KUOPION YLIOPISTON JULKAISUJA D.

LKETIEDE 412
KUOPIO UNIVERSITY PUBLICATIONS D. MEDICAL SCIENCES 412

KAARINA KEMPPINEN

Early Maternal Sensitivity

Continuity and Related Risk Factors

Doctoral dissertation
To be presented by permission of the Faculty of Medicine of the University of Kuopio
for public examination in Auditorium, Mediteknia building, University of Kuopio,
on Friday 17 th August 2007, at 12 noon

Department of Child Psychiatry

University of Kuopio and Kuopio University Hospital
Department of Pediatrics
University of Oulu

JOKA
KUOPIO 2007

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Series Editors:

Professor Esko Alhava, M.D., Ph.D.

Institute of Clinical Medicine, Department of Surgery
Professor Raimo Sulkava, M.D., Ph.D.
School of Public Health and Clinical Nutrition
Professor Markku Tammi, M.D., Ph.D.
Institute of Biomedicine, Department of Anatomy

Authors address:

Department of Child Psychiatry

Kuopio University Hospital
P.O. Box 1777
FI-70211 KUOPIO
FINLAND
Tel. +358 17 174 462
Fax +358 17 172 778
E-mail: kaarina.kemppinen@kuh.fi

Supervisors:

Professor Kirsti Kumpulainen

Department of Child Psychiatry
University of Kuopio
Professor Eila Rsnen
Department of Child Psychiatry
University of Kuopio
Professor Irma Moilanen
Department of Child Psychiatry
University of Oulu
Docent Hanna Ebeling
Department of Child Psychiatry
University of Oulu

Reviewers:

Docent Kaija Puura

Department of Child Psychiatry
University of Tampere
Jari Sinkkonen, M.D., Ph.D.
Save the Children, Helsinki

Opponent:

Professor Tuula Tamminen

Department of Child Psychiatry
University of Tampere

ISBN 978-951-27-0672-3
ISBN 978-951-27-0749-2 (PDF)
ISSN 1235-0303
Kopijyv
Kuopio 2007
Finland

Kemppinen, Kaarina. Early Maternal Sensitivity: Continuity and Related Risk Factors.
Kuopio University Publications D. Medical Sciences 412. 2007. 136 p.
ISBN 978-951-27-0672-3
ISBN 978-951-27-0749-2 (PDF)
ISSN 1235-0303

Abstract
Identifying mother-child dyads at risks and sharing concerns with parents are required for
directed interventions. In this research, the continuity of early maternal sensitivity with
related risk factors and consequences and the identification of risk dyads in well-baby
clinics were studied. The research consists of three follow-up samples: the Observation
sample (n=5), the Well-Baby Clinic sample (n=78-74), and the Linguistic sample (n=27).
Mother-child interaction was assessed by video methods (the PCERA and CARE-Index),
child linguistic development by clinical assessments (the CSBS and RDLS III), and the
following factors by questionnaires based on parental reports: child behavioral problems
(the CBCL/2-3), child linguistic development (the MCDI), and maternal depression (the
EPDS and GHQ).
A short video clip was found to reveal the genuine interactive style as well as did
recurrent observation of the interaction over a year-long period. The results of this
research in particular underline that some features of maternal sensitivity predict
continuous problems in the interaction. In particular, expressions of low affective
engagement and negative affects predict continuous problems, and low sensitivity,
intrusive and highly unresponsive maternal interactive style child behavioral problems
and low co-operation. Furthermore, both postnatal and prenatal, recurrent and transient
maternal depressive symptoms affected the interactive functioning. Mothers assessed as
low in sensitivity both with infants and toddlers reported depressive symptoms already
prenataly.
One fifth of dyads were assessed to need extra support, and one in ten as needing more
intensive interventions, but less than one third of the risk dyads were identified in wellbaby clinics. The public health nurses hesitated to interpret the dyadic interaction as
problematic. However, they were slightly worried about the risk dyads, arranged extra
visits for them, and wanted to share their worries with a supervisor. Furthermore, the
mothers who had evident difficulties in identifying childrens needs in dyadic interaction
also had difficulties in recognizing problems in childrens behavior at toddler age. This
makes it difficult to challenge mothers in interventions.
The findings of this research stress the continuity of problems in early interaction, and
underline both the possibility and importance of the early identification of mother-child
dyads at risk.
National Library of Medicine Classification: WA 310, WA 320, WM 171, WQ 500, WS
105.5.F2, WY 101
Medical Subject Headings: Child Behavior; Depression, Postpartum;
Depression/psychology; Depressive Disorder; Follow-Up Studies; Language
Development; Maternal-Child Health Centers; Mother-Child Relations;
Mothers/psychology; Pregnancy/psychology; Primary Health Care; Risk Factors; Video
Recording

To my family

Acknowledgements
It has taken a long time to collect and process the data for this dissertation, and there are several
people whom I want to thank. First I want to thank the over one hundred families who eagerly
and patiently took part in the three studies of this dissertation. You opened the doors of your
homes and came to us when invited. You are the stars of the videos and the focus of the study.
My interest in preventive work originates from when I was a general practitioner in South
Karelia. The experiences and work-mates in well-baby clinics first encouraged me to train as a
child psychiatrist, and after that to come back to well-baby clinics as a researcher. My first steps
in research were encouraged by my supervisor, the late Professor Eila Rsnen, MD, PhD, to
whom I owe my sincere gratitude. She was interested in child mental issues and research also
after retiring, and was writing with us the draft of the first article, but unfortunately did not live to
see it published. Before passing away Professor Eila Rsnen advised me to request her
successor, Professor Kirsti Kumpulainen, MD, PhD, to be the supervisor of my dissertation. So
Professor Kumpulainen came into this research project during the writing process and taught me
the principals of scientific writing. I am grateful for her invaluable help and support in preparing
this dissertation. She is a very skilled and patient teacher and supervisor. During this process we
also became friends and workmates in teaching medical students.
From the very beginning of this research project Professor Irma Moilanen, MD, PhD, from Oulu
University has been one of my supervisors. I wish to thank her especially for her encouragement.
I am also grateful to her for arranging methodological training and contacts with colleagues in the
Oulu region. These contacts were for me the first steps into the Finnish infant mental health
research network. One of the important contacts but not a new one was Docent Hanna Ebeling,
MD, PhD, the Head of the Child Psychiatric Department in Oulu University Hospital, who came
to be my fourth supervisor. I want to thank her for many brilliant ideas and for suggesting
questions to be answered.
I owe my respectful gratitude to the official reviewers of this dissertation, Dr Kaija Puura, MD,
PhD, of the University of Tampere, and Dr Jari Sinkkonen, MD, PhD, of the Save the Children
organization, for their careful revision of this study. Your comments helped me to improve the
final version of this thesis.
One very important Oulu contact was Pauliina Hiltunen, MD, PhD, whom I want to thank warmly
for exchanging ideas and material with me when beginning this research. Another important Oulu
contact is Leila Paavola, PhD, lecturer in Logopedics. I want to extend my gratitude to her for the
co-operation which created three articles. Videos played an important part in our co-operation,
and a video-based technique also helped in the Kuopio-Oulu connections. Our video meetings
between all my present supervisors and co-writers created a scientific team, which was also open
to new members.
I am grateful to Dr Patricia Crittenden, PhD, for training me in the CARE-Index and attachment
theory. It has been a privilege to be trained by the creator of the method. My fellow-trainee in the
CARE-Index was psychologist Arja Toivonen-Falck, MA, who acted as a video rater, for which I
want to express my deepest thanks. I also want to thank Anne Kauppi, MD, for being a co-worker
and room-mate during the training courses.
I want to give special thanks to Jutta Raita-Hasu, MD, who is also my co-worker and co-writer. I
am grateful also to Hanna Korkala, Marja Tuunanen and Mia Aulanko for their assistance as

medical students during the data collection of the Well-Baby Clinic sample. I also want to extend
my thanks to the secretaries, Liisa Korkalainen and Ritva Jauhiainen, for sending hundreds of
letters during the follow-up. I especially want to express my deep gratitude to public health nurses
Arja Haapakorva, Anneli Hiekkala, Helena Jauhianen, Arja Kaasalainen, Marja Leskinen,
Kaarina Ovaskainen, Pirkko Pellinen, Kartiina Silvasti, Maija Toivanen, Riitta Turunen and their
colleagues, who encouraged the families to take part in the study and filled in questionnaires.
I also want to extend my thanks to the observers and the supervisor, psychologist Anna-Maija
Leiman, MA, of the infant observation group. I also highly appreciate the help given by Anne
Kunelius, MD, Pauliina Hiltunen, MD, PhD, and Marja Kivijrvi, PhD, for acting as the video
raters in the Observation study.
I am indebted to statisticians Pirjo Halonen, MSc, and Vesa Kiviniemi, PhLic, for their expertise
and guidance in statistical analysis. Furthermore, I sincerely thank Senior Lecturer Vivian
Paganuzzi, MA, for his invaluable help in checking the English language of the original articles
and of this dissertation.
This dissertation was financially supported by the Nokia Corporation and the Child Psychiatric
Research Foundation (Finland) and Child Psychiatric Research Foundation, Kuopio Area
(Finland), which are gratefully acknowledged.
I warmly thank my work-mates in the Department of Child Psychiatry of Kuopio University
Hospital, especially the infant mental health team, and teaching coordinator Marja Leena
Karhunen. You have tolerated me and all the interruptions that the research work has caused in
my clinical and teaching work.
Special thanks to the Girlsand colleagues Mari Hmlinen, Leenamari Nyknen-Keklinen
and Saija Roine for the unofficial meetings and for being my friends.
Last autumn I experienced a great loss, when my father passed away after being ill for almost two
decades. I want to express my special gratitude to my mother for taking care of my father during
all these years. I am very grateful to both my parents for also teaching me the importance of hard
work and persistence. I have needed those characteristics many times during this project.
Finally, I want to give my warmest thanks to my dear family. Timo, my darling husband, you
have shared with me the lightest and darkest moments. And furthermore, you have been my
irreplaceable help desk! My dear children, Saara, Riikka and Mikko, you are the best encouragers
in this mothers hobby- and in my life. I have been many times a highly unresponsivemother
during the last year, but after this effort Ill at least try to reach the good enoughrange. And my
future son-in-law Daniel - thanks for stars and arches.
Kuopio, May 2007

Kaarina Kemppinen
Kaarina Kemppinen

Abbreviations and Definitions

Baby Blues

Transient depressive symptoms two weeks after delivery

CARE-Index

Child-Adult Relational Experimental Index

- Child co-operation

Child attending or responding to the dyadic activity

- Child compulsiveness

Child inhibits or minimizes normal responses,

- Child difficulty

Anger, frustration, resistance in child dyadic behavior

- Child passivity

Child is inattentive, playing alone or not playing at all

- Maternal control

Covertly/overtly intrusive, incongruent or demanding

maternal behavior

- Maternal sensitivity

Any pattern of maternal behavior that pleases the infant and

increases the infants comfort and attentiveness and reduces
his/her distress and disengagement

- Maternal unresponsiveness Unengaged, passive and expressionless maternal behavior

CBCL/2-3

Child Behavior Checklist for Ages 2-3 years

CSBS

Communication and Symbolic Behavior Scales

EPDS

Edinburgh Postnatal Depression Scale

GHQ

General Health Questionnaire

MCDI

MacArthur Communicative Development Inventories

PCERA

Parent-Child Early Relational Assessment

PHN

Public Health Nurse

RDLS III

Reynell Developmental Language Scales III

WBC

Well-Baby Clinic

List of original publications

I

Kemppinen K, Kumpulainen K, Rsnen E, Moilanen I, Ebeling H, Hiltunen P,

Kunelius A (2005) Mother-child interaction on video compared with infant
observation: Is five minutes enough time for assessment? Infant Mental Health
Journal, 26, 69-81.

II

Kemppinen K, Kumpulainen K, Moilanen I, Ebeling H (2006) Recurrent and

transient depressive symptoms around delivery and maternal sensitivity. Nordic
Journal of Psychiatry, 60, 191-199.

III

Kemppinen K, Kumpulainen K, Raita-Hasu J, Moilanen I, Ebeling H (2006) The

continuity of maternal sensitivity from infancy to toddler age. Journal of Reproductive
and Infant Psychology, 24, 199-212.

IV

Kemppinen K, Ebeling H, Raita-Hasu J, Toivonen-Falck A, Paavola L, Moilanen I,

Kumpulainen K. Early maternal sensitivity and child behaviour at toddler age: does

low maternal sensitivity hinder identification of behavioural problems? In press,

Journal of Reproductive and Infant Psychology, Vol 25 (2007).

Paavola L, Kemppinen K, Kumpulainen K, Moilanen I, Ebeling H (2006)

Maternal sensitivity, infant co-operation and early linguistic development: Some
predictive relations. European Journal of Developmental Psychology, 3, 13-30.

Contents
1

Introduction ................................................................................................................... 17

Review of literature....................................................................................................... 19
2.1

Maternal sensitivity and mother-child interaction.............................................. 19

2.1.1

Concept of maternal sensitivity ................................................................... 19

2.1.2

Assessment of mother-child interaction and maternal sensitivity............. 23

2.1.3

Continuity of maternal interactive style...................................................... 27

2.1.4

Factors related to maternal sensitivity......................................................... 28

2.1.5

Maternal sensitivity and child development ............................................... 30

2.2

Maternal depression around delivery .................................................................. 34

2.3

Identification of risk dyads in well-baby clinics................................................. 36

Aims of the study .......................................................................................................... 38

Subjects and methods.................................................................................................... 40

4.1

Study procedure and subjects............................................................................... 40

4.1.1

Observation sample (Study I) ...................................................................... 40

4.1.2

Well-baby Clinic sample (Studies II, III, IV) ............................................. 41

4.1.3

Linguistic sample (Study V) ........................................................................ 45

4.2

Methods ................................................................................................................. 46

4.2.1

Parent-Child Early Relational Assessment................................................. 46

4.2.2

CARE-Index ................................................................................................. 47

4.2.3

General Health Questionnaire...................................................................... 50

4.2.4

Edinburgh Postnatal Depression Scale........................................................ 50

4.2.5

CBCL72-3, Child Behavior Checklist for Ages 2-3 years ........................ 51

4.2.6

MacArthur Communicative Development Inventories.............................. 51

4.2.7

Communication and Symbolic Behavior Scales ........................................ 52

4.2.8

Reynell Developmental Language Scales III ............................................. 52

4.2.9

Other measures ............................................................................................. 53

4.2.10

Statistical methods........................................................................................ 54

Summary of results ....................................................................................................... 56

5.1

Continuity of mother-child interactive style ....................................................... 56

5.1.1

One year observation compared with five minute video assessment........ 56

5.1.2

Continuity of mother-child interactive style from infancy to toddler age 58

5.2

Risk factors related to maternal sensitivity ......................................................... 65

5.2.1

Continuity of maternal depressive symptoms around delivery ................. 66

5.2.2

Maternal depressive symptoms around delivery and early maternal

sensitivity ...................................................................................................... 67

5.2.3
5.3

Maternal sensitivity and child development ....................................................... 72

5.3.1

Maternal sensitivity and child co-operation................................................ 72

5.3.2

Maternal sensitivity and child behavior...................................................... 74

5.3.3

Maternal sensitivity and child linguistic development............................... 77

5.4
6

Other risk factors and maternal sensitivity ................................................. 70

Identification of risk dyads in well-baby clinics................................................. 79

Discussion...................................................................................................................... 83
6.1

Continuity of mother-child interactive style ....................................................... 83

6.1.1

A short video representing dyadic interaction............................................ 83

6.1.2

Continuity of maternal sensitivity from infancy to toddler age................. 87

6.2

Risk factors for maternal sensitivity.................................................................... 91

6.2.1

Maternal depression and sensitivity ............................................................ 91

6.2.2

Maternal unemployment, unplanned pregnancy, male sex of the child and

maternal sensitivity....................................................................................... 95

6.3

Maternal sensitivity and child behavior .............................................................. 97

6.3.1

Maternal sensitivity and child co-operation................................................ 97

6.3.2

Maternal sensitivity and child linguistic development............................... 98

6.3.3

Maternal sensitivity and assessment of child behavior............................ 100

6.4

Identification of at risk dyads in well-baby clinics........................................... 106

6.5

Assessment of mothers, children, interaction and culture................................ 110

6.6

Strengths and limitations.................................................................................... 112

Conclusions ................................................................................................................. 116

Implications for clinical practice and future research............................................... 119

References
Original articles

17

Introduction

During the last few decades research in infant mental health has been very active and
generated new knowledge about early parent-child interaction. At the same time
increasing numbers of children have been identified as needing psychiatric treatment
(Reigstad et al. 2004, Sourander et al. 2004), and families with small children as needing
extra support from the child welfare services (Ministry of Social Affairs and Health,
2004). On one hand the increasing amount of knowledge and development of methods for
investigating mother-child interaction and child behavior, and on the other hand the
increasing number of children suffering from behavioral and psychiatric problems, create
new challenges and opportunities for the early identification of and interventions with
families and children at risk for deviant child behavior.

The Finnish well-baby clinic organization reaches almost all families with children from
birth to the age of seven years, and provides a great opportunity for early screening and
intervention (Hakulinen-Viitanen et al. 2005). One of the primary tasks of the well-baby
clinics is to promote the psychic welfare of all children and their families, and especially
in families needing extra support. Each family identified as having difficulties with their
child need extra help, but it has been reported that the resources in many well-baby
clinics are inadequate, and not even all scheduled visits are carried out (HakulinenViitanen et al. 2005). Furthermore, the identification of families and children at risk is
essential not only for well-directed interventions in well-baby clinics and primary care
but also for well-timed consultations and referrals of the risk cases to specialists.

18
Well-timed and well-directed interventions are important for human, organizational and
economic reasons, and to make such interventions possible it is essential to identify
parent-child dyads at risk, Furthermore, as Puura and colleagues (2001) have reported,
public health nurses have found it difficult to discuss with parents the problems they have
identified. The natural changes in both maternal and child behavior, and mothersgreater
willingness to share positive than negative experiences make it difficult to identify and
challenge in discussion the dyads at risk during the scheduled contacts in well-baby
clinics (Belsky & Fearon 2002, Kroes et al. 2005).

Practical methods are needed for early identification of dyads at risk, but it is not easy to
find a simple and reliable method to assess such a complicated system as the parentinfant relationship. However, video recording and assessment of parent-child interaction
has opened up a fascinating world. In particular it is important to identify the features in
early mother-child interaction predicting later problems to help in the early identification
of children and families at risk.

