SOCIAL WITHDRAWAL BEHAVIOR IN INFANCY: A HISTORY OF THE CONCEPT AND A REVIEW OF PUBLISHED STUDIES USING THE ALARM DISTRESS BABY SCALE

Understanding emotion dysregulation from infancy to toddlerhood with a multilevel perspective: The buffering effect of maternal sensitivity

Challenges with childhood emotion regulation may have origins in infancy and forecast later social and cognitive developmental delays, academic difficulties, and psychopathology. This study tested whether markers of emotion dysregulation in infancy predict emotion dysregulation in toddlerhood, and whether those associations depended on maternal sensitivity. When children (N = 111) were 7 months, baseline respiratory sinus arrhythmia (RSA), RSA withdrawal, and distress were collected during the Still Face Paradigm (SFP). Mothers' reports of infant regulation and orientation and maternal sensitivity were also collected at that time. Mothers' reports of toddlers' dysregulation were collected at 18 months. A set of hierarchical regressions indicated that low baseline RSA and less change in RSA from baseline to stressor predicted greater dysregulation at 18 months, but only for infants who experienced low maternal sensitivity. Baseline RSA and RSA withdrawal were not significantly associated with later dysregulation for infants with highly sensitive mothers. Infants who exhibited low distress during the SFP and who had lower regulatory and orienting abilities at 7 months had higher dysregulation at 18 months regardless of maternal sensitivity. Altogether, these results suggest that risk for dysregulation in toddlerhood has biobehavioral origins in infancy but may be buffered by sensitive caregiving.

Social withdrawal behaviour in Nepalese infants and the relationship with future neurodevelopment; a longitudinal cohort study

BACKGROUND

Social withdrawal in infants may be a signal of distress and a precursor for non-optimal development.

OBJECTIVE

To examine the relationship between infant social withdrawal and neurodevelopment up to 4 years in Nepalese children.

METHODS

A total of 597 Nepalese infants 6-11 months old were assessed with the modified Alarm Distress Baby Scale (m-ADBB), and of these, 527 with the Bayley Scales of Infant and Toddler Development 3rd edition (Bayley-III) during early childhood, and the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) and NEPSY-II subtests at 4 years. We examined whether social withdrawal defined by the m-ADBB was associated with neurodevelopmental scores in regression models.

RESULTS

Children socially withdrawn in infancy had lower Bayley-III language scores (-2.6 (95% CI -4.5, -0.7)) in early childhood. This association seems to be driven by the expressive communication subscale (-0.7 (95% CI -1.0, -0.3)), but not the receptive communication subscale (-0.2 (95% CI -0.6, 0.1)). There were no differences in the other Bayley-III scores or the WPPSI-IV and NEPSY-II scores at 4 years in children who were socially withdrawn or not.

CONCLUSION

Social withdrawal in infancy was reflected in early language development but not cognitive functioning at 4 years.

Feasibility and acceptability of using the Alarm Distress BaBy (ADBB) scale within universal health visiting practice in England: a mixed-methods study protocol

INTRODUCTION

The Alarm Distress BaBy (ADBB) scale developed by Guedeney and Fermanian in 2001, is a validated screening tool designed for use by healthcare practitioners to identify infant social withdrawal. This study will explore the acceptability and feasibility of the use of the full ADBB scale and a modified ADBB (m-ADBB) scale as part of routine health visiting visits in England.

METHODS AND ANALYSIS

A mixed methods sequential exploratory design will be used. Five health visitors will be trained in using the ADBB scale and 20 in the m-ADBB scale, from two National Health Service sites in England. Qualitative semi-structured interviews will be carried out with health visitors after they receive the training and again 2 months after using the scales in routine family health visits. Quantitative data will also be collected from the same participants for a range of items during the study period. The theoretical framework of Normalisation Process Theory will underpin the study, to provide in-depth explanations of the implementation process. Qualitative data will be analysed using thematic analysis. Quantitative data will be analysed using descriptive analysis.

ETHICS AND DISSEMINATION

Ethical approval was granted by the University of Oxford Departmental Research Ethics Committee. Dissemination of results will be via organisational websites, social media platforms, newsletters, professional networks, conferences and journal articles.

Infant Social Withdrawal Behavior: A Key for Adaptation in the Face of Relational Adversity

As a result of evolution, human babies are born with outstanding abilities for human communication and cooperation. The other side of the coin is their great sensitivity to any clear and durable violation in their relationship with caregivers. Infant sustained social withdrawal behavior (ISSWB) was first described in infants who had been separated from their caregivers, as in Spitz's description of “hospitalism” and “anaclitic depression.” Later, ISSWB was pointed to as a major clinical psychological feature in failure-to-thrive infants. Fraiberg also described freezing behavior as one of the earliest modes of infant defense in the face of adverse situations threatening the infant's ability to synchronize with caregivers. We hypothesize that ISSWB behaviors are associated with poor vagal brake functioning and that an impaired social engagement system is induced by an impoverished and/or dangerous environment. Recent research using animal models highlight the neurobiology and the genetics of the social Approach/Withdrawal Behavior in infants. The present paper is therefore a plea for social withdrawal behavior to be attributed a more important role as a major psychological defensive mechanism in infancy, and for research into early development and early intervention to make more practical and theoretical use of this concept, thus decreasing the challenge of translation in social neurosciences. This work presents several situations involving developmental hazards in which assessment of ISSWB by means of the Alarm Distress Baby Scale (ADBB) has proven useful, i.e., malnutrition, effects of major maternal depression and or traumatization, assessing social withdrawal in infants with an chronic organic illness (congenital heart disease, Prader-Willi syndrome, cleft lip and/or palate Prader-Willy syndrome, Fetal alcohol syndrome) or assessing ISSWB in out of home placed infants during parental visitation. Relationships between ISSWB and other biophysiological behavioral systems are discussed, particularly links with attachment processes and Porges's polyvagal theory.

