7/8/2012
Keeping the Baby in Mind
Infant Mental Health
in Monmouthshire
Dr Aideen Naughton
Safeguarding Children Service
• What is Infant Mental Health?
• Early Neglect and long-term consequences
• What we have we learned? -Significant Harm
research (Ward 2011)
• Neurobiological Research-from Neurons to
Neighbourhoods (Shonkoff 2000)
• What might work?
• The IMH journey in Monmouthshire
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What is Infant Mental Health?
Definition
IMH is the capacity of infants &
toddlers to experience, regulate and
express emotions; form close and
secure interpersonal relationships and
explore the environment and learn.
(Zero to Three, Improving Maternal and Infant Mental Health,
2005)
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Why does it matter?
• Strong correlation between adverse
experience in early life and later dysfunction
in
– Social development
– Cognitive development
– Physical health and well-being
Risk Factors
• Antenatal Anxiety
• Postnatal depression
• Acute Mental Illness
• Domestic Abuse
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The Brain and Maltreatment
The most sensitive and
responsive organ to the
Environment
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Impact of stress
Impact of deprivation
Timing of insult
Duration of trauma
Consequences for children –
Early Neglect
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Altered neurobiology -Perry 1995, Strathern 2011
Attachment disorder- O’Connor 1999, MacLean 2003
Low self esteem – Steele 1997
Less social interaction – Hoffman –Plotkin 1984
Aggression –Reidy 1997, White & Widom 2003,
Kotch 2008
• Low IQ, learning problems – De Bellis 2005, KendallTackett 1996
• Juvenile delinquency – Steele 1997
• Attempted suicide – Erickson 2011
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Consequences for Adulthood –
Abuse
• Increased health problems– physical & mental
• Alcoholism
• Smoking
• Living in poverty
• Inability to nurture and provide emotional support
when they become parents
Felitti V.J. 1998
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Felitti V.J. 1998
Felitti V.J. 1998
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Felitti V.J. 1998
Significant Harm of Infants study
• Prospective study in 10 LAs
• Sample of 57 children who were subject
of a core assessment, section 47 enquiry
or became looked after before their
first birthdays
• 43 followed until they were three
Ward et al 2010; 2012
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Findings-Identification
• High prevalence of Substance Misuse,
Alcohol, Domestic Abuse, AMH
• Separation from at least one older
child (33% mothers, unknown number
of fathers) before birth of index child
• Just under 65% infants identified
before birth and almost all before 6
months old
Findings-Outcomes
Age 3 yrs , 28 (65%) living with a birth
parent, 15 (35%) permanently placed away
from home.
Living with birth parent
• 16/28 (57%) deemed low risk
• 12/28 (43%) medium, high or severe risk
of significant harm
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Findings-Double Jeopardy
• Over 50% children showing serious
developmental problems (poor speech) and
significant behavioural difficulties
(aggression)
• 60% of the permanently placed children faced
double jeopardy – late separation from abusive
parent, disruption of attachment with interim
carer on permanent placement.
Findings- other
• Specialist parenting assessments- causing
delay, repeated within short timeframes
without interventions in between
• Short term interventions
• Child protection plans of 32 weeks or less
• Quality of kinship care, poor parenting,
previous histories of adversity.
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When do we learn best?
Source: J Heckman & D Masterov (2005) Ch 6, New Wealth for Old Nations: Scotland’s Economic Prospects
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Effects of removing neglected children at various ages
into alternative care but no additional services
Age at
Removal
1st year
Recovery Potential
2nd year
Some recovery but less
3rd year
Less recovery
4th year
No change (100% need SEN and
public funding ++)
Significant recovery
From Neurons to Neighborhoods – the science of
early childhood development
(Jack P. Shonkoff, Deborah A. Phillips 2000)
1. Importance of early life experiences and genetics
on brain and behaviour
2. Central role of early relationships- support vs risk
3. Early life development of powerful capabilities,
complex emotions, essential social skills
4. Capacity to improve developmental outcomes
through early interventions
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Constraints of using knowledge
1. Balancing work and family responsibilities for
parents of all incomes
2. High levels of economic hardship
3. Cultural diversity, persistence of significant racial
and ethnic disparities in health and development
4. Increased numbers of young infants in variable
quality child care for long periods
5. Greater awareness of negative effects of stress
(family/community) on young children
Recommendation 1
Resources on a par with those focused on
literacy and numerical skills should be devoted
to translating the knowledge base on young
children’s emotional, regulatory, and social
development into effective strategies for
fostering:
1. Curiosity persistence, self direction
2. Cooperation, caring attitude and conflict resolution
capabilities with peers
3. Capacity to experience enhanced motivation
associated with feeling competent and loved.
