Research using MORS-SF
Milford, R. and Oates, J. (2009) ‘Universal screening and early intervention for maternal mental health and attachment difficulties’, Community Practitioner, vol. 82, pp. 30-33.
A pilot study developed a protocol for use by health visitors in the first six to eight postnatal weeks, and repeated at nine months, to screen for the risks of maternal mental health problems and subsequent attachment difficulties. Based on this pilot, a care pathway scheme was developed to offer targeted service delivery to women and infants needing enhanced support.
This paper describes the universal screening programme and care pathway scheme that was developed, and the support offered to deliver care. Central to the pathway is the identification of three levels of concern - low, moderate and high. The assignment of clients to moderate and high concern levels initiates the delivery of additional packages of multi-agency care. The initiative also addresses the need to improve health visitor competence and confidence in detecting and responding effectively to difficulties in mother-infant relationships.
You can access the paper here: http://oro.open.ac.uk/id/eprint/17908
Davies, J., Slade, P., Wright, I. and Stewart, P. (2008) ‘Posttraumatic stress symptoms following childbirth and mothers' perceptions of their infants’, Infant Mental Health Journal, vol. 29, pp. 537 – 554.
Postpartum psychological distress can adversely affect the early mother–infant relationship; however, this has not been investigated in relation to posttraumatic stress disorder (PTSD) following childbirth. This article explores whether PTSD symptoms relating to labor and delivery are associated with mothers' early perceptions of their infant. Using labor and childbirth as the stressor criterion, 211 women were assessed at 6 weeks' postpartum for symptoms of intrusions, avoidance, and hyperarousal. Their perceptions of their infants, of mother-to-infant attachment, and infant behavioral characteristics also were evaluated. In sum, 3.8% of the women fulfilled full diagnostic criteria, and a further 21.3% reported clinically significant symptoms on at least one dimension of PTSD. Those meeting full or partial criteria perceived their attachment relationships to be significantly less optimal and reported more negative maternal representations in terms of their infants being less warm and more invasive. They also rated them as being temperamentally more difficult, prone to distress, and less easy to soothe. However, when the effects of depression were partialled, only the effect for perceived warmth remained. Posttraumatic stress symptoms relating to labor and delivery may adversely influence maternal perceptions of infants, with potentially adverse implications for the developing mother–infant relationship. The overlap with depressive symptoms requires further exploration.
Coo, S., Somerville, S., Matacz, R. and Byrne, S. (2018) ‘Development and preliminary evaluation of a group intervention targeting maternal mental health and mother–infant interactions: a combined qualitative and case series report’, Journal of Reproductive and Infant Psychology, vol. 36, pp. 327–343.
Objective and Background: The purpose of this study was to investigate the outcomes of an Emotional Wellbeing Group intervention developed to treat maternal depression and anxiety while concurrently supporting positive development of the mother–infant relationship.
Method: Five women diagnosed with depressive and/or anxiety disorders and their infants completed the Emotional Wellbeing Group. The participants completed pre- and post- intervention assessments which included self-report measures of mood and the motherhood experience, and a video-taped, unstructured play session between mothers and their infants.
Results: Four of the participants reported a clinically significant decrease in their symptoms of anxiety. All mothers reported more positive perceptions of their infants and their experience of motherhood, and showed enhanced maternal sensitivity and responsiveness towards their infants. Depression levels were not shown to improve consistently.
Conclusion: This study provides initial positive evidence to support future research directions and clinical efforts to develop interventions that target both the treatment of perinatal depression and anxiety and the quality of mother–infant interactions. Clinical insights for mental health professionals working with mothers and infants are presented.
McPherson, S., Andrews, L., Taggart, D., Cox, P., Pratt, R., Smith, V. and Thandi, J. (2018) ‘Evaluating integrative services in edge-of-care work’, Journal of Social Welfare and Family Law, vol. 40, pp. 299–320.
