UNIVERSITY OF

WARWICK Infant Mental Health Pathway: October 2013

1

Introduction

Why Perinatal and Infant Mental health?

Marmot (2010)1 identified that in order to reduce future social and health inequalities we need to need to give every child the best

start in life, and this reflects the view that the origins of much adult disease lie in the ‘developmental and biological disruptions

occurring during the early years of life’2 and more specifically to ‘the biological embedding of adversities during sensitive

developmental periods’.2

Both perinatal and infant mental health are therefore major public health issues, and perinatal and infant mental health services are

aimed at giving every the child the best start in life by promoting the wellbeing of parents and their babies across the perinatal

period, in addition to the early identification and treatment of problems that complicate pregnancy and the post-partum year.

For many families, standard perinatal services will help steer them through the life-changing transition to parenthood, while for

others the path maybe more complicated and require a greater intensity of specialised services and support. Whatever the level of

need, the economic case for providing effective services throughout this period is compelling,3 and the commissioning of services

to achieve these ends is supported by a range of policy documents (see below) emphasising the importance of early intervention,

and highlighting the opportunities afforded by the perinatal period.

The perinatal and infant mental health pathway described is both evidence-based in that it underpinned by research about ‘what

works’ during this period, and also includes a focus on primary prevention that goes beyond the traditional focus on the immediate

perinatal period to include preconception services that are aimed at building early resilience and self-respect in young people, and

developing the foundations for healthy and respectful relationships that form the basis for later perinatal wellbeing. It then continues

through pregnancy and the postnatal period until the infant is one year.

The goals of promotion, prevention and treatment during this important period require the commissioning of a diverse range of

services, alongside high standards of service delivery and care. This perinatal and infant mental health pathway has been

developed to support the work of both practitioners working directly with infants and their parents, and managers and

commissioners who have the remit of ensuring that the health, social care and public health services necessary to give every child

the best start in life, are in place.

2

Policy context

The policy context for this perinatal and infant mental health pathway is the Healthy Child Programme (HCP),4 which was revised

in 2009 to take account of recent changes in evidence about the importance of the perinatal period, and which sets the overall

standard in terms of the delivery and commissioning of services from pregnancy to age 5. The Health Visitor Implementation Plan5

describes the government’s strategy for expanding health visiting services, to ensure that families have a positive start, through the

delivery of the Healthy Child Programme.

A number of government reports3,6 have concluded that strategies to promote infant and child welfare should include a commitment

to prevention, and a focus on promoting wellbeing that begins during pregnancy and continues throughout the early years. This has

also been reflected in the review of child protection in England, which emphasises the importance and effectiveness of prevention

and early intervention. A final endorsement is provided by the cross party government strategy for mental health, which employs

‘starting and developing well’ as one of its key objectives.

The need for early prevention and intervention was also highlighted by the Munro Review of child protection services in England,

and the cross-party government strategy for mental health – No Health without Mental Health,7 which highlights ‘starting and

developing well’ as one of its key objectives.

Another significant part of the policy context is the NICE guidance Ante and Postnatal Mental Health is currently being updated, and

will hopefully include a greater focus on the infant.

Infrastructure Requirements

This perinatal and infant mental health pathway relies on the dedication and commitment of a large number of frontline practitioners

such as midwives, health visitors and children’s centre workers. A number of infrastructure requirements are necessary including

the following:

o A fundamental aspect of the provision of good quality and efficient services are the knowledge and skills of the frontline staff involved in their delivery, alongside the adequate staffing of services. A range of innovative ways of working to support the wellbeing of parents and infants have been developed over the past decade, and staff need to be provided with opportunities for continuing professional development (CPD) in order to acquire the necessary skills to deliver these new ways of working.

3

o The research points to the importance of practitioners having access to appropriate supervision and support, and evidence about the value of supervision has now been provided for practitioners such as health visitors in terms of increasing compassion and job satisfaction, as well as reducing burn-out and stress.8

o Other necessary infrastructure requirements include the type of integrated working practices between, for example, midwives and health visitors, and adult mental health practitioners and children’s social service workers, which have been identified as being necessary to both effective information sharing and patient care, in the perinatal period.9

o The full commissioning of the Healthy Child Programme is necessary to enable staff to work towards achieving the best start in life for every child.

An Infant Mental Health Pathway

The pathway is divided into three time periods:

1. Pre-conception

2. Antenatal

3. Postnatal (up to one year)

Within each of the three colour-coded sections, and in keeping with the Health Visitor Implementation Plan (DH 2011), Universal,

Universal Plus and Universal Partnership plus services are identified. Each section starts with an overview of the aims and

objectives for each of the time periods and then presents examples of evidence-based or promising initiatives that should be

provided and references to the relevant evidence. Example programmes from Warwickshire have been utilised in this programme,

but other similar programmes should where appropriate be used.

