The protective role of mentalizing: Reflective functioning as a mediator between child maltreatment, psychopathology and parental attitude in expecting parents

Adverse childhood experiences and psychological maladjustment in adolescence: The protective role of epistemic trust, mentalized affectivity, and reflective functioning

INTRODUCTION

Adverse childhood experiences (ACEs) are psychosocial factors acknowledged as significant contributors to health consequences later in adolescence, including psychological maladjustment. The research suggests that, at a transdiagnostic and transtheoretical level, working on restoring epistemic trust (ET), mentalized affectivity (MA), and reflective functioning (RF) in adolescents with ACEs assumes a central role in the therapeutic process. However, there are still few studies that attempted to investigate the specific role of these sociocognitive factors in the detrimental positive association between levels of experienced ACEs during childhood and psychological maladjustment in nonclinical adolescents.

METHODS

A community sample of 306 Italian cisgender adolescents (61.4% assigned females at birth; age range 13-19 years old; Mage = 16.1, SD = 1.64) self-reported ACEs (Childhood Trauma Questionnaire-Short Form), psychological maladjustment (Strengths and Difficulties Questionnaire), ET (Epistemic Trust, Mistrust and Credulity Questionnaire), MA (Brief-Mentalized Affectivity Scale for Adolescence), and RF (Reflective Functioning Questionnaire). A multiple mediation regression analysis has been performed to explore the association between ACEs and psychological maladjustment through the interaction with socio-cognitive factors.

RESULTS

ACEs are positive predictors of psychological maladjustment later in adolescence. Regardless of gender differences, epistemic mistrust and credulity, processing and expressing emotions, and uncertainty about mental states mediated this association, while epistemic trust, identifying emotions, and certainty about mental states did not configure as significant mediators.

CONCLUSION

Findings suggest that ET disruptions and deficits in RF are risk factors, while MA is a protective factor within the link between ACEs and psychological maladjustment in adolescence. These links help to specify the role of sociocognitive factors in the development of mental problems in adolescents who have been exposed to adverse experiences in childhood.

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.

Complexity of mentalization

The ability to understand other people’s emotions, thoughts, and behaviors is associated with an individual’s ability and his attitude in the context of relationships. The development of this process is associated with different psychosocial factors: parental competence, building a secure attachment and reduced risk of violence in the family as well as the future intrapersonal relationships and social reality of one person Mentalization is empirically associated with resolving psychological tasks in normative dilemmas and also, can influence on the outcome of personal and situational crises. And so forth, passing through the different stages of life and prevention of dysfunctional patterns in the family is facilitated. This text aims to investigate the main characteristics of mentalization, its connection with the etiopathogenesis of some main mental disorders, their course and prognosis. Several studies in recent years confirmed that these connections can enroll mentalization to prevention and psychological therapy in some mental disorders and dysfunctional thinking patterns. On the other hand, it serves as a basis for psychotherapeutic competence expressed in the ability to connect, differentiate, and separate, as the main interactional stages of the psychotherapeutic process.

Dimensional model of adolescent personality pathology, reflective functioning, and emotional maltreatment

Introduction

Childhood emotional abuse (CEA) is a recognized risk factor for adolescent mentalizing challenges. However, there's limited understanding about how CEA might influence personality development and elevate the risk of adolescent personality pathology. A deeper grasp of these pathways is crucial, given that adolescence is a pivotal developmental phase for identity integration, personality consolidation, and the emergence of personality disorders. As the emphasis shifts to dimensional perspectives on adolescent personality pathology, the spotlight is increasingly on adolescents' evolving personality organization (PO). Within this framework, personality disorder manifestations stem from inherent vulnerabilities in PO. A comprehensive understanding of how CEA leads to these inherent vulnerabilities in PO can inform enhanced interventions for at-risk adolescents. Nonetheless, our comprehension lacks insight into potential pathways to PO, especially those involving external factors like maltreatment and individual traits like mentalizing. This study sought to bridge these gaps by employing latent factor analysis and structural equation modeling to explore connections between emotional maltreatment, adolescent mentalizing, and PO.

Methods

A community-based cohort of 193 adolescents (aged 12-17) took part in self-report assessments: the Childhood Experience of Care and Abuse Questionnaire (CECA.Q), the Reflective Functioning Questionnaire for Youth (RFQ-Y), and the Inventory for Personality Organization for Adolescents (IPO-A).

Results

The structural equation model revealed a significant direct influence of CEA on both RFQ-Confusion and PO, and a noteworthy direct effect of RFQ-Confusion on PO. Remarkably, the model accounted for 76.9% of the PO variance. CEA exhibited a significant indirect impact on PO through RFQ-Confusion, which was accountable for 52.3% of the CEA effect on PO, signifying a partial mediation by mentalizing.

Discussion

These insights carry substantial clinical implications, especially for devising integrated, trauma-informed strategies for adolescents with personality pathologies. This is particularly relevant for enhancing mentalizing and bolstering personality consolidation among adolescent CEA survivors.

Towards a more comprehensive understanding of PTSD and parenting

BACKGROUND

The impact of post-traumatic stress disorder (PTSD) on parenting and the parent-child relationship has been well-documented in the scientific literature. However, some conceptual and methodological challenges within this research field remain.

PROCEDURE

We reflect on a number of challenges that we identified while examining the literature in preparation of an individual participant data meta-analysis on the relationships between PTSD and parenting.

