Abstract
Objective:
About 40-50% of parents with children admitted to Neonatal Intensive Care Units (NICU) experience clinically significant levels of depression, anxiety, and trauma. Poor parental mental health can negatively influence parent-child interactions and child development. Therefore, early identification of parents at-risk for clinical distress is of paramount importance.
Methods:
To address this need, the psychosocial team, including psychology and psychiatry, at a large, level 4 Neonatal Intensive Care Unit (NICU) developed a quality improvement initiative to assess the feasibility of screening parents and to determine rates of depression and trauma in the unit.
Results:
About 40% of mothers and 20% of fathers were screened between two weeks of their child’s hospitalization. About 40-45% of those parents endorsed clinically significant levels of depression and anxiety symptoms.
Conclusions:
Recommendations for enhancing the feasibility and effectiveness of this process are discussed and considerations for future clinical and research endeavors are introduced.
Keywords: parental mental health, parents, depression, trauma, screening, NICU
Introduction
About one in ten babies will spend time in a Neonatal Intensive Care Unit (NICU).1,2 The NICU experience is a stressful time for families as parents must navigate concerns related to their baby’s health, while confronting complex emotions that arise with having a child that is medically-complex and establishing their parental role in the medical setting.3,4,5 Parents can experience complex and sometimes contradicting emotions because they are happy about the birth of their child, guilty about the apparent discomfort of their child, disappointed that they did not have a healthy child, uncertain that they can properly care for their baby, and fearful about their child’s long-term outcomes.4 NICU parents also tend to experience high levels of stress given the physical separation of their baby and the need to maintain life obligations outside of the hospital.6 As a result, parents in the NICU report higher levels of mental health symptoms compared to parents with full term healthy babies.7,8,9 Studies demonstrate that up to 40 – 50% of NICU parents exhibit elevated levels of depression and anxiety, and 20 – 40% endorse trauma symptoms shortly after their baby’s birth.7 Vanderbilt and colleagues found that 39% of NICU mothers reported clinically significant levels of depression within the first week of their baby’s hospital stay.10 Further, about 33% of NICU mothers reported suicidal thoughts,8 demonstrating the significant impact of a child’s hospitalization on maternal distress. Few studies have assessed paternal mental health with one of these reporting that 60% of fathers endorsed clinically significant rates of depression within one week of their baby’s NICU admission.9 Lefkowitz and colleagues reported that 35% of mothers and 24% of fathers met criteria for Acute Stress Disorder within the first week of baby’s NICU hospitalization.8 In fact, Geller and colleagues have described the NICU hospitalization as an extremely stressful and often unanticipated and traumatic event that can elevate the risk for mothers to develop or exhibit psychiatric symptoms, including trauma symptoms and posttraumatic stress disorder.3
Parental mental health is particularly important in the context of the NICU given that it can influence parent-child interactions, and, in turn, child development.11,12,13 Higher levels of maternal depression and anxiety have been associated with more pain, poorer cognitive outcomes, and increased irritability in NICU babies.12,14 Greater parental participation in the NICU has been associated with baby weight gain and a greater likelihood of babies to breastfeed.15 Given the notable impact that parents have on child development and health, it is even more crucial to address parental mental health with early identification and intervention. Addressing family distress in the NICU can improve parent-child interactions and baby health. Early identification may also help to decrease hospital stays and costs, as well as improve family-provider interactions.16
Given that having a hospitalized baby is a stressful event for all families, it can be difficult to identify which parents in the NICU may be at risk for clinically significant mental health issues. Without standardized screening in place, families experiencing high levels of distress may be under-recognized and therefore not receive the support that they need. Standardized screening also helps to normalize psychosocial intervention in the NICU by demonstrating that attention to the psychological needs of families is an important standard of care. Given the clear importance of identifying families who may be experiencing depression, anxiety, and/or trauma symptoms in the NICU, clinicians and researchers have argued for standardized parental mental health screening.17,18,18,20 In a 2015 special issue of Journal of Perinatology, NICU clinicians and researchers provided mental health recommendations, which included a need for universal screening to be implemented within this setting.18 With this call for standardized psychosocial screening and support for families, there are a growing number, yet still limited universal screening protocols across NICUs – particularly those that screen both parents (i.e., mothers and fathers) and are in the context of regular clinical care as opposed to a research study.17,20,21 Research that examines implementation of such protocol, therefore, is important in order to translate these 2015 recommendations for screening into clinical practice. Examination of potential screening protocols are needed to: (1) identify feasibility of mental health screening for parents in the NICU; (2) identify families who would benefit from additional psychosocial support and care; and (3) utilize psychosocial providers and multidisciplinary collaborations to effectively connect families to mental health interventions. The current quality improvement initiative was conducted to help translate the recommendations for universal parental mental health screening in the NICU to a clinical setting using existing resources and staffing of the psychosocial team.
