Infant-mother Attachment Research Articles

Deceased-infant carrying in nonhuman anthropoids: Insights from systematic analysis and case studies of bonnet macaques (Macaca radiata) and lion-tailed macaques (Macaca silenus).

Existing models of attachment do not explain how death of offspring affects maternal behavior. Previous descriptions of maternal responsiveness to dead offspring in nonhuman anthropoids have not expounded the wide variation of deceased-infant carrying (DIC) behavior. Through the current study, we attempt to (a) identify determinants of DIC through a systematic survey across anthropoids, (b) quantitatively assess behavioral changes of mother during DIC, and (c) infer death perception of conspecifics. Firstly, we performed phylogenetic regression using duration of DIC as the dependent variable. Secondly, we undertook case studies of DIC in the bonnet monkey and the lion-tailed monkey through behavioral sampling. Results of phylogenetic Generalized Linear Mixed Model (Nspecies = 18; Ncases = 48) revealed a strong homology (H2 = 0.86). We also obtained a high intraspecific variation in DIC and found DIC to be affected by mother's age, context of death, habitat condition, and degree of arboreality. We found bonnet mothers to carry their deceased offspring for 3.56 ± 4.03 SD days (N = 7) with diminished feeding, enhanced passivity, and social isolation during DIC and progressive decline in protection/attentiveness of corpse and attachment. Following Anderson (2016)'s framework of death perception, we interpreted repeated sensory investigation of corpses by mothers as comprehending causality of death, inanimate handling of corpse and its defense as comprehension of non-functionality, and a progressive disinterest of mothers in them as perceiving irreversibility of death. Lastly, we integrated DIC with mother-infant attachment theories and proposed a conceptual model characterizing DIC with causal determinants. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Systematic Review of Psychometric Properties of the Edinburgh Postnatal Depression Scale in Iranian Population

Background: Regarding adverse effects of postpartum depression on maternal mental health and the reduction of mother-infant attachment, there is a need to comprehensively understand Edinburgh Postnatal Depression Scale (EPDS). We aimed to review the validity and reliability of the EPDS in Iranian population to provide comprehensive information for the health providers. Materials and Methods The search procedure was fulfilled on the databases of Medline (via PubMed), Scopus, Cochran Library and Web of Science from inception to April 2018. The quality of studies was assessed by COSMIN checklist. Search keywords include (Edinburgh Postnatal Depression Scale) AND (Psychometric Properties). Results: Three studies identified a two-factor structure and one study found a three-factor structure. Discriminant validity of the EPDS was able to differentiate three groups (minor depression, major depression, and healthy women); but failed to distinguish between women with caesarean section, and women with normal delivery. Internal consistency was reported by four studies. Cronbach’s alpha ranged from 0.7 to 0.79 for total EPDS score. Test-retest reliability was reported only in a study with Intraclass Correlation Coefficient (ICC) > 0.80. In terms of convergent validity, the EPDS was significantly positively correlated with General Health Questionnaire (GHQ) (r=0.76; p<0.001), and Hamilton Depression Rating Scale (HDRS) (r=0.62, p<0.001), and negatively with Short Form Health Survey (SF-36). Sensitivity was almost 0.74%, and specificity ranged from 0.80% to 0.93% at the cut-off point of Conclusion Evidence to support the validity and reliability of the EPDS in Iranian population is sufficient as a screening tool for postnatal depressionto decrease damage to the mother and the baby.

*The efficacy of the attachment-based SAFE® prevention program: a randomized control trial including mothers and fathers

ABSTRACTSAFE® is a primary prevention program to promote secure infant-parent attachment. SAFE explicitly addresses mothers and fathers. In this current first study, efficacy was assessed in a low-risk German sample using a randomized control trial with an active control intervention. A high rate of fathers’ participation was achieved: in SAFE 84.6% and in the control group intervention 73.9% of the fathers participated. Infant-parent attachment was assessed at the end of the year-long programs. There was a significant difference between groups in terms of secure infant-father attachment, but not of infant-mother attachment. In SAFE, 84.6% of the infants were securely attached to their father (n = 39), in comparison to 65.8% in the control group (n = 38). The proportion of secure infant-mother attachment was 66.7% in the SAFE group (n = 54) and 64.0% in the control group (n = 50). The program was successful in promoting infant-father attachment security.

