Quality Of Mother-infant Interaction Research Articles

Family nurture intervention (FNI): methods and treatment protocol of a randomized controlled trial in the NICU

BackgroundThe stress that results from preterm birth, requisite acute care and prolonged physical separation in the Neonatal Intensive Care Unit (NICU) can have adverse physiological/psychological effects on both the infant and the mother. In particular, the experience compromises the establishment and maintenance of optimal mother-infant relationship, the subsequent development of the infant, and the mother's emotional well-being. These findings highlight the importance of investigating early interventions that are designed to overcome or reduce the effects of these environmental insults and challenges.MethodsThis study is a randomized controlled trial (RCT) with blinded assessment comparing Standard Care (SC) with a novel Family Nurture Intervention (FNI). FNI targets preterm infants born 26-34 weeks postmenstrual age (PMA) and their mothers in the NICU. The intervention incorporates elements of mother-infant interventions with known efficacy and organizes them under a new theoretical context referred to collectively as calming activities. This intervention is facilitated by specially trained Nurture Specialists in three ways: 1) In the isolette through calming interactions between mother and infant via odor exchange, firm sustained touch and vocal soothing, and eye contact; 2) Outside the isolette during holding and feeding via the Calming Cycle; and 3) through family sessions designed to engage help and support the mother. In concert with infant neurobehavioral and physiological assessments from birth through 24 months corrected age (CA), maternal assessments are made using standard tools including anxiety, depression, attachment, support systems, temperament as well as physiological stress parameters. Quality of mother-infant interaction is also assessed. Our projected enrolment is 260 families (130 per group).DiscussionThe FNI is designed to increase biologically important activities and behaviors that enhance maternally-mediated sensory experiences of preterm infants, as well as infant-mediated sensory experiences of the mother. Consequently, we are enlarging the testing of preterm infant neurodevelopment beyond that of previous research to include outcomes related to mother-infant interactions and mother-infant co-regulation. Our primary objective is to determine whether repeated engagement of the mother and her infant in the intervention's calming activities will improve the infant's developmental trajectory with respect to multiple outcomes. Our secondary objective is to assess the effectiveness of FNI in the physiological and psychological co-regulation of the mother and infant. We include aspects of neurodevelopment that have not been comprehensively measured in previous NICU interventions.Trial RegistrationClinicalTrials.gov: NCT01439269

The effects of preterm birth on mother–infant interaction and attachment during the infant's first two years

Early mother-infant relationships in preterm populations were evaluated in the context of a systematic review of the literature. A systematic search of three electronic databases (PsychINFO, PubMed and Cochrane Library) was undertaken. Three studies of maternal attachment, 18 studies of mother-preterm infant interaction and eight studies of infant attachment were included. Studies of preterm infant attachment were also evaluated using a meta-analysis. Studies of mother-preterm infant interactions showed that the differences in maternal interaction behavior between mothers of preterm infants and mothers of full-term infants seem to be most evident during the first six months of life. Differences in the preterm infant's interaction behavior seem also to continue for six months after birth. However, five of 18 studies showed an equal or even higher quality of mother-infant interaction in groups of preterm compared to groups of full-term infants. Studies of maternal and infant attachment indicated that preterm infants and their mothers are not at higher risk of insecure attachment than full-term infants and their mothers. The mother-preterm infant relationship is complex, and some relational patterns forecast greater psychological risk than others. It is important to decrease maternal stress and early separation in every possible way during hospitalization as well as after discharge.

Longitudinal associations between the quality of parent−child interactions and children's sleep at preschool age.

This study aimed to examine the prospective longitudinal links between the quality of mother-child and father-child interactions and preschoolers' sleep. Three dimensions of maternal interactive behavior were considered using 70 mother-child dyads, while the quality of father-child interactions was assessed using 41 of these families. Maternal mind-mindedness was assessed at 12 months during a mother-infant free-play sequence, maternal sensitivity was rated at 12 months based on observations performed throughout a home visit, maternal autonomy support was assessed at 15 months with a 10-min problem-solving situation, and the quality of father-child interactions was scored at 18 months, during father-child free play. Children's sleep was assessed at 3 and 4 years using a sleep diary completed by mothers during 3 consecutive days. Results indicated that, after controlling for family socioeconomic status and daycare attendance, the quality of both mother-infant and father-infant interactions was positively related to children's percentage of night-time sleep at preschool age. These findings add to previous literature in suggesting that early caregiving behavior by both mothers and fathers is related to subsequent child sleep.

