Measurement of Maternal-Infant...

10.1177/1078390305278788Horowitz et al.Maternal-Infant Interaction

Measurement of Maternal-InfantInteraction

June Andrews Horowitz, M. Cynthia Logsdon, and Jessie K. Anderson

Evaluating the quality of the maternal-infant relationship is a challenge to researchers and clinicians interested in infantdevelopment and quality of early parenting.The purpose of this article is to describe and critique commonly used measures of maternal-infant interaction to assist researchers in making informed decisions about measuring this variable.The measures reviewed arevaluable approaches to assessment of parent-child interaction for research; several are adaptable for clinical use as well. In se-lecting the most appropriate measure for a particular study, investigators are encouraged to consider the conceptual model onwhich the instrument is based,accessibility of training, extent of previous use, evidence of reliability and validity,and specific re-quirements for equipment, specialized laboratory setting, administration, and scoring. Using maternal-infant interaction mea-sures that are appropriate for clinical practice could assist psychiatric–mental health nurses and other mental health cliniciansto identify problematic aspects of interaction that may be amenable to treatment with interpersonal, cognitive, behavioral, andpsychoeducational strategies. J Am Psychiatr Nurses Assoc, 2005; 11(3), 164-172. DOI: 10.1177/1078390305278788

Keywords: maternal-infant interaction; questionnaires; observer-rated interaction; postpartum depression; mothering; ma-ternal role functioning

The importance of the maternal-infant relationship toinfant development and maternal role satisfaction haslong been established. Researchers from the disci-plines of psychology (e.g., Ainsworth & Bell, 1970;Bowlby, 1958) and medicine (e.g., Brazelton, 1963;Klaus & Kennell, 1976;), as well as renowned nurse re-searchers such as Ramona Mercer (Mercer &Ferketich, 1995), Reva Rubin (1963), and LorraineWalker (Walker, Crain, & Thompson, 1986), helped tobuild the foundation of science in this area. Research-ers have documented impaired maternal-infant rela-tionships in women with various mental health prob-lems, such as postpartum depression (Beck, 1995) andcocaine addiction (Beeghly, Frank, Rose-Jacobs,Cabral, & Tronick, 2003). Furthermore, difficulties inthe maternal-infant relationship can have long-lastingconsequences for children. Consequences, such as im-paired cognitive and emotional development (Beck,1998), insecure attachment (Murray, 1992), and anti-

social behavior such as temper tantrums, less sharing,less social ability with strangers, and lack of control(Uddenberg & Englesson, 1978), have all been docu-mented. As children mature, these developmental dif-ficulties and behaviors may be associated with poorpeer relationships and school-related problems (Sharpet al., 1995). These problems that result from impairedmaternal-infant interaction may lead to referral of thechildren for psychiatric and mental health services.

As the science has evolved, so has measurement ofthe maternal-infant relationship. Early data collectionmethods involved professional observation of mater-nal behavior and infant responses,with the interactionsummarized as an overall impression by the re-searcher (Rubin,1963).Self-report measures also werecommon. More recently, analysis of videotapes ofmaternal-infant interaction has been used to evaluatethe maternal-infant relationship more objectively.Rig-orous training in the coding of the videotapes, atten-tion to interrater reliability, and consultation by ex-perts in the field have become normative.

The purpose of this article, therefore, is to describeand critique commonly used observer-rated measuresof maternal-infant interaction. Literature from nurs-ing,medicine,and psychology for the past 10 years wasreviewed to identify instruments. This review isprovided to assist researchers to make well-informeddecisions about measuring the important variable of

164 Copyright © 2005 American Psychiatric Nurses Association

June Andrews Horowitz, APRN, BC, PhD, FAAN, professor,Boston College, William F. Connell School of Nursing, ChestnutHill, MA; [email protected].

M. Cynthia Logsdon, ARNP, DNS, associate professor, Universityof Louisville, School of Nursing, Louisville, KY; [email protected].

