Guidance

Reflecting on parent-infant relationships: a practitioner’s guide to starting conversations

Published 21 March 2024

Applies to England

About this guidance

This guidance provides 3 conversation prompts for frontline practitioners to explore a parent or carer’s relationship with their baby. It also sets out a 3-step framework for using them to help identify parent-infant relationship difficulties.

The prompts are intended for use by a range of frontline roles including, but not limited to:

• health visitors
• midwives
• nursing associates
• family support workers
• social workers

The guidance has been developed to help implement the recommendation, set out in The best start for life: a vision for the 1,001 critical days in March 2021, for effective mental health support for parents and carers to develop a secure bond with their baby to be integrated into the universal offer to every family.

This guidance has been developed as part of the joint Department for Education and Department for Health and Social Care Family Hubs and Start for Life programme.

You should use this guidance to familiarise yourself with the prompts and as a reference point for the best ways to implement them in your practice.

Parent-infant relationships

Our earliest days are defined by the relationships we have with those closest to us: our parents and carers.

Parent-infant relationships refer to the quality of the relationship between a baby and their parent or carer. Good parent-infant relationships nurture ‘secure attachments’, which are the basis for optimal infant mental health promoting healthy social, emotional and cognitive development.

It is therefore important that practitioners are able to identify parents and carers who may be struggling to connect with their baby and support them as much as possible to do so. The prompts will play an important role in this through supporting you to start conversations with parents and carers about their relationship with their baby.

Developing the prompts

To develop the prompts, we worked with academics, practitioners, parents and carers to gather feedback and build an understanding of what is required to support conversations around parent-infant relationships.

We developed several iterations of the prompts and accompanying guidance and tested them with local authorities. All the feedback combined has allowed us to develop a practical and useful tool that will fit in with existing pathways.

The prompt questions themselves are derived from the Leeds Early Attachment Observation (EAO) tool which is used in the routine 6 to 8-week postnatal health visitor contact.

The Leeds Early Attachment Observation (EAO) tool

Background

The Leeds EAO tool was developed by the Leeds Infant Mental Health Service (Leeds Community Healthcare NHS Trust) in collaboration with Leeds Health Visiting Service. It is for use by the Leeds specialist community public health nurses (SCPHNs) to identify emerging attachment difficulties.

In Leeds, the observation tool is used as part of the universal offer at the routine 6 to 8-week health visitor contact. It is made up of 3 questions about the emerging relationship between the caregiver and baby, followed by a 2-minute observation.

Role of observation

The observation element within the EAO functions as a means for the practitioner to physically see the interactions between the caregiver and baby and to build an understanding of the baby’s experience.

The practitioners in Leeds base their observations on several concepts including:

• sensitivity
• contingency
• vocalisation
• affect
• engagement
• positioning

Training

The Leeds EAO includes mandated training for all SCPHNs. SCPHNs attend a half day introduction to the EAO and a 90-minute follow-up refresher training session. For more information about the Leeds EAO, email leedsimh@nhs.net or contact them on 0113 84 30841.

A 3-step framework to help parents and carers reflect on their relationship with their baby

The prompt questions form just one step of a 3-step framework. This guidance  covers each step of the framework and the considerations you may wish to take when implementing each step.

We have set out a high-level summary of the framework below.

Step 1: starting the conversation

The first step of the framework looks at using the 3 questions to start the conversation with the caregiver about the relationship they have with their baby.

Step 2: identifying potential strengths and areas of need

This step of the framework looks at further exploring the answers the caregiver gave in step 1, especially if the answers raised concerns for you. This step of the framework covers the use of clinically validated assessment tools to investigate further.

Step 3: signposting, referring or providing further support

The final step of the framework looks at referring families and caregivers for additional support if you think it is appropriate.

Step 1: starting the conversation

Creating a safe and open environment, knowing what to say and when to say it can be challenging elements of asking parents and carers about their relationship with their baby. Before asking the 3 conversation prompts, you might want to set the scene by:

• normalising the conversation: reassure parents and carers that talking about parent-infant relationships is something that you do with everybody and that there are no right or wrong answers

• introducing the questions: asking consent to begin a conversation about parent-infant relationships can help you understand if it’s the right time and can help the parent feel more comfortable

• managing expectations: some parents and carers may worry about sharing difficult elements of their relationship with their baby. This is understandable. You can help through assurance that they will not be judged based on any information that they share

Setting the scene with a parent or carer: an example

You could set the scene by saying:

Every relationship between a parent and baby is different: there can be parts of the relationship that are going well and other parts that are more challenging.

I like to ask all parents and carers that I meet about their relationship with their baby. Some parents and carers might not have spent much time thinking about their relationship with their baby yet, but this might be a good opportunity to start exploring this together today.

There are no right or wrong answers. Please do try to be as honest as possible. Is it ok if we talk about this now?

Question 1

What 3 words or phrases would you use to describe your relationship with your baby?

