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Promising Practice Profiles

...whatwerewethinking! Psycho-Educational Program for Parents (PEPP)

The full Promising Practice Profile is available for download in PDF format (519 KB)

Project practice

Early intervention with mothers and fathers soon after the birth of their first child to extend their knowledge and skills in managing infant needs and negotiating the new unpaid workload fairly, thereby alleviating potential mental health problems

Project undertaken by

Start date

February 2006

Focal areas

Program

Invest to Grow (ItG)

Issue

Most people experience psychological turbulence in the months after giving birth, and serious exhaustion causing impaired functioning is very common. Up to 20% of women will experience clinically significant psychological distress, as well as some men. The prevention of postnatal depression is an emergent field that has as yet a limited evidence base.

Sensitive infant care requires knowledge about a baby's developmental capacities, sensitivity to infant behaviours, skills to respond effectively and more time than had been imagined. Current advice about how to manage these obligations is for parents to "trust their intuition". However, intuition is a poorly defined construct, few contemporary parents of a newborn have had prior experience of caring for infants and most underestimate both the time that caretaking requires and the anxiety associated with caring for an infant to whom an emotional attachment is forming.

In addition, the birth of a baby requires renegotiation of unpaid household work, a task made difficult because women are labelled as having "given up work" and are therefore presumed to be able to take on most of the hugely increased workload associated with keeping an infant alive and running a household in which an infant lives. This Promising Practice is based on a view that caring for a newborn should be regarded and named as work, and that a primary prevention and mental health promotion approach which includes both parents and their baby is less stigmatising and more salient than the existing approaches which are based on the recognition of psychiatric symptoms and encouragement to seek treatment.

There is evidence that difficulties in the new parents' relationship, in particular fathers providing limited emotional and practical support after the birth of a baby can contribute to postnatal depression. In addition, unsettled infant behaviour undermines maternal confidence and contributes to anxiety and exhaustion. Anxiety, fatigue and a sense of being insufficiently supported appear to be precursors to the development of depression after childbirth.

Program context

The Key Centre for Women's Health in Society (KCWHS) is Australia's leading research and teaching centre operating within a social model of women's health. It is located in the School of Population Health, Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne. It has a significant national and international training and research program and is acknowledged for its outstanding expertise in women's health. The centre is a designated World Health Organization Collaborating Centre in Women's Health (Asia and Pacific) - one of two such centres worldwide. Mental health and reproductive health are two of the research streams.

Childbirth education programs provide a unique opportunity to prepare new parents with skills and ideas to assist them in the task of adapting to life with a baby. However it is well known that attempts to engage class participants antenatally with parenting content are often unsuccessful; participants' attention is focused on the birth and it can be difficult to imagine in advance what life with a new baby will be like.

The current central focus of education for early parenting is on the establishment of breastfeeding and adequate infant nutrition. In the last five years, the investigators have surveyed three populations of women admitted to early parenting centres (a total of 400 mothers) and asked, among other matters, whether they have been taught infant settling and comfort strategies or been shown how to establish a sustainable daily infant feed, play, sleep routine of care. All responded that they had not. Many added qualitative comments that this was essential knowledge and that their difficulties might have been averted had they been given these skills early in the infant's life (Fisher et al., 2002a, 2002b, 2003).

The importance of prevention and early intervention in postpartum mood disorders is widely recognised, but there is a lack of successful preventive interventions. There appear to be no earlier projects aimed at preventing postpartum depression that have focused on the management of infant behaviour. Very few interventions have attempted specifically to enhance the father's understanding and skills. As a result of an extensive consultation process, The Key Centre for Women's Health in Society developed an early intervention to address the common gaps identified in early parenting education.

The PEPP (Psycho-Educational Program for Parents) program is an innovative mental health promotion intervention for universal application in primary care with fathers, mothers and their first newborns. It addressed two under-recognised risk factors for postnatal psychological disturbance: quality of relationship with partner; and management of infant crying, sleep and settling. The 2-session program was conducted in half-day seminars by maternal and child health nurses. The program provided knowledge and skills training about:

The program sought to demonstrate that assisting fathers with this information, and teaching them skills would lead to less unsettled infant behaviour. This was coupled with training through structured tasks for parents, which aimed to increase their capacity to provide support to each other and to share the workload fairly. Together these strategies were expected to contribute to increased parental awareness of infant developmental needs and increased parental care-taking skills, thereby leading to reduced infant crying, reduced infant resistance to soothing and settling, improved parent-infant interaction and increased parental confidence in and enjoyment of infant care. A trial of the salience and acceptability of PEPP was conducted in seven study sites in Victoria.

