Evaluating a home‐based dyadic intervention: Changes in postpartum depression,maternal perceptions,and mother–infant interactions

Psychotherapeutic treatments that focus on improving the relational processes between mothers with postpartum depression (PPD) and their infants, as well as the mother's individual therapeutic needs, have a great potential to positively impact the mother, her infant, and their relationship (K.J. Nylen, T.E. Moran, C.L. Franklin, & M. O'Hara, 2006 ). Utilizing pilot data from an evaluation of a home‐based dyadic therapy for mothers with PPD and their infants, this article reports on a recent academic–community partnership study. The effectiveness of the intervention was examined, specifically regarding changes in mother's mood, parenting experience, and relationship with her infant. In addition, associations were examined among maternal self‐report variables measuring change from pre‐ to posttreatment in PPD, psychological distress, and maternal perceptions of parenting and those variables measuring change in observer ratings of maternal–infant interactions. Results showed improvements in mothers' depression, distress, and perceptions of parenting as well as many ratings of mothers' interactions with their infants. However, only improvements in maternal perceptions of parenting, such as maternal self‐esteem and parenting stress, were associated with better mother–‐infant interactions. Importance of this research for the field of infant mental health as well as clinical implications are discussed.     

A randomized controlled trial of mother–infant psychoanalytic treatment: II. Predictive and moderating influences of qualitative patient factors

A randomized control trial was performed on 75 dyads in Stockholm, Sweden, with infants under 1½ years. It recruited mothers who worried about the babies, themselves as mothers, and/or the mother–baby relationship. Two groups of mother–infant dyads were compared. One received only Child Health Centre care (the “CHCC” group) while the other received mother–infant psychoanalytic treatment plus CHCC (the “MIP” group). Significant treatment effects were found on mother‐reported depression, interviewer‐rated dyadic relationship qualities and externally rated maternal sensitivity, and near‐significant effects on mother‐reported stress, all in favor of MIP. The objective of this study is to investigate the predictive and moderating influences on outcomes by qualitatively assessed maternal and infant characteristics. The qualitative factors covered maternal suitability for psychoanalysis, and “ideal types” of mother and child, respectively. Outcome measures from two interviews with a 6‐month interval were depression (Edinburgh Postnatal Depression Scale (J. Cox, J. Holden, & R. Sagovsky, 1987 ), stress (Swedish Parental Stress Questionnaire (M. Östberg, B. Hagekull, & S. Wettergren, 1997 ), distress (Swedish Symptom Checklist‐90 (SCL‐90; L.R. Derogatis, 1994 ; M. Fridell, Z. Cesarec, M. Johansson, & S. Malling Thorsen, 2002 ) and infant social and emotional functioning (Ages and Stages Questionnaire: Social–Emotional (J. Squires, D. Bricker, K. Heo, & E. Twombly, 2002 ), relationship qualities (Parent–Infant Global Assessment Scale (PIR‐GAS; ZERO TO THREE, 2005), and videotaped interactions (Emotional Availability Scales, Z. Biringen, J.L. Robinson, & R.N. Emde, 1998 ). Suitability for psychoanalysis predicted outcome only on the PIR‐GAS. Two overarching maternal ideal types were created, reflecting their attitude to the psychoanalytic process: “Participators” and “Abandoned.” The Participators benefited more from MIP than they did from CHCC on maternal interactive sensitivity. A contrasting, but nonsignificant, pattern was found among the Abandoned mothers. Two ideal types of babies emerged: those “Affected” and “Unaffected” by the disturbance, respectively. Among Affected babies, dyadic relationships and sensitivity among their mothers improved significantly more from MIP than they did from CHCC. The superior effects of MIP applied especially to Participator mothers and Affected infants. For Abandoned mothers and Unaffected infants, CHCC seemed to be of equal value.     

