Written evidence submitted by Small Steps Big Changes (CYP0087)
Small Steps Big Changes (SSBC) is one of the National Lottery Community Fund - A Better Start Programme - funded sites, utilising a test and learn approach to support the improvement of social emotional development, communication and language and nutrition outcomes amongst 0-4 year olds in four ethnically diverse wards in Nottingham. SSBC utilises a partnership approach including health, early years, early help, community and voluntary sector providers and parents to improve early years’ child development outcomes. Our partnerships experience and commitment to supporting families with young children to improve outcomes forms the basis of the submission.
Small Steps Big Changes (SSBC) is one of the National Lottery Community Fund - A Better Start Programme - funded sites, utilising a test and learn approach to support the improvement of children’s social emotional development, communication and language and nutrition outcomes amongst 0-4 years olds in four ethnically diverse wards in Nottingham. SSBC utilises a partnership approach including health, early years, early help, community and voluntary sector providers and parents to improve early years’ child development outcomes. Our partnerships experience of supporting families with young children to improve outcomes forms the basis of the submission.
This written evidence principally addresses two areas
1) 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.
2) Addressing capacity and training issues in the mental health workforce.
The evidence provided intentionally widens the boundaries of the system around children and young people’s mental health, to include a focus on the early years. The evidence calls on the committee to recognise the importance of early prevention and early intervention in babies and young children in addressing children’s mental health.
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.
1. Early prevention and early intervention around babies and young children’s mental health should form an important contribution to support efforts to prevent more serious mental health illness developing in children. Investing in early approaches to wellbeing holistically and with the youngest of our population is necessary.
Attention to parental mental health
2. One of the foundations for good socio-emotional development in children is good parental mental health, with poor parental mental health being a known risk factor for later childhood mental health1,2 .
3. Nationally up to the end of March 2020, the number of episodes of “child in need” where parent mental health was identified as a factor, at the end of an assessment increased by 20,810 (15%) from the previous year3.
4. It is estimated that 14% of Nottingham residents with dependent children have poor mental health4.
5. Although many families are able to provide nurturing care for their baby or younger child despite mental health difficulties, some struggle and the consequences of this can be wide ranging. Poor mental health can increase the likelihood of poor attachment and consequent poor cognitive, developmental and social and emotional health outcomes1,2. Poor parental mental health can contribute to family conflict and family breakdown5.
6. It is important to proactively identify those families that need additional support early.
7. Nottingham Family Nurse Partnership (FNP), ADAPT project provides an example where early support for young parents has shown benefits.
As part of the (FNP) ADAPT project, Nottingham City focused on developing a mental health toolkit. The toolkit was designed to enable young parents to;
- Understand their mental health and its impact on their child and relationships
- Provide some strategies for managing mental health
- Improve attachment and responsive parenting
8. In Nottingham Family Nurses have continued to integrate the toolkit into practice and feel it has positive benefits to their clients. Family Nurses report using the toolkit helps the young mothers and fathers understand what mental health is and breaks the stigma around talking about mental health. This often involves acknowledging adverse childhood experiences (ACEs) and helping them to understand how their backgrounds influence their ability to parent. The nurse can advise on what support is available and work with the client to encourage them to accept help, which is often a challenge.
9. The nurse will work with the parents to support attachment and understanding of responsive parenting and to build brain development. The programme’s tools, activities and observations allow for the highlighting of positive interactions, building the client’s self-esteem and confidence in parenting. When the client feels ready to accept support from the Mental Health service, the nurses give encouragement with positive affirmations for attending appointments and accessing treatments.
Increased need for attention to Fathers’ Mental Health
10. The wider system needs to increase recognition and support for fathers’ mental health6.
11. Research has shown that one in 10 new fathers suffers from postnatal depression5 and higher numbers develop anxiety7. Some groups are more at risk than others, with young fathers and those whose partners are suffering with mental health, being at higher risk. It is estimated that 24% to 50% of fathers with depressed partners experience depression themselves8.
12. Paternal depression in the postnatal period is strongly associated with an increased risk of adverse behavioural and emotional outcomes and psychiatric problems in the child9. Depressed fathers have been found to be less likely to play with or read, sing, or tell stories to their babies10 and these behavioral changes can have long-term effects on child development11. Where both parents experience depression, the consequences for the infant can be even more severe12.
