Skip to main content
Top
Published in: Child and Adolescent Psychiatry and Mental Health 1/2019

Open Access 01-12-2019 | Research article

Reduced caregiving quality measured during the strange situation procedure increases child’s autonomic nervous system stress response

Authors: Franziska Köhler-Dauner, Eva Roder, Sabrina Krause, Anna Buchheim, Harald Gündel, Jörg M. Fegert, Ute Ziegenhain, Christiane Waller

Published in: Child and Adolescent Psychiatry and Mental Health | Issue 1/2019

Login to get access

Abstract

Background

Dysfunctional maternal behavior has been shown to lead to disturbances in infant’s regulatory capacities and alterations in vagal reactivity. We aim to investigate the autonomic nervous system (ANS) response of the child during the strange situation procedure (SSP) in relation to the quality of maternal behavior.

Methods

Twelve month after birth, 163 mother–child-dyads were investigated during the SSP. Heart rate (HR) and both, the parasympathetic branch (PNS) via the respiratory sinus arrhythmia (RSA) and the sympathetic branch (SNS) via the left ventricular ejection time (LVET) of the ANS were continuously determined during the SSP using electrocardiogram (ECG) and impedance cardiogram (ICG) measures. Maternal behavior was assessed by using the AMBIANCE measure.

Results

The ANS response in infants of mothers with disruptive behavior compared to infants of non-disruptive mothers was significantly altered during the SSP: HR increased especially when infants of disruptive mothers were alone with the stranger (F (1, 161) = 4.15, p = .04) with a significant vagal withdrawal when being in contact with the stranger despite of presence of the mother (F (1, 161) = 5.11, p = .03) and a significant increase in vagal tone during final reunion (F (1, 161) = 3.76, p = .05). HR increase was mainly based on a decrease in LVET (F (1, 161) = 4.08, p = .05) with a maximum infant’s HR when the stranger came into the room instead of the mother.

