Implementing HoNOSI at Koanga Tupu

With the collection of Health of the Nation Outcome Scales for Infants (HoNOSI) (aged 0-47 months) mandated from 1 July 2024, infant mental health services must understand how to collect and use HoNOSI. In this article, Marion Doherty, Clinical Psychologist/Co-ordinator Koanga Tupu (infant mental health service) at Te Whatu Ora Te Toka Tumai Auckland, looks at what the team did to prepare for implementing the collection of HoNOSI and the importance of having an outcome measure specific to infant mental health.

Koanga Tupu is an infant mental health team based in central Tāmaki Makaurau seeing infants and young children 0 to 4 years and their whānau. We receive referrals from a range of sources (including perinatal mental health services, child development, GPs and paediatricians) and for a range of different presentations – concerns about the social/emotional/mental wellbeing of the infant/young child and/or significant concerns about the parent-infant relationship. We have begun to use HONOSI (Health of the Nation Outcome Scales for Infants) – as a team and individually in our clinical notes.

Rating cases with HoNOSI

In order to get to know the scales, we initially chose a case that we had reviewed in some depth in a team supervision session (including watching film from the parent-child interaction assessment). We rated the case together as a team, along with input from our specialist clinical supervisor. This was very helpful as many of the scales are somewhat different to the HONOSCA scales that many of us are familiar with - having used them in the past for older children. For example, Scale 1 focuses on disruptive behaviour/irritability emotional regulation. With older children, clinicians may rely to some extent on the words of the child themselves (as well as their behaviour). It goes without saying that for this age group, we need to focus on the infant/young child’s behaviour to indicate their emotional state. HONOSI Scale 1 has a number of helpful prompts about what age-appropriate behaviour to include in this rating (e.g. difficulty calming, whining, arching back, stiffening and turning away from eye contact).

Scales 4 (Problems with feeding and eating behaviour) and 5 (Developmental Delays) are also very tailored to the specific needs of this age group. The breadth of questions in these scales (and in other scales) supports us to think about the range of issues and factors that might impact on the infant and their whānau. This is important because it can be easy to focus on the symptoms that parents are most struggling with. The way HONOSI has been designed allows us to consider the way in which difficulties in one area often impact on children’s development in other areas. We have often found in our work that significant difficulties in the parent-infant relationship often have an impact on an infant’s developmental trajectory. Using the HONOSI to rate a child’s difficulties in this area will allow us to see whether interventions that target parent-infant relationships and parental reflective capacity also have a positive impact on developmental trajectories.

The importance of having an outcome measure specific to infant mental health

Having an outcome measure that is specific to infant mental health also supports us to develop a much more nuanced and comprehensive formulation and understanding of the case at the outset. We are aiming to incorporate this into our MDTs; using the scale to have a structured way to think about case presentations (and in order to get to know the measure better as a team). This will assist our formulation and treatment planning, helping us to target our interventions to address the most significant impacted areas first, as indicated by the scale. In addition, being able to review our HONOSI ratings during the treatment/intervention phase will allow us to better track our treatment efficacy. We are experimenting with how we do this as a team – focussing on the overall changes in the ratings may be more helpful in some cases whereas changes on particular rating scales may be more helpful for other cases.

We are also really excited about the potential for HONOSI to be used across our infant mental health teams to track outcomes and change. Infant mental health is an area that is often overlooked in national conversations and by planning and funding organisations. Using the HONOSI can provide us with the opportunity for our work to be more visible on a national level, as the data is collected by the Ministry of Health. We have the opportunity to demonstrate both the level of complexity that we work with and the effective outcomes that we achieve.