Maternal recollected anxiety and mother-infant interaction in preterm infants

Annual Research Review: 'There, the dance is - at the still point of the turning world' - dynamic systems perspectives on coregulation and dysregulation during early development

During development we transition from coregulation (where regulatory processes are shared between child and caregiver) to self-regulation. Most early coregulatory interactions aim to manage fluctuations in the infant's arousal and alertness; but over time, coregulatory processes become progressively elaborated to encompass other functions such as sociocommunicative development, attention and executive control. The fundamental aim of coregulation is to help maintain an optimal 'critical state' between hypo- and hyperactivity. Here, we present a dynamic framework for understanding child-caregiver coregulatory interactions in the context of psychopathology. Early coregulatory processes involve both passive entrainment, through which a child's state entrains to the caregiver's, and active contingent responsiveness, through which the caregiver changes their behaviour in response to behaviours from the child. Similar principles, of interactive but asymmetric contingency, drive joint attention and the maintenance of epistemic states as well as arousal/alertness, emotion regulation and sociocommunicative development. We describe three ways in which active child-caregiver regulation can develop atypically, in conditions such as Autism, ADHD, anxiety and depression. The most well-known of these is insufficient contingent responsiveness, leading to reduced synchrony, which has been shown across a range of modalities in different disorders, and which is the target of most current interventions. We also present evidence that excessive contingent responsiveness and excessive synchrony can develop in some circumstances. And we show that positive feedback interactions can develop, which are contingent but mutually amplificatory child-caregiver interactions that drive the child further from their critical state. We discuss implications of these findings for future intervention research, and directions for future work.

Maternal caring ability with the preterm infant: A Rogerian concept analysis

AIM

To analyze the concept of maternal caring ability for a preterm infant to develop an operational definition.

BACKGROUND

Each year, many newborns are born preterm and admitted to the neonatal intensive care unit (NICU). Although their mothers are prepared for discharge home by the staff, it is difficult to identify an operational definition of their maternal caring ability for the preterm infant.

DESIGN

Concept analysis.

DATA SOURCES

Searches used PubMed, as the primary health-related literature, ProQuest, Science Direct, CINHAL, web of science, Scopus, and Google Scholar. Keywords caring ability, mother, and preterm infant were used to analyze the development of the concept from 1965 to 2020.

METHODS

Rogers' and Knafl's evolutionary approach has been used to explain the concept of maternal caring ability for the preterm infant.

RESULTS

The combined searches yielded 23,291 documents published in English. After the screening process, 43 documents were selected. The Graneheim and Lundman analysis method was used to identify the themes related to the attributes of maternal caring ability. Findings showed the caring ability to have four antecedents (maternal characteristics, support systems, infant characteristics, and the illness severity), four attributes (knowledge and skill in neonatal care, self-efficacy, sensitivity, responsibility, and problem-solving), and three consequences (parental adjustment, improving infant growth and development, and improving parent-infant relationships).

CONCLUSION

The caring ability of the mother of a preterm infant is grounded in an adequate knowledge of caregiving needs of a preterm infant, high caregiving skills, a sense of self-efficacy, problem-solving, sensitivity, and responsibility.

Interactive sequences between fathers and preterm infants in the neonatal intensive care unit

AIMS

The first purpose of the study was to examine fathers' spontaneous communicative behavior with their preterm infants in the neonatal intensive care unit, and how father's and infant's behaviors affected each other. The second purpose was to examine any possible association between the fathers' and/or infants' characteristics and the quality of fathers' behaviors with their infants.

STUDY DESIGN/SUBJECTS/OUTCOME MEASURES

Father-preterm infant dyads (n=20) were assessed at 34-36 weeks postmenstrual age, during a spontaneous face-to-face communication with the infant placed in a heated cot in the NICU, and coded according to the Parent-Preterm Infant Coding System.

RESULTS

The presence of the father's Affiliative Behavior increased the occurrences of infant Gazing at the parent's face. In turn, infant gazing increased the occurrence of paternal Affiliative Behavior. The likelihood of infant's Gazing at the father's face was also significantly elicited by infrequent occurrences of paternal Affectionate Talk, co-occurring with Gazing at infant with Positive Facial Affect (but no Touch). With regard to the predictors of quality in father-infant interactions, we found a significant positive correlation between fathers' level of depressive symptomatology and fathers' Affiliative Behavior.

CONCLUSION

Our results show the of bidirectional sequential patterns of communication between fathers and preterm infants at 35 weeks postmenstrual age, and provide important information about the quality and modalities of paternal communication and their influence on infant behavioral states. From a clinical perspective, these results suggest that father-specific interventions designed to improve and sustain fathers' positive engagement with infants in the NICU should be pursued.

Effects of Gestational Age and Early Parenting on Children's Social Inhibition at 6 Years

Preterm birth (<37 weeks' gestation) has been associated with problems in social functioning. Whether social inhibition is specifically related to preterm birth and whether early parenting may protect against social inhibition difficulties is unknown. To explore effects of gestational age and early parent-infant relationships on social inhibition, 1314 children born at 26-41 weeks gestational age were studied as part of the prospective Bavarian Longitudinal Study. Early parent-infant relationship quality was assessed postnatally with the parent-infant relationship index. Social inhibition was assessed at age 6 years using an experimental procedure, in which nonverbal and verbal responses were coded into social inhibition categories (disinhibited, normally responsive, inhibited). Multinomial logistic regressions indicated that children with lower gestational age showed more socially disinhibited (nonverbal: OR = 1.27 [95% CI = 1.17-1.40], verbal: OR = 1.23 [95% CI 1.13-1.35]) and inhibited (nonverbal: OR = 1.21 [95% CI = 1.11-1.32], verbal: OR = 1.11 [95% CI = 1.01-1.21]) responses. Good early parent-infant relationships were associated with less verbal disinhibition (OR = 0.70 [95% CI = 0.52-0.93]). Findings suggest that children with lower gestational age are at greater risk to be both socially inhibited and disinhibited. Early parenting affected risk of abnormal social responses. Supporting early parent-infant relationships may reduce preterm children's risk for social difficulties.

