ReviewChild-focused maternal mentalization: A systematic review of measurement tools from birth to three
Introduction
The concept of maternal mentalization is widely accepted in its significance for attachment as well as theory of mind research. Many different operationalizations of the construct exist, yet to date, no systematic review of measurement tools capturing the concept has been compiled. One non-systematic, narrative expert review lists four possible assessment options (2008). Moreover Choi-Kain and Gunderson [11] present a very detailed review of one possible operationalization of the construct (see Reflective Functioning Scale below). However, the whole stock of currently available tools to assess maternal mentalizing capacity has not been systematically searched, classified and compared according to dimensions relevant for the transfer into daily practice.
After defining maternal mentalization and providing a brief review of major research results regarding the construct, it is the goal of this systematic review to provide the reader with a detailed description of currently available assessment instruments to measure maternal child-focused mentalization capacity.
Several definitions of the broader term mentalization exist. Taking a psychoanalytical perspective and referring to Mary Main’s elaborations on metacognitive monitoring Main [34] Sharp and Fonagy [54] describe mentalization as “both a cognitive process akin to psychological insight or perspective taking, and an emotional process, that is, the capacity to hold, regulate, and fully experience one’s own and others’ emotions in a non-defensive way without becoming overwhelmed or shutting down” (p. 740). The term reflective functioning in particular is used when this process is referred to in the context of attachment relationships.
Meins et al. [38] argues from a cognitive developmental point of view, connecting maternal mentalizing to children’s theory of mind development as well as the evolvement of secure attachment relationships. The author defines mentalization as the parental understanding that the child is capable of having own representations of the world and different stances that may be taken toward reality. She specifically coined the term mind–mindedness to describe “a mother’s proclivity to treat her infant as an individual with a mind rather than merely as a creature with needs that must be satisfied” (p. 638).
Based on these definitions the authors define maternal child-focussed mentalizing capacity for the purpose of this review as: the maternal ability to be sensitive to and aware of the infants’ mental states, namely its thoughts, feelings, intentions, desires, or wishes. Instruments measuring this particular maternal ability will be the focus of this review.
Since the pioneering work of Mary Main and her colleagues prompted the field of attachment researchers to ‘move to the level of representation’ [35] an increasing interest in the representational or mental world of parents regarding attachment relevant themes can be noted. This resulted in an impressive body of research regarding individual differences in the way parents mentalize and the effects on their children. Today, the capacity for mentalization is regarded as one of the main psychosocial variables mediating the significant influence of parents’ representations of their past attachment experiences upon their child’s current attachment status [67], [22]. A phenomenon which is still awaiting its full resolution by contemporary attachment research, namely the question how attachment is transmitted from generation to generation (‘transmission gap’, IJzendoorn van [29]). Exemplary to that effect Fonagy et al. [21] were amongst the first to be able to link a mother’s overall prenatal reflective functioning (RF), one possible operationalization of mentalizing capacity, to secure attachment at 1 year or 18 months respectively. Similarly Slade et al. [57] present data on the more specific parental reflective functioning. Here, higher maternal RF predicted secure attachment of the infant at 14 months. Employing yet another operationalization of maternal mentalization (appropriate mind related comments) Meins and colleagues showed that this maternal capacity at 6 months was a strong predictor of attachment security at 12 months [38] and 45 or 48 months respectively [41]. Additional evidence for the proposed link between maternal child-focussed mentalization capacity and child’s attachment security comes from Bretherton et al. [1], Solomon and George [60], Oppenheim et al. [46] as well as Koren-Karie et al. [30] (see below). Furthermore higher maternal mentalization capacity is discussed as mechanism to buffer the transmission of trauma on infants [52] as well as the portrayal of disrupted maternal behavior during mother–infant interactions [56].
Within theory of mind research a mother’s capacity to mentalize is recognized as a major environmental factor facilitating the development of a child’s understanding of other people’s mental states as well as their social-cognitive development in general. Exemplary to this field of research Taumoepeau and Ruffman [64] showed that a mother’s recognition and reference to her infant’s mental states (namely desires) at 15 months was the strongest predictor of the child’s own mental state vocabulary and its ability to recognize another person’s emotions at 24 months. Similarly, strong relations have consistently been reported between the maternal mentalization, operationalized as mind–mindedness, and theory of mind tasks [32], [41] as well as parameters of social-cognitive development as evident in the stream of consciousness task [40].
Despite due brevity the scientific as well as clinical relevance of the construct should be demonstrated. Nevertheless currently no systematic overview of available instruments measuring maternal child-focused mentalizing capacity exists. It is the primary goal of this review to summarize the available tools, provide a detailed description of their development, theoretical background and specific definitions employed, as well as delineating assessment details, and psychometric properties. In so doing parallels as well as differences between the constructs applied in the context of child-focused maternal mentalization will be demonstrated. Our second goal is to provide guidance for specific groups of readers by contrasting the instruments regarding aspects of specific content domains, relevance as well as economy and feasibility in clinical practice.
Section snippets
Methods
To answer the research question the method of the systematic literature review guided by PRISMA standards [42] was chosen. Eligible for the review were reports on assessment tools or studies using such tools that (a) focus on the maternal mentalization capacity with regard to their up to 3 year old children
Results
The number of records identified through database searching was n = 238. An additional number of n = 5 records were identified through other sources (reference lists, experts, etc.). After duplicates were removed n = 139 records remained for further analysis. After screening for eligibility on basis of titles and abstracts n = 61 were included in the full text analysis. N = 47 records remained to be included in the qualitative synthesis after further n = 14 were excluded with reason. After removing
Discussion
The current review presents the first systematic overview of the complete stock of assessment tools to measure maternal child-focussed mentalization. Maternal child-focussed mentalization represents a construct which has gained major significance in the field of attachment and theory of mind research. The review indicated that a creative variety of 15 instruments has been developed. In sum they present highly varying degrees of theoretical foundation, psychometric evaluation, and general
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