| Summary: | <p><strong>Background:</strong> The prenatal period and infancy represent significant developmental periods in terms of the long-term wellbeing of children. However, the prevalence of abuse during this period is high and its impact on the long-term development of the child are far-reaching making it a significant public health issue. In the last twenty years a number of interventions have been developed to support vulnerable parents with infants at risk during these important periods, with the most recent interventions being underpinned by mentalization theory. While recent research highlights the potential importance of maternal mentalizing capacities in the occurrence of maltreatment during this period, little is currently known in terms of the effectiveness and mechanisms of change of mentalization-based interventions aiming to improve outcomes for vulnerable parents at risk of child maltreatment.</p>
<p><strong>Objectives:</strong> This research aimed to enhance global initiatives in preventing child maltreatment by concentrating on the crucial period spanning from pregnancy to infancy, which has been identified as an important window of opportunity for effective prevention measures. The objectives of this research were to: systematically review the effectiveness of interventions offered to mothers during the perinatal period that explicitly aim to improve their mentalization, as well as to identify their most common intervention components; qualitatively analyse the perceptions of key stakeholders regarding the impact and mechanisms of change of one such perinatal mentalization-based intervention for pregnant women at-risk of child removal (The Daisy Programme); and to identify the mechanisms of change and parents’ contexts that influence the outcomes of a mentalization-based intervention offered to parents of infants at risk of child maltreatment (The Lighthouse Parenting Programme).</p>
<p><strong>Methods:</strong> This thesis employed three methodological approaches to address these objectives. First, a systematic review and meta-analysis was conducted to examine the effects of mentalization-based interventions offered to mothers from pregnancy to the first year postnatal. This analysis examined the effectiveness of interventions in improving maternal mentalization and parent-infant interaction; moreover, it aimed to identify the components of mentalization based interventions in the perinatal period using thematic analysis. Second, a thematic analysis of a series of in-depth interviews with service users, practitioners, and other stakeholders (primary data) was carried out to explore the impact and mechanisms of change of, the Daisy Programme, a perinatal mentalization-based programme for mothers at risk of having their children removed. Third, a realist evaluation was conducted analysing secondary data from the Supporting Parents Programme RCT study (which evaluated the Lighthouse Parenting Programme) using a mixed methods approach, which included pre- and post-intervention data and a qualitative analysis of end-of-treatment interviews to identify context-mechanism-outcome patterns associated with best and worst outcomes.</p>
<p><strong>Results:</strong> (1) The systematic review and metanalysis of twelve studies (RCTs), provided a total of 829 participants. Meta-analyses showed that mentalization based interventions during the perinatal period had a small significant effect in improving parental reflective functioning (Standardized Mean Difference [SMD]: 0.19, 95% CI [0.02, 0.36]), and small significant effects on infant attachment security (OR: 1.86; 95% CI [1.20, 2.87]) and maternal depression (SMD: -0.16; 95% CI [-0.31, -0.0]). However, after running a sensitivity analysis the effect on parental reflective functioning disappeared. Through inductive analysis we identified (a) components that provide support or information to parents, and (b) components that promote the strengthening of relationships. (2) Results from the qualitative study indicated that key stakeholders (n=15), including service users; providers and wider professionals, felt that the programme helped mothers to improve their relationships, to gain confidence, and to reflect on their mistakes and the need for change. The four main aspects of the programme that stakeholders identified as having led to these changes were: the relational focus of the intervention, the offer of support adapted to parents’ individual needs and circumstances, the support provided to make sense of the past, and the practical support offered. (3) Results from the realist evaluation (n=8) provide some evidence to suggest that the parents with fewer external pressures exhibited positive changes in mistrust, while those with higher levels of childhood adversity coupled with external pressures had less favourable overall outcomes. Significant mechanisms included the safety and empathy of the group, support received to mentalize others, and learning from others' experiences. The online delivery format received mixed feedback.</p>
<p><strong>Conclusions:</strong> The findings of this research suggest that mentalization-based parenting interventions that are delivered during the perinatal period can have a positive effect on parental reflective functioning, infant attachment, and maternal depression. However, these results should be interpreted with caution due to the risk of bias of some of the included studies. Further research is needed to assert their value in supporting vulnerable mothers in this phase.</p>
<p>Data regarding the perceptions of key stakeholders on the impact of the Daisy programme (a newly developed perinatal mentalization-based intervention), suggest that it was perceived to be an important source of support in promoting change for pregnant women with histories of child removal. It therefore seems to be a promising perinatal intervention for pregnant women in these circumstances. However further quantitative evidence is needed to evaluate its effectiveness and impact.</p>
<p>Finally, findings from the realist evaluation stress the importance of considering contextual factors and individual needs in designing interventions to prevent child maltreatment among vulnerable parents with infants at risk of maltreatment. Further research is needed to validate and expand upon these findings, particularly regarding external pressures, adverse childhood experiences and alternative delivery formats.</p>
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