Mothers With Postpartum Psychiatric Disorders: Proposal for an Adapted Method to Assess Maternal Sensitivity in Interaction With the Child

About 15% of mothers suffer from postpartum psychiatric disorders, such as depression, anxiety, or psychosis. Numerous studies have shown maternal caregiving behavior to be negatively affected under these circumstances. The current study sets out to shed light on specific caregiving behaviors of affected mothers in the context of parental mental illness at an early stage. There are several methods to assess maternal caregiving behavior in terms of sensitivity. However, all of them have limitations regarding the peculiarities of mothers with postpartum disorders, that is, changes in affect regulation, and the early onset of the disorder postpartum. With the current study, we provide an adapted method to assess maternal sensitivity based on methods recently approved in attachment research. Two groups of mothers, who were either healthy or had different postpartum disorders, were recorded on video during interactions with their infants. Behaviors were rated regarding responsiveness, promptness, appropriateness, intrusiveness, and positive and negative affect. A first analysis revealed an increased number of deficits on all subscales in mothers with postpartum psychiatric disorders as compared to healthy mothers. Depressive mothers with a single diagnosis had lower scores in responsiveness, promptness, and appropriateness and higher scores on intrusiveness as compared to those in healthy mothers. Here, maternal behavior appears more parent-centered, whereas affect seemed to be relatively unharmed. Moreover, as compared to healthy mothers, mothers with comorbid depression and anxiety symptomatology achieved lower scores on responsiveness, appropriateness, and positive affect and higher scores on intrusiveness and negative affect. It is suggested, that increased deficits are related to the severity of illness in mothers with comorbidities. Results on promptness indicate that these mothers are still capable of maintaining higher vigilance to infant cues. Variance in maternal behavior was relatively high in clinical mothers, showing that some of them are well capable of behaving in a sensitive manner toward their child. One strength of our adapted method is that particular aspects of sensitive parent-child interactions are assessed separately. This may shed light on specific behavior patterns of different postpartum psychiatric disorders, which may in turn relate to specific child outcomes. The manual is open for usage, while reliability testing is required.

Mother-infant interaction assessment at discharge and at 6 months in a French cohort of infants born very preterm: The OLIMPE study

Objectives

The principal aim was to investigate the feasibility of assessing mother-infant interactions at discharge and at 6 months infant corrected age in singletons born before 32 weeks of gestation. The secondary aims were to describe these interactions and their disorders, explore the association between maternal emotional state and the interactions, and assess the relationship between disordered interactions and infant social withdrawal behaviour.

Methods

OLIMPE is an ancillary study of the population-based study EPIPAGE 2, which recruited preterm neonates in France in 2011. 163 dyads participated at discharge and 148 at 6 months. Interactions were observed with the Attachment During Stress (ADS) scale, which includes two behavioural subscales, for the mother (m-ADS) and her infant (i-ADS). Two professionals independently completed the ADS scales for one third of the observations. Maternal emotional state was assessed using self-administered questionnaires of depression, anxiety, and stress. Infant’s social withdrawal behaviour at 6 months was measured by the Alarm Distress Baby scale.

Results

At discharge, 15.3% of the m-ADS scales and 43.3% of the i-ADS scales had at least one unobserved component. At 6 months, all items on both scales were noticeable in >90% of the dyads. Reliability, estimated by the kappa coefficient, ranged between 0.39 and 0.76 at discharge, and between 0.21 and 0.69 at 6 months. Disordered interactions were indicated on 48.6% of the m-ADS scales and 36.5% of the i-ADS scales at discharge. At 6 months, these rates were 32.6% and 26.0%. Disordered interactions at 6 months were associated with identified disorder at discharge. Insecure infant attachment was not influenced by maternal mental health but was strongly associated with infant social withdrawal behaviour.

Conclusions

The ADS scale can be used to screen for early interaction disorders after premature birth and may help to target dyads that would most benefit from early intervention.

Does the development of executive functioning in infants born preterm benefit from maternal directiveness?

OBJECTIVE

Problems in early development of executive functioning may underlie the vulnerability and individual variability of infants born preterm for behavioral and learning problems. Parenting behaviors may aggravate or temper this increased risk for dysfunction. This study assessed how maternal parenting behaviors predict individual differences in early development of executive functioning in infants born preterm, and whether this varies with infant temperament, i.e., self-regulation.

METHODS

Participants were 76 infants born preterm (≤36weeks' gestation and <2500g birth weight) and their mothers. Maternal sensitive responsiveness and directiveness were observed during a mother-infant interaction situation at 7, 10 and 14months corrected age. At the same ages, executive functioning was measured using the A-not-B task. An infant self-regulation questionnaire (IBQ-R) was completed by mothers at 7months.

RESULTS

After controlling for perinatal risk factors, Multivariate Latent Growth Modeling showed that consistently higher levels of maternal directiveness predicted a stronger increase in A-not-B performance, which did not vary with infant self-regulation. No relationship between maternal sensitive responsiveness and development in A-not-B performance in infants born preterm was found.

CONCLUSIONS

These results suggest that preterm infants' early executive functioning development in the first year of life may benefit from a more and consistent directive approach by their mothers. These findings have important implications for early intervention programs aimed at facilitating preterm infants' development.

Object engagement and manipulation in extremely preterm and full term infants at 6 months of age

Delays in the motor domain have been frequently observed in preterm children, especially those born at an extremely low gestational age (ELGA;<28 weeks GA). However, early motor exploration has received relatively little attention despite its relevance for object knowledge and its impact on cognitive and language development. The present study aimed at comparing early object exploration in 20 ELGA and 20 full-term (FT) infants at 6 months of age during a 5-minute mother-infant play interaction. Object engagement (visual vs manual), visual object engagement (no act vs reach), manual object engagement (passive vs active), and active object manipulation (mouthing, transferring, banging, turn/rotating, shaking, fingering) were analyzed. Moreover, the Griffiths Mental Development Scales 0-2 years (1996) were administered to the infants. Relative to FT peers, ELGA infants spent more time in visual engagement, and less time in manual engagement, active manipulation, mouthing, and turning/rotating. Moreover, they had lower scores on general psychomotor development, eye & hand coordination, and performance abilities. Close relationships emerged between manual object engagement and psychomotor development. Clinical implications of these results in terms of early evaluation of action schemes in ELGA infants and the provision of intervention programs for supporting these abilities are discussed.