The principal aims of PEPP were to:

Practice description

The PEPP intervention program was an innovative program based on adult learning principles and developed through clinical practice, incorporating the following key ingredients:

Input from consumers, health professionals and academics

The researchers sought input from literature, from academics and from consumers in the design of the program. This identified the gaps in existing programs and allowed for a clearer focus on the needs of infants and their parents. It was found that the period of around 4-6 weeks after birth is a time of high learning for parents.

Accessible language and learning strategies

The importance of presenting material verbally and in writing was recognised as important at a time of major transition for the parents. Materials were written in accessible language, illustrated and structured to address common problems in infant behaviour, which served as a handy reference after the seminar.

Carefully designed worksheets, derived from evidence and using lay language were used as learning strategies in PEPP seminars. There are specific worksheets for each section of the seminar, which are used by participants to learn language, concepts and problem-solving strategies.

Acknowledgment of the needs of fathers and infants

The involvement of fathers by being present at the seminars was innovative and sought to address this aspect of family functioning early in the life of the first child to enhance healthier parent relationships. The importance of negotiating changes in family and parenting responsibilities was addressed directly.

Demonstrated commitment to improve family relationships

The half-day seminars attended by both parents sought to demonstrate through structured tasks for both parents that the parenting task was a shared one.

Seminars were held in maternal and child health centres which are familiar and accessible settings

The strategy of holding the seminars at maternal and child health centres aimed to ensure that the settings were non-threatening, familiar and not too distant. The setting reinforced the purpose of the seminars - to increase parenting confidence and skill.

Seminars were held at times believed to be convenient to parents

The timing of seminars at weekends was deliberately arranged at times believed to be convenient for both parents.

Small groups of participants at the same life stage provided a supportive environment

The selection of participants with common life stage issues aimed to provide a sense of common concerns, and normality and to reduce anxiety, thereby enhancing openness to learning.

Seminar content was derived from evidence based research

The program was strongly grounded in the findings of clinical practice in work with infants by psychologists and health educators. This gave the content of the seminars strong credibility with participants.

Qualified program facilitators

Three qualified and experienced Maternal and Child Health Nurses known to the centre through their inter-agency collaborations with clinical services were recruited and trained as PEPP facilitators. Therefore, PEPP should be sustainable at local government level in Maternal and Child Health Services (or equivalent in other Australian states) in the future.

A further key ingredient of PEPP is that facilitators are sufficiently prepared and are comfortable with use of the concepts and language that is integral to the conceptualisation of PEPP. For example, household tasks and infant care are dignified with the language of "work", and postnatal mental health is regarded as a matter of family relationships rather an individual woman's failure.

Development of a suite of materials for both participants and seminar facilitators

The resources developed for parents who participated in PEPP seminars were a series of thirteen worksheets, each written in accessible language and attractively illustrated. Worksheets were completed individually by members of a couple and answers compared. Five of the worksheets address common problems in infant behaviours:

Eight of the worksheets address parents' needs and include:

In addition, the material was covered in a book entitled What Were We Thinking! which parents were given to take home with the worksheets for ongoing reference.

In addition, a Handbook for Professionals was specifically developed which comprised an outline of each of the activities, including the objectives, teaching strategies and use of worksheets, introductory scripts and concluding statements. This was used by seminar facilitators in order to maintain consistency and coherence; it was essential that the facilitators were equipped with knowledge of the educational activities and of the language, concepts and theoretical principles underlying PEPP. It will also be used as the basis of train-the­-trainer programs and as a community resource in primary health care.

