Mental health assessment tools for perinatal and early childhood services and research

Research with 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.

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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.

DOI: 10.1002/imhj.20197

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.

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.

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.

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.

DOI: 10.1080/02646838.2018.1443435

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.

DOI: 10.1080/09649069.2018.1493651

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 favourable 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.

DOI: 10.1002/imhj.21553

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.


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.

This was a substudy 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.

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).

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.

DOI: 10.1371/journal.pone.0209122

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.


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.

Adverse effects of perinatal depression on mother–child interaction are well documented; however, the role of maternal perception has not been examined.

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.

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.

The findings have potential implications for our understanding of the impact of maternal depressive and anxiety symptoms on the developing mother–infant relationship.

DOI: 10.1080/02646838.2018.1475726

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.


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.

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.

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.

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.

DOI: 10.1371/journal.pone.0088436

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.


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