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

Effects of multi-component parenting and parental mental health interventions on early childhood development and parent outcomes: a systematic review and meta-analysis

BACKGROUND

Interventions supporting parents of young children often target parenting or parental mental health separately. Multi-component parenting and parental mental health interventions have the potential to improve parenting practices, mental health, and early childhood development. We aimed to examine their impact on child and parent outcomes.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science Core Collection, APA PsycINFO, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and the Global Health Database from inception to Jan 23, 2024. Eligible studies were randomised controlled trials of interventions explicitly targeting parenting behaviours and parental mental health antenatally or in children's first 3 years of life. Screening, extraction, and quality assessment were done independently by two authors. Primary outcomes were cognitive and social-emotional functioning in children and depressive symptoms in parents, meta-analysed as standardised mean differences (SMDs), relative to control. This study is registered with PROSPERO, CRD42022302848.

FINDINGS

We found 5843 records. After screening 2636 (45·1%) titles and abstracts, we manually identified and screened three additional articles and excluded 2177 records. After screening 462 full-length articles, 25 articles, representing a sample size of 8520 children and caregivers, were included. At baseline, mean caregiver age was 27·7 years (SD 5·9) and mean child age (excluding those enrolled during pregnancy) was 14·4 months (8·0). Interventions lasted a mean of 14 months (SD 11) and used a mean of 3·7 behaviour change techniques (2·0). Most interventions dedicated more time to parenting behaviours than to parental mental health. We found significant intervention effects on children's cognitive (SMD 0·19 [95% CI 0·04 to 0·34]; I2=69%) and social-emotional (0·26 [0·17 to 0·34]; I2=47%) outcomes but not on depressive symptoms in female caregivers (-0·18 [-0·36 to 0·002]; I2=86%) relative to control conditions. Risk of bias across studies was moderate, and we found heterogeneity across results.

INTERPRETATION

Multi-component parenting and mental health interventions had a positive effect on child cognitive and social-emotional outcomes, but not on depressive symptoms in parents, suggesting that other factors might contribute to positive ECD outcomes. Interventions might lack adequate focus on mental health to make a discernible impact, highlighting a need for future studies to differentiate and assess contributions of parenting and mental health components to understand independent and collective effects on family outcomes.

FUNDING

Canadian Institutes of Health Research.

Online Intervention Targeting Postnatal Depression and Anxiety in Chilean First-Time Mothers: Feasibility Trial

OBJECTIVE

Internet-based interventions may positively impact maternal symptoms of postnatal depression and anxiety. This study assessed the feasibility, acceptability, perceived usefulness, and preliminary effectiveness of an m-Health version of "What Were We Thinking?" (m-WWWT).

METHODS

A mixed-methods with a 2-arm randomized parallel design was used. From a total of 477 women, 157 met the inclusion criteria. 128 first-time mothers of full-term infants, aged 4-10 weeks, who received health care at primary public health centers in Chile, were randomly assigned to the experimental (EG, n = 65) or control (CG, n = 63) groups; data of 104 of them (53 and 51, respectively) was analyzed. We used percentages and rates to measure feasibility outcomes and mixed analysis of variance (ANOVA) and latent class analyses (LCA) to assess preliminary effectiveness. Participants completed questionnaires on mental health, social support, and maternal self-efficacy upon recruitment and 3 months after completing the intervention. For the qualitative component, 12 women from the EG were interviewed.

RESULTS

Quantitative results show good feasibility outcomes, such as high recruitment (82%), low attrition (EG = 12% and CG = 17%), and high follow-up (EG = 97% and CG = 91%) rates. Qualitative results indicate high acceptability and perceived usefulness of m-WWWT. Mixed ANOVA did not show significant differences between the groups (all p >.05). However, multinomial regression analysis in LCA showed that women with low baseline symptoms of depression and anxiety benefit from the intervention (B = 0.43, 95% confidence interval 1.09-2.16).

CONCLUSION

m-WWWT is feasible to be implemented in Chile; future studies are needed to assess the intervention's effectiveness.

I'm with you, baby: Using parental embodied mentalizing in a pilot study to capture change following the circle of security parenting intervention

Supported by a large body of work demonstrating the impact of infant attachment representations on subsequent development, numerous therapeutic programs have been developed to promote secure attachment, with increasing focus on parental mentalizing. Nonetheless, empirical evidence supporting their effectiveness has yet to be fully established. The current pilot study (N = 24) was designed to evaluate whether and to what extent parents' shifts in parental mentalizing following a brief attachment-based group intervention, namely circle of security parenting (COSP; Cooper, Hoffman & Powell, 2009) can be captured using the parental embodied mentalizing instrument (PEM; Shai & Belsky, 2017). Compared to a waiting list-control group, this small-scale study examined whether community-based low-risk mothers of infants aged 5-48 months show an increase in their observed PEM capacities following the intervention. Secondary self-reported outcome variables parental stress, feeling of competence, and self-compassion. Findings show that PEM ratings improved significantly over time in the COSP group, but not in the control group. Intervention group mother-infant dyads also presented significantly longer embodied interactions communication post intervention compared to the control group. No effects of the COSP on parental stress, competence, or self-compassion were found. Despite the small sample size, these results tentatively suggest that COSP can improve embodied mentalizing abilities.

How do maternal and child health nurses incorporate infant mental health promotion into their clinical practice? Experiences of an Australian municipality

The field of infant mental health (IMH) has offered valuable insights into the critical importance of social-emotional development, including the enduring influence of early experiences throughout life. Maternal and Child Health (MCH) nurses are ideally placed to facilitate knowledge sharing with parents. This Australian-based qualitative exploratory descriptive study explored how MCH nurses incorporate IMH in their clinical practice, and how they share this information with caregivers. Ten community-based MCH nurses participated in voluntary, semi-structured interviews which were transcribed verbatim and analyzed thematically. Findings identified five themes that characterized how MCH nurses incorporated IMH concepts into their practice. These themes were: prioritizing physical health promotion activities, highlighting infant communications, variations in knowledge and application of IMH concepts, workplace time schedules, and the relational nature of the work. Recommendations include encouraging IMH as a health promotion activity, facilitating IMH assessment, further education, reflective supervision, and extension of predetermined appointment times to enable knowledge and skill sharing. Further research is also recommended to provide additional insights into how nurses with IMH training promote and share IMH concepts with caregivers. Adoption of these recommendations would further enhance the care given to families and the role of the MCH nurses.

A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development

This review summarizes the implementation characteristics of parenting interventions to promote early child development (ECD) outcomes from birth to 3 years. We included 134 articles representing 123 parenting trials (PROSPERO record CRD42022285998). Studies were conducted across high-income (62%) and low-and-middle-income (38%) countries. The most frequently used interventions were Reach Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were delivered as home visits. The other half used mixed settings and modalities (27%), clinic visits (12%), and community-based group sessions (11%). Due to the lack of data, we were only able to test the moderating role of a few implementation characteristics in intervention impacts on parenting and cognitive outcomes (by country income level) in the meta-analysis. None of the implementation characteristics moderated intervention impacts on cognitive or parenting outcomes in low- and middle-income or high-income countries. There is a significant need in the field of parenting interventions for ECD to consistently collect and report data on key implementation characteristics. These data are needed to advance our understanding of how parenting interventions are implemented and how implementation factors impact outcomes to help inform the scale-up of effective interventions to improve child development.

