Attendees and apologies
- Dr Anne McFadyen, Perinatal Mental Health Network (PMHN), Infant Mental Health Lead (Chair), PMHN Managed Clinical Network (MCN)
- Dr Marita Brack, Programme Director Psychology of Parenting, NHS Education for Scotland (NES)
- Ms Alex Brown, Programme Support Officer, National Services Scotland (NSS)
- Ms Halle Brown, Early Learning and Childcare Team, Scottish Government (SG)
- Dr Roch Cantwell, Clinical Lead, PMHN MCN
- Ms Elaine Clark, PMHN Nurse Lead, PMHN MCN
- Ms Iona Colvin, Chief Social Work Adviser Children and Families Directorate (SG)
- Dr Fiona Fraser, Consultant Clinical Psychologist, NHS Greater Glasgow and Clyde (GGC)
- Ms Karen Lamb, Interim Head of Specialist Children’s Services, Children’s Services, Glasgow
- Dr Elaine Lockhart, Chair, Faculty of Child and Adolescent Psychiatry, Royal College of Psychiatrists
- Prof Hugh Masters, Chair of PNIMH Programme Board (SG)
- Ms Lesley Metcalf, PNIMH Senior Programme Manager, NSS
- Ms Liz Nolan, Assistant Director, Aberlour Child Care Trust
- Dr Alison Robertson Consultant Clinical Psychologist Maternity and Neonatal Services, NHS GGC
- Ms Harriet Waugh Senior Policy Manager, Perinatal and Early Years Mental Health (SG)
- Ms Carolyn Wilson Team Leader, Supporting Maternal and Child Wellbeing (SG)
- Ms Lesley Jackson, Consultant Pediatrician and Lead Clinician, Strategic Neonatal Network, NSS
- Ms Sally-Ann Kelly, Chief Executive, Aberlour Child Care Trust
- Mr Stephen McLeod, Children and Young People’s Mental Health Programme Board (SG)
- Prof Helen Minnis, Professor of Child and Adolescent Psychiatry, University of Glasgow
- Ms Marie-Claire Shankland, Programme Director, Perinatal & Infant Mental Health NES
- Ms Gillian Sloan, Consultant Child Psychotherapist NHS GGC
- Ms Clare Lee Thompson, Change Agent, Maternal Mental Health Alliance (MMHA) Scotland
- Ms Rachel Love on behalf of Dr Julia Donaldson, Policy and Public Affairs,NSPCC Scotland
- Ms Susan Orr on behalf of Mr Mike Burns Social Work Manager, Children’s Services, Glasgow
Items and actions
Welcome, apologies and introductions
Dr Anne McFadyen welcomed everyone to the first Infant Mental Health Group meeting. Introductions were made and apologies noted as above. She suggested that this meeting be considered a ‘meeting zero’ and going forward we might think of who are the best people to take on the task on planning services.
Dr McFadyen began with a short presentation highlighting the importance of infant mental health, and introducing the discussion paper and the paper outlining the possible remit (including membership) of an Infant Mental Health Group reporting to the PNIMH Programme Board.
Outline of funding
Dr McFadyen informed the group that the Scottish Government had committed £3,000,000 per year for three years, from April 2020, for the establishment of integrated infant mental health (IMH) hubs. She explained that £90,000 was available to be distributed before the end of the 2019/20 financial year.
Use of terminology
Prof Hugh Masters stated that, within the context of the PNIMH Programme Board, the term ‘infant’ was defined as the age range between preconception to three years old, with the initial focus on the first one thousand and one days.
Dr Roch Cantwell mentioned that it was important to agree on definitions, such as what was meant by ‘hub.’ The decision as to whether a hub would be a physical place or a virtual one facilitating pathways between services should, at such an early stage in discussions, be left open so the group could create the most effective model for Scotland.
Prof Masters acknowledged the importance of using the same terminology, specifically in relation to the IMH Group, which should not be referred to as a sub-group as it undermines the importance of infant well-being. He then pointed out that all plans, however referred to, needed to be considered from a long-term perspective, to ensure sustainability.
Ms Harriet Waugh clarified for the group that funding was committed to developing existing services and the pathways between them. Potential new services, and their interactions with established services, were to be explored and discussed.
Ms Iona Colvin remarked that whilst it was important to support the pathways between existing services, there was also a need to support the already established workers, to aid more timely intervention.
Ms Elaine Lockhart asserted that the focus of initial discussions should be on what services a child will receive, not where those services will be. She placed importance on determining what support health visitors would need.
Ms Colvin added that the purpose of the funding should be to join up children’s services, and Mr Masters added to this that the provision of specialist services was also to be equally considered.
Dr Cantwell agreed that universal and specialist care needed to be considered alongside each other, as when workers were given extra training or education they would then need specialists to turn to in the case of an escalation. Dr McFadyen established that by the end of year three of the funding programme, pathways should be established so that all IMH workers know who to turn to.
