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Enhancing parental reflective functioning through early dyadic interventions: A systematic review and meta‐analysis



Parental reflective functioning (PRF) is an important predictor of infant attachment, and interventions that target parent–infant/toddler dyads who are experiencing significant problems have the potential to improve PRF. A range of dyadic interventions have been developed over the past two decades, some of which explicitly target PRF as part of their theory of change, and some that do not explicitly target PRF, but that have measured it as an outcome. However, no meta‐analytic review of the impact of these interventions has been carried out to date. The aim of this review was to evaluate the effectiveness of dyadic interventions targeting parents of infant and toddlers, in improving PRF and a number of secondary outcomes. A systematic review and meta‐analysis was conducted in which key electronic databases were searched up to October 2018. Eligible studies were identified and data extracted. Data were synthesised using meta‐analysis and expressed as both effect sizes and risk ratios. Six studies were identified providing a total of 521 participants. The results of six meta‐analyses showed a nonsignificant moderate improvement in PRF in the intervention group (standardised mean difference [SMD]: –0.46; 95% confidence interval [CI] [–0.97, 0.04]) and a significant reduction in disorganised attachment (risk ratio: 0.50; 95% CI [0.27, 0.90]). There was no evidence for intervention effects on attachment security (odds ratio: 0.71; 95% CI [0.19, 2.64]), parent–infant interaction (SMD: –0.10; 95% CI [–0.46, 0.26]), parental depression (SMD: –1.55; 95% CI [–3.74, 0.64]) or parental global distress (SMD: –0.19, 95% CI [–3.04, 22.65]). There were insufficient data to conduct subgroup analysis (i.e. to compare the effectiveness of mentalisation‐based treatment with non‐mentalization‐based treatment interventions). Relational early interventions may have important benefits in improving PRF and reducing the prevalence of attachment disorganisation. The implications for future research are discussed.
DOI: ./imhj.
Enhancing parental reflective functioning through early
dyadic interventions: A systematic review and meta-analysis
Jane Barlow1Michelle Sleed2,3Nick Midgley2,3
Department of Social Policy and
Intervention, University of Oxford,
Oxford, UK
Research Department of Clinical,
Educational and Health Psychology,
University College London, London, UK
Anna Freud Centre, London, UK
Jane Barlow,Department of Social Policy
and Intervention, University of Oxford,
Oxford OX ER, UK.
Parental reflective functioning (PRF) is an important predictor of infant attach-
ment, and interventions that target parent–infant/toddler dyads who are expe-
riencing significant problems have the potential to improve PRF. A range of
dyadic interventions have been developed over the past two decades, some of
which explicitly target PRF as part of their theory of change, and some that do
not explicitly target PRF, but that have measured it as an outcome. However, no
meta-analytic review of the impact of these interventions has been carried out to
date. The aim of this review was to evaluate the effectiveness of dyadic interven-
tions targeting parents of infant and toddlers, in improving PRF and a number
of secondary outcomes. A systematic review and meta-analysis was conducted in
which key electronic databases were searched up to October . Eligible stud-
ies were identified and data extracted. Data were synthesised using meta-analysis
and expressed as both effect sizes and risk ratios. Six studies were identified pro-
viding a total of  participants. The results of six meta-analyses showed a non-
significant moderate improvement in PRF in the intervention group (standard-
ised mean difference [SMD]: –.; % confidence interval [CI] [–., .])
and a significant reduction in disorganised attachment (risk ratio: .; % CI
[., .]). There was no evidence for intervention effects on attachment secu-
rity (odds ratio: .; % CI [., .]), parent–infant interaction (SMD: –.;
% CI [–., .]), parental depression (SMD: –.; % CI [–., .]) or
parental global distress (SMD: –., % CI [–., .]). There were insuf-
ficient data to conduct subgroup analysis (i.e. to compare the effectiveness of
mentalisation-based treatment with non-mentalization-based treatment inter-
ventions). Relational early interventions may have important benefits in improv-
ing PRF and reducing the prevalence of attachment disorganisation. The impli-
cations for future research are discussed.
dyadic interventions, meta-analysis, parental reflective functioning, systematic review
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©  The Authors. Infant Mental Health Journal published by Wiley Periodicals LLC on behalf of Michigan Association for Infant Mental Health
Infant Ment Health J. ;–. 1
2BARLOW  .
1.1 Early childhood mental health
Infant regulatory disturbances such as excessive crying,
feeding or sleeping difficulties and bonding/attachment
problems have a high prevalence in many countries. For
examples, the Copenhagen Child Cohort Study (n=,)
found a population prevalence of % in regulatory prob-
lems including emotional, behavioural, eating and sleep-
ing disorders, in children aged . years in the region of
% (Skovgaard, ;Skovgaardetal.,). In addi-
tion, a more recent survey on the mental health of chil-
dren and young people in England (Vizard et al., )
found that .% of children aged between  and  years
of age experience a mental health problem. Furthermore,
some regulatory disturbances are stable over time with
one study suggesting that as many as .% of infants and
toddlers (aged – months) show a continuity of emo-
tional and behavioural problems  year after initial pre-
sentation (Briggs-Gowan, Carter, Bosson-Heenan, Guyer,
& Horwitz, ).
Problems of this nature are significant predictors of
longer term difficulties. For example, infant regulatory
problems have a strong association with behavioural prob-
lems, delays in motor, language and cognitive develop-
ment and continuing parent–child relational problems
(DeGangi, Breinbauer, Roosevelt, Porges, & Greenspan,
; Hemmi, Wolke, & Schneider, ). Similarly, inse-
cure and disorganised attachment patterns in infancy are
significant predictors of later psychopathology (Van Ijzen-
doorn, Schuengel, & Bakermans-Kranenburg, ); exter-
nalizing disorders (i.e. conduct and behaviour problems)
(Fearon, Bakermans-Kranenburg, & Van Ijzendoorn, )
and personality disorder (i.e. mental health problems
characterised by enduring maladaptive patterns of emo-
tional regulation, relating and behaviour) (Steele & Siever,
). Individual empirical studies have also found an
association between disorganised attachment and disso-
ciation (Dutra & Lyons-Ruth, ; Lyons-Ruth, );
post-traumatic stress disorder (PTSD) (Macdonald et al.,
) and an increased likelihood of children experienc-
ing symptoms that meet clinical criteria (Borelli et al.,
1.2 Aetiology of regulatory problems
Infant regulatory and attachment problems can best be
understood in a relational context, with disturbances
to the parent–child relationship and parental psychoso-
cial adversity being significant risk factors for infant
Key Findings
. The findings of this review show a moderate
trend toward improvement in parental reflec-
tive functioning and a significant improvement
in disorganised attachment following the pro-
vision of a dyadic intervention to high-risk par-
ents in the postnatal period.
. There was no evidence of a significant improve-
ment in parent-infant interaction, parental
mental health, or security of attachment,
although the impact on maternal depression
was large.
