Interactive coordination of currently depressed inpatient mothers and their infants during the postpartum period

The effect of antepartum depressive and anxiety symptoms on mother-infant interaction: The mediating role of antepartum maternal emotional stress

Anxiety disorders, depression, and emotional stress during the antepartum period are interlinked with adverse child development. The quality of the dyadic interaction seems to play a crucial role in the transmission of these effects. In this study, we explored the mediating effect of antepartum maternal emotional stress (assessed via the Prenatal Emotional Stress Index) regarding the relationship of antepartum maternal depressive (assessed via the Edinburgh Postpartum Depression Scale), anxiety symptoms (assessed via the Stat-Trait-Anxiety-Inventory), and depressive and anxiety disorders (assessed according to the DSM-IV-TR) in the antepartum period on postpartum interactive quality in a longitudinal design. The Face-to-Face-Still-Face Paradigm (FFSF) and the Infant and Caregiver Engagement Phases (ICEP-R) coding system were used to assess the postpartum interactive qualities of the mother-infant dyads. The sample consisted of 59 women, 38 in the clinical and 21 in the control group. We found significant indirect effects of antepartum depressive symptoms and maternal diagnostic status on the mother's neutral engagement and on the latency to the first social positive interactive match during the interaction - effects that were mediated by antepartum stress. Moreover, there was an indirect effect of state anxiety on neutral engagement - mediated by antepartum stress. Therapeutic intervention studies focusing on maternal antepartum regulation of emotional stress and postpartum interactive patterns might be crucial to encounter maladaptive developmental trajectories.

Maternal postpartum anxiety and the development of infant attachment: The effect of body sensations on infant attachment

BACKGROUND

Knowledge about the influences of maternal postpartum anxiety disorders (PAD) on infant development is limited. Aim of this present study is to evaluate the influence of PAD on infant attachment.

METHODS

In a longitudinal study, self-reported anxiety symptoms of N = 70 mothers (N = 28 with PAD diagnosed according to the DSM-IV, N = 42 controls) were examined in the postpartum period and one year later. Infants' attachment was observed in the Strange Situation Test (SST) at the age of 12-24 months.

RESULTS

Results indicate a strong relationship between PAD and infant attachment: infants of mothers with PAD were significantly more likely to be classified as insecure or disorganized than infants of control mothers. Logistic regression analysis led to a significant model with 76.8 % correct classification of infant attachment dependent on the maternal fear of anxiety associated body sensations (OR = 4.848) in the postpartum period. Including maternal sensitivity and interaction behavior, only maternal intrusiveness was additionally associated with infant attachment (ρ = 0.273, p < .05; OR = 45.021, p = .153).

LIMITATIONS

Participants were highly educated. Different anxiety disorders included led to a heterogenous sample. Generalization is diminished. Maternal sensitivity was measured on a global scale, and body tension was self-reported.

CONCLUSIONS

PAD plays a crucial role in the development of infant attachment. Interaction-focused interventions, helping mothers to decrease intrusiveness, and body-focused interventions, helping mothers to deal with their fear of anxiety symptoms, might be promising pathways to buffer the influence of PAD on infant attachment.

[Parental Mentalization and Early Parent-Child Interaction in Mothers with Affective Disorders or Borderline Personality Disorder: A Systematic Review]

The ability to mentalize is central in the context of the parent-child relationship.The parental competence to see the child'smental state as an independent individual is an essential prerequisite for perceiving and interpreting child signals appropriately.These abilities are crucial but not always available under elevated stress levels when confronted with a child's affects and parenting challenges. Despite the clinical and conceptual relevance of mentalization with borderline personality disorder (BPD) and affective disorders, the subject has rarely been systematically addressed in parents.This review provides a systematic overview of parental mentalization in mothers with affective disorders or BPD and its impact on the quality of maternal interactive behaviour. The findings generally revealed a negative association between mothers' parental mentalization and depression or BPD, which varied greatly depending on the mentalization constructs. Both psychiatric diagnosis and current severity of symptoms were found to be relevant. However, some positive aspects of mentalization were not markedly impaired. Further, a lowermentalizing abilitywas associatedwith reduced sensitive behaviour in depressedmothers. The results contribute to a better understanding of the association between mentalization and maternal psychopathology and help refine early interventions in parent-child settings.

From Early Micro-Temporal Interaction Patterns to Child Cortisol Levels: Toward the Role of Interactive Reparation and Infant Attachment in a Longitudinal Study

Parental mental disorders increase the risk for insecure attachment in children. However, the quality of caregiver–infant interaction plays a key role in the development of infant attachment. Dyadic interaction is frequently investigated via global scales which are too rough to uncover micro-temporal mechanisms. Prior research found that the latency to reparation of uncoordinated dyadic states is associated with infant behavioral and neuroendocrine regulation. We investigated the hypothesis that this interactive mechanism is critical in predicting secure vs. insecure attachment quality in infancy. We also assessed the predictive quality of infant attachment regarding neuroendocrine reactivity later in childhood. A subsample of N = 58 dyads (n = 22 mothers with anxiety disorders, n = 36 controls) from a larger study were analyzed. At 3–8 months postpartum, maternal anxiety disorders were diagnosed via a structured clinical interview as well as dyadic interaction during the Face-to-Face-Still-Face (FFSF) was observed and coded on a micro-temporal scale. Infant attachment quality was assessed with the strange situation paradigm at 12–24 months of age. In an overlapping subsample of N = 39 (n = 13 mothers with anxiety disorder; n = 26 controls), we assessed child cortisol reactivity at 5 to 6 years of age. Generalized linear modeling revealed that longer latencies to interactive reparation during the reunion episode of the FFSF as well as maternal diagnosis at 3–8 months of age predict insecure attachment in children aged 12–24 months. Cox regressions demonstrated that dyads with infants who developed insecure attachment at 12–24 months of age were 48% less likely to achieve an interactive reparation at 3–8 months of age. Mixed models revealed that compared to securely attached children, children who had developed an insecure attachment at 12–24 months of age had an increased cortisol reactivity at 5 to 6 years of age during free play. The results confirm the hypothesis that the development of attachment is affected by experienced micro-temporal interactive patterns besides diagnostic categories. They also showed that infants of mothers with postpartum anxiety disorders have a more than fivefold increased risk of developing an insecure attachment than the infants of the control group. Moreover, results imply that these patterns may influence neurohormonal regulation even in preschool aged children.

