Infant mental health: evidence review

Executive Summary

This report covers the key findings of a small sample rapid literature review of research on perinatal and infant mental health within UK contexts as well as brief interviews undertaken with members of the clinical teams in NHS Fife and NHS Lanarkshire. This report contributes to the Evaluability Assessment of the perinatal and infant mental health programme (PNIMH) for which Public Health Scotland were commissioned by the Perinatal and Infant Mental Health programme board in 2020.

It is important to caveat that the literature review covered a small sample of varied research report types which predominantly focussed on clinical use and validation of measures. To address the gap in evidence on how infant mental health (IMH) measures are being used in practice in Scotland, brief interviews were carried out with members of the clinical teams in NHS Fife and NHS Lanarkshire. These boards were chosen as they were the recipients of the PNIMH programme board "Wave 1" funding.

While the findings presented in this report are generally considered to be from reliable sources of evidence, a rapid literature review can only provide a small amount of information and the interviews do not cover the full scope of Scotland. Therefore, it is recommended that further reading be undertaken for a deeper understanding of the larger infant mental health context.

Key Findings:

Definitions of infant mental health vary

• Prevalence rates of IMH have been reported between 16% to 18%, which are similar to that of older children and adolescents. This suggests the need to identify and treat mental health needs at the earliest stages of life.
• Definitions of IMH vary, with conceptualisations falling into two main categories of 0-3 years and 0-5 years. However, the notable majority of organisations and researchers define IMH as up to three years age, due to the differences in stages of development between 0-3 years and 3-5 years.
• IMH should be considered in contexts of secure relationships, safe and stimulating environments, emotion regulation, clinical diagnosis, and social determinants of health.

Considerations for measuring infant mental health

• Accessibility is important when working sensitively with parents and families to ensure successful identification and intervention of IMH issues. The language that is used should convey mental health promotion, rather than stigmatisation. In the case of IMH, this may mean measuring the infant's competencies as well as difficulties, which can encourage family buy-in.
• IMH measures will vary across age and domains. Due to the developmental nature of small children, not all measures cover the same ages or domains. Measures which do range from birth to childhood often measure different domains across time in order to capture developmental sensitivity, but this can make it harder to track progress over time.
• Some tools which are used with toddler and older children are being tested for use with infants. As infants are prelinguistic, these tools have been shown to be better at screening for externalising behaviours. It is difficult to screen for internalising behaviours as parents can only guess at what their young infant is thinking and feeling.
• Importantly for clinicians, the use of some measures may be constrained by time, cost, or access barriers. Measures that are brief, easy to score, and free are more widely used in clinical practice, however this use of simplified measures may mean compromising on assessment sensitivity.

The current development of infant mental health services in Scotland

• Interviews showed that the overarching aim for all measures put into practice are to "keep the baby in mind".
• Quantitative measures which are in place include the Ages and Stages Questionnaire (NHS Fife) and the Observational Indicator Set (NHS Lanarkshire). These measures are considered as providing multidisciplinary teams with scales of easily observable behaviour for ease of referral criteria.
• A qualitative measure is in place with both boards is the Hopes and Expectations Form. This allows parents to highlight 3 areas of development they would like to see by the end of the intervention period.
• A number of challenges have been highlighted in developing new services for IMH needs including;

1) Engagement with parents, particularly during the pandemic,

2) Ensuring that children are not lost in the gaps between services (for example, the gaps and overlaps that occur between infant meant health and early childhood (3-5) mental health services), and

3) Developing new services in the context of a global pandemic. COVID-19 restrictions have meant that staff are developing services and offering training opportunities in virtual workspaces. There is also a concern for staff overwhelm as health visitors and family nurses work to learn new systems during this time.

• Future successful delivery of IMH services can be achieved through increased awareness and understanding of what IMH is, how to recognise IMH issues, and what to do about it. Strategies for increasing awareness may include additional training opportunities for staff, championing multidisciplinary teams, and joined up communication across statutory and third sector services.