Pilot implementation of the mother-baby intervention in the Youth Health Care

Depression is not uncommon in the Netherlands. One in five women and one in ten
men have a
depression at least once in their lives. Only a third of the depressions are
treated at the Mental Health
Care Centers (Vollebergh et al., 2003). Women are especially vulnerable to
depression after the birth of
a child. The prevalence of depressive disorders among mothers after giving
birth is 8 to 15% (O*Hara et
al., 1990). Approximately 200,000 children are born in the Netherlands every
year (www.cbs.nl
consulted on August 18, 2006). An average prevalence of depression of 10% means
20,000 mothers
have a depression in the Netherlands every year.
Depression among young mothers affects the development of young children. In
the first year of their
lives, children of depressed mothers exhibit behavioural, physiological and
biochemical ailments (Field,
1995). At the pre-school and primary school stage, children of depressive
mothers have behavioural
difficulties and problems in their emotional, social and cognitive development,
including their language
development. In some studies, the effects on boys seem to be more serious than
the effects on girls
(Cicchetti et al., 1998; Murray & Cooper, 1996). Children of depressive mothers
have a higher risk of
developing depressive disorders themselves as children or adolescents. There is
also a risk of anxiety
disorders or alcohol dependence in adolescence and young adulthood (Weissman et
al., 1997).
The preventive Mother-Baby Intervention (MBI) is focused on mothers with
depression and their babies.
The aim is to reduce the risks to children of depressed mothers of
developmental stagnation and later
psychopathology by improving the early mother-child interaction. The
intervention has been developed
on the basis of a transactional model focused on the early interaction between
a depressed mother and
her child (Van Doesum et al., 2005). In six to ten home visits, a trained
social worker gives feedback on
the way the mother deals with the baby, with the aim of increasing the mother*s
sensitivity to contact
signals from the child and her cooperation and attunement to the child,
adjusting depressive cognitions
and promoting assertiveness. Video feedback is used as the core method in the
intervention. In an RCT
among seventy-one depressive mothers and their babies, the quality of the
mother-baby interaction in
the experimental condition (intervention group, N = 35) is compared with a
control group (minimal
intervention group, N = 36).
On the primary outcome measurement, a significant improvement is observed in
the sensitivity of the
mother six months after the end of the intervention (Emotional Availability
Scales, Biringen et al., 1998).
This also holds true as regards the responsiveness of the child. In the control
group, there is evidence of
a worsening. The infant-mother attachment security also improves from a risk
score to a score with
normal values (Attachment Q-sort, Waters, 1995). The risk factors for the
children of developmental
stagnation and future psychopathology are thus reduced (Van Doesum et al., in
press; Van Doesum et
al., submitted). It has been repeatedly observed in recent years that there is
an absence in the
Netherlands of instruments and interventions that can be used to promote the
development of young
children in risk situations (Inventgroep , 2005; Programmeringsstudie
Effectonderzoek JGZ (update),
2005).
The 0-4 Youth Health Care (JGZ) facilities have a wide reach (> 90%), but still
do not have adequate
instruments to detect risk situations and perform the kind of interventions
that would provide help with
raising children (Prinsen, 2006). The Public Health Collective Prevention Act
(WCPV) (2003) provides
for the option of performing interventions within the made-to-measure component
of the basic task
package (Basistakenpakket).
The MBI is performed at seventeen Mental Health Care Centers (GGZ) facilities
(LSP Databank, 2005
figures). An estimated 400 mothers were reached this way in 2005. However,
considering the total
number of depressed parents with babies under the age of one (a minimum of
20,000), this figure is
insignificant. With the MBI, mental health care facilities mainly reach mothers
with a serious depression
at a late stage. The disturbed mother-child interaction has thus been going on
for quite some time and is
more difficult to correct.
A broader application of the intervention at the Youth Health Care facilities,
where virtually all mothers
come with their babies for prenatal and postnatal care, can considerably
increase the number of mothers
and babies who can be reached at an early stage. Implementing the intervention
among depressive
mothers requires specific expertise.

Aim : Study the effectiveness of the intervention at the new setting.
Question:
- Is the effectiveness of the MBI the same at the Youth Health Care as at the
Mental Health Care
Centers as regards the outcome measurement of the sensitivity of the mother to
contact signals from the
child?

The effects of the intervention on the mothers and babies are measured via one
pre-test measurement
and two post-test measurements (T0 at the start of the intervention, T1 at the
last session of the
intervention and T2 six months after the completion of the intervention). The
same research instruments
are used as in the previous effect study. The effect of the Mother-Baby
Intervention is stipulated on the
variable quality of the mother-child interaction. The maternal sensitivity is
the main outcome measure.
For this purpose, use is made of the video recordings of the mother-child
interactions in all three of the
measurements. The recordings are scored by a minimum of three trained observers
based on the
Emotional Availability Scales (EAS, Biringen et al., 1998). These scales
measure the quality of the
interaction: the maternal sensitivity and the responsiveness and involvement of
the child. Background
information on the mother and child are collected during the three measurements
using a composite
questionnaire. The level of the mother*s depressive symptoms is measured using
the Beck Depression Inventory
(BDI, Beck et al., 1988).
The effect outcomes of the participants in the pilot implementation are
compared with the results of the
previous effect study (control and experimental group, N = 36 and N = 35
respectively). Power
calculation: In order to define a standardized effect size of d that is larger
than or equal to 0.33
(medium-sized clinical effect) as significant in the statistics with an alpha =
0.05 (one-sided) and power
(1-beta) = 0.80, it is necessary to have forty-two individuals for each
condition. With an anticipated
drop-out of 15% at the most (based on prior research), we can conclude that a
sample of sixty is more
than enough.

The mother-baby intervention comprises a total of 8 to 10 home visits. A home
visitor (qualified health nurse) visits the depressed mother and her infant at
home, where he or she records the mother-child interaction on videotape. A
multi-disciplinary team consisting of specialists in infant mental health care
who are associated with the home visitor*s centre subsequently analyze the
videotape, focusing in particular on the mother*s sensitivity to her infant*s
signals and needs. Based on their analysis of the taped interactions, the
home-visitor then chooses the strategies best suited to achieve these goals and
fine-tunes the intervention to the mother*s needs. Based on the video
observations and the outcome of the discussion with the parents, the mother is
encouraged to expand her range of appropriate communicative behaviours, and is
shown when to respond to the baby's eye-contact, movements or sounds. The
father, when present, is encouraged to support his wife in her interactions
with the child. In addition to the video observations, one or more of the
following techniques are used, depending on the needs of the parents:
modelling, cognitive restructuring, baby massage and practical pedagogical
support.

No risk