 Hello, it's Marco Murray speaking from MHPN. I'd like to welcome everybody to our webinar tonight. The webinar's title is Working Together to Support the Mental Health of Families with Preterm Babies. We've had 788 people register for this online webinar tonight. And so far, close to 250 people have logged in. We expect more to log in as we go through the evening. We have a very talented panel tonight. I'd like to first of all introduce Nina Grillo, a social worker from Melbourne. Good evening, Nina. How are you? Hi, Michael. Well, thank you. How did you first become involved with Perinatal Health and Preterm Babies? Well, I'm a social worker in Melbourne's Royal Women's Hospital. And I've been working in the NICU, which is the Neonatal Intensive Care Unit, for approximately 80 years. Great. So you must have a wealth of experience to share with us tonight. I hope so. Great. Thank you. And next we have Dr. Carolyn Unum, a psychologist from Melbourne as well. Carol, can you tell me how you first became involved with Perinatal Health and Preterm Babies? Well, Michael, I was offered a job when I was midway through my degree. And it was a research assistant job in the Mercy Hospital for Women. And I'd actually had one of my babies in that intensive care unit. And so not only was it an emotional sort of journey, but it was actually very much an academic intellectual journey too, because I'm very interested in the way these babies' brains develop. And it is very interesting, isn't it? It's extremely interesting, yes. And very hopeful. And very positive, I think. Yes. Thank you, Carol. And next we move on to Professor Caroline Zanetti, a psychologist from Western Australia. Good evening, Caroline. Hello. Hi, everyone. How did your career take its turn into Perinatal Health and Preterm Babies? Well, I think it was always an interest of mine. And I'm a Perinatal incident and child psychiatrist. So I've always been interested in mental health of young children, but also in mothers and fathers. And everything seems to have just come together so that I've ended up here. Great. We're so glad to have you here tonight. And last but not least, I'd like to welcome Belinda Horton, an occupational therapist and previous CEO of Panda, the Post and Antinatal Depression Association. You're very welcome, Belinda. How did you first become involved with Perinatal Health and Preterm Babies? Well, thank you, Michael. I prior to going to Panda about 10 years ago, I was providing counseling as an OT and family therapist in outreach and running support groups and then went to Panda. And among the many experiences that men and women have in that Perinatal period, preterm birth was relatively common and right through from that early... those difficulties during pregnancy through to early birth or an unwell baby, even loss of a baby. So through my professional role as an OT and certainly at Panda on the National Health Plan. That's great. Well, we look forward to sharing your expertise and thank you all very much for attending. My name is Mark Lamarie. I'm a GP in Townsville. I have a generalist interest in nearly everything, including babies and parents and life in general. So just a few grand rules tonight. All participants should consider the following grand rules. Be respectful of other participants and panelists. Behave as if you were in a face-to-face activity. Post your comments for panelists in the general chat box and any help with technical issues post in the technical health chat box. Be mindful that comments posted in the chat box can be seen by all participants and panelists. And try and please keep on topic. If you would like to hide the chat, click the small down arrow at the top of the chat box. Your feedback is very important. Please complete the short exit survey which will appear as a pop-up when you exit the webinar. We have some learning outcomes for tonight. You will all have read Bromwell's case. Through an exploration of Bromwell's experience, the webinar will provide participants with the opportunity to, one, identify the risks for perinatal mental health, particularly for mothers with pre-parent babies, to recognize the core principles of and pathways to effective treatment and management of perinatal mental health issues, particularly for mothers with pre-parent babies, and, thirdly, to understand the challenges to an opportunity for providing collaborative care to families experiencing perinatal mental health issues. With that further ado, we will explore the first one and possibly two of those learning outcomes in our slide presentations from each of our excellent presenters. So, I'm going to just turn over to you now, Nina. Thank you, Michael. So, hello, everybody. As I introduced earlier, I'm Nina and I'm a social worker in Melbourne's Royal Women's Hospital and I work in the neonatal unit. So, in my presentation, I'll use the acronym NICU quite a bit. So, NICU does stand for Neonatal Intensive Care Unit and our NICU is one of four level three nurseries in Victoria and by level three, I'm inferring to the highest level of care that can be provided to infants. And babies in our NICU can be born as young as 23 weeks gestation and can weigh as little as 400 grams. In the last 12 months, I would say we've had about 1,600 NICU admissions. So, quite a few babies are born prematurely. I think more than one would expect. The case study of Bronwyn, as you've all read, and her family is very much focused on the month's post discharge from NICU. However, the story begins much before then. My presentation is based on my interaction and my interventions with families when their babies are in-patients. And hopefully it will give you some understanding into the key themes and stresses that are often experienced by mothers in particular and how they've played out month's post discharge, having a wider impact on the family. I see my role as a social worker in NICU is to reduce parental distress by providing opportunity to debrief the shock and the trauma experience of having a premature baby, to normalise feelings of grief and loss, guilt and responsibility, challenge erinous and maladaptive thinking, and help parents with their coping and adjustment to the circumstances. My years of experience as a social worker in NICU has shown me that the parents experience a myriad of emotions, which at times are contradictory, adding more stress and trauma. One of the most significant emotions that parents experience in the initial crisis stage, despite the fear and the worry that they have for their baby, is grief and loss. So I'm going to focus quite a bit on that. So when a pregnancy doesn't reach 40 weeks and the birth plan is abandoned, celebrations don't happen, rights of passage are often lost, it's normal for parents and women in particular to have a grief and loss reaction. And this can really be difficult for the parents to acknowledge and also for their social and peer networks to acknowledge, because grief is often associated when a baby dies or when there's a death. And in these circumstances, the baby is alive. So the losses are quite significant. So there's a loss of the pregnancy. Women often feel quite connected in the second trimester when there's a movement. They have quite an intimate relationship with their baby and that relationship is then interrupted when their baby's born early and women mourn that relationship and not feeling pregnant anymore, not being able to get quite big, believe it or not, they miss the waddle that they were looking forward to experiencing. Rights