Dr McFadyen let the group know that the PNIMH Network and the NSPCC were in the process of collating data on what places and organisations already provide IMH services. She expressed that whilst it may be simpler to improve upon established services, developing services where there are few or none may more properly align with the PNIMH Programme Board’s equity aims. She acknowledged that specialist resources could not exist without the development of established posts, and existing services being joined up.
Summary of case vignette discussion
Dr McFadyen asked the group to divide into four smaller groups to discuss case vignettes one to four (see Appendix one).
(Carolyn Wilson, Halle Brown, Elaine Clark, Alison Robertson)
Group noted Gran’s status unknown, short or long-term placement? Is she supported appropriately to meet emotional needs as well as physical. Note intergenerational issues, possible conflict between adults e.g. mum, gran, other adults. Age appropriate supports needed for children. Care coordination via one professional.
Wider discussion and suggestions.
Must coordinate support across all family dimensions – consider adult mental health alongside IMH.
Develop support for kinship carers, similar to foster carers, as the current focus is on the mother.
Support families to look after children, and to make their own decisions, as ‘one size doesn’t fit all.’
(Karen Lamb, Rachel Love, Harriet Waugh, Iona Calvin)
Group noted history of trauma and loss for mum, bonding and attachment issues. Child’s development given prematurity
Where id dad, does he have PND? What supports are available for whole family? Would perinatal MH Team be helpful to HV?
Wider discussion and suggestions.
Level one Health visitors should have someone to go when they are unsure how to address an issue.
Develop more link worker posts in primary care (to link people with distress to local and self-help networks).
Give Health Visitors more knowledge of support pathways and info on local networks.
Ensure that workers at all levels know who to refer to.
(Liz Nolan, Elaine Lockhart, Fiona Fraser)
Group noted issues re professionals involved. Key worker and through care worker, role of third sector – refer as they could support and some have specific perinatal befriending and offer practical support. Ongoing formulation required. Might depend on where she is. Some areas eg. FV have perinatal care pathways which would cover this situation
Wider discussion and suggestions.
Support for workers so they know where to take issue escalations.
Workers who are trained to provide practical financial support (how and when to spend money).
Young child and mother training for housing project workers as standard.
Pre-birth proactivity – aid mother in anticipating post-birth challenges .
(Roch Cantwell, Marita Brack, Susan Orr)
Group noted that child and family would have had more intensive input pre 12 months. Transition important. Need to address developmental issues. How to support parental consistency?
Wider discussion and suggestions
- aid in the management of practical difficulties
- make transition from adolescent to adult services more seamless
- important to consider the mental health of the father
- support in making care more consistent and regulated
- workers with the ability to aid mothers in understanding responsibilities, and providing loving care
- expensive specialist services can only be provided with practical support to bolster
In general, the discussion reflected concerns about engagement of these vulnerable families with a few participants suggesting specialist IMH services. Most were enthusiastic about referral pathways which allowed Health Visitors, Social Workers and others to seek advice before onward referral.
Membership and agreed actions
Dr McFadyen asked the group to consider their individual roles as members of the IMH Group, and to suggest any other colleagues who might aid in the effectiveness of future meetings.
Action: all parties
Ms Elaine Clark highlighted the need for at least one person from a Maternity background, and Ms Lockhart suggested that someone from the Children and Young People’s Mental Health Programme Board should also be present at future meetings.
Ms Lesley Metcalf agreed to bring together a more structured list of members, when she had received commitment by any of the parties at that meeting, and contact from other interested contributors.
Action: Ms Lesley Metcalf
Gran, aged 39, lives with her partner of five years, her son aged 19, and her two children, Jay (4) and Jordan (22 months). Her daughter, 21, and mother of both boys, has moved down south, perhaps to escape a violent relationship with Jordan’s father. There is little contact but she does turn up at her mother’s home every three or four months and stays for a few days. These visits are usually difficult for everyone.
Jay has lived with his gran since the age of 18 months, and Jordan was placed with her as a kinship carer shortly after his birth. There are regular visits from health visitors. Recently there has been more continuity and the HV has got to know the family better. In particular, she has been able to monitor Jordan’s development. A previous HV had noted that Jay had a slight delay in language at aged three. He was reported to be a clumsy boy who often had tantrums. His development is more on track now and this is attributed to his nursery placement. The children’s social worker sees them every three months or so.
The health visitor is currently concerned about Jordan. She’s noted that he walked late (at 20 months) and does not vocalise much. He seems withdrawn and sad. He seems to be close to his gran but there appears to be a lack of child-focussed interaction. He is taken to the shops in his buggy and with the rest of the family spends a lot of time strapped in his buggy watching TV. The home is clean and he seems well fed and physically cared for.
The health visitor calls a meeting to discuss her concerns and try to bring professionals together to think about what could be done.
