Audio transcript (edited)

ALI CHISOLM: Good afternoon, everyone, and welcome to today's webinar, Understanding and Supporting Infant Mental Health, coproduced by CFCA and Emerging Minds. My name is Ali Chisholm and I work with Emerging Minds National Workforce Centre for Child Mental Health. In today's presentation, we'll be exploring ways that practitioners can feel confident to have sensitive and non-stigmatising conversations with caregivers about infant mental health and wellbeing. To expand on that, let's have a look at the learning objectives, so that we can be clear about what's ahead in the next hour.

So, our learning outcomes are: This webinar will support practitioners to develop an understanding of infant health and wellbeing that can underpin conversations with caregivers, identify signs that infants might be struggling, and start useful conversations with caregivers around infant mental health and wellbeing.

As we proceed, we recognise and pay respect to Aboriginal and Torres Strait Islander peoples, as the traditional owners of the lands we work, play and walk on throughout this country. We acknowledge and respect their traditional connections to their land and waters, culture, spirituality, family and community, for the wellbeing of all Aboriginal and Torres Strait Islander children and their families.

So this is part of a webinar series, CFCA and Emerging Minds and that focuses on infant and child mental health. So an upcoming webinar will include working effectively with Aboriginal and Torres Strait Islander families over the first thousand days of a child's life. And if you're interested, we've got previous webinars, this year in 2021, including Supporting children's wellbeing when working with separating parents, How to recognise complex trauma in infants and children to promote wellbeing, families and homelessness, Supporting parents in improving outcomes for their children and What is the social model of disability and why it is important in child mental health. So you can access those through the CFCA website or Emerging Minds.

So I'd like to go on to introduce our presenters today. We have Kristel Alla. So Kristel is a knowledge translation specialist at the Australian Institute of Family Studies and Kristel is working on child and infant mental health research projects, as well as knowledge translation and research impact activities and strategies, all aiming to improve the child and family wellbeing. Welcome, Kristel.

KRISTEL ALLA: Thank you.

ALI CHISOLM: And we also have Caroline Williamson. So Dr Caroline Williamson is a registered psychologist, who has worked in community mental health and child and family health services in the UK and Australia and Caroline's interests are in perinatal mental health, parenting and parent infant relationships. Welcome, Caroline.

CAROLINE WILLIAMSON: Thank you.

ALI CHISOLM: And you can all find the bio of our presenters on the CFCA website as well. And I'd also like to welcome Tegan. Tegan is a family partner here with Emerging Minds. She's the mother to two twins, almost four, and Tegan has navigated her way through a wide range of services to gain assistance with supporting her sons through the early years of their lives. And through that experience, she's gained a lot of insight around how professionals can support families with infants and young children. So welcome, Tegan.

TEGAN: Hello, everyone.

ALI CHISOLM: Hello. And just to get started, I'd just like to invite our panellists to share a bit about what it is that's captured their interest in working in the field of infant mental health. So perhaps over to you, Kristel.

KRISTEL ALLA: Thank you, Ali. So there's a combination of personal and professional reasons for this. My mum was a psychologist and she would often meet her clients at home, both children and adults, and as a child I would see the next client in our living room, when I would pass it. So sometimes it was somebody I knew and sometimes it was a stranger and I remember thinking "When I grow up, I want to help people too, just like Mum." And then at first I did not consciously think that I would want to work in mental health, particularly because Mum advised against it. She said, "When you grow up, you can be and do anything you want except do not become a psychologist. It's too hard, too hard."

So, as an adult, I dutifully tried to stay away from mental health at first, I got my Bachelor's in political science, Master's in health promotion and all the while trying to stay away from mental health. But the pull was just so strong and so by the time I got to do my PhD, I knew my research passion is in mental health and specifically I knew I wanted to children as early on as possible. So I wanted to prevent the long list of mental health and clinical problems that they can experience later in life because their mental health struggles went unnoticed when they were really young.

So, as a researcher, I use different tools than my mother did as a psychologist. I use research, I use research translation into policy and practice, but I do hope that somewhere behind a child psychologist's door, the line of children struggling is just a little bit shorter because I have helped them. Thank you.

ALI CHISOLM: Thank you, Kristel. And we need all the people we can working in this field as well, so your contribution is very valuable. Thank you for being part of the webinar today. Tegan, I'm curious to hear what it is that's captured your interest and motivated you to be part of our webinar today.

TEGAN: Well, mainly because to make it that little bit easier for parents and families and practitioners to - because infant mental health is quite complex and I just think if it makes it easier for the next family, then that would be a great thing.

ALI CHISOLM: Thank you. We are grateful to have you, so thank you. And Caroline, what is it that's captured your interest in the field of infant mental health?

CAROLINE WILLIAMSON: Well, I'm probably similar to Kristel. I think I've always held a passion for early intervention in mental health and in the UK I worked in adult mental health but it was early intervention services around emerging mental health problems. And I remember kind of my reflections on that work, even though it was defined as being early intervention, it didn't feel early enough. I kind of felt about that there could've been opportunities kind of earlier on in that child's life that services or supports could've come alongside parents and helped.

So I think for me kind of infant mental health, you're there right at the beginning, supporting that journey and supporting the wellbeing and infant mental health. And I also think working with parents, I feel very passionate about. I think that parenthood is such a huge seismic shift in our life when we become a parent and comes with lots of emotions and reactions and kind of even can kind of bring to mind some of our own experiences. So kind of partnering with parents to really understand their journey is something I really enjoy too.

ALI CHISOLM: Thank you. Thank you for being involved as well and so we look forward to hearing your practice wisdom as well. And so I'll now hand it over to Kristel to hear about your paper and infant mental health.

KRISTEL ALLA: Thank you very much. So hi, everyone. As a brief introduction to infant mental health, I'll tell you a little bit about what it is, why it's important and what the most important things to consider are, based on the research evidence. So if you're interested in reading more, my talking points are based on a recent paper I published, together with a colleague of mine. My colleague's name is Dr Trina Hinkley and that was an Emerging Minds joint paper.

