THE IMPORTANCE OF SOCIOEMOTIONAL WELL-BEING
Infant mental health (IMH) has been defined as the healthy socioemotional development of the child (Zero to Three, 2001). Its quality has a pervasive effect on long-term well-being, including personal, social, academic, labor market, and community outcomes (Goodman, Joshi, Nasim, & Tyler, 2015; National Scientific Council on the Developing Child [NSCDC], 2012). Intercepting early socioemotional difficulties has become important for practitioners and policymakers alike (Allen, 2011; Tamminen & Puura, 2015). Such efforts are likely to be most effective when they account for the complex interplay between genetic and environmental risk and protective factors that give rise to early mental health difficulties (O'Connor, 2016). Environmental influences occur across multiple levels including parental characteristics, family structures, and the wider community (Sameroff, Seifer, & McDonough, 2004). Poverty can be especially damaging as it impinges on family processes and the quality of children's home, early childhood, and neighborhood environments (Wadsworth, Evans, Grant, Carter, & Duffy, 2016).
SYSTEMS APPROACHES TO IMH PROMOTION
There have been calls for IMH principles to be embedded into the diverse environments and systems that surround children and families (Finello & Poulsen, 2011; Osofsky & Lieberman, 2011). Zeanah, Stafford, Nagle, and Rice (2005) provide a blueprint to this end, envisaging a service continuum encompassing three nested levels of IMH provision. At the most distal level are universal and preventive services that aim to optimize parenting skills and child development, found primarily in health care, childcare, and family support settings. Next are focused services for at-risk families, for example, home visiting for adolescent mothers. Finally, tertiary interventions offer intensive supports, most commonly channeled through mental health services, such as those targeting acute difficulty within the parent-infant relationship. The blueprint is underpinned by the goal of enhancing parents' skills; service providers' capacity to identify, address, and prevent IMH difficulties; and the provision of appropriate, targeted services for those most in need of support.
In reality, most IMH initiatives reside at the two innermost levels focusing on the immediate family contexts of at-risk children (Zeanah, Stafford, & Zeanah, 2005). While such initiatives are critical to IMH promotion (Axford et al., 2015), their impact is likely to be enhanced by strengthening IMH in the wider community and societal networks in which they reside (NSCDC, 2012; Sameroff, 2000). These include universal and preventive contexts, such as prenatal and primary health care and childcare settings, and more specialized settings, such as welfare and early intervention services (Ashby, Scott, & Lakatos, 2016; Finello & Poulsen, 2011; Perry & Conners-Burrow, 2016). However, practitioners in these fields often have little, if any, mental health training, and the adoption of IMH principles and practices can represent a shift in scope and working practice (Goble & Laurin, 2016; Hinshaw-Fuselier, Zeanah, & Larrieu, 2009; Steed & Roach, 2017). Consequently, some efforts have been made to build awareness of IMH principles and practices through training and supervision. Examples of such strategies in mental health and childcare services have demonstrated increases in IMH provision for young children and improvements in children's socioemotional health, respectively (Knapp, Ammen, Arnstein-Kerslake, Poulsen, & Mastergeorge, 2007; Perry & Conners-Burrow, 2016).
A true continuum of care, however, must raise capacity to promote IMH across multiple services (Finello & Poulsen, 2011). An inherent challenge is meeting the varied training needs of stakeholders with disparate backgrounds and credentials (Weston, 2005). Mental health practitioners often lack knowledge of infant development, whereas those who work directly with infants are rarely trained in mental health (Hinshaw-Fuselier et al., 2009). Initiatives associated with the Harris Professional Development Network (Nelson & Mann, 2011; Osofsky, Drell, Osofsky, Hansel, & Williams, 2016; Thomas, Osofsky, & Powers, 2012), the US and UK Brazelton centers, the Bright Futures guidelines (Hagan, Shaw, & Duncan, 2007), and the World Association for Infant Mental Health (Priddis, Matacz, & Weatherston, 2015) have sought to raise capacity of different service stakeholders through training and supervision, often using an area-based approach. Yet, there has been little evaluation of these initiatives, thus limiting their ability to guide others seeking to adopt similar approaches.
CAPACITY BUILDING IN COMMUNITY HEALTH PROMOTION
Capacity building offers a means of promoting health, in the present case IMH, across a community by changing the community's ability to address health issues through new structures, approaches, and/or values (Crisp, Swerissen, & Duckett, 2000). Acting as a parallel track to health promotion programs, it helps both realize and sustain outcomes (Simmons, Reynolds, & Swinburn, 2011). Reorienting a whole community system to IMH offers long-term gains, but doing so successfully can be challenging and requires a high level of support (Hawe, King, Noort, Jordens, & Llyod, 2000). Hawe et al. (2000) present a capacity-building model that includes three dimensions: infrastructure and service development of new programs, sustainability to ensure that programmatic responses can become independent, and problem-solving capability that refers to more generalized community capacity. Bowen (2000) highlights how this framework is helpful not only in providing a means to define and measure the “invisible work” of health promotion but also in situating capacity building in the context of both programs and wider systems such as communities.
Core components of community capacity building (Hawe et al., 2000; Simmons et al., 2011) include, but are not limited to, ingredients such as strong leadership and vision, as well as an ability to re-envision and acquire resources (Labonte & Laverack, 2001). Applied to IMH, this involves the coordination of services that do not necessarily easily relate (e.g., childcare, welfare, and health services) and may necessitate innovative redistribution of funding (Finello & Poulsen, 2011; NSCDC, 2012). Skill development is essential and should begin with the participation of individual stakeholders, yet it should also transcend to an organizational level (Crisp et al., 2000). This necessitates collaboration and group and collective activities to mobilize intracommunity networks and support (Simmons et al., 2011). Cultivating such relationships in the multidisciplinary IMH context may be difficult if professionals are reluctant to work with those from different training backgrounds (Hinshaw-Fuselier et al., 2009).