19

Review of literature

2.1
2.1.1

Maternal sensitivity and mother-child interaction

Concept of maternal sensitivity

Research into early mother-child interaction and mothering style has increased
enormously during recent decades. The roots of this research lie in earlier work by
psychoanalysts, especially in attachment theory. The concept of maternal sensitivity was
invented in this research tradition. During the first half of the last century the focus of
interest was individuals and adults, but gradually it turned to children, and later on to
mother-infant dyads. Hartmann, known for his theories of ego psychology, introduced the
concepts of fitting togetherand average expectable environmentthus affirming the
crucial importance of maternal contribution to child development (Hartmann 1958). Rene
Spitz (1965) realized that disturbed object relations as early as in the first year of life may
have far-reaching consequences for the childs future. He saw pregnancy as an important
phase of preparation for affective interchanges with the neonate. Three British
psychoanalysts, John Bowlby, Wilfred Bion, and Donald Winnicott, focused almost
simultaneously on the mother-child dyad, although in different ways and from different
perspectives. Bowlby (1969) formulated the tenets of attachment theory, while Bion
(1962) introduced in the term of containmentreferring to mothers capacity of mentally
containingthe childs intolerable affects. As to Winnicott, he described eloquently the
good enoughmother as being able to mentally holdthe child, i.e. have him or her
constantly in her mind as well as mirroringthe childs emotional expressions with her
own expressions and attitudes (Winnicott 1965/1990). Interest in the mother-child
interaction also increased among researchers in developmental psychology. One of the

20
most famous researchers in this field was Vygotsky (1978), who created the concept of a
zone of proximal development to describe the importance of the early social context.

Maternal sensitivity is a central concept used in attachment theory to describe the early
mother-child interaction. Mary Ainsworth, a co-worker of Bowlby and a refiner of the
attachment theory, together with her colleagues (1978) created this concept on the basis
of her empirical studies. She defined maternal sensitivity as the mothers availability and
alertness in well-timed responses to the childs signals, consistently and appropriately,
with an appropriate level of control and negotiation of conflicting goals. This definition
of sensitivity has been used widely, but the concept of sensitivity has also been further
developed and extended to a generic construct covering a wide range of parental
behaviors. Consequently, the exact definitions of sensitivity vary according to the
theoretical background in infant mental health research (see De Wolff & van IJzendoorn
1997).

Besides sensitivity, other concepts such as contingency and reciprocity based on different
theoretical backgrounds have also been created to describe maternal functioning in
mother-child interaction (see Dunham & Dunham 1995). Most of them share the
fundamental assumption of age-appropriate contingent and reciprocal responses between
mother and infant. Some theorists have emphasized the aspects of maternal behavior
whereas others emphasize the expressions of affects and emotional regulation (see
Beckwith et al. 2002). Many theorists have described the maternal interactive style using
the term responsiveness, and the concept is defined as involving temporal contiguity

21
of responses, i.e. promptness and frequency of responses, but without qualitative
assessment (Landry et al. 1997, Tamis-Le-Monda et al. 2001). Other researchers point
out that this may be misleading, because even contingent responses cannot always be
considered to be sensitive, and they have also underlined the importance of
appropriateness of maternal responses to infants behavior (Meins et al. 2001) and
maintaining the infants attention and motivation (Stevens et al. 1998) in describing the
mother-child interactive functioning. A sensitive mother helps the child to modulate not
only positive but also negative states of arousal (Emde 1980, Seifer & Schiller 1995).
Furthermore, it has been pointed out that motherssensitive affects must also be genuine,
with congruence between her affects and behavior, and also across all her sense
modalities (Biringen & Robinson 1991). An ungenuine or incongruent interaction makes
it impossible for the child to correctly interpret either the mothers or his/her own
emotions (Crittenden & DiLalla 1988).

Ainsworths concept of maternal sensitivity has been reconceptualized by infant mental

health specialists (Beckwith et al. 2002). The regulation of emotions and sharing inner
feelings is central in Sterns (2004) concept of affective attunement, whereas Biringen
(Biringen& Robinson 1991) and Emde (1980) with their concept emotional availability
emphasize both maternal sensitivity and nonintrusiveness, and child responsiveness and
involvement. In their recent book Fonagy and colleagues (2002) further remind us that
sensitive maternal interaction has much in common with Bions (1962) concept of
contain. Furthermore, Fonagy et al. (2002) underline, using the term mentalizing, the
caregivers capacity to observe the moment-to-moment changes in the childs mental

22
state, and that the caregivers perception of the child as an intentional being lies at the
root of sensitive caregiving. Crittenden (1988, 2006) defines maternal sensitivity as any
pattern of behavior that pleases the infant, increases the infants comfort and
attentiveness, and also reduces his/her distress and disengagement. A mothers sensitivity
to her child is related to her own early and later experiences with her attachment figures.
Secure attachment is the base for good enough reflective function and the ability to
interpret another persons feeling (Fonagy et al. 2002, Stern 2004). The mothers
representations of her baby may also be distorted because of her earlier averse
experiences, and mother with low sensitivity may either fail to identify or misinterpret
her childs signals (Fraiberg et al. 1975).

According to the transactional model, both the mother and the child with their strengths
and vulnerabilities are active partners in dyadic interaction (Sameroff 1993) and maternal
sensitivity is also considered to be not a characteristic of the mother but a dyadic factor
(Biringen & Robinson 1991, Crittenden 1988, Meins et al. 2001). However, the burden of
responsibility is on the adult. The mothers sensitivity to the childs needs also modifies
the childs ability to engage in interactive functioning (Brodn 2004). It is evident that
although maternal sensitivity has dyadic aspects, mothers are responsible for creating and
making possible mutual attunement in dyadic interaction (Beckwith et al. 2002).

There is variation not only in the definitions and terms used to describe the optimal
maternal interactive style but also in the terms used to describe low sensitivity and
disharmony. According the diagnostic classification for infants and early childhood (Zero

23
to Three 2005), failure in dyadic interaction is described with the terms under- and
overinvolvement, anxiety, anger and with abusiveness. Underinvolvement and
overinvolvement are the main negative end points also in most assessment methods
(Crittenden 1997, Murray et al. 1996, Biringen & Robinson 1991). The underinvolved
relationship is defined as having only sporadic or infrequent maternal involvement or
connectedness with the child, often with low quality care, whereas in the overinvolved
relationship the mother often interferes or dominates and makes developmentally
inappropriate demands. Crittenden (1997) describes the negative end points of sensitivity
with the terms unresponsiveness and control, and her definition of control includes both
overinvolvement and overtly and covertly hostile behavior. Besides the clear patterns of
the negative and positive end points used to describe the interactive style, combinations
of them also are needed to describe the actual maternal functioning in dyadic interaction.

2.1.2

Assessment of mother-child interaction and maternal sensitivity

Although a thorough interview is the basis of all clinical examinations, direct

observations are especially important in the assessment of parent-child interaction. As a
result of the development in infant mental health research and the increasing number of
children and families needing intervention, there has arisen a need for reliable assessment
methods for both research and clinical work. Several aspects need to be assessed in
parent-child interaction, and structured assessment techniques from different theoretical
backgrounds have been developed for both clinical and research purposes (Clark et al.
1993).

24
There is great variation in the methods and procedures used to assess maternal sensitivity
(see de Wolff & van IJzendoorn 1997, Meins et al. 2001). The assessment time varies
from brief moments to extended periods of several days, and the assessments have been
done both at home and in laboratories. The assessment methods vary from maternal
interview to video observations, from free observation to structured tasks, and from
global assessments to particular behaviors, while the focus varies from the quality of the
interactive style to the frequency of a particular behavior.

The first mother-child assessments were direct extended observations in naturalistic

situations at home. Already decades ago psychoanalyst Ester Bick introduced the practice
of psychoanalytic infant observation as part of the training program for child
psychotherapy trainees, which has been part of psychotherapy studies for many
professionals since the 1970s (Reid 1997). The main point of infant observation is to
assess what the observer has seen and felt during the observation, but because it is
conducted according to a standardized protocol and each observation session is recorded
in considerable detail afterwards, it is also used for research purposes in case studies, and
it is possible to apply it in focused studies of infancy (Miller et al. 1989).

Ainsworth and her colleagues (1978) in their Baltimore study also studied mother-infant
dyads in naturalistic home situations, and met the dyads for observations lasting many
hours several times during the infantsfirst year. On the basis of the findings of these
observations, Ainsworth developed the Strange Situation procedure (SSP) to reduce the
time and effort required for extensive naturalistic observations. The SSP is a laboratory

25
procedure designed to activate a child attachment system, and consists of eight episodes
of separations and reunions with the parent and the stranger, and with gradually
increasing stress placed on the infant. It is a widely used and is considered to be a reliable
method to assess mother-child interaction and the security of child attachment (see
Belsky & Cassidy 1994).

However, the SS procedure is also a complex and time consuming method, and shorter
and more convenient procedures for larger samples have been developed. Most of these
methods are also based on multicriterion constructs of sensitivity. According to
attachment theory, promoting the childs survival is the central function of parenting.
Apart from comfort and mutual pleasure, discipline and limit setting are also needed to
protect children, so it has been suggested that maternal sensitivity is best determined in a
situation where both protection and comfort are needed (Claussen & Crittenden 2003).
However, most sensitivity assessment methods developed after the SSP are based on lowstress situations and therefore sensitivity has been defined somewhat differently than in
the SSP, with the increasing stress due the separations.

The assessment methods based on video recordings have made it possible to further
develop exact and objective analyses of the parent-infant relationships especially in large
samples. Video recordings have made it possible to analyze thoroughly the interaction by
allowing us to examine the same situation several times, in short sections, with slow
motion and freeze frame (Stern 2004). They also facilitate the better identification of the
areas of strength and of concern in the interactive style of the dyads (McDonough 1993).

26
In most methods, parental behavior is assessed from the child perspective and child
behavior from the parental perspective, and either free play, feeding or structured
situations are used (Skoovgaard et al. 2004). The scorings are based on the quality,
quantity and frequency of the assessed behavior, temporal contingences and affective
attunement. Although there are several video-based methods for different age groups,
very few assessment methods are adaptable for the different developmental levels of the
child (Seifer & Schiller 1995).

Video-based assessments are considered to be precise and reliable (Skoovgaard et al.

2004), but we must remember that a video clip of a short moment is only a small sample
of interaction in real life and may not always catch the usual interactive style of the dyad.
The presence of a cameraperson during the recording and the fact that the video recorded
interaction will be assessed afterwards may cause stress and affect the dyadic behavior,
and as Clark (1985) points out the parentsopinion of the genuineness of the interaction
on the video must be solicited. However, short video-recorded sessions very seldom
include activation of the attachment system, and more specific procedures are needed to
assess that (Claussen & Crittenden 2003). There are also limitations in the methods and
procedures used to assess the dyadic interaction on the video. When using assessment
methods that seek high objectivity by counting the frequencies of behavior, for example
smiles, the meaning and genuineness of the behavior may be lost. On the other hand,
when using methods based on the scorers interpretation of the actual meaning of
expressed affect, some objectivity may be lost. To be a reliable scorer, extensive training
is needed (Beckwith et al. 2002). However, as Stern (2004) points out, one can often see

27
the larger panorama of life in the small behaviors in a short moment. He argues that a
short video clip of dyadic interaction between infants and mothers may also reveal some
very important details indicating the future development and in some cases the need for
interventions.
2.1.3

Continuity of maternal interactive style

Most investigators have assumed that there is consistency in maternal sensitivity across
development (see the meta-analysis of de Wolff & van IJzendoorn 1997), and moderate
consistency has also been found across different time points, tasks, situations and groups
in many studies (Burns et al. 1997, Levine et al. 1985, Minde et al.1994). However, few
studies have assessed the continuity of maternal sensitivity in follow-up studies (see
Belsky & Fearon 2002), and these studies have used different assessment methods. The
reported stability of maternal sensitivity has varied from moderate (Isabella 1993,
Kivijrvi et al. 2001, Fava Vizziello et al. 2000), to slight (Beckwith et al. 1999,
Bornstein &Tamis-Le Monda 1990). The follow-up time in these studies extends from
six months to one year, and most of the assessments were done during the babys first
year. With a longer follow-up from infancy to four years, Bohlin and Hagekull (2000)
report slight stability in maternal sensitivity, whereas Landry and colleagues (2001)
report moderate stability in the same age range.

Belsky and Fearon (2002) found stability in mother-child interactive style from 15
months to 24 months age by first assessing attachment security and then maternal
sensitivity, and they further assessed child behavior at the age of three. However, they
also raised the question of discontinuity: a highly sensitive mother is not always

28
continuously high in sensitivity, and a low sensitivity mother is not always continuously
low in sensitivity. Furthermore, in some situations the child needs more challenging and
activation, but in others restriction or protection, and infants need different parenting than
do walking and talking toddlers. Maternal sensitivity also means the adjustment of
parental behavior to the childs momentary and age-appropriate needs. Furthermore, it
has been found that the style of mother-child interaction is less stable in high risk dyads
with high levels of life stress (Belsky & Fearon 2002).

Although many aspects of maternal sensitivity and the stability of sensitivity are
disputed, it can be concluded from previous research that early mother-child interaction
and maternal sensitivity are important factors predicting the further mother-child
interaction and the childs future development. Furthermore, both early maternal
sensitivity and the continuity in sensitivity are thought to be equally important. For welldirected and early interventions it is important to identify the dyads at high risk, and
furthermore we must also identify which features of the early interactive style predict
further problems in mother-child interaction and child development. We need evidence
that short video recordings can provide relevant and reliable information about the
constant interactive style of the dyad, and not only about the videotaped moment.

2.1.4

Factors related to maternal sensitivity

Few researchers have studied the associations between maternal sensitivity and maternal
or child-related characteristics and risk factors (see Beckwith et al. 2002, Shin et al.
2006). Such factors may be related to the mothers own history and attachment

29
relationships from her own childhood to the adult age, and to biological and psychosocial
risks related to pregnancy, delivery and the postpartum period. Although there is limited
information about the risk factors related to low maternal sensitivity, there are several
studies emphasizing the association between maternal sensitivity and attachment (see
Beckwith et al. 2002, Shin et al 2006). The mothers own secure attachment has been
found to predict high maternal sensitivity, and high maternal sensitivity has been found to
predict the childs secure attachment to the mother (Fonagy et al. 1991). In their recent
study, Shin et al. (2006) found maternal-fetal attachment to be a predictor of maternal
sensitivity during the postpartum period. As Fraiberg et al. (1975) suggested already 30
years ago, unresolved conflicts from the parents past will be reflected in maternal
representations of the child and be repeated in the interaction with the child.

Mothersunresolved losses and traumas in the past are related to maternal pre- and
postnatal depression (Stern 1995). Maternal postpartum depression in particular has been
identified as a risk factor predicting problems in maternal social functioning and motherchild interaction (Campbell et al. 2004, Martins & Gaffan 2000), but in recent years the
effects of prenatal maternal depression on mother-child interaction and child
development have also been stressed (Diego et al. 2004). A mothers self identity as a
mother, the lack of social support and marital conflicts have also been found to be
important factors predicting early maternal sensitivity (Kivijrvi et al. 2004, Shin et al.
2006). These factors may also indicate mothersdepressive mood, and providing social
support might affect both mothersmood and the self esteem as a mother (Maunthner
1998). Unemployment and financial problems also cause emotional stress for mothers,

30
and have been found to be the important environmental risk factors for maternal
interactive functioning with the child (Sameroff 1993, Shin et al. 2006).

After delivery, both shared and individual experiences of the mother and the child modify
their dyadic interaction and also maternal sensitivity. The transactional model (Sameroff
1993) describes the multidirectional causality between the mother, child and
environment, and as Fonagy and colleagues (2002) say, abnormalities in mothering
represent only one route to limitations in dyadic interaction, and the childs biological
vulnerabilities are also likely to obstruct the optimal dyadic interaction. Even newborn
babies have been identified as active partners in interaction, and child temperament,
prematurity, sensory defects, chronic illness and physical handicap have been found to
affect maternal sensitivity (see Beckwith et al. 2002). Recent research suggests that there
is bidirectional interaction already between the mother and the fetus (Brodn 2004).
Furthermore, the rapid child development during the early years per se modulates the
mother-child interactive functioning and also the maternal sensitivity. As both mothers
and children are active partners in the dyadic interaction, maternal sensitivity as a dyadic
factor must be seen as dyad specific, not a characteristic of the mother. Every child needs
different mothering, and the maternal sensitivity to one child is different from that to a
sibling (Claussen & Crittenden 2003).

2.1.5

Maternal sensitivity and child development

The attachment theory underlines the importance of maternal sensitivity for child
development: Through sensitive interaction the child learns how to attract the parents

31
attention, and get comfort and protection (Claussen & Crittenden 2000, Fonagy 2002). As
Fonagy (2002) says, the parents exploration of the childs mental state in a sensitive
manner enables the child to find the caregivers mind and the child learns to interpret
both his or her own and the caregivers emotions. He further underlines that the motherinfant interaction forms the basis for the childs psychological development, and is
particularly modulated by maternal sensitivity, and suboptimal experiences of care in the
early interaction affect later development by undermining the individuals capacity to
process or interpret information concerning mental states, so that dyssyncrony becomes
the childs experience of the self. In underinvolved interaction the child adapts to
maternal unresponsiveness, and in overinvolved interaction to maternal control and
interferences (Zero to three 2005).

Sensitive mothering has been shown to be associated with the development of a secure
attachment of the child especially in normative samples, even in spite of variety in
definitions and methods of assessment (Beckwith et al. 1999, Belsky & Fearon 2002,
Campbell et al. 2004). However, de Wolff and van Ijzendoorn (1997) postulated in their
meta-analysis of associations between parenting behavior and infant-parent attachment
that there is only a low or moderate association between maternal interactive style and
infant-mother attachment, and they suggest that maternal sensitivity cannot be considered
to be the exclusive and most important factor in the development of attachment. Berlin
and Cassidy (2000) dispute this because de Wolff and IJzendoorn did not include such
aspects as cooperation, emotional support and quality of physical contact in their
definition of sensitivity. The study of de Wolff and van Ijzendoorn reveals that different

32
definitions of maternal sensitivity complicate the use of this concept and make the
comparison of results between different studies difficult.