Jessie K. Anderson, RN, CNM, MSN, staff nurse, Norton Subur-ban Hospital, Louisville, KY; [email protected].

maternal-infant interaction and to inform psychiatric–mental health nurses and other clinicians regardinguse of the measures in research and practice.

INSTRUMENTS

Nursing Child Assessment SatelliteTraining (NCAST) Scales

The NCAST instruments (Barnard et al., 1989;Sumner & Spietz, 1994) evaluate parent-child interac-tion. The NCAST measures were developed under thedirection of Dr.Katherine Barnard and a research teamat the University of Washington School of Nursingthrough the federally funded Nursing Child Assess-ment Project.Literature in the areas of attachment,de-velopmental psychology, psychobiology, and nursingprovided the foundation for NCAST and the child as-sessment model (Byrne & Keefe, 2003; Sumner &Spietz, 1994).

There are two NCAST scales,and they can be used toscore an observed caregiver-child interaction or a vid-eotaped interaction. The two scales were developed to-gether, share the same conceptual basis, but differ inthe following way: The Nursing Child AssessmentTeaching Scale (NCAT) is used during a novel situa-tion, and the Nursing Child Assessment Feeding Scale(NCAF) is applied to a feeding, a familiar and frequentinteraction between parent and child (Byrne & Keefe,2003). Currently, the teaching and feeding scales arereferred to as the Parent-Child Interaction Program.

To use the NCAST scales, training is required to be-come a certified learner or certified trainer. This in-cludes attending a 2 1/2-day workshop and passing areliability test.Costs include a workshop fee ($900) andthe Parent-Child Interaction Program learning mate-rials (feeding and teaching manuals, feeding and teach-ing scale pads, and teaching kit), listed at $182(NCAST-AVENUW, n.d.). Training with a certifiedNCAST trainer may be a substitute for workshop at-tendance. Additional information is available atNCAST-AVENUW, University of Washington, Box357920, Seattle, WA 98195-7920; phone: 206-543-8528;Web site: www.ncast.org.

NCAT. The NCAT (Barnard et al., 1989; Sumner &Spietz, 1994) is one of two instruments that composesthe NCAST tools. The purpose of the NCAT is to assessthe ability of parent and child to engage in “synchro-nous mutual interaction” (Huber, 1991, p. 64). TheNCAT is appropriate for use with parents and their in-fants from birth to 3 years of age. Its six subscales are:Sensitivity to Cues, Response to Distress (if it occurs),Social-Emotional Growth Fostering, Cognitive Growth

Fostering,Child Clarity of Cues,and Child Responsive-ness to Parent (Sumner & Spietz, 1994). A contingencyscore also can be derived from identified items acrossthe subscales. A total of 73 binary items are observedand scored. Dyadic interactive disturbance is sug-gested by responses to less than 43 items (1-6 months),46 items (9-12 months), 52 items (13-24 months), or 53items (25-36 months).

Administration of the NCAT involves observation ofthe parent and child during a novel situation for thepurpose of assessing a dyad’s strengths and areasneeding improvement (NCAST-AVENUW, n.d.). TheNCAT administration begins by directing the parent toselect an age-appropriate skill from the list in thetraining manual and asking the parent to teach theskill to the child.The selected teaching activity is devel-opmentally appropriate but has not yet been masteredby the child. The observer scores parent-infant interac-tive behaviors. Administration takes from 1 to 5 or 6minutes. All NCAT items describe behaviors of thecaregiver, infant, or both. Behaviors that occur arescored as 1, and if behaviors do not occur, they arescored as 0 (NCAST-AVENUW, n.d.).

