DOCTORAL PROGRAM IN PSYCHOTHERAPY

Universidad de Chile
Pontificia Universidad Católica de Chile

DOCTORAL DISSERTATION

AN ANALYSIS OF THE PARENTAL REFLECTIVE FUNCTION, THE QUALITY

OF TRIADIC INTERACTION AND ITS INFLUENCE ON EARLY CHILDHOOD
DEVELOPMENT

María José León Papic

Thesis Supervisor:

Marcia Olhaberry Huber, Ph. D. Pontifical Catholic University of Chile

Co-Tutor:

Vania Martínez Nahuel, Ph. D. University of Chile

Thesis committee:

María Pía Santelices Álvarez, Ph. D. Pontifical Catholic University of Chile

Thesis committee:

Miriam Steele, Ph. D. The New School for Social research, New York

Santiago, December 2017

 This investigation forms part of Fondecyt Start-up Project No. 11140230 (2014 –

2017) “Implementation and Assessment of an Intervention using Video feedback focusing

on Quality of Attachment and Parental Reflective Function, aimed at Mother-Father-Child

Triads with difficulties in Social-Emotional Development in Childhood,” part of the

Innovation Fund for Competitiveness (FIC) of the Ministry of Economy, Promotion and

Tourism, through the Millennium Scientific Initiative, Project ISI30005.

 Summary

The prevalence of social-emotional problems in early childhood continues at a high

level (Centro de Microdatos-Universidad de Chile, 2014). This stage is a critical period in

which the immediate family is the most influential system in childhood development

(Bronfenbrenner, 1987). Conversely, the parental reflective function (RF) is considered a

protective factor in early parenting (Stacks et al., 2014), assuming a relevant role in social-

emotional development in early childhood (Ensink, Bégin, Normandin, & Fonagy, 2016;

Smaling, Huijbregts, van der Heijden, van Goozen, & Swaab, 2016a).

Objective: To describe and analyze the relationship between fathers’ and mothers’ RFs, the

quality of the mother-father-child triadic interaction, and children’s psychomotor

development and social-emotional difficulties.

Method: A non-experimental, transversal and correlational study was developed. Fifty

mother-father-child triads, each in a current relationship that included at least one child from

12–36 months of age, were evaluated. Sociodemographic background, triadic interaction (LTP,

Fivaz-Depeursingue & Corboz-Warnery, 1999), parental RF (PDI-S, Slade, Aber, Berger,

Bresgi, & Kaplan, 2012, assessed by RF Scales, Fonagy, Steele, Steele, & Target, 1998),

psychomotor development (ASQ-3, Squires & Bricker, 2009) and social-emotional difficulties

(ASQ SE, Squires, Bricker, & Twombly, 2002) were measured. Couple relationship

satisfaction (RAS, Hendrick, 1988) and depressive symptoms in the parents (BDI-I, Beck,

Ward, Mendelson, Mock & Erbaugh, 1961) were included as control variables.

Results: A significant effect of the triadic interaction on the child’s social-emotional

difficulties was found. The effect explained 20% of the variance. However, this effect was

not found in the psychomotor development. In addition, the mothers’ RF had a significant
influence on the triadic interaction, explaining 21% of the variance. However, in contrast to

the hypothesis, the mothers’ and fathers’ RFs were not significant variables as direct or

indirect predictors to explain the child’s socio-emotional difficulties or psychomotor

development.

These findings show the importance of the RF on the quality of the mother-father-

child interaction, which in turn influences the child’s social-emotional development.

Additionally, the role of the father and the implications of these findings for research and

clinical purposes are discussed.

 Contents

1. Acknowledgements 11

2. Introduction 12

3. Theoretical and empirical background 17

3.1. Early Childhood Development 17

3.2. The study of the father-mother-child triad and the early family group 21

3.2.1. The origin of the study of the father-mother-child triad 21

3.2.2. Triadic interactions, couple relationship satisfaction and early

childhood development 23

3.2.3. Triadic interactions and childhood development 25

3.2.4. Parental depression, triadic interactions and early childhood

development 28

3.3. Parental Reflective Function 32

3.3.1. Parental reflective function and parenting’s quality and child

outcomes 35

4. The present study 43

4.1. General Objective 44

4.2. Specifics Objective 44

4.3. General Hypothesis 45

4.4. Specifics Hypothesis 45

5. Method 46

5.1. General design of the investigation 46

 5.2. Participants 46

5.3. Procedure 48

5.4. Ethical considerations 51

5.5. Measures and variables 52

5.5.1. Sociodemographic Background Sheet 52

5.5.2. Child psychomotor development 53

5.5.3. Child social emotional difficulties 54

5.5.4. Mother-father-child triadic interaction 55

5.5.5. Parental Reflective Function 60

5.5.6. Depression symptoms 62

5.5.7. Couple relationship satisfaction 63

5.6. Data analysis procedure 63

6. Results 67

6.1. Descriptive Analysis 67

6.1.1. Sociodemographic characteristics 68

6.1.2. Child’s psychomotor and social emotional difficulties 70

6.1.3. Triadic interaction, parental reflective function, couple satisfaction

and parental depressive symptoms 73

6.2. Correlational analysis 78

6.2.1. Associations between mother’s and father’s reflective function,

triadic interaction and child’ psychomotor and social-emotional

development. 81

6.3. Regression Analysis 85

 6.3.1. The triadic interaction, maternal and paternal reflective function as

predictors of the child’s psychomotor development 86

6.3.2. The triadic interaction, maternal and paternal reflective function as

predictors of the child’s social-emotional difficulties 87

6.3.3. Moderator analysis 88

6.3.4. The maternal and paternal reflective function as predictors of the

triadic interaction 91

7. Final model 93

8. Discussion 94

8.1. Ethical considerations 106

9. Reference 108

10. Annexed 138

10.1. Informed Consent Letters 139

10.2. Sociodemographic Background Sheet 145

10.3. Ages & Stages Questionnaires, Third Edition (ASQ-3) 149

10.4. Ages & Stages Questionnaires: Social-Emotional, Second Edition

(ASQ:SE) 158

10.5. Lausanne Triadic Play Procedure (LTP) 166

10.6. FAAS coding sheet 168

10.7. Parent Development Interview Revised, Short Version (PDI-S) 172

10.8. Coding sheet of Parental Reflective Function for Parent Development

Interview Revised 175

10.9. Beck Depression Inventory (BDI-I) 176

10.10. Relationship Assessment Scale (RAS) 178

10.11. Annexed tables 179

10.11.1. Annexed table 1. Mean comparison between participants from

control group and experimental group. 179

10.11.2. Annexed table 2. Mean comparison between boys and girls in

child psychomotor and social-emotional development 179

10.11.3. Annexed table 3. Correlations among study variables and its

subscales and covariables 180

10.12. Scientific publications related with the thesis sample

10.12.1. Family Triadic Interactions, couple satisfaction and Parental

Reflective Function in early infancy: ¿How work together? (Sent to review) 181

10.12.2. Couple Satisfaction and Depression: is Mentalization a Protective

Factor? (In review) 232

10.12.3. Evaluación de las interacciones tríadicas padre-madre-infante en

primera infancia: Una revisión sistemática (In review) 267

10.12.4. Video-feedback intervention to improve parental sensitivity and

the quality of interactions in mother-father-infant triads (Published) 298

10.12.5. Is it possible to improve early childhood development with a

video-feedback intervention directed at the mother- father-child triad? (Sent

to review) 312

10.13. Scientific publications non-related with the thesis sample

10.13.1. Video-feedback intervention in mother-baby dyads with

depressive symptomatology and relationship difficulties (Published) 343

11. Tables

Table 1. Variables and measures 52

Table 2. Psychomotor cutoff points depending on the questionnaire’s age 54

Table 3. ASQ-SE questionnaires description and cutoff points 56

Table 4. The FAAS scales—Brief summary 58

Table 5. Children’s sociodemographics characteristic 68

Table 6. Parents’ sociodemographic and clinical characteristics 69

Table 7. Means of the number of standard deviations of the cutoff point in each

area of child psychomotor development 71

Table 8. Means (SDs) on child’s percentage of socio-emotional difficulties 72

Table 9. Means (SDs) on mother’s and father’s reflective function, depressive

symptoms and couple satisfaction 73

Table 10. Triadic interaction total and subscales means and standard deviation 75

Table 11. Differences in the triadic scores, child’s psychomotor development

and child’s social-emotional difficulties between the three couple’s reflective

function groups 78

Table 12. Correlation between study’s variables and sociodemographic variables 80

Table 13. Correlations among study variables and covariables 83

Table 14. Regression and moderation analysis considering social-emotional

difficulties as dependent variable 90

Table 15. Regression analysis considering triadic interaction as dependent

variable 91
12. Figures

Figure 1. Study flow chart 50

Figure 2. The Lausanne Triadic Play (LTP) procedure 57

Figure 3. Percentage of couple reflective function groups 76

Figure 4. Comprehensive final model 93

 Acknowledgments

I would like to say thank you to the people that support me during this journey.

Thanks to my husband, Gonzalo for his support and for fly away together. Thanks to my

mother, because she was the first that always impelled to reach my dreams.

Thanks to Marcia, my thesis tutor, for her constantly support, generosity and for

dream together in this job. Thanks to Miriam and Howard for opening the doors of his

laboratory and allowing me to live an exciting year in New York.

Finally, there were many people that was so important during this four years, thanks

to all of them, specially, Cata, Javier, Nan, Marta, Coni, Dani, they made it an entertaining

and accompanied experience.

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 2. Introduction

Early childhood is considered a critical and sensitive period in a human being’s life,

worthy of in-depth study. When a baby is born, it is especially vulnerable to certain events

and experiences that, depending upon their presence or absence, have a specific effect on

the child’s growth (Siegel, 1999). Thus, the post-natal environment and initial interpersonal

experiences influence the structural and functional growth of an individual’s brain, general

development, and current and subsequent mental health (Schore, 2000).

National and international studies in early childhood development and mental health

show that 11%–37% of children have some social-emotional difficulties between ages 6–60

months (Bian, Xie, Squires, & Chen, 2017; Briggs-Gowan et al., 2013; Centro de

Microdatos-Universidad de Chile, 2014; Wendland et al., 2014). Similarly, psychomotor

development is an issue that we have not resolved as a society in either Chile or in other

countries of the world; 12–30% of children from 0–3 years present a delay or risk of delay

in psychomotor development (ASQ-3 Technical Report, Centro de Microdatos-Universidad de

Chile, 2014; Schonhaut, Armijo, Schönstedt, Alvarez, & Cordero, 2013). This prevalence is

highly important because early development lays the foundations for later development,

and studies show the links between early developmental difficulties and later behavioral,

cognitive and social-emotional problems (Briggs-Gowan & Carter, 2008; Cheng, Palta,

Kotelchuck, Poehlmann, & Witt, 2014; Essex et al., 2006; Giannovi & Kass, 2012;

Pihlakoski et al., 2006).

Thus, in early childhood, the immediate family (mother, father and child) is the

central and most influential relationship system in which a child develops (Bronfenbrenner,

1987). Interactions occurring in the mother-father-child triad constitute a complex process;

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consequently, studies show that parental behavior observed in dyadic contexts is not

necessarily the same as that observed in triadic contexts (Goldberg, Clarke-Stewart, Rice &

Dellis, 2002; Johnson, 2001; Lindsey & Caldera 2006). The ecological model and systems

theory allows us to understand the complexity of childhood development. These models

propose a holistic and integrated approach to observing reality, allowing the complexity of

human interaction to be appreciated and the evolution of the early family system to be

understood in which another hierarchically superior system is imposed that fosters the new

system’s growth (Bronfenbrenner, 1987; Fivaz-Depeursinge, Fivaz & Kaufmann, 1982).

Attachment theory and intersubjective currents coincide with the above, showing

that the human being, more specifically the human baby, is a psychologically active agent

with an intrinsic tendency to grow and a motivation to establish bonds of affection, to

communicate and to share with human beings who are “wiser” or have a greater likelihood

of survival (Bowlby, 1969; Trevanthen, 1892, 1993, 1998, 2001; Trevanthen & Aitken,

2001; Tronick, 1989). The actions of these “wise beings” integrate the baby into a “human

world” and provide him or her with knowledge of life in society and continuous and

coherent psychological organization (Stern, 1977, 1985).

The persons who are wiser and integrate the child into the “human world” are the

parents. However, although the child’s natural context exceeds dyadic interactions,

historically in psychology, the approach to understanding early child development has

primarily been by studying the dyadic interaction, centered in the mother-child relationship

(Fivaz-Depeursinge, & Corboz-Warnery, 1999). Given the dyadic understanding of

childhood social-emotional development, focusing on the fathers’ characteristics and the

mother-father-child triadic interaction has been secondary. However, we now know that the

father and mother interacting with their child is a key part of family and early childhood

13
development (Bronfenbrenner, 1987; Fivaz-Depaursinge, 1991; Fivaz-Depaursinge, Fivaz

& Kaufmann, 1982), particularly in terms of organization and coordination of the tasks

associated with raising children. The importance of this interaction is reflected in the type

of triadic function observed among father-mother-child. For the child, the ability to interact

in a triad is one of the main tasks in developing an autonomous self and in acquiring social

skills (Hedenbro, 2006; Leidy, Schofield & Parke, 2013)

For the other hand, the scientific literature concurs on which characteristics underlie

the development of sensitive parenting. One is the parental reflective function (Fonagy,

Steele, Steele, Moran, & Higgitt, 1991; Slade, 2005). Various studies have linked the

parental reflective function with the intergenerational transmission of the attachment

(Fonagy et al., 1991; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005), with

parental sensitivity (Grienenberger, Kelly, & Slade, 2005; Rosenblum, McDonough,

Sameroff, & Muzik, 2008) and with the child’s development of social skills and reflective

capacities (Ensink, Bégin et al., 2016; Smaling et al., 2016a; Steele & Steele, 2008).

Additionally, studies have considered the parental reflective function a protective

factor in early parenting (Borelli, Hong, Rasmussen, & Smiley, 2017; Stacks et al., 2014)

and a factor in the transmission of psychopathology (Ensink, Bégin, Normandin, & Fonagy,

2017; Esbjørn et al., 2013; Rothschild-Yakar, Waniel, & Stein, 2013).

Examination of the link between the triadic interaction, the parental reflective

function and child development is ongoing. To date, only one study has linked triadic

interaction and insightfulness (Marcu, Oppenheim & Koren-Karie, 2016). Hence, questions

relating these variables to child development remain open.

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 The above leads to the following research question: What is the relationship among

the mother’s reflective function, father’s reflective function, the quality of the triadic

interaction and the child psychomotor development and social-emotional difficulties?

This question leads us to the general objective of this investigation: To describe and

analyze the relationship between fathers’ and mothers’ reflective functions, the quality of

the triadic interaction, and children’s psychomotor development and social-emotional

difficulties.

To respond to the proposed general objective, a quantitative methodology with a

non-experimental, cross-sectional and correlational design was used. Fifty families were

evaluated, comprising a mother and father in a current relationship with one child from 12–

36 months.

Additionally, to achieve the aim of this study, the following variables were

evaluated: the parental reflective function was evaluated via individual interviews of each

parent, the triadic function was evaluated by recording family interactions, and childhood

development and control variables such as couple relationship satisfaction and parental

depression were measured using scales and questionnaires.

This study provides new information to help understand early childhood

development, which has traditionally been addressed from a dyadic perspective focused on

the mother-baby relationship. Understanding the relationship between 1) two fundamental

variables such as the quality of the father-mother-child interaction and the ability of parents

to reflect on their children’s mental states and 2) the influence of both on childhood

development allows exploring in greater depth and from another perspective the

development of children and family mental health. Additionally, the approach opens a new

area of research and intervention in family and child development and mental health in

15
which the role of the family and the father in early child development is considered at the

same level as that of the mother.

As you read this thesis, you will review research work done over a four-year period.

Beginning with the establishment of the problem, the document proceeds to describe the

theoretical and scientific framework that underlies it, the methodology that provides

robustness and reliability to the study, and the development of the findings. Finally, the

discussion and implications of these findings are presented.

I invite you to enjoy this journey and discover what happens beyond the dyad!

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 3. Theoretical and empirical background

3.1. Early Childhood Development

The first three years of life are the most rapid period of development in the human

lifespan. In this critical period, all areas of the child experience incredibly fast growth. The

brain increases in size four-fold during the preschool period, reaching approximately 90%

of adult volume by age 6, which is reflected in the children’s behavior and skills (Reiss, L.,

Abrams, Singer, Ross, & Denckla, 1996; Iwasaki et al. 1997; Courchesne et al. 2000;

Kennedy & Dehay 2001; Paus et al. 2001; Kennedy, Makris, Herbert, Takahashi, &

Caviness 2002; Lenroot & Giedd, 2006).

A wide range of theories has tried to describe and understand child development,

but no single one has been able to account for all aspects of child development. However,

developmental authors are agreed that early child development depends on constitutional,

maturational and environmental variables in which the environmental and mostly the early

family relationships play a crucial role, affecting how the brain grows and develops and

how the children build their cognitive, motor and social-emotional skills (Benz & Scholtes-

Spang, 2015; Greenspan, DeGangu, & Wieder, 2001).

Because of the multiples theories, finding a clear definition of child development is

not easy. A clear definition of psychomotor development is a gradual and continuous

process of acquiring motor, cognitive and communication skills that begins at conception

and culminates in maturity in which it is possible to identify stages of increasing

complexity. This development has a similar sequence in all children but with a variable

rhythm that depends upon the interaction of the child’s constitution and his/her context

(Illingworth, 1983 in Vericat, & Orden, 2013).

17
 Developing a definition of social-emotional development is more complex because

some social and emotional competences are family, community and culturally dependent.

However, it is known that this development also occurs in a continuum process that is

meaningfully integrated into more advanced levels of complex functioning. The social area

refers to the development of behaviors, abilities and competences that permit engaging and

positively interacting with others (e.g., siblings, peers, and adults) (Rose-Krasnor, 1997;

Squires et al., 2002). For its part, the emotional area, which overlaps with the social

competences, refers to the gradual ability to regulate the emotions effectively to achieve

some goal such as having positive social interaction, learning, and play. The development

of this competence is strongly embedded in early family interactions (Campos, Mumme,

Kermoian, & Campos, 1994; Lyons-Ruth, & Zeanah, 1993; Squires et al., 2002).

Thus, Greenspan and collaborators (2001) indicate that each stage of early

development can be understood as the result of specific patterns of interaction between the

caregiver and the infant. Similarly, Benz, and Scholtes-Spang (2015) propose that one of

the main developmental milestones in early childhood is the achievement of emotional

regulation, which occurs in early interactions with the caregivers and is key to successful

development.

Based on the theoretical background of child development mentioned, it is relevant

to review how the different abilities emerge in the first three years of life. Thus, among

development scientists, there is now a consensus that babies are born with an innate ability

to relate affectively and psychologically with others (Bowlby, 1969; Stern, 1985;

Trevanthen, 1892, 1993, 1998; Trevanthen & Aitken, 2001; Tronick, 1989). At the

beginning, the baby’s interaction is centered on person-to-person. At 3–4 months, empirical

studies have shown that babies already manifest indicators of coordination of attention and

18
affection toward both parents when interacting with them together. These findings suggest

that a child’s capacity to interact with two partners develops concurrently and not

subsequently to dyadic competences (Fivaz-Depeursinge, Favez, Lavanchy, De Noni, &

Frascarolo, 2005; Frascarolo, Favez, Carneiro, & Fivaz-Depeursinge, 2004; McHale, Fivaz-

Depeursinge, Dickstein, Robertson, & Daley, 2008).

At approximately 7–9 months, the ability to participate in three-person interactions

is clearer. The baby has developed purposeful communication, meaning that the child can

show his or her preferences by pointing, sharing states of mind by attracting attention and

influencing the mental states of adults (Wobber, Herrmann, Hare, Wrangham, &

Tomasello, 2014; Tomasello, Carpenter, Call, Behne, & Moll, 2005). The child also can

exchange looks with his or her father and mother in response to their affection and his or

her own emotional states (Fivaz-Depeursinge, & Corboz-Warnery, 1999), becomes able to

recognize the thoughts of others, and can share his or her own emotional states (Carpenter,

Nagell, & Tomasello, 1998; Trevarthen, 1993; Stern, 1985). These skills favor the

regulation of emotional states in contexts of more than two people because the child can

use positive emotional states to indicate its desire to continue the interaction and, in

stressful or annoying exchanges, the baby can express signs of upset to show its desire for

the exchange to stop (Fivaz-Depeursinge & Philipp, 2014).

Additionally, in the first year, the child acquires a whole set of new motor and

communication skills that significantly change how the body moves in and interacts with

the environment (Iverson, 2010). In the toddler years, the development of social

competence is based on milestones in other domains, including symbolic thought, focused

attention, and emotion understanding and regulation that allow the child to engage in more

complex social interactions, join in group activities, begin to form friendships, cooperate

19
with other people to achieve a goal, and function competently within a non-familial social

context (Denham et al., 2003; Feldman, Masalha, & Alony, 2006).

From birth, a nutritive context and sensitive care promote healthy development;

alternatively, a risky environment and conflictive family context negatively affect child

development (Hart & Risley, 1995; Sirin, 2005). Thus, the links between early

psychomotor and social-emotional difficulties and behavioral, cognitive and social-

emotional problems in late infancy are well documented (Briggs-Gowan & Carter, 2008;

Cheng et al., 2014; Essex et al., 2006; Giannovi & Kass, 2012; Pihlakoski et al., 2006).

Additionally, the number of children who today have early social-emotional problems

remains quite high. Different studies show ranges from 11%–37% of children with social-

emotional difficulties in children aged 6–60 months (ASQ-SE Technical Report; Bian et al,

2017; Briggs-Gowan et al., 2013; Wendland et al., 2014). In Chile, 17,1%–24,2% of

children from 12–60 months present social-emotional difficulties (Centro de Microdatos-

Universidad de Chile, 2014).

Concerning the psychomotor area, typically including the communication, cognitive

and motor skills, approximately 69% of the children from 0–66 months experience typical

development, 7,4% present one risk area of delay, and the remaining percentage have

problems in two or three areas (ASQ-3 Technical Report). In Chile, 71%–88% of children

0–3 years of age are in the range of typical development; the rest present a delay or risk of

delay in psychomotor development (Centro de Microdatos-Universidad de Chile, 2014;

Schonhaut et al., 2013).

The national and international data that were exposed show that we continue to owe

children developmental and mental health. Therefore, various countries have been

developing the ability to assess child development in the first year during medical visits

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(e.g., in Chile, this process is called “healthy child control”). Thus, screening child

development from birth is a powerful tool to detect and prevent later problems (Committee

on Children with Disabilities, 2001; Squires, Bricker & Twombly, 2004).

3.2 Study of the Father-Mother-Child Triad and the Early Family Group

How infant and toddler development is highly influenced by early relationships was

described in the above paragraphs. Thus, although the child’s natural context exceeds

dyadic interactions, historically in psychology, the approach to understanding child

development has primarily been by studying the mother-child interaction (Fivaz-

Depeursinge, & Corboz-Warnery, 1999). Fathers have been studied through the father-child

dyad. Such studies have ranged from research on fathers’ presence/absence and on gender

roles to the evaluation of closeness and involvement in rearing and their relationship with

childhood adjustment and development (Lamb, 2013). Conversely, triadic father-mother-

infant family relationships have long been ignored despite being a fundamental domain of

family and childhood development (Fivaz-Depeursinge, & Corboz-Warnery, 1999).

However, in the last decade, a growing number of researchers have been interested in this

important dimension of child and family adjustment.

3.2.1. Origin of the study of the father-mother-child triad

The study of the family, which developed from family therapy, arose in the 1950s in

the United States (Pereira, 1994). From the field of childhood, John Bowlby (1949) studied

the early family group to understand childhood adjustment problems. In 1985, Minuchin

developed structural family therapy, arguing that the parent-child dyad operates in the

context of family subsystems.

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 One of the pioneers in studying the family triad in early childhood was Michael

Lamb (1976), who observed 18-month-old children interacting with their parents. Parke,

Power and Gottman (1979) developed a model to conceptualize and quantify influence

patterns in the family triad. Belsky, Gilstrap and Rovine (1984) studied mother/father-baby

and mother-father dyads and proposed family classifications to analyze different

combinations of the three dyads. By the end of the 1980s, Lewis, in his study “The Birth of

the Family”, came close to determining that the triad is a total system (Lewis, 1989).

Elizabeth Fivaz-Depeursinge and collaborators also began studying triadic family

interactions in the 1980s, seeking to understand family and childhood development, and in

1987 published the first article on the family group addressing families with children in

early childhood (Fivaz-Depeursinge, 1987). At the beginning of the 1990s, an observational

system for analyzing triads was developed called “The Lausanne Triadic Play” (Corboz-

Warnery, Fivaz-Depeursinge, & Bettens, 1993).

The above studies show that the mother-father-child triad can be understood as a

unit with its own structure and characteristics, an entity with a different interaction from

that of the sum of the dyads in which the addition of another person alters the dynamics of

the interaction between dyadic subsystems and gives rise to a more diverse and complex

socio-emotional environment (Fivaz-Depeursinge, & Corboz-Warnery, 1999; McHale &

Fivaz-Depeursinge, 1999; Minuchin, 1985). From this perspective, the Lausanne team

proposed the structural and dynamic foundations of the family triadic interaction, which has

a hierarchical embedded function necessary to establishing a successful interaction. They

indicate that the family must first be corporally available to interact; then, they must

recognize and respect each role. They must also have a common focus of exchange and

sharing and the capacity to share affect. Concerning the dynamic foundation, the authors

22
indicate that every interaction must address fluctuations, transitions and adjustment

(Frascarolo et al., 2004; Favez, Lavanchy, Tissot, Darwiche, & Frascarolo, 2011).

3.2.2. Triadic Interactions, couple relationship satisfaction and early childhood

development

In the study of triad family interactions, the parental subsystem has been extensively

studied in terms of its effect on parenting. In this context, couple satisfaction, defined as the

global and subjective assessment of attitudes, feelings, and assessments of the positive and

negative aspects of the partner and the relationship (Hendrick, 1988), has been conceived as

a variable that plays an important role in the quality of family functioning (Shapiro,

Gottman & Carrère, 2000).

Empirical studies have considered the association between couple satisfaction and

co-parental alliance, triadic interaction and child outcomes. Longitudinal studies with

preschool children and their parents show a relationship between couple satisfaction and

family function, associating discord between parents with negative effects on parenting, co-

parenting and the child (Cummings & Davies, 2010; Davies, Cummings, & Winter, 2004).

Thus, low relationship satisfaction and high levels of conflict between parents have

negative emotional consequences in the child, primarily on his or her emotional regulation

skills and externalizing behavior at school age (El-Sheikh et al., 2009). Furthermore, well-

adjusted couple relationships positively correlate with greater family warmth, cohesion and

interactions and with a greater ability to resolve conflicts (Altenburger, Schoppe-Sullivan,

Lang, Bower & Kamp Dush, 2014).

Teubert and Pinquart (2010) conducted a meta-analysis with longitudinal studies

only, and detected that co-parenting is a significant predictor of change in child

23
psychological adjustment over the time; however, the size effect was small, so the results

should be interpreted with caution. Nevertheless, other longitudinal studies with a non-

referred sample show that marital satisfaction is not linked with child behavior or the

quality of the triadic interaction (Favez et al., 2012).

Additionally, marital satisfaction in a couple with children has a decreasing trend

over time, measured with a 24-month-old child (Kohn et al., 2012), a 30-month-old child

(Trillingsgaard, Baucom, & Heyman, 2014) and at preschool age (Simonelli, Parolin,

Sacchi, De Palo, & Vieno, 2016). Thus, Favez and collaborators (2006) found that for a

triad whose interaction was high quality during pregnancy, a decrease in that quality by

when the child was 18 months old was paradoxically predicted by particularly high marital

satisfaction. In contrast, a decrease in marital adjustment perceived by partners during the

transition to parenthood and until preschool age is associated with an improvement in the

quality of family interactions in this period (Favez, Frascarolo, Carneiro, Montfort, &

Corboz-Warnery, 2006). This observation suggests that a decrease in marital satisfaction is

a necessary and adaptive process for the transition from the dyadic system to the

establishment of triadic family interactions (Simonelli et al., 2016).

The exposed studies show some controversial results. On the one hand, some

studies report a positive and negative association between the variables (e.g., higher couple

satisfaction, higher co-parenting and lower couple satisfaction, lower co-parenting). On the

other hand, some studies show non-association between couple satisfaction and the other

variables, or when couple satisfaction decreases over time, the triadic interaction has better

quality. In summary, the association between couple satisfaction, triadic interaction and

child behavior is not completely consensual. One explanation could be how the studies

assess the variables (questionnaires, observational or interviews). Other possible

24
intervening variables that are not studied in these studies but affect the results (such as

parental stress and some sociodemographic variables) include the homogeneity or

heterogeneity of the sample, the range of the results of the assessed variables, and the

duration of the study, among others.

3.2.3. Triadic Interactions and Childhood Development

Because couple satisfaction has been associated with the quality of triad interaction,

the influence of the quality of early triadic interactions on child development has also been

studied. The ability to interact in a triad has been proposed as one of the main tasks developing

an autonomous self and in acquiring social skills, which are develop from experiences with

primary caregivers and depend on the quality of these interactions (Fincham, 1998; Sroufe,

1996). Consequently, when the child learns to create and maintain relationships involving

more than two people, he or she learns to share affection, attention and a common objective

among three people, learning to address feelings of exclusion by developing greater social

abilities (Liszkowski, Carpenter, Henning, Striano, & Tomasello, 2004; Fivaz-Depeursinge,

& Corboz-Warnery, 1999). Thus, researchers have shown how more positive experience in

a triad prepares children to function more competently with adults and peers in a non-

family, multi-person environment (Feldman & Masalha, 2010).

Empirical studies have shown the effect of the quality of the family triadic

interaction on child social-emotional competence. This influence can be seen at an early

age. For example, mothers and fathers demonstrated more positive and cooperative

interpersonal engagement and coordination in the triadic interaction and the Still-Face

procedure; when their babies were three months old, the infants showed more coordinated

gaze shifts from one parent to the other during the Still-Face challenge (McHale et al.,

25
2008). Likewise, Hedenbro and Rydelius (2014) found that a child’s capacity to make child

contributions and initiate turn-taking sequences at 3 months in the family triad is associated

with the parents' responsiveness, which in turn correlates with the child peer and social

competence at 48 months. Additionally, a higher degree of family coordination is

associated with more relational and social competence with peers at preschool age (Cigala,

Venturelli, & Fruggeri, 2014).

These results can also be found in other cultures. For example, in a normative

sample of Israeli and Palestinian children, infant reciprocity with the mother, engagement

with the father, and harmonious experience in the triad are important contributors to toddler

social competence (Feldman, & Masalha, 2010). Higher marital hostility, a higher level of

co-parental undermining behavior, and ineffective discipline were predictors of toddler

aggression in both cultures (Feldman, Masalha, & Derdikman-Eiron, 2010). Thus, a

longitudinal study that assessed children at infancy, preschool and adolescence indicated

that early maternal and paternal reciprocity were each uniquely predictive of social

competence and lower aggression in preschool, which, in turn, shaped dialogical skills in

adolescence (Feldman, 2010; Feldman, Bamberger, & Kanat-Maymon, 2013).

The evolution of the quality of the triadic interaction has also shown an effect in the

development of the theory of mind in early childhood. Thus, Favez et al. (2012) found three

different patterns of triadic coordination among infants to 5-year-olds (high to high, high to

low, and low to low). They also found that children in a family with stable, high-

coordination interactions obtained higher scores on theory of mind tasks and better

affective outcomes than did children in a family with a trajectory of high-to-low

coordination interaction over time. Moreover, children of the high-to-low group had better

outcomes in theory of mind tasks than did children of the families with a low stable

26
coordination group. These results illustrate the importance of the quality of the triadic

interaction in early childhood (3, 9 and 18 months) in the develop of the theory of mind,

which in turn shows the effect of early family interactions on the development of the

structure of the brain (Shore, 1997).

In terms of attachment, Frascarolo and Favez (1999) found no association between

problematic alliances and insecure attachment. However, in a low-medium income

normative Chilean and German sample, a study found that triadic family interactions were

linked to preschoolers’ attachment security levels (Pérez, Moessner, & Santelices, 2017).

Moreover, scientific evidence shows that mothers in nuclear families in Chile have a

higher quality of mother-child interaction compared with similar mothers in single-parent

families, suggesting that the father plays a favorable role in family heath and child

development (Olhaberry, & Santelices, 2013). Thus, different studies suggest that father

involvement has a positive effect on child development, the mother-father-child

relationship and the couple subsystem (Frascarolo, 2004; Pleck and Masciadrelli, 2004;

Sarkadi, Kristiansson, Oberklaid, & Bremberg, 2008; Wilson & Prior, 2010). For example,

higher levels of father involvement reported by parents corresponded with better interactive

competences in the triadic interaction (Simonelli et al., 2016).

Finally, Fivaz-Depeursinge and Favez (2006) suggest that the interaction between

the child and his or her mother and father can help resolve dysfunctional dyadic interactions

with the other parent because the intervention of a third party with adequate interaction

skills encourages the child to adopt new emotional regulation strategies during the

interaction, thereby reducing tension and stress. However, this proposal is controversial

because studies show contradictory results. For example, Johnson (2001) reports that triadic

contexts displayed less-negative parental behavior than in dyadic situations, and no

27
difference in warmth and responsiveness of the parental behavior between the two contexts.

Another study claims that mothers showed less-sensitive behavior to the child and more

intrusive behavior to the father in triadic contexts in which fathers participated than they

did during dyadic mother-child interaction (Lindsey & Caldera, 2006). Higher levels of

engagement between mother and toddler were associated with lower levels of father

positive parenting and children engaging with him in the triadic context (Kwon, Jeon,

Lewsader, & Elicker, 2012). More recently, Udry-Jørgensen, Tissot, Frascarolo, Despland,

and Favez (2016) showed that parents were significantly more sensitive in the dyad within

the triad context than only in the dyad context. Likewise, family alliance was globally

associated with sensitive parenting, suggesting that the triad is a protective factor for early

infant-parent dyads.

The differences between the dyadic and triadic interactions again show, as

Minuchin (1985) noted, that the family interactions are more than the sum of the various

family subsystems. These differences, could explain other factors that these studies do not

include; it could be that role distribution into the family, the time that each parent expends

with his/her child and the quality of the couple relationship influence these findings. In

addition, the parents’ reflective abilities facilitate think in the other partner and include and

support when interact in three.

3.2.4. Parental Depression, Triadic Interactions, reflective function and Early

Childhood Development

Depression commonly affects adults of parenting age. Depressive disorder had the

highest proportion of total burden across all regions of the world (Whiteford et al., 2010),

and it is one of the main disorders influencing the father/mother-child relationship. From 10%–

28
20% of mothers will be depressed at some time in their lives (National Research Council

and Institute of Medicine, 2009). In Chile, 27.9% (n = 1526) of the women and 11% (n =

908) of the men have depression symptoms from 25–44 years of age (Ministerio de Salud,

Gobierno de Chile, 2011).

The prevalence of postpartum depression in women has been estimated to be from

13%–19% (O'Hara, & McCabe, 2013) and to be approximately 10.4% in men (Paulson &

Bazemore, 2010), with rates three times higher in developing countries (Alvarado et al., 2000;

Evans, Vicuña, & Marín, 2003). Studies show that the number of women with postpartum

depression increases with time; 10% are diagnosed at 8 weeks postpartum, 22% receive the

same diagnosis at 12 months after the baby is born (Barlow et al., 2010), and many of them

can be chronified over time. In Chile, post-natal depressive symptoms affect approximately

40% of women (Jadresic, 2010).

Scientific evidence has shown that postpartum depression has a significantly negative

effect on the child psychomotor, cognitive, emotional and behavioral development (Agnafors,

Sydsjö, & Svedin, 2013; Pilowsky et al., 2008; Podestá et al., 2013; Weissman et al., 2006).

Research consistently associates maternal depression with difficulties in mother-infant

interaction (Olhaberry, Escobar et al., 2013; Hayes, Goodman & Carlson, 2013) and low levels

of self-confidence in themselves and in their role as mothers at the child's pre-school age

(Zietlow, Schlüter, Nonnenmacher, Müller, & Reck, 2014).

The effect of maternal depression on toddlers has been shown to have similar results

as the effect of postpartum depression on infants. Studies report that mothers with

depression symptoms experienced higher rates of conflict, more negativity, and were more

likely to respond destructively to child oppositional behavior than were mothers without

depression symptoms. Offspring of depressed mothers also displayed more tantrums

29
(Caughy, Huang, & Lima, 2009; Leckman-Westin, Cohen, & Stueve, 2009). Additionally,

children with mothers who had depression symptoms were more often excluded by peers

(Cummings, Keller, & Davies, 2005; Kam et al., 2011).

Conversely, mothers’ depression and hostility subclinical symptoms induce in their

infants motor behavior characterized by a major control of the environmental space (Piallini

et al., 2016)

However, causally linking maternal depression with outcomes in children is fraught;

other factors often moderate and mediate the links between maternal depression and the child

outcome. For example, studies show that maternal and paternal depression and negative

parenting behavior can be driven by elevated parental stress (Kamalifard, Hasanpoor,

Kheiroddin, Panahi, & Payan, 2014; Venta, Velez, & Lau, 2016). Alternatively, the negative

effect of the mother’s depression is marginal when mother-toddler interactions are positive

(Leckman-Westin, Cohen, & Stueve, 2009) or when the mother has good emotional regulation

skills (Kam et al., 2011).

Maternal depression also interferes in family function, reducing the ability to interact as

a triad and reciprocity in early social relationships (Feldman, 2007; Seifer, Dickstein, Sameroff,

Magee, & Hayden, 2001). In a longitudinal study with a low-risk sample, Tissot, Favez,

Ghisletta, Frascarolo, and Despland (2017) suggest that parental—mostly maternal—

depressive symptoms, even of mild intensity, might jeopardize the development of healthy

family-level relationships.

Moreover, cohesive families are associated with lower levels of maternal depression

and higher involvement by the father, whereas participation by the father reduces maternal

depression and increases family cohesion (Perren et al., 2003). Thus, Chilean studies show that

cooperative triads exhibit lower levels of depressive symptoms among parents than do non-

30
cooperative families, although more studies are required to explore these findings further

(Olhaberry, Santelices, Schwinn, & Cierpka, 2013; Pérez & Santelices, 2017).

Paternal depression has been studied less than maternal depression; however, paternal

depression also causes adverse effects on the father, on the mother’s mental health, on

relationship satisfaction, on the father’s support of the mother and child and on childhood

psychosocial development (Kane & Garber, 2004; Ramchandani et al., 2011).

Paternal depression increases through the child’s first 5 years of life (Garfield et al.,

2014), and approximately 10% of fathers have depression symptoms in the first year after

childbirth (Fletcher, Feeman, Garfield, & Vimpani, 2011; Paulson & Bazemore, 2010). The

depression affects the father’s style of parenting, reducing positive emotions such as warmth,

sensitivity and responsibility and increasing negative emotions such as hostility, intrusiveness,

and withdrawal. It also causes decreased involvement with his child (Huang & Warner, 2005;

Wanless, Rosenkoetter & McClelland, 2008; Roggman, Boyce, Cook & Cook, 2002; Wilson &

Durbin, 2010). Thus, depression increases the risk of adverse behavioral and emotional

outcomes and psychiatric problems in the child (Ramchandani et al., 2005, 2008).

Maternal and paternal depression are highly correlated (Paulson & Bazemore, 2010);

in comparing maternal and paternal depression, studies show that in fathers, the family

environment, including maternal depression, couple conflict and, to a lesser extent, paternal

noninvolvement, explain two-thirds of the total effect of paternal depression on the child’s

behavior at 3 years. The effect of the mother’s depression on the child was more strongly

associated with subsequent child problems than was paternal depression. Additionally,

family factors explain less than one-quarter of the child outcomes; thus, the association

appears to be better explained by other factors such as direct mother-infant interaction

(Gutierrez-Galve, Stein, Hanington, Heron, & Ramchandani, 2015).

31
 Conversely, depression is also strongly linked with a deficit in the ability to mentalize

the other or oneself, primarily affecting the ability to make inferences with respect to affection,

because this ability has been distorted by emotional states related to depressive symptoms

(Ladegaard, Lysaker, Larsen & Videbech, 2014; Mattern et al., 2015; Uekermann et al., 2008).

A higher mentalization focused on itself (e.g., self-absorbent reflection) at the expense of

mentalizing others could be one cause of the deficit in reflective ability produced by the

depression symptoms, which has been seen in substance abusing mothers with depression

symptoms (Borelli, West, Decoste, & Suchman, 2012; Suchman et al., 2010).

3.3. Parental Reflective Function

In the context of familiar mental health and parenting, mentalization has been

considered a highly important clinical variable that arose at the beginning of the 1990s from

the study of patterns and intergenerational transmission of attachment. It was developed by

Fonagy, Steele, Steele, Moran, and Higgitt, who introduced the concept of “Reflective Self-

Function” in 1991, which they defined as “the internal observer of mental life” (Fonagy et al.,

1991, p. 202). The function is intrinsically related to self-development and organization and is a

central aspect of human social function (Fonagy, Gergely, Jurist, & Target, 2004).

The concept of Reflective Function (RF) refers to the operationalization of the

psychological process preceding the ability to mentalize (Fonagy et al., 1998). The RF has an

intra- and an interpersonal component and measures the capacity to represent one’s own and

others’ behavior in the light of states of mind. This capacity requires the knowledge that

experiences give rise to certain beliefs, feelings and desires, which in turn tend to result in

certain types of behavior (Fonagy et al., 2004). However, to understand one’s own mind and

those of others requires underlying abilities such as the self-regulating abilities that typically

32
develop from secure attachment and that follow the development of the reflective function

(Fonagy & Target, 1997). Reflective functioning and affective regulation are highly

interconnected because self-regulation plays a fundamental role in the development of a sense

of self and agency, which is why the appearance of affective regulation precedes that of

mentalization (Fonagy et al., 2004).

Focusing on parenting competences resulted in the development of the concept of

Parental Reflective Function, which refers to parents’ ability to reflect on themselves as parents,

their ability to represent and understand the child’s internal experiences and their parent-child

relationship, and that links the child’s mental states with his or her behavior (Fonagy et al.,

1998; Slade, 2005).

Some central aspects of the parental reflective function construct are the following: first,

it must be contextualized in the child’s development stage; otherwise, his or her state of mind

cannot be correctly inferred (Slade, 2005). Second, the parents must recognize that states of

mind are opaque; they cannot be fully known and cannot be precisely inferred (Fonagy et al.,

1998; Slade, 2007). Third, parents must recognize that their own and their child’s states of mind

mutually influence one another (Fonagy et al., 1998; Rosenblum, McDonough, Sameroff &

Muzik, 2008). Ordway, Sadler, Dixon, and Slade (2014) include parents’ curiosity about their

children, non-compulsive reflection, recognition of the perspective of the person reflecting on

the other’s states of mind, and confidence in the child’s states of mind.

However, low reflective function levels or prementalizing modes exist and can be

characterized as lacking awareness of the subjectivity of the infant mental world (Fonagy et

al., 2016; Slade, 2005), as inaccuracy in interpreting the infant’s internal states (Meins et

al., 2012), and/or as distorted and often malevolent attributions (Allen, 2006).

Hypermentalizing and pseudomentalization are means of prementalizing modes. The first is

33
another cause of inaccuracy caused by the over interpretation of others’ mental states,

which can be quite intrusive. The second refers to the tendency to engage in mindreading,

but without genuineness, it is more a learned or cliché reflection (Allen, Fonagy, Bateman,

2008, Fonagy et al., 1998).

All of these pre-mentalization modes have been developed further from a theoretical

perspective because the main instruments to assess the reflective function are narrative

based (e.g., Parental development Interview, PDI, Slade et al., 2012; Adult Attachment

Interview, AAI, George, Kaplan, & Main, 1985). The modes are codified by the Reflective

Function Scale (Fonagy et al., 1998), which provides only a single score. Only the Parental

Reflective Function Questionnaire, PRFQ, whose preliminary validation has recently been

published (Luyten, Mayes, Nijssens, & Fonagy, 2017), takes some categories of the

reflective function concept.

It was mentioned that the reflective function and the parental reflective function

have the same origin; however, the focus is different. The first focuses on the general

capacity to reflect, whereas the second focuses on the capacity to reflect about the parenting

role and his/her child. Thus, the association between adult reflective function (assessed by

AAI) and parental reflective function (assessed by PDI) is not expected to be perfect. For

example, Steele and Steele (2008) found a medium significant correlation (r = .50),

showing that the RF is a dynamic, developmental, and bidirectional capacity that might be

to a significant extent context- and relationship-specific (Luyten et al., 2017). For example,

a sample of pregnant women with trauma experiences measured on the AAI manifested

specific deficits in the reflective function about the trauma but not in their general ability to

reflect (Bernazzani, Normandin, & Fonagy, 2014).

34
 Other concepts exist that explore the ability of parents to reflect on children’s mental

states. One of the concepts is Mind-Mindedness, which focuses on the recognition of the child

as a mental agent and a proclivity to use language about states of mind in discourse (Meins,

1997). A similar concept is that of Insightfulness, referring to the “ability to consider the

motives underlying children’s behaviors and emotional experiences in a complete, positive and

child-centered way, bearing in mind the child’s perspective" (Koren-Karie, Oppenheim, Dolev,

Sher, & Etzion-Carasso, 2002, p. 534). Insightfulness is based on the ability to see and feel

from the child’s point of view (Koren-Karie et al., 2002). These concepts are closely related to

the parental reflective function. However, studies suggest that parenting reflectivity is a more

global capacity that, for example, influences mind-minded comments (Rosenblum,

McDonough, Sameroff, & Muzik, 2008) because the concept considers more dimensions,

including the speaker’s own, others’ and the influence of each other’s reflection and also for the

deep way in which the reflective function is assessed.

3.3.1. Parental reflective function and parenting’s quality and child outcomes

Mentalization is considered a fundamental human ability allowing the development of

inter- and intrapersonal functions such as the regulation of affection and productive social

relationships (Slade, 2005). From early experiences with others, the child can find the meaning

of those experiences and build and organize representations about the child’s self and others,

differentiating internal mental reality from external mental reality (Fonagy et al., 2007; Slade,

2005).

From a development perspective, mentalization requires a mental operation in early

childhood in which one finds meaning for one’s own experiences and states of mind from the

states of mind of others (Fonagy et al., 2007). The early experiences with others create the

35
opportunity for the child to construct and organize representations of others and his or herself.

From birth, parents can recognize their children’s non-verbal intentions in which the face-to-

face interaction between infant and caregiver plays a fundamental role in the baby’s

development of representations of affection (Fonagy et al., 2004). The parents’ ability to bear a

representation of their child in mind is fundamental, attributing feelings, desires and intentions

to the child and allowing the child to discover his or her own internal experience via the

representation provided by the caregiver. A proper development of these representations allows

the differentiation of internal and external mental reality (Fonagy et al., 2004; Slade, 2005).

Related to the scientific development of the reflective functions, studies clearly show

three areas. The first, with the most research to support the role of reflective functioning, is the

intergenerational transmission of attachment and parenting (e.g. Steele & Steele, 2008).

The second, which has also been widely investigated, comprises risk samples and parents

with a history of childhood abuse and neglect, focusing on the mother and examining how

the intergenerational transmission of abuse, neglect, and psychopathology functions (e.g.

Ensink et al., 2017). The third area comprises children’s social-emotional outcomes, which

have been less covered (e.g. Kårstad, Wichstrøm, Reinfjell, Belsky, & Berg-Nielsen, 2015).

First, in terms of attachment and parenting, Fonagy and Target (2005) proposed

that the mother’s ability to mentalize allows her to create a physical and psychological

environment propitious for the creation of a secure base for the baby. This hypothesis has been

confirmed in different studies and from different perspectives. For example, one study showed

that a low parental RF is associated with the development of insecure attachment in one-year-

olds (Fonagy et al., 2016; Slade et al., 2005). Another identified an association with a greater

amount of maternal disruption in mother-infant affective communication (Grienenberger et

al., 2005). The authors also show that maternal reflective function predicts the security of

36
attachment beyond maternal sensitivity and the educational level, suggesting that parental

mentalization made an independent contribution and underlies the ability to respond

sensitively to the baby (Grienenberger et al., 2005; Rosenblum, McDonough, Sameroff, &

Muzik, 2008). These findings have also confirmed from the insightfulness (Koren-Karie et al.,

2002) and mind-mindedness perspectives (Meins, Ferryhough, Fradley & Tuckey, 2001);

studies found that higher reflective capacities and infant-parent attachment security were

associated with greater mind-mindedness, with stronger effects for fathers than for mothers

(Arnott, & Meins, 2007).

Conversely, Laranjo, Bernier, and Meins (2008) found that maternal sensitivity

mediates the relationship between mind-mindedness and infant attachment. Two studies

with a mixed sample consisting of women both with and without a history of maltreatment

in childhood found a significant association among maternal reflective function, parenting

sensitivity and secure attachment in which the parenting behaviors mediated the

relationship between reflective function and infant attachment (measured on PDI-RF,

Stacks et al., 2014; measured on AAI-RF, Ensink, Normandin, Plamondon, Berthelot, &

Fonagy, 2016). Finally, in a recently published meta-analysis, Zeegers, Colonnesi, Stams,

and Meins, (2017) suggest that parental mentalization and sensitivity play complementary

roles in explaining attachment security in which the mentalization exerts both a direct and

indirect influence on infant-parent attachment.

Not only the mother-child attachment and parental sensitivity studies have seen the

important role of the reflective function. Studies developed with the PRFQ show a

relationship between parental reflective functioning in mothers and distress tolerance of

their child (Rutherford, Goldberg, Luyten, Bridgett, & Mayes, 2013), which was replicated

and corroborated with a large sample, showing that pre-mentalizing modes correlated with

37
less persistence in a distress-tolerant task (Rutherford, Booth, Luyten, Bridgett, & Mayes,

2015). Currently, the same author suggests that parental RF might be associated with neural

responses to infant affective cues (Rutherford, Maupin, Landi, Potenza, & Mayes, 2017).

Conversely, studies that include a social risk sample have also been centered on the

mother, showing the reflective function as a protector factor to the parenting role. On the

one hand, the results have shown that higher reflective function is a protector factor of

intergenerational transmission of the trauma in mothers (Fonagy, Steele, Steele, Higgitt, &

Target, 1994). On the other hand, mothers with unresolved trauma and low reflective

functioning about the trauma were independent predictors of child disorganization

attachment (Berthelot et al. 2015). Additionally, reflective function was inversely

associated with social risk (education, social support, and substance use) and parenting

negativity (Smaling et al., 2015; Stacks et al., 2014). A study showed that mothers with

lower risk and higher prenatal reflective function when their baby was six months old

exhibited more positive behavior in interaction with their babies (Smaling et al., 2016a).

Mothers with higher risk and poor prenatal reflective function were related to relatively

high infant physical aggression, moderated by maternal intrusiveness (Smaling et al.,

2016b).

Similarly, in Chile, a medium-low socioeconomic sample of mothers studied with

the PRFQ found that insecure attachment and physical neglect in adults were related to

adult pre-mentalization scores (San Cristobal, Santelices, & Fuenzalida, 2017).

In the case of the fathers, the studies centered on substance abuse problems and

partner violence, showing that the fathers had a very limited capacity to think about the

thoughts and feelings of their children (Stover & Spink, 2012). Reflective function was

significantly negatively related to drug use and was correlated with years of education. This

38
relationship was consistent with the literature on mothers (Pajulo et al., 2012). However, it

was reported that the reflective function was not associated significantly with the quality of

the observed and self-reported parenting behaviors (Stover & Coates, 2016).

Related to child social-emotional outcomes, the relationship between mental and

emotion state understanding has been positively associated with social competence at the

preschool age (Cassidy, Werner, Rourke, Zubernis, & Balaraman, 2003), and the influence

of the parents’ (mother and fathers) mental understanding of that ability has been

demonstrated. Kårstad et al., (2015) found that the accuracy of parental mentalization

predicts in the child a greater emotional understanding at ages 4–6. A similar result was

found by Steele and Steele (2008), who showed that the mother reflective functioning

influenced the child’s development of emotional understanding and that the mother’s

reflective function is associated with the child’s reflective function at age 9 (Ensink et al.,

2015).

Heron-Delaney et al. (2016) found that preterm infants of high PDI-RF mothers

showed the most-negative affect and more self-soothing behavior during the Still Face

procedure, whereas infants whose mothers were rated lower on PDI-RF exhibited the most-

negative affect during the reunion-episode in the Strange Situation. Smaling et al. (2017)

found that in a young, pregnant, high-risk woman, prenatal RF was related to lower child

physical aggression when the child was 6, 12, and 20 months old. They also observed

moderating effects of intrusiveness and sensitivity in which higher prenatal reflective

functioning was particularly associated with less infant physical aggression in mothers who

showed no or low signs of intrusiveness. These findings show that a child with a mother

with a higher reflective function has more possibilities to express his/her discomfort when

doing so is expected and has more regulation skills.

39
 As was mentioned, the main method to assess reflective function provides only a

single score despite being a long, expensive and energy-consuming tool. For that reason, some

years ago, mentalization was studied as a multidimensional construct, observing two

dimensions for PDI-RF: self-focused (parent's capacity to mentalize about personal

emotions) and child-focused (parent's capacity to mentalize about the child's emotions and

their effect on the parent). The study showed that self-focused RF, compared with child-

focused RF, was a stronger predictor of maternal contingent behavior (Suchman, DeCoste,

Leigh, & Borelli, 2010). Smaling et al. (2016a) included one more dimension—

relationship-focused mentalization (mentalization about how dynamics in mental processes

influence interpersonal interaction and behavior)—and found that higher levels of self-

focused RF were related to more negative emotionality and externalizing problems in the

child. In addition, higher levels of relationship-focused maternal RF were linked with less

reported child physical aggression at age 20 months. These studies show that there might be

adequate reflective capacities about oneself but less about others, which, for example,

might occur in interventions that are focused on a person outside their relationships and

context.

The reflective function also has been shown to have an influence later in

development. Despite not being the focus of this study, it is interesting to understand how

the parental reflective function affects older children. For example, in preadolescents,

higher maternal reflective function was associated with fewer externalizing difficulties

(Ensink, Bégin et al., 2016; Ensink et al., 2017), and low maternal AAI-RF (but not low

paternal AAI-RF) was a predictor of higher levels of anxiety (Esbjørn et al., 2013).

Additionally, it was shown that children’s mentalization was significantly predicted by

maternal reflective functioning (Scopesi, Rosso, Viterbori, & Panchieri, 2015). In

40
adolescents, the mothers’ and fathers’ reflective function was associated with adolescents’

reflective abilities, but only the fathers’ mentalization was associated with social

competence (Benbassat & Priel, 2012). Adolescent females with eating disorders also

presented significantly lower reflective functioning levels. However, in the case of high

mentalization, these lower levels helped to reduce eating disorder symptomatology

(Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar,

Waniel, & Stein, 2013).

Recently, in a mother-child school-age sample, greater increases in cortisol in

mothers with low levels of reflective function were associated with more over-controlling

behaviors and predicted lower children's reflective abilities, whereas mothers with high

reflective function were associated with fewer over-controlling behaviors (Borelli et al.,

2017). These findings suggest that the maternal reflective function would facilitate

emotional regulation, reducing hostile and controlling behavior with children in times of

stress.

Through the infant life cycle, the study of RF has had different focuses of interest.

In the first years of the child's life, the focus has largely been on parental sensitivity and

attachment, on the mother-child relationship in particular. Later in development, studies

have included a greater variety of social and emotional variables and have examined the

child's outcomes. Conversely, the father, as a study variable, has been included later in the

child’s life cycle, with an increasing number of studies that include him as the child's age

increases.

To summarize, the studies presented show how the parental reflective function plays

an important role in the exercise of parenthood and throughout child and youth

development. The studies suggest that the function is a variable that favors parental

41
competences (Borelli et al., 2017), enhances children's emotional and social development

(Ensink et al., 2015) and is suggested as a protective factor for psychopathology (Ensink,

Bégin et al., 2016; Ensink et al., 2017; Esbjørn et al., 2013; Rothschild-Yakar, Waniel, &

Stein, 2013). Additionally, other studies have shown the RF to be a moderator or mediator in

the relationship between different variables. For example, the maternal reflective function

mediates the association between mother and child attachment (Grienenberger et al., 2005;

Slade, 2005); between mothers’ depressive symptoms and sensitive parental behaviors (Wong,

2012); among experiences of child abuse in parents and adolescent attachment style (Borelli,

Compare, Snavely, & Decio, 2015); and between the effects of accumulated risk and maternal

behavior (Smaling et al., 2016b). These points suggest that the parental reflective function plays

a central role in the intergenerational transmission of attachment and psychopathology.

42
 4. Present Study

Despite the scientific development in early mental health, the number of young

children who continue having developmental difficulties is quite high (Bian et al, 2017;

Briggs-Gowan et al., 2013; Centro de Microdatos-Universidad de Chile, 2014; Schonhaut

et al., 2013; Wendland et al., 2014). The findings of the reviewed studies found that the

mechanism underpinned sensitive parenting, a good parent-child relationship and good

child adjustment in which parental mentalization plays an important role. Nevertheless, the

study of the parental reflective function has been centered on the mother-child relationship

and how maternal characteristics contribute to explain the child’s development, despite

increasing evidence of the significant role of the father in child development and family

adjustment (Cabrera, Tamis-LeMonda, Bradley, Hofferth, & Lamb, 2000; Lamb & Lewis,

2004). Likewise, researchers have seen that the dyadic perspective does not reveal the

complexity and richness of triadic interaction and that the behavior of the mother, father

and child in a triad is not comparable to their behavior in dyadic interactions (Fivaz-

Depeursinge & Favez, 2006; Johnson, 2001; Kwon et al., 2012; Lindsey & Caldera, 2006).

Therefore, considering the antecedents exposed, study of the early father-mother-child

interaction together with the maternal and paternal reflective abilities is especially relevant and

is an important contribution toward understanding child development and family mental

health.

Therefore, the present study will contribute to answering the following research

question: What is the relationship among the mother’s reflective function, father’s reflective

function, the quality of the triadic interaction and the child’s psychomotor development and

social-emotional difficulties?

43
4.1. General Objective

To describe and analyze the relationship between father’s and mother's reflective function,

the quality of triadic interaction, and child’s psychomotor development and social

emotional difficulties.

4.2. Specific Objective

1. To assess the relationship between the father’s and mother’s reflective function and the

quality of the triadic interaction.

2. To assess the relationship between the father’s and mother’s reflective function and the

child’s psychomotor development and socio-emotional difficulties.

3. To assess the relationship between the quality of the triadic interaction and the child’s

socio-emotional development.

4. To evaluate the influence of the father’s and mother’s reflective function and the quality

of the triadic interaction on the child’s psychomotor development and social emotional

difficulties.

44
4.3. General Hypothesis

It is expected that the father’s and mother’s reflective function, the quality of triadic

interaction and the child’s psychomotor development will be positively associated and

negative associated with the child’s social emotional difficulties. And the first three

variables will influence the early childhood development.

4.4. Specific Hypothesis

1. It is expected that the level of father’s and mother’s reflective function will be

positively associated with the quality of the triadic interaction.

2. It is expected that the level of mother’s and father’s reflective function will be

positively associated with the child’s psychomotor development and negative

associated with the child’s social emotional difficulties.

3. It is expected that the quality of the triadic interaction will be positively associated with

the child’s psychomotor development and negative associated with the child’s social

emotional difficulties.

5. It is expected that the level of father’s and mother’s reflective function, and the quality

of the triad interaction will influence the child’s psychomotor development and social

emotional difficulties.

45
 5. Methods

5.1. General design of the investigation

This research uses a quantitative methodology with a non-experimental, transversal and

cross-sectional design. It is non-experimental as the variables will not be controlled and

participant selection will not be randomized. It is transversal as triads will be evaluated in a

single temporal and correlational moment, as the aim is to find a relationship between evaluated

variables.

The variables studied will be:

- Dependent variables: dependent variables are determined by their association with the

child and their importance in the concept of childhood development, including

psychomotor development and social-emotional difficulties.

- Independent variables: triadic interaction and level of paternal and maternal reflective

function were defined as independent variables.

- Control variables: couple relationship satisfaction, and paternal and maternal depression

symptoms were measured as co-variables.

5.2. Participants

The universe of the group of cases corresponded to 85 families participating in

Fondecyt Start-up Project No. 11140230 (see Figure 1). The sample was non-probabilistic,

selected by convenience. Of the 85 families, 60 were invited to participate in this sub-study

46
corresponding to the thesis to opt for the doctorate degree for the author of this study. Of these

60 families, 8 rejected participating, and the data for two were incomplete. Additionally, two

triads were excluded from the database; in one case, the mother’s PDI interviews were not

complete, and in the other case, the father’s PDI interviews were not complete. Concerning the

social-demographic characteristics, the data about child birth order (n=46) and attending

nursery or daycare (n=47) were not complete; however, those triads were maintained in the

study.

The sample of this study consisted of 50 Mother-Father-Child triads from Santiago,

Chile, with children from 12–36 months of age who have social-emotional difficulties. The

families were contacted through family health care centers or kindergartens or were referred by

study participants. All of these triads were participants in the Fondecyt Start-up Project No.

11140230 (2014–2017).

The inclusion criteria were fathers and mothers over 18 years of age, in a current

heterosexual couple relationship and with at least one child between 12 and 36 months,

who presents at least one of the follow social-emotional difficulties: sleep, feeding,

behavioral and emotional or relationship difficulties reported by the parents or by

professionals.

Exclusion criteria considered in the parents and children included the presence of

some disability (intellectual or of the senses), psychoses and/or addictions diagnosed in

adults as evaluated by the health services, by the educational institutions from which they

were referred, or at the first interview with the family.

47
5.3. Procedure

The population participating in this study was part of the Fondecyt Start-up Project

Number 11140230. Participants were referred from the family health care center, nursery and

kindergarten JUNJI (National Board of Children's Gardens of the Ministry of Education of the

Government of Chile) or by the study participants. Participants were contacted by telephone by

members of the research team, who explained the study in detail and evaluated the inclusion

and exclusion criteria. With those triads who met the criteria and agreed to participate, the first

evaluation sessions were coordinated and were held in the triad’s home.

The Fondecyt Project had two groups of participants, one experimental group and one

control group. Families are intentionally referred to one of two groups and were paired by

parents’ educational level and child’s age. Figure 1 shows the study procedure in detail.

The study begun with the triad’s assessment; two evaluators, one clinical psychologist

and one psychology student with previous training on the instruments, evaluated the family.

Both parents first signed the informed consent and then completed surveys about their

social demographic and psychological characteristics. Parents then responded to the

questionnaire related to their child’s psychomotor and social-emotional difficulties. Triadic

interactions were then video recorded. Each assessment took approximately one and a half

hours.

The participants of the experimental group then had a clinical intervention that included

seven sessions, two of assessment and five weekly sessions of video feedback, using video

recordings of interactions between adults and children. However, the participants from the

control group had two assessment sessions and a five-week wait.

48
 Then, both groups had a second assessment; parents again completed questionnaires

about their psychological characteristics and their child’s psychomotor and social-

emotional difficulties, and a new triadic interaction video was recorded. Finally, fathers and

mothers were invited to participate in an individual interview about parenting, which is unique

to this doctoral investigation project and was the author’s contribution to Fondecyt Start-up

Project No. 11140230. The parents who agreed to participate signed a new informed consent

with respect to this particular study. The interview was performed by a subgroup of

psychologists from the Fondecyt Project who were trained by the doctoral student in charge of

this project.

At the end of the second evaluation, all of the triads from the control group participated

in a brief intervention that included three video feedback sessions. The assessments were

conducted in 2016 and 2017.

49
Figure 1

Study flow chart

Initial contact: 131 triads

Does not meet inclusion criteria n = 29
Rejects participation n = 17

Participant triads n = 85 (˃12,69 infant socio-

emotional % problem ASQ-SE)
No randomization
Matching by toddler age and parent’s education

Experimental Group Control Group

n = 43 n = 42

Assesment 1
Attrition rate = 3 Attrition rate = 2

Video Feedback
intervention NO intervention
(5 session) n = 40 n = 40

Assessment 2
(EG n = 40) (CG n = 40)

Current study
Invited to participate n = 60
Rejects participation n = 8
Missing data n = 2
ASQ-3, ASQ-SE, PDI, LTP, BDI, RAS
(EG n = 22) (CG n = 30)

Video Feedback
intervention
(3 session) n = 40

50
5.4. Ethical Considerations

The Fondecyt study had the approval of the institutional Ethics Committee of

Human Research from the Catholic University of Chile and from the Chilean National

Commission of Scientific and Technological Research. This current study also received

ethical approval from the institutional Ethics Committee of Human Research of the University

of Chile.

Participating triads signed the informed consent forms of the Fondecyt Start-up Project

No. 11140230 and of this doctoral research. Both informed consent forms explained the

objective of the investigation, its benefits and risks, data confidentiality, and the voluntary

nature of participation. At the end of the study, triads with a need were referred to their health

services to continue treatment.

Only the responsible investigators of the Fondecyt and of this doctoral research had

access to participant names. The participants were identified in the database by a file number,

guaranteeing their anonymity. However, anonymity could not be guaranteed in the case of the

audio, transcription and videos; therefore, members of the investigation team that accessed the

data also signed a confidentiality agreement. Specific information on each triad cannot be

shared; however, general information obtained from the study can be published in the scientific

field.

51
 5.5. Measures and Variables

The following Table 1 shows the variables of the study, how they are measured and how

they are administrated.

Table 1
Variables and measures

Variable Type Variable description Instrument Administration

Dependent Child’s psychomotor development ASQ-3 Child

Social-emotional difficulties ASQ-SE Child

Independent Triadic interaction quality LTP Father-mother-child

Reflective function RF scale in the PDI Father and mother

Control Couple relationship satisfaction RAS Father and mother

Depression symptoms BDI Father and mother
Sociodemographic variables Socio-demographic sheet Father-mother-child

5.5.1. Sociodemographic background sheet

These sheets were used to collect participant sociodemographic information. They

included questions about child age, gender and birth order, child attending nursery or

kindergarten, parental age, parents’ number of children, parental education, parent job,

parental psychological/ pharmacological treatment and group of origin in the Fondecyt

study (control or experimental group).

52
 5.5.2. Psychomotor development

To assess psychomotor development, the Ages & Stages Questionnaires, Third Edition

(ASQ-3) (Squires & Bricker, 2009) was used. This instrument is a self-reporting questionnaire

for caregivers evaluating the development of children from 1–66 months of age. It consists of

21 questionnaires and scoring sheets at 2–60 months of age. It evaluates 5 areas of

psychomotor development: communication (babbling, vocalization, listening, and

understanding), gross movements (focused on arm, body and leg movements), fine motor

development (focused on hand and finger movements), problem solving (assess learning and

playing with toys) and the personal/social area (focused on solitary play and play with toys

and other children). Each area has 6 questions, in total 30 per set, and takes around 15

minutes. Parents must try activities to assess their child and respond to the items with Yes (10

points), Sometimes (5 points), or Not Yet (0 point); the maximum score is 60 points for each

scale.

The empirically cut off score provides 3 categories of results: at the expectation (child

is developing typically), the child is barely on the expectation (and must be closely

monitored) and below the expectation (the child might be at risk for developmental delays

and should be referred for further assessment; 2 standard deviations below the mean).

Because each set has different cutoff points depending on the questionnaire’s associated age,

one type of scale was created that consists of counting the number of standard deviations that

the child is from his or her age cutoff (see Table 2).

This instrument has a level of validity of 0.82–0.88, a test-retest reliability of 0.91, and

an inter-rater reliability of 0.92 (Squires & Bricker, 2009). In Chile, a validation was developed,

and the result shows adequate psychometric properties (sensitivity of 75%, specificity of 81%,

53
 positive predictive value of 47%, and negative predictive value of 9%) and concurrent

agreement compared with the Bayley-III (Schonhaut et al., 2013).

Table 2

Psychomotor cutoff points depending on the questionnaire’s age

Months Communication Gross motor Fine motor Problem solving Personal-social

12 15.64 21.49 34.50 27.32 21.73
14 17.40 25.80 23.06 22.56 23.18
16 16.81 37.91 31.98 30.51 26.43
18 13.06 37.38 34.32 25.74 27.19
20 20.50 39.89 36.05 28.84 33.36
22 13.04 27.75 29.61 29.30 30.07
24 25.17 38.07 35.16 29.78 31.54
27 24.02 28.01 18.42 27.62 25.31
30 33.30 36.14 19.25 27.08 32.01
33 25.36 34.80 12.28 26.92 28.96
36 30.99 36.99 18.07 30.29 35.33

5.5.3. Social-emotional difficulties

To assess the social-emotional difficulties, the Ages & Stages Questionnaires: Social-

Emotional (ASQ:SE) (Squires et al., 2002) was used. It is a self-reporting questionnaire for

caregivers that solely evaluates the social-emotional development of children from 3–65

months of age. It consists of 8 questionnaires covering the ages (6, 12, 18, 24, 30, 36, 48, and

60 months) and evaluates 7 areas of social-emotional development:

Self-regulation: Evaluates the child's ability or willingness to calm down, settle down or

adjust to psychological or environmental conditions or stimulation.

Docility: Evaluates the ability or willingness to conform to directions and instructions

54
 given by others and obey them.

Communication: Evaluates the ability or willingness to respond or initiate verbal or

non-verbal cues that indicate feelings, affections or internal states. Adaptive

Functioning: Evaluates the ability or willingness to cope with psychological needs, such

as sleeping, eating, safety, etc.

Adaptive function: Evaluates the ability or willingness to start by itself or to respond to

others without instructions (independence movements).

Affection: Evaluates the ability or willingness to demonstrate your own feelings and

empathy for others.

Person interaction: Evaluates the ability or willingness to respond or initiate social

responses to parents, other adults or peers.

To score the questionnaires, the parents’ responses to each item are covered with the

following points: 0 (often or always), 5 (sometimes) and 10 (rarely or never). In addition,

parents indicate whether the behavior of that item is a concern; if the parents check the box, 5

points are added to that item score. Thus, the maximum score by items is 15 points. The results

show two categories: (1) when the child is below the cutoff point, meaning above expectations

(indicating typical social-emotional development), and (2) when the child is above the cutoff

point, meaning below expectations, with more social-emotional difficulties (diagnostic

assessment is required). Because each questionnaire has different numbers of items and cutoff

points (see Table 3), to have one type of score, a percentage of each child's social-emotional

55
difficulties was calculated in relation to the maximum score possible for his/her age. According

to this criterion, the cut-off scores of the forms used vary from 12.69%–14.54%.

The questionnaire takes 15 minutes. This instrument has a level of concurrent validity

ranging from 71%–90%, with an overall agreement of 84%. Test-retest reliability is 89%,

and intra-class correlations were .91 (Squires et al., 2002).

Table 3

ASQ-SE questionnaires description and cutoff points

Questionarie's Number of Max. Total

Cutoff Cutoff in %
months items Score
12 22 330 48 14.55
18 26 390 50 12.82
24 26 390 50 12.82
30 29 435 57 13.10
36 31 465 59 12.69

5.5.4. Mother-father-child triadic interaction

To assess the triadic interaction, the Lausanne Trilogue Play (LTP; Fivaz-

Depeursinge & Corboz-Warnery, 1999) was used. This systematic observational tool

assesses mother-father-child interactions. The activity begins with the triad sitting around a

table forming a triangle. The following instructions are given: “Now you are going to play

as a family in four separate parts. (a) One parent plays actively with the child while the

other parent is present; (b) the parents switch roles; (c) then all play actively together; and

(d) the mother and father talk, and the child is simply present.” The family has between 10

and 15 minutes to complete the task. The interaction is recorded using two cameras, one

focused on the body and face of the parents, the other focused on the child. Figure 2 shows

56
the procedure.

Figure 2

The Lausanne Triadic Play (LTP) procedure

View of parent’s View of Child

Part I
Active dyad +
third party

Part II
Active dyad
+ third party

Part III
3 together

Part IV
Parent’s
discussion +
child playing on
his own

Note. Sourse. Centre d'Etude de la Famille (2007). Views according

to the 4 parts of the LTP. Indications for the LTP Setting for Toddlers, in Pérez and Santelices

(2017).

To codify the LTP, the Family Alliance Assessment Scales (FAAS; Lavanchy,

Tissot, Frascarolo, & Favez, 2013) procedure was used. The triadic interaction was

analyzed by FAAS (see Table 4). The scale assesses five triadic aspects and two subsystem

57
aspects, yielding one triadic total score and three subgroup scores: (a) triadic subsystem

score, (b) the co-parenting dyad, and (c) the child. (a) The triadic subsystems score includes

5 main scales with each subscale: Participation – postures and gazes; Organization – role

implication and structure; Focalization – co-construction and parental scaffolding; Affect

sharing – family warmth and validation; and Interactive sequence – interactive mistakes

during activities and interactive mistakes during transition. (b) The Co-parenting scales

included Support and Conflicts, and (c) the child contribution included Assertiveness and

Toddler engagement. Each dimension is scored (2 = adequate, 1 = moderate, 0 =

inadequate), and the sum of all of the triadic subscale scores ranges from 0–22 points. The

Co-parenting and Child Involvement aggregates, each of which could range from 0–4, plus

the sum of triadic aspects plus the subsystem aspects constitute the “family interaction

score”, ranging from 0–30 points and representing the functionality level of the interaction.

Table 4

The FAAS scales—Brief summary

Theoretical concepts Scales Brief description of appropriate criteria

Triadic susbcales

Participation Postures and gazes The non-verbal cues of the families indicate readiness and
willingness to interact with one another

Inclusion of partners Each and all partners in the interaction are included; no one is
excluded or excludes him/herself from the interaction

Organization Role implication Each partner sticks to his or her role during the play

Structure The game follows the expected interactive structure; all the tasks
requested by the instructions are implemented

Focalization Co-construction Turn-taking is respected, and each can participate without being
interrupted; the topic of the game is shared by all participants

58
 Parental scaffolding Stimulation is adapted to the child’s age and state, in the proximal
zone of development

Affect sharing Family warmth Affects are mainly positive during the interaction, the atmosphere is
warm and supportive

Validation Partners react implicitly to the emotional state of each other by

adjusting to it; if the child expressing negative affects, the parents
help him or her to regulate

Authenticity Affects are congruent with the situation and the behaviors displayed
by the partners; they are not forced or exaggerated

Timing/ Interactive mistakes There are few communication mistakes (misunderstanding,

synchronization during activities miscoordinations), and when they occur, they are repaired quickly

Interactive mistakes When a change in activities occur, the interaction is reorganized in a

during transitions smooth manner, with quick and resolved negotiations

Subsystem aspects

Co-parenting Support Both parents cooperate and support each other, at either an
instrumental or an emotional level

Conflicts No conflict is expressed between the parents, either at a direct,

verbal level, or indirectly by one parent’s interfering in the activities
of the other

Toddler Engagement Is expected to give to her parents enough signals (gazes, use of
words, emotional expressions) about her internal states to allow
them being adjusted

Assertiveness Has to deal with her/his will to impose her ideas, defy her parents at
moments but also negotiating with parents in order to reach a triadic
sharing.
Note. Adapted from Favez et al, 2011.

Studies conducted by the Lausanne team report mean scores of 19 points in a

normative sample and 10.3 in a clinical sample (Favez et al., 2011). Studies developed in

Chile report an average of 10.09 in a nonclinical population at a medium or low

socioeconomic level (Pérez, Moessner, & Santelices, 2017).

The FAAS showed moderate-to-good inter-rater reliability, κ = .61–.90, p < .05

(Favez et al., 2011). The alpha value obtained by the triads of the study was .901. Three

reliable coders, trained with the developers of the FAAS coding in Swiss, evaluated all of

59
the videos, 25% of them were three time coded to calculate the inter-rater reliability for

family scores, ICC=.97, showing an excellent score.

Additionally, categorical evaluation allows three types of Family Interaction to be

determined, with two possible classifications in each type, as revealed by the interactive

function analysis.

- Cooperative (Fluid or tense): the members of the triad work as a team. They participate,

collaborate, and are able to coordinate “well enough” around a joint task.

- Conflictive (covert or over): are a conflict among the triad, which permeates and

influences the family interactions. The triad are unable to coordinate “well enough”

to carry out the task. The conflict would be covert or over and observed in the parent

subsystem or as couple’s coalition towards the child.

- Disorder (with exclusion or chaotic): families with interactions characterized by the self

or hetero exclusion of one of their members. There is a lack or structure and

organization.

5.5.5. Parental reflective function (RF)

The parental reflective function was measured using the Parent Development Interview

– Revised, Short Version, PDI-S (Slade et al., 2012). The PDI-S is a semi-structured

individual interview of parents of children between the ages of 3 months and 14 years that

assesses the narratives of the current and specific relationship with a child. The PDI-S is

used to assess and code the parental reflective function in relation to the child, one’s own

parents, and the self, with questions such as “Describe a time in the last week when you

(and your child) really “clicked”, “What gives you the most joy in being a parent?”, “Does

(your child) ever feel rejected?”, and “How do you think your experiences being parented

60
affect your experience of being a parent now?” There are 29 questions; 15 demand the use

of reflective functioning, and those are coded. The interview takes approximately 40

minutes to complete and is videotaped and transcribed for coding purposes.

To assess RF, each set of questions was coded with the scoring system developed by

Fonagy and colleagues (Fonagy et al., 1998), as adapted for the PDI (Slade, Bernbach,

Grienenberger, Levy, & Locker, 2004). Scoring was based on an 11-point scale, from -1

(negative RF) to 9 (full or exceptional RF). Scores of 5 or greater are considered high

reflective and show clear and solid mental state understanding (Slade et al., 2005).

Scores equal to 3 show a questionable or low RF capacity, frequently use mental

state language such as “happy” or “sad” but without making a clear reflection about them,

and appear somewhat clichéd, banal or superficial. Otherwise, this score might represent

excessively deep and detailed but unconvincing and/or irrelevant responses (Slade,

Bernbach, Grienenberger, Levy, & Locker, 2004). Finally, scores of less than 3 show poor

RF capacity and are characterized as concrete explanations of behavior, avoiding references

to mental states or possibly containing self-serving statements or distortions. Additional

behavioral characterizations could include hostile, bizarre and negative (Slade et al., 2004).

