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RESEARCH ARTICLE
Mind-mindedness and parenting stress in mothers of
preterm and full-term infants: The moderating role of
perceived social support
Chiara Suttora1Nicoletta Salerni2Elena Selvagno2Matteo Porro3,4
Silvana Gangi3,5Chiara Squarza3Laura Gardon3Odoardo Picciolini3,4
Department of Psychology, University of
Bologna, Bologna, Italy
Department of Psychology, University of
Milano-Bicocca, Milano, Italy
Servizio di Follow-up del neonato a
rischio evolutivo, Fondazione IRCCS Ca’
Granda Ospedale Maggiore Policlinico,
Milano, Italy
UO Medicina Fisica e Riabilitativa
Pediatrica, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, Milano,
Italy
UO di Neonatologia e Terapia Intensiva
neonatale, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, Milano,
Italy
Correspondence
Chiara Suttora, Department of Psychology,
University of Bologna, Viale Berti Pichat ,
Bologna, Italy.
Email: chiara.suttora@unibo.it
Abstract
The goal of this study was to examine the effects of preterm birth and maternal
childbirth-related posttraumatic stress and parenting stress on maternal mind-
mindedness (MM). The study also investigated the effects of perceived social
support on parenting stress and MM. Sixty-five preterm (N=) and full-term
(N=) mother–infant dyads were observed at months. Measures of mater-
nal MM were obtained from observations of mother–infant interaction. Mothers
also provided ratings of their posttraumatic stress disorder (PTSD) symptoms,
parenting stress, and perceived social support via an online survey. Experiencing
a preterm birth did not affect mothers’ use of mental state descriptors during
mother–infant interaction. Neither childbirth-related posttraumatic stress nor
parenting stress directly affected maternal ability to comment on the child’s men-
tal states appropriately. However, at medium and high levels of perceived social
support, a negative association between parenting stress and MM was observed.
Maternal perception of being emotionally supported by significant others pro-
moted MM in mothers showing low or mild levels of parenting stress, but not in
mothers experiencing high stress in parenting their infants. Results suggest that
a proclivity to MM might be affected by the interaction between parenting stress
and social support, rather than by childbirth-related variables, such as prematu-
rity.
KEYWORDS
childbirth-related posttraumatic stress, mind-mindedness, parenting stress, preterm birth,
social support
1 INTRODUCTION
Mind-mindedness (MM), a construct developed by Meins
(), represents the caregiver’s ability to read the child’s
internal mental states and treat her or him as an individ-
ual with a mind. Similarly to well-known constructs, such
as reflective functioning (Slade, ) and insightfulness
(Oppenheim & Koren-Karie, ), it refers to parental
engagement with the child at a mental level rather than in
response to her or his contingent physical and emotional
needs, that is, caregiver’s sensitivity.
In the first year of life, MM is measured as the caregiver’s
tendency to comment on the infant’s putative mental
states during social interaction (referred as “observational”
Infant Ment Health J. ;–. © Michigan Association for Infant Mental Health 1wileyonlinelibrary.com/journal/imhj
2SUTTORA .
MM), earning the description of a “type of RF [Reflec-
tive Functioning] in action”(Rosenblum, McDonough,
Sameroff, & Muzik, ). Later on, from toddlerhood
onward, MM assessment relies on the caregivers’ verbal
references to the child’s mental states during an interview
(defined “representational” MM), which simply asks care-
givers to describe their child (Meins, Fernyhough, Russell,
&Clark-Carter,). A relevant difference between the
two approaches is that the observational measure of MM
allows to differentiate the mind-related comments depend-
ing on their appropriateness or, vice versa, lack of attune-
ment to the infants’ ongoing mental state and activity in
the interaction (Meins et al., ).
A growing body of research on maternal MM, assessed
using the observational measure, which represents the
focus of the current study, indicated that MM promotes
parent–child relationships and the child’s socioemotional
and cognitive development. As for the parent–child
relationship, there is convincing evidence demonstrating
significant positive associations between the use of appro-
priate mind-related comments (AMRC) and parental
sensitivity (Laranjo, Bernier, & Meins, ; Meins et al.,
). Both Meins () and Laranjo et al. ()noted
that the propensity to treat infants as individuals with
minds could be a prerequisite for sensitivity; in order to
respond promptly and appropriately to infants’ cues, care-
givers should first attribute an intention to infants’ signals
and states. The relation between MM and attachment has
also been extensively investigated, with the main aim of
examining the capacity of MM to reduce the attachment
transmission gap by accounting for the relation between
caregiver’s attachment representation and infant attach-
ment security (Bernier & Dozier, ). In this context,
significant associations between caregiver’s proclivity to
MM and infant’s attachment security were found, even if
evidence of a robust predictive role of MM is still modest,
as recently reviewed by McMahon and Bernier ().