IMH IN THE IRISH CONTEXT
Despite some references to IMH in Irish health policy (Department of Children and Youth Affairs, 2014; Department of Health, 2013), the concept of IMH is relatively new and largely unknown, and resource provision within public services is limited. For example, specialist maternity mental health services are virtually nonexistent (Begley et al., 2010), with a significant disparity between the professional body for psychiatrists' assessment of actual and required (1.5 vs 18 full-time equivalents) consultant perinatal psychiatrists (College of Psychiatrists of Ireland, 2013; submission paper to the public health service [Health Service Executive; HSE] Medical Education and Training Unit). Similarly, the Heads of Psychology Services Ireland workforce planning report to the HSE and Department of Health and Children conservatively calls for an approximately 30% workforce increase in psychologists, with particular expansion needed in child and adolescent mental health services (CAMHS; Kelly, Byrne, & Faherty, 2012). Moreover, although 12.5% of 3-year-olds exhibit challenging behavior (Williams, Murray, McCrory, & McNally, 2013), only 1% of cases seen by statutory CAMHS relate to 0–4-year-olds (HSE, 2013).
Nonetheless, there is growing momentum at the grassroot level through associations devoted to IMH. Specifically 2004 saw the establishment of a branch of the Marcé Society for Perinatal Mental Health in the United Kingdom and Ireland, followed by the formation of the Irish Association for Infant Mental Health (IAIMH) in 2009. Using a capacity-building principle, the IAIMH has helped develop four independent area-based multidisciplinary IMH network groups offering training and reflective practice (Maguire & Matacz, 2012). In 2014, The Psychological Society of Ireland, Special Interest Group in Perinatal and Infant Mental Health, was created to establish IMH as a domestic mental health specialty.
READY, STEADY, GROW
The present study investigates Ready, Steady, Grow (RSG), an IAIMH affiliated IMH network. Ready, Steady, Grow is one strand in a suite of six initiatives of “youngballymun.” Established in 2007 through joint philanthropic and statutory funding, youngballymun is a 10-year prevention and early intervention strategy operating in a disadvantaged area of North Dublin (Stellenberg & Fanning, 2012). As described by Harvey (2015), the community, which consisted of approximately 16,000 residents in 2011, includes both high- and low-rise housing. The catchment area is designated with disadvantaged status and exhibits high rates of male (37%) and female (26%) unemployment, single parent families (60%), and public housing (52%).
Capacity building is central to the youngballymun model as is reflected in the supports provided for training, mentorship, and interagency collaboration. Charged with serving the 0–3 years age group, RSG is based on the mental health needs of local 4-year-old children (Hayes & Bradley, 2006). A resource assessment subsequently identified a need for sensitive, nonjudgmental ante- and postnatal support; education and information for parents; socioemotional, psychological, and developmental support for children; and the streamlining of local infant health services (Matthews et al., 2007). A service design team comprising representatives from local service providers was convened to design RSG, in collaboration with the Michigan Association for Infant Mental Health (MI-AIMH), and in partnerships with the HSE Speech and Language Therapy, Primary Care Psychology Services, and Public Health Nursing teams, and local community partners.
Ready, Steady, Grow originally comprised three components: an antenatal care program, an IMH training and service model, and the Parent–Child Psychological Support Program (PCPSP). The PCPSP is a center-based service delivering individually tailored interventions to promote infant well-being (0–18 months) in the parenting context. The PCPSP prescribes six visits when infants are 3, 5, 7, 12, 15, and 18 months old, in addition to an introductory session. The program employs physical and mental health screening with a specific emphasis on the caregiver–infant dyad. This includes assessments of height, weight, nutrition, and motor, cognitive, and socioemotional development, as well as brief structured assessments of parent–child interaction. Feedback on this interaction to parents seeks to sustain and promote attunement and synchrony as a means of cultivating secure infant attachment (Cerezo, 2012). Two additional visits are prescribed for families requiring further support as well as onward referral to medical, social work, and speech and language agencies, local community groups, outreach workers, and counseling services.
Implementation of RSG's capacity-building activities commenced in 2009. By 2012, RSG was clearly articulated as an IMH strategy involving a number of services for the 0–3 years age group (Stellenberg & Fanning, 2012, and http://www.youngballymun.org/our_work/ready_steady_grow). The strategy includes five nested spheres each with its own program of work and aligns closely with the model of Zeanah et al. (2005). The strategy seeks to develop (a) parent capacity through the PCPSP and a range of referral services. Referral services include weekly parent and baby/toddler groups, a workshop series codelivered by public health nurses covering postnatal depression, sleeping and feeding, baby massage classes, the Incredible Years Toddler program to strengthen parenting skills and socioemotional development, the Hanen You Make the Difference parent program to promote attuned parent–child interactions with a particular focus on language, and individual therapeutic IMH interventions delivered by a primary care psychologist and the CAMHS team in cases of significant vulnerability/risk. This is complemented by efforts to strengthen (b) practitioner capacity through training, supervision, and consultation; and (c) service capacity through interorganizational collaboration and new and strengthened referral pathways (b and c are described in further detail in the method). This is further supported by (d) the integration of IMH into the national policy framework through the assembly of a nationwide working group undertaking formal policy submissions and dissemination to other interest groups. The final sphere (e) involves broad dissemination activities targeting senior health service managers, heads of discipline, and governmental and agency-level policymakers (the strategy is described in more detail in Supplemental Digital Content and depicted in Figure A.1, available at: http://links.lww.com/IYC/A7, and a timeline of key implementation milestones and activities is presented in Supplemental Digital Content Table A.2, available at: http://links.lww.com/IYC/A7).
In this way, RSG's capacity-building model spans programs and the wider community and societal systems incorporated in the model by Hawe et al (2000). The need for local effort to instigate and guide RSG's design reflects the infrastructural dimension of the model. The development of the PCPSP and strategies to raise practitioner and service capacity encompass sustainability and problem solving to the extent that they represent a community response to local IMH need.
The current study presents a process evaluation of RSG as a case study of a capacity-building approach to health promotion, in this case IMH. The study focuses on RSG's attempts to raise practitioner and service capacity (b and c) using a sequential mixed-methods design (details of the impact/outcome evaluation relating to the PCPSP are reported in University College Dublin [UCD] Geary Institute and UCD School of Psychology, 2013). This study seeks to provide theoretical and practical insights regarding the capacity-building activities used by RSG and to identify the factors that contribute to and hinder its success. The research question was as follows: how and to what extent has RSG built the capacity of the service community around the prevention of young children's health and developmental risk?
Research context: RSG's IMH capacity building
RSG's capacity building was delivered through a training program developed in collaboration with the MI-AIMH, regional branches of the Irish health service, and the IAIMH. The training aimed to promote infant and toddler socioemotional development by increasing the IMH knowledge and skills of service providers working with young children and their families. An IMH mentor was seconded from the MI-AIMH (∼20 months) and took up post in August 2010 to facilitate the delivery of the capacity-building activities. These activities targeted frontline practitioners from community and statutory services. (Supplemental Digital Content Table A.2, available at: http://links.lww.com/IYC/A7, presents a timeline of milestones and activities.)
