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Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.90 no.3 Santiago jun. 2019 


Low quality of mother-child interaction in infants at psychosocial risk is associated with risk of developmental delay

Victoria Binda1 

Francisca Figueroa-Leigh2 

Marcia Olhaberry3 

1 Family Physician. Department of Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Chile.

2 Family Physician, Chile.

3 Psychologist School of Psychology, Pontificia Universidad Católica de Chile, Chile.



Early childhood is a fundamental period in children's development and depends largely on their in teractions with their main caregivers.


To evaluate the association between risk of psycho motor developmental delay (PDD) with mother-child interaction quality, postpartum depressive symptoms, and other factors related to care and environment in healthy infants at psychosocial risk.

Patients and Method:

Analytical cross-sectional study in 181 mothers at psychosocial risk and their children aged under one year seen in Primary Health Care. The presence of risk of PDD was deter mined using the Ages & Stages Questionnaire and its association with interaction quality (CARE In dex), postpartum depressive symptoms (Edinburgh Postpartum Depression Scale), and other factors related to environment and care (questionnaire applied to the mother) was studied through bivariate and multivariate analyses, adjusting for confusing variables.


20% of infants were at risk of PDD. There was an increased risk of presenting risk of PDD after adjusting for predefined control variables with: low-quality mother-child interaction (OR = 2.46, p = 0.03), exclusive breastfeeding (EBF) <6 months (OR = 2.58, p = 0.01), and partner does not help with childcare (OR = 2.97, p = 0.03). No significant association was observed with postpartum depressive symptoms.


In healthy infants at psychosocial risk, low-quality mother-child interaction, EBF <6 months, and the non-involvement of the father in the childcare are associated with a higher risk of PDD.

Keywords: Psychomotor development; mother-child interaction; postpartum depression; risk factors; breastfeeding; psychosocial factors


Child development is a maturation process that de pends on the child’s interaction with others1. The prenatal period to 4-5 years is key to physical, cognitive, and social-emotional development, as it provides the foundation for lifelong development2.

The psychomotor developmental delay (PDD) pre valence in children under 3 years of age in developed countries is between 12-16%3,4. In Chile, according to the latest Quality of Life and Health Survey 2016-175 the prevalence is 9.9% in children under 5 years of age, showing a significant decrease in recent years.

It is very important to detect early PDD since chil dren who do not receive early intervention are more likely to fail in the school system, to have behavio ral problems, low self-esteem, and mental and social health problems such as delinquency, unemployment, and poverty6, with a social and economic impact on the entire society7. At the same time, early detection and intervention have shown effectiveness in impro ving different outcomes such as school performance, quality of jobs, criminal behavior, and school dropout, among others, in addition to a proven reduction in as sociated costs8.

Different risk factors have been described to pre sent PDD9, some of them depend on the characteris tics of the child such as male sex, premature birth, low birth weight, and presence of chronic diseases. Other factors depend on the characteristics of their main ca regivers such as poor quality of interaction with the child, relationship difficulties between parents, men tal health problems, low educational level, and ado lescent parents. Finally, there are context-dependent risk factors such as poverty, poor parenting support, low quality of out-of-home care, and environments that do not stimulate child development. A Chilean study of preschoolers identified that in families where there is greater poverty, no preschool education and/ or illiterate mothers, there is a higher risk of PDD10. Another study in Chilean preschoolers shows higher PDD in children treated in the public health system compared to the private system2. A cohort study con ducted in the United States11 showed that one of the most relevant predictors for an adequate psychomo tor development (PMD) was the mother-child inte raction quality, that is, the more sensitive, responsive, attentive, and cognitively stimulating was the mother during interactions, the better the results obtained in the children’s PMD evaluations. Moreover, a low- quality interaction has been suggested as the possible mechanism by which the characteristics of the pri mary caregivers and the context ultimately impact on the child’s development12.

An example of this is postpartum depression (PPD), considered one of the most influential factors in the mother-child interaction quality and child deve lopment13. This affects the interaction quality and pos sibly impacts on the PMD through this mechanism. The PPD is a prevalent pathology, reported between 20 and 37%(14>15) in the Chilean population, reaching up to 50% in low socioeconomic level sectors16, thus it is relevant for the PDD evaluation.

Considering this background, knowing the factors associated with infantile PDD is crucial for the early identification of children at risk and to intervene on those modifiable factors that allow avoiding the impact of PDD in the long term.


To evaluate the association between PDD risk and a) mother-child interaction quality, b) postpartum depressive symptoms, and c) other factors related to care and context, in healthy infants at psychosocial risk treated in the Primary Health Care (PHC) in Santiago, Chile.

It is expected that both the low quality of interac tion and the presence of postpartum depressive symptoms will be significantly associated with PDD risk, as well as identifying other risk factors related to the care and context of the child.

Patients and Method

Study design

Analytical cross-sectional study.

The data used for this study were obtained from the baseline sample of a randomized clinical study (FONIS SA12/2089), whose objective was to evaluate the effec tiveness of a group intervention17 to increase maternal sensitivity. This study is in the results analysis phase.

