Primary Health Care

Research & Development

The effectiveness of Nurture and Play: a
mentalisation-based parenting group
cambridge.org/phc intervention for prenatally depressed mothers
S.J. Salo1 , M. Flykt2, J. Mäkelä3, Z. Biringen4, M. Kalland1, M. Pajulo5 and
Research R.L. Punamäki2
1
Cite this article: Salo SJ, Flykt M, Mäkelä J, Helsinki University, Helsinki, Finland; 2Tampere University, Helsinki, Finland; 3National Institute for Health and
Biringen Z, Kalland M, Pajulo M, Punamäki RL. Welfare, Helsinki, Finland; 4Colorado State University, US and 5Turku University, Helsinki, Finland
(2019) The effectiveness of Nurture and Play: a
mentalisation-based parenting group
intervention for prenatally depressed mothers. Abstract
Primary Health Care Research & Development Aim: This randomised control trial (RCT) study examined the effectiveness of a mentalisation-
20(e157): 1–11. doi: 10.1017/
S1463423619000914
based perinatal group intervention, Nurture and Play (NaP), in improving mother–infant
interaction quality and maternal reflective functioning and in decreasing depressive symptoms.
Received: 13 June 2019 Background: Few preventive prenatal interventions have been developed for primary health
Revised: 24 September 2019 care settings for mothers with depressive symptoms. Furthermore, previous prenatal interven-
Accepted: 1 November 2019
tion studies have only concentrated on reducing depressive symptoms and have not directly
Key words: addressed enhancing optimal parenting qualities. Methods: The participants were 45 pregnant
depressive symptoms; early intervention; women with depressive symptoms. Women in the randomly assigned intervention group
emotional availability; reflective functioning (n = 24) participated in the manualised, short-term NaP intervention group from pregnancy
until the baby’s age of seven months, whereas control group women received treatment as usual
Author for correspondence:
Saara J. Salo, Helsinki University, Po. Box 9. (TAU). Maternal emotional availability (EA), reflective functioning (RF) and depressive
Siltavuorenpenger 5 A, 00014 Helsinki, Finland. symptoms were measured before the intervention and at the infants’ 12 months of age, and
E-mail: [email protected] changes were evaluated using repeated measure analyses of variances (ANOVAs). Findings:
The results showed that the intervention group displayed higher maternal sensitivity and
RF and more reduction in depressive symptoms than the control group when babies were
12 months old. These findings provide preliminary support for the effectiveness of the NaP
intervention.

Maternal depressive symptoms during pregnancy represent a significant risk for foetal develop-
ment, newborn health, as well as for the infants’ later cognitive, socio-emotional and psycho-
motor development (Field, 2011; Kingston et al., 2012; Field, 2017; Gentile, 2017). Prenatal
symptoms are also likely to persist throughout the first postpartum year (Beeghly et al.,
2002; Austin et al., 2007), with a potential to interfere with optimal child development, often
through their negative impact on the early mother–infant interaction (Field, 2011).
Early interventions have predominantly focused on reducing mothers’ pre- and postnatal
depressive symptoms based on the assumption that reducing depression would decrease its
harmful consequences on parenting (Lefkovics et al., 2014; Tsivos et al., 2015; Field, 2017).
Yet, reducing mothers’ depressive symptoms alone does not appear to lead to improvements
in parenting or in infants’ well-being and development (Forman et al., 2007; Nylen et al.,
2006; Tsivos et al., 2015). Subsequently, it has been suggested that early interventions should
also focus directly on enhancing optimal mother–infant relationships already during pregnancy
and beyond and be offered in primary health care settings to increase their accessibility
(Lefkovics et al., 2014). In the present paper, we first introduce the development of an
intervention model for mothers with depressive symptoms, the Nurture and Play (NaP),
designed to enhance early maternal caregiving qualities starting from pregnancy and continuing
to infant age of seven months. Second, we describe the results of a pilot RCT study, evaluating
the effectiveness of NaP in decreasing maternal depressive symptoms, as well as enhancing
maternal reflective functioning (RF) and emotional availability (EA) in the mother–child
© The Author(s) 2019. This is an Open Access relationship.
article, distributed under the terms of the The EA perspective suggests that at the core of a healthy mother–child relationship is the
Creative Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0/), which
maternal capacity to read and respond to the infant’s emotional cues and the child’s reciprocity
permits unrestricted re-use, distribution, and of emotional responding (Biringen and Easterbrooks, 2012; Biringen et al., 2014). Maternal
reproduction in any medium, provided the EA is a multidimensional construct, comprising dimensions of maternal sensitivity, that is,
original work is properly cited. appropriate affective and behavioural responsiveness towards the child; structuring, that is,
her ability to guide, teach and set limits while remaining in contact; non-hostility, that is, good
regulation of negative affect and non-intrusiveness, that is, ability to follow child lead and to
refrain from interfering behaviour towards him/her. From the child’s side, responsiveness, that
is, appropriate affective responding towards the adult, and involvement, that is, actively seeking

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 2 S.J. Salo et al.

