The International Journal of Psychosocial Rehabilitation

‘Building Babies Brains’: A mental health program
for promoting parenting skills for parents of ‘at risk’ children.

Dr Pam McGrath, B.Soc.Wk., MA., Ph D

 Director International Program of Psycho-Social Health Research (IPP-SHR)
Centre of National Research on Disability and Rehabilitation Medicine
Griffith Health Institute LO5, Level 1 Logan Campus Griffith University Meadowbrook
 Qld 4131 Queensland, Australia Postal Address:
PO Box 1307 Kenmore Qld 4069 Australia
E-mail: pmcgrathgu@gmail.com or p.mcgrath@griffith.edu.au


Ms Nicole Rawson-Huff, BSc (Hons)

 Project Officer
 International Program of Psycho-Social Health Research (IPP-SHR)
 Centre of National Research on Disability and Rehabilitation Medicine
Griffith Health Institute LO5, Level 1 Logan Campus Griffith University Meadowbrook
Qld 4131 Queensland Australia Email: nicolelhuff@yahoo.com.au


Mr Hamish Holewa, B. Sc (Comp Sci), B Ed, GradDipHEcon

Research Associate
Institute of Health and Social Science
CQUniversity
Brisbane Campus
160 Ann St
Brisbane Q 4000
AUSTRALIA Email: h.holewa@cqu.edu.au



Citation:
McGrath P, Rawson-Huff N & Holewa H (2012). ‘Building Babies Brains’: A mental health program for promoting
parenting skills for parents of ‘at risk’ children. 
International Journal of Psychosocial Rehabilitation. Vol 16(2) 106-113

Acknowledgements
The authors would  like to thank the many participants who gave their time and insights to this research project. The authors would also like to thank Mr Neil Alcorn & Ms Teresa Vant and the staff at the Mater Parent Aide Unit, Mater Hospital. The authors wish to acknowledge team members that contributed to this report, including: Ms Mary-Anne Patton, Ms Bo McGrath, Ms Elaine Phillips & Mr Michael Bouwman.The authors acknowledge the support of the Institute of Health and Social Sciences and the Faculty of Sciences, Health and Engineering, CQUniversity and Centre of National Research on Disability and Rehabilitation Medicine, Griffith University.



Abstract
The Building Babies’ Brains (BBB) program aims to educate new parents, particularly parents of children considered psychologically ‘at risk’, about the vital impact their interactions have on their child’s brain development and mental health. BBB offers a comprehensive support package which includes recruitment into the ‘Getting to Know You’ (GTKY) parent education workshops, 12 months Mater Aide follow-up support and 18 months subscription to Noah’s Ark services. This paper presents research findings on an evaluation of the GTKY workshop that indicates that such a program has the potential to be a significant proactive mental health initiative for parents and infants.  Factors associated with positive outcomes include the provision of social support and normalisation of the parenting experience, self-esteem and confidence building through networking with peers, self expression in a non-judgemental group environment, and parental education through information provision. Limitation and suggestions for further developments of the program are included. The hope and expectation is that the findings will help encourage the further development of such programs elsewhere.
Keywords: Mental health, rehabilitation; parents; infants; psychosocial; communication.


Introduction
As Bayer and associates (2007) note, mental health problems are a public health issue affecting as many as 20% of children in modern communities. The quality of parent-infant communication has long-lasting effects and is seen as an important factor associated with the mental health of the developing child (Hotelling, 2004). Attachment studies of families at social risk demonstrates that disorganized attachment behaviours in infancy are important precursors to later psychological and mental health disturbances (Baradon, 1999; Lyons-Ruth et al., 2006).  This early vulnerability is related to patterns of parent-infant affective communication observable by the end of the child's second year. Thus, interventions that promote positive parent-infant interactions are noted as strategies that can help to reduce the risk of poor developmental outcomes for the child (Leitch, 1999). Literature indicates that good infant mental health places the child at a lifelong advantage for sound teenage and adult relationships.

The Building Babies’ Brains (BBB) program aims to educate new parents, particularly parents of children considered psychologically ‘at risk’, about the vital impact their interactions have on their child’s brain development and mental health. BBB offers a comprehensive support package which includes recruitment into the ‘Getting to Know You’ (GTKY) parent education workshops, 12 months Mater Aide follow-up support and 18 months subscription to Noah’s Ark services. This paper presents research findings on an evaluation of the GTKY workshop, independently conducted by the International Program of Psycho-Social Health Research (IPP-SHR), that indicates that such a program has the potential to be a significant proactive mental health initiative for parents and infants. 