Lastly, with funding from the Jack Brockhoff Foundation, in conjunction with Penny Harris of PenPen Productions, the PEPP website (www.whatwerewethinking.org.au) was produced. The content of the site was developed from the PEPP worksheets and materials used in the intervention, as well as the seminar facilitation materials utilised by the trained MCHNs. The official launch of the site took place at the 3rd International Congress on Women's Mental Health on 18 March 2008. This is a critical component of the objective to disseminate the intervention to parents and primary health care practitioners. As of 1 February 2009, the site had received almost 8,000 hits from locations worldwide.

Seminars used a variety of program formats

The program formats were varied to include group discussion, active participation in problem solving and negotiation using carefully designed informational worksheets and skills. The approach used was based on adult education principles - this is effective because it recognises participants' prior learning, promotes group cohesion through sharing of experience, and provides opportunities for group discussion using new language and concepts provided by the facilitator and in the program materials.

Experienced professional facilitators gave each couple support while practicing settling using these strategies. People learn new skills most easily through opportunities for hands-on experience and practice. During PEPP seminars, parents practice wrapping and settling techniques with their own babies. Parent feedback has provided evidence that this is effective, confidence-building and enjoyable.

The first seminar session, "About Babies", outlined infant temperament, including:

The seminar facilitators gave each couple support while they practiced settling their baby using the presented strategies.

The second seminar session, "About Parents", focused on matters relating to the new unpaid workload of infant care and household work and developing strategies to address these in a non-confrontational manner. These included:

Limitations to this practice

Data about participant characteristics at recruitment is available and the Key Centre has been able to compare those parents who were assessed at infant age four weeks and again at infant age six months with those who were assessed in the same ways, but also participated in PEPP seminars. The first limitation is that it appears that although their mental health status was the same, those willing to participate in the seminars were more likely to be well-educated, to speak English at home and to be in a professional or semi-professional occupation than the general Australian population of parents of a newborn. It was concluded that the approach would need to be and can be modified to suit the needs of sub-populations including single mothers, people from culturally and linguistically diverse backgrounds and Indigenous Australians.

The second limitation was that while most women who met eligibility criteria and were offered the opportunity to participate in the seminars accepted, their partners were less willing. Although opportunities to re-schedule the seminar booking were offered and accepted by some, the most common reason for non-participation was that men had Saturday work commitments, preferred to play sport, or were unwilling to attend. The website has been developed as a tool to combat these difficulties; it allows parents to access the PEPP materials from home at their convenience and thus receive the benefits of participation without requiring attendance at a session. Additional effective strategies to recruit fathers to interventions of this kind will need to be developed.

Implementation of this practice

The first step to wide implementation of this approach is to generate evidence about its effectiveness, which will be available by the end of 2008. If effective, it will then require commitment at federal, state and local government levels to changing early parenting health practice. Once this is mobilised, a training strategy for maternal and child health and early childhood nurses and ongoing supervision of their practice will be required. However, these will fit well with the Australian Government's perinatal depression management initiatives.

Research base

The approaches used in PEPP are derived from existing evidence and not covered in routine health or education services for parents of newborns.

Postpartum psychological distress in women

Up to 20% of mothers of newborns experience psychological disturbance of sufficient severity to warrant professional care. A much higher proportion of new mothers may experience significant psychological problems and all have to undergo a process of rapid adjustment. Compromised mental health in mothers of infants is a serious public health problem in all industrialised countries including Australia. It is associated with reduced functioning in women, relationship conflict and long-term risks for the next generation as a result of poorer infant cognitive development and later behavioural difficulties in the children.

The birth of an infant demands dramatic adaptations of a woman. Adjustment to new roles, increase in the unpaid workload and, for some, the physical consequences of adverse reproductive events place great demands on individual psychological resources and existing relationships. Postpartum depression is a clinical and research term used to describe an episode of non-psychotic Major or Minor Depression arising in the year after childbirth (Paykel, 2002). It is characterised by the persistent presence for at least two weeks of sad, low mood and other symptoms including elevated anxiety, guilt, irritability, and social withdrawal. Although hormonal change may contribute to postpartum depression in some women, there is substantial, consistent evidence that psychosocial factors interact to increase risk of postpartum depression (O'Hara & Swain, 1996; Scottish Intercollegiate Guidelines Network, 2002).

