Where is the I in CAMHS?

Sally Hogg
Sally Hogg is Head of Policy and Campaigning at the Parent-Infant Foundation, a national charity that supports the development, growth and quality of specialised parent-infant relationship teams. Sally leads work to raise awareness of the importance of early relationships and babies’ emotional development, and to drive change at a local and national level. This includes coordinating the 1001 Days Movement and All-Party Parliamentary Group. Prior to this, Sally held a number of roles in mental health and children’s charities, and has been a local authority commissioner and a civil servant working on Children’s Policy in the UK and Australia.

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As we enter Infant Mental Health Awareness Week, I argue that policymakers, commissioners and service providers must start thinking infant, children and young people’s mental health.

This week (7-12 June) is Infant Mental Health Awareness Week. There seems to be an awareness week for everything these days, but this is a topic where awareness-raising is much needed because although children and young people’s mental health policies and services should cater for ALL children from birth to 18 and beyond, the focus is often on older, verbal, school-age children and young people. The critical importance of protecting and promoting babies’ mental health is typically overlooked.

Infant mental health describes the social and emotional wellbeing and development of children in the earliest years of life. It isn’t a term used in many parts of the UK (although it is picking up traction, with some cities and devolved nations developing infant mental health strategies and services)[i]. People can be uneasy with the term infant mental health, perhaps because ‘mental health’ is so commonly used to mean ‘mental illness’ and babies cannot have diagnosable mental health conditions in the same way as older people. Perhaps because there is still so little understanding of babies’ brains and development in the general population. Their rights, experiences and emotional needs are often ignored or undervalued.

Not only is infant mental health often missing from our discussions about mental health, it is missing from our policies and practices too. For example, maternal mental health is a “high impact area” (an area of focus) in the Healthy Child Programme but babies’ own mental health is not.i[ii]x So much for no health without mental health.

Within mental health services there are shocking gaps in provision for babies. Even though CAMHS services should serve 0- to 18-year-olds, in 2019, CAMHS services in 42% of CCG areas in England would not accept referrals for children aged two and under.[iii] And even among those that said they accepted referrals and could provide data broken down by age, 36% had not seen a child aged two or under.

There are many reasons why this is wrong. It represents discrimination and inequality, which should not be permissible. Imagine the outcry if cancer services did not accept referrals for children under two? Or if mental health services excluded children for another equality characteristic such as race or disability?

There is a wealth of evidence that shows that the first 1001 days, from pregnancy, are a crucial time in development. Babies’ emotional wellbeing not only affects how they feel and function now but also how their brains develop.[iv] It lays the foundations for lifelong mental health. If we miss the opportunity to intervene early where development is being affected, we risk children experiencing unnecessary suffering and emotional disturbances taking root and escalating into mental health problems. This not only creates costs for the child and their family, but also for society and public services later down the line. If children and young people’s mental health services focus on treating older children rather than attending to the early roots of mental health problems, we are continually mopping the floor rather than turning off the tap.

I am not arguing that CAMHS services, as currently designed and delivered, should be offered to babies. Rather that CAMHS commissioners should ensure that their local offer includes a service that meets the needs of children aged two and under.

Infancy is a special time and it requires a special response. Infant mental health service delivery requires a different approach and a specific set of competencies: practitioners must have a deep understanding of child development and be able to read babies’ pre-verbal cues. Since parent-infant relationships are fundamental to infant mental health, practitioners need the ability to work with parents, babies and their relationships.

Specialised parent-infant relationship teams (also known as PIPs, parent-infant mental health or infant mental health teams) are well placed to provide this specialised care. They are multidisciplinary teams with expertise in supporting and strengthening the important relationships between babies and their parents. These teams work at multiple levels. They are expert advisors and champions for all parent-infant relationships, driving change across their local systems and offering training, supervision and consultation to other professionals. They also offer high-quality therapeutic support for families experiencing severe, complex and/ or enduring difficulties in their early relationships. We call these teams the “rare jewels” – they are scarce (less than 30 across the UK) and small, but where they do exist, they are extremely valuable and highly valued.[v]

The NHS Long Term Plan committed to improving access to specialist services for all children from 0-25.[vi] That plan said nothing specifically about infant mental health, but providing specialist mental health services for children aged 0-2 would require specialist provision – like parent-infant teams – to be in place for all babies who need them.

