The Welch Emotional Connection Screen: validation of a brief mother-infant relational health screen

Measuring Early Relational Health Using PediaTrac TM in a Diverse Sample of Infant-Caregiver Dyads

OBJECTIVE

Early relational health (ERH) is a key developmental predictor and outcome in infancy and early childhood that reflects social-emotional well-being and promotes resilience throughout childhood. Currently, there is no gold-standard developmental screening tool for ERH in pediatric care settings. This study examined the psychometric properties of items assessing ERH that are part of a web-based, caregiver-report screening tool called PediaTrac TM . It was hypothesized that ERH could be reliably estimated and that second-order factors would be revealed within the latent construct ERH.

METHOD

Participants included 571 caregivers of term (n = 331; ≥37 weeks) and preterm (n = 240; <37 weeks) infants recruited shortly after birth from several academic medical centers and a community health clinic. Caregivers completed PediaTrac modules at birth and 2, 4, 6, 9, 12, 15, and 18 months; data for this study are from the newborn through 12-month periods.

RESULTS

Results from Item Response Theory Graded Response Modeling revealed excellent reliability for the PediaTrac ERH domain at all time points, ranging from 0.96 to 0.98. Exploratory factor analyses revealed 4 to 5 second-order factors, representing Parent-Child Relationship, Parent Distress, Parenting Stress, Parenting Efficacy, Sensitivity, and Perceptions of Child, depending on period.

CONCLUSION

The caregiver-report developmental screening tool, PediaTrac, reliably measures ERH during the first year of life. The measure has promising clinical utility in pediatric clinic settings for tracking ERH over time to ensure early social-emotional well-being and to identify concerns as early as possible.

Effects of prenatal psychosocial stress and COVID-19 infection on infant attention and socioemotional development

BACKGROUND

The COVID-19 pandemic dramatically altered the psychosocial environment of pregnant women and new mothers. In addition, prenatal infection is a known risk factor for altered fetal development. Here we examine joint effects of maternal psychosocial stress and COVID-19 infection during pregnancy on infant attention at 6 months postpartum.

METHOD

One-hundred and sixty-seven pregnant mothers and infants (40% non-White; n = 71 females) were recruited in New York City (n = 50 COVID+, n = 117 COVID-). Infants' attentional processing was assessed at 6 months, and socioemotional function and neurodevelopmental risk were evaluated at 12 months.

RESULTS

Maternal psychosocial stress and COVID-19 infection during pregnancy jointly predicted infant attention at 6 months. In mothers reporting positive COVID-19 infection, higher prenatal psychosocial stress was associated with lower infant attention at 6 months. Exploratory analyses indicated that infant attention in turn predicted socioemotional function and neurodevelopmental risk at 12 months.

CONCLUSIONS

These data suggest that maternal psychosocial stress and COVID-19 infection during pregnancy may have joint effects on infant attention at 6 months. This work adds to a growing literature on the effects of the COVID-19 pandemic on infant development, and may point to maternal psychosocial stress as an important target for intervention.

IMPACT

This study found that elevated maternal psychosocial stress and COVID-19 infection during pregnancy jointly predicted lower infant attention scores at 6 months, which is a known marker of risk for neurodevelopmental disorder. In turn, infant attention predicted socioemotional function and risk for neurodevelopmental disorder at 12 months. These data suggest that maternal psychosocial stress may modulate the effects of gestational infection on neurodevelopment and highlight malleable targets for intervention.

Do toys get in the way? The duration of shared emotional experiences is longer when mothers engage their infants without toys

During mother-infant interaction, shared emotional experiences, defined as reciprocal and synchronous emotional sharing between mother and infant, are an indicator of early relational health. Yet, it is unclear how mothers' efforts to engage with their infants relate to dyadic-level shared emotional experiences. Utilizing a sample of 80 randomly selected videos of the NICHD Study of Early Child Care and Youth Development, we examined how mothers' bids for interaction with their 6-month-old infants related to the duration of shared emotional experiences. An event sampling, sequential coding system was used to identify a maternal bid for interaction (i.e., with toy, without toy) and the subsequent presence or absence of a shared emotional experience, including duration of the shared emotional experience. Results indicated that shared emotional experiences were longer following mothers' efforts to engage their infants in play without toys. Findings suggest that methods matter; researchers and practitioners interested in studying and promoting shared emotional experiences between mothers and infants may wish to focus on dyadic interactions without toys.

Behavioral and neural measures of infant responsivity increase with maternal multisensory input in non-irritable infants

INTRODUCTION

Parents often use sensory stimulation during early-life interactions with infants. These interactions, including gazing, rocking, or singing, scaffold child development. Previous studies have examined infant neural processing during highly controlled sensory stimulus presentation paradigms.