Regarding the effects on children developmental out-
comes, parental verbal references to infants’ mental state
during interaction have been related to the development
of children’s ability to attribute mental states to themselves
and others, that is, theory of mind (ToM), with the parental
use of AMRC being positively associated to children’s ToM
at preschool age (Kirk et al., ; Laranjo, Bernier, Meins,
& Carlson, ; Meins, Fernyhough, Arnott, Leekam, &
De Rosnay, ). Parental MM also seems to promote
children’s language development (Laranjo & Bernier, ;
Meins, Centifanti, Fernyhough, & Fishburn, )and,
although evidence is still limited, the development of
executive functioning (Bernier, Carlson, & Whipple, ;
Bernier, Carlson, Deschênes, & Matte-Gagné, ).
Considering its relevance for child development and the
quality of parent–child relationship, investigating which
variables can explain individual differences in parental
MM represents a crucial research question. As we describe
later on, research aiming at identifying the factors and
the conditions that may favor or somewhat interfere with
maternal MM is continuously growing. The present study
contributes to this line of research by investigating how
maternal MM can vary according to different childbirth
experiences (i.e., preterm birth) and different levels of
parenting stress. We hypothesize that experiencing stress
and/or trauma in the perinatal and postnatal period could
prevent mothers to attune to their children’s mental state
and activity, leading to a decrease in the use of AMRC. At
the same time, the role of perceived social support in mod-
erating the impact of maternal stress on MM is under inves-
tigation.
1.1 Understanding individual
differences in MM: The role of child and
parent characteristics
Since its origin, the nature of MM construct has been inten-
sively under debate. Relevant questions refer to whether
MM represents an individual parental trait that operates
similarly with different relational partners, or instead, it
can be considered as a quality of parent–child relationships
(Barreto, Fearon, Osório, Meins, & Martins, ; Meins,
Fernyhough, & Harris-Waller, ). Other questions con-
cern its stability across time (Kirk et al., ; McMa-
hon, Camberis, Berry, & Gibson, ) and across different
assessment approaches (i.e., observational vs. representa-
tional; Illingworth, MacLean, & Wiggs, ). A parallel
line of research that can contribute to clarifying the nature
of MM construct and better understand individual differ-
ences has investigated child, parent, and contextual vari-
ables that can interfere with or instead support parental
proclivity to interpret and attribute mental states to the
child.
Literature addressing the role of child-centered vari-
ables in understanding MM individual differences
observed significant relations between children’s emo-
tional, behavioral, and temperamental difficulties,
and low levels of maternal MM (Demers, Bernier,
Tarabulsy, & Provost, a; Walker, Wheatcroft, & Camic,
), but studies in this topic are still scant and often
restricted to studies approaching MM with the interview
measure.
Regarding parental characteristics, most studies
assessed maternal MM, with fathers’ MM being inves-
tigated only marginally. Mother-centered variables
correlated to MM were examined extensively, with result-
ing data reporting mixed findings. Meins, Fernyhough,
Arnott, Turner, and Leekam () reviewed the literature
SUTTORA . 3
on this topic and documented the absence of significant
associations between MM and maternal variables such
as mothers’ socioeconomic status and educational level
(Meins et al., ;Walkeretal.,). It should be noted
that these studies assessed MM via interview. Considering
both observational and representational MM findings,
McMahon and Bernier () observed a mixed situation
with papers evenly divided in reporting significant and
nonsignificant associations with education and SES.
Other maternal variables contributing to MM were
investigated, for instance age and maternal psychological
functioning. Teen mothers were found to address fewer
appropriate positive mind-related comments to their
infants than adult mothers, and also fewer positive mind-
related comments, when the emotional valence of the
mental descriptors was coded (Demers, Bernier, Tarabulsy,
&Provost,b; Riva Crugnola, Ierardi, & Canevini,
). With respect to depression, data are conflicting
with studies reporting null associations (Crucianelli et al.,
; Meins et al., ) and others observing significant
relationships linking the presence of depression symp-
toms and the use of nonattuned mind-related comments
(NAMRC), although with small effect sizes (Meins et al.,
).
Rearing a child can also be a stressful experience, and
distress can in turn interfere with parental representations,
making it more difficult for caregivers to read and attribute
mental states to their child. Following this direction,
Demers et al. (a) investigated the associations between
parenting stress and maternal MM in a sample of mothers
of -month-old toddlers: findings showed that the use of
positive mind-related descriptors correlated with low lev-
els of parenting stress and with the perception of the child
as easy in temperament. Similarly, Dai, Lim, and Xu ()
observed that in mothers of months old infants, the use
of AMRC significantly correlated with the stress perceived
in parenting, even controlling for maternal income and
education. As stress seems to undermine maternal MM,
Meins et al. () speculated that a lack of social support
would impact maternal tendency to use mind-related com-
ments during interaction; however, their data showed no
significant association with the perception of social sup-
port, as measured with a -item survey developed by Hen-
derson, Duncan-Jones, McAuley, and Ritchie ().
Other variables that captured the attention of
researchers in dealing with individual differences in
MM were related to mothers’ obstetric history. Meins et al.
