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Introduction and Key Concepts

Chapter summary

This chapter covers:

  • What is included in this toolkit
  • Our definition of specialised parent-infant relationship teams and why they are so important
  • Advice about agreeing a shared language
  • Information about other sources of help, support and further reading, including evidence hubs.

There is also a description about the ways the Parent-Infant Foundation can support new and existing providers, commissioners, those setting up an entirely new service and those seeking to develop existing parent-infant provision into a specialised parent-infant relationship team.

You can download this chapter as a PDF here, or simply scroll down to read on screen.

What is this toolkit and who is it for?

Welcome to this toolkit which shares learning, information, resources and advice for commissioners and providers who want to set up, improve or expand parent-infant relationship teams in the UK.

Since 2012, the Parent-Infant Foundation (formerly Parent Infant Partnership UK) has set up and supported seven Parent Infant Partnership (PIP) teams around the UK and built close relationships with other parent-infant relationship teams in the public and voluntary sectors. We have accumulated a great deal of learning about how to establish strong and effective teams.

This document brings together our learning for the first time in one place as well as insights from teams around the UK to help those who wish to set up these important services. We hope it will make it easier for anyone wanting to set up a new team, reducing the risk and workload involved in establishing a new team, and increasing the chances of success.

This toolkit, comprising eight chapters and an additional resources section, includes:

  • The compelling case for specialised parent-infant relationship teams
  • Best evidence, and insights from experts, about setting up and delivering specialised parent-infant relationship teams that are strong, sustainable and cost-effective, and, most importantly, that deliver a service that is attractive and effective for families
  • Information about funding and commissioning, clinical interventions and measuring outcomes

Specialised parent-infant relationship teams are not yet part of mainstream family services across the UK. One reason for this is that there has previously been no clear ‘blueprint’ for how to establish, resource, implement, and evaluate them.

This toolkit provides that blueprint, one that does not advocate or require adoption of a specific model, but is based on evidence and learning, to promote best practice and to support the development and expansion of services that meet local need.

The Toolkit sets out what we and others have learned is best in order to:

  • Establish / maintain strong and sustainable teams that meet the needs of the local community
  • Deliver interventions in a way that is attractive and engaging for families and delivers results
  • Deliver evidence-based interventions for families in a cost-effective way
  • Collect data and measure outcomes

We are committed to improving and updating the toolkit to reflect the latest evidence and learning from the parent-infant relationships sector. During 2019-2020 we will be using the toolkit in a newly developing team, to gain further learning and to review content. We would also be delighted to receive your feedback, insights and ideas for the toolkit.

Please send these to karen@parentinfantfoundation.org.uk. New resources will also be uploaded onto the website periodically, so do check back here from time to time.

Navigating the Toolkit

The chapters and resources that make up this toolkit create a practical guide about how to set up specialised parent-infant relationship teams and share our collective learning about implementation. This is the first edition and the toolkit will be reviewed annually so that it is relevant and responsive to local and national policy changes and reflective of new evidence and learning.

Chapter 1 Navigating the toolkit

This introductory chapter includes information about what all the following chapters cover, the definition of specialised parent-infant relationship teams and why we need them, important notes about agreeing a shared language, and other sources of help, support and further reading, including evidence hubs. There is also a description about the ways the Parent-Infant Foundation can support new and existing providers, commissioners and start-ups.

Chapter 2 The Case for Change

Chapter 2 will help you understand and communicate the reasons why every area in the UK needs a specialised parent-infant relationship team. It condenses the compelling case for parent-infant teams, and their associated systems-level work into ten easily communicated key messages. We summarise the scientific, moral and economic arguments with reference to research and policy.

Chapter 3 Funding and Commissioning A Specialised Parent-Infant Relationship Team

Chapter 3 is a guide to where specialised parent-infant relationship teams fit strategically, what outcomes they can deliver, and an introduction to various commissioning arrangements including joint commissioning, fundraising and grants. You will find our system level Theory of Change here and this will help you think about commissioning for outcomes.