Reference population

181 mothers at psychosocial risk and their chil dren under one year of age, treated at the Juan Pablo II and El Roble Family Health Centers (CESFAM) in the commune of La Pintana, Santiago, Chile, between 2013 and 2015. Considering a population prevalen ce of 17% PDD risk, a figure reported in the Ages & Stages Questionnaire (ASQ) validity study in Chile at 8 months of age18, this sample allows us to study the PDD risk prevalence and its associations, with 5.41% of accuracy and 95% confidence level.

The inclusion criteria were mothers at psychoso cial risk with children between 2 and 12 months of age. The psychosocial risk definition is the one used in PHC in Chile, defined as the presence of one or more psychosocial risk factors detected in the first prenatal control through the Evaluación Psicosocial

Abreviada scale (Abbreviated Psychosocial Evalua tion, EPsA)19, the risk factors considered are first control after 20 weeks, < 6 years of schooling, age < 18 years, substances consumption during pregnan cy (tobacco, alcohol, or drugs), victim of domestic violence, conflicts with maternity, insufficient social or family support, and depressive symptoms. The exclusion criteria were mothers with severe mental health pathology (schizophrenia, mental retardation, and mood disorder with active suicidal ideation), children with serious pathologies (genetic diseases, severe heart disease, and extreme prematurity), and/ or severe psychosocial problems (institutionalization of other children history, complaints of sexual and/ or child abuse).


Mothers who met the inclusion criteria were con tacted by telephone in order to invite them to partici pate. Recruitment was carried out in succession in or der to fulfill the number of participants. The selection interview was conducted at the respective CESFAM by professional CESFAM workers, who collaborated with the study. All mothers who attended the selection in terview agreed to participate and signed the informed consent, then completed the assessment instruments.


Ages & Stages Questionnaire (ASQ Second Edition, translated into Spanish)20 was used for the PMD risk assessment. If one or more areas evaluated are < 2SD, the screening is positive and is considered a PDD risk. In Chile, this scale is validated with good psychometric properties18.

For the evaluation of the mother-child interaction quality, CARE-Index was used which consists of the observation and microanalysis of a 3-minute videota pe of free play between mother and child. It delivers a maternal sensitivity score on a 0-14 scale (the higher the score, the better the sensitivity). Scores from 0 to 6 are considered of low-quality interaction. The videos were evaluated by three coders who were trained by the author of the instrument and obtained the reliabi lity test. The intraclass correlation between coders was > 0.9, p < 0.001. The coding was done independently and was blind to the rest of the measurements.

For the evaluation of postnatal depressive symp toms, the Edinburgh Postnatal Depression Scale22 was used, which consist of 10 questions with a maximum score of 30 points. It is validated in Chile16) with good psychometric properties. The cut-off point of > 10 points was used to consider the presence of postpar tum depressive symptoms.

For the evaluation of other PDD risk factors, par ticipants completed a sociodemographic data and care questionnaire, incorporating characteristics of the child, caregivers, and context that might be associated with the presence of PDD (Table 1).

Table 1 Sociodemographic characteristics of the sample and its association with risk of developmental delay in bivariate analysis. 

Ethical Considerations

The study was approved and met the requirements of the Ethics Committees of the Pontifical Catholic University of Chile and the South East Metropolitan Health Service.

Statistical analysis

The sample description was made by mean, stan dard deviation, and proportions. Chi-square, odds ratio (OR), and T-test were used for bivariate analy ses of independent samples, with a significant p<0.05 value. A multivariate logistic regression analysis was performed with those variables of significant associa tion to measure the effect magnitude, adjusting for the following control variables known as PDD risk factors: male sex, adolescent mother (<18 years at the onset of pregnancy), incomplete maternal schooling (<12 years of study), prematurity (gestational age ≤ 37 weeks), hospitalization of the newborn (NB) ≥ 4 days, and age of the child ≤ 6 months. Statistical analysis was perfor med with SPSS software version 17.


The mean age of the mothers was 25.3 years, (ran ging from 14 to 46 years, SD = 7.07), the mean age of the children was 7.39 months (ranging from 2 to 12 months, SD = 2.12). Table 1 shows the socio-demogra phic and care characteristics of the sample.

20.1% (n=36) of the children were at risk of PDD, 57.3% (n= 102) of the mother-child dyads had low quality of interaction, and 46.7% of the mothers (n = 84) had postpartum depressive symptoms.

25.7% of the dyads with low-quality interaction to be at risk of PDD compared to 13.4% of those with adequate interaction quality (Figure 1). This diffe rence is statistically significant (c2 = 4.07, p = 0.04, OR = 2.25, 95% CI [1.01-5.02].

Figure 1 Prevalence of risk of development delay according to the quality of mother-child interaction (n = 181). 

25% of children of mothers with depressive symp toms were at risk of PDD compared with 15.8% of the children of mothers without depressive symptoms. This difference is not statistically significant (c2 = 2.35 p = 0.12, OR = 2.25, 95% CI [0.84-3.72].

