Developmental care, neonatal behavior and postnatal maternal depressive symptomatology predict internalizing problems at 18 months for very preterm children.

OBJECTIVE: To provide a prospective developmental model for behavioral outcomes in preterm infants in relation to developmental care (DC) practices and postnatal maternal depression. STUDY DESIGN: A longitudinal, multicenter, follow-up study conducted in 25 Italian tertiary neonatal intensive care units (NICUs). Participants were 162 healthy very preterm infants and their mothers. The level of quality of DC was assessed for each hospital. Infant's neurobehavioral profile was evaluated twice: at discharge (T1) and at 18 months for behavioral problems (T3). Maternal depressive symptomatology was measured at T1 and at 6 months (T2). RESULTS: Low-quality DC in NICUs was associated with lower levels of infant neurobehavioral adaptability and higher levels of maternal depressive symptoms. Maternal depressive symptomatology in conjunction with higher infant dysregulation predicted more internalizing problems at 18 months of age. CONCLUSION: DC interventions and postnatal maternal depression, as well as infant behavior have an impact on short- and long-term infant outcomes.

The Still-Face: A Greater Challenge for Infants of Mothers With Borderline Personality Disorder.

The main aim of this study was to ascertain whether infants as young as 3 months of age, whose mothers suffer from borderline personality disorder (BPD), are already at risk of greater dysregulation than infants of mothers without BPD when faced with a minor stressful experience. Nineteen mothers diagnosed with BPD and 41 controls with no history of psychopathology and their 3-month-old infants were observed using Tronick's Face-to-Face Still-Face paradigm. The authors found that infants whose mothers have BPD express less positive vocalizations and less nonautonomic self-regulation than infants of mothers with no psychopathology. The stress of the Still-Face episode affects their gaze and self-regulation behaviors more strongly than those of infants of controls. The Reunion episode seems particularly challenging for mothers with BPD, who show fewer smiles and an increase in intrusive behavior. Because infants and their mothers with BPD are already dysregulated at 3 months postpartum, envisaging very early intervention seems warranted.

Prevalence and predictors of maternal postpartum depressed mood and anhedonia by race and ethnicity.

Aims. Depression requires the presence of either depressed mood or anhedonia, yet little research attention has been focused on distinguishing these two symptoms. This study aimed to obtain the prevalence rates of these two core depression symptoms and to explore the risk factors for each symptom by race/ethnicity. Methods. 2423 White, African American, Hispanic and Asian/Pacific Islander (API) women from the Massachusetts area completed the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2007 to 2008. Results. Socioeconomic variables (SES) accounted for increased rates in depressed mood and anhedonia among African Americans and Hispanics compared with Whites. API women were still 2.1 times more likely to report anhedonia after controlling for SES. Stressors were associated with depressed mood across groups and associated with anhedonia for Whites and Hispanics. Having a female infant was associated with depressed mood for APIs. Being non-US born was associated with anhedonia for Whites, APIs and African Americans, but not Hispanics. Conclusions. Prevalence rates for depressed mood and anhedonia differ across race/ethnic groups and risks associated with depressed mood and anhedonia depend on the race/ethnic group, suggesting the importance of distinguishing depressed mood from anhedonia in depression assessment and careful inquiry regarding symptom experiences with a diverse patient population.

Relationship between hair cortisol and perceived chronic stress in a diverse sample.

Hair cortisol (CORT) is a biomarker of chronic stress via long-term alterations in hypothalamus-pituitary-adrenal axis activity. Relationships to perceived stress measures, however, have rarely been specifically investigated. A diverse sample of 135 adults participated in a study assessing relationships between chronic stress indicator CORT to perceived stress and health indicators. CORT was not correlated to single perceived domain indices but with a global stress composite. Differences in objective and subjective measures were found for sociodemographics: racial/ethnic identity, sex and socioeconomic status (SES). Race by SES interactions predicted both CORT and perceived stress, but produced a complex and partially unanticipated pattern of results. For minorities, low and high SES showed the highest CORT, with mid-SES showing the lowest CORT; there was little change in perceived stress at all levels of SES. For non-minorities, mid-SES showed the highest CORT, with decreases in both CORT and perceived stress in high SES. The unanticipated findings of deleterious outcomes for high SES minorities highlight the importance of investigating potential stressors and moderators, including perceived discrimination and social identity. Moreover, these results suggest that CORT may not always correlate with single stress indices but may provide a global assessment of chronic stress, with implications for the allostatic load literature.