() hypothesized that a mother’s perception of her preg-
nancy and labor experiences could play an essential role in
the development of adequate representations of the new-
born and the child’s future characteristics: women who
have more troubles in their obstetric histories would feel
less attuned to their infants’ emotional needs and mental
states from the beginning, resulting in lower MM attitudes.
Studies on this topic (Dai et al., ; Meins et al., )
confirmed that in Western and non-Western cultures, the
positive recollection of pregnancy and childbirth makes
mothers more likely to get attuned to their infants’ mental
state and to show AMRC during dyadic interactions.
Furthermore, mothers who recalled a highly positive
emotional reaction in the first contact with the newborn
later reported less parenting stress (Dai et al., ). Fur-
thermore, when addressing negative pregnancy and birth
experiences, Camisasca, Procaccia, Miragoli, Valtolina
and Di Blasio () indicated that mothers reporting
childbirth-related posttraumatic stress symptoms were
more likely to make fewer mind-related comments in the
interaction with their children aged months.
1.2 Parental distress and MM: Effects of
perceived social support
A sudden interruption of pregnancy and its culmination
in a preterm birth constitute a very special condition that
could have a significant impact on parental psychological
health, disturbing the process of building representa-
tions of the child and of oneself as a parent (Spinelli
et al., ). Mothers and fathers coping with preterm
birth acknowledge the traumatic load of this experience,
reporting feelings of powerlessness and shock due to
the unpredictability of the event (O’Donovan & Nixon,
). Literature indicated that months after childbirth,
mothers kept experiencing symptoms of posttraumatic
stress, with some evidence showing higher levels of
trauma being associated with infants’ low birth weight,
length of hospitalization, and illness severity (Feeley et al.,
; Holditch-Davis, Bartlett, Blickman, & Miles, ).
When not resolved, early maternal childbirth-related
posttraumatic stress could significantly affect parenting
experience and behavior. Accordingly, literature shows
that the presence of posttraumatic symptoms mediates the
association between preterm birth condition and levels of
parenting stress; mothers who experienced their infant’s
birth as a traumatic event reported higher levels of parent-
ing stress, but mothers who did not experience the event as
traumatic showed lower levels of parental stress (Suttora,
Spinelli, & Monzani, ). Other reports indicated that
preterm birth might lead parents to perceive their role
and the rearing of their child as particularly stressful and
demanding, with a higher level of parenting stress being
documented in both mothers and fathers (Chang & Fine,
; Gray, Edwards, O’Callaghan, Cuskelly, & Gibbons,
). However, findings in this field are controversial
because other studies obtained different results, indicating
no or small effects of preterm birth on parenting stress
4SUTTORA .
(Howe, Sheu, Wang, & Hsu, ; Schappin, Wijnroks,
Venema, & Jongmans, ).
To date, there is only one study investigating the associa-
tion between preterm birth and maternal MM. In this study
(Costantini, Coppola, Fasolo, & Cassibba, ), mothers
of -month-old preterm children showed MM abilities
similar to those of mothers of full-term peers, but vari-
ables such as parenting stress were not considered in the
study design. The researchers focused on the role of MM
in children’s developmental outcomes, and findings indi-
cated that maternal MM contributed significantly to the
growth of linguistic abilities in the second year of life only
for preterm infants, suggesting a different impact of mater-
nal MM due to birth condition.
In this light, the present study aims at exploring
how birth condition (preterm vs. full-term), maternal
childbirth-related traumatic symptoms, and maternal lev-
els of parenting stress can relate to individual differences in
maternal MM measured at months of age during mother–
child interaction. As the literature suggests (Holditch-
Davis et al., ), at months mothers of preterm infants
are still recovering from the traumatic effects of child-
birth; thus, this age may constitute an interesting period for
such an investigation. Significant intercorrelations among
birth conditions, perinatal PTSD symptoms, and parenting
stress are expected. Our main hypothesis is that the sever-
ity of preterm birth and high levels of posttraumatic symp-
toms and parenting stress would interfere with mater-
nal development of adequate representations of the child,
leading to lower levels of MM.
Finally, maternal perceived social support will also be
considered. The perception of being supported by one’s
partner, family, or close friends could have different effects
on parenting stress and related outcomes. Cohen and Wills
() proposed two models describing the impact of social
support on individual wellbeing. The direct or main effect
model claims a direct protective effect of social support
on individuals’ wellbeing, independently from the level
of displayed stress, whereas the buffer model sustains the
idea of perceived social support as a moderator of the
relation between stress and adverse outcomes. Literature
often confirms both models, with data showing main and
moderating effects: a study based on an extensive sample
(Mcconnell, Breitkreuz, & Savage, ) found that social
support had strong direct effects on parent–child health
and wellbeing and a smaller, but significant, role in mod-
erating the impact of parenting stress on positive parent–
child interaction.
In this frame, we aim at understanding whether per-
ceived social support contribution to maternal attitudes
toward children’s mental states could be direct and/or
could buffer the negative effects of maternal distress on
MM.
2 METHOD
2.1 Participants
The sample includes Italian mother–infant dyads (
male, female; firstborn), with infants born preterm
(PT: F =%; firstborn =%) and the remaining infants
born at gestational term (FT: F =%; firstborn =%).