Conclusion

Both, SNS and PNS branches of the child are significantly altered in terms of an ANS imbalance, especially during contract to a stranger, in relation to dysfunctional maternal behavior. Our findings suggest the importance of supporting high quality caregiving that enables the infant to adapt adequately to stressful interpersonal situations which is likely to promote later health.
Literature
1.
go back to reference Calkins SD, Smith CL, Gill K, Johnson MC. Maternal interactive style across contexts: relations to emotional, behavioral and physiological regulation during toddlerhood. Soc Dev. 1998;7:350–69.CrossRef Calkins SD, Smith CL, Gill K, Johnson MC. Maternal interactive style across contexts: relations to emotional, behavioral and physiological regulation during toddlerhood. Soc Dev. 1998;7:350–69.CrossRef
3.
go back to reference Schore AN. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Ment Health J. 2001;22(1–2):7–66.CrossRef Schore AN. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Ment Health J. 2001;22(1–2):7–66.CrossRef
4.
go back to reference Calkins SD, Hill A. Caregiver influences on emerging emotion regulation. In: Handbook of emotion regulation. 229248. 2007. Calkins SD, Hill A. Caregiver influences on emerging emotion regulation. In: Handbook of emotion regulation. 229248. 2007.
5.
go back to reference Hofer MA. Hidden regulators: implications for a new understanding of attachment, separation, and loss. In: Golberg S, Muir R, Kerr J, editors. Attachment theory: social, developmental, and clinical perspectives. Hillsdale, NJ: Analytic Press; 1995. p. 203–30. Hofer MA. Hidden regulators: implications for a new understanding of attachment, separation, and loss. In: Golberg S, Muir R, Kerr J, editors. Attachment theory: social, developmental, and clinical perspectives. Hillsdale, NJ: Analytic Press; 1995. p. 203–30.
6.
go back to reference Laurent HK, Harold GT, Leve L, Shelton KH, Van Goozen SH. Understanding the unfolding of stress regulation in infants. Dev Psychopathol. 2016;28(4pt2):1431–40.PubMedPubMedCentralCrossRef Laurent HK, Harold GT, Leve L, Shelton KH, Van Goozen SH. Understanding the unfolding of stress regulation in infants. Dev Psychopathol. 2016;28(4pt2):1431–40.PubMedPubMedCentralCrossRef
7.
go back to reference Kennedy AE, Rubin KH, Hastings DP, Maisel B. Longitudinal relations between child vagal tone and parenting behavior: 2 to 4 years. Dev Psychobiol. 2004;45(1):10–21.PubMedCrossRef Kennedy AE, Rubin KH, Hastings DP, Maisel B. Longitudinal relations between child vagal tone and parenting behavior: 2 to 4 years. Dev Psychobiol. 2004;45(1):10–21.PubMedCrossRef
9.
go back to reference Moore GA, Hill-Soderlund AL, Propper CB, Calkins SD, Mills-Koonce WR, Cox MJ. Mother-infant vagal regulation in the face-to-face still-face paradigm is moderated by maternal sensitivity. Child Dev. 2009;80(1):209–23.PubMedCrossRef Moore GA, Hill-Soderlund AL, Propper CB, Calkins SD, Mills-Koonce WR, Cox MJ. Mother-infant vagal regulation in the face-to-face still-face paradigm is moderated by maternal sensitivity. Child Dev. 2009;80(1):209–23.PubMedCrossRef
11.
go back to reference Ainsworth MDS, Bell SM, Stayton DF. Infant-mother attachment and social development: socialization as a product of reciprocal responsiveness to signals. 1974. Ainsworth MDS, Bell SM, Stayton DF. Infant-mother attachment and social development: socialization as a product of reciprocal responsiveness to signals. 1974.
12.
go back to reference Gianino AA, Tronick EZ. The mutual regulation model: the infant’s self and interactive regulation and coping and defensive capacities. In: Field TM, McCabe PM, Schneiderman N, editors. Stress and coping across development. Hillsdale: Lawrence Erlbaum Associates, Inc; 1988. p. 47–68. Gianino AA, Tronick EZ. The mutual regulation model: the infant’s self and interactive regulation and coping and defensive capacities. In: Field TM, McCabe PM, Schneiderman N, editors. Stress and coping across development. Hillsdale: Lawrence Erlbaum Associates, Inc; 1988. p. 47–68.
15.
go back to reference Hostinar CE, Gunnar MR. The developmental psychobiology of stress and emotion in childhood. Handb Psychol. 2013;2:121–41. Hostinar CE, Gunnar MR. The developmental psychobiology of stress and emotion in childhood. Handb Psychol. 2013;2:121–41.