Based on the “Poor”, “Low” and “High” RF, different combinations of the couple

RF level were formed—for example, one poor and one low or both low—that will be

presented later.

Studies conducted using the PDI and parental RF scale and reporting mean scores of

5 indicate typical RF in normative samples (Slade et al., 2005); however, in a high risk

simple, a score over 4 has also been found (M = 5.0, Perry, Newman, Hunter, & Dunlop,

2015; M = 4.57, Stacks et al., 2014). To date, no studies have been developed in Chile

using these tools.

61
 Reliability estimates using the coding manual have been shown to be good, with

ICCs ranging from .78–.95 (Slade et al., 2005). Two reliable coders evaluated the

interviews. Inter-rater reliability was calculated on 25% of interviews. Kappa and intra-

class correlation coefficient (ICC) analyses were κ=.76, p < .0001, ICC=.89, ranging from

.77–.95, which is considered adequate by the author of the instrument.

Considering the evidence shown in the theoretical and empirical background of this

study, parental depression symptom and couple satisfaction were included as a control

variable because of their influence in child development (El-Sheikh et al., 2009; Kam et al.,

2011; Leckman-Westin et al., 2009; Piallini, Brunoro, Fenocchio, Marini, Simonelli

Biancotto, & Zoia, 2016; Ramchandani et al., 2008), in the reflective function (Ladegaard et

al., 2014; Mattern et al., 2015; Uekermann et al., 2008) and in the quality of the triadic

interaction (Olhaberry, Santelices et al., 2013; Pérez & Santelices, 2017; Perren et al., 2003;

Simonelli et al., 2016). Socio-demographic characteristics that were significantly associated

with the study variables were also included as control variables.

5.5.6. Depression symptoms

The Beck Depression Inventory (BDI; Beck et al., 1961) was used to assess the

maternal and paternal depression symptoms. This questionnaire is self-reporting and is

composed of 21 items, each scored from 0–3 points, with a total score varying from 0–63 in

which higher scores indicate the presence of more symptoms. Additionally, four categories

of depression are identified: minimum, 0–9; mild, 10–18; moderate, 19–29; and severe, 30–

63. This questionnaire has been widely used and shows good reliability and validity levels,

with an α coefficient of .92 (Beck et al., 1961). The reliability analysis from the Spanish

62
version was adequate, with an α coefficient of .90 (Vázquez & Sanz, 1999). The Chilean

validation study of the instrument reports an alpha value of .92 (Valdés et al., 2017), and

the alpha values obtained by the participants of this study were .828 for the fathers and .832

for the mothers.

5.5.7. Relationship couple satisfaction

The Relationship Assessment Scale (RAS; Hendrick, 1988) was used to assess couple

satisfaction. The RAS is a self-reporting questionnaire that evaluates overall satisfaction

with the couple relationship with a unifactorial structure. It consists of seven items (e.g.,

"How do you consider your partner satisfies your needs? In general, how satisfied are you

with your relationship?"), each scored by a five-point Likert scale in which 1 corresponds

to the lowest level of satisfaction and 5 to the maximum score, with a total score varying

from 7 to 35, where higher scores indicate higher couple satisfaction.

For this study, we used the version adapted by the Chilean authors Rivera and

Heresi (2011), who reported an internal consistency of .90 in a Chilean sample. In the

present study, an α coefficient of .91 was obtained for the mothers and fathers.

5.6. Data Analysis Procedure

Data were analyzed using the statistical software IBM SPSS statistics version 21.0.

First, the triads were characterized by their socio-demographic characteristics and

subsequently by child psychomotor development, social-emotional difficulties, family

interaction, reflective function, parents’ depression symptoms and couple satisfaction. T-

tests were then conducted to assess the equivalence in the means of the parents’ and child

63
variables. “Couple reflective function” groups were created based on the “Poor”, “Low”

and “High” RF combinations of the mother and father RF—for example, one parent poor

and one low or both low). Then, analyses of covariance (ANOVA) were conducted to

examine the differences in the child psychomotor and social-emotional difficulties and in

family interaction scores among the “couple reflective function” groups.

Thereafter, a correlation matrix was computed with the main and control variables

to obtain preliminary results and to assess which co-variables and socio-demographic

characteristics would be used as a control variable in the next analyses.

Thereafter, different models of multiple linear regression analyses were performed

in which the child psychomotor development and social-emotional difficulties were the

dependent variables and the reflective function and family interaction were the independent

variables.

First, the requirements for OLS (Ordinary Least Squares) multiple linear regression

analysis were assessed for each regression model (Stevens, 2009). An analysis of influential

cases was performed for each model, considering potentially influential those with a

Leverage value greater than 2 points and those with a Cook distance greater than 1 point. A

non-case with these characteristics was found. Then, to ensure the absence of

multicollinearity, variance inflation factors (VIF) were reviewed. Both to assist with

interpretation of the data and to avoid the problems of collinearity, all of the predictors

were centered on their grand mean (Shieh, 2011). Only two moderator models had

collinearity problems, which will be mentioned later. Normal distribution of residuals was

assessed using a histogram of studentized residuals. Homogeneity of variance and linearity

of the model were assessed by plotting standardized residuals vs. standardized predicted

64
values. All procedures used indicated no significant deviation from the requirements of

multiple regression analysis.

First, to analyze the contribution of the mothers’ and fathers’ reflective function and

the family interaction on the five dimensions of the child’s psychomotor development, a

stepwise regression was conducted controlling for depression symptoms of the mother and

for some of the sociodemographic characteristics according to the correlation that they had

with the study variables.

Second, the contributions of the mothers’ and fathers’ reflective function and the

triadic interaction to the child social-emotional difficulties using an entry method were

analyzed with multiple linear regression. Two models were tested that, based on the

previous significant correlations, were controlled by mothers’ depression symptoms. One

used the eleven-point reflective function scale, and a second one used the reflective

function score as a dichotomous category (0 = not good enough RF, 1 = good enough RF).

All of the models in which the child social-emotional difficulties are the dependent variable

were conducted with the triadic subscale score instead of the triadic total score because the

triadic total score includes the child subsystem, which assesses the child engagement and

assertiveness, which in turn are parts of the child social-emotional development construct.

Thereafter, the reflective function as a moderator was examined. Four models were

tested, two for the mothers and two for the fathers. The first uses an eleven-point reflective

function scale, and the second uses the reflective function score as a dichotomous category

controlled by maternal depression symptoms. All of them were conducted with the center

on their grand mean to avoid problems of collinearity and to facilitate the data’s

interpretation.

65
 Finally, and according to the results, the influence of the mothers’ and fathers’

reflective functioning on the family interaction was studied using a linear regression with

an entry method. Two steps were tested; first, the fathers’ reflective function was

introduced in the equation, and then the mothers’.

All regression models were performed with variables centered on the grand mean to

avoid problems associated with collinearity. Only the coefficients that contribute

significantly to explain the variance of the study variables will be interpreted.

66
 6. Results

The results are presented in three segments. In the first section, a descriptive

analysis of the socio-demographic data and the study variables is presented. The second

section responds to objectives one, two and three; in this part, bivariate correlations

between the main variables, the control variables and the socio-demographic data were

tested to understand the relationship of the variables and to select which variables would be

retained for further analysis. To respond to objective four, a different multiple regression

model and moderator analysis was conducted to test the contribution of the triadic

interaction and the triadic interaction and the mothers’ and fathers’ reflective function on

the child’s psychomotor and social-emotional development.

6.1. Descriptive Analysis

First, a t test (independent sample) was performed to assess the homogeneity of the

sample between groups of origin (experimental or control) in child’s age, parent’s age and

years of education, child psychomotor and social-emotional difficulties, triadic interaction,

parental reflective function, depressive symptoms and couple satisfaction scores. It was

found that children’s fine motor movements and mothers’ reflective function had

significant differences across groups. Children from the experimental group had M = 1.86

(SD = 1.15) in fine motor, and the control group had M = 1.08 (SD =1.10), t = −2.41, df =

48, p =. 02. The mothers, who were participants from the experimental group in RF, had M

= 4.15 (SD = 1.09), and mothers from the control group had M = 3.33 (SD = 1.06), t =

−2.64, df = 48, p =. 01. The other variables did not differ significantly (see annexed table

1).

67
 6.1.1. Sociodemographic characteristics.

With respect to the child’s sociodemographic characteristics, the range of the child’s

age was from 12–36 months, and the mean age in months was M = 26.57 (SD = 7.59). As

shown in Table 5, most of our sample was firstborn, and one-half of the children attend a

nursery or daycare.

Table 5

Children’s sociodemographic characteristic

Variable f %
Girls 21 42
Boys 29 58
Months’ age
12 to 14 months 3 6
15 to 20 months 12 24
21 to 26 months 8 16
27 to 32 months 12 24
33 to 36 months 15 30
Desired pregnancy 38 76
Type of birth
Vaginal 30 60
Cesarean section 20 40
Was breastfed 46 92
Child birth order (n=46)
1 32 64
2 8 16
3o4 6 13
Attending nursery or daycare (n=47) 24 51.1

Concerning the parents’ sociodemographic characteristics, the mothers’ mean age

was M = 31.52 (SD = 4.84, range = 20–43), and the fathers’ was M = 33.58 (SD = 5.83,

range = 22–49). The range of children in these families was a minimum of 1 and a

maximum of 4, and the mean of children was slightly different from those of men (M =

68
1.57, SD = 0.71) and women (M= 1.72, SD = 0.86) because some members of couples had

children from other relationships. Of the participating couples, 69.6% were raising their

first child.

The level of education of this sample was high compared with the Chilean national

mean (M=13.1, range 19–20 years, and M=12.4, range 30–44, Ministerio de Desarrollo

Social, 2015). The mean in years was M = 15.16 (SD = 2.39) for women and M = 15.32

(DS = 2.39) for men. The range of education for mothers and fathers was 8–17 years, and

most of the couples were employed.

Table 6 shows more details about the social and clinical characteristics. To highlight

the clinical characteristics, the women of this sample have had more psychological and

pharmacological treatment than men.

Table 6

Parents’ sociodemographic and clinical characteristics

Mothers Fathers
Variable
f % f %
Level of schooling
Elementary 2 4 4 8
High School 11 22 5 10
Tecnical studies 8 16 11 22
Universitary 29 58 30 60
Has current paid work 39 78 48 96
Full-time work 25 62.5 47 95.9
Part-time work 14 35 1 2
Have had previous treatment 30 60 21 42
Psychological treatment 11 22 12 24
Pharmacological treatment 4 8 3 6
Psychological and pharmacological 15 30 6 12

69
 6.1.2. Child psychomotor and social-emotional difficulties.

First, t test (independent sample) was performed to assess the homogeneity of the

sample between boys and girls in child psychomotor development and social-emotional

difficulties. No significant differences were found (see annexed table 2). Therefore, the

analysis consecutively analyzes grouped boys and girls.

Concerning the frequency of children below expectations in the psychomotor

development, 70% of the children were above expectations for their age in the five areas

assessed by the ASQ-3. Fourteen percent had one area below the expectation, 10% had two

areas below the expectation, 4% had three areas below the expectation, and 2% of the

children had four areas below the expectation for their age.

With respect to the areas in which the children were below the expectations for their

ages, 8 (16%) children were below the expectations in communication, 1 (2%) in gross

motor, 6 (12%) in fine motor, 5 (10%) in problem solving, and 7 (14%) in personal-social

development. In summary, the areas in which the children had slightly more difficulties

were communication and personal and social development, which are more related to

relationships with others.

Table 7 provides the means of the number of standard deviations of the cut-off point

in each area of child psychomotor development. Again, the means of standard deviations

are positive, showing that the average of children meets the expectations by age for each

area of psychomotor development.

70
Table 7

Means of the number of standard deviations of the cutoff point in each area of child

psychomotor development

Variables M SD Min Max

Communication 1.46 1.26 -2.01 2.94
Gross motor 1.90 0.83 -.32 2.87
Fine motor 1.39 1.17 -1.70 3.06
Problem solving 1.50 1.08 -.95 3.21
Personal-social 1.50 1.07 -1.18 2.93

In relation to social-emotional development, 46% (f = 23) of the children were

above the cutoff at the ASQ-SE, which means that they presented social-emotional

difficulties. The mean of social-emotional difficulties was M = 13.67. Note that the limit

scores to consider social-emotional difficulties are from 12.69% to 14.55%. The mean of

social-emotional difficulties was greater than the limit score, indicating that the mean of

children in this sample have social-emotional difficulties. Additionally, the areas in which

the children showed more difficulties were in the self-regulation and interaction with

people difficulty area (see Table 8).

71
Table 8

Means (SDs) on child’s percentage of socio-emotional difficulties

Variables M SD Min Max

Overall percentage of social-emotional difficulties 13.67 7.14 2.56 37.93
Self regulation difficulties 18.74 12.33 0 55.55
Complacence difficulties 12.00 20.49 0 100
Communication difficulties 8.44 15.32 0 77.77
Adaptative functioning difficulties 14.00 14.56 0 58.33
Autonomy difficulties 15.00 18.21 0 66.66
Affect difficulties 5.11 6.43 0 22.22
Person interaction difficulties 12.85 11.46 0 55.55

% of social-emotional difficulties by range of age

12 – 17 months (n = 3) 19.70 4.55 15.15 24.24
18 – 29 months (n = 20) 13.65 7 2.56 28.21
30 – 35 months (n = 12) 12.45 5.41 6.9 24.14
36 months (n = 15) 13.46 8.78 5.38 37.93

f %
Children with social-emotional difficulties 23 46
Children without social-emotional difficulties 27 54

72
 6.1.3. Triadic interaction, parental reflective function, couple satisfaction and

parental depressive symptoms.

First, differences between the means of the fathers’ and mothers’ reflective function

scores, depression symptoms and couple satisfaction were explored with t test (independent

sample). No significant differences were found (see Table 9).

Table 9

Means (SDs) on mother’s and father’s reflective function, depressive symptoms and couple

satisfaction

Mothers (n = 50) Fathers (n = 50) 95% CI

Variable
M (SD) Min-max M (SD) Min-max t(df=48) p LL UL
Reflective function 3.64 (1.12) 1-6 3.56 (1.11) 2a6 0.45 .66 -0.34 4.42
Depression symptoms 7.40 (6.06) 0 - 34 5.36 (5.34) 0 a 28 1.7 .09 -2.15 1.59
Couple satisfaction 29.96 (4.84) 13 - 35 30.24 (5.94) 14 a 35 -.297 .77 -0.35 0.55
Note. CI = confidence interval; LL = lower limit, UL = upper limit, SE = Social-emotional.

The descriptive analysis of the triadic interactions and their subscale scores are

presented in Table 10. Subsequently, the analysis of the triadic interaction categories shows

that 24% of the triads have a cooperative interaction. This type of interaction is

characteristic of triads whose members work as a team to perform a given task, and the

partners coordinate, negotiate, and cooperate with each other to achieve an engaged

interaction. Some triads can be fluid and optimal, whereas others might be less fluid and

more tense.

Conversely, 54% show a conflictive interaction in which 52% of the triads have a

conflictive covert interaction that characterizes parents who do not coordinate themselves

“well enough” for the task to be performed. Occasionally the parents compete to attract the

73
child’s attention and create a special relationship, or other families present a couple’s

coalition toward the child. Commonly, in this type of triad, the parents express pseudo-

positivity affect despite the tension felt during the interaction. Only 2% of the triads have

overt conflictive behavior, with aggressiveness and hostile interactions.

Finally, 22% of triads have a disordered interaction, with 16% having an exclusion

interaction that characterizes partners whose main characteristic is the self or hetero

exclusion. This exclusion might result from the withdrawal of one of the family members

from the situation or from the exclusion of one of the family members by the other

interaction partners. Six percent of the triads have a chaotic interaction characterized by

partners who interact in a confused context, lacking structure or roles. The stimulations

they propose to the child are chaotic, not synchronous, discontinuous and unpredictable.

Related to the depressive symptomatology, 66% of the women and 78% of the men

presented minimum or non-depressive symptoms (score from 0–9), 32% of the women and

20% of the men presented mild depressive symptoms (score from 10–18), and 2% of the

women and 2% of the men presented moderate or severe depressive symptoms (score from

19–63).

74
Table 10

Triadic interaction total and subscales means and standard deviation

LTP’s subscales M SD Min Max

Participation 2.56 .97 0 4
Organization 2.4 1.1 0 4
Focusing and scaffolding 2.34 .69 1 4
Affect 3.70 1.43 1 6
Timing and synchronization 2.14 .86 0 4
Triadic Subscales Score 13.22 3.59 0 20

Subsystem subscales
Coparenting 2.76 .92 1 4
Toddler: engagement & assertiveness 2.46 1.1 0 4
Triadic Total Score 18.44 4.90 8 26

Quality of the triadic total interaction f %

Cooperative 12 24
Conflictive
Covert 26 52
Overt 1 2
Disordered
Exclusion 8 16
Chaotic 3 6

Concerning the parental reflective function, the results show that 24% of the women

and 18% of the men presented reflective functioning, showing a solid and clear

understanding of their own and others’ mental states. Sixty-four percent of the mothers and

68% of the fathers presented questionable or low reflective functioning, with frequent use

of mental state language such as “happy” or “sad” but without showing a clear or explicit

understanding of their statement. Finally, 12% of the mothers and 14% of the fathers

presented poor reflective functioning characterized by concrete explanations of behavior,

75
avoidance of references to mental states, or possibly containing self-serving statements or

distortions.

To understand how reflective functioning in the parent couples works, “couple

reflective functioning” groups based on “Poor”, “Low” and “High” reflective function were

created, and different combinations between the couple reflective function level were

formed. Graphic 1 shows the couple reflective function groups and distribution. It is

interesting to appreciate how in most couples, both parents have low reflective functioning,

and the extremes, both poor and both reflective, were less represented. Additionally, it is

interesting to notice that the group in which one parent scored poorly and the other scored

reflective does not appear in this sample, showing that couples are similar in their level of

reflective functioning.

Figure 3

Percentage of couple reflective function groups

50

40 44

30

20
22 22
10
2 10
0

¨ Both parents poor (3 – 4)

¨ One parent poor (0 – 2) and other low (3 – 4)
¨ Both parents low (3 – 4)
¨ One parent low (3 – 4) and other reflective (≥5)
¨ Both parent reflective (≥5)

76
 To compare the mean of triadic interaction, child psychomotor development and

child social-emotional difficulties across the couple reflective functioning groups, the five

groups were redistributed in three categories to increase the number of couples in each

group. The new distribution was (1) Poor/Low (included both parents poor and one parent

poor and other low), (2) Low (included both parents low) and (3) Low/high (included one

parent low and the other reflective or both parents reflective). Table 11 shows the one-way

ANOVA with the couple reflective function groups as the independent variable and triadic

score as the dependent variable.

Follow-up contrast analyses using a Bonferroni post hoc test revealed a significant

difference between the triadic scale means among the couple reflective groups, showing

that the main differences are in the extreme groups (Poor/Low and Low/High). In the co-

parenting mean, the difference was between the Poor/Low and Low/High couples.

Concerning the toddler contribution mean, a barely significant difference between

Poor/Low and Low/High couples was found. In the triadic subscale score and triadic total

score, the analyses revealed significant differences between Poor/Low and Both Low

couples and between Poor/Low and Low/High couples; no differences were found between

Both Low and Low/High couples. These results show that triads with Poor/Low reflective

functioning couples had a significantly lower mean in the quality of their triadic interaction

than did the other groups, the Low/High couples in particular.

With respect to social-emotional difficulties and psychomotor development, no

differences were found between the different couple groups.

77
 Table 11

Differences in the triadic scores, child’s psychomotor development and child’s social-
emotional difficulties between the three couple’s reflective function groups

Poor/Lowa Lowb Low/Highc

(n = 12) (n = 22) (n = 16)
M (SD) M (SD) M (SD) F
Coparenting 2.08 (0.55)ac 2.82 (0.91) 3.19 (0.91)ac 6.12*
Toddler contribution 1.83 (0.72)ac 2.41 (1.18) 3.00 (0.97)ac 4.53*
Triadic Subscales Score 10.25 (3.02)abc 13.23 (4.42)ab 15.44 (2.61)ac 9.68*
Triadic Total Score 14.17(3.10)abc 18.45(4.66)ab 21.63(3.44)ac 11.28*
Social-emotional difficulties 14.90 (8.51) 14.22 (6.72) 11.99 (6.77) 0.67
Communication 1.14 (1.07) 1.60 (1.24) -1.51 (1.44) 0.53
Gross motor 1.71 (.62) 2.07 (.78) 1.82 (1.01) 0.86
Fine motor 1.28 (1.32) 1.47 (1.11) 1.36 (1.22) 0.11
Problem-solving 1.37 (.76) 1.69 (1.12) -1.32 (1.23) 0.64
Personal-social 1.88 (0.80) 1.45 (1.05) 1.28 (1.25) 1.13
Note. *p < .01. < >=different; a < >c; a < >b< >c; a < >b.
Poor/Low = Both parents poor (0-2), or one poor and one low (3-4)
Both Low = Both parents Low Reflective (3-4)
Low/High = One parent Low (3-4) and one High, or both High (≥5)

6.2.Correlational analysis

First, the associations between the main study’s variables (mother and father

reflective function, LTP scores, child psychomotor and social-emotional development) and

sociodemographic variables (group, child age, gender and birth order, child attending

nursery or daycare, parent age, parent number of children, parent years of education, parent

has a job, and parent has/had psychological/ pharmacological treatment1) were examined.

The associations are presented in Table 12. The significant correlation between the study

variable and the sociodemographic variables is controlled in the subsequent analysis; in the

1
Group (0 = control, 1= experimental), child attending nursery or daycare (0 = no, 1 = yes), parent has a job
(0 = no, 1 = yes), parental psychological/ pharmacological treatment (0 = no, 1 = yes)

78
case of child psychomotor development, the significant associations were as follows:

child’s communication correlates positively with attending a nursery, negative birth order,

and the mother's number of children. Gross motor development correlates negatively with

the mother's and father’s years of education. Fine motor development correlates positively

with the child’s age and group. Personal-social development correlates negatively with the

mother's years of education and with the father’s years of education. With respect to child

social-emotional difficulties, a non-significant association between this measure and the

sociodemographic variables was found.

79
 Table 12

Correlation between study’s variables and sociodemographic variables

Child Mother Father

Child Child Child Mother Father Mother Father Mother Father Mother Father
Variable Group birth years years
age sex nursery Age Age kids kids job Job treat. treat.
order edu. edu.

Communication .16 .23 -.25 -.42** .38** -.16 -.06 -.29* -.26 -.06 -.12 -.02 -.16 -.13 .18
* *
Gross motor .05 .24 -.07 .08 .13 -.20 -.02 -.02 -.05 -,34 -.30 -.13 -.18 .01 .08
* *
Fine motor .33 .34 -.10 .07 .12 -.04 .24 .15 .19 -.12 -.05 -.12 -.21 .19 .03
Problem solving .27 -.05 -.20 -.14 .24 -.18 -.04 -.08 -.19 .04 .02 -.05 -.28 .13 .25
* *
Personal-social -.12 -.11 .02 .03 .13 -.21 -.10 -.06 -.12 -.36 -.32 -.13 -.26 -.12 .08
% SE difficulties -.24 -.09 .20 -.27 -.26 -.09 -.15 -.12 -.08 .17 .10 -.19 .08 -.08 .19
Triadic total
.14 .18 .04 -.04 .05 -.01 .09 -.07 -.07 .01 .14 -.02 -.21 .01 .00
score
Mother RF .36* .11 -.08 -.08 .03 -.02 .02 -.06 -.03 .18 .16 .23 -.06 .10 .01
Father RF .22 -.01 -.08 .14 .03 .09 .11 .02 -.02 .24 .28 .18 .01 .11 -.03
**
Mother DS -.27 -.15 -.04 .06 -.39 .05 .12 .01 .00 .18 .10 -.10 .05 .27 .07
Mother CS .13 .13 -.02 .14 .08 .01 -.06 .16 .17 -.14 .02 -.03 .04 -.09 -.04
*
Father DS -.13 -.29 -.11 .23 -.14 .12 .13 .06 .01 -.06 -.08 -.01 -.11 -.04 .13
Father CS .10 .22 -.04 -.05 -.04 -.09 -.15 .04 .08 -.09 .03 .02 .15 .00 -.09
Note. Edu = education; Treat = treatment; SE = social-emotional; RF = reflective function; DS = depressive symptoms; CS = couple satisfaction.
*. Correlation is significant at the .05 level (2-tailed).
**. Correlation is significant at the .01 level (2-tailed).

80
 Second, the associations between the study variables and the control variables

(parents’ depression symptoms and parents’ couple satisfaction) were tested (see Table 13).

Maternal depression symptoms were the only control variable that correlated significantly

with the dependent variables, particularly with child psychomotor development and social-

emotional difficulties. In addition, father couple satisfaction correlated significantly with

father reflective function. Additionally, it is interesting to see in Table 13 how the parents’

variables correlate significantly, showing that the parents’ characteristics are associated and

can influence each other.

6.2.1. Aims one, two and three. Associations between the mothers’ and fathers’

reflective functions, triadic interaction and child psychomotor and social-emotional

difficulties.

To test the first hypothesis that the levels of the fathers’ and mothers’ reflective

function will be positively associated with the quality of the triadic interaction, bi-variate

correlations between the mothers’ and fathers’ reflective functioning and triadic interaction

scores were assessed. As was hypothesized, the mothers’ and fathers’ reflective functioning

was significantly positively correlated with triadic total interaction (see Table 13).

Therefore, when the mother and the father have higher reflective function levels, the triadic

total interaction also tends to have higher levels of coordination.

To test the second hypothesis, that the level of mothers’ and fathers’ reflective

function will be positively associated with the child psychomotor development and socio-

emotional difficulties, bi-variate correlations between these variables were conducted (see

Table 13). In contrast to the hypothesis, mothers’ and fathers’ reflective functioning was

81
not significantly correlated with the child psychomotor development or socio-emotional

difficulties.

Finally, to assess the third hypothesis, that the quality of the triadic interaction will

be positively associated with the child psychomotor development and socio-emotional

difficulties, bi-variate correlations between these variables were again performed. The

hypothesis was partially corroborated. First, there was no significant correlation between

the triadic total score and the child’s psychomotor development. However, as expected, a

significantly negative correlation was found between the triadic interaction score and socio-

emotional difficulties (see Table 13) in which triads with higher triadic scores tended to

have children with a lower level of social-emotional difficulties.

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 Table 13

Correlations among study variables and covariables

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1. Communication 1
2. Gross motor .44** 1
3. Fine motor .39** .19 1
4. Problem solving .65** .37** .42** 1
5. Personal-social .54** .49** .31* .51** 1
6. % SE difficulties -.29* -.41** -.24 -.19 -.38** 1
7. Triadic Total Score .22 .22 .18 .10 .07 -.40** 1
8. Triadic Subscale Score .20 .19 .17 .09 .04 -.32* .98** 1
9. Coparenting -.09 .03 -.12 -.13 -.07 -.23 .68** .61** 1
10. Toddler contribution .40** .361* .339* .28* .23 -.52** .70** .59** .21 1
11. Mother RF -.07 -.14 .03 -.15 -.325* -.05 .43** .40** .41** .28 1
12. Father RF -.10 -.15 -.05 -.04 -.20 -.09 .38** .37** .34* .204 .43** 1
13. Mother DS -.37** -.276 -.135 -.269 -.38** .40** -.14 -.10 -.22 -.13 .17 -.12 1
14. Mother CS -.03 .02 .06 -.02 .00 -.01 -.10 -.15 .07 -.02 -.04 .21 -.34* 1
15. Father DS -.10 .02 .01 -.05 .04 -.05 .08 .09 .06 .02 .14 .07 .16 -.34* 1
16. Father CS -.10 -.02 -.12 -.08 -.12 .14 -.10 -.12 .07 -.14 .07 .29* -.19 .72** -.62** 1
Note. SE = social-emotional; RF = reflective function; DS = depressive symptoms; CS = couple satisfaction.
*. Correlation is significant at the .05 level (2-tailed).
**. Correlation is significant at the .01 level (2-tailed).

83
Correlation among triadic interaction, reflective function, child psychomotor development

and socio-emotional difficulties and the control variables

To understand these associations more deeply, a bi-variate correlational analysis

among mothers’ and fathers’ reflective functions, triadic interaction subscales, and child

psychomotor and social-emotional development subscales was examined (see annexed

table 3).

As expected, some of the child psychomotor and social-emotional difficulties

subscale variables correlate with each other. Specifically, child self-regulation difficulties

correlate negatively with fine motor development, r = -.33, p < .01, child communication

difficulties correlate negatively with the child personal-social, r = -.53, p < .01, problem

solving, r = -.45, p < .01, and communication development, r = -.42, p < .01. Child

adaptive difficulties correlate negatively with gross motor, r = -.51, p < .01 and personal-

social development, r = -.33, p < .05.

Oddly, mothers’ reflective function correlates negatively with personal-social

development, r = -.33, p < .05. The fathers’ reflective function correlates with the child

person-interaction difficulties, r = -.28, p < .05.

Conversely, mothers’ reflective function correlates positively with the triadic

subscales, specifically with affect, r = .41, p < .01, interactive sequence, r = .32, p < .05,

and co-parenting, r = .41, p < .01. In addition, the fathers’ reflective function correlates

positively with focus and scaffolding, r = .41, p < .01, affect, r = .37, p < .05, and co-

parenting, r = .34, p < .01.

Triadic total score correlates negatively with child autoregulation difficulties, r = -

.29, p < .05, and triadic subscale score correlates negatively with child social-emotional

84
difficulties, r = -.32, p < .05. For its part, toddler contribution correlates positively with

communication development, r = .40, p < .01, gross motor, r = .36, p < .01, fine motor, r =

.34, p < .05, and problem solving, r = .28, p < .05. It correlates negatively with social-

emotional difficulties, r = .52, p < .01, and their subscale autoregulation, r = -.35, p < .05,

communication difficulties, r = .29, p < .05, adaptive difficulties, r = .29, p < .05, affect

difficulties, r = -.31, p < .05, and person-interaction difficulties, r = -.32, p < .05.

6.3. Regression Analysis

Aim four. Evaluate the influence of the fathers’ and mothers’ reflective function

and the quality of the triadic interaction on the child psychomotor development and socio-

emotional difficulties.

To test the fourth hypothesis that the level of fathers’ and mothers’ reflective

functions and the quality of the triad interaction will influence child psychomotor

development and socio-emotional difficulties OLS (Ordinary Least Squares), multiple

linear regression analyses were conducted. In these analyses, the reflective function and the

triadic interaction were the independent variables, and the child psychomotor development

and social-emotional difficulties were the dependent variables. Based on the significant

correlations detected with the dependent variables, subsequent analyses were controlled for

maternal depression symptoms and some of the sociodemographic variables that correlated

significantly with the dependent variables. Additionally, to facilitate the interpretation of

the data and to avoid collinearity problems, all of the predictors were centered on their

grand mean (Shieh, 2011).

Additionally, an analysis of influential cases was performed for each model,

considering potentially influential those with a Leverage value greater than 2 points and

85
those with a Cook distance greater than 1 point. A non-case with these characteristics was

found.

6.3.1. Triadic interaction, maternal and paternal reflective function as

predictors of the child’s psychomotor development.

First, the contributions of the triadic interaction, maternal and paternal reflective

functions as predictors of the child’s psychomotor development were tested. Child

psychomotor development has five dimensions: communication, gross motor, fine motor,

problem resolution and social-individual development. Because this hypothesis is

exploratory, each regression was examined using the stepwise method to achieve a model

that explains most of the variance when trimming nonsignificant predictors.

First, communication development was run controlled by mother depression

symptoms, child’s birth order, child's attending a nursery or daycare (no = 0, yes = 1), and

mother’s number of children. The results of the analyses showed that only child birth order

(b=-0.412, t(43)=-3.18, p = 0.003) and mother’s depression symptoms (b=-0.358, t(43)=-

2.77, p = 0.008) were significant predictors of child communication development,

explaining 28% of the variance. Lower birth position (e.g., be the first sibling in the family

order) and lower mother depressive symptoms predict more child communication

development.

Gross motor development was run controlled by mothers’ and fathers’ years of

education. The analysis showed that the only significant predictor was mothers’ years of

education (b=-0.336, t(49)=-2.47, p = 0.017), explaining 9% of the variance. Thus, the child

has more gross motor development when the mother has fewer years of education.

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 Third, fine motor development was run controlled by group (control group = 0,

experimental group = 1) and child age. The regression shows that only the age of the child

was the significate predictor (b=0.343, t(49)=2.53, p = 0.015), explaining 10% of the

variance; greater age predicts improved fine motor abilities.

Next, problem-solving development was not controlled. The results of the analyses

reveal that there were no significant predictors.

Finally, personal-social development was controlled by mothers’ depression

symptoms and mothers’ and fathers’ years of education. Mothers’ depression symptoms

(b=-0.326, t(49)=-2.51, p = 0.016) and mothers’ years of education (b=-0.302, t(49)=-2.33,

p = 0.024) were the significant predictor, explaining 20% of the variance, when lower

mother depression symptoms and lower mothers’ years of education predict more child

personal-social development.

It is interesting to see how only control variables and sociodemographic variables

were significant predictors of child psychomotor development, and the study variables

appear non-significant predictors of this child development area.

6.3.2. Triadic interaction, maternal and paternal reflective function as

predictors of the child’s social-emotional difficulties.

The contribution of the triadic interaction, maternal and paternal reflective function

as predictors of child social-emotional problems has been more reported than their effect on

psychomotor development (e.g., Cassidy et al., 2003; Ensink, Bégin et al., 2016; Steele &

Steele 2008). Consequently, the social-emotional difficulties were examined with an initial

regression to theoretically and empirically direct the input of the variables. Non-socio-

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demographic variables correlated significantly with child social-emotional difficulties; thus,

the regression was only controlled by mother depression symptoms.

Additionally, it is important to consider that the LTP procedure and FAAS coding

system assess five triadic aspects and two subsystem aspects: co-parenting and the child

contribution, which included child engagement and assertiveness, which in turn are parts of

the child social-emotional development construct. Thus, to be more rigorous and not assess

the same variable in different ways, for the analysis in which social-emotional difficulties

was the dependent variable, the triadic subscale score was considered a predictor (not the

triadic total score), leaving out the co-parenting and child subsystem.

After controlling for mother depression symptoms, the results revealed a significant

effect of the triadic interaction on child social-emotional difficulties, which with the mother

depression symptoms explain 21% of the variance. However, in contrast to expectations,

there was a non-significant effect of the mothers’ and the fathers’ reflective function on

child social-emotional difficulties (see Table 14).

A second model was tested using the reflective function score as a dichotomous

category, where (0 = not good enough RF, 1 = good enough RF). Again, after controlling

for maternal depression symptoms, only the triadic interaction had a significant effect,

contributing to explain again 21% of the variance (see Table 14).

6.3.3. Moderation analysis

Based on the results obtained, it was hypothesized that the reflective function would

have a moderator effect on child social-emotional difficulties; therefore, four moderation

analyses were run controlling for mother depression symptoms. Two differences analyses

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were proposed for each parent to understand the personal contribution of the reflective

capacities on child social-emotional difficulties. The first would use the regular reflective

function’s eleven-point scale, and the second would use the two reflective function’s

categories (0 = not good enough RF, 1 = good enough RF). However, the second model

could not be used because the collinearity values were greater than the expected

parameters; for the mother, moderation was VIF = 109.74, and for the father, moderation

was VIF = 34.41, thus indicating that the moderation’s values were not robust and reliable.

These values resulted despite all predictors being centered on their main average (Shieh,

2011).

Mothers’ reflective function as a moderator. The model analyzed the mothers’

reflective function using the eleven reflective function-point scale as a moderator. The

regression revealed a non-significant effect as moderator (see Table 14).

Fathers’ reflective function as a moderator. The regular reflective function scale

was also used to test the fathers’ reflective function as a moderator. For the father analysis,

the regression found a non-significant effect as moderator (see Table 14).

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 Table 14

Regression and moderation analysis considering social-emotional difficulties as dependent

variable

Std. 95% CI
Variable B B std. t p R R2 F p
error LL UL
Model 1 .40 .14 8.93 .004
Intercepto 13.67 .94 14.58 .000 11.78 15.55
Mother DS .47 .16 .40 2.99 .004 .15 .78

Model 2 .49 .21 7.34 .030

Intercepto 13.67 .90 15.18 .000 11.86 15.48
Mother DS .43 .15 .37 2.88 .006 .13 .74
Triadic Score -.57 .25 -.29 -2.24 .030 -1.08 -0.06

Model 3 .49 .18 3.62 .849

Intercepto 13.67 .92 14.91 .000 11.82 15.52
Mother DS .45 .16 .38 2.81 .007 .13 .77
Triadic Score -.60 .29 -.30 -.06 .046 -1.19 -.01
Mother RF -.21 .98 -.03 -.22 .830 -2.19 1.77
Father RF .55 .97 .09 .57 .570 -1.40 2.50

Model 4 .48 .16 3.31 .819

Intercepto 13.67 3.84 14.91 .004 3.94 19.42
Mother DS .44 .16 .37 2.81 .008 .12 .75
Triadic Score -.57 .29 -.29 -.06 .059 -1.16 -.02
Mother RF 2 cat 1.74 2.76 .09 .70 .532 -3.82 7.29
Father RF 2 cat .49 2.63 .03 .41 .854 -4.81 5.79

Model 5 .49 .16 2.84 .921

Intercepto 13.71 .1.01 13.57 .000 11.67 15.74
Mother DS .45 .16 .38 2.72 .009 .12 .78
Triadic Score -.61 .3 -.31 -2.03 .048 -1.21 -.004
Mother RF -.21 .99 -.03 -.21 .835 -2.21 1.79
Father RF .56 .98 .09 .57 .573 -1.42 2.53
M RF x TS -.03 .25 -.01 -.10 .921 -.53 .48

Model 6 .50 .16 2.90 .612

Intercepto 13.89 .1.02 13.66 .000 11.84 15.94
Mother DS .43 .17 .37 2.64 .012 .10 .77
Triadic Score -.61 .31 -.33 -2.10 .041 -1.27 -.03
Mother RF -.21 .99 -.03 -.19 .850 -2.19 1.81
Father RF .56 1.01 .11 .67 .505 -1.35 2.70
F RF x TS -.15 .29 -.72 -.51 .612 -.73 0.44
Note. Dendent variable = Percentage of social-emotional difficulties; CI = confidence interval; LL = lower
limit, UL = upper limit; DS = depressive symptoms; M = mother; F = father; RF = reflective function; TS =
triadic score.

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 6.3.4. Maternal and paternal reflective function as predictors of the triadic

interaction.

Considering that the mothers’ and fathers’ reflective functions were not a significant

predictor or moderator of child social-emotional difficulties, new analyses were conducted.

Based on the correlational results, the contributions of the maternal and paternal reflective

function were tested as predictors of quality of the triadic interaction with an entry

regression, using the eleven reflective function’s point scale (see Table 15).

The first step introduced the fathers’ reflective function score, which was a

significant predictor of the triadic interaction. In the second step, the mothers’ reflective

function score was introduced, which was a significant predictor, explaining 17% of the

variance. However, in the third step, when the mothers’ and fathers’ reflective function

were together, the father reflective function significant contribution disappeared. This

disappearance could indicate that the effect of the fathers’ reflective function was due to its

correlation with the mothers’ reflective function (r=.43), which acted as a confounder

variable in the direct relationship; the latter (mothers’ RF) is the one more reliably

associated with the triadic interaction score. However, in the model with the mother and

father reflective function together, father reflective function contributes to increase the

explaining variance to 20%.

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Table 15

Regression analysis considering triadic interaction as dependent variable

Std. 95% CI
Variable B B std. t p R R2 F p
Error LL UL
Model 1 .38 .13 8.19 .006
Intercepto 12.44 2.19 5.67 .000 8.03 16.85
Father RF 1.69 .59 .38 2.86 .006 0.50 2.87

Model 2 .19 .17 11.17 .002

Intercepto 11.58 2.15 5.39 .000 7.26 15.99
Mother RF 1.87 .56 .43 3.34 .002 .75 3.00

Model 3 .49 .20 7.24 .023

Intercepto 9.44 2.46 3.84 .000 4.50 14.38
Father RF 1.06 .62 .24 1.69 .097 -0.20 2.31
Mother RF 1.43 .61 .33 2.35 .023 0.21 2.66
Note. Dendent variable = Triadic interaction; CI = confidence interval; LL = lower limit, UL =
upper limit; RF = reflective function.

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 7. Comprehensive final model

In summary, Figure 3 presents the developed comprehensive model, which

represents the relationships between the study variables.

Figure 4

Comprehensive final model

Note. **p < .01. (two tailed); **p < .05 (two tailed). F = father; M = mother; RF = reflective

function; SE = social emotional.

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 8. Discussion

This study provides evidence with respect to the relationship of the fathers’ and

mothers’ reflective function, the quality of triadic interaction, and child psychomotor

development and social-emotional difficulties. These variables to date have not been

studied together despite their great relevance for understanding the early development and

mental health of children and families.

In terms of psychomotor development, the results show that the percentages of

children who are under expectations on different scales were in the range of 2 to 16%. The

least-lagged area was gross motor development, and the development of communication

(16%) and personal-social (14%) were higher lagged areas. These results are in turn

directly linked to child social and emotional development. These percentages are similar to

those obtained in other Chilean studies, which report that approximately 12 to 29% of the

children present a delay risk in psychomotor development (Centro de Microdatos-

Universidad de Chile, 2014; Schonhaut et al., 2013). The delay in psychomotor

development issue is not resolved. These and other studies show that many children remain

who present problems in this area, and if they are not treated in time, many of these lags

will generate greater difficulties in the future (Briggs-Gowan & Carter, 2008; Cheng et el.,

2014; Essex et al., 2006; Giannovi & Kass, 2012; Pihlakoski et al., 2006).

In relation to socio-emotional development as assessed by the ASQ-SE, the results

show that 46% of children are above the social-emotional difficulty cutoff, indicating that

they have social-emotional difficulties. That this percentage is higher has been confirmed

by other studies, which showed that from 11% to 37% of children have some social-

emotional difficulties in early childhood (Bian et al, 2017; Briggs-Gowan et al., 2013;

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Centro de Microdatos-Universidad de Chile, 2014; Wendland et al., 2014). However, to

interpret these results, it is necessary to consider that these children entered this study

because their parents or professionals who work with, reported one or more difficulties in

the following areas: sleep, feeding, behavioral and emotional or relationship. Although

these reports were subjective evaluations done by the adults, there were real worries about

their children concerning problems that interfered in daily life, because almost half of this

sample was considered by the ASQ-SE an objective and clinical delay or difficulty.

Related to the parents’ variables, the descriptive results show lower averages in

relation to mothers’ and fathers’ parental reflective function than do the results obtained in

international investigations (Control mother RF-PDI group, M= 3.69, Ensink, Bégin, et al.,

2016; Mix clinical and non-clinical mothers RF-AAI, M = 4.52, Ensink, Bégin et al., 2016;

non-clinical sample, mother RF-AAI, M = 4.48; father RF-AAI= 4.22, Fonagy et al., 1991;

non-clinical mother RF-PDI, M = 5.08, Slade et al., 2005).

In this study, the averages and frequencies obtained between mothers and fathers

showed that 24% of mothers and 18% of parents have the capacity to reflect on mental

states. More than half of mothers and fathers (64% and 68%, respectively) show low

reflective capacities; that is, in their discourse, mentalizing language is present. However,

they do not reflect on it. Finally, 12% of mothers and 14% of the parents presented a poor

or negative level of reflective functioning; that is, their descriptions presents no evidence of

an awareness of mental states and suggests that they might even reject the recognition and

use of mental states.

First, to understand these results, note that this sample consisted of parents mostly

raising their first child or in early parenting, in the couple adjustment phase, and with

children with socio-emotional difficulties, experiences associated with changes and stress.

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Additionally, it is important to consider these results and, above all, the last group of

parents described because the scientific literature has demonstrated that a poor or negative

parental reflective functioning is associated in the adult with less persistence in distress-

tolerant tasks (Rutherford et al., 2015). Additionally, poor or negative parental reflective

functioning is associated with a higher level of maternal disruption in mother-infant

affective communication (Grienenberger et al., 2005) and with insecure attachment and

physical neglect (San Cristobal et al., 2017).

For children, having a parent with poor or negative reflective capacities also has

negative consequences throughout development. In early childhood, such a problem can

cause the development of an insecure attachment (Ensink, Normandin et al., 2016; Slade et

al., 2005). In the preschool years, it can cause fewer social competences in children

(Ensink, et al., 2015; Kårstad et al., 2015). At school age, more externalizing problems can

appear (Ensink, Bégin et al., 2016). Moreover, anxiety (Esbjørn et al., 2013) and fewer

reflective function capacities might develop (Scopesi et al., 2015).

Additionally, more than half of the parents have a low or questionable reflective

function, or scores from 3–4 in the reflective function scale. However, their having low

capacities to reflect might not be negative for their children because they are parents who

create a narrative that will recognize other emotions and intentions, although they are not

reflective of them. However, that type of explanation of the experience could be sufficient

at this age. That is, it is possible that as the child grows up, greater reflective capacities will

be demanded of the parents; as Taumoepeau and Ruffman (2006) suggest, maternal

mentalization changes and adjusts according to the child's age.

Another finding that was highly interesting was the "couple reflective function level".

Based on mother and father reflective function, couple combinations were formed (e.g., one

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low and one high), showing that the most frequent is that a parent couple have the same

level of reflective function, or one level high or low. However, this result was interesting to

see because a parent with high reflective function does not come together with one who has

poor capacities. Likewise, the extremes, when both parents present a poor reflective

function (2%) and both high reflective function (10%), were less represented.

To compare, the groups were redistributed in three aggregations. The analyses of

comparisons between the groups showed that there are significant differences between

them in co-parenting; toddler contribution and triadic interaction were the main differences

found in the extreme groups. In other words, the major difference in the quality of family

interaction is generated when the parents each have Poor/low reflective function, composed

of one parent with low reflective function and one poor, or both poor. The Poor/low

reflective function couple had a significantly lower mean in the total triadic interaction than

did the Low and Low/high reflective function couples. These differences were not found in

relation to the child development variables.

These results are in line with what has been found by Marcu et al., (2016) using the

insightfulness measurement. This measurement assesses the parent’s reflective capacities in

interaction with his child, showing that triads in which both parents were insightful had

higher family cooperation scores compared with triads in which only one parent was

insightful and triads in which neither parent was insightful.

In relation to the quality of the triadic interaction, the average obtained by the

families studied was M = 18.44, which is similar to other international non-clinical samples

(M = 19, Favez et al., 2011; Marcu et al., 2016) and higher than clinical samples (M = 10.3,

Favez et al., 2011). In the case of Chile, our mean of triadic interaction (M = 13.22) is

greater than that of other Chilean samples (M = 10.09, Perez et al., 2017). This result could

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occur because, although the other study was not in a clinical sample, it was a population

that lived in a poverty context and had high levels of parental stress (Perez et al., 2017).

Conversely, considering the results with respect to the association between the study

variables, the first hypothesis expected that mothers’ and fathers’ reflective functions would

be significantly positively correlated with family interaction. As was hypothesized, the

result shows that when the mother and the father have higher reflective function levels, the

family triadic interaction also has higher levels of coordination.

Related to each family triadic interaction subscale, the reflective function of both

parents correlates positively with affect and co-parenting. Mother reflective function was

associated with interactive sequence, and the father reflective function positively correlates

with focus and scaffolding. Despite both parents’ influence on the triadic interaction, these

findings show a differentiated contribution between father and mother reflective capacities.

The second hypothesis was rejected, inasmuch as, in contrast to what was

hypothesized, mother and father reflective function were not correlated with child

psychomotor development and socio-emotional difficulties. However, more deeply, when

the child subscales were studied, two weak and odd associations appear. The first was that

mothers’ reflective function was negatively associated with child personal-social

development, which evaluates solitary play and play with toys and other children. The

second was father reflective function, which correlated positively with child person-

interaction difficulties, which assess the ability to respond or initiate social responses to

parents, other adults or peers. These correlations were quite odd because, as studies have

shown, it is expected that parents’ reflective functions positively influence the child’s

personal and social interaction at the preschool age (Cassidy et al., 2003). Nonetheless,

another possible explanation is that children with fathers and mothers with poor or low

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reflective function must seek other interactions to find the stimulus that they do not find in

their parents. However, this hypothesis has not been verified by other studies.

The third hypothesis was partially corroborated because family interaction score and

child psychomotor development were not significantly correlated. However, as expected,

the triadic total interaction score was negatively associated with child socio-emotional

difficulties, which indicates that how fathers and mothers coordinate and support each other

in the interaction with their children and in their upbringing influences how the child

develops social and emotional competences (Feldman, & Masalha, 2010; Greenspan et al.,

2001).

Concerning the control variables, the relationship between parents, both fathers and

mothers, had an inverse association between couple satisfaction and depressive

symptomatology; that is, parents who are more satisfied with their relationship have fewer

depressive symptoms, showing the influence of one over the other, but these symptoms do

not directly affect the child. Nevertheless, couple satisfaction appears to influence

children’s outcomes; the contribution was through the couple subsystem to the parents’

symptomatology, more specifically through the mother depression symptoms on child

psychomotor and social-emotional development. Therefore, incorporating this variable into

working with young families is crucial for understanding the functioning of the parent-

couple subsystem, including a comprehensive examination of child development beyond

the mother/father-child dyad.

The fourth hypothesis was that the level of fathers’ and mothers’ reflective functions

and the quality of the triad interaction would influence child psychomotor development and

socio-emotional difficulties. Related to the influence of family interaction and maternal and

paternal reflective functions on child psychomotor development, the hypothesis was not

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corroborated. In contrast to what was hypothesized, only the social-demographic

characteristics (child birth order, child age, mother education and age) and mother

depression symptoms contribute to explaining child psychomotor development. Thus, the

literature consistently shows how maternal depressive symptomatology affects child

psychomotor development, showing that toddlers with mothers with depression are twice as

likely to have altered psychomotor development as are mothers with no depressive

symptoms (Podestá et al. al., 2013).

The findings were different in relation to child social-emotional difficulties; in this

case, the hypothesis was partially corroborated because only mother depression symptoms

and triadic interaction contributed to explaining 21% of the variance of child social-

emotional development. In other words, families with lower coordination and higher

maternal depression symptoms explain part of the child’s social-emotional difficulties. For

its part, maternal and paternal reflective function had no direct influence on child social-

emotional difficulties. On the one hand, these finding are in line with the early family

literature, which shows that since the 1980s, the immediate family is the most influential

relationship system in which a child develops (Bronfenbrenner, 1987). In the triad, the child

learns to share affection, attention and a common objective (Liszkowski et al., 2004; Fivaz-

Depeursinge, & Corboz-Warnery, 1999), which influences the acquisition of social

competence (Cigala et al., 2014; Feldman, & Masalha, 2010) that, in turn, is reflected in the

child’s socio-emotional adaptation. On the other hand, the question about the influence of

the reflective function remains open.

Additionally, as mentioned, maternal depression symptoms again play an important

role in the explanation of child social-emotional difficulties, as shown in the scientific

literature (Caughy et al., 2009; Kam et al., 2011; Leckman-Westin et al., 2009).

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 Based on the results, an additional hypothesis was that reflective function would have

an indirect effect, as a moderator, on child social-emotional difficulties. Although the

hypothesis and the literature show the reflective function as an intervening variable (Borelli

et al., 2015; Grienenberger et al., 2005; Slade, 2005; Smaling et al., 2016a; Wong, 2012),

neither the mother’s nor the father’s reflective function constituted significant moderators

in the relationship between the quality of the triadic interaction and child socio-emotional

difficulties.

Considering these results and the theoretical background of mentalization, a new

hypothesis was developed that expected that reflective function would influence the triadic

interaction. As expected, the fathers’ reflective function was a significant predictor of the

family interaction and of the mother reflective function, but when both were together, only

the mother reflective function was a significant predictor. This result is interesting to

consider because, although the statistically significant influence of the father disappears

when the mother enters the equation, the variance of the father and mother together is

greater than that of the mother alone, showing a less obvious contribution from the father

than the mother but nonetheless generating a differential contribution.

From a clinical perspective, these results are interesting to interpret; on the one hand,

the scientific evidence has shown the influential role of the parental reflective function in

child social and emotional development (Ensink et al., 2015; Steele & Steele, 2008). On the

other hand, in this study, the contribution is not directly to child development. These

findings show the direct influence of the reflective function on the triadic interaction and of

the triadic interaction on child social-emotional development. Thus, the activity of

mentalizing increases the likelihood that the parent is aware of, for example, the infant’s

needs, thoughts, and feelings but might not necessarily indicate that the parent is able to

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convert his or her thoughts about the infant’s mind into direct, sensitive behavioral

responses. That approach is how studies show that the relationship between parenting

reflective capacities and child outcomes are mediated by parental sensitivity (Laranjo et al.,

2008; Stacks et al., 2014).

Another reflection that emerges from these results is that the main scale that evaluates

reflective function (Reflective function scale, Fonagy et al., 1998) provides a single overall

score. On the one hand, it is a clear and guiding score; on the other hand, it does not capture

the complexity and multidimensionality of parental RF, losing theoretical and clinical

richness of scale. Especially problematic are the pre-mentalizing or pseudo-mentalizing

states, which are difficult to differentiate because the same score can correspond to hyper-

mentalizing, a simple and concrete reflective function, or an unstable reflective capacity

(Fonagy et al., 1998). Likewise, poor scores might correspond to denial of mental states,

distortions, or malevolent attributions (Allen, 2006). These theoretical and clinical

differences suggest that the effect on the child of a low, simple reflective function is

different from that of a parent who hyper-mentalizes.

Thus, Suchman et al. (2010) and Smaling et al. (2016a) have observed three

dimensions of reflective operation using PDI-RF. These dimensions are self-focused, child-

focused and relationship-focused mentalization, showing that self-focused reflective

function was related to less maternal contingency, more negative emotionality and

externalizing problems in the child. Child-focused was associated with more maternal

contingent behavior, and reflective function relationship-focused were reported with less

reported child physical aggression. This type of analysis shows how different forms of

reflective functioning differentially affect the exercise of parenting and child development.

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 To summarize, the findings of this study confirm the contribution of family

coordination and cooperation on child social and emotional development (Cigala et al.,

2014; Feldman, & Masalha, 2010), providing evidence based on a study of families with

children at an early age. This study shows that the father's contribution does not directly

affect the child’s early development; rather, it is in the triad interaction that the father, in

interaction with the mother and child, influences his child’s development, making special

contributions in the focus and scaffolding, affection and co-parenting, which influences the

quality of the triad's functioning. This result has been found by other authors, suggesting

that parent involvement and reciprocity have a positive effect on child development, the

mother-father-child relationship and the couple subsystem (Feldman, 2010; Feldman et al.,

2013; Sarkadi et al., 2008, Wilson & Prior, 2010, Simonelli et al., 2016).

This study shows a leading role of the mother and a secondary role of the father in

child development. This indirect influence of the father can be explained based on the

distribution of social and family roles and the time and type of activities that the father

performs with his child. The reorganization of domestic and foster care has contributed to

increased parental involvement in early childcare and promoted multiple roles within the

family (Lamb, 2013). In recent decades, the rate of economic participation of women has

increased in Chile. However, it remains lower than that of men, male heads of household

predominate (Instituto Nacional de Estadística, 2012), and the mother continues as the main

person in charge of child raising (Fares, Fields, & Kamboukos, 2009; Pleck & Masciadrelli,

2004). This sample is not the exception; 62.5% of the mothers had a full-time job compared

with 95.9% of the fathers, showing that the mother was the main child caregiver.

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 The distribution of roles and tasks and the time that the father and the mother spend

with their child allow us to understand these findings in which, although family interaction

influences child development, the mother more directly influences early child development.

Additionally, these results again confirm the effect of maternal depressive

symptomatology on child development, having an effect not only emotionally but also in

the acquisition of psychomotor skills such as communication and personal-social

development. This finding is in line with broad scientific evidence that demonstrates the

effects of maternal depression on child development and mental health (Caughy et al.,

2009; Cummings et al., 2005; Kam et al., 2011), which appear to affect the child through

direct mother-infant interaction and care. However, a father's depression appears to exert its

influence on children's outcomes through an effect on the couple's relationship satisfaction

(Gutierrez-Galve et al., 2015).

These results invite professionals who work in early childhood to consider changing

the focus of attention from the dyad to the early family, promoting the inclusion of the

father. As shown by these results, the quality of family interaction can be constituted as a

factor that is protective of or detrimental to the social and emotional development of

children. Conversely, reflective function appears to be a variable that influences the quality

of early family interactions because to represent one’s own and others’ mental states

permits understanding, regulating and giving sense to one’s own and others’ behavior

(Fonagy et al., 2004).

Finally, although these results are preliminary and descriptive, the couple reflective

function levels show that the combination of poor and low levels of couple reflective

function is the real source of harm to the triad interaction. As in the attachment theory,

which is disorganized attachment that generates greater childhood psychopathology

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(Madigan, Moran, Schuengel, Pederson, & Otten, 2007), in this case, it is the poor

reflective function that generates worse quality family interaction, and it is the poor quality

of family interaction that generates greater socio-emotional difficulties in the child.

Nevertheless, these findings must be confirmed using larger samples. It is also

recommended to reduce the age gap in children because from 12–36 months, there are

major changes in development, primarily in communication and regulation skills.

Another limitation is that the measures of this study were performed post

intervention, despite having been analyzed and controlled when it was statistically relevant.

Thus, it is recommended that the study subjects perform the evaluation on the same

baseline.

The (non-randomized) recruitment characteristics and the lack of follow-up

evaluations in this study constitute a limitation that prevents the generation of prediction

models that permit observation of causality and the direction of the variables.

In term of the instruments, although the ASQ is a great and broadly used instrument

that can be used by any mental health professional, it is only a screening assessment;

therefore, it only detects more general aspects of child development. Thus, future studies

would benefit from including other means of evaluating child psychomotor and social-

emotional difficulties, such as child symptomatology or some observational task to

complement the ASQ results, particularly for the social and emotional dimension.

It is important to consider that this study constitutes the second study that linked

family interaction and parents’ reflective capacity, and it is the first that additionally

assesses child social-emotional difficulties. Therefore, future studies would benefit from

considering other family members who are in charge of daily childcare, such as

grandmothers, stepmothers, stepfathers, or nannies. Additionally, it is important in early

105
family development to consider the role of siblings and consider how the triad might

actually be an interaction of four or more people.

Moreover, future studies should consider additional reflective function dimensions to

capture the richness, complexity and multidimensionality of parental RF.

8.1. Ethical considerations

As mentioned in the procedure description of this study, this thesis, which is to be

inserted into a Fondecyt project, received the approval of the institutional Ethics Committee

of Human Research from the Catholic University of Chile and from the Chilean National

Commission of Scientific and Technological Research. Additionally, this current study

received ethical approval from the institutional Ethics Committee of Human Research at the

University of Chile.

The participants agreed to participate based on a verbal explanation of the study and

by signing the informed consent forms of Fondecyt Start-up Project No. 11140230 and of

this doctoral research.

During the study, the family data were treated with extreme confidentiality; families

agreed with informed consent that the data would only be used for specialized teaching

purposes. The names were guarded, and it was verified that none of those present had

personal knowledge of the families.

Apart from all formal ethical aspects, all families participated in a brief intervention

with video-feedback. The families in the experimental group did so prior to the evaluation

in this study, and the families in the control group did so after the evaluation of this study.

The intervention was focused on parents' concerns about their child's socio-emotional

development, with a focus on the parents-child relationship. Some of the intervention

106
families were advised to continue with a psychological treatment. The options offered were

the following: increase the number of home intervention sessions, referral to another

professional in the area, or the therapist in charge of the family will continue the treatment

in their private practice with the associated costs. Additionally, for the families who

required it, the therapist in charge contacted family-related professionals, for example, a

preschool teacher or psychiatrist, and generated a report of the final evaluation.

107
9. Refercences

Agnafors, S., Sydsjö, G., & Svedin, C. G. (2013). Symptoms of depression postpartum and

12 years later-associations to child mental health at 12 years of age. Maternal and

Child Health Journal, 17, 405-414. https://doi:10.1007/s10995-012-0985-z

Allen, J. G. (2006). Mentalizing in practice. In J. G. Allen & P. Fonagy (Eds.), Handbook

of Mentalization-Based Treatment (pp. 3-30). NY: Wiley.

Allen, J., Fonagy, P., & Bateman, A. (2008). Mentalizing in clinical practice. Washington:

American Psychiatric Press

Altenburger, L. E., Schoppe-Sullivan, S. J., Lang, S. N., Bower, D. J., & Kamp Dush, C.

M. (2014). Associations between prenatal coparenting behavior and observed

coparenting behavior at 9-months postpartum. Journal of Family Psychology, 28,

495-504. https://doi.org/10.1037/fam0000012

Alvarado, R., Rojas, M., Monardes, J., Perucca, E., Neves, E., Olea, E., & Vera, A. (2000).

Cuadros depresivos en el postparto en una cohorte de embarazadas: construcción de

un modelo causal. Revista Chilena de Neuro-psiquiatría, 38, 84-93.

https://dx.doi.org/10.4067/S0717-92272000000200003.

Arnott, B., & Meins, E. (2007). Links among antenatal attachment representations,

postnatal mind–mindedness, and infant attachment security: A preliminary study of

mothers and fathers. Bulletin of the Menninger Clinic, 7, 132–149.

https://doi.org/10.1521/bumc.2007.71.2.132

Barlow, J., McMillan, A., Kirkpatrick, S., Ghate, D., Barnes, J., & Smith, M. (2010).

Health-let interventions in the early years to enhance infant and maternal mental

108
 health: A review of reviews. Child and Adolescent Mental Health, 15, 178-185.

https://doi:10.1111/j.1475-3588.2010.00570.x

Beck, A., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for

measuring depression. Archives of General Psychiatry, 4, 561-571.

https://doi:1961.01710120031004

Belsky, J., Gilstrap, B., & Rovine, M. (1984). The Pennsylvania Infant and Family

Development Project, I: Stability and change in mother-infant and father-infant

interaction in a family setting at one, three, and nine months. Child Development, 55,

692-705. https://doi.org/10.2307/1130122

Benbassat, N., & Priel, B. (2012). Parenting and adolescent adjustment: The role of

parental reflective function. Journal of Adolescence, 35, 163–174.

https://doi:10.1016/j.adolescence.2011.03.004

Benz, M., & Scholtes-Spang, K. (2015). From normal development to development crisis

and regulatory disorder. In M. Cierpka (Ed.), Regulatory disorders in infants,

assessment, diagnosis and treatment (pp. 1 – 15). Switzerland: Springer.

Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., & Fonagy, P. (2015).

Intergenerational transmission of attachment in abused and neglected mothers: The

role of trauma-specific reflective functioning. Infant Mental Health Journal, 36, 200-

212. https://doi:10.1002/imhj.21499

Bian, X., Xie, H., Squires, J., & Chen, C. Y. (2017). Adapting a parent-completed,

socioemotional questionnaire in china: the ages & stages questionnaires: social-

emotional. Infant Mental Health Journal, 38, 258-266. https://doi:

10.1002/imhj.21626

109
Borelli, J. L., Compare, A., Snavely, J. E., & Decio, V. (2015). Reflective functioning

moderates the association between perceptions of parental neglect and attachment in

adolescence. Psychoanalytic Psychology, 32, 23-35.

https://dx.doi.org/10.1037/a0037858

Borelli, J. L., Hong, K., Rasmussen, H. F., & Smiley, P. A. (2017). Reflective functioning,

physiological reactivity, and overcontrol in mothers: Links with school-aged

children’s reflective functioning. Developmental Psychology, 53, 1680-

1693. https://dx.doi.org/10.1037/dev0000371

Borelli, J. L., West, J. L., Decoste, C., & Suchman, N. E. (2012). Emotionally avoidant

language in the parenting interviews of substance-dependent mothers: associations

with reflective functioning, recent substance use, and parenting behavior. Infant

Mental Health Journal, 33, 506–519. https://doi.org/10.1002/imhj.21340

Bowlby, J. (1949). The study and reduction of group tensions in the family. Human

Relations, 2, 123-128. https://dx.doi.org/10.1177/001872674900200203

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.

https://10.4236/psych.2017.86056

Briggs-Gowan, M. J., & Carter, A. S. (2008). Social-Emotional Screening Status in Early

Childhood Predicts Elementary School Outcomes. Pediatrics, 121, 957–962.

https://doi.org/10.1542/peds.2007-1948

Briggs-Gowan, M. J., Carter, A. S., McCarthy, K., Augustyn, M., Caronna, E., & Clark, R.

(2013). Clinical validity of a brief measure of early childhood social–

emotional/behavioral problems. Journal of Pediatric Psychology, 38, 577-587.

https://doi: 10.1093/jpepsy/jst014

Bronfennbrenner, U. (1987). La Ecología del Desarrollo Humano, Barcelona, Paidos.

110
Cabrera, N. J., Tamis-LeMonda, C. S., Bradley, R. H., Hofferth, S., & Lamb, M. E. (2000).

Fatherhood in the twenty-first century. Child Development, 71, 127–136.

https://doi:10.1111/1467- 8624.00126

Campos, J. J., Mumme, D., Kermoian, R., & Campos, R. G. (1994). A functionalist

perspective on the nature of emotion. Japanese Journal of Research on Emotions, 2,

1-20. https://doi:10.1111/j.1540-5834.1994.tb01289.x

Carpenter, M., Nagell, K., & Tomasello, M. (1998). Social cognition, joint attention, and

communicative competence from 9 to 15 months of age. Monographs of the Society

for Research in Child Development, 63, 176. https://dx.doi.org/10.2307/1166214

Cassidy, K. W., Werner, R. S., Rourke, M., Zubernis, L. S., & Balaraman, G. (2003). The

relationship between psychological understanding and positive social behaviors.

Social Development, 12, 198-221. https://doi: 10.1111/1467-9507.00229

Caughy, M. O. B., Huang, K. Y., & Lima, J. (2009). Patterns of conflict interaction in

mother–toddler dyads: Differences between depressed and non-depressed mothers.

Journal of Child and Family Studies, 18, 10-20. https://doi:10.1007/s10826-008-

9201-6

Centro de Microdatos-Universidad de Chile. (2014). Encuesta longitudinal de primera

infancia. Santiago: Universidad de Chile. Retrieved from:

http://www.superacionpobreza.cl/wp-

content/uploads/2014/03/documento_metodologico.pdf

Cheng, E. R., Palta, M., Kotelchuck, M., Poehlmann, J., & Witt, W. P. (2014). Cognitive

delay and behavior problems prior to school age. Pediatrics, 134, e749-e757.

https://doi: 10.1542/peds.2014-0259.

111
Cigala, A., Venturelli, E., & Fruggeri, L. (2014). Family functioning in microtransition and

socio-emotional competence in preschoolers. Early Child Development and Care,

184, 553-570. https://dx.doi.org/10.1080/03004430.2013.800053

Committee on Children with Disabilities. (2001). Developmental surveillance and

screening of infants and young children. Pediatrics, 108(1), 192-195.

Corboz-Warnery, A., Fivaz-Depeursinge, E., Bettens, C. G., & Favez, N. (1993). Systemic

analysis of father-mother-baby interactions: The Lausanne triadic play.

Infant Mental Health Journal, 14, 298-316. https://doi:10.1002/1097-

0355(199324)14:4<298::AID-IMHJ2280140405>3.0.CO;2-#

Courchesne, E., Chisum, H. J., Townsend, J., Cowles, A., Covington, J., Egaas, B., ... &

Press, G. A. (2000). Normal brain development and aging: quantitative analysis at in

vivo MR imaging in healthy volunteers. Radiology, 216, 672–682.

https://doi.org/10.1148/radiology.216.3. r00au37672

Cummings, E., & Davies, P. (2010). Marital conflict and children: An emotional security

perspective. New York, US: Guilford.

Cummings, E. M., Keller, P. S., & Davies, P. T. (2005). Towards a family process model of

maternal and paternal depressive symptoms: exploring multiple relations with child

and family functioning. Journal of Child Psychology and Psychiatry, 46, 479–489.

doi: 10.1111/j.1469- 7610.2004.00368.x.

Davies, P. T., Cummings, E. M., & Winter, M. A. (2004). Pathways between profiles of

family functioning, child security in the interparental subsystem, and child

psychological problems. Development and Psychopathology, 16, 525-550. https://doi:

10.10170S0954579404004651

112
Denham, S. A., Blair, K. A., DeMulder, E., Levitas, J., Sawyer, K., Auerbach-Major, S., &

Queenan, P. (2003). Preschool Emotional Competence: Pathway to Social

Competence?. Child Development, 74, 238-256. https://doi: 10.1111/1467-

8624.00533

El-Sheikh, M., Kouros, C. D., Erath, S., Cummings, E. M., Keller, P., Staton, L., . . .

Moore, G. A. (2009). Marital conflict and children’s externalizing behavior:

Interactions between parasympathetic and sympathetic nervous system activity.

Monographs of the Society for Research in Child Development, 74, 1–101.

https://doi: 10.1111/j.1540-5834.2009.00501.x

Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2016). Maternal and child reflective

functioning in the context of child sexual abuse: pathways to depression and

externalising difficulties. European Journal of Psychotraumatology, 7: 30611.

https://doi: http://dx.doi.org/10.3402/ejpt.v7.30611

Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2017). Parental Reflective

Functioning as a moderator of child internalizing difficulties in the context of child

sexual abuse. Psychiatry Research, 257, 361-366.

https://doi.org/10.1016/j.psychres.2017.07.051

Ensink, K., Berthelot, N., Bernazzani, O., Normandin, L., & Fonagy, P. (2014). Another

step closer to measuring the ghosts in the nursery: preliminary validation of the

Trauma Reflective Functioning Scale. Frontiers in Psychology, 5, 1471.

https://doi.org/10.3389/fpsyg.2014.01471

Ensink, K., Normandin, L., Plamondon, A., Berthelot, N., & Fonagy, P. (2016).

Intergenerational Pathways From Reflective Functioning to Infant Attachment

113
 Through Parenting. Canadian Journal of Behavioural Science, 48, 9-18.

https://dx.doi.org/10.1037/cbs0000030

Ensink, K., Normandin, L., Target, M., Fonagy, P., Sabourin, S., & Berthelot, N. (2015).

Mentalization in children and mothers in the context of trauma: An initial study of the

validity of the Child Reflective Functioning Scale. British Journal of Developmental

Psychology, 33(2), 203-217. https:// doi:10.1111/bjdp.12074

Esbjørn, B. H., Pedersen, S. H., Daniel, S. I., Hald, H. H., Holm, J. M., & Steele, H. (2013).

Anxiety levels in clinically referred children and their parents: Examining the unique

influence of self-reported attachment styles and interview-based reflective

functioning in mothers and fathers. British Journal of Clinical Psychology, 4, 394-

407. https://doi: 10.1111/bjc.12024

Essex, M. J., Kraemer, H. C., Armstrong, J. M., Boyce, W. T., Goldsmith, H. H., Klein, M.

H., ... Kupfer, D. J. (2006). Exploring risk factors for the emergence of children's

mental health problems. Archives of General Psychiatry, 63, 1246-1256.

https://doi:10.1001/archpsyc.63.11.1246

Evans, M., Vicuña, M., & Marín, R. (2003). Depresión postparto realidad en el sistema

público de atención de salud. Revista chilena de obstetricia y ginecología, 68, 491-

494. https://dx.doi.org/10.4067/S0717-75262003000600006.

Favez, N., Scaiola, C., Tissot, H., Darwiche, J., & Frascarolo, F. (2011). The Family

Alliance Assessment Scales: Steps toward validity and reliability of an observational

assessment tool for early family interactions. Journal Child Family Studies, 20, 23-

37. https://doi:10.1007/s10826-010-9374-7

Favez, N., Frascarolo, F., Carneiro, C., Montfort, V. & Corboz-Warnery, A. (2006). The

development of the family Alliance from pregnancy to toddlerhood and children

114
 outcomes at 18 months. Infants and Child Development, 15, 59-73. https:// doi:

10.1002/icd.430

Favez, N., Lopes, F., Bernard, M., Frascarolo, F., Lavanchy Scaiola, C., Corboz-Warnery,

A., & Fivaz-Depeursinge, E. (2012). The development of family alliance from

pregnancy to toddlerhood and child outcomes at 5 years. Fam Process, 51, 542–556.

https://doi.org/10.1111/j.1545-5300.2012.01419.x

Feldman, R. (2007). Maternal versus child risk and the development of parent–child and

family relationships in five high-risk populations. Development and

Psychopathology, 19, 293–312. https://doi.org/10.1017/S0954579407070150

Feldman, R. (2010). The relational basis of adolescent adjustment: trajectories of mother–

child interactive behaviors from infancy to adolescence shape adolescents' adaptation.

Attachment & Human Development, 12, 173-192.

https://doi:10.1080/14616730903282472

Feldman, R. & Masalha, S. (2010). Parent–child and triadic antecedents of children’s social

competence: Cultural specificity, shared process. Developmental Psychology, 46,

455–467. http://doi.org/10.1037/a0017415

Feldman, R., Bamberger, E., & Kanat-Maymon, Y. (2013). Parent-specific reciprocity from

infancy to adolescence shapes children's social competence and dialogical skills.

Attachment & Human Development, 15, 407-423.

https://dx.doi.org/10.1080/14616734.2013.782650

Feldman, R., Masalha, S., & Alony, D. (2006). Microregulatory patterns of family

interactions: Cultural pathways to toddlers' self-regulation. Journal of Family

Psychology, 20, 614-623. https://dx.doi.org/10.1037/0893-3200.20.4.614

115
Feldman, R., Masalha, S., & Derdikman-Eiron, R. (2010). Conflict resolution in the parent–

child, marital, and peer contexts and children’s aggression in the peer group: A

process-oriented cultural perspective. Developmental Psychology, 46, 310-325.

https://doi: 10.1037/a0018286

Fincham, F. D. (1998). Child development and marital relations. Child Development, 69,

543-574. https://dx.doi.org/10.2307/1132183

Fivaz-Depeursinge E. & Favez, N. (2006). Exploring triangulation in infancy: Two

contrasted cases. Family Process, 45, 3–18. https://doi.org/10.1111/j.1545-

5300.2006.00077.x

Fivaz-Depeursinge, E. (1987). Alliances et mésalliances dans le dialogue entre adulte et

bébé: la communication précoce dans la famille. Neuchâtel et Paris: Delachaux &

Niestlé.

Fivaz-Depeursinge, E. (1991). Documenting a time-bound, circular view of hierarchies: A

microanalysis of parent-infant dyadic interaction. Family Process, 30, 101-

120. http://dx.doi.org/10.1111/j.1545-5300.1991.00101.x

Fivaz-Depeursinge, E. & Corboz-Warnery, A. (1999). The primary triangle, a

developmental systems view of mothers, fathers and infants. London: Basic Books.

Fivaz-Depeursinge, E., & Philipp, D. A. (2014). The baby and the couple: Understanding

and treating young families. Routledge.

Fivaz-Depeursinge, E., Favez, N., Lavanchy, C., De Noni, S., & Frascarolo, F. (2005).

Four-month-olds make triangular bids to father and mother during Trilogue Play with

Still-Face. Social Development, 14, 361–378. https://doi:10.1111/j.1467-

9507.2005.00306.x

116
Fivaz-Depeursinge, E., Fivaz, R., & Kaufmann, L. (1982). Encadrement du développement,

le point de vue systémique: fonctions pédagogique, parentale, thér apeutique. Cahiers

Critiques de Thérapie Familiale el de Pratiques de Réseaux, 4(5), 63-74.

Fletcher, R. J., Feeman, E., Garfield, C., & Vimpani, G. (2011). The effects of early

paternal depression on children’s development. The Medical Journal of

Australia, 195, 685-689. https://doi:10.5694/mja11.10192

Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in

self-organization. Development and psychopathology, 9, 679-700.

https://dx.doi.org/10.1017/S0954579497001399

Fonagy, P., Gergely, G., Jurist, E. L. & Target, M. (Eds.). (2004). Affect regulation,

mentalization and the development of the self. Karnac books.

Fonagy, P., Steele, H., Steele, M., & Target, M. (1998). Reflective Functioning Manual,

Version 5.0, for Application to Adult Attachment Interviews. London: University

College London.

Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgitt, A. (1991). The capacity for

understanding mental states: The reflective self in parent and child and its

significance for security of attachment. Infant Mental Health Journal, 12, 201 – 218.

https://dx.doi.org/10.1002/1097-0355(199123)12:3<201::AID-

IMHJ2280120307>3.0.CO;2-7

Fonagy, P., Steele, M., Steele, H., Higgitt, A., & Target, M. (1994). Theory and practice of

resilience. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 35(2),

231–257. https://dx.doi.org/10.1111/j.1469-7610.1994.tb01160.x

117
Frascarolo, F. (2004). Paternal Involvement in Child Caregiving and Infant

Sociability. Infant Mental Health Journal, 25(6), 509-

521. https://dx.doi.org/10.1002/imhj.20023

Frascarolo, F., & Favez, N. (1999). Comment et a` qui s’attache le jeune enfant? Le Carnet

Psy, 48, 39–40.

Frascarolo, F., Favez, N., Carneiro, C., & Fivaz-Depeursinge, E. (2004). Hierarchy of

interactive functions in father-mother-baby three-way games. Infant and Child

Development,13, 301-322. https://doi: 10.1002/ icd.361

Garfield, C. F., Duncan, G., Rutsohn, J., McDade, T. W., Adam, E. K., Coley, R. L., &

Chase-Lansdale, P. L. (2014). A longitudinal study of paternal mental health during

transition to fatherhood as young adults. Pediatrics, 133, 836-843.

https://doi: 10.1542/peds.2013-3262

George, C., Kaplan, N., & Main, M. (1985). Attachment interview for adults. Unpublished

manuscript, University of California, Berkeley.

Giannovi, P. P., & Kass, P. H. (2012). Predictors of developmental outcomes of high-risk

and developmentally delayed infants and children enrolled in a state early childhood

intervention program. Infants & Young Children, 25, 244-264. https://doi:

10.1097/IYC.0b013e318257ff83

Goldberg, W. A., Clarke-Stewart, A., Rice, J. A., & Dellis, E. (2002). Emotional energy as

an explanatory construct for fathers’ engagement with their infants. Parenting

Science and Practice, 2(4), 379–408. https://doi:10.1207/S15327922PAR0204_03

Greenspan, S., DeGangu, G., & Wieder, S. (2001). The functional emotional assessment

scale (FEAS) for infancy and early childhood: Clinical and research applications.

