Background and rationale {6a}
Poor parenting is a crucial mediator of the intergenerational continuity of child maltreatment. Parents’ mental illness (MI) and parental history of early life maltreatment (ELM) are known to be the most significant risk factors in this vicious cycle of abuse: MI and a history of ELM are both associated with child abuse potential [
1]. Ten years ago a guidance of the World Psychiatric Association (WPA) has been dedicated to the protection and promotion of mental health in children of persons with severe mental disorders indicating that not the diagnosis but severity and chronicity of psychopathology confer an increased risk for child maltreatment [
2]. Furthermore, it has been shown that ELM alone does not significantly impact on parenting behavior but that mothers with a history of MI and severe ELM show a particularly high risk of low maternal sensitivity in interaction with their children [
3,
4]. About 3.8 million minors in Germany live in families with an MI parent [
5]. In a nationwide survey of mental health professionals at psychiatric hospitals in Germany, 38.3% of the surveyed evaluated their patients as being impaired in parenting, at least sometimes, and 52.3% of the surveyed estimated the mental health of their patients’ children to be jeopardized [
6]. Furthermore, MI parents often consider their children as having more psychological/behavioral problems and express a higher need for help in parenting than a healthy control group [
5]. It is important to note that investigations of parenting report statistical associations in large samples. Many parents with severe mental illnesses show excellent caregiving that means a parental MI or experience of ELM do not necessarily lead to poor parenting and it is not inevitable that there is a negative impact on the children’s development. Nevertheless, children living in a family with an MI parent run a higher risk of being affected by various modes of ELM [
7] and of developing psychopathology [
8]. Although studies on parent-child-interaction and maltreatment of minors have been widely restricted to mothers, it has also been shown that ELM in fathers predicts harsh parenting [
9] and parental neglect [
10]. Additionally, MI such as depression in fathers is associated with, e.g., more withdrawn parental behavior [
11] and increased risk of child maltreatment [
12]. Hence, prevention programs for families with an MI parent, which pay particular attention to experiences of ELM in the parent, are urgently needed.
The Guidelines of the World Psychiatric Association (WPA) outline impaired responsiveness to the child’s needs, emotional unavailability, irritability, and disturbed behaviors as common pathways through which MI in parents, irrespective of the specific diagnosis, impact on their child’s well-being [
2]. These pathways interact strongly with poor mentalizing, which has been shown to be a significant mediator of poor parenting and to be particularly impaired by ELM [
13]. Thus, mentalization-based (MB) interventions foster social cognition in parents and provide an important and at the same time trainable basis on which to improve parents’ capacity to understand the meaning of their child’s behavior, resulting in more adaptive interactions and prevention of maltreatment [
14].
A meta-analysis on the effects of parenting programs on child maltreatment prevention encompassing 37 studies provided evidence of positive effects and reduced risk of maltreatment [
15]. Via own literature search, we found eleven different prevention programs that aim to enhance mentalizing in mothers with MI [
16‐
21], in prison [
22] or at other risk, such as teenage mothers [
23], as well as in families [
24,
25] and in caregivers of inpatient psychiatric children [
26]. The efficacy of four of these approaches that aim to prevent abuse by improving mentalizing in parents has been demonstrated in six randomized-controlled trials (RCTs) [
16,
21,
22,
25,
27,
28], and a further two RCTs are currently underway [
26,
29]. Previous studies show that mentalization-based (MB) approaches can be delivered by nurses and social workers (e.g., [
23]). A meta-analysis [
30] including 10 studies encompassing 1628 mother-child dyads with 0–6-year-old children examined the effectiveness of interventions that aimed at promoting maternal sensitivity and reflective functioning. It found that interventions for high-risk families produced the most beneficial effects, with large effect sizes (
d = 1.5). The authors pointed out that studies should include children in addition to infants and should extend measurements of child outcomes. In sum, data provide evidence for the efficacy of MB approaches in preventing parents from abusing their children, whether they are delivered for individuals, families, or in groups. Previous studies have focused on mothers or parent-couples, leaving open the question of whether they are also successful with fathers. Even more importantly, although several studies have been performed in inpatient treatment settings for addiction [
18,
19], so far, no study has been conducted within general psychiatric hospitals for acutely MI parents with different diagnoses of the whole spectrum of mental disorders (e.g., depression, anxiety disorders, borderline personality disorder, addiction, schizophrenia).
We conceptualized a mentalization based-parenting counseling (MB-PC) to improve social cognition in parents in response to their child. In order to evaluate and optimize therapeutic interventions, it is particularly important to understand the biobehavioral mechanisms that underlie these processes and may, thus, induce, influence or moderate the effectiveness of this intervention. Two possible mechanisms of change regarding parenting are social cognition and dyadic synchrony:
First, both affective and cognitive components of social cognition are required for positive parenting: Affective components of social cognition concern the sharing of the child’s emotion (i.e., empathy) and the feelings of warmth and care (i.e., compassion). Cognitive components of social cognition, commonly conceptualized under the terms mentalizing, theory of mind (ToM), or cognitive perspective taking, comprise inferring and reasoning about the child’s cognitive and affective states (i.e., cognitive and affective ToM) [
31]. Compromised social cognition in individuals with mental illness and ELM may be a key factor contributing to poor parenting, which impacts on child well-being and mediates the intergenerational continuity of child maltreatment [
32]. To our knowledge, to date, no study has addressed the question of which components of social cognition may specifically mediate effects of mentalization-based parenting interventions.
Second, dyadic synchrony is commonly found in well-adjusted children and their parents and has been associated with favorable developmental outcomes [
33,
34]. According to the biobehavioral model of parent-child synchrony [
35], dyadic synchrony represents a dynamic regulatory process by which hormonal, physiological, and behavioral cues are exchanged between parent and child during social contact in order to jointly pull each other toward a baseline level characterized by greater stability in the system. In a synchronous relationship, when a child becomes distressed, the caregiver will be able to regulate his/her own feelings of discomfort and adopt a soothing demeanor, helping the child to regain emotional balance [
36]. The parental ability to mentalize has been linked to observational measures of dyadic interactional quality such as higher sensitivity and lower hostility [
37], and these links have also been found in the context of parental ELM and psychopathology [
38,
39]. Biobehavioral synchrony could be affected by MB interventions but to date it has not been studied as a mechanism of change.
Taken together, research up to now shows that parental ELM and MI are associated with poor parenting while poor parenting is a risk factor for child maltreatment. MB interventions for parents have been identified as effective in reducing the maltreatment risk for the next generation while no study so far has addressed a group of acutely MI patients currently treated at general psychiatric hospitals. Furthermore, social cognition and dyadic synchrony are of importance for positive parenting and could be mechanisms of change in MB interventions. The present study therefore aims at investigating the effectiveness of an MB intervention on parenting quality in MI parents and possible biobehavioral mechanisms associated with it. The study is part of the multicenter consortium UBICA II (“Understanding and Breaking the Intergenerational Cycle of Abuse in Families Enrolled in Routine Mental Health and Welfare Services”) situated at three sites (Aachen, Berlin, Heidelberg) and subsuming several studies across Germany, led by the managing site at the Department of General Psychiatry at the University Hospital Heidelberg.