Edited by: Giovanni De Girolamo, Centro San Giovanni di Dio Fatebenefratelli (IRCCS), Italy
Reviewed by: Ming Wai Wan, University of Manchester, United Kingdom; Hiroaki Hori, National Center of Neurology and Psychiatry (Japan), Japan
*Correspondence: Christine Heinisch,
This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry
†These authors have contributed equally to this work.
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About 15% of mothers suffer from postpartum psychiatric disorders, such as depression, anxiety, or psychosis. Numerous studies have shown maternal caregiving behavior to be negatively affected under these circumstances. The current study sets out to shed light on specific caregiving behaviors of affected mothers in the context of parental mental illness at an early stage. There are several methods to assess maternal caregiving behavior in terms of sensitivity. However, all of them have limitations regarding the peculiarities of mothers with postpartum disorders, that is, changes in affect regulation, and the early onset of the disorder postpartum. With the current study, we provide an adapted method to assess maternal sensitivity based on methods recently approved in attachment research. Two groups of mothers, who were either healthy or had different postpartum disorders, were recorded on video during interactions with their infants. Behaviors were rated regarding responsiveness, promptness, appropriateness, intrusiveness, and positive and negative affect. A first analysis revealed an increased number of deficits on all subscales in mothers with postpartum psychiatric disorders as compared to healthy mothers. Depressive mothers with a single diagnosis had lower scores in responsiveness, promptness, and appropriateness and higher scores on intrusiveness as compared to those in healthy mothers. Here, maternal behavior appears more parent-centered, whereas affect seemed to be relatively unharmed. Moreover, as compared to healthy mothers, mothers with comorbid depression and anxiety symptomatology achieved lower scores on responsiveness, appropriateness, and positive affect and higher scores on intrusiveness and negative affect. It is suggested, that increased deficits are related to the severity of illness in mothers with comorbidities. Results on promptness indicate that these mothers are still capable of maintaining higher vigilance to infant cues. Variance in maternal behavior was relatively high in clinical mothers, showing that some of them are well capable of behaving in a sensitive manner toward their child. One strength of our adapted method is that particular aspects of sensitive parent–child interactions are assessed separately. This may shed light on specific behavior patterns of different postpartum psychiatric disorders, which may in turn relate to specific child outcomes. The manual is open for usage, while reliability testing is required.
The birth of a child is typically represented as a fascinating and happy event. In reality though, a few days after child birth, about 40–80% of mothers experience symptoms of depression and emotional lability (
The most common and significant diagnoses of postpartum psychiatric disorders are postpartum depression (
Various symptoms with postpartum onset interfere with the demands of caring for a child and handling motherhood. Therefore, mothers with postpartum disorders often exhibit specific behavioral restraints during interaction with their infant. More specifically, postnatally depressed mothers, as compared to healthy mothers, show fewer positive caregiving behaviors, less emotional involvement, and less responsiveness when interacting with their children (
In sum, postpartum psychiatric disorders compromise a mother’s ability to interact with her child in a sensitive way, which decreases the quality of the mother–child interaction [e.g., Refs. (
Another important component closely related to the concept of sensitivity is
Several methods used to assess parental interactional behavior emphasize the importance of warmth and positive climate, although these aspects are not included in the original definition of sensitivity. Key aspects of depression are depressed mood and loss of interest. Thus, mothers with this diagnosis often experience blunted emotionality or an increase in negative affect. These emotional characteristics compromise the affective climate during mother–child interactions. More precisely, depression lowers the mothers’ capability to flexibly switch between affective states and adjust to their child’s altering affective states and needs sensitively (
Negative affect in mothers with postpartum anxiety disorder reveals itself in stressful and sorrowful behavior (
The relevance of maternal sensitivity is evidenced by numerous studies that identify this domain of caregiving behavior as an important predictor of the child’s attachment (
Observational tools to assess maternal behavior in mother–child interactions are numerous (
First, the Ainsworth Maternal Sensitivity Scale is one of four scales assessing parental behavior (
Second, the NICHD-ECCN Scale for mothers of children from 6 up to 24 months quantifies different aspects of maternal behavior rated from videotaped dyadic semistructured play interactions. It assesses the following aspects of parenting behavior:
Third, Biringen and colleagues (
Fourth, the CARE-Index is a screening tool intended to enable trained professionals to make judgments about the necessity of a family intervention (