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Early Childhood Programmes
• Well defined objectives and evaluations
• Combination of child focussed educational
activities with explicit attention to parent
child interaction patterns and relationship
building- greatest impact
• Elements that enhance social and emotional
development as important as linguistic and
cognitive competence – long-term impacts
include reduction in criminal behaviour
Dante Cicchetti, Fred Rogosch,
Sheree Toth (2006)
Fostering secure attachment in
maltreating families through
preventive interventions
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Randomised Control Trial
137 maltreated 52 controls
• Infant Parent Psychotherapy n = 53
• Parent Psycho-education Intervention
n = 49
• Community Services n = 35
Outcomes
• IPP group
disorganized attachment 87.5%
secure attachment
3.1%
• PPI group
disorganized attachment 83.3%
secure attachment
0%
• CS group
disorganized attachment 92.6%
secure attachment
0%
32.1%
60.7%
45.5%
54.5%
77.8%
no change
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• .........is it possible to do any of this?
Implications for Monmouthshire
What parents do at this very early stage
appears to be absolutely decisive in terms of
child outcomes
Earlier the child receives the support when she
needs it, the better her chances of success in
later life
Core Aim 1: The Early Years CYP Plan 2008-11
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Infant Mental Health Action Plan
• Raising awareness of importance of IMH
• Encouraging personal & professional
development to enable identification of when
infant mental health is at risk
• Providing a framework for the provision of
specific services which aim to enhance infant
mental health where it is less than optimum
• Providing referral pathways and a dedicated
IMH service for the more serious cases
(Monmouthshire CYPP Single Plan Core Aim 1)
Co-ordination of Services
Clear referral pathways
– Postnatal depression protocol (PND)
– Perinatal Pathway for use of AMI pathway
– Joint protocols between CAMHS and
CMHTs for early intervention
– Protocols to support joint working between
midwifery, primary care, substance misuse
services, domestic abuse services
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Co-ordination of Services
Collation of management information
– PND statistics
– Domestic Abuse Statistics on
pregnant women and those with
infants
– Serious Mental Illness in pregnant
women and mothers
Training of Midwives, Health Visitors, GPs,
Social workers, early years and relevant child
health staff on
– Postnatal depression,
– Impact of mental illness, domestic
and substance abuse on infant
mental health,
– Early intervention awareness to
support positive emotional wellbeing
in babies
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Raised Awareness of infant mental
health incorporated into existing
services
• Home Start Service throughout Monmouthshire
• Enhanced provision of Flying Start services available
across Monmouthshire according to need
• Early Thoughtfulness Project established promoting
reflection on emotional development and attachment
in both antenatal and postnatal periods.
• Increased awareness of Gwent Bibliography Scheme
supporting self help initiatives for parents and
babies
• Baby Massage workshops
Specialist Infant Mental Health
Service:
• Specialist Worker (CPN or Health Visitor)
to act as resource for training and
consultation to other staff within primary
care and CMHT.
• ‘Multi-agency Team’ comprising nursing,
medical, and social work staff with enhanced
skills following specialist training to act as a
resource for patients, carers and
professionals in a consultative capacity.
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Specialist Infant Mental Health
Service:
• Named person within each service Midwifery, Health
Visiting, CMHTs, CAMHS, and Paediatrics taking a
special interest in this area of work.
• Leadership and specialist support from a consultant
Psychologist/Psychotherapist
• Detailed training programme to include introduction
to infant observation skills to enhance interventions
aimed at the parent infant relationship.
Achievements to Date
• Attachment Conference - keynote speaker
George Hoskings WAVE Trust (Jan 2009)
• PND Training-detection,early intervention
and referral (universal health services)
• Solihull Approach- HVs,MWs,SWs, Early
Yrs, specialist CAMHs
• PMH nurse completed post grad in Infant
Mental Health(Tavistock clinic)
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• 0-3 focus on vulnerable infants in LSCB
strategic plan
• 10 week courses on Infant Observation skills
(Spring 2010,Autumn 2010,Autumn 2011)
HVs,MWs, Social Care,Early Years, Vol Orgs
• Child Psychotherapist led consultation and work
discussion groups (late 2010)
• Socio emotional development and protection
from harm (0-3) outcomes developed using 0BA
Single CYPP plan (2011-14)
New: Watch, Wait and Wonder
• An early preventive intervention pilot with infants
(0-36 months) and their carers
• Clinics weekly in north and south Monmouthshire
• 8 sessions of brief infant led psychotherapy
• Team working in pairs- Child psychotherapist, adult
psychotherapist, consultant paediatrician, PMHT
nurse (IMH specialist trained)
• External evaluation
• Report through 0-3 Subgroup (steering gp) CYPP
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Watch Wait and Wonder (Cohen 1999)
• An infant-led psychotherapy
• More successful in shifting children to a
more organised and secure attachment,
with corresponding improvements in their
affect regulation (crying/ sleeping
problems reduced) and cognitive
competence.
Meta-analysis BAKERMANS-KRANENBERG, M., VAN IJZENDOORN,M. And
JUFFER, F. (2003).
Watch Wait and Wonder (Cohen 1999)
• Mothers showed a decrease in parenting
stress and depression, and an improved
sense of their parenting and competence.
• Encourages parents to observe (watch),
wait (follow infant’s lead) and reflect
(wonder).
Meta-analysis BAKERMANS-KRANENBERG, M., VAN IJZENDOORN,M. And
JUFFER, F. (2003).
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Any Questions?
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