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Overview

  • Challenges of Parenting
  • Attachment principles
  • Conditions impeding the development of Parenting and Attachment:
    • Perinatal Depression & Anxiety Disorder
    • History of Childhood Sexual Abuse

Challenges of parenting

  • John Bowlby: "To be a successful parent means a lot of very hard work. Looking after a baby or a toddler is a twenty-four-hour-a-day job seven days a week, and often a very worrying one at that. And even if the load lightens a little as children get older, if they are to flourish they still require a lot of time and attention. For many people today these are unpalatable truths. Giving time and attention to children means sacrificing other interests and other activities"
  • Also: "I want also to emphasise that, despite voices to the contrary, looking after babies and young children is no job for a single person. If the job is to be well done and the child’s principal caregiver is not to be too exhausted, the caregiver needs a great deal of assistance"

Physical demands of parenting

Most commonly the caregiver is the mother, but note there are many other people who may be involved (e.g. father, other family members, foster parents)

  • Physiological changes of pregnancy and the postpartum period (body image changes, presence of child changes their psychological view of their role in the world)
  • Time constrictions potentially leading to poor diet and lack of exercise
  • Sleep deprivation

There is no such thing as a normal pregnancy - everyone has troubles (e.g. constipation, heartburn, nausea, etc)

Sleep patterns - first year of life

  • Babies are prone to wake far more than adults, as their average sleep cycles last only 50 minutes, compared to adult’s 90 minute cycles;
  • Babies spend more time in rapid eye movement (REM) sleep, which is thought to be necessary for the extraordinary development happening in their brain. REM sleep is lighter than non-REM sleep, and more easily disrupted;
  • Babies need to be parented to sleep, not just put to sleep. Some babies can be put down while drowsy yet still awake and drift off; others need parental help by being rocked or nursed to sleep; (because of limbic system development)
  • Newborns sleep a lot – typically up to 16 to 17 hours a day. However, most babies don't stay asleep for more than two to four hours at a time, day or night, during the first few weeks of life;
  • All babies wake during the night as part of their normal sleep cycle. They can’t get back to sleep without help. Once a baby knows how to fall back to sleep independently, everyone in the house can enjoy nights of relatively unbroken rest;
  • Somewhere between 4 and 6 months, most babies are capable of sleeping for a stretch of 8 to 12 hours through the night;
  • Nearly 50% of babies under 15 months wake at night

Sleep deprivation (!)

  • aching muscles
  • confusion, memory lapses or loss
  • depression
  • headaches
  • malaise
  • periorbital puffiness
  • increased blood pressure
  • increased cortisol levels
  • irritability
  • obesity - so tired, can't look after themselves or exercise
  • yawning

Therefore mother needs help - to provide a time where the mother knows that no matter what happens, she can sleep. Usually help comes from the mother's mother or from the father.

Social Adjustments demanded of Parents

  • Change of role in the family of origin - the shift from daughter to mother and son to father;
  • Turning toward other women – everybody suddenly turns into a mother in a new mother’s eyes; mother starts to notice other mothers, develop communities with other families
  • Less personal space, more baby space - respecting the infant’s needs takes time. Also feel lonely because you're just looking after the baby, which can't communicate
  • Changes to the couple - seeing each other differently (wife turns into a mother; husband turns into a father); go from a couple to a triangular relationship
  • Finding a new place in society – as a mother;
  • Balancing baby and career; hopefully the mother can stay with the baby for a year
    • Career of the woman will suffer for some good years if the baby is to be looked after properly.

Psychological demand of parenthood

In a sense, a mother has to be borne psychologically much as her baby is born physically. What a woman gives birth to in her mind is not a new human being, but a new identity: the sense of being a mother.


Becoming a mother is accomplished by the labor each woman performs in the landscape of her mind, labor resulting in a motherhood mindset, a deep and private realm of experience.