13. However the importance of father’s mental health around the perinatal period is often overlooked5,13.
14. SSBC has a strategic objective around father inclusive practice. To understand the needs and experiences of fathers, SSBC conducted a consultation between February and September 2020 with 89 fathers across Nottingham. Only 10% of survey respondents had been asked or offered support with their mental health since becoming a father and 91% said it would have been useful to receive information about their own health or mental health14.
15. It is possible that recognition of fathers’ mental health concerns, in areas without the strategic focus on father inclusivity, may be even lower.
Attention to infant mental health
16. The first 1001 days of a baby’s life is a time of unique opportunity, a time of vulnerability and rapid growth and when the foundations for later development are laid. The importance of early infant emotional wellbeing for virtually all aspects of later child development are well researched and documented15.
17. Parents are often receptive to help and in contact with universal services at the start of a baby’s life from conception onwards, therefore providing a unique window of opportunity to intervene.
18. Early support in the first 1001 days for social and emotional development involves tackling adversity. Early traumatic experiences and toxic stress are associated with an increased risk of poor physical and mental health outcomes, including depression16. Early support for social and emotional development also involves supporting parents to provide nurturing care. Improving early relationships could prevent and/or mitigate the cost of adverse childhood experiences (ACEs)17.
19. The estimated costs of ‘late intervention’ in children’s lives include future mental health problems in children & young people with excess costs estimated at between £11,030 and £59,130 annually per child18.
Early relationship difficulties and needs for specialist support
20. Many new babies experience complex relationship difficulties with their primary carer.
21. 25,000 babies <1yr old in England in 2017 lived in a household where there were two of the following present: mental ill-health, domestic violence and/or substance misuse 19.
22. Based on the estimate that one in three children will have insecure attachment to at least one parent, it is suggested that there are approx. 6,900 0-4yr olds with insecure attachment in Nottingham20. This is likely to be an underestimation due to the high levels of social issues including poverty, children in care, domestic abuse and maternal mental health issues, which also affect attachment.
23. The complex and persistent nature of some parent-infant relationship difficulties are beyond the scope of universal or typical early help support, and need specialised, multi-disciplinary intervention. Without specialised help these unresolved problems can affect future outcomes and in the most severe cases, can lead to a child being taken into care. Unresolved parent-infant relationship difficulties can be passed on inter-generationally with long lasting effects and high costs to the public purse.
24. Nationally there is significant variation in relation to mental health provision for children aged 2 and under. While Child and Adult Mental Health Services (CAMHS) services are commissioned to offer support to a 0-18yr age range, due to limited capacity, approximately 42% of CAMHS in England have not accepted referrals for children aged 2 or under21. Older clients have been prioritised by the mental health system as their need is often more observable and therefore urgent.
25. Early evidence suggests that Parent-Infant Relationship (PIR) Teams, which aim to support the parent-infant relationship and ensure positive long term impact on the emotional well-being of babies and parents, are beneficial.
26. Norfolk Parent Infant Mental Health Attachment Project (PIMHAP- 2015) is a parent infant team with a specific focus on working with babies on the ‘edge of care’. The project was commissioned to work with families where there were significant safeguarding concerns, attachment problems in the parent-infant relationship and identified parental mental health problems. An evaluation of the project after the first year of operation found that 85.4% of the families were enabled to remain, or reunite with their child, compared with only 50% ‘edge of care’ cases nationally22.
27. An economic impact evaluation of the Liverpool Parent and Baby Wellness Service (which includes both the postnatal depression service and LivPIP) was undertaken. Using outcomes data on improvements in maternal mental health from the first three years of operation, and applying financial proxies, the cost benefit analysis showed that for every £1 invested in the Parent and Baby Wellness Service £13.18 will be saved by the Public Sector across Health, Social Care, Education and Criminal Justice23.
28. Data from 2019 suggest that in the UK there were 36 specialised PIR teams in operation. However there are nearly 200 Clinical Commissioning Groups (CCG) in England, 7 health boards in Wales, 15 in Scotland and 6 health trusts in Northern Ireland21. Further investment in early years is needed if the goal of 100% of children and young people who need specialist care being able to access it as per the NHS long term plan.
29. Referrals for children under two for CAMHS in Nottingham are currently very low.
30. Small Steps Big Changes has recently commissioned a Parent Infant Relationship (PIR) team for Nottingham from March 2021 for the next 3 years with an annual grant of £350k.
