Prenatal affective cognitive training to reduce the risk of postpartum depression (PACT): study protocol for a randomized controlled trial.

BACKGROUND: Postpartum depression (PPD) affects 30-50% of women with a history of previous depression or bipolar disorder and 8% of women with no history of depression. Negative cognitive biases in the perception of infant cues and difficulties with emotion regulation are replicated risk factors. Current interventions focus on detecting and treating rather than preventing PPD. The aim of this randomized controlled intervention trial is therefore to investigate the potential prophylactic effects of prenatal affective cognitive training for pregnant women at heightened risk of PPD. METHODS: The study will enrol a total of 292 pregnant women: 146 at high risk and 146 at low risk of PPD. Participants undergo comprehensive assessments of affective cognitive processing, clinical depressive symptoms, and complete questionnaires at baseline. Based on the responses, pregnant women will be categorized as either at high or low risk of PPD. High-risk participants will be randomized to either prenatal affective cognitive training (PACT) or care as usual (CAU) immediately after the baseline testing. The PACT intervention is based on emerging evidence for efficacy of affective cognitive training approaches in depression, including cognitive bias modification, attention bias modification, mindfulness-inspired emotion regulation exercises, and working memory training. Participants randomised to PACT will complete five individual computerised and virtual reality-based training sessions over 5 weeks. The primary outcome is the difference between intervention arms in the incidence of PPD, assessed with an interview 6 months after birth. We will also assess the severity of depressive symptoms, rated weekly online during the first 6 weeks postpartum. DISCUSSION: The results will have implications for future early prophylactic interventions for pregnant women at heightened risk of PPD. If the PACT intervention reduces the incidence of PPD, it can become a feasible, non-invasive prophylactic strategy during pregnancy, with positive mental health implications for these women and their children. TRIAL REGISTRATION: ClinicalTrials.gov NCT06046456 registered 21-09-2023, updated 08-07-2024.

Offline and online parental mentalizing in mothers with symptoms of postpartum depression: Examining the association between self-reported parental reflective functioning and interactional mind-mindedness.

Mentalizing is, to a certain extent, considered context specific. However, research on the association between parents' abilities to reflect upon their infant's mental states outside social interaction (offline) versus during ongoing parent-infant interaction (online) is currently limited. This study investigated the association between self-reported offline and online mentalizing in a sample of primarily ethnically Danish mothers (N = 142), with symptoms of postpartum depression, and their 1-11-month-old infants. Offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire-Infant Version (PRFQ-I) and online mentalizing was assessed with interactional mind-mindedness. Ordinal logistic regressions showed that a higher score on the PRFQ-I prementalizing subscale was negatively related to number of overall mind-related comments and appropriate mind-related comments produced by mothers during interaction with their infant. Our results indicate partial overlaps between self-reported parental reflective functioning and mind-mindedness, that is, that particularly offline maladaptive mentalizing is associated with lower levels of mentalizing during interaction in mothers with symptoms of depression. Post-hoc examination of the interaction effect of postpartum depression showed that this association was only evident in mothers with medium to high levels of depression. Findings and implications are discussed.

Se considera, hasta cierto punto, que la mentalización se corresponde con un contexto específico. Sin embargo, la investigación acerca de la asociación entre las habilidades de los padres de reflexionar sobre los estados mentales de sus infantes fuera de la interacción social (no conectada a la internet / fuera de línea) versus la continua interacción progenitor­infante (en línea) es actualmente limitada. Este estudio investigó la asociación entre la auto­reportada mentalización tanto fuera de línea como en línea en un grupo muestra primariamente de madres étnicamente danesas (N = 142), con síntomas de depresión posterior al parto, y sus infantes de 1 a 11 meses de edad. La mentalización fuera de línea se evaluó por medio del Cuestionario del Funcionamiento con Reflexión del Progenitor ­ Versión del Infante (PRFQ­I) y la mentalización en línea se evaluó con el sistema de codificación de Conciencia Mental. La regresión logística ordinal mostró que un puntaje más alto en la sub­escala de pre­mentalización del PRFQ­I se asoció negativamente con el número en general de comentarios relacionados con la mente y de apropiados comentarios relacionados con la mente producidos por las madres durante la interacción con sus infantes. Nuestros resultados indican que hay superposiciones coincidentes parciales entre el funcionamiento con reflexión auto­reportado por el progenitor y la conciencia mental, v.g. que particularmente la mentalización fuera de línea inadaptada se asocia con una conciencia mental en línea menos óptima en madres con síntomas de depresión. Las posteriores examinaciones que el efecto de la interacción de la Escala de Depresión Postnatal de Edimburgo (EPDS) tiene sobre la asociación mostraron que esta característica sólo fue evidente en madres con niveles medianos a altos de depresión. Se discuten los resultados y las implicaciones.

