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To evaluate whether separation anxiety disorder (SAD) develops in the later life of the infants, who were separated from their mothers in relation to being in neonatal intensive care unit (NICU). A group of 57 children, ages over 6 years old who were cared in NICU has been evaluated retrospectively by using the SAD diagnostic scale which is adapted according to DSM-IV. Another age and sex matched 50 children who admitted to the outpatient unit were selected as control group. We found that the scores and incidence of SAD were increased among children who were cared in the NICU and both were correlated with the duration of stay in the NICU. The NICU should be arranged to support the development of the baby. Families should be informed about the necessity of sustaining an early mother-infant interaction. By supporting mother-infant interaction, it will be provided that the baby will establish a more secure relation with his/her mother, develop more healthy and have less behavior problems in the future life.
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ORIGINAL ARTICLE
Separation anxiety disorder increases among neonatal intensive care
unit graduates
Musemma Karabel1, Seda Tan2, Mustafa Mansur Tatli3, Ayse Esra Yilmaz4, Alparslan Tonbul4 & Ahmet Karadag5
1Department of Pediatrics, Fatih University Faculty of Medicine, Ankara, Turkey, 2Department of Psychiatry, Fatih University Faculty
of Medicine, Ankara, Turkey, 3Division of Neonatology, Department of Pediatrics, Fatih University Faculty of Medicine, Ankara,
Turkey, 4Department of Pediatrics, Fatih University Faculty of Medicine, Ankara, Turkey, and 5Division of Neonatology, Department of
Pediatrics, Inonu University School of Medicine, Malatya, Turkey
e Journal of Maternal-Fetal and Neonatal Medicine
2011
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© 2011 Informa UK, Ltd.
10.3109/14767058.2011.592876
1476-7058
1476-4954
The Journal of Maternal-Fetal and Neonatal Medicine, 2011, 1-6, Early Online
Copyright © 2011 Informa UK, Ltd.
ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2011.592876
Correspondence: Dr. Ahmet Karadag, M.D., Inonu University School of Medicine, Department of Pediatrics, Malatya, Turkey. Tel: + 90 422 3410660. Fax:
+ 90 422 3410660. E-mail: ahmetkaradag@gmail.com
Aim: To evaluate whether separation anxiety disorder (SAD)
develops in the later life of the infants, who were separated from
their mothers in relation to being in neonatal intensive care unit
(NICU). Methods: A group of 57 children, ages over 6 years old
who were cared in NICU has been evaluated retrospectively by
using the SAD diagnostic scale which is adapted according to
DSM-IV. Another age and sex matched 50 children who admitted
to the outpatient unit were selected as control group. Results:
We found that the scores and incidence of SAD were increased
among children who were cared in the NICU and both were
correlated with the duration of stay in the NICU. Conclusion:
The NICU should be arranged to support the development of
the baby. Families should be informed about the necessity of
sustaining an early mother-infant interaction. By supporting
mother-infant interaction, it will be provided that the baby will
establish a more secure relation with his/her mother, develop
more healthy and have less behavior problems in the future life.
Keywords: hospitalization, neonatal intensive care unit,
separation anxiety disorder
Introduction
e infants who remain at the hospital for a long-time period
lack their mother’s care, concern and love, so they are negatively
aected [1]. e attachment starts from the rst hour of delivery
and aer that during the rst 6 months of life becoming together
have important roles in the relationship patterns of the future of
infants and their mothers [2].
e quality of the attachment relationship is believed to have
acquired its roots in early maternal interactional style with the rst
physical contact aer birth. e rst contact is not a mandatory
for the process of the development of attachment relationship, but
it is believed to empower the relationship [3]. e authors have
reported that the separation of the mother and infant aer the
rst contact and later coupling aects the quality of the attach-
ment [3]. It was shown that the psychological status of the mother
forms the base of the attachment and has the most signicant role
in the infant-mother relationship [4]. Results of studies on the
attachment patterns of preterm and term babies are conicting.