. We found very few studies that had mea-
sured parental reflective functioning as part of
the evaluation of early dyadic interventions,
despite evidence regarding its importance in
the intergenerational transmission of attach-
Statement of relevance
This research suggests that relational early inter-
ventions may have important benefits in improv-
ing parental reflective functioning and reducing
the prevalence of attachment disorganisation, and
indicates the need for further research on this
emotional, behavioural, eating and sleeping disorders
(Skovgaard et al., ; Skovgaard., ). Infants are born
without the capacity to re-establish emotional regulation
when faced by distress, and thus rely on their primary
carers to help them regulate when they are frightened
or overwhelmed (Beebe et al., ; Tronick & Weinberg,
). The caregiver’s capacity to respond sensitively to the
infant’s needs has long been thought to be a key factor in
the development of secure attachments and infant emo-
tional regulation (Ainsworth, ; Spangler, Schieche,
Ilg, Maier, & Ackermann, ). However, one systematic
review found only modest correlations between maternal
sensitivity and infant attachment security (De Wolff & Van
Ijzendoorn, ), and a later meta-analysis found only a
very small effect size linking parental sensitivity and dis-
organised attachment (Van Ijzendoorn et al., ). These
findings suggested that other factors may play a role in the
development of attachment patterns, prompting a search
for other predictive factors that may underpin attachment
BARLOW  . 3
security and resilience. Research since then has focused on
a number of other potential mechanisms including the par-
ent’s capacity for ‘reflective functioning’ (Slade, ; Fon-
agy, Steele, Moran, Steele, & Higgitt, ).
1.3 Reflective functioning
Infants and young children depend on the parent’s inter-
est in their subjective experience, and their capacity to
make the child’s behaviour meaningful by interpreting it
in terms of underlying mental states. This capacity has
been operationalised as ‘parental reflective functioning’
(PRF), and can be understood as a particular manifesta-
tion of mentalizing, that is the process by which we make
sense of each other and ourselves, implicitly and explic-
itly, in terms of subjective states and mental processes.
PRF is seen as underlying sensitive responding by help-
ing parents to mentally put themselves in the place of
the infant and imagine the infant’s experience (Fonagy
& Target, ). To date, few tools have been developed
to assess PRF, the most widely used being the Reflective
Functioning Scale (Fonagy, Target, Steele, & Steele, )
applied to the Parent Development Interview (PDI-RF:
Slade, Bernbach, Grienenberger, Levy, & Locker, )and
the Parental Reflective Functioning Questionnaire (PRFQ;
Luyten et al., ). The PDI-RF scale is a coding system
that is applied to semi-structured interviews with care-
givers, whereas the PRFQ is a parent self-report question-
Research to date suggests that PRF is strongly asso-
ciated with positive maternal parenting behaviours such
as flexibility and responsiveness, and use of the mother
as a secure base on the part of the infant, whereas low
PRF is associated with emotionally unresponsive mater-
nal behaviours such as withdrawal, hostility and intrusive-
ness (Ensink et al., ; Grienenberger, Kelly, & Slade,
). Consistent with this, the parents’ reflective func-
tioning about their attachment relationships, both past and
present, has been found to be associated with a child’s
secure attachment at  months (Grienenberger, Kelly, &
Slade, ; Suchman, DeCoste, Leigh, & Borelli, ). In
an important study of intergenerational patterns of attach-
ment, Fonagy et al. () showed that mothers with a
history of deprivation who are able to acquire a capacity
for reflective functioning were more likely to have infants
with a secure attachment. The value of PRF in the devel-
opment of affect regulation and secure attachment in the
child has been demonstrated in a number of empirical
studies. For example, mothers’ reflective functioning about
their own early attachment relationships has been shown
to be associated with secure and organised infant attach-
ment (Ensink et al., ; Fonagy, Steele., & Steele., ),
and with less externalizing difficulties in children (Ensink,
Bégin, Normandin & Fonagy, ).
In the context of taking care of infants, reflective func-
tioning is thought to promote sensitive parenting by help-
ing the parent look beyond behaviours to consider what
the child is feeling and to inhibit negative interactions
by helping the parent regulate their own negative reac-
tions and remain focused on the infant’s needs. Even when
their baby is distressed, parents with higher PRF are more
likely to be able to remain relatively calm, and not take it
personally when their infant is dysregulated (Schultheis,
Mayes, & Rutherford, ). This in turn helps the infant
to become regulated. Over time, these patterns of feeling
secure in the belief that others will be there when in dis-
tress underlie the feeling that it is safe and rewarding to
express and share feelings with others when distressed,
and in turn be available and supportive of others when they
are in distress (Ensink et al., ).
1.4 Dyadic psychological interventions
and reflective functioning
A focus on mental states is a central part of most psy-
chological therapies, and it has as such been argued that
a range of therapeutic approaches, including psychody-
namic therapy, Cognitive Behavioural Therapy and Dialec-
tical Behaviour Therapy, can improve the capacity for
mentalisation (Fonagy & Adshead, ). This focus on
promoting mentalizing as a shared feature of a range
of psychological therapies has empirical support in rela-
tion to both adult (Goodman, ) and child therapies
(Goodman, Midgley, & Schneider, ). Mentalisation-
based treatment (MBT) was developed as a particular
approach to working with adults with borderline person-
ality disorder (BPD), based on a hypothesis that BPD
could best be understood as a ‘disorder of mentalizing’,
and that a particular therapeutic focus on promoting this
capacity could ameliorate some of the well-known fea-
tures of BPD, such as poor affect regulation and inter-
personal relations. MBT’s success in improving the men-
talizing abilities of patients with BPD (Bateman & Fon-
agy, ,) led to the development of mentalisa-
tion or reflective functioning–based interventions for a
range of clinical populations, including children and fam-
ilies (Midgley & Vrouva, ; Midgley et al., ), as
well as parent–infant/toddler dyads who are experienc-
ing significant social problems (e.g. Minding the Baby
[MTB]: Sadler et al., ) and substance dependency
(the Mother and Toddler Program: Suchman, DeCoste,
McMahon, Rounsaville, & Mayes, ). These interven-
tions focus on enhancing mothers’ capacity to make sense
of the baby’s thoughts, emotions and intentions, thereby
4BARLOW  .
laying the foundation for sensitive responsiveness and
secure attachment.
As with therapies that target adults, it seems likely that
there may be many routes to developing PRF in parent–
child dyadic therapies regardless of whether that is the pri-
mary aim of the intervention. For example behaviourally
focused sensitivity interventions such as video feedback,
which provide the mother with the opportunity to watch
herself and her infant/toddler during moments of positive
interaction, are used by the therapist to help the mother
to develop a reflective stance by encouraging her to think
about her infant’s internal world (e.g. the therapist might
say to the mother ‘what do you think your baby was feeling
at that moment’?). This is also true of other attachment and
psychotherapeutic approaches; for example Watch, Wait
and Wonder (Cohen et al., ) is an infant-led therapy
that also encourages the mother to develop a reflective
stance by allowing the baby to take the initiative, by watch-
ing and wondering about this activity, and also through
discussion with the therapist about the feelings that this
arouses in her as a person.
1.5 Rationale for review
A range of dyadic interventions have been developed over
the past two decades, some of which explicitly target PRF
as part of their theory of change, and some that do not
explicitly target PRF, but that have measured it as an out-
come. There has to date been one review of PRF and the
use of clinical interventions to improve it (Camoirano,
), but this included all studies irrespective of the study
design and provided only a narrative summary (i.e. no
meta-analysis of data).
The current review updates the existing review (i.e. in
which searches were completed in July ), and includes
only rigorously conducted studies that have made use of an
RCT design and used a recognised measure of parental RF;
it also provides a meta-analysis of the data, where appro-
Published and unpublished studies were identified using
searches of the following online databases: MEDLINE,
stems of the following identifiers or keywords were used
to search the title or abstract either separately or in
conjunction: ‘mentalization’, or ‘mentalisation, or ‘reflec-
tive functioning*’ or ‘mind-mindedness’ or ‘insightful-
ness’ combined with terms to identify interventions and
RCTs. In order to increase the sensitivity of the search, no
methodological or outcome terms were used. Search terms
were adapted as appropriate for the different databases.
