Maternal avoidance, anxiety cognitions and interactive behaviour predicts infant development at 12 months in the context of anxiety disorders in the postpartum period

Infant Behavior and Development 50 (2018) 116–131

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Maternal avoidance, anxiety cognitions and interactive behaviour predicts infant development at 12 months in the context of anxiety disorders in the postpartum period

T

⁎

C. Recka, ,1, B. Van Den Berghd,1, A. Tietzb, M. Müllera, A. Ropeterc, B. Zipserb, S. Pauenc a

Ludwig-Maximilians University, Department of Psychology, Munich, Germany Heidelberg University Hospital, General Psychiatry, Heidelberg, Germany c University of Heidelberg, Department of Psychology, Heidelberg, Germany d Tilburg University, Department of Developmental Psychology, Netherlands b

AR TI CLE I NF O

AB S T R A CT

Keywords: Infant development Anxiety disorder in the postpartum period Mother-infant interaction Maternal avoidance behaviour Maternal neutral engagement

Background: Few studies have examined the relation between anxiety disorders in the postpartum period and cognitive as well as language development in infancy. Aims: This longitudinal study investigated whether anxiety disorder in the postpartum period is linked to infant development at twelve months. A closer look was also taken at a possible link between maternal interaction and infant development. Study design: Subjects were videotaped during a Face-to-Face-Still-Face interaction with their infant (M = 4.0 months). Specific maternal anxiety symptoms were measured by self-report questionnaires (Anxiety Cognition Questionnaire (ACQ), Body Sensations Questionnaire (BSQ), Mobility Inventory (MI)) to check for a connection with infant development. The Bayley Scales of Infant and Toddler Development-III (Bayley-III) were used to assess infant language and cognitive development at one year of age. Subjects: n = 34 mothers with anxiety disorder (SCID-I; DSM-IV) and n = 47 healthy mothers with their infant. Outcome measures: Infant performance on Bayley-III language and cognitive scales. Results: Infants of mothers with anxiety disorder yielded significantly lower language scores than infants of controls. No significant group differences were found regarding infant cognitive development. Exploratory analyses revealed the vital role of “maternal avoidance accompanied” in infant language and cognitive development. Maternal neutral engagement, which lacks positive affect and vocalisations, turned out as the strongest negative predictor of cognitive development. Maternal anxiety cognitions and joint activity in mother-infant interaction were the strongest predictors of infant language performance. Conclusions: Results underline the importance to also consider the interaction behaviour of women with anxiety disorders to prevent adverse infant development.

⁎ Corresponding author at: Ludwig-Maximilians University Munich, Department of Psychology, Clinical Psychology of Childhood and Adolescence, Leopold Str. 13, 80802 Munich, Germany. E-mail address: [email protected] (C. Reck). 1 Shared first authorship.

https://doi.org/10.1016/j.infbeh.2017.11.007 Received 18 August 2017; Received in revised form 21 November 2017; Accepted 21 November 2017 0163-6383/ © 2017 Published by Elsevier Inc.

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1. Introduction In the first year of life, infants develop substantial motor, cognitive, language and socio-emotional skills. The increasing understanding of environmental influences on the neuroplasticity of the young brain stresses the significance of a stimulating environment for optimal child development (Kingston, Tough, & Whitfield, 2012). Exposing infants to a variety of beneficial and ageappropriate stimuli provides an excellent starting point for the developing child (Bornstein & Lamb, 2002; Csibra & Gergely, 2009; Pauen, 2006). Some factors of the immediate environment may be less beneficial for infant development though, e.g. maternal distress or mental health problems. The detrimental effect of maternal depression after child birth on emotional, behavioural, cognitive and language development in infant- and childhood is well-documented (Cornish et al., 2005; Galler, Harrison, Ramsey, Forde, & Butler, 2000; Grace, Evindar, & Stewart, 2003; Murray & Cooper, 1996, 1997; Sohr-Preston & Scaramella, 2006). The prevalence of anxiety disorders in the postpartum period, ranging from approximately 8% (Austin et al., 2010; Goodman, Watson, & Stubbs, 2016; Wenzel, Haugen, Jackson, & Brendle, 2005) to 12.7% (Reck et al., 2008), is comparable to the rates of postpartum depression (Beck & Gable, 2001; Reck et al., 2008; Yonkers et al., 2001); yet, the potential link between anxiety disorder in the postpartum period and infant development has hardly been subject of investigation. The limited research available focused particularly on possible socio-emotional disadvantages in the offspring of women with anxiety disorders (Feldman et al., 2009; Leis, Heron, Stuart, & Mendelson, 2014; Murray, Cooper, Creswell, Schofield, & Sack, 2007; Reck, Müller, Tietz, & Moehler, 2013). To the best of the authors’ knowledge, fewer studies have been dedicated to infant cognitive and language development. The published research in this regard investigated mostly the cognitive and language skills of young children of women with prepartum anxiety disorders (for an overview, Schlotz & Philips, 2009; Stein et al., 2014). These findings are inconsistent, but a vast amount of studies suggested that maternal anxiety in pregnancy is associated with lower cognitive and language development scores in childhood (Brouwers, van Baar, & Pop, 2001; Buitelaar, Huizink, Mulder, de Medina, & Visser, 2003; Davis & Sandman, 2010; Huizink, Robles de Medina, Mulder, & Buitelaar, 2003; King & Laplante, 2005; Laplante et al., 2004; for a review, Van den Bergh, Mulder, Mennes, & Glover, 2005) and adolescence (Mennes, Stiers, Lagae & Van den Bergh, 2006; Mennes, Van den Bergh, Lagae & Stiers, 2009; Van den Bergh, Mennes et al., 2005; Van den Bergh et al., 2006). The findings regarding prepartum anxiety disorders are relevant for the presented study because most women with anxiety disorders in the postpartum period report a prepartum onset of anxiety disorders (Reck et al., 2008; Martini, Weidner, & Hoyer, 2008; Matthey, Barnett, Howie, & Kavanagh, 2003). Although less is known about the potential effects of anxiety disorders in the postpartum period on infants' cognitive and language competencies, there is some empirical evidence that children of postpartum anxious women perform worse on cognitive tasks than those of healthy mothers (for an overview, Glasheen, Richardson, & Fabio, 2010). For example, maternal anxiety and feelings of despair six months postpartum predicted lower scores in a national high school examination at eleven to twelve years of age in the offspring of anxious women (Galler et al., 2004). However, according to Keim and colleagues, maternal trait anxiety and stress level had no significant negative influence on the cognitive development of infants at one year of age (Keim et al., 2011). Furthermore, maternal mental health problems comprising also maternal anxiety had negligible effect on infants' communication performance at eight or twelve months of age (Reilly et al., 2006). Regarding the inconsistent findings on the effects of prepartum and postpartum anxiety disorders on infant cognitive and language development, more research is clearly needed; especially because cognitive and language competencies are crucial for more advanced skills like communication, learning and problem solving. If anxiety disorder in the postpartum period should be linked to less optimal infant development, the question arises through which pathway. Maternal anxiety disorder itself might have an influence on the emerging infant cognitive and language skills. A closer look at the different facets of an anxious symptomatology would clarify if only certain symptoms are detrimental or if an anxiety disorder per se bears a developmental risk for the infant. Another aspect worth considering is the quality of maternal interaction behaviour as the mother usually represents the primary caregiver and largely guides the infant’s experience with the social and non-social world (Csibra & Gergely, 2009; Murray, Kempton, Woolgar, & Hooper, 1993; Papoušek, 2007; Tamis-LeMonda, Bornstein, & Baumwell, 2001). The notion that the mother-infant interaction is as an important source of social learning is supported by numerous findings. First, disturbances in early mother-infant interaction were predictive of poorer infant cognitive outcome at 18 months (for an overview, Murray & Cooper, 1996). Second, research investigating the effects of prolonged mother-infant centred interventions suggested that cognitive and language disadvantages in young children of women with postpartum depression may be counterbalanced by mother-toddler therapy (Cicchetti, Rogosch & Toth, 2000). It has been argued that maternal distress and psychological disorders could compromise mother-infant interaction, which, in turn, might affect infant mental and language skills (Feldman & Eidelman, 2009). For instance, postpartum depressed mother-infant dyads showed altered interactive contingency patterns than control dyads (Beebe et al., 2012). Self-consistency of both partners was lowered along with higher depressive symptoms whereas interactive contingency deviated from an optimal mid-range. In addition, mothers with postpartum depression were less responsive and contingent as well as more withdrawn and intrusive when interacting with their infant compared to controls (Field, Healy, Goldstein, & Guthertz, 1990; Murray & Cooper, 1996; Murray, Fiori-Cowley, Hooper, & Cooper, 1996; Reck et al., 2001). Such interaction styles were associated with various infant emotional and behavioural problems like emotional dysregulation and less efficient processing of contingent relationships (Beebe et al., 2008; Stanley, Murray, & Stein, 2004; Tronick, 1989). This, in turn, has been related to poorer cognitive and emotional functioning in childhood (e.g., Milgrom, Westley, & Gemmill, 2004; Morrell & Murray, 2003; Murray et al., 1993). With regard to maternal depression, it has been demonstrated that impaired infant developmental trajectories were mediated by dysfunctional mother-infant interactions (Edwards & Hans, 2015; Foster, Garber, & Durlak, 2008). Studies dedicated to mother-infant interaction in case of postpartum anxiety disorder are sparse but some have linked maternal 117