First, a series of introductory sessions was delivered including two half-day workshops delivered to 40 service providers by two HSE clinical psychologists/MI-AIMH-endorsed IMH specialists (November 2009). The workshops covered definitions of IMH, IMH principles and strategies, attachment, socioemotional development and emotional regulation, and the intergenerational transmission of parenting influences, drawing on videotaped case material (see Supplemental Digital Content A.3, available at: http://links.lww.com/IYC/A7, for additional detail). Master classes on IMH topics including “Developing Reflection on IMH Practice,” “Infant Brain Development” and “Social Emotional Development” were provided to 150 delegates who attended an IMH conference (December 2009). In addition, a further IMH policy and practice master class “Keeping the Baby in Mind in youngballymun. The Importance of the Early Years: Building a Foundation for Social and Emotional Health” covering IMH principles and practices was provided by Dr. Deborah Weatherston to practitioners and policymakers (January 2010).
This was followed by the main training program, which was competency based following the endorsement model used by the MI-AIMH (http://www.mi-aimh.org/) and was led by the MI-AIMH mentor seconded to RSG. Two programs were delivered (see Supplemental Digital Content A.3, available at: http://links.lww.com/IYC/A7, for additional detail). The first program targeted paraprofessionals providing family support and home help (a service that assists vulnerable families by providing support and practical help with day-to-day tasks and activities) and included four sessions on “A Safe Harbour from Stormy Seas; Supporting the Ballymun Home Support Team” (n = 28) in January–March 2011, and four sessions on “Supports for Strengthening Families” in January and February 2012. Sessions covered information on attachment theory, brain development, IMH principles, and practical strategies for supporting healthy infant development, promoting positive parent–child relationships, working in a home visiting context, and self-care, using practical/group exercises and review of case material. The second program targeted multidisciplinary clinicians working across the community (including psychology, speech and language therapy, public health nursing, social work, youth work, and early childhood care and education; n = 23) in March–July 2011, six sessions on “Supporting First Relationships.” Sessions covered information on IMH principles and attachment and practical strategies for adopting IMH strategies and practices in assessment and the promotion of sensitive caregiving and positive parent–child relationships, drawing on practical/group activities, review of case material, and key IMH readings.
The IMH mentor also provided monthly reflective supervision to primary care and CAMHS psychologists and senior RSG staff where clinicians received professional guidance and support and were encouraged to reflect on their practice as a means to develop IMH competencies. The IMH specialist also provided monthly consultation to early childhood care and education settings. In addition, a monthly IMH study group was established to provide peer support and to deepen knowledge and understanding through case studies, literature reviews, reflection, and peer supervision. Finally, all RSG staff were purposefully seconded from public services to their RSG roles to maximize capacity within existing human resource provision. In addition, staff dedicated to the PCPSP received 16 days of training in program delivery (Cerezo, 2012).
These activities were set within RSG's efforts to promote collaborative working across the service community through codelivered services and the enhanced provision of mental health services through the establishment of referral pathways between the PCPSP and primary and tertiary care.
The present study is a mixed-methods evaluation of RSG's area-based IMH strategy focusing on its capacity-building activities within the service community. It formed part of a process evaluation, which aim to explore the implementation, receipt, mechanisms, and context of an intervention and are especially important when interventions seek to alter whole systems (Moore et al., 2015). The process evaluation adopted a mixed-methods sequential exploratory research design (Cresswell, 2014). First, a review of capacity-building literature and relevant RSG policy and practice documentation was conducted. This informed the design of exploratory qualitative interviews with stakeholders who had undergone IMH training to capture the views of those with direct experience of RSG's capacity-building activities. The interviews further aimed, in combination with the literature, to develop an index of topics that could be incorporated into a survey administered to a wider group of stakeholders, who may or may not have received IMH training. Finally, an integration of the interviews and survey results was conducted to draw conclusions regarding how and to what extent RSG developed IMH capacity. The use of multiple methods is in keeping with the recommendations of Hawe et al. (2000) for the assessment of capacity-building indicators at the community level. The study was exempt from full review by the institution's ethics committee due to its low-risk nature.
The process evaluation ran concurrently to a pre-/postimpact evaluation of the PCPSP on parent and child outcomes (see UCD Geary Institute and UCD School of Psychology, 2013, for full report). Despite high levels of reach (71.6% of those invited participated in the program), engagement was less successful (only 69% completed three or more PCPSP visits). In terms of outcomes, there were some positive changes observed for parenting stress, parental sense of competence, and specific aspects of parent–child interaction. However, there was no evidence that the program had an impact on child development when PCPSP families were compared with a sociodemographically matched comparison group that did not receive the program. Furthermore, while posttreatment levels of secure attachment were generally good, this was not driven by program dosage. While the current process evaluation extends beyond the PCPSP, to include all capacity-building activities that took place, these results are likely to provide valuable information regarding the broader service context within which the main program was set. Moreover, the limited impact of the PCPSP accentuates the importance of RSG's wider success in raising IMH capacity.
Participants, sampling, and recruitment
For the interviews, a sampling frame was designed consisting of 48 stakeholders in the RSG catchment area who were purposefully selected as they had attended one of the main IMH training programs in 2011, or were a member of RSG staff. This led to a sampling frame comprising three stakeholder groups including (a) those not engaged in direct service delivery (e.g., program coordinators and adult mental health professionals, n = 10), (b) local service delivery practitioners (e.g., public health nurses, speech therapists, n = 11), and (c) paraprofessional service delivery personnel (all family support and home help workers, n = 27). As the groups were unequal in size, 10 participants were interviewed from each subgroup; all 10 participants in the first group and 10 randomly selected participants from the latter two groups (Onwuegbuzie & Collins, 2007). Twenty-three of the 30 invited stakeholders (77% response rate) participated in the interviews. Interview participants' gender and area of work are detailed in Table 1.
