In this podcast, we are joined by Sally Hogg, Deputy CEO at the Parent Infant Foundation, to discuss early trauma and the importance of early relationships.
To set the scene, Sally starts by providing details about the 1001 days movement, which she coordinates, and details what it is about the first 1001 days of a child’s life that is so critical.
Sally discusses the impact of Adverse Childhood Experiences on mental and physical health and explores why we should be especially concerned about adversity that occurs early in a child’s life.
Sally talks about how early trauma impacts emotional, behavioural, cognitive, and social functioning, as well as tells us more about the importance of nurturing parent/infant relationships, and how its presence can help a child to be more resilient to negative events.
Sally then discusses how the relationship between babies and their parents can be strengthened, what her message is to CAMH professionals in terms of the role they can play, and her message to policymakers in terms of what they should be doing.
Furthermore, Sally shares her tips on how to reach those parents where there is disorganised attachment, who don’t access services, and how to signpost those families to services.
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Sally Hogg is Deputy CEO 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.
[00:00:32.092] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I am interviewing Sally Hogg, Deputy CEO at the Parent Infant Foundation, a national charity that supports the development, growth, and quality of specialized parent/infant relationship teams.
Today’s focus will be on early trauma and the importance of early relationships. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review, and do share with friends and colleagues. Sally, thanks for joining me. Can you start with a brief introduction about who you are and what you do?
[00:01:19.360] Sally Hogg: Hi Jo, it’s lovely to be with you today. So, I’m Sally Hogg. I’m Deputy CEO at the Parent Infant Foundation, as you said. We’re a small national charity, and we support the development of specialized parent/infant relationship teams. Now those teams can have different names in the local areas where they exist. So sometimes they’re called early attachment services or infant mental health services, or a variety of different names. But what they are is mental health-led services that work with families with a child, either in pregnancy or under two, to support the developing relationship between parents and babies where there is some sort of problem or challenge facing that relationship which might put the baby’s developing social and emotional well-being at risk.
[00:02:01.900] Jo Carlowe: Thank you. How did you come to be interested in child mental health?
[00:02:06.370] Sally Hogg: My degree is in psychology and philosophy, and I was fascinated by developmental psychology back as a teenager and in my early 20s. And so, it’s something that’s really guided my whole career. I went into children’s policy, and then went to work at the NSPCC where I focused on this period from conception to two. And my career since then, for more than the last decade, has focused specifically on supporting families experiencing disadvantage and challenge in that period. Because it’s so critical to children’s development. And those early relationships between parents and their babies, we know are the foundations of so much learning and development and well-being and influence on later life chances.
[00:02:47.472] Jo Carlowe: Well, let’s go into the detail. So, you coordinate the 1001 days movement. This is a group of organizations and professionals who champion the importance of the first 1001 days of the baby’s life. So, from pregnancy to two years of age. What is it about the first 1001 days that is so critical?
[00:03:09.220] Sally Hogg: Well so this period, pregnancy to two, is a period of incredible rapid development. So, there’s a stat which is quite hard to get your head around that more than a million neural connections are made a second in a baby’s brain during that period. So huge amounts of development. And there are two things that are important for that. One is that that development is laying the foundations for everything that the brain is going to do. Its cognition, its social and emotional development, well-being, the foundations for all of that are laid during that period.
And I like to use that analogy of the foundations because it’s not deterministic. But obviously if we’ve got strong foundations, then it’s easier to build a stable structure on that later. Whereas if we’ve got difficult, shaky foundations, then obviously to build a kind of good sustainable structure, to use that building analogy, we’re going to need more support, it’s going to be a bit more difficult.
And that’s kind of the same as the baby’s brain. So, developing those important social and emotional skills and capacities and later well-being and academic achievement are all basically a bit easier if we’ve got those firm foundations to build on. And that development of that foundational brain architecture doesn’t happen according to some predetermined blueprint. It’s shaped by the experiences the child is having, which means this is a time of both opportunity, because if we get this right it can have long term benefits, but also a time of vulnerability. Because if things go wrong in children’s early environments, then it can have this pervasive effect on early development.