With many other methods, but the four named as influential in attachment research, it should be just a matter of choice to evaluate maternal sensitivity in postpartum psychiatric disorders. Indeed, all of them have been in use for clinical research [e.g., Refs. (
First, the onset of postpartum depression starts either already during pregnancy with signs for mental health problems or manifestations of depression and anxiety or immediately after birth or at least very few weeks or months after delivery. In practice, the diagnosis is given with diagnostic criteria until children reach the age of 1, in some hospitals even 2. Here, it is important to note that sensitivity measures vary regarding recommendations on the child’s age range: Whereas the scales of Ainsworth, EA, and CARE-Index allow observation from birth on, the NICHD Scale starts from 6 months of age and was not specifically intentionally developed for newborns or younger infants. Moreover, the CARE-Index and the EA Scales measure dyadic interaction, which increases in older infants. This might account for the number of null findings in studies using the EA Scales in depressed and nondepressed mothers (
Second, the development from and application with regard to attachment theory and research are different. The CARE-Index and the EA Scales can be regarded as further developments of the Ainsworth sensitivity scales and are both very promising in evaluating the dyadic interaction within the developing attachment relationship because sensitive maternal behavior is related to secure attachment. According to Bowlby (
Another limitation is that the NICHD ECCN sample mostly stems from the middle class. For samples who are at specific risk to show highly dysfunctional parenting behaviors, however, it is necessary to use scales that particularly differentiate behavioral nuances at low levels of parenting competence and that allow to measure distinct impairments of specific aspects of parenting behaviors.
Furthermore, all methods vary with regard to the observational situation. Whereas the Ainsworth Maternal Sensitivity Scale and the EA Scales can be applied in different settings, the CARE-Index favors free-play situations, and the NICHD-ECCN Scale requires semistructured situations like diaper change or feeding situation or in the toddler form a manualized procedure. Also, the required recording length ranges from 3 min (CARE-Index) to 30 min (EA Scales). Regarding the special group of mentally ill mothers, the observational situation must be carefully chosen. It should be easy to implement during daily routine of several treatment institutions. Because those mothers are limited in their capacity to play freely with their children, it must not enforce the feeling of insufficiency.
Next, a crucial diagnostic criterion of postpartum depression is depressed mood and loss of interest, whereas arousal is increased in mothers with postpartum anxiety. Affect measures have been considered in all scales but only to a limited degree: Hostility or warmth is measured in the Ainsworth Maternal Sensitivity and EA scales. The NICHD-ECCN sensitivity composite score includes positive and negative regard of the child for youngest children, with changes in the negative affect scale in the toddler form.
Further considerations refer to how differentiated maternal behavior is measured, which is especially important with regard to mothers’ symptom comorbidity. Recent research finds that depression and anxiety during the first 8 weeks postpartum occur simultaneously in 13% of mothers (
To sum up, we propose an adaptation of the described methods to measure sensitivity to fully represent the spectrum of altered behavior in postpartum psychiatric disorders with all its comorbidities. Our intention was to develop a method that is applicable in a clinical routine setting (e.g., mother–baby unit) with reasonable effort for patients and the therapeutic team. At the same time, it should be usable for scientific purposes. Future scientific questions can then focus on how maternal caregiving behavior differs with regard to different diagnoses while taking into account the high number of comorbidities. It is also of special interest if other risk factors associated with postpartum psychiatric disorders are related to specific deficits, for example, parenting stress, traumatic experiences, or lack of social support. And finally, we aim to relate our findings to specific child outcomes to increase our understanding on symptom-specific effects of alterations in parenting behavior that are related to maternal mental illness.
The present paper describes the development of an adapted measure of maternal caregiving behavior for scientific and clinical use in mothers with postpartum psychiatric disorder. The adapted measure specifically considers the clinical setting, peculiarities of postpartum disorders, and a fine-grained description of maternal behavior. We then present a preliminary pilot implementing the adapted measure on 38 mothers admitted to a mother–baby unit and 35 healthy mothers.
This study was carried out in accordance with the Declaration of Helsinki and the permission and recommendations of the Ethics Committee of the Friedrich-Alexander University Erlangen Nuremberg and the Ethics Committee of Technical University Dresden (Ethics committee of the FA: 320_15 B, Ethics committee of the TU: EK450 22013). All participants gave written and informed consent. For all data concerning children, written informed consent was obtained from the parents.
