American Journal of Orthopsychiatry 2003, Vol. 73, No.

1, 5564

Copyright 2003 by the Educational Publishing Foundation 0002-9432/03/$12.00 DOI: 10.1037/0002-9432.73.1.55

Parental Psychopathology, Marital Quality, and the Transition to Parenthood

Sonja Perren, PhD, Agnes von Wyl, PhD, Heidi Simoni, PhD, Werner Stadlmayr, MD, Dieter Brgin, MD, and Kai von Klitzing, MD
University of Basel
This study of 80 expectant rst-time parents investigated the associations among marital quality, parental psychiatric disorders, and parentscapacity to form triadic relationships (Triadic Capacity). The results suggest that marital quality as well as maternal and paternal psychopathology affect child and family development as early as pregnancy, when parents prepare themselves to integrate the future child into their relational world.

Maternal psychopathology and marital discord have been found to be associated with problematic socioemotional development or psychiatric disorders in children (Fincham, 1998; Kelly, 2000; Laucht, Esser, & Schmidt, 1994; Oysermann, Mowbray, Meares, & Firminger, 2000; Rutter & Quinton, 1984; Zeanah, Boris, & Larrieu, 1997). The impact of paternal psychopathology has received less attention. In this study of 80 couples expecting their rst child we investigated the association among maternal psychopathology, paternal psychopathology, marital quality, and parental attitudes toward the unborn child and future family life. Specically, we targeted the parental capacity to form triadic relationships (Triadic Capacity). We hypothesized that (a) the severity of parental psychiatric symptoms is negatively correlated with marital quality and (b) both the presence of a psychiatric disorder and low marital quality independently contribute to the variance of parental Triadic Capacity.

Capacity to Form Triadic RelationshipsA Precursor for Successful Parenthood

Pregnancy is a preparatory period during which prospective parents undergo processes of adaptation. Normally, parents begin to form an emotional bond with the unborn child at the level of mental representations (Lebovici, 1988; Soul, 1982). The quality of these representations has been shown to be predictive of the subsequent quality of parentchild interactions as well as of infant development (Benoit, Parker, & Zeanah, 1997; Fonagy, Steele, & Steele, 1991; Steele, Steele, & Fonagy, 1996; von Klitzing, Simoni, Amsler, & Brgin, 1999; von Klitzing, Simoni, & Brgin, 1999, 2000). Intensive changes in the parental partnership often occur during this early phase of the transition to parenthood (Lewis, 1988a, 1988b). Recent studies have shown that triadic interactions have an important inuence on the development of infants and toddlers (Belsky, Crnic, & Gable, 1995; FivazDepeursinge & Corboz-Warnery, 1999; McHale & Rasmussen, 1998; von Klitzing, Simoni, & Brgin, 1999), over and above the dyadic motherchild interaction conceptualized in attachment models. Bowlbys (1969) hypotheses of infant attachment have generated a substantial amount of research on the interaction between mothers and their infants (see Bretherton, 1985; Waters, Hamilton, & Weineld, 2000). Several studies have shown that infant attachment security cannot be generalized across family relationships (e.g., Belsky & Rovine, 1987; Fox, Kimmerly, & Schafer, 1991; Sagi et al., 1985). On the basis of the ndings of their meta-analysis, van IJzendoorn and De Wolff (1997) advocated a move to a more contextual level in attachment theory and research. Likewise, Cowan (1997) emphasized the necessity of including fathers and considering
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Sonja Perren, PhD, Agnes von Wyl, PhD, Heidi Simoni, PhD, Dieter Brgin, MD, and Kai von Klitzing, MD, Department of Child and Adolescent Psychiatry, University of Basel, Basel, Switzerland; Werner Stadlmayr, MD, University Womens Hospital, University of Basel. Heidi Simoni is now at the Marie Meierhofer-Institut fr das Kind, Zurich, Switzerland. Werner Stadlmayr is now at University Womens Hospital, University of Berne, Berne, Switzerland. This study is part of a longitudinal study that was supported by Swiss National Science Foundation Grant 3232330.91. For reprints and correspondence: Sonja Perren, PhD, Department of Child and Adolescent Psychiatry, University of Basel, Schaffhauserrheinweg 55, CH-4058 Basel, Switzerland. E-mail: sonja.perren@unibas.ch

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marital conict and external stressors as important factors in attachment research. In our concept of Triadic Capacity we try to overcome some of the shortcomings of attachment research by considering the motherfatherchild triad and the larger social context instead of focusing only on the motherchild dyad.