Further Validation of the ORSPI: An Observational Rating Scale of Parental Interactions with their Infants

Background and Aims: The quality of early mother-infant interaction predicts infant developmental outcomes and is an important target for intervention. This study aims to further establish the reliability and validity of the Observational Rating Scale of Parental Interactions (ORSPI) as a measure of mother-infant interaction. Method: i) Videos of 23 mothers interacting with their term-born three month old infant were rated using the ORSPI. Scores were compared to a matched group of 23 mothers with very preterm (VP; < 32 weeks) infants. ii) For 43 mother VP infant dyads, neonatal data were collected at discharge and mother-infant interactions were rated using the ORSPI at 3 months corrected age (CA). Infants' motor (PDI) and cognitive (MDI) development at 2 years CA was assessed using the Bayley Scales of Infant Development-II. Thirteen interactions were re-rated by a second rater to establish inter-rater reliability for the ORSPI. Results: i) Term dyads' ORSPI scores (median=10) were higher than VP dyads' (median=8) (p=0.03). ii) ORSPI scores significantly correlated with MDI (r=0.40) and PDI scores (r=0.62). Regression analyses found infant health (number of days ventilated) (p=0.03) and ORSPI scores (p=0.001) accounted for 40% of variance in PDI scores. Days ventilated (p=0.001) and ORSPI scores (p=0.07) accounted for 35% of variance in MDI scores. Inter-rater agreement was high (Intraclass Correlation = 0.86). Conclusions: The ORSPI has good criterion-related validity, predicting developmental outcomes and discriminating between term and pre-term infants. Inter-rater reliability was excellent supporting its strengths as a simple measure of early mother-infant interaction.

The effects of postnatal maternal depression and anxiety on the processing of infant faces

BackgroundPostnatally depressed mothers have difficulties responding appropriately to their infants. The quality of the mother–child relationship depends on a mother's ability to respond to her infant's cues, which are largely non-verbal. Therefore, it is likely that difficulties in a mother's appraisal of her infants' facial expressions will affect the quality of mother–infant interaction. This study aimed to investigate the effects of postnatal depression and anxiety on the processing of infants' facial expressions.MethodA total of 89 mothers, 34 with Generalised Anxiety Disorder, 21 with Major Depressive Disorder, and 34 controls, completed a ‘morphed infants’ faces task when their children were between 10 and 18 months.ResultsOverall, mothers were more likely to identify happy faces accurately and at lower intensity than sad faces. Depressed compared to control participants, however, were less likely to accurately identify happy infant faces. Interestingly, mothers with GAD tended to identify happy faces at a lower intensity than controls. There were no differences between the groups in relation to sad faces.LimitationsOur sample was relatively small and further research is needed to investigate the links between mothers' perceptions of infant expressions and both maternal responsiveness and later measures of child development.ConclusionOur findings have potential clinical implications as the difficulties in the processing of positive facial expressions in depression may lead to less maternal responsiveness to positive affect in the offspring and may diminish the quality of the mother–child interactions. Results for participants with GAD are consistent with the literature demonstrating that persons with GAD are intolerant of uncertainty and seek reassurance due to their worries.

The Capacity to See Things from the Child's Point of View—Assessing Insightfulness in Mothers with and without a Diagnosis of Depression

Insightfulness is seen as the mental capacity that provides the context for a secure child-parent attachment. It involves the ability to see things from the child's perspective and is based on insight into the child's motives, a complex view of the child and openness to new information about the child. To test our hypothesis that maternal insightfulness is related to maternal depression, we utilized the Insightfulness Assessment (IA) developed by Oppenheim and Koren-Karie to conduct and analyse interviews in which mothers discussed their perceptions of video segments of their interactions with their children. We compared the results of a control group of 30 mothers without a diagnosis of depression with a sample of 23 mothers diagnosed with depression (International Classification of Diseases, 10th Revision). As expected, depression was negatively related to maternal insightfulness. Oppenheim and Koren-Karie have argued that the IA might be used as a diagnostic instrument; our work suggests that the IA might show ways of aiding mothers in improving the quality of mother-infant interaction while they are being treated for depression. Insightfulness is seen as the mental capacity that provides the context for a secure child-parent attachment. Maternal depression was negatively related to maternal insightfulness. The Insightfulness Assessment might be used as a diagnostic instrument. The Insightfulness Assessment might show ways of aiding mothers in improving the quality of mother-infant interaction while they are being treated for depression.