emotional contact with the adult, can be observed. We have shown residential treatment setting among substance-using women did
in our previous study that some of the components of EA are not find association between maternal RF and psychiatric symp-
already observable in maternal interactions towards her unborn toms (Pajulo et al., 2012). Nevertheless, it has been suggested that
child: Maternal sensitivity can be observed in her willingness to parental RF may aid the quality of dyadic interaction, especially in
communicate with the foetus baby with positive emotions, and times of heightened distress as it allows mothers to step back from
maternal non-hostility can be observed in the lack of hostile affects their immediate affective experience and have the capacity to
and behaviours towards the foetus baby (Salo et al., 2019). reflect on their child’s internal experience (Fonagy et al.,1991;
Previously, these kinds of responses have also been described as Slade et al., 2005). Therefore, in NaP, we focused directly on
parts of intuitive parenting, referring to the biological predisposi- improving the maternal skills for RF starting already from
tion for human parenting (Papoušek and Papoušek, 2002). pregnancy.
With regard to prenatal depressive symptoms, some research Several programs aiming to prevent and/or reduce maternal
shows that mothers with prenatal depressive symptoms display depressive symptoms have been described in the literature.
lower levels of emotional attachment towards the foetus Effective treatment models include interpersonal and cognitive
(Alhusen, 2008; Yarcheski et al., 2009). Furthermore, early post- therapies as well as focused prevention programs involving a com-
natal mother–infant interactions are crucial for infant well-being bination of psychoeducation about infant development and attach-
and development, as infants are dependent on the caregiver’s ment and ways to strengthen peer social support (Elliott et al.,
aid in their emotion and stress regulation and cognitive learning 2000; Zlotnick et al., 2001; Zlotnick et al., 2006; Claridge, 2014;
(Sroufe, 2000; Calkins and Hill 2007). Infants typically tune their Field, 2017). Further, yoga-based treatment (Narendran et al.,
emotional signals towards the mother’s voice, gestures, movements 2005; Field et al., 2013) and massage therapy (Field et al., 2010)
and facial expressions (Trevarthen, 1998). Maternal depression can have also been found effective.
thus influence infant’s affective states and emotional responses However, interventions focusing on maternal mood disorders
(Tronick and Reck, 2009). Depressive mothers typically show flat alone have not been found to be sufficient to buffer infant develop-
and unexpressive facial expressions with the infant, and ample ment or mother–infant interaction quality (Nylen et al., 2006;
evidence shows low levels of EA among mothers with postpartum Forman et al., 2007; Poobalan et al., 2007; O’Hara, 2009; Tsivos
depression (Easterbrooks et al., 2000; Van Doesum et al., 2007). et al., 2015). Even though maternal mood may improve, the
Research also indicates the protective influence of sensitive and negative effect of maternal mood disorders on parent–child inter-
positive dyadic interactions, even against a backdrop of maternal action may continue to be manifest. For example, adult-focused
depression. Hayes et al. (2013) found that severe prenatal maternal psychotherapy has been found to be ineffective in sufficiently
depressive symptoms did not predict infant’s disorganised attach- increasing maternal responsiveness or in improving child
ment at 12 months, if the postnatal mother–infant interaction well-being from 6 to 18 months (Forman et al., 2007). Only a
involved more optimal levels of maternal warmth and positive few intervention studies have focused on intervention models with
regard. Likewise, maternal postnatal major depression did not direct parenting components supplementing the treatment of
increase infant’s problematic social engagement at nine months, mood disorders (Tsivos et al., 2015), and even fewer begin during
if mothers showed high sensitivity in the dyadic interaction pregnancy (see Field, 2017).
(Feldman et al., 2009). Accordingly, the treatment elements in When intervention studies have focused only on the postpar-
the NaP were designed to enhance both pre- and postnatal EA. tum period, the results are mixed. For example, van Doesum
Another parenting variable relevant for healthy child develop- et al., (2008) examined the effects of a mother–child intervention
ment when mother has prenatal depressive symptoms may involve on the quality of mother–child interaction, infant–mother attach-
her RF, referring to the parental capability of explicitly describing ment security and infant socio-emotional functioning in dyads of
feelings, intentions and thoughts underlying their own and others’ depressed mothers when infants were 1–12 months old. The results
behaviour (Fonagy et al., 1991; Slade et al., 2009). Pregnancy is a showed that the intervention was effective in increasing the quality
unique phase that requires the mother to imagine the future and of mother–infant interaction. In contrast, a study using perinatal
extend her current understanding of herself, her spouse and life dyadic psychotherapy (PDP), involving both the mother and the
situation to include the child (Slade et al., 2009). Prenatal RF serves infant, did not show changes in parent–child interaction
preparation to motherhood and some research shows that high (Goodman et al., 2015).
prenatal RF, characterised by the capability of imagining oneself Taken together, there are limitations in the above-mentioned
and the future child positively, predicts high quality of parent– intervention studies. First, most focused solely on the reduction
infant interaction (Smaling et al., 2016). In the postpartum period, of depressive symptoms instead of also enhancing parenting.
parental RF is crucial for sensitive caretaking, as it fuels the Second, with few exceptions, the interventions with a dual focus
mother’s accurate understanding of the intentional states of her on parenting and depressive symptoms started only during the
infant and accurate interpretation of infant distress cues (Slade postpartum period, although it is pregnancy that is agreed to be
et al., 2005). In a recent review, high levels of parental postnatal the crucial period for later maternal mental health, parenting
RF were shown to be systematically associated with children’s and child development (Field, 2017). Third, there are mixed find-
optimal socio-emotional development (Camoirano, 2017). ings regarding effectiveness of parenting interventions in the post-
Depressive individuals, on the other hand, tend to show low levels partum period. The present study introduces a prenatal parenting
of symbolisation and willingness to explore their own inner mental intervention, the NaP, which can be offered to all new expectant
state (Luyten et al., 2012), suggestive of low RF (Slade et al., 2005). mothers with depressive symptoms with the potential to reach a
Previous studies on depression and parental RF have so far only wide population of pregnant women. The program aims to reduce
been conducted among high-risk substance-using mothers. the negative impact of depressive symptoms on the mothers, the
A study in an intervention setting found that among mothers with infants and their dyadic interaction and to strengthen maternal
substance use disorders, low level of RF was related to higher RF to enhance future mental health and optimal emotional inter-
depression (Suchman et al., 2010b), while another study in a action. First, to maximise the potential for population uptake, the

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 Primary Health Care Research & Development 3

NaP was developed to be a short-term, manualised and easily All mothers meeting the inclusion criteria (n = 51) were invited
taught, group-based intervention that requires minimal training to participate in the study, the enrolment time spanning one
of the instructors and can be implemented by multiprofessional year (4/2012 and 5/2013). The agreement rate was 92%.
primary health care professionals (e.g., psychologist, well-baby Non-participation was due to practical issues related to childcare
clinic nurse, family worker) working in primary health care set- with older siblings, marital problems and lack of motivation. The
tings. Second, the program is introduced during pregnancy and fathers – if available – were invited to the first meeting and
continues until the infant is seven months old. By then, centering home visit after birth. Although they did not take part in the study
around the ages between three and six months, the most crucial or the intervention (for intervention group), they were given
phase in the development of bio-behavioural synchrony in dyadic information about the study aims and the possibility of getting
interaction is over (Feldman, 2007). Also, as the NaP groups counselling help himself if they needed. All mothers in Finland
involve structured activities and reflective practices, for practical receive bi-monthly medical check-ups during pregnancy and six
reasons, the set-up is easier to manage before the age of around meetings after the birth until the children are 12 months
seven months, when most infants will move, crawl and require a (Hakulinen-Viitanen and Pelkonen, 2009), so both intervention
different intervention set-up suitable for their developing motor and TAU groups received these services. These routine check-
skills. Third, the NaP focuses directly on increasing maternal RF ups last about 15 min, and the main focus is on the physical
and EA in mother–infant interaction, thus strengthening the pro- well-being of the mother and the child as well as giving general
tective processes for infant development. Fourth, the intervention psychoeduation on maternal, paternal and infant psychosocial
facilitates recovery from depressive symptoms by training the well-being and infant development (Hakulinen-Viitanen and
women through cognitive and affect regulation strategies, offering Pelkonen, 2009). The control group mothers did not have any
resources and peer support and fostering access to help and con- parenting-based intervention; they also did not have a special focus
tinuity of care into the transition to parenthood. on the improvement of depressive symptoms. The authors of the
present study did the scoring and reporting of the results. We were
not involved in the data collection.
Study aims and hypotheses
The present, randomised control study examines the effectiveness Procedures
of the NaP intervention in increasing EA and maternal RF and
The design of the randomised control trial (RCT) is shown in the
reducing maternal depressive symptoms in a follow-up design
CONSORT (Moher et al., 2010) diagram in Figure 1. Before ran-
from pregnancy to one year. The hypotheses are, first, that the
domisation, all 45 mothers were seen twice during pregnancy. This
EA (i.e., maternal sensitivity, structuring, non-intrusiveness,
served as a baseline study phase, and data were collected on the
non-hostility and infant responsiveness and involvement) and
study variables, and various background factors using interviews,
RF at the age of 12 months are higher and depressive symptoms
observational measures and standardised questionnaires. After
lower in the intervention group as compared to the treatment as
random selection (by lottery), 24 mothers were invited to partici-
usual (TAU) group. Second, we examined change and hypothesise
pate in the NaP group intervention, while the rest of mothers
that the two EA dimensions observable already during pregnancy
(n = 21) served as a control group.
(i.e., maternal sensitivity and non-hostility) and maternal RF will
increase and, third, that maternal depressive symptoms will
decrease from pregnancy to one year more in the mothers in Nurture and play intervention
the intervention group than in the control group (i.e., an interac- Table 1 presents the structure and treatment elements of each
tion effect). session in relation to the three goals of NaP intervention (Salo
and Lampi, 2019). After meeting all the mothers individually (or
with the father) and doing the interviews (which also served as
Method the pre-test phase for the present study), the bi-weekly held
Pregnancy Groups started. The Baby Groups were held weekly,
Participants
with possible breaks during holidays. Each NaP session lasted
The sample consisted of 45 women invited to the project by their 1.5 h. Afterwards, there were coffee/tea servings for the group
well-baby clinic nurse. The invitation was made personally during for additional 30–45 min. The physical setting was made as
a regular check-up if their Edinburgh Postnatal Depression Scale comfortable as possible, with cushions, bean bag chairs and so
(EPDS; Murray and Cox, 1990) scores were 9 or higher and they on offered for seating. The Baby Group was invited to come
were between 22 and 31 gestational weeks. The recruitments took 15–20 min prior to the starting to give mothers time for feeding,
place in four well-baby clinics in Lahti, a Southern town in Finland. changing nappies and settling together with their baby to the
If the mothers’ scores were beyond 13, they were also guided to group. First, EA was targeted by using playful, Theraplay-based
appropriate communal adult psychiatric services unless they activities (Booth and Jernberg, 2010), such as singing, playing
already had such a contact. Four mothers already had individual musical instrument to the foetus or a postpartum, playing interac-
psychiatric contact during the project (one intervention and three tional activities such as infant massage and peek-a-boo with the
control group mothers). All parents gave their voluntary, informed infants. Theraplay is an active, adult-led, playful parent–child
consent for treatment and were informed of their rights to leave the interaction therapy. All the Theraplay-based activities are designed
treatment at any time. The authors assert that all procedures to promote affectionate contact through physical touch and reci-
contributing to this work comply with the ethical standards of procity (Pregnancy Groups) and synchrony and joint attention
the relevant national and institutional guidelines on human exper- (Baby Groups). Depressed mothers have been shown to have
imentation and with the Helsinki Declaration of 1975, as revised in specific problems in sensitive attunement, using less physical touch
2008. The ethical committee of the City of Lahti approved the and in a less affectionate manner, and using of more negative vocal
study plan. behaviour and less-infant directed speech (Field, 2010; 2011). In