So let's get into it. Infant mental health is sometimes also called social and emotional wellbeing. So infant mental health is defined through three key aspects. The first is a child's capacity to experience and express emotions. So babies who are doing well in relation to this aspect of mental health, they would smile and laugh when they were happy and they would demand their nappy changed when they were uncomfortable.

So the second element is the baby's ability to develop relationships. So babies who do well in this regard would communicate actively with their caregivers. They would seek eye contact, first of all, with their caregivers when they are spoken to.

And the third element is the baby's willingness to learn and explore their environment. So mentally healthy babies seem interested and curious in their environment. And the age for - well, to define a child, an infant life so when we talk about mental health of infants, of babies, I mean aged from birth to 12 months. Good. I got that right because yesterday when I was practising, I kept saying "12 years" So babies, birth to 12 months. It's a time of rapid growth, it's when infants develop their cognition, their self-regulation, their psychosocial skills and early brain development, it's incredibly important, because it has short- and long-term effects for the child. So we have tracked through research many chronic illnesses and adult mental disorders back to poor health in infancy and early childhood.

And we also do know that many babies who are struggling with their mental health, they are not getting the help they need, and we know from surveys with Australian parents that most of them can't recognise the signs of mental health struggles in their infants and they do not know where to get help when signs of struggles do occur. So because of this, parents may need help from practitioners to recognise and monitor these early warning signs of struggles with their babies' mental health. That's my first point, that the mental health of babies is important.

My second point is that there are signs that tell us they are struggling. So when we talk about infant mental health, we don't usually talk about symptoms or a diagnosis of disease and the reason for that is that babies are constantly developing. The Children's Mental Health and Wellbeing Strategy says that the mental health of babies exists on a continuum, so it moves up and down four anchor points: healthy, coping, struggling, unwell. And where they are at any time, is it healthy, is it coping, is it struggling, is it unwell? That can change over time and it changes based on both internal and environmental influences. The babies at those different points in the continuum, they need more or less support.

Now, let's talk about signs that babies are unwell or struggling. For babies, these are typically less obvious than for older children and what makes it difficult to know if there are issues is that some of these changes in their behaviour and physiology can mean mental health struggles or they can also be normal behaviours for babies at certain developmental stages. So some of the example signs of infant mental health struggles, they may include difficulties with sleeping such as babies constantly not sleeping well or there may be changes to their sleeping patterns. They may sleep more or sleep less. The signs may also be that they seem really distressed or restless or grumpy or irritable over a long time and it's really difficult to calm them down when they're upset.

One other sign would be that they may be excessively clingy, not wanting to be apart from their caregiver or it could be signs at the other end where they seem disengaged, they don't make eye contact, they don't want to be held and they may not even cry at all or cry very little or make very few attempts to get their needs met, like being fed or having their nappy changed. So they may also be overacting to what's going on in their physical environment. They may react really strongly to loud noises or excessive light, they may be easily startled. So it's really about deviating from what's normal for this particular body and watching out for signs of struggles that are persistent and severe.

And my third point is that babies do well or not so well dependent on their relationships and the environment they live in. Babies are dependent on their caregiver relationship for survival and for development. So research does tell us that babies do well when they have supportive caregiver relationships, when they have positive relationships with their siblings, when their mothers be healthy in their eating and exercise behaviour through their pregnancy. So all these factors and more can be prospective of good mental health for babies.

And babies do not do well when they are exposed to domestic violence, poverty, when they have lower birth weight or when their caregivers use substances or when they have mental illness. So having these risk factors in their environment can mean that babies do have poor mental health outcomes. And we do know that the best protection for a baby's mental health is good attachment relationships with their caregivers. So babies who are in loving and supportive relationships where their emotional and social needs are met, they have better mental health.

So relationships that are at the other end of the spectrum, those are abusive, those that are neglectful, where caregivers are unavailable or unpredictable, babies tend to have poorer mental health. And these risks and protective factors can have a big impact, especially because they can amplify each other or they exist together and they can interact - can contribute to babies' mental health. So the timing is important, the intensity is important, their accumulation really matters. And it matters for babies' mental health whether, for example, the family has just gone through a big move to another country or another state or there's physical illness in the family or parents have separated. So worst yet, if this is all happening at the same time, not good at all for babies' mental health.

So baby may need more support at times when there is a lot going on, just to be mindful of that. And that's why it's important to understand as much about the relationships and the environment as we can and there are things that practitioners can recommend caregivers to do in their home and family life to support the baby's mental health.

So finally, I will briefly mention some final considerations about these conversations with caregivers around their baby's mental health and then Caroline, you can talk more about this, so I'll just mention three key strategies. Firstly, it's a good idea to include questions about the child's world, relationships and environment in conversations with caregivers around their mental health. Ask about their medical and physical history but also reflect on baby's experiences, their psychological characteristics such as emotional expressions and behaviours.

Secondly, focus on building the confidence and competence of caregivers. Ask about what they and their family are doing well, not just where they're struggling. And ask, for example, what are some of the ways that caregivers can connect with their babies, think what are the strengths in addition to vulnerabilities in these relationships that can be supported. And remember also that yes, it is about the baby and the caregiver recognising their mental states and their needs, however what is needed sometimes, maybe also helping the caregivers understand their own emotions and their own reactions in their relationships with their babies.

Thirdly, another helpful strategy may be to teach caregivers how to communicate with their baby in consistent and nurturing ways and this could include little tips and tools like showing the caregivers how to promote that two way conversation by repeating the sounds that the baby makes and using a calm and soothing voice when they are upset and just gently rocking them for comfort. Or even simply smiling back to the baby to tell them that they're special and that teaches them that a caregiver can be trusted. And there are several more simple ways that can be used to build a loving and responsive relationship this way.

