Randomized controlled trial of the Circle of Security-Intensive intervention for mothers with postpartum depression: maternal unresolved attachment moderates changes in sensitivity.

Postpartum depression is related to inadequately sensitive caregiving, putting infants at risk for insecure attachment. Therefore, promoting sensitive maternal caregiving and secure child attachment is particularly important in postpartum depressed mothers and their infants. In this randomized-controlled-trial, we evaluated the efficacy of the Circle of Security-Intensive (COS-I)-intervention in supporting maternal sensitivity and mother-infant-attachment compared to treatment-as-usual (TAU) with unresolved-maternal attachment as a moderator of treatment effect. Eligible mothers with infants (N=72) 4-9 months-old were randomly assigned to treatment (n=36 dyads). Infant attachment was rated at follow-up (child age 16-18 months) (Strange-Situation-procedure). Maternal sensitivity was measured at baseline and follow-up (Mini-Maternal-Behavior-Q-sort). Maternal-unresolved-attachment was assessed at baseline (Adult-Attachment-Interview). We found no significant differences between treatments in infant attachment nor changes in mothers' sensitivity. However, in COS-I, unresolved-mothers exhibited significantly more change in sensitivity than non-unresolved-mothers, whereas in TAU, the opposite was true. These findings may help to optimize clinical use of COS-I.

[Treatment Satisfaction of Mothers with Postpartum Depression Concerning Circle of Security Intervention]. / Die Behandlungszufriedenheit von postpartal depressiv erkrankten Müttern mit der Kreis der Sicherheit-Intervention.

Treatment Satisfaction of Mothers with Postpartum Depression Concerning Circle of Security Intervention Treatment satisfaction of mothers with postpartum depression who undergo mother-infant treatment is rarely examined, albeit seen as one aspect of treatment success. This study deals with maternal treatment satisfaction concerning the Circle of Security (COS) group intervention, compared to standard-mother-infant treatment (TAU), within a RCT trial. Treatment satisfaction was captured by the Fragebogen zur Beurteilung der Behandlung (FBB-E) of 52 mothers assigned to COS or TAU at children's age between 16 to 18 months. Process quality as well as outcome quality was assessed. Process quality included the evaluation of treatment procedure, information supply, evidence and justification of the measures undertaken, therapist's competence and coordination ability as well as the quality of relationship between therapist and mother. Results showed overall good to high and marginally different treatment satisfaction between both groups. COS-mothers declared themselves significantly more satisfied with the child (FBB-E-subscale: Success concerning the infant) than TAU-mothers. Both groups showed higher treatment satisfaction with the process quality than with the outcome quality of intervention. Overall, COS seem to meaningfully foster the acknowledgment of the child. In mother-infant treatment, particular attention is warranted to aspects of the process quality that attain the mother's treatment satisfaction.

Mothers with acute and chronic postpartum psychoses and impact on the mother-infant interaction.

BACKGROUND: Maternal postpartum psychoses pose a serious risk to the mother-infant interaction. It is unclear how different subtypes of postpartum psychosis, including acute and chronic, might differentially affect the mother-infant interaction. METHOD: A systematic search of electronic journal databases was performed. RESULTS: This systematic review yielded 17 studies with adequate overall study quality. They focused on child custody and involvement of social services as indirect indicators of the mother-infant interaction, observed mother-infant interactions as direct indicators, or potential transitional mechanisms, including memory processing, mind-mindedness, and affect recognition, that may partially explain the effects of psychotic disorders. An acute onset of psychosis during the postpartum period (de novo or relapse) was typically related to better mother-infant interactions. Mothers with schizophrenia have the highest risk of child displacement, and interventions by social services were more likely. However, mothers with postpartum schizophrenia did not exhibit more harm to the child or self-harm than mothers with postpartum depression. Heterogeneity of methodology, case definitions, and assessments characterized the studies; hence, they were not pooled. CONCLUSIONS: In addition to evaluating social risk factors in patients with acute onset and chronic psychoses during the postpartum period, negative preconceptions about motherhood and schizophrenia have to be carefully examined. Clinical research on postpartum psychoses should consider the onset criteria, prevalence of self-harm or harm to the child, significance of specific (e.g., religious) delusions and expressed hostility toward the child. More studies on the impact of first-onset (de novo) postpartum psychoses on the mother-infant interaction are needed.

