infant mental health and emotional well being - chimat

National Conference – Infant Mental Health: Day 1 [1]

CAMHS National Conference

15 & 16 November 2005 – Hilton East Midlands

GETTING IT RIGHT FROM THE START Infant Mental Health and Emotional Well Being in Children and Young People

A conference by: National CAMHS Support Service as part of the Care Services Improvement Partnership;

the Sure Start Unit of the DfES and the Department of Health

CONFERENCE HANDBOOK Day 1 – 15 November 2005


CONTENTS Title Page

Number Introduction 3 Workshop 1: Developing a Parent-Infant Mental Health Strategy: Chasing the Vision

6

Workshop 2: A Primary Mental Health Service for the Under Fives

8

Workshop 3: Learning from Experience: Continuing Professional Development in Infant Mental Health

9

Workshop 4: A Journey Through Childhood From The Child’s Perspective

12

Workshop 5: From Serendipity to Strategy – The Development of an Infant Mental Health Service for Wiltshire

14

Workshop 6: Working strategically to promote mental health and social inclusion for parents with mental health difficulties and their children – The Action 16 Group

16

Workshop 7: The Nuts and Bolts of Developing a Twofolded Perinatal Clinical Services Strategy

19

Workshop 8: HAPPY - health and play primary years

23

Workshop 9: Getting to know your baby – North Tyneside Attachment Strategy

26

Workshop 10: Family Welfare Association Newpin Model of Working with Parents and Children

29

Workshop 11: Primary Care CAMHS – working together

32

Workshop 12: A Collaboration Between Adult and Child Services – Where Does Our Service Fit?

35

Workshop 13: Talking Together Parents’ Workshops

37

Workshop 14: Baby’s first year – patterns for a lifetime

40

Workshop 17: Cambridge Parent Infant Project - CAMPIP

43

Workshop 18: Promoting Families with Mental Health Needs

46

Workshop 19: Clinical Psychology Consultation and Co-Work Model - Working in Redditch Sure Start

49

Workshop 20: CAMHS, Infant Mental Health and Sure Start

53

Workshop 21: Risks, Relationships and Repair

56

Workshop 22: Infant Massage and its Contribution to Attachment Patterns

58


INTRODUCTION Welcome to this conference promoting infant mental health, early intervention, health promotion and problem prevention. This conference has been jointly sponsored by the DfES Sure Start Unit and the National CAMHS Support Service (NCSS). Our intention in setting up this conference was to recognise and champion the developing child and young person within the matrix of all that encompasses emotional health and psychological wellbeing. We recognise the crucial nature of good maternity services, early childhood experiences, good attachments, responsive parenting and the social and emotional components which can enhance the child’s experience of the learning and social environment. This is why we feel passionate about drawing together, in this conference, the strands of peri natal mental health, infant development and health, family and professional experiences in Sure Start and Children’s Centres, the child’s transition into the learning environment of school. Risk and resilience factors exist that can be worked with in order to improve children’s and young people’s mental health and which will enhance positive outcomes for them throughout their development. In this conference we are taking the concept of ‘early intervention’ to mean both early in life and early in terms of reducing the impact of risk factors and strengthening resilience factors both before they are identified (mental health promotion) and after they have been identified (mental health problem prevention). Throughout the structure of the two days, we want to demonstrate the importance of reading across the relevant policy and guidance, and through the workshop format will show how local organisations have: • Built and gained agreement about strategic development of these services. • Demonstrated the links between a written strategy and building a service to support it. • Put those strategies into practice and showcase emerging practice examples. These are the three themes which underpin both days – we want to demonstrate to you a logical progression from strategy to action. The conference programme and structure has been built over the period of about 18 months, in collaboration with DfES Sure Start Unit, Department of Health and our fellow regional development workers in the National CAMHS Support Service. The co-operation demonstrated in bringing these two days to fruition is also a very practical example of joint working in action – mirroring what is also necessary in locality partnerships and in teams, when building strategies to support infants and young people. We too have challenged assumptions, language, policy interpretation and how to achieve positive outcomes.

This handbook contains an outline of each of the 20 workshops available on Day One and contains a wealth of information from colleagues who have not just thought about the problems and the solutions to building services, they have met them head on. We are very grateful to them therefore, that they are willing to share their learning with all of us, helping us to learn from their experiences and not reinvent the wheel. Most of all, this handbook and the handbook for Day Two will provide a crucial reference for the future – practical examples for you to use, share with your partnerships and provide you with contacts you can draw on. This is the important message we wish you to take away: These two days are about thinking, listening, discussing and networking. But most of all, this conference is about action. That is why we are asking all the workshop leaders to invite you to consider and then to write down one action point to take away from each of the workshops as we would like you to extend the time line of your learning beyond today and take your learning back into your local partnerships and communities and build that learning into developing early services and Children’s Centres.


We would like draw to your attention the important policy documents which will frequently be referred to in the conference and ask you to consider the whole of children’s policy when building your services. In that way, you will build coherence and strength through planning and implementation processes. • Every Child Matters: Next Steps

http://www.everychildmatters.gov.uk • The National Service Framework for Children, Young People & Maternity Services

http://www.dh.gov.uk/PolicyandGuidance/HealthandSocialCareTopics/ChildrenServices/fs/en

• Choice for Parents, the best start for Children: The Ten Year Strategy for

childcare http://www.hm-treasury.gov.uk/pre_budget_report/prebud_pbr04/assoc_docs/

prebud_pbr04_adchildcare.cfm

• The National Healthy Schools Programme http://www.wiredforhealth.gov.uk/cat.php?catid=842 • Choosing Health http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuid

ance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=aN5Cor

• Children’s Centres www.surestart.gov.uk/surestartservices/settings/surestartchildrenscentres And the following useful weblinks: • The Association for Infant Mental Health www.aimh.org.uk • The Anna Freud Centre www.annafreudcentre.org • The Tavistock and Portman NHS Trust www.tavi-port.org/departments/c_coursesandproftraining • Young Minds www.youngminds.org.uk

Thank you to all our colleagues in the National CAMHS Support Service, Department of Health and Department for Education and Skills for their support, encouragement and commitment in planning and delivering this conference: Bob Foster, Louise Bridson, Cathy James, Leezah Hertzmann, Jonathan Bacon, Jo Edgar, Petra Mountford, Tracey Merrison, Cathy Street and Roz Rospopa Thank-you to the presenters for sharing their time and agreeing to speak to the whole conference: Professor Woody Caan, Dr Carole Sutton, Bob Foster, Louise Bridson, Dr Sarah Stewart-Brown and Christine McInnes. Our thanks too, to the chairs of both days, Dr Caroline Lindsey and Bob Foster.


Thank you to the impressive list of 40 workshop leaders who have collaborated fully in the planning of the conference and in the production of this handbook. Organising the 40 workshops and nearly 350 delegates is a mammoth task – thank you to everyone who has assisted, especially Jo Edgar, Louise Appleby, Petra Mountford, Tracey Merrison, Hayley Hegarty. Dr Cathy Street of Young Minds edited the handbook, for which grateful thanks. Copies of this handbook and other relevant information will be available after the event on the following websites: National CAMHS Support Service: http://www.camhs.org.uk NIMHE Knowledge Community: http://kc.nimhe.org.uk YoungMinds: www.youngminds.org.uk Jane Sedgewick CAMHS RDW/NIMHE Programme Lead (Yorkshire and Humber) Admin: Hayley Hegarty - 01904 717260 Email: [email protected] Dawn Rees CAMHS Programme Lead, Care Service Improvement Partnership (East of England) and National CAMHS Support Service Admin: Tracey Merrison - 01206 287593 Email: [email protected]


WORKSHOP 1: Developing a Parent Infant Mental Health Strategy: Chasing the Vision Janice Cheng, Deputy Director of Mental Health Commissioning – specialist placements and CAMHS, Uttlesford PCT; Margaret Hurst, Consultant Child Psychotherapist, North Essex Mental Health Partnership NHS Trust; Catherine Lowenhoff, Nurse Consultant (perinatal and Infant Mental Health), North Essex Mental Health Partnership NHS Trust; Toni Scales, Service Manager, CAMHS, North Essex Mental Health Partnership NHS Trust This workshop describes the process undertaken in North Essex to develop a Parent Infant Mental Health Strategy, inspire change and initiate service developments. Although clinicians in specialist Tier 3 services provided the catalyst to develop a co-ordinated approach to meeting the mental health needs of infants and their parents, they also recognised the need for a collaborative approach involving partners and agencies outside their sphere of influence. A key aspect of the process was the engagement of relevant commissioners and stakeholders to ensure that the commitment to parent-infant mental health could be guaranteed and sustained. The focus of the workshop will be how the motivation and skills of passionate practitioners can be translated into systematic, co-ordinated changes in specialist CAMHS service provision, facilitated by pro-active and responsive service managers. Specific service developments include the identification of infant mental health specialists within each Child and Family Consultation Service Team, revised referral criteria, assessment protocols and audit proforma. The workshop will demonstrate a step-by-step approach to the development of the strategy and will include take-home examples of the documentation that will be used to assess the appropriateness and effectiveness of the new service. Development of a Strategy In acknowledgement of the need to develop a comprehensive approach to parent-infant mental health, which transcends traditional service boundaries and involves a whole range of professionals beyond the parameters of specialist CAMHS, a strategy was drafted. This has helped to crystallise the vision of a comprehensive parent-infant mental health service and has encouraged ownership of shared aims and objectives across agencies. Early involvement of the Mental Health Commissioner was essential to ensure that the strategic intent to prioritise parent-infant mental health was incorporated into the CAMHS joint commissioning strategy for Essex. Identification of parent-infant mental health champions and allies at every level has been essential in ensuring that parent-infant mental health has been integrated with, rather than subsumed by, other strategic objectives, for example, parenting and perinatal depression. Clinicians and managers have kept parent infant mental health on the CAMHS agenda through regular contributions to the CAMHS strategic partnership Group and enthusiasm for a renewed emphasis on early intervention was fostered through the provision of a training day subsidised by the Workforce Development Confederation. An important aspect of the training was the inclusion of clinicians, managers and commissioners who were then able to generate additional support for the development through their revitalised appreciation of the importance of the early years. Work is ongoing to ensure that the agenda is included in adult and maternity services plans and is facilitated by the involvement of a nurse consultant with a special responsibility for perinatal and infant mental health.


There is still a long way to go, but the steering group set up within specialist CAMHS feel that they have made a start in designing a branch of the service dedicated to assessing and responding to the needs of the most vulnerable parent-infant relationships. Developing a co-ordinated vision in the first place relied on the foresight and enthusiasm of the Director and Service Manager of CAMHS and the ethos of the Trust which encourages professional feedback and believes in the provision of protected space and time to allow creativity to flourish. Translating the vision into practice has required the involvement, determination and persistence of a much wider group of commissioners, clinicians and managers who have all played a significant part in ensuring that the parent-infant mental health aims and objective are synchronised with other systems and strategies within a flexible framework that is constantly evolving in response to new ideas, research, policy imperatives and new partnerships. Think parent-infant mental health - think PIMHS: P - Persuade, persist and prioritise I - Involve commissioners and key stakeholders from the earliest possible opportunity M - Make time and space to allow creativity to flourish H - Have a voice and make it heard. Hear what others have to say S - Synchronise systems and strategies Contact Details Janice Cheng Email: [email protected] Margaret Hurst Email: [email protected] Catherine Lowenhoff Email: [email protected] Toni Scales Email: [email protected]


WORKHOP 2: A Primary Mental Health Service For the Under Fives Paul Barrows, Child Psychotherapist and Lead Clinician, United Bristol Healthcare Trust and Rosalind Bennet, Primary Mental Health Specialist (Under-Fives) This presentation will look at the development of a Primary Mental Health Service for the Under-Fives, in the context of the attempt to develop a local culture and infra structure supportive of the promotion of infant mental health work. It will also be placed in the context of the broader aim of developing a more over-arching infant mental health strategy. The earliest origins of this process will be outlined, consisting as it did in the promotion of conferences on the subject of IMH and then the institution of an annual conference programme. A parallel development saw the establishment of training in psychoanalytic observational studies. Ros Bennet will describe her experience of this course and refer to the MA Dissertation that she wrote as part of it, on the topic of the contribution of observational skills to the work of the Health Visitor. She will then go on to describe how she was able to establish a specialist infant mental health Heath Visitor post in north Bristol and the evolution and evaluation of this post. We shall then describe how this led to the development and validation of a new PG Dip/MA course specifically related to infant mental health (a Tavistock Clinic course validated by the University of East London). We will include a brief outline of the course. Other related developments in Bristol will also be described. Subsequent to the inception of this course we will describe how we drew upon national developments related to CAMHS and the strategy of developing a cadre of Primary Mental Health Workers. In Bristol a decision was taken to focus these posts on “age and stage” rather than giving them a geographical remit. The rationale for this strategy will be described. This led to the creation of 4 posts across Bristol with a specific remit for the Under-Fives. We will describe the first year of the development of these posts. Finally we will look at how these developments fit in with the development of an overall infant mental health strategy and the challenges that face us in the future in trying to take this forward. Contact Details Paul Barrows Email: [email protected] Tel: 0117 919 0330