Specific Aims
Parental mental health issues are prevalent in the NICU and have important implications for child prognosis and development.13,15 NICU providers have advocated for family-focused mental health screening and initiatives given the relevance to baby and family outcomes, as well as provider burnout and hospital efficiency.16,18 However, there are limited clinically feasible procedures for assessing parental mental health.22 The psychosocial team in a large, level 4 NICU recognized the need to develop and implement a standard of care for parental mental health screening in light of the psychosocial program standard guidelines proposed in 2015 to address the high rates of parental mental health symptoms across NICUs.23 A more thorough examination of clinical screening procedures that can be implemented in the context of “treatment as usual” and without resources specifically dedicated to this protocol is needed. The aims of this quality-improvement initiative are two-fold: (1) to determine the feasibility of universal parental mental health screening in a large, level 4 NICU, and (2) to better quantify the rates of parental distress in this setting that may require psychological interventions. Barriers to implementation and future directions for quality improvement are discussed.
Methods
Setting
This quality-improvement program was conducted in a 98 bed, Level 4 NICU in a free-standing children’s hospital located in the Mid-Atlantic Region of the United States. The hospital serves a heterogeneous and diverse socio-economic population and admits more than 1,300 patients to the NICU each year. As a free-standing pediatric hospital, this NICU treats the most critically ill babies, both nationally and internationally, with complex needs that require specialized medical or surgical interventions.
Population
Eligible families included parents of singleton babies who were in the NICU for 5 – 14 days. This 10-day window allowed families time to adjust to their baby’s transfer and acclimate to the environment and care team. However, the goal was to capture parental mental health early during the baby’s current NICU admission. Many infants were transferred to this NICU unit from their birth hospital and were multiple weeks or months old at the time of transfer. Eligible parents were 18 years old or older, English speaking, and willing to complete surveys. Exclusion criteria included parents with babies who were: 1) actively dying or died before screening; 2) currently on the surgical service with parents that were likely to be screened right after delivery in the specialized maternity unit in the same hospital (e.g., babies with diagnoses such as congenital diaphragmatic hernia or esophageal atresia); 3) discharged or transferred to another hospital within 5 days of NICU admission; or 4) in protective custody. Reasons that families were excluded from the screening protocol are shown in Figure 1.
Figure 1.
Flow of Screening Protocol
As displayed in Figure 1, biological mothers were categorized as primary caregivers and additional caregivers (e.g., fathers, grandmothers, non-biological mothers in same-sex relationships) were categorized as secondary caregivers. Biological mothers were categorized differently because more information was available about their history from the baby’s electronic medical record (EMR). Although all caregivers were approached to participate in this mental health screening and given appropriate referrals for clinical purposes, this quality improvement project focused on the mental health of NICU mothers and fathers. Non-father secondary caregivers were excluded from analyses because: (1) parents were of primary interest for examination of mental health rates, and (2) there was a small number of caregivers who were not biological parents.
Screening Intervention
Psychologists from the NICU led this initiative in collaboration with a psychiatrist from within the hospital. Additional support was provided by doctoral-level, psychology graduate students and their supervisor (Psychologist) from a local affiliated University. This multidisciplinary team was particularly well suited to lead this initiative given their training and expertise in assessment, mental health, and evidence-based interventions. Literature reviews, discussions with other institutions, and input from colleagues, informed the team’s careful selection of assessments, systematic development of the procedures, and approach to gather multidisciplinary support to implement into the unit. The goal was to develop and implement the screening protocol, while the doctoral-level students tracked families and administered the screening measures. The current quality improvement initiative examined the feasibility of the screening protocol and ensured follow up for positive screens.
The implementation of this screening initiative took place over a 15-month period (May 2017 – August 2018). Eligible parents were approached at their baby’s bedside by a trained doctoral-level psychology graduate student in the NICU at least 5 days after the baby’s hospital admission. If only one parent was present at the bedside, that parent was approached, and the second parent was approached at a later time. Students attempted to screen caregiver(s) at the bedside in-person for up to two weeks following their baby’s initial admission with printed copies of the questionnaires. Given that this study was conducted by a small team of psychologists and psychology graduate students, parents were approached on weekdays, as students were only available about 3-4 days/week on weekdays for about 2-3 hours/day. The screening procedures and goals were reviewed and parents were given time to ask questions.