The Building Babies Brains (BBB) Program

The Mater Parent Aide Unit (MPAU) at Mater Children’s Hospital, Brisbane, Australia, in conjunction with Noah’s Ark Children’s Resource Centre has been conducting a pilot project titled, ‘Building Babies Brains’ (BBB). BBB aims to educate new parents, particularly parents of children considered psychologically ‘at risk’, about the vital impact their interactions have on their child’s brain development and mental health. This is in response to peer-reviewed recognition of the need to promote emotional availability and secure attachment during a baby’s first 12 months of life (Berlin & Cassidy, 2001). As Hotelling (2004) details, educational strategies are now available to facilitate and improve the basis of effective communication for parents and their infants. BBB is a support and education package based on presentation and discussion of a training DVD delivered to new parents who have been referred to the Mater Parent Aide Unit from the Community Hospital Integration Nurse and who have difficulty being ‘emotionally’ available to their newborn. The program offers enrolment in the ‘Getting to Know You’ (GTKY) workshops, 12 months support services offered by the Parent Aide Unit and membership to Noah’s Ark play group.

The GTKY  workshops are run over a 7 week period and are designed to educate and support new parents who have difficulty being ‘emotionally available’ for their newborn. The program teaches parents to recognise and respond more appropriately to their infant’s earliest communications, including:  enhancing the infant’s brain development, promoting emotional wellbeing and facilitating the development of ‘secure attachment’. The program is offered to 4 groups of parents over a 12 month period and started on the 21st of July 2008. The GTKY program has been designed and developed by the NSW Institute of Psychiatry. Theoretically the GTKY workshops are based on the Transactional Model (Sameroff, 1975; Sameroff & MacKenzie, 2003) that respects the dual contribution to the child’s development of both nature and reaction to events in the environment. In the Transactional Model the infant is perceived as developing in maturational sequences fostered or hindered by their relationship to significant others responsible for physical, emotional and social support.  The GTKY program recognises the value of early interaction to brain and behavioural development through an understanding of a phenomenon known as ‘neural plasiticity’, which is a process by which experience is incorporated into the structure of the brain. As detailed by Nelson and Bosquet (2000), neural plasticity means that both positive and negative experiences can alter the structure and function of the brain, and as a consequence affect cognitive, social and emotional functioning during infancy.

Methodology
The study was an evaluation of the GTKY workshops based on a qualitative methodology.  Human Research and Ethics Committee approval was obtained from both hospital and university HREC prior to commencement of data collection and full consent obtained from participants. The data collection was conducted at CQ University and analysis and write up completed at Griffith University.

 Interviews were conducted after the participants had completed the course.  The program evaluation focused on the individual positive and negative experiences with the program and the perceived changes that participants experienced in their parenting skills, relationship with their infant and in the infant’s development. 

Potential participants were identified by a MPAU member, who was independent of the course , with the assistance of an IPP-SHR Project Officer. A MPAU member promoted and provided project information about the study during the end of the GTKY courses. Included in this information was a project description and potential requirement if agreeing to participate. Participants were informed that they may be contacted by an IPP-SHR project officer and if they did not wish to participate, that they could either tell the MPAU member or IPP-SHR Project Officer. If they agreed to participate, the IPP-SHR Project Officer arranged an interview time. Participants were selected from the five Building Babies Brains’ courses. Twenty-three potential participants were contacted, with ten declining participation or being unable to be contacted. Thirteen parents participated in the in-depth interviews, consisting of twelve mothers and one father.  Participants ranged in age from 21 to 43 years. A diverse family composition was represented in the cohort with nine married, two separated and two single parent families. Twelve of the families had one child whilst one had a family composition of two children.

Interviews were conducted by an IPP-SHR research member. The interviews were audio recorded, transcribed verbatim and de-identified. Once transcribed, the interviews were loaded into the QSR NVivo computer package and coded (free nodes). The coding was conducted by IPP-SHR project officers experienced in the NVivo computer package. The naming and development of the codes was driven by the exact words of the participants. All data collected were entered into codes. The data were then thematically analysed by collapsing the free nodes down into broad thematic categories and used to provide an evaluation of the BBB program.