About the separation in the newborn period, the risk of “reactive
attachment disorder in infancy or early childhood” has been found
to be high in infants who remain at the hospital for long-term care
and treatment [1]. Goldberg et al. showed that if preterm generally
achieve secure attachment relationships, one can infer that their
earlier interactions have been supportive and appropriate [5].
It was suggested that early life stresses in the neonatal intensive
care unit (NICU) result in formation of stress-sensitive, so this
may have an important role in the formation of depression and
anxiety disorders. e fear of losing the mother again and experi-
encing the separation in the future in these babies may manifest
as an anxiety disorder.
ree or more out of eight criteria dened in DSM-IV are
enough for diagnosing separation anxiety disorder (SAD). In
addition, this anxiety should be unreal, last at least 4 weeks
and cause an important problem or a disorder in the social,
vocational (school) or the other functional areas [6]. e
individuals having the above-mentioned disorder have repeti-
tive and excessive anxiety and distress, worries about getting
lost, having an accident or being ill for themselves and for the
attached person when they leave from home or the attached
person. Besides the psychological symptoms such as attachment
to the parent, not to sleep alone, nightmares, physical complaints
such as throbbing, dizziness, weakness, stomach-ache or head-
ache, nausea and vomiting are oen seen in these children [7].
It has been estimated that 33–40% of children with SAD develop
at least one adult psychiatric disorder. Moreover, children and
adolescents with SAD have been shown to confer an increased
risk for the development of alcoholism and substance abuse than
the control group [8]. erefore, it is important to prevent factors
that may cause SAD, as well as to diagnose children with SAD
early. e study of the eects of prolonged hospitalization on the
infant is important in the development of future depression and
anxiety disorders [9]. However, the eect of the separation in the
neonatal period on SAD has not been studied. Hospitalization in
the NICU for a long time may impair mother-infant relationship
and may cause SAD.
e aim of this study was to evaluate SAD in the later life of
these infants who hospitalized in the NICU in their neonatal
period and at their ages over 6 years old now.
Methods
e study group included 57 infants aged ≥6 years old and who
were hospitalized at the intensive care unit (ICU) for at least
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A3
2 M. Karabel et al.
e Journal of Maternal-Fetal and Neonatal Medicine
3 days in the neonatal period. e children were assessed from
October 2008 to August 2009. ey were followed up in the
pediatrics outpatient clinic of our hospital. e control group
included 50 infants admitted to the outpatient clinic for mild
infection or follow-up. e exclusion criteria were multiple
delivery and neurological problems such as cerebral palsy,
mental motor retardation and hypoxic ischemic encephalopathy.
Children with chronic sicknesses, psychiatric disorders, those
whose mother, father or both have died or whose parents have
divorced were not included in the control group.
e age distributions of the study and control groups were
similar. Each child was assessed rst by a pediatrician and then
by a clinical psychologist who had been blinded to the socio-
demographics and medical history. Patients were evaluated with
structured interview SAD was diagnosed based on at least three
out of eight criteria of DSM-IV, lasting at least 4 weeks at the level
of impairing daily functions [6]. e SAD scores were assessed as
“≤2 criteria” (no) and “≥3 criteria” (yes). e families of patients
with the diagnosis of SAD were informed by a psychiatrist and
clinical psychologist, and underwent consultation for treatment.
e families’ economic status assessments were based on the data
of the State Institute of Statistics for year 2005. e medical history,
socio-demographic details, associated psychiatric symptoms
and factors related to family and school that may have played a
role in SAD were questioned in the study and control groups.
e personality characteristics of child described by the mother
were recorded. e exclusion criteria were multiple delivery, and
neurological problems such as cerebral palsy, mental motor retar-
dation and hypoxic ischemic encephalopathy.