And before I conclude my presentation, I'll summarise the three key messages I'd like you to take away from the presentation. So these are mental health for babies is important. There are signs that tell us that babies are struggling and need support. And mental health of babies is dependent on their relationships and the environment they live in.

So to support them, we really need to look beyond their medical history, at the relationships and the environment. But if you do want more information, have a look at our review paper, there's a link in the hand outs and Emerging Minds also has many excellent resources on infant mental health on their website. I know Caroline and Tegan will give you more context and in depth information about their experiences in supporting the mental health, so I'll now hand you over to their capable hands. Thank you.

ALI CHISOLM: Thank you, Kristel. That's great. And yes, just in reference to Kristel's paper, there is a paper on "Why is infant mental health important?" you can find on our website. And so now moving on, we're going to invite Tegan to share some insights from her experience around the importance of infant mental health. So welcome, Tegan.

TEGAN: Hello, everyone. This is just my understanding and supporting infant mental health presentation. My twin sons were born premature with a low birth weight and the smallest of two was transferred back to the NICU on oxygen and he struggled during the two month hospital stay. He was still gavage fed and struggled with feed until 48 hours before he came home. Sorry. The hospital removed the tube to get him home because his brother had been ready for weeks and I wanted the boys home together. At this time I didn't have stable housing as I was escaping DV from the boys' father and I was quite isolated and I was experiencing high levels of anxiety and needed to think about their physical as well as social and emotional health.

So obviously I was looking for support from any services that were available. I was experiencing everyday stress, which I now know made it harder for my children to cope. I struggled to get my youngest to feed. I had a nurse visit me from in my emergency hotel room, she was from the special care nursery and I could tell that she was stressed and so was I. She quite aggressively told me I had to formula top up my youngest as he'd only gained 10 grams in a week and his brother had gained a hundred grams. It's hard to be able to think about everything that you need to when you are living in a situation like this, so I have learnt that there are many things that practitioners and services can do to make a difference for parents in a situation like I was.

I believe that parents' mental health needs to be a priority in taking care of births, so that are able to support their children in the best way they can. As a single parent, I am the key person who will be with them, setting them up for the rest of their life and I'm always thinking about the fact that I am the one preparing them for - well, to be adults.

I believe services and practitioners can be so important in their approaches to helping parents and caregivers preparing their children for adult life. Because I have twins, I can see the difference as my boys grow up together where one child is struggling in some areas and the other isn't so much. I believe it's my knowledge as their mum that is so important in letting practitioners know about what they will be working with when they support my child and our family.

When you're talking with parents and caregivers about their children's or babies' wellbeing, there are some key things that can make a world of difference to us and it doesn't take much to include in your appointments and conversations. We know our babies better than anyone, so it's really important that we are listened to and believed. What you're seeing in a short appointment time often will not reflect what we are experiencing for the rest of the time.

Remember to show empathy. Judgments about how we are managing whatever we are struggling with are not helpful to a parent or our children and will only make us feel more isolated than we already are. I was looking and asking for help and support and trying to do the best I could for my child, who know was struggling. I often just needed to be shown some humanity.

Parents often need and want information so they can understand what they're dealing with. For myself, I needed to learn about sensory processing, so I have the knowledge to help my son with what he was going through. And a lot of the ideas of what I need to do weren't practical things that would work for our situation. I didn't expect a quick fix but I did expect more individualised support and strategies that helped me understand and step me through what I needed to be thinking about when I responded to my son's frustrations.

For me, learning about infant mental health and being educated as a parent is something that is very important. If someone had sat me down at the beginning and talked to me about infant and children's mental health and wellbeing, it would've been really helpful, just having the many aspects of children's mental health and the impacts of things like housing, social connections, my stress levels, et cetera, explained to me in a way I could understand would have saved me having to work these things out on my own along the way. And this would have given me more of an understanding on how to support my son's mental health and wellbeing.

I can see that my son's frustration levels have decreased over the years, so overall the services have helped, but there have been times when I've accessed services for my son that have cost a lot of money and they were not that practical for me to put in place in our situation.

When thinking about supporting infant mental health, remember that there is a lot of stigma for parents looking for support, so it's important, whatever reason you're looking for help from services, parents and caregivers will obviously respond better when they don't feel judged and they feel heard. I'm still going through the process of getting supports, particularly helping one of my sons, and it can be hard without a clear diagnosis or description of what he's going through.

One of the things I've found most helpful along the way have been parenting groups and support groups. So for practitioners to link parents and caregivers in with people who are going through similar experiences can be really helpful. For me, just having those connections helped me feel less isolated and there were some particularly helpful social workers from a children's community centre who have stood out for me from a time when I needed support. They invited me to social groups and just engaged with me and checked in with me and this made a difference for my family.

Another helpful example of supports that have also stood out to me was the early childhood and family service. Just the little things that went a long way in helping, they offered to write support letters when I had to go to Family Court, as well as making regular visits and they supported linking in with NDIS for my son and helped me to understand what I needed to know about this. And they have really just kept in touch right through to make sure my son's wellbeing is supported and my needs as a parent are looked after, so I can be in the position to support my children.

I can't emphasise enough how much of a difference the children's community centre and early childhood services has made. Like, the consistent phone calls, consistent practitioners, invites to support groups and playgroups, that was extremely helpful for my family.

We are always learning as our children grow through different stages and every baby and child will have different things that we need to deal with along the way. They need different supports to be put in place. Services can help us navigate through the supports and services that we need to use. If we are helped to understand these ourselves, our babies and children will benefit. Thank you.

ALI CHISOLM: Thanks so much, Tegan. It's very valuable hearing from your own experience and your insight and I'm sure many practitioners and professionals and other people working with families will have gained a lot from hearing from you today, so thank you so much for being here, just to hear about how helpful it is to have that regular contact and engagement with other parents and other support groups, it's really helpful to hear, so thank you very much. And now I'd like to reintroduce you to Caroline and so Caroline's going to tell us a little bit about her experience in infant mental health and then we'll have time for the Q and A towards the end. So just I'm having a bit of trouble with my slides, but just bear with me, Caroline.

