CM has a long documented history of increasing broadband risk for later mental health problems (Anda et al. 2006; Gilbert et al. 2015), including, but not limited to, depression (Caldwell et al. 2011; Muzik et al. 2013; Nanni et al. 2012), suicidality (Muzik et al., 2016a; Oh et al. 2016), and PTSD (Koenen and Widom 2009; Muzik et al. 2016b; Schechter et al. 2005). Depressive symptoms in the peripartum period can have detrimental effects on both mother and baby. For example, during pregnancy, mothers with depression (compared to those without) tend to have less social support, have greater difficulty taking care of themselves, have poorer nutrition, use substances, have more difficulty following doctor’s orders, and have relationship difficulties with their partners (Muzik and Borovska 2010). Related, pregnancies of women with depression have a higher risk for slowed fetal growth, preterm deliveries, and low infant birth weight (Muzik and Borovska 2010). During the postpartum period, maternal depression has been associated with a host of parenting difficulties including lower sensitivity, higher disengagement, higher negative affect, lower warmth, and lower empathic responding (Lovejoy et al. 2000). Children born to mothers with depression show greater physiological, behavioral, and psychological difficulties including elevated cortisol (hormone relevant for stress regulation), higher irritability, lower attentiveness, and greater risk for developmental delays (Deave et al. 2008; Field et al. 2006). It is not surprising that depressive symptoms are a major mechanism through which CM infers risk for later parenting difficulties (Martinez-Torteya et al. 2014).

While depression has been a target of many perinatal investigations, PTSD in CM survivors in the peripartum had received less attention over past decades. The Maternal Anxiety in the Childbearing Years (MACY; NIMH MH080147; PI: Muzik) study was developed to address this very gap. MACY longitudinally followed a cohort of mothers who had encountered CM when growing up to better understand these women’s postpartum adaptation during the transitional time into motherhood. One key aspect within this study was to examine the impact of CM history on PTSD symptoms across pregnancy and the postpartum period (Muzik et al. 2016a). Women provided data on their social, psychological, and parenting adaptation and discussed factors that helped them cope during this transition. Women with CM histories, with demographic risk (e.g., low income, minority, maternal age under 21, un-partnered), and with previous prepregnancy PTSD symptoms were at greatest risk for symptom relapse in pregnancy and postpartum (Muzik et al. 2016a; Oh et al. 2016). Specifically, women who encountered the highest levels of stress/trauma in pregnancy (rather than CM history alone) were at highest risk for PTSD symptom exacerbation. Finally, women whose PTSD symptoms increased across the pregnancy also reported higher depressive symptoms and the greatest self-reported bonding impairment with their 6-week old compared to women whose PTSD symptoms decreased or remained stable across pregnancy (Muzik et al. 2013). Whereas a solid body of literature exists for the impact of perinatal maternal depression on parenting, relatively few studies have examined the potential impact of postpartum PTSD on parenting. Thus, more work on CM, perinatal PTSD, and its effects on motherhood adjustment is needed. In the sections below, we do our best to clarify when we are discussing the impact of CM history vs. current PTSD symptoms on parenting capacity.

Beyond self-reported psychological symptoms, CM also places women at risk for difficulties with the physiological regulation of stress. For example, compared to women without CM, women with CM histories have higher cortisol levels, show altered regulation of cortisol, show differential brain activity in response to parenting-relevant tasks, and show altered heart rate variability (indicator of regulation) during parenting tasks (Brand et al. 2010; Moser et al. 2015; Schechter et al. 2012, 2014). Given the established link between CM and disrupted regulation of stress and other negative emotions, it is not surprising that some studies have found that mothers with CM histories report higher levels of parenting stress compared to mothers who were not maltreated as children (Pereira et al. 2012). However, results are mixed as other studies did not find a direct correlate between CM history and parenting stress (Bailey et al. 2012; Lang et al. 2010). In support of this finding of heightened maternal stress is the fact that women with CM histories (compared to those without) also report greater risk for birth complications, tend to be young/have a young co-parent (under 21), feel isolated, have financial problems, live with someone who has violent tendencies, and often present with low levels of social support (Dixon et al. 2005; Jaffee et al. 2013). Though this list of risk factors may seem discouraging, it offers helpful information regarding who is at risk, how to detect risk, and how to intervene to help promote positive outcomes among women with maltreatment histories. Targeted interventions for mothers with CM experience, e.g., Mom Power (Muzik et al. 2015), are described in more detail in later chapters (see Chapter 11).