Psychological Demand of Parenthood Parents are “IT” and their identities are changing

  • The provision of a secure base - parents are their babies’ entire world – more so the mother in the first year of life;
  • Forming new triangles: mother – baby – father; mother – baby – grandmother, the story of a parent’s own upbringing becomes critical!
  • Ensuring baby’s survival – absolute accountability
  • Loving and being loved;
  • Finding altered sensibilities – the news become much more challenging to watch;
  • Accepting the strength of intuition – with a baby, most of the time will be spent in spontaneous activities, requiring mothers to reach blindly into their bag of intuitions and come up with a suitable reaction on the spot...
  • Discovering task ownership
    • “the buck stops here”
    • “on 24/7”
    • “no time off”
  • Mothers become ultra sensitive about seeing anyone else's baby being hurt or separated

A word on Dependence by Winnicott

Two theories to know: 1) Dependence and 2) Attachment theory

It is valuable to recognize the FACT of Dependence. Dependence is real. That babies and children cannot manage own their own is so obvious that the simple facts of dependence are easily lost. It can be said that the story of the growing child is a story of absolute dependence moving steadily through lessening degrees of dependence, and groping towards independence.

A mature child or adult has a kind of independence that is happily mixed in with all sorts of needs, and with love which becomes evident when loss brings about a state of grief.

Baby’s needs take every possible forms and they are not just periodic waves of hunger.

First, there are bodily needs. Perhaps a baby needs to be taken up and put to lie on the other side. Or a baby needs to be warmer, or less enclosed. Or the skin sensitivity needs a softer contact, wool for instance. In this list protection from gross disturbance is taken for granted. Secondly, there are needs of a very subtle kind that can only be met by human contact. Perhaps the baby needs to be involved in the mother’s breathing rhythm, or even to hear or feel the adult heartbeat. Or the smell of the mother or father is needed.

Behind these needs lies the fact that babies are liable to the most severe forms of anxiety that can be imagined. If left for too long (hours, minutes) without familiar and human contact they have experiences which can only be described by such words as:

  • Going to pieces
  • Falling for ever
  • Dying and dying and dying
  • Losing all vestige of hope of the renewal of contacts (as soon as you're out of sight, you don't exist any more; object permanence)

It is an important fact that the majority of babies go through the early stages of dependence without ever having these experiences, and they do this because of the fact that their dependence is recognized and their basic needs are met, and that the mother or mother figure adapts her way of life to these needs.

The thing that ultimately builds up a sense of predictability in the baby is described in terms of the mother’s adaptation to the baby’s needs. This is a matter that is highly complex and difficult to describe in words, and in fact adaptation to the baby’s needs can only be well done, or well enough, by a mother who has temporarily given herself over to the care of her baby. It belongs to the special state that most mothers find themselves in at the end of their nine months’ term, a state in which they are quite naturally oriented to this central thing, the baby, and they know what the baby is feeling like. 


With good care these awful feelings become good experiences, adding up to the total confidence in people and in the world.

  • Going to pieces becomes relaxation and restfulness if a baby is in good hands;
  • Falling for ever becomes the joy in being carried and the excitement and pleasure that belong to being moved;
  • Dying and dying and dying becomes the extraordinary awareness of being alive;
  • Loss of hope in relationships becomes, when dependence is met by consistency, a sense of assurance that even when alone the baby has someone who cares.

When the parents miss out sometimes, this helps the baby grow.

A certain proportion of babies have experienced environmental failure while dependence was a fact, and then, in varying degrees, there is a damage done, damage that can be difficult to repair. At best the baby growing into a child and an adult carries round a buried memory of a disaster that happened to the self, and much time and energy are spent in organizing life so that such pain may not be experienced again...

Attachment behaviour

Any form of behaviour that results in a person attaining or maintaining proximity to some other clearly identified individual who is conceived as better able to cope with the world. It is most obvious whenever the person is frightened, fatigued or sick, and is assuaged by comforting and caregiving. At other times the behaviour is less in evidence.