For the surveys, a wider stratified sampling frame was used. It consisted of 118 stakeholders working across a range of services with parents and children in the RSG catchment area (including those who had and had not received IMH training) and was designed to access perspectives that were more representative of the wider service community. The final sample was reviewed to ensure that it represented professionals working across different organizational levels from senior management to frontline staff (Crisp et al., 2000) and targeted diverse areas of work including family care/home support, youth work, midwifery, general practitioners, community mental health/public health/practice nursing, program administrators/supervisors/coordinators, facilitators of parenting programs and parent/toddler groups, social work, psychology, speech and language therapy, early childhood care and education, psychiatry, and physiotherapy. It also included members of the three groups included in the interviews. Stakeholders were sent the survey by youngballymun, with a total of 40 individuals (37% response rate) participating. Table 1 details the survey respondents' characteristics. Participants had an average of 13 years' experience working in their current area and the majority were female and between 35 and 54 years of age.
Interview and survey development, data collection, and analysis
A semistructured interview schedule informed by the capacity-building literature was developed (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/IYC/A7). The schedule covered five main topics: (1) the stakeholders' role and their relationship to IMH; (2) knowledge and perceptions of RSG; (3) knowledge of, engagement in, and perspectives on IMH capacity building; (4) involvement with and perceptions of the local service community; and (5) perspectives on working practices prior to RSG implementation. Survey questions were developed to include salient themes identified in the stakeholder interviews, in addition to themes outlined in the capacity-building literature (see Supplemental Digital Content Appendix B, Table B.1, available at: http://links.lww.com/IYC/A7). Closed questions covered five areas: (1) perceptions of RSG; (2) perspectives on IMH; (3) perspectives on RSG's capacity-building activities; (4) perceptions of service use relating to RSG programs offered to families; and (5) perspectives on collaboration between stakeholders in the target community.
Interviews, approximately 45 min, were conducted from October to December 2011 in each participant's location of choice by two of the authors (J.L. and G.V.). The survey was distributed by post/mail in February 2012, shortly after the interviews, to limit the influence of temporal trends.
All interviews were transcribed and anonymized before being uploaded to Nvivo 9. Transcripts were analyzed using the principles of thematic analysis (Braun & Clarke, 2006) using both inductive and deductive techniques allowing for the identification of new themes from the interviews as well as those themes already present in the literature. Two researchers assigned initial codes to the transcripts, where codes represented small chunks of the transcript seen to have meaning to the topic. Coding reliability was assessed by assigning a common transcript to both coders and comparing the responses (Guerin & Hennessy, 2002). A high level of agreement was observed and discrepant codes were discussed until agreement was reached. One researcher then worked toward the identification of a framework of themes among the individual codes. Next, the transcripts, codes, and themes were reexamined to further “define and refine” (Braun & Clarke, 2006, p. 92) the themes into a meaningful, coherent pattern that provided a fair and comprehensive overview of the data. Survey data were analyzed descriptively using SPSS. The results of the interviews (see Supplemental Digital Content Table B.2, available at: http://links.lww.com/IYC/A7) and surveys were integrated thematically by two of the authors by comparing interview subthemes and descriptive results for individual survey questions to identify meaningful patterns of commonality and divergence.
The thematic integration of the interviews and surveys resulted in an expanded thematic framework that retained and built on the essence of the original interview themes (confidence in youngballymun, concern about sustainability, frustration about resources), while developing a new theme to reflect IMH capacity more directly. This resulted in four final themes: strong groundwork and enthusiasm, preliminary IMH capacity, a dearth of sufficient resources, and concern about sustainability.
Strong groundwork and enthusiasm
Interview and survey participants were positive about the groundwork that had been laid for IMH capacity development. Interview participants reported that youngballymun had a strong local presence and was generally well regarded, and RSG appeared to benefit from this reputation. Although RSG was recognized to be in its infancy, stakeholders described it as a positive local development, and RSG's IMH capacity-building initiatives were greeted with enthusiasm. As one stakeholder reported: “They're very positive and very willing and eager to develop capacity ..., I get this sense of eagerness and enthusiasm.” The survey results also suggest that many of the conditions for effective capacity building have been established, with the majority of stakeholders indicating that RSG has a clear strategy (89%; n = 321), vision of what they want to achieve (97%; n = 34), and leadership (72%; n = 26).
In addition, there was evidence of stakeholders' personal commitment to IMH. Survey stakeholders endorsed IMH as being either very relevant or relevant to their role (92%; n = 34), an important issue for the target community (97%; n = 37), and being committed to the concept of IMH and raising awareness of it in the target community (100%; n = 37). However, despite individual stakeholder commitment to IMH, there was a sense that further buy-in could be cultivated at an organizational level. Table 2 shows that surveyed stakeholders identified a lack of interest in collaboration between organizations and a disconnect between RSG trying to build capacity and organizations embracing of that idea as the second and third most significant barriers to capacity building.
Preliminary IMH capacity
Participants indicated evidence of preliminary IMH capacity in the service community, as well as scope for further development. The IMH training was endorsed by surveyed stakeholders as being key, with direct training by RSG of frontline staff ranked as the most important factor contributing to successful capacity building (Table 3). Having formal opportunities to share IMH knowledge within and between organizations was ranked second.
Accordingly, the RSG IMH training program/supervision was perceived positively, as the following interview comments illustrate: “[I] loved those training afternoons”; “they really did give us something that was probably overly needed”; “I think certainly the supervision makes a big difference and gives you the confidence to try it [IMH] out.” Yet, a minority of interviewed stakeholders found the training less relevant and suggested that the pace was too slow. Similarly, surveyed stakeholders generally held positive views of training/events with three-quarters (78%; n = 29) indicating that RSG provided relevant staff with appropriate training, and a similar proportion (74%; n = 29) reporting that they had attended meetings/events run by RSG, mostly reported to be good or excellent (86%; n = 25). Those who attended the training (n = 17) were equally positive, indicating that it had benefited their work (88%; n = 15) and they have had the opportunity to apply the skills (94%; n = 16).
In addition, the concept of IMH appeared to have gained traction among surveyed stakeholders. There was a high level of familiarity with the IMH term as most stakeholders reported first hearing the term over a year ago (65%; n = 26). Furthermore, Table 4 (statements 1–4) shows that the majority of stakeholders agreed with a number of broad IMH statements. For example, three-quarters agreed that “the parent is the expert on the baby.”
