Faculty of Social and Behavioural Sciences
Graduate School of Child Development and Education
Minding the Baby: The Effects of the
Mindful with Your Baby/Toddler Training
on Maternal Stress, Sensitivity and
Mind-Mindedness
Research Master Child Development and Education Research Master Thesis
Melissa Goris
Moniek Zeegers, Cristina Colonnesi 19-01-2018
Abstract
High percentages of new mothers experience elevated levels of stress or mental health problems, indicating a need for effective post-natal treatment strategies. Mindful Parenting (MP) interventions already appeared to be effective in reducing maternal mental health problems and improving mother-child interaction quality in the pre-natal period. In the post-natal period, MP interventions might be even more effective, since mothers can directly apply mindful practices in everyday life. The current study aimed to evaluate the effects of an MP group training, Mindful with your Baby/Toddler Training (MBTT), on maternal stress, sensitivity, and mind-mindedness (i.e. mothers’ mentalizing abilities). Furthermore, we investigated whether mind-mindedness moderated the treatment effects. Observational measurements took place at three occasions: a baseline assessment (8 weeks before the intervention), pre-test and post-test. Free-play interactions were recorded to assess maternal sensitivity and proportions of appropriate and non-attuned mind-related comments. Mothers completed a parental stress index at the same assessment occasions and additionally 8 weeks and 1 year after the training. After the training, levels of maternal stress had decreased
significantly, mothers made less non-attuned mind-related comments, and mothers were more sensitive and accepting towards their child. Both follow-up measurements of maternal stress were significantly lower compared to the pre-test scores. No significant differences were found for appropriate mind-related comments and no evidence was found for a moderating effect of mind-mindedness. To conclude, MBTT is a promising intervention to use in the transition into motherhood which could lead to improved maternal mental health and mother-child interaction quality.
Keywords: Mindful Parenting, transition motherhood, stress, mind-mindedness,
Minding the Baby: The Effects of the Mindful With Your Baby Training on Maternal Stress, Sensitivity and Mind-mindedness
In today’s media and in our society, the transition into motherhood is represented as a joyful and exciting time in the lives of women wherein it is assumed that mothering comes on naturally (Winson, 2009). However, for many new mothers, this idealistic image is not a correct representation of their transition, that in practice is also stressful and challenging (Taubman-Ben-Ari, Shlomo, Sivan, & Dolizki, 2009). New mothers often juggle with their new gained responsibilities including (unfamiliar) childcare practices (feeding, sleep
regulation and diaper changing), continuous availability and regular worries about the child’s health and wellbeing (Hung, 2007). These new gained responsibilities constrain mothers to make profound alterations in different areas, such as alterations in their career paths, the ways they supposed to live, sleeping patterns, romantic relations and their identity that can get loss in the role of being a mother (Dew & Wilcox, 2011; Epifanio, Genna, De Luca, Roccella, & La Gruta, 2015). Concludingly, whereas the transition into motherhood is a joyful period, it might also be a risk period wherein mothers cope with high levels of stress.
Stress in new mothers is defined by a discrepancy between the required parenting skills in stressful situations and actual abilities and coping strategies of parents (Belsky, 1984).
Elevated levels of stress can lead to chronic stress, which increases the risk of mental health problems (Lupien, McEwen, Gunnar, & Heim, 2009). A remarkable high percentage of 19.2% of the new mothers develops a major or a minor depression in the first three months after child birth (Gaynes et al., 2005) and about 11.1% of the new mothers develops an anxiety disorder (Reck et al., 2008). Stress and mental health problems (anxiety and depression) can lead to dysfunctional parenting behaviors, such as the lack of sensitive parenting (Nicol-harper, Harvey, & Stein, 2007), and less positive mother-child interactions
(Crnic, Gaze, & Hoffman, 2005). These dysfunctional parenting behaviors impede the optimal development of a child and increase the risk of socio-emotional developmental problems, such as perceived temperamental difficulties (Henrichs et al., 2009).
The severity of the consequences of maternal stress and mental health problems in the first years after childbirth indicate the need for prevention and intervention strategies that help to reduce maternal stress. To date, there are already different interventions available for mothers that experience elevated levels of stress and/or mental health problems. First, to treat mental health problems, such as anxiety and depression, mothers can be treated with
antidepressants. However, in reviews, the effects of antidepressants in the postnatal period are described as non-impressive (Ng, Hirata, Yeung, Haller, & Finley, 2010; Sharma & Sommerdyk, 2013). Moreover, anti-depressants might not work accurately in new mothers because of their lower estrogen levels and the reviewers also indicate that therapeutic effects are needed to gain significant improvements. Second, the risks of anti-depressants in
combination with breast feeding are currently unknown (Gentile, Rossi, & Bellantuono, 2007).
Another researched intervention strategy is psychotherapy, which also specifically focusses on maternal psychological complaints. A review on the effects of psychotherapy showed that it is effective in reducing mental health problems, such as depression and anxiety (Field, 2010). However, there is no evidence that psychotherapy improves the quality of mother-child interactions. For instance, in the study of Foreman et al. (2007), psychotherapy did not improve children’s attachment security and mothers’ ratings of their child’s behavior problems and temperamental difficulties did not decrease after treatment. Thus, both anti-depressants and psychotherapy reduced mothers’ psychological complaints, such as stress and depression, but did not improve mother-child interactions (Field, 2010). Improving
mother-child interaction quality for mothers with maternal mental health problems is important, since mental health problems, like depression, are predictive of child’s
internalizing and externalizing behaviors (Dubois-Comtois, Moss, Cyr, & Pascuzzo, 2013). Contrary, interactions of high quality enhance, social competence, the regulation of emotions and emotional understanding. Therefore, interventions should focus on both; maternal mental health problems and mother-child interactions.