The original research team field tested the NCAT ina longitudinal study of 193 mother-infant dyads at 1, 4,8, and 12 months of age (Sumner & Spietz, 1994).Trainees were required to reach a minimum of 85%agreement with a partner in scoring the NCAT;achievement of interobserver reliability at 85% is builtinto certification required to administer the scale forclinical use (Huber, 1991). For research purposes, 90%reliability is required (Sumner & Spietz, 1994). Strongevidence for content, criterion, and construct validityhas been reported (Barnard et al., 1989; Sumner &Spietz, 1994) along with successful use in practice andresearch (Huber, 1991). The NCAT manual provides adetailed summary of reliability evidence. Cronbach’salphas, indicating internal consistency, were .87, .90,and .88 for White,Black,and Hispanic samples, respec-tively. Test-retest reliability was calculated as 0.85 forthe parent score and 0.55 for the infant score (Sumner& Spietz, 1994). Lower test-retest correlations for in-fant scores are not surprising and likely indicate in-fants’ rapid developmental changes. The NCAT is ameasure of caregiver-infant interaction that has beenused widely and has established strengths for use inclinical practice and research with parents across age,ethnic, and racial groups. Outcomes from numerousstudies have demonstrated the discriminant and hy-pothesis-testing validity of the NCAT (Byrne & Keefe,2003), as well as its ability to detect problems associ-ated with later adverse social and cognitive functioningoutcomes (Britton, Gronwaldt, & Britton, 2001).

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Maternal-Infant Interaction

NCAF.The NCAF is a reliable and valid means of ob-serving and rating caregiver-child interaction during afeeding from birth to 1 year of age (Barnard et al., 1989;Sumner & Spietz,1994).The NCAF consists of 76 itemswithin six subscales. Four subscales provide measuresof parent’s responsibility to the interaction: Sensitivityto Cues, Response to Distress, Social-EmotionalGrowth Fostering, and Cognitive Growth Fostering.The other two subscales provide measures of the child’sresponsibility: Clarity of Cues and Responsiveness toCaregiver. All NCAF items are behavioral descriptionsof caregiver, infant, or both. If they occur, they arescored as 1,and if they do not occur, they are scored as 0(NCAST-AVENUW, n.d.).

The NCAF is applied to the observation of a routinefeeding, a familiar and frequent parent-child encoun-ter, and takes the same time to administer as the feed-ing. Britton et al. (2001) reported interrater reliabilityestimates as 0.89 to 0.92 for NCAST scales (NCAF andNCAT) and internal consistency reliability estimatesas 0.80 to 0.82.

MUTUAL REGULATION SCALES

Several coding systems based on the mutual regula-tion model have been developed. Tronick andassociates at Harvard Medical School have used thesesystems to measure specific aspects of caregiver-infantinteraction (Tronick, Als, & Brazelton, 1980; Tronick &Weinberg, 1997). The mutual regulation model focuseson the interactive nature of development and is basedon the premise that infants are motivated biologicallyto communicate with others to develop intersubjectivestates,such as awareness of their own and others’ affec-tive states. Tronick and Weinberg (1997) summarizedthe process of mutual regulation as “the capacity ofeach of the interactants, child and adult, to expresstheir motivated intentions, to appreciate the intentionsof the partner, and to scaffold their partner’s actions sothat their partner can achieve their goal” (p. 56).Discussion of the coding systems follows.

Maternal Regulatory Scoring System (MRSS). TheMRSS was designed to code the behavior of caregiversin the face-to-face and still-face paradigms and is com-patible with the Infant Regulatory Scoring System(IRSS; Tronick et al., 1980) that is described below. Us-ing the MRSS, raters can code six dimensions of mater-nal behavior: proximity to infant, caregiving behavior,direction of gaze, vocalizations, touch, and eliciting be-havior. Scoring of video-recorded interactions is donemicroanalytically on a second-by-second basis.

Reliability indicators were determined through bothpercentage agreement and kappa values (Weinberg,Tronick,Cohn,& Olson,1999).Mean percentage agree-ment of the dimensions ranged from 76% to 94% for thedefinitions coded for proximity, 75% for the definitionscoded for caregiving, 89% to 98% for the definitionscoded for gaze, 75% to 96% for the definitions coded forvocalization, 80% to 100% for the definitions coded fortouch, and 77% to 93% for the definitions coded for elic-its. Mean kappa scores were 0.79 for MRSS gaze and0.85 for MRSS proximity (Weinberg et al., 1999).