An essential domain of parenting is the ability to make sense of one’s past experiences of being parented and to reconcile those experiences with current parenting beliefs and behaviors. One way of assessing the impact of past trauma on current mental representations of oneself and one’s relationships is through the Adult Attachment Interview (AAI; George et al. 1996). During this interview, a mother talks about the quality of her childhood experiences, her past responses to challenging relational times (e.g., rejection, separation, loss, trauma), and how she considers her childhood experiences to impact her current functioning as a mother. Historically, attachment classifications were noted as secure (marked by awareness of how past relationships link with current mental states) or one of two insecure styles—dismissing/detached (marked by forgetting or denial of past experiences) and entangled/preoccupied (marked by confused and unresolved narratives of how the past impacts the present) (Fonagy et al. 1993). In general, mothers with insecure attachment styles from their childhood were more likely to have infants with insecure attachments at 12 and 18 months (Fonagy et al. 1993). More recently, two classifications on the AAI have been identified as common groupings for mothers with trauma histories: unresolved (lack of full/conscious integration of how past trauma has impacted one in the past and present) and hostile-helpless (pervasive identification with hostile and/or helpless caregivers from the past; globally negative evaluation of caregiver and self that remain unintegrated; Lyons-Ruth et al. 2003). In one study with low-income mothers, maltreatment severity was positively associated with hostile-helpless classifications (Lyons-Ruth et al. 2003). Further, mothers with more severe trauma histories reported greater identification with a hostile caregiver, global devaluation of their caregiver, and a greater sense of themselves as bad. Of note, these relations were no longer significant when the impact of parental loss (losing one’s parent before age 16) was accounted for. Another study with adolescent mothers found that abuse severity was associated with increased risk for unresolved trauma (i.e., an attachment category marked by disorganized/disintegrated processing of past loss or trauma when discussing how past relational experiences impact current experience of relationships including parenting) across pregnancy and the early postpartum period (Madigan et al. 2016). Of note, a different study with adolescent mothers found that a maternal unresolved attachment style resulted in reduced benefits of an attachment-based intervention compared to mothers who were not classified as unresolved (Moran et al. 2005). A related concept to maternal attachment-oriented beliefs is the notion of “secure-base scripts,” or cognitive underpinnings of one’s internal working model of attachment. One study with mothers of young children (16 months) did not find that CM history impacted maternal secure-base scripts (Huth-Bocks et al. 2014). In summary, findings to date suggest that for some mothers CM history may heighten one’s vulnerability toward unhelpful mental representations of one’s past caregiving experiences and current role as a mother but also shows that this risk is dynamic and not deterministic and that for other mothers this link is less linear (or not true). In other words, the impact of CM on maternal beliefs may depend on a multitude of risk and protective factors, and more research on the protective factors is needed to understand even better pathways for resilienc oriented beliefs is the notion of e.

Beyond considering how a mother views her past caregiving experiences and how she views her current role as a mother, it is also important to consider how she perceives her child and understands her child’s thoughts, feelings, and experiences. In the context of motherhood, reflective functioning refers to a mother’s capacity to reflect upon her child’s and her own mental states (thoughts, emotions, intentions) and connect those reflections to her child’s behavior as well as her own parenting behavior (Rosenblum et al. 2008). In community samples, maternal reflective functioning has been associated with more adaptive observed parenting behavior (Rosenblum et al. 2008); however, in traumatized samples the findings are mixed. For example, Schechter and colleagues studied a group of mothers with a history of interpersonal trauma and high demographic risk and assessed the role of reflective functioning on parenting outcomes. His group found that among traumatized mothers, more severe PTSD symptoms were associated with a greater likelihood of having negative representations of the parent-child relationship (Schechter et al. 2005), but trauma symptoms were not associated with reflective functioning. Further, higher maternal reflective functioning, regardless of PTSD severity, was associated with a greater likelihood of appreciating the importance of the parent-child relationship for child development. However, later work by this group did not find a significant relation between trauma symptoms, reflective functioning, and observed maternal behavior (Schechter et al. 2008). Schechter’s group concluded that there is more work to be done to understand the link between reflective functioning and parenting behavior in high-risk samples. Similarly, results from the MACY research group did not find a direct link between CM history or current PTSD symptoms and maternal reflective functioning (when child was 16 months old; Huth-Bocks et al. 2014; Stacks et al. 2014). However, unlike the lack of relation between reflective functioning and observed parenting behavior shown by Schechter’s group, the MACY findings did indicate that maternal reflective functioning was associated with higher maternal sensitivity and lower maternal negativity in observed mother-infant interactions (Stacks et al. 2014). Similarly, Ensink et al. (2016) also reported that CM history was unrelated to reflective functioning and that reflective functioning did predict parenting behaviors and child outcomes. More recently, Berthelot and colleagues (Berthelot et al., 2015) proposed the need to assess reflective functioning in interviews that probe directly for the trauma experience in order to appreciate the true value of RF on mental wellness in the context of trauma history. Based on the rather limited research, to date it appears that CM does not appear to directly impact maternal reflective functioning. This offers a message of hope and suggests that survivors of CM have the capacity to be reflective about their child’s mental states.