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 4 S.J. Salo et al.

Enrollment 4/2012- Assessed for eligibility (n = 51)

EPDS 9 or above
5/2013

Excluded (n = 6 )

Declined to participate (n = 4)
Pre-testing at gw 22–31 Pre-test Other reasons (n = 2)

Randomisedby lottery (n = 45)

Allocation
Allocated to intervention group (n = 24) Allocated to control group (n = 21)
- Four pregnancy nurture and play sessions -Treatment as usual
- Seven baby nurture and play sessions

Post-testing at one year

Follow-Up
Lost to follow-up (n = 0) Lost to follow-up (n = 0)

Analysis
Analysed (n = 24)
Analysed (n = 21)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Figure 1. The design of the randomised control trial (RCT).

the Pregnancy NaP sessions, mothers were invited to touch their on the here and now, active and explicit acknowledging of feelings
tummies, make rhythmic movements to stimulate the foetus and thoughts and stopping non-mentalising.
and to stroke their tummies along with singing lullabies. In the Third, each session included various cognitive and affect
Baby NaP sessions, the focus was on infant massage, various regulation techniques with direct attention on handling the
songs using rhythmic movements and holding and rocking the current depressive mood and related somatosensory experiences,
infant. such as sleep and eating patterns. Cognitive Behaviour Therapy
Second, in terms of the RF, each session dealt with a discussion (CBT) approaches have been found to reduce relapse rates after
topic that was chosen to activate the reflectiveness of the mother, treatment for depression (Hollon et al., 2006). They have also
including feelings and thoughts related to the pregnancy, maternal been found to be effective with pre- and postpartum depression
representations of their childhood history, their ideas about the (Chabrol et al., 2002; Murray et al., 2003). Thus, both identifying
child, their experience of being a mother and their hopes about and modifying the frequency of helpful and harmful thoughts and
their own as well as their child’s future. Here, the focus was on increasing pleasant activities and social skills training were
enhancing explicit parental RF (i.e., mentalisation about under- included. Coping strategies for handling stress were also actively
standing how one’s own mental states such as feelings and practiced and shared between the group members during the
thoughts influence interactive behaviour). In the Baby NaP sessions. In between the sessions, homework and diaries were
Groups, the additional focus was also on how the child’s mental used to both stimulate thinking and feeling towards the child
states operate and influence the child’s behaviour, as well as one’s as well as to find ways of coping with challenges in affect regula-
own mind and behaviour. The most common techniques in tion. Relaxation techniques and massage practices were also
mentalisation-based interventions were utilised to make the pat- offered to all mothers in line with previous research indications
terns of mother–child interaction more understandable (Midgley that such practices have been found to decrease prenatal depres-
and Vrouva, 2013): These include pausing technique, focusing sion (Field, 2017).

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 Primary Health Care Research & Development 5

Table 1. Structure and examples of treatment elements of pregnancy and Baby NaP groups according to the intervention goals

Emotional availability Reflective functioning Depressive symptoms

Pregnancy Nurture and Play group
Session 1
Mother’s attachment Writing to a diary: What kind of nurture Understanding links between past and Psychoeducation on affect
history I want to give to my baby? present relationships regulation
Experience of being pregnant
Session 2
Connecting with the Singing, exploring the babies’ senses with Representations of the baby Psychoeduation on
baby touch, light and music, for example, playing (e.g., drawing a picture of oneself and the baby) depressive thoughts/
a musical instrument to the baby and how to deal with them
following baby’s responses Expectations of the baby

Session 3
Becoming a mother Singing, exploring the babies senses and Representations of becoming a mother Mapping social support
reactions (using baby diary, selecting adjectives, etc.) systems (homework for
fathers)
Relaxation techniques Role transitions
Ambivalence
Session 4
Preparing for birth Drawing a card to the baby Prepare for the birth and actual meeting Dealing with practical
with the baby issues related to sleep,
Relaxation techniques possible fear of child-
birth, social support for
birth, etc.
Baby nurture and play groups
Sessions 1–3
Getting to know the Singing and playing with the babies Reflecting on the birth experience, first weeks with Checking mood using
baby baby (feelings, thoughts) and the screeners
current perceptions of the baby in the
Measuring, peek-a-boo, infant massage, session Checking affect and
lullaby’s thought regulation
strategies
Sessions 4–5
Encouraging Singing and playing with the babies Relationship with the baby Checking affect and
mutuality thought regulation
Measuring, peek-a-boo, infant massage, Grounding mentalising to real observations in the strategies
lullaby’s sessions (using homework and activities (e.g.,
observe your child for 3 min, then tell what you
Taking care of the infant (nurturing) thought the child is feeling, thinking)
Sessions 6–7
Preparing for the Singing and playing with the babies Babies unique personalities Checking affect and
future thought regulation
Taking developmental perspective; when strategies
babies start to separate
Social support systems
Measuring, peek-a-boo, infant massage, Representations of the future
lullaby’s, rough- and tumble play, soap
bubbles, etc.