4

Context of service delivery:

The circle represents the local context - the community. The Universal; Universal Partnership and Universal Partnership Plus

programmes and services that can be provided as part of this infant mental health pathway will be influenced by and should take

account of, the wider community context.

local issues important to you , important to you

Universal Partnership Plus - on-going support for

families

Universal Plus

Support when you need it

Universal Services

contact at key stages- offered to all

5

Overview of the Infant Mental Health Pathway: Pre-Conception

SECTION ONE: Infant Mental Health Pathway: Pre-Conception

Promote safe and enjoyable relationships Build self-esteem and awareness of rights and responsibilities Increase knowledge about the importance of respectful, safe, and enjoyable relationships Develop skills for healthy relationships Promote knowledge about healthy intimate relationships and sexual activity

Preparation for future parenthood Develop knowledge about parenting responsibilities and skills Raise awareness about the importance of parenting

Develop parenting skills

Reduce teenage conception Improve knowledge about sexual intimacy and relationships Provide access to appropriate support services inside education and other settings

Promote planned pregnancy in adults Raise awareness and understanding about the importance of planning pregnancy Provide access to Long Acting Reversible Contraception to would-be parents who face additional challenges

Objectives

1. Promote respectful, safe and enjoyable relationships 2. Preparation for future parenthood 3. Reduce teenage conception 4. Promote the planning of pregnancies

Aims

6

Infant Mental Health Pathway: Pre-Conception

Intervention

Who / when

Personal Social Health and Economic Education (PHSE)

School-based planned programme of learning through which children and young

people acquire the knowledge, understanding and skills they need to manage their

lives now and in the future (http://www.pshe-association.org.uk) including:

Bullying

Drug and Alcohol

Emotional health and Wellbeing

Healthy Lifestyles

Safety

Commissioning of PHSE training from other agencies (e.g. Warwickshire Respect Yourself Campaign (RYC), which launched the Spring Fever’.10 programme in 2013; Warwickshire’s Safeline11 services deliver both anti- bullying workshops and counselling to schools and individuals)

Trained primary and secondary school staff, school nurses Voluntary sector

1. Promote respectful safe and enjoyable relationships Build self-esteem and awareness of rights and responsibilities

Increase knowledge about the importance of respectful, safe, and enjoyable relationships

Develop skills for healthy relationships

Promote knowledge and skills to enable children to develop healthy, intimate relationships

7

Schools to achieve National ‘Healthy Schools’ Status12

Work towards government target of all schools achieving National Healthy Schools Status

School staff

2. Preparation for future parenthood Develop knowledge about parenting responsibilities and skills Raise awareness about the importance of parenting Develop parenting skills

Commissioning and coordination of countywide services

Gather evidence, influence, introduce standards, and commission/deliver Relationship and Sexual Education (RSE) training for various agencies delivering RSE to ensure consistent, key messages countywide

County council

Schools based programmes13 Accessible Relationship and Sexual Health Services (RSE)

(Currently non – statutory) good-quality relationships education: teaching about

respect, honesty, trust, self-esteem and sexual health, starting in primary school

aged children (e.g. Warwickshire Respect Yourself Campaign (RYC) which

launched the ‘Spring Fever’14 programme in 2013)

Classroom-based initiatives (e.g. Roots of Empathy programme15 - see

examples)

Drop- in clinics: Advice, support and signposting (e.g. emphasis on keeping safe and safeguarding)

Anti-bullying policies and programmes: School-based programs to reduce bullying and victimization16

Trained primary and secondary school staff, school nurses and voluntary sector provision School nurses in secondary schools

8

Warwickshire’s Safeline17 services deliver both anti-bullying workshops and counselling to schools and individuals

Counselling services

National and local policies. Programmes delivered by both statutory and voluntary sector School nurses skilled in counselling

Conflict resolution Training for practitioners and participants, on line and face-to-face (e.g. One

Plus One)18

Voluntary sector

Web-based resources

Preparing Tomorrows Parents - http://www.preparetomorrowsparents.org

3. Reduce teenage conception Improve knowledge of sexual intimacy and relationships

Provide access to appropriate support services within education and other settings

Accessible Relationship and Sexual Health Education (RSE) Services

School-based counselling services Primary health care services Local drop-in clinics Online resources (e.g. RYC on line website, a guide to services and Q & A forum; Kooth’ on-line support for young people age 11- 1819) Other national resources (e.g. National Children’s Bureau: Sex Education

Forum)

Primary and secondary school years

9

Provision of contraceptive advice and services

Local services Community Contraception Service (CCS) provides a specialist contraceptive

and sexual health service which responds to individuals of all age groups, and is delivered in a timely and appropriate manner; including dedicated services for young people)

Sexual Health Clinics

Counselling services

Local services Time For You Warwickshire

Online counselling resources RYC online website, a guide to services and Q & A forum; ‘Kooth’ on-line

support for young people age 11- 18 20

School-based counselling services

Primary health care services

Primary health care Voluntary sector services Voluntary sector services Online services School nurses GPs Practice nurses