Postpartum anxiety and adjustment disorders in parents of infants with very low birth weight: Cross-sectional results from a controlled multicentre cohort study

BACKGROUND

Both preterm delivery and survival rates of very low birth weight (VLBW: <1500 g) infants are increasing. To date, the focus on studies about postpartum mental health after preterm birth has been on depression and on women. There is a paucity of research regarding prevalence, risks, and predictors of postpartum anxiety in parents after VLBW birth.

METHODS

Parents with VLBW infants and parents with term infants were recruited into the longitudinal HaFEn-study at the three largest centers of perinatal care in Hamburg, Germany. State anxiety was assessed with the State-Trait-Anxiety Inventory and anxiety and adjustment disorders with a clinical interview one month postpartum. Psychiatric lifetime diagnoses, social support, trait anxiety, stress during birth, socioeconomic status, risks during pregnancy, and mode of delivery were also evaluated. To examine predictors of postpartum state anxiety in both parents simultaneously a multiple random coefficient model was used.

RESULTS

230 mothers and 173 fathers were included. The risk for minor/major anxiety symptoms and adjustment disorders was higher in parents with VLBW infants compared to the term group. The risk for anxiety disorders was not higher in parents with VLBW infants. The most important predictors for postpartum state anxiety were high trait anxiety, the birth of a VLBW infant, high stress during birth, and low social support.

LIMITATIONS

Data reported here are cross-sectional. Thus, temporal relationships cannot be established.

CONCLUSIONS

Our results emphasize the importance of early screening for postpartum anxiety in both parents with VLBW infants.

Práticas Educativas e Indicadores de Ansiedade, Depressão e Estresse Maternos

RESUMO Compararam-se práticas educativas parentais positivas e negativas de 100 mães de bebês, com e sem indicadores de ansiedade, depressão e estresse. Utilizou-se o Inventário de Estilos Parentais de Mães de Bebês, o BDI-III, o IDATE e o ISSL. Com o Teste t de Student, compararam-se os grupos relativamente à presença/ausência de cada indicador e à quantidade de indicadores presentes. Considerou-se como grupo controle as mães sem nenhum dos indicadores emocionais avaliados. Observou-se a presença das práticas negativas punição inconsistente e disciplina relaxada em todos os indicadores avaliados. A presença de dois ou mais indicadores aumentou a frequência da prática negativa de punição inconsistente. Identificar o tipo de prática educativa presente pode contribuir para intervenções pontuais mais eficientes.

Mother-preterm infant interactions at 3 months of corrected age: influence of maternal depression, anxiety and neonatal birth weight

Maternal depression and anxiety represent risk factors for the quality of early mother-preterm infant interactions, especially in the case of preterm birth. Despite the presence of many studies on this topic, the comorbidity of depressive and anxious symptoms has not been sufficiently investigated, as well as their relationship with the severity of prematurity and the quality of early interactions. The Aim of this study was to evaluate the quality of early mother-infant interactions and the prevalence of maternal depression and anxiety comparing dyads of extremely low birth weight (ELBW) and very low birth weight (VLBW) preterm infants with full-term ones. Seventy seven preterm infants (32 ELBW; 45 VLBW) and 120 full term (FT) infants and their mothers were recruited. At 3 months of corrected age, 5 min of mother-infant interactions were recorded and later coded through the Global Ratings Scales. Mothers completed the Edinburgh Postnatal Depression Scale and Penn State Worry Questionnaire. Infant levels of development were assessed through the Griffiths Mental Development Scales. A relation emerged among the severity of prematurity, depression, anxiety, and the quality of interactions. When compared with the FT group, the ELBW interactions were characterized by high maternal intrusiveness and low remoteness, while the VLBW dyads showed high levels of maternal sensitivity and infant communication. Depression was related to maternal remoteness and negative affective state, anxiety to low sensitivity, while infant interactive behaviors were impaired only in case of comorbidity. ELBW's mothers showed the highest prevalence of depressive and anxious symptoms; moreover, only in FT dyads, low maternal sensitivity, negative affective state and minor infant communication were associated to the presence of anxious symptoms. The results confirmed the impact of prematurity on mother-infant interactions and on maternal affective state. Early diagnosis can help to plan supportive interventions.

Maternal Sensitivity in Parenting Preterm Children: A Meta-analysis

BACKGROUND AND OBJECTIVES

Preterm birth is a significant stressor for parents and may adversely impact maternal parenting behavior. However, findings have been inconsistent. The objective of this meta-analysis was to determine whether mothers of preterm children behave differently (eg, less responsive or sensitive) in their interactions with their children after they are discharged from the hospital than mothers of term children.

METHODS

Medline, PsychInfo, ERIC, PubMed, and Web of Science were searched from January 1980 through May 2014 with the following keywords: "premature", "preterm", "low birth weight" in conjunction with "maternal behavio*r", "mother-infant interaction", "maternal sensitivity", and "parenting". Both longitudinal and cross-sectional studies that used an observational measure of maternal parenting behavior were eligible. Study results relating to parenting behaviors defined as sensitivity, facilitation, and responsivity were extracted, and mean estimates were combined with random-effects meta-analysis.

RESULTS

Thirty-four studies were included in the meta-analysis. Mothers of preterm and full-term children did not differ significantly from each other in terms of their behavior toward their children (Hedges' g = -0.07; 95% confidence interval: -0.22 to 0.08; z = -0.94; P = .35). The heterogeneity between studies was significant and high (Q = 156.42; I(2) = 78.9, P = .001) and not explained by degree of prematurity, publication date, geographical area, infant age, or type of maternal behavior.

CONCLUSIONS

Mothers of preterm children were not found to be less sensitive or responsive toward their children than mothers of full-term children.

Primary Care Triple P for parents of NICU graduates with behavioral problems: a randomized, clinical trial using observations of parent-child interaction

Background

Preterm-born or asphyxiated term-born children show more emotional and behavioral problems at preschool age than term-born children without a medical condition. It is uncertain whether parenting intervention programs aimed at the general population, are effective in this specific group. In earlier findings from the present trial, Primary Care Triple P was not effective in reducing parent-reported child behavioral problems. However, parenting programs claim to positively change child behavior through enhancement of the parent–child interaction. Therefore, we investigated whether Primary Care Triple P is effective in improving the quality of parent–child interaction and increasing the application of trained parenting skills in parents of preterm-born or asphyxiated term-born preschoolers with behavioral problems.

