Ready to Relate: Parent interview themes

November 2020

Jane Dickens and Lisa Milne evaluate an intervention using Ready to Relate parent-infant relationship resource cards with parents.

Perinatal mental health costs an estimated £8.1bn per annual cohort of infants, with 72% of these costs related to the infant (Bauer et al, 2014).

Supporting the parent-infant relationship is therefore an important aspect of perinatal mental health care. NICE (2014) recommends assessing the mother-baby relationship and providing associated information. Not all parents need intensive parenting programmes; indeed it has been found that less can be more in regard to parenting interventions and that improving parental sensitivity is more effective than focusing on attachment per se (Bakermans-Kranenburg et al, 2003). More recently, it has been suggested that an effective way of improving parenting and outcomes for infants is to support parents to better understand them (Meins, 2017).

The Ready to Relate (R2R) parent-infant relationship resource cards intervention has been designed to support practitioners working with families to embed key messages around infant mental health and the parent infant relationship.

Two initial pilot evaluations have been reported previously. The first focused on professionals’ perceptions of the resource, the second on mothers’ immediate impressions of a R2R intervention, whereby a practitioner would use the cards as a tool to facilitate a shared discussion about infants. Parents’ feedback regarding the intervention was wholly positive on both accounts.

However, it is important that interventions have a sustained impact (Asmussen et al, 2016). Previous research has suggested that gains from interventions are not necessarily maintained (Barlow et al, 2015).This report shares the findings from three in-depth semi-structured interviews with parents who had been shown the R2R cards one to three years prior to the interview and identifies emerging themes.

Background: R2R cards and model

The idea behind the R2R resource cards and delivery model began in 2015 when a group of interested health visitors and the perinatal mental health lead identified a gap in service. Although there was a growing recognition of the need for more structured perinatal mental health training and support, HVs had no structured way of recognising the key components of secure attachment or of the parent-infant relationship. Training nationally was scanty around this topic, although strong evidence was emerging around 1001 critical days (Wave Trust, 2014). A general lack of knowledge was identified among professionals, and families, around the importance of the parent-infant relationship and seeing the baby as a relational other.

If we are to build a relationship with our babies that is attuned and sensitive, and which enables the parent to protect the infant from toxic stress, the parent must first perceive the infant as a relational other, a person that they can be in a relationship with.

However, the dominant discourse remains of the infant being unaware, who simply cries, feeds, wees, poos and sleeps – a passive being until older (Milne, 2018).

The essential first step that is the foundation of attuned, mind-minded, sensitive parenting is to change the narrative. We need our practitioners, families and communities to perceive our babies as people, and our services need to be able to support this in every intervention and contact across the spectrum of services. By increasing our understanding of infants’ capacities, we will be better able to make sense of their intentions and behaviours.

Changing the narrative

The fundamental aim of the R2R model was to change the narrative about babies to seeing babies as people, born ready to relate and seeking companionship. The R2R model consists of training, the resource cards, champions, consultation and evaluation.

Training

Training was essential. The parent-infant relationship training was developed in 2016. This was initially aimed at health visiting team members, and also relevant and accessible to any professional working with families, such as midwives, children’s social care, children’s centre staff, or perinatal mental health teams. The training is delivered in three sessions:

1. Basic neurodevelopment, and ‘Babies are ready to relate’
2. Emotional regulation, attachment and assessment, key components (mid-range contingency, maternal sensitivity and mind-mindedness
3. The role of the parent, infant cues and observation, basic interventions and case studies.

This training provides a firm foundation for practitioners, enabling them to gain a far deeper understanding of the parent-infant relationship, and how they can put this knowledge into practice, offering a buffer against escalation to a higher tier of need.

Resource

In order to embed the training into practice, a resource was required – a visual resource was thought to be the most effective. The pictorial element of the resource was deemed essential for it to be accessible across cultures and a valuable tool when working through interpreters. The original team used pictures of family and friends.

The R2R resource cards evolved: they were intended to be used both independently or as a complementary tool alongside other interventions, enhancing information sharing. The R2R resource may be used by any practitioner who has a foundational understanding of the parent-infant relationship.