Associations between symptoms of maternal postpartum depression, gestational age and infant social withdrawal: A longitudinal study in a community cohort

Infant social withdrawal is a risk factor for non‐optimal child development; thus, it is important to identify risk factors associated with withdrawal. In a large community sample (N = 19,017), we investigate whether symptoms of maternal and partner postpartum depression (PPD; measured with the Edinburgh Postnatal Depression Scale) and prematurity are predictors of infant social withdrawal (measured with the Alarm Distress Baby Scale). Withdrawal was assessed at 2–3, 4–7 and 8–12 months postpartum. Linear regressions showed that prematurity predicted higher infant social withdrawal at all time points, and maternal symptoms of PPD were positively associated with withdrawal at 2–3 months. Logistic regressions showed that odds for elevated social withdrawal were increased with elevated levels of maternal symptoms of PPD at 2–3 and 8–12 months. Partner's symptoms of PPD were not associated with withdrawal. Future studies should investigate how PPD symptoms and prematurity may impact the individual development of social withdrawal.

Maternal Postpartum Emotional Distress and Preterm Social Withdrawal in the Bedouin Culture

This study aimed to test a serial mediation model proposing that prematurity would be related to changes in maternal emotional distress, which in turn would be related to the mother-child (M-C) interaction, which would ultimately be related to infant social withdrawal. Bedouin mothers and their preterm (n = 48) and full-term (n = 57) infants participated in this study. Mothers' mean age was 27.67 years. In addition, 39.4% of the mothers were primiparas and 60.6% were multiparas. Infants and their mothers were recruited shortly after birth (T1) in the maternity ward or Neonatal Intensive Care Unit (NICU) at Soroka Medical Center and were followed up at ages 6 months (T2) and 12 months (T3). Findings indicated that HIGHER levels of maternal emotional distress during the second half of the first year postpartum and LOWER levels of mother-child interaction, were associated with HIGHER levels of infant social withdrawal at T3. Furthermore, the overall indirect effect suggested that HIGHER levels of maternal nonhostility was a main variable mediating the link between prematurity and LOW levels of infant social withdrawal. Our findings provide evidence that changes in maternal emotional distress during the first year are related to lower infant social withdrawal. Moreover, mothers of premature infants showed higher levels of nonhostility when interacting with their premature infants. These findings highlight the importance of gaining a better understanding of maternal behaviors. Specifically, our study provides important information for researchers and clinicians on a possible mechanism leading to early socioemotional difficulties of premature infants.

The Prevalence of Social Withdrawal in Infants With Cleft Lip and Palate: The Feasibility of the Full and the Modified Versions of the Alarm Distress Baby Scale

BACKGROUND

Social withdrawal is a risk indicator for infant development with both organic and non-organic causes. Cleft lip and palate (CLP) impose a higher risk of physical and emotional distress in infants and alters parent-infant relationships. The ADBB scale is a screening tool to identify social withdrawal as a sign of distress in infants. The aim of this study is to evaluate the prevalence of social withdrawal behavior in infants with CLP using the full 8-item ADBB scale and the modified 5-item ADBB scale, and to examine the feasibility of both scales.

METHODS

145 infants with Cleft Lip and Palate were enrolled and video recorded during a pediatric consultation. All infants were scored by two expert raters trained in ADBB scale, and subsequently scored with the m-ADBB by an independent expert. We measured the interrater agreement for the full ADBB scale and psychometric properties of both scales.

RESULTS

The full ADBB scale identified 15.9% of infants as having social withdrawal behavior (score above cutoff ≥5). Among the infants evaluated with the m-ADBB scale, 44.9% had a score above the suggested cutoff (≥2). For both scales, the item "vocalization" showed the higher scores. We found a good internal consistency for the full ADBB (Cronbach's alpha = 0.82) and an acceptable internal consistency for the modified ADBB (Cronbach's alpha = 0.71). The interrater agreement for the full ADBB scale was excellent (kappa = 0.837). The Spearman correlation coefficient between the total scores of the two versions was 0.88 (P < 0.001).

CONCLUSION

Our results indicate a relatively high prevalence of social withdrawal in infants with Cleft Lip and Palate, especially evaluated with the modified 5-item ADBB scale. We found that the full ADBB and the modified ADBB scales are feasible to use as screening tools of social withdrawal in this population.

CLINICAL TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov, identifier: NCT00993993. The data is the property of Assistance Publique, Hôpitaux de Paris.

The Impact of an Interactive Guidance Intervention on Sustained Social Withdrawal in Preterm Infants in Chile: Randomized Controlled Trial

BACKGROUND

Sustained social withdrawal is a key indicator of child emotional distress and a risk factor for psychological development. Preterm infants have a higher probability of developing sustained social withdrawal than infants born full-term during their first year.

