Candice Franich-Ray

Trauma Reactions in Mothers and Fathers After Their Infant’s Cardiac Surgery

OBJECTIVE To investigate the prevalence and nature of trauma symptoms in mothers and fathers of infants who had cardiac surgery. METHOD Parents of infants who underwent cardiac surgery before 3 months of age were recruited at the time of surgery. 77 mothers and 55 fathers completed the Acute Stress Disorder Scale 1 month after their infant was discharged from hospital. RESULTS 26 of 77 (33.8%) mothers and 10 of 55 (18.2%) fathers satisfied criteria for acute stress disorder. For all symptom clusters, except dissociation, mothers had significantly higher mean scores (and therefore higher levels of symptoms) than did fathers, ps = .01, -.02. 83 percent of parents endorsed at least 1 trauma symptom and 11.4% endorsed only 1 symptom at a clinical level. Symptoms of dissociation were the most commonly endorsed by both parents, with each symptom in that cluster being endorsed at a clinical level by at least 26% of parents. CONCLUSIONS Consistent with our hypotheses, approximately one-third of parents overall, as well as one-third of mothers and close to one-fifth of fathers, experienced trauma symptoms consistent with a diagnosis of acute stress disorder. Most parents experienced at least one symptom at a clinical level, with symptoms of dissociation being the most commonly endorsed symptom cluster. These findings highlight the need for clinical supports for parents.

Early mother-infant relationships after cardiac surgery in infancy

Objective The critical importance of a secure mother-infant attachment relationship for long-term physical and mental health of the child is well established. Our study aim was to explore mothers’ subjective experience of the mother-infant relationship after discharge from hospital following neonatal cardiac surgery. Design Participants were 97 infants who underwent cardiac surgery before the age of 3 months and their mothers. Mothers completed Maternal Postnatal Attachment Scale (MPAS) and Edinburgh Postnatal Depression Scale (EPDS) questionnaires and were interviewed after the infant had been discharged home for 4 weeks. Interviews were analysed using inductive thematic analysis. Results Mean sores on the MPAS were similar to community norms (84.5 (SD 7.2) vs 84.6 (SD 7), p=0.47). 66/91 mothers interviewed described impacts which encompassed four themes; enhanced emotional ties (n=34, 37%), ‘bonding’ difficulties (n=22, 23%), anxiety and worry (n=17, 19%), and caregiving behaviours (n=10, 11%). Mothers who described bonding difficulties had lower MPAS scores (mean 80.6 (SD 10) vs 85.7 (SD 5.7), p=0.0047), were more likely to have a prenatal diagnosis of the cardiac abnormality (OR 2.6, 95% CI 0.89 to 8.9) and higher EPDS score (9.1 (SD 5.3) vs 6.2 (SD 3.9), p=0.01). Higher EPDS scores were associated with lower MPAS scores (r=−0.44, p=0.0001). Conclusions Most mothers report a positive relationship with their infant following cardiac surgery but almost a quarter have difficulties forming a strong emotional tie. Clinical care (including prenatal) of the infant with congenital heart disease requiring surgery should include screening, assessment and appropriate referral for early intervention if mothers are struggling to form a bond with their infant.

Infant cardiac surgery and the father-infant relationship: feelings of strength, strain, and caution.

OBJECTIVE The purpose of this study was to examine the father-infant relationship in infants with congenital heart disease (CHD). METHOD Sixty-three fathers whose infants had cardiac surgery before 3 months of age reported on their attachment relationship with their infant within two months of hospital discharge using both qualitative and quantitative methods. RESULTS Mean scores on the Paternal Postnatal Attachment Scale and scores for patience and tolerance were not different from previously published community norms, ps>.05. Scores for pleasure and interaction (t[50]=-2.383, p=.021, CI: -2.93, -.25) and affection and pride subscale (t[56]=-2.935, p=.005, CI: -1.20, -.23) were significantly lower than community norms. Additionally, 37% of fathers described feeling a strong relationship with their infant whereas 17% reported initial apprehension or condition-specific worry. Fathers with infants who spent fewer days at home prior to admission reported feelings of relationship strain as well as lower pleasure in interaction, affection and pride, patience and tolerance, and overall attachment quality. CONCLUSION Having an infant with CHD affects some father-infant relationships differently than others with some fathers feeling closer to their infant and other fathers feeling reservation about getting too close. One explanation for these differences may be that spending a great deal of time in hospital restricts the number and quality of interactions infants have with their fathers. Opportunities for intervention include clinical psychosocial services encouraging fathers to interact with and provide physical care of their infant, especially if fathers perceive their infant as medically fragile.