[00:04:38.980] Jo Carlowe: Which relates to my next question, which is to do with Adverse Childhood Experiences, often known as ACEs, and its impact on mental health and physical health. Why should we be especially concerned about adversity that occurs early in a child’s life? So, whilst those foundations are been laid.
[00:04:58.840] Sally Hogg: There’s been increasing awareness of this concept of ACEs, Adverse Childhood Experiences, but we need to be really nuanced in our understanding of them because when they occur, and in what context, really affects the extent to which they actually affect a child. So, what we should be really worried about is not necessarily the external adversity, but the child’s experience of that. Because that is what is impacting the child’s well-being and development is how that adversity is experienced.
If you’ve got a very small child and they experience high levels of what we call toxic stress– so persistent unremitting stress because of some sort of factor in the outside world– then that will have an impact, not only on their feelings now, but actually on how their developing stress response systems and brain is developing. Which, because it’s this early foundational period, can then ripple through their later development. Whereas if you have a child who has had very strong, stable early development and has gone through that kind of period of rapid development and then experiences adversity, it will not have that same kind of developmental effect.
[00:06:03.280] Jo Carlowe: Can you say a little more about how early trauma impacts emotional, behavioural, cognitive, and social functioning?
[00:06:12.100] Sally Hogg: We are adaptive as a species. We adapt to the experiences and the environments we live in, and that’s been a kind of benefit to us. But it’s not always a benefit. So if you have a child who has some form of very stressful trauma to them– so that might be experiencing abuse for example, or experiencing neglect where they have long periods where they don’t believe that adults are kind of going to meet their needs and they’re worried about that– that level of stress that they’re experiencing shapes their developing stress response system. So they become more likely to respond to– to show that fight, flight, or freeze response. Which is adaptive. If you live in an environment where the adults around you are a risk to you, or there is a risk of abuse and neglect, then it makes sense that you would have a heightened fight or flight response, because you need to respond quickly to stuff and you need to be very alert to threat.
But that’s not necessarily that adaptive to the rest of your life. So if you imagine a child who has had that traumatic early experience, has a heightened fight or flight response, and then goes to an early year setting where they need to be able to sit on the carpet at story time, they need to be able to play with their friends who might occasionally steal a toy from them, those things are normal parts of the small child’s life– those are going to be much harder to navigate with a child who’s got that heightened stress responses. And they’re more likely to fly off the handle to those things, to respond badly. They’re less likely to trust adults and settle into new relationships with the adults around them, which is very understandable given that they’ve had no reason to trust the adults that they’ve experienced so far in their life. But then that then has knock-on effects on their ability to learn, to thrive, to create social networks around themselves, which we know is so important for later life.
[00:07:55.877] Jo Carlowe: Sally, what can you tell us about the importance of nurturing parent/infant relationships, and how its presence can help a child to be more resilient to negative events?
[00:08:07.000] Sally Hogg: If you imagine a tiny baby, the way that human babies are born. So, they can’t see very far at birth, they can’t move very far by themselves, or at all by themselves as a tiny baby, they are reliant on adults for absolutely everything. Their safety, security, nutrition. So, they experience the world through those relationships. So, they are reliant upon an adult who is responsive to their needs for their very survival, but also for their development. So if you have– if we think back to what we were just talking about adversity, if you have external adversity– so maybe that’s being in a war zone or being in a house where there’s domestic abuse– but you are– but you have an adult in your life who is responsive to your needs and picks you up and cuddles you when you cry or feeds you when you’re hungry, then actually you’re not going to be very aware of that stressful environment in which you live.