Theory of Mind in Pre-school Aged Children: Influence of Maternal Depression and Infants' Self-Comforting Behavior

A milestone of child development is theory of mind (ToM): the ability to attribute mental states, especially beliefs and desires, to other persons and to understand that their behavior is guided by mental states. The learning process about the mental world also takes place in social communication and interaction, beginning in infancy. Infancy is assumed to be a sensitive period for the development of social skills through interaction. Due to limited self-regulatory skills, infants depend on sensitive behavior of their caregivers to regulate affective states and physiological arousal, and in turn, mutually regulated affects allow the infant to gradually acquire the capability to self-regulate negative affective states. Effective and adequate affect regulation is an important prerequisite for environmental interaction and thus for the development of socio-emotional skills. The present study investigated the relation of self-regulatory abilities in infancy and later ToM in pre-school aged children of clinically depressed mothers and healthy controls. The sample comprised of N = 55 mother-child dyads, n = 22 diagnosed with postpartum or lifetime depression according to DSM-IV and n = 33 healthy controls. Mother-infant-interaction was videotaped during the Face-to-Face Still-Face paradigm. At 3 and 42 months postpartum mothers were interviewed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to evaluate maternal psychopathological status according to DSM-IV. At the age of M = 4.0 years, children's ToM abilities were assessed using content-false-belief and location-false-belief tasks. The results of this study show that contrary to our hypotheses, maternal depression did not impair the development of children's ToM-abilities per se. Rather, an interaction effect highlights the role of infant's self-comforting behavior during mother-infant interaction in infancy (3 months postpartum) for ToM-development at pre-school age assessed with the Maxi-task; this association was distinct for female in comparison to male children. The results of this longitudinal study shed light on the discussion, how maternal depression influences child development and point in the direction that self-comforting behaviors in infancy can also be seen as a resource.

Effectiveness of psychological interventions in the treatment of perinatal depression: A systematic review of systematic reviews and meta-analyses

BACKGROUND

Perinatal depression is a high prevalent mental health problem with serious consequences. Evidence about effective psychological interventions in treating perinatal depression has been increasing, but it lacks a comprehensive synthesis of findings.

METHODS

A systematic review of systematic reviews and meta-analyses concerning the effectiveness of psychological interventions in treating perinatal depression (depression during pregnancy and the first 12 months postpartum) in adult women was conducted. The electronic databases MEDLINE (PubMed), PsycINFO, The Cochrane Library, Web of Science and Prospero were searched, on May 2020, using a combination of keywords. Data were independently extracted by two authors and a synthesis of the results was presented. Methodological quality was independently assessed by two authors, using AMSTAR-2.

RESULTS

Seven systematic reviews were included and reported, overall, the effectiveness of psychological interventions in decreasing depressive symptoms in women in the perinatal period, both short and long-term. CBT was found to be the most effective intervention, regardless of the treatment format.

LIMITATIONS

Grey literature was not searched, and some studies may overlap among the included systematic reviews. These (the included reviews) were rated with low methodological quality, which weakens the evidence of the reported results.

CONCLUSIONS

CBT is currently the most evidence-based psychological intervention, provided in different delivery formats (individual, group, face-to-face or Internet-based). Further studies, including systematic reviews, with other types of psychological interventions (e.g., third-wave CBT) and with higher quality are needed.

Maternal Anxiety Symptoms and Self-Regulation Capacity Are Associated With the Unpredictability of Maternal Sensory Signals in Caregiving Behavior

The unpredictability of maternal sensory signals in caregiving behavior has been recently found to be linked with infant neurodevelopment. The research area is new, and very little is yet known, how maternal anxiety and depressive symptoms and specific parental characteristics relate to the unpredictable maternal care. The aims of the current study were to explore how pre- and postnatal maternal anxiety and depressive symptoms and self-regulation capacity associate with the unpredictability of maternal sensory signals. The study population consisted of 177 mother-infant dyads. The unpredictability of the maternal sensory signals was explored from the video-recorded mother-infant free play situation when the infant was 8 months of age. Pre- and postnatal anxiety and depressive symptoms were measured by questionnaires prenatally at gwks 14, 24, 34, and 3 and 6 months postpartum. Maternal self-regulation capacity, a trait considered to be stable in adulthood, was assessed using adult temperament questionnaire when the infant was 12 months of age. We found that elevated prenatal maternal anxiety symptoms associated with higher unpredictability in the maternal care while depressive symptoms were unrelated to the unpredictability of maternal care. Moreover, the association was moderated by maternal self-regulation capacity, as higher anxiety symptoms during pre-and postnatal period were associated more unpredictability among the mothers with low self-regulation capacity. The combination of higher amount of maternal anxiety symptoms and lower self-regulation capacity seems to constitute specific risk for the unpredictable maternal care.

