Attachment‐based intervention for substance‐using mothers: A preliminary test of the proposed mechanisms of change

Although randomized controlled trials examining the efficacy of attachment‐based interventions have been increasing in recent years, adequate measurement of treatment integrity, integrity–outcome associations, and mechanisms of change has been rare. The aim of this investigation was to conduct a rigorous test of proposed mechanisms of change in the Mothers and Toddlers Program (MTP) treatment model, a 12‐session, attachment‐based individual therapy for substance‐using mothers of children birth to 3 years of age. The MTP aims to improve maternal reflective functioning (RF) and representation quality (RQ) to bring about second‐order change in maternal caregiving behavior. Following guidelines from M.K. Nock ( 2007 ), it was hypothesized that (a) therapist adherence to unique MTP treatment components would uniquely predict improvement in RF and RQ and that (b) improvement in RF and RQ would function as unique mechanisms of change (when compared with other potential mechanisms—reduction in depression and increase in abstinence from drug use) in the improvement of caregiving behavior. Findings supported each hypothesis, confirming the proposed mechanisms of the treatment model. However, improvement in maternal depression also uniquely predicted improvement in caregiving behavior. Results underscore the potential value of attachment‐based parenting interventions for improving mother–child relations and the importance of providing these interventions in clinic settings where mothers have access to comprehensive care (e.g., psychiatric services).     

Development and Preliminary Evaluation of Family Minds: A Mentalization-based Psychoeducation Program for Foster Parents

Mentalization-based interventions show promise in improving mental health outcomes for children and parents through increasing a family's reflective functioning, or ability to mentalize. Mentalizing involves the ability to understand behavior in relation to mental states, such as thoughts and feelings, and typically develops within the context of secure attachment relationships. One area not given much consideration when training foster parents is their capacity to mentalize. This study evaluated Family Minds, a newly developed psychoeducational intervention for foster parents, designed to increase their ability to mentalize. The current paper reports on the development and preliminary empirical evaluation of Family Minds in a quasi-experimental study where 102 foster parents received either Family Minds or a typical foster parenting class, which served as a control group. Results indicate that parents who received Family Minds significantly increased their levels of reflective functioning as assessed with the Parental Reflective Functioning Questionnaire and a new Five-Minute Speech Sample procedure coded using the Reflective Functioning Scale, and revealed a tendency to show decreased levels of parenting stress on the Parenting Stress Index, while the control group showed no such improvements. These findings support the hypothesis that a short-term psychoeducational intervention may improve foster parents' ability to mentalize themselves and their children. These skills are very beneficial for foster parents, as they frequently deal with children who come into their home with challenging behaviors, attachment issues, and negative internal working models of relationships. This type of intervention has the potential to lower placement breakdowns and improve the mental health of foster children.     

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 reflective functioning is associated with tolerance of infant distress but not general distress: Evidence for a specific relationship using a simulated baby paradigm

Parental reflective functioning represents the capacity of a parent to think about their own and their child's mental states and how these mental states may influence behavior. Here we examined whether this capacity as measured by the Parental Reflective Functioning Questionnaire relates to tolerance of infant distress by asking mothers (N = 21) to soothe a life-like baby simulator (BSIM) that was inconsolable, crying for a fixed time period unless the mother chose to stop the interaction. Increasing maternal interest and curiosity in their child's mental states, a key feature of parental reflective functioning, was associated with longer persistence times with the BSIM. Importantly, on a non-parent distress tolerance task, parental reflective functioning was not related to persistence times. These findings suggest that parental reflective functioning may be related to tolerance of infant distress, but not distress tolerance more generally, and thus may reflect specificity to persistence behaviors in parenting contexts.     

Reflection in thought and action: Maternal parenting reflectivity predicts mind‐minded comments and interactive behavior

Recent research has identified mothers' mental reflective functioning and verbal mind‐minded comments as important predictors of subsequent infant attachment security. In the present study, we examine associations between mothers' (N = 95) parenting reflectivity expressed in an interview and observed parenting behavior, including verbal mind‐minded comments and interactive behavior during interaction with their 7‐month‐old infants. Parenting reflectivity was coded from the Working Model of the Child Interview. Maternal behavior was assessed via observations of mother–infant interaction during free play and structured teaching tasks. Both maternal appropriate mind‐minded comments as well as other indicators of maternal interactive behavior were coded. Parenting reflectivity was positively correlated with mind‐minded comments and behavioral sensitivity. Hierarchical multiple regression analyses indicated that parenting reflectivity contributed to maternal behavior beyond the contributions of mothers' educational status and depression symptoms. Discussion emphasizes the importance of individual differences in parental capacity to accurately perceive and mentalize their infants' experience, and the consequences of these differences for caregiving behavior.     

