Assessment of Early Parent Child Relationships

Assessment of Early Parent–Child Relationships

Roseanne Clark, Audrey Tluczek, Elizabeth C. Moore, and Amber L. Evenson
The Oxford Handbook of Infant, Toddler, and Preschool Mental Health Assess
ment (2 ed.)
Edited by Rebecca DelCarmen-Wiggins and Alice S. Carter
Print Publication Date: Feb 2020 Subject: Psychology, Clinical Psychology

Online Publication Date: Dec 2019 DOI: 10.1093/oxfordhb/9780199837182.013.3
Abstract and Keywords
Using a relational approach to assessment integrates the theoretical application of devel

opmental, psychological and psychiatric disciplines (Clark, Tluczek, & Gallagher, 2004;
Sameroff & Emde, 1989; Sameroff, McDonough, & Rosenblum, 2004). Clark, Tluczek,
Moore, and Evenson (2019, Chapter 2) presents a review of these perspectives. This
chapter introduces best practices in the assessment of parent–child relationships and pro
vides an in-depth description and illustration of the Parent–Child Early Relational Assess
ment, composed of both objective ratings and a subjective video replay interview used to
engage the parent in assessing his or her relationship with his or her child. In addition,
reliability, validity, research findings, and the clinical utility of a wide range of parent–
child relationship assessment tools and procedures are provided. The importance of con
sidering the individual contributions of the parent, the infant or young child, the family,
and the cultural context in the assessment process is highlighted. Guidelines are also in
cluded on the use of relational assessments in research and to inform clinical practice.
Keywords: Parent-infant observation, parent–child observation, parent–child interaction, parent–child early rela
tional assessment, relationship assessment, parent–child relationship assessment tools
Assessment of the Parent–Child Relation

(p. 47)
ship: Best Practices

The American Academy of Child and Adolescent Psychiatry (Thomas et al., 1997) Practice
Parameters for the Assessment of Infants and Toddlers and Zero to Three’s Diagnostic
Task Force and Assessment Protocol Project (Weston et al., 2003; Zero to Three, 1994)
have recommended that the psychiatric evaluation of children under 3 years of age, and
more recently up to 5 years of age (Zeanah & Lieberman, 2016; Zero to Three, 2016), in
clude an assessment of the parent–child relationship. The goal is to obtain a comprehen
sive picture of the parent–child relationship within its sociocultural context. The informa
tion learned from a relational assessment can assist the clinician in formulating an inter
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vention plan and in evaluating progress during the therapeutic process. Sources of infor
mation should include the parents and other caregivers, the child, the extended family
when indicated, day-care providers, and the primary health care provider. If the family is
involved in other services, such as social services, mental health services, or early inter
vention services, information should also be obtained from these collateral sources.
Through an interview process with the parent, such as the ERA Video Replay Interview
(Clark, 1985, 2010, 2015), the Working Model of the Child Interview (WMCI, Zeanah &
Benoit, 1995), or the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996),
identification of a parent’s internal working model of relationships, or “ghosts in the
nursery” (Fraiberg, Adelson, & Shapiro, 1980), is better understood. Parental attitudes
and perceptions of their infant or child, the meaning of the child’s behavior, and their in
ternal working model (Bretherton, 1985) of what can be expected in a relationship devel
op within their own past experiences in early attachment (p. 48) relationships. Disturbed
or adverse past relationship experiences may result in a parent misinterpreting and pro
jecting negative attributions or feelings onto the infant; for example, the parent may mis
interpret certain behaviors of the infant as demanding, negative, or attacking (Zero to
Three, 1994).
The University of Wisconsin Parent–Infant and Early Childhood Program’s Relational As
sessment Model uses a multimodal approach and actively involves the parents through in
terviews, observations, and parent report assessment instruments (Clark, Seidl, & Paul
son, 1997; Clark, Burk, Hewitt, & Hipke, 2006). Observations of parent–child interactions
are conducted across developmentally salient situations. Assessment procedures are
structured to address particular domains appropriate to the child’s level of development.
For example, infants need emotionally available parents who are capable of reading their
cues and responding in a sensitive and timely fashion (Ainsworth, 1969; Stern, 2002),
whereas toddlers need caregiving that is respectful of their emerging autonomy and pro
vides cognitive and emotional scaffolding, clear expectations, consistent limit setting, and
assistance in managing transitions, with affective and behavioral regulation. Note that an
observation of interactions should be considered just one snapshot in time, whereas the
parent–child relationship represents the child’s and parent’s “sense and quality of con
nectedness” over time and across settings (Clark, 1985, 2010, 2015). The parent’s mood
and parenting capacities, the family’s stress, and the family’s access to and need for so
cial supports and resources should also be assessed through the interview as part of the
parent–child relationship assessment. Assessment approaches in this chapter include in
terview, self-report, and observational measures.
Interview With Parents
Developing a trusting relationship with the parents is critical to the assessment process.
Taking a collaborative approach with parents throughout the assessment may build such
an alliance. At the onset of the interview, parents should be asked about their concerns
about their child and what they would like to get out of the assessment. By empathically
listening to parents’ experiences of their child and their struggles in parenting, the clini
cian is providing a parallel process of attunement and responsiveness with the parents
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that they can then, with thoughtful exploration and support, provide for their child. Ele
ments of the parent interview that are particularly salient to an assessment of the parent–
child relationship include the following:
1. Demystify the assessment process by explaining the multimodal nature of the as
sessment procedures and the parents’ significant role in the assessment process.
2. Ask parents what their hope is regarding what they will receive from the evalua
tion process.
3. Provide a safe, comfortable, developmentally appropriate environment for the
child/children and parents. Ideally, all members of the family household as defined by
the parents should attend the initial evaluation. Having the whole family present pro
vides the clinician information about family dynamics, including sibling relationships
and cross-generational alliances.
4. Assess the parents’ optimal parenting capacities across several developmentally
salient situations (e.g., routine tasks of daily living such as feeding, diapering, teach
ing and setting limits, play, separations/reunions).
5. Involve the parents in assessing their child’s regulatory capacities and behaviors
and their capacity to see their child as a separate individual by observing the child
together and discussing what you and they are observing.
6. Inquire about presenting problems and parents’ perspectives regarding the mean
ing of the child and his or her behaviors by asking parents to describe their child and
their impressions about the source or cause of the concerns.
7. Include a perinatal history about the pregnancy, labor, and delivery. This time rep
resents the critical beginnings of the child’s relationship with each parent. An un
planned or medically high-risk or stressful pregnancy or a complicated labor or deliv
ery may have profound implications for the parent–child relationship. Ask open-end
ed questions (e.g., What was the pregnancy like for you?) to allow parents to share
those aspects of the experience that are important to them.
8. Involve parents in assessing their relationship by reviewing a video recording of
the parent and child interacting together. Help them focus on strengths, notice their
child’s cues, and validate parents’ concerns. “Wonder along with” the parents about
who their child reminds them of in general and when the problem behaviors are
present. This information may help to elucidate parents’ projections of negative in
tentionality attributed to their child.
9. Assess the sociocultural context of the parent–child relationship, respecting and
appreciating the family’s beliefs and values. Recognize the parents as the experts in
their (p. 49) personal sociocultural environment and ask them to educate you about
their life experiences and worldviews. Seek additional consultation from cultural ex
perts to address the clinician’s cultural knowledge deficits or biases.
10. Provide parents with feedback about the assessment findings with a caring, non
judgmental attitude about the parents or their parenting style. This approach will fa
cilitate a therapeutic joining with the parents vital to the development of a collabora
tive therapeutic relationship.
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Observations of Parent–Child Interactions
When conducting an assessment of the quality of the parent-child relationship using ob
servational methods, there are several key points to remember:
1. Note the intensity, frequency, and duration of the affect and behavior exchanged
between parent and child. This information may differentiate normal interactions
from disturbed interactions and assist the clinician in determining the seriousness of
a relationship problem. For example, the Diagnostic Classification of Mental Health
and Developmental Disorders of Infancy and Early Childhood (DC:0–5) Axis II uses
this information to categorize caregiver–child relationships as levels of quality to dis
tinguish well-adapted, at-risk, compromised, and disordered relationships (Zero to
Three, 2016).
2. Assess the quality of interaction within the context of the situation. For example,
differentiate parental directives or conversation related to structured tasks from play
interactions in which the parent is following the child’s lead or engaging the child in
a mutually enjoyable social interaction.
3. Consider parents’ responses relative to the child’s age and developmental level.
Examples of reading cues and responding sensitively include a mother who adjusts
the way she holds her infant after noticing the child’s discomfort in a particular posi
tion or the father who responds to his toddler tugging at his arm by a caring touch,
talking to, or picking up his child.
4. When the child engages in behavior to seek the parent’s attention, negative test
ing or oppositional behavior, note whether the parent responds to the child verbally
or behaviorally in a way that suggests he or she experiences the child’s behavior as
resistant or “bad.”
5. Note whether the rapidity and regularity with which the parent responds to the
child are contingent on the child’s cues, requests, or needs and helps the child feel
that his or her actions are effective.
6. Differentiate a genuine sense of connectedness from “going through the motions.”
An emotionally connected parent is aware of and involved with the child even when
not actively interacting with the child. The parent is attentive to the child, subtly
monitoring the child with an empathic awareness of the child’s emotional state. Con
nectedness may also include seeing the child as a separate individual.
7. Assess the parent’s capacity to reflect the child’s affect and/or behavior through
echoing (with infants), gazing, confirmation of affect, behavior, approval, encourage
ment, and praise, as well as labeling the child’s internal feeling states. This process
of mirroring represents the parent’s emotional availability and affective attunement
to the infant or young child.
8. Assess the parent’s capacity for scaffolding by looking at the amount and way in
which the parent gains, helps to focus, and sustains the child’s attention to the rele
vant aspects of the situation. Scaffolding is a process in which parents recognize
their child’s developmental capacities and provide a physical and socioemotional en
vironment that gives the child an opportunity to expand his or her capacities (Vygot
sky, 1978). Just as a metal scaffold allows construction workers to build taller build
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ings, parents’ emotional and cognitive scaffolding helps their child reach higher lev
els of cognitive, social, and motor skills as well as emotional and behavioral regula
tion. Scaffolding with a younger infant may be manifested by protective caregiving.
With an older child, this process may include assistance such as teaching, demon
strating, stating expectations clearly, and setting limits with a sensitivity to the
child’s affective and cognitive functioning.
9. Note the parents’ consistency and predictability in their interactions with their
child as well as the parents’ capacity to follow their child’s lead versus directive or
intrusive behavior.
10. Observe from the child’s perspective as well. Ask the question, If I were this
child, what would I see/experience when I look up at my mother or father?
11. Observe the child’s affect, mood, emotional lability, temperament, activity level,
attentional capacities, persistence, quality of play, social initiative and responsive
ness, compliance, (p. 50) communicative and motor competence, visual contact, and
assertion or aggressivity.
12. After the observations, ask the parent(s) how typical the interaction was. If the
parents indicate that it was different from usual, inquire about how it was different
and what the parent(s) attributes this to. For example, parent(s) may state that the
child was much more cooperative than usual and that they rarely have the opportuni
ty to play with their child one on one. Such information informs the diagnostic
process and the planning for therapeutic intervention.
13. Observe the dyadic organization and regulation in the interaction and parent’s
capacity to pace and coordinate with the child’s needs and actions, as well as the af
fective tone of the dyad and capacity for mutual enjoyment, joint attention, reci
procity, and goodness of fit.
A structured and systematic approach to assessing parent–child interactions is central to