Searches were conducted for papers published in English,
for the entire time periods for which the databases are
available up until October .
2.1 Inclusion/exclusion criteria
Only studies that met the following criteria were included:
Randomised controlled trials (RCTs) evaluating the effec-
tiveness of early interventions targeting parents of infants
or toddlers up to  months of age, with the aim
of improving parental functioning and/or parent–infant
interaction. Studies had to have measured PRF as an
outcome using a standardised (i.e. interview-based or
parent-report) instrument. We also extracted data for sec-
ondary outcomes – attachment security or parent–infant
interaction, and parental mental health. Studies were
excluded if they involved the delivery of an interven-
tion without a standard treatment or non-intervention
control group. We did not include unpublished doctoral
Titles and abstracts were reviewed by the lead author,
and final decisions about the papers to be included were
made by two study authors. Two review authors conducted
the ‘Risk of bias’ assessments using The Cochrane Collab-
oration ‘Risk of bias’ assessment tool (Higgins & Green,
), with each domain being assessed as at low, high or
unclear (uncertain) risk of bias.
2.2 Computation of effect sizes
Data were extracted using a standardised data extraction
process. In all cases, we extracted the post-intervention
data, except where the data were reported by age of the
infant, in which case we selected the most immediate post-
intervention point (usually -months of age). Effect sizes
were calculated using Revman  (The Nordic Cochrane
Centre, The Cochrane Collaboration, ). Distributions
of scores from primary papers have been presented as odds
ratios (ORs) or standardised mean differences (SMDs),
depending on the nature of the primary data, with % con-
fidence intervals (CIs). Data were combined using a ran-
dom effects model due to the high level of heterogeneity in
outcomes measured. Statistical heterogeneity was assessed
using the Istatistic. The importance of the observed value
of Iis dependent on the magnitude and direction of effects
and strength of evidence for heterogeneity (e.g.p-value
from the χtest, or a CI for I). An Igreater than %
was interpreted as evidence of substantial heterogeneity. A
χtest of heterogeneity was performed and a significance
BARLOW  . 5
FIGURE 1 PRISMA flow chart of included studies
level <. was interpreted as evidence of heterogeneity.
Effect sizes were weighted according to the inverse of their
variance to ensure that studies in with the more precise
estimates had a greater influence on the overall effect size
(Hedges & Olkin, ).
The PRISMA flow chart (Figure ) shows that a total of
 records were identified following removal of dupli-
cates, and that these were all screened with  full-text
articles being assessed for suitability. A total of six stud-
ies were included (see Table ), the remaining studies
being excluded because they were not RCTs; or they
provided follow-up rather than immediate post interven-
tion data; the children were over  months old; they
were an ongoing study; or they provided no quantitative
The included studies targeted a range of parents, includ-
ing high-risk primiparous women with demographic risk
factors (Sadler et al., ; Sleed, Slade, & Fonagy, );
mothers experiencing mental health problems and high
levels of social adversity (Fonagy, Sleed, & Baradon, );
mother–infant dyads in prison (Fonagy et al., )orthose
taking part in substance treatment programs (Suchman
et al., ). Only one of the six studies included toddlers
(Suchman et al., ), the remainder targeted babies <
A number of interventions were delivered, all of which
were dyadic, relational and manualised attachment-based
interventions. Four interventions were explicitly informed
by concepts relating to mentalisation in terms of the under-
lying theory of change (Sadler et al., ; Sleed et al.,
; Suchman et al., ,), the remaining two being
informed by psychoanalytic theory with a primary focus
on changing maternal representations of the infant (Fon-
agy et al., ; Sleed, Baradon, & Fonagy, ).
6BARLOW  .
TABLE 1 Included studies
Author Results – Post-intervention
Primary included
studies Population
Intervention and control
conditions Outcome measure used and timing Intervention Control
Fonagy et al.,  Parents with mental health
problems who were also
experiencing high levels
of social adversity and
their young infants (<
psychotherapy (mean
number of sessions )
(PIP) (n=);
Standard secondary and
specialist primary care
treatment (n=)
Parental representations – The Parent Development
Interview (PDI)
Parent–infant interaction – Emotional Availability Scale
(EAS); Coding Interactive Behaviour System (CIB)
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
Depression – Centre for Epidemiological Studies
Depression Scale (CES-D)
Global distress – Brief Symptom Inventory (BSI)
Master – Mastery Scale (MS)
Mother–Object Relations Scale (MORS)
- Warmth
- Intrusion
Parenting Stress Index (PSI) – total score
Ages and Stages Questionnaire (ASQ: SE)
 month follow-up reported (not  month)
. (.)
. (.)
. (.)
% (n=)
% (n=)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
–. (.)
. (.)
. (.)
. (.)
% (n=)
% (n=)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Sadler et al ()Primiparous pregnant
women attending
nurse-midwifery group
prenatal care sessions.
Mentalisation-based home
visiting programme
(Minding the Baby -
MTB) (n=)Usual care
control group (n=)
Maternal reflective functioning – The Parent
Development Interview (PDI)
Maternal Depression Centre for Epidemiological
Studies Depression Scale (CES-D)
Global distress – Brief Symptom Inventory (BSI)
Maternal–child relationship – Atypical Maternal
Behaviour Instrument for Assessment and
Classification (AMBIANCE)
- Disrupted
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
AMBIANCE assessed at  months; all other measures at
 months.
. (.)
. (.)
. (.)
.% (n=)
.% (n=)
. (.)
. (.)
. (.)
Slade et al () Young first time mothers
living in underserved,
poor, urban communities
Mentalisation-based home
visiting programme
(Minding the Baby
[MTB]) (n=)
Usual treatment control
group (n=)
Maternal reflective functioning postnatal – Parent
Development Interview – Revised (PDI)
Maternal child relationship – Atypical Maternal
Behaviour Instrument for Assessment and
Classification (AMBIANCE) Scale ( months)
- Disrupted
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
. (.)
. (.)
.% (n=)
.% (n=)
. (.)
. (.)
. (.)
. (.)
. (n=)
.% (n=)
. (.)
. (.)
BARLOW  . 7
TABLE 1 (Continued)
Author Results – Post-intervention
Primary included
studies Population
Intervention and control
conditions Outcome measure used and timing Intervention Control
Maternal Depression Centre for Epidemiological
Studies Depression Scale (CES-D)
Post-traumatic stress disorder (PTSD) – Mississippi
Scale for the Assessment of PTSD – Civilian Form
Assessed at  months infant age
Sleed et al  Mothers and babies in
Attachment-based group
intervention (New
Beginnings) (mean
number of session .)