Postnatal depression and its association with adverse infant health outcomes in low- and middle-income countries: a systematic review and meta-analysis

Background

Postnatal Depression (PND) is a mood disorder that steals motherhood and affects the health and development of a newborn. While the impact of PND on motherhood and newborn in developed countries are well described, its epidemiology and health consequences in infant is not well known in middle-and low-income countries. The objective of this review was to determine the burden and association of PND with adverse infant health outcomes in low-and middle- income countries.

Methods

We searched observational studies written in the English language and conducted in middle-and low-income countries between December 1st, 2007, and December 31st, 2017. The CINHAL, MEDLINE, Emcare, PubMed, Psych Info, and Scopus databases were searched for the following search terms: PND, acute respiratory infection, pneumonia, diarrhea, exclusive breastfeeding, common infant illnesses, and malnutrition. We excluded studies in which the primary outcomes were not measured following a standardized approach. We have meta-analyzed the estimates from primary studies by adjusting for possible publication bias and heterogeneity. The analysis was conducted in Stata 14. The study was registered in PROSPERO protocol number CRD42017082624.

Result

Fifty-eight studies on PND prevalence (among 63,293 women) and 17 studies (among 32,454 infants) on infant health outcomes were included. PND prevalence was higher in the low-income countries (Pooled prevalence (PP) = 25.8%; 95%CI: 17.9–33.8%) than in the middle-income countries (PP = 20.8%; 95%CI: 18.4–23.1%) and reached its peak in five to ten weeks after birth. Poor obstetric history and social support, low economic and educational status, and history of exposure to violence were associated with an increased risk of PND. The risk of having adverse infant health outcomes was 31% higher among depressed compared to non-depressed postnatal mothers (Pooled relative risk (PRR) = 1.31; 95%CI: 1.17–1.48). Malnutrition (1.39; 1.21–1.61), non-exclusive breastfeeding (1.55; 1.39–1.74), and common infant illnesses (2.55; 1.41–4.61) were the main adverse health outcomes identified.

Conclusions

One in four and one in five postnatal mothers were depressed in low and middle-income countries, respectively. Causes of depression could be explained by social, maternal, and psychological constructs. High risk of adverse infant health outcomes was associated with PND. Timely screening of PND and evidence-based interventions were a pressing need in low and middle-income countries.

Maternal prenatal depression, PTSD, and problematic parenting: the mediating role of maternal perceptions of infant emotion

Background: Perinatal illness is alarmingly common and has negative effects on maternal and infant well-being. Depression and posttraumatic stress disorder (PTSD), specifically, are characterised by negative views of the self and others, which may impact a mother's perceptions of herself and her child. Objective: This study examined the relationship between depression and PTSD symptoms, maternal perceptions of infant emotions, and parenting behaviours. Methods: 120 pregnant, mostly low-income women and their infants (after birth) participated in a longitudinal study. Maternal depression and PTSD symptoms were assessed during pregnancy and 1 year postpartum; maternal perceptions of infant emotions and parenting quality were assessed at 1 year. Results: Correlation analyses revealed significant, negative associations between prenatal (but not postnatal) psychiatric symptoms and positive perceptions of infant emotions, as well as between positive perceptions of infant emotions and negative parenting. Results also revealed significant indirect effects of prenatal depressive and PTSD symptoms on negative parenting via perceptions of infant emotion (95% CIs:.0013 -.0200 and.0008 -.0083, respectively). Conclusion: Findings highlight that mothers should be routinely screened for psychiatric symptoms during the perinatal period, and perceptions of infant emotions may be an important target for parent-infant mental health interventions.

Rethinking Intrusiveness: Exploring the Sequential Organization in Interactions Between Infants and Mothers

To date, studies investigating maternal postpartum depression (PPD) have mainly focused on identifying failures in interactions of postpartum depressed mothers and their infants, often attributed to single dysfunctional maternal behaviors. Intrusiveness has been identified as a dysfunctional behavior characterizing mothers suffering from PPD. However, this research does not consider the co-constructed and sequential nature of social interactions, in which single behaviors cannot be conceived as isolated or disconnected units. The aim of the work presented in this paper was to explore the interactional dynamics underlying maternal behaviors previously identified as intrusive by mainstream literature on postpartum depression. Through a conversation analytical approach, we analyzed filmed interactions between mothers with and without postpartum depression and their 3-months-old infants. The analyses of 4 selected episodes illustrate similar dyadic activities, yet presenting different levels of mutuality and affective attunement. Results showed two normative features of social interactions that contributed to the different quality in the mutual adjustment of the partners: interactional rhythm and preliminaries. Interactional rhythm refers to the structuring of infants' spontaneous activity into a turn sequence, whereas preliminaries consist of verbal or nonverbal moves that anticipate following action. As evident from our analytical observations, what seems to be hindering the mutual coordination (previously labeled as “intrusive”) is not based on specific individual behaviors but on the absence or violation of such interactional norms. Adopting an interactive and dynamical framework, we shifted the focus from maternal behaviors considered as dysfunctional to observing the unfolding of interactional aspects contributing to better or poorer sequential structuring. We argue that these aspects shape the possibilities for the infant's participation. Finally, we discuss the theoretical and methodological implications of adopting a conversation analytical approach for a better understanding of the relational dynamics related to clinical and non-clinical interactions.

