UNIVERSITY OF
WARWICK
Warwickshire Infant Mental Health Pathway: January 2014
Introduction
Why Perinatal and Infant Mental health?
Marmot (2010)1 identified that in order to reduce future social and health inequalities we 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’ 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 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 is underpinned by research about ‘what
works’ during this period, and also includes a focus on primary prevention. This 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. The pathway
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.
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’ currently being updated,
which 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.
2
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.
3
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.
Universal Partnership Plus
- on-going support for
families
Universal Plus
Support when you need it
Universal Services
contact at key stages- offered
to all
local issues important to you , important to you
4
Table 1: Prevalence of Perinatal Mental Health Problems: Warwickshire
Registered births
2012
Suffering depression in the
postnatal period
(10%)
Mental disorder requiring
referral for psychological
therapies
(80 per 1,000 deliveries)
Mental disorder requiring
referral to a specialist
perinatal mental health
service
(40 per 1,000 deliveries)
Psychotic episode requiring
in-patient admission
(0.2%)
Non-psychotic depression
Requiring in-patient
admission
(0.2%)
Pre-existing serious mental
illness complicating and
affecting birth
(0.2%)
Warwickshire
North
Rugby
South
Warwickshire
Warwickshire
2286
1261
2758
6305
229
126
276
631
183
101
221
504
91
50
110
252
5
3
6
13
5
3
6
13
5
3
6
13
Source: Office for National Statistics – Vital Statistics Tables - Live births (2012)
5
Table 2: Births in Warwickshire
England
Warwickshire
North
Rugby
South
Births
694.241
6,305
2,286
1,261
2,758
Crude birth rate /1,000 population
13.0
11.5
12.2
12.5
10.6
Source: Office for National Statistics – Vital Statistics Tables 2012
Table 3: Numbers of 0-5 year olds (inclusive)
Warwickshire
North
Rugby
South
37,853
13,517
7,691
16,645
Source: Mid 2012 population estimates, ONS
Table 4: Children subject to a Child Protection Plan as at 31 December 2013 aged 5 or under
North
Rugby
South
Warwickshire TOTAL
Unborn
3
1
1
5
Under 1
27
6
17
50
1 yr
23
6
14
43
2 yr
27
3
17
47
3 yr
22
2
9
33
4 yr
22
4
12
38
5 yr
13
4
5
22
Warwickshire TOTAL
137
26
75
238
6
Table 5: Family Nurse Partnership Uptake and Referrals - Jan 2013 to Jan 2014
Total No. Notifications No. Declined Not able to Contact Not Eligible* Miscarried Not Recruited Total Enrolled
South
36
3
3
3
1
10
16
Rugby
24
1
0
5
1
12
5
North
89
4
1
19
6
48
11
Please note, *those ‘not eligible’ were mostly due to gestation rather than their age. Those ‘not recruited’ were due to lack of capacity
The figures are dependent on midwives sending their booking forms and not all forms from the South are sent
Table 6: Number of fixed term and permanent exclusions from Warwickshire schools - Autumn and Spring Terms only
2012/13
Note: Data represents the number of exclusions NOT the number of pupils excluded as some pupils will have more than 1 fixed term exclusion during the
year
Permanent
North (North Warwickshire and Nuneaton and Bedworth Districts)
5
South (Warwick and Stratford on Avon Districts)
4
Rugby (Rugby District)
1
Fixed Period
North Warwickshire
130
Fixed Period
Nuneaton and Bedworth
388
Fixed Period
Rugby
373
Fixed Period
Stratford on Avon
349
Fixed Period
Warwick
303
Permanent
North Warwickshire
2
Permanent
Nuneaton and Bedworth
3
Permanent
Rugby
1
Permanent
Stratford on Avon
2
Permanent
Warwick
2
7
Table 7: Referrals to CAMHS 2013 - 2014
CAHMS SERVICE - No Of Referrals
Number of referrals from Primary Health Care
Number of referrals from Child Health
Number of referrals from Social Services
Number of referrals from Education
Number of referrals from YOS
Number of referrals from Learning Disability Service
Number of referrals from Adult Mental Health
Number of referrals from voluntary/ Independent sector
Number of self-referrals
Number of other Trust Referrals
Total Number of Referrals
Number of inappropriate Referrals
Gender
Male
Female
Area
North
Rugby
South
Coventry
Out of Area
Age
Aged 0 - 4
Aged 4 - 9
Aged 9 - 14
Aged 14 -16
Aged 16 -18
April /May /June
513
61
20
109
0
0
0
0
0
100
803
164
July/Aug/Sept
485
64
0
66
0
0
0
0
30
111
756
265
154
146
140
110
144
43
98
10
5
76
45
100
19
10
5
73
110
89
23
1
67
77
75
30
8
Overview of the Infant Mental Health Pathway: Pre-Conception
Aims
1.
2.
3.
4.
Promote respectful, safe and enjoyable relationships
Preparation for future parenthood
Reduce teenage conception
Promote the planning of pregnancies