WORKSHOP 3: Learning From Experience – Continuing Professional Development in Infant Mental Health Peter Toolan, Consultant Child and Adolescent Psychotherapist, Outcomes UK & Scottish Institute of Human Relations Introduction More training and professional development opportunities are needed by a range of front line professionals and service managers responsible for the delivery of government recommendations on early interventions promoting infant mental health. Many professionals share a motivation to be able to do something to help prevent problems from developing between parents and infants, to prevent situations of sometimes desperate unhappiness, and to help promote the foundations of better mental health and development in children. There is a growing recognition that an accessible but intermediate level of training and support which is necessary in order to sustain service development, is missing. Underlying this recognition is the understanding that infancy is the time of the greatest importance as the basis of all future development; of the brain, the personality; of security of attachment and the time of greatest potential, both positive and negative. The 10 week Intensive Professional Development Course in Infant Mental Health developed by Peter Toolan and Francesca Calvocoressi at the Scottish Institute of Human Relations, aims to address the need to promote a ‘skills-escalator’ model for supporting service development alongside training. The Importance of Infancy and Early Intervention The need to provide an adequate thinking space to allow for richer perspectives and understandings of personality development and the complexities of parent–infant relationships is emphasised. This approach provides an introduction to some key theoretical studies and brings this together with a focus on the working experiences of participants. This practice element includes an exploration of participants’ experiences of direct observation of parents and infants. The immediate aim for this training approach is to deepen the participants’ framework of understanding of conscious and unconscious factors involved in early developmental processes and to introduce new thinking about early preventative intervention. Our belief is that practitioners’ own experiences and knowledge of local needs should be the basis of building a culture of focussed thinking and practice development. One issue which is emphasised is that everyone has the potential to develop some important work in this area, whilst acknowledging the shortfall in ongoing support in the system for such development. Even with limited supportive learning opportunities, many professionals can and do make a difference and get involved in significant preventative work. Those who the course is aimed at include: health visitors, early years teachers, midwives, nursery nurses, social workers, psychologists, psychiatrists, therapists, CAMHS workers and others who are willing to develop their thinking and practice. Course Structure The structure of the approach draws upon participants’ own casework and clinical experiences and introduces a new experience of observation from a non-participant and role-free viewpoint. This allows participants to begin to develop new perspectives; both on the


value of being able to bring to bear an observational stance in order to gain a deeper understanding of the phenomena of parent – infant relationships and also to develop greater insight into the nature of their own role and their functioning in their professional interactions with parents and infants. Theory In the theoretical strand of the course, a developmental paradigm is used in order to structure the study of seminal clinical and theoretical discoveries and also a number of key pioneering clinical approaches. This draws upon a number of schools of thought including: Developmental Psychology, Neurobiology, Attachment Theory, Psychoanalytic theory and practice – in particular, from the field of Child Psychotherapy. The course holds onto a relational as well as a developmental perspective throughout, but key subjects of study include: • The emotional landscape • Infant development research • Personality development • Intergenerational issues • The role of the practitioner

All of these are considered in terms of the key players; Mother, Father, The Baby & The Couple, and the relationships between them. Further theoretical study areas (together with some of the key authors) include: • Attachment (Bowlby, Main, Ainsworth). • The language of interaction and infant capabilities, (Stern, Brazelton, Cramer). • The capacity for emotional containment and internal unconscious processes (Freud,

Klein, Bion). • Play, emotional ‘holding’, the infant–parent relationship, parental states of mind

(Winnicott et.al). • Neuropsychiatric perspectives and the impact of trauma (Schore, Perry, Gerhardt, Sue-

Moore et.al). Practice The second parallel strand of the course concerns practice although the two strands overlap and “speak to” one another. There is an experiential emphasis to the learning process in which two elements are emphasised: • Work discussion seminars link what is being learned theoretically with participants past

and particularly, current ongoing and developing interactive work experiences involving parents and infants.

• The importance of observation. Many courses of study and therapeutic trainings make use of a style of very focussed and painstaking infant observation developed by Esther Bick to gain insights into the internal world and emotional development of infants. Although relatively very brief, the course allows participants an experience of this approach and allows a further interest to be fostered. This type of observational study develops crucially important faculties in those undertaking them which are of enormous benefit in developing practice in early intervention with parent and infants. These faculties revolve around: • The capacity to see; to attend; to absorb and to reflect.


These qualities are explored in small seminar groups within the practice discussion strand of the course. The overall emphasis of the approach is to stress the need for an ongoing professional development process and to stimulate the discourse about building an infant mental health culture within districts localities and regions across the UK. The longer term structural aim is the development of a modular skills escalator programme at Diploma level and above. Alongside this, the aim is to foster greater consent for the building-in of a framework of peer support and supervision linking professionals and agencies sharing common goals in the promotion of infant mental health and early intervention. This course is to be ‘rolled out’ in other parts of the UK (starting with Newcastle, in summer ’06), following its successful development in Edinburgh. Contact Details Peter Toolan M.Psych.Psych. Consultant Child & Adolescent Psychotherapist Outcomes UK & Scottish Institute of Human Relations Email: [email protected] Tel: 0191 212 2259


WORKSHOP 4: A Journey Through Childhood From The Child’s Perspective Dr Arthur Paynter, Paediatrician, Central Clinic, Carlisle Much evidence about the importance of early environment and early experience in relationship to child development is now is now coming to light. There are many exciting programmes (Sure Start, Solihull). This talk is not an attempt to present more evidence. It is not a scientific or evidence based presentation, nor a presentation of a model of care or practice. This is an imaginative talk! It aims to celebrate the marvel and wonder of childhood. Child growth and development is truly fascinating. I hope I can enthuse participants with the wonders of infant & child development, and the marvel of maternal infant relationship. I have worked as a paediatrician for 30 years, and in this context have worked with children and families and with all the statutory agencies (health education and social services and many voluntary services.) I have reflected on services and systems. I would like to share some thoughts and concepts with a wide audience. This talk /workshop is geared to the community in general, not to a specific or professional group. The material in the talk is based on the natural biology of the child (anatomy physiology and psychology). I look at the natural pathway of child development and the way nature has designed it to proceed. (We are indeed fearfully and wonderfully made.) Firstly, I will describe some deeply held misconceptions about children and childhood. I suggest that the way we as a society have a distorted perspective on childhood. Behaviour modification is deeply entrenched in the way we as a society treat children, and it has its place in altering undesirable behaviour, but if carrot and stick becomes the way of life of the young child, we risk producing donkeys! Secondly, the pragmatic model of business management, and the factory model encourages us to be ‘outcome oriented’, yet with outcome orientation we run the risk of producing battery hens! We must do better than that! It is a child’s right and privilege to be enfolded and nurtured within an environment unconditional love (by parents and society). When this is done, outcome takes care of itself. Finally the markets and the media have a free hand to infiltrate everywhere to undermine the health, well being and development of children. Surely our aim as an adult society is to nurture children such that they develop into free human beings, capable of imparting purpose and direction to their lives? How can we do this? Our biology has designed a truly wonderful and awesome system, and it has designed us for survival, but unlike other animals, it has also programmed us for an extraordinarily wide range of experiences and environments. We must respect and support this design, rather than over ride it with our own agenda, our anxiety and our fears (or hopes!). I describe the biology (particularly the sense organs and the neurology) of the child: I describe the primitive reflexes and their purpose, in terms of survival and development. The primitive reflexes are designed to generate a strong physical and emotional response from mother. This is the stage on which the natural process of interaction (reciprocity) takes place, but this process requires acknowledgment and support. All the senses, vision,


hearing, touch, taste smell, position and movement, will not develop or become integrated without nurture. In a natural state they are nurtured unconsciously/subconsciously, and occur holistically. (An activity or pattern of behaviour will nurture several senses and also nutrition together thus facilitation sensory integration). The system however, is vulnerable. I describe the adult support and the environmental support required for this natural process to occur. I discuss the way we live now and the values of our society and describe the adverse effects that some of these values on the process of child development. The values of industrial and post-industrial life and the pressures of consumerism have slowly nibbled away at the support systems necessary for optimal child development. I take the listener on an imaginary journey through childhood from the child’s perspective, starting with sensory experiences in the womb and the experience of birth. I emphasise the importance of the mother baby bond, the process of attachment, and continue the journey through infancy; the discovery of the external world through the senses, the experience of touch, sight, sound and movement. I describe the development of the motor system; the development social interaction of language and communication and finally, abstract thought. I also describe how easily we can overlook the natural process and drift in to abnormal patterns and damaging behaviour. This emphasis of this talk is the first phase of childhood, the perfection of the sensory motor sensory motor system (age 0 to 7), in preparation for the next phases. However, it will briefly touch on the second phase (7 to puberty), when the emotional and imaginative faculties develop, and the final phase puberty to adulthood, the flowering of the rational mind. Each phase requires a very different support. The adult community, particularly policy makers and service developers, need to be aware of the biology of childhood. While I do not quote chapter and verse, there is nothing original in this talk. It is a synthesis of many great minds including Rudolf Steiner, Jean Liedelloff, Joseph Chiltern Pearce, Frederick Leboyer, Colwyn Trevarthen, Antonella Sansone and many others. Contact Details Arthur Paynter Central Clinic 50 Victoria Place Carlisle CA1 1HN Tel: 01228 603271


WORKSHOP 5: From Serendipity to Strategy – The Development of an Infant Mental Health Service For Wiltshire Dr Shirley Gracias, Consultant in Child and Adolescent Psychiatry and Clinical and Medical Lead for AWP CAMHS The importance of the early years has long been understood in terms of physical development. This relationship has been reinforced by recent findings suggesting that diet in the early years may causative in the development of diseases such as Diabetes and Obesity in later life. In the past decade, the link between social experience in infancy and the later development of relationships has been made explicit. A decade of brain development research, and investigations based on attachment theory, has revealed the importance of interactions with caregivers in infancy not only on subsequent relationships but also on the development of the brain. At the same time, evidence is also emerging that intervention at this stage is cost effective and has a sustainable impact. Despite this knowledge and an emphasis on “evidence based” practice, services aimed at enhancing infant mental health are limited and patchy. Historically, Specialist CAMHS seldom sees infants. They do not present with behavioural, emotional or psychiatric disorders that can be classified in current diagnostic systems, and so seldom meet the criteria for acceptance by Specialist CAMHS. The NSF for Children highlights the need for early intervention with infants as an area for development in the new Comprehensive CAMHS. This article describes how a Specialist CAMHS, in a large Mental Health Trust, has been able to move from “having an interest”, and developing when serendipity allowed, to a position where Infant Mental Health Service (IMHS) are being planned strategically. In 1995 the author moved to the service, where there were significant problems caused by the practice of the previous Consultant Psychiatrist. The clinical team was split from the medical provision and there was no service for infants. The arrival of the author led to a change in practice (longer assessments and the offer of psychological therapies as an adjunct to medication) and the opportunity for the team to reunite, but also presented problems with throughput. A waiting list was created; this was made worse by the author, with other team members, reassessing all cases left by the previous Consultant. The team agreed that children under five be offered a brief psychotherapy intervention without having to wait. When cases seen in this “fast track” were reviewed, it was found that there were high levels of early separation in case histories, along with postnatal depression. A similar finding emerged from the reviews of known children’s cases. Coupled with findings from international and national research it was agreed by the team that setting aside time for the under fives was justified. Initially the Under Fives service was run by the author and Child Psychotherapy colleagues. To promote ideas we organised two conferences and became involved in teaching on a local course about Postnatal Depression. In addition, we established Health Visitor Consultations and an Infant Mental Health Forum for the area, comprising professionals from all agencies. However, it continued to be difficult to convince Commissioners of the importance of Infant Mental Health and no funding for development was forthcoming. In 1999, we were suddenly presented the opportunity to bid for slippage from other projects. We were successful in gaining funding to run a project piloting a particular approach – Watch Wait and Wonder- with relationship development. This pilot ran in 2000 and was evaluated the following year. On the strength of the project, the local commissioners invested £35,000 to develop a small service in our area. However, there was no investment countywide, and the original funding has never been increased. Consequently, only our part of the county has


seen the development of a small IMHS that has been able to offer a limited amount of clinical work (based on Watch Wait and Wonder), training and consultation. We have also been actively involved in the development of a postnatal depression pathway for the locality and have been in discussion with the Adult Mental Health Service (AMHS) about the development of an integrated Perinatal Mental Health Service. A training morning, run jointly with the voluntary sector and the Local Authority, was successful in convincing the CAMHS Commissioners of the impact of the early years on brain and relationship development, and also the potential savings from intervening in infancy. The Commissioners for the County have now expressed an interest in developing services for infants and are developing a strategy for an IMHS within the tiered framework of the whole CAMHS. The author, at the Commissioners request, is currently ‘mapping and gapping’ the countywide provision of mental health services for children under three. An Under Fives Forum has been re-established and is currently working on a training strategy that could be rolled out across the County. Hence, we have moved from a position where development was serendipitous, to one where developments are being planned in a strategic framework. Through this process we have learnt some lessons that may be of interest to others. The key things in driving development have been: • An enthusiasm for, and a firm conviction in, Infant Mental Health. • The involvement of a multiagency group in planning. • Engagement with the national agenda and the Children’s NSF. • Engaging in a dialogue with the Commissioners that involved a discussion of the

evidence base and possible cost efficiencies.

Difficulties encountered have included: • Trying to provide a robust clinical service and training and consultation without enough

resources. This has meant that complex cases have often only seen one clinician (when two should have been actively involved) and training demands cannot be met.

• Resource problems in AMHS hindering joint thinking about women with babies who have mental health problems that may not meet the criteria for entry to AMHS, but are severe enough to impact adversely on their baby.

• ‘Mapping and gapping’ takes significant amounts of time. Public Health Departments need to be able to understand the needs of Infants and do this work, rather than relying on enthusiastic clinicians.