OBJECTIVE

To compare the effect of a behavioral guidance intervention to that of routine pediatric care on sustained social withdrawal behavior in preterm infants.

DESIGN

Multicenter randomized clinical trial.

PARTICIPANTS

Ninety nine moderate and late preterm newborns and their parents were recruited and randomized into two groups, i.e., Intervention (n = 49) and Control (n = 50). Both groups attended medical check-ups at 2, 6 and 12 months and were assessed with the Alarm Distress Baby Scale. The intervention group received a standardized behavioral intervention if the neonatologist detected sustained social withdrawal. Also, parents filled out the Edinburgh Postnatal Depression Scale, the modified-Perinatal Posttraumatic Stress Disorder Questionnaire, and the Impact of Event Scale-revised.

RESULTS

At baseline, the prevalence of withdrawal was 4.0% (95% CI: 0.03-14.2) for the control group and 22.4% (95% CI: 13.0-35.9) for the intervention group [OR = 0.22, p = 0.028 (95% CI =0.06-0.84)]. At 6 months, the prevalence was 10.0% (95% CI: 3.9-21.8) for the control group and 6.1% (95% CI: 2.1-16.5) for the intervention group [OR = 2.09, p = 0.318 (95% CI = 0.49-8.88)]. At 12 months, the prevalence was 22.0% (95% CI: 12.8-35.2) for the control group and 4.1% (95% CI: 1.1-13.7) for the intervention group [OR = 6.63, p = 0.018 (95% CI = 1.39-31.71)]. Logistic generalized estimating equation models were performed. The pooled crude OR (considering diagnosis at 6 and 12 months) was 3.54 [p = 0.022 (95% CI = 1.20-10.44); Cohen's d= 0.70]. In the case of pooled adjusted OR, the model considered diagnosis (0 = Withdrawal, 1 = Normal) as the dependent variable, time of evaluation (1= 6 months, 2 = 12 months) and group (0 = Control, 1 = Experimental) as factors. In this case, the pooled adjusted OR was 3.57 [p = 0.022 (95% CI = 1.20-10.65); Cohen's d = 0.70].

CONCLUSION

Assessment and intervention of sustained social withdrawal in preterm infants via standardized instruments benefits families by reducing its prevalence, and possible associated negative outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03212547, identifier: NCT03212547.

Maternal depression and infant social withdrawal as predictors of behaviour and development in vertically HIV-infected children at 3.5 years

BACKGROUND

In low- and middle-income countries, there is a high prevalence of post-partum depression and it is often associated with HIV status. Maternal depression negatively affects mothering and can lead to social withdrawal in infants. Maternal depression and infant social withdrawal can have deleterious long-term effects on children's behaviour and neurodevelopmental trajectories.

AIM

To investigate whether maternal depression and infant social withdrawal at 10-12 months post-partum were significant predictors of child behaviour and development at 42 months.

METHOD

Seventy-four mother-infant dyads living with HIV were followed in a prospective, longitudinal design. Mothers were assessed for depression using the Center for Epidemiologic Studies Depression scale (CES-D). Infant social withdrawal was assessed by the modified Alarm Distress Baby Scale (m-ADBB), and development and behaviour were evaluated by the Griffiths Mental Development Scales (GMDS) and the Child Behavior Checklist (CBCL), respectively.

RESULTS

Maternal depression  explained 4.8% of the variance in child behaviour (β = 0.98, t = 2.05, p < 0.05) and 10.3% of the variance in development   (β = -0.30, t = -2.66, p < 0.05). Infant social withdrawal   was not a significant predictor of behaviour   (β = 3.27, t = 1.36, p = 0.18), but it did uniquely explain 7% of the variance in development (β = -1.32, t = -2.48, p < 0.05).

CONCLUSION

In the context of HIV, screening for maternal depression and the quality of mother-infant interactions are important (especially in the 1st year post-partum), given the significant long-term impact they have on behaviour and neurodevelopment.

ABBREVIATIONS

ANOVA: analysis of variance; ART: antiretroviral therapy; CBCL: Child Behavioral Checklist; CES-D: Center for Epidemiologic Studies Depression Scale; CHEI: children HIV-exposed and infected; CHER: Children with HIV Early Antiretroviral Treatment Trial; CHEU: children HIV-exposed and uninfected; CHUU: children HIV-unexposed and -uninfected; GMDS: Griffiths Mental Development Scales; HIV: human immunodeficiency virus; LMIC: low- and middle-income countries; m-ADBB: modified Alarm Distress Baby Scale; NRF: National Research Foundation; SAMRC: South African Medical Research Council; WHO: World Health Organization.