of passage are lost, so there are no baby showers, there's no nesting and a lot of women have an even finished work and not finishing work can inhibit that transition for them into parenting. There's the loss of the idealised birth, birth plans are abandoned, there's the loss of the idealised baby, the hopes and dreams that you had for yourself as a parent or for your child, a challenge. Women feel disappointment in their body. Their celebrations are lost as well. So when a baby's born, there are flowers, there's cards, there's balloons, there's acknowledgement. When a baby's born prematurely, there's none of that. I often walk into a hospital room and there is no acknowledgement that the baby has been born and this is really distressing for parents, in particular first-time parents. First-time parents never get that experience again and acknowledgement is really important. So I will often congratulate parents when their baby's born early, despite the challenges that may lay ahead. Along with feelings of sadness and loss, there's also fear and disappointment and women in particular will experience an overwhelming feeling of guilt and responsibility. Guilt in not being able to protect their baby. They often question themselves, what could have I done differently? Did I make this happen? And they feel disappointment that their body wasn't able to carry the pregnancy to term. Guilt again is a really normal response and I spend a lot of time supporting women in debriefing their pregnancy and helping them understand that much of what occurs in a pregnancy is out of their control. So it's important for women to recognise that it is normal to feel guilty, but there is nothing that they are guilty of. Guilt is a reoccurring theme in NICU and it plays out later in parenting styles often. In addition to feeling guilt and loss and disappointment, there's also feelings of happiness and relief and joy. Relief is often expressed, especially if a pregnancy has been complicated or labour has been threatening for quite some time and then the baby is born at a viable gestation. These contradictory feelings can be exhausting and confusing to parents. They feel happy to see their baby, but then they also feel sad that they are born early and that they're scared that they're suffering from all the medical intervention. They can feel happy with the progress, but waiting and wondering and are worried that the baby will experience a setback. Only today, I met with a mother in the NICU whose baby has just gone into an open cot. And that's a huge step for a baby. It means that they're progressing quite well. They're at lesser risk of infections, but instead of celebrating this, this mother was really concerned that her baby would be at more risk of infection. So she was slightly excited that she would have a better relationship with her baby, but she was also fearing what may come. When there's a twin pregnancy and then the death of a twin, there's also added complications, which I think we can see with Bronwyn. Parents can often find it difficult to express the emotions associated with grief to the full extent as they've got a surviving baby. There again exists that grief, joy, contradiction and also guilt. The guilt comes from the joy and the relief that you feel for the surviving twin and the guilt and the sadness that you feel for the baby that has died. Families don't get to fully mourn the death of the deceased twin and the twin often doesn't get full acknowledgment. I think we have to recognise that the tragedy is not lessened because there is another baby of the same age, but unfortunately, a lot of the families of people with a deceased twin fail to provide them with that support and not quite understanding the full sense of loss that they would be feeling. The negative experience I think is also important for us to recognise is very different for men and women and the pressures can often be felt within a relationship as a result. Experience can be different due to the roles and responsibilities within a family and again also because of the guilt felt by mothers and this can impact on their parenting experience. Classically, we see this in our case study. We see the tension in the relationship and that's based on the couple's different experience and their different ways of experiencing the same situation with their different roles and responsibilities that they have in the family. Also important in my supportive role to help parents respond and rethink their parenting experience. As mentioned earlier, there can be the loss of the parenting expectation and the loss of the self as the idealised parent. The neonatal period is critical to the development of the parent-child relationship and can form the basis for later child development. Maternal psychological distress can also be associated with subsequent emotional and behavioural problems in children as we can see in Bonlun's Old Sun. Intervention to decrease parental distress in NICU has important implications for parenting styles and subsequent child development. Parents of preterm babies are more likely to show rigid, intrusive and often overprotective parenting and some mothers in particular can become unduly anxious about the health of their preterm babies. And this again is seen in our case study of Bonlun. She appears to have an overprotective parenting style with her surviving twin and one could say is emotionally neglectful of her older children, her older child, viewing his behaviour as naughty rather than seeing that he needs support in transitioning into a new family model. Just sum up. Really, really good, Nina. We'll just ask you to quickly summarise and move on to the next question. Thank you, Michael. I'm right there actually. Just sum up, I think it's really important to recognise the level and trauma and the grief that impacts on perinatal mental health and their coping following the birth of a premature baby. And I think we can see in Bonlun's presentation that her psychological distress and unresolved grief and guilt and the wider implications it then has on her family. One of the challenges that I've noticed in my experience in NICU is that despite the level of support that families do get during their NICU admission, the focus is very much on the baby. It's on the survival and their well-being. And it's very challenging then to get parents to reflect on their own coping beyond the initial crisis stage. And it's often not until they discharge time that all that starts to unravel and this is where the community supports are really crucial. I think that will be it for me, Michael. I've probably run out of time, have I? No, that's fine, Nina. You have one slightly over, but you're allowed to have one. Sorry about that. No, thanks very much for that. That was a very exciting presentation. Psychodynamic angle and it's good to have a specialist to enlighten us on the social work as you point excellent presentation. Thanks very much. Now, we're just going to move on to Carol now. Carol Newnum's going to give us her psychologist perspective. Oh, yes, thank you, Michael. And good evening, everybody. I've been working with, in research, with parents of premature babies in the nursery for about 20 years now. So not only do I have sort of the nerdy approach, but I also have the clinical approach and the clinical experience of what's happening for these parents. Just a few definitions to start off with. Preterm means a baby's born at less than 37 weeks. So a baby born at 36 weeks and six days is a preemie. There's about