identifying the areas of strength as well as areas of concern that may contribute to distur
bances in the parent–child dyad. Researchers (e.g., Ainsworth, Blehar, & Waters, 1978;
Barnard, 1979; Bromwich, 1976; Clark, 1985, 1999; Emde, 1992; Feldman, Dollberg, &
Nadam, 2011; Lyons-Ruth, Bronfman, & Parsons, 1999) have identified specific character
istics of the parent, the infant or child, and the parent–child interaction that deserve at
tention during a relational assessment. The Parent–Child Early Relational Assessment
(PCERA), a method that incorporates both an objective assessment of strengths and areas
of concern across situations and a subjective component that involves parents in assess
ing their relationship with their infant or child and the meaning of their infant or child’s
behavior through a video replay interview, is described in the next section. This is fol
lowed by descriptions of several other empirically validated methods for assessing the
quality of the parent–child relationship. See Tables 3.1, 3.2, and 3.3 for overviews of these
instruments.
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Table 3.1. Parent–Child Relationship Assessment Instruments: Parental Interview Measures
Instrument Age Domains Reliability(/validi Description

ty
Adult Attachment Adult Narrative/adjec Moderate interrater Semistructured in

Interview (AAI; tives early attach reliability (k = .56–. terview used for re
George et al., 1996) ment relationships 63), and low dis search and clinical
rated: criminant validity purposes.
Secure/autonomous for memory, intelli 18 questions
Dismissive gence, and social 1 hour to adminis
Preoccupied desirability. ter
Unresolved/disorga AAI scores corre Highly established;
nized spond with their in however, it requires
fants’ attachment a lot of training (18
classification in the days) and time to
Strange Situation. code.
Audiotape of inter
view is coded by
raters trained to re
liability.
Reflective function
ing can also be as
sessed.
Page 6 of 62
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Insightfulness As Parents of toddlers Parent domains: Studies examining Well suited to re
sessment (IA; Ko and preschoolers Insight into child’s the utility of the IA search and clinical
ren-Karie, Oppen motives reveal significant purposes.
heim, Dolev, Sher, & Openness relationships be Promising utility in
Etzion-Carasso, Complexity in de tween IA categories work with both low-
2002; Oppenheim & scription of child and child attach and high-risk chil
Koren-Karie, 2002, Maintenance of fo ment classifications dren and growing
2009; Oppenheim, cus on child and child behavior. evidence that in
Koren-Karie, & Sa Richness of descrip There is growing sightfulness may in
gi, 2001) tion of child evidence of concur crease the impact of
Coherence of rent and predictive intervention.
thought validity (e.g., Lau Video replay proce
Acceptance sanne Trilogue Play dure.
Anger procedure) with co Interviews are tran
Worry ordination and co scribed and coded.
Separateness from operation.
child IA post–Circle of Se
curity Intervention
predicted child se
curity of attach
ment at follow-up.
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Parent Develop Parents of infants Parental affective High interrater reli 90-minute semi
ment Interview and young children experiences ability (intraclass structured inter
(PDI)–R (Slade, Degree, acknowl correlation = .78 view with the par
Aber, Bresgi, Berg edgment, and mod to .95). ent (brief version is
er, & Kaplan, 2003); ulation of anger Construct validity 45 minutes).
Reflective function Neediness with the AAI—Re Revised version as
ing codes: Slade, Degree, acknowl flective functioning sesses for reflective
Aber, Bresgi, Berg edgment, and mod on the PDI was functioning.
er, & Kaplan, 2004. ulation of separa shown to be corre 45 items
tion distress lated with reflective
Degree and ac functioning on the
knowledgment of AAI (Slade, 2005;
guilt Slade et al., 2005).
Experience of joy
and pleasure
Sense of competen
cy and efficacy
Child affective ex
periences
Representation of
child anger
Child separation
distress
Child dependence–
independence
State of mind
Coherence
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Richness of percep
tion
Working Model of Parents of infants Richness of percep WMCI has demon Grounded in attach
the Child Interview and toddlers tion strated strong inter ment theory.
(WMCI; Zeanah & Openness to change rater reliability for Well suited to re
Barton, 1989; Coherence classification scor search and clinical
Zeanah, Benoit, Intensity of involve ing (k = .76–.79). purposes
Barton, & Hirsh ment Strong concurrent Time intensive; re
berg, 1996) Caregiving sensitiv validity with the quires training and
ity Parent–Child Early coding from an au
Acceptance/rejec Relational Assess dio recording.
tion ment and predictive Structured inter
Infant difficulty validity with the view
Fear of loss Strange Situation. 60 minutes to ad
Affective tone minister
Narrative organiza
tion
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Table 3.2. Parent–Child Relationship Assessment Instruments: Parent–Child Observation Measures
Instrument Age Domains Reliability/validity Description
Atypical Maternal Infancy Affective communi Concurrent validity Useful for high-risk
Behavior Instru cation errors with the Strange Si samples.
ment for Assess Role/boundary con tuation has been es
ment and Classifica fusion tablished (intra
tion (Bronfman, Frightened/disori class correlation
Madigan, & Lyons- ented behavior and [ICC] = .75–.84)
Ruth, 1992–2009) voices and the Frighten
Intrusiveness/nega ing, Frightened,
tivity Dissociated or Dis
Withdrawal organized Behavior
on the Part of the
Parent Scale (total
atypical behavior
score, ICC = .67)
Coding Interactive Newborns, infants, Parental sensitivity Validated across a Utility in studies of
Behavior (CIB; Feld toddlers, preschool Parental intrusive wide range of ages both at-risk and
man, 1998) ers, school-age chil ness and cultures. healthy dyads.
dren, adolescents, Parental limit set 43 codes rated on a
and adults ting 5-point Likert scale
Child involvement Prerecorded video
Child withdrawal tape is coded.
Child compliance
Dyadic reciprocity
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Dyadic negative Shown sensitivity to

state differences in par
ent–child interac
tions related to
family’s culture, sex
of the parent, and
social-emotional/bi
ological risk fac
tors, as well as
changes in interac
tions resulting from
intervention (inter
nal consistency of
maternal and infant
scales k = .83–.94).
Significant correla
tions between ma
ternal sensitivity on
the CIB and child
intelligence and so
cial engagement (r
= .25–.67).
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Clinical Problem- 24–54 months (with Parent: High internal con Nine episodes—
Solving Procedure modifications as Emotional availabil sistency of items (Ω range of activities is
Rating Scale (Crow young as 12 ity = .88 child items well suited for clini
ell & Feldman, months, see Nurturance/em and .84 for caregiv cal observations.
1988) Zeanah, Larrieu, pathic responsive er items) and corre Parents’ interview
Heller, & Valliere, ness lates with other would be helpful to
2000) Protection measures of parent– establish ecological
Comforting/re child relationship validity.
sponse to distress quality (r = .51–.56,
Teaching p = .001).
Play
Discipline/limit set
ting
Instrumental care/
structure/routines
Infant:
Emotion regulation
Security/trust/self-
esteem
Vigilance/self-pro
tection/safety
Comfort-seeking
Learning/curiosity/
mastery
Play/imagination
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Self-control/cooper
ation
Self-regulation/pre
dictability
Emotional Availabil Infancy/early child Parent: Low to high inter Grounded in attach
ity Scales (Biringen, hood version: birth– Sensitivity rater reliability ment and emotional
2000, 2008; Birin 5 years old. Structuring when measuring at availability theo
gen et al., 2005; Nonintrusiveness tachment (k = .24– ries; although pri
Biringen, Robinson, Nonhostility 1.0) and parent– marily used in re
& Emde, 1998) Child: child relationship search, may be use
Responsiveness to quality (k = .70–. ful for assessing in
the parent 98). tervention pro
Involvement of the Strong cross-con grams. Observation
parent text reliability when sessions >15 min
comparing scores utes yield stronger
from a laboratory predictive value.
setting and home Used in over 20
setting (Bornstein countries
et al., 2006).
Nursing Child As Infancy (including Mother: High interrater reli Ratings of home ob
sessment Satellite premature infants) Sensitivity to the ability (k = .89–.92) servations widely
Training (NCAST) through 3 years for child’s cues and internal consis used for clinical and
the Teaching Scale. Response to the tency (α = .80–.82). research purposes.
Birth to 12 months child’s distress NCAST is primarily
for the Feeding Fostering social- used by nurses.
Scale. emotional growth
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NCAST Parent– Fostering cognitive High concurrent va Training is re

Child Interaction growth lidity with the quired.
Feeding and Teach Infant or child: Strange Situation
ing Scales (Feeding Clarity of cues has been estab
Scale) (Teaching Responsiveness to lished (r =.19; p = .
Scale) (Barnard, caregiver 023).
1979; Sumner & Discriminates high-
Spietz, 1994a, risk from normative
1994b) dyads
Parent total score
has predictive valid
ity for child IQ at 3–
5 years.
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Parent–Child Early Birth to 5 years old Parental factors: High interrater reli Theoretically and
Relational Assess Positive affective in ability (.85) and in empirically derived
ment (PCERA) volvement and ver ternal consistency scales rated from
(Clark, 1985, 2010, balization (α = .78–.94). video-recorded ob
2015) Negative affect and Discriminant validi servations to identi
behavior ty has been estab fy areas of strength
Intrusiveness, in lished differentiat and concern. The
sensitivity, and in ing high-risk from PCERA includes a
consistency normative dyads video replay inter
Infant or child fac (parents with de view to engage
tors: pression, other psy parent(s) in assess
Positive affect, com chiatric and alcohol ing their relation
municative and so and other drug ship with their child
cial skills abuse disorders, and for collabora
Quality of play, in premature infants tive goal setting in
terest, and atten and infants with clinical settings.
tional skills other medical con Widely used for re
Dysregulation and ditions) search and clinical
irritability purposes.
Parent–child dyadic 29 parental items,
factors: 28 infant or child
Mutuality and reci items, and 8 dyadic
procity items.
Disorganization and
tension
Video reply and in
terview:
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Meaning of child Construct, concur Four 5-minute seg

and child’s behavior rent and predictive ments of feeding/
Parent’s perception validity established snack, structured
of self in parenting with the AAI, secu task, free play, and
role rity of attachment separation/reunion
Parent’s history of in the Strange Situ episodes.
being parented ation and the At Used international
tachment Q-Sort, ly.
the WCMI, and the Training is re
Child Behavior quired.
Checklist (see re
view by Clark, 2010,
2015).
Documents change
in the quality of
mother–child inter
actions following
therapeutic inter
vention (Minde,
Faucon, & Falkner,
1994).
Cross-cultural valid
ity established in
use on six conti
nents.
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Parenting Interac 10 to 47 months Affection High interrater reli For use with di
tions with Children: Responsiveness ability (k = .69–.80), verse ethnic
Checklist of Obser Encouragement internal consistency groups, particularly
vations Linked to Teaching (α = .68–.79), and for practitioners
Outcomes (Rog moderate to high working with at-risk
gman et al., 2013) confirmatory facto families.
ry analysis (r = . Checklist of 29 ob
43–.86). servable behaviors.
Content validity
was strong (i.e., av
erage rating of 2.6
of 3).
Construct validity
ranged from low to
moderate at 14, 24,
and 36 months of
age (r = .13–.65).
Predictive validity
was strong for later
child language, cog
nitive, and social-
emotional out
comes.
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Page 19 of 62