Methods

For this pragmatic, open randomized clinical trial, participants were recruited from a cohort of infants admitted to the neonatal intensive care units of two Dutch hospitals. Children aged 2–5 years, with a gestational age <32 weeks and/or birth weight <1500 g and children with a gestational age 37–42 weeks and perinatal asphyxia were included. After screening for a t-score ≥60 on the Child Behavior Checklist, children were randomly assigned to Primary Care Triple P (n = 34) or a wait-list control group (n = 33). Trial outcomes were the quality of parent–child interaction and the application of trained parenting skills, both scored from structured observation tasks.

Results

There was no effect of the intervention on either of the observational outcome measures at the 6-month trial endpoint.

Conclusions

Primary Care Triple P, is not effective in improving the quality of parent–child interaction nor does it increase the application of trained parenting skills in parents of preterm-born or asphyxiated term-born children with behavioral problems. Further research should focus on personalized care for these parents, with an emphasis on psychological support to reduce stress and promote self-regulation.

Trial registration

Netherlands National Trial Register NTR2179. Registered 26 January 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-014-0305-4) contains supplementary material, which is available to authorized users.

Maternal Concepts and Expectations regarding a Preterm Infant

The objective of the present study was: (a) to identify the concerns, verbally expressed, of 50 mothers regarding their preterm infants (PT) and then compare their verbal expression with those of 25 mothers of full-term infants (FT); and (b) to correlate the mothers' verbal expressions with maternal and infant variables. The following instruments were used to compose and characterize the sample: Structure Clinical Interview for DSM III-R Non-Patient (SCID/NP), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), and medical charts. Results showed that there was no difference between groups in term of mothers' expectations and conceptualizations; both groups exhibited predominantly positive expectations and concepts. In comparison with FT mothers, PT mothers verbally expressed more feelings and reactions predominantly negative or conflicting in relation to infant birth. Higher levels of maternal anxiety and depression in the PT Group were correlated with more verbal expressions about negative or conflicting emotions. In addition, lower birth weight, higher neonatal risk and longer length of stay in intensive care nursery of the infants were related with more negative or conflicting concepts by the mothers.

Comparative Network Analysis of Preterm vs. Full-Term Infant-Mother Interactions

Several studies have reported that interactions of mothers with preterm infants show differential characteristics compared to that of mothers with full-term infants. Interaction of preterm dyads is often reported as less harmonious. However, observations and explanations concerning the underlying mechanisms are inconsistent. In this work 30 preterm and 42 full-term mother-infant dyads were observed at one year of age. Free play interactions were videotaped and coded using a micro-analytic coding system. The video records were coded at one second resolution and studied by a novel approach using network analysis tools. The advantage of our approach is that it reveals the patterns of behavioral transitions in the interactions. We found that the most frequent behavioral transitions are the same in the two groups. However, we have identified several high and lower frequency transitions which occur significantly more often in the preterm or full-term group. Our analysis also suggests that the variability of behavioral transitions is significantly higher in the preterm group. This higher variability is mostly resulted from the diversity of transitions involving non-harmonious behaviors. We have identified a maladaptive pattern in the maternal behavior in the preterm group, involving intrusiveness and disengagement. Application of the approach reported in this paper to longitudinal data could elucidate whether these maladaptive maternal behavioral changes place the infant at risk for later emotional, cognitive and behavioral disturbance.

Rethinking stress in parents of preterm infants: a meta-analysis

BACKGROUND

With improved medical outcome in preterm infants, the psychosocial situation of their families is receiving increasing attention. For parents, the birth of a preterm infant is generally regarded as a stressful experience, and therefore many interventions are based on reducing parental stress. Nevertheless, it remains unclear whether parents of children born preterm experience more stress than parents of term-born children, which would justify these interventions. This meta-analysis provides a comprehensive account of parental stress in parents of preterm infants, from birth of the infant through to their adolescence. Mean levels of stress in specific domains of family functioning were investigated, and stress levels in parents of preterm and term infants, and fathers and mothers of preterm infants, were compared. Furthermore, we investigated moderators of parental stress.

METHODS AND FINDINGS

A random-effects meta-analysis was conducted including 38 studies describing 3025 parents of preterm (<37 wk) and low birth weight (<2500 g) infants. Parental stress was measured with two parent-reported questionnaires, the Parenting Stress Index and the Parental Stressor Scale: Neonatal Intensive Care Unit. The results indicate that parents of preterm-born children experience only slightly more stress than parents of term-born children, with small effect sizes. Furthermore, mothers have slightly more stress than fathers, but these effect sizes are also small. Parents report more stress for infants with lower gestational ages and lower birth weights. There is a strong effect for infant birth year, with decreasing parental stress from the 1980s onward, probably due to increased quality of care for preterm infants.

CONCLUSIONS

Based on our findings we argue that prematurity can best be regarded as one of the possible complications of birth, and not as a source of stress in itself.

Avaliação do impacto da prematuridade na saúde mental de puérperas

O presente estudo tem como objetivo comparar a ocorrência de sintomas de ansiedade e depressão em mães de bebês prematuros e mães de bebês a termo. Trata-se de um estudo transversal, descritivo, de abordagem quantitativa. As participantes (n=40) foram submetidas à avaliação de rastreamento executada como rotina pelo Serviço de Psicologia de um hospital filantrópico do interior paulista mediante a aplicação da Escala Hospitalar de Ansiedade e Depressão (HAD). Constatou-se que, entre as mães de bebês prematuros, 75% apresentavam sintomas clinicamente significativos de ansiedade e 50% apresentavam sintomas clinicamente significativos de depressão. Já entre as mães de bebês a termo, 65% não apresentavam sintomas clinicamente significativos de ansiedade e tampouco depressão. Ademais, a superioridade da pontuação média obtida pelas primeiras alcançou significância estatística. Os resultados corroboram a literatura, que sugere que a prematuridade tende a ter impacto negativo na saúde mental da mulher que vivencia essa situação.