CAROLINE WILLIAMSON: Yes, no problem.

ALI CHISOLM: There we go.

CAROLINE WILLIAMSON: I'll begin anyway. Thank you, Tegan. I just probably also want to extend my thanks for sharing your experiences and examples of what was supported and also reflections on what opportunities were perhaps overlooked in your journey and what might've been helpful that I think we can all take learnings from.

I'd like to share some of my reflections and experiences of approaching conversations with parents about infant mental health and opportunities I find to offer support. And my reflections are based primarily on experiences of working as a parent infant therapist in a child and family health service. So in this service, parents will access support for different reasons and different opportunities present, so it may be for a routine health check, parents might be experiencing issues around feeding or settling, they might not be enjoying certain aspects of parenting or struggling to make sense of certain behaviours. They may be experiencing challenges in their relationships or might be experiencing their own powerful emotions, such as anxiety and depression.

And I suppose it's my view that really each consult that we have with an infant and a parent can be an opportunity to start that conversation. And as Kristel and Tegan's mentioned, I think if we can aim to make conversations about emotional development as important as conversations that we might have about growth and physical development, put it on the agenda right at the beginning, and then it can start to reframe these conversations, reduce kind of stigma and the blame that Tegan mentioned, and that we're not just having conversations when we notice a concern but we're sharing information right from the beginning about what can promote emotional wellbeing in infants.

So the slide with the continuum on, I find that this can be a really useful place to start with families and introduce this visual image about infants' emotional wellbeing being on a continuum, because I think it really normalises the idea that for any of us, for each of us, including babies and infants, that mental health and emotional wellbeing isn't a static position, we're not either well or unwell, but rather our position on the continuum can change over time. The parent infant relationship is also highlighted underneath here because this really does, as has been mentioned, underpin the infant mental health. We can't think about or support infant mental health without thinking about this relationship because it's through this relationship how babies learn to understand and express emotion and develop confidence in the world.

So sharing this continuum with a parent can be an entry into a discussion, so kind of even having this visually available. And it can start the discussion about what healthy infant mental health might look like. So we might start to think with parents about areas of an infant's life, such as sleep, activity level, feeding, emotional expression and interests that they show in the world and think about how each of these areas might look for babies when things are going well. And as Tegan mentioned, I think we're bringing together then the parents' observations about the uniqueness of their child, what they notice and also joining that and sharing what you might expect to notice. So we're coming kind of from sharing knowledge about that really.

And then that conversation can - that reflective conversation can continue and we might think about what we might notice if our infant, our baby wasn't coping so well. So we might ask "Do you notice changes in your infant's sleeping or routine and they appear to be struggling?" Or kind of vice versa, if we notice changes in our baby's sleep and activity levels, what might be going on for them? And it presents in kind of this continuum as well, also presents the opportunity to think about how a child environment and the relationships, the experiences, family stress and support, all have the potential to influence kind of a person's position on that continuum. And that could be in either direction.

So we might kind of have those curious questions around do you notice that your infant might react differently in different situations? Or how does your baby adjust to changes in routine? Or kind of really explore if there have been any changes recently that might influence where your baby might find themselves on that continuum. So, as Kristel mentioned about trying to think about the environment, using this in this way opens up to think about what might influence where somebody might be.

I think it's really important to talk about the reciprocal nature of the infant parent relationship, just as a reminder that the wellbeing of one, so either for the parent or the infant, will always influence the wellbeing of the other, as Tegan highlighted. So when we're attending to and supporting infant mental health, we have to give attention to the parent as well. I think it's equally important to understand and connect with a parent's journey and their experiences and attend to their relationship with the infant. And I think sharing this as well will help parents understand sometimes that we might ask or we might have questions or think about what support we might provide. That's not just focused on the infant as an individual, but kind of supports around the family and trying to - about how we manage their circumstances.

So if we move on to the next slide, kind of I've just probably highlighted here that when we're having conversations about child development and I'm sure that people do anyway but we kind of - I think we always try and endeavour to approach those conversations from a position of really wanting to be an ally or a partner with a parent, that we kind of are joining, I suppose, with this mutual goal of supporting an infant's health and development and that the parents bring their expertise about their child and circumstances and our goal is to tailor the information and the guidance that we might know about infant mental health really to the individual needs of that child.

As we've mentioned, kind of highlighting that infant's emotional development is one aspect of development that alongside physical development, cognitive development and that they all influence on another. So we need to give equal attention to kind of each really. And with that in mind, probably even wondering ourselves what do we ask if we look at our own assessments or kind of our own ways we engage with family, what do we ask about infant mental health and what do we include?

And we might begin that with very general and open questions such as the one I've highlighted here about temperament, just wondering about an infant's temperament. And this might help us to understand how a parent experiences the baby and it also might just present another opening opportunity really to talk about differences in infants' temperaments and the challenges and joys around that and support parents to think about how we can tailor and adapt parenting to the child's temperament to nurture that development.

I do acknowledge it can be trickier to examine and support social and emotional development than say gross motor development because much of emotion we think of as being internal. But as Kristel highlighted, that most emotional responses in infants will present as behaviours or physiological responses such as kind of excessive crying or sleep or feeding issues and kind of unsettled behaviours. So kind of another way of engaging and supporting infant mental health might be to kind of explore that with parents. Does your baby have a routine around sleeping and eating. How does your child let you know that they're hungry or tired or need a nappy change? So we're starting to understand how they might express that need. How do they let you know when they need you close?

So sharing that every infant can become easily overwhelmed by unfamiliar sensations in their environment, such as noises or new smells or separations, because they're developing that repertoire of emotions and beginning to understand what that is and need somebody do that alongside them. So we might consider with parents, what does your - when they're upset, what helps your baby to calm down. "Does your baby like to be picked up and held? How does your baby react when you pick her up and talk to her?" Also kind of thinking that that gives us some kind of understanding about the relationship as well.