Prisoners with no
intervention (n=)
Parental Reflective Functioning – Parent Development
Interview (PDI)
Mother-Infant Interaction – Coding Interactive
Behaviour Scales (CIB) – Dyadic Attunement
Mother Object Relations Scale (MORS) – Warmth
Centre for Epidemiological Studies Depression Scale
All assessed immediately post-intervention
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Suchman et al () Mothers of babies/toddlers
taking part in
-week attachment-based
individual parenting
therapy (The Mothers
and Toddlers Program –
MTP) (n=
Parenting education (PE)
Parental reflective functioning – Parent Development
Interview (PDI)
Caregiving behaviour – Nursing Child Assessment
Satellite Training (NCAST) Total Contingency for
Caregiving Behaviour
Depression – Beck Depression Inventory (BDI)
Global Distress – Brief Symptom Inventory (BSI)
Substance Use
Assessed immediately post-intervention
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Suchman et al () Mothers caring for a child
between  and 
months with a history of
alcohol and drug
-week mentalisation
based individual therapy
(Mothering from the
Inside Out – MIO)
Parent education (PE)
Parental reflective functioning – Parent Development
Interview (PDI)
Representations of the child – Working Model of the
Child Interview (WMCI)
Mother-Infant Interaction – Coding Interactive
Behaviour Scales (CIB)
– Maternal sensitivity
Global distress - Brief Symptom Index (BSI)
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Insecure/Disorganised
Assessed at  months infant age
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
8BARLOW  .
MTB (Sadler et al., ) comprises a mentalisation-
based home visiting program, which is delivered by a team
that includes a nurse practitioner and a clinical social
worker. The intervention begins in pregnancy and contin-
ues to the child’s second birthday with an average of 
sessions of  hr being delivered. The focus of the sessions
depends on the family’s needs at the time of the visit but the
intervention is anchored in the development of a therapeu-
tic relationship (e.g. support, empathy, reassurance and
praise) and a reflective stance (i.e. being curious with the
mother about the child’s and parent’s thoughts and feel-
The Mothers and Toddlers Program (Suchman et al.,
) and Mothering from the Inside Out (Suchman et al.,
) consist of  weeks of individual parenting therapy
designed as an adjunct to outpatient substance abuse treat-
ment. The focus is on the therapeutic alliance, and the use
of a mentalizing stance on the part of the therapist to help
parents begin to understand the way in which their actions
are influenced by thoughts, emotions and intentions.
New Beginnings (Sleed et al., ) and Parent Infant
Psychotherapy (PIP) (Fonagy et al., ) are both rela-
tional interventions that focus on parents’ representations
(internal working models) of the parenting role and the
baby, while at the same time focusing on the baby’s com-
munications, the meaning of these and parents’ responses
in the here and now of the sessions. Past and current rela-
tional experiences may be addressed, but in both interven-
tions the baby is an active participant and central focus
of the sessions. New Beginnings is a group-based eight-
session intervention, whereas PIP is an open-ended inter-
vention that involves a therapist, one or both parents and
the baby.
Figure shows the results of the critical appraisal. Over-
all, the included studies were of moderate quality with
most meeting only three of the quality appraisal criteria.
3.1 Reflective functioning
All six studies included an assessment of RF using the PDI
(Slade et al., ). The meta-analysis included a total of
 participants, and the results were not significant but
show a trend favouring the intervention group: Standard-
ised Mean Difference (SMD) –. (% CI [–., .],
p=.) but with significant heterogeneity (χ=.,
df =, p<.; I=%) (see Figure ).
3.2 Mother–infant interaction
All studies included a measure of parental sensitiv-
ity/contingency that could be combined in a meta-analysis
FIGURE 2 Summary of risk of bias of included studies. +Con-
dition was met low risk; Condition was not met (in this case
because it was not possible to do so) high risk; Remainder not known
unknown risk
providing an overall sample size of . Three studies
used the Coding Interactive Behaviour (CIB) coding (Feld-
man, ) (Fonagy et al., ; Sleed et al., ; Such-
man et al., ); one study used the Nursing Child Assess-
ment Teaching Scale (NCAST; Bernard & Eyers, ;
(Suchman et al., ); and two studies used the Atypi-
cal Maternal Behaviour Instrument for Assessment and
Classification (AMBIANCE, version ; Bronfman, Par-
sons, & Lyons-Ruth, ; Sadler et al., ; Slade et al.,
We combined data from the ‘Total Contingency’ domain
of the NCAST, and the overall disruption score on the
AMBIANCE. The results show no evidence of effectiveness
– SMD: –. (% CI [–., .], p=.) and high levels
of heterogeneity (χ=., df =, p=., I=%) (see
Figure ).
3.3 Attachment
Four studies measured attachment, all of which used using
the Strange Situation Procedure (SSP) (Ainsworth, Blehar,
Waters, & Wall, ) (Fonagy et al., ; Sadler et al.,
BARLOW  . 9
FIGURE 3 Forest plot of meta-analysis for reflective functioning
FIGURE 4 Forest plot of meta-analysis for mother–infant interaction
; Slade et al., ; Suchman et al., ). A total of
 participants were included in the meta-analysis of
secure attachment (see Figure ) and  in the meta-
analysis of disorganised attachment (see Figure ). The
results indicate that although rates of secure attachment
were not higher than those of controls (OR: .; % CI
[., .], p=.) with a high level of heterogeneity
(χ=., df =, p=., I=%), the rates of disor-
ganised attachment – the most pathognomonic of attach-
ment classifications – were significantly lower in the inter-
vention groups (OR: .; % CI [., .], p=.)
with low levels of heterogeneity (χ=., df =, p=.,
3.4 Parental depression
Five of the included studies measured parental depression.
Four used the Centre for Epidemiological Studies Depres-
sion Scale (CES-D) (Radloff, ) (Fonagy et al., ;
Sadler et al., ; Slade et al., ; Sleed et al., );
and one used the Beck Depression Inventory (BDI) (Beck,
Steer, & Brown, ) (Suchman et al., ). A total of
 participants were included, and the results show a
large but non-significant difference favouring the control
group (SMD: –., % CI [–., .], p=.) with an
acceptable level of heterogeneity (χ=., df =, p=.,
I=%) (see Figure ).
3.5 Parental global psychiatric distress
Four of the included studies measured global distress using
the Brief Symptom Inventory (Derogatis, ;(Fonagy
et al., ; Sadler et al., ; Suchman et al., ,).
A total of  participants were included, and the results
show a small but non-significant improvement favouring
the intervention group (SMD: –., % CI [–., .]).
There was again a high level of heterogeneity (χ=.,
df =p=., I=%) (see Figure ).
Although other reviews have examined the effectiveness of
early dyadic interventions in improving parental sensitiv-
ity (e.g. Bakermans-Kranenburg, Van Ijzendoorn, & Juffer,
) and attachment security (e.g. Barlow, Bennett, Midg-
ley, Larkin, &Wei, ), this is the first quantitative review
to explicitly focus on PRF as an outcome of early dyadic
Despite the evidence regarding the importance of PRF
in promoting sensitive parenting behaviours and infant
attachment security, this review found only six studies
that measured the effectiveness of a dyadic intervention
in improving reflective functioning in parents of infants
and toddlers. A meta-analysis of findings from these six
studies, including  parent–infant/toddler dyads, found
10 BARLOW  .
FIGURE 5 Forest plot of meta-analysis for secure attachment
FIGURE 6 Forest plot of meta-analysis for disorganised attachment
that there was a non-significant but trend-level improve-
ment in PRF in the intervention group, as assessed by
the Reflective Functioning Scale on the Parent Develop-
ment Interview. PRF is important because of its association
with positive maternal parenting behaviours and infant
attachment security. Furthermore, infants in the interven-
tion group were less likely to be classified as having a dis-
organised attachment. These findings suggest that dyadic
attachment-based interventions can have important long-
term benefits for infants and toddlers.