ICU in which all patients are hospitalized is a unit with 15 beds
giving Level III intensive care service with a patient to nurse ratio
of 1:3 per each shi. In the ICU, babies are followed up either in an
incubator or a warmer. Parents are not allowed to stay overnight
but mothers can visit their babies whenever they want during the
day. Daily visits of up to 30 minutes are allowed for fathers as well.
Baby care is entirely under the control of the nurses; however, if
they desire, the mothers may feed their babies via a feeder or breast
feed them. e blood pressure, pulse, respiratory rate, saturation
and temperature of the babies are monitored throughout their
hospitalization. Loudness in the ICU is kept under 50 decibels
at all times. ICU lights are dimmed at nights in order to retain
diurnal rhythm.
In order to perform screening for psychological symptoms,
aer the clinical interview, the mothers underwent Symptom
Checklist-Revised (SCL-90-R) measurements. e study protocol
was approved by the local Ethics Committee.
e SCL-90-R is a self-rated scale containing 90 items
consisting of eight psychiatric symptom domains, including the
Global Severity Index, Positive Symptom Total, and Positive
Symptom Distress Index subscales [10]. In this study, all 90 items
were administered. Informed consent was obtained from all
parents of the newborns involved in the study.
Statistics
e data were installed and analyzed using the SPSS for Windows
11.5 (SPSS Inc, USA) pocket program. When dening the factors
aecting SAD, the logistic regression analysis was used if the
independent variable was a two-sided categorical variable. e
analysis for the status of being in the NICU and the categorical
data were compared using the chi-square and the Fisher’s exact
Chi-square tests. Student’s t-test was used when the continuous
variables were parametric. e Mann–Whitney U test was
used for non-parametric results. e correlation between the
continuous variables was analyzed using the Pearson correlation
analysis whether they were parametric and using the Spearman
correlation analysis whether they were not parametric. Numbers
and percentages were given for the categorical data and the mean
± standard deviation and/or median were given for the continuous
data. e level of signicance was set as p < 0.05.
Results
ere were a total of 107 children in the study. Of these, 57 were
hospitalized in the NICU. e mean duration of stay in the NICU
was 10 days. e gestational week and the birth weight were lower
in the study group when compared to the control group. e rate
of caesarean delivery was higher and the frequency of the mother
being the caregiver was higher aer discharge in NICU group
(Table 1).
Of the study group, 51% (n = 29) underwent ventilator therapy,
mean duration of this therapy was 4 days (1–21 days). e reasons
for being in the NICU were; prematurity (n = 15; 26%), respiratory
distress syndrome (n = 13; 23%), transient tachypnea of the
newborn (n = 12; 21%), pneumonia (n = 7; 12%), feeding problems
Table 1. Demographic details of infants staying in the intensive care unit and the control group.
Characteristics
Study group n = 57
mean ± SD; (%)
Control group n = 50
mean ± SD; (%) p
Age (year) 8.6 ± 2.1 7.96 ± 1.7 0.62
Gestational week 34.1 ± 1.3 39 ± 1.6 0.0001
Gender
Female 24 (42) 27 (54) 0.248
Male 33 (58) 23 (46)
Type of delivery
Normal vaginal 16 (28) 27 (54) 0.01
Caesarian section 41 (72) 23 (46)
Birth weight (gram) 2065 ± 75 3278 ± 535 0.0001
Infant care
Mother 50 (88) 24 (48) 0.0001
Others 7 (12) 17 (52)
SAD (score) 4 ± 2 2.3 ± 2.6 0.0001
SAD
Yes 33 (%58) 13 (%26) 0.0001
No 24 (%42) 37 (%74)
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Separation anxiety disorder and NICU 3
Copyright ©  Informa UK, Ltd.