I've stressed here again the importance of the parent infant relationship but I realise I'm kind of coming back to throughout, but I think it's how infants come to understand themselves and the world around them. So if we can spend time exploring this too with parents, we might gently explore what's it like being a parent to this particular infant and what do you enjoy the most and what do you enjoy less? And as has been highlighted from the other presenters, really trying to understand the context that parents are raising their children in, general questions like this on the slide or perhaps specific questions. "Can I ask about how you're coping at the moment? And do you have any other supports that you have, either from family or services? And how would you recognise if things were becoming more challenging and difficult for you and for your family?"

So if we move to slide four, it's the next slide, we've thought about laying the foundations for supporting infant mental health and I suppose what we're really highlighting is supporting parents to think about their baby as an emotional being that needs help and guidance to make sense of emotions and learn to regulate emotions. Having those conversations where we adopt that curious position alongside a parent about what might be going on inside their baby, an infant, or wondering about what the meaning is behind the behaviours that we observe.

I will often encourage parents to kind of notice and name and link emotions out loud with their infant as an opportunity to support that development. You know, thinking that for an infant it's as though feelings inside them might just happen almost randomly. Might start squirming or become uncomfortable and become upset and if they're left to manage that on their own, it's like the brain and the nervous system are really trying to make sense of that feeling, but they've got nothing to anchor it to or to connect it to to the outside world.

Often automatically as parents we will make that link, we'll kind of recognise it and maybe think it's a nappy change that's needed or that they're cold, but if we're able to kind of say that out loud that we're noticing it, that "Oh, you're upset now" and "Oh, you need a nappy change" and it begins to help infants to kind of recognise emotions and anchor it as well to make sense of and the meaning behind their emotions.

As has been mentioned, kind of another way of providing support might be around providing practical support and guidance around establishing routines with parents. I think, as Tegan highlighted, I think we've set the foundations of trying to understand the individual infant and their circumstances, then we can tailor that support that we provide. But we might encourage parents to talk to the baby about their routines, talk about what they're doing in the moment with the baby to help them prepare and support them to feel secure. "I'm going to pick you up now" or "Let's put you in the chair" so that it's preparing them and you're naming what you're doing.

Similarly supporting parents to talk to the babies about the new sounds and experiences and letting them know what they're hearing and noticing, just reminding them that they maybe need to stay very close at first as they warm up to those new places, so that they begin to feel safe and secure to explore the world. Giving ideas around age appropriate play and ways to connect with the baby, songs and nursery rhymes, using baby names and songs to make them feel special and equal and connecting with community groups and supports. So really becoming familiar with what groups and services might be on offer in the local area and so that we can link in and be aware of those services to support parents to link in to them as well.

On the next slide, I kind of recognise there might be times that parents might present with an issue or a behaviour that they're struggling with and while we might kind of think about or wonder about infant mental health, parents might not recognise it as such or might just be looking for help to fix a behaviour, feeling really overwhelmed. And I suppose in those instance, I think we need to first really hold and connect to the parents' experiences before we wonder about the baby.

So I know I've highlighted ways that we might kind of curiously wonder with parents about what's going on for the child but if we were to do this straight away in those instances and ask what you think is bothering her, then the parent can often feel frustrated and overwhelmed or even quite anxious if you don't know and they've come to you for support.

So I think it's important also to just acknowledge how stressful and overwhelming it can be when we're unsure how to respond or don't know what's causing behaviours and we might have more success in supporting parents in these moments if we first validate their struggle, kind of acknowledging that it's really hard work taking care of a baby and thinking about how can we help you and support you in those moments. Just continuing to explore and attend to both and I think once we've validated and supported parents, then we can kind of bridge and attend to the infant and be able to work with them about their experiences.

If we move along to the next slide, thanks, Ali, I think this slide on reflective parenting, I think I'm just probably highlighting that. I think what we have been talking about throughout my presentation is really trying to support a parent's reflective capacity, thinking about what lies beneath behaviour that might be going on inside our baby. And I feel that supporting kind of reflective parenting, as it's named here, is really our biggest opportunity to support infant mental health.

Research has found in the first two years of life, that the most important factor in a child's development was how well mothers were able to interpret the baby's feelings and this was a much stronger predictor than family background and socioeconomic status. So the better a mother was at interpreting their infant's intentions and moods and the faster the infant becomes in expressing their thoughts and feelings through language and play. And obviously being able to do that helps them to have healthy relationships as they progress forward.

And I think when we're supporting reflecting parenting, we're really helping a parent understand their own emotions as well and then using this to bridge to the child and their emotional world. So supporting parents to building in a pause if you like, so when they experience a struggle, what's happening right now, what am I noticing for me and what am I noticing for my baby.

And then the final slide, I've just kind of - I think that just acknowledging that there will still always or still often be parents and families that maybe need the support beyond what we can offer. And then our role might be to support parents to connect with other services and I think it can feel confusing enough at times for professionals to know what services are out there and kind of that change once a month. So kind of I was encouraging to stay involved with families while they wait to be seen by the right support. We still have that role to play in continuing to promote the infant wellbeing through these reflective conversations and identifying and supporting the strength in the family. Thanks, Ali. Sorry, I feel like I might've gone a lot longer there but I hope it was okay.

ALI CHISOLM: Thank you. No, that's great. So many excellent strategies to share today, so thank you for going over them. I think it's really interesting to think about that continuum and when there's opportunities to continue some support for the family and some guidance and some of those strategies you mentioned and other times when we're looking for other referral pathways if they're more struggling or down the continuum. And it's so helpful to hear that with children that age, it is always changing and fluctuating and that we can go, as we can as adults, up and down the continuum and it's obviously very contextual as well.

CAROLINE WILLIAMSON: Yes, yeah.

