J. ChildPsychol. Psychiat. Vol. 32, No. 3, pp. 423-438, 1991 Printed in Great Britain.

002!-%30/91 13.00 + 0.00 Pergamon Press pic © 1991 Association for Child Psychology and Psychiatry

Maternal Anxiety: a 5-Year Review of an Intervention Study B. Barnett,* M. F. Schaafsma,t A.-M. Guzman^ and G. B. Parker^ Abstract—Primiparous women were divided into groups according to their post-partum trait anxiety scores. Professional or non-professional support for the first 12 months was offered to two subgroups of high trait anxiety subjects. At the 5-year follow-up the high-anxiety mothers (w = 57) manifested more psychological and social pathology than moderate- and low-anxiety mothers {ri = 43), and their children also showed signs of poorer adaptation. There was evidence of improved outcome for mothers in the professional intervention group, but not for their children. Child psychopathology was predicted best by maternal psychosocial variables, and to a lesser extent by child temperament variables. The relation of infant attachment and temperament measures to subsequent psychopathology is discussed. Keywords: Mothers' anxiety, infant attachment, infant temperament, intervention

Introduction High levels of anxiety in the mother have been held to promote deficient psychosociad development of the child, mediated by anomalous parenting behaviours such as overprotection and deficient care (Berg & McGuire, 1974; Eisenberg, 1958; Ironside, Lewis & Halsau, 1969; Jenkins, 1968; Kagan & Moss, 1962; Levy, 1943; Parker, 1983; Rutter, 1976). We therefore designed a naturalistic cohort study to assess adaptation to parenthood of primiparous women who differed in their levels of trait anxiety, and also to examine the effects of anxiety-reducing strategies on two subgroups of high-anxiety subjects. The hypothesis that high maternal trait anxiety results in childhood problems would be further supported if reduction in the postulated risk factor was associated with improved development in the children. Details of the first phase of the research have been published (Barnett, Hanna

Accepted manuscript received 21 June 1990

* School of Psychiatry, University of New South Wales, Australia. 'Department of Child and Family Psychiatry, Prince of Wales Hospital, Randwick, Australia. "'"Anxiety Disorders Clinic, St Vincent's Hospital, Sydney, Australia. SSchool of Psychiatry, University of New South Wales, Australia. Requests for reprints to: Professor B. Barnett, Department of Child and Adolescent Psychiatry, Liverpool Hospital, Liverpool, NSW 2170, Australia.

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& Parker, 1983; Barnett & Parker, 1985, 1986; Barnett, Blignault, Holmes, Payne & Parker, 1987; Parker & Barnett, 1987). In summary, primiparous v^omen {n = 627) were screened on the third or fourth post-partum day using the Spielberger State-Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch & Lushene, 1970). Subgroups of high-(« = 92), moderate-(n = 31) and low-anxiety (w = 29) subjects were derived. The high-anxiety subjects were randomly assigned to non-professional (support from a lay person but experienced mother) or professional (support from a social worker, who was required to address a number of possible target areas) intervention, or a non-intervention control group. Other maternal assessments included: state depression initially and at 3 months (Beck, Ward, Mendelson, Mock & Erbaugh, 1961); trait depression and a second measure of trait anxiety (Costello & Comrey, 1967); social network initially and at 1 year, measured by the Interview Schedule for Social Interaction (ISSI) (Henderson, Byrne & Duncan-Jones, 1981); neuroticism and extroversion (Eysenck & Eysenck, 1964); life events for the year prior to delivery and 1 year later (Barnett et al, 1983); and how the subject perceived characteristics of her own parents, measured by the Parental Bonding Instrument (PBI) (Parker, Tupling & Brown, 1979). The main infant assessments were of temperament (Persson-Blennow & McNeil, 1979) when the infant was 6 months old, and ofthe attachment relationship between mother and infant at 1 year using the Strange Situation Procedure (SSP) (Ainsworth, Blehar, Waters & Wall, 1978). We found a significant reduction of state and trait anxiety in both intervention groups compared with the controls, but this was more marked in the professional group (Barnett & Parker, 1985). High levels of maternal anxiety were found to be associated with a number of perinatal complications in the child and in the mother, with less maternal confidence and many more maternal difficulties during the first year as a parent (Barnett & Parker, 1986). Nevertheless, no differences were found among the five groups in the security of infant attachment at 12 months. A follow-up study was designed to take place when these children had started school (i.e. at 5 years of age). As before, our hypotheses were that: (a) high trait anxiety in women would predict (i) increased problems in adaptation to the maternal role, and (ii) more problems in psychosocial development ofthe children; (b) appropriate early postnatal intervention for subjects with high trait anxiety would reduce psychopathology in both mother and child; and (c) psychosocial problems in the 5-year old children would relate more to maternal psychopathology than to child variables such as temperament or gender.