Maternal substance use and mother–infant feeding interactions

The purpose of this study was to examine the impact of maternal polydrug cocaine use during pregnancy and associated risk factors such as maternal psychopathology and negative infant temperament on the quality of mother–infant feeding interactions at 2 months of infant age. Participants were 45 mother–infant dyads (19 cocaine‐exposed and 26 nonexposed) who were recruited at birth and assessed again 2 months of infant age. Mother–infant interactions during feeding were videotaped and coded with regard to dyadic reciprocity, maternal noncontingency, and dyadic conflict. Results indicated that maternal cocaine use was associated with higher dyadic conflict. Moreover, cocaine‐using mothers were also more likely to use marijuana and alcohol, and use of such substances was associated with lower dyadic reciprocity and higher maternal noncontingency during interactions. Results also suggested that one pathway to higher dyadic conflict during interactions among cocaine‐using mothers was through the impact of cocaine on infant risk conditions like lower gestational age and negative temperament (e.g., higher distress to novelty). Interventions focusing on promoting the quality of mother–infant interactions in combination with substance abuse treatment may be especially promising for this population. ©2001 Michigan Association for Infant Mental Health.     

A randomized controlled trial of mother–infant psychoanalytic treatment: I. Outcomes on self‐report questionnaires and external ratings

Mother–infant relationship disturbances occur in three domains: maternal distress, infant functional problems, and relationship difficulties. They constitute common clinical problems. In Sweden, they are usually handled by nurses as part of public Child Health Centre care. Severe cases are referred to child psychiatry services. This randomized controlled trial compared two groups of mother–infant dyads in a Stockholm sample. One received only Child Health Centre care (the “CHCC” group) while the other received mother–infant psychoanalytic treatment plus CHCC (the “MIP” group). Eighty dyads of mothers and infants under 1½ years of age where the mothers had serious concerns about themselves in their role as mothers, their infants' well‐being, or the mother–baby relationship were randomly selected for either the MIP or the CHCC group. The primary outcomes were mother‐reported depression, mother‐reported infant functional problems, and interviewer‐based relationship assessments, all at 6 months after joining the project. Secondary outcomes were mother‐reported stress and general psychic distress, externally rated video‐recorded interactions, and the consumption of healthcare at the CHC, again all after 6 months. Intent‐to‐treat analyses of Treatment × Time effects significantly favored MIP treatment for maternal depression, mother–infant relationships, and maternal sensitivity. Effects were nearly significant on maternal stress, but nonsignificant on mother‐reported infant functional problems, general psychic distress, maternal interactive structuring and nonintrusiveness, infant responsiveness and involvement, and healthcare consumption. MIP treatment improved mother–infant relationships and maternal sensitivity and depression, all of which are known to influence child development. If effects persist and are reproduced, MIP treatment holds promise for more widespread use.     

Consistency in infant sleeping arrangements and mother–infant interaction

This study examined the association between infant sleeping arrangements (i.e., habitual co‐sleeping, inconsistent co‐sleeping, and non‐co‐sleeping) and quality of mother–infant interaction during play in a sample of mothers, each with a typically developing infant (N=70). Mother–infant dyads who experienced consistency in infant sleeping arrangements in a typical week at 6 months (i.e., habitual co‐sleeping or non‐co‐sleeping) were characterized by more positive maternal and infant behavior and dyadic quality of interaction at 9 months compared with dyads who experienced inconsistency in sleeping arrangements. Additionally, a greater amount of co‐sleeping per week was associated with an increased duration of breastfeeding, mothers working fewer hours, less infant temperamental intensity, and less maternal depression. This study underscores the advantages of empirically based studies that consider consistency in infant sleep experience as a factor that is associated with more positive mother–child interaction.     

