Personalized Mobile Health-Enhanced Cognitive Behavioral Intervention for Maternal Distress: Examining the Moderating Role of Adverse Childhood Experiences

BACKGROUND

Maternal history of trauma is a risk factor for distress during pregnancy. The purpose of this paper was to examine the theorized differential impact of a cognitive behavioral intervention (Mothers and Babies Personalized; MB-P) on maternal distress and emotional regulation for those with ≥ 1 adverse childhood experiences (ACEs; vs no ACEs) from pregnancy to 3 months postpartum.

METHODS

Between August 2019 and August 2021, eligible pregnant individuals aged ≥ 18 years, < 22 weeks' gestation, and English-speaking were recruited from 6 university-affiliated prenatal clinics. Participants (N = 100) were randomized to MB-P (n = 49) or control (n = 51). Analyzable data were collected for 95 participants. Analyses tested progression of change (slope) and at individual timepoints (panel analysis) for perinatal mental health outcomes.

RESULTS

The majority of participants (n = 68, 71%) reported experiencing > 1 ACE (median = 1, range: 0-11). Participants demonstrated significant differential effects for depressive symptoms in absence of ACEs (standardized mean differences [SMD] = 0.82; 95% confidence interval [CI] = [0.13-1.51]) vs in presence of ACEs (SMD = 0.39; 95% CI = [-0.20 to 0.97]) and perceived stress in absence of ACEs (SMD = 0.92; 95% CI = [0.23-1.62]) vs in presence of ACEs (SMD = -0.05; 95% CI = [-0.63 to 0.53]). A panel analysis showed significantly reduced depressive symptoms postintervention and increased negative mood regulation at 3 months postpartum for individuals with ACEs.

CONCLUSIONS

Findings support effectiveness of the MB-P intervention to reduce prenatal distress for all pregnant individuals. Preliminary exploration suggests the possibility that individuals with ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention.

Developmental trajectories of internalizing distress among ethnic minoritized mothers following childbirth: Associations with early child psychological adjustment

A substantial body of work has established that mothers' internalizing distress can negatively affect children's socioemotional development. Yet few studies have examined how distinct patterns of mothers' distress over time differentially impact child behaviors across early childhood. To address this gap, the current study explored developmental trajectories of mothers' internalizing distress and examined the associations of these patterns with child adjustment outcomes. Mexican immigrant, Dominican immigrant, and African American mothers (N = 272) were annually assessed for internalizing distress over the first 6 years following childbirth. Children's psychological adjustment (internalizing, externalizing, and hyperactivity behaviors) was measured at the last yearly assessment in first grade. A growth mixture model revealed two distinct classes of distress where mothers were classified as having low stable distress (82.4%) or moderate distress that began as stable then declined when their children were 64 months old (17.6%). Children of mothers in the moderate, late decline class showed greater internalizing, externalizing, and hyperactivity behaviors in the first grade compared to children of mothers in the low stable class. Findings highlight the necessity of supporting the mental health of ethnic minoritized mothers following childbirth and further expand our knowledge of family psychopathology to promote healthy psychological adjustment in children.

Maternal prenatal distress exposure negatively associates with the stability of neonatal frontoparietal network

Maternal prenatal distress (PD), frequently defined as in utero prenatal stress exposure (PSE) to the developing fetus, influences the developing brain and numerous associations between PSE and brain structure have been described both in neonates and in older children. Previous studies addressing PSE-linked alterations in neonates' brain activity have focused on connectivity analyses from predefined seed regions, but the effects of PSE at the level of distributed functional networks remains unclear. In this study, we investigated the impact of prenatal distress on the spatial and temporal properties of functional networks detected in functional MRI data from 20 naturally sleeping, term-born (age 25.85 ± 7.72 days, 11 males), healthy neonates. First, we performed group level independent component analysis (GICA) to evaluate an association between PD and the identified functional networks. Second, we searched for an association with PD at the level of the stability of functional networks over time using leading eigenvector dynamics analysis (LEiDA). No statistically significant associations were detected at the spatial level for the GICA-derived networks. However, at the dynamic level, LEiDA revealed that maternal PD negatively associated with the stability of a frontoparietal network. These results imply that maternal PD may influence the stability of frontoparietal connections in neonatal brain network dynamics and adds to the cumulating evidence that frontal areas are especially sensitive to PSE. We advocate for early preventive intervention strategies regarding pregnant mothers. Nevertheless, future research venues are required to assess optimal intervention timing and methods for maximum benefit.

Maternal Distress and Adolescent Mental Health in Poor Chinese Single-Mother Families: Filial Responsibilities-Risks or Buffers?