FINDINGS

We address 1) the presence of 'trauma-islands'; 2) the need for transdiagnostic theoretical frameworks for mechanisms between PTSD and parenting; 3) the lack of developmental perspectives; 4) the overuse of self-reported retrospective measures; 5) the need to study more diverse samples and cultural contexts; and 6) the lack of research on resilience and post-traumatic growth in parenting. Based on these reflections, we offer suggestions on strategies for responding to these challenges through: 1) welcoming open science; 2) working towards shared theoretical frameworks; 3) doing more longitudinal research 4) expanding the methodological palette; 5) centering lived experience; and 6) taking systemic inequality into account.

CONCLUSION

With this commentary, we aim to open a discussion on next steps towards a more comprehensive understanding of the association between PTSD and parenting, and inspire collaborative research.

Childhood Maltreatment History and Borderline Personality Symptoms: The Role of Mentalization Difficulties Among Vulnerable Women

Mentalization difficulties may be one reason why individuals who experienced childhood maltreatment (CM) are at increased risk for borderline personality (BP) symptoms. The goal of this study was to identify specific aspects of mentalization associated with CM and determine their role in the short-term course of BP symptoms. A total of 253 mothers with a previous mental health diagnosis completed online surveys at three times over 9 months. A cross-lag panel model was tested to estimate reciprocal effects between mentalization measures and BP symptoms and indirect effects from CM to mentalization to BP symptoms. At baseline, women with more CM endorsed more difficulty with general mentalization, emotional clarity, and reflecting on childhood experiences. Lack of emotional clarity and disorganized responding about childhood served as indirect paths from CM to subsequent BP symptoms and showed bidirectional associations with BP symptoms over time. Thus, these may be particularly important treatment targets in this population.

Adolescent mentalizing and childhood emotional abuse: implications for depression, anxiety, and borderline personality disorder features

Background

There is preliminary evidence that childhood emotional abuse (CEA) is a risk factor for adolescent mentalizing difficulties (Uncertainty/Confusion about mental states) and borderline personality features and that Uncertainty/Confusion about mental states mediate the relationship between CEA and adolescent borderline personality features, but these findings need replication. Furthermore, no previous studies have examined the relationship between adolescent mentalizing deficits, anxiety, and depression in the context of CEA.

Objectives

This study examined the associations between CEA, adolescent borderline personality features, depression and anxiety symptoms and tested a pathway model where Uncertainty/Confusion about mental states mediates the relationships between CEA and adolescent borderline personality features, depression and anxiety symptoms.

Method

A clinical sample of 94 adolescents completed the Reflective Function Questionnaire for Youth (RFQY) to assess mentalizing, the Childhood Experiences of Care and Abuse Questionnaire (CECA-Q), the Borderline Personality Disorders Features Scale (BPFS-C), and the Beck Youth Inventories for Depression (BDI-Y) and Anxiety (BAI-Y).

Results

Uncertainty/Confusion about mental states partially mediated the relationship between CEA and borderline traits as well as anxiety. In addition, there was an indirect effect where CEA predicted Uncertainty/Confusion about mental states, which then predicted depression.

Discussion

The findings are consistent with the mentalizing model of psychopathology and provide new evidence that Uncertainty/Confusion about mental states might be a critical mentalizing deficit that characterizes the associations between CEA and adolescent BPD features and depression and anxiety symptoms. Uncertainty/Confusion may be a transdiagnostic risk factor for adolescent psychological distress and dysfunction. We discuss the clinical implications.

A deeper look at the association between childhood maltreatment and reflective functioning

Childhood maltreatment is theorized as impeding the development of reflective functioning (RF; ability to perceive and interpret oneself and others in terms of mental states). However, previous research typically failed to support this association or yielded small sized and mixed associations. This study aims to provide a deeper look at the association between childhood maltreatment and RF by characterizing two non-mentalizing categories. One-hundred-and-sixteen pregnant women (mean age = 27.62, SD = 4.52) from the community (48.3% with a university degree, 96.5% in a relationship with the other parent) retrospectively reported on childhood abuse and neglect using the Childhood Trauma Questionnaire. They also participated in the Adult Attachment Interview subsequently coded using the Reflective Functioning Scale. Participants with poor to low RF were allocated to one of two groups (disavowal-distancing or distorted-inconsistent) using indicators provided in the RF Scale. No association was found between childhood maltreatment and overall RF when controlling for education level. A multinomial logistic regression revealed that childhood maltreatment was strongly predictive of a disrupted, over-analytical and inconsistent reflection about mental states but not of a tendency to discourse little about mental states. This tendency was rather only predicted by education level. Findings suggest that childhood maltreatment would lead to specific impairments in RF and that not considering how individuals fail to mentalize about attachment relationships may mask strong associations between RF and its determinants and correlates, including childhood maltreatment.

The effect of childhood maltreatment on adult survivors' parental reflective function, and attachment of their children: A systematic review

BACKGROUND

Parental reflective function (PRF) is a candidate mechanism in the transmission of intergenerational trauma. This systematic review examined (1) the association between parental history of childhood maltreatment and PRF, (2) how PRF relates to attachment in children of parent survivors, and (3) whether PRF moderates the association between parental maltreatment history and child attachment.

METHODS

Ten databases were searched (from inception to 10^th November 2021). Inclusion criteria were primary study, quantitative, parent participants, measures of childhood maltreatment, and postnatal PRF. Exclusion criteria were qualitative, intervention follow-up, gray literature, or a review study. Risk of bias was assessed using recommended tools. Data were narratively synthesized.