Promote safe and enjoyable relationships
Objectives





Preparation for future parenthood




SECTION
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
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
 Infant
Provide Mental
access toHealth
appropriate
support services
inside education and other settings
ONE:
Pathway:
Pre-Conception

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
9
Infant Mental Health Pathway: Pre-Conception
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
Intervention

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 antibullying workshops and counselling to schools and individuals)
Who / when
Trained primary and secondary
school staff, school nurses
Voluntary sector
10

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)
Trained primary and secondary
school staff, school nurses and
voluntary sector provision
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
School nurses in secondary schools
11

 Warwickshire’s Safeline17 services deliver both anti-bullying workshops and
counselling to schools and individuals
National and local policies.
Programmes delivered by both
statutory and voluntary sector
 Counselling services
School nurses skilled in counselling
Conflict resolution
Voluntary sector
 Training for practitioners and participants, online and face-to-face (e.g. One Plus
One)18

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’ online support for young people age 11- 1819)
 Other national resources (e.g. National Children’s Bureau: Sex Education
Forum)
Primary and secondary school
years
12

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

Primary health care
Voluntary sector services
Counselling services
Online counselling resources
 RYC online website, a guide to services and Q & A forum; ‘Kooth’ online support
Online services
for young people age 11- 18 20
School-based counselling services
School nurses
GPs
Primary health care services

Support for Care Leavers
Practice nurses
Statutory social care services
Voluntary sector services
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

Support for Parents of adolescents
 Online resources (e.g. NSPCC ‘Parent line’21)
 Parenting programmes for parents of adolescents (e.g. Teen seminars offered
by Warwickshire family and parenting team)
Voluntary sector
13
 Other national/local support (e.g. Online resources from the NSPCC, Barnardos
or Action for Children)

Commissioning and coordination of countywide services
Commissioning and coordination of
county-wide 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
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
 Pre-conception counselling
 Online 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)
 Youth counselling services

Provision of contraceptive advice and services
 Community Contraception Service (CCS) provides a specialist contraceptive
Who / when
Community perinatal mental health
services and voluntary sector
Primary care statutory and
14
and sexual health service which responds to individuals of all age groups,
including dedicated services for young people
voluntary sector providers
 Sexual Health Clinics
 Promote use of Long Acting Reversible Contraception (LARC24) where
appropriate to increase planned pregnancy


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)
Support for Care Leavers (e.g. Factors enabling care leavers transition to
independent living25)
Primary care statutory and
voluntary sector providers
Statutory social care services
Voluntary services
 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 website http://www.respectyourself.info)

Services for refugees and asylum seekers
26
 English as a second language (ESL) classes available (n.b. MIND
language skills as a key factor in preserving mental health)
identified
Classes provided by various
providers. Some arranged through
Children’s centres.
15