Method Maternal assessment again included interview and questionnaires, including: (1) comprehensive assessment of state and trait anxiety (STAI), autonomic, phobic and generalized anxiety, and panic attacks (semi-structured interview); (2) lifetime estimate of depressed episode (Diagnostic Interview Schedule, DIS; Wing & Robins, 1983); (3) obsessionality, using the Lynfield Obsessional-Compulsive Questionnaires (Allen & Tune, 1975); (4) social network, i.e. availability and adequacy of attachment (AVAT and AD AT), and of social integration (AVSI and ADSI), again using the ISSI (Henderson etal., 1981); (5) a pre-coded, semi-structured interview to assess general health and circumstances, marital

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relationship, domestic and financial situation, subsequent pregnancies and their outcome; and (6) interviewer ratings of mood. Assessment ofthe child consisted ofthe Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1981) completed by the teacher and by each parent. The parental CBCL form generates six scores: (1) activity; (2) social; (3) total behavioral problems; (4) profile of behavioral problems; (5) internalizing; and (6) externalizing. The activity and social scales form part of the social competence scales and are expected to yield higher scores in 'normal' than in 'disturbed' children. The total behavioral problems score indicates the severity of problems, while the profile allows assessment of the degree to which the child manifests various kinds of behavioural problems. The internalizing score reflects a particular set of behaviour problem subscales, and, like the behavioral problems subscale or profile, varies according to the sex of the child. The externalizing score is similarly derived. The internalizing/externalizing dichotomy reflects a distinction between fearful, inhibited, overcontrolled behaviour, as against aggressive, antisocial, undercontroUed behaviour. Teachers' CBCL report forms have scores assessing academic performance and total adaptive functioning (academic performance score plus items relating to the child's work, behaviour and happiness in comparison with other children), as well as a number of scales similar to those in the pzirent report form.

Results One-tailed tests of significance were used to test hypotheses regarding the effects of high trait anxiety and the effects of intervention on maternal and child adaptation and psychopathology. A rejection region of/? < 0.05 was employed and a Bonferroniadjusted alpha level was used throughout for non-orthogonal comparisons (Hall & Bird, 1985). Where a trend is reported this implies a p range of 0.05-0.1. The sample at the b-year follow-up

Of the original 147 mothers, 32 could not be traced and six declined further participation. In addition, data collection was incomplete for nine mothers. Subsequent analyses were performed only on the data fromi the 100 mothers with complete data sets. Corresponding fathers' and teachers' CBCL report forms {n = 68 and n = 65, respectively) were available for the children of these 100 mothers. Table 1 shows the distribution of subjects across groups and over time. While numbers were adequate in each group for the main analyses, the high drop-out in group 3 should be noted. There was a significant difference in drop-out rates across groups over the 5 years (x^ = 9.64; d.f. 4; /? = 0.047), with the highest being in groups 3 (45%) and 2 (32%). No difference was found in baseline state or trait anxiety scores between those who dropped out (n = 43) and those who remained.

Table 1. Subjects remaining in the study at 5 years compared with the original anxiety groupings Group 1. 2. 3. 4. 5.

Non-professional intervention Professional intervention High-anxiety control Moderate-anxiety control Low-anxiety control

Original {n = 152) 30 31 31 31 29

1 year = 147) 30 31 28 29 29

5 years {n = 100) 23 20 14

22 21

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The average age of the subjects at follow-up was 34 years (range 24-49) and they had an average of 2.1 children (range 1-4). One mother was divorced and 5% were separated; 39% were employed in part-time work and 7% in full-time work. Socioeconomic status according to husband's occupation (Congalton, 1969) was 13.5% high SES, 53.1% high-medium, 29.2% medium-low, and 4.2% low. During the course ofthe study, 49% of husbands had changed their job and 42% of subjects had changed their address. Among these variables, only social class (x^ = 7.8d.f. 3; /> < 0.05) and involvement in recreational activities outside the home (x^ = 4.7; d.f. 3; p< 0.05) discriminated significantly between the high-anxiety and other groups. Fewer high-anxiety subjects were represented in the upper socioeconomic strata and involved in outside hobbies. Maternal variables

Anxiety and the effects of intervention. Differences between the groups in anxiety levels at 5 years were examined by MANOVA for four anxiety measures, namely: state anxiety, trait anxiety, autonomic anxiety symptoms, and total frequency of autonomic symptoms, and univariate F test values indicated that the groups differed on all those measures. Planned contrasts comparing the original high-anxiety groups with the combined moderate- and low-anxiety groups on anxiety and other psychopathology variables revealed significant differences on several measures of anxiety and depression, as well as in maternal confidence, and a trend towards more psychological problems since the first birth (cf. Table 2). Thus the initially highly anxious mothers continued to show greater pathology. Because of our focus on long-term effects of intervention, changes over time in state and trait anxiety were examined with repeated measures MANOVA tests over the six testing periods (0, 3, 6, 9, 12 and 66 months). There was a significant difference across testing periods {F = 3.49; d.f. 6,569; />< 0.001) between the groups {F = 11.43; d.f. 8,188; p < 0.001) and for group by time interaction (F = 1.74; d.f. 24,341; /? < 0.01). Orthogonal planned comparisons of changes in anxiety scores between initial testing and 5 years were therefore performed for all groups. There was a significant decrease in state anxiety in both the non-professional (t = 2.04; d.f. 171; p< 0.05) and professional (t = 2.75; d.f. 171; p

Maternal anxiety: a 5-year review of an intervention study.

Primiparous women were divided into groups according to their post-partum trait anxiety scores. Professional or non-professional support for the first...
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