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American Journal of Orthopsychiatry Copyright 2003 by the Educational Publishing Foundation2003, Vol. 73, No. 1, 5564 0002-9432/03/$12.00 DOI: 10.1037/0002-9432.73.1.55

Maternal psychopathology and marital discord

have been found to be associated with problematic

socioemotional development or psychiatric disorders

in children (Fincham, 1998; Kelly, 2000; Laucht,

Esser, & Schmidt, 1994; Oysermann, Mowbray,

Meares, & Firminger, 2000; Rutter & Quinton, 1984;

Zeanah, Boris, & Larrieu, 1997). The impact of pater-

nal psychopathology has received less attention. In

this study of 80 couples expecting their first child

we investigated the association among maternal

psychopathology, paternal psychopathology, marital

quality, and parental attitudes toward the unborn childand future family life. Specifically, we targeted the

parental capacity to form triadic relationships (Triadic

Capacity). We hypothesized that (a) the severity of

parental psychiatric symptoms is negatively corre-

lated with marital quality and (b) both the presence of

a psychiatric disorder and low marital quality inde-

pendently contribute to the variance of parental

Triadic Capacity.

Parental Psychopathology, Marital Quality,and the Transition to Parenthood

Sonja Perren, PhD, Agnes von Wyl, PhD, Heidi Simoni, PhD,Werner Stadlmayr, MD, Dieter Brgin, MD, and Kai von Klitzing, MD

University of Basel

This study of 80 expectant first-time parents investigated the associations among marital quality,

parental psychiatricdisorders,and parentscapacityto formtriadic relationships (TriadicCapacity).

The results suggest that marital quality as well as maternal and paternal psychopathology affect

child and family development as early as pregnancy, when parents prepare themselves to integrate

the future child into their relational world.

Capacity to Form Triadic RelationshipsAPrecursor for Successful Parenthood

Pregnancy is a preparatory period during which

prospective parents undergo processes of adaptation.

Normally, parents begin to form an emotional bond

with the unborn child at the level of mental represen-

tations (Lebovici, 1988; Soul, 1982). The quality of

these representations has been shown to be predictive

of the subsequent quality of parentchild interactions

as well as of infant development (Benoit, Parker, &

Zeanah, 1997; Fonagy, Steele, & Steele, 1991;Steele, Steele, & Fonagy, 1996; von Klitzing, Simoni,

Amsler, & Brgin, 1999; von Klitzing, Simoni, &

Brgin, 1999, 2000). Intensive changes in the parental

partnership often occur during this early phase of the

transition to parenthood (Lewis, 1988a, 1988b). Re-

cent studies have shown that triadic interactions have

an important influence on the development of infants

and toddlers (Belsky, Crnic, & Gable, 1995; Fivaz-

Depeursinge & Corboz-Warnery, 1999; McHale &

Rasmussen, 1998; von Klitzing, Simoni, & Brgin,

1999), over and above the dyadic motherchild inter-

action conceptualized in attachment models.

Bowlbys (1969) hypotheses of infant attach-

ment have generated a substantial amount of re-

search on the interaction between mothers and their

infants (see Bretherton, 1985; Waters, Hamilton, &

Weinfield, 2000). Several studies have shown that in-

fant attachment security cannot be generalized across

family relationships (e.g., Belsky & Rovine, 1987;

Fox, Kimmerly, & Schafer, 1991; Sagi et al., 1985).

On the basis of the findings of their meta-analysis,

van IJzendoorn and De Wolff (1997) advocated a

move to a more contextual level in attachment theoryand research. Likewise, Cowan (1997) emphasized

the necessity of including fathers and considering

Sonja Perren, PhD, Agnes von Wyl, PhD, Heidi Simoni,PhD, Dieter Brgin, MD, and Kai von Klitzing, MD,

Department of Child and Adolescent Psychiatry, University

of Basel, Basel, Switzerland; Werner Stadlmayr, MD,

University Womens Hospital, University of Basel.

Heidi Simoni is now at the Marie Meierhofer-Institut fr

das Kind, Zurich, Switzerland. Werner Stadlmayr is now at

University Womens Hospital, University of Berne, Berne,

Switzerland.