An intervention strategy for mothers that might overcome the disadvantages of previously described intervention strategies, is mindful parenting (MP). Mindfulness refers to paying attention at the present moment and observing it non-judgmentally, whereas MP is the application of mindful observations in parenting and parent-child interactions (Kabat-Zinn, 2003). In MP interventions parents are taught to: a) observe and listen to their child fully focused and without judgement, b) to recognize and to make a distinction between their own emotions and those of the child, and c) to lower parental reactivity in parent-child interactions and to feel compassionated for themselves and their child (Duncan, Coatsworth, &
Greenberg, 2009). Research on MP interventions in the post-natal period is yet scarce, but MP interventions carried out in the pre-natal period has shown promising results (Dunn, Hanieh, Roberts, & Powrie, 2012; Shaddix, 2014). These interventions were effective in reducing anxiety and depression, even in the six-months later postpartum follow-up (Dunn et al., 2012). It did not only improve maternal mental health problems, but also mother-child-interactions; it improved maternal self-regulation and increased maternal attunement to the child (Shaddix, 2014).
Since prenatal MP interventions has shown promising results, postnatal MP interventions in the presence of babies might be even more effective. That is, MP in the postnatal period could learn mothers to directly apply mindful practices in everyday life in order to be
attentive and responsive to their own needs and the needs of their babies. A study of Perez-Blasco, Viguer and Rodrigo (2013) investigating the effects of a MP intervention in the presence of babies showed that it is effective in reducing levels of maternal stress, anxiety and distress. Second study, also investigating the effects of MBTT and using part of the data of the current study, concluded that MBTT was effective in improving maternal well-being and mother-child interaction quality (questionnaire) (Potharst, Aktar, Rexwinkel, Rigterink, & Bögels, 2017). Furthermore, MP seems to overcome the disadvantages of previous intervention methods; a) mindful parenting is a non-pharmaceutical but therapeutic
intervention, b) mindful parenting does not only focus on maternal mental health problems but also on ways to improve mother-child interactions, and c) when the intervention is finished, mothers are equipped with a set of mindful parenting skills which they can directly apply in stressful parenting situations (Bögels & Restifo, 2013).
The current study investigates the effects of a new postpartum MP intervention; Mindful
with your baby/toddler training (MBTT), which is based on the MP training developed by
Bögels and Restifo (2013). MBTT is unique in a way that it is one of the first mindful
parenting trainings in which children are present during the mediation sessions. Meditation in the presence of the children has important advantages; a) mothers can practice stressful child-related situations, b) mothers can practice their attentiveness to thoughts and experiences they might have towards a child, c) therapists can notice attachment and relationship problems between mother and the child (Bögels & Restifo, 2013). To evaluate the effects of MBTT, the current study will focus on both improvement in maternal mental health (reductions in
maternal stress) and improvements of mother-child interactions (increasing the levels of sensitivity and mind-mindedness), since previous intervention strategies were incapable to reach significant improvements in both domains.
Mother-Child Interaction Quality. A sensitive parent could be described as one acting in correspondence with the needs of the child, which are represented in perceptual and emotional signals (Ainsworth, Bell, & Stayton, 1974). Mothers with mental health problems, such as depression, in general are less sensitive (Lovejoy, Graczyk, O’Hare, & Neuman, 2000). Sensitive parenting is important because it enhances the ability of a child to handle social processes, learn children how they could regulate negative emotions and how they could cope with psychological distress (Feldman, 2007). Mind-mindedness could be
described as the parental tendency to read the internal states (whishes, thoughts and feelings) of the child. This tendency is assessed by parents use of mind-related speech during parent-child interaction or when describing their parent-child (Meins, 1997; Meins & Fernyhough, 2015). The reading of the child’s internal state could be either accurately represented in appropriate mind-related comments or inaccurately in non-attuned mind-related comments. Both
sensitivity and mind-mindedness are positively related to beneficial child outcomes. They contribute to; a secure infant-parent attachment relationship and children’s development of self-regulation and social understanding (Bernier, Carlson, & Whipple, 2010; Laranjo, Bernier, & Meins, 2008; Sharp & Fonagy, 2008; Taumoepeau & Ruffman, 2008).
While mind-mindedness and sensitivity are two distinct concepts, they have in common that they require good parental mentalizing abilities, i.e. accurately reading the internal state of the child (Meins, 2013; Sharp & Fonagy, 2008). Without these abilities, it becomes more unlikely that parents (accurately) refer to the child’s internal state (mind-mindedness) or to act in correspondence with the child’s internal state (sensitivity). It is expected that mindfulness increases both mind-mindedness and sensitivity, since mindfulness can be seen as a prerequisite for parental mentalization skills (Whittingham, 2016).
In MBTT mothers are taught different mindful practices that could enhance parental mentalizing abilities. First, mindfulness teaches parents to guide their attention towards the present moment whenever their thoughts wander to the unconscious mind or when they are distracted by their own emotions, schedules or surrounding (Kabat-Zinn, 2003). This technique stimulates parents to take notice of what is going on with their child at a specific moment, and, by doing so, parents learn to observe with their full attention resulting in more accurate interpretations of the child’s internal state (Surrey, 2005). Secondly, in the MBTT sessions, parents learn to observe their own and their child’s internal experiences without judgement. Having an open and neutral stance during interactions, helps mothers to truly understand their child’s state of mind, and helps mothers to distinguish the child’s internal state from their own agenda, wishes or expectations (Duncan et al., 2009).
Next to our hypothesis that mindfulness, and in particular MBTT, would enhance mind-mindedness and sensitivity, it is also plausible that mind-mindedness moderates the effect that MBTT has on sensitivity. This expectation is based on studies investigating the indirect effect that mind-mindedness has on attachment security. These studies indicate that in the prediction of attachment security, mind-mindedness indirectly effects attachment security through sensitivity (Laranjo et al., 2008; Zeegers, Colonnesi, Stams, & Meins, 2017 in press). These results support the hypothesis of Meins (1999) which stated that mind-mindedness could be a prerequisite for sensitivity. In other words, parents need to have the tendency to read the child’s mind (mind-mindedness) and need to be able to do this in an appropriate way before a parent can act in correspondence to the child’s internal state (sensitivity). Thus, it is expected that mothers improve on mind-mindedness, suggesting an increased tendency to refer to the child’s internal state and appropriately referring to that state, mothers would also be more sensitive towards their children.