one in 20 Australian babies born preterm and that ends up being something like 25,000 babies a year. So even though you might think that prematurity is quite uncommon, it's actually very common. So in any one classroom, for example, or any one group of mothers that you likely to have premature birth. In Australia, it doesn't seem to be associated with socioeconomic status. That's not so in America, certainly up until when they had free healthcare. But in Australia, we see that it's pretty evenly distributed across SES groups. And just to have a useful way of applying the definitions to groups of premature babies, we talk about extremely very and late preterm babies. The extremely and very preterm babies will spend mostly months in a neonatal intensive care unit, a NICU. And so parents and babies are separated for quite a long time. And while their survival has now improved dramatically, for example, some of you may remember that Jackie Kennedy had a baby born at 32 weeks, who then died. And that would be very unusual these days. So our babies survive. But there are these elephants in the room. And of course, parents are always fearful that their baby might die at any one time. There's a terrible rollercoaster of health problems for most parents. But there's the other elephant in the room, which means that the child may have developmental problems. And it's a very real worry for parents because between 50 and 75% of these children will go on to have some sort of developmental problem. So it's quite a huge percentage of this population. And the developmental problems are in every area of development and at every level. So there'll be physical problems, there'll be sensory problems, there'll be cognitive problems, there'll be socio-emotional problems. And they go from being very mild to being very severe. And usually it's connected with how early the gestation was for the baby, but not always. So we can have babies born at 36 weeks who end up with cerebral palsy and babies born at 26 weeks who end up being quite well-developed. So there are no guarantees about this. This is just a slide that was taken at the mercy, as you can see in 2007. And it gives you just a bit of an idea of parents being separated from their baby and yet so much wanting to be part of the baby's life and holding hands there above the isolate. So parents, as Nina has spoken about, they often have a prolonged trauma. And it's both acute so that they will, for example, fear that phone call. The phone will ring, especially if it's a night phone call, and there will be that terrible chill of, is this the hospital ringing, tell me that either the baby's died or that there's been a downturn and they need to come in. And there's also this chronic anxiety that happens so that there's an ongoing worry that there'll be a downturn and it goes on for weeks and months. So when you think about trauma, if you think about post-traumatic stress disorder, for example, most people would come about that from a very acute trauma, say if they'd been in a car accident or in a hold-up, for example, but these parents have trauma that lasts for a long time, so it's chronic, but it's also acute because anything can happen at any time. And so there's a roll-out of this into the mental health, especially of the mothers. And in one Australian study, it was found that the incidence of postnatal depression in the year following a premature birth was about 60%. Now, the normal incidence in a normal birth is about 10% to 15%. So you can see that there's great distress and it rolls out not immediately. There's also increased anxiety and post-traumatic stress disorder found in these parents. And there seems to be sort of a natural history of what happens with parents. So when the baby is still in hospital, certainly in our studies, we found no PND in our group. Now, other studies have found postnatal depression, but there was none in our group. But there's something quite brittle going on, especially with the parents. So there can be dissociation. Like, they don't hear what people say, they don't hear what the doctors are saying. There's obviously extreme anxiety. And there's something I call present-traumatic stress disorder, which is like they're already, they're still going through the terrible stress and therefore they're not quite with it. And you actually see a progression as the baby goes through the nursery, the parents go through the nursery as well and recover to some extent as well. And anecdotally, we find that about six months later, after the baby's home and sleeping through, and they can eventually breathe out a little bit that, in fact, things can fall down around their ankle. So I've seen a number of parents where they get PND around six months. So there's chronic ongoing mental health issues for the parents. There can be insecure attachments with the baby because neither the baby nor the parent is often a very good social partner to the other. There's a lot of smothering going on with the mother not being able to let go of that psychological term maternal obsession. And maternal obsession is when a parent can't bear to take their eyes off their newborn baby or off their little baby, can't bear to let them out of their sight. But as their anxiety goes down over time, they can relax a little bit with their baby. But this often doesn't happen with parents of preterm babies. So in terms of Bromwin, we are seeing an extreme example of history for this mother. Let me just go on to the next slide. There are very valid reasons for her to be anxious. And in my experience, all parents have anxiety and trauma that can affect their mental health. And as Nina suggested, mothers will tend to focus on their baby. And when you try and do something for them in the hospital, then they actually hardly want to do anything for themselves. They focus on their baby. And this is why I can catch up with them later. So in summary, this is a trauma that is prolonged for many parents. And as people who know about trauma will know that it kind of gets into their body like post-traumatic stress does. And so there needs to be, I think, a sort of an unwinding. And there needs to be special help for these parents. And they're quite common. Thank you. Thanks, Carol. That was very, very useful information. And the description of anxiety and PTSD was very eloquent and real. I'd just like to let all participants know that, following the clinicians' presentation, we will be having a question and answer session where each clinician can ask any other clinician a question. And we would also welcome you as participants to put your questions. We now have over 330 people online. So obviously we won't get to everybody's question, but the panel will be able to answer them later on for you. So with that further ado, we'll move on to our next presentation from Caroline Zanetti. Thank you, Caroline. Talk from the sort of perspective that we would take if Bronwyn was presenting to our service or coming to see me in my pressure. There are many issues in her story that make her vulnerable to postnatal depression and anxiety. Firstly, the extremely premature birth of the twin meant that she didn't have an opportunity to negotiate her way through the psychological tasks of pregnancy. Indeed, because it was a twin pregnancy, she's likely to have been focused on the longer-term picture of how she would cope with her three-year-old Oscar as well as two little babies all at once. So accomplishing these psychological tasks is essential for making a good adjustment to