One of the major factors is the quality of a woman's relationship with her partner. Research shows that women are in a heightened state of dependence in advanced pregnancy and while mothering a newborn. However, much less research has been conducted about first time fathers and their transition to fatherhood. It would appear from the available research that new fathers may show their distress about their changed roles and the impact of fatherhood in different ways to first time mothers. It is also clear that many first time fathers seem ill-prepared for the stresses associated with the transition to father and parenthood (Condon et al., 2004). Partners who are able to respond by suspending their own needs; providing increased reassurance, encouragement and affection; providing an increased contribution to the unpaid household workload and becoming competent at infant care provide psychological protection. In contrast, those with gendered stereotypes about unpaid household work and infant care and do little of it, who are absent from home for long hours pursuing independent leisure activities or who are critical, angry, coercive or intimidating exert significant psychological risk (Wilson et al. 1996; Fisher et al., 2002).

Occupational fatigue

Increasing evidence shows that poor physical health after childbirth, including fatigue, contributes to poor mental health (Brown & Lumley, 2000). Profound fatigue is widespread among mothers of newborns but is often normalised or trivialised despite the adverse impact it exerts on normal daily functioning (Milligan et al., 1996; Brown & Lumley, 2000). Fatigue has been regarded as symptomatic of depression but an alternative view is that fatigue arises because the unpaid workload of mothering a newborn is severely underestimated. Exhaustion may be a precursor for the development of depression in women whose unpaid workload of household tasks and infant care is neither acknowledged nor shared (Fisher et al., 2002). Men who did spend more time on the unpaid domestic/household work did so for a relatively short period. They also reported reduced amounts of sleep but not significant enough to be problematic (Condon et al. 2004).

Effects on infants of postpartum depression

Infants are highly dependent on maternal primary care and developmentally sensitive to interpersonal interactions (Murray & Cooper, 1997). Impairments in a mother's interpersonal functioning are thought to influence the quality and sensitivity of her interactions with her baby and thereby reduce the infant's optimal development (Murray & Cooper, 1997a, 1997b). Compared to children of mothers who were psychologically well, children of mothers who experienced postpartum depression have been found to have poorer cognitive development, including abstract reasoning and visual-motor performance at age 18 months and in the pre­school year (Lyons-Ruth et al., 1986; Murray et al., 1996).

Social development and emotional development also appear to be affected. Studies of the behaviour of infants in face to face interactions with their depressed mothers in the first year of life have reported fewer positive facial expressions, more negative expressions and protest behaviour, higher levels of withdrawn behaviour and avoidance, more fussing and an absence of positive affect (Murray & Cooper, 1997). Two-month-old infants whose mothers were depressed had higher rates of disrupted behaviour and were more likely to avoid contact with their mothers than comparison infants (Murray et al., 1996). Moreover, infants are less likely to form secure emotional attachments when the mother is depressed (Murray & Cooper, 1997).

To date, most investigations in this field have presumed that infants' developmental outcomes reflected parenting factors (Murray & Cooper, 1997). Relatively little research has examined the opposite proposition, that infant behaviour can exert an adverse effect on a mother's mood but the relationship may be reciprocal. However, there is emerging evidence that infant behaviour, especially prolonged, inconsolable crying; frequent night-time waking and feeding difficulties, exert an adverse effect on parental mood and sense of competence. Infants are born with distinguishable variation in intrinsic characteristics or temperament and these exert a significant effect on the infant's interactions with caregivers (Oberklaid et al., 1984). Temperamentally difficult infants usually display little rhythmicity of sleeping and feeding patterns, are easily aroused, have difficulty adapting to changes in the environment, react with great intensity and cry for longer periods. Infant crying is highly arousing to caretakers, but there is wide individual variation in the amount and intensity of infant crying and fussing in the first year of life (Lehtonen, 2000).

Infant settling and soothing skills

Parents need to be equipped with skills to respond effectively to infant crying. Contemporary infant care advice encourages parents to trust their intuition and to provide infant care that feels appropriate. For example, parent education encourages parents to distinguish infant cries and discern whether these are indicating pain, hunger, a startle reaction or fatigue. However, there is little empirical support for the notion that these cries are in fact specific or distinguishable and in reality parents have to use other contextual and behavioural factors to decode them (Craig et al., 2000). In response to the widespread instruction to "feed on demand", most parents interpret infant cries as hunger and offer the breast or bottle. However, when caring for an inconsolable infant and having a comfort repertoire that only includes feeding, parents can feel ineffective and helpless, and confidence can diminish rapidly. Prolonged infant crying has been shown to contribute directly and independently to deterioration in the familial emotional environment (Lehtonen, 2000), including increasing the risk of child abuse.

