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.     

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.     

THE MOTHERS AND TODDLERS PROGRAM, AN ATTACHMENT-BASED PARENTING INTERVENTION FOR SUBSTANCE-USING WOMEN: RESULTS AT 6-WEEK FOLLOW-UP IN A RANDOMIZED CLINICAL PILOT

Previously, we reported posttreatment findings from a randomized pilot study testing a new attachment-based parenting intervention for mothers enrolled in substance-use treatment and caring for children ages birth to 3 years (N.E. Suchman, C. DeCoste, N. Castiglioni, T. McMahon, B. Rounsaville, & L. Mayes, 2010). The Mothers and Toddlers Program (MTP) is a 12-session, weekly individual parenting therapy that aims to enhance maternal capacity for reflective functioning and soften harsh and distorted mental representations of parenting. In a randomized pilot study, 47 mothers who were enrolled in outpatient substance-abuse treatment and caring for children between birth and 3 years of age were randomized to the MTP versus the Parent Education Program (PE), a comparison intervention that provided individual case management and developmental guidance. At the end of treatment, mothers in the MTP condition demonstrated better reflective functioning, representation quality, and caregiving behavior than did mothers in the PE condition. In this investigation, we examined whether the benefits of MTP at posttreatment were sustained at the 6-week follow-up. Recently, we also identified two components of parental reflective functioning: (a) a self-focused component representing the parent's capacity to mentalize about strong personal emotions (e.g., anger, guilt, or pain) and their impact on the child and (b) a child-focused component representing the parent's capacity to mentalize about the child's emotions and their impact on the mother (N. Suchman, C. DeCoste, D. Leigh, & J. Borelli, 2010). In this study, we reexamined posttreatment outcomes using these two related, but distinct, constructs.     

Dyadic Treatment,Reflective Functioning,and Videofeedback: Fostering Attachment with Families in the Foster Care System

The Building Blocks Program encourages parent-child bonding, attachment, and reflective functioning based on theories of nonverbal communication and mentalization. In the Building Blocks Program, young children who are in foster care or at risk of being in foster care are seen in dyadic sessions with their birth parents in a clinical setting. The parents come in with traumatic histories, including adverse childhood experiences, disrupted connections, mental illness, ongoing exposure to poverty and violence, and have little social support. The children have significant medical, emotional, and/or cognitive challenges. In this article, all aspects of the Building Blocks Program are described, including training for therapists, treatment for parents and children in supervised play/visitation sessions, Reflective Supervision with therapists in group and individual sessions, and the model of Nested Mentalization. Using video and videofeedback as a vehicle for positive change, therapists promote emotional healing and parent-child attachment. In Reflective Supervision, supervisors make every effort to understand the thoughts and feelings of the therapists. A holding environment is provided for the therapists who, in turn, hold the parent, who can then hold the child. Two cases are described that demonstrate the many layers of complexity in the Building Blocks model, and how the multifaceted levels of complicated systems are addressed.     

Mentalizing in Parents after Traumatic Loss. Analysis of Couple Counseling

Abstract

The aim of the study is to explore whether bereaved parents’ capacity to mentalize is related to their progression through grieving and how it changes during couple therapy. The clients’ RF levels were assessed using the Reflective Functioning Scale and Psychotherapy Reflective Functioning Scale Manual. The content of the sessions was analyzed using Thematic Analysis. At the beginning of the therapy, concrete images of the child’s death were more frequent and the parents’ RF was lower than their general RF level. As the therapy progressed these images were gradually supplanted by more mental references to the deceased child.     

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.     

The Parental Reflective Functioning Questionnaire in Mothers and Fathers of School-Aged Children

Research on parental reflective functioning (PRF)—defined as parents’ capacity to comprehend the developing mind of their child, reflect upon it, and hold in mind the inner life of the child—has mostly involved mothers of infants and young children, and rarely fathers and parents of school-aged children. The present study sought to extend research on PRF by examining aspects of the construct that are still scarcely explored, such as the role of gender and attachment; to investigate whether there were differences between mothers’ and fathers’ PRF and whether there were differences in PRF related to the gender and age of the child; and, finally, to assess the association between PRF and each parent’s attachment style. The Parental Reflective Functioning Questionnaire (PRFQ) and the Attachment Style Questionnaire (ASQ) were administered to a community sample of mothers and fathers of 385 children aged 3–10 years. A multi-group factor analysis supported the hypothesized three-factor model among both fathers and mothers. Univariate and multivariate analyses of variance showed that mothers had higher levels of interest and curiosity in their children’s mental states than fathers. Parents of daughters showed higher pre-mentalizing modes than parents of sons. Parents of preschool children showed less nonmentalizing modes than parents of children aged 8–10. Correlations between PRFQ and ASQ showed that both mothers’ and fathers’ interest in thinking about their child’s internal experience and in taking the child’s perspective were correlated with higher levels of secure attachment style. Research implications are discussed.     

