THE DEVELOPMENT and VALIDATION of an OBSERVATIONAL CODING SYSTEM for REAL-TIME PARENT-ADOLESCENT MENTALIZING by Salome Vanwoerde

THE DEVELOPMENT AND VALIDATION OF AN OBSERVATIONAL CODING SYSTEM FOR REAL-TIME PARENT-ADOLESCENT MENTALIZING

by Salome Vanwoerden

A dissertation submitted to the Department of Psychology, College of Liberal Arts and Social Sciences in partial fulfillment of the requirements for the degree of

Doctor of Philosophy

in Psychology

Chair of Committee: Carla Sharp, PhD

Committee Member: Barbara De Clercq, PhD

Committee Member: Stephanie Stepp, PhD

Committee Member: Paras Mehta, PhD

Committee Member: Julia Babcock, PhD

University of Houston May 2020

DEDICATION This dissertation is dedicated to my parents, Cas and Gita Vanwoerden. Nobody works harder to do what they love more than you, beyond any obstacles that are placed in your way. You both have always encouraged me to chase my dreams, whatever they may be, and believed in me completely that I could achieve them. With your support, everything seems possible and yet it is a constant source of comfort to know that you will accept me for whatever I choose. Thank you.

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ACKNOWLEDGMENTS There are a number of people that I owe my most sincere gratitude for their support in completing this project. First and foremost, I would like to thank my advisor, Dr. Carla Sharp, for providing guidance throughout my PhD. Thank you for opening so many doors for me and allowing me to chase big ideas while reigning me in when I’ve gone too far. I am ever grateful for our intellectual conversations and I look forward to opportunities to continue this collaboration. Thank you to Daniel Paulus for being my rock through this graduate school experience. I appreciate your encouragement when I need the motivation, your ear when I need support, and the enthusiasm when it is time to go on an adventure. This research would not have been possible without the tireless work of the graduate students in the Developmental Psychopathology Lab: Francesca Penner, Kiana Wall, Jake Leavitt, Ronnie McLaren, Eric Sumlin, Jessica Hernandez, and Sophie Kerr. Francesca, Kiana, Ronnie, and Eric dedicated many hours to code the data. All graduate students, in addition to research assistants Miana Graves, Estrella Godinez, Samantha Annab, Lauren Palmer, Frances Saubon, Dakota Broadway, Caroline Pearson, and Kathleen DiBacco, helped recruit and assess participants as well as manage many organizational aspects of the study. A special thank you to Francesca and Kiana for being an ever-helpful sounding board for ideas and thoughts while running this study. I appreciate the care that you put into this study. Dr. Laurel Williams facilitated our team’s access to the Texas Children’s Hospital Outpatient Psychiatry Clinic in order to recruit a large proportion of our sample. Dr. Karyn Hall provided access to the Dialectical Behavior Therapy Center of Houston for recruitment. This project would not have been possible without their support. Dr. Stephanie Stepp also generously made her data available for the development study. I would also like to thank my funding sources, including the NIMH with an F31 predoctoral training fellowship and APA’s Division 53 with the Routh Dissertation Award. Last but not least, I would like to acknowledge all of the families who participated in these studies.

ABSTRACT Mentalizing, or the ability to attribute mental states to the self and others and to understand how mental states affect behavior, forms the basis of humans’ capacity to build and maintain relationships with one another. Mentalizing deficits can be categorized as hypermentalizing or hypomentalizing and are found in a range of pathology, contributing to poor psychosocial functioning. Adolescence is a key developmental period in the study of mentalizing given dramatic changes in the adolescent social brain that coincide with social reorientation. Despite the importance of mentalizing for adolescent mental health, existing tools assess mentalizing as a stagnant property of a single individual, relying mostly on non-self-referential stimuli or hypothetical scenarios. Further, existing tools fail to account for the developmental origins of mentalizing, which are based in the parent-child relationship. Across two studies, we addressed this gap by developing (Study 1) and evaluating (Study 2) a coding system that can measure mentalizing as it occurs during a real-time parent- adolescent interaction. In Study 1, archival data of parent-adolescent dyads participating in a conflict-discussion paradigm were used to develop a coding manual and evaluate reliability and face validity. In Study 2, we tested the validity of the coding system against existing measures of mentalizing, interpersonal problems, relationship quality, and borderline personality disorder in a sample of 72 outpatient adolescents and their mothers. Results demonstrated that the coding system was reliable across raters and face valid. Furthermore, convergent validity with a task- based measure of mentalizing (but not self-report or narrative-based mentalizing) was demonstrated. Quality of observed mentalizing in the dyad converged with