This study is part of a longitudinal study that was

supported by Swiss National Science Foundation Grant

3232330.91.

For reprints and correspondence: Sonja Perren, PhD,

Department of Child and Adolescent Psychiatry, Univer-sity of Basel, Schaffhauserrheinweg 55, CH-4058 Basel,

Switzerland. E-mail: [email protected]


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56 PERREN ET AL.

marital conflict and external stressors as important

factors in attachment research. In our concept of

Triadic Capacity we try to overcome some of the

shortcomings of attachment research by considering

the motherfatherchild triad and the larger socialcontext instead of focusing only on the motherchild

dyad.

Triadic CapacityConceptand Assessment

To assess parents attitudes toward the child and

the future family, we used the concept of Triadic

Capacity, which was developed by our research group

(Brgin & von Klitzing, 1995; von Klitzing, Simoni,

et al., 1999; von Klitzing, Simoni, & Brgin, 1999).Triadic Capacity describes the intrapsychic and inter-

personal readiness of the parents to integrate the child

as an important third person into their mental and re-

lational lives. Specifically, it is defined as the capacity

of fathers and mothers to anticipate their future fam-

ily relationships, without excluding either themselves

or their partners from the relationship with the infant.

Triadic Capacity is considered to be a resource for

coping with the transition to parenthood and estab-

lishment of the family.

Triadic Capacity is assessed at the level of mental

representations. Attachment theorists have increas-ingly moved to the level of representation over the

last 15 years (Main, Kaplan, & Cassidy, 1985), espe-

cially through the application of the Adult Attachment

Interview (George, Kaplan, & Main, 1985), which

evaluates the speech of adults about their dyadic ex-

periences with their parents during childhood. The

concept of Triadic Capacity extends this approach by

including additional aspects of intra- and interper-

sonal functioning: the structure of the parental part-

nership, quality of interparental dialogue (cognitive

and emotional), flexibility and triangularity of theirmental representations, and transgenerational conti-

nuity of well-integrated experiences of triadic rela-

tionships. If both parents have formed rich and

flexible mental representations of their future child

that include the partner, if they openly exchange ideas

about their future family life, if this dialogue is em-

bedded in a partnership free from projections and

within coherent memories of relationships with the

family of origin, the developing parenthood is charac-

terized by a high Triadic Capacity. In contrast, if the

parents mental representations are meager and/or

rigid, with tendencies to exclude the partner or self(I am the only important caretaker, The baby will

probably reject the father, I wont be important to

the baby; babies are mothersbusiness); if there is no

or poor-quality dialogue between the parents; and if

there are no coherent memories of triadic relation-

ships with the parents of origin (many family conflicts

with tendencies toward exclusion), the developingparenthood is characterized by a low Triadic Capac-

ity. We consider the Triadic Capacity of parents an

important precondition for the formation of a growth-

promoting parentchild relationship.

Method

Procedure

This study is part of an ongoing prospective, longitudinal

study of 80 couples and their firstborn infants. During thesecond trimester of pregnancy, parents completed several

questionnaires on psychopathology, marital quality, and so-

ciodemographics. During the last trimester of pregnancy,

parents were interviewed to evaluate their capacity to form

triadic relationships (Triadic Capacity). In addition, biologi-

cal risk factors for pregnancy were ascertained.

Participants

Eighty couples expecting their first child participated in

the study. They were recruited by staff of the university

womens hospital or from private gynecologists. In our sam-ple the prevalence of psychosocial or biological risk factors

is higher than in the general population. We made every ef-

fort to engage the future fathers, and only 18 fathers refused

to participate. In these cases, mothers took part in the study

without their partners. Eight fathers participated only par-

tially (completed only the interview or only the question-

naires). The reasons given for nonparticipation by the fathers

included language difficulties, time constraints, lack of in-

terest, or severe marital conflicts. As our clinical experience

has shown that families in which the fathers decline to par-

ticipate are sometimes the most disturbed and problematic,

we included the 18 cases without paternal participation in

our study to ensure ecological validity and clinical rele-vance. Detailed information on the participation rates are

shown in Table 1.