Maternal stress. In this study, it is hypothesized that MBTT would reduce the levels of maternal stress. This hypothesis is in concordance with the results of earlier research indicating that mindfulness meditations are effective in reducing stress (Gouveia, Carona, Canavarro, & Moreira, 2016; Perez-Blasco et al., 2013; Potharst et al., 2017). To illustrate, the study of Bögels, Hellemans, Van Deursen, Römer and Van Der Meulen (2014), wherein the effects of MP interventions in mental health care were evaluated, found that MP
interventions reduced parental stress with effect sizes that could be described as medium. Besides from the hypothesis that MBTT would reduce the levels of maternal stress, it is also plausible that mind-mindedness could act as a moderator in this relationship. When parents misinterpret the child’s internal state, including intentions, wishes and cognitions, there is a higher chance of parents interpreting this internal state in a negative way (Crnic & Low, 2002; McMahon & Meins, 2012). These negative interpretations can in turn lead to higher levels of perceived parenting stress (McMahon & Meins, 2012). Thus, we expect that when mothers improve more on mind-mindedness (i.e. make more appropriate mind-related comments or less non-attuned mind-related comments), they are less likely to interpret child behaviour and internal state as negative resulting in a reduction of perceived parenting stress.
The Current Study. In the current pilot study, a longitudinal design consisting of three measurement occasions (waitlist, pretest and posttest) was used to evaluate the effectiveness of MBTT on both maternal mental health (stress) and the mother-child interaction quality (mind-mindedness and sensitivity). For investigation of maternal stress, two extra follow-up (8 weeks and a year later) occasions were available. Using multilevel modeling we
investigated whether mind-mindedness, sensitivity and maternal stress would change after the intervention. Furthermore, we investigated the possible moderator effect of mind-mindedness
on the other outcome variables stress and sensitivity. In other words, did changes in mind-mindedness scores predict changes in mothers’ sensitivity and stress.
Method Participants
In this pilot study, 44 mothers (Mage = 35.06, SD = 4.62, age range: 25.65-46.46 years)
took part in the training because of elevated stress levels and/or mental health problems, such as anxiety or depression. Eight weeks before the start of the intervention, the maternal
average level of stress (M = 63.24, SD = 19.05; NOSI-K) was significantly higher than the cutoff score (56) of average level of stress in a non-clinical sample of mothers t(28) = 2.047,
p = 0.05. The levels of maternal stress (M = 65.65, SD = 22.73) at the pre-test condition were
also above average t(36) = 2.582, p = 0.014. Table 6 represents the percentages and frequencies of levels of maternal stress compared to clinical and non-clinical samples.
In total 9 of the 44 mothers in the current study dropped out, with the main reason to receive additional treatment. Eight weeks before the start of the intervention, the mean scores of mothers that dropped-out on all outcome variables of interest did not differ significantly from the mothers that did not dropped out (range t-scores: -1.147; 0.103, range p-values: 0.261; 0.979). Mothers participated with their children aged between 0 and 4 years old (23 boys, 21 girls, Mage = 1.3, SD = 0.97). Mothers signed an informed consent prior to the start
of the research and the study received approval from the ethical committee in November 2015 (2017-CDE-7946 & 2015-CDE-4747 ).
Materials and procedure
Research procedure. The current study used only part of a larger dataset established to investigate the effects of MBTT. The study design consisted of waitlist (T1), pre-test (T2) and post-test (T3) assessments. All measurements occasions were eight weeks apart from
each other, starting with the waitlist assessment, eight weeks before the first training session was scheduled. Only for maternal stress some additional follow-up measures for 26 mothers were available. Assessment of the waitlist measurement was only possible for mothers who were registered eight weeks before the start of the training. The observational measurements preferably took take place at the mother´s home, aiming for more natural observations and higher external validity compared to lab-observations. During the home-visits, students made video-tapes of 10-minute free play interactions in which the mothers were instructed to play with their baby as they would if they had some free time together. Later, all videos were coded on mind-mindedness and sensitivity by trained observers. Furthermore, the researchers conducted the mind-mindedness interview and a 4-minute face-to-face interaction. However, these measurements were not used in this study.
Whenever it was not possible to observe the mothers at home, observations took place at UvA Minds. In general, means of our outcome variables of interest on all measurement occasions did not differ across the two different settings (observations at home or at UvA Minds). Only at the pre-test there was one significant difference between the two settings: proportions of non-attuned mind-related comments were higher in observations that took place at UvA Minds compared to home observations t(32) = -2.183, p = 0.036.
Maternal stress. The Nijmeegse Ouderlijk Stress Index-Kort (NOSI-K, shortened version) is a Dutch questionnaire designed to estimate the levels of experienced parental stress. The questionnaire consists of 25 items, in which parents choose on a 6-point Likert scale to which extent they agree with a stance on parental stress. An example of an item is: “Considering only this child, parenthood is more difficult than I thought it would be’’. The answer options range from (1) I completely disagree to (6) I completely agree. Each answer option is connected to a score and all scores can be summed into a total parental stress score.
The higher the scores are, the more stress the mothers experience. Norm scores, adjusted for parental gender and sample (clinical or not), are available and can be used to classify mothers as having above average, average or beneath average levels of experienced parental stress.
Whereas the 25-item version of the NOSI-K is appropriate to use in the infant groups, an adaption of the NOSI-K (23-item version) is more suitable for measuring maternal stress of mothers in baby groups. In this adaptation two items were deleted that do not match the developmental stage of babies. First deleted item is; “My child’s attention fades more often than I thought”. Second deleted is item; “When I prohibit something, later, my child will do this again”. In all multilevel analyses, the test scores of the 23-item version will be used for all mothers, also for mothers participating in infant groups, to gain more statistical power. Norm scores for the 23 and 25 item versions are represented in Table 5. The reliability of the NOSI-K has been estimated within a range of .92 and .95 (Egberink, Frima, & Vermeulen, 2014). In the current study, Cronbach’s alphas for the 23-item version were found to be good; respectively 0.895 at waitlist, 0.937 at pre-test and 0.903 at post-test condition.