Triadic CapacityConcept and Assessment

To assess parents attitudes toward the child and the future family, we used the concept of Triadic Capacity, which was developed by our research group (Brgin & von Klitzing, 1995; von Klitzing, Simoni, et al., 1999; von Klitzing, Simoni, & Brgin, 1999). Triadic Capacity describes the intrapsychic and interpersonal readiness of the parents to integrate the child as an important third person into their mental and relational lives. Specically, it is dened as the capacity of fathers and mothers to anticipate their future family relationships, without excluding either themselves or their partners from the relationship with the infant. Triadic Capacity is considered to be a resource for coping with the transition to parenthood and establishment of the family. Triadic Capacity is assessed at the level of mental representations. Attachment theorists have increasingly moved to the level of representation over the last 15 years (Main, Kaplan, & Cassidy, 1985), especially through the application of the Adult Attachment Interview (George, Kaplan, & Main, 1985), which evaluates the speech of adults about their dyadic experiences with their parents during childhood. The concept of Triadic Capacity extends this approach by including additional aspects of intra- and interpersonal functioning: the structure of the parental partnership, quality of interparental dialogue (cognitive and emotional), exibility and triangularity of their mental representations, and transgenerational continuity of well-integrated experiences of triadic relationships. If both parents have formed rich and exible mental representations of their future child that include the partner, if they openly exchange ideas about their future family life, if this dialogue is embedded in a partnership free from projections and within coherent memories of relationships with the family of origin, the developing parenthood is characterized by a high Triadic Capacity. In contrast, if the parents mental representations are meager and/or rigid, with tendencies to exclude the partner or self (I am the only important caretaker, The baby will probably reject the father, I wont be important to

the baby; babies are mothers business); if there is no or poor-quality dialogue between the parents; and if there are no coherent memories of triadic relationships with the parents of origin (many family conicts with tendencies toward exclusion), the developing parenthood is characterized by a low Triadic Capacity. We consider the Triadic Capacity of parents an important precondition for the formation of a growthpromoting parentchild relationship.

Method Procedure
This study is part of an ongoing prospective, longitudinal study of 80 couples and their rstborn infants. During the second trimester of pregnancy, parents completed several questionnaires on psychopathology, marital quality, and sociodemographics. During the last trimester of pregnancy, parents were interviewed to evaluate their capacity to form triadic relationships (Triadic Capacity). In addition, biological risk factors for pregnancy were ascertained.

Participants
Eighty couples expecting their rst child participated in the study. They were recruited by staff of the university womens hospital or from private gynecologists. In our sample the prevalence of psychosocial or biological risk factors is higher than in the general population. We made every effort to engage the future fathers, and only 18 fathers refused to participate. In these cases, mothers took part in the study without their partners. Eight fathers participated only partially (completed only the interview or only the questionnaires). The reasons given for nonparticipation by the fathers included language difculties, time constraints, lack of interest, or severe marital conicts. As our clinical experience has shown that families in which the fathers decline to participate are sometimes the most disturbed and problematic, we included the 18 cases without paternal participation in our study to ensure ecological validity and clinical relevance. Detailed information on the participation rates are shown in Table 1. On average, couples had been living together for 3.9 years (SD 3.3). Fifty-seven couples were married (71%). The participation rate of the fathers in the Triadic Interview was not signicantly associated with marital status, 2(1, N 80) 0.352, p .553. Although not all couples were married, questions related to both married and unmarried couples are referred to as marital. Medical records of pregnancies were evaluated and assessed. Twenty-seven prospective mothers needed medical care in the hospital (33.8%) and experienced difcult pregnancies. This high percentage of difcult pregnancies is due to the specialization of the university hospital in clinically high-risk pregnancies.