motherhood and fatherhood with each new child. And on the slides you'll see, I've just sort of listed the general sort of area in which these psychological tasks lie. And you might even think back to your own experience of having to make these sorts of adjustments. And generally, it all happens quite unconsciously as you go along through the pregnancy. And the developing pregnancy helps that process. But with a really premature pregnancy, of course, as Nina said, just doesn't happen. And next we have to recognize the effects of a traumatic delivery on both parents. A trauma makes people feel both overwhelmed and very alone. Often parents can't talk fully about what happened even with each other. And this increases their sense of isolation and makes them more prone to anxiety. The death of Harrison added immeasurably to the trauma that Thomas' medical needs would have been preoccupying. And it's a possibility that both parents psychologically walled off thoughts about the delivery and the loss of one of their babies, and thus let themselves unable to process it completely. This is a form of dissociation. And the presence of a little space in the garden could be a sign of some healthy acknowledgement of their grief. But it would be important to find out more about it, what that space actually means to them, how they use it. And indeed, you know, what their affect is like when they're just even talking about it. And in Bromman's story, she was very fearful. So it's still a pretty raw place, I'd say. Bromman herself is very interesting. As a vet nurse, we might imagine her as a caring, practical person. And up to the first home visit, she's maintained a bright and macular appearance and appears on top of it all. This suggests a reliance on a strategy of holding people at a distance from her underlying vulnerabilities. I think we need to third slide now. That's okay. Yeah, that's correct. Perhaps she has a belief that she's the person who gives help and comfort rather than receiving it. And this sort of strategy is usually one that develops very early in a person's life. So not having practice in asking and receiving help and comfort can leave a person very overwhelmed when the need gets very big. And it's clear that Bromman and her family have needed a lot of help. So anxiety about looking needy and unable to cope adds to the actual problem. And people often develop depression in this context, feeling like a failure at every level. Now we note that Bromman's mum is there helping. But it'd be interesting to know is the helpful practical or somewhat emotional as well? How well can Bromman sort of ask her mother for help and acceptance? Oscar's predicament's very poignant. There appears to be little time for Bromman and Barry to make arrangements to have his emotional needs met during this traumatic and very busy time. At three, he will have been very anxious about his mother and is old enough taking the idea of death and to have some very big worries about it. Barry's work demand, especially if the family had financial concerns, would have made him relatively unavailable. And Bromman felt the need to focus on Thomas. So her criticism of Barry and their disputes about his availability will have left Oscar feeling more anxious and alone, particularly if he's sort of aware of it, which he probably is. It appears that Bromman's finding it difficult to empathize with Oscar. And perhaps his needs remind her of her own unacknowledged vulnerability. Similarly, Barry doesn't appear to be coping well. He seems like a distant figure to us as we see him through Bromman's eyes. He's not found a way of helping her in a manner that's settling and comforting to her. And perhaps she doesn't make it easy, but it's also important to consider that her preoccupation with Thomas has made it difficult for her to give him emotional support as he comes to terms with their loss and current circumstances. So it would be important for his mental health to be assessed as well as Bromman. A few months post-partum... Sorry, I'll just see the next slide on. Did I have one? Sorry, okay. A few months post-partum, the signs of impending mental and emotional collapse are present, but it's not clear whether Bromman will accept help. At this point, a mental health assessment is essential, and the severity of the change in her presentation makes it likely that she'd probably need an IT to present medication in addition to the chance to talk more about her situation. The later development of panic attacks suggests that she didn't seek psychological support. It's often only when a person is in a state of panic that they will seek help. It's interesting to note that in Bromman's case, her anxiety makes it harder for her to function at work, and again, this will also make her vulnerable to a co-existing depression. Considerations about mental health often get pushed away with medical and practical issues at present, and this indicates the need to really build them into routine care right from the start. That's all I've got to say for now. That's great, Caroline. Thank you very much for that perspective on us. It was both a psychodynamic and a practical perspective on pre-term diabetes and prenatal health. Very much appreciated. Now, move on to Belinda's presentation. Thanks, Michael. We've had a really great overview from Nina Carroll and Caroline. And as an occupational therapist with family therapy training as well, I'd like to focus on the more long-term impact of a pre-term birth, so looking at community support and, I guess, the time point at which Bromman and Barry find themselves now. So, from an IT's point of view, one of the things that we did very well at Panda and continue to do, I'm sure, on the national health line was a biopsychosocial approach underpinned by systems theory and thinking about that antidote, I guess, to the medical model where the individual is seen as the problem. And the previous speakers have talked very well about expanding that focus in consideration for Barry and the children. So, not only is that biopsychosocial approach to be considered for causes but symptoms and interventions as well. And the outcome being that there needs to be a combination of those services and supports in an ongoing way in the community to secure the best outcome for recovery and well-being for the whole family. The other part that I wanted to highlight is the psychodynamic approach that we have seen a great deal in my counseling experience and also on the national health line at Panda. And Caroline has talked about that collision of, I guess, the parents both from and in Barry's own experiences of their child toward an attachment as well as their family of origin and how that resurfaces with the birth of a baby in all situations, really, in a way that could be termed as unfinished business. And a resolution needs to occur in that process but when it collides with something like a pre-term baby an ill or demanding baby or the loss of a baby or trauma and then relationship difficulties, it is almost like a collision of emotional processes that is very distracting and very difficult for mum to be fully available to the baby and there would be questions then about attachment and the relationship between mother and baby or father and baby. And a lot of those family of origin messages come through in scripts and beliefs that are not usually questioned and have been applied to managing other adult challenges but are not actually helpful in parenthood. When I read Bronwyn's case study, I was left with a whole