Prevention starts with the relationship: the use of video feedback at home

Preventative strategies aimed at avoiding child overweight and obesity clearly represent the ideal one should strive towards. As of today, there are no standardized guidelines that help us in this, but there are numerous recommendations that encourage good daily practices which improve the child’s health following birth. In cases where the adoption of these best practices proves challenging, the key question to ask is “how can we promote health to prevent child overweight from the perinatal stage?” As examples, we will describe several strategies that can be easily adopted by practitioners who deal with prenatal and perinatal care, and then we will describe our approach.

Barnett (1995) lists five possible strategies to prevent the occurrence of disorders during the perinatal phase: (1) discuss with future parents their feelings of adequacy vs. inadequacy in their role as parents; (2) facilitate as much as possible the transition to parenthood, promoting self-reliance and keeping stress, anxiety, and symptoms of depression within a reasonable range; (3) recognize those who are at risk of mood disorders or other pathologies; (4) actively intervene with those who display a clear clinical condition; (5) recognize and support those who are at risk of becoming fragile parents, because of their own vulnerability or because of temperamental and/or individual aspects of the child. The first approach to consider is therefore definitely informational. Information acts as prevention in and of itself, and in order to play this role, it needs to reach those requiring intervention. This aspect must be enriched and integrated with the possibility of providing a support network around the mother-child dyad, activating modalities of communication that reinforce competencies and aimed at problem-solving, supporting, at the same time, the exploration of the parental experience.

Along these prevention pathways, a series of possible early interventions could be added for families that show an above-average risk of developing perinatal disorders and/or psychopathological conditions. Early interventions include home visiting (Olds & Kitzman 1990; Olds et al. 1997), supporting pre-term babies, and psychotherapy for women with high levels of anxiety and post-partum depressive/psychotic disorders. The summary table showed below reports the synthesis of the empirical studies that dealt with interventions in the perinatal period.

In addition, more recent literature documents the use of Video-feedback Intervention to Promote Positive Parenting (VIPP), which is a useful tool to offer early support and to actively help the dyads at risk. The value of using VIPP is the possibility for direct access to the mother-child interaction, without having to rely on the parents' reports. The specific objective of VIPP is to increase the mother’s responsiveness and to help create a safe context for the attachment bond (Bakermans-Kranenburg, van Ijzendoorn, & Juffer 2003). This type of intervention is most effective if it is introduced in the first year of life. During this developmental phase, particularly in the case of firsttime mothers, caregivers are more likely to accept advice and suggestions for issues they are facing for the first time. In these situations, the family routine has not yet been established and the problems are still new and transient.

VIPP, as created by Juffer, Bakermans-Kranenburg, and Van Uzendoorn (2008), has these essential objectives: (1) to promote the parents’ ability to pay attention to the signals and needs expressed by the child; (2) to help the parents develop observation and empathy; (3) to reinforce the positive behaviours adopted by the parents, especially those that evidence sensitivity towards the child; and (4) to engage the parents in a dialogue about their past attachment experiences and about the possible influence these might be having on their relationship with their child. VIPP was in fact created to help struggling parents take a step back with respect to the emotional spiral in which they and the child find themselves, examining what emerges and observing the interactions from a different point of view. The procedure can vary in its application, but fundamentally uses two main approaches (Bakermans-Kranenburg, van Ijzendoorn, & Juffer 2003; Fukkink 2008; Juffer & Steele 2014). In the first approach, the use of video feedback focuses on (1) behaviour and the gateway into the relationship is based on the interactions and behaviours observed within the dyad (Stern, 1985, 2004). In this case, the use of video recording helps maintain the focus on the here and now (e.g., McDonough 2005). In the second approach, the focus is on (2) the mother’s mental representations of herself, of the child, and of their relationship, as gateway for intervention. In this case, video recording is used to gain quicker access into the mother’s early experiences (Lieberman 2004). The distinction between these two approaches is not always clear and. in some cases, a combined approach is used (Beebe 2003; Cramer 1998; Egeland, Weinfeld, Bosquet, & Cheng 2000).

In summary, within V1PP the focus remains on the meaningful and real events occurring in the dyadic relationship, avoiding the use of judgements, even if positive, and avoiding direct attempts aimed at changing behaviours. The result of this type of approach leads to an awareness of the dynamics of the relationship and to a maturational process of thought, that we could call "mindful”.

In our clinical practice, as will later be shown with a clinical example, we adopt a V1PP procedure that has been adapted to the context of perinatal eating disorders and, more specifically, to the risk of intergenerational transmission of overweight. The research of Stein et al. (2006) is the only study we know of that used this approach in a systematic way, adapting it to the perinatal diet. From this starting point, we concentrated on the need to prevent the conflict that characterizes meals, focusing our observations on the emotional exchange between mother and child, as a means to producing new knowledge on the relational context. Our protocol includes 12 meetings: six of these are dedicated to video-recording meals at home, and in the remining six, using footage from the previous recordings, the mother’s behaviours and those of her child are observed and reflected upon, together with the mother. The video recording takes place every other meeting, while during the obser-vation/dialogue meeting, the focus is gradually shifted towards certain fundamental relational behaviours. Specifically, there are three central steps: (1) keeping the children’s perspective in mind, focusing on the signals they give; (2) confronting the parents' perspective, emphasizing the moments of mutual exchange, sharing, and emotional tuning within the dyad; (3) promoting in the mother the exploration of those behaviours that, according to her, represent “signals of conflict in relation to food”.

The case of Sara and Matteo will now be described, keeping in mind the characteristics of video-feedback interventions in the perinatal period.