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Feb 5, 2019 - Plan.6 These projects are based on a similar programme to the ... focus is given to the Olds7 paper in view of ... visiting can improve maternal and child health. ... order to further enhance mother-infant relationships ... ty of the mother to her child and her respon- .... this reason the opportunity to consult with.
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Targeted home visiting intervention: the impact on mother-infant relationships Anne Marie Walker Clinical psychologist, Solihull Child & Adolescent Mental Health Service (CAMHS), Solihull Care Trust Rebecca Johnson Clinical psychologist, Solihull CAMHS, Solihull Care Trust Catherine Banner Jill Delaney Rita Farley Margaret Ford Helen Lake Health visitors, Solihull Care Trust Hazel Douglas Consultant clinical psychologist and child psychotherapist, Solihull CAMHS, Solihull Care Trust Abstract This paper reviews and reflects on six papers, which describe various early home visiting interventions that resulted in positive outcomes, particularly in relation to the mother-infant relationship. The papers were published in a special issue of the Infant Mental Health Journal in 2006. We provide a brief overview of each paper, highlighting the conclusions drawn across the six papers. Key learning points for health visitors in the UK are explored throughout. Suggestions for improvements to the way in which health visiting services in the UK are structured in order to further enhance mother-infant relationships are described. The overall finding is that motherinfant relationships and interactions can be improved through early home visiting interventions over a period of time, and that this prevents childhood problems later on. It is recommended that specific patient groups be targeted and offered tailored programmes of interventions that have a relevant theoretical base, by trained nursing staff who are supported by an infant mental health consultant. Key words Mother-infant relationships, home visiting, infant mental health, early intervention Community Practitioner 2008; 81(3): 30-33.

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Introduction The importance of working with families and children has been highlighted by Every Child Matters1 and the National Service Framework (NSF) for children.2 Health visitors play a major role in the delivery of this care, yet measuring the outcomes of their interventions has frequently been regarded as problematic.3 In 2006, a special issue of the Infant Mental Health Journal4 focussed on early preventative intervention and home visiting and the subsequent improvements to mothers’ and children’s mental health. This edition of the journal was published at an opportune time for early preventative interventions, as the UK government has only recently established 10 intensive health-led parenting support projects, with rigorous evaluations builtin,5 as part of the Social Exclusion Action Plan.6 These projects are based on a similar programme to the US Nurse-Family Partnership (NFP) by Olds.7 This paper reviews the six key papers in the Infant Mental Health Journal Special Issue. After a brief overview of each paper, we present the research outcomes under three distinct themes relating to the different types of outcomes found across the six papers: first, the impact of homevisiting interventions on the parent-infant relationship; second, the findings about which client groups benefit from the interventions; and third, the findings relating to the professionals who deliver the interventions. Finally, we make suggestions about how health visiting in the UK could be improved based on these findings. Brief overview In this section we provide an overview of each of the papers for the purposes of identifying them in the later sections of this paper. More detailed descriptions of the work explained in each of the papers can be found in the later sections, although less focus is given to the Olds7 paper in view of the fact that it has been discussed at length prior to its implementation across the 10 pilot sites mentioned above5 and its advantages, disadvantages and applicability to

health visiting are relatively well known. The first paper by Olds,7 The nurse-family partnership: an evidence-based preventive intervention, summarises a 27-year-long programme of research, which aims to identify whether perinatal and infant home visiting can improve maternal and child health. The second paper, The process and promise of mental health augmentation of nurse home-visiting programs: data from the Louisiana nurse family partnership by Boris et al,8 elaborates on Olds’ NFP model, targeting first-time impoverished mothers and their families. It describes a training protocol for nurses and mental health consultants designed to increase the focus on infant mental health, arguing that the NFP is lacking in this area. Third, Nurse home-visiting: perspectives from nurses by Zeanah et al,9 examines the role of the nurse in the NFP programme. The results of focus groups with experienced NFP nurses are presented regarding their perspectives, challenges and rewards in considering this work. The fourth paper, Assessing mediated models of family change in response to infant home visiting: a twophase longitudinal analysis by Lyons-Ruth and Easterbrooks10 sets out, in a two-phase longitudinal analysis, to assess whether a ‘mediated model of change’ could account for the long-term effects of infant homevisiting services observed at five and seven years in a high-risk cohort. Ammaniti et al,11 A prevention and promotion intervention program in the field of mother-infant relationship, analysed the efficacy of early home-visiting in enhancing the quality of mother-infant interactions in mothers with high psychosocial risk factors, or high levels of depressive symptoms. Finally, Heinicke et al,12 Pre- and postnatal antecedents of a home-visiting intervention and family developmental outcome, measured factors influencing the parent, the mother-child relationship and the child’s socioemotional development pre-birth and postnatally in relation to the outcome of a home visiting intervention. What these papers have in common is that they all consider the impact of early March 2008 Volume 81 Number 3

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intervention on the mental health of children and their mothers, on motherinfant relationships in the short and long term, and thereby on the reduction of problems in later childhood. We will now summarise the key findings and conclusions that have emerged from these papers.