Measures for screening clinical depression during pregnancy (Bergink et al.,

2011). In the present study, a cut-off of 9 points was used.
Edinburg Postnatal Depression Scale
Cronbach’s alphas were 0.85 and 0.80 (pre- and postnatal,
The EPDS is a widely used and reliable 10-item self-report for the
respectively).
assessment of symptoms of depression (Murray and Cox, 1990). It
asks about feelings of happiness and sadness, fears, self-blame,
sleeping problems and thoughts about harming oneself during Emotional availability: prenatal and infancy versions
the previous week on a four-point scale (0–3). It is commonly used Observations of EA were conducted on semi-structured video-
for both pre-and postpartum to screen for depression (Venkatesh taped setting designed by Ann Jernberg and her colleagues called
et al., 2016). The cut-off for the presence of mild depressive symp- the Marschak Interaction Method (MIM) (Jernberg et al., 1985;
toms is 9/10 (Murray and Cox, 1990). A cut-off of a 9 in the second Salo and Booth, 2019). In the MIM’s, mother is asked to perform
and third trimester has been shown to have most predictive value playful activities with the foetus (Prenatal), for example, play a

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 6 S.J. Salo et al.

musical instrument to your tummy baby, or the baby (Infancy), or be the hardest times during the first six months of your baby’s
play a familiar game together (Infancy) (Salo and Booth, 2019). In life?’). The Parent Development Interview (PDI-RF; Slade et al.,
practice, the mother is asked to read the MIM tasks from a set of 2005) is a 45 item semi-structured clinical interview intended to
cards that the experimenter gives. The materials needed are in examine the parents’ representations of their children, themselves
small bags. Experimenter leaves the room. The videotaped as parents and their relationships with the child. The interview
situation lasts about 15–20 min. strives in a number of ways to tap into parents’ understanding
EA scales (Biringen, 2008) were used to score the observations of their child’s behaviour, thoughts and feelings and asks the
from the MIM setting. In the 4th edition of the original scales, EA is parents to provide real-life examples of charged interpersonal
comprises of six dimensions – parental sensitivity, structuring, moments: ‘Describe a time in the last week when you and your
non-intrusiveness, non-hostility, child responsiveness and child child really clicked’ and then ‘a time when you and your child really
involvement – rated on a seven-point Likert-type scales. All of didn’t click’.
the dimensions are rated as global perceptions (a Likert scale from In evaluating both pre- and postnatal RF, audiotaped narratives
1 to 7) with the overall aim of capturing the emotional connection were transcribed verbatim and scored for parental RF by trained
in the dyad. In the prenatal phase, adaptations of the two adult coders who were reliable in PI and PDI scoring by Arietta Slade
scales – sensitivity and non-hostility – were created to measure or her team members (first and fifth author). Here, Finnish
EA during pregnancy in collaboration with Z. Biringen (Salo translations of the scoring manual were used (Pajulo, 2004).
et al., 2016) with established validity with widely used early parent- Both interviews take approximately 1–1.5 h to administer. The
ing measures (Salo et al., 2019). Thus, prenatal sensitivity com- signs of mentalising coded from the interviews can be divided into
prises the assessment of overall affective quality, attunement four categories: (a) the parent’s awareness of the nature of different
towards the foetus, evidenced, for example, by touching the tummy mental states, (b) the parent’s clear and exact intention to under-
and commenting on the baby’s movements, and responding to stand the mental states underlying behaviour, (c) the parent’s
them with positive affect, for example, being rated highly sensitive ability to recognise developmental aspect of mental states and d)
(7) would require expressions of positive affect in the face as well as the parent’s ability to consider mental states in relation to the inter-
gentle touching of the tummy, using hands to hold the tummy, viewer. Freshness and spontaneity of reflections about specific
stroking the tummy, turning head towards the tummy while talk- interaction episodes are taken into account, and the importance
ing to the foetus as opposed to a very still-face expression, not of episodic memory is emphasised. Generalised expressions, opin-
touching one’s tummy at all while performing the tasks, etc. In ions or clichés are not considered signs of true RF. The number of
lower scores, there is either a pseudo-quality in maternal affect, indications of true reflectiveness found in the transcribed narrative
that is, it is overly positive and bright and lacks authencity is the basis for assigning an overall score. The greater the number of
(4), or depressed and withdrawn affects with little orientation specific and varied indications of RF, the higher the score on an
(psychological or behavioural) towards the foetus (3). In the lowest eleven-point scale, with a score of −1 indicating a rejection of
end of scores (1 and 2), there are awkward expressions, or total RF and scores 6–9 representing exceptionally high ability for
shutting down. Adult non-hostility characterises the ability to han- RF. Twenty percent of the interviews were scored by two
dle one’s negative emotions. It is manifested in the absence of hos- independent raters (first and fifth author), and the inter-rater-
tile responses, and overt or covert hostile behaviour. The most reliability was 0.95 (Pearson’s r) for the PI and 0.98 (Pearson’s r)
hostile adult is openly exhibiting his or her hostility in facial for the PDI.
expression and voice. Hidden or covert hostility includes showing
impatience or boredom, but it need not be directed at the child. The
Analysis strategy
high points refer to lack of any hostile qualities (7). The midpoint
scores refer to covert hostility (4) where mother has occasionally Missing values were replaced with expectation-maximisation (EM).
negative expressions in face, posture and touch (tensed eyebrows, To test for the success of the randomisation procedure, group
angry mouth, etc.). In lower scores, there are some to several differences in background variables (educational level, marital status
expressions of hostility, for example, negativity in the face, posture and parity) were tested with Fisher’s exact tests and pre-intervention
or touch (such as poking the foetus), critical remarks, minimising levels of study variables (mother’s sensitivity, non-hostility, RF
the situation or the foetus, making sarcastic or negative comments and depressive symptoms) with Student’s t-tests. Student’s t-tests
warranting scores 3, 2 or 1, respectively. were conducted to address the first research question, whether
A trained rater (first author) rated all the tapes, with 20% of the mother–infant EA (i.e., maternal sensitivity, structuring, non-
tapes rated also by a second trained rater (second author). Both intrusiveness, non-hostility and infant responsiveness and involve-
were reliable in the EAS 4th edition and trained by Z. Biringen. ment) and maternal RF at the age of 12 months are higher and
Five tapes were checked together with the method developer maternal depressive symptoms lower in the intervention group as
(Z.B). Inter-rater reliability (Pearson’s r) was 0.89 for sensitivity compared to the TAU group. To address the second research ques-
and 0.84 for non-hostility, respectively, for the Prenatal EA and tion, whether the two EA dimensions observable already during
0.92 for sensitivity, 0.88 for structuring, 0.79 for non-intrusiveness, pregnancy (i.e., maternal sensitivity and non-hostility), and mater-
0.82 for non-hostility, 0.84 for child responsiveness and 0.80 for nal RF will increase and third that maternal depressive symptoms
child involvement for the Infancy EA. will decrease from pregnancy to one year more in the mothers in
the intervention group than in the TAU group (i.e., a interaction
The pregnancy and parent development interviews effect), three repeated measure analyses of variances (ANOVAs)
The Pregnancy Interview (PI-RF; Slade et al., 2007) is a semi- were conducted. The intervention/TAU group was the independent
structured clinical interview with 22 questions regarding a variety variable and pre- and post-intervention measurements of (a) EA
of mental states related to mothers’ emotional experience with maternal sensitivity and non-hostility towards the infant, (b) mater-
pregnancy and her expectations, hopes and fears regarding her nal RF and (c) maternal depressive symptoms were the dependent
future relationship with the child (e.g., ‘What do you think will time variables.

