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

Childhood maltreatment and mentalizing capacity: A meta-analysis

BACKGROUND

The protective role of mentalizing capacity against the adverse effects of childhood maltreatment (CM) is acknowledged; however, empirical studies have yielded diverse conclusions regarding the relationship between childhood maltreatment and mentalizing capacity.

OBJECTIVE

This meta-analytic review aims to comprehensively summarize and quantify the association between childhood maltreatment and mentalizing capacity.

PARTICIPANTS AND SETTING

A total of 23 studies involving 3910 participants were included in the analysis.

METHODS

Systematic searches across eight bibliographic databases identified peer-reviewed publications describing empirical studies on the interplay between CM and mentalizing capacity. Effect sizes (r) were synthesized using random-effects models. A moderated effects analysis was conducted on five variables: participant gender, age group, mental health status, mentalizing capacity measurement, and childhood maltreatment measurement.

RESULTS

The findings showed a significant moderate negative correlation between childhood maltreatment and mentalizing capacity (r = -0.21, 95 % CI = [-0.26, -0.15]). This suggests that heightened severity of childhood maltreatment corresponds to lower mentalizing capacity. Moreover, the strength of this correlation was influenced by participant gender, age group, mental health status, mentalizing capacity measurement, and CM measurement.

CONCLUSIONS

The controversy surrounding the link between CM and mentalizing capacity gains clarity when considering significant moderating variables. The pooled effect provides a preliminary definition of the magnitude and direction of this correlation.

Social Cognition in Opioid Use Disorder

Background: Opioid use disorder (OUD) is associated with significant functional impairment and neurocognitive dysfunction, but only a handful of studies have investigated social cognitive abilities in this condition. This study aimed to investigate facial emotion recognition accuracy/biases and two different aspects of theory of mind (ToM) (ToM-decoding vs ToM-reasoning) in people with recovered OUD. Methods: The participants included 32 people with recovered OUD who were on Buprenorphine + Naloxone (B/N) maintenance treatment and 32 healthy controls. In addition to neurocognitive tasks, both groups were assessed by a facial emotion recognition task, the faux pas recognition task, and the reading the mind from the eyes task. Results: In comparison to healthy controls, people on B/N maintenance treatment showed deficits in facial emotion recognition (d = 1.32) and both aspects of ToM (d = 0.87-1.21). In analyses of individual emotions, people on B/N maintenance treatment had decreased accuracy in recognition of anger and fear and had a bias to identify other emotions as sad. The duration of opioid use was robustly associated with difficulties in the recognition of anger. Conclusion: People in B/N maintenance treatment have significant difficulties in recognizing the emotions and mental states of others. Deficits in social cognition might be important for understanding the difficulties in interpersonal and social functioning in people with OUD.

The Spanish version of the reflective functioning questionnaire: Validity data in the general population and individuals with personality disorders

INTRODUCTION

Mentalization or reflective functioning (RF) is the capacity to interpret oneself or the others in terms of internal mental states. Its failures have been linked to several mental disorders and interventions improving RF have a therapeutic effect. Mentalizing capacity of the parents influences the children's attachment. The Reflective Functioning Questionnaire (RFQ-8) is a widely used tool for the assessment of RF. No instrument is available to assess general RF in Spanish-speaking samples. The aim of this study is to develop a Spanish version of the RFQ-8 and to evaluate its reliability and validity in the general population and in individuals with personality disorders.

METHODS

602 non-clinical and 41 personality disordered participants completed a Spanish translation of the RFQ and a battery of self-reported questionnaires assessing several RF related constructs (alexithymia, perspective taking, identity diffusion and mindfulness), psychopathology (general and specific) and interpersonal problems. Temporal stability was tested in a non-clinical sub-sample of 113 participants.

RESULTS

Exploratory and confirmatory factor analyses suggested a one-factor structure in the Spanish version of the RFQ-8. RFQ-8 understood as a single scale was tested, with low scorings reflecting genuine mentalizing, and high scorings uncertainty. The questionnaire showed good internal consistence in both samples and moderate temporal stability in non-clinical sample. RFQ correlated significantly with identity diffusion, alexithymia, and general psychopathology in both samples; and with mindfulness, perspective taking, and interpersonal problems in clinical sample. Mean values of the scale were significantly higher in the clinical group.

DISCUSSION

This study provides evidence that the Spanish version of the RFQ-8, understood as a single scale, has an adequate reliability and validity assessing failures in reflective functioning (i.e., hypomentalization) in general population and personality disorders.

Reflective functioning in mothers with addictions: Differential relationships involving family history of mental illness and substance use

Parental reflective functioning (RF) is often cited as an important domain in which mothers with addictions struggle in their roles as parents, though the links between addiction and RF remain unclear. Exposure to attachment trauma associated with parental mental illness and substance use is commonly associated with both addiction and lower RF. We thus examined how family history of parental mental illness and substance use may relate to the RF of mothers with addictions. One hundred ninety-four mothers in outpatient substance use treatment completed the Parent Development Interview and provided information about whether their mothers and fathers experienced mental illness or problems with substance use. Univariate ANOVAs revealed an interaction between family history of maternal mental illness and maternal substance use. Among mothers with a history of maternal substance use, those with a history of maternal mental illness had higher RF than those who had no history of maternal mental illness. Among mothers who did not report a family history of maternal mental illness, mothers who had a family history of maternal substance use exhibited significantly lower RF than mothers with no family history of maternal substance use. Exposure to paternal mental illness or substance use was not associated with mothers' RF. These findings highlight the importance of disentangling the contributions of attachment trauma to mothers' RF and utilizing interventions that support mothers' capacity to reflect about how their early experiences of being cared for by a mother with a mental illness or addiction may impact their current caregiving behaviors.

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.