Task-oriented and bottle feeding adversely affect the quality of mother-infant interactions after abnormal newborn screens.

To examine effects of newborn screening and neonatal diagnosis on the quality of mother-infant interactions in the context of feeding. Study compared the quality of mother-infant feeding interactions among 4 groups of infants classified by severity of newborn screening and diagnostic results: cystic fibrosis (CF), congenital hypothyroidism, heterozygote CF carrier, and healthy with normal newborn screening. The Parent-Child Early Relational Assessment and a task-oriented item measured the quality of feeding interactions for 130 dyads, infant ages 3 to 19 weeks (M = 9.19, SD = 3.28). The Center for Epidemiologic Studies Depression Scale and State-Trait Anxiety Inventory measured maternal depression and anxiety. Composite Indicator Structure Equation Modeling showed that infant diagnostic status and, to a lesser extent, maternal education predicted feeding method. Mothers of infants with CF were most likely to bottle feed, which was associated with more task-oriented maternal behavior than breastfeeding. Mothers with low task-oriented behavior showed more sensitivity and responsiveness to infant cues, as well as less negative affect and behavior in their interactions with their infants than mothers with high task-oriented scores. Mothers of infants with CF were significantly more likely to have clinically significant anxiety and depression than the other groups. However, maternal psychological profile did not predict feeding method or interaction quality. Mothers in the CF group were the least likely to breastfeed. Research is needed to explicate long-term effects of feeding methods on quality of mother-child relationship and ways to promote continued breastfeeding after a neonatal CF diagnosis.

Iron-Deficiency Anemia in Infancy and Mother-Infant Interaction During Feeding

This study was conducted to compare quality of mother-infant interaction during feeding in infants with or without iron-deficiency anemia (IDA). Infants and caregivers were screened at their 9- to 10-month-old health maintenance visits at an inner-city clinic in Detroit. Those who were full-term and healthy received a venipuncture blood sample to assess iron status. Of the 77 infants who met final iron status criteria, 68 infants and mothers were videotaped during feeding interaction at the Child Development Research Laboratory. The quality of mother-infant interaction during feeding was scored on the Nursing Child Assessment Feeding Scale. Twenty-five infants with IDA (hemoglobin [HB] <110 g/L and at least 2 abnormal iron measures) were compared to 43 nonanemic infants (HB > or = 110 g/L) using analysis of variance and general linear models with covariate control. Mothers of IDA infants responded with significantly less sensitivity to infant cues and less cognitive and social-emotional growth fostering behavior than mothers of nonanemic infants. The pattern of results was similar for scales of contingent behaviors. The magnitude of the differences in maternal ratings was large (0.8-1.0 SD after covariate adjustment). IDA infants were rated significantly lower on clarity of cues and overall (effect sizes 0.5 SD). IDA in infancy was associated with less optimal mother-infant interaction during feeding. Future interventions might target feeding interaction and consider effects on infant iron status and developmental/behavioral outcomes among IDA infants, as well as infant feeding practices per se.

Mellow Babies: A group intervention for infants and mothers experiencing postnatal depression

Maternal postnatal depression has been associated with both short- and long-term negative effects for the child’s emotional, social and cognitive well-being (Murray &amp; Cooper 1997; Halligan et al., 2007). Therapies that focus on supporting mothers have shown accelerated improvement in maternal well-being, but few positive effects for infants (Cooper et al., 2003; Murray et al., 2003). Where interventions focus on addressing mother-infant interaction there appears greater chance of benefit to both mothers and children (Poobalan et al., 2007).A small waiting list controlled trial of a 14-week Mellow Babies group intervention was carried out with 17 mothers and infants under one year. Mellow Babies aims to promote both mother-infant interaction and maternal well-being. Changes in maternal depression (Edinburgh Postnatal Depression Scale) and the quality of mother-infant interaction (video observation) were assessed.Maternal mood in mothers attending Mellow Babies improved, with a significant difference in EPDS scores, relative to the control group, at follow-up. Post-intervention, there was a significant difference in levels of positive interactions between groups, favouring mothers attending Mellow Babies. The difference in negative interaction between Mellow Babies and waiting-list control group approached significance, with less negative interaction observed between mothers and infants who attended the group. Participant feedback on the content and process of Mellow Babies was highly positive.The study showed benefits from Mellow Babies for mothers and infants who had exposure to postnatal depression. Further studies with longer-term follow-up and infant outcome measures may substantiate these initial findings.