Parenting the parent without losing sight of the child. A qualitative study of therapists' experiences with intergenerational adversities in perinatal psychotherapy

The complex work of addressing intergenerational adversities, like violence, abuse, and neglect through perinatal psychotherapy, is understudied. Especially noticeable is the paucity of studies giving voice to the therapists. This study explored therapeutic processes through the perspectives of seven Norwegian therapists. A qualitative approach was chosen with individual interviews and a follow-up focus group. Data were analyzed using reflexive thematic analysis. We identified one overarching theme: To maintain a reflective therapeutic capacity, and two main themes with associated subthemes: 1) Alliance work when a caring system comes to therapy to fight generations of adversities and 2) The complex therapeutic work of addressing generational adversities in perinatal psychotherapy. Findings from the present study indicate that maintaining a reflective stance is essential yet challenging when addressing intergenerational adversities, requiring a holding environment for the therapists. The primary vehicle of change was perceived as a safe enough therapeutic alliance to explore new ways of being together, contrasting earlier experiences. A key question raised was how to give caregivers enough time to trust the therapist without compromising the safety and development of the child. The essence of the therapeutic work was to reduce risk factors and increase protective factors through multiple ports of entry.

Applications of dialectical behavioural therapy in the perinatal period: A scoping review

Psychological distress is the most common complication of pregnancy. High-risk concerns can include severe emotion dysregulation, suicidality and self-injury, and health risk behaviours, which bear substantial consequences for caregivers and families. Yet, effective, comprehensive interventions for high-risk caregivers have received limited attention. Dialectical behaviour therapy (DBT) is a frontline treatment for such concerns. Accordingly, we conducted a scoping review on the implementation of DBT in the perinatal period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Seven studies were identified; study designs included case studies and single-arm pilot trials. Most studies used DBT-informed protocols with significant adaptations, few included multiple components of DBT (i.e. skills group, individual therapy, phone coaching and consultation team), and none met criteria for adherent delivery of all four modes of DBT treatment. Findings suggest DBT-informed interventions may be successfully implemented to treat a range of perinatal mental health symptoms, including borderline personality disorder, depression, anxiety, and post-traumatic stress, and to promote emotion regulation and positive parenting behaviours. While results provide preliminary support for perinatal DBT, this literature is scant and empirical rigour considerably lacking. Clinical implications and future directions are outlined to aid researchers and providers in addressing the ongoing perinatal mental health crisis and developing sorely needed interventions to address the needs of high-risk caregivers.

Harsh parenting among veterans: parents' military-related PTSD, mentalization, and pre-military trauma

Objectives

Veteran parents experiencing posttraumatic stress disorder (PTSD) may resort to harsh parenting. The indirect pathway from parental military-related PTSD to harsh parenting, and the moderating role of parents' pre-military trauma histories, has been less explored. Informed by mentalization theory, as well as trauma-sensitive and posttraumatic growth perspectives, we aim to explore the associations between veteran parents' military-related PTSD, mentalization, harsh parenting, and prior trauma before military service.

Methods

Data were collected from an online research panel of 509 veteran parents with children under 10. We employed Structural Equation Models to test indirect and moderating effects.

Results

We identified an indirect effect of parental pre-mentalization from military PTSD to harsh parenting [corporal punishment: b = 0.35, p < 0.001, 95% CI (0.23, 0.46); psychological aggression: b = 0.14, p < 0.001, 95% CI (0.09, 0.19)]. Multi-group analysis on four parent groups (parents with only pre-military physical trauma, parents with only pre-military psychological trauma, parents with both pre-military physical and psychological trauma, and parents with no pre-military physical or psychological trauma) highlighted differences in these associations, particularly between parents with only pre-military physical trauma and those without any physical and psychological trauma. The military-related PTSD effects on psychological aggression, corporal punishment, and pre-mentalization were all significantly higher for parents without pre-military physical and psychological trauma.

Conclusion

Modifying parents' interpretation of their child's mental states can potentially counteract the effects of veterans' military PTSD on harsh parenting. Family-based programs should be created considering veteran parents' pre-military trauma histories.

Mind-mindedness and styles of interaction of young fathers with their infants at three months: a pilot study

BACKGROUND

Fatherhood at a young age can be characterized by a multiproblematic background with several risk factors that can negatively affect father-child relationships, the father's well-being and child's social-emotional development.

METHODS

This pilot study evaluated paternal interaction styles and mentalization in a sample of 22 young fathers and their 3-month-old infants and compared these variables with those of 22 adolescent and young mothers (the fathers' partners). Parent-infant interaction were codified with Care-Index to evaluate styles of interaction and with Mind-Mindedness system to evaluate mentalization.

RESULTS

The results showed that young fathers had high scores in controlling behaviors and low scores in sensitivity, placing them in a risk range. The young father's interaction profile did not differ from the young mother's interaction profile. Infants had high scores in passive behaviors and low scores in cooperative behaviors, placing them in a high-risk range. Moreover, young fathers had more nonattuned mind-related comments than their partners.

CONCLUSIONS

The findings indicate that low responsiveness and low mind-mindedness characterize the quality of adolescent and young father-infant interactions, highlighting the value of providing early intervention to support the father-child relationship, enhancing the father's sensitivity and his ability to keep the infant in mind.

Impact of the Mediational Intervention for Sensitizing Caregivers on Mentalizing in Orphans and Vulnerable Children in South Africa

The Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalization-based intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa working with Community-Based Organization (CBO) careworkers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child's early environment as critical resources for enhancing children's mentalizing capacity. In this study we evaluated the treatment effect of MISC on children's mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.

Parental mentalising among mothers with intellectual disability or ADHD: Links with experiences of abuse, neglect and psychosocial risk

BACKGROUND

Parental mentalising difficulties are robustly linked to caregiving problems. Mothers with intellectual disability are at risk for caregiving problems, but knowledge on their parental mentalising abilities is lacking. The present study aimed to fill this gap.

METHOD

Thirty mothers with mild intellectual disability, and 61 comparison mothers with ADHD, were assessed for parental mentalising using the Parental Reflective Functioning Questionnaire. Contributions of intellectual disability, maternal exposure to childhood abuse/neglect and psychosocial risk to parental mentalising were examined through hierarchical regression analysis.

RESULTS

Mothers with intellectual disability had a heightened risk for parental mentalising difficulties, in the form of elevated prementalising. Intellectual disability and cumulative childhood abuse/neglect uniquely predicted prementalising among the mothers, whereas cumulative psychosocial risk added to the risk for prementalising specifically among mothers with intellectual disability.

CONCLUSIONS

Our findings support contextual models of caregiving, and suggest a need for mentalisation-based support for parents with mild intellectual disability.

Looking back to light the path forward: Ghosts in the Nursery revisited

The infant health movement was launched nearly 50 years ago with the publication of the now classic paper, Ghosts in the Nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships, written by Selma Fraiberg, Edna Adelson, and Vivian Shapiro (1975). This paper offers us lessons for infant mental health practice that have been proven true time and again over the last 50 years. These lessons both underscore the factors essential to clinical progress across a range of interventions, and remind us of the significant challenges we face in these times of massive, global trauma and oppression, extreme economic hardship, and systemic racism. This commentary reviews the key lessons of Fraiberg and her colleagues' classic paper, addresses some of the challenges inherent in retaining the breadth and substance of Fraiberg's model in contemporary practice, and proposes a model for conceptualizing infant and early childhood mental health practice that is geared toward building the relational foundations of reflection (Slade, 2023).