The NeMo real-time fMRI neurofeedback study: protocol of a randomised controlled clinical intervention trial in the neural foundations of mother-infant bonding

INTRODUCTION

Most mothers feel an immediate, strong emotional bond with their newborn. On a neurobiological level, this is accompanied with the activation of the brain reward systems, including the striatum. However, approximately 10% of all mothers report difficulties to bond emotionally with their infant and display impaired reward responses to the interaction with their infant which might have long-term negative effects for the child's development. As previous studies suggest that activation of the striatal reward system can be regulated through functional MRI (fMRI)-based neurofeedback (NFB), we have designed and investigate fMRI-NFB training to treat maternal bonding difficulties.

METHODS AND ANALYSIS

In the planned trial, mothers will be presented pictures of their infant and real-time fMRI (rtfMRI), peripheral measures, neural, endocrine, psychophysiological and behavioural measures will be assessed. Mothers with bonding difficulties (n=68) will be randomised to one of two double-blind intervention groups at 4-6 months postpartum. They will participate in three repeated NFB training sessions with rtfMRI-NFB training to increase activation of (a) the ventral striatum or (b) the anterior cingulate. Interview data and real-time mother-infant interaction behaviour pre-intervention, post-intervention and at follow-up will serve as clinical outcome measures.

ETHICS AND DISSEMINATION

Study procedures are in line with the recommendations of the World Medical Association (revised Declaration of Helsinki) and were approved by the Ethics Committee of the Medical Faculty, s-450/2017, Heidelberg University. All participants will provide written informed consent after receiving a detailed oral and written explanation of all procedures and can withdraw their consent at any time without negative consequence. Results will be internationally published and disseminated, to further the discussion on non-pharmacological treatment options in complex mental disorders.

TRIAL REGISTRATION NUMBER

DRKS00014570; Pre-results.

Childhood experiences of maltreatment, reflective functioning and attachment in adolescent and young adult mothers: Effects on mother-infant interaction and emotion regulation

BACKGROUND

Maternal childhood experiences of maltreatment affect parenting and have consequences for a child's social-emotional development. Adolescent mothers have a higher frequency of a history of maltreatment than adult mothers. However few studies have analyzed the interactions between adolescent mothers with a history of childhood maltreatment and their infants.

OBJECTIVE

The aim of the study was to examine the effect of maternal childhood experiences of maltreatment on mother-infant emotion regulation at infant 3 months, considering both infant and mother individual emotion regulation and their mutual regulation.

PARTICIPANTS

Participants were 63 adolescent and young adult mother-infant dyads recruited at a hospital.

METHODS

The mothers were administered the Adult Attachment Interview to evaluate reflective functioning and attachment and the Childhood Experiences of Care and Abuse was used to evaluate maternal childhood experiences of maltreatment. Mother-infant interactions were coded with a modified version of the Infant Caregiver Engagement Phases.

RESULTS

Dyads with mothers with childhood maltreatment (vs dyads with mothers with no maltreatment) spent more time in negative emotional mutual regulation (p = .009) and less time in positive and neutral mutual emotion regulation (p = .019). Cumulative maternal childhood experiences of maltreatment were associated positively with mother and infant negative states at individual and dyadic level and with the AAI scales of Passivity and Unresolved Trauma (p < .05). The effect of cumulative maternal childhood experiences of maltreatment on mother-infant emotion regulation was direct and not mediated by maternal attachment and reflective function.

CONCLUSIONS

Maternal childhood experiences of maltreatment increase the risk connected to early motherhood, affecting mother-infant emotion regulation.

The impact of maternal anxiety disorder on mother-infant interaction in the postpartum period

Background

This study investigated whether postpartum anxiety disorder is associated to altered patterns of infant as well as maternal engagement in a Face-to-Face-Still-Face interaction (FFSF).

Sampling and methods

n = 39 women with postpartum DSM-IV anxiety disorder and n = 48 healthy mothers were videotaped during a FFSF with their infant (M = 4.1 months).

Results

Infants of the clinical group showed significantly less positive engagement during the play episode than infants of controls. This result depended on infant sex: male controls demonstrated more positive interaction than males of anxious mothers. There was no such effect for female infants who engaged significantly less positively during the play episode than males and did not change their positive engagement during the FFSF. These findings imply pronounced interactive positivity and early vulnerability to maternal anxiety symptoms in male infants. Only the infants of the controls showed the still-face effect. They also protested significantly more during the still-face, while the clinical infants’ protest increased significantly during the reunion. Women of both groups did not differ in their interaction. Maternal intrusiveness was associated to infant protest in the course of the FFSF.

Conclusions

Results suggest that mother-infant intervention should consider affect regulation and infant sex-specific characteristics in anxious mother-infant dyads.

Longitudinal relations among maternal depressive symptoms, maternal mind-mindedness, and infant attachment behavior

The relations among maternal depression risk, maternal mind-mindedness, and infants' attachment behavior were longitudinally examined in a community sample of mother-infant dyads. Maternal self-reported depression risk was measured at the infant ages of 6 weeks, 4 months, and 12 months. Maternal mind-mindedness, assessed from mothers' comments about infants' mental states (e.g., infants' thoughts, desires, or emotions), was measured during mother-infant interactions when infants were 4 months. Infants' attachment behavior was assessed at one year. Mothers' depression risk decreased over the infants' first year, with the sharpest decline between 6 weeks and 4 months. Mothers at risk for depression when infants were 6 weeks showed less appropriate mind-mindedness at 4 months. Mind-mindedness was not related to maternal depression risk at the infant age of 4 months or 12 months. Infants' degree of disorganized attachment behavior at one year was positively associated with maternal depression risk at 6 weeks and negatively associated with maternal appropriate mind-mindedness at 4 months. Mothers who are at risk for depression in their infants' early lives may be hampered in their capacity to respond appropriately to their infants' mental states. Infants with mothers who have difficulty responding appropriately to their mental states, as suggested by low appropriate mind-mindedness, may feel less known and recognized by their mothers, a key theme in the origins of disorganized attachment.