Bthesda, MD: Interdisciplinary Council on Developmental and Learning Disorders.

118
Grienenberger, J., Kelly, K., & Slade, A. (2005). Maternal reflective functioning, mother–

infant affective communication, and infant attachment: Exploring the link between

mental states and observed caregiving behavior in the intergenerational transmission

of attachment. Attachment & Human Development, 7, 299–311.

https://dx.doi.org/10.1080/14616730500245963

Gutierrez-Galve, L., Stein, A., Hanington, L., Heron, J., & Ramchandani, P. (2015).

Paternal depression in the postnatal period and child development: mediators and

moderators. Pediatrics, 135, e339-e347. https://doi:10.1542/peds.2014-2411

Hayes, L. J., Goodman, S. H., & Carlson, E. (2013). Maternal antenatal depression and

infant disorganized attachment at 12 months. Attachment & Human Development, 15,

133-153. https://doi: 10.1080/14616734.2013.743256

Hedenbro, M. (2006). The family triad-the interaction between the child, its mother, and

father from birth to the age of 4 years (Doctoral dissertation). Karolinska Institutet,

Stockolm. Sweden.

Hedenbro, M. & Rydelius, P.A. (2014). Early interaction between infants and their parents

predicts social competence at the age of four. Acta Paediatr, 103, 268–274.

https://doi:10.1111/apa.12512

Hendrick, S. (1988). A generic measurement of relationship satisfaction. Journal of

Marriage and the Family, 50, 93-98. https://dx.doi.org/10.2307/352430

Heron-Delaney, M., Kenardy, J. A., Brown, E. A., Jardine, C., Bogossian, F., Neuman, L.,

... & Pritchard, M. (2016). Early maternal reflective functioning and infant emotional

regulation in a preterm infant sample at 6 months corrected age. Journal of pediatric

psychology, 41, 906-914. https://doi: 10.1093/jpepsy/jsv169

119
Huang, C. C., & Warner, L. A. (2005). Relationship characteristics and depression

among fathers with newborns. Social Service Review, 79, 95-118.

https://dx.doi.org/10.1086/426719

Illingworth, R. S. (1983). El Desarrollo Infantil en sus Primeras Etapas. In Vericat, A., &

Orden, A. B. (2013). Psychomotor development and its disorders: between normal

and pathological development. Ciencia & Saude Coletiva, 18, 2977-2984.

https://dx.doi.org/10.1590/S1413-81232013001000022.

Instituto Nacional de Estadística, INE. Síntesis de Resultados Censo 2012. Santiago:

Instituto Nacional de Estadísticas de Chile.

Iverson, J. M. (2010). Developing language in a developing body: the relationship between

motor development and language development. Journal of Child Language, 37, 229–

261. https://doi.org/10.1017/S0305000909990432

Iwasaki, N., Hamano, K., Okada, Y., Horigome, Y., Nakayama, J., Takeya, T., ... & Nose,

T. (1997). Volumetric quantification of brain development using MRI.

Neuroradiology, 39(12), 841–846.

Jadresic, E. (2010). Depresión en el embarazo y el puerperio. Revista Chilena de Neuro-

psiquiatría, 48, 269-278. https://doi:10.4067/S0717-92272010000500003

Johnson, V. K. (2001). Marital interaction, family organization, and differences in parent

behavior: Explaining variations across family interaction contexts. Family Process,

40, 333–342. https://doi:10.1111/j.1545-5300.2001.4030100333.x

Kam, C. M., Greenberg, M. T., Bierman, K. L., Coie, J. D., Dodge, K. A., Foster, M. E., ...

& Conduct Problems Prevention Research Group. (2011). Maternal depressive

symptoms and child social preference during the early school years: Mediation by

120
 maternal warmth and child emotion regulation. Journal of abnormal child

psychology, 39, 365-377. https://doi:10.1007/s10802-010-9468-0

Kamalifard, M., Hasanpoor, S., Kheiroddin, J. B., Panahi, S., & Payan, S. B. (2014).

Relationship between fathers' depression and perceived social support and stress in

postpartum period. Journal of Caring Sciences, 3, 57-66. https://doi:

10.5681/jcs.2014.007

Kane, P., & Garber, J. (2004). The relations among depression in fathers, children's

psychopathology, and father–child conflict: A meta-analysis. Clinical Psychology

Review, 24, 339-360. https://dx.doi.org/10.1016/j.cpr.2004.03.004

Kårstad, S. B., Wichstrøm, L., Reinfjell, T., Belsky, J., & Berg-Nielsen, T. S. (2015). What

enhances the development of emotion understanding in young children? A

longitudinal study of interpersonal predictors. British Journal of Developmental

Psychology, 33, 340–354. https://doi:10.1111/bjdp.12095.

Kennedy, D. N., Makris, N., Herbert, M. R., Takahashi, T. & Caviness, V. S. (2002). Basic

principles of MRI and morphometry studies of human brain development.

Developmental Science, 5, 268–278. https://doi: 10.1111/1467-7687.00366

Kennedy, H., & Dehay, C. (2001). Gradients and boundaries: limits of modularity and its

influence on the isocortex. [Commentary]. Developmental Science, 4(2), 147–148.

Kohn J. L., Rholes S. W., Simpson J. A., Martin A. M., Tran S., & Wilson C. L.

(2012). Changes in marital satisfaction across the transition to parenthood: the role of

adult attachment orientations. Personality & Social Psychology Journal, 38, 1506–

1522. https://doi:10.1177/0146167212454548

Koren-Karie, N., Oppenheim, D., Dolev, S., Sher, E., & Etzion-Carasso, A. (2002).

Mothers' insightfulness regarding their infants' internal experience: relations with

121
 maternal sensitivity and infant attachment. Developmental Psychology, 38, 534-42.

https://doi.org/10.1037/0012-1649.38.4.534

Kwon, K. A., Jeon, H. J., Lewsader, J. T., & Elicker, J. (2012). Mothers' and Fathers'

Parenting Quality and Toddlers' Interactive Behaviours in Dyadic and Triadic Family

Contexts. Infant and Child Development, 21, 356-373. https://doi: 10.1002/icd.1746

Ladegaard, N., Lysaker, P. H., Larsen, E. R., & Videbech, P. (2014). A comparison

of capacities for social cognition and metacognition in first episode and

prolonged depression. Psychiatry research, 220, 883-889.

https://doi:10.1016/j.psychres.2014.10.005

Lamb, M. E. (1976). Effects of stress and cohort on mother- and father-infant interaction.

Developmental Psychology, 12, 435–443. https://doi.org/10.1037/0012-1649.12.5.435

Lamb, M. E. (2013). The father's role: Cross cultural perspectives. Routledge.

Lamb, M. E., & Lewis, C. (2004). The development and significance of father–child

relationships in two-parent families. En M. E. Lamb (Ed.), The role of the father in

child development (4th ed., pp. 272–305). New York, NY: Wiley.

Laranjo, J., Bernier, A., & Meins, E. (2008). Associations between maternal mind-

mindedness and infant attachment security: Investigating the mediating role of

maternal sensitivity. Infant Behavior and Development, 31, 688-695. https:// doi:

10.1016/j.infbeh.2008.04.008.

Lavanchy, C., Tissot, H., Frascarolo, F., & Favez, N. (2013). Family Alliance Assessment

Scale (FAAS): Coding Manual, short versión. Center for Family Studies, University

of Psychotherapy, DP-CHUV, University of Lausanne, Switzerland and Departament

of Psychology, FPSE, University of Geneva, Switzerland. Unpublished draft.

122
Leckman-Westin, E., Cohen, P. R., & Stueve, A. (2009). Maternal depression and mother–

child interaction patterns: Association with toddler problems and continuity of effects

to late childhood. Journal of Child Psychology and Psychiatry, 50, 1176-1184.

https://doi:10.1111/j.1469-7610.2009.02083.x

Leidy, M. S., Schofield, T. J., & Parke, R. D. (2013). Fathers’ contributions to children’s

social development. Handbook of father involvement: Multidisciplinary perspectives,

2, 151-167.

Lenroot, R. K., & Giedd, J. N. (2006). Brain development in children and adolescents:

Insights from anatomical magnetic resonance imaging. Neuroscience and

Biobehavioral Reviews, 30, 718–729. https://doi:10.1016/j.neubiorev.2006.06.001

Lewis, J. M. (1989). The birth of the family. An empirical inguiry. New York:

Bruner/Mazel.

Lindsey, E., & Caldera, Y. (2006). Mother-father-child triadic interaction and mother-child

dyadic interaction: Gender differences within and between contexts. Sex Roles, 55,

511–521. https://doi:10.1007/s11199-006-9106-z

Liszkowski, U., Carpenter, M., Henning, A., Striano, T., & Tomasello, M. (2004). Twelve-

month-olds point to share attention and interest. Developmental Science, 7, 297–307.

https://dx.doi.org/10.1111/j.1467-7687.2004.00349.x

Luyten, P., Mayes, L.C., Nijssens L, & Fonagy, P. (2017). The parental reflective

functioning questionnaire: Development and preliminary validation. PLoS ONE

12(5): e0176218. https://doi. org/10.1371/journal.pone.0176218

Lyons-Ruth, K., & Zeanah, C. H., Jr. (1993). The family context of infant mental health: I.

Affective development in the primary caregiving relationship. In C. H. Zeanah, Jr.

(Ed.), Handbook of infant mental health (pp. 14-37). New York: Guilford Press.

123
Madigan, S., Moran, G., Schuengel, C., Pederson, D. R. & Otten, R. (2007). Unresolved

maternal attachment representations, disrupted maternal behavior and disorganized

attachment in infancy: links to toddler behavior problems. Journal of Child

Psychology and Psychiatry, 48, 1042–1050. https://doi:10.1111/j.1469-

7610.2007.01805.x

Marcu, I., Oppenheim, D., & Koren-Karie, N. (2016). Parental insightfulness is associated

with cooperative interactions in families with toddlers. Journal of Family Psychology,

30, 927-934. https://dx.doi.org/10.1037/fam0000240

Mattern, M., Walter, H., Hentze, C., Schramm, E., Drost, S., Schoepf, D., ... & Schnell, K.

(2015). Behavioral Evidence for an Impairment of Affective Theory of Mind

Capabilities in Chronic Depression. Psychopathology, 48(4), 240-250.

http://doi:10.1159/000430450

McHale, J., Fivaz-Depeursinge, E., Dickstein, S., Robertson, J., & Daley, M. (2008). New

evidence for the social embeddedness of infants' early triangular capacities. Family

Process, 47, 445-463. https://dx.doi.org/10.1111/j.1545-5300.2008.00265.x

McHale, J.P. & Fivaz-Depeursinge, E. (1999). Understanding triadic and family group

interactions during infancy and toddlerhood. Clinical Child and Family Psychology

Review, 2, 107-127. https://dx.doi.org/10.1023/A:1021847714749

Meins, E. (1997). Security of attachment and the social development of cognition. Hove

England: Psychology Press.

Meins, E., Fernyhough, C., de Rosnay, M., Arnott, B., Leekam, S. R., & Turner, M. (2012).

Mind-mindedness as a multidimensional construct: Appropriate and nonattuned

mind-related comments independently predict infant–mother attachment in a socially

124
 diverse sample. Infancy, 17, 393–415. https://dx.doi.org/10.1111/j.1532-

7078.2011.00087.x

Meins, E., Fernyhough, C., Fradley, E., & Tuckey, M. (2001). Rethinking maternal

sensitivity: Mothers’ comments on infants’ mental processes predict security of

attachment at 12 months. Journal of Child Psychology and Psychiatry, 42, 637–648.

https://dx.doi.org/10.1111/1469-7610 .00759

Ministerio de Salud, Gobierno de Chile. (2011). Encuesta nacional de salud (ENS) 2009-

2010. Retrieved from:

http://web.minsal.cl/portal/url/item/bcb03d7bc28b64dfe040010165012d23.pdf

Minuchin, P. (1985). Families and individual development: Provocations from the

field of family therapy. Child Development, 56(2), 289–302.

http://dx.doi.org/10.2307/1129720

National Research Council and Institute of Medicine (2009). Depression in parents,

parenting, and children: Opportunities to improve identification, treatment, and

prevention. Committee on Depression, Parenting Practices and the Healthy

Development of Children, Board on Children, Youth and Families, Division on

Behavioral and Social Sciences and Education. Washington, DC: The National

Academies Press.

O'Hara, M. W., & McCabe, J. E. (2013). Postpartum depression: current status and future

directions. Annual review of clinical psychology, 9, 379-407. https://doi:

10.1146/annurev-clinpsy-050212-185612

Olhaberry, M., & Santelices, M. P. (2013). Father's presence and the quality of mother-

child interaction: A comparative study on Chilean nuclear and single-mother families.

Universitas Psychologica, 12(3), 833-844.

125
Olhaberry, M., Escobar, M., San Cristóbal, P., Santelices, M. P., Farkas, C., Rojas, G., &

Martínez, V. (2013). Intervenciones psicológicas perinatales en depresión materna y

vínculo madre-bebé: una revisión sistemática. Terapia Psicológica, 31, 249-261.

https://doi:10.4067/S0718-48082013000200011

Olhaberry, M., Santelices, M.P., Schwinn, L., & Cierpka, M. (2013). La tríada padre-

madre-infante: evaluación de las alianzas familiares a través del lausanne trialogue

play, apego y niveles de depresión parental. Revista Argentina de Clínica

Psicológica, 22, 85-94.

Ordway, M. R., Sadler, L. S., Dixon, J., & Slade, A. (2014). Parental reflective functioning:

analysis and promotion of the concept for paediatric nursing. Journal of Clinical

Nursing, 23, 3490-3500. https://doi: 10.1111/jocn.12600

Pajulo, M., Pyykkönen, N., Kalland, M., Sinkkonen, J., Helenius, H., Punamäki, R. L., &

Suchman, N. (2012). Substance-abusing mothers in residential treatment with their

babies: Importance of pre- and postnatal maternal reflective functioning. Infant

Mental Health Journal, 33, 70– 81. http://dx.doi.org/10.1002/imhj.20342

Parke, R. D., Power, T. G., & Gottman, J. M. (1979). Conceptualizing and quantifying

influence patterns in the family triad. Social interaction analysis: Methodological

issues, 231-252.

Paulson, J.F., & Bazemore, S.D., (2010). Prenatal and postpartum depression in fathers and

its association with maternal depression: a meta-analysis. Journal of the American

Medical Association, 303, 1961-1969. https://dx.doi.org/10.1001/jama.2010.605

Pereira, R. (1994). Revisión histórica de la Terapia Familiar. Psicopatología, 14, 5-17.

126
Pérez, F., & Santelices, M. P. (2017). Alianza tríadica familiar y salud mental parental.

Terapia Psicológica, 35, 23-33. https://dx.doi.org/10.4067/S0718-

48082017000100003

Pérez, F., Moessner, M., & Santelices, M. P. (2017). Beyond the dyad: the relationship

between preschoolers’ attachment representations and family triadic interactions.

Infant Mental Health Journal, 38, 198–209. https://doi:10.1002/imhj.21633

Perren, S., von Wyl, A., Simoni, H., Stadlmayr, W., Burgin, D., & von Klitzing, K. (2003).

Parental psychopathology, marital quality, and the transition to parenthood.

American Journal of Orthopsychiatry, 73, 55– 64. https://dx.doi.org/10.1037/0002-

9432.73.1.55

Piallini, G., Brunoro, S., Fenocchio, C., Marini, C., Simonelli, A., Biancotto, M., & Zoia, S.

(2016). How Do Maternal Subclinical Symptoms Influence Infant Motor

Development during the First Year of Life? Frontiers in Psychology, 7, 1685.

https://doi.org/10.3389/fpsyg.2016.01685P

Pihlakoski, L., Sourander, A., Aromaa, M., Rautava, P., Helenius, H., & Sillanpaa, M.

(2006). The continuity of psychopathology from early childhood to preadolescence: a

prospective cohort study of 3012-year-old children. European Child and Adolescent

Psychiatry, 15, 409–417. https://doi.org/10.1007/s00787-006-0548-1

Pilowsky, D., Wickramaratne, P., Talati, A., Tang, M., Hughes, C., Garber, J., Malloy,

E.,… & Weissman, M. (2008). Children of depressed mothers 1 year after the

initiation of maternal treatment: findings from the STAR* D-Child Study. American

Journal of Psychiatry, 165, 1136-1147. https://doi: 10.1176/appi.ajp.2008.07081286

127
Pleck, J. H., & Masciadrelli, B. P. (2004). Paternal involvement by U.S. residential fathers:

Levels, sources, and consequences. In M. E. Lamb (Ed.), The role of the father in

child development (pp. 223–271). New York, NY: Wiley.

Podestá, L., Alarcón, A. M., Muñoz, S., Legüe, M., Bustos, L., & Barría, M. (2013).

Alteración del desarrollo psicomotor en hijos de mujeres con depresión posparto de la

ciudad de Valdivia-Chile. Revista Médica de Chile, 141, 464-470.

https://dx.doi.org/10.4067/S0034-98872013000400007

Ramchandani, P. G., Psychogiou, L., Vlachos, H., Iles, J., Sethna, V., Netsi, E., & Lodder,

A. (2011). Paternal depression: an examination of its links with father, child and

family functioning in the postnatal period. Depression and Anxiety, 28(6), 471-477.

https://doi: 10.1002/da.20814

Ramchandani, P. G., Stein, A., O'connor, T. G., Heron, J. O. N., Murray, L., & Evans, J.

(2008). Depression in men in the postnatal period and later child psychopathology: a

population cohort study. Journal of the American Academy of Child & Adolescent

Psychiatry, 47, 390-398. https://doi:10.1097/CHI.0b013e31816429c2

Reiss, A. L., Abrams, M. T., Singer, H. S., Ross, J. L., & Denckla, M. B. (1996). Brain

development, gender and IQ in children: a volumetric imaging study. Brain, 119,

1763–1774. https://doi.org/10.1093/brain/119.5. 1763.

Rivera, D., & Heresi, E. (2011). Integración de la teoría del apego y modelos basados en la

evidencia en la comprensión de la satisfacción marital. Revista Argentina de Clínica

Psicológica, 20, 57 – 66. https://dx.doi.org/10.4067/S0718- 22282012000100005

Roggman, L.A., Boyce, L.K., Cook, G.A., & Cook, J. (2002). Getting dads involved:

predictors of father involvement in early head start and with their children. Infant

Mental Health Journal, 23, 62-78. https://dx.doi.org/10.1002/imhj.10004

128
Rose-Krasnor, L. (1997), The Nature of Social Competence: A Theoretical Review. Social

Development, 6, 111–135. https://doi:10.1111/j.1467-9507.1997.tb00097.x

Rosenblum, K. L., McDonough, S. C., Sameroff, A. J., & Muzik, M. (2008). Reflection in

thought and action: maternal parenting reflectivity predicts mind-minded comments

and interactive behavior. Infant Mental Health Journal 29, 362–376.

https://doi: 10.1002/imhj.20184

Rothschild-Yakar, L., Levy-Shiff, R., Fridman-Balaban, R., Gur, E., & Stein, D. (2010).

Mentalization and relationships with parents as predictors of eating disordered

behavior. Journal of Nervous and Mental Disease, 198, 501–507. https://doi:

10.1097/NMD.0b013e3181e526c8

Rothschild-Yakar, L., Waniel, A., & Stein, D. (2013). Mentalizing in self vs. parent

representations and working models of parents as risk and protective factors from

distress and eating disorders. Journal of Nervous and Mental Disease, 201, 510-518.

https://doi: 10.1097/NMD.0b013e3182948316

Rutherford, H. J., Booth, C. R., Luyten, P., Bridgett, D. J., & Mayes, L. C. (2015).

Investigating the association between parental reflective functioning and distress

tolerance in motherhood. Infant Behavior and Development, 40, 54-63.

https://doi.org/10.1016/j.infbeh.2015.04.005

Rutherford, H. J. V., Goldberg, B., Luyten, P., Bridgett, D. J., & Mayes, L. C. (2013).

Parental reflective functioning is associated with tolerance of infant distress but not

general distress: Evidence for a specific relationship using a simulated baby

paradigm. Infant Behavior & Development, 36.

https://doi.org/10.1016/j.infbeh.2013.06.008

129
Rutherford, H. J., Maupin, A. N., Landi, N., Potenza, M. N., & Mayes, L. C. (2017).

Parental reflective functioning and the neural correlates of processing infant affective

cues. Social neuroscience, 12(5), 519-529. doi:

http://dx.doi.org/10.1080/17470919.2016.1193559

San Cristobal, P., Santelices, M. P., & Fuenzalida, D. A. M. (2017). Manifestation of

Trauma: the effect of early traumatic experiences and adult attachment on parental

reflective functioning. Frontiers in Psychology, 8, 449 - https:// doi:

10.3389/fpsyg.2017.00449

Sarkadi, A., Kristiansson, R., Oberklaid, F. & Bremberg, S. (2008). Fathers' involvement

and children's developmental outcomes: a systematic review of longitudinal studies.

Acta Pædiatrica, 97, 153–158. https://doi:10.1111/j.1651-2227.2007.00572.x

Schonhaut, L., Armijo, I., Schönstedt, M., Alvarez, J., & Cordero, M. (2013). Validity of

the Ages and Stages Questionnaires in Term and Preterm Infants. Pediatrics, 131,

e1468-e1474. https://doi:10.1542/peds.2012-3313.

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment &

Human Development, 2, 23-47. https://dx.doi.org/10.1080/146167300361309

Scopesi, A. M., Rosso, A. M., Viterbori, P., & Panchieri, E. (2015). Mentalizing abilities in

preadolescents’ and their mothers’ autobiographical narratives. The Journal of Early

Adolescence, 35, 467-483. https://doi:10.1177/ 0272431614535091.

Seifer, R., Dickstein, S., Sameroff, A. J., Magee, K. D., & Hayden, L. C. (2001). Infant

mental health and variability of parental depression symptoms. Journal of American

Academy of Child and Adolescent Psychiatry, 40, 1375–1382.

https://dx.doi.org/10.1097/00004583-200112000-00007

130
Shapiro, A. F., Gottman, J. M., & Carrere, S. (2000). The baby and the marriage:

Identifying factors that buffer against decline in marital satisfaction after the first

baby arrives. Journal of Family Psychology, 14, 59-70.

https://dx.doi.org/10.1037/0893-3200.14.1.59

Shieh, G. (2011). Clarifying the role of mean centring in multicollinearity of interaction

effects. British Journal of Mathematical and Statistical Psychology, 64, 462–477.

https://doi:10.1111/j.2044-8317.2010.02002.x

Shore, R. (1997). Rethinking the brain. New insights into early development. New York:

Families and Work Institute.

Siegel, D. J. (1999). The developing mind. New York: Guilford Press.

Simonelli, A., Parolin, M., Sacchi, C., De Palo, F., & Vieno, A. (2016). The role of father

involvement and marital satisfaction in the development of family interactive

abilities: A multilevel approach. Frontiers in Psychology, 7, 1725.

https://doi.org/10.3389/fpsyg.2016.01725

Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & human

development, 7, 269-281. https://doi.org/10.1080/14616730500245906

Slade, A. (2007). Reflective parenting programs: Theory and development. Psychoanalytic

Inquiry, 26, 640-657. https://dx.doi.org/10.1080/07351690701310698

Slade, A., Aber, L., Berger, B., Bresgi, I., & Kaplan, M. (2012). Parent development

interview revised, short version. Unpublished.

Slade, A., Bernbach, E., Grienenberger, J., Levy, D., & Locker, A. (2004). Addendum to

Fonagy, Target, Steele, & Steele reflective functioning scoring manual for use with

the Parent Development Interview. Unpublished Manuscript. New York, NY: The

City College and Graduate Center of the City University of New York.

131
Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal

reflective functioning, attachment, and the transmission gap: A preliminary

study. Attachment & Human Development, 7, 283–298. https://

doi:10.1080/14616730500245880

Smaling, H. A., Huijbregts, S. C. J., van der Heijden, K. B., Hay, D. F., van Goozen, S. H.

M., & Swaab, H. (2017). Prenatal reflective functioning and development of

aggression in infancy: the roles of maternal intrusiveness and sensitivity. Journal of

Abnormal Child Psychology, 45, 237-248. https://doi:10.1007/s10802-016-0177-1

Smaling, H. J. A., Huijbregts, S. C. J., van der Heijden, K. B., van Goozen, S. H. M., &

Swaab, H. (2016a). Maternal reflective functioning as a multidimensional construct:

Differential associations with children’s temperament and externalizing behavior.

Infant Behavior and Development, 44, 263-274.

https://doi:10.1016/j.infbeh.2016.06.007.

Smaling, H. J., Huijbregts, S. C., Suurland, J., van der Heijden, K. B., Mesman, J., van

Goozen, S. H., & Swaab, H. (2016b). Prenatal reflective functioning and accumulated

risk as predictors of maternal interactive behavior during free play, the Still-Face

paradigm, and Two Teaching Tasks. Infancy, 21, 766-784. https://doi:

10.1111/infa.12137

Smaling, H. J., Huijbregts, S. C., Suurland, J., van der Heijden, K. B., van Goozen, S. H.

M., & Swaab, H. (2015). Prenatal reflective functioning in primiparous women with a

high-risk profile. Infant Mental Health Journal, 36, 251-261.

https://doi:10.1002/imhj.21506

Squires, J. & Bricker, D. (2009). Ages & Stages Questionnaires en español: A Parent-

Completed Child-Monitoring System. 3rd ed. Baltimore, Md.: Paul H. Brookes.

132
Squires, J., Bricker, D. & Twombly, E. (2002). Ages & Stages Questionnaires: Social-

Emotional: A Parent-Completed Child-Monitoring System for Social-Emotional

Behaviors. Baltimore, Md.:Paul H.Brookes.

Squires, J., Bricker, D. & Twombly, E. (2004), Parent-completed screening for social

emotional problems in young children: The effects of risk/disability status and gender

on performance. Infant Mental Health Journal, 25, 62–73.

https://doi:10.1002/imhj.10084

Sroufe, L. A. (1996). Emotional development: The organization of emotional life in the

early years. New York, NY: Cambridge University Press.

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., &

Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with

childhood maltreatment histories: Links to sensitive parenting and infant attachment

security. Attachment & Human Development, 16, 515-533. https:// doi:

10.1080/14616734.2014.935452

Steele, H., & Steele, M. (2008). On the origins of reflective functioning. En F. N. Busch

(Ed.), Mentalization: Theoretical considerations, research findings, and clinical

implications (pp.133–158). New York, NY: Analytic Press.

Stern, D. (1977). La primera relación: madre-hijo. Ediciones Morata.

Stern, D. (1985). El mundo interpersonal del infante. Una perspectiva desde el

psicoanálisis y la psicología evolutiva. Buenos Aires: Paidós.

Stevens, J. (2009). Applied multivariate statistics for social sciences New York: Routledge.

Stover, C. S. & Coates, E. E. (2016). The relationship of reflective functioning to parent

child interactions in a sample of fathers with concurrent intimate partner violence

133
 perpetration and substance abuse problems. Journal of Family Violence, 31, 433–442.

https://doi.org/10.1007/s10896-015-9775-x

Stover, C., & Spink, A. (2012). Affective awareness in parenting of fathers with co-

occurring substance abuse and intimate partner violence. Advances in Dual

Diagnosis, 5, 74-85. https://doi:10.1108/17570971211241903.

Suchman, N. E., DeCoste, C., Leigh, D., & Borelli, J. (2010). Reflective functioning in

mothers with drug use disorders: Implications for dyadic interactions with infants and

toddlers. Attachment & Human Development, 12, 567-585. https://doi:

10.1080/14616734.2010.501988

Taumoepeau, M., & Ruffman, T. (2008). Stepping stones to others’ minds: Maternal talk

relates to child mental state language and emotion understanding at 15, 24, and 33

months. Child Development, 79, 284-302. https://doi:10.1111/j.1467-

8624.2007.01126.x.

Teubert, D., & Pinquart, M. (2010). The association between coparenting and child

adjustment: A meta-analysis. Parenting: Science and Practice, 10, 286-307.

https://dx.doi.org/10.1080/15295192.2010.492040

Tissot, H., Favez, N., Ghisletta, P., Frascarolo, F. & Despland, J. N. (2017). A longitudinal

study of parental depressive symptoms and coparenting in the first 18 months. Family

Process, 56, 445–458. https://doi:10.1111/famp.12213

Tomasello, M., Carpenter, M., Call, J., Behne, T., & Moll, H. (2005). Understanding and

sharing intentions: The origins of cultural cognition. Behavioral and Brain Sciences,

28, 675–735. https://dx.doi.org/10.1017/S0140525X05000129

134
Trevarthen, C. (1993). The self born in intersubjectivity: The psychology of an infant

communicating. The perceived self: Ecological and Interpersonal Sources of Self-

Knowledge, 121-173.

Trillingsgaard, T., Baucom, K. J., & Heyman, R. E. (2014). Predictors of change in

relationship satisfaction during the transition to parenthood. Family Relations, 63,

667-679. https://doi: 10.1111/ fare.12089

Tronick, E. Z. (1989). Emotions and emotional communication in infants. American

Psychologist, 44, 112-119. https://dx.doi.org/10.1037/0003-066X.44.2.112

Udry-Jørgensen, L., Tissot, H., Frascarolo, F., Despland, J. N., & Favez, N. (2016). Are

parents doing better when they are together? A study on the association between

parental sensitivity and family-level processes. Early Child Development and Care,

186, 915-926. https://dx.doi.org/10.1080/03004430.2015.1068768

Uekermann, J., Channon, S., Lehmkämper, C., Abdel-Hamid, M., Vollmoeller, W., &

Daum, I. (2008). Executive function, mentalizing and humor in major depression.

Journal of the International Neuropsychological Society, 14, 55-62.

https://dx.doi.org/10.1017/S1355617708080016

Valdés, C., Morales-Reyes, I., Pérez, J. C., Medellín, A., Rojas, G., & Krause, M. (2017).

Propiedades psicométricas del inventario de depresión de Beck IA para la población

chilena. Revista Médica de Chile, 145, 1005-1012. https://dx.doi.org/10.4067/s0034-

98872017000801005

Venta, A., Velez, L., & Lau, J. (2016). The role of parental depressive symptoms in

predicting dysfunctional discipline among parents at high-risk for child maltreatment.

Journal of Child and Family Studies, 25, 3076-3082. https://doi: 10.1007/s10826-

016-0473-y

135
Wanless, S. B., Rosenkoetter, S. E., & McClelland, M. M. (2008). Paternal depression and

infant cognitive development: implications for research and intervention. Infants &

Young Children, 21, 134-141. https://doi: 10.1097/01.IYC.0000314484.46958.e4

Wendland, J., Danet, M., Gacoin, E., Didane, N., Bodeau, N., Saïas, T., ... & Chirac, O.

(2014). French Version of the Brief Infant-Toddler Social and Emotional Assessment

Questionnaire–BITSEA. Journal of Pediatric Psychology, 39, 562-575.

https://doi:10.1093/jpepsy/jsu016

Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., ...

& Burstein, R. (2013). Global burden of disease attributable to mental and substance

use disorders: findings from the Global Burden of Disease Study 2010. The Lancet,

382, 1575-1586. https://dx.doi.org/10.1016/S0140-6736(13)61611 -6.

Wilson, S., & Durbin, C.E. (2010). Effects of paternal depression on fathers’ parenting

behaviors: a meta-analytic review. Clinical Psychology Review, 30, 167-180.

https://dx.doi.org/10.1016/j.cpr.2009.10.007

Wobber, V., Herrmann, E., Hare, B., Wrangham, R., & Tomasello, M. (2014). Differences

in the early cognitive development of children and great apes. Developmental

Psychobiology, 56, 547-573. https:// doi: 10.1002/dev.21125

Wong, K. (2012). A study of the effect of maternal depressive symptoms on the mother-

infant relationship and protective effect of maternal reflective functioning (Master

dissertation). Wayne State University, Detroit, Michigan.

Zeegers, M., Colonnesi, C., Stams, G. J., & Meins, E. (2017). Mind matters: a three-level

meta-analysis on parental mentalization and sensitivity as predictors of infant-parent

attachment. Psychological Bulletin. https://doi:10.1037/bul0000114.

136
Zietlow, A. L., Schlüter, M. K., Nonnenmacher, N., Müller, M., & Reck, C. (2014).

Maternal self-confidence postpartum and at pre-school age: The role of depression,

anxiety disorders, maternal attachment insecurity. Maternal and Child Health

Journal, 18, 1873-1880. https://doi: 10.1007/s10995-014-1431-1

137
10. Annexed

138
10.1. Informed Consent Letters

CARTA DE CONSENTIMIENTO INFORMADO

Le estamos invitando a participar en el proyecto de investigación “Análisis de la

función reflexiva parental, la calidad de la interacción tríadica y su influencia en el desarrollo
infantil temprano”, el cual es la investigación de Tesis para optar al grado de Doctor en
Psicoterapia, otorgado por las Escuelas de Psicología de la Universidad de Chile y la Pontificia
Universidad Católica de Chile. Este a su vez forma parte del proyecto FONDECYT de
Iniciación Nº 11140230 (2014 – 2017) titulado “Implementación y Evaluación de una
Intervención con Videofeedback focalizada en la Calidad Vincular y la Función Reflexiva
Parental, dirigida a Tríadas Madre-Padre-Hijo/a con dificultades en el Desarrollo
Socioemocional Infantil”, y del Fondo de Innovación para la Competitividad (FIC) del
Ministerio de Economía, Fomento y Turismo, a través de la Iniciativa Científica Milenio,
Proyecto IS130005.
La investigación propuesta consiste en una entrevista individual, dirigida a padres y
madre de niños/as entre 1 y 3 años, mayores de 18 años y en relación de pareja actual que sean
participantes del Proyecto FONDECYT de Iniciación Nº 11140230. Esta entrevista busca
conocer la capacidad de padres y madres de reflexionar sobre los sentimientos, deseos y
necesidades de uno mismo y de su hijo/a.
Esta investigación tiene por objetivo analizar la relación entre la capacidad de los
padres de reflexionar sobre los sentimientos de sí mismo y de su hijo/a y la interacción madre-
padre-hijo/a, evaluando la influencia en el desarrollo infantil. El estudio incluirá a un número
total de 50 familias conformadas por padre – madre – hijo.
Si usted acepta participar se le realizará una entrevista que tiene una duración
aproximada de 40 minutos, la que será grabada en audio y luego transcrita. Esta entrevista
considera preguntas sobre la descripción del niño/a, sobre la relación padre/madre-hijo/a y
sobre la experiencia de ser padre/madre. Esta será realizada por un Psicólogo Clínico. La
entrevista podrá ser realizada en su domicilio o en dependencias de la Escuela de Psicología de
la Pontificia Universidad Católica de Chile, pudiendo usted elegir el lugar.
Su participación no implica riesgos para usted, salvo la posibilidad de sentirse
incómoda/o al contestar algunas preguntas. Una vez finalizada la entrevista y en caso de que
usted lo requiera, recibirá contención emocional y una devolución de los aspectos relevantes
vistos en la entrevista y se le orientará para que acceda a atención profesional de mayor
duración para abordar sus dificultades si usted lo requiere y desea recibirla.
En cuanto a los beneficios, además del beneficio que este estudio significará para el
progreso del conocimiento, su participación le podrá ayudar a ampliar su perspectiva sobre la
relación que establece con su hijo/a y la forma en que se influyen mutuamente, contribuyendo a
mejorar la comprensión de sus conductas y sentimientos, así como la relación entre ambos.
Es necesario aclarar que usted no recibirá ninguna compensación económica por su
participación en el estudio, como también que la entrevista realizada no presenta costo alguno
para usted.
Si usted decide no participar en esta investigación, de igual forma seguirá siendo parte
del estudio “Implementación y Evaluación de una Intervención con Videofeedback focalizada
en la Calidad Vincular y la Función Reflexiva Parental, dirigida a Tríadas Madre-Padre-
Hijo/a con dificultades en el Desarrollo Socioemocional Infantil”.
Toda la información derivada de su participación en este estudio será conservada en
forma de estricta confidencialidad. Sólo la investigadora responsable tendrá acceso a los
nombres de los participantes, identificando a los participantes por un número de entrevista.

139
 Los resultados de esta investigación serán utilizados sólo para este estudio y
contribuirán al desarrollo de herramientas para el trabajo con familias con niños/as pequeños/as
que presentan alguna dificultad en su desarrollo, su comportamiento o sus relaciones familiares.
Cualquier publicación o comunicación científica de los resultados de la investigación será
completamente anónima.
Su participación en esta investigación es totalmente voluntaria y se puede retirar en
cualquier momento comunicándolo al investigador, sin que ello esto afecte en nada su
participación en el estudio “Implementación y Evaluación de una Intervención con
Videofeedback focalizada en la Calidad Vincular y la Función Reflexiva Parental, dirigida a
Tríadas Madre-Padre-Hijo/a con dificultades en el Desarrollo Socioemocional Infantil”. De
igual manera el investigador podrá determinar su retiro del estudio si consideran que esa
decisión va en su beneficio.
Usted recibirá una copia íntegra y escrita de este documento firmado. Si usted requiere
cualquier otra información sobre su participación en este estudio puede comunicarse con:
María José León Papic, al +56 2 23341262 investigador responsable de este estudio o con
Marcia Olhaberry Huber, mpolhabe@uc.cl o al teléfono +56 2 23341262, investigadora
responsable del proyecto FONDECYT de Iniciación Nº 11140230, Escuela de Psicología,
Pontificia Universidad Católica de Chile, ubicada en Vicuña Mackenna 4860, Comuna de
Macul, Santiago.
En caso de duda sobre sus derechos debe comunicarse con el Presidente del “Comité de
Ética de Investigación en Seres Humanos”, Dr. Manuel Oyarzún G., Teléfono: 2-978.9536,
Email: comiteceish@med.uchile.cl, cuya oficina se encuentra ubicada a un costado de la
Biblioteca Central de la Facultad de Medicina, Universidad de Chile en Av. Independencia
1027, Comuna de Independencia.
Después de haber recibido y comprendido la información de este documento y de haber
podido aclarar todas mis dudas, otorgo mi consentimiento para participar en el proyecto
“Análisis de la función reflexiva parental, la calidad de la interacción tríadica y su influencia
en el desarrollo infantil temprano”.

Muchas gracias por su valiosa cooperación.

Acepto que la transcripción de la entrevista sea usada con fines de investigación, resguardando
nuestras identidades. Sí __ No___

Acepto que la información obtenida de la transcripción de la entrevista sea usada con fines de
publicación científica resguardando nuestras identidades. Sí __ No___

Acepto que la transcripción de la entrevista sea usada con fines de docencia especializada,
resguardando nuestros nombres y verificando que ninguno de los presentes tenga conocimiento
personal de la familia videada. Sí __ No___

Acepto que el investigador responsable, finalizada la evaluación pueda volver a contactarme en

futuras ocasiones Sí __ No___

Nombre: ________________________________________________ Rut:______________

Firma: __________________________________________________ Fecha: ____________
Nombre del investigador: María José León Papic Rut: 15.911.969-6
Firma:_________________________________________________ Fecha: ____________

140
 CARTA DE CONSENTIMIENTO INFORMADO

El presente estudio, titulado: “Implementación y Evaluación de una Intervención con Videofeedback

focalizada en la Calidad Vincular y la Función Reflexiva Parental, dirigida a Tríadas Madre-Padre-Hijo/a
con dificultades en el Desarrollo Socioemocional Infantil”, forma parte del proyecto FONDECYT de
Iniciación Nº 11140230 (2014 – 2017), el cual a su vez es parte del Fondo de Innovación para la
Competitividad (FIC) del Ministerio de Economía, Fomento y Turismo, a través de la Iniciativa Científica
Milenio, Proyecto IS130005. y cuenta con el patrocinio de la Pontificia Universidad Católica de Chile. La
presente carta tiene por objetivo ayudarle a tomar la decisión de participar o no en este estudio junto a su
hija/o.

La investigación propuesta consiste en una intervención psicoterapéutica que utiliza la grabación en

video de interacciones entre adultos y niños como herramienta. Se dirige a tríadas compuestas por la madre, su
hijo(a) pequeño y su padre u otro adulto que desempeñe el rol de cuidador primario. Busca favorecer la
comprensión del comportamiento infantil y las relaciones familiares, contribuyendo positivamente a mejorar
los vínculos y la salud mental.
Los resultados de esta investigación serán utilizados sólo para este estudio y contribuirán al desarrollo
de herramientas para el trabajo con familias con niños/as pequeños/as que presentan alguna dificultad en sus
vínculos, su comportamiento o sus relaciones familiares. Una vez finalizado el estudio, si usted lo desea, se le
entregarán los resultados cualitativos obtenidos en la evaluación final y se les invitará a una presentación de
los resultados generales. En caso de identificar alguna dificultad que implique riesgo para su salud física y/o
mental o la de su hijo/a, esta le será comunicada y posteriormente informada a un profesional competente del
Centro de Salud en el cual ustedes se atienden.
Si decide participar en el estudio, se le solicitará a usted y al padre/madre de su hijo (u otro adulto en
el rol parental) que firmen esta carta de consentimiento. La participación consistirá en ser parte de 2
evaluaciones de aproximadamente una hora y media de duración y de una intervención en apego y en la
capacidad de reflexionar sobre los sentimientos, deseos y necesidades en uno mismo y los otros o función
reflexiva. Será realizada por 1 Psicólogo Clínico y 1 Estudiante de Psicología en su último año. Las 2
evaluaciones mencionadas consisten en: una grabación de juego madre-padre-niño/a de aproximadamente 10
minutos, dos grabaciones de 3 minutos de juego libre adulto niño/a (madre-niño y padre-niño), contestar
preguntas sobre el comportamiento y las emociones de su hijo(a), responder preguntas sobre sus sentimientos
y sobre sus vínculos significativos. Las evaluaciones y la intervención podrán ser realizadas en el Consultorio
en el que ustedes se atienden o en su domicilio, pudiendo usted elegir el lugar.
Su participación no implica riesgos para usted y su hijo(a), salvo la posibilidad de sentirse incómoda/o
al contestar algunas preguntas. En relación a los beneficios de participar, muchos estudios muestran el efecto
positivo para la madre, el padre y sus hijos/as pequeños de ser parte de un programa de apoyo en apego y
función reflexiva, especialmente cuando los niños/as muestran dificultades en su comportamiento (lloran
mucho, les cuesta dormir, no comen bien, entre otros). Una vez finalizada la intervención y en caso de que
usted, su hijo/a o su padre (u otro adulto en el rol parental) lo requieran, recibirán contención emocional y se
les orientará para que accedan a atención profesional de mayor duración para abordar sus dificultades.
A pesar de lo anterior, su participación es voluntaria y usted es libre de dejar el estudio en cualquier
momento, sin que esto afecte en nada la atención que su hijo(a) y su familia reciben en el Centro de Salud al
que asisten.
Toda la información que usted entregue, así como la información obtenida en la observación de su
hijo(a) es confidencial. Sólo la investigadora responsable tendrá acceso a los nombres de los participantes, el
equipo de investigación y quienes analicen los videos, accederán a los datos identificando a los participantes
por un número de folio, lo cual asegurará su anonimato. No obstante, es importante considerar que en el caso
de los videos el anonimato no puede asegurarse. Por lo mismo, los miembros del equipo de investigación que
accedan a los datos firmarán también un compromiso de confidencialidad. No se compartirá con nadie la
información particular de usted o su hijo(a), sin embargo la información general que se obtenga del estudio
puede ser publicada en el ámbito científico si usted lo autoriza.

141
 Muchas gracias por su valiosa cooperación.

CONSENTIMIENTO:

Declaro que he leído el presente documento, se me ha explicado en qué consiste esta investigación y mi
participación en la misma, he tenido la posibilidad de aclarar mis dudas y tomo libremente la decisión de
participar en la Intervención en videofeedback para mejorar la calidad de mis relaciones familiares, a cargo de
la Psicóloga Marcia Olhaberry Huber. Además se me ha dado entrega de un duplicado firmado de este
documento.

Acepto que los videos e información obtenida sean usados con fines de investigación, resguardando nuestras identidades.

Sí __ No___

Acepto que la información obtenida en el estudio sea usada con fines de publicación científica resguardando nuestras
identidades.

Sí __ No___

Acepto que los videos sean usados con fines de docencia especializada, resguardando nuestros nombres y verificando que
ninguno de los presentes tenga conocimiento personal de la familia videada.

Sí __ No___

__________________________ __________________________
Nombre Participante Firma Participante

__________________________ __________________________
RUT Participante Relación con el niño/a

__________________________ ___________________________
Firma Investigador Responsable Fecha

Si tiene alguna pregunta puede comunicarse con Marcia Olhaberry Huber, mpolhabe@uc.cl o al
teléfono 23341262, Escuela de Psicología, Pontificia Universidad Católica de Chile, Vicuña Mackenna
4860, Comuna de Macul, Santiago. Si usted tiene alguna consulta o preocupación respecto a sus
derechos como participante de este estudio, puede contactar al Comité de Ética de la Escuela de
Psicología de la Pontificia Universidad Católica de Chile, E-mail comité.etica.psicologia@uc.cl, fono
2354-5883.

142
 CARTA DE CONSENTIMIENTO INFORMADO

El presente estudio, titulado: “Implementación y Evaluación de una Intervención con Videofeedback

focalizada en la Calidad Vincular y la Función Reflexiva Parental, dirigida a Tríadas Madre-Padre-Hijo/a
con dificultades en el Desarrollo Socioemocional Infantil”, forma parte del proyecto FONDECYT de
Iniciación Nº 11140230 (2014 – 2017) y del Instituto MILENIO: Intervención y cambio en depresión y cuenta
con el patrocinio de la Pontificia Universidad Católica de Chile. La presente carta tiene por objetivo ayudarle a
tomar la decisión de participar o no en este estudio junto a su hija/o.
La investigación propuesta consiste en una intervención psicoterapéutica que utiliza la grabación en
video de interacciones entre adultos y niños como herramienta. Se dirige a tríadas compuestas por la madre, su
hijo(a) pequeño y su padre u otro adulto que desempeñe el rol de cuidador primario. Busca favorecer la
comprensión del comportamiento infantil y las relaciones familiares, contribuyendo positivamente a mejorar
los vínculos y la salud mental.
Los resultados de esta investigación serán utilizados sólo para este estudio y contribuirán al desarrollo
de herramientas para el trabajo con familias con niños/as pequeños/as que presentan alguna dificultad en sus
vínculos, su comportamiento o sus relaciones familiares. Una vez finalizado el estudio, si usted lo desea, se le
entregarán los resultados cualitativos obtenidos en la evaluación final y se les invitará a una presentación de
los resultados generales. En caso de identificar alguna dificultad que implique riesgo para su salud física y/o
mental o la de su hijo/a, esta le será comunicada y posteriormente informada a un profesional competente del
Centro de Salud en el cual ustedes se atienden.
Si decide participar en el estudio, se le solicitará a usted y al padre/madre de su hijo (u otro adulto en
el rol parental) que firmen esta carta de consentimiento. La participación consistirá en ser parte de 2
evaluaciones de aproximadamente una hora y media de duración y de una intervención en apego y en la
capacidad de reflexionar sobre los sentimientos, deseos y necesidades en uno mismo y los otros o función
reflexiva. Será realizada por 1 Psicólogo Clínico y 1 Estudiante de Psicología en su último año. Las 2
evaluaciones se realizarán al comienzo y luego de terminada la intervención. La intervención estará
compuesta por al menos 5 sesiones de frecuencia semanal, de una hora y media de duración. Las 2
evaluaciones mencionadas consisten en: una grabación de juego madre-padre-niño/a de aproximadamente 10
minutos, dos grabaciones de 3 minutos de juego libre adulto niño/a (madre-niño y padre-niño), contestar
preguntas sobre el comportamiento y las emociones de su hijo(a), responder preguntas sobre sus sentimientos
y sobre sus vínculos significativos. Las evaluaciones y la intervención podrán ser realizadas en el Consultorio
en el que ustedes se atienden o en su domicilio, pudiendo usted elegir el lugar.
Su participación no implica riesgos para usted y su hijo(a), salvo la posibilidad de sentirse incómoda/o
al contestar algunas preguntas. En relación a los beneficios de participar, muchos estudios muestran el efecto
positivo para la madre, el padre y sus hijos/as pequeños de ser parte de un programa de apoyo en apego y
función reflexiva, especialmente cuando los niños/as muestran dificultades en su comportamiento (lloran
mucho, les cuesta dormir, no comen bien, entre otros). Una vez finalizada la intervención y en caso de que
usted, su hijo/a o su padre (u otro adulto en el rol parental) lo requieran, recibirán contención emocional y se
les orientará para que accedan a atención profesional de mayor duración para abordar sus dificultades.
A pesar de lo anterior, su participación es voluntaria y usted es libre de dejar el estudio en cualquier
momento, sin que esto afecte en nada la atención que su hijo(a) y su familia reciben en el Centro de Salud al
que asisten.
Toda la información que usted entregue, así como la información obtenida en la observación de su
hijo(a) es confidencial. Sólo la investigadora responsable tendrá acceso a los nombres de los participantes, el
equipo de investigación y quienes analicen los videos, accederán a los datos identificando a los participantes
por un número de folio, lo cual asegurará su anonimato. No obstante, es importante considerar que en el caso
de los videos el anonimato no puede asegurarse. Por lo mismo, los miembros del equipo de investigación que
accedan a los datos firmarán también un compromiso de confidencialidad. No se compartirá con nadie la
información particular de usted o su hijo(a), sin embargo la información general que se obtenga del estudio
puede ser publicada en el ámbito científico si usted lo autoriza.
Muchas gracias por su valiosa cooperación.

143
 CONSENTIMIENTO:

Declaro que he leído el presente documento, se me ha explicado en qué consiste esta investigación y mi
participación en la misma, he tenido la posibilidad de aclarar mis dudas y tomo libremente la decisión de
participar en la Intervención en videofeedback para mejorar la calidad de mis relaciones familiares, a cargo de
la Psicóloga Marcia Olhaberry Huber. Además se me ha dado entrega de un duplicado firmado de este
documento.

Acepto que los videos e información obtenida sean usados con fines de investigación, resguardando nuestras identidades.

Sí __ No___

Acepto que la información obtenida en el estudio sea usada con fines de publicación científica resguardando nuestras
identidades.

Sí __ No___

Acepto que los videos sean usados con fines de docencia especializada, resguardando nuestros nombres y verificando que
ninguno de los presentes tenga conocimiento personal de la familia videada.

Sí __ No___

__________________________ __________________________
Nombre Participante Firma Participante

__________________________ __________________________
RUT Participante Relación con el niño/a

__________________________ ___________________________
Firma Investigador Responsable Fecha

Si tiene alguna pregunta puede comunicarse con Marcia Olhaberry Huber, mpolhabe@uc.cl o
al teléfono 23341262, Escuela de Psicología, Pontificia Universidad Católica de Chile, Vicuña
Mackenna 4860, Comuna de Macul, Santiago. Si usted tiene alguna consulta o preocupación
respecto a sus derechos como participante de este estudio, puede contactar al Comité de Ética
de la Escuela de Psicología de la Pontificia Universidad Católica de Chile, E-mail
comité.etica.psicologia@uc.cl, fono 2354-5883.

144
10.2. Sociodemographic Background Sheet

N. Folio: Grupo:
FECHA:
Evaluador/a:

FICHA DE ANTECEDENTES SOCIODEMOGRÁFICOS

PROYECTO FONDECYT N°11140230

1. Datos de la madre
Nombre madre:
Fecha de nacimiento: Edad: Nacionalidad:
Trabajo remunerado Jornada:
SI __ NO __ Completa ____ Media ____ Menos que media ____
Actividad:
Vivienda: Propia __ Arrendada __ Nº habitaciones: Nº Camas:
Allegada __
Dirección Particular:
Nº personas que viven en esa dirección:
Nº de hijos: Teléfonos de contacto:
Embarazo deseado: Parto:
SI __ NO__ Normal ___ Cesárea ___ Fórceps ___

Estado Civil Actual Escolaridad

1 Soltero/a 1 Analfabeto/a
2 Conviviente 2 Básica Incompleta
3 Casado/a 3 Básica Completa
4 Anulado/a/Separado/a 4 Media Incompleta
Viudo/a 5 Media Completa
5 6 Técnico-profesional
7 Superior Universitaria

145
MADRE:

Tratamiento psicológico actual SI ___ NO ___ Motivo______________________

Tratamiento psicológico anterior SI ___ NO ___ Motivo ______________________
Fecha ____________ Duración ________________
Cantidad de sesiones_______
Tratamiento farmacológico actual SI ___ NO ___ Motivo_______________________
Tratamiento farmacológico anterior SI ___ NO ___ Motivo _______________________
Fecha ____________ Duración ________________
2. Datos del padre

Nombre padre:
Fecha de nacimiento: Edad: Nacionalidad:
Trabajo remunerado Jornada:
SI __ NO __ Completa ____ Media ____ Menos que media
____
Actividad Nº hijos:
Contacto con el niño Frecuencia: Diaria ____ Semanal ____ Mensual
SI __ NO __ ____
Trimestral ___ Semestral ____ Anual _____ Otro
____
Actividades que realiza con el niño: Alimentación __ Baño y aseo __ Juego y
estimulación __Otra:
____________________________________________________________

Estado Civil Actual Escolaridad

1 Soltero/a 1 Analfabeto/a
2 Conviviente 2 Básica Incompleta
3 Casado/a 3 Básica Completa
4 Anulado/a/Separado/a 4 Media Incompleta
Viudo/a 5 Media Completa
5 6 Técnico-profesional
7 Superior Universitaria
PADRE:
Tratamiento psicológico actual SI ___ NO ___ Motivo__________________
Tratamiento psicológico anterior SI ___ NO ___ Motivo __________________
Fecha _______ Cantidad de sesiones_______
Tratamiento farmacológico actual SI ___ NO ___ Motivo__________________

146
Tratamiento farmacológico anterior SI ___ NO ___ Motivo __________________
Fecha _______ Duración ________________

3. Datos del niño

Nombre del niño: Edad:

Fecha de nacimiento Lactancia Materna:
SI ___ NO ___ Edad destete ___________
Lugar en la Fratría: Asistencia a Sala Cuna:
SI ___ NO ___ Desde ___________ Hasta
__________
Dónde duerme: Cama padres__ Cuna en pieza de padres__ Pieza solo/a o con
hmnos_______
Enfermedades Trazadoras:
SI ___ NO ___ Digestivas ___________ Respiratorias _______ Cutáneas
________
Otros antecedentes relevantes:

4. Composición familia de la tríada (con quienes viven):

NOMBRE EDAD ACTIVIDAD PARENTESCO CON

EL NIÑO(A)

147
Nivel educacional de quien aporta el
ingreso principal del hogar
1 Educación básica incompleta o
inferior
2 Básica Completa
3 Media incompleta (incluyendo
Media Técnica)
4 Media completa o técnica
incompleta.
5 Universitaria incompleta. Técnica
completa
6 Universitaria completa.
7 Post Grado (Magíster, Doctorado
o equivalente)
¿Cuál es la profesión o trabajo de la
persona que aporta el principal ingreso
de este hogar? Por favor describa.
1 Trabajos menores ocasionales e
informales (lavado, aseo, servicio
doméstico ocasional, “pololos”,
cuidador de autos, limosna).
2 Oficio menor, obrero no
calificado, jornalero, servicio
doméstico con contrato.
3 Obrero calificado, capataz, junior,
micro empresario (kiosko, taxi,
comercio menor, ambulante).
4 Empleado administrativo medio y
bajo, vendedor, secretaria, jefe de
sección. Técnico especializado.
Profesional independiente de
carreras técnicas (contador,
analista de sistemas, diseñador,
músico). Profesor primario o
secundario.
5 Ejecutivo medio (gerente, sub-
gerente), gerente general de
empresa media o pequeña.
Profesional independiente de
carreras tradicionales (abogado,
médico, arquitecto, ingeniero,
agrónomo).
6 Alto ejecutivo (gerente general)
de empresa grande. Directores de
grandes empresas. Empresarios
propietarios de empresas
medianas y grandes.
Profesionales independientes de
gran prestigio.
148
10.3. Ages & Stages Questionnaires, Third Edition (ASQ-3)
 Ages & Stages
Questionnaires®

24 meses
23 meses 0 días a 25 meses 15 días

Cuestionario de
Favor de proveer los siguientes datos. Al completar este formulario, use solamente
una pluma de tinta negra o azul y escriba legiblemente con letra de molde.

Fecha en que se completó el cuestionario:

Información del niño/a:

Inicial de su
Nombre del niño/a: segundo nombre: Apellido(s) del niño/a:

Sexo del niño/a:

Masculino Femenino
Fecha de nacimiento del niño/a:

Información de la persona que está llenando este cuestionario

Inicial de su
Nombre: segundo nombre: Apellido(s):
Parentesco con el niño/a:
Padre/madre Tutor Maestro/a Educador/a o asistente
de preescolar
Dirección: Abuelo/a u Madre/padre
otro pariente de acogida Otro/a:

Estado/
Ciudad: Provincia: Código postal:

# de
teléfono Otro # de
País: de casa: teléfono:

Su dirección electrónica:

Los nombres de las personas que le están ayudando a llenar este cuestionario:

Información del programa

# de identificación del niño/a:

# de identificación del programa:

Nombre del programa:

Ages & Stages Questionnaires® in Spanish, Third Edition (ASQ-3™ Spanish), Squires & Bricker
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 Cuestionario de 24 meses 23 meses 0 días a
25 meses 15 días
En las siguientes páginas Ud. encontrará una serie de preguntas sobre diferentes actividades que generalmente hacen los niños.
Puede ser que su niño/a ya pueda hacer algunas de estas actividades, y que todavía no haya realizado otras. Después de leer
cada pregunta, por favor marque la respuesta que indique si su niño/a hace la actividad regularmente, a veces, o todavía no.

Puntos que hay que recordar: Notas:

✓ Asegúrese de intentar cada actividad con su niño/a antes
❑ ____________________________________________
de contestar las preguntas.
✓ Complete el cuestionario haciendo las actividades con su
❑
____________________________________________
niño/a como si fueran un juego divertido.
____________________________________________
✓ Asegúrese de que su niño/a haya descansado y comido.
❑
____________________________________________
✓ Por favor, devuelva este cuestionario antes de esta fecha:
❑
_______________. ____________________________________________

A esta edad, muchos niños no cooperan cuando se les pide hacer cosas. Quizás Ud. tenga que intentar hacer las actividades más de
una vez con su niño/a. Si es posible, intente hacer las actividades cuando su niño/a tenga buena disposición. Si su niño/a puede hacer
la actividad, pero se niega a hacerla, marque “sí” en la pregunta.

COMUNICACION SI A VECES TODAVIA NO

1. Sin enseñarle primero, ¿puede señalar con el dedo el dibujo correcto

cuando Ud. le dice, “Enséñame dónde está el gatito”, o le pregunta,
“¿Dónde está el perro?” (Solamente tiene que identificar un dibujo
correctamente.)

2. ¿Imita su niña una oración de dos palabras? Por ejemplo, cuando Ud.
dice “Mamá juega”, “Papá come”, o “¿Qué es?”, repite ella la misma
frase? (Marque “sí” aun si sus palabras sean difíciles de entender.)

3. Sin darle pistas señalándole o usando gestos, ¿puede su niño seguir al

menos tres de las siguientes instrucciones?

a. “Pon el juguete en la d. “Busca tu abrigo”.

mesa”.
e. “Dame la mano”.
b. “Cierra la puerta”.
f. “Agarra tu libro”.
c. “Tráeme una toalla”.

4. Si Ud. señala un dibujo de una pelota (gatito, vaso, gorro, etc.) y le pregunta
a su niña “¿qué es?”, ¿puede identificar y nombrar al menos un dibujo?

5. ¿Puede decir dos o tres palabras juntas que representen ideas dife-
rentes, como: “Veo perro”, “Mamá llega casa”, o “¿Se fue gatito”?
(No cuente las combinaciones de palabras que expresen una sóla idea
como “se acabó”, “está bien”, y “¿qué es?”) Escriba un ejemplo de
una combinación de palabras que dice su niño:

página 2 de 7
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 Cuestionario de 24 meses página 3 de 7

COMUNICACION (continuación) SI A VECES TODAVIA NO

6. ¿Puede usar correctamente al menos dos palabras como “mi”, “yo”,

“mía”, o “tú”?

TOTAL EN COMUNICACION

MOTORA GRUESA SI A VECES TODAVIA NO

1. ¿Su niño puede bajar las escaleras si usted lo lleva de la mano? Puede
agarrarse de la pared o de la barandilla también. (Ud. puede hacer esta
observación en la tienda, en el parque, o en casa.)

2. Al enseñarle cómo se da una patada a un balón, ¿intenta

su niño dar la patada moviendo la pierna hacia adelante o
caminando hasta tocar el balón? (Si ya sabe dar una patada
al balón, marque “sí” en esta pregunta.)

3. ¿Su niño sube o baja al menos dos escalones sin ayuda?

Puede agarrarse de la pared o de la barandilla.

4. ¿Su niña corre bien y sabe detenerse sin chocar con las
cosas o caerse?

5. ¿Puede saltar su niño, levantando ambos pies del suelo a

la vez?

6. Sin apoyarse en ningún objeto, ¿sabe su niño dar una *

patada a un balón moviendo la pierna hacia atrás y luego
hacia adelante?*

TOTAL EN MOTORA GRUESA

*Si marcó “sí” o “a veces”
en la pregunta 6, marque
“sí” en la pregunta 2.

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 Cuestionario de 24 meses página 4 de 7

MOTORA FINA SI A VECES TODAVIA NO

1. Normalmente, ¿puede su niño meterse la cuchara en la boca sin que se

le caiga la comida?

2. ¿Sabe darle la vuelta a las hojas de un libro sin ayuda? (Tal vez pase
más de una hoja a la vez.)

3. ¿Rota (gira) la mano su niña al intentar abrir una puerta, darle cuerda a
un juguete, jugar con un trompo, o poner y quitar una tapa de un
frasco?

4. ¿Su niño prende y apaga interruptores (como el de la luz)?

5. ¿Puede su niña poner siete cubitos o juguetes uno sobre otro sin
ayuda? (También puede usar carretes de hilo, cajitas, o juguetes que
midan aproximadamente 1 pulgada, o 3 centímetros.)

6. ¿Sabe meter un cordón (o agujeta) por el agujero

de objetos pequeños como cuentas de madera,
sopa de macarrones o de rueditas, o por los
agujeros de los zapatos?

TOTAL EN MOTORA FINA

RESOLUCION DE PROBLEMAS SI A VECES TODAVIA NO

Marque “sí”
1. Después de observarlo/la a Ud. dibujar una línea de
arriba a abajo usando una crayola (o pluma o lápiz),
¿su niño intenta dibujar una línea recta en cualquier
dirección en la hoja de papel? (Marque “todavía no” Marque “todavía no”
si su niño hace rayas o garabatos de un lado para
otro.)

2. Después de dejar caer una migaja o un Cheerio (cereal de desayuno)

en una pequeña botella transparente, ¿pone la botella al revés para
sacarlo? (No le muestre cómo hacerlo.) (Puede usar una botella de re-
fresco o un biberón.)

3. ¿Su niña juega con objetos imaginándose que son otras cosas? Por
ejemplo, ¿se pone un vaso junto a la oreja jugando como si fuera un
teléfono? ¿Se pone una caja en la cabeza como si fuera un gorro? ¿Usa
un cubito u otro juguete pequeño para revolver la comida?

4. ¿Guarda su niño las cosas en el sitio apropiado? Por ejemplo, ¿sabe

que sus juguetes deben estar en el estante, que su cobija se pone en la
cama, y que los platos se ponen en la cocina?

5. Si quiere algo que no alcanza, ¿busca su niña una silla o una caja para
subirse encima y alcanzarlo (por ejemplo, para agarrar un juguete que
está en el mostrador de la cocina o para “ayudarle” en la cocina)?

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 Cuestionario de 24 meses página 5 de 7

RESOLUCION DE PROBLEMAS (continuación) SI A VECES TODAVIA NO

6. Mientras su niño lo/la observa, ponga cuatro

objetos, como unos cubos o unos carritos, en
línea recta. ¿Lo/la intenta imitar poniendo al menos
cuatro objetos en línea recta? (También puede
usar carretes de hilo, unas cajitas, u otros juguetes.)

TOTAL EN RESOLUCION DE PROBLEMAS

SOCIO-INDIVIDUAL SI A VECES TODAVIA NO

1. ¿Sabe su niño beber de un vaso y bajarlo nuevamente sin que se le

caiga mucho del contenido?

2. ¿Lo/la imita a Ud. su niña, haciendo las mismas actividades que Ud.
hace, por ejemplo limpiar algo que se le ha caído, pasar la aspiradora,
afeitarse, o peinarse?

3. ¿Come con un tenedor?

4. Al jugar con un animalito de peluche o con una muñeca, ¿lo mece, le

da de comer, le cambia los pañales, lo acuesta, etc.?

5. ¿Su niño empuja un carrito con ruedas, un cochecito de bebé, u otro

juguete con ruedas, evitando chocar con las cosas y saliéndose en re-
versa de un rincón si no puede girar?

6. ¿Su niña se refiere a sí misma diciendo “yo” más que su propio nom-
bre? Por ejemplo, suele decir “yo lo hago” en lugar de “Susana lo
hace”.
TOTAL EN SOCIO-INDIVIDUAL

OBSERVACIONES GENERALES
Los padres y proveedores pueden utilizar el espacio después de cada pregunta para hacer comentarios adicionales.

1. ¿Cree Ud. que su niño/a oye bien? Si contesta “no”, explique: SI NO

2. ¿Cree Ud. que su niño/a habla igual que los otros niños de su edad? Si contesta SI NO
“no”, explique:

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 Cuestionario de 24 meses página 6 de 7

OBSERVACIONES GENERALES (continuación)

3. ¿Puede Ud. entender casi todo lo que dice su niño/a? Si contesta “no”, explique: SI NO

4. ¿Cree Ud. que su niño/a camina, corre, y trepa igual que los otros niños de su edad? SI NO
Si contesta “no”, explique:

5. ¿Tiene algún familiar con historia de sordera o cualquier otro impedimento auditivo? SI NO
Si contesta “sí”, explique:

6. ¿Tiene Ud. alguna preocupación sobre la visión de su niño/a? Si contesta “sí”, SI NO

explique:

7. ¿Ha tenido su niño/a algún problema de salud en los últimos meses? Si contesta SI NO
“sí”, explique:

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 Cuestionario de 24 meses página 7 de 7

OBSERVACIONES GENERALES (continuación)

8. ¿Tiene alguna preocupación sobre el comportamiento de su niño/a? Si contesta “sí”, SI NO

explique:

9. ¿Le preocupa algún aspecto del desarrollo de su niño/a? Si contesta “sí”, explique: SI NO

Ages & Stages Questionnaires® in Spanish, Third Edition (ASQ-3™ Spanish), Squires & Bricker
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 ASQ-3: Compilación de datos 24 meses 23 meses 0 días a
25 meses 15 días

Nombre del niño/a: Fecha de hoy:

# de identificación del niño/a: Fecha de nacimiento:

Nombre del programa/proveedor:

1. CALIFIQUE EL CUESTIONARIO Y PASE EL PUNTAJE TOTAL DE CADA SECCION AL GRAFICO DE ABAJO: Véase ASQ-3 User’s
Guide para obtener más detalles, incluyendo la manera de ajustar el puntaje si faltan respuestas a algunas preguntas. Califique
cada pregunta (SI = 10, A VECES = 5, TODAVIA NO = 0). Sume los puntos de cada pregunta, anotando el puntaje total en la línea
provista al final de cada sección del cuestionario. En el gráfico de abajo, anote el puntaje total de cada sección, y rellene el círculo
correspondiente.
Puntaje
Área Límite Total 0 5 10 15 20 25 30 35 40 45 50 55 60
Comunicación 25.17
Motora gruesa 38.07
Motora fina 35.16
Resolución de
problemas 29.78
Socio-individual 31.54

2. TRANSFIERA LAS RESPUESTAS DE LA SECCION TITULADA “OBSERVACIONES GENERALES”: Las respuestas escritas en negrita o
con mayúsculas requerirán un seguimiento. Véase el capítulo 6 del ASQ-3 User’s Guide para obtener información sobre las pautas a seguir.
1. ¿Oye bien? Sí NO 6. ¿Preocupaciones sobre la vista? SI No
Comentarios: Comentarios:
2. ¿Habla como otros niños de su edad? Sí NO 7. ¿Hay problemas de salud recientes? SI No
Comentarios: Comentarios:
3. ¿Ud. entiende lo que dice su niño/a? Sí NO 8. ¿Preocupaciones sobre comportamiento? SI No
Comentarios: Comentarios:
4. ¿Camina, corre, y trepa como otros niños? Sí NO 9. ¿Otras preocupaciones? SI No
Comentarios: Comentarios:
5. Historial: ¿Hay problemas auditivos en la familia? SI No
Comentarios:
3. INTERPRETACION DEL PUNTAJE Y RECOMENDACIONES PARA EL SEGUIMIENTO DEL ASQ: Para determinar el nivel de
seguimiento apropiado, hay que tomar en cuenta el Puntaje total de cada sección, las respuestas de la sección titulada “Obser-
vaciones generales”, y también factores adicionales, tales como considerar si el niño/a tiene oportunidades para practicar las
habilidades.
Si el Puntaje total está dentro del área , el puntaje del niño/a está por encima de las expectativas, y el desarrollo del niño/a
parece estar bien hasta ahora.
Si el Puntaje total está dentro del área , el puntaje está apenas por encima de las expectativas. Proporcione actividades
adicionales para ayudarle al niño/a y vigile su progreso.
Si el Puntaje total está dentro del área , el puntaje está debajo de las expectativas. Quizás se requiera una evaluación
adicional más a fondo.
4. SEGUIMIENTO DEL ASQ: Marque todos los que apliquen. 5. OPCIONAL: Anote las respuestas
______ Dar actividades adicionales y reevaluar en _____ meses. específicas (S = SI, V = A VECES,
N = TODAVIA NO, R = falta esta respuesta).
______ Compartir los resultados con su médico familiar (primary health care provider).
______ Referirlo/la para una evaluación auditiva, visual, o de comportamiento. (Marque 1 2 3 4 5 6
con un círculo todos los que apliquen.)
Comunicación
______ Referirlo/la a un médico familiar u otra agencia comunitaria (favor de escribir la
razón): _______________________________________________________________. Motora gruesa

______ Referirlo/la a un programa de intervención temprana/educación especial para Motora fina

niños preescolares para hacer una evaluación adicional. Resolución de
problemas
______ No tomar medidas adicionales en este momento.
Socio-individual
______ Medida adicional (favor de escribirla): ___________________________________ .

Ages & Stages Questionnaires® in Spanish, Third Edition (ASQ-3™ Spanish), Squires & Bricker
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10.4. Ages & Stages Questionnaires: Social-Emotional, Second Edition (ASQ:SE)
 Edades y Etapas: Social-Emocional
Un Cuestionario Completado por los Padres para Evaluar el Comportamiento Social-Emocional de los Niños*
Por Jane Squires, Diane Bricker y Elizabeth Twombly
con la ayuda de Suzanne Yockelson, Maura Schoen Davis y Younghee Kim
Copyright © 2002 por Paul H. Brookes Publishing Co.

24 Meses/2 Años
Cuestionario
(Para niños de 21 a 26 meses de edad)

Puntos Importantes de Recordar:

˛ Las preguntas por turno usan “niño” o “niña” como ejemplos. Por
favor conteste todas las preguntas sin importar si usted tiene un niño
o una niña.
˛ Por favor devuelva este cuestionario antes del día .
˛ Si tiene alguna pregunta o preocupación acerca de su bebé o acerca
de este cuestionario, por favor llame a .
˛ Muchas gracias y por favor espere llenar otro cuestionario en

* Translated from the English:

Ages & Stages Questionnaires ®: Social-Emotional:
A Parent-Completed, Child-Monitoring System
for Social-Emotional Behaviors, Squires et al.
© 2002 Paul H. Brookes Publishing Co.

1
 Edades y Etapas: Social-Emocional
Un Cuestionario Completado por los Padres para Evaluar el Comportamiento Social-Emocional de los Niños*
Por Jane Squires, Diane Bricker y Elizabeth Twombly
con la ayuda de Suzanne Yockelson, Maura Schoen Davis y Younghee Kim
Copyright © 2002 por Paul H. Brookes Publishing Co.

ASQ:SE 24 Meses/2 Años

Cuestionario
(Para niños de 21 a 26 meses de edad)

Por favor dé la siguiente información.

Nombre del niño/a:

Fecha de nacimiento del niño/a:

Fecha de hoy:

Persona llenando este cuestionario:

¿Cúal es su relación con el niño/a?

Su número de teléfono:

Su dirección (para correspondencia):

Ciudad:

Estado: Código postal:

Haga una lista de cualquier otra persona que le asista en llenar este cuestionario:

Programa de administración/proveedor:

* Translated from the English:

Ages & Stages Questionnaires ®: Social-Emotional:
A Parent-Completed, Child-Monitoring System
for Social-Emotional Behaviors, Squires et al.
© 2002 Paul H. Brookes Publishing Co.

2
 LA MARQUE SI
Por favor lea cada una de las preguntas con cuidado y MAYORÍA ESTO ES
1. Marque el cuadro q que describa mejor el comportamiento de su niño/a y DE LAS ALGUNAS RARA VEZ UNA PRE-
2. Marque el círculo m si este comportamiento le preocupa VECES VECES O NUNCA OCUPACIÓN

1. Cuando usted le habla a su niña, ¿le mira a

usted? qC qV qX m

2. ¿Parece ser su niño demasiado amistoso con

los desconocidos? qX qV qC m

3. ¿Se ríe o se sonríe su niña cuando usted

juega con ella? qC qV qX m

4. ¿Tiene su niño el cuerpo relajado? qC qV qX m

5. Cuando usted se va, ¿se queda alterada y

llorando su niña durante más de una hora? qX qV qC m

6. ¿Les saluda o les dice hola su niño a los

adultos que él conoce? qC qV qX m

7. ¿A su niña le gusta que la abracen o la

acurruquen? qC qV qX m

8. Cuando su niño está alterado, ¿se puede

calmar dentro de 15 minutos? qC qV qX m

9. Al levantar a su niña, ¿se pone rígida y arquea

la espalda? qX qV qC m

10. ¿A su niño le interesan las cosas alrededor

de él, como personas, juguetes y comida? qC qV qX m

TOTAL EN LA PÁGINA

Edades y Etapas: Social-Emocional, Squires y otros. 24 meses/2 años

© 2002 Paul H. Brookes Publishing Co. 3
 LA MARQUE SI
MAYORÍA ESTO ES
DE LAS ALGUNAS RARA VEZ UNA PRE-
VECES VECES O NUNCA OCUPACIÓN

11. ¿Llora, grita o hace berrinche su niña durante

mucho rato? qX qV qC m

12. ¿Usted y su niño disfrutan de la hora de

comida juntos? qC qV qX m

13. ¿Tiene su niña problemas con la alimentación,

como llenarse la boca, vomitar, comer cosas que
no son comida o _______________________ ?
(Usted puede anotar cualquier problema.) qX qV qC m

14. ¿Duerme su niño por lo menos 10 horas dentro

de un período de 24 horas? qC qV qX m

15. Cuando usted señala a alguna cosa, ¿mira su

niña en la dirección de que usted señala? qC qV qX m

16. ¿Tiene su niño dificultad para dormirse a la

hora de la siesta o en la noche? qX qV qC m

17. ¿Se estriñe o tiene diarrea su niña? qX qV qC m

18. ¿Sigue su niño instrucciones sencillas?

Por ejemplo, ¿se sienta cuando se lo piden? qC qV qX m

19. ¿Le avisa su niña como se siente con gestos

o palabras? Por ejemplo, ¿le avisa cuando
tiene hambre, se lastima o está cansada? qC qV qX m

TOTAL EN LA PÁGINA

Edades y Etapas: Social-Emocional, Squires y otros. 24 meses/2 años

© 2002 Paul H. Brookes Publishing Co. 4
 LA MARQUE SI
MAYORÍA ESTO ES
DE LAS ALGUNAS RARA VEZ UNA PRE-
VECES VECES O NUNCA OCUPACIÓN

20. ¿Lo/la busca con la mirada su niño para

asegurarse que usted está cerca cuando él
está explorando lugares nuevos, como un
parque o la casa de un amigo? qC qV qX m

21. ¿Hace su niña las cosas una y otra vez

y parece incapaz de dejar de hacerlo? Unos
ejemplos son mecerse, manotear, dar
vueltas o _______________________ .
(Usted puede anotar cualquier otra cosa.) qX qV qC m

22. ¿A su niña le gusta escuchar cuentos o

cantar canciones? qC qV qX m

23. ¿Se lastima su niño a propósito? qX qV qC m

24. ¿A su niño le gusta estar con otros

niños? qC qV qX m

25. ¿Intenta su niña lastimar a otros niños,

adultos o animales (por ejemplo, pateando
o mordiendo)? qX qV qC m

26. ¿Ha expresado alguien preocupación por el

comportamiento de su niño? Si usted marcó
“algunas veces” o “la mayoría de las veces”,
por favor explique: qX qV qC m

TOTAL EN LA PÁGINA

Edades y Etapas: Social-Emocional, Squires y otros. 24 meses/2 años

© 2002 Paul H. Brookes Publishing Co. 5
 27. ¿Tiene usted preocupación por las costumbres de comer y dormir de su niña? Si así es, por favor
explique:

28. ¿Hay algo que le preocupa de su niño? Si así es, por favor explique:

29. ¿Cuáles son las cosas que disfruta más de su niña?