The predictors of change in reflective parenting therapy: Uncovering the influence of parental reflective functioning and child temperament in predicting the improvement in parent-child relationship and child outcome following DUET group intervention

Parental reflective functioning (PRF) is the ability of parents to understand their child's behavior in light of underlying mental processes; it is a core element in the parent-child relationship. RF is also considered crucial for self-regulation for both parents and their children. We investigated the relationship between improvement in PRF after DUET group intervention (a RF-based intervention) and improvement in the parent-child interaction, child RF, and child adjustment, and we examined whether these improvements were distinct for children with different temperamental traits (e.g., effortful control). Eighty-four parents completed the DUET program and were assessed before and after the intervention. PRF was measured using observation (mind-mindedness) and a questionnaire. Statistical analysis included hierarchical regression and moderation of regression analysis. Results showed that improvement in the parent-child interaction, child RF, and child behavioral problems were related to improvement in PRF. Furthermore, we found that child temperament acted as a moderator in the link between PRF and child RF, supporting a vantage sensitivity model, meaning that it was the more sensitive children who benefitted the most as a result of the positive change in their parents' RF. Clinical and future directions of this study are discussed.

Psychosocial Stressors and Resources in Parents Using Home-Visiting Programs in Early Childhood: A Study Protocol

Psychosocial stressors and resources present in the early life of a child play a crucial part in determining outcomes later in life. Preventive early childhood intervention services aim to reduce negative and increase positive outcomes. Home-visiting programs are an example for preventive services that are common in many countries.The present study focusses on a wide spread home-visiting program in Germany and has three main objectives: First, to characterize the professionals that conduct and the families who participate in the program. Second, to study relations between a broad range of resources and stressors. Third, to analyse potential outcome variables for future efficacy studies on early childhood intervention services. The goal is to recruit 130 professionals and 500 families from 20 cities and municipalities in Germany. For families with two caregivers, both are invited to participate. Questionnaire topics for professionals and families include a range of stressors and resources, need for support, and the work focus of the professionals. Statistical analyses will mainly be descriptive, exploring the complex interplay of stressors and resources in vulnerable families.These results will not only provide insights into how the program is currently conducted and whom it serves, but might also help to further accelerate the program and the training of professionals.

Mentalizing in first-time fathers: reflective functioning as a mediator between attachment representation and sensitivity

Sensitivity in parent-child interaction is essential for child development. Since fathers are increasingly involved in childrearing, identifying factors leading to paternal sensitivity is crucial. We examined the relation between attachment representation and reflective functioning (RF) as factors influencing paternal sensitivity in a longitudinal study including N = 40 first-time fathers (Mage = 33) and their 6-month-old children. We used the Adult Attachment Interview during pregnancy to assess paternal attachment representation and general RF, the Parental Development Interview to assess fathers' parental RF, and the Emotional Availability Scale to measure sensitivity at child's age of 6 month. Data show that secure paternal attachment representation, high general and parental RF are associated with higher levels of paternal sensitivity. Further, parental RF mediates the association between attachment representation and paternal sensitivity. These findings contribute to the identification of a causal interplay in that they suggest an explanatory effect of RF on the association between fathers' attachment representation, and sensitivity.

Virtual interviewing with marginalized young adult mothers: appreciating the New Norm

BACKGROUND AND OBJECTIVE

Virtual interviewing in qualitative research may promote inclusion, diversify samples, and maximize participation, but there is limited research regarding methodological best practices for marginalized study populations. Emerging adult (ages 18-29) and young adult (through age 40) mothers have ongoing stressors and competing responsibilities that may preclude participation with in-person interviews. The purpose of this article is to describe the processes and experiences of virtual interviewing among young adult mothers living in under-resourced communities, based on their responses to specific interview questions.

DESIGN AND SAMPLE

As part of an explanatory sequential mixed methods study, qualitative interviews were conducted with a sample of young adult mothers who had previously participated in randomized controlled trials testing an intensive early home visiting intervention. Thirty-one participants (M = 29.7 years, SD = 2.5) who identified as Black (39%), Hispanic (55%), and White (7%), were interviewed using Zoom.

RESULTS

The overarching theme was Zoom: Appreciating the New Norm. Identified categories were Practical Benefits of Virtual Interviewing, Sharing Stories, and Drawbacks of Virtual Interviewing.

CONCLUSION

Findings support virtual interviewing as a feasible and potentially ideal method for qualitative studies with emerging/young adults. Further research to examine this approach with other marginalized populations may lead to more inclusive representation in qualitative research.

Thinking about the next generation: The case for a mentalization-informed approach to perinatal and intergenerational mental health

BACKGROUND

There has been substantial progress made across multiple disciplines to emphasize the importance of perinatal mental health both for parents and offspring. This focuses on what has been termed the 'First 1000 Days' from conception to the child's second birthday. We argue that our understanding of this issue can go further to create an intergenerational approach to mental health. Despite the existence of theoretical frameworks and practical approaches to implementation, there are gaps in the understanding of perinatal and intergenerational mental health including which psychological mechanisms are implicated in the transmission of risk and resilience within the perinatal period; and how to leverage these into treatment approaches.

AIMS AND METHODS

In this paper, we explore the potential for mentalization as a candidate psychological approach to intergenerational mental health.

RESULTS

We contextualize this issue in terms of the points of contact between mentalization and broader theoretical models such as the social determinants of health and the Developmental Origins of Health and Disease (DoHaD) model. Further, we provide an overview of the existing evidence base for the relevance of mentalization to perinatal mental health.

DISCUSSION

Finally, we sketch out an outline model for integrating mentalization into perinatal and intergenerational mental health, highlighting several areas of opportunity to develop research and practice from diverse geographies and demographics. Here, we suggest that integration of mentalization with other conceptual frameworks such as DoHaD can mutually enrich the understanding of each model, pointing the way towards more effective early and preventative interventions.

Mother-infant interaction context matters for verbal and non-verbal parental mentalization: an initial portrait of associations between parental embodied mentalizing, mind-mindedness, and maternal characteristics in a structured and unstructured context

Introduction

Interest in studying the parental embodied mentalizing (PEM), which refers to implicit and non-verbal processes of parental mentalization, is relatively recent. Therefore, little is known about how PEM, in complementarity with the verbal parental mentalization, is associated with maternal characteristics regarding mother-infant interaction contexts. This exploratory study aimed to investigate the associations between the non-verbal and verbal dimensions of parental mentalization- PEM and mind-mindedness, respectively, - in relation to a wide spectrum of parental characteristics in different interactive mother-infant contexts (toys and no toys).

Methods

Among a sample of 107 mother-infant dyads at moderate psychosocial risk, mothers' sociodemographic information (age, education, and income), psychological characteristics (depression and anxiety), cognitions (self-efficacy and perceived maternal impact), and attitudes (overprotection and parental warmth) were assessed via self-report questionnaires when the infant was 4 and 8 months old. The PEM and mind-mindedness were evaluated through observation made during a videorecorded sequence of mother-infant interaction in a context of free play with and without toys at 8 months of age.

