Copenhagen Infant Mental Health Project: A Randomized Controlled Trial Comparing Circle of Security-Parenting and Care as Usual as Interventions Targeting Infant Mental Healths Risks

Background and rationale Infant mental health is a significant public health issue as early adversity and exposure to early childhood stress has life-long consequences for these affected children on outcomes such physical and mental health, educational attainment, labor market success and family formation. Infants are - as a result of their dependency, vulnerability and relative social invisibility - more exposed to mental health risks than older children. Infants may be at risk due to a particular biological risk (e.g. infantile autism, retardation, prematurity, physical disabilities etc) or to psycho-social risks in the family (e.g. mentally ill parents, poverty, drug/alcohol abuse etc). Recent Danish estimates suggest that one in five families is at risk of inadequate parenting resources and child neglect.

There is by now solid evidence that the establishment of attachment relationships, i.e. a stable emotional bond with a caregiver - mostly the parent - is one of the most important developmental milestones in infancy. Early parent-child attachment relationships function as a blueprint for future social relationships and serve as a framework within which children learn how to deal with stressful situations and to regulate the accompanying negative emotions. Insecure and disorganized attachment is a significant risk for longitudinal child development and psychopathology, as the ability to regulate ones feelings of stress and negative emotions is important for a wide range of socio-emotional outcomes ranging from social competence, moral development and empathy, to academic achievement. Recent meta-analyses show that insecure and disorganized children have a higher risk of developing mental problems later in life. Insecurely attached children are also more likely than securely attached children to develop internalizing problems, such as anxiety and depressive symptoms, as well as externalizing problems such as aggressive behavior. For externalizing problems, the risk was even higher for disorganized children. Furthermore, research into early brain development indicates that brain development can be physiologically altered by severe stress imposed by neglect and inadequate parenting during a child's early years.

Evidence from attachment research shows that sensitive parenting, where the parent is alert and able to understand the infant's expression of emotional states and able to manage and meet the infant's needs contingently, adequately and in a comforting way will lead to the establishment of a pattern of secure attachment in the child. Lack of availability, inconsistent availability, misunderstanding of the infant's emotional expression and parental behavior that frightens the infant may all lead to an insure attachment and in the most severe cases a disorganized attachment. This is indicative of a breakdown of an organized (secure or insecure) attachment behavioral strategy. Disorganized attachment is considered to be the result of parental behavior that is frightening for the child. An extreme example of such behavior is child maltreatment, but all sorts of parental behavior that are not comprehensible for the child, such as dissociation, which is common in depressed parents, is potentially frightening for the child. This sort of behavior results in the paradoxical situation that the parent is a source of comfort and a source of fear at the same time. Thus, in stress situations the child does not know what to do, and the behavioral strategy collapses .

Infant social withdrawal indicates infant distress and early attachment disturbances and is a known risk factor for infant mental health. Infant social withdrawal is indicated by a lack of either positive (e.g. smiling, eye contact) or negative vocal protestations. Sustained withdrawal behavior in infants can be seen as a chronic diminution of the attachment system, which is gradually generalized into a diminished engagement and lowered reactivity to the environment at large. In more European countries the use of the validated systematic screening method, Alarm Distress Baby Scale (ADBB) for identifying infant delayed socio-emotional development in infant mental health clinics and in home visiting programs have shown promising results.

Postnatal depression (PND) is another known risk for infant mental health. A meta-analysis shows that up to 19% of new mothers may experience minor or major depression during the first months postpartum. If only including major depression, the prevalence was found to be 7.1 %. In a more recent European study, 1,066 women were followed from pregnancy to 12 months postpartum. The results indicated that 9.6% of new mothers may experience a major depressive episode during the first year after delivery. No estimates were given for minor depression. Most cases develop within the first three months with a peak incidence of about 4-6 weeks.