PRENATAL REFLECTIVE FUNCTIONING IN PRIMIPAROUS WOMEN WITH A HIGH-RISK PROFILE

Offline and online parental mentalizing in mothers with symptoms of postpartum depression: Examining the association between self-reported parental reflective functioning and interactional mind-mindedness

Mentalizing is, to a certain extent, considered context specific. However, research on the association between parents' abilities to reflect upon their infant's mental states outside social interaction (offline) versus during ongoing parent-infant interaction (online) is currently limited. This study investigated the association between self-reported offline and online mentalizing in a sample of primarily ethnically Danish mothers (N = 142), with symptoms of postpartum depression, and their 1-11-month-old infants. Offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire-Infant Version (PRFQ-I) and online mentalizing was assessed with interactional mind-mindedness. Ordinal logistic regressions showed that a higher score on the PRFQ-I prementalizing subscale was negatively related to number of overall mind-related comments and appropriate mind-related comments produced by mothers during interaction with their infant. Our results indicate partial overlaps between self-reported parental reflective functioning and mind-mindedness, that is, that particularly offline maladaptive mentalizing is associated with lower levels of mentalizing during interaction in mothers with symptoms of depression. Post-hoc examination of the interaction effect of postpartum depression showed that this association was only evident in mothers with medium to high levels of depression. Findings and implications are discussed.

What tools should be used to identify women in need of additional support in pregnancy?

OBJECTIVE

This study aimed to identify and inform recommendation of self-report and interview-based instruments that are feasible, reliable and valid to evaluate the quality of the maternal-fetal relationship (MFR).

BACKGROUND

Several constructs predicting parent-infant interaction and later infant adjustment are used to assess mothers' thoughts and feelings towards their unborn baby, including reflective functioning, mind-mindedness, representation, and fetal attachment. As yet, there is no existing review comparing the quality and accessibility of instruments across each of these constructs.

METHODS

A systematic literature review was undertaken to synthesise psychometric information on measures reporting on the MFR. Searches of six databases were conducted. English articles were selected based on inclusion and exclusion criteria. The QATSDD checklist was used to assess study quality.

RESULTS

 Of 669 studies identified, 28 met inclusion criteria. Thirteen different instruments were identified for evaluation. Reported reliability and validity varied significantly across instruments, as well as availability for research and/or clinical use.

CONCLUSION

Suggestions for research and clinical practice include further evaluation of the psychometric properties of tools, particularly for self-report measures of reflective functioning, use of interviews to scaffold reflexivity, and development of clinical policies and procedures to clarify care pathways for expectant mothers needing further support.

Early psychosocial risk factors and postnatal parental reflective functioning

Psychosocial factors have been found to relate to parental reflective functioning (PRF), a parent's ability to mentalize about themselves and their child. Relations between maternal psychosocial risk factors and PRF were investigated in a community sample. A sample of mothers (n = 146) was assessed for risk factors when infants were 6 months, infant temperament was assessed using an observational measure, and PRF was assessed with the Parent Development Interview-Revised (PDI). PRF was measured again with the Parental Reflective Functioning Questionnaire (PRFQ) when children were 4 years (n = 105) and 5 years (n = 92), with an additional sample of mothers (n = 48) tested at these two timepoints. Results showed that in infancy, total maternal psychosocial risk related to lower PDI-PRF; regression analyses highlighted low socioeconomic status, unplanned pregnancy, and low maternal anxiety as independent predictors of lower PDI-PRF. PDI-PRF scores at 6 months did not relate to PRFQ scores, but PRFQ subscales showed stability over time from age 4-5. Results are discussed with regard to the impact of maternal psychosocial risk and infant temperament on PRF and the stability and concordance of PRF measures.

Evaluation of the Danish version of the prenatal parental reflective functioning questionnaire in early pregnancy as a screening tool

Parental reflective functioning (PRF) is the capacity to focus on feelings and experiences in oneself as a parent and in the child. Research has demonstrated that, the better the PRF the better outcomes for the child. This paper evaluated the Danish version of the prenatal parental reflective functioning questionnaire (P-PRFQ). We used data from a cluster-randomized trial of pregnant women recruited from Danish general practice. The sample included 605 mothers. Factor structure and internal consistency were investigated. Linear regression analysis was used to examine the associations between the P-PRFQ score and the five most predictive variables. The confirmatory factor analyses supported the three-factor model. The P-PRFQ had moderate internal consistency. The regression analysis showed a decrease in the P-PRFQ score with increasing age, increasing parity, current employment, better self-reported health, lower anxiety score, and fewer negative life events with persistent impact. The directions of the associations between P-PRFQ score and the predictive variables were opposite of what was hypothesized raising questions about whether the P-PRFQ can be used as an early pregnancy screening tool assessing prenatal PRF. Further validation studies are required to assess the extent to which the P-PRFQ truly measures reflective functioning.