Caregivers were asked to complete two screening measures (see Measures section). The measures took approximately 5-10 minutes to complete. These measures were scored immediately after being administered. Parents who screened positive were provided with referrals and appropriate clinical interventions. Specifically, if parents received a positive score on a screening measure, the trained graduate student contacted the psychologist and/or social worker assigned to the family, who then followed up with the caregiver and conducted a more in-depth clinical assessment. The NICU social workers and psychologists, who have expertise and training in the areas of depression, anxiety, and trauma, determined if further supportive interventions or more targeted individual or family services were necessary. If needed, they conducted safety assessments and connected parents to appropriate outpatient services or emergency care.
Trained graduate students also extracted information from the baby’s EMR between May 2017 and December 2018. Socio-demographic information about the biological mothers and babies were collected (see Measures section for specific socio-demographic questions). Information was not available for fathers in the EMR. After data were entered from EPIC into RedCap, 25% of the data was checked for reliability and consistency, and a lead psychologist resolved inconsistencies. No baby or parent identifying information was gathered for the purposes of the current analysis. All parents were assigned a number and scores on screening measures and socio-demographics from the baby’s chart were matched based on those numbers.
Measures
Socio-demographics
Unidentified socio-demographic information was collected from the baby’s EMR including the baby’s race/ethnicity, principal diagnosis, and total length of stay. Information on maternal age, prior maternal psychiatric diagnosis, psychotropic medication usage during pregnancy, history of infertility/loss, insurance status and zip code was also collected as available. Information about fathers was not available beyond the name and contact information.
Depressive Symptoms
The Center for Epidemiologic Studies Depression Scale (CES-D)24 is a 20-item self-report questionnaire widely used to assess depression symptoms in the general population. Parents were asked to report depressed mood, guilt, worthlessness, helplessness, difficulty functioning in daily life, and hopelessness over the past seven days. Parents rated their symptoms of depression on a 4-point Likert-type scale ranging from rarely/none of the time (0) to most/all of the time (3) during the past week. Total scores ranged from 0 to 60 with higher scores indicating more depressive symptoms experienced at a greater frequency. A cutoff score of 16 indicates risk for clinical depression.24 Previous studies have demonstrated strong internal consistency ranging from .85 to .90.25 The CES-D has been correlated with other distress symptom measures in mothers of preterm babies, including hospital stress and concern about child’s health (r = .73 to .89).12
NICU-related Trauma
The Impact of Event Scale–Revised (IES-R)26 is a 22-item self-report measure that focuses on subjective distress caused by a traumatic event, including intrusive, hyperarousal, and avoidance symptoms. It is one of the most widely used global self-report assessments for posttraumatic stress.27 Parents rated their subjective experience of visiting their baby admitted in the NICU over the past 7 days to gauge early signs of post-traumatic stress. Responses were scored on a 4-point Likert-type scale ranging from 1 (not at all) to 4 (often). The total score ranged from 0 to 88, with higher scores indicating more trauma symptoms. A cut-off score of 24 indicates clinically significant concern for posttraumatic stress disorder (PTSD).27 The IES-R has demonstrated high internal consistency ranging from .78 to .89.27 The IES-R has been correlated with various other measures of psychological distress, such as anxiety and somatization.27 This scale has been used in a variety of populations including survivors of sexual assault, combat, and natural disasters26 in addition to NICU parents.28
Analysis
Quantitative analyses were conducted to examine the screening data. Descriptive statistics were used to examine: (1) rates of parents who were screened (compared to not screened), (2) rates of parents who screened positive or negative for psychological distress, and (3) socio-demographics of these groups (screened and not screened; positive and negative screens). Tests of differences (chi-square and independent t-tests) were conducted to determine differences in socio-demographics between those who were screened and not screened as well as those who screened positive and negative for depression and/or trauma.
Ethical Considerations
This QI initiative was reviewed and determined exempt (did not meet the criteria for requiring human subjects research) by the hospital’s Institutional Review Board. Reasons given were as follows: the project is consistent with the institution’s definition of a quality improvement program, the parents were not patients of the institution, risk was seen as minimal, and all data were de-identified. The authors declare no competing interests.