range of questions both in what was present in the information provided but also what wasn't and the following slides are fairly lengthy and perhaps are more of a written resource for people to go through at a later date but looking at the occupational challenges and bias like a social wellbeing and function, the issues identified there were raised for me from that in terms of how Bronwyn and Barry were managing both their mental health issues and particularly how she was managing the time and demands of being at home perhaps for the first time, full time for a long time and perhaps not having the skills in managing the demands of her children, her household, there are evidence of type, you know, lack of tidiness and she hadn't corrected or fixed Oscars with wallpaper. She was also managing a deterioration in her personal hygiene and also finding it difficult to manage her return to work both her ever-increasing level of trauma and anxiety through the panic attacks at work but also whether her capacity in her home life has deteriorated since returning to work. The possible interventions to address those in the community are highlighted there and thinking about what kind of practical support could be brought into the home as well as support for Oscars through the special childcare benefits and also whether perhaps the occupational therapist or a community-based psychologist, social worker might be able to speak with her or encourage her to speak to her employer about adapting her work demands during her treatment and recovery. Thinking about the attachment issues, bringing in the contributors of family, of origin, trauma and grief and the lack of additional space for Oscar raised questions for me about the impact of her early return to work at four months after Oscar's birth and it's very common to see difficulties in that attachment relationship following the birth of a second child and so not only is she very... if she's struggling with the emotional processes of the twins but I would have concerns about her attachment with Oscar. We also don't know anything about her feeding experiences both with Oscar and Harrison and it is really important to be thinking about both the emotional and physical experiences that she's had through either breastfeeding or supplementary feeding. Some of the interventions would be counseling for Bronwyn and Barry separately to talk about their family of origin experiences and I think this should be certainly a conversation for all new parents of what they bring to their new parenting experience but particularly when there is an episode of extreme trauma and loss and grief as it's about Bronwyn and Barry have experienced. Also looking at some kind of reparative parenting and attachment support for Bronwyn and Oscar and all of these... this is timeliness of these interventions and when they should happen is really dependent on the family's readiness that this would possible intervention. Grief counseling for Bronwyn and provision of additional health line support and numbers of possible services identified there. The other person who's very silent in the case study is Barry and it seems to me to be very important to be thinking about the impact of the trauma of the preterm birth and the loss of the twin and also Oscar's health issues. It seems very common presentation well after the perinatal period for Dad to withdraw or to manage his own trauma and grief and perhaps mental health issues through self-medication with long hours at work, alcohol, drugs and not being present in the family emotionally. So we also don't know anything about his relationship with his children or his parenting skills and obviously his relationship conflict with Bronwyn is feeling unheard and unsupported. I haven't been pushing these slides around, sorry. That's okay. Which one are you on now? I've just gone through to them. The family relationship challenges, looking at the possible interventions would be couple counseling and counseling for Barry to explore his experiences and finally looking at the social issues. One thing highlighted for me that would be really important to support both Bronwyn and Barry to access is peer support and both with parents of preterm babies such as life's little treasures. There are a lot of really great support groups around but also peer support through an organisation such as SANS or SIDS and Kids in the loss and grief experiences. Peer support perhaps with other parents of a child with a hearing disability and also referral of Bronwyn and her kids to something like a supported play group in a local community to build her social connection. Thank you. Thank you very much, Linda. That was a very complete presentation. We're so grateful for the slides that you've prepared and remembering all participants of those slides will be available on the MHPN website for you to access and read a ledger. Now we come to our question and answer session and basically it's around about how we can all learn from each other and cooperate with each other as clinicians in assisting the care of preterm babies, premature babies and their families and their mental health needs. And there was one excellent comment that Caroline made and Caroline, you wish to ask Carol a question around about the mental health needs of premature infants. Yes, I did. Actually, I just wanted to ask Carol what her thoughts were about the mental health needs of premature infants. Often the physical health is such a focus and yet there's a little person there as well. So I was just wondering what your thoughts were, Caroline. You opened a Pandora's box, said Caroline. Well, when I said before that prematurely born children have developmental problems in all areas, that includes social-emotional areas and it includes attachment problems with their parents and I hope that perhaps our audience knows about attachment. I don't really want to go into what attachment means but if you want to look up attachment theory it's used by everybody who works with babies and young children and mothers. It's a well-accepted theory of how a child builds security within the world. So if you think about what happens for the prematurely born baby, first of all they go through maternal separation and then they go through many, many ways in which they are uncomfortable and, dare I say it, in another situation we would talk about these babies as being abused babies because they have heel pricks, pin pricks, they have functioning, they have IVs in put in, they have all sorts of medical procedures that will cause some pain and distress and so the very start of the way their central nervous system is being set up is not how we would want it to be for a child and when I said that they often are not very good social partners that's because they have learned often to be frightened of human touch and human contact and unless the study that we did we actually helped parents to interact with their babies in ways to maintain a level of coping in the babies so that the mothers were able to assess the stress levels in their babies. So the mothers need to be super sensitive to their baby's stress so that they can start to provide this feeling of security and safety in their world so we know that they are more at risk for all sorts of social emotional problems but even the cognitive problems and behavioural problems can be based on that lack of security and safety within the world so the parents and premiers in my mind have a huge job to do to help their children create this defence that other babies just