Perinatal mental health services

Position statement Last updated: Oct 2021 Published in Australia Reference: PS #57

This position statement outlines requirements for effective perinatal mental health services for parents, their babies and families.

Purpose

This position statement has been developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to inform service providers, education and research bodies, medical and health professionals, and the general community about what is required to adequately provide perinatal mental health services to parents and their babies and families.

Key messages

The perinatal period (generally from conception to end of first postnatal year) is a time of upheaval and recurrence of pre-existing mental health episodes as well as the onset of new episodes.
Integral to perinatal psychiatry practice across assessment, treatment, management plans and service delivery is the consideration of three domains: maternal mental health, parenting and the mother-infant relationship, and infant health and wellbeing. Across these three domains it is important to consider partner, family, and key supports.
Specialist perinatal mental health services are well recognised in helping treat mothers as well as supporting infant wellbeing and the relationship between mother and baby. These services are also increasingly focussing on partner’s and father’s mental health. Evidence demonstrates improved outcomes for those families who are able to access these specialist services. These services also frequently provide expertise in women’s mental health in the reproductive years.

Definitions

Given the multidimensional scope of ‘perinatal and infant mental health’ there is some variation across definitions to allow for differences in terminology seen on the ground across jurisdictions in Australia and New Zealand.

The perinatal period is defined as the period covering from conception to end of first postnatal year but in some settings can cover up to 2-3 years postpartum.[1]
Parenting and the parent-infant relationship can be impacted by parental mental health disorders, and as such, is an important component of assessment and management of perinatal mental health disorders. Perinatal mental health is underpinned by an understanding of an attachment framework. The impact of parental mental health disorders may include the experience of parenting (e.g. bonding) and parenting stress, parenting skills and behaviour and the quality of the parent-infant relationship including attachment. It should be recognised that a parent’s mental health condition does not inevitably impact on the emerging relationship with her child and not all dyads will require such interventions. However, consideration of supports, safety and child protection and the impact of parental mental health on parenting and the parent-infant relationship should be part of all perinatal mental health assessments. If an intervention is required, it is important to consider the specific issue/s, appropriate interventions and the evidence base for improving parenting and/or the quality of the relationship.
Perinatal Mental Health Services (PMHS), also known as Perinatal and Infant Mental Health Services (PIMHS), generally refer to services provided from pre-conception to 12 months of age. Community PMHS services may cover mothers and babies and in some services, fathers/partners, up to three years after birth. PMHS include community, inpatient, outpatient, outreach and consultation-liaison services.
While the primary referred patient for PMHS is the parent for mental health concerns, essential to the delivery of perinatal mental health care is always the consideration of not only parental mental health but also the impact of mental health disorders on parenting, the parent-infant relationship, and the infant’s health and development.[3]
Although PMHS include assessment and consideration of infant health, development and wellbeing, the primary referred patient is not the infant. If specific health, development or mental health concerns were identified for the infant, separate from the management of parental mental health, then an appropriate referral to a clinician or service that has expertise specifically in infant health and development (e.g. paediatrician) or mental health (e.g. child and adolescent psychiatrist with infant mental health expertise) is recommended. Therefore, PMHS are distinct in scope and expertise from child health or child mental health.
Mother Baby Units (MBU) provide mental health treatment in an inpatient setting to women facing a severe mental health crisis accompanied by their babies usually from late pregnancy until 12 months postpartum.[2] Where the mother is not the primary caregiver, these services are equally applicable to the primary caregiver and their baby. MBU differ from early parenting residential units as MBU are mental health units, staffed to provide mental health inpatient treatment. While early parenting residential units might have adjunct mental health assessment or supports, they are usually for brief admissions around supporting early parenting and do not provide acute mental health inpatient treatment.

Background

Pregnancy, childbirth and postpartum are periods of unique risk for women for new episodes and relapse of mental disorders, with evidence also demonstrating the potential impact on partner/father’s mental health. The effects of maternal mental disorders can be devastating on the mother, baby and surrounding community. Without adequate management, symptoms and associated impairment of functioning can sometimes persist for years. Suicide is regularly reported as a leading indirect cause of maternal death.[4-6]

Perinatal mental health disorders include all adult mental health disorders. Both pregnancy and the postpartum periods influence the risk of new onset of a mental disorder and the risk of relapse. There are also potential differences across the perinatal period for the risks, benefits and efficacy of mental health treatments.[7] The perinatal period also has a unique mental health disorder, postpartum psychosis, which occurs in around 0.05-0.2% of women giving birth and is a condition specifically of the perinatal period with onset up to 4-6 weeks following childbirth and associated with increased risk of suicide and infanticide.[8]

Currently, there are no service standards specific to PMHS, despite models of care in PMHS being distinct from adult mental health services across the areas of assessment, treatment and service delivery. There is also no official training accreditation or curriculum for perinatal psychiatry.