Recent Australian evidence shows that the most common difficulties reported by mothers with moderate depression to their maternal and child health nurses are prolonged infant crying and settling and feeding behavioural disturbance (Morse et al., 2004). It has been shown that women admitted to a brief residential early parenting program are more likely to be depressed if their partners are critical and unsupportive and if they feel unable to settle or comfort their crying babies (Fisher et al., 2002).

Prevention of postnatal depression

There have been nine published randomised controlled trials of primary interventions to prevent postpartum depression conducted either during pregnancy or in the days after birth, but none has been successful (Lumley & Austin, 2001). These reviewers concluded that the events in the early weeks of the infant's life are more salient and that the inclusion of the father is essential (Lumley & Austin, 2001). Most of the published trials excluded the baby's father and none involved the infant. Evidence-based early interventions including both the partner and the baby and which prevent maternal psychological distress, promote parental confidence and assist unsettled infant behaviour are needed.

Strategies to support fathers

The Parenting Information Project, a part of the Australian Government's Stronger Families and Communities Strategy for early childhood prevention and intervention initiatives, identified and documented best practice parenting programs and information which would support parents more effectively. The report emphasised the importance of engaging fathers and making services more inclusive for males (Commonwealth of Australia, 2004). The project also noted that fathers prefer hands-on, experiential approaches to learning about child development. They also have a desire to increase their confidence with handling babies, learn more about behaviour management techniques, and understand how their relationship with their partner alters when they become parents (Commonwealth of Australia, 2004).

Evidence regarding sleep behaviour management

There is limited evidence about the effectiveness of some components of these trialled strategies. Three prospective cohort studies investigated the use of sleep behaviour management strategies that aim to reduce unsustainable sleep associations, to provide low stimulus comfort while the infant is learning to settle to sleep and to establish a routine of regular daytime sleeps in addition to reducing night-time feeds at an appropriate age. The strategies were taught via individualised programs, written information, use of diaries and with additional professional support in a residential early parenting setting. All reported significant improvements in reduced overnight waking, less infant distress during settling to sleep and reduction in sleep associations. These were sustained at least in the short term (Adair, Armstrong, & Leeson, 1994).

More recently there have been two randomised controlled trials of these psycho-educational approaches to infant sleep disorder and maternal mood disturbance. Hiscock and Wake (2002) surveyed mothers attending maternal and child health clinics in three local government areas in Melbourne, Australia. All mothers who reported that their infants aged 6-12 months had woken on more than five nights in a week, were waking more than three times a night, taking more than 30 minutes to fall asleep, or requiring parental presence to fall asleep in the preceding fortnight were included in the trial. The intervention group received three educational consultations with an experienced paediatrician, in which an infant sleep behaviour management plan was tailored to individual families who also received information about the development and management of sleep problems. The control group was given written information about normal infant sleep patterns. Infant sleep and maternal mental health were measured two and four months later by mailed self-report questionnaires. There were significantly fewer infant sleep problems (p <.005) in the intervention than the control group at two and four month follow up. In addition, maternal mood improved by two months (average reduction in EPDS scores of -3.7) and remained stable at four months. None of these included fathers.

Outcomes

The implementation of PEPP in regional and metropolitan centres in Victoria is expected to have the following benefits:

The effectiveness of PEPP has been measured through comparison of two sequentially recruited groups on indicators of participant health and wellbeing, and family functioning. Follow-up of the second group was finalised in mid 2008, data analysis is ongoing, and results are in preparation for publication. Due to these factors, only preliminary outcomes can be reported at present. These are:

Evidence of outcomes

Detailed records of recruitment and participation rates were collected and systematically documented. The program processes were assessed by facilitator and participant evaluation, and local government area (LGA) and program reference group (PRG) feedback. The information gathered through these key project relationships provides insight into the factors associated with successful partnerships between scholarly, community, and government collaborators. Further, it indicates factors external to the program that can have an impact on project implementation in the short term and/or its applicability to standard health care settings in the longer term.

