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This paper describes a paradigm shift occurring in neonatal intensive care. Care teams are moving from a focus limited to healing the baby's medical problems towards a focus that also requires effective partnerships with families. These partnerships encourage extensive participation of mothers and fathers in their baby's care and ongoing bi-directional communication with the care team. The term Newborn Intensive Parenting Unit (NIPU) was derived to capture this concept. One component of the NIPU is family-integrated care, where parents are intimately involved in a baby's care for as many hours a day as possible. We describe six areas of potentially better practices (PBPs) for the NIPU along with descriptions of NIPU physical characteristics, operations, and a relationship-based culture. Research indicates the PBPs should lead to improved outcomes for NIPU babies, better mental health outcomes for their parents, and enhanced well-being of staff.

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This article provides a rationale for and brief description of the process of developing recommendations for program standards for psychosocial support of parents with babies in the neonatal intensive care unit (NICU). A multidisciplinary workgroup of professional organizations and NICU parents was convened by the National Perinatal Association. Six interdisciplinary committees (family-centered developmental care, peer-to-peer support, mental health professionals in the NICU, palliative and bereavement care, follow-up support and staff education and support) worked to produce the recommendations found in this supplemental issue. NICU parents contributed to the work of each committee.

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This article describes recommended activities of social workers, psychologists and psychiatric staff within the neonatal intensive care unit (NICU). NICU mental health professionals (NMHPs) should interact with all NICU parents in providing emotional support, screening, education, psychotherapy and teleservices for families. NMHPs should also offer educational and emotional support for the NICU health-care staff. NMHPs should function at all levels of layered care delivered to NICU parents. Methods of screening for emotional distress are described, as well as evidence for the benefits of peer-to-peer support and psychotherapy delivered in the NICU. In the ideal NICU, care for the emotional and educational needs of NICU parents are outcomes equal in importance to the health and development of their babies. Whenever possible, NMHPs should be involved with parents from the antepartum period through after discharge.

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Having a baby hospitalized in a neonatal intensive care unit (NICU) is a potentially traumatic event for parents. This article summarizes research documenting heightened symptoms of depression and post-traumatic stress in these parents and reviews studies of the relationship of parental distress with impaired infant and child development. We describe an array of validated screening devices for depression and post-traumatic stress, along with research on risk factors for elevated scores. In making recommendations for screening both mothers and fathers for emotional distress in the NICU, we (a) present commentary on the pros and cons of screening, (b) propose a timetable for screening and (c) describe both supportive interventions for parents in the NICU and a variety of referral possibilities for parents most at risk.

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OBJECTIVE: To enhance the clinical utility of the Perinatal Post-Traumatic Stress Disorder (PTSD) Questionnaire (PPQ), the current study sought to refine the measure by changing the item response options from dichotomous choices to a likert scale format. STUDY DESIGN: Using a convergent/divergent validity design and two data sources (traditional survey and World Wide Web), 58 high-risk and 86 low-risk mothers answered four questionnaires. RESULTS: Principal components analysis of items on the modified PPQ revealed three components conceptually similar to the diagnostic criterion associated with PTSD. In addition, convergent and divergent validity of the modified measure was supported. The clinical utility of the modified PPQ was established with a strong positive likelihood ratio. CONCLUSION: The modified PPQ is a useful clinical tool for identifying mothers experiencing significant emotional distress during the postnatal period so they may be referred for mental health services.

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A measurement model of perinatal stressors was first evaluated for reliability and then used to identify risk factors for postnatal emotional distress in high-risk mothers. In Study 1, six measures (gestational age of the baby, birthweight, length of the baby's hospitalization, a postnatal complications rating for the infant, and Apgar scores at 1 and 5 min) were obtained from chart reviews of preterm births at two different hospitals. Confirmatory factor analyses revealed that the six measures could be accounted for by three factors: (a) Infant Maturity, (b) Apgar Ratings, and (c) Complications. In Study 2, a modified measurement model indicated that Infant Maturity and Complications were significant predictors of postnatal emotional distress in an additional sample of mothers. This measurement model may also be useful in predicting (a) other measures of psychological distress in parents, and (b) measures of cognitive and motor development in infants.