Contact details Dr Shirley Gracias Email: [email protected] Tel: 01225 352281 Address: Family Health Centre, The Halve, Trowbridge, Wilts BA14 8SA


WORKSHOP 6: Working Strategically To Promote Mental Health and Social Inclusion for Parents With Mental Health Difficulties and Their Children – The Action 16 Group Clare Mahoney and Kate O’Mara, NIMHE/North West Development Centre (part of Care Services Improvement Partnership/CSIP); Monica Cabello and Marie Diggins, Social Care Institute for Excellence (SCIE); Louise Wardale and Claire Turner, Barnardo’s Action with Young Carers “Words were like scrambled eggs when I was reading when I lived with my mum because I wasn’t’ coping very well at home. Children get stressed” Keeping the Family in Mind Report 1999 This paper outlines recent national developments in relation to addressing the needs of parents with mental health difficulties and their children. It begins by summarising key issues and concerns, and then describes recent developments and current policy opportunities. It ends with a list of key contacts. Background and Context Research and enquiry reports have established the possible adverse effects of parental mental illness on child development, well-being and safety, as well as the need for mental health and children and family services to work collaboratively to meet the needs of families. The following extract from ‘Crossing Bridges’ highlights the potential impact of mental health on parenting, on the child, over time and across generations: Between one in four and one in five adults with experience a mental illness during their lifetime. At the time of their illness, at least a quarter to a half of these will be parents. Their children have an increased rate of mental health problems, indicating a strong link between adult and child mental health. Parental mental illness has an adverse effect on child mental health and development, while child psychological and psychiatric disorders and the stress of parenting impinge on adult mental health. Furthermore, the mental health of children is a strong predictor of their mental health in adulthood. (Falkov, A 1998:1)

There have been a number of national and local developments in response to these findings including: a national training programme, the development of interagency protocols and the recruitment of specialist interface workers, all designed to improve collaborative working and outcomes for families. However, despite the enthusiasm and commitment demonstrated by these developments, change has been patchy and slow with a number of interrelated barriers continuing to get in the way of progress. Some of these are described as follows: Discrimination • Parents with mental health problems are one of four groups most likely to face barriers

in getting MH needs addressed (SEU/OPDM 2004). • Gender, race, mental illness, parenthood, each carry the double or triple jeopardy of

discrimination. • Women are afraid to come forward for help, particularly black women. (Darton et al,

1994). • 80% black women with children in care referred for MH, compared to 20% of white

mothers (Barn, 1990).


• Children and young people caring for a parent are the group most likely NOT to be offered a carers assessment. (Dearden et al, 2004)

Specialisation Separation and specialisation in health and social care services has resulted in staff in adult mental health services focussing on the adult with insufficient attention paid to the adult as a parent and his/her dependent children. Staff in children’s services put insufficient emphasis on the mental health needs of parents and the potential adverse impact on children. (Falkov, A. 1996; Woodley, 1995).

Policy and operational frameworks The increasing number of national strategies and frameworks aligned to core specialist areas appear to perpetuate existing barriers. A national based approach to raising standards and improving outcomes for all family members does not exist. Local managers and practitioners are faced with the challenge of seeking out the relevant points and then translating them into cohesive family-based policy locally. As families do not divide in the way that services and professionals do, sorting through the muddle can lead to fragmented and diluted service responses with practice guidance that does not have a ‘must do’ element. Recent National Policy developments and Initiatives Now with the responsibility for children’s services moved to the Department for Education and Skills (DfES) and mental health services remaining with the DH, there is even more impetus to support ‘joined up thinking’ and ‘working together’ at a national level to create guidance and standards that cross health and social care and mental health and children’s services. In the last year, there have been some significant national developments, which have focussed on collaboration between different organisation and departments. The work reinforces the importance of links between CAMHS and Adult Mental Health services and the need to involve the whole family in the recovery process. Some of these developments are as follows: • The Social Exclusion Unit (SEU) in their report Social Exclusion and Mental Health

(2004) identified parents with mental health problems and their children as one of four groups most likely to face barriers to getting their health and social needs addressed

• The Social Care Institute for Excellence (SCIE) is conducting a review of evidence of existing practice in supporting parenting needs in partnership with NICE.

• The Parental Mental Health and Child Welfare Network continues to grow in membership and strength, producing newsletters, electronic information and hosting national study days.

• The Action 16 group has been established to identify, plan and co-ordinate a set of actions which will progress Action 16 as described in the Mental Health and Social Exclusion report 2004, in partnership with SCIE, DH, DfES and other key strategic agencies and departments.

• A national review of the quality of and access to family visiting facilities within hospitals is underway

• Every Child Matters (Department of Education and Skills) includes specific reference to mental health issues.

• The Child and Maternity NSF has been published


• The needs of young carers are better understood – through the work of organisations such as Barnardos and their Keeping the Family in Mind initiative.

• The needs of parents and family support approaches are better understood and profiled (SCIE review - practice mapping element).

References Barn, R. (1990). Black children in Local Authority Care: Admission Patterns. New Community, 16(2), pp.229-246. Darton, K; Gorman, J. and Sayce, L. (1994). Eve Fights Back – The Successes of MIND’s Stress on Women Campaign. London: Mind Publishers. Falkov, A. (1995). Fatal Child Abuse and Parental Psychiatric Disorder. Department of Child and Family Psychiatry, UMDs and West Lambeth. Mayes, K; Diggins, M. and Falkov, A. (1998). Crossing Bridges – Training Resources for Working with Mental Ill Parents and their Children. London: Department of Health/Pavilion. Office of the Deputy Prime Minister (2004). Mental Health and Social Exclusion. Social Exclusion Unit Report. London: ODPM. Gopfert, M; Harrison, P. and Mahoney, C. (1999). Keeping the Family in Mind. Liverpool (unpublished/grey literature). Contact Details Action 16 Group - Clare Mahoney/Kate O’Hara National Institute for Mental Health in England (NIMHE), North West Development Centre (NW DC) Part of Care Services Improvement Partnership (CSIP) Tel: (+0044) 0161 351 4925 / Mob: 0794 115 6255 / Fax: (+0044) 0161 351 4936 Email: mailto:[email protected] Web: http://www.nimhenorthwest.org.uk / http://www.csip.org.uk Have you visited our Knowledge Community?: http://kc.nimhe.org.uk SCIE/NICE review & Parental Mental Health and Child Welfare Network – Monica Cabello/Marie Diggins Social Care Institute for Excellence (SCIE), Goldings House, 2 Hay's Lane, London SE1 2HB Direct line 020 7089 7109 / switchboard 020 7089 6840 / textphone 020 7089 6893 Fax 020 7089 6841 / www.scie.org.uk/mhnetwork Barnardos Action with Young Carers and Keeping the Family in Mind – Louise Wardale Keeping the Family in Mind, Barnardo’s Action with Young Carers, 24 Colquitt Street, Liverpool L1 4DE Tel: 0151 708 7323 Email: [email protected]/[email protected] Claire Turner – Principal Policy and Practice Officer Four Gables, Clarence Road, Horsforth, Leeds LS18 4LB Tel: 0113 3933228 Email: [email protected]


WORKSHOP 7: The Nuts and Bolts of Developing a Twofolded Perinatal Clinical Services Strategy Dr Trudie Rossouw, Consultant Child and Adolescent Psychiatrist and Interim Clinical Director CAMHS & Amanda Jones, Parent-Infant Psychotherapist, North East London MHT Location, Population and Demographics The service is in North East London Mental Health trust (NELMHT), which has a population over 1 million and covers 4 boroughs. The population is culturally diverse, with high levels of deprivation and asylum seeking groups. One of the boroughs has one of the highest rates of teenage pregnancies in the country. Brief History of Service Development From the outset, our intention was to provide a specialist Tier 3 Infant Mental Health Service. Fortunately one of our local Sure Start projects was originally prepared to fund two consultant sessions and six psychotherapy sessions dedicated to infant mental health. These posts were delivered and managed through the structure of the Child & Adolescent Mental Health Service. We provided Sure Start with monthly figures so that the service’s performance could be measured. Sure Start also commissioned an independent organisation to carry out an in-depth assessment into the quality of our service, outcomes of the service, and user satisfaction. At this point, the limit was that we could only provide a service for Sure Start families. However, during this pilot phase, and due to the success of Sure Start’s own evaluation, we were able to negotiate with CAMHS commissioners. In the end this resulted in the service being funded through mainstream CAMHS funding in 2 of the 4 boroughs of NELMHT. The CAMHS strategy groups of the two remaining boroughs have infant mental health as a top priority for future funding. The plan is to have specialist parent-infant psychotherapists based in each borough, forming a virtual PAN NELMHT infant mental health service. Amanda Jones is now Clinical Lead NELMHT PIMHS. Perhaps this is a good time to mention that the term infant mental health was not helpful at all in negotiating with commissioners. Although it makes sense to the clinicians, to commissioners it sounds as if we were talking about mad babies! We therefore decided to change the name of the service and since we started to call the service a Parent-Infant Mental Health Service (PIMHS) everyone understands one another. Our service takes referrals from pre-birth – 3 yrs of age and the majority of our referrals are babies under the age of 1. We have a wide referral base with referrals coming from health visitors, midwives, the local young teenage pregnancy service, GP’s, paediatricians, social services and CMHTs. Through the work of PIMHS, we became aware of the deficit in mental health liaison provision to maternity services. We found the following difficulties: adult services were overworked and financial resources were stretched. What complicated the situation further, was that adult psychiatric services were organised on a borough basis through CMHT’s, yet maternity services were organised through 2 acute trusts. For maternity services this created great difficulties as they had several psychiatric providers to liaise with, which created confusion and risk. They mostly wanted one liaison service to liaise with. Under my leadership, a steering group was formed consisting of our Chief Executive, adult borough directors, clinical lead of the parent-infant mental health service, maternity director,


clinical directors of adult services and maternity. As the steering group had a membership beyond mental health services, as well as chief executive input, it placed us in a better position to draw up a business case for a maternity liaison service for each acute trust. Our chief executive agreed to discuss the business case with relevant commissioners to produce funding. As the perinatal lead within the Trust I was given the remit to develop a Perinatal Clinical Services Strategy which formed part of the overall clinical services strategy of the Trust. My colleague, Amanda Jones and I then produced the strategy which has since been approved and supported by the Trust board. This means that we have developed a model which truly joins up a critical triangle: parent-infant mental within CAMHS - adult maternity services - adult mental health services. Our aim is to ensure that every mother who conceives in our area will follow an integrated perinatal care pathway that is able to highlight vulnerabilities and provide a range of services to care for both parent and baby throughout the perinatal period. From an academic perspective, we have also been keen to research the model of parent-infant psychotherapy we use within PIMHS. Amanda Jones has completed her doctorate at the Tavistock Centre on Parent-Infant Psychotherapy and this has led to many invitations to present the clinical model she developed both nationally and internationally. She is also doing another research study with Howard Steele involving first-time high-risk teenage mothers. Within one of the boroughs PIMHS provides for, we receive over 120 parent-infant cases per year (out of a total of 850). This raises questions as to how we will manage referrals as time goes on as we do think serious attachment difficulties warrant a Tier 3 intervention with a specialist in parent-infant psychotherapy. Strategic Drivers • NSF for children, highlighting early intervention and prevention • Every child matters • Why mother’s die: confidential inquiry into maternal deaths • Antenatal care: Routine care for pregnant women – NICE • Post natal depression and puerperal psychosis Service Description The service can be best conceived of as an integration of services which are separately integrated into and separately funded through CAMHS services and adult services.

Both services will be strongly linked together. The PIMHS service is integrated in CAMHS and the liaison service will have strong links with CMHT’s. Both services will have links with social services and the primary sector. The role of PIMHS is as follows – in addition to providing a clinical service, where Parent-Infant psychotherapy is the therapeutic model, it provides training for health visitors and midwives to enable them to pick up cases where the attachment relationship between mothers and their babies is at risk. Such training also aims to enable them to intervene in mild cases. It also provides consultation and training to social workers and family support workers.

PIMHS virtual team in CAMHS

Adult maternity liaison service in the 2 acute trusts


The maternity liaison service(in each acute trust) will consist of a full time midwife, a full time CPN, a full time staff grade psychiatrist and a session of a liaison consultant psychiatrist. Their role would be as follows: The midwife will initially be trained with the first group of midwives through the PIMHS service. Thereafter she will undertake training of all the midwives in the catchment area of the acute Trust. She will also help midwives to be more able to support pregnant women in the community, as well as to be able to identify cases in need of intervention. The CPN and staff grade psychiatrist will do mental state assessments on patients identified through screening at booking clinics in order to determine level of risk and treatment or support needed. In cases of known and severe mental illness, the liaison team will refer them to their local CMHT for further follow-up. Cases of milder depression or anxiety will be managed either by the CPN and staff grade directly of via them linking them to their local primary care services. Cases identified where child protection or parenting/attachment might be an issue, such as cases with previous history of child protection concern, unresolved loss or grief, may be referred to the PIMHS service in their area. The crucial element of the strategy is ensuring that all services have clear lines of communication and referral pathways which will ensure less risk. With regards to acute crisis erupting in labour wards due to unsuspected mental health issues, an acute 24hr psychiatric service will still be available through the junior doctor on-call rota. Treatment Pathways will look as follows: Pre-Birth Cases with SMI Mild depression Possible attachment Or previous history or anxiety related issues CMHT Liaison service or PIMHS Local primary care

Pre-natal screening by midwives

Mental Health Liaison Service


Post Birth SMI Attachment issues Mild cases CMHT PIMHS Primary Sector (HV/GP/Family support workers/social worker/ children’s centre) Contact Details Dr Trudie Rossouw Email: [email protected]

Amanda Jones Email: [email protected]

