Infant mental health
The importance of Early Intervention
The importance of the mental health and wellbeing of children and young people has increasingly been recognised. A growing body of research has demonstrated that mental health difficulties in childhood and adolescence, if left untreated, often continue into adulthood, and persistent mental health difficulties across childhood place children and young people at risk of a host of negative outcomes in adulthood, related to not only their mental health, but also their social, educational and employment outcomes, which have a direct impact on their life chances (REF 1). This, along with concerns related to rising prevalence rates of mental health difficulties among children and young people, has led to a renewed emphasis of the importance of early intervention and prevention in supporting mental health. As well as the evidence demonstrating that effective early intervention and prevention for mental health and wellbeing can improve life outcomes for children and young people, it is also recognised that early intervention delivers important benefits for society and generates positive returns on investments (REF 2, 3). Investments in early intervention can generate cumulative benefits, reducing opportunity cost and the need for remedial spending on more intervention and additional layers of support later in life. Furthermore, an expanding evidence base has continued to demonstrate the fundamental importance of the antenatal period and earliest years of life in relation to child development, lifelong health and wellbeing (REF 4). There is now strong consensus that very early life experiences, particularly parent infant relationships, create the building blocks for developmental pathways that impact a range of psychological and social outcomes throughout life. Brain development research has also demonstrated that infancy offers a special “window of opportunity” for intervention. Thus, the importance of early intervention for mental health and wellbeing, both in terms of support taking place during the earliest years of life, and at an early stage in the development of difficulties, is now well established.
In recognition of the importance of early intervention and prevention approaches for children and young people’s mental health and wellbeing, NHS Education for Scotland was commissioned by the Scottish Government to develop the Early Intervention Framework for Children and Young People’s Mental Health and Wellbeing (Early Intervention Framework). The Early Intervention Framework is a web-based resource that provides a digital database of evidence-based psychologically informed prevention and early intervention approaches designed to improve the mental health and wellbeing of children and young people from the antenatal period to 18 years. Providing comprehensive information for each intervention included in the database across the six key dimensions of implementation captured within the Hexagon Tool (and also utilised within the Matrix), the Early Intervention Framework aims to support services to make fully informed decisions about what interventions might be implementable and sustainable for their specific, local context, in order to improve the use of prevention and early intervention approaches for children and young people’s mental health and wellbeing. The selection of over 100 interventions in the Early intervention Framework reflects the diverse contributors to a child’s developmental trajectory and the importance of the many systems that surround a child and family.
Given the substantial volume of early intervention and prevention approaches to support children and young people’s mental health and wellbeing already captured within the Early Intervention Framework, which also includes interventions with less well-established evidence bases, early intervention more broadly will not be included in the Matrix, and those who are interested in more information around early intervention are directed to the Early Intervention Framework. Therefore, the focus of this section of the Matrix is on psychological interventions and therapies for supporting Infant Mental Health, that is, early intervention in relation to the earliest years of life covering the antenatal period until 36 months. A Good Practice Guidance for practitioners and services in relation to the delivery of Infant Mental Health interventions and approaches has also been developed.
Brief definition
Infant mental health describes babies and young children’s capacity to experience, regulate and express emotions, form close and secure relationships, and explore and learn about their environment. Positive IMH is created and supported primarily through the development of sensitive, warm, and responsive early relationships between the child and key caregivers.
Click here to view Good Practice Guidance for Practitioners and Services
Estimating the prevalence of infant mental health difficulty or disorder is noted to be complex due to a range of issues including lack of awareness and recognition (REF 5), and the use of overlapping constructs in the infant mental health field. Existing data suggest that rates of disorders in children up to 6 years are comparable to those of older children and adolescents at about 17% (REF 6). Prevalence rates for children under 3 are less well understood although a similar rate is found in a key Danish study which focused on 18-month-old infants and classified 18% in the general population presenting with serious mental health disorders (REF 7). Attachment classification is often used as a method to identify prevalence of difficulty in the parent infant relationship. It is estimated that around 10-25% of young children in the general population will be classified as experiencing a disorganised attachment with their main caregiver, and that this will predict a range of poor social, emotional, and educational outcomes (REF 8). Attachment insecurity or disorganisation is likely to be much more prevalent where there are family and community risk and stress factors.