Examining Mothers' Childhood Maltreatment History, Parental Reflective Functioning, and the Long-Term Effects of the Minding the Baby® Home Visiting Intervention

Research is needed to better understand how childhood maltreatment history affects parental reflective capacities, and whether early childhood interventions help mitigate these effects. We examined associations between childhood maltreatment and current parenting (parental reflective functioning, parenting behaviors) among mothers who participated in a follow-up study (N = 97) of the Minding the Baby® (MTB) randomized control trial. MTB is a home visiting program that aims to help mothers understand their child's mental states (feelings, intentions, needs) by promoting parental reflective functioning. Mothers retrospectively reported childhood maltreatment using the Childhood Trauma Questionnaire. Endorsing a higher number of childhood maltreatment subtypes was associated with less supportive/engaged parenting and higher pre-mentalizing modes, or difficulty with appropriately reflecting on the child's mental states. These relationships were not moderated by participation in the MTB intervention. However, exploratory analyses of individual maltreatment subtypes revealed that participation in MTB may mitigate the harmful effects of childhood emotional abuse on pre-mentalizing modes, specifically. Further research is needed to understand the mechanisms through which early childhood interventions may prevent intergenerational cycles of maltreatment.

Prenatal Reflective Functioning as a Predictor of Substance-Using Mothers' Treatment Outcome: Comparing Results From Two Different RF Measures

Mothers with prenatal substance use disorder (SUD) often show broad deficits in their reflective functioning (RF), implying severe risk for the relationship with their baby. Two different types of prenatal maternal RF may be important for parenting: adult attachment-focused-RF (AAI-RF), regarding parent's own childhood experiences, and parenting-focused RF (PRF) regarding their own current process of becoming a parent. However, their inter-relations and potentially different roles for parenting intervention outcomes are not clear. This study examined the associations between mothers' prenatal AAI-RF and pre- and post-natal PRF, and their role in mother-infant interaction and substance use as treatment outcomes. The participants were 57 treatment-enrolled pregnant mothers with SUD and 50 low-risk comparison mothers. AAI-RF was measured with the Adult Attachment Interview. For a subsample of 30 mothers with SUD, PRF was measured with Pregnancy Interview (during pregnancy/pre-intervention), and with Parent Development Interview at 4 months (during intervention). Mother-infant interaction was measured with Emotional Availability Scales at 4 and 12 months (post-intervention), and maternal substance use by post-natal substance relapses. Prenatal AAI-RF and pre- and post-natal PRF were highly associated with each other. Only higher prenatal PRF predicted better mother-infant interaction quality at 4 months and less substance use during the child's first year. Interestingly, prenatal PRF and AAI-RF predicted opposite changes in mother-infant interaction: lower prenatal PRF, but higher AAI-RF predicting more positive change. AAI-RF was especially associated with a change in maternal intrusiveness and hostility, indicating that it represents a more general regulatory tendency. Further studies are needed in larger and lower-risk samples. Our results suggest, however, that AAI-RF and PRF are partially distinct and should be uniquely targeted in perinatal interventions.

School age effects of Minding the Baby-An attachment-based home-visiting intervention-On parenting and child behaviors

Multiple interventions have been developed to improve the caregiver-child relationship as a buffer to the effects of early life adversity and toxic stress. However, relatively few studies have evaluated the long-term effects of these early childhood interventions, particularly on parenting and childhood behaviors. Here we describe the early school-age follow-up results of a randomized controlled trial of Minding the Baby ® (MTB), a reflective, attachment-based, trauma-informed, preventive home-visiting intervention for first-time mothers and their infants. Results indicate that mothers who participated in MTB are less likely to show impaired mentalizing compared to control mothers two to eight years after the intervention ended. Additionally, MTB mothers have lower levels of hostile and coercive parenting, and their children have lower total and externalizing problem behavior scores when compared to controls at follow-up. We discuss our findings in terms of their contribution to understanding the long-term parenting and childhood socio-emotional developmental effects of early preventive interventions for stressed populations.