Single motherhood and poverty have a significant, negative impact on mothers and their children. When their mothers experience maternal distress, adolescent children have to take up more instrumental and emotional filial responsibilities to comfort their mother and adapt to related changes. Based on 325 mother-child dyads of Chinese single-mother families experiencing economic disadvantage, this study examined the relationship between maternal distress and adolescent mental health problems (indexed by anxiety and depression) and the moderating roles of instrumental and emotional filial responsibilities. Results indicated that maternal distress was positively associated with anxiety and depression in adolescent children. In addition, instrumental filial responsibility intensified the associations of maternal distress with adolescent anxiety and depression. Moreover, the moderating role of emotional filial responsibility in the predictive relationship between maternal distress and adolescent anxiety was different in boys and girls. Adolescent girls with more emotional filial responsibility reported higher adolescent anxiety than did those who shouldered less emotional filial responsibility when their mother exhibited more distress, whereas the relationship between maternal distress and adolescent anxiety was stable in boys, regardless of emotional filial responsibility. In short, the present study showed that parentification was likely to occur in poor Chinese single-mother families, and adolescent children who took up a more caregiving role in the family exhibited poorer mental health. Family counselling and tangible support for single-mother families experiencing economic disadvantage are urged.

Music Therapy in Preterm Infants Reduces Maternal Distress

Preterm delivery is a stressful event for mothers, posing them at risk for post-traumatic stress reactions. This study examined the degree of depressive symptoms and post-traumatic stress in mothers of preterm infants born before 32 gestational weeks depending on whether the infant received music therapy in the neonatal intensive care unit (NICU) or not. We included 33 mothers of preterm infants enrolled in a previously described prospective randomized controlled trial, of whom 18 received music therapy (mean mothers' age 34.1 ± 4.6 years) and 15 did not (mean mothers' age 29.6 ± 4.2). The degree of depressive symptoms, anxiety and acute stress reactions of these mothers were measured by using the German version of the Center for Epidemiologic Studies Depression Scale (CES-D) and Impact of Events Scale-Revised (IES-R) one week after birth (T1) and at infants' hospital discharge (T2). 605 music therapy sessions with a mean duration of 24.2 ± 8.6 min (range 10 to 50 min) were conducted two times a week from the second week of life (T1) until discharge (T2) to the infants from the intervention group. The infants from the control group received standard medical care without music therapy. The mean total CES-D score decreased from T1 (mean 34.7, 95% Confidence Interval (CI) 31.1-38.1) until T2 in all mothers (mean 16.3, 95% CI 12.6-20.1). Mothers whose infants received music therapy showed stronger declines of depressive and stress symptoms (with music therapy: CES-D mean difference of total score 25.7, 95% CI 20.0-31.3, IES-R mean difference of total score 1.7, 95% CI 0.9-2.5, IES-R mean difference of subcategory hyperarousal 10.2, 95% CI 6.2-14.3; without music therapy: CES-D mean difference of total score 9.5, 95% CI 3.8-15.3, IES-R mean difference of total score 0.1, 95% CI -1.0-1.2, IES-R mean difference of subcategory hyperarousal 1.6, 95% CI -4.7-7.9). Effect sizes were strong for CES-D, IES-R, and the hyperarousal subcategory, moderate for intrusion, and low for avoidance. These findings show that mothers of preterm infants are highly susceptible to supportive non-medical interventions such as music therapy to reduce psychological symptoms and distress during their infants' NICU stay.

Maternal Distress during Pregnancy and the Postpartum Period: Underlying Mechanisms and Child's Developmental Outcomes-A Narrative Review

Maternal mental health may be considered a determining factor influencing fetal and child development. An essential factor with potentially negative consequences for a child's psychophysiological development is the presence of maternal distress during pregnancy and the postpartum period. The review is organized and presented to explore and describe the effects of anxiety, stress, and depression in pregnancy and the postpartum period on adverse child developmental outcomes. The neurobiology of maternal distress and the transmission mechanisms at the molecular level to the fetus and child are noted. In addition, the paper discusses the findings of longitudinal studies in which early child development is monitored concerning the presence of maternal distress in pregnancy and the postpartum period. This topic gained importance in the COVID-19 pandemic context, during which a higher frequency of maternal psychological disorders was observed. The need for further interdisciplinary research on the relationship between maternal mental health and fetal/child development was highlighted, especially on the biological mechanisms underlying the transmission of maternal distress to the (unborn) child, to achieve positive developmental outcomes and improve maternal and child well-being.

