Infant mental health: evidence review

Introduction

Policy context

In May 2020, Public Health Scotland were commissioned by the PNIMH Programme Board to conduct an Evaluability Assessment of the Scottish Government's Perinatal and Infant Mental Health programme (Public Health Scotland, 2021). The Evaluability Assessment is a systematic and collaborative process that is undertaken to inform whether and how to create an evaluation plan (What Works Scotland, 2018). The Evaluability Assessment set out recommendations for seven studies to be carried out, one of which was a literature review of perinatal and infant mental health, with potential focusses including appropriate pathways and/or interventions for infant mental health (IMH). This report is intended to contribute to the evaluation process as outlined in the Evaluability Assessment.

Prevalence rates of infant mental health

Considering assessment issues, worldwide prevalence rates of mental health issues among infants are more difficult to determine than in older children or adults (Lyons-Ruth et al., 2017). It has been suggested, however, that such prevalence rates for infants are likely comparable to those of older children and adolescents and may similarly sit somewhere between 16% and 18% of the general population (Skovgaard, 2010; von Klitzing, 2015). These numbers suggest that the early identification of IMH issues is critical for effective intervention at the earliest possible time. Additionally, current events regarding the COVID-19 pandemic have increased difficulties in access to health services. A survey across the UK showed that 30% of respondents reported that health visitor drop-in clinics were no longer operating in their area, and 28% reported all health visitor appointments being carried out remotely, either via telephone or online (Home-Start.org, 2021). Lack of access to in-person health visitor appointments could have a knock-on effect for identifying additional mental health issues in infants as well as their parents. Considering the large number of risk factors, and that the mental health needs of infants are often easily overlooked (Parent-Infant Foundation, 2021), it is important to determine what the most appropriate measures of IMH are.

Aims and underlying questions

The primary aim of this research is to review the literature regarding appropriate measures for identifying IMH issues. The following research questions underpin this review:

• What factors are considered when choosing appropriate measures of infant mental health?
• What measures for identifying infant mental health issues are currently being used in Scotland?
• How have Covid-19 pandemic restrictions affected the identification of infant mental health issues across Scotland?

Methods

A rapid literature review on IMH and its measurement was conducted. Databases were searched for peer-reviewed literature, government, and third sector publications, as well as unpublished papers such as dissertations. The search was conducted through a number of established databases, including APA PsycInfo, Pubmed and Medline. Additionally, an extended search request was submitted to the Scottish Government Library, where specialist librarians conducted a search through recognised trusted databases (see Annex A for full details of search terms). All searches were limited to English language, research conducted within the UK, and a time period of 2016-2021. This time limit was set for two reasons – firstly, a search going back five years was expected to yield enough literature for a rapid review, and secondly, the DC:0-5 (ZERO TO THREE, 2016), a diagnostic manual for mental health in infancy and early childhood, was most recently revised and updated in 2016.

Reliability of the evidence base

The database search retrieved 18 papers that were used in the rapid review. The literature included published, peer-reviewed journal articles, Government reports, and an unpublished Doctoral thesis. Two evidence based reviews (both peer reviewed) which have been recently undertaken (Foreman, 2015; Szaniecki & Barnes, 2016) are also included in this report.

The evidence for definitions of and factors associated with IMH is largely compiled from peer reviewed journal articles from the UK, Europe, and North America, as well as Government reports, and prominent infant mental health organisations, such as the Association for Infant Mental Health (AIMH). These papers would generally be considered reliable sources of evidence.

The evidence for considerations of appropriate mental health measures is largely compiled from evidence based reviews and so it is recommended that for a deeper understanding of the individual measures, further reading should be undertaken. Trials concerning downward extensions of measures with psychometric validation are also included and reported on. These were retrieved in the form of peer reviewed journal articles and an unpublished thesis. The sample sizes of these trials vary in size (n=93, Patel et al., 2021; n=1112, Eneberi, 2017) and are made up of predominantly white, well-educated parents, which could create a risk of bias. Overall, these literature sources are generally considered to be reliable, however extending the literature search to include international evidence, particularly in regions that are comparable to the UK, such as North America, Europe, and Australasia would increase the robustness of the evidence base in future reports.

Where papers reported measures that are in use in Scotland, communication with relevant organisations was undertaken to ensure that this information is still up to date.

Evidence gaps

The literature review returned research on IMH and its measurement are, by majority, clinical research publications and third sector reports, however little evidence concerning real-world practice of IMH assessments is available. This means that while there is evidence that measures have construct validity and reliability within experimental research, there is little to no evidence of the impact that the early assessment of IMH might have on infant mental health in clinical and health settings across the country. Part of this issue may stem from the fact that dedicated infant mental health services are currently relatively undeveloped in the UK, as evidenced by the Scottish Government report titled "Delivering Effective Services" (2019). To address this evidence gap, desk research was carried out to explore what measures are currently being developed for use in Scotland.

In 2019, the Scottish Government dedicated funding for investment in perinatal and infant mental health services, and an IMH delivery plan was created to develop integrated services for infants and families across Scotland (Scottish Government, 2020). In 2019 – 2020, the PNIMH Programme Board allocated funds to two health boards: NHS Fife and NHS Lanarkshire, as a "First Wave" project to support initial service development (Scottish Government, 2020). Interviews were held with clinical practitioners at both NHS Fife and NHS Lanarkshire to understand what IMH measures are being put into place in Scotland, the challenges that they are facing and their recommendations for successful roll out of services across the country.