This is a neutral question to encourage the parent or carer to think about their baby and how they relate to one another. It helps you to get a sense of their feelings towards the baby.

What you might hear

The caregiver might respond using positive words such as ‘loving’ or ‘cuddly’ or negative words such as ‘hard work’ or ‘worrying’. They might focus on physical attributes that the baby has. They might describe what the baby does, or they might describe the baby’s emerging personality.

The words the caregiver chooses may give an indication as to how they are feeling generally about the relationship they have with their baby and you may wish to try and find out a little bit more about why they picked those particular words. The caregiver also might struggle to answer with 3 words or find this question difficult to respond to.

You may wish to remind them that it is ok to take their time in answering the question and that there is no right or wrong answer.

When you want to find out more information and delve deeper

You could follow up by asking:

Can you tell me a little more about why you chose those words or sentences?

Question 2

What brings you the most joy in the relationship with your baby?

This question brings out the positive side of being a parent or carer. As part of  a strengths-based approach, it can be a helpful reminder for the parent of what is going well.

What you might hear

The caregiver might describe recent developmental milestones, or they might focus on activities that bring joy to both parent and baby. For example, “I love it when I blow raspberries and my baby giggles.”

They might struggle to point to positive things about being a parent or carer and instead bring the conversation towards things they are worried about.

When you want to find out more information and delve deeper

You could follow up by asking:

What is it about that part of the relationship that makes it your favourite?

You may wish to provide a tailored example here such as:

How do you feel when you are feeding your baby?

Question 3

What is your biggest fear about your relationship with your baby?

This question focuses on aspects of the relationship that a parent or carer may be struggling with.

As part of a strengths-based approach, it can be useful to remind parents of some of the positives they have talked about and how it could be applied here.

It is also important to acknowledge any worries or fears the parent has shared, thank them for their honesty and recognise that this might be something they might like to change and have some support with.

What you might hear

The caregiver might worry that their baby doesn’t like them or that they are struggling to bond or connect with their baby. They might express concern over physical development or their ability to provide necessities for their baby.

If a caregiver does not understand this question or does not talk about their relationship with their baby, you could prompt them to think about worries instead of fears in the first instance to open the conversation up gently.

When you want to find out more information and delve deeper

Sharing a fear may be daunting. Take the opportunity to build your relationship with the parent or carer by empathising with their position:

Thank you for sharing that with me. It’s understandable that you feel worried about that. Lots of people caring for a small baby have a similar fear.

After empathising with this fear, you could follow up by asking:

Is this similar or different to your relationship with your other children?

or:

How long have you been worried about this?

Giving the baby a voice: the role of observation

Observing the relationship between a baby and their parent or carer is a valuable addition to asking these prompt questions. Although we cannot ask babies about their relationship with their parent or carer, by watching them closely we can begin to understand their experience of the relationship.

An observation helps to determine whether what is being discussed in the questions matches with what is being observed, or if there are any differences that you may wish to consider more carefully.

What you might see as you ask these questions

What you see may tell you more than your conversation with a caregiver. For example, a baby’s cry is their way of communicating that they need something from their parent or carer. If a baby cries at any point, then you have a good opportunity to observe the relationship.

Reassure the caregiver to take their time so they do not feel ‘rushed’ to stop their baby from crying to get back to your conversation.

‘Stepping back’ and allowing interactions between the infant and caregiver to unfold without interruptions will help you to gauge the emotional responses of both the infant and carer and to get a general feeling for how those interactions develop.

You may wish to consider:

• does the caregiver respond quickly to the baby’s cry?
• how does the caregiver talk to their baby? Do they use soothing words? Is it calm and loving or abrupt and harsh?
• does the caregiver make eye contact with the baby?
• does the caregiver seem to have a range of ways to calm their baby or do they seem unsure about what their baby might need - for example, talking, cuddling, rocking, feeding or changing their nappy?

A parent-infant relationship goes 2 ways. You may wish to consider what the baby does and how the baby would describe the interactions from their perspective:

• do they make eye contact with their caregiver?
• do they calm when their caregiver attempts to soothe them?
• what do you notice about their facial expressions and how they change as they interact with their caregiver?
• what is their body language like - for example, does their body relax if they are cuddled or do they seem stiff and tense?

The use of observations will help you to tune into the baby’s ‘voice’ and bring a strengths-based approach to support. For example, you could reflect on what you have seen:

Did you notice how your baby looked at you and calmed as you spoke to them and made eye contact? That was lovely to see and will help your baby grow and develop.

Your observations may also give you more information about what support a caregiver may need, such as support to interpret their baby’s cues.

Step 2: identifying potential strengths and areas of need

For most parents and carers, an initial conversation will be all that is required to identify any needs. You may decide, however, that it’s appropriate to move onto the next step in this framework to identify potential areas of need so you can determine if further support  is required.