Chapter 4 Clinical Interventions and Evidence-Informed Practice

This chapter of the Parent-Infant Foundation toolkit will help you think about which therapeutic approaches your specialised parent-infant relationship team might offer. It introduces some of the clinical guidance, such as NICE quality standards relevant to parent-infant relationship work, and an example of a clinical Theory of Change. There are brief descriptions of some of the most popular and effective evidence-based practices in parental engagement, assessment and intervention in parent-infant relationship work, so that families can receive effective interventions tailored to their needs. This chapter also includes information about approaches to workforce training and consultation.

Chapter 5 Setting up a Specialised Parent-Infant Relationship Team and Preparing for Operational Delivery

There are three phases of setting up a specialised parent-infant team: preparing for operational delivery, starting the parent-infant work and steady-state management. This chapter covers the first of these, including information about things to do before you start accepting referrals such as creating referral pathways, clarifying step up, step down and step out relationships, establishing strategic and operational relationships across the system, and marketing and promotion.

Chapter 6 From Set-up to Sustainability

Chapter 6 will help you on your development journey from opening the doors to families to becoming a sustainable service. The information is sourced from the collective expertise of many practitioners, clinical and operational leads and implementation specialists across the field of parent-infant relationships, including many of the existing teams.

Topics covered include how to manage referrals and waiting lists, initial contact and engagement, screening and assessment, managing beginnings and endings with families, and follow-up. It is not intended as a guide in how to be a parent-infant practitioner, but as a collection of learning and prompts to guide you in how you organise the work with families.

Chapter 7 Recruitment, Management and Supervision of a Specialised Parent-Infant Relationship Team

This chapter provides information about the professionals who make up a specialised parent-infant relationship team and the roles they fulfil, so that you can plan the constituents of your team.

We have included some information about recruitment and there are helpful insights from existing teams about getting the management and supervision arrangements right.

Chapter 8 Managing Data and Measuring Outcomes

In the final chapter, you will find guidance about how to set clinical goals, team outputs and outcomes and how to go about measuring them. There is a helpful table describing various clinical assessment and outcome measurement tools, guidance about how to capture and review data, and some guidance on information sharing.

Bibliography

This is a useful list of academic papers, text books, policy documents and relevant websites.

Network Area of the Parent-Infant Foundation website

The Network area of our website contains various free-to-download templates and examples of policies, processes, parent-facing and professional-facing leaflets, terms of reference, job descriptions, person specifications and service agreements, shared by parent-infant relationship teams around the UK. These will help you see what other services have already developed so that you can use them as a blueprint if necessary.

The Network area is free of charge but access requires registration. Please visit the Network area to register.

What are specialised parent-infant relationship teams?

Specialised parent-infant relationship teams are multi-disciplinary teams with expertise in supporting and strengthening the important relationships between babies and their parents or carers. Teams work with primary caregivers, including parents, foster carers, grandparents or others who may be playing this role. In this toolkit, when we refer to parents, it is shorthand for this wider group.

Parent-infant relationship teams can help parents to overcome difficulties, build on existing strengths and develop new capacities to provide the sensitive, responsive and appropriate care that their babies need to thrive.

There is local variation in how teams are constituted and commissioned, which interventions they offer, and whether they work with particular needs or populations. All teams include at least one and often several highly-experienced psychologist or psychotherapist with specific expertise in parent-infant relationships.

Characteristics of specialised parent-infant relationship teams

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They are ideally multidisciplinary teams, which include highly skilled mental health professionals such as clinical psychologists and child psychotherapists, with expertise in infant and parent mental health and in supporting and strengthening the important relationships between babies and their parents or carers. [1]

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They are experts and champions. They use their expertise to help the local workforce to understand and support all parent-infant relationships, to identify issues where they occur and take the appropriate action. This happens through offering training, consultation and/or supervision to other professionals and advice to system leaders and commissioners.