relationship quality of the dyad. Lastly, low quality mentalizing as assessed with the observational coding system was associated with adolescents’ borderline personality features, particularly for those who were highest in severity. In conclusion, this is the first observational measure of real-time mentalizing based in the parent-adolescent relationship, which can be reliably and validly used to advance clinical and research interests.

TABLE OF CONTENTS

DEDICATION ...... III ACKNOWLEDGMENTS ...... IV ABSTRACT ...... V LIST OF TABLES ...... VIII LIST OF FIGURES ...... IX I. INTRODUCTION ...... 1 Background and Significance ...... 1 The Current Study ...... 10 II. STUDY 1...... 12 THE DEVELOPMENT OF AN OBSERVATIONAL CODING SYSTEM FOR MOTHER-ADOLESCENT MENTALIZING .... 12 Methods ...... 13 Results ...... 18 III. STUDY 2 ...... 19 AN EMPIRICAL EVALUATION OF AN OBSERVATIONAL CODING SYSTEM FOR ADOLESCENT MENTALIZING ...... 19 Methods ...... 21 Results ...... 32 IV. GENERAL DISCUSSION ...... 48 Limitations, Strengths, and Future Directions ...... 63 REFERENCES ...... 66 APPENDICES ...... 97 A. OBSERVATIONAL CODING SYSTEM...... 97

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LIST OF TABLES

Table 1. Interrater reliability and descriptive statistics for observational codes ...... 124 Table 2. Correlations and descriptive statistics for main study variables (focused on adolescent variables) ...... 125 Table 3. Correlations and descriptive statistics for main study variables (focused on mother variables)...... 126 Table 4. Correlations and descriptive statistics for main study variables (focused on dyadic variables) ...... 127 Table 5. Results from APIM model with forms of maladaptive mentalizing ...... 128 Table 6. Results from APIM models with forms of maladaptive observed mentalizing and total MASC scores ...... 129 Table 7. Linear regression predicting borderline symptoms from indicators of mentalizing including MASC error scores ...... 130

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LIST OF FIGURES

Figure 1. Theoretical model of mentalizing ...... 131 Figure 2. Significant results from APIM model with forms of maladaptive mentalizing ...... 132 Figure 3. Significant results from APIM model with MASC total score and maladaptive observed mentalizing...... 133 Figure 4. Simple slopes analysis of the effect of adolescent-reported borderline features on observed mentalizing at different levels of mother-reported borderline features ...... 134

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I. INTRODUCTION The NIMH Research Domain Criteria (RDoC) project has defined Systems for

Social Processes as one of the five domains that stand to reclassify psychopathology in terms of the underlying dimensions of observable behavior and neurobiological measures (Insel et al., 2010). Systems for Social Processes include mechanisms representing individuals’ experience of interpersonal events. The purpose of this dissertation was to develop and test an observational coding system to evaluate one particular example of systems for social processes: mentalizing. Mentalizing is an important psychological mechanism that has implications for both healthy and atypical functioning. In fact, mentalizing impairments have been observed in a wide range of psychopathology, with theory suggesting that has a key role in the development of these pathologies (Luyten et al., 2020). Given that adolescence is a particularly sensitive period in the development of psychopathology, the current study focused on this developmental phase. Furthermore, mentalizing is fostered in the context of parent-child interactions, although existing measures of mentalizing fail to account for the dynamic and interactional basis of mentalizing. By introducing an innovative, ecologically valid method to assess mentalizing within the attachment context, an important gap in existing measurement methods will be filled, improving future research and clinical work.