Social inequality in parent-infant relations: Epidemiological study of community nurse records

Background: Some studies suggest that favourable socioeconomic circumstances are associated with better parent-child relations but the documentation of such an association is limited and inconsistent. Few studies focused on infancy, few studies relied on objective measurement of parent-infant relations, and few studies included more than one measurement of parent-infant relations in the first year of life. Aims: To report the prevalence of objectively measured problems in parent-infant relations during the first year of life and to examine the association between socioeconomic circumstances and parent-infant relations in an unselected community sample of infants. Methods: Cross-sectional study of a community sample of children from birth to 10 months in 15 municipalities in Denmark, n = 11,765. The exposure variables were population register data about socioeconomic circumstances: (a) parents' education, (b) family composition, (c) parents' origin, and (d) parents' occupational status. The outcome variable was the health visitor's concerns about the parent-infant relation assessed at four home visits from birth to 10 months after delivery. Results: The proportion of children with concerns about the parent-infant relation was 10.5%, 7.8% at one home visit and 2.8% at two or more home visits. Logistic regression analyses showed that all four indicators of socioeconomic circumstances were associated with concerns about the parent-infant relation in the first year of life. Conclusions: The risk of problematic parent-infant relations were significantly elevated among, children of immigrant parents, and children of parents with shorter education and not in education or work.

Maternal Shared Pleasure, Infant Withdrawal, and Developmental Outcomes in a High Risk Setting in South Africa

Background: Infants in lower middle income countries are often exposed to early adversities which may lead to suboptimal caregiving environments and place them at risk of not achieving their developmental potential. Synchrony and positive engagement in the mother-infant relationship plays a critical role in buffering the impact of early adversity. Shared Pleasure (SP) is considered a marker of high intensity positive interaction and may hold a promise of improving developmental outcomes. Methods: This study was part of a prospective observational study of mothers with and without mental illness in South Africa. Dyadic videos were assessed for SP and infant withdrawal (using the Alarm Distress Baby Scale) at 6 months. Infant developmental outcomes were assessed using the Bayley's Scales for Infant and Toddler Development, third edition at 18 months. Results: Ninety-one dyads were assessed for SP. The occurrence of SP was low (20%). There was no significant association with an EPDS measure of maternal depression (p = 0.571) and SP moments. Infant withdrawal was high (72%) and associated with male infant gender (p = 0.025). There was a significant association between the occurrence of SP and a lower score of infant withdrawal (estimate = -1.29; SE = 0.4; p = 0.0002). The number of SP moments at 6 months was significantly associated with motor (estimate = 2.4; SE = 0.9; p = 0.007) and marginally significant with cognitive scores (estimate = 1.9; SE = 1.0; p = 0.052) at 18 months. Regression modelling differential outcomes showed a greater improvement in cognitive scores at 18 months in infants with an SP moment compared to those without an SP moment [SP average difference (AD) = 7.4 (2.4), no SP AD = 10.4 (1.2); p = 0.012]. Infants without an SP moment experienced a larger decrease in motor scores at 18 months compared to those with an SP moment [SP AD = -3 (3.0); no SP AD = -10.6 (1.5), p = 0.027]. Conclusion: While the occurrence of SP in this sample was low and the rates of infant withdrawal were high, there were promising results suggesting early positive SP interactions may contribute to improvements in subsequent developmental outcomes.

The Feasibility of the Full and Modified Versions of the Alarm Distress Baby Scale (ADBB) and the Prevalence of Social Withdrawal in Infants in Nepal

Background

Sustained social withdrawal in infancy may have organic and nonorganic causes and could hinder normal development. The Alarm Distress Baby (ADBB) scale is a widely validated screening tool of social withdrawal in children 2–24 months. The aim of the current study was to evaluate the full and modified ADBB in Nepalese infants in a community-based study.

Methods

We enrolled 600 infants who were video recorded during a pediatric examination. The 36 infants first enrolled were scored by an expert rater, and the subsequent 64 infants were scored by two trained staff with the full ADBB scale. Of the 600 enrolled infants, 597 videos (including the 100 infants scored with the full ADBB) were scored with the modified ADBB (m-ADBB) scale by the trained staff, with 7% double scoring. We measured the interrater agreement and psychometric properties of both scales.

Results

In the 64 infants scored with the full ADBB by two raters, the concordance correlation coefficients (CCCs) indicated poor interrater agreement. For the m-ADBB, the CCCs were better indicating acceptable agreement between raters. The greatest lower bound (GLB) for reliability coefficient for the full ADBB scored by an expert rater indicated good internal consistency, whereas the GLB coefficient for the m-ADBB indicated poorer internal consistency. The Spearman correlation coefficient between the total scores of the two versions was 0.82 (P < 0.001). Among the infants scored with the full ADBB, 25% had a score above cutoff (≥5). Scored with the m-ADBB in the full sample, 11.4% of the infants had a score above the suggested cutoff (≥2). In both versions, children achieved high scores on vocalization.

Conclusion

Our findings suggest that the m-ADBB is an acceptable approach to achieve adequate interrater agreement in a large community-based study in Nepal. Results indicate high prevalence of social withdrawal in this population. There are, however, uncertainties on the internal consistency of the scales in this setting, and the validity of the scales needs to be investigated further. More effective training strategies for administration and additional cultural-specific instructions could be important measures to explore before implementing the scale further in this setting.