OBJECTIVE

In this study, we investigated infant behavioral and neural responsiveness during a mother-child social interaction during which the mother provided infant stimulation with a progressive increase in the number of sensory modalities.

METHODS

We prospectively collected and analyzed video-coded behavioral interactions and electroencephalogram (EEG) frontal asymmetry (FAS) from infants (n = 60) at 2-4 months born at ≥ 34 weeks gestation. As the number of sensory modalities progressively increased during the interaction, infant behaviors of emotional connection in facial expressiveness, sensitivity to mother, and vocal communication increased significantly. Conversely, infant FAS for the entire cohort did not change significantly. However, when we accounted for infant irritability, both video-coded behaviors and EEG FAS markers of infant responsiveness increased across the interaction in the non-irritable infants. The non-irritable infants (49%) demonstrated positive FAS, indicating readiness to engage with, rather than to withdraw from, multisensory but not unisensory interactions with their mothers.

RESULTS

These results suggest that multisensory input from mothers is associated with greater infant neural approach state and highlight the importance of infant behavioral state during neural measures of infant responsiveness.

Qualitative insights from a randomized clinical trial of a mother-child emotional preparation program for preschool-aged children

BACKGROUND

Early life stress and adversity conveys risk for emotional, behavioral, and developmental disorders. To address this risk in the preschool population, Mother-Child Emotional Preparation (MCEP) was tested as an in-school dyadic intervention for facilitating mother-child emotional connection through mother-child calming cycles. In a computer-generated block randomized controlled trial enrolling preschool-aged children and their mothers, in partnership with an early childhood learning center, we at Columbia University Irving Medical Center tested effects of MCEP across multiple domains. Within this RCT we designed a qualitative sub-study to understand how MCEP aligns with calming cycle theory and its impact on mothers and the mother-child relationship.

METHODS

A qualitative researcher observed 14 group MCEP sessions consisting of nurture specialists facilitating reciprocal calming interactions through shared emotional expression between mothers and their preschool-aged children. We conducted two waves of participant interviews in English or Spanish, per participant preference. Participants (n = 8) were majority Hispanic at or below the federal poverty level. Group session observations were coded and analyzed for frequency, co-occurrence, variance by session, and alignment with calming cycle theory, incorporating demographic variables and attendance. Interview transcripts were translated from Spanish to English if needed, then coded and analyzed using thematic analysis.

RESULTS

Qualitative analysis revealed mothers' experiences of MCEP. Data demonstrated that calming position and emotional expression were mutually supportive, and that barriers to connection were calming cycle entry-points, not barriers. At the group level, supported by nurture specialists, fellow participants helped each other progress through calming cycles. Moreover, MCEP adapted to meet individual dyad needs, and mothers described its far-reaching impact.

CONCLUSIONS

Qualitative methods show that MCEP helps mother-child dyads emotionally connect through the calming cycle and fills a gap in early childhood education services. This study generated insights for quantitative studies and suggested implications for MCEP dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03908268 , Registered April 9, 2019-Retrospectively registered.

Breastfeeding at Any Cost? Adverse Effects of Breastfeeding Pain on Mother-Infant Behavior

Breast milk is considered the ideal infant nutrition, and medical organizations encourage breastfeeding worldwide. Moreover, breastfeeding is often perceived as a natural and spontaneous socio-biological process and one of the fundamental roles of new mothers. While breastfeeding is beneficial, little scientific consideration has been given to its potential psychological challenges. Here, we investigate the phenomenon of breastfeeding pain in mothers and its association with maternal and infant behavioral regulation. During the postpartum weeks, the mother-infant dyad can be considered one allostatic unit directed at infant regulation and development. We hypothesize that pain comprises an allostatic challenge for mothers and will thus impair the capacity for dyadic regulation. To test this, we recruited 71 mothers with varying levels of breastfeeding pain and videotaped them with their infants (2-35 weeks old) during spontaneous face-to-face interactions. We quantified the individual differences in dyadic regulation by behaviorally coding the second-by-second affective expressions for each mother and infant throughout their interactions. We tested the extent to which breastfeeding pain alters affect regulation during mother-infant interactions. We discovered that mothers with severe breastfeeding pain express less affective expressions and less infant-directed gaze during interactive moments of engagement and play than mothers with no or moderate pain. Moreover, infants of mothers experiencing pain during breastfeeding express less affective expressions and more mother-directed gaze while interacting with their mothers than infants of mothers who are not in pain. This demonstrates that the allostatic challenge of maternal pain interferes with the behavioral regulation of both mothers and infants. Since the mother-infant dyad is a codependent allostatic unit, the allostatic challenges of one partner can impact the dyad and thus potentially impact child development, bonding, and mother and infant well-being. The challenges of breastfeeding should be considered in addition to the nutritional advances.

