Abstract
Keywords
Statement of context
Perinatal services aim to support and enable mothers experiencing mental health problems arising during pregnancy or within 12 months of childbirth. There is a focus on minimising the impact of the mother’s mental health on mother–infant bonding and promoting safe, effective parenting for the developing infant. Most mothers expect to form a positive relationship with their infant within the first weeks following birth. When this does not happen, or they encounter difficulties in daily occupations in caring for themselves or their infant, there can be detrimental effects for the mother’s mental health and the cognitive and emotional development of the infant (Appleton et al., 2012; Department of Health, 2011; NICE, 2017; Tickell, 2011). Mothers have also been observed to experience social interaction difficulties with their infant and other social partners during these daily occupations (Allen and Duncan-Smith, 2011; Field, 2010). The need to establish the use of appropriate outcome measures for perinatal mental health services that identify social interaction issues and support mothers in their roles with their infant is recognised (PHE, 2016). Current standards and guidance stipulate strong indicators for the robust assessment and outcomes of mother–infant interactions (NHS, 2016; NICE, 2017; RCP, 2016); however, there are few tools that have been standardised for this setting. Of the specialist standardised assessments measuring mother–infant interactions, such as the CARE1 index (Crittenden, 2018), Parent Infant Relational Assessment Tool (PIRAT) (Broughton, 2014) and Video Interaction Guidance (VIG) (VIG, 2018), none are standardised for use within mental health populations or focus on daily occupations. While there are several interventions effective in improving mother–infant interaction, their efficacy for mothers with mental health diagnoses are still unknown (NICE Guidelines, 2017).
Critical reflection on practice
The mother and baby mental health unit in this analysis is in England. Mothers are admitted from the second trimester of pregnancy up to 12 months postnatally (with their baby if postnatal). Informal and formal assessments and observations with mothers and their babies are an integral part of the unit assessment process. A unique element of mother and baby mental health units is the combined approach of treating the mother’s mental health needs alongside her baby to support and enable bonding and attachment with baby and safe and effective parenting. Parenting is a multi-faceted occupation that requires participation in many necessary and desired daily occupations both with and on behalf of the infant. Occupations are central to occupational therapy practice (Fisher, 2014). To support theory-based practice, the occupational therapist wanted to use an assessment that was occupation-centred and thus supported occupation-based interventions (Fisher, 2014). Social skills are essential for developing relationships with others and necessary for almost all desired occupations (Fisher and Griswold, 2018) and, for mothers and their new infants, this is a very important time. O’Brien and Lynch (2011) assert that good quality social interactions are fundamental to the success of such occupations. Moreover, Fisher and Griswold (2018) found the primary social partner’s quality of social interaction (the person with whom the mother interacts the most) has the greatest impact on the mother’s own social interactions. Unless appropriate and relevant assessments are carried out in the mother’s everyday setting, including people who are typically present during her everyday routines and occupations, crucial aspects of social interaction may be missed, invalidating information gathered.
Despite having a written protocol, staff in the unit had commented on a range of differences in how mothering occupations and mother–infant interactions were observed, documented and reported by the team. Moreover, the team routinely used non-standardised screening tools and informal observations during the perinatal pathway to identify and support the achievement of patient-identified goals. The occupational therapist used some standardised tools as appropriate (Occupational Circumstances Interview and Rating Scale (OCAIRS), Forsyth et al., 2005; Model of Human Occupation Screening Tool (MOHOST), Parkinson et al., 2006; the Assessment of Motor and Process Skills (AMPS), Fisher and Jones, 2012). Following team discussions about the need to measure individual outcomes for mothers and document team outcomes, it was agreed to introduce the Evaluation of Social Interaction (ESI).
The trust’s research and development lead determined that ethical approval was not necessary as the changes to introduce another standardised assessment were part of usual treatment; the process that followed formed an evaluation of usual practice. No potentially identifying information is provided in this article.
