Covid-19 has presented challenges and opportunities for infants and families

Covid-19 has presented challenges and opportunities for infants and families

Did you know that this week (June 7-13) is Infant Mental Health Awareness Week?

To mark the occasion the Psychological Society of Ireland (PSI) Special Interest Group in Perinatal and Infant Mental Health (SIGPIMH) has revealed fascinating insights into the impact the Covid-19 pandemic has had for infants and families.

The group promotes clinical practice, education and research regarding the health and development of parents and infants from conception and pregnancy through to five years postpartum, within the discipline of Psychology in addition to interdisciplinary cooperation with other medical and allied health professions.

Last month, West Be Well was pleased to play a small part in this sector by hosting a free Minding Mothers: Minding Babies webinar on behalf of Mayo Infant Mental Health Forum.

Perspectives from infant mental health research highlight both the challenges and opportunities COVID-19 has presented to infants and families.

The pandemic has disrupted many cultural and societal norms related to welcoming a new baby into the world.

Cocooning, social distancing and physical restrictions have disconnected a baby from its community in a myriad of ways.

However, the virus and its associated restrictions have led many parents to spend longer periods of time at home with increased opportunities for developing the parent-infant relationship.

A number of studies have reported closer family connection, enhanced communication, greater emotional expressiveness (Günther-Bel, Vilaregut, Carratala, Torras‐Garat, & Pérez‐Testor, 2020) and closer parent–child bonds during this time (Chu, Schwartz, Towner, Kasparian, & Callaghan).

However, research has yielded mixed findings.

A number of studies have also reported mother-infant bonding difficulties and increased parenting stress (Hiraoka & Tomoda, 2020; Mayopoulos et al., 2021; Oskovi-Kaplan et al., 2020).

Infant mental health refers to socio-emotional development from birth to three years of age. This includes infants’ capacity to express and regulate their emotions, begin to form relationships, and explore their environment (HSE, 2017).

The first 1,000 days are now accepted to be the most significant in a child’s development (Unicef, 2013).

Leading child health experts worldwide agree that the care given during the first 1,000 days has more influence on a child’s future than any other time in their life.

Infant mental health is associated with social-emotional, behavioural and cognitive development across the lifespan.

Despite good literacy amongst parents about infant physical development, there is a lack of knowledge about infant social and emotional development (Coyle, De Flumere, Sarma & Maguire, 2021).

A similar “baby blindspot” exists in children and young people’s mental health policies, strategies and services (The Parent Infant Foundation, 2021).

In keeping with this view, the theme for Infant Mental Health Awareness Week 2021 is including infants in children and young people’s mental health.
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Infants are dependent on parents for their care and so the quality of the parent-infant relationship has a significant influence on infant mental health and well-being.

A considerable body of research indicates the critical importance of responsive caregiving (Landry, Smith & Swank, 2006). This
includes a parents’ capacity to pick up on and respond appropriately and consistently to infant cues.

Infants are unable to independently regulate their own emotional states. They require co-regulation from the parent which involves attunement (accurate interpretation) and modelling together with contingent meeting of needs such as for comfort and soothing.

Having the expectation that their needs will be consistently met, helps infants to learn to self-soothe and self-regulate (Raby et al, 2015).
This highlights the critical importance of supporting parents in the first instance in order to support infant mental health.

It is unsurprising that there has been a reported increase in perinatal mental health difficulties as a result of the Covid-19 pandemic (Basu et al., 2021).

Elevated rates of post-traumatic stress, anxiety, depression and loneliness have been reported (Basu et al., 2021).

Women who experience mental health difficulties are at higher risk of experiencing a disruption in the mother-infant bond.

Research has indicated that the failure to build a positive, secure parent-infant bond is associated with significant deficits in infant neuropsychological, behavioural and social-emotional domains throughout the lifespan (Masheroni & Ionio, 2018).

In particular, the association between insecure or disorganised attachment style and poor social-emotional functioning in the long-term is well documented in the research literature (Ranson & Urichuk, 2008).

Mental health professionals have experienced increased difficulty in assessing mothers and their infants throughout Covid-19.

Observational assessments of parent-infant interaction provide crucial insight into the quality of the parent-infant attachment relationship, helping to identify early infants at risk of difficulties (Lotzin et al., 2015).

To combat the challenges of COVID-19 restrictions, there has been a move to parent-infant observational assessments online (Stiles-Shields,
Plevinsky, Psihogios, & Holmbeck, 2020).

While this is a necessary and useful adaptation, the online format presents increased challenges particularly around engaging parents.