16.
go back to reference Diener ML, Mangelsdorf SC, McHale JL, Frosch CA. Infants’ behavioral strategies for emotion regulation with fathers and mothers: associations with emotional expressions and attachment quality. Infancy. 2002;3(2):153–74.CrossRefPubMed Diener ML, Mangelsdorf SC, McHale JL, Frosch CA. Infants’ behavioral strategies for emotion regulation with fathers and mothers: associations with emotional expressions and attachment quality. Infancy. 2002;3(2):153–74.CrossRefPubMed
17.
go back to reference Sroufe LA. Emotional development: the organization of emotional life in the early years (Cambridge Studies in Social and Emotional Development). Cambridge: Cambridge University Press; 1996.CrossRef Sroufe LA. Emotional development: the organization of emotional life in the early years (Cambridge Studies in Social and Emotional Development). Cambridge: Cambridge University Press; 1996.CrossRef
18.
go back to reference Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment. A psychological study of the strange situation. Hilsdale: Lawrence Erlbaurn; 1978. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment. A psychological study of the strange situation. Hilsdale: Lawrence Erlbaurn; 1978.
19.
go back to reference Bowlby J. Attachment and loss: attachment. Vol. 1. 1969. Bowlby J. Attachment and loss: attachment. Vol. 1. 1969.
21.
go back to reference Wolff MS, Ijzendoorn MH. Sensitivity and attachment: a meta-analysis on parental antecedents of infant attachment. Child Dev. 1997;68(4):571–91.PubMedCrossRef Wolff MS, Ijzendoorn MH. Sensitivity and attachment: a meta-analysis on parental antecedents of infant attachment. Child Dev. 1997;68(4):571–91.PubMedCrossRef
22.
go back to reference Waters SF, Mendes WB. Physiological and relational predictors of mother-infant behavioral coordination. Adapt Hum Behav Physiol. 2016;2(4):298–310.CrossRef Waters SF, Mendes WB. Physiological and relational predictors of mother-infant behavioral coordination. Adapt Hum Behav Physiol. 2016;2(4):298–310.CrossRef
23.
go back to reference Fox NA, Card JA. Psychophysiological measures in the study of attachment. In: Handbook of attachment: theory, research, and clinical applications. 1999. p. 226–45. Fox NA, Card JA. Psychophysiological measures in the study of attachment. In: Handbook of attachment: theory, research, and clinical applications. 1999. p. 226–45.
24.
go back to reference Cacioppo JT, Berntson GG, Larsen JT, Poehlmann KM, Ito TA. The psychophysiology of emotion. In: Lewis M, Haviland-Jones JM, editors. The handbook of emotion. New York: Guildford Press; 2008. Cacioppo JT, Berntson GG, Larsen JT, Poehlmann KM, Ito TA. The psychophysiology of emotion. In: Lewis M, Haviland-Jones JM, editors. The handbook of emotion. New York: Guildford Press; 2008.
25.
go back to reference Cacioppo JT, Berntson GG, Larsen JT, Poehlmann KM, Ito TA. The psychophysiology of emotion. Handb Emot. 2000;2:173–91. Cacioppo JT, Berntson GG, Larsen JT, Poehlmann KM, Ito TA. The psychophysiology of emotion. Handb Emot. 2000;2:173–91.
26.
go back to reference Cassidy J, Shaver PR. Handbook of attachment: theory, research, and clinical applications. New York: Guilford Press; 1999. p. 925. Cassidy J, Shaver PR. Handbook of attachment: theory, research, and clinical applications. New York: Guilford Press; 1999. p. 925.
27.
go back to reference Hill-Soderlund AL, Mills-Koonce WR, Propper CB, Calkins SD, Granger DA, Moore GA, Gariépy JL, Cox MJ. Parasympathetic and sympathetic responses to the strange situation in infants and mothers from avoidant and securely attached dyads. Dev Psychobiol. 2008;50(4):361–76.PubMedCrossRef Hill-Soderlund AL, Mills-Koonce WR, Propper CB, Calkins SD, Granger DA, Moore GA, Gariépy JL, Cox MJ. Parasympathetic and sympathetic responses to the strange situation in infants and mothers from avoidant and securely attached dyads. Dev Psychobiol. 2008;50(4):361–76.PubMedCrossRef
29.
go back to reference Loman MM, Gunnar MR. Early experience and the development of stress reactivity and regulation in children. Neurosci Biobehav Rev. 2010;34(6):867–76.PubMedCrossRef Loman MM, Gunnar MR. Early experience and the development of stress reactivity and regulation in children. Neurosci Biobehav Rev. 2010;34(6):867–76.PubMedCrossRef
