Preventive intervention with infants and families: The NBAS model

Peripartale psychische Belastung und Auswirkungen auf die frühe Elternschaft

Hintergrund

Peripartale elterliche Angst und Depressivität zeigten Zusammenhänge mit kindlichen emotionalen und Verhaltensauffälligkeiten. Mögliche Erklärungsansätze umfassen pränatal prägende Einflüsse auf das Ungeborene sowie das postpartale Fortwirken psychischer Belastung auf die Eltern-Kind-Beziehung. Dabei kommt dem elterlichen Vertrauen in die eigenen Fähigkeiten eine mögliche protektive Rolle zu, das wiederum durch die eigene psychische Belastung und das kindliche Verhalten maßgeblich beeinträchtigt sein kann.

Fragestellung

Diese Studie untersucht, wie sich pränatale schwangerschaftsspezifische Ängste auf das Vertrauen in die eigenen Fähigkeiten als Mutter in der frühen Elternschaft auswirken und wodurch dieser Effekt vermittelt wird.

Material und Methoden

Als Teil einer prospektiven Längsschnittstudie beantworteten 116 Mütter im letzten Schwangerschaftsdrittel (T0) und der 3. Woche (T1) postpartal Fragebögen zu schwangerschaftsspezifischen Ängsten, mütterlichem Selbstvertrauen, postpartaler Depressivität und kindlicher Irritabilität.

Ergebnisse

Es zeigte sich, dass der Zusammenhang zwischen pränatalen Ängsten und mangelndem mütterlichen Selbstvertrauen nicht über das Erleben kindlicher Irritabilität, sondern entscheidend über das Erleben postpartaler Depressivität vermittelt wurde. Die mütterliche Parität spielte ebenfalls eine Rolle.

Schlussfolgerung

Pränatale schwangerschaftsspezifische Ängste können postpartaler Depressivität vorausgehen und so indirekt das mütterliche Vertrauen in die eigenen Fähigkeiten beeinträchtigen. Die Wachsamkeit für elterliche psychische Belastung und die Weiterentwicklung von Behandlungsansätzen mit Beginn in der Schwangerschaft sind notwendig und erfordern eine enge interprofessionelle Zusammenarbeit zwischen eltern- und kindbezogenen Disziplinen.

The "EA brief": A single session of parent feedback and coaching to improve emotional attachment and emotional availability (EA)

The goal of this study was to determine the extent to which a brief parenting intervention provided the context for helping families to support positive mother-child interactions as well as more optimal mother and child outcomes. Participants in this study were middle income mothers and their children were between 0-3 years of age (N = 25 dyads). Participants were filmed via Skype during a 20-minute mother-child free play and completed questionnaires (Time 1) before attending the brief intervention (involving: a single session of one-on-one parent feedback and coaching, and information via group meeting, texts, and reading) followed by a repeat of the 20-minute Skype interaction and the completion of the same questionnaires (Time 2). Paired samples t-tests were performed, revealing that mothers reported improvements in their personal well-being (using the Flourishing Scale), reports about the mother-child relationship (using the Emotional Availability Self Report), and observed interactions, particularly the child's side of the relationship (using the Emotional Availability System), from pretest to posttest. Results are discussed in terms of a single session of parent feedback and coaching (in conjunction with an informational group session and texts) potentially having a role in "planting a seed" for observed and self-reported parenting enhancement and child development.

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother-infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.

Getting Started on the Special Care Baby Unit: Preparation and Protocol

Attempts are being made to introduce occupational therapy onto Special Care Baby Units. To help those who are planning a new service, this article offers a personal account of the evolution of occupational therapy on the Winnicett Baby Unit at St Mary's Hospital, London, and describes the protocol on which the service there is based.

T. Berry Brazelton, MD: a lifetime of contributions from a giant in our field

TOPIC

Dr. T. Berry Brazelton's contributions span over 60 years and have shaped the interdisciplinary field of infant-parent work.