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We evaluated the validity of the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) as a measure of posttraumatic stress symptomatology. Mothers of high-risk infants (N = 91) and healthy, full-term infants (N = 51) answered the PPQ and two other convergent measures of posttraumatic stress disorder symptoms, the Impact of Event Scale (IES) and the Penn Inventory (PI). The Need for Cognition Scale (NCS) was used as a divergent measure. Correlations among the convergent measures were significantly greater than the correlation between the PPQ and NCS. High-risk mothers also scored higher than normal mothers on the PPQ and IES. The results support the validity of the PPQ.

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We investigated the relationship between the stress of a high-risk birth and the development of symptoms of posttraumatic stress disorder in mothers. Six measures of perinatal stressors (gestational age of the baby, birth weight, length of hospital stay for the baby, a postnatal complications rating for the infant, and Apgar scores at 1 and 5 minutes) were used to predict the frequency of posttraumatic stress symptoms. Severity of infant complications, gestational age, and length of stay accounted for 35% of the variance in reports of posttraumatic stress symptoms. Both mothers of premature infants and mothers of term infants hospitalized in a neonatal intensive care unit reported significantly more symptoms of posttraumatic stress than mothers of healthy term infants (p < 0.01). We conclude that the birth of an infant at high risk, especially one with severe medical complications, can have long-term emotional consequences for the baby's mother.

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We studied several predictors of severity of apnea and caretakers' anxiety about home cardiorespiratory monitoring in 476 families with infants enrolled in a perinatal follow-up program. Thirty-six (8%) of the infants had apparent life-threatening events at home. These infants were compared with the remaining infants, who had benign outcomes. Normal pneumograms and normal cerebral computed tomographic scans predicted the absence of significant respiratory problems (99% and 100% true negative rates, respectively). Infants with these signs may not require home monitoring. This study used a stringent criterion of periodic breathing (< or = 3% of quiet time) in defining a normal pneumogram. A more common criterion (< or = 10%) would have accurately predicted only 45% and missed 55% of the infants with life-threatening events. Level of caretakers' anxiety about monitoring was related to severity of apnea. Parental anxiety about monitoring may have been overestimated in previous research.

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The benefits of hypnotic analgesia as an adjunct to childbirth education were studied in 60 nulliparous women. Subjects were divided into high and low hypnotic susceptibility groups before receiving 6 sessions of childbirth education and skill mastery using an ischemic pain task. Half of the Ss in each group received a hypnotic induction at the beginning of each session; the remaining control Ss received relaxation and breathing exercises typically used in childbirth education. Both hypnotic Ss and highly susceptible Ss reported reduced pain. Hypnotically prepared births had shorter Stage 1 labors, less medication, higher Apgar scores, and more frequent spontaneous deliveries than control Ss' births. Highly susceptible, hypnotically treated women had lower depression scores after birth than women in the other 3 groups. We propose that repeated skill mastery facilitated the effectiveness of hypnosis in our study.

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A series of experiments was conducted to assess the influence of home-cage lighting conditions on shock-induced aggression in rats. The first two experiments tested rats six times within 24 hr and demonstrated that subjects maintained on a light/dark (LD) cycle fought more than rats maintained on a 24-hr light schedule (LL). In addition, a periodic trend could be identified in the data of the LD groups but not in the data of the LL groups. The second two experiments assessed the effects of castration on this lighting effect. Castration of adults did not influence the lighting effects, but castration of weanling rats eliminated the group difference between LL and LD groups. However, the LD rats castrated at weaning did show the periodic trend characteristic of all of the LD groups tested within 24 hr. Two additional experiments assessed the effects of time of testing in between-subjects designs. Time of testing was a significant variable in the LD groups but unimportant in the LL groups. A final experiment demonstrated that the difference between the LD and LL groups does not emerge in a daily testing procedure.

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In two studies, free-roaming male rats (aggressors) were shocked in the presence of male target rats restrained in either an upright or a supine posure. In addition, in Experiment II, two levels of aggressor shock intensity (0.8 mA or 2.0 mA) were used while targets received one of three levels of shock (0.5 mA, 1.5 mA, or 2.5 mA). In both studies, upright targets were attacked less than supine targets. Frequency of aggression was directly related to level of aggressor shock intensity in Experiment II. Also, attack by 0.8-mA aggressors against supine targets was inversely related to level of target shock intensity. The low level of attack against upright targets was interpreted in terms of a threat diaplay. Similarily, it was concluded that the target shock-intensity effect in Experiment II was due to specific threat behaviors displayed by those supine rats that received the highest-intensity shocks.

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