According Stern (1989) every moment of early interaction creates an episodic memory
and representation of the interactive experience in the mind. Representations which are
similar to each other form a generalized representation of early interaction, Stern (1995)
has also underlined the importance of subjective and affective experiences in early
interaction, the schema-of-being-with. Both the representations of early experiences and
the schemas-of-being-with help the infant to analyze new experiences and also to predict
new episodes in the interaction, and thus enable the childs psychic development.
According to the transactional model, the childs development is part of a continuous
interaction between the genotype, phenotype and environtype, and in this process parents
are also seen as major regulating agencies of child development (Sameroff 1993).

The repetition of episodes that are very much alike also creates the repetition of a
particular neural activation, and the formation of more and more permanent neural
structures (Mntymaa & Tamminen 1999). The development of new synapses and
integrating neurons into more complex units is dependent on the childs interaction
experiences (Mntymaa 2006, Perry et al. 1995, Siegel 2001). Early parent-infant
interaction especially has been found to organize the infants experiences, and good
mother-infant interaction may even modify the impact of biological risks on child
development (Mntymaa 2006).

33
Early mother-child interaction and maternal sensitivity have been shown to predict child
attachment (Crittenden 1995, Koren-Karie et al. 2002), and cognitive abilities (Murray et
al. 1996, Stams et al. 2002). However, few studies have investigated early mother-child
interaction and child socio-emotional behavior (Hay & Pawlby 2003, Kochanska et al.
1999, Mntymaa 2006). Carter and colleagues (2001) found that high maternal emotional
availability to the infant predicts fewer externalizing symptoms two years later. In
clinical samples, both intrusive and unresponsive maternal interactive style (Cassidy et
al.1996, Gerhold et al. 2002, Shaw et al. 1998) have been found to predict child
behavioral problems, whereas in non-clinical samples only intrusive and not
unresponsive maternal interactive style has been found to do so (Hay & Pawlby 2003,
Mntymaa et al. 2004).

Similar to mother child interaction in general, child language acquisition is also

transactional: sensitive maternal interaction supports child communication and the childs
communication elicits maternal responses (Yoder & Warren 2001). The good enough
early mother-child interaction has been emphasized as enabling child language
acquisition (Bloom & Lahey 1978). Child participation in the communicative interaction
begins in the very early experiences, and infants are already able to participate in
bidirectional vocal dialogues with parents. At about nine months of age the child
becomes even more capable of more elaborate forms of intersubjectivity and begins to
use gestures and vocalizations intentionally to exert a preplanned effect on another
person, i.e. to use intentional communication (Trevarthen & Aitken 2001), which is
considered to be a precursor to language development (Bates 1979). However, mother-

34
child linguistic communication is also highly dependent on the mothers initiations and
ability to interpret the infants signals (e.g., Bruner 1981, Menyuk et al. 1995). It has
been suggested that adequate mother-child interaction during the transition from the
prelinguistic stage to referential speech is especially important for language development
(see Barrett et al. 1991).

2.2

Maternal depression around delivery

Maternal postnatal depression is a common and widely discussed subject in research

concerning mother-child interaction and infant mental health. It has been reported to be
an important factor predicting unresponsive or controlling maternal behavior in motherinfant interaction (Campbell et al 1995, Martins & Gaffan 2000). Maternal depression
may also delay the behavioral and emotional development of the child (Field et al. 1996,
Hay et al. 2001, Luoma et al. 2001). Furthermore, children of depressive mothers have
been identified to be at risk for insecure attachment (Fonagy et al. 1991).

However, there are also differences in the results in studies dealing with maternal
depression, and this can at least partly be explained by taking into account the different
definitions of maternal depression. The severity (Judd et al. 1996), timing (Campbell et
al. 1995) and chronicity (McLennan et al. 2001) of depression are considered to be the
most important factors in assessment. Continuous depressive symptoms have been
identified as having a greater influence on the mother-child interaction than transient
symptoms (McLennan et al. 2001). But as Assel and colleagues (2002) found, few studies
have investigated the continuity of depression and dysphoria. Evidence of the effects of

35
prenatal depression on postnatal functioning is also somewhat contradictory. Both
Campbell (1995) and Luoma and colleagues (2001) suggest that prenatal depression
affects postnatal dyadic functioning, whereas Weinberg and co-workers (2001) found no
clear evidence of such an effect. The expression of depressive symptoms at a certain time
point can be part of a depressive continuity or just a single mood drop, and Angst and
colleagues (2000) suggest that depression and associated differences in timing, continuity
and severity are better viewed as a spectrum rather than a set of discrete subtypes.

Previous depression studies have focused on the influence of major depressive disorders,
but recently some researchers have suggested that subclinical depression (elevated scores
in depression questionnaires but not meeting the diagnostic criteria) should also be
considered as a risk factor for social functioning (Assel et al. 2002) and for the later onset
of major depression (Judd et al. 1997). It has been claimed that the effects of subclinical
depression on social functioning are similar in profiles to major depression (Chen et al.
2000). However, few studies have evaluated the influence of subclinical depressive
symptoms on mother-infant interaction, and their findings have been somewhat
contradictory. Campbell and colleagues (1995) suggest that chronic depression with
major symptoms, but not subclinical depressive symptoms, compromise maternal
postnatal functioning, whereas the Weinberg team (2001) suggests that mothers with
subclinical depression also showed poorer psychosocial functioning than control mothers.
Negative mother-child outcomes have also been found according to self reports with
dysphoric mothers (Field et al.1996). It is unclear whether such symptoms should be
considered a part of normal variation or a risk factor (Carmin 1998).

36
2.3

Identification of risk dyads in well-baby clinics

Childrens physical health in general has been good in recent decades in Finland. At the
same time the number of psychosocial problems has increased, and such problems have
also become as an important focus of interventions in well-baby clinics. The main task of
well-baby clinics is to support all families with small children, but it is equally important
to identify the dyads at risk and give them or arrange extra support. Good screening
procedures are essential for finding the dyads needing interventions. (Ministry of Social
Affairs and Health 2004)

Mothers are the principal informants concerning their childrens well-being and
behaviour (Bird et al.1991, Kentgen & Klein 1997, Sourander 2001) both in clinical and
research work, as they know their childrens temperament, habits and everyday life. Most
screening studies are based solely on their responses to questionnaires. It is evident that
the younger the child, the greater is the importance of the information given by mothers,
as mothers are the ones who spend most time with their infants (Skovgaard et al. 2004).
However, not even mothers are perfect informants. Agreement between mothers and
other informants has been found to be only modest when assessing child behavioural
problems (Achenbach et al. 1987, Gross et al. 2004, Stanger & Lewis 1993). Studies have
been conducted on how mothersindividual characteristics affect their reports: Naijman
and colleagues (2001) found that the more emotionally impaired the mother, the more she
describes her child with externalizing symptoms. Furthermore, studies that rely only on
mothersreports may be even misleading, and the interpretations of data from behavior
problem checklists must always consider the nature of the observer (Spiker et al. 1992).

37
To get a more versatile picture of child behaviour, the use of other informants besides
mothers has been recommended (Najman et al. 2000; Skovgaard et al. 2004; Vogels et al.
2003). The number of studies based not only on mothersbut also on fathersreports is
growing. Fathers have most of the same advantages and limitations as informants as
mothers, but most of them spend less time with their infants and are not so familiar with
babieseveryday lives. Although agreement between mothers and fathers has been found
to be moderate (Derks et al. 2004), parents are not always unanimous. Limited correlation
between informants presents challenges when combining data.

As professionals, public health nurses (PHNs) in well baby clinics are important
informants in screening small children, because they meet almost all children from
infancy up to school age, and especially frequently during the first two years. They have
been reported to identify child behavioral problems (Paavilainen &Tarkka 2003), but
attention has also been drawn to the fact that many cases are missed in primary care
(Reijneveld et al. 2004). Puura and colleagues (2001) were especially concerned that the
PHNs found it difficult to explore the problems they had identified. Families at risk
should be offered extra interventions in well-baby clinics, and well directed interventions
require not only the early identification of such families but also sharing concerns with
them. The question for preventive work in well-baby clinics is, do parents and public
health nurses see the same problems and have the same impressions of childrens
behavior?

38

Aims of the study

Families at risk need extra interventions in well baby clinics and well directed
interventions require identification of them and sharing concerns with the parents. In this
research the continuity of early maternal sensitivity, the risk factors for maternal
sensitivity, child developmental consequences of mother-child interactive style, and the
identification of risk dyads among full-term babies in well-baby clinics were studied in
three samples Observation, Well-Baby Clinic and Linguistic Sample. The expectation
was that early maternal sensitivity would predict child behavior, and mothers assessed as
low in sensitivity would provide some clues about the need for intervention, and thus
might be identified and given extra support in well-baby clinics.

A. The aim in the Observation sample (Study I) was to determine

-

whether a video recording of a few minutesduration provides comparable data to

those obtained via observations spread over a year and whether it also describes the
continuous dyadic interactive style.

B. The aims in the Well-baby Clinic sample (Studies II, III and IV) were to
investigate
-

the continuity of maternal sensitivity from infancy to toddler age

whether early maternal sensitivity predicted child behaviour two years later

the risk factors related to maternal sensitivity

the continuity of maternal depressive symptoms

whether risk dyads are identified by public health nurses in well-baby clinics

39
-

whether parents and public health nurses see the same problems in child behaviour

whether risk dyads get extra support in well baby clinics.

C. The aim in the Linguistic sample (Study V) was to investigate

-

the association between mother-child interactive style and the development of child
linguistic skills.

40

Subjects and methods

4.1 Study procedure and subjects

4.1.1 Observation sample (Study I)
Although neither observation nor videotaped interactions are ever exactly equivalent to
real interaction (Zeanah et al. 1997), the purpose of this study was to discover how well a
video recording of a few minutesduration represents the general affective style of
mother-infant dyads, and whether it provides comparable data to those obtained via
observations spread over a year. In the Observation sample (Study I) the findings
obtained in five mother-infant dyads from a five-minute videotaped interaction were
compared with those of observations of infants, totaling approximately 40 hours,
performed weekly by experienced child mental health workers during the first year of the
infants life.

Five child mental health workers with 5-21 years experience who had taken part in infant
observations while undergoing child psychotherapy training took part in the study. They
observed the mother-child dyads for one hour weekly from birth to the childs age of one
year, and the mother-child dyads were video recorded in free play situations at the childs
age of one year. The Parent-Child Early Relational Assessment (PCERA, Clark 1985)
was used as the assessment method for both the video recordings and the observations.
The assessment procedure of the observation and video recordings is described in detail
in Study I.

41
4.1.2

Well-baby Clinic sample (Studies II, III, IV)

The second sample, the Well-baby Clinic (WBC) sample, comes from the two-year
follow-up study collected in 1997-2001 in six well-baby clinics in Kuopio (Studies II, III,
and IV). Four of the well-baby clinics served children and their families only after
delivery, and in two of them the public health nurses worked with mothers already during
pregnancy. The public health nurses in the maternity clinics invited the first-time mothers
at the 36-37 th week of pregnancy to participate in the study.

The schedule of the study is presented in Figure 1, and the number of participants and
dropouts in Figure 2. From late pregnancy to childs age of 24 months there were seven
contacts with the families five by mail and two meetings with the families. In this
report the data from five contacts (before delivery and at childs age of 2 weeks, 6-8
weeks, 4 months and 24 months) are reported. Besides basic demographic data,
information about the parents health and especially depressive symptoms (GHQ,
Goldberg et al. 1997; EPDS, Cox et al.1987), family life and child development, behavior
(CBCL/2-3, Achenbach 1992) and health was obtained. At childs age of 6-8 weeks and
24 months, the parent-child interaction was video recorded and assessed using the
CARE-Index (Crittenden & DiLalla 1988). We also inquired about maternal education,
parental relationship, IVF-fertilization, problems and experiences related to pregnancy
and delivery, the need and length of neonatal intensive care, parentsworries about the
child, length and experiences of breastfeeding and support the parents had obtained from
well-baby clinics and their own families. As we did not find any statistically significant

42
differences when these factors were compared with maternal sensitivity, or depressive
mood they are not further discussed in this report.

Three to four weeks before delivery 149 families were invited to take part in the study,
but as many as 39 (26%) refused. The public health nurses were asked whether they
thought that there were any special reasons why these families had refused, and they
reported that in 25 cases there may be some family-related risk factor. Eleven (7%) of the
families who had promised to take part did not respond. Actually, 99 families answered
the first questionnaires before delivery but five of them dropped out after the first contact,
and another seven families during the follow-up. Eight families refused to have the video
recording. Two infants fell asleep before the video recording at age of 6-8 weeks.
Altogether 78 mothers took part in the study at the first four time points, and 75 motherchild dyads were also video recorded at childs age of 24 months. One video-recorded
family did not return the CBCL/2-3 questionnaires at childs age of 24 months.

The sample consisted of full-term babies. The children were distributed in a normal range
regarding gender, birth weight, and five-minute Apgar points (Table 1). Two children had
luxatio coxae, and one child a fractured clavicle with no further complications, but there
were no other major problems with the childrens health. Three mothers were single.
Most of the families came from the upper or middle socioeconomic classes according to
the occupational status of the partner assessed to have the higher status. Before starting
maternity leave, 24% of mothers were unemployed.

J________________________________________
VIII/99 CBCL, CARE-Index, IFEEL, GHQ, BDI
child and parental data II / 2001
Public health nurses: Worries

+______________________________________
II/99 Child and parental data, child temperament V / 2000
Doctors: Worries

I /2001

43

H37=37th week of pregnancy, GHQ=General Health Questionnaire, EPDS=Edinburgh Postnatal Depression Scale, BDI=Becks Depression Inventory,
IFP=IFEEL Pictures, NPI= Neonatal Perception Inventory, CBCL=Child Behavior Check List

+ Contact by letters, J Meeting the family

I/2000

+___________________________________
VIII/98 Child and parental data
XII / 99

+ ____________________________________
XII/97 EPDS, child and parental data, NPI III /99

J_____________________________________
IX/97 IFP, CARE-Index, child and parental data I / 99
Public health nurses: Worries

+_________________________________________
VIII/97 EPDS, BDI, child and delivery data
XII / 98

Figure 1. Timetable of the Well Baby Clinic study.

24 months

18 months

12 months

4 months

6-8 weeks

2 weeks

+_________________________________________
VII/97 GHQ, basic data, pregnancy data,
XI / 98

I/99

H37

I/98

VII/97

Age

44

Table 1. Basic data of (A) mothers, (B) families and (C) children at the beginning of the
WBC study (n=78)

n (%)
(A) Maternal data
Maternal age at delivery
Maternal basic education
- upper secondary school
- compulsory basic education
Maternal employment before
maternity leave
- employed
- unemployed
- studying
(B) Family data
SES status of family according to
higher status of partners
- upper or middle
- lower
Structure of family
- married or cohabiting parents
- single mother
(C) Pregnancy and birth data
In vitro fertilization
Gender of child
- boys
- girls
Birth weight
Five minute Apgar points
- 10
-9
-8

Range

Mean (sd)

19-42 years

28.6 years

2560- 4790g

mean 3355g

52 (67%)
26 (33%)
48 (62%)
19 (24%)
11 (14%)

59 (76%)
19 (24%)
75 (96%)
3 (4%)
11 (14%)
38 (49%)
40 (51%)
6 (8%)
68 (87%)
4 (5%)

45

Figure 2. Time points of contacts, number of mothers and drop outs in the WBC sample.

37th
week

99 (100%) mothers

- 5 mothers dropped out

2
weeks

94 (95%) mothers

- 8 mothers refused video

recording

6-8
weeks

84 (85%) motherchild dyads

- 2 babies fell asleep

- 4 mothers dropped out

4
months

78 (79%) mothers

- 3 mothers dropped out

24
months

75 (76%) motherchild dyads

- 1 mother did not return the

CBCL/2-3

DELIVERY

4.1.3

Linguistic sample (Study V)

The Linguistic sample consisted of 27 mothers and their first-born full term infants
delivered in Oulu University Hospital (Study V). Mother-child interaction was assessed
at the infants age of 10 months and childrens early communicative and linguistic
development at 12 months, and later language outcome at 30 months. The mother-child
interaction was assessed using the CARE-Index (Crittenden and DiLalla 1988), childrens
early communicative and linguistic development using the MacArthur Communicative
Development Inventories (MCDI, Fenson et al. 1994, Lyytinen 1999) and the
Communication and Symbolic Behavior Scales (CSBS, Wetherby & Prizant 1993), and

46
their later linguistic competence using the Reynell Developmental Language Scales III
(RDLS III, Edwards et al. 1997, Finnish version 2001).

4.2
4.2.1

Methods
Parent-Child Early Relational Assessment

The Parent-Child Early Relational Assessment (PCERA) developed by Roseanne Clark

(1985) was used in the Observation sample (Study I) as the assessment method for both
the video recordings and the observations. The PCERA is a video-based parent-child
interaction assessment method (suitable from 0 to 7 years) measuring both the affective
and behavioural characteristics expressed by the child and the parent in dyadic interaction
in four situations, each lasting five minutes (free play, eating, separation-reunion, and
structured task). In our study, free play was selected for assessment because it was
considered to be the most similar to the unstructured observation situation between the
mother and infant. Areas of strength and areas of concern are measured by 29 parental, 28
child and 8 dyadic items. Each item is scored on a five-point Likert-type rating scale in
the areas of concern (scores 1-2), some concern (score 3), or strength (scores 4-5)
according to the frequency, duration, and intensity of the behaviour.

In the Observation sample (Study I) the videos were assessed independently by three
PCERA-trained raters A, B and C. Kappa was used to measure the agreement between
rater pairs to identify the most similar raters: agreement was moderate (0.413) between
raters A and B, and fair between B and C (0.346), and also between A and C (0.294) in
all ratings. Thus, video raters A and B, with the most similar ratings, were chosen for

47
further assessments. The proportion of agreement between video raters A and B was 4/55/5 in 52 items, 3/5 in 8 items, and 2/5-1/5 in 5 items. According to the combination of
kappa and the proportion of agreement, the inter-rater reliability was moderate or higher,
and was considered sufficient in 54 items.