Maternal mentalization and child emotion regulation: A comparison of different phases of early childhood

Parental reflective functioning refers to the parents' ability to reflect on the internal mental states of their children, which will make them respond more sensitively to their children´s need. The relation between parental reflective functioning and child emotion regulation has been considered a key factor in early childhood parenting but further research is needed about this relationship throughout child's development. The aim of this paper was to analyze this interaction considering the early childhood development stages. Three hundred and eighty one mothers of babies between 0 and 26 months of age participated in the study. The PRFQ and ASQ:SE-2 questionnaires were administered to assess parental reflective functioning and child emotion regulation, respectively. Results showed that maternal RF and child emotion regulation do not follow a linear process according to the childhood development stages, and also that the maternal PM dimension generates a conditional effect in children's emotion regulation. These results highlight the importance of paying attention to specific early childhood developmental stages to understand how maternal reflective functioning influences child´s ability to calm and adjust to her/his environment.

“A Window of Opportunity”: Parenting and Addiction in the Context of Pregnancy

Purpose of Review

Maternal prenatal substance use presents a multilevel risk to child development and parenting. Although parenting interventions are increasingly integrated into substance use treatment, prenatal parenting processes have not received equal attention within these interventions. This article aims to synthesize the evidence on the specific prenatal risk factors affecting the development of early parenting of substance-using mothers, as well as interventions focusing on those factors.

Recent Findings

Both neurobiological and psychosocial risk factors affect the prenatal development of parenting in the context of maternal substance use. Maternal–fetal attachment, mentalization, self-regulation, and psychosocial risks are important in treatment and highly intertwined with abstinence. Although parenting interventions seem to be highly beneficial, most studies have not differentiated between pre- and postnatal interventions or described pregnancy-specific intervention elements.

Summary

Due to the salience of pregnancy in treating substance-using parents, interventions should begin prenatally and include pregnancy-specific parenting focus. Further research on prenatal interventions is warranted.

Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms

Pregnancy offers a unique period for initiating preventive parenting interventions. Disturbances in maternal-fetal bonding may indicate suboptimal parenting and a need for intervention. However, more knowledge is needed on the development of maternal-fetal bonding among at-risk groups. The study aim was to examine psychosocial correlates of maternal-fetal bonding among pregnant women identified to be at risk socially and regarding their mental health. The sample consisted of 78 at-risk pregnant women participating in a perinatal intervention study: Godt på Vej Sammen [A Good Start to Life—an Early Cross-sectorial Intervention]. This study was cross-sectional reporting on the baseline characteristics of the participants. In the beginning of the second trimester, participants completed questionnaires assessing maternal-fetal bonding (the Maternal Antenatal Attachment Scale [MAAS]), prenatal parental reflective functioning, adult attachment style, and depressive symptoms. We compared the distribution of MAAS styles with norms from a recent Dutch community sample. In addition, we tested associations between psychosocial variables and the quality and intensity of MAAS scores in regression models and performed Chi-square analyses to assess the association of MAAS styles with psychosocial variables. First, compared to women from a community sample, approximately half of the women in our sample presented lower and suboptimal MAAS scores. Second, insecure avoidant adult attachment style was negatively associated with MAAS intensity, and depressive symptoms were negatively associated with MAAS quality. Third, prenatal parental reflective functioning positively correlated with both quality and intensity of MAAS. Fourth, we found no association between insecure anxious adult attachment style and MAAS scores. Fifth, women with a negative disinterested MAAS style demonstrated the highest avoidant attachment scores, while women with a positively preoccupied MAAS style demonstrated the highest prenatal parental reflective functioning scores. The results suggest that there is a need to differentiate among at-risk pregnant woman and that prenatal screening using the MAAS may help identify those who need preventive parenting interventions and what those interventions should focus on. A main limitation of the study is the lack of a representative group of at-risk pregnant women which limits the generalizability of the study results to all risk groups.

Minding the Baby®: Enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program

In this article, we describe the results of the second phase of a randomized controlled trial of Minding the Baby (MTB), an interdisciplinary reflective parenting intervention for infants and their families. Young first-time mothers living in underserved, poor, urban communities received intensive home visiting services from a nurse and social worker team for 27 months, from pregnancy to the child's second birthday. Results indicate that MTB mothers' levels of reflective functioning was more likely to increase over the course of the intervention than were those of control group mothers. Likewise, infants in the MTB group were significantly more likely to be securely attached, and significantly less likely to be disorganized, than infants in the control group. We discuss our findings in terms of their contribution to understanding the impacts and import of intensive intervention with vulnerable families during the earliest stages of parenthood in preventing the intergenerational transmission of disrupted relationships and insecure attachment.