La mentalisation est, dans une certaine mesure, considérée comme étant spécifique au contexte. Cependant les recherches sur le lien entre les capacités des parents à réfléchir sur les états mentaux de leur bébé en dehors de l'interaction sociale (hors connexion) par rapport à l'interaction continue parent­bébé (en ligne) sont en ce moment limitées. Cette étude s'est penchée sur le lien entre la mentalisation auto­déclarée hors connexion et en ligne chez un échantillon de mères en grande partie danoises (N = 142), avec des symptômes de dépression postpartum et leurs bébés âgés de 1 à 11 mois. La mentalisation hors connexion a été évaluée au moyen du Questionnaire de la Fonction Réflexive Parentale ­ Version Nourrisson (en anglais PRFQ­I) et la mentalisation en ligne a été évaluée au moyen du système de codage esprit­sensibilité. Des régressions logistiques ordinales ont montré qu'un score plus élevé à la sous­échelle PRFQ­I était lié de manière négative au nombre de commentaires généraux liés à l'esprit et à des commentaires liés à l'esprit appropriés produits par les mères durant l'interaction avec leur bébé. Nos résultats indiquent des chevauchement spartiels entre la fonction réflexive parentale auto­rapportée et la sensibilité, c'est­à­dire que la mentalisation inadaptée en particulier hors­connexion est liée à une sensibilité moins qu'optimale chez les mères avec des symptômes de dépression. L'examen a posteriori des effets de l'interaction de l'EPDS sur ce lien a montré que cela n'était que vrai chez les mères avec des niveaux de dépression de moyens à élevés. Les résultats et implications sont discutés.

The significance of parental mentalizing for four-year-old children's solitary pretend play.

BACKGROUND: Pretend play is a signature behavior of early childhood and is considered to reflect the child's emerging symbolic function, enabling the interpretation of social signals, language development, and emotion understanding. While theory links parental mentalizing with children's pretend play, only a few studies have investigated this association. These studies are limited to infancy and early toddlerhood, and child pretend play is assessed during play with an adult (social play). Based on the assumption that child solitary pretend play reflects the child's 'baseline' pretend play ability, in this study, we investigated children's pretend play at its peak, i.e., during the preschool age, without the facilitation of another player. The overall objective was to investigate if parental mentalizing increases pretend play complexity in children. METHODS: The sample consisted 99 Danish mothers and their 4-year-old children. Employing a cross-sectional design, we hypothesized that parental mental state language, as an indicator of 'online' mentalizing during interaction with the child, is a mechanism through which 'offline' mentalizing, measured as parental reflective functioning, is associated with child solitary pretend play. Child pretend play complexity was observed and coded with an adapted version of the 12-Step Play Scale. Maternal offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire, and maternal online mentalizing was assessed by coding the mothers' mental state language during interaction with the child using a modified version of the mind-mindedness coding scheme. RESULTS: While there was no direct effect of maternal offline reflective functioning on child pretend play, online mental state language mediated the link between offline maternal reflective functioning and child pretend play. CONCLUSIONS: These results provide support for the theoretically assumed link between parental mentalizing and children's capacity for pretend play. Furthermore, our study contributes to the literature on parental mentalization, suggesting that parental mentalizing facilitates child development only if the parent can translate this ability into 'mentalizing in action'.

The parental reflective functioning questionnaire: Infant version in fathers of infants and association with paternal postpartum mental health.

The parents' capacity to reflect upon the psychological processes in their child, termed parental reflective functioning (PRF) can be impaired by parental mental health problems. The present study aimed to investigate the factor structure of an infant version of the Parental Reflective Functioning Questionnaire (PRFQ-I) in a low-risk sample of 259 Danish fathers of 1-11-month-old infants to investigate measurement invariance of the PRFQ-I between fathers and mothers; and to examine the association between PRF and paternal depressive symptoms, psychological distress, and parenting stress. Confirmatory factor analysis supported a three-factor model of the PRFQ-I. Multi-group factor analysis indicated partial measurement invariance. Multiple linear regressions showed that paternal depressive symptoms were not associated with PRF. There was an interaction effect of paternal depressive symptoms and general psychological distress on paternal interest and curiosity in their infant's mental state and certainty of infant mental state. Increased parenting stress was associated with impaired PRF on all three subscales of the PRFQ-I. These results provide further evidence for a multidimensional, brief assessment of paternal reflective skills and insight into how variability in paternal psychological functioning relates to impaired PRF in the postpartum period.