get. Can I just add to that Carol that in the Royal Women's Hospital we have a very strong focus on baby-led care and developmental care where we work very closely with the parents to help them understand their baby's behaviour and then support their babies in a nurturing way while they're in the NICU. Yes. I agree with everything you said Carol. It's a terrible thing for any human being to be in a situation where you're completely helpless and people just come and do things to you that are uncomfortable and sometimes painful but just random times from your perspective and you can't see the purpose of it at all. So it's a very difficult start for a baby as they start to sort of encounter the world to find that the world is really not prepared to sort of meet them on their terms at all and I think the work you've done in your research and the practical aspects of your research in actually helping parents to recognise the baby's feelings in the moment, the baby's actual physical state and to be able to respond to that makes such a difference to both the parent and to the baby in terms of feeling like they're both effective participants in the world rather than just helplessly carried along by events. If I could, Mike would just add one little bit to this. The study we did was based on a previous study started in America and it's been replicated around the world now but in that earliest study it was a similar thing, helping parents understand the stress signs in their babies and responding in a way to help the baby stay in a coping range and they followed those children through until they were nine and they really only looked at cognitive development but after nine years the cognitive development of the babies' mothers were in that study right back when they were in the nursery were looking much more like full-term children and in our own study we're actually following our babies up now and we've just started our six and a half year follow-up but we did MRI scans of the baby's brains at term equivalent and at term equivalent there'd been changes for the better in the white matter cabling in the baby's brain simply we think because of the mother's way of handling their babies even before the babies had got home so it's really powerful this sense for the babies to feel safe in the world. It would literally change the way their brains are developing. You're both very wise in your statements and we know how important the first year of life is in a person's mental health trajectory for the rest of their lives so it would make much sense that that would apply particularly to pre-term babies. Linda, you had a question that I thought might be ideal for Nina around about strategies that would assist mental health professionals beyond the individuals. Would you be able to expand on that and perhaps Nina could reply to us? Yeah, sure. We have a lot of, I think, interest in this broader biopsychiatric function of wellbeing but practice tends to be quite siloed and discipline-specific and either health professionals are not communicating when they are or attached to this family within the community and that creates that siloed or discipline-specific perspective or the practitioner themselves is not seeing the family holistically or biopsychologically. And yet we know theoretically and in research that that will only assure the best outcome for the whole family if there is that combination of support. So, yeah, certainly happening. Nina could you address that question of how do we work with service providers and health professionals to board and either their practice to be beyond discipline-specific or at least to build that collaborative multi-disciplinary approach with limited resources and perhaps a limited network? I don't know if I have the answer to that because that's quite a big question and I think you're right in that we often do work in silos and within our own sort of knowledge base and that is a detriment to families. So I'm not, I think it's a, I'm not quite sure if I have an answer to that unfortunately. I don't know, has anybody else got any thoughts on that? I know that within my own work I do find it very difficult to, specifically for the perinatal population when they've had a premature baby, I do find it very difficult for families to get support within the community. They often do feel very isolated through their experience and it is quite difficult to get a holistic service. So we often will refer families based on risk issues or based on mental health, but to get one service that will support them in a holistic way is, I can't say that I've been able to identify that as yes. One of the things that as a helpline, pandas helpline would take that and many other helplines take that holistic view at a time of readiness when the family, mum or dad are seeking that support as a referral agency as well as a helpline counseling service to consider all aspects of what is happening for that family when the family is requiring it. It's the age-old thing of providing information and resources and pamphlets and fact sheets to people in NICU or at the time of discharge, but they're not actually ready to receive those services for quite some time. So helpline can be a really important and timely support. We also find that the maternal and child health nurse is obviously often the first point of entry to for families when they post discharge and I'll often refer to a GP. So I'm actually quite interested, Markle, how you might support a family when they may present to your clinic after having a premature baby and having heightened anxiety because through the mental health plan, I know that is one avenue of referral that we use quite a lot. Yes, the mental health plan is certainly a very useful agency. Unfortunately, you only get about ten visits now on that in any one calendar year and often you will find that patients may have accessed that mental health plan earlier in the pregnancy and it's also fairly region-specific. So we're fortunate and thankful to have many perinatal assets, both in the community and through Queensland Health and in the community through our Medicare local, but many areas don't have that backup and particularly in rural areas, it's really difficult to deliver. So often a GP is just looking for a silo that's willing to pop out its head and be holistic and that's often what a GP is trying to do and services come and services go and cutbacks and often it just falls back on the GP's skills themselves to manage the anxiety. I hope that answers the question. I have been pre-warned about that question. I should have said the asked the question, but I wasn't able to before you asked it. But basically I think that would be a GP's experience of it, but there just aren't enough agencies out there. I did also notice a really interesting question from Jane Akrod is one of our participants and she was saying, she was wondering because we have last day at home months now, is the pressure to return to work an issue in managing perinatal and pre-term babies? Could I please say something? I work at St John of God's Sidiaco Hospital where we have a perinatal and infant mental health service, the Raphael Centre and there are several Raphael centres around Sydney and rural Victoria, Bendigo, Ballarat, Geelong, Warrnambool and one in Sydney at Blacktown and two in Perth, Sidiaco Hospital and also Murdoch. And our services are integrated, the perinatal and the infant. So we're looking at the mother and the infant and all of our programs are oriented to including the fathers