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Assessment of infant attachment: a role for health visitors?

Authors: Jane Barlow, Angela Underdown and Ann Pettit
Date: Feb. 2009
From: Community Practitioner(Vol. 82, Issue 2)
Publisher: Ten Alps Publishing
Document Type: Letter to the editor
Length: 595 words

In Ann Pettit's paper in the November issue, we were perplexed to see that health visitors (HVs) are being taxed with the job of
assessing infant attachment using a tool that appears to have been designed locally for this purpose with the goal of
quantifying infant behaviours at birth, six weeks and three months, and seven- to 12-months based on the Ainsworth
classification.

Assessing infant attachment is a complex job typically undertaken by psychologists under controlled conditions in a clinical
setting. Furthermore, observable infant attachment behaviours do not begin until after seven months, and in the absence of a
care pathway it might be argued that such assessments are not only futile but potentially unethical.

The revised Child Health Promotion Programme (CHPP) emphasises working in partnership with parents to assess carer-infant
interaction (not infant attachment), recommending observation and support in all contact with parents. Many HVs have not had
specialist training to undertake this role with confidence, nor to provide the sort of evidence-based interventions (such as Video
Interaction Guidance) to work in supportive partnerships with families experiencing difficulties. Some methods recommended in
the CHPP are new, and should be included in core training and continuing professional development. Trusts should not be
coercing HVs into undertaking assessments beyond their remit, but providing finance and support for them to develop their
skills to provide the support now part of the CHPP. Early interactions play a key part in establishing healthy development, and
when families need extra help they should be able to access high-quality support from skilled professionals.

Jane Barlow Professor of public health in the early years and director of Warwick Infant and Family Wellbeing Unit

Angela Underdown Course tutor, Warwick Infant and Family Wellbeing Unit

Thank you for your pertinent points. Assessing attachment is a complex process and one many consider the role of a clinical
psychologist, but HVs can contribute through their observations to this process. Bowlby (1988) describes the development of
attachment behaviour in phases and Browne et al (2006) suggest HVs can play a significant role in observing these pre-
attachment behaviours in the first year, not only once the attachment is formed after seven months. I agree that undertaking
assessments in the absence of a care pathway is questionable ethically, and as the research highlighted there is a need to
develop a care pathway and services to support this. Alternatively, it could be argued that as HVs search for and identify
needs, they can then make a case for the development of services.

While the CHPP talks primarily about assessing carer-infant interactions, it also suggests that the child health review should
include an evaluation of child-parent attachment (p19) and provides examples of what might be used in universal and
progressive services (such as NCAST/ Brazelton). I would argue that with present resources these tools are not practical for
use in a universal service. As recommended by the research, there is a need to develop a framework to help practitioners
assess infant-carer interactions and for additional training and support for HVs.

The local tool was introduced after a safeguarding children's board recommendation that HVs needed to evidence attachment
assessment. Together with government reports, this has led to the expectation that this is part of the HV role. One difficulty is in
the term 'attachment', and I think we should talk about carer-infant interactions or relationship. I welcome suggestions for
developing a framework for expected observable infant behaviours that the research participants identified would be helpful
 when undertaking these assessments, please email: ann.pettit@swessex.nhs.uk

Ann Pettit Health visitor, South West Essex Primary Care Trust

Barlow, Jane^Underdown, Angela^Pettit, Ann

Copyright: COPYRIGHT 2009 Ten Alps Publishing

http://www.tenalpspublishing.com

Source Citation
Barlow, Jane, et al. "Assessment of infant attachment: a role for health visitors?" Community Practitioner, vol. 82, no. 2, Feb. 2009,
p. 37. Gale Academic OneFile, link.gale.com/apps/doc/A192802951/AONE?u=finger_main&sid=bookmark-AONE. Accessed
26 Feb. 2024.

Gale Document Number: GALE|A192802951