Associations Between Maternal Postpartum Depression, Infant Social Behavior With a Stranger, and Infant Cognitive Development

Maternal postpartum depression (PPD) has been found to be related to infant social withdrawal during mother-infant interaction, and this may spill over on infant interactive behavior in other social contexts and impact infant psychosocial development. We investigated whether PPD was associated with infant social withdrawal during interaction with a tester in a psychological test situation and whether infant social withdrawal in the test situation mediated the association between PPD and infant cognitive scores reported in a previous study. Participants were 28 PPD dyads and 41 control dyads. We assessed infant social behavior and cognitive development with the Alarm Distress Baby Scale and the cognitive scale of the Bayley Scales of Infant and Toddler Development, third edition, at four months. More symptoms of maternal depression were associated with more infant social withdrawal. The association between maternal depressive symptoms and cognitive scores was at most partially mediated by infant social withdrawal in the test situation (<29.6%). Our results add to the existing literature on the effects of PPD on infant social behavior in other contexts than the one constituted by the mother. More research is needed to shed light on the mechanisms through which PPD impacts infant cognitive development.

Interactive Guidance Intervention to Address Sustained Social Withdrawal in Preterm Infants in Chile: Protocol for a Randomized Controlled Trial

Background

Preterm newborns can be exposed early to significant perinatal stress, and this stress can increase the risk of altered socioemotional development. Sustained social withdrawal in infants is an early indicator of emotional distress which is expressed by low reactivity to the environment, and if persistent, is frequently associated with altered psychological development. Infants born prematurely have a higher probability of developing sustained social withdrawal (adjusted odds ratio 1.84, 95% CI 1.04-3.26) than infants born full term, and there is a correlation between weight at birth and sustained social withdrawal at 12 months of age.

Objective

The aims of this study are to compare the effect of the interactive guidance intervention to that of routine pediatric care on sustained social withdrawal in infants born moderately or late preterm and to explore the relationship between sustained social withdrawal in these infants and factors such as neonatal intensive care unit hospitalization variables, parental depression, and posttraumatic stress symptoms.

Methods

This study is designed as a multicenter randomized controlled trial. Moderate and late preterm newborns and their parents were recruited and randomized (1:1 allocation ratio) to control and experimental groups. During neonatal intensive care unit hospitalization, daily duration of skin-to-skin contact, breastfeeding, and parental visits were recorded. Also, a daily score for neonatal pain and painful invasive procedures were recorded. After discharge from neonatal intensive care, for the duration of the study, both groups will attend follow-up consultations with neonatologists at 2, 6, and 12 months of age (corrected for gestational age) and will receive routine pediatric care. Every consultation will be recorded and assessed with the Alarm Distress Baby Scale to detect sustained social withdrawal (indicated by a score of 5 or higher). The neonatologists will perform an interactive guidance intervention if an infant in the intervention group exhibits sustained social withdrawal. In each follow-up consultation, parents will fill out the Edinburgh Postnatal Depression Scale, the modified Perinatal Posttraumatic Stress Disorder Questionnaire, and the Impact of Event Scale–revised.

Results

Recruitment for this trial started in September 2017. As of May 2020, we have completed enrollment (N=110 infants born moderately or late preterm). We aim to publish the results by mid-2021.

Conclusions

This is the first randomized controlled trial with a sample of infants born moderately or late preterm infants who will attend pediatric follow-up consultations during their first year (corrected for gestational age at birth) with neonatologists trained in the Alarm Distress Baby Scale and who will receive this interactive guidance intervention. If successful, this early intervention will show significant potential to be implemented in both public and private health care, given its low cost of training staff and that the intervention takes place during routine pediatric follow-up.

Trial Registration

ClinicalTrials.gov NCT03212547; https://clinicaltrials.gov/ct2/show/NCT03212547.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17943

The effects of socio-affective environment

This chapter focuses on new concepts and new paradigms shedding light on the complex issue of socioenvironmental factors that affect the psychologic development of the child. Longitudinal controlled studies have sorted out "what leads to what under which circumstances," adding to the heuristic value of the addition of risks and of the Bronfenbrenner's ecologic model of development and disentangling the socioeconomic status (SES) from poverty. We emphasize the importance of taking attachment styles and attachment disorganization into account for a better understanding of both normal development and early psychopathology. Intervention studies demonstrate the real life effect of the gene-environment interaction with or without epigenetic processes. Thus, this chapter deals with paradigmatic situations as ADS, Prader-Willi, or prematurity as they allow us to learn more about early development and epigenetic influences.

Maternal and infant characteristics connected to shared pleasure in dyadic interaction

The aim of the study was to analyze which maternal factors (depressive symptoms, effect of life events, maternal sensitivity and structuring) and infant characteristics (temperament, social withdrawal symptoms, interactive behavior, genotype, gender) contribute to shared pleasure (SP) in parent-infant interaction. Participants were 113 mother-infant dyads. The mothers filled in the Edinburgh Postnatal Depression Scale, the Infant Behavior Questionnaire, and the Life Events Questionnaire. The dyads were videotaped in a free-play situation, and the videos were analyzed using the Alarm Distress Baby Scale and the Emotional Availability Scales. The infants were genotyped for four genes involved in emotion regulation. The occurrence and duration of SP (SP-MD) in mother-infant interactions were analyzed from the videotapes. Higher maternal sensitivity and depressive symptoms, better infant responsiveness, and the infant having the GG variant of the gene tryptophan hydroxylase isoform 2 (TPH2) -307 were associated with the occurrence of SP. Lower level depressive symptoms, better maternal structuring, and greater infant involvement were associated with the longer duration of SP. Those dyads where the mother and infant were best able to read each other's positive cues and to respond to them were more likely to experience mutual positive affect, as seen in SP.