ALI CHISOLM: So thank you. I'm just aware that we probably have some questions coming in so we may move on to a few Q and A now, I think. Just before we do that, I just - no, that's all, we're all good to go, we might just change the slides. Thank you. So thank you, everyone, for your presentations and contribution. We can invite Kristel back to the screen and Tegan as well. So although we don't see Tegan here on the screen, we've got her as her audio, so Tegan is with us for some Q and A. And so that's so helpful, thank you for your presentations. So I've got a question. This is probably recapping a little bit, so over to perhaps to hear from Tegan a little bit, so what can practitioners do to better support parents who have young children struggling with social and emotional wellbeing?

TEGAN: I believe that if practitioners, where practical, can provide like a comfortable space for children to play in the appointments, so then the parents can talk and the practitioners can listen, everyone's quite more relaxed. And that no matter what the issue, whether it be a child not sleeping or behaviour, it's beneficial for the practitioners just to listen, whatever the parents' concerns are and to continue to follow up and encourage with the family.

Maybe have like a block of appointments, much like a physio or mental healthcare plan block, so it's like the same person that you're seeing overall. And then in this time the family could build some trust and rapport with the practitioners and the practitioners can get a whole approach of what is really happening with the family's lives and whether it be clinical, social, emotional, all of the above.

ALI CHISOLM: Thanks, Tegan. Thank you. And I'm just thinking - so people who have joined us today may be just wanting to start show some interest in the field and to start to develop their professions or maybe further down and they're experienced in that. So I'm just wondering, from your paper, Kristel, was there some strategies for practitioners that are wanting to start to explore and support infants in their work with families, if something came out of your research?

KRISTEL ALLA: It's a great question. One easy step is go seek more information. There are actually lots of resources available that also links to the resources for more information in our paper, so there are links to online courses, podcasts, more webinars, there's lots of useful links and sources on the Emerging Minds website. I guess another step would be to reflect on the different aspects of the practice that may support better outcomes for referrals and also for caregivers' self-care.

So thinking about things like so how to tap into those networks of support, how do I focus more on infants and engage families in my practice? How do I, in my assessment processes, support consistently asking questions about baby's social and emotional wellbeing, for example. And also becoming more aware of yes, there are risk and protective factors at play and how to use them in initial conversations with caregivers and how to use them for support. So yeah, there's a lot around awareness we can do and just use - there is lots of links and links and resources also in our paper, so just feel free to use them as well, I think. 

ALI CHISOLM: Thank you. Thank you. And Caroline, I'm wondering from a child and family health service, if practitioners are wanting to support and have those conversations with parents, but not sure or confident in starting those conversations. Do you have any suggestions in an organisation or in your practice how clinicians or practitioners can gain - look for confidence or find some knowledge or -

CAROLINE WILLIAMSON: Yes. I think it can be, can't it, I think sometimes we can really - I think because of what Tegan highlighted as well, we can sometimes kind of feel a bit hesitant in case we're wondering what the parents' experiences is going to be of us talking about those things, about raising a topic like infant mental health and can feel a bit like "Oh, you know, does this mean that kind of something's wrong?"

And I think I suppose that's kind of why I try and think about how do we frame it in just understanding generally the developmental needs of a child, that this is one area that - and I suppose when you said then like what could help hesitancy, I think it's even thinking about what assessments perhaps that we do already that are routine and how do we introduce it. But this is just one aspect of development that we're here to partner with you and try and support and nurture and kind of come alongside you into trying to understand.

So, as I mentioned, you're not just raising it when there's a concern there, but it's just part of that routine conversation really. And I think in the same way that we think about infants or babies learning kind of physical developments and milestones, kind of talking about for infants, they don't have a template for emotions, they do rely on others to name and help them understand emotions and we can then open up a conversation around "So what can we do together to think about how we might support that?" How can we think about opportunities to help out - what can we notice in our child when they maybe are kind of got a need?

But it doesn't necessarily mean that anything's wrong but when they're trying to express an emotion, what do we notice in them and that curiosity about that and how can we help them to feel more secure and confident in exploring the world so that they kind of see that kind of to begin with that might be alongside a parent and feeling that that has to come from a place of safety.

So yeah, so I think trying to just, as we've talked about, just trying to make it part of routine conversations and I think the strength in that as well is that then if we, in our relationship with a parent or even if parents access support at other times, if we've kind of - this has been a part of normal conversations, then it makes it easier down to the track to kind of raise issues that we're wondering about because it's kind of already got a framework in our minds that emotional development is something that we can think about together.

ALI CHISOLM: Thank you.

CAROLINE WILLIAMSON: I hope that answered that, yes.

ALI CHISOLM: I like the idea of it becoming part of the routine, sort of developmental checks and being able to have those conversations. And also you've highlighted a couple of times about really building that - becoming an ally with the parent and it reminds -

CAROLINE WILLIAMSON: Yes, yeah.

ALI CHISOLM: - me of Tegan. Tegan, when you were speaking of building that relationship and being available and checking up regularly and starting to develop that relationship and getting to know all of what might be happening, if that's what a family are coming to, if they're coming with a few multiple sort of things happening and trying to understand the behaviour or what's happening, what's the emotion behind the behaviour. So it gives an opportunity just to have those conversations. Is it common to see symptoms of mental health challenges in infants for parents who are not experiencing their own mental health challenges or adversities or trauma?

CAROLINE WILLIAMSON: Yes, yeah. So I think often when I was thinking about that then, I think in my mind I went straight to I feel like that would be possible but I think I was then also reminded about thinking about that reciprocal nature of the relationship. Sorry if I've interrupted anybody else answering that. I kind of think about how the wellbeing in one kind of really impacts on the wellbeing of another that often when I see parents, if there is struggles with an infant's emotional wellbeing, if you like, then that really can the own parents' own continuum if it likes can really kind of affect how they're emotionally just into that and it could be a struggle and but it can be quite difficult to make sense of things. So that's not to say that they'll always be there together but I think we're very much kind of in tune, if you like, really in trying to equally support the parent as much as the infant in those occasions.