Background and Significance Definitions

Mentalizing is a social-cognitive construct that refers to the capacity to think about and reflect on mental states of the self and other and to understand others’ behaviors based on the underlying mental states that drive them, which includes desires, thoughts, feelings, and wishes (C. D. Frith & Frith, 2008, 2012; U. Frith &

Frith, 2003). Mentalizing is often used interchangeably with theory of mind. However, mentalizing is a broader concept referring to the metacognitive capacity to reflect on internal states (Fonagy et al., 2011). Mentalizing is a multidimensional construct, with heterogenous forms of impairments. However, these impairments overall present as an inability to think about or accurately identify mental states underlying observable behavior, either in the self or others (Abu-Akel & Shamay-Tsoory, 2011). As detailed below, mentalizing is relevant for a wide range of outcomes across the lifespan, both in terms of healthy social and cognitive processes, and in relation to psychopathology.

Implications for typical development

Individual differences in mentalizing ability relate to a variety of important social and cognitive developmental outcomes among healthy youths. In the social domain, mentalizing longitudinally predicts social competence (Devine et al., 2016) as well as the quality (Bosacki, 2015) and number (Fink et al., 2015) of social relationships. Cross-sectionally, mentalizing relates to the quality of social relationships (Hughes & Leekam, 2004) and peer acceptance (Caputi et al., 2012;

Slaughter et al., 2015). In the academic domain, mentalizing predicts reading comprehension ability (Guajardo & Cartwright, 2016) and is associated with school adjustment (Dunn, 1995; Dunn et al., 2002) and academic competency (Eisenberg et

al., 2005). It is notable that these associations exist when controlling for language or verbal ability, which is predictor of mentalizing development (Astington & Baird,

2005). Finally, mentalizing has been linked with other important psychosocial outcomes such as aggression (Gomez-Garibello & Talwar, 2015; Kokkinos et al.,

2016), empathy (Bensalah et al., 2016; Bruneau et al., 2015; Dvash & Shamay-Tsoory,

2014), and emotion regulation (Fonagy et al., 2004; Hudson & Jacques, 2014).

Clearly, mentalizing represents an important mechanism in socioemotional development and relates to a range of important outcomes. Individual differences in mentalizing have been shown to relate to gender and age. Females typically outperform males on mentalizing tasks (Devine & Hughes, 2013; Krach et al., 2009), although this differences appears to decrease with age (Charman et al., 2002). Overall, mentalizing ability increases with age through adolescence when age-appropriate tasks are used (Dumontheil et al., 2010; Keulers et al., 2010) as cognitive abilities and language develop.

Implications for psychopathology

Aligned with the RDoC approach to highlight transdiagnostic mechanisms, mentalizing deficits are found in a wide range of disorders including autism spectrum disorders (Hutchins et al., 2016; Kimhi, 2014; Peterson et al., 2016; Schuwerk et al.,

2015), mood disorders (Bora, Bartholomeusz, et al., 2016; Epa & Dudek, 2015;

Montag et al., 2010), anxiety disorders (Buhlmann et al., 2015; Hezel & McNally,

2014; Washburn et al., 2016), eating disorders (Laghi et al., 2014), schizophrenia spectrum disorders (Clemmensen et al., 2015; Ho et al., 2015; Popolo et al., 2016;

Rominger et al., 2016), personality disorders (Herpertz et al., 2014; Lazarus et al.,

2014; Sharp & Vanwoerden, 2015; Vonk et al., 2015), and neurodegenerative disorders (Bora et al., 2015a, 2015b; Bora, Velakoulis, et al., 2016; Moreau et al.,

2016; Raffo De Ferrari et al., 2015). While deficits are heterogeneous across these disorders, mentalizing partially accounts for deficits in interpersonal functioning that contribute to psychological distress (Venta & Sharp, 2015). To better classify heterogeneous deficits, a taxonomy of mentalizing has been developed that classifies deficits into two different dimensions: hyper- and hypo -mentalizing, which describe the degree of mental state attribution (Badcock & Crespi, 2006; Crespi & Badcock,

2008; Gambin et al., 2015). Hypermentalizing refers to over-attribution of mental states in which individuals attribute mental states to others in absence of objective data to support these attributions. This often leads to misunderstandings that not only undermine interactions, but the development of close interpersonal relationships (Bo et al., 2017; Sharp, Pane, et al., 2011). On the other side, hypomentalizing refers to lack of reference to mental states altogether and a reliance on physical or concrete attributes of others’ behaviors (Dziobek et al., 2006). Illustrated in Figure 1, a model of mentalizing has been developed, which suggests that, similar to cognitive performance

(e.g., Mayes, 2006), mentalizing performance depends on the level of arousal, such that accurate mentalizing occurs under optimal levels of arousal and impairments are more likely to occur when arousal is either high or low (Gambin et al., 2015).