Differential ethnic associations between maternal flexibility and play sophistication in toddlers born very low birth weight

Children born very low birth weight (<1500 g, VLBW) are at increased risk for developmental delays. Play is an important developmental outcome to the extent that child's play and social communication are related to later development of self-regulation and effective functional skills, and play serves as an important avenue of early intervention. The current study investigated associations between maternal flexibility and toddler play sophistication in Caucasian, Spanish speaking Hispanic, English speaking Hispanic, and Native American toddlers (18-22 months adjusted age) in a cross-sectional cohort of 73 toddlers born VLBW and their mothers. We found that the association between maternal flexibility and toddler play sophistication differed by ethnicity (F(3,65) = 3.34, p = .02). In particular, Spanish speaking Hispanic dyads evidenced a significant positive association between maternal flexibility and play sophistication of medium effect size. Results for Native Americans were parallel to those of Spanish speaking Hispanic dyads: the relationship between flexibility and play sophistication was positive and of small-medium effect size. Findings indicate that for Caucasians and English speaking Hispanics, flexibility evidenced a non-significant (negative and small effect size) association with toddler play sophistication. Significant follow-up contrasts revealed that the associations for Caucasian and English speaking Hispanic dyads were significantly different from those of the other two ethnic groups. Results remained unchanged after adjusting for the amount of maternal language, an index of maternal engagement and stimulation; and after adjusting for birth weight, gestational age, gender, test age, cognitive ability, as well maternal age, education, and income. Our results provide preliminary evidence that ethnicity and acculturation may mediate the association between maternal interactive behavior such as flexibility and toddler developmental outcomes, as indexed by play sophistication. Addressing these association differences is particularly important in children born VLBW because interventions targeting parent interaction strategies such as maternal flexibility must account for ethnic-cultural differences in order to promote toddler developmental outcomes through play paradigms.

Mutter-Kind-Interaktion bei Frühgeborenen

Die Mutter-Kind-Interaktion (MKI) Frühgeborener ist im Vergleich zu Reifgeborenen durch eine erhöhte mütterliche Intrusivität und Kontrolle gekennzeichnet. Analysiert wurde die MKI von Früh- und Reifgeborenen im Alter von 36 Monaten. 39 Frühgeborene < 1500 g (Studiengruppe) und 26 Reifgeborene (Kontrollgruppe) wurden im korrigierten Alter von 36 Monaten mittels Mannheimer Methode zur standardisierten Beobachtung der MKI im Kleinkindalter untersucht. Hierzu werden zwei fünfminütige Interaktionssituationen videographisch aufgezeichnet. Für die Lernsituation konnte nachgewiesen werden, dass die Mütter Frühgeborener weniger supportiv, häufiger restriktiv und unangemessen steuern, „negativer“ auf ihre Kinder reagieren und häufiger „negative“ Interaktionsauffälligkeiten zeigen. In der Spielsituation zeigte sich, dass Mütter frühgeborener Kinder häufiger negative Interaktionsauffälligkeiten sowie eine höhere negative Gestimmtheit und eine unangemessenere Steuerung aufweisen. Die Lernsituation zeigte sich in der Gruppe der Frühgeborenen als die „schwierigere“ Interaktion. Die Problematik der Mutter- Kind-Interaktion Frühgeborener bedarf besonderer Beachtung sowie früher Interventionen.

No longer pregnant, not yet a mother: giving birth prematurely to a very-low-birth-weight baby

In this article we present the findings of a qualitative examination of 30 mothers of very-low-birth-weight babies. Interviews conducted with the mothers when the babies were still in neonatal hospitalization show that virtually all the mothers described their delivery both as a traumatic event, and as a nonevent in which they felt that they barely participated. Most of them blamed themselves for not carrying full term, some blamed others, and some believed the premature delivery saved their baby's life. Following their truncated pregnancies, their "nonparticipation" in the delivery, and their separation from their newborn immediately after the delivery, virtually all the women reported difficulty grasping that they were mothers. Many reported a sense of loss, emptiness, and frustration that the baby was no longer inside. The women took a variety of measures, including magical means and parenting behaviors, to safeguard their vulnerable babies and to become mothers within the constraints of the neonatal unit.

Attachment security and language development in an Italian sample

We investigated the influence of biological immaturity and attachment security on linguistic development and tested whether maternal language mediated the impact of security on the child’s linguistic abilities. Forty mother–child dyads were followed longitudinally, with the child’s attachment security assessed at 24 months of age through trained observers’ Attachment Q-Sorts, and linguistic abilities assessed at 24 and 30 months through observational measures and maternal reports. Both factors were found to contribute, though not independently, to the prediction of the child’s linguistic abilities, and the mediation model was confirmed.

Maternal speech to preterm infants during the first 2 years of life: stability and change

BACKGROUND

Studies on typical language development documented that mothers fine-tune their verbal input to children's advancing skills and development. Although premature birth has often been associated with delays in communicative and language development, studies investigating maternal language addressed to these children are still rare.

AIMS

The principal aim of this longitudinal study was to investigate the maternal speech directed at very preterm children by examining its changes across time and the stability of maternal individual styles.

METHODS & PROCEDURES

A sample of 16 mother-preterm infant dyads participated in semi-structured play sessions when children were 6, 12, 18 and 24 months of corrected age. Maternal speech directed at the children was analysed in terms of lexical and syntactical complexity as well as verbal productivity. Also children's motor, cognitive and communicative skills were assessed.

OUTCOMES & RESULTS

Results highlight an overall increase in the lexical and syntactical complexity and in the amount of maternal speech across the first years of life. At the same time, individual maternal communicative styles seem stable as infants grow older, even if between 12 and 18 months all the indices' predictive values decrease, indicating a noteworthy modification in individual maternal styles. Furthermore, between 12 and 18 months predictive relationships between children's motor and vocal skills and maternal changes in input were found.

CONCLUSIONS & IMPLICATIONS

Verbal input addressed to children born preterm during the first 2 years of life does not seem to differ considerably from the language usually used with full-term infants. Nevertheless, maternal verbal adjustments seem to be predicted by earlier infant achievements in vocal and motor development. This suggests that infants' motor skill maturation may function as a major signal for mothers of preterm babies to adjust aspects of their linguistic interactive style.

