Written evidence submitted by The Parent-Infant Foundation (CYP0050)
The Parent-Infant Foundation is a national charity that works to ensure that all babies have a sensitive, nurturing relationship to lay the foundation for lifelong mental and physical health. We do this through supporting the growth and quality of specialised parent-infant relationship teams across the UK.
Infant mental health is an incredibly important, but often neglected and poorly understood, aspect of children and young people’s mental health. It refers to the mental health of children during pregnancy and in the first two years of life, to include babies and toddlers.
Early relationships are fundamental to mental health. Young children need sensitive, responsive adults to help them to bring difficult emotions under control (for example, through soothing them when they cry). Parents’ responses shape how babies experience their emotions and how they learn to regulate and express these emotions. Early relationships set a template for how babies begin to think about themselves and others.
It is estimated that around 10-25% of young children experience significantly distorted relationships with their main carer(s) that will predict a range of poor social, emotional and educational outcomes, including poorer outcomes at EYFS, disruption to speech and language development, higher risk of mental health problems during childhood and later life, difficulties with relationships and social care, increased risk-taking behaviours such as substance misuse, increased risk of later antisocial behaviour and poorer emotional and behavioural self-control .[iii] This kind of ”disorganised attachment” is more prevalent in families living with stress factors such as domestic abuse, substance misuse, parental mental illness, exposure to trauma and poverty.
The first 1001 days, from pregnancy, is a period of uniquely rapid growth when the brain is highly sensitive to positive and negative influences. Babies brains are most ‘plastic’ or adaptable in this period as many millions of neural connections are made and then pruned, and the architecture of the brain is developed.[iv] A large body of research shows that early relationships, emotional wellbeing and development influence a range of later outcomes, including children’s learning and earning potential; emotional and social skills, and mental and physical health.[v], [vi],[vii],[viii],[ix],[x],[xi],[xii],[xiii]
Although children’s futures are not determined by the age of two, emotional wellbeing in the early years is strongly linked to later outcomes.[xiv], [xv] By protecting and promoting babies’ emotional wellbeing and development – improving infant mental health and strengthening parent-infant relationships – we have an opportunity to put children on a positive developmental trajectory, better able to take advantage of other opportunities that lie ahead.
Too often, mental health – even children’s mental health – is discussed without reference to infant mental health. There is often a “baby blindspot” and the needs of the youngest children are overlooked despite clear evidence that mental health problems during the earliest years significantly increase the likelihood of educational, social and other mental health problems during later childhood and later life.
The Children and Young People’s Mental Health Coalition now talks about infant, children and young people’s mental health. The same approach should be reflected across Governments, the NHS and local authorities around the UK. The Select Committee can model this through adopting the language of “infant, children and young people’s mental health” wherever relevant. All future mental health strategies and action plans, including any responses to support mental health in response to the COVID-19 crisis, must explicitly consider babies and set out clear, tailored responses to meet their needs.
The pandemic has further increased risks to infant mental health, widened inequalities and depleted services. In a survey of professionals working with families in the first 1001 days, 98% of respondents said babies their organisation works with had been impacted by parental anxiety/stress/depression affecting bonding/responsive care. This was widespread with 73% of respondents reporting that many of the babies they work with were impacted.[xvii] Action to protect and promote infant mental health is more important than ever.
The crisis is stressful for everyone, but for babies (born and unborn) this is happening at a critical time in their development where they are particularly vulnerable to family stress and anxiety. Without rapid and effective intervention, the negative impact of the pandemic on so many children’s development during this critical life phase will have repercussions on their mental health for years to come. Now more than ever we need to invest in equitable access to specialised mental health provision for these children.
There has been substantial focus on the academic “catch-up” for older children after the pandemic. A similar focus is required on recovery for all children, including the youngest, whose mental health has been affected by the pandemic.
As with older children, mental health support for young children should include specialised services as part of a graduated response model which ranges from universal support for all families, to targeted and specialist services for those who need extra help.
Specialised parent-infant relationship teams provide therapeutic support where babies’ development is most at risk due to severe, complex and/or enduring difficulties in their early relationships. These teams are called different names, including Infant Mental Health, Parent-Infant Mental Health or PIP services. We call them specialist parent-infant relationship teams because they focus on the relationship between a baby and their parents or caregivers as the main way in which to improve infant mental health.