Cocaine exposure is associated with subtle compromises of infants' and mothers' social-emotional behavior and dyadic features of their interaction in the face-to-face still-face paradigm.

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

Similar and functionally typical kinematic reaching parameters in 7- and 15-month-old in utero cocaine-exposed and unexposed infants.

This study examined the effects of intrauterine cocaine exposure on the reaches of 19 exposed and 15 unexposed infants at 7 and 15 months using kinematic measures. Infants sat at a table and reached for a rattle, a toy doll, and a chair. Videotaped reaches were digitized using the Peak Performance system. Kinematic movement variables were extracted (e.g., reach duration, peak velocity, movement units, path length) and ratios computed (e.g., path length divided by number of movement units). Regardless of exposure status, reaches of older infants were faster, more direct, had fewer movement units, and covered more distance with the first movement unit. Exposed infants covered more distance per movement unit than unexposed infants, but there were no other significant differences. Reaches of exposed and unexposed infants were essentially similar. Importantly, reach parameters for these high-risk infants were similar to reach parameters for infants at lower social and biological risk.

Prenatal drug exposure and maternal and infant feeding behaviour.

OBJECTIVE: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. METHODS: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. RESULTS: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants' feeding problems. CONCLUSIONS: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

[The role of implicit knowledge in therapeutic change. Some implications of developmental observations for adult psychotherapy]. / Die Rolle des impliziten Wissens bei der therapeutischen Veränderung. Einige Auswirkungen entwicklungspsychologischer Beobachtungen für die psychotherapeutische Behandlung Erwachsener.

Several aspects of development change that are dependent on interactions between parent and infant are examined for their value in casting light on the process of change in adult psychotherapies. First, the domain of implicit knowledge (where changes necessarily occur in nonverbal infants) is identified. The vast majority of therapeutic change is found to occur in this domain. We then examine the improvised, largely unpredictable, nonlinear environments toward mutual goals that characterize the process of parent-infant and therapist-patient interactions. Finally, we provide a microdescription of these processes and provide a terminology for the "moments" that make up their flow. Of particular importance is the "moment of meeting", in which the participants interact in a way that created a new implicit, intersubjective understanding of their relationship and permits a new "way-of-being-with-the-other". We view "moments of meeting" as the key element in bringing about change in implicit knowledge, just as interpretations are thought to be the key element in bringing about change in explicit knowledge.

A mediational model for the impact of exposure to community violence on early child behavior problems.

This study examined how maternal distress mediates the link between exposure to community violence (CV) and the development of early child behavior problems. Research was conducted among 160 children, 3,0 to 5,11 in age, who resided in high-crime neighborhoods. Using structural equation modeling, latent variables were constructed to identify model components: maternal socioeconomic status (SES) and public assistance status, exposure to CV (maternal perceptions of local violence, social disorder, and fear of crime; and frequency of child cowitnessing violent events), family aggression (partner aggression toward mother and partner aggression toward child), maternal distress (global distress and posttraumatic stress disorder symptoms), and early child behavior problems (internalizing and externalizing). Bivariate correlations indicated that CV, maternal distress, and early child behavior problems were significantly intercorrelated. A series of structural equation models was specified to estimate the direct and indirect effect of CV on early child behavior problems. A direct model indicated a significant path from CV to early child behavior problems, after controlling for maternal SES and family aggression. The direct CV-early child behavior problems path diminished, however, when maternal distress was included in the model, after controlling for maternal SES and family aggression. Results are consistent with a mediation model of the impact of maternal distress symptoms on the link between CV and early child behavior problems.