In this step, we suggest you ask more in-depth questions using a standardised questionnaire or assessment tool that you have been trained to use and are familiar with. There are several questionnaires and tools available that can help you with this such as the:

• Alarm Distress Baby Scale
• Newborn Behavioural Observation tool
• Mothers Object Relations Scales

You may wish to discuss your choice of tool with your line manager or supervisor. The assessment tools will help you to identify when further support or referrals are required.

We recommend that you adopt an evidence-based assessment questionnaire that is already used in your area.

Introducing a questionnaire or assessment tool to find out more

The assessment questionnaire might have suggestions for how you introduce it to parents and carers, but you could start by saying:

I’d like to find out a little bit more about some of the things we’ve talked about today, if that’s OK with you?

I’ll be asking some questions from the Newborn Behavioural Observation tool and this will help us consider some of your thoughts and feelings a little further.

It’s nothing to worry about and as with the first questions, take your time and remember there are no right or wrong answers.

Step 3: signposting, referring or providing further support

By this stage you will have identified if there is a need for further support. Where established, you should follow your local referral pathways for families who would benefit from additional parent-infant relationship support. If safeguarding concerns arise, you must follow your local procedures.

Areas with limited support for parent-infant relationships

We know that some areas of England do not currently have a support offer for parent-infant relationship difficulties.

In such cases, using step 1 to help the caregiver feel heard and understood is still the right action to take. You could use the antenatal and postnatal topic guide cards within the Centre for Parent and Child Support’s promotional guides to support you in continuing the conversation. The promotional guides are a useful resource for helping practitioners and families explore antenatal and postnatal experiences as well as foetal and infant development and family health and wellbeing.

You could also signpost to online resources that the caregiver may find helpful. The Better Health: Start for Life website provides NHS trusted advice and support on understanding and bonding with a baby. There are also some other useful self-help resources, such as Watch Me Play!

You may also consider signposting to the GP or other local services if you feel a family may benefit from this.

Tips for implementing the prompt questions

To support you in using the conversation prompts, you may also wish to consider the following.

Trauma-informed practice

Trauma-informed practice means being sensitive to the trauma that caregivers may have experienced and actively seeking to prevent re-traumatisation. You may be interested in the NHS England trauma-informed care e-learning module.

Think family - including fathers and co-parents

The healthy child programme highlights the importance of ensuring that fathers and co-parents are actively involved in care. The conversation prompts have been designed to be used with all parents and carers and we would encourage you to use them with fathers and co-parents wherever possible.

It is recommended that you consider the NHS England good practice guide on involving and supporting partners and other family members.

Training

You might want to access further training about parent-infant relationships as part of your continued professional development. NHS England have created an e-learning programme to develop an understanding of perinatal and infant mental health.

Supervision

Integrating any new resource into an existing way of working can be challenging. When you first begin using the prompts we encourage you to discuss using them with any clinical supervisor you have access to.

Application for different professions

The prompts have been designed to be used by a range of practitioners including:

• health visitors: making every interaction count with parents and carers is something that you will already be doing as skilled practitioners. You might find the prompts are useful for you and colleagues in the skill-mix team when talking to parents about bonding and early attachment relationships as part of delivering the healthy child programme. For example, the prompts could lend themselves well to conversations during the mandated reviews when exploring the parent-infant relationship
• midwives: some women and birthing people experience difficulties in bonding with their baby during pregnancy. Being asked about this can be a relief for parents and carers who may feel embarrassed or shame for not being as connected with their baby as they believe they ‘should’. For example, at 36 weeks you can have conversations with parents and carers about caring for their newborn baby and their mental health both before and after birth
• early years practitioners: as practitioners who work with families every day, the prompts can support you to have conversations with parents and carers about their relationship with their baby. They have been designed to be used within your existing interactions with families once you have built a positive and trusting relationship
• team leaders: if you are a team leader, you might find the prompts to be a helpful resource to use when training and supporting your staff. They can help build confidence in starting the conversation
• service managers: you may wish to consider how the prompts fit into your local systems and pathways to ensure local practitioners build relationships across teams  and understand local procedures. You may also want to consider how an understanding of parent-infant relationships becomes part of your service through training and awareness raising

Annex A: the prompts at a glance

Set the scene    

Every relationship between parents or carer and their baby is different: there can be parts that are going well and parts that are more challenging.

Normalising the conversation

I like to ask all parents and carers about their relationship with their baby.

Introducing the questions

Is it ok if we talk about this?

Managing expectations

Some parents and carers might find this strange. Remember that there are no right or wrong answers.

Step 1: starting the conversation

What 3 words or phrases would you use to describe your relationship with your baby?

What brings you the most joy in the relationship with your baby?

What is your biggest fear about your relationship with your baby?

Step 2: identifying potential strengths and areas of need

Use an assessment tool or questionnaire.

Step 3: signposting, referring or providing further support

Getting advice

Some parents and carers might benefit from signposting resources available locally or online.

Getting help

Some parents and carers might benefit from open access or universal support.

Getting more help

Some parents and carers might benefit from specialist parent-infant relationship support.