Disentangling the Dyadic Dance: Theoretical, Methodological and Outcomes Systematic Review of Mother-Infant Dyadic Processes

Background: During the last decades, the research on mother-infant dyad has produced a great amount of data, methods and theories, which largely contributed to set a revolution in the way we look at developmental changes during infancy and childhood. Very different constructs depict the different aspects of the "dyadic dance" occurring between a mother and her infant; nonetheless, a comprehensive and consistent systematization of these concepts in a coherent theoretical landscape is still lacking. Aim: In the present work, we aim at disentangling the different theoretical and methodological definitions of 9 dyadic constructs and we highlight their effects on infants' and children developmental outcomes. Methods: A literature search has been conducted on three databases-PubMed, Scopus, Web of Science. Three different reviews are reported here: (1) a review on the theoretical definitions of dyadic constructs; (2) a review of operational definitions, settings and methods of dyadic processes; (3) a systematic review of dyadic processes' outcomes for infants' and children developmental trajectories. Results: Two constructs emerged as wide meta-theoretical concepts (reciprocity and mutuality) and seven described specific processes (attunement, contingency, coordination, matching, mirroring, reparation, synchrony). A global model resuming the relationships among different processes is reported, which highlights the emergence of two specific cycles of dyadic functioning (i.e., matching-mismatching-reparation-synchrony; contingency, coordination, attunement, mirroring). A comprehensive review of the adopted measures is also provided. Finally, all the processes provided significant contributions to infants' behavioral, cognitive, and socio-emotional development during the first 3 years of age, but limited research has been conducted on specific processes (e.g. reparation and mirroring). Conclusion: The present study provides an original research-grounded framework to consider the different nature of mother-infant dyadic processes within a unified dyadic eco-system. Different levels of evidence emerged for the role of diverse mother-infant dyadic processes on infants' and children development. Open questions and future research directions are highlighted.

Maternal avoidance, anxiety cognitions and interactive behaviour predicts infant development at 12 months in the context of anxiety disorders in the postpartum period

BACKGROUND

Few studies have examined the relation between anxiety disorders in the postpartum period and cognitive as well as language development in infancy.

AIMS

This longitudinal study investigated whether anxiety disorder in the postpartum period is linked to infant development at twelve months. A closer look was also taken at a possible link between maternal interaction and infant development.

STUDY DESIGN

Subjects were videotaped during a Face-to-Face-Still-Face interaction with their infant (M = 4.0 months). Specific maternal anxiety symptoms were measured by self-report questionnaires (Anxiety Cognition Questionnaire (ACQ), Body Sensations Questionnaire (BSQ), Mobility Inventory (MI)) to check for a connection with infant development. The Bayley Scales of Infant and Toddler Development-III (Bayley-III) were used to assess infant language and cognitive development at one year of age.

SUBJECTS

n = 34 mothers with anxiety disorder (SCID-I; DSM-IV) and n = 47 healthy mothers with their infant.

OUTCOME MEASURES

Infant performance on Bayley-III language and cognitive scales.

RESULTS

Infants of mothers with anxiety disorder yielded significantly lower language scores than infants of controls. No significant group differences were found regarding infant cognitive development. Exploratory analyses revealed the vital role of "maternal avoidance accompanied" in infant language and cognitive development. Maternal neutral engagement, which lacks positive affect and vocalisations, turned out as the strongest negative predictor of cognitive development. Maternal anxiety cognitions and joint activity in mother-infant interaction were the strongest predictors of infant language performance.

CONCLUSIONS

Results underline the importance to also consider the interaction behaviour of women with anxiety disorders to prevent adverse infant development.

Protocol for the Northern babies longitudinal study: predicting postpartum depression and improving parent-infant interaction with The Newborn Behavioral Observation

INTRODUCTION

Postpartum depression (PPD) is a prevalent disorder. Studying the factors related to PPD will help to identify families at risk and provide preventive interventions. This can in turn improve the developmental trajectories for the children. Several previous studies have investigated risk factors for PPD. However, few studies have focused on cognitive vulnerability factors. The first aim of the present study is to explore a range of protective and risk factors, including cognitive factors, for PPD, parent-infant interactions and child development. The second aim of the study is to evaluate the effectiveness of The Newborn Behavioral Observation (NBO) as a universal preventive intervention delivered in routine practice. The NBO is a brief relationship-enhancing intervention that may reduce depressive symptomatology in mothers.

METHODS

The study is a longitudinal observational study with an intervention. The observational study uses a prospective cohort design, whereas the intervention study has a non-randomised cluster-controlled design comparing a group receiving NBO with a group receiving standard care. The intervention group will receive three NBO sessions within the first 4 weeks postdelivery. Between 2015 and 2018, approximately 200 families will be recruited in the municipality of Tromsø, Norway. Parents are recruited during pregnancy, and assessments will be performed during gestational weeks 16-22, 24-30 and 31, and at 6 weeks, 4 months and 6 months postdelivery. Predictor variables include several cognitive vulnerability factors including early maladaptive schemas, implicit attitudes and cognitive processing of emotionally valenced infant facial information.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research Ethics in Northern Norway has approved the project. The research team has collaboration with local health services and can assist participants who need more extensive follow-up. Results from the project will be disseminated in international and national peer-reviewed journals, and at courses and conferences.