(n = 2; 3.5%), sepsis (n = 3; 5.5%), and intrauterine growth retarda-
tion (n = 5; 9%). e SAD score was signicantly higher in those
who had stayed in the NICU (p < 0.001). e rate of SAD was 26%
in children who had not stayed in the NICU, and it was 58% in
children who had stayed in the NICU. e relative risk was 3.9
(95% CI: 1.7–8.9) (Figure 1). e factors (family, school, mother
and the other individual characteristics) that may aect having
SAD in the study group have been presented in Table 2. e rela-
tive risk for SAD was 8.8 (95% CI: 1.7–46.2) in children who had
stayed in the NICU ≥20 days compared to those with shorter stays
in the NICU (<10 days). e relative risk for SAD was 3.3 (95%
CI: 0.9–12.5) in children who had undergone ventilator therapy
for ≥4 days compared to those who had not undergone ventilator
therapy. When the correlation between SAD scores and variables
that may aect SAD was studied in the study group, it was found
that the SAD score increased signicantly as the duration of stay
in the NICU increased (r = 0.28; p < 0.05). ere was no signi-
cant relationship between the other variables and SAD scores. e
relationship between the demographic details and SAD scores of
the study group was studied. As the number of criteria dening
SAD increased, the rate of day-care/school rejection increased
and the academic performance was signicantly impaired.
Mothers were assessed psychiatrically using the SCL–90-R
scale. ere was no signicant dierence between the groups for
the psychiatric symptoms. us, it was found that the mothers
of the study and the control groups were similar and normal in
terms of psychiatry.
Discussion
is study has shown that staying in the NICU increases the inci-
dence of SAD and this risk correlates with the duration of stay.
e relative risk of SAD was signicantly increased four-fold in
children staying in the NICU. e number of criteria for the risk
and diagnosis of SAD showed an increase as the duration of stay
in the NICU increased. Despite the reports in previous studies,
the fear of losing the mother again and the fear of re-experiencing
the separation re-emerges in future manifestations as SAD in
babies separated from their mothers and staying in the NICU in
early infancy [9]. ere are no studies about SAD in infants in the
NICU in the literature to our knowledge.
ere are many studies on how babies in ICUs aect their
mothers. Even though there are many studies researching the
bonding and attitudes of the mothers towards their babies in ICUs
[11–13], the aects of restrictions regarding admittance to the ICUs
on mothers [14], there is no study on the aects of hospitalization
in ICUs on the separation anxiety during childhood. Hence, we
believe that our study will spark further similar studies.
Preterm babies are generally less awake, less mobile and pay
less attention [15]. ese features hinder the families in under-
standing their infants’ demands and emotions, and hence,
rendering the process of responding to them and stimulating
them dicult. e higher incidence of SAD in our study group
which mainly comprised preterm infants may be due to birth
weeks, more frequent and longer ventilator need, and high risk
of hospital re-admission. On the other hand, catching up the
attachment pattern late as they are separated from the primary
caregiver for longer periods may increase the incidence of SAD.
In our study, the majority of infants who remained at the
hospital for long term in the NICU were preterm infants or
low birth weight infants. It was suggested that this was related
to their more likely status of being delivered through caesarean
section than in the control group, and their birth weights being
signicantly lower than that of the control group.
e reasons of staying in the NICU in our study were consistent
with the literature. e majority of patients were preterm and the
most common accompanying diagnosis was respiratory distress
syndrome. e risk of SAD was signicantly higher, especially in
infants who underwent ventilator therapy for ≥4 days. Ventilator
therapy and the related complications may both extend the stay
in the NICU, may hinder the mother-infant interaction and the
attachment that can only be created by the warmth reected from
the mother gure. In a study, it was shown that families perceived
their babies in the NICU as more vulnerable and were afraid of
touching them and were more anxious for the NICU process and
thereaer [16]. Ventilator therapy irritates the parents and causes
them to be timid and distant with the fear of harming the baby,
not embracing, and not even touching the baby.
It was reported that children with SAD had families with lower
socioeconomic status [17]. is literature nding is supported by
the fact that these children have single parents. e families of
the study and the control groups of our study were selected from
middle-high economic class individuals and it was aimed that at
least some of the environmental factors in the pathogenesis of
SAD would be eliminated.