as much as possible as well and at Sidiaco we're particularly blessed because we're actually co-located with the hospital. So we see a lot of pregnant women and we are able to visit parents in hospital. We have a consultation liaison service actually to the NICU as well as they do at Murdoch and I think bringing mental health alongside the other areas of medical care during pregnancy is really key to addressing all these problems because you really need to make mental health care part of routine care during pregnancy and also during the early years of children's lives. We work quite closely with a number of GPs. Again, the GPs out there at the Colface. I think if you just have a perinatal service to refer to, you're only looking really at the mother's mental health. But just an infant mental health service is primarily on the child or infant's mental health but the whole family needs to be included in the way that a service is structured. My view. Yes, so I think that's quite a wise view and it is unfortunate that we have some style of the rent. So, yes. Not including land. Yes, yes. There was a very interesting question from one of our participants again in relation to Aboriginal and Indigenous patients and clients and cultural implications and particularly because a number of premature infants in that demographic is increasing. Does anybody care to comment on that? Linda here. We're not so much to address the issue of Indigenous families but the really varied experiences of culturally diverse families. There's an online training program through the Victorian Transcultural Mental Health Service that is targeting cultural competence in a perinatal period and has been very well utilised by a whole range of multidisciplinary groups. So, that might be something that that questioner could follow on. Thank you very much for that. I know King Edward Hospital in Perth, they have a specific service for Indigenous parents and there are many. Of course, one of the major problems for them is being isolated from their normal supports up at home and the needs of the babies can be very poorly met often if the babies stick up in an isolated community. So, it's very difficult. It is difficult, yes. And I'm also interested in the cultural elements that you were just discussing. Linda, could you just expand on that, please? Yes. It's a Victorian-based service attached to St Vincent Hospital, Victorian Transcultural Mental Health Unit, if you Google that. And they've done, for many years here in Victoria, cultural competence training in mental health. But there have been a group of stakeholders who've contributed to that training being customised, I guess, for perinatal mental health experiences among cultural and diverse groups targeting health professional school development. And it's an online accredited training programme that people can access. Yes, thank you very much. And also, I should mention that many of the rural Medicare locals have got expertise in perinatal and Indigenous perinatal services running, which hopefully will continue with the primary health networks when they get online. We're coming towards the end of our session. Do any of our panellists have any question they'd like to ask one of the other panellists that hasn't been discussed already? Well, when I think about Bronwyn in our case study, I'm the person who put that case study together. And there was so much, there was such a dense lot of issues for Bronwyn to face. But in the end, what she had trouble with was actually going to work and also problems with providing a nurturing home for her family. And I notice that a number of people, including our audience, have talked about practical help for these parents. They're exhausted and they're not just exhausted from like a sleep, they're exhausted from ongoing anxiety for a long time that never goes away. And so my question was to Carolyn, but maybe to everybody, is there any way we can help the parents at a practical level to mobilise people in the community to help parents in this situation? Can I respond a little bit to that? Because I did notice a lot of the comments about the return to work and from the audience, asking about whether she should have had a greater return to work or whether she should have had more support. Would it have been difficult to sort of let her boss know that she needed that level of support? My thoughts were really that this one has gone from being pretty high-functioning to really not functioning well at all. There were indications that everybody in the family was suffering. And I don't think you can really just go back to work and function well if underneath it all, you've got a profounder pressure, which I think she would have had and she certainly had disabling anxiety. I think she would have needed that treated because the evidence is that if you don't treat postnatal depression, it persists. And what's more, it recurs. And the other, it's also been really solidly shown that problems that arise in the parent-infant relationship due to depression do not resolve with the treatment of the depression. So therefore, you've really got to be looking at the mental health and the interactional style of all family members, all the relationships. So I think if you just focus on the practical support, which is indeed really critical for some mothers, particularly those who are very isolated, you're going to miss the need to also fix the mental health because if you don't fix that, the mental health of the mother, the children are exposed in an ongoing way to an emotional environment that's actually really going to affect their development in every domain throughout their lives and make them more prone to depression and make it harder for them to be the good parents they'd like to be when they have children of their own. Thank you very much. Unfortunately, time is marching on. I'm just, I feel so privileged to have sat here, especially that I would just listen to all this expertise. We're now going to ask our panel to sum up. Nina, you are first off the rank and you have two minutes to sum up and I will be quite punitive if you go over two minutes. Okay. I think what's really important to, if anyone is supporting a family who've had a premature baby is just to recognize the level of trauma that parents experience when they do have a premature baby and often the trauma can unravel post months past a discharge. And what I tend to find is there's four stages in my role with women, there's the crisis stage, that's the debrief, it's the normalizing and the validating of the grief and the trauma, then there's the maintenance where families are very much about focusing on the baby during the NICU experience. I often hear women say, if I'm okay, if my baby's okay, I'm okay. So they're very focused on the baby. It's very hard to get them to refocus on themselves. The third stage is then the discharge planning. Again, it's all about the baby and then it's home. That's when we get home and there is, survival is no longer questioned, routine is established and that's when the trauma starts to unravel. I think community supports are very important. We've got engaging the maternal and child health nurse, engaging in GP and also linking in with support services that like Panda, sorry, Panda is also a very important service for families but what I think is really important to break down the isolation is linking families in with premium specific support groups. So life of the treasures, premium babies, because families will talk about feeling very