Despite evidence of preliminary capacity, reports also indicated opportunities for further IMH training and activities. Nearly half of stakeholders identified that there were insufficient IMH-related community activities (45%; n = 18). Some interview stakeholders reported their desire/need for further training and yet held concerns about their organizations having the necessary resources. Similarly, 82% (n = 14) of surveyed stakeholders indicated that although they were confident in their skills, they would like further RSG training. Table 5 shows higher levels of desired, compared with actual, stakeholder involvement in each decision-making category (informed, consulted, and responsible). Although 25% reported not being involved in key decisions relating to community IMH activities, only 5% believed that this should be the case. This corresponds with a disparity between those reporting being (13%), versus those who believed they should (23%), be consulted in key IMH decisions.
A dearth of sufficient resources
Both interview and survey stakeholders recognized insufficient resources as an obstacle to the potential of an IMH approach. A dearth of financial resources was highlighted by interviewed stakeholders as a major barrier as demonstrated in the following quotation: “I think it's probably a difficult time to be trying to build capacity in communities because of the nature of resources ... the purse strings are being tightened nicely so I think that probably makes it more difficult.” Similarly surveyed stakeholders rated a lack of financial resources as the leading barrier to IMH capacity development (Table 2).
A number of related issues were also highlighted by some interviewed stakeholders. This included a lack of staff replacement, which was linked to pressurized working environments, as indicated in the following quotation:
[My colleague] is on maternity leave and there isn't anyone else at the moment ... her role won't be filled through [core] funding, unless through other funding, so there really is nobody else at the moment.... I'm kind of concerned, motivation at the moment among the [staff] is quite low. We don't have any staff, we're run from billy to jack and it's just very difficult to keep providing a service ... obviously, IMH doesn't become the priority when you've got no staff.
Stakeholders also noted the organizational pressure to quantify work output in terms of client turnover as a restrictive factor. One participant drew attention to the varied and perhaps immeasurable nature of their work saying:
Some people need a real longer term outreach ... that is something you can't show at the end of the year in your statistics ... the manager says what were you doing with your time here? There is someone else on the waiting list.
Furthermore, stakeholders who deal with broad age ranges of clients reported difficulty in allocating resources to infants, as is seen in the following quotation: “It's been difficult for us resource-wise as we can't take on working with babies as well as everything else.”
Collectively, these conditions were described as limiting the amount of time and effort stakeholders could devote to IMH, as highlighted by the following two participants: “There is not enough of time going into the children. We get an hour, in some places I get half an hour. A half hour is no use to nobody.”; “They approached us to get involved [in further IMH] but we don't have the time.” This perspective was shared by a quarter of surveyed stakeholders (27%; n = 10) who indicated that they could not make sufficient time to identify and address IMH requirements with their current work demands. In addition, half of surveyed stakeholders reported their desire/need to identify and address IMH needs but not having the resources to do so (51%; n = 20).
Concern about sustainability
Sustainability was another area of concern. There was a sense among interviewed stakeholders that the longevity of an IMH culture may be difficult to secure beyond RSG's lifetime. As one stakeholder commented: “They've created something that's working really well, I think, ‘oh God, what's going to happen when they go?.’ That's the bit that worries me.” The phased withdrawal of a RSG-based IMH consultant generated particular concern among interviewed stakeholders who were apprehensive about whether momentum could be sustained in her absence, as conveyed in the following quotation:
I'm a bit anxious about it, how we're going to hold it together ... that's what her role is, so she's the person who holds that and can bring it along kind of whereas the rest of us are learning it and getting to know it.
At the service community level, stakeholders also referred to the ongoing need for organizations to take ownership of the IMH approach and responsibility for its realization. One interview participant noted: “It's one thing for RSG to inform other services about it [IMH], it's another thing for the other services to ... nurture that more and discuss it and re-discuss it and bring it back within our own services.” For some stakeholders, this involved ensuring that IMH capacity was not solely dependent on specific individuals, as is highlighted by the following quotation:
Sustainability is a big barrier. Like how to sustain and really, how to embed it in services I think still needs to be done. I am one professional here. If I ... leave here and get another job ... well then they've lost one of their connections.
Surveyed stakeholders gave less emphasis to sustainability. Although a considerable proportion (47%; n = 17) agreed that RSG's success was the direct result of a few committed individuals, the majority indicated that RSG's work was sustainable in the long term (74%; n = 28).
This article presents a case study of RSG as a capacity-building model applied to IMH promotion and may provide insights for those seeking to adopt capacity-building models for other areas of child health promotion. The findings suggest that the RSG model has been successful in establishing many of the components thought to be essential to effective capacity building including perceived leadership, vision, and strategy (Hawe et al., 2000; Simmons et al., 2011). Overall, stakeholders embraced RSG, the IMH agenda, and RSG's efforts to promote knowledge and skill development. This reflects the stakeholder commitment and participation that underpin successful community capacity-building efforts (Hawe et al., 2000). Such traction in a short 2-year period, and in systems with little IMH tradition and infrastructure, is noteworthy and may be relevant for communities with similar profiles.
There is evidence of some nascent IMH capacity, reflecting preliminary skills in the service community. In addition, the development of an IMH study group could be considered a signal of the social support and grassroots problem solving that are central to capacity-building success (Hawe et al., 2000). Yet, there is a strong sense that this work remains gradual and ongoing. Many stakeholders desired more involvement in IMH decision making and greater service community engagement with the IMH agenda. There was also a sense that there was room to cultivate greater shared vision and collaboration within the service community, which is significant as both act as key mechanisms to engender hope, collective efficacy, and cohesion (Labonte & Laverack, 2001). This gap is unsurprising, given the level of innovation that IMH represents for Irish health provision, thus an ongoing process of stakeholder and service engagement is to be expected. Stakeholders also desired further individualized training opportunities, in keeping with best practice views that IMH training should be tailored and continuous (Finello & Poulsen, 2011; Priddis et al., 2015).
Critically, resources were central to the stakeholders' accounts. Stakeholders emphasized limitations in financial, human, and temporal resources as significant constraints to the integration of IMH into service practices. These concerns are to be expected, given cutbacks following the economic recession and are consistent with accounts that funding reductions have constricted domestic CAMHS provision and interagency collaboration (McElvaney, Tatlow-Golden, Webb, Lawlor, & Merriman, 2013). Yet, the issue of funding is not peculiar to Ireland, being highlighted in both US IMH provision (Zero to Three, 2012) and collaboration between perinatal and IMH services in Australia (Myors, Cleary, Johnson, & Schmied, 2015). The emphasis on resources is also in keeping with capacity-building models, where adequate resources are essential to bolster and potentiate community-level activity (Simpson, Wood, & Daws, 2003).
