Intranasal Oxytocin and Maternal Neglect
Condition: Maternal Behavior
Study type: Interventional

Summary: 
      The investigators plan to conduct functional MRI scanning with a group of mothers who are
      blindly and randomly assigned either intranasal oxytocin or a placebo. The purpose of this
      investigation is to explore how oxytocin may modify early maternal brain and behavioral
      responses to infant cues. This study will examine, for the first time, a potential
      pharmacological intervention for maternal neglect which targets core neurobiological
      deficits. This may eventually be used to supplement and augment other psychosocial and
      behavioral interventions.

      In addition, the investigators will examine sex differences in parental brain and behavioral
      responses to oxytocin by also recruiting fathers to participate in a similar protocol.
    

Detailed description: 
      The investigators plan to conduct fMRI scanning with a group of mothers who are blindly and
      randomly assigned either intranasal oxytocin or a placebo.

      Aim 1: To determine whether intranasal oxytocin (IN-OT) affects parental brain responses to
      infant cues, as measured during functional MRI (fMRI) scanning.

      Hypothesis 1 (i): Compared to placebo, mothers who receive intranasal oxytocin will show
      greater activation of mesocorticolimbic dopamine reward regions in the brain, including the
      ventral striatum and the medial prefrontal cortex, when viewing their own vs. unknown infant
      faces during fMRI scanning. Hypothesis 1 (ii): Compared to placebo, fathers will show greater
      activation of social-cognitive circuits, including the dorsal prefrontal cortex (dPFC).

      Aim 2: To determine whether IN-OT affects parental behavioral responses to infant cues, as
      measured by videotaped parent-infant interaction procedures.

      Hypothesis 2 (i): Compared to placebo, parents who receive intranasal oxytocin will score
      higher on an overall measure of maternal sensitivity, during a free play parent-infant
      interaction procedure (CARE-Index). Hypothesis 2 (ii): Compared to placebo, mothers who
      receive intranasal oxytocin will demonstrate more frequent emotionally contingent responses
      with their infant during the recovery phase of a modified Still-Face procedure.

      Aim 3: To determine whether attachment security interacts with the effect of IN-OT on
      maternal brain and behavioral responses to infant cues.

      Hypothesis 3 (i): Compared to secure (Type B) mothers, mothers with insecure/dismissing (Type
      A) attachment will have a greater brain and behavioral response to IN-OT (as described in
      Hypotheses 1 and 2), with a 2-way interaction effect seen between treatment and attachment
      groups. Hypothesis 3 (ii): Compared to Type B mothers, mothers with insecure/preoccupied
      (Type C) attachment will have a reduced brain and behavioral response to IN-OT (as described
      in Hypotheses 1 and 2), with a 2-way interaction effect seen between treatment and attachment
      groups.

      Aim 4: To determine whether brain reward activation is associated with other indirect
      measures of emotional neglect in mothers.

      Hypothesis 4 (i): Maternal brain reward system activation, both with and without IN-OT, will
      be positively correlated with 1) maternal sensitivity (as measured by the CARE-Index), 2) the
      contingency of maternal responses to infant behavioral cues.

      Initial enrollment: Recruitment will occur during the postpartum period. In addition to
      recruiting from EPIC medical record, the investigators plan to execute other recruiting
      measures in the form of advertising. Parent(s) will be recruited via newspaper, internet,
      public postings, and mass mailings. Once eligibility is confirmed, subjects will be scheduled
      for a study visit where they will be informed of confidentiality and consented before
      participating in any study activities.

      Visit 1: 4 Months Post-Partum - Adult Attachment Interview (AAI). During this visit, each
      enrolled woman will participate in a modified version of the Adult Attachment Interview
      (AAI), a semi-structured 1½-2 hour-long interview involving specified questions and follow-up
      inquiries relating to childhood relationships with attachment figures. The investigators will
      also collect sociodemographic, breastfeeding data, and screening information for depression.
      The EPDS will be repeated during subsequent visits in order to calculate mean scores.