[Comorbid Personality Disorders and Parenting Stress in Mothers with Postpartum Depression]. / Komorbide Persönlichkeitsstörungen und Parenting Stress bei postpartal depressiv erkrankten Müttern.

The original peer-reviewed paper presents the results of the analysis of the effects of psychiatric comorbidities of maternal postpartum depression, anxiety disorder and personality disorder (PD) on parenting stress. In the aforementioned analysis, mothers without PD (depression/ anxiety only) were compared to mothers with Borderline PD and mothers with other PD. Depending on the maternal PD, different sources of parenting stress have been revealed as specific to the mothers' experience of parenting stress, suggesting differential indications for psychosocial interventions to ease the burden of stress on the mother-infant system.

Parenting stress and postpartum depression/anxiety in mothers with personality disorders: indications for differential intervention priorities.

To date, parenting stress has rarely been examined in clinical samples of mothers with postpartum comorbid Axis-I disorders and Axis-II personality disorders (PD). Previous research has shown important links between maternal psychopathology and the development of child psychopathology. For these reasons, a clinical sample (N = 54) of mothers with various PD and comorbid depression/anxiety disorders were compared in this study. The clinical sample was divided into three groups based on PD: without PD, other PD, and borderline PD (BPD), and then matched according to depression/anxiety diagnoses and age. Parenting stress index (PSI, Abidin, 1995) scores were compared between these subsamples and to a nonclinical control group. No significant differences were found between mothers with various PD on global PSI scores. However, further examination of the PSI subscale scores revealed that PD were linked to an impaired sense of competence and positive reinforcement in relation to parenting. Compared to mothers with other PD, mothers with BPD had significantly more interpersonal issues. Compared to the nonclinical controls, clinically referred mothers had significantly higher PSI global and subscale scores, with notable PD-specific exceptions. These results illustrate the need for more differentiated treatment options for mothers with postpartum depression and/or anxiety disorders with PD to prevent later development of psychopathology in children of these mothers.

Maternal emotion dysregulation is related to heightened mother-infant synchrony of facial affect.

A heightened synchrony between the mother's and infant's facial affect predicts adverse infant development. We know that maternal psychopathology is related to mother-infant facial affect synchrony, but it is unclear how maternal psychopathology is transmitted to mother-infant synchrony. One pathway might be maternal emotion dysregulation. We examined (a) whether maternal emotion dysregulation is positively related to facial affect synchrony and (b) whether maternal emotion dysregulation mediates the effect of maternal psychopathology on mother-infant facial affect synchrony. We observed 68 mothers with mood disorders and their 4- to 9-month-old infants in the Still-Face paradigm during two play interactions. The mother's and infant's facial affect were rated from high negative to high positive, and the degree of synchrony between the mother's and infant's facial affect was computed with a time-series analysis. Emotion dysregulation was measured with the Difficulties in Emotion Regulation Scale, and psychopathology was assessed with the Symptom Checklist-90-Revised. Higher maternal emotion dysregulation was significantly associated with higher facial affect synchrony; emotion dysregulation fully mediated the effect of maternal psychopathology on facial affect synchrony. Our findings demonstrate that maternal emotion dysregulation rather than maternal psychopathology per se places mothers and infants at risk for heightened facial affect synchrony.

Gaze Synchrony between Mothers with Mood Disorders and Their Infants: Maternal Emotion Dysregulation Matters.