This information is for commissioners, managers, trainers and practitioners to consider the evidence base for the delivery of psychological interventions for supporting IMH.
This topic introduction page covers evidence-based psychological interventions for supporting Infant Mental Health, covering the antenatal period until 36 months of age, and the psychological practice in which these interventions can be delivered. It is inclusive of interventions that are suitable as prevention and early intervention approaches to support the general population (universal), and interventions for families where there may be risks factors that may impact on IMH, and/or those families where there are concerns about IMH and the parent-infant relationship (targeted). This topic page and table are limited to those IMH interventions that have established the highest levels of evidence and reported effect sizes (ES) available in support of them, and does not provide an exhaustive coverage of all possible approaches that are available to support Infant Mental Health. The Early Intervention Framework, includes a fuller range of Infant Mental Health interventions and approaches that services may wish to consider for use.
This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory.
With regard to treatments for infant mental health difficulties, the focus of intervention is primarily on identifying difficulties within the relationships the child has with their primary caregiver(s) and providing support to strengthen these relationships. There are challenges in measuring short- and long-term effects of relationship-based interventions and the UK evidence base about the impact of different interventions on the infant caregiver relationship is still developing. Those interventions consistently associated with larger effects include a focus on increasing positive parent-child interactions; the importance of parenting consistency; and opportunities for parents to practise new skills with their child during sessions (REF 9). Recent research further highlights the benefits of content on responsive caregiving with these interventions producing four times greater effects on child cognitive development, parenting knowledge, parenting practices, and parent child interactions than interventions that do not include content on responsive caregiving (REF 10).
There is high-level evidence to support the delivery of a range of psychological interventions and therapies related to Infant Mental Health, and the interventions presented in the table are categorised according to their underlying theoretical bases. Various IMH Attachment Theory based interventions have demonstrated a range of effect sizes from small to large, when delivered to targeted populations where there are identified risk factors, or where there are IMH concerns, and small effect sizes when delivered universally. IMH interventions underpinned by Social Learning Theory (in combination with other theoretical models) have demonstrated small-large effect sizes both when delivered to families where there are IMH difficulties, or other risk factors, as well as for more community-based populations. IMH interventions drawing upon Psychoanalytic Psychotherapeutic approaches targeted to families have shown effect sizes ranging from small to large. Universal IMH interventions underpinned by Cognitive Behaviour Therapy (combined with Attachment Theory) and Psychoeducation have demonstrated medium-large and medium effect sizes respectively. The effect sizes demonstrated by these interventions make these approaches viable options for the early intervention and treatment of IMH difficulties in children.
There are a range of interventions with sufficient evidence to be included in the treatment tables for IMH. Given the vast array of interventions in the IMH field, only those interventions with the highest levels of evidence, and which have also demonstrated their effectiveness are included in the tables, as examples of the types of possible interventions available. The tables are therefore not an exhaustive list of all possible IMH interventions, and serve to highlight the types of psychological interventions and therapies with the highest levels of evidence and efficacy.