Cross-Cultural Affective Neuroscience.

Panksepp, the father of Affective Neuroscience, dedicated his life to demonstrate that foundations of mental life and consciousness lay in the archaic layers of the brain. He had an evolutionary perspective emphasizing that the subcortical affective systems come prior to cortical cognitive systems. Based on his life-long work, the Affective Neuroscience Personality Scales (ANPS) was constructed, and a new neurodevelopmental approach to personality was started. The new approach suggested that personality was formed based on the strengths and/or weaknesses found in the subcortical basic affective systems, which are initially regulated by the mother-infant attachment styles and later by early life experiences. ANPS measured six basic affects: CARE, PLAY, SEEK, SADNESS, FEAR, and ANGER; along with a Spirituality subscale. Up to date, it has been translated to several languages, and these studies confirmed that ANPS is a reliable and valid tool. Based on the observation that these ANPS studies have both universal and culturally specific findings, cross-cultural affective neuroscience (CAN) was initiated in 2012, with the approval of Panksepp. As a new research field, CAN aims to investigate the influence of culture on the regulation of basic affective systems. CAN claims that this influence can be studied by observing the cultural variations in (1) the level of emotional interdependency, (2) the types of reinforced or suppressed affects, and (3) the types of affects that accompany interdependent or independent self-construals. Cross-cultural comparisons of Turkish and American ANPS findings and the results of our first Euro-Asian CAN project among Japan, Turkey, and Germany support these claims. These cultures regulate the basic affective systems in unique ways, while maintaining certain similarities with each other. In a way, each culture has a unique affective personality profile and a specific function in the global affective network. The conclusion of this review shares guidelines, suggestions and ethical codes for future CAN researches.

Postpartum Depression Experience Among Jordanian Mother With Hospitalized Infant in Neonatal Intensive Care Unit: Incidence and Associated Factors

Postpartum depression (PPD) is a global mental health problem that affects about 13% to 19% of mothers who have recent given birth. This problem increases if the infant is admitted to the intensive care unit (NICU). The aims of this study were to examine the prevalence and risk factors of postpartum depression among mothers with hospitalized infant on NICU and to explore mothers experience after admitting their infants to the NICU. A varied methods research design were undertaken in two hospitals in Jordan. The Edinburgh Postpartum Depression Scale (EPDS) was used to survey 188 Jordanian mothers with infants in the NICU, it deals with semi-structured in-depth interviews to identify the themes that characterize mothers PPD experience in the NICU. The quantitative results of this study showed that the mothers with hospitalized infant in NICU experienced high level of PPD with the mean score was 20.81 (SD = 4.92). With regard to qualitative results, two major themes with nine subthemes : the first one is Postpartum Depression Experience and the second theme was sources that influence postpartum depression. &#x0D; &#x0D; In conclusion, the mothers with hospitalized infant in NICU experience PPD. the PPD mothers experience many manifestations during this situation such as : shock, surprise, crying, Anhedonia,hopelessness and thinking about harming themselves or their babies after admission of their infants to the NICU, Also there are many sources that influence postpartum depression such as baby gender, lack of knowledge, social support, mother role, mother infant attachment, stigma and shame.

Korean infant–mother attachment security: longitudinal predictions of peer play interactions and behavioural problems in early childhood

ABSTRACT This study aimed to examine the effect of attachment security in 17-month-olds on their peer play interactions and behavioural problems at ages 4 and 6 years, respectively, in Korea. By employing structural equation modelling, we analyzed the data of 183 children and their mothers, which were extracted from the Panel Study on Korean Children (2009–2013). The results indicated that higher attachment security at 17 months was associated with positive play interactions with peers at age 4, which in turn led to fewer internalizing and externalizing problems at age 6. Conversely, lower attachment security at 17 months was related to negative play interactions with peers at age 4, which in turn led to more externalizing problems at age 6. These findings highlight the importance of early infant–mother attachment security to enhance peer competence and protect against behavioural problems in early childhood.