Prenatal risk and physical aggression during the first years of life: The gender-specific role of inhibitory control

Prenatal risk and a lack of inhibitory control have consistently been related to the development of physical aggression in older children. This study examined whether inhibitory control mediated the relation between prenatal risk and aggression in infants and toddlers. The role of gender in this mediation model was also examined. The sample consisted of 161 mother-child dyads (83 boys). A prenatal cumulative risk score was created from a number of well-established risk factors including maternal psychopathology, substance use, and social and socioeconomic disadvantages. At 12 months, children performed an inhibitory control task. Physical aggression was assessed through maternal reports at 12 and 20 months of age. Results showed that higher prenatal risk was associated with more physical aggression. Inhibitory control mediated this association at both 12 and 20 months: higher prenatal risk was related to lower inhibitory control, which in turn led to higher aggression. At 20 months, gender moderated the mediation effect: the mediating role of inhibitory control was only found for girls. These results suggest that even before 2 years of age, inhibitory control is an important construct involved in the relation between prenatal risk and physical aggression.

The prenatal maternal representations of mothers at risk of recurrent care proceedings in the Family Drug and Alcohol Court: A thematic analysis

BACKGROUND

A substantial number of birth mothers experience repeat removals of their infants and children due to child protection concerns. The perspectives of mothers going through repeat removals and their experiences of pregnancy are insufficiently researched.

AIMS AND METHODS

The current qualitative study aimed to explore the maternal representations of five pregnant mothers at risk of recurrent care proceedings. A thematic analysis of these mothers' responses to the Pregnancy Interview focused on their representations of themselves as mothers, of their babies, and of the mother-baby relationship.

RESULTS

Seven key themes were identified: (1a) "Uncertainty and fear of losing the baby," (1b) "Uncertainty but hope of becoming a mother," (2) "Not wanting to be like their own mother," (3) "Experiencing recovery and pregnancy as two interdependent processes," (4) "Struggling to imagine the baby," (5) "The omnipresence of previous children," (6) "Pleasure at starting to have a connection with the baby," and (7) "Noting the baby's dependency."

CONCLUSION

The results are clinically relevant as they highlight grief, maternal self-identity, recovery from substance abuse, and ability to manage uncertainty as critical areas of intervention for these mothers.

Aggressive behavior during toddlerhood: Interrelated effects of prenatal risk factors, negative affect, and cognition

Prenatal risk, temperamental negative affect, and specific cognitive abilities have all individually been identified as predictors of behavior problems during early childhood, but less is known about their interplay in relation to aggression during toddlerhood. This study examined the main and interaction effects of prenatal risk, negative affect, inhibitory control, attention, and vocabulary in the prediction of aggression in 150 children (75 boys). During pregnancy, a cumulative risk index was calculated based on the presence of 10 well-established maternal risk factors, such as prenatal substance use, maternal psychiatric disorder, and financial problems. Negative affect was measured at 6 and 20 months using maternal report. Child cognition was examined at 30 months using laboratory tasks for inhibitory control and attention, and a questionnaire was administered to assess vocabulary. In addition, mothers reported on their children's aggressive behavior at 30 months. Higher prenatal risk and negative affect at 20 months and, to a lesser extent, at 6 months were related to more aggression at 30 months. Poorer inhibitory control and, to a lesser extent, vocabulary at 30 months also predicted higher levels of aggressive behavior. Two-way interaction effects were found for cumulative risk and inhibitory control, negative affect (at 20 months) and inhibitory control, and negative affect (at 6 months) and vocabulary: aggressive behavior was most pronounced when combinations of high prenatal risk, high negative affect, and poor cognition were present. These results suggest that the impact of prenatal risk and child temperament depends in part on child's cognitive development during toddlerhood.

The Role of Inhibitory Control, Attention and Vocabulary in Physical Aggression Trajectories From Infancy to Toddlerhood

Physical aggression has its origin very early in development, but no studies to date have examined physical aggression trajectories starting before the age of 1.5 years. This study examined whether cognition plays a role in the development of physical aggression from infancy onward. In a sample of 182 mother-child dyads (94 boys; 88 girls), child physical aggression was assessed by maternal report using the Physical Aggression Scale for Early Childhood at 12, 20, and 30 months. Children performed cognitive tasks measuring inhibitory control and attention, and mothers rated children's vocabulary at 12 and 30 months. Results showed that differential development of physical aggression already starts at 12 months of age: low-stable, low-increasing, moderate-decreasing and high-stable trajectory groups were identified. Inhibitory control, attention and vocabulary at 12 months and development of these abilities from 12 to 30 months were selectively related to the likelihood of following the low-increasing and moderate-decreasing trajectories compared to the low-stable physical aggression trajectory. This study is the first to show that specific aspects of cognition and cognitive development are related to differential physical aggression development from infancy onward.