4.2.2

CARE-Index

The CARE-Index (Child-Adult Relational Experimental Index, Crittenden & DiLalla

1988, Crittenden 1997) was used to assess mother-child interaction both at the age of 6-8
weeks and 24 months in the Well-Baby Clinic sample (Studies II, III and IV) and at the
childs age of 10 months in the Linguistic sample (Study V). The assessment procedure
of the CARE-Index consists of ratings of 3-5 minutes (in our studies 5 minutes) of
videotaped free play interaction. The coding system is based on assessing the adults
sensitivity to the infants signals, and child co-operation with the adult. Both maternal
and child interaction are assessed according to seven variables: facial expression,
vocal expression, position and body contact, expression of affection, turn taking,
control, and choice of activity. The first four refer to shared affects (affect items)
and the final three to temporal contingencies (items of temporal contingences) within
the dyad.

Each maternal variable is assessed on a scale from 0 to 2 for sensitivity, and the sum of
sensitivity scores gives the global score for maternal sensitivity. Correspondingly, the child
variables are assessed for cooperation, and the sum of cooperation scores gives the global score
for child co-operation. Crittenden recommends the CARE-Index especially for screening, and

48
in her scoring system, scores from 0 to 6 are considered to be in the intervention range (5-6
inept, 0-4 at risk), and scores from 7 to 14 in the adequate range (7-10 adequate, 11-14
sensitive/co-operative) (Table 2, Crittenden 2006). Low maternal sensitivity is profiled as
controlling and/or unresponsive, and low child cooperation as compulsive compliant, difficult
and/or passive. Maternal control can be divided into covertly and overtly intrusive and
incongruent maternal behavior, but as there was hardly any overt intrusiveness in this study, the
term controlis used in this study to refer to covert intrusiveness but also includes slight overt
control.

The term sensitive means that mothers gain high mutual synchrony, and adequate
interaction includes periods of dyssynchrony but no need for intervention. Ineptinteraction
describes moderate dyadic dyssynchrony but without maternal hostility or lack of empathy. If
interactions are assessed at the at risklevel, mothers have evident difficulties in creating
mutual synchrony and are highly passive and/or controlling. Sensitivity assessed to be at least
adequate, i.e. above intervention range (Table 2), can be equated with Winnicotts (1965/1990)
term good enough mothering.The terms at least adequate, above the intervention leveland
good enoughare used as synonyms in this research. To avoid confusion between the terms
sensitive and sensitivity, the sensitivity range 11-14 (sensitive) is called high in
sensitivity(Study V). Furthermore, to be more respectful to mothers, we used the description
moderate problemsas a synonym for the term inept.

49
Table 2. CARE-Index dyadic synchrony scale with the synonyms used as descriptors of dyadic
interaction.

Description of range

Above intervention range At least adequate - Good enough

- Sensitive/Co-operative high in sensitivity/co-operation

Scores

7-14
11-14

- Adequate adequate play with periods of dyssychrony

7-10

Intervention range- Under intervention level

0-6

- Inept moderate problems in interaction

5-6

- At risk high risk, evident problems in interaction

0-4

In the WBC sample (Studies II-IV), the video recordings were made by three persons, one of
whom did the scoring of the videos. To guarantee blindness to the other data collected, the
scoring of videos for each age group was done more than half a year after the video recording
had been done for the whole age group, and the other data were examined and combined with
the video data after all video scorings had been done. The inter-rater reliability between the two
independent raters (Toivanen-Falck and Kemppinen) was studied in 20% of the dyads in both
video recorded situations. The raters had been trained by Crittenden. The intraclass correlation
between raters was 0.825 (0.817-0.919 in descriptors) in maternal sensitivity, and 0.904 (0.6460.783 in descriptors) in child cooperation at the first time point, and 0.801 (0.578-0.680 in

50
descriptors) in maternal sensitivity and 0.806 (0.580-0.741 in descriptors) in child cooperation
at the second time point. The item by item sensitivity and co-operation scorings were exactly
the same in 72% cases at the first, and in 79% cases at the second assessment point. In the
Linguistic sample (Study V), the video recordings were done by the first author (L. Paavola)
and the scorings by the second author (Kemppinen) of the original paper.

4.2.3

General Health Questionnaire

The General Health Questionnaire (GHQ-12) was used to assess the mothersmental
well-being in the 37th week of pregnancy and at childs age of 24 months in the Wellbaby clinic sample (Studies II and III). The GHQ is a 12-item and four-point scale
questionnaire, with questions covering depression, anxiety and self-esteem, and is well
accepted, valid and reliable for screening (Goldberg et al. 1997) and commonly used in
the culture studied (Holi et al. 2003). The cut-off point of 3 or more is commonly used in
screening and indicates not only clinical depression but also minor symptoms (sensitivity
71.4-91.4% and specificity 71.0-89.7 %; Goldberg et al. 1997).

4.2.4

Edinburgh Postnatal Depression Scale

In the Well-baby Clinic sample (Studies II and III), the mothers filled in the Edinburgh
Postnatal Depression Scale (EPDS) two weeks (EPDS I) and four months (EPDS II) after
delivery. The EPDS is a commonly used and sensitive method for screening postnatal
depression in the culture studied (Luoma 2001). A cut-off point of 10 or more (sensitivity
100%, specificity 87; Eberhard-Gran et al. 2001) is recommended for screening in

51
primary care and was used to distinguish between no and minor depressive symptoms
(Boyce et. al.1993). A higher cut-off point of 13 or more (sensitivity 64%, specificity
96%; 8) was used to identify mothers with major depressive symptoms. These cut-off
points are referred to as minor and major depressive symptoms, respectively, and the term
depressive symptoms is used for a combination of minor and major symptoms in this
study.

4.2.5

CBCL72-3, Child Behavior Checklist for Ages 2-3 years

Both parents completed the Child Behavior Checklist /2-3 (CBCL/2-3) at the childs age
of 24 months in the Well-baby Clinic sample (Study IV). The CBCL/2-3 is a valid and
reliable questionnaire to rate child behavioral and emotional problems at the age of 2-3
years (Achenbach 1992). The scale consists of 99 items, which can be combined into a
total problem scale and six syndrome scales: anxious/depressed, withdrawn, aggressive
behavior, destructive behavior. The syndrome scales can further be combined into two
grouping scales: internalizing (anxious/depressed, withdrawn) and externalizing
(aggressive behavior, destructive behavior) scales.

4.2.6

MacArthur Communicative Development Inventories

In the Linguistic sample (Study V), the Finnish version of the MacArthur Communicative
Development Inventories (MCDI; Fenson et al. 1994, Lyytinen 1999) based on parents
reports was used to assess childrens phrase and vocabulary comprehension as well as
vocabulary production at the age of 12 months. In addition, there is a composite measure

52
describing early symbolic action and communicative gestures, called Total Gestures,
derived from parental reports.

4.2.7

Communication and Symbolic Behavior Scales

The Communication and Symbolic Behavior Scales (CSBS; Wetherby & Prizant 1993)
were used in the Linguistic sample (Study V) at childs age of 12 months to assess
communicative behavior. The videotaped CSBS procedure includes direct sampling of
child communicative behavior with an examiner, in the presence of the parent. It includes
assessment of childrens communicative, social-affective, and symbolic skills. Child
communicative behavior is rated according to seven cluster scores (communicative
function, gestural, vocal and verbal, reciprocity, social-affective signaling and symbolic
behavior) and the composite score, CSBS-Total.

4.2.8

Reynell Developmental Language Scales III

The Finnish version of the Reynell Developmental Language Scales III (RDLS III;
Edwards et al. 1997, Finnish version 2001) was used in the Linguistic sample (Study V)
to assess childrens comprehensive and expressive language skills at the child age of 30
months. The Comprehension scale of the RDLS III tests comprehension of singe words
and basic relations between words, understanding of attributes and spatial relation,
understanding of thematic roles in sentences as well as complex grammatical and
inferencing skills, and the Expressive scale the childs ability to label objects, describe

53
activities and define words, and it assesses the childs abilities to use appropriate
vocabulary and grammatical structures.

4.2.9

Other measures

Questionnaires were used to elicit basic demographic data concerning the parents, the
birth and the newborn baby in all three samples (Studies I-V), and also concerning child
development, parental and child well-being, everyday life in families, and their use of
well-baby clinic services in the WBC sample (Studies II, III, IV). In the WBC sample,
the parents filled in questionnaires at the 37th week of pregnancy, and at childs age of 2
weeks, 4, 12 and 18 months. Parents were interviewed during the contacts related to the
video recordings at childs age of 6-8 weeks and 24 months. In this report we use the
prenatal and postnatal (2 weeks) and interview data (6-8 weeks).

Information about clinical contact with health care professionals because of depression
during pregnancy was elicited in the interview concerning mothershealth and family
relationships. The history of clinical contact because of depression was combined with
the information given in the GHQ to represent the depressive symptoms during
pregnancy: mothersreports of depression either in the interview or in the GHQ, or both,
represented prenatal depression.

During the familiesscheduled visits to the well baby clinic at childs age of 6-8 weeks
and 24 months, the public health nurses assessed their own worries about the childs
behavior or health (somatic health, growth, motor development, psychic well-being

54
depression, irritability, crying , anxiety, fearfulness, abilities in interaction, eating and
sleeping difficulties) or parentspsychic and somatic well-being and health and parentchild interaction, and need for extra support in well-baby clinics, on a five-point Likerttype scale questionnaire (from 1= very worried, to 5= not at all worried).

The public health nurses also assessed, in a more detailed questionnaire at the childs age
of 24 months, on a five point scale their worries about mother-child interaction in ten
maternal items (general anger, depression, anxiety and enthusiasm, displeasure expressed
toward the child, enjoyment, flexibility, creativity, intrusiveness and contingent responses
to behavior appropriate to the childs age ), eleven child items (happy, apathetic or
depressed, anxious, irritable, sober, alertness, avoiding, seeking comfort from parent,
explores environment in age-appropriate manner, makes initiations toward parent,
responds to parents initiations), and three dyadic items (joyfulness, flatness, reciprocity).

4.2.10 Statistical methods

Several statistical methods were used to describe the results of this research. The
statistical analyses were carried out with the SSPS for Windows (version 11.5).
1. Percentages, means, standard deviations and ranges were used to characterize the
WBC and Linguistic samples.
2. The kappa coefficient was used as the primary statistical method to assess the
agreement of two PCERA raters in the Observation sample, the stability of the
dichotomized mother-child interactive style (CARE-Index) between the two

55
assessment points, and

the agreement between the video assessments and

mothersand public health nursesreports in the Well Baby Clinic sample.

3. The proportion of agreement was used in addition to kappa to assess the
similarities between the raters in the Observation sample.
4. Intraclass correlations were used to describe the agreement between the video
raters in the Well-Baby Clinic sample.
5. Fishers Exact Test was used to detect associations between maternal sensitivity
and related categorical factors in the Well-Baby Clinic sample.
6. Pearsons 2-test for independence was used to detect associations between the
mothersdepressiveness expressed in categorized questionnaire scales and their
own reports of depression, and between low maternal sensitivity and related
categorical factors in the Well-Baby Clinic sample.
7. Pearson correlations were used to describe the stability of mother-child interactive
style between the two assessment points in the Well-Baby Clinic sample, and to
describe the relationships between early communicative skills and later language
outcomes in the Linguistic sample.
8. Students t-test was used to compare variables of child communicative and
linguistic development in the Linguistic sample between sensitivity/cooperation
groups.
9. The T-test and one-way analysis of variance and post hoc Dunnetts T-test were
used to test the differences in means of maternal sensitivity and child co-operation
between different maternal depression groups in the Well-Baby Clinic sample.
10. Bonferoni correction was used in multiple comparisons when necessary.

56

Summary of results

5.1
5.1.1

Continuity of mother-child interactive style

One year observation compared with five minute video assessment

In the Observation Study (Study I), a short video clip was compared with one year
observation in five mother-child dyads. The inter-rater reliability was moderate or higher
in 54 PCERA items, and the video rating in these items were compared with the
observation ratings. In 42 (78%) of 54 PCERA items

there was at least moderate

agreement (kappa 0.41 1.00 or proportion of agreement 4/5-5/5), and in another 7

(13%) items fair (kappa 0.21-0.40 or proportion of agreement 3/5) agreement between the
video and observation ratings, and both methods revealed the areas of strength and of
concern of the dyads. Altogether 23 PCERA items were found to identify at least some
difficulties in interaction, but only in sixteen of these items the inter-rater reliability was
sufficient between the two video raters.

In 15 items with a rating of 5/5 agreement in all dyads, according to both the video raters
and observersassessments, the ratings were consistently assessed to be in the area of
strength also by both video raters. Most of these variables were related to negative
expressions, behavioral or affective disturbances or adaptive abilities and skills.
Problems in the interactive style according to both the video raters and observers
assessment were identified in 15 items. Among these items the agreement between video
rater and observers was at least moderate in six (parental items flat tone of voice,
enthusiastic mood, and mirroring, child items sober and quality of exploratory
play, and dyadic items joint attention) and fair in two (parental items contingent

57
responsivity to childs positive behaviorand creativity). It was slight or poor in seven
items (parental items expressed enjoyment and pleasure toward the child, positive
physical contact, amount of verbalization, social initiative, reading childs cues, and
flexibility, and dyadic item reciprocity). Only two items describing negative
interactive style (maternal flat voice, child sober mood) were assessed as identifying
problems in dyadic behavior, but these items identified the dyad which was also assessed
to have constant problems according to several other items. Most items describing
positive interactive style and identifying the areas of concern in the interactive style
according to both observation and video assessment were connected with the parental and
dyadic engagement in the interaction. Five items with slight or poor agreement (maternal
reading child cues, positive physical contact, amount of verbalization, and
flexibility, and child consolability) between video rater and observer gave rise to
questions about how the video recording situation affected the behavior of the dyads, and
about the limits of assessment methods and assessment of dyads with children of different
ages and dyads from different cultures. According to these items, four mothers had been
assessed as having hardly any positive physical contacts, and three mothers were assessed
as using more verbalization or reading the childs cues more sensitively on the video
compared with the observation.

After the video recording all the mothers claimed that the interaction had been similar to
their usual interaction: only one mother added further comment, saying that she had been
a little anxious and her child had flu. This dyad was identified as problematic according

58
to several items in the video assessment but the observer had not been worried about this
mother and her child.

5.1.2

Continuity of mother-child interactive style from infancy to toddler age

In the Well-baby Clinic sample (Study III), the interactive style of 75 mother-child dyads
was assessed using the CARE-Index when the child was aged 6-8 weeks and 24 months
in order to examine the stability of maternal sensitivity from infancy to toddler age.
Soon (6-8 weeks) after delivery, in 73% (55) of dyads maternal sensitivity was assessed
as being above the intervention level (good enough) but only in 57% (42) of dyads was
child co-operation above this level, according to the CARE-Index. At the childs age of
two years, the number of mothers (59, 79%) and children (61, 81%) assessed as being
above the intervention level in their interactive style was slightly higher than at the first
assessment point.

Most of the mothers claimed that the video recorded interaction was quite similar to their
usual interaction with the child. However, at the childs age of 6-8 weeks 17 (23%)
mothers said in their answer to the open question the video recorded interaction was
clearly different from the usual one: more than half (9) of them reported differences in the
amount of their own verbalization, and almost a quarter (4) reported that they had been
anxious because of the video recording. Furthermore, six of the mothers who had
reported such differences said that the infant had been focused on the new environment,
and three reported some somatic problem in their child (tiredness, hiccupping, and colds
with sneezing). At the childs age of 24 months only 3 (4%) mothers claimed that there

59
was a clear difference between the video recorded session and free play sessions at home,
and they explained on one hand that either the mother, the child or both had been more
quiet, and on the other hand that they had been pushing the child to play on the video.

MATERNAL INTERACTIVE STYLE

Mean (sd)

Pearson correlation

Mean (sd)

2.96 (3.01)

UNRESPONSIVENESS
* 0.428 (<0.0005)

3.71 (2.81)

3.49 (2.72)

CONTROL
* 0.435 (<0.0005)

1.80 (2.16)

7.60 (2.46)

6-8 weeks

SENSITIVITY
* 0.576 (<0.0005)

Childs age

8.51 (2.89)

24 months

Figure 3. Means (sd) of maternal sensitivity, control and unresponsiveness at the childs
age of 6-8 weeks and 24 months, and the correlation between sensitivity, control and
unresponsiveness between the assessment points.

60
The maternal interactive style was moderately stable from infancy to toddler age, as the
assessments of maternal sensitivity (Pearson correlation 0.576) correlated significantly
between these two time points (Figure 3). Furthermore, not only sensitivity but also
control (0.435) and unresponsiveness (0.428) as descriptors of low sensitivity correlated
significantly between these two assessment points.

CHILD INTERACTIVE STYLE

Mean (sd)
4.45 (2.93)

Pearson correlation

PASSIVITY

Mean (sd)
3.23 (2.30)

1.55 (1.94)
1.72 (2.37)

DIFFICULTY

1.47 (2.27)

COMPULSIVE
COMPLIANCE

6.47 (2.83)

CO-OPERATION

6-8 weeks

Childs age

0.87(1.45)

8.36 (2.48)

24 months

Figure 4. Means (sd) of child co-operation, compulsive compliance, difficulty and

passivity at the childs age of 6-8 weeks and 24 months, and the correlation of cooperation between the assessment points.

61
The stability of the childrens interactive style between these two assessment points was
lower than that of the mothers (Figure 4), but the association between the dichotomized
child cooperation assessments was significant (Kappa 0.221, p=0.058). Furthermore,
even slight child compulsive compliance in infancy predicted both low co- operation
(Pearson correlation 0.364, p=0.001) and also high difficulty (Pearson correlation 0.531,
p<0.001) at toddler age.

To assess the probability of maternal sensitivity remaining from infancy to toddler age in
the same dichotomized category (good enoughor intervention range) we composed
four groups according to the scorings at these two time points (Figure 5): 49 (65%)
mothers were assessed twice as good enough(above-above); 6 (8%) mothers first as
good enoughand then at intervention level (above-below); 10 (13%) mothers first at
intervention level and then as good enough(below-above); and 10 (13%) mothers twice
at intervention level (below-below).

Sensitivity remained in the same dichotomized sensitivity category (above/below the

intervention range) in 59 (79%) dyads between the assessment points (Kappa 0.667;
Figure 5). The probability of remaining in the same category was higher among mothers
assessed as good enough, since 89% of these mothers, compared with only 50% of
those assessed as below the intervention level, were assessed similarly at both assessment
points. But besides the moderate stability, there was also a slight upward shift in the
means of maternal sensitivity and unresponsiveness, and accordingly a downward shift in
the mean of maternal control (Figure 3).