NELMHT - CAMHS Loxford Hall Loxford Lane Ilford, Essex IG1 2PL

Cases picked up by health visitor screening or by GP’s, social workers or other


WORKSHOP 8: Health and Play Primary Years Sam Preston, Coordinator, On Track Bradford Bradford District Healthy Minds Strategy identified the valuable contribution front line services offer in identifying mental health problems. This programme seeks to extend this further to enable early years groups and schools to apply skills and knowledge and become a major contributor to both the mental health promotion and prevention agendas. The pilot study identified a particular need for specialist early years transitional support to be developed as Tier 1 provision within schools. It is estimated that if in line with national statistics, up to 19,000 children and young people in Bradford may experience a mental health problem or disorder before reaching adulthood. (BDCYPSP, 2004) This presentation of the HAPPY programme will explore one solution to developing early prevention provision utilising and investing in developing existing practitioners’ skills enabling transferability and sustainability within existing services. It is widely accepted that the mental health problems faced by children and young people are rarely due to any single factor, more usually a culmination of different factors which together produce difficulties. Unresolved difficulties impact not only on emotional and psychological wellbeing but affect general health, social inclusion, and ability to access education, which in turn increases the risk of offending. This programme is focused on improving the early years transition into school for all children but was developed with a particular focus on those children who have been unable to access nursery provision residing in an area of high multiple deprivation. The presentation will outline how the overall aim, to enhance social integration, develop and support emotional and psychological wellbeing, has been achieved together with a details of the outcomes through a review of the robust evaluation process. An overview of each of the six sessions will be presented. Although each session has defined aims and objectives, they are thematically linked to help children to explore, develop, maintain and improve social skills/peer networking, to encourage and provide opportunities to experience solitude in a positive environment and to explore the foundations of a healthy lifestyle and develop decision making and planning skills. Each session follows a set structure of an introductory game followed by discussion group activity, themed creative activity, time to share work, free choice non-directed play on themed tables and an exit game. Sessional content consists of the following topics – (age appropriate delivery) Session 1: Role playing game with Persona doll – discussion content: • What it feels like to be in a new place • What it feels like to meet new people – children/adults • Personal safety • When does it feel good to talk • When does it feel good to listen • Being a new pupil in school Creative activity – a picture of me (how child sees them self)


Session 2: Families (inter generational / gender / ethnicity family dolls) • What is a family – are all families the same? • Relationships – roles and maintaining relationships • Respect – appropriate behaviour • Managing family conflict – who can help me, and how can I help? Working together • Your school family Creative activity – a collage of my school family Session 3: Physical and emotional feeling – explores themes through pictures, board masks and role play puppets. • What it feels like to be __________ • What it feels like when you are __________ • When you might feel __________ • How do others feel when you are __________

(E.g. happy, sad, angry, quiet, loud, alone, together, safe, unsafe) Creative activity – mask making Session 4: Builds on previous week. Opens with recap of feelings and how they make you feel inside and outside, how you act. Role play scenario – child selects feelings/emotion picture on interactive whiteboard – discuss: • Think of a time when you were __________ • How did you feel? • Was it a good/bad experience? Choose colours for both and circle. Creative activity – emotional blanket – fabric squares and pens. Session 5: Conflict Resolution – responses modelled using puppets • What is a friend? • How/where can you make new friends? • What do you expect of friends? • What do your friends expect of you? • Why can you sometimes fall out? • How to make friends again • Sometimes friendships change • How to have friends and be on your own Creative activity – friendship jigsaws. Session 6: The Mind and Body Squad Brings together previous 5 weeks learning in practical application. • 5 mins warm up game • 20 mins delivery – circuit activities • 5 mins water stop • 20 mins delivery – team work relays • 5 mins cool down • Healthy food tasting session


The presentation will also outline the key policies which influenced the programmes development such as Every Child Matters, The National Service Framework for Children & Maternity Services, Choosing Health and Healthy Minds Strategy. The main focus of this presentation will be to demonstrate a model for development of such programmes. The content will cover: • How to incorporate policy context into the delivery of frontline service provision • How to apply traditional project management techniques to ensure success • The method used to develop a multi agency / multi disciplinary development process • The pilot, monitoring and evaluation process • How to move beyond the pilot stage and gain strategic support As part of the presentation there will be an opportunity for discussion, reflection and sharing of ideas. Contact Details Sam Preston Tel: 01274 435 205 Email: [email protected]


WORKSHOP 9: Getting To Know Your Baby – North Tyneside Attachment Strategy Theresa Maddison and Tina Yarborough, Primary Mental Health Workers, North Tyneside Introduction North Tyneside Infant Mental Health project is a developing service which supports early infant attachment with the parent/carer. The service is a three tiered development. There is general agreement from research studies and literature that a secure attachment can protect a child against mental health difficulties and can provide a buffer in the event of adverse life events (Svanberg, 1998). Similarly Rutter (1995) argues that although insecure attachment cannot be equated with psychopathology, it must be regarded as an important vulnerability factor. The literature presented highlights a need to promote the emotional development of children and to develop primary and early intervention strategies. This philosophy is also reflected in both national and local policy – for example, the National Service Framework (NSF) for Mental Health (1999) promotes mental health and emotional wellbeing and the National Service Framework (NSF) for children, Young People and Maternity Services (2004) promotes positive mental health and emotional wellbeing. The North Tyneside Children and Young Peoples Strategic Plan 2003-2006 prioritises vulnerable children and North Tyneside Children and Young Peoples Preventative Strategy (2004) prioritises early intervention as a means of reducing poor outcomes. What Works in Promoting Children’s Mental Health (Sure Start, 2004) informs us that attachment based interventions can treble the number of infants assessed as securely attached (Van den Boom, 1994). The North Tyneside Infant Mental Health project service development is outlined thus: Tier 1 uses the Baby Bonding leaflet called ‘Getting to know your baby’. This was developed by a multi agency working group to raise universal awareness for new parents about the importance of early bonding with their baby. This leaflet was launched across North Tyneside in April 2005. We aim to evaluate its effectiveness in 2006. Tier 2 is a project being developed to support parents where difficulties in the early attachment relationships are identified. The project uses a video based coding system, the Care Index tool (Crittendon, 1984). The coding is used to assess interactions between parents and their babies. Brief interventions are introduced to enable parents to develop positive interactions with their babies. Tier 3 of the service development is a highly specialised Parenting Programme. This is called the ‘Mellow Parenting Programme’ developed by psychologists Maggie Mills and Christine Puckering. The Mellow Parenting Programme was delivered for the first time in North Tyneside in 2002. Families with identified complex difficulties can access this programme for longer, more intensive support. North Tyneside has developed a strategy for the delivery of this multi agency programme across the borough. This is supported and driven by a multi agency steering group. Reasons for the Service Development The proportion of securely attached infants is reported to be between 55-65% and this is consistent across most cultures (Van Ijzendoorn 1995). Based on this assumption, the


number of insecurely attached infants born in North Tyneside in the last year is approximately 800. There is evidence that insecurely attached infants are less socially competent (Moss, 1994), experience problems at school (Moss, 1994) and can exhibit substantial aggression (Soloman, 1995). On the other hand, research evidence indicates that a securely attached infant has better school adjustment (Finnegan et al 1996); greater concentration in play (Belsky & Isabella, 1988); greater language skills (Van Ijzendoorn, 1995) and a more positive self perception (Verschveren et al 1996). Secure attachment is likely to develop if the parent provides emotional warmth and security, prompt response to baby’s stress, moderate and appropriate stimulation and reliability in meeting the baby’s needs (De Wolff, 1997). No other service currently exists with the sole aim of promoting secure infant attachment in North Tyneside. The North Tyneside Baby Bonding steering group evolved to develop the three tiered Infant Attachment service. The aim of the multi disciplinary steering group is to raise the profile of attachment and to develop prevention, early intervention and specialist services to address the needs of children and families within the borough of North Tyneside. References Belsky, J. & Isabella, R. (1988). Maternal, infant and social-contextual determinants of attachment security. In Belsky, J. & Nezworski, T. (Eds.). Clinical Implications of Attachment, pp. 41-94. Hillsdale: Lawrence Erlbaum Associates. Crittendon, P.M. (1984). Care Index Coding tool. Department of Health (2004). The NHS Improvement Plan: Putting People at the Heart of Public Services . London: HMSO. Department of Health (2003). Getting the right start: The National Service Framework for Children, Young People and Maternity Services – Emerging Findings. London: HMSO. Department of Health (1999). A National Service Framework for Mental Health – Modern Standards and Service Models. London: HMSO. Department of Health (2004). The National Service Framework for Children Young People and Maternity Services . London: HMSO. De Wolff, M. S. & Van Ijzendoorn, M.H. (1997). Sensitivity and attachment: A meta-analysis on parental antecedents of infant attachment. Child Development, 68, pp. 571-591. Finnegan, R.A. Hodges, E.V.E. & Perry, D.G. (1996). Preoccupied and avoidant coping during middle childhood. Child Development, 67, pp. 1318-1328. Moss, E. (1994). Attachment and teacher-reported behaviour problems during the preschool and early school-age period. Development and Psychopathology, 8, pp. 511-525. North Tyneside Children and Young People’s Plan 2003-2006. North Tyneside Children and Young People’s Preventative Strategy 2004.


Rutter, M. (1995). Clinical implications of attachment concepts-retrospect and prospect. Journal of Child Psychology and Psychiatry and Allied Disciplines, 36, pp. 133-151. Solomon, J. (1995). Children classified as controlling at age six: Evidence of disorganised representational strategies and aggression at home and at school. Development and Psychopathology, 7, pp. 447-463. Svanberg, P. O. (1998). Attachment, resilience and prevention. Journal of Mental Health, 7(6), pp.543-578. Van den Boom, D. C. (1994). The influence of temperament and mothering on attachment and exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child Development, 65, pp. 1457-1477. Van Ijzendoorn, M. H. (1995). Adult attachment representations, parental responsiveness, and infant attachment: A meta-analysis on the predictive validity of the adult attachment interview. Psychological Bulletin, 117, pp. 387-403. Verschveren, K; Marcoen, A. & Schoefs, V. (1996). The internal working model of the self, attachment, and competence in 5 year olds. Child Development, 65, pp. 2493-2511. Contact Details Theresa Maddison, Primary Mental Health Worker, North Tyneside has been involved in North Tyneside’s Infant Mental Health project for over 4 years. Theresa is a member of the steering groups for Baby Bonding and Mellow Parenting Programme. Theresa is involved in establishing and providing service delivery across all tiers of the project. Email: [email protected] Tina Yarborough, Primary Mental Health Worker, North Tyneside became involved in the project 2 years ago. Tina was involved in the development, launch and evaluation of the ‘Getting to know your baby’ leaflet and is a trained facilitator delivering the Mellow Parenting Programme across the borough of North Tyneside. Email: [email protected]


WORKSHOP 10: Family Welfare Association Newpin Model of Working with Parents and Children Jacqui Lederer, Newpin Development Manager, Family Welfare Association Introduction The Family Welfare Association has worked with individuals and families in the greatest need since 1869, offering unique services in a variety of settings to provide support to families when they are at their most vulnerable. Two of these services that impact positively on the mental health of parents and children are being presented at this conference. • Building Bridges provides a flexible home based support service for parents with

enduring mental health problems and their children. • Newpin provides centre based structured support for parents and their children under

five where there is a range of identified mental health and parent/child relationship difficulties.

History Newpin was first set up in Southwark in the early eighties by a group of professionals at Guys Hospital who were concerned about high levels of isolation and depression among parents and the high incidence of child abuse and neglect. Initially envisaged as a support network with an emphasis on empowering parents to help each other, Newpin now has 25 years experience of developing user involvement in service delivery. Many of our trained staff today began their link with Newpin as service users. Newpin has historically worked with parents with significant mental health problems and the attachment-based model is able to meet the needs of this group, particularly in terms of supporting the secure attachment of the child. An evaluation of Newpin (Cox et al, 1990) showed an improvement in the mental health of parents, an increased understanding of others and improvement in parent’s abilities to recognise and meet their children’s needs. Current Context Since amalgamating with FWA in April 2004, we have continued to deliver the evidence based Newpin model of working. However, we are further developing our practice to be able to offer a more specialist service to meet the needs of parents referred to us with identified mental health problems. In addition, we are strengthening our links with both adult and child and adolescent community mental health teams to improve co-ordination for our service users. In a four tier model of service provision, Newpin operates at tier two/three.

The Newpin model contributes to the National Service Framework Standard 9 by supporting the mental health and psychological well-being of children and young people. It also provides a service that contributes to all five areas of the Every Child Matters Outcomes Framework. The service is currently commissioned by eight London boroughs. Description of Service Newpin is an empowering, strengths-based model of intervention that aims to: • Help parents break the cyclical effect of destructive family behaviour by addressing

insecure attachment patterns. • Improve the mental health of parents, reducing depression and increasing self-

confidence.


• Prevent emotional and physical abuse of children. • Reduce parent’s isolation by increasing support network. • Bring about lasting change in the quality of life for both parents and children. FWA Newpin works with parents who are main carers and their children under five where there is a significant difficulty in the parent/child relationship and /or an identified mental health problem. This may range from mild postnatal depression to more serious bi-polar disorder. When there are complex mental health or child protection issues, Newpin works in close partnership with mental health services and social services. Referral can be professional or self- referral. Newpin works therapeutically through: 1. Providing a secure base where parents can explore themselves and their relationships

(Pound 1994). The parent who as a child had experienced an unavailable or unpredictable mother and has responded by either withdrawal or ambivalence to others can begin to play out the various patterns of insecure attachment in the safety of the Newpin setting. Regular attendance at the centre – two or three times a week for about 2 years allows trust to build up and parents and children make new, healthy relationships with staff and other centre users. As a sense of security increases, the parent will be able to respond more sensitively to their children’s needs.

2. The concept of mutual support where every member is expected to support other

parents drawing on their own strengths and abilities. Combined support from both trained staff and other parents enables vulnerable families to be held through times of extreme distress.

3. Working with the parent /child relationship. There is recognition that the unmet needs

of the parent need to be addressed alongside the needs of the child and that without this nothing can change for the child. This has been called ‘treating the hurt child in the parent’ (Jenkins 1987). To balance this, there is an expectation that parents will, with support, meet their adult responsibilities to their child.

