This paper describes an innovative intervention in infant mental health, provided by Queanbeyan Child and Adolescent Mental Health Services. Until this project started, there was no clear pathway for referral or defined treatment for severe mental health problems in children who had not reached school age. For the six children and their parents who participated in this pilot program, the trajectory towards mental health problems has been turned around, with the outcome being better mental health for the whole family including infants their siblings and their parents. This pilot program has been designed and evaluated with issues of sustainability and generalisability in mind, so the next stage of the program will be the expansion of the treatment program.

To make specialist mental health treatment available to families caring for a young child suffering the onset of emotional or behavioural problems.

In mental health, specialist services are rarely sought for children under school age, even though many young children suffer from severe emotional and behavioural problems. It is apparent that mental health issues are more likely to be identified once a child has reached school age, yet the problem has often existed untreated for years. The earlier mental health problems can be treated, the more effective the treatment is. The problem of delayed identification of mental health problems came to light through the study of referral patterns to mental health services. Mental health services need to reorient their practices to incorporate earlier treatment, thereby preventing years of suffering for patients and their carers.

During the antenatal and perinatal period, the GSAHS program 'Integrated Perinatal Care' identifies children at risk of poor health outcomes later in life. In the Queanbeyan region, hundreds of children each year are identified as being at risk. Although mental health attends the Integrated Perinatal Care meeting each fortnight, a very small proportion of these children are offered treatment, primarily because mental health workers were not trained in treating mental health problems effectively at such a young age.

The multidisciplinary team (midwives, nurses, social workers, psychologists) working to identify children at risk gave feedback to mental health. The Child and Adolescent Mental Health team were asked to expand their services available to these at risk children. The Child and Adolescent Mental Health team surveyed the evidence based practice guidelines to find the most effective treatment available for young children’s emotional and behavioural problems. The Circle of Security program was found to be the best researched and most effective program available.

Make prevention everybody's business: The Circle of Security program focuses on identifying emotional and behavioural problems in children before the age of 5. Treating the problems early prevents more costly treatments being needed at a later stage. Children are prioritised for the program if they are already identified as 'at risk' by the Integrated Perinatal Care program.

The Circle of Security program provides a best-practice, evidenced based treatment for at risk children right at the onset of the problems. It is a significant improvement because there was no treatment program available for these children prior to the Circle of Security program.

Create better experiences for people using health services: The Circle of Security recognises the crucial role of carers in the recovery of mental illness by working primarily with carers to bring about the child’s recovery. This program has built strong links with the non-government sector to bring much needed expertise into the project.

Child and adolescent mental health staff researched a number of treatment programs in order to identify the program with the best evidence base for treatment. The Circle of Security Program was selected because of its rigorous testing and excellent treatment outcomes (Marvin et al, 2002; Hoffman et al, 2006). Staff attended a 10 day Circle of Security training course to learn to effectively deliver the treatment.

Project stakeholders were identified and engaged early in the process. Clinicians, managers and strategic advisors within mental health worked together to lobby support for the project from the mental health executive. External stakeholders were engaged from community health, maternity, education and the non-government sector to support the project. The Queanbeyan Child and Adolescent Mental Health team planned and delivered the treatment with support and governance from the Prevention and Early Intervention arm of mental health.

Six children suffering from emotional and behavioural problems were identified as high risk and their parents were invited to participate in the treatment program. The parents were involved in the planning of the treatment program and had input into the mode of delivery to ensure it met their needs. For example, childcare was provided because this was identified as essential, and the time and day of the week for the program was carefully chosen to meet the needs of the children and their parents.

The treatment involved comprehensive assessment including a parent interview and observations of the parent and child interacting together through a variety of tasks. The parents met each week for 20 weeks with 2 group therapists. The group therapists video taped them-selves delivering the treatment to improve their own practice. Each week, the therapists attended supervision to watch themselves on the tape and receive feedback about how to improve their therapy skills.

The therapists taught the parents how to better understand and respond to their children’s needs. As a result of the parents being able to meet their children’s emotional needs, the children’s emotional and behavioural problems have improved. The parents watch video tape of their interactions with their child. With help from the group therapists and the group members, each parent identifies their primary difficulty in responding to their child’s needs and identifies what they can do differently to help their child.

The evaluation plan was formulated before the program began. A number of self report measures were identified as appropriate. With the parents' permission, measures were administered each week so that improvement could be tracked. The program is still continuing, and already the measures show evidence of success.

Children's mental health problems have improved as a result of their parents better meeting their emotional needs. The table below summarises the improvements.

The graph below shows that as a result of improving their relationship with their children, the parents are feeling better. Parents' scores for depression, anxiety and stress have all reduced.

Clinical staff reported the project has been beneficial for them as well. Some of the staff feedback has been:

The goal is for the program to become self-sustaining. The plan is to seek funding for continued supervision until a worker can take on the role of supervising other therapists and the treatment process can sustain itself. Given the rural and remote setting of GSAHS services it is a great advantage that Circle of Security supervision has already been implemented with telephone and computer technology, eliminating the need for travel over long distances.

From the start, the Circle of Security program has been implemented with the intention of transferring the program to other Health services. Once a NSW Health employee is able to supervise other workers, the project can be transferred to other Areas and other settings. The plan is for the treatment to be next rolled out in the rural town of Braidwood, which has been identified as particularly in need of support to help young children with emotional and behavioural problems. Other CAMHS services are entering the planning stages to implement Circle of Security in their local area.

• Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers' and preschoolers' attachment classifications: the circle of security intervention. Journal of Consulting and Clinical Psychology, 74 (6), 1017-1026.
• Marvin, R., Cooper, G., Hoffman. K, & Powell, B. (2002). The circle of security project: attachment-based intervention with caregiver-preschool child dyads. Attachment and Human Development, 4 (1), 107-124.

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