The information held within the R2R resource cards and the parent-infant relationship training is based on evidence and brings it to the people who really matter – the families.

Participant	Age	Ethnicity
Mother 1	30-35	South Asian
Mother 2	25-30	South Asian
Father 1	30-35	South Asian

Evaluation methodology

This study aims to investigate parents’ responses to R2R and the impact of the R2R cards on their understanding and perception of their infants and parenting.

Three parents were revisited one to three years after the HV had shown them the R2R with their first child. The mothers had originally seen the cards at two weeks, six weeks, and three to four months. The father was introduced to the resource when the infant was nine months. They had not seen the resource since that occasion. All three had had a subsequent child and two were expecting their third child.

Semi-structured interviews, lasting about 20 minutes, were carried out in the parent’s home and were videoed with the parent’s consent. Ethical approval was not required because this was a service evaluation.

Results

Each of the participants remembered the resource and the messages contained, and the conversation with the HV. Furthermore, they also identified the impact that the resource had on their understanding of their infant and consequent changes to their parenting. The change was sustained, according to the parents, in the parenting of subsequent children.

The use of the R2R resource had a positive impact on participants’ parenting and helped them to understand their baby.

Themes

Recall

All the participants strongly remembered the R2R resource, over one year post-intervention. The memory of the resource was interlinked with the accompanying discussion that the parents had with the HV and it may be that the visual tool helped families retain the information. Research has suggested that memories are more strongly made when supported by multisensory experiences (Lindner et al, 2009). These parents experienced being engaged with their HV, the verbal discussion and the visual stimulation of the R2R resource which facilitated the conversation. The information that parents recalled was connected, by parents, to changes in their understanding of their infants, their parent-infant relationship, and parenting.

It is important to note that R2R intervention includes the R2R cards being used as a catalyst for a shared conversation with the trained practitioner. The following quote emphasises how the cards and conversation are kept in mind by the mother: ‘So, I remember seeing that from the cards – so every time I do contact with the little one it reminds me of what you told me’ (Mother 2).

As well as remembering the cards generally, parents volunteered information about mutual gaze, babies’ development, how to engage with their baby, the hypothalamus-pituitary-adrenal (HPA) axis, crying, neurodevelopment, and the importance of being responsive.

Neurodevelopment

Parents particularly reported recalling and valuing information regarding the neurodevelopment of the infant. For example, Father 1 said: ‘I think the brain development, that was really important, it did give me this help, because through each of these stages, this is how the brains are developing.’

Parents were interested in the detail shared: ‘The synapses – that’s the one that just stayed with me. I like the way it actually shows you on the cards, the little pictures about the brain cells’ (Mother 1).

One overwhelming theme was parents’ excitement over their recall of information from R2R. It seems that there is a thirst for knowledge among parents wanting to understand their babies. Mother 1 reported: ‘I think if I missed that crucial part – like if you were not telling me – I wouldn’t have really known how important and just bonding with your child [is].’

Parents were excited by new knowledge. Mother 1 shares again: ‘Hang on a minute, this is something that I didn’t know about.’

They reported a sense of revelation in receiving information about the potential impact of their relationship with their child on their child’s development. For example: ‘Oh my goodness, really, did the brains develop since they’re born till [they are] 3, and the cells – it’s just crazy’ (Mother 1).

Parents could convey a sense of a profound and transformative relationship with their infant. Father 1 used the word ‘spiritual’: ‘I think that was really good and informative and I think spiritual – and the connection you’ve got with your baby.’

Positive words

Parents used words such as ‘love’, ‘pleasure’, and ‘really good’ to convey the effect of their increased insight into the parent-infant interaction. Mother 2 shared her joy in the following two quotes: ‘There was another one, eye contact, mother and baby. Oh, I loved that’ and ‘So you know, I love doing that, I used to do it with him, and I do it with my second one now.’

The pleasure has inspired repetition of certain interactions, suggesting a change in parenting based on positive experiences.

Sharing with others

When talking about R2R and the information they took from this, parents wanted to share what they had learned with others. For example, Father 1 said: ‘I think that will help quite a lot of families, you know, especially if you’ve got no experience similar to myself – I didn’t have any experience of understanding about these kind of things.’