Results

The results showed distinct associations between PEM and mind-mindedness regarding maternal characteristics: PEM was associated with the mother's age, education, anxiety and maternal warmth, whereas mind-mindedness was related to cognitions. Both were linked to family income. Regarding mother-infant interaction contexts (toys vs. no toys), the results indicate that the capacity to verbally and non-verbally mentalize differs.

Discussion

These findings shed light on distinctive associations between non-verbal and verbal parental mentalization in relation to certain maternal characteristics, and highlight that the mother-infant interaction context may play an important role in the expression of maternal mentalizing capacity.

Maternal Attachment Networks and Mother-Infant Bonding Disturbances among Mothers with Postpartum Major Depression

The literature suggests that maternal insecure attachment is a risk factor for postpartum depression which, in turn, affects motherinfant bonding. However, recent research in attachment suggests that the investigation of attachment networks provides further insight in the understanding of psychological outcomes. This study aims to test a model according to which mothers' attachment towards each of their parents contributes to explain attachment towards their romantic partners, which itself is associated with maternal postpartum depression and, in turn, with motherinfant bonding. The Attachment Multiple Model Interview, the Edinburgh Postnatal Depression Scale, and the Postpartum Bonding Questionnaire were administered to 90 mothers of infants under 6 months of age (32 with postpartum major depression). Results showed that attachment towards the partner (1) is best explained by attachment to the father and (2) mediates the link between attachment to the father and depression severity. Also, depression severity mediates the link between attachment to the partner and motherinfant bonding. These results highlight the role of attachment models towards the romantic partner and the father in the perinatal period and the relevance of attachment-focused therapeutic programs in treating postpartum maternal depression.

Attachment-Related Differences in Emotion Regulation in Adults: A Systematic Review on Attachment Representations

In recent years, there has been an increase in the prevalence of mental disorders connected with affective dysregulation and insecure attachment. Therefore, it is even more important to understand the interplay between an individual's attachment representation and patterns of emotion regulation. To our knowledge, this is the first systematic review to examine this association. PsycInfo, PsyArticles, and PubMed were searched for studies that examined attachment-related differences in emotion regulation in adults. To examine the unconscious attachment representation, only studies using the Adult Attachment Interview or the Adult Attachment Projective Picture System were included. Thirty-seven peer-reviewed studies (with a total of 2006 subjects) matched the PICO criteria. Emotion regulation was measured via four objective approaches: autonomic nervous system, brain activity, biochemistry, or nonverbal behavior. Across all measurements, results reveal a significant correlation between attachment representation and emotion regulation. Secure attachment correlates consistently with balanced emotion regulation, whereas it is impaired in insecure and dysfunctional in unresolved attachment. Specifically, unresolved individuals display counterintuitive responses and fail to use attachment as a resource. Insecure-dismissing attachment is associated with an emotionally deactivating strategy, while on a physiological, biochemical, and nonverbal level, emotional stress is still present. There is still a lack of studies examining preoccupied individuals. In addition to interpreting the results, we also discuss the risk of bias, implications for psychotherapy and coaching, and an outlook for future research.

Effects of the Attachment Video-feedback Intervention (AVI) on parents and children at risk of maltreatment during the COVID-19 pandemic

BACKGROUND

The global health crisis caused by the COVID-19 pandemic has led to an increase in situations of risk of child abuse and neglect.

OBJECTIVE

The objective of this study was to examine whether the Attachment Video-feedback Intervention (AVI) program can improve protective factors (decrease parental stress and household chaos, increase parent-child emotional availability and parental reflective functioning) that may diminish child maltreatment in a group of families at risk for child abuse and neglect during the COVID-19 pandemic.

PARTICIPANTS AND SETTING

The sample consisted of 41 children aged between 0 and 5 years (M_age = 35.36 months, SD = 14.65; 85.4 % boys) and their parents (M_age = 35.44, SD = 6.04; 75.6 % mothers).

METHODS

The study design incorporated two randomized groups (Intervention group: AVI; Control group: treatment as usual) with pre- and post-test evaluations.

RESULTS

In comparison to the control group, parents and children exposed to the AVI showed increases in emotional availability. Parents in the AVI group also presented increases in certainty regarding their child's mental states and reported lower levels of household chaos compared to those of the control group.

CONCLUSIONS

The AVI program is a valuable intervention for increasing protective factors in families at risk of child abuse and neglect in times of crisis.

Participation in an Attachment-Based Home Visiting Program Is Associated with Lower Child Salivary C-Reactive Protein Levels at Follow-Up

OBJECTIVE

Exposure to early childhood adversity is associated with an increased risk for physiological disruption, including increased inflammation. Early interventions that support the mother-child relationship have been shown to potentially buffer negative psychosocial outcomes related to early adversity, but it is unclear whether these interventions have long-term biological effects. We evaluated whether prior participation in Minding the Baby® (MTB), an attachment-based home visiting intervention for young mother-infant dyads living in underserved communities, is associated with lower child salivary inflammatory biomarkers compared with controls at follow-up.

METHODS

Ninety-seven maternal-child dyads (n = 43 intervention and n = 54 controls) enrolled in a follow-up study of the MTB randomized controlled trial, an average of 4.6 years after RCT completion. Children provided salivary specimens. We used adjusted linear regression to examine the relationship between MTB participation and child salivary inflammatory biomarkers (C-reactive protein [CRP], interleukin [IL]-1β, IL-6, IL-8, and TNF-α).

RESULTS

Children were on average 6.6 years old, 48% female, and identified as non-Hispanic/Latino Black/African American (34%) and Hispanic/Latino (63%). Participation in MTB was associated with lower salivary CRP levels (β = -0.31, SE = 0.28, p = 0.003) compared with controls. Participation in MTB was not associated with salivary cytokine levels.

DISCUSSION

Participation in an intensive two-generation home visiting intervention such as MTB may reduce salivary inflammatory biomarkers associated with early childhood adversity. Replication and further research are needed to improve the understanding of the potential for early childhood interventions to buffer the biological embedding of early adversity.

STEP-COVID: a pilot study of a prenatal intervention for pregnant women during the COVID-19 pandemic

The COVID-19 pandemic has been associated with a global increase in psychological distress in pregnant women. This study evaluated the effects of STEP-COVID, a six-session mentalization-based prenatal group program offered online during the COVID-19 pandemic. The 100 participants were allocated to STEP-COVID or to the natural trajectory of prenatal care. Pre- and post-intervention assessments included measures of psychological distress, post-traumatic symptoms and positive affectivity. Perception of change during pregnancy on resilience-promoting factors was also assessed at post-intervention. A significant decrease in psychological distress and post-traumatic symptoms and an increase in positive affectivity were observed in participants in the intervention condition, whereas only post-traumatic symptoms improved in the control condition. Women who participated in STEP-COVID also reported greater changes during pregnancy on resilience-promoting factors than women in the control condition. Results hold promise for buffering the effect of the pandemic on the mental health of pregnant women using brief online interventions. Clinical trial registration: NCT05419167 (15/06/2022).

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health.