Reframing caring for parents who struggle with substance-use disorders

Nancy Suchman and the colleagues she influenced have produced ground-breaking and attitude-challenging work in understanding how parenting and substance use come together. Dr Suchman and her colleagues make the claim that there is nothing about a substance-use disorder that precludes effective and sensitive caring for children especially with interventions that focus on the parent–child relationship. Suchman's legacy is to highlight how substance use as an illness pulls individuals away from important, caring relationships and limits their giving themselves to those relationships. Restoring the salience of caring relationships and of the individual's ability to care may be as impactful on their substance use as a strict focus on the reduction of drug use and achieving abstinence.     

Parenting stress and competence among mothers of young children with substance use disorders: The roles of trauma and reflective functioning

Posttraumatic stress symptoms are prominent in the lives of parents of young children with substance use disorders (SUD). Parenting experiences, particularly stress and competence, impact parenting behaviors and concomitant child growth and development. Factors that promote positive experiences of parenting, such as parental reflective functioning (PRF), and protect the mother and child from negative outcomes are crucial to understand to develop effective therapeutic interventions. The current US study analyzed baseline data from a parenting intervention evaluation to examine how length of substance misuse, PRF, and trauma symptoms were associated with parenting stress and parenting sense of competence among mothers in treatment for SUDs. Measures included the Addiction Severity Index, PTSD Symptom Scale-Self Report, Parental Reflective Functioning Questionnaire, Parenting Stress Index/Short Form, and Parenting Sense of Competence Scale. The sample included 54 predominantly White mothers with SUDs who had young children. Two multivariate regression analyses found that (1) lower parental reflective functioning and higher posttraumatic stress symptoms were associated with higher parenting stress, and (2) only higher posttraumatic stress symptoms were associated with lower levels of parenting sense of competence. Findings underscore the importance of addressing trauma symptoms and PRF when aiming to improve parenting experiences for women with an SUD.     

Improved Perceptions of Emotion Regulation and Reflective Functioning in Parents: Two Additional Positive Outcomes of Parent-Child Interaction Therapy

The purpose of this study was to test whether Parent-Child Interaction Therapy (PCIT), a widely used effective therapy for children’s externalizing behaviors and parenting problems, was associated with improvements in parents’ emotion regulation and reflective functioning. We also investigated whether these improvements had unique associations with children’s improvements in externalizing and internalizing symptoms. Participants were 139 Australian children aged 29 to 83 months and their caregivers; all were referred for child externalizing behavior problems coupled with parenting skill deficits or high parent stress. All data were gathered via a questionnaire completed prior to and after completion of PCIT. Significant improvements were found in parents’ self-reported emotion dysregulation and capacity to use cognitive reappraisal for emotion regulation. There was also improvement in parents’ self-report of children’s symptoms, parenting practices, and reflective functioning in the form of prementalizing, which measured a low capacity to understand the emotional world of the child. Multiple regression showed that improvements in cognitive reappraisal, prementalizing, and negative parenting practices were associated with improvement in children’s symptoms. The findings extend the existing evidence for PCIT as an effective parenting intervention, adding parents’ perceived emotion regulation and reflective functioning to the list of positive outcomes from PCIT. Improved emotion regulation and reflective functioning, unique from changes in parenting practices, could be mechanisms that help explain why PCIT has been associated with improvements in children’s externalizing behaviors.     

Emotionally avoidant language in the parenting interviews of substance‐dependent mothers: Associations with reflective functioning,recent substance use,and parenting behavior

Parenting and emotion regulation are two known, and potentially interrelated, areas of impairment among substance‐abusing mothers. In this study, we examine substance ‐abusing mothers' (positive and negative) emotion language word use during their discussion of negative parenting experiences on the Parent Development Interview for its association with reflective functioning (RF), recent substance‐use history, and sensitivity to child cues. Within a sample of 47 methadone‐maintained mothers, we evaluate the hypothesis that linguistic evidence of emotional avoidance (more frequent positive feeling words and less frequent negative emotion words) will be associated with lower RF, more recent substance use, and more insensitive parenting. Further, we evaluate whether language use mediates the association between self‐focused RF and insensitive parenting. Results of hierarchical regressions suggest that more frequent positive feeling word use, but not negative emotion word use, is associated with lower RF, more recent substance use, and lower sensitivity to child cues. Positive feeling word use partially mediates the association between self‐focused RF and insensitive parenting. Results are discussed in the context of their contribution to the literature on emotion and parenting in substance‐abusing populations.     