You’re going to be very buffered from it, because your world as a tiny baby is such a contained one. So, relationships can really buffer children from external adversity. But if we don’t have those relationships, then things that objectively don’t seem as traumatic can feel much more traumatic and be much more stressful for a baby. So, if you go back to that baby who is totally reliant on an adult for everything and they are left alone to cry for long periods of time repeatedly and have no one responding to their needs, that’s going to feel like a kind of life-threatening situation to a small baby, and their bodies are going to be flooded with stress. So that lack of a nurturing relationship can be some of the worst form of adversity a baby can face because it feels so stressful. And that’s that experience of stress that is the thing that’s going to affect a baby’s well-being and development. So, it’s the relationship, really, that the baby experiences that affects their stress level. And those stress levels and that experience with early trauma is affecting their later development.
We also know that a lot of positive development happens through relationships. So, if you think about how a baby learns to understand the world and language around them, it comes through talking to parents. It comes to a baby showing an interest in something and the parent naming it, and that’s how they understand, oh, that’s what that thing is. If a baby points to something, the parent points back at it. Or we have what’s called serve and return interactions, where a baby might babble and a parent might talk back to them, and they’re learning that early conversation. There’s so much happening in that early relationship, but there’s one more thing I want to talk about, which is also about emotional regulation. So, babies aren’t born able to regulate their emotions. They have to develop that capability. And it is such an important factor throughout life. And it happens through the experience of having adults who help to regulate their emotions for them. So, when parents pick a baby up when they cry and soothe them, they’re teaching that baby what it feels like to put that emotion back under control. And it’s through those experiences and that early learning that babies can learn to understand what their emotions are, and how to contain them.
[00:11:11.343] Jo Carlowe: I’m wondering, is there a difference between neglect and abuse, in terms of its impact on the child? So given that a parent with depression, for example, might be emotionally unavailable, but not abusive, or not intentionally abusive.
[00:11:27.468] Sally Hogg: Abuse can often, particularly I think to us as adults, feel like it’s much worse than neglect. It feels much worse to harm a child, rather than to have this passive maltreatment and neglect. But actually what we know from a baby is that neglect is really harmful. That actually not having your needs met is an incredibly stressful experience. Now abuse takes many forms. And it is obviously harmful and stressful and damaging to a baby.
But it also depends on the context in which that abuse exists, and whether or not there is simultaneously some form of containing relationship. So, if a baby has, for example, I don’t want to use gender stereotypes. But maybe, for example, a mother who is around and containing and meeting their needs, maybe mom’s boyfriend occasionally comes and maybe might be abusive to that child. That abuse is undoubtedly wrong and harmful. But the baby is still experiencing, most of the time, a containing, care-giving relationship, which is important to their well-being. So, we need to understand that kind of whole context in which abuse and neglect happens, and whether anybody is meeting that baby’s needs around the edges of that. If there is one secure, responsive, contained relationship, that can protect a lot against, perhaps, what other adults in the child’s life are doing. That’s not to say, obviously, that we shouldn’t be stopping that abuse. But in terms of understanding the impact it has on baby, we need to see how their needs are being met on the ground.
[00:12:52.642] Jo Carlowe: How can the relationship between babies and their parents be strengthened? And I’m thinking, presumably, some parents have not had the type of parenting themselves that allows them to be emotionally well-regulated.
[00:13:05.950] Sally Hogg: Yeah, so intergenerational transmission of trauma and of poor relationships definitely exists. And it’s important to say we can really help to strengthen the relationships between parents and their babies, when parents don’t have those kind of templates of responsive care that they can draw on, or when there’s other things going on in their lives. You mentioned earlier about maternal mental health problems. And we do know that whilst some women with mental health problems are still able to provide that sensitive, nurturing care that babies need, it is harder in the context of your own mental health problems to keep your baby’s needs in mind and to respond to them. And so some women will have problems doing that. And there are lots of therapeutic interventions that can strengthen and repair any relationships. They might be parenthood psychotherapy, they might be, sometimes, group work. Groups like Circle of Security, or Watch, Wait, and Wonder. There are these kind of lovely manual programs with increasing evidence that works.
