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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.
... Wiegand-Grefe, 2017). Folglich ist es von großer Bedeutung, psychisch belastete Eltern möglichst frühzeitig in den Fokus von Beratungsangeboten und der klinischen Versorgung zu rücken, wobei der Ansatz mentalisierungsbasierter Interventionen in den vergangenen Jahren einen Zuwachs erlebt hat (Barlow, Sleed, Midgley, 2020). ...
... Insbesondere die positiven Aspekte sowie gelungenen PRF-oder MM-Aspekte könnten in spezifischen Interventionen aufgegriffen und als Grundlage genutzt werden, um stufenweise elterliche Mentalisierung und eine neugierige Haltung gegenüber dem Kind zu fördern, wie in einigen mentalisierungsbasierten Interventionen bereits etabliert (Barlow et al., 2020;Volkert et al., 2019). Für Interventionsstudien könnte es entsprechend bedeuten, dass sich Veränderungen negativer Mentalisierungsaspekte schwerer oder erst später im Verlauf erfassen lassen. ...
... Eltern mit BPS wird ein Interventionsprogramm angeboten, welches sich jedoch primär auf den erkrankten Elternteil richtet (Nijssens, Luyten, Bales, 2012). Eine Kombination aus mentalisierungsbasierten Ansätzen sowie der Förderung der Qualität der Eltern-Kind-Interaktion steht im Fokus beinahe aller Programme, wobei die videogestützte Veranschaulichung den Eltern die Möglichkeit gibt, mit Unterstützung kindliche Signale aufzugreifen und Interesse für zugrundeliegende mentale Zustände des Kindes zu wecken (Barlow et al., 2020). ...
The ability to mentalize is central in the context of the parent-child relationship. The parental competence to see the child's mental state as an independent individual is an essential prerequisite for perceiving and interpreting child signals appropriately. These abilities are crucial but not always available under elevated stress levels when confronted with a child’s affects and parenting challenges. Despite the clinical and conceptual relevance of mentalization with borderline personality disorder (BPD) and affective disorders, the subject has rarely been systematically addressed in parents. This review provides a systematic overview of parental mentalization in mothers with affective disorders or BPD and its impact on the quality of maternal interactive behaviour. The findings generally revealed a negative association between mothers’ parental mentalization and depression or BPD, which varied greatly depending on the mentalization constructs. Both psychiatric diagnosis and current severity of symptoms were found to be relevant. However, some positive aspects of mentalization were not markedly impaired. Further, a lower mentalizing ability was associated with reduced sensitive behaviour in depressed mothers. The results contribute to a better understanding of the association between mentalization and maternal psychopathology and help refine early interventions in parent-child settings.
... Although the association between parental mentalization or parents' RF and the parenting quality appears to be clear, a recent meta-analysis on interventions for PRF improvement found no evidence for a significant improvement in parentchild interaction, partially due to the heterogeneity of behavioral measures (Barlow et al., 2020). The authors further noted that the behavioral improvement might not be merely grounded in an increase of sensitive parenting but a reduction of disruptive parenting. ...
... On the positive side, PRF is considered the basis for parents to understand the child's internal states underlying behavior (Slade, 2005), which could promote their ability to better tune in to the child's affects by showing, for example, sensitive reactions. As Barlow et al. (2020) argued, promoting PRF might not directly help parents to adapt more sensitive and responsive behavior but rather to recognize and prevent dysfunctional behavior, particularly relevant for highrisk samples (Madigan et al., 2006). ...
... Another related issue to these findings could be a difference in the rate of change for PRF and parenting behavior (Sleed et al., 2013). More specifically, behavioral changes may take longer to become evident than changes in PRF (Barlow et al., 2020). Accordingly, it would be necessary to adjust the interval and frequency of post-treatment follow-ups to determine whether and how the changes in both constructs are related to each other. ...
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Background: Parental reflective functioning (PRF) refers to parents’ mental capacity to understand their own and their children’s behaviors in terms of envisioned mental states. As part of a broader concept of parental mentalization, PRF has been identified as one of the central predictors for sensitive parenting. However, the unique contribution of PRF to the quality of various parenting behaviors has not yet been addressed systematically. Thus, the present article provides a systematic overview of current research on the associations between PRF or its sub-dimensions and observed parenting behaviors in infancy and early childhood, while considering the influence of contextual factors. Methods: The review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Systematic searches were carried out in five electronic databases. The eligibility and methodological quality of the identified studies were assessed using pre-defined criteria and a standardized checklist. Results: Sixteen studies with moderate to high quality on a total of 15 parenting behaviors were included, the majority of which examined positive parenting behaviors, while negative parenting behaviors were rarely investigated. Most of the associations indicated a positive effect of PRF on parenting behavior, with mostly small-sized effects. The strength and direction of the associations varied depending on the dimensionality of PRF, observation settings, sample types, socioeconomic factors, and cultural background. Moreover, five assessment instruments for PRF and 10 observation instruments for parenting behaviors were identified. Conclusion: In summary, PRF has shown a positive association with parenting quality. However, its complex interaction with further contextual factors emphasizes the need for differentiation of PRF dimensions and the consideration of the observation settings, assessment time points, psychosocial risks, and sample types in observational as well as intervention studies. Further high-quality studies with multivariate analyses and diverse study settings are required.