Mind-mindedness (observations). The 10-minute video-fragments of the free-play interactions were coded on mind-mindedness using a coding-system based on the Mind-Mindedness Coding Manual developed by Meins and Fernyhough (2015). All video-fragments were transcribed and coded by two trained scholars in order to calculate the proportions of appropriate and non-attuned mind-related comments. Mind-related comments are comments that relate to the mental state of the child and include comments regarding the child’s: (a) wishes: comments referring to what a child wants, prefers, desires or the intention a child has, (b) cognitions: statements about the thoughts children could have, the decisions they make, what they know or they remember (c) emotions: comments referring to the emotional state of the child, (d) epistemic states: comments in which mothers indicate that
they think the child is fooling her or when the child makes a joke and (e) speech on behalf of
the child: assumes that a mother can empathize with her child, evidenced by the mother
making a comment that could be said or thought by the child. Comments not categorized as mind-related referred to the child’s; perception (“Do you see that?”), saying/talking (“what do you say?”), non-specific states (“what is the matter?”), or general comments which include all remaining comments.
Mind-related comments could be classified as either appropriate or non-attuned. A comment is appropriate when it is in concordance with the observers reading of the child’s internal state and appropriately follows the behaviors of the child. On the contrary, comments are non-attuned when the observers disagree with the mother’s interpretation of the child’s current internal state and her comment does not appropriately follow child behaviors. Proportions for appropriate and non-attuned mind-related comments are calculated by dividing the number of appropriate and non-attuned mind-related comment by the total number of comments.
Further, we coded whether mothers’ mind-related comments were made with an irritated tone of voice (Meins & Fernyhough, 2015). Earlier research on mind-mindedness in a clinical sample, showed that clinical mothers made appropriate mind-related comments but were more inclined to use an irritated tone (Pawlby et al., 2010). Consequently, these mind-related comments did not contribute to interactions of higher qualities even though they were appropriate. Since our sample consists of mothers with above average levels of stress this could be interesting to take in to account in the current study.
To assess whether the mind-mindedness scores were consistent, the inter-observer reliability (Cohen’s Kappa) was calculated using an additional observer. The Cohen’s Kappa was calculated for two different observation categories; (1) whether the observer thought a
comment was related or not and (2) whether the observers agreed whether a mind-related comment was appropriate or non-attuned. Based on the Cohen’s Kappa scale descriptions of Landis and Koch (1977) it could be concluded that the inter-observer reliability for both categories are almost perfect with an K of 0.97 for the first category and 0.87 for the second.
Ainsworth Sensitivity scales. To determine maternal sensitivity, two 9-point Maternal Sensitivity rating scales, based on the sensitivity scale descriptions of Ainsworth (1969), were used. The first scale, sensitivity versus insensitivity, was assessed to determine whether a mother was sensitive or in sensitive to the signals of her child. Sensitive mothers made themselves available to perceive child signals, could interpret these signals and could act accurately upon them. The second sensitivity scale, acceptance versus rejection,
determined the balance between positive and negative feelings of mothers concerning her child. Furthermore, it also described whether mothers were patient, whether they accepted a negative internal state of the child and whether mothers had respect for the child’s autonomy. A comprehensive overview of the scoring procedure and scale descriptions can be found in Appendix A.
All video-fragments were coded independently by two trained scholars. For more reliable scores, the video-fragments were coded blindly. This means that the raters did not know whether they were coding the waiting-list, pre-test or post-test condition. Observers compared their results of each video-fragment resulting in an average intra-class correlation (ICC, consistency, average measures) that could be described as excellent (ICC = .83) for the sensitivity versus insensitivity scale and good (ICC = .70) for the acceptance versus rejection scale (Cicchetti & Domenic, 1994). Moreover, for more reliable and less subjective scores,
the two raters discussed every video-fragments of which the scores differed between the two observers until they reached consensus about the final score.
The Intervention. MBTT consists of eight weekly sessions with two hours scheduled each week, and an additional follow-up session eight weeks after the end of the training. The MBTT sessions are executed in small training groups with a maximum of 6 participants per group. Each group is led by an experienced MBTT trainer. In all sessions, except for the first and the fifth, the children are present. The sessions without children allow for a clear
introduction (first session), for a deeper discussion of (emotional) topics, and for full concentration on practicing mindful meditation. On the contrary, the sessions with the children allow for mothers to directly apply their learned mindfulness skills when they are in their parental role. This makes the training more generalizable to the everyday life of a parent.
Structural components of the training are formal mindfulness meditations based on mindfulness-based stress reduction and mindfulness-based cognitive therapy. Another import component of the trainings involves meditations in which mothers focus on their child. For instance, a watching meditation, in which mothers are asked to watch every step and behavior of the child and to empathize with the thoughts and the discoveries of the child.
In the present study, one of the trainers was accompanied by an Infant Mental Health Specialist (IMHs). IMHs offer psychological guidance to mothers, evaluate progress in mothers and in the interaction between mother and child. The other MBTT trainer was not accompanied by an IMHs, but by a student of the department of Child Development and Education. However, for both the students as the IMH-specialist, the main task involved observing the children during the meditation sessions and to signal the mothers when the child needed their mother’s attention.
Data analysis. The current study used multilevel data analyses to evaluate the effects of MBTT on parental stress, mind-mindedness and sensitivity. Multilevel models entail that lower level units are nested within the higher-level units. In this study, the three different measurement occasions are nested within individual mothers. An important advantage of multilevel models is that it allows for the violation of the assumption of independence between the observations (Snijders & Bosker, 2012). This is important in the current study since the measurements were repeated and thus not independent from each other. Another advantage as mentioned by Snijders and Bosker (2012) is that multilevel models are more flexible in dealing with unbalanced data structures. This holds that, if data is missing at random or completely at random, participants of which not all measurements occasions are available can still be included in the study (Kwok et al, 2008). This is appropriate considering that not all mothers participated in the waitlist condition.