The virtual format places additional responsibility on parents around accessing virtual platforms and organising the time and space to attend while assertive outreach is not possible.
There has also been a significant loss of normative opportunities to observe parent-infant interaction amongst community gatekeepers such as Public Health nurses and G.P.s.

In the UK only 1 in 10 parents of children under two reported seeing a health visitor face-to-face during the pandemic (Best Beginnings, 2020).

In Ireland, over half of the infants born last year missed a routine developmental health check (McLoughlin & Bowers, 2021).

These developmental checks can be supportive and reassuring and are central to highlighting early intervention needs amongst infants before difficulties become entrenched (HM Government, 2018).

As developmental health checks are universal to all families, they are uniquely positioned to identify and provide support to all families in need (Appelton, 2015, Appelton, 2021).

The reduction in service provision has further compounded the lack of support and social isolation of families with young babies who were already restricted from family and peer social networks during COVID-19.
Adaptations have also been developed to provide parent and infant intervention online.

For mothers who are experiencing difficulties in their relationship with their baby, interventions such as video interaction guidance have been adapted to an online format.

Preliminary results show a high level of satisfaction from both clients and practitioners (University of Sussex, 2021). However a concern remains about the challenges of engaging the most vulnerable parents and infants remotely, where assertive outreach options are unavailable.

Perinatal Mental Health Services have begun to employ telephone and cloud computing technology to adapt their services for pregnant women and new mothers who are experiencing mental health difficulties.

Dr Mas Mahady (Perinatal Psychiatrist) in University Maternity Hospital Limerick (UMHL), asserted that what they are doing “essentially remains the same, only it’s being delivered by phone or online” (HSE, 2020).

Online service provision includes patient appointments, mother-baby groups and antenatal education.

Similar adaptations have been made to perinatal mental health services in the other maternity hospitals.

Swinsburg, and Kasparian (2021) highlighted some of the benefits of virtually administered parent-infant appointments, including increased convenience and flexibility for scheduling, reduced time and cost for travel/time off work and no need for PPE.
Another potential benefit of remote healthcare appointments is the opportunity to “meet parents where they are”, providing greater convenience and flexibility (Rihl, 2020).

The online platforms were anecdotally described by service providers as user-friendly and effective, although it is not clear how the mothers are experiencing the service adaptations.

A recent online survey with mothers in the UK highlighted that some mothers valued digital health appointments, while others were left feeling unsupported, isolated and anxious (Best Beginnings, 2020).

The impact of the Covid 19 pandemic and resulting restrictions is inevitably compounded for families of vulnerable and sick babies in neonatal and paediatric intensive care units.

Ordinarily having an infant in neonatal intensive care (NICU) is perceived as a traumatic and stressful life event (Ionio et al., 2016; Stefana and Laevlli, 2016).

Parents whose infants are being treated in the NICU are at high risk for depression, anxiety and acute traumatic stress with potential negative implications for parenting and infant development (Mendelson et al, ; Gulczynski, 2016).

One prospective study of expectant women during the pandemic found almost 50% had fears of having a premature baby or foetal anomalies as a result of the pandemic (Thapa et al., 2020).

Parental visits to NICU and PICU were significantly reduced during the pandemic to decrease footfall and limit potential transmission (Darcy Mahoney et al., 2020).

In many cases just one parent at a time was allowed access to their baby. While the World Health Organisation recommended that mothers
with suspected or confirmed COVID-19, who were otherwise well, should not be separated from their infants (WHO, 2020), in reality some parents were not allowed access to their baby for days or weeks.

These separations of parent and infant accentuated the emotional distress and psychological impact on parents (Bembich et al, 2020). Parents also perceived a negative impact on their ability to care for and connect with their baby (Muniraman, Ali, Cawley, et al., 2020).

Video conferencing was employed to facilitate parents in communicating with NICU and having contact with their infant (Epstein et al., 2017). While this may provide some comfort and reassurance, it is likely much less efficacious for promoting the parent- infant bond.
Conclusion
In light of the unprecedented challenges COVID-19 has presented, it is important to consider the potential consequences on parent and infant mental health.

While services strived to continuously adapt and maintain some continuity of care, the quality of service offered has inevitably been unduly compromised.

From primary care to tertiary services, COVID-19 has resulted in significant loss of opportunities for picking up on and responding early to the needs of infants and their families.

It is well known that infant mental health is linked to long term social-emotional and behavioural outcomes for children. If service providers intervene successfully before age 2, potential negative consequences in the long-term can be ameliorated.

While the long term implications of the COVID-19 pandemic are, as yet, unknown, the vital importance of including infants in children and young people’s mental health policies and strategies has been brought into sharp focus.
You can also find out more about SIGPIMH by clicking HERE.
You can also follow the group on Twitter and Instagram.