DESIGN

Systematic review, meta-analysis.

SETTING

Healthcare setting or home.

PARTICIPANTS

Infants under 1 month of age.

INTERVENTIONS

HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods.

MAIN OUTCOME MEASURES

Cognitive development in children at 0-36 months.

RESULTS

Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence).

CONCLUSIONS

We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required.

PROSPERO REGISTRATION NUMBER

CRD42019122021.

The efficacy of group delivered mentalization-based parenting interventions: A systematic review of the literature

Mentalization refers to the capacity to understand and interpret one's own and others mental states. There is good evidence for individualised treatments aimed at increasing this capacity with children and adolescents. However, there has been no focused synthesis of the literature concerning specifically group delivered mentalization-based parenting interventions. The current study aimed to systematically review the literature in relation to group delivered mentalization-based parenting interventions. Three databases were searched to identify N=515 studies that were screened and reported according to PRISMA guidelines. Inclusion criteria were met by N=10 studies. Interventions varied in terms of content, but often included psychoeducation, experiential group exercises and homework tasks. The length and setting of interventions did not appear to influence outcomes. Significant improvements in parental reflective functioning were found in eight of the ten studies. There was mixed evidence for the efficacy in terms of other parental and child outcomes. This may be due to the lack of high quality studies and the absence of longer-term follow-ups. There is a need for future research to conduct high quality studies with greater diversity in participating parents and long-term follow-up.

Bringing a mentalizing framework to understanding mothers with addiction: The groundbreaking work of Nancy E. Suchman

Nancy Suchman is remembered as a pioneer whose mentalization-based intervention-Mothering from the Inside Out (MIO)-transformed the treatment of parents struggling with substance use disorders. Specifically, Suchman's work highlighted the neural mechanisms underlying substance use disorders and identified the promotion of parental mentalizing as a key therapeutic focus in enhancing early parent-child relationships. Her work transformed parenting support models for this population of parents. Several randomized controlled trials (RCT) show the effectiveness of MIO in promoting parental reflective functioning (PRF) and positive relational outcomes in parents with substance use disorders and their children. Suchman's MIO model has since been extended to parenting in many contexts. She is also remembered as a generous colleague, a gifted researcher and clinician, and an inspiration to generations of researchers and practitioners working with parents who aspire to raise healthy, secure children despite multiple challenges and adversities. This special issue compiles the work of researchers inspired by Suchman as they carry on her legacy in examining aspects of parental mentalization. Collectively, the research presented yields confirmation of MIO core assumptions, offers new insights into roles of positive sentiment and savoring in mentalization processes, and presents evaluations of MIO in multiple contexts and with new adaptations.

Parental insightfulness is associated with mother-father-child interactions among families of preschoolers with an Autism Spectrum Disorder diagnosis

BACKGROUND

Parental insightfulness underlies parental sensitive behavior and is associated with secure attachment among Typically Developing (TD) children and also among children with Autism Spectrum Disorder (ASD). Moving beyond the parent-child dyad, a study of TD children and their parents linked mothers' and fathers' combined insightfulness to triadic interactions. The goal of the current study was to examine this association in families with children with ASD. The hypothesis was that the interactions in families in which both parents are insightful will be more cooperative than in families in which only one or neither parent was insightful.

METHODS

Eighty preschooler boys with ASD and both of their parents participated in the study. Parental insightfulness was assessed employing the Insightfulness Assessment (IA) and mother-father-child interactions were observed and coded employing the Lausanne Triadic Play (LTP) procedure.

RESULTS

As expected, families in which both parents were insightful displayed higher parental coordinated support in the LTP than families in which one or neither parent was insightful, controlling for children's IQ and severity of symptoms. Children's engagement with their parents was associated with their IQ and severity of symptoms but not with parental insightfulness.

CONCLUSIONS

The importance of considering paternal, in addition to maternal insightfulness as a foundation for parental coordinated support in family interactions, is discussed, as well as the contribution of the LTP in assessing family interactions with children diagnosed with ASD.

Safe haven in adolescence: Improving parental reflective functioning and youth attachment and mental health with the Connecting and Reflecting Experience

Attachment security provides a well-documented protective developmental function for children exposed to individual- and community-level trauma, yet the effectiveness of prevention and intervention efforts targeting attachment during adolescence has been relatively underexplored. The Connecting and Reflecting Experience (CARE) program is a transdiagnostic, bi-generational, group-based, mentalizing-focused parenting intervention developed to dismantle the intergenerational transmission of trauma and support secure attachment relationships across the developmental spectrum within an under-resourced community. This exploratory study evaluated outcomes among caregiver-adolescent dyads (N = 32) in the CARE condition of a nonrandomized clinical trial at an outpatient mental health clinic within a diverse, urban U.S. community with disproportionate trauma exposure exacerbated by COVID-19. Caregivers predominantly identified as Black/African/African American (47%), Hispanic/Latina (38%), and/or White (19%). At pre- and post-intervention, caregivers completed questionnaires regarding parental mentalizing and their adolescents' psychosocial functioning. Adolescents completed scales regarding attachment and psychosocial functioning. Results showed a significant decrease in caregivers' prementalizing on the Parental Reflective Functioning Questionnaire, improvement in adolescent psychosocial functioning on the Youth Outcomes Questionnaire, and an increase in adolescents' reports of attachment security on the Security Scale. These preliminary findings suggest that mentalizing-focused parenting interventions may be effective in fostering improved attachment security and psychosocial functioning during adolescence.

Envisioning motherhood: Mental-state language in caregiving narratives across the perinatal period

Nancy Suchman's work highlighted the fundamental role of maternal mentalization in maternal addiction, mental health, and caregiving challenges. In this study, we aimed to examine the role of mental-state language (MSL) as a measure of mentalization in prenatal and postnatal narratives and their sentiment in a sample of 91 primarily White mothers from the western United States, followed from the second trimester of pregnancy, through the third trimester, to 4 months postpartum. Specifically, we investigated the use of affective and cognitive MSL in prenatal narratives when mothers visualized caring for their baby and postnatal narratives when mothers compared their prenatal visualization to the current caregiving reality. Results indicated moderate consistency in MSL between the second and third trimesters, but prenatal and postnatal MSL was not significantly correlated. Across all time points, higher use of MSL was related to more positive sentiment, indicating an association between mentalization and positive caregiving representations across the perinatal period. Women used more affective than cognitive MSL in prenatal imagination of caregiving, but this pattern was reversed in their postpartum reflection. Implications on assessing parental mentalization prenatally and considering the relative dominance of affective and cognitive mentalizing are discussed while considering study limitations.

Mothering from the Inside Out: Results of a community-based randomized efficacy trial testing a mentalization-based parenting intervention for mothers with addictions

Mothering from the Inside Out (MIO) is a mentalization-based parenting intervention developed to address challenges common among mothers experiencing substance use disorders (SUDs) and previously deemed effective when delivered by research clinicians. This randomized clinical trial was designed to test the efficacy of MIO when delivered by community-based addiction counselors in Connecticut, USA. Ninety-four mothers [M(SD)age = 31.01(4.01) years; 75.53% White] caring for a child 11-60 months of age were randomly assigned to participate in 12 sessions of either MIO or psychoeducation. Caregiving, psychiatric, and substance use outcomes were assessed repeatedly from baseline through 12-week follow-up. Mothers who participated in MIO showed decreased certainty about their child's mental states, and decreased depression; their children demonstrated increased clarity of cues. Participation in MIO was not associated with the same degree of improvement that was observed in prior trials where MIO was delivered by research clinicians. However, when delivered by community-based clinicians, MIO may be protective against a deterioration in caregiving over time often seen in mothers with addictions. The drop in efficacy of MIO in this trial raises questions about intervention-intervenor fit. Research should examine factors influencing MIO effectiveness to close the science-to-service gap common in the dissemination of empirically validated interventions.

