Diane Holditch-Davis

Depressive symptoms in mothers of prematurely born infants

Objective: This longitudinal, descriptive study described the level of depressive symptoms in mothers of preterm infants from birth through 27 months corrected age and examined factors associated with depressive symptoms. The framework for the study was guided by an ecological developmental systems perspective and an adaptation of the Preterm Parental Distress Model. Methods: In this model, we hypothesize that a mothers emotional distress to the birth and parenting of a prematurely born child is influenced by personal and family factors, severity of the infants health status, and illness-related stress and worry. Participants were 102 mothers of preterm infants who were off the ventilator and not otherwise dependent on major technology at enrollment. Results: Mean depressive symptoms scores on the Center for Epidemiologic Studies Depression Scale (CES-D) during hospitalization were high and more than half the mothers (63%) had scores of ≥16 indicating risk of depression. Depressive scores declined over time until 6 months and then were fairly stable. Unmarried mothers, mothers of infants who were rehospitalized, and mothers who reported more maternal role alteration stress during hospitalization and worry about the childs health had more depressive symptoms through the first year. Mothers who reported more parental role alteration stress during hospitalization (odds ratio [OR] = 1.570, 95% confidence interval [CI]: 1.171–2.104) and more worry about the childs health (OR = 2.350, 95% CI: 1.842–2.998) were more likely to experience elevated CES-D scores that put them at risk of depression. Also, mothers of rehospitalized infants had decreasing odds of elevated CES-D scores over time (OR = 0.982 per week, 95% CI: 0.968–0.996). Conclusions: Findings have implications for the support of mothers during hospitalization and in the early years of parenting a preterm infant.

Mothers' stories about their experiences in the neonatal intensive care unit.

The purpose of this article is to let mothers tell the stories of their neonatal intensive care unit (NICU) experiences and to determine how well these experiences fit the Preterm Parental Distress Model. Interviews were conducted with 31 mothers when their infants were six months of age corrected for prematurity and were analyzed using the conceptual model as a framework. The analysis verified the presence in the data of the six major sources of stress indicated in the Preterm Parental Distress Model: (1) pre-existing and concurrent personal and family factors, (2) prenatal and perinatal experiences, (3) infant illness, treatments, and appearance in the NICU, (4) concerns about the infant’s outcomes, (5) loss of the parental role, and (6) health care providers. The study indicates that health care providers, and especially nurses, can have a major role in reducing parental distress by maintaining ongoing communication with parents and providing competent care for their infants.

Parenting the prematurely born child: Pathways of influence

Recognizing the importance of parents in the lives of preterm infants, investigators and clinicians have increasingly focused on the needs of parents during the period when their infant is hospitalized in a neonatal intensive care unit and the impact of this experience on their subsequent parenting. The purpose of this report is to summarize research findings from over two decades of research, present a framework for understanding the various influences on parents of prematurely-born children, and suggest clinical interventions that are important in helping parents both in the hospital and after discharge.

Distress and growth outcomes in mothers of medically fragile infants.

BACKGROUND With recent advances in medical and nursing care, many high-risk infants are surviving the neonatal period with severe, life-threatening chronic illnesses, resulting in extended hospitalizations and/or frequent rehospitalizations and long periods of dependence on technology for survival. OBJECTIVE To describe the factors predicting maternal adjustment in mothers caring for medically fragile infants. METHOD Subjects were mothers (n = 67) whose infants had a serious life-threatening illness requiring hospitalization and technology for survival. Data for this longitudinal study were collected at enrollment and hospital discharge, and at 6, 12, and 16 months after birth. Distress was measured as depressive symptoms using the Center for Epidemiologic Studies Depression Scale, and growth was assessed using a personal developmental impact rating scale. Data about personal characteristics, parental role attainment, infant-illness characteristics, and maternal illness distress were collected. RESULTS Mothers of medically fragile infants experience distress and growth as a result of their childs illness. Mean scores on the depression scale at both time points were moderately high and a high percentage of mothers scored at risk for depressive symptoms. Maternal developmental impact ratings at 6 months were neutral to slightly negative and at 16 months were between neutral and positive. While the mean depressive symptom scores and maternal developmental ratings were lower at the later time points, these differences were not significant. Maternal depressive symptoms and developmental impact ratings were moderately but negatively correlated at 6 and 16 months, indicating that higher depressive symptoms were related to more negative developmental impact ratings. Distress was influenced by maternal characteristics, hospital environmental stress, and worry about the childs health. Growth was influenced by characteristics of the childs illness, hospital environmental stress, concern about the childs health, and level of maternal role attainment. CONCLUSIONS Nurses should consider personal characteristics and level of parental role attainment as well as characteristics of the child and illness-related distress in their approaches to intervention with mothers of critically ill infants.