When untreated or undertreated mental illness in the perinatal period is associated with significant costs in addition to increased morbidity and mortality for women and poorer outcomes for children and families. For instance, Deloitte estimated the cost to Australia of loss of productivity associated with maternal perinatal depression was $86.59 million and the burden of disease associated with 16,575 disability adjusted life years (see Deloitte Access Economics, 2012). Furthermore, it is likely that moderate to severe mental disorders are also more likely to adversely impact outcomes for women and children and as such specialist services and care are of paramount importance to improving mental health outcomes for our community now as well as into the future.

Integrating mental health care with universal maternity care services

The RANZCP supports the vision of the World Health Organization in that 'Every pregnant woman and newborn receives quality care throughout pregnancy, childbirth and the postnatal period'. [9]

This includes access to multidisciplinary teams and specialist PMHS integrated into antenatal care when this is necessary as part of maternity care, as recommended in the National Clinical Practice Guidelines for Mental Health Care in the Perinatal period (2017) and the RANZCP Clinical Practice Guideline for the management of schizophrenia and related disorders (2016) and the National Strategic Approach to Maternity Services (2019).

The collaboration between key professional groups involved in maternity services has begun to deliver an improved holistic approach to care, for example the development of the ‘Maternity Care in Australia framework for a healthy new generation of Australians’ (2017) by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the National Strategic Approach to Maternity Services (2019). Services should be readily available throughout the entire antenatal and postnatal periods, regardless of location. Services should also be collaborative, culturally informed and integrated across service type.[1, 10] Routine antenatal screening for risk factors associated with mental health disorders should be implemented as part of the range of health services accessed by pregnant women.[1] While research findings have been mixed as to whether screening per se improves outcomes for perinatal mental health, identifying and treating mental health disorders early has unequivocal benefits for maternal and longer term infant/child outcomes.[11, 12] Broader, related psychosocial risks such as family violence are important to consider in both the screening and service delivery components of perinatal mental health care within maternity, community and MBU services.[1, 13] Appropriate screening and assessment methods for perinatal depression and anxiety for Aboriginal and Torres Strait Islander women are important, examples include the Kimberley Mum’s Mood Scale and 'Baby Coming You Ready?'.

There should be additional considerations for Aboriginal, Torres Strait Islander, Māori and cultural communities who may have cultural or religious beliefs and practices which affect marriage and kinship surrounding the birth and early postpartum period, as well as child-rearing stages. These should be respected providing they are compatible with the well-being and safety of the mother and child. It is important that services work with these populations to ensure they are providing culturally safe and competent services.

Community services

There is a range of private, non-government and public community-based specialised PMHS offering expert, multi-disciplinary management of perinatal mental health disorders in the community. Ideally, these services are able to offer expert care across the continuum of severity of perinatal mental health disorders, as well as provide parenting and parent-infant relationship interventions as required. Some of these services provide mental health services for fathers and partners as well as family-based interventions. Strong links with primary care, adult mental health and services with expertise in infant and child mental health as well as with services for infant health and development are ideal for the provision of holistic care.

Consultation-liaison and outpatient services

The adverse effects of perinatal mental health morbidity have been increasingly recognised and addressed through a number of national programs and initiatives. This includes various maternity hospitals that have integrated PMHS and the establishment of two Australian specialist antenatal clinics specifically for severe mental health disorders.[14, 15]

Consultation-liaison and outpatient services within maternity care often also provide expert care in other areas of women’s mental health including those requiring mental health care in related areas of gynaecology, pregnancy loss, menopause and reproductive assistance as well as to parents of babies admitted to Neonatal Intensive Care Units. Staff within these services require skills in broader areas of women’s and family mental health.

Specialised perinatal mental health services

Delivery of appropriate maternity care for people with perinatal mental health disorders requires integrated consultation-liaison/outpatient services within maternity care as well as specialist community teams and inpatient MBU. An ideal specialist perinatal service would be organised on a hub-and-spoke basis, with integrated PMHS within tertiary maternity services that are linked with a specialist mental health inpatient MBU and designed to ensure equitable access to women in rural, regional and remote areas of Australia. Both the PMHS and MBU would be closely integrated with specialised perinatal community services in each locality. These services additionally require strong links with adult mental health services, specialist infant and child development and health services and specialised infant and child mental health services.