Evidence for cultural differences in affect during mother-infant interactions

Maternal care is considered a universal and even cross-species set of typical behaviors, which are necessary to determine the social development of children. In humans, most research on mother-infant bonding is based on Western cultures and conducted in European and American countries. Thus, it is still unknown which aspects of mother-infant behaviors are universal and which vary with culture. Here we test whether typical mother-infant behaviors of affect-communication and affect-regulation are equally represented during spontaneous interaction in Palestinian-Arab and Jewish cultures. 30 Palestinian-Arab and 43 Jewish mother-infant dyads were recruited and videotaped. Using AffectRegulation Coding System (ARCS), we behaviorally analyzed the second-by-second display of valence and arousal in each participant and calculated the dynamic patterns of affect co-regulation. The results show that Palestinian-Arab infants express more positive valence than Jewish infants and that Palestinian-Arab mothers express higher arousal compared to Jewish mothers. Moreover, we found culturally-distinct strategies to regulate the infant: increased arousal in Palestinian-Arab dyads and increased mutual affective match in Jewish dyads. Such cross-cultural differences in affect indicate that basic features of emotion that are often considered universal are differentially represented in different cultures. Affect communication and regulation patterns can be transmitted across generations in early-life socialization with caregivers.

Parenting Style Interventions in Parents of Preterm and High-Risk Infants: Controversies, Cost, and Future Directions

This review highlights the current state of evidence on interventions whose primary purpose is to change parenting style in parents of preterm, and other-high risk, infants. To date, interventions for parents of preterm infants are heterogeneous with variability in intervention timing, measured outcomes, program components, and cost. Most interventions target parental responsivity/sensitivity. Most reported outcomes are short-term, measured at age less than 2 years. The few studies that report later child outcomes in prekindergarten/school-aged children are encouraging, overall indicating improved cognition and behavior in the children of parents who received a parenting style intervention.

Maternal pandemic-related stress during pregnancy associates with infants' socio-cognitive development at 12 months: A longitudinal multi-centric study

BACKGROUND

Prenatal maternal stress is a key risk factor for infants' development. Previous research has highlighted consequences for infants' socio-emotional and cognitive outcomes, but less is known for what regards socio-cognitive development. In this study, we report on the effects of maternal prenatal stress related to the COVID-19 pandemic on 12-month-old infants' behavioral markers of socio-cognitive development.

METHODS

Ninety infants and their mothers provided complete longitudinal data from birth to 12 months. At birth, mothers reported on pandemic-related stress during pregnancy. At infants' 12-month-age, a remote mother-infant interaction was videotaped: after an initial 2-min face-to-face episode, the experimenter remotely played a series of four auditory stimuli (2 human and 2 non-human sounds). The auditory stimuli sequence was counterbalanced among participants and each sound was repeated three times every 10 seconds (Exposure, 30 seconds) while mothers were instructed not to interact with their infants and to display a neutral still-face expression. Infants' orienting, communication, and pointing toward the auditory source was coded micro-analytically and a socio-cognitive score (SCS) was obtained by means of a principal component analysis.

RESULTS

Infants equally oriented to human and non-human auditory stimuli. All infants oriented toward the sound during the Exposure episode, 80% exhibited any communication directed to the auditory source, and 48% showed at least one pointing toward the sound. Mothers who reported greater prenatal pandemic-related stress had infants with higher probability of showing no communication, t = 2.14 (p = .035), or pointing, t = 1.93 (p = .057). A significant and negative linear association was found between maternal prenatal pandemic-related stress and infants' SCS at 12 months, R2 = .07 (p = .010), while adjusting for potential confounders.

CONCLUSIONS

This study suggests that prenatal maternal stress during the COVID-19 pandemic might have increased the risk of an altered socio-cognitive development in infants as assessed through an observational paradigm at 12 months. Special preventive attention should be devoted to infants born during the pandemic.

Effects of skin-to-skin contact on full-term infants' stress reactivity and quality of mother-infant interactions

Skin-to-skin contact (SSC) between mothers and their infants has beneficial effects in both preterm and full-term infants. Underlying mechanisms are largely unknown. This randomized controlled trial assessed whether daily SSC in full-term mother-infant dyads: (1) decreases infants' cortisol and behavioral reactivity to a mild naturalistic stressor, and (2) facilitates interaction quality between infants and mothers (i.e., improved maternal caregiving behavior and mother-infant adrenocortical synchrony). Pregnant Dutch women (N = 116) were recruited and randomly allocated to an SSC or care-as-usual condition. The SSC condition performed 1 h of SSC daily, from birth until postnatal week 5. In week 5, mothers bathed the infant (known mild stressor). Infant and maternal cortisol was sampled at baseline, 25 and 40 min after bathing, and infant and maternal behavior was rated. Results did not indicate effects of SSC on infant behavioral and cortisol reactivity to the bathing session. Similarly, no effect of SSC was found on maternal caregiving behavior and mother-infant adrenocortical synchrony. In conclusion, the findings provide no evidence that daily mother-infant SSC is associated with full-term infants' behavioral and adrenocortical stress reactivity or mother-infant interaction quality. Future studies should replicate these findings and unveil other potential mechanisms underlying beneficial effects of SSC.

