terveiset kauniista Etelä-Afrikasta!

terveiset kauniista Etelä-Afrikasta!

Symposium title: Baby s mind in mind: three new Finnish studies evaluating and enhancing pre-and postnatal parental capacity to mentalise about the baby and parenting WAIMH Cape Town 2012

Projects/Studies regarding: New pre-and postnatal RF assessment questionnaire method and pilot data: Finn Brain birth cohort (presenter: M Pajulo) Prenatal RF intervention for substance abusing pregnant women for use in university hospitals (presenters: Z Boukydis, H Pajulo) A mentalisation-based group intervention for first-time parents and babies to be used in primary health care (presenter: M VonKoskull)

Concept of mentalising/rf Capacity to: -think and wonder about feelings and experience -within self and others -behind behavior -giving value to this wondering Roots: in psychodynamic theory, attachment theory and research, & cognitive psychology (Fonagy et al. 2002, Allen et al. 2008, Bateman et al. 2012)

Thinking about feeling, feeling about thinking I think of what I think I think of what you think I think of how I feel I think of how you feel I feel about my thinking I think of how my feelings may affect your feelings I think of how your feelings may affect how I feel I think of how difficult it is to know how you think or feel I think of how it may show out how I feel/how you feel

Mentalising/RF capacity: both emotional and cognitive capacity both implicit and explicit -spontaneous, unnoticed -conscious, careful thinking and focus of working both in self and others both through observable signs or behavior (the smaller the child) directly focusing on internal experience within self and other

Mentalising/RF makes it possible for a parent: To consider/see alternative explanations to other people s/child s behavior Hence: diminishing mis-interpretations in interaction and communication increasing feelings of safety in relationships

Mentalising/RF in early parenting baby has a separate, individual mind and experience to be curious about the baby s perspective and point of view to value this not knowing, but wondering from early on the smaller the child, the more challenging especially demanding (but important) during pregnancy (Slade et al. 2005)

Why focus on parental RF? prerequisite for sensitive interaction and caregiving enhances secure attachment in child has potential to break the intergenerational transimission/chain of insecure attachment accurate and clear focus/point of intervention especially important focus of work with psychosocial high risk samples and parenting under stress!

Parental RF: Consequences for child development: crucial for the child s own RF development enhances healthy social, emotional and cognitive development in the child

Understanding brings flexibility and joy!

Pre-and postnatal parental mentalising. Assessment methods and pilot data from Finn Brain birth cohort.

Research team (this part of the large study) Marjukka Pajulo, MD, PhD, University of Turku Hasse Karlsson, Prof., University of Turku Linnea Karlsson, University of Turku Camilla Öst, Åbo Akademi Susanna Kortesluoma, University of Turku Elina Halme-Chowdhury, Åbo Akademi International collaboration: Linda Mayes, Prof., Yale Child Study Center, CT, USA Patrick Luyten, University of Leuven, Belgium & Anna Freud Center, London, UK

Finn Brain cohort study Longitudinal follow-up of children from pregnancy till late adulthood Integrates knowledge from psychiatry, infant psychiatry, pediatrics, obstetrics, molecular genetics, neuroimaging Risk and protective factors in child s brain development and whole development Mechanisms of their impact

Pilot study Follow-up till 2 years of child s age Testing methodology and design Factor analysis of the prenatal questionnaire Large cohort data collection started in autumn 2011 (n= 10 000 families) Funding: Academy of Finland, Gyllenberg Foundation

Specific aim: to explore Role of early parental mentalising capacity for child attachment and development (prenatal RF, postnatal RF, toddler RF) In relation to other pre-and postnatal risk and protecting factors First time: -with a questionnaire method P-PRFQ, PRFQ -during pregnancy -also with fathers -possible to explore in large samples

Participants and design: pilot pregnant women/families attending routine ultrasound examination in maternity care (Turku area/south-western Finland) at 18-22 weeks of gestation self-report questionnaires at 22 and 32 gwk, 3 and 6 months postpartum hospital records on delivery and birth status

