This chapter describes infant mental health and why it is important. Those working in perinatal mental health services have a key role in ensuring that it is attended to by assessing and supporting the developing mother-infant relationship. The journey into services and the roles of team members and others are presented. Effective interventions to support the primary and wider family relationships should be offered when required.

Autism research and clinical practice is a rapidly evolving branch of psychiatry. This chapter explores autism through the lenses of the neurodiversity paradigm, challenging the deficit-based model whilst remaining stark about significant healthcare inequalities and challenges that autistic people face. It considers the perinatal journey from an autistic perspective, highlighting some of the common challenges autistic mums (to be) can face, and makes suggestions for approaches to take when working with autistic patients.

Child safeguarding is an integral part of the work of perinatal mental health services and the health and social care services they work in partnership with. Serious case reviews repeatedly identify parental mental illness as one of the most significant risk factors for child maltreatment and infants under one year old as the most vulnerable group of children. This chapter describes the key issues that perinatal mental health clinicians, and the professionals and services they work in partnership with, should consider when working with women and families to ensure that children’s well-being is promoted and that they are protected from harm. Learning from child serious case reviews is highlighted. There is a focus on the processes and important considerations when there is a child, or unborn baby, who is the subject of a Child in Need or Child Protection Plan and when there are significant concerns about parenting capacity necessitating formal parenting assessment and/or care proceedings.

This chapter introduces the practice of infant observation; both as a module on psychoanalytic trainings, and as a helpful clinical skill in assessment and treatment within perinatal services. Babies need to be protected and nourished, but also, crucially, to be drawn into relationships with attentive, responsive adults. The chapter underlines the need to look at each baby as an individual and to observe how he is responding to the care he is receiving. The suggestion is made that in perinatal settings, paying attention to the baby’s experience is a vital part of the work.

This chapter focuses on writing medico-legal court reports in the context of being either a) the treating clinician or b) an independent expert, with a focus on reports for child safeguarding and family court processes. It highlights the range of parenting issues that might arise in the context of perinatal mental illness, as well as the roles and duties of writing a report, and areas to include within the report and its structure. The primary objective for family courts is to ensure that children remain with birth parents unless there are overriding risks of significant harm and neglect to the child. Psychiatrists and clinicians therefore have a duty to be able to write high-quality professional witness and expert witness reports which assist courts in the case of maternal/parental mental health conditions and their potential effects on developing infants and children. Whether a baby remains in the care of the birth mother (and family) or not, has profound effects on both, over lifetimes. However, it is ultimately the task of the judge in the family court to weigh up the available evidence submitted by different experts and parties and make the final recommendations.

The transition to parenthood brings much joy but also challenges and strains to all families. Where mothers are experiencing perinatal mental health disorders, this is an additional challenge which impacts the wider family system. Partners and other family members may have to take on additional responsibilities, manage worries about the mother’s mental health, and potentially deal with their own mental health difficulties. Indeed, partners – including fathers, co-mothers and step-parents – may be particularly vulnerable to poor mental health at this time.

The partners’ mental health is a crucial aspect of family functioning in the perinatal period that can impact on the whole family. Paternal depression and anxiety disorders have implications for family relationships, including the couple relationship, the co-parenting relationship and the relationship with the baby – with potential adverse consequences for child and family outcomes.

Practitioners have a role in supporting prevention of paternal mental health disorders and working to reduce barriers to help-seeking and uptake of support where needed. These practices not only serve to improve the well-being of fathers and partners; well-supported family members who feel included and have their own mental health needs met will also have a significant positive impact on maternal recovery and well-being.

Fundamentally, a psychiatric patient’s relationship with the health professionals treating her depends on developing trust and that trust relies on understanding on both sides: that is why it is so critical for a clinician to have as deep an understanding as possible of his or her patient’s perspective. It’s unusual for a patient with a physical ailment to feel a need to deliberately conceal things from her clinician but this is a common occurrence for women in a perinatal mental health setting. The main reason for this is fear; fear of having her children taken away, fear of being ‘judged’ for wanting to have a child while coping with a chronic mental illness. This chapter will provide an overview of the research I have conducted since 2010 to identify and record the experiences of women in receipt of perinatal mental health services or, in some cases, of women not in receipt of the services they needed.

Making decisions about prescribing medication for mental disorders in childbearing women is a task that may have profound and long-lasting implications for a mother and her family, and it is important that prescribers have access to up-to-date summaries and interpretations of research that examines how safe these medications are in pregnancy and lactation.

Because it is not possible to test a drug’s reproductive safety in randomised controlled trials, research has to rely on less rigorous study designs. The inherent difficulties and other methodological problems have meant that interpretation of the evidence has often been difficult. However, the volume and quality of research has dramatically increased in recent years. Current findings concerning antidepressant, antipsychotic and mood-stabilising medication during pregnancy and lactation are summarised in this chapter, and recommendations for clinical practice are made referring to published guidelines where they are available.