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Table 1 Participation Patterns Broken Down by Parental Psychiatric Status

Participation in Triadic Interview Parental psychiatric status (couple) Mother and father categorizable Mother and father no disorder Mother or father with disorder Mother and father with disorder Father not categorizable Mother no disorder Mother with disorder Mother not categorizable Total Mother and father 53 34 16 3 3 2 1 56 (70%) Mother only 9 3 4 2 15 7 7 1 24 (30%) Mother and father 59 37 19 3 Questionnaires completed by Mother only 2 1 1 16 9 7 18 (22%) Neither mother nor father 1 1 2 1 1 3 (4%) N (%) 62 (78%) 37 (46%) 20 (26%) 5 (6%) 18 (22%) 9 (11%) 8 (10%) 1 (1%) 80

59 (74%)

The mean age of the mothers was 30.6 years (SD 5.2), and the mean age of the fathers was 32.8 years (SD 4.9). The only inclusion criterion was being able to speak and understand German. Thus, most of the couples were Swiss or had grown up in Switzerland and spoke German (61 couples). At least 1 of the partners of the remaining 19 couples spoke a foreign language and had not grown up in Switzerland. School and professional education of both parents served to determine educational status. Ten percent of the families were assigned to a lower educational status, 21% to lower middle, 26% to middle, 21% to upper middle, and 21% to upper educational status. The participating couples were a very heterogeneous sample in terms of language, cultural background, age, and social class.

Psychopathology
Individual psychopathology was assessed by means of the German version of the Revised Symptom Checklist by Derogatis (1977, SCL90R; German: Franke, 1995). We used the Global Severity Index to establish psychopathology. Scores were transformed into T values based on sex norms (M 50, SD 10). Because we were interested in the effect of educational status, we did not apply the education norms. The norms are based on the scores of a normative sample consisting of 501 women and 505 men from Germany (age: M 34, SD 10.5) from various educational backgrounds (similar to our Swiss population; see Franke, 1995). We used a cutoff point of T 60 to differentiate persons with and without psychiatric disorder. To include all clinically relevant information in the assessment, (severe and obvious) psychiatric disorders, either self-reported or reported by others, were used to complement the SCL90R assessment. For example, some participants reported psychiatric symptoms in the general medical history but denied these symptoms when completing the SCL90R. Moreover, a few mothers who participated alone in the interview assessment

described severe psychiatric disorders of their partners. These fathers were thus also identied as having psychiatric disorders, even when they had scores in the normal range of SCL90R or missing SCL90R scores. The disorders reported included drug or alcohol abuse (5 participants), major depression (4), obsessivecompulsive disorder (2), anxiety disorder (2), somatoform disorders (2), and multiple disorders (1). Finally, 11 fathers and 27 mothers were identied as having psychiatric disorders. If participants did not complete the SCL90R and did not report a psychiatric disorder (18 fathers and 1 mother), we categorized their psychopathology status as missing. This avoided miscategorization of these cases as the absence of psychiatric disorder rather than missing information. Details of participation patterns broken down by parental psychiatric status are shown in Table 1. As in clinical practice, every available information source was included in the diagnosis of psychiatric disorders. This procedure allowed families considered to be at risk, such as those with drug-addicted fathers, to be included in our study, enhancing its clinical relevance and ecological validity. However, this procedure might cause methodological biases due to the different ways of assessing psychiatric disorders. To control for possible biases, we also performed the statistical analyses using symptom severity solely as assessed by SCL90R. In the following discussion of the results we distinguish between psychiatric disorder (presence 1, absence 0) and severity of symptoms (Global Severity Index sum score of SCL90R).

Marital Quality
Participants completed the Partnership Questionnaire on marital quality (Hahlweg, 1988). The total scores of this instrument can be used to establish overall marital quality. Hahlweg (1996) showed that the questionnaire is highly intercorrelated with other instruments, such as the Dyadic Adjustment Scale (Spanier, 1976) and the Marital Adjustment

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PERREN ET AL. interdependent components of the parental Triadic Capacity (for extensive discussion: von Klitzing, Simoni, & Brgin, 1999). The internal consistency of the ve scales was very high (Cronbachs .95). Thus, we used the mean score of the ve scales to establish Triadic Capacity. Interrater reliability (intraclass correlation) was .83. Where there was a major non-agreement (more than one scale-point difference), three raters performed a consensus rating. For all other interviews, the mean score of all three raters was used for subsequent analyses. Validity of the Triadic Interview has been established in previous studies (von Klitzing, Simoni, et al., 1999; von Klitzing, Simoni, & Brgin, 1999). Ratings were carried out for couples. Because a previous study showed maternal scores to be highly signicantly correlated with couple scores (von Klitzing, Simoni, & Brgin, 1999), we used the scores of the mothers interview in cases where the father had not participated. To control for a possible bias associated with this procedure, we used fathers nonparticipation as a control variable in some analyses.