Preterm and full-term infants did not differ in gender, Χ
(, ) =., p=., or birth order, Χ(, ) =., p=..
Inclusion criteria for preterm infants were having a
weight of less than , g and a gestational age < weeks
at birth. Exclusion criteria for the preterm and full-term
group were the presence of genetic abnormalities, severe
neurofunctional impairment, defined as Neurofunctional
Assessment greater than (Picciolini, Gianni, Vegni,
Fumagalli, & Mosca, ), and/or neurosensory disabil-
ities (blindness or deafness). On average, preterm children
were hospitalized for . (N=;SD =.) days and
had a gestational age of . (SD =.) weeks and a birth
weight of , (SD =) g, whereas full-term children
had a gestational age of . (SD =.) weeks and a birth
weight of , (SD =) g.
Because infant birth weight and gestational age were
highly correlated (r=., p<.), a Prematurity Index
was calculated for all infants by standardizing and sum-
ming these two variables (Poehlmann, Schwichtenberg,
Bolt, & Dilworth-Bart, ). The Prematurity Index scores
ranged from –. to –. (M=–., SD =.) for
preterm infants and from . to . (M=., SD =.)
for term infants, with higher scores representing less pre-
maturity.
Mothers had a mean age of . (SD =.) years in
the preterm group and of . (SD =.) in the full-
term group, with a significant difference between groups, t
() =–., p=.; maternal education was lower for the
preterm group, with . (SD =.) years for PT mothers
and . (SD =.) for FT mothers, t() =., p=..
Only two mothers out of were originally from another
country, but they were very fluent in Italian, their second
language. All mothers were Caucasian.
Parents of preterm infants eligible for the study were
approached for enrollment in the follow-up service of the
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Poli-
clinico; this service only includes patients from its own
neonatal intensive care unit (NICU). Parents of full-term
infants were recruited to participate in the study by writ-
ten invitations that were sent to families based on birth
records provided by neighboring cities. The ethics commit-
tees of authors’ institutions approved the study and written
informed consent was obtained from all parents.
Hospitalization data from one preterm participant were missing.
SUTTORA . 5
2.2 Procedure and measures
When the infants were -month old (M=., SD =.
for term infants; M=., SD =. corrected age for
preterm infants), dyads were invited to participate in a
videotaped play session lasting from to min, depend-
ing on the infant’s state and fussiness. Face-to-face inter-
actions with the infant in a baby seat were chosen in order
to favor the relational exchanges in dyads, as most of the
infants at this age are still not able to seat properly with-
out support. Dyads were free to use some age-appropriate
toys available in the room. For each dyad, maternal MM
was assessed using the first min of the videotaped inter-
action to avoid infant’s fatigue and to obtain comparable
measures. First, maternal utterances directed at the child
were fully transcribed and then coded according to the
MM coding manual, version . (Meins & Fernyhough,
). A coder classified each maternal comment as mind-
related if it included a reference to the infant’s desires,
wishes, preferences, intentions, epistemic states, emotions
and attempts to manipulate others’ beliefs, and mental pro-
cesses, such as memories or decisions. In addition, mater-
nal utterances that were meant to be said by the infant
were coded as mind-related. Once a comment was coded
as mind-related, the coder further classified it as appropri-
ate or nonattuned according to the criteria included in the
Coding Manual . (Meins & Fernyhough, ). A mind-
related comment was considered appropriate when the
coder agreed on the maternal interpretation of the child’s
current mental state based on child observable behavior.
Mind-related comments were coded as nonattuned when
mothers failed to identify children’s current internal state
correctly. A second coder, trained by the first author and
blind to the study’s hypotheses, coded a randomly selected
% of the mother–infant interactions ( out of pairs).
Interrater reliability between the two coders, tested with
intraclass correlation, was . for appropriate comments
and . for nonattuned comments.
In the present study, the amounts of AMRC and NAMRC
were used as measures of maternal MM. As suggested by
Meins and Fernyhough (), to control for maternal ver-
bosity, proportional frequencies of AMRC and NAMRC
were calculated relative to the total amount of maternal
verbal utterances.
Following the play session, mothers completed an
online survey including several questionnaires. Among
these, mothers completed the Perinatal PTSD Ques-
tionnaire (PPQ)—Modified version (Callahan, Borja, &
Hynan, ) and the Parenting Stress Index-Short Form
(PSI-SF; Abidin, ; Italian validation by Guarino, Di
Blasio, D’Alessio, Camisasca, & Serantoni, ). The PPQ
is a -item questionnaire that assesses childbirth-related
posttraumatic symptoms, including intrusiveness or re-
experiencing, avoidant behaviors, hyperarousal, and gen-
eral posttraumatic symptoms. Mothers were asked to indi-
cate on a -point Likert scale ( =notatallto =often, for
more than a month) how often they experienced the symp-
toms after childbirth. The total PPQ score ranges from
to , with high values representing greater posttraumatic
symptom severity (α=.).ThePSI-SFisacommonlyused
measure of stress related to parenting, including items
rated from to on a Likert scale ( =strongly disagree;
=strongly agree) assessing parental distress, parent–child
dysfunctional interaction, and the burden of dealing with
a difficult child. In the present work, only the total stress
scale score (PSI) was considered, with high values indicat-
ing greater parenting stress (α=.).
