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Nicole Letourneau PhD RN Professor & Norlien/ACHF Chair in Parent-Infant Mental Health Faculties of Nursing & Medicine (Pediatrics). Child Health Intervention and Longitudinal Development Studies (CHILD) Research Program. March 8, 2013 Eyes High Research Series. www.CHILDstudies.ca.

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Child health intervention and longitudinal development studies child research program

Nicole Letourneau PhD RN

Professor & Norlien/ACHF Chair in Parent-Infant Mental Health

Faculties of Nursing & Medicine (Pediatrics)

Child Health Intervention and Longitudinal Development Studies (CHILD) Research Program

March 8, 2013

Eyes High Research Series

www.CHILDstudies.ca


Overview

Overview

CHILD Studies Program

Next Steps

  • Attachment Intervention for vulnerable/

  • disadvantaged families

  • Birth cohort follow-up on relationship of parental stress & distress on children’s neurodevelopment

  • Parenting, social support & child development

  • Community–based intervention research

  • Exemplar studies

    • Lien MOMS Link

    • Fetal Programming

www.CHILDstudies.ca


Child studies program parent infant relationships determinants of health

CHILD Studies Programparent-infant relationships &determinants of health

www.CHILDstudies.ca


Child objectives

CHILD Objectives

  • Develop and test parent support interventions to promote healthy infant/child development;

  • Conduct secondary analysis of longitudinal cohorts and systematic reviews to uncover intervention targets to promote children’s healthy development;

  • Conduct community-based research methods (integrated knowledge transfer).

www.CHILDstudies.ca


Social determinants of health

Social determinants of health

  • Early childhood development

  • Income and social status

  • Education and literacy

  • Social support networks

  • Biology and genetics

  • Employment, working conditions, and occupational health

  • Physical environment

  • Individual and public health services

  • Gender & culture

  • Personal health practices

Public Health Agency of Canada, 2010

www.CHILDstudies.ca


Social determinants of health1

Healthy child

development

Parenting

Social support

Social determinants of health

  • Healthy child development

  • Social support

  • Health services interwoven

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Optimal parent-infant interaction is characterized by:

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Assessment

Intervention

Outcome

Resiliency

Risk

Factors

Protective

Factors

-Infant/child characteristics (e.g. temperament, chronic conditions)

-Parental health (e.g. depression, chronic health conditions)

-Adolescent parenting

-Low education

-Poverty

-Lack of maternal support

-Intimate partner violence

Cognitive Development

High-Quality Parent-

Infant/Child Interaction

Behavioural Development

Social Support

Figure 1. Clinical Model of Parent-Child Interaction

(adapted from Letourneau, 1997).

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


States of arousal

States of arousal

  • Flooded (e.g. crying)

  • Hyper-alert (e.g. fussy)

  • Calmly focused & alert

  • Hypo-alert

  • Drowsy

  • Asleep

www.CHILDstudies.ca


Maternal child interaction self regulation

Maternal-child interaction &self-regulation

Critical aspect of regulating a baby’s states involves modulating the intensity of stimulus to engage and sustain the baby’s attention i.e not trigger the impulse to cry, avert gaze, or shut down.

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Adult sensitivity is any pattern of behavior that pleases the infant and increases the infant’s comfort and attentiveness and reduces its distress and/or disengagement. (Crittenden, 2011)

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Mothers are “hidden” regulators of their infants’ endocrine & nervous systems

www.CHILDstudies.ca


What interferes with maternal sensitivity

What interferes with maternal sensitivity?

Attachment & trauma history

Mental health problemsCurrent

Family violenceor Past

Maternal addictionsstress

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

How does stress and adversity get under the skin to affect health and development???

www.CHILDstudies.ca


Depressed mothers

negative perceptions of normal infant behavior

↓ likely to pick up on infants’ cues or respond to needs

↓ emotionally expressive

↓ affectionate and ↑anxious

↓ sensitive and appropriate interactions

↑ negative in their play

speak more slowly and ↓ often

Depressed mothers

www.CHILDstudies.ca


Relationships with infants

Relationships with infants

PPD ↓ maternal-child interaction quality and enjoyment in maternal role--moderate to large effect (Beck, 1995; Murray et al. 2003)

Disturbances in mother-child interactions are observed at one year postpartum, even when mothers are no longer depressed.

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

When I tried to encourage some social interaction with her newborn, Stephanie would respond that she often just stared at Emma. While other relatives laughed and cooed to the baby, Stephanie claimed that she did not know how and had no desire to do that. Some of her responses were “ I don’t know what to say”, “Is it bad that I just stare at her?” and “Am I being a bad mother?”