PURPOSE

It is easy to lose sight of the foundational contributions to understandings and perspectives that currently seem universal or inherent. Brazelton's work began in the 1950s when prevailing belief suggested newborns could not see or hear, much less contribute to interactional processes, speak through their behavior, and be equal partners in the development of the parent-child relationship.

CONCLUSIONS

Brazelton's immense contributions are intrinsic to infant, child, and family work, particularly infant mental health, and continue to shape the nature of this interdisciplinary field.

Perinatal dyadic psychotherapy: design, implementation, and acceptability

Maternal postpartum depression (PPD) and mother-infant relationship dysfunction have reciprocal effects on each other and thus an integrated approach that addresses both problems simultaneously may lead to improved outcomes. This study aimed to determine the feasibility, acceptability, and preliminary efficacy of a new intervention, Perinatal Dyadic Psychotherapy (PDP), for the early treatment of maternal PPD. PDP is designed to promote maternal mental health and facilitate optimal mother-infant relationships via (a) a supportive, relationship-based, mother-infant psychotherapeutic component, and (b) a developmentally based infant-oriented component focused on promoting positive mother-infant interactions. This paper describes the pilot use of PDP with six acutely depressed postpartum women. Nurses delivered the intervention over eight home visits. Results indicate that PDP is a feasible, acceptable, and safe intervention with this population. All participants achieved remission of depression with significant reduction of depression and anxiety symptoms, suggesting that PDP is a promising treatment for PPD.

Healthy Steps: a systematic review of a preventive practice-based model of pediatric care

The preventive role of anticipatory guidance in pediatric practice has gained increasing importance over the last two decades, resulting in the development of competing models of practice-based care. Our goal was to systematically evaluate and summarize the literature pertaining to the Healthy Steps Program for Young Children, a widely cited and utilized preventive model of care and anticipatory guidance, Medline and the bibliographies of review articles for relevant studies were searched using the keywords: Healthy Steps, preventive care, pediatric practice and others. Other sources included references of retrieved publications, review articles, and books; government documents; and Internet sources. Relevant sources were selected on the basis of their empirical evaluation of some component of care (e.g., child outcomes, parent outcomes, quality of care). From 21 identified articles, 13 met the inclusion criteria of empirical evaluation. These evaluations were summarized and compared. Results indicated that the Healthy Steps program has been rigorously evaluated and shown to be effective in preventing negative child and parent outcomes and enhancing positive outcomes. Despite limited information concerning cost effectiveness, the Healthy Steps Program provides clear benefit through early screening, family-centered care, and evidence-based anticipatory guidance. It is recommended that the Healthy Steps program be more widely disseminated to relevant stakeholders, and further enhanced by improved linguistic and cultural sensitivity and long term evaluation of cost effectiveness.

Toward Better Beginnings

The study hypothesized that short-term interventions applied to a high-risk pregnancy population could improve parenting attitudes and home environments, measured by two inventories. Mothers received prenatal and well child care from one provider group at two urban practice sites. Participants were divided into intervention ( N = 33) and comparison ( N = 39) groups. Interventions included (a) training residents and clinic physicians, nurses, and ancillary staff to use interactions with patients to encourage parental sensitivity and understanding of child development and (b) a short-term nurse home visiting program engaging mothers in guided self-observation to enhance parental sensitivity to infant cues. Intervention participants demonstrated higher Adult—Adolescent Parenting Inventory scores than the comparison group. Significant differences overall between comparison and intervention groups occurred for 2 of 6 domains of the Infant—Toddler HOME Inventory. Short-term primary care and nursing interventions may be effective in high-risk families to promote more nurturing parenting attitudes and behaviors.