Mothers were also asked to complete the Multidimen-
sional Scale of Perceived Social Support (MSPSS; Zimet,
Dahlem, Zimet, & Farley, ), a -item self-report ques-
tionnaire that investigates the social support a person expe-
riences from family, friends, and significant others. The
Italian version of the scale was used in this study (Di Fabio
& Busoni, ). Participants expressed their agreement
with the statements on a -point Likert scale ( =very
strongly disagree;=very strongly agree). High values rep-
resented high levels of perceived social support (α=.).
2.3 Analysis plan
Preliminary analyses included exploring data distribution
and examining differences between mothers of preterm
and full-term infants regarding the main variables, that
is, childbirth-related posttraumatic stress and parenting
stress, perceived social support, and MM using indepen-
dent t-tests. In the main analysis section, consistent with
our aims, associations among study variables in the whole
sample were examined using Pearson’s correlation. Mod-
eration analysis was then used to examine the main and
buffering effects of perceived social support on the asso-
ciation between maternal stress and MM. Two modera-
tion analyses were performed with the PROCESS macro
(Hayes, ) using IBM SPSS Statistics version . The
PROCESS macro uses bootstrapping methods to assess
the interaction between design variables. The interactions
between independent and moderating variables on the
dependent variable were tested at each of the three levels of
the moderator (−, , and +SD). Significant interactions
are those in which % confidence intervals do not contain
zero. All variables were standardized into z-scores before
being entered into the moderation models.
6SUTTORA .
TABLE 1 Descriptive statistics of the study main measures by group
Tot al sam ple
(N=65)
Preterm group
(N=32)
Full-term group
(N=33)
Mean (SD)Mean(SD)Mean(SD)t(p)
PPQ . (.) . (.) . (.) –. (.)
PSI . (.) . (.) . (.) . (.)
MSPSS . (.) . (.) . (.) . (.)
AMRC . (.) . (.) . (.) –. (.)
NAMRC . (.) . (.) . (.) –. (.)
Abbreviations: PPQ, Perinatal PTSD Questionnaire;PSI, Parenting Stress Index; MSPSS, Multidimensional Scale of Perceived Social Support; AMRC, mind-related
appropriate comments; NAMRC, mind-related nonattuned comments.
TABLE 2 Pearson correlations between the study variables
12345
. PI
. PPQ –. (.)a
. PSI . (.) . (.)
. MSPSS . (.) –. (.) –. (.)
. AMRC –. (.) –. (.) –. (.) –. (.)
. NAMRC –. (.) . (.) . (.) . (.) . (.)
Abbreviations: PI, Prematurity Index; PPQ,Perinatal PTSD Questionnaire; PSI, Parenting Stress Index; MSPSS, Multidimensional Scale of Perceived Social Support;
AMRC, mind-related appropriate comments; NAMRC, mind-related nonattuned comments.
ar(p).
3RESULTS
3.1 Preliminary analyses
The descriptive statistics of posttraumatic stress, parenting
stress, perceived social support, and MM measures in FT
and PT mothers are shown in Table . Estimates of skew-
ness and kurtosis for PPQ, PSI, and MSPSS scores were
within reasonable limits, with skewness ranging from
–. to . and kurtosis from –. to .. However,
scales were not normally distributed (Shapiro-Wilk test,
p<.). Distribution for AMRC was normal, with data low
in skewness, ., and kurtosis, –.. The data for nonat-
tuned were non normal, highly skewed, ., and high
in kurtosis, .. Because data were skewed, we also ran
nonparametric tests (Mann–Whitney’s Uand Spearman’s
ρ). The results did not differ, so t-tests and Pearson’s cor-
relations are reported in Table and Table , respectively.
The results of independent t-tests comparing the two
groups of mothers did not reveal any significant differ-
ences due to birth condition. Childbirth-related posttrau-
matic symptoms, assessed with PPQ, were similar among
mothers. In our sample, mothers, eight of FT (%) and
seven of PT dyads (%), were at risk of perinatal PTSD—
according to Callahan et al. (), PPQ scores equal to or
higher than are at risk, with scores ranging from to
. As for the PSI, the results revealed that of FT mothers
(%) and seven of PT mothers (%) scored at or above the
PSI’s th percentile (PSI >), exhibiting medium to high
distress in parenting their children. Mothers of preterm
and full-term children reported similar levels of social sup-
port.
As to the key study outcome, namely, maternal MM,
t-test results indicated the absence of statistically signifi-
cant differences due to birth condition. In agreement with
literature results, AMRC and NAMRC represented the %
and %, respectively, of the total number of comments.