Edades y Etapas: Social-Emocional, Squires y otros. 24 meses/2 años

© 2002 Paul H. Brookes Publishing Co. 6
 ASQ:SE Sumario Informativo del 24 o Mes/2 o Año
Nombre del niño/a: Fecha de nacimiento del niño/a:

Persona llenando el cuestionario: Relación al niño/a:

Dirección (para correspondencia): Ciudad: Estado: Código postal:

GUÍA DE CALIFICAR

1. Asegúrese de que el padre haya contestado todas las preguntas y haya marcado la columna de preocupación si es necesario. Si todas las preguntas
han sido completadas, avance a la segunda etapa. Si hay preguntas que no han sido completadas, debe ponerse en contacto con los padres para
obtener las respuestas o, si es necesario, calcular una calificación de punto medio (refiérase a las páginas 40 y 41 de The ASQ:SE User’s Guide).
2. Examine cualquier comentario del padre. Si no hay comentarios, avance a la tercera etapa. Si el padre ha anotado una respuesta, refiérase a la
sección “Parent Comments” en las páginas 40–42 de The ASQ:SE User’s Guide para determinar si la respuesta indica un comportamiento que
quizás sea de preocupación.
3. Usando el sistema de puntos provisto debajo:
C (por cero) al lado del cuadro marcado = 0 puntos
V (por el número romano V) al lado del cuadro marcado = 5 puntos
X (por el número romano X) al lado del cuadro marcado = 10 puntos
Preocupación marcada = 5 puntos
Suma:
Puntos totales en la página 3 = _____
Puntos totales en la página 4 = _____
Puntos totales en la página 5 = _____
Calificación total del niño/a = _____

INTERPRETACIÓN DE LA CALIFICACIÓN

1. Examine los cuestionarios

Examine las respuestas del padre. Tome en consideración de manera especial las preguntas individuales que tienen 10 ó 15 puntos y cualquier
comentario hecho por los padres oralmente o por escrito. Ofrezca consejos, apoya e información a las familias y mándelas a un especialista si la
calificación y las consideraciones para mandar a una evaluación indican que es necesario.
2. Transfiera la calificación total del niño/a
En la tabla debajo, llene la calificación total del niño/a (transfiera la calificación total de más arriba).

Intervalo del cuestionario Calificación de límite Calificación del ASQ:SE del niño/a

24 meses/2 años 50

3. Criterio para mandar a una evaluación de la salud mental

Compare la calificación total del niño/a con la calificación de límite en la tabla más arriba. Si la calificación del niño/a cae arriba de la calificación de
límite y los factores en la cuarta etapa han sido considerados, mande al niño/a para una evaluación de la salud mental.
4. Consideraciones para mandar a una evaluación de la salud mental
Siempre es importante interpretar la información de una evaluación en el contexto de otros factores que están influyendo la vida de un niño/a.
Considere los siguientes variables antes de mandar para una evaluación de la salud mental. Refiérase a las páginas 45–50 en The ASQ:SE User’s
Guide para consejos adicionales relacionados a estos factores y para sugerencias para dar seguimiento.

• Factores del ambiente/tiempo

(Por ejemplo, ¿El comportamiento del niño/a es igual en la casa que en la escuela?, ¿Han sido uno sucesos difíciles en la vida reciente del niño/a?)

• Factores del desarrollo

(Por ejemplo, ¿El comportamiento del niño/a está relacionado a una etapa del desarrollo o a un desarrollo retrasado?)

• Factores de la salud
(Por ejemplo, ¿El comportamiento del niño/a está relacionado a los factores de la salud o a los factores biológicos?)

• Factores de la familia/la cultura

(Por ejemplo, ¿El comportamiento del niño/a es aceptable dado el contexto cultural o el contexto familiar?)

Edades y Etapas: Social-Emocional, Squires y otros. 24 meses/2 años

© 2002 Paul H. Brookes Publishing Co. 7
10.5. Lausanne Triadic Play Procedure (LTP)

Global comments

Parents and toddler’s seats make an equilateral triangle that facilitate a triadic play.
Parents are asked not to move their seats because of the cameras (which couldn’t film
them correctly if they move); but of course, parents can move their bodies on their seats.
This is a way to guarantee a setting as more identical as possible between families, and
so to allow rigorous comparisons.

We give to the parents a clock, visible to both parents, to help them to manage the time
(according to the instructions).

Cameras

Camera 1: this camera is mounted on a tripod and focuses the child's torso and face.
Camera 2: this camera is mounted on a tripod and focuses the parents torso and face.

Needed material for the LTP

42. - Seats, table and toys.

- Parents’ and child seats in a child chair.

43. - Child table

44. - Toys. They are thought to stimulate symbolic play and co-constructed
activities. Comments about toys: Toys actually used in our setting:

- Tree puppetry

- Tree spoons

- Tree animals

LTP Instructions

The consultant shows there are two cameras, and invited to the parents to seat in each
chair and play with the child. We are going to ask you to play together, as a family.
Try to do as you usually do. This play is going to take place in four parts. In the first
part, one of you will play with your child and the other one will simply be present. Do
you decide who begins. During this time, the other parent will be simply present.
Second part: After a few minutes, when you will feel ready, you can change roles and
the other parent play with X, and the other will be simply present. After a few minutes,
you will pass on to the third part of the play, in which you will all three plays together
during a few minutes. Then, at the end, you will pass on the fourth part: you, the
couple, will discuss with each other and X is on his own, playing with toys. Take your
time. It is up to you to decided when you move from one part to the next. Generally, it
takes between 8 – 12 minutes. You can begin as soon as you are ready. For each part,
you can choose how long you play.

During the play child wants to get out to the seat or cry or need something, you can try
to calm and bring him back to the play.

Do you have any questions?

I will be outside this room. Please give a signal to the cameras when you start and when
you finish and call me when you are finished and if there is any problem.
10.6. FAAS coding sheet
 Coding sheet FAAS

Coder : Family n° :
Infant/toddler/Child’s age:

Alliance : Cooperative
(A) Fluid / (B) Tense
Conflicted
(C1) Covert / (C2) Overt
Disordered
(D1) Exclusive / (D2) Chaotic

Appropriate Moderate Inappropriate

Postures
Participation
Gazes

Role implication
Organization
STRUCTURE

Task fulfillment

Co-construction
Focalization Parental
scaffolding
Family warmth

Affect sharing Validation

Authenticity

Mistakes during
DYNAMIC

shared activities
Interactive
sequence Mistakes during
transitions

Total

Family score:

SUB-SYSTEMS
Appropriate Moderate Inappropriate

Support
Coparenting
Conflict

Engagement
Child
contribution Self-regul. / assert. /
partnership
 Comments

Postures

Participation

Gazes

Role implication

Organization

Task fulfillment
STRUCTURE

Co-constr.

Focalization

Parental scaffolding

Family warmth

Affect Validation
sharing

Authenticity
 Mistakes during
shared activities
DYNAMIC

Interactive
sequence

Mistakes during
transitions

Support

Coparenting

Conflicts
SUB-SYSTEMS

Engagement

Child
contribution

Self-regul. / assert. /
partnership

Global comments :
10.7. Parent Development Interview Revised, Short Version (PDI-S)

Authors: Slade, Aber, Berger, Bresgi & Kaplan (2003)

A. Perspectiva del niño/a.

Hoy, vamos a conversar sobre usted y sobre su hijo/a (C). Empezaremos, hablando
sobre la relación entre su hijo/a y usted, y luego, un poco acerca de su propia
experiencia como hijo/a.
Vamos a comenzar, hablándome un poco sobre su familia, ¿Quien vive en su familia?
¿Cuantos hijos tiene? ¿Que edades tienen? (Aquí el entrevistador desea saber cuántos
hijos, edades, -incluyendo a los que vivan fuera de casa-, los padres y otros adultos que
vivan en casa. Si se da una situación de crianza atípica, (adopción, acogida), una
historia de acogidas o adopciones diversas, quienes han sido sus cuidadores primarios,
etc.; Asimismo, si se observa, una historia de divorcio, o de múltiples desplazamientos o
cambios, tratar de obtener algunos detalles, o bien lo necesario para crear un contexto
que haga comprensible la entrevista).

1. Me gustaría empezar, intentando comprender, el tipo de persona que es su hijo/a….,

vamos a ver, ¿Podríamos comenzar, escogiendo tres adjetivos, (palabras) que
describan a su hijo/a…? (Hacer una pausa mientras escoge los adjetivos.) Ahora,
volvamos a cada adjetivo. ¿Le viene a la memoria algún recuerdo o incidente con
respecto a _____? (Examine y obtenga un recuerdo específico para cada adjetivo).

2. Muy bien. Ahora, volvamos a su hijo /a… En una semana corriente, ¿Qué es lo que
describiría como las cosas que prefiere hacer, sus ratos preferidos?

3. ¿Y los momentos o situaciones, con los que tiene más problemas o dificultades?

4. ¿Qué le gusta mas de su hijo /a?

5. ¿Y qué le gusta menos de su hijo/a?

B. Perspectiva de la relación.

1. Me gustaría que escogiera tres adjetivos, que usted sienta que reflejan la relación
entre usted y su hijo/a. (Pausa mientras se escogen los adjetivos). Ahora, volvamos
a cada adjetivo, ¿Le viene a la mente alguna memoria o incidente en relación
a_____? (Examine y obtenga un recuerdo específico para cada adjetivo).

2. Describa un momento, en la última semana, en el que usted y (su hijo/a),

conectaran completamente, se encontraran en perfecta sintonía. (Sondee e
investigue si es necesario) ¿Puede decirme algo sobre estos momentos? ¿Como
se sentía? ¿Cómo le parece que se sentía su hijo/a?).

3. Ahora, descríbame, por favor, un momento en la última semana, en el que (su

hijo/a) realmente no se encontraran en sintonía para nada., no conectaran, o no
hubiera forma de coincidir en nada. (Sondear si es necesario: ¿Puede contarme un
poco más sobre este momento? ¿Cómo se sentía usted? ¿Como cree que se sintió
(su hijo/a)?
4. ¿Cómo le parece que su relación con (su hijo/a) está afectando el desarrollo de la
personalidad de (su hijo/a)?

C. Experiencia afectiva de la paternidad.

1. ¿Puede describirse como padre?

2. ¿Qué le da su mayor alegría como padre/madre?

3. ¿Cual es su mayor dolor o dificultad siendo padre o madre?

4. Cuando esta preocupado/a o inquieto/ a por (su hijo/a), ¿Qué suele sentir que le
preocupa más?

5. ¿Como le parece que su hijo/a le ha cambiado?

6. Cuénteme sobre un momento durante la última semana en el que se sintiera

realmente enfadado/a o irritado como madre/padre. (Sondee si es necesario:
¿Puede contarme un poco más sobre la situación?, ¿Cómo maneja los
sentimientos de enfado?). 6a. ¿Qué efecto cree usted, que estos sentimientos tiene
sobre su hijo?

7. Cuénteme acerca de algún momento de la semana pasada o la anterior, en la que

usted se sintiera culpable como madre/padre. (Sondear si es necesario: ¿Puede
hablarme un poco más sobre la situación? ¿Como maneja su sentimientos de culpa
hacia su hijo/a? ). 7a. ¿Qué tipo de efecto tiene estos sentimientos sobre su hijo/a?

8. Cuénteme sobre un momento en las dos últimas semanas, en el que se sintiera

realmente necesitado/a de que alguien cuidara de usted. (Investigar si es
necesario: ¿Puede hablarme un poco más sobre esta situación? ¿Cómo maneja
estos sentimientos de estar necesitado? ). 8a.¿Qué tipo de efecto cree usted que
estos sentimientos tiene sobre (su hijo/a)?

9. Cuando su hijo está alterado o disgustado o contrariado, ¿Qué es lo que él/ella

hace? ¿Qué hace usted en estos momentos?

10. ¿Se ha sentido su hijo/a rechazado alguna vez?

D. Historia familiar de los padres.

Ahora, me gustaría preguntarle algunas cosas acerca de sus padres, y de cómo las
experiencias de su infancia podrían haber afectado a sus propias experiencias sobre la
paternidad. ( como madre o padre).

1. ¿Cómo le parece que sus experiencias de pequeño con sus padres, afectan a sus
experiencias actuales siendo madre/padre?
2. ¿En qué quiere ser como su madre y en qué no quier serlo como madre?

3. ¿Y como su padre?

4. ¿En qué es usted como su madre y en qué no lo es?

5. ¿Y como su padre?

E. Separación /pérdida.

1. Ahora, me gustaría que pensara un poco en los momentos en que usted y su hijo,
por algún motivo, no se encontraran juntos, cuando se hayan separado alguna vez.
¿Me los puede describir? (Sondear: ¿Qué tipo de efecto ha tenido en el niño/a? ¿Y
qué tipo de efecto ha tenido (tuvo) en usted?). Nota: Si el padre describe una
separación no reciente (por ejemplo, mas de un año), repita la pregunta
intentando algo más cercano.

2. ¿Recuerda algún momento en la vida de su hijo/a en que sintiera como si lo

estuviera perdiendo un poco? ¿Cómo lo sintió eso, para usted?

3. ¿Hay alguien que sea importante para usted, y que (su hijo/a) no conozca, pero que
le gustaría que fuera más cercano a su hijo/a?

4. ¿Piensa usted que en la vida de su hijo/a, han habido experiencias que hayan sido
un revés o contratiempo para el/ella?

F. Mirando hacia atrás, mirando hacia delante.

1. Ahora, su hijo tiene ya_____ años/meses, y usted es una madre/padre con
experiencia (modificar si es más apropiado). Si tuviera la oportunidad de hacerlo
todo otra vez, ¿Qué cambiaría? ¿Qué es lo que no cambiaría? ¿Alguna cosa más que
le gustara añadir? Muchas gracias y mucha suerte.
10.8. Coding sheet of Parental Reflective Function for Parent Development
Interview Revised

Sujeto: Puntaje total:

Codificador: Fecha:

Tipo Puntaje RF Notas

Sintonía

No sintonía

Personalidad

Alegría

Dolor, tristeza

Cómo te ha cambiado

Enojo

Culpa

Necesidad

C upset

Rechazo

Padres

Separación niño

Separación adulto

Pérdida
10.9. Beck Depression Inventory (BDI-I)
10.10. Relationship Assessment Scale (RAS)

Hendrick, 1988 adaptado por Rivera & Heresi, 2011

Por favor indique con una X el número que mejor corresponde a su relación de
pareja. Conteste lo más sinceramente posible pues no hay respuestas ni buenas
ni malas, o adecuadas o inadecuadas.
1. ¿De qué manera considera Ud. que su pareja satisface sus necesidades?
1 2 3 4 5
Pobremente Término Extremadamente bien
medio
2. ¿En general, ¿Hasta qué punto está satisfecho/a con su relación de pareja?
1 2 3 4 5
Insatisfecho Término Muy satisfecho
medio
3. ¿En comparación con la mayoría las parejas, ¿cómo calificaría a la suya?
1 2 3 4 5
Pobremente Término Excelente
medio
4. ¿Con qué frecuencia desea NO haberse casado con su esposa/o?
1 2 3 4 5
Siempre Con Nunca
frecuencia
5. ¿Hasta qué punto su relación de pareja satisface sus expectativas iniciales?
1 2 3 4 5
En absoluto Término Absolutamente
medio
6. ¿Cuánto ama a su pareja?
1 2 3 4 5
Muy poco Término Mucho
medio
7. ¿Cuántos problemas hay en su relación de pareja?
1 2 3 4 5
Muchos Lo normal Pocos
Compruebe que no ha dejado ninguna frase sin contestar
 10.11. Annexed tables

10.11.1. Annexed table 1. Mean comparison between participants from control group
and experimental group

EG (n=20) CG (n=30) 95% IC

Variable
M SD M SD t(df=48) p LL UL
Child's age 7.61 -1.84 .07 -8.23 0.37
Mother's Age 32.15 4.99 31.10 4.773 -0.75 .46 -3.87 1.77
Father's Age 34.15 5.30 33.20 6.21 -0.56 .58 -4.36 2.46
Father years’ education 15.90 1.92 14.93 2.61 -1.42 .16 -2.34 0.40
Mother years’ education 15.30 2.23 15.07 2.52 -0.34 .74 -1.63 1.16
Communication 1.70 1.16 1.30 1.31 -1.10 .28 -1.13 0.33
Gross motor 1.95 0.87 1.87 0.81 -0.31 .76 -0.56 0.41
Fine motor 1.86 1.15 1.08 1.10 -2.41 .02 -1.43 -0.13
Problem solving 1.85 0.97 1.26 1.10 -1.92 .06 -1.19 0.03
Personal-social 1.34 1.08 1.60 1.08 0.84 .41 -0.36 0.89
% SE difficulties 11.57 6.87 15.07 7.09 1.73 .09 -0.56 7.57
Family Score 19.30 4.16 17.87 5.33 -1.01 .32 -4.28 1.41
Mother's RF 4.15 1.09 3.33 1.06 -2.64 .01 -1.44 -0.19
Father's RF 3.85 1.27 3.37 .96 -1.53 .13 -1.12 0.15
Mother's depression 5.45 3.80 8.70 6.95 1.91 .06 -0.18 6.68
Mother couple satisfaction 30.70 4.21 29.47 5.24 -0.88 .38 -4.05 1.58
Father's depression 4.45 6.80 5.97 5.32 0.88 .38 -1.94 4.97
Father couple satisfaction 30.80 3.86 29.87 5.03 -0.70 .49 -3.60 1.74
Note. EG = experimental group; CG = control group; CI = confidence interval; LL = lower limit, UL =
upper limit, SE = Social emotional; RF = reflective function.

10.11.2. Annexed table 2. Mean comparison between boys and girls in child
psychomotor and social-emotional development

Girsl (n = 21) Boys (n = 29) 95% CI

Variable
M SD M SD t (df = 48) p LL UL
Communication 1.82 1.03 1.20 1.36 1.75 .09 -0.09 1.33
Gross motor 1.97 0.77 1.85 0.87 0.50 .62 -0.36 0.60
Fine motor 1.53 1.21 1.29 1.16 0.71 .48 -0.44 0.92
Problem solving 1.75 1.16 1.31 1.00 1.41 .16 -0.18 1.05
Personal-social 1.47 1.08 1.52 1.09 -0.14 .89 -0.67 0.58
% SE difficulties 12.01 6.46 14.87 7.48 -1.41 .16 -6.94 1.21
Note. CI = confidence interval; LL = lower limit, UL = upper limit, SE = Social emotional.
 10.11.3. Annexed table 3. Correlations among study variables and its subscales and covariables

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
1 1
2 .44* 1
3 .39* .19 1
4 .65* .37* .42* 1
5 .54* .49* .31+ .51* 1
-.41*
6 -.29+ -.24 -.19 -.38* 1

7 -.17 -.18 -.33+ .03 -.14 .70* 1

8 .05 -.13 .06 -.02 -.15 .53* .23 1
9 -.42* -.24 -.13 -.45* -.53* .21 -.16 .13 1
+
10 -.19 -.51* -.20 -.21 -.33 .54* .42* .11 .00 1
11 -.21 -.07 -.10 .02 .01 .27 .23 -.07 -.04 .10 1
+
12 -.03 .05 -.04 -.20 -.16 .29 .00 .40* .12 -.02 -.09 1
13 -.17 -.24 .08 -.12 -.14 .64* .22 .45* .06 .17 .14 .22 1
+
14 .22 .22 .18 .10 .07 -.40* -.29 -.19 -.07 -.10 -.26 -.07 -.29+ 1
15 .20 .19 .17 .09 .04 -.32+ -.24 -.20 -.04 -.04 -.23 -.07 -.26 .98* 1
16 .22 .08 .12 .12 .03 -.23 -.18 -.11 .01 -.12 -.32* .00 -.22 .65* .69* 1
17 .10 .09 .21 .03 .10 -.27 -.13 -.10 -.03 -.13 -.20 .02 -.17 .65* .67* .56* 1
+
18 .15 .01 -.07 -.04 -.07 -.13 .00 -.22 -.17 .28 -.09 -.14 -.29 .63* .64* .23 .22 1
19 .07 .14 .10 .01 -.08 -.21 -.23 -.18 -.01 .00 -.05 -.08 -.10 .74* .75* .26 .16 .60* 1
+
20 .10 .32 .06 .10 .08 -.23 -.16 -.10 .03 -.09 -.17 .04 -.24 .79* .78* .42* .49* .44* .52* 1
21 -.09 .03 -.12 -.13 -.07 -.23 -.20 -.08 .15 -.01 -.13 -.04 -.16 .68* .61* .25 .39* .42* .55* .54* 1
" + + + + + + + +
22 .40* .36 .34 .28 .23 -.52* -.35 -.11 -.29 -.29 -.31 -.05 -.32 .70* .59* .43* .39* .36 .39* .54* .21 1
23 -.07 -.14 .03 -.15 -.33+ -.05 -.08 -.16 .08 .16 -.01 .12 -.13 .43* .40* .14 .18 .33+ .41* .32+ .41* .28 1
+ +
24 -.10 -.15 -.05 -.04 -.20 -.09 -.05 -.05 -.02 .14 -.03 -.15 -.28 .38* .37* .21 .23 .41* .37* .11 .34 .20 .43* 1
25 -.37* -.28 -.14 -.27 -.38* .40* .27 .03 .00 .38* .15 .20 .24 -.14 -.10 -.19 -.19 .29* .026 -.12 -.22 -.13 .17 -.12 1
26 -.03 .02 .06 -.02 .00 -.01 -.15 .11 -.07 -.02 .06 .04 -.03 -.10 -.15 -.17 -.16 -.13 -.01 -.14 .07 -.02 -.04 .21 -.34+ 1
27 -.10 .02 .01 -.05 .04 -.05 .10 -.11 .11 .03 .10 -.23 -.12 .08 .09 -.16 .08 .19 .12 .15 .06 .02 .14 .07 .16 -.34+ 1
+
28 -.10 -.02 -.12 -.08 -.12 .14 -.08 .08 -.05 .15 .04 .15 .07 -.10 -.12 -.04 -.23 -.10 -.02 -.11 .07 -.14 .07 .29 -.19 .72* -.62* 1
Note. 1 = Communication; 2 = Gross motor; 3 = Fine motor; 4 = Problem solving; 5 = Personal-social; 6 = Percentage of social emotional difficulties; 7 = Percentage autoregulation difficulties;
8 = Percentage complacence difficulties; 9 = Percentage communication difficulties; 10 = Percentage adaptative difficulties; 11 = Percentage affect difficulties; 12 = Percentage autonomy
difficulties; 13 = Percentage person-interaction difficulties; 14 = Triadic Total Score; 15 = Triadic Subscales Score; 16 = Participation; 17 = Organization; 18 = Focusing; 19 = Affect; 20 =
Interactive mistakes; 21 = Coparenting; 22 = Toddler contribution; 23 = Mother reflective function; 24 = Father reflective function; 25 = Mother depressive symptoms; 26 = Mother couple
satisfaction; 27 = Father depressive symptoms; 28 = Father couple satisfaction.

180
10.12. Scientific publications related with the thesis sample

10.12.1. Family Triadic Interactions, Parental Reflective Function and child

social-emotional difficulties in early infancy: ¿How work together?

María José León Papic

University of Chile

Marcia Olhaberry

Pontifical Catholic University of Chile

Author Note

María José León, Faculty of Medicine, University of Chile; Marcia Olhaberry, Psychology

School, Pontifical Catholic University of Chile.

This research was supported by grants of the National Fund for Scientific and

Technological Developments, FONDECYT, Nº 11140230, and with the support of the

Millennium Institute for Research in Depression and Personality, Project IS130005.

Correspondence concerning this article should be addressed to Marcia Olhaberry, Escuela

de Psicología, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4890,

Macul, Santiago, Chile. Email: mpolhabe@uc.cl.

181
Abstract

The prevalence of social-emotional problems in early childhood continues at a high

level (Centro de Microdatos-Universidad de Chile, 2014). This stage is a critical period in

which the immediate family is the most influential system in childhood development

(Bronfenbrenner, 1987). Conversely, the parental reflective function (RF) is considered a

protective factor in early parenting (e.g. Stacks et al, 2014), such that maternal and paternal

RF may be assumed to have an additive, joint influence on children’s development over

time (Smaling et al., 2016; Steele & Steele, 2008).

Objective: To describe and analyze the relationship between fathers’ and mothers’ RFs, the

quality of the mother-father-child triadic interaction, and children’s social-emotional

difficulties.

Method: A non-experimental, transversal and correlational study was developed. Fifty

mother-father-child triads, each in a current relationship that included at least one child from

12–36 months of age, were evaluated. Sociodemographic background, triadic interaction (LTP,

Fivaz-Depeursingue & Corboz-Warnery, 1999), parental RF (PDI-S, Slade et al., 2012, RF

Scales, Fonagy et al, 1998), and social-emotional difficulties (ASQ SE, Squires, Bricker, &

Twombly, 2011).

Results: A significant effect of the triadic interaction on the child’s social-emotional

difficulties was found. The effect explained 20% of the variance. In addition, the mothers’

RF had a significant influence on the triadic interaction, explaining 9% of the variance.

However, in contrast to the hypothesis, the mothers’ and fathers’ RFs were not significant

variables as direct or indirect predictors to explain the child’s socio-emotional difficulties.

These findings show the importance of maternal RF on the quality of the the three-

way mother-father-child interaction, which in turn influences the child’s social-emotional

182
development. Additionally, the possibly less significant role of the father and the

implications of these findings for research and clinical purposes are discussed.

Key words: parental reflective function, couple satisfaction, triadic interaction

Resumen

La prevalencia de problemas socioemocionales en la primera infancia continúa a un

alto nivel (Centro de Microdatos-Universidad de Chile, 2014). Esta etapa es un período

crítico en el cual la familia inmediata es el sistema más influyente en el desarrollo infantil

(Bronfenbrenner, 1987). Por el contrario, la función reflexiva parental (FR) se considera un

factor protector en la crianza temprana (p. ej., Stacks et al, 2014), de modo que se puede

asumir que la FR materna y paterna tiene una influencia aditiva conjunta en el desarrollo de

los niños (Smaling et al., 2016; Steele & Steele, 2008).

Objetivo: describir y analizar la relación entre los FR de padres y madres, la calidad de la

interacción triádica madre-padre-hijo y las dificultades socioemocionales de los niños.

Método: se desarrolló un estudio no experimental, transversal y correlacional. Se evaluaron

50 tríadas de madre-padre-hijo, en una relación actual que incluía al menos un niño de 12 a

36 meses de edad. Antecedentes sociodemográficos, interacción triádica (LTP, Fivaz-

Depeursingue & Corboz-Warnery, 1999), FR parental (PDI-S, Slade et al., 2012, escala de

FR, Fonagy et al., 1998), y las dificultades socioemocionales (ASQ SE, Squires, Bricker y

Twombly, 2011).

Resultados: se encontró un efecto significativo de la interacción triádica en las dificultades

socioemocionales del niño. El efecto explicó el 9% de la varianza. Además, la FR de las

madres tuvo una influencia significativa en la interacción triádica, lo que explica el 21% de

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la varianza. Sin embargo, en contraste con la hipótesis, los FR de las madres y los padres no

fueron variables significativas como predictores directos o indirectos para explicar las

dificultades socioemocionales del niño.

Estos hallazgos muestran la importancia del FR materno en la calidad de la

interacción tripartita madre-padre-hijo, que a su vez influye en el desarrollo social y

emocional del niño. Además, se discute el posible papel menos importante del padre y las

implicaciones de estos hallazgos para fines de investigación y clínicos.

Palabras claves: función reflexiva parental, satisfacción de pareja, interacción tríadica

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Introduction

Early childhood is considered a critical and sensitive period in a human being’s life,

worthy of in-depth study. When a baby is born, it is especially vulnerable to certain events

and experiences that, depending upon their presence or absence, have a specific effect on

the child’s growth (Siegel, 1999). Thus, the post-natal environment and initial interpersonal

experiences influence the structural and functional growth of an individual’s brain, general

development, and current and subsequent mental health (Schore, 2000).

National and international studies in early childhood development and mental health

show that 11%–37% of children have some social-emotional difficulties between ages 6–60

months (Bian Xie, Squires, & Chen 2017; Briggs-Gowan et al., 2013; Centro de

Microdatos-Universidad de Chile, 2014; Wendland et al., 2014). This prevalence is highly

important because early development lays the foundations for later development, and

studies show the links between early developmental difficulties and later behavioral,

cognitive and social-emotional problems (Briggs-Gowan & Carter, 2008; Cheng, Palta,

Kotelchuck, Poehlmann, & Witt, 2014; Essex et al., 2006; Giannovi & Kass, 2012;

Pihlakoski et al., 2006).

Thus, in early childhood, the immediate family (mother, father and child) is the

central and most influential relationship system in which a child develops (Bronfenbrenner,

1987). Interactions occurring in the mother-father-child triad constitute a complex process;

consequently, studies show that parental behavior observed in dyadic contexts is not

necessarily the same as that observed in triadic contexts (Goldberg, Clarke-Stewart, Rice &

Dellis, 2002; Johnson, 2001; Lindsey & Caldera, 2006). However, although the child’s

natural context exceeds dyadic interactions, historically in psychology, the approach to

understanding early child development has primarily been by studying the dyadic

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interaction, centered in the mother-child relationship (Fivaz-Depeursinge, & Corboz-

Warnery, 1999). Given the dyadic understanding of childhood social-emotional

development, focusing on the fathers’ characteristics and the mother-father-child triadic

interaction has been secondary.

In the context of familiar mental health and parenting, reflective functioning has

been considered a highly important clinical variable that arose at the beginning of the 1990s

from the study of patterns and intergenerational transmission of attachment, where maternal

reflective function was introduced as a relevant role in the parenting area and child

development (Fonagy, Steele, Steele, Moran, & Higgitt, 1991; Slade, 2005). Accordingly,

the study of reflective functioning in developmental research has centered on the mother-

child relationship, despite increasing evidence of the significant role of the father in child

development and family adjustment (Cabrera, Tamis-LeMonda, Bradley, Hofferth, & Lamb,

2000; Lamb & Lewis, 2004).

Parental reflective functioning

The parental reflective function refers to parents’ ability to reflect on themselves as

parents, their ability to represent and understand the child’s internal experiences and their

parent-child relationship, and that links the child’s mental states with his or her behavior

(Fonagy, Steele, Steele, & Target, 1998; Slade, 2005). Slade (2005) has suggested that

reflective functioning should be considered a fundamental human ability with long-reaching

importance for inter- and intrapersonal functions such as the regulation of affection and

productive social relationships.

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 The literature on reflective functioning can be summarized as applying to three areas of

study. The first, with the most research to support the role of reflective functioning, is the

intergenerational transmission of attachment and parenting (e.g. Steele & Steele, 2008).

The second, which has also been widely investigated, comprises risk samples and parents

with a history of childhood abuse and neglect, focusing on the mother and examining how

the intergenerational transmission of abuse, neglect, and psychopathology functions (e.g.

Ensink, Bégin, Normandin, & Fonagy, 2017). The third area comprises children’s social-

emotional outcomes, which have been less covered (e.g. Kårstad, Wichstrøm, Reinfjell,

Belsky, & Berg-Nielsen, 2015).

First, in terms of the intergenerational relevance of reflective functioning, Fonagy,

Gergely, Jurist, & Target (2005) proposed that the mother’s ability to mentalize allows her to

create a physical and psychological environment propitious for the creation of a secure base for

the baby. This hypothesis has been confirmed in different studies. For example, two studies

showed that a low parental reflective function is associated with the development of insecure

attachment in one-year-olds (Slade, Grienenberger, Bernbach, Levy, & Locker, 2005). Another

identified an association with a greater amount of maternal disruption in mother-infant

affective communication (Grienenberger, Kelly, & Slade, 2005). The authors also show that

maternal reflective function predicts the security of attachment beyond maternal sensitivity and

the educational level, suggesting that parental mentalization made an independent

contribution and underlies the ability to respond sensitively to the baby (Grienenberger et al.,

2005; Rosenblum, McDonough, Sameroff, & Muzik, 2008). Additionally, in a recently

published meta-analysis, Zeegers, Colonnesi, Stams, and Meins (2017) suggest that

maternal and paternal mentalization and sensitivity play complementary roles in explaining

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attachment security in which the mentalization exerts both a direct and indirect influence on

infant-parent attachment.

Related to child social-emotional outcomes, the relationship between mental and

emotion state understanding has been positively associated with social competence at the

preschool age (Cassidy, Werner, Rourke, Zubernis, & Balaraman, 2003), and the influence

of the parents’ (mother and fathers) mental understanding of that ability has been

demonstrated. Kårstad et al., (2015) found that the accuracy of parental mentalization

predicts in the child a greater emotional understanding at ages 4–6. A similar result was

found by Steele and Steele (2008), who showed that the mother reflective functioning

influenced the child’s development of emotional understanding and that the mother’s

reflective function is associated with the child’s reflective function at age 9 (Ensink,

Normandin, Target, Fonagy, Sabourin, & Berthelot, 2015).

Heron-Delaney et al. (2016) found that preterm infants of high reflective function

mothers showed the most-negative affect and more self-soothing behavior during the Still

Face procedure, whereas infants whose mothers were rated lower on reflective function

exhibited the most-negative affect during the reunion-episode in the Strange Situation.

Smaling et al. (2017) found that in a young, pregnant, high-risk woman, prenatal reflective

function was related to lower child physical aggression when the child was 6, 12, and 20

months old. They also observed moderating effects of intrusiveness and sensitivity in which

higher prenatal reflective functioning was particularly associated with less infant physical

aggression in mothers who showed no or low signs of intrusiveness. These findings show

that a child with a mother with a higher reflective function has more possibilities to express

his/her discomfort when doing so is expected and has more regulation skills.

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 To sum up through in the infant life cycle, the study of reflective function has had

different focuses of interest. In the first years of the child's life, the focus has largely been

on parental sensitivity and attachment, on the mother-child relationship in particular. Later

in development, studies have included a greater variety of social and emotional variables

and have examined the child's outcomes. Conversely, the father, as a study variable, has

been included later in the child’s life cycle, with an increasing number of studies that

include him as the child's age increases.

Triadic Interactions and early childhood development

The influence of the quality of early triadic interactions on child development has

also been studied. The ability to interact in a triad has been proposed as one of the main tasks

developing an autonomous self and in acquiring social skills, which are develop from

experiences with primary caregivers and depend on the quality of these interactions

(Fincham, 1998; Parke, 1996; Sroufe, 1996). Consequently, when the child learns to create

and maintain relationships involving more than two people, he or she learns to share

affection, attention and a common objective among three people, learning to address

feelings of exclusion by developing greater social abilities (Liszkowski, Carpenter,

Henning, Striano, & Tomasello, 2004; Fivaz-Depeursinge & Corboz-Warnery, 1999).

Thus, researchers have shown how more positive experience in a triad prepares children to

function more competently with adults and peers in a non-family, multi-person

environment (Feldman & Masalha, 2010).

Empirical studies have shown the effect of the quality of the family triadic

interaction on child social-emotional competence. This influence can be seen at an early

age. For example, mothers and fathers demonstrated more positive and cooperative

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interpersonal engagement and coordination in the triadic interaction and the Still-Face

procedure; when their babies were three months old, the infants showed more coordinated

gaze shifts from one parent to the other during the Still-Face challenge (McHale, Fivaz-

Depeursinge, Dickstein, Robertson, & Daley, 2008). Likewise, Hedenbro and Rydelius

(2014) found that a child’s capacity to make child contributions and initiate turn-taking

sequences at 3 months in the family triad is associated with the parents' responsiveness,

which in turn correlates with the child peer and social competence at 48 months.

Additionally, a higher degree of family coordination is associated with more relational and

social competence with peers at preschool age (Cigala, Venturelli, & Fruggeri, 2014).

These results have been observed in a range of diverse cultures. For example, in a

normative sample of Israeli and Palestinian children, infant reciprocity with the mother,

engagement with the father, and harmonious experience in the triad are important

contributors to toddler social competence (Feldman & Masalha, 2010). Higher marital

hostility, a higher level of co-parental undermining behavior, and ineffective discipline

were predictors of toddler aggression in both cultures (Feldman, Masalha, & Derdikman-

Eiron, 2010). Thus, a longitudinal study that assessed children at infancy, preschool and

adolescence indicated that early maternal and paternal reciprocity were each uniquely

predictive of social competence and lower aggression in preschool, which, in turn, shaped

dialogical skills in adolescence (Feldman, 2010; Feldman, Bamberger, & Kanat-Maymon,

2013).

The evolution of the quality of the triadic interaction has also shown an effect in the

development of the theory of mind in early childhood. Thus, Favez et al. (2012) found three

different patterns of triadic coordination among infants to 5-year-olds (high to high, high to

low, and low to low). They also found that children in a family with stable, high-

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coordination interactions obtained higher scores on theory of mind tasks and better

affective outcomes than did children in a family with a trajectory of high-to-low

coordination interaction over time. Moreover, children of the high-to-low group had better

outcomes in theory of mind tasks than did children of the families with a low stable

coordination group. These results illustrate the importance of the quality of the triadic

interaction in early childhood (3, 9 and 18 months) in the develop of the theory of mind,

which in turn shows the effect of early family interactions on the development of the

structure of the brain (Shore, 1997).

In terms of attachment, Frascarolo and Favez (1999) found no association between

problematic alliances and insecure attachment. However, in a low-medium income

normative Chilean and German sample, a study found that triadic family interactions were

linked to preschoolers’ attachment security levels (Pérez, Moessner, & Santelices, 2017).

Moreover, scientific evidence shows that mothers in nuclear families in Chile have a

higher quality of mother-child interaction compared with similar mothers in single-parent

families, suggesting that the father plays a favorable role in family heath and child

development (Olhaberry & Santelices, 2013). Thus, different studies suggest that father

involvement has a positive effect on child development, the mother-father-child

relationship and the couple subsystem (Frascarolo, 2004; Pleck & Masciadrelli, 2004;

Sarkadi, Kristiansson, Oberklaid, & Bremberg, 2008). For example, higher levels of father

involvement reported by parents corresponded with better interactive competences in the

triadic interaction (Simonelli, Parolin, Sacchi, De Palo, & Vieno, 2016).

Finally, Fivaz-Depeursinge and Favez (2006) suggest that the interaction between

the child and his or her mother and father can help resolve dysfunctional dyadic interactions

with the other parent because the intervention of a third party with adequate interaction

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skills encourages the child to adopt new emotional regulation strategies during the

interaction, thereby reducing tension and stress. However, this proposal is controversial

because studies show contradictory results. For example, Johnson (2001) reports that triadic

contexts displayed less-negative parental behavior than in dyadic situations, and no

difference in warmth and responsiveness of the parental behavior between the two contexts.

Another study claims that mothers showed less-sensitive behavior to the child and more

intrusive behavior to the father in triadic contexts in which fathers participated than they

did during dyadic mother-child interaction (Lindsey & Caldera, 2006). Higher levels of

engagement between mother and toddler were associated with lower levels of father

positive parenting and children engaging with him in the triadic context (Kwon, Jeon,

Lewsader, & Elicker, 2012). More recently, Udry-Jørgensen, Tissot, Frascarolo, Despland,

and Favez (2016) showed that parents were significantly more sensitive in the dyad within

the triad context than only in the dyad context. Likewise, family alliance was globally

associated with sensitive parenting, suggesting that the triad is a protective factor for early

infant-parent dyads.

The differences between the dyadic and triadic interactions again show, as

Minuchin (1985) noted, that the family interactions are more than the sum of the various

family subsystems. These differences, could explain other factors that these studies do not

include; it could be that role distribution into the family, the time that each parent expends

with his/her child and the quality of the couple relationship influence these findings. In

addition, the parents’ reflective abilities facilitate believing the other partner and inclusion

and support when interacting with a child.

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The present study

Examination of the link between the triadic interaction, the parental reflective

function and child development is ongoing. To date, only one study has linked triadic

interaction and parents capacity to reflect under insightfulness measurement (Marcu,

Oppenheim & Koren-Karie, 2016). This instrument assesses the parent’s reflective

capacities in interaction with his child, showing that triads in which both parents were

insightful had higher family cooperation scores compared with triads in which only one

parent was insightful and triads in which neither parent was insightful. Hence, questions

relating these variables to child development remain open and is an important contribution

toward understanding child and family mental health.

Considering the evidence presented, this study pursue two aims. The first objective, it

is compare the means of family interaction and couple satisfaction between the different

couple reflective function groups. The second aim, is examined the relationship between

father’s and mother's reflective function, the quality of triadic interaction, and child’s social

emotional difficulties.

As well as Marcu et al., (2016) found, it is expected differences in the mean of the

family interaction and child’s social emotional difficulties among the different groups. Also

it is expected that father and mother’s s reflective functioning, as well, as the triadic

interaction, contribute to explain the child’s social emotional difficulties.

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Methods

Participants

Mother-Father-Child triads from Santiago, Chile, with children from 12–36 months of

age who have social-emotional difficulties. The families were contacted through family health

care centers or kindergartens or were referred by study participants.

Participating toddlers were 12–38 months old (M = 26.70, SD = 7.77 months), 58%

were males, 64% were firstborn. The halves of the children (51.1%) were attending nursery

or preschool. Mothers ranged in age from 20 to 43 (M= 31.52, SD= 4.84) and fathers from

22 to 49 age old (M= 33.58, SD= 5.83). The level of education of the mothers and fathers

were high, 37 mothers and 41 fathers had a technical or university degree, and 39 mothers

and 49 fathers had a current paid work.

The inclusion criteria were fathers and mothers over 18 years of age, in a current

heterosexual couple relationship and with at least one child between 12 and 36 months,

who presents at least one of the follow social-emotional difficulties: sleep, feeding,

behavioral and emotional or relationship difficulties reported by the parents or by

professionals.

Exclusion criteria considered in the parents and children included the presence of

some disability (intellectual or of the senses), psychoses and/or addictions diagnosed in

adults as evaluated by the health services, by the educational institutions from which they

were referred, or at the first interview with the family.

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Procedure

The population participating in this study was part of the Fondecyt Start-up Project

Number 11140230. Participants were referred from the family health care center, nursery and

kindergarten JUNJI (National Board of Children's Gardens of the Ministry of Education of the

Government of Chile) or by the study participants. Participants were contacted by telephone by

members of the research team, who explained the study in detail and evaluated the inclusion

and exclusion criteria. With those triads who met the criteria and agreed to participate, the first

evaluation sessions were coordinated and were held in the triad’s home.

The study begun with the triad’s assessment; two evaluators, one clinical psychologist

and one psychology student with previous training on the instruments, evaluated the family.

Both parents first signed the informed consent and then completed surveys about their

social demographic and psychological characteristics. Parents then responded to the

questionnaire related to their child’s social-emotional difficulties. Triadic interactions were

then video recorded and finally, fathers and mothers were participated in an individual

interview about parenting. Each assessment took approximately two hours. At the end of the

evaluation, all of the triads participated in a brief intervention that included three video

feedback sessions. The assessments were conducted in 2016 and 2017.

This study had the approval of the institutional Ethics Committee of Human

Research from the Catholic University of Chile, University of Chile and from the Chilean

National Commission of Scientific and Technological Research. Participating triads signed

the informed consent forms which explained the objective of the investigation, its benefits and

risks, data confidentiality, and the voluntary nature of participation.

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Measures

Personal information form. Used to collect the participants sociodemographic

information, and included questions about, child age, gender and birth order, child

attending nursery or preschool, parents age, parents number of children, parents’ years of

education, and parent has a job1.

Social-emotional difficulties. To assess the social-emotional difficulties, the Ages & Stages

Questionnaires: Social-Emotional (ASQ:SE) (Squires, Bricker, & Twombly, 2002) was used.

This questionnaire was used for the screening and monitoring of social-emotional

difficulties. It can be used with children from 3 months to 65 months of age. There are eight

forms for each age range, and the number of items varies by form. The questionnaire is

completed by the parent and scored according to the number of concerns the parent reports.

In the current investigation, the parents reported directly to the therapists who performed

the intervention. Higher total scores indicated problems whereas low scores suggested that

the child’s social and emotional behavior was considered appropriate by his or her parent.

The instrument considers seven subscales: Self-regulation, Compliance, Communication,

Adaptive Functioning, Autonomy, Affect and Interaction with People. Considering the age

diversity of the participating children and the use of different evaluation templates

according to age, it is not possible to compare the direct scores obtained. Thus, the degree

of the problems of each child was calculated relative to the maximum for the child’s age.

The cut-off scores of the ASQ-SE templates used a range from 12.69 to 14.54. The average

obtained in the study was 13.66 for the total sample of children, a score indicating

significant difficulties in socio-emotional development.

1
Child attending nursery or kindergarten (0 = no, 1 = yes), parent has a job (0 = no, 1 = yes).

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 Mother-father-child triadic interaction. To assess the triadic interaction, the

Lausanne Trilogue Play (LTP; Fivaz-Depeursinge & Corboz-Warnery, 1999) was used.

This is systematic observational tool, which assesses mother– father–child interactions. The

activity begins with the triad sitting around a table forming a triangle, the following

instructions are given: “Now you going to play as a family in four separate parts (a) One

parent plays actively with the child while the other parent is present; (b) the parents switch

roles; (c) then all play actively together; and (d) the mother and father talk and the child be

simply present. The family has between 10 and 15 minutes to complete the task. The

interaction is recorded using two cameras, one focus on the body and face of the parents,

and other focuses on the child.

The family interaction was analyzed by the The Family Alliance Assessment Scales

(FAAS; Lavanchy, Tissot, Frascarolo, & Favez, 2013), the scale asses five triadic aspects

and two subsystems aspects given one total family score and three subgroups scores (a) the

triadic as a whole, (b) the co-parenting dyad, and (c) the child. (a) The triadic as a whole

includes 5 main scales whit each subscales: Participation: postures and gazes; Organization:

role implication and structure; Focalization: co-construction and parental scaffolding;

Affect sharing: family warmth and validation; and Timing/ synchronization: interactive

mistakes during activities and interactive mistakes during transition. (b) The Co-parenting

scales included: Support and Conflicts, and (c) The child contribution included:

Assertiveness and Toddler’s engagement. Each dimension is scored (2 = adequate, 1 =

moderate, 0 = inadequate), the sum of all the triadic aspects scores constitutes the Triadic

score ranging between 0 to 22 points. The Coparenting and Child Involvement aggregates,

each of which could range between 0 to 4, and the sum of triadic aspects plus the subsystem

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aspects constitutes the “family interaction score” ranging between 0 to 30 points which

represents the functionality level of the interaction.

Studies conducted by the Lausanne team report mean scores of 19 points in a

normative sample and 10.3 in a clinical sample (Favez, Scaiola, Tissot, Darwiche &

Frascarolo, 2011). Studies developed in Chile report an average of 10.09 in nonclinical

population of medium and low socioeconomic level (Pérez et al., 2017).

The FAAS showed moderate-to-good inter-rater reliability, κ = .61–.90, p < .05,

(Favez et al., 2011). The alpha value obtained by the triads of the study was .901. Three

reliable coders, trained with the developers of the FAAS coding in Swiss, evaluated the

videos, 25% of them were three time coded to calculate the inter-rater reliability for family

scores, ICC=.97, showing an excellent score.

Parental Reflective function (RF). Was measured using the Parent Development

Interview–Revised, Short Version, PDI-S (Slade, Aber, Berger, Bresgi, & Kaplan, 2012).

The PDI-S is a semi-structured individual interview of parents of children between the ages

of 3 months and 14 years that assesses the narratives of the current and specific relationship

with a child. The PDI-S is used to assess and code the parental reflective function in

relation to the child, one’s own parents, and the self, with questions such as “Describe a

time in the last week when you (and your child) really “clicked”, “What gives you the most

joy in being a parent?”, “Does (your child) ever feel rejected?”, and “How do you think

your experiences being parented affect your experience of being a parent now?” There are

29 questions; 15 demand the use of reflective functioning, and those are coded. The

interview takes approximately 40 minutes to complete and is videotaped and transcribed for

coding purposes.

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 To assess reflective function, each set of questions was coded with the scoring

system developed by Fonagy and colleagues (Fonagy et al., 1998), as adapted for the PDI

(Slade, Bernbach, Grienenberger, Levy, & Locker, 2004). Scoring was based on an 11 point

scale, from -1 (negative RF) to 9 (full or exceptional RF). Scores of 5 or greater are

considered high reflective and show clear and solid mental state understanding (Slade et al.,

2005). Scores equal to 3 show a questionable or low reflective function capacity, frequently

use mental state language such as “happy” or “sad” but without making a clear reflection

about them, and appear somewhat clichéd, banal or superficial. Otherwise, this score might

represent excessively deep and detailed but unconvincing and/or irrelevant responses

(Slade, Bernbach, Grienenberger, Levy, & Locker, 2004). Finally, scores of less than 3 show

poor reflective function capacity and are characterized as concrete explanations of

behavior, avoiding references to mental states or possibly containing self-serving

statements or distortions. Additional behavioral characterizations could include hostile,

bizarre and negative (Slade et al., 2004).

Based on the “Poor”, “Low” and “High” reflective function, different combinations

of the couple reflective function level were formed—for example, one poor and one low or

both low—that will be presented later.

Studies conducted using the PDI and parental reflective function scale and reporting

mean scores of 5 indicate typical reflective function in normative samples (Slade et al.,

2005); however, in a high risk simple, a score over 4 has also been found (M = 5.0, Perry,

Newman, Hunter, & Dunlop, 2015; M = 4.57, Stacks et al., 2014). To date, no studies have

been developed in Chile using these tools.

Reliability estimates using the coding manual have been shown to be good, with

ICCs ranging from .78–.95 (Slade et al., 2005). Two reliable coders evaluated the

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interviews. Inter-rater reliability was calculated on 25% of interviews. Intra-class

correlation coefficient (ICC) analyses were ICC=.89, ranging from .77–.95, which is

considered adequate by the author of the instrument.

Data analysis procedure

Data were analyzed using the statistical software IBM SPSS statistics version 21.0.

First, the triads were characterized by their socio-demographic characteristics and

subsequently by child social-emotional difficulties, triadic interaction and reflective

function. T-tests were then conducted to assess the equivalence in the means of the mother

and fathers’ variables and the child (boys and girls) variables. “Couple reflective function”

groups were created based on the “Poor”, “Low” and “High” reflective function

combinations of the mother and father reflective function —for example, one parent poor

and one low or both low). Then, analyses of covariance (ANOVA) were conducted to

examine the differences in the child social-emotional difficulties and in triadic scores

among the “couple reflective function” groups.

Then, a correlation matrix was computed with the main and control variables to

obtain preliminary results and to assess which co-variables and socio-demographic

characteristics would be used as a control variable in the next analyses.

Thereafter, different models of multiple linear regression analyses were performed

in which the child social-emotional difficulties were the dependent variables and the

reflective function and triadic interaction were the independent variables. Also, the

reflective function as a moderator between the triadic interaction and the child social-

emotional development was examined.

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 Finally, and according to the results, the influence of the mothers’ and fathers’

reflective functioning on the triadic interaction was studied using a linear regression with

an entry method. Two steps were tested; first, the fathers’ reflective function was

introduced in the equation, and then the mothers’.

First, the requirements for OLS (Ordinary Least Squares) multiple linear regression

analysis were assessed for each regression model (Stevens, 2009). An analysis of influential

cases was performed for each model, considering potentially influential those with a

Leverage value greater than 2 points and those with a Cook distance greater than 1 point. A

non-case with these characteristics was found. Then, to ensure the absence of

multicollinearity, variance inflation factors (VIF) were reviewed. Both to assist with

interpretation of the data and to avoid the problems of collinearity, all of the predictors

were centered on their grand mean (Shieh, 2011). Normal distribution of residuals was

assessed using a histogram of studentized residuals. Homogeneity of variance and linearity

of the model were assessed by plotting standardized residuals vs. standardized predicted

values. All procedures used indicated no significant deviation from the requirements of

multiple regression analysis. Only the coefficients that contribute significantly to explain

the variance of the study variables will be interpreted.

Results

Descriptive Analysis

First, differences in child social-emotional difficulties between boys and girls were

explored. No significant differences were found. Therefore, the consecutively analyzes

grouped boys and girls. Also, differences between the means of the fathers’ and mothers’

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 reflective function scores and couple satisfaction were explored. No significant differences

were found (see Table 1).

Table 1

Means (SDs) on mother’s and father’s reflective function, depressive symptoms and couple

satisfaction

Mothers (n = 50) Fathers (n = 50) 95% CI

Variable
M (SD) Min-max M (SD) Min-max t(df=48) p LL UL
Reflective function 3.64 (1.12) 1-6 3.56 (1.11) 2a6 0.45 .66 -0.34 4.42
Depression symptoms 7.40 (6.06) 0 - 34 5.36 (5.34) 0 a 28 1.7 .09 -2.15 1.59
Couple satisfaction 29.96 (4.84) 13 - 35 30.24 (5.94) 14 a 35 -.297 .77 -0.35 0.55
Note. CI = confidence interval; LL = lower limit, UL = upper limit, SE = Social-emotional.

In relation to social-emotional development, 46% (f = 23) of the children were

above the cutoff at the ASQ-SE, which means that they presented social-emotional

difficulties. The mean of social-emotional difficulties was M = 13.67. Note that the limit

scores to consider social-emotional difficulties are from 12.69%–14.55%. The mean of

social-emotional difficulties was greater than the limit score, indicating that the mean of

children in this sample have social-emotional difficulties. Additionally, the areas in which

the children showed more difficulties were in the self-regulation and interaction with

people difficulty area (see Table 2).

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Table 2

Means (SDs) on child’s percentage of socio-emotional difficulties

Variables M SD Min Max

Overall percentage of social-emotional difficulties 13.67 7.14 2.56 37.93
Self regulation difficulties 18.74 12.33 0 55.55
Complacence difficulties 12.00 20.49 0 100
Communication difficulties 8.44 15.32 0 77.77
Adaptative functioning difficulties 14.00 14.56 0 58.33
Autonomy difficulties 15.00 18.21 0 66.66
Affect difficulties 5.11 6.43 0 22.22
Person interaction difficulties 12.85 11.46 0 55.55

% of social-emotional difficulties by range of age

12 – 17 months (n = 3) 19.70 4.55 15.15 24.24
18 – 29 months (n = 20) 13.65 7 2.56 28.21
30 – 35 months (n = 12) 12.45 5.41 6.9 24.14
36 months (n = 15) 13.46 8.78 5.38 37.93

f %
Children with social-emotional difficulties 23 46
Children without social-emotional difficulties 27 54

The descriptive analysis of the triadic interactions and their subscale scores are

presented in Table 3.

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Table 3

Triadic interaction total and subscales means and standard deviation

LTP’s subscales M SD Min Max

Participation 2.56 .97 0 4
Organization 2.4 1.1 0 4
Focusing and scaffolding 2.34 .69 1 4
Affect 3.70 1.43 1 6
Timing and synchronization 2.14 .86 0 4
Triadic Subscales Score 13.22 3.59 0 20

Subsystem subscales
Coparenting 2.76 .92 1 4
Toddler: engagement & assertiveness 2.46 1.1 0 4
Triadic Total Score 18.44 4.90 8 26

Concerning the parental reflective function, the results show that 24% of the women

and 18% of the men presented reflective functioning, showing a solid and clear

understanding of their own and others’ mental states. Twenty-four percent of the mothers

and 18% of the fathers presented questionable or low reflective functioning, with frequent

use of mental state language such as “happy” or “sad” but without showing a clear or

explicit understanding of their statement. Finally, 12% of the mothers and 14% of the

fathers presented poor reflective functioning characterized by concrete explanations of

behavior, avoidance of references to mental states, or possibly containing self-serving

statements or distortions.

To understand how reflective functioning in the parent couples works, “couple

reflective functioning” groups based on “Poor”, “Low” and “High” reflective function were

created. To compare the mean of triadic interaction and child social-emotional difficulties

across the couple reflective functioning groups, three categories were formed. The

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distribution was (1) Poor/Low (included both parents poor and one parent poor and other

low), (2) Low (included both parents low) and (3) Low/high (included one parent low and

the other reflective or both parents reflective). Table 4 shows the one-way ANOVA with

the couple reflective function groups as the independent variable and triadic scores and

child social-emotional difficulties as the dependent variable.

Follow-up contrast analyses using a Bonferroni post hoc test revealed a significant

difference between the triadic scale means among the couple reflective groups, showing

that the main differences are in the extreme groups (Poor/Low and Low/High). In the co-

parenting mean, the difference was between the Poor/Low and Low/High couples.

Concerning the toddler contribution mean, a barely significant difference between

Poor/Low and Low/High couples was found. In the triadic subscale score and triadic total

score, the analyses revealed significant differences between Poor/Low and Both Low

couples and between Poor/Low and Low/High couples; no differences were found between

Both Low and Low/High couples. These results show that triads with Poor/Low reflective

functioning couples had a significantly lower mean in the quality of their triadic interaction

than did the other groups, the Low/High couples in particular.

With respect to social-emotional difficulties, no differences were found between the

different couple groups.

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 Table 4

Differences in the triadic scores, child’s psychomotor development and child’s social-
emotional difficulties between the three couple’s reflective function groups

Poor/Lowa Lowb Low/Highc

(n = 12) (n = 22) (n = 16)
M (SD) M (SD) M (SD) F
Coparenting 2.08 (0.55)ac 2.82 (0.91) 3.19 (0.91)ac 6.12*
Toddler contribution 1.83 (0.72)ac 2.41 (1.18) 3.00 (0.97)ac 4.53*
Triadic Subscales Score 10.25 (3.02)abc 13.23 (4.42)ab 15.44 (2.61)ac 9.68*
Triadic Total Score 14.17(3.10)abc 18.45(4.66)ab 21.63(3.44)ac 11.28*
Social-emotional difficulties 14.90 (8.51) 14.22 (6.72) 11.99 (6.77) 0.67
Note. *p < .01. < >=different; a < >c; a < >b< >c; a < >b.
Poor/Low = Both parents poor (0-2), or one poor and one low (3-4)
Both Low = Both parents Low Reflective (3-4)
Low/High = One parent Low (3-4) and one High, or both High (≥5)

Correlational analysis

First, the associations between the main study’s variables and sociodemographic

variables (child age, gender and birth order, child attending nursery or daycare, parent age,

parent number of children, parent years of education, and parent has a job2) were examined.

Non-significant association between the main and the sociodemographic variables was

found.

Regarding the main variables association, mothers’ and fathers’ reflective

functioning was significantly positively correlated with triadic total interaction (see Table

5). Therefore, when the mother and the father have higher reflective function levels, the

triadic total interaction also tends to have higher levels of coordination, However, the level

2
Child attending nursery or daycare (0 = no, 1 = yes), parent has a job (0 = no, 1 = yes).

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 of mothers’ and fathers’ reflective function was not significantly correlated with the child

or socio-emotional difficulties.

A significantly negative correlation was found between the triadic interaction score

and socio-emotional difficulties (see Table 5) in which triads with higher triadic scores

tended to have children with a lower level of social-emotional difficulties.

Table 5

Correlation among triadic interaction, mother and father reflective function, and child’s

psychomotor socio-emotional difficulties.

1 2 3 4 5 6 7
1. % SE difficulties 1
2. Triadic Total Score -.40** 1
3. Triadic Subscale Score -.32* .98** 1
4. Coparenting -.23 .68** .61** 1
5. Toddler contribution -.52** .70** .59** .21 1
6. Mother RF -.05 .43** .40** .41** .28 1
7. Father RF -.09 .38** .37** .34* .204 .43** 1
Note. SE = social-emotional; RF = reflective function.
*. Correlation is significant at the .05 level (2-tailed).
**. Correlation is significant at the .01 level (2-tailed).

Regression Analysis

To test the level of fathers’ and mothers’ reflective functions and the quality of the

triadic interaction will influence child socio-emotional difficulties multiple linear

regression analyses were conducted. In these analyses, the reflective function and the

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triadic interaction were the independent variables, and the child social-emotional

difficulties were the dependent variables.

It is important to consider that the LTP procedure and FAAS coding system assess

five triadic aspects and two subsystem aspects: co-parenting and the child contribution,

which included child engagement and assertiveness, which in turn are parts of the child

social-emotional development construct. Thus, to be more rigorous and not assess the same

variable in different ways, for the analysis in which social-emotional difficulties was the

dependent variable, the triadic subscale score was considered a predictor (not the triadic

total score), leaving out the co-parenting and child subsystem.

The results revealed a significant effect of the triadic interaction on child social-

emotional difficulties, explaining 9% of the variance. However, in contrast to expectations,

there was a non-significant effect of the mothers’ and the fathers’ reflective function on

child social-emotional difficulties (see Table 6).

Based on the results obtained, it was hypothesized that the reflective function would have a

moderator effect on child social-emotional difficulties; therefore, moderation analyses for

each parent were run. In both cases the regression revealed a non-significant effect as

moderator (see Table 6).

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 Table 6

Regression and moderation analysis considering social-emotional difficulties as dependent

variable

Std. 95% CI
Variable B B std. t p R R2 F p
error LL UL
Model 1 .32 .09 5.55 .023
Intercepto 13.67 .97 14.14 .000 11.73 15.61
Triadic SS -.64 .27 -.32 -2.35 .023 -1.19 -.09

Model 3 .33 .05 .18 .834

Intercepto 13.67 .98 13.89 .000 11.69 15.65
Triadic SS -.72 .31 -.36 -2.31 .026 -1.35 -.09
Mother RF .55 1.01 .09 .54 .590 -1.45 2.59
Father RF .07 1.02 .01 .07 .943 -1.98 2.13

Model 5 .341 .04 .29 .595

Intercepto 14 1.08 13 .000 11.73 16.07
Triadic SS -.74 .32 -.37 -2.33 .024 -1.37 -.10
Mother RF .54 1.02 .09 .53 .597 -1.51 2.6
Father RF .10 1.03 .02 .10 .922 -1.98 2.18
M RF x TS -.14 .26 -.08 -.54 .595 -.67 .39

Model 6 .36 .05 .96 .333

Intercepto 14.10 1.08 13.08 .000 11.93 16.27
Triadic SS -.80 .32 -.40 -2.48 .017 -1.45 -.15
Mother RF .54 1.01 .09 .53 .596 -1.50 2.58
Father RF .35 1.06 .06 .33 .742 -1.79 2.49
F RF x TS -.30 .30 -.14 -.98 .333 -.91 .31
Note. Dendent variable = Percentage of social-emotional difficulties; CI = confidence interval; LL = lower
limit, UL = upper limit; M = mother; F = father; RF = reflective function; Triadic SS = triadic subscale score.

Considering that the mothers’ and fathers’ reflective functions were not a significant

predictor or moderator of child social-emotional difficulties, new analyses were conducted.

Based on the correlational results, the contributions of the maternal and paternal

reflective function were tested as predictors of quality of the triadic total interaction with an

entry regression (see Table 7). The first step introduced the fathers’ reflective function

score, which was a significant predictor of the triadic interaction. In the second step, the

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mothers’ reflective function score was introduced, which was a significant predictor,

explaining 20% of the variance. However, in the second step, when the mothers’ reflective

function entered the regression, the fathers’ reflective function significant contribution

disappeared. This disappearance could indicate that the effect of the fathers’ reflective

function was due to its correlation with the mothers’ reflective function (r=.43), which

acted as a confounder variable in the direct relationship; the latter (mothers’ RF) is the one

more reliably associated with the triadic interaction score. However, in the model with the

mother and father reflective function together, father reflective function contributes to

increase the explaining variance.

Table 7

Regression analysis considering triadic interaction as dependent variable

Std. 95% CI
Variable B B std. t p R R2 F p
Error LL UL
Model 1 .38 .13 8.19 .006
Intercepto 12.44 2.19 5.67 .000 8.03 16.85
Father RF 1.69 .59 .38 2.86 .006 0.50 2.87

Model 2 .19 .17 11.17 .002

Intercepto 11.58 2.15 5.39 .000 7.26 15.99
Mother RF 1.87 .56 .43 3.34 .002 .75 3.00

Model 3 .49 .20 7.24 .023

Intercepto 9.44 2.46 3.84 .000 4.50 14.38
Father RF 1.06 .62 .24 1.69 .097 -0.20 2.31
Mother RF 1.43 .61 .33 2.35 .023 0.21 2.66
Note. Dendent variable = Triadic interaction; CI = confidence interval; LL = lower limit, UL =
upper limit; RF = reflective function.

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Discussion

This study provides evidence with respect to the relationship of the fathers’ and

mothers’ reflective function, the quality of triadic interaction, couple satisfaction and child

social-emotional difficulties. These variables to date have not been studied together despite

their great relevance for understanding the early development and mental health of children

and families.

In relation to socio-emotional development as assessed by the ASQ-SE, the results

show that 46% of children are above the social-emotional difficulty cutoff, indicating that

they have social-emotional difficulties. That this percentage is higher has been confirmed

by other studies, which showed that from 11% to 37% of children have some social-

emotional difficulties in early childhood (Bian et al, 2017; Briggs-Gowan et al., 2013;

Centro de Microdatos-Universidad de Chile, 2014; Wendland et al., 2014). However, to

interpret these results, it is necessary to consider that these children entered this study

because their parents are professionals who work with and reported one or more difficulties

in the following areas: sleep, feeding, behavioral and emotional or relationship. Although

these reports were subjective evaluations done by the adults, there were real worries about

their children concerning problems that interfered in daily life, because almost half of this

sample was considered by the ASQ-SE an objective and clinical delay or difficulty.

Related to the parents’ variables, the descriptive results show lower averages in

relation to mothers’ and fathers’ parental reflective function than do the results obtained in

international investigations (Control mother RF-PDI group, M= 3.69, Ensink, Bégin,

Normandin & Fonagy, 2016; Mix clinical and non-clinical mothers RF-AAI, M = 4.52,

Ensink, Normandin, Plamondon, Berthelot, & Fonagy, 2016; non-clinical sample, mother

RF-AAI, M = 4.48; father RF-AAI= 4.22, Fonagy et al., 1991; non-clinical mother RF-PDI,

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M = 5.08, Slade et al., 2005).

In this study, the averages and frequencies obtained between mothers and fathers

showed that 24% of mothers and 18% of parents have the capacity to reflect on mental

states. More than half of mothers and fathers (64% and 68%, respectively) show low

reflective capacities; that is, in their discourse, mentalizing language is present. However,

they do not reflect on it. Finally, 12.5% of mothers and 14% of the parents presented a poor

or negative level of reflective functioning; that is, their responses presents no evidence of

an awareness of mental states and suggests that they might even reject the recognition and

use of mental states.

First, to understand these results, note that this sample consisted of parents mostly

raising their first child or in early parenting, in the couple adjustment phase, and with

children with socio-emotional difficulties, experiences associated with changes and stress.

Additionally, it is important to consider these results and, above all, the last group of

parents described because the scientific literature has demonstrated that a poor or negative

parental reflective functioning is associated in the adult with less persistence in distress-

tolerant tasks (Rutherford, Booth, Luyten, Bridgett, & Mayes, 2015). Additionally, poor or

negative parental reflective functioning is associated with a higher level of maternal

disruption in mother-infant affective communication (Grienenberger et al., 2005) and with

insecure attachment and physical neglect (San Cristobal, Santelices, Fuenzalida, 2017).

For children, having a parent with poor or negative reflective capacities also has

negative consequences throughout development. In early childhood, such a problem can

cause the development of an insecure attachment (Ensink et al., 2016; Slade et al., 2005). In

the preschool years, it can cause fewer social competences in children (Ensink, Normandin

et al., 2015; Kårstad et al., 2015). At school age, more externalizing problems can appear

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(Ensink, Bégin et al., 2016). Moreover, anxiety (Esbjørn, Pedersen, Daniel, Hald, Holm, &

Steele, 2013) and fewer reflective function capacities might develop (Scopesi, Rosso,

Viterbori, & Panchieri, 2015).

Additionally, more than half of the parents have a low reflective function, or scores

from 3–4 in the reflective function scale. However, their having low capacities to reflect

might not be negative for their children because they are parents who create a narrative that

will recognize other emotions and intentions, although they are not reflective of them.

However, that type of explanation of the experience could be sufficient at this age. That is,

it is possible that as the child grows up, greater reflective capacities will be demanded of

the parents; as Taumoepeau and Ruffman (2008) suggest, maternal mentalization changes

and adjusts according to the child's age.

Another finding that was highly interesting was the "couple reflective function

groups". Based on mother and father reflective function, couple combinations were formed

(e.g., one low and one high), showing that the most frequent is that a parent couple have the

same level of reflective function, or one level high or low. However, this result was

interesting to see because a parent with high reflective function does not come together

with one who has poor capacities.

The analyses of comparisons between the groups showed that there are significant

differences between them in co-parenting; toddler contribution and triadic interaction were

the main differences found in the extreme groups. In other words, the major difference in

the quality of family interaction is generated when the parents each have Poor/low

reflective function, composed of one parent with low reflective function and one poor, or

both poor. The Poor/low reflective function couple had a significantly lower mean in the

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total total triadic interaction than did the Low and Low/high reflective function couples.

These differences were not found in relation to the child social-emotional difficulties.

These results are in line with what has been found by Marcu et al., (2016) using the

insightfulness measurement. This measurement assesses the parent’s reflective capacities in

interaction with his child, showing that triads in which both parents were insightful had

higher family cooperation scores compared with triads in which only one parent was

insightful and triads in which neither parent was insightful.

In relation to the quality of the total triadic interaction, the average obtained by the

families studied was M = 18.44, which is similar to other international non-clinical samples

(M = 19, Favez et al., 2011; M = 18,76, Marcu et al., 2016) and higher than clinical

samples (M = 10.3, Favez et al., 2011). In the case of Chile, our mean of triadic subscales

interaction (M = 13.22) is greater than that of other Chilean samples (M = 10.09, Pérez et

al., 2017). This result could occur because, although the other study was not in a clinical

sample, it was a population that lived in a poverty context and had high levels of parental

stress (Pérez et al., 2017).

Conversely, considering the association between the study variables, the result shows

that when the mother and the father have higher reflective function levels, the triadic

interaction also has higher levels of coordination. Also, triadic total interaction score was

negatively associated with child socio-emotional difficulties, which indicates that how

fathers and mothers coordinate and support each other in the interaction with their children

and in their upbringing influences how the child develops social and emotional

competences (Feldman & Masalha, 2010; Greenspan, DeGangu, & Wieder, 2001).

But, in contrast to what was hypothesized, mother and father reflective function were

not correlated with child socio-emotional difficulties.

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 In the same way, the findings corroborated partially the second hypothesis, because

only triadic interaction contributed to explaining 9% of the variance of child social-

emotional difficulties. In other words, triads with lower coordination explain part of the

child’s social-emotional difficulties. For its part, maternal and paternal reflective function

had no direct influence on child social-emotional difficulties. On the one hand, these

finding are in line with the early family literature, which shows that since the 1980s, the

immediate family is the most influential relationship system in which a child develops

(Bronfenbrenner, 1987). In the triad, the child learns to share affection, attention and a

common objective (Liszkowski et al., 2004; Fivaz-Depeursinge & Corboz-Warnery, 1999),

which influences the acquisition of social competence (Cigala et al., 2014; Feldman &

Masalha, 2010) that, in turn, is reflected in the child’s socio-emotional adaptation. On the

other hand, the question about the influence of the reflective function remains open.

Based on the results, an additional hypothesis was that reflective function would have

an indirect effect, as a moderator, on child social-emotional difficulties. Although the

hypothesis and the literature show the reflective function as an intervening variable

(Borelli, Compare, Snavely, & Decio, 2015; Grienenberger et al., 2005; Slade, 2005;

Smaling, Huijbregts, van der Heijden, van Goozen, & Swaab, 2016; Wong, 2012), neither

the mother’s nor the father’s reflective function constituted significant moderators in the

relationship between the quality of the triadic interaction and child socio-emotional

difficulties.

Considering these results and the theoretical background of mentalization, a new

hypothesis was developed that expected that reflective function would influence the triadic

interaction. As expected, the fathers’ reflective function was a significant predictor of the

family interaction and of the mother reflective function, but when both were together, only

215
the mother reflective function was a significant predictor. This result is interesting to

consider because, although the statistically significant influence of the father disappears

when the mother enters the equation, the variance of the father and mother together is

greater than that of the mother alone, showing a less obvious contribution from the father

than the mother but nonetheless generating a differential contribution.

From a clinical perspective, these results are interesting to interpret; on the one hand,

the scientific evidence has shown the influential role of the parental reflective function in

child social and emotional development (Ensink, Normandin et al., 2015; Steele & Steele,

2008). On the other hand, in this study, the contribution is not directly to child

development. These findings show the direct influence of the reflective function on the

triadic interaction and of the triadic interaction on child social-emotional development.

Thus, the activity of mentalizing increases the likelihood that the parent is aware of, for

example, the infant’s needs, thoughts, and feelings but might not necessarily indicate that

the parent is able to convert his or her thoughts about the infant’s mind into direct, sensitive

behavioral responses. That approach is how studies show that the relationship between

parenting reflective capacities and child outcomes are mediated by parental sensitivity

(Laranjo, Bernier, & Meins, 2008; Stacks et al. 2014; Ensink, Normandin et al., 2016).

Another reflection that emerges from these results is that the main scale that evaluates

reflective function (Reflective function scale, Fonagy et al., 1998) provides a single overall

score. On the one hand, it is a clear and guiding score; on the other hand, it does not capture

the complexity and multidimensionality of parental reflective function, losing theoretical

and clinical richness of scale. Especially problematic are the pre-mentalizing or pseudo-

mentalizing states, which are difficult to differentiate because the same score can

correspond to hyper-mentalizing, a simple and concrete reflective function, or an unstable

216
reflective capacity (Fonagy et al., 1998). Likewise, poor scores might correspond to denial

of mental states, distortions, or malevolent attributions (Allen, 2006). These theoretical and

clinical differences suggest that the effect on the child of a low, simple reflective function is

different from that of a parent who hyper-mentalizes.

Thus, Suchman, DeCoste, Leigh, and Borelli (2010) and Smaling et al. (2016) have

observed three dimensions of reflective operation using PDI-RF. These dimensions are self-

focused, child-focused and relationship-focused mentalization, showing that self-focused

reflective function was related to less maternal contingency, more negative emotionality

and externalizing problems in the child. Child-focused was associated with more maternal

contingent behavior, and reflective function relationship-focused were reported with less

reported child physical aggression. This type of analysis shows how different forms of

reflective functioning differentially affect the exercise of parenting and child development.

To summarize, the findings of this study confirm the contribution of family

coordination and cooperation on child social and emotional development (Cigala et al.,

2014; Feldman & Masalha, 2010), providing evidence based on a study of families with

children at an early age. This study shows that the father's contribution does not directly

affect the child’s early development; rather, it is in the triad interaction that the father, in

interaction with the mother and child, influences his child’s development. This result has

been found by other authors, suggesting that parent involvement and reciprocity have a

positive effect on child development, the mother-father-child relationship and the couple

subsystem (Feldman, 2010; Feldman et al., 2013; Sarkadi et al., 2008; Simonelli et al.,

2016).

This study shows a leading role of the mother and a secondary role of the father in

child development. This indirect influence of the father can be explained based on the

217
distribution of social and family roles and the time and type of activities that the father

performs with his child. The reorganization of domestic and foster care has contributed to

increased parental involvement in early childcare and promoted multiple roles within the

family (Lamb, 2013). In recent decades, the rate of economic participation of women has

increased in Chile. However, it remains lower than that of men, male heads of household

predominate (Instituto Nacional de Estadística, 2012), and the mother continues as the main

person in charge of child raising (Pleck & Masciadrelli, 2004). This sample is not the

exception; 62.5% of the mothers had a full-time job compared with 95.9% of the fathers,

showing that the mother was the main child caregiver.

The distribution of roles and tasks and the time that the father and the mother spend

with their child allow us to understand these findings in which, although family interaction

influences child development, the mother more directly influences early child development.

These results invite professionals who work in early childhood to consider changing

the focus of attention from the dyad to the early family, promoting the inclusion of the

father. As shown by these results, the quality of family interaction can be constituted as a

factor that is protective of or detrimental to the social and emotional development of

children. Conversely, reflective function appears to be a variable that influences the quality

of early family interactions because to represent one’s own and others’ mental states

permits understanding, regulating and giving sense to one’s own and others’ behavior

(Fonagy et al., 2004).

Finally, although these results are preliminary and descriptive, the couple reflective

function levels show that the combination of poor and low levels of couple reflective

function is the real source of harm to the triad interaction. As in the attachment theory,

which is disorganized attachment that generates greater childhood psychopathology

218
(Madigan, Moran, Schuengel, Pederson, & Otten, 2007), in this case, it is the poor

reflective function that generates worse quality family interaction, and it is the poor quality

of family interaction that generates greater socio-emotional difficulties in the child.

Nevertheless, these findings must be confirmed using larger samples. It is also

recommended to reduce the age gap in children because from 12–36 months, there are

major changes in development, primarily in communication and regulation skills.

The (non-randomized) recruitment characteristics and the lack of follow-up

evaluations in this study constitute a limitation that prevents the generation of prediction

models that permit observation of causality and the direction of the variables.

In term of the instruments, although the ASQ-SE is a great and broadly used

instrument that can be used by any mental health professional, it is only a screening

assessment; therefore, it only detects more general aspects of child development. Thus,

future studies would benefit from including other means of evaluating child social-

emotional difficulties, such as child symptomatology or some observational task to

complement the ASQ-SE results.

It is important to consider that this study constitutes the second study that linked

family interaction and parents’ reflective capacity, and it is the first that additionally

assesses child social-emotional difficulties. Therefore, future studies would benefit from

considering other family members who are in charge of daily childcare, such as

grandmothers, stepmothers, stepfathers, or nannies. Additionally, it is important in early

family development to consider the role of siblings and consider how the triad might

actually be an interaction of four or more people.

Moreover, future studies should consider additional reflective function dimensions to

capture the richness, complexity and multidimensionality of parental reflective function.

219
Refercences

Allen, J. G. (2006). Mentalizing in practice. In J. G. Allen & P. Fonagy (Eds.), Handbook

of Mentalization-Based Treatment (pp. 3-30). NY: Wiley.

Bian, X., Xie, H., Squires, J., & Chen, C. Y. (2017). Adapting a parent-completed,

socioemotional questionnaire in china: the ages & stages questionnaires: social-

emotional. Infant Mental Health Journal, 38, 258-266. https://doi:

10.1002/imhj.21626

Borelli, J. L., Compare, A., Snavely, J. E., & Decio, V. (2015). Reflective functioning

moderates the association between perceptions of parental neglect and attachment in

adolescence. Psychoanalytic Psychology, 32, 23-35.

https://dx.doi.org/10.1037/a0037858

Briggs-Gowan, M. J., & Carter, A. S. (2008). Social-Emotional Screening Status in Early

Childhood Predicts Elementary School Outcomes. Pediatrics, 121, 957–962.

https://doi.org/10.1542/peds.2007-1948

Briggs-Gowan, M. J., Carter, A. S., McCarthy, K., Augustyn, M., Caronna, E., & Clark, R.