RESULTS

One-thousand-and-two articles were retrieved, of which eleven met inclusion criteria (N = 974 participants). Four studies found a significant association between parental childhood maltreatment and disrupted PRF, six did not, one found mixed results. One study reported the association between childhood maltreatment and attachment (nonsignificant results).

DISCUSSION

There is no clear evidence PRF is routinely disrupted in parent survivors, though there is high heterogeneity in studies. Future research should standardize design to better understand whether PRF is a candidate mechanism in intergenerational trauma.

OTHER

PROSPERO CRD42020223594.

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.

Exploring and Deepening the Facets of Mentalizing: The Integration of Network and Factorial Analysis Approaches to Verify the Psychometric Properties of the Multidimensional Mentalizing Questionnaire (MMQ)

Mentalization is a complex and multifaceted trans-theoretical and trans-diagnostic construct that has found increasing application in the clinical context. This research aimed at deepening the psychometric properties of the Multidimensional Mentalizing Questionnaire (MMQ), a 33-item theoretically based self-report questionnaire allowing for a comprehensive assessment of mentalizing, by integrating factor analysis and network analysis approaches. A sample of 1640 participants (M_age = 33 years; SD = 13.28) was involved in the research. The six-factor structure was confirmed for the MMQ, and both the total and the subdimensions demonstrated good reliability. The network analysis has further enriched these results, showing the central role of the items attributable to Emotional Dysregulation or Reflexivity in influencing the network as well as the contribution of aspects related to Relational Discomfort in managing the flow of communication flow. Such findings may have useful clinical implications and emphasize the usefulness of the MMQ in both research and clinical practice.

On the complex and dimensional relationship of maternal posttraumatic stress disorder during early childhood and child outcomes at school-age

BACKGROUND

Several studies have shown associations between maternal interpersonal violence-related posttraumatic stress disorder (PTSD), child mental health problems, and impaired socioemotional development. However, the existing literature lacks evidence linking constellations of risk factors such as maternal interpersonal-violence-related PTSD, psychopathology, and interactive behavior with toddlers and outcome measures at school-age.

METHODS

This study involved a prospective, longitudinal investigation of 62 mothers and examined the relationship between maternal variables measured when children were in early childhood (mean age 27 months), and child outcomes when children were school-age (age mean = 83.2 months) while retaining a focus on the context of maternal PTSD. To identify and weigh associated dimensions comparatively, we employed sparse canonical correlation analysis (sCCA) aimed at associating dimensions of a dataset of 20 maternal variables in early childhood with that of more than 20 child outcome variables (i.e., child psychopathology, life-events, and socioemotional skills) at school-age.

RESULTS

Phase 1 variables with the highest weights were those of maternal psychopathology: PTSD, depressive and dissociative symptoms, and self-report of parental stress. The highest weighted Phase 2 child outcome measures were those of child psychopathology: PTSD, anxiety, and depressive symptoms as well as peer bullying and victimization.

CONCLUSIONS

sCCA revealed that trauma-related concepts in mothers were significantly and reliably associated with child psychopathology and other indicators of risk for intergenerational transmission of violence and victimization. The results highlight the dimensional and multifaceted nature-both for mothers as well as children-of the intergenerational transmission of violence and associated psychopathology.

Childhood maltreatment and sense of parenting competence: The mediating role of parental reflective functioning and perceived social support

OBJECTIVES

Childhood maltreatment has a negative impact on a sense of parenting competition. However, its underlying mechanisms are still unknown. The present research aimed to investigate the roles of parental reflective functioning and social support as mediating factors in the relationship between childhood maltreatment and negative feeling of parenting competence.

METHODS

A cross-sectional study was carried out on 489 parents of children aged 5 to 13 between October 23 and December 12, 2021, in Shiraz, Iran. Participants completed the Childhood Trauma Questionnaire (CTQ), Parenting Sense of Competence Scale (PSOC), Perceived Social Support Scale (PSSS), and Parental Reflective Functioning Questionnaire (PRFQ). Structural equation modeling (SEM) was applied using AMOS 22 to test our conceptual model.

RESULTS

The results of structural equation modeling indicated that childhood maltreatment had a negative direct effect on the sense of parenting competence. Furthermore, childhood maltreatment had a negative indirect effect on the sense of parenting competence through both parental reflective functioning and perceived social support.

CONCLUSIONS

The findings suggested that increased exposure to childhood maltreatment may have decreased parental competence. However, the important role of parental reflective functioning and perceived social support in the relationship between childhood maltreatment and parenting competence should not be ignored. These results can have some implications for counselors working with parents with childhood trauma experiences.

Personality functioning and the pathogenic effect of childhood maltreatment in a high-risk sample

BACKGROUND

While the psychopathological sequalae of childhood maltreatment are widely acknowledged, less is known about the underlying pathways by which childhood maltreatment might lead to an increased risk for mental health problems. Recent studies indicated that impaired personality functioning might mediate this relationship. The aim of the present paper was to extend the current literature by investigating the mediating effect of impaired personality functioning between different types of childhood maltreatment and self-reported mental health problems in a high-risk sample.

METHODS

Overall, 173 young adults (mean age = of 26.61 years; SD = 3.27) with a history of residential child welfare and juvenile justice placements in Switzerland were included in the current study. The Childhood Trauma Questionnaire (CTQ-SF), Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1) and the self-report questionnaires of the Achenbach System of Empirically Based Assessment scales (ASEBA) were used. Mediation analyses were conducted through structural equation modeling.