Five multilevel models were used to investigate the research questions with the following outcome variables of interest: (1) maternal stress, (2) proportion of appropriate mind-related comments, (3) proportion of non-attuned mind-related comments, (4) sensitivity versus insensitivity scale and (5) the acceptance versus rejection scale. Dummy codes were created to indicate the three different measurement occasions with pre-test scores set to redundant to use it as a reference variable. In the models predicting sensitivity, acceptance and maternal stress the mind-minded deviation score between pre- and post-test were added as predictor to investigate the possible moderation effect of mind-mindedness. The
significance-level of p < 0.05 is used to assess whether the effects in the prediction models are significant.
Also, we examined whether our control variables were associated with any of our outcome variables of interest. The first control variable is which of the two MBTT trainers
gave the training sessions. This is to control for possible differences between the two trainers and the fact that one of the trainers was accompanied by an IMH-specialist. The second control variable is infant age. It might be harder for mothers to practice mindfulness in the presence of older children since toddlers may demand more attention from their mother.
Investigating the correlations between our control variables and our outcome variables of interest during pre-test there appeared to be a significant correlation between the child’s age and maternal sensitivity pre-test scores. Mothers with older children had higher
sensitivity scores compared to mothers with younger children. Therefore, we controlled for child age in the multilevel model predicting sensitivity scores in an additional analysis.
Results
Preliminary analyses. The inspection of the skewness and kurtosis values indicated no evidence against the assumption of normality, since the values of both skewness and kurtosis for all outcome variables of interest were smaller than 2 times their standard error, except for the proportions of appropriate and non-attuned mind-related comments. Also, the histogram of non-attuned mind-related comments did show some skewed distributions. Furthermore, we checked the QQ-plots of the level-one residuals of our initial multilevel models. There was no evidence for violations of this assumption for most of these variables. Only the plot for non-attuned mind-related comments showed some deviations of the normal distribution. Therefore, we checked whether log-transformations would improve the
distribution of this variable and would influence the results. The normal distribution did not improve after the transformation. Also, multilevel models with the transformed and
untransformed variables showed similar results. We therefore chose to perform the multilevel analysis with the untransformed (raw) values of non-attuned mind-related comments. Table 1 present descriptive statistics and Table 6 presents percentages and frequencies of the seven
levels of maternal stress according to the NOSI-K categories in clinical and non-clinical samples.
Correlations between the outcome measures. At all measurement occasions, there were significant high positive correlations between the 23-item and the 25-item version of the NOSI-K and between both sensitivity scales. Only for the pre-test measurement, appropriate mind-related comments correlated significantly with the 23-item version of the NOSI-K. Furthermore, only at post-test measurement non-attuned mind-related comments were negatively significantly correlated with both sensitivity scales. Correlations between the outcome variables of interest and age were significant with: maternal stress (only 25-item version) at post-test, sensitivity scale at pre-test, acceptance scale at post-test and proportions of non-attuned mind-related comments at post-test. All correlations are represented in Table 3. Additionally, Table 4 represents correlations between deviation scores of all outcome variables of interest and control variables.
Maternal stress. Table 2 presents the results of the multilevel analyses for all outcomes variables with and without the moderation effect of mind-mindedness
(non-attuned). Maternal stress decreased significantly from pre- to post-test, showing a small effect size (Cohen’s d = 0.36; Cohen, 1988). There were no significant differences in the level of experienced maternal stress between the waitlist condition and the pre-test. Maternal stress at the first follow-up measurement was significantly lower than the pre-test levels of maternal stress β = -12.28, p < 0.001 , d = -0.64. Maternal stress at the second follow-up measurement was also significantly lower than the pre-test levels of maternal stress β = -12.54, p = 0.019, d = -0.65. Both follow-up effects were medium in size. Also, mind-mindedness did not
Mind-mindedness. Inspection of the data showed that appropriate mind-related comments with an irritated tone were almost non-existing. Moreover, none of the mothers made irritated comments in more than one of the three video-fragments. Thus, calculating proportions and conducting multilevel-analyses was unnecessary.
Proportions of appropriate mind-related comments did not significantly change from pre- to post-test. On the other hand, proportions of non-attuned mind-related comments decreased significantly between pre- and post-test, showing a large effect (d = -0.71). Proportions of appropriate and non-attuned mind-related comments did not differ between waitlist and pre-test measurements.
Sensitivity. Mothers scored significantly higher on the sensitivity versus rejection scale at the post-test compared to the pre-test. Sensitivity scores did not differ between waitlist and pre-test. Also, mothers scored significantly higher on the acceptance versus rejection at the post-test compared to the pre-test. Acceptance scores did not differ between waitlist and pre-test condition. The effect sizes on sensitivity scores were found to be small (d = 0.33), whereas the effect sizes on acceptance scores could be described as medium (d = 0.51). Also, mind-mindedness did not moderate the effect that MBTT has on maternal sensitivity and acceptance.
Maternal age. As mentioned above mothers with an older child were more sensitive at pretest. Therefore, we included child age in the multilevel model predicting parental sensitivity scores in an additional analysis. Age of the child was a significant positive
predictor of maternal sensitivity scores (taken all measurement times together). Moreover, the interaction effect of post-test with the age of the child appeared to be non-significant. This indicates that mothers with older children (toddlers) did not increase in sensitivity compared mothers with younger infants.
Discussion
The current study aimed to investigate the effects of MBTT on maternal mental health (stress) and on the interaction quality between mother and child (mind-mindedness and sensitivity). It was hypothesized that MBTT would reduce maternal stress and improve mother-child interaction quality by enhancing maternal levels of sensitivity and
mind-mindedness. After MBTT, levels of maternal stress had decreased significantly and this effect remained 8 weeks and one year after the training. Furthermore, after the training, mothers made significantly less non-attuned mind-related comments and were more sensitive and accepting towards their children. No significant differences were found for appropriate mind-related comments and moderating effects of mind-mindedness appeared to be non-significant.