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anxiety to intrusive, angry and controlling parenting as well as to lower maternal self-efficacy (Adam, Gunnar, & Tanaka, 2004; Bögels & Brechman-Toussaint, 2006; Creswell, Apetroaia, Murray, & Cooper, 2013; Van der Bruggen, Stams & Bögels, 2008; Reck, Noe, Gerstenlauer, & Stehle, 2012). Crugnola et al. (2016) found that maternal anxiety was an even stronger predictor of less adapted mother-infant patterns, such as negative affective-behavioural matching states, than maternal depression. Maternal directive interaction styles at twelve months of infant age have been related to poorer receptive language skills at the age of two (Murray & Hornbaker, 1997), whereas a facilitative interaction mode, characterised by sensitivity and elaborateness, in which the mother follows the toddler’s focus of attention, demonstrated a positive impact on the cognitive development of toddlers (Murray & Hornbaker, 1997; Treyvaud et al., 2009). The latter is a connection that has been demonstrated in many research efforts (Murray, Hipwell, Hooper, Stein, & Cooper, 1996; Lemelin, Tarabulsy, & Provost, 2006; Page, Wilhelm, Gamble, & Card, 2010). While some studies suggested that mothers with postpartum anxiety disorder are less sensitive (Feldman et al., 2009; Feldman, Greenbaum, Mayes, & Erlich, 1997; Warren et al., 2003), which is reflected in fewer warm, affectionate and positive interactive behaviour, others could not find deficits in this regard (Murray et al., 2007; Weinberg, Beeghly, Olson, & Tronick, 2008; Kaitz, Maytal, Devor, Bergman, & Mankuta, 2010). Until now, hardly any study has examined the possible interplay of anxiety disorder after child birth, mother-infant interaction and infant language as well as cognitive development. A greater understanding of potential interconnections would allow designing prevention and intervention strategies customised to the specific needs of anxious women and their children from early age on (Kingston et al., 2012). Therefore, we aimed to investigate if anxiety disorder in the postpartum period is associated with infant cognitive and language skills at twelve months of age and if specific interactive behaviours play a mediating role in this relationship. The first set of confirmatory analyses compares the language and cognitive development of infants of healthy mothers to infants of mothers with current DSM-IV anxiety disorder (Saß, Wittchen, & Zaudig, 1994). In accordance with the majority of studies dealing with pre- and postpartum anxiety, infants of mothers with anxiety disorder in the postpartum period are expected to yield lower scores in cognitive and language tests than infants of healthy controls. The second part of the study deals with the role of specific anxiety symptoms (Agoraphobic Cognitions Questionnaire, ACQ; Body Sensations Questionnaire, BSQ; Mobility Inventory, MI: MIA/MIB; Ehlers, Margraf, & Chambless, 2001) and micro-analytically coded interactive behaviours (German revision of the Infant and Caregiver Engagement Phases; Reck, Noe, Cenciotti, Tronick, & Weinberg, 2009) in infant language and cognitive development. In line with the confirmatory analyses, we expected that specific anxiety symptoms would be negatively associated with infant developmental outcomes and, thus, would mediate the effects of maternal anxiety disorders on infant development. Consistent with prior studies on maternal depression, we further assumed interactive behaviours to mediate the association between maternal anxiety disorder and infant language and cognitive development. However, to the best of the authors’ knowledge, no empirical data is available about an association between such micro-analytical behavioural markers and infant language and cognitive development in the context of maternal anxiety disorders. Although macro-analytical scales of the quality of mother-infant interaction, like maternal sensitivity, seem crucial for infant development in various domains (e.g., DiCorcia & Tronick, 2011), very little is known about the underlying micro-analytical mechanisms (Mesman, 2010). To date, it is difficult to assess which micro-analytical behavioural markers indicate sensitivity. Thus, the second set of the presented analyses is exploratory without specific hypotheses. The current study contributes to previous research by two means. First, the confirmatory analyses of the presented research provide additional empirical data about possible impacts of maternal anxiety disorder on infant development. Second, the results of the exploratory analyses may serve as a starting point for further investigations of micro-analytical interaction processes regarding anxiety disorders in the postpartum period. The gained insights can then be used to design early preventive therapeutic interventions (Downing, Wortmann-Fleischer, Einsiedel, Jordan, & Reck, 2014; Reck et al., 2004). 2. Method 2.1. Participants Participants took part in a longitudinal study dealing with anxiety disorder in the postpartum period, mother-infant interaction and infant development. Subjects were recruited between June 2006 and October 2010 in a German town by means of flyers, newspaper advertisements and public birth announcements. Women were also recruited from the General Psychiatry or the University Women’s Hospital. Approval of the study was obtained from the Medical Ethical Committee of the University. Initially, N = 122 women were recruited. The presented data refer to the first assessment at an average age of four months (mother-infant interaction, diagnostic interview) and the third and final assessment with one year of age (child development). The clinical group had to meet the criteria for a diagnosis of anxiety disorder according to DSM-IV (Saß et al., 1994). The diagnosis was based on a full version of the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I) (Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997). All DSM-IV anxiety disorders were considered: panic disorder, panic disorder with agoraphobia, agoraphobia without history of panic disorder, generalized anxiety disorder, social phobia, obsessive compulsive disorder, posttraumatic stress disorder, anxiety disorder not otherwise specified and specific phobias; yet, a mere diagnosis of specific phobia was not sufficient to be classified as a clinical subject due to its relatively low clinical relevance for everyday functioning. Women with a lifetime diagnosis of psychosis and bipolar disorder were not eligible to participate in the remaining assessments. n = 14 women dropped out due to this criterion. To rule out a confounding effect of comorbid disorders in the clinical group, we excluded any women with other current comorbid Axis-I disorders than anxiety disorder (n = 2 women were excluded because of a comorbid major depressive episode). Healthy controls needed to have no current or lifetime SCID-I diagnosis and should not have received 118