On average, couples had been living together for 3.9 years

(SD 3.3). Fifty-seven couples were married (71%). The

participation rate of the fathers in the Triadic Interview

was not significantly associated with marital status,

2(1,N 80) 0.352, p .553. Although not all couples

were married, questions related to both married and unmar-

ried couples are referred to as marital. Medical records of

pregnancies were evaluated and assessed. Twenty-seven

prospective mothers needed medical care in the hospital

(33.8%) and experienced difficult pregnancies. This high

percentage of difficult pregnancies is due to the spe-

cialization of the university hospital in clinically high-risk

pregnancies.


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PSYCHOPATHOLOGY, MARRIAGE, AND FIRST PARENTHOOD 57

Table 1

Participation Patterns Broken Down by Parental Psychiatric Status

Participation in QuestionnairesTriadic Interview completed by

Parental psychiatric Mother Mother Mother Mother Neither motherstatus (couple) and father only and father only nor father N(%)

Mother and father categorizable 53 9 59 2 1 62 (78%)Mother and father no disorder 34 3 37 37 (46%)Mother or father with disorder 16 4 19 1 20 (26%)Mother and father with disorder 3 2 3 1 1 5 (6%)

Father not categorizable 3 15 16 2 18 (22%)Mother no disorder 2 7 9 9 (11%)Mother with disorder 1 7 7 1 8 (10%)Mother not categorizable 1 1 1 (1%)

Total 56 (70%) 24 (30%) 59 (74%) 18 (22%) 3 (4%) 80

The mean age of the mothers was 30.6 years (SD 5.2),

and the mean age of the fathers was 32.8 years (SD 4.9).

The only inclusion criterion was being able to speak and

understand German. Thus, most of the couples were Swiss

or had grown up in Switzerland and spoke German (61 cou-

ples). At least 1 of the partners of the remaining 19 couples

spoke a foreign language and had not grown up in

Switzerland.

School and professional education of both parents served

to determine educational status. Ten percent of the families

were assigned to a lower educational status, 21% to lower

middle, 26% to middle, 21% to upper middle, and 21% to

upper educational status. The participating couples were a

very heterogeneous sample in terms of language, cultural

background, age, and social class.

Psychopathology

Individual psychopathology was assessed by means of the

German version of the Revised Symptom Checklist by

Derogatis (1977, SCL90R; German: Franke, 1995). We

used the Global Severity Index to establish psychopathol-

ogy. Scores were transformed into T values based on sex

norms (M 50, SD 10). Because we were interested inthe effect of educational status, we did not apply the educa-

tion norms. The norms are based on the scores of a norma-

tive sample consisting of 501 women and 505 men from

Germany (age: M 34, SD 10.5) from various educa-

tional backgrounds (similar to our Swiss population; see

Franke, 1995).

We used a cutoff point ofT 60 to differentiate persons

with and without psychiatric disorder. To include all clini-

cally relevant information in the assessment, (severe and ob-

vious) psychiatric disorders, either self-reported or reported

by others, were used to complement the SCL90R assess-

ment. For example, some participants reported psychiatric

symptoms in the general medical history but denied these

symptoms when completing theSCL90R. Moreover, a few

mothers who participated alone in the interview assessment

described severe psychiatric disorders of their partners.

These fathers were thus also identified as having psychiatric

disorders, even when they had scores in the normal range of

SCL90R or missing SCL90R scores. The disorders

reported included drug or alcohol abuse (5 participants),

major depression (4), obsessivecompulsive disorder (2),

anxiety disorder (2), somatoform disorders (2), and multiple

disorders (1). Finally, 11 fathers and 27 mothers were identi-

fied as having psychiatric disorders. If participants did not

complete the SCL90R and did not report a psychiatric

disorder (18 fathers and 1 mother), we categorized their psy-

chopathology status as missing. This avoided miscategoriza-

tion of these cases as the absence of psychiatric disorder

rather than missing information. Details of participation

patterns broken down by parental psychiatric status are

shown in Table 1.

As in clinical practice, every available information source

was included in the diagnosis of psychiatric disorders. This

procedure allowed families considered to be at risk, such as

those with drug-addicted fathers, to be included in our study,

enhancing its clinical relevance and ecological validity.