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 Primary Health Care Research & Development 7

Table 2. Percentage (%) distributions of the background characteristics by Table 3. Mean and standard deviations of the baseline variables in intervention
group status (intervention versus comparison) and control groups

Intervention Control Intervention Control

Fisher’s M SD M SD t (43) P
n % n % exact test P
Pre-intervention RF 3.05 1.34 2.65 1.44 −0.96 0.34
Educational level 0.22
Pre-intervention 3.54 1.21 3.38 1.08 −0.46 0.65
Low 12 50 15 71.4 sensitivity
High 12 50 6 28.6 Pre-intervention 4.03 1.03 3.65 1.17 −1.14 0.26
non-hostility
Marital status 0.11
Pre-intervention 12.67 3.02 11.10 3.48 −1.62 0.11
Married or 19 82.6 21 100 depression
co-habiting
Single 4 17.4 0 0
Parity 0.07
Primiparous 13 54.2 17 81 Table 4. Group differences in maternal RF, EA and depressive symptoms at child
age of one year (post-intervention)
Multiparous 11 45.8 4 19
Intervention Control
M SD M SD t (43) P
Maternal RF 4.05 1.33 2.92 1.45 −2.73 0.009

Results Maternal sensitivity 4.77 0.68 3.76 0.96 −4.13 <0.001

Descriptive statistics Maternal structuring 4.07 0.93 4.10 0.94 0.11 0.91
Maternal 4.57 1.53 4.45 1.53 −0.31 0.76
Background characteristics for the intervention and TAU group non-intrusiveness
are shown in Table 2. Socioeconomic status was assessed by the
level of education from 1 (primary school), 2 (high school and Maternal 4.56 0.77 4.47 1.06 −0.33 0.74
non-hostility
trade school), 3 (university degree) and 4 (doctoral degree). Due
to sample size, it was re-classified into two classes, representing Child responsiveness 4.27 0.74 4.13 1.04 −0.52 0.60
low (primary and high or trade school) and high educational level Child involvement 3.72 0.80 3.89 0.91 0.68 0.50
(university and doctoral degrees). Over half had either high school
Maternal depression 8.16 2.99 9.65 3.92 1.42 0.16
or trade school or university degree of education. Most mothers
were married or co-habiting, and over half were first-time mothers.
The groups did not differ in any of the background characteristics.
To test the success of the randomisation procedure, we tested
the differences in group means in study variables at baseline,
shown in Table 3. No group differences were found.
Our first question was whether mother–infant EA (i.e., maternal
sensitivity, structuring, non-intrusiveness, non-hostility and infant
responsiveness and involvement) and maternal RF at the age of
12 months were higher and maternal depressive symptoms lower
in the intervention group as compared to the TAU group. In line
with the hypothesis, results in Table 4 show that maternal RF
and sensitivity were higher among intervention than TAU group
mothers. However, contrary to the hypotheses, there were no group
differences in maternal structuring, maternal non-intrusiveness,
maternal non-hostility, infant responsiveness, infant involvement
or maternal depressive symptoms.
Our second question was whether intervention group mothers
showed a greater increase in maternal sensitivity, non-hostility and
RF and greater decrease in depressive symptoms from pregnancy
(pre-intervention) to one year of age (post-intervention). Related
to change in maternal EA variables from pre- to post-intervention, Figure 2. Change in maternal sensitivity from pre- to post-intervention

the results showed a significant group × time interaction effect,

FWilks’ Lambda (2, 42) = 6.63, P = 0.003, η2 = 0.24. In accordance
with the hypothesis, univariate tests confirmed that mothers main effects showed that both groups showed increased
in the intervention group showed a greater increase in EA sensi- sensitivity and non-hostility from pre- to post-intervention,
tivity than control mothers, F (1, 43) = 9.26, P = 0.004, FWilks’ Lambda(2, 42) = 17.64, P < 0.001, η2 = 0.46. Univariate tests
η2 = 0.18, illustrated in Figure 2. However, contrary to the first indicated that the effect was significant both for sensitivity,
hypothesis, the intervention did not improve maternal F(1, 43) = 33.07, P < 0.001, η2 = 0.44, and non-hostility,
non-hostility, F(1, 43) = 0.62, P = 0.44, η2 = 0.014. Significant F(1, 43) = 14.23, P < 0.001, η2 = 0.25.

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 8 S.J. Salo et al.

