Each year, 2% to 9% of the newborns require specialised care in neonatal intensive care units (NICU). The majority are premature infants (born before 37 weeks of gestational age) who weigh less than 2500 g at birth. Modern medical technology has forced back the frontiers of viability so that a growing number of babies, even as young as 23 to 24 weeks gestation with weights as low as 500 gram, are currently surviving . With the improved survival chance of preterm infants, there is a growing concern for their developmental outcome and future quality of life.
Studies have consistently found a high incidence of abuse among children with a history of neonatal medical problems, premature birth and low birth weight [2, 3]. Infants experiencing poorer fetal growth or preterm birth are at increased risk of physical, emotional, or abuse or neglect independent of maternal age and socioeconomic status . One of the explanations proposed for the relation between neonatal problems and non-optimal parenting is a delay or disturbance in parent-infant bonding. This hypothesis suggests that due to neonatal problems, the development of an affectionate bond between the parent and the infant is impeded . The disruption of an optimal parent-infant bond -in its turn- may pre-dispose distorted parent-infant interactions and thus facilitate abusive or neglectful behaviours. However, this hypothesis has not been tested empirically in a prospective study.
Bonding & attachment
Parental bonding and attachment are two interrelated concepts. “Bonding” can be described as: “the establishment of an emotional connection of the parent to the infant” . This bond is not assumed to be bidirectional per se; it is more seen as unidirectional, from the parent to the infant. The process of forming a bond with a baby begins during pregnancy and develops further after birth. Forming such a bond is fundamental for the development of the baby . The process of bonding, in its turn, sets the stage for the evolvement of attachment, which develops later in childhood , and which can be described as: ‘the capacity to form selective, enduring and mutual relationships” [8–10].
Premature birth may impede or disturb parental bonding and the later relationship between parent and child. The process of bonding from the parent to their infant may be compromised due to several causes. . Early separation attributable to the infant’s bio-medical complications, invasive medical treatments, as well as the anticipated loss of the baby may result in physical and emotional distance between parents and their preterm newborn . These circumstances can be so emotional, frightening and overwhelming for parents that they turn away from their baby. Alternatively, these feelings may push them to overstimulate the baby in a desperate search for a reassuring response from the infant. At the same time, parental negative feelings (e.g. confusion, detachment, fear) may impede the establishment of a well-balanced parent-infant relationship and can be the source of parent-infant attachment difficulties [13, 14].
Psychological stress responses
The first years after birth are a unique emotional experience for most parents, also when the infant is born at term and in good health. . However, parents of preterm infants face many specific problems engendered by timing of birth, a prolonged hospital stay, distinctive patterns of behaviour, and development in the infant’s early years. Parents’ expectations for a normal delivery and giving birth to a healthy infant are violated, and they must come to terms with disappointment and possible loss as well as fears for their infant’s health and future [16, 17]. Parents of premature infants nurture under stressful, hectic and worrying circumstances. This stressful aspect of preterm birth and its psychological impact on parents have long been acknowledged .
The stressful nature of the Neonatal Intensive Care Unit (NICU) environment for parents is also well documented. The physical environment is a major source of stress for parents, with bright lights, noisy life support and monitoring equipment, and chemical scents. Furthermore, viewing their ill infant connected to equipment by tubes and wires and surrounded by medical personal can be very disturbing. However, the greatest source of stress experienced by these parents is often the loss of their expected and desired parental role. Parents often report feelings of disappointment and frustration because they cannot perform their normal parenting task (e.g. feeding) as they had expected. Moreover, they also may feel extreme distress and helplessness about not being able to protect their infant from harm .
Parents’ emotional reactions to the NICU experience can vary from disappointment, guilt, sadness, depression, hostility, anger, fear, anxiety, grief, helplessness to a sense of failure and loss of self-esteem . After birth of a premature infant, high levels of depression and anxiety are common for both parents [21, 22]. One month after birth, mothers of premature infants have been found to be at greater risk of psychological stress than mothers of full-term infants , with 10% of mothers of premature infants in one study experiencing severe symptoms of psychological distress neonatally and one third experiencing clinically levels of depression and anxiety .
Only recently a few studies have examined preterm birth and parents’ experiences from a trauma perspective. Studies indicate that parents of preterm infants report a high incidence of PTSD reactions, still lasting 1 year after the infant’s birth [25–28]. Feelings of depression, anxiety and post traumatic stress may negatively interfere with parent-infant interaction .
Parent - infant interaction
The quality of the parent-infant interaction is an important mediating factor between perinatal risk and later infant competencies. Important characteristics of parent-infant interaction are sensitive and responsive interactional behaviour, which -in its turn- fosters optimal infant cognitive and social development [24, 30–33]. ‘Parental sensitivity’ can be described as: the ability to perceive infant’s signals accurately, and ‘parental responsiveness’ as the ability to respond to these signals promptly and appropriately . Well-timed parent-infant interaction attuned to infants’ cues, helps to regulate infants’ physiological (e.g. heart rate, respiration and body temperature), behavioural, social and emotional responses (e.g. distress) .
The birth of a premature infant and its hospitalization interrupt the expected development of interactive skills for both the parents and the infant. First of all, parents cannot hold and nurture their baby frequently or spontaneously. In addition, parents are dependent on the nursing staff to support them. Adding to the stressful situation, the distinctive physical appearance and behavioural characteristics of premature infants may also impede the development of positive parent-infant relationships .
