Written evidence submitted by AiMH-UK (CYP0083)

Part 1: What progress have the Government made on children and young people’s mental health, including but not limited to: the ambitions laid out in the 2017 Green Paper; improving access to mental health services; and addressing capacity and training issues in the mental health workforce

• While the ambitions of the Green Paper were wide-ranging in terms of school-aged children, there are only 3 paragraphs devoted to addressing the needs of very young children (i.e. infants and toddlers).

.1 The first of these paragraphs states that ‘we will commission further research into interventions that support parents and carers to build and/or improve the quality of attachment relationships with their babies’.

While the progress in terms of the proposed research on this topic has been slow some research projects are beginning to have an impact, such as for example:

• The results of the research on video interaction and positive parenting (ViPP) developed by Leiden University () led by Professor Ramchandani has paved the way for incorporating training in and delivering ViPP as part of NHS LTP to expand pre-existing perinatal mental health services.

• Participatory music is effective in promoting recovery from postnatal depression, which impacts in turn on the quality of bonding and attachment. This is now part of one of the largest studies evaluating the impact of the arts on physical and mental health. www.kcl.ac.uk/news/worlds-largest-study-into-impact-of-arts-on-physical-and-mental-health;  https://breatheahr.org/news/melodies-for-mums-expansion-wellcome/

It is very likely that this will promote new ways of working; in addition, non-verbal therapies are likely to be more effective in hard to reach populations where culture and language barriers result in limited access to interventions.

.2 The second paragraph focuses on ‘increasing the capacity of specialist perinatal mental healthcare’ with a £364m package of care.’ 

The £364m package of care has indeed now been implemented but while some services are providing interventions for women experiencing bonding/interactional problems, there has to date been no development of fully embedded parent-infant mental health pathways within perinatal mental health services (PMHS), whereby all women are screened not only for mental health problems but also for interactional problems, with services delivered by specially trained practitioners to address these problems.

A Perinatal Mental Healthcare Pathway for Infant Mental Health was developed in 2015 by the pan London perinatal mental health network, and was endorsed by the co-clinical directors of the Maternity and Mental Health Strategic Clinical Networks. One of the authors was Dr Maddeleine Miele (Consultant Perinatal Psychiatrist, CNWL NHS Foundation Trust, Chair of the North West London Perinatal Mental Health Clinical Network), who is a Board member of AiMH.

The pathway outlines five different strands that sit across the perinatal mental health life span, including parent-infant mental health. The key IMH Service Line Strand flow diagram is included below.

We recommend this pathway as a model, in terms of service provision and workforce development. With the need to extend PMHS services to include infants up to age 2 years, there is a need to further develop this pathway.

Screening for parent-infant difficulties has been limited by the lack of a validated screening tool; progress was made with the validation of the PIIOS and the establishment of the training from Warwick University. A systematic approach is required to incorporate the training as mandatory for health visiting and allied professionals such as nursery nurses and children centres' staff. A proportion of specialist perinatal mental health services across the UK have received this training.

.3 The third paragraph states that further work will be undertaken in terms of ‘Supporting healthcare professionals to understand the importance of healthy, low-stress pregnancies and healthy childhoods; and increasing the capability of midwives to support women with perinatal mental health issues’.

While there has been some piecemeal change with, for example, some local authorities appointing specialist mental health midwives, what is needed is a systematic approach to change, with the above topics being fully embedded within all midwifery training programmes; and required CPD on the topic for all trained midwives.

Health visitors and nursery nurses (who are increasingly taking on, from their health visitor colleagues, the direct work with families) also need to receive training in providing support for women with perinatal mental health issues and their infants.

Some progress has been made with the establishment of PMHS. Part of their remit is to offer supplemented care by training and supervising non-specialist staff. Some services offer IMH training. A few CAMHS services (see below) have an embedded parent-infant service, where clinicians provide support and training to front-line staff such as midwives, health visitors and early years practitioners.

Some medical schools routinely teach infant mental health and this is reflected in the Follow My Footsteps project at Imperial College Medical School, led by Professor Mitch Blair and Dr Robert Boyle, and its inclusion within the Phase 1 training of medical students at the University of Warwick.

• In terms of improving access to mental health services, despite the fact there is a similar prevalence for regulatory problems in children under 2 years of age, as for older children (e.g. 1:20), and that these regulatory problems are the basis for later problems, the Parent-Infant Foundation (2019) Report Rare Jewels showed that there is very little mental health provision at all for children aged 2 and under. Although children and young people’s mental health services (CAMHS) is nominally a service for 0-18 year olds, data collected through Freedom of Information suggested that in 42% of Clinical Commissioning Group (CCG) areas in England, CAMHS services would not accept referrals for children aged 2 and under. Furthermore, they found that there are only 27 specialised parent-infant teams across the whole of the UK.

Examples include:

• Avon & Wiltshire NHS Trust - IMH service embedded within CAMHS
• Livewell South West (Devon) - IMH team in CAMHS
• North West Boroughs Healthcare NHS Foundation Trust, Baby and Infant Bonding Support service (BIBS)
• East London Foundation NHS Trust has a number of dedicated parent-infant posts - CAMHS-based, working closely with respective PMHS.

Many more CAMHS need to incorporate an IMH service to be meeting the requirement for a 0-18 service.