Results
Feasibility of Screening Protocol
During the 15-month period (5/13/17 – 8/9/18), a total of 1,609 babies were admitted to the NICU. Of them, 439 families were approached to participate in the screening protocol and 380 were deemed eligible. Of the 380 families, 378 primary biological mothers and 325 secondary caregivers, which included 308 fathers, were eligible for mental health screening. Of the 378 biological mothers, 148 (39.2%) were screened with at least one measure. Of the 308 fathers, 73 (21.5%) were screened with at least one measure. Analyses will provide information about the screening, mental health rates, and socio-demographics of mothers and fathers. The flow of the screening protocol is displayed in more detail in Figure 1.
Screening Outcomes among NICU Parents
Of the 148 biological mothers who were screened, 68 (45.6%) endorsed a clinically significant level of depression and/or trauma. In fact, of the 148 biological mothers, 39 (26.4%) were positive for both depression and trauma, 19 (12.8%) were positive for only depression, and 10 (6.7%) were positive for only trauma. Of the 73 fathers who were screened, 30 (41.1%) screened positive for depression and/or trauma. More specifically, of the 73 fathers, 16 (21.9%) were positive for depression and trauma, 5 (6.8%) were positive for only depression, and 9 (12.3%) were positive for only trauma. Results are displayed in Figure 1.
Socio-demographics of Biological Mothers and Babies
Families Screened for Mental Health Symptoms
Socio-demographics of biological mothers who were screened and not screened for mental health symptoms are displayed in Table 1. This socio-demographic information was gleaned from the baby’s admission note. The absence of information about maternal reproductive and psychiatric information in the intake note might have meant that the mother did not have a significant history in these areas, or that the information was omitted or not known. However, an examination of the available socio-demographic information provides valuable information to describe the sample of mothers, babies, and families in NICU.
Table 1.
Biological Mother Socio-Demographics from Baby Chart by Screened and Not Screened (N = 380)1
| Screened (n = 160) |
Not Screened (n = 220) |
|||||
|---|---|---|---|---|---|---|
| Available maternal psychiatric history | n (%) | n (%) | ||||
| Depression2 | 20 (12.5%) | 10 (4.5%) | ||||
| Anxiety | 13 (8.1%) | 11 (5%) | ||||
| Bipolar disorder | 3 (1.9%) | 3 (1.4%) | ||||
| Schizophrenia | 0 | 1 (0.5%) | ||||
| Cognitive/learning disorder | 0 | 1 (0.5%) | ||||
| Substance Abuse | 5 (3.1%) | 14 (6.4%) | ||||
| Trauma-Related Disorders | 3 (1.9%) | 1 (0.5%) | ||||
| Attention-deficit/hyperactivity disorder | 0 | 0 | ||||
| Other diagnoses3 | 1 (0.6%) | 1 (0.5%) | ||||
| None reported | 128 (80.0%) | 187 (85.0%) | ||||
| Available maternal psychotropic use during pregnancy | ||||||
| Presence | 12 (7.5%) | 16 (7.3%) | ||||
| None known | 148 (92.5%) | 204 (92.7%) | ||||
| Available maternal reproductive history4 | ||||||
| In-vitro fertilization | 3 (1.9%) | 5 (2.3%) | ||||
| Intrauterine insemination | 3 (1.9%) | 3 (1.4%) | ||||
| Clomid | 2 (1.3%) | 2 (0.9%) | ||||
| Pregnancy Loss (e.g., miscarriage) | 10 (6.3%) | 10 (4.5%) | ||||
| Prior baby loss | 11 (6.9%) | 13 (%) | ||||
| Reduction of fetus from current pregnancy | 1 (0.6%) | 0 | ||||
| Preterm delivery of previous child | 1 (0.6%) | 0 | ||||
| Elective abortion | 9 (5.6%) | 22 (10%) | ||||
| History of infertility | 1 (0.6%) | 0 | ||||
| None reported | 125 (78.1%) | 172 (78.2%) | ||||
| Insurance | ||||||
| Private*** | 95 (59.4%) | 92 (41.8%) | ||||
| Public (Medicaid)*** | 65 (40.6%) | 127 (57.7%) | ||||
| Unknown | 0 | 1 (0.5%) | ||||
| Total (N = 319) Missing from chart (n = 61) |
Screened (n = 139) Missing from chart (n = 21) |
Not Screened (n = 180) Missing from chart (n = 40) |
||||
| M ± SD | Range | M ± SD | Range | M ± SD | Range | |
| Maternal Age (N = 319 out of 380) | 30.69 ± 5.73 | 18 – 45 | 30.70 ± 5.45 | 19 – 45 | 30.53 ± 5.96 | 18 – 45 |
Note. Asterisk indicates significant differences between groups
p < .05
p <.01
p<.001.
