Relationship-based interventions, like infant mental health, target the caregiving relationship as a way to support infant attachment security and social-emotional development.  In theory, IMH therapists support reflective functioning when they provide developmental guidance, speak for the baby, remain curious about both parents’ and infants’ internal experiences and help parents reflect on and re-process experiences and emotions from their own childhood. As such, reflective functioning is an important construct in IMH research and practice.

Reflective functioning is the capacity to reflect upon internal experiences (thoughts, emotions and intentions) in self and others and to link these internal experiences with behaviors (Rosenblum, McDonough, Sameroff, & Muzik, 2008; Sharp & Fonagy, 2008; Slade, 2005).  A small body of research suggests that reflective functioning is the foundation for parenting sensitivity, which is associated with a variety of positive developmental outcomes, including a secure attachment. Secure attachment, in turn, is related to prosocial behavior, emotion regulation, and psychosocial adjustment (for a review, see Thompson, 2008).  Interventions aimed at increasing reflective functioning, beginning as early as in pregnancy, are of interest to research and to clinicians utilizing infant mental health models.

The effectiveness of these interventions is tested by measuring reflective functioning at the beginning of the intervention, in pregnancy, and then again following intervention after the child has been born. The problem with this is that we do not actually know if reflective functioning remains stable across the transition to parenthood or increases as the parent-child relationship develops, the child’s cues become clearer, or the child develops language. Not knowing if reflective functioning increases naturally as a relationship unfolds makes it difficult to determine if interventions are actually successful.

Research Questions

In the Early Relationships Lab at the Merrill Palmer Skillman Institute we are studying reflective functioning in pregnancy and postpartum to better understand a) whether risk factors influence the ability to be reflective (i.e. a history of maltreatment and depression), b) how reflective functioning supports sensitivity and a secure attachment, c) whether IMH services support parents’ reflective capacity and d) factors that influence stability and change in reflective functioning across the transition to parenting.

Overview of Study Methods

All of our studies assess parental reflective functioning with a one-hour semi-structured interview that asks parents to reflect on their own and their children’s internal experiences. The interview is coded for parents’ use of mental state language (language about their children’s internal mental and feeling states such as the parent commenting on what she thinks her child is thinking or feeling), their ability to link mental states to behavior (such as the parent linking her perceptions of the child’s emotions, goals or intentions to the child’s behavior) and their curiosity to understand other’s minds (Slade, 2005). We are assessing reflective functioning in three studies.

Wayne County Baby Court. We are evaluating whether this collaborative approach is effective at improving safety, permanency and well-being.  Parent-infant dyads receiving Baby Court services work with an infant mental health clinician who is part of a collaborative team that includes the DHHS caseworker and the child’s attorney. The evaluation includes a pre- and post-test parent-child interaction task, a developmental assessment, a clinical interview to assess reflective functioning and parents’ report on their child’s social-emotional development.

The PuRPLE Study. We are testing the stability and change in reflective functioning in a subsample of mothers participating in a larger longitudinal study that assesses fetal brain development, parenting and child development across infancy. Our team has spent the last two years collecting data from women beginning during pregnancy and then again when the infant is seven months. We assess reflective functioning at both time points. Parents also complete a variety of self- report measures about mental health, stress, social support, temperament and parenting.  The dyad participates in the still-face procedure and we also test the infants’ development.

The MACY Study. This longitudinal study (PI: Muzik) followed mothers, with and without histories of child maltreatment, and their infants through the preschool period. The study sought to better understand how trauma shapes mental health, parenting representations, parenting behavior and subsequent child biology and attachment. The MACY team interviewed more than 100 mothers using the Parent Development Interview, which was coded by the team in the Early Relationships Lab. Some self-report data was collected via phone when the infant was four months. Dyads participated in home visits when the infant was 6 months, a lab visit at 15 months and mothers were interviewed by phone when the infant was 18 months.

Results

 Risk and Reflection. Our findings from the MACY study suggest that women who have a history of childhood maltreatment demonstrate a wide range of reflective functioning. Although most women in the study tended to have few demographic risks, for example most were married and college educated, the presence of a single demographic risk factor (low income, low level of education, young or single parent) was associated with lower reflective functioning scores. Contrary to our expectations, maternal reflective functioning was not related to experiencing maltreatment as a child, experiencing multiple types of maltreatment as a child, or having a depression or PTSD Diagnosis (Muzik, et al., 2015; Stacks, et al., 2014).