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They offer direct support for families who need specialised help. This includes targeted work with families experiencing early difficulties whose needs cannot be met by universal services alone, and specialist therapeutic work with families experiencing severe, complex and/or enduring difficulties in their early relationships, where babies’ emotional wellbeing and development is particularly at risk.

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They assess families and offer individualised programmes of support to meet their needs drawing on a toolkit of both professional practice and evidence-based programmes.

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Their focus is on the parent-infant relationship. They do not work only with an individual child or parent(s) but with the dyad or triad (although there may be particular sessions in which parents see a therapist on their own).

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There is a clear referral pathway to enable families who need support to access the service. Families are referred because of concerns about difficulties in their early relationships, which is putting or could put babies’ emotional wellbeing and development at risk. Unlike other mental health services there does not need to be a clinical diagnosis in the adult or child for families to be eligible for the service.

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They accept referrals for children aged two and under and their parent(s). Some work from conception, others from birth. (Some services see older children too, and some are currently expanding to reach other preschool children, up to the age of four).

Parent-infant teams generally work at two levels:

  • They are expert advisors and champions for parent-infant relationships. They use their expertise to help the local workforce to understand and support parent-infant relationships, to identify issues where they occur and take the appropriate action.

    This happens through training, consultation and/or supervision to other professionals. This level of work also includes strategic influencing to promote the sustainability and local political support for the team by engaging with commissioners, funders, local elected members and other local decision makers.

  • They offer direct support to families. This includes targeted work with families experiencing early difficulties, and specialist therapeutic work with families experiencing severe, complex and/or enduring difficulties in their early relationships, where babies’ emotional wellbeing and development is particularly at risk.

These two tiers of activity mean that, when specialised parent-infant relationship teams are functioning effectively and embedded within their local system, they can help to promote healthy relationships for all babies in their locality through working with other services and offer early and effective intervention to those most at risk.

Specialised teams are part of the parent-infant relationships ecosystem

Anyone who works with families during the first 1001 days can help to protect and promote babies’ emotional wellbeing, and to support early relationships. Many professionals in the public, private and voluntary sector have developed a specialist expertise in babies’ emotional wellbeing and offer interventions, including evidence-based programmes, to support parent-infant relationships. For example, health visitors can play a particularly important role as they work with every family during this important period.

Some health visiting services have specialists in infant mental health who offer interventions to support families who need additional help. Some Child and Adolescent Mental Health Services (CAMHS) have time dedicated to working with children under two, although not all focus on the parent-infant relationship.

Some perinatal adult mental health teams and Adult IAPT (Improving Access to Psychological Therapies) teams are increasingly thinking about and in some cases beginning to support the parent-infant relationship.

Other services may have professionals who have the expertise but not the time or mandate to offer families’ therapeutic support. These are all important parts of the ecosystem that supports babies’ emotional wellbeing.

Whilst these parts of the system are unlikely to offer the same therapeutic intensity of specialised, multi-disciplinary parent-infant relationship teams, it is important that all relevant teams and services work together in as integrated a way as is possible.

Work with babies is very different from work with older children. Babies are developing more quickly, they are completely dependent on adults, and they cannot talk to us; they communicate their distress in different ways. Babies are also more vulnerable to abuse.

In work with parents and infants, the ‘client’ is their two-way relationship and it takes specialised training and interventions to hold both parties therapeutically and work in the interaction between them. Parent-infant teams can offer a range of relationship-focussed therapies in a way which is tailored to the needs of each family.

Forty-five per cent of serious case reviews in England relate to babies under the age of one year and in England and Wales, babies are eight times more likely to be killed than older children. [2]

Why do we need specialised parent-infant relationship teams?