IRSS.The IRSS was designed to code the behavior ofinfants younger than 1 year of age. Investigators de-rived the IRSS from the Modified Monadic Phase Scor-ing System (Tronick et al., 1980), observations of theyoung infant’s coping repertoire (Brazelton,Koslowski,& Main, 1974), and Gianino’s (1985) research on self-comforting and exploratory behavior. Tronick’s face-to-face still-face paradigm (Weinberg & Tronick, 1994)has been shown to elicit a wide range of affectivebehaviors from infants by confronting them with anage-typical developmental task (face-to-face social in-teraction with the mother), an age-appropriate stress(the mother holding still face and remaining unrespon-sive), and a reunion episode during which the infantand mother negotiate the interaction after it has beendisrupted by the still face (reunion face-to-face interac-tion with the mother).The infant’s behavior is coded ac-cording to nine dimensions of infant behavior: socialengagement, object engagement, scans, vocalizations,gestures, self-comforting, distancing, autonomic stressindicators, and inhibition. Scoring of video-recorded in-teraction is done microanalytically on a second-by-sec-ond basis.

Interobserver reliability was assessed in two ways.First, reliability was assessed through agreement ofboth coders scoring the same code in the same 1-secondinterval. The mean percentage agreement for the IRSScodes and AFFEX codes (Izard & Dougherty, 1980), an-other coding system, was 0.91. Second, when there wassufficient variability in the codes, reliability was deter-mined using Cohen’s kappas. The mean kappa was0.69 (Weinberg & Tronick, 1994).

Infant and Caregiver Engagement Phases System.This system was designed to code infant-adult interac-tions. It is made up of a set of mutually exclusive infantand caregiver phases of interactive engagement andseveral additional regulatory codes.

Caregiver and Child Mutual Regulation System(CCMR).The CCMR was designed to code the behaviorof children 30 months or older and the behavior of their

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mothers. The CCMR provides codes for four dimen-sions of child and maternal behaviors:child affect, childactions and maternal response, maternal affect, andchild play. In addition, the CCMR provides codes for thefollowing specific behavioral dimensions: facial expres-sion, direction of gaze, and vocalizations and affectiveconfigurations. Coding is continuous and occurs forevery instance of a behavior.

Information about these measures is available fromthe authors on request.To inquire,contact Marta Kath-erine Weinberg, Ph.D., Children’s Hospital, Child De-velopment Unit, 1295 Boylston St., Suite 320, Boston,MA 02215; phone: 617-355-6948; e-mail: [email protected].

THE AINSWORTH STRANGESITUATION PROCEDURE (SSP)

The SSP (Ainsworth, Blehar, Waters, & Wall, 1978),the recognized criterion measure of attachment, hasbeen used widely for the past 25 years. Extensive evi-dence of the SSP’s reliability and validity for use withchildren 1 year and older has been reported (Androzzi,Flangan, Seifer, Brunner, & Lester, 2002; Britton et al.,2001; Lamb, Thompson, Gardner, & Charnov, 1985).The SSP is based on Bowlby’s (1969) theoretical workon characteristics of attachment and was developed toassess infant exploratory behavior in the presence andabsence of the mother. “The strange situation is de-signed as a series of episodes of increasing stress, inwhich attachment behavior would be elicited” (Cusson,1993, p. 70).

Administration of the SSP involves observation ofthe child’s exploration behavior and use of the parentas a secure base and observation of the child’s reactionto strangers, to separation,and to reunion with the par-ent. Observations involve seven 3-minute episodesplus an introduction to the room that lasts about 30 sec-onds. Observers code behavior exhibited by the parentand child in the strange situation by using a series ofscales that measure proximity and contact seeking,avoidance, resistance, search behavior,and distance in-teraction. Also, children’s attachment security (i.e., se-cure, insecure, or disorganized) is classified. Attach-ment is rated according to four levels. Secureattachment is characterized by a child who uses theparent as a secure base of exploration, seeks proximityof the parent when distressed, and responds to sooth-ing from the parent by becoming calm.Insecure attach-ments are coded as either avoidant or resistant. Even ifdistressed, the avoidant infant ignores the parent. Incontrast, the resistant infant mingles proximity-seeking

and angry-resistant behavior. Reunion episodes aremost likely to spark such behaviors from the resistantinfant.