TRIALS REGISTRATION NUMBER

NCT02538497; Pre-results.

Association between maternal postnatal depressive symptoms and infants' communication skills: A longitudinal study

Postnatal depression (PND) is associated with adverse effects on a broad range of child outcomes, including language problems. The current study aimed to investigate if the time of exposure to maternal PND symptoms measured with the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks, 4 months and 6 months postpartum were related to the infants' communication skills measured with the Ages and Stages Questionnaires (ASQ) at 12 and 24 months. Secondly, to study to what extent the number of exposures to high level of PND symptoms (i.e., EPDS score≥10) might be associated with level of communication skills later (at 12 and 24 months), and last, to determine to what extent maternal PND symptoms at 6 weeks were related to changes in the developmental course of communication skills from 4 to 24 months. 1555 children and their mothers participate in the study. Regression analyses indicated that PND at 4 months were associated with lower levels of communicative skills at 12 (coefficient -0.37, 95% CI -0.63 to -0.12, p=0.004) and 24 months (coefficient -0.34, CI -0.56 to -0.13, p=0.002). Infants of mothers with an EPDS sum score≥10 obtained at a minimum of two time points, had significantly worse communicative skills at 12 months than infants of mothers with no indication of PND (difference -6.12, CI -11.14 to -1.09, p=0.017). No such significant relations were found at 24 months. However, linear mixed effects analysis showed that mothers' depressive symptoms at 6 weeks were not significantly related to changes in infant communication scores from age 4 to 24 months. These findings suggest that symptoms of maternal PND symptoms should be taken into account for communication development in infancy.

Perceived parenting stress in the course of postpartum depression: the buffering effect of maternal bonding

Research investigating maternal bonding and parenting stress in the course of postpartum depression is lacking. Aim of the study was to investigate the development and potential mediation of both constructs in the course of postpartum depression. n = 31 mothers with postpartum depression according to DSM-IV and n = 32 healthy controls completed the German version of the Postpartum Bonding Questionnaire and the Parenting Stress Index at two measuring times: acute depression (T1) and remission (T2). At T1, the clinical group reported lower bonding and higher parenting stress. Bonding was found to partially mediate the link between maternal diagnosis and parenting stress. Furthermore, the clinical group reported lower bonding and higher parenting stress averaged over both measurement times. However, at T2, the clinical group still differed from the controls even though they improved in bonding and reported less parenting stress. A significant increase of bonding was also observed in the control group. Maternal bonding seems to buffer the negative impact of postpartum depression on parenting stress. The results emphasize the need for interventions focusing on maternal bonding and mother-infant interaction in order to prevent impairment of the mother-child relationship.

Effectiveness of an Attachment-Based Intervention Program in Promoting Emotion Regulation and Attachment in Adolescent Mothers and their Infants: A Pilot Study

This pilot study examined the effectiveness of an attachment-based intervention program, PRERAYMI, based on video technique, psychological counseling and developmental guidance in improving the style of interaction and emotion regulation of adolescent mothers and their infants after 3 and 6 months of intervention. Analyses revealed that adolescent mothers who participated in the intervention (vs. control group adolescent mothers) increased their Sensitivity and reduced their Controlling style after both 3 and 6 months of treatment. Infants who participated in the intervention (vs. control group infants) increased their Cooperative style and reduced their Passive style from 3 to 9 months. Moreover, the intervention group dyads (vs. control group dyads) increased the amount of time spent in affective positive coordination states (matches), decreased the amount of time spent in affective mismatches, and had a greater ability to repair mismatches from 3 to 9 months. Furthermore, the intervention group dyads (vs. control group dyads) increased the amount of time spent in reciprocal involvement in play with objects from 3 to 9 months. The quality of maternal attachment did not affect the intervention effect.

Effects of Maternal Anxiety Disorders on Infant Self-Comforting Behaviors: The Role of Maternal Bonding, Infant Gender and Age

BACKGROUND/AIMS

We investigated the links between maternal bonding, maternal anxiety disorders, and infant self-comforting behaviors. Furthermore, we looked at the moderating roles of infant gender and age.

METHODS

Our sample (n = 69) comprised 28 mothers with an anxiety disorder (according to DSM-IV criteria) and 41 controls, each with their 2.5- to 8-month-old infant (41 females and 28 males). Infant behaviors were recorded during the Face-to-Face Still-Face paradigm. Maternal bonding was assessed by the Postpartum Bonding Questionnaire.

RESULTS

Conditional process analyses revealed that lower maternal bonding partially mediated between maternal anxiety disorders and increased self-comforting behaviors but only in older female infants (over 5.5 months of age). However, considering maternal anxiety disorders without the influence of bonding, older female infants (over 5.5 months of age) showed decreased rates of self-comforting behaviors, while younger male infants (under 3 months of age) showed increased rates in the case of maternal anxiety disorder.

CONCLUSIONS

The results suggest that older female infants (over 5.5 months of age) are more sensitive to lower maternal bonding in the context of maternal anxiety disorders. Furthermore, results suggest a different use of self-directed regulation strategies for male and female infants of mothers with anxiety disorders and low bonding, depending on infant age. The results are discussed in the light of gender-specific developmental trajectories.