Enhancing the quality of mother and infant interactions through early homevisiting interventions First, we consider the outcomes from the identified papers relating to the interaction quality between mothers and their infants. The NFP, described in Olds’ article,7 targeted low-income first-time mothers. The programme involved intensive homevisits by nurses commencing during pregnancy and continuing for two years. Nurses were chosen because of their formal training in women’s and children’s health and their competency in managing complex situations often presented by ‘at risk’ families. The results in the home-visited groups were extremely favourable, including better emotional and language development in the infants, improved parental care, and fewer injuries and ingestions that may be associated with child abuse and neglect. Lyons-Ruth and Easterbrooks10 also found that early home visiting services accounted for positive child outcomes at 18 months, five years and seven years of age. Two outcomes relating to child outcomes and family interactions were reported. First, the escalation of problem behaviours in children over time, seen in the non-visited group and considered to be signs of serious maladaptation, did not occur among those families who received home visiting for the longest period of time. This is thought to be due to a shift in the family dynamics resulting from the input of early services. Second, generalised family relational skills emerged as a result of early input, including a shift in parental problem solving skills, family communication styles and parental investment. These enhanced skills enabled parents to continue to negotiate children’s problem behaviours over time, and facilitate the child to resume an appropriate developmental trajectory. This paper is important because it is one of the few studies currently available which explores the impact of infant health visiting on problem behaviours evident by school age. Ammaniti et al11 also investigated the effects of early home visiting on the quality March 2008 Volume 81 Number 3

of mother-infant interactions, comparing mothers who had a high number of psychosocial or depressive risk factors with those with low depressive and low psychosocial risk factors. Thirty mothers with depressive risk factors, 28 with psychosocial risks and 33 low-risk mothers were randomly distributed between the home-visited group, receiving weekly visits for the first six months and fortnightly for the next six months, and a control group, receiving scheduled visits only in order to collect outcome data. The intervention focused on facilitating and enhancing a mother’s capacity to read and interpret her infant’s cues and behaviours, while avoiding direct advice. Adult attachment and maternal representations during pregnancy and after the birth of the infant were evaluated, as well as depressive symptoms during the first year. At six months, mothers in the home-visited group had improved their ability to interact with their child. Maternal responsiveness to the child’s signals, sensitivity behaviours and cooperative interactions between mother and child had increased, while interfering behaviours and negative affective states had decreased. The authors conclude that sensitive and encouraging support from a home visitor affects the emotional availability of the mother to her child and her responsiveness. In this way, home visiting support was felt to function as a secure base, as described by Bowlby,13 that allowed the mothers to acknowledge themselves and to explore their child’s behaviour. Interestingly, at 12 months, differences between visited and non-visited groups persisted, but to a lesser degree. This was felt to be due to the child reaching a developmental stage where the mother faces new tasks and challenges relating to autonomy and self-assertion. This would seem to highlight the importance of continuing home visiting as the child becomes more assertive in his/her second year. Heinicke et al12 also found that outcomes of child and mother-child measures, such as mothers’ responsiveness and use of appropriate control, and child’s attachment, autonomy, self-regulation and response to control, this time taken at different intervals over 24 months, were directly related to the mother’s involvement with the home visiting intervention in the seven-to-12month period of the infant’s life. Secure attachment in the mother predicted a

greater degree of involvement. In this study, home visiting occurred again in an intensive way, weekly during the first year and fortnightly in the second. In support of the above argument, the authors suggest that sustaining the intervention beyond six months allowed the more difficult emotional issues to be addressed, and led to the positive outcomes at two years. It is interesting that those within the group who had unresolved issues of childhood loss or trauma, but presented as coherent and having the capacity for a relationship, were the most involved in the intervention. It was found that the experience of supportive relationships around the mother influenced her parenting and her child’s development. We discuss this further in the next section. In summary, what is clear from these papers is that intensive early home visiting can have a positive impact, both in the short-term (the first six months) and longterm (up to seven years of age) on motherinfant relationships. Specifically, improvements were found in the quality of parental care,7 family relational skill,10 maternal ability to read, interpret and act appropriately on infant cues,11,12 the supportive relationships for the mother and in children’s autonomy and selfregulation.12 Longer-term, positive outcomes appear to be related to the length of the intervention period, particularly during the second year of the child’s life.11,12