22 gwk 32 gwk Baby 3 months Baby 6 months Background data Prenatal RF Postnatal RF Attachment to fetus Parenting stress Parenting stress Postpartum bonding/risk for neglect & abuse

Findings from the pilot: Sampling: 80% acceptance to participate of those offered 119 mothers and their 73 partners/fathers at 32 gwk 99 mothers and their 57 partners/fathers at 6 months

Preliminary results Significant positive correlations between prenatal RF and prenatal attachment to baby Both in mothers and fathers Associated but distinct concepts

Preliminary results, cont.: Associations/positive correlations found between parents within one family in levels of: -pre-and postnatal RF -emotional bonding with the newborn baby/risk of neglect -parenting related stress Accumulation of both benefitial and risk conditions within families?

Conclusions Prenatal and postnatal PRFQ questionnaires seem promising tools to assess parental mentalising Prenatal RF associated with prenatal attachment: suggesting RF as a tool, route, point of intervention in working for better prenatal attachment? Results suggest to invest in intervening already during pregnancy

Vanhempien mentalisaatiokykyä vahvistava interventio ensimmäistä lastaan odottaville perheille, perusterveydenhuollon käyttöön

Työryhmät Projektijohtajat: Malin VonKoskull, Folkhälsan Förbundet Anne Viinikka, MLL Interventiotutkimus: Mirjam Kalland (PI), Åse Fagerlund, Marjukka Pajulo, Martina Salven, Riikka Korja, Tuovi Hakulinen-Viitanen

Parents First - program (Yale 2002) Föräldrarskapet Främst (Folkhälsan 2006 alk.) Vahvuutta Vanhemmuuteen (Folkhälsan, MLL ja THL yhteistyössä, 2010 alk.)

Vahvuutta Vanhemmuuteen (Folkhälsan, MLL ja THL yhteistyössä) 12 tapaamiskerran RF ryhmäinterventio perheeseen ensimmäinen vauva äitiysneuvoloiden perhevalmennusryhmien pohjalta odotusaikana kootut perheiden ryhmät äiti, isä, vauva max kuusi perhettä per ryhmä

Vahvuutta Vanhemmuuteen, rakenne kaksi koulutettua vetäjää (neuvolan th, MLL:n tt) joka toinen viikko, 1.5 tuntia per kerta alkavat kun vauva noin 4 kk tavallisia vapaaehtoisia perheitä laajennetaan parhaillaan valtakunnalliseksi, neuvolatyön osaksi, koulutus menossa mukana nyt 72 kuntaa, 150 koulutettua ryhmänohjaajaa, 20 kouluttajaa

Vahvuutta Vanhemmuuteen kunkin tapaamiskerran vetäminen manualisoitu sisältää kolme erilaista elementtiä vanhempien RF kyvyn vahvistamiseksi: 1) kunkin kerran valittu teema ja sen pohjustus 2) mentalisaatiota inspiroivat tietyt kysymykset ja pohdinnan liikkeelle lähettäminen 3) kotiin annettavat tehtävät ja niiden kokemusten läpikäynti

Muita RF elementtejä: -vetäjien ei-tietäminen, ihmettelyn inspirointi -tarkat arkipäivän esimerkit tärkeitä (episodinen muisti) -puolisot kuulevat toistensa ajatuksia ja havaintoja vauvasta -kuulevat muiden vanhempien ajatuksia ja ihmetyksiä -ilon tuottaminen, hauskuus tapaamisissa ja arjessa -yhdessä ruokailu, yhdessäolon inspirointi

Teemojen aiheet: 0 kerta: Tutustuminen, kertojen pohjustus 1. kerta: Vauvalla oma persoona aivan alusta asti 2. kerta: Perheenjäsenten erilaiset persoonat ja temperamentit 3. kerta: Odotukset ja toiveet 4. kerta: Vaikutamme toisiimme 5. kerta: Voimakkaat tunteet 6. kerta: Siirtymätilanteet haasteena 7. kerta: Lapsen riippuvuus ja itsenäisyys 8. kerta: Ristiriitaiset ja vastakkaiset tunteet 9. kerta: Lapsen käyttäytymisen alla olevat tunteet 10. kerta: Vanhemman omat vaikeat tunteet 11. kerta: Perheelle tärkeät muut ihmiset