Children living on ‘the edge-of-care’ are typically known to local safeguarding authorities and are considered likely to face risks to their safety. Many are subject to a child protection plan and/or involved in ‘pre-proceedings’ processes. A growing number of their parents face (un)diagnosed mental health difficulties as well as economic and social precarity. This article draws on a mixed methods evaluation of a pilot service in the East of England offering a therapeutically led attachment-based intervention for families. The service cross-cuts health and social care, allowing psychologists and psychotherapists to work alongside social workers and other practitioners. The evaluation examined psychological and safeguarding
outcomes and explored practitioner perspectives. A key outcome was that 85.4% of families were enabled to remain, or reunite with their child, compared with an estimated 50% of ‘edge-of-care’ cases nationally. This supports the need for similarly oriented interventions that could help lower the incidence of child removals.
Fonagy, P., Sleed, M. and Baradon, T. (2016) ‘Randomized controlled trial of parent–infant psychotherapy for parents with mental health problems and young infants’, Infant Mental Health Journal, vol. 37, pp. 97–114.
There is a dearth of good-quality research investigating the outcomes of psychoanalytic parent–infant psychotherapy (PIP). This randomized controlled trial investigated the outcomes of PIP for parents with mental health problems who also were experiencing high levels of social adversity and their young infants (<12 months). Dyads were clinically referred and randomly allocated to PIP or a control condition of standard secondary and specialist primary care treatment (n = 38 in each group). Outcomes were assessed at baseline and at 6-month and 12-month follow-ups. The primary outcome was infant development. Secondary outcomes included parent–infant interaction, maternal psychopathology, maternal representations, maternal reflective functioning, and infant attachment. There were no differential effects over time between the groups on measures of infant development, parent–infant interaction, or maternal reflective functioning. Infant attachment classifications, measured only at the 12-month follow-up, did not differ between the groups. There were favorable outcomes over time for the PIP-treated dyads relative to the control group on several measures of maternal mental health, parenting stress, and parental representations of the baby and their relationship. The findings indicate potential benefits of parent–infant psychotherapy for improving mothers’ psychological well-being and their representations of their baby and the parent–infant relationship.
Bhopal, S., Roy, R., Verma, D., Kumar, D., Avan, B., Khan, B., et al. (2019) ‘Impact of adversity on early childhood growth & development in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS)’, PLoS ONE, vol. 14, e0209122.
Introduction: Early childhood development is key to achieving the Sustainable Development Goals and can be negatively influenced by many different adversities including violence in the home, neglect, abuse and parental ill-health. We set out to quantify the extent to which multiple adversities are associated with impaired early childhood growth & development.
Methods: This was a sub-study of the SPRING cluster randomised controlled trial covering the whole population of 120 villages of rural India. We assessed all children born from 18 June 2015 for adversities in the first year of life and summed these to make a total cumulative adversity score, and four subscale scores. We assessed the association of each of these with weight-for-age z-score, length-for-age z-score, and the motor, cognitive and language developmental scales of the Bayley Scales of Infant Development III assessed at 18 months.
Results: We enrolled 1726 children soon after birth and assessed 1273 of these at both 12 and 18 months of age. There were consistent and strongly negative relationships between all measures of childhood adversity and all five child growth & development outcome measures at 18 months of age. For the Bayley motor scale, each additional adversity was associated with a 1.1 point decrease (95%CI -1.3, -0.9); for the cognitive scales this was 0.8 points (95%CI -1.0, -0.6); and for language this was 1.4 points (95%CI -1.9, -1.1). Similarly for growth, each additional adversity was associated with a -0.09 change in weight-for-age z score (-0.11, -0.06) and -0.12 change in height-for-age z-score (-0.14, -0.09).
Discussion: Our results are the first from a large population-based study in a low/middle-income country to show that each increase in adversity in multiple domains increases risk to child growth and development at a very early age. There is an urgent need to act to improve these outcomes for young children in LMICs and these findings suggest that Early Childhood programmes should prioritise early childhood adversity because of its impact on developmental inequities from the very start.
Lefkovics, E., Rigó, J. Jr., Kovács, I.,Talabér, J., Szita, B., Kecskeméti, A., Szabó, L., Zsolt Somogyvári, Z. and Baji, I. (2018) ‘Effect of maternal depression and anxiety on mother’s perception of child and the protective role of social support’, Journal of Reproductive and Infant Psychology, vol. 36, pp. 434-448.
Objective: The purpose of this study was to investigate the impact of postpartum depressive and anxiety symptoms on maternal perception of the infant and the protective role of social support.
Background: Adverse effects of perinatal depression on mother–child interaction are well documented; however, the role of maternal perception has not been examined.