Specifically, the results supported the hypotheses that maternal

EA dimension of sensitivity as well as maternal RF was higher
at one year of child age in the NaP intervention group as compared
to the TAU group. Also, the results further showed that maternal
sensitivity and RF increased, whereas depressive symptoms
decreased more in the intervention group from pre- to postnatal
phase although in both groups there were positive changes.
Maternal sensitivity is viewed as a key characteristic underlying
the development of a child’s secure attachment (De Wolff and Van
Ijzendoorn, 1997; Ainsworth et al., 2015). It encompasses the core
sense of safety that another human being is willing and able to fully
read, understand and respond to one’s needs, which in infancy
means survival. In the EA framework, a sensitive mother expresses
positive emotions towards the child and is open towards his/her
communication cues and signals (Biringen et al., 2014). Here,
intervention group mothers showed more sensitivity when the
Figure 3. Change in maternal reflective functioning from pre- to post-intervention
baby was one year old, indicating the benefits of participating in
the NaP intervention. Furthermore, although emotional sensitivity
expressed towards the foetus in videotaped assessment is likely to
be different than the reciprocal relational sensitivity with the
infant, increased maternal sensitivity from pregnancy until the
baby was one year old indicates that it is possible to encourage
depressive mothers to develop a positive emotional bond already
from pregnancy. The result of the effectiveness of the NaP in
increasing maternal sensitivity from pre-to postnatal period is
important, because depressive mothers tend to have negative
feelings already towards the foetus (Alhusen, 2008). Such NaP
therapeutic elements as rhythmic touch and emotion interpreta-
tion to help the pregnant mother to feel, focus and reciprocate
the movements of the future baby may have contributed to the
improvements in sensitivity.
Yet, in contrary to the hypotheses, the other dimensions of the
EA – namely, structuring, non-intrusiveness, non-hostility and
child responsiveness and involvement did not differ between the
study groups. Furthermore, NaP was not effective in reducing
Figure 4. Change in maternal depressive symptoms from pre- to post-intervention maternal hostility from pre- to postnatal period. Mothers suffering
from depressive symptoms often show hostile and intrusive inter-
active behaviours with their infants and face difficulties in guiding
Related to change in maternal RF from pre- to post-intervention, and structuring their interaction and communication (Field, 2010;
the results showed a significant group × time interaction effect, Murray et al., 2015). However, because the NaP intervention
FWilks’ Lambda (1, 43) = 9.49, P = 0.004, η2 = 0.18. Figure 3 shows, highly focused very much on creating positive emotional connec-
in accordance with the hypothesis, that intervention group mothers tion and pleasurable moments of meeting, it is possible that it
showed a greater increase in RF than control mothers. Yet, neglected to focus on the other EA dimensions, here reducing hos-
significant main effects indicate all mothers showed increase in tility. In the present sample, the level of hostility was not as low as
RF from pre- to post-intervention, FWilks’ Lambda (1, 43) = 28.53, sensitivity. Nevertheless, in the future, it might be relevant to add
P < 0.001, η2 = 0.40. interventive elements helping mothers to increasingly understand
Related to change in mother’s depressive symptoms from pre- her problems in affect regulation and possible trauma history
to post-intervention, the results showed a significant group × time which is typical in maternal prenatal depression (Seng et al.,
interaction effect, FWilks’ Lambda (1, 43) = 5.40, P = 0.025, η2 = 0.11. 2014) as these techniques have previously been found to be the
Figure 4 shows, as hypothesised, that intervention group mothers effective in reducing hostility and intrusiveness (Belt et al.,
showed a greater decrease in depressive symptoms than the control 2012). In the future, it might be relevant to add interventive ele-
mothers. Yet, all mothers showed decrease in depressive symptoms ments helping mothers to increasingly understand her problems
from pre- to post intervention, FWilks’ Lambda (1, 43) = 20.38, in affect regulation and possible trauma history which is typical
P < 0.001, η2 = 0.3. in maternal prenatal depression (Seng et al., 2014) as these tech-
niques have previously been found effective in reducing hostility
and intrusiveness (Belt et al., 2012). Similarly, the NaP did not
Discussion
reveal any effects on the infants’ side of the EA, namely, respon-
NaP is a mentalisation-based parenting intervention aimed to siveness and involvement. As maternal depressive symptoms have
support mother–infant interaction quality among prenatally been show to have negative effects, especially involving the child’s
depressed mothers in primary health care settings. This study emotional responsiveness and interactive behaviours (Field, 2011),
showed preliminary support for the effectiveness of NaP interven- focusing more directly on the infant’s side of the emotional inter-
tion model for mothers with prenatal depressive symptoms. action in future development of the NaP seems relevant.

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 Primary Health Care Research & Development 9

The NaP intervention was effective in increasing maternal RF this study contributes to the discussion on the appropriate inter-
more among the intervention than control mothers. Interestingly ventions for prenatal interventive work in at-risk samples, focusing
also, RF increased in both intervention and TAU groups from especially on the early emotional signs of caregiving. Future studies
pregnancy to infancy, but the improvement was significantly more with follow-up of the present sample will focus on evaluating the
substantial for those in the intervention group. This overall long-term effects of the NaP intervention.
increase in RF from pre- to postnatal phase has been demonstrated
previously in a non-randomised intervention study with Acknowledgements. We want to thank Baby Magic team members for their
substance-abusing mothers (Pajulo et al., 2012). Pre- and postnatal contribution in doing the NaP intervention.
RF are by nature qualitatively different: one measuring imaginary
relationship and the other actual perceptions of the child and
related mentalising of the child’s behaviours. Such improvements References
are nevertheless important, because the high capacity for RF is
Ainsworth MDS, Blehar MC, Waters E and Wall SN (2015) Patterns of
thought to be beneficial for dyadic relations and found to be a pro- attachment: A psychological study of the strange situation. New York:
tective factor for infant development (Camoirano, 2017). The prior Psychology Press.
evidence of the effectiveness of early RF-based interventions Alhusen JL (2008) A literature update on maternal–foetal attachment. Journal
focused on mothers with substance-use problems (Pajulo et al., of Obstetric, Gynecologic & Neonatal Nursing, 37, 315–328.
2006; Suchman et al., 2008; 2010a; 2010b; Pajulo et al., 2012; Austin MP, Tully L and Parker G (2007) Examining the relationship between
Suchman et al., 2017) as well as mothers living in the prison system antenatal anxiety and postnatal depression. Journal of Affective Disorders,
(Baradon et al., 2008). The current study extends the previous find- 101, 169–174.
ings to mothers with prenatal depressive symptoms. Baradon T, Fonagy P, Bland K, Lénárd K and Sleed M (2008) New beginnings–
The finding that NaP intervention was also effective in reducing an experience-based programme addressing the attachment relationship
depressive symptoms concurs with previous findings on interven- between mothers and their babies in prisons. Journal of Child
Psychotherapy, 34, 240–258.
tions using similar therapeutic elements (Elliott et al., 2000;
Beeghly M, Weinberg MK, Olson KL, Kernan H, Riley J and Tronick EZ
Zlotnick et al., 2001; 2006; Field, 2010). Again, although depressive (2002) Stability and change in level of maternal depressive symptomatology
symptoms also decreased in the control group, the reduction was during the first postpartum year. Journal of Affective Disorders, 71, 169–180.
more pronounced in the intervention group. Previous research has Belt RH, Flykt M, Punamäki RL, Pajulo M, Posa T and Tamminen T (2012)
shown that for some women, postpartum depression spontane- Psychotherapy groups and individual support to enhance mental health and
ously remits. In Finland, the well-baby clinic provides regular early dyadic interaction among drug‐abusing mothers. Infant Mental Health
medical check-ups during pregnancy and after birth, aiming to Journal, 33, 520–534.
contribute to optimal infant development and maternal health, Bergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R,
offering also information about depressed mood (Hakulinen- van Baar A and Pop V (2011) Validation of the Edinburgh depression scale
Viitanen and Pelkonen, 2009). Our finding that this TAU with during pregnancy. Journal of Psychosomatic Research, 70, 385–389.
depression monitoring by a public health nurse may be an effective Biringen Z (2008). Emotional Availability (EA) scales manual, fourth edtion.
Part 1: Infancy/Early Childhood version (child aged 0–5 years).
intervention is supported by a number of studies which have
Unpublished manuscript. Boulder.
shown that low-intensity interventions, such as guided self-help Biringen Z, Derscheid D, Vliegen N, Closson L and Easterbrooks MA (2014)
via written materials, limited professional support, or Internet- Emotional availability (EA): theoretical background, empirical research using
delivered interventions are effective in postpartum patients with the EA Scales, and clinical applications. Developmental Review, 34, 114–167.
Major Depressive Disorder, even when depression is severe Biringen Z and Easterbrooks MA (2012) Emotional availability: concept,
(Bower et al., 2013). They are, however, hardly effective on improv- research, and window on developmental psychopathology. Development
ing parenting problems inherent in maternal depression (see and Psychopathology, 24, 1–8.
Lefkovics et al., 2014). Booth P and Jernberg AM (2010) Theraplay: helping parents and children build
The limitations of the study are that the sample size was small, better relationships through attachment-based play. San Francisco, CA:
and the results need to be verified using a larger sample. The use of Jossey-Bass.
multiple qualitative measurements including transcribed inter- Bower P, Kontopantelis E, Sutton A, Kendrick T, Richards DA, Gilbody S,
Knowles S, Cuijpers P, Andersson G, Christensen H and Meyer B (2013)
views and videotaped recordings may nevertheless pose practical
Influence of initial severity of depression on effectiveness of low intensity
challenges for larger intervention studies. Furthermore, as the interventions: meta-analysis of individual patient data. BMJ, 346–540.
effects of parental depressive problems in terms of the later child Calkins SD and Hill A (2007) Caregiver influences on emerging emotion regu-
development and health are often cumulative in nature (Goodman lation. In Gross JJ, editor, Handbook of emotion regulation. The Guilford
et al., 2011), the role of the fathers’ mental health, dyadic father– Press: New York, 229–248.
infant interaction and paternal reflective function need more atten- Camoirano A (2017) Mentalizing makes parenting work: a review about paren-
tion. In the present study, fathers were offered additional help in tal reflective functioning and clinical interventions to improve it. Frontiers in
guiding them into necessary mental health services if needed, but Psychology, 8, 14.
they did not take part in the group sessions Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B and Mullet E
Despite these limitations, our study adds to the existing litera- (2002) Prevention and treatment of post-partum depression: a controlled
ture on early intervention programs for mothers with depressive randomized study on women at risk. Psychological Medicine, 32, 1039–1047.
Claridge AM (2014) Efficacy of systemically oriented psychotherapies in the
tendencies starting from pregnancy. Pregnancy is a unique phase
treatment of perinatal depression: a meta-analysis. Archives of Women’s
that requires the mother to envision many unknowns about her life Mental Health, 17, 3–15.
situation, her spouse, and of course, the formation of an emotional De Wolff MS and Van Ijzendoorn MH (1997) Sensitivity and attachment: a
bond to her child. NaP adds to the science of early interventions by meta‐analysis on parental antecedents of infant attachment. Child
focusing also on the positive aspects of early caregiving. NaP is a Development, 68, 571–591.
short-term, cost-effective group-based intervention that can be Easterbrooks A, Biesecker G and Lyons-Ruth K (2000) Infancy predictors of
easily delivered multiprofessionally in primary health care. Thus, emotional availability in middle childhood: the roles of attachment security