Therefore, although not typically achieved in standard mentalizing tasks, in order to comprehensively assess mentalizing deficits, it is imperative to induce and/or measure

levels of arousal. Initial research utilizing this taxonomy has demonstrated that borderline personality disorder (BPD) is uniquely related to hypermentalizing (Sharp,

Pane, et al., 2011; Vaskinn et al., 2015) and psychosis (Langdon et al., 2005), while psychopathy and autism relate to hypomentalizing (Fretland et al., 2015; Montag et al.,

2010). A method for evaluating the full taxonomy has been created with the Movie

Assessment for Social Cognition (Dziobek et al., 2006); although limitations of this measure exist as discussed below.

Adolescence as a sensitive period of social-cognitive development and change

While the majority of research on mentalizing deficits has focused on infancy and early childhood, it is now clear that the neural regions underpinning mentalizing undergo significant functional development during adolescence (Vetter et al., 2014), which warrants a specific focus of mentalizing during this phase. Findings of continued neural development during adolescence is complemented by behavioral research showing there are concurrent increases in self-consciousness, greater complexity of peer relationships, and a greater emphasis placed on these relationships

(Steinberg & Morris, 2001). Ultimately, optimal development of mentalizing is especially salient during adolescence when significant neural development coincides with unique challenges in the social environment (Blakemore & Mills, 2014).

Therefore, mentalizing impairments may put adolescents at greater risk for experiencing psychopathology due to the difficulty these adolescents may have in navigating their changing social worlds. This is especially relevant because adolescence is also a crucial period in the onset of psychopathology. Approximately

50% of individuals in the United States will meet criteria for a psychiatric disorder in their lifetime with the first onset occurring in childhood or adolescence (Kessler et al.,

2005). 46.3% of adolescents report a psychiatric diagnosis and are 90% more likely to use mental health services than children according to NIMH and CDC (Merikangas et al., 2010). It is crucial to examine processes associated with mental health to assist in appropriate identification and intervention during this sensitive phase.

Assessment of mentalizing

Task-based assessments of mentalizing are the gold standard method of measurement. These tasks take the form of short stories or vignettes (Fiske, 1991), sometimes illustrated with cartoons (Baron-Cohen, 1994; Happé, 1994), acted out with puppets (Pears & Moses, 2003), or with videos (such as the MASC; Dziobek et al., 2006; McDonald, 2012); recognizing emotions from facial expressions (Ekman &

Friesen, 1976), the eye region of faces (Baron-Cohen et al., 2001), whole body displays (Lorey et al., 2012), and audio recordings (Rutherford et al., 2002). Other tasks have been developed that require subjects to take the perspective of another while following instructions or taking part in a cognitive task (Symeonidou et al.,

2015). Finally, another class of measures is the coding of mentalizing from narrative reports or interviews (Ensink et al., 2001; Fonagy et al., 1998).

Despite the number of previously validated instruments to assess mentalizing, there are some noted limitations for existing tasks. First, standard tasks tend to suffer from ceiling effects when abilities are relatively developed as they are among adolescents and adults (Slaughter & Repacholi, 2003). Second, mentalizing tasks often

do not capture the social demands present in real-time interpersonal interactions as they tend to require subjects to explicitly reason about mental states or reflect on mental states of others (Child and Adult Reflective Function Scales; Ensink et al.,

2001; Slade, 2005), which differs from the automatic perception of and response to others during interactions (Klin, 2000). Additionally, in using hypothetical scenarios to assess mentalizing (e.g., videos of fictional characters such as the MASC), social situations are not relevant to subjects; in fact naturalistic social interactions activate multiple neural systems critical to interpersonal interactions that are not activated when perceiving more constrained, artificial stimuli used in traditional tasks (Redcay et al., 2010). Finally, it is the case that mentalizing impairments in some populations may only be present in situations eliciting high emotional arousal (Sharp &

Vanwoerden, 2015) and that ‘neutral’ testing situations of a laboratory may not replicate emotional situations present in interpersonal interactions (Brüne & Brüne-

Cohrs, 2006).