| Recommendation | Who for? | List of Interventions | Type of Psychological Practice | Evidence | Efficacy |
|
These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Attachment Theory Including: |
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|
Targeted |
Enhanced |
High |
Medium - High |
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| Targeted | Enhanced | High | Low | ||
|
Universal and targeted |
Enhanced | High | High | ||
|
Universal and targeted |
Skilled | High | Low | ||
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Social Learning Theory / Attachment Theory Including: |
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|
Targeted |
Specialist |
High |
High |
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|
Universal and targeted |
Enhanced | High |
Low - High |
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| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Social Learning Theory / Family Systems Theory Including: |
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|
Universal and targeted |
Enhanced | High | Low | ||
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Social Learning Theory/Cognitive Learning Theory Including: |
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| Targeted |
Enhanced |
High | Medium | ||
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Social Learning Theory / Cognitive Behavioural Theory (CBT) Including: |
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|
Universal and targeted |
Skilled and Enhanced |
High |
Low - High |
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|
Universal and targeted |
Skilled |
High |
Low -Medium |
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| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Cognitive Behaviour Therapy (CBT) / Attachment Theory Including: |
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| Universal | Family Foundations | Enhanced | High | Medium - High | |
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Psychoanalytic Psychotherapy including: |
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| Targeted | Child First | Enhanced | High | Low - Medium | |
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Psychoanalytic Psychotherapy/Attachment/Developmental Psychopathology Including: |
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| Targeted | Child Parent Psychotherapy | Specialist | High | Medium - High | |
| These interventions are all recommended. Please see the Early Intervention Framework Hexagon Tool to review which is the most appropriate intervention for your context. |
Based on Psychoeducation including: |
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| Universal | EasyPeasy | Skilled | High | Medium | |
1. Centre on the Developing Child at Harvard University (2016). From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families. Retrieved from www.developingchild.harvard.edu.
2. First 1001 Days (2021) Evidence Brief 6 Investing in Babies
3. Bachmann CJ, Beecham J, O’Connor TG, Briskman J and Scott S (2021) A good investment: longer term cost savings of sensitive parenting in childhood. J Child Psychol Psychiatr, 63 (1), 78-87.
4. National Scientific Council on the Developing Child (2020). Connecting the Brain to the Rest of the Body: Early Childhood Development and Lifelong Health Are Deeply Intertwined Working Paper No. 15. Retrieved from www.developingchild.harvard.edu
5. Lyons-Ruth K, Todd Manly J, Von Klitzing K, Tamminen T, Emde R, Fitzgerald H, Paul C, Keren M, Berg A, Foley M, Watanabe H. The Worldwide Burden of Infant Mental and Emotional Disorder: Report of the Task Force of the World Association for Infant Mental Health. Infant Ment Health J. 2017 Nov;38(6):695-705. doi: 10.1002/imhj.21674. Epub 2017 Oct 31. PMID: 29088514.
6. von Klitzing K, Döhnert M, Kroll M, Grube M. Mental Disorders in Early Childhood. Dtsch Arztebl Int. 2015 May 25;112(21-22):375-86; quiz 386. doi: 10.3238/arztebl.2015.0375. PMID: 26149380; PMCID: PMC4496484.
7. Skovgaard, A. (2010). Mental health problems and psychopathology in infancy and early childhood. An epidemiological study. Danish Medical Bulletin, 57:1-30.
8. Van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized Attachment in Early Childhood: Meta-Analysis of Precursors, Concomitants, and Sequelae. Development and Psychopathology, 11, 224-249.
http://dx.doi.org/10.1017/s0954579499002035
9. Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of abnormal child psychology, 36(4), 567-589
10. Jeong J, Franchett EE, Ramos de Oliveira CV, Rehmani K, Yousafzai AK (2021) Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis. PLoS Med 18(5): e1003602.
Thanks to the IMH Advisory Group and Good Practice Guidance Working Group members, and our colleagues who wrote the case vignettes included in the Good Practice Guidance:
Dr Beatrice Anderson; Dr Marita Brack; Ann Bradwell; Dr Catherine Cavanagh; Dr Kirsten Coull; Dr Jean Cowie; Dr Andrew Dawson; Julia Donaldson; Raquib Ibrahim; Dr Donna Mason; Dr Anne McFadyen; Pamela Murray; Dr Juan Perez Olaizola; Matthew Power; Dr Christine Puckering; Joan Rutherford; Karen Smith; Dr Julie Stephen