Subsyndromal depressive symptoms and major depression in postpartum women.

This study documents differences in the psychosocial functioning of women three months postpartum with subclinical depression, major depression prior to the birth of the baby, major depression both pre- and post-birth, and no depression. An understanding of these differences may have implications for intervention insofar as maternal depression places at risk not only the mother's functioning but her infant's development, as well.

The Touchpoints Pediatric Asthma Program.

The Brazelton Touchpoints Center at the Child Development Unit, Children's Hospital, Boston, MA, designed a program intended to change the way asthma is managed in medical offices across the United States. This program was recently implemented at five pediatric asthma practices in the Chicago area where asthma prevalence is alarmingly high.

Infant health care use and maternal depression.

OBJECTIVE: To determine whether women who frequently bring their neonates for problem-oriented primary care visits or emergency department visits are at elevated risk of having depressive symptoms. DESIGN: Analysis of 2 prospective cohort studies of mothers and their infants: (1) a telephone interview study of mothers and infants after birth at an urban teaching hospital (the hospital cohort) and (2) the 1988 National Maternal and Infant Health Survey, a nationally representative sample of women who had live births in 1988. PARTICIPANTS: A total of 1015 women in the hospital cohort surveyed at 3 and 8 weeks post partum and 6779 women with data from the national survey. MAIN OUTCOME MEASURE: Depressive symptoms above the Center for Epidemiologic Studies Depression Scale cutoff score of 15. RESULTS: After controlling for sociodemographic variables and parity, women exhibited high levels of depressive symptoms if their infants had more than 1 problem-oriented primary care visit (hospital cohort: odds ratio, 2.0 [95% confidence interval, 1.1-4.3]; national survey cohort: odds ratio, 2.0 [95% confidence interval, 1.5-3.0]). Women were more likely to have high levels of depressive symptoms if their infants had even 1 emergency department visit (hospital cohort: odds ratio, 3.2 [95% confidence interval, 1.5-6.9]). Frequent well-child visits were not associated with maternal depressive symptoms. CONCLUSIONS: Neonatal health care use patterns predict women at risk for postpartum depression. Recognition of these signature patterns of service use by pediatric health care providers may facilitate early diagnosis and treatment of postpartum depression and improve outcomes for women and their families.

Prenatal cocaine exposure, child development, and the compromising effects of cumulative risk.

On the whole, the literature suggests that toddlers and young children who are exposed prenatally to cocaine exhibit few, if any, consistent differences in developmental functioning compared with demographically similar, nonexposed, age-matched controls. The paucity of cocaine-related findings does not mean that prenatally cocaine-exposed children are free from developmental problems. Cocaine-exposed infants may well have specific deficits that are masked by confounding factors in study designs; however, more important is the worrisome finding that the average performance of both drug-exposed and nonexposed children in the literature tends to be poorer than expectations for age. This problem likely stems from the fact that most study children in the literature (regardless of exposure status) come from low-income backgrounds and consequently have been exposed to multiple medical and social risk factors associated with long-term poverty. The fact that exposure to multiple risk factors has powerful, compromising effects on children's outcomes may overshadow any specific effects of prenatal cocaine exposure. The problem of high cumulative risk in the literature raises both methodologic and clinical issues. To disentangle the relationship among prenatal cocaine exposure and other comorbid risk factors in predicting children's outcomes, investigators in future studies should recruit samples with varying levels of accumulated risk. This increased range of risk will also permit researchers to evaluate the interaction of exposure status and risk status and identify specific protective factors that may contribute to resilient outcomes for these infants. This information will be helpful in the design and timing of intervention services for these high-risk infants and their families. On a clinical level, when exposed children present for interventional services, professionals must not limit their remedial efforts to drug treatment alone. Rather, clinicians should also view prenatal drug exposure as a possible marker for the presence of multiple medical and social risk factors (e.g., maternal psychopathology, social isolation, child maltreatment, domestic violence, or inadequate caregiving). Because any of these factors may place children in developmental jeopardy, these comorbid risk factors must be considered, together with prenatal drug exposure, and, when possible, treated. Although confronting this wide range of problems may seem overwhelming, many conditions associated with poverty are treatable. Moreover, from the perspective of the cumulative risk model, interventions are most likely to succeed if they attempt to reduce the overall burden of risk rather than targeting single risks.

Gender differences in emotional expressivity and self-regulation during early infancy.

Eighty-one 6-month-old infants and their mothers were videotaped in Tronick's face-to-face still-face paradigm to evaluate gender differences in infant and maternal emotional expressivity and regulation. Male infants had greater difficulty than female infants in maintaining affective regulation during each episode, including the still face. Mother-son dyads had higher synchrony scores than mother-daughter dyads but took longer in repairing interactive errors. In addition, maternal affect, matching, rate of change between matching and mismatching states, and synchrony in the play preceding the still face differentially mediated male and female infants' responses to the still face and reunion play. The developmental implications of these gender differences are discussed.

Emotional characteristics of infants associated with maternal depression and anxiety.

Infants as young as 3 months are able to detect depression in their mothers. Depressed mothers are sufficiently different from nondepressed mothers in affect and interaction that the social, emotional, and cognitive functioning of their infants are compromised. This article reviews current findings on the effects of maternal depression and psychiatric illness on infants.

The impact of maternal psychiatric illness on infant development.

Maternal depression and anxiety are associated with compromises in infant and maternal social and emotional functioning. In this paper, we briefly review the literature on this topic and present some preliminary findings on a group of mothers in treatment for major depressive disorder, panic disorder, or obsessive-compulsive disorder. The findings suggest that the symptom reports of treated mothers with established DSM diagnoses were similar overall to those of control mothers. However, the mothers' psychiatric illness had a compromising effect on their interactions with their infants and on their infants' social and emotional functioning. The implications of these results are discussed.

Non-interpretive mechanisms in psychoanalytic therapy. The 'something more' than interpretation. The Process of Change Study Group.

It is by now generally accepted that something more than interpretation is necessary to bring about therapeutic change. Using an approach based on recent studies of mother-infant interaction and non-linear dynamic systems and their relation to theories of mind, the authors propose that the something more resides in interactional intersubjective process that give rise to what they will call 'implicit relational knowing'. This relational procedural domain is intrapsychically distinct from the symbolic domain. In the analytic relationship it comprises intersubjective moments occurring between patient and analyst that can create new organisations in, or reorganise not only the relationship between the interactants, but more importantly the patient's implicit procedural knowledge, his ways of being with others. The distinct qualities and consequences of these moments (now moments, 'moments of meeting') are modelled and discussed in terms of a sequencing process that they call moving along. Conceptions of the shared implicit relationship, transference and countertransference are discussed within the parameters of this perspective, which is distinguished from other relational theories and self-psychology. In sum, powerful therapeutic action occurs within implicit relational knowledge. They propose that much of what is observed to be lasting therapeutic effect results from such changes in this intersubjective relational domain.

Maternal and infant health: effects of moderate reductions in postpartum length of stay.

BACKGROUND: The Newborns' and Mothers' Health Protection Act of 1996 prohibits payers from restricting "benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours." The law recognizes the basic right of women and physicians to make decisions about aptness of discharge timing. OBJECTIVE: To provide data as a basis for decisions about aptness of discharge timing by studying the effect of voluntary, moderate reductions in length of postpartum hospital stay on an array of maternal and infant health outcomes. DESIGN: A prospective cohort study. Patients were surveyed by telephone at 3 and 8 weeks postpartum. SETTING: A teaching hospital where 38% of the patients are in a managed care health plan with a noncompulsory reduced stay program offering enhanced prepartum and postpartum services, including home visits. PATIENTS: Consecutive mothers discharged after vaginal delivery during a 3-month period. MAIN OUTCOME MEASURES: The outcomes were health services use within 21 days, breast-feeding, depression, sense of competence, and satisfaction with care. Multivariate analyses adjusted for sociodemographic factors, payer status, services, and social support. RESULTS: Of 1364 eligible patients, 1200 (88%) were surveyed at 3 weeks; of these 1200, 1015 (85%) were resurveyed at 8 weeks. The mean length of stay was 41.9 hours (SD, 12.2 hours). Of patients going home in 30 hours or less, 60.8% belonged to a managed care health plan. The length of stay was not related to the outcomes, except that women hospitalized shorter than 48 hours had more emergency department visits than those staying 40 to 48 hours (adjusted odds ratio, 5.78; 95% confidence interval, 1.19-28.05). CONCLUSIONS: When adequate postpartum outpatient care is accessible, a moderately shorter length of postpartum stay after an uncomplicated vaginal delivery had no adverse effect on an array of outcomes. Researchers and policy makers should seek to better define the content of postpartum services necessary for achieving optimal outcomes for women and newborns; funding should be available to provide such services, regardless of the setting in which they are provided.

Elevated plasma norepinephrine after in utero exposure to cocaine and marijuana.

OBJECTIVE: To compare plasma catecholamine concentrations between cocaine-exposed and unexposed term newborns and to determine the relationship between plasma catecholamines and newborn behavior. METHODS: Forty-six newborn infants participating in a prospective study of the neonatal and long-term effects of prenatal cocaine exposure were studied. Based on maternal self-report, maternal urine screening, and infant meconium analysis, 24 infants were classified as cocaine-exposed and 22 as unexposed. Between 24 and 72 hours postpartum, plasma samples for norepinephrine (NE), epinephrine, dopamine, and dihydroxyphenylalanine analysis were obtained. The Neonatal Behavioral Assessment Scale was administered at 1 to 3 days of age and at 2 weeks of age by examiners masked to the drug exposure status of the newborns. RESULTS: The cocaine-exposed newborns had increased plasma NE concentrations when compared to the unexposed infants (geometric mean, 923 pg/mL vs 667 pg/mL). There were no significant differences in plasma epinephrine, dopamine, or dihydroxyphenylalanine concentrations. Analysis for the effect of potential confounding variables revealed that maternal marijuana use was also associated with increased plasma NE, although birth weight, gender, and maternal use of alcohol or cigarettes were not. Geometric mean plasma NE was 1164 pg/mL in those infants with in utero exposure to both cocaine and marijuana compared to 812 pg/mL in those exposed to only cocaine and 667 pg/mL in those exposed to neither. Among the cocaine-exposed infants, plasma NE concentration correlated with an increased score for the depressed cluster (r = .53) and a decreased score for the orientation cluster (r = -.43) of the Neonatal Behavioral Assessment Scale administered at 1 to 3 days of age. Adjusting for marijuana exposure had no effect on these relationships between plasma NE and the depressed and orientation clusters. CONCLUSION: Plasma NE is increased in newborns exposed to cocaine and marijuana. Increased plasma NE is associated with selected neurobehavioral disturbances among cocaine exposed infants at 1 to 3 days of life but not at 2 weeks.

The Neurobehavioral Assessment Scale as an instrument for early long-term prognosis and intervention in major disability in high-risk infants.

Evaluated the hypothesis that more effective prognosis is achieved by assessing the modifiability of infants' reactions than by evaluating the presence or absence of normal/abnormal reactions. To evaluate this hypothesis the Neurobehavioral Assessment Scale (NAS) was developed. The NAS assesses the extent to which infants can change their responses in functional contexts. The NAS was administered to 102 high-risk infants repeatedly over the first 16 months of life. Analysis confirmed that the modifiability of performance was predictive of outcome significantly earlier in development than scoring the same items in terms of their normalcy or abnormalcy.