Visual Expressions of Children's Strengths, Difficulties and Wishes in Person Picking an Apple from a Tree Drawings among Preschoolers Living in Areas of Persistent Political Violence

The present study sought to inquire into the subjective experience of 156 preschoolers (age 4-6.9 years) living in an area of political violence in Israel (on the border with the Gaza Strip) during a period of massive bombing. Children were invited to draw a Person Picking an Apple from a Tree (PPAT), and were interviewed on their sense of self-potency using the CAMP, a measure of potency. Teachers were asked to report problems in executive functions using a few BRIEF scales; and mothers filled out a questionnaire for maternal distress (BSI), a measure of their child strengths and difficulties (SDQ), and were asked to provide their assessment regarding the extent to which their child was exposed to political violence. Findings reveal associations between mothers' distress, the degree of exposure of their child to trauma, and the child's emotional symptoms. PPAT analysis identified four main factors: Tree Generosity, Person Agency, Vividness, and As-Real-R. Positive associations were found between self-potency and the main factors of the drawings; negative associations were found between the child's difficulties in executive functions and the drawing's four main factors; and two small negative associations were found between the child's emotional symptoms and Tree Generosity and As-Real-R factors. The following associations were found within each gender group: mothers' depression degree was associated with boy's Tree Generosity, and mother's perceptions of their girl's exposure to trauma was related to Person Agency, Tree Generosity, and As-Real-R factors; furthermore, a significant difference was found between the narrative focus of drawings in this sample and the narrative focus of drawings of a sample of the same age group from a non-war zone. In addition, narrative focus was found to be related to children's self-potency. The discussion deals with the study's findings through the prism of developmental psychology, self-agency, object-relations, and art-therapy theories.

Fatal pulmonary oedema associated with severe pre-eclampsia: challenges and lessons

Pre-eclampsia complicated by pulmonary oedema, severe hypertension, tachycardia and desaturation is a devastating condition. A comprehensive understanding of the aetiopathogenesis during such an emergency is challenging in the absence of functional and responsive point-of-care imaging, and laboratory and other critical-care services. An unbooked 26-year-old gravida 3 para 1+1 presented to a primary healthcare clinic with features of pre-eclampsia, severe hypertension and pulmonary oedema. The only available antihypertensive drug, methyldopa, was administered. The patient was transferred to a district hospital and subsequently referred to a tertiary hospital. On arrival, she was booked for caesarean delivery and in the maternity ward a central venous pressure (CVP) line was inserted. The patient developed pneumothorax and died in the intensive care unit undelivered. This case highlights many lessons, which are discussed. If CVP monitoring is indicated before caesarean delivery, consideration must be given to line insertion in the operating room to facilitate rapid delivery should the patient's condition deteriorate.

Psychological Distress Prospectively Predicts Later Sleep Quality in a Sample of Black American Postpartum Mothers

Objective: Previous longitudinal studies have demonstrated prospective relationships between maternal sleep quality and subsequent psychological distress in the postpartum period. Despite evidence for prospective relationships between mood and subsequent sleep quality in adult populations, this direction has not been examined in postpartum women. We aimed to test prospective relationships between sleep quality and subsequent psychological distress, as well as the plausible reverse possibility, in a sample of Black American postpartum mothers (n = 146).Participants: Mothers were recruited prenatally from two hospitals in a Southeastern city of the United States. Eligible and interested mothers enrolled in a follow-up study on infant development. Data from the current study were obtained during the follow-up study.Method: Mothers reported on their psychological distress (i.e., anxiety, depression, stress) and sleep quality at 3- and 6-months postpartum. We performed hierarchical linear regressions to explore whether 1) maternal sleep quality at 3-months postpartum would predict maternal psychological distress at 6-months postpartum, after adjustment for mothers' earlier psychological distress, and 2) whether psychological distress at 3-months postpartum would predict maternal sleep quality at 6-months postpartum, after adjustment for mothers' earlier sleep quality.Results: Maternal sleep quality at 3-months postpartum was not a significant predictor of psychological distress at 6-months postpartum. However, maternal psychological distress at 3-months postpartum was a significant predictor of sleep quality at 6-months postpartum.Conclusions: Mothers' psychological distress earlier in the postpartum was a significant predictor of their later sleep quality. Replication is needed in large, prospective studies, with results stratified by race/ethnicity.

Associations Between Maternal Distress During Early Life Periods and Offspring Respiratory Infections and Allergic Outcomes

Background

Increasing evidence suggests that maternal distress is a risk factor for development of respiratory infections and allergic diseases in the offspring. We aim to evaluate the link between maternal distress during critical periods in early life, namely the preconception, pregnancy and postnatal periods, and development of respiratory infections and allergic diseases in the offspring from the Singapore PREconception Study of long Term maternal and child Outcomes (S-PRESTO) cohort.

