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ACQ Volume 11, Number 3 2009 165
Mental health
Lisa Dyer
long been aware of the critical period for language
development – birth to four years of age. It is well established
that the first two to three years of life are considered vital for
developing emotional control and set the foundations for
competence and coping skills, elemental to learning and
health throughout life (McCain & Mustard, 1999).
Attachment describes the affective bond between an
infant and a primary caregiver (Bowlby, 1988). Through
healthy attachments the infant learns to respond in socially
acceptable and flexible ways, demonstrating a range of
appropriate spontaneous reactions and emotions. By 6
to 12 months of age infants have usually learnt to elicit a
desired response from their caregiver (Cooper, Hoffman,
Marvin, & Powell, 2001). The relationship between early
attachment, emotional regulation, language development,
and cognitive development has become increasingly clear
(Van IJzendoorn, 1995). Van IJzendoorn’s meta-analysis
revealed that (i) the quality of parent infant attachment is
strongly associated with language development and (ii)
insecure attachment is more often associated with lower
cognitive functioning and language competence. Insecure
emotional attachment and poor stimulation are thought
to lead to: restricted school readiness, low educational
attainment, problem behaviour, and increased risk of social
marginalisation in adulthood (Wilkinson & Marmot, 2003).
Early attachment is dependent on many factors including
the primary caregiver’s mental health. Field (1995) found
that 3-month-old infants who detected depression in their
mothers demonstrated developmental delays at the age
of 1. Interestingly, “treating mothers’ depression, even
successfully, is not in itself sufficient to change the mother–
child relationship, or the mother’s negative view of the child”
(Forman, O’Hara, Stuart, Gorman, Larsen, & Coy, 2007,
p. 507). In contrast, interventions designed specifically to
improve a mother’s sensitivity to her infant’s communication
have been successful, particularly with low-risk samples
(e.g., van den Boom, 1995). Focusing on just one aspect
of parenting behaviour is likely to have less effect upon
the overall parent–child relationship (Egeland, Weinfield,
Bosquet, & Cheng, 1999), suggesting that partnerships
between services such as CAMHS and CHS with a holistic
approach are more likely to effect change.
The START group, a weekly program over two months,
is facilitated by two speech pathologists, one each from
CAMHS and CH. Up to eight caregivers and their infants
attend. Pre and post interviews provide outcome measures
based upon the results of the Communication and Symbolic
Behavior Scales™ (CSBS) Infant Toddler Checklist (Wetherby
& Prizant, 2001), which screens early language and symbolic
The START group aims to develop the
protective life skills of good communication.
Through story, song, and rhyme “at risk”
families cement the parent-child relationship
and promote healthy social emotional
development. By increasing caregivers’
awareness of infant development the START
group, supporting the development of
caregiver-infant interaction, fosters
attachment, communication skills, and global
development.
T he Story Telling and Rhyme Time (START) group
evolved in the corridors of the Cranbourne Integrated
Care Centre in the City of Casey, 45 kms south east
of Melbourne’s CBD. With 146 new residents moving into
the area each week, Casey is one of the country’s fastest
growing municipalities (as of 2006 census, www.casey.vic.
. Understandably, the workload of
maternal and child health nurses has grown exponentially in
recent times and through their partnerships with Child and
Adolescent Mental Health Service (CAMHS) and Community
Health (CH), a growing number of “at risk” mother–infant
dyads – that is, dyads presenting with attachment disorder,
post natal or general depression, lower socioeconomic
status, babies of low birth weight or perinatal complication,
and/or infants/toddlers who have been abused (Baker
& Cantwell, 1987) – have been referred to post natal
depression self-help groups or Parent and Infant Relationship
Support(PAIRS) groups. It was observed by CH that a
proportion of these infants presented for speech pathology
services at 2 or 3 years of age. The question was raised
“Had we missed the boat?” The World Health Organization’s
Report on the Social Determinants of Health emphasises the
role of early intervention to reduce the risk of disadvantage
(Wilkinson & Marmot, 2003). With this in mind, the idea of
a group that would support the mother–infant relationship
while enhancing the carers’ language enrichment skills at a
very early age was born!
The START group, a multi-faceted program, draws on a
range of existing programs including The Parent–Child
Mother Goose Programme ® (2003;
mothergooseprogram/), Keys to Caregiving® (NCAST-AVENUW;
), and Parent Child Interaction
Teaching Scales (NCAST, 1995; ), and
taps into the literature supporting the crucial link between
early attachment and development. Speech pathology has
Clinical insights
A good start to attachment: The Story Telling and
Rhyme Time (START) group
Lisa Dyer