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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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PSYCHOPATHOLOGY, MARRIAGE, AND FIRST PARENTHOOD 59
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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PSYCHOPATHOLOGY, MARRIAGE, AND FIRST PARENTHOOD 61
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
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PSYCHOPATHOLOGY, MARRIAGE, AND FIRST PARENTHOOD 63
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