Commentary: "Autism: a disorder linked with some trouble in intermodal matching? Putting things together a bit further": a commentary on Falck-Ytter et al. (2018)

Falck-Ytter et al. () (Journal of Child Psychology and Psychiatry 59: 872-880) designed an elegant study with 10-month-old siblings of children with autism using an eye-tracking task.

Maternal Distress and Infant Social Withdrawal (ADBB) Following Infant Cardiac Surgery for Congenital Heart Disease

Background:

Mothers and infants are exposed to multiple stresses when cardiac surgery is required for the infant. This study reviewed infant responsiveness using a standardized objective observational measure of social withdrawal and explored its association with measures of maternal distress.

Methods:

Mother–infant pairs involving infants surviving early cardiac surgery were assessed when the infant was aged two months. Infant social withdrawal was measured using the Alarm Distress Baby Scale. Maternal distress was assessed using self-report measures for maternal depression (Edinburgh Postnatal Depression Scale), anxiety (Spielberger State-Trait Anxiety Scale), and parenting stress (Parenting Stress Index–Short Form). Potential associations between infant social withdrawal and maternal distress were evaluated.

Results:

High levels of maternal distress and infant social withdrawal were identified relative to community norms with a positive association. Such an association was not found between infant social withdrawal and the cardiac abnormality and surgery performed.

Conclusion:

The vulnerability of infants requiring cardiac surgery may be better understood when factors beyond their medical condition are considered. The findings suggested an association between maternal distress and infant social withdrawal, which may be consistent with mothers’ distress placing infants subjected to cardiac surgery at substantially increased risk of social withdrawal. However, it is unclear to what extent infant withdrawal may trigger maternal distress and what the interactive effects are. Further research is warranted. Trialing a mother–infant support program may be helpful in alleviating distress and improving the well-being and outcomes for these families.

Protecting the child while preserving the relationship: Using baby's relational withdrawal to gauge the effect of parental visitation

The impact of children's interactions with parents in the context of out-of-home placements is receiving much-needed cross-disciplinary attention. However, the paucity of instruments that can reliably represent young children's experiences of such interactions precludes a nuanced evaluation of their impact on wellbeing and development. In response to this empirical gap, the present study investigates children's relational withdrawal as a clinically salient, easily observable and conceptually valid measure of infants' and toddlers' responses to parents. Relational withdrawal, challenging behaviors and salivary cortisol were assessed before, during and after parental visits. Conceptually, the findings suggest that observations of relational withdrawal correlate meaningfully with measure of neurobiological reactivity. Clinically, three profiles of cross-variable responses in children appeared, distinguishing between groups that experience increased, decreased or unchanged levels of stress in response to parental visits. Taken together, the findings lend empirical support to systematic observations of relational withdrawal to bolster evaluations of young children's experience of parental visitation during out-of-home placements.

Relations between Automatically Extracted Motion Features and the Quality of Mother-Infant Interactions at 4 and 13 Months

Bodily movements are an essential component of social interactions. However, the role of movement in early mother-infant interaction has received little attention in the research literature. The aim of the present study was to investigate the relationship between automatically extracted motion features and interaction quality in mother-infant interactions at 4 and 13 months. The sample consisted of 19 mother-infant dyads at 4 months and 33 mother-infant dyads at 13 months. The coding system Coding Interactive Behavior (CIB) was used for rating the quality of the interactions. Kinetic energy of upper-body, arms and head motion was calculated and used as segmentation in order to extract coarse- and fine-grained motion features. Spearman correlations were conducted between the composites derived from the CIB and the coarse- and fine-grained motion features. At both 4 and 13 months, longer durations of maternal arm motion and infant upper-body motion were associated with more aversive interactions, i.e., more parent-led interactions and more infant negativity. Further, at 4 months, the amount of motion silence was related to more adaptive interactions, i.e., more sensitive and child-led interactions. Analyses of the fine-grained motion features showed that if the mother coordinates her head movements with her infant's head movements, the interaction is rated as more adaptive in terms of less infant negativity and less dyadic negative states. We found more and stronger correlations between the motion features and the interaction qualities at 4 compared to 13 months. These results highlight that motion features are related to the quality of mother-infant interactions. Factors such as infant age and interaction set-up are likely to modify the meaning and importance of different motion features.

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.

Implementation of the Alarm Distress Baby Scale as a universal screening instrument in primary care: feasibility, acceptability, and predictors of professionals' adherence to guidelines

BACKGROUND

Infant socioemotional development is often held under informal surveillance, but a formal screening program is needed to ensure systematic identification of developmental risk. Even when screening programs exist, they are often ineffective because health care professionals do not adhere to screening guidelines, resulting in low screening prevalence rates.

OBJECTIVES

To examine feasibility and acceptability of implementing universal screening for infant socioemotional problems with the Alarm Distress Baby Scale in primary care. The following questions were addressed: Is it possible to obtain acceptable screening prevalence rates within a 1-year period? How do the primary care workers (in this case, health visitors) experience using the instrument? Are attitudes toward using the instrument related to screening prevalence rates?

DESIGN

A longitudinal mixed-method study (surveys, data from the health visitors' digital filing system, and qualitative coding of answers to open-ended questions) was undertaken.

SETTING AND PARTICIPANTS

Health visitors in three of five districts of the City of Copenhagen, Denmark (N=79).