Streamlined support and referral between specialist perinatal mental health services, adult and child mental health services, primary care should be provided and designed to consider best practice for a variety of population groups. Inclusion of peer support within models of care and links to appropriate peer-led services is also an important component of contemporary PMHS. There is a need to further build the evidence base for specialist PMHS through evaluation and additional research.

In the UK, it has been estimated that 3-5% of the delivered population will require the services of specialised perinatal mental health teams.[12] A specialised perinatal team will assess and manage women with serious mental health disorder or complex disorders often as an integrated part of her antenatal care and where the presentation cannot be appropriately treated by primary care services.

There is increasing recognition of the burden and importance of father and partner mental health, this area of practice requires expertise in treating mental health disorders in adults with additional awareness and capacity of addressing any impact of father/partner mental health during this transition to parenthood on the person, their family and their child in the same way as in the management of maternal perinatal mental health. Unlike in pregnant women, there is not the requirement for a different evidence base as there are not significant physiological changes across this period or unique disorders, such as postpartum psychosis, for those that are/have not been pregnant. As with the management of maternal perinatal mental health, there needs to be consideration of the importance of assessing the need for additional intervention around impacts on the father/parent-infant relationship and on the infant and where required referral for specialist care.

Parent infant/mother baby units

Best practice recommends joint mother and baby admissions when hospitalisation is required for mental health care in late pregnancy and the first 12 months postpartum.[1] Public MBU are able to manage complex and severe mental health disorders, and as such, offer treatment including to women who require involuntary treatment. Joint admission to a dedicated unit sustains proximity of mothers (or the primary caregiver) and their infants, which has been demonstrated to help the woman gain increased confidence in her parenting role.[16, 17] However for some women, further interventions for the mother-infant relationship is required to improve this relationship.[18, 19]

In addition to providing a multi-disciplinary and holistic approach to treatment, MBU also have an important role in training specialists in perinatal mental health.[2] However, currently there are limited publicly funded inpatient MBU across Australia and New Zealand. The Royal College of Psychiatrists (UK) has estimated there is a need for one eight-bedded unit for every 15,000 deliveries. Currently both Australia and New Zealand fall well short of this recommended number of beds. This significant lack of access must be addressed. In conjunction, the allocation of mental health resources to perinatal mental health must be guided by robust and ongoing data collection.

It is important that MBU are able to accommodate admissions from late pregnancy until 12 months postpartum (please see ‘Further Reading’ section below). Where there is an available bed, admissions should be able to occur 24 hours a day, seven days a week and women with severe and complex mental health disorders should be able to be managed in the MBU without requiring a prior admission to an adult mental health unit or needing to transfer to an adult unit outside of exceptional circumstances (for example, if there are concerns about the safety of a baby on the unit or seclusion is required).[20] This requires the appropriate skill sets necessary for managing acute and severe mental health conditions in the mother to be available as well as appropriate physical design of the units to ensure safe care of mothers and babies. MBU should also include a

nursery for when the mother is unable to safely care for her baby overnight or during the day. In addition, the infant may require health reviews and nursing care when the mother is unable to care for her baby and staff will require skills to ensure this can be safely undertaken.

MBU provide comprehensive care for the mother and baby as opposed to viewing the infant as an ‘add-on’ while caring for the mother. Assessment of the mother-infant relationship as well as infant wellbeing is an integral part of services, and specialist interventions address the mother-infant relationship and promoting health and wellbeing for the infant. As with any intervention, when parenting or mother-infant psychological interventions are offered for the dyad, family or infant, there should be consideration of the indication and area of concern with the intervention targeting this, while also considering the strength of the evidence base for a particular program. As part of any assessment of parenting and of a parent-child relationship, there should be consideration of safety and child protection concerns. Where infants are under the care of child protection services, consideration of this as part of management is also required.

As the infant is also resident on a MBU it is usually required at a minimum to undertake physical, developmental, and socio-emotional health checks and monitoring during admission. There should also be clear pathways during and following admission for expert paediatric and infant psychiatry/mental health care if required.