Routinely used interventions to improve attachment in infants and young children: a national survey and two systematic reviews

BACKGROUND

Attachment refers to an infant's innate tendency to seek comfort from their caregiver. Research shows that attachment is important in promoting healthy social and emotional development. Many parenting interventions have been developed to improve attachment outcomes for children. However, numerous interventions used in routine practice have a limited evidence base, meaning that we cannot be sure if they are helpful or harmful.

OBJECTIVES

This research aimed to conduct a large-scale survey to identify what interventions are being used in UK services to improve child attachment; conduct a systematic review to evaluate the evidence for parenting attachment interventions; and develop recommendations for future research and practice.

DESIGN AND METHODS

We worked closely with our Expert Reference Group to plan a large-scale survey focused on relevant UK services. We then conducted two systematic reviews. One searched for all randomised controlled trial evidence for any attachment parenting intervention. The second searched for all research for the top 10 routinely used interventions identified from the survey.

RESULTS

The survey collected 625 responses covering 734 UK services. The results identified the 10 most commonly used interventions. The responses showed a limited use of validated measures and a wide variety of definitions of attachment. For the first review, seven studies were included from 2516 identified records. These were combined with results from previous reviews conducted by the team. Meta-analyses showed that, overall, parenting interventions are effective in reducing disorganised attachment (pooled odds ratio 0.54, 95% confidence interval 0.39 to 0.77) and increasing secure attachment (pooled odds ratio 1.85, 95% confidence interval 1.36 to 2.52). The second review searched the literature for the top 10 routinely used interventions identified by the survey; 61 studies were included from 1198 identified records. The results showed that many of the most commonly used interventions in UK services have a weak evidence base and those with the strongest evidence base are not as widely used.

CONCLUSIONS

There is a need for better links between research and practice to ensure that interventions offered to families are safe and effective. Possible reasons for the disparity include the cost and accessibility of training. There is also a need for improved understanding by professionals regarding the meaning of attachment.

LIMITATIONS

Although the survey had good geographical spread, most respondents were based in England. For review 2 we were unable to access a large number of papers; however, we conducted extensive reference checking to account for this.

FUTURE WORK

There is a need for robust research to test the efficacy of routinely used attachment interventions. Research could also explore why routinely used interventions are not consistently subject to thorough evaluation; how to embed dissemination, cost-effectiveness, fidelity and sustainability into research; and how to keep clinical practice up to date with research developments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019137362.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 2. See the NIHR Journals Library website for further project information.

Association between maternal reflective function and preschool children’s cognitive abilities

Children’s cognitive abilities (e.g., working memory) are associated with mental health, adaptive behaviors, and academic achievement, and may be enhanced by parental reflective function (i.e., capacity to reflect on mental states, feelings, thoughts, and intentions in one’s child and oneself). We evaluated associations between maternal reflective function and children’s cognitive abilities alone and while controlling for parent-child attachment and interaction quality, and psychosocial (i.e., maternal depressive symptoms, adverse childhood experiences) and sociodemographic (e.g., socioeconomic status) factors. Our sample, recruited in Canada, was primarily white and included 73 mothers and their 4–5 year old preschool children. Maternal reflective function was measured with the Reflective Functioning Scale applied to the Parent Development Interview and the Parental Reflective Functioning Questionnaire. Multiple regression analyses revealed that maternal reflective function was associated with children’s cognitive abilities. The Parent Development Interview rated child-reflective function was associated with children’s higher verbal comprehension alone and while adjusting for covariates (e.g., parent-child interaction quality, socioeconomic status), and the Parental Reflective Functioning Questionnaire Interest and Curiosity with higher verbal comprehension while adjusting for parent-child interactions and attachment pattern. The Parental Reflective Functioning Questionnaire Certainty in Mental States was associated with higher working memory scores for children while adjusting for covariates. Full Scale IQ and Visual Spatial Index were not significantly associated with maternal reflective function. Associations were found between secure and disorganized attachment with higher verbal comprehension and lower working memory, respectively. These findings highlight the importance of high maternal reflective function to cognitive abilities in early childhood.

Benefits of a Universal Intervention in Pediatric Medical Homes to Identify and Address Health-Related Social Needs: An Observational Cohort Study

OBJECTIVE

Compare rates of identification of families with health-related social needs (HRSN) and connection to resources by targeted versus universal, pediatric clinic-based interventions.

METHODS

This observational cohort study included 1677 families that received care (January 2017-May 2020) at 8 pediatric medical homes in 3 states implementing Developmental Understanding and Legal Collaboration for Everyone (DULCE)-a universal, evidence-based intervention that addresses HRSN for families with infants. We divided the cohort into 2 groups using 4 common risk criteria in targeted programs serving families with infants; 862 families had no high-risk characteristics (Risk Criteria Absent [RCA]); 815 families had high-risk characteristics (Risk Criteria Present [RCP]). We compared both groups by prevalence of HRSN and connection to supports and estimated the performance of high-risk criteria to identify HRSN.

RESULTS

DULCE identified 990 families with HRSN, compared to an estimated 274 families, if a risk-targeted approach had been used. More than half of RCA families had HRSN, 11% used resources at enrollment, and 42.5% accessed resources through DULCE. Simultaneously, 68.8% of RCP families had ongoing HRSN although 46.0% used resources at enrollment; 63.9% accessed additional resources through DULCE. Commonly used risk criteria had a sensitivity of 55.3% (95% confidence interval [CI], 52.2%-58.5%), specificity of 61.1% (95% CI, 57.2%-64.9%), positive predictive value of 68.8% (95% CI, 65.4%-72.0%), and negative predictive value of 46.9% (95% CI, 43.5%-50.4%).

CONCLUSIONS

Risk criteria commonly used to identify families for targeted interventions are imperfect proxies for HRSN. Universal, medical home-based approaches can play a key role in supporting families with infants.

Beyond Children's Mental Health: Cultural Considerations to Foster Latino Child and Family Mental Health

Clinicians trained to assess and treat child psychopathology are facing an increasing need to expand their clinical expertise outside of traditional frameworks, which have historically focused largely on the child or the child-mother dyad. Clinicians treating children also need to be prepared to assess and address the systems of care that affect a child's mental health, starting with their family. There is a scarcity of Latino mental health providers and limited clinical opportunities or settings that serve this population by incorporating a developmental, cultural, and sociopolitical framework into high quality care of the whole family.

