The early months and promoting attachment

The early years are a period of rapid development – for an infant and their emotional and mental health, sensitive, responsive, trusted and nurturing relationships are fundamental. Parents should help them to feel safe to explore the world, becoming resilient and curious children, while also providing a safe space for them to return to in distress.

While current adverse circumstances, past adverse experiences and traumatic experiences can all impact the relationship development between parent and child, socioeconomic risks can also negatively impact children. It’s not parents alone who determine the state of the child – parents should be provided with any support they might need to invest in their infant’s earliest years; it pays off exponentially for generations to come.

In 2019, the NHS long term plan set the ambition to provide “a comprehensive offer for 0-25 year olds that reaches across mental health services for children, young people and adults” by 2023/24 and references the consideration of the needs of 0-5 year olds.

The North West Coast (NWC) Parent Infant and Early Years Relationships (PIER) Network was established in 2022 to support the transformation of provision for children from conception to age 5, through stakeholder engagement and quality improvement initiatives across the two Integrated Care System areas of Cheshire and Merseyside and Lancashire and South Cumbria. The Network brings together stakeholders from perinatal mental health and CYP mental health, as well as universal service providers from across health, maternity, early years education, social care, third sector and local authority providers and commissioners.

The service focuses on the relationship between parent and child as a unit, as opposed to two individuals, providing early year’s relationship support from the age of conception until the child’s fifth birthday.

This community approach focuses specifically on strengthening family relationships and the community in which the family lives, to foster trusting relationships with both the families it is supporting and the village that surrounds them. These relationships allow many parents to feel comfortable enough to reach out and access the support they need and that their children deserve.

Best practice service model – parent, infant and early years relationship services

Read the North West Coast Clinical Network’s Best Practice Service Model for Parent Infant and Early Years Relationship Services here…

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The essential task of the first year of life is to form an attachment relationship – this means making sure the child feels protected and safe, which is as vital for mental health as it is for physical health.

Attachment is about safety; seeking closeness when we feel under threat. Crucially, attachment is NOT the same as love, but it sets a template for the rest of our life when we feel threatened. Do we feel like we can turn to somebody else when we need help, or feel like we have to sort it out ourselves? It lends itself to our interdependency on other people as we get older.

Human babies are unique in remaining vulnerable for almost a year of their lives. They cry when feeling vulnerable, scared or under threat, which might include:

  • Feeling hungry
  • Cold
  • Unwell
  • Lonely
  • Loud environment
  • Unfamiliar things

Their attachment process becomes: threat > stress > attachment behaviour (crying, reaching, etc) > response from carer. If the response is:

  • Sensitive responsiveness (comfort, reassurance, soothing), then the baby experiences relief and regulation, which leads to psychological impacts including security, resilience, and wellbeing. Neurobiological responses include normal stress response, capacity to regulate and healthy brain development.
  • Insensitive/misattunement (reject, ignore, minimise), then the baby experiences prolonged stress and dysregulation, psychological effects including insecurity, distress. Neurobiological impacts include a sensitised stress response, dysregulation and impaired brain development.

This diagram demonstrates the cycle…

In pregnant women, the baby feels what the mother feels, making reducing maternal stress critical. That emotional connection continues after birth – if the mother and baby are in tune with one another.

The Circle of Security shows the importance of the parent attending to the child’s needs:

Reciprocity shows that, when mother and baby are sensitively responding to one another and in tune with one another, one person’s response depends on what the other person is doing. This involves turn taking and mirroring each other, like a tennis match – not as opponents, but as a team. A secure attachment is like being physically fit – you have to work on it repeatedly.

The parent needs to strike a balance between encouraging their child to engage with their curiosity, to explore and discover and feel confident in their freedom knowing that they’re being watched over by their parent (a secure base in which to roam from), whilst providing comfort and open arms whenever they meet something they’re unsure about (a safe haven to return to).

Sensitive, loving responses – such as comfort and reassurance – means the child will likely grow up feeling worthy of love, understanding how to express their emotions, ask for help and regulate their emotions accordingly.

You’re not on your own:
How social prescribing can help

Best for Baby Too uses ‘social prescribing’ as a practical new resource for new mums and mums-to-be, helping them access extra information and support before and after the birth of their child.

It’s designed to give every child the best possible start in life. Alongside the baby-focused information you’d traditionally get from a midwife or health visitor, social prescribers can help with a wide range of worries such as finances, childcare, confidence and isolation – where new parents may not know where to turn for support.

The period from when a baby is conceived until they are 12 months old is known as the ‘peri-natal’ period, and is critical for mother, baby and families. Babies experience rapid neurological growth and physical development during this time.

Supporting mother and baby relationships

“All parents want the best start in life for their children, so we owe it to all our mums and their babies to make it as easy for them as possible – which is what social prescribing is all about. If our Liverpool mums are happy and stress-free and enjoying life, our Liverpool babies will be too.”

Dr. Melisa Campbell: public health consultant, Liverpool City Council

Liverpool has some of the sharpest health inequalities in the country – a baby girl born in Kensington can expect to live 13 fewer years in good health than one born and raised in Kensington in London. Social prescribing has an important role to play in helping to address these health inequalities, and improving health and wellbeing for many new families across the city.