The structures that support this intervention are: • A centre-based service that is available Monday to Friday. • A parent contact list for use during the evenings and weekends. • Home assessments for new referrals. • Befriending by an established member of the centre. • A drop-in living room and playroom at least 3 days a week. • A weekly therapeutic parent support group. • A personal development programme with modules on parenting skills, family play

programme, befriending training and making choices. • Workshops on subjects requested by members e.g. art, healthy eating. • Members meetings to involve users in the running of the service. • On-going evaluation of use of the service. Summary The service aims to facilitate strong, healthy attachments between parents and children by placing an emphasis on preventing emotional abuse and recognising the impact of the parents’ own childhood on both their mental health and parenting skills. Newpin is a long-term intensive service offering an evidence–based model and can provide a successful intervention for some of the most troubled families that come into contact with statutory services.


Five key learning points: • We need to work with attachment patterns in a multi-tiered way: parent’s attachment to

the worker/child’s attachment to the parent, in order to facilitate secure attachment for the child.

• User member’s process is developmental: working with the resources and strengths of

an individual as well as their needs empowers them to develop skills and take on responsibility, for example, befriending.

• User involvement within Newpin requires specific structures and support at all levels

from developing a sense of ownership of the centre to specific voluntary roles and training to work in the organisation.

• Newpin is able to provide a non-pathologising, non-stigmatising service for parents with

mental health problems but recognises the need to develop close ties with statutory mental health services.

• In providing an attachment based model of intervention, it has been of paramount

importance to address with equal attention issues around separation. Newpin seeks to do this through explicitly focussing on structures that address presence and absence (holidays, week-ends, lunch breaks). We recognise that this is a difficult time for members and time and space should be given to work through the leaving process.

References Cox, A.D; Puckering, C; Pound, A; Mills, M. and Owen, A.L. (1990). The evaluation of a home -visiting and befriending scheme: NEWPIN. Final research report to the Department of Health. Jenkins, A. (1987). Recognising and treating the hurt child in the parent. In Families Matter. Whitfield, R. and Baldwin, D. (Eds) Collins Fount. Pound, A. (1994). NEWPIN: A befriending and therapeutic network for carers of young children. London: H.M.S.O. Contact Details Jacqui Lederer Email: [email protected]


WORKSHOP 11: Primary Care CAMHS – Working Together Jane Marshall, Consultant Clinical Psychologist and Service Lead, Working Together, Royal Liverpool Children's Trust (Alder Hey)

Introduction ‘Working Together’ is a Prevention / Early Intervention CAMH service, based in a Community Centre. We are currently funded to provide a service in the North and Central Areas of Liverpool. We don’t know at this stage whether the expected funding for the remaining third of the City will be forthcoming. We are only 18 months into the service. We have 5 Clinical Psychologists, 1 Mental Health Practitioner, 1 Family Therapist and an Assistant Psychologist. One of the psychologists acts as a link professional with Building Bridges, which is a Community based project aimed at addressing the mental health needs of the Black and Minority Ethnic population in Liverpool. The Main Focus The main focus of the service is on capacity building for frontline workers and for parents. The aim is to facilitate an understanding of the context of children’s lives and encourage people to look at children’s difficulties and distress within the context of the relationships within which they occur. Rather than viewing the child or young person as the problem and as the recipient of ‘treatment’, change is seen as happening through relationships and intervening in the systems and contexts in which these relationships operate: family, school, peer, community, neighbourhood, and health services. Working Together Objectives 1. To enhance the ability of frontline workers to promote the emotional well-being of children, young people and their families, and to respond appropriately to internalised and externalised emotional distress. 2. To enhance parents’ capacity to understand children’s emotional needs and to respond appropriately to internalised and externalised emotional distress – with an emphasis on pregnancy to the child’s 6th birthday. 3. To provide direct work to children, young people and their families ‘early in the life of the child and / or early in the life of the problem’, in order to prevent an escalation of difficulties and the need for more intensive and costly interventions. Delivery Training and Consultation Training, consultation and supervision (as well as joint working) are part of an overall strategy of building the capacity of frontline workers to understand the context of children’s lives and respond appropriately to children in distress. We are working in partnership with Liverpool Mental Health Awareness to deliver Child Mental Health Awareness Training (Level I) to 1000 frontline workers in Liverpool throughout 2006. We have plans to complement this with further training drawing on the Solihull Approach as a Level II Training, to provide a model for work with children and families.


Training for a wide range of professionals regarding services for black and minority ethnic children and families is delivered through Building Bridges. We offer consultation to pre-school providers and health workers. We hope to be hosted by Children Centre clusters, with one practitioner per cluster, given that there are 17 Children’s Centres and there will eventually be 30 in the City. This includes support to an NCH Family Support and Youth Mentoring Project whose remit is prevention/ early intervention with regard to young people aged 6-11 years, and consultation to YPAS for their work with 10-16 year olds. We provide telephone consultation to frontline workers through a duty rota system.

Group Work With Parents Group work and parenting programmes are aimed at enhancing parent/infant attachment, containment, reciprocity and effective and appropriate behaviour management. We are piloting ‘Growing Together’ within one Children’s Centre, which is an initiative to promote parent-infant attachment and reduce speech and language difficulties and behaviour problems in the pre-school years. We also coordinate focus group meetings with parents of children with disabilities who are from the BME community, identifying unmet need and facilitating the setting up of a buddy system. We plan to offer the Solihull Approach Parenting Programme to parents of pre-school children, starting in September 2006 Joint Working Joint working is a process of facilitating collaboration between parents and frontline workers in order to indirectly benefit the child / young person / family experiencing difficulty. Joint working is offered initially in preference to direct work and can be requested by any practitioner. A record of the meeting(s) is sent to those who were present (and the parents, whether or not they choose to attend), and is only sent to others if the parents want the information to be shared. Direct Work Requests for direct work with families are received either by Building Bridges or via the CAMHS Centralised Assessment and Brief Intervention Service (CABI). Priority is given to work relating to children from infancy to 6th birthday and where the onset of difficulty of less than 6 months (6 weeks for school refusal). Requests for work with children / young people 6-16 are accepted where the difficulty is new (not a different presentation of a longstanding difficulty) and onset of difficulty is of less than 6 months (6 weeks for school refusal). These criteria also apply to direct work that might develop from joint working. Focus of the Workshop The aim of the workshop is to provide a space for discussing the challenges of setting up a new service aimed at prevention/early intervention: Where do you start and what evidence base do you draw on? Balancing the demands of commissioners who are in a hurry to see quantifiable ‘outputs and outcomes’ with a thoughtful attention to the process of engagement and change.


Achieving a cultural shift in the way services are provided and managing the discomfort of uncertainty. The challenge of demonstrating efficacy and effectiveness.

Contact Details Jane Marshall Email: [email protected] Tel: 0151 283 0404


WORKSHOP 12: A Collaboration Between Adult and Child Services – Where Does Our Service Fit? Dr Margaret Bamforth, Consultant Child and Adolescent Psychiatrist: Dr Sheena Pollet, Consultant Psychiatrist in Psychotherapy; Gloria Collins, Clinical Nurse Specialist in Psychotherapy, 5 Boroughs Partnership Trust In order to address the question posed in our workshop title, it is necessary to provide a brief history of the service before looking at the current context for service development and drawing on the lessons we have learned over 16yrs of experience. The Psychotherapy Family Unit (PFU) was developed from 1989 as a joint venture between adult psychotherapy and child mental health services. The service aimed to use psychoanalytic therapeutic approaches informed by systemic thinking when working with families with young children where parenting difficulties had been identified. The collaboration between adult and child services was key as the patient was conceptualised as the ‘parent-child’ relationship. The importance of a cognitive-behavioural approach was recognised and this approach was incorporated into the ‘Family Day’, which was developed to intervene with difficult-to-reach families and included a mothers’ group, relationship play, lunch (when behavioural work took place) and for some families, the parent-child game. At the time the service developed, the climate within the NHS supported and nurtured the development of innovative services. Other ingredients included two psychiatrists keen to intervene in the intergenerational transmission of emotional disturbance and borderline personality disorder, a staff group trained in group analytic work and eager to learn and the release of staff and funding from the closure of a community hospital. Unfortunately with a limited number of staff (the full costs of providing the service never materialised) it became impossible to sustain the provision of the Family Days. The service today consists of a number of elements, the core of which is psychoanalytic Brief Parent-Infant Psychotherapy developed with the support of Dilys Daws. PFU staff run community-based Postnatal Depression support groups with Health Visitors which means they are visible and accessible to HVs seeking informal consultation about cases. The work with post-natally depressed mothers serves as a bridge between community and adult mental health services. Senior nursing staff are trained in family therapy and jointly provide a family therapy clinic with CAMHS. Links with adult psychotherapy have been maintained and all PFU staff continue to provide input to the adult psychotherapy service. In our 16 years, there have been several NHS reconfigurations. We always regard these as providing opportunities to be seized, while knowing that we will have to struggle hard yet again to keep our joint service alive, despite the enormous advantage of our sharing a building. Due to major recent NHS changes, where our collaboration fits in today’s multi-agency partnership world is the question our workshop aims to address with your help.

We are a specialist service, so in ‘CAMHS speak’, we are at Tier 3 but there is little recognition of the role of a Tier 3 service in Infant Mental Health. We are regarded with suspicion by the local Sure Start Schemes because of the stigma they perceive mental health services bring. The service remains within adult psychological therapy but is a low priority in the cash-strapped local health economy. Infant Mental Health is a low priority for CAMHS and not a current LDP target for CAMH. Posts are frozen – a vital HV liaison post has been unfilled for 18mths.


So although what we provide fits with the NSF CAMHS targets and the outcomes articulated in ‘Every Child Matters’ and delivers a modern model of service provision – through supervision, consultation and training to support community services, current service configuration is resulting in ‘failure to thrive’. Our learning points: We recognise that these learning points will match the experience of many services working with families with young children. The strand that runs through all our work and that underlines these learning points is how our service has been enhanced by the collaboration between adult and child services and how we have learnt together, bringing different perspectives to our work. 1. Maintaining a venture that crosses the traditional divide between child and adult

services is always difficult. NHS policy change, management reorganisations and change in patterns of service provision massively increase that struggle. One factor is that the need and demand for such a service are often hidden as families present through a mixture of problems to a variety of services. Work with young children and their families is recognised as a priority, (Sure Start etc) but within Health it is difficult to maintain interest in such a service when it has to compete with many priorities

2. There is a need to address problems early. The experience of CAMHS professionals is

that relationship and attachment difficulties become entrenched and if not dealt with early then families determinedly present the child as the problem later. Early intervention can reach the real issues quickly, as emotions are more accessible during times of transition, parents are highly motivated and new parenthood can precipitate the re-emergence of unprocessed traumas.

3. Our work has taught us how an adult can become profoundly disorganised when their

child’s life cycle overlaps with their own areas of vulnerability (e.g. the terrors aroused by childhood sexual abuse, the childhood death of a sibling/parent). At such times, the parent can present chaotically and repeatedly to adult services without the relevance and impact of parenthood to the presentation/decompensation being recognised and formulated. Unrecognised, such parents form a significant proportion of the ‘revolving door’ patients (especially women) whose treatment costs are very high.

4. Where the parent/child life cycle strains overlap, we agree with parent-infant clinician

and scientist, Daniel Stern, that it will often be appropriate for the adult/child/family unit to present for appropriate focussed help at several points in a life. This does not mean unsuccessful intervention.

We recognise the important role of Health Visitors as parent-infant experts and see it as crucial to find ways of working with and alongside them that are meaningful, useful and beneficial to them, us and, of course, to children and families. Contact Details Dr Margaret Bamforth Email: [email protected] Dr Sheena Pollet Email: [email protected] Gloria Collins Email: [email protected]


WORKSHOP 13: Talking Together Parent Workshops Liz Jackson, Speech and Language Therapist and Bharti Tank, Specialist Teacher This project was run by the Language Support Team; a collaborative team of teachers and therapists who offer training and advice on children’s communication to teaching staff and Early Years practitioners in Leicestershire. The team is funded by Leicester, Leicestershire and Rutland Specialist Community Child Health Services Speech and Language Therapy Service and Leicestershire County Council Educational Psychology Service. Talking Together is based on a parent programme run by Bowbridge Primary School in Notts. Aim To help parents from areas of social deprivation to encourage their child’s communication skills through use of everyday routines and situations. This was based on evidence that teaching language through everyday routines is effective as it can be directly incorporated into daily life rather than carrying over skills from an artificial context (Hart 85). Method The project was set up and run as a collaborative project involving agencies already familiar to the targeted parents. For example Surestart and Homestart hosted two workshops and Bookstart Plus contributed to sessions and donated equipment. Speech and Language Therapists, Area SENCOs and Educational Psychologists helped to identify settings. The team approached 10 early years settings in Leicestershire asking them to host the workshops. Each setting committed 1 member of trained staff to co-run the workshops, a separate room for parents to meet and free childcare for younger siblings on the morning of the workshop. A meeting was held to discuss roles of the staff and a group ethos was developed based on evidence from previous successful programmes (Dunst, Trivette and Deal, 1988) – • To establish an informal, supportive atmosphere • To be flexible and adapt to the needs of the group • To model appropriate language and interaction with children using everyday

routines/situations

Setting staff advertised the workshops to parents using flyers and face-to-face persuasion! A maximum of 8 parents were invited to workshop sessions. The workshops ran once weekly for 6 weeks and lasted for up to 2 hours. A different theme was chosen for each week – for example, cooking, bathtime, shopping, songs, books and play. The format for each session was as follows: • First half - parents and staff only. Staff facilitated discussion with parents on their

personal experiences of sharing daily activities (for example, cooking) with their child. Staff suggested ways to involve children in activities thus enhancing the child’s language. Discussions also explored how a child’s self esteem and confidence would be boosted by feeling useful in these situations.

• Coffee break - a chance for parents to chat informally • Second half – parents, staff and children present. Each parent/child pair was able to

take part together in the practical activity of the day (for example, making a pizza face).


Staff circulated informally and ‘modelled’ the strategies discussed in the first half of the session. At the end of the workshop parents and children were able to take home whatever they had made.