ALI CHISOLM: Thank you. We have another question here regarding sort of normal infant sleep and giving that wide and varied presentation of infant sleep, it's obviously there's a lot of variation in what is normal, how do you determine when there are some sleep issues becomes more of a mental health struggles or it's classed as typical? I wonder, Caroline, if you can answer that one.

CAROLINE WILLIAMSON: It's a good question because I think we often, you know, especially as a parent, we can become quite anxious if we're feeling that an infant's not getting enough sleep or kind of sleeping too much, so I think what I would probably try to explore, as well as kind of maybe giving information about what maybe sleep patterns we might notice with an infant and what routines that we might expect, but also kind of really try and understand again the parents' experience of that, kind of how much - is it an issue to them? Like, what's their struggle with that sleep?

I think that would help me to determine and understand infant sleeps a bit more about what's going on and how is this impacting on the parent or the family and kind of try and really understand and piece together the impact of kind of that sleep routine on all the family.

ALI CHISOLM: Thank you. Kristel,

KRISTEL ALLA: I'd like to add to that just my two cents that it's really about looking out for persistent sleep problems, things that happen over a long time and it's hard to give an exact time period, this is after - if your child hasn't been sleeping probably after one day or three days or weeks or months, or don't go into months... But it's hard to give an exact because it is not an exact science. All babies are different. So just look out for things that happen over a long time, don't let it get to too long.

ALI CHISOLM: Yep.

TEGAN: Also, if a parent has followed the parenting advice, like the parents information line or the GP and hospital's advice and that they have a good routine in place and healthy meals, and healthy play and engaging with their child, and if they're in doubt, they should always - and they've got all those things in place, they should always just ask, because generally, if you've done all of that and the child still isn't settling for hours and hours, obviously there's something else going on. Just ask, I guess.

ALI CHISOLM: Thank you. Yes. And the next question as well that's come in is do you have advice for practitioners when working with parents who are facing multiple adversities or come in when there's a lot going on, not just focused on sleep or you find out when you're exploring sleep there's actually a lot more coming. Do you have advice to practitioners on how to best support families when there's so much happening at the time?

TEGAN: Yeah, like to listen to the parents' initial concerns without an individual opinion or judgment and sometimes parents and caregivers who are facing multiple adversities in their life can be extremely overwhelmed and may actually need help working out what needs to be addressed first and in which order. And help them prioritise what needs attention first, what practical things need addressing. And it can be helpful for you to just listen and help them get clear and make sense of their own situation and just making the time to listen and map out a way forward through whatever is going on in their families, their lives really.

ALI CHISOLM: And that can be - it sounds like having that regular appointments and that engagement with them and the relationship with the clinicians can help that too, from what you've mentioned in your presentation, Tegan. Thank you.

CAROLINE WILLIAMSON: And I also was just thinking, Ali, just kind of to add to that because that kind of really resonated in kind of like you say, listening to and trying to understand the parents' circumstances. And I was also thinking, even in terms of building that relationship and engaging with parents, our connecting point might not be to begin with about infant mental health, it might be that we connect to support a parent that is facing some adversity in their life, kind of some housing or financial problem.

And if we can I suppose help them to support them in that and think about that and kind of get them the supports that they need, then that's kind of strengthening our relationship and partnership with a parent as well, but kind of then can then pave the way sometimes to some of those trickier conversations about how do we also think that this might be impacting in the family as well. So I think joining them and trying to think about and get some insight into the impact of those adversities on themselves and also on the family can be really helpful.

ALI CHISOLM: Thank you.

TEGAN: Can I just make one more suggestion?

ALI CHISOLM: Yeah.

TEGAN: I know this is a bit prior to a parent coming and saying, "I need help with sleep or stress" or whatever's happening at the time, but it would be really helpful I think if they set up something like they do with breastfeeding, you know, when you first have your baby. So just to understand all the aspects and they feel - make it comfortable so they can ask help, so it's not this scary thing, I'm struggling, I don't want to ask for help. No one wants to admit they're struggling, do they?

ALI CHISOLM: What a good initiative. What a good idea.

KRISTEL ALLA: Yeah.

ALI CHISOLM: Normalise needing to support breastfeeding, yeah. Good idea. So we have time for one more question before we wrap up. There's a lot of questions that have come in around people asking about tools. So what emotional wellbeing screening tools can practitioners use in practice for infant mental health? If anyone knows of any to share?

CAROLINE WILLIAMSON: So I can begin with kind of reflections of kind of thinking about what we use within a child and family health service and so within child and family health, they use an ages and stages questionnaire and interestingly, there's one specifically for social and emotional development. As a part of routine, we'll often complete the ASQ but it's not as routine to complete the ASQ social and emotional scale. So I think that can be useful.

I probably - when you mentioned then, Ali, about screening, I kind of felt like it would be perhaps - it is a screening but I thought actually also even just using that kind of tool, if you like, as a reflective tool, but it's not necessarily to screen is there a problem or is there not, but actually it being an opportunity to think about and just start that reflective conversation with a parent about social and emotional wellbeing. You know, what do we notice? Do we notice changes in sleeping that - so it not just being kind of a screen but actually a conversation starter or kind of support would be how I would encourage it to be used really.

ALI CHISOLM: Thank you. Thank you. And I'm just aware we're running out of time. I just want to acknowledge that there's been quite a few questions coming in around more specific questions, looking for some individual sort of support and we don't have scope for that today. I know that sometimes this can raise some reflections on our own experiences and families, so I just want to ensure that if - or mention that if you're looking for some additional support, there are trusted professionals such as your child maternal health nurse or your GP if you wanted to seek some more individualised support. And there's also online resources such as the PANDA website or Beyond Blue and so we'll include some of those list of resources as well as the parenting helpline, we'll include that in our resources today.