However, this procedure might cause methodological biases

due to the different ways of assessing psychiatric disorders.

To control for possible biases, we also performed the statis-tical analyses using symptom severity solely as assessed by

SCL90R.

In the following discussion of the results we distinguish

between psychiatric disorder (presence 1, absence 0)

and severity of symptoms (Global Severity Index sum

score of SCL90R).

Marital Quality

Participants completed the Partnership Questionnaire on

marital quality (Hahlweg, 1988). The total scores of this

instrument can be used to establish overall marital quality.

Hahlweg (1996) showed that the questionnaire is highly

intercorrelated with other instruments, such as the Dyadic

Adjustment Scale (Spanier, 1976) and the MaritalAdjustment


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58 PERREN ET AL.

Test (Locke & Wallace, 1959). We used this instrument

instead of the more widely known Dyadic Adjustment

Scale because we consider it to be culturally more appropri-

ate for our SwissGerman sample. We transformed scores

into Tvalues (M

50, SD

10) to compare participantsmarital quality to the normative group.The normativesample

consists of 104 men and 131 women: German; mainly mid-

dle class;91%married;age:M 35.1, SD 6.9; duration of

marriage: M 10.2, SD 6.4 (see Hahlweg, 1996). Scores

of fathers and mothers were significantly associated (r

.816,p .000). Hence, if both parents completed the ques-

tionnaire, we used the mean value of the couple. If the father

did not participate, we used the mothers score in the

analyses.

Triadic Capacity

To assess parents capacity and readiness for engaging in

triadic relationshipsthat is, for integrating the child as a

third person into their relational world (Triadic Capacity)

an interview instrument (the Triadic Interview) was devel-

oped in an earlier project (see Brgin & von Klitzing, 1995;

von Klitzing, Antusch, Amsler, & Brgin, 1995). This is a

semistructured psychodynamic interview that includes both

parents. A well-trained and clinically experienced female

psychologist interviewed the expectantparents during the last

trimester of pregnancy. The interviews were all videotaped

andlastedabout 2 hr. TheTriadic Interview provides as much

structure as necessary to elicit comparable results but as little

structure as possible in order to gain access to the inner worldof the parents in a way that is familiar to clinicians.

The following topics were addressed with all parents:

their own childhood experiences, genesis and emotional

course of pregnancy, mental representations of the unborn

child, changes in the marital relationship, expectations of

future family relationship, and the role of the prospective

grandparents. In order to assess the Triadic Capacity of the

couples, the interviewer plus two extensively trained inde-

pendent raters, who were blind to the other relevant details

of the subjects, coded all interviews following a detailed

coding scheme (von Klitzing, 1996). The coding system is

clinically oriented and aims to integrate all of the detailed

information acquired into broader dimensions. The contentand the overall structure of the interview, including the

coherence between descriptions and narratives and the

expressed emotionality, are evaluated. All this information is

then summarized using five 9-point scales describing the fol-

lowing aspects: (a) quality of personal functioning and part-

nership dynamics, (b) flexibility of mental representations of

the unborn child, (c) quality of the inner triadic scene con-

cerning future family relationships, (d) quality of parental

dialogue, and (e) narrative coherence of the descriptions of

the parentsown (triadic) childhood experiences. Definitions

and criteria of these scales are described in the rating glos-

sary, with low numbers indicating low quality and high num-bers indicating high quality (von Klitzing, 1996).

The five scales of the Triadic Interview were highly inter-

correlated, probably because the underlying dimensions are

interdependent components of the parental Triadic Capacity

(for extensive discussion: von Klitzing, Simoni, & Brgin,

1999). The internal consistency of the five scales was very

high (Cronbachs .95). Thus, we used the mean score of

the five scales to establish Triadic Capacity.Interrater reliability (intraclass correlation) was .83.

Where there was a major non-agreement (more than one

scale-point difference), three raters performed a consensus

rating. For all other interviews, the mean score of all three

raters was used for subsequent analyses. Validity of the

Triadic Interview has been established in previous studies

(von Klitzing, Simoni, et al., 1999; von Klitzing, Simoni, &

Brgin, 1999).