The fact that intervention effects were found on the PDI-
RF measure is encouraging because the variability on the
FIGURE 7 Forest plot of meta-analysis for maternal depression
FIGURE 8 Forest plot of meta-analysis for maternal global distress
BARLOW  . 11
RF scale is limited, with the majority of parents in clinical
populations showing RF levels only at the moderate to low
end of the scale, thereby reducing the potential range and
sensitivity to treatment change (Sleed et al., ). How-
ever, the fact that this systematic review found treatment
effects on PRF in the large pooled sample suggests that this
instrument may be sensitive to treatment change in suffi-
ciently powered studies. Improvements in parental RF that
are numerically small may be clinically very important.
The positive intervention effect on infant attachment
disorganisation is also clinically important because this
group of infants are most at risk of later psychopathol-
ogy (Carlson, ;Holmes,). Although the meta-
analysis did not show any intervention effects on attach-
ment security or parent–infant interactions, these find-
ings may suggest that the interventions were successful
in interrupting pathways to disorganisation through medi-
ating factors other than maternal sensitivity, which only
accounts for a small amount of variance in predicting
attachment disorganisation (Van Ijzendoorn et al., ).
It is now widely accepted that the pathway to disorgani-
sation is marked by a wider range of disrupted parental
behaviours, such as frightening, frightened/disoriented,
role reversed and withdrawal behaviours (Madigan et al.,
). That we were not able to detect impacts on the inter-
action is possibly due to the fact that this meta-analysis
was conducted using combined data from three quite dif-
ferent measures of parent–infant interaction, only one of
which (the AMBIANCE) specifically measures disrupted
maternal behaviours associated with disorganisation. This
may have made it difficult to detect any overall effects
of the interventions on such disrupted behaviours (e.g.
Sadler et al., ). The mechanism of change in such
interventions may not therefore simply be about improv-
ing parents’ sensitive responsiveness to their infants, but
rather helping them to mentalise their own and their
child’s psychological experiences, thereby reducing dis-
rupted behaviours that can lead to attachment disorgani-
The results of this review did not indicate an overall
intervention effect on parental mental health – depression
or general psychiatric distress. This finding is likely due to
the heterogeneous nature of the various samples included.
The one study that explicitly targeted parents with men-
tal health difficulties (Fonagy et al., ) did in fact show
strong treatment effects on a range of mental health diffi-
culties; this suggests that positive outcomes in this domain
are secondary and probably only likely for parents identi-
fied as experiencing mental health difficulties in the first
The studies varied in the degree to which they focused
on mentalisation with four being explicitly mentalisation-
based interventions (Sadler et al., ; Slade et al., ;
Suchman et al., ,), and the remaining two being
based on a different theory of change regarding parental
internal working models (Fonagy et al., ; Sleed et al.,
). Although the two studies with a different theory of
change (Fonagy et al., ; Sleed et al., ) showed evi-
dence of improved PRF albeit with only borderline signif-
icance, it is highly likely that a focus on internal working
models is also effectively changing PRF.
In terms of the mentalisation-based interventions, fur-
ther thought should be given to whether the way in which
these have been translated into practice in terms of the
program content, frequency and duration and fidelity to
the program model provides the necessary mechanisms
to bring about change in key outcomes such as PRF, sen-
sitivity and child attachment status. One paper (Such-
man, Decoste, Rosenberger, & McMahon, ) that has
explicitly examined the mechanisms involved in the effec-
tive delivery of a mentalisation-based intervention for
mothers and toddlers (Suchman et al., ,) iden-
tified the core model components as being the fostering
of reflective functioning, fostering of representation qual-
ity, and development of attachment-based developmental
guidance. This study found that therapist fidelity to the
unique and essential mentalisation-based practices asso-
ciated with improved maternal reflective functioning and
representation quality (RQ) led to improvement in each of
these domains as well as maternal caregiving behaviour. It
also found that improvement in overall RQ uniquely corre-
sponded to improvement in caregiving behaviour, account-
ing for around % of the variance. Improvement in parental
depression was also found to have unique predictive valid-
ity, accounting for around % of the variance. Overall,
% of the predicated variance in caregiving behaviour was
accounted for by the proposed mechanisms of change.
This review has a number of limitations. We identified
only a small number of studies, most of which had low
numbers of participants; thus, the resulting meta-analyses
were in all likelihood underpowered as reflected by the
moderate to large but nonsignificant results for some of
the secondary outcomes. Furthermore, although there was
significant unexplained statistical heterogeneity, it was not
possible to undertake subgroup analysis to explore this
further. The unexplained heterogeneity may reflect the
diverse and sometimes high risk (e.g. prison population
and substance-dependent women) involved in some of the
included studies. It may also reflect the diverse nature of
the interventions included in the meta-analysis; for exam-
ple the interventions ranged from dyadic home-based pro-
grammes to dyadic clinic-based programmes, and parent
only group and individual interventions. In addition, we
used the immediate post-intervention follow-up data col-
lection point, and few studies had longer term follow-
up data available. This is a major limitation of studies
12 BARLOW  .
of very early interventions because it may take time for
reductions in risk factors to translate into improved dyadic
functioning as measured by standardised instruments. For
example, the alleviation of maternal psychiatric sympto-
mology is likely to increase the infant’s capacity to form
a secure attachment to his/her mother (Atkinson et al.,
), but the effects of such improvements may not be
seen behaviourally within the relatively short follow-up
periods of most studies.
It is important that future studies include larger sam-
ples and a consistent set of measures, particularly in the
assessment of variables that might explain how such inter-
ventions effectively disrupt pathways to attachment dis-
organisation. These could include measures of parental
behaviour (such as the AMBIANCE; Bronfman et al.,
) or multidimensional measures of parental represen-
tations (such as the Assessment of Representational Risk)
that explicitly measure factors associated with attachment
disorganisation. In addition, future studies should have
longer follow-up periods to enable a truly developmental
understanding of the impact of early interventions.
The sample of studies included in this review were
also limited by the small number of studies that had
included an evaluation of PRF, leaving open the possi-
bility that other, more effective interventions, may also
be impacting on PRF but without this impact being cap-
tured by research evaluation. For example, many inter-
ventions that are showing high levels of effectiveness in
terms of maternal sensitivity and infant attachment secu-
rity, such as video feedback, have not measured their
impact on PRF (Sleed et al., ). Given the hypoth-
esis that improving PRF may be a shared mechanism
across a range of different intervention programmes (not
only mentalisation-based interventions), it will be impor-
tant for future studies of a wide range of dyadic parent–
infant interventions to find ways to capture their impact
on PRF.
Despite the importance of PRF in terms of the aetiology of
infant regulation and attachment, this review suggests that
such functioning is not yet being routinely assessed when
examining the effectiveness of dyadic interventions for par-
ents and infants or toddlers. The findings also suggest
that dyadic attachment-based interventions are a poten-
tially effective method of improving PRF and reducing the
chances of disorganised attachment in the infant. A range
of factors were discussed with regard to the failure to show
any benefit in terms of the remaining outcomes including
the studies being underpowered and having diverse high-
risk populations, the translation into practice of the pro-
gramme mechanisms and the sensitivity of measures of
change in high-risk groups.
One of the authors (MS) was involved in the conduct of one
of the included studies.
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How to cite this article: Barlow J, Sleed M,
Midgley N. Enhancing parental reflective
functioning through early dyadic interventions: A
systematic review and meta-analysis. Infant Ment
Health J.;../imhj.
... Besonders der noch junge Säugling gerät angesichts der hohen Bedürftigkeit von Müttern/Eltern oft aus dem Blick des Hilfesystems. Die Pandemie führt hier, wie auch in zahlreichen anderen Bereichen von Jugend-, Familienhilfe und Familiengesundheit, zu einer weiteren Zuspitzung von Isolation und Belastung der Familien mit geringen Ressourcen (Barlow et al., 2020). ...