The NHS Long Term Plan for England committed to improving access to specialist services for all children from 0-25. It stated that “over the coming decade the goal is to ensure that 100% of children and young people who need specialist care can access it”[xix]
Delivering this requires specialist provision – like parent-infant relationship teams – to be in place for all babies who need them. However, the NHS Long Term Plan says nothing explicitly about services for the youngest children. The Government has not made any subsequent statements about the need to improve provision for the youngest children and, no clear plans have been put in place to improve mental health services for this age group or monitoring of progress towards this goal. This is revealed in these recent Parliamentary Questions:
PQ 120765 asked 25th November 2020, answered 11th December 2020.
To ask the Secretary of State for Health and Social Care, what steps his Department has taken to increase access to specialist children and young people’s mental health provision, specifically for children in the first two years of life as part of the NHS Long Term Plan?
Our ambition in the NHS Long Term Plan is to create a comprehensive offer for 0–25-year-olds that reaches across mental health services for children, young people and adults.
Through the Plan we are increasing mental health funding by at least an additional £2.3 billion a year by 2023/24. This will see an additional 345,000 children and young people, and 370,000 adults, accessing specialist mental health care if they need it.
In addition, the Rt hon. Member for South Northamptonshire (Andrea Leadsom MP) is leading a new review, commissioned by the Prime Minister, into improving health outcomes of babies and young children. The review will consider the barriers that impact on early-years development, including social and emotional factors and early childhood experiences. She is expected to submit her findings and policy recommendations from the first phase of the Review into Early Years Health in January 2021. This will contribute to the Government’s vision for excellence in early-years health.
PQ 120766 asked 25th November 2020, answered 3rd December 2020.
To ask the Secretary of State for Health and Social Care, whether his Department collects data on access to specialist children and young people’s mental health provision disaggregated by users’ ages; and what steps he has taken to ensure equality of access for children of different ages.
This information is collected by NHS Digital via the mental health services dataset. However, data cannot be provided in the format requested until an agreed methodology is in place based on recent changes to the way the data is collected.
PQ 120767 asked 25th November 2020, answered 7 December 2020.
To ask the Secretary of State for Health and Social Care, how many more children aged 0-2 are accessing specialist children and young people’s mental health provision as at 25 November 2020 than were accessing such services at the time when the NHS Long Term Plan was published in January 2019.
The information is not available in the format requested.
There are fewer than 40 specialised parent-infant relationship teams in the UK: most babies live in an area where these services do not exist and vast areas of the country have no provision. These teams are referred to as “rare jewels” because they are scarce and small, but where they do exist, they are extremely valuable and highly valued.[xx]
There is very little mental health provision at all for children aged 2 and under. Even though CAMHS services should cater for 0-18-year-olds, in 2019 CAMHS services in 42% of CCG areas in England would not accept referrals for children aged 2 and under. And of those that said they accepted referrals and could provide data broken down by age, 36% had not actually seen a child age 2 or under.[xxi] Our mental health system is focussed on older children and often fails to recognise or respond to the needs of babies – despite the vital importance of early emotional wellbeing.
We welcome the NHS Long-Term Plan commitment to include parent-infant relationship support within perinatal mental health services. This is very helpful to promote and protect the mental health of babies whose mothers have moderate or severe mental health problems that meet the threshold for specialist perinatal mental health services. However, this alone does not meet the needs of families where mothers do not meet this threshold. There are a range of other risk factors that put early relationships and babies’ social and emotional development at risk. This includes (but is not limited to), families where fathers or other caregivers have serious mental health problems, where there might be concerns about abuse and neglect, or where the parent-infant relationship is being compromised through parent’s experiences of bereavement, previous child loss or unresolved trauma. Access to mental health services for babies should be dependent on the risks to their mental health, and not contingent on other factors such as their mother’s mental health needs.
There are current and predicted shortfalls in the workforce needed to meet the mental health needs of babies and young children. Existing parent-infant teams already report recruitment difficulties, yet there must be a rapid growth in the workforce to deliver the NHS Long Term Plan commitments of specialist children and young people’s mental health services and growth of parent-infant therapy within perinatal mental health services. NHSE and HEE must be clear about the skills and competencies required to deliver this specialised work and set out a plan for how sufficient numbers of appropriately qualified and skilled staff will be trained to deliver the planned service provision. Action is required to ensure those progressing through professional training currently are being equipped with appropriate competencies to join the expanding parent-infant workforce, and to deliver professional development to upskill existing professionals who may wish to move into this speciality.
