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Ready to Relate – Themes from interviews with parents one to three years after having used the Ready to Relate cards with a professional

17 November 2020

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

Research summary

  • This paper shares the findings of a preliminary service evaluation of the Ready to Relate (R2R) resource cards intervention. The evaluation follows families who have had the R2R shared with them one to three years previously. 
  • The evaluation aimed to explore parents’ perceptions of the cards and the impact on their parenting. 
  • R2R includes a pictorial resource, sharing key messages about infants and the parent-infant relationship.
  • R2R information is intended to shift the narrative regarding babies, supporting prevention and contributing to buffering against adverse childhood experiences by effectively sharing knowledge with families that supports attuned parent-infant relationships and sensitive parenting. 
  • Families have reported finding joy, excitement and pleasure in their parenting, which information from sharing the R2R cards has enhanced.
  • Families also demonstrated that they recalled the information and reported changes in their parenting with their infant and subsequent children.

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. National training was minimal 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.

Babies are amazing. Babies are relational others. Babies are people. 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.

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.

Table 1: Demographics of parents interviewed


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.’

Mother 1 explains: ‘You said, oh look –this is what you can do with your child like from very early on like – I think if I missed that crucial part; like if you were not telling me I wouldn’t have really known how brains develop.’ 

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). 

The importance of oxytocin was remembered and appreciated, as Mother 2 explains: ‘Right, yeah, and these are good hormones [points to oxytocin card] and obviously when baby’s happy… which I found useful.’

Mutual gaze had also been recalled and this was particularly valued by parents. Mother 2 recalls: ‘You know the eye contact – I’m sure there is a card in here looking into your baby’s eyes, and having that connection of how the brain’s developing…. I remember you saying that when the baby is looking at you and you’re staring and you’ve got that bond, you know, straight away, that bond.’  

Excitement and revelation

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. The tone of voice emphasised the enthusiasm alongside the spoken word. 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.’

Parents gave the impression of the cards being empowering. For example, Father 1 explains: ‘I think all of the cards are really, really important to know about’ and showed how he had taken forward his understanding from the cards and given value and meaning to these interactions, such as: ‘Then when you understand that this kind of looking and talking to your child is developing them it gives you more than to do.’ 

Mother 2 shared: ‘And it was really important that I actually knew that as a parent, and [pause, louder tone] the cards were really helpful because I just went and did it myself, like.’

This latter quote emphasises the liberation and ownership this parent experienced and the influence on her parenting.

Parents 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. 

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 – I love it! [very excited tone] so I do it more [happy expression]’ (Mother 2). 

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: ‘They’re very short, very informative. 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.’ 

This father has highlighted that he did not have any prior knowledge regarding the parent-infant relationship and was enthusiastic to share this with others he could identify with. 

Recognising the lack of knowledge and the struggles mothers can experience, Mother 2 stated: ‘I think loads of mothers don’t know what to do or bond with their babies, they think a baby is a baby who doesn’t understand, but the baby does, every time you hug them they know they’re being loved, even if you talk to them the baby knows you’re interacting in a sort of way.’

In this quote, Mother 2 also expresses a sense of her understanding of the baby as a participant in the interaction and the importance of repeated, positive interactions. 

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.’

Providing knowledge to parents may have a ripple effect of enhancing knowledge across communities, as Mother 2 illustrates: ‘I was talking to my friends who had babies and I said, do you know about their brains – how quickly they develop?’

Changed parenting behaviours 

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.

Talking to the baby more/looking at baby /picking up baby more/reading baby a story – each of these give the impression of active engagement with the infant due to the information. Parents identified mutual gaze as important, and 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 cos I can understand him and we are communicating more.’

The information provided permission to rebel against advice discovered online, as Mother 2 shares: ‘So I don’t believe what it said on the internet to leave them for two minutes or five minutes, cos leaving them they’re releasing the more bad hormones, we want the good hormone oxytocin… so when you showed me the cards well that’s what I do I cuddle them I hug them , they go quiet they know, want reassurance that someone’s there.’

Understanding my baby

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 2 described her baby as one with their own likes and dislikes. She prepared food she liked for the baby, and understood he did not, and noted: ‘He didn’t like it, but I do.’ 