... Auf Seiten der Mitarbeiter:innen der Frühen Hilfen und Früher Intervention steigt das Risiko, infolge der persönlich wie beruflich anhaltenden Belastung durch die Pandemie und der erheblichen Zunahme der zu versorgenden belasteten Familien, einerseits eine erhöhte Arbeitsbelastung und andererseits eine geringere Arbeitszufriedenheit und Selbstwirksamkeit zu erleben, mit allen zu erwartenden Folgen für Arbeitsmotivation, -qualität und -fähigkeit (Barlow et al., 2020). Umso mehr möchten wir den interdisziplinären Diskurs darüber anstoßen, wie wir in unseren Professionen in der Arbeit mit Babys, Kleinkindern und ihren Eltern eine gleichbleibend hohe Qualität für alle Beteiligten (Fachkräfte wie Klient:innen/Patient:innen) sicherstellen können -unabhängig vom jeweiligen Schwerpunkt unserer professionellen Tätigkeit in Diagnostik, Begleitung, Beratung oder Behandlung. ...
... Humans are born with inherent social and interpersonal capacities (Luyten et al., 2020), but the ability to mentalize must be "practiced" and developed within the "serve and return" (Sharp et al., 2020) of the early caregiving environment with attachment figures (Fonagy et al., 2002;Fonagy & Target, 2003;. Caregiver reflective function (RF) is a specific operationalization of caregiver mentalizing within the attachment relationship and has been associated with positive caregiving behavior (Barlow et al., 2021;Camoirano, 2017) and attachment security (Slade, 2005;Zeegers et al., 2017). Reflective functioning is the overt manifestation of an individual's mentalizing capacity (Slade, 2005), with mentalizing referring to the broader construct that is not necessarily tied to attachment. ...
Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalizationbased intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa by working with Community-Based Organization (CBO) care workers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child’s early environment as critical resources for enhancing children’s mentalizing capacity. In this study, we evaluated the treatment effect of MISC on children’s mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.
... Higher reflective functioning enables parents to try to identify the reasons behind problem behaviors and engage constructively with their child (Khoshroo & Seyed Mousavi, 2021), and so it is perhaps not surprising that child adjustment difficulties in the current sample were higher in families in which mothers' reflective functioning did not increase in the early years as it suggests that they may have found it challenging to alter their representations as their child developed. Interventions aimed at increasing parental reflective functioning during infancy and toddlerhood have been found to show improvements (Barlow et al., 2021) so may be a useful target for focusing support. ...
... Meta-analytic evidence from 6 studies, 4 of which relate to 'Minding the Baby' and 'Mothering from the Inside Out' (Barlow et al., 2021) suggests that although these types of programmes may reduce rates of attachment disorganization in infants, results do not suggest any benefit over comparison interventions with regard to secure attachment classification, quality of mother-infant interaction, maternal depression or maternal distress, although improvements in maternal reflective function trend towards significance. However, it should be noted that even pooling across studies overall sample sizes are small (depression, the largest comparison in the review was based on n = 450), and the heterogeneity of samples and underlying interventions urge caution in the interpretation of these results. ...
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Background: There has been substantial progress made across multiple disciplines to emphasize the importance of perinatal mental health both for parents and offspring. This focuses on what has been termed the 'First 1000 Days' from conception to the child's second birthday. We argue that our understanding of this issue can go further to create an intergenerational approach to mental health. Despite the existence of theoretical frameworks and practical approaches to implementation, there are gaps in the understanding of perinatal and intergenerational mental health including which psychological mechanisms are implicated in the transmission of risk and resilience within the perinatal period; and how to leverage these into treatment approaches. Aims and methods: In this paper, we explore the potential for mentalization as a candidate psychological approach to intergenerational mental health. Results: We contextualize this issue in terms of the points of contact between mentalization and broader theoretical models such as the social determinants of health and the Developmental Origins of Health and Disease (DoHaD) model. Further, we provide an overview of the existing evidence base for the relevance of mentalization to perinatal mental health. Discussion: Finally, we sketch out an outline model for integrating mentalization into perinatal and intergenerational mental health, highlighting several areas of opportunity to develop research and practice from diverse geographies and demographics. Here, we suggest that integration of mentalization with other conceptual frameworks such as DoHaD can mutually enrich the understanding of each model, pointing the way towards more effective early and preventative interventions.
... A recent review of the efficacy of group MBT parenting interventions (Lavender et al., 2022) has shown evidence that they generally improve PRF and reduce parenting stress, however results were mixed for other parent mental health and child outcomes. Although the theory of MBT interventions is compelling and outcome results are promising, there is a lack of strong evidence supporting these relatively new and rarely available interventions (Barlow et al., 2021;Camoirano, 2017;Izett et al., 2021;Lo & Wong, 2022;Sleed et al., 2022). ...
We report on two preliminary evaluations of a group intervention, targeting vulnerable infants and their mothers within the first 6-months postpartum. The Mother–Baby Nurture R program aims to strengthen the developing infant–mother attachment relationship by increasing maternal mentalizing. These studies were undertaken with pre-post evaluations with the mothers of infants under 10-months of age. The mother–infant dyads participated in ten 2-h group sessions. Study one (N = 69 dyads) included self-reported maternal depression, anxiety, and parenting confidence. In study two (N = 27 dyads), parenting stress and reflective functioning were measured by self-report, and reflective functioning coded on the 5 min speech sample (completed by N = 22). Results from study one confirmed a decrease in depression (p < .001, d = .79) and anxiety (p < .001, d = .72) symptoms, and an increase in mothers’ scores for parenting confidence (p < .001, d=−.98). Results from Study Two demonstrated a significant decrease in parenting stress (p < .001, d = .94) and significant improvement in measures of self-report reflective functioning (p = .007, .024; d = .56, .61). These findings are preliminary yet promising indications that this program could be effective in alleviating parenting stress, depression, and anxiety, and improving mother’s reflective functioning and parenting confidence. Further research is needed, with a control group and long-term follow-up assessments.
... al. 2015a; Levy et al. 2019; Dorn & Rohde 2021; Slade & Sadler 2019; Strathearn et al. 2009).Daher sollten diese Interventionen so früh wie möglich erfolgen und auf die kindliche Entwicklung und Frühe Beziehung fokussieren(Emde 1991;Barlow, Sleed, Midgley 2020;Bürk et al. 2016;Emde 2018;Hommel 2021Hommel , 2022Sleed 2013;Tereno et al. 2019; Turpyn et al. 2021).Frühe Intervention in einer unsicherenWelt: Wir haben nicht mehr die Zeit, nicht zu handeln Die Covid-Pandemie, der Krieg in der Ukraine, die Klimakatastrophe und andere zunehmende Krisen sind miteinander verknüpft und Folge unserer Ausbeutung des Planeten, der Menschen und Tiere (Hurrelmann & Albrecht 2020; Winetrobe 2022). Mit dem physikalischen Klima und dem menschlichen Klima sind wir an einem kritischen Punkt angelangt. ...
