Department of Psychology, University of Reading
Section of Perinatal Psychiatry, Institute of Psychiatry, London, UK
Department of Neurologic and Psychiatric Sciences, University of Florence, Italy
Department of Psychology, University of Minho, Braga, Portugal
Child and Adolescent Psychiatry, University of Zurich, Switzerland
Department of Psychiatry Medical Center, University of Michigan, Ann Arbor, Michigan, USA
University Department of Psychiatry, Centre Hospitalier Charles Perrens, Bordeaux, France
Department of Psychology, University of Reading, UK
TCSPND Group*
Correspondence: Sue Conroy, PO71, Section of Perinatal Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. E-mail: s.conroy{at}iop.kcl.ac.uk
* TCSPND Group membership and funding detailed in Acknowledgements, p.
iv, this supplement.
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ABSTRACT |
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Aim To establish the usefulness of the Global Ratings Scales of MotherInfant Interaction and the InfantToddler version of the Home Observation for the Measurement of the Environment (ITHOME), and to test expected associations of the measures with characteristics of the social context and with major or minor depression.
Method Both assessments were administered postnatally in four European centres; 144 mothers were assessed with the Global Ratings Scales and 114 with the ITHOME. Affective disorder was assessed by means of the Structured Clinical Interview for DSMIV Disorders.
Results Analyses of motherinfant interaction indicated no main effect for depression but maternal sensitivity to infant behaviour was associated with better infant communication, especially for women who were not depressed. Poor overall emotional support also reduced sensitivity scores. Poor support was also related to poorer ITHOME scores, but there was no effect of depression.
Conclusions The Global Ratings Scales were effectively applied but there was less evidence of the usefulness of the ITHOME.
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INTRODUCTION |
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Measures
The Global Ratings Scales of Mother-Infant Interaction
(Murray et al,
1996b) were developed to assess differences in
mother-infant interaction between groups of women with or without postnatal
depression. Using these scales, Murray et al reported significantly
reduced sensitivity towards the infant for mothers who had
experienced postnatal depression. These findings, using a relatively low-risk
sample, are consistent with those of other researchers who have noted
distinctly impaired interaction styles for mothers experiencing postnatal
depression in high-risk samples (e.g.
Field et al, 1985;
Cohn et al, 1986). The
scales have also been used with different clinical groups such as mothers with
schizophrenia (Riordan et al,
1999) and borderline personality disorder
(Crandell et al,
2003). Furthermore, the scales have been successfully used by
researchers in cross-cultural settings: Cooper et al
(1999) found that the scales
could discriminate between the maternal interactions of well women and those
with depression in a South African peri-urban sample, while Sepulveda et
al (1999) reported the
sensitivity of the scales to the impact of interventions in samples of women
with depression and women living in conditions of adversity in a Venezuelan
study. The scales have also been found to predict infant and child cognitive
outcome at 18 months and 5 years of age (Murray et al,
1996a,b).
The instrument was chosen for use in our study because it is neither a time-consuming microanalytic scale nor overly global; it is thus relatively quick to rate, while maintaining clinical sensitivity. It has been shown to be sensitive to impaired interaction even in low-risk samples, and has further been found to discriminate between families who are or are not living in conditions of adversity (Murray et al, 1996b).
The Global Ratings Scales are a video-based assessment of the quality of mother-infant engagement that can be applied from 2 months to 6 months post-partum. With increasing infant age some scales are sensitively adjusted so that dimensions are comparable across ages. Five-minute video recordings of mother-infant face-to-face interactions are made either in the mother's home or in a laboratory setting. Mothers are instructed simply to play with their infants in any way they choose without the use of toys. Maternal behaviour is rated on four dimensions that describe the degree to which a mother's behaviour is appropriately adjusted to her infant: sensitivity, intrusiveness, remoteness, and overt behaviour relevant to clinical levels of depression (such as happiness, energy level, self-absorption and tension). Infant behaviour is rated on three dimensions, describing the infant's positive engagement in the interaction, and behaviour on a lively-inert scale and on a fretful-contented scale. A final dimension assesses the quality of the overall interaction between mother and infant.
