Parent-child interactive behavior in a German sample of parents with and without a mental illness: model replication and adaption of the Coding Interactive Behavior system.

Studies using observational measures often fail to meet statistical standards for both reliability and validity. The present study examined the psychometric properties of the Coding Interactive Behavior (CIB) System within a German sample of parent-child dyads. The sample consisted of 149 parents with and without a mental illness and their children [n experimental group (EG) = 75, n control group (CG) = 74] who participated in the larger Children of Mentally Ill Parents at Risk Evaluation (COMPARE) study. The age of the children ranged from 3 to 12 years (M = 7.99, SD = 2.5). Exploratory factor analysis supported a five-factor model of the CIB with items describing 1) parental sensitivity/reciprocity, 2) parental intrusiveness, 3) child withdrawal, 4) child involvement, and 5) parent limit setting/child compliance. Compared to international samples, the model was reduced by two independent dyadic factors. Testing for predictive validity identified seven items with predictive power to differentiate parental group membership. The CIB factors did not seem to be sufficiently sensitive to illustrate differences in interaction within a sample of parents with various mental illnesses. To apply the CIB to the described sample or similar ones in the future, additional measurement instruments may be necessary.

The effect of antepartum depressive and anxiety symptoms on mother-infant interaction: The mediating role of antepartum maternal emotional stress.

Anxiety disorders, depression, and emotional stress during the antepartum period are interlinked with adverse child development. The quality of the dyadic interaction seems to play a crucial role in the transmission of these effects. In this study, we explored the mediating effect of antepartum maternal emotional stress (assessed via the Prenatal Emotional Stress Index) regarding the relationship of antepartum maternal depressive (assessed via the Edinburgh Postpartum Depression Scale), anxiety symptoms (assessed via the Stat-Trait-Anxiety-Inventory), and depressive and anxiety disorders (assessed according to the DSM-IV-TR) in the antepartum period on postpartum interactive quality in a longitudinal design. The Face-to-Face-Still-Face Paradigm (FFSF) and the Infant and Caregiver Engagement Phases (ICEP-R) coding system were used to assess the postpartum interactive qualities of the mother-infant dyads. The sample consisted of 59 women, 38 in the clinical and 21 in the control group. We found significant indirect effects of antepartum depressive symptoms and maternal diagnostic status on the mother's neutral engagement and on the latency to the first social positive interactive match during the interaction - effects that were mediated by antepartum stress. Moreover, there was an indirect effect of state anxiety on neutral engagement - mediated by antepartum stress. Therapeutic intervention studies focusing on maternal antepartum regulation of emotional stress and postpartum interactive patterns might be crucial to encounter maladaptive developmental trajectories.

Maternal postpartum anxiety and the development of infant attachment: The effect of body sensations on infant attachment.

BACKGROUND: Knowledge about the influences of maternal postpartum anxiety disorders (PAD) on infant development is limited. Aim of this present study is to evaluate the influence of PAD on infant attachment. METHODS: In a longitudinal study, self-reported anxiety symptoms of N = 70 mothers (N = 28 with PAD diagnosed according to the DSM-IV, N = 42 controls) were examined in the postpartum period and one year later. Infants' attachment was observed in the Strange Situation Test (SST) at the age of 12-24 months. RESULTS: Results indicate a strong relationship between PAD and infant attachment: infants of mothers with PAD were significantly more likely to be classified as insecure or disorganized than infants of control mothers. Logistic regression analysis led to a significant model with 76.8 % correct classification of infant attachment dependent on the maternal fear of anxiety associated body sensations (OR = 4.848) in the postpartum period. Including maternal sensitivity and interaction behavior, only maternal intrusiveness was additionally associated with infant attachment (ρ = 0.273, p < .05; OR = 45.021, p = .153). LIMITATIONS: Participants were highly educated. Different anxiety disorders included led to a heterogenous sample. Generalization is diminished. Maternal sensitivity was measured on a global scale, and body tension was self-reported. CONCLUSIONS: PAD plays a crucial role in the development of infant attachment. Interaction-focused interventions, helping mothers to decrease intrusiveness, and body-focused interventions, helping mothers to deal with their fear of anxiety symptoms, might be promising pathways to buffer the influence of PAD on infant attachment.