62
The early maternal interactive style was compared between the above mentioned
sensitivity groups formed according to the constant and transient maternal interactive
styles. First the mothers assessed as needing intervention at either or both time points
(above-below, below-above, below-below) were compared with the ones assessed twice
as good enough (above-above), and then the mothers assessed as below the intervention
level at either time point (above-below, below-above) were compared with the ones
assessed as below the intervention level at both time points (below-below, Figure 5).

MATERNAL SENSITIVITY AT CHILDS AGE OF 6-8 WEEKS

Above intervention level, n=55

Number
of dyads

49

Above intervention level, n=59

Below intervention level, n=20

10

10

Below intervention level, n=16

MATERNAL SENSITIVITY AT CHILDS AGE OF 24 MONTHS

Figure 5. Number of dyads in dichotomized sensitivity groups (above or below

intervention level 7) at childs age of 6-8 weeks and 24 months.

63
The mothers in the group assessed twice as good enough (above-above) were assessed as
significantly higher in sensitivity than the mothers in all the other groups at the childs
age of 6-7 weeks, and the mothers in the group assessed twice at intervention level
(below-below) were assessed as significantly lower than those in the transient groups
(above-below, below-above). The maternal sensitivity in most (80%) dyads of the group
assessed twice at intervention level (below-below) was described by evident problems,
and in most (80%) dyads assessed with increasing sensitivity (below-above group) as
having moderate problems already in the interaction with the infant. The maternal
interactive style in the group assessed twice at intervention level (below-below) was also
assessed as significantly more unresponsive.

The mothers who were assessed twice at intervention level (below-below) had been
assessed as most often having difficulties in expressing sensitivity in their affective
behavior. At the childs age of 6-8 weeks, the interactive style of almost all (90%)
mothers assessed to be at intervention level at both time points (below-below) was scored
zero in sensitivity in at least one affect item, but such very low scorings in affect items
were found in only 0-30% of dyads in the other sensitivity groups (Table 3). However, in
half (n=38) of all dyads maternal sensitivity was scored zero in at least one of the items
of temporal contingencies. Such low scorings in items of temporal contingencieswere
found in all dyads in the groups assessed at the intervention level in infancy, but also in
one third of dyads in the group assessed twice as good enough.

64

Table 3. Number of dyads with low scorings (sensitivity=0) in the affect items and in the
items of temporal contingences 6-8 weeks after delivery in the sensitivity groups
combined according to the continuity of maternal interactive style

Low (=0)
scoring in
sensitivity

Maternal sensitivity groups according to continuity of maternal

interactive style
AboveAboveBelowBelowAll
above1
below2
above3
below4
n=49
n=6
n=10
n=10
n=75

Affect items

13

Items of
temporal
contingencies

14

10

10

38

Maternal sensitivity twice above, 2 first above and then below, first below and then above, twice below
intervention level at childs age of 6-8 weeks and 24 months.
1

For further study of the continuity of low early maternal sensitivity in the WBC sample
(Study IV), the mothers who had been assessed at intervention level in sensitivity at the
childs age of 6-8 weeks (n=20, 27%) were divided according to the original CAREIndex scoring ranges into inept(n=10, 13.5%) and at risk(n=10, 13.5%) groups
(Figure 6). Two years later, in the riskgroup, the mean of maternal sensitivity was still
at the intervention level, and significantly lower than in the ineptand the good enough
groups (Figure 6). The mothers in the riskgroup were significantly more unresponsive
than those in the good enoughgroup.

65

SENSITIVE & ADEQUATE

n=54 (9+45)
6-8 weeks

24 months

8.8+1.5

9.3+2.5

INEPT
n=10

5.4+0.5

7.4+ 2.3

RISK
n=10
3.3+0.7

4.8+ 2.0

Figure 6. Continuity of maternal sensitivity (means and standard deviations) from 6-8
weeks to 24 months in three sensitivity groups created at childs age of 6-8 weeks using
the CARE-Index.

5.2

Risk factors related to maternal sensitivity

In the Well-baby Clinic sample (Study II), in accordance with the inclusion criteria, the
mothers had full term pregnancies with no special problems. Furthermore, the newborn
babies had no major heath problems and all but three of them were born to two-parent
families. However, we found four risk factors associated with maternal sensitivity both at
the childs age of 6-8 weeks and at 24 months.

66
5.2.1

Continuity of maternal depressive symptoms around delivery

In the Well-baby Clinic Sample (Study II, n=78), seven mothers reported a clinical
contact with a health care professional because of depression during pregnancy, 21
mothers reported depressive symptoms according to the GHQ three weeks before
delivery, and altogether 23 mothers reported some depressive symptoms during
pregnancy. Depressive symptoms were reported by 21 (27%) mothers two weeks after
delivery (EPDS I) and by 17 (22%) mothers four months after delivery (EPDS II). Nearly
half (n=36, 46%; Figure 7) of the mothers reported having depressive symptoms at least

Figure 7. Continuity of maternal depressive symptoms from pregnancy to 4 months

(ADFG=before delivery, BDEG=two weeks after delivery, CEFG= 4 months after
delivery; A, B and C once, D, E, F and G recurrently).

67
once around delivery, and half of these (n=18, 23%) reported having such symptoms
recurrently, and seven (9%) of the mothers at every time point (Figure 7). Most (76%) of
the mothers reporting depressive symptoms two weeks after delivery also reported
recurrent symptoms.

5.2.2

Maternal depressive symptoms around delivery and early maternal

sensitivity

Early maternal depression was compared with maternal sensitivity in the Well-baby
Clinic sample: in Study II the timing, severity and continuity of depressive symptoms
around delivery were compared with maternal early sensitivity, and in Study III the
continuity of maternal sensitivity was compared with the timing of depression.

Almost half of the mothers (n=36) reported depressive symptoms at least once around
delivery and were assessed as significantly lower in sensitivity in their interaction with
the infants than non-depressive ones (n=42). Eight (19%) non-depressivemothers were
assessed to be at the intervention level, and only three (7%) at the risk level, whereas
among mothers (n=36) who reported depressive symptoms at least once, 14 (39%) were
assessed to be at the intervention level and 9 (25%) at the risk level (Figure 8). The
differences between these two groups were statistically significant. The means of
sensitivity were also significantly different between the mothers reporting depressive
symptoms at least once either before delivery or four months after delivery (n=13,
subgroup AC) and those reporting no depressive symptoms. More than half (n=7, 54%)
of them had been assessed at intervention level and more than a third (n=5, 38%) at

68

Figure 8. Means of maternal sensitivity, number of mothers assessed at intervention or at

risk level, and number of mothers assessed as depressive by the public health nurses in
subgroups formed according to the continuity of maternal depressive symptoms (A, B
and C once, DEFG recurrently depressive), n=number of mothers in each group,
I(r)=number of mothers assessed at intervention (risk) level in sensitivity, M (sd)=means
(standard deviations), Dphn=number of mothers assessed as depressive by public health
nurses.

risk level. In the group of mothers reporting recurrent depressivesymptoms (n=18,

23%, subgroup DEFG,) six (33%) mothers were assessed to be at the intervention level
and four (22%) at the risk level. Most mothers (n=9, 75%) assessed to be at the risk level
reported depressive symptoms before or after delivery and also reported major depressive
symptoms two weeks after delivery. The mean of maternal sensitivity was above the

69
intervention range in both the EPDS I/minor and EPDS I/major groups, and did not differ
significantly in either of these groups from that of the group of non-depressivemothers.
However, most of the mothers expressing minor (73%) or major (83%) depressive
symptoms in the EPDS I reported them recurrently.

Ten (13%) mothers reported major and seven (9%) only minor depressive symptoms in
the EPDS II four moths after delivery. Eight (80%) of the mothers reporting major and
three (42%) reporting minor symptoms in the EPDS II reported recurrent symptoms. The
mean of sensitivity was at the intervention level among both the mothers reporting minor
and those reporting major depressive symptoms. The difference was significant between
mothers reporting major depressive symptoms in the EPDS II and those reporting nondepressive symptoms, but not between mothers reporting minor and those reporting nondepressive symptoms.

The interactive style of mothers in the baby bluessubgroup (group B, Figure 8) was
different from that among all other subgroups, also among mothers who reported
depression only once before delivery or 4 months after delivery (groups A and C). Five
mothers reported depressive symptoms around delivery only in the EPDS I two weeks
after delivery (baby blues, group B), and four of these mothers were assessed as above
the intervention level, and none at the risk level. Mothers other those in the baby blues
subgroup scoring above the cut-off point for depression only once comprised subgroup
AC in Figure 8. As many as seven (54%) mothers in the AC subgroup were assessed to
be at the intervention level, and 5 (38%) even at the risk level.

70
The number of mother reporting depressive symptoms around delivery was two to three
times higher among the mothers assessed at intervention level both at childs age of 6-8
weeks and 24 months (below-below, Figure 5) than in the other three sensitivity groups
(Table 4) in the WBC sample (Study III). All these mothers in the group assessed twice at
intervention level had reported depressive symptoms around delivery, 80% of them
already prenataly. Mothers in this group had expressed depression significantly more than
mothers in the group assessed twice as good enough (above-above) according to both the
clinical contact and the GHQ (Table 3). However, two years later mothers reported
depressive symptoms according to the GHQ equally frequently in all four sensitivity
groups (16-20%).

5.2.3

Other risk factors and maternal sensitivity

Besides maternal depression, three other risk factors were found in the WBC sample to be
associated with maternal sensitivity assessed at the intervention level at the childs age of
6-8 weeks: unplanned pregnancy, maternal unemployment before maternity leave, and
male sex of the child. Two years later, maternal sensitivity assessed at the intervention
level was still associated with unplanned pregnancy and maternal unemployment, but not
with male sex of the child. All mothers had reported that the pregnancy was wanted
although it was unplanned in 19% of cases. Maternal age and education, socio-economic
status of the family, duration of parental relationship, in vitro fertilization and maternal
delivery experiences were not found to be associated with mother-child interaction in the
WBC sample.

71

Table 4. Number of mothers expressing depressive symptoms before delivery (clinical

contact and GHQ) and 4 months (EPDS) and 24 months (GHQ) after delivery, unplanned
pregnancy, unemployment and male sex of the child in the sensitivity groups combined
according to the continuity of maternal interactive style.
Maternal sensitivity groups according to continuity of
maternal interactive style
Risk factors

Aboveabove1
n=49

Abovebelow2
n=6

I. Maternal depression

A. Before delivery

Belowabove3
n=10

Belowbelow4
n=10

n=75

2 (20%)

8 (80%)

22 (29%)

0 (0%)

4 (40%)

7 (9%)

All

*
9 (18%)

3 (50%)

*
- clinical contact

3 (6%)

0 (0%)

*
- GHQ, 37th week

8 (16%)

3 (50%)

2 (20%)

7 (70%)

20 (27%)

B. EPDS, 4 months

9 (18%)

1 (17%)

2 (20%)

5 (50%)

17 (23%)

*
A+B

16 (32%)

3 (50%)

3 (30%)

10 (100%)

32 (43%)

C. GHQ, 2 years

8 (16%)

2 (33%)

1 (10%)

2 (20%)

13 (17%)

II. Unplanned
pregnancy

4 (8%)

3 (50%)

3 (30%)

4 (40%)

14 (19%)

III. Maternal
unemployment

7 (14%)

3 (50%)

5 (50%)

4 (40%)

19 (25%)

8 (80%)

5 (50%)

35 (47%)

*
IV. Male babies

19 (39%)

3 (50%)
3

Maternal sensitivity twice above, 2 first above and then below, first below and then above, twice below
intervention level at childs age of 6-8 weeks and 24 months.
1

*Fisher
s exact test, Bonferoni correction, two group compared with each other, p=0.047-0.000.

72
Both unplanned pregnancy and unemployment were less common also among mothers
who were assessed as good enough in sensitivity in the interaction both with their infants
and toddlers (Table 4): over four-fifths (83%) of mothers in the group assessed first as
good enough and then at intervention level (above-below), 60% both in the group
assessed first at risk level and then as good enough (below-above) and in the group
assessed twice at intervention level (below-below), and 20% in the group assessed twice
as good enough in sensitivity (above-above) reported either unplanned pregnancy or
unemployment. Only 39% of the babies in the group assessed twice as good enough
(above-above) were boys, compared with as many as 80% in the group assessed first at
intervention level and then as good enough (below-above). In the two other sensitivity
groups there were as many girls as boys.

5.3
5.3.1

Maternal sensitivity and child development

Maternal sensitivity and child co-operation

In the Well-Baby Clinic sample (the Study III), early maternal sensitivity at the childs
age of 6-8 weeks predicted child interactive style at toddler age. Early maternal
sensitivity correlated positively with child cooperation and negatively with difficulty
(Table 5), and early maternal control negatively with child cooperation and positively
with difficulty at the childs age of two years. Early maternal unresponsiveness did not
seem to predict later child behavior. However, there was a significant correlation between
high early maternal unresponsiveness and low child co-operation

73
Table 5. Maternal sensitivity at childs age of 6-8 weeks compared with child cooperation at childs age of 24 months (n=74).

Child co-operation
at childs age of
24 months

Maternal sensitivity at childs age of 6-8 weeks

Sensitivity
r
p
Co-operation

0.444

Difficulty

Control
p

Unresponsiveness
r
p

<0.0005

- 0.289

0.012

0.099

0.401

-0.278

0.017

0.443

<0.0005

-0.164

0.163

Compulsive
compliance

-0.078

0.510

-0.041

0.732

0.092

0.437

Passivity

-0.180

0.124

-0.047

0.692

0.185

0.115

r: Pearson correlation
p: statistical significance

(Pearson correlation 0.312, p=0.007) and high passivity (Pearson correlation 0.381,
p=0.001) at toddler age. Furthermore, as reported in Study IV, early maternal sensitivity
assessed at risk level predicted problems in toddlers behavior (Figure 9): child cooperation was significantly lower in the group of mothers assessed at risk level than in the
other two sensitivity groups (inept and good enough). The toddlers of the risk group
mothers were also significantly more passive than those of mothers who had been
assessed as good enough.

74

14

12

Child co-operation, 24 months

10

2
0
N=

54

10

10

Goog enough

Inept

Risk

Sensitivity groups

Figure 9. Child co-operation at childs age of 24 months in the sensitivity groups defined
according to the early maternal sensitivity at the childs age of 6-8 weeks. *Dunnetts ttest, the Riskgroup is compared with other groups, the mean of difference is significant
at the 0.05 level.

5.3.2

Maternal sensitivity and child behavior

Although early maternal sensitivity predicted child co-operation and also the public
health nursesworries about children at the childs age of two, the association with the
mothersreports of child behavior on the CBCL/2-3 was less clear (Study IV). According
to the CBCL/2-3 total problem score at the childs age two, only three (4%) children were
rated by their mothers in behavioral problems as above the clinical range (T score >70) or
in the borderline range (T score 60-63). Two of these mothers who had scored their
children high were assessed as good enoughand one as having moderate problemsin

75
sensitivity. Nine (12.2%) mothers scored their children above the clinical range (T score
>70) in at least one of the six CBCL/2-3 syndrome scales.

The early maternal sensitivity assessed at risk levelaccording to the CARE-Index was
not associated with high scorings in the externalizing, internalizing and total CBCL/2-3
problem. The mothers assessed as having moderate problemsin early dyadic interaction
scored their children highest, while those assessed as having evident problems (at risk)
scored lowest on the internalizing, externalizing and total problem scales (Figure 10). The
difference was statistically significant between moderate problemsand riskgroups in
externalizing symptoms (Figure 11).
100

80

60

CBCL Total

40

20

0
N=

54

10

10

Sens-adeq

Inept

Risk

Sensitivity groups

Figure 10. Means of mothersCBCL total scores at childrens age of 24 months in

sensitivity groups created at childrens age of 6-8 weeks.

76

40

CBCL externalizing symptoms

30

20

10

0
N=

54

10

10

Good enough

Inept

Risk

Sensitivity groups

Figure 10. Means of mothersCBCL total scores at childrens age of 24 months in

sensitivity groups created at childrens age of 6-8 weeks. *Dunnetts t-test, the Risk
group is compared with other groups, the mean of difference is significant at the 0.05
level.

The mothers in the ineptgroup scored their children highest and the mothers in the
riskgroup lowest on the internalizing, externalizing and total problem CBCL/2-3 scales.
The riskgroup mothers scored their children on the CBCL/2-3 similarly to the good
enough group mothers, but significantly lower than those in the inept group in
externalizing symptoms (Figure 10).

Mothersand fathersCBCL/2-3 scorings correlated significantly with each other in the

problem scores on externalizing (Pearson correlation 0.408), and internalizing (0.267)

77
symptoms. However, in the ineptand risksensitivity groups, the correlations between
mothersand fathersscorings were not significant. Unlike mothers, fathers scored their
children highest on the CBCL/2-3 in the riskgroup (Table 6).

5.3.3

Maternal sensitivity and child linguistic development

In the Linguistic sample (Study V, n=27), the impact of maternal sensitivity on child
linguistic development was studied. Most of the mothers (20) were assessed as good
enough (6 highly sensitive, 14 adequate), seven mothers as inept, and none at risk level in
sensitivity at the childs age of ten months. In general, the children whose mothers were
assessed as inept in sensitivity, were scored lower also in the language measures than the
rest of the children. There were no significant differences between adequate and highly
sensitive groups.

At the childs age of twelve months the children in the group assessed as high in maternal
sensitivity had the highest scores in the MCDI test, and the group assessed as inept had
the lowest scores. In the composite score for early communicative gestures and symbolic
actions, Total Gestures, the differences between the inept and both the sensitive and
adequate groups were statistically significant. Furthermore, at the childs age of one year
the CSBS test showed that the children of mothers assessed as good enough in sensitivity
were more advanced in their early communicative and linguistic skills than the ones
whose mothers were assessed as inept. Statistically significant differences between the
sensitive and inept mothers were found also in the use of gestural communicative means
and in the communicative composite score CSBS-Total. In addition, the difference in the

78
Table 6. Mean (sd) of CBCL/2-3 symptom scores in externalizing and internalizing, and
total problem scales assessed (A) by mothers, and (B) by fathers in maternal sensitivity
groups.