Biopsychosocial risk factors for preterm birth and postpartum emotional well-being: a case-control study on Turkish women without chronic illnesses

AIMS AND OBJECTIVES

The study aimed to determine bio-psycho-social risk factors for preterm birth in a sample of Turkish women without chronic illnesses and evaluate their anxiety and depression in early postpartum period.

BACKGROUND

Preterm birth is a devastating event with long-term health and social implications. Studies have identified several risk factors; however, the contribution of these causes differs by ethnic groups.

DESIGN

This case-control study was conducted in a tertiary hospital in Istanbul over one year. In total, 149 preterm mothers were included in the case group and 150 term mothers who delivered in the same day with a case group woman were included in the control group. Chronic illnesses and anomalies were excluded.

METHOD

Data were gathered using a form that addressed risk factors for preterm birth. Multidimensional Scale of Perceived Social Support, Beck Depression Inventory and Spielberger's State-Trait Anxiety Inventory were administered within 24-72 hours after birth.

RESULTS

Logistic regression analysis revealed that partner's lower education (≤ 8 years), history of preterm birth, antenatal hospitalisation, genitourinary infection and irregular prenatal care were significant risk factors. Perceived social support from family and friends were significantly lower in preterm group. Preterm mothers experienced significantly more anxiety and depressive symptoms in early postpartum.

CONCLUSION

Many of the socio-economical and obstetric causes of preterm births were similar to other countries with higher preterm birth rates. Preterm births were associated with lower social support along with more anxiety and depressive symptoms in early postpartum.

RELEVANCE TO CLINICAL PRACTICE

Women who have established risk factors can be targeted for more intensive antenatal care for the prevention of preterm birth. Increased maternal anxiety and depression reveal the necessity of emotional support immediately after birth.

Differential genetic susceptibility to child risk at birth in predicting observed maternal behavior

This study examined parenting as a function of child medical risks at birth and parental genotype (dopamine D4 receptor; DRD4). Our hypothesis was that the relation between child risks and later maternal sensitivity would depend on the presence/absence of a genetic variant in the mothers, thus revealing a gene by environment interaction (GXE). Risk at birth was defined by combining risk indices of children's gestational age at birth, birth weight, and admission to the neonatal intensive care unit. The DRD4-III 7-repeat allele was chosen as a relevant genotype as it was recently shown to moderate the effect of environmental stress on parental sensitivity. Mothers of 104 twin pairs provided DNA samples and were observed with their children in a laboratory play session when the children were 3.5 years old. Results indicate that higher levels of risk at birth were associated with less sensitive parenting only among mothers carrying the 7-repeat allele, but not among mothers carrying shorter alleles. Moreover, mothers who are carriers of the 7-repeat allele and whose children scored low on the risk index were observed to have the highest levels of sensitivity. These findings provide evidence for the interactive effects of genes and environment (in this study, children born at higher risk) on parenting, and are consistent with a genetic differential susceptibility model of parenting by demonstrating that some parents are inherently more susceptible to environmental influences, both good and bad, than are others.

MATERNAL ANXIETY SYMPTOMS AND MOTHER-INFANT SELF- AND INTERACTIVE CONTINGENCY

Associations of maternal self-report anxiety-related symptoms with mother-infant 4-month face-to-face play were investigated in 119 pairs. Attention, affect, spatial orientation, and touch were coded from split-screen videotape on a 1-s time base. Self- and interactive contingency were assessed by time-series methods. Because anxiety symptoms signal emotional dysregulation, we expected to find atypical patterns of mother-infant interactive contingencies, and of degree of stability/lability within an individual's own rhythms of behavior (self-contingencies). Consistent with our optimum midrange model, maternal anxiety-related symptoms biased the interaction toward interactive contingencies that were both heightened (vigilant) in some modalities and lowered (withdrawn) in others; both may be efforts to adapt to stress. Infant self-contingency was lowered ("destabilized") with maternal anxiety symptoms; however, maternal self-contingency was both lowered in some modalities and heightened (overly stable) in others. Interactive contingency patterns were characterized by intermodal discrepancies, confusing forms of communication. For example, mothers vigilantly monitored infants visually, but withdrew from contingently coordinating with infants emotionally, as if mothers were "looking through" them. This picture fits descriptions of mothers with anxiety symptoms as overaroused/fearful, leading to vigilance, but dealing with their fear through emotional distancing. Infants heightened facial affect coordination (vigilance), but dampened vocal affect coordination (withdrawal), with mother's face-a pattern of conflict. The maternal and infant patterns together generated a mutual ambivalence.

Prematurity, maternal posttraumatic stress and consequences on the mother-infant relationship

OBJECTIVE

Premature birth is a stressful experience for parents. This study explores the links between maternal posttraumatic stress, maternal attachment representations of the infant and mother-infant dyadic interactions.

METHODS

The study enrols 47 preterm (GA<34 weeks) and 25 full-term infants. The Perinatal Posttraumatic Stress Disorder Questionnaire was administered to evaluate maternal posttraumatic stress symptoms. At 6 months of corrected age, maternal attachment representations of the infant were explored and coded with the Working Model of the Child Interview. Interactive characteristics were explored in a videotaped play session and coded with the Care Index.

RESULTS

Full-term mothers were more likely to follow a "Cooperative" dyadic pattern of interaction with the infant and demonstrate Balanced representations of the infant. Preterm mothers with high posttraumatic stress symptoms were more likely to follow a "Controlling" dyadic pattern of interaction, with more Distorted representations. In contrast, preterm mothers with low posttraumatic stress symptoms were more likely to fall into a "Heterogeneous" group of patterns of dyadic interaction, with Disengaged representations. Interestingly, in Cooperative preterm dyads, only 23% of the mothers demonstrated Balanced representations, despite rates of 69% in full-term Cooperative dyads.

CONCLUSION

Premature birth affects both mother-infant interaction characteristics and maternal representations of attachment with the infant. In particular, a "Controlling" dyadic pattern was associated with high maternal posttraumatic stress symptoms and Distorted maternal representations. It is important to examine the impact of maternal posttraumatic stress on the parent-infant relationship in order to plan supportive, preventive interventions in the neonatal period.