Work with babies is different from work with older children; babies and many young children are non-verbal and cannot talk about their distress. Therefore, additional practitioner training is required to observe a child’s behavioural communication of distress and to learn how to work through the parent-infant interaction to address the psychological needs of the child. The work is also particularly complex because there are at least three therapeutic targets; the emotional distress of the baby, that of the parent(s) and then the interactions between them. This is skilled work that requires specialist expertise.
Work to protect and promote babies’ mental health requires:
Very few professionals are routinely trained in parent-infant relationship work as part of their core training. In virtually all professions, including midwifery, health visiting and clinical psychology, these skills are developed through voluntary, post-qualification training. An exception to this is parent-infant psychotherapy, where the core training covers perinatal and early infancy work, including undertaking supervised weekly observation of infants and their caregivers from birth until their second birthday.
There is no national workforce development plan for infant mental health staff nor any nationally adopted competencies framework. A charitable organisation, the Association for Infant Mental Health in the UK (AiMH UK), has developed a framework of infant mental health competencies which includes the skills, knowledge and behaviours that enable practitioners to deliver high-quality care to babies and their families. This competency framework has been developed for all staff working with infants and their parent/s/caregivers from pregnancy to the second year of life. It has three levels to distinguish between (1) general knowledge and skills, (2) advanced knowledge and skills, and (3) the knowledge and skills required to supervise and manage. The AiMH framework suggests practitioners working in specialised parent-infant teams would be expected to have skills at the higher levels, but also play a role in upskilling the wider workforce.
There is a clear case for investing in infant mental health. If babies have a difficult start it can lead to an increased risk of a wide range of poor physical and mental health, social, educational and economic outcomes.[xxii], [xxiii] However, effective early intervention – including the provision of specialised parent-infant work - can prevent emotional disturbances from impacting on children’s development or taking root and escalating into mental health problems.
The lasting and pervasive impacts of early adversity create a clear economic case for investing in the first 1001 days.[xxiv] It is more cost-effective to act early, rather than pick up the pieces when problems occur. Effective early action leads to accumulated savings by preventing other services being required later in the child’s life and improves the child and family’s participation in the economy.
Supporting early relationships requires a coordinated system of services and support to be available, ranging from universal support for all families, to targeted and specialist services for those who need extra help. These services must be working together as part of care pathways, which ensure that families receive the right support at the right time. Babies and toddlers are different from older children, so it is important that services can respond to their unique needs.
Across the UK, many services work with families to support infant mental health. Some – such as perinatal mental health services – have grown in recent years. Others - such as health visitors in England - have experienced significant cuts or perhaps never existed at all. There is huge unwarranted geographical variation in the quality and capacity of services, which reflects differences in local decisions and priorities rather than the level of need or demand for these services. Whilst some decision makers are taking action to improve infant mental health, others are doing very little. National Government leadership and investment is required to ensure all babies across the country have access to services that meet their needs.
Alongside providing direct support, specialist parent-infant teams are also expert advisors and champions for all parent-infant relationships, driving change across their local systems and empowering professionals to turn families’ lives around through the provision of training, consultation and supervision. This means that they build capacity in universal services and influence wider system change to promote and protect infant mental health, alongside providing direct therapeutic support.
There are examples of local areas, regions and devolved nations in the UK who are taking concerted action to improve their infant mental health provision. For example, Greater Manchester is the first area of the country to achieve a parent-infant team in every local authority. The region has a vision of integrated working which sees perinatal mental health teams (including Mother and Baby Units), Adult Mental Health (including the Improving Access to Psychological Therapies Teams), parent-infant teams and voluntary sector services working closely together to ensure no children fall through the gap. Good practice in this area sees close communication between teams at all stages of the care pathway.
Children and young people’s mental health policy and provision should meet the needs of ALL children from 0-18. There is clear and compelling evidence that early mental health and emotional development lays a foundation for later health and wellbeing. Around 10-25% of young children are at risk of significantly negative outcomes without intervention to support early relationships and mental health.
Without rapid and effective intervention, the impact of the COVID-19 pandemic on our most vulnerable babies will have repercussions on their mental health for years to come. Now more than ever we need to invest in equitable access to specialised mental health provision for these children.
There is often a “baby blind-spot” and the needs of the youngest children are overlooked despite clear evidence that mental health problems during the earliest years significantly increase the likelihood of educational, social and other mental health problems during later childhood and later life.