31.
go back to reference Larsen JT, Berntson GG, Poehlmann KM, Ito TA, Cacioppo JT. The psychophysiology of emotion. Handb Emot. 2008;3:180–95. Larsen JT, Berntson GG, Poehlmann KM, Ito TA, Cacioppo JT. The psychophysiology of emotion. Handb Emot. 2008;3:180–95.
32.
go back to reference Turner JR. Individual differences in heart rate response during behavioural challenge. Psychophysiology. 1989;26:497–505.PubMedCrossRef Turner JR. Individual differences in heart rate response during behavioural challenge. Psychophysiology. 1989;26:497–505.PubMedCrossRef
33.
go back to reference Scheeringa MS, Zeanah CH, Myers L, Putnam F. Heart period and variability findings in preschool children with posttraumatic stress symptoms. Biol Psychiatry. 2004;55(7):685–91.PubMedCrossRef Scheeringa MS, Zeanah CH, Myers L, Putnam F. Heart period and variability findings in preschool children with posttraumatic stress symptoms. Biol Psychiatry. 2004;55(7):685–91.PubMedCrossRef
34.
go back to reference Bar-Haim Y, Marshall PJ, Fox NA. Developmental changes in heart period and high-frequency heart period variability from 4 months to 4 years of age. Dev Psychobiol. 2000;37(1):44–56.PubMedCrossRef Bar-Haim Y, Marshall PJ, Fox NA. Developmental changes in heart period and high-frequency heart period variability from 4 months to 4 years of age. Dev Psychobiol. 2000;37(1):44–56.PubMedCrossRef
35.
go back to reference Alkon A, Boyce WT, Davis NV, Eskenazi B. Developmental changes in autonomic nervous system resting and reactivity measures in Latino children from 6 to 60 months of age. J Dev Behav Pediatr. 2011;32(9):668–77.PubMedCrossRef Alkon A, Boyce WT, Davis NV, Eskenazi B. Developmental changes in autonomic nervous system resting and reactivity measures in Latino children from 6 to 60 months of age. J Dev Behav Pediatr. 2011;32(9):668–77.PubMedCrossRef
36.
go back to reference Alkon A, Lippert S, Vujan N, Rodriquez ME, Boyce WT, Eskenazi B. The ontogeny of autonomic measures in 6- and 12-month-old infants. Dev Psychobiol. 2006;48(3):197–208.PubMedCrossRef Alkon A, Lippert S, Vujan N, Rodriquez ME, Boyce WT, Eskenazi B. The ontogeny of autonomic measures in 6- and 12-month-old infants. Dev Psychobiol. 2006;48(3):197–208.PubMedCrossRef
37.
go back to reference Blair C, Berry D, Mills-Koonce R, Granger D, Investigators FLP. Cumulative effects of early poverty on cortisol in young children: moderation by autonomic nervous system activity. Psychoneuroendocrinology. 2013;38(11):2666–75.PubMedPubMedCentralCrossRef Blair C, Berry D, Mills-Koonce R, Granger D, Investigators FLP. Cumulative effects of early poverty on cortisol in young children: moderation by autonomic nervous system activity. Psychoneuroendocrinology. 2013;38(11):2666–75.PubMedPubMedCentralCrossRef
38.
go back to reference Cacioppo JT, Uchino BN, Bernston GG. Individual differences in the autonomic origins of heart rate reactivity: the psy-chometrics of respiratory sinus arrhythmia and preejection period. Psychophysiology. 1994;31:412–41.PubMedCrossRef Cacioppo JT, Uchino BN, Bernston GG. Individual differences in the autonomic origins of heart rate reactivity: the psy-chometrics of respiratory sinus arrhythmia and preejection period. Psychophysiology. 1994;31:412–41.PubMedCrossRef
39.
go back to reference Cacioppo JT, Berntson GG, Binkley PF, Quigley KS, Uchino BN, Fieldstone A. Autonomic cardiac control. II. Noninvasive indices and basal response as revealed by autonomic blockades. Psychophysiology. 1994;31(6):586–98.PubMedCrossRef Cacioppo JT, Berntson GG, Binkley PF, Quigley KS, Uchino BN, Fieldstone A. Autonomic cardiac control. II. Noninvasive indices and basal response as revealed by autonomic blockades. Psychophysiology. 1994;31(6):586–98.PubMedCrossRef
40.
go back to reference Thayer JF, Uijtdehaage SH. Derivation of chronotropic indices of autonomic nervous system activity using impedance cardiography. Biomed Sci Instrum. 2001;37:331–6.PubMed Thayer JF, Uijtdehaage SH. Derivation of chronotropic indices of autonomic nervous system activity using impedance cardiography. Biomed Sci Instrum. 2001;37:331–6.PubMed
41.