3.2 Main analyses
Pearson’s correlation analyses were performed to inves-
tigate the associations between childbirth-related PTSD
symptoms, parenting stress, perceived social support, and
the use of mind-related comments during mother–infant
interactions. To maximize the statistical power and given
the results of our preliminary analyses, data from the
two groups of mothers were aggregated and the Prema-
turity Index was considered as a measure of prematurity
severity.
As reported in Table , maternal scores in the PPQ sig-
nificantly correlated with PSI scores; specifically, mothers
with pronounced posttraumatic stress symptoms related
to childbirth were also at higher risk of experiencing
parenting stress at months. Furthermore, high parenting
stress was associated with lower levels of perceived social
SUTTORA . 7
TABLE 3 Moderation analyses of PPQ and MSPSS on appropriate mind-mindedness (AMRC)
Model BSE t pLLCI ULCI
Constant –. . –. . –. .
PPQ –. . –. . –. .
MSPSS –. . –. . –. .
PPQ ×MSPSS –. . –. . –. .
Model summary RR
p
. . .
PPQ ×MSPSS Rchange p
. .
Abbreviations: PPQ, Perinatal PTSD Questionnaire; MSPSS, Multidimensional Scale of Perceived Social Support.
TABLE 4 Moderation analyses of PSI and MSPSS on appropriate mind-mindedness
Model BSE t pLLCI ULCI
Constant –. . –. . –. .
PSI –. . –. . –. .
MSPSS . . . . –. .
PSI ×MSPSS –. . –. . –. –.
Model summary RR
p
. . .
PSI ×MSPSS Rchange p
. .
Abbreviations: PSI, Parenting Stress Index; MSPSS, Multidimensional Scale of Perceived Social Support.
support (MSPSS). The results indicated a lack of signifi-
cant associations between the use of AMRC and NAMRC
and maternal reported levels of childbirth-related posttrau-
matic stress and parenting stress. Associations between
MM measures and MSPSS scores were also not significant.
The severity of prematurity failed to account for individual
differences in MM, childbirth-related posttraumatic stress,
parenting stress, and perceived social support.
As highlighted in the introduction, social support may
buffer the adverse effects of stress on parenting behaviors
and attitudes; in this sense, the interaction among mater-
nal stress, posttraumatic and/or parenting stress, and the
level of perceived social support may explain differences
in maternal MM. Only AMRC were considered in the fol-
lowing analyses. The latter decision relies upon previous
results indicating that only AMRC relate to positive par-
enting and maternal sensitivity (Meins et al., ). Two
moderation models were hypothesized.
The first model considered how levels of perceived social
support (MSPSS) moderated the association between peri-
natal posttraumatic symptoms and maternal MM. The
interactions were tested at each of three levels of the mod-
erator variable (−, , and +SD; i.e., at low, medium, and
high levels of perceived social support). This first model
yielded no significant results, as shown in Table , thus
implying the absence of significant interactions between
the level of posttraumatic stress and perceived social
support on maternal MM. The second model tested the
moderation by perceived social support of the association
between parenting stress and maternal MM. The results
reported in Table indicated that although there was no
direct effect of parenting stress on maternal MM, the inter-
action between PSI and MSPSS was significant (B=–.,
t=–., p=., f=.) at average values of the moder-
ator (conditional effect =–., t=–., p=., % CI [–
., –.]) and at +SD of the moderator (conditional
effect =–., t=–., p=., % CI [–., –.]). The
interaction was not significant at – SD of the moderator
(conditional effect =–., t=., p=., % CI [–.,
.]). The effect size of the interaction was in the medium
range according to Aguinis, Beaty, Boik, and Pierce ().
At medium and high levels of perceived social support,
parenting stress was negatively related to maternal MM
(Figure ). For low levels of perceived social support, the
interaction was not significant (t=., p=., %
CI [–., .]).
4DISCUSSION
Considering the role of parental MM in promoting child
development and parent–child relationship, we aimed at
8SUTTORA .
FIGURE 1 Perceived social support ×parenting stress on
appropriate mind-related comments (AMRC)
examining the impact on MM of a set of variables related to
childbirth and parenting experience. The principal intent
of the present study was to explore the effects of maternal
stress on maternal MM in a sample of mothers of preterm
and full-term infants aged months. The study also con-
sidered the support that mothers perceived from their fam-
ilies, friends, and significant others as a variable that might
play a protective role in their psychological well-being and
parenting behaviors.