Attachment-Based Parenting Interventions and Evidence of Changes in Toddler Attachment Patterns: An Overview

There is strong evidence to show links between attachment security in young children and a range of positive outcomes in social, emotional, and psychological domains. The aims of this review were to provide a narrative summary of (1) the attachment-based interventions currently available for caregivers of toddlers aged 12–24 months and for which research about the impact of the program on child attachment patterns has been reported, and (2) the empirical effectiveness of these interventions at improving attachment security. A number of interventions were shown to be associated with shifts to secure and/or organized attachment, with Child-Parent Psychotherapy and Attachment and Biobehavioral Catch-Up emerging as the interventions with the strongest evidence bases. For most interventions, evidence came from just a single research study, and in some cases from studies that were not randomized controlled trials. In order for clinicians to make informed decisions about the interventions they use with parents and toddlers, it is vital that further research be conducted to test the efficacy of all available attachment-based parenting programs using randomized controlled trial designs, in a range of settings and clinical and cultural groups, and with longitudinal follow-ups.

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.

Process mining the trajectories for adolescent-to-mother violence from longitudinal police and health service data

AIM

The aim was to discover longitudinal trajectories and patterns of events preceding adolescent-to-mother family violence in a geographic locale in Australia.

DESIGN

This was a retrospective case series.

METHODS

Routinely collected administrative data were sourced and linked from police and health service electronic records for adolescents born between 1994 and 2006 who had been issued a legal action for a family violence-related offence (n = 775). A time-stamped log of events from birth (where available) was created. Process mining was employed to discover dominant events and trajectories in the log from birth until adolescents' first recorded offence against their mother.

RESULTS/FINDINGS

Most adolescents in the case series offended against mothers (63%, n = 486). Trajectory analysis confirmed dominant early childhood events were repeated exposure to parental intimate partner violence (P-IPV), parental drug and/or alcohol use and neglect. During early adolescence, pathways towards adolescent-to-mother violence involved other offending, drug and/or alcohol use and mental health service contact.

CONCLUSION

The trajectories evidenced provide a complex picture of the emergence of adolescent-to-mother violence. From an early intervention perspective, it was found that many children and mothers were identifiable from police records in early childhood, at an average age of 35 months. Responses to adolescent family violence need to acknowledge the impact of childhood trauma and emerging mental health problems, along with strategies to mitigate the effect of P-IPV on mother-to-child relationships.

IMPACT

This is the first large-scale study to specifically examine trajectories from birth for adolescents who engage in violence towards mothers. The findings have important implications for the design and delivery of early intervention childhood services and interagency collaboration in nursing and midwifery services. In early adolescence, contact with mental health services represents an opportunity for screening and support interventions. This is an important preventive timepoint for family violence, adolescent drug and alcohol use and other offences.

Minding the Baby versus usual care: study protocol for a quasi-cluster-randomized controlled study in Denmark of an early interdisciplinary home-visiting intervention for families at increased risk for adversity

BACKGROUND

Inequality in health can have profound effects on a child's opportunities later in life. To prevent these downstream effects in families at increased risk of adversity, programs are needed to provide support and improve well-being across several domains. The present trial is aimed at assessing the effectiveness of the Minding the Baby® (MTB) home visiting intervention in improving the mother-child relationship, parental reflective functioning, well-being, and mental health, as well as child development and well-being in families at known risk of adverse health, relational, and developmental outcomes.

METHODS

The study is a pragmatic, prospective, quasi-cluster-randomized controlled trial in which seven Danish municipalities were randomized to MTB training in either 2018 or 2019. A total of 250 pregnant women at increased risk of adversity will be recruited (75 care as usual families and 175 intervention families). Care as usual families will be recruited before and after the MTB training. The MTB intervention is an attachment-based, interdisciplinary home visiting intervention offered from the third trimester of pregnancy until the child is 2 years old. The participants are assessed at baseline, and when the infant is 3, 12, and 24 months old. The primary outcome is maternal sensitivity measured by the Coding Interactive Behavior scale applied to video recordings of mother-infant interactions. Secondary outcomes include parent-child interaction, parental reflective functioning, parental mental health, maternal satisfaction, parental stress, and child development and well-being. The treatment effect is estimated as a fixed effect using a binary indicator of MTB treatment, and cluster-robust standard errors based on wild bootstrap are used for inference.

DISCUSSION

This is the first trial of MTB in a Scandinavian context and will include the largest sample yet in a trial of MTB. The trial is expected to contribute to knowledge about the effect of early support for pregnant women, their infants, and their families at increased risk of adversity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03495895 . The study was registered on April 12, 2018.

The Transition to Parenthood in Obstetrics: Enhancing Prenatal Care for Two Generation Impact

Obstetrics, the specialty overseeing infant and parent health before birth, could be expanded to address the inter-related areas of parents' prenatal impact on children's brain development and their own psychosocial needs during a time of immense change and neuroplasticity. Obstetrics is primed for the shift that is happening in pediatrics, which is moving from its traditional focus on physical health to a coordinated, whole child, two or multi-generation approach. Pediatric care now includes developmental screening, parenting education, parent coaching, access to developmental specialists, brain-building caregiving skills, linkages to community resources, and tiered interventions with psychologists. Drawing on decades of Developmental Origins of Health and Disease research highlighting the prenatal beginnings of future health and new studies on the transition to parenthood describing adult development from pregnancy to early postpartum, we propose that, similar to pediatrics, the integration of education and intervention strategies into the prenatal care ecosystem should be tested for its potential to improve child cognitive and social-emotional development and parental mental health. Pediatric care programs can serve as models of change for the systematic development, testing and, incorporation of new content into prenatal care as universal, first-tier treatment as well as evidenced-based, triaged interventions according to level of need. To promote optimal beginnings for the whole family, we propose an augmented prenatal care ecosystem that aligns with, and could build on, current major efforts to enhance perinatal care individualization through consideration of medical, social, and structural determinants of health.

Stressed Mothers Receiving Infant Mental Health-Based Early Head Start Increase in Mind-Mindedness

Maternal mind-mindedness is a characteristic of supportive parenting and contributes to many positive social–emotional outcomes in early childhood. However, there is limited knowledge of mind-mindedness among parents experiencing parenting stress from low-income settings. This is a critical gap in evidence given the robust role of supportive parenting in children’s development and the capacity of home-based interventions to improve children’s outcomes through enhancing supportive parenting. This study examined: (1) maternal mind-mindedness, operationalized as mothers’ appropriate mind-related comments (MRC), across toddlerhood in mothers of toddlers who participated in infant mental health (IMH) based Early Head Start (EHS) services; and (2) whether parenting stress moderated EHS program effects on appropriate MRC over time. Data from a primarily White midwestern site in the United States were collected at study enrollment and when toddlers were 14-, 24-, and 36-months of age (N = 152; mothers M_age = 22.4 years, SD = 5.1; toddlers M_age = 14.4 months, SD = 1.3; 51% females). Data included parent-completed questionnaires and observed parent–child interactions, which were coded for MRC. Although there were no main effects of EHS programming on mothers’ appropriate MRC over time, multilevel growth curve modeling indicated that parenting stress moderated EHS effects on mothers’ appropriate MRC over time. Among mothers with greater parenting stress, those who received IMH-based EHS services demonstrated greater proportions of MRC over time as compared to mothers with greater stress in the control group. IMH-based parenting interventions that target parenting stress may promote appropriate MRC in low-income populations during toddlerhood.

