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Children socially withdrawn in infancy had lower Bayley-III language scores (-2.6 (95% CI -4.5, -0.7)) in early childhood.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differences in the other Bayley-III scores or the WPPSI-IV and NEPSY-II scores at 4 years in children who were socially withdrawn or not.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.

Queens of hearts: Exploring the lived experiences of mothers caring for infants with complex congenital heart disease in Sri Lanka

This qualitative study explored the lived experiences of eight Sri Lankan mothers of infants with complex congenital heart disease (CCHD) using semi-structured interviews. Four themes were generated as: illness perception, communication with medical staff, challenges faced, and coping mechanisms. These provided insight into the multi-faceted nature of mothers' experiences, importance of medical-caregiver communications and their need for psychosocial services. The findings enhance the limited knowledge of South-Asian primary CCHD caregiver experiences and will help in improving psychosocial support services in Sri Lanka.

Australian National Standards of Care for Childhood-onset Heart Disease (CoHD Standards). 1st Edition

These first Australian National Standards of Care for Childhood-onset Heart Disease (CoHD Standards) have been developed to inform the healthcare requirements for CoHD services and enable all Australian patients, families and carers impacted by CoHD (paediatric CoHD and adult congenital heart disease [ACHD]) to live their best and healthiest lives. The CoHD Standards are designed to provide the clarity and certainty required for healthcare services to deliver excellent, comprehensive, inclusive, and equitable CoHD care across Australia for patients, families and carers, and offer an iterative roadmap to the future of these services. The CoHD Standards provide a framework for excellent CoHD care, encompassing key requirements and expectations for whole-of-life, holistic and connected healthcare service delivery. The CoHD Standards should be implemented in health services in conjunction with the National Safety and Quality Health Service Standards developed by the Australian Commission on Safety and Quality in Health Care. All healthcare services should comply with the CoHD Standards, as well as working to their organisation's or jurisdiction's agreed clinical governance framework, to guide the implementation of structures and processes that support safe care.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

The effect of nursing care and follow-up for mothers of infants undergoing congenital heart surgery: a quasi-experimental study

Improvements in congenital heart surgery have resulted in an increasing number of infants surviving, but there remain concerns about home care and difficulties experienced by mothers. This study was designed to evaluate the effect of nursing care and follow-up for the mothers of infants undergoing congenital heart surgery on anxiety, care burden, and self-efficacy. The study was designed as a quasi-experimental study with a pre-test and post-test control group design. The study included 40 mothers whose infants had undergone congenital heart surgery. Nursing care was provided to the mothers of the infants included in the study group through a total of six home follow-ups until the third month after surgery, guided by the North American Nursing Diagnosis Association and Nursing Diagnosis System and Nursing Interventions Classification. Data were collected through Care Needs Identification Form, Spielberger's State-Trait Anxiety Inventory, Zarit Burden Interview, and Parental Self-efficacy Scale. The mean State-Trait Anxiety Inventory and Zarit Burden Interview scores for the mothers in the intervention group decreased, while the mean Parental Self-efficacy Scale scores increased as the follow-up progressed and it was determined that by the third month, the difference between the mothers in the intervention group and those in the control group in terms of post-test State-Trait Anxiety Inventory, Zarit Burden Interview, and Parental Self-efficacy Scale had become statistically significant. Providing appropriate nursing care practices to the mothers of the infants had undergone congenital heart surgery in home setting has the potential to decrease the problems experienced by the mothers.

Sustained social withdrawal behavior and 'difficult' temperament among infants, in relation to maternal affectivity in a low-income area of Kinshasa, Democratic Republic of Congo