Research has shown that the appearance of preterm infants is judged as less attractive than full term infants and their behaviour is observed as less alert, less attentive, less active and less responsive than that of full-term infants. Furthermore, preterm infants engage in fewer broad smiles, are relatively fussy and irritable, are more difficult to soothe, show more mixed behavioural cues, show more sensory-defensive behaviours and are described as more temperamentally difficult than term peers. Moreover, preterm infants diverge in the way they cry; babies who have experienced stressful medical conditions differ acoustically from healthy infants, namely the sound of their crying is perceived as more aversive and physiologically arousing to adults than those of full-term infants [37–47].
Several studies have examined the interaction styles of parents, in particular mothers, of preterm infants during the neonatal period [1, 37–39, 48–50]. However the findings until now are still inconclusive. Some preterm mothers are focused in their interaction towards stimulation, while others show more affective withdrawal. A possible mediating factor in interaction style is the presence of post traumatic stress in parents. Mothers of preterm infants with post traumatic stress symptoms were more likely to have “controlling” dyadic patterns of interaction and to show distorted infant representations. Preterm infants of these “controlling” dyads have significantly less positive outcomes compared to full-term infants. They display more behavioural problems (particularly eating problems) and have lower developmental social skills.
The (over)stimulating approach of preterm mothers has been a point of discussion, considered by some authors as an adaptive and compensatory reaction to the specific difficulties presented by the preterm infant’s immaturity, and seen by others as intrusive and controlling behaviour, unfavourable to the preterm infant’s outcome [1, 38, 51]. These distinct findings can partially be explained by major advances in neonatology over the last 20 years, to greater parental attendance and participation in the infant’s care in the NICU, as well as to the improved emotional support given to the parents during the neonatal period. However, since smaller and more immature preterm infants are currently surviving, with longer hospitalisations; parent-infant interactions and parent-infant relationships are still at risk .
The barriers to parenting experienced in the NICU and parents’ psychological stress responses after delivery of premature infants, may negatively influence the parent-infant relationship and the infants’ long-term developmental outcome. The postponement of parenting and the emotional and psychological stress, may cause parents not being able to emotionally connect to their infant at time of discharge, and may contribute to greater parenting risk and child vulnerability [24, 53, 54]. These findings highlight the importance of therapeutic interventions during hospitalisation in the NICU aiming at improvement of parent-infant interactions and early parental- therapeutic support focusing on the psychological impact after premature birth. .
In general, early individualized family based interventions during neonatal hospitalisation and the transition to home, have been shown to reduce parental stress and depression, increase parental self-esteem, and improve positive early parent-preterm infant interactions . During hospitalisation parental self-confidence has to be reinforced repetitively and evaluated before discharge because insecure parents at discharge are more likely to have problems with their infants at home, which may lead to persistent parent-infant relationship problems .
Parents with infants at risk (e.g., ill or premature infants) may need additional support to develop well-balanced positive relationships. Parents of premature infants often experience ambivalent or negative emotions toward their infants and/or about themselves during hospitalisation and after discharge. Half of the mothers of very preterm infants felt that they had to cope with negative feelings when first seeing their infant and 65% had negative or ambivalent feelings in the first weeks at home after hospital discharge. These results suggest that these mothers may require support in coping with negative feelings concerning these early experiences. Parental support could start immediately after birth to promote initial moments of positive interaction between parent and infant .
Preventive post-hospital discharge interventions focused at preterm infants and their parents may improve social and emotional developmental outcomes [56–58]. Research has shown that preventive trauma intervention for mothers resulted in significantly less traumatic impact at discharge, although without intervention 77% of preterm mothers showed significant psychological trauma 1 month after birth and 49% 1 year later . Joined observations of the infant’s social cues guided by mental health practitioners, help parents to better understand and attune to their infants individual characteristics and the premature infant’s salient limitations in their social interaction. The process of joint observation stimulates parental attention and preoccupation with the baby, parental competence in reading the infant’s cues and responding sensitively and responsively to the infant’s behaviour. It further provides them with the opportunity to nurture the infant while experiencing an affective and positive experience, which reinforces the parent-infant bonding process . It enables parents to overcome often frightening, traumatic images of their infant and it prevents the beginning of a negative vicious circle of pessimistic emotions, which could threaten the development of a harmonious parentinfant relationship .
Video interaction guidance (VIG)
Video Interaction Guidance (VIG) is a method for nurses and pedagogic workers in the clinical (hospital) setting to guide and support the attunement and positive contact between parent and infant during the hospital stay . VIG uses edited video feedback to help parents identify their strengths and to achieve desired goals. Key elements of the method are adoption of a collaborative and empowering approach to the parent and to offer a framework of theoretically derived communication/contact principles to analyze interactions. Edited film elements are used to provide feedback of “positive exceptions” and, through discussion of these self-modeling examples, to facilitate reflection and develop parental self-efficacy. VIG interventions consist of approximately 3–5 sessions.
International studies have shown similar short-term interaction guidance interventions to be effective in increasing positive caregiver behaviour. After two video feedback sessions a significant reduction in the degree of negativity of parental attributions towards their child was found  and a significant decrease of disrupted behaviour following two sessions was observed .