Mentally ill mothers currently attending a video-based interaction therapy in a mother–baby day unit were asked to participate in the study. Video recordings were made on a voluntary basis. Treatment institutions were the Mother-Baby-Day-Unit of the Clinic of Psychiatry and Psychotherapy of the Paracelsus University Clinic Nuremberg Psychiatry in Nuremberg and the Mother-Baby-Day-Unit of the Clinic for Psychotherapy and Psychosomatics of the University Clinic Carl Gustav Carus at the Technical University in Dresden. In these units, mothers spent time from 8 to 16 o’clock each day for an average of 8 weeks, during which they receive a variety of interventions (e.g., group therapy, psychoeducation, personal counseling, and art therapy). A special focus lies in the improvement of mother–child interaction by providing sensitivity training, baby massage, and mother–baby bonding therapy. Video interaction therapy starts soon after the initial assessment with numerous sessions during the whole stay in treatment. In these sessions, mothers watch videotapes of themselves interacting with their infant and get feedback about positive sequences from their therapist. They are then supported by their therapist to enhance such behaviors and integrate them into daily life situations.
The total sample of mothers who agreed to participate in the current study consisted of 102 mothers with postpartum disorders (67 stemming from the Dresden Unit and 35 from the Nuremberg Unit) and of 38 healthy/nonclinical mothers. For mentally ill mothers, the diagnoses were depression, anxiety, compulsive disorder, PTSD, substance abuse {of medium extent [alcohol, tetrahydrocannabinol (THC), or nicotine during pregnancy and continuing]}, bipolar disorder, personality pathology, and/or psychosis (order according to frequency). More than half of the patients had more than one diagnosis.
Clincial diagnoses were based on clinical assessment according to International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria, video recordings were made by an interaction therapist, and questionnaires were assessed as self-ratings.
Observation and analysis of mother–child interaction were used for the development of the adapted sensitivity scales. Videos were recorded in clinical routine for therapeutic use at the beginning of their therapy. Mothers were instructed to act as normal as during daily routine.
The method is based on the Ainsworth Maternal Sensitivity Scale (
With respect to behavioral deficits in mentally ill mothers (as described above), the following scales were defined: caregiver’s
The scale
The scale
These three scales were chosen based on Ainsworth’s definition of sensitivity and the NICHD descriptions, whereas both of them use an overall score for all three types of behaviors referred to as “sensitivity.”
The method and the rating scheme are described at length in the manual at the appendix (compare
Scales and blinded videos were repeatedly discussed on lab meetings and with trained sensitivity observers. Other scales, as measuring maternal speech or body contact, were rejected during adaptation because they were not directly related to the concept of sensitivity, although many mothers also show deficits here.
In total, six scales were rated on a 9-point scale ranging from one to five with semisteps in between. Defined anchor points are 1, 2, 3, 4, and 5. Low values indicated low characteristics of the regarding scale, whereas high values go along with frequent observation of the behavior in the scale.
Analyses were conducted by five postgraduate psychology students who participated in a seminar on “observational tools to assess baby’s signals” and underwent intense reliability training by experienced researchers. Reliability training included reading literature on sensitivity, discussing videos with mother–child interaction and doing pre-ratings to find misperceptions or positive or negative observation bias on a weekly basis for 6 months. They were trained with the help of the manual and an assessment sheet (see the Manual) analyzing the categories: Responsivity, promptness, appropriateness, intrusiveness, and negative and positive affect. Note: Observers who are familiar and reliable with other sensitivity scales should be able to use the method with less intense training.
Raters were blind to diagnoses. All five students were required to become highly reliable, with all κ > 0.85 before they were allowed to score the videos included in the study. According to McHugh (
For the present study, we examined a subset of the clinical sample including 31 mothers from the Nuremberg Unit and seven mothers from the Dresden Unit with postpartum depression and/or anxiety disorder. The clinical sample was recruited consecutively from 2016 to 2018. Infants were healthy as seen by Pediatrics from the hospital. There was a massive reduction of usable videos because during the pilot phase, criteria for the recordings of the videos for scientific usage have been developed.
Videos were excluded if they were <3 min in length (according to the standard CARE-Index procedure), recorded after the third week of admission, the patient presented with three clinical diagnoses on the basis that the underlying disorder was unclear (e.g., depression and anxiety and personality disorder and substance abuse), invisibility of important parts of the interaction, strong sound problems, or lack of questionnaire data.