She identified that she adapted her parenting to meet the needs of her two children as individuals, realising that they had their own personalities: ‘… but I’ve noticed they’re two different people, so there’s that as well that I’ve learnt, even though they’re brothers they’re both different, they sleep differently – I’ve learnt that they’re a different child.’

This understanding related to parents identifying that they communicated with their baby more: ‘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 cos I can understand him and we are communicating more.’ 

The understanding invited the parents to give greater attention to the babies, as Father 1 says: ‘But then when you understand that this kind of looking and talking to your child is developing them it gives you more that to do more with them.’ 

There was a sense that parents valued themselves more as they realised their babies needed them. 

Understanding the baby suggested a benefit to the parent in regards to energising them to keep going as it would be worth it, as the following comments suggest:

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’ (Mother 2).

‘When you understand that this kind of looking and talking to your child is developing them it gives you more that to do more with them they develop’ (Father 1). 

Mother 2 also shares: ‘When I hug him when he was a baby, or my second, he goes calm then I calm down, so were both in that same state.’

The above quote indicates an awareness of the mutual regulation cycle that is experienced by mum and baby. 

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.’ 

She then goes on to realise the continuation of this after birth: ‘But when they’re born it’s really important you give them that sort of attention as well.’ 

Mother 1 also shares how parent’s increased knowledge can be exciting and motivating: ‘Somebody comes and refreshes your brain and you think, oh, I need to keep going and develop your child.’ 

Given that parenting can be exhausting and challenging for parents, to appreciate the value of their relationship with their baby may be of particular importance. Mother 1 realises: ‘They’re taking everything in, their brains are taking everything in. When they’re very young you need to be there for them, I know you’re going to be doing so many other things like washing bottles or cleaning this or doing other things in that time you really need to make sure that you’re there for the baby.’ 

Companionship

The parents appear to have become aware of the infant’s need for companionship (Trevarthen, 2005). The data conveys that the experience of companionship with their infant brings meaning and pleasure to the parents. 

I like that cos I can understand him and we are communicating more’; ‘and sometimes he holds my hand and just stare at me and I know it’s that bond we are getting, I feel loved more, and I am sure he is as well’ (Mother 2). 

Companionship is demonstrating the reciprocity of the relationship and mutuality, reflected here again by Mother 2: ‘so you can see its two ways, yes two ways.’

Mother 2 reflects: ‘Sometimes he holds my hand and just stares at me and I know it’s that bond we are getting, I feel loved more, and I am sure he is as well.’ 

And: ‘Yeah, still a baby and I am still learning loads from him. He’s obviously still learning.’ 

Mother 1 goes on to say: ‘Then they wake up and then you just leave them there and they’re just lying there but that’s the crucial part, that’s the time you can start engaging with your baby you can actually hold them close to you, you can look into their eyes.’
 


Discussion

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. 


Recommendations

The families interviewed for this evaluation are of south Asian ethnicity. Although this is small pilot evaluation, the voice of this community is often under-represented and the results of these interviews are promising, indicating that further research should be pursued with a larger and diverse cohort of participants.  

R2R appears to support making every contact count, enhancing the delivery of key messages by way of a shared conversation with a trained practitioner and supported by an accessible visual stimulus. The key messages are evidence based and embedded into leading programmes such as the Healthy Child Programme (Department of Health, 2009) and 1001 Critical Days (Wave Trust, 2014). The R2R resource lends itself to enhancing universal work, and also as a simple accessible intervention when additional need is identified to support families’ understanding of their baby. It can also be used with ease alongside any other existing programmes. The resource’s versatility due to its pictorial nature enables a non-prescriptive and empowering approach, allowing families alongside the professional to share information together. Feedback from interpreters highlights the pictorial element as an aide to sharing information when spoken English is not the main shared language. 


Conclusion

Knowledge around the parent-infant relationship belongs to the families – it is the parents (or main carers) who have the most profound impact on the developing infants’ mental health. The R2R resource enhances sharing information, and can be used by any professional working with families with infants, in a way which is valued and enjoyed by families, which in turn supports building stronger relationships and infant mental health.

Jane Dickens is strategic breastfeeding lead and Lisa Milne is clinical lead of the Specialist Mother and Baby Mental Health Service at Bradford District Care NHS Foundation Trust. 


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.

Department of Health. (2009) Healthy child programme. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf (accessed 5 November 2020).

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).

 

 

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