A lowered and heightened synchrony between the mother's and infant's nonverbal behavior predicts adverse infant development. We know that maternal depressive symptoms predict lowered and heightened mother-infant gaze synchrony, but it is unclear whether maternal emotion dysregulation is related to mother-infant gaze synchrony. This cross-sectional study examined whether maternal emotion dysregulation in mothers with mood disorders is significantly related to mother-infant gaze synchrony. We also tested whether maternal emotion dysregulation is relatively more important than maternal depressive symptoms in predicting mother-infant gaze synchrony, and whether maternal emotion dysregulation mediates the relation between maternal depressive symptoms and mother-infant gaze synchrony. We observed 68 mothers and their 4- to 9-month-old infants in the Still-Face paradigm during two play interactions, before and after social stress was induced. The mothers' and infants' gaze behaviors were coded using microanalysis with the Maternal Regulatory Scoring System and Infant Regulatory Scoring System, respectively. The degree of mother-infant gaze synchrony was computed using time-series analysis. Maternal emotion dysregulation was measured by the Difficulties in Emotion Regulation Scale; depressive symptoms were assessed using the Beck Depression Inventory. Greater maternal emotion dysregulation was significantly related to heightened mother-infant gaze synchrony. The overall effect of maternal emotion dysregulation on mother-infant gaze synchrony was relatively more important than the effect of maternal depressive symptoms in the five tested models. Maternal emotion dysregulation fully mediated the relation between maternal depressive symptoms and mother-infant gaze synchrony. Our findings suggest that the effect of the mother's depressive symptoms on the mother-infant gaze synchrony may be mediated by the mother's emotion dysregulation.

Observational tools for measuring parent-infant interaction: a systematic review.

The quality of the parent-infant interaction is essential for the infant's development and is most objectively measured by observation. The existing observational tools for assessing parent-infant interaction were identified and described, and their psychometric soundness was evaluated. Twenty electronic databases from inception through June 2013 were searched. Validity was evaluated in five domains (test content, response process, internal structure, relations to other variables, and consequences). Of the 23,961 citations identified, 24 tools were included. Most tools demonstrated a valid rating procedure, reproducibility, and discriminant validity, based on studies with credible quality. The tools lacked factorial and predictive validity, and standardized norms. Further refinement of the existing tools is needed, particularly in the domains of content validity and consequential validity. The synthesized validity evidence and descriptions of the tools reported in this review might guide clinicians and researchers in the selection of an appropriate tool.

A randomized controlled trial comparing Circle of Security Intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill mothers: Study Protocol.

BACKGROUND: Psychopathology in women after childbirth represents a significant risk factor for parenting and infant mental health. Regarding child development, these infants are at increased risk for developing unfavorable attachment strategies to their mothers and for subsequent behavioral, emotional and cognitive impairments throughout childhood. To date, the specific efficacy of an early attachment-based parenting group intervention under standard clinical outpatient conditions, and the moderators and mediators that promote attachment security in infants of mentally ill mothers, have been poorly evaluated. METHODS/DESIGN: This randomized controlled clinical trial tests whether promoting attachment security in infancy with the Circle of Security (COS) Intervention will result in a higher rate of securely attached children compared to treatment as usual (TAU). Furthermore, we will determine whether the distributions of securely attached children are moderated or mediated by variations in maternal sensitivity, mentalizing, attachment representations, and psychopathology obtained at baseline and at follow-up. We plan to recruit 80 mother-infant dyads when infants are aged 4-9 months with 40 dyads being randomized to each treatment arm. Infants and mothers will be reassessed when the children are 16-18 months of age. Methodological aspects of the study are systematic recruitment and randomization, explicit inclusion and exclusion criteria, research assessors and coders blinded to treatment allocation, advanced statistical analysis, manualized treatment protocols and assessments of treatment adherence and integrity. DISCUSSION: The aim of this clinical trial is to determine whether there are specific effects of an attachment-based intervention that promotes attachment security in infants. Additionally, we anticipate being able to utilize data on maternal and child outcome measures to obtain preliminary indications about potential moderators of the intervention and inform hypotheses about which intervention may be most suitable when offered in a clinical psychiatric outpatient context. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88988596.

Insightfulness and later infant attachment in clinically depressed and nonclinical mothers.