In contrast, inclusion criteria were a good quality of the video, recording at the beginning of the therapy, and at least one of the diagnoses from the spectrum of depression, anxiety, or compulsive disorder.
The control group was acquired in the area of Erlangen Nuremberg, Germany, and videos were recorded during home visits. The control mothers were recruited
All mothers were instructed to act as usual during daily routine. All videos included a semistandardized situation, where they changed the diapers of their infant or fed him or her. In addition, parents were asked to play with their infant without instruction.
The Brief Symptom Inventory (BSI) (
In addition, there are three global scores for general mental stress: GSI, intensity [(Positive Symptom Distress Index (PSDI)], and number of reported symptoms [positive symptom total (PST)].
Scores can be transformed into T scores with different norms for academic students or adults in general, as well as men and women. Here, we used T scores for women (nonstudent) to assess the global severity of mental illness. Clinically relevant GSIT scores are above ≥63 (
To assess postpartum symptoms of depression, we used the Edinburgh Postnatal Depression Scale (EPDS) (
We used SPSS 25.0 for analysis. To examine differences between group variables, we used
Mothers of both groups were at the same age in the beginning of the thirties and had the same, relatively high, educational background (
Demographic data for healthy and clinical mothers.
Healthy mothers (n = 35) |
Clinical mothers (n = 38) | ||
---|---|---|---|
Mean SD | Significant differences | ||
Maternal age (years) | 31.49 ± 4.27 | 30.02 ± 5.38 | n.s. |
Education with A Level (%) | 62.85 | 55.26 | n.s. |
Age of child (weeks) | 49.60 ± 25.22 | 27.75 ± 21.39 |
|
Sex of child (boy:girl) | 16:19 | 19:19 | |
PTs having relatives with psychiatric disorder | 11 | 22 | Χ2 (1, |
EPDS (sum) | 5.77 ± 3.98 | 17.32 ± 5.55 |
|
BSI (GSI) | 46.97 ± 12.03 | 74.83 ± 7.72 |
|
Values indicate means and standard deviations. PTs, participants; EPDS [sum], sum score of the Edinburgh Postnatal Depression Scale; BSI [GSI], Brief Symptom Inventory [Global Severity Index]; n.s., not significant.
Psychopathology was significantly higher in the clinical group as indicated by measures of the BSI (GSI) and EPDS. In the control group most participants (27 of 35) had scores below 10, while 5 participants had an EPDS score between 10 and 12, indicating a medium degree of postpartum depressive symptoms, and 3 of them had scores above 12 (clinical relevance). In contrast, in the clinical group, almost all mothers (36 of 38) had scores above 12, whereas 2 of them scored between 10 and 12.
We used multivariate ANOVA to test if the group of healthy mothers differs in maternal sensitivity significantly from the clinical group. Although not significant (F(6,66) = 1.690;
Comparison of the sensitivity subscales for healthy and clinical mothers.
Healthy mothers |
Clinical mothers | ||
---|---|---|---|
Mean SD | Significant differences | ||
Responsivity | 4.16 ± 0.73 | 3.67 ± 0.89 | F(1,71) = 6.431; |
Promptness | 4.01 ± 0.66 | 3.54 ± 0.93 | F(1,71) = 6.214; |
Appropriateness | 3.97 ± 0.86 | 3.32 ± 1.00 | F(1,71) = 8.942; |
Intrusiveness | 2.13 ± 0.83 | 2.88 ± 1.15 | F(1,71) = 10.203; |
Negative affect | 1.67 ± 0.69 | 2.12 ± 0.86 | F(1,71) = 5.984; |
Positive affect | 4.33 ± 0.86 | 3.85 ± 0.94 | F(1,71) = 5.003; |
We tested for maternal and child age as possible parameters influencing sensitivity. Spearman correlation revealed no significance with these factors for none of the scales neither in the group of healthy nor clinical mothers (compare
No correlation of maternal behavior with maternal or child age.