go back to reference Tronick E, Als H, Adamson L, Wise S, Brazelton TB. The infant’s response to entrapment between contradictory messages in face-to-face interaction. J Am Acad Child Psychiatry. 1978;17(1):1–13.PubMedCrossRef Tronick E, Als H, Adamson L, Wise S, Brazelton TB. The infant’s response to entrapment between contradictory messages in face-to-face interaction. J Am Acad Child Psychiatry. 1978;17(1):1–13.PubMedCrossRef
42.
go back to reference Gunnar MR, Larson MC, Hertsgaard L, Harris ML, Brodersen L. The stressfulness of separation among nine-month-old infants: effects of social context variables and infant temperament. Child Dev. 1992;63(2):290–303.PubMedCrossRef Gunnar MR, Larson MC, Hertsgaard L, Harris ML, Brodersen L. The stressfulness of separation among nine-month-old infants: effects of social context variables and infant temperament. Child Dev. 1992;63(2):290–303.PubMedCrossRef
43.
go back to reference Bazhenova OV, Plonskaia O, Porges SW. Vagal reactivity and affective adjustment in infants during interaction challenges. Child Dev. 2001;72(5):1314–26.PubMedCrossRef Bazhenova OV, Plonskaia O, Porges SW. Vagal reactivity and affective adjustment in infants during interaction challenges. Child Dev. 2001;72(5):1314–26.PubMedCrossRef
48.
go back to reference Calkins SD, Keane SP. Cardiac vagal regulation across the preschool period: stability, continuity, and implications for childhood adjustment. Dev Psychobiol. 2004;45(3):101–12.PubMedCrossRef Calkins SD, Keane SP. Cardiac vagal regulation across the preschool period: stability, continuity, and implications for childhood adjustment. Dev Psychobiol. 2004;45(3):101–12.PubMedCrossRef
49.
go back to reference Stifter CA, Dollar JM, Cipriano EA. Temperament and emotion regulation: the role of autonomic nervous system reactivity. Dev Psychobiol. 2011;53(3):266–79.PubMedCrossRef Stifter CA, Dollar JM, Cipriano EA. Temperament and emotion regulation: the role of autonomic nervous system reactivity. Dev Psychobiol. 2011;53(3):266–79.PubMedCrossRef
52.
go back to reference Porges SW. The polyvagal theory: phylogenetic contributions to social behavior. Physiol Behav. 2003;79(3):503–13.PubMedCrossRef Porges SW. The polyvagal theory: phylogenetic contributions to social behavior. Physiol Behav. 2003;79(3):503–13.PubMedCrossRef
53.
go back to reference Bush NR, Caron ZK, Blackburn KS, Alkon A. Measuring cardiac autonomic nervous system (ANS) activity in toddlers—resting and developmental challenges. J Vis Exp. 2016;108:53652. Bush NR, Caron ZK, Blackburn KS, Alkon A. Measuring cardiac autonomic nervous system (ANS) activity in toddlers—resting and developmental challenges. J Vis Exp. 2016;108:53652.
56.
go back to reference Hinnant JB, Elmore-Staton L, El-Sheikh M. Developmental trajectories of respiratory sinus arrhythmia and preejection period in middle childhood. Dev Psychobiol. 2011;53(1):59–68.PubMedPubMedCentralCrossRef Hinnant JB, Elmore-Staton L, El-Sheikh M. Developmental trajectories of respiratory sinus arrhythmia and preejection period in middle childhood. Dev Psychobiol. 2011;53(1):59–68.PubMedPubMedCentralCrossRef
57.
go back to reference Roder E et al. Maternal separation and contact to a stranger more than reunion affect the autonomic nervous system in the mother–child dyad. 2019 (in submission). Roder E et al. Maternal separation and contact to a stranger more than reunion affect the autonomic nervous system in the mother–child dyad. 2019 (in submission).
59.
go back to reference Calkins SD, Graziano PA, Berdan LE, Keane SP, Degnan KA. Predicting cardiac vagal regulation in early childhood from maternal–child relationship quality during toddlerhood. Dev Psychobiol. 2008;50(8):751–66.PubMedPubMedCentralCrossRef Calkins SD, Graziano PA, Berdan LE, Keane SP, Degnan KA. Predicting cardiac vagal regulation in early childhood from maternal–child relationship quality during toddlerhood. Dev Psychobiol. 2008;50(8):751–66.PubMedPubMedCentralCrossRef
60.
go back to reference Adam EK, Klimes-Dougan B, Gunnar MR. Social regulation of the adrenocortical response to stress in infants, children, and adolescents. In: Human behavior, learning, and the developing brain: atypical development. 2007. p. 264–304. Adam EK, Klimes-Dougan B, Gunnar MR. Social regulation of the adrenocortical response to stress in infants, children, and adolescents. In: Human behavior, learning, and the developing brain: atypical development. 2007. p. 264–304.