Short‐term psychodynamic infant–parent interventions at Child health centers: Outcomes on parental depression and infant social–emotional functioning

Randomized controlled trials (RCTs) demonstrate efficacy of parent–infant psychotherapy, but its applicability and effectiveness in public health care are less known. The method followed is Naturalistic study evaluating Short‐term Psychodynamic Infant–Parent Interventions at Child Health Centers (SPIPIC) in Stockholm, Sweden. One hundred distressed mothers with infants were recruited by supervised nurses. Six therapists provided 4.3 therapy sessions on average (SD = 3.3). Sessions typically included the mothers, often with the baby present, while fathers rarely attended sessions. The Edinburgh Postnatal Depression Scale (EPDS) and the Ages and Stages Questionnaire: Social–Emotional (ASQ: SE) were distributed at baseline and at 3 and 9 months later. Data from a nonclinical group were collected simultaneously to provide norm data. Multilevel growth models on the mothers’ questionnaire scores showed significant decreases over time on both measures. Nine months after baseline, 50% achieved a reliable change on the EPDS and 14% on the ASQ: SE. Prepost effect‐sizes (d) were 0.70 and 0.40 for EPDS and ASQ: SE, figures that are comparable to results of other controlled studies. Psychotherapists integrated with public health care seem to achieve good results when supporting distressed mothers with brief interventions in the postnatal period. SPIPIC needs to be compared with other modalities and organizational frameworks.     

Six‐month follow‐up of two mother–infant psychotherapies: Convergence of therapeutic outcomes

Fifty‐eight mothers and infants participating in two infant–mother psychotherapeutic interventions in a comparative infant–mother clinical intervention study were followed six months after treatment ended. One treatment was an infant‐led psychotherapy, Watch, Wait, and Wonder (WWW). The other was a more traditional mother–infant psychodynamic psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately five months. Results indicated that positive effects observed from the beginning to the end of treatment in both treatment groups in infant symptoms, parenting stress, and mother–infant interaction were maintained or improved further at six‐month follow‐up. Additionally, decreased maternal depression, gains in infant cognitive development and emotion regulation, and improved infant–mother attachment security or organization had been observed posttreatment only in the WWW group. Interestingly, between the posttreatment to follow‐up period the PPT group also showed such gains. Thus, for these variables it would be more accurate to say that the outcomes were similar for the two treatment groups but change emerged at a different pace. Nevertheless, an advantage persisted in the WWW group in relation to mothers' comfort dealing with infant behaviors and their ratings of parenting stress which improved more in this group from the end of treatment to follow‐up. The direct inclusion of the infant as an initiator in WWW was set forth as an explanation of differentially timed treatment effects. ©2002 Michigan Association for Infant Mental Health.     

Kangaroo mother care and mother‐premature infant dyadic interaction

The aim of this study was to investigate the psychological impact of Kangaroo Mother Care (KMC) on mother‐infant bonding in cases of premature delivery. Examined variables were mother‐infant relationships, maternal anxiety levels, and infant interactive signals. The KMC method requires that babies be undressed and held upright between their mother's breasts for a minimum of 1 hr a day, from birth until they are discharged from hospital. The present study examined 40 premature infants and their mothers, with 21 dyads experiencing KMC and 19 receiving traditional care (TC). Maternal emotional stress was assessed with the Parent Stress Index‐Short Form questionnaire (Abidin, 1990), and mother‐newborn interactive style was assessed with the Nursing Child Assessment Feeding Scale (Barnard, 1975). Results revealed a better mother‐infant interactive style, a significant decrease in maternal emotional stress, and better infant ability to make requests and respond to parental interactive style in the KMC group.     

Affect expression in prenatally psychotropic exposed and nonexposed mother–infant dyads

This prospective study examined infant, maternal, and dyadic affective profiles at three months postpartum in infant–mother dyads that were exposed to psychotropic medications in utero compared with nonexposed control dyads. Control dyads of nondepressed mothers and their infants showed many similarities in affect expression with mother–infant dyads who were exposed to selective serotonin reuptake inhibitors (SSRIs) alone for treatment of maternal depression. In contrast, mothers who received SSRIs and Rivotril (Benzodiazepine derivative) for treatment of depression and anxiety expressed both positive and negative affect towards their infants. Clinical implications regarding use of psychotropic medications such as SSRIs alone or in combination with other drugs for treatment of maternal anxiety and depression during pregnancy are discussed. Clinicians should be aware of the possible differential response in maternal–infant interaction in a mixed diagnosis group (i.e., depression and anxiety) regarding infant temperament, possibly suggesting latent behavioral teratogenicity with psychotropics. ©2002 Michigan Association for Infant Mental Health.     