Is one secure attachment enough? Infant cortisol reactivity and the security of infant-mother and infant-father attachments at the end of the first year

ABSTRACTAttachment security is theorized to shape stress reactivity, but extant work has failed to find consistent links between attachment security to mothers and infant cortisol reactivity. We examined family configurations of infant-mother and infant-father attachment security in relation to infant cortisol reactivity. One-year old infants (N = 180) participated in the Strange Situation with mothers and fathers in two counterbalanced lab visits, one month apart (12 and 13 months). Infants with secure attachments only to their fathers and not their mothers had higher cortisol levels than infants with a secure attachment to mother and also exhibited a blunted cortisol response (high at baseline and then a decrease after stress). Results suggest that a secure attachment to father may not be enough to reduce infant stress reactivity when the infant-mother attachment is insecure, and future research is needed to uncover the family dynamics that underlie different family configurations of attachment security.

Individual Differences in Maternal, Marital, Parenting and Child Outcomes Following Perinatal Loss: A Longitudinal Study

ABSTRACTObjective: To examine the impact of past perinatal loss on mothers and children in a community sample and to consider maternal race and adult attachment status as moderators.Background: Prior perinatal loss has been shown to impact subsequent maternal parenting and child outcomes, but findings have been inconsistent particularly in minority mothers and samples not chosen due to perinatal loss history.Methods: Participants were 204 first-time mothers from a longitudinal study about predictors of sensitivity. Mothers completed the Adult Attachment Interview prenatally and reported on depressive symptoms and marital satisfaction prenatally and at 6 months and 1 year postpartum. Maternal sensitivity was observed at 6 months and 1 year, and infant-mother attachment security was assessed via the Strange Situation when children were 1 year old. Mothers reported on their reproductive history and current attitudes about the target child during the preschool period.Results: Fifty-eight (28.43%) mothers had a history of prior perinatal loss. Between group analysis revealed no differences based on perinatal loss and no moderation by maternal race or adult attachment. However, within the loss group, mothers who experienced losses later in the gestational period had less positive feelings about parenting and their children had less secure attachments to them; and mothers who had more perinatal losses had higher depressive symptoms at 1 year postpartum and less positive attitudes about parenting independent of race and SES.Conclusion: In the circumstance of multiple and later perinatal losses maternal well-being and child outcomes may be negatively impacted.

Infant-directed speech enhances recognizability of individual mothers’ voices

Adult speakers commonly alter their voices when talking to infants, giving rise to an infant-directed speech (IDS) style. Here we tested the effects of infant-directed speech on the recognizability of a speaker’s voice. 10 Swiss-German mothers were recorded talking to their infants IDS and talking to an adult experimenter (in adult-directed speech, ADS). We studied the indexical properties using Mel-frequency cepstral coefficients (MFCCs). By using an unsupervised K-means clustering algorithm, the segmental 13-dimensional MFCCs were clustered and reduced to two dimensions using Principal Component Analysis. Results showed that the relative area of IDS occupied in the 13-dimensional space was significantly larger compared to the area occupied by ADS. A supervised language-independent Gaussian Mixture Model revealed that this expansion benefitted the recognizability of mothers’ voices. This means that the higher indexical variability in IDS fosters recognition of individual mothers. Results are consistent with the view that IDS may have evolved in part as a strategy to promote indexical signaling by a mother to her offspring, thereby promoting mother-infant attachment and fostering offspring survival.

The role of mother-infant bond in neonatal abstinence syndrome (NAS) management

The opioid crisis affects pregnant women and their infants. In the past two decades, the number of infants born with neonatal abstinence syndrome (NAS) has quadrupled causing the cost of healthcare expenditures to climb sharply. Pharmacological and non-pharmacological approaches are recommended for the management of NAS. Despite the attention NAS has recently received, treatment recommendations are limited to the hospital setting with much less focus on discharge planning. Additionally, the literature on NAS management does not consider research promoting mother-infant attachment. Recently, more emphasis has been placed on taking a holistic approach to NAS management. However, scholarly writings and research in this area are scarce. This article provides a review of current literature on NAS management and attachment-based interventions. Recommendations for practice and future research focused on holistic, non-pharmacological approaches to NAS management are provided.

