During her PhD project, Marion van den Heuvel (Cognitive Neuropsychology, Tilburg University) conducted research into the influence of maternal anxiety on the child during pregnancy. She studied the effects of maternal anxiety on the baby. At that time, she saw more and more studies on the mother's brain during pregnancy, indicating that the mother's brain changes after having a first child. Marion got interested in this and wondered how the brain develops in the case of anxious mothers. The idea arose not only to look at the mother's or the child's brain separately but to study them together. For this idea, Marion received a Veni grant from NWO (the Dutch Research Council) in 2019. The research is now in full swing, with some adjustments due to the corona measures.

Unfamiliarity with postnatal anxiety
Compared to postnatal depression, there is still sparse literature on postnatal anxiety. However, the impact of postnatal anxiety appears to be significant for both mother and child. Mothers who are anxious during pregnancy are often also anxious after childbirth. The mother’s anxiety can cause a disturbed relationship with the child. From other studies, Marion knows that children often take over fear from the mother. “When children are young, this can manifest itself in various complaints such as poor sleep, abdominal pain, or crying. These are often signs that children are not happy and healthy.” As children get older, the consequences can also be more serious. Marion says that depression, anxiety, drugs use, or deviant behavior, for example, can occur later in life.

Understanding the daily lives of anxious mothers
Because so little is known about what postnatal anxiety looks like and about the interaction between anxious mothers and children, Marion knew she had to use new methods to gain insight. She opted for experience sampling questionnaires to see how behavior is related to feelings (of anxiety). The mothers receive a pop-up on their smartphones several times a day for a week to register their behaviors, thoughts, and feelings of anxiety. She does this in two different groups: a group of anxious women and a control group. She works with two groups to compare what is normal and what is not. Many mothers check if their baby sleeps well, but non-anxious mothers are not driven by fear and are reassured after checking. Anxious mothers remain anxious, even after checking, and they continue to check, which does not reduce their anxiety.

The mothers who participate in the experience-sampling questionnaire come from the Brabant Study (Dutch only), from which data on the pregnancy and birth are already known. Prior to the study, Marion makes a home visit to all mothers to explain the research and to conduct a psychiatric interview.

Synchronization of the brains
Marion is interested whether mother and baby are literally on the same wavelength. In the second phase of the research, she will measure in the lab to what extent the brains of mother and baby produce brain waves in the same way, in other words whether the brain shows synchronization. She does this both in the group of anxious mothers as in the control group. Marion would like to know to what extent synchronization between mother and baby differs between the two groups. She is still uncertain about the results, but does have an idea. “A lot of research has already been done into synchronization. More synchronization is often associated with effects that are more positive. For example, research has been done on the learning process of babies. If there was more synchronization between mother and baby, the baby will have learned more. With normal interaction, you see that the baby also initiates synchronization from time to time, e.g., when the baby makes sounds or seeks eye contact. In the case of an anxious mother, I expect it to come mainly from the mother, in other words that the mother takes over completely. The baby has less chance to indicate when (s)he wants contact and when contact is over.”

Focus groups
What behavior do anxious women show and what are their experiences? In what ways are they restricted in their daily lives? To get an answer to this, Marion works with focus groups of mothers. The first meetings, before the corona outbreak, gave many new insights about the behavior and feelings of anxious mothers. Marion uses these insights to draw up the experience-sampling questionnaire. It also became clear how serious the problem is. “For example, some women do not dare to get into the car with their babies, or they do not hand over their babies to others, sometimes not even to their own partners.” Marion explains that the focus groups were very emotional. “After the focus groups, I am even more motivated to work on this topic. The issues are even more intense than I thought. I already thought that these women were under-treated and that they didn’t know what they are suffering from and what they could do about it – and that was confirmed. Much stronger than I already thought.”

Postnatal anxiety or postnatal depression?
Much is already known about postnatal depression. Maternity nurses have been trained to recognize postnatal depression and information leaflets are available, for example. However, there is a big difference with postnatal anxiety. Marion: “The literature I found showed that mothers who are anxious show completely different behaviors from mothers who are depressed. Mothers who are depressed often give very little response to the baby. They are a bit tired and a bit numb in their expressions. Well-known is the way of communicating with babies in which you talk in very high voice, called ‘motherese’ or ‘child-directed language.’ The tone is higher, slower, and with more emphasis. Research has been done that shows that depressed women do this a bit less. Women who are very anxious, on the other hand, do this in an exaggerated manner. It is more difficult to pick up the signals of anxiety because, if you look at these mothers from distance, you see very involved and enthusiastic mothers. Only when you look closely, you see that the mother’s behavior is not quite in line with the baby. For example, when the baby is tired and overexcited and the mother is still very enthusiastic, if a mother constantly checks on the baby, finds it difficult to tolerate when the baby is not happy for a moment and cries. Only then you will see that something is not quite right.” Precisely because these women seem so involved and enthusiastic, it is important to measure behavior in everyday life, at that moments when things are difficult. There is also comorbidity because many women with depression also show anxiety, and many women with anxiety also show depression. “I really want to look at the women who either have only anxiety, or for whom the anxiety is in the foreground.”

The purpose of the project
Postnatal anxiety is often underdiagnosed, not diagnosed, or misdiagnosed as postnatal depression. Therefore, women often do not get the right help. Marion would like to develop an app, checklist, or online self-test to give women insight into what is normal and what is not. “It would be great if women were more likely to tell the midwife or at the clinic that they suffer from postnatal anxiety. Most anxious women who participated in the focus groups indicated that they did not get any help at all and that they missed it very much. Only when they saw our ad of the study did they thought: that’s what I had!”

The birth of BABI
When the questionnaire is done, the project team celebrates its birth with birth announcement cards and the questionnaire is given a name, the “BABI”, which stands for ‘Baby related Anxiety and Behavior Inventory’. In addition, the team works “open source” by making the questionnaire available for everyone, but also by publishing all the steps of the study in an article. “The intention is to share everything because Experience Sampling as a research method is still very novel. We will show how we approached it step by step.”

Interest in babies and children
It is not surprising that Marion puts the welfare of babies and mothers at the center of her research. Already in primary school, she liked to help preschoolers. She supervised holiday work for youngsters, volunteered at the children’s helpline, and in her Bachelor’s and Master’s thesis, children also took a central stage. “In terms of research, I am particularly interested in early development, because there is a lot of plasticity. Babies really suck everything up. The brain grows very fast, so a lot can go wrong. Babies are very vulnerable and very resilient at the same time, which I find interesting. I also like working with parents because most of them really want to do it all very well. Especially with parents and their first child, I like to see the change. I have also been interested in the bond between mother or father and the baby for a long time.”

The project team
The project team consists of Marion van den Heuvel (assistant professor, Cognitive Neuropsychology, Tilburg University), Myrthe Boekhorst (data manager/post-doctoral researcher, Medical and Clinical Psychology, Tilburg University), Jessica Vergeer (junior researcher, Cognitive Neuropsychology, Tilburg University) and Irene den Boer (project assistant and student Tilburg University).

The project team is still looking to expand. Are you a statistician with interest in the analysis of intensive longitudinal data and would you like to participate in this interesting project as a collaborator? Please contact Marion or let TESC know, and we will be happy to put you in contact.

More information
Do you want to know more about research by Marion van den Heuvel? Take a look at her website.

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