources when needed.

Beliefs that support and sustain all early

preventative interventions.• Optimal growth and

development occur within

early nurturing relationships.

• The birth and care of a baby

offer a family the possibility

of new relationships, growth

and change.

• What happens in the early

years affects the course of

development across the

entire lifespan.

Characteristics of a preventative intervention.

• Its purpose is to increase the probability of normal

developmental trajectories in later life.

• It aims to prevent conditions that have not yet

occurred, risk proactive and increasing resilience.

• Generally conducted with families where the

infant does not show a diagnosable disorder.

• The approach is based on a model of development

where both risks and protective factors shape the

paths whereby individuals may become vulnerable

or resistant to later stresses and developmental

deviance.

• Universal prevention strategies provide the

essential foundation needed to identify families at

risk and for other interventions to be effective.

• The earlier the intervention the more positive

outcomes are likely to be, in part because there is

less likelihood for secondary complications.

• A focus on the parent-baby interaction and parental

attributions of the infant may be necessary for

optimum socio-emotional outcomes for the child.

• For families with multiple risks no single

intervention can be effective and numerous

components of treatment are needed from different

services. (See: www.IMHPromotion.ca )

“Early identification of individuals at risk is the first

step towards engaging families and offering them

programmes and services that will help parents to do

the best for their child and improve their child’s

health and wellbeing.”Healthy lives, brighter futures. DCSF & DOH (2009)

Without universal and invisible health

visiting early identification is a myth.

A preventative service can use a risk-

analysis in order to offer intervention

before the caregiver / baby relationship becomes too

severely compromised and a baby suffers needlessly.

Progressive universalism is key. (N.B.: Please contact me if you would like a check list for risk analysis.)

The Healthy Child Programme – your official

port of entry to promoting infant mental health.

The Healthy Child Programme (HCP) is the key

universal public health service for improving the

health and wellbeing of children using health and

development reviews, health promotion, parenting

support, screening and immunization programmes.

The HCP begins in pregnancy and recommends the

use of a range of universal, targeted and indicated

strategies aimed at promoting the wellbeing of both

the pregnant woman, her partner, and the unborn

baby. The interventions suggested are as follows. -

Promotional interviews: Following the

ante-natal promotional interview at 28

weeks, a later one is conducted by the

same health visitor at around 6-8 weeks

postnatal. This is a window of

opportunity for promoting maternal mental

health and the developing attachment

relationship with the infant, as well as identifying

any need for additional support. The postnatal

interview also focuses on supporting the provision of

sensitive and attuned parent-infant interaction, so

having time to make a relationship, to observe a

relationship and to think about a relationship is

essential.

Observing parent-infant interaction: The HCP

recommends that practitioners use routine contacts

with families as key opportunities to observe and

support the developing parent-infant

relationship. The aim of such observation is to

identify the type of ‘passive’ or ‘intrusive’ parent-

infant interaction in need of further support from

the health visitor; or those less

frequent cases where the caregiving

is seriously sub-optimal and

requires referral to a specialist

practitioner including infant mental

health and child protection

services.

Introducing the Social Baby: The Healthy Child

Programme recommends that both parents should be

introduced to their ‘social baby’ as soon as possible,

and that this should involve the delivery of

information about the sensory and perceptual

capabilities of their baby using media-based (e.g. The

Social Baby book/video) or other validated tools (e.g.

Brazelton Scale) that are available.

Anticipatory guidance is a preventative technique

recommended by the HCP. This strengthens parenting

by offering information about growth, change and

development and encouraging interaction. Some

parents need to be coached to work in their infant’s

‘zone of proximal development’.

Promoting closeness: The HCP also recommends

that practitioners promote closeness and

sensitive/attuned parenting by encouraging parents to

provide skin-to-skin care and the use of soft baby

carriers; and by ensuring that parents are invited to

attend an infant massage class (evidence-based for

PND).

