Like all people, babies experience a range of emotions in response to what happens in their lives. Although they cannot recognise and describe it to us, babies can feel happy and secure, or stressed and distressed. If things aren’t right, their emotional wellbeing can be affected. Early mental health influences how children learn to experience, manage and express emotions, and feel safe and secure to venture into the world around them. Infant mental health describes the social and emotional wellbeing and development of children in the earliest years of life. It reflects whether children have the secure, responsive relationships that they need to thrive.
Early relationships are fundamental to infant mental health and set a template for how babies begin to think about themselves and others. Parents’ responses shape how babies experience their emotions and how they learn to regulate and express these emotions; for example, through soothing them when they cry. In this way, the parent-infant relationship can act as a significant conduit of mental health difficulties from one generation to the next. It is estimated that around 10–25% of young children experience significantly distorted relationships with their main carer(s) that will predict a range of poor social, emotional and educational outcomes.1 This kind of disorganised attachment is much more prevalent in families living with stress factors such as conflict, substance misuse, parental mental illness, exposure to trauma and severe poverty.
Why does infant mental health matter?
The first 1,001 days after conception is a period of uniquely rapid development. Babies’ brains are most ‘plastic’ or adaptable in this period, as many millions of neural connections are made and then pruned, and the brain’s emotional regulation systems are forged.2 Although children’s futures are not wholly determined by the age of two, wellbeing in the early years is strongly linked to later outcomes.3 Bowlby wrote, ‘…the pathway followed by each developing individual and the extent to which he or she becomes resilient to stressful life events, is determined to a very significant degree by the pattern of attachment developed during the early years’.4 By protecting and promoting babies’ emotional wellbeing and development – improving infant mental health and strengthening parent-infant relationships – there is an opportunity to put children on a positive developmental trajectory, so they are better able to withstand the stresses and strains of life ahead. A large body of research shows that early relationships, emotional wellbeing and development are associated with later wellbeing.
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Emotional and social skills
A child’s early relationships shape their perceptions of themselves and others and teach them how to regulate their emotions and control their impulses. This lays the groundwork for children’s developing emotional wellbeing, resilience and adaptability; key competences that will help them to thrive.
Mental and physical health
Research shows a strong connection between exposure to stress in pregnancy and early life, and later mental health problems.5,6 Supporting infant mental health can prevent emotional disturbances from taking root and escalating into mental health problems.
Early relationships set templates and expectations for future relationships. Secure, nurturing relationships give babies the skills to form trusting relationships with others. Relational capability is essential for living a healthy and fulfilling life and making a positive contribution to the lives of others.
Good infant mental health enables children to understand and manage emotions and behaviours and to form positive trusting relationships. It can reduce later risky and antisocial behaviour and the costs it brings.7
Children who have had good early relationships start early education and school better equipped to be able to make friends and learn.8
Good infant mental health increases the chances of babies going on to achieve their potential in later life and contributing to society and the economy.9
Effective early action also leads to accumulated savings by preventing other services being required later in the child’s life and improves the child and family’s participation in the economy. ‘Investing in early childhood development is good for everyone – governments, businesses, communities, parents and caregivers, and most of all, babies and young children... And investing in early childhood development is cost-effective. Compelling financial research from America suggests that for every $1 spent on early childhood development interventions, the return on investment can be as high as $13’.10
What is specialised parent-infant relationship therapy?
Effective early intervention to support the parent-infant relationship can prevent a baby’s emotional distress escalating into mental health difficulties and ultimately disorder. Infant mental health teams are known as ‘specialised parent-infant relationship teams’ because it is not the infant who is the client, but the relationship between the baby and their parents or caregivers. Specialised parent-infant relationship teams are multidisciplinary teams providing therapeutic support where babies’ development is most at risk due to severe, complex and/or enduring difficulties in their early relationships. Alongside providing direct support, they are also expert advisors and champions for all parent-infant relationships, driving change across their local systems and empowering professionals to turn families’ lives around. Because of the diverse and important role these teams play, they can be jointly funded by Clinical Commissioning Groups (CCGs) and children’s services and/or public health within local authorities.
Babies and toddlers are different from older children, so it is important that services can respond to their unique needs. We advocate that all practitioners in specialised parent-infant relationship teams should have expertise in infant mental health and in supporting and strengthening the important relationships between babies and their parents or carers. We recommend that all staff should have obtained level two in the Association of Infant Mental Health Competency framework11 and should be working towards level three.
Most effective parent-infant relationship therapies focus on improving the sensitive attunement between the parent(s) and baby. This might be achieved through a combination of approaches which strengthen parental reflective functioning and/or bring to awareness the parents’ ‘ghosts in the nursery’,12 those often unseen but influential emotional wounds from the parents’ own upbringing. Skilled practitioners hold the infant, the parent(s) and the relationships in equal esteem, and the work can be surprisingly complex as it explores the intersection between the internal worlds of at least two or more participants. Psychotherapeutic theory and practice feature heavily, as does use of video feedback work to help parents see their interaction with their child through a more objective, often strengths-based, lens. The work can stir up unresolved infantile feelings in the therapists too, so good quality reflective supervision is essential to effective practice.
What infant mental health provision exists in the UK?