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28 | frühe Kindheit | 0322 | Thema Entwicklungskrisen im Angesicht der Katastrophe Auswirkungen der gegenwärtigen existenziellen Bedrohungen durch Pandemie, Krieg und Klimakatastrophe auf die frühe Entwicklung und Beziehung von Babys, Kleinkindern und ihren Eltern | Von Susanne Hommel Menschen gehen mit Krisen sehr unterschiedlich um. Während die einen psychisch belastet sind, unter Ängsten und Depressionen leiden, sind die anderen kurz niedergeschlagen, passen sich an die neuen Bedingungen dann scheinbar leicht an und gehen aus der Krise unbeschadet hervor. Der Begriff Resilienz stammt ursprünglich aus der Materialkunde, wo der englische Ausdruck "resilience" die Eigen-schaft eines Materials beschreibt, nach starker Verformung wieder die ursprüngliche Gestalt anzuneh-men. Auf den Menschen übertragen, bezeichnet Resilienz die Fähigkeit, schwierige Lebenssituationen ohne anhaltende psychische Beeinträchtigung zu überstehen (Kalisch 2017). Wie Resilienz entsteht, ist eine Frage, die die Wissenschaft seit Längerem interessiert. Der Pionier der Resilienzforschung, Viktor Frankl, ein jüdischer Psychiater, hat in seinem Buch " …trotzdem Ja zum Leben sagen" (1946) eindrück-lich geschildert, dass Menschen trotz schlimm-ster Bedrohung psychisch gesund bleiben können. Seine Lebensgeschichte dient häufig als Beispiel, dass Menschen auch anhaltende existenzielle Bedrohung durch Vernichtung und Tod physisch wie psychisch überleben können. Philosophisch gesehen beruht ein konstruktiver Umgang der Menschen und der Menschheit mit individueller und kollektiver Bedrohung, Trauma, Belastung, Beschädigung, massivem Stress, Defiziten und Risi-kolagen auf dem Grundsatz der Veränderbarkeit, dem Potenzial von Entwicklungsspielräumen und in diesem Sinne sowohl auf dem Prinzip Hoffnung (Bloch 1985) als auch dem Prinzip Verantwortung (Jonas 1998). Basierend auf einem positiven Men-schenbild, welches die Bedeutung von sozialen Verhältnissen, mental-kognitiven Strukturen, Handlungsfähigkeit sowie Gen-Umwelt-Interakti-onen betont. Im weiteren medizinischen und psychologischen Diskurs der 1950er Jahre über den Begriff Resilienz ist die Forschung der US-amerikanischen Entwick-lungspsychologin Emmy Werner bedeutsam, die zeigen konnte, dass jedes dritte Kind trotz Armut, elterlichem Alkoholismus, häuslicher Gewalt und Misshandlung widererwartend psychisch gesund und sozial gut integriert war und sich zu einem psychisch stabilen, erfolgreichen Erwachsenen entwickelte (Werner 2011, 2012): "Vulnerable but invincible" (verletzlich, doch unbesiegbar) nannte Werner diese Kinder. Entscheidende Faktoren für diese positive Entwicklung waren Humor, die Bereitschaft, Hilfe anzunehmen, Optimismus sowie eine gewisse Form von Spiritualität. Und von erheb-licher Bedeutung war zudem die Bindung an eine konstante Bezugsperson, egal ob Mutter, Vater, Großmutter, Onkel oder Lehrerin. Entscheidend war, dass es eine Person gab, die an das Kind glaubte und ihm vermittelte, dass es so, wie es ist, gut, richtig und angenommen ist. Kinder reagieren unterschiedlich auf existenzielle Krisen wie Krieg. So beobachtete Anna Freud 1944, dass Babys und Klein-kinder in Kriegszeiten wenig Angst zeigten, wenn es ihrer Mutter gelang, ihre eigenen Gefühle soweit zu regulieren, dass sie ihrem Kind ausreichend Sicherheit vermitteln konnte. Und dass sie im Falle der Trennung von der Mutter, im Kontext der "war nurseries" von Anna Freud und ihren Kolleg:innen betreut, sich im Kontakt mit einer fremden Bezugsperson schnell beruhi-gen konnten, wenn diese Bezugsperson emotional verfügbar und bezogen war (Freud 1944, 1973; Pretorius 2019). Die Säuglingsforschung gibt uns seit den 1970er Jahren einen umfassenden Einblick in die Zusammenhänge elterlicher psy-chischer Belastung, kindlicher Regulationsfähigkeiten und der Qualität der Eltern-Kind-Interaktion und Beziehung in unserem kulturellen Raum.
... Our study fills this gap. Moreover, the literature on interventions aimed at enhancing parental reflective functioning is limited in general (Barlow et al., 2020;Lo & Wong, 2022) and among parents of children with developmental disabilities even more so. Studies show that interventions can effectively enhance reflective functioning in general (Burgdorf et al., 2019;Menashe-Grinberg et al., 2021;Townshend et al., 2016) and can also be effective specifically for parents of children with neurodevelopmental disabilities (Sealy & Glovinsky, 2016). ...
Background: Parental reflective functioning has a positive effect on parents' wellbeing. It is associated with positive outcomes for their children. However, there is little research on it among parents of toddlers with severe developmental disabilities. Aims: We examined an early bio-psycho-social rehabilitative intervention with parents of toddlers with severe developmental disabilities in daycare programs and its contribution to their parental reflective functioning and coping. Methods and procedures: Seventy parents of children (ages 3 months to two and half years) responded to measures before and after the intervention in their children's daycare programs. Structural equation modeling of the mediation model revealed that the therapeutic inputs were associated with more adaptive coping strategies by increasing parental reflective functioning. Outcomes and results: Parents who participated in an intervention of 13 sessions or more significantly increased their reflective functioning. The path analysis showed that parental reflective functioning after the intervention mediated the association between its prior level and the therapeutic inputs, and the parents' proactivity and search for support. Conclusions and implications: Parental reflective functioning positively affects parents' adaptive coping styles. A bio-psycho-social intervention targeting parental reflective functioning benefits parents of toddlers with severe developmental disabilities.
... Hence, if this is the case, interventions must focus on the opacity of mental states, and parents must be helped to realize that they actually do not know the mind of their child as well as they think they do. To date, several interventions that may foster PRF have been developed (for an overview, see Barlow et al. 2021;Camoirano 2017;. Core ingredients that have been identified in those intervention programmes are psychoeducation, role plays, and group discussions with other parents (Lo and Wong 2022). ...
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Research suggests that parental reflective functioning (PRF)—that is, the parent’s capacity to envision the mind of the child—is a key factor in understanding the child’s reflective capacities. Yet, most existing measures of PRF assume that it is a broad trait-like feature. This study investigated cross-sectional relationships between domain-specific PRF, operationalized as mothers’ estimates of the Theory of Mind (ToM) capacities of their children (mother’s ToM estimates; MTE), and ToM acquisition in 83 preschool children, using a multidimensional approach. Results showed that the accuracy of MTE was positively related to the children’s capacity for ToM, while the degree of certainty of inaccurate MTE was negatively related to ToM acquisition. The implications of these findings for the conceptualization of PRF and its relationship to ToM and other features of social cognition in children are discussed.
... Our results appear to suggest that parental reflective functioning is one of the most important predictors of child outcomes over and above parental mental health. Current interventions designed to improve parental reflective functioning, both group-based and dyadic, are still being refined and there is limited evidence for their effectiveness (Barlow et al., 2021;Lo and Wong, 2022). The findings of the current study support the continued development of these interventions as they indicate changes in parental reflective functioning may contribute to changes in child outcomes. ...