METHODS

We describe and evaluate the implementation process from the date the health visitors started the training on how to use the Alarm Distress Baby Scale to one year after they began using the instrument in practice. To monitor screening prevalence rates and adherence to guidelines, we used three data extractions (6, 9, and 12 months post-implementation) from the electronic filing system. Surveys including both quantitative and open-ended questions (pre- and post-implementation) were used to examine experiences with and attitudes towards the instrument. Descriptive and inferential statistical and qualitative content analyses were used.

RESULTS

Screening prevalence rates increased during the first year: Six months after implementation 47% (n=405) of the children had been screened; 12 months after implementation 79% (n=789) of the children were screened (the same child was not counted more than once). Most (92%) of the health visitors reported that the instrument made a positive contribution to their work. The majority (81%) also reported that it posed a challenge in their daily work at least to some degree. The health visitors' attitudes (positive and negative) toward the Alarm Distress Baby Scale, measured 7 months post-implementation, significantly predicted screening prevalence rates 12 months post-implementation.

CONCLUSIONS

Adding the Alarm Distress Baby Scale to an established surveillance program is feasible and accepTable Screening prevalence rates may be related to the primary care worker's attitude toward the instrument, i.e. successful implementation relies on an instrument that adds value to the work of the screener.

To which extent social withdrawal at the age of 1 year is associated with IQ at 5-6 years old? Results of the EDEN mother-child cohort

The present study aims to determine to which extent social withdrawal at 1 year is associated with the child's IQ at the end of the preschool period. Children (N = 1045) from the EDEN mother-child cohort were assessed for social withdrawal behaviours at 1 year by trained midwives using the Alarm Distress BaBy (ADBB) scale. Midwives also examined infants' language and motor development at 1 year. At the age 5-6 years, IQ scores were based on the WPPSI-III. Linear regression models were used to determine the association between IQ and ADBB, adjusted for a broad range of pre- and postnatal environmental factors and for language and motor skills scores at 1 year. After adjusting for environmental factors, children with social withdrawal at 1 years (ADBB ≥5; N = 195) had significantly lower IQ scores at 5-6 years (-2.81 IQ points; p value 0.007) compared to children without social withdrawal (ADBB <5; N = 847). When motor and language skills at 1 year were included in the previous model, no association between social withdrawal and IQ at 5-6 years was found. Being socially withdrawn at 1 year is associated with lower IQ scores at 5-6 years. The potential influence of these developmental aspects on each other (withdrawal behaviour and language/motor skills) may occur early in development. Our results improve our understanding of the outcomes of early social withdrawal behaviour and call for early detection of delay in acquisition of language/motor skills among socially withdrawn young children.

Dyssynchrony and perinatal psychopathology impact of child disease on parents-child interactions, the paradigm of Prader Willi syndrom

BACKGROUND

Infant-mother interaction is a set of bidirectional processes, where the baby is not only affected by the influences of his caregiver, but is also at the origin of considerable modifications. The recent discovery of biological correlates of synchrony during interaction validated its crucial value during child development. Here, we focus on the paradigmatic case of Prader-Willi Syndrome (PWS) where early endocrinal dysfunction is associated with severe hypotonia and early feeding disorder. As a consequence, parent-infant interaction is impaired. In a recent study (Tauber et al., 2017), OXT intranasal infusion was able to partially reverse the feeding phenotype, infant's behavior and brain connectivity. This article details the interaction profile found during feeding in these dyads and their improvement after OXT treatment.

METHODS

Eighteen infants (≤6months) with PWS were recruited and hospitalized 9days in a French reference center for PWS where they were treated with a short course of intranasal OXT. Social withdrawal behavior and mother-infant interaction were assessed on videos of feeding before and after treatment using the Alarm Distress Baby (ADBB) Scale and the Coding Interactive Behavior (CIB) Scale. Raters were blind to treatment status.

RESULTS

At baseline, infants with PWS showed hypotonia, low expressiveness of affects, fatigability and poor involvement in the relationship with severe withdrawal. Parents tended to adapt to their child difficulties, but the interaction was perturbed, tense, restricted and frequently intrusive with a forcing component during the feeding situation. After OXT treatment, infants were more alert, less fatigable, more expressive, and had less social withdrawal. They initiated mutual activities and were more engaged in relationships through gaze, behavior, and vocalizations. They had a better global tonicity with better handling. These modifications helped the parents to be more sensitive and the synchrony of the dyad was in a positive transactional spiral.

CONCLUSION

Dys-synchrony can be induced by children's pathology as well as parental pathology with emotional and developmental impact in the both cases. The PWS paradigm shows us the necessity to sustain early parents-child relationship to avoid establishment of a negative transactional pattern of interaction that can impact child's development.

The Use of Oxytocin to Improve Feeding and Social Skills in Infants With Prader-Willi Syndrome

BACKGROUND AND OBJECTIVES

Patients with Prader-Willi syndrome (PWS) display poor feeding and social skills as infants and fewer hypothalamic oxytocin (OXT)-producing neurons were documented in adults. Animal data demonstrated that early treatment with OXT restores sucking after birth. Our aim is to reproduce these data in infants with PWS.