Table 3.3. Parent–Child Relationship Assessment Instruments—Parent Self-Report
Instrument Age Domains Reliability/validity Description
Parenting Stress In 1 month to 12 years Parent domains: High internal con Self-report paper-
dex (PSI; Abidin, Competence sistency for the and-pencil instru
1986, 2012) Isolation child (α = .78–.88), ment used clinically
Attachment parent (α = .75–. and in research
Health 87), and total score The fourth edition
Role restriction (α = .98) domains. has been translated
Depression Test–retest reliabili into other lan
Spouse ty was moderate to guages and used in
Child domains: high (.63, .91, and . ternationally
Distractibility/hy 96 for child, parent, Approximately 20
peractivity and total stress minutes to adminis
Adaptability scores, respective ter
Reinforces parent ly). 120 items
Demandingness High internal con The PSI Short Form
Mood sistency on PSI, is useful for clini
Acceptability fourth edition, cians because of its
Life Stress Short Form (α = . ease of use.
88–.90) for parent
domain subscales
and child domain
subscales.
Page 20 of 62

Parent–Child Early Relational Assessment

The PCERA (Clark, 1985, 2010, 2015) is a widely used and well-established observational
measure that has been validated across a wide range of ages from birth through age 5,
with mothers and fathers, across cultures, and with normative and high-risk dyads (Clark,
1985, 2010, 2016; Dallay & Guedeney, 2016; Landorph & Clark, 2013). The PCERA cap
tures the infant or child’s experience of the parent, the parent’s experience of the infant
or child, the affective and behavioral characteristics that each bring to the interaction,
and the quality or tone of the dyadic relationship. The quality of the parent–child relation
ship is assessed from video-recorded observations of the infant or child interacting with
the parent during four 5-minute segments that include feeding, structured task, free play,
and separation/reunion (Clark, 1985; Clark, 1999; Clark, 2010; Clark, 2015; Farran, Clark,
& Ray, 1990). The rating scales are based on empirical developmental studies (e.g.,
Clarke-Stewart, 1973; Matas, Arend, & Sroufe, 1978; Sander, 1964) and attachment
(Ainsworth, 1969), psychodynamic (Stern, 1985, 2002; Winnicott, 1965, 1970), and Soviet
cognitive-linguistic theories (Vygotsky, 1978) and are informed by clinical observations of
the domains of functioning seen as important for differentiating parents experiencing dif
ficulties in parenting from well-functioning parents and aspects of infant temperament,
affect, and behavior vulnerable to stress, medical vulnerability and family functioning
(Clark, 1983; Musick, Clark, & Cohler, 1981). The PCERA identifies areas of strength and
areas of concern in the parent, the infant or child, and the dyad. The PCERA may be used
as part of an initial diagnostic evaluation to formulate relationship issues, develop a rela
tional profile, collaborative goal setting with parent(s), focus intervention efforts, monitor
progress in therapy, assess outcomes in treatment efficacy studies, and research with
families at risk for early relational disturbances.
Ratings are made on a 5-point Likert scale for 29 domains of parental functioning, 30 do
mains of infant/child functioning, and 8 domains of dyadic functioning. The amount, dura
tion, and intensity of affect and behavior exhibited by the parent, the infant or child, and
the dyad are rated:
1. Items assessing aspects of parental behavior and affect include parental positive
and negative affect, mood, sensitivity and contingent responsivity to the infant or
child’s cues, flexibility/rigidity, capacity to structure and mediate the environment,
genuine visual regard, connectedness, mirroring, and creativity/resourcefulness, etc.
2. Infant/child items include positive and negative affect, somber/serious mood, irri
tability, social initiative and responsiveness, interest/gaze aversion, assertion/aggres
sivity, persistence, impulsivity, emotional regulation, etc.
3. Dyadic items include mutual enjoyment, tension, reciprocity, joint attention, good
ness of fit, etc.
(p. 51) (p. 52) (p. 53) (p. 54)The parent, infant/child, and dyadic scales were
(p. 55) (p. 56)
initially developed on a clinical intervention project funded by the National Institute of

Mental Health studying maternal psychiatric disorders and the quality of the mother–
Page 21 of 62

child relationship (Clark, 1983). The PCERA has been further developed for use with nor
mative and other at-risk populations (Clark, 1999; Clark, Hyde, Essex, & Klein, 1997;
Clark, Paulson, & Conlin, 1993; Clark, Tluczek, & Brown, 2008). Clark (1983) and Good
man and Brumley (1990) found that PCERA scores differentiated patterns of mothers
with depression and mothers with schizophrenic disorders from the patterns of well-func
tioning mothers. In studies of mother–infant interaction with mothers with substance
abuse problems, mothers with a range of psychiatric problems, and well-functioning
mothers, Siqveland, Haabrekke, Wentzel-Larsen, and Moe (2014) found that mother–in
fant interaction quality as measured by the PCERA improved from 3 months to 12 months
for the well-baby group and the group with psychiatric problems; however, the mother–in
fant interaction quality worsened across time for the group with maternal substance
abuse problems. The PCERA has also been found to differentiate positive and less sensi
tive mother–infant interactions with babies in the neonatal intensive care unit (Gerstein,
Poehlmann-Tynan, & Clark, 2015; Korja et al., 2008; Poehlmann, Burnson, & Weymouth,
2014; Weber & Harrison, 2014). When assessing babies with very low birth weights, Stolt
et al. (2014) found that the PCERA factors of maternal positive affective involvement (at 6
months) and maternal communication (at 12 months) were associated with child lan
guage skills at 2 years. The PCERA has excellent internal consistency and concurrent and
predictive validity (Clark, 1999) as well as concurrent validity, specifically with the WMCI
(Korja et al., 2010). The PCERA ratings of early mother–infant interaction have been cor
related with both concurrent measures of child temperament, behavior, and parenting
stress and later quality of mother–child interactions and security of attachment behaviors
at 12 months (Mothander, 1990; Teti, Nakagawa, Das, & Wirth, 1991) and has been found
to document change following therapeutic intervention (Clark, 1999; Minde, Faucon, &
Falkner, 1994; St. Petersburg–USA Orphanage Research Team, 2009). With clinical inves
tigators choosing the PCERA for use in a variety of clinical programs and research
projects internationally, studying high-risk and normative populations, the PCERA has be
come one of the most widely used clinical research measures.
Each of the four situations in the PCERA provides a window for understanding what has
been shared in the early parent–child relationship. Each situation may be experienced dif
ferently by parents, with some eliciting conflictual feelings and others allowing for feel
ings of competence in the parenting role. After the interaction procedure has been ex
plained to parents, written consent is obtained for video recording. The clinician explains
that the video recording is for the family’s benefit so that the parent and clinician can
view the video together in (p. 57) a reflective manner during a subsequent session. The
following explanation is provided to parents: “We understand that this is a snapshot of
one point in time. We’ll be interested in your sharing with us afterwards how the interac
tion is alike or different from how things usually go.” The video-recording procedure in
volves placing the camera at a 45-degree angle to the parent and infant or child, who are
seated together, and using a medium shot to capture the facial expressions, behavior, and
dyadic interactions of the parent and the child.
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During the feeding situation, the parent and young child are provided a snack of juice and
crackers and told, “We are interested in seeing [child’s name] and you during a feeding or
a snack time together. Please be with [child’s name] as you usually would.” If the mother
is breastfeeding, she is asked whether she would be comfortable being video recorded
during a feeding time with her baby. The feeding situation allows for an assessment of the
parent’s capacity for nurturance and social interaction as well as sensitivity to the child’s
cues and need for regulation. The child’s readability, affect regulation, social initiative,
and responsivity during feeding may also be assessed. Comfort, tension, and regulation of
the dyad in this situation are observed.
The instructions and nature of the structured task are determined by the age of the infant
or child. For example, parents of infants under 7 months are asked to change their baby’s
diaper and attempt to get the baby interested in shaking a rattle. Parents of children be
tween 8 and 12 months are given two cups and a toy and asked to hide a toy under one
cup and alternately hide it under the second cup within the child’s sight and have the
child try to find it. It is also suggested that, if time permits, they may read a book togeth
er. For children 13 months and older, parents are asked to build a tower of three cubes
and have the child do the same. With a child of 19 months and older, the task includes
building a tower with more cubes, building a bridge of blocks, and having the child make
a design with colored blocks that matches the increasingly challenging block design
cards. This task is always a little too difficult for the child to complete on his or her own.
The structured task situation allows for an assessment of the parents’ capacity to struc
ture and mediate the environment according to the child’s developmental and individual
needs. Some of the tasks tap the child’s emerging abilities and require adult cognitive
scaffolding as well as emotional availability for the child to complete the task successful
ly. The child’s attentional skills, persistence, and interest in complying with parental ex
pectations in a structured situation are observed. The dyad’s capacity for joint attention
to an activity, reciprocity in negotiations, and mutuality may be assessed.
Instructions for the free play situation are as follows: “This is a free play time with your
child. Please play with your child as you normally would.” For infants under 6 months, the
instructions include: “Here are some toys you may use if you choose.” For children over 6
months, the instructions are: “You or [child’s name] may chose the toy(s) that you would
like to play with together.” The standard toy list for the PCERA includes rattles, plastic
keys, a busy box, two toy telephones, a ball, two puppets, a doll, a bottle, a blanket, small
cars or trucks, bristle blocks, crayons and paper, and plastic animal and human family fig
ures. The free play situation allows for an assessment of the parents’ capacity to be play
ful with and enjoy their child as well as to follow their child’s lead in play. The child’s ca
pacity for exploratory and representational play and the dyad’s capacity for social interac
tion, mutuality, and reciprocity can be observed.
At the end of the instructions for the free play, parents are also given instructions for the
separation/reunion episode. They are told, “We’d also like to see how things go for
[child’s name] when you leave the room. After 5 minutes of play I’ll knock on the door but
won’t come in. Let [infant/child’s name] know that you’re going to be leaving the room
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briefly to talk with the assessor. Then please come stand outside the room for a few min
utes with me.” To ensure the child’s safety, this episode is only conducted when there is a
one-way mirror or video camera or when another adult is in the room the child. Is in This
situation allows assessment of the parents’ ability and level of comfort in preparing the
child for a brief separation. The child’s capacity for self-regulation and quality of mood
and exploratory play during the parents’ absence are assessed. The dyad’s quality of af
fect and engagement at reunion may also be observed.
Confirmatory factor analyses of 12-month free play interactions revealed eight factors:
Parent Factor I, Parental Positive Affective Involvement and Verbalization; Parent Factor
II, Parental Negative Affect and Behavior; Parent Factor III, Parental Intrusiveness, Insen
sitivity, and Inconsistency; Infant Factor IV, Infant Positive Affect, Communicative and So
cial Skills; Infant Factor V, Infant Quality of Play, Interest, and Attentional Skills; Infant
Factor VI, Infant Dysregulation and Irritability; Dyadic Factor VII, Dyadic Mutuality and
Reciprocity; and Dyadic (p. 58) Factor VIII, Dyadic Disorganization and Tension. High in
ternal consistency of factors at 4, 12, 24 months and 4.5 years has been determined, in
terrater reliability, and predictive and discriminant validity have been established for the
PCERA (Clark, 1983, 1999; Clark, Hyde, et al., 1997; Clark et al., 1993) in numerous stud
ies with normative and high-risk populations. Training is highly recommended and con
sists of 40 hours of didactic lectures, video ratings, and consensus discussion prior to rat
ing of four standardized videos and achievement of exact interrater agreement at or
above 0.85 and/or within one scale point agreement of 0.90 or above.
A video replay interview, in which brief segments of the video-recorded interactions are
played back and reviewed with the parents, is an important part of the assessment
process. In a semistructured interview, the parents’ perceptions, attitudes, and goals dur
ing the interactions with the infant or child are explored. Objective assessments often fail
to answer questions about what parents are experiencing with their infant or child. The
Video Replay Interview allows parents to share what they were seeing, doing, and feeling
in relation to their infant or child as well as their perceptions of their infant or child and
themselves in the parenting role. By wondering along with the parents about their per
ceptions, attitudes, and feelings about their infant or child, the clinician can gain insight
about parents’ phenomenological experience of the parent–child relationship that influ
ences their behavioral interactions with their infant or child. Before the video is re
viewed, parents are asked, “How was this interaction like or different from how things
usually go at home for [child’s name] and you together?”; “What was the most enjoyable
part of this session for you?”; “What part was the most difficult or did you like the least?”;
and “Do you have any questions or comments about the video recording?”
Video segments to review with parents are selected prior to the Video Replay interview.
In the first segment, the video is paused at a point when the infant or child’s face can be
seen clearly on the screen. The meaning of the infant or child to the parent is assessed
with questions such as, “I wonder who [child’s name] looks like or reminds you of [physi
cal features, temperament, behavior]?” “How did you select your child’s name?” and
“How would you describe that person and your relationship with them?” The next seg
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ment shown is when the parent is not responding to the child’s cues. The parent’s capaci
ty to read their infant or child’s cues may be assessed. In addition, parents’ capacity for
reflective functioning is assessed, that is, the ability to reflect on the internal affective ex
perience of their child and themselves (Fonagy & Target, 1998; Slade, 1999). The clini
cian asks parents, “How were you feeling during that interaction?” “What do you imagine
was going on for your child?” and “What do you imagine your child may have been feeling
then?” This process helps the clinician to assess the parents’ capacity to see the child as a
separate individual and their ability to empathically read their child’s cues or misinter
pret their child’s cues or attribute negative intentionality to their child’s behavior, making
it difficult to respond empathically. In addition, the clinician can also help parents to ex
pand their perceptions of their child and his or her behavior and increase their ways of
being with their child by wondering with them about alternative explanations for the in
fant or child’s behavior.
To assess the reinforcement value of the infant or child and parents’ sense of competence
in the parenting role, the clinician stops the video at a point when parent and child are
experiencing a mutually satisfying interaction and wonders, “How do you imagine [child’s
name] felt at that moment?” Then the clinician asks parents what they think they did to
elicit this positive response from their child. The clinician offers additional observations
that amplify parents’ strengths in reading their child’s needs and responding in a devel
opmentally sensitive manner. Additional questions in the video replay interview inform
the clinician about parents’ experience of parenting this child and include, “How would
you describe yourself as a parent?” “In general, what have you found most difficult or
frustrating about being a parent of [child’s name]?” “What have you found most enjoyable
about being a parent of [child’s name]?” “When do you feel best, or that you have done
well as a parent?” and “Did becoming a parent change you as a person in any way? If so,
how?”
Finally, it is extremely valuable to obtain a relational history from each parent to better
understand his or her own template of being parented or his or her internal working mod
el of relationships. The following questions may be asked during the video replay inter
view or at a subsequent session: “How would you compare yourself to your own parents?”
“What do you remember about being parented by your mother or father when you were
young?” “What three words would you use to describe your mother or father? Please give
specific examples that illustrate these adjectives.” “How was discipline (p. 59) handled in
your family?” “Who was available/responsive to you?” and “Who kept you safe, physically
and emotionally (or did not)?” (George et al., 1996).
The use of video replay in clinical interventions with parent–child dyads has been de
scribed as a powerful tool to enable therapeutic change in the client (Clark & Metcoff,
1983; Musick et al., 1981; Steele et al., 2014). Steele and colleagues (2014) described the
use of video as a way to enhance the therapeutic alliance by watching and experiencing
the interaction together. Steele et al. suggested that watching the video together can re
duce distortions of the experience and requires the therapist to be sensitive to the
caregiver’s experience while reviewing the footage and emphasized the importance of
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empowering and supporting the caregiver during this time. Video review also allows the
caregiver to reflect on the interaction, contributing to reflective functioning.
Case Illustration of the Parent-Child Early Relational Assessment Relational