Outcome 1: Uptake of intervention

In the intervention group, 120 couples attended a PEPP seminar and almost all mothers and fathers completed evaluations.

Outcome 2: Intervention satisfaction

1) Participant evaluation

All PEPP participants completed a questionnaire rating their perceptions of the quality and usefulness of the intervention after completion of the 2-session program. Overall, almost all mothers and slightly fewer fathers reported an increased understanding of infant temperament; almost all mothers and fathers found learning infant settling strategies useful and three-quarters of parents stated that they could now discuss parenting more effectively with each other. Two thirds of the participants reported an immediate increase in confidence and more than 95% concurred that the content was useful for all parents.

Comments from participants about what was learned from the intervention included the following:

Very good to have worksheets focusing on parents' relationships - I didn't realise how hard having a baby would be on ours, and I haven't been sure how to address the problems/resentment. Through the seminar, I value more the need to openly communicate about all aspects of parenting.

Daytime sleep needs to be 1.5-2hrs - our baby has only been sleeping for 30-45mins in the day - I thought if she woke that she must not be tired. Information on sleep cycles was great. Information on settling was good - particularly the heart beat and rocking technique.

Exactly how much time it takes to do stuff with a baby - there is a reason I feel so tired and never seem to get everything done.

The feed-play-sleep pattern (invaluable!); baby signals i.e., tired or hungry; the need for more sleep during the day for our baby and in her own room - not in the lounge room with us.

Rethink household jobs. Support my husband - he is feeling left out and a bit unsure about the way our life has changed. Be careful to have time out together as a family.

2) Facilitator evaluation

Facilitators were also asked to complete an evaluation form after each seminar. This form captured the completeness of the delivered program, the facilitator's rating of how well the objectives for each session were achieved, any unforseen events or contextual factors which may have affected the session, and any feedback or comments the facilitator wished to provide. There were 41 seminars in total, attendance ranged from 2-7 couples per seminar, and the feedback from these sessions was extremely positive. Open ended responses from facilitators regarding the first session - "About Babies" - included the following:

Good session, very "hands on" fathers; very supportive & keen to learn and participate.

Parents especially dads were very keen to practice wrapping their own baby and settling.

Comments regarding the second session - "About Parents" - included the following:

Feedback (verbal) from parents was excellent. Thought it was great to spend the hours together looking at their relationships and all things related to the baby. All left feeling more positive.

Good session, supportive partners who did reflect back on their own fathers parenting and availability.

The couple participated exceptionally well. Very open about their circumstances. Overall a very perceptive couple and wanting to change to adjust to improved parenting.

Policy analysis

This Promising Practice is innovative in that it responds to recent and emerging research on the prevalence of postnatal depression and the major factors that can be addressed to mitigate this. The emphasis on evidence-based intervention is an important contribution.

The PEPP project builds on the universal Victorian Maternal and Child Health Program, extending the skills, and resources of maternal and child health nurses, creating an intervention that could be provided for any group of parents. The preliminary evaluation findings suggest that the main limitation concerns the fact that its appeal has been strongest for well-educated, professional families. The difficulty of engaging fathers was also noted.

The finding that early intervention post-birth to instil baby settling skills and to renegotiate workloads can be effective is particularly important at a time when early parenting centres are being re-evaluated.

Project evaluations

The effectiveness of the PEPP intervention was tested by the Key Centre in a sequential controlled trial of two groups, each of 196 couples, recruited through maternal and child health nurses at the first home visit after the birth of a first baby. They were drawn from seven local government areas in urban and regional Victoria. While the outcome data pertaining to maternal mental health six months postpartum is still being collected, data about participant evaluations of the seminars is available.

Project related publications

See other publications of the Key Centre for Women's Health in Society.

The work of the three Early Parenting Centres in Victoria are described in their annual reports which are available on their websites.

It should be noted that in 2008 there was a statewide review of early parenting programs being undertaken by the Victorian Department of Human Services.

References

Boyce, et al. (2004). The First-Time Fathers Study: A prospective study of the mental health and wellbeing of men during the transition to parenthood. Australian and New Zealand Journal of Psychiatry, 38, 56-64.

