Reflecting on Babies in the NICU: An exploration of Parental Reflective Functioning in a quaternary neonatal intensive care unit

Abstract

When an infant is admitted to the neonatal intensive care unit (NICU), parents are confronted with the challenge of developing relationships with their very sick infant while trying to comprehend the medical situation and their own emotional reactions. Although Parental Reflective Functioning (PRF) is important for early parent-infant relationships, its role in mental health and attachment relationship outcomes of infants admitted to NICU and their parents has not been evaluated. The prospective “Reflecting on Babies in NICU” (ROBIN) study aimed to determine whether PRF was measurable in NICU and predicted subsequent mental health problems.

Parents of infants who were at least 3 weeks of age and admitted to a quaternary NICU at the Royal Children’s Hospital Melbourne without ever having been home were prospectively enrolled. PRF was evaluated using the Parental Reflective Functioning Questionnaire (PRFQ) and, in a nested substudy, a specifically developed NICU version of the Parent Development Interview (PDI:NICU). Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) were classified according to the Acute Stress Disorder Scale (ASDS) and Posttraumatic Stress Disorder Checklist (PCL-5) respectively. The association between baseline PRF and parent self-reported feelings of attachment, measured by the Maternal, and Paternal, Postnatal Attachment Scales (MPAS/PPAS), and parental emotional functioning, was evaluated both while the infant remained in NICU and at 10 months of infant-age.

Evaluable data were available for 69 infants (67 mothers and 38 fathers) enrolled between July 2014 and April 2016. Baseline PRFQ subscale scores were similar to previously published studies. Baseline PRF scores from the PDI:NICU were available for 19 mothers. The mean overall score was 5.4 (SD 1.1, range 4-7), and the pattern of individual demand question scores was similar to previously published profiles. This indicates that PRF is measurable in the NICU-setting.

Paired PRFQ results at baseline and at 10 months were available for 57 parents. For mothers, the PRFQ subscales correlated closely over time, whereas for fathers only the Pre-Mentalizing Mode subscale was correlated. This suggests that the PRF being measured in NICU may be an enduring trait, rather than a state influenced by the acute condition, more for mothers than fathers.

PRF at baseline was highly correlated with self-reported attachment-quality at 10 months. Specifically, high PRFQ Pre-Mentalizing Mode (PM) subscale scores in NICU predicted dyads with subsequent “at risk” attachment, implying that parents with poorer PRF in NICU are more likely have parent-infant relationship difficulties as their child grows.

Acute stress disorder affected 38% of mothers and 41% of fathers at baseline. Higher baseline PRF, especially the PRFQ Interest and Curiosity about Mental States (IC) subscale, was associated with risk of concurrent ASD. Higher baseline IC scores were also associated with risk of PTSD at 10 months in mothers.

These findings present a dilemma. Lower capacity for PRF in NICU may jeopardise the developing parent-infant relationship, but higher PRF may create emotional trauma for parents. Infant Mental Health resources and a “nested mentalization” approach to care are vital for infants and their at-risk parents in NICU, so they can be held “in mind” in supported ways.