Targeted groups In the previous section we concluded that home visiting can have a lasting positive impact on interactions between parents and infants, we will now review the findings on which client groups seem to benefit from such interventions. Several of the papers report outcomes relating to characteristics of parents to whom interventions were offered. These findings have important implications for future services, and are therefore worthy of separate consideration. First, Olds found that the functional and economic benefits of the home-visitation programme were greatest for low-income, unmarried families at greater risk of welfare dependence, substance abuse and crime.7 Cost analysis revealed no net savings to government or society for serving families in which mothers were married or of higher social class. However, where the mother was unmarried and on 4 COMMUNITY PRACTITIONER

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3low-income at registration, the savings exceeded the cost of the programme by a factor of four over the life of the child. Olds warns that the risk of ‘watering down’ intervention programmes occurs in an attempt to access all families. The evidence presented in his paper amounts to a strong argument against universality when planning early interventions targeting mother-infant relationships. Ammaniti et al’s11 findings have further implications with regard to providing targeted interventions to certain groups. As described above, this study focused on mother-infant groups defined as having psychosocial and depressive risk factors. Psychosocial risk factors and maternal depression are often related in high-risk samples. The authors recognised that combining these two factors under a single negative category, as is generally done, could prevent the opportunity to clarify the way in which parental behaviour affects their children. Therefore, the two variables were defined separately to examine the independent effects on mother-infant interactions and infant development. Starting from the sixth month, there was greater improvement in the home-visited groups compared to the non-home-visited group, in the mothers’ ability to positively interact with their infants. The data confirmed that a positive and trusting relationship with a weekly home-visitor had a significant effect on the depressive mothers who demonstrated both more sensitive behaviours and the ability to cooperate with the child. Although depressive symptomatology was not modified, those mothers who did not have a substantial psychosocial risk tended to behave as ‘good-enough’ mothers as a result of the intervention – that is, they appropriately responded to the child’s signals and were able to scaffold interaction in a way that engaged the child in sustained interactions. This finding is particularly important in light of studies that underline the critical association between maternal depression and intrusive or withdrawn behaviours.14 In the same vein, mothers who had high levels of psychosocial risk factors seemed to benefit from the intervention in their decreased negative affective state and interfering behaviours. This paper concludes that the best functioning mothers were those who benefited the least from a home-visiting programme. One of the main implications

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from the Ammaniti et al11 study is again the need to provide targeted interventions to groups identified at risk antenatally by appropriately trained staff. They identify the importance of separating out those mothers at risk from depression from those at risk from psychosocial factors – arguing that there are definite differences between the two groups – in order to provide the best opportunity for designing specific interventions for specific groups of mothers. The idea of targeting specific groups is also supported by Heinicke et al’s12 paper, in which there were implications for targeting those parents who demonstrated a capacity for a relationship, despite unresolved issues of childhood loss or trauma, because they were the most involved in the intervention resulting in improved positive outcomes for the child. In summary, it seems that the greatest gains, and economic investment, have been made with parents with risk factors such as being unmarried or on a low-income at the time of the birth,7 or psychosocial and/or depressive risk factors.11 One study recommends differentiating the intervention according to these different categories of risk/need,11 and one recommends targeting parents within a group with risk factors (such as unresolved issues of loss and trauma) who can demonstrate a capacity for a relationship.12

Mental health support and training So far, we have looked at what the impact of early home visiting can be, and to whom it can offer the maximum benefit. We shall now consider what the selection of papers says about who should deliver the interventions. Olds7 reports that in some NFP trials, paraprofessionals were used to determine if the same beneficial effects were produced as when nurses visited. Of interest is that paraprofessionals produced effects that were approximately half of those produced by the trained nurses. This suggests the importance of having trained specialist nurses, such as the UK equivalent of health visitors, to enhance the quality of motherinfant interactions. Boris et al8 describe the rationale for, and the process of providing, an enhanced NFP programme in Louisiana. The augmentation was the addition of specially-trained mental health professionals to consult with some teams of nurse home visitors because of data documenting the negative impact of maternal mental health problems on young

