Parent Infant Relationship Cards – Bradford District Care NHS Foundation Trust

The Parent-Infant Relationship Resource Cards (PIRRC) are a visual, interactive tool to help practitioners assess, discuss and share healthcare information with families and to make NICE recommended interventions accessible. The cards aim to improve and enhance the parent‐infant relationship and promote infant attachment and optimal infant development. The Parent-Infant Relationship Resource Cards (PIRRC) are a highly visual tool designed to facilitate understanding of the parent-infant relationship for practitioners and parents.

Highly Commended - National CYPMH Awards 2019


  • From start: No
  • During process: No
  • In evaluation: Yes


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

Find out more

  • Lisa Milne - Clinical Lead for Perinatal Mental Health and Parent-Infant Therapist - Bradford District Care NHS Foundation Trust





What We Did

The Parent-Infant Relationship Resource Cards (PIRRC) are a visual, interactive tool to help practitioners assess, discuss and share healthcare information with families and to make NICE recommended interventions accessible. The cards aim to improve and enhance the parent‐infant relationship and promote infant attachment and optimal infant development. The Parent-Infant Relationship Resource Cards (PIRRC) are a highly visual tool designed to facilitate understanding of the parent-infant relationship for practitioners and parents. They aim to enhance behaviours which may contribute to a secure attachment between caregiver and child and support infant mental health and brain development.

The pictorial aspect of the PIRRC enables the cards to be accessible across cultures; the resource is also a valuable tool when working with interpreters. As PIRRC is an interactive tool it can be used to make interventions to help parents develop the skills and knowledge to enrich their parent-infant relationship. This tool is suitable for any professional working with families with infants, including health visitors, family support workers, midwives and practitioners working in early years, mental health and social care. The cards aim to improve the parent‐infant relationship and promote infant attachment and optimal infant development by helping to develop the parent’s understanding of their infant and how they respond to interaction. For example, the extent to which the parent responds in a timely and attuned manner; the child’s involvement and parent’s positive engagement, and the infant’s ability to seek and maintain closeness to the parent. Secure infant attachment leads to positive outcomes; the infant can be comforted when distressed and will use the parent as a secure base from which to explore the environment.

Practitioners are able to use the resource cards to work directly with the parent and infant in the home to identify unconscious patterns of relating and behaving. The pictorial cards help to embed parent infant relationship training into practice. For example: •Pictures allow discussion, time to wonder and think. •Information on the back of the cards can be used as a prompt for health professionals or early years practitioners to discuss key pieces of information around specific aspects of the parent infant relationship with the parents so they can understand their baby. •Cards can be used to reinforce key messages as well as intervention when professionals identify a need or mismatch of response from parents to baby. The first prototype was in place in 2016. The Parent Infant Relationship Training was also implemented at this time, so the PIRRC provided the perfect tool to put the learning from the training directly into practice and take the messages to the people who it is most important for – the families. Following the initial use of the PIRRC, we then sought feedback from parents and professionals, both within Bradford District and nationally, and have adapted accordingly. There is a new section, ‘not naughty’, to support both professionals and parents understand that young children are not ‘naughty’, and realise that their brains do not have the development to overcome their impulsive desires. There are also suggestions for parents and professionals to support simple interventions with the parent and child into place.


Wider Active Support

The initial working group where the PIRRC originated was a collaboration between Perinatal Mental Health and Health Visiting service. Now all the Midwifery teams in Bradford District have the PIRRC and identify that these are useful from pregnancy onwards. The Midwifery Antenatal Parent Education service in Airedale General Hospital now embed the PIRRC into their programmes to enhance sharing messages for families. The Neonatal Intensive Care Unit in Bradford Royal Infirmary ( a level 3 high dependency Neonatal Unit) have utilised the PIRRC as this also ties in closely with the Baby Friendly Initiative accreditation for Breast Feeding and Relationship Building. The Local Authority the Family Hubs Prevention and Early Help service has adopted the use of the PIRRC, and training is available to all teams to embed the PIRRC into their practice. Better Start Bradford has incorporated their use also into their Breast Feeding Service, Family Action Baby Steps service and the Family Action Perinatal Mental Health support volunteers. The Doula Voluntary Sector service also has adopted their use, working towards a District Wide implementation, thus enabling families to ensure they receive consistent messages from voluntary and statutory sectors.