La capacidad de los progenitores de reflexionar sobre los procesos sicológicos en sus niños, a lo cual se le denomina funcionamiento reflexivo de los progenitores (PRF), puede ser debilitado por los problemas de salud mental de los progenitores. El presente estudio se propuso investigar la estructura de factores de una versión infantil del Cuestionario de Funcionamiento Reflexivo de los Progenitores (PRFQ-I) en un grupo muestra de bajo riesgo de 259 papás daneses de infantes de 1-11 meses de nacidos para investigar la invariabilidad de las medidas del PRFO-I entre papás y mamás; y para examinar la asociación entre PRF y los síntomas depresivos paternos, la angustia sicológica y el estrés de crianza. Los confirmatorios análisis de factores apoyaron un modelo de tres factores del PRFQ-I. Los análisis de factores de multigrupos indicaron la parcial invariabilidad de las medidas. Regresiones múltiples lineales mostraron que los síntomas depresivos paternos no estaban asociados con PRF. Se dio un efecto de interacción de los síntomas depresivos paternos y la angustia sicológica general sobre el interés y la curiosidad paternas en cuanto al estado mental de sus infantes, así como la certeza en cuanto al estado mental infantil. Se asoció el aumento de estrés de crianza con un debilitado PRF en todas las tres subescalas del PRFQ-I. Estos resultados proveen evidencia adicional para una evaluación multidimensional, breve, de las habilidades reflexivas del progenitor e información acerca de cómo la variabilidad en el funcionamiento sicológico paterno se relaciona con el debilitado PRF en el período posterior al parto.

La capacité des parents à réfléchir aux processus psychologiques chez leur enfant, appelée fonctionnement de réflexion parentale (PRF en anglais) peut être compromise par des problèmes de santé mentale parentale. Cette étude s'est donné pour but d'étudier le facteur de structure d'une version nourrisson du Questionnaire de Fonctionnement de Réflexion Parentale (abrégé en anglais PRFQ-I) chez un échantillon à faible risque de 259 pères danois de bébé de 1-11 mois pour étudier l'invariance de mesure du PRFQ-I entre les pères et les mères; et pour examiner le lien entre le PRF et les symptômes dépressifs paternels, la détresse psychologique, et le stress de parentage. Une analyse factorielle confirmatoire a soutenu le modèle à trois facteurs du PRFQ-I. Une analyse factorielle multi-groupes a indiqué une invariance de mesure partielle. De multiples régressions linéaires ont montré que les symptômes dépressifs paternels n'étaient pas liés au PRF. On a noté un effet d'interaction des symptômes dépressifs paternels et de la détresse psychologique générales sur l'intérêt paternel et la curiosité pour l'état mental de leur bébé et la certitude de l'état mental du bébé. Le stress de parentage accru était lié à un PRF altéré sur toutes les trois sous-échelles du PRFQ-I. Ces résultats offrent une justification pour une évaluation brève et pluridimensionnelle des compétences de réflexion paternelles et un aperçu sur la manière dont la variabilité dans les fonctionnement psychologique paternel se rapporte au PRF altéré dans la période postpartum.

Promoting interactive skills and mind-mindedness among early childcare professionals: study protocol for a randomized wait-list controlled trial comparing the Circle of Security approach with care as usual in center-based childcare (the SECURE project).

BACKGROUND: In countries where the majority of young children are enrolled in professional childcare, the childcare setting constitutes an important part of children's caregiving environment. Research consistently shows that particularly the quality of the daily interactions and relationship between young children and their professional caregivers have long-term effects on a range of developmental child outcomes. Therefore, professional caregivers' capacity for establishing high quality interactions with the children in their care is an important target of intervention. METHODS: A prospective, parallel, cluster-randomized wait-list controlled trial is used to test the efficacy of the attachment- and mentalization theory informed Circle of Security (COS) approach adapted to the childcare setting (COS-Classroom) on caregiver interactive skills and mind-mindedness. Participants are professional caregivers of children aged 0-2.9 years working in center-based childcare in Denmark. Approximately 31 childcare centers, corresponding to an estimated 113 caregivers, are expected to participate. The primary outcome is caregiver Sensitive responsiveness measured with the Caregiver Interactive Profile Scales (CIP-scales). Secondary outcomes include caregiver Mind-mindedness, the five remaining CIP-scales (Respect for autonomy, Structure and limit setting, Verbal communication, Developmental stimulation, and Fostering positive peer interactions), and caregivers' resources to cope with work-related stress. Data on structural factors (e.g., staff stability, caregiver-child ratio, and level of pre-service education), caregiver attachment style, acceptability and feasibility of the COS-C together with qualitative data on how the participants experience the COS-C is additionally collected to investigate moderating and confounding effects. DISCUSSION: Examining the effectiveness of the COS-C in center-based childcare contributes to the knowledge of evidence-based intervention programs and can potentially improve the caregiver quality early childcare. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04654533. Prospectively registered December 4, 2020, https://clinicaltrials.gov/ct2/show/NCT04654533 .