Although there are 378 biological mothers, 380 baby charts include maternal demographics.
Depression includes all forms of mood disorders expect for bipolar disorder
Other diagnoses include adjustment disorder and unknown psychiatric illness.
Mothers could have experienced multiple reproductive events, so this N will be larger than 380.
Notably, 20 (12.5%), 13 (8.1%), and 3 (1.9%) of the mothers screened had a history of depression, anxiety, and trauma identified in the child’s medical record, respectively. Among mothers who were not screened, 10 (4.5%), 11 (5%), and 1 (0.5%) had a history of depression, anxiety, and trauma identified in the child's medical record, respectively. A small number of biological mothers who were screened were noted to be on psychotropic medication during pregnancy (n = 12; 7.5%) according to information in the admission note in the EMR. In terms of insurance, 65 (40.6%) of mothers screened had public insurance (Medicaid) and 127 (57.7%) of mothers who were not screened had public insurance (Medicaid). However, reports of maternal preexisting mental health conditions and psychotropic medications may be much higher given that they are likely limited from available EMR information. See Table 1 for more information including maternal reproductive history and age. Baby characteristics (race/ethnicity and length of stay in NICU) were obtained from the EMR for this initiative and are presented in Table 2.
Table 2.
Baby Characteristics by Parents Screened and Not Screened (N = 380)
| Screened (n = 160) |
Not Screened (n = 220) |
|||||
|---|---|---|---|---|---|---|
| Ethnic-racial background | n (%) | n (%) | ||||
| White | 85 (53.1%) | 88 (40%) | ||||
| African-American/Black | 31 (19.4%) | 65 (29.5%) | ||||
| Latina/Latino/Hispanic | 3 (1.9%) | 2 (0.9%) | ||||
| Asian | 5 (3.1%) | 2 (0.9%) | ||||
| Indian | 2 (1.3%) | 2 (0.9%) | ||||
| Native American | 0 | 1 (0.5%) | ||||
| Native Hawaiian/Pacific Islander | 0 | 1 (0.5%) | ||||
| Other1 | 33 (20.6%) | 59 (26.8%) | ||||
| Missing from chart | 1 (0.6%) | 0 | ||||
| Total (N = 380) | Screened (n = 160) | Not Screened (n = 220) | ||||
| M ± SD | Range | M ± SD | Range | M ± SD | Range | |
| Length of Stay in Days (N = 380) | 44.45 ± 64.91 | 4 – 611 | 50.22** ± 69.63 | 4 – 611 | 40.26** ± 61.07 | 5 – 381 |
Note. Asterisk indicates significant differences between groups
p < .05
p <.01
p<.001.
No other information regarding race/ethnicity is available in medical chart.
Tests of differences (chi-square and independent t-tests) were conducted to determine differences in socio-demographics between those who were screened and not screened for depression and/or trauma. Notably, mothers with private insurance were more likely to be screened than mothers with public insurance, χ2(1) = 11.15, p = .001. Further, mothers who had babies in the NICU for a longer length of stay were more likely to be screened, t(342) = −3.25, p <.01. Mothers who were and were not screened did not differ on any other socio-demographics (e.g., mental health and reproductive history).
Families Screened Positive for Mental Health Symptoms
Among the biological mothers screened, available information was gleaned from baby’s EMR. Table 3 displays socio-demographic information of mothers who screened positive for depression and/or trauma and those who screened negative for depression and trauma and their babies. Among available maternal data and mothers who screened positive for depression and/or trauma, 13 (16.9%), 10 (13%), and 1 (1.3%) had a history of depression, anxiety, and trauma, respectively. For mothers who screened negative, 7 (8.4%), 3 (3.6%), and 2 (2.4%) had a history of depression, anxiety, and trauma reported in medical records, respectively. For mothers who screened positive for either or both measures, 36 (46.8%) had public insurance (Medicaid), and 29 (34.9%) of mothers who screened negative had public insurance. Additional maternal information, including reproductive history is presented in Table 3. Babies’ characteristics (race/ethnicity, length of stay in NICU, parental visitation during their NICU stay) were also collected from the EMR and are presented in Table 4.
Table 3.