METHODS

We conducted a phase 2 escalating dose study of a short course (7 days) of intranasal OXT administration. We enrolled 18 infants with PWS under 6 months old (6 infants in each step) who received 4 IU of OXT either every other day, daily, or twice daily. We investigated the tolerance and the effects on feeding and social skills and changes in circulating ghrelin and brain connectivity by functional MRI.

RESULTS

No adverse events were reported. No dose effect was observed. Sucking assessed by the Neonatal Oral-Motor Scale was abnormal in all infants at baseline and normalized in 88% after treatment. The scores of Neonatal Oral-Motor Scale and videofluoroscopy of swallowing significantly decreased from 16 to 9 (P < .001) and from 18 to 12.5 (P < .001), respectively. Significant improvements in Clinical Global Impression scale scores, social withdrawal behavior, and mother-infant interactions were observed. We documented a significant increase in acylated ghrelin and connectivity of the right superior orbitofrontal network that correlated with changes in sucking and behavior.

CONCLUSIONS

OXT is well tolerated in infants with PWS and improves feeding and social skills. These results open perspectives for early treatment in neurodevelopment diseases with feeding problems.

Copenhagen infant mental health project: study protocol for a randomized controlled trial comparing circle of security -parenting and care as usual as interventions targeting infant mental health risks

BACKGROUND

Infant mental health is a significant public health issue as early adversity and exposure to early childhood stress are significant risk factors that may have detrimental long-term developmental consequences for the affected children. Negative outcomes are seen on a range of areas such as physical and mental health, educational and labor market success, social network and establishing of family. Secure attachment is associated with optimal outcomes in all developmental domains in childhood, and both insecure and disorganized attachment are associated with a range of later problems and psychopathologies. In disadvantaged populations insecure and disorganized attachment are common, which points to the need of identifying early risk and effective methods of addressing such problems. This protocol describes an experimental evaluation of an indicated group-based parental educational program, Circle of Security-Parenting (COS-P), currently being conducted in Denmark.

METHODS/DESIGN

In a parallel randomized controlled trial of two intervention groups this study tests the efficacy of COS-P compared to Care as Usual (CAU) in enhancing maternal sensitivity and child attachment in a community sample in the City of Copenhagen, Denmark. During the project a general population of an estimated 17.600 families with an infant aged 2-12 months are screened for two known infant mental health risks, maternal postnatal depression and infant social withdrawal. Eligible families (N = 314), who agree to participate, will be randomly allocated with a ratio of 2:1 into the COS-P intervention arm and into CAU. Data will be obtained at inclusion (baseline) and at follow-up when the child is 12-16 months. The primary outcome is maternal sensitivity. Secondary outcomes include quality of infant attachment, language, cognitive and socioemotional development, family functioning, parental stress, parental mentalizing and maternal mental wellbeing.

DISCUSSION

The potential implications of the experimental evaluation of an indicated brief group-based parenting educational program to enhance parental sensitivity and attachment are discussed.

TRIAL REGISTRATION

ClinicalTrials.govID: NCT02497677 . Registered July 15 2015.

Social Withdrawal Behaviour at One Year of Age Is Associated with Delays in Reaching Language Milestones in the EDEN Mother-Child Cohort Study

Objective

The aim of the study was to examine the relationship between social withdrawal behaviour at one year and motor and language milestones.

Materials and Methods

One-year old children from the EDEN French population-based birth cohort study (Study on the pre- and postnatal determinants of the child’s development and prospective health Birth Cohort Study) were included. Social withdrawal at one year was assessed by trained midwives using the Alarm Distress BaBy (ADBB) scale. Midwives concurrently examined infants’ motor and language milestones. Parents reported on child’s psychomotor and language milestones, during the interview with the midwife.

Results

After adjusting for potential confounding factors, social withdrawal behaviour was significantly associated with concurrent delays in motor and language milestones assessed by the midwife or the parents.

Discussion

Higher scores on social withdrawal behaviour as assessed with the ADBB were associated with delays in reaching language milestones, and to a lesser extent with lower motor ability scores. Taking the contribution of social withdrawal behaviour into account may help understand the unfolding of developmental difficulties in children.

Pediatricians, Well-Baby Visits, and Video Intervention Therapy: Feasibility of a Video-Feedback Infant Mental Health Support Intervention in a Pediatric Primary Health Care Setting

This case series study evaluated the feasibility and acceptability of a behavioral/cognitive psychological intervention in a pediatric primary health care setting during standard well-baby visits. The aim of the intervention was to support caregivers' sensitivity and mentalization in order to promote infant mental health (IMH). Four neonates from birth to 8 months were consecutively enrolled to test a short video-feedback intervention (Primary Care - Video Intervention Therapy, an adaptation of George Downing's Video Intervention Therapy to primary care) conducted by a pediatrician. The 5 min interaction recording and the video-feedback session were performed during the same well-baby visit and in the same pediatrician's office where the physical examination was conducted. During the study period, six video-feedback sessions were performed for each baby at different ages (1, 2, 3, 4, 6, 8 months). A series of different interactional situations were filmed and discussed: touch, cry, affective matching, descriptive language, feeding, separation and autonomy. The intervention was easily accepted and much appreciated by all four families enrolled. This study aimed to answer a dilemma which pediatric providers generally face: if the provider wishes to respond not only to physical but also IMH issues, how on a practical level can this be done? This case series study indicates that Primary Care - Video Intervention Therapy can be a promising new tool for such a purpose.