The original publication (Ainsworth et al.,1978) pro-vides detailed description of the SSP’s development, in-cluding evidence for its reliability and validity, proce-dures and scoring, and interpretation of data.Extensive training by a recognized expert in the fieldand availability of an appropriate laboratory settingare needed to use the SSP. Interested investigators areencouraged to search the literature and the Internet toidentify training and laboratory facilities that may beaccessible.

THE DYADIC MUTUALITY CODE (DMC)

The DMC (Censullo, 1991; Censullo, Bowler, Lester,& Brazelton, 1987) is a measure of responsiveness inthe parent-infant relationship from birth to 6 months.The DMC was formerly known as the Dyadic MiniCode, before being renamed in 1991. Attachment the-ory provides the DMC’s theoretical basis (Ainsworthet al., 1978; Bowlby, 1969). In relation to the DMC, re-sponsiveness is understood as the parent’s ability to ac-commodate to the infant’s behavior and to give it mean-ing through adaptive behavioral responses.

The DMC is scored from live or videotaped observa-tions of face-to-face interaction according to the follow-ing procedure. The researcher or clinician tells the par-ent to place the infant so that the parent and infant cansee each other’s faces and then instructs the parent toplay with the baby as she or he usually does without us-ing a toy or pacifier.The parent-infant dyad is observedfor 5 minutes, and the interaction is scored. DMC scor-ing involves rating six items that represent key compo-nents of responsiveness: mutual attention, positive af-fect, turn taking, maternal pauses, infant clarity ofcues, and maternal sensitivity (Censullo, 1991). Itemsare scored as 1 or 2 (absent or present) and summed fora total score raging from 6 to 12.Responsiveness can bemeasured as a continuous variable or can becategorized as low (6-8),moderate (9),and high (10-12).

Evidence of reliability includes calculations for Co-hen’s kappa as 0.86 for the total score, ranging from0.63 to 0.92 for the six individual items (Censullo et al.,1987). Cronbach alphas for the total scale were calcu-lated as .66 to .70 over three time points from 4 to 8weeks to 14 to 18 weeks after birth when used in clini-cal intervention trial (Horowitz et al., 2001). Moderateconcurrent validity between the DMC and the MonadicPhase Scale (Tronick et al., 1980) was indicated by apoint biserial analysis (.488, p < .01). The instrument



discriminated between preterm and full-term groupsaccording to expected differences to provide evidencefor construct validity (Censullo et al., 1987).

Training in administration procedures and scoringis required to use the DMC.Interested researchers maycontact Dr. Meredith Censullo, Georgetown University,School of Nursing and Health Studies, St. Mary’sHall, 3700 Reservoir Road, NW, Washington, DC20057-1107; phone: 202-687-7921; e-mail: [email protected].

INTERACTION RATING SCALE (IRS)

The IRS provides a scoring system to measure moth-ers’ sensitivity to infant cues (Field, 1980; Field et al.,2000). The IRS has been used in a variety of studies in-cluding research with depressed mother-infant dyads(Field et al., 1998) and in a study on the effects of ma-ternal and paternal depression on parent-child interac-tion (Field, Hossain, & Malphurs, 1999).

Administration involves video recording parent-infant interactions during feeding and/or face-to-faceplay (either 3- or 5-minute play interactions). Codinginvolves microanalyses with a 3-point Likert-type cod-ing scale (with high ratings being optimal) and in-cludes the following behavior ratings: (a) infant’s state,physical activity,head orientation,gaze behavior, facialexpressions, vocalizations, fussiness, and vocalizationsand (b) mother state, physical activity, head orienta-tion, gaze behavior, facial expressions, vocalizations, si-lence during infant gaze aversion, imitative behaviors,contingent responsivity, and game playing.