While a few tasks have been developed that assess for mentalizing ability in real-time (Dumontheil et al., 2010), these only require subjects to keep another’s perspective in mind while making non-social decisions. There is clearly a gap for assessment tools that capture mentalizing as it occurs in real-time during interpersonal interactions. Zaki and Ochsner (2009) have summarized the ways in which real-life social information differs from lab-based artificial stimuli: first, social cues are multimodal, including visual, semantic, and prosodic information; they are dynamic, with information to be integrated being presented serially or simultaneously; and

finally, they are contextually embedded such that perceivers tend to have access to information, such as past behavior, that informs their interpretation of social cues.

Therefore, research must begin to study mentalizing as it occurs during interactions; one method to accomplish this is systematic behavioral observation, which has the ability to capture how mentalizing functions within ongoing interpersonal interactions by coding the presence of predefined behaviors in the context of a predetermined paradigm (Bakeman & Gottman, 1997).

Of note, parent-adolescent interaction paradigms have frequently been used to observe dynamics that cannot be measured comprehensively with standard task-based methods. Some of the parent-adolescent dynamics that have been measured using observational coding systems of parent-adolescent interactions include parenting behaviors (e.g., praise; Hill et al., 2008), parent and adolescent affect (Hops et al.,

1995), support-validation (Furman & Shomaker, 2008), quality of communication (J.

P. Allen et al., 2000), relationship quality (Lyons-Ruth et al., 2005), and more recently, aspects of synchrony, or mutuality (Lindsey et al., 2008). These are coded from parent-adolescent interactions that take place in the laboratory. Specifically, parent-adolescent dyads are instructed to discuss pre-specified topics, which either fall into the domain of conflict discussion, problem-solving, or pleasant activity planning; however, conflict discussion tasks tend to achieve greater levels of emotional salience

(Fosco & Grych, 2013). Despite the insight that these assessments have provided for parent-adolescent dynamics, there is clearly a gap for assessing social cognition, or attention to the internal states between parents and adolescents, in the context of

emotionally charged interactions.

We were particularly interested in the use of parent-adolescent conflict as a context from which to evaluate mentalizing. For one, previous studies of parent- adolescent dynamics related to psychopathology have relied on conflict paradigms for observational coding (e.g., Dixon-Gordon et al., 2015; Kaufman et al., 2019). Parent- child conflicts occur more frequently as offspring enter adolescence and represent an important context in which parents employ socialization strategies (Branje, 2018).

Lastly, as opposed to more neutral interactions, conflict discussions are successful in eliciting stress and negative affect (Thomas et al., 2017), which puts a strain on mentalizing capacity (Fonagy & Bateman, 2008). That being said, it is during these moments of interpersonal conflict that mentalizing is crucial to resolve conflict and maintain relationship closeness, but also for parents to socialize positive mentalizing capacities for their children. In sum, eliciting high arousal is an ideal context to put mentalizing to the test.

Centrality of the parent-adolescent relationship to the development of mentalizing

It has long been noted that the environment plays a large role in facilitating children’s mentalizing development, particularly the parent-child relationship

(Carpendale & Lewis, 2004). Fonagy and colleagues (1991; 2007) introduced a developmental theory of mentalizing, which conceptualizes attachment relationships as the developmental context for the emergence of mentalizing. Specifically, when attachment figures attend to their child’s internal states, they inevitably contribute to

the creation of a second-order representation of these states that ultimately permits manipulation and regulation of mental states, and forms the foundations for individuation. Over time, these interactions foster the child’s mentalizing skills with improved competencies in navigating the social environment.