Reflective Functioning, Parenting and Attachment. Consistent with previous research, our findings from the MACY study suggest that mothers with higher levels of reflective functioning demonstrate more sensitivity and less negativity when interacting with their infants. Further, maternal reflective functioning differed among infant attachment classifications. Mothers of infants classified as secure had higher reflective functioning scores than mothers of infants classified as avoidant or disorganized. The mechanism by which reflective functioning was associated with attachment was through parental sensitivity (Stacks et al., 2014).

The PuRPLE Study is ongoing; however, preliminary findings suggest that mothers with balanced representations of their attachment relationships with their infants have higher prenatal reflective functioning scores than mothers with disengaged representations (Alismail, et al., 2015;).  Further, mothers who had more instances of being reflective throughout their prenatal interview used more attuned mind-minded comments during the still-face procedure, r = .51, p = .02, (Alrajhi, et al., 2015).

Stability and Change in Reflective Functioning. Preliminary results from the PuRPLE study suggest that maternal reflective functioning in pregnancy is highly correlated with postnatal reflective functioning, r  = .74, p  = .001 and that it increases across the transition to parenthood t(30) = -3.80, p = .001. Future analyses will explore factors associated with stability and change. One factor that may support change in RF is IMH treatment. Preliminary findings from 10 Baby Court parents who have completed the pre- and post-test suggest that parental reflective functioning scores increase as a result of treatment, t(9) = -4.81, p = .001.

Conclusions

Across our studies, it appears that parental reflective functioning is related to observed parenting, infant attachment classification, and mother’s working model of her child. Further, mothers who experience maltreatment as children or who have diagnoses of depression and PTSD demonstrate a range of reflective functioning scores. It will be important to understand what factors support parental reflective functioning in the context of these risks that are usually associated with less sensitive parenting. Our findings also suggest that reflective functioning, while generally fairly stable over time, can increase for some parents across the transition to parenthood. One factor that appears to support parental reflective functioning is IMH treatment.

Key Implications for Practice 

• Maternal reflective functioning is associated with parenting quality and attachment.
• Maternal reflective functioning can change over time and IMH treatment may be effective at supporting parental reflective functioning.

References

Alismail, F., Wong, K., Villa, A., Antilla, C., Beeghly, M., & Stacks, A. (2015, May).Maternal Attachment Representations of the Infant in the First Year of Life: The Influence of Prenatal Reflective Functioning and Depression.Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Alrajhi, N., Costner, S., Stacks, A., Villa, A., Antilla, C. &Beeghly, M. (2015, May). The Role of Reflective Functioning and Maternal Mind Mindedness on Infants’ Language Development in the First Year: Preliminary Findings.  Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Muzik, M., Stacks, A. M., Rosenblum, K. L., Huth-Bocks, A., &Beeghly, M. (2015, May).  The Effects of Trauma and Depression on Parenting Representations and Child Outcomes: Findings from the MACY Study. Workshop presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

Rosenblum, K.L., McDonough, S., Sameroff, A. J. &Muzik, M. (2008). Reflection in thought and action: Maternal parenting reflectivity predicts mind-minded comments and interactive behavior. Infant Mental Health Journal, 29(4), 362-376.

Sharp, C. &Fonagy, P. (2008). The parent’s capacity to treat the child as a psychological agent: Constructs, measures and implications for developmental psychopathology. Social Development, 17(3), 737-754.

Slade, A.  (2005). Parental reflective functioning: An introduction. Attachment and Human Development, 7(3), 269-281.

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. & Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with maltreatment histories: Links to sensitive parenting and infant attachment security. Attachment and Human Development, 16(5), 515-533.

Thompson, R. (2008). Early attachment and later development: Familiar questions, new answers. In  J. Cassidy & P. R. Shaver (Eds). Handbook of Attachment: Theory, Research and Clinical Applications (pp. 348-365). New York: Guilford.

Wong, K., & Stacks, A. M., Ghrist, F., Vila, A., Antilla, C. &Beeghly, M.  (2015, May). Is Reflective Functioning Stable from Pregnancy to Postpartum: Preliminary Findings? .Poster presented at the biennial meeting of the Michigan Association for Infant Mental Health, Kalamazoo, MI.

 Contact Information

For more information contact: Ann M. Stacks at amstacks@wayne.edu