Across the UK, there is huge geographical variation in the quality and capacity of services, which reflects differences in local decisions and priorities rather than the level of need or demand for these services. Gaps in specialist services to improve infant mental health are particularly bleak. There are only about 36 specialised parent-infant relationship teams in the UK, meaning that most babies live in an area where these services do not exist. These teams are known as ‘rare jewels’ because they are scarce and small, but where they do exist, they are extremely valuable and highly valued.13 There is very little mental health provision for children aged two and under. Even though Child and Adolescent Mental Health Services (CAMHS) should cater for birth–18 year olds, in 2019, CAMHS services in 42% of CCG areas in England did not accept referrals for children aged two and under. And of those that said they accepted referrals and could provide data broken down by age, 36% had not seen a child under the age of two.13 The recent Babies in Lockdown14 report finds that support and risks for vulnerable or marginalised families are likely to have got worse as a result of the pandemic. However, things should be changing: the NHS Long Term Plan for England committed to improving access to specialist services for all children from birth–25. It stated that, ‘…over the coming decade, the goal is to ensure that 100% of children and young people who need specialist care can access it’.15 This requires specialist provision – like parent-infant relationship teams – to be in place for all babies who need them.
Who needs infant mental health support?
Most parents want to do the best for their babies, but some live in situations that make this hard. Stress factors such as, but not limited to, domestic abuse, mental illness, substance misuse, unresolved trauma and poverty can make it harder for parents to protect, support and promote young children’s development. The more adversities a family faces, the harder it can be for them to meet their babies’ needs.16 Tens of thousands of babies in the UK live in families experiencing stress factors like these described. Not all these children will have poor mental health, and other children without these risk factors may have social and emotional problems; but over 7,000 unborn babies and 20,000 children under one in England alone are recognised as being ‘children in need’.17 Many of these babies will have experienced significant difficulties in their early relationships that can take a significant toll on their mental and physical health and development.
Additionally, it is likely that many babies who experience significant risks are not known to services. Research by the Children’s Commissioner suggests that fewer than half of babies in England living with adults experiencing mental health problems, substance misuse issues or domestic abuse are recognised as ‘children in need’.18
The case to protect and promote infant mental health is strong, but provision of services is poor. Addressing infant mental health offers a key to unlocking the potential of our nation going forwards, creating resilient, caring communities that are better able to cope with future trauma. Therefore, all discussion of children’s mental health must include infants. Too often, it does not. Future mental health strategies, action plans and investment, including any response to COVID-19, must explicitly consider babies and deliver clear, tailored responses to meet their needs.
1 Van Ijzendoorn M, Schuengel C, Bakermans-Kranenburg M. Disorganised attachment in early childhood: a meta-analysis of precursors, concomitants and sequele. Development and Psychopathology 1999; 11: 225–249.
2 Harvard Center for the Developing Child. Brain architecture. [Online.] https://developingchild.harvard. edu/science/key-concepts/ brain-architecture/ (accessed 22 September 2020).
3 Feinstein L. Inequality in the early cognitive development of British children in the 1970 cohort. Economica 2003; 70(277): 73–97.
4 Bowlby J. A secure base: parent-child attachment and healthy human development. London: Routledge; 1988.
5 O’Donnell K, Glover V, Barker ED, O’Connor TG. The persisting effect of maternal mood in pregnancy on childhood psychopathology. Development and Psychopathology 2014; 26(2): 393–403. https://doi. org/10.1017/S0954579414000029 (accessed 30 September 2020).
6 Straatmann VS, Lai E, Lange T, Campbell MC, Wickham S, Andersen AMN, Taylor-Robinson D. How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK millennium cohort study. Journal of Epidemiological Community Health 2019; 73(11): 1049–1060.
7 Gaik LP, Abdullah MC, Elias H, Uli J. Development of antisocial behaviours. Proceida Social and Behavioural Sciences 2010; volume 7. https://doi.org/10.1016/ j.sbspro.2010.10.052 (accessed 30 September 2020).
8 Geddes H. Attachment in the classroom: the links between children’s early experience, emotional wellbeing and performance in school. London: Worth Publishing; 2006.
9 Feinstein L. Social and emotional learning: skills for life and work. [Online.] 2015. https://www.eif.org. uk/report/social-and-emotionallearning-skills-for-life-and-work (accessed 30 September 2020).
10 WHO, UNICEF and the World Bank. Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. [Online.] 2018. https://www. who.int/maternal_child_adolescent/ child/nurturing-care-framework/en/ (accessed 22 September 2020).
11 Association for Infant Mental Health. [Online.] 2018. https://aimh. org.uk/infant-mental-healthcompetencies-framework (accessed 30 September 2020).
12 Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of American Academy of Child Psychiatry 1975; 14(3): 387–421.
13 Hogg S. Rare jewels: specialised parent-infant relationship teams in the UK. [Online.] 2019. https:// parentinfantfoundation.org.uk/ our-work/campaigning/rarejewels/#fullreport (accessed 22 September 2020).
14 Best Beginnings, Home Start UK, Parent Infant Foundation. Babies in lockdown (2020). https:// parentinfantfoundation.org.uk/ our-work/campaigning/babies-inlockdown/ (accessed 30 September 2020).
15 NHS England Long Term Plan. [Online.] 2019. https://www. longtermplan.nhs.uk/online-version/ (accessed 22 September 2020).
16 Centre for Longitudinal Studies (CLS). Multiple risk factors in young children’s development. [Online.] 2012. http://cls.nemisys3.uk.com/ library-media/documents/WP%20 2012-1%20Multiple%20risk%20 factors%20in%20young%20 children’s%20development%20-%20 SABATES,%20R%20AND%20 DEX,%20S.pdf (accessed 22 September 2020).
17 Department for Education. Characteristics of children in need: 2017 to 2018 England. [Online.] 2018. https://assets.publishing.service.gov. uk/government/uploads/system/ uploads/attachment_data/ file/762527/Characteristics_of_ children_in_need_2017-18.pdf (accessed 22 September 2020).
18 Miles A. A crying shame: a report by the Office of the Children’s Commissioner into vulnerable babies [Online.] 2018. https://www. childrenscommissioner.gov.uk/ wp-content/uploads/2018/ 10/A-Crying-Shame.pdf (accessed 30 September 2020).