Little is known about the relationship between maternal affectivity, social withdrawal and temperament in infants in low-income countries. The goal of the study was to assess the prevalence of social withdrawal behavior in infants aged 8 ± 2.3 months and to explore associations between maternal affectivity during pregnancy and postpartum, infant social withdrawal (as a sign of stress) and 'difficult' temperament as assessed by the mothers. 458 mother-infant dyads were recruited in the city's public mother and child health-care centers. The eight items of the Alarm Distress Baby scale (8-ADBB) and the five-item M (modified) ADBB (M-ADBB) were used to assess sustained withdrawal behavior (ISSWB). The Goldberg Depression and Anxiety Scales were used to assess maternal affectivity and mental well-being. A specially designed questionnaire was used to identify stressful events faced by the mother during pregnancy. The ELDEQ-QCB was used to assess the degree of difficulty in managing the baby. Using the M-ADBB, we found a striking figure of 69.2% for ISSWB with 8-ABB (range 0-29) and 72.7% with the M-ADBB (range 0-10). ISSWB was linked to negative maternal affectivity and to high incidence of stressful events for the mothers, and to the child being viewed as 'difficult' by the mother. Positive prenatal affectivity was a protective factor of ISSWB (OR 0.46). Results are compared with previous studies in Africa. Early screening for ISSWB and identification of factors affecting maternal mental well-being could help in early intervention and increase the chances of better child development.

Predictors of behavioural and emotional outcomes in toddlers with congenital heart disease

OBJECTIVES

Children with congenital heart disease (CHD) are at risk for psychological challenges, including internalising (e.g., depression, anxiety) and externalising (e.g., aggression, inattention) problems. The present study aimed to investigate the development of psychological concerns in early childhood by identifying predictors of behavioural and emotional problems in toddlers with CHD.

METHODS

Children with CHD who were seen for neurodevelopmental (ND) evaluation at 12 ± 3 months of age, who completed the Bayley Scales of Infant Development-III (BSID-III) and whose parents completed the Child Behavior Checklist (CBCL), a standardised measure of emotional/behavioural problems at age 24-36 months, were included in the study (n = 144). CBCL scores were compared to test norms and classified as normal or abnormal. A classification tree was used to assess the association between CBCL scores and demographic and clinical variables.

RESULTS

Multi-variable tree analyses revealed lower BSID-III language composite scores at age 9-15 months predicted clinical CBCL internalising (p < 0.001), externalising (p = 0.004) and total scores (p < 0.001) at age 24-36 months. Lower maternal education levels also predicted clinical CBCL internalising (p < 0.0001), externalising (p < 0.001) and total scores (p < 0.0001).

CONCLUSIONS

Lower language abilities and lower maternal education predict increased behavioural and emotional problems in toddlers with CHD. These risk factors should be considered during routine ND evaluations to allow for earlier identification of children with CHD and their families who may benefit from psychological support.

Psychological Outcomes and Interventions for Individuals With Congenital Heart Disease: A Scientific Statement From the American Heart Association

Although resilience and high quality of life are demonstrated by many individuals with congenital heart disease, a range of significant psychological challenges exists across the life span for this growing patient population. Psychiatric disorders represent the most common comorbidity among people with congenital heart disease. Clinicians are becoming increasingly aware of the magnitude of this problem and its interplay with patients’ physical health, and many seek guidance and resources to improve emotional, behavioral‚ and social outcomes. This American Heart Association scientific statement summarizes the psychological outcomes of patients with congenital heart disease across the life span and reviews age-appropriate mental health interventions, including psychotherapy and pharmacotherapy. Data from studies on psychotherapeutic, educational‚ and pharmacological interventions for this population are scarce but promising. Models for the integration of mental health professionals within both pediatric and adult congenital heart disease care teams exist and have shown benefit. Despite strong advocacy by patients, families‚ and health care professionals, however, initiatives have been slow to move forward in the clinical setting. It is the goal of this scientific statement to serve as a catalyst to spur efforts for large-scale research studies examining psychological experiences, outcomes, and interventions tailored to this population and for integrating mental health professionals within congenital heart disease interdisciplinary teams to implement a care model that offers patients the best possible quality of life.