For a person to know that an attachment figure is available and responsive gives him a strong and pervasive feeling of security, and so encourages him to value and continue the relationship. Whilst attachment behaviour is at its most obvious in early childhood, it can be observed throughout the life cycle, especially in emergencies.

Since it is seen in virtually all human beings, it is regarded as an integral part of human nature. The biological function attributed to it is that of protection. To remain within easy access of a familiar individual known to be ready and willing to come to our aid in an emergency is clearly a good insurance policy – whatever our age.

Attachment Theory – the contribution of John Bowlby

Attachment theory shows how early interpersonal experiences with figures of attachment give the person the experience that there are people who are both a base and a heaven of security.

A second aspect is that negative emotions (anger, sadness and fear) are valued and considered precious communications about internal states and the internal states of others – these emotions are controllable thanks to the help pf those who are there to help the child

This interaction enables the person/child to develop a model of others as worthy to trust and dependable in case of need – as well as develop a sense of self as worthy of interest even at times of distress

Secure attachment

  • Enables the individual to communicate openly about negative emotions;
  • Face up to challenges in life, because the individual has confidence in others, which gives him a sense of personal worth
  • This leads to effective emotional regulation and subtle cognitive strategies, which all offer a choice of adaptive strategies (when the individual is confronted with unsettling negative emotions)

Insecure attachment styles

Someone had this experience enough times in life that it becomes their way to relate to the world (things didn't go well, and this results in an anxious reaction to things).

  • Preoccupied/ anxious – the child is met with an inconsistent caregiver/mother, who is at times sensitive and available and at others absent and insensitive. The result is a state of confusion, guilt, poor self esteem and an inability to tolerate negative emotions, which may look self centered from the outside because the individual is so taken by a struggling internal state.
  • Dismissive – the child’s distress is not treated in a respectful manner, is often dismissed or not even noticed. So the child develops a self reliant, emotionally detached (or cut off), dismissive or denigrating of emotional pain internal coping strategy for stressful times. These people may not even notice when they are distress of experiencing a negative emotion
  • Disorganised – this is related to trauma. The same person who is the attachment figure is also harmful. So the child is often terrified – because there is nothing more terrifying to a child than loosing her attachment figure. These terrifying times are extremely disorganizing and lead to fragmentation and dissociative responses. In other words, dealing with negative emotions become impossible.
    • Trauma - long stretches of absence, parents who are unwell, sexual abuse
      • Child is actually terrified of parent figure, become switched-off, memory losses, go blank in a stressful situation, later in life they binge drink to cut off (dealing with negative emotions has been severely cut off)

Conditions impeding the development of parenting and attachment

Depression and anxiety disorders: the mother is preoccupied therefore not available and attuned to her infant (doesn't have a "baby-centric" thought pattern) Insecure attachment styles (child is then more prone to developing depressive illness - both genetically and because of insecure attachment styles; must be treated by psychotherapy, which has a more lasting impact than medication)
History of trauma: the mother is deeply unable to relate to her baby, because her baby reminds her of her own background, which was emotionally unbearable (baby is unbearable) Disorganised attachment styles

Prevalence and incidence of mental illness in the perinatal period

See Beyondblue guidelines about mental illness

  • Estimates of the prevalence of mental health disorders in the perinatal period vary widely depending on study parameters (Austin & Priest 2005), with results affected by characteristics of the sample (e.g. only first-time mothers), definition and measurement of disorder (e.g. screening tool or diagnostic interview; cut-off score used) and whether point or period prevalence is reported (Buist et al 2008).
  • A large Australian study (n=52,000) (including women from Aboriginal and Torres Strait Islander and non-English speaking backgrounds, rural and regional areas, and the public and private health sectors) found that around 9% of women experienced depression in the antenatal period and 16% in the postnatal period (Buist & Bilszta 2006);
  • in a meta-analysis of 28 international studies, the point prevalence estimates for major and minor depression ranged from 6.5% to 12.9% (1.0% to 5.6% for major depression alone) at different trimesters of pregnancy and months in the first year after the birth, and the period prevalence showed that as many as 19.2% of women had a depressive episode in the first 3 months postpartum (7.1% for major depression) (Gavin et al 2005);
  • in an Australian survey of women assessed postnatally using the EPDS (n=12,361), the point prevalence of women scoring more than 12 varied from 5.6% to 10.2%, depending on the State/Territory in which they were screened and whether they were recruited in public or private health care (e.g. 6.4% versus 3.6% respectively, in WA) (Buist et al 2008);
  • in a recent Australian study (n=1,549), 20.4% of women assessed during late pregnancy and reviewed at 2, 4 and 6–8 months after the birth had an anxiety disorder (approximately two- thirds with comorbid depression) and almost 40% of women with a major depressive episode had a comorbid anxiety disorder (Austin et al 2010);