Test (Locke & Wallace, 1959). We used this instrument instead of the more widely known Dyadic Adjustment Scale because we consider it to be culturally more appropriate for our SwissGerman sample. We transformed scores into T values (M 50, SD 10) to compare participants marital quality to the normative group. The normative sample consists of 104 men and 131 women: German; mainly middle class; 91% married; age: M 35.1, SD 6.9; duration of marriage: M 10.2, SD 6.4 (see Hahlweg, 1996). Scores of fathers and mothers were signicantly associated (r .816, p .000). Hence, if both parents completed the questionnaire, we used the mean value of the couple. If the father did not participate, we used the mothers score in the analyses.

Triadic Capacity
To assess parents capacity and readiness for engaging in triadic relationshipsthat is, for integrating the child as a third person into their relational world (Triadic Capacity) an interview instrument (the Triadic Interview) was developed in an earlier project (see Brgin & von Klitzing, 1995; von Klitzing, Antusch, Amsler, & Brgin, 1995). This is a semistructured psychodynamic interview that includes both parents. A well-trained and clinically experienced female psychologist interviewed the expectant parents during the last trimester of pregnancy. The interviews were all videotaped and lasted about 2 hr. The Triadic Interview provides as much structure as necessary to elicit comparable results but as little structure as possible in order to gain access to the inner world of the parents in a way that is familiar to clinicians. The following topics were addressed with all parents: their own childhood experiences, genesis and emotional course of pregnancy, mental representations of the unborn child, changes in the marital relationship, expectations of future family relationship, and the role of the prospective grandparents. In order to assess the Triadic Capacity of the couples, the interviewer plus two extensively trained independent raters, who were blind to the other relevant details of the subjects, coded all interviews following a detailed coding scheme (von Klitzing, 1996). The coding system is clinically oriented and aims to integrate all of the detailed information acquired into broader dimensions. The content and the overall structure of the interview, including the coherence between descriptions and narratives and the expressed emotionality, are evaluated. All this information is then summarized using ve 9-point scales describing the following aspects: (a) quality of personal functioning and partnership dynamics, (b) exibility of mental representations of the unborn child, (c) quality of the inner triadic scene concerning future family relationships, (d) quality of parental dialogue, and (e) narrative coherence of the descriptions of the parents own (triadic) childhood experiences. Denitions and criteria of these scales are described in the rating glossary, with low numbers indicating low quality and high numbers indicating high quality (von Klitzing, 1996). The ve scales of the Triadic Interview were highly intercorrelated, probably because the underlying dimensions are

Results Comparisons Between the Study Sample of Expectant Parents and Normative Samples
We calculated one-sample t tests to assess differences between our sample and the normative sample (Franke, 1995). The fathers severity of symptoms was signicantly lower than the male normative sample, t(76) 3.165, p .002. Mothers did not differ signicantly from the normative group, t(58) 0.825, p .421. In comparison with the normative sample, mothers scored signicantly higher on somatization and depression but lower on paranoid ideation and psychoticism. Fathers scored lower on somatization, obsessivecompulsion, interpersonal sensitivity, and psychoticism (see Table 2). Next, we compared the marital quality of our sample to the normative sample (Hahlweg, 1996). We calculated a one-sample t test for overall marital quality (comparison score: T 50). Mothers and fathers scored signicantly higher on marital quality than the normative sample (mothers: M 57.7, SD 12.1, t[76] 5.183, p .000; fathers: M 57.6, SD 9.8, t[58] 8.505, p .000).

Is Psychopathology Associated With Marital Quality of the Parental Couple?

Associations among marital quality, severity of symptoms and sociodemographic variables were analyzed. The severity of maternal and paternal

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Table 2 Description of Symptom Checklist-90Revised Subscales and Global Severity Index

Mothers (n 77) Psychiatric symptom Somatization Obsessivecompulsive Interpersonal sensitivity Depression Anxiety Angerhostility Phobic anxiety Paranoid ideation Psychoticism Severity of symptoms *p .05. **p .01. M 54.23** 47.97 48.58 52.57* 51.08 51.61 52.18 46.29** 46.96** 51.05 SD 11.71 11.03 10.07 9.77 11.15 10.90 10.30 10.50 10.00 11.19 T 60 (%) 28.6 14.3 9.1 18.2 19.5 16.9 23.7 11.7 15.6 20.8 M 46.36** 45.75** 47.22* 49.05 50.88 48.83 50.69 47.95 46.93** 45.12** Fathers (n 59) SD 9.80 11.16 10.32 10.72 10.07 10.30 9.17 9.87 8.72 11.85 T 60 (%) 10.2 8.5 10.2 13.6 15.3 10.2 20.3 13.6 10.2 10.2