... The study findings support shifts in maternal affect and responsiveness. Future research should address whether quantitative change in parental reflective functioning occurs after such brief intervention, or is a reasonable expectation, given its developmental value to the infant (Barlow et al., 2021). ...
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Research points to the significant impact of maternal distress on the parent‐infant relationship and infant development. The Newborn Behavioral Observations (NBO) is a brief intervention supporting the infant, the parent and their relationship. This randomized controlled trial examined the effectiveness of the NBO in a population with antenatal distress and risk of postnatal depression (PND). Pregnant, first‐time mothers with current anxiety or depression symptoms or past mental illness were recruited from two Australian hospitals. Participants received three NBO sessions in the first month of life plus treatment as usual (TAU), or, TAU‐only. Outcomes assessed at infant age 4 months included mother‐infant interaction quality; maternal anxiety and depression symptoms; and depression diagnosis. Of 111 pregnant individuals randomized, 90 remained eligible and 74 completed the trial (82.2% retention). There were intervention effects on emotional availability F(6, 67) = 2.52, p = .049, Cohen's d = .90, with higher sensitivity and non‐intrusiveness in the intervention group (n = 40) than the comparison group (n = 34). There was an intervention effect approaching significance for anxiety symptoms at 4 months (p = .06), and a significant effect over time (p = .014), but not for depression symptoms. Anxiety and depression symptoms significantly reduced to sub‐clinical levels within the intervention group only. There were fewer depression diagnoses (n = 6) than expected across groups, with no observed intervention effect. No adverse intervention effects were seen. Exploratory analysis of sensory processing sensitivity suggested differential susceptibility to distress and intervention benefits. The NBO was accepted and exerted meaningful effects on relationship quality and distress; and may enhance the infant's interaction experience and maternal emotional adjustment in at‐risk populations.
... Findings that mentalizing, and the capacity to reflect on traumatic experiences in particular (i.e., trauma-specific reflective functioning), provide an important buffer between trauma, features of PTSD such as dissociation, and intergenerational transmission of trauma (43), have further substantiated the mentalizing approach to trauma. Moreover, there is increasing evidence for the effectiveness of preventive interventions rooted in MBT for families at risk for maltreatment and abuse (44)(45)(46)(47). Yet, no study to date has directly investigated the impact of trauma on outcomes of MBT among individuals with borderline personality disorder. ...
Objective: Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP). Methods: All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment. Results: Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP. Conclusions: Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.
... For instance, there is evidence that PRF is associated with maternal neural sensitivity to infant affective cues [6] and with tolerance of infant distress [7,8]. In addition, several studies have also shown that higher levels of PRF are associated with attachment security in children [1,[9][10][11][12][13]. ...
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This study examines the factor structure and psychometric properties of the Portuguese Parental Reflective Functioning Questionnaire (PRFQ). The PRFQ is a brief questionnaire of parental reflective functioning that comprises three subscales: pre-mentalizing modes of mental states, certainty about mental states, and interest and curiosity in mental states. Two independent samples were included in the study: a sample composed of 710 mothers of children aged 0 to 36 months (Study 1) and a sample composed of 120 mothers of children aged 1 to 5 years (Study 2). Each sample completed a different set of self-report questionnaires. The original correlated three-factor structure was confirmed through confirmatory factor analyses. The three PRFQ subscales exhibited adequate reliability and correlated in the expected directions with several outcomes (psychopathology symptoms, emotion dysregulation, parent attachment, and parenting styles). The Portuguese PRFQ is a psychometrically robust measure of parental reflective functioning appropriate for research use in Portugal.
... In addition, once the mother begins to understand her mental states, it will still take time for the child to shift their "expectation" of interactions. The longer they have adapted to a particular attachment template, the longer it may take to develop the confidence in using the parent as a source of comfort (Stovall-McClough and Dozier, 2004;Barlow et al., 2021). It is also possible that children of mothers with severe PTSD symptoms did benefit from the intervention, but that these mothers were not reliable reporters of their infants' symptoms early on and became more insightful as treatment progressed. ...