Expressed Emotion,Parental Stress,and Family Dysfunction Among Parents of Nonclinical Italian Children

Expressed emotion (EE) is an index of the amount of emotion typically displayed by a family member or caretaker characterized by high emotional involvement, hostility or criticism. The aims of the current study were (a) to examine EE, stress and helplessness in childcare, and family functioning in mothers and fathers of elementary and junior high school children without clinical mental health problems living in a “nonclinical” family context; (b) to assess relationships between child age, gender, socio-economic status and EE; and (c) to investigate whether there are some factors—in a “normal family” context—that play a crucial role in the quality of EE. EE, assessed using the Five Minute Speech Sample (FMSS), and questionnaires assessing parenting alliance, family functioning, parenting stress index, and the parent’s state of helplessness in caring for the child were completed by a community-based Italian sample of mothers and fathers of children (N = 381) aged 6–14 years (M = 9.8, SD = 2.25). As expected, low rates in all FMSS variables were found for mothers and fathers, without significant differences between them. Mothers and fathers who showed high EE scores reported higher family non-adaptive functioning. Mothers also reported higher parental stress and higher Helplessness in caring for the child. Mothers’ stress and fathers’ reports of higher family non-adaptive functioning were the most consistent predictors of EE. Further research is needed to highlight associations between EE and family functioning.     

Parenting anxiety and stress: does gender play a part at 3 months of age?

In this study, the authors compared 90 pairs of mothers and fathers with respect to aspects of negative emotionality experienced in the early parenting role. Mothers and fathers of 90 healthy 3-month-old infants completed questionnaires pertaining to parenting stress and separation anxiety. Mothers reported significantly higher levels of negative emotionality than did fathers. An interaction effect of parent with child gender on the level of parenting stress was indicated. Mothers of sons reported more stress than did mothers of daughters. The child's gender was not related to the level of separation anxiety expressed by mothers and fathers. The findings suggested that, at 3 months of age, the child's gender plays a role in the parenting experience, but the impact is (a) moderated by the parent's gender and (b) construct-specific (e.g., stress). These findings are in line with a multidetermined model of parenting.     

Supporting Japanese Mothers of Children with ADHD: Cultural Adaptation of the New Forest Parent Training Programme

International practice guidelines recommend medication and behavioral intervention as evidenced‐based treatments for attention deficit hyperactivity disorder (ADHD). Currently in Japan, the availability of non‐pharmacological interventions for ADHD is limited. We report the results of a pilot and a proof‐of‐concept study for a new behavioral intervention for Japanese mothers of children with ADHD. The pilot study delivered a standard six‐session behavioral intervention and two parent‐support sessions. Participants approved the group format and requested additional support to change parenting practices and behavioral strategies targeting ADHD symptoms. For the proof‐of‐concept study, the intervention was revised to include five sessions of pre‐intervention support followed by six sessions of the New Forest Parent Training Programme (NFPP), an evidence‐based intervention for ADHD. The revised intervention, NFPP‐Japan, was associated with reductions in the mothers’ reports of children's ADHD symptoms and aggression, more effective parenting practices, and reduced parenting stress. The pilot and proof‐of‐concept studies indicate that it is possible to successfully modify Western behavioral interventions for Japanese mothers and to justify a randomized controlled trial evaluation of the NFPP‐Japan, which is currently underway.     

The affective structure of supportive parenting: depressive symptoms, immediate emotions, and child-oriented motivation

This study investigated the maternal concerns and emotions that may regulate one form of sensitive parenting, support for children's immediate desires or intentions. While reviewing a videotape of interactions with their 1-year-olds, mothers who varied on depressive symptoms reported concerns and emotions they had during the interaction. Emotions reflected outcomes either to children (child-oriented concerns) or to mothers themselves (parent-oriented concerns). Child-oriented concerns were associated with fewer negative emotions and more supportive behavior. Supportive parenting was high among mothers who experienced high joy and worry and low anger, sadness, and guilt. However, relations depended on whether emotions were child or parent oriented: Supportive behavior occurred more when emotions were child oriented. In addition, as depressive symptoms increased, mothers reported fewer child-oriented concerns, fewer child-oriented positive emotions, and more parent-oriented negative emotions. They also displayed less supportive behavior. Findings suggest that support for children's immediate intentions may be regulated by parents' concerns, immediate emotions, and depressive symptoms.     

Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning

This study examined changes in parent functioning resulting from parental participation in a behavioral parent training (PT) program specifically designed for school-aged children with attention-deficit hyperactivity disorder (ADHD). Relative to wait list controls, subjects who completed the nine-session PT program showed significant posttreatment gains in both child and parent functioning, which were maintained 2 months after treatment. In particular, there were PT-induced reductions in parenting stress and increases in parenting self-esteem, which accompanied parent-reported improvements in the overall severity of their child's ADHD symptoms. In addition to their statistical importance, these findings are discussed in terms of their clinical significance, utilizing methods developed by Jacobson and Truax (1991).This project was supported in part through BRSG grant S07RR05712-19 awarded to Arthur D. Anastopoulos by the Biomedical Research Support Program, Division of Research Resources, National Institutes of Health.     

Factor Analytic Structure and Validity of the Parental Feelings Inventory: A Brief Report

Previous research has highlighted the important role of parental emotions in parent–child interactions and child development. The present study presents the Parental Feelings Inventory (PFI), a new rating scale designed to assess parental emotions within the parenting role. The PFI presents emotion adjectives and asks parents to indicate the degree to which they experience that emotion in their role as parents. This study investigates the factor analytic structure and psychometric properties of this scale in a sample of parents with 3-year-old children. Participants included 149 mothers and 107 fathers of preschool-age children. The results provide support for a three-factor solution (Angry, Happy, and Anxious/Sad). This scale demonstrated good reliability and correlated with other measures of parent and child functioning. These findings provide support for the overall utility of the PFI as a measure of emotional experiences in the parenting role.     

Parenting,Family Loneliness,and Peer Functioning in Boys with Attention-Deficit/Hyperactivity Disorder

The goal of the present study was to consider the associations between family functioning (parenting and family loneliness) and peer functioning in a sample of boys with ADHD (N = 110) and their mothers (N = 108) and fathers (N = 53). Results indicated that higher paternal warmth was associated with more peer acceptance, less peer rejection, and less problematic social behavior, but only for boys who reported low levels of family loneliness. In addition, more paternal power assertion was related to less peer acceptance, but only for boys who reported low levels of family loneliness. Maternal warmth and power assertion were not significantly related to boys' peer functioning. We discuss these findings in the context of the processes by which parenting may affect the peer relationships of these children.     

Caregivers's Stress Secondary to Raising Young Children with HIV Infection: A Preliminary Investigation

This study examined the impact of caring for a child with HIV infection on biological mothers (also infected with HIV), familial caregivers, and foster mothers. Levels of reported parenting stress, emotional functioning, the impact of the child's illness, and coping strategies utilized were compared. Participants were 35 female caregivers of young children (birth to 5 years) with HIV infection. Demographic variables reflected group differences: biological mothers were younger, foster mothers had greater monthly income, and children who were living with relatives were older. Group differences were noted with regards to parent related stress, anxiety, and depression with foster mothers reporting lower levels. The types of coping strategies utilized were generally similar across groups. Results suggest that young, biological caregivers of children with HIV infection may benefit from careful assessment with regard to their need for psychological intervention.     

A Dialectical Behavior Therapy Skills Group Case Study on Mothers With Severe Emotion Dysregulation

Parenting is an emotionally demanding endeavor, which can be particularly challenging for parents who struggle with psychopathology and lack the regulation skills to manage their own emotional lability. Although dialectical behavior therapy (DBT) is an effective treatment that directly targets emotion dysregulation, little is known about whether DBT might also improve parenting behaviors. A DBT skills group was employed to examine whether DBT skills are utilized by mothers in their parenting and whether skill use improves parenting. Four mothers with severe emotion dysregulation who met diagnostic criteria for at least one Axis I disorder were part of a case study, in which they completed a DBT skills group for mothers, and two of the mothers participated in an in-depth exit interview regarding their use of DBT skills in their parenting. The mothers reported substantial changes in their parenting during the exit interview and modest improvements were found for parenting in pre- to posttreatment parenting assessments. This paper describes the various parenting contexts in which DBT skills were used and discusses maternal emotion regulation as a potential pathway from DBT skills to improved parenting.     

A Developmental Psychopathology and Neurobiological Model of Borderline Personality Disorder in Adolescence

The antecedents and risk factors and for developing borderline personality disorder (BPD) are now well documented, but there is a paucity of developmental models to understand the key processes through which they impact on the development of BPD in adolescents. In this article, we present a developmental psychopathology model of BPD in adolescence and link the difficulties adolescents with BPD have with impulsivity and self regulation, with risk factors such as genetic vulnerability, parenting and trauma. We propose a number of psychological processes through which these risk factors undermine personal and interpersonal functioning, and makes it particularly difficult to engage with the challenges of adolescence. These key psychological processes undermine the integration of the self, with extreme unintegrated affects and extreme representations of self and others, undermining the capacity to mentalize. We then make links to possible neurobiological underpinnings of the disturbances in affect, Theory of Mind and interpersonal difficulties in adolescents with BPD.     

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.