Preterm Infant Neurodevelopmental Care Training Program and Mother-Infant Attachment

Objectives: Preterm birth and admission to the neonatal intensive care unit (NICU) would disrupt mother-infant attachment. Neurodevelopmental care training and support of family programs are essential for the family of such infants. The purpose of this study was to investigate the effect of neurodevelopmental care training program for mothers with preterm infants on mother-infant attachment at one month’s age. Materials and Methods: Study population included all the mothers of preterm infants born in the hospitals of Tehran in 2018. The research was designed as a multicenter cluster clinical trial and four hospitals were randomly selected and divided into intervention and control groups. Before the intervention, the mother-infant attachment was measured by the Maternal-Postnatal Attachment Scale (MPAS). The mothers in the intervention group received a 12-session preterm infant neurodevelopmental care training program while the control group only received the routine care in the unit. Finally, the mother-infant attachment was re-measured in both groups at the one month corrected age. Results: No significant difference was observed in the attachment score before and after the intervention in the control group but the mother-infant attachment score was significantly different in the intervention group (57.75±11.09 vs. 78.27±4.54). Conclusions: The neurodevelopmental care training program was effective and increased the mother-infant attachment rate.

Mother-infant cortisol attunement: Associations with mother-infant attachment disorganization.

This study explores the conceptualization of mother-infant cortisol attunement both theoretically and empirically, and its association with mother-infant attachment disorganization. In a community sample (N = 256), disorganization and cortisol were assessed during the Strange Situation Procedure (SSP) at infant age 17 months. Salivary cortisol was collected at baseline, and 20 and 40 min after the SSP. We utilized three statistical approaches: correlated growth modeling (probing a simultaneous conceptualization of attunement), cross-lagged modeling (probing a lagged, reciprocal conceptualization of attunement), and a multilevel model difference score analysis (to examine the pattern of discrepancies in mother-infant cortisol values). Correlated growth modeling revealed that disorganized, relative to organized, dyads had significant magnitude of change over time, such that, among disorganized dyads, as mothers had greater declines in cortisol, infants had greater increases. The difference score analysis revealed that disorganized, relative to organized, dyads had a greater divergence between maternal and infant cortisol values, such that maternal values were lower than infant values. Disorganized attachment status was not significantly associated with attunement when conceptualized as reciprocal and lagged in the cross-lagged model. Findings suggest that mother-infant dyads in disorganized attachment relationships, who are by definition behaviorally misattuned, are also misattuned in their adrenocortical responses.

Father-child play, child emotional dysregulation, and adolescent internalizing symptoms: A longitudinal multiple mediation analysis.

Emerging literature suggests fathers may contribute uniquely to child development and emotional health through play. In the present study, a multiple mediational model was analyzed using data from 476 families that participated in the NICHD Study of Early Child Care and Youth Development. After accounting for infant-mother attachment, infant temperament, and family income and stability, a significant indirect effect from father-child play quality to adolescent internalizing symptoms was found through father-reported child emotional dysregulation, B = -.05, 95% confidence interval; CI [-.14, -.01]. Specifically, in first grade, dyads where fathers were rated highly on sensitivity and stimulation during play, and children demonstrated high felt security and affective mutuality during play, had children with fewer father-reported emotional dysregulation problems in third grade, B = -.23, 95% CI [-.39, -.06]. Children with fewer emotional dysregulation problems had lower self-reported internalizing symptoms at age 15, B = .23, 95% CI [.01, .45]. Mothers' ratings of children's emotional dysregulation were not a significant mediator. Results are discussed regarding the importance of father-child play for children's adjustment as well as the usefulness of inclusion of fathers in child developmental research.

Cortisol secretion moderates the association between mother-infant attachment at 17 months and child behavior at age 5 years.

This study examined infant cortisol secretion as a moderator of the association between mother-infant attachment security at age 17months and child behavior at age 5years. A longitudinal community sample of 96 mother-child dyads participated in the strange situation procedure (SSP) at age 17months. Cortisol was collected at baseline, and at 20 and 40min post-SSP. Maternal reports of child behavior were collected at age 5years. Results revealed that the associations between nonsecure mother-infant attachment and higher total, internalizing, and externalizing behavior were stronger for infants with high cortisol secretion, relative to infants with low cortisol secretion. The model of interaction differed depending on the outcome, with diathesis-stress explaining variance in total as well as internalizing behavior, and with differential susceptibility explaining variance in externalizing behavior. These findings augment our understanding of risk and resilience to the impact of the early rearing environment on later psychopathology.

