Report. The. Surrey Parent-Infant Mental Health Service

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1 Report On The Surrey Parent-Infant Mental Health Service Lynda Dawson Health visitor Specialist Cathy Madley-Dowd Health Visitor Specialist

2 Introduction The Parent-Infant Mental Health (PIMH) service is a specialised service that has recently been introduced to all localities within Surrey PCT. The service has been developed in partnership with Children and Adolescent Mental Health, Social Care & the Health Visiting Team. Politically, the driving focus of the service is the Every Child Matters and Surrey Community Service remit to improve the emotional, mental and physical wellbeing of children. Attachment problems were an unmet need of the current 0-19 service. The PIMH service addresses this unmet service by offering early intervention to parents who are identified as being at risk of poor attachment with their infant. In Surrey PCT there are births annually of which 5200 mother-infant dyads are potentially at risk of insecure attachment. Importance of the PIMH service Perinatal mental health problems are common, many are serious and they can have long lasting effects on maternal health and child development. (RCP 2000). Infants who experience secure attachments have the best foundation on which to build their future emotional and mental well being, but secure attachments are only observed in 60% of infants and this pattern is repeated down through generations. The risks to the baby of poor attachment are failure to thrive, apathy and delayed social, emotional, language and / or motor development. Approximately 10% of infants experience disordered attachments and these babies are the ones most likely to go on to develop behavioural difficulties in their pre-school years and conduct disorders and youth offending in their later childhood. They are also more likely to develop significant mental health problems. Infants of parents with mental health needs, and / or relationship difficulties, teenage parents and those with learning difficulties are at risk of poor attachment due to the emotional unavailability of the main carer usually the mother. Management of postnatal depression makes no specific provision for the mental health of the infant. Although support for mothers has the potential to improve matters for infants, the evidence suggests that: Emotional well being of babies needs to be addressed independently. (Barrows, 2003) Both severe and less severe conditions respond well to treatment particularly when detected early. This is also a crucial time for a newborn baby in terms of brain development, personality development, formation of attachment patterns, development of the capacity to think, social skills, learning to use language which leads to the formation of a psychic structure that will affect the child s coping and functioning in all aspects of their later life (Fonagy et al, 1991, 1993, 2000). New mothers are more vulnerable to mental health problems and a number of factors contribute to this increase in vulnerability. Failing to deal with perinatal mental health problems has adverse consequences for both mother and baby. The rate of psycho-social disorders amongst children is 10-15% in the UK with levels being particularly high in areas of deprivation (DOH 2007) and

3 maternal mental health has a significant impact on child development and the wellbeing of families. Ultimately, the mental and physical wellbeing of the nation and the cohesiveness and security of society are a function of how children develop and grow in their early years. Description of the PIMH Service The strategic approach of the PIMH service involves promotion of parentinfant mental health through Raising awareness of its importance amongst professionals Encouraging personal & professional development to enable identification of when parent-infant mental health is at risk. This leads to appropriate referrals into the PIMH service Provision of a framework of specific services which aim to enhance parent-infant mental health to identified families Referral pathways for more serious cases The PIMH training programme To facilitate working in partnership with other organisations to ensure the above objectives are met and to develop interagency provision of this new service an ongoing training programme by the PIMH Service has been developed; it involves a tiered approach depending on the amount of involvement of the individual. 1. Level 1 Half day workshop on Infant mental health, attachment and brain development. This is provided for staff and management to raise awareness of PIMH. Attended by approximately 200 staff 2. Level 2 Observation training provided for all staff working directly with families to enable identification of families for referral into the PIMH service. Attended by 70 staff 3. Level 3 Infant Massage training provided for staff involved in providing this intervention for families in groups or individually. Undertaken by 60 staff 4. Level 4 Specialist Module in Maternal & Infant Mental Health (provided externally). This module has been undertaken by a total of 12 staff to enable them to participate in the provision of the observation training Consultation from psychotherapists for staff undertaking infant massage courses with parents has been provided for approximately 224 staff in 32 sessions across Surrey. Two PIMH conferences took place; staff who are in contact with infants in their professional role were targeted 300 staff attended.