Support for Care Leavers Factors promoting care leavers transition to independent living

Stable placements whilst in care Access to and continuity of professional and informal support for young people as they prepare for the transition out of care

Statutory social care services Voluntary sector services

Support for Parents of adolescents On-line resources (e.g. NSPCC ‘Parent line’21)

Voluntary sector

10

Parenting programmes for parents of adolescents (e.g. Teen seminars offered by Warwickshire family and parenting team)

Other national/local support (e.g. On line resources from the NSPCC, Barnardos or Action for Children)

Commissioning and coordination of countywide services

Commissioning and introduction of standards for delivery of Relationship and Sexual Education (RSE) training for various agencies delivering RSE to ensure consistent, key messages countywide

Commissioning and coordination of county-wide services

4. Promote planned pregnancies in adults

Raise awareness and understanding about the importance of planning pregnancy

Provide access to Long Acting Reversible Contraception to would-be parents who face additional challenges

Intervention Who / when

Pre-conception counselling

On-line pre- conception services (e.g. Foresight 22 - see example below)

National and local pre-conception counselling services (NHS Family planning

Clinics)

Conflict resolution skills training for practitioners and participants; online

and face-to-face (e.g. One Plus One23)

Young counselling services (e.g. Time For You - Warwickshire)

Community perinatal mental health

services and voluntary sector

11

Provision of contraceptive advice and services Community Contraception Service (CCS) provides a specialist contraceptive

and sexual health service which responds to individuals of all age groups, including dedicated services for young people

Sexual Health Clinics Promote use of Long Acting Reversible Contraception (LARC24) where

appropriate to increase planned pregnancy

Primary care statutory and voluntary sector providers

Services for drug and alcohol dependency Access to advice about Long Acting and Reversible Contraception (LARC), and

specialist treatment (e.g. Compass Warwickshire - specifically for under 18’s; Supporting Drug and Alcohol Recovery Service provided in Warwickshire by The Recovery Partnership)

Primary care statutory and voluntary sector providers

Support for Care Leavers (e.g. Factors enabling care leavers transition to independent living25)

Stable placements while in care Access to and continuity of professional and informal support for young people

as they prepare for transition out of care (e.g. Care leavers be supported by a ‘leaving care worker’ and also a Personal Adviser (PA) from the charity Barnardo’s)

Easy and confidential access to sexual health information (e.g. Respect yourself campaign on-line website www.respectyourself.info)

Statutory social care services Voluntary services

12

Services for refugees and asylum seekers

English as a second language (ESL) classes available (n.b. MIND26 identified

language skills as a key factor in preserving mental health)

Classes provided by various providers. Some arranged through Children’s centres.

Services for individuals with learning disabilities

Specialist pregnancy services (e.g. The Charity FPA offer Specialist sexual health services for people with learning disabilities - http://www.fpa.org.uk)

Staff involved in the care of vulnerable, young people

Medication planning in pregnancy (e.g. Severe Mental Illness)

Medication planning prior to pregnancy and commenced as soon as pregnancy confirmed27

Primary care statutory and voluntary sector providers in conjunction with specialist services such as perinatal psychiatry

Examples

13

•Canadian developed, school-based programme where a mother and baby visit a class weekly, outcomes include an increasing social and emotional knowledge, decreasing aggression and increasing prosocial behaviour e.g. sharing, helping and including. 14 Current RCT by Queens University Belfast (Sept11-Dec15)

Roots of Empathy

•Warwickshire website: offers online counselling, support and advice to children and young people on a variety of issues

Kooth.com

Warwickshire website

•Free 24hr counselling service, support with issues which cause distress or concern to children and young people including child abuse, bullying, depression, substance misuse, parental separation and pregnancy

Childline

•Lessons on relationships and sexuality in primary schools has been found to promote knowledge and enhance pupil assertiveness 9

Spring Fever

Overview of the Infant Mental Health Pathway: Antenatal

Promote and prepare men and women for a healthy emotional transition to parenthood

Support emotional preparation for parenthood Support development of new roles Increase knowledge about the parent-infant relationship and early development of foetus and baby Develop communication and conflict resolution skills

Support parents developing relationship with baby Promote bonding by increasing reflective function

Promote parental mental health

Prevent anxiety and depression Support healthy couple relationships Support development of social networks

Identify and support parents with additional needs Identify parents with Universal Plus level needs (e.g. anxiety/depression, unwanted pregnancy, learning or physical disability,

lack of social support, care leavers etc.) Identify parents with Partnership Plus needs (e.g. unresolved loss, substance dependence, severe mental illness, domestic

abuse)

Objectives

1. Promote and prepare men and women for a healthy emotional transition to parenthood

2. Promote parental mental health

3. Support parents to understand the emotional and developing needs of their infant

4. Identify and support parents with additional needs (Universal Plus and Universal Partnership Plus services)

Aims

15

Infant Mental Health Pathway: Antenatal

Interventions Who /When

Routine Antenatal Care (e.g. Health and social care assessment of needs, risk and choices)