Mother-Infant Emotion Regulation at Three Months: The Role of Maternal Anxiety, Depression and Parenting Stress

BACKGROUND

While the association between anxiety and postpartum depression is well known, few studies have investigated the relationship between these two states and parenting stress. Furthermore, a number of studies have found that postpartum depression affects mother-infant emotion regulation, but there has been only one study on anxiety and emotion regulation and no studies at all on parenting stress and emotion regulation. Therefore, the primary aim of our study is to identify, in a community sample of 71 mothers, the relationship between maternal depression, anxiety, and parenting stress. The second aim is to examine the relationship between anxiety, postpartum depression, and parenting stress and mother-infant emotion regulation assessed at 3 months.

METHODS

Mother-infant interaction was coded with a modified version of the Infant Caregiver and Engagement Phases (ICEP) using a microanalytic approach. The Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), and Parenting Stress Index-Short Form (PSI-SF) were administered to the mothers to assess depression, anxiety, and parenting stress, respectively.

RESULTS

Analysis revealed correlations between anxiety and depression, showing that parenting stress is associated with both states. In a laboratory observation, depression was correlated with both negative maternal states and negative dyadic matches as well as infant positive/mother negative mismatches; anxiety was correlated with both negative maternal states and infant negative states as well as mismatches involving one of the partners having a negative state. Multiple regression analysis showed that anxiety is a greater predictor than depression of less adequate styles of mother-infant emotion regulation. Parenting stress was not shown to predict such regulation.

Maternal Emotional Availability and Its Association with Maternal Psychopathology, Attachment Style Insecurity and Theory of Mind

BACKGROUND/AIMS

High maternal emotional availability (EA) positively affects various domains of child development. However, the question of which factors promote or hinder maternal EA has not been investigated systematically. The present study investigated several maternal characteristics, namely maternal psychopathology, maternal attachment style insecurity, and theory of mind (ToM) as possible factors that influence maternal EA.

METHODS

The sample was comprised of 56 mothers and their preschool-aged children. Half of the mothers were diagnosed with postpartum depression and or anxiety disorders according to DSM-IV, and the other half were healthy controls.

RESULTS

The results showed that both low maternal attachment style insecurity and high ToM skills significantly predicted maternal EA sensitivity, independently from maternal postpartum and concurrent psychopathology and education. Moreover, maternal attachment style insecurity fully mediated the link between maternal postpartum psychopathology and sensitivity.

CONCLUSION

The findings suggest that maternal attachment style security can buffer negative effects of maternal psychopathology on maternal sensitivity in the mother-child interaction.

The impact of postpartum depression and anxiety disorders on children's processing of facial emotional expressions at pre-school age

To enhance understanding of impaired socio-emotional development in children of postpartum depressed or anxious mothers, this longitudinal study addressed the question of whether maternal postpartum depression and anxiety disorders result in deficits in children's processing of facial emotional expressions (FEEs) at pre-school age. Thirty-two mothers who had fulfilled Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for postpartum depression and/or anxiety disorder and their pre-school aged children were tested for FEE processing abilities and compared to a healthy control group (n = 29). Child assessments included separate tasks for emotion recognition and emotion labelling. Mothers completed an emotion recognition test as well as the Structured Clinical Interview for DSM-IV Axis I Disorders I (SCID-I). Children of postpartum depressed and/or anxious mothers performed significantly worse than control children at labelling, but not at recognizing facial expressions of basic emotions. Emotion labelling at pre-school age was predicted by child age and maternal postpartum mental health, but neither current maternal mental health nor current maternal emotion recognition was associated with child FEE processing. Results point to a specific importance of early social experiences for the development of FEE labelling skills. However, further studies involving sensitive measures of emotion recognition are needed to determine if there might also exist subtle effects on FEE recognition.

A pilot randomised controlled trial to evaluate the feasibility and acceptability of the Baby Triple P Positive Parenting Programme in mothers with postnatal depression

Few interventions for Postnatal Depression (PND) have focused on parenting difficulties; the aim of this research was to investigate the feasibility and evaluate a parenting intervention (Baby Triple P) in women with PND. This was a pilot randomised controlled trial (RCT) to evaluate and determine the feasibility of the newly developed Baby Triple P compared with treatment as usual (TAU) in women with PND. In all, 27 female participants aged from 18 to 45 years (mean age = 28.4 years, standard deviation (SD) = 6.1), with a primary diagnosis of major depression and an infant under 12 months (mean age = 6.2 months, SD = 3.2 months), were recruited from primary care trusts in Greater Manchester, United Kingdom. Participants were randomly allocated to receive either eight Baby Triple P sessions in addition to TAU or TAU only. Outcomes were assessed at post-treatment (Time 2) and 3 months post-treatment (Time 3). Self-report outcomes were as follows: Beck Depression Inventory, Oxford Happiness Inventory, What Being the Parent of a New Baby is Like, Postpartum Bonding Questionnaire and the Brief Parenting Beliefs Scale-baby version. An assessor-rated observational measure of mother-infant interaction, the CARE Index and measure of intervention acceptability were also completed. Significant improvements from Time 1 to Time 2 and Time 1 to Time 3 were observed across both groups. Although women allocated to Baby Triple P showed more favourable improvements, the between-group differences were not significant. However, the intervention was highly acceptable to women with PND. A large-scale RCT is indicated.

Interventions for postnatal depression assessing the mother-infant relationship and child developmental outcomes: a systematic review

Postnatal depression (PND) has negative effects on maternal well-being as well as implications for the mother–infant relationship, subsequent infant development, and family functioning. There is growing evidence demonstrating that PND impacts on a mother’s ability to interact with sensitivity and responsiveness as a caregiver, which may have implications for the infant’s development of self-regulatory skills, making the infant more vulnerable to later psychopathology. Given the possible intergenerational transmission of risk to the infant, the mother–infant relationship is a focus for treatment and research. However, few studies have assessed the effect of treatment on the mother–infant relationship and child developmental outcomes. The main aim of this paper was to conduct a systematic review and investigate effect sizes of interventions for PND, which assess the quality of the mother–infant dyad relationship and/or child outcomes in addition to maternal mood. Nineteen studies were selected for review, and their methodological quality was evaluated, where possible, effect sizes across maternal mood, quality of dyadic relationship, and child developmental outcomes were calculated. Finally, clinical implications in the treatment of PND are highlighted and recommendations made for further research.