Maternal age | Child age | ||
---|---|---|---|
|
|||
1 | Responsivity | −0.078 | 0.221 |
2 | Promptness | −0.185 | 0.122 |
3 | Appropriateness | −0.157 | 0.297 |
4 | Intrusiveness | 0.048 | −0.154 |
5 | Negative affect | −0.039 | 0.042 |
6 | Positive affect | 0.212 | −0.045 |
|
|||
1 | Responsivity | −0.074 | 0.137 |
2 | Promptness | −0.043 | 0.084 |
3 | Appropriateness | 0.033 | 0.066 |
4 | Intrusiveness | −0.100 | −0.164 |
5 | Hostility | −0.276 | −0.320 |
6 | Positive affect | 0.230 | 0.017 |
As visible in
Intercorrelations of maternal sensitivity in the control group (
Clinical group | Healthy control group | ||||||
---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | ||
1 | Responsivity | 1 | 0.934*** | 0.883*** | −0.661*** | −0.529*** | 0.506** |
2 | Promptness | 0.955*** | 1 | 0.835*** | −0.585*** | −0.478** | 0.460** |
3 | Appropriateness | 0.826*** | 0.846*** | 1 | −0.753*** | −0.592*** | 0.594*** |
4 | Intrusiveness | −0.664*** | −0.620*** | −0.824*** | 1 | 0.493** | −0.446** |
5 | Negative affect | −0.758*** | −0.707*** | −0.760*** | 0.742*** | 1 | −0.837*** |
6 | Positive affect | 0.694*** | 0.659*** | 0.756*** | −0.715*** | −0.913*** | 1 |
Asterisks label significance (**p ≤ 0.005, ***p ≤ 0.001).
One goal of the development of the adapted method is to analyze sensitivity with respect to specific symptoms of depression to better differentiate between groups of different mental disorders. In the group of healthy mothers, we found mothers who scored subclinical to moderate on depression or EPDS and/or BSI and were clinically conspicuous. We decided not to exclude them from earlier analysis because they were “healthy enough” not to be in treatment. However, in an additional analysis, we put them in a separate group, named “healthy with mild depressive symptoms” (
Comparisons of the sensitivity subscales for groups with different degrees of depressive symptoms, ranging from no symptoms to comorbidities.
Healthy mothers | Clinical mothers | ||||||
---|---|---|---|---|---|---|---|
No depression |
Mild depression | Depression | Depression + anxiety | ||||
|
|
|
|
|
|
||
EPDS | 3.96 ± 2.31 | 11.87 ± 1.35 | 0.000 | 14.87 ± 5.43 | 0.000 | 18.61 ± 5.03 | 0.000 |
BSI GSI | 43.03 ± 7.83 | 61.50 ± 12.75 | 0.013 | 72.81 ± 7.47 | 0.000 | 76.89 ± 3.98 | 0.000 |
Responsivity | 4.24 ± 0.69 | 3.87 ± 0.79 | n.s. | 3.65 ± 0.97 | 0.029 | 3.73 ± 0.88 | 0.047 |
Promptness | 4.05 ± 0.62 | 3.87 ± 0.79 | n.s. | 3.53 ± 1.04 | 0.050 | 3.57 ± 0.91 | n.s. |
Appropriateness | 4.07 ± 0.80 | 3.62 ± 0.99 | n.s. | 3.21 ± 1.04 | 0.006 | 3.42 ± 1.03 | 0.025 |
Intrusiveness | 2.02 ± 0.82 | 2.50 ± 0.75 | n.s. | 2.88 ± 1.27 | 0.008 | 2.79 ± 1.04 | 0.012 |
Negative affect | 1.67 ± 0.65 | 1.69 ± 0.84 | n.s. | 2.00 ± 0.98 | n.s. | 2.16 ± 0.74 | 0.048 |
Positive affect | 4.33 ± 0.82 | 4.31 ± 1.03 | n.s. | 4.00 ± 1.01 | n.s. | 3.78 ± 0.85 | 0.040 |
Mean and standard deviation. p values belong always to comparisons from the group left to them with healthy mothers without depression.
n.s., not significant. See ref. (
EPDS, Edinburgh Postnatal Depression Scale; BSI GSI, brief symptom inventory, global severity index.
We used multivariate analysis to test whether the sensitivity scales differ significantly between the four groups (healthy vs. mild symptoms vs. clinical with depression vs. clinical with depression and comorbidities). Not significantly, but descriptively, with increasing severity, sensitivity gets worse. Healthy but mildly depressed mothers have lower values in sensitivity but not in their affect. Clinically burdened mothers differ significantly in their sensitivity pattern from that of healthy mothers. Whereas mothers with depression respond less, are less prompt, less appropriate, and more intrusive, their affect does not differ significantly from that of healthy mothers. Mothers with additional diagnoses of anxiety are less responsive, less appropriate, and more intrusive and show more negative and less positive affect but are not significantly less prompt.