Brown, S., & Lumley, J. (2000). Physical health problems after childbirth and maternal depression at six to seven months postpartum. British Journal of Obstetrics and Gynaecology, 107(10), 1194-201.

Condon, J. P. (2004). Parenting Information Project. Canberra: Department of Family and Community Services: Commonwealth of Australia.

Craig, D., Gilbert-Macleod, C. A., & Lilley, C. M. (2000). Crying as an indicator of pain in infants. In R. G. Barr, B. Hopkins, & J. A. Green (2000) Crying as a sign, a symptom and a signal. London: Mac Keith Press.

Fisher, J., Feekery, C. et al. (2003). Treatment of maternal mood disorder and infant behaviour disturbance in an Australian private mothercraft unit: A follow-up study. Archives of Women's Mental Health, 7(Suppl 1), s1-s5.

Fisher, J. R. W., C. J. Feekery, et al. (2002). Health and social circumstances of women admitted to a private mother baby unit. A descriptive cohort study. Australian Family Physician, 31(10), 966-969.

Fisher, J. R. W., C. J. Feekery, et al. (2002). Nature, severity and correlates of psychological distress in women admitted to a private mother-baby unit. Journal of Paediatrics and Child Health, 38, 140-145.

Hiscock, H., & M. Wake (2002). Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. The British Medical Journal, 324, 1062-1066.

Leeson, R., et al., (1994). Managment of infant sleep problems in a residential unit. Child: Care Health And Development, 20, 89-100.

Lehtonen, L., Gormally, S., & Barr, R. G. (2000). "Clinical pies" for etiology and outcome in infants presenting with early increased crying. In: R. G. Barr, B. Hopkins & J. A. Green (eds.) Crying as a sign, a symptom and a signal. London: Mac Keith Press.

Lumley, J., & Austin, M. V. (2001). What interventions may reduce postpartum depression. Current Opinion in Obstetrics and Gynaecology, 13, 605-611.

Lyons-Ruth, K., D. Zoll, et al. (1986). The depressed mother and her one year old infant: Environment, interaction, attachment and infant development. In: E. Z. Tronick and T. Field (eds.) Maternal depression and infant disturbance: New directions for child development. San Francisco: Jossey-Bass.

Milligan, R., Lenz, E. R.,  et al. (1996). Postpartum fatigue: Clarifying a concept. Scholarly Inquiry for Nursing Practice: An International Journal,10(3), 279-291.

Morse, C., Durkin, S., et al. (2004). Improving the postnatal outcomes of new mothers." Journal of Advanced Nursing, 45(5), 465-474.

Murray, L., & Cooper, P. (Eds.) (1997). Postpartum depression and child development. London: The Guilford Press.

Murray, L., & Cooper, P. J. (1997). Effects of postnatal depression on infant development. Archives of Diseases in Childhood, 77, 99-101.

Murray, L., Fiori-Cowley, A., et al. (1996). The impact of postnatal depression and associated adversity on early mother infant interactions and later infant outcome. Child Development, 67, 2512-2516.

Nikolopoulou, M., & St James-Roberts, I.  (2003). Preventing sleeping problems in infants who are at risk of developing them. Archives of Disease in Childhood, 88, 108-111.

Oberklaid, F., Prior, M., et al. (1984). Temperament in Australian infants. Australian Paediatric Journal,20,181-184.

O'Hara, M. W., & Swain, A. M. (1996). Rates and risks of postpartum depression: A meta-analysis. International Review of Psychiatry, 8, 37-54.

Paykel, E. S. (2002). Mood disorders: Review of current diagnostic systems. Psychopathology, 35(2/3), 94-99.

Scottish Intercollegiate Guidelines Network. (2002). Postnatal depression and puerperal psychosis. A national clinical guideline. Edinburgh: Royal College of Physicians.

Wilson, L. M., Reid, A. J., et al. (1996). Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. Canadian Medical Association Journal, 154(6), 785-799.

Contact

Dr Jane Fisher

Email Dr Jane Fisher

Website

www.whatwerewethinking.org.au

www.kcwhs.unimelb.edu.au

More information

More information on the Promising Practice Profiles can be found on the Communities and Families Clearinghouse Australia website.

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