Confirmatory to our expectations, MBTT could be regarded as a promising
intervention for both maternal mental health and mother-child interaction quality. MBTT led to significant lower levels of maternal stress at the post-test (small effect) and even continued to improve to a larger effect size (medium) at the first follow-up 8 weeks after the post-test. This effect remained at the second follow-up one year later. The further increase of an effect is called ‘a sleeper effect’ and is common in parenting interventions (Van Aar, Leijten, Orobio de Castro, & Overbeek, 2016). Whereas this study did not find any moderator effect for the existence of sleeper effects in parenting interventions, we hypothesize that mothers needed to integrate the set of learned mindfulness skills in everyday life to gain even more reductions in maternal stress. The medium effects of MP on maternal stress are comparable to the effects found in other MP studies with (Potharst et al., 2017) and without (Bögels et al., 2014) the presence of the children during the sessions. The effects of the current study are smaller than in the study of Perez-Blasco et al. (2013). They reported large effect-sizes when comparing the levels of maternal stress of mothers that receive MP intervention in the
presence of their babies versus a control condition. However, with the lack of follow-up measurements it is not clear whether these large effects sustained over time.
Also in line with our hypotheses, mother-child interaction quality increased from pre- to post-test. First, mothers made significantly less non-attuned mind-related comments at the post-test (large effect). However, contrary to our hypotheses we did not find a significant effect for appropriate mind-related comments. This means that the number of mind-related comments did not increase, but mothers did show more attunement to their child’s mental states. This result is in line with the study of Schacht et al. (2017) investigating the effects of video-feedback intervention with the aim of improving mind-mindedness. After this
intervention, mothers showed less non-attuned mind-related comments, whereas no
significant effects were found for appropriate mind-related comments. These results suggest that MBTT does not increase the tendency of parents to read the child’s internal state, but suggest that MBTT helps mothers to interpret the child’s internal state more accurately.
An explanation for this result may be that appropriate mind-related comments reflect parents’ tendency to mentalize (i.e., being inclined to make sense of the child’s mental states). This tendency is partly formed by parents’ rearing- and attachment-related experiences with their own parents (Arnott & Meins, 2007; Milligan, Khoury, Benoit, & Atkinson, 2015). This tendency may therefore be difficult to change within an 8-week time span. Non-attuned comments, on the other hand, do not necessarily represent parents’ tendency to mentalize frequently, but reflect whether parents mentalize accurately (i.e., appropriate connections between the baby’s behaviour and putative states are formed). Because MBTT explicitly stimulates the parental mind in being free from distortions and judgement, parents can learn to interpret the child’s internal state more accurately, leading to fewer non-attuned mind-related comments.
Secondly, MBTT had significant effects on both sensitivity scales; small improvements on the sensitivity versus insensitivity scale and medium effects on the
acceptance versus rejection scale. The small versus medium effects of both sensitivity scales
could be explained by the content of MBTT. The meditation sessions in which children are present are focused on mothers’ awareness and ability to be less judgemental toward child behaviours and signals. These meditations are particularly focused on mindful and cognitive processes, rather than behavioural processes. Parents are asked to observe their child in a non-judgemental way and to accept the emotional cues that they receive from their child. Thus, parents explicitly practice with being more accepting towards the infant’s state (which in turn seems to be more related to the acceptance scale). On the other hand, parents are not explicitly encouraged to act sensitively upon their child’s signals, which lies at the heart of the sensitivity scale. This could be an explanation for the difference in effect sizes. Some caution should be warranted concerning the results of the sensitivity scale, since additional analyses showed that being sensitive was confound with children’s age (i.e., older mothers behaved more sensitive towards their children). Thus, the mechanisms of change may be different for mothers with young baby’s and mothers with an older child. For each of the outcome variables of interest no significant differences were found between waitlist and pre-test condition, suggesting that effects are mostly attributable to the intervention and not to time.
Contrary to our hypotheses no evidence was found for a moderating effect of mind-mindedness on the effect that MBTT has on maternal stress and sensitivity. A possible theoretical explanation for these results might be that MBTT did not increase parental tendency to read the child’s internal state (i.e. no improvement on appropriate mind-related comments), but only improved the accuracy of the maternal interpretations of the child intern
state (i.e. reduction of non-attuned mind-related comments). It might be that only appropriate mind-related comments and not non-attuned mind-related comments could moderate the effects of the intervention on maternal stress and sensitivity. However, we could not test this hypothesis since appropriate mind-related did not improve. Another explanation for the non-significant moderator effects concerns a lack of power to detect interaction effects due to a small sample size (Aiken & West, 1991).
We also did not find any support for the hypothesis that mothers in a clinical sample often make irritated mind-related comments because of which these comments will not contribute to the mother-child interaction quality. This could possibly be explained by the fact the mothers in our sample do have clinical problems, but do not have severe clinical problems such as the study of Pawlby et al. (2010). Mothers in the latter study were hospitalized because off a severe episode of psychiatric illness. To illustrate, the levels of maternal stress were beneath the average of mothers in a clinical sample. Thus, the detection of irritated mind-related comments might only be relevant in severe clinical samples and not samples with mild clinical complaints.
Limitations and Future Directions. First, caution is warranted in interpreting causality in our results. Whereas the non-significant differences between the waitlist and pre-test conditions controls for some of the time related variance, conclusions about causality are limited by the lack of randomized control groups. Future research should preferably perform randomized controlled trials which do allow for conclusions about causality. A second limitation is the relative small sample size of the current study, which is especially important when one wants to construct more complex (i.e. add more predictors) to the multilevel models (Bosker & Snijders, 2012). The small sample size is even more problematic for some of the timepoints with missing values, such as the waitlist condition. In future research with
larger samples, it would be interesting to construct more complex models with the interaction effects of moderators and control variables.