Project management and collaboration was managed using Quadrant™, an online Qualitative collaboration software tool.

Results
The Course Experience
Most participants were referred to the course by Mater Parent Aide staff, with some referrals originating from the Young Women’s Program and from other health care professionals at the Mater Hospital. Most participants indicated that they wanted additional support and appreciated the referral to the program:
•    I kind of went along because I felt that I needed as much support as I could get.

Participants noted that attending the course after the birth of their baby was beneficial as it allowed them to raise issues associated with their newborns as they happened. Participants indicated the informality of the course and the small class sizes gave them confidence in expressing issues to the group, for example:
•    Cause it was only two mothers we had a bit of time just to talk generally, just about us rather than the course and so in that sense I think I got my needs met in that I was able to talk about those issues, yeah.

The participants also appreciated the non-judgemental environment, for example:
•    (Interviewer) Was there an accepting feel within the room that you could pretty much throw anything out there? (P) Yeah yeah it was pretty open for it, yeah it was fine yeah, it is nice to feel that space.

For courses that did not have a high attrition rate, the ability to socialise following the formal component of the course was also valued, for example:
•    The best thing I liked was very, very friendly. It’s not like formal meeting sort of thing [unclear] having sandwiches and then tea, watch DVD and then talking about things with other mums.

However, even in such a supportive environment, one participant indicated that participating in a group is a difficult experience, for example,
•    Yeah for me personally I found it quite difficult, I’ve had a pretty tough time throughout, yeah having both of them so yeah I find the whole group thing quite -difficult personally but not because they’re not lovely and everything.

For some, the continuing relationships between course participants led to the development of a playgroup after the course had finished.
•    Yep, yeah so it’s been really good because  … we decided you know we all got on so we made like a baby group that we see every fortnight.
However, for courses in which the majority of attendees failed to attend, participants indicated that the course did not offer many social opportunities. For some, travel distance or return to work inhibited relationships with course participants after the cessation of the course despite participants mentioning that it may be beneficial.

Two participants indicated that their male partners attended the course and that they were appreciative  that the course was open to partners. One participant also appreciated the learning opportunity that the course provided for her partner, particularly as this was the first child for her partner. However, due to the lack of other fathers present in the course and the consequently high number of mothers present, two participants indicated that, after the initial welcoming experience, their male partner felt intimidated and ceased course participation.

Course Structure and Delivery
The BBB course is based on the viewing of a DVD on baby development followed by informal discussion of the content and the distribution of relevant written material.  Tea and refreshments were offered as part of the informal group experience.  There was some disagreement on the suitability of course structure and delivery.

Some participants indicated that the DVD was the correct length as due to fatigue from caring for a newborn, they were not able to remember much material and appreciated the reduced information and content:
•    …weren’t very long at all. That was great because you know if they had’ve given us a big lengthy DVD, you know, lots of material, I basically wouldn’t, I wouldn’t of been able to concentrate cause I was only really able to concentrate for short periods you know.

However, a few participants indicated that it would have been better to have a more structured and organised course with much more content.  In particular, participants indicated that the DVD was not long enough and did not cover enough content for the time dedicated to the course.

There was a strong indication that the amount of written information provided to course participants was adequate, with many indicating that they already felt overburdened with information and written material from other sources. 

Practical Issues to Course Attendance
The team at BBB organised transport for the course attendees. A majority of participants indicated that the provision of transport, and communication with BBB concerning the arrangement of transport facilitated course attendance. Some participants indicated that the provision of transport assisted them in leaving the house with their baby and decreased isolation, apprehension and anxiety, for example:
Yeah they did, they did at first cause otherwise I’m not allowed to drive for a couple weeks (Interviewer) yes cause your operation, yes. (P) yeah that was really helpful, so I wouldn’t feel confident drive myself and the baby at that time, really nervous as well.

Participants also noted the ease of parking helped in maintaining course attendance.

Social Support and Normalisation
A majority of participants indicated that the BBB’s course allowed them the opportunity to leave their domestic premises and attend a social function which catered for themselves and their infants, for example:
•    It does help because I know a lot of people they won’t really go out. If they have some sort of social interaction they’ve got more of a reason to you know be social with their babies and that.