Profile, Video Replay Interview, and Collaborative Development of the Par
ent–Infant Relationship Development Plan
Josie, a young mother living on her own with her 12-month-old daughter, Kira, was re
ferred for a relational assessment because of concerns of the home visitor working with
them regarding the mother’s ambivalent feelings and negative verbalizations toward her
infant, as well as her unpredictability in caring for her, often leaving Kira with relatives
for days at a time. Josie was wary of meeting a new person but was intrigued by the
video-recording of her and her daughter together. The psychologist and home visitor let
Josie know that the video-recording was for her and that she would receive a DVD of their
time together and that we would wonder with her what was alike or different from how
things usually go with her to collaboratively develop goals for their time together in the
mother–infant therapy group. Mother and daughter were video-recorded using the
PCERA in a 5-minute feeding, a 5-minute structured task, and a 5-minute free play situa
tion. An appointment was set for the Video Replay Interview to respectfully engage Josie
in assessing her relationship with Kira as well as herself in the mothering role. Strengths,
areas of some concern, and areas of concern were rated by reviewing the video prior to
the next appointment. Selected items are illustrated in the Relational Profile in Table 3.4.
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Table 3.4. Parent–Child Early Relational Assessment: Relational Pro

file, Selected Items
Area of Area of Area of

concern some con strength
cern
Parental tone of voice
Annoyed, angry, hostile X
Parental affect
Expressed positive af X

fect
Expressed negative af X

fect
Parental characteristic
mood
Irritable, frustrated, an X

gry mood
Anxious mood X
Parental expressed atti

tudes toward child
Displeasure, disap X
proval, criticism
Enjoyment, pleasure X
Parental affective and be

havioral involvement
Quality and amount of X

physical contact: positive
Amount of verbalization X
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Quality of verbalizations X
Contingent responsivity X
to child’s positive or age-
appropriate behavior
Contingent responsivity X
to child’s perceived nega
tive and/or unresponsive
behavior
Parent reads child cues X

and responds sensitively
and appropriately
Parental style
Intrusiveness X
Consistency/predictabil X
ity
Child mood/affect
Apathetic/withdrawn/ X
depressed mood
Anxious/tense/fearful X
mood
Irritable/frustrated/an X
gry mood
Sober/serious mood X
Child behavior/adaptive
abilities
Avoiding/averting/resis X
tance
Compliance/noncompli X
ance
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Assertion/aggressivity X
Self-regulation/organi X
zational capacities
Consolability/soothabili X
ty
Child communication
Visual contact X
Communicative compe X
tence
Dyadic affective quality of

interaction
Frustrated, angry, hos X

tile
Flat, empty, constricted X
Mutual enthusiasm, joy X

fulness, enjoyment, dyadic
“joie de vivre”
Dyadic mutuality in inter

action
Reciprocity X
Organization/regulation X
of interactions
From Clark (1985, 2015).
To understand better the meaning of Josie’s ambivalent behavior and verbalizations with
her daughter, the video was reviewed to select segments to replay with Josie, including a
segment in which she could see Kira’s face large on the screen, one in which Josie missed
or did not respond sensitively to Kira’s cues, and another of a positive interaction in
which Kira responded to Josie. Josie shared that how they were together the week before
was how they are usually, except that they do not play together very much because she
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works nights and Kira stays with relatives, and when Josie picks Kira up, she herself is
usually too tired to play.
In the part of the Video Replay that focused on her own experience of being parented,
Josie shared that her father “wasn’t around at all” and that her mother was beaten and
killed in a drug-related incident when Josie was a toddler. Josie was raised by her grand
mother, who abused her both verbally and physically. She was also “beaten up” in middle
school and sent to live with an aunt in another city. She described multiple losses and
traumatic experiences and shared that her auntie had been there for her with love and
consistency. Her sisters helped her but she could not count on them regularly because of
their own struggles. Josie shared that she has struggled with anxiety, depression, and im
pulsive behavior that has gotten her in trouble with her siblings, who she was both close
with and “at war with,” other family members, and at work, resulting in her being fired
from two cashier jobs. This young woman expressed distrust of her own capabilities as
well as what she could expect from others, which contributed to the unpredictability of
her being home when her home visitor came. She seemed to have internalized the nega
tive attitude and extreme frustration that her grandmother expressed toward her with
her own child. When asked who Kira looks like or reminds her of, Josie responded that
“She looks like her Daddy … his mouth … especially when she is angry.” She talked about
Kira’s temperament by describing her as “a sweet, cuddly baby.” In a segment of her
reading a board book to Kira, Josie taught her the sound that a cow makes and how to
turn the pages of the book. She was effective in gaining and focusing her daughter’s at
tention on the book and she saw that Kira responded to her. This was reinforcing for
Josie. In the next segment, Kira turned one of the pages quickly and the force of the
board book page on her mother’s hand was responded to with Josie yelling, “Ouch! Why
you hurting me?” Kira cried and her mother responded, “You look like a fish.” Kira looked
away and at the (p. 60) other toys on the floor that were brought for the assessment and
found some small cars. Kira expressed enthusiasm in seeing what she could make happen
in pushing the cars across the floor and one of them hit her mother in the leg, to which
her mother responded, “Why you have to be so mean?” She brought out a puppet and
said, “Hey, what’s up?” “Do you like me?” (three times) and then she picked up a toy
phone and said, “Hey girlfriend, where you at? You’re late … you’re grounded!” She then
took the pop-up toy and demonstrated to Kira how to play with it, saying “You do it!”
There was some teasing with a rattle, at first not letting Kira reach it, and then Josie
threw it at her. Then Josie ran a car (p. 61) over Kira’s foot and then apologized and kissed
her daughter’s foot, saying “I’m sorry, little girl.” Kira cried again. When asked in the
Video Replay what her daughter might be feeling, Josie laughed and said, “I threw the
rattle at her … she saw it so she wanted it so I threw it at her. Maybe ‘cause I ran over
her foot with the car … she hit my foot with it before!” With empathy and support, Josie
evidenced insight and began to make some connections with how her reactions to Kira,
such as attributing negative intentionality to developmentally appropriate behaviors, may
be related to hurtful behaviors she experienced when she was young. When asked how
she would describe her relationship with her grandma, who she called Ma, she exclaimed
“either she didn’t pay any attention to me or she was Mean! … She hit me with a belt,
Page 30 of 62

broom, extension cord, switch and shoes.” This was noted compassionately by the inter
viewer as likely being very frightening and confusing for a child. When wondered with
about how she compared herself to her Ma, she said “I see everything in myself.” Her
concern about being like her Ma was reflected by the interviewer as she wondered with
Josie whether she would appreciate some support in learning other ways of being with
her child. Josie responded with a nod of her head and added, “As a mom I am still learn
ing. The more they grow, the more you get more reactions. You don’t know what to expect
… she better not get into my hair stuff!” When wondered with about what she found most
enjoyable about being a parent, Josie responded, “I miss being pregnant, I got a lot of at
tention.” When asked when she feels best or feels like she is doing well as a parent, she
responded, “When I can provide for my baby.” Josie expressed some distrust and ambiva
lence, but also some motivation to participate in the mother–infant therapy group be
cause she said she wanted to be a “good mom.” The PCERA Video Replay interview con
cludes with collaborative goal setting with the parent and the development of a Parent–
Child Relationship Development Plan. Josie was engaged, with the support of her home
visitor and the psychologist, in identifying relationship goals for their work together. Ta
ble 3.5 presents an example of a Parent–Child Relationship Development Plan.
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Table 3.5. Mother–Infant Relationship Development Plan
Name of mother: Baby’s age: Name of baby: Kira