Support mothers (and fathers where possible) in the transition to parenthood and in the promotion of bonding and attachment.28 Encourage mothers and fathers to reflect on their developing baby and what their unborn baby may be like

Promote parental wellbeing (e.g. Encourage ‘mindfulness’,29 promote relaxation, address anxiety and depression, support healthy couple relationships, support the development of social networks

Midwives, health visitors medical staff, allied health professionals, children’s centre staff

1. Promote and prepare men and women for a healthy emotional transition to parenthood Support development of new roles Support emotional preparation for parenthood Increase knowledge about the parent-infant relationship and early development of the foetus and baby

Develop communication and conflict resolution skills

Aims

1. Promote and prepare men and women for a healthy emotional transition to parenthood 2. Promote parental mental health 3. Support parents to understand the emotional and developing needs of their infant 4. Identify and support parents with additional needs (Universal Plus and Universal Partnership Plus services)

16

Support the role of fathers - engage and promote the role of the father30,31 Signposting to information and services as appropriate

Resources:

Maternal Emotional Wellbeing and Infant Development: A Good Practice Guide for Midwives32 Healthy habits for baby and you33 Apps (e.g. Getting to Know your Baby36 Best Beginnings Bump to Breastfeeding NCT online information and resources34)

Antenatal Clinics Midwifery clinics in children’s centre

Midwives, health visitors,

children’s centre Staff

Antenatal Promotional Guide 34 (28 weeks) to identify women with additional needs (e.g. anxiety/depression; domestic abuse; substance dependency)

Midwives to inform heath visitors of pregnancy (follow-up with information as necessary i.e. change of pregnancy status) and health visitor to conduct interview using the Promotional Guide and inform midwives of named health visitor team

Health visitor

Antenatal Preparation for Parenthood Programmes Offered to all parents, but particularly first time parents.35 Programmes should include the ‘transition to parenthood’, getting to know your unborn baby and negotiating new roles in addition to physical aspects of pregnancy. For example:

Universal programmes: Pregnancy, Birth and Beyond: Resource pack for all providers of antenatal education36 Solihull Approach antenatal course37 National Childbirth Trust (NCT) 38

Midwives/health visitors, children’s centre Staff

17

Mellow Bumps39

Targeted programmes: Baby Steps (NSPCC)40 Nurturing Parents Programme (PEEP)41

Voluntary sector

Voluntary sector

Practitioner training in supporting couple relationships

One Plus One – Relationship Support (Brief Encounters)Training42 Solihull Approach43

Health professionals and children’s centre practitioners

Infant Mental Health (IMH) Champions

Practitioner with ‘Perinatal and Infant Mental Health’ training to provide an advisory service to colleagues; liaise with specialist mental health services; cascade training to others and provide on-going support and motivation

Midwives, health visitors, children’s centre staff

Unicef Baby Friendly Accreditation44 45

Breast feeding coordinators in post, promotion of breastfeeding advice and support Breastfeeding buddies46

Midwives, health visitors, medical staff, allied health professionals, children’s centre staff

2. Support parents developing relationship with baby

Promote bonding by increasing parental reflective function: Getting to Know Your Baby app and website36

Bookstart - reading to bump 58 Antenatal Promotional Guide 34

Midwives, health visitors, children’s centre staff

18

3. Promote parental mental health Prevent anxiety and depression Support healthy couple relationships Support development of social networks

Practitioner training in supporting couple relationships – see above

Antenatal Promotional Guide - see above Health visitors

Group-based Programmes

Mindfulness-based Stress-Based Reduction Programmes in Pregnancy47 31

Trained midwife, health visitor, voluntary sector staff

Antenatal Preparation for Parenthood Programme - see above

4. Identify and support parents with additional needs Identify parents with Universal Plus level needs (e.g. anxiety/depression, unwanted pregnancy, learning or physical

disability, lack of social support, care leavers etc.) Identify parents with Partnership Plus needs (e.g. unresolved loss, substance dependence, severe mental illness,

domestic abuse)

Identification of women in need of additional support Midwifery screening at booking-in Health visitor Antenatal Promotional Guide - see above

Midwife, health visitor

Referral pathways for women with additional needs

Universal Plus

Additional visits by health visitor/midwives

As appropriate via midwives, health visitors, GP

19

Group-based support (see above) Family Nurse Partnership48 49

Universal Partnership Plus

Domestic abuse support worker Substance/alcohol misuse worker; Parents Under Pressure Programme50 Perinatal psychiatrist/psychologist/CPN/crisis team IAPT (Improving Access to Psychological Therapies)

Specialist practitioners in NHS and voluntary sector

1. Identify and support parents with additional needs

Examples of good practice:

stic abuse)

• Solihull Approach Antenatal course: antenatal parenting group consisting of five-session course for mothers, fathers, partners, birth partners and grandparents

Solihull Approach

• Voluntary sector service providing comprehensive antenatal education and support. Available nationally