symptoms was signicantly negatively correlated with marital quality: The more severe the psychiatric symptoms, the lower the marital quality (r .396, p .000; r .282, p .030). Moreover, marital quality was signicantly negatively correlated with duration of living together (r .269, p .020). By contrast, marital quality was not signicantly correlated either with age of participants or with educational level. We calculated t tests using marital quality as a dependent variable. The presence or absence of psychiatric disorders, legal marital status, difcult pregnancy, and nonparticipation of fathers served as independent variables. Analyses showed that couples in which there was no paternal psychiatric disorder had a higher marital quality than couples where a paternal psychiatric disorder was present (presence: M 47.5, SD 15.0, n 10; absence: M 59.9, SD 8.9, n 51), t(59) 3.55, p .001. Moreover, lower marital quality was reported when fathers did not participate in the study (nonparticipation: M 51.6, SD 15.7, n 22; participation: M 58.8, SD 9.1, n 55), t(75) 2.51, p .023. No signicant differences in terms of maternal psychiatric disorder, marital status, or difcult pregnancy were noted.

Does the Presence or Absence of Psychiatric Disorders or Marital Quality Contribute to the Variance of Triadic Capacity?
Triadic Capacity was signicantly negatively correlated with the severity of maternal or paternal symptoms: The more severe the mothers or fathers

symptoms, the lower their Triadic Capacity (r .368, p .001; r .289, p .027). The Triadic Capacity of couples reporting higher marital quality was rated higher than that of couples reporting lower marital quality (r .516, p .000). Moreover, the higher the educational level of participants, the higher their Triadic Capacity (r .352, p .001). In contrast, Triadic Capacity was not signicantly correlated with age of participants or duration of cohabitation/ marriage. Furthermore, we performed t tests using Triadic Capacity as a dependent variable (see Table 3). In line with the results reported above, psychiatric disorders, legal marital status, difcult pregnancy, and nonparticipation of fathers served as independent variables. Mothers and fathers with psychiatric disorders were rated lower on Triadic Capacity than parents without psychiatric disorders. Moreover, married couples scored higher on Triadic Capacity. Similarly, mothers who participated without their partners were rated lower on Triadic Capacity than other participants. This last nding might, however, be a methodological artifact, because the absence of the father may have inuenced the interviewer and/or the interview raters. We next conducted regression analyses to determine whether marital quality or the presence or absence of psychiatric disorders independently accounted for the variance in parental Triadic Capacity. As a rst step we used educational level, with the other predictor variables entered hierarchically in the following order: maternal psychiatric disorder, paternal psychiatric disorder, marital quality. To exclude possible rating biases due to nonparticipation of fathers, we included only those families where both parents participated (N 52). We used

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Table 3 t Tests and Mean Scores of Triadic Capacity by Various Independent Variables
True Variable Maternal psychiatric disorder Paternal psychiatric disorder Unmarried couple Difcult pregnancy Nonparticipation of fathers **p .01. M 3.13 2.93 3.20 3.42 3.17 SD 0.44 0.48 0.47 0.54 0.42 n 27 11 23 27 24 M 3.55 3.56 3.49 3.41 3.51 Not true SD 0.39 0.38 0.42 0.40 0.42 n 52 51 57 53 56 t 4.423 4.834 2.695 .097 3.322 df 77 60 78 78 78 p .000** .000** .009** .923 .001**

the binary variable psychiatric disorder rather than the severity of symptoms as independent variable because of the broader range of clinical information given by self-ratings and anamnestic reports.1 As can be seen in Table 4, educational level signicantly predicted couples Triadic Capacity. The inclusion of maternal psychiatric disorder did not signicantly increase the model t. Next, paternal psychiatric disorder was included in the model. This step gave a model with signicantly better t. As did educational level, fathers psychiatric disorder predicted low Triadic Capacity. Finally, couples marital quality was included in the regression analysis, which signicantly increased the model t. In summary, the presence or absence of psychiatric disorders of fathers, marital quality, and educational level each independently predicted a low Triadic Capacity of expectant parents.