Ratings were carried out for couples. Because a previous

study showed maternal scores to be highly significantly cor-

related with couple scores (von Klitzing, Simoni, & Brgin,

1999), we used the scores of the mothers interview in cases

where the father had not participated. To control for a possi-ble bias associated with this procedure, we used fathers

nonparticipation as a control variable in some analyses.

Results

Comparisons Between the StudySample of Expectant Parentsand Normative Samples

We calculated one-sample t tests to assess differ-

ences between our sample and the normative sample(Franke, 1995). The fathers severity of symptoms

was significantly lower than the male normative sam-

ple, t(76) 3.165,p .002. Mothers did not differ

significantly from the normative group, t(58)

0.825, p .421. In comparison with the normative

sample, mothers scored significantly higher on soma-

tization and depression but lower on paranoid

ideation and psychoticism. Fathers scored lower on

somatization, obsessivecompulsion, interpersonal

sensitivity, and psychoticism (see Table 2).

Next, we compared the marital quality of our sam-

ple to the normative sample (Hahlweg, 1996). We cal-culated a one-sample ttest for overall marital quality

(comparison score: T 50). Mothers and fathers

scored significantly higher on marital quality than the

normative sample (mothers: M 57.7, SD 12.1,

t[76] 5.183, p .000; fathers: M 57.6, SD

9.8, t[58] 8.505,p .000).

Is Psychopathology Associated WithMarital Quality of the Parental Couple?

Associations among marital quality, severity of

symptoms and sociodemographic variables were

analyzed. The severity of maternal and paternal


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Table 2

Description of Symptom Checklist-90Revised Subscales and Global Severity Index

Mothers (n 77) Fathers (n 59)

Psychiatric symptom M SD T 60 (%) M SD T 60 (%)

Somatization 54.23** 11.71 28.6 46.36** 9.80 10.2Obsessivecompulsive 47.97 11.03 14.3 45.75** 11.16 8.5Interpersonal sensitivity 48.58 10.07 9.1 47.22* 10.32 10.2Depression 52.57* 9.77 18.2 49.05 10.72 13.6Anxiety 51.08 11.15 19.5 50.88 10.07 15.3Angerhostility 51.61 10.90 16.9 48.83 10.30 10.2Phobic anxiety 52.18 10.30 23.7 50.69 9.17 20.3Paranoid ideation 46.29** 10.50 11.7 47.95 9.87 13.6Psychoticism 46.96** 10.00 15.6 46.93** 8.72 10.2Severity of symptoms 51.05 11.19 20.8 45.12** 11.85 10.2

*p .05. **p .01.

symptoms was significantly negatively correlated

with marital quality: The more severe the psychiatric

symptoms, the lower the marital quality (r.396,

p .000; r.282, p .030). Moreover, marital

quality was significantly negatively correlated with

duration of living together (r.269,p .020). By

contrast, marital quality was not significantly corre-

lated either with age of participants or with educa-

tional level.

We calculated t tests using marital quality as a

dependent variable. The presence or absence ofpsychiatric disorders, legal marital status, difficult

pregnancy, and nonparticipation of fathers served as

independent variables. Analyses showed that couples

in which there was no paternal psychiatric disorder

had a higher marital quality than couples where a

paternal psychiatric disorder was present (presence:

M 47.5, SD 15.0, n 10; absence: M 59.9,

SD 8.9, n 51), t(59) 3.55, p .001. More-

over, lower marital quality was reported when fathers

did not participate in the study (nonparticipation:

M 51.6, SD 15.7, n 22; participation: M58.8, SD 9.1, n 55), t(75) 2.51, p .023.

No significant differences in terms of maternal psy-

chiatric disorder, marital status, or difficult pregnancy

were noted.

Does the Presence or Absence ofPsychiatric Disorders or MaritalQuality Contribute to the Varianceof Triadic Capacity?

Triadic Capacity was significantly negatively

correlated with the severity of maternal or paternal

symptoms: The more severe the mothers or fathers

symptoms, the lower their Triadic Capacity (r

.368,p .001; r.289,p .027). The Triadic

Capacity of couples reporting higher marital quality

was rated higher than that of couples reporting lower

marital quality (r .516, p .000). Moreover, the

higher the educational level of participants, the higher

their Triadic Capacity (r .352, p .001). In con-

trast, Triadic Capacity was not significantly correlated

with age of participants or duration of cohabitation/

marriage.

