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Moureau A, Cordemans L, Gregoire C, Benoît P, Delvenne V. A 5 years' experience of a parent-baby day unit: impact on baby's development. Front Psychiatry 2023; 14:1121894. [PMID: 37398587 PMCID: PMC10308312 DOI: 10.3389/fpsyt.2023.1121894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/12/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Psychiatric Mother-Baby Units are well established in France, United Kingdom, and Australia, mostly in full-time hospitalization. Inpatient units are considered as best practice for improving outcomes for mothers and babies when the mother is experiencing severe mental illness and many studies have showed the effectiveness of care for the mother or the mother-infant relationship. Only a limited number of studies have focused on the day care setting or on the development of the baby. Our parent-baby day unit is the first day care unit in child psychiatry in Belgium. It offers specialized evaluation and therapeutic interventions focused on the baby and involves parents with mild or moderate psychiatric symptoms. The advantages of day care unit is to reduce the rupture with social and family living. Aims The objective of this study is to evaluate the effectiveness of parent-baby day unit in prevention of babies' developmental problems. First, we present the clinical characteristics of the population treated in the day-unit in comparison to the features presented in the literature review about mother-baby units, which usually receive full-time treatment. Then, we will identify the factors that might contribute to a positive evolution of the baby's development. Materials and methods In this study, we retrospectively analyze data of patients admitted between 2015 and 2020 in the day unit. Upon admission, the 3 pillars of perinatal care - babies, parents, and dyadic relationships - have systematically been investigated. All the families have received a standard perinatal medico-psycho-social anamnesis, including data on the pregnancy period. In this unit, all the babies are assessed at entry and at discharge using the diagnostic 0 to 5 scale, a clinical withdrawal risk, and a developmental assessment (Bayley). Parental psychopathology is assessed with the DSM5 diagnostic scale and the Edinburgh scale for depression. Parent-child interactions are categorized according to Axis II of the 0 to 5 scale. We have evaluated the improvement of children symptomatology, the child development and the mother-child relation between the entrance (T1) and the discharge (T2) and we have compared two groups of clinical situations: a group of patients with a successful evolution (considering baby's development and the alliance with the parents) and a group of unsuccessful evolution during hospitalization. Statistical analysis We use descriptive statistics to characterize our population. To compare the different groups of our cohort, we use the T-test and non-parametric tests for continue variables. For discrete variables, we used the Chi2 test of Pearson. Discussion The clinical population of the day unit is comparable to the mother-baby units in terms of psychosocial fragility but the psychopathological profile of the parents entering the day unit shows more anxiety disorder and less post-partum psychosis. The babies' development quotient is in the average range at T1 and is maintained at T2. In the day unit, the number of symptoms as well as the relational withdrawal of the babies is reduced between T1 and T2. The quality of parent-child relationship is improved between T1 and T2. The children of the group of pejorative evolution had a lower developmental quotient at the T1 and an overrepresentation of traumatic life events. Conclusion These results indicate that parent-baby day unit lead to positive outcomes in clinical situations with anxio-depressive parents, relational withdrawal of the babies, functional problems of the babies but not when a significant impact on the development of the baby already exists. The results of this study can guide therapeutic approaches for the benefit of care in parent-baby day units, and improve the development of the child and of the dyadic relationships.
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Affiliation(s)
- Audrey Moureau
- Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
- Child and Adolescent Psychiatry Department, Queen Fabiola Children’s University Hospital, Brussels, Belgium
| | - Louise Cordemans
- Child and Adolescent Psychiatry Department, Queen Fabiola Children’s University Hospital, Brussels, Belgium
- Faculty of Psychology, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Gregoire
- Child and Adolescent Psychiatry Department, Queen Fabiola Children’s University Hospital, Brussels, Belgium
- Faculty of Psychology, Université Libre de Bruxelles, Brussels, Belgium
| | - Pirmez Benoît
- Faculty of Statistics, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Veronique Delvenne
- Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
- Child and Adolescent Psychiatry Department, Queen Fabiola Children’s University Hospital, Brussels, Belgium
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The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis. Lancet Public Health 2023; 8:e203-e216. [PMID: 36841561 DOI: 10.1016/s2468-2667(22)00342-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 02/25/2023]
Abstract
BACKGROUND There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants. METHODS In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291. FINDINGS 18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I2 98·8%; τ2 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I2 96·8%; τ2 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I2 97·4%; τ2 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I2 96·6%; τ2 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner. INTERPRETATION One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants. FUNDING UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.