Wired to Connect: The Autonomic Socioemotional Reflex Arc

We have previously proposed that mothers and infants co-regulate one another’s autonomic state through an autonomic conditioning mechanism, which starts during gestation and results in the formation of autonomic socioemotional reflexes (ASRs) following birth. Theoretically, autonomic physiology associated with the ASR should correlate concomitantly with behaviors of mother and infant, although the neuronal pathway by which this phenomenon occurs has not been elucidated. In this paper, we consider the neuronal pathway by which sensory stimuli between a mother and her baby/child affect the physiology and emotional behavior of each. We divide our paper into two parts. In the first part, to gain perspective on current theories on the subject, we conduct a 500-year narrative history of scientific investigations into the human nervous system and theories that describe the neuronal pathway between sensory stimulus and emotional behavior. We then review inconsistencies between several currently accepted theories and recent data. In the second part, we lay out a new theory of emotions that describes how sensory stimuli between mother and baby unconsciously control the behavior and physiology of both. We present a theory of mother/infant emotion based on a set of assumptions fundamentally different from current theories. Briefly, we propose that mother/infant sensory stimuli trigger conditional autonomic socioemotional reflexes (ASRs), which drive cardiac function and behavior without the benefit of the thalamus, amygdala or cortex. We hold that the ASR is shaped by an evolutionarily conserved autonomic learning mechanism (i.e., functional Pavlovian conditioning) that forms between mother and fetus during gestation and continues following birth. We highlight our own and others research findings over the past 15 years that support our contention that mother/infant socioemotional behavior is driven by mutual autonomic state plasticity, as opposed to cortical trait plasticity. We review a novel assessment tool designed to measure the behaviors associated with the ASR phenomenon. Finally, we discuss the significance of our theory for the treatment of mothers and infants with socioemotional disorders.

At the feet of storytellers: Equity in early relational health conversations

Early Relational Health (ERH) focuses attention on family-baby relationships during the first 1000 days of life. Positive ERH enhances child health and development and family wellbeing. Universal, early identification of RH and vulnerability could add value to care. How to screen, when, where, and with whom is the question. Tools and models for screening are practitioner-centered. Bias can affect family engagement and outcomes. This may be problematic for African American families. Authors present findings of a discourse analysis and phenomenological study of experiences of African American families' and HealthySteps Specialists' (HSS) of color with screening ERH in Washington, D.C., USA (N = 13). Findings indicate relevance, acceptance and utility may be influenced by positionality, cultural context, issues of equity, and engagement in mutual reflection. A family-centered approach that opened space for non-dominant knowledge about ERH made positive differences in engagement and utility for families and practioners alike. Health and vulnerability were detected reliably using this approach. Outcomes include new theories about ERH-focused visits with African American families and infants, and a new model for centering ERH in pediatric practice, entitled Early Relational Health Conversations. ERH-C is a family reflection model, not necessarily dyadic. It may have value for other populations. Future directions in ERH-C research are suggested.

Early relational health: Innovations in child health for promotion, screening, and research

Relational experiences during infancy and early childhood are key drivers for building health, social emotional development, and learning capacities, each vital for wellbeing. The U.S. child health sectors share a commitment to universal health promotion, prevention and early intervention, and a growing enthusiasm for the research-affirmed primacy of caregiver-child interactions during the critical first 1000 days of life. Given our nation's growing children's mental health crisis, racial justice awakening and the need to reimagine equitable supports for young families post-COVID19, the child health sectors seek new tools and clinical approaches that blend science-to-practice innovations with co-developed activities that are meaningful to families. This special section brings together papers about a journey of co-discovery between researchers, clinicians, and parents during the development and refinement of new video- and interview-based dyadic relational screening and monitoring tools. The collection of papers addresses a range of topics including early relational health (ERH), development and validation of the Early Relational Health Screen, its application within research and clinical settings, and thoughtful discussions from multiple perspectives. Informed by the diversity informed tenets, this journey highlights not only science-informed approaches, but also co-development with families of equitable approaches to understanding and serving children and their caregivers.