Furthermore, we performed t tests using TriadicCapacity as a dependent variable (see Table 3). In

line with the results reported above, psychiatric dis-

orders, legal marital status, difficult pregnancy, and

nonparticipation of fathers served as independent

variables. Mothers and fathers with psychiatric disor-

ders were rated lower on Triadic Capacity than par-

ents without psychiatric disorders. Moreover, married

couples scored higher on Triadic Capacity. Similarly,

mothers who participated without their partners were

rated lower on Triadic Capacity than other partici-

pants. This last finding might, however, be a method-ological artifact, because the absence of the father

may have influenced the interviewer and/or the inter-

view raters.

We next conducted regression analyses to de-

termine whether marital quality or the presence or

absence of psychiatric disorders independently ac-

counted for the variance in parental Triadic Capacity.

As a first step we used educational level, with the

other predictor variables entered hierarchically in

the following order: maternal psychiatric disorder,

paternal psychiatric disorder, marital quality. To

exclude possible rating biases due to nonpartici-

pation of fathers, we included only those families

where both parents participated (N 52). We used


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60 PERREN ET AL.

Table 3

t Tests and Mean Scores of Triadic Capacity by Various Independent Variables

True Not true

Variable M SD n M SD n t df p

Maternal psychiatric disorder 3.13 0.44 27 3.55 0.39 52 4.423 77 .000**Paternal psychiatric disorder 2.93 0.48 11 3.56 0.38 51 4.834 60 .000**Unmarried couple 3.20 0.47 23 3.49 0.42 57 2.695 78 .009**Difficult pregnancy 3.42 0.54 27 3.41 0.40 53 .097 78 .923Nonparticipation of fathers 3.17 0.42 24 3.51 0.42 56 3.322 78 .001**

**p .01.

1We also performed the same regression using severity

of symptoms. The analysis yielded identical results, with

the exception of one variable: paternal severity of symptoms

did not reach significance in Model 4 (

.200,p .099). This inconsistency might be due to the shared

method variance.

the binary variable psychiatric disorder rather than

the severity of symptoms as independent variablebecause of the broader range of clinical information

given by self-ratings and anamnestic reports.1

As can be seen in Table 4, educational level sig-

nificantly predicted couples Triadic Capacity. The in-

clusion of maternal psychiatric disorder did not

significantly increase the model fit. Next, paternal

psychiatric disorder was included in the model. This

step gave a model with significantly better fit. As did

educational level, fathers psychiatric disorder pre-

dicted low Triadic Capacity. Finally, couples marital

quality was included in the regression analysis, which

significantly increased the model fit. In summary,

the presence or absence of psychiatric disorders of

fathers, marital quality, and educational level each

independently predicted a low Triadic Capacity of

expectant parents.

Discussion

The findings indicate that marital quality and

parental psychopathology are factors of major impor-

tance for the transition to parenthood, with the sever-

ity of psychiatric symptoms and poor marital qualitynegatively associated with successful transition. The

educational level of the parents, paternal psycho-

pathology, and marital quality each contribute

independently to the variance of parental attitudes

toward their future child and family life.

The results support Cowans (1997) notion that the

relative neglect of fathers is the most important omis-

sion in the field of attachment research and that mari-

tal conflicts and external stressors have an important

impact on the parentchild relationship. Our results in

fact emphasize the importance of the mental health of

both fathers and mothers, and of marital quality and

educational level, in early family development.

Marital Quality During Pregnancy

It is surprising that our study sample reported

higher marital quality than the normative sample.

The high marital quality might be related to the ex-

perience of first pregnancy. Being pregnant could be

a positive challenge, not only for the expectant

mother undergoing substantial physical changes, but

for the father and the marital relationship as well.

Thus, expectant parents share a common experience

and a common goal and perhaps are drawn closer

together. Another explanation could lie in the selec-

tion of the study sample. Couples with high marital

quality might have been more willing to participate

in the study. In contrast, couples with low marital

quality might have decided against participation

through shame or unwillingness to talk about their

problems.