Study protocol of the COMPARE-Interaction study: the impact of maternal comorbid depression and anxiety disorders in the peripartum period on child development.

INTRODUCTION: To date, there are only few studies that compare the consequences of peripartum maternal depressive disorders (PD) versus depressive with comorbid anxiety disorders (PDCA) for infant and child development. As comorbidity is associated with greater impairment and symptom severity related to the primary diagnosis, comorbidity in mothers might raise their offspring's risk of developing internalising or externalising disorders even more than has been noted in conjunction with PD alone. METHODS AND ANALYSIS: This study aims to analyse the impact of parental psychopathology, particularly peripartum depression in mothers with and without comorbid anxiety disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) on child cognitive and socioemotional development. Maternal/paternal psychopathology, mother-infant/father-infant interaction and child development are assessed at four measurement points over the first 2 years (T1: 3-4 months postpartum, T2: 12 months postpartum, T3: 18 months postpartum and T4: 24 months postpartum). The mediating role of mother-infant/father-infant interaction and infant stress reactivity in the relationship between PD/PDCA and infant cognitive and socioemotional development will be analysed. In the ongoing study, 174 families (n=58 mothers with PD, n=58 mothers with PDCA and n=58 healthy controls) will be recruited in inpatient and outpatient centres as well as maternity hospitals in Munich and Heidelberg. ETHICS AND DISSEMINATION: This study is implemented in accordance with the current guidelines of the World Medical Association (revised Declaration of Helsinki) and the General Data Protection Regulation of the European Union. The study procedures were approved by the independent ethics committees of the Department of Psychology, Ludwig-Maximilians-University Munich (74_Reck_b) and of the Medical Faculty, University Heidelberg (S-446/2017). Participation is voluntary. A signed written informed consent form must be obtained from each study subject prior to any study-specific procedure. Participants can withdraw from the study at any point in time without giving a reason or being subjected to any future disadvantages. In case of withdrawal from the study, the subject's data and material will be kept unless the participant asks for data removal. Results will be published and disseminated to further the discussion on the effects of maternal PD and PDCA on parent-infant interaction, infant stress reactivity and child development. Furthermore, study results will be presented at international congresses and expert conferences.

Theory of Mind in Pre-school Aged Children: Influence of Maternal Depression and Infants' Self-Comforting Behavior.

A milestone of child development is theory of mind (ToM): the ability to attribute mental states, especially beliefs and desires, to other persons and to understand that their behavior is guided by mental states. The learning process about the mental world also takes place in social communication and interaction, beginning in infancy. Infancy is assumed to be a sensitive period for the development of social skills through interaction. Due to limited self-regulatory skills, infants depend on sensitive behavior of their caregivers to regulate affective states and physiological arousal, and in turn, mutually regulated affects allow the infant to gradually acquire the capability to self-regulate negative affective states. Effective and adequate affect regulation is an important prerequisite for environmental interaction and thus for the development of socio-emotional skills. The present study investigated the relation of self-regulatory abilities in infancy and later ToM in pre-school aged children of clinically depressed mothers and healthy controls. The sample comprised of N = 55 mother-child dyads, n = 22 diagnosed with postpartum or lifetime depression according to DSM-IV and n = 33 healthy controls. Mother-infant-interaction was videotaped during the Face-to-Face Still-Face paradigm. At 3 and 42 months postpartum mothers were interviewed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to evaluate maternal psychopathological status according to DSM-IV. At the age of M = 4.0 years, children's ToM abilities were assessed using content-false-belief and location-false-belief tasks. The results of this study show that contrary to our hypotheses, maternal depression did not impair the development of children's ToM-abilities per se. Rather, an interaction effect highlights the role of infant's self-comforting behavior during mother-infant interaction in infancy (3 months postpartum) for ToM-development at pre-school age assessed with the Maxi-task; this association was distinct for female in comparison to male children. The results of this longitudinal study shed light on the discussion, how maternal depression influences child development and point in the direction that self-comforting behaviors in infancy can also be seen as a resource.