Quality of Life of Mothers of Infants Subjected to Neonatal Cardiac Surgery: The Importance of Psychosocial Factors

Background: The World Health Organization acknowledges quality of life (QOL) as subjectively perceived overall well-being by the individual and recognizes it as an essential construct for overall health and wellness. The purpose of this study was to examine the association of infant, environmental, and parental factors with the QOL of mothers of infants at four months post-hospital discharge from cardiac surgery. Methods: Secondary analysis of prospectively collected data from the REACH randomized clinical trial of telehealth home monitoring. The sample included mothers (n  =  148) of infants with congenital heart disease who provided data at four months post-discharge. Ten imputations were generated using fully conditional specification methods to address missing data and were combined. All analyses were performed on the imputed data. Mothers' QOL was the main outcome of the analysis, as measured by the Ulm Quality of Life Inventory for Parents. Predictors on QOL were identified based on the World Health Organization QOL framework which recognizes the multidimensional domains influencing QOL that include personal factors, environmental factors, and physical factors related to disease and functioning. Results: The treatment and control groups did not differ on any study variable, thus data were collapsed and analyzed together. Final multivariable model found that the combination of dyadic adjustment, social support, parenting stress, and post-traumatic stress symptoms explained approximately three-quarters of the variance in QOL scores. Conclusions: QOL for mothers of infants with congenital heart disease is largely influenced by psychosocial factors. Future research targeted toward improving maternal QOL should include psychosocial interventions that address social networks and stress.

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.

Role alteration predicts anxiety and depressive symptoms in parents of infants with congenital heart disease: a pilot study

BACKGROUND

Parents of infants born with critical congenital heart disease are at risk for adverse mental health symptoms. The purpose of this study was to identify infant-, parent-, and environmental-based stressors for mothers and fathers after their infants' cardiac surgery, and to explore relationships between stressors and mental health symptoms of anxiety and depression.

METHODS

This study enrolled 28 biological mother-father dyads from families admitted to the paediatric cardiac intensive care unit for cardiac surgery at one free-standing children's hospital in the Northeast. Paired t-tests were used to examine group differences between mothers and fathers on perceived stressors and mental health symptoms, while linear mixed effects modelling was used to explore the predictive relationship between perceived stressors, personal factors, and mental health symptoms.

RESULTS

Mothers reported higher perceived stressor scores of parental role alteration (t = 4.03, p < 0.01) and infant appearance and behaviour (t = 2.61, p = 0.02), and total perceived stress (t = 2.29 p = 0.03), compared to fathers. Mothers also reported higher anxiety (t = 2.47, p = 0.02) and depressive symptoms (t = 3.25, p < 0.01) than fathers. In multivariable analysis, parental role alteration significantly predicted anxiety (t = 5.20, p < 0.01, d = 0.77) and depressive symptoms (t = 7.09, p < 0.01, d = 1.05) for mothers and fathers. The consensus subscale of the Dyadic Adjustment Scale also significantly predicted depressive symptoms (t = -2.42, p = 0.02, d = 0.04).

CONCLUSION

Parents were distressed during their infant's admission for surgical repair for critical congenital heart disease. Parental role alteration was significantly associated with parental anxiety and depressive symptoms, while poor relationship quality was associated with depressive symptoms, highlighting areas for potential nursing-led psychosocial led interventions.

Parent-child bonding and attachment during pregnancy and early childhood following congenital heart disease diagnosis

Diagnosis and treatment of congenital heart disease (CHD) can present challenges to the developing parent-child relationship due to periods of infant hospitalization and intensive medical care, parent-infant separations, child neurodevelopmental delay and feeding problems, and significant parent and child distress and trauma. Yet, the ways in which CHD may affect the parent-child relationship are not well-understood. We systematically reviewed the evidence on parental bonding, parent-child interaction, and child attachment following CHD diagnosis, according to a pre-registered protocol (CRD42019135687). Six electronic databases were searched for English-language studies comparing a cardiac sample (i.e., expectant parents or parents and their child aged 0-5 years with CHD) with a healthy comparison group on relational outcomes. Of 22 unique studies, most used parent-report measures (73%) and yielded mixed results for parental bonding and parent-child interaction quality. Observational results also varied, although most studies (4 of 6) found difficulties in parent-child interaction on one or more affective or behavioural domains (e.g., lower maternal sensitivity, lower infant responsiveness). Research on parental-fetal bonding, father-child relationships, and child attachment behaviour was lacking. Stronger evidence is needed to determine the nature, prevalence, and predictors of relational disruptions following CHD diagnosis, and to inform targeted screening, prevention, and early intervention programs for at-risk dyads.