Indeed, social contact and creating a network was mentioned as a strong factor for continued attendance, for example:
•    It was more the social side of things, I think that's why I kept going.

Many participants found that being able to attend a social situation in a safe and relaxed environment assisted in creating confidence to be able to leave their house with their new born.   A majority of participants indicated that they felt an affinity with staff and described them in positive terms. Participants noted that this helped them to continue participation in the course, for example:
•    I mean it was lovely, they were all lovely you know and they provided lunch and that was nice.

Participants indicated that the informal method of the course and strong social environment assisted in raising questions to peers, learning from others and normalising their own experience of caring for an infant. Sharing experiences of parenting allowed participants to reflect on their practices and gain confidence and lessen anxiety associated with their perceived parenting abilities, for example:

•    No I really enjoyed it, I enjoyed all those little moments because of it and you know I knew things were normal and I was doing things right so it just made me more relaxed and happy with what I was doing.
This was particularly important for parents that did not have many other parents in their immediate social network. Participants also noted that it was helpful to compare and observe babies of similar age and their development. Many participants indicated that the information provided by the course made them more confident parents, enabling them to better interact with their newborn, for example:
•    No just keep on doing that and yeah, just keep helping out other mothers who, like me who you know, haven’t had a lot to do with kids and sort of been thrown into the deep end so yeah it’s good. Yeah I did, I actually was very thankful that I did that course because I was, when I was telling other people about the course they were like, wow I wish I had done that when my kids were little so you know, yeah so.


Baby Development Issues and Bonding
Most participants indicated that the course helped in understanding development, nurturing and the importance of interaction.  Participants indicated that the course enabled them to understand cues and gestures made by their infant and how to respond appropriately to such communications, for example:
•    Oh like you know maintaining, just like you know some of the things like eye contact and learning how when they’re tired and when they’re hungry and how they communicate and you know that smile that they give right at the beginning isn’t wind, it’s actually, you know they’re actually smiling at you. I got some beautiful smiles and I appreciated that when she said that cause when (baby) did smile it was like, ‘yes she’s smiling, it’s not wind’ you know.

Understanding subtle cues associated with infant fatigue was also commonly noted and appreciated by course participants, for example:
•    What I do particularly remember was like we were talking about looking out for baby signs, like baby messages. Like when they’re tired, when they blink a lot and when they’re you know because of their attention span they, it’s quite small, yeah I never really knew much about that.

Likewise, it was noted that the participants learnt the importance of activities such as eye-contact and its impact on infant neural development, for example:
•    I saw DVD, even really brand newborn baby can see who’s their mum through contact them with eyes, things like that. I really didn’t expect that, I didn’t know that so that was I think, that was you know the biggest information that I got from.

The course also assisted participants in understanding the impact that a positive social and caring environment had on brain development, for example:
•    They showed us a diagram that was quite recent about a baby’s brain and how to make it positive and you know a good childhood how many things in the brain there was whereas if they had I don’t know, I guess parents that were mean to them and like from an abusive childhood the development would go back because the first five years are the most important as childhood like with the developmental and foundations and making them safe and that.

Content associated with learning baby cues and signs were appreciated as participants indicated the material had not been covered in other parenting classes.

Recommendations

Participants provided discussion on a number of limitations of the present course and made recommendations for the future development of the program. Many participants indicating that not only would they have liked to know about the course before birth, but to have had the chance to meet and develop relationships with other expectant parents and develop familiarity with the course convenors. Early contact would provide parents with a good opportunity to obtain information regarding the immediate time after birth.

Participants felt that the title ‘Building Babies Brains’ was incorrect as it did not reflect the course’s primary emphasis on understanding babies cues and the impact that positive relationships have on neurological development. The need to  explain the course content and objectives before enrolment was emphasised.

Numerous participants felt the DVD and course content was too basic and condescending. Some participants felt that the information presented in the course was already readily available and wished that they had been informed of the content before participation. In particular, a majority of participants indicated that they would have appreciated more discussion regarding the reality of caring for a newborn and the time and energy required. Participants indicated they would appreciate information and the opportunity to discuss issues associated with fatigue, time management and relationship information. This is particularly important as many participants indicated they had fragmented relationships and unstable living situations. In addition, every participant expressed a desire to obtain more information regarding breastfeeding and would have appreciated the support and advice of a lactation consultant. A strong recommendation from the research is that a lactation consultant and child health nurse be integrated in the class content and delivery.