Stile di attaccamento adulto, interazione precoce madre-bambino e rischio depressivo

- This report presents the preliminary data from a study conducted on 43 (primiparae) first time mothers with the aim of investigating possible links between the attachment style of the mothers to be, their mood disturbances during the transitional phase from pregnancy to early post-partum and the quality of their early interaction with the baby. We postulated that women with insecure attachment would show poorer sensitivity in the motherinfant interaction and a tendency towards a potentially depressed mood. The results established a link between the mother's attachment style and the quality of the early mother-infant interaction: particularly significant were the low scores in the area of maternal sensitivity which might be indicative of a reduced ability to attune to the baby's needs and difficulty in establishing and maintaining meaningful relationships.Key Words: Adult attachment style, early mother-infant interaction, maternal responsiveness, depressive risk

Video interaction guidance inviting transcendence of postpartum depressed mothers' self-centered state and holding behavior.

By sometimes evoking self-absorbed and avoidance behaviors in new mothers, postnatal depression affects the quality of mother-infant interaction, which in turn may invoke distress and avoidance in the infant and cause even more lasting impairment in the child's development. Three depressed mothers, A, B, and C, are reported upon after having been offered counseling in accordance with the Marte Meo approach through jointly watching with the therapist video replays of themselves interacting with their newborns. Clinical vignettes are offered which indicate how empathic and positive support of a sensitive therapist can be helpful in inviting the mother's recognition of her importance to her infant and facilitating mutually gratifying interaction between mother and child. Protocol analyses of select sessions of video-related therapy reveal that two of the mothers sometimes complete the therapist's unfinished statements in an other-centered manner, thereby transcending their initial self-centered state. This is most dramatic in the case of Mother A, who starts out in the first session almost incapable of speech, merely nodding or shaking her head. In addition to other indications of improved mother-infant interaction, comparison of pre- and postguidance windows regarding the three mothers' holding behaviors reveals a shift from an avoidance or anxious stance to closer and more secure holding.

Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances.Design...

Maternal anxiety and depression after a premature infant's discharge from the neonatal intensive care unit: explanatory effects of the creating opportunities for parent empowerment program.

Understanding the processes through which interventions work for mothers of premature infants is necessary for the advancement of science and the translation of efficacious interventions into clinical practice settings. To test a theoretical model examining the processes through which an educational-behavioral intervention program (Creating Opportunities for Parent Empowerment [COPE]) influences mothers' anxiety and depression 2 months after discharge of their premature infants from the neonatal intensive care unit (NICU). A secondary analysis was conducted using data from a randomized controlled trial with 246 mothers of low-birth-weight preterm infants who were assigned randomly to COPE or placebo control conditions. Measures included mothers' stress in the NICU, mothers' anxiety and depression, and mothers' beliefs about their infants and their role. Observers blind to study group condition also rated the quality of mother-infant interaction in the NICU. Structural equation modeling suggested that the model tested provided a reasonable fit to the data, chi2(64) = 97.67, p = .004, root mean square error of approximation = .046, comparative fit index = .97. Participation in COPE was both directly and indirectly, via associations with increased maternal beliefs and less maternal depression and anxiety in the NICU, related to mothers' decreased posthospital depression and anxiety. Participation in the COPE program also was associated with higher mother-infant interaction scores. Implementation of COPE could lessen postdischarge maternal anxiety and depression, which may improve outcomes for both mothers and preterm infants.

Does esophageal atresia influence the mother-infant interaction?