The present study aimed at adapting observational methods assessing sensitivity in caregivers to a group of mothers with postpartum mental disorders. Therefore, we screened 102 videos of mentally ill mothers interacting with their infants to identify specific parenting behaviors associated with different postpartum mental disorders. These specific behaviors are described in the manual, which can be found in the supplements. With respect to the main deficits of maternal caregiving behavior, we combined different measurement scales for sensitivity. More precisely, with special regard to attachment research, the Ainsworth’s Maternal Sensitivity Scale (
In a second step, we used the adapted scales for a preliminary analysis aiming to investigate whether the method is applicable in a clinical group. Therefore, we compared caregiving behavior in a group of mothers at the beginning of treatment in a psychiatric mother–baby unit to that of a group of healthy mothers. Results revealed that mentally ill mothers have difficulties in all aspects of sensitivity, intrusiveness, and affect. Mothers with postpartum psychiatric disorders were found to be less responsive, respond slower, less adequate and to be more intrusive and show more negative and less positive affect toward their children. These findings are not surprising because it has been repeatedly described that postpartum depression can result in tremendous problems regarding mother–child interactions [e.g., Refs. (
A second aim was to see whether assessing different aspects of sensitivity separately would help identify typical behavior patterns of mothers with mental disorders dependent on their diagnosis or other risk factors for altered mother–child interaction. Here, we found that the severity of symptoms is an important factor influencing maternal sensitivity in the present sample. Even in the healthy group, we observed that mild depressive symptoms already reduce sensitivity, however, the effect was rather small. This is in line with recent research showing that subclinical depressive symptoms may increase hostility and negative affect (
The difficulties with sensitivity and intrusiveness in depressive-only mothers have repeatedly been found in earlier studies. Responsiveness, the perception and reaction to a child’s signal, has repeatedly been shown to be lower in postpartum depression (
As general explanation, the disturbances in altered mother–child interaction are caused or accompanied by altered brain activation. Mothers with postpartum depression have shown weaker activation of reward and motivation areas, such as the thalamus, nucleus accumbens, caudate, and key emotion regulation areas, such as the lateral orbitofrontal cortex (
In our subsample, mothers with depression and anxiety comorbid presented another behavioral pattern. This group showed deficits in all scales, except promptness, which may represent the increase of impairment caused by the double diagnosis.
Earlier findings on maternal anxiety describe mothers as less responsive and withdrawing from interaction, also in trait anxiety of healthy mothers after birth [e.g., Refs. (
The finding that responsiveness, appropriateness, and intrusiveness are worsened in comorbidly ill mothers may reflect a commonality with depressed mothers’ behavior, namely, that they act more parent-centered and less intuitive. The constant alertness reflected in the promptness scale could give a hint to their inner conflict between “waiting for signals” and “not being able to react flexible.” This conflict is also visible on the affect scale because they show less cheerful play and more negative affect mimically and verbally, more distressed behavior, or emotional flattening. Negative affect in maternal anxiety has been observed through stress and sorrowful behavior (
In sum, the presented scales successfully identify specific deficits in mother–child interaction of mothers with postpartum psychiatric disorders. It further shows that these deficits differ depending on the diagnosis or comorbidity of mothers and thus provide simplifications for tailored therapeutic intervention. Although for depressed-only mothers, a training on improving appropriate reactions and on understanding of infant’s signals and needs might be sufficient, mothers with depression and anxiety comorbidity may need further support in their own emotion regulation. Our method is very detailed, but it is still closely related to the concept of sensitivity. Therefore, it is suited for the investigation of maternal behavior as a predictor of later attachment security.
Results of our study are based on a group of healthy mothers and a subgroup of mothers admitted in a psychiatric/psychosomatic Mother-Baby-Day-Unit Nuremberg or Dresden. Healthy and nonhealthy mothers did not differ in their educational degree or age. One limitation was that the children of clinical mothers were younger than those of the control group because of a change of admission requirements in the hospital while the study was still ongoing. However, there was no correlation of the scales with child’s age.