Methods

Maternal perceived distress was evaluated using validated questionnaires including Beck Depression Inventory-II (BDI-II) administered during three time periods: preconception (three months apart at four timepoints), pregnancy (during each trimester) and postnatal (3 and 6 months post-delivery). Child eczema, rhinitis and wheeze outcomes were evaluated using a modified ISAAC questionnaire at ages 3, 6, 12, and 18 months. Child allergic sensitization was determined by skin prick testing at 18 months.

Results

Among 332 mother-child pairs studied, higher maternal distress during preconception and pregnancy increased the risks of wheeze development in the first 18 months; for example, preconception and pregnancy BDI-II scores ≥20 were associated with increased risks of wheeze by 18 months [adjusted risk ratios 3.2 (95%CI 1.1-9.4) and 2.5 (1.0-5.9), respectively]. Emotional and practical support from family during preconception decreased the risks of offspring wheeze. No associations were observed between maternal distress and offspring eczema, rhinitis and allergic sensitization.

Conclusion

Maternal distress during critical early life periods was associated with offspring wheeze in the first 18 months of life. Supporting maternal mental health even before pregnancy could reduce the risk of offspring wheeze.

Prenatal maternal depressive symptoms of Chinese pregnant women and twin newborns' physical health: the moderating role of infant sex

Consequences of prenatal maternal depressive symptoms on infant health are well established. But the results of infants' sex differences of such consequences are mixed. The current study examines whether any association exists between prenatal maternal depressive symptoms and infant physical health different for the sex of newborns. A sample of 84 women pregnant with twins reported depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) in the late gestational stage. The Apgar scores of newborns were assessed by healthcare providers at 1, 5, and 10 minutes after birth. The relationship of maternal prenatal depressive symptoms and newborns' physical health was moderated by infant sex. Higher depressive symptoms were associated with a lower Apgar index among newborn boys but not girls. Fetus environment or biomarkers related to sex may be a key mechanism of the effect of prenatal depression symptoms on newborns' health. Tailored interventions targeting maternal depression symptoms may be warranted.

Being born and growing up in the Ribeirão Preto and São Luís cohorts

This thematic issue consists of 14 articles derived from studies of the BRISA birth cohort (Ribeirão Preto, State of São Paulo and São Luís, State of Maranhão, northeastern Brazil, a socially and economically less developed region). In these more than 40 years of existence, these cohorts have been able to document the increase in women's education, the improvement of health conditions, the creation of a public Unified Health System (SUS) that provides universal and free access to health care, eradication of hunger, and transition of the nutritional status characterized by a decrease in malnutrition rates and an increase in obesity in Brazil. Particularly in reproductive health, the country experienced a significant drop in fertility, a decrease in maternal and child mortality, and an increase in breastfeeding rates. Universal access to prenatal care and hospital delivery was accompanied by an excessive number of cesareans without clinical indication and early-term births and premature births, largely due to scheduled cesareans. Articles with a longitudinal and transversal methodological approach are presented, using structural equation analysis and propensity score, together with multivariate regressions, which gave a robust analytical treatment to articles in this thematic issue.

Maternal Distress and Offspring Neurodevelopment: Challenges and Opportunities for Pre-clinical Research Models

Pre-natal exposure to acute maternal trauma or chronic maternal distress can confer increased risk for psychiatric disorders in later life. Acute maternal trauma is the result of unforeseen environmental or personal catastrophes, while chronic maternal distress is associated with anxiety or depression. Animal studies investigating the effects of pre-natal stress have largely used brief stress exposures during pregnancy to identify critical periods of fetal vulnerability, a paradigm which holds face validity to acute maternal trauma in humans. While understanding these effects is undoubtably important, the literature suggests maternal stress in humans is typically chronic and persistent from pre-conception through gestation. In this review, we provide evidence to this effect and suggest a realignment of current animal models to recapitulate this chronicity. We also consider candidate mediators, moderators and mechanisms of maternal distress, and suggest a wider breadth of research is needed, along with the incorporation of advanced -omics technologies, in order to understand the neurodevelopmental etiology of psychiatric risk.

Feeding and Growth in Infants With Cleft Lip and/or Palate: Relationships With Maternal Distress

OBJECTIVE

To examine relationships between early feeding and growth and maternal distress in infants with and without cleft lip and/or palate (CL/P).

DESIGN

Cross-sectional.

SETTING

Pediatric academic medical center in the Midwestern United States.

PARTICIPANTS

Mothers of infants 1 to 12 weeks old with CL/P (n = 30) and without CL/P (control group, n = 30) were recruited at craniofacial clinic or pediatrician appointments.

MAIN OUTCOME MEASURE(S)

Maternal responses on the Feeding/Swallowing Impact Survey (FS-IS), Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF), and Edinburgh Postnatal Depression Scale. Infant feeding history and growth measurements were obtained.