Infant emotional responses to challenge predict empathic behavior in toddlerhood

Although emotional responses are theorized to be important in the development of empathy, findings regarding the prediction of early empathic behavior by infant behavioral and physiological responses are mixed. This study examined whether behavioral and physiological responses to mild emotional challenge (still face paradigm and car seat task) in 118 infants at age 6 months predicted empathic distress and empathic concern in response to an empathy-evoking task (i.e, experimenter's distress simulation) at age 20 months. Correlation analyses, corrected for sex and baseline levels of physiological arousal, showed that stronger physiological and behavioral responses to emotional challenge at age 6 months were positively related to observed empathic distress, but not empathic concern, at age 20 months. Linear regression analyses indicated that physiological and behavioral responses to challenge at 6 months independently predicted empathic distress at 20 months, which suggests an important role for both physiological and behavioral emotional responses in empathy development. In addition, curvilinear regression analyses showed quadratic associations between behavioral responses at 6 months, and empathic distress and empathic concern at 20 months, which indicates that moderate levels of behavioral responsivity predict the highest levels of empathic distress and empathic concern.

Pregnant women's history of childhood maltreatment and current opioid use: The mediating role of reflective functioning

There is an association between the experience of childhood maltreatment and opioid misuse in adults, especially for women. However, we know little about this association in pregnancy, and less about processes that could be the target of interventions to help women better parent their infants. We examined reflective functioning as a putative process. Reflective functioning is the ability to interpret one's own and others' behavior in terms of underlying mental states, e.g., emotions, motivations, and beliefs. We sampled 55 pregnant women who misused opioids and 38 women at high risk due to medical factors, e.g., heart disease. We assessed maltreatment with the Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parigger, 2015), and reflective functioning with the Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016). Maltreatment variables included the sum of severity across all subtypes, number of subtypes experienced, and severity of sexual, physical, and emotional abuse, and of neglect. We created a categorical opioid user group variable: women who used opioids in pregnancy vs. high-risk medical comparisons. We found that women who used opioids in pregnancy had poorer reflective functioning than did high-risk medical comparisons. We also created an opioid use severity scale (ranging from 0 to 3) from urine assays and history of prescribed opioids from medical records. Using Hayes (2012)'s bootstrapping PROCESS macro, we found that reflective functioning mediated the association between all maltreatment variables and opioid use severity. We discuss the results in terms of how best to intervene to improve women's reflective functioning, which may help their ability to parent.

Associations between empathy, inhibitory control, and physical aggression in toddlerhood

Impaired empathy has been associated with aggression in children, adolescents and adults, but results have been contradictory for the preschool period. Impaired inhibitory control also increases the risk of aggression, and possibly moderates empathy‐aggression associations. The current study investigated whether empathy and inhibitory control are associated with aggression in toddlerhood. Furthermore, we aimed to clarify the role of inhibitory control in empathy and aggression, specifically, whether inhibitory control moderates the association between empathy and aggression. During a laboratory visit at age 30 months (N = 103), maternal reports of physical aggression were obtained and child inhibitory control was examined using a gift delay task. Empathy was examined by obtaining behavioral observations and recording physiological responses (heart rate response and respiratory sinus arrhythmia response) to an empathy‐eliciting event (i.e., simulated distress). Reduced inhibitory control was associated with more aggression. Behavioral and physiological indicators of empathy were not associated with aggression. Hierarchical regression analyses revealed an interaction effect of heart rate response to distress simulation with inhibitory control in the prediction of aggression. Post hoc analyses indicated a negative association between heart rate response and aggression when inhibitory control was high, but a positive association was found in toddlers who demonstrated low inhibitory control. These results suggest that children are less aggressive when they have both high levels of empathy and inhibitory control. Therefore, both empathy and inhibition are important targets for interventions aiming to reduce or prevent aggression at a young age.