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Fig. 1. Study-drop-outs and case-exclusions.

psychotherapy at any time of their life. All infants were healthy and had a gestational age at birth of no less than 37 weeks. The Bayley assessments of n = 25 infants were missing due to study drop-out. The main reasons for not participating were time restrictions, no-show or not being available by phone. The study drop-outs and exclusions are demonstrated in Fig. 1. The final sample (N = 81) is comprised of n = 34 Caucasian women with anxiety disorder and n = 47 Caucasian healthy women without current or previous mental health disorders, each with their infant.

2.2. Procedure At the first assessment at three to eight months postpartum (for full demographic statistics see Table 1), the mother-infant interaction was assessed at the video laboratory. After an initial settling-in period and overview of the procedures, the Face-to-Face119

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Table 1 Descriptives of subgroups and tests on comparability.

Maternal age (years) Infant age at study entry (months) Infant age at developmental test (months)

Overall M (SD)

Control M (SD)

Anxiety M (SD)

t (p)

Female M (SD)

Male M (SD)

t (p)

32.9 (5.3) 4.0 (1.4) 12.0 (0.1)

33.4 (5.4) 4.0 (1.5) 12.0 (0.3)

32.1 (5.2) 4.1 (1.3) 12.0 (1.0)

1.08 (.29) 0.10 (.92) 0.38 (.70)

33.1 (5.1) 4.2 (1.5) 12.0 (0.9)

32.5 (5.8) 3.8 (1.3) 12.0 (0.5)

0.51 (.61) 0.92 (.36) 0.10 (.92)

Maternal education

Overall f (%)

Control f (%)

Anxiety f (%)

U (p)

Female f (%)

Male f (%)

U (p)

University degree University entrance qualification High secondary qualification Low secondary qualification

43 (53.1) 20 (24.7) 13 (16.0) 5 (6.2)

26 (55.4) 12 (25.5) 8 (17.0) 1 (2.1)

17 (50.0) 8 (23.5) 5 (14.7) 4 (11.8)

725.0 (.44)

27 (51.9) 12 (23.1) 10 (19.2) 3 (5.8)

16 (55.2) 8 (27.6) 3 (10.3) 2 (6.9)

713.0 (.67)

Number of children

Overall f (%)

Control f (%)

Anxiety f (%)

U (p)

Female f (%)

Male f (%)

U (p)

One child Two children Three children

49 (60.5) 26 (32.1) 6 (7.4)

26 (55.3) 16 (34.0) 5 (10.7)

23 (67.7) 10 (29.4) 1 (2.9)

683.5 (.20)

37 (71.1) 12 (23.1) 3 (5.8)

12 (41.4) 14 (48.3) 3 (10.3)

532.5 (.01)

Social status

Overall f (%)

Control f (%)

Anxiety f (%)

χ2 (p)

Female f (%)

Male f (%)

χ2 (p)

Not married Married

21 (27.3) 56 (72.7)

10 (22.7) 34 (77.3)

11 (33.3) 22 (66.6)

1.07a (.30)

13 (25.5) 38 (74.5)

8 (30.7) 18 (69.2)

0.24b (.62)

Infant gender

Overall f (%)

Control f (%)

Anxiety f (%)

χ2 (p)

Female f (%)

Male f (%)

χ2 (p)

Female infants Male infants

52 (64.2) 29 (35.8)

29 (61.7) 18 (38.3)

23 (67.6) 11 (32.4)

0.30c (.58)

/ /

/ /

/

a b c

0 cells have expected count less than 5, minimum expected count is 9.00. 0 cells have expected count less than 5, minimum expected count is 7.09. 0 cells have expected count less than 5, minimum expected count is 12.17.

Still-Face (FFSF) experiment (Adamson & Frick, 2003; Mesman, van IJzendoorn, & Bakermans-Kranenburg, 2009; Provenzi, Giusti, & Montirosso, 2016; Tronick, Als, Adamson, Wise, & Brazelton, 1978) was conducted. For the face-to-face procedure, the child was secured in an infant seat vis-à-vis to his/her mother. The FFSF assessment procedure comprised three phases of two minutes each. It started with a face-to-face baseline interaction in which the mother was instructed to play with her infant as she always does but without the aid of toys and a pacifier. After two minutes, the mother turned her head aside while counting quietly to ten. A still-face episode then took place in which the mother was required not to engage in any mimic or gestural manner but to simply look across the infant without talking (so called “still-face”). The procedure concluded with a reunion phase in which the mother resumes the face-to-face play with her infant. The FFSF paradigm assesses how mother-infant dyads manage emotionally stressful situations by means of the still-face episode, a sudden interruption of the normal interaction by the mother. Such maternal non-responsiveness creates a prolonged state of interactive mismatch and represents an interactive stressor to the child (Cohn & Tronick, 1989), causing considerable alterations of the infant’s affective and self-regulatory behaviour (also known as the “still-face effect”; Field, Vega-Lahr, Goldstein, & Scafidi, 1987; Haley & Stansbury, 2003; Mayes & Carter, 1990; Weinberg & Tronick, 1996). In the reunion episode of the FFSF, mother and infant are faced with the challenge of re-establishing interactive coordination (e.g., Weinberg & Tronick, 1996). The dyadic adaption process called interactive repair, especially in the reunion episode, has recently been found to be beneficial for infant stress-regulation assessed with salivary cortisol (Müller, Zietlow, Tronick, & Reck, 2015). The clear advantage of the FFSF paradigm is its standardised procedure. Moreover, the reunion episode is particularly informative about dyadic affect regulations skills. After the FFSF, a full version of the SCID-I (Wittchen et al., 1997) was carried out for a classification as a healthy or anxious mother. In the end, a set of questionnaires covering specific aspects of an anxious symptomatology was handed out to the mother. At twelve months postpartum, the Bayley Scales of Infant and Toddler Development-III (Bayley, 2006) were used to assess child development.

