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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




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



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


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


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

www.CHILDstudies.ca


What interferes with maternal sensitivity
What interferes with endocrine & nervous systemsmaternal sensitivity?

Attachment & trauma history

Mental health problems Current

Family violence or Past

Maternal addictions stress

www.CHILDstudies.ca


www.CHILDstudies.ca endocrine & nervous systems


www.CHILDstudies.ca endocrine & nervous systems


www.CHILDstudies.ca endocrine & nervous systems


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 health and development???

↓ 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 health and development???

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


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 Link 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?”Telephone support for depressed mothers

www.CHILDstudies.ca


Exemplar lien moms link
Exemplar: Lien MOMS Link 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?”


Exemplar lien moms link1
Exemplar: Lien MOMS Link 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?”


I have become increasingly 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?”

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

www.CHILDstudies.ca


Hypothalamic pituitary adrenal hpa axis
Hypothalamic-Pituitary Adrenal 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?” (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 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?”

www.CHILDstudies.ca


b=.07, p=.01 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?”

www.CHILDstudies.ca


b=.06, p=.04 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?”

www.CHILDstudies.ca


Hpa axis
HPA Axis 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?”

  • 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 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?”

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


Maternal child 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?”

interaction

quality

regulates infants’

responses to stress

www.CHILDstudies.ca


Apron alberta pregnancy outcomes nutrition study

Fetal Programming of Infant Stress Reactivity 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?”

ApRON(Alberta Pregnancy outcomes & Nutrition Study)

www.CHILDstudies.ca


Questions About: 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?”

● 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)


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


Protective factor? life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

Outcome

Stress & distress

During pregnancy

www.CHILDstudies.ca


Does maternal child interaction life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

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 THINKING life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, Attachment as a marker of relationship quality

www.CHILDstudies.ca


Assessment life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

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” life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,


Secure attachment
Secure attachment life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

Sensitivity and parental availability are key determinants of secure attachment

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


There is no such thing as a baby— life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, Winnicott


What is attachment
What is Attachment? life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

  • 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? life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, 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 survival From Crittenden A&P, 2008

www.CHILDstudies.ca


www.CHILDstudies.ca life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,


www.CHILDstudies.ca life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,


www.CHILDstudies.ca life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,


Insecure life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, attachment

Primary caregiver :

  • Insensitive

  • Disengaged

  • Uninvolved

  • Emotionally flat

  • Controlling

    Infants develop:

  • Self-protective strategies


Insecure attachment infancy
Insecure attachment life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, -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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

  • 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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

(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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

Non-depressed

Depressed

Teti, Gelfand, Messinger, & Isabella (1995)


PPD & attachment: preschoolers life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

Non-Depressed

Depressed

Teti, et al. (1995).


Next Studies: life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, CAN-ATTACH (Canadian attachment network-Action team on triadic attachment and child health)APrON Follow-Up

www.CHILDstudies.ca


www.CHILDstudies.ca life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,


Research question
Research Question life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

  • 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


Questions About: life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

● 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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

  • 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 life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to,

  • 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: life-the air she breaths, the food and drink she consumes, the chemicals she’s exposed to, Nicole.Letourneau

@ucalgary.ca

Thank you!

www.CHILDstudies.ca


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