Methods: We used the data of 431 women enrolled in a prospective study in a single maternity unit. Depressive and anxiety symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), the State Trait Anxiety Inventory (STAI), and the mother’s perception of infant with the Mother’s Object Relation Scale (MORS). We used Multidimensional Scale of Perceived Social Support (MSPSS) in order to measure social support.
Results: Depressive and anxiety symptoms were positively associated to less positive emotions and a more dominant attitude of child as perceived by mothers. This association was even more significant in the case of trait anxiety. Perceived social support has been found to be a protective factor which was able to reduce this tendency.
Conclusion: The findings have potential implications for our understanding of the impact of maternal depressive and anxiety symptoms on the developing mother–infant relationship.
Wan, M. W., Downey, D., Strachan, H., Elliott, R., Williams, S. R., and Abel, K. M. (2014) ‘The neural basis of maternal bonding’, PLoS ONE, vol. 9, e88436.
Background: Accumulating evidence suggests that mothers show a different pattern of brain responses when viewing their own compared to other infants. However, there is inconsistency across functional imaging studies regarding the key areas involved, and none have examined relationships between brain and behavioural responses to infants. We examined the brain regions activated when mothers viewed videos of their own infant contrasted with an unknown infant, and whether these are associated with behavioural and self-reported measures of mother-infant relations.
Method: Twenty right-handed mothers viewed alternating 30-sec blocks of video of own 4–9 month infant and an unfamiliar matched infant, interspersed with neutral video. Whole brain functional magnetic resonance images (fMRI) were acquired on a 1.5T Philips Intera scanner using a TR of 2.55 s. Videotaped mother-infant interactions were systematically evaluated blind to family information to generate behavioural measures for correlational analysis.
Results: Enhanced blood oxygenation functional imaging responses were found in the own versus unknown infant contrast in the bilateral precuneus, right superior temporal gyrus, right medial and left middle frontal gyri and left amygdala. Positive mother-infant interaction (less directive parent behaviour; more positive/attentive infant behaviour) was significantly associated with greater activation in several regions on viewing own versus unknown infant, particularly the middle frontal gyrus. Mothers’ perceived warmth of her infant was correlated with activations in the same contrast, particularly in sensory and visual areas.
Conclusion: This study partially replicates previous reports of the brain regions activated in mothers in response to the visual presentation of their own infant. It is the first to report associations between mothers’ unique neural responses to viewing their own infant with the quality of her concurrent behaviour when interacting with her infant and with her perceptions of infant warmth. These findings provide support for developing fMRI as a potential biomarker of parenting risk and change.
Coster, D., Brookes, H. & Sanger, C. (2015) ‘Evaluation of the baby steps programme: pre and post measures study’, London: NSPCC.
The NSPCC has been running a new antenatal programme for vulnerable parents called Baby Steps, which aims to support mothers and fathers during pregnancy and in the weeks after birth. Self-report questionnaires were used to look at the changes experienced by parents who had attended the programme. Positive changes across a range of outcomes were reported, including:
- Both mothers and fathers reported an increase in their attachment to their unborn baby.
- Parents’ feelings of warmth towards their baby increased during the programme, but the change was greater for mothers than for fathers.
- Mothers who had completed Baby Steps reported lower rates of adverse birth outcomes (i.e. premature birth, low birth weight and Caesarean section) compared with the general population, though it is not known whether this was representative of all mothers who attended the programme.
- Parents’ relationship satisfaction with their partners remained stable throughout the programme, for those who had the lowest levels of relationship satisfaction at the start of the programme their satisfaction improved.
- Both mothers and fathers reported a decrease in anxiety between the start and the end of the programme.
- Parents with moderate or high levels of depression reported a decrease in symptoms by the end of the programme.
- Parents’ self-esteem had increased slightly by the end of the programme. Research suggests that such improvements will increase the capacity of parents to care for and nurture their baby and will ultimately lead to better outcomes for children.
Overall, the findings indicate that Baby Steps is a promising intervention. However, as the study did not include a comparison group, more research is needed to be sure that improvements in outcomes were the direct result of the programme.
Deierl, A., Platonos, A.A. and Banerjee, J. (2018) ‘Evaluation of parental experience post-discharge and development of a parent focus group’, Journal of Neonatal Nursing, vol. 24, pp. 21-28.