There’s also a lot of lovely interventions that use video, giving strength-based feedback. So infant teams who we advocate for and support often use interventions called either [INAUDIBLE] or Vick. And what that means is that they will film a mom or a dad and their baby, and then pick out from that film moments where the relationship is working really nicely, what we call moments of attunement, where maybe the baby is gazing up at the parent and their eyes connect. Or maybe the baby points at something, the parent names it, and that relationship is working. And then they will pick out that clip of video and talk the parent through that. And on the basis of that real strengths-based feedback, they will be able to increase– help the parent to increase more of those positive moments. And to take joy and build their confidence as a parent and to understand what providing that nurturing care looks and feels like, both to them and their baby.
[00:14:56.710] Jo Carlowe: Is it easy for parents to access those types of services and interventions?
[00:15:00.442] Sally Hogg: No it’s not, and that’s kind of why my role exists, to campaign for more of this support. So, we know there are only 42 specialized parent/infant relationship teams in the whole of the UK. So, most babies live in an area where there isn’t one. And that number is increasing, and we’ve seen some great policy changes and investment to improve the access to this sort of support. But there is still a long way to go. And we have, what we call, a sort of baby blind spot in our mental health services. That although we should have a comprehensive system of mental health services where you have perinatal services, but other services that work with families in this early period that support parent relationship, even if it’s– mom doesn’t have a mental health problem. All the way through to CAMHS services and services for older children and young people. And at the moment, although we describe it a naught to 25 CAMS service, actually that naught to five bit, in particular the naught to two bit of that is very often missing. We did some freedom of information requests a couple of years ago that showed that around half of mental health services in this country wouldn’t take a referral for a child under two.
[00:16:08.748] Jo Carlowe: Given that, what’s your message, then, to CAMH professionals in terms of the role they can play?
[00:16:14.415] Sally Hogg: I would encourage everybody to think about this idea of CAMHS being this naught to 25 system. And so, making sure that there is service available for the youngest children. And that isn’t just about extending a current CAMHS service and changing the referral criteria, because obviously babies need something very different to what older children need. And it isn’t– it’s about working with the dyad or the triads of the parents and the baby together in order to strengthen the relationship and enable the parents to support the baby’s mental health. And that requires specialist skills and expertise. So, there’s a need for CAMHS services to think about ensuring they have an offer for babies and very young children that is delivered by people with the skills to work with babies and young children and their parents.
There are– for people in areas– and so half of local authorities in England are getting what’s called Start for Life funding. And that has an element of it, 100 million across 75 areas, which is for parent relationship support, alongside perinatal mental health services. So, anybody working a CAMHS service in an area that’s getting that money might want to try and tap into that to help them to expand and to build the specialist expertise within CAMHS. It can feel very difficult. There are such huge burdens on CAMHS services, and so much urgent needs. It can feel very difficult to think about having to use scarce resources to do more. It’s often hard to think about the needs of babies being as urgent and as important as the needs of older children, because they don’t feel as demanding. When you’ve got older children where they are turning up in A&E having self-harmed or with eating disorders or behaviour problems at school, there’s a knock-on effect there for other services and for society. And the child themselves will be presenting much more obviously their trauma. And so, we need to be the people who tune in to and advocate for babies, because baby’s mental health needs are just as serious, just as important as those for older children, but far less visible unless we know what we’re looking for. And there’ll be far fewer people advocating for those babies to get the support they need.
But we know that many of those babies, if they don’t get the emotional support now, will end up being the children who need more CAMHS services later on. There is lots and lots of evidence sharing really strong connections between your social and emotional development and the strength of your parenting relationships at zero to three, and you’ll need mental health services at 13, 15. So to use a metaphor, simultaneously turning off the taps and mopping the floor. Our teenagers aren’t going to go away straight away, but we need to take that long term view of trying to tackle mental health problems earlier in order to create a CAMHS system that isn’t always picking up this really ingrained, very difficult need later on.
[00:19:05.770] Jo Carlowe: So, Sally, what’s your message, then, to policymakers? What should they be doing?