Infant mental health has, and always will matter. But perhaps it is now more of a concern than ever. Babies are likely to have suffered the secondary impacts of the COVID-19 pandemic which is happening at an important time in their development where they are particularly vulnerable to family stress and anxiety. Mothers and fathers who have faced birth and new parenthood under lockdown have also experienced stress at a key transitional point in their life.  Too many babies were vulnerable in the UK before this crisis. 53% of children in poverty in the UK are aged under 5.[vii] 25,000 babies in England live in households where their parent(s) are already struggling with at least two significant issues – parental mental illness, domestic abuse and/or substance misuse.[viii] These issues, and others, are likely to have escalated during lockdown and their impact on babies will have intensified. Families who experienced parent-infant relationship problems before the pandemic are likely to have experienced more relational trauma over recent months, and it is likely that other families who were perhaps “just coping”  are no longer able to meet their babies’ emotional needs during these difficult times. High-quality interventions are now required to ensure that babies who have been exposed to stress and adversity do not experience problems in the longer term.

Promoting infant mental health offers a key to unlocking the potential of our nation going forwards – creating resilient, caring communities that are better able to withstand and cope with future trauma.  Therefore, all future mental health strategies and plans, including any responses to support mental health in response to the COVID-19 crisis, need to explicitly consider babies and set out clear, tailored responses to meet their needs. The Children and Young People’s Mental Health Coalition now routinely talk about infant, children and young mental health. The same approach should be reflected across Governments, the NHS and local authorities around the UK. Our language, our policies and our services need to change. There can be no mental health without infant mental health.

The author has declared no conflicts of interest in relation to this article.

References

[i] For example: Scotland, Northern Ireland 

[ii] Greater Manchester Health and Social Care Partnership (2020) Perinatal and Parent Infant Mental Health Service: Championing 1001 Critical Days

[iii] Hogg, S. (2019) Rare Jewels: Specialised Parent-Infant relationship teams in the UK. PIPUK

[iv] Center on the Developing Child (2007). The Science of Early Childhood Development (InBrief). Retrieved from

[v] Hogg, S. (2019) Rare Jewels: Specialised Parent-Infant relationship teams in the UK. PIPUK

[vi] NHS (2019) Long Term Plan

[vii] Poverty amongst families whose youngest child is 0-4, using a measure of 60% median income after housing costs. Houses below average income 2018/19.

[viii] Miles, A. (2018). A Crying Shame A report by the Office of the Children’s Commissioner into vulnerable babies in England

Discussion

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Good to read this; shining a helpful light on the gap in CAMHS & HV services by focusing attention on the need to support responsive parent-infant relationships in order for babies to experience optimal emotional health & wellbeing. Let’s hope your message is spread far & wide!

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Really important article highlighting that vital importance of infant mental health- having worked in CAMHS for a number of years, services and knowledge around infant mental health often felt hit and miss, children I often saw in primary school could have been supported differently had we thought about their mental health development when smaller. No health without mental health is a key reminder for us all and the earliest opportunities are the best time to make the difference – thanks for continuing to ensure this message is out there and especially now when stressors for new parents and babies are going to be exacerbated.

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Unfortunate this critical message is not being covered and addressed by Childrens Services and Family Courts when deliberating on child custody cases. As research developments are confirming the importance of understanding the nuerological development of infants, relationships and environments and applying them to careegivers, there appears to be a gap in applying in custody cases. Importantly during this period of development, normal physical and cognitive development occurs and emotional and social development deficits do not become apparent until later this then becoming the basis for future difficlties in all other areas.

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