Reflective Parenting Programs: Theory and Development

Recent research has indicated that parental reflective functioning or mentalization plays a crucial role in the development of a range of healthy adaptations in both parent and child. While many parenting interventions developed over the course of the last 20 years have implicitly attempted to enhance mentalization in parents, this article describes an effort to directly intervene with parents to enhance or encourage the development of reflective capacities. In this article, the broad outlines of a reflective parenting approach are described. Two reflective parenting programs are then considered, one a group intervention designed for low-risk parents, the other a home visiting intervention designed for high-risk parents and children.     

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.     

The Association Between Reflective Functioning and Parent–Child Relationship Quality

Research consistently links adult and infant attachment styles, yet the means by which attachment is transmitted is relatively elusive. Recently, attention has been directed to the psychological underpinnings of caregiver sensitivity—originally thought to be the mechanism of transmission—as indicated by caregivers’ ability to keep in mind children’s mental states when interpreting children’s behavior, or reflective functioning. Unfortunately for researchers, extant measures of reflective functioning are time-consuming and require extensive observation and coding. A self-report measure could help facilitate the study and assessment of reflective functioning in research and clinical settings. This study investigated the relationship between parental reflective functioning and multiple aspects of the parent–child relationship, by using a new, self-report measure of reflective functioning. Participants were 79 caregivers (M _age = 31.8 years) who completed self-report measures assessing reflective functioning, parent–child relationship characteristics, perceived rejection in early relationships, attachment anxiety and avoidance in current close relationships, depression, and substance use. The results indicated that reflective functioning is a strong predictor of parent–child relationship quality (i.e., parental involvement, communication, parent satisfaction, limit setting, and parental support), independent of other potential indicators. Findings support parental reflective functioning as a contributor to the quality of parent–child relationship and suggest that a parent’s capacity to reflect on the mental states of his or her child in parent–child interactions may provide a key target for interventions that aim to improve parent–child relationships.     

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.     

Infant mental health home visiting in the context of an infant—toddler court team: Changes in parental responsiveness and reflective functioning

This article describes an infant–toddler court team in Michigan, the community-based participatory research approach to the implementation evaluation, and the resulting changes in parenting. Like other court teams, Michigan's Baby Court is led by a science-informed jurist, and all service providers are knowledgeable about the developmental needs of young children and engage in collaborative communication throughout the case. Relationship-based treatment in the form of infant mental health home-visiting was provided to families. Sixteen parents participated in pre- and posttest evaluation visits to assess changes in parents’ reflective functioning and interactions with their child. Findings suggest improvements in parents’ responsiveness, positive affect, and reflective functioning, with moderate effects. Higher risk parents demonstrated significant changes in reflective functioning, as compared to those at lower risk. These findings add to and support the limited literature on the effectiveness of infant–toddler court teams, which include relationship-based and trauma-informed services.     

“Wondering” and Beyond: Discussion of Arietta Slade's “Reflective Parenting Programs”

Arietta Slade describes the development of two reflective parenting programs that are based on Fonagy's and his colleagues' construct of reflective functioning. The merits of focusing on a defined theoretical construct are that it enables the conceptualization of the parent and child experiences that should be targeted and outlined in an intervention program. The discussion questions the extent to which parents, and in particular those with difficult histories, can be open to this intervention. The psychoanalytic literature has shown that parent–child interactions are affected by parents' past experiences that might be projected or attributed to their children. It is suggested that the intervention program should also address the parent and his or her past. Helping parents to arrive at a more integrated understanding of their own development could help them to be more open to the experiences of their children.     

Development of an Intervention for Foster Parents of Young Foster Children with Externalizing Behavior: Theoretical Basis and Program Description

Foster parents are often faced with serious externalizing behaviors of their foster child. These behavioral problems may induce family stress and are related to less effective parenting and often increase. Foster children with behavioral problems are also more at risk of placement breakdown. An intervention to support foster parents of young foster children with externalizing behaviors is necessary to improve the effectiveness of foster placements. Based on research on effective parenting interventions and special needs of foster children, a treatment protocol was developed. This paper describes theoretical foundations for the content and form of the intervention and gives an overview of the modular treatment protocol. Preliminary outcomes of this intervention as well as challenges and future developments and research activities are discussed.     