National Childbirth Trust (NCT)

• Nurturing Parents programme. A targeted programme for first time parents based based on the concept of Reflective Function. Pilot study currently underway

PEEP (Parents Early Education Partnership)

• On- line framework for the delivery of antenatal education. Consists of a resource pack for leaders of community groups and activities.It covers the physiological aspects of pregnancy and birth, but also addresses the emotional transition to parenthood in greater depth and recognises the need to include fathers and other partners in groups and activities

Pregnancy , Birth and Beyond

Overview of the Infant Mental Health Pathway: Postnatal to 1 Year

Aims

Support parents to provide an environment that fosters the infant’s emotional, behavioural, social and cognitive development

Promote parent-infant interaction that is sensitive/attuned and high in reflective function Promote secure attachment

Promote continued healthy social and emotional transition to parenthood Support the development of new roles Prepare men and women for the social changes and emotional challenges of the transition to parenthood Development of communication and conflict resolution skills

Promote parental mental health Encourage mental wellbeing Support healthy couple relationships Support the development of social networks Identify mental health problems early and create a culture where parents are confident to seek help

Identify parents in need of additional support Identify parents with Universal Plus level needs (e.g. anxiety/depression, unwanted pregnancy, learning or physical disability, lack

of social support, care leavers etc) Identify parents with Partnership Plus needs (e.g. unresolved loss, substance dependence, severe mental illness, domestic

abuse)

Objectives

1. Support parents to provide an environment that fosters the infant’s emotional, behavioural, social and cognitive

development

2. Promote continued healthy social and emotional transition to parenthood

3. Promote parental mental health

4. Identify parents in need of additional support (Universal Plus and Partnership Plus services)

Infant Mental Health Pathway: Postnatal to 1 year

1. Support parents to provide an environment that fosters the infant’s emotional, behavioural, social and cognitive development

2. Promote continued healthy social and emotional transition to parenthood 3. Promote parental mental health 4. Identify parents in need of additional support (Universal Plus and Partnership Plus services)

1.Support parents to provide an environment which fosters the infant’s emotional, behavioural, social and cognitive development

Promote parent-infant interaction that is sensitive/attuned and high in reflective function Promote secure attachment

Interventions Who

Unicef Baby-Friendly hospital

Baby to breast following delivery Skin-to-skin care post delivery

Midwives in delivery suite

Promotion of parent-infant interaction

Skin-to-skin contact 51 Infant carriers52 Breastfeeding support53 Cues-based infant massage programmes54 55

Midwives, health visitors, children’s centre practitioners, GP’s

Aims

References

23

Introduce the social baby using media-based resources

Getting to know your Baby’ app36 for parents and website for professionals. Social baby book and DVD56 Zero to Three ‘Healthy Minds’ resources 57 Baby Express newsletter57 Standardized tools to teach parents about the social baby (e.g. Brazleton Neonatal Behavioural Assessment Scale)58

Midwives, health visitors, children’s centre practitioners, GP’s

Promoting early learning and home learning environment

PEEP59

Baby express60 Bookstart61

Health visitors, children’s centre practitioners, early years librarians

Temperament-based anticipatory guidance62

Bath and bedtime routines

Midwives and health visitors, at every postnatal contact

Inform parents about available resources

NHS Information Service for Parents63 Netmums64 online support group for parents Family Information Service, Local services (i.e. Warwickshire County Council)65

Provided jointly by NHS, Department of Health and Department for Education Voluntary sector

Promote secure infant attachment Promote parental reflective function

Train practitioners to ‘model’ reflective parenting (Universal) Minding the Baby Programme (e.g. NSPCC)66 (Targeted)

Primary care, children’s centre and voluntary sector staff who have been trained to deliver these methods of

References

24

Nurturing Parents Programme (e.g. PEEP)43 (Targeted)

Promote ‘Secure Base’ parenting Train practitioners to ‘model’ secure base behaviour (Universal) Circle of Security programme67 (Targeted)

Specialist intervention for parent-infant relationship difficulties

Video-interaction guidance68 69 (Targeted) Parent-infant psychotherapy (i.e. Watch, Wait and Wonder70)

working

2. Promote continued healthy social and emotional transition to parenthood Support the development of new roles Prepare men and women for the social changes and emotional challenges of the transition to parenthood Development of communication and conflict resolution skills

Promote continued attendance of antenatal/ postnatal transition to parenthood classes (see above)

Support fathers Dads groups Infant massage groups for dads

Support for couple relationships One Plus One – Brief Encounters45

Support development of social networks Invitation to attend infant massage group Children’s centre activities

Midwives, health visitors, children’s centre practitioners, GP’s

References

25

3. Promote parental mental health Support mental wellbeing Support healthy couple relationships Support the development of social networks Identify mental health problems early and create a culture where parents are confident to seek help

Support mental wellbeing

Teach ‘mindfulness’ skills or invite to stress reduction groups Encourage parent ‘special time’ for self Encourage the use of relaxation techniques