2.3. Instruments 2.3.1. Assessment of maternal anxiety in the postpartum period 2.3.1.1. Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I). Maternal anxiety and comorbid as well as a history of other Axis-I mental disorders were assessed with the German version of the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I; Wittchen et al., 1997). The SCID-I is a widely used semi-structured interview for the diagnosis of Axis-I disorders. The authors of the German version evaluated the psychometric properties regarding reliability, applicability and efficacy as satisfying. 120

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2.3.1.2. Assessment of anxiety symptoms 2.3.1.2.1. Agoraphobic Cognitions Questionnaire (ACQ), Body Sensations Questionnaire (BSQ) and the Mobility Inventory (MI: MIA/ MIB). The German revised editions of the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ) and the Mobility Inventory (MI) were chosen to assess some chore symptoms of anxiety disorders (Ehlers et al., 2001). The combination of three self-report questionnaires gives a differential picture of anxiety cognitions, physical symptoms and avoidance behaviour. The ACQ, consisting of 14 questions, assesses the frequency of typical anxiety cognitions with scales ranging from 1 (“thought never occurs”) to 5 (“thought always occurs when I am nervous‘). The BSQ with 17 items measures the extent of fear of anxiety related physical symptoms on a five-point Likert scale with 1 (“not frightened or worried by this sensation’) to 5 (‘extremely frightened by this sensation’). Moreover, the MI with a total of 27 items describes the predominant agoraphobic situations and the avoidance of such situations. The authors argue that it also indicates the severity of the anxious symptomatology. The MI is subdivided into the Mobility Inventory Alone (MIA) and the Mobility Inventory Backened (MIB; i.e. accompanied by a person trusted). Whereas the former assesses the extent of avoidant behaviour when unaccompanied, the latter assesses the degree of avoidant behaviour when accompanied by a person trusted, each on a five-point scale ranging from 1 (“never avoid”) to 5 (“always avoid”). The internal consistency ranging from Cronbach’s α = 0.88 (ACQ) to 0.95 (MIA and MIB; BSQ = 0.92) in our sample was comparable to that reported by Ehlers et al. (2001) and can, thus, be evaluated as good to excellent. 2.3.2. Coding of mother-infant interactions Infants’ and mothers’ behaviour during the FFSF was coded by two trained and reliable coders using the German translation and revision of the micro-analytical Infant and Caregiver Engagement Phases (ICEP-R; Reck et al., 2009). The coders were blind to the hypotheses of the study and the maternal psychiatric status. ICEP-R phases combine information from the infant’s and caregiver’s (in this case, the mother’s) face, direction of gaze and vocalisations. A description of the ICEP-R engagement phases can be found in Appendix B. We coded the video tapes using the Noldus Observer Video-Pro® coding system with one second time intervals. 31% of the videotapes (n = 28 dyads of N = 90 videotapes) were randomly selected and coded by two independent study coders. Both coders were not aware which videos were used for assessing coding reliability. In accordance with other studies (Reck et al., 2011; Montirosso et al., 2015) we used Cohen’s κ (Cohen, 1960) to compute inter-rater reliability. It was κ = 0.73 for the infant codes and κ = 0.78 for the maternal codes. Thus, the inter-rater reliability of our study coders is comparable to those reported in previous studies (Reck et al., 2011; Montirosso et al., 2015). We decided to focus on the reunion episode of the FFSF paradigm, as this phase is particularly informative about interactive regulatory processes because it follows the stress inducing still-face episode (Weinberg & Tronick, 1996). The relative time duration of infant and caregiver interactive behaviour as well as of dyadic engagement during the FFSF reunion episode was calculated as follows: the sum of seconds in which infant, caregiver or the dyad engages in each ICEP-R category divided by the total duration of the reunion episode. For descriptive results, the relative time duration was multiplied with 100%. Because maternal non-infant focused engagement, withdrawal, hostility and infant withdrawal occurred too rarely in the given sample (on average below 1.0% in all phases), we refrained from describing and analysing these codes. Participants generally maintained a still-face during the second phase of the FFSF: ICEP-codes were given for less than 0.2% of time. The descriptive statistics of interactive measures are demonstrated in Appendix A. 2.3.3. Infant development 2.3.3.1. Bayley Scales of Infant and Toddler Development-III. The Bayley Scales of Infant and Toddler Development-III (Bayley-III; Bayley, 2006) assess the development of infants and toddlers between one and 42 months of age. The test battery covers the domains of cognition, language, motor, social-emotional and adaptive development. Whereas the first three aspects are assessed by means of behavioural observation, the latter two areas are measured with questionnaires. The overall duration of the Bayley-III is usually between 50 and 90 min (Albers & Grieve, 2007). The investigators of this study were blind to the mother’s mental health status. The test battery consists of five IQ-scaled composite scores. Firstly, the Cognitive Scale, comprising in total 91 items (the number of measured items depends on infant age), assesses sensori-motor development, exploration and manipulation, object relatedness, concept formation and memory. Secondly, the Language Scale is composed of the two subscales receptive and expressive communication. While the former tests pre-verbal behaviour, vocabulary development, understanding of morphological markers, social referencing and verbal comprehension with 49 items, the expressive communication measures pre-verbal communication, vocabulary development and morpho-syntactic development with a total of 48 items. In addition, the Bayley Scales include a Gross- and Fine-Motor Scale, a Social-Emotional Scale, and an Adaptive Behaviour Scale. In this study, we focused on the language and cognitive composite scores because of the rather small sample size. Moreover, as the authors wished to focus on infant development that can be assessed by an objective rater, it seemed reasonable to not include maternal assessment of socio-emotional and adaptive behaviour. The Bayley-III normative data was generated from a sample of 1700 children aged 16 days to 42 months born in the United States of America, and was stratified by age, sex, ethnicity, parental education level and geographic region. The Bayley-III indices and subscales demonstrate good internal consistency. The Bayley-III indices and subscales demonstrate good split-half-consistency according to the Spearman-Brown formula (Albers & Grieve, 2007). The average reliability coefficient for the scales was r = 0.94 or greater and average stability coefficients were r = 0.80 or greater across all ages. Regarding construct validity, confirmatory factor analysis of the subtests of the Cognitive, Language, and Motor scales supported a three-factor model across all ages. The Bayley-III scales have been normed for German infants and children. 121