The first 1001 days of life, from conception to age two, is a time of unique opportunity and vulnerability. It is a period of particularly rapid growth, when the foundations for later development are laid. During this time, babies’ brains are shaped by the interactions they have with their parents, even in the womb. The evidence is clear: at least one secure, responsive relationship with a consistent adult is a vital ingredient in babies’ healthy brain development. Persistent difficulties in early relationships can have pervasive effects on many aspects of child development, with long term costs to individuals, families, communities and society.

During this period, babies are completely dependent on adults to survive. The parent-foetal relationship develops according to the idea’s parents formed from their own past experiences, without much input from the child.

After birth, babies continue to be unable to talk about their feelings and needs, although they do communicate these in different ways. Therefore, work with babies in the first 1001 days is different from work with older children and requires a specific set of competencies: practitioners must have a deep understanding of child development and the skills to read babies’ pre-verbal cues.

They need the ability to work with adults about to become parents, parents, babies and their relationships. This is skilled work that requires specialist expertise. It is also truly preventative work: acting from conception onwards to prevent potential harm to babies’ emotional wellbeing and later mental health.

The unique opportunities and challenges during the first 1001 days, and the need for practitioners to have specific expertise to work effectively with families during this period, create a strong case for the existence of specialised parent-infant relationship teams.

baby brain facts IG1

The importance of a shared language from the start

We encourage local systems to discuss use of terms and language from the outset, to avoid confusion and improve mutual understanding and communication. The emotional wellbeing of babies, sometimes called infant mental health [3], [4] refers to how well babies experience, regulate and express emotions, and is dependent upon the quality of the relationship between infant and carers.

Our own research has shown that the term ‘infant mental health’ can sometimes give the wrong impression: either that the problem is located only in the child or that this work is only about mental health. Practitioners told us that ‘mental health’ is often (mis)understood as ‘mental illness’ which is difficult to understand when thinking about babies.

At the Parent-Infant Foundation, we talk about the ‘parent-infant relationship’ and its impact on the ‘emotional wellbeing of babies’. Some areas find the term attachment or early attachment helpful as this focuses on the relationship between parents and infants, although we have found that attachment can have different definitions in lay and professional circles. There are also some criticisms about the overuse and misinterpretation of attachment as a concept.[5]

There can also be confusion about the term ‘perinatal’. Adult perinatal mental health services focus on the emotional wellbeing of the primary carer, often the mother. Their work tends to start and end according to the mental health needs of the adult and the relationship with the baby is not the core focus of the work.

Some perinatal mental health teams do offer specialised parent-infant relationship work as a supplement and the NHS 10-year plan encourages this. However, many do not so this should not be assumed. Specialised parent-infant relationship teams focus on improving the quality of relationship between the parent(s) and baby, and the emotional wellbeing of the baby. Therefore, perinatal adult mental health services and specialised parent-infant relationship teams are ideal complementary services and should work closely together where both exist.

It is important to consider the specialised work of a parent-infant relationship team with regard to local definitions of early help and early intervention. Direct therapeutic parentinfant work occurs in the first two years of life (hence, it is ‘early in the life course’) but is often complex and involves very high levels of need just like CAMHS work for older children (hence also ‘specialised’). Clarification about this point locally promotes a shared understanding between strategic partners about how the teams’ work fits with early help/intervention policy documents and commissioning. Without this clarity, misunderstandings may arise about the potential commissioning routes of teams.

Finally, at the Parent-Infant Foundation we use the term ‘specialised parent-infant relationship teams’ to distinguish multidisciplinary teams with a dedicated remit and referral pathway. For shorthand, we use parent-infant teams. This is distinct from individual practitioners who offer parent-infant relationship work as part of their broader work in another service, such as specialist infant mental health visitors. These are not hard and fast definitions but offer some helpful clarity in language and thinking.

How can the Parent-Infant Foundation help?

The Parent-Infant Foundation is a national charity which believes that all babies should have a sensitive, nurturing relationship to lay the foundation for lifelong emotional wellbeing, mental and physical health. We are the only national charity proactively supporting the growth and quality of specialised parent-infant relationship teams across the UK, and campaigning for policy change. We bring together and support the sector, providing a collaborative leadership and a much-needed national voice.