Maternal childhood abuse and neglect predicts offspring development in early childhood: The roles of reflective functioning and child sex

BACKGROUND

Recent evidence suggests that offspring of mothers having been exposed to childhood abuse and neglect (CA&N) are at increased risk of developmental problems and that boys are more affected by maternal CA&N than girls. Since impairments in reflective functioning (RF) have been associated with maternal CA&N and offspring development, RF could represent a key mechanism in these intergenerational risk trajectories.

OBJECTIVE

This study evaluated mediating (RF) and moderating (child sex) mechanisms in the association between maternal CA&N and child development.

PARTICIPANTS AND SETTING

In a longitudinal setting, 111 mothers completed measures during pregnancy and between 11 and 36 months postpartum.

METHODS

CA&N and impairments in RF were assessed during pregnancy and offspring development was measured during the longitudinal follow-up using the Ages and Stages Questionnaires (ASQ-3). Child development was operationalized in two ways: using the global score at the ASQ-3 and using a dichotomous score of accumulation of delays across domains of development.

RESULTS

Structural equation modeling indicated that RF mediated the association between maternal CA&N and offspring development. Child sex moderated the association between CA&N and the clustering of developmental problems (Wald = 5.88, p = 0.02), with boys being particularly likely to accumulate developmental delays when their mother experienced CA&N (RR = 2.62). Accumulation of developmental problems was associated with impairments in maternal RF in girls and with maternal exposure to CA&N in boys.

CONCLUSIONS

Results provide novel insights on the role of mentalization and child sex in the association between maternal CA&N and child development.

Parental Reflective Functioning and Its Association With Parenting Behaviors in Infancy and Early Childhood: A Systematic Review

Background

Parental reflective functioning (PRF) refers to parents' mental capacity to understand their own and their children's behaviors in terms of envisioned mental states. As part of a broader concept of parental mentalization, PRF has been identified as one of the central predictors for sensitive parenting. However, the unique contribution of PRF to the quality of various parenting behaviors has not yet been addressed systematically. Thus, the present article provides a systematic overview of current research on the associations between PRF or its sub-dimensions and observed parenting behaviors in infancy and early childhood, while considering the influence of contextual factors.

Methods

The review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Systematic searches were carried out in five electronic databases. The eligibility and methodological quality of the identified studies were assessed using pre-defined criteria and a standardized checklist.

Results

Sixteen studies with moderate to high quality on a total of 15 parenting behaviors were included, the majority of which examined positive parenting behaviors, while negative parenting behaviors were rarely investigated. Most of the associations indicated a positive effect of PRF on parenting behavior, with mostly small-sized effects. The strength and direction of the associations varied depending on the dimensionality of PRF, observation settings, sample types, socioeconomic factors, and cultural background. Moreover, five assessment instruments for PRF and 10 observation instruments for parenting behaviors were identified.

Conclusion

In summary, PRF has shown a positive association with parenting quality. However, its complex interaction with further contextual factors emphasizes the need for differentiation of PRF dimensions and the consideration of the observation settings, assessment time points, psychosocial risks, and sample types in observational as well as intervention studies. Further high-quality studies with multivariate analyses and diverse study settings are required.

The vulnerability of insecure minds: The mediating role of mentalization in the relationship between attachment styles and psychopathology

Insecure attachment is linked to mentalizing difficulties and psychopathology. The current study aimed to examine if failures in mentalization, as observed in the form of uncertainty about mental states, mediated the relationship between attachment styles and global psychopathology in a group of 812 adults (66.5% females) from the community. Participants completed measures on attachment styles, uncertainty about mental states, and clinical symptoms. The authors found that uncertainty about mental states was a partial mediator of the associations between attachment styles and psychopathology. Furthermore, the findings supported the role of secure attachment in protecting from mentalization failures and psychopathology; on the contrary, increased scores on attachment styles involving a negative view of the self (preoccupied and fearful attachment styles) predicted high levels of uncertainty about mental states and psychopathology. Accordingly, clinicians may wish to promote mentalizing abilities in individuals who display a negative view of the self embedded in their attachment styles.

Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse

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A professional organization does not recommend opioid detoxification in pregnancy.

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Medically-assisted treatment (MAT) is recommended to reduce relapse and dropout.

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We sampled 55 pregnant women who misused opioids who chose detoxification or MAT.

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There was no dropout in either group and more relapse with MAT than detoxification.

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Replication and follow-up are needed to assess relative rates of relapse postpartum.

The American College of Obstetricians and Gynecologists recommends medication-assisted treatment (MAT) for pregnant women who misuse opioids rather than detoxification because of possible relapse and dropout from treatment (ACOG, 2017). In a prospective study, fifty-five pregnant women with an opioid use disorder were offered a choice of MAT or detoxification. Ethical concerns precluded random assignment. We assessed dropout, treatment outcome, relapse, other illicit drug use, infant neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Of 55 women, 13 initially chose MAT and 42 women chose detoxification. All women received behavioral support. No one dropped out of treatment prior to delivery. All women who chose MAT initially remained on MAT. Of women who chose detoxification, 23% switched to MAT, 30% tapered below initial MAT doses, and 45% fully detoxified by delivery. There was a significant difference in opioid relapse between women on MAT (26%) and those who detoxified (0%), but no differences for other illicit drug use. Infants of women on MAT were more likely to have neonatal NOWS (91%) than infants of women who tapered below initial MAT doses but did not fully detoxify (62%). Infants of mothers who tapered (62%) were more likely to have NOWS than infants of women who fully detoxified (0%). Women on MAT reported significantly lower sexual abuse severity than did women who tapered or detoxified. It is critical to replicate the current findings and to follow up with mothers and their infants postpartum to ascertain the long-term impact of tapering or detoxification during pregnancy.