From Zauderer (2008)

www.CHILDstudies.ca


Lien moms link telephone support for depressed mothers

Lien MOMS LinkTelephone support for depressed mothers

www.CHILDstudies.ca


Exemplar lien moms link

Exemplar: Lien MOMS Link


Exemplar lien moms link1

Exemplar: Lien MOMS Link


Child health intervention and longitudinal development studies child research program

I have become increasingly

interested in HOW maternal-infant interaction relates to better outcomes in children

www.CHILDstudies.ca


Hypothalamic pituitary adrenal hpa axis

Hypothalamic-Pituitary Adrenal (HPA) Axis

Cortisol is secreted by the adrenal cortex via pulsations that follow a 24-hour (diurnal) circadian profile (Hellhammer, 2009)

  • Stressors (like PPD) stimulate the activation of the HPA which triggers the release of the steroid hormone cortisol from the adrenal gland (Essex, 2002)

www.CHILDstudies.ca


Diurnal rhythm

Diurnal Rhythm

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

b=.07, p=.01

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

b=.06, p=.04

www.CHILDstudies.ca


Hpa axis

HPA Axis

  • Sensitive periods of enhanced brain plasticity

    vulnerable to long-term effects of cortisol

  • Over-activation of the HPA system related to:

    • decreases in brain volume

    • inhibition of neurogenesis

    • disruption of neuronal plasticity

    • abnormal synaptic connectivity

      (Gunnar, 2009)

www.CHILDstudies.ca


Hpa axis1

HPA Axis

Prolonged exposure to elevated levels of cortisol predict:

  • increased insulin resistance & obesity

  • diminished immune responses

  • reduced cognition, memory

  • fear behaviours, hypervigilance

  • attention deficits, behavioural problems

  • disturbances with emotional regulation & self control (Essex, 2002, Gunnar, 1998)

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Maternal child

interaction

quality

regulates infants’

responses to stress

www.CHILDstudies.ca


Apron alberta pregnancy outcomes nutrition study

Fetal Programming of Infant Stress Reactivity

ApRON(Alberta Pregnancy outcomes & Nutrition Study)

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Questions About:

● Diet & activity

● Mental & physical health

● Medical history

● Biological fathers

Questions About

● Infant health & development

● Maternal mental & physical

health

● Infant/child feeding

● Maternal diet & activity

1st Trimester 2nd Trimester 3rd Trimester 3 months 6 1 2 3

(1-13 weeks) (14-26 weeks) (27-42 weeks) post partum months year years years

Extended knowledge transfer work & potential future follow-up

Delivery

Physical Measurements

● Maternal nutrient status (blood)

● Prenatal & delivery records

● Child neurocognitive assessment (age 3)

● Child DNA (at 3 months only)

● Maternal and child anthropometrics

● Breast milk analysis

Physical

Measurements

● Maternal nutrient

status (blood)

● Maternal urine (18 wks)

● Anthropometrics

● Maternal & Paternal DNA

(once)


Child health intervention and longitudinal development studies child research program

Much of what a pregnant woman encounters in her daily life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, even the emotions she feels-is shared in some fashion with her fetus. The fetus incorporates these offerings into its own body and makes them part of its flesh and blood.

Annie Murphy Paul

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Protective factor?

Outcome

Stress & distress

During pregnancy

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Child health intervention and longitudinal development studies child research program

Does maternal child interaction

quality operate to help the

growing infant cope with stress

before they are physiologically

mature?

Can mci overcome the effects

of exposure to prenatal stress &

distress?

www.CHILDstudies.ca


Next steps emerging thinking attachment as a marker of relationship quality

Next Steps: EMERGING THINKINGAttachment as a marker of relationship quality

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Assessment

Intervention

Outcome

Resiliency

Risk

Factors

Protective

Factors

-Infant/child characteristics (e.g. temperament, chronic conditions)

-Parental health (e.g. depression, chronic health conditions)

-Adolescent parenting

-Low education

-Poverty

-Lack of maternal support

-Intimate partner violence

Cognitive Development

High-Quality Parent-

Infant/Child Interaction

Behavioural Development

Social Support

Figure 1. Clinical Model of Parent-Child Interaction

(adapted from Letourneau, 1997).


Today s thinking

Intervention

Evaluation/Outcomes

Assessment

Risk

Factors

Protective

Factors

Resiliency

Cognitive Ability

Language Ability

Toxic Stress:

-Parental

depression

-Family violence

-Addictions

High-Quality Parent-

Infant Interaction

Attachment

Security

Social-emotional

development

Today’s thinking…

Social Support

Physical health

-stress reactivity

-immune health

Reflective Function


Not what i mean by attachment

Not what I mean by “attachment”


Secure attachment

Secure attachment

Sensitivity and parental availability are key determinants of secure attachment

(Cassidy & Shaver, 1999; Trapolini et al., 2007)


Child health intervention and longitudinal development studies child research program

There is no such thing as a baby—Winnicott


What is attachment

What is Attachment?

  • The pattern of a specific relationship

  • A self-protective strategy

  • 4 patterns—Types A, B, C & D (A/C)

  • Type B infants are securely attached

    Pattern reflects whether children feel secure in the availability and responsiveness of caregivers

    Bowlby, 1988; Ainsworth, 1978; Crittenden, 2005


Why these strategies

Why these strategies?