Modeling Parents and Nurses' Relationships

Over the past 20 years, the transition to parenting has been widely investigated as much in nursing as in psychology. The challenges of this developmental period, such as developing parenting efficacy, and the resources available to one or both parents have been explored. Different factors have been found to influence parents' perceived efficacy, such as the quality of social support, the quality of the marital relationship, and the level of stress and anxiety. Little attention has been paid, however, to the influence of nurses' relationships with parents on parents' development of parenting efficacy, especially with multiparous parents. This information is needed to better understand nurses' contribution to parenting development. A model of the primary variables of interest—perceived parenting efficacy, critical events, and nurses' collaborative and help-giving practices—is presented.

The effectiveness of early intervention and the factors related to child behavioural problems at age 2: a randomized controlled trial

BACKGROUND

The aim of this study was to assess the effectiveness of early home-based intervention as a community health service and evaluate the influence of both early maternal depression and mother-infant relationships on child behavioral problems at age 2 in a longitudinal setting.

METHODS

A randomized controlled trial was conducted in this study. A total of 95 mother-infant pairs were assigned randomly to intervention (48) or control (47) groups. The intervention group received monthly specific home visits between the infant ages of 5 and 9 months while the control group received only routine center-based services. Maternal depression and the mother-infant relationship were assessed by medical checkups at the ages of 4 and 10 months. Child behavioral problems were assessed at age 2.

RESULTS

The intervention had no significant impact on child behavioral problems. However, for mothers who had a disturbed relationship with their infants, the rate of improvement in the quality of the relationship was higher in the intervention group. Disturbed mother-infant relationships at 10 months and early maternal depression significantly increased the risk of high scores on the Child Behavior Checklist (CBCL).

CONCLUSIONS

These findings indicate that intervention is most likely to have a positive impact on the quality of mother-infant relationships in cases where the relationship is disturbed and that a disturbed mother-infant relationship and maternal depression during infancy are relevant to the future mental health of the child. To prevent difficulties in child functioning, more prolonged interventions focusing on disturbed mother-infant relationships may be required.

Thoughts on health supervision: learning-focused primary care

Primary care clinicians confront a long list of topics that are supposed to be covered during well-child visits, but evidence for the effectiveness of preventive counseling for most issues is limited, and it is doubtful that covering more topics confers correspondingly enhanced clinical benefits. Amid growing professional interest in rethinking primary care, 3 ideas that would facilitate constructive change are proposed. First, face-to-face time between doctors and parents should be allocated as a scarce resource, with priority given to topics that are both important and uniquely responsive to in-office intervention. Second, to maximize the educational value of anticipatory guidance, visits could focus on experiential, as opposed to merely didactic, learning. Finally, recommendations for primary care should be based on evidence, rather than expert opinion. Competing protocols for preventive care ought to be subjected to large-scale, coordinated research. The unit of analysis should be the visit or series of visits, rather than a single intervention. A crucial first step would be the definition of universal outcome measures.

Does Maternal Warmth Moderate the Effects of Birth Weight on Twins' Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms and Low IQ?

The moderating effect of maternal warmth on the association between low birth weight and children's attention-deficit/hyperactivity disorder (ADHD) symptoms and low IQ was studied in 2,232 twins. Half of 5-year-old children had low birth weights, below 2,500 g. Maternal warmth, a component of expressed emotion, was coded from mothers' audiotaped descriptions of each child. Both parents and teachers rated children's ADHD symptoms, and the children were administered an IQ test. Results showed a significant interaction between children's birth weight and maternal warmth in predicting mothers' and teachers' ratings of ADHD. The interaction was not significant for IQ. The findings suggest that the effect of children's birth weight on their ADHD symptoms can be moderated by maternal warmth and that enhancing maternal warmth may prevent behavior problems among the increasing population of low-birth- weight children.

