Choosing a clinically relevant but insufficiently documented question is the first step of a sound clinical research. This is precisely what has been done by Baptista et al.1
They start by reminding us that 15 million babies are born preterm worldwide, and that this number is still rising. Mothers of multiple preterm infants (and their partners) are exposed to increased risk for depression, anxiety, and parenting stress. Considering the number of preterm babies worldwide, there is clearly a mental health issue to be addressed. Moreover, little is known on the intermediate variables, which may buffer or increase the negative effect of a multiple preterm birth on the parent's caregiving abilities, acting in a negative transactional spiral.2
The results of the study by Baptista et al.1 are therefore important, and they are striking. There is a clear effect of multiple preterm births, but only in the context of socioeconomic disadvantages. What was new here was the effect size (F[1.95]=5.25). If it is true that the hallmark of good research is the fact that is yields surprise, then the study by Baptista et al.1 is a good one. Contrarily to what could be expected, no differences were observed between mothers of multiple preterm children vs. those of a single preterm child in terms of maternal anxiety and stress. Then, we want to know more. Of course, it is only when a study is completed that one sees precisely how it should have been done. For example, it would have been interesting to know more on the effects of multiple preterm births on fathers. Do they suffer the same impact than mothers, and are the under the same influence of socioeconomic status? What is the role, if any, of the co-parenting alliance on anxiety, stress, and depression associated with preterm multiple birth, and on the impact on the relationship? Answering those questions is essential, but a different frame of research is needed.
To further investigate causal relationships, it is necessary to move from a single frame of thoughts to one that is more sequential, more developmental, and more probabilistic.3 The medical community is in search of the factors that can positively or negatively influence the developmental trajectories of the infants, as well as the caregiver's abilities, considering the genetic susceptibility of both partners in their individual reaction to stress. Such studies have been conducted, for example, by Costa and Figuereido,4,5 on a non-clinical sample followed from birth onward, and by Baptista et al.,6 on a Portuguese institutionalized sample.
These studies require a considerable power and the variables have to be carefully controlled. It also requires a longitudinal design, if some trickier questions are to be answered, such as what is the role of the child's ability to cope with stress stemming from interactive difficulties with parents. Costa and Figuereido4 explored the several developmental trajectories of infants that are dependent on a complex interaction between the infant's temperament and his/her ability to develop a social withdrawal reaction in face of maternal depression.
Studies trying to capture the complex interplay of factors (relational and temperamental, as well as genetic or epigenetic) require assessments tools that directly evaluate the child's experience and his/her behaviors when faced with relational hazards.
This is why the Alarm Distress Baby scale was designed.7–9 Among the several validations of the scale, two were made in Brazil, one in a day care center, the other in Baby-Friendly clinics.10,11
Finally, the key issue is to understand why, in a similar context, some do better than others. This question leads the issue of screening for the most vulnerable individuals, in order to help them earlier and more effectively.12 To achieve this goal, we need simple and validated assessments of the caregiver's ability, but also some tools that directly assess the child's defensive reaction when faced with relational difficulties.
Conflicts of interestThe author declares no conflicts of interest.