Antenatal period

  • antenatal depressive symptoms are as common as postnatal symptoms (Austin 2004; Milgrom et al 2008);
  • depression identified postnatally begins antenatally in up to 40% of women (Austin 2004); and
  • anxiety disorders may be as common as depression in the perinatal period (Wenzel et al 2003; Austin & Priest 2005).

Postnatal period

Non-psychotic disorders occurring in the postnatal period include depression, a range of anxiety disorders (including generalised anxiety, phobias, obsessive compulsive disorder and posttraumatic stress disorder [Rogal et al 2007], adjustment disorder, panic disorder and agoraphobia [Matthey et al 2003]). Psychotic disorders such as new onset puerperal psychoses are uncommon but may occur within 2–3 weeks of birth (Cohen & Nonacs 2005). Bipolar disorder may occur during pregnancy or after birth as a first episode or continuation or relapse from an episode before the pregnancy

  • More women fulfill criteria for minor rather than major depression in the postnatal period. However, minor depression often occurs with anxiety and other disorders and a significant number of women who experience minor depression will develop major depression (Austin 2004). Depression experienced postnatally sometimes persists through more than one pregnancy — between 20% and 40% of women with a past episode of depression in the postnatal period will relapse after the birth of a subsequent child (Milgrom et al 1995; Austin & Priest 2005).
  • Complex perinatal presentations frequently include the confounding effects of childhood abuse (Buist et al 2008), drug and/or alcohol abuse (Allen et al 1998) and domestic violence (Bacchus et al 2004; Taft et al 2004).

Impact of mental health disorders in the perinatal period - women

  • Postpartum depressive symptoms combined with extreme fatigue and the additional responsibilities of a new baby can create difficulties in the woman’s close relationships and in her capacity to care for her baby (Priest & Barnett 2008).
  • As well as the suffering associated with compromised mental health, anxiety and depressive disorders are associated with relationship stresses that can lead to a loss of social networks and subsequent isolation if not resolved.
  • Although mental health disorders are a leading cause of indirect maternal mortality, the suicide rate in the first postpartum year is lower than at other times (Boyce & Barton 2007). However, among women with a severe disorder, the risk increases at this time.
  • In the longer term, depression may also have an impact on a woman’s involvement in the workforce and her eligibility for life insurance, travel insurance or income protection insurance.

Impact of mental health disorders in the perinatal period - Infant

  • Parental mental health is universally acknowledged as one of the key determinants for healthy development in infants (Murray & Cooper 2003).
  • It is well-recognised that infant social, psychological, behavioural and cognitive development occurs in the context of a caregiving relationship and that the mother (or primary caregiver) and infant are a unit.
  • When the relationship is good or ‘good enough’, mother and infant are sensitive, responsive and attuned to each other (Winnicott 1960).
  • Attachment theory has increased understanding of the impact of the quality of this relationship on infant brain development and its contribution to later psychological functioning (Bowlby 1969; Fonagy et al 1994; Schore 2001; Siegel 2001; De Bellis et al 2002).
  • During critical periods of brain development, an appropriate caregiving relationship is particularly important (Schore 2001).

