Ming Wai Wan

The impact of maternal psychopathology on child–mother attachment

This review aims to consider evidence for the impact of maternal psychopathology on the child’s attachment to the mother, and the role of this in mediating the known transmission of developmental and clinical risk to children. The studies reviewed focus on mothers with depression and psychotic disorder. A number of studies (mainly of mothers with depression) demonstrate an association between insecure/disorganised infant attachments and severe maternal psychopathology, whether chronic or current, in the presence of comorbid disorder, maternal insecure or unresolved attachment state of mind, trauma/loss, or low parenting sensitivity. Whether such effects last into middle childhood, however, is unclear. Our understanding of the role of attachment in determining developmental trajectories in this group is at an early stage. Some evidence suggests that attachment may have a role in mediating the intergenerational transmission of internalising and other problems in this group, although the presence of co-occurring contextual risk factors may account for the variability in findings. A multifactorial longitudinal approach is needed to elucidate such factors. However, the current literature highlights which subgroups are likely to be vulnerable and provides an evidence-based rationale for taking an attachment-based approach to intervention in this group.

Quality of interaction between at-risk infants and caregiver at 12–15 months is associated with 3-year autism outcome

BACKGROUND   Recent models of the early emergence of autism spectrum disorder (ASD) propose that infant intrinsic risk susceptibilities in behaviour may be amplified by interaction within the early social environment into an increasingly atypical developmental trajectory. This study examines whether 6- and 12-month parent-infant interactions in at-risk siblings differ from those with low-risk and whether--in at-risk siblings--such interactions predict later 3-year classification of ASD or no ASD. METHOD   Within the British Autism Study of Infant Siblings (BASIS), 6-min videotaped episodes of parent-infant free play in infants at 6-10 months (45 at-risk siblings and 47 low-risk siblings) and 12-15 months (43 at-risk siblings and 48 low-risk siblings) in a laboratory setting were rated on the Manchester Assessment of Caregiver-Infant Interaction (MACI), blind to participant information. Standard tests were administered for concurrent behavioural signs of ASD features and developmental level. Systematic consensus diagnostic classification of ASD was made at 3 years for the at-risk siblings. RESULTS   Parent nondirectiveness and sensitive responsiveness differed in relation to ASD/risk status (at-risk ASD, at-risk no-ASD and low-risk) at both 6 and 12 months. At 6 months, infant liveliness was lower in the at-risk groups; at 12 months, infant attentiveness to parent and positive affect were lower in the at-risk group later diagnosed with ASD. Dyadic mutuality and intensity of engagement showed a group effect at 12 months. Dyadic mutuality, infant positive affect and infant attentiveness to parent at 12 months (but not 6 months) predicted 3-year ASD outcome, whereas infant ASD-related behavioural atypicality did not. CONCLUSIONS   This is the first prospective evidence that early dyadic interaction between at-risk infants and their parents is associated with later diagnostic outcome in ASD. Possible explanations for these findings and their theoretical implications are considered.

Parent-infant interaction in infant siblings at risk of autism

Recent models of the early emergence of autism spectrum disorder (ASD) propose an interaction between risk susceptibility and the infants social environment, resulting in a progressively atypical developmental trajectory. The infants early social environmental experience consists mostly of interaction with caregivers, yet there has been little systematic study of early parent-infant interaction in infants at risk of ASD. This study examined the global characteristics of parent-infant interaction in 6- to 10-month-old infants with an older sibling diagnosed with ASD (at-risk sibs), in comparison with a group of infants with no family history of ASD (low-risk sibs). As part of the British Autism Study of Infant Siblings (BASIS), 6-min videotaped unstructured play interactions of mother-infant dyads (45 at-risk sibs and 47 low-risk sibs) were rated on global aspects of parent-infant interaction, blind to participant information. Differences in global characteristics of interaction were observed in both infant and parent contributions in the at-risk group compared to low-risk controls. In analyses adjusted for age and developmental level, at-risk sib infants were less lively, and their parents showed higher directiveness, and lower sensitive responding (as a trend after adjustment). Level of infant liveliness was independent of other interactive behaviour. Consistent with reports in previous literature in older children with autism and in other neurodevelopmental disorders, our findings may suggest that infants at genetic risk are exposed to a more directive interactive style relatively early in infancy. We discuss possible explanations for these findings and implications for further developmental study and intervention.

Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial

Summary Background Risk markers for later autism identified in the first year of life present plausible intervention targets during early development. We aimed to assess the effect of a parent-mediated intervention for infants at high risk of autism on these markers. Methods We did a two-site, two-arm assessor-blinded randomised controlled trial of families with an infant at familial high risk of autism aged 7–10 months, testing the adapted Video Interaction to Promote Positive Parenting (iBASIS-VIPP) versus no intervention. Families were randomly assigned to intervention or no intervention groups using a permuted block approach stratified by centre. Assessors, but not families or therapists, were masked to group assignment. The primary outcome was infant attentiveness to parent. Regression analysis was done on an intention-to-treat basis. This trial is registered with ISCRTN Registry, number ISRCTN87373263. Findings We randomly assigned 54 families between April 11, 2011, and Dec 4, 2012 (28 to intervention, 26 to no intervention). Although CIs sometimes include the null, point estimates suggest that the intervention increased the primary outcome of infant attentiveness to parent (effect size 0·29, 95% CI −0·26 to 0·86, thus including possibilities ranging from a small negative treatment effect to a strongly positive treatment effect). For secondary outcomes, the intervention reduced autism-risk behaviours (0·50, CI −0·15 to 1·08), increased parental non-directiveness (0·81, 0·28 to 1·52), improved attention disengagement (0·48, −0·01 to 1·02), and improved parent-rated infant adaptive function (χ2[2] 15·39, p=0·0005). There was a possibility of nil or negative effect in language and responsivity to vowel change (P1: ES–0·62, CI −2·42 to 0·31; P2: −0·29, −1·55 to 0·71). Interpretation With the exception of the response to vowel change, our study showed positive estimates across a wide range of behavioural and brain function risk-markers and developmental outcomes that are consistent with a moderate intervention effect to reduce the risk for later autism. However, the estimates have wide CIs that include possible nil or small negative effects. The results are encouraging for development and prevention science, but need larger-scale replication to improve precision. Funding Autistica, Waterloo Foundation, Autism Speaks, and the UK Medical Research Council.

What predicts poor mother-infant interaction in schizophrenia?

BACKGROUND Poor clinician-rated parenting outcome and observed interactive deficits in mothers with schizophrenia admitted to a psychiatric mother and baby unit (MBU) reflect continuing concerns over the parenting capacity of this group. However, little is known about whether interaction deficits are accounted for by severity of illness or adverse social circumstances typically experienced by these mothers. METHOD Thirty-eight women with severe perinatal illness (schizophrenia n=13; affective disorders n=25) and their infants were observed in play interaction a week prior to MBU discharge. Clinical and sociodemographic data were also obtained. RESULTS Mothers with schizophrenia and their infants were rated to have poorer interactive behaviour than the affective disorders group. Infant avoidance of the mother was associated with a lack of maternal sensitivity and responsiveness. The deficits in mother-infant interaction found in the schizophrenia group could not be accounted for by our measures of illness severity or factors relating to adverse social circumstances. CONCLUSIONS The results replicate and extend previous findings showing poor interactive behaviours in mothers with schizophrenia, their infants, and in the dyad, in a range of areas following clinical recovery. The findings suggest that factors other than illness duration, dose of medication, marital status and occupational status are explanatory for the interactive deficits associated with maternal schizophrenia. Parenting interventions that aim to improve maternal sensitivity need to be developed specifically for this group.

A review of mother–child relational interventions and their usefulness for mothers with schizophrenia

This review evaluates empirical studies that have attempted to improve observed mother–infant relationships in order to inform a potential approach for mothers with schizophrenia, a growing group of vulnerable families where mothers are known to have relational difficulties. Parenting intervention studies in: (1) mothers with a mental disorder; (2) other vulnerable groups were reviewed. Only interventions that empirically evaluated observations of mother–child interaction or child attachment were included, and their potential usefulness for mothers with schizophrenia was examined. Nine studies involved mothers with mental disorder; none involved mothers with psychotic disorder specifically. Overall, approaches that emphasise the mother–child dyad, such as sensitivity-focused behavioural techniques and toddler–parent psychotherapy, were most efficacious for improving maternal sensitivity/child attachment. Although individual psychological therapies are the more conventional treatment, little current evidence suggests that mother–infant relations improve with symptom reduction. The usefulness of the available evidence for informing interventions with mothers with schizophrenia is discussed in the context of their clinical needs. Feasibility studies are needed, which provide a focus on enhancing maternal sensitivity directly within a multi-level support package.

The service needs of mothers with schizophrenia: a qualitative study of perinatal psychiatric and antenatal workers.