Josie 12 months
Areas of relationship Goals Strategies/ap

to be addressed in proaches
dyadic sessions
Kira being smart and Kira will in • Encourage Josie to

learning to talk is im crease her lan narrate Kira’s play
portant to her mother. guage develop • Encourage Josie to
ment. use puppets as well as
telephones to have
reciprocal dialogue
with Kira
• Support Josie in
reading and book
sharing with Kira
Josie expressed difficul Expanding • Checking in with

ty limiting reactivity Josie’s percep Josie about her emo
and staying engaged in tions of Kira’s tional experience in in
activities with Kira actions, mov teracting with Kira
when Kira does not re ing past her and reflect with her
spond and she feels she projections of about how her percep
is “being mean.” negative inten tions of Kira may be
tionality. influenced by her own
history of early attach
ment relationships.
• Provide nonjudg
mental developmental
guidance regarding
her 12-month-old’s
emerging autonomy
and interest in explor
ing her environment.
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Josie will bring

Kira to group
regularly and
stay engaged
with her even
when she is ex
periencing
frustration.
• Wondering with
Josie about what Kira
is feeling and needing
in the moment.
• Speaking for Kira to

amplify her cues and
help convey her actual
intentions.
There are limited expe Expand oppor • Encourage mother

riences of shared joy tunities for and to use bright eyes and
between Josie and Kira. experiences of smile at Kira, with
shared positive games like peek-a-boo
affect and joy and mirror play.
through songs, • Speak for the baby
games, and to amplify her respon
play. siveness and shared
dyadic enjoyment.
Josie would like to con Josie will make • Josie will engage in
tinue to grow in aware initial phone individual and dyadic
ness of, and capacity to call to set ap psychotherapy to ad
tolerate exploring, the pointment for dress her own trauma
loss and trauma that individual ther and loss as well as
she experienced as a apy. dyadic support for her
young child and how relationship with Kira.
that may contribute to
her experience of her
daughter’s lack of re
sponsiveness at times
and age-appropriate
physicality.
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Encourage
Josie to consid
er trauma-in
formed child–
parent psy
chotherapy.
Client signature Mother–infant Date

dyadic thera
pist signature
Review of Other Parent–Child Interaction As

sessment Methods
Parent Interview Measures
Adult Attachment Interview

The AAI (George et al., 1996) is a semistructured, hour-long interview method consisting
of 18 questions used to classify a parent’s state of mind with respect to attachment. Par
ents are asked to describe their salient early childhood relationship experiences and to
give five adjectives that best describe their relationship with each parent, followed by
specific memories to support each adjective. Hesse (1999) described the central task on
this interview as “producing and reflecting upon memories related to attachment while si
multaneously maintaining coherent discourse with the interviewer” (pp. 396–397). The
narrative is classified as secure/autonomous, dismissive, preoccupied, or unresolved/dis
organized. An early study of AAI psychometric properties found moderate test–retest reli
ability of AAI classifications (dismissing, autonomous, or preoccupied; k = .63), but relia
bility was lower when the unresolved classification was considered (k = .56) (Bakermans-
Kranenburg & van IJzendoorn, 1993). When looked at with adverse childhood experiences
and emotional support, Murphy and colleagues (2014) found that the more adverse child
hood experiences and less emotional support the women experienced in childhood, the
more likely they were to be categorized as unresolved regarding past trauma or unable to
be classified on the AAI. Parents’ attachment classifications on the AAI have been found
to be associated with their child’s attachment behavior with that parent (van IJzendoorn,
1995). Tests of discriminant validity indicated that AAI classifications were unrelated to
non-attachment-related memory, verbal and performance intelligence, and social desir
ability (Bakermans-Kranenburg & van IJzendoorn, 1993). In a more recent examination of
adult attachment measures, Ravitz and colleagues (Ravitz, Maunder, Hunter, Sthankiya,
& Lancee, 2010) determined that the AAI “remains the most established instrument with
excellent psychometric properties” (p. 428).
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H. Steele and Steele (2008) suggested that beyond its use in research, the AAI is helpful
in clinical work. For example, when this interview is conducted at the beginning of thera
py, themes that emerge regarding the parents’ early attachment relationships can help
establish treatment goals and a therapeutic alliance. Another important clinical use of the
AAI is learning about a client’s experience of trauma and loss, defensive processes, repre
sentations of self and other, and ghosts and angels in the nursery. The AAI can also be
used to observe the client’s reflective functioning (H. Steele & Steele, 2008).
The Insightfulness Assessment

The insightfulness assessment (IA; Koren-Karie, Oppenheim, Dolev, Sher, & Etzion-Caras
so, 2002; (p. 62) (p. 63) Oppenheim & Koren-Karie, 2009; Oppenheim, Koren-Karie, & Sa
gi, 2001) evaluates parents’ capacity to empathically understand their infant, toddler, or
preschooler’s internal experiences of the world. The IA involves video recording the child
and parent during a play activity. Subsequently, the parent views segments of the video
during an interview designed to assess his or her perspective about the child. The IA
scales provide the basis for four classifications: positively insightful, one-sided, disen
gaged, and mixed. There is evidence to support underlying IA validity and reliability in
differentiating securely attached from insecurely attached parent–child dyads. Mothers
classified as positively insightful have been associated with securely attached children,
mothers identified as one-sided tended to have insecure/ambivalent children, and moth
ers in the mixed classification had children with insecure/disorganized attachment pat
terns (Oppenheim & Koren-Karie, 2002). In a recent review of studies examining the un
derlying utility and validity of the IA, Oppenheim and Koren-Karie (2013) found that the
disengaged classification is associated with emotional distance. They also found support
for using the IA with fathers, highlighting the usefulness of examining insightfulness with
other caregivers beyond the mother–infant dyadic context. Finally, change in parental
classification from noninsightful to insightful has been associated with improvement in
preschool children’s behavior following a therapeutic treatment program (Oppenheim,
Goldsmith, & Koren-Karie, 2004). Gray, Forbes, Briggs-Gowan, and Carter (2015) found
that 42% of this nonclinical, high-risk, low-income caregiver sample with violence-ex
posed children were considered insightful and that caregiver insightfulness was a protec
tive factor for children exposed to violence because children whose caregivers were re
flective and attuned on the IA were reported to have fewer behavioral problems and less
negative affect.
Parent Development Interview

The Parent Development Interview–Revised (PDI-R; Slade, Aber, Bresgi, Berger, & Ka
plan, 2003) is a 90-minute semistructured interview used to assess the parent’s reflective
functioning by asking the caregiver questions about mental representations of oneself, his
or her child, and their relationship (Slade, 2005; Slade, Grienenberger, Bernbach, Levy, &
Locker, 2005). The PDI-R includes questions about the present and ongoing parent–child
relationship that ask the parent to describe recent times when the parent and child got
along, when they did not get along, when the parent felt angry or needy, or when the
child needed attention (Slade et al., 2005). The interviewer records the parent’s response
Page 35 of 62

to events as well as the child’s response to the interactions described by the parent. Reli
ability is measured using intraclass correlations, which range from .78 to .95 (Slade et al.,
2005). The construct validity of the PDI is determined by looking at the association with
the AAI. Reflective functioning on the PDI is correlated with reflective functioning in the
AAI (Slade, 2005; Slade et al., 2005).
The PDI has been used in several clinical research studies, including with a population of
substance-abusing mothers. Suchman and colleagues used the PDI to assess maternal re
flective functioning before and after a 20-week mother–toddler therapy intervention and
found that the intervention did produce more maternal reflective functioning (medium to
large effect sizes) (Suchman, DeCoste, Castiglioni, Legow, & Mayes, 2008). Emotionally
avoidant language (use of more positive and less frequent negative feeling words) was al
so analyzed in the PDI with substance-abusing mothers. Borelli, West, DeCoste, and Such
man (2012) found that use of positive, but not negative, feeling words during the PDI was
correlated with lower reflective functioning, recent self-reported substance abuse, and
poorer maternal sensitivity.
Working Model of the Child Interview

The WMCI (Zeanah & Barton, 1989; Zeanah, Benoit, Barton, & Hirshberg, 1996) system
atically examines parental perceptions of their infant or toddler. Comprising an hour-long
interview, the WMCI has been found to be correlated with the child’s behavior in the
Strange Situation, classifications derived from the AAI, and mother–child interactive be
havior (Benoit, Parker, & Zeanah, 1997; Dayton, Levendosky, Davidson, & Bogat, 2010;
Zeanah & Barton, 1989; Zeanah, Benoit, Hirshberg, Barton, & Regan, 1994) and has been
adapted for use in clinical settings (Zeanah & Benoit, 1995; Zeanah, Larrieu, Heller, &
Valliere, 2000). Narrative features emerge that are considered clinical indices of the na
ture of the parents’ experience of the child. Concurrent validity with the PCERA (Korja et
al., 2010) and high interrater reliability (Rosenblum, Zeanah, McDonough, & Muzik,
2004) have been established.
(p. 64) Parent–Child Observation Measures
Atypical Maternal Behavior Instrument for Assessment and Classification

The Atypical Maternal Behavior Instrument for Assessment and Classification (AM
BIANCE; Bronfman, Parsons, & Lyons-Ruth, 1992–2004) is an expanded version of Main
and Hess’s (1992) coding system of frightened/frightening behaviors to include a broader
range of caregiving approaches presented in high-risk populations (Lyons-Ruth et al.,
2013). The AMBIANCE examines contradictory communications, maternal withdrawal,
and negative-intrusive and role-confused behaviors during the Strange Situation Proce
dure. More specifically, the AMBIANCE codes behaviors from an open-ended list that in
cludes more than 140 items, and ratings are assigned on a 7-point scale. Together, care
givers can be given a qualitative score that reveals a global level of disrupted communica
tion (Lyons-Ruth et al., 2013; Out, Bakermans-Kranenburg, & Van IJzendoorn, 2009). It is
also possible to assign a classification of either disrupted or nondisrupted communica
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tion. Role boundary confusion is defined as the extent to which a parent elicits affection
from his or her baby or draws the baby’s attention to him- or herself rather than following
the baby’s cues. In early studies of the AMBIANCE, maternal role boundary confusion in
infancy was found to be highly correlated with negative intrusive behavior toward the in
fant, as evidenced by hostility or unnecessary involvement with the baby’s ongoing activi
ty. Together, role confusion and negative intrusive behaviors were predictive of infant dis
organized attachment behavior during the Strange Situation Procedure (Lyons-Ruth et
al., 1999; Vulliez-Coady, Obsuth, Torreiro-Casal, Ellertsdottir, & Lyons-Ruth, 2013). Over
all, as a measure, the AMBIANCE has demonstrated adequate construct and discriminant
validity (Lyons-Ruth et al., 1999; Lyons-Ruth, Bureau, Holmes, Easterbrooks, & Brooks,
2012).
Coding Interactive Behavior