1.3  In terms of addressing capacity and training issues in the mental health workforce:

The skills required to work with pregnant women, with parents of newborn babies, with older babies and young toddlers, and with older children and young people, are necessarily different. This indicates the need for specialist skills and training. At whatever professional level practitioners enter the field, they need to be equipped with the knowledge, skills and behaviours to enable them to increase their capability and capacity to work effectively. Infant mental health (IMH) is currently not universally considered as substantive core curriculum for professionals who work directly with babies/ infants and their families. This issue therefore needs to be addressed as a matter of urgency (see below for further information).

Part 2: The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing

The research now clearly demonstrates that the foundations for later mental health are established during ‘sensitive developmental periods’ in which the child is building up the ‘internal working models’ of themselves and others, that are the basis of their later capacity for self-regulation and interactions with other people, and that will serve them for a lifetime. The first 1000 days, and indeed the entire preschool period, are key windows of opportunity in which to both optimize the mental health of all children, and to prevent the development of problems in high risk groups. Research from reliable studies have shown that around 1:5 babies experience significant regulatory problems, and that these are the basis for later mental health problems. Changing the system to focus on early intervention, not only in terms of children in primary schools, but from conception onwards, would provide a much more cost-effective method of improving mental health outcomes for all children. 

Part 3: How the Government can learn from examples of best practice, including from other countries?

Examples of best practice with regard to promoting the mental health of children from infancy involves the embedding of specialist practitioners into pre-existing services:

Some PMHS employ specialist parent-infant clinicians, in addition to the nursery nurses whose primary role is to provide parent-infant support. Most PMHS are staffed by practitioners who are trained in adult mental health, not IMH (including the clinical psychologists who are often tasked with leading on IMH). The requirement for specialist IMH clinicians embedded within PMHS is a priority.

Examples of PMHS with IMH specialist practitioners:

NELFT Perinatal Parent Infant Mental Health Service – a specialist service with a large team of IMH clinicians including perinatal psychiatrists, perinatal community mental health practitioners, psychotherapists and psychologists

CNWL Wandsworth Perinatal and Parent Infant Mental Health Service: specialist psychotherapy service offering consultation, assessment and treatment to new parents

Avon & Wiltshire NHS Trust - Parent-Infant Therapist employed within perinatal team

Other models of working include:

Parent-infant specialist teams: specialised parent-infant relationship teams are multidisciplinary teams with expertise in supporting and strengthening the important relationships between babies and their parents. These teams work at multiple levels. They are expert advisors and champions for all parent-infant relationships, driving change across their local systems and empowering professionals to turn families’ lives around. They also offer high-quality therapeutic support for families experiencing severe, complex and/or enduring difficulties in their early relationships, putting babies on a positive developmental trajectory and better able to take advantage of the opportunities that lie ahead (see https://parentinfantfoundation.org.uk/teams/locations/).

Building Attachment and Bonds Service (BABS): this national award-winning service supports parents to build secure attachments and loving bonds with their babies, whilst breaking negative life cycles. The service is provided by clinical psychologists, midwives and volunteers. They provide easy to access community-based therapeutic interventions and support, for pregnant women, new parents and their partners, who are struggling with their emotional wellbeing and/or adjusting to their newborn baby. By offering attachment-based therapeutic support in the antenatal/postnatal period, they are able to help parents 'separate out' all of the difficulties that get in the way and impact on the parent-infant bond and relationship.

Pregnancy based child protection services: Walsall DAISY Programme is an intensive attachment-based perinatal programme for parents who have had a previous child removed from their care and are at risk of having a recurrent infant removed. This programme works with families in the Family Justice System, and the DAISY model has at its heart intensive attachment and mentalisation-based interventions which focus on building healthy attachments between mother and baby from conception onwards.

Workforce development

Infant mental health training and awareness-raising needs to be embedded within the existing training of all practitioners working with parents, infants and young children (as above, including midwives, health visitors and nursery nurses, and perinatal practitioners).

An Infant Mental Health CPD System has been developed by AiMH to support IMH practitioners to map their practice against the Infant Mental Health Competency Framework (IMHCF) - a national set of competencies. Practitioners can map their skills against the IMHCF and identify areas in which further IMH training is needed. Practitioners can apply for recognition of their skills on the Infant Mental Health Recognition Register (IMHRR). All UK-based IMH training programmes are being assessed and mapped against the IMHCF. This will improve the quality control and accessibility of IMH training programmes for all IMH practitioners.

Within the Perinatal Mental Healthcare Pathway for Infant Mental Health, a number of evidence-based approaches which offer training are recommended, including:

• Family Nurse Partnership
• Video feedback approaches (including VIPP)
• Circle of Security
• Minding the Baby
• Brazleton (NBO and NBAS)
• Mellow Babies (Mellow Parenting)

IMH trainings recommended by AiMH include:

-            OXPIP bespoke training (including Watch, Wait and Wonder and Video Interaction Guidance ) and supervision in infant mental health.

-            Anna Freud Centre (AFC) Mentalizing in Practice: Working with Parents and Babies – aims to enhance clinical practice by drawing on psychoanalytic and mentalization research and clinical work to encourage reflectiveness.

-            Tavistock and Portman: Perinatal and early years work: a psychoanalytic observational approach - a practice-based and theoretical approach to understanding infant and young children’s emotional, social and cognitive development from a psychodynamic perspective - observational skills, increased understanding of the factors which can promote healthy emotional development in babies, infants and pre-school aged children, leading to early identification and assessment of difficulties.

February 2021