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2.4. Data analysis We used the Statistical Package for Social Sciences (IBM® SPSS® v. 24.0.0.0) for all analyses conducted in this study. Power analyses were computed using G-Power v. 3.1.9.2 (Faul, Erdfelder, Buchner, & Lang, 2009; Faul, Erdfelder, Lang, & Buchner, 2007). To assure that the procedure of list-wise case-exclusions was valid for our data set, we used Little’s MCAR-test (Little, 1988). This test evaluates if the missing-completely-at-random-condition (MCAR) is fulfilled. If not significant, differences between the excluded cases and the remaining sample are unlikely. In addition, missing values are unlikely to depend on third variables. For the MCAR-test, we considered the following variables: maternal age and education, marital status, number of children, infant age and sex, gestation age, APGAR values, diagnostic group, specific anxiety symptoms, infant development (Bayley-III) and interaction data (ICEP-R). Furthermore, differences concerning maternal age and education, infant age and sex, number of children and marital status between controls and their clinical counterparts and between males and females were explored (via t-tests, U-tests and χ2-tests) to ensure comparability between the groups. For the main analyses, main effects of group and infant sex and their interaction effect on infant development were tested by twoway ANOVAs. α-errors of the two confirmative analyses were Holm-Bonferroni-adjusted (i.e. α = 0.025 for the first and α = 0.05 for the second ANOVA). The confirmatory results are presented according to this procedure. Trends are not interpreted. Effect sizes are reported as partial η2 which is a sample-based estimator of explained variance (multiplied by 100%). According to Cohen (1988), η2 = 0.01 are small, η2 = 0.06 are medium-sized and η2 = 0.14 are large effects. In the first step of the additional analyses, we correlated diagnostic status and anxiety symptoms with data of mother-infant interaction and infant development to find variables possibly mediating a link between maternal anxiety and infant development. Mediation analyses were conducted according to conditional process analyses − a regression based approach – using the SPSS®Makro “PROCESS” (v. 2.16; Hayes, 2013) in a second step. The standard errors and 95% confidence intervals (CI) of the indirect (mediated) effects are bootstrapped and bias-corrected (N = 5000 samples). Variables were mean-centred for product terms. In a third step, multiple linear backward regressions were used to evaluate the most predictive variables for infant development in the current data set. The backward procedure was chosen since forward regressions bear the risk of not accounting independent variables with small but meaningful effects. In backward regression, variables are eliminated if their elimination does not significantly change the explanative value (R2) of the model. For all additional analyses, empirical p-values are two-tailed (critical α = 0.05) and were not adjusted. Thus, these results are explorative due to accumulation of α-errors. 3. Results 3.1. Preliminary data analyses and sample characteristics The MCAR-test turned out to be non-significant (χ2 = 971.73, df = 993, p = 0.68), i.e. list- and pairwise case-exclusions were valid for our sample, missing values did not depend on third variables and the sub-population is representative for the larger sample. Complete group statistics are demonstrated in Table 1. Within the overall sample, the age of women ranged from 22 to 45 years. More than two thirds of the sample were married. Regarding maternal education level, participants predominantly qualified for university entrance or held a university degree. More than half of the women had one child including the index infant, while almost one third had two children. Infants had a mean age of 4 months at the first assessment and 12 months at the second assessment. More than half of the infants were female. Of the n = 34 women of the clinical sample, n = 20 women suffered from more than one DSM-IV anxiety disorder. n = 20 women had a generalized anxiety disorder. n = 17 women were diagnosed with a panic disorder with or without agoraphobia or an agoraphobia without history of panic disorder, n = 14 women had an obsessive-compulsive disorder. n = 6 women were diagnosed with social phobia, while n = 1 woman suffered from post-traumatic stress disorder and n = 2 were diagnosed with an anxiety disorder not otherwise specified. Of the n = 34 women, n = 21 retrospectively reported an onset of anxiety disorder prior to pregnancy, while n = 7 mentioned an onset during pregnancy. n = 5 women had a postpartum onset of anxiety disorder. Even though most women had a prepartum onset, each participant fulfilled the criteria for anxiety disorder three months postpartum. There was no effect of group or infant sex on maternal age, infant age, maternal education or marital status (for group comparisons see Table 1). Additionally, the male-to-female sex ratio did not differ between the infants of the clinical and the control group. Only number of children differed significantly between families with female infants and those with male infants: more precisely, women with a male study infant had fewer children than women with a female study infant. Consequently, ANOVAs were adjusted for number of children. The language composite scores of n = 5 infants were missing. To assure that missing data did not skew the results in the data subset, an additional Little’s MCAR-test was run in the final sample which turned out as non-significant (χ2 = 609.80, df = 644, p = 0.83). 3.2. Main analyses 3.2.1. Language development Anxiety disorder had a significant effect on infant language development (F1,71 = 9.21, p < 0.01, η2 = 0.115). Infants of mothers with anxiety disorder scored significantly lower on language development (M = 89.97, SD = 8.20) than infants of controls (M = 96.56, SD = 9.31). There was no effect of infant sex (F1,71 = 9.21, p = 0.07) or number of children (F1,71 = 0.58, p = 0.45). No interaction effect between diagnosis and infant sex was found (F1,71 = 0.27, p = 0.61). The power to find a large effect (f = 0.40) in 122

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this analysis was 1-β = 0.93. The power for medium-sized effects (f = 0.25) was 1-β = 0.58 and 1-β = 0.14 for small effects (f = 0.10). There were n = 2 infants in the control group and n = 7 infants in the clinical group scoring below one SD off the mean. 3.2.2. Cognitive development The mean score of control infants (M = 105.4, SD = 8.7) and infants of the clinical sample (M = 101.6, SD = 9.6) did not differ significantly (F1,76 = 1.64, p = 0.21). Furthermore, no effect of infant sex (F1,76 = 0.42, p = 0.52) or number of children (F1,76 = 0.16, p = 0.69) was found. The interaction term “diagnosis x infant sex” was also non-significant (F1,76 = 2.46, p = 0.12). The power to find a large effect (f = 0.40) in this analysis was 1-β = 0.94. The power for medium-sized effects (f = 0.25) was 1β = 0.60 and 1-β = 0.14 for small effects (f = 0.10). There was no infant scoring below one SD off the mean. 3.3. Additional analyses 3.3.1. Correlational analyses The language composite score was associated with each subscale assessing specific anxiety symptoms except avoidance behaviour alone (MIA) (ACQ: r = −0.358, p = 0.004; BSQ: r = −0.318, p = 0.012; MIB: r = −0.323, p = 0.016). Joint activity/looking was the only interactive variable correlating with infant language development (r = 0.288, p = 0.023). Maternal diagnostic status was not associated with any interactional data but with each scale of anxiety symptoms (ACQ: r = 0.647, p < 0.001; BSQ: r = 0.604, p < 0.001; MIA: r = 0.467, p < 0.001; MIB: r = 0.411, p = 0.001), suggesting anxiety symptoms may potentially mediate the association between maternal anxiety disorder and infant language development. Cognitive development was associated with avoidance behaviour accompanied by a person trusted (MIB: r = −0.263, p = 0.042), maternal positive engagement (r = 0.271, p = 0.026) and maternal neutral engagement (ρ = −0.294, p = 0.016). Maternal positive engagement was the only interactive variable that was additionally associated with anxiety symptoms, i.e. avoidance behaviour accompanied by a person trusted (MIB: r = −0.289, p = 0.029), implying that maternal positive engagement may be regarded as a potential mediator between maternal avoidance behaviour accompanied by a person trusted (MIB) and infant cognitive development. 3.3.2. Language composite score Additional analyses tested whether the effect of maternal anxiety disorder on infant language development was mediated by specific anxiety symptoms. Firstly, there was a significant total effect of maternal anxiety disorder on infant language development (B = −7.826, S.E. = 2.555, t = −3.063, p = 0.003, CI = [−12.951;−2.701]). Secondly, there was a significant direct effect of anxiety disorder on infant language development (B = −6.227, S.E. = 2.745, t = −2.268, p = 0.028, CI = [−11.735;−0.719]). However, besides this effect, the association between anxiety disorder and infant language development was partly mediated by avoidance behaviour accompanied by a person trusted (MIB) (B = −1.599, S.E. = 0.794, CI = [−3.348;−0.469]). Approximately 7% (R2 = 0.070, S.E. = 0.034, CI = [0.017;0.143]) of the variance in infant language development can be explained by this mediation. None of the models revealed significant mediation effects of anxiety cognitions (ACQ) or physical symptoms (BSQ). However, a backward regression procedure with specific anxiety symptoms and joint activity/looking in mother-infant interaction as predictors revealed maternal anxiety cognitions (ACQ) and joint activity/looking as the strongest predictors of infant language development (see Table 2 and Fig. 2). 3.3.3. Cognitive composite score We tested whether the association of maternal avoidance behaviour accompanied by a person trusted (MIB) on infant cognitive development was mediated by maternal positive engagement. Firstly, there was a significant total effect of maternal avoidance behaviour accompanied by a person trusted (MIB) on infant cognitive development (B = −8.507, S.E. = 3.954, t = −2.151, p = 0.036, CI = [−16.431;−0.583]). Secondly, there was no significant direct effect of avoidance behaviour accompanied by a person trusted (MIB) on infant cognitive development (B = −6.107, S.E. = 4.013, t = −1.522, p = 0.134, CI = [−14.153;1.939]). The association between avoidance behaviour accompanied by a person trusted (MIB) and infant cognitive development was Table 2 Stepwise backward regression of specific anxiety symptoms and interactional variables on the language composite score.