The influence of maternal optimality and infant temperament on parenting stress at 12 months among mothers with substance abuse and psychiatric problems

The present prospective longitudinal study aimed to investigate the long‐term impact of maternal optimality assessed during pregnancy on parenting stress at infant age 12 months. In this study the concept of optimality was utilized to investigate maternal variations regarding resources during pregnancy in relation to later parenting stress, among three different groups of mothers that were recruited from substance abuse treatment, psychiatric outpatient treatment and well‐baby clinics respectively. The influence of infant temperament on parenting stress was also examined. All mothers were interviewed during pregnancy. At 12 months, infant temperament (Colorado Childhood Temperament Inventory; Rowe & Plomin, 1977) and stress in the parent and child domain (Parenting Stress Index; Abidin, 1955) were assessed. Results demonstrated higher levels of parenting stress among mothers in the clinical groups, compared to the non‐clinical group. Furthermore, it was the maternal psychiatric optimality index in combination with child temperament characteristics (child emotionality) that contributed uniquely to stress in the parent domain, while stress in the child domain was significantly associated only with child temperament characteristics (both child emotionality and soothability). The association between maternal psychiatric optimality assessed in pregnancy, infant temperament and parenting stress when the infants were 12 months old, points to the importance of simultaneously addressing the mothers' own psychological distress, and to support positive mother–infant interactions. Each woman's individual optimality profile may be used to display needs of follow‐up in order to prevent enduring effects of non‐optimality on parenting stress.     

Infant irritability and early mother–infant reciprocity patterns

This study investigated how various forms of neonatal irritability (at 3 days) and irritability at 10 weeks are related to reciprocal interactions between mothers and their infants. Fifty‐six fullterm, first‐born male infants were examined using the Neonatal Behavioral Assessment Scale (NBAS‐K) at 3 days postpartum. Each infant was rated for irritability to aversive stimuli, general irritability, consolability and responsiveness to visual–auditory stimuli. At 10 weeks of age, during a home visit, mother–infant reciprocity was scored for gaze, smile, vocalization and hold behaviors. Based upon maternal reports and behavioral observations, infant irritability was scored at 10 weeks using the NBAS‐K scoring system. Findings revealed that: (1) there were two distinct forms of reciprocity: social and physical; (2) general irritability at 3 days was negatively related to reciprocal hold interaction and positively related to reciprocal social interaction at 10 weeks, and (3) neonatal irritability to aversive stimuli (at 3 days) was positively related to subsequent reciprocal social interaction. Regression analyses showed that neonatal variables were the foremost predictors of reciprocal hold at 10 weeks. Findings are discussed in terms of (1) the need to differentiate between social and physical behavioral patterns, and (2) time‐lag effects with respect to mother–infant interactions. Copyright © 1999 John Wiley & Sons, Ltd.     

Infant touching behaviour during mother–infant face‐to‐face interactions

The study of infant communication during mother–infant interactions has largely focused on infants' distal behaviours, while neglecting their more proximal behaviours, such as touch. Yet, touch is an important modality through which infants and mothers communicate; it is also a vital means through which infants self‐regulate and explore their surroundings. The present study was designed to investigate the touching behaviours of 44, 51/2‐month‐old, healthy, full‐term infants during face‐to‐face mother–infant interactions. A still‐face (SF) procedure was used in order to examine differences in the types and locations of infant touch across normal and perturbed interaction periods, when mothers exhibit changes in their emotional availability. Results revealed that infant touch varied with changes in maternal availability. During the SF period, when mothers were unavailable, infants used more active, soothing, and reactive tactile behaviours (stroke, finger, pat, and pull), and they spent more time touching themselves. In contrast, infants used mostly passive touch (static) during the Normal periods, when their mothers were available. They also spent a significant portion of time touching their mothers. The variations in infant touch across periods suggest that infants communicate their affective states through touch. The findings also support the regulatory and exploratory roles of infant touch, especially during periods of maternal unavailability. Copyright © 2007 John Wiley & Sons, Ltd.     