- what are your concerns for each of the children?
- what should be offered to this family, and is this different from services for each of the children?
- ideally what would this package look like?
- what else do you want to know?
- which professionals should be involved?
Young Nicole is 9 months old. She was born prematurely at 28 weeks gestation and discharged home from NNU to her parents’ care at the age of two months, just a few days before the expected date of delivery. She is her parents’ first child.
There were two previous pregnancies which ended in miscarriage, the last two years ago at 16 weeks.
Her mother is 36 years old and has worked as a finance officer since leaving university. Her father, also 36, is a Solicitor.
The health visitor feels concerned about the mother’s offhand attitude to her baby. She knows that it was hard for this parent to commit to her baby while her life was in danger early on, but also know that the baby now needs to be engaged with by her mum. You are worried about her development not being supported by mum, and about the mum’s lack of emotionality. At the health visitor’s suggestion, mum attended her GP to seek help about how she was feeling. The GP prescribed an antidepressant and now sees her for review every eight weeks.
On enquiry, it is difficult to get this mum to articulate her own feelings. She talks about lack of sleep and how tired she is but offers little about her thoughts and feelings or how she understands her baby’s emotional state. The baby is quite and compliant during the day, often sleeping (or appearing to sleep). She is reported to be distressed in the early evening and it is very hard to settle her. She wakes though the night and mum than bottle feeds her as a way of settling her.
The health visitor feels out of her depth and is worried about the future for both mum and baby. She has only met dad once and finds it hard to understand what role he has in the care of both.
- what are your concerns?
- what else do you want to know?
- who can the Health Visitor ask to help?
- is there a service you know about that could meet the needs of this family? What could you do to help them engage?
- if not, what would this service look like?
A 19-year-old woman, 36 weeks pregnant, is anxious and convinced that she won’t be able to bond with her baby. Her own history is of having been accommodated at the age of 14 years when she was out of parental control. She did not return to live with her mother and step-father and has a strained relationship with them. She was supported by social work to move to a housing association flat at the age of 17. Support is available to help her with finances and home-making.
Her key worker has noticed that as the pregnancy has progressed she has become more avoidant, often not answering the door or being out when he calls. The last time he saw her she talked about episodes of panic and recurrent thoughts that her baby would be disabled and hard to bond with.
He has liaised with maternity services and notes that she had attended midwife appointments until a few weeks ago. She is due to attend again this week. The midwife has tried to introduce her to a family nurse but so far has not managed to do this for a variety of reasons (sick leave, holidays etc). The key worker thinks she should have a mental health assessment but cannot arrange a GP appointment without her consent. He has contacted her social worker and hopes that they can arrange support for her. He is unsure if a pre-birth planning meeting is required. He fears that his client would perceive that as an attempt to remove her child.
- who else could the keyworker share his concerns with?
- what should he do now?
- in the absence of significant disorder, who could provide support?
- what third sector agencies could provide support/intervention?
- what training is available for housing project workers to help them to deal with this type of situation?
- would any intervention offered depend on where she lived?
- are you aware of any localities where there is a ready-made support system in place?
Young Lewis is 14 months old. He lives with his mother and father, both of whom have mental health problems. His mother is 22 years old and has a history of admissions to hospital both in adolescence and in the post-natal period. Shortly after Lewis’s birth she developed a florid psychosis and was admitted with Lewis to a Mother and Baby Unit under the Mental Health Act. She was very unwell for three to four weeks and then in recovery was helped to get to know and care for her infant. She was discharged when Lewis was five months old and had very close follow-up from the local perinatal mental health service. Her care was handed over to adult mental health services a month ago and has regular meetings with a CPN and psychiatrist.
The baby’s dad also has mental health input. He is 34 years old and has also been in and out of hospital. He has had no acute episodes of mental illness in the past five years. He takes prescribed medication irregularly and uses cannabis to help him keep ‘chilled’. He is very involved in Lewis’s care but can be a bit rough in his interactions. The couple’s relationship can be fiery at times but mostly is calm with a shared focus on bringing up the baby. In their daily lives they seem a bit chaotic and at times run out of money and don’t pay their rent. They use a food bank at times to get nappies and other necessities.
On meeting them, the CPN is immediately struck by their vulnerability and has sought a meeting with the health visitor to discuss the situation. She has noticed that although the couple do their best to meet Lewis’s physical needs there is an inconsistency in their emotional care. Lewis is a lively toddler and enjoys rough-housing with his dad but struggles to calm down without lots of physical holding.
- what are your main concerns for family members?
- what resources can the CPN access to help support this toddler and his family?
- she is aware that parenting programmes are available but knows little about them and doubts she could persuade the couple to attend. Are there any outreach services available?
- should she or the health visitor call a Child in Need meeting?
- what might this achieve?
- are there local authority or third sector family centres or support services that could help?
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