61.
go back to reference Bugental DB, Martorell GA, Barraza V. The hormonal costs of subtle forms of infant maltreatment. Horm Behav. 2003;43(1):237–44.PubMedCrossRef Bugental DB, Martorell GA, Barraza V. The hormonal costs of subtle forms of infant maltreatment. Horm Behav. 2003;43(1):237–44.PubMedCrossRef
62.
go back to reference Cicchetti D, Rogosch FA. The impact of child maltreatment and psychopathology on neuroendocrine functioning. Dev Psychopathol. 2001;13(4):783–804.PubMedCrossRef Cicchetti D, Rogosch FA. The impact of child maltreatment and psychopathology on neuroendocrine functioning. Dev Psychopathol. 2001;13(4):783–804.PubMedCrossRef
63.
go back to reference Abidin RR. Parenting stress index. 4th ed. Lutz: PAR; 2012. Abidin RR. Parenting stress index. 4th ed. Lutz: PAR; 2012.
64.
go back to reference Cohen S. Contrasting the Hassles Scale and the Perceived Stress Scale: who is really measuring appraised stress? Am Psychol. 1986;41:716–8.CrossRef Cohen S. Contrasting the Hassles Scale and the Perceived Stress Scale: who is really measuring appraised stress? Am Psychol. 1986;41:716–8.CrossRef
65.
go back to reference Bronfman E, Madigan S, Lyons-Ruth K. Atypical maternal behavior instrument for assessment and classification (AMBIANCE). Manual for coding disrupted affective communication. Cambridge: Department of Psychiatry, Harvard Medical School; 1992–2009 (Unpublished manual). Bronfman E, Madigan S, Lyons-Ruth K. Atypical maternal behavior instrument for assessment and classification (AMBIANCE). Manual for coding disrupted affective communication. Cambridge: Department of Psychiatry, Harvard Medical School; 1992–2009 (Unpublished manual).
66.
go back to reference Main M, Hesse E. Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening parental behavior the linking mechanism? In: Greenberg M, Cicchetti D, Cummings E, editors. Attachment in the preschool years: theory, research, and intervention. Chicago: University of Chicago Press; 1990. p. 161–82. Main M, Hesse E. Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening parental behavior the linking mechanism? In: Greenberg M, Cicchetti D, Cummings E, editors. Attachment in the preschool years: theory, research, and intervention. Chicago: University of Chicago Press; 1990. p. 161–82.
67.
go back to reference Hesse E, Main M. Second-generation effects of unresolved trauma in nonmaltreating parents: dissociated, frightened, and threatening parental behavior. Psychoanal Inquiry. 1999;19(4):481–540.CrossRef Hesse E, Main M. Second-generation effects of unresolved trauma in nonmaltreating parents: dissociated, frightened, and threatening parental behavior. Psychoanal Inquiry. 1999;19(4):481–540.CrossRef
68.
go back to reference Grienenberger J, Kelly K, Slade A. Maternal reflective functioning, mother-infant affective communication and infant attachment: exploring the link between mental states and observed caregiving behavior in the intergenerational transmission of attachment. Attachment Hum Dev. 2005;7:299–311.CrossRef Grienenberger J, Kelly K, Slade A. Maternal reflective functioning, mother-infant affective communication and infant attachment: exploring the link between mental states and observed caregiving behavior in the intergenerational transmission of attachment. Attachment Hum Dev. 2005;7:299–311.CrossRef
71.
go back to reference Vitolo E, Colombo A, Castini D, Morabito A. Evaluation of systolic time intervals in a group of healthy children 10–12 years old. Acta Cardiol. 1991;46:631–40.PubMed Vitolo E, Colombo A, Castini D, Morabito A. Evaluation of systolic time intervals in a group of healthy children 10–12 years old. Acta Cardiol. 1991;46:631–40.PubMed
Metadata
Title
Reduced caregiving quality measured during the strange situation procedure increases child’s autonomic nervous system stress response
Authors
Franziska Köhler-Dauner
Eva Roder
Sabrina Krause
Anna Buchheim
Harald Gündel
Jörg M. Fegert
Ute Ziegenhain
Christiane Waller
Publication date
01-12-2019
Publisher
BioMed Central
Published in
Child and Adolescent Psychiatry and Mental Health / Issue 1/2019
Electronic ISSN: 1753-2000
DOI
https://doi.org/10.1186/s13034-019-0302-3

Other articles of this Issue 1/2019

Child and Adolescent Psychiatry and Mental Health 1/2019 Go to the issue