An innovative curriculum for primary care neonatology

This article describes the design of an innovative curriculum for pediatric residency newborn nursery rotation. In 1989, the Accreditation Committee for Graduate Medical Education added the requirement of newborn care to pediatric residency training; in 1996, the Accreditation Committee for Graduate Medical Education expanded that requirement. Specifically, certification required 4 weeks of newborn care, separate from any neonatal intensive care experience, and with at least 2 weeks in a newborn nursery. In response, we designed a structured newborn nursery curriculum for our pediatric residency training program. Three areas of focus were identified, from which the content and the strategies for teaching were derived. The areas of focus were (1). primary care, (2). confluence of levels of care that arise in newborn care, and (3). limitations and advantages of the structure and the environment of the rotation. The curriculum was implemented on a pediatric level 1 (PL-1) rotation entitled "primary care neonatology."

Touchpoints: changing the face of pediatric nurse practitioner education

Touchpoints is an interdisciplinary relational model of healthcare primarily used with parents and young children. The underlying premise of the Touchpoints approach is to support the parent/child relationship during the health encounter by enhancing parents' efforts to optimize their child's physical and psychological development. Nurse practitioners who use this approach in practice find they are able to connect quickly to the parents' most urgent concerns for their child. Our experience has been that a pediatric nurse practitioner program that uses Touchpoints as the underlying framework can assist students in achieving a holistic view of families by focusing the curriculum more directly on development and relationships. Students learn that building a relationship with parents, and joining them in the care of their child, produces an atmosphere in the health encounter of mutual respect and trust. Parents leave the encounter feeling satisfied their concern for their child has been heard and questions have been seriously discussed; students leave feeling competent and valued by their patients. Touchpoints provides a model for teaching and demonstrating the development of interpersonal relationships by using the language of the child's behavior.

Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study

BACKGROUND

A high rate of maternal depression and associated disturbance in the mother-infant relationship has been found in an indigent peri-urban South African community, Khayelitsha. The question arises whether a community-based intervention could be beneficial.

AIMS

To train community workers to deliver an intervention to mothers and infants in Khayelitsha, and to compare mothers and infants receiving this intervention with a sample receiving no such intervention.

METHOD

Four Khayelitsha women were trained in a mother-infant intervention, which they delivered to 32 women recruited in late pregnancy. At 6 months post-partum, maternal mood, the mother-infant relationship and infant growth were assessed. The findings were compared with a matched group of 32 mothers and infants.

RESULTS

There was no reliable impact of the intervention on maternal mood. However, compared with the comparison sample, the quality of mother-infant engagement was significantly more positive for those who had received the intervention.

CONCLUSIONS

The pilot study produced preliminary evidence of a benefit of a community-based mother-infant intervention delivered by trained, but otherwise unqualified, community workers, sufficient to warrant a formal controlled evaluation of this treatment.

When is an assessment an intervention? Parent perception of infant intentionality and language

OBJECTIVE

To determine whether the process of having parents rate their infant's intentionality and language using parent-report questionnaires influences parents' tendency to view infants as intentional or linguistic.

METHOD

The Infant Intentionality Questionnaire (IIQ) and the MacArthur Communicative Development Inventories (CDI) were administered to three groups of mothers. Forty mothers completed the interviews longitudinally when their infants were 8, 10 and 12 months old. A group of 20 mothers completed the interviews longitudinally when their infants were 10 and 12 months old. A third group of 20 mothers completed the interviews at 12 months only.

RESULTS

IIQ scores increased across age but also were higher if parents had more experience with the questionnaire. CDI scores increased with age, but there was no effect of repeated testing.

CONCLUSIONS

Previous experience with the IIQ seems to have enhanced the tendency to perceive intentionality. In contrast, repeated testing with the CDI did not alter parent perception of child language. These results suggest that some parent-report instruments (e.g., the IIQ) can alter the test-taker's awareness and thus could serve as an intervention. Parent-report instruments that tap something that is salient, familiar, and easily observable (e.g., the child's language) are less likely to alter the parent's perception.

Parent concerns in long-term follow-up

Consideration of the long-term follow-up of at-risk infants must take into account the role of parents and family contexts. Cognitive and social-emotional adaptation for a premature low birthweight infant is a product of complex transactions between biological and environmental risk and ameliorative factors that operate within powerful family and cultural contexts. Parental behaviors, psychosocial functioning, and social cognitions are particularly important in order to understand long-term developmental outcomes for infants as well as other family members. Interventions for high-risk infants have shown that these can be effective in reducing anxiety and concerns among parents and optimizing parent-child relationships.