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
16
Roots of Empathy
•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 (Sept11Dec15)
Kooth.com
Warwickshire website
•Warwickshire website: offers online counselling, support and advice to children and young people on a
variety of issues
Childline
•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
Spring Fever
•Lessons on relationships and sexuality in primary schools has been found to promote knowledge and
enhance pupil assertiveness 9
17
Overview of the Infant Mental Health Pathway: Antenatal
Aims
1. Promote and prepare men and women for a healthy emotional transition to parenthood
2. Support parents to understand the emotional and developing needs of their infant
3. Promote parental mental health
4. Identify and support parents with additional needs (Universal Plus and Universal Partnership Plus services)
Objectives

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 to understand the emotional and developing needs of their infant
 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)
Infant Mental Health Pathway: Antenatal
Aims
1.
2.
3.
4.
Promote and prepare men and women for a healthy emotional transition to parenthood
Support parents to understand the emotional and developing needs of their infant
Promote parental mental health
Identify and support parents with additional needs (Universal Plus and Universal Partnership Plus services)
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
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
Midwives, health visitors
medical staff, allied health
professionals, children’s
centre staff
 Promote parental wellbeing (e.g. Encourage ‘mindfulness’,29 promote relaxation,
address anxiety and depression, support healthy couple relationships, support the
development of social networks
19
 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 Baby34, Best Beginnings35 Bump to Breastfeeding
NCT online information and resources )

Antenatal Clinics
 Midwifery clinics in children’s centre

Antenatal Promotional Guide 36 (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

Midwives, health visitors,
children’s centre Staff
Health visitor
Antenatal Preparation for Parenthood Programmes
Offered to all parents, but particularly first time parents.37 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 education38
 Solihull Approach antenatal course39
 National Childbirth Trust (NCT) 40
Midwives/health visitors,
children’s centre Staff
20

 Mellow Bumps41
Voluntary sector
Targeted programmes:
 Baby Steps (NSPCC)42
 Nurturing Parents Programme (PEEP)43
Voluntary sector
Practitioner training in supporting couple relationships
 One Plus One – Relationship Support (Brief Encounters)Training44
 Solihull Approach45

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

Health professionals and
children’s centre
practitioners
Midwives, health visitors,
children’s centre staff
Unicef Baby Friendly Accreditation46 47
 Breast feeding coordinators in post, promotion of breastfeeding advice and support
 Breastfeeding buddies48
Midwives, health visitors,
medical staff, allied health
professionals, children’s
centre staff
2. Support parents to understand the emotional and developing needs of their infant

Promote bonding by increasing parental reflective function:
 Getting to Know Your Baby app and website34
58
 Bookstart - reading to bump
36
 Antenatal Promotional Guide
Midwives, health visitors,
children’s centre staff
21
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

Group-based Programmes
 Mindfulness-based Stress-Based Reduction Programmes in Pregnancy

Health visitors
49 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
22


Group-based support (see above)
Family Nurse Partnership50 51
Universal Partnership Plus
 Domestic abuse support worker
 Substance/alcohol misuse worker; Parents Under Pressure Programme52
 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
23
Examples of good practice:
Solihull Approach
• Solihull Approach Antenatal course: antenatal parenting group consisting of five-session course for
mothers, fathers, partners, birth partners and grandparents
National Childbirth Trust (NCT)
• Voluntary sector service providing comprehensive antenatal education and support. Available nationally
PEEP (Parents Early Education Partnership)
• Nurturing Parents programme. A targeted programme for first time parents based based on the
concept of Reflective Function. Pilot study currently underway
Pregnancy , Birth and Beyond
• Online 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
stic abuse)
Overview of the Infant Mental Health Pathway: Postnatal to 1 Year
Aims
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)
Objectives

Support parents to provide an environment that fosters the infant’s emotional, behavioural, social and cognitive
development



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





Promote parent-infant interaction that is sensitive/attuned and high in reflective function
Promote secure attachment
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)
Infant Mental Health Pathway: Postnatal to 1 year
Aims
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 53
Infant carriers54
Breastfeeding support55
Cues-based infant massage programmes56 57
Midwives, health visitors, children’s
centre practitioners, GPs
References