The baby is always at the centre of the work with the Parent Infant Relationship. The impact of the parent infant relationship on the baby’s brain development, and the mental physical and social well being is at the heart of the PIRRC. In order to co-produce the PIRRC, we have sought feedback from service users and potential parents to be. In the initial stages of the design, feedback was sought from a wide arena. Permission was gained to take samples of the pictures to Morrisons Farmer Boy food production unit, engaging with workers from varied backgrounds, genders and ages for feedback which influenced some of the design process. Parents have found that the PIRRC has enabled them to realise just how amazing their baby is, which has in turn enabled extremely positive behaviour change. To see some of this feedback please follow the links below:


Looking Back/Challenges Faced

Looking back, the PIRRC has followed a path of steady fruition. If it would have been possible to engage a wider workforce from the start, that would be a possible change – i.e. we initially rolled out the PIRRC with Health Visitors, however if resources were available this could have been implemented then within Local Authority Children’s Centres and Children’s Social Care. The biggest challenge has been maintaining the profile of the implementation of the PIRRC whilst services have changed their delivery and structure, within a climate of austerity. This means that members of staff change and reduce, training may be easily missed or not currently running, and the potential threat is that the PIRRC would not be properly implemented. This then would lead to inconsistent messages to families, undermining the initial positive feedback and ultimately not implementing the change for the baby at the centre of the delivery. We have managed to persevere and maintain good working relationships across the district with a range of services.

As the body of evidence grows supporting the importance of the first ‘2001 days’ – from conception to the age of 2, and services recognise the importance of ‘Adverse Childhood Experiences (ACES)’ , recognition for the PIRRC as a tool to implement these key messages enables longevity. Current challenges include continuing providing training and supporting implementation of the PIRRC to ensure practitioners are able to use the resource affectively. With reduced budgets this has to become interwoven more closely with existing services, so identifying what forums and training already exist where the PIRRC can also be incorporated is a key priority. One positive factor of the PIRRC is that is not a separate piece of work for practitioners to ‘learn’ or implement, but is interwoven to enhance any existing service delivery, reinforcing and underpinning key messages. For example, this has been able to happen through the delivery of the Healthy Child Programme in Health Visiting, the Specialist Mother And Baby Service (SMABS) delivery, and also the UNICEF Baby Friendly Breast Feeding and Relationship Building courses for Health Visiting team members, Midwives, Neonatal Nurses and the family Hub Prevention and early help workforce.

The positive feedback from women has driven the enthusiasm to continue embedding the PIRRC into services working with families, young people and children. The investment of face to face training has been tremendously valuable to ensure messages continue to be kept alive and nourished, which enables the messages to continue to reach families, reminding them that babies are amazing.



There are three elements to our plans for sustainability: 1) Internal staff – The full health visiting service in the Trust – have completed training using the PIRRC (which is approximately. 150 staff). Within the health vising service there are 7 special interest Perinatal and Infant Mental Health Champions. A component of their role is to offer support to colleagues and continue supporting and implementing the use of the PIRRC. The SMABS team are also specifically trained in using and implementing the PIRRC and are envisaged to continue this role within their team and with the wider workforce to support sustainability within the organisation. There are plans to roll out training to the Wakefield District where the Trust also delivers health visiting services. 2) Local agencies – The Local Authority Prevention and Early Help Family Hub model has been in place from October 2018.

This service has fully endorsed the use of the PIRRC and has and has purchased cards for all the 4 hubs. Training to embed the use of the PIRRC will be rolled out during 2019. The family Hub within Better Start Bradford are also involved in further training and an evaluation process for the use of PIRRC. Other local agencies who have purchased the cards from us include the Better Start Breastfeeding Service, Family Action Perinatal and Baby Steps Programme, Bradford Doula Service and the Midwifery and Neonatal Services across the district. Since 2018, a total of 144 cards sets have been sold to key partners in our District area which further 3) National profile The PIRRC tool that has been fully developed into a practical tool and is now available to any health professional to purchase online at a price of £25. The service has worked with colleagues at the Trust through the iCare programme and an external agency (Medipex) to make the resource available online at Ennovations. Beyond the several local organisations purchasing and using the tool in services, the PIRRC tool has already been purchased by 14 organisations from across the UK and plans are in place to product through tailored online campaigns as well as at exhibition stands at a range of perinatal mental health conferences.