RESULTS

Having an infant with CL/P revealed greater impact on maternal health-related quality of life due to feeding problems (F = 4.83, P = .03). Mothers of infants with CL/P reported average range Total Stress scores on the PSI-4-SF, which were higher than controls (F = 4.12, P = .05). Edinburgh Postnatal Depression Scale scores did not differ between groups. Compared to controls, infants with cleft palate had lower percentiles for weight (t = 4.13, P = .04) and length (t = 2.93, P = .01). Higher FS-IS scores were associated with longer feeding duration (r = 0.32, P = .01) and lower weight (r = -0.31, P = .02) and length (r = -0.32, P = .02).

CONCLUSIONS

Despite receiving early team care and feeding interventions, mothers of infants with CL/P reported higher stress and more challenges with feeding and growth. Future studies should examine targeted psychosocial interventions to improve feeding and growth outcomes in infants with CL/P.

"It's Hard Being a Mama": Validation of the Maternal Distress Concept in Becoming a Mother

New mothers actively adapt to new demands and challenges in the mothering role but some may find this adjustment difficult and distressing, depending on their perceptions and resources. Previous research on maternal distress is primarily concentrated on needs of mothers with depression but nonpathological approaches of viewing difficulties in early parenting should be explored. A secondary analysis of a descriptive, qualitative study was completed on new, low-income mothers in early parenthood to determine how maternal distress influences mothers' transition to becoming a mother and to validate the use of the Maternal Distress Concept in the clinical setting. Findings reveal new mothers experience maternal distress on various levels: stress, adaptation, functioning, and connecting. Implications for practice and education are discussed.

Infant, Maternal, and Neighborhood Predictors of Maternal Psychological Distress at Birth and Over Very Low Birth Weight Infants' First Year of Life

OBJECTIVE

To use a social-ecological conceptualization to analyze change of maternal distress, defined as depression, anxiety, and perinatal-specific post-traumatic stress (PPTS), across very low birth weight (VLBW) infants' first year of life and to identify infant, maternal, and neighborhood predictors of these changes over time.

METHODS

Mothers of VLBW infants (n = 69) completed psychological distress questionnaires 2 to 4 weeks after infant birth, 2 weeks before infant discharge from neonatal intensive care unit, and at infants' 4- and 8-month corrected age (age adjusted for prematurity). Infant and maternal sociodemographic data were collected from medical chart review. Neighborhood data were obtained through US census data. Multilevel linear growth modeling was used to (1) predict unstandardized estimates of mothers' initial levels of depression, anxiety, and PPTS at the time of infant's birth and the rate of change of these markers of distress over time and (2) model unstandardized estimates of infant, maternal, and neighborhood as predictors of distress at infants' birth and change over time.

RESULTS

Unstandardized estimates from multilevel linear growth modeling revealed depression (-2.8), anxiety (-1.4), and PPTS (-0.7) declined over infants' first year of life (<0.001). Mothers residing in lower-income homes and neighborhoods, respectively, reported lower anxiety (-11.2, p = 0.03) and PPTS (-31.1, p = 0.01) at infant birth. Greater infant birth weight predicted both lower anxiety (-0.02, p = 0.02) and lower PPTS (-0.02, p = 0.005).

CONCLUSION

Mothers psychologically recover over VLBW infants' first year of life. Results add to a building literature about socioeconomically disadvantaged mothers of preterm infants, reporting lower distress; this warrants additional research.

Prenatal Immune and Endocrine Modulators of Offspring's Brain Development and Cognitive Functions Later in Life

Milestones of brain development in mammals are completed before birth, which provide the prerequisite for cognitive and intellectual performances of the offspring. Prenatal challenges, such as maternal stress experience or infections, have been linked to impaired cognitive development, poor intellectual performances as well as neurodevelopmental and psychiatric disorders in the offspring later in life. Fetal microglial cells may be the target of such challenges and could be functionally modified by maternal markers. Maternal markers can cross the placenta and reach the fetus, a phenomenon commonly referred to as “vertical transfer.” These maternal markers include hormones, such as glucocorticoids, and also maternal immune cells and cytokines, all of which can be altered in response to prenatal challenges. Whilst it is difficult to discriminate between the maternal or fetal origin of glucocorticoids and cytokines in the offspring, immune cells of maternal origin—although low in frequency—can be clearly set apart from offspring's cells in the fetal and adult brain. To date, insights into the functional role of these cells are limited, but it is emergingly recognized that these maternal microchimeric cells may affect fetal brain development, as well as post-natal cognitive performances and behavior. Moreover, the inheritance of vertically transferred cells across generations has been proposed, yielding to the presence of a microchiome in individuals. Hence, it will be one of the scientific challenges in the field of neuroimmunology to identify the functional role of maternal microchimeric cells as well as the brain microchiome. Maternal microchimeric cells, along with hormones and cytokines, may induce epigenetic changes in the fetal brain. Recent data underpin that brain development in response to prenatal stress challenges can be altered across several generations, independent of a genetic predisposition, supporting an epigenetic inheritance. We here discuss how fetal brain development and offspring's cognitive functions later in life is modulated in the turnstile of prenatal challenges by introducing novel and recently emerging pathway, involving maternal hormones and immune markers.