There were problems with the program for those who attended groups with small numbers. Indeed for some, the group numbers were sometimes as small as two attendees. For those with a male partner, there was agreement on the need to incorporate greater partner involvement. Such participants thought that a group specifically designed for fathers would assist in their parent confidence and skills, understanding their baby and contribute to having a greater involvement in parenting.

Discussion

The findings indicate that the BBB program assisted parents to better understanding infant brain development and methods of infant communication. Participants indicated that they were better able to apply this new knowledge and understood the importance of positive nurturing and interaction with their infants. Leitch (1999) had similar findings with regards to the use of videotaped educational information as a method of facilitating very early mother-infant interaction. The findings resonate with the work of Censullo (1994) who found that there was a significant increase in the level of responsiveness and parental self-esteem scores after the intervention  based on a parent/infant interaction coaching procedure.  

Participants indicated that this social component and knowledge gained from the course assisted in raising their confidence levels regarding their parenting skills and ability.  The provision of transport, venue location and easy parking was also noted as a positive practical component to course attendance. Participants also indicated that the course provided opportunity to socialise with other parents who were also experiencing similar phases of development with their infant. This social component normalised their parent experience and alleviated social isolation.  Scott and associates’ (2001) research on parent-focused education groups similarly found that social contact was an important aspect of the group experience and provided evidence of continuity of this contact after the completion of the groups.  Scott and associates (2001) concluded that  such programs may be an important vehicle for enhancing social support during the transition to parenthood and thus be a useful primary prevention strategy.

The range of recommendation for future development of the course are useful not only for the convenors of the present BBB course but for other readers seeking to run such a program.

Conclusion
The findings from the BBB program provide fresh insights on the potential for parental support and education groups as a proactive mental health strategy. The hope and expectation is that the research findings can be used by others in the field of mental health for further program development as a resource that can reach a wide diversity of parents. 

References:

Baradon T. (1999) Directions. Nurturing nature. Mental Health Care, 2,6:208.

Bayer J., Hiscock H., Morton-Allen E., Ukoumunne O., Wake M. (2007) Prevention of mental health problems: rationale for a universal approach. Archives of Disease in Childhood, 92, 1: 34-8.

Berlin L. & Cassidy J. (2001) Enhancing early child-parent relationships: Implications of adult attachment research, Infant and Young Children, October, 14,2:64-76.

Censullo M. (1994) Strategy for promoting greater responsiveness in adolescent parent/infant relationships: report of a pilot study, Journal of Pediatric Nursing, 9,5:326-32.

Hotelling B. (2004) Tools for teaching. Newborn capabilities: parent teaching is a necessity. Journal of Perinatal Education, 13,4:43-9.

Leitch D. (1999) Mother-infant interaction: achieving synchrony. Nursing Research. 48,1:55-8.

Lyons-Ruth K., Dutra L., Schuder M., Bianchi I. (2006) From infant attachment disorganization to adult dissociation: relational adaptations or traumatic experiences? Psychiatric Clinics of North America, 29,1:63-86.

McGrath P, Holewa, H., Huff, N., & Patton, M., (2011). Participant Feedback and Service Provision Evaluation on Project, “Building Babies’ Brains: A Mater Parent Aide Project in Partnership with Noah’s Ark (BBB)”. International Program of Psycho-Social Health Research, Brisbane, Australia.

Nelson C. & Bosquet M. (2000) Neurobiology of fetal and infant development: Implications for infant mental health. In  Handbook of infant mental health.  Zeanah C (Ed)., (2nd Ed), Giolford Press, New York, NY, US.

Sameroff A. (1975) Transactional models in early social relations. Human Development, 18, 1-2: 65-79.

Sameroff A. & MacKenzie M. (2003) A quarter-century of the transactional model: how have things changed? Zero to Three, 24, 2: 14-22.

Scott D., Brady S., Glynn P. (2001) New mother groups as a social network intervention: consumer and maternal and child health nurse perspectives.  Australian Journal of Advanced Nursing, 18,4:23-9.


 


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