From Early Micro-Temporal Interaction Patterns to Child Cortisol Levels: Toward the Role of Interactive Reparation and Infant Attachment in a Longitudinal Study.

Parental mental disorders increase the risk for insecure attachment in children. However, the quality of caregiver-infant interaction plays a key role in the development of infant attachment. Dyadic interaction is frequently investigated via global scales which are too rough to uncover micro-temporal mechanisms. Prior research found that the latency to reparation of uncoordinated dyadic states is associated with infant behavioral and neuroendocrine regulation. We investigated the hypothesis that this interactive mechanism is critical in predicting secure vs. insecure attachment quality in infancy. We also assessed the predictive quality of infant attachment regarding neuroendocrine reactivity later in childhood. A subsample of N = 58 dyads (n = 22 mothers with anxiety disorders, n = 36 controls) from a larger study were analyzed. At 3-8 months postpartum, maternal anxiety disorders were diagnosed via a structured clinical interview as well as dyadic interaction during the Face-to-Face-Still-Face (FFSF) was observed and coded on a micro-temporal scale. Infant attachment quality was assessed with the strange situation paradigm at 12-24 months of age. In an overlapping subsample of N = 39 (n = 13 mothers with anxiety disorder; n = 26 controls), we assessed child cortisol reactivity at 5 to 6 years of age. Generalized linear modeling revealed that longer latencies to interactive reparation during the reunion episode of the FFSF as well as maternal diagnosis at 3-8 months of age predict insecure attachment in children aged 12-24 months. Cox regressions demonstrated that dyads with infants who developed insecure attachment at 12-24 months of age were 48% less likely to achieve an interactive reparation at 3-8 months of age. Mixed models revealed that compared to securely attached children, children who had developed an insecure attachment at 12-24 months of age had an increased cortisol reactivity at 5 to 6 years of age during free play. The results confirm the hypothesis that the development of attachment is affected by experienced micro-temporal interactive patterns besides diagnostic categories. They also showed that infants of mothers with postpartum anxiety disorders have a more than fivefold increased risk of developing an insecure attachment than the infants of the control group. Moreover, results imply that these patterns may influence neurohormonal regulation even in preschool aged children.

Emotional Stress During Pregnancy - Associations With Maternal Anxiety Disorders, Infant Cortisol Reactivity, and Mother-Child Interaction at Pre-school Age.

There is growing evidence that even milder forms of maternal stress or anxiety during pregnancy affect the fetus causing possible long-term consequences for infant and child development. The mechanisms through which prenatal maternal stress may affect the unborn are not yet entirely clarified. Due to limited self-regulatory skills after birth, infants depend on sensitive behavior of their parents to regulate affective states and physiological arousal. Dyadic affect regulation has been linked to various developmental patterns up to adolescence and thereby represents a key element of early social relationships. Aim of the study was to evaluate possible long-term consequences of emotional stress during pregnancy and postpartum anxiety disorders, as well as infant postpartum cortisol reactivity on mother-child-interaction at pre-school age. The sample comprised of N = 63 mother-infant dyads at study entry, n = 28 diagnosed with postpartum anxiety disorders according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), n = 35 were healthy controls. Mothers were interviewed with the Structured Clinical Interview for DSM-IV Disorders at an average infant age of M = 4.1 months and filled out a questionnaire regarding emotional stress during pregnancy. Further, they were videotaped during the Face-to-Face-Still-Face paradigm (FFSF), a widely used mild socio-emotional stressor for infants. To determine infant stress-reactivity, infant salivary cortisol was collected before, immediately after and 20 min after the FFSF. Missing values were estimated by multiple imputations. At the age of M = 5.3 years, mother-child-interaction was re-assessed in a follow-up sample of n = 30 dyads via a free-play situation. Moreover, dimensional measures for anxiety were assessed. Mothers in the clinical group reported significantly higher stress scores than the control group. Infant stress reactivity in the early postpartum period and maternal anxiety symptoms at the 5-year follow-up assessment were significantly associated with dyadic interaction quality at pre-school age. Even though maternal stress during pregnancy did not directly predict mother-child interaction quality at pre-school age, it was significantly correlated with infant cortisol reactivity during postpartum period. Nevertheless, caution should be taken when interpreting the results considering the small sample size.