Introducing the ESI into the mother and baby unit
The ESI is an observational tool standardised for use with anyone from 2 years 6 months through to older adults. It has demonstrated good validity and reliability based on an international sample of 14,791 people, including persons with medical, learning disability or mental health diagnoses as well as those without any disability (Fisher and Griswold, 2018). It can be used in any relevant environment, such as a person’s home, local community or clinical setting, where two social occupations are observed for each assessment. The ESI encompasses 27 social interaction skills, which are all rated during each interaction observed. Results are generated in linear form, indicating the person’s quality of social interaction. (Fisher and Griswold, 2018).
Over a 6-month evaluation period, 12 mothers were admitted to the unit with their baby, from a wide geographical area. Diagnoses included schizophrenia, bipolar disorder, emotionally unstable personality disorder and post-partum psychosis. For some mothers this was their first contact with mental health services. The team included mental health nurses, nursery nurses, an occupational therapist, a psychologist and a consultant psychiatrist. The occupational therapist introduced the ESI as part of the initial assessment process undertaken during the first week of admission. During these discussions, each mother identified social occupations that she thought important in her mothering roles. For example, mothers were observed playing with baby, changing baby’s nappy, bathing baby, conversing with peers and staff when preparing bottle feeds, buying goods in the local shop, catching the bus, buying a drink in the café or conversing socially with visiting family members. Each observation was undertaken and scored by the occupational therapist, who was fully trained and calibrated to use the ESI. All 27 social interaction skills (see Table 1) were observed and rated after both interactions using a four-point rating scale, where the quality of each social interaction skill is rated as competent, questionable, ineffective or severely limited (Fisher and Griswold, 2018).
Social interaction skills.
Raw scores for each of the two social exchanges were entered into the ESI software, a special application of the many-faceted Rasch analysis (Fisher and Griswold, 2018) and an ESI measure generated in a results report. The ESI measures the level of social interaction skill, expressed in logits, which is depicted graphically on a line of social interaction, where higher scores (in logits) represent greater competence in social interaction skill and a lower score represents diminished competence in social interaction skill. This graphic representation of linear (hierarchical) scores allows direct comparisons of ESI measures generated before and after the intervention. When interpreting ESI results, each mother’s ESI measure can be compared with a cut-off point located at 1.0 logit on the ESI scale. Those scoring at or above the cut-off demonstrate generally competent social interactions (polite, respectful, well-timed, mature). Those with a diminished quality of social interaction will have an ESI measure that falls below 1.0 logit, and typically demonstrate social interactions that are questionable, mildly, moderately or markedly ineffective/immature (Fisher and Griswold, 2018).
Following assessment, each mother met with the occupational therapist to discuss her results and collaboratively agree goals and occupation-based intervention plans. Interventions were delivered through a multi-disciplinary approach and took place in their naturalistic settings, which included the mother and baby unit, another clinic, a local community venue or the mother’s home. The nursery nurses were a key part of this collaboration so that appropriate input on parenting skills and activities were included for mother and baby on a daily basis. Key social partners, and their impact on the quality of social interaction, were also included when goal-planning. Generally, goals were met through individual interventions and included mothers working with baby and a range of social partners on a daily basis while being supported to participate in necessary and chosen occupations for parenting. Using information from the ESI assessment, key family members and professionals were supported in learning and understanding how to best communicate to support successful parenting and social interactions with mother and baby. This included how to share information, follow instructions or provide positive role models for the mother to learn from.
Following 4–6 weeks’ intervention at/before discharge, a second ESI was completed. Two more social exchanges were observed and rated, and scores were entered into the ESI software. A second ESI progress report was generated, which displayed both measures of social interaction (before and after intervention). Any change in overall social interaction is displayed graphically along the ESI measure (see Figure 1). These ESI results contributed to team decision-making by mapping progress and facilitated decisions about discharge from the unit.
An example of an Evaluation of Social Interaction (ESI) progress report.
Re-evaluations were completed with eight of the mothers. Three mothers were discharged before re-evaluation was completed and one chose not to participate in the re-assessment (Table 2). Of the eight mothers re-evaluated, seven (88%) demonstrated statistically significant change whereby the two ESI measures differed by at least the sum of the standard errors for each ESI measure (at p ≤ 0.15 as specified in the manual (Fisher and Griswold, 2018: 190)).