A Diagnosis of Denial: How Mental Health Classification Systems Have Struggled to Recognise Family Violence as a Serious Risk Factor in the Development of Mental Health Issues for Infants, Children, Adolescents and Adults

Child and adolescent mental health services (CAMHS) routinely overlook assessing for, and providing treatment to, infants and children living with family violence, despite family violence being declared endemic across the globe. As contemporary neuro-developmental research recognises the harm of being exposed to early relational trauma, key international diagnostic texts such as the DSM-5 and ICD-10 struggle to acknowledge or appreciate the relational complexities inherent in addressing family violence and its impacts during childhood. These key texts directly influence thinking, funding and research imperatives in adult services as well as CAMHS, however, they rarely reference family violence. Their emphasis is to pathologise conditions over exploring causality which may be attributable to relational violence. Consequently, CAMHS can miss important indicators of family violence, misdiagnose disorders and unwittingly, not address unacceptable risks in the child’s caregiving environment. Notwithstanding urgent safety concerns, ongoing exposure to family violence significantly heightens the development of mental illness amongst children. CAMHS providers cannot and should not rely on current diagnostic manuals alone. They need to act now to see family violence as a significant and important risk factor to mental health and to treat its impacts on children before these develop into enduring neurological difficulties.

Relationship between Social-Emotional and Neurodevelopment of 2-Year-Old Children with Congenital Heart Disease

OBJECTIVE The purpose of this study was to describe social-emotional outcomes and the relationship with neurodevelopmental outcomes in a cohort of 2-year-old children who underwent surgery for congenital heart disease (CHD) in infancy, and explore the relationship between the outcomes and parental and surgical factors. DESIGN A two-center prospective cross-sectional cohort study. PATIENTS A cohort of 105 2-year-olds who underwent surgery in infancy for severe CHD MEASURES: Social-emotional and neurodevelopment was evaluated with the Infant and Toddler Social and Emotional Assessment tool (ITSEA), and the Bayley Scales of Infant Toddler Development, Third Edition. RESULTS Neurodevelopment was delayed in the CHD cohort with significantly worse results compared to published Australian-based norms in all domains (P < .001) and in the Cognitive (P < .001) and Language (P < .001) domains with respect to the reported American norms. Social-emotional outcome was similar to Australian norms in all domains but better than the American based norms in the Internalizing domain (P < .05). Higher maternal education was associated to better neurodevelopmental outcome in all domains and better scores in the internalizing and externalizing domains of the ITSEA. There was a moderate correlation (r = 0.43, P < .001) between Language and social-emotional competence. Motor development was influenced by the need for a significant cardiac reoperation. CONCLUSIONS The influences of social factors may be underestimated in the outcome of children with CHD. Language development in those with CHD may be improved with intervention targeting social-emotional competence; further research is needed in this area.

Long-term alteration of the hypothalamic-pituitary-adrenal axis in children undergoing cardiac surgery in the first 6 months of life

Abstract Children with congenital heart disease (CHD) have poorer neurodevelopmental and psychological outcomes. The mechanisms underlying this remain unclear. One mechanism could be that the stressful experience of cardiac surgery early in life influences long-term hypothalamic–pituitary–adrenal (HPA) axis regulation. Dysregulation of the HPA axis has been linked to poorer neurocognitive and psychological outcomes in other study populations. This case–control study aims to compare HPA-axis regulation (circadian rhythm and reactivity) using salivary cortisol in 3- to 5-year-olds with CHD who did and did not have cardiac surgery prior to 6 months of age. Saliva samples for cortisol analysis were collected from preschoolers with CHD (N = 28, Males = 18, Females = 10) over two weekend days, and before and after an echocardiogram. Caregiver education, child age, sex, and cardiac disease severity score were included as confounders. Multilevel analysis (hierarchical linear modeling) was used to analyze the data. The analysis for the cortisol circadian rhythm shows that the early surgery group has a flatter diurnal slope secondary to lower mean weekend morning waking cortisol levels than controls but similar mean bed time values. Multilevel analysis of the stress response to an echocardiogram indicates that the early surgery group has an increased response when compared to the control group. This is the first study to show that cardiac surgery prior to 6 months of age is associated with a different pattern of HPA-axis regulation at 3–5 years of age.