Other limitations concern the observations. First, the settings of the video-observations were not standardized. Whereas it was encouraged to film mothers in the natural context of their own homes, this was not always possible. However, this was the first study to conduct observational measures in order to evaluate actual changes in mother-child
interactions after MBTT. Another limitation concerns shared method variance which implies that coding mind-mindedness and sensitivity based on the same free-play video-fragments could bias the results. Future research should be guided by the recommendations of
Mcmahon and Bernier (2017) in which they emphasize that mind-mindedness and sensitivity should not only be coded using different video fragments, but also at different time point in order to observe both construct more reliably.
Despite the limitations and the directions for future research, the current study is one of the first to examine the effects of MBTT, which is one of the first post-natal MP
interventions in the presence of children. This study extents the knowledge of previously studies by investigating the effects of the intervention on mother child-interaction quality. It complements the study of Potharst et al. (2017) which stated that in future research mother-child interaction quality should be measured using observations instead off questionnaires for more reliable results (Mirron, Lewis, & Zeanah, 2009).
The current study confirmed the results of earlier studies indicating that MP
interventions could improve maternal mental health and mother-child interaction quality. In addition, the current study confirms that MP interventions are not only effective in de pre-natal period (Dunn et al, 2012; Shadix et al, 2014), but the efficacy extends to the post-pre-natal period. Furthermore, MBTT is in contrast to anti-depressants and psychotherapy effective in
reducing both maternal mental health and mother-child interaction quality. Anti-depressants and psychotherapy were only effective in improving maternal mental health and not in interaction quality. Interventions aimed at improving mother-child interactions are important, since poor interaction quality is associated with negative child developmental outcomes and interactions of high quality are associated with positive child developmental outcomes (Dubois-Comtois et al., 2013). Future research could compare the results of MBTT with treatment consisting of anti-depressants and psychotherapy.
In future research, it is also important to investigate other determinants of the mother-child interaction quality, such as attachment security, and other determinants of maternal mental health, such as anxiety and depression. Furthermore, future research should
investigate whether the enhanced mother-child interaction quality indeed leads to better child outcomes, such as social competence, emotion regulation and emotional understanding (Dubois-Comtois et al., 2013). Also, whereas the current study showed that MP interventions in the post-natal period have promising results, in future research it would be interesting to investigate whether interventions in the presence of children is more effective than MP interventions in the pre-natal period.
To conclude, the current study confirms the promising effects of MBTT on maternal mental health (stress) and mother-child interaction quality. Based on these promising effects, we encourage to perform randomized controlled trails in future research to determine causal effects more reliably. When effective, MBTT can be used to improve maternal mental health and prevent negative child outcomes by improving the mother-child interaction quality.
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Table 1 Descriptive statistics and estimated marginal means for the different outcome variable of interest predicted by measurement occasions.
Waitlist Pre-test Post-test
Outcome N M SD range N M SD range N M SD range
Maternal stress 29 63.24 19.05 35-109 37 65.65 22.73 26-122 33 58.46 17.40 27-107 Proportion appropriate
mind-related comments 30 0.05 0.04 0-0.15 35 0.04 0.03 0-0.12 28 0.05 0.03 0-0.11
Proportion non-attuned
mind-related comments 30 0.02 0.02 0-0.07 35 0.02 0.02 0-0.07 28 0.01 0.01 0-0.04
Sensitivity vs. insensitivity 31 5.68 1.87 2-9 37 5.73 2.12 1-9 31 6.61 1.78 3-9
Table 2 Parameter estimates, standard errors and F-values of the multilevel models predicted by measurement occasion and the moderating effect of mind-mindedness non-attuned
Waitlist Pre-test (intercept) Post-test Deviation score
mind-mindedness non-attuned mindedness non-Deviation mind-attuned*post-test
B(SE) F P B(SE) F p B(SE) F p B(SE) F P B (SE) F p
Maternal stress .39 .02 .902 65.05 414.14 .000 -7.31 6.35 .014 .54 .02 .886 64.25 220.45 .000 -9.74 6.49 .014 -230.76 1.920 .176 43.13 .09 .763 Sensitivity -.03 .01 .929 5.68 321.05 .000 .65 4.98 .030 -.07 .05 .833 6.00 201.05 .000 .24 .44 .512 -3.06 .04 .852 -14.71 1.17 .285 Acceptance .17 .22 .644 5.88 323.78 .000 1.05 8.93 .004 .22 .30 .585 6.26 211.88 .000 .53 1.60 .212 9.10 .31 .580 -25.80 2.73 .105 App MRC’s .01 .577 .451 .04 61.82 .000 .01 .835 .365 NA MRC’s .00 .10 .757 .02 52.07 .000 -.01 10.55 .002
Table 3 Correlations for outcome variables and control variables at each measurement occasion Time 1. 2. 3. 4. 5. 6. 7. 8. 1. maternal stress (23) T1 1 T2 1 T3 1 2. maternal stress (25) T1 1.00** 1 T2 1.00** 1 T3 1.00** 1 3. sensitivity T1 -.15 -.09 1 T2 -.19 -.04 1 T3 -.01 -.22 1 4. acceptance T1 -.23 -.12 .92** 1 T2 -.15 .05 .93** 1 T3 -.09 -.25 .87** 1 5. appropriate mind-related comments T1 .37 .28 -.01 .04 1 T2 .35* .37 -.05 .01 1 T3 .08 .31 .33 .34 1 6. non-attuned mind-related coments T1 -.07 -.60 -.11 -.25 .16 1 T2 .13 .19 .16 .09 .07 1 T3 -.09 .07 -.39* -.40* .19 1 7. group T1 .05 .05 -.20 -.23 -.07 -.18 1 T2 -.14 -.14 .06 .03 .13 .09 1 T3 -.29 -.29 -.11 -.09 .11 .04 1 8. age of child T1 -.20 -.24 .35 .29 -.51 -.43 -.31 1 T2 -.28 -.43 .52* .38 -.14 -.21 -.31 1 T3 -.37 -.62* .42 .55* -.23 -.53* -.09 1
*. correlation is significant at 0.05 level (2-tailed) **. correlation is significant at 0.01 level (2-tailed)
Table 4 correlations between deviation scores of all outcome variables of interest and control variables (age of the child in months and trainer)
M(n) 1. 2. 3. 4. 5. Child age trainer 1. deviation scores maternal stress -7.39 (33) 1 0.217 -0.144 2. deviation scores sensitivity 0.55 (31) 0.247 1 0.176 -0.160 3. deviation scores acceptance 0.97 (31) 0.202 0.812 ** 1 0.175 -0.132 4. deviation scores appropriate MRC’s 0.01 (28) 0.099 -0.038 -0.085 1 0.085 0.217 5. Deviation scores non-attuned MRC’s -0.01 (28) 0.030 -0.046 0.014 0.060 1 -0.043 -0.041
Table 5 NOSI-K categories of maternal stress for the 23 and 25 item version Very low low Beneath
average average average Above high Very high Non
clinical 23 items 25 items <26 <28 27 - 30 29 - 33 31 – 39 34 – 42 40 – 56 43 – 61 57 - 67 62 - 73 74 - 89 68 - 82 >83 >90 Clinical 23 items <42 43 - 54 55 – 66 67 - 89 90 - 101 102- 110 >111
Table 6 Percentage frequencies of levels of maternal stress compared to clinicial and non-clinical samples.