Marital Quality During Pregnancy

It is surprising that our study sample reported higher marital quality than the normative sample. The high marital quality might be related to the experience of rst pregnancy. Being pregnant could be a positive challenge, not only for the expectant mother undergoing substantial physical changes, but for the father and the marital relationship as well. Thus, expectant parents share a common experience and a common goal and perhaps are drawn closer together. Another explanation could lie in the selection of the study sample. Couples with high marital quality might have been more willing to participate in the study. In contrast, couples with low marital quality might have decided against participation through shame or unwillingness to talk about their problems. Furthermore, self-ratings of marital quality were signicantly negatively correlated with duration of cohabitation. This nding corresponds to other studies demonstrating a decline in marital satisfaction over time. This decline is larger in couples after the birth of the rst baby (Cowan & Cowan, 1988). These results might also be due to a tendency to evaluate the marital relationship more realistically over time. As marital quality was self-assessed, there might have been some overidealization of the relationship, especially by couples with little experience of living together before becoming parents.

Discussion
The ndings indicate that marital quality and parental psychopathology are factors of major importance for the transition to parenthood, with the severity of psychiatric symptoms and poor marital quality negatively associated with successful transition. The educational level of the parents, paternal psychopathology, and marital quality each contribute independently to the variance of parental attitudes toward their future child and family life. The results support Cowans (1997) notion that the relative neglect of fathers is the most important omission in the eld of attachment research and that marital conicts and external stressors have an important impact on the parentchild relationship. Our results in fact emphasize the importance of the mental health of both fathers and mothers, and of marital quality and educational level, in early family development.

1 We also performed the same regression using severity of symptoms. The analysis yielded identical results, with the exception of one variable: paternal severity of symptoms did not reach signicance in Model 4 ( .200, p .099). This inconsistency might be due to the shared method variance.

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Table 4 Summary of Hierarchical Regression Analysis for Variables Predicting Couples Triadic Capacity
Model statistic Model 1 (R .283) Model 2 (R2 .296)
2

F change (df s) 20.13(1, 51), p .000 0.89(1, 50), p .349 8.91(1, 49), p .004 6.37(1, 48), p .015

Variable Educational level Educational level Maternal psychiatric disorder Educational level Maternal psychiatric disorder Paternal psychiatric disorder Educational level Maternal psychiatric disorder Paternal psychiatric disorder Marital quality

.532 .491 .119 .435 .087 .337 .346 .137 .282 .285

p .000** .000** .349 .001** .465 .004** .005** .235 .013* .015*

Model 3 (R2 .404) Model 4 (R2 .474)

*p .05.

**p .01.

Psychopathology and Marital Quality

As hypothesized, we found a signicant negative correlation between the severity of symptoms of both parents and self-reported marital quality. The reasons for this negative association might be bidirectional: Psychiatric disorders are frequently associated with relational difculties and might therefore lead to marital problems; conversely, marital problems might have caused or at least enhanced psychiatric symptoms such as depression. Watson, Elliott, Rugg, and Brough (1984) showed that psychiatric disorders during pregnancy are associated with marital dissatisfaction and postnatal depression.

Psychopathology, Marital Quality, and Early Development of Parenthood

As hypothesized, parents Triadic Capacity was negatively correlated with the severity of parental symptoms and positively correlated with marital quality. Most studies investigating associations between the marital relationship and child development focus on marital conicts and divorcethat is, the negative side of the marital relationship (Fincham, 1998; Howes & Markman, 1989; Kelly, 2000). However, a high-quality marital relationship entails more than just the absence of conict: It can be considered a positive resource for the transition to parenthood. Couples with a high-quality relationship probably cope better with the extension of the marital dyad to the motherfatherchild triad. Although parental psychiatric disorder is considered to be a risk factor for child psychopathology, the mechanisms of this intergenerational transmission

process are only partially understood. Explanatory models include the quality of parentchild interactions, genetic transmission, and psychosocial factors (Rutter, 1999). Our study demonstrates that problematic attitudes toward the child and the future family triad in families with a high level of parental psychopathology and with low marital quality can be diagnosed during pregnancy. The negative inuence of paternal psychopathology on child adjustment in infancy and early childhood was neglected for a long time (Phares & Compas, 1992). Our study shows that the presence and severity of psychiatric disorders in fathers are associated with low marital quality and low Triadic Capacity assessed during pregnancy. As this is a stable correlation, even when controlling for mothers symptoms, marital quality, and educational level, paternal psychiatric disorder should be considered not only as having indirect adverse effects as a stress factor in the motherchild environment but also as directly inuencing the quality of triadic family processes.