The development of parenting: nursing resources

Successful parenting has a major impact on the emotional well-being and cognitive development of young children. Infants gain their sense of self at an early age through their interactions with their caregivers. Nurses can play a unique role in helping parents and caregivers learn about their infant's abilities and behavior and in providing interventions to foster positive parent-infant interactions. Several resources are presented that the professional can use to help parents learn about their newborn's individual communication patterns and needs.

The role of infant factors in postnatal depression and mother-infant interactions

A large group of infants of primiparous women who were at high risk fo r postnatal depression (N=188) and a smaller group of those at low risk (N=43) were assessed in the neonatal period using the Neonatal Behavioural Assessment Scale. Poor motor scores and high irritability were strongly predictive of the onset of maternal depression by eight weeks postpartum. These effects obtained after taking account of both maternal mood in the neonatal period and maternal perceptions of infant temperament. Poor motor scores and high levels of infant irritability in the neonatal period also predicted less optimal infant behaviour in face-to-face interactions with the mother at two months postpartum. Neonatal behaviour did not predict the persistence of depression, nor did it predict the quality of maternal behaviour in interaction with the infant.

Psychosocial interventions for very low birthweight infants: their scope and efficacy

With the burgeoning of infant psychiatry, and the increasing survival and development of cohorts of very low birthweight (VLBW) infants, psychiatrists are becoming increasingly involved with other professionals in designing and implementing early intervention programs. Psychosocial interventions for VLBW infants generally report positive results regardless of the orientation of the practitioners, or the stated goal of the intervention: however, they have often taken place independently of longitudinal research, and sometimes without grounding in theories of infant and family development. This paper first reviews the current state of research and findings related to infant-focussed, parent-directed, and interactional programs. Second, it addresses a number of basic questions to be considered by psychiatrists involved in consulting to neonatal intensive care units, who have to appraise, design or implement intervention programs with this group. Throughout this discussion, it is proposed that the notion of infants at developmental risk needs to be supplemented by that of caregivers at risk, and that the professional boundaries which these distinctions represent need to be overcome.

An Introduction to Occupational Therapy for High Risk Infants on Special Care Baby Units

This article introduces a role for occupational therapy in Special Care Baby Units (SCBUs). The relevance of occupational therapy is discussed, a potential client group is identified and effective intervention studies are briefly described. Skills and training needs are reviewed and suggestions given for occupational therapy. Some likely problems are discussed.

Effects of nursing intervention on adolescents' maternal role attainment

The purpose of this study was to evaluate the effects of a nursing intervention program on affective and behavioral dimensions of maternal role attainment. The sample comprised 20 primiparous adolescents, ages 12-19 years, from predominantly black and Hispanic backgrounds. Adolescents were randomly assigned to either an experimental or a control group. Participants in the experimental group received an intervention that included four 1 1/2 hour classes held at weekly intervals, selected maternal-fetal interactive activities, recording of fetal movements, and maintaining of maternal diaries. Five instruments were used in the study: Cranley's Maternal-Fetal Attachment Scale (MFAS); the two Semantic Differentials, Myself as Mother and My Baby; the Pharis Self-Confidence Scale; and the Nursing Child Assessment Feeding Scale (NCAFS). Adolescents receiving intervention demonstrated a significant increase in prenatal attachment (MFAS scores) but showed no differences in actual mothering behaviors (NCAFS scores) as compared with adolescents in the comparison group. Although significant correlations existed among the affective measures, they were not significantly related to the measures of mothering behaviors. These results suggest that the intervention program was primarily beneficial to adolescents' achievement of the maternal role through enhancement of maternal-fetal attachment. The data also raise questions about theoretical assumptions concerning the relationship between affective and behavioral components of mothering.