So thank you once again, everyone, for contributing and being part of the webinar. I'm sure many people have found that really valuable listening and hearing your experiences. Thanks also to the CFCA for your behind the scenes support and please follow the links on the screen and Emerging Minds website as well as CFCA to continue the conversation and find the recording and find those additional resources as well. So thanks, Kristel, Caroline, Tegan. Thank you.

TEGAN: Thank you.

CAROLINE WILLIAMSON: Thanks.

KRISTEL ALLA: Thank you.

WEBINAR CONCLUDED

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Slide outline

1. Understanding and supporting infant mental health

Kristel Alla, Caroline Williamson and Tegan 
CFCA Emerging Minds Webinar 10 November 2021

2. Understanding and supporting infant mental health

Kristel Alla, Caroline Williamson and Tegan

3. Learning outcomes

This webinar will support practitioners to:

• develop understandings of infant health and wellbeing that can underpin conversations with caregivers
• identify signs that infants might be struggling
• start useful conversations with caregivers around infant mental health and wellbeing.

4. Acknowledgements

We recognise and pay respect to Aboriginal and Torres Strait Islander peoples as the Traditional Owners of the Lands we work, play, and walk on throughout this Country. We acknowledge and respect their Traditional connections to their Land and Waters, culture, spirituality, family, and community for the wellbeing of all Aboriginal and Torres Strait Islander children and their families.

5. Webinar series

CFCA and Emerging Minds webinar series: Focus on infant and child mental health

Upcoming webinars include:

• Working effectively with Aboriginal and Torres Strait Islander families over the first 1,000 days of a child’s life

Previous webinars in 2021:

• Supporting children’s wellbeing when working with separating parents
• How to recognise complex trauma in infants and children to promote wellbeing
• Families and homelessness: Supporting parents and improving outcomes for children
• What is the social model of disability and why is it important in child mental health?

6. Housekeeping

• Send through your questions via the question box at any time during the webinar.
• All our webinars are recorded.
• The slides are available in the handout section on the webinar platform.
• The video, audio, transcript and presenters’ responses to additional questions will be posted on our website and YouTube channel in the coming week.

7. Presenters

• Kristel Alla 
  Knowledge Translation Specialist, Australian Institute of Family Studies
• Tegan 
  Family Partner
• Caroline Williamson 
  Psychologist, Child and Family Health Service SA
• Ali Chisolm (Facilitator) 
  Practice Development Officer, Emerging Minds

8. My family’s experience

• Premi twins with low birth weight, on oxygen
• Experiencing DV
• No stable housing
• Quite isolated
• High levels of anxiety and stress

9. From a parent’s perspective…

A parent’s mental health and wellbeing supports baby’s mental health and wellbeing!

We are setting them up for life.

There are everyday considerations.

10. Talking with parents about their baby’s wellbeing

• Listen to us
• Believe us
• Show empathy and be non-judgemental
• Have humanity
• Empower us with information and practical strategies

11. Supporting infant mental health

Keep in mind…

• There’s a lot of stigma
• It’s not always clear

Helpful supports and practices

• Support groups / Parent & Caregiver groups / Social groups
• Regular engagement and check-ins
• Practical supports that take away some of the stress
• Education and guidance for parents

12. Emerging Minds: Mental Health Continuum

Left to right arrow representing the parent-infant relationship

Thriving, coping, struggling, unwell, connecting with specialist services, exploration and support, promotion

13. Foundations to supporting Infant Mental Health

• Partnering with parents as the experts of their child’s life.
• Infant’s mental health as important as physical health to a child’s wellbeing.
• Questions about social and emotional wellbeing being a routine part of conversations/exploration with parents
  • Opening Qs: How would you describe your baby’s temperament?
  • How is your baby’s sleep/feeding? Are there any behaviours that worry you?
• Sharing what ‘good’ mental health might look like in an infant.

14. Foundations to supporting infant mental health part 2

The importance of parent-infant relationship:

• Opening Qs:
  • What do you enjoy most about your baby?
  • What do you least?
  • What’s it like for you when baby becomes upset?
  • What do you do?
• Supporting the parent – Are there any experiences/circumstances that might make parenting more challenging for you?

15. Foundations to supporting infant mental health part 3

• Discussing ways to support the parent-infant relationship/infant mental health:
  • Noticing and observing baby – ‘watch and wonder’
  • Support routines
  • Play/being-with activities
  • Connecting with community groups/supports

16. Supporting infant mental health part 2

• Notice behaviours that may be an indication of infant mental health struggle – e.g. sleep, feeding, responsiveness.
• Adopt a curious position when a parent presents with an issue (e.g. sleeping/feeding/crying) or if you want to raise/explore an issue with a parent 
   

–I’m wondering if we can spend some time thinking about this together a little more … when you first noticed … what you notice … what others have noticed … what helps and what doesn’t? What you think is happening? Etc.

• Understanding of child’s environment/context.
• Identifying risk and protective factors.

17. Supporting ‘reflective parenting’

• The behaviour is on the outside, the meaning of a behaviour is on the inside.
• A parent’s behaviour/responses are linked to something in their mind, and baby’s behaviour is linked to something in their baby’s mind.
• We can never know the mind of another, but we can be curious, we can wonder, we can infer:
  • Supports attunement
  • Develop empathy, compassion
  • Understanding to meet own and baby’s needs
  • Our behaviour and emotional state can influence another and vice versa.

18. Engaging other supports

• Identifying pathways to support
  • Parents (Mental health care plans, Family Services)
  • Parent-infant therapy
  • Child and Family Health services/Paediatricians
  • Community supports
  • Online resources – e.g. Raising Children’s network
• Ongoing support
  • Promoting infant wellbeing
  • Reflective conversations
  • Identifying strengths

19. Q & A Discussion

20. Feedback survey

Thanks for joining us.

A short feedback survey will pop up as you leave the webinar. If you could spare 5 mins to answer it, we would greatly appreciate it.

We will continue answering your questions offline and post this extra content online with the recording of the webinar.