Introduce the social baby using media-based resources






Getting to know your Baby’ app34 for parents and website for professionals.
Social baby book and DVD58
Zero to Three ‘Healthy Minds’ resources 59
Baby Express newsletter57
Standardized tools to teach parents about the social baby (e.g. Brazleton
Neonatal Behavioural Assessment Scale60 and Newborn Behavioral
Observations (NBO) system61
Promoting early learning and home learning environment
Health visitors, children’s centre
practitioners, early years librarians
 PEEP62
 Baby express63
 Bookstart64

Temperament-based anticipatory guidance65
Midwives and health visitors, at every
postnatal contact
 Bath and bedtime routines

Inform parents about available resources
66
 NHS Information Service for Parents
 Netmums67 online support group for parents
 Family Information Service, Local services (i.e. Warwickshire County
Council)68

Midwives, health visitors, children’s
centre practitioners, GPs
Promote secure infant attachment
Promote parental reflective function
 Train practitioners to ‘model’ reflective parenting (Universal)
Provided jointly by NHS, Department of
Health and Department for Education
Voluntary sector
Primary care, children’s centre and
voluntary sector staff who have been
27
References
 Minding the Baby Programme (e.g. NSPCC)69 (Targeted)
 Nurturing Parents Programme (e.g. PEEP)43 (Targeted)
trained to deliver these methods of
working
Promote ‘Secure Base’ parenting
 Train practitioners to ‘model’ secure base behaviour (Universal)
 Circle of Security programme70 (Targeted)
Specialist intervention for parent-infant relationship difficulties
 Video-interaction guidance71 72 (Targeted)
 Parent-infant psychotherapy (i.e. Watch, Wait and Wonder73)
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 Encounters44

Support development of social networks
 Invitation to attend infant massage group
 Children’s centre activities
Midwives, health visitors, children’s
centre practitioners, GPs
28
References
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, GPs
Support for healthy couple relationships
Voluntary sector
44

 One Plus One - Brief Encounters

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, GPs
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 Guide36 (includes Whooley questions)

Screen parent-infant interaction
Health visitor at 8 weeks
29
References
 Parent-Infant Interaction Observation Scale (PIIOS)74
 Ages and Stages Questionnaire75

Support mental wellbeing
Health visitors, children’s centre
practitioners, GPs
 Teach ‘mindfulness’ skills or invite to stress reduction groups
 Encourage parent ‘special time’ for self
 Encourage the use of relaxation techniques