Supporting fathers: The same methods for

supporting mothers also work with fathers (e.g.

infant massage, NBAS), and the HCP recommends

the delivery of father–baby/toddler groups that

promote opportunities for play and guided

observation. The research also shows that the most

effective methods of supporting fathers involves

opportunities for active participation with, or

observation of, their baby/toddler; repeated

opportunities for practice of new skills; and

practitioners being responsive to individual paternal

concerns. The HCP also points to the importance

of addressing parental conflict.

Areas of observation. Areas of thought. Areas of intervention.

Change any one part of such a tight system

and the rest will be affected.

Wider

community

and social

environment.

Extended

family.

Parents.Caregiving

relationship.Infant.

Parental

pasts.

Home

environment.

What has to be held in mind when working

with vulnerable families?• The central importance of relationships; the aim,

rationale and method for early intervention.

• An awareness of how the caregiving relationship

can be affected by interior and exterior pressures.

• A developmental perspective, including -

• The extended wiring up of the brain in the first 3

years of life; with executive function and self

regulatory skills being late arrivers and easily

compromised by early adverse experiences – the

stress that leads to maladaptive responses.

• The need for regular reflective supervision.

You are helping during the time when early

relationship-based experiences, those set up and

maintained by attachment, are shaping the basic

organization of the right brain - the neurological core

of the unconscious and the site of the capacity for

empathy, internal working models and self control.

So - no pressure!

The two basic principles of brain development are:

‘neurons that fire together wire together’ and ‘use it

or loose it’, creating appropriate neural networks.These sensitive periods of ‘proliferate and prune’ are when the baby’s brain architecture is most

shaped by experience. – But you do get a second chance in adolescence!

Number of

synaptic

connections

in the brain.

The infant brain has many more

synapses than the adult brain. These

connections rapidly increase in

waves after birth, then begin to

decline as the brain specializes.

Into adulthood.The first year.

Vision,

hearing, touch.

Symbols, relationships,

ideas, language.

Critical thinking, reflective thinking,

considered responses.

Peak

Synaptic density.

Over time the child

acquires increasingly

complex skills.

Windows of opportunity – interventions differ

depending on infant’s developmental stage.

Prenatal. An emphasis on the mental, emotional

and physical health of the mother (and father),

preparation for the birth and new baby, parental

attributions and expectations towards unborn baby

and parenthood, the identification of risk factors

and setting up appropriate support.

Immediate post-natal. Support if baby is

premature. Encouragement of breastfeeding if

appropriate, emphasis on the health of mother and

neonate, facilitating relationship, physical care of

baby, reinforcing the role of father.

1 to 3 months. Helping parents to soothe the baby

and recognize the baby’s signals and states by

promoting ‘mind-mindedness’. A time of getting to

know the baby and his or her temperamental

characteristics. Parents encouraged to access other

support if needed. The visual cortex is in a period of

critical growth, and it is important for the

developing language centres in the brain for the

baby to be engaged in conversation. The

diencephalon (hypothalamus, thalamus and basal

ganglia) is beginning to mature, and these areas

influence motor control, secondary sensory

processing, metabolism and hormonal balance.

4 to 7 months. Promoting the beginning of a selective

secure attachment to parents through appropriate

responsiveness. Need to encourage curiosity and play,

motor skills, communication and suitable stimulation

for building cognitive skills. Just chatting and

messing about. ‘Serve and return’ interactions. The

limbic system begins to wire up at about 5 months,

and this ‘emotional brain’ attunes to the social

environment while regulating internal states. This is

the beginning of the capacity for memory, emotional

regulation, attachment and primary sensory

integration. Helping parents attune to and soothe the

baby remains important, as is turning television off.

8 to 12 months plus. The pre-frontal cortex is

beginning to connect up enabling the baby to begin

to think and make decisions – such as selective

relationships. This marks the beginnings of

reasoning, stranger anxiety, problem-solving and

secondary sensory integration; thus appropriate

cognitive and sensory stimulation within the context

of caring relationships is increasingly important.

Toddlerhood. Supporting (and explaining) the

child’s growing autonomy and sense of self,

emotional regulation and loss of magical thinking.

Offer help with age appropriate limit-setting

through distraction (not the ‘naughty step’!).

Pre-school years. During this time the emphasis

should be on helping the child cope with negative

emotions (e.g. fears, sadness, loneliness, anger,

frustration, jealousy); promoting the ability to

express thoughts and feelings in words (the

encouragement of ‘reflective function’) so that it

becomes easier to inhibit aggression, resolve

conflicts through negotiation and pro-social

behaviour; encourage pretend play, cooperation,

empathy, learning and rule compliance, and

positive self-esteem. – And continue to discourage

television!(Use this resource: http://www.zerotothree.org/baby-brain-map.html)

Your work hinges on being able to make and

sustain relationships with vulnerable families.

“In this context, the ultimate impact of any

intervention is dependent upon both staff expertise

and the quality and continuity of the personal

relationship established between the service

provider and the family that is

being served.” (p.365)

(Neurons to Neighborhoods)

So do not let yourself be hassled

by managers who want to impress

with number-crunching. Babies

are more important than targets.

Positive relationships put you in a position

to nurture everyday protective factors.• For children growing up under adversity, a close and

warm attachment with an effective and sensitive parental figure is a universal protective factor.

• As is an environment that reinforces and supports any exploration or positive efforts made by the child.

• A powerful protective factor for parents is close relationships with other adults that afford social support and reduce isolation. A stable and supportive marital relationship is a powerful buffer against the effects of life stresses that may be unavoidable.

• Relationships with service providers who can provide long-term emotional and social support is thus an important intervention in itself.

The principles of preventative intervention

from an infant mental health perspective.

• Since relationships are the organizers of early

development the prime focus is always on

supporting the caregiver relationship. This involves

attending to the infant’s social and emotional world

and the parent’s changing subjective experiences

of the child as well as the interactions between

them.

• Process is as important as content in intervention;

and the process of developing trust takes a variable

amount of time.

All progress can take

time for a baby! All

babies are individuals.

• The first and central task

is to create a respectful

and collaborative working alliance with the family,

one laced with trust.

• The team delivering the intervention must be a

relationship-based organization.

And this demands -

• A working knowledge of ‘parallel process’ – how

relationships affect relationships – is essential. I.e.

how management-staff relationships and intra team

relationships affect intervenor-family relationships,

and how these in turn affect the caregiving

relationship.

• The development of reflective function, self-

awareness, is a necessary professional competency.

A case of seeing yourself from the outside and the

other from the inside.

• Reflection should be encouraged at all levels, and

must be backed up by regular and protected

reflective supervision.

• Avoid pathologizing, looking for a diagnosis, or

‘parent blaming’ in any way, as all reduce the

ability to understand, create a barrier to

relationships and impact parental self-esteem.

• Identify, treat and / or collaborate with others in

the treatment of any identified disorders of

infancy, developmental delays and disabilities,

regulatory disorders, parental mental illness or

trauma and family dysfunction.

• Help the parents access other

suitable services and resources

in a timely manner when

needed.

In conclusion – why we are all here.

Important relationships during the first years of life

“form the foundation and scaffold on which

cognitive, linguistic, emotional, social, and moral

development unfold.” (p.349) Neurons to Neighborhoods.

And …

You are the early warning system for the

next generation!

So don’t let the next government leave you floating in space.

Association of Infant Mental Health (UK).

This is an organisation for those interested in all

branches of infant development as well as early

intervention with babies and their families. It goes

with reduced rates at their workshops and

conferences, with access to a lot of information on

the website. Group membership for Children’s

Centres. Application forms

from:

Administrator AIMH(UK).

email: info@aimh.org.uk

website: www.aimh.org.ukThe advisory panel.

See this important report

from the D of E and the

WAVE Trust:

http://www.wavetrust.org

Plus the ‘The 1001

Critical Days’ manifesto:

http://www.1001criticald

ays.co.uk/the_coalition.p

hp where you can also

find

the crucial APPG Report

‘Building Great Britons’