Support for fathers, secondary carers and other family members should also be integral within services. This support should entail culturally appropriate service provision, such as acknowledgement and integration of relationships outside the mother-baby relationship. For example, it should be ensured that there is appropriate support and integration of whānau ora for Māori populations in all perinatal mental health services, as well as culturally informed care for Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) communities.[21] Additional stressors for Aboriginal and Torres Strait Islander women from rural and remote areas related to travel, delivering out of country, and limited supports in metropolitan areas must also be considered.[22] All services need to consider specific needs of LGBTQIA+ and gender diverse families to ensure these groups are suitably supported within models of care. This includes considering the admission of primary caregivers who may not be the baby’s mother or identify as a woman and whether existing models of partner support is appropriate for partners in LGBTQIA+ families.

Parents with intellectual and developmental disability may present as high risk due to vulnerability and mental health concerns. These risks should be assessed and managed based on the individual context.[23] Specific needs of mothers who give birth to children with developmental conditions at, or shortly after birth, must also be considered. For example, specialist disability health supports may be required.

Partners including fathers are also at increased risk of experiencing mental health problems across the perinatal period and services should ensure there are appropriate supports for fathers in place as well as referral pathways to ensure there is access to relevant services for further treatment when required.[24]

This statement should be read in association with RANZCP Position Statement 56: Children of parents with a mental illness and RANZCP Position Statement 59: Mental health care needs of children in out-of-home care.

Attachment and mental health

Attachment theory describes the process by which children during early life learn to use their parents as a secure base to explore their environment. With a focus on the development of early relationships, attachment theory is highly relevant to the delivery of PMHS. Attachment classifications such as disorganised attachment can be confused with DSM-5 attachment disorders. It is important to note that unlike the DSM-5 disorders, attachment classifications, including disorganised attachment, do not necessarily indicate neglect or maltreatment of a child.[25, 26]

Attachment researchers have operationalised attachment theory into distinct classifications for research using standardised measures, including the Adult Attachment Interview (AAI) and the

Strange Situations Procedure (SSP). While attachment theory and research provides mental health clinicians with a framework for understanding the development of parent-infant relationships, it is important in the context of perinatal mental health clinical practice that there is careful consideration around the applicability of attachment measures and treatments.[27] For example, the current research measures for attachment, such as the SSP and AAI, were not designed for clinical assessment, care planning or interventions. Attachment research measures require specific training and reliability certification to administer and analyse, and their sensitivity and specificity are not sufficient to provide an individual diagnosis.[25, 26]

Research examining whether insecure or disorganised attachment is predicted by maternal perinatal mental health or predicts a child’s risk for the development of mental health disorders later in life largely demonstrate a modest effect size at most, with various studies indicating no association.[25, 28] Research regarding specific attachment interventions is limited in the context of perinatal mental health disorders. A recent randomised controlled trial (RCT) of an attachment intervention in postnatal depression found no impact of the intervention on attachment outcomes.[29] A further recent RCT found the addition of an attachment intervention to Cognitive Behavioural Therapy (CBT) did not result in improved attachment outcomes than CBT alone.[12] There is a need for more research examining the role of attachment measures and interventions specifically in the context of perinatal mental health disorders before integrating these into the delivery of care.

While there are challenges in integrating attachment theory into perinatal mental health clinical practice, it is important to recognise the significant contribution attachment theory makes to ensuring clinicians approach care with a developmentally informed understanding of the vulnerability and impact of perinatal mental health disorders. As well understanding the importance of avoidance of unnecessary separations, such as through the provision of timely access to MBUs when inpatient mental care is required or through having parents room in during admissions of infants for inpatient care. Furthermore, understanding the impact that poorer perinatal mental health can have in increasing vulnerability for poorer parent-infant relationship and also infant outcomes. Future research is required to develop clinically relevant and valid diagnostic measures and evidence-based interventions for attachment in the context of perinatal mental health disorders.

Recommendations

Routine screening, early identification and management of mental illness in the perinatal period

Implement routine, universal antenatal and postnatal screening or identification for risk factors associated with mental health conditions and poor adjustment to parenting together with appropriate and adequate access as required to specialist assessment and treatment for perinatal mental health.
Implement screening in conjunction with pathways for appropriate care for family violence given the association with mental health disorders in pregnancy and postpartum.
Include culturally appropriate screening recommendations within all screening programs.