Anxiety, dysphoria, and depression symptoms in mothers of preterm infants

To compare presence and severity of clinical symptoms of anxiety, dysphoria, and depression in mothers of preterm and of full-term infants and to observe changes in symptoms of mothers of preterm infants during hospitalization of the infants and after discharge, 50 mothers of preterm infants and 25 mothers of full-term infants completed the State-Trait Anxiety Inventory and the Beck Depression Inventory. The mothers with preterm infants had significantly higher clinical symptoms of State Anxiety during hospitalization than the group with full-term infants, but the clinical symptoms of anxiety in mothers of preterm infants decreased significantly after discharge. The health staff in a neonatal intensive care unit should not only be aware of infants' clinical status but also of the mothers' emotional state.

The role of maternal anxiety in the early postpartum period: screening for anxiety and depressive symptomatology in Greece

BACKGROUND

From birth to the first year postpartum, there is a critical period for the development of affective disorders. Maternal anxiety has received little attention even though it is associated with a number of adverse outcomes. Symptoms of anxiety often comorbid with depression and pertain a significant role in the maintenance of postpartum distress. The purpose of this study is to assess anxiety and depressive symptomatology in a Greek population and to examine their relationship. This study investigated the demographic and socio-psychological factors that are associated with the onset of the symptoms of postpartum distress.

METHOD

The study was conducted at the perinatal hospital Elena Venizelou in Greece. Two hundred thirty-five mothers met the inclusion criteria and participated in the study. The state-trait inventory was administered to screen symptoms of anxiety. It incorporates the state subscale that measures symptoms of temporal anxiety, and trait subscale that measures personality predisposition to anxiety. The Edinburgh postpartum depression scale (EPDS) inventory was administered to screen for symptoms of depression. The first assessment was conducted in 2-3 days after labor and the follow-up assessment was conducted in 3 months postpartum by telephone. A standard survey questionnaire was used for the purposes of collecting the demographic data.

RESULTS

Symptoms of postpartum depression had 14.5% of mothers on the first screening and 4.6% at the follow-up (EPDS >or= 14). State anxiety symptoms were manifested by 22.9% of the sample on the first screening and 12.6% at the follow-up. Trait anxiety symptoms exhibited 24.6% of the sample on the first screening and 14.3% at the follow-up. There was comorbidity between the symptoms of anxiety and depression. The comorbidity was evident even when the anxiety subscale of the EPDS was removed. State anxiety was correlated with primiparity, admission to the NICU and negative experience of labor. Trait anxiety was correlated with the marital status of the mother. The symptoms of depression were correlated with the young age of the mother and negative experience of labor.

CONCLUSION

Symptoms of maternal anxiety are common after labor in Greece and persist in the early postpartum period. This finding suggests that the impact of maternal anxiety should be considered when studying postpartum distress. The comorbidity amongst anxiety and depressive symptomatology persisted at 3 months postpartum making women more vulnerable to postpartum distress. Given this result screening prior to hospital discharge is essential as it can provide an indication of the mothers who are susceptible to developing affective disorders.

How is maternal recollection of the birth experience related to the behavioral and emotional outcome of preterm infants?

OBJECTIVES

To investigate how mother's recollections of birth experiences and first contact with the newborn relate to the child's behavioral and emotional problems at five to six years of age.

METHODS

The study included 28 mothers of preterm (birth weight < or =2500 g) and 39 mothers of full-term children, born in Tampere University Hospital in 1998. When the children were five to six years old, maternal recollections of the birth experiences were assessed using the Clinical Interview for Parents of High-Risk Infants (CLIP) and children's behavioral and emotional problems were assessed using the Child Behavior Checklist (CBCL).

RESULTS

Mothers of the preterm children still had more negative recollections of the labor (p < 0.001) and first contact with the newborn (p < 0.001) than mothers of the full-term children. These recollections related to the child's behavioral and emotional symptoms when the child was five to six years old in the preterm group but not in the full-term group.

CONCLUSION

The impact of mother's birth experience seems to have long-lasting effects on the preterm child. This finding emphasizes the importance of early physical mother-infant contact and supporting the mothers of preterm infants, especially if they articulate negative or traumatic experiences related to the birth of their child.

Maternal depression is associated with mother-infant interaction in preterm infants

AIM

The purpose of this study was to assess the prevalence and the background factors of maternal depressive symptoms and their relation to the quality of mother-infant interaction in a group of preterm infants and their mothers.

METHODS

The signs of maternal depression were evaluated in 125 mothers of very preterm infants (birth weight < or = 1500 g or < 32 gestational weeks) at 6 months of infant's corrected age using Edinburgh Postnatal Depression Scale (EPDS). The association between maternal depressive symptoms and the quality of mother-infant interaction as assessed by the parent child early relational assessment method (PCERA) method was studied at 6 and 12 months of corrected age in 32 preterm infants who were their mothers' firstborn infants and singletons.

RESULTS

The prevalence of depression assessed by EPDS in mothers of very preterm infants was 12.6%. Most interestingly, the number of postnatal signs of depression associated negatively with the quality of the maternal interaction behaviour with their preterm infants.

CONCLUSIONS

This study suggests that maternal depression may be a risk factor in the development of the mother-infant relationship between preterm infants and their mothers. Therefore, it would be important to identify signs of depression in mothers of preterm infants to offer early support.

Regulation of anxiety during the postpartum period

Healthy mother-infant interactions are critical for the physical, cognitive, and psychological development of offspring. Such interactions rely on numerous factors, including a positive maternal emotional state. However, many postpartum women experience emotional dysregulation, often involving elevated anxiety. Neuroendocrine factors contributing to the onset of postpartum anxiety symptoms are mostly unknown, but irregularities in hypothalamic-pituitary-adrenal axis function, reduced prolactin and oxytocin signaling, or parturitional withdrawal of ovarian, placental and neural steroids could contribute to anxiety in susceptible women. Although the causes of initial onset are unclear, postpartum anxiety can be mitigated by recent contact with infants. Numerous neurochemical systems, including oxytocin, prolactin, GABA, and norepinephrine mediate this anxiolytic effect of infant contact. Insight into the etiology of postpartum anxiety disorders, and how contact with infants helps counter existing anxiety dysregulation, will surely facilitate the diagnosis and treatment of postpartum women at risk for, or experiencing, an anxiety disorder.