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Burtchen N, Alvarez-Segura M, Urben S, Giovanelli C, Mendelsohn AL, Guedeney A, Schechter DS. Effects of maternal trauma and associated psychopathology on atypical maternal behavior and infant social withdrawal six months postpartum. Attach Hum Dev 2022; 24:1-27. [PMID: 36371796 DOI: 10.1080/14616734.2022.2142894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/29/2022] [Indexed: 11/15/2022]
Abstract
Maternal psychopathology given a history of maltreatment and domestic violence exposure increases the risk for child psychopathology. Infant social withdrawal is one warning sign of adverse developmental outcomes including child anxiety and depression. It remains unclear how maternal trauma-related psychopathology might affect infant social withdrawal six-months postpartum. METHODS One-hundred ninety-five women and their six-month-old infants were studied in an at-risk community sample. Maternal trauma history, posttraumatic stress (PTSD) and major depressive (MDD) disorders were assessed. Maternal and infant behaviors were coded from videotaped interactions. RESULTS Maternal trauma was correlated with atypical maternal behavior (AMB) and infant social withdrawal (p ≤ .001). PTSD and MDD, and comorbid PTSD/MDD predicted increased AMB (p ≤ .001) but only maternal MDD was predictive of infant social withdrawal (p ≤ .001). Effects of maternal MDD on infant withdrawal were mediated by AMB. CONCLUSIONS At six-months postpartum, maternal MDD was associated with infant withdrawal. AMB is an important target for early intervention.
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Affiliation(s)
- Nina Burtchen
- Clinic for Psychosomatic Medicine and Psychotherapy, Freiburg University Medical Center, Freiburg, Germany
- Department of Pediatrics, New York University, New York University Grossman School of Medicine, New York, NY, USA
| | - Mar Alvarez-Segura
- Child and Adolescent Psychiatry Service, Department of Psychiatry, Abat Oliba CEU University, Barcelona, Spain
- Department of Child & Adolescent Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Sébastien Urben
- Child & Adolescent Psychiatry Service, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Alan L Mendelsohn
- Department of Pediatrics, New York University, New York University Grossman School of Medicine, New York, NY, USA
| | - Antoine Guedeney
- Child & Adolescent Psychiatry Service, Hôpital Bichat-Claude
- Bernard Faculty of Medicine, University of Paris Diderot, Paris, France
| | - Daniel S Schechter
- Department of Child & Adolescent Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
- Child & Adolescent Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and Faculty of Biology and Medicine, Lausanne, Switzerland
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The mediating role of adolescents' loneliness and social withdrawal in the association between maternal depressive symptoms and suicidality in adolescence: A 20-year population-based study. Dev Psychopathol 2021; 34:1045-1053. [PMID: 33487191 DOI: 10.1017/s0954579420001753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We examined whether adolescents' loneliness and social withdrawal mediated the association between maternal depressive symptoms and adolescent suicidality. Secondary analyses on the Québec Longitudinal Study of Child Development data were conducted (n = 1,623). Each mother completed the Centre for Epidemiologic Studies Depression Scale (at child ages 5 months, 1.5, 3.5, 5, and 7 years). Adolescent's social withdrawal (adolescent, father, and teacher reported at 10, 12, and 13 years) and loneliness (adolescent reported at 10, 12, and 13 years), were assessed using items from the Social Behavior Questionnaire and the Loneliness and Social Satisfaction Questionnaire, respectively. Adolescents completed self-reports to assess suicidal thoughts and attempts at 13, 15, 17, and 20 years. Children of mothers with higher levels of maternal depressive symptoms had an increased risk for suicidality (OR = 1.15, 95% CI: 1.03-1.28). Loneliness explained 16% of the total effect of maternal depressive symptoms on adolescent suicidality (indirect effect OR = 1.02, 95% CI: 1.00-1.04). There was no indirect effect of maternal depressive symptoms on adolescent suicidal outcomes via social withdrawal (indirect effect OR = 1.00, 95% CI: 0.99-1.02). Interventions that target loneliness may be beneficial for decreasing the risk for suicidality among adolescents of mothers with depressive symptoms.