Maternal perceptions of her child and the bond between mother and child have important implications for the day to day experience of parenting. Not surprisingly, research is mixed on whether and how CM impacts such maternal perceptions. For example, the MACY team found that mothers with CM histories report higher levels of bonding impairment than mothers without CM histories toward their 6-month-old babies; however, the persistence of bonding problems across postpartum was predicted by postpartum psychological symptoms (PTSD and depression) rather than CM history per se (Muzik et al. 2013). Schechter’s group (2010) also reported a significant correlation between maternal PTSD symptoms and self-reported dysfunctional parent-child interactions. Of note, maternal depression was highly correlated with PTSD in their sample (r = 0.80) suggesting that the combination of depression and PTSD symptoms may have explained the results (rather than PTSD symptoms alone). Only few studies report detrimental effects of CM experience, even when accounting for maternal psychopathology. Further, research with community mothers and their 1-year-old child demonstrated that, after controlling for maternal depression and PTSD symptoms, maternal history of emotional abuse was positively related to self-reported dysfunctional infant-parent interactions, whereas maternal history of physical abuse and maternal history of sexual abuse were unexpectedly positively related to self-reported adaptive parent-infant interactions (Lang et al. 2010). Finally, one study found that families which had a caregiver with a CM history (mother, father, or both) reported higher levels of self-reported indifference about their baby compared to families in which neither caregiver had a CM history (Dixon et al. 2005). This finding came from the Child Assessment Rating Evaluation (CARE) program, which was a longitudinal population cohort study that followed thousands of families in Essex, England from 1995 to 1998 (Dixon et al. 2005).

Regarding maternal views of her child’s temperament, results are also mixed. In fact, there is more research to support the notion that CM does not notably alter the ways mothers view their children than to support the notion that CM history biases perceptions. Specifically, the only support found for perception bias comes from the Oregon Youth Study where 206 boys and their parents recruited from the highest crime-rate areas of a medium-sized city were followed (Pears and Capaldi 2001). This research group found that parental abuse history was positively associated with parental perceptions that their young child (0–5 years) is difficult (e.g., colicky, behavior problems, emotional problems). In contrast, more studies have null results. For example, other research has shown that women with and without sexual abuse histories have equitable levels of enjoyment in their relationship with their child (Roberts et al. 2004). Similarly, Lang and colleague’s research with community mothers found no differences in mothers with or without CM histories in their self-report of their infants’ positive affectivity or regulatory capacity. Further, mothers with a significant history of emotional abuse described their infants as demonstrating a lower level of distress and a greater level of regulation compared to mothers without emotional abuse histories (Lang et al. 2010).

Another important domain of parenting is confidence in one’s parenting abilities. Feeling competent and capable is something that most parents likely struggle with from time to time; however, research has shown that mothers with CM histories may be particularly vulnerable to doubt their parenting abilities. For example, one study with mothers of preschool-aged children (4–6 years) found that maternal childhood sexual abuse history was associated with self-reported concerns regarding parenting competence (Bailey et al. 2012). Very relevant to this finding is the fact that in this study, self-reported parenting variables (including concerns about parenting competence) did not relate to observed parenting behaviors. In other words, these mothers perceived themselves as less competent, yet their views of parenting competence were not predictive of actual observed parenting behaviors. Similarly, other research has shown that CM may lower a mother’s confidence and self-efficacy in her parenting skills (Caldwell et al. 2011; Roberts et al. 2004); however, the relation between CM and confidence about parenting is not direct. Rather, CM heightens risk for symptoms of psychological distress (e.g., depression/anxiety), which in turn, lower a mother’s confidence and self-efficacy regarding her ability to be a parent. In a sample of low-income, predominately African-American mothers, Banyard (1997) found that maternal depression and history of childhood neglect predicted maternal hopelessness about future parenting. Further, self-reported maternal parenting satisfaction was predicted by maternal depression and maternal history of physical and sexual abuse. In terms of pathways of effect, Banyard et al. (2003) reported that trauma history lowered parenting satisfaction and that this was best explained as mediated by maternal depression. Despite the fact that some mothers with CM histories doubt their parenting skills and abilities, there is no research to support that women with CM histories differ from women without CM histories in their knowledge of child development or tendency to have unrealistic developmental expectations (Bert et al. 2009; DiLillo and Damashek 2003; Ruscio 2001). Put together, studies such as these suggest that for some mothers, CM has the potential to reduce confidence and hopefulness about parenting; however, not all survivors of CM doubt their parenting abilities. Rather, it seems that mothers experiencing psychological symptoms (namely depression) are at greatest risk for doubting their parenting skills.