One in three patients in Liverpool contact their GP with concerns that can’t be addressed clinically, including isolation, money worries and mental distress. But our unique approach to social prescribing has seen GPs and other health professionals partner with organisations such as Citizens Advice, to help patients access information and activities that can boost their wellbeing and improve their quality of life.

Best for Baby Too works with GP practices, health professionals and community organisations to make sure that new mums know they have a place to turn to for support, so that they can enjoy time together with their baby.

Research by the University of Liverpool shows that patients referred by Liverpool Women’s Hospital Trust are living with disproportionate disadvantage – health problems exacerbated by the wider determinants. Households referred to the service have very high levels of health need compared to other people in Liverpool, with

  • 70% living in poverty
  • 90% long term conditions
  • Levels of learning disabilities and autism in children from households receiving support more than double the Liverpool average
  • Health and social care costs are twice as high in households receiving CAP support compared to the rest of Liverpool
  • An estimated 1 in 3 ‘complex families’ households have received support form CAP since 2018
    Uptake greatest amongst all ethnic minority groups

Learning from the programme shows the need for active and ongoing service promotion and relationship building with key health staff, with service staff visible and engaged and encouraging referrals.

Key services:

PIER supports the development of mental health support for children aged 0-5, including parent infant mental health.

Sitting alongside and working jointly with other specialist services, PIER Services support parents directly, through a range of evidence-based interventions – as well as providing consultation and training to other providers. The PIER Service model is founded in trusting relationships. By fostering and valuing feelings of trust between service users and professionals or peer supporters, service users will feel supported into, through and out of the service. This will promote the development of trusting relationships within their families.

Silver Birch supports local communities to access treatment and care if they’ve experienced loss, distress or trauma during pregnancy and birth. The service is made up of therapists, psychologists, assistant psychologists, specialist midwives and peer support workers. Its role is to identify distress that has come from the maternity, neonatal or reproductive journey, working to support trauma, loss and fear around pregnancy and the maternity setting, for those experiencing moderate to severe mental health.

Citizens Advice on Prescription is a blended social welfare and wellbeing support model, focusing on low income families on the perinatal pathway.

Established in 2012/13, Citizens Advice on Prescription created a city-wide welfare (anti-poverty) service for front-line health in primary and secondary care in Liverpool. Focusing on staff working with patients living with poor health and disadvantage, the service was expanded in 2020 to include a children and families programme – with a particular focus on perinatal pathway. This service was aimed at pregnant woman or households with a child under one year, encouraging referrals from health staff working with young families struggling to make ends meet, whilst experiencing poor health. It now works with around 1,000 clients a year, 250 of whom come from the Women’s Hospital Outreach.

Research by the University of Liverpool shows that patients referred by Liverpool Women’s Hospital Trust are living with disproportionate disadvantage – health problems exacerbated by the wider determinants. Households referred to the service have very high levels of health need compared to other people in Liverpool, with…

  • 70% living in poverty
  • 90% long term conditions
  • Levels of learning disabilities and autism in children from households receiving support more than double the Liverpool average
  • Health and social care costs are twice as high in households receiving CAP support compared to the rest of Liverpool
  • An estimated 1 in 3 ‘complex families’ households have received support form CAP since 2018
  • Uptake greatest amongst all ethnic minority groups

Learning from the programme shows the need for active and ongoing service promotion and relationship building with key health staff, with service staff visible and engaged and encouraging referrals.

PSS parent-baby services provide mental health support for new and expectant parents, helping them build sensitive, nurturing and trusted relationships with their children, so that they can develop into emotionally healthy and secure adults. “We help parents and carers see and respond to their baby’s present needs. We do this by supporting them to overcome blocks; for example, to reprocess early trauma or birth trauma, recognise their baby as a unique individual, understand the baby’s developmental needs and practical issues like housing and money.” By assessing the current circumstances of the family and how they interact with the child, PSS develops a framework of support to help the family identify goals and work towards them. The service’s goal is to encourage responsiveness between parent and child, allowing them to understand and meet the needs of the child in a sensitive way, so that the child feels safe and understood, and the parent feels confident in themselves as parents.

These exists to support the sharing of clinical best practice and service improvement across Cheshire, Merseyside, Lancashire and South Cumbria, and include ones with a focus on Perinatal and Parent Infant and Early Years Relationships, that help support a range of quality improvement projects and events with stakeholders from across health and social care. Relationships are held central to our approach to all projects and we recognise the need to nurture relationships across our system in order to support the development and improvement of services.

If you’d like to be included as part of the Clinical Networks and receive weekly update emails on this work, please respond and note which Networks you would like to be included in, by email to Bethany.Luxmoore@nhs.net.

Works with all stakeholders interested in Mental Health for women and families from conception to 2 years postnatal, across the whole pathway and spectrum of need. From 2019, this included a specific focus on parent-infant relationships through the work of the Early Years Mental Health Network to develop services for families with children under the age of 5 years old.