children and mother-infant relationships. The consultant supported nurses by providing direct services to selected clients, regular case consultation and guidance to the nurses. This addition to the original NFP programme was aimed to enable the nurses, who were not from a mental health background, to shift their approach from a medical model to a psychosocial model. The evidence suggested it was possible to train mental health clinicians to become effective infant mental health consultants and to strengthen the team approach to the NFP. The nurses, despite encountering considerable psychopathology and high levels of job-related stress, reported fewer instances of severe burnout. Ongoing support and validation by the consultants was identified by the nurses as important. Zeanah et al9 presented qualitative data from focus groups designed to elicit the experiences of nurses from the Louisiana NFP,8 capturing both the potential impact of augmenting nurse teams with a mental health professional and cataloguing the nurses’ personal reflections on their experiences. In a similar way to health visiting in the UK, the nurses were identified as the appropriate professionals to undertake homevisiting because of their training in maternal and child health and their expertise in teaching and working with families. Robinson3 states that UK health visitors are the only professionals who have been trained to integrate successful parenting, bio-psycho and socio-economic factors into their assessment of health need and planning of appropriate interventions. This is especially the case for those health visitors trained in additional approaches, such as the Solihull Approach.15 The nurses from the Louisiana programme were given specific training for the purposes of the programme, including infant mental health training. They worked with the mother to set goals for herself and her infant and helped the mother develop skills to enable her to meet these goals. As reported by Boris et al,8 Zeanah et al9 also found that the nurses who had readily available mental health support cited this as an important resource. The nurses reported that the families’ difficult life circumstances, coupled with mental health diagnoses made it difficult for their clients to set goals or plan for the future, and for this reason the opportunity to consult with a mental health practitioner was essential. They also suggest that specific attention March 2008 Volume 81 Number 3

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should be paid to the impact on nurses of dealing with mental health problems encountered in the NFP programme. All of the nurses reported that their personal lives were affected by their work. The authors suggest that peer or consultative supervision is indicated to minimise this impact. In summary, the papers suggest it is important to have either trained specialist nurses or infant mental health consultants to support the nurses8,9 to enhance the quality of mother-infant interactions,7 as well as peer or consultative supervision9 to minimise the impact of working with mental health problems in families.

Conclusion Several points have been drawn from the Journal of Infant Mental Health Special Edition4 that might influence our thinking about the delivery of health visiting in the UK. This is an exciting time for infant mental health and child development for three reasons. First, there is growing evidence that experience and environment in early infancy affect the formation of neural pathways in the brain,16-18 thereby having a lasting impact on the long-term mental health of the child, adolescent and adult populations of the future. Second, we are in a time of rapid growth of research into infant and child development19 – and third, there is an emphasis on improving the delivery of services using evidencebased practice. What the papers have in common is the finding that, overall, early home visiting interventions enhance the quality of mother-infant interactions, improving maternal ability to read, interpret and act appropriately on infant cues as well as children’s autonomy and self-regulation. There is evidence of better infant emotional and language development, family relational skills and improved parental care of the child over a long-term period up to five and seven years, when the parent has had an intensive early home intervention. This can be thought of as an inoculation effect; in other words enhanced family relational skills continue to help the family to negotiate children’s problem behaviours over time. Targeting specific groups with tailored programmes of interventions has demonstrated cost effectiveness over time. ‘Watering down’7 services to reach everyone is contraindicated. All groups for whom the early home visiting interventions were March 2008 Volume 81 Number 3

provided benefited, but those at greater risk benefited the most significantly, implying the need for targeting groups with tailored programmes of intervention by specialised trained nursing staff. Regarding the theoretical and clinical framework of the interventions, there appear to be demonstrated benefits of a model that highlights the relationship with the mothers, providing them with a secure base and emotional support, to help them to interact with the child and to understand the child’s signals and behaviours.7 It has been demonstrated elsewhere,20 that integrating a specific model – in this case the Solihull Approach, although there are others – into general public health roles can lead to a paradigm shift in working with families.14 Other models that help mothers more accurately interpret their infant’s behaviour include the infant-led psychotherapy program called ‘Watch, Wait and Wonder’.21 What has been demonstrated by the selected papers is the need for specialist, trained and supported health visitors providing an intensive tailored package of home visiting for the first year of the infant’s life, with continued, but less intensive support in the second year of the child’s life. Because of the importance of the nurse-client relationship in achieving positive outcomes, non-mental health nurses must shift their approaches and techniques from a medical to a psychosocial model. Another method of achieving this is by providing a mental health consultant, trained in infant mental health to support the health visitors, together with a relevant theoretical base. However, it has also been argued by the current authors that this may also be achieved through the integration of a mental-health-oriented theoretical framework, such as the Solihull Approach, into nurses’ day-to-day practice. The resulting paradigm shift can reshape the nurse’s professional expectations and potentially influences their experience of their work in a positive way by reducing burnout and job-related stress. In summary, it would seem that supporting health visitors to offer targeted interventions to high-risk parents of young infants, using additional training to provide a framework for thinking about mental health in both the parent and infant, and the relationship between the two. This should be combined with ongoing support from trained infant mental health consultants, and would be the best way of taking into account the findings