The project was evaluated by giving parents a short pictorial ticksheet to complete at the end of each session. Then both parents and setting staff took part in group interviews at the end of the project to gather their views. Attendance was also recorded for each workshop. Results and Evaluation Feedback revealed that 100% of parents enjoyed 100% of the workshops. The parents particularly enjoyed: • the opportunity to spend 1:1 time with their child in a fun situation • the informal, relaxed atmosphere enabling parents to discuss issues and share

experiences • seeing their child behaving and participating in workshops in a positive way

Parents reported that they had learned strategies such as: “slowing down and talking at the child’s level” “let him do things for himself, and talking more about what is happening” It was evident that parents were able to use the experiences from workshops and transfer them into the home environment. Comments indicated that some daily routines such as cooking and bathtimes had become more fun and interactive and other activities (for example, shopping) had become “less stressful”. Setting staff enjoyed the opportunity to talk to parents in a relaxed environment. They felt workshops were successful because the activities were highly practical and also because the onus was always on the child rather than the adult. Some staff commented that resource issues were sometimes difficult to manage. (for example, availability of space, staff and crèche facilities). Attendance varied considerably across the settings. The highest and most stable attendance figures were at settings such as a Surestart mother and toddler group and a Homestart crèche. This was probably due to the parents being familiar with the setting and having a well established relationship with setting staff. It was evident that parents felt comfortable and at ease in these environments and were therefore more likely to attend. Lower attendance was seen at the Family Centres where parents often had other issues preventing them from attending. In general, it was evident that the commitment of staff to talk to parents and encourage them to attend each week was crucial to the success of the workshops. The Future The team will continue to support Early Years settings in Leics. in setting up parent workshops. We are also aiming to train colleagues in Health and Education in running these workshops so that they can reach a wider audience. We also feel that helping parents apply strategies through daily routines rather than giving them an extra ‘programme of activities’ to carry out is a successful approach and should be used to inform future work.


References Dunst, C; Trivette, C. and Deal, A. (1988). Enabling and Empowering Families. Principles and Guidelines for Practice. Cambridge MA: Brookline Books Inc. Gibbard, D. (1994). Parental-based intervention with pre-school language delayed children. European Journal of Disorders of Communication. 29, pp.131-150. Marfo, K. (ed) (1988). Parent-Child Interaction and Developmental Disabilities. Theory, Research and Intervention. New York: Praegar. Tetreault, S; Parrot, A. Trahan, J. (2003). Home activity programs in families with children presenting with global developmental delays: evaluation and parental perceptions. International Journal of Rehabilitation Research, 26(3), pp.165-173. Warr-Leeper, Genese, A. (2001). A Review of Early Intervention Programs and Effectiveness Research for Environmentally Disadvantaged Children. Journal of Speech and Language Pathology and Audiology, 25 (2), pp. 89-102 Contact Details Liz Jackson, Speech and Language Therapist Email: [email protected] Bharti Tank, Specialist Teacher Email: [email protected] Leicestershire Educational Psychology Department OEM Building Whiteacres Cambridge Road Whetstone Leics LE8 6ZG. Tel: 0116 284 5100


WORKSHOP 14: Baby's First Year - Patterns for a Lifetime Carry Gorney, Family Therapist; Vicky Aldridge, Specialist Nurse CAMHS; Dipti Aistrop, Health Visitor and Julie Mitchell, Health Visitor, Sheffield "Although it is sometimes more difficult to engage her than her children, it is with the mother that the greatest leverage for change exists" (White & Watts 1973) Sheffield South West Child and Adolescent Mental Health Services (SW CAMHS) initiated this project as part of a Tier 2 approach to mental health promotion. Currently, a Sheffield CAMHS Infant Mental Health Strategy is just a glint in strategic eyes. However, we hope this pilot programme, together with our evaluation and research findings, will help to inform and promote discussion with senior clinicians and managers within our CAMHS system with a view to a strategy being formulated. The aim of our programme is to nurture a healthy attachment between high-risk mothers and their babies in the first year of the child's life in order to promote their positive social and emotional development. There is a window of opportunity to work with this elusive, reluctant, vulnerable at risk client group - it comes around the birth of their baby when they are in a life transition and in touch with new life bringing new hope; the dream of a positive loving relationship. At the same time we hope to support our mums during this transition, to help them alter their view of themselves while building on their existing skills, increasing their confidence and sense of pleasure in the growing bond between them and their babies. In addition, our programme is about hope and creating positive new stories - it invites everyone involved to understand and value the importance of conversations. Since January last we have created a safe and positive environment within which our participating mothers' stories can be told and heard. Our conversations act like mirrors, reflecting ourselves, shaping and evolving our identities. Who do these mums talk to? How do they make choices about whose voices they invite into their lives? Are there ways we can create a context for positive and healing conversation to take place in the community? Our working experiences have led us to recognise the importance of supporting groups and neighbourhoods, to find common ground, to build the confidence to engage with each other in communication hence witnessing each others strengths. We will demonstrate how we have built a small community comprising 8 Mums with their Babies, 8 Home Start volunteers, 2 Health Visitors, a CAMHS Specialist Nurse and a Family Therapist. The current culture of celebrity and fame, with recognition dependant on image and wealth, has made it imperative that we nurture the ecology of our everyday interactions and find ways to value community. Finding our place in the neighbourhood amongst those who can share our joys and concerns can comfort our distress, celebrate our uniqueness, nurture our capacity to lead fulfilled lives and support us to enable our children do the same. This pilot programme started at a point of new and exciting developments in the understanding of how humans become fully human and learn to relate emotionally to others. Through recent research in the neuroscience field we have access to a full biological explanation of our social behaviour through scientific understanding of infancy, significantly the development of our social brain. Behavioural traits, illness and criminality are not predestined and unavoidable. Current research leads us to believe that if the resources are made available the harm done to one generation need not be transmitted to the next: a damaged child need not inevitably become a damaged or damaging parent. Our mums were referred because they were identified as being at risk of experiencing parenting problems due to a range of difficulties - poverty, youth, a lack of education, social isolation, substance abuse difficulties and stressful life circumstances . Healthy attachment no longer rests in the


domain of the ‘soft’ sciences of psychology but is clearly essential to stimulating the growth of neurotransmitters in the baby's brain. The programme is adapted from the Steps Toward Effective, Enjoyable Parenting Project (STEEP) based in Minnesota and developed in response to an innovative study (The Parent Child Project) carried out in 1975 by Dr. Byron England, Dr. Amos Deinard and Dr. Alan Stroufe. This is a manualised intervention with video training materials. It utilises regular home visiting, video and group work, reaching out to first time Mothers before the baby is born and travelling alongside them during the baby's first year. The key areas of the Mum's development and our interventions include: • Skills and knowledge - promoting sensitivity to the infants cues and signals, realistic

expectations of behaviour through understanding of physical and emotional developmental stages/needs; provided by health visitors - video analysis/playback; input from regular one to one visiting; baby massage/yoga

• Insight and understanding - group sessions for Mum to explore her own developmental

history, how that affects her own parenting; exploring current choices/actions, problem solving how to move her life forward

• Support - providing a model of consistent and informed support throughout the year

within a positive therapeutic context; encouraging peer friendships to evolve • Empowerment - encouragement and confidence building to identify/utilise local

resources, communication systems (phones, computers) and local employment/training opportunities

Seeing is Believing Our presentation illustrates the idea of moving therapeutic conversations into the community by presenting a set of images. We show the way we work to nurture the relationship between the Mums and their Babies and how this takes place in group work and with regular volunteer visits throughout the year. We also demonstrate the work done in playing videos back to Mums in their own homes. We invite members of the workshop to participate in an exercise which demonstrates how we have trained the volunteers to analyze and discuss the video with their assigned Mum. The young women witness each other being good mothers and are encouraged by specialist CAMHS workers to express these observations and experiences. The volunteers in turn witness the Mums and Babies grow and change over the year - it is our experience that even the least confident Mum has responded positively to seeing herself and her baby on video. The professional team, through on-going supervision, witness the volunteers develop their own knowledge of the complexity of attachment issues and understanding of the challenges facing these mothers. The word conversation comes from the Greek meaning "making poetry with" - the Babies know about finding the poetry. They watch, wait and create their little poems of sounds and smiles and gestures with their Mums. As the year passes they reach out to other members of this small community and greet each other with increasing curiosity.


Contact Details

Vicky Aldridge Email: [email protected];

Carry Gorney Email: [email protected]

CAMHS South West Flockton House 18 Union Road Sheffield SLL 9EF.

Dipti Aistrop Email: [email protected]

Health Visitor Hanover Medical Centre William Street Sheffield S10 2EB.

Julie Mitchell Email: [email protected]

Tramways Medical Centre 54 Holme Lane Sheffield S6 4JQ


WORKSHOP 17: Cambridge Parent Infant Project - CAMPIP Carol Hughes, Consultant Child Psychotherapist and Susan Cochrane, Health Visitor, Cambridge In Cambridge an active group of professionals committed to Infant Mental Health (IMH) found ourselves facing a number of facts of life: • Following a needs assessment in our catchment area, we established that about 450

cases a year were in need of an infant mental health service. • Knowledge about and commitment to Infant Mental Health was entirely at

practitioner level. While various NSFs and policy documents pointed to the need for an IMH service, we found managers and commissioners uninformed, and indeed, sceptical about this.

• There was no new funding for an Infant Mental Health service. So, faced with the ‘luxury’ of no new funding we had carte blanche to address the questions: What, who and how (we already knew the why). What would an Infant Mental Health Service look like? Who would be involved? Who would we like to reach? (Our client group?) And how would we deliver it? How could we develop something viable out of existing resources? As practising clinicians our approach was soundly based upon clinical principles, clinical and outcome literature and shared clinical experience as we began to work together. One size fits all? As we began to explore the evidence base, the clinical needs of patients in our differing services and best practice examples throughout the country, it became apparent to us that we could not easily find one therapeutic model that we could apply to all clinical presentations. There is evidence for a number of interventions, although as yet, there is no randomised control trial to consider the relative efficacy of these interventions. Even a well funded tier 3-style IMH service would be unable to meet a clinical need of 450 cases a year. But more importantly, the severity and presentation of clinical need will not always warrant or be best addressed through a tier 3-style clinical service.

We developed two guiding principles:

• Multiple ports of entry to deliver a multilevel IMH service and

• A ‘critical mass’ of IMH professionals

This concept of multiple ports of entry is familiar within the field of Infant Mental Health, and is one which we have found particularly apposite to a developing Infant Mental Health Service.

The challenge for IMH is that existing services are organised into either adult or child services. IMH challenges us to consider news ways of working that obliterates this divide: the attachment relationship between infants and their parents is the client. Therefore existing services must reorganise to put the attachment relationship central to service delivery.


Babies cannot wait: research evidence is clear that there is a sensitive period for the development of secure attachment. This is from the 3rd trimester of pregnancy to 2 years of age. The literature points to the need for timely interventions – best delivered by workers close to the family, with an existing good relationship, often within the home. The Mental Health Foundation review (2002) concluded that to reach maximum numbers that a range of interventions would be necessary utilising a range of approaches – or as we envisaged it, multiple points of entry.

We set about training and educating ourselves in order to develop our knowledge. Our meetings were open to all who were interested and we kicked off the process with a large conference followed by formal and informal meetings and discussion groups. These groups aimed to reach across agencies, disciplines and tiers of service. This was expressly with the purpose of creating a local ‘critical mass’ of IMH practitioners who could each within their own field of practice utilise IMH knowledge and skills to help their client group, and raise awareness and skills levels within their agencies.

4 ½ years later, we regularly have about 40 people attending our open meetings and we are constantly being asked to organise and deliver specific training – for example, on the Solihull approach, Attachment or Infant Mental Health.

As we collaborated on raising awareness and informing ourselves we developed relationships across the traditional divides of health, social services, hospital and community boundaries. We began to refer cases to each other and engage in joint working.

We began to be aware that activity in one arena led to increased collaboration and co-working in other areas and a ‘racheting up’ effect began to occur.

Our joint working increased, trust and collaboration across disciplines and agencies increased, awareness of the need for more and specific training increased, more people from other agencies joined our open meetings and training groups. As we developed our

CAMH

Health visitors

Social services

Adult mental health

Paediatrics: hospital & community Voluntary sector

Sure Start

Neonatal

Midwifery

Children’s disability service

‘critical mass’


knowledge and skills so CAMPIP developed and evolved in an incremental way. It diversified and has had a growing impact on local services.

We did indeed begin to reach a ‘critical mass’ and CAMPIP became an identity rather than an idea. The ‘racheting up’ effect took us into presentations to Commissioners and our various management structures, putting IMH onto the strategic development map. As a result of aligning agendas with local strategic developments, we have produced for Assistant Children’s Director and Sure Start manger a ‘Competency Framework for IMH Practitioners’. (Available upon request.)

We created an interagency, multi disciplinary steering group with the express aim of further developing a significant critical mass of IMH professionals in the area. The steering group has senior clinicians or managers from Sure Start, Adult Psychiatry, Neonatal nursing, research Psychology, Research Health Visiting, Health Visitor Practitioners, Child Psychotherapy, Child psychiatry, Clinical Psychology and Primary Care Counselling.

CAMPIP the Clinical Service was born out of this. This is a tier 2/3 clinical service consisting of a Child psychotherapist 2 Health Visitors, a Clinical Psychologist (for children with disabilities) and a Primary Care Counsellor. We also use the Steering Group as consultants to the service, and have enlisted their direct clinical help in cases (e.g. adult psychiatry). We aim to further our aims of skilling local professionals by requiring that all referring professionals actively co-work clinical cases with us. We have built in group clinical supervision in which we all learn from each other as cases progress. We also offer group clinical case consultation and clinical supervision to professionals working in this area in cases not referred to the clinical service. CAMPIP the clinical Service is in its infancy. It is devised to build on the existing evidence base for clinical interventions, but also builds in a range of baseline and outcome measures to inform us as we grow.