Service provision and models of care

Introduce public mental health MBU in all Australian states and territories and more accessible MBU across all District Health Boards in New Zealand, with appropriate staffing levels, equating to a minimum of one eight-bedded unit for every 15,000 deliveries.
Ensure mothers and babies remain together during treatment (where the mother is the primary carer), and the involvement of other parents and/or caregivers is supported, except in cases where the baby’s and/or mother’s emotional or physical wellbeing may be at risk.
Where the baby’s primary caregiver is not their biological mother, the principle of consideration of keeping baby with a primary caregiver during inpatient treatment should remain best practice.
Incorporate parent-and-baby joint admission into industry standards by prospective policy makers and health care funders. Further, health care funders should recognise the importance of parent-and-baby joint admission and the inherent additional costs of ensuring the safety and care of a baby on an inpatient unit. Within Activity Based Funding models this requires the funding includes the additional cost of the co-admission of the baby and does not rely on independent admission of the baby for inpatient healthcare.
Increase access to and delivery of integrated multi-disciplinary antenatal consultation-liaison and outpatient services within maternity services for women with severe mental health conditions.
Ensure all PMHS comprise a workforce of appropriately trained staff with specialist expertise in the assessment and management of perinatal mental health.
Improve detection of need for multi-disciplinary co-ordination to manage complex care within maternity services, including mental health, family violence, substance abuse and other psychosocial complexities such as personality dysfunction.
Map service and workforce standards and needs for public PMHS delivered within maternity services and community PMHS including within existing mental health services and mental health MBU. Ensure access for all eligible women regardless of geographical location, while also whenever possible and safe offer expert care through options such as telehealth and support of rural practitioners by specialist metropolitan services, to optimise care delivered close to home.

Evidence-informed practice

Conduct further research to examine the follow up outcomes from universal screening for perinatal mental health.
Support research on the mental health outcomes associated with admission into MBU so as to strengthen clinician understanding of evidence-based best practice.
Ensure the allocation of resources towards perinatal mental health is guided by robust and continuing data collection.
Develop and adapt guidelines for access to care that are relevant, applicable and appropriate for use in rural/remote services, for Aboriginal and Torres Strait Islander, Māori, and CALD women, which should be considered by governments as part of their funding model.
Develop management flowcharts outlining locally relevant resources that reflect pathways to care to assist in promoting optimal care, given available services will vary across jurisdictions (including where they are limited owing to workforce shortages).

Workforce

Ensure staffing requirements for PMHS include core competencies training, including skills in managing mental disorders in pregnancy and postpartum periods as well as broader skills such as identifying and managing complex psychosocial issues (e.g. those related to family violence, alcohol and drug dependency, and past trauma history).

Responsible committee: Section for Perinatal and Infant Psychiatry Committee

References

1. Austin MP, Highet N, Group at EW. Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence; 2017.

2. Galbally M, Sved-Williams A, Kristianopulos D, Mervuri K, Brown P, Buist A. Comparison of public mother-baby units in Australia: similarities, strengths and recommendations. Australasian Psychiatry. 2018;8 Nov 2018:1-5.

3. Galbally M, Watson SJ, Boyce P, Nguyen T, Lewis AJ. The mother, the infant and the mother-infant relationship: What is the impact of antidepressant medication in pregnancy. Journal of affective disorders. 2020 Jul 1;272:363-70.

4. Queensland Health. Queensland Mothers and Babies, 2014 and 2015. 2018.

5. Australian Institute of Health and Welfare. Maternal deaths in Australia 2012–2014. 2017.

6. Perinatal and Maternal Mortality Review Committee. Seventh Annual Report of the Perinatal and Maternal Mortality Review Committee, Reporting Mortality 2011. Third Report to the Health Quality & Safety Commission. Wellington, New Zealand: PMMRC; 2013.

7. Galbally M, Blankley G, Power J, Snellen M. Perinatal mental health services: what are they and why do we need them?. Australasian Psychiatry. 2013 Apr;21(2):165-70.

8. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet. 2014 Nov 15;384(9956):1789-99.

9. Tuncalp O, Were W, MacLennan C, Oladapo O, Gulmezoglu A, Bahl R, et al. Quality of care for pregnancy women and newborns – the WHO vision. BJOG. 2015;122:1045-9.

10. Oates M. Perinatal mental health services: Recommendations for the provision of services for childbearing women, College Report CR197. Royal College of Psychiatrists; 2015.

11. Burger H, Verbeek T, Aris-Meijer JL, Beijers C, Mol BW, Hollon SD, Ormel J, Van Pampus MG, Bockting CL. Effects of psychological treatment of mental health problems in pregnant women to protect their offspring: Randomised controlled trial. The British Journal of Psychiatry. 2020 Apr;216(4):182-8.