31. We believe a PIR relationship team will be a preventative measure, removing pressure from other services later in a child’s lifespan. Instead of waiting to provide support through the already stretched educational sector or indeed rely on the busy services such as CAMHS, a PIR team can lay the foundations for good child mental health through early relationship building, developing resilience and supporting strong emotional well-being in infanthood. It is hoped it will support joint working and integration between preventative and treatment services.
Prevention and Early Intervention needs for babies and younger children in light of Covid-19.
32. Early indications suggest that the Covid-19 pandemic will create a perfect storm around babies and young children’s mental health.
33. The Covid-19 virus has directly and indirectly added additional stresses to families which has the potential to impact on parental mental health. All families who responded to SSBC commissioned research conducted by Nottingham Trent University reported worrying about the virus, either catching it themselves or passing it on to their baby or child24 . Indirect stresses result from significant reductions in family income, secondary to unstable employment, threats of redundancy or increased living costs. Community and voluntary sector partners report increased referrals to food banks.
34. Local evidence suggests a marked increase in early parenting support requirements. Triple P tip sheets given out, which provide first line advice for emotional and behavioural problems in babies and younger children, increased to 235 between April 2020-June 2020, compared to 84 tip sheets for the same period the previous year.
35. SSBC commission a unique peer Family Mentor service across four wards in Nottingham. During the initial lockdown, they were able to provide some on-going support to parents, through wellbeing calls. In total between 1116 wellbeing calls were made. Over a quarter of families which were known to the Family Mentor service, had regular wellbeing calls, defined as contact five or more times, suggesting high need amongst these families.
36. Locally as the crisis hit, an increasing number of parents were reporting feelings of low mood and increased anxiety with increased numbers signposted to their GP to discuss their mental health.
37. Survey evidence from Best Beginnings, suggests nationally that as a result of the pandemic many more parents experienced concerns with mental health, with 6/10 (61%) of parents reporting significant concerns around their mental health. The same survey suggested that only one third of parents expressed confidence in their ability to access the mental health support that they needed25
38. Services which support new parents, babies and young children’s emotional wellbeing have also been directly and indirectly impacted by the pandemic. During the first national lockdown, due to NHS prioritisation of services and other directives, there was a decrease in the amount of face to face contact between health visiting and other early intervention services and families. This decreased the amount of contact time with professionals to make mental health disclosures.
39. Some concerns have been raised around the adequacy and safety of remote mental health assessments, especially in the absence of an established relationship. Services felt the early identification of mental health concerns benefited from face to face contact allowing optimum opportunity for observation, assessment and sensitive discussion.
40. New parent groups and toddler groups which normally operate on a face to face basis were paused, removing valuable sources of support for new families. Postnatal mental health issues are often attributed to loneliness, which is perpetuated during national and local lockdowns. Some services are now operating these groups via a virtual model, but it is uncertain at this time whether virtual delivery confers similar benefits to parents’ wellbeing.
41. We are also concerned about the potential impact in the short and long term of increasing poverty following Covid-19 amongst our families and the longer term mental health of parents due to potential increases in poverty amongst families and the impact this will have on them. In longitudinal studies, the family stress model highlights the impact of economic pressures upon parents’ mental health, impacting upon relationships and causing difficulties with parenting 26.
42. All of this points to likely significant increase in need and we are concerned that because of current investment levels in services which are responsible for prevention and early intervention there will be a lack of capacity to support the increased need.
Capacity concerns for prevention and early intervention to support babies and young children’s wellbeing
43. Nationally local authority budgets have been reduced and are under significant pressure which has meant the system for primary prevention and early intervention for babies and younger children is under strain. Pre Covid needs were already high. In March 2020 18,460 babies <1yr old were identified by LAs as being ‘in need’ largely due to risk factors in the family home and 63,000 1- 4 year olds in need.
44. Local authorities have been under strain in relation to the delivery of public health functions, since its transfer from the NHS. Despite a ring-fenced public health grant being provided to local authorities, the grant remit for spending expanded in the local authority context. This was coupled with a reduction in the value of the grant. The net result has been a decrease in overall funding for prevention work associated with the public health grant27. Many services which support families, that do not serve a statutory function, have experienced a reduction in their incomes. An example of this is Health Visiting services nationally, who are the lead professionals for the primary prevention programme the Healthy Child Programme (HCP). Since the transfer of funding to local authorities there has been a fall in Health Visitor numbers nationally28.
