BC Council for Families (BCCF): Growing Together Toolkit

The Growing Together: Supporting the mental health and wellness of young children, mothers, and their families Toolkit is a collaborative project with partners from the Government of BC (Ministry of Health, Ministry of Children and Family Development, and Ministry of Education), Health authorities (Public Health, Reproductive Mental Health Programs, and Infant Development Programs), and community support (CPNP and CAPC programs, BC Council for Families (BCCF), and BC Healthy Child Alliance) with funding provided by the Province of British Columbia as part of the implementation of Healthy Minds, Healthy People – A Ten Year Plan to Address Mental Health and Substance Use in BC (2010).  The toolkit is designed to meet the needs of service providers working with mothers with mental health, substance use, and other life challenges, and their young children and families.

The Toolkit is designed to be:

• A resource for community service providers who work with mothers and their young children and families
• A complement to existing resources
•  Evidence informed
• A cross-pollinated representation across different organizations, disciplines, and areas of focus.
• An encouragement to providers to look at the whole family

The Toolkit starts from a wellness base and provides tools for workers to support families if something goes wrong.  It provides:

• Background information for providers on key concepts related to infant mental health
• Worksheets for use individually or in groups.  The Parent Handouts are available in Arabic, English, French, Korean, Punjabi, Simplified Chinese, Spanish, Tagalog and Vietnamese.
• Additional references and web links for further information

The March 23 webinar was presented by Dr. Lenora Marcellus, Associate Professor, School of Nursing, University of Victoria.  In an earlier BCCF webinar, Dr. Marcellus had spoken with Lea Laberge, then Coordinator of Frog Hollow Family Programs in Vancouver, who had run focus groups and field tested the Toolkit prior to release. Lea Laberge’s implementation suggestions from the previous webinar are also incorporated into this report.

Along with the Toolkit, a simultaneous project has been the development of “Journey to Wellbeing”, an online course and suite of practice support resources for public health nurses and other social service providers who work with perinatal women and families.  The course includes four modules:  Education and Prevention; Screening and Assessment; Treatment and Self-Management; and Coping and Support.  It includes practice support tools including a quick reference guide, a summary of key messages, advanced group learning sessions, and additional resources.

Up to 70% of mental health problems and illnesses begin in childhood or adolescence.  An estimated 1.2 million Canadian children and youth are affected by mental illness.  Less than 20% will receive appropriate treatment.  Stigma, lack of access to services, and lack of awareness are major issues. The lifetime cost of childhood mental health disorders is estimated to be approximately $200 billion in Canada.

The World Health Organization’s Improving Maternal Mental Health (2008) stated that the links between mental health problems and maternal health are a major cause for concern because they directly or indirectly increase maternal morbidity and mortality.  Attention to mental health problems of pregnant women and mothers and integration of mental health care into existing mental health programs and activities contributes tot the Millennial Development Goal of improving maternal health.

In Canada, we had our first national mental health strategy released in 2012 (Changing Directions, Changing Lives) developed by the Mental Health Commission of Canada.  The goal was for all people living in Canada to achieve their best possible mental health and wellbeing: “With infants and children, the focus is on becoming resilient and attaining the best mental health possible as they develop.”

The BC Ten-Year Plan (2010) addresses mental health and substance use issues. The priorities for BC include: “Promote mental health in early childhood and throughout life:  Given that early child development lays the foundation for health and wellness, it is increasingly evident that children must be at the center of a public mental health strategy [“Preventing mental health disorders in children: A public health priority” Canadian Journal of Public Health, 98 (3),  174-178, 2007]”  The 2012 progress report included Healthy Start (routine prenatal services and enhanced services for families in greater need) and BC Health Connections project (Nurse Family Partnership RCT designed to help first-time parents succeed).

Released in 2006, Addressing Perinatal Depressions: A Framework for BC’s Health Authorities recommended a coordinated approach to perinatal depression.

• Without treatment, perinatal depression affects all aspects of a woman’s health, and that of her baby.
• With the right strategy and a coordinated approach it can be detected early and effectively treated.
• The Framework for Action includes 4 pillars:
  • Education and prevention
  • Screening and diagnosis
  • Treatment and self-management
  • Coping and support networks

Another excellent resource that complements the Toolkit is an information sheet for Early Childhood Development and Parent Support Providers, Social and Emotional Development in the Early Years (BCHCDA). This resource provides an excellent range of materials and videos for use in workshops with families.