isolated in the community and people, general mothers groups, not being able to support their needs. That's great. Thank you very much. Nina, that's fantastic. Carol, would you like to go next please? Well, my sum up is a little bit the same as Nina's. I think if you miss the trauma and I hope we've sort of shown, Nina and I especially have shown you some of the trauma that the parents have gone through, like it is truly trauma and so even if a child is presenting, a prematurely born child is presenting to a podiatrist or a speech pathologist or a psychologist or someone else, no matter what the issues are for that child, if you miss the trauma that's happened in that family, you're going to miss a whole aspect of how you can help that family. So although some parents will come out of it with varying degrees of mental health problems and as Carolyn so rightly said it has long-term effects then on the future functioning of the family but even within some of the more mundane aspects of medical problems if you can sort of scratch the surface a little bit and see how the family is functioning that would be helpful I think too. Thanks. Thank you very much Carol. So it is really important to have that holistic outlook isn't it? Yeah. Thank you very much for that. Carolyn could you summarize for us? Yeah, okay. I completely agree with everything that Carol has said and Nina too. You know it's critical that you're holding in mind the way in which this background can dog the family, dog the child throughout and recognize that you need to be thinking about trauma at each point not just imagine that it has all gone away because the child seems to be developing well now. Similarly for the family, as Carol said before many of these women don't present with some clear depressive or anxiety symptoms till after six months and we found in our own studies that certain extent of the people who come to our service have actually had an identifiable problem just built and built and built over the first six months but they haven't sought help until after that six months or even later than that. And it's not that the problem suddenly arose at six months the mental health problem, it was there all along grumbling along so I think as clinicians we need to be really aware of the vulnerabilities of new families and particularly families with premature children and sort of ask the questions about how everybody's doing and how they're feeling and how the relationship's preparing. The vulnerability of each individual in the family. Yes, the whole family. You've got to take a whole family perspective I think. Yes. Thanks, Michael. Thank you very much, Caroline. And now, Belinda, we'll just move on to your summing up. Thank you. Thank you. I guess just to highlight that the number of complex issues facing Bronwyn and Barry and their family and with highlighted trauma, perinatal mental health attachments, grief and loss and other issues and really it will be determined by each individual's journey through every one of those complex issues as to their readiness to engage in support and services. And we've heard the timeline of around six months. It may well be lifelong that these issues are going to continue, as Caroline said, to dog the family. The issue of actually supporting families to engage in services when they are ready for them can be most supported in my observation by the presence of peer support. So as was mentioned, the referral to premise specific support organisations, not until Bronwyn or Barry would sit with another parent who's experienced even a smaller part of their journey that much of this makes sense or that they will listen truly to that recommendation to seek counselling or medical support. And so I think always in that holistic multidisciplinary support for this family, never forget that referral to a support organisation that can bring together a team or a community support base around Bronwyn and Barry that is about that lived experience of any one of those aspects of what's happening for that family. Thank you, Belinda. And would you describe Panda as being such an organisation? Well, it's definitely, yes, and that would encompass all of those. But there are so many wonderful organisations and I think as clinicians and health professionals, it can be really difficult to trust the consumer-delivered service or the lived experiences of any one of those really complex issues. But it is very, very important that we understand the services that are available to parents like Bronwyn and Barry and allow our own fears and trust that the consumer-delivered services are extremely important and powerful. Thank you. Thank you very much for that. I feel very humble having listened to all these marvellous presentations and that I've learnt so much. And I can see from the participants' comments that they have learnt a lot as well. We're very unfortunate in having our participants give their impressions from their practice and also to put questions to the panel. Just a few thoughts on what's been discussed tonight. Two of the terms that come to me in summing up are trauma and anxiety. And I must admit as a GP, whenever I think of perinatal health, mental health, I immediately think of postnatal depression. But it would appear to me from listening to the speakers that there's probably a lot of anxiety present leading up to the presentation of a depressed parent in my surgery. I'm just wondering if that might not be the experience of other clinicians here tonight. The exhaustion that parents experience, just the psychological exhaustion, the physical exhaustion, having to possibly work and then go to the hospital, having to be with the child, the loss of that feeling of completeness and happiness, the separation from the baby, often abruptly the feeling of crisis and the need to debrief the needs of the baby and the concerns and worries about the future for the baby, the concerns that one may have for the baby two, three, four or five years down the track depending on their perinatal condition. Of course, postnatal depression is a very important condition and I think everybody is on the lookout for that. But I have learned a lot tonight in that we probably should be adopting a much more holistic attitude towards both the baby and the parents. Somebody did mention too about Barry. Barry is the silent witness too much of tonight and perhaps in a future webinar we may be able to explore the husband and further a little bit more deeply. Lastly, the grief and loss that was suffered by Bromel when she lost her little baby, Harrison, obviously is going to have a lot more effect on this. Some of the participants gave them their own life experiences from their own life experience describing conditions such as agoraphobia and anxiety that persisted in parents who lost the baby and certainly the value of support organizations throughout Australia such as Panda. I'd just like to thank everybody for their participation tonight. Please ensure you complete the exit period before you log out. It will appear just in after the session closes. Specifics of attendance for this webinar will be issued within two weeks. Each participant will be sent a link to online resources associated with this webinar within two to three business days. Please keep an eye on our website for future MHPN webinars. Visit mhpn.org.au upcoming webinars to register. I would like to thank the panel very much and I would also like to thank the 336 participants who've logged in tonight. I wish you all well and practice well. Thank you.