Support for healthy couple relationships
 One Plus One44
Support development of social networks
 Invite to attend infant massage group
 Encourage to attend children’s centre activities
 Use of local voluntary sector services to support families (i.e. the national
charity Home-Start76)
Voluntary sector
Health visitors, children’s centre
practitioners
Voluntary sector services
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
Health visitors and midwives refer
through GPs to specialist perinatal
30
References
 Group-based support (see above)
 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.
mental health services
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.).
31
References
Examples:
The Neonatal Behavioural Assessment Scale (NBAS)
•The NBAS is is a neuro-behavioural assessment of the newborn, designed to document the newborn's contribution to the parentinfant 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
Newborn Behavioural Observations Systems Training (NBO)
•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.
'Getting to know your baby’ app and website
•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.
Video Interaction Guidance (VIG)
•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.
The Tavistock 'Under Fives' infant mental health service
•The service is for parents and babies or toddlers who are struggling with the ordinary problems of development. Services are
delivered to those who have a worry relating to their baby or young child, whether it is temporary or long standing, major or
minor. A variety of talking therapies may be offered. (http://www.tavistockandportman.nhs.uk/underfivesmentalhealthservice)
32
References
Examples continued:
Mellow Babies
•Mellow Babies programme has undergone a randomized waiting list controlled trial.
Clinically and statistically significant positive effects on maternal depression and Mother
child interaction
Parents Under Pressure
•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
Minding the Baby
•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.
Video Interactive Guidance (VIG)
•Fukkink, R. G. (2008). Video feedback in widescreen: A meta-analysis of family programs
Clinical Psychology Review 28(6): 904-916.
33
References
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1
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2
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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
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7
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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
http://www.rutgerswpf.org
11
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12
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13
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14
Evaluation of the Spring Fever programme. Rutgers WPF and CPS. An evaluation of the programme used in upper primary school. Accessed at
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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
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34
References
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. http://www.safeline.org.uk/
18
One Plus One On line support and training. The Couple Connexion. http://thecoupleconnection.net/
19
Kooth. Online counselling. http://www.Kooth.com
20
Kooth. Online counselling. http://www.Kooth.com
21
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22
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23
One Plus One On line support and training. The Couple Connexion. http://thecoupleconnection.net/
24
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25
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26
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27
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28
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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
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31
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32
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33
DH. Healthy habits for baby and you (2012) available for health professionals to order online. http://www.nhs.uk/start4life
34
Getting to Know your Baby App and Website: http://www.your-baby.org.uk
35
Best Beginnings. www.bestbeginnings.org.uk/
36
Purra, K, Davis , H, Mantymaa, M, Tamminen, T, & Roberts, R. (2005). The Outcome of the European Early promotion Project. Mother child interaction The
International Journal of Mental Health Promotion, 7(1), 82 - 94.
37
NICE: (2007) Guidelines on Antenatal and Postnatal Mental Health. London: DoH
38
DH (2011) Preparation for Birth and Beyond: resource pack for those providing parenthood groups. London.
39
Solihull Approach www.solihullapproachparenting.com
40
NCT, Online resources http://www.nct.org.uk.
41
Mellow Bumps. Mellow parenting. http://www.mellowparenting.org
42
Baby Steps. National Society Prevention Cruelty to Children. http://www.nspcc.org.uk
43
Nurturing Parents Programme. Peers Early Education Programme (PEEP) http://www.peep.org.uk
44
One Plus One – Supporting couple relationships. http://www.oneplusone.org.uk
45
Solihull Approach http://www.solihullapproachparenting.com
46
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47
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36
References
48
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practice briefing: HDA.
49
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.
50
Barnes, J et al (2009) Nurse-Family Partnership Programme: Implementation in England – Second Year in 10 Pilot Sites: the infancy period. London DCSF.
51
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
52
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trial. Journal of Substance Abuse Treatment, 32(4), 381-390.
53
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WHO Reproductive Health Library; Geneva: World Health Organization
54
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Increased Physical Contact on the Development of Attachment. Child Development, 61(5), 1617-1627
55
Dyson, L., Renfrew, M., McFadden, A., McCormick, F., Herbert, G., & THomas, J. (July 2006). Promotion of breastfeeding initiation and duration. London.
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56
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57
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58
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59
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60
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61
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37
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62
Parents Early Education Partnership (PEEP) http://www.peep.org.uk/
63
Baby Express. http://www.thechildrensfoundation.co.uk/baby-express.php
64
Bookstart. http://www.bookstart.org.uk
65
Cameron J R & Rice DC (1986). Developing Anticipatory Guidance Programs Based on Early Assessment of Infant Temperament: Two Tests of a
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66
NHS Information Service for Parents www.nhs.uk/InformationServiceForParents/pages/home.aspx.
67
Netmums http://www.netmums.com
68
Warwickshire Family Information Service. www.warwickshire.gov.uk/fis
69
Minding the Baby. NSPCC. www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/minding_the_baby_wda85606.html
70
Circle of Security. Early intervention programme for parents and children. http://circleofsecurity.net/
71
Video Interaction Guidance. NICE public health guidance: Social and emotional wellbeing: early years Issued: October 2012
72
Fukkink, R. G. (2008). Video feedback in widescreen: A meta-analysis of family programs Clinical Psychology Review 28(6): 904-916
73
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
74
Svanberg, P. O., Barlow, J., & Tigbe, W. (2013). The Parent–Infant Interaction Observation Scale: reliability and validity of a screening tool. Journal of
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75
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38