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 10 S.J. Salo et al.

and maternal depressive symptomatology. Attachment & Human Murray D and Cox JL (1990) Screening for depression during pregnancy with
Development, 2, 170–187. the Edinburgh Depression Scale (EDDS). Journal of Reproductive and Infant
Elliott SA, Leverton TJ, Sanjack M, Turner H, Cowmeadow P, Hopkins J and Psychology, 8, 99–107.
Bushnell D (2000) Promoting mental health after childbirth: a controlled Murray L, Cooper PJ, Wilson A and Romaniuk H (2003) Controlled trial of
trial of primary prevention of postnatal depression. British Journal of the short-and long-term effect of psychological treatment of post-partum
Clinical Psychology, 39, 223–241. depression: 2. Impact on the mother–child relationship and child outcome.
Feldman R (2007) Parent–infant synchrony and the construction of shared The British Journal of Psychiatry, 182, 420–427.
timing; physiological precursors, developmental outcomes, and risk condi- Murray L, Fearon P and Cooper P (2015) Postnatal depression, mother–infant
tions. Journal of Child Psychology and Psychiatry, 48, 329–354. interactions, and child development. In Gemmill JMAW, Fearon P, editors,
Feldman R, Granat A, Pariente C, Kanety H, Kuint J and Gilboa-Schechtman E Identifying perinatal depression and anxiety: Evidenced-based practice in
(2009) Maternal depression and anxiety across the postpartum year and infant screening, psychosocial assessment, and management. Wiley. 139–164.
social engagement, fear regulation, and stress reactivity. Journal of the American Narendran S, Nagarathna R, Narendran V, Gunasheela S and Nagendra
Academy of Child & Adolescent Psychiatry, 48, 919–927. HRR (2005) Efficacy of yoga on pregnancy outcome. Journal of
Field T (2010) Postpartum depression effects on early interactions, parenting, Alternative & Complementary Medicine, 11, 237–244.
and safety practices: a review. Infant Behavior and Development, 33, 1–6. Nylen KJ, Moran TE, Franklin CL and O’Hara MW (2006) Maternal depres-
Field T (2011) Prenatal depression effects on early development: a review. sion: a review of relevant treatment approaches for mothers and infants.
Infant Behavior and Development, 34, 1–14. Infant Mental Health Journal: Official Publication of The World
Field T (2017) Prenatal depression risk factors, developmental effects and inter- Association for Infant Mental Health, 27, 327–343.
ventions: a review. Journal of Pregnancy and Child Health, 4, 301. O’Hara MW (2009) Postpartum depression: what we know. Journal of Clinical
Field T, Diego M, Delgado J and Medina L (2013) Yoga and social support Psychology, 65, 1258–1269.
reduce prenatal depression, anxiety and cortisol. Journal of Bodywork and Pajulo M (2004) Finnish translations of the PI and PDI manuals. Unpublished
Movement therapies, 17, 397–403. manuscript. Turku: Turku University.
Field T, Diego M and Hernandez-Reif M (2010) Prenatal depression effects Pajulo M, Pyykkönen N, Kalland M, Sinkkonen J, Helenius H, Punamäki RL
and interventions: a review. Infant Behavior and Development, 33, 409–418. and Suchman N (2012) Substance‐abusing mothers in residential treatment
Fonagy P, Steele M, Steele H, Moran GS and Higgitt AC (1991) The capacity with their babies: importance of pre- and postnatal maternal reflective
for understanding mental states: the reflective self in parent and child and its functioning. Infant Mental Health Journal, 33, 70–81.
significance for security of attachment. Infant Mental Health Journal, 12, Pajulo M, Suchman N, Kalland M and Mayes L (2006) Enhancing the effec-
201–218. tiveness of residential treatment for substance abusing pregnant and parent-
Forman DR, O’Hara MW, Stuart S, Gorman LL, Larsen KE and Coy KC ing women: focus on maternal reflective functioning and mother–child
(2007) Effective treatment for postpartum depression is not sufficient to relationship. Infant Mental Health Journal: Official Publication of The
improve the developing mother–child relationship. Development and World Association for Infant Mental Health, 27, 448–465.
Psychopathology, 19, 585–602. Papoušek H and Papoušek M (2002) Intuitive parenting. In Bornstein MH,
Gentile S (2017) Untreated depression during pregnancy: Short-and long-term editor, Handbook of parenting Volume 2. Biology and ecology of parenting,
effects in offspring. A systematic review. Neuroscience, 342, 154–166. 182. New Jersey: Lawrence Erlbaum Associates, 183–207.
Goodman JH, Prager J, Goldstein R and Freeman M (2015) Perinatal dyadic Poobalan AS, Aucott LS, Ross L, Smith WCS, Helms PJ and Williams JH (2007)
psychotherapy for postpartum depression: a randomized controlled pilot Effects of treating postnatal depression on mother–infant interaction and child
trial. Archives of Women’s Mental Health, 18, 493–506. development: systematic review. The British Journal of Psychiatry, 191, 378–386.
Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM and Heyward D Salo S and Booth P (2019) The MIM handbook. Chicago: Theraplay Institutute.
(2011) Maternal depression and child psychopathology: a meta-analytic Salo S, Flykt M and Biringen Z (2016) Pregnancy version of the Emotional
review. Clinical Child and Family Psychology Review, 14, 1–27. Availability Scales (Pre-EA). Unpublished Manual. Helsinki: Helsinki
Hakulinen-Viitanen T and Pelkonen M (2009) Lastenneuvola lapsen ja University.
perheen terveyden ja hyvinvoinnin edistäjänä. In Lammi-Taskula J, Salo S, Flykt M, Isosävi S, Punamäki R-L, Kallnd M, Biringen Z and Pajulo M
Karvonen S and Salme S, editors, Lapsiperheiden hyvinvointi. Helsinki: (2019) Validating an observational measure of prenatal emotional availabil-
THL, 152–161. ity among mother’s with depressive tendencies. Journal of Prenatal and
Hayes LJ, Goodman SH and Carlson E (2013) Maternal antenatal depression Perinatal Psychology and Health, 34, 1–23.
and infant disorganized attachment at 12 months. Attachment & Human Salo S and Lampi H (2019) Nurture and play intervention for groups manual.
Development, 15, 133–153. Unpublished Manual. Helsinki: Helsinki University.
Hollon SD, Stewart MO and Strunk D (2006) Enduring effects for cognitive Seng JS, D’andrea W and Ford JD (2014) Complex mental health sequelae of
behaviour therapy in the treatment of depression and anxiety. Annual Review psychological trauma among women in prenatal care. Psychological Trauma:
of Psychology, 57, 285–315. Theory, Research, Practice, and Policy, 6, 41.
Jernberg A, Wickersham M and Thomas E (1985) Prenatal MIM. Slade A, Bernbach E, Grienenberger J, Levy D and Locker A (2005) Addendum
Unpublished Handbook. Chicago: The Theraplay Institute. to reflective functioning scoring manual for use with the Parent Development
Kingston D, Tough S and Whitfield H (2012) Prenatal and postpartum mater- Interview. Unpublished Manuscript. New York: City University of New York.
nal psychological distress and infant development: a systematic review. Child Slade A, Cohen LJ, Sadler LS and Miller M (2009) The psychology and psycho-
Psychiatry & Human Development, 43, 683–714. pathology of pregnancy. Handbook of Infant Mental Health, 3, 22–39.
Lefkovics E, Baji I and Rigó J (2014) Impact of maternal depression on Slade A, Grienenberger J, Bernbach E, Levy D and Locker A (2005) Maternal
pregnancies and on early attachment. Infant Mental Health Journal, 35, reflective functioning, attachment, and the transmission gap: a preliminary
354–365. study. Attachment and Human Development, 7, 283–298.
Luyten P, Fonagy P, Lemma A and Target M (2012) Depression. In Bateman Slade A, Patterson M and Miller M (2007) Addendum to Fonagy, Target, Steele
AW and Fonagy P, editors, Handbook of mentalizing. Washington, DC: & Steele reflective functioning scoring manual for use with the Pregnancy
American Psychiatric Publishing, Inc., 385–418. Interview. Unpublished Manuscript. New York, NY: The City College and
Midgley N and Vrouva I, editors, (2013) Minding the child: Mentalization- Graduate Center of the City University of New York.
based interventions with children, young people and their families. London: Smaling HJ, Huijbregts SC, Suurland J, Heijden KB, Mesman J, Goozen SH
Routledge. and Swaab H (2016) Prenatal reflective functioning and accumulated risk as
Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, predictors of maternal interactive behavior during free play, the still‐face
Elbourne D, Egger M, & Altman DG (2010) CONSORT 2010 statement: paradigm, and two teaching tasks. Infancy, 21, 766–784.
updated guidelines for reporting parallel group randomised trials. BMJ Sroufe LA (2000) Early relationships and the development of children. Infant
(Clinical Research Ed), 340, 332. Mental Health Journal, 21, 67–74.