45. Without a significant increase in the value of the Public Health grant, the current pressures on local authorities, exacerbated by Covid-19 will put further pressure on already stretched services that support primary prevention and early intervention for babies, younger children and their parents. We feel strongly that failure to address this will only exacerbate mental health concerns in children and young people and call for increased investment in prevention and early intervention for babies and very young children.
Addressing capacity and training issues in the mental health workforce
46. Alongside the workforce in schools, we consider that training issues and capacity in the mental health workforce should extend to all practitioners working with the family so they can be skilled confident and competent in discussing and supporting mental health needs of parents, babies and younger children.
47. Upskilling a wider workforce may assist in reducing pressure from specialist services for mental health
48. Infant mental health is not well understood. Across the system, more training is needed in early child and brain development.
49. Prevention and Early InterventionLocally investment is currently being made into perinatal mental health training and also Institute of Health Visiting (IHV) infant mental health champion training. The local Nottingham 0-19 service takes a “think family” approach to mental health and is in the process of strengthening pathways to support this. There is recognition that this itself takes time and capacity. With staff training, comes increased recognition of mental health difficulties and there is concern that the currently stretched system does not have sufficient capacity to support families where needs are established.
50. Investment in capacity to provide training is needed. Capacity issues have limited the ability of those skills within the system to be spread more widely across the system. Locally SSBC have funded 0.5 FTE post specifically to spread the learning from the FNP ADAPT programme across the system.
Training needs for Fathers’ Mental Health
51. Professionals are unable to access robust national guidance to support families where paternal mental health difficulties feature. The NICE guidelines ‘Antenatal and postnatal mental health: clinical management and service guidance’ [NICE CG192] do not acknowledge paternal postnatal depression within their clinical guidelines. The term ‘partner’ when used is only used in relation to the way in which this individual influences the wellbeing of the mother 29.
52. National evidence suggests a capacity and training gap around perinatal paternal mental health. Whilst this is actively being considered for those fathers whose partners require specialist inpatient mental health support, many more fathers are likely to need support 5.
53. Our locally commissioned consultation alongside national evidence points to the need for better training for health care staff to enable them to evaluate the perinatal health needs of fathers.5, 14. To support paternal mental health needs, staff need training around raising the issue of mental health, appropriate screening tools and knowledge and pathways to support onward referral if necessary30. Training the workforce that has contact with fathers around the perinatal period to improve their confidence in having these conversations is key to encouraging fathers to speak openly about their mental health.
54. There is no standard practice nationally for screening around paternal mental health. The Edinburgh Postnatal Depression Scale (EPDS) is currently only completed with women and although a validated tool for use with men, there is some suggestion that the EPDS may miss some fathers experiencing mental health concerns5, 13.
55. Local fathers suggested that the process for questions around mental health should follow the same process as for mothers, with midwives and others providing a regular check-up14
56. Given the current pressures on the system, additional capacity will be needed to support improved detection and management of paternal mental health.
Specialist Early Intervention Training Needs
57. Therapeutic work with babies is significantly different from work with older children and requires a specific set of competencies. It is skilled work that requires specialist expertise in child development and the unconscious communications between parents and their babies.
58. Locally the Parent Infant Relationship team will commit to a training programme alongside supervision from psychologists for the whole of the Early Years workforce. Locally this has been enabled by National Lottery Community Fund resources, however it is important to recognise this investment in other areas will need to be sufficiently resourced.
59. We call on the committee when considering the early intervention needs of children and young people’s mental health, to recognise the value and place in the system of prevention and early intervention for babies and very young children.
60. Any integrated approach to children and young people’s mental health needs to consider the capacity and training issues around supporting both mothers and fathers around their own mental health as well as the early needs of babies and young children.
61. The system of support for babies and younger children is under strain. We feel strongly that failure to address this will only exacerbate mental health concerns in children and young people and call for increased investment in prevention and early intervention for babies and very young children.
 A child “in need is defined under the Children Act 1989 as a child who is unlikely to reach or maintain a satisfactory level of health or development, or their health or development will be significantly impaired without the provision of children's social care services, or the child is disabled.
 * A child “in need is defined under the Children Act 1989 as a child who is unlikely to reach or maintain a satisfactory level of health or development, or their health or development will be significantly impaired without the provision of children's social care services, or the child is disabled.