(2013). Clinical validity of a brief measure of early childhood social–

emotional/behavioral problems. Journal of Pediatric Psychology, 38, 577-587.

https://doi: 10.1093/jpepsy/jst014

Bronfennbrenner, U. (1987). La Ecología del Desarrollo Humano, Barcelona, Paidos.

Cabrera, N. J., Tamis-LeMonda, C. S., Bradley, R. H., Hofferth, S., & Lamb, M. E. (2000).

Fatherhood in the twenty-first century. Child Development, 71, 127–136.

https://doi:10.1111/1467- 8624.00126

220
Cassidy, K. W., Werner, R. S., Rourke, M., Zubernis, L. S., & Balaraman, G. (2003). The

relationship between psychological understanding and positive social behaviors.

Social Development, 12, 198-221. https://doi: 10.1111/1467-9507.00229

Centro de Microdatos-Universidad de Chile. (2014). Encuesta longitudinal de primera

infancia. Santiago: Universidad de Chile. Retrieved from:

http://www.superacionpobreza.cl/wp-

content/uploads/2014/03/documento_metodologico.pdf

Cheng, E. R., Palta, M., Kotelchuck, M., Poehlmann, J., & Witt, W. P. (2014). Cognitive

delay and behavior problems prior to school age. Pediatrics, 134, e749-e757.

https://doi: 10.1542/peds.2014-0259.

Cigala, A., Venturelli, E., & Fruggeri, L. (2014). Family functioning in microtransition and

socio-emotional competence in preschoolers. Early Child Development and Care,

184, 553-570. https://dx.doi.org/10.1080/03004430.2013.800053

Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2016). Maternal and child reflective

functioning in the context of child sexual abuse: pathways to depression and

externalising difficulties. European Journal of Psychotraumatology, 7: 30611.

https://doi: http://dx.doi.org/10.3402/ejpt.v7.30611

Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2017). Parental Reflective

Functioning as a moderator of child internalizing difficulties in the context of child

sexual abuse. Psychiatry Research, 257, 361-366.

https://doi.org/10.1016/j.psychres.2017.07.051

Ensink, K., Normandin, L., Plamondon, A., Berthelot, N., & Fonagy, P. (2016).

Intergenerational Pathways From Reflective Functioning to Infant Attachment

221
 Through Parenting. Canadian Journal of Behavioural Science, 48, 9-18.

https://dx.doi.org/10.1037/cbs0000030

Ensink, K., Normandin, L., Target, M., Fonagy, P., Sabourin, S., & Berthelot, N. (2015).

Mentalization in children and mothers in the context of trauma: An initial study of the

validity of the Child Reflective Functioning Scale. British Journal of Developmental

Psychology, 33(2), 203-217. https:// doi:10.1111/bjdp.12074

Esbjørn, B. H., Pedersen, S. H., Daniel, S. I., Hald, H. H., Holm, J. M., & Steele, H. (2013).

Anxiety levels in clinically referred children and their parents: Examining the unique

influence of self-reported attachment styles and interview-based reflective

functioning in mothers and fathers. British Journal of Clinical Psychology, 4, 394-

407. https://doi: 10.1111/bjc.12024

Essex, M. J., Kraemer, H. C., Armstrong, J. M., Boyce, W. T., Goldsmith, H. H., Klein, M.

H., ... Kupfer, D. J. (2006). Exploring risk factors for the emergence of children's

mental health problems. Archives of General Psychiatry, 63, 1246-1256.

https://doi:10.1001/archpsyc.63.11.1246

Favez, N., Scaiola, C., Tissot, H., Darwiche, J., & Frascarolo, F. (2011). The Family

Alliance Assessment Scales: Steps toward validity and reliability of an observational

assessment tool for early family interactions. Journal Child Family Studies, 20, 23-

37. https://doi:10.1007/s10826-010-9374-7

Favez, N., Lopes, F., Bernard, M., Frascarolo, F., Lavanchy Scaiola, C., Corboz-Warnery,

A., & Fivaz-Depeursinge, E. (2012). The development of family alliance from

pregnancy to toddlerhood and child outcomes at 5 years. Fam Process, 51, 542–556.

https://doi.org/10.1111/j.1545-5300.2012.01419.x

222
Feldman, R. (2010). The relational basis of adolescent adjustment: trajectories of mother–

child interactive behaviors from infancy to adolescence shape adolescents' adaptation.

Attachment & Human Development, 12, 173-192.

https://doi:10.1080/14616730903282472

Feldman, R. & Masalha, S. (2010). Parent–child and triadic antecedents of children’s social

competence: Cultural specificity, shared process. Developmental Psychology, 46,

455–467. http://doi.org/10.1037/a0017415

Feldman, R., Bamberger, E., & Kanat-Maymon, Y. (2013). Parent-specific reciprocity from

infancy to adolescence shapes children's social competence and dialogical skills.

Attachment & Human Development, 15, 407-423.

https://dx.doi.org/10.1080/14616734.2013.782650

Feldman, R., Masalha, S., & Derdikman-Eiron, R. (2010). Conflict resolution in the parent–

child, marital, and peer contexts and children’s aggression in the peer group: A

process-oriented cultural perspective. Developmental Psychology, 46, 310-325.

https://doi: 10.1037/a0018286

Fincham, F. D. (1998). Child development and marital relations. Child Development, 69,

543-574. https://dx.doi.org/10.2307/1132183

Fivaz-Depeursinge E. & Favez, N. (2006). Exploring triangulation in infancy: Two

contrasted cases. Family Process, 45, 3–18. https://doi.org/10.1111/j.1545-

5300.2006.00077.x

Fivaz-Depeursinge, E. & Corboz-Warnery, A. (1999). The primary triangle, a

developmental systems view of mothers, fathers and infants. London: Basic Books.

Fonagy, P., Gergely, G., Jurist, E. L. & Target, M. (Eds.). (2004). Affect regulation,

mentalization and the development of the self. Karnac books.

223
Fonagy, P., Steele, H., Steele, M., & Target, M. (1998). Reflective Functioning Manual,

Version 5.0, for Application to Adult Attachment Interviews. London: University

College London.

Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgitt, A. (1991). The capacity for

understanding mental states: The reflective self in parent and child and its

significance for security of attachment. Infant Mental Health Journal, 12, 201 – 218.

https://dx.doi.org/10.1002/1097-0355(199123)12:3<201::AID-

IMHJ2280120307>3.0.CO;2-7

Frascarolo, F. (2004). Paternal Involvement in Child Caregiving and Infant

Sociability. Infant Mental Health Journal, 25(6), 509-

521. https://dx.doi.org/10.1002/imhj.20023

Frascarolo, F., & Favez, N. (1999). Comment et a` qui s’attache le jeune enfant? Le Carnet

Psy, 48, 39–40.

Giannovi, P. P., & Kass, P. H. (2012). Predictors of developmental outcomes of high-risk

and developmentally delayed infants and children enrolled in a state early childhood

intervention program. Infants & Young Children, 25, 244-264. https://doi:

10.1097/IYC.0b013e318257ff83

Goldberg, W. A., Clarke-Stewart, A., Rice, J. A., & Dellis, E. (2002). Emotional energy as

an explanatory construct for fathers’ engagement with their infants. Parenting

Science and Practice, 2(4), 379–408. https://doi:10.1207/S15327922PAR0204_03

Greenspan, S., DeGangu, G., & Wieder, S. (2001). The functional emotional assessment

scale (FEAS) for infancy and early childhood: Clinical and research applications.

Bthesda, MD: Interdisciplinary Council on Developmental and Learning Disorders.

224
Grienenberger, J., Kelly, K., & Slade, A. (2005). Maternal reflective functioning, mother–

infant affective communication, and infant attachment: Exploring the link between

mental states and observed caregiving behavior in the intergenerational transmission

of attachment. Attachment & Human Development, 7, 299–311.

https://dx.doi.org/10.1080/14616730500245963

Hedenbro, M. & Rydelius, P.A. (2014). Early interaction between infants and their parents

predicts social competence at the age of four. Acta Paediatr, 103, 268–274.

https://doi:10.1111/apa.12512

Heron-Delaney, M., Kenardy, J. A., Brown, E. A., Jardine, C., Bogossian, F., Neuman, L.,

... & Pritchard, M. (2016). Early maternal reflective functioning and infant emotional

regulation in a preterm infant sample at 6 months corrected age. Journal of pediatric

psychology, 41, 906-914. https://doi: 10.1093/jpepsy/jsv169

Instituto Nacional de Estadística, INE. (2012). Síntesis de Resultados Censo 2012.

Santiago: Instituto Nacional de Estadísticas de Chile.

Johnson, V. K. (2001). Marital interaction, family organization, and differences in parent

behavior: Explaining variations across family interaction contexts. Family Process,

40, 333–342. https://doi:10.1111/j.1545-5300.2001.4030100333.x

Kårstad, S. B., Wichstrøm, L., Reinfjell, T., Belsky, J., & Berg-Nielsen, T. S. (2015). What

enhances the development of emotion understanding in young children? A

longitudinal study of interpersonal predictors. British Journal of Developmental

Psychology, 33, 340–354. https://doi:10.1111/bjdp.12095.

Kwon, K. A., Jeon, H. J., Lewsader, J. T., & Elicker, J. (2012). Mothers' and Fathers'

Parenting Quality and Toddlers' Interactive Behaviours in Dyadic and Triadic Family

Contexts. Infant and Child Development, 21, 356-373. https://doi: 10.1002/icd.1746

225
Lamb, M. E. (2013). The father's role: Cross cultural perspectives. Routledge.

Lamb, M. E., & Lewis, C. (2004). The development and significance of father–child

relationships in two-parent families. En M. E. Lamb (Ed.), The role of the father in

child development (4th ed., pp. 272–305). New York, NY: Wiley.

Laranjo, J., Bernier, A., & Meins, E. (2008). Associations between maternal mind-

mindedness and infant attachment security: Investigating the mediating role of

maternal sensitivity. Infant Behavior and Development, 31, 688-695. https:// doi:

10.1016/j.infbeh.2008.04.008.

Lavanchy, C., Tissot, H., Frascarolo, F., & Favez, N. (2013). Family Alliance Assessment

Scale (FAAS): Coding Manual, short versión. Center for Family Studies, University

of Psychotherapy, DP-CHUV, University of Lausanne, Switzerland and Departament

of Psychology, FPSE, University of Geneva, Switzerland. Unpublished draft.

Lindsey, E., & Caldera, Y. (2006). Mother-father-child triadic interaction and mother-child

dyadic interaction: Gender differences within and between contexts. Sex Roles, 55,

511–521. https://doi:10.1007/s11199-006-9106-z

Liszkowski, U., Carpenter, M., Henning, A., Striano, T., & Tomasello, M. (2004). Twelve-

month-olds point to share attention and interest. Developmental Science, 7, 297–307.

https://dx.doi.org/10.1111/j.1467-7687.2004.00349.x

Madigan, S., Moran, G., Schuengel, C., Pederson, D. R. & Otten, R. (2007). Unresolved

maternal attachment representations, disrupted maternal behavior and disorganized

attachment in infancy: links to toddler behavior problems. Journal of Child

Psychology and Psychiatry, 48, 1042–1050. https://doi:10.1111/j.1469-

7610.2007.01805.x

226
Marcu, I., Oppenheim, D., & Koren-Karie, N. (2016). Parental insightfulness is associated

with cooperative interactions in families with toddlers. Journal of Family Psychology,

30, 927-934. https://dx.doi.org/10.1037/fam0000240

McHale, J., Fivaz-Depeursinge, E., Dickstein, S., Robertson, J., & Daley, M. (2008). New

evidence for the social embeddedness of infants' early triangular capacities. Family

Process, 47, 445-463. https://dx.doi.org/10.1111/j.1545-5300.2008.00265.x

Minuchin, P. (1985). Families and individual development: Provocations from the

field of family therapy. Child Development, 56(2), 289–302.

http://dx.doi.org/10.2307/1129720

Olhaberry, M., & Santelices, M. P. (2013). Father's presence and the quality of mother-

child interaction: A comparative study on Chilean nuclear and single-mother families.

Universitas Psychologica, 12(3), 833-844.

Pérez, F., Moessner, M., & Santelices, M. P. (2017). Beyond the dyad: the relationship

between preschoolers’ attachment representations and family triadic interactions.

Infant Mental Health Journal, 38, 198–209. https://doi:10.1002/imhj.21633

Pihlakoski, L., Sourander, A., Aromaa, M., Rautava, P., Helenius, H., & Sillanpaa, M.

(2006). The continuity of psychopathology from early childhood to preadolescence: a

prospective cohort study of 3012-year-old children. European Child and Adolescent

Psychiatry, 15, 409–417. https://doi.org/10.1007/s00787-006-0548-1

Pleck, J. H., & Masciadrelli, B. P. (2004). Paternal involvement by U.S. residential fathers:

Levels, sources, and consequences. In M. E. Lamb (Ed.), The role of the father in

child development (pp. 223–271). New York, NY: Wiley.

Rosenblum, K. L., McDonough, S. C., Sameroff, A. J., & Muzik, M. (2008). Reflection in

thought and action: maternal parenting reflectivity predicts mind-minded comments

227
 and interactive behavior. Infant Mental Health Journal 29, 362–376.

https://doi: 10.1002/imhj.20184

Rutherford, H. J., Booth, C. R., Luyten, P., Bridgett, D. J., & Mayes, L. C. (2015).

Investigating the association between parental reflective functioning and distress

tolerance in motherhood. Infant Behavior and Development, 40, 54-63.

https://doi.org/10.1016/j.infbeh.2015.04.005

San Cristóbal, P., Santelices, M. P., & Fuenzalida, D. A. M. (2017). Manifestation of

Trauma: the effect of early traumatic experiences and adult attachment on parental

reflective functioning. Frontiers in Psychology, 8, 449 - https:// doi:

10.3389/fpsyg.2017.00449

Sarkadi, A., Kristiansson, R., Oberklaid, F. & Bremberg, S. (2008). Fathers' involvement

and children's developmental outcomes: a systematic review of longitudinal studies.

Acta Pædiatrica, 97, 153–158. https://doi:10.1111/j.1651-2227.2007.00572.x

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment &

Human Development, 2, 23-47. https://dx.doi.org/10.1080/146167300361309

Scopesi, A. M., Rosso, A. M., Viterbori, P., & Panchieri, E. (2015). Mentalizing abilities in

preadolescents’ and their mothers’ autobiographical narratives. The Journal of Early

Adolescence, 35, 467-483. https://doi:10.1177/ 0272431614535091.

Shieh, G. (2011). Clarifying the role of mean centring in multicollinearity of interaction

effects. British Journal of Mathematical and Statistical Psychology, 64, 462–477.

https://doi:10.1111/j.2044-8317.2010.02002.x

Shore, R. (1997). Rethinking the brain. New insights into early development. New York:

Families and Work Institute.

Siegel, D. J. (1999). The developing mind. New York: Guilford Press.

228
Simonelli, A., Parolin, M., Sacchi, C., De Palo, F., & Vieno, A. (2016). The role of father

involvement and marital satisfaction in the development of family interactive

abilities: A multilevel approach. Frontiers in Psychology, 7, 1725.

https://doi.org/10.3389/fpsyg.2016.01725

Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & human

development, 7, 269-281. https://doi.org/10.1080/14616730500245906

Slade, A., Aber, L., Berger, B., Bresgi, I., & Kaplan, M. (2012). Parent development

interview revised, short version. Unpublished.

Slade, A., Bernbach, E., Grienenberger, J., Levy, D., & Locker, A. (2004). Addendum to

Fonagy, Target, Steele, & Steele reflective functioning scoring manual for use with

the Parent Development Interview. Unpublished Manuscript. New York, NY: The

City College and Graduate Center of the City University of New York.

Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal

reflective functioning, attachment, and the transmission gap: A preliminary

study. Attachment & Human Development, 7, 283–298. https://

doi:10.1080/14616730500245880

Smaling, H. A., Huijbregts, S. C. J., van der Heijden, K. B., Hay, D. F., van Goozen, S. H.

M., & Swaab, H. (2017). Prenatal reflective functioning and development of

aggression in infancy: the roles of maternal intrusiveness and sensitivity. Journal of

Abnormal Child Psychology, 45, 237-248. https://doi:10.1007/s10802-016-0177-1

Smaling, H. J. A., Huijbregts, S. C. J., van der Heijden, K. B., van Goozen, S. H. M., &

Swaab, H. (2016). Maternal reflective functioning as a multidimensional construct:

Differential associations with children’s temperament and externalizing behavior.

229
 Infant Behavior and Development, 44, 263-274.

https://doi:10.1016/j.infbeh.2016.06.007.

Squires, J., Bricker, D. & Twombly, E. (2002). Ages & Stages Questionnaires: Social-

Emotional: A Parent-Completed Child-Monitoring System for Social-Emotional

Behaviors. Baltimore, Md.:Paul H.Brookes.

Sroufe, L. A. (1996). Emotional development: The organization of emotional life in the

early years. New York, NY: Cambridge University Press.

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., &

Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with

childhood maltreatment histories: Links to sensitive parenting and infant attachment

security. Attachment & Human Development, 16, 515-533. https:// doi:

10.1080/14616734.2014.935452

Steele, H., & Steele, M. (2008). On the origins of reflective functioning. En F. N. Busch

(Ed.), Mentalization: Theoretical considerations, research findings, and clinical

implications (pp.133–158). New York, NY: Analytic Press.

Stevens, J. (2009). Applied multivariate statistics for social sciences New York: Routledge.

Suchman, N. E., DeCoste, C., Leigh, D., & Borelli, J. (2010). Reflective functioning in

mothers with drug use disorders: Implications for dyadic interactions with infants and

toddlers. Attachment & Human Development, 12, 567-585. https://doi:

10.1080/14616734.2010.501988

Taumoepeau, M., & Ruffman, T. (2008). Stepping stones to others’ minds: Maternal talk

relates to child mental state language and emotion understanding at 15, 24, and 33

months. Child Development, 79, 284-302. https://doi:10.1111/j.1467-

8624.2007.01126.x.

230
Udry-Jørgensen, L., Tissot, H., Frascarolo, F., Despland, J. N., & Favez, N. (2016). Are

parents doing better when they are together? A study on the association between

parental sensitivity and family-level processes. Early Child Development and Care,

186, 915-926. https://dx.doi.org/10.1080/03004430.2015.1068768

Wendland, J., Danet, M., Gacoin, E., Didane, N., Bodeau, N., Saïas, T., ... & Chirac, O.

(2014). French Version of the Brief Infant-Toddler Social and Emotional Assessment

Questionnaire–BITSEA. Journal of Pediatric Psychology, 39, 562-575.

https://doi:10.1093/jpepsy/jsu016

Wong, K. (2012). A study of the effect of maternal depressive symptoms on the mother-

infant relationship and protective effect of maternal reflective functioning (Master

dissertation). Wayne State University, Detroit, Michigan.

Zeegers, M., Colonnesi, C., Stams, G. J., & Meins, E. (2017). Mind matters: a three-level

meta-analysis on parental mentalization and sensitivity as predictors of infant-parent

attachment. Psychological Bulletin. https://doi:10.1037/bul0000114.

231
 and interactive behavior. Infant Mental Health Journal 29, 362–376.

https://doi: 10.1002/imhj.20184

Rutherford, H. J., Booth, C. R., Luyten, P., Bridgett, D. J., & Mayes, L. C. (2015).

Investigating the association between parental reflective functioning and distress

tolerance in motherhood. Infant Behavior and Development, 40, 54-63.

https://doi.org/10.1016/j.infbeh.2015.04.005

San Cristóbal, P., Santelices, M. P., & Fuenzalida, D. A. M. (2017). Manifestation of

Trauma: the effect of early traumatic experiences and adult attachment on parental

reflective functioning. Frontiers in Psychology, 8, 449 - https:// doi:

10.3389/fpsyg.2017.00449

Sarkadi, A., Kristiansson, R., Oberklaid, F. & Bremberg, S. (2008). Fathers' involvement

and children's developmental outcomes: a systematic review of longitudinal studies.

Acta Pædiatrica, 97, 153–158. https://doi:10.1111/j.1651-2227.2007.00572.x

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment &

Human Development, 2, 23-47. https://dx.doi.org/10.1080/146167300361309

Scopesi, A. M., Rosso, A. M., Viterbori, P., & Panchieri, E. (2015). Mentalizing abilities in

preadolescents’ and their mothers’ autobiographical narratives. The Journal of Early

Adolescence, 35, 467-483. https://doi:10.1177/ 0272431614535091.

Shieh, G. (2011). Clarifying the role of mean centring in multicollinearity of interaction

effects. British Journal of Mathematical and Statistical Psychology, 64, 462–477.

https://doi:10.1111/j.2044-8317.2010.02002.x

Shore, R. (1997). Rethinking the brain. New insights into early development. New York:

Families and Work Institute.

Siegel, D. J. (1999). The developing mind. New York: Guilford Press.

228
Simonelli, A., Parolin, M., Sacchi, C., De Palo, F., & Vieno, A. (2016). The role of father

involvement and marital satisfaction in the development of family interactive

abilities: A multilevel approach. Frontiers in Psychology, 7, 1725.

https://doi.org/10.3389/fpsyg.2016.01725

Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & human

development, 7, 269-281. https://doi.org/10.1080/14616730500245906

Slade, A., Aber, L., Berger, B., Bresgi, I., & Kaplan, M. (2012). Parent development

interview revised, short version. Unpublished.

Slade, A., Bernbach, E., Grienenberger, J., Levy, D., & Locker, A. (2004). Addendum to

Fonagy, Target, Steele, & Steele reflective functioning scoring manual for use with

the Parent Development Interview. Unpublished Manuscript. New York, NY: The

City College and Graduate Center of the City University of New York.

Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal

reflective functioning, attachment, and the transmission gap: A preliminary

study. Attachment & Human Development, 7, 283–298. https://

doi:10.1080/14616730500245880

Smaling, H. A., Huijbregts, S. C. J., van der Heijden, K. B., Hay, D. F., van Goozen, S. H.

M., & Swaab, H. (2017). Prenatal reflective functioning and development of

aggression in infancy: the roles of maternal intrusiveness and sensitivity. Journal of

Abnormal Child Psychology, 45, 237-248. https://doi:10.1007/s10802-016-0177-1

Smaling, H. J. A., Huijbregts, S. C. J., van der Heijden, K. B., van Goozen, S. H. M., &

Swaab, H. (2016). Maternal reflective functioning as a multidimensional construct:

Differential associations with children’s temperament and externalizing behavior.

229
 Infant Behavior and Development, 44, 263-274.

https://doi:10.1016/j.infbeh.2016.06.007.

Squires, J., Bricker, D. & Twombly, E. (2002). Ages & Stages Questionnaires: Social-

Emotional: A Parent-Completed Child-Monitoring System for Social-Emotional

Behaviors. Baltimore, Md.:Paul H.Brookes.

Sroufe, L. A. (1996). Emotional development: The organization of emotional life in the

early years. New York, NY: Cambridge University Press.

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., &

Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with

childhood maltreatment histories: Links to sensitive parenting and infant attachment

security. Attachment & Human Development, 16, 515-533. https:// doi:

10.1080/14616734.2014.935452

Steele, H., & Steele, M. (2008). On the origins of reflective functioning. En F. N. Busch

(Ed.), Mentalization: Theoretical considerations, research findings, and clinical

implications (pp.133–158). New York, NY: Analytic Press.

Stevens, J. (2009). Applied multivariate statistics for social sciences New York: Routledge.

Suchman, N. E., DeCoste, C., Leigh, D., & Borelli, J. (2010). Reflective functioning in

mothers with drug use disorders: Implications for dyadic interactions with infants and

toddlers. Attachment & Human Development, 12, 567-585. https://doi:

10.1080/14616734.2010.501988

Taumoepeau, M., & Ruffman, T. (2008). Stepping stones to others’ minds: Maternal talk

relates to child mental state language and emotion understanding at 15, 24, and 33

months. Child Development, 79, 284-302. https://doi:10.1111/j.1467-

8624.2007.01126.x.

230
Udry-Jørgensen, L., Tissot, H., Frascarolo, F., Despland, J. N., & Favez, N. (2016). Are

parents doing better when they are together? A study on the association between

parental sensitivity and family-level processes. Early Child Development and Care,

186, 915-926. https://dx.doi.org/10.1080/03004430.2015.1068768

Wendland, J., Danet, M., Gacoin, E., Didane, N., Bodeau, N., Saïas, T., ... & Chirac, O.

(2014). French Version of the Brief Infant-Toddler Social and Emotional Assessment

Questionnaire–BITSEA. Journal of Pediatric Psychology, 39, 562-575.

https://doi:10.1093/jpepsy/jsu016

Wong, K. (2012). A study of the effect of maternal depressive symptoms on the mother-

infant relationship and protective effect of maternal reflective functioning (Master

dissertation). Wayne State University, Detroit, Michigan.

Zeegers, M., Colonnesi, C., Stams, G. J., & Meins, E. (2017). Mind matters: a three-level

meta-analysis on parental mentalization and sensitivity as predictors of infant-parent

attachment. Psychological Bulletin. https://doi:10.1037/bul0000114.

231
10.12.2. Couple Satisfaction and Depression: is Mentalization a Protective Factor? (In
review)

Satisfacción de Pareja y Depresión: ¿Es la Mentalización un Factor Protector?

Couple Satisfaction and Depression: is Mentalization a Protective Factor?

Título corrido: Depresión, mentalización y relación de pareja

Autores: María José León*, Marcia Olhaberry**, Cristóbal Hernández**, Catalina

Sieverson*.

Afiliación Institucional: *Universidad de Chile, Facultad de Medicina, **Pontificia

Universidad Católica de Chile, Escuela de Psicología.

232
 En el marco del bienestar y la salud mental familiar, la relación entre

satisfacción de pareja y sintomatología depresiva ha sido bien documentada.

Una segunda generación de estudios se ha focalizado en encontrar variables

que modulen esta relación. En este contexto, el rol de la función reflexiva, en

la relación entre estas dos variables, no ha sido estudiado. El presente

estudio, analizó el efecto moderador de la función reflexiva (RF

Scale) sobre la relación entre la satisfacción de pareja (RAS) y

la sintomatología depresiva (BDI) en 50 parejas con hijos menores de 3

años. Los resultados muestran un efecto de moderación de la función

reflexiva en la relación entre satisfacción de pareja y sintomatología

depresiva. Padres y madres con alta satisfacción de pareja presentan baja

sintomatología depresiva independientemente de su nivel de función

reflexiva, pero aquellos con baja satisfacción de pareja y alta función

reflexiva presentan altos niveles de sintomatología depresiva. Se discuten las

implicancias clínicas de estos resultados.

Palabras claves: mentalización, función reflexiva, satisfacción de pareja,

depresión.

Regarding family wellbeing and mental health, relationship between couple

satisfaction and depressive symptoms has been well documented. A second

generation of studies has been focused on those variables that modulate this

relationship. This study analyzed the reflective functioning’s (RF Scale) moderator

role in the relation between couple satisfaction (RAS) and depressive symptoms

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 (BDI) in a sample of 50 couples with children under 3 years old. Fathers and

mothers with a higher couple satisfaction showed lower depressive

symptomatology, regardless their level of reflective functioning. Although those

with lower couple satisfaction and higher reflective function showed higher levels

of depressive symptoms. Clinical implications are discussed.

Key words: mentalization, reflective function, couple satisfaction, depression.

En el marco del bienestar y la salud mental familiar, las investigaciones actuales han

demostrado consistentemente cómo los síntomas depresivos de un miembro de la pareja

afectan la satisfacción en la relación, la salud mental y el bienestar del otro, y cómo se

constituyen en un factor de riesgo para la salud mental de los hijos (Davies, Coe, Martin,

Sturge-Apple, & Cummings, 2015; Tissot, Favez, Ghisletta, Frascarolo, & Despland,

2016).

La asociación entre satisfacción de pareja y síntomas depresivos ha sido estudiada y

documentada (Beach, 2001; Fincham, Beach, Harold, & Osborne, 1997), existiendo una

segunda generación de investigaciones focalizadas en identificar variables intervinientes

que podrían modificar esta relación (Beach, 2001). En esta línea, el estudio de los

mecanismos subyacentes a la relación entre satisfacción de pareja y depresión ha cobrado

mayor importancia, analizando algunas investigaciones la influencia del género y el

neuroticismo (Davila, Karney, Hall, & Bradbury, 2003), del nivel de conflicto marital y el

tiempo de relación (Kouros, Papp, & Cummings, 2008), así como del estilo de apego y el

estilo de comunicación (Heene, Buysse, & Van Oost, 2007).

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 En este contexto, la mentalización o función reflexiva, es uno de los constructos

relevantes en la construcción de interacciones sociales y de pareja, y su rol en la relación

entre satisfacción pareja y depresión aún no ha sido estudiado (Fonagy, Gergely, Jurist, &

Target, 2004). La función reflexiva se define como la capacidad de interpretar los

comportamientos propios y de otros a la luz de estados mentales. Esto implica reconocer

conscientemente que las experiencias dan lugar a creencias y emociones, y que éstas junto a

los deseos, dan origen a ciertos tipos de comportamiento (Fonagy et al., 2004). Diferentes

investigaciones han demostrado también el rol influyente de la función reflexiva, ya sea

como moderador o mediador, en la relación entre distintas variables, por ejemplo: entre el

estilo de apego de la madre y el estilo de apego del hijo (Slade, Grienenberger, Bernbach,

Levy, Locker, 2005), entre los síntomas depresivos de la madre y las comportamientos

parentales (Wong, 2012), entre las experiencias de maltrato en la infancia de los padres y el

estilo de apego adolescente (Borelli, Compare, Snavely, & Decio, 2015), entre otros.

Por su parte, la sintomatología depresiva se ha vinculado a dificultades en la capacidad

de mentalizar, interfiriendo en la habilidad para hacer inferencias respecto a la afectividad

de sí mismo y del otro. Esto ocurre a partir de la distorsión que provocan los estados

emocionales propios de la depresión, los que tiñen la experiencia y generan un mayor foco

en la propia vivencia que en la de los otros miembros de la familia (Belvederi et al., 2016;

Fischer-Kern et al., 2013; Ladegaard et al., 2014; Mattern et al., 2015; Sethna, Murray, &

Ramchandani, 2012; Uekermann et al., 2008). Sin embargo, esta relación varía y depende

de la severidad y cronicidad de los síntomas; cuando la sintomatología depresiva es baja o

moderada no se relacionaría con la función reflexiva (Turner, Wittkowski, & Hare, 2008).

No obstante, la relación entre la función reflexiva y satisfacción de pareja, no ha sido

estudiada, como tampoco el rol de la función reflexiva en la relación entre estas dos

235
variables. Es así, como este estudio busca responder una pregunta que aún se encuentra

abierta, explorando el rol de la función reflexiva en la relación entre satisfacción de pareja y

síntomas depresivos en parejas con hijos en edad temprana.

Tanto desde un punto de vista teórico como empírico se concibe que la satisfacción en

la relación de pareja es una de las variables que juega un rol importante en la calidad del

funcionamiento familiar (Shapiro, Gottman & Carrère, 2000). En relación a las etapas del

ciclo vital, la literatura científica muestra que la satisfacción de la pareja puede disminuir

significativamente con el nacimiento de los hijos y durante los primeros años de crianza

(Castellano, Velotti, Crowell, & Zavattini, 2014; Christopher, Umemura, Mann, Jacobvitz,

& Hazen, 2015). En este sentido, el nacimiento de un hijo puede gatillar una crisis al

interior de la pareja, debido a la necesidad de reorganizar la relación, el funcionamiento

familiar y el espacio personal a partir de su llegada, quedando en un segundo plano las

necesidades personales y de la pareja (Cox, & Paley, 2003; Favez et al., 2012).

Adicionalmente, estudios reportan consistentemente las altas tasas de prevalencia de

depresión en edad fértil y posterior al nacimiento de un hijo. En efecto, las tasas de

depresión reportadas entre el 2009-2010 en Chile, muestran que un 27,9% de mujeres y un

11% de hombres entre 25 y 44 años presenta sintomatología depresiva (Ministerio de Salud

[MINSAL], 2011) y que la sintomatología depresiva posterior al nacimiento de un hijo

afecta alrededor del 40% de las mujeres (Minsal, 2013) y a un 10,4% de los hombres

(Paulson & Bazemore, 2010).

En los hombres la depresión ha sido menos estudiada que en las mujeres, sin embargo,

los estudios muestran que la sintomatología depresiva posterior al nacimiento de un hijo

causa efectos adversos en ellos, en la salud mental de la mujer y también en la satisfacción

de pareja (Bielawska-Batorowicz & Kossakowska-Petrycka, 2006; Goodman, 2008;

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Paulson & Bazemore, 2010; Wee, Skouteris, Pier, Richardson & Milgrom, 2011). En

estrecha relación con la satisfacción de pareja, la presencia de sintomatología depresiva

además aumenta el nivel de conflicto parental y disminuye el soporte y apoyo entre ambos

miembros (Tissot, Favez, Ghisletta, Frascarolo, & Despland, 2016).

En relación a las trayectorias de la satisfacción de pareja y la sintomatología depresiva,

los estudios muestran diferencias según sexo. Fincham y colaboradores (1997) encontraron

que para los hombres las trayectorias causales emergen desde la depresión hacia la

satisfacción marital, mientras que para las mujeres las trayectorias causales fueron inversas,

desde la satisfacción hacia la depresión. En relación a los efectos cruzados entre hombres y

mujeres, algunos estudios muestran que la depresión en las mujeres predice un descenso en

la satisfacción marital en los hombres (Faulkner, Davey, & Davey, 2005). En la misma

línea, Gabriel y colaboradores (2010), encontraron que la satisfacción marital y los

síntomas depresivos dependen del sexo, sugiriendo la necesidad de generar modelos de

análisis e intervención que sean sensibles al sexo de los miembros de la pareja. Si bien los

estudios que revisan la satisfacción de pareja y la sintomatología depresiva reportan

diferencias según el sexo, los pocos estudios que han analizan la función reflexiva en

hombres y mujeres, muestran que los promedios en esta variable son semejantes (Borelli, St

John, Cho, & Suchman, 2016; Fonagy, Steele, Steele, Moran y Higgit, 1991). Esto podría

explicarse considerando que la función reflexiva es una capacidad más estable que la

satisfacción de pareja y la sintomatología depresiva y que constituye un mecanismo interno

que está a la base de otros proceso psicológicos como la regulación del afecto y el

establecimiento de relaciones sociales productivas (Fonagy et al., 2004; Slade, 2005).

Otro aspecto relevante en la satisfacción de pareja es el manejo de conflictos,

mostrando la literatura que su presencia no resulta necesariamente destructiva, sino que lo

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potencialmente destructor son los patrones relacionales disfuncionales (Tapia, 2009).

Gottman (1999) describió que aquellas parejas que referían satisfacción en su relación eran

aquellas capaces de discriminar qué dificultades podían ser efectivamente resueltas y que,

además, eran capaces de desarrollar diálogos respetuosos y emocionalmente afectuosos al

referirse a sus problemas recurrentes. De esta manera, es posible pensar que la presencia de

un funcionamiento reflexivo, que facilita el diálogo a partir de la compresión de si mismo y

del otro, podría favorecer el enfrentamiento adecuado de los conflictos y las emociones

negativas (Benbassat & Priel, 2012), contribuyendo también a identificar las circunstancias

que facilitan o dificultan la relación de pareja y la crianza (Benbassat & Priel, 2015).

La función reflexiva ha sido estudiada principalmente en madres y escasamente en

padres, no existiendo literatura científica que evalúe su relación con la satisfacción de

pareja. Como se mencionó anteriormente, los vínculos que esboza la literatura son

indirectos y fundamentalmente enfocados en el estudio de la función reflexiva y el

desarrollo infantil, la salud mental y el funcionamiento parental. Sin embargo, a partir de la

definición del constructo y de investigaciones realizadas entre padres/madres e hijos, es

posible hipotetizar una asociación entre la función reflexiva y la satisfacción de pareja,

requiriéndose evidencia empírica para el testeo de este planteamiento.

A partir de los antecedentes anteriormente expuestos, el objetivo de este estudio es

evaluar la relación que se establece entre la satisfacción de pareja, la sintomatología

depresiva y el nivel de función reflexiva de parejas con hijos entre 12 a 36 meses.

Considerando los hallazgos de estudios anteriores, (1) se evaluará el rol moderador del sexo

entre la satisfacción de pareja y la sintomatología depresiva, (2) y se evaluará también el rol

moderador de la función reflexiva en la relación entre la satisfacción de pareja y la

sintomatología depresiva. Se espera una asociación negativa entre la sintomatología

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depresiva y el nivel de satisfacción de pareja. Se espera que el sexo cumpla un rol

moderador entre la satisfacción de pareja y la sintomatología depresiva. Se hipotetiza que la

función reflexiva cumplirá un rol moderador entre la satisfacción de pareja y la

sintomatología depresiva.

Método

Participantes

La población de este estudio fueron 50 hombres y 50 mujeres, en relación de pareja actual,

con hijos y hijas en edad temprana, contactados a través de servicios de salud. Las parejas

participantes residían en 21 comunas de la región Metropolitana.

El muestreo fue intencionado y los criterios de inclusión considerados en el estudio

fueron los siguientes: ser mayores de 18 años, en relación de pareja actual, con al menos un

hijo entre 12 y 36 meses de edad con alguna de las siguientes dificultades socioemocionales:

dificultad en la regulación conductual, emocional, dificultades en la regulación del sueño, llanto

y/o la alimentación, dificultades en la relación con uno o ambos padres, evaluadas inicialmente

por los servicios de salud derivantes. Posteriormente las dificultades socio-emocionales fueron

evaluadas a través del cuestionario de auto-reporte para cuidadores ASQ-SE (Squires, Bricker,

& Twombly, 2002) con la plantilla correspondiente a la edad de cada niño.

Los criterios de exclusión fueron presencia de discapacidad intelectual, psicosis o daño

orgánico, presencia de dependencia o abuso de sustancias en los adultos, familias que presenten

abuso sexual y/o violencia física infantil actual; y enfermedades médicas en el niño que

expliquen sus dificultades socioemocionales, evaluadas por los servicios de salud derivantes.

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Instrumentos

Ficha de antecedentes para caracterizar sociodemográficamente al grupo familiar. Este

instrumento contiene preguntas breves orientadas a obtener información sociodemográfica:

nivel educacional, actividad actual y número de hijos. También incluye preguntas sobre el

historial de tratamientos psicológicos y psiquiátricos.

Evaluación de la Función Reflexiva en Parent Development Interview – Revised Short

Version (PDI-R; Slade, Aber, Berger, Bresgi, & Kaplan, 2012). Es una entrevista semi-

estructurada individual dirigida a padres y madres de niños entre 3 meses y 14 años, que evalúa

narrativas derivadas de la relación actual y específica con un hijo. Las preguntas tratan sobre la

descripción que el padre/madre hace de su hijo, respecto a la relación padre/madre-hijo, sobre

la descripción como padre/madre, y preguntas respecto sobre cómo las propias experiencias

con sus padres impactan en su forma actual de ser padre/madre. La entrevista tiene una

duración aproximada de una hora, es grabada en audio para luego transcribirse completamente

y ser posteriormente analizada y codificada. Contiene 29 preguntas, 15 de ellas de demanda y

14 de permiso. Las preguntas de demanda, en comparación a las de permiso, son aquellas que

explícitamente demandan el uso de la función reflexiva y son aquellas que se codifican para

evaluar esta competencia (Fonagy, Steele, Steele & Target, 1998).

Las entrevistas en parentalidad son codificadas con el Adeendum Reflective Functioning

Scale (RF Scale; Fonagy et al., 1998) para el uso en la Parent Development Interview (Slade,

Bernbach, Grienenberger, Levy, & Locker, 2005). Éste consiste en un manual desarrollado para

la codificación de la función reflexiva específicamente para la Parent Development Interview

(Slade et al., 2012). La escala consta de 11 puntos que van del -1 (función reflexiva negativa) al

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9 (función reflexiva completa o excepcional). Puntajes bajo 3 indican una pobre capacidad

reflexiva, es decir, en su discurso predomina el escaso uso de estados mentales, o evitación de

ellos, en ocasiones con narrativas egocéntricas o con muestras de distorsión. Puntajes entre 3 y

4 puntos muestran un nivel bajo de funcionamiento reflexivo, es decir, existe presencia de

estados mentales en la narrativa, pero con una baja capacidad reflexiva, mientras que puntajes

sobre 5 muestran una clara y evidente capacidad de reflexionar sobre estados mentales (Slade et

al., 2005).

Dos codificadores ciegos al resultado de los participantes en las demás variables de estudio,

entrenados y certificados como confiables, codificaron el 25% de las entrevistas en conjunto.

Se evaluó el coeficiente de Kappa y el coeficiente de correlación de interclase (CCI) para

calcular la confiabilidad interjueces, mostrando ambos buenos puntajes κ=.76, p < .0001,

ICC=.89.

Relationship Assessment Scale (RAS; Hendrick, 1988). Para evaluar satisfacción global

con la relación de pareja. Es un cuestionario de auto-reporte que consta de siete ítems evaluados

en una escala Likert de 5 puntos, desde 1 (no me representa para nada) a 5 (me representa

totalmente). A mayor puntaje, mayor satisfacción en la relación de pareja. Estudios chilenos

reportan un alpha de Cronbach de 0,71 para este instrumento (Rivera, Cruz y Muñoz, 2011), y

en el presente estudio se obtuvo un valor alpha de cronbach de 0,92.

Inventario Para la Depresión de Beck (BDI; Beck, Ward, Mendelson, Mock &

Erbaugh, 1961). Para evaluar sintomatología depresiva en los adultos. Es un cuestionario de

auto-reporte que consta de 21 ítems con puntajes teóricos que varían entre 0 y 63 y se definen

cuatro categorías de depresión: mínima o no deprimida (0-9 puntos), leve (10-18), moderada

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(19-29) y severa (30-63). Cada ítem ofrece cuatro opciones de respuesta con puntajes entre 0

(ej: no me siento triste) y 3 (ej: ya no puedo soportar esta pena). En la versión chilena,

actualmente en proceso de validación, se reporta un coeficiente alpha de Cronbach de 0,86 en

población clínica (Morales-Reyes, Valdés, Pérez, Medellín & Dagnino, 2015). En el presente

estudio se obtuvieron valores de alpha de Cronbach de 0,84.

Procedimiento

Este estudio utiliza una metodología cuantitativa, de diseño no experimental, transversal y

correlacional. El estudio cuenta con certificación de los comités de ética institucionales de la

Pontificia Universidad Católica de Chile, Universidad de Chile y de la Comisión Nacional de

Investigación Científica y Tecnológica. Las mediciones fueron realizadas entre los años 2015 y

2016 por psicólogos que participaron exclusivamente en la investigación y evaluaron de

manera individual a los participantes con los instrumentos mencionados.

Los participantes fueron derivados por profesionales de centros de salud, con atención

directa a niños entre 12 y 36 meses y sus padres. El derivante, médico o psicólogo en su

mayoría, al pesquisar alguna dificultad socio-emocional en el niño les explica al padre o a la

madre la existencia de un proyecto de investigación de la Pontificia Universidad Católica de

Chile, el cual evalúa y entrega apoyo psicológico para familias con hijos entre 12 a 36

meses de edad, invitándoles a ser contactados para ser invitados a participar del proyecto.

Luego de la derivación, los participantes son contactados telefónicamente por la coordinadora

del proyecto de investigación, quien les explica en detalle el estudio, en caso de acceder a

participar, se coordina la sesión de evaluación, la cual pueden ser en el domicilio o en

dependencias de la Escuela de Psicología de la Pontificia Universidad Católica de Chile,

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realizándose la mayoría en los domicilios de las familias. De las 58 parejas que accedieron a

participar, 8 de ellas desertaron del estudio.

La evaluación es realizada por un psicólogo clínico, quien lidera la evaluación,

acompañado de un estudiante de psicología. Los participantes comienzan la evaluación con la

lectura y firma de una carta de consentimiento informado en la cual se explicita el objetivo del

estudio, sus beneficios (de apoyo psicológico, no se entrega beneficio económico) y riesgos, la

confidencialidad en el manejo de los datos obtenidos y la voluntariedad de su participación. En

este sentido, se explicitó a los participantes su libertad para dejar el estudio en cualquier

momento, sin que esto afecte en nada la atención recibida en el centro de salud al que

regularmente asisten. Posteriormente se completa la ficha de antecedentes sociodemográficos,

luego responden a los cuestionarios (BDI, RAS) y finalmente se lleva a cabo la entrevista

individual a cada padre (PDI-R), la cual es grabada en audio, para luego ser transcrita y

codificada.

Al finalizar la evaluación, se le entrega a la familia una retroalimentación de la

evaluación realizada e información psicoeducativa respecto a las dificultades que presentan

como padres y su hijo (por ejemplo: manejo respetuoso de las pataletas, destete, entre

otros). Sumado a lo anterior, la totalidad de las familias participantes en este estudio

recibieron una intervención breve utilizando video-feedback orientada a mejorar la calidad

de las relaciones familiares y el desarrollo infantil.

Análisis de datos

Los análisis se realizaron utilizando el software estadístico R (Development Core Team,

2008).

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 En primer lugar, las parejas estudiadas fueron caracterizadas en función de sus

antecedentes sociodemográficos, y posteriormente de acuerdo de su función reflexiva,

satisfacción de pareja y sintomatología depresiva. Luego, se estimó una matriz de

correlación para evaluar las inter-relaciones entre las variables de interés, tanto para padres

como para madres.

Posteriormente se procedió a realizar un modelo de regresión multi-nivel para dar

cuenta de la naturaleza anidada de los datos en parejas (Kenny, Kashy & Cook, 2006)

utilizando el paquete “nlme” (Pinheiro, Bates, DebRoy, Sarkar & R Core Team, 2017) de

modelos lineales y no lineales mixtos para el software estadístico R. En primer lugar, se

realizó un modelo nulo (sin predictores) para evaluar el grado en que la variabilidad de la

sintomatología depresiva de los participantes es explicada por su pertenencia a la pareja.

Dicho modelo permitió apreciar que un 13.2% de la variabilidad de la sintomatología

depresiva es explicada por la pareja (ICC: 0.132), lo que justifica la utilización de un

modelo multi-nivel para así evitar la probabilidad de error tipo I asociada a ignorar la

dependencia de los datos al grupo.

Resultados

En relación a los análisis descriptivos realizados de los antecedentes sociodemográficos

de la población estudiada, las mujeres se encontraban en un rango de edad entre 20 y 43

años de edad (M = 31,52, DE = 4,84) y los hombres entre 22 y 49 años de edad (M = 33,58,

DE = 5,83). El promedio de hijos de las mujeres fue M= 1,72 (DE= 0,86) y de los hombres

M= 1,57 (DE= 0.71), teniendo como mínimo un hijo y máximo 4 y habiendo algunos

miembros de las parejas que tenían hijos de relaciones anteriores. Un 69,6% de las parejas

se encontraba criando a su primer hijo.

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 El nivel de educación de los hombres (M = 15,18, DE = 2,43) y de las mujeres (M =

15,16, DE = 2,39) era alto, 37 mujeres y 41 hombres tenían un título técnico o universitario,

y 39 mujeres y 49 hombres tenían un trabajo remunerado actual. Respecto de la proporción

de tratamiento psicológico actual, 10% de las mujeres y el 6% de los hombres se

encontraba en tratamiento psicológico al momento de la evaluación.

Análisis Descriptivos de la Función Reflexiva, la Satisfacción de Pareja y la

Sintomatología Depresiva

En primer lugar se evaluó la existencia de una diferencia significativa en las medias

entre madres y padres en satisfacción de pareja (madres M= 29,96, DE=4,84, padres

M=30,24, DE= 5.94, t(df=98)=-,297, p=,767) sintomatología depresiva (madres M= 7,4,

DE=6,06, padres M=5,36, DE= 5.94, t(df=98)=1,70, p=,092) y función reflexiva (madres

M= 3,64, DE=1,12, padres M=3,56, DE= 1,11, t(df=98)=,445, p=,657), los resultados

mostraron que no existen diferencias estadísticamente significativas en las variables

estudiadas entre padres y madres.

En relación a la sintomatología depresiva se observa que el 66% de las mujeres y el

78% de los hombres presenta sintomatología mínima o no deprimida/o, el 32% de las

mujeres y el 20% de los hombres presentan sintomatología leve y el 2% de las mujeres y el

2% de los hombres presentan síntomas moderados a severos.

En relación a la función reflexiva, se observa que el 24% de las madres y el 18% de los

padres presentan una clara y evidente capacidad de reflexionar sobre estados mentales. La

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mayor cantidad de parejas (64% madres y 68% padres) muestran presencia de estados

mentales en sus narrativas, pero con una baja capacidad reflexiva, finalmente el 12% de las

madres y el 14% de los padres presenta un nivel pobre de funcionamiento reflexivo, sin

mostar conciencia de los estados mentales.

Análisis correlacionales

En primer lugar se realizó una correlación entre las variables de estudio y las variables

sociodemográficas (sexo, edad, años de educación, número de hijos, tener trabajo actual

remunerado y tener tratamiento psicológico actual) y sólo se encontró una relación

estadísticamente? significativa entre función reflexiva y años de educación, por lo que se

consideró como variable control en los análisis posteriores. En relación a las principales

variables del estudio, es posible observar una correlación estadísticamente? significativa

entre la satisfacción de pareja y la sintomatología depresiva (ver tabla 1).

[Insertar tabla 1 aprox. aquí]

Para evaluar la influencia de la satisfacción de pareja y la función reflexiva en la

sintomatología depresiva de las parejas se realizó un modelo de regresión multinivel con un

estimador REML (Restricted Maximum Likelihood) dado que ofrece estimados de varianza

más precisos para muestras pequeñas (Peugh, 2010). Para favorecer la interpretación de los

datos y evitar los problemas de colinealidad se centraron todos los predictores sobre su gran

media (Shieh, 2011) y no sobre la media del grupo para así evitar eliminar la variabilidad

aportada por la pareja (Kenny, Kashy & Cook, 2006, Campbell & Kashy, 2002). Por otro

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lado, dado que los residuos del modelo no se distribuyeron normalmente se transformó la

variable dependiente, que presentaba una asimetría positiva en base al logaritmo natural,

para así asegurar una estimación más robusta. Con el objetivo de obtener estimados

estandarizados, todas las variables fueron transformadas a puntaje Z. Las variables

agregadas al nivel 1 son el sexo (-0.5 mujer, 0.5 hombre), años de escolaridad del

participante como variable de control, satisfacción con la relación de pareja y FR.

Siguiendo la notación de Preacher, Curran & Bauer (2006) para los efectos de interacción,

se tomó como predictor focal la satisfacción de pareja, cuya relación con la sintomatología

depresiva fue moderada por el sexo, por un lado, y la función reflexiva, por el otro. Al

tratarse de datos diádicos (dos unidades por grupo), se dejó variar únicamente el intercepto

según la variable de nivel 2 (pareja), ya que es necesario tener más unidades por grupo que

efectos aleatorios en el modelo (Kenny, Kashy & Cook, 2006).

El modelo propuesto puede resumirse en la ecuación de nivel 1:

BDI$% = β(% + β*% +,-. + β/% 0ñ.2 4, ,25.6789474 + β:% +7;92<7559ó> 4, ?78,@7

+ βA% BC>59ó> D,<6,-9E7 + βF% +7;92<7559ó> 4, ?78,@7 - +,-.

+ βG% +7;92<7559ó> 4, ?78,@7 - BC>59.> D,<6,-9E7 + r$%

Y en la siguiente ecuación de nivel 2:

β(% = γ(( + µ(%

Es posible observar en la tabla 2 que, ajustando por variabilidad aportada por la variable

de nivel 2, la satisfacción de pareja es un predictor significativo y negativo de la

247
sintomatología depresiva (b=-0,552, t(44)=-6,186, p<0,001), mientras que el sexo (b=-

0.161, t(44)=-1.954, p>0.05, los años de escolaridad (b=-.000, t(44)-0.002, p>0.05) y la

función reflexiva (b=0.101, t(44)=1.108, p>0.05) no lo fueron.

[Insertar tabla 2 aprox. aquí]

Sin embargo, fue posible observar un efecto de moderación del sexo sobre la relación

entre la satisfacción de pareja y la sintomatología depresiva (b=-0.197, t(44)=-2.320,

p<0.05), donde a menores niveles de satisfacción, las madres presentaron menores niveles

de sintomatología depresiva que los hombres, aun cuando los padres presentaron una menor

sintomatología que las mujeres.

Por otro lado, fue posible observar que la función reflexiva ejerció un efecto de

moderación en la relación entre la satisfacción de pareja y la sintomatología depresiva, en

donde padres y madres con una baja función reflexiva, con alta y baja satisfacción con su

pareja presentaron una similar sintomatología depresiva. Mientras que en el caso de una

alta función reflexiva, aquellas personas con una baja satisfacción con la pareja presentaron

altos niveles de sintomatología depresiva y aquellas con una alta satisfacción con la pareja

presentaron bajos niveles de síntomas (figura 1). Dichos efectos de interacción fueron

graficados utilizando el paquete sjPlot (Lüdecke, 2017) para el software estadístico R.

Para modelos multi-nivel es posible contar con dos estimados de varianza explicada, R2

marginal que describe la varianza explicada por los efectos fijos y un R2 condicional que

describe la varianza explicada por los efectos fijos y aleatorios en su conjunto (Nakagawa

& Schieltzeth, 2013), los que fueron calculados utilizando el paquete “piecewiseSEM”

(Lefcheck, 2015) para R que contiene una función para estimar aquellos valores en modelos

lineales mixtos y modelos lineales mixtos generalizados. Se observó entonces que los

248
efectos fijos por sí solos explicaron un 35% de la varianza de la sintomatología depresiva

(R2GLMM(m)=0.349) mientras que los efectos fijos y aleatorios en su conjunto explicaron un

40% de la varianza de la misma (R2GLMM(c)=0.0.396).

[Insertar figura 1 aprox. aquí]

Discusión

Este estudio provee evidencia respecto a la relación entre la satisfacción de pareja, la

función reflexiva y la sintomatología depresiva en madres y padres con hijos pequeños,

variables que hasta la fecha no han sido estudiadas en conjunto, pese a su relevancia para

comprender el desarrollo personal, familiar y la salud mental de parejas en etapas iniciales

de la crianza infantil.

En primer lugar, respecto a los resultados descriptivos es interesante rescatar que los

promedios en función reflexiva son más bajos que los resultados obtenidos en

investigaciones internacionales (Ensink et al., 2016; Slade et al., 2005). Los promedios en

hombres y mujeres muestran que sus relatos se caracterizan por presentar estados mentales

(tales como “feliz”, “seguro”, “triste”, “confiado”, etc), pero sin una evidente capacidad de

reflexionar en torno a ellos. Esto es relevante debido a que la literatura presenta que niveles

más altos de función reflexiva se relacionan con un estilo de apego seguro y por el

contrario, niveles más bajos, se vinculan con experiencias de trauma sin resolver y patrones

de apego inseguro (Borelli et al., 2015; Ensink et al., 2016).

En relación a la satisfacción de pareja los promedios son semejantes al de otras

poblaciones (Dinkel, & Balck, 2005), los cuales parece representar un nivel moderado a

alto de satisfacción de pareja. Y en cuanto a la sintomatología depresiva, padres y madres

249
muestran bajos niveles de depresión, con puntajes levemente mayores en las madres, lo que

podría explicarse a partir de la robusta literatura que señala la mayor prevalencia de

depresión en mujeres, especialmente en edad fértil (MINSAL 2011, 2013; Paulson &

Bazemore, 2010).

Respecto a las hipótesis planteadas en este estudio, tal como se esperaba, los resultados

confirman que la satisfacción de pareja constituye un predictor significativo para la

depresión, encontrándose que padres y madres menos satisfechos con su relación presentan

una mayor sintomatología depresiva. Este resultado es consistente con los hallazgos

reportados en investigaciones anteriores que dan cuenta de la relación entre estas variables

(Beach, 2001; Fincham, Beach, Harold, & Osborne, 1997) y su impacto en la salud mental

de la pareja y los hijos (Davies, Coe, Martin, Sturge-Apple, & Cummings, 2015; Tissot,

Favez, Ghisletta, Frascarolo, & Despland, 2016). En este sentido, los hallazgos de este

estudio reafirman el valor de incorporar la variable satisfacción de pareja en los procesos de

diagnóstico e intervención en padres y madres con hijos menores de 3 años, ya que entrega

información relevante sobre el subsistema de pareja, no detectada a partir otras variables

individuales.

Adicionalmente, el modelo mostró también un efecto de moderación del sexo sobre la

relación entre la satisfacción con la pareja y la sintomatología depresiva, donde a menores

niveles de satisfacción, las madres presentaron menor sintomatología depresiva que los

padres. Esto muestra que la baja satisfacción con la relación de pareja se asocia a mayores

síntomas depresivos en los hombres que en las mujeres, confirmando la hipótesis de

moderación del sexo y a su vez evidenciando la necesidad de desarrollar modelos

comprensivos que integren las diferencias según el sexo en esta variable, tanto para los

diagnósticos como para la implementación de intervenciones psicoterapéuticas. Estos

250
resultados se alinean con los planteamientos de Gabriel, Beach & Bodemann (2010)

quienes destacan la necesidad de generar modelos de análisis e intervención que consideren

y sean sensibles al sexo de los miembros de la pareja.

En relación a la principal hipótesis de este estudio, los resultados también la confirman,

mostrando que la función reflexiva cumple un rol moderador en la relación entre

satisfacción de pareja y depresión. Específicamente los resultados muestran que aquellas

personas con alta satisfacción de pareja presentan bajos niveles de sintomatología

depresiva, independiente de sus niveles de función reflexiva, y aquellas que presentan baja

satisfacción de pareja y una alta función reflexiva, presentan mayores niveles de depresión

que quienes tienen una baja función reflexiva.

Estos resultados podrían explicarse considerando que una mayor función reflexiva

podría implicar, mayores capacidades para la auto-observación y la identificación del

propio malestar y sufrimiento, por lo que sería esperable que sujetos con una mayor función

mentalizante pudieran registrar y reportar una mayor insatisfacción de pareja y una mayor

sintomatología depresiva en escalas de auto-reporte, si es que efectivamente esto

corresponde con su vivencia actual. En este sentido, esto reflejaría sus recursos en relación

a la capacidad de reconocer los propios conflictos e identificar el malestar que estos

generan. Sin embargo, la adecuada función reflexiva no tendría necesariamente una

relación lineal con el bienestar subjetivo y con la satisfacción de pareja pudiendo, muchas

veces, el malestar o el conflicto con la relación de pareja, dar cuenta de procesos

individuales de reconocimiento, elaboración, madurez y crecimiento propios de una

adecuada función mentalizante. Adicionalmente, una adecuada capacidad para reconocer

los conflictos no implica necesariamente el contar con una adecuada manera de resolverlos,

lo que podría explicar la presencia de un alto funcionamiento reflexivo en padres y madres

251
que se encuentran insatisfechos con su relación y que presentan además sintomatología

depresiva. Los resultados muestran también, que una adecuada función reflexiva no es un

factor protector directo para la depresión, sino que favorece la capacidad de reconocer la

propia subjetividad, la del otro y la mutua influencia, lo que no necesariamente reduce los

síntomas.

Sumado a lo anterior, 69,6% de los participantes son madres y padres de su primer

hijo, por lo que enfrentan experiencias nuevas y cambios profundos asociados al ajuste de

pareja, a la necesidad de incorporar nuevos roles y a los cambios en la identidad que este

nuevo escenario implica. En este sentido, más allá de su funcionamiento reflexivo, estos

cambios podrían incrementar la insatisfacción con la relación y también la depresión.

Respecto a las implicancias clínicas del estudio desarrollado, resulta relevante

mencionar la importancia de incluir en los diagnósticos y las intervenciones variables

asociadas a la diada parental, como la satisfacción de pareja, especialmente en la

comprensión de la sintomatología depresiva en el contexto de la parentalidad temprana. Un

gran número de investigaciones focalizadas en este período, han estudiado la

sintomatología depresiva en padres y madres, por sus efectos negativos en el desarrollo y la

salud mental familiar e infantil, pero muy pocos han incluido la satisfacción de pareja y las

diferencias entre padres y madres para comprenderla.

Sumado a lo anterior, incluir variables de mayor estabilidad, como la función reflexiva,

en la comprensión de la relación entre la satisfacción con la relación de pareja y los

síntomas depresivos permite distinguir elementos subyacentes a la sintomatología que

pueden constituir recursos para la intervención o dar cuenta de la necesidad de

intervenciones a largo plazo.

252
 En conclusión, este estudio reconfirma la estrecha relación que existe entre la

satisfacción de pareja y la sintomatología depresiva, demostrada consistentemente a lo

largo del tiempo y agrega en la comprensión de esta relación un aspecto de mayor

estabilidad en el funcionamiento y altamente asociado a la salud mental, como es la función

reflexiva.

En cuanto a futuros estudios que consideren estas variables, sería de gran valor clínico

realizar investigación preventiva, considerando parejas que aún no se han convertido en

padres. De esta forma se podrían abordar las dificultades en la relación y la sintomatología

clínica sin la exigencia y las demandas asociadas a la parentalidad. Esto permitiría una

mejor preparación en la pareja para la llegada de los hijos y el enfrentamiento de los

desafíos de la crianza, así como también reducir el impacto negativo de las tensiones

parentales y la depresión en el desarrollo y la salud mental infantil. Futuros estudios

podrían también incluir variables infantiles, lo que permitiría analizar la contribución de la

FR en el desarrollo y la salud mental del niño y testear la hipótesis comprensiva que se

propone para entender que explica que padres con baja satisfacción y alta función reflexiva

presenten alta sintomatología depresiva.

Dentro de las limitaciones del estudio, es importante destacar el moderado tamaño

muestral que lleva a tomar los resultados con cautela, ya que no permite una variabilidad

suficiente de participantes, que incluya un mayor número de casos con alta función

reflexiva y alta sintomatología depresiva. Por último constituye también una limitación el

que se trate de un estudio transversal, en donde probablemente el comportamiento de las

variables y su asociación podría ser diferente, como muestran algunas investigaciones que

consideran depresión parental (Tissot, Favez, Ghisletta, Frascarolo, & Despland, 2016).

253
Referencias

Beach, Steven R. H. (Ed). (2001). Marital and family processes in depression: A scientific

foundation for clinical practice, (pp. 3-24). Washington, DC, US: American

Psychological Association.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. & Erbaugh, J. (1961). An inventory for

measuring depression. Archives of General Psychiatry, 4, 561-571.

doi:10.1001/archpsyc.1961.01710120031004

Belvederi Murri, M., Ferrigno, G., Penati, S., Muzio, C., Piccinini, G., Innamorati, M., ... &

Amore, M. (2016). Mentalization and depressive symptoms in a clinical sample of

adolescents and young adults. Child and Adolescent Mental Health.

doi:10.1111/camh.12195

Benbassat, N., & Priel, B. (2012). Parenting and adolescent adjustment: The role of

parental reflective function. Journal of Adolescence, 35(1), 163–174. doi:

10.1016/j.adolescence.2011.03.004.

Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., ... &

Zule, W. (2003). Development and validation of a brief screening version of the

Childhood Trauma Questionnaire. Child Abuse & Geglect, 27(2), 169-190.

Bielawska-Batorowicz, E., & Kossakowska-Petrycka, K. (2006). Depressive mood in men

after the birth of their offspring in relation to a partner's depression, social support,

fathers' personality and prenatal expectations. Journal of Reproductive and Infant

Psychology, 24(1), 21-29. http://doi.org/10.1080/02646830500475179

Borelli, J. L., St John, H. K., Cho, E., & Suchman, N. E. (2016). Reflective functioning in

parents of school-aged children. The American journal of orthopsychiatry, 86(1), 24-36.

254
 doi: 10.1037/ort0000141

Borelli, J. L., Compare, A., Snavely, J. E., & Decio, V. (2015). Reflective functioning

moderates the association between perceptions of parental neglect and attachment in

adolescence. Psychoanalytic Psychology, 32(1), 23-35.

http://dx.doi.org/10.1037/a0037858

Campbell, L., & Kashy, D. A. (2002). Estimating Actor, Partner, and Interaction Effects for

Dyadic Data Using PROC MIXED and HLM: A User-Friendly Guide. Personal

Relationships, 9(3), 327–342. doi:10.1111/1475-6811.00023

Castellano, R., Velotti, P., Crowell, J. A., & Zavattini, G. C. (2014). The role of parents’

attachment configurations at childbirth on marital satisfaction and conflict strategies.

Journal of Child and Family Studies, 23(6), 1011-1026. doi: 10.1007/s10826-013-9757-

Chile, Ministerio de Salud (2011). Informe Encuesta Nacional de Salud, ENS 2009-2010.

Santiago, Chile: MINSAL.

Chile, Ministerio de Salud (2013). Guía clínica AUGE: depresión en personas de 15 años y

más (2a ed.). Santiago, Chile: Subsecretaría de Salud Pública.

Christopher, C., Umemura, T., Mann, T., Jacobvitz, D., & Hazen, N. (2015). Marital

quality over the transition to parenthood as a predictor of coparenting. Journal of Child

and Family Studies, 24(12), 3636-3651. doi: 10.1007/s10826-015-0172-0

Cox, M. J., & Paley, B. (2003). Understanding families as systems. Current Directions in

Psychological Science, 12, 193–196. doi:10.1111/1467-8721.01259.

Davies, P. T., Coe, J. L., Martin, M. J., Sturge-Apple, M. L., & Cummings, E. M. (2015).

The developmental costs and benefits of children’s involvement in interparental

255
 conflict. Developmental Psychology, 51(8), 1026. doi: 10.1037/dev0000024

Davila, J., Karney, B. R., Hall, T. W., & Bradbury, T. N. (2003). Depressive symptoms and

marital satisfaction: within-subject associations and the moderating effects of gender

and neuroticism. Journal of Family Psychology, 17(4), 557-570. doi: 10.1037/0893-

3200.17.4.557

• Faulkner, R. A., Davey, M., & Davey, A. (2005). Gender-related predictors of

change in marital satisfaction and marital conflict. The American Journal of Family

Therapy, 33(1), 61-83. http://dx.doi.org/10.1080/01926180590889211

Favez, N., Lopes, F., Bernard, M., Frascarolo, F., Lavanchy Scaiola, C., Corboz-Warnery,

A., & Fivaz-Depeursinge, E. (2012). The development of family alliance from

pregnancy to toddlerhood and child outcomes at 5 years. Family Process, 51(4), 542-

556. doi: 10.1111/j.1545-5300.2012.01419.x

Fincham, F. D., Beach, S. R., Harold, G. T., & Osborne, L. N. (1997). Marital satisfaction

and depression: Different causal relationships for men and women?. Psychological

Science, 8(5), 351-356. doi: https://doi.org/10.1111/j.1467-9280.1997.tb00424.x

Fischer-Kern, M., Fonagy, P., Kapusta, N. D., Luyten, P., Boss, S., Naderer, A., ... &

Leithner, K. (2013). Mentalizing in female inpatients with major depressive disorder.

The Journal of Nervous and Mental Disease, 201(3), 202-207. doi:

10.1097/NMD.0b013e3182845c0a

Fonagy, P., Gergely, G., & Target, M. (2007). The parent–infant dyad and the construction

of the subjective self. Journal of Child Psychology and Psychiatry, 48(3-4), 288–328.

http://doi:10.1111/j.1469- 7610.2007.01727.x

Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgitt, A. (1991). The capacity for

understanding mental states: The reflective self in parent and child and its significance

256
 for security of attachment. Infant Mental Health Journal, 12(3), 201 – 218.

http://dx.doi.org/10.1002/1097-0355(199123)12:3<201::AID-

IMHJ2280120307>3.0.CO;2-7

Fonagy, P., Gergely, G., Jurist, E. L. & Target, M. (Eds.). (2004). Affect Regulation,

Mentalization and the Development of the Self. Karnac books.

Fonagy, P., Steele, H., Steele, M., & Target, M. (1998). Reflective Functioning Manual,
Version 5.0, for Application to Adult Attachment Interviews. London: University
College London.
Gabriel, B., Beach, S. R., & Bodenmann, G. (2010). Depression, marital satisfaction and

communication in couples: Investigating gender differences. Behavior Therapy, 41(3),

306-316. doi: 10.1016/j.beth.2009.09.001.

Goodman, J. H. (2008). Influences of maternal postpartum depression on fathers and on

father–infant interaction. Infant Mental Health Journal, 29(6), 624–643. Doi:

http://dx.doi.org/10.1002/imhj.20199

Gottman, J. (1999). The Marriage Clinic. A Scientifically based marital therapy. New York,

NY: W. W Norton & Company Ltd.

Heene, E., Buysse, A., & Van Oost, P. (2007). An interpersonal perspective on depression:

The role of marital adjustment, conflict communication, attributions, and attachment

within a clinical sample. Family Process, 46(4), 499-514. doi: 10.1111/j.1545-

5300.2007.00228.x

Hendrick, S. (1988). A Generic Measure of Relationship Satisfaction. Journal of Marriage

and The Family, 50, 93-98. doi: 10.2307/352430

Kenny, D. A., Kashy, D.A., & Cook, W. L. (2006). Dyadic data analysis. New York:

Cambridge University.

257
Kouros, C. D., Papp, L. M., & Cummings, E. M. (2008). Interrelations and moderators of

longitudinal links between marital satisfaction and depressive symptoms among couples

in established relationships. Journal of family psychology: Jfp: journal of the Division

of Family Psychology of the American Psychological Association (division 43), 22(5),

667-677. 10.1037/0893-3200.22.5.667.

Ladegaard, N., Lysaker, P. H., Larsen, E. R., & Videbech, P. (2014). A comparison of

capacities for social cognition and metacognition in first episode and prolonged

depression. Psychiatry Research, 220(3), 883-889.

http://doi:10.1016/j.psychres.2014.10.005

Lefcheck, Jonathan S. (2015) piecewiseSEM: Piecewise structural equation modeling in R

for ecology, evolution, and systematics. Methods in Ecology and Evolution. 7(5): 573-

579.<doi:10.1111/2041-210X.12512>

Lüdecke D (2017). sjPlot: Data Visualization for Statistics in Social Science. R package

version 2.3.1, https://CRAN.R-project.org/package=sjPlot.

Mattern, M., Walter, H., Hentze, C., Schramm, E., Drost, S., Schoepf, D., ... & Schnell, K.

(2015). Behavioral Evidence for an Impairment of Affective Theory of Mind

Capabilities in Chronic Depression. Psychopathology, 48(4), 240-250.

http://doi:10.1159/000430450

Morales-Reyes, I., Valdés, C., Pérez, J. C., Medellín, A. & Dagnino, P. (2015). Propiedades

psicométricas del Inventario de Depresión de Beck para la población chilena.

Manuscrito en preparación.

Paulson, J.F., & Bazemore, S.D., (2010). Prenatal and postpartum depression in fathers and

its association with maternal depression: a meta-analysis. Journal of the American

Medical Association, 303(19), 1961-1969. http://dx.doi.org/10.1001/jama.2010.605

258
Peugh, J. L. (2010). A practical guide to multilevel modeling. Journal of School

Psychology, 48(1), 85–112. doi:10.1016/j.jsp.2009.09.002

Pinheiro J, Bates D, DebRoy S, Sarkar D and R Core Team (2017). nlme: Linear and

Nonlinear Mixed Effects Models. R package version 3.1-131, https://CRAN.R-

project.org/package=nlme.

Preacher, K. J., Curran, P. J., & Bauer, D. J. (2006). Computational Tools for Probing

Interactions in Multiple Linear Regression, Multilevel Modeling, and Latent Curve

Analysis. Journal of Educational and Behavioral Statistics, 31(4), 437–448.

doi:10.3102/10769986031004437

R Development Core Team (2008). R: A language and environment for statistical

computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-

07-0, URL http://www.R-project.org.

Rivera, D., Cruz, C., y Muñoz, C. (2011). Satisfacción en las Relaciones de Pareja en la

Adultez Emergente: El Rol del Apego, la Intimidad y la Depresión. Terapia

Psicológica, 29(1), 77-83. https://dx.doi.org/10.4067/S0718-48082011000100008

Rothschild-Yakar, L., Levy-Shiff, R., Fridman-Balaban, R., Gur, E., & Stein, D. (2010).

Mentalization and relationships with parents as predictors of eating disordered

behavior. The Journal of nervous and mental disease, 198(7), 501-507. doi:

10.1097/NMD.0b013e3181e526c8.

Sethna, V., Murray, L., & Ramchandani, P. G. (2012). Depressed fathers' speech to their 3-

month-old infants: a study of cognitive and mentalizing features in paternal speech.

Psychological Medicine, 42(11), 2361-2371. doi:10.1017/S0033291712000487

Shapiro, A.F., Gottman, J.M., & Carrère, S. (2000). The baby and the marriage: Identifying

factors that buffer against decline in marital satisfaction after the first baby arrives.

259
 Journal of Family Psychology, 14(1), 59-70. doi: 10.1037//0893-3200.14.1.59.

Shieh, G. (2011). Clarifying the role of mean centring in multicollinearity of interaction

effects. British Journal of Mathematical and Statistical Psychology, 64(3), 462–477.

doi:10.1111/j.2044-8317.2010.02002.x

Slade, A., Aber, J. L., Berger, B., Bresgi, I., & Kaplan, M. (2012). The parent development

interview–revised, short version. Unpublished protocol.

Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal

reflective functioning, attachment, and the transmission gap: A preliminary study.

Attachment & Human Development, 7(3), 283–298. doi:10.1080/14616730500245880

Slade, A., Bernbach, E., Grienenberger, J., Levy, D., & Locker, A. (2005). Addendum to

Fonagy, Target, Steele, & Steele reflective functioning scoring manual for use with the

Parent Development Interview. Unpublished Manuscript. New York, NY: The City

College and Graduate Center of the City University of New York.

Squires, J., Bricker, D. & Twombly, E. (2002). Ages & Stages Questionnaires: Social-

Emotional: A Parent-Completed Child-Monitoring System for Social-Emotional

Behaviors. Baltimore, Md.:Paul H.Brookes.

Tapia, L., Poulsen, G., Armijo, I., Pereira, X. y Sotomayor, P. (2009). Resolución de

entrampes en parejas en conflicto: aproximaciones desde las parejas y los terapeutas.

Revista Argentina de Clínica Psicológica, 18(2), 101- 114.

http://dx.doi.org/10.4067/S0717-92272014000100006

Taubner, S., Zimmermann, L., Ramberg, A., & Schröder, P. (2016). Mentalization

Mediates the Relationship between Early Maltreatment and Potential for Violence in

Adolescence. Psychopathology, 49(4), 236. doi: 10.1159/000448053

Turner, J. M., Wittkowski, A., & Hare, D. J. (2008). The relationship of maternal

260
 mentalization and executive functioning to maternal recognition of infant cues and

bonding. British Journal of Psychology, 99(4), 499-512. doi:

10.1348/000712608X289971

Uekermann, J., Channon, S., Lehmkämper, C., Abdel-Hamid, M., Vollmoeller, W., &

Daum, I. (2008). Executive function, mentalizing and humor in major depression.

Journal of the International Neuropsychological Society, 14(1), 55-62. doi:

10.1017/S1355617708080016

Wee, K. Y., Skouteris, H., Pier, C., Richardson, B., & Milgrom, J. (2011). Correlates of

ante and postnatal depression in fathers: A systematic review. Journal of affective

disorders, 130(3), 358-377. http://dx.doi.org/10.1016/j.jad.2010.06.019

Wong, K. (2012). A study of the effect of maternal depressive symptoms on the mother-

infant relationship and protective effect of maternal reflective functioning (Tesis de

maestría, Wayne State University, Detroit, Míchigan). Extraído de

http://digitalcommons.wayne.edu/oa_theses/200/

261
Nota del autor

María José León y Catalina Sieverson Universidad de Chile, Facultad de Medicina,

Santiago, Chile; Marcia Olhaberry, y Cristóbal Hernández, Pontificia Universidad

Católica de Chile, Escuela de Psicología, Santiago, Chile.

El artículo es parte de la tesis de María José León para Optar al Grado de Doctor en

Psicoterapia de la Universidad de Chile.

La elaboración de este artículo contó con el apoyo otorgado por el Fondo Nacional de

Desarrollo Científico y Tecnológico, a través del Proyecto FONDECYT de Iniciación Nº

11140230 liderado por Marcia Olhaberry, y recibió apoyo del Fondo de Innovación para la

Competitividad (FIC) del Ministerio de Economía, Fomento y Turismo, a través de la Iniciativa

Científica Milenio, Proyecto IS130005.

Correspondencia a: Marcia Olhaberry, Escuela de Psicología, Pontificia Universidad

Católica de Chile, Av. Vicuña Mackenna 4890, Macul, Santiago, Chile. Email:

mpolhabe@uc.cl.

262
 Tabla 1

Correlación entre las variables principales y sociodemográficas del estudio.

1 2 3 4 5 6 7 8 9
1. Satisfacción pareja 1
2. Síntomas
-,474** 1
depresivos
3. Función reflexiva ,113 ,126 1
4. Sexo ,030 -,169 -,045 1
5. Edad -,067 ,055 ,039 ,191 1
7. Número de hijos ,105 ,036 -,020 ,000 ,535** 1
*
6. Años de educación -,059 ,044 ,221 ,025 -,081 -,256* 1
8. Trabajo actual ,027 -,138 ,132 ,268** ,265** ,118 ,023 1
9. Tt. psicológico
-,172 ,098 -,062 -,074 ,229* ,097 -,043 ,004 1
actual
Nota. Sexo: 1=mujer, 2=hombre, trabajo actual remunerado: 0= no tener trabajo, 1= tener
trabajo, tratamiento psicológico actual: 0= no tener tratamiento actual, 1= tener tratamiento
actual.
*p <,05, ** p <,01

263
Tabla 2

Regresión multinivel.

Efectos Fijos Beta Error Estándar gl Valor t. Sig.