The aim of this pilot study was to investigate the relationship between maternal insightfulness and sensitivity and subsequent infant attachment security and disorganization in clinically depressed and nonclinical mother-infant groups. Nineteen depressed mothers with infants ages 3 to 11 months participated in this study. Twenty nonclinical mother-infant dyads were matched to the clinical sample according to infant sex and age. Maternal depression was assessed using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994), insightfulness using the Insightfulness Assessment (IA), and sensitivity using the Maternal Sensitivity Scales (M.D.S. Ainsworth, 1969). IA classifications and subscales were considered separately. Later infant attachment was assessed by the Strange Situation Procedure (M.D.S. Ainsworth, M.C. Blehar, E. Waters, & S. Wall, 1978). Depressed mothers tended to have less securely attached children than did nonclinical mothers. Within the clinical sample, the insightfulness categories correlated slightly moderately with attachment security, but were not related to attachment disorganization. Within the nonclinical sample, the IA categories were slightly moderately associated with attachment security and with disorganization. On IA subscales, relationship patterns differed in clinically depressed and nonclinical mother-infant dyads. These findings provide the first evidence of the predictive power of the IA categorization and subscales on subsequent infant attachment. They also may allow the development of different foci of intervention for enhancing insightful caregiving.

[Dimensions of parental rearing styles in alcohol dependent patients: first results of the questionnaire on parental attitudes and rearing practices (FEPS)]. / Dimensionen elterlicher Erziehungsstile bei alkoholabhängigen Patienten: Erste Befunde zum Fragebogen zu Erziehungseinstellungen und Erziehungspraktiken (FEPS).

To date no instrument for the assessment of parenting styles is available in the German -language area that has been validated in patients with addictive disorders. Therefore the aim of this study was the confirmatory evaluation of the factor structure of the Questionnaire on Parental Attitudes and Rearing Practices (FEPS) in 186 alcohol dependent patients. The model as proposed by the test developers with the 4 factors Care, Autonomy, Low Punishment, and Low Material Reinforcement showed acceptable fit when residual correlations were allowed (mother: χ(2)/df=1,92, RMSEA=0,07, TLI=0,79; father: χ(2)/df=1,75, RMSEA=0,07, TLI=0,82). All factors showed sufficient factor reliabilities as well as good to very good internal consistencies. Factor loadings, discriminations and difficulties of the indicators could be regarded as good, with the exception of 2 items. These results indicate the factorial validity of the FEPS in patients with alcohol dependence.

Head position and expressed emotion of adolescents with schizophrenia and their caregivers compared to non-patient controls.

BACKGROUND: Family interactions with schizophrenia patients and caregivers rated as high expressed emotion (EE) are characterized by increased negative non-verbal behaviour. Head position is one important component of non-verbal behaviour and has not been examined in relation to EE before. The aim of this pilot study was to investigate the influence of caregivers' EE on the head position of adolescents with schizophrenia and their caregivers. SAMPLING AND METHODS: 15 adolescent schizophrenia patients and 17 non-patient adolescents were videotaped during a 10-min problem-solving task with their caregiver. The head position was coded by the Berner System of Non-Verbal Behaviour. The caregivers' EE level (high EE vs. low EE) was measured by the Five-Minute Speech Sample. RESULTS: Adolescent patients and non-patients showed a higher frequency of averted head positions towards high EE caregivers compared to low EE caregivers (ß = 47.85, t = 2.41, p = 0.023). They displayed longer mean times of averting towards high EE caregivers compared to low EE caregivers (ß = -1.78, t = -2.51, p = 0.018). An indirect approach was shown more frequently by adolescent patients towards low EE compared to high EE caregivers (ß = 39.99, t = 2.31, p = 0.028). In contrast, non-patient adolescents showed a more indirect approach towards high EE caregivers compared to low EE caregivers. Caregivers of schizophrenia patients had head positions with a straight ahead lowered approach for a longer time compared to caregivers of non-patients (ß = -29.75, t = -2.51, p = 0.018). Within the patient and non-patient groups, low EE caregivers showed longer total times of positions with a straight ahead lowered approach than high EE caregivers. CONCLUSIONS: High EE communication may be characterized by a higher ratio of averting head position in adolescents, which is especially pronounced in adolescents with schizophrenia. Low EE communication seems to be better adjusted by a more indirect approach being shown by the adolescent and straight ahead lowered head positions by the caregiver, especially when the adolescent suffers from schizophrenia.