Infant Parasympathetic and Sympathetic Activity during Baseline, Stress and Recovery: Interactions with Prenatal Adversity Predict Physical Aggression in Toddlerhood

Exposure to prenatal adversity is associated with aggression later in life. Individual differences in autonomic nervous system (ANS) functioning, specifically nonreciprocal activation of the parasympathetic (PNS) and sympathetic (SNS) nervous systems, increase susceptibility to aggression, especially in the context of adversity. Previous work examining interactions between early adversity and ANS functioning in infancy is scarce and has not examined interaction between PNS and SNS. This study examined whether the PNS and SNS moderate the relation between cumulative prenatal risk and early physical aggression in 124 children (57% male). Cumulative risk (e.g., maternal psychiatric disorder, substance (ab)use, and social adversity) was assessed during pregnancy. Parasympathetic respiratory sinus arrhythmia (RSA) and sympathetic pre-ejection period (PEP) at baseline, in response to and during recovery from emotional challenge were measured at 6 months. Physical aggression and non-physical aggression/oppositional behavior were measured at 30 months. The results showed that cumulative prenatal risk predicted elevated physical aggression and non-physical aggression/oppositional behavior in toddlerhood; however, the effects on physical aggression were moderated by PNS and SNS functioning. Specifically, the effects of cumulative risk on physical aggression were particularly evident in children characterized by low baseline PNS activity and/or by nonreciprocal activity of the PNS and SNS, characterized by decreased activity (i.e., coinhibition) or increased activity (i.e., coactivation) of both systems at baseline and/or in response to emotional challenge. These findings extend our understanding of the interaction between perinatal risk and infant ANS functioning on developmental outcome.

Empathic distress and concern predict aggression in toddlerhood: The moderating role of sex

Impaired empathy is an important risk factor of aggression, but results are contradictory in toddlerhood. The association between empathy and aggression may differ for empathic distress and empathic concern in response to empathy-evoking situations, and for boys and girls. Therefore, the current study investigated whether empathic distress and empathic concern at age 20 months (N = 133, 69 boys) predicted aggression at ages 20 and 30 months (N = 119, 62 boys), while taking a potential moderating effect of sex into account. Empathic behavior was observed during a distress simulation task 20 months post-partum. Physical aggression was assessed through maternal report, using the Physical Aggression Scale for Early Childhood. Linear regression analyses revealed sex differences in the associations between empathic distress and concern on the one hand and physical aggression at age 20 months on the other. Furthermore, physical aggression at age 30 months was predicted by the interaction of sex with empathic distress at age 20 months, while controlling for aggression at age 20 months. More empathic distress and concern were associated with less physical aggression in girls, but not in boys. The findings indicate that the prediction of physical aggression by empathic distress was more robust over time than for empathic concern. This study sheds new light on the intricate relationship between empathy, aggression, and sex from a developmental perspective.

Reflective Functioning on the Parent Development Interview: validity and reliability in relation to socio-demographic factors

The Reflective Functioning coding of the Parent Development Interview (PDI-RF) is a widely used method for assessing a caregivers' capacity for mentalization. However, little is known about its psychometric properties.The aim of this study was to examine the distributions and discriminant and criterion validity of the PDI-RF scale in relation to a number of demographic and socioeconomic factors.Mothers of infants and toddlers (N = 323) from low, medium, and high-risk samples were interviewed with the PDI and transcripts were coded for RF. Demographic and socio-economic data were recorded.The PDI-RF scale showed high inter-rater reliability, internal consistency, and criterion validity. Modest associations with some sociodemographic variables and PDI-RF were found, but together these only accounted for a small amount of variance in the measure, suggesting adequate discriminant validity. Overall, the scale had good psychometric properties, although some caveats for its use were identified.

Exploring parental mentalization in postnatal phase with a self-report questionnaire (PRFQ): Factor structure, gender differences and association with sociodemographic factors. The Finn Brain Birth Cohort Study

The objective was to explore the preliminary functioning of a self-report questionnaire designed to assess parental reflective functioning (PRFQ, Luyten et al., 2009, unpublished manual) during early postnatal phase and with a large population-based sample. Parental reflective functioning (PRF) refers to parental capacity to focus on experience and feelings, within self, in the child and underlying observed reactions. Individual differences in PRF reportedly affect child attachment and socio-emotional development. Cost-effective tools to assess key areas of early parenting are needed for both research and clinical purposes. The factor structure of a 36-item version suitable for early postnatal phase was explored using population-based data from the Finn Brain Birth Cohort Study (425 mothers and 237 fathers). Exploratory and confirmatory factor analysis resulted in a 14-item version comprising four factors capturing relevant aspects of early PRF. The factor structure was further tested with separate participants from the cohort (1030 mothers and 422 fathers). Mothers tended to score higher than fathers in PRF. Among mothers, parity, age, and financial situation were associated with postnatal mentalization. Level of education was associated with postnatal mentalization in both genders. The 14-item PRFQ-Fi has potential to serve as a new screening tool for very early parenting.