RESULTS

Overall, 76.3% (N = 132) participants indicated at least one type of childhood maltreatment, with emotional neglect being most commonly reported (60.7%). A total of 30.6% (N = 53) participants self-reported mental health problems. Emotional abuse (r = 0.34; p < .001) and neglect (r = 0.28; p < .001) were found to be most strongly associated with mental health problems. In addition, impaired personality functioning was fond to be a significant mediator for overall childhood maltreatment (β = 0.089; p = 0.008) and emotional neglect (β = 0.077; p = 0.016). Finally, impaired self-functioning was found to be a significant mediator when both self-functioning and interpersonal functioning were included as potential mediators in the relationship between overall childhood maltreatment (β1 = 0.177, p1 = 0.007) and emotional neglect (β1 = 0.173, p1 = 0.003).

CONCLUSION

Emotional neglect may be particularly important in the context of childhood maltreatment, personality functioning, and mental health problems and, therefore, should not be overlooked next to the more "obvious" forms of childhood maltreatment. Combining interventions designed for personality functioning with trauma-informed practices in standard mental health services might counteract the psychopathological outcomes of maltreated children and adolescents.

Psychoanalytic Interventions with Abusive Parents: An Opportunity for Children's Mental Health

Research has extensively shown that most people who experience maltreatment in their childhood develop mental disorders, psychosocial adjustment problems, and, in many cases, become maltreating adults themselves. Preventing child maltreatment and treating abused children and abusive parents are, therefore, pressing public health issues. As established by the UK Children Act in 1989, child development is enhanced by remaining in the family whenever the child's safety is assured. Thus, developing prevention and intervention programs for the purpose of repairing, whenever possible, the child-parent relationship should be a social priority. This narrative review focuses on the psychoanalytic studies related to intrapsychic dynamics and therapeutic intervention for physically abusive parents. The role of the transgenerational transmission of abuse and parents' narcissistic fragility is crucial. Psychoanalytic interventions focus on helping the parent work through their past painful experiences and narcissistic vulnerability. Parent-child psychotherapy and mentalization-based treatment have been found to be prevalent, while there is scarce literature regarding intensive individual psychoanalytic treatment. Within the framework of attachment theory, brief interventions were developed; however, they did not prove effective for those parents who suffered experiences of maltreatment or severe neglect in childhood and for whom long-term parent-child psychotherapy resulted, which proved to be the most effective.

Childhood trauma and posttraumatic stress symptoms in adolescents and young adults: The mediating role of mentalizing and emotion regulation strategies

OBJECTIVES

Childhood trauma (physical, emotional, sexual abuse and/or physical and emotional neglect) represents a specific risk for developmental perturbations and long-term negative outcomes. Adolescents and young adults with childhood trauma have rarely experienced a single type of traumatic event but rather multiple traumatic experiences. However, studies on adolescent PTSD are sparse. This study examines the possible mediating role of mentalizing, cognitive and interpersonal emotion regulation strategies between multiple types of childhood trauma exposure and PTSD in adolescents and young adults.

METHODS

The sample consisted of 456 adolescents and young adults aged 15 and 25, recruited from four high schools and one university. Participants completed self-report questionnaires assessing childhood trauma, mentalizing, cognitive and interpersonal strategies of emotion regulation and PTSD.

RESULTS

Structural Equation Modeling revealed that multiple types of childhood trauma exposure have a significant indirect effect on PTSD symptoms through its association with hypomentalizing and maladaptive cognitive strategies of emotion regulation (i.e. self-blame, rumination, catastrophizing). Results also showed a significant indirect effect between multiple types of childhood trauma exposure and PTSD symptoms through its association with hypomentalizing and maladaptive interpersonal strategies of emotion regulation (i.e. emotional reactivity and tendency to avoid emotional connection). Indirect paths were also run in reverse to control for the direction of the effect.

CONCLUSION

Our findings show that exposure to multiple types of childhood trauma contributes to severe PTSD through several complex pathways including both hypomentalizing and maladaptive emotion regulation strategies in adolescence and young adulthood.

Conceptualisation and Measurement of Reflective Process in Psychotherapy: A Systematic Scoping Review

Psychological therapies use talk as a means to produce change for individuals who are experiencing distress. Despite a significant body of research comparing approaches, there is little evidence for the superiority of one model over another. The process of reflection has been suggested as a common factor across modalities, and research aiming to measure this phenomenon is emerging. This scoping review is focussed on the conceptualisations, measurement and process outcomes of reflective talk as it occurs during therapy. Twenty-two studies were selected from a total of 3712 papers identified following a systematic search of SCOPUS, MEDLINE, PsychINFO and Web of Science databases. A variety of descriptors emerged: intrapersonal constructs such as mentalization and metacognition tended to view reflectivity as an individually acquired skill or trait, where other descriptors adopted an interpersonal understanding of reflection as co-constructed through dialogue. Our findings suggest a shift from individual to intersubjective understandings of reflecting processes in therapy may be a valuable area for future research.

Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary research on Developmental Trauma (DT), which is inextricably linked to disruptions in social cognition, physiological and behavioral regulation, and parent-child attachments. Developmental trauma associated with early experiences of abuse or neglect leads to multi-faceted and longstanding consequences and underscores critical periods of development, complex stress-mediated adaptations, and multilevel, trans-theoretical influences in the diagnostic formulation and treatment of traumatized children, adolescents, and adults. Psychological and medical correlates of Developmental Trauma Disorder are considered, and directions for future research are discussed.