Type A minimize awareness of feelings and do what will be reinforced and to avoid doing what will be punished—disorders of inhibition and compulsion.

E.g a child responded to negatively each time she cries may develop a Type A strategy.

Type C focus on feelings as guides to behaviour—disorders of anxiety and obsessiveness tied to too great a reliance on negative affect.

E.g. a child who is ignored by a passive parent unless acts out may develop Type C strategy

www.CHILDstudies.ca


What is an attachment figure

What is an Attachment Figure?

  • Protection and comfort

  • Person who is there when you need…

  • Long-term intimate, reciprocal relationship

  • Affectively charged

  • Person-specific

  • Basis for physical and psychological survivalFrom Crittenden A&P, 2008

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

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Child health intervention and longitudinal development studies child research program

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Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Insecureattachment

Primary caregiver :

  • Insensitive

  • Disengaged

  • Uninvolved

  • Emotionally flat

  • Controlling

    Infants develop:

  • Self-protective strategies


Insecure attachment infancy

Insecure attachment-infancy

Cassidy & Shaver, Handbook of Attachment

Avoidant:

  • Show signs of ignoring, looking or turning away from caregiver

  • make no effort to maintain contact with caregiver

    Ambivalent:

  • Seek contact with caregiver then resist contact angrily once achieved


Attachment development

Attachment & development

Over the lifespan, insecure attachment is associated with:

  • Problems with intimacy and affection

  • Trust issues

  • Low self-esteem

  • Difficulty maintaining relationships

  • Behavioural, academic and mental health problems


Danger is the problem

Danger is the problem

  • Insecure attachment is not the problem…danger is the problem

  • Anxious/insecure attachment is the solution

Anxious/insecure attachment is the child’s strategy for eliciting protection and comfort from the parent.


Attachment

Attachment

(Ainsworth; Crittenden; Main)

  • Type A (Insecure-Avoidant; 10-20%)

  • Type B (Secure; 65%)

  • Type C (Insecure-Ambivalent; 10-15%)

  • Type D (Disorganized-drawn from A&C; 0-15%)


Ppd attachment infancy

PPD & attachment: infancy

Non-depressed

Depressed

Teti, Gelfand, Messinger, & Isabella (1995)


Child health intervention and longitudinal development studies child research program

PPD & attachment: preschoolers

Non-Depressed

Depressed

Teti, et al. (1995).


Child health intervention and longitudinal development studies child research program

Next Studies:CAN-ATTACH (Canadian attachment network-Action team on triadic attachment and child health)APrON Follow-Up

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

www.CHILDstudies.ca


Research question

Research Question

  • What is the effect of parenting support intervention for families affected by toxic stress (depression, violence, addictions) on

    • attachment security

    • infant health

    • neurodevelopment?

www.CHILDstudies.ca


Child health intervention and longitudinal development studies child research program

Questions About:

● Diet & activity

● Mental & physical health

● Medical history

● Biological fathers

Questions About

● Infant health & development

● Maternal mental & physical

health

● Infant/child feeding

● Maternal diet & activity

1st Trimester 2nd Trimester 3rd Trimester 3 months 6 1 2 3

(1-13 weeks) (14-26 weeks) (27-42 weeks) post partum months year years years

Extended knowledge transfer work & potential future follow-up

Delivery

Physical Measurements

● Maternal nutrient status (blood)

● Prenatal & delivery records

● Child neurocognitive assessment (age 3)

● Child DNA (at 3 months only)

● Maternal and child anthropometrics

● Breast milk analysis

Physical

Measurements

● Maternal nutrient

status (blood)

● Maternal urine (18 wks)

● Anthropometrics

● Maternal & Paternal DNA

(once)


Research question1

Research Question

  • What is the relationship between parental depression (mother, father, both) timing (prenatal, postpartum), duration (acute, chronic) on infant’s health and neurodevelopment?

  • Does parent-child interaction quality and attachment moderate the relationship between depression and child outcome?

www.CHILDstudies.ca


Acknowledgements

Acknowledgements

  • Funders: CIHR, SSHRC, CIFAR, ACHF, Norlien Foundation, NCE AllerGen, CLLRNET, NIH, Province of NB, NBHRF, AIHS

  • Co-investigators: C. Dennis, G. Giesbrecht, B. Kaplan, D. Dewey, T. Campbell, L. Duffett-Leger, M . Stewart, K. & M. Pruett, N. Suchman, L. Strathearn, F. McMaster & others

  • Community partners: especially CUPS, Sykes Telecare, Peel Public Heath, Dept. of Health GNB, RESOLVE partners and so many others

  • Students & Staff: P Tryphonopolous, M. Hart, P. Khatavkar, J. Phillips, J. Colpitts, B. Watson, S. Bhogal, J. Joschko, C. Vanderploeg, L. Pollock, L. Anis, and so many others


Thank you

Email: Nicole.Letourneau

@ucalgary.ca

Thank you!

www.CHILDstudies.ca


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