Results of Evaluation of Social Interaction (ESI) evaluations before and after intervention.
NOTE: All changes (in logits) from before to after interventions are significant except Mother 10 (a negative value indicates a deterioration of –0.1, which is not significant).
Implications for practice
The introduction of the ESI into the mother and baby unit highlighted three changes.
Strengths and limitations of specific social interaction skills were easily identified from the results of the ESI. This enabled mothers (and key social partners) to be aware of the good quality social interactions needed for the infant’s development and effective parenting. Knowing what their strengths were enabled mothers to draw on these when interacting with social partners (often adults) and work towards improving less competent social interactions (typically with their infant). Mothers reported feeling more confident and motivated when they could see changes (improvements) in their ESI scores. Information from the ESI, such as strengths with transitions, thanks, gesticulates and clarifies; and limitations with acknowledges/encourages, matches language, replies, looks, takes turns and empathises (see Table 1), assisted with much more focused and collaborative working by all members of the team. The ESI enabled the team to assess and clearly document social interaction observations of mother and baby in a standardised way. Documenting strengths with mothers helped strengthen the therapeutic relationship; having demonstrable outcomes assisted with discharge planning and identifying levels of support needed on returning home. Being able to record baseline and post-intervention measures enabled the team to document quantitative outcomes as evidence of changes in the mother’s occupational performance and improvements in her social interactions. Preliminary findings suggest the ESI is appropriate for use in mother and baby mental health units. ESI results focused discussions on actual observations of individual mothers about the quality of their social interactions with their infant and other relevant social partners, and these could be tracked during her recovery journey. The ESI helped the team to coordinate together with mothers, a service approach that aimed to improve specific and individual aspects of mothers’ interactions that supported bonding and safe and effective parenting. Moreover, including the ESI in the assessment process enabled the team to work together, alongside each mother, to address each mother’s mental health needs, thus contributing to the need for demonstrable service outcomes.
Summary
Occupational therapy is still a relatively new role within mother and baby mental health services in the United Kingdom. In this small-scale practice analysis, the multi-disciplinary team were able to explore together a common approach to assessing the quality of the mothers’ social interactions and whether the ESI results supported parent-focused goals and interventions. Preliminary evidence suggests the changes that resulted supported improved team-working and more collaborative interventions that were relevant to mothers in preparing for discharge from the unit. The team were better able to describe and document outcomes for individual mothers and for the unit overall. To our knowledge, the ESI has not been used previously in this setting. The small numbers of participants in the study, along with the lack of service user opinion, are limitations of this evaluation. Further work is now required to test the ESI in a larger study and seek qualitative feedback from participants on the acceptability of the assessment in this setting. Furthermore, it was noted that some social interaction skill limitations, such as places self, looks, turns towards, replies and takes turns, were common for many mothers. Further evaluation, in a larger study, could also explore if there is a relationship between these skill limitations antenatally and those who go on to experience difficulties bonding with baby.
Key messages
The ESI helped mothers to understand the importance of good quality social interactions with baby and key social partners and provided the team with a way of documenting relevant and specific qualitative information as well as a quantitative measure of team outcomes.
Preliminary findings suggest the ESI may be an appropriate tool to help target occupation-focused interventions for mothers in mother and baby mental health units and provide individual and service outcomes.
Footnotes
Acknowledgements
The authors wish to thank all the staff at the mother and baby unit for their support and collaboration through this service evaluation.
Research ethics
The trust lead for research and development was consulted and advised that ethical approval was not required for this practice analysis as changes introduced were part of usual treatment.
Consent
Consent was not applicable or required for this practice analysis.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The authors acknowledge funding of £1000 from the Royal College of Occupational Therapy for the AMPS UK and Ireland Research and Development Award.
Contributorship
Belinda Williams – conception of the idea, collected and analysed primary data, literature review, co-writing/reading of all sections of the article.Gill Chard – development of the idea and methodology, literature review, data analysis, co-writing/reading of all sections of the article.