Best Practice Guidelines for Mental Health Disorders in the Perinatal Period (BC Reproductive Mental Health Program & Perinatal Services BC, 2014) promotes understanding that, although mental illness is serious, with the right strategy and a coordinated approach, it can be detected early and effectively, and offers clinical guidelines and care path plans for practitioners. It points out that as many as 1 in 5 women will experience a mental health issue during pregnancy, often without any previous history, along with increased vulnerability.

The Mothers’ Mental Health Toolkit: A Resource for the Community (2012) was developed as a community-driven resource with CPNP and CAPC settings specifically in mind. The website also provides a range of PowerPoint and video resources.  This resource points out that:

• A woman is at the highest risk in her lifetime of developing a new mental illness in the first year after a baby is born.
• At least 15% of new mothers experience significant postpartum mood disorders and many more report important difficulties in coping and adjusting.
• 60-70% of women with a serious postpartum mood disorder have no previous history to alert them.
• 50% of women with a postpartum mood disorder never seek treatment.
• Without treatment and support, 30% will remain chronically affected and symptomatic, limited in their capacity to mother, to work, and to engage in their community.

A mother’s mental health:

• Enhances her capacity to promote healthy practices emotionally and physically for her children.
• Creates stability of self and emotional regulation for young children.
• Supports strong parent-child attachment critical to behavioural regulation, self-worth and resiliency in children.

The new Toolkit focuses on infants, so it works together well with these complementary resources to look at the whole child and the whole family together.  The resources are great starting points for discussion with parents.  Lea Laberge pointed out that, in talking to ESL mothers, their first languages often do not have terminology for directly translating these concepts, so translation, and finding means of expression for concepts in other languages, is an important piece of the work of producing support materials for families.  The Toolkit affirms the practices already in place in many community support programs, as well as offering new ideas.

Infant mental health takes place in the context of relationships with family and other significant people in their life.  The key actions that are required for health social and emotional development are:

• Consistent and sensitive caregiving: An essential part of infant development is consistency in their life and need to know that they have caregivers who can pick up on the cues that they share about whether or not they are engaging with something.  That can be a challenge for a parent who is coping with a lot of life stresses (e.g. poverty, food or housing insecurity).  The challenge as caregivers and community workers is how we support developing this consistency of response within these contexts.
• Repair: It is important to let parents know that 100% parenting perfection is not possible.  No parent will consistently pick up on everything that their child is doing, and that’s okay within the context of a consistent relationship with the child.  It is where it is not at a level where the child gets the regular stimulation that they need, that cracks can develop in the relationship.  If it is consistent enough it will repair, but if it is chronic and ongoing then there are impacts for the child’s healthy development. For frontline workers, the role of supporting parents to be able to work through those processes and do the best that they can is invaluable.  Offering parents the opportunity and support to get down on the floor and play with their child during program, or sit and have lunch together, affirms and assists in building the parent-child relationship.  The resilience model demonstrates the balance of risk and protective processes that interact to build strengths for families.
• Serve and Return:  The interactions pattern between an infant and their parent or caregiver that demonstrates the connection they have and the responsiveness they have to each other.  When a parent is dealing with multiple stresses, and for a mother with mental health issues, this can be a really hard thing to do. For program staff, showing parents how the small things, like smiling, giggling, looking directly at the child when talking, are the important issues; it’s not necessary to go out and buy a lot of toys or computers or do a lot of expensive activities.  The key things are the everyday relational interactions with your child.