CBCL/2-3 scales,
24 months

(A) Mothers assessment

Maternal sensitivity group, 6-8 weeks

Good
enough
Inept
Risk

All

n=54

n=10

n=74

n=10

*
Externalizing symptoms

12.8 (6.2)

17.3 (6.5)

11.1 (4.2)

13.2 (6.2)

Internalizing symptoms

6.3 (4.6)

7.9 (5.7)

6.1 (3.3)

6.5 (4.6)

Total

32.6 (16.2)

41.0 (15.7)

27.7 (8.3)

33.0 (15.5)

(B) Fathers assessment

n=48

n= 8

n=7

n=63

Externalizing symptoms

11.5 (5.8)

10.2 (5.8)

15.3 (10.3)

11.7 (6.4)

*
Internalizing symptoms

5.1 (3.4)

5.1 (4.4)

9.3 (9.8)

5.5 (4.6)

Total

28.1 (13.2)

26.1 (14.6)

39.6 (33.2)

29.0 (16.5)

*Dunnett
s t- tests, the
Riskgroup is compared with other groups, the mean difference is significant at the
0.05 level

79
early symbolic skills between the groups of mothers assessed as adequate and inept was
statistically significant.

According to the RDLS-III, maternal sensitivity contributed to comprehensive skills of

the language between the highly sensitive and inept maternal group, but no statistically
significant differences were found between the maternal sensitivity groups in expressive
skills at 30 months. Furthermore, several relations were found between the
communicative and linguistic skills at the childs age of 12 months and later advances in
language at the childs age of 30 months. All the MCDI test variables correlated with the
RDLS III comprehensive scale, but none with the expressive scale. However, both
gestural and verbal communicative means and reciprocity assessed by the CBCS and the
CBCS total score correlated also with the RDLS III expressive scale.

5.4

Identification of risk dyads in well-baby clinics

Maternal depressive symptoms were found to be a risk factor for maternal sensitivity,
which underlines the importance of identifying any such symptoms in well-baby clinic.
At the childs age of 6-8 weeks the public health nurses assessed fourteen (14%) mothers
as depressive in the initial sample (n=99), but six of these dropped out of the study.
However, the public health nurses identified only six (17%) mothers reporting depressive
symptoms around delivery among those who continued to participate in the WBC study.
Four of these six mothers also themselves reported having depressive symptoms
recurrently around delivery. Furthermore, the public health nurses identified only two of

80
Table 7. Public health nurses assessment of parental dyadic interactive style at childs
age of 6-8 weeks and 24 months in the sensitivity groups defined according to early
maternal sensitivity 6-8 weeks after delivery.

Public health
nurses
assessment of
the parental
interactive
style

Maternal sensitivity 6-8 weeks after delivery

Adequate or
sensitive

Inept

Risk

All

6-8 weeks, n

56

10

12

78

No Worries

52

68

Worries

10

24 months, n

48

62

No Worries

45

57

Worries

thirteen mothers who reported having major symptoms in either of the EPDS
questionnaires, and one of seven mothers reporting clinical contact because of depression.

Identifying failures in dyadic mother-child interaction was also difficult for the public
health nurses, and they hesitated to report problems in dyadic interaction (Study II). The
PHNs reported worries about the early parental interactive style according to the global
assessment in 10 (13%) dyads at the childs age of 6-8 weeks (Table 7), and identified six
(27%) dyads which were rated to be at the intervention level according to the video

81
Table 8. Public health nursesassessment of childrens (n) need for extra support in the
well-baby clinic, and requests for supervision for children and their families (n) at childs
age of 24 months.

Public health
nurses
assessments

Worries about
child mental
health or
behavior
Referral due
mental health

Maternal sensitivity
Adequate or
sensitive
n= 48

Inept

Risk

All

n= 8

n= 7

n= 63

25 (39%)

14 (29%)

5 (63%)

6 (86%)

1(2%)

0 (0%)

1 (14%)

2 (3%)

Extra visits in
well-baby clinic

- with public
health nurses

9 (18%)

1 (13%)

5 (71%)

15 (24%)

- with
physicians

13 (25%)

4 (50%)

0 (0%)

17 (27%)

Public health
nurses
requesting
supervision

*
4 (8%)

0 (0%)

9 (14%)
5 (71%)

*Fisher
s exact test, Bonferoni correction, the Risk group compared with the other groups, p=0.018-0.002.

assessment at this age, and four (33%) of those rated to be at the risk level. At the childs
age of two years, they identified three (20%) of the dyads assessed at intervention level
and two (29%) of those assessed at risk level. However, they failed to identify more that
two thirds of the dyads assessed at intervention or risk level.

82
The public health nurses reported worries about the childs mental health and behavior in
several dyads (n=25, 39%), and significantly more often in the risk group (86%) than in
the good enough group (Table 8). Furthermore, the PHNs invited the children in the risk
group to make extra visits to the well baby clinic, but also requested supervision for
themselves because of these children and their families. However, they did not arrange
extra visits with the physician for the risk group, and only one child in this group was
referred for consultation because of mental health problems.

83

Discussion

The goal of this research was to study the continuity of mother-child interactive style and
the factors related to low maternal sensitivity in a non-clinical sample in order to
facilitate the early identification of the dyads at risk in well-baby clinics. The findings
underlined both the continuity and importance of good enough early maternal sensitivity:
Firstly, a short video clip was found to reveal the genuine interactive style of the motherchild dyad and early maternal functioning to predict later maternal and child interactive
functioning and child development. Secondly, both prenatal and postnatal maternal
depression was related to maternal interactive functioning. Thirdly, the mothers with
moderate problems in the interaction with the child were sensitive enough to identify
child problem behavior, whereas mothers who had evident difficulties in identifying
childrens needs also had difficulties in recognizing problems in childrens behavior.
Public health nurses were worried about the mother-child dyads whose interaction was
scored as problematic according to the video assessment, however, they hesitated to
describe them as problematic but would have liked to have supervision in helping the risk
dyads.

6.1
6.1.1

Continuity of mother-child interactive style

A short video representing dyadic interaction

Similar instructions and arrangements for video recording sessions give equal starting
point for each dyad, but some adults may experience being video recorded as more or less
distressing and therefore the interaction during recording may contain artificial elements.
However, in spite of the possibility of such distress, most of the mother-child dyads

84
created good enough mutual synchrony during a short video recorded free play session in
each sample of this research. The findings in the Observation study, in particular, suggest
that a short video clip catches the genuine style of the interaction and can give us reliable
data: In more than three fourths of the PCERA items the data obtained via the video
recordings of five minutesduration correlated significantly with those obtained via the
observations spread over a year.

Expressions of negative behavior and emotions on the short video clip especially were
highly associated with the same kind of behavior seen in the extended observation.
However, as in this study, parental expressions of negative affects have been reported to
be very rare in a short video clip (Burns et al. 1997, Pajulo et al. 2001). These findings
suggest that any expression of negative affects on video may indicate continuous
problems and should always be taken into account as an important marker of concern in
the dyadic parent-child interaction. Such expressions always indicate that a more detailed
assessment of the interaction should be undertaken.

In the voluntary non-clinical Observation sample, however, the most informative parental
and dyadic PCERA items were the ones concerning positive engagement in the
interaction. High scorings in these items described the positive interactive style of the
dyad but low scorings in such items also identified the areas of concern in the interactive
style. The same items have been identified as indicating problems in interaction also in
larger studies (Burns et al. 1997, Clark et al. 1997, Frankel and Harmon 1996, Kivijrvi
et al. 2001, Pajulo et al. 2001, Scher 2001). Such items also seem to identify not only the

85
interactive style during the short video recorded situation but also the more constant
interactive style of the dyad. Therefore, the absence of positive engagement in dyadic
interaction must be considered to be an important marker, especially when screening risk
dyads in non-clinical samples.

Although the agreement between video ratersand observersassessments was high in

most items, it was not sufficient especially in the items based on the amount and
frequencies of activities. This finding suggests that the frequencies of activities during a
short period must be interpreted carefully. There may be several reasons for this
discrepancy. It is likely that the amount and frequencies of activities are affected by the
video recording situation or other simultaneous factors. Probably the distress caused by
the video recording affects especially the adults behavior. On the other hand, the
younger the child, the more his/her physiological state and needs may change during a
short time period.

The disagreement between the short video and long observation was most evident in the
amount of parental positive physical contacts. Low levels of physical contact have been
shown to be typical of withdrawn dyads (Hart et al. 1999) and high risk dyads (Polan &
Ward 1994). However, in this study, with volunteer participants, the mothers had hardly
any positive physical contact with their one-year old child on the video, although the
observers had identified an at least adequate amount of physical contact during longer
periods. It is hard to give any firm reason for this discrepancy. One explanation might be
the childs age (Bohlin & Hagekull 2000), as the one-year-old children were able to walk

86
away from their mothers and interaction could take place also from a slight distance. This
explanation is supported by the previous findings that physical contacts are also rare in
the control groups of other PCERA studies of one-year-old children (Burns et al. 1997,
Pajulo et al. 2001). Another explanation might be cultural: in earlier studies using the
PCERA method in other ethnic groups, physical contacts have been more common than
in the Observation sample (Burns et al. 1997, Clark et al. 1997). We must also note that
the observers could not count the frequencies of physical contacts during the home visits
so they had to estimate the general amount of behavior, whereas the video assessment
was based on counting the exact amount of physical contacts.

There was a discrepancy between the short video clip and long observation also in the
amount of verbalization and in reading the childs cues. The fact that they were on video
with the child around the time of onset of first words may be why most mothers
expressed a greater amount of verbalization, and the same reasons may also have
activated mothers to read the childs cues more frequently. Furthermore, there was the
same problem with these items as with the items of physical contact, i.e. the observers
could not count the frequencies, whereas the video assessment was based on counting the
frequencies of activities, In any case, the discrepancy in the amounts of maternal
activities and the continuity in positive engagement between short and long observations
support Belsky and Cassidys (1984) suggestion that mothers are less consistent in the
amount of stimulation than in dyadic responsiveness and engagement.

87
6.1.2

Continuity of maternal sensitivity from infancy to toddler age

Several studies have discussed the importance of early mother-child interaction, and the
importance of later experiences and the continuity of maternal caregiving has also been
raised (Beckwith et al.1999, Landry et al. 2001). The findings of the WBC study both
underline the importance of early interaction and confirm previous assumptions of the
continuity of maternal sensitivity (Seifer et al. 1996, Stern 1995): Early maternal
sensitivity predicted later sensitivity, controlling interactive style remained controlling,
and unresponsive was unresponsive two years later. Continuity in mother-child
interaction was identified especially in high sensitivity dyads, as 90% of mothers who
managed to gain mutual synchrony with infants created dyadic engagement also with
toddlers. However, it has to be remembered that nobody is always perfectly sensitive and
responsive, and slight or even moderate dyssynchrony does not mean continuous
difficulties in mothering (Belsky & Fearon 2002). Gergely and Watson (1999) and later
Stern (2004) have discussed that high but imperfect synchrony between the mother and
child may be the best promoter of child development. Half of the mothers assessed as
needing intervention in the WBC sample were in the same sensitivity category two years
later. These findings are in line with previous findings (Landry et al. 2001) that the
strengths are more stable than the difficulties in early interaction.

Waters and colleagues (2000) have underlined both continuity and development in
mother-child interactive style. In the WBC sample also, despite the moderate stability of
maternal sensitivity, there was a slight shift and development in maternal caregiving style
from infancy to toddler age: in most dyads, sensitivity scores were slightly higher and

88
control scores slightly lower. The development in maternal interactive style and decrease
in maternal control have also been found in previous studies: in their review article,
Lovejoy and colleagues (2000) point out that parenting matures as the children grow up,
and they suggest that mothers might try to engage their infants in interaction using more
adult-centered, controlling behavior than they use with elder children. It has also been
suggested (Feldman & Klein 2003, Landry et al. 2000) that moderate early maternal
control may have positive effects on interaction and child development, and it should
decrease as the child grows up and gains more behavioral repertoires. On the other hand,
infants are considered to be the most vulnerable and to need the most sensitive care
giving, and they are most interested in interaction that is perfectly contingent with their
own behavior during the first three months (Gergely & Watson 1999). The findings of the
WBC study also stress, as do Mntymaa and colleagues (2004), the risk effect of early
maternal control. The evident risk effect of early maternal control does not, however,
exclude the possibility that slight early control may also have positive effects. It is very
difficult to determine whether slight controlling behavior is actually structuring and
encouraging new experiences or demanding that the child obeys the adult (Crittenden
2006).

Most mothers in the Well-Baby Clinic sample were described as at least slightly
unresponsive in their interaction with both infants and toddlers. The low level of activity
may partly be explained by the fact that the assessments were based on the free play
situation, which does not especially activate maternal behavior. Control is not needed
when there is no task to be performed or danger requiring protection of the child.

89
However, the maternal unresponsiveness further increases as the child grows up, and
even the mothers assessed as good enough in sensitivity seemed to expect the child to
initiate the interaction especially at toddler age. The high maternal unresponsiveness with
the toddler may not only refer to low mutual attunement but also to features of Finnish
culture: moderate maternal unresponsiveness seems to be common and also a part of
good-enough mothering in our culture. This is in line with Crittendens and Claussens
(2000) suggestion that cultural characteristics become increasingly important after
infancy. The findings in the WBC sample also support Moilanen and colleagues(2000)
suggestion that the independence of small children is encouraged in Finnish culture.
Since unresponsiveness and passivity are considered to predict child avoidant attachment
(Beckwith et al. 1999, Crittenden 1997), these findings also provide one explanation why
avoidant attachment is so common in our culture (Moilanen et al. 2000).

To help in the identification of dyads at continuous risk, a study was made to find out
what other features of early maternal dyadic behavior besides low sensitivity with high
control or unresponsiveness would predict continuous problems in maternal interactive
functioning. In the WBC study more than half of the mothers had evident difficulties
according to at least one CARE-index item in creating mutual synchrony with the infant
according to the temporal contingencies, but almost all mothers assessed twice at risk
level in sensitivity had evident difficulties also according to sharing affects. This is in line
with the finding of Landry et al. (2001), as they also found that especially low affectional
involvement is associated with consistency in low responsiveness. Furthermore, it

90
supports the Observation study finding of the continuity and importance of positive
engagement.

Unresponsive maternal affective engagement means that the mother looks away from the
child, has an unchanging or rigid facial expression, talks in a monotonous or strained tone
of voice, is silent, positions herself uncomfortably or at a distance from the child, or holds
the baby away from her body. Controlling behavior, on the other hand, may include
intrusive poking or manipulating the infants body, showing no warmth or attention.
Since the results of WBC study indicate that any of these items may refer to continuous
problems in interaction, they can also be used in the early identification of dyads at high
and constant risk. The identification of any of these features in a mother-infant interaction
should reinforce the suspicion of severe and stable problems, and lead to more thorough
clinical assessment. The importance of these features has also been underlined by Jaffe
and colleagues (2001) in their suggestion that the early failure in mutual attunement of
facial, vocal and tactile positive affects predicts not only dyadic functioning but also child
behavior, attachment and neurological development. Both Fonagy (2002) and Meins and
colleagues (2001) underline the importance of affective engagement when they suggest
rethinking the concept of maternal sensitivity. Furthermore, the finding that imperfect
temporal contingency can also be found in dyads with continuous high maternal
sensitivity supports the suggestion a temporal missmatch does not necessarily indicate
actual problems in dyadic interaction and can even promote child development (Gergely
& Watson 1999, Stern 2004).

91
6.2
6.2.1

Risk factors for maternal sensitivity

Maternal depression and sensitivity

There are numerous studies of postnatal maternal depression (for example Beck 1995,
Beck 2001, Bgedahl-Strindlund & Brjesson1998, Evans et al. 2001, Luoma et al. 2001,
McLennan et al. 2001, OHara & Swain 1996) but few of the continuity of depressive
symptoms (Assel et al. 2002, Luoma et al. 2004, Stowe et al. 2005). In the WBC study
the continuity, timing and severity of maternal depressive symptoms and their effect on
the mother-child interaction were assessed. Half of the mothers reported at least minor
depression around delivery at least once and half of them also recurrently. The findings
suggest, as do the ones of Lane and colleagues (1997) that any depressive symptoms - not
only major but also minor symptoms - around delivery must be considered as part of a
depressive continuum. These findings differ from those of Beeghly and colleagues
(2002), who found continuity only in major depression. However, although there was
evident continuity in maternal depressive symptoms around delivery in the WBC sample,
it did not mean continuity of maternal depression to the childs age of two years.

Not only continuous but also transiently reported, and not only postnatal but also before
delivery reported, depressive symptoms were found to be a risk for maternal interactive
functioning in the WBC study. In particular, mothers who had problems in engaging their
children in dyadic interaction both in infancy and toddler age reported depression around
delivery, and most of them already before delivery. The findings also support Levinsoln
and colleagues(2000) claim that the clinical importance of maternal depression does not
depend on crossing the threshold for the diagnosis of major depression. The diverse

92
spectrum of maternal depression around delivery is a challenge for primary health care.
It has been suggested in recent studies (Campagne 2003, McLennan et al. 2001, Thoppil
et al. 2005) that not only major but also minor depression around delivery should be
considered a target of intervention.

However, it is also important to remember that even continuous and major depression
does not inevitably impair maternal social functioning (Frankel & Harmon 1996), and
also in the WBC sample half of the mothers with depressive symptoms managed to gain
mutual engagement with their infants. As Sarkkinen (2003) and Craemer (1999) point
out, the effect of maternal depression on mother-child interaction depends on its
psychodynamic focus. If the focus of depression is not the child or motherhood, the
interaction with the child may even be a source of joy for the mother.

Grace and colleagues (2003) suggest that only chronic depressive symptoms affect the
interactive style, but Weinberg and colleagues (2001) claim that transiently depressive
symptoms are also a risk for maternal interactive functioning, as was also found in the
WBC study. However, it is impossible to tell how long transiently or recurrently
expressed depressive symptoms will exist, and whether the motherstransient mood drop
is just a transient or a more continuous state of mind. But as in the WBC study, Henshaw
and colleagues (2004) discovered that most mothers reporting depressive symptoms soon
after delivery had not a transient mood drop but recurrent or even chronic depression. The
findings of the WBC study suggest that baby blues i.e. maternal depressive symptoms
only two weeks after delivery is different also from other transient depressive

93
symptoms. Unlike other mothers who had expressed depressive symptoms only at one
time point, the baby blues mothers managed to gain good enough interactive functioning,
which suggests that the mothersdepressive mood may have been only a transient selflimiting condition (Judd et al. 1996).