Parental role alteration strongly influences depressive symptoms in mothers of preoperative infants with congenital heart disease

BACKGROUND

Mothers of infants with congenital heart disease are at risk for depression.

OBJECTIVES

This study explored the influence on maternal depressive symptoms of several known factors for mothers in the pediatric cardiac intensive care unit, including perceived stressors, attachment, and anxiety.

METHODS

This study was a secondary analysis of 30 mothers of infants awaiting cardiac surgery. Linear regressions were calculated to determine the relationships between perceived stressors, maternal attachment, anxiety, and maternal depressive symptoms.

RESULTS

Nearly half of mothers reported depressive symptoms above the measure cut-off score, indicating they were at risk for likely clinical depression. Subscales of perceived stress explained 61.7% of the variance in depressive symptoms (F = 11.815, p<0.0001) with parental role alteration subscale as the strongest predictor (standardized beta=0.694, p = 0.03).

CONCLUSIONS

Findings underscore the importance of mental health screening and instituting nursing practices to enhance parental role for mothers of infants awaiting cardiac surgery.

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 impact of having a baby with cleft lip and palate on parents and on parent-baby relationship: the first French prospective multicentre study

BACKGROUND

The objective of this prospective, multidisciplinary and multicenter study was to explore the effect of a cleft lip, associated or not with a cleft palate, on parents, on parent-infant relationship, and on the baby's relational development. It also highlighted how the type of cleft and the timing of the surgery could impact this effect.

METHOD

158 infants, with Cleft lip with or without Palate, and their parents participated in this multicenter prospective cohort. Clinical evaluations were performed at 4 and 12 months postpartum. The impact on the parents and on the parent-infant relationship was evaluated by the Parenting Stress Index (PSI), the Edinburgh Post-partum Depression Scale (EPDS) and the Impact-on-Family Scale (IOFS). The relational development of the infant was assessed using the Alarm Distress Baby Scale (ADBB). The main criteria used to compare the infants were the severity of cleft and the time of surgery.

RESULTS

The timing of surgery, the type of malformation or the care structure had no effect on social withdrawal behaviors of the child at 4 and 12 months postpartum (ADBB). Furthermore, early intervention significantly decreased maternal stress assessed with the PSI at 4 months. Parents for whom it had been possible to give a prenatal diagnosis were much better prepared to accept the waiting time between birth and the first surgical intervention (IOFS). Higher postpartum depression scores (EPDS) were found for both parents compared to the general population.

CONCLUSION

A joint assessment of the mental health of both infants and parents is required in the follow-up of cleft lip and palate. Even if most families are remarkably resilient faced with this major cause of stress, a significant proportion of them could require help to deal with the situation, especially during this first year of follow-up. An assessment of the child's social withdrawal behaviour and of the parental stress and depression appears useful, in order to adapt care to infant and parent's needs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00993993. Registered 10/14/2009 <.

Early Emotional, Behavioural and Social Development of Infants and Young Children with Congenital Heart Disease: A Systematic Review

The experiences of diagnosis of congenital heart disease (CHD), cardiac surgery and hospitalisation(s) are distressing and represent a significant stressor for a child and family, which may impact psychosocial development. This systematic review provides a synthesis of psychosocial outcomes of infants and young children with congenital heart disease who had cardiac surgery early in life. Twenty-eight studies related to infant and young children's psychosocial development, specifically emotional, social and behavioural functioning were identified. Variability was related to methodological factors including differences in study design, varying measurement tools and heterogeneous samples. Despite these limitations, the majority of studies were of high quality. The most common finding was a high prevalence of low-severity emotional and behavioural dysregulation. Young children with severe CHD or comorbid conditions experienced greater impairment, with higher rates of externalising behaviour problems, although internalising behaviour problems were also evident. This review integrates findings from literature in the past 28 years on the psychosocial well-being of infants and young children with CHD and demonstrates a risk for emotional, social and behavioural development difficulty, and, importantly, that symptoms of psychosocial impairment are detectable very early in infancy. We advocate for assessment and monitoring of emotional and behavioural regulation and social development to be routinely conducted from infancy to enable prevention and early intervention.