When Parents Fail to Mind the Child: Lower Mentalizing in Parents Who Maltreat Their Children

Mentalization is considered an essential ability for social cognition as well as a crucial competency in parenting to further the development of internal structures that are decisive for self organization and affect regulation in children. Yet, few empirical studies have investigated whether, and to what extent, parents who maltreat their children poorly mentalize. The aim of this research was to study the mentalization ability in a group of parents who maltreated their children and had been referred by the Courts for Child Custody and Parenting Plan Evaluation (Group 1), and in a comparison, non-clinical group of parents (Group 2). Adult Attachment Interview (AAI), rated in terms of both the Berkeley AAI System and the Reflective Functioning Scale was administered. Group 1 had severely impaired reflective functioning (RF) in 83.3% of cases, whilst impaired RF was found in only 12.5% of Group 2 parents. For the most part, parents in Group 1 showed Negative Reflective Functioning, systematically resisting taking a reflective stance, and the parents who most severely maltreated their children showed distorted and/or self-serving passages associated with a particular type of dismissing pattern of attachment (DS2) based on the derogation of attachment. The frequent occurrence of derogation in these parents likely explains how much the devaluation of relationships and attachment needs, presumably acquired during childhood with defensive purposes and in order to exclude the pain and perception of emotional weakness from awareness, hinders the capacity to care for children in the full respect of their needs.

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.

Development and validation of a self-report measure assessing failures in the mentalization of trauma and adverse relationships

BACKGROUND

The way people process trauma and adverse relationships may be more predictive of subsequent adaptation than trauma exposure in itself. However, there is currently no self-report instrument assessing failures in the mentalization of trauma and adverse relationships.

OBJECTIVE

We developed the Failure to Mentalize Trauma Questionnaire (FMTQ) and evaluated its psychometric properties. The FMTQ is a 29-item self-report instrument designed to assess different indications of failures in the mentalization of trauma and adverse relationships.

PARTICIPANTS AND SETTING

A total of 975 participants (84 % women; 37 % exposed to child maltreatment) were recruited in the course of larger research protocols on parenting.

METHODS

Participants completed the FMTQ and measures of childhood maltreatment, psychopathology (post-traumatic stress symptoms, dissociative symptoms, level of personality dysfunction), general mentalization and intimate partner violence.

RESULTS

Exploratory factor analysis, supported by a confirmatory factor analysis, identified seven factors with good internal consistency that corresponded to different types of failures in the mentalization of trauma and adverse relationships and that loaded on a general factor. A dose-effect association was observed between the severity of childhood maltreatment, and the severity of failures in the mentalization of trauma and adverse relationships (r_s = .49, p < .01). The FMTQ total score explained a significant proportion of variance in psychopathology and intimate partner violence, both in participants with histories of childhood maltreatment and participants without childhood maltreatment.

CONCLUSION

The FMTQ is a promising, concise and efficient measure of failures in the mentalization of trauma and adverse relationships that may facilitate clinical screening and research with adults who experienced trauma.

The psychological factors mediating/moderating the association between childhood adversity and depression: A systematic review

Accumulating evidence suggests that individuals with a history of childhood adversity are at greater risk for developing depression. Potential psychological mechanisms have not been well-established. Our study aims to identify psychological variables consistently mediating/moderating the link between childhood adversity to depression. We systematically searched articles from 1990 to October 2021 on online databases including PubMed, Web of Science and PsycINFO. Studies that examined a mediating/moderating role of psychological variables between childhood adversities and depression were included. Totally, 33 records were included. The review identified maladaptive schema, negative automatic thoughts, and avoidance as mediators of the relationship between childhood adversity and depression. Additionally, resilience was identified as both a mediator and moderator of the association between childhood adversity and depression. In general, cognitive dysfunction, avoidance behaviors and impaired resilience may be a by-product of childhood adversity and may contribute to increased risk for depression. Interventions that target at challenging negative cognition and improving resilience may be effective to prevent or treat depression in individuals with a history of childhood adversity.

Psychometric Properties and Measurement Invariance of the Childhood Trauma Questionnaire (Short Form) Across Genders, Time Points and Presence of Major Depressive Disorder Among Chinese Adolescents

Purpose

The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is a widely used self-report tool designed to assess juveniles' experiences of abuse and neglect. The current study examined the psychometric properties, particularly measurement invariance of the CTQ-SF in Chinese non-clinical adolescents and adolescents with major depressive disorder (MDD).

Methods

Participants included 1,507 high school students (non-clinical sample) from Hunan Province and 281 adolescent patients with major depressive disorder (MDD sample) from The Second Xiangya Hospital. We examined the reliability and validity of CTQ-SF, confirm the five-factor model of the CTQ-SF. Multiple-group confirmatory factor analysis (CFA) was used to examine the measurement invariance across genders, presence of depression, and over time.

Results

The CTQ-SF had good internal consistency in a non-clinical sample (Cronbach's α = 0.85) and MDD sample (Cronbach's α = 0.86). Good test-retest reliability (ICC = 0.72) and Adequate validity were also observed. Good fit of the five-factor CTQ-SF model was confirmed in both samples. Multiple-group CFA confirmed that the CTQ-SF had the scalar invariance across genders and the presence of MDD, as well as over time.