In addition to impaired proximal interaction styles of mothers experiencing postnatal depression, another mediator of poor outcome may be the overall quality of the child's home environment (Duncan et al, 1994; Hurt et al, 1998; Petterson & Albers, 2001). The maternal behaviour of mothers with depression has been described as generally less competent than that of those who are not depressed, being more helpless, disorganised, hostile and critical, and less responsive and active (Gelfand & Teti, 1990; Goodman, 1992). It is likely, therefore, that the overall quality of the home environment will be reduced.
The Infant-Toddler version of the Home Observation for the Measurement of the Environment (IT-HOME; Caldwell & Bradley, 1984) assesses the quality and quantity of stimulation and support available to the child in the home environment. As a predictor of later development, IT-HOME scores show significant relationships with children's later language development, intellectual performance and academic achievement (Bradley et al, 1994). As an outcome measure, the HOME has significant relationships with poverty, social class, marital status, maternal age, education and mental health status (Watson et al, 1996). The instrument has been used in many studies in the USA and elsewhere, including South America, Europe, Asia, Africa and Australia. Items in the inventory are based on reviews of child development theory and research and information from professionals working with children. Items are traditionally clustered into six sub-scales based on content, item and factor analysis. Bradley et al (1994) reported differences in the factor structure of the IT-HOME for White, Black and Hispanic Americans and recommended examination of the factor structure for other cultural groups. Caution was urged in using the sub-scales in cultural groups whose child-rearing practices differ substantially from those of the dominant American culture.
The IT-HOME is administered in the home, with the baby and caregiver present and the baby awake. About half of the items are scored from observation and about half from interview. There is no standard question format or probe - interviewers are advised to ask questions in their own way and adjust questions in light of answers already given, although the training manual provides some suggested probes to introduce topics. There are 45 binary choice (yes/no) items clustered into six sub-scales: parental responsiveness, acceptance of the child, organisation of the environment, learning materials, parental involvement and variety of stimulation (see Table 3).
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Transcultural Study of Postnatal Depression
The primary aim of the Transcultural Study of Postnatal Depression
(TCS-PND) was to develop (or modify), translate and validate research
instruments that could be used in future studies of postnatal depression in
different countries and cultures. The instruments were chosen to assess key
aspects of the maternity experience, namely clinical diagnosis, the
psychosocial context of pregnancy and motherhood, maternal attachment style,
mother-infant interaction, the child's environment, and health service
structure, use and its associated costs. The modified and translated research
tools were piloted to test how well they worked in a perinatal setting and in
other languages and populations. This paper reports on the piloting of two of
these instruments: the Global Ratings Scales to assess mother-infant
interactions, and the IT-HOME.
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METHOD |
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Sample
Eligible women were recruited in antenatal clinics or classes by a
researcher who obtained informed consent from those who agreed to take part.
Sample sizes in each centre varied from 20 to 60, with a total of 296 for the
study as a whole. The Global Ratings Scales and the IT-HOME were administered
to sub-samples of the 248 women interviewed postnatally: 144 for the Global
Ratings Scales and 114 for the IT-HOME. Demographic characteristics of the
centre samples are described by Asten et al
(2004, this supplement).
Other measures
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I;
First et al, 1994) is
a semi-structured interview for making the major DSM-IV diagnoses
(American Psychiatric Association,
1994). In this study a research version of SCID-I designed for use
with non-patient populations (SCID-I/NP;
First et al, 1996) was modified to produce an instrument for assessing postnatal depression in
different cultural contexts: the SCID-PND
(Gorman et al, 2004,
this supplement). The SICD-PND was administered at both antenatal and
postnatal interviews, thus providing a continuous assessment of depressive
disorder from the beginning of pregnancy up to 6 months postnatally.