Purpose Chronic illness in infancy may influence parent-infant interaction. We assessed quality of mother-infant interaction in children with esophageal atresia (EA) and searched for predictors for impaired interaction. Methods The study group comprised 37 one-year-old infants with EA born in 1999 to 2002 and their mothers. A comparison group comprised 10 infants with urologic problems without feeding difficulties and their mothers. Parent Child Early Relational Assessment was used to assess mother-child interaction in feeding and play situation. General Health Questionnaire and State Trait Anxiety Inventory were used to assess maternal psychological distress and anxiety. Results Many aspects of mother-EA infant interaction showed strength. However, mothers of EA children were compared to control-mothers significantly influenced in their ability to interact and the EA-mothers' “positive affective involvement, sensitivity, and responsiveness” during feeding was in range of concern. Small but significant effect of the mother's feeling of incompetence on their interaction was found. Conclusion Mothers' attitude during feeding was negatively influenced in interaction between mother and infant with EA. The results suggest possibility for improvement in mother infant interaction by enhancing mothers' welfare when caring for infants with EA in medical services.

A Pilot Study to Test the Feasibility and Effectiveness of an Intervention to Help Teen Mothers and Their Mothers Clarify Relational Boundaries

Teen mothers and their mothers experience conflict due to poor relational boundaries. This conflict can result in maternal stress, which can affect the quality of mother-infant interactions. The purpose of this pilot study was to test the feasibility and effectiveness of an intervention to improve relational boundaries between teen mothers and their mothers. Seven first-time teen mothers living with their mothers or mother figures completed the cognitive-behavioral intervention. Participants evaluated each session and the accompanying homework. Relational boundaries were observed before and after the intervention. Results revealed many feasibility issues including scheduling, language, and sample recruitment. Findings are discussed, and recommendations for further research are offered.

A Randomized Controlled Trial of a Home‐Visiting Intervention Aimed at Preventing Relationship Problems in Depressed Mothers and Their Infants

This study examined the effect of a mother-baby intervention on the quality of mother-child interaction, infant-mother attachment security, and infant socioemotional functioning in a group of depressed mothers with infants aged 1-12 months. A randomized controlled trial compared an experimental group (n = 35) receiving the intervention (8-10 home visits) with a control group (n = 36) receiving parenting support by telephone. There were assessments pre, post, and follow-up after 6 months. The intervention had positive effects on the quality of mother-infant interaction. Infants in the experimental group had higher scores for attachment security and for one aspect of socioemotional functioning, namely, competence. The intervention proved successful in preventing deterioration of the quality of mother-child interaction.

Maternal behavior and maternal stress are associated with infant behavioral development in macaques

The simultaneous effects of naturally occurring individual differences in maternal care and maternal peripartum stress on infant development have been sparsely reported in nonhuman primates. In this work, we used a comparative approach to assess how changes in peripartum maternal excreted cortisol levels and the quality of mother-infant interactions correlate with infant behavioral development in group-living rhesus and Japanese macaques. We tested the hypothesis that peripartum maternal stress was associated with infant behavioral characteristics during development. Due to the difference in mothering style between the two species, we provided separated analyses for two groups. A sample of mother-infant pairs (Japanese macaques, N = 14; rhesus macaques, N = 10) was observed during the first 3 months of the infant's life. Follow-up observations (at 5, 7, and 9 months of age) were collected for the infants. Maternal cortisol levels were measured during the peripartum period. We found preliminary evidence that maternal peripartum stress and differences in key components of maternal behavior are associated with infant behavior throughout the developmental phase. We also provided a working hypothesis regarding maternal behavior and maternal stress as factors playing unique roles in different components of infant behavioral development.

Repercussões do comportamento interativo de mães com depressão no desenvolvimento do comportamento exploratório do bebê