The Toolkit incorporates:

• A workbook
  •  Information for service providers
  • Worksheets for parents
  • Additional resources
• Environmental scan of existing resources
• Poster
• Webcast

Key ways to support families in our programs:

• Helping women and their families feel comfortable talking about mental health and substance use
• Lea Laberge commented that, when she started to field test the Toolkit with her staff, frontline workers expressed concern about addressing the topic of mental health with families.  She stresses that the responsibility for diagnosing and prescribing is for health professionals, and the Toolkit makes it clear that what they are already doing on the ground in family programs and drop-ins is exactly what parents and children need to foster healthy attachment and healthy mental development.  The Toolkit offers practical help for the families and has a lot of resources on parenting advice, and lots of referral information to help assist with next steps.
• Families are often afraid to discuss mental health, for fear of stigma and/or discrimination, so staff should really follow the lead of the mother, and proceed cautiously at first into discussion. Sometimes, too, when families are feeling completely overburdened with stresses, attachment interactions can seem like ‘just one more thing’ that they feel they have to deal with, and it is all too much, but the Toolkit highlights, in the 7 ‘everyday opportunities’ section, how easy it can be to integrate relational strategies into normal routines.  An important role for frontline staff is to affirm the things parents are already doing with their children, and draw attention why these interactions are valuable to the child’s development.
• Providing information on developmental milestones, including social and emotional development
• Creating culturally appropriate environments

Parenting in the Early Years:  Strategies for mothers with mental health and substance use challenges.

The Seven “Everyday Opportunities” include:

• Sleep and Rest:  Laberge noted that sleep is a really big topic, and one that focus groups wanted to spend a lot of time on.  Mothers commented that it is hard for them to relax enough to nap when their baby sleeps, as this is the only time they have to get anything done.  It served as a reminder that, when presenting the information, it is important to point out that these strategies are suggestions, rather than instructions, and are not designed to create additional pressures for them.  One of the things the mothers really wanted to talk about was how we can build bedtime routines and help our children to settle to sleep at night, such as the 4 B’s: brush teeth, bath, book and bed.
• Routines and Transitions: Building family routines can help children manage change.  Using the program structure as a model helps parents see how structure and routine can help children with transitions.  For families who have unstructured work schedules, having even one routine, such as bedtime, can help.
• Feeding:  Feeding is a big issue for mothers.  Helping parents understand how feeding can help build attachment. It is important for program staff to understand that breastfeeding can potentially be challenging for mothers who have experienced sexual abuse.  Mothers who are using substances will need professional advice on whether or not it is safe to breastfeed, depending on what drugs they are using.  For families with particular challenges, it is important to get accurate information and then support mothers and families to make the decisions that work for them. 
• Activity and Play:  These worksheets affirm what the family programs are already doing with parents, and letting parents know that there are lots of activity and play options that do not require spending money or purchasing items.  Support for parents includes helping them recognize the cues their infant or toddler are giving that indicate whether or not they are ready to participate in an activity, particularly important with highly sensitive children or children who have been exposed to substances in utero, or have other developmental delays.
• Touch:  Touch is a very important component of developing attachment and positive feelings between the child and the caregiver, but for mothers who are having challenges, there may be days where that is just too much to handle.  It is important to reassure parents that it you are having a bad day, or dealing with sensitivity issues or other challenges, then someone else, such as a program worker, can hug your child for you, and that there is no need to feel guilty around that.  Also, some children are more sensitive around touch, and need more space, so responding on an individual basis matters.
• Communication:  It is helpful for program staff to model ‘serve and return’ with children, and to point out when they see it taking place between parent and child, supporting mothers in their learning about interacting with their child. These are ways of helping to promote positive mental health of both mothers and babies.
• Community Resources:  Links to support services.

Laberge commented that the Toolkit worksheets are useful for Nobody’s Perfect classes, parenting classes and mother’s support groups, as well as for individual one-to-one conversations with parents in drop-in programs.  They are also valuable for use in staff training sessions.

The worksheets promote wellness and can be used with the whole drop-in or parenting class, so if staff don’t want to bring up the topic of mental health specifically, they can be used with group in a generic sense of let’s see what we can do together to help each other.  Laberge noticed that, when she was doing focus groups, most people registered as ‘I want to help my friend’, so that’s an indication that there is still fear and stigma around the topic, but it is also a way of introducing the topic as ways in which parents can help each other.  In program, she usually introduces the subject of mental health as, “Do you want ways in which you can help yourself or help others?”

For vulnerable families, whilst the individual risk factors at one point in time might be manageable, the accumulation and interaction of multiple risk factors over a longer period of time creates ‘pile-up’ and it is hard to predict when the tipping point might occur to push a family into a crisis.  Working with families in programs on a long-term basis builds caring relationships and trust that help parents open up and be willing to reach out for support.