Step I

Step II

Step III

a b

Parameter

B (unstandardized)

SE

Lower CI bound (95%)

Upper CI bound (95%)

t

p(two-tailed)

R2 (pa)

Anxiety cognitions Body sensations Avoidance behaviourb Shared attention Anxiety cognitions Body sensations Shared attention Anxiety cognitions Shared attention

−4.016 −1.766 −2.825 50.134 −5.492 −1.859 −50.512 −7.565 50.392

5.132 2.599 6.099 23.865 3.992 2.572 23.666 2.765 23.557

−14.325 −6.987 −15.075 −2.201 −13.507 −7.022 −3.000 −13.113 3.122

6.292 3.455 9.425 98.067 2.522 3.304 98.024 −2.017 97.662

−0.783 −0.679 −0.463 2.101 −1.376 −0.723 2.134 −2.736 2.139

0.438 0.500 0.645 0.041 0.175 0.473 0.038 0.008 0.037

0.210 (0.017)

Omnibus ANOVA. Avoidance behaviour (accompanied).

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0.206 (0.008)

0.198 (< 0.003)

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Fig. 2. Scatter-plot between language composite score and values predicted by multiple regression onto anxiety cognitions and shared attention.

completely mediated by maternal positive engagement (B = −2.400, S.E. = 1.732, CI = [−6.732;−0.208]). Approximately 4% (R2 = 0.041, S.E. = 0.026, CI = [0.002;.107]) of the variance in infant cognitive development can be explained by this mediation. However, a backward regression procedure with maternal neutral engagement as an additional predictor revealed neutral engagement to be the strongest predictors of infant cognitive development (see Table 3 and Fig. 3). 4. Discussion The overall aim of this study was to examine whether anxiety disorders in the postpartum period are connected to infant cognitive and language skills at one year of age. In accordance with our hypothesis, infants of mothers with anxiety disorder in the postpartum period achieved lower scores in language development than infants of healthy controls. Contrary to our expectations, no significant group differences were found regarding infant cognitive performance. A closer look at maternal interaction and anxiety symptoms further revealed the crucial role of maternal anxious avoidance in infant language and cognitive development. While maternal anxiety cognitions and joint activity in mother-infant interaction were revealed as the strongest predictors of infant language performance, neutral engagement of the mother turned out as the strongest negative predictor of infant cognitive performance at one year of age. Regarding language performance, it is important to mention that, on a descriptive level, more infants of the clinical group scored one standard deviation below the average score than infants of the control group. This finding suggests that maternal anxiety disorder may potentially affect infant language development within the scope of clinical relevance. However, the given frequencies were too low to test this distribution for statistical significance. 4.1. Maternal avoidance behaviour and infant development We expected that specific anxiety symptoms would be negatively associated with infant developmental outcomes and, thus, would mediate the effects of maternal anxiety disorders on infant development. This was only true to some extent for avoidance behaviour accompanied by a person trusted (MIB): the connection between infant language scores and maternal anxiety disorder was partially Table 3 Stepwise backward regression of maternal interactive variables on the cognitive composite score.

Model I Model II a

Parameter

B (unstandardized)

SE

Lower CI bound (95%)

Upper CI bound (95%)

t

p(two-tailed)

R2 (pa)

Positive engagement Neutral engagement Neutral engagement

10.796 −14.083 −18.439

7.219 7.931 7.446

−3.624 −29.926 −33.310

25.217 1.760 −3.567

1.496 −1.776 −2.476

0.140 0.081 0.016

0.117 (0.019)

Omnibus ANOVA.

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0.086 (0.016)

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Fig. 3. Scatter-plot of cognitive composite score regressed onto maternal neutral engagement.

mediated by avoidance behaviour accompanied by a person trusted. Thus, both, anxiety disorder and avoidance behaviour accompanied, seem to negatively influence infant language performance. Infant cognitive performance was also predicted by avoidance behaviour accompanied. The given findings raise the question why avoidance behaviour plays such a crucial role in infant development. Avoidance of threatening stimuli is a common symptom of most anxiety disorders. According to the authors of the Mobility Inventory (MI), avoidance indicates the severity of an anxious symptomatology (Ehlers et al., 2001). More precisely, the subscale MIB refers to the degree of anxious stimuli avoidance in company. Maternal avoidance behaviour when being accompanied by a person trusted may reflect how severely these women are affected by the anxiety disorder: they participate only in an apparently safe environment in which fearful stimuli are not easily encountered and the presence of a person trusted does not seem to reduce anxiety symptoms. Avoidance behaviour at such a scale is likely to interfere with everyday functioning of the mother. Such impairment surely causes additional distress, reinforcing maternal anxiety and avoidance, creating a less beneficial and stimulating environment for the infant. This might be reflected in poorer infant cognitive and language performance in the long run and should be studied in future research. Murray and colleagues argue that infants learn about the emotional significance of environmental stimuli by referring to other people (Murray et al., 2008). This notion is supported by research with socially phobic mothers and their infants: infant social avoidance was predicted by expressed maternal anxiety as well as reduced maternal encouragement to interact with a stranger (Murray et al., 2007). De Rosnay and colleagues reported similar findings: infants who had followed a socially anxious interaction between their mother and a stranger were significantly more fearful and avoidant with this stranger than infants who had watched their mother interacting normally with a stranger (de Rosnay, Cooper, Tsigaras, & Murray, 2006). In the discussed empirical work, infants might refrain from the stranger because they noticed their mother’s anxiety and reluctance to interact with the unknown person. The same behavioural pattern may apply to infants of mothers with panic disorder, agoraphobia or specific phobia who avoid the respective anxiety provoking situation. On the contrary, infants' curiosity is enhanced by the supporting presence of an encouraging mother. This creates a secure base for the infant to explore the surrounding environment (Bornstein, Mash, Arterberry, & Manian, 2012), which, in turn, facilitates infant’s responses to stimuli by influencing possibilities for self-actions. Thereby, the infant’s sense of self-efficacy is strengthened, the feeling of being an active agent, which is of vital importance for later developmental outcomes (Bigelow, 1999). If anxious mothers should indeed be less encouraging, the infant may be less likely to explore her/his environment. Fewer successful handling of novel stimuli causes less feelings of mastery. Consequently, the infant’s self-efficacy is strengthened to a smaller extent which, in turn, could reduce infant explorative behaviour and response to environmental stimuli. Less frequent exposure and exploration of new stimuli is also associated with fewer occasions to experience habituation. Habituation speed increases with experience and is an important predictor of cognitive development (Kavšek, 2004; Ruddy & Bornstein,1982). Mothers who show avoidance of new stimuli may offer only limited opportunities to train habituation processes which might be associated with less optimal infant cognitive and language development. Furthermore, maternal avoidance behaviour has been linked to increased infant distress to novelty which correlated strongly with infant cortisol reactivity in a prior analysis of the current sample (Reck et al., 2013). The increased physiological arousal in infants of highly avoiding mothers might interfere with the learning capacity of the infants (Seehagen, Schneider, Rudolph, Ernst, & Zmyj, 2015). These notions should be addressed in future 125