The Coding Interactive Behavior manual (CIB; Feldman, 1998) is a global rating system
for coding parent–infant interactions using a set of observable behaviors. The CIB has
demonstrated sensitivity to differences in parent–child interactions related to the family’s
culture, sex of the parent, social-emotional risk factors as well as biological risk factors,
and differences as a result of intervention (Feldman, Weller, Eidelman, & Sirota, 2003;
Keren, Feldman, & Tyano, 2001). The CIB codes 43 behaviors using a 5-point scale, with 1
indicating a minimal level and 5 indicating a maximal level of the specified behavior.
Twenty-two behavior codes pertain to the parent (e.g., intrusiveness, limit setting), 16 are
child codes (e.g., withdrawal, compliance), and 5 are dyadic codes (e.g., reciprocity, nega
tive state). The codes are averaged into several composite scores that are theoretically
based and meant to touch on varied aspects of the mother–infant relationship (Feldman &
Eidelman, 2009). The CIB is designed to code interactions with children ranging from
birth through adolescence. As a coding system, the CIB has demonstrated adequate inter
nal consistency and test–retest reliability and exhibited suitable predictive validity in nu
merous investigations with low- and high-risk samples (Feldman & Eidelman, 2009).
Clinical Problem-Solving Procedure

The clinical problem-solving procedure developed by Crowell and Feldman (1988) is
based on the tool-use task developed by Matas et al. (1978). Although formal coding sys
tems exist, the procedure can be used in clinical settings without regard to the research
coding (Larrieu & Bellow, 2004). This assessment was originally developed for use with
children ages 24 to 54 months old; however, it has been adapted for use with children 6
to 60 months. The Crowell procedure consists of nine episodes consisting of free play,
clean-up, bubbles, four teaching tasks, separation, and reunion. In this procedure, the
parent is given a variety of common toys and activities and instructed to play with the
child. Sprang and Craig (2015) found the clinical problem-solving procedure child and
adult scales to be internally consistent and appraised it for the thoroughly defined scales
and items. They suggested that the high internal consistency for each scale provides sup
port for use of the two separate scales measuring a child’s affective presentation and
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caregiver responsiveness or combined as a total score of relational functioning (Sprang &

Craig, 2015).
Emotional Availability Scales

The Emotional Availability Scales (EAS), fourth edition (Biringen, 2008; Biringen, Robin
son, & Emde, 1998), assess the emotional availability for both the parent and the child.
Emotional availability emerged as a relationship construct, in which members of a dyadic
interchange (e.g., parent and child) engage in reciprocal interactions, which, ideally, be
come smoother over time. The infancy and early childhood version of the EAS is used for
children from birth to 5 years old. Parental sensitivity, (p. 65) structuring, nonintrusive
ness, and nonhostility are assessed in the context of a parent–infant interaction. Children
are observed for their responsiveness and involvement with parents. The EAS uses global
ratings, taking the context into account, to make clinical judgments about the quality of
behavioral interactions. As an example, when using the EAS with disadvantaged dyads
across five age points in infancy and early childhood, Stack et al. (2012) found that mater
nal structuring was associated with responsiveness and maternal sensitivity was associat
ed with child involvement. The EAS has been found to be associated with security of at
tachment (Biringen, 2000), and when used during observations that last 15 minutes or
longer, the EAS demonstrated stronger predictive value of the attachment relationship
(Biringen et al., 2005). When comparing EAS scores in a laboratory setting and a home
setting, Bornstein et al. (2006) found strong cross-context reliability. In a large-scale re
view of the EAS, the measure demonstrated adequate to high interrater and test–retest
reliability and validity and documented change in emotional availability in relation to
therapeutic programming or intervention (Biringen, Derscheid, Vliegen, Closson, & East
erbrooks, 2014).
Nursing Child Assessment Satellite Training Parent–Child Interaction

Scales
The Nursing Child Assessment Satellite Training (NCAST) Parent–Child Interaction Feed
ing and Teaching Scales are based on observations made in the home to assess mother
and child behaviors on 149 variables: 76 in the Feeding Scale and 73 in the Teaching
Scale (Barnard, 1979; Kelly & Barnard, 2000; Sumner & Spietz, 1994a, 1994b). Designed
for use with infants and young children up to 36 months of age for the Teaching Scale and
up to 12 months for the Feeding Scale, the NCAST scales have been widely used with in
fants at risk as a result of prematurity, failure to thrive, and maltreatment (Farran et al.,
1990). The NCAST has measured the quality of mother and child interactions in samples
of children with developmental delays and social-economic disadvantages (Barnard,
1994). During feeding and teaching activities, the absence or presence of behaviors is rat
ed, indicating a mother’s sensitivity to her child’s cues, responsiveness to a child’s dis
tress, and ability to foster social-emotional and cognitive growth. For example, through
the use of the NCAST, Britton, Britton, and Gronwaldt (2006) found that mothers who
chose to breastfeed were more sensitive to their babies’ cues during interactions and that
sensitivity remained for mothers who continued to breastfeed beyond 3 months postpar
tum. Half of the items in each scale examine a dyad’s capacity for reciprocity and contin
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gent responsiveness, capacities considered important for learning and developmental

tasks. Children’s behaviors are rated on two subscales for clarity of cues and responsive
ness to the caregiver. The teaching scales for young children 3 months and older are
more strongly correlated with cognitive development than the feeding scales and have
predictive validity when examining children’s language and cognitive outcomes at 3 and 5
years of age. Although the domains of parental functioning in the NCAST are central to
positive parent–child interactions and early childhood social-emotional development, use
of the NCAST scales in mental health settings may be limited by presence/absence rat
ings, reducing the possibility of measuring incremental change with therapeutic interven
tion. The NCAST is primarily used by home-visiting nurses and social workers (Dallay &
Guedeney, 2016). Training and certification are required by a certified NCAST instructor.
Parenting Interactions With Children: Checklist of Observations Linked to

Outcomes
The Parenting Interactions With Children: Checklist of Observations Linked With Out
comes (PICCOLO; Roggman, Cook, Innocenti, Jump Norman, & Christiansen, 2013) is an
observational tool developed to measure parenting interactions. Specifically, the PICCO
LO examines aspects of developmentally accommodating caregiving approaches that fall
into four behavioral domains: affection, responsiveness, encouragement, and teaching.
Roggman and colleagues (2013) indicated that the predictive value for each of these do
mains may vary depending on the ethnicity and age of the child. The PICCOLO has exhib
ited interrater reliability across scales and internal consistency across scales, and confir
matory factory analysis demonstrated moderate to high factor loading across the four do
mains. Content validity was determined by having practitioners rate each item in regard
to its significance in caregiving, with the average rating of importance being 2.6 of 3.
Construct validity for the PICCOLO domains ranged from low to moderate when compar
ing it to another measure of parenting used in the Early Head Start Research and Evalua
tion Project at 14, 24, and 36 months of age. Predictive validity of the PICCOLO was de
termined based on significant (p. 66) correlations with later child language, cognitive, and
social-emotional outcomes (Roggman et al., 2013) and high correlations with other mea
sures examining the strength of child–caregiver relationships in childcare settings (Nor
man & Christiansen, 2013). The PICCOLO has shown promising utility for work with high-
risk families, particularly for practitioners working in home-based settings, because it
helps identify tangible recommendations and strategies and increases parenting self-effi
cacy by identifying areas of strength (Wheeler et al., 2013).
Parent Self-Report Measure

Parenting Stress Index
The Parenting Stress Index–Fourth Edition (PSI-4) is a 120-item, self-report inventory
measuring the parent’s perception of specific areas of stress in the parent–child relation
ship (Abidin, 1986, 2012). The PSI measures experience of stress within parent domains
(competence, isolation, attachment, health, role restriction, depression, spouse), within
child domains (distractibility/hyperactivity, adaptability, reinforces parent, demanding
ness, mood, and acceptability), and on a Life Stress scale. Parent and child items are
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scored on a 5-point scale (from 1 = strongly agree to 5 = strongly disagree). For the Life
Stress items, the respondent simply indicates whether a specific life event (e.g., divorce,
loss of job, and pregnancy) has occurred within the past 12 months. The PSI-4 has
demonstrated high internal consistency and test–retest reliability and has maintained its
factor structure, reliability, and validity across numerous translations (Abidin, 2012). The
PSI-4 also comes in a short-form version, which was derived from the long version and
takes approximately 10 minutes to complete (PSI-4-SF; Abidin, 2012). The PSI-4-SF con
tains three subscales, including Parental Distress, Parent–Child Dysfunctional Interaction,
and Difficult Child, and the sum of these domains allows the examiner to obtain a Total
Stress score. The PSI-4-SF has also demonstrated high internal consistency across items.
The PSI-4 has been revised to improve cultural sensitivity of language, while also includ
ing fathers in the standardization sample. Additionally, the normative pool was updated to
match the demographic composition of the 2007 U.S. Census (Abidin, 2012).
Diagnosis of Relational Disorder

Understanding the quality of the parent–infant relationship is an important part of devel
oping a diagnostic profile for infants and young children. The primary relationships of in
fants and young children contribute not only to the development of children’s personality
and structure of psychological defenses but also to young children’s beliefs about what is
possible to expect in relationships with others.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi

tion
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; Ameri
can Psychiatric Association, 2013), is a dimensional classification system developed to as
sist clinicians and researchers in the identification, study, and/or treatment of individuals
with mental health problems. Several diagnoses address disturbances in the parent–child
relationship. Reactive attachment disorder is defined as “a pattern of markedly disturbed
and developmentally inappropriate attachment behaviors, in which a child rarely or mini
mally turns preferentially to an attachment figure for comfort, support, protecting, and
nurturance” (p. 266). To receive this diagnosis, the child must have an underdeveloped
attachment relationship with his or her caregiver and show related symptoms before age
5. Specifically, this diagnosis requires emotionally withdrawn behavior toward caregivers,
social and emotional disturbances, and insufficient care of the child. Disinhibited social
engagement disorder is another diagnosis in the DSM-5 that describes a child’s response
to insufficient care. Children with disinhibited social engagement disorder may have no
or reduced inhibitions and approach and interact with unfamiliar adults in overly familiar
verbal or physical ways. This may include the child leaving his or her caregiver in unfa
miliar settings with no hesitation and rarely or never checking back with the caregiver.
Insufficient care (i.e., neglect, repeated changes in caregivers, unusual rearing settings)
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is a criterion for disinhibited social engagement disorder, and the insufficient care is
thought to be the cause of the disinhibited behavior.
The DSM-5 also includes codes for psychosocial and environmental conditions that should
be addressed by a clinician. The category of relational problems includes a code for par
ent–child relational problems: “the main focus of clinical attention is to address the quali
ty of the parent–child relationship or when the quality of the parent–child relationship is
affecting the course, prognosis, or treatment of a mental or other medical disorder” (p.
715). It is important to note that the parent in this definition is the primary caregiver of
the child, not necessarily (p. 67) the biological parent. This parent–child relational prob
lem is usually accompanied by behavioral, cognitive, or affective impaired functioning. Al
though not found in the DSM-5 system, the medical diagnosis of a nonorganic failure to
thrive has been associated with a disturbance in the parent–child relationship. This disor
der is usually recognized by the child’s pediatrician when a child who shows no other
signs of illness demonstrates poor growth patterns that cannot be accounted for by
parental growth patterns or further medical testing. Such patterns have been associated
with caregiver deprivation and neglect. These children often manifest other signs of child
neglect or maltreatment, such as poor hygiene and/or frequent accidental injuries (Tun
nessen, 1999). Table 3.6 illustrates several classification systems used for describing at
tachment disorders. Although these systems vary in their classification, each system de
scribes a disturbance in the balance between the child’s proximity-seeking and explo
ration of the environment.
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Table 3.6. Attachment/Relationship Classification Systems
System of clas Types Manifestations