Behavioral assessment was located differently for clinical and healthy mothers that may have caused different levels of stress or comfort during observation.
Another limitation of the study is the rather small sample size in the group with comorbidities with respect to the fact that they are diagnosed with different and/or several anxiety disorders. Anxiety disorders manifest in a wide range: generalized anxiety disorder, OCD, panic disorder, and birth-related PTSD. In the postpartum period, sometimes the severity and symptoms do not rise to the level of an anxiety disorder diagnosis (e.g., hypervigilant concerns and attention for the baby, extreme lability, constant worry) but nevertheless can cause significant distress and disturb mother–child interactions (
During development of the method, it was noted repeatedly that “responsiveness” and “promptness” correlate highly significantly and were difficult to separate. We thought about combining these two scales again as the NICHD-ECCN Scale does but decided to keep them separate. First, we found “promptness” to differentiate between depressed-only and depressed-anxious mothers, as presented above. Second, during scale adaptation, we often found single videos (psychosis or very severe depression), where the difference was more obvious as responsiveness was very delayed. Third, all scales correlate with each other what is typical in this research sector. All EA Scales (
A related discussion concerns the scaling of the subunits. A rank of 3 (the mean) relates to a mother who behaves a bit more often with good caregiving skills than bad. Healthy mothers rank relatively high (around 4 from 5). Our present clinical subsample ranges from 5 to 2; only in training videos did we find ratings of 1. Why is this so and should we have adapted the scaling? The scale is not conceptualized to separate very good from perfect maternal behavior. With a rank of 4 or 5, we can assume that the behavior in the observed sequence was ideal. It must be noted that the situation was short had only little instruction. A healthy mother often knows how to perform ideally and can act so for a certain amount of time in stress-free situations. Mentally ill mothers are not necessarily “disturbed” in their sensitivity but limited in their capacities (
In hospital routine, we implemented video observations with a length of 10 min displaying diaper-changing situations and free play. Especially in the group of mentally ill mothers, videos from the beginning of our studies were strikingly shorter. Whereas the CARE-index requires 3 min of observation of mother–child interaction only, the EA Scales (
According to our clinical observations, mentally ill mothers seem to lack ideas for interactive play that may evoke feelings of insufficiency in the face of a given play task. If in future studies, higher differences between the groups are favored, stress in observation situation can be increased by using more difficult tasks or observe mothers with siblings (
The present adapted method is useful to measure sensitivity in postpartum psychiatric disorders. Moreover, it should allow testing for relationships to attachment qualities with later strange situation procedures. Still, the next phase of research includes validation work with other observational tools and measures of attachment. Moreover, an extension of the sample with other diagnoses as psychosis and OCDs is planned. Analyses for further understanding of the disorder and its relation to maternal behavior and then child outcome are prospects. Of further importance in the group of mothers with postpartum psychiatric disorders is the interplay of genetic and caregiving influences in the prediction of attachment and further development of the child. It could be shown that higher maternal sensitivity can be a buffer for disorganized attachment in cases of genetic risk (
To describe the full spectrum of deficits in mother–child interaction, risk and protection factors for altered sensitivity postpartum psychiatric disorders should be assessed. Own childhood experiences are a crucial factor for the quality of sensitivity, with adverse experiences leading to less sensitivity, whereas positive experiences make warm and sensitive parenting more likely (
This study was carried out in accordance with the Declaration of Helsinki and the permission and recommendations of the Ethics Committee of the Friedrich-Alexander University Erlangen Nuremberg and the Ethics Committee of Technical University Dresden (Ethics committee of the FA: 320_15 B, Ethics committee of the TU: EK450 22013). All participants gave written and informed consent. For all data concerning children, written informed consent was obtained from the parents.
CH and MG designed and conducted the study, created the manual, and wrote the manuscript. SG was involved in study design, setup of the manual, assessment of control group, and editing the manuscript. JJ-H and SS were involved in study design and assessment of the clinical group and editing the manuscript. JF worked on the manual and the introduction. GS was involved in study design, edits on the manual, statistics and edits on the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We thank Melanie Tamara Kungl and Jennifer Schneider for editing the manuscript, and Julia Fenkl, Melanie Lindner, Tina Riedl, Sonja Rapp, and Sarah Schwab for observation of mother–child interaction, and Martin Schmucker for help regarding statistics.
The Supplementary Material for this article can be found online at: