Effects of parental mental illness on infants

Plenary Infants COPMI 1-2 nov Oslo 2010

Karin van Doesum, PhD

Dimence Raboud University Nijmegen

Netherlands

Impact on Infants of Mentally ill parents: Challenges for

interventions

World conference

1 & 2 of November 2010


Deventer Dimence / Radboud University Nijmegen The Netherlands

RBUP Nord Tromsø Norway

Overview

• Impact of parental mental illness on (unborn)

babies

• Risk factors

• Parent-baby interaction in mentally ill

mothers

• Preventive interventions during pregnancy

and early life birth

• Challenges for interventions

• Conclusions

Not about fathers �

Impact of parental MI during pregnancy on child development

• � Cortisol level and heartrithm, brain development

• Lower birth weight

• Complications during delivery

• Prematurity

• Difficulties in temperament

• More ADHD

• � Social- emotional, motoricand cognitive development

(Kinsella & Monk, 2009; Van de Bergh et al., 2005)

Impact on first year of lifeParental mental illness occurs at a time:

- of maximum infant dependency

- when infants are highly sensitive to others’ communication

Parents with mental illness experience difficulties in meeting social and emotional, physical needs of their babies

They might be not directly abusive but show frightening and confusing behavior which leaves the infant disorderly and uncontrolled

‘A baby cannot exist alone: it is

essentially part of relationship’

(Winnicot, 1965)

• Physiologically: ↑ stress-level (cortisolelevations during mother-infant interactions)

• Negative behavior

• Difficult temperament

• Avoiding eye-contact

• Less positive emotions

• 50% insecure attachment relation:avoidant and disorganized attachment pattern

• Brain development: Infants of depressed mothersexhibited reduced left frontal activity (less positive emotions)

• Problems in social-emotional and cognitivedevelopment

• Risk of developing wide range of severe mental disorders

• Often other problems

Impact on first year of lifeWhat kind of transmission mechanism are

playing a role?

• Genetic transmission

• Physiological processes during pregnancy and delivery

• Risk factors during pregnancy and delivery

But central role

Mother – child interaction




Netherlands

Theoretical Model

Early mother-child

interaction- Quality of m-c interaction

- Parental competence:

- Sensitivity, structuring,

emotional availability

Contextual stress and supportContextual stress and supportSocial stressors: marital discord, economic disadvantage, life-events

Social support: from spouse, family, friends, professionals

Long-term

health

outcomes

Healthy

development

Maladaptation

Behavioral

problems

Child Child Innate characteristics Innate characteristics -- temperament

- gender

- genetic features

- neurobiological features

Demographic feature- age

Developmental Developmental

outcomesoutcomesVulnerabilities:

- Insecure attachment

- Impaired development:

cognitive delays

Coping abilities:

- Secure attachment

- IQ: cognitive competence

- Psychobiological dev.

Genetic mechanism

Neurobiological mechanism

Characteristics of MI Characteristics of MI

mothermother-- Symptoms

- Cognitions, feelings of

parental incompetence

- Severity, chronic, onset

- Comorbidity

- Personality / education

- Timing

In pregnancy:Stress, smoking,

complications delivery

© Van Doesum, Hosman & Riksen-Walraven

What does an infant need?

• Security

• Communication

• Relationship / bonding

• Autonomy

• Self esteem and self expression

• Realistic limits setting

Best opportunity: quality of the parent-child interaction

by improving parental sensitivity, structuring and

cooperation

Depressed mothers interactionDepressed mothers interaction

• show sad and flat affect

• are more anxious, less sensitive,

uninvolved

• speak less frequent with their child

• communicate more negative

(irritated, angry)

• give less structure and use less

discipline

(o.a. Albright & Tamis-Lemonda, 2002; Field, 1984, 1998;

Murray et al. 1996; Teti et al. 1995; Murray & Cooper,

1997 , 2009 Radke-Yarrow, 1990)

Maternal anxiety disorder

Often comorbid with depression

• Overcontrol /involvement /protection

• Negativity

• Talk too much but not to the child

• Unavailable for their child

• Obsessional thoughts about their babies health

and cleanliness

• Problems in sharing the responsibility of the child

Mothers with borderlinepersonality disorder

• Less sensitive

• Poorly attuned

• Lack of responsivity

• More intrusive

• Less structure

o Babies are les well social and emotionally organized

o High risk for disorganized attachment

Mothers with psychotic disorder

• Emotional unavailable

• Ignores emotional needs of the infant

• Unpredictable behavior

• Offer no structure

• Sometimes unsafe for the child because of

there distorted ideas, images.