sification
Strange Situa Secure Securely attached infants explore

tion (Ainsworth, Insecure- environment while intermittently
Blehar, & Wa avoidant making visual or physical con
ters, 1978; Main Insecure- tacts with parent; seek proximity
& Solomon, resistant of parent when distressed; reach
1986) Disorga for and seek comfort from parent
nized/dis following brief separation/re
oriented union.
Insecure-avoidant infants are up
set when left with an unfamiliar
person or in a strange setting.
During the reunion, they may ac
tively resist any attempts to be
comforted by turning away and
squirming to get down if picked
up.
Insecure-resistant infants have
difficulty feeling comfortable in a
strange situation; are warier of
strangers and tend to get more
upset when the parent leaves the
room; during separation/reunion
they show ambivalence to the
parent, first approaching and
then pushing the parent away.
Disorganized/disoriented infants
show an inconsistent mix of ap
proach and avoidance behavior
when reunited with parents after
a brief separation.
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Diagnostic and Reactive Children with reactive attach

Statistical Manu attach ment disorder rarely show prefer
al of Mental Dis ment dis ence to an attachment figure dur
orders, fifth edi order ing times of comfort, support,
tion (American Disinhibit protection, and nurturance; are
Psychiatric Asso ed social emotionally withdrawn from care
ciation, 2013) engage givers; have an impaired ability
ment dis to form new relationships; are in
order sufficiently cared for and com
Parent– monly experience childhood ne
child rela glect.
tional Children with disinhibited social
problem engagement disorder interact
with unfamiliar adults in overly
familiar verbal or physical ways;
do not or rarely check back with
caregiver after leaving the care
giver in unfamiliar settings; lack
hesitation when with unfamiliar
adults; have experienced insuffi
cient care (neglect, repeated
changes of caregivers, or unusual
rearing environments).
Children with parent–child rela
tional problem are in treatment
where the predominant focus of
treatment is the parent–child re
lationship or when the parent–
child relationship is affecting an
other medical or mental disorder.
Children show cognitive, behav
ioral, or affective functioning im
pairment.
International Parent– Children with parent–child con

Classification of child con flicts show problems in their rela
Diseases, 10, flict: tionships. These terms are used
Clinical Modifi Parent–bio to describe the necessity of treat
cation (World logical ment and used for billing and re
Health Organiza child con imbursement.
tion, 2016) flict
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Parent–
adopted
child con
flict
Parent–fos
ter child
conflict
DC:0–5 (Zero to Relation Children with a relationship spe

Three, 2016) ship spe cific disorder exhibit emotional or
cific disor behavioral disturbances in one
der relationship with a caregiver;
Reactive show aggression, fear, or self-en
attach dangering behaviors; refuse to
ment dis comply with sleeping, eating, or
order toileting; are at risk for potential
Disinhibit developmental harm; show signs
ed social of distress.
engage Young children with reactive at
ment dis tachment disorder are emotional
order ly withdrawn; have inhibited be
Axis II: haviors with adult caregivers; do
Caregiver– not seek developmentally appro
infant rela priate comfort when distressed;
tionship show minimal or no responses
(Part A) when comfort is given to them;
and care rarely engage in social reci
giving en procity with caregivers; have
vironment vchallenges with emotion regula
(Part B): tion (i.e., little or no positive af
Level 1: fect, fearlessness, and irritabili
well-adapt ty).
ed to good- Children with disinhibited social
enough re engagement disorder frequently
lation engage unfamiliar adults by go
ships; no ing with them, verbally or physi
clinical cally interacting with them, or be
concern ing unaware of their own familiar
caregivers’ whereabouts.
Axis 11:
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Level 2: (Part A) Caregivers in relation

strained to ships must ensure physical safe
concerning ty; provide for basic needs; con
relation vey psychological commitment
ships; at and emotional investment; estab
risk; inter lish routines and structure; rec
vention not ognize and respond to the child’s
required emotional needs and signals; pro
but moni vide comfort in distress; teach
toring is and socially stimulate; socialize,
suggested discipline, and engage in play;
Level 3: show interest in the child’s indi
compro vidual experiences and perspec
mised to tives; engage in reflectiveness to
disturbed ward child’s developmental tra
relation jectory; incorporate child’s point
ships; clin of view; tolerate ambivalent feel
ical con ings in the caregiver–child rela
cern; inter tionship.
vention re Considerations of the infant con
quired tribution to the relationship in
Level 4: clude temperamental disposi
disordered tions; sensory profile; physical
to danger appearance; physical health; de
ous rela velopmental status; mental
tionships; health; learning style.
clinical (Part B) Caregiving environments
concern; are characterized by the people’s
interven problem-solving; conflict resolu
tion re tion; caregiving role allocation;
quired and caregiving communication: in
urgent strumental; caregiving communi
cation: emotional, emotional in
vestment, behavior regulation,
and coordination; sibling harmo
ny.
International Classification of Diseases-10, Clinical Modification,

Parent–Child Conflict
The International Classification of Diseases-10, Clinical Modification (ICD-10-CM), is pub

lished and authorized by the World Health Organization and gives clinicians codes that
are used to communicate necessity of treatment and for billing and reimbursement. In
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the ICD-10-CM, three codes are given under the category of parent–child conflict: parent–
biological child conflict, parent–adopted child conflict, and parent–foster child conflict.
The parent–child conflict section falls under the larger category of problems related to
upbringing (World Health Organization, 2016).
Diagnostic Classification of Mental Health and Developmental Disorders of

Infancy and Early Childhood
The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy
and Early Childhood (Zero to Three, 2016) is a multiaxial classification system designed
to provide clinicians and researchers a diagnostic profile of an infant’s or young child’s
functioning within the context of his or her caregiving environment. The DC:0–5 is intend
ed to be used by infant mental health professionals in clinical settings who work with chil
dren through 5 years of age. The axes include Axis I, Clinical Disorders; Axis II, Relation
al Context; Axis III, Physical Health Conditions and Considerations; Axis IV, Psychosocial
Stressors; and Axis V, Developmental Competence. The DC:0–5 is a recently revised and
further developed diagnostic nosology expanding the age range and disorders in the DC:
0–3 and DC:0–3R. Of relevance to this chapter, DC:0–5 has included the relationship spe
cific disorder on Axis I and has expanded Axis II to include Caregiver–Infant/Young Child
Relationship Adaptation and Caregiving Environment and Infant/Young Child Adaptation
(Zero to Three, 2016).
The following relational disorders are on Axis I of DC:0–5.
Axis I: Relationship Specific Disorder

Relationship specific disorder focuses on the caregiver–infant/child relationship. A rela
tionship specific disorder is determined when “the infant/child exhibits a persistent emo
tional or behavioral disturbance in the context of one particular relationship with a
caregiver” (Zero to Three, 2016, p. 136). Zero to Three emphasizes the importance of
these symptoms manifesting in the context of only one relationship in the child’s life, not
presenting in more than one relationship. This disorder can be manifested in different
ways, including aggression, fear, self-endangering behaviors, refusal to comply (i.e.,
sleeping, eating, toileting), or opposition. The diagnosis is only given when the function
ing of the child or family is impaired. This impaired functioning may be seen as distress in
the child, impaired relationships, limited participation in developmentally appropriate ac
tivities, limited family participation in daily routines and activities, or limited ability for
the child to learn and develop appropriately (Zeanah & Lieberman, 2016; Zero to Three,
2016).
Axis I: Reactive Attachment Disorder

In DC:0–5, the original DC:0–3 reactive attachment disorder has been divided into two
distinct diagnostic classifications: reactive attachment disorder and disinhibited social en
gagement disorder. To receive a diagnosis of reactive attachment disorder, the child must
display “a pattern of emotionally withdrawn, inhibited behavior with adult caregivers”
and “a pattern of emotion regulation difficulties characterized by reduced or absent posi
tive affect and episodes of excessive or unexplained fearfulness or irritability/anger with
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caregivers” (Zero to Three, 2016, p. 126). The child’s withdrawn and inhibited behavior
must be characterized by no or minimal developmentally appropriate comfort-seeking
and social engagement (Zero to Three, 2016). To receive (p. 68) (p. 69) (p. 70) this diagno
sis, a child must have experienced insufficient care (neglect) and/or repeated change of
caregivers (limiting the child’s ability to form secure attachments), and these experiences
must be believed to have caused the child’s behaviors. Another criterion for this diagno
sis is that the child’s symptoms or the caregiver’s response to these symptoms are impair
ing and significantly impact the child’s and/or family’s functioning (Zero to Three, 2016).
Axis I: Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder describes a child with a history of neglect who
regularly and indiscriminately interacts with unknown adults without hesitation. This can
be manifested in willingness to go with unfamiliar adults, physically or verbally interact
ing with strangers, or lack of interest in following familiar caregivers’ whereabouts. As
with relational specific disorder and reactive attachment disorder, the symptoms experi
enced by the child are significantly impairing (Zero to Three, 2016).
Axis II: Relational Context

In DC:0–5, Axis II is used to describe one or more of the infant or young child’s primary
caregiver relationships, because the caregiving context is seen as central to every diag
nostic evaluation (Zero to Three, 2016).
Part A—Caregiver–Infant/Young Child Relationship Adaptation

Both dimensions of caregiving and the infant’s contributions to the relationship are as
sessed. The assessment should include observations of caregiver–infant interactions as
well as interviews with the caregiver to determine their attitudes toward and perceptions
of the child. These assessment methods are meant to focus on the dynamics between the
dyad, not the individuals themselves (Zeanah & Lieberman, 2016). The Parent–Infant Re
lationship Global Assessment Scale from DC:0–3 is no longer used to assess for Axis II. In
stead DC:0–5 uses a four-level scale “with more detailed relational anchors designed to
guide clinical intervention” (Zeanah & Lieberman, 2016, p. 518). Part A is composed of 14
Caregiver Dimensions (e.g., providing physical safety, structure and routines, discipline,
recognition and response to emotional needs and signals, and comfort for distress, as well
as reflective capacity and tolerance for ambivalent feelings in the caregiver–infant/young
child’s relationship) and 7 Infant/Child Dimensions (i.e., temperament, sensory profile,
physical health and appearance, mental health from Axis I, developmental status from Ax
es I and V, and learning style). Each of the Caregiver Dimensions and the infant contribu
tions is marked as an area of strength, a concern, or not a concern. These ratings then as
sist in categorizing the relationship into one of four levels: well-adapted to good-enough
relationships (Level 1; relationships that are not of clinical concern), strained to concern
ing relationships (Level 2; at risk and in need of monitoring and potentially intervention),
compromised to disturbed relationships (Level 3; clinical level requiring intervention), or
disordered to dangerous relationships (Level 4; clinical level requiring urgent interven
tion) (Zero to Three, 2016).
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Part B—Caregiving Environment and Infant/Young Child Adaptation