Conclusion

The CTQ-SF is an effective and reliable tool for assessing child maltreatment in Chinese adolescents (non-clinical sample and MDD sample). The results suggest that the horizontal and longitudinal invariance of CTQ-SF are strongly established, which means CTQ-SF can be meaningfully used to compare outcomes among Chinese adolescents (non-clinical sample and MDD sample). The experience of child maltreatment, especially neglect (emotional and physical), was found to be common in Chinese adolescents.

Mediation-Moderation Links Between Mothers' ACEs, Mothers' and Children's Psychopathology Symptoms, and Maternal Mentalization During COVID-19

Research has suggested adverse childhood experiences (ACEs) as a transdiagnostic risk factor for a variety of affective disorders. They are also linked with a parent's tendency toward affect dysregulation and hyperarousal, which may interfere with parenting and children's wellbeing. On the other hand, maternal mentalization can serve as a moderating factor that can help parents regulate their arousal, shielding children during adverse circumstances. We studied the mediated links between ACEs and mothers' and children's psychopathology symptoms during COVID-19 to determine whether maternal mentalization and the child's age moderate these links. Using results from 152 Israeli mothers of children aged 3-12 years recruited during the month-long lockdown in Israel, we documented that the mothers' ACEs were linked with increased risk of depressive and anxiety symptoms and with children's internalizing and externalizing behaviors. Moreover, as hypothesized, the mothers' symptoms of depression and anxiety mediated the links between their ACEs and their children's internalizing behaviors. In addition, the mothers' mentalization skills and, in the case of their depressive symptoms, their child's age, moderated these indirect links. For mothers of young children (3-6 years old) with higher mentalization levels, the link between the mothers' ACEs and the children's behavior problems was weaker compared to mothers with low mentalization levels. For mothers of older children (6-12 years old), and only in the case of maternal depressive symptoms, higher levels of maternal mentalization were linked with more internalizing behaviors. We discuss the potential clinical implications of the findings.

Parental Reflective Functioning as a Moderator of the Link Between Prematurity and Parental Stress

We examined group differences between parents, both mothers and fathers, of premature and full-term infants to determine whether they differed in their reports of subjective parenting stress and in their level of parental reflective functioning (PRF). We also tested whether each parent's reflective functioning moderated the links between birth status (prematurity vs. full-term) and parenting stress. A sample of 73 cohabiting, heterosexual Israeli families with a premature (28-36th week gestational age, N = 34) or full-term infant (37th week and above gestational age, N = 39) participated, comprising the two parents' groups. Infants' age averaged 7.07 months (SD = 1.28). Each parent completed the Parent Stress Inventory (PSI) individually to determine his/her subjective personal and childrearing stress levels. The Parent Development Interview (PDI-R2-S) was used to obtain each parent's PRF (self and child/relation-focused) level. Findings showed that the premature and full-term parents did not differ in their PSI scores or PRF levels. However, mothers' self-focused PRF moderated the link between prematurity and personal parenting stress, whereas fathers' self-focused PRF moderated the link between prematurity and childrearing parenting stress. Furthermore, fathers' and mothers' PRF operated differently in the premature and full-term parents' groups. The findings highlight the importance of mothers' and fathers' PRF in predicting parents' subjective stress in general and particularly in the case of infant prematurity. We discuss these findings and their relevance for preventive and therapeutic perinatal interventions.

Video Intervention Therapy for primary caregivers in a child psychiatry unit: a randomized feasibility trial

BACKGROUND

During child psychiatry hospitalization, working with the families or attachment figures is a challenge, most of the children who are admitted to these units come from multi-problem families, with limited research in this area. Video feedback (VF) interventions have proved to be a powerful resource to promote parental and child well-being in small children and has been used with parents with a psychiatric condition. Parental Reflective Functioning (PRF) is one of the parental abilities that can be improved with VF and could be especially important in coping with conflict and negative emotions in older children. The aim of this study is to implement Video Intervention Therapy (VIT) to enhance PRF in primary caregivers of inpatient psychiatric children. As there is no published research using VF with parents of children with severe psychopathology in a hospitalized context. This report, then, becomes a much needed pilot study providing evidence for a larger randomized control trial (RCT).

METHODS

The study is a single-center, two-arm feasibility randomized control trial with a qualitative component. Block randomization was done to generate a 2:1 allocation, leaving more participants in the intervention group. The intervention comprises four modules; every module has both one video-recorded play session and one VIT session (in a group setting) per week. Evaluation of the caregivers included assessments of PRF and well-being, and child assessment included parent-ratings and clinician-ratings of symptomatology and general functioning.

RESULTS

Thirty participants were randomized; eligibility and recruitment rate were 70.6% and 83.3%, respectively. The compliance-to-intervention rate was 85% in the VIT group and 90% in the control group. All participants completed entry evaluation and 90% at the 3-month follow-up. The intervention was acceptable to participants and feasible for therapists to deliver. Outcome data must be treated with caution due to the small numbers involved, yet indicate that the VIT may have a positive effect in improving parental and child mental health outcomes.

CONCLUSIONS

VIT for primary caregivers of child inpatient children was feasible to deliver and acceptable for participants, therapist, and the staff unit involved; there is sufficient evidence to undertake a full-scale effectiveness RCT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03374904 . Registered on 14 December 2017.