Mother–infant attachment, musical idol worship, and the origins of human behaviour

Actors, sportspeople, and politicians may be idolised for their appearance, personality, skills, or ideals. The idolisation of musicians additionally involves transcendental musical emotions. Fans devote extraordinary amounts of time, energy and money to following, empathising with, identifying with and imitating their idols. During great performances, fans experience altered states of consciousness. Existing evolutionary approaches can explain social dominance hierarchies but not specific fan behaviours. Another approach involves the mother schema: the perceptions, cognitions, and emotions that the late foetus and early infant (3rd and 4th trimesters) associate with the mother and her changing behaviours and physical/emotional states. The mother schema was an evolutionary response to the fragility (altriciality) of human infants, born earlier due to a larger brain and upright gait. Active reciprocal interactions between infants and carers (e.g. motherese) involve both the carer’s infant schema and the infant’s mother schema. In later life, the typical emotions of the mother schema are evoked by stimulus patterns reminiscent of the mother as perceived by the infant. In ritual situations, where the focus is on shared subjectivity, similar patterns and emotions are created. Evolutionary by-products of the mother schema include musical behaviours, religious behaviours and musical idol worship. The theory can explain why musical idols are perceived as all-loving, all-knowing and/or all-powerful, and is consistent with psychosocial functions of music and religion such as social cohesion and identity, collective motivation, empathy and mood regulation, catharsis and coping, distraction and entertainment, conflict resolution, and skill transfer.

ON BEING MOTHER AND PATIENT: DIALECTICAL STRUGGLES DURING MEDICALLY HIGH-RISK PREGNANCY.

Medically high-risk pregnancy (MHRP) affects 3 to 10% (diagnosis-dependent) of pregnant women in the United States (National Institute of Child Health Development, 2015), threatening maternal and fetal well-being. Although mothers' prenatal distress and mother-infant attachment after birth have been quantitatively researched, little research has examined women's lived experiences of MHRP in the United States. We examined 16 women's experiences of MHRP during hospitalization at an urban, Northeastern U.S. hospital using an interpretive phenomenological approach. Our qualitative findings provide new understanding of how women expend tremendous energy simultaneously navigating new roles of mother and patient. While negotiating these roles, they experienced dialectical struggles and uncertainty relating to emotion management, locus of control, appraisals of self/others, and relational self. Women managed these conflicts within the contexts of their emerging maternal identity, patient-provider relationships, and social relationships. Women struggled as they managed emotion, determined their level of responsibility for fetal outcomes, appraised others and themselves, and worried about how they were perceived. This amplified distress and contributed to women's emotional exhaustion, sense of being overwhelmed, and stress burden. New explication of these energy-depleting dynamic processes underlying women's experiences of MHRP and their impact on the future mother-infant relationship is considered, and strategies for psychosocial support are identified.

Maternal-fetal emotional relationship during pregnancy, its related factors and outcomes in Iranian pregnant women: a panel study protocol

BackgroundConsidering the importance of attachment in child’s development and mother’s health, various related factors and also lack of necessary information in this regard in our country, the research team decides to conduct this study to evaluate maternal-fetal attachment during pregnancy, its changes and post-partum consequences on mother-infant relationship. This process should be studied during pregnancy and also after delivery so that the effect of related factors and the changes in attachment over time could be determined and comprehensible information about the effective underlying conditions on this issue would be gathered.MethodsThe present research is a longitudinal study (panel study). Data gathering would start at the first trimester, continue during second and third trimesters of pregnancy, first visit after delivery, second, fourth and end sixth months later. Pregnant women in the first trimester would be selected and contacted. If they have inclusion criteria, they would be selected as a participant. At first, their demographic-reproductive characteristics, Beck Depression Inventory (BDI), Spielberger State-Trait Anxiety Inventory (SSTAI), The Social Support Appraisal (SSA), Adult Attachment Scale (AAS) and Parental Bonding Instrument (PBI) would be completed; during the second trimester, BDI, SSTAI and Cranley’s Maternal-Fetal Attachment Scale (CMFAS) would be completed. In the third trimester, the same questionnaires would be completed.During the first month after birth, Avant’s questionnaire of Mother-Infant Attachment Behaviors would be completed. At the second, fourth and sixth months after delivery Muller’s Mother -Infant Attachment Scale would also be completed.DiscussionThe results of the study will be provided to maternal child health policy-makers in the health system. This information could not be obtained through cross-sectional studies and through one episode of data collection and more studies are needed to provide us a perspective of the mother-infant relation over time. Studying attachment during pregnancy would provide us a chance to learn more about this process.