Dyadic Coping and Its Underlying Neuroendocrine Mechanisms - Implications for Stress Regulation.

Previous research suggests that neuroendocrine mechanisms underlie inter-individual stress coping in couples. The neuropeptide oxytocin (OT), while regulating stress-sensitive HPA-axis activity might be crucial in this process. The purpose of this study was to examine the impact of dyadic coping abilities and OT on HPA-axis outcomes and constructive behavior during couple conflict. We conducted a secondary analysis of our previous database (Ditzen et al., 2009), assessing the modulating role of dyadic coping and intranasal OT on couple conflict behavior. The data revealed a significant interaction effect of the dyadic coping by oneself score and OT on cortisol responses during couple conflict, suggesting that particularly individuals with low a priori dyadic coping benefit from OT in terms of dampened HPA-activity. The results are in line with previous research suggesting OT's central role for stress regulation and prosocial behavior. Furthermore, an interaction with dyadic coping indicates adaptations in the sensitivity of the OT system during the individual attachment and relationship history. These data add to the evidence that the neuroendocrine attachment systems influence couple behavior. Future studies of neurobiological mechanisms underlying dyadic coping will be of high relevance for the development of prevention and intervention programs.

Early life maltreatment but not lifetime depression predicts insecure attachment in women.

Early life maltreatment (ELM) poses a risk for the development of insecure attachment and depression over the life span, depending on the type of maltreatment (physical, sexual, emotional, neglect) and its severity. The aim of this study was to investigate the influence of ELM and lifetime depression on adult insecure attachment in a female sample (N = 188), consisting of n = 81 women with ELM and n = 107 without ELM. Women with ELM reported significantly higher scores on insecure attachment than women without ELM. A significant interaction effect for ELM × lifetime depression was found: Contradictory to the hypotheses, women with ELM but without lifetime depression scored highest on avoidant attachment, differing significantly from women with ELM and lifetime depression, even though the severity of ELM was higher among women with ELM and lifetime depression and they experienced significantly more severe neglect and sexual abuse, but not physical or emotional abuse. Regression analyses revealed that ELM was the only predictor of avoidant attachment, explaining 15.5% of the variance. Results underline the strong influence of ELM on adult attachment and are of special importance for prevention and intervention programs.

Effects of Maternal Anxiety Disorders on Infant Self-Comforting Behaviors: The Role of Maternal Bonding, Infant Gender and Age.