Biological Mother Socio-Demographics by Positive and Negative Screenings (N = 160)
| Positive Screen (n = 77) |
Negative Screen (n = 83) |
|
|---|---|---|
| Maternal psychiatric history | n (%) | n (%) |
| Depression1 | 13 (16.9%) | 7 (8.4%) |
| Anxiety | 10 (13%) | 3 (3.6%) |
| Bipolar disorder | 0 | 3 (3.6%) |
| Schizophrenia | 0 | 0 |
| Cognitive/learning disorder | 0 | 0 |
| Substance abuse | 3 (3.9%) | 2 (2.4%) |
| Trauma-Related Disorders | 1 (1.3%) | 2 (2.4%) |
| Attention-deficit/hyperactivity disorder | 0 | 0 |
| Other diagnoses2 | 1 (1.3%) | 0 |
| None reported | 56 (72.7%) | 72 (86.7%) |
| Maternal psychotropic usage during pregnancy | ||
| Presence | 4 (5.2%) | 8 (9.6%) |
| None known | 73 (94.8%) | 75 (90.4%) |
| Maternal reproductive history | ||
| In-vitro fertilization | 1 (1.3%) | 2 (2.4%) |
| Intrauterine insemination | 2 (2.6%) | 1 (1.2%) |
| Clomid | 1 (1.3%) | 1 (1.2%) |
| Miscarriage | 7 (9.1%) | 3 (3.6%) |
| Prior baby loss | 5 (6.5%) | 5 (6.0%) |
| Reduction of fetus from current pregnancy | 1 (1.3%) | 0 |
| Preterm delivery of previous child | 1 (0.6%) | 1 (1.2%) |
| Elective abortion | 4 (5.2%) | 5 (6.0%) |
| History of infertility | 1 (1.3%) | 0 |
| None reported | 57 (74.0%) | 68 (81.9%) |
| Insurance | Positive (n = 77) | Negative (n = 83) |
| Private | 41 (53.2%) | 54 (65.1%) |
| Public (Medicaid) | 36 (46.8%) | 29 (34.9%) |
Note. Asterisk indicates significant differences between groups
p < .05
p <.01
p<.001.
Depression includes all forms of mood disorders expect for bipolar disorder
Other psychiatric diagnoses include adjustment disorder.
Table 4.
Baby Characteristics by Positive and Negative Screenings (N = 160)
| Positive Screen (n = 77) |
Negative Screen (n = 83) |
|||
|---|---|---|---|---|
| Ethnic-racial background of newborn | n (%) | n (%) | ||
| White | 40 (51.9%) | 45 (54.2%) | ||
| African-American/Black | 23 (29.9%) | 8 (9.6%) | ||
| Latina/Latino/Hispanic | 0 | 0 | ||
| Asian | 2 (2.6%) | 2 (2.4%) | ||
| Indian | 0 | 2 (2.4%) | ||
| Native American | 0 | 0 | ||
| Native Hawaiian/Pacific Islander | 0 | 0 | ||
| Other1 | 12 (15.6%) | 25 (31.3%) | ||
| Missing from chart | 0 | 1 (1.2%) | ||
| Principal diagnosis of newborn | ||||
| Prematurity | 19 (24.7%) | 12 (14.5%) | ||
| Genetic syndrome / constellation | 10 (13%) | 16 (19.3%) | ||
| Neurological condition | 8 (10.4%) | 17(20.5%) | ||
| Respiratory Diagnoses (Not associated with prematurity) | 8 (10.4%) | 14 (16.9%) | ||
| Myelomeningocele | 7 (9.1%) | 4 (4.8%) | ||
| Other diagnostic categories2 | 24 (32.5%) | 20 (24.1%) | ||
| Positive Total (n = 77) |
Negative Total (n = 83) |
|||
| M ± SD | Range | M ± SD | Range | |
| Length of Stay in Days (N = 160) | 44.21 ± 52.64 | 6 – 259 | 55.80 ± 82.26 | 4 – 611 |
Note. Asterisk indicates significant differences between groups
p < .05
p <.01
p<.001.
No other information regarding race/ethnicity is available in medical chart.
Most common diagnostic categories are reported. ‘Other’ categories reported in dataset and include bronchiolitis, cardiac, GI, infection-sepsis, MAS, metabolic condition, and other.
