Examining the implications of contextual stress and maternal sensitivity for infants' cortisol responses to the still face paradigm.

Infants' hypothalamic-pituitary-adrenocortical (HPA) axis responses to acute stressors are theorized to be shaped by parents' sensitive responsiveness to infants' cues. The strength and direction of the association between maternal sensitivity and infants' HPA responses may depend on the context in which maternal sensitivity is observed and on broader environmental sources of stress and support. In this preregistered study, we used data from 105 mothers and their 7-month-old infants to examine whether two empirically identified forms of contextual stress-poor maternal psychosocial wellbeing and family socioeconomic hardship-moderate the association between maternal sensitivity and infants' cortisol responses to the Still-Face Paradigm (SFP). Results indicated that maternal sensitivity during the free play and family socioeconomic hardship interacted to predict infants' cortisol responses to the SFP. Specifically, maternal sensitivity during this non-distressing interaction was negatively associated with cortisol responses only among infants whose mothers were experiencing relatively high socioeconomic hardship. Exploratory analyses revealed that poor maternal psychosocial wellbeing was positively associated with overall infant cortisol production during the SFP. Altogether, these findings suggest that experiences within early parent-infant attachment relationships and sources of contextual stress work together to shape infant HPA axis activity.

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

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

Pregnant women's autonomic responses to an infant cry predict young infants' behavioral avoidance during the still-face paradigm.

Research suggests that women's autonomic nervous system responses to infant cries capture processes that affect their parenting behaviors. The aim of this study was to build on prior work by testing whether pregnant women's autonomic responses to an unfamiliar infant crying also predict their infants' emerging regulation abilities. Participants included 97 women in their third trimester of pregnancy, located in the United States. Most participants identified as White/non-Hispanic (48%) or Hispanic (30%), their mean age was approximately 30 years, and the modal family income was $40,000-$79,999. Pregnant women's respiratory sinus arrhythmia (RSA) and skin conductance levels (SCL)-which are thought to capture emotional engagement and behavioral inhibition, respectively-were measured while the women watched a relaxing video and a video of an unfamiliar infant crying. Approximately 7 months later, women and their infants completed the still-face paradigm (SFP). Infants' avoidance and resistance behaviors during the SFP reunions were rated. Pregnant women's RSA and SCL responses to the infant cry video uniquely predicted infants' avoidance (but not resistance) during the SFP. Infants displayed higher levels of avoidance when their mothers exhibited lower levels of RSA reactivity or when their mothers exhibited higher levels of SCL activity in response to the infant cry video. Maternal sensitivity during mother-infant free-play interactions did not mediate the associations between pregnant women's autonomic responses to the cry video and infants' avoidant behavior during the SFP. Discussion focuses on potential mechanisms underlying associations between pregnant women's autonomic responses to infant distress and infants' socioemotional development. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The persistent associations between early institutional care and diurnal cortisol outcomes among children adopted internationally.

Young children in institutional care experience conditions that are incompatible with their needs for attachment relationships. As a result, early institutionalization is expected to have lasting effects on the regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis. The current study tested whether early institutionalization has persistent consequences for diurnal HPA axis outcomes among 130 children who had been adopted internationally between the ages of 6 and 48 months. Daily cortisol samples were collected from children at two time points: shortly after adoption (average of 5.3 months after adoption) and approximately 3 years later (average of 39.2 months after adoption). Shortly after adoption, children who had experienced a long duration of institutional care had lower morning cortisol levels and more blunted declines in cortisol across the day than children who experienced minimal or no institutional care. Three years later, children who had experienced a long duration of institutionalization continued to exhibit low morning cortisol levels and also exhibited low bedtime cortisol levels. Altogether, these results support the idea that early adversity results in the downregulation of the HPA axis and suggest that the effects of institutionalization on HPA axis functioning may persist several years after children are adopted into highly enriched families.

Gaps in procedural experience and competency in medical school graduates.

OBJECTIVES: The goal of undergraduate medical education is to prepare medical students for residency training. Active learning approaches remain important elements of the curriculum. Active learning of technical procedures in medical schools is particularly important, because residency training time is increasingly at a premium because of changes in the Accreditation Council for Graduate Medical Education duty hour rules. Better preparation in medical school could result in higher levels of confidence in conducting procedures earlier in graduate medical education training. The hypothesis of this study was that more procedural training opportunities in medical school are associated with higher first-year resident self-reported competency with common medical procedures at the beginning of residency training. METHODS: A survey was developed to assess self-reported experience and competency with common medical procedures. The survey was administered to incoming first-year residents at three U.S. training sites. Data regarding experience, competency, and methods of medical school procedure training were collected. Overall satisfaction and confidence with procedural education were also assessed. RESULTS: There were 256 respondents to the procedures survey. Forty-four percent self-reported that they were marginally or not adequately prepared to perform common procedures. Incoming first-year residents reported the most procedural experience with suturing, Foley catheter placement, venipuncture, and vaginal delivery. The least experience was reported with thoracentesis, central venous access, and splinting. Most first-year residents had not provided basic life support, and more than one-third had not performed cardiopulmonary resuscitation (CPR). Participation in a targeted procedures course during medical school and increasing the number of procedures performed as a medical student were significantly associated with self-assessed competency at the beginning of residency training. CONCLUSIONS: Recent medical school graduates report lack of self-confidence in their ability to perform common procedures upon entering residency training. Implementation of a medical school procedure course to increase exposure to procedures may address this challenge.

Advances in abdominal trauma.

Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.

Cause-and-effect analysis of risk management files to assess patient care in the emergency department.

OBJECTIVES: Identifying the etiologies of adverse outcomes is an important first step in improving patient safety and reducing malpractice risks. However, relatively little is known about the causes of emergency department-related adverse outcomes. The objective was to describe a method for identification of common causes of adverse outcomes in an emergency department. This methodology potentially can suggest ways to improve care and might provide a model for identification of factors associated with adverse outcomes. METHODS: This was a retrospective analysis of 74 consecutive files opened by a malpractice insurer between 1995 and 2000. Each risk-management file was analyzed to identify potential causes of adverse outcomes. The main outcomes were rater-assigned codes for alleged problems with care (e.g., failures of communication or problems related to diagnosis). RESULTS: About 50% of cases were related to injuries or abdominal complaints. A contributing cause was found in 92% of cases, and most had more than one contributing cause. The most frequent contributing categories included failure to diagnose (45%), supervision problems (31%), communication problems (30%), patient behavior (24%), administrative problems (20%), and documentation (20%). Specific relating factors within these categories, such as lack of timely resident supervision and failure to follow policies and procedures, were identified. CONCLUSIONS: This project documented that an aggregate analysis of risk-management files has the potential to identify shared causes related to real or perceived adverse outcomes. Several potentially correctable systems problems were identified using this methodology. These simple, descriptive management tools may be useful in identifying issues for problem solving and can be easily learned by physicians and managers.