Development and reliability of the coding system evaluating maternal sensitivity to social interactions with 34- to 36-week postmenstrual age preterm infants

Maternal sensitivity (MS), the ability to perceive and synchronously respond to the social signals (SSs), is affected by prematurity. The development of early supportive psychotherapy to foster MS, before discharge of the infant from the neonatal intensive care unit (NICU) is a major challenge in the prevention of subsequent developmental and mental disorders in the child. There are currently no reliable methods for evaluating MS to social interactions with very to moderate preterm infants. We investigated the reliability of a newly developed procedure for assessing MS in interactions between the mother and her 34- to 36-week postmenstrual age (PMA) preterm infant: the Preterm Infant Coding System for Maternal Sensitivity (PRICOSMAS).

METHOD

This study encompassed three steps: testing of the capacity to videorecord SSs in very to moderate preterm infants, selection, by an expert committee, of the recordable and relevant SSs, and investigation of the internal consistency and interrater reliability. The synchronicity between infant and mother's SSs was determined on a 1 s period basis, using ELAN software. Preterm infants born after 25-weeks gestational age (GA) were included while being between 34- and 36-weeks PMA. A perinatal risk inventory score > 10 for the infant precluded from inclusion. Interrater reliabilities were assessed independently by two raters blind to the clinical situation of the mother and infant.

RESULTS

The resulting PRICOSMAS encompassed two four-item SS sections, one covering the preterm infant's SSs and the other, the mother's SSs. Reliability was assessed on a sample of 26 videorecorded observations for 13 mother-preterm infant dyads. Infants' mean age at birth was 30.4 ± 3.1-weeks GA (range: 26.4-35) and PMA at the time of the test was 34.7-weeks (±0.8). Internal consistency ranged from 0.81 to 0.89. Interrater reliability ranged from substantial to almost perfect (0.73-0.88).

CONCLUSION

This study shows that the infants' SSs and MS can be reliably scored in preterm infants as young as 34- to 36-weeks PMA. Our findings suggest that the PRICOSMAS is sufficiently reliable for use, including in NICU, by healthcare professionals or researchers for coding early parent-infant interactions with 34- to 36-week PMA preterm infants.

The preterm infant-parent programme for attachment-PIPPA Study: a randomised controlled trial

BACKGROUND

There is increasing recognition of adverse mental health consequences of preterm birth and the impact on social-emotional development. However, the quality of the developing parent-infant relationship may be protective, with enhanced maternal sensitivity to infants' cues associated with improved outcomes.

METHODS

Eighty mothers and their preterm infants born <32 weeks gestation were randomised to intervention and standard care groups. Intervention comprised reflective interview, observation of infant cues and video interaction guidance (VIG). The primary outcome, maternal sensitivity during play, was measured by the Child Adult Relationship Evaluation-Index. Secondary outcomes were infant social-emotional problems measured by the Ages and Stages Questionnaire-Social-Emotional version.

RESULTS

There was no statistically significant difference between the intervention and standard care groups in maternal sensitivity during play at 9 months corrected age (CA). In the secondary outcome analysis at 12 months CA, infants in the intervention group had fewer self-regulation problems than infants whose mothers received standard care. Per-protocol analysis revealed that infants whose mothers completed VIG had significantly fewer communication problems.

CONCLUSIONS

This early attachment-focussed intervention integrating VIG for mothers and their preterm infants did not enhance maternal sensitivity; however, there were effects on infant social-emotional problems at 12 months CA.

IMPACT

Preterm birth can adversely affect infant and parent mental health and the quality of the parent-infant relationship. Early intervention to support parent-infant interaction can have positive effects on infant social-emotional development. There was no statistically significant difference in maternal sensitivity during play at 9 months CA. However, there were fewer infant self-regulation and communication problems reported by mothers at 12 months CA following intervention. Further evaluations of attachment-focussed interventions in the neonatal intensive care unit are needed.

The Welch Emotional Connection Screen: Adapting observational methods to pediatric primary care via resident training

The Welch Emotional Connection Screen (WECS) is a novel instrument that is a brief, practicable, evidenced-based observational screening tool for assessing relationship health between parent and child. The WECS requires observing 2-3 min of face-to-face interactions between parent and child, without toys, prompts, paradigms or technology. Here, we describe a translational project from the coding lab to the primary care provider via a residency training program conducted with 50 residents during a 30-day developmental and behavioral pediatrics medical resident education rotation. The aims of this study were to evaluate the efficacy of WECS pediatric resident training: 1) to improve residents' accuracy in recognizing the dyadic behaviors of emotional connection (EC) via WECS training; and 2) to improve residents' attitudes, self-efficacy, and perceived professional norms (ASPPN) pertaining to Early Relational Health in Pediatrics. Results indicate that using a rapid prototyping approach to training, residents improved in their identification of dyads showing low to midrange levels of emotional connection. As well, resident attitudes about the importance of relationship health in pediatrics and their self-efficacy in identifying emotional connection improved significantly after this brief resident training.