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Lachman A, Burger M, Jordaan ER, Leppanen J, Puura K, Niehaus DJH. Maternal Shared Pleasure, Infant Withdrawal, and Developmental Outcomes in a High Risk Setting in South Africa. Front Psychiatry 2021; 12:668009. [PMID: 34354608 PMCID: PMC8329093 DOI: 10.3389/fpsyt.2021.668009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Anusha Lachman
- Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| | - Marlette Burger
- Physiotherapy Division, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Esmè R Jordaan
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa.,Statistics and Population Studies, University of the Western Cape, Cape Town, South Africa
| | - Jukka Leppanen
- Department of Psychology and Speech-Language Pathology, University of Turku, Turku, Finland
| | - Kaija Puura
- Department of Child Psychiatry, Tampere University, Tampere, Finland
| | - Dana J H Niehaus
- Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
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Harris RA, Santos HP. Maternal depression in Latinas and child socioemotional development: A systematic review. PLoS One 2020; 15:e0230256. [PMID: 32163494 PMCID: PMC7067456 DOI: 10.1371/journal.pone.0230256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/25/2020] [Indexed: 01/02/2023] Open
Abstract
Background Although substantial research exists on the debilitating effects of maternal depression on child development, little is known about Latina mothers with depression and their young children within the broader context of sociocultural and economic stressors. Objectives What is the relationship between maternal depression in Latina mothers and their children’s socioemotional outcomes through early developmental windows (0–5 years)? Methods We searched electronic databases PubMed, CINAHL, and PsycINFO in this systematic review, pre-registered via PROSPERO (CRD42019128686). Based on pre-determined criteria, we identified 56 studies and included 15 in the final sample. After extracting data, we assessed study quality with the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results We found inverse correlations between maternal depression and child socioemotional outcomes; furthermore, we found evidence of a moderating and mediating role of maternal depression between contextual stressors and child outcomes. Children of U.S.-born Latina mothers had poorer developmental outcomes than children of foreign-born Latina mothers across socioemotional domains and throughout early developmental windows. Conclusions Future research must examine underlying mechanisms for the potential Latino paradox in young Latino children’s socioemotional outcomes. Policies should support mental health of Latina mothers as early as the prenatal period.
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Affiliation(s)
- Rebeca Alvarado Harris
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Hudson P. Santos
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Institute for Environmental Health Solutions, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Re JM, Dean S, Mullaert J, Guedeney A, Menahem S. Maternal Distress and Infant Social Withdrawal (ADBB) Following Infant Cardiac Surgery for Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2018; 9:624-637. [DOI: 10.1177/2150135118788788] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jennifer M. Re
- Psychiatry Department, Monash University, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Suzanne Dean
- Psychiatry Department, Monash University, Melbourne, Victoria, Australia
| | - Jimmy Mullaert
- Denis Diderot University, Paris, France
- Biostatistics, Epidemiology and Clinical Research Department, APHP, Paris, France
| | - Antoine Guedeney
- Denis Diderot University, Paris, France
- Department of Child and Adolescent Psychiatry, APHP, Paris, France
| | - Samuel Menahem
- Psychiatry Department, Monash University, Melbourne, Victoria, Australia
- Paediatric Cardiology Unit, Monash Medical Centre, Melbourne, Victoria, Australia
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Smith-Nielsen J, Tharner A, Krogh MT, Vaever MS. Effects of maternal postpartum depression in a well-resourced sample: Early concurrent and long-term effects on infant cognitive, language, and motor development. Scand J Psychol 2016; 57:571-583. [DOI: 10.1111/sjop.12321] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 06/27/2016] [Indexed: 01/28/2023]
Affiliation(s)
| | - Anne Tharner
- BabyLab; Department of Psychology; University of Copenhagen; Copenhagen K Denmark
| | - Marianne Thode Krogh
- BabyLab; Department of Psychology; University of Copenhagen; Copenhagen K Denmark
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Precursors of social emotional functioning among full-term and preterm infants at 12 months: Early infant withdrawal behavior and symptoms of maternal depression. Infant Behav Dev 2016; 44:159-68. [DOI: 10.1016/j.infbeh.2016.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 01/14/2023]
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Facchini S, Martin V, Downing G. 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. Front Psychol 2016; 7:179. [PMID: 26909063 PMCID: PMC4754769 DOI: 10.3389/fpsyg.2016.00179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/29/2016] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Sergio Facchini
- Pediatric Primary Care Unit, Azienda per l'Assistenza Sanitaria n. 5 "Friuli Occidentale" Pordenone, Italy
| | - Valentina Martin
- Department of Developmental Psychology and Socialisation, University of Padova Padova, Italy
| | - George Downing
- Clinical Faculty, Pitié-Salpêtrière Hospital and Université Paris 8 Paris, France
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