Influence of dyadic matching of affect on infant self-regulation

BACKGROUND/AIMS

Affective behavioural matching during face-to-face interaction fosters the transition from mutual regulation to infant self-regulation. Optimum midrange models of mother-infant interaction hold that moderate degrees of dyadic matching facilitate infant socio-emotional development. The aim of this study was to examine which degree of dyadic matching is most beneficial for infant self-regulation.

METHODS

To evaluate this model, 3 groups of highly, midrange and poorly matched dyads were created from a mixed sample of 68 dyads with healthy and post-partum depressed mothers and their infants (age range = 1-8 months, mean age = 3.9 months). Mother-infant interactions were videotaped in the face-to-face still-face paradigm (FFSF) and micro-analytically coded. Specifically, the relation between affective behavioural matching in FFSF play and infant positive and negative affect in FFSF still face and FFSF reunion was explored.

RESULTS

Contrary to our expectation, we found a monotonous trend for all groups: the more matching in FFSF play, the more positive and less negative affect the infant showed in FFSF still face and FFSF reunion, respectively.

CONCLUSION

The present findings further illuminate the association between different degrees of dyadic matching in early mother-infant interaction and infant self-regulation. Further research should focus on the integration and replication of findings and conceptual approaches to further evaluate and refine the concept of midrange matching and make it applicable to therapeutic work with mothers and their infants.

What Dyadic Reparation Is Meant to Do: An Association with Infant Cortisol Reactivity

BACKGROUND

The latency to reparation of interactive mismatches (interactive repair) is argued to regulate infant distress on a psychobiological level, and maternal anxiety disorders might impair infant regulation.

SAMPLING AND METHODS

A total of 46 dyads (19 mothers with an anxiety disorder, 27 controls) were analyzed for associations between interactive repair and infant cortisol reactivity during the Face-to-Face-Still-Face paradigm 3-4 months postpartum. Missing cortisol values (n = 16) were imputed. Analyses were conducted on both the original and the pooled imputed data.

RESULTS

Interactive repair during the reunion episode was associated with infant cortisol reactivity (original data: p < 0.01; pooled data: p < 0.01) but not maternal anxiety disorder (p > 0.23). Additional stepwise regression analyses found that latency to repair during play (p < 0.01), an interaction between distress during the first trimester of pregnancy and latency to repair during reunion (p < 0.01) and infant self-comforting behaviors during the reunion episode (p = 0.04) made independent contributions to cortisol reactivity in the final regression model.

CONCLUSIONS

This is the first study demonstrating that interactive repair is related to infant psychobiological stress reactivity. The lack of a relation to maternal anxiety disorder may be due to the small sample size. However, this result emphasizes that infants respond to what they experience and not to the maternal diagnostic category.

Motherhood in adolescent mothers: maternal attachment, mother-infant styles of interaction and emotion regulation at three months

Early motherhood is considered a risk factor for an adequate relationship between mother and infant and for the subsequent development of the infant. The principal aim of the study is to analyze micro-analytically the effect of motherhood in adolescence on the quality of mother-infant interaction and emotion regulation at three months, considering at the same time the effect of maternal attachment on these variables. Participants were 30 adolescent mother-infant dyads compared to 30 adult mother-infant dyads. At infant 3 months, mother-infant interaction was video-recorded and coded with a modified version of the Infant Caregiver Engagement Phases and the Adult Attachment Interview was administered to the mother. Analysis showed that adolescent mothers (vs. adult mothers) spent more time in negative engagement and their infants spent less time in positive engagement and more time in negative engagement. Adolescent mothers are also less involved in play with their infants than adult mothers. Adolescent mother-infant dyads (vs. adult mother-infant dyads) showed a greater duration of negative matches and spent less time in positive matches. Insecure adolescent mother-infant dyads (vs. insecure adult mother-infant dyads) demonstrated less involvement in play with objects and spent less time in positive matches. To sum up adolescent mother-infant dyads adopt styles of emotion regulation and interaction with objects which are less adequate than those of dyads with adult mothers. Insecure maternal attachment in dyads with adolescent mothers (vs. adult mother infant dyads) is more influential as risk factor.

Maternal responsiveness and sensitivity reconsidered: some is more

Is it always or necessarily the case that common and important parenting practices are better, insofar as they occur more often, or worse, because they occur less often? Perhaps, less is more, or some is more. To address this question, we studied mothers' microcoded contingent responsiveness to their infants (M = 5.4 months, SD = 0.2) in relation to independent global judgments of the same mothers' parenting sensitivity. In a community sample of 335 European American dyads, videorecorded infant and maternal behaviors were timed microanalytically throughout an extended home observation; separately and independently, global maternal sensitivity was rated macroanalytically. Sequential analysis and spline regression showed that, as maternal contingent responsiveness increased, judged maternal sensitivity increased to significance on the contingency continuum, after which mothers who were even more contingent were judged less sensitive. Just significant levels of maternal responsiveness are deemed optimally sensitive. Implications of these findings for typical and atypical parenting, child development, and intervention science are discussed.