Evidence of reliability and validity has been docu-mented. For example, in one study, between-raterreliabilities were assessed for one third of the video-tapes by calculating kappa coefficients. Coefficientsranged from 0.81 to 0.95 for the infant ratings and from0.81 to 0.96 for the mother/stranger ratings (Field,Healy, Goldstein, Perry, & Bendell, 1988). In anotherstudy, adequate interrater agreement for 25% of thesample was assessed by computing Cohen’s kappas oneach of the ratings (M = 0.81 for the parent’s scale and0.73 for the infant’s scale). The internal consistency forthe two scales was satisfactory (Cronbach’s alpha = .77for the parent’s scale and .73 for the infant’s scale;Fieldet al., 1999). Demonstration of validity of the IRS in-cludes expected differentiation between infants of de-pressed versus nondepressed mothers (Field et al.,1999; Martinez et al., 1996).

Training and video recording coding of mother-infant face-to-face interactions with microanalysesequipment are needed to use and code the IRS. For in-formation, researchers can contact Dr. Tiffany Field,

Touch Research Institute, University of Miami Schoolof Medicine, P.O. Box 016820, Miami, FL 33101; phone:305-243-6781; e-mail: [email protected].

PARENT-CHILD EARLY RELATIONSHIPASSESSMENT (PCERA)

The PCERA (also referred to as the Early RelationalAssessment Scale) is a videotape-based scoring systemdesigned to code the affective and behavioral charac-teristics of mother and child during interaction, as wellas the quality of the relationship (Burns, Chethik,Burns, & Clark, 1991; Clark, 1999; Clark, Musick,Stott, Klehr, & Cohler, 1984). Variables were selectedon the basis of theoretical and empirical work onparent-child interaction (Clark, Hyde, Essex, & Klein,1997).

The original version of the Early Relational Assess-ment Scale consists of 65 variables,and each variable isa 5-point Likert-type rating scale with 1 = poorest and5 = best. The videotaped dyadic sequence consists ofseveral segments or situations in which the mothersare instructed to engage their infants in feeding, struc-tured play,unstructured play,and conversation.The 65variables are scored for each of these four situation seg-ments (Burns et al.,1991).Hutcheson,Black,and Starr(1993) modified the measure to avoid redundancy, in-crease clarity, and eliminate items not relevant to feed-ing sessions.This revision resulted in the PCERA,a 42-item rating scale organized into parent, child, anddyadic subscales that include maternal behaviors suchas positive and negative affect, sensitive and contin-gent responses to infant’s cues, quality of visual andphysical interaction, mirroring infant’s feeling states,structuring the environment, flexible versus rigid re-sponses, and intrusiveness (Clark et al., 1997).

The PCERA has demonstrated reliability. Burnset al. (1991) reported an interrater agreement of 93%between two trained coders across all 65 variables. Inthe Grych and Clark (1999) study, Cronbach’s alpha in-dicators of internal consistency for these scales acrosstwo time points ranged from .83 to .93. Infant and ma-ternal scales derived from factor analyses of mother, in-fant, and dyadic variables had Cronbach’s alphas from.78 to .94 in two studies (Clark,1999;Clark et al.,1997).Black, Dubowitz, Hutcheson, Berenson-Howard, andStarr (1995) reported using weekly reliability checksthat produced interrater reliability estimates that ex-ceeded 0.90 and internal consistencies of greater than0.84 for each factor. Kivijarvi et al. (2001) reported theaverage percentage of agreement from all variables intheir study as 79%, and Hutcheson et al. (1993) re-


Horowitz et al.

ported a range of agreement estimates using Finn’s rfrom .87 to .99.

In several studies, investigators selected specificitems from the PCERA to represent a new scale orscore. Black, Schuler, and Nair (1993) found the inter-nal consistency of their nurturance score to be .91, asdetermined by Cronbach’s alpha. Pridham, Schroeder,Brown, and Clark (2001) reported an internal consis-tency range from .84 to .91 for the different codingswithin their scale, using standardized alpha coeffi-cients. Pridham, Lin, and Brown (2001) found an inter-nal consistency range from 0.85 to 0.94 within twoscales in their study.