Intercepto 0,027 0,088 49 0,312 0,756
Sexo -0,161 0,082 44 -1,954 0,057
Años de Escolaridad 0,000 0,089 44 -0,002 0,999
Satisfacción Pareja -0,552 0,089 44 -6,186 0
Funcion Reflexiva 0,101 0,091 44 1,108 0,274
Satisfacción * Sexo -0,197 0,085 44 -2,320 0,025
Satisfacción * Función
R -0,192 0,094 44 -2,034 0,048

Efecto Aleatorio Varianza Residual

Intercepto 0,243 0,799

264
Figura 1

Efecto de moderación del sexo en la relación entre la satisfacción de pareja y la

sintomatología depresiva

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Figura 2

Efecto de moderación de la función reflexiva en la relación entre la satisfacción de pareja y

la sintomatología depresiva

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10.12.3. Evaluación de las interacciones tríadicas padre-madre-infante en primera
infancia: Una revisión sistemática (In review)

Evaluación de las interacciones tríadicas padre-madre-infante en primera infancia:

Una revisión sistemática

Assessment of triadic father-mother-infant interactions in infancy and early

childhood: A systematic review.

Marcia Olhaberry*
María José León**
Constanza Mena*
Magdalena Seguel*
Irma Morales-Reyes*

*Escuela de Psicología, Pontificia Universidad Católica de Chile

**Departamento de Psiquiatría y Salud Mental Oriente, Universidad de Chile.

Correspondencia: Marcia Olhaberry, Av. Vicuña Mackenna 4860, Macul, Santiago de
Chile. Email: mpolhabe@uc.cl
4

4
Nota de los autores: Especiales agradecimientos al Proyecto Fondecyt Nº11140230 y al Proyecto IS 100018 Instituto
Milenio para la investigación en Depresión y Personalidad.

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 Evaluación de las interacciones tríadicas padre-madre-infante en primera infancia:

Una revisión sistemática

Resumen

De manera creciente, las investigaciones actuales en primera infancia buscan enriquecer la

comprensión de las interacciones tempranas y sus efectos en la salud mental y el desarrollo

infantil, ampliado su mirada desde la díada madre-infante hacia la tríada, que incluye

también al padre. En este recorrido, clínicos e investigadores han desarrollado herramientas

y métodos de codificación para analizar las interacciones familiares triádicas, pero no se

cuenta con una sistematización en relación con los procedimientos e instrumentos

existentes para evaluar el funcionamiento triádico en familia temprana. Considerando estos

antecedentes se analizan 57 estudios publicados entre los años 1990 y 2014, que presentan

métodos e instrumentos de evaluación de las interacciones familiares tríadicas desde la

gestación hasta los 4 años de edad del niño/a. Los resultados muestran que la mayoría de

los estudios utilizan el instrumento Lausanne Triadic Play en sus versiones pre y post-natal

para el análisis de la tríada, desarrollando modelos de codificación y análisis.

Palabras clave: Interacciones triádicas, instrumentos de evaluación, sistemas de

codificación.

Abstract

Current studies in infancy have increasingly broadened their view from the mother-infant

dyad to a triad including the father, searching to enrich the comprehension of early

interactions and their effect on mental health and child development. In this journey,

clinicians and researchers have developed tools and coding methods to analyze triadic

interaction without a systematization regarding the existing procedures and instruments for

assessing triadic functioning in the early family. Considering this background, 57 studies

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published between 1990 and 2014 that used methods and assessment instruments for triadic

family interactions from gestation to four-year-old children are analyzed. The results show

that the majority of studies use the Lausanne Triadic Play instrument for analyzing triads,

in its pre and postnatal versions, developing codification models and analysis in clinical and

non-clinical samples.

Key Word: Triadic interactions, assessment tools, codyng systems.

Introducción

Los complejos cambios sociales ligados al desarrollo, al aumento de la

productividad y la redistribución de roles, han impactado la forma de vivir de las personas y

la conformación de las familias (Pérez y Olhaberry, 2014). La familia postmoderna se ha

caracterizado por la fortaleza de la estructura nuclear, por sus múltiples formas de

organización, por la baja y tardía nupcialidad y por el control y la disminución de las tasas

de natalidad (Gómez & Guardiola, 2014; Cerda, 2007). El origen de esta profunda

transformación puede deberse, en parte, a la salida de la mujer al mundo público, a la

inserción progresiva al mercado laboral y por lo mismo, a la delegación y reorganización de

las tareas domésticas y de crianza. Es por eso que con el aumento de las tasas de

empleabilidad femenina y la distribución más equitativa de los roles sociales, la sociedad

cada vez valora más la participación del padre en la crianza temprana de los/las hijos/as,

favoreciendo a la vez el desempeño de este en múltiples roles dentro de la familia (Lamb,

2010; Kromelow, Harding, & Touris, 1990).

Históricamente la forma de comprender a los niños/as ha sido mediante el estudio

de la interacción madre-infante, pese a que el contexto natural del niño/a va más allá de las

interacciones diádicas, el estudio de éstas ha ganado un gran espacio en la literatura

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científica (Fivaz-Depeursinge, & Corboz-Warnery, 1999). La incorporación del padre en

mundo científico, ha sido mediante los estudios de la díada padre-hijo, los cuales han

transitado desde investigación sobre presencia/ausencia del padre y la relación con los roles

de género, hacia la evaluación de la calidez, cercanía e implicancia del padre en la crianza y

su relación con el ajuste y desarrollo infantil (Lamb, 2010). Por su parte, las interacciones

familiares tríadicas padre-madre-infante fueron ignoradas por mucho tiempo, pese a ser un

dominio fundamental del desarrollo familiar y del niño/a (Fivaz-Depeursinge, & Corboz-

Warnery, 1999).

El estudio de la familia, desde la terapia familiar, surge a partir de los años 50 en

Estados Unidos, desde el psicoanálisis con el estudio de las familias de pacientes con

esquizofrenia y desde la antropología mediante la comprensión de los trastornos de la

comunicación en familias con integrantes con esquizofrenia (Pereira, 1994). Desde la

psiquiatría infantil Jonh Bowlby (1949) estudia al grupo familiar para así poder comprender

los problemas de ajuste infantil. Inspirado en los trabajos realizados por Bowlby, John Bell

desarrolla un método de trabajo llamado terapia familiar grupal (Bell, 1983).

Contemporáneo a Bell, Minuchin (1985) desarrolla la terapia familiar estructural, desde ella

argumenta que la díada padre-hijo opera en el contexto de las relaciones con los otros

miembros de la familia, sin embargo desde la teoría sistémica pocos estudios han

examinado las características de la interacción triádica en infancia temprana.

Uno de los pioneros en el estudio de la tríada fue M. Lamb, quien en 1976 observó a

niños de 18 meses en interacción con sus padres y madres. Tres años más tarde, Parke,

Power y Gottman (1979) desarrollaron un modelo para conceptualizar y cuantificar

patrones de influencia dentro de la tríada familiar. En 1984 Belsky, Gilstrap y Rovine,

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estudiaron las díadas madre-bebé, padre-bebé y madre-padre y desarrollaron tipologías de

familias a partir de los análisis de las diferentes combinaciones entre las tres díadas

(Belsky, Gilstrap & Rovine, 1984). Posteriormente, a fines de los 80’ Lewis, se aproxima a

afirmar que la tríada es un sistema total, a partir de su estudio “The Birth of the Family”

(Lewis, 1989). Paralelamente a las observaciones y desarrollos teóricos de Lewis,

Elizabeth Fivaz-Depeursinge y colaboradores comienzan a estudiar las interacciones

familiares tríadicas, buscando conocer el desarrollo familiar y del infante. Presentan en

1987 el primer artículo sobre alianzas familiares en familias con hijos/as pequeños (Fivaz-

Depeursinge, 1987), desarrollando a comienzos de los años 90’ un sistema de análisis de las

interacciones tríadicas llamado “The Lausanne Triadic Play” (Corboz-Warnery, Fivaz-

Depeursinge, & Bettens, 1993).

La tríada madre-padre-infante ha sido observada y comprendida desde dos

perspectivas, por una parte, la teoría sistémica tradicional la considera una suma de

subsistemas diádicos y por otra, ha sido considerada una unidad que muestra una estructura

y características propias. Esta segunda mirada la considera una entidad de interacción

diferente a la suma de intercambios diádicos, donde la adición de un tercero altera la

dinámica de los subsistemas diádicos y da lugar a un entorno socio-emocional más diverso

y complejo (McHale & Fivaz-Depeursinge, 1999).

Desde la perspectiva del desarrollo infantil temprano existe bastante consenso en

que los bebés nacen con una capacidad innata para relacionarse afectiva y psicológicamente

con otros (Stern, 1985, Trevarthen, 1993). Inicialmente el bebé interactúa con un adulto a la

vez para luego comenzar a interactuar con los objetos del entorno. A los 5 meses desarrolla

juegos más complejos persona-objeto-persona, y alrededor de los 7 a 9 meses aparece la

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habilidad de interactuar con dos personas a la vez, surgiendo en el niño/a la capacidad de

reconocer la mente del otro, de compartir sus propios estados emocionales, y de

intercambiar la mirada entre su padre y su madre en respuesta a las propuestas afectivas de

estos y al estado emocional del bebé (Carpenter, Nagell, & Tomasello, Butterworth, &

Moore, 1998; Fivaz-Depeursinge, & Corboz-Warnery, 1999; Stern, 1985, Trevarthen,

1993). Estas capacidades permiten que el bebé desarrolle una comunicación intencional,

muestre preferencias, comparta estados mentales e influya en los estados mentales de los

adultos (Tomasello, Carpenter, Call, Behne, & Moll, 2005; Wobber, Herrmann, Hare,

Wrangham, & Tomasello, 2014). Favorecen también los aprendizajes para la regulación de

estados emocionales en contextos de más de dos personas, aprendiendo a mostrar señales

de querer continuar la interacción durante estados positivos, y a mostrar señales de malestar

frente al deseo de cambiar el tipo intercambio (Fivaz-Depeursinge & Philipp, 2014). El

desarrollo de estas competencias se construye a partir de las experiencias con los

cuidadores primarios y según la calidad de estas interacciones, el infante aprenderá a

compartir el afecto, la atención y un objetivo en común entre tres personas, teniendo a su

vez que afrontar los sentimientos de exclusión y desarrollar mayores habilidades sociales

(Fincham, 1998; Fivaz-Depeursinge, & Corboz-Warnery, 1999; Hedenbro, 2006;

Liszkowski, Carpenter, Henning, Striano, & Tomasello, 2004)

Los infantes progresivamente van absorbiendo e internalizando la relación que

establecen con sus padres y estas relaciones influyen en el desarrollo emocional del niño/a,

principalmente en habilidades de regulación (Fivaz-Depeursinge, & Corboz-Warnery,

1999). El desarrollo emocional del infante es facilitado por patrones familiares triádicos

coordinados y comprometidos, ya que el niño/a se ve envuelto en un ambiente más afectivo

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y flexible (Fivaz-Depeursinge, Frascarolo & Corboz-Warnery, 1996). Interacciones

cooperativas entre los padres y un clima emocional cálido y positivo durante el primer año

de vida, le otorgan al niño/a un contexto de experiencias beneficiosas y un desarrollo social

positivo (Raikes & Thompson, 2006; Teubert & Pinquart, 2010). Tanto la reciprocidad en

la relación con la madre, como el involucramiento y compromiso social en la relación con

el padre son predictores de la competencia social del infante, como también lo es la

cohesión de la familia durante las interacciones triádicas (Feldman & Masalha, 2010).

La investigación muestra que una experiencia más positiva dentro de la tríada

prepara a los niños para funcionar de manera más competente con adultos y compañeros en

un entorno multipersonal no familiar (Feldman & Masalha, 2010). Por el contrario, cuando

los niños participan de patrones familiares disfuncionales o con conflictos parentales,

aprenden comportamientos desadaptativos para protegerse de los afectos negativos que

genera el conflicto (Cummings & Davies, 2010). Estudios longitudinales documentan

preocupantes efectos a largo plazo de la falta de coordinación crónica, el comportamiento

intrusivo, y el antagonismo entre los padres, interfiriendo el desarrollo de adecuados

mecanismos regulatorios en el niño y el ajuste con sus pares (McHale, 2007). No obstante,

la interacción positiva del niño con uno de sus padres, puede ayudar a resolver

interacciones diádicas disfuncionales con el otro. La intervención de un tercero con

habilidades interaccionales adecuadas favorece la regulación emocional y contribuye a la

reducción de la tensión y el estrés en el niño (Fivaz-Depeursinge & Favez, 2006). Sin

embargo, estos hallazgos no son consistentes, existiendo estudios que muestran una menor

frecuencia de conductas parentales negativas en contextos triádicos que en contextos

diádicos y ausencia de diferencias en relación a las conductas parentales positivas (Johnson,

273
2001). Otras investigaciones muestran una mayor frecuencia de conductas maternas

positivas al estar los padres presentes (Lindsey & Caldera, 2006), así como más conductas

parentales positivas y menos negativas en contextos diádicos que en triádicos (Kwon, Jeon,

Lewsader, & Elicker, 2012).

A partir del reconocimiento de la capacidad infantil temprana de participar en

interacciones triádicas y su importancia en el desarrollo de un self autónomo y en la

adquisición de competencias sociales (Hedenbro, 2006; Leidy, Schofield & Parke, 2013), el

estudio de la tríada en primera infancia se vuelve relevante. Considerando además la

importancia de las relaciones padre-madre-infante en el desarrollo y la salud mental infantil

y familiar, así como el bajo número de estudios y publicaciones centrados en la tríada, en

contraste con las numerosas investigaciones en torno a la díada (madre-hijo/a

principalmente, y secundariamente padre-hijo/a y padre-madre), el objetivo de este artículo

es revisar la literatura existente sobre métodos e instrumentos de evaluación de las

interacciones tríadicas familiares durante la primera infancia, considerada desde la

gestación hasta los 5 años de edad. Busca también distinguir las variables que han sido

evaluadas, discutir su valor diagnóstico y psicoterapéutico, así como los procedimientos de

codificación.

Método

Se realizó una revisión de las publicaciones que evalúan a la tríada madre-padre-

infante, desde enero de 1990 hasta diciembre del 2014. Se revisaron las siguientes bases de

datos: PsycArticles, PsycInFo, Pubmed, Science direct y Scopus.

Las palabras claves usadas para la revisión fueron:

274
 Triadic*interaction

Triangular*interaction

Triadic*alliance

Family*triad

Triadic*play

Triangular*relationship

Se incluyeron estudios que evaluaron el funcionamiento triádico en población

clínica y no clínica, ya que se consideró que por tratarse de una variable estudiada en menor

grado en primera infancia, era relevante considerar los procedimientos y hallazgos ligados a

la psicopatología y a las dificultades del desarrollo infantil temprano, así como el

funcionamiento triádico normativo observado en población general. Adicionalmente,

considerando que los vínculos tempranos entre padres, madres e hijos/as se desarrollan

desde la gestación, se incluyeron estudios que evaluaron las interacciones tríadicas desde el

embarazo y con posterioridad al nacimiento, dada la relevancia de ambos períodos en el

desarrollo y en la salud mental infantil y parental.

La revisión inicial realizada en las bases de datos mencionadas y a partir de las

palabras claves señaladas, arrojó 451 artículos en inglés y español. Se excluyeron artículos

de revisión y teóricos, así como textos repetidos, quedando un total de 375. En un segundo

análisis se excluyeron aquellos estudios que evaluaban otro tipo de tríadas diferentes a la

tríada madre-padre-infante (incluyendo abuelos, más de un hijo/a y madre o padre, u otros

parientes), quedando 116 artículos a texto completo. Finalmente se seleccionan aquellos

artículos que incluyeron la evaluación de tríadas madre-padre-infante desde el embarazo

hasta los 4 años de edad del hijo/a, obteniéndose 57 artículos para su análisis. El proceso de

275
selección se detalla en la figura 1.

Insertar figura 1 aproximadamente aquí

Resultados

A partir de los criterios de inclusión previamente definidos, se realiza un primer

análisis de los 57 artículos seleccionados, el que considera los aspectos generales de cada

estudio. En los antecedentes incluidos se reportan los autores, el año de publicación, el país

de origen, el tamaño muestral y las características de los participantes, diferenciando si se

trata de población clínica o no, sus principales características y si se considera al hijo/a

durante el embarazo o con posterioridad al nacimiento. Se detalla también el tipo de diseño

desarrollado en cada estudio y si el procedimiento de evaluación de las interacciones

tríadicas cuenta con una sistematización o no. La información descrita se reporta en la tabla

1.

Insertar Tabla 1 aproximadamente aquí

Luego de la primera selección de artículos se revisan los métodos utilizados en cada

estudio para la evaluación de las interacciones triádicas, identificando a aquellos que

refieren un procedimiento y un método de codificación sistematizado. Se toma esta

decisión considerando la importancia metodológica de contar con procedimientos que

permitan asegurar en mayor medida una adecuada medición de las variables, una mayor

confiabilidad en los resultados de los estudios y la posibilidad de entrenamiento para

aquellos clínicos e investigadores que decidan utilizarlos.

Del total de artículos incluidos 34 (59,64 %) refieren un método sistematizado para

la evaluación y codificación del funcionamiento familiar triádico y 23 (40,35 %) no

cuentan con un método sistematizado. Se revisan los estudios con un método sistematizado

276
y se profundiza en su objetivo general, el método de evaluación y codificación, así como en

las variables que este último procedimiento contempla.

De los 34 estudios, 32 (94,12%) de ellos utilizan el procedimiento definido en el

Lausanne Triadic Play, LTP (Fivaz-Depeursingue & Corboz-Warnery, 1999) para la

evaluación de las interacciones triádicas y dos (5,88%) lo hacen a partir de un

procedimiento de juego. Gordon, Zagoory-Sharon, Leckman y Feldman (2010) utilizan el

“juego libre” videado en dos visitas domiciliarias, durante la primera graban a cada padre

jugando con el/la niño/a por separado, durante la segunda graban al padre, la madre y al

niño/a jugando a partir de la consigna “jueguen los tres como ustedes siempre lo hacen”.

Feldman & Masalha (2010) graban 15 minutos de “juego libre” entre los padres y el niño/a,

pero agregan además una caja con juguetes (contiene muñecas, una manta, set de té,

animales, autos, herramientas y un teléfono), buscando promover la creatividad en la

interacción.

Dentro de los 32 estudios que utilizan el LTP, se distinguen variaciones, 18

(56,25%) consideran sólo la versión para postnatal, uno (3,13%) incluye el LTPs que

evalúa interacciones triádicas durante el embarazo, 10 (31,25%) combinan el LTPs y el

LTP, dos (6,25%) combinan el LTP y el protocolo de la Triadic Interview Coding (TIC) y

uno (3,13%) utiliza una versión adaptada del LTP.

En cuanto a los objetivos planteados por los estudios, los 18 que utilizan el LTP

postnatal se focalizan en el apego parental; en trastornos específicos, como la depresión

materna o la sintomatología infantil; y en aspectos del desarrollo infantil como la capacidad

de interactuar simultáneamente con ambos padres, las habilidades sociales, los celos y la

comunicación no verbal. Buscan evaluar la relación de las variables descritas con las

distintas dimensiones del intercambio triádico, principalmente la co-parentalidad, la calidad

277
de las interacciones y las alianzas familiares. Otros analizan las diferencias culturales en el

intercambio triádico y también evalúan las propiedades del instrumento profundizando en

las variables que permite distinguir.

Sólo un estudio utiliza de manera aislada el LTPs, buscando evaluar sus propiedades

psicométricas, destacando que la mayoría de las investigaciones que lo incorporan lo hacen

junto al LTP infant o toddler buscando evaluar el valor predictivo de las interacciones

triádicas durante el embarazo para la calidad de las interacciones triádicas luego del parto.

Evalúan específicamente la co-parentalidad, las alianzas familiares y aspectos específicos

del desarrollo infantil.

La revisión muestra que para la evaluación de las interacciones familiares triádicas

se han utilizado principalmente variantes del LPT inicial, dependiendo del objetivo del

estudio, de la edad y la etapa del desarrollo del niño/a. El LTP inicial fue creado por

Corboz-Warnery, Fivaz-Depeursinge, Bettens, & Favez, (1993) con el objetivo de contar

con una herramienta observacional que permitiera evaluar interacciones triádicas en

familias con niños(as) en infancia temprana y desde entonces ha sido usado en distintos

estudios y se han desarrollado sus distintas versiones.

El LTPs es una adaptación del LTP postnatal y fue creado con el objetivo de

estudiar la alianza familiar durante el embarazo y la transición a la parentalidad. Permite

observar y evaluar la co-parentalidad y la coordinación entre los padres en relación al bebé

por nacer, mediante un juego de roles con un muñeco que representa al hijo/a. Favorece

también el despliegue de comportamientos parentales intuitivos, que son activados

mediante el juego con el muñeco (Carneiro, Corboz-Warnery, & Fivaz-Depeursinge, 2006).

En cuanto al procedimiento, la actividad comienza con una entrevista semiestructurada de

21 preguntas a los padres donde se recogen sus representaciones sobre el bebé por nacer.

278
Luego el facilitador los invita a comenzar la interacción, al igual que en el LTP Postnatal,

los padres se sientan en forma triangular, el bebé es representado por un muñeco con forma

de bebé. Idealmente la interacción es filmada con tres cámaras en forma simultánea,

editándose las imágenes en una sola pantalla. El facilitador le pide a los padres que

imaginen el momento en que se encontrarán por primera vez con su bebé, y se les pide que

jueguen con el muñeco como si fuera su hijo/a considerando 4 etapas, en la primera uno de

los padres juega con el “bebé”, en la segunda cambian roles, en la tercera los tres juegan

juntos, y finalmente permiten que el “bebé vaya a dormir” y los padres conversan sobre la

experiencia. Se les explicita que disponen aproximadamente de 5 minutos para realizar la

actividad (Carneiro, Corboz-Warnery, & Fivaz-Depeursinge, 2006).

Las dimensiones analizadas para el LTP Prenatal son diferentes a las consideradas

para el LTP Postnatal (Favez, Frascarolo, Fivaz-Depeursinge, 2006). EL LTP Prenatal se

codifica incluyendo 5 escalas que consideran los siguientes valores para su puntuación: 0 =

inapropiado, 1 = parcialmente apropiado y 2 = apropiado. Las tres primeras escalas fueron

creadas exclusivamente para analizar el LTP Prenatal.

Capacidad lúdica co-parental (Co-Parent Playfulness): Evalúa la capacidad de la

pareja para crear un espacio lúdico y construir de manera conjunta un juego. Estructura del

juego: Esta escala evalúa la capacidad de la pareja para darle una estructura a los cuatro

segmentos del juego acorde a las instrucciones dadas. Se consideran dos dimensiones: la

diferenciación entre los cuatro segmentos del juego y la duración de cada uno.

Comportamientos parentales intuitivos: esta escala evalúa los comportamientos intuitivos

de los padres, mediante 6 comportamientos descritos en la literatura (Papousek &

Papousek, 1987), mantención de la postura corporal con orientación al rostro del niño, la

distancia de la cabeza del bebé que favorezca el diálogo, el habla, sonrisas, caricias y

279
balanceo, la exploración del cuerpo del bebé y la preocupación por su bienestar. Estos

comportamientos se codifican en cada padre en separado como presentes o ausentes, para

luego unir los puntajes de ambos padres en un puntaje global. Cooperación de la pareja:

esta escala evalúa el grado de cooperación activa entre la pareja durante el juego, usando

palabras, gestos que faciliten la articulación del juego y el apoyo mutuo. Calidez familiar:

esta escala evalúa el afecto y humor compartido durante el juego, considera la expresión de

afecto y ternura como pareja y hacia el bebé, con palabras, gestos tiernos y cálidos y

sonrisas de complicidad (Carneiro, Corboz-Warnery, & Fivaz-Depeursinge, 2006).

El LTP postnatal, al igual que el prenatal, requiere la grabación de interacciones de

juego entre la madre, el padre y el bebé, quienes son ubicados en tres asientos formando un

triángulo equilátero. Para niños pequeños el setting considera sólo 3 asientos, para toddlers

se agrega una mesa redonda al centro y el uso de 3 pares de juguetes. Se les entrega la

indicación de jugar como habitualmente lo hacen, pero siguiendo una estructura que

incluye 4 etapas, 1) padre o madre juegan activamente con el niño/a mientras el otro adulto

sólo está presente, 2) luego estos roles se invierten entre los padres, 3) luego padre, madre y

niño(a) juegan activamente y 4) finalmente padre y madre conversan y el niño/a

simplemente está presente. El procedimiento permite determinar 3 tipos de Alianza

Familiar con dos opciones en cada una de ellas: 1) Alianza cooperativa, la que puede ser a)

fluida o b) tensa, 2) Alianza conflictiva, la que puede ser a) encubierta o b) abierta y

Alianza desordenada, la que puede ser a) con exclusión o b) caótica. El tipo de alianza

familiar se determina a partir de la evaluación de la participación (capacidad de la tríada

para trabajar juntos e incluir a todos, considera también la postura corporal de los

participantes y las miradas), la organización (capacidad de tolerar los distintos roles que el

juego propone y generar una adecuada estructura), la focalización (capacidad de todos los

280
miembros de enfocarse en la tarea, proponer un juego co-construido y adecuado a la edad

del niño/a) y el manejo de los afectos (considera la validación, el apoyo emocional y la

autenticidad). El instrumento permite evaluar también los quiebres en la interacción y la

capacidad de reparación, la auto-regulación en el niño/a y la co-parentalidad (capacidad de

apoyo y resolución de conflictos). Cada uno de estos aspectos puede ser considerado

adecuado, moderado o inadecuado para la codificación, lo que permite la obtención de

puntajes.

Insertar tabla 2 aproximadamente aquí

.
Discusión

Si bien el estudio de la tríada familiar se ha vuelto cada vez más relevante para

clínicos e investigadores, el trabajo sistemático en la creación, evaluación y aplicación de

instrumentos para la evaluación de las interacciones tríadicas tempranas ha sido

desarrollado principalmente por el equipo liderado inicialmente por Elisabeh Fivaz

Depeursinge a partir de la creación del Lausanne Triadic Play. La primera versión del LTP

fue creada por Corboz-Warnery, Fivaz-Depeursinge, Bettens, & Favez, (1993) con el

objetivo de contar con una herramienta observacional que permitiera evaluar interacciones

triádicas en familias con niños(as) pequeños. Desde entonces, ha sido usado en numerosos

estudios desarrollados por el equipo creador del instrumento, por investigadores de Estados

Unidos y Europa, y de manera inicial en Chile.

En 1999 Fivaz-Depeursinge, & Corboz-Warnery, publican la metodología de uso y

la codificación del LTP y hasta el año 2006 todas las publicaciones revisadas consideraron

la versión del LTP inicial. El 2006 se publica la versión prenatal del LTP (LTPs),

desarrollada por Carneiro, Corboz-Warner, & Fivaz-Depeursinge (2006), dando inicio a

281
estudios principalmente longitudinales que evalúan la calidad de las interacciones triádicas

y las alianzas familiares desde la gestación hasta los primeros años de nacido el infante,

dando cuenta de su mantención cuando no se realiza un proceso de intervención.

Actualmente se ha implementado también una aplicación adaptada del LTP para

adolescentes y sus padres, desarrollada en Italia (Gatta et al, 2015), que da cuenta del

creciente interés que el instrumento ha generado, ligado al consenso actual en relación a la

importancia de la inclusión del padre y la madre al diagnosticar e intervenir en niños/as y

adolescentes.

En términos generales, las investigaciones publicadas revisadas que evalúan el

funcionamiento triádico temprano, lo estudian considerando también variables clínicas

como el apego parental, sintomatología en los padres y/o en el niño, aspectos del desarrollo

infantil y dimensiones específicas de la diada parental como la co-parentalidad. Asociado al

funcionamiento triádico, el LTP en sus versiones pre y postnatal identifica además tipos de

alianzas familiares, que distinguen interacciones adecuadas y problemáticas, y que tienden

a la estabilidad desde el embarazo hasta el postparto (Favez et al, 2013).

Otro aspecto relevante en relación al LTP y su uso, tiene relación con los estudios que

buscan revisar y mejorar sus propiedades psicométricas, estudiando los procedimientos de

codificación y su validez. Estos procedimientos han apoyado su uso como medida de la

calidad del funcionamiento triádico familiar en la clínica y también en investigación

(Simonelli et al., 2012).

Probablemente la existencia de numerosos estudios que evalúan a la triada madre-

padre-infante principalmente con el LTP, se explica por su enorme valor clínico, por la

solidez metodológica que ha logrado y la consistencia de los resultados obtenidos en

estudios desarrollados en distintos lugares del mundo. En este sentido es también un

282
instrumento que permite la convergencia de distintas miradas teóricas en relación a la

primera infancia y la familia temprana, integrando los aspectos diádicos, desarrollados de

manera extensa por la Teoría del apego, la mirada familiar, desarrollada por los Modelos

sistémicos y también el mundo interno y los aspectos subjetivos de los participantes

presentes en la interacción, que representan una mirada desde los Modelos Psicodinámicos.

Dentro de las virtudes del LTP en sus distintas versiones, es importante destacar que

cuenta con un procedimiento estandarizado y con una codificación manualizada, lo que

promueve la obtención de resultados válidos y confiables, permitiendo además el

aprendizaje del método de evaluación a través de entrenamiento. Puede también ser

utilizado con distintos fines, para contribuir al desarrollo teórico en la comprensión del

funcionamiento familiar temprano, para uso diagnóstico, para uso terapéutico y para la

evaluación de resultados de intervenciones psicoterapéuticas. A nivel teórico, profundiza en

la mutua influencia entre los subsistemas diádicos al interior de la triada familiar,

mostrando que el funcionamiento diádico y el triádico se influyen mutuamente pero no de

manera lineal, pudiendo observarse parejas de padres en conflicto que logran adecuadas

interacciones diádicas con sus hijos/as y parejas de padres con adecuada satisfacción

marital que muestran déficit en las interacciones diádicas con sus hijos/as y en las

interacciones triádicas.

A nivel diagnóstico, permite identificar de manera muy precoz, durante la gestación,

interacciones triádicas problemáticas y también detectar dimensiones específicas en ellas.

Permite distinguir el nivel de participación de cada miembro de la familia, identificando

exclusiones y auto-exclusiones, la forma en que cada uno ocupa roles pasivos y activos, la

capacidad de sostener una estructura en torno a una tarea específica, el nivel de

involucramiento y coordinación afectiva, la capacidad de reparar errores en la

283
comunicación, de apoyarse mutuamente y de trabajar como un equipo. Estas dimensiones

pueden también constituir focos de intervención en el trabajo clínico con la familia,

pudiendo el material grabado ser utilizado también para la aplicación de video-feedback en

relación al funcionamiento triádico.

El uso del LTP en distintos países y la congruencia teórica y conceptual que los

estudios muestran en sus resultados, permite inferir la validez transcultural del instrumento

y las distinciones que entrega. A pesar de esto, aún se requieren nuevos estudios en

América Latina para respaldar estos hallazgos en contextos familiares que muestren una

mayor diversidad cultural.

En cuanto a las desventajas de su uso, aún no hay una relación clara entre los tipos de

alianzas familiares y los puntajes totales obtenidos al codificar los distintos ítems que

considera el instrumento. Las alianzas familiares constituyen una medida observacional

cualitativa, que distingue entre alianzas familiares suficientemente buenas (alianzas

cooperativas) y aquellas que requieren intervención (alianzas conflictivas y desordenadas);

y el puntaje total una medida cuantitativa que indica mayor o menor calidad en las

interacciones triádicas, pero que no cuenta con un punto de corte para su interpretación.

Por otro lado, por tratarse de un instrumento relativamente nuevo, la mayoría de los

estudios se focalizan en población normativa, requiriéndose nuevas investigaciones en

población clínica para ampliar su uso y enriquecer las posibilidades de interpretación de sus

resultados.

En síntesis, el LTP es el instrumento mayoritariamente utilizado para evaluar la

calidad del funcionamiento familiar triádico en infantes y sus padres, cuenta con un sólido

respaldo teórico y empírico, y estos antecedentes permiten destacar y promover su uso para

el trabajo clínico y en investigación.

284
 Referencias
Altenburger, L. E., Schoppe-Sullivan, S. J., Lang, S. N., Bower, D. J., & Kamp Dush, C.
M. (2014). Associations between prenatal coparenting behavior and observed
coparenting behavior at 9-months postpartum. Journal of Family Psychology, 28(4),
495. http://dx.doi.org/10.1037/fam0000012.

Bell, J. E. (1983). Family group therapy. In Handbook of Family and Marital Therapy (pp.
231-245). Springer, US.

Belsky, J., Gilstrap, B., & Rovine, M. (1984). The Pennsylvania Infant and Family
Development Project, I: Stability and change in mother-infant and father-infant
interaction in a family setting at one, three, and nine months. Child Development,
692-705.

Bingham, G. E., Kwon, K. & Jeon, H. (2013). Examining relations among mothers',
fathers', and children's language use in a dyadic and triadic context, Early Child
Development and Care, 183(3-4), 394-414.
http://dx.doi.org/10.1080/03004430.2012.711590.

Bowlby, J, (1949). The study and reduction of group tensions in the family. Human
Relations, 2, 123-128. http://dx.doi.org/10.1177/001872674900200203.

Cairo, S., Darwiche, J., Tissot, H., Favez, N., Germond, M., Guex, P., ... & Despland, J. N.
(2012). Family interactions in IVF families: change over the transition to parenthood.
Journal of Reproductive and Infant Psychology, 30(1), 5-20.
http://dx.doi.org/10.1080/02646838.2012.669830.

Cummings, E.M., & Davies, P. (2010). Marital conflict and children: An emotional security
perspective. New York, NY: Guilford.

Cannon, E., Schoppe-Sullivan, S., Mangelsdorf, S., Brown, G., & Szewczyk, M. (2008).
Parent characteristics as antecedents of maternal gatekeeping and fathering behavior.
Family Process, 47(4), 501-519. http://dx.doi.org/10.1111/j.1545-5300.2008.00268.x.

Carneiro, C., Corboz-Warnery, A., & Fivaz-Depeursinge, E. (2006). The Prenatal Lausanne
Trilogue Play: A New Observational Assessment Tool of the Prenatal Co-Parenting
Alliance. Infant Mental Health Journal, 27(2), 207-228.
http://dx.doi.org/10.1002/imhj.20089.

Carpenter, M., Nagell, K., Tomasello, M., Butterworth, G., & Moore, C. (1998). Social
cognition, joint attention, and communicative competence from 9 to 15 months of
age. Monographs of the society for research in child development, i-174.
http://dx.doi.org/10.2307/1166214.

285
Cerda, R. (2007). Cambios demográficos: desafíos y oportunidades de un nuevo escenario.
Pontificia Universidad Católica de Chile, Vicerrectoría de Comunicaciones y Asuntos
Públicos.

Corboz Warnery, A., Fivaz Depeursinge, E., Bettens, C. G., & Favez, N. (1993).
Systemic analysis of father mother baby interactions: The Lausanne triadic play.
Infant Mental Health Journal, 14(4), 298-316.

Curran, M. A., Hazen, N. L., & Mann, T. (2009). Representations of marriage and
expectations of parenthood: Predictors of supportive coparenting for first-time
parents. Parenting: Science and Practice, 9(1-2), 101-122.
http://dx.doi.org/10.1080/15295190802656794.

de Mendonça, J. S., Cossette, L., Strayer, F. F., & Gravel, F. (2011). Mother-child and
father-child interactional synchrony in dyadic and triadic interactions. Sex roles,
64(1-2), 132-142. http://dx.doi.org/10.1007/s11199-010-9875-2.

Elliston, D., McHale, J., Talbot, J., Parmley, M., & Kuersten-Hogan, R. (2008).
Withdrawal from coparenting interactions during early infancy. Family process,
47(4), 481-499. http://dx.doi.org/10.1111/j.1545-5300.2008.00267.x.

Favez, N., Frascarolo, F., & Fivaz-Depeursinge, E. (2006). Family alliance stability and
change from pregnancy to toddlerhood and marital correlates. Swiss Journal of
Psychology/Schweizerische Zeitschrift für Psychologie/Revue Suisse de Psychologie,
65(4), 213. http://dx.doi.org/10.1024/1421-0185.65.4.213.

Favez, N., Frascarolo, F., Carneiro, C., Montfort, V., Corboz-Warnery, A., & Fivaz-
Depeursinge, E. (2006). The development of the family alliance from pregnancy to
toddlerhood and children outcomes at 18 months. Infant and Child Development,
15(1), 59-73. http://dx.doi.org/10.1002/icd.430.

Favez, N., Frascarolo, F., Lavanchy Scaiola, C. & Corboz-Warnery, A. (2013). Prenatal
Representations of Family in Parents and Coparental Interactions as Predictors of
Triadic Interactions During Infancy. Infant Mental Health Journal, 34: 25–36.
http://dx.doi.org/10.1002/imhj.21372.

Favez, N., Lopes, F., Bernard, M., Frascarolo, F., Lavanchy Scaiola, C., Corboz-Warnery,
A., & Fivaz-Depeursinge, E. (2012). The development of family alliance from
pregnancy to toddlerhood and child outcomes at 5 years. Family process, 51(4), 542-
556. http://dx.doi.org/10.1111/j.1545-5300.2012.01419.x.

Feldman, R. & Masalha, S. (2010). Parent–Child and Triadic Antecedents of Children’s

Social Competence: Cultural Specificity, Shared Process. Developmental Psychology,
46, 455–467. http://dx.doi.org/10.1037/a0017415.

286
Feldman, R. (2007). Maternal versus child risk and the development of parent–child and
family relationships in five high-risk populations. Development and psychopathology,
19(02), 293-312. http://dx.doi.org/10.1017/S0954579407070150.

Feldman, R., & Masalha, S. (2010). Parent–child and triadic antecedents of children’s
social competence: Cultural specificity, shared process. Developmental Psychology,
46(2), 455. http://dx.doi.org/10.1037/a0017415.

Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2003). Testing a family intervention
hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to
family interaction, proximity, and touch. Journal of Family Psychology, 17(1), 94.
http://dx.doi.org/10.1037/0893-3200.17.1.94.

Fincham, F. D. (1998). Child development and marital relations. Child development, 543-
574.

Fivaz-Depeursinge, E. (1987). Alliances et mésalliances dans le dialogue entre adulte et

bébé: la communication précoce dans la famille. Actualités pédagogiques et
psychologiques.

Fivaz-Depeursinge, E. & Corboz-Warnery, A. (1999). The primary triangle, a

developmental systems view of mothers, fathers and infants. London. Basic Books.

Fivaz-Depeursinge, E., Cairo, S., Scaiola, C. L., & Favez, N. (2012). Nine-month-olds'
triangular interactive strategies with their parents' couple in low-coordination
families: A descriptive study. Infant Mental Health Journal, 33(1), 10-21.
http://dx.doi.org/10.1002/imhj.20314.

Fivaz-Depeursinge, E., Favez, N., Lavanchy, S., De Noni, S., & Frascarolo, F. (2005).
Four-month-olds Make Triangular Bids to Father and Mother During Trilogue Play
with Still-face. Social Development, 14(2), 361-378. http://dx.doi.org/10.1111/j.1467-
9507.2005.00306.x.

Fivaz-Depeursinge E. & Favez, N. (2006). Exploring triangulation in infancy: two

contrasted cases. Family Process 45, 3-8.

Fivaz-Depeursinge, E., Frascarolo, F., & Corboz-Warnery, A. (1996). Assessing the triadic
alliance between fathers, mothers, and infants at play. New Directions for Child and
Adolescent Development, 1996(74), 27-44.
http://dx.doi.org/10.1002/cd.23219967404.

Fivaz-Depeursinge, E., Lopes, F., Python, M., & Favez, N. (2009). Coparenting and
toddler's interactive styles in family coalitions. Family process, 48(4), 500-516.
http://dx.doi.org/10.1111/j.1545-5300.2009.01298.x.

287
Fivaz-Depeursinge, E., & Philipp, D. A. (2014). The baby and the couple: Understanding
and treating young families. Routledge.

Fincham, F. D. (1998). Child development and marital relations. Child development, 543-
574.

Frascarolo, F., Besse, V., & Favez, N. (2005). Non-verbal behavioural patterns in trilogue
play transitions and family alliances. Early Child Development and Care, 175(7-8),
681-696. http://dx.doi.org/10.1080/0300443042000266204.

Frascarolo, F., Favez, N., & Fivaz-Depeursinge, E. (2003). Fathers’ and mothers’
performances in father-mother-baby games. European journal of psychology of
education, 18(2), 101-111. http://dx.doi.org/10.1007/BF03173479.

Frascarolo, F., Favez, N., Carneiro, C., & Fivaz-Depeursinge, E. (2004). Hierarchy of
interactive functions in father-mother-baby three-way games. Infant and Child
Development, 13(4), 301-322. http://dx.doi.org/10.1002/icd.361.

Gatta, M., Sudati, L., Sisti, M., Comis, I., Svanellini, L., Simonelli, A. & Battistella, P.A.
(2015) Intergenerational Transmission of Attachment. Family Interactive Dynamics
and Psychopathology: What kind of Relationship in Adolescence? International
Neuropsychiatric Disease Journal 4(2): 84-91, 2015

Goldberg, W. A., Clarke-Stewart, A., Rice, J. A., & Dellis, E. (2002). Emotional energy as
an explanatory construct for fathers’ engagement with their infants. Parenting
Science and Practice, 2(4), 379–408.
http://dx.doi.org/10.1207/S15327922PAR0204_03.

Gómez, E. O., & Guardiola, V. J. V. (2014). Hacia un concepto interdisciplinario de la

familia en la globalización. Justicia juris, 10(1), 11-20.

Gordon, I., & Feldman, R. (2008). Synchrony in the Triad: A Microlevel Process Model of
Coparenting and Parent-Child Interactions. Family Process, 47(4), 465-479.
http://dx.doi.org/10.1111/j.1545-5300.2008.00266.x.

Gordon, I., Zagoory-Sharon, O., Leckman, J. F., & Feldman, R. (2010). Oxytocin, cortisol,
and triadic family interactions. Physiology & behavior, 101(5), 679-684.
http://dx.doi.org/10.1016/j.physbeh.2010.08.008.

Guzell, J. R., & Vernon-Feagans, L. (2004). Parental perceived control over caregiving and
its relationship to parent–infant interaction. Child Development, 75(1), 134-146.
http://dx.doi.org/10.1111/j.1467-8624.2004.00659.x.

Hazen, N., Jacobvitz, D., & McFarland, L. (2005). Antecedents of boundary disturbances in
families with young children: Intergenerational transmission and parent-infant

288
 caregiving patterns. Journal of emotional abuse, 5(2-3), 85-110.
http://dx.doi.org/10.1300/J135v05n02_05.

Hedenbro, M. (2006). The family triad-the interaction between the child, its mother, and
father from birth to the age of 4 years. Doctoral Dissertation, Karolinska Institutet,
Stockolm, Sweden.

Hedenbro, M. and Tjus, T. (2007). A case study of parent-child interactions of a child with
autistic spectrum disorder (3-48 months) and comparison with typically-developing
peers, Child Language Teaching and Therapy, 23 (2), 201-222.
http://dx.doi.org/10.1177/0265659007076294.

Hedenbro, M., & Rydelius, P. A. (2014). Early interaction between infants and their parents
predicts social competence at the age of four. Acta Paediatrica, 103(3), 268-274.
http://dx.doi.org/10.1111/apa.12512.

Hedenbro, M., Shapiro, A. F., & Gottman, J. M. (2006). Play With Me at My Speed:
Describing Differences in the Tempo of Parent-Infant Interactions in the Lausanne
Triadic Play Paradigm in Two Cultures. Family process, 45(4), 485-498.
http://dx.doi.org/10.1111/j.1545-5300.2006.00184.x.

Jacobvitz, D., Hazen, N., Curran, M., & Hitchens, K. (2004). Observations of early triadic
family interactions: Boundary disturbances in the family predict symptoms of
depression, anxiety, and attention-deficit/hyperactivity disorder in middle childhood.
Development and psychopathology, 16(3), 577-592.
http://dx.doi.org/10.1017/S0954579404004675.

Jessee, A., Mangelsdorf, S. C., Brown, G. L., Schoppe-Sullivan, S. J., Shigeto, A., &
Wong, M. S. (2010). Parents’ differential susceptibility to the effects of marital
quality on sensitivity across the first year. Infant Behavior and Development, 33(4),
442-452. http://dx.doi.org/10.1016/j.infbeh.2010.04.010.

Johnson, V. K. (2001). Marital interaction, family organization, and differences in parent

behavior: Explaining variations across family interaction contexts. Family Process,
40(3), 333–342. http://dx.doi.org/10.1111/j.1545-5300.2001.4030100333.x

Keren, M., Feldman, R., Namdari-Weinbaum, I., Spitzer, S., & Tyano, S. (2005). Relations
between parents' interactive style in dyadic and triadic play and toddlers' symbolic
capacity. American Journal of Orthopsychiatry, 75(4), 599.
http://dx.doi.org/10.1037/0002-9432.75.4.599.

Khazan, I., Mchale, J. P., & Decourcey, W. (2008). Violated wishes about division of
childcare labor predict early coparenting process during stressful and nonstressful
family evaluations. Infant mental health journal, 29(4), 343-361.
http://dx.doi.org/10.1002/imhj.20183.

289
Klitzing, K. V., Simoni, H., & Bürgin, D. (1999). Child development and early triadic
relationships. The International Journal of Psychoanalysis, 80, 71.
http://dx.doi.org/10.1516/0020757991598576.

Kromelow, S., Harding, C., & Touris, M. (1990). The role of the father in the development
of stranger sociability during the second year. The American Journal of
Orthopsychiatry, 60(4), 521–530. http://dx.doi.org/10.1037/h0079202.

Kwon, K. A., Jeon, H. J., Lewsader, J. T., & Elicker, J. (2012). Mothers' and Fathers'
Parenting Quality and Toddlers' Interactive Behaviours in Dyadic and Triadic Family
Contexts. Infant and Child Development, 21(4), 356-373.
http://dx.doi.org/10.1002/icd.1746.

Lamb, M. E. (1976). Effects of stress and cohort on mother– and father–infant interaction.
Developmental Psychology, 12, 435–443. http://dx.doi.org/10.1037/0012-
1649.12.5.435.

Lamb, M. E. (2010). The father’s role: Cross cultural perspectives. Nueva Jersey, Estado
Unidos: Jonh Wiley & Sons, Inc

Leidy, M., Schofield, T., & Parke, R. (2013). Fathers’ contributions to children’s social
development. En: N. Cabrera and C. Tamis-LeMonda (Eds.), Handbook of father
involvement: Multidisciplinary perspectives, (1st ed., pp.151-167). Nueva York:
Routledge.

Lewis, J. M. (1989). The birth of the family: An empirical inquiry. Psychology Press.

Lindsey, E., & Caldera, Y. (2006). Mother-father-child triadic interaction and mother-child
dyadic interaction: Gender differences within and between contexts. Sex Roles, 55,
511–521. http://dx.doi.org/10.1007/s11199-006-9106-z.

Liszkowski, U., Carpenter, M., Henning, A., Striano, T., & Tomasello, M. (2004). Twelve-
month-olds point to share attention and interest. Developmental Science, 7(3), 297–
307. http://dx.doi.org/10.1111/j.1467-7687.2004.00349.x.

McHale, J. P. (1995). Coparenting and Triadic Interactions During Infancy: The Roles of
Marital Distress and Child Gender. Developmental Psychology, 31(6), 985-996.
http://dx.doi.org/10.1037/0012-1649.31.6.985.

McHale, J. P., & Fivaz-Depeursinge, E. (1999). Understanding triadic and family group
interactions during infancy and toddlerhood. Clinical Child and Family Psychology
Review, 2(2), 107-127.

McHale, J. P. (2007). When infants grow up in multiperson relationship systems. Infant

Mental Health Journal, 28(4), 370-392. http://dx.doi.org/10.1002/imhj.20142.

290
McHale, J. P., & Coates, E. E. (2014). Observed coparenting and triadic dynamics in
African American fragile families at 3 months’ postpartum. Infant Mental Health
Journal, 35(5), 435-451. http://dx.doi.org/10.1002/imhj.21473.

McHale, J. P., & Rasmussen, J. L. (1998). Coparental and family group-level dynamics
during infancy: Early family precursors of child and family functioning during
preschool. Development and psychopathology, 10(01), 39-59.
http://dx.doi.org/10.1017/S0954579498001527.

McHale, J. P., & Rotman, T. (2007). Is seeing believing?: Expectant parents’ outlooks on
coparenting and later coparenting solidarity. Infant Behavior and Development, 30(1),
63-81. http://dx.doi.org/10.1016/j.infbeh.2006.11.007.

McHale, J. P., Kazali, C., Rotman, T., Talbot, J., Carleton, M., & Lieberson, R. (2004). The
transition to coparenthood: Parents' prebirth expectations and early coparental
adjustment at 3 months postpartum. Development and Psychopathology, 16(03), 711-
733. http://dx.doi.org/10.1017/S0954579404004742.

McHale, J., Fivaz-Depeursinge, E., Dickstein, S., Robertson, J., & Daley, M. (2008). New
evidence for the social embeddedness of infants' early triangular capacities. Family
process, 47(4), 445-463. http://dx.doi.org/10.1111/j.1545-5300.2008.00265.x.

Minuchin, P. (1985). Families and individual development: Provocations from the field of
family therapy. Child Development, 56, 289–302. http://dx.doi.org/10.2307/1129720.

Olhaberry, M., Santelices, M. Schwinn, L., & Cierpka, M. (2013). La Tríada Padre-Madre-
Infante: Evaluación de las alianzas familiares a través del Lausanne Trialogue Play,
apego y niveles de depresión parental. Revista argentina de clínica psicológica,
22(1), 85.

Pancsofar, N., Vernon-Feagans, L., Odom, E. & Roe, J. R. (2008). Family relationships
during infancy and later mother and fathervocabulary use with young children, Early
Child Research, 23(4), 493-503. http://dx.doi.org/10.1016/j.ecresq.2008.07.001

Papoušek, H., & Papoušek, M. (1987). Intuitive parenting: A dialectic counterpart to the
infant's integrative competence. Handbook of Infant Development, (2nd Ed, pp 669-
720) New York: Willey.

Parke, R. D., Power, T. G., & Gottman, J. (1979). Conceptualizing and quantifying
influence patterns in the family triad. Social interaction analysis: Methodological
issues, 231-252.

Pereira, R. (1994). Revisión histórica de la Terapia Familiar. Psicopatología, 14, 5-17.

291
Pérez, F. y Olhaberry, M. (2014). Involucramiento del Padre en la Crianza: Una Mirada
Tríadica de las Relaciones Familiares Tempranas. Revista SUMMA Psicológica UST,
11(2), 9-18.

Raikes, H. A., & Thompson, R. A. (2006). Family emotional climate, attachment security
and young children's emotion knowledge in a high risk sample. British Journal of
Developmental Psychology, 24(1), 89-104.

Schoppe-Sullivan, S. J., Altenburger, L. E., Settle, T. A., Kamp Dush, C. M., Sullivan, J.
M., & Bower, D. J. (2014). Expectant fathers' intuitive parenting: associations with
parent characteristics and postpartum positive engagement. Infant Mental Health
Journal, 35(5), 409-421. http://dx.doi.org/10.1002/imhj.21468.

Schoppe-Sullivana, S. J., Mangelsdorfb, S. C., Brown, G.L. & Szewczyk Sokolowski, M.

(2007). Goodness-of-fit in family context: Infant temperament, marital quality, and
early coparenting behavior, Infant Behavior & Development,30, 82-96.
http://dx.doi.org/10.1016/j.infbeh.2006.11.008.

Shapiro, A. F., Nahm, E. Y., & Gottman, J. M. (2011). Bringing Baby Home Together:
Examining the Impact of a Couple-Focused Intervention on the Dynamics within
Family Play. American Journal of Orthopsychiatry, 81(3), 337-350.
http://dx.doi.org/10.1111/j.1939-0025.2011.01102.x.

Simonelli, A., Bighin, M., & De Palo, F. (2012). Coparenting interactions observed by the
prenatal lausanne trilogue play: An Italian replication study. Infant Mental Health
Journal, 33(6), 609-619. http://dx.doi.org/10.1002/imhj.21350.

Simonelli, A., De Palo, F., & Bighin, M. (2014). From pregnancy to the 9th month: the
development of early interactive-relational competencies of the child in the family
context. Interdisciplinary Journal of Family Studies, IXX(1), 110-130.

Stern, D.N. (1985). El Mundo Interpersonal del Infante. Paidós, Barcelona.

Szabó, N., Dubas, J. S., & van Aken, M. A. (2012). And baby makes four: The stability of
coparenting and the effects of child temperament after the arrival of a second
child. Journal of family psychology, 26(4), 554. http://dx.doi.org/10.1037/a0028805.

Szabó, N., Semon Dubas, J. & van Aken, M. A. G. (2014). Jealousy in Firstborn Toddlers
within the Context of the Primary Family Triad, Social Development, 23 (2), 325-
339. http://dx.doi.org/10.1111/sode.12039

Szabó, N., Semon Dubas, J., Karreman, A., van Tuijl, C., Dekovic, M. & van Aken, M. A.
G. (2010). Understanding human biparental care: does partnerpresence matter?, Early
Child Development and Care, 181 (5), 639-647.

292
Talbot, J. A., Baker, J. K., & McHale, J. P. (2009). Sharing the love: Prebirth adult
attachment status and coparenting adjustment during early infancy. Parenting:
Science and Practice, 9(1-2), 56-77. http://dx.doi.org/10.1080/15295190802656760.

Teubert, D., & Pinquart, M. (2010). The association between coparenting and child
adjustment: A meta-analysis. Parenting: Science and Practice, 10(4), 286-307.

Tissot, H., Scaiola, C. L., Frascarolo, F., Despland, J. N., Stiefel, F., & Favez, N. (2014).
Family Alliance as a Moderator of the Link Between Maternal Postpartum
Depression and Child Symptoms Assessed by Both Parents. Journal of Family Issues,
35(11) 1520-1542. http://dx.doi.org/10.1177/0192513X13488522

Tomasello, M., Carpenter, M., Call, J., Behne, T., & Moll, H. (2005). Understanding and
sharing intentions: The origins of cultural cognition. Behavioral and Brain Sciences,
28, 675–735. http://dx.doi.org/10.1017/S0140525X05000129.

Trevarthen, C. (1993). The self born in intersubjectivity: The psychology of an infant

communicating. En U. Neisser (Eds.), The perceived self: Ecological and
interpersonal sources of self-knowledge, (1st ed., pp. 121-173). Cambridge:
Cambridge University Press.

Umemura, T., Jacobvitz, D., Messina, S. & Hazen, N. (2013) Do toddlers prefer the
primary caregiver or the parent with whom they feel more secure? The role of toddler
emotion. Infant Behavior & Development, 36, 102-114.
http://dx.doi.org/10.1016/j.infbeh.2012.10.003.

Von Klitzing, K., Simoni, H., Amsler, F., & Bürgin, D. (1999). The role of the father in
early family interactions. Infant Mental Health Journal, 20(3), 222-237.
http://dx.doi.org/10.1002/(SICI)1097-0355(199923)20:3%3C222::AID-
IMHJ2%3E3.3.CO;2-2

Wobber, V., Herrmann, E., Hare, B., Wrangham, R., & Tomasello, M. (2014). Differences
in the early cognitive development of children and great apes. Developmental
Psychobiology, 56(3), 547-573. http://dx.doi.org/10.1002/dev.21125.

293
Figura 1: Diagrama de flujo de la información en las distintas fases de la revisión.

Número de registros o citas identificados Número de registros o citas adicionales

en las búsquedas: identificados en otras fuentes:
451 0

Número total de registros o citas eliminadas:

76

Número total de registros o citas únicas Número total de registros o citas

cribadas: duplicadas eliminadas:
375 259

Número total de artículos a texto completo Número total de artículos a

analizados para decidir su elegibilidad: texto completo excluidos:
116 59

Número total de artículos incluidos en la

síntesis cualitativa de la revisión
sistemática:
57

294
Tabla 1. Estudios incluidos en la revisión

Autores País(es) Diseño Muestra Procedimiento de

Evaluación
Altenburger et al. (2014) EE.UU NE, L NC, 182 M-P-N (3ªTEm/9m) LTPs y LTP S
Bingham et al. (2013) EE.UU NE, T NC, 63 M-P-N (16-37m) IT NS
Cairo et al. (2012) Suiza NE, L NC, 31 M-P-N (E/9) LTPs y LTP S
Cannon et al. (2008) EE.UU NE, T NC, 97 M-P-N (3,5m) IT NS
Carneiro et al. (2006) Suiza NE, L NC, 41 M-P-N (6mEm/3m) LTPs y LTP S
Curran et al. (2009) EE.UU E, L NC, 125 M-P-N (2ª) IT NS
de Mendonça et al. (2011) Canadá E, T NC, 42 M-P-N (32m) JL NS
Elliston et al. (2008) EE.UU NE, L NC, 115 M-P-N (3m) LTP S
Favez et al. (2006) Suiza NE, L NC, 38 M-P-N (5mEm/3/9/10m) LTPs y LTP S
Favez et al. (2006) Suiza NE, L NC, 39 M-P-N (5mEm/3/18m) LTPs y LTP S
Favez et al. (2012) Suiza NE, L NC, 38 M-P-N (5mEm/3/9/18m) LTPs y LTP S
Favez et al. (2013) Suiza NE, L NC, 42 M-P-N (5mEm/3/18m) LTPs y LTP S
Feldman & Masalha (2010) Israel CE, L NC, 155 M-P-N (20-21m/33-34m) JL NS
Feldman (2007) Israel NE, T C,NC, 145 M-P-N (4m), SDAM, BP JL NS
Feldman et al. (2003) Israel CE,T C, NC, 146 M-P-N (3m), BP IT NS
Fivaz-Depeursinge et al. (1996) Suiza NE, L C, NC, 28 M-P-N (0-4ª) LTP S
Fivaz-Depeursinge et al. (2005) Suiza NE, T NC, 6 M-P-N (4m) LTP+still face S
Fivaz-Depeursinge et al. (2009) Suiza NE, L NC, 87 M-P-N (5mEm/3/9/18m) LTP S
Fivaz-Depeursinge et al. (2012) Suiza NE, T NC, 38 M-P-N (5mEm/3/9/18m) LTPs y LTP S
Frascarolo et al. (2003) Suiza NE, T NC, 42 M-P-N (3m) LTP S
Frascarolo et al. (2004) Suiza NE, L NC, 80 M-P-N (3 - 4m) LTP S
Frascarolo et al. (2005) Suiza NE, T NC, 6 M-P-N (3m) LTP S
Gordon & Feldman (2008) Israel NE, L NC, 94 M-P-N (5m) JL NS
Gordon et al. (2010) Israel NE, L NC, 37 M-P-N (2m/6m) JL NS
Guzell & Vernon-Feagans (2004) EE.UU NE, T NC, 66 M-P-N (12-14m) JL NS
Hazen et al. (2005) EE.UU NE, L NC, 31 M-P-N (8-24m) IT NS
Hedenbro & Tjus (2007) Suecia NE, L C, 20 M-P-N (3/9/18/48m), NA LTP S
Hedenbro & Rydeliu. (2014) Suecia NE, L NC, 15 M-P-N (3/9/18/48m) LTP S
Hedenbro et al. (2006) EEUU y Suecia NE, L NC, 40 M-P-N (3m) LTP S
Jacobvitz et al. (2004) EE.UU NE, L NC, 125 M-P-N (24m/7ª) IT NS
Jesseea et al. (2010) EE.UU NE, L NC, 65 M-P-N (1ºTE/3,5m/12m) IT NS
Khazanet al. (2009) EE.UU NE, L NC, 119 M-P-N (3ªTEm/3m) LTP S
Kwon et al. (2012) EE.UU E, T NC, 67 M-P-N (16-36m) IT NS
Lindsey et al. (2006) EE.UU NE, T NC, 60 M-P-N (11-15m) JL NS
McHale & Coates (2014) EE.UU NE, T C, 19 M-P-N (3m), PS LTP S
McHale & Rasmussen (1998) EE.UU NE, L NC, 37 M-P-N (8-11m / 3ª) IT NS
McHale & Rotman (2007) EE.UU NE, L NC, 110 M-P-N (3m) LTP S
McHale (1995) EE.UU NE, L NC, 47 M-P-N (8,5-11m) IT NS
McHale et al. (2004) EE.UU NE, L NC, 50 M-P-N (3m) LTP S
McHale et al. (2008) EE.UU NE, L NC, 113 M-P-N (3m) LTP S
Olhaberry et al. (2013) Chile NE, T NC, 10 M-P-N (3-10,5m ) LTP S
Pancsofar et al. (2008) EE.UU NE, L NC, 74 M-P-N (12/24m) IT NS
Schoppe-Sullivan et al. (2014) EE.UU NE, L NC, 182 M-P-N (3ªTEm/3m) LTPs y LTP S
Schoppe-Sullivana et al. (2007) EE.UU NE, L NC, 97 M-P-N (3ªTEm/3,5m) IT NS

295
Shapiro et al. (2011) EE.UU E, L NC, 116 M-P-N (3-4,5m) LTP S
Simonelli et al. (2011) Italia NE, L NC, 70 M-P-N (7mEm/4/9m) LTPs y LTP S
Simonelli et al. (2012) Italia NE, L NC, 98 M-P-N (7mEm) LTPs S
Spitzer & Tyano (2005) Israel NE, L NC, 35 M-P-N (3ª) JL NS
Szabó et al. (2012) Holanda NE, L NC, 88 M-P-N (23.43m) LTP S
Szabó et al. (2014) Holanda NE, T NC, 87 M-P-N (16-28m) LTP S
Szabóa et al. (2010) Holanda NE, L NC, 87 M-P-N (36m) IT NS
Talbotet al. (2009) EE.UU NE, L NC, 119 M-P-N (3m) LTP S
Tissot et al. (2013) Suiza NE, T NC, 65 M-P-N (3m) LTP S
Umemura et al. (2013) EE.UU NE, L NC, 97 M-P-N (12-15m/24-29m) IT NS
Von Klitzing et al. (1999) Suiza NE, L NC, 41 M-P-N (4m) LTP y TIC S
Von Klitzing et al. (1999) Suiza NE, L NC, 35 M-P-N (1/4/7/12m) LTP y TIC S

Nota: E= Estudio experimental, NE= Estudio no experimental, L= Estudio longitudinal, T=

Estudio transversal, C= Población clínica, NC= Población no clínica, PS= Padres
separados, SDAM= Síntomas ansiosos y depresivos maternos, BP= Bebé prematuro, NA=
Niños/as con autismo, Em= Embarazo, TEm= Trimestre de embarazo, S= Procedimiento de
evaluación sistematizado, NS= Procedimiento de evaluación no sistematizado.

Tabla 2. Objetivos y variables de los estudios que incluyen un procedimiento específico

para la evaluación de las interacciones familiares tríadicas y un método de codificación.
Autores Objetivo Evaluación Codificación
Altenburger et al. (2014) Estudiar IT pre y postnatales. LTPs CRS
LTP LTPsCS
Cairo et al. (2012) Describir la evolución las IT en parejas que LTPs y LTP FAAS
concibieron mediante fertilización in vitro.
Carneiro et al. (2006) Presentación de un instrumento de LTPs y LTP CFRS LTPsCS
evaluación de la AF prenatal.
Favez et al. (2006) Evaluar AF, AP, TI y adaptación a los 18 m. LTPs y LTP GETCEF
Favez et al. (2006) Estudiar el desarrollo de la AF desde el LTPs y LTP GETCEF LTPsCS
embarazo hasta los 2 años del bebé.
Favez et al. (2012) Estudiar el impacto de la AF a los 2 a en el LTPs y LTP GETCEF LTPsCS
desarrollo emocional y cognitivo a los 5 a.
Favez et al. (2013) Explorar el valor predictivo de las IT y LTPs y LTP GETCEF LTPsCS
representaciones prenatales sobre las
postnatales.
Feldman & Masalha (2010) Evaluar IT desde los 5 a 33m. JL CIB
Fivaz-Depeursinge et al. Presentar el LTP como un método para la LTP GETCEF
(1996) evaluación de IT.
Fivaz-Depeursinge et al. Evaluar la CP y estilos interactivos del niño LTP GETCEF
(2009) en coaliciones familiares.
Fivaz-Depeursinge et al. Comparar las estrategias interactivas entre LTPs y LTP GETCEF LTPsCS
(2012) familias con BC y AC.
Frascarolo et al. (2004) Evaluar la jerarquía de las funciones de la LTP GETCEF
IT.
Frascarolo et al. (2005) Explorar la relación entre AF y LTP GETCEF THEME
comunicación no verbal.
Gordon et al. (2010) Evaluar IT y oxitocina y cortisol en los JL CIB
padres.
Hedenbro & Tjus (2007) Estudiar la comunicación entre recién LTP CPICS
nacidos y sus padres.
Hedenbro & Rydeliu. Evaluar IT los 3 m del niño y sus habilidades LTP CPICS
(2014) sociales a los 4 años.
Hedenbro et al. (2006) Comparar el tiempo de juego triádio en LTP CPICS
familias suecas y de EEUU. TICS

296
Khazanet al. (2009) Evaluar AP, CP y participación en el LTP CFRS
cuidado del bebé.
McHale & Coates (2014) Examinar la crianza compartida en padres LTP CFRS GETCEF
que residen separados.
McHale & Rotman (2007) Examinar el efecto de las expectativas LTP CFRS
prenatales sobre la IT y la CP.
McHale et al. (2004) Evaluar el valor predictivo de las LTP CRS
representaciones para la CP temprana.
McHale et al. (2008) Describir la capacidad de compartir la LTP CFRS GETCEF
atención con ambos padres a los 3m y su
relación con la IT.
Olhaberry et al. (2013) Evaluar la relación entre el tipo de AF, AA y LTP GETCEF
DP.
Schoppe-Sullivan et al. Examinar la CIP-H pre y Postnatal. LTPs LTPsCS
(2014) LTP
Shapiro et al. (2011) Evaluar el programa “Bringing Baby LTP TICS
Home”.
Simonelli et al. (2011) Estudiar la CPp y Postnatal. LTPs y LTP CFRS LTPsCS
Simonelli et al. (2012) Evaluar las propiedades psicométricas del LTPs CFRS LTPsCS
LTPs.
Szabó et al. (2012) Estudiar la estabilidad de la CP y su relación LTP (adaptado) CFRS
con el TI con el 2º hijo.
Szabó et al. (2014) Estudiar los celos infantiles. LTP CED
Talbotet al. (2009) Estudiar el apego parental y el ajuste en la LTP CRS
CP. CFRS
Talbotet et al. (2009) Estudiar el apego parental y el ajuste CP LTP Couples Rating
System; CFRS
Tissot et al. (2013) Evaluar la asociación entre DM y síntomas LTP FAAS
infantiles a los 3m y el rol moderador de la
AF
Von Klitzing el at. (1999) Estudiar el desarrollo de las interacciones LTP; TIC TIC
desde el embarazo hasta el primer año del
niño/a.
Von Klitzing et al. (1999) Investigar la influencia del padre en las IT. LTP; TIC TIC
NOTA: IT= interacción triádica, CIP-H=calidad de la interacción padre-niño, DM=
depresión materna, AF= alianza familiar, CPp= co-parentalidad prenatal, AA= apego
adulto, DP= depresión parental, CP= co-parentalidad, TI= temperamento infantil, LTPs=
Lausanne Trialogue Play prenatal, LTP= Lausanne TRialogue Play, JL= juego libre, TIC=
codificación de la entrevista triádica, BC= baja coordinación, AC= alta coordinación, AP=
ajuste de pareja, CED= hostilidad; negatividad, acercamiento, evitación; distracción;
búsqueda, CFRS= cooperatividad, calidez, sensibilidad, competitividad, descalificación,
sobre estimulación, desconexión, estrés infantil. GETCEF= participación, focalización.
CRS= cooperación; placer; competencia; desagrado, LTPsCS= placer; estructura,
parentalidad intuitiva, cooperación, calidez, FAAS= posturas y miradas, inclusión,
implicación, estructura, co-construcción, andamiaje parental, calidez, validación del niño,
autenticidad, errores y su reparación, TICS= afecto infantil, afecto facial, vocalizaciones,
postura corporal, CIB= sensibilidad y responsibidad, intrusividad, afecto infantil,
compromiso y reciprocidad, CPICS= contribución, afirmación, clarificación, turnos,
triangulación, foco familiar, contacto ocular, inclusión/exclusión, sincronía, THEME=
organización y contacto afectivo, considera categorías tríadicas e individuales, TIC=
contenido del lenguaje, expresión emocional, calidad del funcionamiento y del diálogo,
fantasías sobre el niño por nacer y sobre la relación tríadica, capacidad de interacción
triádica.