Avaliação de sintomas de ansiedade e depressão em mães de neonatos pré-termo durante e após hospitalização em UTI-Neonatal

OBJETIVO: Identificar sintomas em nível clínico de ansiedade, disforia e depressão em mães de neonatos pré-termo, comparando dois momentos, durante e após a hospitalização do bebê em Unidade de Terapia Intensiva Neonatal (UTIN). MÉTODOS: 43 mães de neonatos pré-termo de muito baixo peso, sem antecedentes psiquiátricos, foram avaliadas através dos Inventários de Ansiedade Traço-Estado e de Depressão de Beck. Foram realizadas duas avaliações, uma durante a hospitalização do bebê e outra após a alta hospitalar. RESULTADOS: Na primeira avaliação, 44% das mães apresentaram sintomas clínicos de ansiedade, disforia e/ou depressão. Após a alta hospitalar do bebê, houve redução significativa do número de mães (26%) com esses sintomas clínicos em relação à primeira avaliação (p<0,008). Os níveis de ansiedade-estado diminuíram significativamente da primeira para a segunda avaliação (de 35% para 12%; p<0,006). Não foi detectada diferença significativa entre as duas avaliações quanto aos demais sintomas clínicos. CONCLUSÃO: As mães de bebês pré-termo apresentaram ansiedade situacional e necessitam de suporte psicológico para enfrentar a internação do bebê.

Maternal posttraumatic stress response after the birth of a very low-birth-weight infant

OBJECTIVE

For parents, the premature birth of a child represents a traumatic event for which they are poorly prepared. To date, the focus of scientific interest has been on maternal psychological stress responses, such as anxiety and depression, or on appropriate coping mechanisms, whereas only scant attention has been paid to the traumatic aspect of the maternal experience after very low-birth-weight (VLBW) birth. The present study is the first to investigate the posttraumatic stress response of mothers after the birth of a VLBW infant in a prospective longitudinal study.

METHODS

Fifty mothers of VLBW infants were examined at four measuring time points (1-3 days pp, 14 days pp and 6 and 14 months pp) with respect to posttraumatic symptoms [Impact of Event Scale (IES-R)], psychiatric diagnosis (SKID I for DSM-IV) and the extent of depression [Beck Depression Inventory (BDI) and Montgomery Asberg Depression Scale (MADRS)] and anxiety [State-Trait Anxiety Inventory (STAI) and Hamilton Anxiety Scale (HAMA)]. The control group comprised a group of 30 mothers after the uncomplicated spontaneous birth of a healthy child.

RESULTS

At all four measuring timepoints (except 6 months pp), the mothers of the premature infants recorded significantly higher values for traumatic experience and depressive symptoms and anxiety compared with the controls. In contrast to the mothers in the control group, the mothers of the premature infants displayed no significant reduction in posttraumatic symptoms (IES-total), even 14 months after birth.

CONCLUSION

The results indicate that the situation of a mother who has given birth to a VLBW infant is a complex, with long-term traumatic event necessitating ongoing emotional support extending beyond the period immediately after the birth.

Prematurity, maternal stress and mother-child interactions

OBJECTIVE

Previous studies have shown that premature birth and the immaturity of the child can affect the quality of the parent-child relationship. The present study examines the relationship between maternal and infant interactional behavior over time and infant perinatal risk factors as well as maternal perinatal recollected traumatic experience. Few studies have explored the relationship between maternal stress and the quality of parent-infant interaction.

DESIGN

Mother-child interaction was recorded at 6 and 18 months of infant's age, in a population of 47 preterm infants (GA<34 weeks) and 25 full-term infants, born in 1998, during a play interaction. According to the Care Index, sensitivity, control and unresponsiveness have been used to code maternal interactional characteristics, and cooperation, compliance-compulsiveness, difficulty and passivity have been used to code the infant's interactional characteristics. The level of maternal stress was evaluated with the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ), and the infant's perinatal risk factors were assessed with the Perinatal Risk Inventory (PERI).

RESULTS

Mothers of high-risk infants, as well as mothers that had experienced traumatic stress in the perinatal period, were less sensitive and more controlling at 6 months. The interactional behavior of the preterm infant was different from that of the full-term infant at 18 months of age, and was correlated with maternal traumatic stress but not with perinatal risk factors.

CONCLUSION

These results underline the importance of maternal traumatic experience related to premature birth and its potential long lasting influence on mother-child interactional behavior.

Mother-infant interaction in premature infants at three months after nursery discharge

Both the immature and disorganized behaviour of the premature infant and the psychosocial or socioeconomic factors which adversely affect a mother's responsiveness to her premature infant can jeopardize the mother-infant relationship. At three months after infant hospital discharge, the interactions of 50 premature infants (< or = 32 weeks) and their mothers were videotaped and coded using the Nursing Child Assessment Feeding Scale. The relationship between data derived from the feeding interaction and maternal psychosocial and infant perinatal variables collected at one month after birth and at three months after discharge from hospital were examined. Results showed that the mothers' use of coping strategies both in hospital and at home were important factors in explaining mother-infant interaction.

Early preventive attachment-oriented psychotherapeutic intervention program with parents of a very low birthweight premature infant: results of attachment and neurological development

The birth of a very small preterm infant (< or = 1500 grams) can be a traumatizing experience for many parents. A developmental risk model is presented that is the background to an early attachment-oriented preventive psychotherapeutic intervention. This comprehensive parent-centered intervention program is composed of supportive group psychotherapy, attachment-oriented focal individual psychotherapy, a home visit and video-based sensitivity training. The intervention aims at improving parental coping, the process of attachment and parent-infant interaction. In a prospective longitudinal design mothers were randomly assigned to a control (N = 44) and an intervention group (N = 43) after preterm delivery. Results show that the percentage of secure (control vs. intervention group: 77.8% vs. 59.4%) and insecure (control vs. intervention group: 8.3% vs. 31.3% avoidant, 13.9% vs. 9.4% ambivalent) attachment quality in high-risk preterm infants is comparable to results from studies with term infants. There was no significant statistical difference in terms of quality of attachment of the preterm infants between the control group and the intervention group. However, only in the control group, impaired neurological development corresponded significantly with an insecure quality of attachment, but not in the intervention group, although there were significantly more neurologically impaired infants in the intervention group. This result is discussed as an effect of the intervention program.