Muller-Nix observed that positive and early mother-infant
interaction was closely related to the future establishment of
a trustful relationship with the mother, having less behavior
Figure 1. Separation anxiety disorder scores of the study and control groups. e horizontal axis shows the groups and the vertical axis shows the scores for
separation anxiety disorder. e horizontal thin line shows the cuto for separation anxiety disorder; it is an indicator for <3 and ≥3 criteria. e dots show
the score distribution of individuals for separation anxiety disorder.
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4 M. Karabel et al.
e Journal of Maternal-Fetal and Neonatal Medicine
problems in the pre-school child, and better improvement of the
cognitive functions in the school child [18]. Postpartum care by
the mother should be especially mentioned here. In our study, we
found that care of the infant aer discharge from the ICU was
mostly undertaken by the mother. is nding suggests that
although the babies in the study group received more care by the
primary caregiver aer ICU, the reason for the increased inci-
dence of SAD may be the impact of early separation, both on the
infant and on the mother, in addition to the possibility of experi-
encing problems when mothers were le alone with babies. e
support and guidance to the mother by the husband or elderly
members of the family aer discharge from NICU may have also
been eective. In this context, the family’s style of child rearing is
important.
e pathogenesis of the SAD includes family attitudes and
the child rearing style of the family. When the families with
intensive separation anxiety were assessed, it was found that the
children were over-protected by their mothers [9]. Hirshfeld
and Biederman showed in a pilot study that emotional over-
involvement was signicantly associated with child SAD in
the at-risk sample [19]. Anxiety of the parent or the caregiver
causes an increase in the anxiety of the child [20]. Families
feel high levels of desperation and stress in the NICU, because
the happiness and dream of having a healthy baby is at risk.
Furthermore, families in general have inadequate knowledge on
caring and establishing a relationship with their preterm baby
during the stay in the NICU and aer discharge. Parents who
have witnessed the challenging process their baby has had at the
NICU and who were separated from their babies for a long time
may be overprotective or may keep the child always at home or
under care aer discharge with the anxiety that something bad
will happen and may not permit the free individualization of the
child. is may cause the child who was in the NICU to insist
on staying at home when he/she needs to go away from home or
Table 2. e eect of clinical and demographic factors on separation anxiety disorder risk during and aer the stay in the neonatal intensive care unit in
the study group.
Sociodemographic details (n = 57) n (%) Odd’s ratio (%95 CI) p
Gender
Female 24 (42)
Male 33 (58) 1.7 (0.6–5.1) 0.3
Type of delivery
Normal vaginal 16 (28)
Caesarian section 41 (72) 2.2 (0.7–7.2) 0.18
Duration of stay in NICU (days)
<10 (R) 27 (47)
10–19 14 (24) 1.2 (0.3–4.5) 0.73
≥20 16 (29) 8.8 (1.6–46.2) 0.01
Duration of ventilation (days)
No (R) 28 (49)
1–3 12 (21) 1 (0.3–3.9) 1
4–9 17 (30) 3.3 (0.8–12.4) 0.04
Infant care
Mother 50 (88)
Others 7 (72) 1.9 (0.3–11.1) 0.44
Family conict
No 50 (88)
Yes 7 (12) 1.9 (0.3–11.1) 0.44
Divorce
No 53 (93)
Yes 4 (7) 0.7 (0.01–5.4) 0.74
Loss in family
No 54 (95)
Yes 3 (5) 1.5 (10.1–17.3) 0.75
Change of school
No 54 (95)
Yes 3 (5) 0.34 (0.03–4.03) 0.39
Educational status of the mother
University (R) 19 (33)
High school 25 (44) 1.35 (0.40–4.50) 0.62
Primary 13 (23) 1.44 (0.34–6.06) 0.61
Similar problem in mother
No 51(89)
Yes 6 (11) 4.1 (0.45–37.7) 0.21
Accompanying somatic complaints
No 54 (95)
Yes 3 (5) 0.3 (0.03–4.03) 0.39
(R), reference category.