The aim of the Integrated Family Delivered Neonatal Care (IFDC) project is to improve parent-experience, parent-infant bonding, parental mental health, and infant health outcomes by pioneering a new care model at Imperial College Healthcare NHS Trust based on international evidence. It is particularly challenging to measure parent experience in neonatology, and there isn't a uniform internationally accepted tool for this. Understanding parents' experiences is vital to understand how quality of care can be improved. As parents are in a very vulnerable situation in the neonatal unit progressing on an often long, unpredictable and complicated journey, special approach and tools are needed to distill their overwhelming experience.
Within the expanse of the Quality Improvement project we hoped to focus and achieve the following objectives:
- To develop a sustainable feedback model for parent experience to collect feedback on neonatal care using validated tools.
- To establish a parent focus group to collect feedback about our care and to create an experience co-designed parent educational material for our project.
Chasson, M., Ben‑Yaakov, O. and Ben‑Ari, O. (2021) ‘Meaning in Life among New Mothers before and during the COVID‑19 Pandemic: The Role of Mothers’ Marital Satisfaction and Perception of the Infant’, Journal of Happiness Studies, vol. 22, pp. 3499-3512.
On the assumption that existential questions may arise in the face of the transition to motherhood in the shadow of a global crisis, we sought to compare the levels of presence of meaning and search for meaning in life between two samples of new mothers: one recruited before the outbreak of COVID-19, and the other during the pandemic. In addition, we examined the associations between mother’s marital satisfaction and perception of the infant on the one hand, and the two aspects of meaning in life on the other, investigating whether these variables mediate the link between research group and meaning in life. The results indicate that mothers reported significantly higher perception of infant’s warmth and presence of meaning before than during the pandemic. Furthermore, they displayed greater marital satisfaction and more search for meaning during the pandemic than prior to it. For the whole sample, higher marital satisfaction and perception of infant’s warmth were related to higher presence of meaning, and lower marital satisfaction and perception of the infant’s invasiveness were related to higher search for meaning. Finally, mother’s marital satisfaction and perception of the infant fully mediated the relationship between the research group and the two aspects of meaning in life. These findings are significant in that they provide, for the first time, evidence of changes in meaning in life among new mothers in a crisis situation, along with the importance of their perceptions of their relationships with the infant and spouse under these circumstances.
Sleed, M., Baradon, T. and Fonagy, P. (2013) ‘New Beginnings for mothers and babies in prison: A cluster randomized controlled trial’, Attachment & Human Development, vol. 15, pp. 349-367.
Mothers in prison represent a high-risk parenting population. New Beginnings is an attachment-based group intervention designed specifically for mothers and babies in prison. This cluster randomized trial examined the outcomes for 88 mothers and babies participating in the New Beginnings program and 75 dyads residing in prisons where the intervention did not take place. Outcomes were measured in terms of parental reflective functioning, the quality of parent-infant interaction, maternal depression, and maternal representations. Mothers in the control group deteriorated in their level of reflective functioning and behavioral interaction with their babies over time, whereas the mothers in the intervention group did not. There were no significant group effects on levels of maternal depression or mothers’ self-reported representations of their babies over time. An attachment-based intervention may mitigate some of the risks to the quality of the parent–infant relationship for these dyads.
Abel, K.M., Elliott, R.E., Downey, D., Strachan, H., Elmadih, A., Wieck, A., Williams, S., Crowell, J. and Wan, M.W. (2018) ‘Preliminary evidence for neural responsiveness to infants in mothers with schizophrenia and the implications for healthy parenting’, Schizophrenia Research, vol. 197, pp. 451-457.
Schizophrenia is a severe mental illness that may significantly affect maternal sensitive behaviour. Neural correlates of maternal behaviour represent a potentially valuable means of differentiating objectively between healthy mothers expressing variations in maternal sensitivity. As mothers with schizophrenia (MWS) show deficits in behavioural responses to infants compared to healthy mothers, we explored whether maternal brain responses to infant stimuli would be significantly reduced in MWS. We also examined whether differences in maternal behaviour between healthy and ill mothers (during play interactions with own infant) were associated with differences in brain activation to infant stimuli. We found no evidence of differential ‘maternal brain’ responses or ‘maternal behavioural’ responses in 11 new MWS compared to 20 healthy new mums; neither were neural responses to infants linked to behavioural or cognitive aspects of the mother's relationship with her infant in MWS. These preliminary findings suggest maternal sensitivity differences between MWS and healthy mothers, suggested in previous studies, may be reversible in stable treated MWS.
