University of Oxford

Today, the Institute of Health Visiting (iHV) is delighted to share the overwhelmingly positive findings from their mixed-methods feasibility study into the use of the Alarm Distress Baby Scale (ADBB) in routine health visiting practice in England.

The study, commissioned and funded by The Royal Foundation Centre for Early Childhood, was conducted in partnership with Professor Jane Barlow from the University of Oxford. It sought to explore how acceptable and feasible health visitors found using the baby observation aid, the ADBB, and its shorter modified version, the m-ADBB, during their routine 6-8-week visits to families.

During the ten-month study, health visitors trained in the ADBB and m-ADBB were recruited from South Warwickshire NHS Foundation Trust and Humber Teaching NHS Foundation Trust. Quantitative and qualitative data were collected over a four-month period, during which the trained health visitors used their enhanced skills and knowledge to observe babies’ behaviours and interactions and identify those in need of a more thorough assessment or additional support.

Health visitors described the ADBB approach as “hugely beneficial” and “of great importance” to their practice. Findings demonstrate that both training programmes (ADBB and m-ADBB) were rated highly by all study participants, giving a new theoretical perspective, additional knowledge and skills, and a new vocabulary for explaining their observations of a baby’s behaviour. The use of the shorter validated 5-item version of the scale, the m-ADBB, was found to require minimal additional time and was considered easy to embed into routine health visiting practice (for example, the observation could be undertaken when parents were undressing their baby, or the baby was being weighed). Using the m-ADBB in this way enabled health visitors to:

Have more meaningful conversations with parents and carers about the emotional wellbeing of their baby;
Promote positive parent-infant interactions, attachment, and bonding; and
Identify those babies and families in need of greater support during this critical period of development.

Dr Jane Barlow, Professor of Evidence Based Intervention and Policy Evaluation at The University of Oxford, who oversaw the evaluation of the trial said:

“Babies are born with amazing social abilities. They are ready to relate and engage with the world around them, communicating how they feel through their behaviours.

“Whereas previous approaches have focused on the parents’ perspective, this training has really helped health visitors to ‘read’ the baby during interactions and develop greater sensitivity in terms of the observation of potential attachment and bonding issues that would not have been identified without the training.

“The feedback from those involved has been overwhelmingly positive. It is truly exciting to think about the impact this could have on families right across the country as we enter the next phase of this research.”

Alison Morton, CEO of the Institute of Health Visiting, said:

“Babies can’t talk, but there is now good evidence that they can communicate their experiences of the world around them when we tune in to their behaviours. We are therefore delighted by the positive findings from this study which found that the modified ADBB tool was very workable within universal health visiting practice, providing an important new way for health visitors to observe babies interacting with the people around them. There are many reasons why a baby might be distressed or withdrawn. Spotting these problems as early as possible is important as it will enable health visitors to work with families to ensure that they get the right support and babies can thrive.”

During the study period, health visitors identified behavioural concerns in 23 (10%) of babies as a result of using the m-ADBB. Health visitors were then able to work with families to explore the many possible reasons for this and determine the most appropriate next steps. All identified families were offered additional support, ranging from follow-up visits, emotional wellbeing visits and video interaction guidance (VIG) as well as connections to Child and Family Centres and referrals to Specialist Perinatal Mental Health and other local support services where indicated.

Conclusions and next steps

The quality of interactions that a baby has with their parent or caregiver is associated with their long-term development outcomes. Health visitors have a key opportunity in their routine contacts with families to promote optimal parent-infant interactions and identify emerging concerns. However, assessing these interactions can be quite complex, requiring a robust theoretical understanding as well as sound clinical observational skills.

The ADBB training introduced health visitors to the concept of social withdrawal – a coping mechanism that babies may use if they are experiencing some sort of stress in the environment around them. The additional understanding gained from observing babies’ behaviour from this perspective sat very well alongside health visitors’ existing skills. It helped them to consider how babies let us know they are ‘here, and engaging with the world’ and identify where additional support may be needed.

Executive Director of The Centre for Early Childhood, Christian Guy, said:

“The quality of the relationships between babies and their parents or carers, during the first weeks and months of life, shapes their developing brains and lays the foundations for their future health and wellbeing. So, it is vital that we provide families with the best possible advice and support at this crucial time.

“The results of the initial phase of testing are so encouraging. We now want to move quickly to ensure we build on this work, bringing the benefits of this model to more health visitors across the country so that, ultimately, more babies and their families get the support they need to thrive.”

In light of the positive findings of this study, the report includes recommendations for a second phase of research and evaluation of the tool in the UK context. In addition to several suggested research strands, consideration should also be given to:

a UK-based training programme with amendments to the training to align with the UK context, incorporating the training improvement recommendations from this study
Evaluation of the impact of training in more health visiting sites across the UK
Support systems for health visitors if ADBB/m-ADBB are adopted within health visiting practice, to include continuing professional development, supervision, learning resources and practice opportunities

The iHV, in partnership with the University of Oxford, would like to express its sincere thanks to The Royal Foundation Centre for Early Childhood for funding this important study and for their support and oversight throughout the study period.

Training in the ADBB and m-ADBB was kindly provided by Alexandra Deprez and Jocelyne Guillon of Humagogie training centre. Further details can be found at adbb-scale.com.

To read the full report and recommendations click here

To cite this report , please use the link to the pdf here: https://bit.ly/4a7z2hT

The research team would like to acknowledge the governance and guidance of the Expert Advisory Group:

Alison Morton (Chair) – Institute of Health Visiting
Dr. Sarah McMullen – The Royal Foundation Centre for Early Childhood
Hannah Sereni – Start for Life Unit
Wook Hamilton – Parent-Infant Foundation
Professor Crispin Day – South London and Maudsley NHS Foundation Trust
Lynne Reed and Wendy Nicholson – Office for Health Improvement and Disparities
Sarah Muckle – City of Bradford Metropolitan District Council, Director of Public Health
Professor Carl May – London School of Hygiene & Tropical Medicine

And the dedicated health visitors, managers and research departments at the Humber Teaching NHS Foundation Trust and South Warwickshire University NHS Foundation Trust who participated in the study.

Watch Sky News article: ‘Overwhelmingly’ positive results for trial funded by Princess of Wales as part of early years work

Oxford University study recommends commissioning of Specialist Health Visitors in Perinatal and Infant Mental Health throughout UK to tackle growing social cost issue

Oxford University has published research examining the training and qualifications of Specialist Health Visitors in Perinatal and Infant Mental Health (Sp HV PIMH), and their role in supporting health visitors and families at risk of /or experiencing mental health problems during the perinatal period.

The report recommends that Sp HV PIMH should be commissioned throughout the UK to tackle this issue, which has an extremely high social and financial cost. Currently, Sp HV PIMH constitute just 0.8% of the health visiting workforce (in England). The Oxford research found that in some areas Sp HV PIMH posts had never been funded, and in other areas the funding had been discontinued or cut – these were cited as the biggest barriers to the promotion of perinatal and infant mental health.

Perinatal mental health issues can have a devastating impact on women and their families, and results in a financial cost of £8.1 billion for each one-year cohort of births in the UK, with 72% of this cost relating to adverse impacts on the child. As such, maternal and family mental health has been designated as one of six high-impact areas for the health visiting workforce.

Abigail Reynolds, a mum with lived experience, shared:

“I was diagnosed with severe Anorexia Nervosa in early 2019, when I was seven months pregnant with my second child. The past three years have been unimaginably challenging, but my health visitor‘s support throughout my illness and recovery has enabled me to rebuild my life, to learn how to care for myself as well as my children – and to believe I am worthy of that care – and to gain the confidence to begin using my personal experience to help educate and support others in both the eating disorders and perinatal mental health areas.

“Health visitors are so well placed within the community, and have a unique opportunity to build trusting relationships with the whole family to support family mental health – they are a vital part of the system.”

The study surveyed 41 Sp HV PIMH and 3 Perinatal and Infant Mental Health Champions, who described their casework as focusing on areas such as parental antenatal depression, antenatal anxiety, general anxiety, birth trauma, postnatal depression and panic attacks, using a range of interventions including listening visits and motivational interviewing amongst others.

Survey respondents reported current barriers to the promotion of PIMH as being a lack of funding (82.3%) and a lack of understanding among commissioners about PIMH (64.7%) and the role of HVs in PIMH (73.5%) – with the discontinuity in funding that has occurred over recent years being perceived to have led to a constant need to reinvent the wheel.

Melita Walker, Head of Mental Health at the Institute of Health Visiting, said:

“We welcome this timely report which clearly sets out the important role of Specialist PIMH Health Visitors. Health visitors have a key role in supporting good family mental health. However, even before the Covid-19 pandemic, there were many system challenges to ensuring that all families had access to the right care at the right time. So this year, more than ever, the time has been absolutely right to have a focus on leadership – the role of the Specialist Health Visitor in Perinatal and Infant Mental Health and how a well-resourced health visiting service, as part of the PIMH system, can maximise the opportunity for good family mental health and wellbeing.

“The timing of this report fits very well with priorities for family mental health and the Government’s recent commitment for PIMH in the last budget. Its recommendations echo what national think tanks, such as the Maternal Mental Health Alliance and the First 1001 Days Movement, are campaigning for and provides policy makers and commissioners with sound evidence to improve family mental health through an effective health visiting service.”

Download Specialist Health Visitors in Perinatal and Infant Mental Health (Sp HV PIMH) Report