Missing Very low Low Beneath
average Average Above average High Very high Waitlist Non-clinical 15 (34.1) - - 3 (6.8) 11 (25) 2 (4.5) 9 (20.5) 4 (9.1) Clinical 15 (34.1) 4 (9.1) 8 (18.2) 4 (9.1) 9 (20.5) 2 (4.5) 2 (4.5) - Pre-test Non-clinical 7 (15.9) 1 (2.3) 1 (2.3) 2 (4.5) 11 (25) 6 (13.6) 7 (15.9) 9 (20.5) Clinical 7 (15.9) 5 (11.4) 8 (18.2) 8 (18.2) 9 (20.5) 5 (11.4) - 2 (4.5) Post-test Non-clinical 11 (25) - 1 (2.3) 2 (4.5) 15 (34.1) 5 (11.4) 6 (13.6) 4 (9.1) Clinical 11 (25) 4 (9.1) 13 (29.5) 5 (11.4) 10 (22.7) - 1 (2.3) -
Scale 1: Sensitivity versus insensitivity to the baby’s signals
Scale description: This scale describes the mother’s ability to perceive and to interpret accurately the
signals and communications implicit in her infant’s behavior, and given this understanding, to respond to them appropriately and promptly.
This scale consists four different components: (a) Awareness of signals
• Accessibility versus ignoring and neglecting: A mother cannot be sensitive when she is not accessible to the communications of the baby (this condition is necessary for sensitivity but not sufficient).
• Threshold: high threshold mothers respond only to the most obvious signals, whereas low threshold mothers respond to almost every signal of the child. A sensitive mother has a low threshold.
(b) Accurate interpretation of the signals
• Mothers’ awareness: An inattentive mother misses the prodromal sign of a infant’s state and is therefore often unable to interpret the infant’s state correctly.
• Freedom from distortion: the extent in which mothers bias the perceptions of their child’s signals based on their own wishes, mood or fantasy (example: mother not in the mood for interaction -> interprets the fussy bids for attention as fatigue and puts the child in bed).
• Empathy: the mother must be able to empathize with her baby’s feelings and wishes before she can respond sensitive to them = seeing things from the baby’s point of view.
(c) An appropriate response to them
• The mother acts in a way that corresponds with the signal the child has given a sensitive mother gives the baby what his communications suggests he wants.
Note that some situations do ask for limit setting and a mother that acts against the wishes of the child. However, in such interactions the sensitive mother acknowledges the baby’s wishes even though she does not accede to them. • The (appropriate) response is well-resolved and completed: for example,
when comforting the baby, the mother holds the child long enough so that the baby does not want to be picked up immediately when put down. A low sensitive mother shows fragmented and incomplete responses to the baby’s signals.
(d) A prompt response to them
• Whether a response (appropriate or not) is delayed or not in the case of a delayed response, the child cannot link this response to his own signal. A
sensitive mother’s response is not delayed = the infant is enabled to feel competent in influencing the social situation indicated by the direct response of the mother.
Description of the different scores 9 = highly sensitive
• The mother is highly aware of the signals of the infant. • She acts promptly and accurate upon the signals of the infant.
• The interpretation of the signals is not biased by the wishes, mood or fantasy of the mother.
• The mother is not only able to read the obvious signals, but interprets even the smallest signals (she has a low threshold).
• The mother gives the child what his signals indicates he wants. Note: when the infant wants something he cannot get or needs limit setting, the mother acknowledges the infant’s signals and offers for example an acceptable alternative.
• Mothers actions are well-rounded and complete the mother’s action makes the infant feel satisfied.
• For toddlers: the mother “scaffolds” her instructions to her child during play 7 = sensitive
• Like the highly sensitive mother, the sensitive mother is aware of the infant’s signals and acts promptly and accurately upon them. However, she might not interpret the very small signals or sometimes misses the infant’s cues (through dividing her attention).
• Clear infant signals are never interpreted wrong!
• The mother’s perceptions of child behavior are not distorted: the mother sees things through the child’s point of view.
• These mothers are somewhat less sensitive then mothers with higher scores, so their responses might not be prompt or accurate all the time.
• Although there are some mismatches the mother’s interventions and interactions are
never seriously out of tune with the baby’s tempo, state and communications. 5 = inconsistently sensitive
• There are periods wherein the mother is quite sensitive, but there are also occasions in which the mother is insensitive to the baby’s communications.
• Her awareness may be intermittent.
• Her perceptions may be distorted in regard to 1 or 2 aspects but accurate in other important aspects.
• She is more frequently sensitive than insensitive 3 = insensitive
• This mother frequently fails to respond the infant’s signals appropriately and/or promptly.