Jones, R., Slade, P., Pascalis, O. and Herbert, J.S (2013) ‘Infant interest in their mother’s face is associated with maternal psychological health’, Infant Behavior & Development, vol. 36, pp. 686-693.
Early experience can alter infants’ interest in faces in their environment. This study investigated the relationship between maternal psychological health, mother–infant bonding and infant face interest in a community sample. A visual habituation paradigm was used to independently assess 3.5-month-old infants’ attention to a photograph of their mother’s face and a stranger’s face. In this sample of 54 healthy mother-infant pairs, 57% of mothers (N = 31) reported symptoms of at least one of stress response to trauma, anxiety, or depression. Interest in the mother-face, but not stranger-face, was positively associated with the mother’s psychological health. In regression analyses, anxiety and depression predicted 9%of the variance in looking to the mother-face. Anxiety was the only significant predictor within the model. No direct associations were found between mother–infant bonding and infants’ face interest. Taken together, these findings indicate that infant’s visual engagement with their mother’s face varies with maternal symptoms of emotional distress, even within a community sample.
McDonald, S., Pauline Slade, P., Spiby, H. & Iles, J. (2011) ‘Post-traumatic stress symptoms, parenting stress and mother-child relationships following childbirth and at 2 years postpartum’, Journal of Psychosomatic Obstetrics & Gynecology, vol. 32(3), pp.141–146.
This study examined the prevalence of childbirth-related post-traumatic stress (PTS) symptoms at 2 years postpartum and the relationship between such symptoms and both self-reported parenting stress and perceptions of the mother-child relationship. 81 women completed measures of childbirth-related PTS symptoms at 6 weeks and 3 months postpartum; these results were used in an exploration of their predictive links with mother-child relationship and parenting measures at 2 years. 17.3% of respondents reported some PTS symptoms at a clinically significant level at 2 years postpartum. However, these symptoms were only weakly linked to parenting stress and were not related to mothers’ perceptions of their children. However earlier PTS symptoms within 3 months of childbirth did show limited associations with parenting stress at 2 years but no association with child relationship outcomes once current depression was taken into account. Implications for clinical practice and the concept of childbirth-related posttraumatic stress disorder are discussed.
B. Szabó, B. & Miklósi, M. (2022) ‘The relationship between mothers’ attachment style, mindful parenting, and perception of the child’, European Psychiatry (conference paper EPP 0719).
Introduction: Maternal attachment style plays a major role in the intergenerational transmission of psychopathology. Previous studies indicated that a secure attachment style is associated with higher levels of mindfulness and a higher quality of the parent-child relationship.
Objectives: The aim of this study was to explore the relationship between the mothers’ attachment style, mindful parenting, and perception of the child.
Methods: Data were collected from 144 non-clinical mothers, who have a child below the age of 3 years. Mothers completed self-report questionnaires including the following scales: a demographic questionnaire, Attachment Style Questionnaire (ASQ), Interpersonal Mindfulness in Parenting Scale (IMP), and the Mothers’ Object Relations Scale (MORS-SF). Mediation analyses with Mothers’ Object Relations Scale warmth and invasion subscales as dependent variables, mother’s attachment style as an independent variable and mindful parenting as a mediator were conducted.
Results: In mediation analysis, the direct effects of the mothers’ attachment style on the perception of the child were not significant. However, indirect effects through mindful parenting were significant; higher levels of mindful parenting were associated with higher levels of MORS-SF warmth and lower levels of MORS-SF invasion.
Conclusions: These findings suggest that attachment styles are related to the perception of the child through mindful parenting. Mindfulness-based parenting training might be useful in case of attachment-related problems to improve the parent-child relationship.
Armstrong, V.G., & Ross, J. (2022) ‘Art at the Start: A controlled trial and close observation of parent-infant art therapy intervention ‘, PsyArXiv.