Midwives, health visitors, children’s centre practitioners, GP’s

Support for healthy couple relationships

One Plus One - Brief Encounters45

Voluntary sector

Support development of social networks

Invite to attend infant massage group Encourage to attend children’s centre activities

Midwives, health visitors, children’s centre practitioners, GP’s

4. Identify parents in need of additional support (Universal Plus and Partnership Plus services) Identify parents with Universal Plus level needs (e.g. anxiety/depression, unwanted pregnancy, learning or

physical disability, lack of social support, care leavers etc.) Identify parents with Partnership Plus needs (e.g. unresolved loss; substance dependence; severe mental

illness; domestic abuse)

Postnatal Interview using the Promotional Guide 34 (includes Whooley questions)

Screen parent-infant interaction

Health visitor at 8 weeks

References

26

Parent-Infant Interaction Observation Scale (PIIOS)71 Ages and Stages Questionnaire72

Support mental wellbeing

Teach ‘mindfulness’ skills or invite to stress reduction groups Encourage parent ‘special time’ for self Encourage the use of relaxation techniques

Health visitors, children’s centre practitioners, GP’s

Support for healthy couple relationships

One Plus One45

Voluntary sector

Support development of social networks

Invite to attend infant massage group Encourage to attend children’s centre activities

Health visitors, children’s centre practitioners

4. Identify parents in need of additional support Identify parents with Universal Plus level needs (e.g. anxiety/depression; unwanted pregnancy; learning or

physical disability, lack of social support, Care leavers, etc.) Identify parents with Partnership Plus needs (e.g. unresolved loss; substance dependence; severe mental

illness; domestic abuse)

Identification of strategies as above

Referral pathways for women with additional needs Universal Plus

Additional visits by health visitor/midwives Group-based support (see above)

Health visitors and midwives refer through GP’s to specialist perinatal mental health services

References

27

Family Nurse Partnership49,50 Universal Partnership Plus

Domestic abuse support worker Substance/alcohol dependency worker; Parents Under Pressure IAPT (Improving Access to Psychological Therapies) National counselling

service for parents with Anxiety and Depression Access to a specialist perinatal and infant mental health services (e.g. Mother

and Baby In-Patient and Day Units; parent-infant psychotherapy; Perinatal psychologist.

Referrals may be made directly to IAPT services. Women may also self-refer to IAPT services Specialist mental health practitioners (e.g. psychologist; psychiatrists etc.).

References

28

Examples:

•The NBAS is is a neuro-behavioural assessment of the newborn, designed to document the newborn's contribution to the parent-infant system, the competencies and individual differences of the newborn, as well as any difficulties. The main feature of the NBAS is that it is an interactive assessment, which gives a clear profile of the baby's behaviour, and how it must feel to parent the infant.

•Britt GC and Myers BJ (1994) The effects of Brazelton intervention: a review. Infant Mental Health Journal, 15, 278-292

The Neonatal Behavioural Assessment Scale (NBAS)

•Use of the Newborn Behavioural Observations Systems Training (NBO) The NBO is a relationship-building tool between practitioner and parent, that supports the developing parent-infant relationship, and provides an introduction to their infant’s behaviour.

Newborn Behavioural Observations Systems Training (NBO)

•APP/website for Health visitors/other practitioners to use with parents who are pregnant or with babies under 6 months to enhance appropriate parent infant interaction.

'Getting to know your baby’ app and website

•A Relationship-Based Intervention to help improve communication and interaction, promote empathy and wellbeing.Video interaction guidance is an intervention through which a “guider” aims to enhance communication within relationships . It works by engaging clients actively in a process of change towards realizing their own hopes for a better future in their relationships with others who are important to them. Guiders are themselves guided by the values and beliefs around respect and empowerment.

Video Interaction Guidance (VIG)

References

29

Examples continued:

•Mellow Babies programme has undergone a randomized waiting list controlled trial. Clinically and statistically significant positive effects on maternal depression and Mother child interaction

Mellow Babies

•Parents with drug or alcohol misuse, who have a child under 2 in their care receive a 20 week programme which aims to support family functioning , develop parenting skills and caring relationships with infants

Parents Under Pressure

•NSPCC delivered intensive home visiting programme for vulnerable and at risk first time mothers under 25 and their babies. Delivered by social workers and health staff. Currently being evaluated.

Minding the Baby

•Fukkink, R. G. (2008). Video feedback in widescreen: A meta-analysis of family programs Clinical Psychology Review 28(6): 904-916.

Video Interactive Guidance (VIG)

References

30

Section 3: References

1 Marmot M. (2010) Fair Society, Healthy Lives: strategic Review of health Inequalities in England Post 2010. London: Marmot Review

2 Shonkoff JP, Boyce WT, McEwen BS. (2009) Neuroscience, Molecular Biology and the Childhood Roots of Health disparities: Building a New Framework for

Health promotion and Disease Prevention. JAMA 301; 21: 2252-2259 3 Knapp M, McDaid M and Parsonage M (2011) Mental Health Promotion and Prevention: The Economic Case. Department of Health, London.