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914
 Primary Health Care Research & Development 11

Suchman N, DeCoste C, Castiglioni N, Legow N and Mayes L (2008) The moth- developmental outcomes: a systematic review. International Journal of
ers and toddlers program: preliminary findings from an attachment-based Women’s Health, 7, 429.
parenting intervention for substance-abusing mothers. Psychoanalytic Van Doesum K, Hosman M, Riksen-Walraven J and Hoefnagels C (2007)
Psychology, 25, 499. Correlates of depressed mothers’ sensitivity toward their infants: the role
Suchman NE, DeCoste C, Castiglioni N, McMahon TJ, Rounsaville B and of maternal, child, and contextual characteristics. Journal of the American
Mayes L (2010a) The mothers and toddlers program, an attachment-based Academy of Child and Adolescent Psychiatry, 46, 747–756.
parenting intervention for substance using women: post-treatment results Van Doesum KT, Riksen-Walraven JM, Hosman CM and Hoefnagels C
from a randomized clinical pilot. Attachment & Human Development, 12, (2008) A randomized controlled trial of a home‐visiting intervention aimed
483–504. at preventing relationship problems in depressed mothers and their infants.
Suchman NE, DeCoste C, Leigh D and Borelli J (2010b) Reflective function- Child Development, 79, 547–561.
ing in mothers with drug use disorders: implications for dyadic interactions Venkatesh KK, Nadel H, Blewett D, Freeman MP, Kaimal AJ and Riley LE
with infants and toddlers. Attachment & Human Development, 12, (2016) Implementation of universal screening for depression during
567–585. pregnancy: feasibility and impact on obstetric care. American Journal of
Suchman NE, DeCoste CL, McMahon TJ, Dalton R, Mayes LC and Borelli J Obstetrics and Gynecology, 215, 517–e1.
(2017) Mothering from the inside out: results of a second randomized clinical Yarcheski A, Mahon NE, Yarcheski TJ, Hanks MM and Cannella BL (2009) A
trial testing a mentalization-based intervention for mothers in addiction meta-analytic study of predictors of maternal–fetal attachment.
treatment. Development and psychopathology, 29, 617–636. International Journal of Nursing Studies, 46, 708–715.
Trevarthen C (1998) The concept and foundations of infant intersubjectivity. Zlotnick C, Johnson SL, Miller IW, Pearlstein T and Howard M (2001)
In Braten S, editor, Intersubjective communication and emotion in early Postpartum depression in women receiving public assistance: pilot study
ontogeny. Cambridge: University Press, 15–46. of an interpersonal-therapy-oriented group intervention. American
Tronick E and Reck C (2009) Infants of depressed mothers. Harvard Review of Journal of Psychiatry 158, 638–640.
Psychiatry, 17, 147–156. Zlotnick C, Miller IW, Pearlstein T, Howard M and Sweeney P (2006) A pre-
Tsivos ZL, Calam R, Sanders MR and Wittkowski A (2015) Interventions for ventive intervention for pregnant women on public assistance at risk for
postnatal depression assessing the mother–infant relationship and child postpartum depression. American Journal of Psychiatry, 163, 1443–1445.

Downloaded from https://www.cambridge.org/core. IP address: 86.121.125.227, on 12 Apr 2021 at 08:52:54, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000914