Effects on the baby during pregnancy

  • Maternal distress during pregnancy influences obstetric and birth outcomes (Priest & Barnett 2008) and can adversely affect the developing fetal brain and thus influence infant behaviour (Glover & O’Connor 2002). Maternal anxiety is associated with difficult infant temperament (Austin et al 2005a), increased infant cortisol (Grant et al 2009) and behavioural difficulties in childhood (O’Connor et al 2002).
  • Antenatal distress increases risk of attentional deficit/hyperactivity, anxiety, and language delay (Talge et al 2007), and of later mental health problems (O’Connor et al 2002).

Physical effects on the infant

  • Postpartum maternal mental health disorders have an impact on:
    • breastfeeding,
    • infant nutritional status and
    • health and growth rates

Mother–infant attachment

  • Having a caregiver who provides consistent, responsive care helps infants to learn to recognise the nature of their own emotions, and to regulate their own behaviour and emotional states (Bowlby 1951).
  • When the mother is experiencing depression, the mother–infant relationship is more likely to experience difficulties and infants are at increased risk of developing insecure attachment and psychopathology (Murray & Cooper 1996; Misri & Kendrick 2008; Murray 2009; Tronick & Reck 2009). Insecure attachment, role modelling and poorer parenting techniques can lead to poor emotional and behavioural outcomes for children (Murray & Cooper 1997a; 1997b; Buist 1998) and impaired cognitive development (Milgrom et al 2004).

Old notes

Parenting

  • Definition – the parents’ capacity to meet the infant’s physical emotional and social needs
    • Ie: raising a child
    • No qualifications required
    • Normal life experience and a significant event
  • Overwhelming and rewarding
    • Demanding with many responsibilities
  • Parenting is a 2 way relationship
    • Relationship between caregiver and child has a significant role in child outcome
    • Failure of this relationship – insecure attachment, may result in various consequences

Parenting style

  • Determines child development and behaviour
  • 2 models
    • Dimensional
      • Scale between restrictive and permissive; loving and hostile
    • Categorical
      • Permissive – warm, caring, liberal and relaxed about behaviour and discipline
      • Authoritarian-restrictive – highly controlling, less emotionally close, strict, non-negotiable ideas
      • Authoritative – loving, warm, enforces rules and demands achievement

Challenges for infant/mother

  • Birth
    • Infant communication
    • Babies develop attraction to humanbeings
      • Show this by smiling, gurgling • Birth-3 months
    • Infantcomfortsself