This chapter examines recent evidence concerning the need to explicitly intervene with the mother-infant dyad in order to ensure optimal outcomes for the infant where there are concerns about postnatal mental health problems. The chapter describes the importance of dyadic interaction in terms of the capacity of the infant for later affect regulation and wider aspects of development, in addition to evidence concerning the impact of perinatal mental health problems on such interaction. A number of different methods of assessing mother-infant interaction in order to identify whether an intervention is needed are described, in addition to a range of dyadic methods of working that are explicitly focused on improving the interaction.

The perinatal frame of mind is a concept aiming to capture the unique mental state, context and experiences of individuals planning a pregnancy and during the perinatal period. It implies that every aspect of the physical, social, psychological and psychiatric care of women in this period requires a deep understanding of them as individuals. This encompasses many aspects of a woman’s life experience: from childhood to her current context, including traumatic and more positive experiences, cultural factors, relationships, mental and physical illness and their risks and relevance to the perinatal context, her journey to becoming pregnant, and her strengths. The term asks that we think not only about the woman, her well-being and needs, but also those of the fetus or infant, the intimate partner and/or co-parent, and other family members. We should consider the relationships between the parents and the infant, as well as within the couple and among other family members. So, we don’t just think about the woman, but the community and cultural context surrounding her, which includes the partner, family, friends, and often, and importantly, health and social professionals and services, who can provide the right kind of support to help navigate any mental health challenges.

Women with intellectual disabilities have children more frequently than in the past. This is partly a result of changes in attitudes towards people with intellectual disabilities. Institutional care in many parts of the world is less common and sterilisation of women with intellectual disabilities is less frequent. However, women with intellectual disabilities experience greater social disadvantage than other women, negative attitudes towards their having children, and judgements about their abilities to parent successfully. They have poorer pregnancy and neonatal health outcomes due to health inequalities and socio-economic deprivation and are more likely to have their children removed from their care. The rate of mental disorders in women with intellectual disabilities is high leading to increased utilisation of healthcare services during the perinatal period and after delivery. Recognising perinatal mental disorders in women with intellectual disabilities can be challenging for clinicians because of communication difficulties in the woman and a lack of training for the clinician. Assessment and support to women with intellectual disabilities and mental disorders has to be adapted to take account of their individual needs. Training of clinical staff in understanding intellectual disabilities is essential in enhancing the care they receive and ensuring equity of access to services.

This chapter is an essential guide to recognising and treating ADHD in the perinatal period, an increasingly common scenario which specialist community and inpatient perinatal services face. We explore issues specific to assessing and treating women with ADHD. The features of how the disorder is classified are discussed, including information on how ADHD may present differently in women. The challenges of identifying ADHD in females are considered along with common comorbidities. A summary of guidance on treating this disorder in adults is included, with information on pharmacological and non-pharmacological treatment options. An outline of the essential investigations required before initiating medication for a woman is provided, along with details on the necessary ongoing physical health monitoring. Both stimulant and non-stimulant medicines are discussed with details on the various formulations available in the UK and practical tips on prescribing in the perinatal period. Specific issues to explore at follow-up are outlined. Special consideration is given to recognising and treating ADHD in the perinatal period. This includes during the pre-conceptual period, prescribing in pregnancy and the postnatal period including breastfeeding. The impact of ADHD on parenting is also considered. This is essential reading on a commonly misunderstood disorder for all perinatal clinicians.

Mothers who kill their own children are unusual women whose offences often elicit fear, horror and condemnation in others. Psychiatrists may be asked to assess such women to explore the relationship between the offence and maternal mental illness, and the potential risk to other children. In this chapter, I discuss some available data on mothers who kill, in terms of criminal justice statistics, and review accounts of motives for such killings. I briefly discuss the legal processes that mother who kill must face, and the role of the psychiatrist. I then discuss some recent research about the role of maternal attachment security in relation to attitudes towards children and the transition to motherhood and the potential for psychological disorder that arise during that transition. I also comment on social factors, such as the role of partners and fathers. I conclude with some discussion about the management of cases where mental illness is a risk factor for filicide, and the associated child protection issues that may arise in such cases.

This chapter contains an outline of fetal development, describing general organogenesis in the first trimester, and then brain development in the second and third trimesters. The effects of maternal well-being, therapeutic medication, tobacco and alcohol on the developing fetus are explored. Finally, the current format of antenatal care, screening and fetal medicine in the UK National Health Service is described. There is a glossary of common conditions that are diagnosed antenatally, which are not specific to women who take prescribed or recreational drugs. The majority of such women have normal pregnancies and give birth to healthy babies at term.