• Anti-psychotic medication may supress their

sensitivity towards the child




Netherlands

What can we do? Opportunities for early preventive interventions

Health care: midwives, gyneacologist, public health nurse

Mental health care: psychiatrist, therapist, social work

Programs:

stressmanagement,

support, information

Parent-baby programs,

supportgroups, parent-infant

therapy

Healthy pregnancyand brain development

Low stress

Time

in mts - 9 0 12

Secure attachment

Healthy development

POP-poli paediatrician,

gynaecologist, psychologist

screen pregnant women for MI

Home-visiting programs for high risk families

Interventions during pregnancy

• Early detection of mental disorders in(pregnant) mothers and early treatment

• Healthy pregnancy promotion and intervention : psycho-education, social support, stressmanagement, relaxation

f.e Program for pregnant MI women: ‘Zwanger en dan?’(Dimence NL) Mothers and babies program (Muňoz,2007)

• During pregnancy and delivery interdisplinary cooperation (gynaecologist, midwives, psychiatrist, public health service for young children) in NL : POP-poli

• Good enough parenting in disadvantaged families; Nurse-Family Partnership program for teenage mothers (Olds, 2004 )

Number of effect studies is small

Parent-baby intervention

Brok & Van Doesum

Aim

Improve the quality of the parent-child interaction : maternal

sensitivity and secure attachment

Targetgroup

Mentally ill parents (mostly mothers) who have treatment for their mental health problems and have baby until 12 months

Home-visits: 8 -10 times

Strategy : tailored to needs, early intervention, home visits, improving social support

Methods

• Video feedback: - improve positive interactions- stimulate new positive interactions

• cognitive restructuring

• practical pedagogical support

• modeling

• baby massage

The treatment of the mother is separated from the home-visiting service

Father is always involved

Parent-baby intervention

Brok & Van Doesum

Positive effect on m-c interaction and

attachment and social emotional

competence 6 mts after the intervention

(Van Doesum, Riksen-Walraven, Hosman

& Hoefnagels, 2008)

Interventions for MI parents and infants

Effectstudies available for depressed mothers and

babies

• Improving parent-baby interaction in depressed

mothers: maternal sensitivity and attachment:

- mother-baby intervention / mother-infant therapy (van Doesum, 2008; Gelfand,1996; Clark et al 2003 etc )

• Treatment of the mental ill parent.

• Group interventions for mother-babies

• Infant massage

No effect research (yet) on interventions for mothers with

other mental disorders

Aims

• Short-term effectiveness of preventive interventions in

enhancing depressed mothers’ sensitivity toward their child

• What type of intervention is most effective?

Studies:

13 interventions, reported

in 10 controlled outcome studies

Meta-analysis Improving maternal sensitvity in depressed mothers

Kersten-Alvarez et al in press 2011




Netherlands

• Meta-analytic results showed a small to medium, significant

mean effect size with large variation in individual effect sizes.

• Interventions including baby massage were highly effective in

improving maternal sensitivity.

• In contrast, individual therapy for the mother proved

ineffective in terms of improving maternal sensitivity.

• Two other significant predictors: greater effect sizes were the

inclusion of a support group and the use of a higher number

of intervention methods

Meta-analysis

• Preventive interventions for MI mothers and babies: improving m-b interaction: including baby-massage, support group and more than 1 method

• Make combinations of programs during pregnancy and after delivery, or programs for high risk groups: f.e David Olds programs including mother-baby intervention.

• Make care plans in cooperation between agency’s

• More effect studies needed including combination of interventions and chains of interventions

• Further development: programs for pregnant women with MI

• The fathers? As I said important there is more knowlegdeavailable

Challenges for Interventions and research

Next conference?

What’s in a Smile?Maternal Brain Response to Infant CuesStrateheart, Li, Fonagy & Montague, 2008

• Responses of mother’s brain to her own infant’s facial expressions

• Dopaminmergic reward-related brain regions were activated specially in reponse to happy infant faces (pictures)

• This give some insight in the neural basis of mother-infant attachment

• Title of this study in Dutch newspapers:

Mothers Get High On Baby Smiles

Effects of parental mental illness on infants

Health & Medicine

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