Empirically, the link between quality of the parent-child relationship and growth in infant and child mentalizing has been well supported (Dykas & Cassidy,

2011; Vanwoerden et al., 2015); however, the value of parental attention to youth mental states during adolescence, a time of a substantial growth spurt in mentalizing

(Blakemore, 2010; Mills et al., 2014), for the development of this capacity has not been an extensive focus of inquiry (however, see Quek et al., 2018). During this developmental phase marked by significant neurobiological maturation and environmental reorganization (Blakemore, 2008), the form and content of parent- adolescent interactions change, although the influence of the parent-child relationship remains significant for children’s psychosocial development (Laursen & Collins,

2009). Particularly, maternal relationships have been shown to be closer and more engaged (Smetana et al., 2006) as well as more trusted (Mayseless et al., 1998) than paternal relationships. However, the significance of quality of maternal-adolescent mentalizing for the development of adolescents’ own mentalizing ability is unknown.

The Current Study

In sum, guided by a well-established model of mentalizing (Figure 1; Badcock

& Crespi, 2006; Crespi & Badcock, 2008; Gambin et al., 2015), we developed, in a first study, a novel observational coding system in order to evaluate the overall quality

of mentalizing demonstrated by adolescents and their mothers as well as to qualify the types of mentalizing impairments as either hypermentalizing or hypomentalizing.

Observational coding was designed to take place in the context of a parent-adolescent conflict discussion task, given the role of the attachment context in the development and maintenance of mentalizing discussed earlier. Also, by utilizing a conflict discussion task, it was possible to elicit variable levels of emotional arousal in order to observe deficits in mentalizing that may not otherwise be detected in a neutral situation.

In a second study, a psychometric focus was taken on the coding system by evaluating interrater reliability and convergent validity with existing measures of mentalizing and related constructs. We further addressed construct validity by testing the incremental validity of observed mentalizing in predicting adolescent borderline personality features, above and beyond associations with existing measures of mentalizing. Borderline personality disorder (BPD) was used as an “example disorder” for where mentalizing capacity goes awry. Given that BPD is conceptualized as an attachment-based disorder (Agrawal et al., 2004), it is not surprising that it is characterized by impairments in mentalizing (Fonagy & Luyten, 2009; Lazarus et al.,

2014). It is within attachment contexts that individuals with BPD are most susceptible to failures in mentalizing. However, given the transdiagnostic status of mentalizing and consistent with an RDoC perspective, the ultimate goal was to develop a mentalizing task to assess mentalizing in a variety of disorders to identify and assess a malleable treatment target within Systems for Social Processes. Current interventions

for adolescent psychopathology explicitly target the parent-adolescent relationship

(e.g., Dialectical Behavior Therapy; Rathus & Miller, 2000) and mentalizing capacity

(e.g., Mentalization Based Therapy; J. G. Allen & Fonagy, 2006). However, the purported mechanism of change has never been explicitly assessed and these interventions would benefit from a thorough assessment of parent-adolescent mentalizing.

II. STUDY 1

THE DEVELOPMENT OF AN OBSERVATIONAL CODING SYSTEM FOR

MOTHER-ADOLESCENT MENTALIZING

Study 1 addressed the development of an observational coding system to assess mentalizing during a real-time parent-adolescent interaction. Towards this end, archived videotapes of mother-adolescent conflict paradigms were used to develop a mentalization-based coding scheme guided by Bakeman and Gottman’s (1997) approach to observational coding system development. A well-established taxonomy of mentalizing was used to code mentalizing deficits in the form of hypermentalizing and hypomentalizing in addition to positive indices of mentalizing among each individual and lastly, a scale indicating the quality of dyadic mentalizing. Attention was paid to differences in mentalizing presentation based on demographic characteristics including ethnicity/race, gender, and age. Next, face validity was evaluated by a network of mentalization-based experts and adjustments to the coding system were made based on their feedback. Lastly, reliability was evaluated on 20

videotapes. It was hypothesized that adequate interrater reliability (intraclass correlation coefficient > .70) and face validity would be reached.

Methods

Participants and Procedures

Existing videotapes from a previous study, the study of Emotional and

Personality Development in Youth (EPDY; R01MH101088), conducted by Dr. Stepp at the University of Pittsburgh, were used. Forty parent-child dyads were randomly selected from the larger set of participants who participated with their female caregiver. Children selected for the current study ranged in age from 12-13 (Mage =

12.60, SD = .50) and were 55% female. Reported racial composition for children was

50% White, 40% Black, and 10% biracial. One child identified as Hispanic/Latino.