A combined variable of either major or minor depression with an onset date within 6 months of delivery was used in this study. Rates of postnatal depression differed between centres: five women (31%) in the Bordeaux sample reported an episode of postnatal depression (before filming at 6 months), compared with ten (22%) of the Porto sample (before filming at 3 months) and four (22%) of Vienna's sample (before filming at 6 months). None of the Florence or Zurich samples reported any postnatal depression.
The Contextual Assessment of Maternity Experience (CAME) was developed to assess the psychosocial context of the maternity experience in different cultural settings (Bernazzani et al, 2004, this supplement). The CAME includes assessment of recent life adversity in eight domains (marital, social, parental, health, housing and financial, work, criminal and legal, and geopolitical); emotional support, and feelings about the pregnancy and motherhood. Severe and non-severe adversity were distinguished in each domain separately and in all domains together. All centres had comparable levels of severe adversity at postnatal interview (26-44%). Two variables distinguishing poor emotional support in the postnatal period were used: poor support from the woman's partner; and poor overall support from the partner, one very close other and all others in the woman's social network. A lower proportion of women in Bordeaux had poor support from their partner (10% compared with 31-41% elsewhere) and a higher proportion of women in Porto than in the other centres had poor overall support (50% compared with 20-28% elsewhere), although neither difference was statistically significant.
Procedure
Postnatal interviews were conducted at around 6 months following delivery
(4 months in Zurich), and the Global Ratings Scales and the IT-HOME were
administered at the same time as the other study instruments, except in the
case of Porto where the Global Ratings Scales and the IT-HOME were
administered at around 3 months post-partum. Video recordings for the Global
Ratings Scales were mainly conducted in the maternal home, with the mother
sitting facing her baby, who was seated in an infant chair. A mirror was
placed next to the baby and the interaction was filmed from behind the
mother's shoulder, so that the frame included the infant's face and whole body
as well as a full-face reflection of the mother. Scoring was conducted by
raters masked to the mother's psychiatric status. The IT-HOME was, of course,
always administered in the maternal home.
Training and reliability
The original manual for rating the Global Ratings Scales
(Gunning et al, 1999) was revised for the study to include details on the procedure for conducting
the assessment, and further details on a number of the rating definitions.
Raters were trained over a comprehensive 3-day course, with subsequent
refresher sessions. Following training, selected teams translated the rating
schedule. A Portuguese version of the scales was already available. To gain
reliability raters had to score ten standard interactions, rating the first
five for practice and feedback and an additional five as the final reliability
check. Where necessary, further training feedback was supplied to ensure
consistent ratings. All four centres passed this reliability assessment with
intra-class correlations ranging from 0.70 to 0.89. Further to this, a
transcribed copy of a tape from the rater's sample was sent to M.G. for a
comparative analysis as a final check of consistency.
A training video and manual for the IT-HOME produced by the instrument's authors were used for training purposes (Caldwell & Bradley, 1984). Following training, selected teams translated the inventory items (and suggested interview probes) into their own language. A Portuguese translation was already available. Since administration of the IT-HOME is based on observations made and questions asked during the course of a home visit, format checks of interrater reliability between centres were not considered feasible.
Analyses
Comparisons of mean summary scores by centre were conducted using one-way
analysis of variance (ANOVA) where data upheld assumptions of a normal
distribution and homogeneity of variance, and a Kruskal-Wallis test where the
data did not meet parametric assumptions. Relationships with independent
variables were examined using t-tests. Principal components analysis
was used to examine the factor structure of the IT-HOME and internal
consistency was measured using Cronbach's .
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RESULTS |
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The Porto centre scores, therefore, were lower than the three other centres
for three scales: sensitivity, depression and overall interaction. Since past
research had revealed the sensitivity dimension to be particularly important,
an explanation for the differences on this scale was sought. The Porto sample
had significantly higher proportions of manual social class
mothers (2=25.97, d.f.=3; P<0.0001) and fathers
(
2=14.09, d.f.=3; P=0.003), and of mothers with low
educational levels (
2=41.58, d.f.=3; P<0.0001),
relative to Bordeaux, Vienna and Zurich.