Factors Associated with Maternal Wellbeing at Four Months Post-Partum in Ireland

This study aimed to examine factors associated with maternal wellbeing at four months post-partum in the Irish context. Socio-demographic, health behaviour and infant feeding data were collected in pregnancy, at birth and at 17 weeks post-partum. Maternal distress, body image and resilience were measured at 17 weeks post-partum. Binary logistic regression predicted maternal distress and statistical significance was taken at p < 0.05. One hundred and seventy-two women were followed-up in pregnancy, at birth and at 17 weeks post-partum. Three in five (61.6%, n106) initiated breastfeeding. At 17 weeks post-partum, 23.8% (n41) were exclusively or partially breastfeeding and over a third (36.0%, n62) of all mothers were at risk of distress. In multivariate analyses, independent predictors of distress included: low maternal resilience (p < 0.01, odds ratio (OR): 7.22 (95% confidence interval [CI]: 2.49⁻20.95)); unsatisfactory partner support (p = 0.02, OR: 3.89 (95% CI: 1.20⁻12.65)); older age (p = 0.02, OR: 1.11 (95% CI: 1.02⁻1.21)); and breastfeeding (p = 0.01, OR: 2.89 (95% CI: 1.29⁻6.47)). Routine assessment of emotional wellbeing and targeted interventions are needed to promote a more healthful transition to motherhood among women in Ireland.

Infant Sleeping Arrangements, Social Criticism, and Maternal Distress in the First Year

The present study examined differences in social criticism and maternal distress and in household, maternal, and infant characteristics between families who co-slept with their infants beyond 6 months and those who moved their infants to a separate room by 6 months. Data for infant sleeping arrangements, preferences for their sleeping arrangement choices, criticism, depressive and anxiety symptoms, and worries about infant sleep were collected from 103 European American mothers during the infant's first year. Mothers who co-slept with their infants beyond 6 months (persistent co-sleepers) were more likely than mothers who moved their infants to solitary sleep by 6 months to receive criticism and report depression and worry about infants' sleep behavior, even after controlling for preference for the sleep arrangement they used. Interestingly, criticism was associated with maternal depression and worries only for persistent co-sleeping mothers. Further, these mothers had lower income, reported greater space constraints, were younger, single, or unemployed, less likely to have a Bachelor's degree, and more likely to have infants with greater negative affectivity or problematic night waking, compared to mothers of solitary sleeping infants. Adherence to cultural norms regarding infant sleeping arrangements may be a strong predictor of social criticism and maternal well-being.

Using fathers as a negative control exposure to test the Developmental Origins of Health and Disease Hypothesis: A case study on maternal distress and offspring asthma using Swedish register data

BACKGROUND

Developmental Origins of Health and Disease Hypothesis (DOHaD) studies are often observational in nature and are therefore prone to biases from loss to follow-up and unmeasured confounding. Register-based studies can reduce these issues since they allow almost complete follow-up and provide information on fathers that can be used in a negative control analysis to assess the impact of unmeasured confounding.

AIM

The aim of this study was to propose a causal model for testing DOHaD using paternal exposure as a negative control, and its application to maternal distress in pregnancy and offspring asthma.

METHODS

A causal diagram including shared and parent-specific measured and unmeasured confounders for maternal (fetal) and paternal exposures is proposed. The case study consisted of all children born in Sweden from July 2006 to December 2008 ( n=254,150). Information about childhood asthma, parental distress and covariates was obtained from the Swedish national health registers. Associations between maternal and paternal distress during pregnancy and offspring asthma at age five years were assessed separately and with mutual adjustment for the other parent's distress measure, as well as for shared confounders.

RESULTS

Maternal distress during pregnancy was associated with offspring asthma risk; mutually adjusted odds ratio (OR) (OR 1.32, 95% CI 1.23, 1.43). The mutually adjusted paternal distress-offspring asthma analysis (OR 1.05, 95% CI 0.97, 1.13) indicated no evidence for unmeasured confounding shared by the mother and father.

CONCLUSIONS

Using paternal exposure in a negative control model to test the robustness of fetal programming hypotheses can be a relatively simple extension of conventional observational studies but limitations need to be considered.