Breast feeding and infant development in a cohort with sibling pair analysis: the Japan Environment and Children's Study

OBJECTIVES

To investigate the association between breast feeding and infant development during the first year of life using sibling comparison.

DESIGN

Nationwide prospective birth cohort study with sibling pair analysis.

SETTING

15 regional centres that participated in the Japan Environment and Children's Study.

PARTICIPANTS

This study included 77 119 children (singleton, term birth and no malformation/severe diseases) whose mothers were registered between January 2011 and March 2014, including 3521 duos or trios of siblings.

PRIMARY OUTCOME MEASURES

The primary outcome was developmental delay at 6 and 12 months of age, assessed using the Japanese translation of the Ages and Stages Questionnaires, third edition. Multivariable regression analyses adjusted for confounders were performed to estimate the risk ratios of delay associated with any or exclusive breast feeding. Pairs of siblings discordant for statuses were selected, and conditional regression analyses were conducted with a matched cohort design.

RESULTS

Developmental delay was identified in 6162 (8.4%) and 10 442 (14.6%) children at 6 and 12 months of age, respectively. Any breast feeding continued until 6 months or 12 months old was associated with reduced developmental delay at 12 months of age (adjusted risk ratio (95% CI): 0.81 (0.77 to 0.85) and 0.81 (0.78 to 0.84), respectively). Furthermore, exclusive breast feeding until 3 months was associated with reduced developmental delay at 12 months of age (adjusted risk ratio, 0.86 (95% CI 0.83 to 0.90)). In sibling pair analysis, the association between any breast feeding until 12 months and reduced developmental delay at 12 months of age persisted (adjusted risk ratio, 0.64 (95% CI 0.43 to 0.93)).

CONCLUSIONS

The present study demonstrated the association of continuous breast feeding with reduced developmental delay at 1 year of age using sibling pair analysis, in which unmeasured confounding factors are still present but less included. This may provide an argument to promote breastfeeding continuation.

Music therapy enhances preterm infant's signs of engagement and sustains maternal singing in the NICU

Hospitalized preterm infants are exposed to stressful stimuli and early parental separation, which can undermine their long-term development and mother-infant bonding. Family-centered music therapy can enable positive mother-infant interactions, mediated by maternal infant-directed singing. This study aimed to investigate the effects of music therapy on preterm infant's signs of engagement, namely Eye Opening (EO) and Smiling (SM), and maternal vocalizations. Participants were 30 mother-preterm infant dyads in a Brazilian Neonatal Intensive Care Unit (NICU), divided into a Music Therapy Group (MTG) and a Comparison Group (CG). The MTG participated in 6 sessions of the Music Therapy Intervention for the Mother-Preterm Infant Dyad (MUSIP), with the aim of supporting maternal singing with the infant. Prior to discharge, all mothers were filmed during a Non-singing (NS) and Singing (S) interactional condition; in the S condition, mothers were explicitly asked to address their infants by singing. Results of video and audio analysis showed that infants in the MTG displayed greater Eye Opening (EO) frequency compared to CG, but only when they were in an initial awake state at test, suggesting that music therapy can potentialize infants' alertness, by increasing their disposition and chances of being engaged in the interaction with the mother. Non-religious mothers appeared to sing significantly more in the MTG than in the CG. These preliminary findings indicate that music therapy in the NICU could promote infant's signs of engagement during interactions and can sustain maternal singing, especially with non-religious mothers in Brazil.

How babies learn: The autonomic socioemotional reflex

BACKGROUND

Human and animal research has long documented the negative effects of early traumatic events on long-term development and socioemotional behavior. Yet, how and where the body stores these memories remains unclear. Current theories propose that the brain stores such memory in the subcortical limbic system. However, a clear theory of change with testable hypothesis has yet to emerge.

AIMS

In this paper, we review the classical Pavlovian conditioning learning tradition, along with its functional variant. Then, we review calming cycle theory, which builds upon the idea that mother/infant learning is distinct from other types of learning, requiring a new set of assumptions in light of functional Pavlovian conditioning.

CONCLUSION

Calming cycle theory states that learning of behaviors associated with subcortical autonomic physiology is separate and distinct from learning of behaviors associated with cortical physiology. Mother/infant autonomic learning starts in the uterine environment via functional Pavlovian co-conditioning that is stored as conditional reflexes within the dyad's autonomic nervous systems. These reflexes are preserved transnatally as autonomic socioemotional reflexes (ASRs), which can be used to monitor mother-infant relational health. The functional Pavlovian co-conditioning mechanism can be exploited to change the physiological/behavioral reflex response. The theory provides a well established learning mechanism, a theory of change and a method of change, along with a set of hypotheses with which to test the theory. We present evidence from a randomized controlled trial with prematurely born infants and their mothers that supports calming cycle theory.