      Visits 2A&B and 3A&B: Intranasal Oxytocin vs. Placebo Administration In this double-blind
      cross-over placebo-controlled trial of intranasal oxytocin, maternal brain and behavioral
      responses to infant cues will be assessed within & between subjects. Each participant will be
      administered both the active (oxytocin) and inactive (placebo) nasal spray just prior to
      separate behavioral or fMRI scanning sessions, with order of administration balanced across
      subjects and between attachment groups. All involved will be blinded to the identity of the
      oxytocin or placebo sprays. Before each visit, parent(s) will be asked to abstain from
      tobacco, food and drink (except water) for at least 2 hours prior to the visit. The
      investigators will attempt to schedule visits during the latter half of the mother's
      menstrual cycle, to minimize potential confounding from fluctuations in estrogen levels.
      Mothers without regular menstrual cycles will be scheduled one month apart. Mothers who are
      still breastfeeding will be asked to feed their infant at least one hour prior to the visit.
      For the four visits involving intranasal drug administration (two behavioral testing visits
      and two fMRI scanning visits), the following protocol will apply: participants will be given
      a urinary pregnancy test prior to the start of each visit. If a mother tests positive, she
      will be excluded from the study due to theoretical concern about possible effects of oxytocin
      on uterine contraction. Due to the fact that the pregnancy test may still not detect an early
      pregnancy, the mothers will also be asked to abstain from unprotected sexual intercourse
      during the 2 weeks prior to the visit, and will confirm, in signing the consent form, that
      there is no substantial chance of a current pregnancy. Just prior to drug administration, the
      parent(s) will complete the Positive and Negative Affect Scale, to rate her current emotions,
      for comparison to post-spray. The parent(s) will then self-administer a dose of either
      oxytocin (3 puffs per nostril [4 IU per puff] = 24 IU total) or a placebo spray that contains
      only the inactive ingredients of the oxytocin solution. Both experimenters and subjects will
      be blind to the treatment they are receiving. A stopwatch will be started at the moment the
      subjects begins intranasal administration, so that the behavior assessment or fMRI scanning
      can begin exactly 50 minutes later. Most other studies of intranasal oxytocin have used a 50
      minutes delay time, based on CSF studies of other intranasally administered neuropeptides,
      such as the analogous hormone vasopressin. Forty minutes after drug administration, the PANAS
      will be repeated.

      Visits 2A&B: 5-6 Months Postpartum - Behavioral Response

        1. On arrival, the parent(s) and infant will be escorted into a behavioral observation room
           at the Clinical Nutrition Research Center, where the infant will be introduced to some
           developmentally appropriate toys. Questionnaires completed at home will be reviewed
           (Infant Behavior Questionnaire [IBQ], Parenting Stress Index [PSI] and demographics and
           breastfeeding questionnaire), and if incomplete will be completed at this time.

        2. Each parent will then self-administer the nasal spray, which has been previously
           randomized by the investigational pharmacy to be either oxytocin or placebo. During the
           following waiting period, the Bayley Scales of Infant Development screener will be
           completed with the infant, to exclude developmental delays in areas of fine motor, gross
           motor, language or social development. This will be performed by a research associate
           who has been trained in the use of this standardized tool.

        3. Fifty minutes after the nasal spray is administered, each parent will rejoin their
           infant to each participate in a videotaped "free play" interaction on the floor for 3
           minutes (described below). The recording will later be coded for dyadic interactions
           using a 14-point sensitivity scale in the CARE-Index.

        4. A modified still-face procedure will then be conducted during the next 3 minutes(as
           described below).

        5. The parent(s) will then be taken to another area of the building, while the infant is
           videotaped to obtain face images that will be used during the subsequent scanning
           visits. During the brief separation period, the infant will be secured in a mounted car
           seat, and videotaped while using age appropriate toys to elicit smiling (and neutral)
           facial expressions. This should last no more than 10 minutes. Crying faces will also be
           elicited, if necessary, by briefly leaving the infant alone in the room, secured in the
           car seat, while the video recorder is running. The infant will be observed at all times
           from behind a one-way mirror, and only left to cry for around 35-40 seconds. Infant cry
           will also be recorded at this time.