Grych and Clark (1999) reported that the PCERAdemonstrated concurrent and discriminant validity us-ing the same length of parent-child interactions in-cluded in their study. Discriminant and concurrent va-lidity has been demonstrated for children and mothersfrom a broad spectrum of the population, including Af-rican American mothers and their children withnonorganic failure to thrive (Black et al., 1995) andlow-income families (Clark, Paulson, & Conlin, 1993).

Administration and scoring require training.For ad-ditional information, interested researchers may con-tact Dr. Rosanne Clark at the University of Wisconsin,Department of Psychiatry, 6001 Research Blvd., Madi-son, WI 53719; e-mail: [email protected].

MOTHER-INFANT COMMUNICATIONSCREENING (MICS)

The MICS (Raack, 1989) is an instrument specifi-cally developed to screen for high-risk mother-child in-teraction in busy clinic settings.Researchers have usedthe MICS to quantify the quality of parent-child inter-action for mother-infant dyads with infants youngerthan 1 year of age. The MICS is based on Raack’s workin early language development, which indicated a rela-tionship between language readiness and maternal in-teraction and on the child assessment model (Barnardet al., 1989; Sumner & Spietz, 1994). Three conceptsunderpin the MICS: synchronicity, reciprocity, and mu-tuality (Raack, 1989); these concepts also provide afoundation for the NCAST (Byrne & Keefe, 2003; Sum-ner & Spietz, 1994) and the DMC (Censullo, 1991).However, in comparison to the other rating scales re-viewed, the MICS contains greater emphasis on devia-tions from optimal communication as the basis fordysfunctional interactions.

The MICS can be scored during a routine health en-counter; scoring the interaction during history takingis recommended. The Language/Synchrony subscalecontains eight items, and the Activity subscales range

between three and five items each. The items in thissubscale are scored for all interactions, and they aresupplemented by observations from one or more addi-tional subscales based on the infant’s current activityor state. The choice of Activity subscales includes: Rest,Distress, Feeding, or Play/Neutral State. Each MICSobservation item has five options that are scored from 1to 5; a score of 3 or below indicates need for furtherassessment.

Limited evidence of validity and potential threats toreliability inherent in a tool with few items and brief,nonstandardized administration have been identifiedas weaknesses of the MICS (Conoley & Impara, 1995).However, additional support for reliability and validityof the MICS has been demonstrated. Byrne and Keefe(2003) assessed the comparative reliability and valid-ity of the MICS and NCAT. Internal consistency reli-ability of the MICS was demonstrated by Cronbach’salphas of .89 to .94 for the MICS total score.

To establish content validity of the MICS, speechand language therapy experts conducted pilot studiesto identify appropriate item content. The ability of theMICS to measure anticipated behavioral changes in anintervention study contributed evidence of hypothesistesting or construct validity of the MICS (Keefe,Froese-Fretz, & Kotzer, 1997). Byrne and Keefe (2003)found significant positive correlations between MICStotal scores and NCAT total scores and between similarsubscales to provide support for criterion validity of theMICS. Surprisingly, the Distress subscale on the MICSdid not correlate with the NCAT Response to Distresssubscale, or with any other NCAT subscale, except for aweak correlation with Sensitivity to Cues (r = .36, p =.04); different operational definitions of infant distressmight account for this finding (Byrne & Keefe, 2003).

The MICS (copyrighted in 1989 by Catherine B.Raack) was designed to be self-taught by professionalsthrough study of a manual. Copyrighted printed fold-ers are required for scoring the observations. A video-tape is optional for those users who want a review of theunderlying communication concepts and typical sce-narios. No special equipment is needed for the observa-tions. Packets of 25 folders, the manual, and the video-tape are commercially distributed. For moreinformation, contact Kathy Krauss, Community Ther-apy Services, 333 W. Irving Park Road, Suite 206,Roselle, IL 60172; phone: 630-893-7995.

