Holding the Family: it’s all about relationships Dr Christine Puckering & Penny Rackett Association for Infant Mental Health-UK Executive Committee Members Leads for Scottish Hub

We are hard wired to need relationships Brain development Still face experiment Attachment theory, etc etc Did you know that a smile not only lights up the baby’s brain but also that of the parent, in the same place that responds to addiction? (Strathearn et al., 2009) Relationships are meant to be addictive! This helps explain the Bakerman-Kranenburg et al’s findings (2004) that in order to impact upon an relationship, the intervention has to be relationship-focussed. Improving maternal mental health DOES NOT GUARANTEE that the relationship with the baby will also improve.

We know the mental health can affect relationships, but is that always the case? Kaplan et al (2007) found that prenatal psychiatric diagnoses do not predict poor parent-child relationships unless coupled with low maternal sensitivity, and some have high levels of sensitivity Baby Extra in the Netherlands (uses Video Interaction Guidance) is a pre- and post-natal intervention targeted at parents with a psychiatric diagnosis and/or drug/alcohol misuse: out of 500 families, over 90% of children developed a secure attachment VIG has shown to lower parental stress and depression as well as improve the quality of the relationship (Hoffenkampf et al, 2015; Rackett & Macdonald, 2014) Mellow Babies lowers maternal depression while improving the parent- child relationship

The importance of relationships in the context of trauma Trauma creates fear, which leads to a desire for proximity to an attachment figure for stress reduction If a parent receives an intervention that focuses on attunement and mentalisation within a relationship, and uses a an emotionally attuned relationship to do so, the parent is given an opportunity to: 1) Develop sensitivity and emotional attunement towards their child 2) Develop the capacity to mentalise their own states and those of their child, through a shared understanding 3) Reach emotional co-regulation with their child In this way, focusing on the relationship can help a parent live with trauma including PTSD

So the relationship can be a source of resilience for parents with mental health difficulties Video example using Video Interaction Guidance

Outcomes for the whole family The effects of untreated postnatal depression has an effects on relationships, families and children lower levels of emotional and cognitive development and higher levels of behavioural problems and psychological disorders among children (Boyce 1994; Cox et al 1993. Evans et al 2001. Hay et al 2001. Holden 1991; Murray and Cooper 2003; Murray 1992; Sharp 1994; Webster 2002). Depression in partners (Webster A, 2002, The forgotten father: the effect on men when partners have PND, Community Practitioner, 75, no 10, 390-3) Higher rates of divorce (Boyce P, 1994, Personality dysfunction, marital problems and postnatal depression. In Cox J and Holden J (eds) Perinatal Psychiatry: the use and misuse of the EPDS. London: Gaskell)

Effects on the children of untreated depression lower levels of emotional and cognitive development higher levels of behavioural problems and psychological disorders How do you think this then impacts upon maternal mental health? Murray, L and Cooper PJ (2003) (eds) Postpartum depression and child development. New York: Guildford, 201-20. Murray L, (1992) The impact of postnatal depression on infant development, Journal of Child Psychology and Psychiatry, 9, 6, 372-378. RCoG Sharp D Growing up in Scotland (2010) http://www. gov.scot/ resource/doc/310476/0097973.pdf at al, 2001, Intellectual problems shown by 11 year old children whose mothers had postnatal depression, Journal of Child Psychology and Psychiatry, 42, 871-89. Sharp D, 1994, The effect of depression on the development of the child. Postnatal depression symposium. London: Royal Postgraduate Medical, School, Institute of Obstetrics and Gynaecology.

PERINATAL MENTAL HEALTH CURRICULAR FRAMEWORK: A framework for maternal and infant mental health (2019) Promoting the understanding that mental wellbeing is determined by many factors, including biological, psychological and social factors The importance of promoting mental wellbeing across the whole spectrum of mental health The perinatal period, and the parent-infant relationship, are crucial for the health and wellbeing of the infant, as well as any other children in the family, both in the present and in terms of long-term outcomes The importance of the mental wellbeing of not only the mother, but her infant, partner and other family members The safety and wellbeing of infants and children should always remain central Discrimination and stigma related to mental health difficulties needs to be eliminated or reduced A strengths-based approach to the care of all women, infants and their families should be adopted.

The Scottish Government’s 2005 framework, The Mental Health of Children and Young People: A Framework for promotion, prevention and care Interventions focused during pregnancy and at the time around the birth are likely to be the most effective in preventing mental health problems of a child. Interventions which improve and enhance the well-being of the mother and of the baby and promote the mother-infant bond ie focus on the relationship Psycho-social aspects of pregnancy, promote good early parent-child interaction, attachment and support problem-solving skills’

Dads are affected by mum’s perinatal mental health as partners but also can contribute to the baby’s well-being and have their own well-being affected in turn video of dad and baby

£50 million for Perinatal Mental Health Services Let’s remember that the family is an interactive unit: by paying attention to relationships, we alleviate mental health difficulties for ALL

Report of the MCN –perinatal mental health RECOMMENDATION 10. NHS boards should ensure that perinatal mental health services identify a parent-infant mental health lead who will co-ordinate evidence-based interventions and provide clinical expertise to the specialist team. This resource may be provided on a regional basis. WHAT ARE YOU DOING TO IMPLEMENT RELATIONSHIP FOCUSSED, EVIDENCE BASED INTERVENTIONS IN YOUR AREA?