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Background The present study examined the efficacy of the Michigan Model of Infant Mental Health-Home Visiting (IMH-HV) infant mental health treatment to promote the socioemotional wellbeing of infants and young children. Science illuminates the role of parental “co-regulation” of infant emotion as a pathway to young children’s capacity for self-regulation. The synchrony of parent–infant interaction begins to shape the infant’s own nascent regulatory capacities. Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, and who struggle with symptoms of post-traumatic stress may have greater challenges in co-regulating their infant, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression, and depression. Early intervention that targets the infant–parent relationship may help buffer the effect of parental risk on child outcomes. Methods Participants were 58 mother–infant/toddler dyads enrolled in a longitudinal randomized control trial testing the efficacy of the relationship-based IMH-HV treatment model. Families were eligible based on child age (<24 months at enrollment) and endorsement of at least two of four socio-demographic factors commonly endorsed in community mental health settings: elevated depression symptoms, three or more Adverse Childhood Experiences (ACEs) parenting stress, and/or child behavior or development concerns. This study included dyads whose children were born at the time of study enrollment and completed 12-month post-baseline follow-up visits. Parents reported on their own history of ACEs and current posttraumatic stress disorder (PTSD) symptoms, as well as their toddler’s socioemotional development (e.g., empathy, prosocial skills, aggression, anxiety, prolonged tantrums). Results Maternal ACEs predicted more toddler emotional problems through their effect on maternal PTSD symptoms. Parents who received IMH-HV treatment reported more positive toddler socioemotional wellbeing at follow-up relative to the control condition. The most positive socioemotional outcomes were for toddlers of mothers with low to moderate PTSD symptoms who received IMH-HV treatment. Conclusion Results indicate the efficacy of IMH-HV services in promoting more optimal child socioemotional wellbeing even when mothers reported mild to moderate PTSD symptoms. Results also highlight the need to assess parental trauma when infants and young children present with socioemotional difficulties.
... Parental mentalizing has been operationalized as parental Reflective Functioning (PRF), and refers to the quality of mentalizing in the context of attachment relationships, and the parent's capacity to think about mental states in relation to their own and their child's behavior. Parental RF is considered to play an important role in parenting, and therefore the development of children's attachment security (Stacks et al., 2014;Ensink et al., 2016;Camoirano, 2017;Barlow et al., 2021). Parents with higher PRF display more sensitivity in their interactions with their infants, and are more likely to have securely attached infants (Grienenberger et al., 2005;Slade et al., 2005a;Rosenblum et al., 2008). ...
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The period of infancy and early childhood is a critical time for interventions to prevent future mental health problems. The first signs of mental health difficulties can be manifest in infancy, emphasizing the importance of understanding and identifying both protective and risk factors in pregnancy and the early postnatal period. Parents are at a higher risk of developing mental health problems during the perinatal period. An understanding of the evidence around prevention and intervention for parental anxiety and depression is vital to the process of prevention of early mental health disorders in infants and young children. Here we review the existing prevention and treatment interventions in the early years focusing on the period from conception to 3 years – the majority targeting parents in order to improve their mental health, and that of their infants. Elements of successful programs for parents include psychoeducation and practical skills training, as well as work on the co-parenting relationship, developing secure attachment, and enhancing parental reflective functioning. While both targeted and universal programs have produced strong effect sizes, universal programs have the added benefit of reaching people who may otherwise not have sought treatment. In synthesizing this information, our goal is to inform the development of integrated models for prevention and novel early intervention programs as early in life as possible.
Mentalization refers to the capacity to understand and interpret one’s own and others mental states. There is good evidence for individualised treatments aimed at increasing this capacity with children and adolescents. However, there has been no focused synthesis of the literature concerning specifically group delivered mentalization-based parenting interventions. The current study aimed to systematically review the literature in relation to group delivered mentalization-based parenting interventions. Three databases were searched to identify N=515 studies that were screened and reported according to PRISMA guidelines. Inclusion criteria were met by N=10 studies. Interventions varied in terms of content, but often included psychoeducation, experiential group exercises and homework tasks. The length and setting of interventions did not appear to influence outcomes. Significant improvements in parental reflective functioning were found in eight of the ten studies. There was mixed evidence for the efficacy in terms of other parental and child outcomes. This may be due to the lack of high quality studies and the absence of longer-term follow-ups. There is a need for future research to conduct high quality studies with greater diversity in participating parents and long-term follow-up.
This special section dedicated to papers concerned with change processes in psychodynamic child and adolescent psychotherapy poses a set of interesting questions. What makes an intervention psychodynamic? How do we measure psychotherapy process? How can we bring psychodynamically-oriented treatment to a wider community, especially those that would not otherwise have access? These questions highlight the rich dialogue that can take place when we draw on psychoanalytic constructs and techniques to inform clinically relevant research, and then extrapolate these, to bring treatment to where they are desperately needed.