Children were recruited from pediatric primary care and ambulatory psychiatric treatment clinics in Pittsburgh. Mothers ranged in age from 26-53 (Mage = 40.65, SD =

6.92) and were 55% White, 40% Black, and 5% Asian. One mother identified as

Hispanic/Latina.

The EPDY study was a larger longitudinal study taking place over three evenly spaced assessments across 27 months. During each assessment, participants came into the lab to complete interviews, questionnaires, and a parent-child interaction task.

Included in this task was a videotaped conflict discussion task with their caregiver, which was the focus of the current study and is described in more detail below. All study procedures were approved by the appropriate institutional review board as well as the Clinical and Translational Science Institute (CTSI) pediatric practice-based

research network. Both youth and parents provided written informed consent and were compensated for their time.

Conflict Discussion Task. Caregivers and adolescent offspring were videotaped while completing a structured conflict discussion task in the laboratory

(Hot Topics Task; O’Connor, Hetherington, Reiss, & Plomin, 1995). Chosen due to the properties of the task, this task elicits high levels of arousal in both members of the dyad. Prior to engaging in the conflict discussion, parents and adolescents completed a checklist of common areas of conflict between parents and adolescents. Each topic was rated independently by caregivers and adolescence for both the intensity and frequency. Next, a research assistant chose two topics, which were rated highest by both caregivers and adolescents in terms of intensity and frequency. While the information about frequency and intensity ratings as well as which topics were chosen for discussion, it was not entered into our database1 and therefore we are not able to report descriptive characteristics about the topics chosen by dyads. Next, caregivers and adolescents were instructed to discuss the topic chosen for 8 minutes, with the instruction of trying to resolve the conflict. These interactions have been used frequently to assess patterns of interactions between parents and adolescent children

(e.g., Furman & Shomaker, 2008).

Coding system development. To develop the coding system, we followed

Bakeman and Gottman’s (1997) outline for developing observational methods.

1 A committee member advised that we describe the conflict discussion topics chosen in terms of intensity and frequency; however, by the time this recommendation was made, the University of Houston had closed down its buildings to non-essential activity due to COVID-19 and thus data was not able to be retrieved and entered. 14

Specifically, sequential behaviors were identified to evaluate the presence and quality of mentalizing by individual members of the dyad while considering both content and affect. Informed by coding systems designed to assess mentalizing from narrative interviews (e.g., the PRFS; Slade et al., 2015), as well as theoretical and clinical descriptions of mentalizing, an outline of the types of mentalizing behaviors were created. Specifically, we considered types of maladaptive mentalizing such as hyper and hypomentalizing, but also the polarities of mentalizing, which was proposed by

Fonagy and Luyten (2009). We included clinical descriptions of the ways in which mentalizing can break down (pretend mode, certainty, teleological mode) from manuals of Mentalization Based Therapy (e.g., Bateman & Fonagy, 2004). Also, from these sources, we compiled a list of indications that mentalizing is being engaged optimally (e.g., maintaining a curious stance, flexibility, relaxed nature). Using this as an outline, Ms. Vanwoerden watched 40 randomly selected archived videos from the

EPDY dataset and qualitatively analyzed interactions to develop a catalog of behavior codes falling under each of these categories. From these lists and in discussion with collaborators and mentors, the number of codes were broken down in order to achieve relatively independent codes while also reducing redundancy across codes. It was important to maintain a minimal number of codes as to not overwhelm coders. A total of seven codes were developed: three codes for mothers, three codes for adolescents, and a final dyadic code. The three individual codes were the same across mothers and adolescents and consisted of a code for positive indications of mentalizing (such as maintaining a curious stance, being open to the perspective of the other, use of mental

state language, complexity of language, balancing a focus of the self and other), hypermentalizing (e.g., making assumptions about the mental states of others, particularly in assuming malintent; over certainty about one’s perspective; hostility; automatic reactions to perceived intentions of the other), and hypomentalizing (e.g., lack of mental state consideration, focus on concrete and observable facts of a situation, rigidity about the structure of the conversation versus considering the information being provided by the other person in the moment). Our scale of dyadic mentalizing quality was based on how well the members of the dyad relayed information between each other. Indications for this scale included sharing positive affect, back and forth of dialogue, and an attempt to reach a shared perspective (versus reaching a concrete resolution).