Furthermore, self-ratings of marital quality were

significantly negatively correlated with duration of

cohabitation. This finding corresponds to other stud-

ies demonstrating a decline in marital satisfaction

over time. This decline is larger in couples after the

birth of the first baby (Cowan & Cowan, 1988). These

results might also be due to a tendency to evaluate themarital relationship more realistically over time. As

marital quality was self-assessed, there might have

been some overidealization of the relationship, espe-

cially by couples with little experience of living

together before becoming parents.


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Table 4

Summary of Hierarchical Regression Analysis for Variables Predicting Couples Triadic Capacity

Model statistic Fchange (dfs) Variable p

Model 1 (R2 .283) 20.13(1, 51),p .000 Educational level .532 .000**Model 2 (R2 .296) 0.89(1, 50),p .349 Educational level .491 .000**

Maternal psychiatric disorder .119 .349Model 3 (R2 .404) 8.91(1, 49),p .004 Educational level .435 .001**

Maternal psychiatric disorder .087 .465Paternal psychiatric disorder .337 .004**

Model 4 (R2 .474) 6.37(1, 48),p .015 Educational level .346 .005**Maternal psychiatric disorder .137 .235Paternal psychiatric disorder .282 .013*Marital quality .285 .015*

*p .05. **p .01.

Psychopathology and Marital Quality

As hypothesized, we found a significant negative

correlation between the severity of symptoms of both

parents and self-reported marital quality. The reasons

for this negative association might be bidirectional:

Psychiatric disorders are frequently associated with

relational difficulties and might therefore lead to mar-

ital problems; conversely, marital problems might

have caused or at least enhanced psychiatric symp-

toms such as depression. Watson, Elliott, Rugg, and

Brough (1984) showed that psychiatric disorders dur-ing pregnancy are associated with marital dissatisfac-

tion and postnatal depression.

Psychopathology, Marital Quality,and Early Development of Parenthood

As hypothesized, parents Triadic Capacity was

negatively correlated with the severity of parental

symptoms and positively correlated with marital

quality. Most studies investigating associations be-tween the marital relationship and child development

focus on marital conflicts and divorcethat is, the

negative side of the marital relationship (Fincham,

1998; Howes & Markman, 1989; Kelly, 2000). How-

ever, a high-quality marital relationship entails more

than just the absence of conflict: It can be considered

a positive resource for the transition to parenthood.

Couples with a high-quality relationship probably

cope better with the extension of the marital dyad to

the motherfatherchild triad.

Although parental psychiatric disorder is consid-

ered to be a risk factor for child psychopathology, the

mechanisms of this intergenerational transmission

process are only partially understood. Explanatory

models include the quality of parentchild interac-

tions, genetic transmission, and psychosocial factors

(Rutter, 1999). Our study demonstrates that problem-

atic attitudes toward the child and the future family

triad in families with a high level of parental psy-

chopathology and with low marital quality can be

diagnosed during pregnancy.

The negative influence of paternal psychopathol-

ogy on child adjustment in infancy and early

childhood was neglected for a long time (Phares &

Compas, 1992). Our study shows that the presenceand severity of psychiatric disorders in fathers are

associated with low marital quality and low Triadic

Capacity assessed during pregnancy.As this is a stable

correlation, even when controlling for motherssymp-

toms, marital quality, and educational level, paternal

psychiatric disorder should be considered not only as

having indirect adverse effects as a stress factor in the

motherchild environment but also as directly influ-

encing the quality of triadic family processes.

Role of Educational Level

The educational level of thefamilies was negatively

correlated with the severity of motherssymptoms and

positively correlated with parental Triadic Capacity.

The negative statistical correlation between mothers

psychopathology and Triadic Capacity disappears

when controlling for the coupleseducational level. In

a statistical sense, educational level is a variable with

a mediating function (Baron & Kenny, 1986). This

phenomenon is due to the high association between

psychopathology and educational level.