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Introduction The transition to parenthood is a high-risk period for many parents and is an important period for child development. Research has identified that parental mental health, reflective functioning (capacity to consider mental states of oneself and others) and coparenting (capacity to work together well as a parenting team) may be particularly significant predictors of later child outcomes, however these factors have seldom been considered together. The present study therefore aimed to investigate the relationship between these factors and the extent to which they predict child social emotional development. Methods Three hundred and fifty parents of infants aged 0 to 3 years 11 months were recruited to complete an online Qualtrics questionnaire. Results Results indicate that both positive coparenting and parental reflective functioning (Pre-mentalizing and Certainty subscales) were found to significantly predict child development. General reflective functioning (Uncertainty subscale) predicted parental depression and anxiety, however unexpectedly, parental mental health was not a significant predictor of child development, but did predict coparenting. General reflective functioning (Certainty subscale) was also found to predict coparenting, which in turn was found to predict parental reflective functioning. We found an indirect effect of general reflective functioning (Certainty) on child SE development via parental reflective functioning (Pre-mentalizing). We also found an indirect effect of negative coparenting on child development via parental reflective functioning (Pre-mentalizing). Discussion The current results support a growing body of research highlighting the important role reflective functioning plays in child development and wellbeing as well as parental mental health and the interparental relationship.
Adoption: Beginning of New Bonds is a six-week online parenting program specifically designed to enhance Parental Reflective Functioning (PRF) with the goal of improving Emotional bond, parental satisfaction, and reducing general and parental stress levels. In 2021, a pilot study of this program was conducted with 30 Brazilian couples who had adopted one or two children aged up to five years and 11 months at the time the training began. Further analysis of the training program-related variables could refine research hypotheses and improve the assessment process before proceeding with larger-scale replications. Thus, this study aimed to measure various parental variables associated with the Emotional bond, including PRF, Emotional bond, general stress, parental stress, and stress related to parental satisfaction, before and after participation in the pilot. The findings revealed that participants exhibited low levels of PRF. Furthermore, a significant improvement in the Emotional bond and parental satisfaction was observed between the pre- and post-tests. This study highlights the importance of testing the assessment of the variables of interest in a pilot to enhance evaluation. The study also discussed future directions for parenting programs aimed at enhancing the parent-child Emotional bond.
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Emotion regulation encapsulates the capability to successfully manage an ongoing emotional experience, particularly in social interactions, and thus may be especially significant to early parent-child relationships. In particular, the capacity to adjust emotions may support parental mentalization and reflective functioning – how parents think about their own and their child’s mental states and how these mental states effect behavior. To examine this issue, we investigated the association between emotion regulation, emotion dysregulation, and parental reflective functioning in a maternal sample (N = 97). We found that mothers with higher tendencies to suppress their emotions and who had more difficulties with emotion regulation engaged in greater levels of pre-mentalizing (i.e., a non-mentalizing mode). Mothers with poorer emotional awareness also evidenced less interest and curiosity in their child’s mental states. Finally, mothers who reported greater difficulty setting goals also evidenced a reduced capacity to recognize that their infant’s mental states are not directly observable. Taken together, our findings support the relationship between different aspects of emotion regulation and maternal reflective functioning, suggesting that emotion regulation should be integrated in empirical and intervention work that targets maternal mentalization.
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Parent–infant psychotherapy for improving parental and infant mental health - Volume 23 Issue 4 - Jane Barlow, Cathy Bennett, Nick Midgley, Soili K. Larkin, Yinghui Wei
Borderline personality disorder (BPD) is a severe personality dysfunction thought to affect some 2% of the population. This title presents a psychoanalytically oriented treatment for BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the first account of this treatment for BPD.
This research compared two forms of psychodynamic psychotherapeutic interventions for 67 clinically referred infants and their mothers. One was an infant-led psychotherapy delivered through a program called Watch, Wait, and Wonder (WWW). The other was a mother–infant psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately 5 months. A broad range of measures of attachment, qualities of the mother–infant relationship, maternal perception of parenting stress, parenting competence and satisfaction, depression, and infant cognition and emotion regulation were used. The WWW group showed a greater shift toward a more organized or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Moreover, mothers in the WWW group reported a larger increase in parenting satisfaction and competence and decrease in depression compared to mothers receiving PPT. Both WWW and PPT were successful in reducing infant -presenting problems, decreasing parenting stress, and reducing maternal intrusiveness and mother–infant conflict. Some potential reasons for the differential treatment effects and the theoretical, clinical, and methodological implications from the findings are discussed. ©1999 Michigan Association for Infant Mental Health.
The revised edition of the Handbook offers the only guide on how to conduct, report and maintain a Cochrane Review ? The second edition of The Cochrane Handbook for Systematic Reviews of Interventions contains essential guidance for preparing and maintaining Cochrane Reviews of the effects of health interventions. Designed to be an accessible resource, the Handbook will also be of interest to anyone undertaking systematic reviews of interventions outside Cochrane, and many of the principles and methods presented are appropriate for systematic reviews addressing research questions other than effects of interventions. This fully updated edition contains extensive new material on systematic review methods addressing a wide-range of topics including network meta-analysis, equity, complex interventions, narrative synthesis, and automation. Also new to this edition, integrated throughout the Handbook, is the set of standards Cochrane expects its reviews to meet. Written for review authors, editors, trainers and others with an interest in Cochrane Reviews, the second edition of The Cochrane Handbook for Systematic Reviews of Interventions continues to offer an invaluable resource for understanding the role of systematic reviews, critically appraising health research studies and conducting reviews.
The Reflective Functioning coding of the Parent Development Interview (PDI-RF) is a widely used method for assessing a caregivers’ capacity for mentalization. However, little is known about its psychometric properties. The aim of this study was to examine the distributions and discriminant and criterion validity of the PDI-RF scale in relation to a number of demographic and socioeconomic factors. Mothers of infants and toddlers (N = 323) from low, medium, and high-risk samples were interviewed with the PDI and transcripts were coded for RF. Demographic and socio-economic data were recorded. The PDI-RF scale showed high inter-rater reliability, internal consistency, and criterion validity. Modest associations with some sociodemographic variables and PDI-RF were found, but together these only accounted for a small amount of variance in the measure, suggesting adequate discriminant validity. Overall, the scale had good psychometric properties, although some caveats for its use were identified.
Parental reflective functioning (PRF) is a robust predictor of parenting sensitivity and secure infant attachment, but its assessment requires extensive resources, limiting its integration into research and clinical practice. The Mini-Parent Reflective Functioning Interview (Mini-PRFI) assesses the parent’s capacity to mentalize for his/her 6 month old infant (rated using the PRF coding system; Slade et al., 2004). In the current study we examined Mini-PRFI scores were associated with theoretically-related constructs; to establish a point of comparison, we evaluated links between Mini-PRFI scores alongside RF assessed from the Adult Attachment Interview (AAI). Mother–infant dyads (N = 88) completed the AAI before the birth of the infant, the Mini-PRFI and an interaction task (rated for insensitive) when infants were 6 months old, as well as the Strange Situation Procedure when infants were 16 months old. Mini-PRFI scores were strongly positively associated with AAI RF and negatively associated with maternal insensitivity. Mini-PRFI scores predicted infant attachment organization (secure/insecure, organized/disorganized) at 16 months, and this effect was mediated by parenting insensitivity.These findings suggest that the Mini-PRFI predicts theoretically-related attachment constructs,demonstrating the promise of the Mini-PRFI to increase the accessibility of interview-based PRF measurements to clinicians and researchers. Keywords: reflective functioning, mentalization, attachment, sensitivity, disorganization