The influence of postnatal depression on the mother-infant interaction has been identified
in several studies (see Beck 1995), but in recent years a growing number of studies have
also stressed the importance of prenatal depression (Brennan et al. 2000, Carter et al.
2001, Diego et al. 2004, Luoma et al. 2001). It has been suggested that depression can be
even more common during pregnancy than postnataly (Evans et al. 2001). In the WBC
sample, prepartum depression was related to low maternal interactive functioning, and
especially to continuous problems in maternal interactive style. These findings raise the
questions of how and when maternal prenatal depressive symptoms are mediated to
postnatal dyadic interaction. One mediating factor might be the continuity of depressive
symptoms from the prenatal to the postnatal period (Glasser 2000, Yonkers et al. 2001) or
the residual symptoms (Fava 1999) of prenatal depression. Furthermore, recent studies
have discussed the impact of prenatal maternal attachment on postnatal interaction and
child development (Lindgren 2001, Siddiqui & Hglff 2000). Several studies have also
emphasized the prenatal biological mediation of depression from mother to child: genetic
components (Rice et al. 2005), maternal stress with elevated cortisone levels (Field et al.
2006, OConnor et al. 2003), and mothersinability to take care of their own and fetal
needs (Lindgren 2001). As the GHQ identifies both depression and anxiety (Goldberg et
al 1997), the children whose mothers were screened with it in the WBC sample may also

94
have suffered not only maternal depression but also anxiety prenataly. In the WBC
sample the mothers who had difficulties in dyadic interaction reported more commonly
unplanned pregnancies and unemployment than the sensitive ones, which may have
caused extra stress. In particular, unplanned pregnancy may affect the pre- and postnatal
maternal representations of the baby (Lindgren 2001). It has also been suggested that
there may also be both prenatal and postnatal crucial periods during which the child is
especially vulnerable for maternal depression or stress (Morell & Murray 2003). The
WBC study indicates that there may be both pre- and postnatal mediation of depressive
symptoms to mother-child interaction, but cannot answer the question of how and when it
may happen. In any case, the findings of the WBC study suggest that the adverse effects
may be maintained by low maternal sensitivity after delivery, as prenatal depression was
found to be related to continuous problems in mother-child interaction.

As an association between maternal depressive symptoms and caregiving style was

found, the WBC study, like Seifer and colleagues (2001), stresses the importance of
assessing not only clinical but also minor, not only chronic but also transient, and not
only postnatal but also prenatal maternal depressive symptoms. Like those of Seifer and
colleagues, these findings reveal the importance of assessing not only maternal mood but
also the mother-child dyadic functioning.

95
6.2.2

Maternal unemployment, unplanned pregnancy, male sex of the child and

maternal sensitivity

As in previous studies, unemployment, unplanned pregnancy and male sex of the child
seemed to be significant risk factors, besides depression, in the non-clinical WBC sample
. Both unemployment and unplanned pregnancies as stress factors are likely to create a
burdensome situation for a mother-to-be and play a substantial role in adaptation to
motherhood (Beck 2001, McLennan et al. 2001). The findings of the WBC study suggest
that such stress may affect the mother-child interaction not only soon after delivery but
also at toddler age. This may indicate that mothers with unplanned pregnancies are rigid
and ambivalent in adaptation to an unexpected life event and to motherhood. But
unplanned pregnancies have also been found to be related to mothersrisky behaviors and
averse life experiences (DAngelo et al. 2004), which may refer to poor life control.
Negative experiences at the beginning of the pregnancy may provide negative
representations of the expected baby, which may further provide difficulties in the
postnatal mother-child interaction (Lindgren 2001). These associations suggest that both
family planning and contraception can be important tools in preventive mental health
work, and interventions during pregnancy and early childhood are needed to help the
mothers to adapt to their new and challenging life situation.

As many as one quarter of the mothers had been unemployed before maternity leave at
the end of the 1990s, which is equivalent to the unemployment rate among young females
in this age group in the area studied (Statistics Finland 1997). Unemployment means
social and economic uncertainty for the pregnant woman and her family. In such an

96
unstable situation it may be hard to make plans for having a baby and adapting to the new
role as a mother, in particular when unemployment is related to low maternal self esteem
(Shin et al. 2006). However, as in the study of Belsky and Fearon (2002), unemployment
was found to be related in some of the cases to transient and decreasing problems in
interactive functioning in the WBC study, which suggests that finding a solution to
unemployment or related problems may be related to a more favorable course of the
maternal interaction with the child. As Beckwith and colleagues (1999) suggest,
preventive interventions should also be directed at employment and the economic
security of families with small children.

Male sex of the infant was related to low maternal sensitivity at infancy, but unlike in
previous studies (Beckwith et al.1999, Morrell & Murray 2003) not at toddler age.
Having a male infant seems to be challenging for first-time mothers, but at toddler age
the sex of the child does not play such a significant role in the mothering style. This study
does not, however, suggest any mechanism through which this is mediated. Beckwith and
colleagues (1999) report more continuity in low maternal sensitivity experienced by boys,
and also an association with dismissing interactive style. Boys have been referred more
often to child mental health services (Keren et al. 2001) and further research is needed to
determine whether boys are especially vulnerable to problems related to early mothering
(Morrell & Murray 2003). However, it must remembered that in the WBC sample the
number of dyads assessed as needing intervention was small at both time points and no
firm conclusions can be drawn from this finding.

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6.3
6.3.1

Maternal sensitivity and child behavior

Maternal sensitivity and child co-operation

Maternal sensitivity promotes child co-operation, and vice versa, and this relationship
explains the high correlation between current maternal and child interactive style
(Crittenden 1997). The results of the WBC sample underline that early maternal
sensitivity also lays the foundation for the later child interactive style. Fonagy et al.
(2002) also underline the importance of maternal sensitive behavior in early interaction
for later child behavior and explain that suboptimal experiences in early interaction affect
later child development by undermining the individuals capacity to interpret information
concerning mental states. The findings in the WBC study stress not only the importance
of early but also continuous maternal sensitivity. In accord with results of previous
studies (Fonagy et al. 2002, Seifer et al. 1996), the continuity of the child interactive style
was not, however, so clear between these two assessment points. This is understandable,
as there are huge developments in childrens interaction abilities during two years, and
several moment-related factors affecting childrens behavior both in infancy and at
toddler age. Fonagy et al. (2002) further explain the lower continuity in child dyadic
behavior by the fact that in the presymbolic period the infant is not yet required to
represent the thoughts or feelings of the caregiver.

In clinical samples, both intrusive and unresponsive maternal interactive styles have been
found to predict child behavioral problems (Cassidy et al. 1996, Shaw et al. 1998),
whereas in non-clinical samples only intrusive maternal interactive style has been found
to be a predictor (Hay & Pawlby 2003, Mntymaa 2006). In congruent with the previous

98
findings it was also found in the WBC sample that especially early maternal control and
intrusiveness predicts problems in child dyadic behavior two years later. However, unlike
the previous studies the findings in the WBC study suggest that also maternal
unresponsiveness is related to problems in dyadic functioning: Low early maternal
sensitivity is associated to high maternal unresponsiveness and high child passivity both
in infancy and at toddler age. These results suggest that if a mother does not make
initiations and is not emotionally engaged in dyadic interaction there is also risk for child
development. Furthermore, such risk dyads can be identified also in non-clinical samples.

6.3.2

Maternal sensitivity and child linguistic development

In accord with some earlier findings (Belsky & Fearon 2002, Laakso et al. 1999) the
results of the Linguistic sample indicated that the higher the maternal sensitivity was in
the second half of the first year, the more active the children were in their intentional
communication and in language comprehension around the onset of first words. These
findings suggest that maternal sensitivity supports the development of childrens early
symbolic skills as well as their learning to express their intentions by gestures. However,
maternal interactive style did not seem to have an effect on the childs early productive
vocabulary. In accord with some earlier findings maternal sensitivity was associated with
the comprehensive but not with the expressive skills at childs age of two and a half year
(Cusson 2003, Murray & Hornbaker 1997). However, since many of the early capacities
supported by maternal sensitivity also affected later receptive skills, maternal sensitivity
can be considered to lay the foundation also for receptive language development.

99
The finding that maternal sensitivity predicted the development of the childs
comprehensive language but not expressive language reminds us that maternal sensitivity
is one important but not the only one factor related to the childs behavior and
development, as is pointed out by Laakso et al. (1999). Many other factors besides
maternal sensitivity also contribute to the child linguistic development and there may be
other factors also within the mother-infant interaction predicting the development of
expressive skills more than general maternal sensitivity in the second half of the childs
first year. For example, an association between the mothers activity in speaking with her
child and child language acquisition has been found in many studies (e.g. Masur 1997,
Paavola et al. 2005, Stevens et al. 1998), and it has been suggested that maternal speech
may be especially important around the emergence of productive vocabulary (Barrett et
al. 1991). Factors in infants genes and prematurity have been suggested to be more
influential for expressive language development than maternal sensitivity (Riitesuo
2000). Furthermore, the older the child, the more there are also other environmental
factors and social contacts affecting the childs behavior and development (Laakso 2003).

In the Linguistic sample, good enough maternal sensitivity was found to support child
linguistic skills, and moderate problems in maternal sensitivity were found to predict
problems in the childs comprehensive language skills. However, none of the mothers in
this sample was assessed at risk level, and the effects on child language development of
evident problems in engaging the child in mutual interaction could not be evaluated.
Previous studies (Belsky & Fearon 2002) have suggested that continuous problems in
mother-child

interaction

effect

both

comprehensive

and

expressive

language

100
development, and the findings in the WBC sample further suggest that early interaction
assessed to be at risk level is related to continuous problems in interaction. The research
in this area is scanty and further research is needed to assess the effects of maternal
sensitivity assessed at risk level on child language abilities and especially on expressive
language development.

6.3.3

Maternal sensitivity and assessment of child behavior

In the WBC sample the mothers who had evident problems in gaining mutual attunement
with their infants had problems in dyadic interaction also two years later: the mothers
were assessed as the most unresponsive and their children as the lowest in co-operation
and the highest in passivity. Fathers and public health nurses also described the children
of risk group dyads as the most problematic. In the light of previous studies (Bohlin &
Hagegull 2000, Hay & Pawlby 2003), it was expected that lower early maternal
sensitivity would also be associated with mothershigher scorings of child behavioral
problems. However, the mothers assessed as having evident problems in dyadic
interaction described their children as the least problematic, and the mothers assessed as
having only moderate problems described their children as the most problematic.
Although the cross-informant agreement has been found to be low also in previous
studies (Henningan et al. 2006, Gross et al. 2004, Spiker et al. 1992), the inconsistency
between video-based assessments and mothersreports was an unexpected finding which
needs an explanation. The reasons for the discrepancy between different informants may
lie in the sample, the different context in which the assessments were done, differences in

101
informantsperspectives and the accuracy of the methods used (Henningan et al. 2006,
Gross et al. 2004).

Maternal sensitive behavior behavior that pleases the infant and increases the infants
comfort and attentiveness and reduces its distress and disengagement requires
appropriate identification and interpretation of the childs signals and behavior (Claussen
& Crittenden 2000, Crittenden 2006). Evident problems in sensitivity mean evident
difficulties also in identifying and interpreting child behavior, and may even hinder the
identification of child problem behavior. On the other hand, mothers with moderate
problems in sensitivity may be sensitive enough to identify child behavioral problems.
Intrusive and controlling mothers are overinvolved and may even misinterpret the childs
signals, while unresponsive mothers are underinvolved and their low sensitivity may even
hinder them from identifying the childs signals and problem behavior (Claussen &
Crittenden 2000, Zero to Three 2005).

The suggestion that unresponsive mothers do not see their toddlers as problematic may
provide one explanation for the findings of previous studies that unresponsiveness has not
been found to be related to child behavioral problems in non-clinical samples. It can also
explain why results based on mothers reports are sometimes surprising or even
misleading (Bradley & Corwyn 2005, Spiker et al. 1992) and child behavior
questionnaires seem to underestimate the prevalence of child behavior problems (Harris
et al. 1996, Najman et al. 2005). These results also support Foremans (2002) claim that
the assessment of child behavior should not be based only on mothers reports in

102
questionnaires: information should be collected from different sources (Assel et al. 2002)
and conflicting information should also be taken into consideration (Kroes et al. 2005).
Observation-based methods especially help to provide a fuller picture of small children
with their caregivers.

Unresponsiveness has been identified as a risk for child development in clinical samples
among depressive (Kochanska et al. 1991) and stressed (Ostberg 1998) mothers. The risk
mothers in the non-clinical WBC sample also reported stress and depression, which
makes their low scorings of child behavioral problems even more surprising (Seifer et al.
2001). The effects of maternal depression on their reports of child behavior have been
frequently examined (Kroes et al. 2005, Youngstrom et al. 1999), and researchers have
debated whether maternal depression actually increases child behavioral problems or
distorts their perceptions of child behavior (Rischters 1992). Kroes and colleagues (2003
& 2005) report contradictory findings in two papers on this topic: in one study depressive
mothers report fewer, and in another study more, behavior problems than professionals.

It is also difficult to determine which behaviors in infancy and at toddler age should be
considered as deviant (Keren et al. 2001, Reijneveld et al. 2004, Wakshlag & Danis
2004). Although questionnaires seem to underestimate child behavioral problems, the
prevalence of parent-reported problem behavior in this age group varies widely (6-50%,
see Koot & Verhulst 1991) depending on the methods and cut-off points used. In the
WBC sample, as previous studies (Koot & Verhulst 1991, Mntymaa et al. 2004,
Sourander et al. 2001, Uljas et al. 1999), the total problem score of the CBCL/2-3 shows

103
that only a few children met the criteria for the clinical or borderline range. But as
Najman and colleagues (2005) suggest, this method may not screen all the children with
behavioral problems. One reason for this may be that the CBCL screens problem
behavior, whereas most parents usually describe their children with mainly positive
expressions (Baumann and Kolko, 2002, Benzies et al. 2004). Pavuluri and colleagues
(1996) suggest that parents see only half of cases as cases, as they believe the symptoms
to be transient. Furthermore, Najman and colleagues (2001) point out that the most
emotionally impaired dyads are the most likely to be lost in follow-up studies, and this
may also affect the results of this study.

The mothers and fathers were quite unanimous in their CBCL/2-3 assessments in the
good enough group, but not in the intervention groups. The fathers reported most often
internalizing problems in the risk group, which is in line with the high child passivity
scores in this group (Kochanska et al. 1991), but there was high diversity in the fathers
scorings in the risk group. The high diversity in fathersscorings in the risk group and
disagreement between the fathersand the mothersscorings may reflect an actual great
diversity in the childs interactive style with each parent, but it may also indicate that it
was more difficult for these parents to describe their childrens behavior. Both Faraone
(1995) and Thompson (1993) and colleagues show that the identification of internalizing
problems is especially difficult for parents. Furthermore, as Crittenden (2006) point out,
parental unresponsiveness is related not only to passive but also to difficult child
behavior, and it may change with the dyadic partner and in different situations.

104
In line with the suggestion that two-year old children are easily seen as problematic
(Wakschag & Danis 2004), the public health nurses reported worries about more than one
third of the toddlers, but as in the study of Reijneveld et al. (2004) they assessed child
behavioral problems as mild . However, the PHNs mentioned such slight worries
especially among risk group children. They described the dyadic interaction of the risk
group children as passive and only slightly showing joy, which Keren et al. (2001) found
to be important factors in identifying high-risk children in this age group. - The problems
in mother-child interaction predict problems in child behavior but they are not equivalent
to child psychiatric disorders. According to the video assessment in the WBC study, more
than one fourth (26%) of mother-child dyads were assessed to be at the intervention level
and half (13.5%) of them to need intensive interventions. Epidemiological studies of
child emotional and behavioral disorders in this age group are scanty, but these figures of
low maternal sensitivity are surprisingly similar to those for emotional and behavioral
disorders (14-26.4%) among preschoolers (Egger & Angold 2006).

The differences between the maternal and other assessments in the WBC study indicate
that the risk group mothers see their childrens behavior differently, with fewer
behavioral problems, than other informants. As Zeanah (1997) assumes, high differences
between informants suggest that there are differences in the meaning that parents and
professionals attribute to the childrens behavior. It has been suggested that observers are
always a part of the system being observed (Alasuutari 1992), but all the informants of
the WBC study had a different perspective in assessing the children: mothers assess their
children as a real partner of the dyad, whereas the video scorers in particular observe the

105
dyad as outsiders. From the maternal perspective, childrens passivity may be a good and
expected interactive style, as Bradley and Corwyn (2005) conclude in their study.
Furthermore, as maternal unresponsiveness and child passivity are in many cases
entangled with each other (Crittenden 1997), their behavior may strengthen each other in
the dyadic behavior. Toddlerspassivity may also be more difficult to identify than
externalizing behavior (Reijneveld et al. 2004, Keren et al. 2001). However, as Pajulo
and colleagues (2001) speculate, risk mothers assessment of their children as nonproblematic rather than difficult may sometimes also be a protective factor. Actually, it
means that the children have adapted to the interactive style of the attachment figure to
get protection and comfort (Claussen & Crittenden 2000).

Najman and colleagues (2005) found that a majority of cases identified with the CBCL
came from families where there are few or no risk factors, whereas the ones who did not
meet the caseness criteria came from families with many risk factors. They suggest that
not only may the mothers emotional state influence her observations, but also children
may be compulsive compliant and avoid presenting these symptoms to the mother. In the
WBC sample, the risk group children were found to be only fairly compulsive, but that
also must be considered a risk sign. The low scorings in compulsiveness in the risk group
may have been related to the fact that we were studying a non-clinical sample with no
evidence of maltreatment. Furthermore, in free-play situations with no tasks to be
performed, neither protection, comfort nor restriction was needed and compulsive
behavior was not provoked (Claussen & Crittenden 2000). In any case, as Crittenden
(2006) suggests, dyads screened to be at risk should be further studied with the Strange

106
Situation procedure or another methods, including developmentally appropriate stress. It
has also been reported that parental unresponsiveness may turn into avoidance, and
therefore be a high risk for children (Shaw et al. 1998). Combs-Orme and colleagues
(2004) point out that the highest risk may exist among mothers who are unconcerned
about their parenting in the face of problems. Passive children may also start to behave in
a more externalizing way to keep the unresponsive mothers attention, and thus be at risk
for externalizing symptoms or conduct disorders (Olson et al. 2000). In clinical practice it
is quite common to meet school-aged children with behavioral problems, whose mothers
say that their children were very calm and easy in infancy and toddlerhood, and one may
wonder whether the mothers are telling us about the same kind of history as may be seen
in the risk group of the WBC sample.