OBJECTIVE The study sought to (1) understand the perspectives of perinatal psychiatric and antenatal health service workers on the service and support needs of mothers with schizophrenia; (2) obtain their views on the feasibility and potential effectiveness of a proposed parenting intervention tailored for this group. METHOD Twenty-eight perinatal psychiatry and antenatal service workers were interviewed using a semi-structured methodology, and anonymised verbatim transcripts analysed for content themes. RESULTS Many respondents felt that women with schizophrenia received insufficient postnatal support. Perceived needs were: support with adjustment/coping; parenting skills and sensitivity training; maintaining mental health; continuity of care and community support; and encouraging bonding. Service integration/continuity and social stigma were recurring themes that impacted on recommendations, such as the need for interdisciplinary communication and mental health education for midwives. The parenting program was generally well received, although many raised concerns regarding patient involvement and specific intervention characteristics. CONCLUSION The views of health workers are a valuable complement to the service user perspective. They highlight the needs of this high-risk group in their transition to motherhood, and how they might be met, as well as a need for staff training so that parenting interventions are better understood as positive prevention work.

Mother and baby unit admissions: feasibility study examining child outcomes 4–6 years on

Objective: To compare the cognitive, social cognitive, behavioural, emotional and attachment security outcomes of children whose mothers were admitted to a psychiatric mother and baby unit (MBU) with those of offspring of mothers not admitted and with standardized norms. Method: Children aged 4–6 years of mothers admitted (following childbirth) to the dedicated psychiatric MBUs in Manchester, and still living with their mother, were traced for recruitment. Observational and multi-informant measures of developmental functioning were administered during a home visit. Results: From 94 consecutive admissions, 16 children participated and showed no poorer developmental outcomes than comparison children or standardized child norms. Girls, securely attached children and children of mothers with no current mental illness tended to show the most positive outcomes. Conclusion: Possible reasons for low participant recruitment are discussed. Our provisional findings suggest that interventions should focus on improving infant attachment security, targeted at women with psychotic and chronic illness, who have no partner and/or who have a male child.

Randomised trial of a parent-mediated intervention for infants at high risk for autism: longitudinal outcomes to age 3 years

Background There has been increasing interest in the potential for pre‐emptive interventions in the prodrome of autism, but little investigation as to their effect. Methods A two‐site, two‐arm assessor‐blinded randomised controlled trial (RCT) of a 12‐session parent‐mediated social communication intervention delivered between 9 and 14 months of age (Intervention in the British Autism Study of Infant Siblings‐Video Interaction for Promoting Positive Parenting), against no intervention. Fifty‐four infants (28 intervention, 26 nonintervention) at familial risk of autism but not otherwise selected for developmental atypicality were assessed at 9‐month baseline, 15‐month treatment endpoint, and 27‐ and 39‐month follow‐up. Primary outcome: severity of autism prodromal symptoms, blind‐rated on Autism Observation Schedule for Infants or Autism Diagnostic Observation Schedule 2nd Edition across the four assessment points. Secondary outcomes: blind‐rated parent–child interaction and child language; nonblind parent‐rated communication and socialisation. Prespecified intention‐to‐treat analysis combined estimates from repeated measures within correlated regressions to estimate the overall effect of the infancy intervention over time. Results Effect estimates in favour of intervention on autism prodromal symptoms, maximal at 27 months, had confidence intervals (CIs) at each separate time point including the null, but showed a significant overall effect over the course of the intervention and follow‐up period (effect size [ES] = 0.32; 95% CI 0.04, 0.60; p = .026). Effects on proximal intervention targets of parent nondirectiveness/synchrony (ES = 0.33; CI 0.04, 0.63; p = .013) and child attentiveness/communication initiation (ES = 0.36; 95% CI 0.04, 0.68; p = .015) showed similar results. There was no effect on categorical diagnostic outcome or formal language measures. Conclusions Follow‐up to 3 years of the first RCT of a very early social communication intervention for infants at familial risk of developing autism has shown a treatment effect, extending 24 months after intervention end, to reduce the overall severity of autism prodromal symptoms and enhance parent–child dyadic social communication over this period. We highlight the value of extended follow‐up and repeat assessment for early intervention trials.

Secure attachment promotes the development of effortful control in boys.

Although effortful control (EC), a regulatory aspect of temperament, is associated with a wide range of developmental outcomes, knowledge about EC promoters is scarce. This study explored whether secure attachment promoted the development of EC from preschool to school age in a community sample of 903 Norwegian children. EC was measured using the parent-reported Children’s Behavior Questionnaire at four (T1) and six (T2) years of age, and attachment was measured using the Manchester Child Attachment Story Task at T1. Previous research has indicated that a child’s gender and socioeconomic status are possible covariates of EC; hence, these factors were included in the analyses. Despite considerable rank-order stability in EC, secure attachment contributed to an increase in EC. Furthermore, gender moderated the effect of attachment: secure attachment promoted EC in boys only. These findings emphasize preschool boys’ need for emotional security to facilitate effortful capacities in their transition to school.