presented in six papers published in a special issue of the Infant Mental Health Journal, which we consider to be most relevant to current UK public health service delivery.

References 1 Department of Health, Department for Education and Skills. Every Child Matters. Norwich: The Stationary Office, 2004. 2 Department of Health, and Department for Education and Skills. The National Service Framework for Children, Young People and Maternity Services. Norwich: The Stationary Office, 2004. 3 Robinson J. Domiciliary health visiting; a systematic review. Community Practitioner 1999; 72(2): 15-8. 4 Infant Mental Health Journal 2006; 27: 1 Jan-Feb. 5 Every Child Matters Change for Children: Health-led parenting support. Available at: http://www.everychildmatters.gov.uk/parents/healthledsupport/ (accessed 21 December 2006). 6 Reaching Out: An Action Plan on Social Exclusion. The social exclusion task force. Cabinet Office: Crown Copyright; 2006. Available at: http://www.cabinetoffice.gov.uk/social_exclusiontask_force/publications/re aching_out/reaching_out.asp (accessed on 26 February 2007). 7 Olds D. The nurse-family partnership: an evidencebased preventive intervention. Infant Mental Health Journal 2006; 27(1): 5-25. 8 Boris NW, Larrieu JA, Zeanah PD, Nagle GA, Steier A, McNeill P. The process and promise of mental health augmentation of nurse home-visiting programs: data from the Louisiana nurse-family partnership. Infant Mental Health Journal 2006; 27(1): 26-40. 9 Zeanah PD, Larrieu JA, Boris NW, Nagle GA. Nurse home visiting: perspectives from nurses. Infant Mental Health Journal 2006; 27(1): 41-54. 10 Lyons-Ruth K, Easterbrooks MA. Assessing mediated models of family change in response to infant home visiting: a two-phase longitudinal analysis. Infant Mental Health Journal 2006; 27(1): 55-69. 11 Ammaniti M, Speranza AM, Tambelli R, Muscetta S, Lucarelli L, Vismara L, Odorisio F, Cimino S. A prevention and promotion intervention program in the field of mother-infant relationship. Infant Mental Health Journal 2006; 27(1): 70-90. 12 Heinicke CM, Goorsky M, Levine M, Ponce V, Ruth G, Silverman M, Sotelo C. Pre- and postnatal antecedents of a home visiting intervention and family developmental outcome. Infant Mental Health Journal 2006; 27(1): 91-119. 13 Bowlby J. A Secure Base. London: Routledge, 1969. 14 Tronick EZ, Weinberg MK. Depressed mothers and infants: failure to form dyadic states of conciousness. In: Murray, Cooper PJ (eds) Postpartum Depression and Child Development. NewYork: Guildford Press. 15 Whitehead RE, Douglas H. Health visitor’s experience using the solihull approach. Community Practitioner 2005; 78(1): 20-3. 16 Gerhardt S. Why Love Matters: how affection shapes a baby’s brain. London: Brunner-Routledge; 2004. 17 Hall D, Elliman D. Health for All Children (Fourth Edition). Oxford: Oxford University Press; 2003. 18 Schore AN. Effects of a secure attachment relationships on right brain development, affect regulation and infant mental health. Infant Mental Health Journal 2001; 22(1-2): 7-66. 19 Clifton R. Lessons from infants:1960-2000. Infancy 2001; 2(3): 285-309. 20 Douglas H. The Solihull Approach (Fifth ed). Cambridge: Jill Rogers Associates, 2006. 21 Cohen NJ, Muir E, Parker CJ, Brown M, Lojkasek M, Muir R, Barwick M. Watch, wait and wonder: testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal 1999; 20: 429-51.

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