The association of educational level with mea-

sures of psychopathology and Triadic Capacity may


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62 PERREN ET AL.

be partly due to methodological biases. The ques-

tionnaire we used to assess psychopathology

(SCL90R) yields higher levels of psychopathology

for people with less education (Franke, 1995). This

may be a methodological artifact due to distorted re-sponse tendencies. Likewise, the positive association

between Triadic Capacity and educational level might

reflect a rating bias as a result of the raters own

educational levels (all raters had university degrees)

and role models.

Nevertheless, the significant correlation between

psychopathology and educational level may also re-

flect real associations. On the one hand, participants

with less education may have had more psychosocial

stressors in their environment, which may have trig-

gered psychiatric disorders. Alternatively, people withpsychiatric disorders may have been unable to receive

higher education because of their illness. Likewise,

the association between Triadic Capacity and educa-

tional level could reflect the existence of more tradi-

tional family role models in families with low socio-

economic status. In traditional role models fathers are

often seen as being less important for the child, partic-

ularly during infancy and early childhood. Parents

with less education may have developed lower Triadic

Capacities because, in their conceptualization of their

future parenthood, fathers had a more distant relation-

ship with the baby. This result clearly does not implythat poorly educated people will become bad parents.

Nevertheless, a good education may be a protective

factor by improving reflective functions that help to

overcome difficult developmental experiences during

the transition to parenthood.

Clinical Implications

Our findings have certain clinical implications.

First, paternal as well as maternal psychopathology

should be assessed when one is evaluating risk factors

for development in infancy. Second, marital quality

may be a resource for coping with the transition to

parenthood; thus, interventions concerning marital

conflicts may be important during pregnancy. Third,

medical interventions during pregnancy mostly focus

on the biological health of mother and baby. As preg-

nancy is not solely a biological process but also

involves important intrapsychic and interpersonal

processes, intervention programs for these aspects

should also be developed.

Such intervention programs for prenatal care mustbe based on an interdisciplinary approach. This

means that obstetricians, psychiatrists, pediatricians,

and child psychiatrists create interdisciplinary pro-

grams to accompany risk families across the transi-

tion to parenthood. In our early intervention program

for infants with regulatory disorders we try to inte-

grate the triadic approach. In general, we encouragefathers to participate in the consultations with our

interdisciplinary team of child psychiatrists, pediatri-

cians, and nurses. This approach has proved to be

very successful. We assume that interventions using a

similar conceptualization that begin as early as preg-

nancy would also be a promising approach.

Methodological Strengths and Limitationsand Future Research Directions

We made every effort to motivate fathers to partic-

ipate in this study. Of the 80 fathers, 62 agreed to par-

ticipate (at least partially). This rate of participation is

high compared with other studies. One strength of our

study is that we did not rely solely on self-report mea-

sures but established the Triadic Capacity of parents

by means of an intensive interview, which was rated

by trained experts.

Some mothers were interviewed without their

partners. Nevertheless, Triadic Capacity was also

evaluated in these cases. This may represent a

methodological limitation. However, an earlier study,in which only couples with both parents present were

evaluated, showed a high degree of association be-

tween fathers and mothers Triadic Capacity (von

Klitzing, Simoni, & Brgin, 1999).

A further limitation of our study is that parental

psychopathology was assessed from self-ratings:

Funding limitations prevented us from using stan-

dardized interview measures for that purpose.

Ourstudywasconductedona Swiss,mainlymiddle-

class sample (probably comparable to an American

White middle-class population) and cannotbe extrapo-

lated to individuals of other socialcultural back-

grounds.We stronglyencouragesimilarstudies inother

countries and cultural contexts in order to investigate

the cross-cultural validity of our triadicapproach.

The present study is based on data collected during

pregnancy. Thus, we evaluated parenthood at the

level of parental mental representations and not of ob-

served parentinfant interaction. In a next step we

will investigate whether we can replicate our findings

on the association between mental representations

and standardized observation of family interactions

during infancy (von Klitzing, Simoni, et al., 1999;von Klitzing, Simoni, & Brgin, 1999, 2000) in fam-

ilies at severe psychosocial risk. In future research we


9/10


aim to evaluate the longitudinal associations between

the intra- and interpersonal processes of pregnancy

and variations in family development and childrens

social competence and mental health in the preschool

years.

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Received November 15, 2001

Revision received April 1, 2002

Accepted July 28, 2002 I

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