In 2019, children and young people’s mental health services in 42% of areas in England did not accept referrals for children aged 2 and under. The youngest children are therefore excluded from mental health services, and specific action is required to ensure their needs are met.
In order to deliver the NHS Long Term Plan for England commitment to improve access to specialist services for all children, action is required to grow specialised parent-infant relationships teams across the country. Significant workforce development is required to underpin this.
The case to protect and promote infant mental health is strong, and COVID-19 makes it all the more important. Government must take strategic action, matched with investment, to improve infant, children and young people’s mental health.
 Throughout this document we use parents to refer to babies’ primary caregivers – they may not always be the child’s biological parents.
[i] NHS England (2019) Long Term Plan. P50.
[ii] National Scientific Council on the Developing Child. (2004). Young children develop in an environment of relationships. Working Paper No. 1. Retrieved from http://www.developingchild.net
[iii] Van Ijzendoorn, M., Schuengel, C. & Bakermans-Kranenburg, M. (1999) Disorganised attachment in early childhood: A meta-analysis of precursors, concomitants and sequele. Development and Psychopathology, 11, 225-249
[v] Geddes, H. (2006) Attachment in the Classroom: the links between children’s early experience, emotional wellbeing and performance in school. London: Worth Publishing.
[vi] Bergin, C. and Bergin, D. (2009) Attachment in the Classroom. Educational Psychology Review, 21, 141-170.
[vii] Siegel, D. (2012) The Developing Mind: How relationships and the brain interact to shape who we are. New York: Guildford Press.
[viii] Feinstein, L (2015) Social and Emotional learning: skills for life and work. Early Intervention Foundation
[ix] O’Donnell, K., Glover, V., Barker, E. D. & O’Connor, T. G. (2013). The persisting effect of maternal mood in pregnancy on childhood psychopathology. Development and Psychopathology
[x] Straatmann, V. S., Lai, E., Lange, T., Campbell, M. C., Wickham, S., Andersen, A. M. N., ... & Taylor-Robinson, D. (2019). How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK Millennium Cohort Study. J Epidemiol Community Health, 73(11), 1049-1060.
[xi] Hambrick, EP., Crawner, TW. & Perry, BD. (2019). Timing of Early-Life Stress and the Development of Brain-Related Capacities. Front. Behav. Neurosci., 13:183. doi: 10.3389/fnbeh.2019.00183. https://www.frontiersin.org/articles/10.3389/fnbeh.2019.00183/full
[xii] Sitnick, SL., Galàn, CA., & Shaw, DS (2018). Early childhood predictors of boys’ antisocial and violent behavior in early adulthood. Infant Mental Health Journal, 40(1): 67-83. https://onlinelibrary.wiley.com/doi/full/10.1002/imhj.21754
[xiii] Fraiberg, S., Adelson, E., & Shapiro, V. (2003). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Parent-infant psychodynamics: Wild things, mirrors and ghosts, 87, 117.
[xiv] Feinstein, L. (2003). Inequality in the early cognitive development of British children in the 1970 cohort. Economica, 70(277), 73-97.
[xv] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
[xvi] Bowlby, J. (1988) p172-173 A secure base: Parent-child attachment and healthy human development. Basic Books.
[xvii] Reed, J and Parish, N (2021). Working for Babies: Lockdown Lessons for Local Systems, First 1001 Days Movement
[xviii] Ramchandani, P (2020) COVID 19, We can ward off some of the negative impacts on children. New Scientist https://www.newscientist.com/article/mg24532773-000-covid-19-we-can-ward-off-some-of-the-negative-impacts-on-children/
[xix] NHS England (2019) Long Term Plan. P50.
[xx]Hogg, S. (2019) Rare Jewels: Specialised parent-infant relationship teams in the UK. PIP-UK
[xxi] Hogg, S. (2019) Rare Jewels: Specialised parent-infant relationship teams in the UK. PIP-UK
[xxii] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
[xxiii] Hambrick, EP., Crawner, TW. & Perry, BD. (2019). Timing of Early-Life Stress and the Development of Brain-Related Capacities. Front. Behav. Neurosci., 13:183. doi: 10.3389/fnbeh.2019.00183. https://www.frontiersin.org/articles/10.3389/fnbeh.2019.00183/full
[xxiv] Heckman, J. The economics of human potential. https://heckmanequation.org/