4 The staff groups that have been involved in the training have included health visiting (public health nursing), tier 2 & 3 Child & Adolescent Mental Health staff, Social workers both generic and specialists from the fostering & permanency teams, family support workers, prison health staff, Connexions workers for teenage pregnancy, Homestart, Women s refuge, and A2 Housing Charity for teenage mothers. Once staff have received the appropriate training two staff members facilitate a 5 week infant massage course. These groups are therapeutic in nature and concentrate on enhancing the interaction and therefore the relationship between the mother and infant. If there is a good response the episode of care is closed with liaison back to the health visitor. If there is less than satisfactory response a referral is made to CAMHS where further work is offered to help form a secure attachment between mother and infant. Evaluation of the PIMH Service Refer to Table 1 for reasons for referrals into the PIMH Service for 2008 There is often more than one reason for referral into the service but these figures represent the most important presenting issue. Table 1 Psycho-social factors impacting on parents ability to bond with their infant included domestic abuse, isolation, mental health and learning disability 56% Identified Relationship Issues presenting as unsettled or 33% unhappy infant, lack of parenting confidence Teenage Parents (may include many of the above issues 6% too) Infant based issues e.g. prematurity or disability 5% The mothers mental health and parenting capacity dominate the referrals into the PIMH Service as they are impacting on the mother-infant relationship. On completion of the course the parent-infant dyad outcomes are measured by group leaders, refer to table 2 for the outcomes for 2008 Table 2 Marked improvement in mother infant interactions 20% Some improvement in mother infant interactions 60% Further work/referral required 10% Dropped out of group 10% In 2008 the group leaders observed an 80% improvement on parental warmth towards the infant and enhanced sensitivity to the infants cues. During this period the parents evaluations reflected common positive themes which will impact on improved parenting capacity, refer to table 3.

5 Table 3 Getting to know other mothers (reduced social isolation) 32% Better bond with baby 27% More confident with baby 15% Spend more time getting to know baby 13% More relaxed parent/infant 13% Some comments obtained from the evaluations were: My HV said it would be good to attend because of my PND. I didn t want to attend but I did and I am so glad, it is the first time I m beginning to enjoy motherhood and I feel I m doing something positive with my baby. I spend more time communicating and enjoying my baby. The classes were wonderful they helped me to have such a happy and positive start to our relationship. I ll never forget it. I was surprised at how much I opened up. I felt much better for it Through a recent audit health visiting staff have commented on how provision of this service has positively impacted on their workload. As a result of the mothers attending the PIMH service, health visitors are able to offer less individual intervention. Health visitors said mothers appeared to build their confidence, reduce their anxiety and as a result they sought support from health visitors when needed and used clinics appropriately. Mothers suffering from depression, anxiety, or coming to terms with a child with a disability have strongly benefited from the service through reduced isolation, sharing similar experiences and receiving professional support. The mothers have seized the opportunity to learn to positively tune into their baby; through massage and being able to share their similar experiences aided their road to recovery. This provision of service has led to positive outcomes for the mother-infant dyads, reduced health visitor input for these complex families who have engaged with the service and less referrals to level 3 services which is financially cost effective. The development of PIMH service has implications on workforces such as the health visiting team and the CAMHS Service. Over the past year the service has provided intervention at tier 1, 2 and 3 for approximately 830 families; 15 of these have so far been seen within CAMHS, although it is likely that these numbers will increase as the service fully develops Surrey wide. It is anticipated that the potential improvement in mental health for both parents and their children will reduce the number of referrals for older children to CAMHS in the future, resulting in cost savings.

6 Conclusion Statistics show that childhood mental health disorders in Britain are escalating. To combat this major problem research shows offering early intervention targeting the infant-carer relationship is much more effective than treating the childhood disorder when it manifests itself. Investing in the PIMH service ensures these children have more opportunity to reach their full potential in life. The importance of this dynamic research is reflected in the recent government recommendations (Face the Future 2007 and the Nice Guidelines on Antenatal and Postnatal Mental Health 2007)

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