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research as they have not been investigated in the presented study. Altogether, based on the gained insights, avoidance behaviour of the mother should be addressed in the treatment of anxiety disorders in the postpartum period. 4.2. Maternal interaction behaviour, maternal anxiety cognitions and infant language development Consistent with prior studies on maternal depression, we expected interactive behaviour to mediate the association between maternal anxiety disorder and language development. The exploratory analyses revealed that infant language development was predicted by joint activity of mother and infant during the FFSF procedure as well as maternal anxiety cognitions (ACQ). The latter finding is consistent with previous research dealing with women diagnosed with generalized anxiety disorder: maternal cognitions such as worry and rumination were associated with less maternal responsiveness to infant vocalization and less maternal vocalization (Stein et al., 2012). Anxiety cognitions may simply distract the mother; limiting her ability to focus on the infant's signals and to fully engage in interactive play and vocalization with her child. This could be linked to less optimal infant language competence in the long-term. According to the ICEP-R (Reck et al., 2009), infant and caregiver are jointly attending to the same object in “joint activity/ looking” engagement phase. Infant and mother are coordinating their gaze but are not looking at each other. The infant must be looking at the object, while the caregiver’s gaze may shift from infant to object. This code captures the infant’s perspective of a social interaction with the caregiver via an object. Joint activity differs from joint attention; the latter referring to a mental state which is usually achieved by children around nine months of age, where the child is able to mentally represent the object as well as the focus of attention of the interactive partner (Striano & Stahl, 2005). Regarding the predictive role of joint activity in infant language performance, the following could be assumed: Joint activity during mother-infant interaction is likely to be accompanied by conversations about the surrounding environment which presumably stimulate infant language skills. Future studies should investigate the made assumptions further. 4.3. Maternal interaction behaviour and infant cognitive development We assumed that interactive behaviour would mediate the association between maternal anxiety disorder and cognitive development. Infants of mothers with anxiety disorder did not differ from infants of controls regarding cognitive performance but the further explorative analyses of this study revealed that maternal positive engagement mediated the effect of maternal avoidance behaviour accompanied by a person trusted (MIB) on cognitive development. In other words, the more avoidance behaviour in company by the mother, the fewer maternal positive interaction engagement and, therefore, the lower the infant’s cognitive score. However, a backward regression revealed maternal neutral engagement as the strongest predictor of infant cognitive performance; that is, the more maternal neutral engagement, the lower the infant’s cognitive score at one year of age. The finding that maternal positive engagement is linked to maternal avoidance behaviour, and as consequence, to infant cognitive development, reflects the prominent role of mothers’ non-verbal as well as verbal positive behaviour in social interactions. The latter is characterised by expressed positive affect in the form of smiling, laughing and vocalizing (baby talk or singing). The expression of positive affect is viewed as an important aspect of maternal warmth and sensitivity as well as responsive and contingent parenting; aspects that have been linked to early child mental and language development (Bornstein & Tamis-LeMonda, 1989; Grant, McMahon, Reilly, & Austin, 2010; Landry, Swank, Assel, Smith, & Vellet, 2001; Lemelin et al., 2006; Pearson et al., 2011; Tamis-LeMonda et al., 2001). In a study by Cohn and Tronick (1989), infants’ affective expression was limited to neutral or negative displays, if the mother did not express positive emotions during interaction. The infants also became less involved with persons and objects around them. Moreover, increased parental positive affect and sensitivity were not only related to greater social-emotional competence but to more optimal cognitive developmental outcomes (Treyvaud et al., 2009). These findings altogether suggest that infant expression of emotion depends on the mother’s affect expression and stress the importance of positive affect for infant development. The negative link between maternal neutral engagement in early infancy and cognitive scores at twelve months of age may be explained by an insufficiently stimulating mother-infant interaction. The caregiver engagement phase “neutral engagement” refers to behaviour, where the caregiver is following the infant’s activity with interest while having neutral facial expressions (ICEP; Weinberg & Tronick, 1999; Reck et al., 2009). Neutral maternal engagement lacks the expression of positive affect and, thus, the already outlined benefits of the latter for infant development (Bornstein & Tamis-LeMonda, 1989; Grant et al., 2010; Lemelin et al., 2006; Pearson et al., 2011). A neutrally engaging mother who is passively following her infant's activities also does not engage much in interactive games and entertaining interactions. Furthermore, in neutral interaction the mother remains silent or makes use of adult speech without positive vocalisations. Verbal descriptions, explanations and encouragement of the mother, however, seem to play a predictive role in infant cognitive performance (Page et al., 2010). Within the first twelve months of life, mothers predominantly use baby talk, also known as infant-directed speech (Schneider, 2012), which is more effective in eliciting infant attention than adult speech (Cooper & Aslin, 1990). Baby talk with its distinct pronunciation, intonation and pauses promotes language comprehension and acquisition (Männel & Friederici, 2009). Moreover, it contains important information about the environment (Snow et al., 1976), enabling the infant to associate spoken words with specific objects. Overall, mothers who largely use adult speech when interacting with their infant provide only little age-appropriate verbal vocalisations which may, in turn, be less beneficial for the cognitive skills of their infants. In addition, a neutrally engaging mother gives only limited emotional cues to encourage infant language learning. These notions must be further examined in studies paying attention to maternal speech and infant development. It is important to mention that, unlike infant cognitive development, infant language performance was not related to maternal neutral interaction in the presented study. This may seem somewhat surprising. Future studies should take a closer look at infant language performance and 126