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Separation anxiety disorder and NICU 5
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attend school, to have diculty or to feel anxiety. us, being in
the NICU is a risk factor alone for SAD and furthermore, it leads
parents to be overprotective and anxious and may contribute to
the development of SAD.
Berstein suggested that there is a higher rate of depressive
and anxiety disorders in rst-degree relatives of children with
SAD, and there is a higher frequency of family dysfunction
[21]. Biederman reported that having parents with anxiety
disorder and depression will facilitate the development of SAD
in the child [22,23]. In our study, the Global Severity Index,
e Positive Symptom Distress Index, (PSDI), and the Positive
Symptom Total (PST), subscores of SCL-90- R, which were used
to dene the contribution of the mother’s psychiatric condition
to SAD were within the normal ranges, and we could not nd a
signicant dierence between the study and the control groups.
e mothers were asked for similar symptoms in childhood and
no signicant dierences were found between the two groups.
e lack of assessment of fathers for the psychiatric conditions
and the lack of questioning the other siblings for the similar
complaints was limitations of our study. However, family conict
and divorce were assessed for the environmental factors stem-
ming from the family, because marital conicts, illness or loss of
a family member are among the factors facilitating SAD besides
hospitalization of the child [24]. In our study, there was no signif-
icant dierence between the two groups in terms of the number
of siblings and the history of loss in the family. Although the inci-
dence of divorce and family dysfunction were higher in the study
group, the dierence was not signicant. When it was taken into
consideration that environmental factors may determine SAD,
the mother being at home or not may be accepted as a factor
aecting the symptom distribution in children. When it was
taken into consideration that the educational status of mothers
of children with SAD may cause dierences in the attitudes of
mothers in case of problems, it was noticed that the educational
status of the mothers in the control group was signicantly higher
than that of the study group. It was reported in one study that
children whose mothers were at home could have more available
conditions for sustaining their symptoms [25]. e higher educa-
tional status of mothers in the control group may be related to
the increase of the possibility of using antenatal care, which may
reduce the baby’s need for NICU. ese better educated mothers
may notice the symptoms at an early stage and may seek help
before the child develops any dysfunction. Although the age of
mothers in the study group was higher than that of the control
group, it was not statistically signicant. e higher age in the
study group may be related to the relatively decreased fertility in
this age group and increased admissions for assisted reproduc-
tion techniques.
e main characteristic of SAD is the feeling of extreme anxiety
due to separation from home or from the gure of attachment.
Francis showed that anxiety about parents getting harmed, having
nightmares and school refusal were the most frequent symptoms
in children with the diagnosis of SAD [26]. In the same study, it
was shown that children with SAD had more frequent somatic
complaints and that children with somatic complaints had more
frequent school rejection. In our study, more than half of the
children with SAD demonstrated school rejection without having
school change or problems with teachers or friends, and the
academic performance declined as the number of criteria for SAD
increased. Although the accompanying somatic complaints were
more prevalent in the control group, the dierence was not signif-
icant. Our results support those of the study by Zeanah which
suggested that children with insecure attachment to their parents
in the rst 3 years of life experienced more problems compared
to children with secure attachment about problem-solving in the
pre-school period [27].
In conclusion, our rst study in this area has shown that
staying in the NICU increases the prevalence of SAD and that
this increase directly correlates with the duration of stay. In this
context, it should be emphasized that one should focus not only
on the physical changes of infants staying in the NICU but also on
the developmental support meeting the cognitive and emotional
needs. e suggestions about individualized care and environ-
mental changes should be formed by the families and the health
ocials. e unit should be arranged to support the development
of the baby. Families should be informed about the necessity of
sustaining an early mother-infant interaction. By supporting
mother-infant interaction, it will be provided that the baby will
establish a more secure relation with his/her mother, develop
more healthy and have less behavior problems in the future life.
Declaration of interest: e authors report no conicts of
interest.