4 DH. (2009). Healthy Child Programme: Pregnancy and the first five years of life. London: Department of Health

5 Department of Health. (2011). Health Visitor Implementation Plan - A Call to Action. London: Stationery Office

6 Munro, E. (2011). The Munro Review of Child Protection: Final Report. A child-centred system. London: Department for Education

7 DH. (2011). No health without mental health. A cross government mental health outcomes strategy for people of all ages. London: Department of Health

8 Wallbank S, Hatton, S. (2011). Reducing burnout and stress: the effectiveness of clinical supervision. Community Practitioner, 84(7), 31- 35

9 Leadsom A, Field F, Burstow, P & Lucas, C (September 2013 ). The 1,001 critical days: the importance of the conception to age two period: a cross party

manifesto. London: DH. 10

Evaluation of the Spring Fever programme. Rutgers WPF and CPS. An evaluation of the programme used in upper primary school. Accessed at , the http://www.rutgerswpf.org 11

Safeline – surviving abuse. www.safeline.org.uk/ 12

Healthy schools. Department for Education. (webpage) http://www.education.gov.uk/schools/pupilsupport/pastoralcare/a0075278/healthy-schools: accessed on 26.09.12. 13

Farrington D, Ttofi M. (2009) Campbell Systematic Reviews. School based programs to reduce bullying and victimization. 14

Evaluation of the Spring Fever programme. Rutgers WPF and CPS. An evaluation of the programme used in upper primary school. Accessed at , the http://www.rutgerswpf.org 15

Santos R.G., Chartier M.J., Whalen, J.C., Chateau D., Boyd L. Effectiveness of the Roots of Empathy (ROE) Program in Preventing Aggression and Promoting Prosocial Behavior: Results from a Cluster Randomized Controlled Trial in Manitoba. Poster presented at the Banff Conference on Behavioral

References

31

Sciences, Banff, March 2008. 16

DfES (2006) Teenage Pregnancy Next Steps: Guidance for Local Authorities and Primary Care Trusts on Effective Delivery of Local Strategies. London

17

Safeline – surviving abuse. www.safeline.org.uk/ 18

One Plus One On line support and training. The Couple Connexion. http://thecoupleconnection.net/ accessed 17.01.13. 19

Kooth. On line counselling. Kooth.com 20

Kooth. On line counselling. Kooth.com 21

NSPCC. On line support for parents. http://www.nspcc.org.uk/help-and-advice/for-parents-and-carers/expert-advice-for-parents-ask-jane/expert-advice-fo- parents-ask-jane-2_wda93586.html accessed 17.01.13 22

Foresight. www.foresight-preconception.org.uk 23

One Plus One On line support and training. The Couple Connexion. http://thecoupleconnection.net/ accessed 17.01.13. 24

NICE/SCIE ‘Promoting the quality of life of looked-after children and young people’ accessed on line www.nice.org.uk/guidance/PH28 25

Fauth, R., Hart, D., & Payne, L. (2012). Supporting Care Leavers' sucessful transition to independent living. NCB Research Centre, London: National Childrens's Bureau.

26

MIND, A civilised society: Mental health provision for refugees and asylum-seekers in England and Wales, 2009 (Report accessed on line at http://www.mind.org.uk/assets/0000/5695/refugee_report_2.pdf January, 2013) 27

Gregoire, A (2004) Maternal Mortality and Mental Health: Challenges and Solutions. Conference presentation 28

Barlow, J., & Underdown, A. (2007). The transition to parenthood: the role of the health visitor. In M. Bannon & Y. Carter (Eds.), Practical Paediatric Problems in Primary Care. Oxford: Oxford University Press. 29

Vieten, C., & Astin, J. (2008). Effects of a mindfulness- based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Archives of Womens Health 11, 67-74. 30

Magill-Evans, J., Harrison, M. J., Rempel, G., & Slater, L. (2006). Interventions with fathers of young children: systematic literature review. Journal of Advanced Nursing, 55(2), 248-264.

References

32

31

Ferguson, H., & Gates, P. (2013). Early intervention and holistic, relationship-based practice with fathers: evidence from the work of the Family Nurse Partnership. Child & Family Social Work 32

Underdown, A, & Barlow, J. (2012). Maternal Emotional Wellbeing and Infant Development. In RCM (Ed.). London: Royal College Midwives Trust. 33

DH. Healthy habits for baby and you (2012) available for health professionals to order online on line. www.nhs.uk/start4life 34

Purra, K, Davis , H, Mantymaa, M, Tamminen, T, & Roberts, R. (2005). The Outcome of the Europena Early promotion Project. Mother child interaction The International Journal of Mental Health Promotion, 7(1), 82 - 94. 35

NICE: (2007) Guidelines on Antenatal and Postnatal Mental Health. London: DoH

36

DH (2011) Preparation for Birth and Beyond: resource pack for those providing parenthood groups. London.