Analyses of mother's class, partner's class and mother's education in relation to sensitivity scores showed that the sensitivity score was significantly lower where the partner's class was manual (F(1,137)=3.275; P=0.01). After controlling for the effects of partner's class, the centre differences in mean sensitivity scores were no longer significant. There was a similar trend for depression ratings (F(1,137)=3.258; P=0.073), and a significant difference for the overall interaction ratings (z=-2.005; P=0.045), whereby lower mean scores obtained where partner's class was manual. When centre effects on these dimensions were re-examined controlling for social class they were found to be non-significant.
Depression
Global Ratings for the Zurich sample were not included in depression
analyses since no index group was available for comparison. Since the numbers
of participants with depression within individual centres' samples were low,
an analysis of the pooled sample was conducted.
Table 2 shows the spread of the
pooled Global Ratings summary score means by depression status. Although
scores for sensitivity, depression, infant engagement, infant
fretfulness and overall interaction were lower for the
depression group, the differences were not statistically significant. Internal
correlations of maternal and infant Global Ratings indicated that higher
levels of maternal sensitivity were associated with better infant engagement
ratings (r=0.57), better infant liveliness scores (r=0.44)
and less infant fretfulness (r=0.36); all P<0.0001. When
the effects of depression status were tested, sensitivity remained correlated
with infant engagement and liveliness ratings only for the non-depressed
group. For the depressed group non-intrusive maternal interaction was
negatively correlated with infant engagement scores (r=-0.63;
P=0.004), indicating that more intrusive styles were associated with
better infant engagement. Furthermore, a more remote style was associated with
poor infant liveliness scores (r=0.55; P=0.015).
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Adversity
Univariate tests revealed no significant effects for the presence of total
antenatal or postnatal adversity on Global Ratings summary variables where
centre data were pooled. However, women who experienced severe antenatal
adversity in the social domain (no adversity, n=129; adversity,
n=15) showed some evidence of lower scores on the sensitivity scale,
and there was an indication that severe postnatal adversity in the
reproduction/parenthood domain (no adversity, n=118; adversity,
n=12) was associated with lower depression ratings on the Global
Ratings Scales (F(1,142)=3.178; P=0.077;
F(1,128)=3.48; P=0.064, respectively).
Support
Poor overall emotional support (good support, n=85; poor support,
n=44) was related to lower mean sensitivity scores
(F(1,127)=4.084; P=0.045). Analyses of
between-group differences revealed that mean sensitivity scores of women who
were not depressed and had good postnatal support were significantly higher
than those of women who had experienced depression in conjunction with poor
postnatal support (z=-2.403; P=0.016), suggesting an
additive effect.
IT-HOME
In light of the cautioning by Bradley et al
(1994) on the use of IT-HOME
sub-scale scores with different cultural groups, it seemed appropriate to
examine the factor structure of the instrument in this study. Principal
components analysis for the pooled sample showed a different factor structure
from that of the conventional sub-scales, with 13 factors with eigenvalues
greater than 1 being retained. Closest to the original sub-scales was a factor
consisting of the majority of items from the responsiveness and acceptance
sub-scales. No consistent pattern was apparent for the remaining factors.
Table 3 shows individual item
loadings on the first five factors. One item (child taken regularly to
doctor's or clinic) had to be excluded owing to zero variance across
all four centres. Unfortunately, it was not possible to conduct meaningful
principal components analyses separately for each centre, owing to the large
number of items with zero variance in one or other centre. In light of these
findings, total IT-HOME scores rather than sub-scale scores were used in
further analyses.