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... Hospitalization may also delay the attachment and impede the mothereinfant relationship. To solve the problem, KMC can establish the attachment by physical contact between the preterm newborn and the mother in the NICU (Franklin, 2006;Johnson, 2008;Karabel et al., 2011). Consequently, it strengthens the quality of the parenteinfant relationship psychologically, socially, and emotionally and also affects the long-term outcome of growth and development. ...
... Consequently, it strengthens the quality of the parenteinfant relationship psychologically, socially, and emotionally and also affects the long-term outcome of growth and development. On the contrary, it should be tangibly noted that the attachment disorder, as a product of maternal separation or lack of mother care may lead in complications such as failure to thrive, separation anxiety disorder, personality disorder, school problems, crime and so on (Karabel et al., 2011;Ludington-Hoe et al., 1999). ...
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The aim of this investigation was to determine nurses' viewpoint about the impact of Kangaroo Mother Care on the attachment between mother and infant. Methods: A descriptive study was carried out with the staff (23 nurses) of an NICU of a University Hospital in Iran. Data were collected through self-report method (Avant Maternal Attachment Behavior Scale) and analyzed by use of SPSS. Findings: The majority of the participants had positive viewpoint on the subject of study. The affectionate behavioral subscale had the most effect on the mother-infant attachment, while the item " holding without skin contact" of proximity maintaining subscale was looked at as the most disagree and strongly disagree item (68.2%) of the attachment scale. Conclusion: According to the nurses' viewpoints, mother-infant attachment behavior are strengthened by applying the Kangaroo Mother Care. Furthermore, the benefits of this type of care are mentioned.
... No register studies examined specific anxiety disorders separately. One small cohort study found that treatment in a neonatal intensive care unit (NICU) was associated with specific phobias (19) and two identified it to associate with separation anxiety disorders (19,20). ...
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Objective Mode of delivery and well-being markers for newborn infants have been associated with later psychiatric problems in children and adolescents. However, only few studies have examined the association between birth outcomes and anxiety disorders and the results have been contradictory.Methods This study was a Finnish population-based register study, which comprised 22,181 children and adolescents with anxiety disorders and 74,726 controls. Three national registers were used to collect the data on exposures, confounders and outcomes. Mode of delivery, the 1-min Apgar score, umbilical artery pH and neonatal monitoring were studied as exposure variables for anxiety disorders and for specific anxiety disorders. Conditional logistic regression was used to examine these associations.ResultsUnplanned and planned cesarean sections increased the odds for anxiety disorders in children and adolescents (adjusted OR 1.08, 95% CI 1.02–1.15 and aOR 1.12, 95% CI 1.05–1.19, respectively). After an additional adjustment for maternal diagnoses, unplanned cesarean sections remained statistically significant (aOR 1.11, 95% CI 1.04–1.18). For specific anxiety disorders, planned cesarean sections and the need for neonatal monitoring increased the odds for specific phobia (aOR 1.21, 95% CI 1.01–1.44 and aOR 1.28, 95% CI 1.07–1.52, respectively).Conclusions Birth by cesarean section increased the odds for later anxiety disorders in children and adolescents and unplanned cesarean sections showed an independent association. Further studies are needed to examine the mechanisms behind these associations.
... The experimental models used to explore anxiety commonly include only adult animals, usually rodents, despite the fact that anxiety is an emotional disorder that occurs not only in adults but also in children (Kessler et al., 2005; Shamir-Essakow et al., 2005) and adolescents (Medina-Mora et al., 2007). Attention in a neonatal intensive care unit at birth may be related to an increased risk for the subsequent development of separation anxiety disorder (Karabel et al., 2012). Social phobia, for which the age of onset is B11 years old, is the most common anxiety disorder at this age, and constitutes a risk factor for subsequent depressive illness and the development of substance abuse (Chavira et al., 2004; Mason et al., 2004; Kessler et al., 2005; Stein and Stein, 2008). ...
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