Part B allows the assessor to attain a more holistic view of the nature of family, caregiv
ing, and sibling relationships; communication quality, including collaboration and cooper
ation; and conflict resolution experienced by young children in their environment, and
therefore, more than individual relationships with caregivers must be evaluated. Part B is
composed of eight caregiving environment items to characterize the relationship network
of the child (Zero to Three, 2016). These ratings of strength, not a concern, and concern
contribute to the determination of levels of adaptive functioning of the caregiving envi
ronment. Similar to Part A, these levels include well-adapted to good-enough caregiving
relationships (Level 1; environments that do not need clinical attention), strained to con
cerning caregiving relationships (Level 2; there is need for monitoring and potentially in
tervention), compromised to disturbed caregiving relationships (Level 3; clinical level re
quiring intervention), and disordered to dangerous caregiving relationships (Level 4; clin
ical level requiring urgent intervention because of severe impairments in the family that
compromise the child’s development and safety) (Zeanah & Lieberman, 2016; Zero to
Three, 2016).
Because relationships are central to a young child’s health and development, it is impor
tant to note that if a child’s relationships have been determined to have an Axis II rating
of Level 2, 3, or 4 on Part A or B but the child is currently asymptomatic, that child may
be considered at risk for psychopathologies described in Axis I in the future (Zeanah &
Lieberman, 2016).
(p. 71) Integrating Culturally Sensitive Approaches

The integration of culturally sensitive and respectful approaches in the assessment of the
parent–child relationship is critical to obtaining an accurate picture of the young child in
the context of his or her family, community, and larger sociocultural environment. Parent
ing is inherently culture-bound. Each parent’s cultural worldview is influenced by a host
of intersectional identities including, but not limited to race/ethnicity, gender, orientation,
age, education, economic status, and religious beliefs (Lor, Crooks, & Tluczek, 2016). Cul
ture forms the child’s identity and sense of self, which makes cultural awareness especial
ly important in early childhood practice and research (Tamminen, 2006). The early par
ent–infant relationship is the child’s first introduction to culture. Around the world, early
parent–infant interactions share similarities and differences at various levels. For exam
ple, mothers from different cultures may all be responsive to a baby’s cry, yet they might
differ in how they choose to respond (i.e., touching the baby, feeding the baby, speaking
to the baby). Although there are similarities, these unique differences are a result of cul
ture (Tamis-LeMonda & Song, 2012). The meaning of the child and his or her behavior to
the parents as well as the parents’ response to the child will be shaped by the parent’s
cultural lens.
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Additionally, interactions will look different depending on a family’s community and cul
tural context. For instance, parents in Western cultures tend to vocalize to their infant,
gaze at their infant, and display objects to their child more frequently than parents in
African, Middle Eastern, and Far Eastern cultures. However, parents from these Eastern
cultures provide their infants with more physical contact than parents from Western cul
tures. Parents in Eastern cultures more commonly place their infants on their laps, invit
ing physical contact but no gaze, whereas parents in Western cultures are less likely to
have their children on laps, which provides less physical contact but more opportunities
for eye contact (Feldman, 2007). Even when comparing mothers of subcultures within the
larger Western culture, different parenting beliefs arise, which lead to differing parenting
practices (Senese, Bornstein, Haynes, Rossi, & Venuti, 2012). Some cultures value inde
pendence in the infant and toddler, while others value interdependence. Families in some
cultures must focus on the survival of their infants, while others are able to focus on the
achievements of their infants. The parents’ beliefs about infant development and the
forces that support infant learning and development may also differ and result in various
parenting styles across cultures (McCollum & McBride, 1997). Beliefs about successful
infant adjustment, age of reaching various milestones in early childhood, and when and in
what ways to care for the child depend on cultural beliefs and affect parenting strategies
(Bornstein, 2012). For example, Japanese families tend to want their children to be emo
tionally mature, showing self-control, good manners, and interdependence, while Ameri
can families tend to want their children to be independent, assertive, verbally competent,
and self-actualized (Bornstein, 2012). When assessing parenting approaches across indus
trialized cultures, Bornstein (2012) saw that mothers who focused on the infant’s physical
development had infants who became more motorically competent, and mothers who fo
cused on social interaction with their infant had infants who were more interactive with
their mothers.
Culturally congruent clinical assessments and interventions require continuous examina

tion of one’s own cultural beliefs and biases, a desire to learn about the cultural other,
cross-cultural engagement, knowledge of the family’s culture, and cross-cultural interper
sonal skills (Campinha-Bacote, 2002; Day & Parlakian, 2003; Dudas, 2012; Gaskins,
2006). Assessments should either be standardized within the populations they are used in
or revised to become conceptually, semantically, and operationally equivalent (Fisher et
al., 2002). Together, observational methods and consultation with cultural brokers (indi
viduals knowledgeable about the dominant culture as well as the particular underrepre
sented culture) can provide clinicians valuable insights and serve as liaisons between the
assessment team and family (Day & Parlakian, 2003; Klotz & Canter, 2006). For observa
tional relational measures, it is especially important to consider the infant’s entire care
giving network to determine who best to observe with the child. Discussing infant devel
opment and parenting beliefs with the caregiver(s) will also inform the assessors and aid
them in their interpretations (Miron, Lewis, & Zeanah, 2009). Bernstein, Harris, Long, Ii
da, and Hans (2005) suggested that observational assessments provide a strength from a
multicultural perspective and point to the importance of diversity in coders.
Page 49 of 62

The Diversity-Informed Infant Mental Health Tenets were developed by the Irving Harris
(p. 72) Foundation Professional Development Network (Irving Harris Foundation, 2012).
These tenets include the importance of self-awareness in regard to personal values and
beliefs, a diversity-informed stance toward infants and families (i.e., work to acknowledge
privilege and combat discrimination, recognize and respect nondominant bodies of knowl
edge, honor diverse family structures), practice/research field participants (i.e., under
stand that language can be used to hurt or heal, support families in their preferred lan
guage, allocate resources to systems change, make space and open pathways for diverse
professionals), and broader advocacy (i.e., advance policy that supports all families).
These diversity tenets are important in promotion of the professional’s self-reflection and
sensitive and respectful consideration of family values when conducting parent–child rela
tionship assessments.
Conclusion
In conclusion, assessment of the parent–child relationship and, when indicated, diagnosis
of a relationship disturbance or disorder are important components, if not the center
pieces, of a clinical assessment of mental health in the infant or young child. Actively en
gaging parents in the assessment process is respectful and fosters a partnership between
clinician and family in development of the therapeutic intervention. When parents take an
active role in the assessment process and feel their concerns, strengths, and motivations
have been heard and understood by the clinician, they are more likely to engage in the
assessment and follow-through with therapeutic intervention. By conducting assessments
of each member of the parent–child dyad as well as the dyadic and family unit, the clini
cian obtains information that is essential to developing treatment goals, ports of entry
and intervention strategies. Goals should be developed collaboratively with parents for
the child and each parent–child relationship. When assessing the infant or young child in
the context of his or her caregiving environment, it is critical that the process include the
acquisition of information from others such as day-care providers, pediatricians, mental
health providers, early intervention and home visiting programs, social services, alcohol
and other drug addiction treatment providers, and the court system. In our experience,
the most successful interventions involve coordination of services across settings with
regular communication. Empathically listening to the parents’ struggles and reflecting
their feelings and concerns enhances the therapeutic relationship between clinician and
parent. Finally, assessing the quality of the parent–child relationship should be an ongo
ing process because early childhood is a time of rapid change and parents are often faced
with increased challenges as well as opportunities for growth and development in the
parenting role, and the strengths and needs of the parent–child dyad will change as the
relationship evolves.
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Assessment of Early Parent Child Relationships

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Assessment of Early Parent–Child Relationships

Assessment of Early Parent–Child Relationships

Print Publication Date: Feb 2020 Subject: Psychology, Clinical Psychology

Abstract and Keywords

Using a relational approach to assessment integrates the theoretical application of devel­

Assessment of the Parent–Child Relation­

ship: Best Practices

Subscriber: OUP-USA Mirror; date: 10 August 2020

Interview With Parents

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Observations of Parent–Child Interactions

Subscriber: OUP-USA Mirror; date: 10 August 2020

A structured and systematic approach to assessing parent–child interactions is central to

Subscriber: OUP-USA Mirror; date: 10 August 2020

Table 3.1. Parent–Child Relationship Assessment Instruments: Parental Interview Measures

Instrument Age Domains Reliability(/validi­ Description

Adult Attachment Adult Narrative/adjec­ Moderate interrater Semistructured in­

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Table 3.2. Parent–Child Relationship Assessment Instruments: Parent–Child Observation Measures

Instrument Age Domains Reliability/validity Description

Subscriber: OUP-USA Mirror; date: 10 August 2020

Dyadic negative Shown sensitivity to

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

NCAST Parent– Fostering cognitive High concurrent va­ Training is re­

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Meaning of child Construct, concur­ Four 5-minute seg­

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Table 3.3. Parent–Child Relationship Assessment Instruments—Parent Self-Report

Instrument Age Domains Reliability/validity Description

Subscriber: OUP-USA Mirror; date: 10 August 2020

Parent–Child Early Relational Assessment

initially developed on a clinical intervention project funded by the National Institute of

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Subscriber: OUP-USA Mirror; date: 10 August 2020

Case Illustration of the Parent-Child Early Relational Assessment Relational

Subscriber: OUP-USA Mirror; date: 10 August 2020

Table 3.4. Parent–Child Early Relational Assessment: Relational Pro­

Area of Area of Area of

Parental tone of voice

Annoyed, angry, hostile X

Expressed positive af­ X

Expressed negative af­ X

Irritable, frustrated, an­ X

Parental expressed atti­

Parental affective and be­

Quality and amount of X

Subscriber: OUP-USA Mirror; date: 10 August 2020

Parent reads child cues X

Subscriber: OUP-USA Mirror; date: 10 August 2020

Dyadic affective quality of

Using a relational approach to assessment integrates the theoretical application of devel

Assessment of the Parent–Child Relation

Instrument Age Domains Reliability(/validi Description

Adult Attachment Adult Narrative/adjec Moderate interrater Semistructured in

NCAST Parent– Fostering cognitive High concurrent va Training is re

Meaning of child Construct, concur Four 5-minute seg

Table 3.4. Parent–Child Early Relational Assessment: Relational Pro

Expressed positive af X

Expressed negative af X

Irritable, frustrated, an X

Parental expressed atti

Parental affective and be

Frustrated, angry, hos X

Mutual enthusiasm, joy X

Dyadic mutuality in inter

Areas of relationship Goals Strategies/ap

Kira being smart and Kira will in • Encourage Josie to

Josie expressed difficul Expanding • Checking in with

There are limited expe Expand oppor • Encourage mother

Review of Other Parent–Child Interaction As

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi

System of clas Types Manifestations

Strange Situa Secure Securely attached infants explore

Diagnostic and Reactive Children with reactive attach

International Parent– Children with parent–child con

DC:0–5 (Zero to Relation Children with a relationship spe

Level 2: (Part A) Caregivers in relation

The International Classification of Diseases-10, Clinical Modification (ICD-10-CM), is pub

Culturally congruent clinical assessments and interventions require continuous examina