37 Solihull Approach www.solihullapproachparenting.com

38

NCT, On line resources http://www.nct.org.uk. Accessed 20.12.12 39

Mellow Bumps. Mellow parenting. mellowparenting.org 40

Baby Steps. National Society Prevention Cruelty to Children. www.nspcc.org.uk 41

Nurturing Parents Programme. Peers Early Education Programme (PEEP) www.peep.org.uk 42

One Plus One – Supporting couple relationships. www.oneplusone.org.uk 43

Solihull Approach www.solihullapproachparenting.com 44

Bartington S, Griffiths L, Tate A, Dezateux C and the Millennium Cohort Study Child Health Group.(2006) Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK? International Journal of Epidemiology 45

Broadfoot M, Britten J, Tappin DM and MackKenzie JM. The Baby Friendly Initiative and breastfeeding rates in Scotland. (2005) Arch Dis Child Fetal Neonatal Ed. 90:114-116 46

Dyson, L, Renfrew, M, McFadden, A, McCormick, F, Herbert, G, & Thomas, J. (July 2006). Promotion of breastfeeding initiation and duration. Evidence into practice briefing: HDA.

References

33

47

Vieten, C., & Astin, J. (2008). Effects of a mindfulness- based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Archives of Womens Health 11, 67-74. 48

Barnes, J et al (2009) Nurse-Family Partnership Programme: Implementation in England – Second Year in 10 Pilot Sites: the infancy period. London DCSF. 49

Barnes, J., Ball, M., Meadows P., Howden, B., Jackson, A., Henderson, J., and Niven, L., (2011) The Family Nurse Partnership Programme in England: Wave 1 Implementation in toddlerhood and a comparison between Waves 1 and 2a implementation in pregnancy and infancy. London, Department of Health 50

Dawe, Sharon, & Harnett, Paul. (2007). Reducing potential for child abuse among methadone-maintained parents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment, 32(4), 381-390. 51

Puig G, Sguassero Y. Early skin-to-skin contact for mothers and their healthy newborn infants: RHL commentary (last revised: 9 November 2007). The WHO Reproductive Health Library; Geneva: World Health Organization 52

Anisfeld, E., Casper, V., Nozyce, M., & Cunningham, N. (1990). Does Infant Carrying Promote Attachment? An Experimental Study of the Effects of Increased Physical Contact on the Development of Attachment. Child Development, 61(5), 1617-1627 53

Dyson, L., Renfrew, M., McFadden, A., McCormick, F., Herbert, G., & THomas, J. (July 2006). Promotion of breastfeeding initiation and duration. London. National Institute for Health and Clinical Excellence 54

Massage intervention for promoting mental and physical health in infants aged under six months. Cochrane Database of Systematic Reviews 2007 (4). 55

Underdown A. (2011) Interventions to support early relationships: mechanisms identified within infant massage programmes. Community Practitioner. 2011;84(4):21-6 56

Murray, L., & Andrews, L. (2000). The Social Baby: Understanding Babies Communication from Birth. Richmond, UK: CP Publishing. 57

Zero to Three Healthy Minds resources for parents. Downloadable from www.zerotothree.org/ 58

Das Eiden R & Reifman (1996). A Effects of Brazelton Demonstrations on Later Parenting: A Meta-Analysis. Journal of Pediatric Psychology 21(6):857- 868. 59

Parents Early Education Partnership (PEEP) www.peep.org.uk/ 60

Baby Express. www.thechildrensfoundation.co.uk/baby-express.php

References

34

61

Bookstart. www.bookstart.org.uk 62

Cameron, J. R., & Rice, D. C. (1986). Developing Anticipatory Guidance Programs Based on Early Assessment of Infant Temperament: Two Tests of a Prevention Model. Journal of Pediatric Psychology, 11(2), 221-234. doi: 10.1093/jpepsy/11.2.221 63

NHS Information Service for Parents www.nhs.uk/InformationServiceForParents/pages/home.aspx. Accessed 11.02.13. 64

Netmums www.netmums.com 65

Warwickshire Family Information Service. www.warwickshire.gov.uk/fis 66

Minding the Baby. NSPCC. www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/minding_the_baby_wda85606.html 67

Circle of Security. Early intervention programme for parents and children. http://circleofsecurity.net/ 68

Video Interaction Guidance. NICE public health guidance: Social and emotional wellbeing: early years Issued: October 2012 69

Fukkink, R. G. (2008). Video feedback in widescreen: A meta-analysis of family programs Clinical Psychology Review 28(6): 904-916 70

Cohen, NJ, Muir, E, Lojkasek M, Muir R, Parker CJ, Barwick M, & Brown M. (1999). Watch, wait, and wonder: Testing the effectiveness of a new approach to mother–infant psychotherapy. Infant Mental Health Journal, 20(4), 429-451