BACKGROUND/AIMS: We investigated the links between maternal bonding, maternal anxiety disorders, and infant self-comforting behaviors. Furthermore, we looked at the moderating roles of infant gender and age. METHODS: Our sample (n = 69) comprised 28 mothers with an anxiety disorder (according to DSM-IV criteria) and 41 controls, each with their 2.5- to 8-month-old infant (41 females and 28 males). Infant behaviors were recorded during the Face-to-Face Still-Face paradigm. Maternal bonding was assessed by the Postpartum Bonding Questionnaire. RESULTS: Conditional process analyses revealed that lower maternal bonding partially mediated between maternal anxiety disorders and increased self-comforting behaviors but only in older female infants (over 5.5 months of age). However, considering maternal anxiety disorders without the influence of bonding, older female infants (over 5.5 months of age) showed decreased rates of self-comforting behaviors, while younger male infants (under 3 months of age) showed increased rates in the case of maternal anxiety disorder. CONCLUSIONS: The results suggest that older female infants (over 5.5 months of age) are more sensitive to lower maternal bonding in the context of maternal anxiety disorders. Furthermore, results suggest a different use of self-directed regulation strategies for male and female infants of mothers with anxiety disorders and low bonding, depending on infant age. The results are discussed in the light of gender-specific developmental trajectories.

Intergenerational Transmission of Internalizing Behavior: The Role of Maternal Psychopathology, Child Responsiveness and Maternal Attachment Style Insecurity.

BACKGROUND: Maternal depression and anxiety disorders are risk factors for the development of internalizing disorders in offspring. Maternal attachment has been discussed as one factor accounting for transmission. The aim of this study was to investigate child internalizing behavior at preschool age on a symptomatic and behavioral level and possible links to maternal mental health over time and maternal attachment style insecurity in a sample of postpartum depressed and anxious mothers. SAMPLING AND METHODS: Child internalizing behavior at preschool age was rated by the Child Behavior Checklist (CBCL), the Caregiver-Teacher Report Form (C-TRF), and during a mother-child free-play situation. We focused on child responsiveness as it has been linked to child internalizing behavior. Maternal attachment style insecurity was tested to mediate the link between maternal mental health (assessed postpartum and at preschool age with the Structured Clinical Interview for DSM-IV Axis-I Disorders, SCID-I) and child internalizing behavior/child responsiveness. Of the overall sample (n = 58), 28 women were diagnosed with postpartum depression and/or anxiety disorders according to DSM-IV, and 30 were healthy controls. Data were collected 3-9 months after delivery and at preschool age (mean = 4.6 years). RESULTS: At preschool age, children of postpartum depressed and anxious mothers were rated significantly higher on child internalizing behavior by mothers, fathers, and additional caregivers compared to the control group. Child internalizing behavior rated by mothers was influenced by current psychiatric symptoms; maternal attachment style insecurity did not mediate this link. During interaction, children in the clinical group displayed significantly less child responsiveness compared to the control group. Maternal attachment style insecurity mediated the relationship between maternal mental health over time and child responsiveness. CONCLUSIONS: The results emphasize the need for interventions focusing on mother-child interaction and maternal attachment.

Maternal self-confidence postpartum and at pre-school age: the role of depression, anxiety disorders, maternal attachment insecurity.

The aim of this study was to analyze the impact of maternal postpartum depression and/or anxiety disorders according to DMS-IV on maternal self-confidence throughout infancy and early childhood. Exploratively, associations between maternal attachment insecurity and maternal self-confidence at pre-school age were examined. The sample (N = 54) of this prospective longitudinal study was comprised of n = 27 women with postpartum depression and/or anxiety disorders according to DSM-IV criteria and n = 27 healthy women without present or history of mental health disorders or psychotherapy. Data was collected in the postpartum period (M = 60.08 days) and at pre-school age (M = 4.7 years). Subjects were recruited between 2004 and 2011 in South Germany. Data revealed a significant difference in maternal self-confidence between clinical and control group at child's pre-school age: Women with postpartum depression and/or anxiety disorder scored lower on maternal self-confidence than healthy controls, but only if they had current SCID-diagnoses or partly remitted symptoms. According to explorative analyses maternal attachment insecurity turned out to be the strongest predictor of maternal self-confidence at pre-school age besides maternal mental health status. The results emphasize the impact of attachment insecurity and maternal mental health regarding maternal self-confidence leading to potential adverse long-term consequences for the mother-child relationship. Attachment based interventions taking maternal self-confidence into account are needed.