Family nurture intervention in the NICU increases autonomic regulation in mothers and children at 4-5 years of age: Follow-up results from a randomized controlled trial

Background

Maturation of multiple neurobehavioral systems, including autonomic regulation, is altered by preterm birth. The purpose of this study was to determine the long-term effects of Family Nurture Intervention (FNI) in the NICU on autonomic regulation of preterm infants and their mothers.

Method

A subset of infants and mothers (48% of infants, 51% of mothers) randomly assigned to either standard are (SC), or SC plus the FNI in the NICU in a prior RCT (ClincalTrials.gov; NCT01439269) returned for follow-up assessments when the children were 4 to 5 years corrected age (CA). ECGs were collected for 10 minutes in mothers and their children while children were in their mothers’ laps. Heart rate, standard deviation for heart rate, respiratory sinus arrhythmia (RSA)–an index of parasympathetic regulation, and a measure of vagal efficiency were quantified.

Results

Both children and mothers in the FNI group had significantly greater levels of RSA compared to the SC group (child: mean difference = 0.60, 95% CI 0.17 to 1.03, p = 0.008; mother: mean difference = 0.64, 95% CI 0.07 to 1.21, p = 0.031). In addition, RSA increased more rapidly in FNI children between infancy and the 4 to 5-year follow-up time point (SC = +3.11±0.16 log_e msec^2, +3.67±0.19 log_e msec² for FNI, p<0.05). These results show that the rate of increase in RSA from infancy to childhood is more rapid in FNI subjects.

Conclusion

Although these preliminary follow-up results are based on approximately half of subjects originally enrolled in the RCT, they suggest that FNI-NICU led to healthier autonomic regulation in both mother and child, when measured during a brief face-to-face socioemotional interaction. A Pavlovian autonomic co-conditioning mechanism may underly these findings that can be exploited therapeutically.

Psychosocial and medical adversity associated with neonatal neurobehavior in infants born before 30 weeks gestation

BACKGROUND

Psychosocial adversity escalates medical risk for poor outcomes in infants born <30 weeks gestation. Neonatal neurobehavior and maternal psychological and socioenvironmental assessments may identify the earliest specific intervention needs. We hypothesized that maternal prenatal anxiety, depression, and adverse medical and socioenvironmental conditions would be associated with less optimal neonatal neurobehavior at neonatal intensive care unit (NICU) discharge.

METHODS

We studied 665 infants at 9 university NICUs. Risk indices of socioenvironmental, maternal, and neonatal medical factors were obtained from standardized, structured maternal interviews and medical record reviews. Brain injuries were classified by consensus ultrasonogram readings. NICU Network Neurobehavioral Scale (NNNS) exams were conducted at NICU discharge.

RESULTS

On the NNNS, generalized estimating equations indicated infants of mothers with prenatal anxiety had less optimal attention, and those born to mothers with prenatal depression had increased lethargy. Maternal medical complications predicted suboptimal reflexes. Socioenvironmental risk predicted lower self-regulation and movement quality. Infants with more severe neonatal medical complications had lower attention, increased lethargy, and suboptimal reflexes.

CONCLUSIONS

Combined information from the observed associations among adverse prenatal maternal medical and psychosocial conditions, and neonatal complications may assist in the early identification of infants at elevated neurobehavioral risk.

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

AIMS

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

STUDY DESIGN/SUBJECTS/OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

The practical utility of the Welch Emotional Connection Screen for rating parent-infant relational health

Emotional Connection (EC) measured by the Welch Emotional Connection Screen (WECS) was related to the Parent-Infant Interaction Rating System (PIIRS), a 5-point adaptation of the rating system developed for the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (e.g., NICHD Early Child Care Research Network, 1999, Developmental Psychology, 35, 1399). Parent-infant dyads (n = 49 mothers; 43 fathers) were videotaped during face-to-face interaction at infant age 6 months; interactions were coded with both the WECS and PIIRS. At age 3, mothers completed the Child Behavior Checklist. WECS ratings of EC were associated with PIIRS rating items for both mother-infant and father-infant dyads. Mother-infant EC related positively to maternal sensitivity and positive regard for child, child positive mood and sustained attention, and dyadic mutuality, and negatively with maternal intrusiveness. Father-infant EC related positively to fathers' positive regard for child, child positive mood and sustained attention, and dyadic mutuality. Mother-infant EC predicted child behavior problems at age 3 better than mother-infant PIIRS ratings of dyadic mutuality. With fathers, neither EC nor dyadic mutuality ratings predicted mother-reported child behavior problems. Findings highlight the practical utility of the WECS for identifying potentially at-risk dyads and supporting early relational health.