Mother 2 explained that R2R helped her make sense of new information as she was receiving conflicting information from the older generation: ‘This generation is different, so I think these should be used with the new generation.’

Changed parenting behaviour

Excitingly for practitioners, the results indicate that the use of R2R has contributed to positively changing parenting behaviours. Parents volunteered a number of ways in which they connected the information from R2R to changed parenting behaviours.

Father 1 describes the pleasure it gave him: ‘Obviously it is important to pick them up but then when you understand that this kind of looking and talking to your child is developing them, it gives you more.’

The change in behaviour was maintained in Mother 2’s parenting of subsequent children: ‘So you know, I love doing that, I used to do it with him, and I do it with my second one now. And I like that ‘cause I can understand him and we are communicating more.’

Understanding

Parents described a greater understanding of the babies, as Father 1 identifies: ‘I think and believe that having an understanding regarding parenting and regarding the mental development of your children and the connection with the bond I think is very important.’

This understanding was related to them making new sense of their babies. For example, Mother 2 described that her baby cried for a reason: ‘I didn’t know, it made me do it more [cuddling and picking up] the more he used to cry I thought oh he’s releasing bad hormones so I better give him a cuddle, so I would go to him. And obviously that helped because I am doing it again [with second child].’

Mother 1 realises that her baby was already aware of her before birth: ‘They can actually recognise you and even [when] you’re speaking to them – like when they’re in the stomach – they can probably hear you and such.’

Conclusion

The parents all reported that the use of the R2R resource had a positive impact on their parenting and helped them understand their baby. They reported pleasure in their relationship with their infant, and value in their parenting, which they connected to the information they took from the R2R resource.

That parents both recalled the cards and identified the positive impact of the cards on their relationship with their infant and that their parenting is exciting. R2R is a simple intervention that supports practitioners in providing efficient and effective conversations with parents, which appears to have a sustained positive impact. The results may not be surprising in the light of analysis that has indicated that less intensive interventions may be successful (Bakermans- Kranenburg et al, 2003). This is an intervention that is easy to apply in a wide variety of settings, including health visiting and mental health.

It is not clear from the evaluation why the R2R intervention was as effective as it appears. It may be that the experience of a shared conversation that is positive and exciting, delivered face to face, with interesting accessible stimulus was key to its impact.

The R2R resource is a simple intervention tool that supports practitioners to provide efficient and effective conversations with parents, which have a sustained positive impact in regards to their parenting behaviours, perception of and relationship with their infant.

Although this is a small pilot study with south Asian participants, the results of these interviews are promising and indicate that further research should be pursued with a larger and more diverse cohort of participants.

References

Asmussen K et al. (2016) Foundations for life: what works to support the parent-child interaction in the early years? See: bit.ly/EIF_foundations_for_life (accessed 29 October 2020).

Bakermans-Kranenburg MJ et al. (2003) Less is more: meta- analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin 129(2): 195-215.

Barlow J et al. (2015) Parent-infant psychotherapy for improving parental and infant mental health. Cochrane Database of Systematic Reviews 1: CD010534.

Bauer A et al. (2014) Costing perinatal mental health and understanding cost effectiveness: a research project Oct 2013 – Sept 2014. London School of Economics: London.

Lindner K et al. (2009). Visual versus auditory learning and memory recall performance on short-term versus long-term tests. Modern Psychological Studies 15(1): 6.

Meins E. (2017) Overrated: the predictive power of attachment. The Psychologist 30: 20-4.

Milne E et al. (2018) The mother-infant bond: a systematic review of research that includes mothers’ subjective experience of the relationship. Community Practitioner 91(7): 45-7.

NICE. (2014) Antenatal and postnatal mental health: clinical management and service guidance. See: bit.ly/NICE_CG192

Trevarthen C. (2005) ‘Stepping away from the mirror – pride and shame in adventures of companionship’ – reflections on the nature of and emotional needs of infant intersubjectivity. In: Carter CS et al (eds). Attachment and bonding: a new synthesis. MIT Press: Cambridge, MA.

Wave Trust. (2014) The 1001 critical days: the importance of the conception to age two period. See: bit.ly/WT_1001 (accessed 28 October 2020).