        6. Infant face images with various degrees of affect-happy, neutral and sad-will then be
           extracted from the digital video recording, for use in the subsequent fMRI procedure
           (Visit 3). The images will be standardized for size, orientation and background using
           Adobe Photoshop. All of the face images will be rated on degree of affect using a
           5-point adaptation of the Self-Assessment Manikin (SAM), categorizing each image into
           one of five affect groups: very happy, happy, neutral, sad or very sad. These faces will
           be matched on age, sex, ethnicity and degree of affect with a large database of
           "unknown" infant faces.

        7. Approximately one month later, at a comparable time in the menstrual cycle, the basic
           procedure will be repeated for each subject, except that those who received intranasal
           oxytocin will be given placebo, and vice versa.

      Visit 3A&B: 8-9 Months Postpartum - Brain Response

        1. Three months after the first behavioral response session, each parent will attend two
           scanning sessions at the Human Neuroimaging Laboratory, Baylor College of Medicine.
           Intranasal oxytocin or placebo will again be administered as described above. Infant
           face images from Visit 3A will be used in Visit 4A scanning session, and Visit 3B with
           4B, to ensure that the repeat scanning session uses comparable but unique face images.
           The images from both sessions will be matched on degree of facial affect. Prior to
           intranasal drug administration on the first scanning visit, the parent(s) will complete
           the Positive and Negative Affect States (PANAS) questionnaire.

        2. During the waiting period, the parent(s) will complete questionnaires.

        3. Fifty minutes after the administration of the nasal spray, the parent(s) will
           participate in the functional MRI scanning session, passively viewing a series of unique
           infant face images and hearing cries of her own infant and of an unknown infant. Using
           an event-related fMRI design, randomly presented images will be viewed for 2 seconds,
           with a random inter-stimulus interval of 2, 4 or 6 seconds (Fig 3). The 60 images will
           be equally divided into 3 affect groups - happy, neutral or sad, with the intensity of
           happy and sad affect balanced between the "own" and "unknown" faces. The order of the
           images from each of the 6 groups (OH, ON, OS, UH, UN, US) will be pseudo-randomized
           within the run, but not between subjects.

        4. All imaging will be performed using a 3 Tesla Siemens MRI scanner. Visual images will be
           generated using a LCD projector, and presented to the parent(s) via an overhead mirror
           display. Regional brain activation will be assessed by measuring changes in
           blood-oxygen-level-dependent functional MRI signal (BOLD-fMRI).

        5. Subjects will participate in a single whole-brain functional run of around 185 scans
           each.

        6. High-resolution T1-weighted structural images will then be acquired.

        7. After the scanning session, each parent will be asked to rate each of the infant face
           images on how they thought the infant was feeling, as well as their own feelings of
           pleasure or arousal, using an adaptation of the Self-Assessment Manikin.

      b. After the parent(s) has completed the questionnaires, 2 out of 4 randomly selected modules
      of the Bayley Scales of Infant Development screener will be completed with the infant.

      c. The parent(s) will then rejoin their infant to participate in a videotaped "free play"
      interaction on the floor for 3 minutes. The recording will later be coded for dyadic
      interactions using a 14-point sensitivity scale in the CARE-Index.
    

Intervention name(s): Intranasal Oxytocin; Placebo; Functional MRI scanning
Intervention type(s): Drug; Drug; Procedure
Intervention description(s): Intranasal oxytocin (24IU) given 50 minutes prior to behavior assessment or scanning; Intranasal placebo spray given 50 minutes prior to behavior assessment or scanning; All study participants underwent two functional MRI scanning visits. On one occasion this was after receiving an intranasal dose of oxytocin; on the other occasions, after receiving intranasal placebo dose.
Other intervention name(s): Syntocinon
Intervention MeSH terms: Oxytocin
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Basic Science