PREDICTORS OF EMOTIONAL AND BEHAVIORAL PROBLEMS IN 1-YEAR-OLD CHILDREN: A LONGITUDINAL PERSPECTIVE

Emotional and behavioral problems at an early age can reasonably be considered a high-risk factor for later mental health disorders. The aim of the article is to reveal predictive factors of 1½-year-old children's emotional and behavioral problems. The study was a part of a prospective birth-cohort study. The study sample consisted of 172 full-term infants (born during Gestational Weeks 37-42) and their mothers. Emotional and behavioral problems at the age of 1½ years were measured using the Child Behavior Checklist for Ages 1½-5 (T. Achenbach & L. Rescorla, 2000), which was completed by mothers. Emotional and behavioral problems at age of 1½ years were more prevalent in infants born via cesarean section, as compared to infants born vaginally without administration of medication. Newborns' suboptimal functioning after birth, complicated emotional acceptance of pregnancy, a couple's nonsatisfactory relationship during pregnancy, maternal distress during pregnancy and in the first months after childbirth, and inflexible and parent-oriented attitudes toward infant-rearing also predicted children's emotional and behavioral problems independent of sociodemographic factors. Results suggest that biomedical and psychosocial factors which manifest themselves in the prenatal and perinatal periods can have associations with later infant and child mental health.

Clinical, psychological and maternal characteristics in early functional constipation

BACKGROUND

This cross-sectional study investigated the clinical features of functional constipation (FC) at preschool age, as well as emotional and behavioral characteristics of the children, psychological symptom level and parental attitudes of the mothers, and compared these with that of non-referred typically developing controls with normal intestinal habits.

METHODS

Participants included 65 children with FC (mean age, 43.6 ± 15.4 months; range, 25-72 months), 59 healthy controls (mean age, 46.9 ± 14.5 months; range, 25-72 months) and the mothers of the children. The Childhood Behavior Checklist, Symptom Checklist 90 and Parental Attitude Research Instrument were filled in by the mothers.

RESULTS

Participants with FC had higher problem scores than the comparison children in a variety of emotional and behavioral parameters. Approximately half exhibited internalizing and one-third had externalizing problems in the clinical range. The mothers of the patient group had higher levels of psychological distress, overprotective parenting and strict discipline. On multiple logistic regression analysis child psychopathology, maternal education level and maternal distress were independently associated with FC.

CONCLUSION

Behavior problems are common in children with FC from an early age. Low level of education and high psychological distress of the mothers seem to be important risk factors for constipation and should be assessed carefully in the management of these cases.

Maternal distress influences young children's family representations through maternal view of child behavior and parent-child interactions

Distress of a parent is a key influence on the quality of the child's experience in the family. We hypothesized that maternal distress would spill over into more negative views of their children's behaviors and less emotional availability in their relationships. Further, we investigated whether these cumulative experiences contributed to children's emerging narratives about mothers and family life. In this longitudinal study, mothers of young twin children reported their distress on three occasions in relation to: self, the marital relationship, and the family climate. Mothers also reported on their children's externalizing behavior problems. Mother-child interaction was observed focusing on maternal sensitivity and child responsivity. Children responded to story stem beginnings about challenging situations in the family and their narratives were scored for family conflict and cohesion themes. Actor-partner interdependence model methods of dyadic data analysis accounted for the inclusion of both twins in the analysis. Results from structural equation models supported the hypothesized cumulative experience of maternal distress on children's family life representations for both family conflict and family cohesion. A family environment in which children are exposed to persistent maternal distress early in life may have cumulative effects, influencing how mothers interact with and view their children's behavior at later developmental stages. Moreover, exposure to repeated distress for longer periods of time may contribute to an intergenerational continuity of distress for the child that may become rooted in negative affective bias in their own view of family relationships.

Maternal satisfaction with administering infant interventions in the neonatal intensive care unit

OBJECTIVE

To examine mothers' satisfaction with administering interventions for their preterm infants and with the helpfulness of the study nurse by comparing massage with auditory, tactile, visual, and vestibular stimulation (ATVV intervention), kangaroo care, and education about equipment needed at home and to explore whether mother and infant characteristics affected maternal satisfaction ratings.

DESIGN

Three-group experimental design.

SETTING

Four neonatal intensive care units (NICUs) (two in North Carolina, two in Illinois).

PARTICIPANTS

Two hundred and eight (208) preterm infants and their mothers.

METHODS

When the infant was no longer critically ill, mother/infant dyads were randomly assigned to ATVV, kangaroo care, or the education group all taught by study nurses. At discharge and 2 months corrected age, mothers completed questionnaires.