O impacto da depressão materna para o desenvolvimento infantil tem sido amplamente estudado e vem sendo compreendido a partir de um referencial teórico interacionista, em que a qualidade da interação mãe-bebê é o foco de atenção nestes estudos. Os comportamentos interativos das mães com depressão costumam ser caracterizados como intrusivo ou retraído. Para os autores, ambos os estilos podem repercutir de maneira negativa no desenvolvimento do bebê, pois a estimulação e a modulação do estado de alerta que a mãe oferece são inadequadas para a regulação emocional do bebê. Pouco ainda se sabe sobre as repercussões dos estilos de comportamento interativo materno para o desenvolvimento do comportamento exploratório do bebê durante o primeiro ano de vida. Nesse sentido, o presente artigo procura refletir teoricamente acerca do desenvolvimento emocional do bebê e, em particular, sobre o comportamento exploratório do bebê no contexto da depressão materna. Inicialmente, busca-se descrever alguns estudos sobre a interação mãe-bebê e o desenvolvimento sócio-emocional no primeiro ano de vida, em seguida, estudos empíricos sobre o desenvolvimento do bebê no contexto da depressão materna, e finalmente, os estudos empíricos sobre os comportamentos interativos mãe-bebê no contexto da depressão materna. Para tanto, parte-se de algumas perspectivas teóricas, as quais entendem o desenvolvimento do comportamento exploratório do bebê a partir do sentido de competência e controle voluntário, assim como da exploração manual, tátil e visual, do direcionamento da atenção, das demonstrações de preferência e curiosidade, e capacidade de locomoção, bem como dos comportamentos de exploração do ambiente e cooperação. A importância de se considerar o comportamento da mãe para melhor compreender o desenvolvimento do comportamento exploratório do bebê advém da idéia de que a mãe precisa apresentar comportamentos de permissividade e encorajamento em relação aos comportamentos do bebê, promovendo o sentido de competência e controle voluntário do bebê, a fim de que este possa se separar e tornar-se seguro para explorar o ambiente. Da mesma forma, a expressão contínua do sentimento materno de confiança e expectativa durante os comportamentos de exploração do bebê é fundamental para o desenvolvimento e manutenção dos comportamentos de exploração bebê, o que independe do quadro depressivo materno.

Depressed and Well Mothers' Emotion Interpretation Accuracy and the Quality of Mother—Infant Interaction

AbstractThe inadequate parenting associated with mothers' depression may be related to mothers' problems in interpreting infants' emotional expressions. The relations between depressed and well mothers' accuracy at interpreting babies' facial expressions and the quality of the mothers' interactions with their infants were examined. In partial support of our hypotheses, depressed mothers' level of depressive symptoms was associated with less accuracy, especially regarding positive emotions. Contrary to expectations, depressed mothers did not differ from well mothers in terms of their emotion accuracy. Furthermore, depressed mothers' accuracy at interpreting infants' emotions was not significantly related to the quality of their interaction with their infants; in contrast, well mothers' accuracy for infants' negative emotions was associated with better interaction quality. These findings provide new information about depressed mothers' emotional interpretations and their parenting. The different pattern of findings for depressed and well mothers suggests that other mediating factors are important, which are discussed.

Infant-mother interaction as a predictor of child's chronic health problems.

Psychological stress is associated with physical illnesses like asthma or infections. For an infant, situations perceived as stressful are highly dependent on the relationship with the caregiver. Constantly poor mother-infant interaction increases the child's vulnerability to stressful conditions and experiences. The aim of the study was to investigate the impact of the quality of early mother-infant interaction on the subsequent physical health of the child. Poor mother-infant interaction was hypothesized to be associated with chronic or recurrent health problems in the child. Fifty-seven mother-infant dyads from families at risk of psychosocial problems and 63 from non-risk families, altogether 120 dyads, participated in the study. Families were drawn from normal population, from well-baby clinics in the city of Tampere, Finland. Infants were full-term and healthy, families with severe risks like psychotic illnesses of the parents or a history of child protection concerns were excluded from the study. After the initial interview with the mother, the mother-infant interaction was videotaped when the infants were 8-11 weeks of age and the interaction was assessed using the Global Rating Scale for Mother-Infant Interaction (Murray et al. 1996a). After the 2-year follow-up mothers were interviewed again and the health problems of the child were elicited. Poor dyadic mother-infant interaction and infant's poor interactive behaviour assessed at two months were separately associated with the physical health of the child during the two-year follow-up. After adjusting for other factors in the logistic regression analysis infant's poor interactive behaviour remained as a significant predictor of chronic or recurrent health problems in the child. Infant's health problems at the time of the initial interview and day care centre attendance were also significant predictors. The results suggest that interactional issues between a mother and her infant are related to the child's subsequent physical health. Children with recurrent or chronic health problems may have relationship difficulties with which they need help. Also, early avoidant behaviour of the infant should be regarded as an indicator of the infant's distress with possibly adverse outcomes in the child's physical health, among other consequences.