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Introduction Adults who have histories of childhood trauma have been noted to display greater somatization, dissociative symptoms and affect dysregulation. What happens in the parent-child relationship when those traumatized children become parents? A potential link to somatization in the child has been suggested by several prior studies. Children who have early attachment disturbances had more physical complaints if their mothers displayed less maternal sensitivity during observed parent-child interactions. Yet, the intergenerational link between maternal and child somatization has not been sufficiently explored in a longitudinal study in order to understand the potential impact of maternal trauma history and related psychopathology on subsequent child somatization and psychopathology. Methods This paper examined prospective, longitudinal data of 64 mother-toddler dyads (mean age = 2.4 years, SD = 0.7) who were later studied when children had a mean age of 7 years. Mothers with and without histories of interpersonal violence (IPV; physical/sexual abuse and/or family violence exposure) were included. Mothers with IPV histories were oversampled. Linear and Poisson regression models were used to test the associations between maternal IPV-related post-traumatic stress disorder (PTSD) with maternal somatization severity when children were toddlers, and between maternal somatization and maternal interactive behaviors with child somatization by maternal report and clinician-rated assessment at school-age. Results Maternal PTSD severity was significantly associated with increased maternal somatization severity ( p = 0.031). Maternal somatization severity during the child's early childhood predicted both maternal report of child somatization ( p = 0.011) as well as child thought problems ( p = 0.007) when children were school-aged. No association was found between maternal somatization and child-reported psychopathology. The study did not find that maternal alexithymia, caregiving behaviors or child exposure to violence contributed significantly to the model examining the association between maternal and child somatization. Conclusion The results are in line with the hypothesis of intergenerational transmission of somatization in the context of IPV and related maternal PTSD during formative early development. We interpret this as an expression of psychological distress from mother to child, as maternal trauma and pathology affect the caregiving environment and, thus, the parent–child relationship. The authors conclude with a discussion of implications for parent–infant and early childhood intervention.
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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
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Mothers with histories of alcohol and drug addiction have shown greater difficulty parenting young children than mothers with no history of substance misuse. This study was the second randomized clinical trial testing the efficacy of Mothering From the Inside Out (MIO), a 12-week mentalization-based individual therapy designed to address psychological deficits commonly associated with chronic substance use that also interfere with the capacity to parent young children. Eighty-seven mothers caring for a child between 11 and 60 months of age were randomly assigned to receive 12 sessions of MIO versus 12 sessions of parent education (PE), a psychoeducation active control comparison. Maternal reflective functioning, representations of caregiving, mother–child interaction quality, and child attachment were evaluated at baseline and posttreatment and 3-month follow-up. Mother–child interaction quality was assessed again at 12-month follow-up. In comparison with PE mothers, MIO mothers demonstrated a higher capacity for reflective functioning and representational coherence at posttreatment and 3-month follow-up. At 12-month follow-up, compared to PE cohorts, MIO mothers demonstrated greater sensitivity, their children showed greater involvement, and MIO dyads showed greater reciprocity. As addiction severity increased, MIO also appeared to serve as a protective factor for maternal reflective functioning, quality of mother–child interactions, and child attachment status. Results demonstrate the promise of mentalization-based interventions provided concomitant with addiction treatment for mothers and their young children.
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
In the last decade several studies have investigated the role of parental reflective functioning (RF), defined as the parental ability to understand his/her child’s mental states, on the child’s development. Herein, a narrative review on parental RF is presented aimed at (1) presenting an overview of the existing empirical studies, (2) pinpointing unrequited questions, and (3) identifying future research directions. Specifically, the current review focused on (a) the impact of parental RF on the quality of caregiving and the child’s attachment security, (b) the effect of parental RF on the child’s emotion regulation and the child’s RF, (c) maternal RF in women with a history of neglect and abuse, (d) the efficacy of mentalization-based clinical interventions, and (e) the recently developed Parental Reflective Questionnaire. The following terms “maternal RF,” “paternal RF,” “parental RF,” “parental mentalization,” “maternal mentalization,” and “paternal mentalization” were searched in titles, abstracts, and main texts using Medline, Web of Science, and Scopus databases. Next, a search in Mendeley was also conducted. Inclusion criteria comprised original articles if they refer to the RF Scale (Fonagy et al., 1998) and were published in an English language, peer-reviewed journal before July, 2016. According to exclusion criteria, dissertations, qualitative or theoretical papers, and chapters in books were not taken into account. The review includes 47 studies that, taken together, supported the notion that higher parental RF was associated with adequate caregiving and the child’s attachment security, whereas low maternal RF was found in mothers whose children suffered from anxiety disorders, impairment in emotion regulation, and externalizing behaviors. In addition, higher parental RF was associated with better mentalizing abilities in children. However, unexpected findings have emerged from the most recent randomized controlled trials that tested the efficacy of mentalization-based interventions in high risk samples of mothers, raising questions about the suitability of the verbal measures in capturing the mentalizing processes at the root of the parental capacity to be adequately responsive to the child’s emotional needs.