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maternal neutral interaction behaviour to clarify this matter. 4.4. Limitations To begin with, although typical for many clinical studies, our sample size was relatively small. Consequently, the validity of nullfindings (especially for small and medium-sized effects) cannot be fully evaluated. Insufficient power might apply to the missing group difference in infant cognitive performance, however, large effects of maternal anxiety disorder on infant cognitive development can be ruled out in our analyses. Besides, because of α-error cumulation, the findings of the additional analyses must be interpreted with caution. Due to the cross-sectional assessment of the interactive variables and maternal psychopathology, causal conclusions cannot be drawn. Prospective studies with repeated measurements of interactive behaviour should explore the reported findings. Another limitation of this study is the substantial portion of women with a university degree, limiting the representativeness of the sample. In addition, most of the clinical sample reported a prepartum onset of anxiety disorder. Because of a possible retrospective bias, the accuracy of this data remains unclear. Nevertheless, it is possible that the found results refer to effects of prepartum anxiety on the developing nervous system and behaviour of the infant (Grant et al., 2010). These effects are linked to a functional alteration of the infant’s hypothalamic-pituitary-axis (HPA; Grant et al., 2009). High cortisol-levels, in turn, are associated with impaired neurodevelopment in prefrontal cortex regions (Carrion, Weems, Richert, Hoffman, & Reiss, 2010; Kremen et al., 2010). These regions are related to e.g. impulsiveness (Schilling et al., 2012) and emotion regulation (Bruehl et al., 2013) in adolescence and adulthood. However, due to low cell-frequencies for reported postpartum disorder onsets, we were not able to distinguish between prepartum and postpartum effects. Nevertheless, postpartum quality of mother-infant interaction has moderated the association between maternal distress in pregnancy and infant cortisol reactivity in previous study (e.g., Müller et al., 2015). It has been argued that prenatal adversity may interact with genetic and postnatal environmental aspects (Schlotz & Philips, 2009). Longitudinal research including assessment of prepartum and postpartum psychopathology (or even better, of pre-pregnancy psychopathology) seems the best strategy to improve our understanding of the interplay between fetal programming and postpartum interaction regarding infant development (Schlotz & Philips, 2009). 4.5. Conclusions and implications The presented results contribute to the limited research in the field of anxiety disorder after child birth and provide impulses for a therapeutic framework tailored to the specific needs of anxious mothers. All in all, the gained data reveal the vital role of maternal behaviour for infant cognitive and language development. More precisely, the findings recommend focusing especially on the reduction of anxiety symptoms such as maternal avoidance behaviour. From a cognitive behavioural perspective, the respective women should be encouraged to expose themselves to the anxiety related stimuli. By facing anxiety cognitions and avoidance behaviour, the anxious symptomatology is likely to decrease. In addition, a stimulating and encouraging learning environment is created in which infants can explore and familiarise themselves with a broader range of stimuli. It is also of crucial importance to target specific mother-infant interaction patterns. According to the outcomes, strong emphasis should be placed on the use of baby talk, positive facial expressions as well as positive vocalisations. By means of video based motherinfant therapy (Downing et al., 2014; Papousek, 2000), beneficial and less beneficial interactive behaviour can be addressed to promote healthy infant development. Thereby, the respective mothers acquire a broader repertoire of interactive behaviour and gain greater self-confidence when interacting with their infant. The presented study provides first insights into the interplay between anxiety disorder after child birth, mother-infant interaction and infant development within the first year of life. Longitudinal studies are required to test whether the found associations persist in later childhood and if possible adverse outcomes in child development may be prevented. Financial support This study was funded by the German Research Foundation (DFG), Kennedyallee 40, 53175 Bonn, Germany (Study RE/2249 3-1). Acknowledgements Foremost, we would like to thank the women who participated in this study with their children. We would also like to thank the staff of the mother-infant unit of the University Hospital for their commitment and support. Appendix A Mean proportions of engagement phases (%) during the reunion episode of the FFSF according to group.

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Control group M (SD)

Clinical group

Total

Min–Max

M (SD)

Min–Max

M (SD)

Min–Max

Maternal engagement phases Positive engagement 24.1 (15.0) Positive vocalisations 56.8 (18.1) Neutral engagement 13.1 (16.7) Intrusive engagement 5.4 (13.6)

0.0–59.3 12.8–97.6 0.0–66.4 0.0–61.4

21.7 (17.8) 58.4 (19.1) 12.2 (10.8) 6.9 (12.2)

0.0–64.3 31.2–100.0 0.0–37.2 0.0–44.7

23.2 (16.1) 57.4 (18.4) 12.8 (14.6) 6.0 (13.0)

0.0–64.3 12.8–100.0 0.0–66.4 0.0–61.4

Infant engagement phases Positive engagement Social monitoring Object engagement Protest behaviour

6.9 (8.7) 31.6 (25.0) 48.6 (28.2) 11.7 (29.7)

0.0–31.0 0.0–92.0 0.0–92.7 0.0–100.0

7.3 (10.5) 28.5 (25.5) 44.2 (25.3) 17.5 (25.7)

0.0–35.8 0.0–87.1 3.4–96.4 0.0–94.8

7.1 (9.4) 30.4 (25.1) 46.9 (27.0) 13.9 (28.1)

0.0–35.8 0.0–92.0 0.0–96.4 0.0–100.0

Dyadic engagement Gaze Shared attention

25.9 (22.1) 2.1 (0.9)

0.0–89.4 0–30.2

29.8 (24.1) 0.8 (0.5)

0.7–87.0 0.0–11.1

27.4 (14.1) 1.6 (0.6)

0.0–89.4 0–30.2

Appendix B. Infant Engagement Phases Infant and Caregiver Engagement Phases Revised Version (ICEP-R; Reck, Noe, Cenciotti, Tronick, & Weinberg, 2009) (short description). Infant Engagement Phases Negative Engagement: The infant is in a negative affective state and must display negative facial expression and/or crying vocalizations. Negative engagement is coded if it is impossible to differentiate between “Protest” and “Withdrawn.” Protest: The infant is protesting and often displays facial expressions of anger or is crying. Withdrawn: The infant is minimally engaged with the caregiver and often shows a sad facial expression and/or whimpering vocalizations. Object/Environment Engagement: The infant looks at distal or proximal objects while displaying an interested or a neutral facial expression. The infant may manipulate proximal objects. Social Monitor: The infant looks at the adult’s face with a neutral or an interested facial expression. Social Positive Engagement: The infant looks at the adult’s face while displaying a facial expression of joy. The infant may be vocalizing in a positive manner, laughing, babbling or squealing. Caregiver Engagement Phases Negative Engagement: The adult is negative, intrusive, hostile, or withdrawn. Negative Engagement is coded if it is impossible to differentiate between “Hostile/Intrusive” and “Withdrawn.” Hostile: The adult’s engagement with the baby is characterised by hostile affect/behaviour. The adult’s facial expressions are upset or aggressive. Vocalizations are high pitched and follow one another staccato-like and the voice is cracking. The adult is curt with the baby, and might push, drag or pull him/her. She may make fun of her baby, for example by imitating vocalizations or mimic expressions. Intrusive: The adult’s engagement with the baby is characterised by obtrusive affect and behaviour. The adult’s facial expressions are tensed, stressed or little authentic. The infant is not given the chance to respond to maternal initiatives as these follow one another too fast and do not await infant reactions. The caregiver is dominating the interaction and may interrupt the infant’s activities in order to pursue her/his own “program”. The infant’s activities are restrained, for example by turning his or her face around in order to make eye contact, by holding tight hands or feet while playing etc. The adult stimulates the infant excessively without caring about infant signals of discomfort and/or withdrawal. Regardless of the infant’s behaviour, the adult acts too loud, too expressively and too close to her/his child. Withdrawn: The adult is minimally engaged with the baby. Typically, a sad or flat facial expression is displayed. The adult may be silent or speak in a flat, monotone voice. Non-Infant-Focused Engagement: The adult is involved in a non-infant-focused activity. Social Monitor/No Vocalizations or Neutral Vocalizations: The adult watches the baby while his or her facial expressions are neutral. The adult can be silent or vocalize to the baby in a neutral manner. Social Monitor/Positive Vocalizations: The caregiver’s gaze is focused on the infant. Although his or her facial expressions are neutral, she vocalizes to the baby in a positive manner (e.g., she may use “baby talk”). 128

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Social Positive Engagement: The caregiver expresses positive affect such as smiles and laughter and vocalizes to the baby in a positive tone using baby talk or singing; nothing is exaggerated in the caregiver’s speaking or singing. Dyadic gaze information Dyadic Eye-Contact: Infant and caregiver are coordinating their gaze by looking at each other’s face. Joint Activity/Looking: Infant and caregiver are jointly attending to the same object. The infant and the mother are coordinating their gaze but are not looking at each other. The infant must be looking at the object, while the caregiver’s gaze may shift from infant to object. Objects may be the caregiver’s hand or an infant body part and the game is not a facial interplay game, but one in which the hands are equivalent to an object. While this code requires a mutual interaction, it captures the infant’s perspective of a social interaction with the caregiver via an object. The infant can display any facial expression.

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