Tests of differences (chi-square and independent t-tests) were conducted to determine differences in socio-demographics between those who screened positive or negative for depression and/or trauma. Socio-demographics did not differ between biological mothers who screened positive or negative. However, fathers with Medicaid (n = 24) reported higher levels of depression, t(73) = 3.18, p < .01, and trauma, t(72) = 1.95, p < .01, compared with fathers with private insurance (n = 51).
Discussion
A primary aim of this quality improvement project was to examine the feasibility of implementing standardized mental health screening of parents in a large, high acuity NICU. The secondary aim was to better identify the rates of parents requiring more intensive interventions than general psychosocial care. Recommendations for universal screening were put forth in response to prior research indicating that parents of NICU babies are at increased risk for both depression and anxiety in comparison to parents in the general populations.18 However, specific protocols for the implementation of these recommendations have not yet been clearly delineated. This quality improvement project utilized psychology graduate students to administer screeners, and existing psychosocial staff, including social workers and psychologists, to follow-up with parents who scored above screener cut-offs. Using the current protocol, which included graduate students attempting to administer the screeners for up to two weeks, results of this project indicate that only 39% of eligible mothers and 21% of eligible fathers were screened. Notes kept by the students indicated that 75% of the screening attempts resulted in parents not being present at the bedside. In fact, families with babies who were in the NICU longer were more likely to be screened. These rates are likely related to the availability of the students conducting the screening, who were unable to be in the unit 24 hours/day, 7 days/week. It is important for NICU providers across the country to understand the challenges in implementing mental health protocols with existing infrastructure and the need for multidisciplinary support and assistance to enhance feasibility and improve screening rates. Parental mental health screening protocols are not standard of care in all NICUs, despite attempts to implement such programs.17,20 This demonstrates that there are unique logistical, financial, and social barriers that warrant creative problem-solving (e.g., collaboration with medical and nursing providers, technology adaptation) to successfully implement screening into clinical settings. In fact, Moreyra and colleagues demonstrate the value of having social workers assist with screening efforts and were effective in capturing most of their proposed sample.20
Parents of NICU babies have many potential barriers to being at the hospital, including caring for other children at home, returning to work, or transportation difficulties. It is possible that fathers may be present less often as they are more likely to have to return to work, while mothers may be on maternity leave and available to visit the hospital for longer periods, despite inconsistent policies on paid leave. Given that this is one of the first studies to include fathers,29 this information is novel as it highlights unique challenges to mental health screening for fathers. In addition, findings revealed that mothers with private insurance were more likely to be screened (59%) than mothers with public insurance (41%). Prior literature suggests that mothers with public insurance may fewer opportunities for hospital visitation because of fewer maternity leave benefits, financial need to return to work earlier, or more difficulties with transportation or childcare.30 Given these factors, it may be that a greater portion of parents, especially those with more barriers to visiting the hospital, would be captured if screening was conducted on weekends and in the evenings outside of typical work hours. This may have been especially beneficial to reach fathers, as well as parents with public insurance.
A secondary aim of the current project was to determine the rates of parental distress in our NICU to assess the degree of psychosocial support resources needed to provide follow-up assessment and potential intervention. In line with prior studies that have found high rates of symptoms of depression and anxiety among NICU parents,7,8,20,29 we found that 45% of participating mothers and 41% of participating fathers scored above the clinical cut-off on either the depression or post-traumatic stress screener. These rates are particularly striking given that about 13-17% of mothers and 8-10% of fathers in the general population experience depression during the postpartum period.31,32 Further, the demographic information that was available for the current sample is consistent with general U.S. population demographics (~50% of the babies were white, ~40% of mothers had Medicaid), suggesting that rates may be similar in other large NICU samples.33 Results suggest the need to screen mothers, as well as fathers, which is important because fathers needs tend to be overlooked in the NICU and during the postpartum period in general.9 In addition, fathers with public insurance were especially likely to have high levels of distress. This finding is consistent with prior evidence that income is a risk factor for postpartum depression34 – which highlights the vulnerabilities of this subset of NICU parents. In other words, the unique role of the father (e.g., coming and going from hospital, managing outside responsibilities) combined with social stressors (e.g., resources, finances) suggests that they might be an under-recognized group who would especially benefit from psychosocial referrals and supports. Of note, of the parents who scored above the cut-off, more parents scored above the cut-off on both measures (26% of mothers and 22% of fathers) than on one screener only. This highlights the known high degree of comorbidity between depression and anxiety, although it remains important to assess both dimensions as they have different implications for difficulties that parents may experience in the NICU setting. Moreover, depression and anxiety can be responsive to different treatment interventions.35,36 Overall, this initiative was clinically useful given that it alerted psychologists in the unit to families who might benefit from additional psychosocial services. As a result, more families were identified for follow-up support, highlighting the value of continued implementation of parental mental health screening across NICUs.