297
10.12.4. Video-feedback intervention to improve parental sensitivity and the quality
of interactions in mother-father-infant triads (Published)

298
Mental Health in Family Medicine (2017) 13: 532-543
esearch rticle
Video-feedback
Research Article intervention to improve parental
Open Access
sensitivity and the quality of interactions in
mother-father-infant triads
Marcia Olhaberry
chool of sycholo y onti cia niversidad at lica de hile
ar a os e n
niversity of hile hile
arta scobar
chool of sycholo y onti cia niversidad at lica de hile
Daniela Iribarren
chool of sycholo y onti cia niversidad at lica de hile
Irma Morales-reyes
chool of sycholo y onti cia niversidad at lica de hile
arla lvare
chool of sycholo y onti cia niversidad at lica de hile
AbstrAct
The quality of dyadic and triadic family interactions during
early childhood significantly influences social-emotional
development and childhood mental health. Video feedback is
a valuable psychotherapeutic tool for intervention in the early
family. A brief intervention using this technique, aimed at
mother-infant-father triads with difficulties in social-emotional
development, was developed. Eighty triads, composed of
heterosexual couples between 20 and 43 years of age for
mothers, between 22 and 54 years of age for fathers, and
between one and three years of age for children, participated.
The results show a significant increase in the quality of triadic
Background
The empirical evidence supports the importance of early
emotional bonding and experiences for brain development and
childhood mental health, with parents being the main source
of interactional experiences during the first years of life [1].
Considering these approaches, a growing number of studies
and interventions have focused on family relationships and
parenting during this stage of human development [2-5].
Parental skills are tested from the birth of the first child, who,
based on the demands associated with parenting, modify the family
organization and the couple relationship [6,7]. Faced with these
changes, the expression of affection and complicity between parents
acts as a protective factor for the proper exercise of parenthood [8].
In this line, studies show that the father's emotional support for
the mother has been associated with a greater maternal ability to
respond sensitively to the baby's cues [9-11].
In the context of parenting, the ability of both parents to share
the tasks associated with parenting, provide mutual support,
and show commitment is called co-parenting [12]. Adequate
2017 Mental Health and Family Medicine Ltd
hile
hile
hile
hile
hile
interactions (Wilks'λ = 0.735, F (1, 77) = 27,794; p < 0.000)
and co-parenting (Wilks'λ = 0.098, F (1, 77) = 8.395; p =
0.005) as well as parental sensitivity (Wilks'λ = 0.661, F (1,
77) = 39.42; p < 0.000) and sensitivity in the mothers (Wilks'λ
= 0.585, F (1, 77) = 54,706, p < 0.000) who were the object
of the intervention. The fathers significantly reduced their
nonresponsive behavior (Wilks 'λ = 0.903, F (1, 77) = 8.441;
p = 0.005), and the mothers reduced their controlling behavior
(Wilks' λ = 0.916, F (1, 77) = 7.084; p = 0.009).
MeSh Headings/ Key words: Video feedback; Parental
sensitivity; Triadic interactions
co-parenting is beneficial and has been associated with greater
congruence between the attachment patterns of both parents
[13,14]. Complementarily, competitive and hostile co-parenting
has been associated with internalizing and externalizing
symptomatology in the child during the preschool stage [15,16].
From a systemic view, the various elements of a family system
are connected, and there is an interrelation between the conjugal
and parental subsystems [17]. In this sense, the literature shows
the influence of the couple subsystem on the tasks associated
with raising small children and on co-parenting [18], in addition
to the influence of these variables on functioning [19].
In the exercise of early parenting, dysfunctional family
relationships negatively impact children, which is associated
with deficits in children's cognitive and socioemotional
development [20]. Specifically, different variables that influence
the quality of family interactions have been identified, such as
maternal depressive symptomatology and stress in parenting
[21,22]; maternal emotional deregulation [23]; and experiences
of early parental adversity [24,25].
Complementarily, the scientific literature shows that parents
533 Marcia Olhaberry, María José León, Marta Escobar, et al.
who develop a relationship with high levels of support and
commitment have greater resources to interact in a sensitive
manner with their children, whereas conflicting couples present
more difficulties in achieving positive interactions [26]. In
addition, the individual characteristics of each member of the
parental dyad also influence the quality of interactions with their
children, with differences also found associated with the gender
of the parent [27,28].
Although children are often born and raised in family
settings that include two primary caregivers, most studies in
early infancy have focused on the mother-baby or mother-
infant dyad. From this dyadic view of parenting, the adult's
sensitive response, i.e., the adult's ability to read and interpret
the child's cues associated with his or her needs and to respond
appropriately and contingently [29], has been a widely revised
concept and has been associated with the pattern of child
attachment developed toward both parents [30,31]. However,
this approach has changed over time, from a focus on the
behavioral aspects of the adult and the child to an approach that
includes internal and representational aspects of the participants
and that considers the mutual influence between both members
of the dyad [32,33].
Research has consistently shown the protective value of
adequate maternal sensitivity in child development [31,34,35]
specifically for socio-emotional development [4,5,33,36] and
the child’s mental health [37]. However, this relationship is
not linear, as demonstrated by a recent study. The study shows
that maternal psychosocial imbalances in the presence of high
sensitivity will not be associated with infant symptomatology,
with sensitivity, in this sense, as a protective role for children's
mental health in adverse circumstances [34].
Although the value of parental sensitivity in child
development and mental health is well-established among
clinicians and researchers, its understanding within the triadic
dynamic, i.e., that which include the father and mother in
the interaction with the child, has been less studied. Recent
research describes the differences and similarities between
parents, noting that socioeconomic status affects the sensitivity
of both parents but that the level of satisfaction with the couple
relationship affects only the parents [38]. In this same line,
the differences between parents in the capacity to respond to
and interpret children's needs have been evaluated, and it has
been found that mothers more positively evaluate expressions
of happiness and intense childhood emotions, both positive and
negative, as more extreme compared to fathers [22].
Expanding this view, the mother-father-infant triad is a
unit with its own structure and characteristics, in which the
participation of a third person modifies the dyadic dynamic,
generating greater interactional complexity and socio-emotional
diversity [39].
Cooperative triadic interactions, in a climate of warmth
between parents during the first years of life, are child-friendly
experiences that promote healthy social development [40-
42]. Triadic family cohesion, reciprocal relationships with
the mother, and involvement and social commitment in the
relationship with the father are predictors of social skills in
the child [43]. When children engage in chronic dysfunctional
family interactions or recurrent parental conflicts, they develop
maladaptive behaviors in the face of conflict management,
a failure to develop adequate regulatory mechanisms, and
difficulties in peer relationships [44,45]. However, maintaining
positive interactions with one parent promotes learning in the
child that contributes to reducing stress and facilitating their
self-regulatory mechanisms, thus also improving dysfunctional
interactions with the other parent [46].
Early Interventions and Video Feedback
Many studies have shown that it is possible to improve the
quality of parent-child interactions and to promote children's
socio-emotional development through early interventions
[2,3,47]. However, the inclusion of the father in interventions
in families with children under three years of age is still scarce.
The father has been included mainly in an indirect manner,
through interventions focused on the co-parenting relationship
and its influence on child development [48-50]. The studies that
directly include fathers are those involving preterm children
[51] and preventive programs to promote positive parenting
behaviors within the mother-father-baby family system [52].
In the context of early interventions, video feedback is a
technique that is increasingly used as a central or complementary
tool [53-57]. It consists of the video recording of interactions
between the adult(s) and the child, which are then analyzed by
the therapist and presented to the parents. This technique has
been shown to facilitate and accelerate internal and behavioral
changes, generating an affective experience shared with the
therapist and between the parents and the child [58,59]. In
addition, it allows parents to learn about their children's non-
verbal language, skills, and behaviors, thereby facilitating new
forms of interaction [60,61].
Interventions that use this technique show significant
improvements in the quality of parent-child interactions,
child development and clinical symptomatology [56,62,63].
Two meta-analyses emphasize the value of video feedback
as a therapeutic tool due to its effectiveness in increasing
parenting skills from a small number of sessions, which allows
for favourable results in a short period of time and at low cost
[47,62]. Some studies have sought to explain the effectiveness
of video feedback by suggesting that working with parents with
videotaped interactions will allow them to see themselves, their
child, and the relationship with greater perspective and less
emotional intensity, which will facilitate the development of
a reflective space with the therapist [54,64]. In this sense, the
therapeutic space offers parents an instance of self-observation
and observation of their child as a distinct human being with his
or her own mental states, also facilitating the recognition of the
mutual influence between them [54,57].
In Chile, this technique has been used with low-income
multi-problem families [65] and with mother-infant dyads with
depressive symptomatology, showing improvements in maternal
sensitivity [66], but we do not have interventions that use it
including the father and the mother simultaneously. The above
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 534
background supports the relevance of early dyadic and triadic
family interactions in children's socio-emotional development,
the need to include the father in interventions, and the value
of video feedback as an early family psychotherapeutic tool.
Considering the above, the present study evaluates changes
in maternal and paternal sensitivity as well as in the quality of
triadic interactions after a video-feedback intervention directed
at the mother-father-infant triad.
Method
Design
A quasi-experimental study was conducted to evaluate
the differences between the pre- and post-intervention
measurements in the participants belonging to the experimental
and control groups.
Participants
A total of 80 mother-father-child triads between one and three
Flow Chart: articipants o chart
years old, living in the Metropolitan Region of Santiago, Chile,
with difficulties in children's social and emotional development
(evaluated with the ASQ-SE) [67] participated in this study.
Families were contacted through preschools and public health
centers and were referred by the study participants. Forty
triads were part of the experimental group (EG) and received
a video-feedback intervention after the initial evaluation. Forty
triads were part of the control group (CG) and did not receive
the intervention between the pre- and post-measurements. The
control group received the intervention after the evaluations
were completed (Flow Chart).
The inclusion criteria of the study were being fathers and
mothers over 18 years of age, in a current heterosexual couple
relationship, and with at least one child aged between 12 and 36
months, with socio-emotional difficulties reported by the parents
or by one or more of the referring professionals (behavioral,
emotional regulation, and sleep, eating, and/or relationship).
The exclusion criteria considered in the parents and the children
were the presence of some disability (intellectual and of the
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 535
senses), psychoses diagnosed in adults, and/or the presence of
addictions.
Instruments
The pre- and post-video-feedback intervention measurements
were performed using the following instruments:
Personal information form: This instrument was used
to collect the participants' sociodemographic information and
mental health history. It was used to collect the participants’
sociodemographic information and included questions about
children’s age, gender, and birth order, the parents’ age, the
parents’ number of children, the parents’ years of education,
whether the parent has a job, and whether the parents have/had
psychological/pharmacological treatment.
CARE-Index, Experimental Index of Child-Adult
Relationships [68]. The instrument involves a 3-5-minute video
recording of play interaction between the child and the adult.
The coding system defines three descriptors for the adult, i.e.,
sensitive, controlling, and non-responsive, and four for the
infant, i.e., cooperative, difficult, compulsive, and passive. It
considers a dyadic sensitivity scale that ranges from 0 to 14
points, with 0-4 signalling “risk”, 5-6 “inept”, 7-10 “adequate”,
and 11-14 “sensitive”; scores below 7 indicate the need for
intervention. The video coding was performed by psychologists
trained by the author of the instrument and reached a reliability
of ≥ 0.7 in the various scales used. The coding of the videos was
performed without the presence of information regarding the
source of the videos, i.e., belonging to either the experimental
group or the control group. The inter-rater reliability between
the three coders who participated in the study was kappa =
0.830 (p = 0.000).
Lausanne Triadic Play (LTP) [6]: This instrument consists
of a semi-structured procedure for the observation and evaluation
of triadic family interaction. It requires the video recording of an
interaction game between the mother, the father and the infant,
with the instruction to play as they typically do but following a
structure that considers four stages: 1) the mother or the father
actively plays with the child while the other adult is only present;
2) these roles are reversed between parents; 3) the father, the
mother and the child play actively; and, 4) finally, the father and
the mother interact and the child is simply present. The three
participants are placed in an equilateral triangle with three seats
and a table in the center. To develop the activity, they each have
three sets of three small toys, which facilitate symbolic play and
the development of co-constructed activities (puppets, cups, and
animals). The family interaction is recorded with two cameras,
one directed to the body and face of the parents and another
to the body and face of the infant. To perform the activity, the
family is informed that they have between 10 and 15 minutes in
total to perform the four stages and that they themselves regulate
the distribution of time through a clock located in a visible
place for both parents. The process of coding the interaction is
based on "The Family Alliance Assessment Scales" [69]. The
scores obtained in the total quality of the triadic interactions can
vary between 0 and 30 points and consider seven dimensions:
participation, organization, focalization, affect sharing,
miscoordinations, co-parenting and support conflicts, and child
regulation/assertiveness. Studies conducted by the Lausanne
team report average scores of 19 points in a normative sample
and 10.3 in a clinical sample [69]. Studies developed in Chile
report an average of 10.09 in a non-clinical population of
medium and low socioeconomic status [70]. The alpha value
obtained by the triad of the study in the LTP is 0.901. The videos
were coded by three independent coders certified by the author
of the instrument.
Beck Depression Inventory, BDI [71]. This is a self-reporting
questionnaire composed of 21 items. It evaluates current
depressive symptoms. In this test, the subject must choose the
phrase that best describes his or her emotional state over the
previous week from a set of four alternatives ordered from
lowest to highest severity. Each item may be evaluated from 0 to
3 points, with a total score varying from 0 to 63. Higher scores
indicate greater depressive symptoms, and four categories of
depression are identified: minimum, 0-9; mild, 10-18; moderate,
19-29; and severe, 30-63. The reliability analysis is adequate,
having been obtained from the Spanish version applied to
patients with psychological disorders with an alpha value = 0.90
[72]. The Chilean validation study of the instrument reports an
alpha value of 0.92 [73]. The alpha value obtained in the present
study is 0.828 for fathers and 0.832 for mothers.
Process
The study was certified by the Institutional Ethics
Committees of the Pontifical Catholic University of Chile and
the National Commission for Scientific and Technological
Research (CONICYT).
The families were contacted through professionals from day
cares and JUNJI preschools (National Board of preschools of
the Ministry of Education of the Government of Chile), through
family public health centers (FPHC) and the spontaneous
demand of parents. For the participation of the families in the
study, the parents were initially informed of the characteristics
of the research, and the inclusion and exclusion criteria were
evaluated. Those who met the criteria and agreed to participate
signed an informed consent form at the first evaluation session.
Once the above was done, the instruments were applied in
the homes of the participants. The evaluations were initiated
with the recording of the triadic interaction (LTP) and dyadic
interaction (CARE-Index) and, finally, the application of the
scales and questionnaires. The measurements were made during
the years 2015 and 2016 by clinical psychologists who were
trained to use the instruments deployed.
The mother-infant dyad with maternal depressive
symptomatology [66] was also considered as a general model
for the video-feedback intervention, also adding elements
oriented toward the triadic aspects of the interaction [74]. The
intervention was performed in the homes of families with a
weekly frequency. The video recordings of interaction between
the adults and the child, their analysis, and the review with
the parents of segments that showed positive aspects were
considered. The recordings for the CARE-Index and LTP were
used for video-feedback sessions 2, 3, and 4. In session 5, new
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 536
Figure 1: riadic video-feedback intervention
videos of triadic feeding and dyadic play were recorded, which
were worked on in session 6. Seven sessions were considered
in total, two sessions of evaluation and five sessions of
intervention directed to the father, the mother, or the parental
dyad. The first six sessions were performed by the same pair
of therapists, whereas the final evaluation was performed by a
family unknown to the couple, avoiding that the link created
with the therapists could influence the results. The following
diagram shows the outline of the sessions (Figure 1):
Each therapeutic process was developed by two clinical
psychologists with at least one semester of training in the care
of families and children under three years of age using video
feedback. The training consisted of participating in weekly
clinical meetings and a two-day training on early childhood,
parenting, and the use of the instruments. The clinical meetings
included a presentation of the triads and the analysis of the
videos and the scripts elaborated for the video feedback,
considering the focus of intervention. The team included a
total of 18 clinical psychologists, of whom six had previous
experience in the psychotherapeutic use of video feedback.
Session 1: This session considered the application of the
instruments, the recording of the videos, and the exploration of
the concerns of the mother and the father about the child or about
the relationship. Then, the modality of the work was explained,
and the figure (mother or father) that would be worked on in the
second session was agreed upon.
Post-session work: The therapist pair identified the negative
and positive sequences in the selected video to be used in the
next session, seeking to link the interactions observed with the
parents' concerns. Segments of positive interactions were then
selected, defining their therapeutic use, and they were presented
at the weekly clinical meeting and, subsequently, to the parents.
This scheme was repeated after each session until the closure, in
session 6.
Sessions 2 and 3: According to the family decision, in
session 2, work with the mother or the father began. The selected
sequences were reviewed in the dyad free play video clips
recorded with the child. A task was built to perform between
sessions based on the reflections and discoveries made by the
parent in watching the video. In session 3, the same scheme was
repeated with the other parent.
Session 4: We worked with the parental dyad from the
observation of positive aspects of the video of triadic interaction
and defined a task to perform between sessions linked to learning
and reflections.
Session 5: New videos were videotaped, two free play
mother-infant and father-infant dyads, and video of mother-
father-infant triadic feeding. The triadic video consisted of a
shared collation of healthy foods defined as enjoyable for the
three participants.
Session 6: Work was done with the parental dyad from the
observation of the videos recorded in session 5. The general
process of intervention and learning was evaluated with the
family, and a closure was performed.
Session 7: In this session, the post-intervention evaluation
was performed.
Analysis of data
Before performing the statistical analysis of the data, we
evaluated the presence of atypical values and the fulfillment of
the assumptions of the statistical tests performed, particularly
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 537

Table 1: escriptive tatistics of the participants sociodemo raphic data

EG n = 40 CG n = 40 Mean Difference
Variable
M (S.D) Min. - Max. M (S.D) Min. - Max. T observed Sig.
Mo age (years) M = 32.83 (S.D. = 5.17) 20-43 M = 31.70 (S.D. = 4.76) 23-42 T78 = 1.012 0.314
F age (years) M = 35.63 (S.D. = 6.71) 24-54 M = 33.70 (S.D. = 5.88) 22-49 T78 = 1.365 0.176
Child’s age (months) M = 25.08 (S.D. = 7.64) 8-36 M = 24.15 (S.D. = 7.57) 12-36 T78 = 0.547 0.586
Mo Ed. (years) M = 14.90 (S.D. = 2.55) 7-17 M = 15.03 (S.D. = 2.82) 8-17 T78 = -0.208 0.836
M = 15.13 (S.D. =
F Ed. (years) M = 15.05 (S.D. = 2.53) 8-17 8-17 T78 = -0.132 0.895
2.54).
perimental roup ontrol roup ean tandard deviation o other ather d ducation

regarding the normality of the variables using the Kolmogorov-
Smirnov test and the evaluation of the QQ. Seven of the 11
variables studied are distributed in a normal manner according to
the Kolmogorov-Smirnov test (p > 0.005). For the remaining four
variables, the dispersion was evaluated as a function of the QQ
plots, and it was considered that the deviation was not enough to
discourage the use of parametric tests. The significance criterion
used was α = 0.05. A descriptive analysis of the main variables
studied in each group was conducted. To evaluate the effects of
the intervention on the variables of the quality of both dyadic
and triadic interactions, repeated-measures analyses of variance
(ANOVAs) were performed using the pre- and post-measurement
as the intrasubject factor and the group to which it belongs as an
intersubjective factor, also controlling according to the age of the
child at the time of the evaluation. The assumption of homogeneity
was evaluated with the Box test. Sphericity was not evaluated
because there were only two groups in the intersubjective factor
and two measurements in the intrasubject factor.
Results
not fulfilled and that no significant interaction effect between
group and sex (F (1.156) = 0.406, p = 0.525) or a main effect of
the group (F (1,156) = 3,656; p = 0.08) is observed. However,
a significant main effect of sex is observed (F (1,156) = 16,510,
p = 0.000). Thus, in both groups, mothers have higher levels
of depressive symptomatology than fathers. Specifically, the
mothers of the EG present an average of 11.48 points (SD =
6.90) and the fathers an average of 7.05 (SD = 6.06). In the CG,
the mothers have an average of 9.08 points (SD = 5.99) and the
fathers an average of 5.85 points (SD = 4.64).
Finally, independent samples were tested for differences
between groups with respect to the age of the parents and
the child and the years of schooling. There are no significant
differences between the groups (p > 0.05; Table 1), and as
reported above, there are also no differences in their workday
or in their depressive symptomatology. In this manner, it can
be stated that the groups are homogeneous with respect to
these variables and, therefore, were not considered as control
variables in the rest of the analyses.

Descriptive analysis Comparative analysis

The EG triads are composed of mothers with a mean age of
32.83 years (SD = 5.17), fathers with a mean age of 35.63 years
(SD = 6.71), and children with a mean age of 25.08 months
(SD = 7.64). The CG triads are composed of mothers with a
mean age of 31.7 years (SD = 4.76), fathers with a mean age of
33.7 years (SD = 5.88), and children with a mean age of 24.15
months (SD = 7.57). Regarding their level of schooling, in the
EG, the mothers have an average of 14.90 years (SD = 2.55)
and the fathers an average of 15.05 years of formal education
(SD = 2.53). In the CG, the mothers have a mean of 15.03 years
(SD = 2.82) and the fathers a mean of 15.13 years (SD = 2.54).
Regarding the working day, 58.1% of the mothers and 92.5%
of the fathers work full-time. In the CG, 67.7% of the mothers
and 97.4% of the fathers work full-time. A chi square test
was performed to evaluate the differences in the working day
according to group, and no differences were found (χ23 = 4,127;
p = 0.248). A test was also performed to evaluate the differences
in the working day by sex, and in this case, differences were
found, with fathers having a greater proportion of full-time
work than mothers (χ23 = 24,916, p = 0.000).
To evaluate the differences in the levels of depressive
symptomatology of fathers and mothers by group, a bifactorial
ANOVA was performed. The results show that the assumption
of homogeneity of variance (F (3, 156) = 2.710; p = 0.047) is
Quality of the triadic interaction, co-parenting and
involvement, and self-regulation of the child. As noted above,
to evaluate the effects of the intervention on the variables, a
mixed ANOVA was performed. In relation to the quality of the
triadic interaction, the assumption of homogeneity (Box’s M =
5.447; F (3, 1095120) = 1,765; p = 0.151) is fulfilled, and a significant
interaction effect between measurement and group is observed
(λ of Wilks = 0.735, F (1.77) = 27,794; p < 0.000). The details are
shown in Table 2. Specifically, the EG shows an increase from
an initial mean of 12.88 (SD = 5.32) to a post-intervention mean
of 18.75 points (SD = 4.54); in contrast, in the CG, the score
remains unchanged between measurements 1 (M1 = 15.63, SD1
= 6.20) and 2 (M2 = 16.38, SD2 = 6.11), as shown in Figure 2.
With regard to co-parenting, the assumption of homogeneity
(Box’s M = 0.917; F (3, 1095120) = 0.297; p = 0.828) is fulfilled, and
a significant interaction effect between measurement and group
is observed (Λ of Wilks = 0.098, F (1.77) = 8,395, p = 0.005). The
details can be observed in Table 2. Specifically, the EG shows
an increase from an initial mean of 2.05 (SD = 0.93) to a post-
intervention mean of 2.80 points (SD = 0.88); in contrast, in the
CG, the score remains unchanged between measurements 1 (M1
= 2.35, SD1 = 0.86) and 2 (M2 = 2.53, SD2 = 0.96). This finding
can be observed in Figure 2.
In relation to the child's involvement and self-regulation,
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 538

Table 2: escriptive statistics of the triadic interaction descriptors

Observed
Variable M Ev.1 n = 40 M Ev.2 n = 40 Wilks’s λ F observed Sig. Size Effect
Power
Triadic IQ EG M = 12.88 (S.D. = 5.32) M = 18.75 (S.D. = 4.54)
0.735 F (1.77) = 27.794 0 0.265 0.999
Triadic IQ CG M =15.63 (S.D. = 6.20) M = 16.38 (S.D. = 6.11)
Co-parent.EG M = 2.05 (S.D. = 0.93) M = 2.80 (S.D. = 0.88)
Co-parent. CG M = 2.35 (S.D. = 0.86) M = 2.53 (S.D. = 0.96) 0.902 F (1.77) = 8.395 0.005 0.098 0.816
Child’s ISR EG M = 2.08 (S.D. = 1.35) M = 2.70 (S.D. = 1.09)
Child’s ISR CG M = 2.18 (S.D. = 1.32) M = 2.00 (S.D. = 1.22) 0.921 F (1.77) = 6.602 0.012 0.079 0.718
perimental roup ontrol croup nteraction s quality nvolvement self-re ulation o-parent o-parentin

Table 3: requencies and percenta es in sensitivity

Quality of the triadic interaction, co- predictors by roup
parenting, and children’s involvement and Predictors CG n = 40 EG n = 40
self-regulation Mothers Pre F (%) Post F (%) Pre F (%) Post F (%)
20 At risk 4 (10.0) 6 (45,2) 6 (15.0) 0
Inept 22 (55.0) 20 (51.6) 23 (57.5) 9 (22.5)
15
Adequate 13 (32. 5) 14 (3.2) 9 (22.5) 23 (57.5)
10 Sensitive 1 (2.5) 0 (0.0) 2 (5.0) 8 (20.0)
Pre Post Pre Post
5
Fathers F (%) F (%) F (%) F (%)
0
At risk 3 (7.5) 1 (2.5) 8 (20.0) 0
QTI pre QTI post C pre C post I & SR pre I & SR post Inept 23 (57.5) 24 (60.0) 18 (45.0) 8 (20.0)
EG CG Adequate 10 (25.0) 14 (35) 10 (25.0) 26 (65.0)
Sensitive 4 (10.0) 1 (2.5) 4 (10.0) 6 (15.0)
uality of triadic interaction o-parentin
nvolvement and self-re ulation perimental roup ontrol roup
Figure 2: uality of the triadic interaction co-parentin and
children s involvement and self-re ulation in and in Maternal Sensitivity
the pre- and post-assessments
9 8.48
8
the assumption of homogeneity (Box’s M = 0.898; F (3, 1095120) = 7 6
6 5.95
0.291; p = 0.832) is also met, and a significant interaction effect 5 6.05
between the measurement and group is observed (λ of Wilks = 4
0.921, F (1.77) = 6.602, p = 0.012). The details can be observed in 3
2
Table 2. Specifically, the EG shows an increase from an initial 1
mean of 2.08 (SD = 1.35) to a post-intervention mean of 2.7 0
Maternal Sensitivity in assessment 1 Maternal Sensitivity in assessment 2
points (SD = 1.09); in contrast, in the CG, the score remains
unchanged between measurements 1 (M1 = 2.18, SD1 = 1.32) EG CG

and 2 (M2 = 2.00, SD2 = 1.22) (Figure 2).
Sensitivity, descriptor controller, and non-responsive
descriptor. Regarding the quality of the interactions in the
dyads of the study, at a descriptive level, the results show lower
frequencies of risk linked to the experimental group after the
intervention and a greater need for subsequent intervention
in the dyads that did not receive the intervention with video
feedback, in both the mothers and the fathers (Table 3).
As established above, to evaluate the effects of the
intervention on the sensitivity, the controlling descriptor and the
nonresponsive descriptor, mixed ANOVA was performed. In the
case of the mothers’ sensitivity, the assumption of homogeneity
(Box’s M = 25.155; F (3, 1095120,000) = 8.152; p = 0.000) is
not met. The results show a significant interaction effect between
measurement and group (λ of Wilks = 0.585, F (1.77) = 54.706;
p = 0.000). The details can be observed in Table 4. Specifically,
the mothers of the EG have significantly increased their mean
Figure 3: aternal sensitivity before and a er intervention
in the and in the
sensitivity from 6.00 points (SD = 1.71) to 8.48 points (SD =
2.06), whereas the mothers of the CG maintain stable levels of
sensitivity between both measurements (M1 = 6.05, SD1 = 1.60,
M2 = 5.95, SD2 = 1.47), as shown in Figure 3.
In the case of fathers, the assumption of homogeneity (Box’s
M = 2.433; F (3, 1095120,000) = 0.789; p = 0.500) is met, and
a significant interaction effect between measurement and group
is observed (λ of Wilks = 0.661, F (1.77) = 39.42; p < 0.000).
The details are shown in Table 4. Specifically, the fathers of the
EG show a significant increase in their sensitivity, rising from
an average of 6.3 points (SD = 2.07) to an average of 8.63 points
(SD = 2.18); in contrast, the fathers of the CG maintain their
stable levels between measurements 1 and 2 (M1 = 6.28, SD1 =
1.91, M2 = 6.45, SD2 = 1.91), as shown in Figure 4.
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 539

Table 4: escriptive statistics aternal and maternal sensitivity by roup

Effect Observed
Variable Mean Ev.1 Mean Ev. 2 Wilks’s λ F observed Sig.
Size Power
EG Mat. Sens M = 6.00 (S.D. = 1.71) M = 8.48 (S.D. = 2.06)
CG Mat. Sens M = 6.05 (S.D. = 1.60) M = 5.95 (S.D. = 1.47) 0.585 F (1.77) = 54.706 0.000 0.415 1
EG Pat. Sens M = 6.08 (S.D. = 1.956) M = 8.63 (S.D. = 2.18)
CG Pat. Sens M = 6.28 (S.D. = 1.91) M = 6.45 (S.D. = 1.91) 0.661 F (1.77) = 39.42 0.000 0.339 1
M Non-responsiv. EG M = 3.38 (S.D.= 2.31) M = 2.3 (S.D. = 2.12)
M Non-responsiv. CG M = 2.88 (S.D. = 2.26) M = 2.75 (S.D. = 2.00) 0.974 F (1.77) = 2.095 0.152 0.026 0.298
F Non-responsiv. EG M = 4.15 (S.D. = 2.80) M = 2.20 (S.D. = 2.31)
F Non-responsiv. CG M = 3.28 (S.D. = 2.11) M = 3.05 (S.D. = 2.45) 0.903 F (1.77) = 8.241 0.005 0.097 0.809
M Controlling EG M = 4.63 (S.D. = 2.52) M = 3.23 (S.D. = 2.07)
M Controlling CG M = 5.08 (S.D. = 2.25) M = 5.28 (S.D. = 2.04) 0.916 F (1.77) = 7.084 0.009 0.084 0.748
F Controlling EG M = 3.55 (S.D. = 2.73) M = 3.18 (S.D. = 2.07)
F Controlling CG M = 4.45 (S.D. = 2.32) M = 4.35 (S.D. = 2.47) 0.997 F (1.77) = 0.229 0.634 0.003 0.076
perimental roup ontrol roup at ens aternal ensitivity at ens aternal ensitivity other ather
on- esponsiv on- esponsiveness

Controlling descriptor of the mother

Paternal Sensitivity
6
10 5.08 5.28
5
9
8.63
8 4
4.63
7 6.28 3.23
3
6.45
6
2
5 6.3
4 1

3 0
2 Controlling descriptor of the mother in Controlling descriptor of the mother in
assessment 1 assessment 2
1
0 EG CG
Paternal Sensitivity in assessment 1 Paternal Sensitivity in assessment 1
Figure 5: ontrollin descriptor of the mother before and
EG CG a er the intervention in the and in the
Figure 4: aternal sensitivity before and a er intervention in
the and in the
Non responsive descriptor of the father
Regarding the controlling descriptor, the assumption of 4.5
4
4.15

homogeneity (Box’s M = 0.526; F (3, 1095120,000) = 0.170; p 3.5

= 0.916) in the mothers is met, and the results show a significant 3
3.28
3.05
2.5
interaction effect between measurement and group (wilks' λ = 2
2.2

0.916, F (1.77) = 7.084, p = 0.009). The details are shown in 1.5

Table 4. Specifically, the mothers in the EG have significantly
improved this aspect, decreasing their average from 4.63 points
(SD = 2.52) to 3.23 points (SD= 2.07), whereas the mothers in
the CG maintain controlling levels that are stable between the
two measurements (M1 = 5.08; SD1 = 2.25; M2 = 5.28; SD2 =
2.04), as shown in Figure 5.
In the case of fathers, the assumption of homogeneity (Box’s
M = 4,217; F (3, 1095120,000) = 1,367; p = 0.251) is fulfilled,
and there is no significant effect of the intervention (λ de Wilks =
0.997, F (1.77) = 0.229, p = 0.634). The details can be observed
in Table 4.
Regarding the nonresponsive descriptor, the assumption of
homogeneity (Box’s M = 0.275; F (3, 1095120,000) = 0.089;
p = 0.966) is met in the mothers, and there is no significant
effect of the intervention (λ wilks = 0.974, F (1.77) = 2.095; p =
0.152). The details can be observed in Table 4.
1
0.5
0
Non responsive descriptor of the father in Non responsive descriptor of the father in
assessment 1 assessment 2
EG CG
Figure 6: on-responsive descriptor of the fathers before
and a er the intervention in the and in the
In the case of fathers, the assumption of homogeneity (Box’s
M = 6,409; F (3, 1095120,000) = 2,077; p = 0.101) is met,
and the results show a significant interaction effect between
measurement and group (λ of Wilks = 0.903, F (1.77) = 8.241,
p = 0.005). The details can be observed in Table 4. Specifically,
the fathers in the EG have significantly improved this aspect,
decreasing their average from 4.15 points (SD = 2.80) to 2.20
points (SD = 2.31), whereas the fathers in the CG maintain their
levels of no responsiveness between both measurements (M1 =
3.28, SD1 = 2.11, M2 = 3.05, SD2 = 2.45), as shown in Figure 6.
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 540
Discussion
As expected, the brief intervention implemented with video
feedback showed a positive effect on the quality of family
relationships. This effect was observed both in the quality
of triadic interactions (mother-father-child) and in dyadic
interactions, confirming the clinical value of this tool, which has
already been reported in previous research [47,62,63].
Deepening the observed changes in triadic interactions, the
results of the intervention show positive effects both globally
and in the parental and child subsystems. Specifically, the
parental subsystem increases the quality of co-parenting, that
is, the ability of parents to come together to co-ordinate the
tasks associated with parenting. This ability implies mutual
cooperation and support between the father and mother as well
as the ability to confront conflicts and generate solutions that
are adjusted to the context and the needs of their children. This
ability is particularly important during the first years of life
because it has been associated with healthy social development
in children [40-42]. In addition, the results show improvements
in the child subsystem. An increase in self-regulatory resources
for children and the ability to actively engage in interaction
with both parents, experiencing passive and active roles, are
demonstrated. In other words, the intervention shows that it is
useful for the process of child development and social insertion
as an active subject and not only as a recipient of care.
Considering the mutual influence and interrelation between
the different systems and family subsystems, it is congruent that
the observed improvements in the quality of the interactions in
the EG are observed at both the dyadic and the triadic levels. In
this vein, it can be hypothesized that parents who support each
other in parenting tasks and show adequate triadic interactions
will also have the resources and skills to sensitively respond
to the needs of their children. In turn, the results of this study
coincide with previous research showing that the emotional
support that the father provides to the mother positively
contributes to maternal sensitivity [9-11]. However, the quality
of the interactions with the children can also influence the
individual characteristics of both the father and the mother, with
the literature showing differences according to the sex of the
parent [27]. In this sense, we can explain the differences found
in the sensitivity of the fathers and mothers of the EG, who all
improved their sensitivity scores, that is, the ability to read and
interpret the child's signals appropriately, showing concordant
and contingent responses and being able to capture the attention
of the infant and to reduce their stress and anxiety. However,
the deficit aspects were different between parents. The mothers
significantly improved in reducing their controlling behavior
in interactions with their children, that is, decreased hostility,
intrusiveness, and anger. Meanwhile, the fathers improved on
reducing nonresponsive behavior, characterized by difficulties
in detecting infant signals or making them at a high threshold
because of the poor ability to follow the child's interactional
proposals and because of low expressiveness during the
encounters.
The differences reported between the parents and the EG,
with decreases in nonresponsive and controlling behavior,
respectively, account for a differentiating effect of the
intervention in them. Although in recent decades the rate of
economic participation of women in Chile has increased, it
is still lower than that of men, and male heads of household
predominate [75]. In view of the above, traditional roles in
which mothers are the individuals who take responsibility for
directly educating their children, being able to interact with them
from controlling behaviors, unlike fathers, who, traditionally
providers, could tend toward more nonresponsive behaviors, are
perpetuated. The effect of the intervention performed with video
feedback shows a modification in these behaviors, when the
triadic family subsystem is included, despite the socio-cultural
roots in which these roles are grounded. In this sense, a reflection
arises not only from the social role traditionally attributed to the
father in the upbringing but also from the exclusion often made
by professionals who intervene in the early family, who have
mainly focused on the mother-infant dyad.
Although the mothers of both groups present higher
depressive symptomatology scores than their partners, it is in the
EG that they increase their sensitivity toward children, reduce
controlling behaviors, and improve the quality of co-parenting.
At the triadic level, positive interactions imply family
cohesion, reciprocity, involvement, and commitment in the
participants, with this functioning being associated with an
adequate social and affective development for children [44-
46]. At the dyadic level, the ability of parents to read, interpret,
and respond sensitively to children's cues and needs is highly
relevant for their association with development, clinical
symptomatology, and child attachment [4,5,30,31,33,34,37].
Taking into account the noted elements, the results of this
study will also have positive consequences in the participating
children, and it is necessary to evaluate and analyse specifically
the infantile variables.
It is a strength of the study that it achieves favourable
results based on a brief, focused intervention that includes the
father, the mother, and the infant and that uses video feedback.
Although the intervention requires unnecessary implements
in psychotherapy such as video and screen cameras for its
implementation as well as the participation of two therapists in
home visits, the observed effectiveness and low cost support
their clinical value. The above considers the low number of
sessions and the benefit for the three members of the family
group from the same intervention.
The reduced sample size, the recruitment characteristics
(non-randomized) and the number of measurements (pre- and
post-intervention, without a third follow-up measurement) are
considered part of the limitations of this study. This last limitation
implies cautious consideration of the results in relation to the
effect of the intervention. It is necessary to conduct new studies
that include follow-up measurements to assess the stability of the
quality improvement of triadic interactions, parental sensitivity,
co-parenting, and self-regulation of the children and that
contribute to the generation of public policies that contemplate
intervention at critical moments in the development of children.
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 541
In turn, the question is opened for new studies on the effect
of video-feedback intervention in populations of children and
adolescents with characteristics and mental health difficulties
that are different from those considered in this study. In addition,
there is the need to include the evaluation of the variables of the
child beyond what is manifested in the triadic interaction.
Authors' Note
We would like to express our gratitude for the support
and funding from the National Commission for Scientific
and Technological Research, CONICYT Chile, the Fondecyt
Initiation Project No. 11140230, and the Innovation Fund for
Competitiveness of the Ministry of Economy, Development,
and Tourism, Millennium for Research in Depression and
Personality Institute (Milenio para la Investigación en Depresión
y Personalidad, MIDAP), Project IS130005.
REFERENCES
1. Nelson H, Kendall G, Shields L. Neurological and biological
foundations of children’s social and emotional development:
an integrated literature review. J Sch Nurs. 2014; 30: 240-
250.
2. Pontoppidan M. The effectiveness of the Incredible years
parents and babies program as a universal prevention
intervention for parents of infants in Denmark: Study
protocol for a pilot randomized controlled trial. Trials. 2015;
16: 386-397.
3. Pontoppidan M, Klest S, Moller T. The incredible years
parents and babies program: A pilot randomized controlled
trial. PLoS ONE. 2016; 11.
4. Riera J. Improving quality of mother-child relationship and
their attachment, as a factor of mental health: A systematic
review of interventions. Universidad de Barcelona,
Barcelona, España. 2016.
5. Salomonsson M, Sorjonen K, Salomonsson B. A long-term
follow-up study of a randomized controlled trial ofmother-
infant psychoanalytic treatment: Outcomes on mothers and
interactions. Infant Ment Health J. 2015; 36: 542-555.
6. Fivaz-Depeursinge E, Corboz-Warnery A. The primary
triangle, a developmental system view of mothers, fathers
and infants. London, UK: Basic Books. 1999.
7. Fivaz-Depeursinge E, Philipp D. The baby and the couple.
New York, US: Routledge. 2014.
8. Shapiro A, Gottman J, Carrere S. The baby and the marriage:
Identifying factors that buffer against decline in marital
satisfaction after the first baby arrives. J Fam Psychol. 2000;
14: 59-70.
9. Hyunjeong S, Young-Joo P, MiJa K. Predictors of maternal
sensitivity during the early postpartum period. J Adv Nurs.
2006; 425-434.
10. Olhaberry M, Santelices M. Presencia del padre y calidad
de la interacción madre-hijo(a): un estudio comparativo
en familias monoparentales chilenas nucleares y
monoparentales. Universitas Psychologica. 2013; 12: 833-
843.
11. Valenzuela M. Maternal Sensitivity in a Developing
Society: The context of urban poverty and infant chronic
undernutrition. Dev Psychol. 1997; 33: 845-855.
12. McHale J, Kuersten-Hogan R. Introduction: The dynamics
of raising children together. J Adult Dev. 2004; 11: 221-234.
13. Caldera Y, Lindsey E. Coparenting, mother-infant
interaction, and infant-parent attachment relationships in
two-parent families. J Fam Psychol. 2006; 20: 275.
14. Olhaberry M, Santelices M, Schwinn L, Cierpka M. La
tríada padre madre-infante: Evaluación de las alianzas
familiares a través del Lausanne Trialogue Play, apego y
niveles de depresión parental. Revista Argentina de Clínica
Psicológica Fundación AIGLE. 2013; 22: 85-94.
15. Elliston D, McHale J, Talbot J, Parmley M, Kuersten-Hogan
R. Withdrawal from coparenting interactions during early
infancy. Family Process. 2008; 47: 481-498.
16. Frosch C, Mangelsdorf S. Marital behavior, parenting
behavior, and multiple reports of preschoolers' behavior
problems: mediation or moderation? Dev Psychol. 2001; 37:
502-519.
17. Le Y, McDaniel B, Leavitt C, Feinberg M. Longitudinal
associations between relationship quality and coparenting
across the transition to parenthood: A dyadic perspective. J
Fam Psychol. 2016; 30: 918-926.
18. Durtschi J, Soloski K, Kimmes J. The dyadic effects of
supportive coparenting and parental stress on relationship
quality across the transition to parenthood. J Marital Fam
Ther. 2016; 43: 308-321.
19. Oronoz B, Alonso-Arbiol I, Balluerka N. A Spanish
adaptation of the parental stress scale. Psicothema. 2007; 19.
20. Berry D, Blair C, Willoughby M, Garrett-Peters P, Vernon-
Feagans L. Household chaos and children’s cognitive and
socio-emotional development in early childhood: Does
childcare play a buffering role? Early Child Res Q. 2016;
34: 115-127.
21. Salomonsson B, Sleed M. The Ages & Stages Questionnaire:
Social–Emotional: A validation study of a mother‐report
questionnaire on a clinical mother–infant sample. Infant
Ment Health J. 2010; 31: 412-431.
22. Parsons C, Young K, Jegindoe E, Stein A, Kringelback M.
Interpreting infant emotional expressions: Parenthood as
differential effects on men and women. Q J Exp Psychol.
2017; 70: 554-564.
23. Bark C, Baukhage I, Cierpka M. A mentalization-based
primary intervention program for stress prevention during
the transition from family care to day care. Mental Health &
Prevention. 2016; 4: 49-55.
24. Kapeleris A. Children’s socio-emotional development
and adjustment: Role of maternal trauma, mentalization
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 542
and parenting style. Tesis para optar al grado de Doctor,
Unversity of Windsor. 2014.
25. Lomanowska A, Boivin M, Hertzman C, Fleming A.
Parenting begets parenting: A neurobiological perspective
on early adversity and the transmission of parenting styles
across generations. Neuroscience. 2017; 342: 120-139.
26. Bernier A, Jarry-Boileau V, Lacharité C. Marital satisfaction
and quality of father–child interactions: The moderating role
of child gender. J Genet Psychol. 2014; 175: 105-117.
27. Armenta-Hurtarte C, Sánchez-Aragón R, Díaz-Loving R.
De qué manera el contexto afecta la satisfacción con la
pareja? Suma Psicológica. 2012; 19: 51-62.
28. Korja R, Latva R, Lehtonen L. The effects of preterm birth
on mother–infant interaction and attachment during the
infant's first two years. Acta Obstet Gynecol Scand. 2012;
91: 164-173.
29. Ainsworth M, Blehar M, Waters E, Wall S. Patterns of
attachment: A Psychological study of the strange situation.
New Jersey, US: Erlbaum. 1978.
30. John A, Sheffield A, Halliburton A. Looking beyond
maternal sensitivity: Mother-child correlates of attachment
security among children with intelectual diasbilities in urban
india. J Autism Dev Disord. 2012; 42: 2335-2345.
31. Planalp E, Braungart-Rieker J. Temperamental precursors
of infant attachment with mothers and fathers. Infant Behav
Dev. 2013; 36: 796-808.
32. Jia R. Dynamic mother-infant and father-infant interaction:
Contribution of parents’ and infants’ facial affect and
prediction from depression, empathy and temperament. Tesis
para optar al grado de Doctor, The Ohio State University.
2014.
33. Mi-Sung H. The role of maternal verbal sensitivity during
parent-child shared book reading in socio-emotional
functioning in the preschool years. Tesis para optar al grado
de Doctor, University of New Jersey. 2012.
34. Bouvette-Turcot A, Bernier A, Leblanc E. Maternal
psychosocial maladjustment and child internalizing
symptoms: Investigating the modulating role of maternal
sensitivity. J Abnorm Child Psychol. 2017; 45: 157-170.
35. Olhaberry M, Santelices M. Presencia del padre y calidad
de la interacción madre-hijo: Un estudio comparativo en
familias chilenas nucleares y monoparentales. Universitas
Psychologica. 2011; 12: 833-843.
36. Briggs-Gowan M, Carter A, Irwin J, Wachtel K, Cicchetti
D. The brief infant-toddler social and emotional assessment:
Screening for social-emotional problems and delays in
competence. J Pediatr Psychol. 2004; 29: 143-155.
37. Sidor A, Fischer C, Eickhorst A, Cierpa M. Influence of
early regulatory problems in infants on their development at
12 months: A longitudinal study in a high-risk sample. Child
Adolesc Psychiatry Ment Health. 2013; 35: 1-14.
38. Lickenbrock D, Braungart-Rieker J. Examining antecedents
of infant attachment security with mothers and fathers: An
ecological systems perspective. Infant Behav Dev. 2015; 39:
173-187.
39. McHale J, Fivaz-Depeursinge E. Understanding triadic and
family group interactions during infancy and toddlerhood.
Clin Child Fam Psychol Rev. 1999; 2: 107-127.
40. Leidy M, Schofield T, Parke R. Fathers’ contributions to
children’s social development. En: Cabrera, N. & Tamis-
LeMonda, C. (Eds.), Handbook of father involvement:
Multidisciplinary perspectives, Nueva York: Routledge.
2013.
41. Raikes H, Thompson R. Family emotional climate,
attachment security and young children's emotion knowledge
in a high-risk sample. Br J Dev Psychol. 2006; 24: 89-104.
42. Teubert D, Pinquart M. The association between coparenting
and child adjustment: A meta-analysis. Parenting: Science
and Practice. 2010; 10: 286-307.
43. Feldman R, Masalha S. Parent–child and triadic antecedents
of children’s social competence: Cultural specificity, shared
process. Dev Psychol. 2010; 46: 455.
44. Cummings E, Davies P. Marital conflict and children: An
emotional security perspective. New York, US: Guilford.
2010.
45. McHale J. When infants grow up in multiperson relationship
systems. Infant Behav Dev. 2007; 28: 370-392.
46. Fivaz-Depeursinge E, Favez N. Exploring triangulation in
infancy: Two contrasted cases. Family Process. 2006; 45:
3-8.
47. Bakermans-Kranenburg M, Van Ijzendoorn M, Juffer F.
Less is more: Meta-analyses of sensitivity and attachment
interventions in early childhood. Psychological Bulletin.
2003; 129: 195.
48. Cowan C, Cowan P, Pruett M, Pruett K. An approach to
preventing coparenting conflict and divorce in low-income
families: Strengthening couple relationships and fostering
fathers' involvement. Family Process. 2007; 46: 109-121.
49. Doherty W, Erickson M, LaRossa R. An intervention to
increase father involvement and skills with infants during
the transition to parenthood. J Fam Psychol. 2006; 20: 438-
447.
50. Hawkins A, Lovejoy K, Holmes E, Blanchard V, Fawcett E.
Increasing fathers’ involvement in child care with a couple-
focused intervention during the transition to parenthood.
Family Relations. 2008; 57: 49-59.
51. Feldman R, Weller A, Sirota L, Eidelman A. Testing a family
intervention hypothesis: The contribution of mother-infant
skin-to-skin contact (kangaroo care) to family interaction,
proximity, and touch. J Fam Psychol. 2003; 17: 94.
52. Shapiro A, Nahm E, Gottman J. baby home together:
Examining the impact of a couple-focused intervention on
 Video-feedback intervention to improve parental sensitivity and the quality of interactions in mother-father-infant triads 543

the dynamics within family play. Am J Orthopsychiatry. Psychotherapy: Psychopathology, Process and Outcome.
2011; 81: 337-350. 2015; 18: 82-92.
53. Facchini S, Martin V, Downing G. Pediatricians, well- 67. Squires J, Bricker D, Heo K, Twombly E. Ages & Stages
baby visits, and video intervention therapy: Feasibility of a Questionnaires: Social-Emotional. A parent-completed,
videofeedback infant mental health support intervention in a child-monitoring system for social-emotional behaviors.
pediatric primary health care setting. Front Psychol. 2016; Baltimore: Brookes. 2002.
7: 179.
68. Crittenden P. A Dynamic-Maturational Model of Attachment.
54. Hoivik M, Lydersen S, Drugli M, Onsoien R, Hansen Aust N Z J Fam Ther. 2006; 27: 105-115.
M, et al. Video feedback compared to treatment as usual
69. Favez N, Scaiola C, Tissot H, Darwiche J, Frascarolo F. The
in families with parent-child interaction problems: A
Family Alliance Assessment Scales: Steps toward validity
randomized controlled trial. Child Adolesc Psychiatry Ment
and reliability of an observational assessment tool for early
Health. 2015; 9.
family interactions. J Child Fam Stud. 2011; 20: 23-37.
55. Groeneveld M, Vermeer H, van Ijzendoorn M, Linting M.
70. Pérez F, Moessner M, Santelices M. Beyond the dyad:
Randomized video-feedback intervention in home-based
The relationship between preschoolers’ attachment
childcare: Improvement of children’s wellbeing dependent
representations and family triadic interactions. Infant Ment
on time spent with trusted caregiver. Child Youth Care
Health J. 2017; 38: 198-209.
Forum. 2016; 45: 587-606.
71. Beck A, Ward C, Mendelson M, Mock J, Erbauch J. An
56. Rusconi-Serpa S, Sancho-Rossignol A, McDonough S.
inventory for measuring depression. Arch Gen Psychiatry.
Video feedback in parent-infant treatments. Child Adolesc
1961; 4: 561-571.
Psychiatr Clin N Am. 2009; 18: 735-751.
72. Vásquez C, Sanz J. Fiabilidad y valores normativos de la
57. Steele M, Steele H, Bate J, Knafo H, Kinsey M, et al.
versión española del Inventario para la Depresión Beck de
Looking from the outside in: The use of video in attachment-
1978 en pacientes con trastornos psicológicos. Clínica y
based interventions. Attach Hum Dev. 2014; 16: 402-415.
Salud. 1999; 10: 59-81.
58. Beebe B. Brief mother-infant treatment using
73. Valdés C, Morales-Reyes I, Pérez J, Krause M, Rojas G, et
psychoanalytically informed video microanalysis. Infant
al. Propiedades Psicométricas del BDI-A en la población
Ment Health J. 2003; 24: 24-52.
chilena. Manuscrito enviado para publicación. 2017.
59. Beebe B. Mother-infant research informs mother-infant
74. Favez N, Frascarolo F, Keren M, Fivaz-Depeursinge E.
treatment. Psychoanal Study Child. 2005; 60: 7-46.
Principles of family therapy in infancy. In Zeanah, C.
60. Beebe B. Mother–infant research informs mother–infant (2012), Handbook of Infant Mental Health (468-484). New
treatment. Clin Soc Work J. 2010; 38: 17-36. York, US: Guilford Press. 2009.
61. Beebe B. My journey in infant research and psychoanalysis: 75. INE. Síntesis de Resultados Censo 2012. Santiago: Instituto
Microanalysis, a social microscope. Psychoanalytic Nacional de Estadísticas de Chile. 2012.
Psychology. 2014; 31: 4-25.
ADDRESS FOR CORRESPONDENCE:
62. Fukkink R. Video feedback in widescreen: A meta-analysis arcia lhaberry chool of sycholo y onti cia niversi-
of family programs. Clin Psychol Rev. 2008; 28: 904-916. dad at lica de hile hile -mail mpolhabe uc cl
63. Yagmur S, Mesman J, Malda M, Bakermans-Kranenburg M, Submitted 04 September, 2017
Ekmekci H. Video-feedback intervention increases sensitive Accepted 22 September, 2017
parenting in ethnic minority mothers: A randomized control
trial. Attach Hum Dev. 2014; 16: 371-386.
64. Doria M, Kennedy H, Strathie C, Strathie S. Explanations
for the success of video interaction guidance (VIG): An
emerging method in family psychotherapy. The Family
Journal: Counseling and Therapy for Couples and Families.
2014; 22: 78-87.
65. Suárez N, Muñoz M, Gómez E, Santelices M. Terapia de
interacción guiada: Una nueva modalidad de intervención
con familias multiproblemáticas y en riesgo social. Terapia
Psicológica. 2009; 27: 203-213.
66. Olhaberry M, León M, Seguel M, Mena C. Video-feedback
intervention in mother-baby dyads with depressive
symptomatology and relationship difficulties. Research in
10.12.5. Is it possible to improve early childhood development with a video-feedback
intervention directed at the mother- father-child triad? (Sent to review)

312
 Attachment & Human Development

Fo

Is it possible to improve early childhood development with

rP
a video-feedback intervention directed at the mother-
father-child triad?
ee

Journal: Attachment & Human Development

rR

Manuscript ID Draft

Manuscript Type: Original Research Paper

ev

child development, socio-emotional development, early intervention, triadic

Keywords:
interaction, video-feedback
iew
On
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URL: http://mc.manuscriptcentral.com/rahd
Page 1 of 40 Attachment & Human Development

1
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3 Is it possible to improve early childhood development with a video-
4
5 feedback intervention directed at the mother-father-child triad?
6
7
8 Marcia Olhaberry1*, María José León2, Catalina Sieverson2, Marta
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10 Escobar1, Daniela Iribarren1, Irma Morales-Reyes1, Constanza Mena1,
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12
Fanny Leyton1
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Escuela de Psicología, Pontificia Universidad Católica de Chile (School of
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16 Psychology, Pontifical Catholic University of Chile)
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Universidad de Chile (University of Chile)
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21 *Corresponding author: Marcia Olhaberry, Av. Vicuña Mackenna 4860, Macul, Chile.
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Phone: 56223547579 Psicóloga, PhD
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25 E-mail: mpolhabe@uc.cl
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28 María José León, e-mail: mjoseleon@gmail.com
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30 Catalina Sieverson, e-mail: catasieverson@gmail.com

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33 Marta Escobar, e-mail: martaescobarv@gmail.com

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Daniela Iribarren, e-mail: daniela.iribarrenj@gmail.com
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Irma Morales-Reyes, e-mail: iomorale@uc.cl
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40 Constanza Mena, e-mail: cmena1@uc.cl
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43 Fanny Leyton, e-mail: foleyton@uc.cl
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45 Word count: 6.007
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48 Funding acknowledgements
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50 This work was supported by the Comisión Nacional de Investigación Científica y
51 Tecnológica (National Commission for Scientific and Technological Research,
52 CONICYT), Chile; the Fondecyt Initiation Project No. 11140230; the Innovation Fund
53 for Competitiveness of the Ministerio de Economía, Fomento y Turismo (Ministry of
54 Economy, Development and Tourism); and finally, the Instituto Milenio para la
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Investigación en Depresión y Personalidad (Millennium Institute for Research on
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Depression and Personality, MIDAP), Project IS130005.
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 Attachment & Human Development Page 2 of 40

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3 Is it possible to improve early childhood development with a video-
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5 feedback intervention directed at the mother-father-child triad?
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8 Relationships with primary caregivers provide the context for early childhood
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development, and evaluating those relationships during the early years can detect
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11 difficulties that may influence future mental health. Video feedback is a valuable
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intervention tool in early childhood, both for family relationships and child
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14 development. An intervention was implemented using this technique, focused on
15 mother-father-child triads that were experiencing difficulties in social-emotional
16
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17 development. Participants were 80 mother-father-infant triads (EG = 40, CG =
18 40), with children between 1 and 3 years old. Socio-emotional difficulties
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20 decreased significantly in the children who received the intervention (Wilks λ =
21 0.930, F (1, 78) = 5.907; p =.017). There was also an increase in psychomotor
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23 development in communication (Wilks λ = 0.948, F (1,78) = 4.284; p =.042) and
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24 fine motor skills (Wilks λ = 0.875, F (1,78) = 11.185; p =.001) in children in the
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26 EG compared with children in the CG.
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Keywords: child development; socio-emotional development; early intervention;
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30 triadic interaction; video-feedback intervention

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33 Background
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The early years of life constitute a valuable opportunity to lay the foundations of child
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development. The scientific literature indicates that development does not occur as
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40 isolated events, but rather in the context of interpersonal relationships in which children
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42 participate (Bernal, 2005; Greenspan, DeGangu, & Wieder, 2001; Nelson, Kendall, &
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44 Shields, 2014). Because of infants and toddlers’ immaturity, early childhood has been
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46 considered a critical period during which fundamental processes for further
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development occur (Shonkoff, Phillips, & National Research Council, 2000). It has
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51 been reported that the influence of the context in which the infant develops can modify
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53 the child’s brain structure and shape its maturation process, interacting with genetically
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55 programmed aspects (National Scientific Council on the Developing Child, 2004).
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3 Between birth and three years of age, important achievements occur in
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5 cognitive, linguistic, social, emotional and psychomotor development (Shonkoff et al.,
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7 2000; Thompson, 2001). At nearly two years of age, an explosive increase is expected
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9 in children’s vocabulary and in children’s ability to identify emotions in themselves and
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in others and to regulate their own emotions (Cicchetti, 1990; Papalia & Feldman,
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13
14 2012). At this stage, a nurturing environment and responsive parenting will promote
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16 healthy development; risky contexts can negatively affect child development (Hart &
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18 Risley, 1995; Sirin, 2005).
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20 According to the child development literature, there is worldwide consensus that
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22 the acquisition of social-emotional skills occurs simultaneously with the achievement of
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skills such as motor control, reasoning and communication (Thompson, 2001). Some
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27 authors noted that child development depends on constitutional, maturational and

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29 environmental variables and that each stage can be understood as the result of specific
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31 patterns of interaction between the caregiver and the child (Greenspan et al., 2001;
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33 Greenspan, 2007). In the same sense, Benz and Scholtes-Spang (2015), proposed that
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35 one of the primary early childhood development milestones is achieving emotional
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regulation, which occurs from the first interactions with caregivers and is the key to
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40 successful development.
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With regard to the stages of the life cycle and changes within the family system,
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44 the scientific literature demonstrates that parents’ marital satisfaction may significantly
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46 decrease in their children’s first years (Castellano, Velotti, Crowell, & Zavattini, 2014;
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48 Christopher, Umemura, Mann, Jacobvitz, & Hazen, 2015). In this sense, the birth of a
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50 child can trigger a crisis within the couple because of the need to reorganize roles,
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personal space and family functioning after the child’s arrival, changing the relationship
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55 and neglecting personal needs and the needs of the couple (Cox & Paley, 2003; Favez et
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 Attachment & Human Development Page 4 of 40

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3 al., 2012; Fivaz-Depeursinge & Philipp, 2014). Sometimes, these changes are not
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5 implemented adequately and generate dysfunctional relationships, which negatively
6
7 affect children's cognitive and socio-emotional development (Berry et al., 2016).
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9 Many studies in this area showed the protective value of the quality of early
10
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interaction with the mother in child development (Bouvette-Turcot, Bernier, & Leblanc,
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14 2017; Planalp & Braungart-Rieker, 2013), in social-emotional development (Briggs-
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16 Gowan, Carter, Irwin, Wachtel, & Cicchetti, 2004; Kim, 2012; Riera, 2016;
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18 Salomonsson, Sorjonen, & Salomonsson, 2015), and in the mental health of the child
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20 (Sidor, Fischer, Eickhorst, & Cierpka, 2013).
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22 However, the ability to participate in triad interactions has been defined as one
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of the primary tasks for developing an autonomous self and acquiring social skills,
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27 which develop from experiences with primary caregivers (Fincham, 1998; Parke, 1996;
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29 Sroufe, 1996). Consequently, when a child learns to create and maintain relationships
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31 involving more than two people, he learns to share affection, attention and a common
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33 goal among three people, learning to address feelings of exclusion associated with the
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35 development of greater social skills (Fivaz-Depeursinge & Corboz-Warnery, 1999;
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Liszkowski, Carpenter, Henning, Striano, & Tomasello, 2004). In this manner,
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40 reciprocal relations with the mother, involvement with the father and family cohesion in
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the triad have been described as predictors of adequate child social skills (Feldman &
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44 Masalha, 2010). In addition, cooperative interactions within the mother-father-child
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46 triad during the first years of life are positive experiences for the child that enhance his
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48 social development (Leidy, Schofield, & Parke, 2013; Raikes & Thompson, 2006;
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50 Teubert & Pinquart, 2010). The involvement of children in chronic dysfunctional
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interactions and family interactions with conflicted parents hinders the development of
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55 adaptive conflict management skills and is associated with flaws in regulatory
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3 mechanisms and greater difficulties in peer relationships (Cummings & Davies, 2010;
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5 McHale, 2007).
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7 Studies conducted in samples of American children observed that 11% to 37%
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9 presented a risk in social-emotional development (ASQ-SE Technical Report; Bian,
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Xie, Squires, & Chen, 2017; Briggs-Gowan et al., 2013; Briggs et al., 2012; Wendland
12
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14 et al., 2014).With regard to psychomotor development, which typically includes
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16 communicative, cognitive and motor skills, approximately 69% of children between 0
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18 and 66 months demonstrated typical development, 7.4% presented a risk in one area,
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20 and 23.6% presented risks in two or three areas (ASQ-3 Technical Report).
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22 Chilean studies reported significant difficulties in psychomotor development
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during early childhood, with 17.4% of children being monitored for risk and between
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27 7.2% and 12.73% of children under 2 years of age considered delayed (Centro de
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29 Microdatos-Universidad de Chile, 2010; Schonhaut et al., 2010; Schqnhaut & Armijo,
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31 2014). With regard to the socio-emotional development of children in Chile, studies
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33 indicated that the difficulties increased with age, with a risk of 17.1% at 12 months and
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35 24.2% at 18 months of age. Subsequently, between 18 and 60 months, 10.8% of the
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children had clinically significant socio-emotional difficulties. However, analyzing
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40 these figures according to socioeconomic level indicated that lower family income was
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associated with greater difficulties in children's socio-emotional development (Centro
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44 de Microdatos-Universidad de Chile, 2010; 2014).
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46 Conversely, variables such as breastfeeding, the presence of tracer diseases,
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48 birth order and attendance at daycare were reported as influential factors in early
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50 childhood development. Some studies indicated that breastfeeding is a multi-
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determinate practice, associated with individual, family and community variables
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55 (Victora et al., 2016) and therefore may not necessarily be directly related to child
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 Attachment & Human Development Page 6 of 40

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3 development (Woodward & Liberty, 2017). However, some studies demonstrated the
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5 positive influence of breastfeeding on infant neurodevelopment but not as the only
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7 variable that explains it (Bryan et al., 2004; Jansen, Weerth, & Riksenwalraven, 2008).
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9 In addition, the physical act of breastfeeding may promote mother-infant interaction,
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thus influencing the child's socio-emotional and cognitive development (Kim et al.,
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14 2011; Reynolds, 2001). Other studies noted that skin-to-skin contact plays an important
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16 role in maternal sensitivity, a variable that has been positively associated with child
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18 development (Bystrova et al., 2009; Narvaez et al., 2013; Swain, Lorberbaum, Kose, &
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20 Strathearn, 2007).
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22 With regard to birth order, we have described the positive effect of older siblings
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on socio-emotional development, which may be explained by learning and experiences
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27 associated with daily interaction with older children (Metwally et al., 2016).
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29 Another factor that may directly or indirectly affect early childhood
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31 development is daycare. In this respect, the fact that parents have this type of support
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33 network favors parental competencies in differential manners, benefiting parents with

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35 anxiety attachments and influencing those with evasive attachments (Green, Furrer, &
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McAllister, 2007). Considering the complexity of this variable, the need to consider
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40 multiple factors to explain its influence on child development has emphasized, in
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particular, the age of admission, the quality of the daycare centers and reasons for
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44 admission (Friedman & Boyle, 2008).
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46 Parental ability to identify early difficulties in the development of their children
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48 is a protective factor, and their denial and/or normalization may create more severe
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50 problems in the future. Indeed, parents report significant concerns regarding the socio-
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emotional development of their young children, and many of them appear open to
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55 receive short-term intervention (Briggs et al., 2012). Timely and accurate identification
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Page 7 of 40 Attachment & Human Development

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3 of problems in early childhood development, often associated with mental health, is the
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5 first step toward early intervention, favoring effective outcomes for children, their
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7 families and communities (Squires, Bricker, & Twombly, 2004). However, few studies
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9 indicate the optimal age at which to detect these problems (Caselman & Self, 2008; De
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Wolff, Theunissen, Vogels, & Reijneveld, 2013; Schqnhaut & Armijo, 2014).
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14 Children’s health is more commonly evaluated by their psychomotor
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16 development because of its association with school performance later on; however,
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18 proper evaluation also requires the inclusion of socio-emotional development
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20 assessments because of their relation to the quality of family ties and mental health,
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22 particularly in at-risk populations (Briggs et al., 2012; Squires, Bricker, Heo, &
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Twombly, 2001).
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28 Video feedback as a family intervention tool in early childhood
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In the context of early interventions aimed at improving and promoting the quality of
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33 parent-child interactions, child development and mental health, there is sufficient

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35 empirical evidence to support the use of video feedback to achieve these goals
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37 (Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Pontoppidan, 2015;
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39 Pontoppidan, Klest, & Sandoy, 2016; Riera, 2016; Salomonsson et al., 2015). The two
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41 meta-analyses that studied the effects of interventions using video feedback as a tool
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concluded that in a few sessions, it is possible to achieve a moderate change in parental
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46 skills (Bakermans-Kranenburg et al., 2003; Fukkink, 2008).
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48 Studies that specifically analyze the effect of video feedback on children's socio-
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50 emotional development present mixed results and are few compared with those
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52 analyzing parental variables or variables associated with interaction with children.
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54 Fukkink's meta-analysis, which reviews 28 studies conducted up to 2006,
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concluded that there is a statistically significant effect of achieving changes in children's
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 Attachment & Human Development Page 8 of 40

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3 behavior, with a small to medium effect size (ES = 0.33, SD 0.10). That study also
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5 identified a moderating effect in high-risk families (with depressed, adolescent, low-
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7 income or single parents) in which the positive effects of video feedback were lower
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9 (Fukkink, 2008).
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Clinical trials following this review reported the evaluation of outcomes in
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14 children in different settings and with varying effects. Moss et al. (2011) reported that a
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16 greater proportion of children in the video-feedback group changed their attachment
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18 pattern from insecure to safe and from a disorganized attachment to an organized
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20 pattern. It should be noted that studies indicated that although a direct effect of video
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22 feedback in children is often not identified, various moderating effects have been
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analyzed and reported (Groeneveld, Vermeer, van Ijzendoorn, & Linting, 2016; Hoivik
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27 et al., 2015; Kalinauskiene et al., 2009; Moss et al., 2011; Van Zeijl et al., 2006). Van
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29 Zeijl et al. (2006) observed that in the intervention group, hyperactivity significantly
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31 decreased in children from families with greater marital discord and with more daily
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33 problems. Moss et al. (2011) observed that for the intervention group, internalizing and
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35 externalizing problems diminished significantly as the children grew older, unlike the
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control group, in which these problems increased with age. Groenveld et al. (2016)
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40 observed a moderating effect of the time spent with the caregiver while receiving the
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intervention, noting that the children's well-being in the group receiving the intervention
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44 significantly increased the more familiar they were with their caregiver. Hoivik et al.
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46 (2015) observed a delayed but substantial effect of video feedback in social-emotional
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48 development, reporting that at a six-month follow-up, the children in the intervention
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50 group had greater self-regulation, compliance, adaptive functioning, autonomy, affect
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and interaction with others.
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Page 9 of 40 Attachment & Human Development

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3 This technique has been used in Chile in mother-infant dyads exhibiting
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5 depressive symptoms, demonstrating improvements in the caregiver's sensitivity to the
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7 child’s needs (Olhaberry, León, Seguel, & Mena, 2015) and in dyads of low-income
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9 multiproblem families (Delucchi, Quinteros, Muzzio, & Álvarez, 2009). Although video
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feedback is considered an evidence-based intervention, research on the mechanisms of
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14 change is limited. Doria, Kennedy, Strathie, and Strathie (2014) proposed that the key
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16 components of video feedback are the support and reception of the therapist(s), the
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18 observation of the recorded interactions, the focused approach to achievement and the
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20 recording of ensuing sessions as proof of change and success. The mechanisms
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22 underlying the proposed intervention are the cognitive goal process and the possibility
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of building a new reality together.
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27 The antecedents presented support the relevance of early detection of childhood

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29 developmental difficulties, of the quality of dyadic and triadic family interactions, and
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31 the value of video feedback as an early family psychotherapeutic tool. Considering the
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33 above, the present study evaluates the changes in children’s socio-emotional and
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35 psychomotor development following a video-feedback intervention focused on the
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mother-father-child triad. Recently, favorable results of this intervention on parental
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40 sensitivity and the quality of triadic interactions have been reported (Olhaberry et al.,
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2017), both studies being components of the same research project (Fondecyt de
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44 Iniciación N°11140230, CONICYT, Chile).
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Method
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Design
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53 The study was part of a wider project that assessed mother-father-child triads pre- and
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55 post-intervention (Fondecyt de Iniciación N°11140230, National Commission for
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 Attachment & Human Development Page 10 of 40

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3 Scientific and Technological Research, CONICYT, Chile). The present study used a
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5 quasi-experimental design to evaluate the children’s outcomes. The results from both
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7 control and experimental groups were compared before and after the intervention.
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11 Participants
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13 Families with children (one to three years old) who presented socio-emotional
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difficulties as assessed by the ASQ:SE (Squires, Bricker, & Twombly, 2002) from
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18 Santiago, Chile, were recruited through daycare and public health centers or referred by
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20 other participants. A total of 80 mother-father-toddler triads participated in the study.
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22 Forty were assigned to the experimental group (EG) and were assessed before and after
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24 receiving a video-feedback intervention. The remaining forty families were assigned to

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the control group (CG) and received the video feedback intervention after being
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assessed twice, with a gap of approximately 5 weeks between assessments.
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[Figure 1 near here]
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36 The inclusion criteria for the study included the following:
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38 parents were required to be at least 18 years old, currently in a heterosexual

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40 relationship, and have a child aged 12 to 36 months with socio-emotional difficulties
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42 reported by parents or the referrer. Difficulties were related to behavior, sleep, eating,
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emotion, and/or relational difficulties. Parents with diagnosed psychosis and/or
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47 addictions and parents or children with disabilities were not included in the study.
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50 Measures
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53 The following measures were used at both time points:
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Page 11 of 40 Attachment & Human Development

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3 Personal information sheet: This sheet was used to collect families’
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5 sociodemographic information such as the child’s age, gender, birth order and number
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7 of siblings as well as parents’ age, years of education, employment situations, and any
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9 history of psychological/pharmacological treatment.
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Ages and Stages Questionnaires, ASQ-SE, (Squires, Bricker, & Twombly, 2003):
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14 This questionnaire was used for the screening and monitoring of social-emotional
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16 difficulties. It can be used with children from 3 months to 65 months of age. There are
Fo
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18 eight forms for each age range, and the number of items varies by form. The
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20 questionnaire is completed by the parent and scored according to the number of
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22 concerns the parent reports. In the current investigation, the parents reported directly to
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the therapists who performed the intervention. Higher total scores indicated problems
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27 whereas low scores suggested that the child’s social and emotional behaviour was
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29 considered appropriate by his or her parent. The instrument considers seven subscales:
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31 Self-regulation, Compliance, Communication, Adaptive Functioning, Autonomy, Affect
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33 and Interaction with People. Considering the age diversity of the participating children
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35 and the use of different evaluation templates according to age, it is not possible to
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compare the direct scores obtained. Thus, the degree of the problems of each child was
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40 calculated relative to the maximum for the child’s age. The cut-off scores of the ASQ-
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SE templates used a range from 12.69 to 14.54. The average obtained in the study was
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44 13.66 for the total sample of children, a score indicating significant difficulties in socio-
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46 emotional development.
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48 Ages and Stages Questionnaires, ASQ-3 (Squires, Twombly, Bricker, & Potter,
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50 2009): This questionnaire is used to screen young children for developmental delays,
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that is, to identify those children who are in need of further evaluation and those who
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55 appear to be developing normally. ASQ3 has 21 questionnaires to use with children
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 Attachment & Human Development Page 12 of 40

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3 from 1 month to 5 and a half years of age addressing five developmental areas:
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5 Communication, Gross Motor, Fine Motor, Problem Solving and Personal-Social. Each
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7 questionnaire contains 30 questions, grouped by developmental area, regarding a child’s
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9 everyday activities.
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13 Procedure
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This study was certified by the ethics committees of the Pontifical Catholic University
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18 of Chile and the National Commission for Scientific and Technological Research
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20 (CONICYT).
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22 As mentioned above, families were recruited through professionals from JUNJI
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24 (National Board of Preschools of the Ministry of Education of the Government of Chile)

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nurseries and preschools, family public health centers (FPHC), and self-referrals. In the
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first contact with parents, the parents were informed of the study’s goals, and the
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inclusion and exclusion criteria were assessed. Families who met the criteria and were
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33 willing to participate in the study gave their informed consent, after which a home visit
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35 was arranged for their data to be collected. Then, the first assessment session was video-
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37 recorded to measure the quality of triadic and dyadic interactions (see results in
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39 Olhaberry et al., 2017), and scales and questions were completed. Data were collected
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41 during 2015 and 2016 by psychotherapists who were previously trained in the use of the
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above-mentioned questionnaires.
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46 The model of the video-feedback intervention was based on an intervention used
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48 previously with mother-infant dyads exhibiting maternal depressive symptoms
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50 (Olhaberry et al., 2015) although certain elements were added to focus the intervention
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52 on triadic interactional aspects (Favez, Frascarolo, Keren, & Fivaz-Depeursinge, 2009).
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54 The intervention included weekly home visits during which the interaction between
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adults and children was video recorded. This material was then analyzed to review
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Page 13 of 40 Attachment & Human Development

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3 portions of the film that showed positive relational aspects with the parents. The dyadic
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5 and triadic interactions that were filmed during the initial assessment were used for the
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7 second, third and fourth video-feedback sessions. New triadic feeding interactions and
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9 dyadic play were filmed during the fifth session, to be reviewed later with parents
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during the sixth session. The entire process included a total of seven sessions, two of
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14 which were used for assessments and five for video-feedback intervention with the
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16 father, mother or the parental couple. The first evaluation session and all of the
Fo
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18 intervention sessions were conducted by the same pair of psychotherapists, whereas the
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20 final evaluation session was conducted by psychotherapists whom the family did not
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22 previously know, to prevent the bond with the clinicians from interfering with the
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results. The following diagram obtained from the larger study (Olhaberry et al., 2017)
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27 presents the procedure followed for the sessions:

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29 [Figure 2 near here]
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33 Each intervention was led by two psychotherapists with at least one semester of
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35 training in the use of video feedback with families and children under the age of three.
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The training entailed participating in weekly two-hour clinical meetings as well as two
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40 days of training on infancy and toddlerhood, parenting and the use of the various
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measures considered in the study. Each triad was presented during the clinical meetings,
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44 during which the videos were analyzed and the scripts for the video feedback further
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46 developed, establishing the primary goal of the intervention. The clinical team was
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48 formed by 18 psychotherapists, of whom six had previous experience using video
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50 feedback.
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3 Session 1. During this session, videos were recorded and questionnaires
4
5 completed. The parents’ concerns regarding their child’s development or their
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7 relationship with their child were also explored.
8
9 Post-session work: After the first session, the psychotherapists analyzed the
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videos to identify negative and positive sequences that would be discussed with the
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14 parents in the following session. This procedure was followed after each session until
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16 the end of the intervention (Session 6).
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18 Sessions 2 and 3: The father and mother participated in one session each; the
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20 order depended on what they had agreed to in Session 1. With each parent, the
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22 sequences selected from the dyadic play videos were reviewed. After the discussion and
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according to what the parent had discovered after observing him/herself in the video, a
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26
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27 task was established for the parent to implement until the next session. The same
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29 procedure was followed with the other caregiver in Session 3.
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31 Session 4: This session considered the parental couple, observing positive
32
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33 aspects of their triadic video.

34
35 Session 5: During this session, new videos were recorded. These included
36
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mother-child and father-child free play and a triadic feeding interaction.
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40 Session 6: The videos recorded during Session 5 were discussed with the
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parental couple. The psychotherapists and the family evaluated the intervention,
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44 highlighting what they had learned throughout this process and providing an ending.
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46 Session 7: Post-intervention assessment.
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50 Analysis of data
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52 As the first analysis strategy, outliers and normality assumptions of the variables used in
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54 the parametric tests were assessed using the Kolmogorov-Smirnov test and Q-Q plots.
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The Kolmogorov-Smirnov test showed that 6 of the 13 studied variables had a normal
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3 distribution (p >.005). Dispersing the remaining 7 variables was evaluated as a function
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5 of the Q-Q plots, and the deviation was not significant, allowing for the use of
6
7 parametric tests. A significance level of α = 0.05 was used. As a second strategy, a
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9 descriptive analysis of the relevant sociodemographic and clinical variables was
10
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conducted to perform t tests for independent samples and χ2 tests to compare the groups
12
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14 and determine their homogeneity. Finally, to evaluate the effects of the intervention on
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16 child development, repeated measures ANOVA (rANOVA) was performed using the
Fo
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18 pre- and post-measurement as an intrasubject factor and the group to which it belonged
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20 as an intersubject factor. The assumption of homogeneity was evaluated with the Box
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22 test. Because there were two groups in the intersubjective factor and two measurements
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in the intrasubject factor, the sphericity assumption was not evaluated.
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28 Results
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31 Descriptive analysis
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34 Both the EG and the CG comprised 40 homogeneous triads with regard to the age of the
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36 parents and the child and the education levels of the parents, which were evaluated by t-
37
tests for independent samples, the details of which may be observed in Table 1
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40 Homogeneity was also observed between the groups with regard to the place that the
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42 child occupied in the family, the parents’ work day, attending daycare, breastfeeding
43
44
and the presence of tracer diseases. To evaluate the homogeneity of the groups with
45
46
47
respect to these variables, χ2 tests were performed, the details of which can be observed
48
49 in Table 2. It is important to note that gender differences in the work day were observed
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51 in both groups, with the fathers having a greater proportion of full time work than the
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53 mothers (χ23= 24.916, p =.000).
54
55 [Table 1 near here]
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3 [Table 2 near here]
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Comparative analysis
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Overall development measured with the ASQ-3
10
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12 With regard to the Communication Area measured by the ASQ-3, the assumption of
13
14 homogeneity (Box’s M = 4.349; F (3, 1095120) = 1.409; p =.238) was satisfied. There was
15
16 also a significant interaction effect between the measurement and the group to which it
Fo
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belonged (Wilks λ = 0.948, F (1,78) = 4.284, p =.042) and a significant principal effect of
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21 the measurement (Wilks λ = 0.422, F (1,78) = 106.781, p <.000). Although both groups of
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23 children improved their performance, the children in the EG improved more than the
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25 children in the CG. Specifically, at the first evaluation, the CG children scored an
26
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27 average of -0.14 standard deviations from the cut-off point considered normal for their
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29 age (SD = 0.97) at a mean of 1.24 (SD = 1.35); the EG children improved their
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30
31
performance even further, averaging -0.47 on the first evaluation (SD = 0.96) and an
32
iew

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34 average of 1.60 (SD = 1.22) on Evaluation 2 (see Figure 3 and Table 3).
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36 In the Fine Motor Area, the mixed ANOVA was consistent with the
37
homogeneity assumption (Box’s M = 1.348; F (3, 1095120) = 0.437; p =.727), and an
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40 interaction effect was observed between the group and the evaluation (Wilks λ = 0.875,
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42 F (1,78) = 11.185; p =.001). Specifically, children in the experimental group improved

43
44
their performance from an average of 0.90 standard deviations from the cutoff that was
45
46
47
considered normal (SD = 0.30) to an average of 1.92 (SD = 1.22) over the cutoff point.
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49 Children in the control group maintained their performance from an average of 0.93
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51 (SD = 0.27) to an average of 0.98 (SD = 1.35) (see Table 3 and Figure 3).
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3 Intervention does not affect a child's developmental capacity in the Problem
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5 Solving Scale, Personal-Social or Gross Motor areas. Details of the analyses of group
6
7 comparison can be seen in Table 3 and the behavior of both analyses in Figure 3.
8
9 [Figure 3 near here]
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[Table 3 near here]
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14
15
16
Fo
17 Social-emotional development measured with the ASQ-SE
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19 First, the effect of the intervention on the Global Percentage of Problems in Social-
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21 Emotional Development was evaluated. In the mixed ANOVA, the assumption of
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homogeneity (Box’s M = 3.675; F (3, 1095120) = 1.191; p =.311) was fulfilled, and it was
25
26 observed that although the percentage of problems in the socio-emotional area
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28 decreased in the children of both groups, the decrease was even more significant in the
29
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30 EG than in the CG (Wilks' λ = 0.930, F (1,78) = 5.907, p =.017) (see Table 3).
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32 Specifically, the EG decreased from 18.08% for Assessment 1 (SD = 11.05) to 12.07%
iew

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34 for Assessment 2 (SD = 7.86), while the CG showed no difference, 15.92% for
35
36
Assessment 1 (SD = 8.28) and 14.66% for Assessment 2 (SD = 7.13), which can be
37
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39 seen in Figure 4.
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41 [Figure 4 near here]
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43 [Table 4 near here]
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45 The specific scales indicate that in the Percentage of Problems in Compliance,
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47 the assumption of homogeneity of variances was not met (Box’s M = 11.992; F (3, 1095120)
48
49
= 3.886; p =.009). There was a significant interaction effect between the group and the
50
51
52 measurement (Wilks’ λ = 0.918, F (1,78) = 7.002; p =.01). Specifically, the EG children
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54 improved in this area from 23.75% in Measurement 1 (SD = 23.54) to 8.75% in
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3 Measurement 2 (SD = 14.61), whereas the CG showed no difference, 13.79% (SD =
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5 22.61) in Measurement 1 and 11.33% (SD = 25.37) in Measurement 2 (see Table X).
6
7 In the Percentage of Problems in Interaction with People, the assumption of
8
9 homogeneity of variances was also not met (Box’s M = 10.055; F (3, 1095120) = 3.259; p
10
11
=.021), and a significant interaction effect was observed between the group and the
12
13
14 measurement (Wilks’ λ = 0.834, F (1,78) = 15.523; p <.000). In this case, the EG children
15
16 improved from 16.20% (SD = 15.19) to 9.27% (SD = 9.26), whereas the CG children
Fo
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18 showed an increase in their problems from 10.11% (SD = 10.31) to 13.94% (SD =
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20 11.30).
21
22 Significant intervention effects in the specific scales of Percentage of Problems
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in Self-regulation, Percentage of Problems in Communication, Percentage of Problems
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27 in Adaptive Functioning, Percentage of Problems in Autonomy, and Percentage of

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29 Problems in Affect were not observed (p>.05) (see Table 4).
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32 Discussion
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33
34
35 As indicated by previous research on the benefits of video feedback in early
36
37 intervention, its focused use in the mother-father-child triad demonstrated favorable
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39 outcomes in child development (Bakermans-Kranenburg et al., 2003; Pontoppidan,
40
41 2015; Pontoppidan et al., 2016; Riera, 2016; Salomonsson et al., 2015). The
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44
improvements were observed in the socio-emotional and psychomotor development of
45
46 children belonging to the EG. Specifically, there was an increase in children's
47
48 communication skills and fine motor skills. The improvement in the “communication”
49
50 area may be explained by the focus of intervention in dyadic and triadic family
51
52 relationships and their effect on the child's communication skills. Enriching the
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54 interactional proposal parents offered to their children increased face-to-face contact,
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affective connection, use of verbal language, synchrony, and reading adjusted to the
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3 children's needs as well as quality, positively affecting the child's communication skills
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5 (Greenspan et al., 2001). In addition, the increase in the quality of triadic interactions
6
7 during the first years of life has been associated with adequate child social development
8
9 (Leidy et al., 2013; Raikes & Thompson, 2006; Teubert & Pinquart, 2010), which may
10
11
also contribute to the development of communication skills in children.
12
13
14 The increase in “fine motor” skills in the children of the intervention group may
15
16 be attributed to the improvement in the skills regulating affection and behavior by
Fo
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18 increasing the quality of the dyadic relationships and the triadic interactions with the
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20 father and mother. In this sense, the literature demonstrates that children who participate
21
22 in dysfunctional family interactions or with recurrent parental conflicts have difficulty
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developing adequate regulatory mechanisms (Cummings & Davies, 2010; McHale,
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27 2007); thus, focusing on family interactions and their consequent improvement

28
29 contributes to improving children's regulatory mechanisms. The development of fine
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31 motor skills requires longer periods of concentration and focus, which may be interfered
32
iew

33 by self-regulation difficulties. In this sense, achieving adequate regulatory mechanisms

34
35 may be a prerequisite for developing the attention and concentration necessary for
36
37
practices associated with the greater coordination and precise hand movements that fine
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40 motor skills require. In fact, the literature has indicated that the development of fine
41
motor function is closely related to the development of executive function, an ability
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44 involved in attentional change, working memory and inhibitory control (Cameron et al.,
45
46 2012).
47
48 These effects are consistent with a significant global improvement in
49
50 socioemotional development in children in the EG and in some of the areas.
51
52
53
Specifically, “compliance” and “interaction with people” improved only in the EG; in
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55 the CG, the former remained the same and the latter became worse. The two areas in
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3 which significant improvements were observed can be directly related to the quality of
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5 family interactions, directly addressed by the intervention. In fact, “compliance” alludes
6
7 to the “obedience” of the child and its ability to follow everyday rules at home.
8
9 “Interaction with others” considers the child's ability to respond and/or initiate social
10
11
responses with parents, other adults or peers in typical situations. These results indicate
12
13
14 that the intervention improves and enriches daily interactions within the families,
15
16 offering an opportunity to “take advantage” of the instances that already exist (food,
Fo
17
18 changing, order, simple play).
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20 With regard to the improvements observed in socio-emotional development, the
21
22 areas showing an increase coincide with those reported in previous studies that also
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assessed socio-emotional development with ASQ-SE (Hoivik et al., 2015). Although the
25
26
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27 cited study also observed an increase in self-regulation, autonomy and affection, all of
28
29 these changes may not explain the differences among studies or the amplification of the
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31 improvements obtained immediately following the intervention.
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iew

33 It is likely that the first aspects to show change concern elements directly
34
35 associated with interactional practices, such as following instructions, completing a
36
37
task, sharing an activity, taking turns speaking and sharing positive affection. In this
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40 sense, such exchanges may form the basis for those internal changes that could require
41
more time to establish, such as self-regulation, which is also associated with adequate
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44 autonomy and managing affection. It may be hypothesized, then, that these changes
45
46 may also be expressed in the children studied once the changes in interactions are
47
48 consolidated by practice over time.
49
50 The presence of significant changes immediately following the end of the
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52
53
intervention may also be explained by the inclusion of the triad, with the simultaneous
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55 participation of the father and the mother. In this sense, the intervention may have an
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3 influence at different levels, including the dyadic interactions of the child with his
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5 mother and his father separately but also in the triadic interactions that create different
6
7 emotional and bonding experiences. The mutual influence between the subsystems
8
9 within the family, in which the dyadic and triadic functioning influence one another but
10
11
not in a linear manner, being able to observe parents in conflictive relationships who
12
13
14 achieve adequate dyadic interactions with their children and parents in satisfactory
15
16 relationships who exhibit deficits in dyadic interactions or in triadic interactions with
Fo
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18 their children.
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20 The video-feedback intervention employed in this study is significant for its
21
22 brevity and cost-effectiveness in promoting changes in early childhood development. A
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highlight of this intervention is the home visit: on the one hand, it allows the child to be
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27 observed in his/her daily context, favoring a diagnostic understanding, and contributes

28
29 to adherence because the family is not required to leave the home. This facilitates the
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31 regularity of the sessions and the therapeutic alliance insofar as the visits of the
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33 therapists in the home favor the building of trust with the family. The psychotherapeutic
34
35 work developed in family homes, coupled with limited objectives and focused
36
37
interventions, facilitates a feeling of achievement and satisfaction in the parents because
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40 they feel competent in the parental role.
41
The families' feelings of self-efficacy were highlighted as a component of
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44 change mentioned by the participants in video-feedback interventions. Also cited were
45
46 the experience of greater satisfaction in the role, increased self-esteem and changes in
47
48 parental practices, aspects that are constantly reinforced by considering the positive
49
50 attitudes of parents and their achievements session by session (Doria et al., 2014).
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Parents emphasized the value of reflection on self-observation as enhancing existing
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55 parental skills that favor child development. Video-feedback interventions that focus on
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3 parental resources seek to render it easier for parents to identify and enhance their
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5 parental skills. This process occurs through reflective dialogue with the therapist and the
6
7 amplification of skills the parents already possess and rediscover in observing their own
8
9 interactions.
10
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Finally, the intervention presented in this study was developed with pairs of
12
13
14 therapists, which may be an important factor when intervening with triads because it
15
16 allows triad members to experience separate interaction spaces with therapists. In
Fo
17
18 addition, the opportunity to have two therapists enriches the diagnostic formulation and
19
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20 provides greater support for the regulation and well-being of the child during the
21
22 sessions.
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25
26 Limitations
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Within the limitations of the study, there is a lack of randomization in the allocation of
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the participating families to the groups and a lack of follow-up measurements. In future
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33 studies, it would be important to repeat the measurements at 6 months after the

34
35 intervention to assess the permanence of the observed changes and the appearance of
36
37 modifications in other areas of development.
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41 Acknowledgements
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43 The authors would like to thank to all the clinicians team that hardly work attending
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45 these families, as well as, the families that opened their home and received this
46
47
intervention.
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50 Additionally, the authors thank the economical supports of the the Comisión Nacional
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52 de Investigación Científica y Tecnológica (National Commission for Scientific and
53
54 Technological Research, CONICYT), Chile; the Innovation Fund for Competitiveness
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56 of the Ministerio de Economía, Fomento y Turismo (Ministry of Economy,
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3 Development and Tourism); and finally, the Instituto Milenio para la Investigación en
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5 Depresión y Personalidad (Millennium Institute for Research on Depression and
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7 Personality, MIDAP).
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9
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13 Disclosure statement
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No potencial conflict of interest was reported by the authors.
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3 References
4
5 Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2003). Less is
6
7
more: Meta-analyses of sensitivity and attachment interventions in early
8 childhood. Psychological Bulletin, 129, 195–215.
9
10 Benz, M., & Scholtes-Spang, K. (2015). From normal development to development
11 crisis and regulatory disorder. In M. Cierpka (Ed.), Regulatory disorders in
12
13 infants, assessment, diagnosis and treatment (pp. 1–15). Switzerland: Springer.
14
15 Bernal, J. J. Y. (2005). El estudio de la infancia desde la psicología cultural: Un
16 encuentro de perspectivas. Avances en Psicología Latinoamericana, 23(1), 63–
Fo
17
18 76.
19
Berry, D., Blair, C., Willoughby, M., Garrett-Peters, P., Vernon-Feagans, L., & Mills-
rP
20
21 Koonce, W. R. (2016). Household chaos and children’s cognitive and socio-
22
23 emotional development in early childhood: Does childcare play a buffering role?
ee

24 Early Childhood Research Quarterly, 34, 115–127.

25
26 Bian, X., Xie, H., Squires, J., & Chen, C. Y. (2017). Adapting a parent‐completed,
rR

27
28 socioemotional questionnaire in china: the ages & stages questionnaires: social‐
29
emotional. Infant Mental Health Journal, 38, 258-266.
ev

30
31 Bouvette-Turcot, A.-A., Bernier, A., & Leblanc, É. (2017). Maternal psychosocial
32
iew

33 maladjustment and child internalizing symptoms: Investigating the modulating

34 role of maternal sensitivity. Journal of Abnormal Child Psychology, 45(1), 157–
35
36 170.
37
Briggs-Gowan, M. J., Carter, A., Irwin, J., Wachtel, K., & Cicchetti, D. (2004). The
On

38
39 brief infant-toddler social and emotional assessment: Screening for social-
40
41 emotional problems and delays in competence. Journal of Pediatric Psychology,
ly

42
29, 143–155.
43
44 Briggs-Gowan, M. J., Carter, A. S., McCarthy, K., Augustyn, M., Caronna, E., & Clark,
45
46 R. (2013). Clinical validity of a brief measure of early childhood social–
47 emotional/behavioral problems. Journal of pediatric psychology, 38, 577-587.
48
49 Briggs, R. D., Stettler, E. M., Silver, E. J., Schrag, R. D. A., Nayak, M., Chinitz, S., &
50
Racine, A. D. (2012). Social-emotional screening for infants and toddlers in
51
52 primary care. Pediatrics, 129, e377–e384.
53
54
55
56
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
Page 25 of 40 Attachment & Human Development

1
2
3 Bryan, J., Osendarp, S., Hughes, D., Calvaresi, E., Baghurst, K., & Klinken, J.-W.
4
(2004). Nutrients for cognitive development in school-aged children. Nutrition
5
6 Reviews, 62(8), 295–306.
7
8 Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A.-S., Ransjö-Arvidson, A.-B.,
9 Mukhamedrakhimov, R., … Widström, A.-M. (2009). Early contact versus
10
11 separation: Effects on mother-infant interaction one year later. Birth, 36(2), 97–
12
13
109.
14 Cameron, C. E., Brock, L. L., Murrah, W. M., Bell, L. H., Worzalla, S. L., Grissmer, D.,
15
16 & Morrison, F. J. (2012). Fine motor skills and executive function both
Fo
17
contribute to kindergarten achievement. Child Development, 83, 1229–1244.
18
19 Caselman, T. D., & Self, P. A. (2008). Assessment instruments for measuring young
rP
20
21 children's social-emotional behavioral development. Children & Schools, 30(2),
22 103–115.
23
ee

24 Castellano, R., Velotti, P., Crowell, J. A., & Zavattini, G. C. (2014). The role of parents’
25
26
attachment configurations at childbirth on marital satisfaction and conflict
rR

27 strategies. Journal of Child and Family Studies, 23, 1011–1026.