Internal consistency
Reliability analyses indicated that one item (family has a
pet) was inconsistent with others in the total IT-HOME scale. Internal
consistency, measured using Cronbach's , for the resulting 44-item
scale for the pooled sample was 0.86. The
values for each separate
centre were also adequate (Bordeaux 0.73, Porto 0.84, Vienna 0.81), apart from
in Florence, where
=0.64.
Mean scores
A total score was computed by adding together all 44 items, with higher
scores indicating that more items were credited. A comparison of mean total
scores using one-way ANOVA showed a significant difference between centres
(F(3,110)=18.86; P<0.001), with post
hoc tests revealing that scores in Porto and Florence were lower than
those in Bordeaux and Vienna. As with the Global Ratings scores, possible
explanations were sought for the discrepancies between centres by examining
the effects of demographic variables. Pooled scores showed expected
relationships with social class and maternal education. Scores were
significantly higher where the mother had been educated to the level of
diploma or degree, compared with high school or less (t=5.94;
P<0.001), and where both mother's and father's social class was
non-manual (mother's social class, t=3.71, P<0.001;
partner's social class, t=3.33, P=0.001). There was a
non-significant trend for higher scores where the baby was first-born
(t=1.80, P=0.074) but no difference in scores according to
maternal age.
Unlike the Porto sample, parents' social class and mother's educational level in the Florence sample were similar to those in Bordeaux and Vienna. The main way in which the Florence sample differed was in a higher proportion of first-born babies, which would tend to imply higher scores. Likely explanations for centre differences with Florence, therefore, remained unclear. Although the social class of both parents and maternal educational level were closely related to IT-HOME total scores, and varied between centres, controlling for these variables did not entirely remove the significant differences between centres. In further analyses, therefore, controls were made for centre status. The IT-HOME scores did not, on the whole, show the relationships with other variables that might have been expected. In particular, there was no difference in scores according to depression status, nor were there any effects for antenatal or postnatal adversity, whether examined as adversity in any of the eight domains or as separate domains. However, scores were significantly lower where the mother was rated as receiving poor support from her partner (F=5.47; P=0.02).
Correlations with Global Ratings Scales
As expected, pooled IT-HOME total scores correlated with several Global
Ratings Scales (controlling for centre differences) - in particular, with
maternal sensitivity (r=0.29; P=0.007), remoteness
(r=0.31; P=0.004) and depression (r=0.24;
P=0.03). Interestingly, when the effect of depressed status was
tested, the correlations were stronger for the non-depressed group and were no
longer significant for the depressed group.
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DISCUSSION |
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A comparison of the Global Ratings Scales summary scores by centre revealed lower scores for the Porto sample on the key dimension of sensitivity in addition to the depression and overall interaction dimensions. This could be attributed to the greater proportions of parents of lower social class and lower maternal education in the Porto sample. When social class was controlled for, the differences between centres were no longer significant.
Analysis of depression did not yield significant findings when considered alone. There are a number of reasons why this might be the case: first, it could in part reflect the fact that this was mostly a self-selected, low-risk sample, among whom marked impairments in interactive behaviour in the context of depression were unlikely. It could also reflect the fact that, even when samples were pooled, the number of mothers with depression was low (n=19), and the study might have been insufficiently powered to detect significant differences according to depression status. Finally, by the time of the observations of mother-infant interactions, a number of women categorised as depressed because they had experienced depression at some point between birth and 6 months might have recovered, and their interactions might have correspondingly improved. However, analysis of internal correlations between maternal and infant scales of the Global Ratings showed that higher maternal sensitivity scores were associated with better infant communication and liveliness, and less fretfulness. When the effects of depression were considered, the above relationship remained true only for the non-depressed group, whereas scores for the depressed group showed associations between non-intrusiveness and poorer infant engagement, and remote maternal interaction and low levels of infant activity. The pattern of results for the depressed group suggests a more withdrawn style of maternal interaction where the infant is inactive. It is not clear from the data, however, whether the latter finding is due to the depressed group's tendency towards remoteness, which would also preclude a high intrusiveness score. That the association between maternal sensitivity and better infant performance during the interaction was true only for the non-depressed group indicates that where behaviour is not compromised by depression, mother and infant act to sustain each other's smooth interaction. Where depression exists, the relationship is not found and effects are less clear. These findings reflect those of Murray et al (1996b), who reported a significant correlation between sensitivity and infant engagement where a main effect for depression had also been demonstrated.