Objective: This two-part study seeks to evidence an art therapy intervention for parent-infant attachment relationships, looking at the improvements to the parents’ wellbeing and attachment perception and the changes in the infants’ experiences with their caregiver.
Method: Study one was a controlled trial with 105 participating parent/caregivers and their infants between 0 and 3 years, identified due to concerns about their relationship. They were quasi randomised to attend a 12-week art therapy group or treatment as usual. Measures were collected focused on the parents’ wellbeing and their perceptions of their infant. In study 2 a sample of 37 dyads had video footage from their first and penultimate sessions analysed to look for observable changes in the different channels of communication upon which attachments are predicated.
Results: The control trial showed intervention participants had significantly improved parental wellbeing, significant increases in attachment warmth and significant decreases in intrusion. This was in contrast to the control sample who showed a significant decrease in wellbeing, stable warmth, and significant increases in intrusion. The observation study showed that there was a significant increase in the communicative behaviours from the parents to the infant which would support attachments between the first and penultimate sessions.
Conclusions: We conclude that this intervention showed beneficial outcomes for parents and infants when compared with treatment as usual and therefor makes a robust case for the inclusion of art therapy intervention within the interventions available to improve attachment outcomes for at risk early relationships.
Cheung, S.L.F. (2018) ‘Impact of Maternal Childbirth Trauma on Mother-Child Bonding, PTSD and Depression’, Alliant International University. (Doctoral thesis).
Maternal childbirth trauma describes a range of adverse experiences that can occur during and after childbirth, including danger to the mother or child, unplanned emergency procedures and negative interactions with those present during the birth. Existing research reveals that mothers who experienced negative childbirth experiences may develop postpartum posttraumatic stress symptoms and impaired bonding with their children. There is a need for research in Hong Kong evaluating the relationship between negative childbirth experiences and long-term outcome such as postnatal posttraumatic stress, depression and problems in mother-child bonding. In the present study, 170 mothers who indicated that they had a stressful childbirth experience sometime during the past three years completed demographic measures, measures of childbirth experience including the Childbirth Experience Questionnaire, two measures of maternal-child bonding (the Mothers Object Relations Scale – Short Form and the Maternal Postpartum Attachment Scale), and two measures of emotional problems (the Patient Health Questionnaire-9 evaluating depression and the Impact of Events Scale – Revised measuring posttraumatic symptoms). Approximately 15.3% and 21.3% of the sample reported posttraumatic and depression symptoms within clinical ranges, respectively. Pairwise correlational analyses showed that income, education, history of psychiatric problems during pregnancy, and negative childbirth experience (but not time since the childbirth) predicted poorer maternal-child bonding, posttraumatic and depression symptoms. Of all sources of childbirth stress, the experience of conflictual information and confrontational interactions with medical staff during childbirth appear to be most related to posttraumatic and depression symptoms and poorer maternal bonding. Hierarchical multiple regression analyses showed that, after controlling for demographic variables, negative childbirth experience predicts a significant degree of variance in maternal-child bonding, effects that are mediated by posttraumatic stress and depression. Thematic analysis of an open-ended question regarding impact of childbirth experience on mothers’ lives identified core themes such as mothers’ concerns for their and their child’s physical health, psychological distress, and concerns about future pregnancies. Mothers also reported continued negative memories related to communication with medical staff during labour and delivery. Practical implications for clinical psychology, hospital policy and future research are discussed.
(Order No. 10813400). Available from ProQuest Dissertations & Theses Global. (2040829357).
Cameron, J. & Shepherd, A.L. (2018) ‘Evaluation of outcomes from an evidence-based programme for mothers and babies’, Journal of Health Visiting, vol. 6 (10), pp. 499-505.
This article describes the development and testing of an 8-week group-based intervention for mothers and babies in County Armagh, Northern Ireland. The components of the intervention were evidence-based and included baby massage, baby yoga, video feedback and information on infant brain development. Mothers were encouraged to reflect on how they were brought up and the impact that had on their own parenting. The study compared 33 mother–baby intervention dyads with a control group of 33 dyads. The pre- and post-intervention measures included video-recorded play interactions and questionnaires about mothers' positive feelings towards their babies and overall mental health. The results showed no differences between the groups after intervention and no improvement in either group. This article considers how and why evidence-based techniques might have failed to produce evidence of change.