Keskustelua inspiroivat kysymykset, esimerkkejä 3. tapaaminen, teema Odotukset ja toiveet : Mitä toiveita, unelmia tai pelkoja sinulla oli lapseesi liittyen raskauden aikana? Minkälaisia ne ovat nyt kun hän on noin puolivuotias? Oletko huomannut, onko lapsesi jollain tavalla erilainen kuin kuvittelit silloin odotusaikana? Miltä se tuntuu sinusta? 5. tapaaminen, teema Voimakkaiden tunteiden käsittely : Mikä lapsessasi herättää sinussa voimakasta iloa? Entä suuttumusta? Saako perheessänne näyttää voimakkaita tunteita? Miten ne mahtavat näkyä sinusta itsestäsi ulospäin?

Esimerkkejä koti tehtävistä : Pysähdy tarkkailemaan ja kuvittelemaan hetkeksi maailmaa vauvasi näkökulmasta. Valitse jokin rauhallinen hetki, jolloin hän on tyytyväinen. Mitä hän mahtaa nähdä, kuulla, ajatella, kokea? Asetu vaikka selälleen lattialle, samaan asentoon hänen kanssaan Syökää yhdessä, yhtaikaa. Pienestäkin lapsesta voi olla innostavaa syödä välillä myös yhdessä äidin ja isän kanssa. Antakaa hänelle lusikka ja katsokaa mitä tapahtuu. Lapsi opettelee kaikilla aisteillaan, hän saa tilaisuuden opetella uutta taitoa. Ja sinä voit opetella sietämään sotkua.

Vanhempien palautekysely int. jälkeen Tunnen itseni varmemmaksi vanhempana 62% Ymmärrän paremmin lapseni tarpeita ja tunteita 55% Jatkoimme ryhmässä alkanutta pohdintaa vauvasta kotona puolison kanssa 73% Isät ovat olleet hyvin aktiivisesti mukana, kokeneet ryhmät erityisen hyvänä

Vaikuttavuustutkimus (keräys meneillään) Verrataan: Interventioon osallistuneet vanhemmat (n=200 perhettä), ja osallistumattomat (n=1500) Mittausajankohdat: loppuraskaus, ennen ja jälkeen intervention (3kk, 1v) ja seuranta (2v) Mitataan mm.: -vanhempien psyykkinen vointi, mentalisaatiokyky, parisuhdetyytyväisyys -vanhemmuudesta koettu stressi -lapsen kehitys Hypoteesi: -interventioon osallistuneet voivat merkitsevästi paremmin, RF korkeampi (mechanism of change?)

Lisätietoja kiinnostuneille: Malin von Koskull RN, Project manager Folkhälsans Förbund rf Paasikivenkatu 4 00250 Helsinki FINLAND malin.vonkoskull@folkhalsan.fi +358 44 7881011

Developing prenatal RF intervention for substance abusing pregnant women to enhance mother-child relationship and reduce substance abuse

Collaborative study between clinics of obstetrics, child psychiatry (infant psychiatry) and sociopediatrics at university hospital

Primary Investigators Eeva Ekholm, M.D., Docent, Turku University Hospital, Dept. of Obstetrics and Gynecology Zack Boukydis, Ph.D., Visiting Professor, Department of Pediatrics, Turku University, Turku, Finland & Semmelweis University Medical School, Budapest Hungary Marjukka Pajulo, M.D., Docent, University of Turku, Finland, Dept. of Child Psychiatry

Team/other contributors and special thanks: Outi Kallioinen, research nurse, child psychotherapist, Turku University Hospital Tiia Nikkola, social worker, Turku University Hospital Irmeli Lehtonen, psychiatric nurse, Turku University Hospital Laura Kortekangas, MD, Turku University Hospital Jorma Piha, MD, Professor., University of Turku, Dept. of Child Psychiatry Pirjo Anttila, MD, socio-pediatrist, Turku University Hospital, Helena Pajulo, medical student, University of Tampere Malin VonKoskull, project coordinator, Folkhälsan Förbundet