RSG's sustainability was also a concern for some stakeholders, although this varied across interviews and surveys. This discrepancy could be driven by the time lag between the methods (∼2–6 months) and may correspond with greater embedding of IMH principles and practices. Alternatively, it could reflect differences in the samples' proximity to the initiative and the IMH agenda. Regardless, initial apprehension regarding RSG's viability as important individuals withdraw from their roles is a natural reaction in the early stages of capacity building. The speed of the process, however, may be critical, as devolving community development initiatives too quickly may undermine success and jeopardize sustainability, which is the essential purpose of community capacity building (Simmons et al., 2011; Simpson et al., 2003).
These results should be considered cautiously in the context of the study's limited regional implementation and the methodological issues described later. The study benefited from a sequential mixed-methods design whereby maximizing our ability to investigate both exploratory (interviews) and confirmatory (survey) questions (Teddlie & Tashakkori, 2009), combining their complementary strengths and nonoverlapping weaknesses (Johnson & Turner, 2003). Yet temporal factors are important, given that the study ran concurrent to RSG's consolidation and evolution as an IMH strategy (Stellenberg & Fanning, 2012). Such developments are natural in the real-world applications of novel, complex community interventions and yet render meaningful evaluation more challenging (Hawe, Shiell, & Riley, 2004). In this way, the study is best considered as being a formative rather than summative account, which can be used in the ongoing modification of the initiative (Green & Tones 1999). Another limitation was the collection of data at one time point only. It would have been instructive to have matched survey data on core variables at baseline, following IMH training, and a longer term follow-up to provide more confident inferences about both initial signals and sustained changes in capacity.
In terms of the samples' composition, as the interview sample was purposefully recruited on the basis of attendance at training, it may have been biased toward individuals and organizations that were receptive to IMH. In contrast, the survey sought to reach across the wider service community, yet generalizability is an issue, given the low response rate and the absence of certain targeted stakeholder groups. Although roughly half of those surveyed had undergone IMH training, we do not have information regarding its intensity (introductory vs. main training). However, the response rate is consistent with other domestic postal surveys of professionals (Harnett, Dolan, Guerin, Tierney, & Walls, 2007) and may reflect local research fatigue due to four other youngballymun evaluations being conducted at the same time. The inclusion of RSG staff members provides valuable “insider” perspectives, yet it is difficult to delineate these views from the wider service community. Potential overlap in the survey and interview samples also makes it difficult to distinguish commonalities as representing duplication or consensus, or both.
Implications and future research
Despite these limitations, the study provides theoretical and practical insights for the burgeoning international IMH community and others seeking to adopt and evaluate capacity-building models for child health promotion. The salience of central tenets of the capacity-building model of Hawe et al. (2000) within stakeholders' accounts offers preliminary support for the broader utility of the framework within child health promotion. Nascent IMH capacity in a community characterized by high socioeconomic risk with limited existing IMH infrastructure suggests that “positive deviance” (Labonte & Laverack, 2001) is possible. If this is effective and sustained, capacity-building models (Hawe et al., 2000) predict that these skills should generalize to other health issues, for example, the detection of developmental disabilities. Success in raising capacity across the RSG community is likely to be especially valuable in light of only moderate benefits to parents (parental stress, self-competence, parent–infant interaction) and children (developmental quotient, attachment) identified in the PCPSP impact evaluation (UCD Geary Institute and UCD School of Psychology, 2013). Indeed, contemporary perspectives in community capacity building suggest that the development of competence and collaboration can generate independent and additional health outcomes (Simmons et al., 2011). Although it is possible that it may take longer than the 2-year evaluation period to see impacts on child outcomes, the PCPSP impact analysis suggests that families are likely to need a network of diverse early intervention supports from service providers with IMH competencies.
The challenges experienced by RSG are unlikely to be peculiar to RSG and thus may be noteworthy pitfalls for others undertaking capacity-building approaches. First, frequent, dependable, ongoing, and bespoke supports for training and supervision appear essential (Finello & Poulsen, 2011; Priddis et al., 2015). Second, targeted efforts may be needed to mobilize sufficient organizational and stakeholder participation and collaboration, particularly for those whose disciplinary background or organizational context contributes to their reticence. Further scoping to map organizations' progress in joining collaborative efforts and identify sources of resistance may help in selecting techniques specific to conflict (e.g., negotiation), rather than consensus models of decision making and change (Hawe et al., 2000). Identifying key personnel to diffuse information may also help shepherd an IMH approach into more reluctant areas of the service community (Mann, Boss, & Randolph, 2007). Third, although RSG's sustainability strategy (e.g., secondments) appears adaptive, it is important that stakeholders are supported in adopting increasing ownership for IMH.
Finally, and perhaps most challenging, is the need for external resources and systemic IMH infrastructure. The allocation of adequate human resources that meet minimum standards of recommended practice is central to the realization of IMH. To safeguard against future losses in capacity, IMH needs to be incorporated into relevant third-level curricula, such as welfare, health, mental health, early childhood care and education, and early intervention (Priddis et al., 2015). Like in other international settings, domestic models of care need to be reconfigured to account for the IMH needs of the 0–3s (Zero to Three, 2012). Services, such as CAMHS, are constrained not only by access to IMH training but also by their organizational remit to accept cases specific to infants and their families. Care must also be collaborative and integrative in a way that provides comprehensive, dependable, and seamless IMH provision for families (Myors et al., 2015).
In regard to future research, further published studies of IMH capacity-building initiatives are needed to inform the application of these models and ultimately policy and practice. It would be instructive to examine the respective contribution of capacity-building elements—for example, the presence of key individuals, vertical communication within organizations, or links between different community services—to help inform the allocation of resources within community initiatives. Valuable extensions on the study presented here would include more intensive assessment of competency growth, assessments of services' implementation of IMH principles, practices and fidelity after training, service users' experiences, and children's socioemotional outcomes (Knapp et al., 2007; Myors et al., 2015). Mapping the impact of increases in IMH capacity on children's referral pathways and the respective benefit of different interventions for child outcomes would be particularly valuable in light of only modest outcomes associated with the PCPSP. Finally, greater cross-national discussion regarding service design and evaluation may also help share knowledge and shape a global research agenda, similar to recent discourse in youth mental health (McGorry, Bates, & Birchwood, 2013).