Interaction between prenatal risk and infant parasympathetic and sympathetic stress reactivity predicts early aggression

Nonreciprocal action of the parasympathetic (PNS) and sympathetic (SNS) nervous systems, increases susceptibility to emotional and behavioral problems in children exposed to adversity. Little is known about the PNS and SNS in interaction with early adversity during infancy. Yet this is when the physiological systems involved in emotion regulation are emerging and presumably most responsive to environmental influences. We examined whether parasympathetic respiratory sinus arrhythmia (RSA) and sympathetic pre-ejection period (PEP) response and recovery at six months, moderate the association between cumulative prenatal risk and physical aggression at 20 months (N=113). Prenatal risk predicted physical aggression, but only in infants exhibiting coactivation of PNS and SNS (i.e., increase in RSA and decrease in PEP) in response to stress. These findings indicate that coactivation of the PNS and SNS in combination with prenatal risk is a biological marker for the development of aggression.

Prenatal Reflective Functioning and Development of Aggression in Infancy: the Roles of Maternal Intrusiveness and Sensitivity

Maternal reflective functioning (RF) has been associated with quality of parent-child interactions and child development. This study investigated whether prenatal RF predicted the development of infant physical aggression and whether maternal sensitivity and/or intrusiveness mediated or moderated this association. The sample consisted of 96 first-time mothers (M = 22.57 years, SD = 2.13) and their infants (54 % male). Prenatal RF was measured with an interview, maternal behavior was observed during free play at 6 months post-partum, and infant physical aggression was assessed at 6, 12, and 20 months using maternal reports. Multivariate analyses of variance showed that relatively poor prenatal RF was related to relatively high infant physical aggression. These associations were moderated by maternal intrusiveness, with significant differences in physical aggression between RF-groups reportedly only in the absence of intrusiveness. Generally, mothers reported an increase in physical aggression between 6 and 12 months, except when they had both low RF-skills and were relatively less sensitive. It is concluded that prenatal RF is associated with (development of) infant physical aggression, and may be targeted in intervention programs aimed at reducing early physical aggression. Less adequate parenting, however, may counteract the beneficial effects of good RF, or obscure insight into children's behavioral development.

Mentalizing Makes Parenting Work: A Review about Parental Reflective Functioning and Clinical Interventions to Improve It

In the last decade several studies have investigated the role of parental reflective functioning (RF), defined as the parental ability to understand his/her child’s mental states, on the child’s development. Herein, a narrative review on parental RF is presented aimed at (1) presenting an overview of the existing empirical studies, (2) pinpointing unrequited questions, and (3) identifying future research directions. Specifically, the current review focused on (a) the impact of parental RF on the quality of caregiving and the child’s attachment security, (b) the effect of parental RF on the child’s emotion regulation and the child’s RF, (c) maternal RF in women with a history of neglect and abuse, (d) the efficacy of mentalization-based clinical interventions, and (e) the recently developed Parental Reflective Questionnaire. The following terms “maternal RF,” “paternal RF,” “parental RF,” “parental mentalization,” “maternal mentalization,” and “paternal mentalization” were searched in titles, abstracts, and main texts using Medline, Web of Science, and Scopus databases. Next, a search in Mendeley was also conducted. Inclusion criteria comprised original articles if they refer to the RF Scale (Fonagy et al., 1998) and were published in an English language, peer-reviewed journal before July, 2016. According to exclusion criteria, dissertations, qualitative or theoretical papers, and chapters in books were not taken into account. The review includes 47 studies that, taken together, supported the notion that higher parental RF was associated with adequate caregiving and the child’s attachment security, whereas low maternal RF was found in mothers whose children suffered from anxiety disorders, impairment in emotion regulation, and externalizing behaviors. In addition, higher parental RF was associated with better mentalizing abilities in children. However, unexpected findings have emerged from the most recent randomized controlled trials that tested the efficacy of mentalization-based interventions in high risk samples of mothers, raising questions about the suitability of the verbal measures in capturing the mentalizing processes at the root of the parental capacity to be adequately responsive to the child’s emotional needs.

The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis

BACKGROUND

Previous reviews have provided preliminary insights into risk factors and possible prevalence of Post-traumatic Stress Disorder (PTSD) postpartum with no attempt to examine prenatal PTSD. This study aimed to assess the prevalence of PTSD during pregnancy and after birth, and the course of PTSD over this time.

METHODS

PsychINFO, PubMed, Scopus and Web of Science were searched using PTSD terms crossed with perinatal terms. Studies were included if they reported the prevalence of PTSD during pregnancy or after birth using a diagnostic measure.