o Infantdevelopstrustformother 􏰀 Mother meets basic needs o Aresocial,enjoysocialinteractions • 4-6 months o Indiscriminateattraction–cantellbetweenfamiliarandstrange,smileatfamiliar o Allowcarebystrangers o Reciprocalexchangeswithmother o haveafeeding,sleeping,wakingroutine • Physical development: o Sitwithoutsupport–6months o Standsholdingon–7months,pullstostanding–9months o Turnstoavoice,putsfoodinmouth o Wavesbye-bye–8months • 7 months onwards o Discriminateattachment–havespecificattachments o Separationanxiety 􏰀 Clinginess, important form other to encourage independence o Objectpermanence o Avoidclosenesswithstrangers • 1 year on: o Walk,simplecommands,simplewords:mama,dada,drinksfromcup,fingerfeeds • 1-2 years o Waryofstrangers,sociallyresponsive o Multipleattachments o Tantrums,individualisation  Attachment • Definition: an intense emotional relationship between 2 people that endures through time and causes stress and sorrow with prolonged separation o Anevolvingprocessthatbeginsinpregnancyandstrengthensovernext2years o Occursinallchildrentosomedegree Maternal sensitivity and infant responsiveness • A key determinant in the development of attachment o Sensitivemother: 􏰀 Interprets infants communications, responds to infant’s needs, accepting, cooperating, accessible 􏰀 Promotes secure attachment o Insensitivemother: 􏰀 Interacts on own terms and wishes 􏰀 Promotes insecure attachment • Infant responsiveness – other key determinant in development of attachment o Referstotheabilityoftheinfanttorespondtoandinteractwiththemother o Requiresintactneurodevelopmentalfunction Attachment theory :John Bowlby • Considered attachment of infants to mother as a biological safety mechanism to allow infant to stay close to mother o Fromhere,mothersuppliesabasefromwhichtoexplore o Psychologicaldevelopmentisformedbythisparent-childrelationship • Parent-child relationships are important in the child’s development, personality and future relationships Strange situation experiment: Mary Ainsworth • Examines infant reactions to separation from mother • Method: o Childentersroomwithmotherandplayswithtoys o Strangerentersroomandtriestointeractwithinfant o Motherleavesroom–firstseparation o Strangertriestointeractwithinfant o Motherreturns–firstreunion o Infantisalone,strangerentersandtriestointeract–secondseparation o Motherreturns,strangerleaves–secondreunion • Allows determination of 4 patterns of attachment: o Secureattachment:55-65%normalsamples(normal) 􏰀 Infant uses mother as a base from which to explore 􏰀 Separation doesn’t induce undue stress 􏰀 Reunites actively and positively with mother 􏰀 Prefers mother to stranger o Insecure–avoidantattachment–20-30%ofnormalsamples(selfsufficient,distance) 􏰀 Avoids parents and caregiver 􏰀 Muted distress in absence of mother 􏰀 Minimal response on reunion 􏰀 No preference to stranger or mother o Insecure-ambivalentattachment–5-15%ofnormalsample 􏰀 Suspicious of strangers 􏰀 Extreme distress on separation 􏰀 Resists reunion and distress continues o Disorganisedattachment–10-20%normal,45-80%maltreatingsamples 􏰀 Lack of clear attachment behaviour on separation/reunion with mother 􏰀 Passive, disconnected, dazed 􏰀 Can be confused/apprehensive with mother • Has been both comforted and frightened by mother • Cross-cultural: o Secureattachmentismostcommoneverywhere,othersvary o Needtokeepinmindchild-rearingcustoms  Barriers to optimal parenting/attachment • Postnatal mental illness • History of inadequate parenting • Lack of support • Psychosocial stressors • History of trauma Postnatal mental illness • Parent may not be able to meet the demands on the child and thus can affect bonding and attachment • Types: o Postpartum‘blues’ 􏰀 Majority of new mothers: 50-80% 􏰀 First week after birth to about day 10, transient mood, disturbed sleep, feeling of attachment to baby • No suicidal thoughts, hopelessness, worthlessness • May lead to PND, 􏰀 Care of baby is not impaired o Puerperalpsychosis 􏰀 Psychiatric emergency 􏰀 Uncommon: 1/1000 􏰀 Occurs within 1 month of pregnancy o Postnataldepression 􏰀 Very common. 1/7 women who give birth, many are unrecognised 􏰀 Diagnosis: • 5ormoreina2weekperiodof: o Depressedmood,diminishedinterest/pleasure,appetite,sleepdisturbance, agitation, retardation, drained energy, worthlessness, guilt, decreased concentration, suicidal, thoughts of death 􏰀 Sequelae • Mother: o Untreated,50-70%stilldepressed,6monthslater 􏰀 1⁄4 chronic, 1⁄4 recurrent o Adverseconsequenceonmaternalconfidenceandparentingskills o Oftenresultsininsecureattachment • Infant: o Social,emotional,cognitive,behaviouraldevelopmentimpaired o Attachmentcompromised • Other o Familydisintegration,publiccosts 􏰀 Detection can be hard because: • Mother hides symptoms • Poor sleep is seen as normal 􏰀 Predicting • Antenatal: o Previouspsychiatrictreatment,mentalillness(past,present),familyhistory o Screeninginpregnancyandpostpartum o Triageandmonitor • Edinburgh PND scale o Brief10itemquestionnaire o Notdiagnostic,butidentifiespeoplewhomayneedfurtherassessment