DISCUSSION

The measures of parent-child interaction reviewedin this article share several strengths. First, they arebased on interrelated, sound theoretical foundations



and empirical evidence concerning the importance ofresponsive, contingent parent-child interaction in pro-moting optimal child development. However, a differ-ence between the theoretical foundation of the MICSand that of other measures is noteworthy.Although theMICS is grounded in the child assessment model thatprovides the foundation for the NCAST tools and isconsistent with the conceptualization of the other mea-sures reviewed, the MICS also is founded on the viewthat deviations from optimal communication are pri-mary sources of dysfunctional interactions. This per-spective is implied in the conceptual basis of all themeasures but is more intrinsic to the MICS than it is tothe other measures.Second,all of the measures requirescoring by a trained observer, thereby avoiding bias in-herent in sole reliance on available self-report instru-ments. MICS training can be self-taught, and all othermeasures require training from approved trainers orthe instrument’s developer. Third, evidence of reliabil-ity and validity exists for all measures; however, theMICS has the least psychometric support for its reli-ability and validity as a research measure of parent-child interaction. Furthermore, the MICS and DMChave a small number of items and rather limited use inresearch in comparison to the other measures re-viewed. Yet simple administration and brief scoringmethods render the MICS and DMC easily adaptablefor clinical use. Although training requirements forclinical use of NCAST are stringent, its effectiveapplication to practice is well documented (Huber,1991;NCAST-AVENUW,n.d.;Sumner & Spietz,1994).

Administration and scoring requirements vary. TheSSP requires a laboratory setting to administer. TheTronick and Weinberg mutual regulation measuresand the IRS are scored microanalytically so that “real-time” live scoring is precluded. Thus, in comparison tothe SSP and the Tronick and Weinberg approaches, theother measures reviewed can be more readily adaptedfor clinical use, and cost of use is reduced because spe-cialized equipment is not needed or is minimal; that is,only video-recording equipment may be needed.Age re-quirements for the child observed also differ. Notably,the SSP requires that the child be 1 year or older so thatit cannot be used with young infants.

IMPLICATIONS

Evaluating the quality of mother-infant interactionwhen the mother’s ability to relate to her infant iscompromised or when the infant exhibits behavioralproblems is critically important. Fostering a healthymaternal-infant relationship, particularly in at-risksituations, may help to prevent subsequent childhood

developmental, behavioral, and mental health prob-lems. Moreover, when impaired maternal-infantrelationships are not identified and treated, resultantproblems often lead to referral of the children for psy-chiatric and mental health services.

Using those measures that are appropriate for clini-cal practice could assist psychiatric–mental healthnurses to identify problematic aspects of interactionthat may be amenable to treatment with interpersonal,cognitive, behavioral, and psychoeducational strate-gies. Clinical researchers have shown that such strate-gies can improve the quality of mother-infant interac-tion among at-risk mother-infant dyads (Horowitzet al., 2001) and that treatment of related maternalproblems such as depression can have positive effectson the quality of maternal responsiveness (Logsdon,Wisner, Hanusa, & Phillips, 2003). Making a referral tocolleagues trained in use and coding of these measuresmay be fruitful when systematic clinical evaluationand monitoring of disturbed mother-infant interac-tions are indicated.

In summary, these measures are valuable ap-proaches to assessment of mother-infant interactionfor research, and several (NCAST, DMC, PCERA, andMICS) are adaptable for clinical use as well. Use withfathers and other care providers also is possible. Theseobserver-rated measures have advantages over self-re-port rating scales because they produce more objectivedata, although practical considerations sometimesmay preclude use of observer-rater measures in favor ofself-report tools. In selecting the most appropriate in-strument for a particular study, investigators are en-couraged first to evaluate the match between the theo-retical underpinnings of the measures and theconceptualization of the variables being studied. Sec-ond, investigators need to consider accessibility oftraining, extent of previous use, evidence of reliabilityand validity, and specific requirements for equipment,specialized laboratory setting, administration, scoring,and overall costs. Also, psychiatric–mental healthnurses and other mental health clinicians may use themeasures that are appropriate for clinical applicationto assess and monitor the quality of mother-infant in-teraction, particularly when relational difficulties aresuspected or known.

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