Infant communication and the mother–infant relationship: The importance of level of risk and construct measurement

Infants' emerging communication skills are understood to be associated with the maternal relationship, particularly for children experiencing high levels of social risk. This study attempts to determine the extent to which this association is influenced by (a) the mental health risk of the dyad and (b) different operational definitions and measurement of both the dyadic relationship and the construct of “communication.” Ninety‐six infants (10–30 months) and their mothers were recruited: A total of 46 were at‐risk dyads referred to a mental health clinic for relationship‐based emotional and/or behavioral difficulties, and 50 were nonrisk dyads not seeking mental health services and served as a normative reference or comparison group. Several factors were assessed: (a) developmental competence, (b) maternal psychopathology, (c) quality of mother–infant interaction during play, (d) attachment security classification, (e) prelinguistic and social‐affective communication, and (f) linguistic communication. In all infants studied, the quality of mother–infant interaction during play, rather than the attachment security classification, was associated with infants' prelinguistic and social‐affective communication abilities, but not with linguistic communication. Different aspects of mother–infant interaction predicted prelinguistic communication for clinic and comparison infants whereas only infant age predicted linguistic communication. All infants displayed communication abilities in the normal range, but the statistically poorer performance demonstrated by clinic‐referred infants could become clinically meaningful in later childhood. Best practices should include communication screening of infants presenting with attachment problems and screening for relational difficulties in infants presenting with communication delays. ©2004 Michigan Association for Infant Mental Health.     

Mothers' affect dysregulation,depressive symptoms,and emotional availability during mother–infant interaction

Maternal affect dysregulation and maternal depressive symptoms were examined as predictors of maternal emotional availability (EA) during mother–infant interaction in a nonclinical sample. In particular, we investigated if affect dysregulation predicts EA and is more important than are depressive symptoms in predicting EA. Questionnaire measures and 30 min of free play were obtained from 46 mothers of 4‐ to 5‐month‐old infants. Mothers' self‐reported affect dysregulation was inversely related to EA, but mothers' depressive symptoms were not related to EA. More specifically, mothers' tendency to use unhealthy externalizing behaviors to reduce tension and distress predicted less EA. These results suggested that even in relatively low‐risk samples, mothers' self‐reported affect dysregulation, particularly the tendency to act out inappropriately in response to tension and distress, may be a more proximal predictor of EA than are depressive symptoms.     

Watch,wait, and wonder: Testing the effectiveness of a new approach to mother–infant psychotherapy

This research compared two forms of psychodynamic psychotherapeutic interventions for 67 clinically referred infants and their mothers. One was an infant‐led psychotherapy delivered through a program called Watch, Wait, and Wonder (WWW). The other was a mother–infant psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately 5 months. A broad range of measures of attachment, qualities of the mother–infant relationship, maternal perception of parenting stress, parenting competence and satisfaction, depression, and infant cognition and emotion regulation were used. The WWW group showed a greater shift toward a more organized or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Moreover, mothers in the WWW group reported a larger increase in parenting satisfaction and competence and decrease in depression compared to mothers receiving PPT. Both WWW and PPT were successful in reducing infant ‐presenting problems, decreasing parenting stress, and reducing maternal intrusiveness and mother–infant conflict. Some potential reasons for the differential treatment effects and the theoretical, clinical, and methodological implications from the findings are discussed. ©1999 Michigan Association for Infant Mental Health.     

Perceived mother‐infant relationship difficulties in postnatal depression

Postnatal depression has been associated with mother–infant relationship difficulties, but there has been less research in clinical populations. This study aims to identify characteristics of reported mother–infant relationship difficulties in mothers with postnatal depression who had been referred to a tertiary Mother and Baby Service. Forty‐one mothers with postnatal depression completed self‐report and interview measures with regards to their mental state, social adversity, and perceptions on their relationship with their infants. Almost one‐third of mothers (31.7%) reported severe difficulties, including rejection of the infant and maternal pathological anger. A low birth weight and maternal dissatisfaction towards their social role were found to be significantly related to perceived mother–infant interaction difficulties. Self‐reports correlated satisfactorily with interview schedules. A significant proportion of mothers reported difficulties in relating to their infants which can be reliably identified by means of the self‐report measures used. Copyright © 2004 John Wiley & Sons, Ltd.     