RESULTS

All groups were satisfied with the intervention and with nurse helpfulness, and the degree of satisfaction did not differ among them. Intervention satisfaction, but not nurse helpfulness, was related to recruitment site. Older, married, and minority mothers were less satisfied with the intervention but only at 2 months. Higher anxiety was related to lower intervention satisfaction at discharge and lower ratings of nurse helpfulness at discharge and 2 months. More depressive symptoms were related to lower nurse helpfulness ratings at 2 months.

CONCLUSIONS

Mothers were satisfied with interventions for their infants regardless of the intervention performed. Maternal satisfaction with the intervention was related to recruitment site, maternal demographic characteristics, and maternal psychological distress, especially at 2 months. Thus, nursing interventions that provide mothers with a role to play in the infant's care during hospitalization are particularly likely to be appreciated by mothers.

Influence of early regulatory problems in infants on their development at 12 months: a longitudinal study in a high-risk sample

BACKGROUND

This study examined the extent to which regulatory problems in infants at 4 and 6 months influence childhood development at 12 months. The second aim of the study was to examine the influence maternal distress has on 4-month-old children's subsequent development as well as gender differences with regard to regulatory problems and development.

METHODS

153 mother-child dyads enrolled in the family support research project "Nobody slips through the net" constituted the comparison group. These families faced psychosocial risks (e.g. poverty, excessive demands on the mother, and mental health disorders of the mother, measured with the risk screening instrument Heidelberger Belastungsskala - HBS) and maternal stress, determined with the Parental Stress Index (PSI-SF). The children's developmental levels and possible early regulatory problems were evaluated by means of the Ages and Stages Questionnaires (ASQ) and a German questionnaire assessing problems of excessive crying along with sleeping and feeding difficulties (SFS).

RESULTS

A statistically significant but only low, inverse association between excessive crying, whining and sleep problems at 4 and 6 months and the social development of one-year-olds (accounting for 5% and 8% of the variance respectively) was found. Feeding problems had no effect on development. Although regulatory problems in infants were accompanied by increased maternal stress level, these did not serve as a predictor of the child's social development at 12 months. One-year-old girls reached a higher level of development in social and fine motor skills. No gender differences were found with regard to regulatory problems, nor any moderating effect of gender on the relation between regulatory problems and level of development.

CONCLUSIONS

Our results reinforce existing knowledge pertaining to the transactional association between regulatory problems in infants, maternal distress and dysfunctionality of mother-child interactions. They also provide evidence of a slight but distinct negative influence of crying and sleeping problems on children's subsequent social development. Easily accessible support services provided by family health visitors (particularly to the so-called "at-risk families") are strongly recommended to help prevent the broadening of children's early regulatory problems into other areas of behavior.

Prevention of postpartum traumatic stress in mothers with preterm infants: manual development and evaluation

Premature birth has been associated with multiple adverse maternal psychological outcomes that include depression, anxiety, and trauma as well as adverse effects on maternal coping ability and parenting style. Infants who are premature are more likely to have poorer cognitive and developmental functioning and, thus, may be harder to parent, both as infants and as they get older. In response to these findings, a number of educational and behavioral interventions have been developed that target maternal psychological functioning, parenting, and aspects of the parent-infant relationship. The current study aimed to both develop and evaluate a treatment that integrates, for the first time, effective interventions for reducing symptoms of posttraumatic stress disorder (PTSD) and enhancing maternal-infant interactions. Conclusions from the study indicate that the intervention is feasible, able to be implemented with a high level of fidelity, and is rated as highly satisfactory by participants. Though encouraging, these findings are preliminary, and future studies should strive to reproduce these findings with a larger sample size and a comparison group.

Effectiveness of therapeutic behavioral interventions for parents of low birth weight premature infants: A review

Premature birth has been associated with a number of adverse maternal psychological outcomes that include depression, anxiety, and trauma as well as adverse effects on maternal coping ability and parenting style. Infants and children who were premature are more likely to have poorer cognitive and developmental functioning and, thus, may be harder to parent. In response to these findings, there have been a number of educational and behavioral interventions developed that target maternal psychological functioning, parenting and aspects of the parent-infant relationship. Since the last comprehensive review of this topic in 2002, there have been a significant number of developments in the quality of the studies conducted and the theoretical models that address the experience of parents of premature infants. In the current review, eighteen new interventions were identified and grouped into four categories based on treatment length and the target of the intervention. Findings suggest a trend towards early, brief interventions that are theoretically based, specifically target parent trauma, and utilize cognitive behavioral techniques. Although it is difficult to generalize study findings, conclusions from the review suggest that targeted interventions may have positive effects on both maternal and infant outcomes.