Facial emotional expression in schizophrenia adolescents during verbal interaction with a parent.

Research on emotional expression in adult schizophrenia patients has indicated an impairment of the patients' facial expressions during social interaction. However, it is unclear whether schizophrenia adolescent-onset patients show comparable disturbances in facial expression. Our aim was to analyze facial emotions in adolescents with schizophrenia spectrum psychoses compared with non-patient controls during a problem-solving discussion with their primary caregivers. We assessed facial expressions of emotions and speaker position (speaking vs. listening) in schizophrenia and non-patient adolescents matched for age and gender. The facial emotions were coded with the Emotional Facial Action Coding System. Schizophrenia adolescents showed significantly lower rates per minute of expressions indicating positive emotions compared with non-patient adolescents (ß = -0.95, 95 % CI [-1.34, -0.57], t (37.92) = -5.00, p ≤ 0.001). In contrast, there was no lower rate of expressions indicating negative emotions of schizophrenia adolescents (ß = 0.10, CI [-0.42, 0.61], t (35.03) = 0.38, p = 0.709). While the negative facial expressions of non-patient adolescents were related to speaking (ß = 0.63, CI [0.34, 0.92], t (26) = 4.50, p = < 0.001), this relationship was not observed in schizophrenia adolescents. Our results indicated an emotion-specific impairment of positive facial expressions in schizophrenia adolescents early in the course of illness and a deviant relation between facial emotional expressions and speech.

The capacity to see things from the child's point of view--assessing insightfulness in mothers with and without a diagnosis of depression.

UNLABELLED: Insightfulness is seen as the mental capacity that provides the context for a secure child-parent attachment. It involves the ability to see things from the child's perspective and is based on insight into the child's motives, a complex view of the child and openness to new information about the child. To test our hypothesis that maternal insightfulness is related to maternal depression, we utilized the Insightfulness Assessment (IA) developed by Oppenheim and Koren-Karie to conduct and analyse interviews in which mothers discussed their perceptions of video segments of their interactions with their children. We compared the results of a control group of 30 mothers without a diagnosis of depression with a sample of 23 mothers diagnosed with depression (International Classification of Diseases, 10th Revision). As expected, depression was negatively related to maternal insightfulness. Oppenheim and Koren-Karie have argued that the IA might be used as a diagnostic instrument; our work suggests that the IA might show ways of aiding mothers in improving the quality of mother-infant interaction while they are being treated for depression. KEY PRACTITIONER MESSAGE: Insightfulness is seen as the mental capacity that provides the context for a secure child-parent attachment. Maternal depression was negatively related to maternal insightfulness. The Insightfulness Assessment might be used as a diagnostic instrument. The Insightfulness Assessment might show ways of aiding mothers in improving the quality of mother-infant interaction while they are being treated for depression.

[Attachment and attachment-based intervention: the Circle of Security intervention project in Hamburg]. / Bindung und Bindungstherapie Die Hamburger Interventionsstudie "Kreis der Sicherheit".

Since the early sixties empirical research into early childhood and the parent-infant relationship has increased, commonly informed by attachment theory. The mutually regulated interaction within the attachment and care giving relationship of mother and infant gives this relationship its exceptional emotional quality. Early attachment experiences organize socio-emotional and cognitive development beyond childhood. Attachment theory and research define observable behaviors and the level of internal representations as an intervening variable of the transmission of attachment patterns between mother and child. Basic attachment derived concepts are the starting points of the Circle of Security approach. The Circle of Security Intervention Project in Hamburg for mothers with postpartum mental illness and their infants is described in more detail. Specific aspects are discussed with reference to a diagnostic case study.