Barriers and Limitations
There were several barriers to this screening initiative that are important to note. First, in this quality improvement initiative, less than 50% of the families on the unit were screened, so sampling bias cannot be ruled out when interpreting findings. This screening rate is likely related to the fact that team members conducting the screening (i.e., two psychologists, several graduate students) were unable to be on the unit 24 hours/day, 7 days/week and demonstrates the need for additional strategies (e.g., assistance from nurses and social workers, technology-based surveys) to capture more families. Further, only English-speaking families were included in this quality improvement initiative. For full-scale implementation, it may be necessary to utilize hospital interpretation services (e.g., phone, in-person) and offer measures in multiple languages to help capture diverse families’ experiences in the NICU. Additionally, this screening protocol was a quality improvement initiative and therefore the protocol was refined and adapted as it was being implemented. Finally, this screening was conducted within a fast-paced clinical setting and therefore there were logistical, social, and emotional barriers to completing the surveys (e.g., balancing assessments with medical team needs, pumping and breastfeeding schedules, parental sleep deprivation, emergency situations).
Conclusions
The results of this quality improvement project highlight the need for thoughtful strategies for the successful implementation of the recommendations for parental screening in the NICU18 as part of the standard of care, particularly due to the high rates of parental distress. Future projects should help determine whether the EMR, dedicated personnel for screening, availability of screening at a variety of times of day and days of the week, and different screening modalities (e.g., online survey), would help facilitate greater equity in screening, reducing barriers to screening for certain groups. Developing a collaboration with nursing may help to maximize successful screening. Nurses are present with the baby 24 hours per day and see families in evenings and on weekends and therefore could remind them to complete measures and/or link to measures. Then, providers such as a clinical nurse specialist in mental health, social worker, or psychologist could provide follow-up assessment and treatment recommendations. Though this project was limited to English-speaking parents, there is a need for parent mental health screening measures that have been both translated and validated in additional languages to be incorporated in this work, as parents with limited English proficiency face additional challenges in the NICU setting.37,38 In the setting of a children’s hospital, limited information about parental history in the EMR creates challenges in identifying and optimally supporting parents with pre-existing vulnerabilities. However, achieving an ideal balance between access to information that is relevant to the care of the baby and protecting parents’ privacy is difficult to achieve.
While this project and many other studies of parent screening examine levels of parental distress at one time point in the NICU,17,18,19 future work is needed to examine the longitudinal trajectory of parental distress across the course of high-risk pregnancy, NICU admission, step-down unit, and post-NICU period. Understanding the continuity and discontinuity of parental distress over time would allow for more targeted interventions and for an even greater positive impact on important outcomes such as reducing the baby’s length of stay, increasing effective parenting, and enhancing developmental outcomes. Screening across these time points and settings would also facilitate continuity of care through promoting a warm hand off among providers from one system of care to the next.
Ultimately, identification of screening models that are inclusive, timely, and effective are needed for parents of NICU babies. While research studies often include funding for resources such as additional personnel to implement screening, methods that are possible without such added support are necessary to truly advance best practices. Universal screening protocols can be implemented without adding financial burden to institutions, especially if they are considered a standard of care and utilize current services and staff already in place. For example, brief screening measures could be included as a part of intake assessments or in welcome packets to families in the NICU. The implementation of such screening protocols as standard of care, when connected to effective treatment strategies, will help create the best outcomes for medically fragile babies and their families as they confront the challenges of NICU hospitalization.
Acknowledgements
The authors wish to thank Christina DiSanza, MS, Arianna Albanese, MS, and Gaby Russo, MS for their contributions in collecting mental health information from parents and gathering socio-demographics from baby’s medical charts. We also want to extend our sincere gratitude to The Children’s Hospital of Philadelphia Social Work team, including Monica Straszewski, MSW, Ali Pomar, MSW, LSW, Lindsey Kunkel, MSW, LCSW, Ma Luisa Hasiuk, MSW, LCSW, Meredith Huber, MSW, LSW, and Jill Scott, MSW, LCSW, for their support with implementation and follow-up assessments with N/IICU parents.
Declarations:
No funds, grants, or other support was received. This quality improvement (non-research) study did not require ethics approval.
Footnotes
Conflict of Interest: The authors declare no competing interests.
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