Patterns of distress in African-American mothers of preterm infants.

Objective: To examine inter-relationships among stress due to infant appearance and behavior in the neonatal intensive care unit (NICU), parental role alteration stress in the NICU, depressive symptoms, state anxiety, posttraumatic stress symptoms, and daily hassles exhibited by African-American mothers of preterm infants and to determine whether there were subgroups of mothers based on patterns of psychological distress. Method: One hundred seventy-seven African-American mothers completed questionnaires on their psychological distress at enrollment during infant hospitalization and 2, 6, 12, 18, and 24 months after term. Results: Psychological distress measures were intercorrelated. There were four latent classes of mothers: the low distress class with low scores on all measures; the high NICU-related stress class with high infant appearance and parental role stress and moderate scores on other measures; the high depressive symptoms class with high depressive symptoms and state anxiety and moderately elevated scores on NICU-related stress and posttraumatic stress symptoms; the extreme distress class with the highest means on all measures. Infants in the high stress class were sicker than infants in the other classes. The extreme distress class mothers averaged the lowest educational level. The classes differed on distress measures, worry about the child, and parenting stress through 24 months with the extreme distress class having the highest values. Conclusion: Although different types of maternal psychological distress were substantially related, there were distinct subgroups of mothers that were identifiable in the NICU. Moreover, these subgroups continued to differ on trajectories of distress and on their perceptions of the infants and parenting through 24 months after term.

Neurophysiologic assessment of brain maturation after an 8-week trial of skin-to-skin contact on preterm infants

OBJECTIVE Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Analyses of EEG-sleep studies can compare functional brain maturation between SSC and non-SSC cohorts. METHODS Sixteen EEG-sleep studies were performed on eight preterm infants who received 8 weeks of SSC, and compared with two non-SSC cohorts at term (N=126), a preterm group corrected to term age and a full-term group. Seven linear and two complexity measures were compared (Mann-Whitney U test comparisons p<.05). RESULTS Fewer REMs, more quiet sleep, increased respiratory regularity, longer cycles, and less spectral beta were noted for SSC preterm infants compared with both control cohorts. Fewer REMs, greater arousals and more quiet sleep were noted for SSC infants compared with the non-SSC preterms at term. Three right hemispheric regions had greater complexity in the SSC group. Discriminant analysis showed that the SSC cohort was closer to the non-SSC full-term cohort. CONCLUSIONS Skin-to-skin contact accelerates brain maturation in healthy preterm infants compared with two groups without SSC. SIGNIFICANCE Combined use of linear and complexity analysis strategies offer complementary information regarding altered neuronal functions after developmental care interventions. Such analyses may be helpful to assess other neuroprotection strategies.

The development of sleeping and waking states in high-risk preterm infants☆

Abstract This study examined the development of sleeping and waking states in high-risk preterm infants. Thirty-seven preterm infants were observed from 7 p.m. to 11 p.m. weekly from the time their conditions were no longer critical until term age or hospital discharge. An average of 3.6 observations was conducted on each infant between 29 and 39 weeks conceptional age (CA). During the observations, the occurrence of eight sleep-wake states was recorded every 10 s. The intensity of rapid eye movements in active sleep and the regularity of respiration in quiet sleep were also rated. Similar state patterns were found at all ages, with active sleep the most frequent state, quiet sleep the second most frequent, and drowsiness and sleep-wake transition third and fourth. Waking states made up only small percentages of the observations at every age. Despite these similarities, four states exhibited significant changes over age: the amount of active sleep decreased, and fuss, cry, and quiet sleep increased. The organization of the sleep states also increased, as evidenced by an increase in the percent of active sleep with rapid eye movements and an increase in the regularity of respiration in quiet sleep. The severity of illness experienced by the infants had only minor effects on these patterns. These findings demonstrate that even high-risk infants show behavioral states by 29 weeks CA and that considerable state development occurs over the preterm period. Additional research is needed to determine the effects of time of day, caregiving environments, and specific insults on state development.

Cyclicity of Neonatal Sleep Behaviors at 25 to 30 Weeks' Postconceptional Age

Previous sleep studies of preterm neonates describe the rudimentary expression of sleep state cyclicity after 30 wk postconceptional age (PCA), with stability over multiple cycles only after 36 wk PCA. The research objective for this study was to determine whether sleep state cyclicity was expressed in neonates of 25–30 wk PCA, using two criteria for state identification. Our neonatal sleep consortium includes a total cohort of 359 children who were healthy and medically ill neonates who were recruited from three obstetric-neonatal services and received multiple-hour EEG sleep studies. A subset of the 33 youngest preterm infants were selected to evaluate the first of serial 2- to 3-h EEG-sleep recordings to assess the presence of sleep state cyclicity. One neonatal neurophysiologist visually assigned EEG-sleep characteristics for each record. Rapid eye movement (REM) counts and EEG discontinuity were specifically chosen to assess whether sleep cyclicity was expressed. A combined measure of REM and EEG discontinuity were used in an autocovariance analysis to assess cycling and mean cycle duration. A mean cycle duration of 68 ± 19 min with a range of 37–100 min was determined from the REM-EEG discontinuity state for 24 neonates. The remaining nine infants had absent or poor sleep cyclicity. Sleep state cyclicity is expressed for a majority of neonates between 25 and 30 wk PCA, reflecting an ultradian biologic rhythm during the early perinatal stage of brain development.

Personal, family, and health-related correlates of depressive symptoms in mothers with HIV.

This study examined longitudinally depressive symptoms in 54 HIV-infected mothers with infants. The contribution of selected personal and family characteristics and health-related factors to depressive symptoms also was explored. Most of the women were single and African American, and most were on public assistance. Data were collected when the infants were approximately 3, 6, and 12 months of age. About a third of the mothers were at risk for depression, as indicated by Center for Epidemiologic Studies Depression Scale scores above the cutoff. The best predictors of depressive symptoms were feelings of stigma, self-perceptions of health, and physical symptoms, all factors associated with HIV. The findings have implications for helping HIV-infected mothers with depressive symptoms and stigma related to HIV.

An HIV self-care symptom management intervention for African American mothers.

BackgroundHuman immunodeficiency virus (HIV) infection has become a serious health problem for low-income African American women in their childbearing years. Interventions that help them cope with feelings about having HIV and increase their understanding of HIV as a chronic disease in which self-care practices, regular health visits, and medications can improve the quality of life can lead to better health outcomes. ObjectiveThis study aimed to determine the efficacy of an HIV self-care symptom management intervention for emotional distress and perceptions of health among low-income African American mothers with HIV. MethodWomen caregivers of young children were randomly assigned to self-care symptom management intervention or usual care. The intervention, based on a conceptual model related to HIV in African American women, involved six home visits by registered nurses. A baseline pretest and two posttests were conducted with the mothers in both groups. Emotional distress was assessed as depressive symptoms, affective state, stigma, and worry about HIV. Health, self-reported by the mothers, included the number of infections and aspects of health-related quality of life (i.e., perception of health, physical function, energy, health distress, and role function). ResultsRegarding emotional distress, the mothers in the experimental group reported fewer feelings of stigma than the mothers in the control group. Outcome assessments of health indicated that the mothers in the experimental group reported higher physical function scores than the control mothers. Within group analysis over time showed a reduction in negative affective state (depression/dejection and tension/anxiety) and stigma as well as infections in the intervention group mothers, whereas a decline in physical and role function was found in the control group. ConclusionsThe HIV symptom management intervention has potential as a case management or clinical intervention model for use by public health nurses visiting the home or by advanced practice nurses who see HIV-infected women in primary care or specialty clinics.