Infant visual habituation and parental psychological distress

Research is equivocal concerning the relationship between parental psychological distress and infant cognitive functioning. Four potential limitations of the literature are addressed: reliance on mothers' but not fathers' psychological distress, use of categorical measures of psychological distress, use of standardized measures of infant cognitive functioning, and failure to take into account potential gender differences. Ninety‐nine twin pairs and both their mothers and fathers were assessed. Infants cognitive functioning was assessed using an infant‐controlled habituation–recovery–dishabituation task. Maternal and paternal psychological distress was assessed using the Symptom Check List‐90‐Revised. No gender differences were obtained for infant visual information‐processing abilities or parental psychological distress. Maternal and paternal psychological distress was related to female visual encoding abilities only. It was concluded that parental psychological distress might degrade parent–infant interactions. Characteristics of girls when faced with parents exhibiting psychiatric difficulties may exacerbate difficulties of parent–infant interactions, thereby hindering the full development of cognitive abilities involved in the process of habituation. A need exists to examine the relationship between parental psychological distress and infant visual attention separately for girls and boys. ©2001 Michigan Association for Infant Mental Health.     

When two are a family: looking backward and looking forward in a group intervention with single‐by‐choice mothers

Objective: We describe a preventive short‐term group intervention with nine single‐by‐choice (SBC) mothers to provide maximal support for parental functioning and to minimize possible emotional and/or developmental difficulties in their children. Method: Dynamically oriented group work (fifteen one‐and‐a‐half‐hour sessions) focused on: elaboration of painful experiences in the peri‐natal period; reducing stress, tension and guilt; helping mothers with problematic aspects of parenting through work on parental self‐image and perceptions of the child and the dyadic interaction; and strengthening their acceptance of the chosen family model. Results: Therapeutic gains described by mothers and facilitators include: reduced tension, anxiety and guilt; improved integration of the mother's parental self‐image and perception of the child; reduced ambivalence in dyadic relationships; strengthening the mother's fantasized triadic relationships; better acceptance of chosen family pattern; mothers' willingness to tell children their birth story. Conclusion: Dynamically oriented preventive group intervention with SBC mothers can identify potential psychological risk factors and help mothers with sensitive aspects of parenting.     

Patterns of psychological distress in mothers of preterm infants

Mothers of preterm infants experience significant psychological distress, with elevated levels of inter-correlated depressive, stress, anxiety and post-traumatic stress symptoms. In a sample of racially and ethnically diverse mothers of preterm infants, we identified differing patterns of psychological distress during infant hospitalization and examined the effect of these psychological distress patterns on longitudinal trajectories of each psychological distress measure and on maternal perceptions of the child over the first year of the infant's life. Mothers of preterm infants (N = 232) completed five questionnaires assessing depressive symptoms, anxiety, post-traumatic stress symptoms, stress due to infant appearance, and stress due to parental role alteration during enrollment during the neonatal hospitalization, discharge, and at 2, 6, and 12 months of age adjusted for prematurity. Latent class analysis on the enrollment psychological distress variables allowed us to identify five sub-groups of mothers exhibiting similar patterns of psychological distress, differing primarily in degree and type: low distress, moderate distress, high NICU-related distress, high depressive and anxiety symptoms, and extreme distress. These classes continued to show different longitudinal trajectories for the psychological distress measures through 12 months corrected age. Mothers in the extreme distress class and, to a lesser degree, mothers in the high depressive and anxiety symptom class remained at risk of significant psychological distress one year after discharge and had less positive perceptions of their child (greater worry and higher perceptions of child vulnerability). In conclusion, distinctive sub-groups of mothers during hospitalization had different patterns of psychological distress throughout the 12-month period and may require different interventions in the NICU.