12. Stein A, Netsi E, Lawrence PJ, Granger C, Kempton C, Craske MG, Nickless A, Mollison J, Stewart DA, Rapa E, West V. Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trial. The Lancet Psychiatry. 2018 Feb 1;5(2):134-44.

13. Suparare L, Watson SJ, Binns R, Frayne J, Galbally M. Is intimate partner violence more common in pregnant women with severe mental illness? A retrospective study. International journal of social psychiatry. 2020 May;66(3):225-31.

14. Galbally M, Snellen M, Walker S, Permezel M. Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care. Australian & New Zealand Journal of Psychiatry. 2010 Feb;44(2):99-108.

15. Nguyen TN, Faulkner D, Frayne JS, Allen S, Hauck YL, Rock D, Rampono J. Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic. Medical Journal of Australia. 2013 Apr;199:S26-9.

16. Salmon M, Abel K, Cordingley L, Friedman T, Appleby L. Clinical and parenting skills outcomes following joint mother–baby psychiatric admission. Australian & New Zealand Journal of Psychiatry. 2003 Oct;37(5):556-62.

17. Gillham R, Wittkowski A. Outcomes for women admitted to a mother and baby unit: a systematic review. International Journal of Women's Health. 2015;7:459-76.

18. Wright T, Stevens S, Reed PW, Wouldes TA. Post‐discharge outcomes for mothers and the mother–infant relationship following admission to a psychiatric Mother–Baby Unit. Infant mental health journal. 2020 Nov;41(6):770-82.

19. Wright T, Jowsey T, Stanton J, Elder H, Stevens S, Wouldes TA. Patient experience of a psychiatric Mother Baby Unit. Plos one. 2018 May 30;13(5):e0198241.

20. Royal College of Psychiatrists R. Standards for Inpatient Perinatal Mental Health Services. Perinatal Quality Network for Perinatal Mental Health Services. 2018;6th Edition.

21. Ministry of Health. Healthy Beginnings: Developing perinatal and infant mental health services in New Zealand. Wellington: New Zealand; 2012.

22. Bhat SK, Marriott R, Galbally M, Shepherd CC. Psychosocial disadvantage and residential remoteness is associated with Aboriginal women’s mental health prior to childbirth. International journal of population data science. 2020;5(1).

23. Lamont A, Bromfield L. Parental intellectual disability and child protection: Key issues Canberra: Australian Institute of Family Studies; 2009 [Available from: https://aifs.gov.au/cfca/publications/parental-intellectual-disability-and-child-protection-key-i].

24. Gutierrez-Galve L, Stein A, Hanington L, Heron J, Ramchandani P. Paternal depression in the postnatal period and child development: mediators and moderators. Pediatrics. 2015 Feb 1;135(2):e339-47.

25. Granqvist P, Sroufe LA, Dozier M, Hesse E, Steele M, van Ijzendoorn M, Solomon J, Schuengel C, Fearon P, Bakermans-Kranenburg M, Steele H. Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers. Attachment & human development. 2017 Nov 2;19(6):534-58.

26. Forslund T, Granqvist P, van IJzendoorn MH, Sagi-Schwartz A, Glaser D, Steele M, Hammarlund M, Schuengel C, Bakermans-Kranenburg MJ, Steele H, Shaver PR. Attachment goes to court: child protection and custody issues. Attachment & Human Development. 2021 Jan 7:1-52.

27. Galbally M, Stein A, Hoegfeldt CA, van IJzendoorn M. From attachment to mental health and back. The Lancet Psychiatry. 2020 Oct 1;7(10):832-4.

28. Forslund T, Granqvist P, van IJzendoorn MH, Sagi-Schwartz A, Glaser D, Steele M, Hammarlund M, Schuengel C, Bakermans-Kranenburg MJ, Steele H, Shaver PR. Attachment goes to court: child protection and custody issues. Attachment & Human Development. 2021 Jan 7:1-52.

29. Ramsauer B, Mühlhan C, Lotzin A, Achtergarde S, Mueller J, Krink S, Tharner A, Becker-Stoll F, Nolte T, Romer G. Randomized controlled trial of the Circle of Security-Intensive intervention for mothers with postpartum depression: maternal unresolved attachment moderates changes in sensitivity. Attachment & human development. 2020 Nov 1;22(6):705-26.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.