Attachment security and cortical responses to fearful faces in infants

ABSTRACTThe present study measured event-related potentials (ERPs) to investigate whether cortical responses to facial expressions of fear are associated with the development of secure and insecure patterns of infant–mother attachment during the first year. Based on previous findings showing reduced attentional biases to fearful faces in infants with insecure and disorganized attachment, we hypothesized that insecure and disorganized attachment would be associated with reduced ERP differentiation of fearful from non-fearful faces. ERPs to facial expressions were measured at 7 months of age and attachment was assessed at 14 months of age with the Strange Situation Procedure (n = 61). Occipitotemporal face-sensitive ERP responses particularly in the time range of the N290 component were related to attachment security at 14 months. Only securely attached infants showed age-typical cortical discrimination of fearful from non-fearful faces at 7 months, whereas a similar pattern of ERP responses was not observed in infants with insecure and disorganized attachment. These results add to previous findings by suggesting that patterns of secure and insecure infant attachment are related to early-emerging differences in the perceptual processing of facial emotions, which could have implications for the development of social competence.

The effectiveness of Kangaroo Mother Care (KMC) on premature infant health progression in a neonatal care unit in Maternity and Children’s Hospital, Jeddah

Background: Preterm birth is considered to be the largest direct cause of neonatal mortality. Of all early neonatal deaths that have occurred within the first 7 days of life, 28% are due to preterm birth. The Kangaroo Mother Care (KMC) decreases risk of mortality, infection severity, increases infant growth, breastfeeding, and mother-infant attachment. The aim of this study is to evaluate the effectiveness of Kangaroo Mother Care on premature health progression in the neonatal care unit in the Maternity and Children’s Hospital, Jeddah. Method: Study Design: A quasi-experimental design was chosen, using data collected via the Kangaroo Mother Care Assessment Flow Sheet. Setting: Maternity and Children’s Hospital (MCH) Al-Mousaa'dya branch, a Ministry of Health (MOH) Governmental hospital, Jeddah, KSA Sample: A convenient Sample of thirty premature neonates who fulfilled the inclusion criteria who were admitted on the neonatal intensive care unit at the mentioned setting during data collection period. Permission had been obtained from all mothers of participating infants. A control group was used for comparison. Tools and instruments: The data were collected using the Kangaroo Mother Care Assessment Flow Sheet. Result: the survival rate of study group is very high as no death was noted, no statistical differences before and after KMC but the data showed that the health status of neonate was stabilized, also findings showed that weight gain increased from 1.36 kg in the first attempt to 1.48 Kg in the fifth attempt. Regarding length of stay, study group neonate had higher length of hospitalization (48±19.87) comparing to other studies Conclusion: Kangaroo Mother Care maintains all premature neonatal physiological parameters and weight gain while the neonatal length of stay in current study was high compared to other global studies. Recommendation: There is a necessity to implement KMC at all NICU in Ministry of Health Hospitals, to develop a protocol and guidelines for KMC implementation. To organize continuing nurse training and education program for neonatal intensive care units nurses. Further studies should be conducted on a larger scale in Kingdom of Saudi Arabia for generalizability and to study the factors of prolonged neonatal length of stay on NICU.

Predisposing Factors for Elevated Restricted and Repetitive Behavior in Typically Developing Toddlers.

Little is known about the relation between levels of restricted and repetitive behavior (RRB) in infants and parent factors. The present study investigated maternal and psychosocial factors (depressive symptoms, socio-economic status, social support) and mother-infant engagement factors (mind-mindedness, sensitivity, and infant-mother attachment security) as predictors of children's RRB at age 26months in a sample of 206 mothers and children. Maternal depressive symptoms predicted levels of sensory and motor repetitive behavior and rigid, routinized, and ritualistic repetitive behavior. Lower socioeconomic status also predicted independent variance in children's sensory and motor repetitive behavior. The relations between maternal depressive symptoms and both types of RRB were not mediated through observational measures of maternal sensitivity or mind-mindedness at 8months, or attachment security at 15months. The results are discussed in terms of whether stress regulation, self-stimulation, and genetic susceptibility can help explain the observed link between maternal depressive symptoms and RRB in the child.