Role of Educational Level

The educational level of the families was negatively correlated with the severity of mothers symptoms and positively correlated with parental Triadic Capacity. The negative statistical correlation between mothers psychopathology and Triadic Capacity disappears when controlling for the couples educational level. In a statistical sense, educational level is a variable with a mediating function (Baron & Kenny, 1986). This phenomenon is due to the high association between psychopathology and educational level. The association of educational level with measures of psychopathology and Triadic Capacity may

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be partly due to methodological biases. The questionnaire we used to assess psychopathology (SCL90R) yields higher levels of psychopathology for people with less education (Franke, 1995). This may be a methodological artifact due to distorted response tendencies. Likewise, the positive association between Triadic Capacity and educational level might reect a rating bias as a result of the raters own educational levels (all raters had university degrees) and role models. Nevertheless, the signicant correlation between psychopathology and educational level may also reect real associations. On the one hand, participants with less education may have had more psychosocial stressors in their environment, which may have triggered psychiatric disorders. Alternatively, people with psychiatric disorders may have been unable to receive higher education because of their illness. Likewise, the association between Triadic Capacity and educational level could reect the existence of more traditional family role models in families with low socioeconomic status. In traditional role models fathers are often seen as being less important for the child, particularly during infancy and early childhood. Parents with less education may have developed lower Triadic Capacities because, in their conceptualization of their future parenthood, fathers had a more distant relationship with the baby. This result clearly does not imply that poorly educated people will become bad parents. Nevertheless, a good education may be a protective factor by improving reective functions that help to overcome difcult developmental experiences during the transition to parenthood.

and child psychiatrists create interdisciplinary programs to accompany risk families across the transition to parenthood. In our early intervention program for infants with regulatory disorders we try to integrate the triadic approach. In general, we encourage fathers to participate in the consultations with our interdisciplinary team of child psychiatrists, pediatricians, and nurses. This approach has proved to be very successful. We assume that interventions using a similar conceptualization that begin as early as pregnancy would also be a promising approach.

Methodological Strengths and Limitations and Future Research Directions

We made every effort to motivate fathers to participate in this study. Of the 80 fathers, 62 agreed to participate (at least partially). This rate of participation is high compared with other studies. One strength of our study is that we did not rely solely on self-report measures but established the Triadic Capacity of parents by means of an intensive interview, which was rated by trained experts. Some mothers were interviewed without their partners. Nevertheless, Triadic Capacity was also evaluated in these cases. This may represent a methodological limitation. However, an earlier study, in which only couples with both parents present were evaluated, showed a high degree of association between fathers and mothers Triadic Capacity (von Klitzing, Simoni, & Brgin, 1999). A further limitation of our study is that parental psychopathology was assessed from self-ratings: Funding limitations prevented us from using standardized interview measures for that purpose. Our study was conducted on a Swiss, mainly middleclass sample (probably comparable to an American White middle-class population) and cannot be extrapolated to individuals of other socialcultural backgrounds. We strongly encourage similar studies in other countries and cultural contexts in order to investigate the cross-cultural validity of our triadic approach. The present study is based on data collected during pregnancy. Thus, we evaluated parenthood at the level of parental mental representations and not of observed parentinfant interaction. In a next step we will investigate whether we can replicate our ndings on the association between mental representations and standardized observation of family interactions during infancy (von Klitzing, Simoni, et al., 1999; von Klitzing, Simoni, & Brgin, 1999, 2000) in families at severe psychosocial risk. In future research we

Clinical Implications
Our ndings have certain clinical implications. First, paternal as well as maternal psychopathology should be assessed when one is evaluating risk factors for development in infancy. Second, marital quality may be a resource for coping with the transition to parenthood; thus, interventions concerning marital conicts may be important during pregnancy. Third, medical interventions during pregnancy mostly focus on the biological health of mother and baby. As pregnancy is not solely a biological process but also involves important intrapsychic and interpersonal processes, intervention programs for these aspects should also be developed. Such intervention programs for prenatal care must be based on an interdisciplinary approach. This means that obstetricians, psychiatrists, pediatricians,

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aim to evaluate the longitudinal associations between the intra- and interpersonal processes of pregnancy and variations in family development and childrens social competence and mental health in the preschool years.

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Received November 15, 2001 Revision received April 1, 2002 Accepted July 28, 2002