This case study of RSG, a capacity-building approach to IMH promotion, is presented to offer theoretical and practical insights to those seeking to develop similar initiatives. RSG's initial progress points to the feasibility of such models in fostering IMH capacity in contexts of high socioeconomic risk and weak IMH infrastructure, which are likely to be mirrored in other international settings. However, our findings suggest that the long-term viability of such initiatives may hinge on their ability to foster strong stakeholder participation and collaboration, provide dynamic and bespoke training solutions, mobilize sufficient resources, and catalyze wider systemic change. Further research is needed to assess how other initiatives perform against capacity-building frameworks and with respect to their impact on service practices, service users' experiences, and children's outcomes.
Allen G. (2011). Early intervention: The next steps. An independent report to Her Majesty's government. Retrieved from https://http://www.gov.uk
Ashby B., Scott S., Lakatos P. P. (2016). Infant mental health
in prenatal care. Newborn and Infant Nursing Reviews, 16, 264–268. doi: 10.1053/j.nainr.2016.09.017.
Axford N., Sonthalia S., Wrigley Z., Goodwin A., Ohlson C. S., Bjornstad G., Toft A. (2015). The best start at home. Retrieved from http://http://www.eif.org.uk
Begley C., Higgins A., Lalor J., Sheerin F., Alexander J., Nicholl H., Kavanagh R. (2010). The strengths and weaknesses of publically funded Irish health services provided to women with disabilities in relation to pregnancy, childbirth and early motherhood. Retrieved from https://nursing-midwifery.tcd.ie/assets/publications/pdf/nda-report-final-2010.pdf
Bowen S. (2000). Capacity building
to improve health: A health promotion perspective. New South Wales Public Health Bulletin, 11, 28–29.
Braun V., Clarke V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa
Cerezo A. (2012). The parent-child psychological support programme: Promoting Infant Mental Health
in Irish children. ChildLinks, 2, 26–29.
College of Psychiatrists of Ireland. (2013). Workforce planning report 2013–2023. Retrieved from http://http://www.irishpsychiatry.ie
Cresswell J. W. (2014). Research design: Qualitative, quantitative and mixed methods
approaches. London: Sage Publications.
Crisp B. R., Swerissen H., Duckett S. J. (2000). Four approaches to capacity building
in health: Consequences for measurement and accountability. Health Promotion International, 15, 99–107. doi:10.1093/heapro/15.2.99
Department of Children and Youth Affairs. (2014). Better outcomes, brighter futures: The national policy framework for children and young people. Retrieved from http://http://www.dcya.gov.ie
Department of Health. (2013). Healthy Ireland: A framework for improved health and wellbeing 2013–2025. Retrieved from http://health.gov.ie/wp-content/uploads/2014/03/HealthyIrelandBrochureWA2.pdf
Finello K. M., Poulsen M. K. (2011). Unique system of care issues and challenges in serving children under age 3 and their families. American Journal of Community Psychology, 49, 417–429. doi:10.1007/s10464-011-9458-6
Goble C. B., Laurin D. E. (2016). Creating career pathways and infusing infant mental health
into early care and education professional preparation. Zero to Three, 37, 23–28.
Goodman A., Joshi H., Nasim B., Tyler C. (2015). Social and emotional skills in childhood and their long-term effects on adult life. Retrieved from http://http://www.eif.org.uk
Green J., Tones K. (1999). For debate. Toward a secure evidence base for health promotion. Journal of Public Health, 21, 133–139. doi:10.1093/pubmed/21.2.133
Guerin S., Hennessy E. (2002). Pupils' definitions of bullying. European Journal of Psychology of Education, 17, 249–261. doi:10.1007/BF03173535
Hagan J. F., Shaw J. S., Duncan P. M. (2007). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Harnett A., Dolan B., Guerin S., Tierney E., Walls M. (2007). Informing families of their child's disability: National best practice guidelines. Consultation and research report. Retrieved from http://http://www.fedvol.ie
Harvey B. (2015). Ballymun: A social profile 2007–2015. Youngballymun report. Retrieved from http://youngballymun.org/fileadmin/user_upload/performance_story_report/Foundational_Activities/Item_1_Ballymun_A_Social_Profile_2007-2015_Brian_Harvey.pdf
Hawe P., King L., Noort M., Jordens C., Llyod B. (2000). Indicators to help with capacity building
in health promotion. Sydney, Australia: NSW Health Department.
Hawe P., Shiell A., Riley T. (2004). Complex interventions: How “out of control” can a randomised control trial be? British Medical Journal, 328, 1561–1563. doi:10.1136/bmj.328.7455.1561
Hayes N., Bradley S. (2006). Ballymun needs analysis: Final report. Dublin, Ireland: Centre for Social and Educational Research, Dublin Institute of Technology.
Health Service Executive [HSE]. (2013). Fifth annual child and adolescent mental health service report. Retrieved from http://http://www.hse.ie
Hinshaw-Fuselier S., Zeanah P. D., Larrieu J. (2009). Training in infant mental health
. In Zeanah C. H. (Ed.), Handbook of infant mental health
(pp. 533–548). New York, NY: Guilford Press.
Johnson R. B., Turner L. A. (2003). Data collection strategies in mixed methods
research. In Tashakkori A., Teddlie C. (Eds.), Handbook of mixed methods
in social and behavioural research (pp. 297–319). Thousand Oaks, CA: Sage.
Kelly J., Byrne M., Faherty D. (2012). Heads of Psychology Services Ireland workforce planning survey report 2011. Retrieved from http://lenus.ie/hse/bitstream/10147/252652/1/HPSIWorkforcePlanningSurveyReport2011.pdf
Knapp P. K., Ammen S., Arstein-Kerslake C., Poulsen M. K., Mastergeorge A. (2007). Feasibility of expanding services for very young children in the public mental health setting. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 152–161. doi:10.1097/01.chi.0000246058.68544.35
Labonte R., Laverack G. (2001). Capacity building
in health promotion, part 1: For whom? And for what purpose? Critical Public Health, 11(2), 111–127. doi:10.1080/09581590110039838
Maguire C., Matacz R. (2012). Bridging the gap in service development in north cork primary and continuing care: The development and integration of an Infant Mental Health
Model into Existing Service Delivery. ChildLinks, 2, 30–34.