28
29 Centro de Microdatos-Universidad de Chile. (2014). Encuesta longitudinal de primera
ev

30 infancia. Santiago: Universidad de Chile.

31
32 Christopher, C., Umemura, T., Mann, T., Jacobvitz, D., & Hazen, N. (2015). Marital
iew

33
34 quality over the transition to parenthood as a predictor of coparenting. Journal of
35 Child and Family Studies, 24, 3636–3651.
36
37 Cicchetti, D. (1990). An organizational perspective on attachment beyond infancy:
On

38
Implications for theory, measurement, and research. In M. T. Greenberg, D.
39
40 Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years:
41
Theory, research, and intervention (pp. 3–49). Chicago: University of Chicago
ly

42
43 Press.
44
45 Cox, M. J., & Paley, B. (2003). Understanding families as systems. Current Directions
46
47 in Psychological Science, 12(5), 193–196.
48 Cummings, E. M., & Davies, P. T. (2010). Marital conflict and children: An emotional
49
50 security perspective. New York, NY: Guilford Publications.
51
De Wolff, M. S., Theunissen, M. H. C., Vogels, A. G. C., & Reijneveld, S. A. (2013).
52
53 Three questionnaires to detect psychosocial problems in toddlers: A comparison
54
55 of the BITSEA, ASQ:SE, and KIPPPI. Academic Pediatrics, 13, 587–592.
56
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
 Attachment & Human Development Page 26 of 40

1
2
3 Delucchi, N. S., Quinteros, M. M., Muzzio, E. G., & Álvarez, M. P. S. (2009). Terapia
4
de interacción guiada: Una nueva modalidad de intervención con familias
5
6 multiproblemáticas y en riesgo social. Terapia Psicológica, 27, 203–213.
7
8 Doria, M. V., Kennedy, H., Strathie, C., & Strathie, S. (2014). Explanations for the
9 success of video interaction guidance (VIG): An emerging method in family
10
11 psychotherapy Family Journal, 22(1), 78–87.
12
13
Favez, N., Frascarolo, F., Keren, M., & Fivaz-Depeursinge, E. (2009). Principles of
14 family therapy in infancy. In C. Zeanah (Ed.), Handbook of infant mental health
15
16 (pp. 468–484). New York, NY: Guilford Press.
Fo
17
Favez, N., Lopes, F., Bernard, M., Frascarolo, F., Scaiola, C. L., Corboz-Warnery, A.,
18
19 & Fivaz-Depeursinge, E. (2012). The development of family alliance from
rP
20
21 pregnancy to toddlerhood and child outcomes at 5 years. Family Process, 51,
22 542–556.
23
ee

24 Feldman, R., & Masalha, S. (2010). Parent–child and triadic antecedents of children’s
25
26
social competence: Cultural specificity, shared process. Developmental
rR

27 Psychology, 46, 455–467.

28
29 Fincham, F. D. (1998). Child development and marital relations. Child Development,
ev

30 69, 543–574.
31
32 Fivaz-Depeursinge, E., & Corboz-Warnery, A. (1999). The primary triangle: A
iew

33
34 developmental systems view of mothers, fathers, and infants. London, UK: Basic
35 Books.
36
37 Fivaz-Depeursinge, E., & Philipp, D. A. (2014). The baby and the couple. New York,
On

38
NY: Routledge.
39
40 Friedman, S. L., & Boyle, D. E. (2008). Attachment in US children experiencing
41
nonmaternal care in the early 1990s. Attachment & Human Development, 10,
ly

42
43 225–261.
44
45 Fukkink, R. G. (2008). Video feedback in widescreen: A meta-analysis of family
46
47 programs. Clinical Psychology Review, 28, 904–916.
48 Green, B. L., Furrer, C., & McAllister, C. (2007). How do relationships support
49
50 parenting? Effects of attachment style and social support on parenting behavior
51
in an at-risk population. American Journal of Community Psychology, 40(1-2),
52
53 96–108.
54
55 Greenspan, S., DeGangu, G., & Wieder, S. (2001). The functional emotional assessment
56 scale (FEAS) for infancy and early childhood: Clinical and research
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
Page 27 of 40 Attachment & Human Development

1
2
3 applications. Bthesda, MD: Interdisciplinary Council on Developmental and
4
Learning Disorders.
5
6 Greenspan, S. I. (2007). Great kids: Helping your baby and child develop the ten
7
8 essential qualities for a healthy, happy life. Philadelphia, PA: Hachette.
9 Groeneveld, M. G., Vermeer, H. J., van Ijzendoorn, M. H., & Linting, M. (2016).
10
11 Randomized video-feedback intervention in home-based childcare:
12
13
Improvement of children’s wellbeing dependent on time spent with trusted
14 caregiver. Child & Youth Care Forum, 45, 587–606.
15
16 Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of
Fo
17
young American children. Baltimore, MD: Brookes.
18
19 Hoivik, M., Lydersen, S., Drugli, M., Onsøien, R., Hansen, M., & Nielsen, T. (2015).
rP
20
21 Video feedback compared to treatment as usual in families with parent–child
22 interactions problems: A randomized controlled trial. Child and Adolescent
23
ee

24 Psychiatry and Mental Health, 9(1), 3.

25
26
Jansen, J., Weerth, C., & Riksenwalraven, J. (2008). Breastfeeding and the mother–
rR

27 infant relationship—a review. Developmental Review, 28, 503–521.

28
29 Kalinauskiene, L., Cekuoliene, D., Van Ijzendoorn, M. H., Bakermans-Kranenburg, M.
ev

30 J., Juffer, F., & Kusakovskaja, I. (2009). Supporting insensitive mothers: The
31
32 Vilnius randomized control trial of video-feedback intervention to promote
iew

33
34 maternal sensitivity and infant attachment security. Child: Care, Health and
35 Development, 35, 613–623.
36
37 Kim, H. M.-S. (2012). The role of maternal verbal sensitivity during parent-child
On

38
shared book reading in socio-emotional functioning in the preschool years
39
40 (Tesis para optar al grado de doctor), Rutgers The State University of New
41
Jersey, New Brunswick.
ly

42
43 Kim, P., Feldman, R., Mayes, L. C., Eicher, V., Thompson, N., Leckman, J. F., &
44
45 Swain, J. E. (2011). Breastfeeding, brain activation to own infant cry, and
46
47 maternal sensitivity. Journal of Child Psychology and Psychiatry, 52, 907–915.
48 Leidy, M., Schofield, T., & Parke, R. (2013). Fathers’ contributions to children’s social
49
50 development. In N. J. Cabrera & C. S. Tamis-LeMonda (Eds.), Handbook of
51
father involvement: Multidisciplinary perspectives (1st ed., pp. 151–167). New
52
53 York, NY: Routledge.
54
55
56
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
 Attachment & Human Development Page 28 of 40

1
2
3 Liszkowski, U., Carpenter, M., Henning, A., Striano, T., & Tomasello, M. (2004).
4
Twelve-month-olds point to share attention and interest. Developmental Science,
5
6 7, 297–307.
7
8 McHale, J. P. (2007). When infants grow up in multiperson relationship systems. Infant
9 Mental Health Journal, 28, 370–392.
10
11 Metwally, A. M., Salah El- Din, E. M., Shehata, M. A., Shaalan, A., El Etreby, L. A.,
12
13
Kandeel, W. A., … Rabah, T. M. (2016). Early life predictors of socio-
14 emotional development in a sample of Egyptian infants. PLoS One, 11,
15
16 e0158086.
Fo
17
Moss, E., Dubois-Comtois, K., Cyr, C., Tarabulsy, G. M., St-Laurent, D., & Bernier, A.
18
19 (2011). Efficacy of a home-visiting intervention aimed at improving maternal
rP
20
21 sensitivity, child attachment, and behavioral outcomes for maltreated children: A
22 randomized control trial. Development and Psychopathology, 23(1), 195–210.
23
ee

24 Narvaez, D., Gleason, T., Wang, L., Brooks, J., Lefever, J. B., & Cheng, Y. (2013). The
25
26
evolved development niche: Longitudinal effects of caregiving practices on
rR

27 early childhood psychosocial development. Early Childhood Research

28
29 Quarterly, 28, 759–773.
ev

30 National Scientific Council on the Developing Child. (2004). Young children develop in
31
32 an environment of relationships (Working Paper No. 1). Retrieved from
iew

33
34 http://www.developingchild.net
35 Nelson, H. J., Kendall, G. E., & Shields, L. (2014). Neurological and biological
36
37 foundations of children’s social and emotional development: An integrated
On

38
literature review. Journal of School Nursing, 30(4), 240–250.
39
40 Olhaberry, M., León, M. J., Seguel, M., & Mena, C. (2015). Video-feedback
41
intervention in mother-baby dyads with depressive symptomatology and
ly

42
43 relationship difficulties. Research in Psychotherapy: Psychopathology, Process
44
45 and Outcome, 18(2), 82–92.
46
47 Olhaberry, M., León, M. J., Escobar, M., Iribarren, D., Morales-Reyes, I., & Álvarez, K.
48 (2017). Video-feedback intervention to improve parental sensitivity and the
49
50 quality of interactions in mother-father-infant triads. Mental Health in Family
51
Medicine, 13, 532–543.
52
53 Papalia, D. E., & Feldman, R. D. (2012). Desarrollo humano (12th ed.). Santiago,
54
55 Chile: McGraw Hill Education.
56 Parke, R. D. (1996). Fathers (Vol. 33). Cambridge, MA: Harvard University.
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
Page 29 of 40 Attachment & Human Development

1
2
3 Planalp, E. M., & Braungart-Rieker, J. M. (2013). Temperamental precursors of infant
4
attachment with mothers and fathers. Infant Behavior and Development, 36,
5
6 796–808.
7
8 Pontoppidan, M. (2015). The effectiveness of the incredible years parents and babies
9 program as a universal prevention intervention for parents of infants in
10
11 Denmark: Study protocol for a pilot randomized controlled trial. Trials, 16, 386–
12
13
397.
14 Pontoppidan, M., Klest, S. K., & Sandoy, T. M. (2016). The incredible years parents
15
16 and babies program: A pilot randomized controlled trial. PLoS One, 11,
Fo
17
e0167592.
18
19 Raikes, H. A., & Thompson, R. A. (2006). Family emotional climate, attachment
rP
20
21 security and young children's emotion knowledge in a high risk sample. British
22 Journal of Developmental Psychology, 24(1), 89–104.
23
ee

24 Reynolds, A. (2001). Breastfeeding and brain development. Pediatric Clinics of North

25
26
America, 48(1), 159–171.
rR

27 Riera, J. (2016). Improving quality of mother-child relationship and their attachment, as

28
29 a factor of mental health: A systematic review of interventions. Barcelona,
ev

30 España: Universidad de Barcelona.

31
32 Salomonsson, M. W., Sorjonen, K., & Salomonsson, B. (2015). A long-term follow-up
iew

33
34 study of a randomized controlled trial of mother-infant psychoanalytic
35 treatment: Outcomes on mothers and interactions. Infant Mental Health Journal,
36
37 36, 542–555.
On

38
Schonhaut, L., Armijo, I., Millán, T., Herreros, J., Hernández, K., Salgado, A. M., &
39
40 Cordero, M. Á. (2010). Comparación de la evaluación tradicional del desarrollo
41
psicomotor versus una prueba autoadministrada. Revista Chilena de Pediatría,
ly

42
43 81, 498–505.
44
45 Schqnhaut, B., & Armijo, I. (2014). Aplicabilidad del ages & stages questionnaires para
46
47 el tamizaje del desarrollo psicomotor. Revista Chilena de Pediatría, 85(1), 12–
48 21.
49
50 Shonkoff, J. P., Phillips, D. A., & National Research Council. (2000). From neurons to
51
neighborhoods: The science of early childhood development. Washington, DC:
52
53 National Academies Press.
54
55 Sidor, A., Fischer, C., Eickhorst, A., & Cierpka, M. (2013). Influence of early
56 regulatory problems in infants on their development at 12 months: A
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
 Attachment & Human Development Page 30 of 40

1
2
3 longitudinal study in a high-risk sample. Child and Adolescent Psychiatry and
4
Mental Health, 7(1), 35.
5
6 Sirin, S. R. (2005). Socioeconomic status and academic achievement: A meta-analytic
7
8 review of research. Review of Educational Research, 75, 417–453.
9 Squires, J., Bricker, D., Heo, K., & Twombly, E. (2001). Identification of social-
10
11 emotional problems in young children using a parent-completed screening
12
13
measure. Early Childhood Research Quarterly, 16, 405–419.
14 Squires, J., Bricker, D., & Twombly, E. (2002). Ages & stages questionnaires: Social-
15
16 emotional (ASQ:SE): A parent-completed, child-monitoring system for social-
Fo
17
emotional behaviors. Baltimore, MD: Brookes.
18
19 Squires, J., Bricker, D., & Twombly, E. (2003). The ASQ: SE user’s guide for the ages
rP
20
21 & stages questionnaires, social-emotional: A parent completed, child-
22 monitoring system for social-emotional behaviors. Baltimore, MD: Brookes.
23
ee

24 Squires, J., Bricker, D., & Twombly, E. (2004). Parent-completed screening for social
25
26
emotional problems in young children: The effects of risk/disability status and
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27 gender on performance. Infant Mental Health Journal, 25(1), 62–73.

28
29 Squires, J., Twombly, E., Bricker, D. D., & Potter, L. W. (2009). ASQ-3 user's guide
ev

30 (3rd ed.). Baltimore, MD: Paul H. Brookes Pub.

31
32 Sroufe, L. A. (1996). Emotional development: The organisation of emotional life in the
iew

33
34 early years (Cambridge studies in social and emotional development). New
35 York, NY: Cambridge University Press.
36
37 Swain, J. E., Lorberbaum, J. P., Kose, S., & Strathearn, L. (2007). Brain basis of early
On

38
parent?infant interactions: Psychology, physiology, and in vivo functional
39
40 neuroimaging studies. Journal of Child Psychology and Psychiatry, 48, 262–
41
287.
ly

42
43 Teubert, D., & Pinquart, M. (2010). The association between coparenting and child
44
45 adjustment: A meta-analysis. Parenting, 10, 286–307.
46
47 Thompson, R. A. (2001). Development in the first years of life. Future of Children,
48 11(1), 20–33.
49
50 Van Zeijl, J., Mesman, J., Van Ijzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer,
51
F., Stolk, M. N., Alink, L. R. A. (2006). Attachment-based intervention for
52
53 enhancing sensitive discipline in mothers of 1- to 3-year-old children at risk for
54
55 externalizing behavior problems: A randomized controlled trial. Journal of
56 Consulting and Clinical Psychology, 74, 994–1005.
57
58
59
60 URL: http://mc.manuscriptcentral.com/rahd
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3 Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., …
4
Rollins, N. C. (2016). Breastfeeding in the 21st century: Epidemiology,
5
6 mechanisms, and lifelong effect. The Lancet, 387, 475–490.
7
8 Wendland, J., Danet, M., Gacoin, E., Didane, N., Bodeau, N., Saïas, T., ... & Chirac, O.
9 (2014). French Version of the Brief Infant-Toddler Social and Emotional
10
11 Assessment Questionnaire–BITSEA. Journal of pediatric psychology, 39, 562-
12
13
575.
14 Woodward, L., & Liberty, K. (2017). Breastfeeding and child psychosocial
15
16 development. encyclopedia on early childhood development. Retrived from
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http://www.child-encyclopedia.com/
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3 Tables
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5 Table 1. Descriptive statistics of the participants’ sociodemographic data.
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7 EG n=40 CG n=40 Mean Difference
Variable
8 M (S.D) Min. - Max. M (S.D) Min. – Max. T observed Sig.
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10 M=32.83 M=31.70
Mo age (years) 20-43 23-42 T78 =1.012 .314
11 (S.D=5.17) (S.D=4.76)
12 M=35.63 M=33.70
13 Fa age (years) 24-54 22-49 T78 =1.365 .176
14 (S.D=6.71) (S.D=5.88)
15 Child’s age M=25,08 M=24.15
16 12-36 12-36 T78 =0.547 .586
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(months) (S.D=7.64) (S.D=7.57)
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18 M=14.90 M=15.03
Mo Ed. (years) 7-17 8-17 T78 =-.208 .836
19 (S.D=2.55) (S.D=2.82)
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M=15.05 M=15.13
21 Fa Ed. (years) 8-17 8-17 T78 =-.132 .895
22 (S.D=2.53) (S.D=2.54).
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24 Note. EG, Experimental Group; CG, Control Group; M, Mean; S.D, Standard
25 Deviation; Mo, Mother; F, Father; Ed, Education.
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5 Table 2. Frequency and percentages of the participants’ sociodemographic data.
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7 EG n=40 CG n=40 Goodness of Fit
Variable
8 F % F % χ2
Sig.
observed
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10 1 29 72.5 28 70.0
11 Birth 2 8 20.0 8 20.0
12 χ2 (3)=0.351 .950
order 3 2 5.0 2 5.0
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14 4 1 2.5 2 5.0
15 χ2
16 Breastfeeding 37 92.5 39 97.5 .305
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18 χ2
19 Day care 24 68.6 19 48.7 .084
(1)=2.987
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21 χ2
Tracer diseases 14 35.0 15 37.5 .750
22 (1)=0.102
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24 18 58.1 21 67.7 .246
25 mother (1)=4.147
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27 37 92.5 38 97.4 .513
father (1)=1.334
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30 Note. EG, Experimental Group; CG, Control Group, f, frequency, % percentage

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3 Table 3. Descriptive statistics of the child's development measured with the ASQ-3.
4 Wilks’ Size Observed
5 Variable ASQ-3 M Ev.1 n=40 M Ev. 2 n=40 Fobserved Sig.
λ Effect Power
6 Comm. EG -0.47 1.60
7 (S.D=0.96) (S.D=1.22)
0.948
F (1, 78)
.042 .052 .534
Comm. CG -0,14 1.24 =4.284
8
(S.D=0.97) (S.D=1.35)
9 Prob. Solv. EG 1.43 1.72
10 (S.D=0.99) (S.D=1.14)
0.998
F (1, 78) =
.673 .002 .070
11 Prob. Solv. CG 1.27 1.43 0.179
(S.D=1.06) (S.D=1.11)
12 Pers-Soc. EG 1.33 1.58
13 (S.D=1.21) (S.D=1.06) F (1, 78) =
0.998 .694 .002 .068
14 Pers-Soc. CG 1.25 1.39 0.156
15 (S.D=1.02) (S.D=1.18)
Gross Mot. 1.52 1.84
16 EG (S.D=0.95) (S.D=1.18) F (1, 78) =
Fo
0.987 .312 .013 .171
17 Gross Mot. 1.87 1.92 1.035
18 CG (S.D=0.98) (S.D=0.76)
Fin. Mot. EG 0.90 1.92
19 (S.D=0.30) (S.D=1.22) F (1, 78) =
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20 0.875 .001 .125 .910
Fin. Mot. CG 0.93 0.98 11.185
21 (S.D=0.27) (S.D=1.35)
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23 Comm., Communication; Prob. Solv., Problem Solving; Pers-Soc., Personal-Social;
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24 Gross. Mot., Gross Motor; Fin. Mot., Fine Motor, EG, Experimental Group; CG,
25 Control Group
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3 Table 4. Descriptive statistics of child development measured using the ASQ-SE.
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Variable M Ev.1 M Ev. 2 Size Observed
5 Wilks’ λ Fobserved Sig.
6
ASQ-SE n=40 n=40 Effect Power
7 Glob. Probl. EG 18.08 12.07 0.930 F (1, .017 .070 .670
8 (S.D=11.05) (S.D=7.86) 78) =
9 Glob. Probl. CG 15.92 14.66 5.907
(S.D=8.28) (S.D=7.13)
10 Self-reg. EG 20.45
11 (S.D=12.17) 15.04
12 (S.D=12.54) 0.980 F (1, 78) = .212 .020 .237
13 1.584
Self-reg. CG 21.81
14 (S.D=12.17) 20.50
15 (S.D=12.38)
16 Comp. EG 23.75
Fo
17 (S.D=23.53) 8.75
(S.D=14.61) 0.918 F (1, 78) = .010 .082 .743
18 7.002
19 Comp. CG 13.75
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20 (S.D=22.61) 13.33
21 (S.D=25.37)
Adap. Func. EG 19.26
22 (S.D=18.65) 14.28
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24 Note. Glob. Probl., Global Problem; Self-reg., Self-regulation; Comp., Compliance;

25 Adap. Func., Adaptive Functioning; Auton., Autonomy; Comm., Communication; Aff.,
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Initial contact: 131 triads
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8 Does not meet inclusion criteria n = 29
9 Rejects participation n = 17
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11 Participant triads n = 85
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13 No randomization
Matching by toddler age and parents’ education
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17 Experimental Group Control Group
18 n = 43 n = 42
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Video-feedback
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intervention NO intervention
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28 Current study
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36 Video-feedback
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Figure 1. Study flow chart. Copy from "Video-feedback intervention to improve parental sensitivity and the quality of interactions in
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6 mother-father-infant triads,” by M. Olhaberry, M. J. León, M. Escobar, D. Iribarren, I. Morales-Reyes, I., & K. Álvarez, 2017, Mental
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5 ASQ-3 IN MEASURES 1 AND 2
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7 2.5
1.92 1.84 1.87 1.92
8 2 1.6 1.72 1.58
1.43 1.52 1.33
9 1.5 1.24 1.27 1.43 1.25 1.39
10 0.9 0.93 0.98
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25.0 23.8
7 21.8
8 20.5 20.5
20.0 18.1 19.3
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15.9 16.2 16.7 15.8 15.9
15.4 15.515.4
10 14.7 15.0
15.0 13.8 13.9 14.3
11 12.1 11.7
11.3 10.1 10.6
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10.13. Scientific publications non-related with the thesis sample

10.13.1. Video-feedback intervention in mother-baby dyads with depressive

symptomatology and relationship difficulties (Published)

343
Research in Psychotherapy: Psychopathology, Process and Outcome © 2015 Italian Area Group of the Society for Psychotherapy Research
2015, Vol. 18, No. 2, 82-92 ISSN 2239-8031 DOI: 10.7411/RP.2015.102

Video-feedback intervention in mother-baby

dyads with depressive symptomatology
and relationship difficulties

Marcia Olhaberry1 , María José León2, Magdalena Seguel1, & Constanza Mena1

Abstract. Post-partum depression (PPD) is one of the most common complications

associated to maternal suffering, negative effects for the baby, and difficulties in the
relationship. Video-feedback is a particularly effective technique used in dyadic ear-
ly interventions. A brief intervention for mother-infant dyads with maternal depres-
sive symptomatology was implemented using this technique, and was assessed in a
longitudinal, quasi-experimental and quantitative study. 61 mother-baby dyads par-
ticipated, with ages ranged from 18 to 41 years in mothers, and 8,4 to 18,8 months
in their babies. The results show an improvement in the quality of the interaction,
with a significant increase of maternal sensitivity, and a significant decrease in con-
trol. A significant reduction of depressive symptomatology was not found, although
the frequency of major depression episodes and bonding risk decreased.

Keywords: early intervention, video-feedback, depression, maternal sensitivity

Human beings are born before attaining neurological
maturity, which means that a large part of brain de-
velopment must occur during the first years of life
(Greenspan & Benderly, 1998). For this reason, the
post-partum environment and the early interperson-
al experiences between a child and his/her main
caregivers will influence the structural and functional
evolution of his/her brain, his/her development, and
his/her future mental health (Storfer, 1999; Schore,
2000; Mendes & Seidl-de-Moura, 2014).
Upon the basis of microanalytic studies of moth-
er-baby interactions, child development theories
have shifted from considering that the mother uni-
laterally molds the child to propounding mutual in-
fluence (Stern, 1985). This has led current studies to
regard the primary caregiver-child dyad as their
unit of study. In this regard, there is consensus
among researchers that the verbal and non-verbal
communication process in the dyad contributes to
the development of reciprocity, the exchange of in-
1
Escuela de Psicología, Pontificia Universidad Católica de
Chile.
2
Universidad de Chile.
Correspondig Author: Marcia Olhaberry, Escuela de Psi-
cología, Pontificia Universidad Católica de Chile;
email to: mpolhabe@uc.cl
formation and feelings between both participants,
and the quality of their bond (Trevarthen & Ait-
ken, 2001). Thus, the caregiver's interactive skills
are associated with the child's expression of affec-
tion and type of response, especially during the first
years of life (Kivijarvi, Voeten, Niemela, Raiha, Ler-
tola, & Piha, 2001).
Maternal mental health problems have been iden-
tified as a highly relevant factor in early mother-baby
relationships and bonding quality, with postpartum
depression (PPD) being one of the most common
complications associated with maternal distress, neg-
ative effects for the baby, and relationship and bond-
ing difficulties (O'Hara & McCabe, 2013).
PPD shares characteristics with depression at
other stages of the life cycle, with symptoms such as
tiredness and feelings of loneliness and guilt (Leahy-
Warren & McCarthy, 2007), as well as irritability,
low spirits, emotional instability, anxiety, and sleep-
ing disorders (American Psychiatric Association,
2013), with the latter often being regarded as part
of the normal experience during this period (Hal-
breich & Karkun, 2006).
In general terms, international studies show that
between 6% and 38% of women suffer from depres-
sion during or after pregnancy (Field, 2011), with
PPD prevalence ranging from 13% to 19% (O'Hara
83 Video-feedback intervention in mother-baby dyads
& McCabe, 2013). These figures are higher in devel-
oping countries (Evans, Vicuña, & Marín, 2003):
PPD surpasses 20% according to some studies con-
ducted in Latin American communities (Moreno
Zaconeta, Domingues Casulari da Motta, & França,
2004; Urdaneta, Rivera, García, Guerra, Baabel, &
Contreras, 2010).
In Chile, a third of women display symptoms of de-
pression and/or anxiety during pregnancy, while the
prevalence of postpartum depression exceeds 40%
(Jadresic, 2010). Studies show that the number of
women with PPD increases over time; that is, while
10% are diagnosed after 8 weeks of postpartum, 22%
receive this diagnosis 12 months after their baby is
born (Barlow, McMillan, Kirkpatrick, Ghate, Barnes
& Smith, 2010), which stresses the need to provide
support and monitoring during the first years of the
baby's life.
Regarding the consequences of PPD for children,
several negative effects have been described which
impact their cognitive, emotional, and behavioral de-
velopment, as well as the mother-child relationship
(Field, 2011). Research shows that the babies of de-
pressive mothers cry more often, are difficult to calm
down, display more negative emotions, and avoid vis-
ual contact with the mother (Radesky, Zuckerman,
Silverstein, Rivara, Barr, Taylor, Lengua & Barr,
2013). At the psychological level, studies note that re-
tarded development, mental health problems, cogni-
tive deficits in pre-school and elementary school, and
behavioral problems are more frequently present in
the children of depressed mothers than in those of
non-depressed ones (Podestá, Alarcón, Muñoz, Legüe,
Bustos, & Barría, 2013). In this context, the children
of depressive mothers are at a higher risk of develop-
ing psychopathologies and particularly mood disor-
ders (Pawlby, Hay, Sharp, Waters, & O'Keane, 2009).
With respect to the mother-baby relationship, a
number of flaws have been described in the parenting
abilities of mothers with PPD, such as low sensitivity,
lack of enjoyment, intrusive behaviors, negative emo-
tions, and punitive behaviors during the interaction,
as well as high stress and negative perceptions of their
babies' behavior (Wan & Green 2009). Likewise, de-
pressed mothers have been observed to have low con-
fidence in themselves and in their role (Zietlow,
Schlüter, Nonnenmacher, Müller, & Reck, 2014).
Based on the difficulties of depressive mothers to dis-
play sensitive behaviors and positive and synchronic
affects with their babies, perinatal maternal depres-
sion has also been associated with insecure child at-
tachment (Hayes, Goodman, & Carlson, 2013) and
with greater negative effects on the bond depending
on the severity and chronicity of the mother's depres-
sion (McMahon, Barnett, Kowalenko, & Tennant,
2006).
Multiple studies show that early interventions, in
general, foster adequate child development and in-
crease caring behaviors and sensitive response from
mothers towards their children (Bakermans-
Kranenburg, Van IJzendoorn, & Juffer, 2003). How-
ever, in the case of PPD, most psychological interven-
tions focus on reducing the mother's depression, with
only a few attempting to simultaneously modify ma-
ternal depression and bonding quality (Milgrom,
Schembri, Ericksen, Ross, & Gemmill, 2011; Olhaber-
ry, Escobar, San Cristobal, Santelices, Farkas, Rojas,
&Martínez, 2013). Studies reveal that the treatment of
maternal depression does not necessarily entail im-
provements in the mother-baby relationship (Cooper
& Murray, 1995); thus, psychotherapeutic interven-
tions that fulfill the mother's mental health needs have
not always been shown to efficiently improve the ba-
by's results, nor have they been observed to generate
positive changes in child attachment (Murray,
Cooper, Wilson, & Romaniuk, 2003).
Video Feedback Psychotherapeutic
Interventions
Video feedback is an especially effective technique
used in early interventions. It has been applied to
pursue a number of therapeutic objectives, either by
itself or combined with other techniques (Kali-
nauskiene, Cekuoliene, Van IJzendoorn, Bakermans-
Kranenburg, Juffer, & Kusakovskaja, 2009). These
interventions comprise 3 to 4 video recording ses-
sions of the mother and the baby playing together for
15 to 20 minutes (Rusconi-Serpa, Rossignol, &
McDonough, 2009). Afterwards, the recorded scenes
are analyzed and certain sequences are selected to
work with the adult, generally the mother.
This technique can reveal details of the mother-
baby interaction which are usually undetectable while
they happen due to their complexity and speed. Ana-
lyzing the interaction with the parents makes it possi-
ble to focus on specific aspects, which provides an op-
portunity to process and reflect on successful and dif-
ficult moments of the interaction (Fonagy, Gergely,
Jurist, & Target, 2002). This allows parents to observe
themselves, identify emotions, and reorganize their
mental representations of themselves and the baby
(Beebe, 2003). Thus, with the therapist's help, these
images are shown to the mother in order to foster her
reflection on her baby's physical and verbal cues, as
well as on her own representational models and bond-
ing experiences (Rusconi-Serpa, Sancho Rossignol &
McDonough, 2009). According to Beebe (2014), video
feedback allows parents to learn about their babies'
non-verbal language, thus promoting new forms of
interaction. The objective is to provide parents with a
new perspective on the child's non-verbal language
and his/her skills and behaviors (Beebe, 2010).
Video feedback interventions have been imple-
mented and evaluated in a variety of specialized pro-
grams for outpatients in several cultures (Marvin,
Cooper, Hoffman, & Powell, 2002; Yagmur, Mesman,
Malda, Bakermans-Kranenburg, & Ekmekci, 2014).

Studies reveal that these interventions significantly
improve the sensitive response of mothers towards
their babies and increase their feelings of self-efficacy
associated with childrearing (Kalinauskien et al., 2009;
Yagmur et al., 2014). On the other hand, these inter-
ventions have been observed to successfully reduce
maternal symptomatology in hospital settings (Bilszta,
Buist, Wang, & Zulkefli, 2012), as well as in the home,
improving the quality of child attachment and of the
mother-child relationship (Van Doesum, Riksen-
Waraven, Hosman, Hoefnagels, 2008).
Other studies stress the contribution of video feed-
back in strengthening the mother's observation skills,
increasing empathy and sensitivity to the baby's needs,
and reinforcing the positive childrearing behaviors
observed in the video (Van Zeijl, Mesman, Van IJzen-
doorn, Bakermans-Kranenburg, Juffer, Stolk & Alink,
2006). In this context, some studies ascribe the posi-
tive results of video feedback interventions to their
contribution to parental self-esteem and self-efficacy,
which has a positive impact on the quality of parents'
interaction with their children. Some of the factors
found to be associated with these changes are: consid-
ering the reason for requesting professional help and
integrating it in the intervention, having a positive ex-
perience during the first recording, focusing on posi-
tive aspects, promoting reflexive skills to understand
one's emotional and mental states as well as the baby's,
and creating a new way of understanding the dyad
through reflection and conversation with the therapist
(Doria, Kennedy, Strathie & Strathie, 2013).
In the specific case of PPD, evidence indicates that
after a video feedback intervention, mothers discover
a more positive image of themselves and increase their
enjoyment of the time they spend with their children,
which has a positive impact on their bond (Vik &
Braten, 2009).In Chile, this technique has been ap-
plied in vulnerable families, and has been shown to
improve maternal sensitivity (Suárez, Muñoz, Gómez,
& Santelices, 2009); however, it has not been specifi-
cally applied in dyads with mothers displaying depres-
sive symptomatology.
Considering the information presented and the im-
portance of early interventions in at-risk groups, we
developed a brief video feedback intervention for
mother-child dyads with maternal depressive symp-
tomatology. We expected the intervened dyads to im-
prove their interaction quality after the intervention,
in terms of an increase in maternal sensitivity levels
and a reduction in bonding risk and depressive symp-
tomatology.
Method
Design
A longitudinal, quasi experimental study was con-
ducted to evaluate the differences between the pre-
and post-intervention measurements in the experi-
mental and control groups. The interventions and
Olhaberry et al. 84
evaluations were carried out during 2013 and 2014.
Participants
The participants in the present study were part of
an intervention program for the promotion of ma-
ternal sensitivity and the reduction of depressive
symptomatology that started in 2012 and ended on
2014. The participants belonged to a low or middle-
low socioeconomic status and received healthcare
in 5 public health centers located in peripheral areas
of Santiago, Chile. The inclusion criteria considered
for the study were: the presence of one or more risk
factor for depression, depressive symptomatology
(BDI score ≥ 5), at least 18 years old, a pregnancy
compatible with the life of the mother and the baby,
and absence of severe physical psychopathology,
addictions and/or psychosis. The pregnant women
agreed to participate voluntarily in the study, previ-
ously signing a letter of informed consent in accord-
ance with the ethical requirements in force in Chile.
The program included 4 measurements and 3 in-
terventions, which considered different moments
and modalities. Initially, 134 pregnant women were
included into the program, 49 received the work-
shop for pregnant women and 85 were part of the
control group. After the birth, 83 dyads continued
to participate, 49 received a second group work-
shop and 31 continued in the control group. Finally,
61 dyads remained in the program, 30 received the
video feedback intervention and 31 continued in
the control group.
The first intervention consisted in 5 group ses-
sions and was conducted during pregnancy in
groups of approximately 8 women. The second con-
sisted in 4 sessions directed to mother-infant dyads
with approximately 4 dyads per group; and the
third consisted in 4 individual video-feedback ses-
sions (see flow chart in Figure 1).
For the research reported in this manuscript, 61
mother-child dyads were studied, all of them with
maternal depressive symptomatology and receiving
the usual treatment in public health centers in San-
tiago de Chile (brief individual psychotherapy
and/or pharmacological therapy). 30 dyads were
part of the experimental group and received the
usual intervention provided by the health center
alongside a video-feedback one. 31 dyads com-
prised the control group and only received the usual
treatment provided by public health centers. The
dyads were not randomly assigned to the groups, as
due to ethical reasons at the beginning of the pro-
gram all women were invited to participate in the
group interventions while these were conducted.
Once the interventions concluded, the contacted
dyads that met the inclusion criteria were integrat-
ed to the control group. Dyads from the experi-
mental group were included in an intervention pro-
gram aimed at reducing depression and promoting
85 Video-feedback intervention in mother-baby dyads

a secure mother-baby bond, which included two sion are identified: minimum, 0-9; mild, 10-18;
group workshops and the video feedback interven- moderate, 19-29; and severe, 30-63. The reliability
tion, which is analyzed in the present study. The analysis is adequate, having been obtained from the
dyads from the control group did not receive any of Spanish version applied to patients with psycholog-
these interventions. ical disorders with an alpha value = 0.90 (Vázquez
& Sanz, 1999).
STUDY FLOW CHART Diagnostic Classification of Mental Health
Inital enrolment: 134 pregnant women and Developmental Disorders of Infancy and
(BD ≥5 risk factors for depression) Early Childhood, Zero to Three, DC: 0 – 3R
(Link Egger, H., Fenichel, E., Guedeney, A., Wise, B
& Wright, H., 2005). Mothers were asked to respond
No Randomization if the criteria for a depressive disorder in infancy was
present or absent in their babies. When fulfilling all
characteristics, depression was assessed. The instru-
ment was incorporated to include an assessment of
depression in the infant, considering the relevance of
Experimental Group Control Group this variable not only in the mother as well in the
n = 49 n = 85 child.
Mini-international neuropsychiatric interview
(Sheehan, Lecrubier, Harnett-Sheehan, Janavs,
Group workshop
during pregnancy Weiller, Bonara, Keskiner, Schinka, Knapp, Sheehan
No intervention & Dunbar, 1997). Explores 17 mental disorders de-
(5 sessions)
fined in the DSM-IV-R, focusing on the patient's cur-
n = 49 BIRTH n = 31
rent symptomatology. In our study, the mood disor-
ders module was used in order to obtain a clinical di-
Group workshop agnosis of current major depression and to detect su-
with mother-infant icide risk and its level (mild, moderate, or high).
dyads (4 sessions) CARE-Index, Experimental Index of Child-
No intervention
Adult Relationships (Crittenden, 2006). Consid-
n = 30 n = 31 ers a 3- to 5-minute video recording of play interac-
tion between the child and the adult. The coding
Video-feedback No Current system defines three descriptors for the adult: sensi-
(4 sessions) intervention study tive, controlling, and non-responsive, and four for
the infant: cooperative, difficult, compulsive, and
passive. It considers a dyadic sensitivity scale that
Final Assessment ranges from 0 to 14 points, with 0-4 signaling “risk”,
5-6 “inept”, 7-10 “adequate”, and 11-14 “sensitive”;
scores below 7 indicate need for intervention. The
Figure 1. Flow chart video coding was conducted by psychologists
trained by the author of the instrument, and
Instruments reached a reliability of ≥ 0.7 in the various scales
used. The videos' codification was made without
The pre- and post-video feedback intervention the presence of information regarding the source of
measurements were conducted using the following the videos, neither the belonging to the experi-
instruments: mental nor control group. The inter-judge reliabil-
Personal information form: used to collect the ity between the 3 codifiers that participated in the
participants' sociodemographic information and study was 0.72, which is considered adequate by the
mental health history. author of the instrument.
Beck Depression Inventory, BDI (Beck, Ward, The instrument was included to assess the quality
Mendelson, Mock & Erbaugh, 1961). This is a self- of mother-infant interactions considering its utility
reporting questionnaire which is composed of 21 and clinical richness, the use of observational mate-
items. It evaluates current depressive symptoms. In rial and the existence in Chile of codifiers certifi-
this test, the subject must choose the phrase that cated by the author.
best describes their emotional state over the previ-
ous week from a set of four alternatives ordered Procedure
from lower to higher severity. Each item may be
evaluated from 0 to 3 points, with a total score vary- The women were first contacted during pregnancy
ing from 0 to 63. Higher scores indicate greater de- and invited to participate in the program. Then, af-
pressive symptoms, and four categories of depres- ter two interventions they were invited to partici-

pate with their children in the video-feedback in-
tervention through the health centers that they at-
tended. A scale was applied to evaluate their de-
pressive symptomatology (BDI); those who ob-
tained 5 or more points and presented one or more
of the risk factors usually identified during preg-
nancy in Chile (late involvement in prenatal care,
low educational attainment, use or abuse of con-
trolled substances, gender violence, maternal con-
flicts, insufficient social support, and depressive
symptoms) were included in the program and asked
to sign an informed consent letter. At this point,
their sociodemographic data were collected. Then,
a clinical diagnosis of mood disorders according to
the DSM-IV R (MINI) was conducted. After their
babies were born, videos were recorded to evaluate
maternal sensitivity and the quality of the interac-
tion through the CARE-Index. The mothers' de-
pressive symptoms were measured again after the
video-feedback intervention. All evaluations were
conducted by psychologists and senior clinical psy-
chology students, previously trained to apply each
of the instruments. The study was carried out sim-
ultaneously with the psychological and/or psychiat-
ric treatments provided by the health center. The
information associated with these treatments was
included in the study and its variables were con-
trolled when performing the statistical analyses.
We took into account the intervention in guided
interactions developed by McDonough (1993,
2004) and the ODISEA model developed in Chile
by Gómez and Muñoz (2013) to generate a 4-
session adaptation. The intervention was adapted,
considering the necessity of generating a procedure
for depressive mothers and their infants, adjusted
to their emotional necessities and feasible to im-
plement in the mother's home in a low number of
sessions. The considered models do not directly ad-
dress depression; neither they are exclusively ori-
ented to dyads with toddlers. It was implemented
by five pairs of psychologists, formed in the model
in a 30-hours training that included weekly clinical
meetings to analyze and discuss the cases.
First Session: The mother's concerns over the
child or the relationship are explored. Then, a 15
minute video is recorded of the mother-child play
interaction with an age-appropriate set of toys, and
finally the experience is discussed and a task con-
nected with the experience is defined.
Post-session work: the two therapists identify the
positive and negative sequences in the video, in or-
der to link the interactions observed to the mother's
concerns. Afterwards, they select segments from
positive interactions, defining their therapeutic use
and the focus of the intervention. In addition, they
define questions to be asked to the mother while
she watches the segments that refer to both partici-
pants' emotional experiences, internal states, needs,
and relationship. The questions are intended to fos-
Olhaberry et al. 86
ter the mother's recognition of the child's needs, her
sensitive response, her mentalizing function, and
her identification of mutual influence.
Second session (Feedback): The selected sequences
are shown and the mother is prompted to reflect on
these segments through questions about them; af-
terwards, a new task is co-constructed. The dura-
tion of this session is approximately 60 minutes.
Sessions 3 and 4 replicate the structure of the first
2, but a video in which the mother feeds her child is
added, in order to introduce an everyday activity
that involves a higher level of stress than free play.
Session 4 also includes an evaluation of the process.
The sessions were conducted once a week, having
completed the entire intervention in one month.
The main intervention techniques used during
the video-feedback sessions with the mother were:
speaking for the child, questions (about the ob-
served, its relation with other interactions, about
the child, about themselves), deliver information
about the child´s developmental stage, identifica-
tion of sensitive interaction chains, reinforcement
for the mother, exploration of inner states that un-
derlies the conduct, reflection, build new meanings.
Data analysis
Before statistically analyzing the data, we evaluated
the presence of atypical values and the fulfillment of
the assumptions of the statistical tests conducted,
specifically an assessment of the normality of the
variables was conducted through the Kolmogorov-
Smirnov Z test and QQ graphics were assessed for
the analysis of atypical data. The significance crite-
rion used was α = 0.05. We conducted a descriptive
analysis of the variables studied in each group, their
levels of association, and finally a pre- and post-
intervention comparison between the groups using
a mixed ANOVA. Due to their possible effect on
the results, the variables -assistance to psychological
treatment-, and -assistance to pharmacological
treatment- were controlled during the intervention,
including them as co-variables.
Results
Descriptive statistics
The sociodemographic information collected indi-
cates that the participants' mothers’ mean age is
27.64 (SD = 6.19), and that it ranges from 18 to 41.
The participating children had a mean age of 13.9
months of age (SD = 2.59), with ranges between 8.4
and 18.8. No significant differences are observed
between the groups in terms of the mothers' age (p
>.05), years of education (p >.05), or number of
children (p >.05). Also, no differences exist between
the groups in terms of the proportion of women
with a couple (p > .05) or between the age and sex
87 Video-feedback intervention in mother-baby dyads

of the children in the two groups (p > .05). Tables 1 quality of the mother-baby interaction as measured
and 2 detail the descriptive statistics of each group through the CARE-Index, the results show an in-
in the variables mentioned. crease in maternal sensitivity over time in the ex-
perimental group dyads, with their post-
Table 1. Descriptive statistics of the participants' sociode- intervention score being statistically higher than
mographic data
that of the control group dyads in this variable
Experimental
(Wilks' λ= 0.739, F (1, 59) = 20.883; p < .001). The
Control Group power observed for this test was .99 and the effect
Group
(n = 31)
(n = 30) size was ηp2 = .261 Figure 1 shows the variations in
maternal sensitivity between the groups after re-
Variable M SD M SD
ceiving the intervention.
Mother's age (years) 28.23 6.184 27.03 6.250 The results of the analysis of the other maternal
Years of education 11.74 2.352 11.87 2.488 behavior descriptors show significant inter-group
Child's age (months) 13.28 2.720 14.620 2.290 differences in the controlling descriptor, with signifi-
cantly higher scores in the non-intervened group
Table 2. Frequencies and percentages of the participants‘ (Wilks' λ = 0.863, F (1, 59) = 9.331; p < .001). The
sociodemographic data power observed for this test was .85 and the effect
Experimental size was ηp2 = .137. The scores for maternal non-
Control Group responsiveness do not vary significantly over time or
Group
(n = 31) between groups (power = .16 ; effect size ηp2 = .016 ;
(n = 30)
p ˃ .05). Figure 2 shows the variations in controlling
Variable Frequency % Frequency % maternal behavior by group.
Has a couple 30 96.8 23 76.7
N° of children
1 8 25.8 13 43.3
2 15 48.4 11 36.7
≥3 8 25.9 6 20.0
Female child 15 48.4 12 40.0

Tables 3 and 4 show the averages and standard

deviations of the mothers' and the children's inter-
action descriptors and depressive symptomatology
in the pre and post measurements, by group.

Comparative analyses
In order to determine the effectiveness of the video
feedback intervention in the variables studied,
analyses were applied to compare both groups using
mixed ANOVA.
Figure 1: Evolution of maternal sensitivity in the control and
experimental groups before and after the video feedback inter-
vention. The power of the test was .994.

Regarding the effects of the intervention on the

Table 3. Descriptive statistics of the mother-infant interaction descriptors

Control Group Experimental Group
(n = 31) (n = 30)
Pre Post Pre Post
Descriptor M (SD) M (SD) M (SD) M (SD)
Mother
Sensitive 4.35 (1.01) 4.65 (0.83) 6.40 (1.90) 8.23 (1.79)
Controlling 4.87 (3.13) 5.55 (3.13) 4.30 (2.52 2.70 (2.43)
Non responsive 4.84 (3.30) 3.84 (3.36) 3.33 (2.77) 3.07 (2.16)
Infant
Cooperative 3.94 (1.12) 4.52 (0.89) 6.07 (2.06) 7.90 (1.78)
Difficult 2.74 (2.92) 0.97 (1.62) 1.50 (1.88) 2.00 (2.28)
Compulsive 3.19 (2.89) 5.16 (2.59) 2.23 (2.23) 1.77 (1.94)
Passive 4.23 (2.62) 3.32 (2.34) 4.27 (2.63) 2.30 (1.41)
 Olhaberry et al. 88

Table 4. Averages and standard deviations of maternal depressive symptomatology (BDI) by group, and frequencies and
percentages by depression diagnostic category.

Control Group Experimental Group

(n = 31) (n = 30)
Pre Post Pre Post
M (SD) Freq (%) M (SD) Freq (%) M (SD) Freq (%) M (SD) Freq (%)
Total BDI 12.42 (10.90) 11.87(9.04) 12.03(7.88) 9.43(7.20)

Minimum (0-9) 3.4(2.4) 15(48.4) 4.8(2.4) 16(51.6) 4.92(3.2) 12(40) 5.1(2.5) 19(63.3)
Mild (10-18) 14.5(2.9) 9(29.0) 14.3(2.7) 8(25.8) 13.2(2.6) 12(40) 13.1(2.8) 8(26.7)
Moderate (19-29) 24.5(5.2) 4(12.9) 21.6(1.1) 5(16.1) 20.5(1.9) 4(13.3) 26.6(2.0) 3(10.0)
Severe (30-63) 34.6(2.8) 3(9.7) 34.0(2.8) 2(6.5) 30.5(0.7) 2(6.7) 0(0) 0(0)

With respect to the quality of the interaction in
the studied dyads, the results reveal smaller fre-
quencies of bonding risk in the experimental group
and a stronger need for subsequent intervention in
the dyads that were not intervened using video feed-
back (see table 5).
The analyses conducted to determine the differ-
ences between the groups in maternal depressive
symptomatology show a reduction in the average
scores of both, but the differences are not statisti-
cally significant (Wilks' λ = 0.982, F (1, 58) = 1.086;
p > .001). The power observed for this test was .17
and the effect size was ηp2 = .018). Even though the
intervention was not observed to have an effect on
the mothers' depressive symptoms, the major de-
pression and childhood depression frequencies are
lower in the intervened group, association that is
statistically significant (Χ22 = 8.099; p = .017). The
frequencies of these variables in the pre and post
measurements are presented in table 6.

Table 6. Frequencies (F) and percentages (%) of maternal major

depression (MD) and childhood depression before and after the
intervention, evaluated with the MINI and the DC:0-3R.
Control Group Experimental Group
n = 31 n = 30

Pre Post Pre Post

Figure 2. Evolution of maternal control in the experimental and
control groups before and after the video feedback interven- Freq (%) Freq (%) Freq (%) Freq (%)
tion. The power of the test was .852. Maternal MD 23 (72.4) 13 (41.9) 19 (63.3) 3 (10.0)
Childhood
Table 5. Frequencies (F) and percentages (%) by group in the depression 5 (16.1) 13 (41.9) 5 (16.6) 1 (3.3)
Sensitivity Scale categories (risk, inept, adequate, sensitive).
Sensitivity Control Group Experimental Group
Scale (n = 31) (n = 30) Discussion

Pre Post Pre Post Studies focusing on early childhood have consist-
Freq (%) Freq (%) Freq (%) Freq (%) ently shown the clinical relevance of early interven-
Risk 13 (41.9) 14 (45,2) 3 (10.0) 0 tions in mother-infant dyads that experience diffi-
Inept 18 (58.1) 16 (51.6) 19 (63.3) 5 (16.7) culties in the establishment of the first bond
Adequate 0 1 (3.2) 5 (16.7) 19 (63.3) (Schore, 2000), which emphasizes the need of con-
Sensitive 0 0 3 (10.0) 6 (20.0) ducting them when mothers are depressed or dis-
play high symptomatology (O'Hara, & McCabe,
With respect to the quality of the interaction in 2013).
the studied dyads, the results reveal smaller fre- Consistently with the theoretical literature re-
quencies of bonding risk in the experimental group viewed, the results of the intervention conducted
and a stronger need for subsequent intervention in confirm the effectiveness of early video feedback in-
the dyads that were not intervened using video terventions in dyads with maternal depressive symp-
feedback (see table 5). tomatology and relationship difficulties. The results
89 Video-feedback intervention in mother-baby dyads
reveal a significant increase in maternal sensitivity
and child cooperativeness in the intervened dyads,
and in a qualitative level, along with lower frequen-
cies of bonding risk, which reveals a positive effect
on these variables and confirms one of our hypothe-
ses. These results are especially relevant if we consid-
er the positive association between adequate mater-
nal sensitivity and the generation of a secure attach-
ment pattern in the baby, as well as its link with posi-
tive emotional, cognitive, and social development
(Coppola, Vaughn, Cassiba, & Constantini, 2006).
A more specific analysis of the results in the area
of mother-baby bond quality shows that the signifi-
cant changes associated with the intervention are
observed mostly in maternal sensitivity and control-
ling behavior, with the former increasing and the
latter decreasing in the experimental group. That is,
the mothers in the experimental group display an
increased ability to read children's signals, interpret
them adequately, and respond suitably and in ac-
cordance with their needs, alongside a decrease in
their hostile behavior, in terms of overt or con-
cealed anger, which can be manifested through in-
congruity in maternal behavior or direct intrusions.
These results are consistent with previous studies,
which report improved sensitivity and reduced in-
trusive behavior in mothers during their interac-
tions with their babies (Kalinauskien et al., 2009;
Yagmur et al., 2014). It is relevant to highlight that
the mothers in the non intervened group display in-
creased controlling behavior, associated with hostil-
ity, which warns us about this group's greater bond-
ing risk and points to the clinical value of video
feedback for the early prevention of child abuse. As
previously noted (Kalinauskien et al., 2009; Yagmur
et al., 2014), early interventions with video feed-
back foster maternal self-efficacy, which can pro-
vide mothers with more security and promote the
use of regulatory mechanisms other than hostility.
Likewise, the intervention made it possible for
mothers to more clearly detect their babies' emo-
tional needs, allowing them to provide more sensi-
tive and assertive responses.
Despite the significance of the findings in relation
to the increase of the maternal sensitivity in the in-
tervened group, is important to highlight that the
average scores obtained for this variable in the pre-
vious-to-intervention measure, are significantly
higher for the mothers in the experimental group.
The same is observed in the number of dyads that
present a pre-intervention bonding risk, with a
higher frequency for the control group than for the
experimental group. These findings could be ex-
plained because of the positive effect of participat-
ing in the group workshops before the vid-
eo/feedback intervention, even though the signifi-
cant rise in sensitivity after the last measure, is only
observed in the experimental group dyads, showing
the control group sustained levels for maternal sen-
sitivity and bonding risk frequency.
Regarding the non-responsive maternal behavior,
the literacy describes in depressive mothers a ten-
dency to become inward to their own inner states,
showing themselves less available emotionally and
psychologically toward their babies, and with diffi-
culties to response to the infant signs, especially
when are shown with a low threshold (Pawlby et al.,
2009). In this matter, differences post-intervention
were not found for this descriptor as it was ex-
pected, what could be explained because of the
characteristics of the developmental stage of the
children (average age 13,9 months), characterized
for the increasing achievement of gross motor skills
that allows a further autonomy and movement,
which probably activates a controlling behavior in
mothers when the sensitivity is affected. Further
longitudinal studies assessing the variations in ma-
ternal behavior descriptors according to the stage of
children´s development are required, in order to
confirm or denied this hypothesis.
When considering qualitatively the Sensitivity
Scale results for both groups, dyads with bonding
risk increase in the control group and disappear in
the experimental group; in the latter, also, the num-
ber of dyads in the adequate and sensitive categories
increases, which indicates a global improvement in
the quality of mother-child exchanges.
With respect to maternal depressive sympto-
matology, no significant differences were observed
between the groups, with both displaying minimal
symptom reduction in the final measurement. Alt-
hough the intervention was expected to contribute
to reducing the mothers' symptoms, the results did
not confirm this hypothesis. Nevertheless, qualita-
tively the higher frequency of major depression di-
agnoses in the mothers and children in the non in-
tervened group point to the positive influence of
the intervention on depression. It is also notewor-
thy that the number of children who meet the major
depression criteria increases in the control group
(from 5 to 13) even though the number of de-
pressed mothers is reduced in it (from 23 to 13).
Complementarily, the intervened group includes
some mothers diagnosed with major depression in
the final measurement (3 mothers), but none of
them is within the risk category in the sensitivity
scale, which may indicate that maternal sensitivity
and depression are not necessarily associated. Some
studies (NICHD Early Child Care Research Net-
work, 1999; Maughan, Cicchetti, Toth & Rogosch,
2007) have suggested that maternal sensitivity may
be a factor that moderates the noxious impact of
maternal depression on the baby's development. In
this regard, the intervention conducted may be a
useful tool for interrupting the transgenerational
transmission of depression from mothers to their
children. On the other hand, the differences found
between the major depression diagnoses and the

symptomatology measurements stress the need to
include both elements, because screening instru-
ments often give false positives and false negatives;
therefore, more thorough diagnoses are needed for
the early identification of the aspects that may hin-
der the construction of a positive mother-child bond.
Some researchers (Székely et al., 2014) have pro-
posed that, in order to increase the benefits result-
ing from early interventions, it is necessary to con-
sider both maternal sensitivity and depression. Even
though the results of the present study do not reveal
a significant reduction in depressive symptomatol-
ogy, it was possible to establish that video feedback
interventions are a useful tool to improve the quali-
ty of the mother-child bond, reduce the frequency
of major depressive episodes, and, possibly, inter-
rupt the transgenerational transmission of psycho-
pathology from mothers to their children. In addi-
tion, it is important to hypothesize about the specific
contribution of the use of video-feedback in the in-
crease of maternal sensitivity, which could be ex-
plained by its favorable effect on parental self-esteem
and self-efficacy and the positive impact of these var-
iables in the quality of the mother-infant interactions
(Doria, Kennedy, Strathie & Strathie, 2013).
Nevertheless, these findings must be confirmed us-
ing larger samples, and also taking into account the
father's influence on mother-infant interaction, along
with other aspects of the mother's personality struc-
ture which may interfere with the results or require
parallel interventions (dyadic and individual). The
lack of follow-up evaluations in this study is a limita-
tion that makes it impossible to test the permanence
of the changes observed, and should be an aspect to
be considered in future research. In addition, another
limitation of this study is the quasi-experimental de-
sign utilized and the impossibility of distinguishes in
a precise manner between the effect of the video
feedback intervention and the effect of the previous
group interventions. The existence of babies under
the age of 12 months in the sample constitutes also a
limitation, because most of the successful video-
feedback intervention consider dyads with children
above this age. These aspects must be taken into ac-
count when considering the reach of the results.
Likewise, follow-up evaluations could look into po-
tential reductions in maternal depressive sympto-
matology, because the positive effects of the inter-
vention on the bond can provide a less stressful con-
text, thus benefiting the mother's mood (Matthey,
Kayanagh, Howie, Barnett & Charles, 2004).
Acknowledgments
Authors' note: We are thankful for the support and
funding provided by the National Committee for
Scientific and Technological Research (CONICYT
Chile), by Fondecyt Projects Nº3120109 and
N°11140230, and by the Innovation for Competi-
Olhaberry et al. 90
tiveness Fund (FIC), part of the Ministry of Econo-
my, Development, and Tourism, through the Mil-
lennium Scientific Initiative, Project IS130005. We
also thank the team of clinical psychologists who par-
ticipated in the implementation of the intervention:
Marta Escobar, Johana Zapata, Ángela Miranda,
Macarena Romero, Catalina Sieverson, Trinidad Il-
lanes, Francisca Siles, Franchesca Aguirre, and Clau-
dia Aldana.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washing-
ton, DC: Author.
Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., &
Juffer, F. (2003). Less is more: meta-analyses of sensitivity
and attachment interventions in early childhood. Psychologi-
cal Bulletin, 129(2), 195. doi: 10.1037/0033-2909.129.2.195
Barlow, J., McMillan, A., Kirkpatrick, S., Ghate, D., Barnes,
J., & Smith, M. (2010). Health-let interventions in the
early years to enhance infant and maternal mental health:
A review of reviews. Child and Adolescent Mental Health,
15, 178-185. doi: 10.1111/j.1475-3588.2010.00570.x
Beebe, B. (2003). Brief mother–infant treatment using psy-
choanalytically informed video feedback. Infant Mental
Health Journal, 24(1), 24–52. doi: 10.1002/imhj.10042
Beebe, B. (2010). Mother–Infant Research Informs Moth-
er–Infant Treatment. Clinical Social Work Journal, 38(1),
17-36. doi: 10.1007/s10615-009-0256-7
Beebe, B. (2014). My Journey in Infant Research and Psy-
choanalysis: Microanalysis, a Social Microscope. Psycho-
analytic Psychology, 31(1), 4–25. doi: 10.1037/a0035575
Bilszta, J. L., Buist, A. E., Wang, F., & Zulkefli, N. R. (2012).
Use of video feedback intervention in an inpatient peri-
natal psychiatric setting to improve maternal parenting.
Archives of Women's Mental Health, 15(4), 249-257. doi:
10.1007/s00737-012-0283-1
Cooper, P. J., & Murray, L. (1995). Course and recurrence
of postnatal depression. Evidence for the specificity of the
diagnostic concept. The British Journal of Psychiatry,
166(2), 191-195. doi: 10.1192/bjp.166.2.191
Coppola, G., Vaughn, B., Cassiba, R. & Costantini, A.
(2006). The attachment script Representation procedure
in an Italian simple: Associations with Adult Attachment
Interview scales and with maternal sensitivity. Attach-
ment & Human Development, 8(3): 209-219.
doi: 10.1080/14616730600856065
Doria, M. V., Kennedy, H., Strathie, C., & Strathie, S. (2013).
Explanations for the Success of Video Interaction Guid-
ance (VIG): An Emerging Method in Family Psychothera-
py. The Family Journal: Counseling and Therapy for Couples
and Families, 00(0), 1-10. doi: 10.1177/1066480713505072
Evans, M., Vicuña, M., & Marín, R. (2003). Depresión post-
parto realidad en el sistema público de atención de salud.
Revista chilena de obstetricia y ginecología, 68(6), 491-494.
doi: 10.4067/S0717-75262003000600006
Field, T. (2011). Prenatal depression effects on develop-
ment. Infant Behavior and Development, 34, 1-14. doi:
10.1016/j.infbeh.2010.09.008
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Af-
fect regulation, mentalization, and the development of self.
New York: Other Press.
Greenspan, S. & Benderly, B. (1998). El crecimiento de la
mente. Barcelona, Paidós.
Halbreich, U. & Karkun, S. (2006). Cross-cultural and social
diversity of prevalence of postpartum depression and de-
91 Video-feedback intervention in mother-baby dyads
pressive symptoms. Journal of Affective Disorders, 91, 97-
111. doi: 10.1016/j.jad.2005.12.051
Hayes, L. J., Goodman, S. H., & Carlson, E. (2013). Mater-
nal antenatal depression and infant disorganized attach-
ment at 12 months. Attachment & human development,
15(2), 133-153. doi: 10.1080/14616734.2013.743256
Jadresic, E. (2010). Depresión en el embarazo y el puerperio.
Revista chilena de neuro-psiquiatría, 48(4), 269-278. doi:
10.4067/S0717-92272010000500003
Kalinauskiene, L., Cekuoliene, D., Van IJzendoorn, M. H.,
Bakermans‐Kranenburg, M. J., Juffer, F., & Kusakovskaja,
I. (2009). Supporting insensitive mothers: the Vilnius ran-
domized control trial of video‐feedback intervention to
promote maternal sensitivity and infant attachment securi-
ty. Child: Care, Health and Development, 35(5), 613-623.
Kivijarvi M., Voeten M., Niemela P., Raiha H., Lertola K.,
Piha J. (2001). Maternal Sensitivity Behavior and Infant
Behavior in Early Interaction. Infant Mental Health Jour-
nal, 22(6), 627-640. doi: 10.1002/imhj.1023
Leahy-Warren, P. & McCarthy, G (2007) Postnatal depression:
Prevalence, mothers' perspectives, and treatments. Archives
of Psychiatric Nursing, 21(2): 91-100. doi: 10.1016/j.apnu.
2006.10.006
Marvin R, Cooper G, Hoffman K, Powell B (2002) The Cir-
cle of Security project: attachment-based intervention
with caregiver–pre-school child dyads. Attachment Hu-
man Development, 4(1), 107–124.
doi: 10.1080/14616730252982491
Matthey, S., Kavanagh, D., Howie, P., Barnett, B., y Charles,
M. (2004). Prevention of postnatal distress or depression:
An evaluation of an intervention at preparation for
parenthood classes. Journal of Affective Disorders, 79, 113-
126. doi: 10.1016/S0165-0327(02)00362-2
Maughan, A., Cicchetti, D., Toth, S. & Rogosch, F. (2007).
Early-occurring Maternal Depression and Maternal Nega-
tivity in Predicting Young Children’s Emotion Regulation
and Socioemotional Difficulties. Journal of Abnormal Child
Psychology, 35, 685-703. doi: 10.1007/s10802-007-9129
McMahon, C. A., Barnett, B., Kowalenko, N. M., & Ten-
nant, C. C. (2006). Maternal attachment state of mind
moderates the impact of postnatal depression on infant
attachment. Journal of Child Psychology and Psychiatry,
47(7), 660-669. doi: 10.1111/j.1469-7610.2005.01547.x
Mendes, D. M. L. F. & Seidl-de-Moura, M. L. (2014). Dif-
ferent Kinds of Infants’ Smiles in the First Six Months
and Contingency to Maternal Affective Behavior. Spanish
Journal of Psychology, 17 (e80), 1-12.
doi: 10.1017/sjp.2014.86
Milgrom, J., Schembri, C., Ericksen, J., Ross, J., & Gemmill,
A. W. (2011). Towards parenthood: An antenatal inter-
vention to reduce depression, anxiety and parenting diffi-
culties. Journal of affective disorders, 130(3), 385-394. doi:
10.1016/j.jad.2010.10.045
Moreno Zaconeta, A., Domingues Casulari da Motta, L.,
&França, P. S. (2004). Depresión postparto: prevalencia
de test de rastreo positivo en puérperas del Hospital Uni-
versitário de Brasília, Brasil. Revista chilena de obstetricia
y ginecología, 69(3), 209-213.
Murray, L., Cooper, P. J., Wilson, A., & Romaniuk, H.
(2003). Controlled trial of the short-and long-term effect
of psychological treatment of post-partum depression 2.
Impact on the mother—child relationship and child out-
come. The British Journal of Psychiatry, 182(5), 420-427.
doi: 10.1192/bjp.182.5.420
NICHD Early Child Care Research Network (1999). Chro-
nicity of Maternal Depressive Symptoms, Maternal Sensi-
tivity, and Child Functioning at 36 Months. Developmen-
tal Psychology, 35 (5), 1297-1310. doi: 10.1037/0012-
1649.35.5.1297
O'Hara, M. W., & McCabe, J. E. (2013). Postpartum depres-
sion: current status and future directions. Annual Review of
Clinical Psychology, 9, 379-407. doi: 10.1146/annurev-
clinpsy-050212-185612
Olhaberry, M., Escobar, M., San Cristobal, P., Santelices, P.,
Farkas, Ch., Rojas, G., Martínez, V. (2013). Intervencio-
nes psicológicas perinatales en depresión materna y
vínculo madre-bebé: Una revisión sistemática. Terapia
Psicológica, 31(2), 249-261. doi: 10.4067/S0718-
48082013000200011
Pawlby, S., Hay, D., Sharp, D., Waters, C., & O’Keane, V.
(2009). Antenatal depression predicts depression in ado-
lescent offspring: prospective longitudinal community-
based study. Journal of Affective Disorders, 113, 236–243.
doi: 10.1016/j.jad.2008.05.018
Podestá, L., Alarcón, A. M., Muñoz, S., Legüe, M., Bustos, L.,
& Barría, M. (2013). Alteración del desarrollo psicomotor
en hijos de mujeres con depresión posparto de la ciudad
de Valdivia-Chile. Revista médica de Chile, 141(4), 464-
470. doi: 10.4067/S0034-98872013000400007
Radesky, J. S., Zuckerman, B., Silverstein, M., Rivara, F. P.,
Barr, M., Taylor, J. A., Lengua, L., & Barr, R. G. (2013).
Inconsolable infant crying and maternal postpartum de-
pressive symptoms. Pediatrics, 131(6), e1857-e1864. doi:
10.1542/peds.2012-3316
Rusconi-Serpa, S., Sancho Rossignol, A., & McDonough, S.
C. (2009). Video feedback in parent-infant treatments.
Child and Adolescent Psychiatric Clinics of North America,
18(3), 735-751. doi: 10.1016/j.chc.2009.02.009
Schore, A.N. (2000). Attachment and the regulation of the
right brain. Attachment and Human Development, 2, 23-
47. doi: 10.1080/146167300361309
Sheehan, D. V., Lecrubier, Y., Harnett-Sheehan, K., Janavs
J., Weiller, E., Bonara, L.I., Keskiner, A., Schinka, J.,
Knapp, E., Sheehan, M.F., Dunbar, G.C. (1997). Reliabil-
ity and Validity of the MINI International Neuropsychi-
atric Interview (M.I.N.I.): According to the SCID-P. Eu-
ropean Psychiatry, 12, 232-241.
Stern, D. (1985). El mundo interpersonal del infante. Una
perspectiva desde el psicoanálisis y la psicología evolutiva.
Buenos Aires: Paidós.
Storfer, M. (1999). Myopia, intelligence, and the expanding
human neocortex: Behavioral influences and evolutionary
implications. International Journal of Neuroscience, 98,
153-276. doi: 10.3109/00207459908997465
Suárez, N., Muñoz, M., Gómez, E. & Santelices, M. (2009)
Terapia de Interacción Guiada: Una Nueva Modalidad
de Intervención con Familias Multiproblemáticas y en
Riesgo Social. Terapia Psicológica; 27(2),203-213.
Székely, E., Lucassen, N., Tiemeier, H., Bakermans-
Kranenburg, M., Van IJzendoorn, M., Kok, R. & Herba,
C. (2014). Maternal depressive symptoms and sensitivity
are related to young children’s facial expression recogni-
tion: The Generation R Study. Development and Psycho-
pathology, 26, 333-345. doi: 10.1017/S0954579413001028
Trevarthen, C. & Aitken, K. (2001). Infant intersubjectivi-
ty: Research, Theory, and Clinical Applications. Journal
of Child Psychology and Psychiatry, 42(1), 3-48. doi :
10.1111/1469-7610.00701
Urdaneta, J., Rivera, A., García, J., Guerra, M., Baabel, N., &
Contreras, A. (2010). Prevalencia de depresión posparto
en primigestas y multíparas valoradas por la Escala de
Edimburgo. Revista chilena de obstetricia y ginecología,
75(5), 312-320. doi: 10.4067/S0717-75262010000500007
Van Doesum, K., Riksen‐Walraven, J. M., Hosman, C. M.,
& Hoefnagels, C. (2008). A randomized controlled trial
of a home‐visiting intervention aimed at preventing rela-
tionship problems in depressed mothers and their infants.
Child Development, 79(3), 547-561. doi: 10.1111/j.1467-

8624.2008.01142.x
Van Zeijl, J., Mesman, J., Van IJzendoorn, M. H., Bakermans-
Kranenburg, M. J., Juffer, F., Stolk, M. N. & Alink, L. R.
(2006). Attachment-based intervention for enhancing sensi-
tive discipline in mothers of 1-to 3-year-old children at risk
for externalizing behavior problems: a randomized con-
trolled trial. Journal of Consulting and Clinical Psychology,
74(6), 994. doi: 10.1037/0022-006X.74.6.994
Vik, K. & Braten, S. (2009). Video interaction guidance in-
viting transcendence of postpartum depressed mothers'
self-centered state and holding behavior. Infant Mental
Health Journal; 30(3):287–300. doi: 10.1002/imhj.20215
Wan, M. W., & Green, J. (2009). The impact of maternal
psychopathology on child–mother attachment. Archives
of Women's Mental Health, 12(3), 123-134. doi:
10.1007/s00737-009-0066-5
Yagmur, S., Mesman, J., Malda, M., Bakermans-Kranenburg,
M. J., & Ekmekci, H. (2014). Video-feedback intervention
Olhaberry et al. 92
increases sensitive parenting in ethnic minority mothers: a
randomized control trial. Attachment & Human Develop-
ment, 16(4), 371-386. doi: 10.1080/14616734.2014.912489
ZERO TO THREE (2005). Diagnostic classification of men-
tal health and developmental disorders of infancy and early
childhood: Revised edition (DC:0-3R). Washington, DC:
ZERO TO THREE Press.
Zietlow, A. L., Schlüter, M. K., Nonnenmacher, N., Müller,
M., & Reck, C. (2014). Maternal Self-confidence Postpar-
tum and at Pre-school Age: The Role of Depression, Anx-
iety Disorders, Maternal Attachment Insecurity. Mater-
nal and Child Health Journal, 18(8), 1873-1880. doi:
10.1007/s10995-014-1431-1
Submitted: May 2015
Accepted: November 2015
Published: December 2015