[00:19:10.862] Sally Hogg: They should be ensuring that there are mental health services in every area of the country, with the specialist skills and resource to work with parents and babies where those early relationships are at risk. So, there are 42 specialized parent relationship teams around the UK, as I said. We would like to see one in every single area, and we believe that’s key to giving every child the best start in life. And we think babies have a right to that support, just as all of the rest of us have a right to mental health services. But also, there will be huge returns on investing in that because, as I said at the start of this, those early years and those early relationships are so foundational to so many outcomes. So if we can get this right, our school systems will see the benefit, our CAMHS systems will see the benefit later down the line. Our criminal justice systems will see the benefit, because all of those outcomes are strongly associated with quality of care and relationship that children have in their early social and emotional skills.
[00:20:08.360] Jo Carlowe: Earlier in this podcast, you spoke about the importance of the first 1001 days of a baby’s life. It could lead one to feel a bit pessimistic about the chances of those children who did not get adequate nurturing before the age of two. What’s your view on this? Is there a window after which intervention is only of limited value, or is there always cause for optimism?
[00:20:32.833] Sally Hogg: There’s always cause for optimism. We can always improve a child and an adult’s life. If two was too late, then why would we have later mental health services or CAMHS? Why would any adult try therapy? We can always change the trajectory of people’s development and well-being, but it becomes harder later. There’s no critical window by which stuff has to be done in order, and for everything else. But as I used that foundation analogy earlier, it’s easier to get things right early on, and later interventions will then have more impact if you build it on that strong foundation. So, there’s a real case to get it right early. But if we don’t, then there are two things we need to do.
One is to continue to provide the therapeutic care that children need, but also to have a trauma-informed system that recognizes how early trauma might impact children and is sympathetic to that and helps them to respond to that. So, an example of that is, if we have children who– I talked earlier about a child who has experienced early trauma and early relationship problems then struggling in an early year setting to behave, to make friends, to have relationships with adults. Now it’s really important that child still has mental health supports to help him or her to manage their stress and emotions and to deal with that early trauma. But also, it’s important that that early year setting interprets that child’s behaviour as the result of early trauma and as a sign of a vulnerability in that child, and not as a child who is naughty and needs punishment. So we need a trauma-informed, compassionate system that is able to recognize that we didn’t get it right for all children at the start, and some children are carrying the experience of that trauma through them. And rather than increase the disadvantage they face by being punitive and excluding them from opportunities, we need to reach out and do even more to help those children to build their social networks, to learn to develop to trust adults, to try and reduce that risk that they face.
[00:22:36.533] Jo Carlowe: Sally, is there anything else in the pipeline for you that you’d like to mention?
[00:22:40.338] Sally Hogg: In terms of Westminster policy, there are a number of opportunities coming up, which we hope will help to improve the provision of parent relationship support. So I talked about the Start for Life program. There is 100 million going to 75 local authorities in England to support both perinatal mental health and parent relationship support. There will be a lot of decisions happening locally about how that money is spent. It’s a real opportunity to start to build the supports.
Now, it’s very easy to think about parent relationships and to sort of fall back on the kind of nice universal provision. Let’s do singing groups and playgroups for all parents and their babies. And that provision is lovely, and is beneficial, but we really need to think about the children who are not getting good enough care. 15% of children are at risk of disorganized attachment. It’s those children where parent relationship support will really change their trajectory of their life and their life chances. And we really need to make sure that money that’s going into local systems– and I would encourage anyone who’s listening to this with mental health expertise to be trying to get involved in those discussions in our local system, to bring that mental health expertise to ensure that the interventions that that money is spent on are evidence-based in which of the families who need it most.
We also know that government are thinking around the future of mental health strategy. There’s a consultation at the moment on mental health plan. It’s really positive to see in that consultation lots of questions about parents and babies. So we hope that will translate into a mental health strategy. And when the NHS long term plan is rewritten and we have a new set of goals for the mental health system going forward, we hope that within that, we’ll see this increased focus on the youngest children and making sure their needs are met.