The effectiveness of psychoeducation interventions on prenatal attachment: A systematic review

OBJECTIVE

Positive prenatal attachment facilitates parental role adaptation and psychological adjustment during pregnancy, which is a significant predictor of postpartum attachment. The objective of this systematic review was to examine the effect of psychoeducation interventions on prenatal attachment of pregnant women and their partners.

DESIGN

Systematic literature searches of randomized controlled trials (RCTs) were conducted from January 2000 to January 2021, using databases: CINAHL, Embase, Medline, PsycInfo, PubMed, Web of Science and Cochrane Central Register of Controlled Trial and through hand-searching. Studies were independently selected by two reviewers, who also assessed the methodological quality of the included studies using the Cochrane Risk of Bias Tool. Narrative synthesis was conducted due to the significant clinical and methodological heterogeneity.

SETTING/PARTICIPANTS

Fifteen studies met the eligibility criteria for this review, among which 11 studies focused on pregnant women and four studies on their partners.

FINDINGS

The psychoeducation interventions in the included studies showed consistent favorable effects on prenatal attachment. Nine out of the 11 included studies showed statistical significant effects on maternal fetal attachment. Three out of the four studies reported significant effects favoring paternal fetal attachment.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The preliminary evidence suggests that psychoeducation interventions have potential favorable effects on maternal fetal attachment and can enhance paternal fetal attachment. However, more studies are needed for investigating the effects of psychoeducation on paternal fetal attachment and for enhancing the validity of the evidence. Our review recommends that healthcare professionals to include psychoeducation as a part of their prenatal care for promoting prenatal attachment. Common characteristics of the interventions could act as references when designing psychoeducation programs for enhancing prenatal attachment.

Link between History of Childhood Maltreatment and Emotion Dysregulation in Adults Suffering from Attention Deficit/Hyperactivity Disorder or Borderline Personality Disorder

Childhood maltreatment (CM) may have a long-term effect on emotion regulation. This study aimed to explore the relationship between CM and emotion dysregulation (ED) in a heterogeneous population. Four hundred seventy French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 ADHD + BPD, N = 61 clinical controls) completed the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), the Childhood Trauma Questionnaire (CTQ), and the Relationship Scales Questionnaire (RSQ). Reports of childhood maltreatment experiences were significantly associated with increased levels of emotion reactivity in all our groups and in the whole population, with a greater use of non-adaptive cognitive emotion regulation strategies and insecure attachment patterns. Emotional abuse showed the strongest effect. Further analysis indicated that an anxious attachment style significantly mediated the relationship between CM and the use of non-adaptive cognitive emotion regulation strategies and emotion reactivity. The results of our study suggest an impact of CM on ED and a potentially marked effect of emotional abuse. They also indicate a potentially mediating role of insecure attachment in the relationship between a history of childhood abuse and emotion reactivity and a higher use of non-adaptive cognitive emotion regulation strategies in adulthood.

“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.

Family Minds: A randomized controlled trial of a group intervention to improve foster parents' reflective functioning

Family Minds is a brief group psychoeducational parenting intervention designed to increase the reflective functioning (RF) and mentalization skills of foster parents. RF is important for foster parents who have to build relationships with children whose adverse experiences increase their risk for psychosocial challenges. A randomized controlled trial (RCT) for Family Minds was conducted in Texas with 89 foster parents. The main aims of this study were to examine whether the intervention could significantly increase the RF/mentalization skills of the foster parents and decrease their parenting stress. After 6 weeks, compared with the control group, intervention foster parents improved their RF via a lowering of pre-mentalizing and also significantly decreased parenting stress related to parent-child dysfunctional interactions. Other measures of RF and parenting stress showed no significant differences between groups. Foster child behavior was not significantly different between groups, although data at 6 months showed a possible lowering of internalizing symptoms for children of intervention parents. This RCT provides some encouraging evidence that Family Minds may increase RF in foster parents, improve parental sensitivity and their ability to emotionally regulate, decrease parenting stress related to challenging interactions with their foster children, and possibly decrease children's internalizing behavior.

Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders

Background: There are indications of associations between the ability to mentalize and psychological defense mechanisms. However, only a few studies have focused on these associations, and even fewer have included empirical analyses. In the present study, we aimed to fill this research gap by analyzing the link between the ability to mentalize and psychological defense mechanisms in patients with mental disorders. We examined whether changes in defense mechanisms are predicted by an increase in mentalization or whether such changes are only related to reductions in psychopathology and interpersonal problems. Methods: A clinical sample of N = 89 patients was studied during and after inpatient psychiatric rehabilitation. Repeated-measures analyses of variance were performed to determine changes in mentalization, psychological defense, psychopathology, and interpersonal problems over the course of therapy and post-treatment. Linear regression analyses were used to predict the change in defense patterns based on an increase in mentalization. Results: Maladaptive defense mechanisms were significantly reduced during inpatient therapy and remained low until follow-up, whereas neurotic and adaptive defense mechanisms did not change significantly. The results of the regression analyses indicated that mentalization played an important role in the reduction in maladaptive defense during and after inpatient rehabilitation for mental disorders, whereas reductions in psychopathology and interpersonal distress were only partially associated with a reduction in maladaptive defense. Conclusion: We conclude that mentalization is vital for reducing maladaptive defense mechanisms, which are commonly associated with mental disorders. In therapy, an increase in patients' capacity to mentalize may be a practicable approach to diminish maladaptive defense mechanisms.

Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic

INTRODUCTION

Prenatal maternal distress has a negative impact on the course of pregnancy, fetal development, offspring development, and later psychopathologies. The study aimed to determine the extent to which the coronavirus disease 2019 (COVID-19) pandemic may aggravate the prenatal distress and psychiatric symptomatology of pregnant women.

MATERIAL AND METHODS

Two cohorts of pregnant volunteer women were evaluated, one that was recruited before the COVID-19 pandemic (n = 496) through advertisements in prenatal clinics in Quebec, Canada, from April 2018 to March 2020; the other (n = 1258) was recruited online during the pandemic from 2 April to 13 April 2020. Prenatal distress and psychiatric symptomatology were measured with the Kessler Distress Scale (K10), Post-traumatic Checklist for DSM-5 (PCL-5), Dissociative Experiences Scale (DES-II), and Positive and Negative Affect Schedule (PANAS).

RESULTS

The 1754 pregnant women (M_age  = 29.27, SD = 4.23) were between 4 and 41 gestational weeks (M = 24.80, SD = 9.42), were generally educated (91.3% had post-high-school training), and financially well-resourced (85.3% were above the low-income cut-off). A multivariate analysis of covariance controlling for age, gestational age, household income, education, and lifetime psychiatric disorders showed a large effect size (ES) in the difference between the two cohorts on psychiatric symptoms (Wilks' λ = 0.68, F_6,1400  = 108.50, P < .001, partial η²  = 0.32). According to post-hoc analyses of covariance, the COVID-19 women reported higher levels of depressive and anxiety symptoms (ES = 0.57), dissociative symptoms (ES = 0.22 and ES = 0.25), symptoms of post-traumatic stress disorder (ES = 0.19), and negative affectivity (ES = 0.96), and less positive affectivity (ES = 0.95) than the pre-COVID-19 cohort. Women from the COVID-19 cohort were more likely than pre-COVID-19 women to present clinically significant levels of depressive and anxiety symptoms (OR = 1.94, χ² [1] = 10.05, P = .002). Multiple regression analyses indicated that pregnant women in the COVID-19 cohort having a previous psychiatric diagnosis or low income would be more prone to elevated distress and psychiatric symptoms.

CONCLUSIONS

Pregnant women assessed during the COVID-19 pandemic reported more distress and psychiatric symptoms than pregnant women assessed before the pandemic, mainly in the form of depression and anxiety symptoms. Given the harmful consequences of prenatal distress on mothers and offspring, the presently observed upsurge of symptoms in pregnant women calls for special means of clinical surveillance.

A New Parental Mentalization Focused Ultrasound Intervention for Substance Using Pregnant Women. Effect on Self-reported Prenatal Mental Health, Attachment and Mentalization in a Randomized and Controlled Trial

The effect of a novel mentalization-based parenting intervention was explored on prenatal self-reported mentalization (P-PRFQ), attachment (MFAS), depression (EPDS) and anxiety (STAI) among women with substance use problems. The participants were 90 pregnant women referred to obstetric outpatient care due to recent or current substance use and randomized into intervention (n = 46) and control (n = 44) groups. The intervention group received three interactive 4D ultrasound sessions and a week-by-week pregnancy diary. The control condition was constituted of treatment-as-usual in obstetric care. Unfortunately, the efficacy of the intervention on maternal prenatal mental health, attachment, and parental mentalization was not substantiated. The negative results may be related to the small sample size, the patient-reported outcomes, or insufficient efficacy within this high-risk group. In the context of high psychosocial risks and follow-up by Child Welfare Services, the patient-reported outcomes may have underestimated prenatal adversity. The role of the research context, methodology, and possible sources of bias in the outcome assessment are discussed.

The trial registration number in the ClinicalTrials.gov: NCT03413631

The Effect of Grandmothers' Presence on the Provision of Multidisciplinary Perinatal Support for Pregnant and Postpartum Women with Psychosocial Problems

Background

Pregnant and postpartum women with psychosocial problems are prone to face limited or absent perinatal functional support from biological grandmothers due to familial dysfunction. The study aimed to investigate whether the involvement and presence of biological maternal grandmothers providing practical support for their pre/postnatal daughters (ie, pregnant women) during the perinatal period may influence the number of support services provided by multidisciplinary agencies, including child consultation centers and municipal offices.

Participants and methods

This is a retrospective cohort study based on the medical records of all pregnant women with psychosocial problems that visited, gave birth, and received intervention from the hospital-based child protection unit at the Chiba University Hospital between February 2018 to March 2019. The primary outcome was to identify whether there was a difference in the number of multidisciplinary agencies providing perinatal support between pregnant women with and without the presence of functional support from biological maternal grandmothers during the perinatal period.

Results

We identified 114 pregnant and postpartum women with psychosocial problems. Seventy-six of these participants (66.7%) had functional support from their biological maternal grandmothers during the perinatal period, and 38 participants (33.3%) did not. The number of agencies involved with participants who lacked functional support was significantly higher than participants with functional support (t(55.14) = 2.98, p < 0.01). This finding was consistent among pregnant and postpartum primipara participants (n = 70) (t(68) = 3.87, p < 0.001), but not multipara (n = 44).

Conclusion

The findings indicate that the presence and functional support of biological maternal grandmothers influence the support that is needed from multidisciplinary perinatal support systems by pregnant and postpartum women with psychosocial problems. Primipara mothers without support from their own mothers may need greater multidisciplinary support.