Although the experience of general adversity in this sample was not clearly related to the quality of mother-infant interactions, there was consistent evidence that maternal sensitivity was reduced in the context of social adversity (both experienced antenatally, and in terms of poor overall support from a mother's partner, other significant relationships and others), and this was particularly marked for mothers who were also depressed. It is possible that the symptoms of mothers with depression within this group were more marked within the interpersonal domain. If so, it would be unsurprising that the intensely interpersonal nature of the mother-infant relationship should also prove difficult to negotiate. It is worth noting that, in the study by Murray et al (1996b), it was similarly the case that general adversity was unrelated to poor mother-infant attachment, whereas adversity concerning poor relations with the woman's own mother was strongly related to this outcome.
Principal components analysis of IT-HOME scores revealed a different factor structure from that of the conventional sub-scales, thus limiting the use of the instrument in this sample to analyses using total scores. The IT-HOME total scores differed by centre, with Porto and Florence having lower scores than Bordeaux and Vienna. Unlike the Global Rating Scales analyses, controlling for relevant demographic variables did not entirely remove the significant centre differences. Since no formal checks of interrater reliability between centres were undertaken for the IT-HOME, it is possible that differences between centres might have arisen from differences in administration and coding of the instrument. The IT-HOME scores did not show anticipated relationships with either depression status or adversity, although scores were lower where the mother had poor support from her partner. Correlations between IT-HOME scores and several of the Global Ratings Scales demonstrate convergent validity between the two measures.
Reviewing the research literature on the use of the HOME across cultures, Bradley et al (1996) noted limited variability in HOME scores obtained in European studies, with mean scores tending to be close to those for middle-class US families. Possible reasons included more homogeneity in many European samples than in the original American norming sample, and the instrument's aim being to distinguish environments posing a risk for children's development from those offering adequate support and stimulation. State welfare provision in European countries means that living conditions are generally better than those of chronically poor US families. It is likely, therefore, that within this small, predominantly middle-class sample the IT-HOME did not discriminate between groups owing to limited variability in scores. Although centres found the instrument easy and quick to administer, some items were considered inappropriate for use with 6-month-old babies. In light of these results, the IT-HOME does not appear to be an ideal instrument to examine the effects of postnatal depression on the home environment of infants in a European setting.
It is of note that only four centres finalised reliability and filming for the Global Ratings Scales assessment. Centres indicated that obtaining equipment and recruiting additional raters who could be masked to mothers' depression status were the main difficulties preventing participation. However, a positive outcome of the study is that most centres found the dimensions of the tool relevant for use in clinical settings in addition to research. Furthermore, following the completion of the European Union study, one European centre and one in Japan have successfully used the scales in further research: the Porto group found the scales effective in assessing the impact on mother-infant interaction of an intervention programme for adolescent mothers (Figueiredo et al, 2000), and a group in Mie has conducted a preliminary study of postnatal depression and mother-infant interaction in a Japanese sample (Okano et al, 2002).
In summary, where centres had the means to conduct filming and recruit additional raters, the Global Ratings Scales were successfully used to detect differences in mother-infant interactions between women with postnatal depression and a non-depressed control group, particularly in the presence of poor social support. Further to the TCS-PND study, the assessment is being used by centres within and beyond Europe, indicating the success of the primary aim of the European Union study - the harmonisation of research methods for use in future studies of postnatal depression.
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Clinical Implications and Limitations |
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LIMITATIONS
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