Contact Details Carol Hughes Email: [email protected] Susan Cochrane Email – [email protected]

Address:

CAMPIP Cambridge Parent Infant Project Brookside Clinic Douglas House 18d Trumpington Road Cambridge CB2 2AH


WORKSHOP 18: Promoting Families with Mental Health Needs

Stephen Gilles, Senior Practitioner, and Claire Dempster, Family and Systemic Psychotherapist, Lambeth Child and Adolescent Mental Health Service '..despite recurring pleas from all quarters, it remains hard to bridge the gap between mental health work with adults and child care work with children and families.' 1

Setting the Context The Promoting Families with Mental Health Needs project was set up by the Health Action Zone on the basis of research indicating a high level of concern about the impact of parental mental ill health on children: “One of the main risks to children whose parents have mental health problems is the failure of adult psychiatric services and child protection agencies to understand each other and communicate adequately.” 2

As Falkov’s work in Lambeth, from where the above quotation is taken, illustrates, it is vital to understand what such concerns mean for families and practitioners – and to be aware of potential pitfalls. The Focus of the Project Jointly managed by the South London and Maudsley Trust and Lambeth Social Services, the project started in June 2001 and began accepting referrals in October 2001. It focuses on three areas of work:

• Clinical work through assessment, support and therapeutic intervention to children, young

people and their families. • The provision of training to other professionals to increase awareness and develop

understanding. • Consultation to agencies and other professionals.

The Current Team And Range Of Interventions Offered The Project is located is located within a CAMHS team and this gives us the opportunity to draw on the multi disciplinary nature of our colleagues. At present the team consists of two workers who have a background in Social Work and Systemic Practice. It is important to be clear that the work requires a significant level of therapeutic skill and a sophisticated understanding of social work policy and practice.

The large proportion of work carried out has been using family therapy as the main mode of intervention. This has a good evidence base in relation to behavioural issues (conduct related disorders) as well as depression and anxiety. However, the choice to use family therapy has been a response to a range of issues. Thinking with children and their families, and other professionals - about their beliefs, patterns and ideas, including in relation to

1 Tunnard, J. (2004) Summary - Research in practice: parental mental health problems. Messages from research, policy and practice.

2 Falkov (1996) Working Together – Chapter 8, Serious case reviews.


mental health difficulties - is particularly relevant to us. In our experience these are crucial matters in the therapy.

Individual work does occur with children and young people (and sometimes parents). This is likely to be using Family/Systemic Psychotherapy to think with young people alone about their difficulties and experiences.

Referrals to the Team Analysis of recent referrals reveals the following: 33% came from Adult Mental Health Services, 21% from Social Services, 11% from CAMHS, 9% from Education and 5% from GPs. That the largest group of referral comes from Adult Mental Health is testimony to the amount of liaison and training carried out with teams in the borough and the response from them. A significant number of the families referred also have other agencies involved, for example, Children and Families Social Work services. This increases the level of complexity for families as well as practitioners, in terms of case management, clinical governance and clinical practice. With regard to the sex and age of children referred to the project, 19% were in the 0-4 age group, 30% in the 5-9 age group, 39% in the 10-14 age group and 12% in the 15-18 age group. The high figure recorded for the 10-14 age group may well indicate the longer-term impact of parental mental health on children. Figures for the ethnicity of the children referred are as follows: 50% were from black or black British/Caribbean families; 24% were dual heritage white and black Caribbean; 22% were white British and 17% were black or black British Ghanaian.

Some of our Experiences In our experience, there are a significant number of families who experience isolation, stigma associated with mental health problems, anxiety and fear – including about the role of child mental health services. Families often express reservations with respect to how any concerns about their children might be understood in relation to their mental health. Many parents are also very aware that their mental health is detrimental to their children’s development. All these factors can make engagement a significant challenge. Establishing a robust enough relationship to explore these matters requires time, sensitivity and perseverance and is essential if these families are to be engaged. From our experience, that there are no easy answers or rapid solutions to these issues.

What often gives help and meaning to this engagement process is to discuss the existing professional systems and networks a family may have – and to engage with these. We find it important to be mindful that often families are experiencing other difficulties including discrimination, social exclusion, poverty, domestic violence and substance misuse. The intensifying impact that these issues can have on parents experiencing mental issues should not be underestimated. 73% of our families are single parent households, which often compounds the experience of isolation for many of our parents and children. Our view is that for therapeutic relationships to then be meaningful, a degree of longevity is experienced as useful.

Our work has also thrown up dilemmas about how parental authority operates for a parent whose needs are at times profound and tasks/roles need to be fulfilled by grandparents or older children. Supporting children in these situations, where behavioural difficulties, sibling rivalries and fighting can emerge in response to high levels of anxiety about a parent who is at times, unable to respond, is a delicate task.


Some Learning Points • Initial engagement often benefits from initial outreach. Attention to this part of the

process can often determine the progress and efficacy of any future work. This includes working with existing professional systems and workers and using known community locations and home visits as appropriate.

• Interagency and multi disciplinary work is a vital component as it gives us access to other

professionals as well as enabling us to take account of the needs of different professional systems and cultures.

• The availability of joint clinical work - e.g. adult mental workers or psychiatric colleagues

has proved fruitful for learning and practice, and also, has highlighted the need for clarity with families about roles/responsibilities and tasks.

• In our view, a frequently overlooked area of work is the application of professional skills

to strategic planning, such as network and planning meetings. • It is important to recognise the relationships between adult, child mental health and social

services. Genuine interagency work is in the service of families is vital, but frequently hard to do. It requires a genuine commitment from all stakeholders. A quality therapeutic service is not sufficient where other issues require the work and attention of other agencies.

Conclusion What we hope that this Project has demonstrated is that is possible to achieve progress for parents and children where services are built on parent’s strengths and aspirations for their children, and where mental health problems do not obscure or dominate the agenda. Contact Details Steve Gilles Senior Practitioner Email: [email protected] Tel: 0207 274 5459 Claire Dempster Family and Systemic Psychotherapist Email: [email protected] Tel: 0207 274 5459


WORKSHOP 19: Clinical Psychology Consultation and Co-Work Model – Working in Redditch Sure Start

Dr Alexandra Cooper and Dr Catherine Binney, Clinical Psychologists, SureStart Redditch

Background

Sure Start is a National Government programme which aims to achieve better outcomes for children, parents and communities. Sure Start programmes are targeted at children under the age of 4 and their families living in areas of high deprivation. Sure Start programmes share several targets, one of which is to improve social and emotional development, “in particular, by supporting early bonding between parents and their children, helping families to function and by enabling the early identification and support of children with emotional and behavioural difficulties”.1

Clinical Psychology in Redditch Sure Start

The clinical psychology post is a varied role that includes:

• Offering a range of psychological perspectives on children’s and families difficulties (developmental, cognitive, behavioural, systemic and psychodynamic).

• Providing training on children’s psychological development and mental health (e.g. to childcare providers, social services staff, Health Visitors).

• Running/contributing towards groups for parents. • Sharing and applying research and evaluation knowledge and skills. • Contributing to service development and planning. • Contributing at other professionals’ clinics. • Providing consultation for people working with children in relation to mental health. • Co-working cases with other professionals. The Evidence Base More research and literature is emerging that discusses the interaction between infant brain development, early relationships and a child’s overall development. This body of literature highlights the role of early intervention and prevention. “Certain windows of time are critical for the creation of brain pathways for attention, perception, memory, motor control, modulation of emotion, the capacity to form relationships and language. These pathways are created in response to the stimulation that takes place within the relationship between baby and caregiver, known as the experience-dependent or ‘use dependent’ development of the brain.” 2

Additionally, research indicates that early intervention services can be effective and cost-saving.3 “…economic analysis suggests that early childhood interventions are effective. There are indications that they can bring savings in public expenditure for special education, social services, health, welfare assistance and criminal justice”.4


Policies and Strategies

The clinical psychology consultation and co-work model is extremely relevant to many current policies and strategies, nationally and locally. The National Service Framework for Children and Young People 5 states:

“Early attachment and bonding between parents and their babies is important and needs to be supported… this necessitates CAMHS (Child and Adolescent Mental Health Services) working closely with primary care services, services for adults and early years support services such as Sure Start”

Government plans outlined in the 2004 Act, Every Child Matters 6 (ECM) makes reference to existing early years services, such as Sure Start and supports the continuation and development of such services. Standards have been identified that stress the need to support children’s mental health and identify children’s health needs at an early stage. Current emphasis is on the provision of services to meet these needs through Children’s Centres.

The clinical psychology consultation and co-work model is also relevant to the local Primary Care Trust’s identified priorities, regarding improving the health and wellbeing of children and tackling inequalities by reducing variation in access to health care. Origins of the Idea Several years ago, a Clinical Child Psychology primary care post was funded on a temporary basis by the local Primary Care Group. This post aimed to put into practice the recommendations of the Together We Stand document 7 by focusing on early intervention at a primary (Tier 1) level and partnership working across agencies and tiers. This post later informed the development of clinical psychology practice in Redditch Sure Start.

Consultation and Co-working Model

In the first instance, consultation is offered to professionals who can include members of the Sure Start team (such as Midwives, Family Support Assistants and Nursery Nurses), Health Visitors, voluntary agency workers and Social Services staff.

During consultation, certain considerations are taken into account to inform the decision as to whether direct involvement by clinical psychology or other services is required:

• Is the worker able to give you a clear view of the case? • How complex are the mental health needs in relation to this case? • How confident does the worker seem in their ability to meet the family’s needs? • Might the child have a developmental disorder or specific mental health problem? • Is it appropriate that the worker assesses or addresses this family’s needs?

Consultation can be described as a structured response to a particular presented problem where the psychologist guides and supports the people in direct contact with the person with the problem, offering psychological knowledge and skills. Potential benefits include:

• More cost effective and less time consuming (for the psychologist) than direct work (and therefore able to be more readily available.)

• Empowering for the worker, who can develop skills and knowledge. • Fewer professionals involved with the family. • Support for the worker.


• Increased confidence for the worker. • Knock-on benefits for the family.

Co-working can be described as two professionals jointly attending sessions with families. Both professionals contribute to assessment and intervention. The co-workers share the administrative and liaison aspects of the case as deemed appropriate. Potential benefits include:

• Support for the worker.

• A psychological assessment of difficulties.

• Combined experience, insight, knowledge and skills of the worker and psychologist.

• Learning experience for both worker and psychologist.

• Only one appointment for the family to attend. Setting up the Service The following considerations were important when setting up the consultation/co-work model.

• What were the existing services?

• Was the service replacing or supplementing existing services?

• Who were the potential consultees?

• What were relations like with that group? (Inter-professional, inter-service, inter-agency). It was also considered important to promote the service and meet with professionals for consultation in their place of work, rather than expecting them to come to the psychologist. A ‘solution-focused’ model of consultation was employed, which contrasts with other, more problem-focused approaches and is future-orientated and capitalizes on resources. Future Directions and Lessons Learned We are currently in the process of evaluating the service more formally. However, feedback from professionals and families has been positive. As part of Sure Start’s focus on the sustainability of services we are considering how this service and model may be usefully applied in Children’s Centres and universal services, after Sure Start programmes cease. We have found that the model has been extremely beneficial in building partnership working and that this way of working allows easy access to clinical psychology at Tiers 1 and 2.

References DfES (2002). Making a difference for children and families. Sure Start. DfES publications (Prolog). See also www.surestart.gov.uk Davies, M. (2002). A few thoughts about the mind, the brain, and a child with early deprivation. Journal of Analytical Psychology, 47, pp. 421-435. Shonkoff, J. & Meisels, S. (2000). Handbook of early childhood intervention 2nd Ed. The Child Psychotherapy Trust. (2003). Reducing risks – relationship based services for babies and parents. London: The Child Psychotherapy Trust and Association for Infant Mental Health


DoH and DfES (2004). The National Service Framework for Children, Young People and Maternity Services. London: HMSO. DfES (2004). The Children Act 2004 - Every Child Matters: Change for Children. London: HMSO.

NHS Health Advisory Service (1995). Child and adolescent mental health services: Together we stand. London: HMSO.

Contact Details Alexandra Cooper Email: [email protected] Catherine Binney Email: [email protected] Telephone number for both: 01527 65681


WORKSHOP 20: CAMHS, Infant Mental Health and Sure Start Lorraine Robinson, CAMHS Infant Mental Health Worker, Leicester

Introduction

The National Service Framework for Children, Young People and Maternity Services identifies the need for early intervention in the early years. It is acknowledged that “appropriate parenting styles are fundamental to caring for babies and children’s mental health. And that early attachment and bonding between parents and their babies is important and needs to be supported’. It goes on to highlight that ‘dedicated expertise in Tiers 2 and 3 services, supporting the work of a range of professionals, will ensure urgent responses to vulnerable parents and their infants.” This gap was responded to with the proposal of seconding a CAMHS professional to work within the SureStart Team, specifically with this identified group. The proposal was put forward as one of the priorities in the bids for new monies in the 2003/2006 CAMHS Joint Strategy Group. In addition, it was proposed that funding for the post should come from the PCT Grant for 2006. However, other proposals took precedence and the post was placed on hold. However, Ann Marshall the Programme Manager for SureStart Beaumont Leys & Stocking Farm had been present at one of the consultation events and was keen for the post to go ahead. She suggested SureStart fund a one year pilot project. It was also agreed that it would be essential to evaluate the effectiveness of the post and therefore money was also made available to do this.