[00:24:26.890] Jo Carlowe: I’m just wondering how you reach those parents where there is disorganized attachment, who don’t access services. How do you signpost those families to services?
[00:24:37.325] Sally Hogg: If you think about the period from conception to two, there are very few families who don’t have any contact with services at all. Most women will have a midwife present when they give birth. Our most vulnerable families may not be engaging with some services — are likely to be engaging in others. They will have some contact with the state at some point, and they will give birth in hospital. So it’s really important that we do think about this kind of an integrated system of care that really reaches parents where they are, and where they need us.
If we have services in particular venues and we rely on particular referrals to get families through the door, it will always be hard and we have to think very, very creatively about where parents are, who they trust, where their relationships are, and we need to work with those systems and structures to help get parents into the support at the right time. We need to recognize that, just as I talked about the children where there’s heightened fight or flight responses and lots of reasons why they reasonably would not trust adults, that the parents we’re talking about here are often the same.
They might be people who themselves were taken into the care system and maybe didn’t have a very good experience with the care system, so they experience the care system as something that let them down fundamentally. They may have had really difficult relationships with a number of public services. They may have had previous children removed. There are very, very good reasons why those people would not trust public services and the state. Very, very reasonable ones. And also, things within them, because of the trauma they’ve experienced, that make it hard for them to form trusting relationships with anybody. If they’ve got a heightened flight or fight response and disorganized attachment themselves, they’re likely not to turn up to appointments. They’re likely to be very difficult to deal with. They’re likely to be very, very hard and challenging to work with.
And so we need a system that is able to respond compassionately and consistently to their needs, irrespective of that. We cannot have a system that relies on families to reach out, to trust us, to be fair to themselves, to turn up at the same place, the same time every week, and punishes them if they don’t. Because that is not how to make the relationships that we need with the families who most need our help. And it’s also why we need a workforce in those services who are not only skilled in offering the interventions, but also have the support they need, including things like reflective supervision, in order to work effectively with families who might be very difficult to work with.
[00:27:03.580] Jo Carlowe: Are you hopeful for the future?
[00:27:06.100] Sally Hogg: Yes, because I’m lucky enough to see through my work wonderful examples of these services in practice. There’s an infant mental health service, a parent relationship service, called the infant mental health service in Leeds who are just celebrating their 10th anniversary. And I was lucky enough to go and see them recently and hear about just some of the cases that the families whose life changed, the babies whose lives have changed. And when I see that, I know we can do this, and I know there are lots of people who want to do this and who see the evidence about why it matters. I think there are challenges ahead. The policy environment and the funding environment is not always conducive, but I think we are seeing a growth in these services and I hope we will continue to do that.
[00:27:48.965] Jo Carlowe: Thank you. Finally, Sally, what is your takeaway message for those listening to our conversation?
[00:27:55.150] Sally Hogg: Keep babies in mind. So we talk about changing the language from just talking about children and young people’s mental health to talking about babies, children, and young people’s mental health. So if you can do one thing, wherever you are in the system, start using that language. Because once you start talking about babies, and if your service becomes a babies, children, and young people’s mental health service, or your strategy is a babies, children, and young people’s service, then somebody says, well, where are the babies in this? It encourages that thinking of making sure we are inclusive of the needs of our youngest children. And from that, follows thinking about, do we have the services and the workforce and the skills and the provision that works for our youngest children? I would love everyone to go away from here and have a conversation that results in them setting up a parent relationship team in their local area, but I know that lots of people won’t necessarily be in the position or have the power to do that. But just make that language change and keep challenging and keep asking where are the babies. Keep– if you spot a baby blind spot in your local area, talk about it. Talk about the fact that babies don’t get the services they need. And let’s together try and get that change in culture and conversation that might then lead to changes in policy and practice.
[00:29:03.400] Jo Carlowe: Sally, thank you ever so much. For more details on Sally Hogg, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do you share with friends and colleagues.
Thank you. This is a very informative podcast and has led me to think about how we can try to improve practice and connect more with the midwifery service to support more vulnerable parents perinatally