As (Table 1) shows, out of the studied variables using the socio-demographic and care questionnaire, in the bivariate analysis the following variables were signifi cantly associated with PDD risk: exclusive breastfee ding (EBF) < 6 months or age at entry to the study, father does not help with child care, and age of the child ≤ 6 months.

When multivariate analysis was performed using logistic regression, adjusting for possible predefined confounding variables (male sex, adolescent mother, incomplete maternal schooling, prematurity, NB hos

pitalization, and age < 6 months) it was observed that a low quality of mother-child interaction, EBF < 6 months, and father not helping with child care increa sed the PDD risk (Table 2).

Table 2 Multivariate analysis of the factors associa ted with the risk of developmental delay in infants at psychosocial risk. 


This study shows a positive association between low-quality of mother-child interaction with the pre sence of PDD risk in healthy infants at psychosocial risk. The low quality of mother-child interaction in creases by 2.4 times the chances of presenting PDD risk by adjusting for variables known by their association with PDD. No significant association was observed between postpartum depressive symptoms and PDD risk. Other detected risk factors in this study were EBF < 6 months or age at entry the study, and lack of invol vement of the father in the child care.

It is confirmed in Chilean mother-child dyads that the presence of low-quality interaction between mother and child in the first year of life is associated with a greater presence of problems in infant develo pment. This association is consistent with the inter national literature where insensitive parenting in the first year of life is associated with worse cognitive and social outcomes until at least 48 months of age23,24. On the other hand, the quality of interaction presents high stability from the first year of life12,25, influencing from such an early age on developmental outcomes to fu ture.

The importance of the father in child development is increasingly studied26, single-parent families are recognized as a risk factor for PDD11. In our study, the presence of the father at home was not the variable associated with PDD, but the father involvement with child care. This could be similar to studies that evalua te the good quality of father-child interaction23 as very relevant to developmental outcomes.

The absence of association between postpartum depressive symptoms and PDD in our sample may be given mainly by two reasons: 1) lack of sufficient n to find the difference, and 2) being a cross-sectional stu dy and in young infants. The presence of depressive symptoms in the mother does not yet visibly affect the child’s PMD, but their effect could be found later in children, as observed in the cohort studied by Lung et al.27, which did not show association between maternal mental health and PDD at 18 months of age, but did at 36 months.

It is important to consider that the factors of care and context are interrelated11, a mother who has a supportive partner in child care has less stress and less likelihood of depressive symptoms. In this way, the mother is more likely to have good quality interactions with her child that are stimulating for his or her development.

In relation to the evaluated care factors, the asso ciation found between PDD risk and EBF < 6 months is very interesting, which is also supported by the li terature. There are studies that demonstrate a linear

“dose-response” type association between the EBF du ration and motor and cognitive development, where this relationship is independent of the characteristics of children and their parents28,29.


For this study, the ASQ scale was used in its second edition in Spanish, which is not the same adapted and validated version of this questionnaire in Chile20, sin ce, at the time of study recruitment, the results of the validation were not yet available. There is no direct interaction assessment of the father or another care giver relevant to the child, which would be ideal, as its developmental relevance is studied and it can act as a buffer in the event of inadequate interaction with the mother23. There are limitations due to it is a cross-sec tional study; we only observe the association between the variables, we do not know how the quality of the interaction and depressive symptoms observed influence the PMD of these children in the future, although the literature guarantees their stability over time. Also, we do not know if the low quality of the observed interaction is partly given by the presence of PDD. In the literature, it is proposed that this influence is reciprocal since the interaction is more challenging with a child who does not present the expected development25. The results come from a sample of low socioeconomic level and at psychosocial risk, so they are not generalizable to the entire population.

The results of this study are relevant to the public policies of our country. Since it is a sample coming from a context of psychosocial risk, it is necessary to know which are the factors associated with PDD, espe cially those that are modifiable through appropriate in terventions, such as those found in this study: promo ting the quality of mother-infant interaction, encou raging the involvement of the father in the child care, and promoting when possible the EBF for 6 months. On the other hand, it is necessary to incorporate within the care provided to children detected with PDD the evaluation of quality of mother-child interaction and offer interventions that promote maternal sensitivity to achieve improvement in developmental outcomes. There are several studies showing that interventions can be effective in increasing maternal sensitivity30.

Studies are required to show that interventions focused on increasing maternal sensitivity directed at children with PDD show better results in their long term development.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regulations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Financial Disclosure: The present study was funded by FONIS (Chilean Na tional Fund for Health Research) FONIS SA12 | 2089 project. FONIS did not influence the design of the stu dy; in the collection, analysis or interpretation of data; nor in the preparation, revision or approval of this ma nuscript.

Aknowledgments: We would like to thank the mothers and children who participated in this study, the Health Centers Juan Pa blo II and El Roble of La Pintana and Patricia López, Paula Ramírez and María Isabel Moya who collabora ted with the research.


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Received: June 18, 2018; Accepted: November 29, 2018

Correspondence: Victoria Binda. E-mail:

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