The Circle of Security Parenting Program (COS-P): A Randomized Controlled Trial of a Low Intensity,Individualized Attachment-Based Program With at-Risk Caregivers

The Circle of Security–Parenting Intervention (COS-P; Cooper et al., 2009) is a psychoeducational program for caregivers of young children that has been widely disseminated. The program is founded in attachment theory and relies on computer-delivered content and parent reflection and discussion to teach concepts of safety and security to promote better caregiver-child relationships and child wellbeing. The present study is a randomized controlled trial of COS-P, individually delivered to 85 Australian caregivers (51 COS-P, 34 waitlist control) who reported parenting distress and child disruptive behaviors. Caregivers completed a baseline assessment and repeated the assessment after completion of COS-P or 8 weeks on the waitlist. Caregivers completed surveys to report child symptoms, and parenting stress, anxious and avoidant attachment, reflective functioning, parenting practices, and depressive symptoms. No differences in COS-P vs. waitlist participants were found at baseline. Analyses of complete data (35 COS-P, 25-26 waitlist) revealed a greater decline in caregivers’ attachment anxiety and negative parenting relative to waitlist, but only attachment anxiety in intent-to-treat analyses. Other improvements were found, but these extended to both the COS-P and waitlist conditions and did not differ between conditions. Overall, effects of COS-P were small and rarely significant, suggesting the need to consider alternative programs that have evidence of effectiveness when providing services to at-risk families.     

Training Parents in Forgiving and Reconciling

Teaching parents how to forgive transgressions of parenting partners may reduce negative emotions, increase positive emotions, and, thus, decrease parenting stress. We implemented a waiting-list design to investigate the efficacy of a 9-hour psychoeducational group intervention, Forgiveness and Reconciliation through Experiencing Empathy (FREE), presented to 27 parents and caregivers of children 0–9 years old. Participants receiving FREE exhibited increased forgiveness of a target offense by the parenting partner and increased forgiveness of all parenting offenses. This study offers initial evidence that an intervention to promote forgiveness and reconciliation in parents could be beneficial and might improve parenting relations.     

Childhood obesity and parental reflective functioning: Is there a relation?

Background/ObjectiveIn recent decades, the prevalence of childhood obesity has increased, with the major implications for public health. However, the factors that contribute to obesity in children are still poorly understood. The present study aimed to investigate the role of parental reflective functioning (PRF) in childhood obesity.MethodIn a cross-sectional design, 120 sets of parents of 60 children (n = 30 with obesity, age range 6–11) were recruited by local paediatricians. Parents completed the Parental Reflective Functioning Questionnaire. Children's and parents’ weight (assessed by BMI), as well as their socio-economic status (SES), were assessed to explore the contribution of PRF in the prediction of children's weight, controlling for parents’ weight and SES.Resultst-test showed significant differences with medium effect sizes in BMI, SES and PRF between parents of children with and without obesity. The best model resulted from hierarchical multiple regression analyses and showed that mothers’ PRF predicted children's BMI above and beyond the prediction by parents’ BMI and SES.ConclusionsLow maternal PRF could be an important target for intervention strategies, highlighting the need to consider parental responses to children's emotions in the treatment of childhood obesity, particularly in parents with low SES and high BMI.     

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.     

PATERNAL AND MATERNAL REFLECTIVE FUNCTIONING IN THE WESTERN AUSTRALIAN PEEL CHILD HEALTH STUDY

While past research on the care of infants has been mostly with mothers, in recent times there has been a renewed attention to the father–infant relationship. This study examined differences between mother and father parental reflective functioning (PRF) or parental mentalizing; that is, the parental capacity to reason about their own and their children's behaviors by taking into consideration intentional mental states. Data were collected from 120 couples with a 1‐year‐old child who were participants in the West Australian Peel Child Health Study. Parental mentalizing was assessed using the Parental Reflective Functioning Questionnaire (PRFQ; Luyten, Mayes, Nijssens, & Fonagy, 2017 ). Results showed that mother and father mentalizing with their children was independent and that mothers scored slightly higher levels of mentalizing than did fathers. Paternal mentalizing was weakly associated with family income and father education, and was more strongly associated with family functioning than with maternal mentalizing. Implications for theorizing on PRF and fatherhood more generally are discussed.     

Effectiveness of a Multiple Family Group Intervention for Juvenile First Offenders in Reducing Parent Stress

Parenting practices are major influences on incidents of juvenile delinquency. Stress experienced by parents of children with behavioral problems is a leading contributor to parenting practices. We investigated the extent to which parental stress was reduced by participation in an established multiple group family intervention, the Family Solutions Program, developed to reduce recidivism among juvenile offenders. We also examined parent stress by gender, ethnicity, dropout rates, intervention benefits at 3-month follow-up, single- versus two-parent households, and across dimensions of family functioning and parent-adolescent communication. Parents reported greater levels of parent stress than non-clinical parents prior to intervention. Parental stress did diminish in response to intervention, but not until follow-up to intervention completion. No differences were found on initial parent stress level between completers and non-completers of the intervention or between parent stress and gender or ethnicity of the parent; however, single-parent household was associated with significantly higher levels of parent stress. Family functioning was significantly negatively correlated with parental stress. Finally, open communication between juvenile first offenders and their parents improved significantly in response to the intervention both at post-intervention and at follow-up.