As reviewed in the introduction, previous literature sug-
gests that maternal MM could be affected by negative and
traumatic experiences during pregnancy and childbirth
(Camisasca, Procaccia, Miragoli, Valtolina, & Blasio, ;
Dai et al., ). Experiencing pregnancy and labor as neg-
ative can distort early representations of the child, as the
mother does not feel attunement with the newborn from
the outset (Meins et al., ). Considering preterm birth
as a potentially traumatic condition, we aimed at investi-
gating MM and its association with the caregiver’s perina-
tal PTSD symptoms and parenting stress in this population
too. Our findings suggested that mothers of preterm and
full-term children made comparable amounts of appropri-
ate and nonattuned mind-related comments during inter-
action. The experience of preterm birth did not affect
maternal tendency to refer to the child in terms of men-
tal and inner states. This result is consistent with the study
of Costantini et al. () that failed to highlight any dif-
ferences in the MM of mothers of preterm children in the
second year of life. Accordingly, recent results from the
study of Ruiz, Witting, Ahnert, and Piskernik ()indi-
cated no differences due to birth status in the overall lev-
els of reflective functioning between mothers of term and
preterm children. However, specifically investigating the
topics extracted from the Parental Development Interview
(Slade, Aber, Bresgi, Berger, & Kaplan, )withalatent
Dirichlet allocation modeling technique, the authors high-
lighted that mothers of children born preterm tended to
reflect more intensively than mothers of full-term children
on their children’s thoughts and feelings. It could then be
that mothers of preterm reveal similar uses of MM during
interaction than mothers of full-term infants, but, when
asked to reflect on their infants’ thoughts and feelings,
they exhibit a higher understanding of their infant mental
states.
In our findings, preterm birth and its severity also had
no effects on mothers in terms of stress, with mothers
from the two conditions reporting comparable levels of
posttraumatic and parenting stress. These results could be
unexpected considering the suddenness of preterm birth,
its threatening effects on a child’s survival, well-being,
and development. One possible interpretation could
concern the fact that preterm infants with severe neuro-
functional impairments and/or neurosensory disabilities
were excluded from the present study, as their conditions
are rare and difficult to compare with those of healthier
preterm (Picciolini et al., ; Tommiska, Östberg, & Fell-
man, ). Empirical evidence highlights that parents of
children with developmental disabilities are at increased
risk of experiencing psychological stress and trauma
compared to other parents (Lee, ). Future studies
should investigate how preterm birth and the presence
of developmental or neurosensory disabilities interact in
affecting parents’ well-being and emotional reactions.
Another explanation is that posttraumatic stress reac-
tions in preterm parents may depend upon the level of hos-
pital care and support provided. In a work by Montirosso,
Provenzi, Calciolari, and Borgatti (), the parental
experience of stressors related to the NICU environment
was assessed in Italian NICUs with the Parental Stressor
Scale: Neonatal Intensive Care Unit (PSS: NICU; Miles,
Funk, & Carlson, ). Findings showed that maternal
perception of care and support during hospitalization, cal-
culated separately for each NICU, made a significant con-
tribution to reducing maternal stress. These findings can
help give sense to the observed results, as acknowledged in
the study’s limitations section. At the same time, it is worth
noting that risk factors for the development of posttrau-
matic stress symptoms, such as obstetric complications,
inadequate intrapartum care, and history of psychological
problems, are often reported in full-term pregnancies, a
piece of evidence that could help to understand the lack
of significant differences in our sample (Ayers, Harris,
Sawyer,Parfitt,&Ford,; Simpson & Catling, ).
Putting aside the preterm birth, one of the main pur-
poses of the study was to understand the effects of
childbirth-related posttraumatic stress, parenting stress,
and social support on maternal MM. The results showed
the absence of associations among maternal MM, perina-
tal PTSD symptoms, and parenting stress; thus, childbirth-
related posttraumatic stress and parenting stress showed
SUTTORA . 9
no direct effects on maternal MM, in contrast with previ-
ous studies’ findings. Camisasca et al. () observed that
mothers who used fewer mental descriptors during the
interaction with their months old children were likely
to report more childbirth-related PTSD symptoms. As for
parenting stress, both Dai et al. () and Demers et al.
(a) observed negative associations with the caregivers’
tendency to appropriately attribute mental states to their
children when children were and months old, respec-
tively.
However, other analyses helped in clarifying these pre-
liminary results. First, parenting stress resulted negatively
correlated with perceived social support; mothers who per-
ceived good support from their partners, families, and
friends expressed less stress in dealing with the care of
their children. In this sense, maternal perception of being
sustained by her significant others may reduce parenting
stress appraisal or even prevent it. At the same time—
because our analyses are correlational—low levels of par-
enting stress may lead mothers to perceive their social net-
works as more supportive. Second, the results of moder-
ation analyses showed a significant interaction between
perceived social support and parenting stress on MM, at
specific levels of social support. For mothers reporting low
support from their interpersonal relationships, the asso-
ciation between parenting stress and maternal MM was
not significant. Contrariwise, for adequate and high lev-
els of social support, high levels of MM were associated
with low levels of stress. In other words, a high social sup-
port promoted MM for mothers experiencing no difficul-
ties in child-rearing but still resulted in low MM for moth-
ers reporting stress in dealing with their parental tasks.