In addition to this toolkit, the Parent-Infant Foundation can offer you support in the following ways:

1. Bespoke development, implementation and strategic consultation, advice and mentoring

Through our work directly setting up and supporting seven services over the last six years, and our close relationships with other specialised parent-infant relationship teams around the country, we have accumulated a great deal of learning about how to establish strong and effective services in different community settings.

Our existing knowledge and ongoing learning are accessible throughout the UK on our website, through individual conversations and through working with us in partnership.

2. Access to the Parent-Infant Network

Every practitioner in a specialised parent-infant relationship team around the UK is invited to join the national Parent-Infant Network: a free, multi-disciplinary collective which provides a space for shared learning and information, continued professional development, peer

discussions and mutual support. The Network’s aim is to facilitate sharing of resources, good practice and help with common challenges and to foster a shared drive to improve the reach, quality and impact of teams.

The Network offers two free face-to-face events each year and we plan to deliver several webinars on topics of shared interest by the end of 2019/20. Networking and collaboration are further facilitated through the Network newsletter.

3. Quality Standards

Via the Parent-Infant Network, we are developing a set of service standards for teams which will complement the Association of Infant Mental Health UK (AIMH UK)’s competencies for individual practitioners. Over the coming year we will co-create these standards with teams, with a view to the establishment of an accreditation process through peer review.

4. Data Management

The Parent-Infant Foundation provides a free software offer to any specialised parent-infant relationship team in the UK. The Foundation’s data portal can be used to track bespoke output and outcome data often missed from statutory or off-the-shelf data management systems.

This helps local teams to communicate more easily with stakeholders, funders and commissioners, to benchmark their performance against an anonymised national data set, and to support their quality improvement work.

5. Policy and Campaigns

Part of our mission is to convince national and local decision makers across the UK about the importance of policies and services to support parent-infant relationships, and specifically about the importance of specialised parent-infant relationship teams. We provide a national voice for the sector and campaign tirelessly for change. We coordinate the Conception to Age Two All-Party Parliamentary Group and the 1001 Critical Days Movement. Our most recent report Rare Jewels: Specialised Parent-Infant Relationship Teams in the UK makes the case for national promotion of specialised parent-infant teams.

6. Contributing to the Evidence Base

In addition to disseminating academic research findings and signposting to good sources of evidence, the Parent-Infant Foundation supports the creation of new evidence through its own research and evidence activities.

Further sources of help, support, evidence, useful reports and websites

Each of the chapters in the toolkit signposts to topic-specific sources of help, evidence, resources and guidance. In the Bibliography, you will find helpful information of general interest in the arena of parent-infant relationships and babies’ emotional wellbeing.

Downloads

You can download this chapter as a PDF here.

Alternatively you can download the full toolkit as a PDF here.

Footnotes

[1] Services work with primary caregivers, including parents, foster carers, grandparents or others who may be playing this role. In this report, when we refer to parents, it is shorthand for this wider group.

[2] Cuthbert C, Rayns G & Stanley K (2011). All Babies Count, Prevention and protection for vulnerable babies. NSPCC. https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/search2?searchTerm0=C3380

[3] Osofsky JD & Fitzgerald HE (2000). WAIMH Handbook of Infant Mental Health. p. 30. New York: John Wiley & Sons.

[4] Zero to Three. (2001) Definition of infant mental health. Washington, DC: Zero to Three Infant Mental Health Steering Committee.

[5] Meins, E (2017) Overrated: The predictive power of attachment. The Psychologist,. https://thepsychologist.bps.org.uk/volume-30/january-2017/overrated-predictive-power-attachment

This chapter is subject to the legal disclaimers as outlined here.

This chapter is correct at the time of publication, 1st October 2019, and is due for review on 1st January 2021.

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