Factor structure of the parental reflective functioning questionnaire and association with maternal postpartum depression and comorbid symptoms of psychopathology.

Parental reflective functioning (PRF) refers to the parent's capacity to envision mental states in the infant and in themselves as a parent, and to link such underlying mental process with behavior, which is important for parenting sensitivity and child socio-emotional development. Current findings have linked maternal postpartum depression to impaired reflective skills, imposing a risk on the developing mother-infant relationship, but findings are mixed, and studies have generally used extensive methods for investigating PRF. The present study examined the factor structure and measurement invariance of the Danish version of the 18-item self-report Parental Reflective Functioning Questionnaire (PRFQ) in a sample of mothers with and without diagnosed postpartum depression. Moreover, the association between PRF and maternal postpartum depression in mothers with and without comorbid symptoms of personality disorder and/or clinical levels of psychological distress was investigated. Participants included 423 mothers of infants aged 1-11 months. Confirmatory factor analysis supported a three-factor structure of the PRFQ; however, item loadings suggested that a 15-item version was a more accurate measure of PRF in mothers of infants. Multi-group factor analysis of the 15-item PRFQ infant version indicated measurement invariance among mothers with and without diagnosed postpartum depression. Multinomial logistic regression showed that impaired PRF was associated with maternal psychopathology, although only for mothers with postpartum depression combined with other symptoms of psychopathology. These results provide new evidence for the assessment of maternal self-reported reflective skills as measured by a modified infant version of the PRFQ, as well as a more nuanced understanding of how variance in symptomatology is associated with impaired PRF in mothers in the postpartum period in differing ways.

Can the Edinburgh Postnatal Depression Scale-3A be used to screen for anxiety?

BACKGROUND: Anxiety in the ante- and postnatal period is prevalent, often co-occurs with depression, and can have adverse consequences for the infant. Therefore, perinatal mental health screening programs should not only focus on depression but also on detecting anxiety. However, in many already implemented perinatal screening programs, adding extra screening instruments is not feasible. We examine the utility of a subscale of the Edinburgh Postnatal Depression Scale (EPDS) consisting of items 3, 4, and 5 (EPDS-3A) for detecting anxiety in new mothers. METHODS: We used confirmatory factor analysis (CFA) to confirm the presence of the EPDS-3A found in a previous study (n = 320) where exploratory factor analysis (EFA) was used. For the CFA we used a sample of new mothers (n = 442) with children aged 2-11 months recruited from the same population from which mothers for the previous study was recruited. Three models were tested and compared. Receiver operating characteristics of the EPDS-3A were investigated in relation to anxiety caseness status on the combined sample (N = 762). Sample weighing was used to match the dataset to the target population. Cross tabulation was used to investigate the proportion of anxiety cases identified by the EPDS-3A above those identified with the total EPDS. RESULTS: The presence of the EPDS-3A was confirmed. An EFA-driven, two-dimensional 7-item model showed the best data fit with one factor representing the anxiety subscale consisting of items 3, 4, and 5. An EPDS-3A score of ≥ 5 was the most optimal for identifying cases of anxiety (sensitivity: 70.9; specificity: 92.2; AUC: 0.926). Further, we found that the EPDS-3A identifies an additional 2.5% of anxiety cases that would not have been identified with the total EPDS. CONCLUSIONS: The EPDS-3A can be used as a time-efficient screening for possible anxiety in ante- and postnatal mothers. However, adding the EPDS-3A to routine screening with the total EPDS does not lead to a substantial increase in the number of women identified. In line with previous studies, this study confirms that the EPDS identifies anxiety in addition to depression. Therefore, assessment and treatment adjusted to the specific emotional difficulties is imperative.

Associations Between Maternal Postpartum Depression, Infant Social Behavior With a Stranger, and Infant Cognitive Development.

Maternal postpartum depression (PPD) has been found to be related to infant social withdrawal during mother-infant interaction, and this may spill over on infant interactive behavior in other social contexts and impact infant psychosocial development. We investigated whether PPD was associated with infant social withdrawal during interaction with a tester in a psychological test situation and whether infant social withdrawal in the test situation mediated the association between PPD and infant cognitive scores reported in a previous study. Participants were 28 PPD dyads and 41 control dyads. We assessed infant social behavior and cognitive development with the Alarm Distress Baby Scale and the cognitive scale of the Bayley Scales of Infant and Toddler Development, third edition, at four months. More symptoms of maternal depression were associated with more infant social withdrawal. The association between maternal depressive symptoms and cognitive scores was at most partially mediated by infant social withdrawal in the test situation (<29.6%). Our results add to the existing literature on the effects of PPD on infant social behavior in other contexts than the one constituted by the mother. More research is needed to shed light on the mechanisms through which PPD impacts infant cognitive development.