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Theory of mind as a predictor of maternal sensitivity in women with severe mental illness

  • J. Rigby (a1), S. Conroy (a2), M. Miele-Norton (a3), S. Pawlby (a2) and F. Happé (a4)...



Research has shown that maternal mental illness can affect mother–infant interactions with implications for infant outcomes. Severe and chronic mental illness (SMI), particularly schizophrenia, is associated with the greatest risk. Schizophrenia is also associated with impairments in attribution of mental states, ‘theory of mind’ (ToM). Recent attachment research has suggested that maternal mentalizing skills are strongly associated with attachment outcome in infants. To date, no research has explored the relationship between ToM and maternal sensitivity in mothers with SMI using standard tests of ToM. The present study was designed as an exploratory study in order to investigate this.


A total of 40 women with SMI in the postpartum period were administered a battery of ToM tasks and general neuropsychological tasks. The women were also filmed in an unstructured play session with their infants, which was coded for maternal sensitivity using the Crittenden CARE-Index.


One ToM task, the Frith–Happé Animations, predicted maternal sensitivity across all diagnoses. There was also an effect of diagnosis, with lower sensitivity observed in women with schizophrenia. ToM impairments did not fully explain the effect of diagnosis on sensitivity. Mothers of girls were rated as being more sensitive than mothers of boys.


The results suggest that ToM is a significant predictor of maternal sensitivity across all mental health diagnoses, extending the results of studies focusing on healthy populations. Clinical interventions emphasizing the importance of understanding the perspective of the infant may enhance maternal sensitivity.


Corresponding author

*Address for correspondence: J. Rigby, D.Psych., South London and Maudsley NHS Foundation Trust, London, UK. (Email:


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Abell, F, Happé, F, Frith, U (2000). Do triangles play tricks? Attribution of mental states to animated shapes in normal and abnormal development. Cognitive Development 15, 116.
Ainsworth, MDS, Blehar, M, Waters, E, Wall, S (1978). Patterns of Attachment. Lawrence Erlbaum Associates: Hillsdale, NJ.
Albertsson-Karlgren, U, Graff, M, Nettelbladt, P (2001). Mental disease postpartum and parent–infant interaction – evaluation of videotaped sessions. Child Abuse Review 10, 517.
Atkinson, L, Raval, V, Benoit, D, Poulton, L, Gleason, K, Goldberg, S, Pederson, D, Moran, G, Myhal, N, Zwiers, M, Leung, E (2005). On the relation between maternal state of mind and sensitivity in the prediction of infant attachment security. Developmental Psychology 41, 4253.
Baron-Cohen, S, Wheelwright, S, Hill, J, Raste, Y, Plumb, I (2001). The “Reading the Mind in the Eyes” test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry 42, 241252.
Benton, AL, Hamsher, K de S. (1989). Multilingual Aphasia Examination. AJA Associates: Iowa City, IA.
Bora, E, Yucel, M, Pantelis, C (2009 a). Theory of mind impairment: a distinct trait-marker for schizophrenia spectrum disorders and bipolar disorder? Acta Psychiatrica Scandinavica 120, 253264.
Bora, E, Yucel, M, Pantelis, C (2009 b). Theory of mind impairment in schizophrenia: meta-analysis. Schizophrenia Research 109, 19.
Bowler, DM (1992). “Theory of mind” in Asperger's syndrome. Journal of Child Psychology and Psychiatry 33, 877893.
Brüne, M (2005). “Theory of mind” in schizophrenia: a review of the literature. Schizophrenia Bulletin 31, 2142.
Castelli, F, Happé, F, Frith, U, Frith, C (2000). Movement and mind: a functional imaging study of perception and interpretation of complex movement patterns. NeuroImage 12, 314325.
Costrafreda, S, Fu, SH, Picchioni, M, Toulopoulou, T, McDonald, C, Kravariti, E, Walshe, M, Prata, D, Murray, RM, McGuire, PK (2011). Pattern of neural responses to verbal fluency shows diagnostic specificity for schizophrenia and bipolar disorder. BMC Psychiatry 11, 18.
Crittenden, P (2004). CARE-Index: Infant Coding Manual. Family Relations Institute: Miami, FL.
Fearon, RMP, Fonagy, P, Schuengel, C, van IJzendoorn, MH, Bakermans-Kranenburg, MJ, Bokhorst, CL (2006). In search of shared and nonshared environmental factors in security of attachment: a behaviour–genetic study of the association between sensitivity and attachment security. Developmental Psychology 42, 10261040.
Fonagy, P, Steele, M, Steele, H (1991). Maternal representations of attachment during pregnancy predict the organisation of infant–mother attachment at one year of age. Child Development 62, 891905.
Goodman, SH, Brumley, HE (1990). Schizophrenic and depressed mothers: relational deficits in parenting. Developmental Psychology 26, 3139.
Harrington, L, Siegert, RJ, McClure, J (2005). Theory of mind in schizophrenia: a critical review. Cognitive Neuropsychiatry 10, 249286.
Hay, DF, Pawlby, S, Sharp, D, Asten, P, Mills, A, Kumar, R (2001). Intellectual problems shown by 11 year old children whose mothers had postnatal depression. Journal of Child Psychology and Psychiatry 42, 871890.
Herold, R, Tenyi, T, Lenard, K, Trixler, M (2002). Theory of mind deficit in people with schizophrenia during remission. Psychological Medicine 32, 11251129.
Hipwell, AE, Kumar, R (1996). Maternal psychopathology and prediction of outcome based on mother–infant interaction ratings. British Journal of Psychiatry 169, 655661.
Hipwell, AE, Goossens, FA, Melhuish, EC, Kumar, R (2000). Severe maternal psychopathology and infant–mother attachment. Development and Psychopathology 12, 157175.
Isabella, R, Belsky, J (1991). Interactional synchrony and the origins of infant–mother attachment: a replication study. Child Development 62, 373384.
Janssen, I, Krabbendam, L, Jolles, J, van Os, J (2003). Alterations in theory of mind in patients with schizophrenia and non-psychotic relatives. Acta Psychiatrica Scandinavica 108, 110117.
Kenny, M, Conroy, S, Pariante, C, Seneviratne, G, Pawlby, S (2013). Mother–infant interaction in mother and baby units: before and after treatment. Journal of Psychiatric Research 47, 11921198.
Langdon, R, Coltheart, M (1999). Mentalising, schizotypy, and schizophrenia. Cognition 71, 4371.
McElwain, NL, Booth-LaForce, C (2006). Maternal sensitivity to infant distress and nondistress as predictors of infant–mother attachment security. Journal of Family Psychology 20, 247255.
Mehta, UM, Bhagyavathi, HD, Kumar, CN, Thirthalli, J, Gangadhar, BN (2014). Cognitive deconstruction of parenting in schizophrenia: the role of theory of mind. Australia and New Zealand Journal of Psychiatry 48, 249258.
Meins, E (2013). Sensitive attunement to infants’ internal states: operationalizing the construct of mind-mindedness. Attachment and Human Development 15, 524544.
Meins, E, Fernyhough, C, Wainwright, R, Gupta, M, Fradley, E, Tuckey, M (2002). Maternal mind-mindedness and attachment security as predictors of theory of mind understanding. Child Development 73, 17151726.
Murray, L, Halligan, S, Cooper, P (2010). Effects of postnatal depression on mother–infant interactions and child development. In The Wiley-Blackwell Handbook of Infant Development (ed. Bremner, J. and Wachs, T.), pp. 192220. Wiley-Blackwell: Hoboken, NJ.
Nelson, HE (1982). The National Adult Reading Test (NART): Test Manual. NFER-Nelson: Windsor.
Pawlby, S, Fernyhough, C, Meins, E, Pariante, CM, Seneviratne, G, Bentall, RP (2010). Mind-mindedness and maternal responsiveness in infant–mother interactions in mothers with severe mental illness. Psychological Medicine 40, 18611869.
Riordan, D, Appleby, L, Faragher, B (1999). Mother–infant interaction in post-partum women with schizophrenia and affective disorders. Psychological Medicine 29, 991995.
Russell, TA, Reynaud, E, Herba, C, Morris, R, Corcoran, R (2006). Do you see what I see? Interpretations of intentional movement in schizophrenia. Schizophrenia Research 81, 101111.
Sharp, C, Fonagy, P (2008). The parent's capacity to treat the child as a psychological agent: constructs, measures and implications for developmental psychopathology. Social Development 17, 737754.
Sharp, D, Hay, DF, Pawlby, S, Schmucker, G, Allen, H, Kumar, R (1995). The impact of postnatal depression on boys’ intellectual development. Journal of Child Psychology and Psychiatry 36, 13151336.
Sidor, A, Kunz, E, Schweyer, D, Eickhorst, A, Cierpka, M (2011). Links between maternal postpartum depressive symptoms, maternal distress, infant gender and sensitivity in a high-risk population. Child and Adolescent Psychiatry and Mental Health 5, 7.
Smith, PB, Pederson, DR (1988). Maternal sensitivity and patterns of infant–mother attachment. Child Development 59, 10971101.
Snellen, M, Mack, K, Traner, T (1999). Schizophrenia, mental state, and mother–infant interaction: examining the relationship. Australian and New Zealand Journal of Psychiatry 33, 902911.
Sprong, M, Schothorst, P, Vos, E, Hox, J, Van Engeland, H (2007). Theory of mind in schizophrenia: meta-analysis. British Journal of Psychiatry 191, 513.
Steadman, J, Pawlby, S, Mayers, A, Bucks, R, Gregoire, A, Miele-Norton, M, Hogan, A (2007). An exploratory study of the relationship between mother–infant interaction and maternal cognitive function in mothers with mental illness. Journal of Reproductive and Infant Psychology 25, 255269.
Tronick, E, Reck, C (2009). Infants of depressed mothers. Harvard Review of Psychiatry 17, 147156.
Wan, M, Penketh, V, Salmon, M, Abel, K (2008). Content and style of speech from mothers with schizophrenia towards their infants. Psychiatry Research 159, 109114.
Wan, M, Salmon, M, Riordan, D, Appleby, L, Webb, R, Abel, K (2007). What predicts poor mother–infant interaction in schizophrenia? Psychological Medicine 37, 537546.
Zobel, I, Werden, D, Linster, H, Dykierek, P, Drieling, T, Berger, M, Schramm, E (2010). Theory of mind deficits in chronically depressed patients. Depression and Anxiety 27, 821828.


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Theory of mind as a predictor of maternal sensitivity in women with severe mental illness

  • J. Rigby (a1), S. Conroy (a2), M. Miele-Norton (a3), S. Pawlby (a2) and F. Happé (a4)...


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