International Collaboration Consultants: Linda C. Mayes, M.D., Arnold Gesell Professor in Child Psychiatry, Pediatrics and Psychology, Yale Child Study Center and Yale School of Medicine, CT, USA Nancy Suchman, Ph.D., Associate Professor., Dept. of Psychiatry, Yale School of Medicine, CT, USA Lauren Jansson, M.D. Professor in Pediatrics; Johns Hopkins School of Medicine, Baltimore, MD, USA

Substance use in early parenting Many psychosocial obstacles for the mothers to become attached to the baby The same neuronal pathways are activated in reward system related to substance abuse! Substances have hijacked the reward system from the baby Normal parenting preoccupation does not occur The reward system has to be captured back to the baby (Li & Sinha 2008)

Other findings: stress regulation systems change due to substance abuse and exposure crying of the baby is even more stressful for these mothers! (Chaplin & Sinha 2011)

All this means that especially powerful methods and intervention practices are needed for these mother-baby pairs! Has to be simple and feasible enough to be carried out at hospital maternity policlinics!

Research Program: Main Intervention Components Prenatal ultrasound consultation work with additional RF focus (Boukydis 2006; 2012) Prenatal week-by-week RF focused diary: -specific attention to observing and thinking of the fetus/baby and own feelings (Pajulo et al. 2012)

RF and Ultrasound consultation Ultrasound imaging is a powerful tool: it enables to see the fetus/baby much more alive and already an individual person The mother s/parent s thinking and view of the baby can be reinforced with accurate questions and observations about the baby s movements, activity, amount of exploring the environment (seeing him as active, curious, calm, courageous etc. )

Ultrasound Consultation: Integrating RF The concept of mentalising is added by paying more attention to experience and feelings, both the parent s own and those that they imagine their baby may have, while observing the child on the ultrasound screen

Mentalization Focused Pregnancy Diary -designed for this study -short sections, unique for each week, regarding: fetal development, especially those developing fetal capacities important in regard of the mother-child interaction somatic and psychological changes in the mother during pregnancy baby s specific needs at each phase of pregnancy, hints of ways in which the mother can enhance her own and the baby s well-being small task or an RF-question to get the mother to stop and think for a moment about her baby and becoming a parent

Mentalization Focused Pregnancy Diary Cont.: Imaging week by week fetal size/growth Place to write about how the week has been for the mother pages designed for the mother to write a message/letter to her future baby, to perhaps be given later the her child? parenting related quotes from literature

Prenatal intervention procedure <22 gwk 10-23 gwk 24 gwk 30 gwk 34 gwk 35 gwk 40 gwk Recruitment Pre-int. questionnaires 1. US session 2. US session 3. US session Post-int. questionnaires Diary work Opening The diary Diary work Diary work Diary work Present for the baby

Participants: -randomly assigned to either intervention (n=40) or control group (n=40) -routine clinical interviews, treatment arrangements, consultations and and somatic follow up/screens carried out as usual with both groups Recruitment and data collection going on Acceptance rate/participation 80% of all fulfilling the inclusion criteria

Time points of assessments: Pre-intervention (<24 gwk) Post-intervention (end of pregnancy, 35 gwk) Delivery First postpartum days 3 months of child s age 1 year of child s age

Intervention efficacy study Outcomes assessed f.ex.: -substance use -depressive and anxiety symptoms -mentalising capacity -maternal-fetal attachment -somatic conditions of pregnancy and child -newborn neurobehavior -child development -emotional bonding/neglect -need for child protection actions/substitutional care

Hypothesis: Intervention group doing significantly better (f.ex.in terms of amount of substance abuse, psychiatric symptoms, mother and child health, need for substitutional care for the child etc.) RF: mechanism of change?

Kiitos!