Further research is needed to confirm whether low maternal sensitivity and

unresponsiveness may hinder the mothers from identifying child passivity. Nevertheless,
the findings in the WBC study suggest that we must be careful when interpreting small
childrens behavior according to maternal reports only. Observations and video-based
assessment methods are irreplaceable both in infant mental research and clinical work
with babies and their parents.

6.4

Identification of at risk dyads in well-baby clinics

It commonly happens that depressive mothers are not identified in primary care and wellbaby clinics (Bgedahl-Strandlund & Brjesson 1998, Cooper & Murray 1997, RiecherRossler et al. 2003). In the WBC sample the public health nurses also failed to identify

107
not only transient and minor but also recurrent and major maternal depressive symptoms.
Identification of depression during the short visit may be difficult because of mood
fluctuations. Furthermore, current depression may also be related to either normal or
impaired social functioning (Craemer 1977, Sarkkinen 2003). Maternal depression is
often an invisible inner feeling and mothers do not always look as miserable as they feel
(Frankel & Harmon 1996). The most constant depressive symptoms may also have been
hidden during the visit to the well baby clinic and may be seen only when the mother is at
home alone with her baby. As has been suggested, the use of questionnaires would help
in both identifying depression and initiating discussion about maternal mental states
(Ebenhard-Gran et al. 2001, Luoma 2004).

Children at toddler age can easily be thought to be problematic (Gross et al. 2004), and as
was pointed out in the previous section, in the WBC study the public health nurses
assessed the toddlers behavior as problematic more commonly than the mothers.
However, the PHNs also identified all the risk group children as problematic. As experts
in child development, they are used to assessing childrens behavior, but as has been
found also in previous studies (Keren et al. 2001, Reijneveld et al. 2004) they were
reluctant to describe dyadic behavior as problematic. Keren and colleagues (2001) point
out that behind the childs problematic behavior may, however, be problems in parentchild interaction. In line with the findings of the European Early Promotion Project
(Papadopoulou et al. 2005), the PHNs failed to identify a great proportion of the dyads
assessed as needing intervention according to the global assessment. However, in a more
detailed assessment they reported slight worries about most risk dyads. They also

108
arranged extra visits for risk dyads and reported that they would have liked to have
supervision in dealing with them. But they did not arrange extra visits with physicians for
the risk dyads. The conclusion is that the PHNs were worried about the risk dyads, but
their worries were not clearly formulated and, furthermore, they seemed to keep their
worries to themselves. The PHNshesitation in their assessments is not surprising, as
they were asked to assess the dyad during the first appointment after delivery, but the
same kind of hesitation was also evident at the childs age of two.

As most mothers assessed at the risk level in sensitivity were mainly passive and did not
see their childrens behavior as problematic, not only identification but also intervention
is difficult: it is not easy to see something that is missing, to react to unresponsiveness
and passivity, and to challenge the mothers to discuss problems which may be unseen and
unnamed for them (Gerhold et al. 2002, Guedeney & Fermanian 2001). The findings of
the WBC study stress that a more detailed assessment is needed when any worries arise,
and thorough observation is essential when working with small babies and their families.
A real reason to be worried usually lies behind slight worries, and failing to recognize a
case is more probable than being worried without any reason. In line with Sturners and
colleagues (2007) recent proposal, it can be suggested that criteria and checklists for
assessing parent-child interaction are needed in primary care. As they suggest, such tools
are needed to assess not only the disorders but also the strengths and subthreshold
symptoms of dyadic interaction. They propose that such a method should be adapted
from the DC:0-3 classification (Zero to three 2005) by adding criteria to assess also
strengths and milder symptoms. Such a method would give the primary care and infant

109
mental health services a common language for bidirectional discussion and ways to
develop appropriate and well-directed interventions for families with infants. Such a
method would also be useful to both clinicians and researchers (Seifer et al 2001).

All families with small children should get support in well-baby clinics and mothers
should have opportunities to discuss their new life situation, mood and ambivalent
feelings about the pregnancy, maternity and baby (Ministry of Social Affairs and Health,
2004). The findings of the WBC study show that mothers with moderate problems in
gaining mutual attunement with their infants have good enough sensitivity to identify
their childrens problem behavior. However, they need extra support with extra contacts
in well-baby clinics and might also profit from such interventions. In case of evident
problems in dyadic interaction a consultation with an infant mental health specialist is
needed. Public health nurses should be encouraged to share their worries about motherchild dyads with the physicians in well-baby clinics, and together they could promote and
design early interventions and assess the need for consultations. As is underlined in the
international childrens mental health promotion training project EEPP (Davis & Tsiantis
2005), well-baby clinic workers should have the opportunity to get supervision in their
challenging work both for carrying out the interventions in primary care and encouraging
the high risk dyads to see specialists.

Inadequate resources both in well-baby clinics and infant mental health care must be
important reasons for the small number of extra visits to well-baby clinics and lack of
referrals to specialists. At the end of the 1990s, families had nine visits with the public

110
health nurses during the first two years, instead of the recommended ten (Ministry of
Social Affairs and Health, 2004), and the situation is the same a decade later in the area
studied (City of Kuopio 2007). Also, not all scheduled visits with physicians took place
(Hakulinen-Viitanen et al. 2005, City of Kuopio 2007). To maintain and develop the
standard of preventive work in well-baby clinics, it is essential to ensure team work with
adequate numbers of public health nurses and physicians. Besides the scheduled visits,
extra resources are needed especially for early interventions, as both maternal depression
and problems in mother-infant interaction have been identified as suitable targets for
effective interventions (Clark et al 2003, Horowitz et al. 2001, McLennan & Offord
2002). Finnish researchers have also found evidence that such preventive work is
effective (Aronen & Kurkela 1996, Davis et al. 2005, Puura et al 2005).

6.5

Assessment of mothers, children, interaction and culture

As Hiram Fitzgerald (2006) points out in his recent article, adapting an assessment
method from one culture to another is always problematic. Culture affects not only the
object studied but also the researcher and the research methods as all of them are part of
the culture in which they have been born or created. The culture is taken into
consideration when translating questionnaires from one language to another, but besides
the language, the subjects and interpretations of items studied are also culture related
(Berry et al. 1992), and therefore it is important to understand what is valued and
expected in the culture studied (Emde 2006). Culture influences the expressions of
distress and difficulty, which must be recognized when diagnosing or treating disorders
(Emde & Spicer 2000).

111
In particular, the assessment of interaction is affected by the culture. Besides the method
and object-related factors, the scorer and his/her culture affect the result of the
assessment. In this research, two different video based methods, the PCERA and the
CARE-Index, were used to assess the style of mother-child interaction. There are many
differences between these methods, but they have common theoretical backgrounds and
hence there are similarities in the contents of the items (Ahlqvist & Kanninen 2003). The
PCERA, with several items, is seeking high objectivity, and seeking to identify the
affective engagement of the dyad, whereas the aim of the CARE-Index assessment is to
interpret also the intentions and genuineness of the dyadic behavior. When aiming for
high objectivity, the interpretation of intentions may be lost, and vice versa.

In the WBC and Linguistic samples, not only the risk mothers but also most of the
sensitive Finnish mothers were given some unresponsive scores on the CARE-Index,
whereas evident intrusiveness was very rare. The public health nurses also saw some
passivity among the risk dyads, but they considered it only as a slight worry.
Furthermore, in the Observation sample rare physical contact with one-year-old children
seem to be so typical for our culture that the observers did not consider such behavior to
be problematic. As found in previous studies, these findings underline that quietness,
distal parenting and independence are typical and valued in our northern culture (Keller et
al. 2004, Moilanen et al. 2000). However, the findings also suggest that high
unresponsiveness should be considered to be a risk and target of intervention. These
findings present both clinical and research work with the challenge of finding out how
much unresponsiveness should actually be considered a good and adaptive style for

112
raising children in our culture, and how much is a risk for child development.
Furthermore, as Tamminen (2006) argues, globalization has created new challenges also
for our northern culture. This is also a challenge for professionals working with small
children.

6.6

Strengths and limitations

To get a comprehensive picture of early parent-child interaction and child development it

has been recommended to use both follow-ups and also different methods and sources of
information (Gross et al. 2004, Henningan et al. 2006, Kroes et al. 2005), This research
consists of three reasonably long follow-ups of infants and their mother. Each includes
several contacts with the family. Not only mothers but also fathers and public health
nurses were requested to describe maternal, child and dyadic behavior. Besides
questionnaires all of the studies included at least one video assessment of mother-child
interaction. Two different video assessment methods were used, but only one to describe
one sample.

The focus of child psychological and psychiatric research moved from individuals to
dyads throughout the 20th century, and it is now moving to triads (Fivaz-Depeursinge &
Favez 2006). Both mothering and fathering takes place in a triadic context, and a nondepressive parent may promote the child development when the other parent is depressive
(Mezulius et al. 2004). However, the focus of this research was on the dyadic motherchild interaction, and data concerning fathers and father-child interaction in the WBC
sample were not analyzed.

113
It is likely that the information given in advance about the study, with its fairly long
follow-ups and several contacts in each sample, may have influenced the selection
(Najman et al. 2001). All first-time mothers with full-term pregnancies visiting the wellbaby clinics should have been invited take part in the Well-Baby clinic study. However,
there was evident selection among the participants of this study, as the public health
nurses reported more maternal depression among drop-out mothers than among others.
On the other hand, the participants in the Linguistic study and the Observation study were
volunteers, who may be the most eager and the ones who to have resources to take part in
such laborious follow-up studies (Ronckers et al. 2004). None of the mothers had evident
difficulties in engaging the child in mutual interaction in either the Linguistic sample nor
the Observation sample. However, more than one fifth of mothers in all three studies
were assessed as having problems in gaining mutual attunement with their children, and
the frequencies of dyadic problems were found to be quite similar to those of child
behavioral disorders at preschooler age (Egger & Angold 2006).

Another limitation in each study is the sample size. This is true especially in the
Observation sample, with five dyads, but it included very intensive observation of each
dyad. The Linguistic sample with 27 dyads was also small, but we consider it important
because its main purpose was to form a basis for further research by exploring the
associations between maternal sensitivity and early communicative and linguistic skills in
low-risk families. The WBC sample can be considered to be fairly large for a video-based
study (Beck 1995, Crittenden & DiLalla 1988, Frankel & Harmon 1996). However, in
order to study the impact of the continuity of interactive style and depressive symptoms,

114
the WBC sample had to be divided into small subgroups, resulting in a fall in the power
of the statistical tests.

In line with the suggestion by de Wolff and van IJzendoorn (1997), moderate stability
was found in maternal sensitivity in the WBC sample over two years even though the
assessments were carried out in different places the first assessment at the child
psychiatry out patient department and the second at home. One can speculate that if the
assessments of maternal sensitivity had been made in the same environment at both time
points, the stability might have been higher than reported in our study.

In the WBC study, one limitation was the use of different methods the GHQ and the
EPDS in the assessment of maternal mood before and after delivery. The EPDS had
been recommended and validated only for postpartum use (Matthey 2000) when the study
was designed, which is why the GHQ questionnaire was chosen for prenatal use. The
GHQ has been developed to assess both depression and anxiety, but the EPDS has also
been found to assess not only depression but also anxiety (Brouwers et al. 2001).
Furthermore, as Hiltunen (2003) reports in her dissertation, the GHQ and EPDS are
highly interrelated.

The public health nurses in the WBC sample were asked to assess mothersand fathers
mental health and well-being separately, and the parent-infant relationship by a global
assessment. However, as the mothers visited the well-baby clinic more frequently, the
public health nurses assessments of parent-child relationships were considered to

115
represent the relationship between mother and child although it may include worries of
both parents.

116

Conclusions

Several conclusions can be drawn from Studies I-V.

1. Continuity of mother-child interaction

-Maternal caregiving behaviour with an infant predicts the mothers interactive style also
with a toddler. Any signs of very low affective engagement in early dyadic interaction
predict continuous problems in maternal caregiving style.
- Among full-term babies, more than one fifth of mother-child dyads need extra support
in well-baby clinics, and more than one tenth need even more intensive interventions
because of difficulties in dyadic interaction.
- A short video clip can reveal the genuine mother-child interactive style and is highly
comparable with the interaction observed recurrently over a year. An interactive style
with negative expressions in video-recorded interactions indicates continuous problems in
dyadic interaction, and failure in positive dyadic engagement may also identify the risk
dyads. However, the frequencies of activities in the video-recorded sessions must be
interpreted carefully, as they may have been affected by the video-recording situation and
may sometimes even be misleading.

2. Maternal depression and sensitivity

- Maternal depressive symptoms are very common around delivery time, and form a
spectrum of recurrent and transient, major and minor symptoms. Half of first-time
mothers with full-term pregnancies experience depressive symptoms around delivery, and
one quarter even recurrently.

117
- Not only postnatal but also prenatal, and not only recurrently but also transiently
expressed maternal depressive symptoms around delivery constitute a risk for maternal
interactive functioning. Mothers who have evident difficulties in dyadic engagement have
both pre- and postnatal depressive symptoms.
- The baby blues mothers with only transient depressive symptoms soon after delivery
manage to gain sensitive dyadic interaction with the infants. However, in most cases it is
not simply baby blues in depressive symptoms soon after delivery, as three fourths of
such mothers reported recurrent symptoms.

3. Maternal sensitivity and child development

- Early maternal caregiving style is related to the childs later development. In particular,
an intrusive maternal interactive style and also very low maternal involvement predict
low child co-operative functioning at toddler age.
- Maternal sensitivity predicts childrens early symbolic skills, motivates children to
actively express their intention, and lays the foundation for the childs receptive
language.
- Mothers who have evident difficulties in identifying infantsneeds in dyadic interaction
may also have difficulties in recognizing problems in child behavior.

4. Identification of risk dyads in well-baby clinics

- Although public health nurses are cautious in their assessments of mother-child
interaction, they report slight worries about the dyadic behavior of risk dyads, and also
arrange extra visits to well-baby clinics for such dyads. However, public health nurses do

118
not share their worries about risk dyads with physicians, and such dyads are not referred
to child mental health services.

119

Implications for clinical practice and future research

This research underlines the importance of good enough early maternal sensitivity for
child development. Signs of control or high unresponsiveness in a short video clip were
found to predict problems in dyadic interaction and child behavior. Mothers who had
evident problems in gaining mutual synchrony did not identify their childrens passivity.
All these findings stress the importance of observation and assessment of dyadic
interaction.

A short observation was found to provide reliable information about dyadic interaction,
and this should be adapted in well-baby clinical work for the early identification of
families and children needing extra help. Video recordings, which offer the possibility of
re-viewing segments, slow motion and freezing frames, provide us with a good
instrument for the detailed identification of the strengths and difficulties of the dyadic
interaction. Video-based training should be provided for all well-baby clinic workers.
Such training would help them in interpreting their worries based on clinical
observations. Furthermore, check lists to assess dyadic interaction would also help in
assessments done without video recordings during clinical appointments to confirm the
global impressions done without a camera.

Suitable methods for well-baby clinics to assess parent-child interaction could be

developed on the basis of the DC:0-3 classification and by adapting the video methods
used in this study. Being able to observe would help well-baby clinic workers to discuss
issues together, and, would also help in figuring out what to say to support parents or

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motivate them for extra interventions. The focus of interventions in well-baby clinics
should be especially on the identification of childrens signals. When there are evident
problems in the dyadic interaction, referral to an infant mental health specialist is needed.

The continuity in mother-child interaction and maternal depressive symptoms underlines

the importance not only of early interventions, but also of continuity in maternal and
well-baby clinical work (Ministry of Social Affairs and Health 2004). Such continuity in
the work with the families helps not only in the identification of at risk families but
especially in the exploration of difficult subjects with parents when they are experiencing
great changes in their lives. For early well-directed interventions, the risk dyads should be
identified and the intervention should begin already during pregnancy and continue after
delivery.

To develop preventive work in well-baby clinics in the future, it is essential to ensure

team work with an adequate number of both public health nurses and physicians. Besides
the scheduled visits, extra contacts with families are needed for more thorough
assessments and especially to carry out early interventions. Furthermore, well-baby clinic
workers should be able to have consultations with and supervision by infant mental health
workers to plan together tailored interventions for the dyads they are worried about.

If there are evident problems in mother-child interaction, or if interventions in well-baby

clinics would be insufficient, the dyads should be referred to infant mental health
specialists. When the problems in dyadic interaction are related to minor maternal

121
depression, the focus of the intervention should also be on the dyad or the family and
carried out by child mental health services. If maternal depression reaches the clinical
range, adult mental health services are also needed. In such cases co-operation between
infant and adult mental health services and well-baby clinics is necessary. To ensure early
and effective interventions for children and families with evident problems, the infant
mental health services need to be further developed.

To confirm the findings of this research, further studies with larger samples and longer
both pre- and postnatal follow-ups are needed. As there is evident continuity both in
prenatal maternal depression and in postnatal maternal functioning, research on maternal
prenatal engagement with the expected child is needed. In this research the focus was on
maternal sensitivity, and further research is needed to assess fathersroles in childrens
development, and especially to assess the triadic father-mother-child interaction in the
family. The data on the fathers who took part in the WBC study are waiting to be
analyzed.

122
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List of original publications

I

Kemppinen K, Kumpulainen K, Rsnen E, Moilanen I, Ebeling H, Hiltunen P,

Kunelius A (2005) Mother-child interaction on video compared with infant
observation: Is five minutes enough time for assessment? Infant Mental Health
Journal, 26, 69-81.

II

Kemppinen K, Kumpulainen K, Moilanen I, Ebeling H (2006) Recurrent and

transient depressive symptoms around delivery and maternal sensitivity. Nordic
Journal of Psychiatry, 60, 191-199.

III

Kemppinen K, Kumpulainen K, Raita-Hasu J, Moilanen I, Ebeling H (2006) The

continuity of maternal sensitivity from infancy to toddler age. Journal of
Reproductive and Infant Psychology, 24, 199-212.

IV

Kemppinen K, Ebeling H, Raita-Hasu J, Toivonen-Falck A, Paavola L, Moilanen

I, Kumpulainen K. Early maternal sensitivity and child behaviour at toddler age:
does low maternal sensitivity hinder identification of behavioural problems?
In press, Journal of Reproductive and Infant Psychology, Vol 25 (2007).

Paavola L, Kemppinen K, Kumpulainen K, Moilanen I, Ebeling H (2006)

Maternal sensitivity, infant co-operation and early linguistic development: Some
predictive relations. European Journal of Developmental Psychology, 3, 13-30.

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