Mann T. L., Boss J., Randolph S. (2007). Pathways to prevention: A training and technical assistance initiative to increase program capacity to address infant mental health
issues in Early Head Start. Infant Mental Health
Journal, 28(2), 106–129. doi:10.1002/imhj.20125
Matthews A., Gallagher P., Redmond M., Dunne S., MacGabhann L., Staines A., Stevenson C. (2007). A needs and resource assessment to inform the design and development of an antenatal support and parent support program: A report prepared for youngballymun. Dublin, Ireland: School of Nursing: Dublin City University.
McElvaney R., Tatlow-Golden M., Webb R., Lawlor E., Merriman B. (2013). Someone to care: The mental health needs of children and young people with experience of the care and youth justice systems. Dublin, Ireland: Children's Mental Health Coalition. Retrieved from http://http://www.drugsandalcohol.ie
McGorry P., Bates T., Birchwood M. (2013). Designing youth mental health services for the 21st century: Examples from Australia, Ireland and the UK. British Journal of Psychiatry, 202, s30–s35. doi:10.1192/bjp.bp.112.119214
Moore G. F., Audrey S., Barker M., Bond L., Bonell C., Hardeman W., Baird J. (2015). Process evaluation of complex interventions: Medical Research Council guidance. BMJ, 350, h1258. doi:0.1136/bmj.h1258
Myors K. A., Cleary M., Johnson M., Schmied V. (2015). A mixed methods
study of collaboration between perinatal and infant mental health
clinicians and other service providers: Do they sit in silos? BMC Health Services Research, 15, 316. Retrieved from http://dx.doi.org/10.1186/s12913-015-0977-y
National Scientific Council on the Developing Child. (2012). Establishing a level foundation for life: Mental health begins in early childhood: Working Paper 3. Retrieved from http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/working_papers/wp6/
Nelson F., Mann T. (2011). Opportunities in public policy to support infant and early childhood mental health. American Psychologist, 66, 129–139. doi:10.1037/a0021314
O'Connor T. G. (2016). Developmental models and mechanisms for understanding the effects of early experiences on psychological development. In Cicchetti D. (Ed.), Developmental psychopathology (Vol. 1, pp. 156–198). New Jersey, NJ: Wiley.
Onwuegbuzie A. J., Collins K. M. T. (2007). A typology of mixed methods
sampling designs in social science research. The Qualitative Report, 12(2), 281–316.
Osofsky J. D., Drell M. J., Osofksy H. J., Hansel T. C., Williams A. (2016). Infant mental health
training for child and adolescent psychiatry: A comprehensive model. Academic Psychiatry. Advance online publication. doi:10.1007/s40596-016-0609-9
Osofsky J. D., Lieberman A. F. (2011). A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children. American Psychologist, 66, 120–128. doi:10.1037/a0021630
Perry D. F., Conners-Burrow N. (2016). Addressing early adversity through mental health consultation in early childhood settings. Family Relations, 65, 24–36. doi:10.1111/fare.12172
Priddis L., Matacz R., Weatherston D. (2015). Building a workforce competency-based training program in infant/early childhood mental health. Infant Mental Health
Journal, 36, 623–631. doi:10.1002/imhj.21535
Sameroff A. J. (2000). Ecological perspectives on developmental risk. In Osofsky J. D., Fitzgerald H. E. (Eds.), WAIMH handbook of infant mental health
. Infant mental health
in groups at high risk (Vol. 4, pp. 3–33). New York, NY: John Wiley & Sons.
Sameroff A. J., Seifer R., McDonough S. C. (2004). Contextual contributions to the assessment of infant mental health
. In DelCarmen-Wiggins R., Carter A. (Eds.), Handbook of infant, toddler, and preschool mental health assessment (pp. 61–76). New York, NY: Oxford University Press.
Simmons A., Reynolds R. C., Swinburn B. (2011). Defining community capacity building
: Is it possible? Preventive Medicine, 52, 193–199. doi:10.1016/j.ypmed.2011.02.003
Simpson L., Wood L., Daws L. (2003). Community capacity building
: Starting with people not projects. Community Development Journal, 38, 277–286. doi:10.1093/cdj/38.4.277
Steed E. A., Roach A. T. (2017). Childcare providers' use of practices to promote young children's social-emotional competence. Infants and Young Children, 30, 162–171. doi:10.1097/IYC.0000000000000092
Stellenberg A., Fanning M. (2012). Ballymun—an infant mental health
community: The Ready, Steady, Grow strategy. ChildLinks, 2, 17–21.
Tamminen T., Puura K. (2015). Infant/early years mental health. In Thapar A., Pine D., Leckman J., Scott S., Snowling M., Taylor E. (Eds.), Rutter's child and adolescent psychiatry (pp. 882–893). West Sussex: John Wiley & Sons.
Teddlie C., Tashakkori A. (2009). Foundations of mixed methods
research: Integrating quantitative and qualitative approaches in the social and behavioural sciences. London: Sage Publications.
Thomas K., Osofsky J. D., Powers S. (Eds.). (2012). Emerging issues in infant mental health
from the Irving Harris Foundation Professional Development Network [Special issue]. Zero to Three, 33(2).
University College Dublin Geary Institute and University College Dublin School of Psychology. (2013). Evaluation of the overall success and impact of Ready, Steady, Grow. Retrieved from http://http://www.youngballymun.org
Wadsworth M. E., Evans G. E., Grant K., Carter J. S., Duffy S. (2016). Poverty and the development of psychopathology. In Cicchetti D. (Ed.), Developmental psychopathology (Vol. 4, pp. 136–179). New Jersey, NJ: Wiley.
Weston D. R. (2005). Training in infant mental health
: Educating the reflective practitioner. Infants and Young Children, 18(4), 337–348.
Williams J., Murray A., McCrory C., McNally S. (2013). Growing up in Ireland: National longitudinal study of children. Development from birth to three years. Dublin, Ireland: The Stationery Office.
Zeanah P. D., Stafford B. S., Nagle G. A., Rice T. (2005). Addressing social-emotional development and infant mental health
in early childhood systems. Retrieved from http://files.eric.ed.gov/fulltext/ED496853.pdf
Zeanah P. D., Stafford B., Zeanah C. H. (2005). Clinical interventions to enhance infant mental health
: A selective review. Los Angeles, CA: National Centre for Infant and Early Childhood Health Policy at UCLA.
Zero to Three. (2001). Definition of infant mental health
. Washington, DC: Zero to Three Infant Mental Health
Zero to Three. (2012). Making it happen: Overcoming barriers to providing infant-early childhood mental health. Retrieved from http://http://www.zerotothree.org
1Percentages are valid percentages that account for missing data.