We can suppose that mothers who perceive support from
their network, but at the same time still perceive high lev-
els of stress from parenting demands, can feel this pat-
tern as incongruent and attribute their difficulties to the
child or to dyadic relational aspects, reducing their ability
to comprehend and read the child’s mental states. In our
data, social support did not moderate the adverse effects of
stress on parenting behaviors but instead promoted MM in
mothers showing no or mild parenting stress. In this light,
our findings did not confirm the stress-buffering hypoth-
esis on social support, but rather provided data on a pro-
motive effect of support on maternal MM. Summarizing,
the perception of social support—a qualitative rather than
a quantitative aspect of this construct—resulted associ-
ated with lowered parenting stress overall, which could be
interpreted as a direct effect on stress, but fails at buffering
the negative effect of parental stress on MM.
Östberg and Hagekull () addressed how social sup-
port, and other variables such as daily workload or child
fussiness, affect parenting stress in a sample of Swedish
mothers, testing Cohen and Wills’s () dual model
of social support. They found social support to have
direct and indirect—through maternal workload—effects
on parenting stress; however, moderating effects of social
support were not observed as the model was shown to
apply to all mothers, independently from the amount of
social support reported. Other studies succeeded in finding
buffering effects of support on parenting stress in moth-
ers of preterm and full-term children (Crnic, Greenberg,
Ragozin, Robinson, & Basham, ; Lutz et al., ). For
instance, Lutz et al. () found that maternal percep-
tion of information support by family members (i.e., the
provision of knowledge and facts) improved child’s behav-
ioral regulation—assessed with the Parent-Child Early
Relational Assessment (PCERA; Clark, )—for moth-
ers who perceived more stress related to parenting but not
for those reporting less stress. Mothers who feel as more
demanding the task of parenting may benefit more from
information support as reflected in more positive mother–
child interaction. In our study, the measure of social sup-
port (MSPSS) captures the perception of emotional social
support rather than other kinds of social support, such as
information support, instrumental support (i.e., provision
of concrete resources, such as money or childcare), pres-
ence of tangible aid, and positive social interaction (Arm-
strong, Birnie-Lefcovitch, & Ungar, ; Lutz et al., ).
In this sense, it is possible to hypothesize that although
more concrete types of social support can moderate the
adverse effects of stress on the quality of parent–child inter-
action, emotional support can have beneficial effects only
in mothers not experiencing significant parenting difficul-
ties. In a similar direction, Guralnick, Hammond, Neville,
and Connor () found that for parents of children
with developmental disabilities high parenting support—
in form of advices on parenting specific problems and
assistance with child care responsibilities—promoted less
child- and parent-related stress, whereas emotional sup-
port and validation from others exerted limited effects on
parental stress. As social support is a multidimensional
construct, differences in the effects of support on stress
and other outcomes can depend on the functional and/or
structural aspects of social support considered in the study
design (Armstrong et al., ; Cohen & Wills, ; Gural-
nick et al., ).
5 CLINICAL IMPLICATIONS AND
LIMITATIONS
A better understanding of the effects of different dimen-
sions of social support on parenting stress and related out-
comes could inform healthcare professionals on how to
intervene in such circumstances. Based on our findings,
interventions and programs directed at promoting parents’
10 SUTTORA .
social support can help them in their childrearing prac-
tices by reducing stress, both in typical and atypical con-
ditions, such as preterm birth. However, our results also
highlighted that high emotional social support per se is
not enough to reduce the negative effects of high parenting
stress on maternal MM. The early identification of parents
at risk of acute stress is pivotal to provide them with social,
educational, and psychological interventions oriented at
supporting and promoting their ability to attune to their
infants’ mental states, such as the Minding the Baby (Slade
et al., ) and the Mothering Inside Out (Suchman, Ord-
way, de las Heras, & McMahon, )programs.
Before closing the discussion, some important limita-
tions of our study design deserve to be mentioned. The
first refers to the study sample; putting aside the sample
size, the preterm group includes only very low birth weight
infants from a single NICU unit. As studies show, care and
support may vary dramatically from one NICU to another,
leading to results that are not always easy to interpret.
In this study, given the lack of differences in stress and
MM among the mothers in the groups, we may speculate
about the availability of good-quality NICU care; however,
this conclusion should be better addressed with specific
studies. A second limitation refers to the cross-sectional
nature of the study’s design, which does not permit to
draw conclusions about the causal relationships among
the measured variables. Longitudinal designs investigat-
ing preterm birth, stress, and different dimensions of social
support as predictors of maternal MM are needed. At last,
another limitation and an important topic for future stud-
ies concerns the lack of data on children’s development
and well-being. Studies of parenting are fundamental but
can lack impact when they do not consider children’s
developmental outcomes.
The study involves human participants. All procedures
performed in studies involving human participants were in
accordance with the ethical standards of the institutional
and/or national research committee (Ethic committee
of the University of Milano Bicocca, n◦) and with
the Helsinki Declaration and its later amendments
or comparable ethical standards. Informed consent was
obtained from all individual participants involved in the
study.
ORCID
Chiara Suttora https://orcid.org/---
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How to cite this article: Suttora C, Salerni N,
Selvagno E, et al. Mind-mindedness and parenting
stress in mothers of preterm and full-term infants:
The moderating role of perceived social support.
Infant Ment Health J. ;–.
https://doi.org/./imhj.