Exploring maternal reflective functioning as a predictor of mother-child dyadic behaviour over time in a clinical context

The current study examined 20 participants from group attachment based intervention (GABI), who completed the adult attachment interviews (AAI; George, et al., 1985) as part of a RCT to test the efficacy of GABI compared with treatment as usual, in order to explore the possible benefits higher RF for treatment outcome in terms of interactive mother and child behaviour. Mothers' AAIs were analyzed using the reflective functioning (RF) rating scale (Fonagy, et al., 1998), yielding overall RF scores, prompted/demand RF scores, and spontaneous RF scores, and parent-child dyadic interactive behaviour was coded utilizing the coding interactive behaviour (CIB: Feldman, 1998) manual. Children's age ranged from 2-25 months, mean=14 months. 86.7% of the sample identified English as their primary language, with 13.3% identified speaking both Spanish and English. RF in AAIs obtained at intake from some GABI mothers was expected to be linked to the quality of the parent-child interaction (observed with the CIB), at intake (T1), at end-of treatment T2), and at sixmonth follow-up (T3). Results confirmed this impression insofar as lower overall RF was linked to T1 levels of higher intrusiveness from mothers. At end of treatment (T2), mothers' higher spontaneous RF scores were significantly linked to maternal praising (of the child), child positive affect, child alertness. At 6-month follow up (T3), mother's spontaneous RF scores correlated significantly and positively with maternal elaborating with child positive affect. Discussion focuses on the importance of assessing RF in parents entering therapy with their children as it may provide insight into what parent or child behaviours may be targeted. And the RF scores will highlight which mothers need special attention to stimulate their interest and attention to attachment-related processes in themselves, and in their children.

Focusing on Racial, Historical and Intergenerational Trauma, and Resilience: A Paradigm to Better Serving Children and Families

Research across populations demonstrates that intergenerational trauma can have lasting biological, psychological, and social consequences and affects groups of individuals in different ways. An appreciation of intergenerational trauma as experienced in diverse populations is important not only for understanding vulnerabilities and risk but also for cultivating opportunities for posttraumatic growth and healing. Understanding the contexts of trauma for children and families and the unveiling of structural inequities, both past and present, offers the opportunity to address these in using clinical and systems of care approaches in the public health spheres.

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 FACAM study: protocol for a randomized controlled study of an early interdisciplinary intervention to support women in vulnerable positions through pregnancy and the first 5 years of motherhood

BACKGROUND

Inequality in health can have profound short- and long-term effects on a child's life. Infants develop in a responsive environment, and the relationship between mother and infant begins to develop during pregnancy. The mother's ability to bond with the fetus and newborn child may be challenged by mental health issues which can cause impaired functioning and poorer health outcomes. Families with complex problems need interdisciplinary interventions starting in early pregnancy to be prepared for motherhood and to ensure healthy child development. This study aims to examine the effects of an early and coordinated intervention (the Family Clinic and Municipality (FACAM) intervention) offered to vulnerable pregnant women during pregnancy and the child's first year of life on the mother-child relationship, maternal social functioning, mental health, reflective functioning, well-being, parental stress, and the development and well-being of the child.

METHODS

The study is a prospective randomized controlled trial where we will randomize 320 pregnant women enrolled to receive antenatal care at the family clinic at Odense University Hospital, to either FACAM intervention or usual care. The FACAM intervention consists of extra support by a health nurse or family therapist during pregnancy and until the child starts school. The intervention is most intensive in the first 12 months and also includes attachment-based support provided either individually or in groups. The participants are assessed at baseline, and when the infant is 3 and 12 months old. The primary outcome is maternal sensitivity measured by the Coding Interactive Behavior (CIB) instrument. Secondary outcomes include prenatal parental reflective functioning, mental well-being, depressive symptoms, breastfeeding duration, maternal satisfaction, child development, parent competence, parental stress, and activities with the child.

DISCUSSION

The trial is expected to contribute knowledge about the effect of early coordinated support in antenatal and postnatal care for vulnerable pregnant women and their families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03659721 . Registered on September 6, 2018.

Measuring Parental Reflective Functioning: Further Validation of the Parental Reflective Functioning Questionnaire in Portuguese Mothers of Infants and Young Children

This study examines the factor structure and psychometric properties of the Portuguese Parental Reflective Functioning Questionnaire (PRFQ). The PRFQ is a brief questionnaire of parental reflective functioning that comprises three subscales: pre-mentalizing modes of mental states, certainty about mental states, and interest and curiosity in mental states. Two independent samples were included in the study: a sample composed of 710 mothers of children aged 0 to 36 months (Study 1) and a sample composed of 120 mothers of children aged 1 to 5 years (Study 2). Each sample completed a different set of self-report questionnaires. The original correlated three-factor structure was confirmed through confirmatory factor analyses. The three PRFQ subscales exhibited adequate reliability and correlated in the expected directions with several outcomes (psychopathology symptoms, emotion dysregulation, parent attachment, and parenting styles). The Portuguese PRFQ is a psychometrically robust measure of parental reflective functioning appropriate for research use in Portugal.

Emotion regulation during pregnancy: a call to action for increased research, screening, and intervention

This paper serves as a call to action for increased focus on emotion regulation during pregnancy. We make this case by summarizing the limited research to date on this topic, which has demonstrated that emotion regulation in pregnant people has important mental health, caregiving, and developmental correlates throughout the perinatal period. Given its crosscutting and modifiable nature, bolstering emotion regulation during pregnancy has the potential for considerable intergenerational consequences, and it is critical to further investigate this construct.

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.

Effectiveness of a large-scale home visiting programme (PIM) on early child development in Brazil: quasi-experimental study nested in a birth cohort

BACKGROUND

A large-scale parenting programme with weekly home visits (Primeira Infância Melhor (PIM)) has been implemented in the south of Brazil for nearly two decades, but lacks evaluation of its effects on early childhood development (ECD). This quasi-experimental study aimed to assess the effects of PIM in real-life settings within a population-based birth cohort study.

METHODS

Data from the 2015 Pelotas Birth Cohort Study and the state programme information system were linked to identify study children who received PIM. Propensity score matching was used to create a comparable control group (using one-to-one matching) to estimate the effect of PIM on ECD measured at age 4 years. First, the impact of any enrolment in PIM was evaluated; then the intervention group was stratified according to whether enrolment occurred during pregnancy or after birth. Double adjustment was applied in linear regression to analyse child development scores, and Poisson regression for delayed development (below the 10th percentile of whole cohort). Effect modification due to family income was explored.

RESULTS

There was no evidence that any enrolment in PIM (601 pairs) by age 4 years was associated with child development. However, PIM starting during pregnancy (estimated for 121 pairs) predicted higher development scores (0.27 SD; 95% CI 0.02 to 0.52), and 71% lower prevalence of delayed development (prevalence ratio=0.29; 95% CI 0.13 to 0.69), compared with the control group. There was strong statistical evidence (p=0.003, test of interaction) that the effect of PIM starting in pregnancy was larger than when starting after birth (480 pairs). The effect of PIM starting during pregnancy was found to be restricted to poorer families.

CONCLUSIONS

In a real-life setting, PIM was effective only when starting during pregnancy and only for poorer families. A higher-quality programme might be more effective with a broader population.