Policy to Practice

The post was funded by SureStart but managed by CAMHS. It was accepted in theory that the first month would be spent in getting to know colleagues and their roles, deciding on the priorities that I would be focused on and thinking about how these could be achieved and evaluated. Whilst meeting with SureStart colleagues and those in Adult Mental Health, the opportunity was taken to discuss the role and promote Infant Mental health. This had the immediate effect of people saying, “now you’ve said that you’ve made me think”, and was then often followed by a discussion of whether cases would make appropriate referrals. This made clear that a practice model needed to be developed which would include establishing priorities, referral procedures and care pathways.

The Priorities The priorities were established as follows: Early identification, assessment and therapeutic intervention pre-natally of prospective parents who may, for whatever reason, be at an increased risk of developing difficulties attaching to their baby.


Training and therapeutic intervention at the Smart Start nursery to enable provision of input to the 24 Health and Social Care children as these children are more likely to have an increased vulnerability to future mental health difficulties. Post natal intervention for families who are experiencing relationship / attachment difficulties to minimise and prevent future mental health difficulties.

Early Identification A criteria for identifying those cases most at risk of developing attachment difficulties with their baby was devised. For this to be most effective, current practice was reviewed in order to establish the best way of eliciting the information that would be needed to consider those prospective parents that meet the criteria. On receipt of a referral a joint appointment with a midwife is arranged. This is then followed by further assessment and intervention as appropriate. Assessment may involve gathering more information through one to one consultation and /or the use of the Thereplay Pre-natal Marshak Intervention Method. Intervention may involve a variety of approaches including Solution focused, psychodynamic and pre-natal Theraplay. It may also involve liaising with and referring to the Adult Mental Health Service.

Smart Start Nursery By devising a questionnaire it was possible to obtain a base line measurement of the knowledge of the staff at the nursery regarding Infant Mental Health. This was followed by writing and delivering a training session entitled ‘Infant Mental Health, What is it? Prevention and Intervention’. The training also provided the staff with some insight into the use of Group Theraplay which is a form of intervention that is particularly useful for working with children who may be having difficulty in connecting to significant adults or other children, or who have difficulties connecting to emotions. A number of Theraplay Nurture groups are now facilitated at the nursery. It is hoped that these will have a direct benefit to the children and provide ongoing training and support for the staff.

Post Natal Intervention A criteria to identify children who may be vulnerable to developing mental health difficulties was devised in order to select those cases that would benefit from CAMHS input. As part of the referral procedure, consultation is available to colleagues to discuss cases. Assessment includes establishing the needs of parents and children and considering if a diagnostic criteria is warranted. This may require further clarification within mainstream specialist CAMHS or Adult Mental Health. In most cases, in the first instance it is possible to provide early intervention locally. Generally there is an emphasis on building healthy attachments and offering a flexible needs-led service. In cases where there are significant attachment difficulties, Individual Family Theraplay is offered to facilitate positive changes within the family dynamics. In conjunction with the Health Visitors and other SureStart Professionals, a Post Natal Group is facilitated. The overall aim of which is to help parents to consider the emotional impact of having a baby, the changes it makes to relationships with partners, parents and other children and to offer support to parents in forming a healthy attachment to their babies.


There is a drive to actively involve more fathers to attend and be a part of SureStart. Therefore, as well as encouraging their attendance at the post-natal group, training on Mentorship to local dads has been offered.

The Future This is an emerging practice which began in June 2005, so watch this space … Contact Details Lorraine Robinson CAMHS Infant Mental Health Worker Surestart Beaumont Leys and Stocking Farm Surestart Centre 20 Home Farm Walk Beaumont Leys Leicester LE4 0RW Tel: 0116 295 4585 Email: [email protected]


WORKSHOP 21: Risks, Relationships and Repair Robin Balbernie, Consultant Child and Adolescent Psychotherapist, Gloucestershire Partnership Trust & Sure Start

This is an account of delivering an Infant Mental Health Service in the community as part of the Sure Start project in Cheltenham. Two of us brought in from CAMHS, a community worker and three volunteers offer a dedicated service for two days a week, working almost exclusively in the home. We also run a rolling programme of relevant seminars. Our intervention aims to affect the relationship between infant and parents, and hopefully alter the balance of probability for the development of secure attachment. In our clinical work, the main approach is infant-parent work, concentrating on the relationship between baby and caregiver. However, there are always other issues that need to be thought about and, where appropriate, we can introduce ‘hard to reach’ families to the Sure Start Family Centres for the wide range of help and support on offer there. Cheltenham Sure Start also hosts a volunteer-based ‘Befriender’ scheme, and we regularly involve each other in offering help to families in the area. In direct work we have found the use of video recordings helpful, following the Interaction Guidance model of Susan McDonough. The mothers filmed with their babies usually find this useful as it enables them to see their relationship with their child from the outside and in action. It is a good technique for developing the capacity for reflective function, a core component of the sensitive and responsive caregiving that is the foundation of secure attachment. The majority of referrals have been made by Health Visitors, Midwives and other members of the extended Sure Start Team, followed by a smattering from Social Workers and Adult Mental Health. We have tried to get across the principal of referring on the basis of vulnerability rather than crisis. There is a large body of research that has examined how different stresses can impact the caregiving relationship in a negative way. Since the baby is continually adapting to this relationship, which can almost be regarded as the infant’s evolutionary niche, anything that distorts it will have an effect on the baby’s development. We use a simple, research-based, check list which, unsurprisingly, reveals just how over-burdened so many families are with multiple difficulties. It is the accumulation of stresses that increasingly puts the parent-baby relationship at jeopardy. In general four or more moderate risk factors found together warrant intervention, and with this approach, help can be offered before something has gone wrong. This seems sometimes to be hard to get across to referrers who are geared to respond more to a crisis that has already happened rather than one which can be anticipated and then possibly prevented. However, there are certain obvious circumstances that are sufficiently worrying for them to stand alone as a reason for offering help. In the families we have worked with, we have found: severe mental illness and depression (61%), alcohol and/or drug abuse (16%); a background of severe abuse, neglect or loss in childhood (50%); the infant a victim of maltreatment (11%); and violence reported in the family (41%). The majority of the parents referred to our service appear to find that it provides a form of help that they want to access. It has been difficult to get going with a few. A fairly common reason, perhaps a feature of the population Sure Start is there to work with, is that many families simply move out of area or have motives for remaining ‘unseen’. The referrals that did not engage all had severe problems with such issues as their own mental health, domestic violence and ambivalence or outright hostility about statutory services (frequently together) that would need to be addressed before there could be any space in their life to consider their relationship with their baby.


There seem to be improvements in every family that we have visited, not forgetting that for many, if not most, of them no deterioration in the relationship between infant and parent can count as a certain achievement. We use the Parent-Infant Relationship Global Assessment Scale (Zero to Three, 1994:67) to record the quality of the infant-parent relationship as observed at the beginning of contact and then again at the end. This scale offers a qualitative measure of relationship problems, and does not focus on specific symptomatic behaviours that might also be present. We have found that this consistently correlates with number of risk factors. We have recently begun to take advantage of a new assessment tool, the Ages & Stages Questionnaire for Social & Emotional Development. (Paul H. Brookes Publishing Co., ISBN 1-55766-533-8) This is giving us a very useful clinical measure. The greater majority of the babies and toddlers (so far) involved with our service seem to be developing within acceptable limits. It is impossible to generalise the issues addressed during the sessions, every mother brings her own unique history and current circumstances to bear upon the relationship they have with their baby. Many have been neglected and abused themselves, and come from difficult family circumstances in their own childhoods; frequently we find that this goes with having been in foster-care or late adoption. We rarely find post-natal depression that has appeared out of the blue. The depressions we seem to work with are, in general, caused by numerous other life-events and are usually long-standing. A new baby, with all the demands that entails, becomes a situation of normal high stress meeting strained resources . Many of the mothers we see completely lack any family support, and for these the wider Sure Start scheme is tremendously helpful. Low self-esteem, lack of confidence and mental health difficulties are common issues, frequently made worse by a sense of guilt that then becomes another push into a negative spiral of interaction with their infant. Domestic violence, both current and in the past, is a tremendous problem for some, with all the problems that this is known to cause children. Further details of our service and the assessment measures used will be given in the presentation. Contact Details Robin Balbernie Email: [email protected]


WORKSHOP 22: Infant Massage and Its Contribution to Promoting Infant Mental Health Liz Hope, Health Visitor and Certified Infant Massage Instructor (CIMI), SureStart Whitehaven Local Programme; & Kay Cartmell, Maternal/Infant Metal Health Project Leader; RHV, CIMI, West Cumbria PCT Overview of Presentation SureStart Whitehaven is a SureStart Local Programme led by a voluntary sector family centre (Howgill Family Centre), which has been providing additional, innovative services and interventions to families in West Cumbria for 5 years. Infant mental health promotion has been an integral thread running throughout the programme since its inception. A multi-agency team of practitioners from Health, Education, Social Services, Pre-School Learning Alliance and the Voluntary Sector, have been working collaboratively on various projects to promote the mental health and emotional well-being of infants, children and families, in the antenatal and postnatal period and in the pre-school years. Infant massage is one of the most popular interventions that the programme provides. Infant massage is a two-way communication process based on Indian massage, Swedish massage, Reflexology and Yoga and was developed in the USA by Vimala McClure in 1976 who founded the International Association of Infant Massage (I.A.I.M.). It is a tool to facilitate bonding and attachment between care-giver and infant in a practical and loving way, thus being an important first step in the development of the dyadic relationship between parent and child. Liz Hope and Kay Cartmell are health visitors who were seconded to the SureStart Local Programme and subsequently trained and qualified as Infant Massage Instructors with the I.A.I.M. in 2001. I.A.I.M. mission statement: “The purpose of the International Association of Infant Massage is to promote nurturing touch and communication through training, education and research, so that parents, care-givers and children are loved, valued and respected throughout the world community.”

Since qualifying as C.I.M.I.’s, Liz and Kay have delivered individual and couple home based massage sessions and group courses . They also provide a weekly drop-in class held in a local library. Cohorts are fully evaluated by questionnaire at the end of each course. Here are some comments from the end of course evaluation questionnaires: Question: What did you like best about the course? “Learning how to sooth my baby” “Everything. Very informal sessions. Great for a crack also.” “Time to talk to other mothers and very relaxing for me and Daniel.” “We both felt relaxed and could go at our own pace.”

“Contact with the baby and learning different things as we done the course.”


“Meeting other mothers and babies.” “We were all able to share our experiences and problems positively.” “The one to one communication with your child. It was done in the home.” “The layout – small and informal.” Question: How has the massage affected your relationship with your baby? “My baby is so content now and we can communicate much better. It has brought us closer together.”

“Taught how to use ‘quality time’ more effectively.” “We are more receptive to each other and we know each others needs.” “It has given me more confidence in understanding what she likes/dislikes.” “Bonded better and can get good eye contact. Both feel very relaxed after.” “Encouraged more quality time. Helped before bedtime. Relaxed baby and helped with bath time.” “Yes, my baby and I have bonded really well. I have found this group has really motivated me and is a very valuable service.” “I am more responsive to Ellie’s signals.” “It is our relaxing time, and it calms Jenna down to a chill.” “Great for bonding with baby. Baby loves being massaged. Have met other Mum and babies which we are keeping in touch with – made new friends.” This workshop will give an absorbing insight into infant massage and its many benefits to both infants and carers. It will focus particularly on how the mechanisms of infant massage encourage attachment and bonding, enhancing the relationship between caregiver and infant and promoting infant mental health. Infant massage seeks to enhance the sensitivity of parents to their child’s needs, by developing observational skills. It seeks to consolidate attachment patterns and builds parental confidence in nurturing their child in a non-threatening, non-stigmatising enjoyable way. The workshop will demonstrate how infant massage can help parents recognise their infant’s signals and cues and become more responsive and attuned to their child’s needs. The presentation will draw on key standards and outcomes from the NSF for Children, Young People and Maternity Services and Every Child Matters, Change for Children and will consider how infant massage relates to them. During the workshop we hope to show video clips/ photos of parents massaging their babies and you will be able to test some of the oils used in the massage process and see the demonstration dolls. The workshop will also include an interactive element, where you will learn some massage strokes yourself! Since qualifying as C.I.M.I.’s Liz and Kay, through the SureStart service and taking referrals from baseline colleagues, have been able to reach and teach parents who would otherwise


not have engaged in therapeutic work. Vulnerable adults, teenage parents, mothers and fathers suffering from post natal depression, socially excluded adults with learning difficulties or special needs, parents coping following a premature birth and parents with twins and triplets have all benefited from learning this valuable skill. Infant massage does not end when the baby crawls away to explore his world. The technique once mastered, can be adapted to the needs of the growing child and young person, providing a safe, nurturing relationship between carer and child through preschool, school and teenage years. The massage is only undertaken when permission has been sought thus respecting the child’s wishes. The positive touch technique helps with emotional issues, allowing the child / young person to share difficult experiences in a supportive way. From the very outset of their massage journey, parents can be aware that massage is not just for their baby, but is a tool to stay in touch with their child for years to come. References Adamson, S. (1996). Teaching baby massage to new parents. Complementary Therapies in Nursing and Midwifery, 2, pp. 151-159. Hart, J. et al. (2003). Health visitor run baby massage classes: investigating the effects. Community Practitioner, 76(4), pp. 138-142. McClure, V. (1998). Teaching Infant Massage: A Handbook for Instructors IAIM. Boulder: Colorado. Onozawa, K. et al. (2000) Infant massage improves mother-infant interaction for mothers with postnatal depression. Journal of Affective Disorder, 63, pp. 201-20.7 Contact Details Liz Hope Email: [email protected] Kay Cartmell Email: [email protected]


Further copies are available from:

Jo Edgar Business Manager, NCSS

Leicestershire, Northampton & Rutland Strategic Health Authority

Lakeside House 4 Smith Way, Grove Park

Enderby, Leicester LE19 1SS

t: 0116 295 7574

e: [email protected]

Produced November 2005

[Note on copyright © - The material contained within this handbook remains the intellectual property of the author]

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