RESULTS

59 studies (N =24267) met inclusion criteria: 35 studies of prenatal PTSD and 28 studies of postpartum PTSD (where 4 studies provided prevalence of PTSD in pregnancy and postpartum). In community samples the mean prevalence of prenatal PTSD was 3.3% (95%, CI 2.44-4.54). The majority of postpartum studies measured PTSD in relation to childbirth with a mean prevalence of 4.0% (95%, CI 2.77-5.71) in community samples. Women in high-risk groups were at more risk of PTSD with a mean prevalence of 18.95% (95%, CI 10.62-31.43) in pregnancy and 18.5% (95%, CI 10.6-30.38) after birth. Using clinical interviews was associated with lower prevalence rates in pregnancy and higher prevalence rates postpartum.

LIMITATIONS

Limitations include use of stringent diagnostic criteria, wide variability of PTSD rates, and inadequacy of studies on prenatal PTSD measured in three trimesters.

CONCLUSIONS

PTSD is prevalent during pregnancy and after birth and may increase postpartum if not identified and treated. Assessment and treatment in maternity services is recommended.

Understanding the unfolding of stress regulation in infants

Early identification of problems with psychosocial stress regulation is important for supporting mental and physical health. However, we currently lack knowledge about when reliable individual differences in stress-responsive physiology emerge and which aspects of maternal behavior determine the unfolding of infants' stress responses. Knowledge of these processes is further limited by analytic approaches that do not account for multiple levels of within- and between-family effects. In a low-risk sample (n = 100 dyads), we observed infant cortisol and mother/infant behavior during regular play and stress sessions longitudinally from age 1 to 3, and used a three-level model to separately examine variability in infant cortisol trajectories within sessions, across years, and across infants. Stable individual differences in hypothalamus-pituitary-adrenal axis regulation were observed in the first 3 years of life. Infants of less sensitive and more intrusive mothers manifested stress sensitization, that is, elevated cortisol levels during and following stress exposure, a profile related to behavioral distress. These findings have important practical implications, suggesting that children at risk for long-term stress dysregulation may be identified in the earliest years of life.

Maternal reflective functioning as a multidimensional construct: Differential associations with children's temperament and externalizing behavior

Maternal reflective functioning (RF) has been associated with children's behavioral development. This study examined maternal prenatal and postnatal RF, as measured by the Pregnancy Interview and Parent Development Interview, as multidimensional constructs. It was also examined whether the RF-dimensions were associated with children's temperament and externalizing behavior, as assessed by several questionnaires. The sample consisted of 123 first-time mothers (M age=22.85years, SD=2.21) and their children (M age=19.97months, SD=0.85, 56% male). Two related but distinct dimensions were found for prenatal RF, termed self-focused and child-focused mentalization. Three dimensions were observed for postnatal RF, termed self-focused, child-focused, and relation-focused mentalization. Results showed that prenatal RF negatively related to reported child physical aggression. Postnatal self-focused RF was positively linked to externalizing behavior and negative emotionality in offspring, while relation-focused RF scores were negatively associated with child physical aggression. Findings show that it is important to also look at the specific RF-dimensions when examining the effects of maternal RF on children's behavioral development, as differential associations with behavioral outcomes exist. Discussion further focuses on the importance of these findings in prevention and clinical practice, and suggestions are being made to further improve the measurement of maternal RF-dimensions.

Infant autonomic nervous system response and recovery: Associations with maternal risk status and infant emotion regulation

This study examined whether risk status and cumulative risk were associated with autonomic nervous system reactivity and recovery, and emotion regulation in infants. The sample included 121 6-month-old infants. Classification of risk status was based on World Health Organization criteria (e.g., presence of maternal psychopathology, substance use, and social adversity). Heart rate, parasympathetic respiratory sinus arrhythmia, and sympathetic preejection period were examined at baseline and across the still face paradigm. Infant emotion regulation was coded during the still face paradigm. Infants in the high-risk group showed increased heart rate, parasympathetic withdrawal, and sympathetic activation during recovery from the still face episode. Higher levels of cumulative risk were associated with increased sympathetic nervous system activation. Moreover, increased heart rate during recovery in the high-risk group was mediated by both parasympathetic and sympathetic activity, indicating mobilization of sympathetic resources when confronted with socioemotional challenge. Distinct indirect pathways were observed from maternal risk to infant emotion regulation during the still face paradigm through parasympathetic and sympathetic regulation. These findings underline the importance of specific measures of parasympathetic and sympathetic response and recovery, and indicate that maternal risk is associated with maladaptive regulation of stress early in life reflecting increased risk for later psychopathology.