Evaluation (Peer or Academic)

During a pilot study of health visitors and nursery nurses, of 150 participants, 95 per cent of respondents were overwhelmingly positive about the cards. Respondents credited the cards with: encouraging positive parenting and interaction between the parent and infant; learning to understand the importance of infant cues to respond appropriately to babies and positively influencing aspects of neurodevelopment. For further details read the full evaluation report…



We carried out an initial evaluation of the use of the PIRRC when we first used them with families. This evaluation had very positive results with families reporting that they discovered things about their babies they had not known. They realised their babies were amazing and wanted to relate and interact. This discovery enabled a more interactive positive relationship with their baby. The feedback follows: Initial Parent Feedback for Parent-Infant Relationship Resource Cards 2016 9 South East Asian mothers provided feedback and the mothers were keen to do so: ‘I didn’t know a little baby was able to communicate so much. I wish I had known this with my first child who is 2 ½ and I find it difficult with behaviour and fussy eating just now.’ (mother of 6 week old baby) ‘I have been talking to my baby and looking into her eyes much more because the HV showed me the cards. I think my baby and I are very close because of this (Talking and look-ing into her eyes).’ (mother of 2 week old baby) ‘I like the slides of the brain growth, I didn’t know it was so important to respond to my baby before. I am looking out for her signs more now. I didn’t know she could communicate be-fore’. (mother of 6 week old baby) ‘I want the best for my baby. I wish my parents knew all this. They don’t understand me and my baby. The HV has helped me have confidence in bringing up my baby, and the cards/pictures made it easier to understand’. (mother of 9 month old baby) ‘I already have been looking into my baby’s face and he looks at me. But I didn’t know that it was actually helping his development. I am amazed about how much a new baby can do. The cards have helped me.’ (mother of 2 week old baby) ‘[The pictures are] to the point with a lot of information but in a few words – the pictures are also good, for example – the crying picture explains what kind of cry.

When speak-ing/smiling at a baby – you don’t know why you are doing it but I understand why now.’ (mother of 10 week old baby) Parent feedback themes: • Increasing knowledge • Understanding baby • Enhancing Closeness • Endorsing appropriate behaviour already doing with baby, positively changing behaviour and encouraging specific behaviour • Confidence • Mutual gaze, cues, brain development, baby’s communication • Understanding what parents do The cards were used at clinics and home by an experienced HV. The cards were used at the antenatal visit, birth visit at 6 weeks, 10 weeks and 9 months • 100% of mothers stated that the cards were very helpful • 100% of mothers stated that the use of the cards made them more aware of how important the relationship is between you and your child • 100% of mothers stated that the use of the cards made them feel more confident caring for their baby • 100% of mothers stated that the use of the cards made them understand more about the way that their baby was communicating with them • 100% of mothers stated that the use of the cards helped them to interact with their baby better • 100% of mothers stated that the way the cards looked was helpful • 100% of mothers stated that pictures were helpful to understand the meaning • 78% of mothers stated that the size of the cards was helpful A further evaluation interviewing parents 2 years on demonstrates that the parents had taken information from the original use of the PIRRC, which had both influenced change with their first baby, and gone on to inform their relationship with their second baby. They had found meaning from using the PIRRC, enabling and empowering them to understand their baby better. This demonstrates a sustainable change in parenting from a simple intervention of a practitioner using the PIRRC with them. The evaluation is continuing with Better Start Bradford.



We are keen to continue sharing our work with other agencies on a national level, because our evaluations show that the PIRRC really make a difference, ultimately, for the families. Practitioner and family feedback has been excellent. This has encouraged us to showcase our work at several conferences and events nationally, including: Begin Before Birth Annual Conference 2016, North West London Perinatal Mental Health Consortium Annual General Conference 2016 (winning an award for Innovation in Practice), Westminster Briefings 2016, Marce Society Annual Conference 2017, the Association of Infant Mental Health annual conference 2017, and the Institute of Health Visiting Perinatal and Infant Mental Health conference 2018 with a runner up award for the Poster Competition ‘Revolutionising the Parent Infant Relationship – Bradford’s Parent Infant Relationship Resource Cards’. We have been invited to present our work around the PIRRC at the UNICEF Baby Friendly Initiative Annual Conference in 2016. We have also shared the PIRRC within Bradford at various events including the iCare poster presentations, Better Start Bradford Learning Forum, and Health Visitor and Midwifery Forums. We also have information available on the BDCFT website which is available to all.



Can you please tell us who your service is commissioned by and provided by?

The nomination is for a product (Parent Infant Relationship Cards) that has been developed by Jane and Lisa as and has been in clinical practice for over 3 years. Jane and Lisa work in different clinical and service areas but have collaborated on developing the product. Jane has traditionally been involved in the delivery of children’s services commissioned through the local authority and is now the strategic lead for breastfeeding (Bradford) and Lisa is a clinical expert working in peri-natal mental health services which are commissioned through the NHS nationally and locally through the CCGs (Bradford). Lisa is currently the clinical lead in the Specialist Mother and Baby Mental Health Service.

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