Birth practices: Maternal-neonate separation as a source of toxic stress

Maternal-neonate separation for human newborns has been the standard of care since the last century; low birth weight and preterm infants are still routinely separated from their mothers. With advanced technology, survival is good, but long-term developmental outcomes are very poor for these especially vulnerable newborns. The poor outcomes are similar to those described for adversity in childhood, ascribed to toxic stress. Toxic stress is defined as the absence of the buffering protection of adult support. Parental absence has been strictly enforced in neonatal care units for many reasons and could lead to toxic stress. The understanding of toxic stress comes from discoveries about our genome and epigenetics, the microbiome, developmental neuroscience and the brain connectome, and life history theory. The common factor is the early environment that gives (a) signals to epigenes, (b) sensory inputs to neural circuits, and (c) experiences for reproductive fitness. For human newborns that environment is direct skin-to-skin contact from birth. Highly conserved neuroendocrine behaviors determined by environment are described in this review. The scientific rationale underlying skin-to-skin contact is presented: autonomic development and regulation of the physiology leads to emotional connection and achieving resilience. Maternal-neonate separation prevents these critical neural processes from taking place, but also channel development into an alternative developmental strategy. This enables better coping in a stressful environment in the short term, but with permanently elevated stress systems that negatively impact mental and physical health in the long term. This may explain the increasing incidence of developmental problems in childhood, and also Developmental Origins of Health and Disease. Arguments are presented that maternal-neonate separation is indeed a source of toxic stress, and some suggestions are offered toward a "zero separation" paradigm.

Parenting and Child Development: A Relational Health Perspective

A child's development is embedded within a complex system of relationships. Among the many relationships that influence children's growth and development, perhaps the most influential is the one that exists between parent and child. Recognition of the critical importance of early parent-child relationship quality for children's socioemotional, cognitive, neurobiological, and health outcomes has contributed to a shift in efforts to identify relational determinants of child outcomes. Recent efforts to extend models of relational health to the field of child development highlight the role that parent, child, and contextual factors play in supporting the development and maintenance of healthy parent-child relationships. This review presents a parent-child relational health perspective on development, with an emphasis on socioemotional outcomes in early childhood, along with brief attention to obesity and eating behavior as a relationally informed health outcome. Also emphasized here is the parent-health care provider relationship as a context for supporting healthy outcomes within families as well as screening and intervention efforts to support optimal relational health within families, with the goal of improving mental and physical health within our communities.

Darwin's Other Dilemmas and the Theoretical Roots of Emotional Connection

Modern scientific theories of emotional behavior, almost without exception, trace their origin to Charles Darwin, and his publications On the Origin of Species (1859) and The Expression of the Emotions in Man and Animals (1872). The most famous dilemma Darwin acknowledged as a challenge to his theory of evolution through natural selection was the incomplete Sub-Cambrian fossil record. However, Darwin struggled with two other rarely referenced theoretical and scientific dilemmas that confounded his theories about emotional behavior. These included (1) the origin of social instincts (e.g., altruism, empathy, reciprocity and cooperation) and the reasons for their conservation in evolution and (2) the peripheral control of heart rate vis-à-vis emotional behavior outside of consciousness. Darwin acknowledged that social instincts are critical to the survival of some species, but had difficulty aligning them with his theory of natural selection in humans. Darwin eventually proposed that heart rate and emotions are controlled via one's intellect and cortical mechanisms, and that instinctive behavior is genetically programmed and inherited. Despite ongoing efforts, these two theoretical dilemmas are debated to this day. Simple testable hypotheses have yet to emerge for the biological mechanisms underlying instinctive behavior or the way heart rate is controlled in infants. In this paper, we review attempts to resolve these issues over the past 160 years. We posit that research and theories that supported Darwin's individualistic brain-centric and genetic model have become an "orthodox" Western view of emotional behavior, one that produced the prevailing behavioral construct of attachment as developed by John Bowlby. We trace research and theories that challenged this orthodoxy at various times, and show how these challenges were repeatedly overlooked, rejected, or misinterpreted. We review two new testable theories, emotional connection theory and calming cycle theory, which we argue resolve the two dilemmas We show emerging scientific evidence from physiology and a wide variety of other fields, as well from clinical trials among prematurely born infants, that supports the two theories. Clinical implications of the new theories and possible new ways to assess risk and intervene in emotional, behavioral and developmental disorders are discussed.