In creating the manual, multiple ways to code data were considered. First, following Rosenblum’s (Rosenblum, 1978) stages of creating a coding system, narrative summaries of conflict discussion were written. From these descriptions, a decision was made to follow a global coding scale, which is similar to other coding schemes for mentalizing (e.g., the Child Reflective Function Scale; Ensink et al.,

2001). This would entail that a single score is assigned for each scale that summarizes the extent to which each of these forms of mentalizing were being displayed over the course of the interaction. Given that mentalizing is a relatively transparent process, using a global scale would require coders to consider multiple sources of information

(behaviors of one individual as well as reactions from the other person, content of discussion as well as nonverbal behavior) and combine this information with their

knowledge and familiarity of mentalizing and the specific codes in the system. After qualitative analysis was completed, a draft of the coding manual was presented to a series of experts in the field mentalizing. Feedback was provided and relevant changes to the manual were made.

Coder training. Upon finalizing the manual, a team of four graduate students were trained to use the manual following procedures informed by published standard approaches to training coders (Bakeman & Gottman, 1997; Margolin et al., 1998).

Coders were trained and supervised closely by Ms. Vanwoerden throughout the whole training and coding process. Before training, all coders were instructed to review the coding manual to familiarize themselves with codes. Then, in an extended initial training consisting of two days of approximately 3-hour lectures by Ms. Vanwoerden, codes were described, distinctions between codes were highlighted, and applicable decision trees were presented. Further, 5 archived videos were watched and coded as a group. After this initial training period, coders were each assigned 10 archived videos that were pre-coded by Ms. Vanwoerden and were required to code these videos at the predetermined level of interrater reliability before they started coding for the validation sample. Through this process, coders were provided with feedback. Further reliability meetings took place on a bi-weekly basis through the duration of the study.

All training and reliability meetings were conducted in a group format in order to encourage coders to discuss questions and clarifications.

Data Analytic Strategy

We relied on qualitative analysis of existing videotapes of parent-adolescent conflict discussion (described above), as well as an evaluation of face validity with a series of content experts. Considerations of the properties of the coding system were described above in the Coding System Development section. As developmental differences in mentalizing capacity between mothers and adolescents was expected

(and observed, qualitatively), we developed person-specific instructions for mentalizing within each scale (see Appendix A for the coding manual). To evaluate interrater reliability, we used a two-way mixed model to calculate intraclass correlations across the five coders for a set of 20 cases. A threshold of .70 was set to determine adequate reliability based on previous research and published guidelines

(Stemler, 2004).

Results

In order to provide a coding scale with adequate differentiation of mentalizing ability, a rating scale from 1 to 7 was used with low values always representing lower quality of mentalizing. Anchor points for every odd-point of the scale were described and included concrete examples for both adolescents and mothers. Both nonverbal and verbal aspects of behavior were considered in the coding scale. Appropriateness of mentalizing was also a consideration via noticing the impact of behavior on the other dyad member (e.g., accurate mental state attribution based on the verbal and nonverbal information provided by the other dyad member). As expected, mentalizing by mothers was more notable and explicit compared to mentalizing by adolescents.

However, adolescent mentalizing was indicated partly by responsiveness toward

mothers. After a draft of the coding manual was developed, it was presented to a panel of mentalizing experts who have conducted extensive clinical and empirical work on mentalizing across the lifespan. Feedback was provided and adjustments to the coding manual were made.

After the finalization of the coding manual and training of coders, Ms.

Vanwoerden and the team of graduate students (five total coders) coded a set of 20 videos randomly selected from the archival dataset. Interrater reliability was calculated and deemed adequate (³ .70) for all scales, with values listed in Table 1. Interestingly, reliability was lowest for scales regarding mothers’ mentalizing. Although based on a limited sample (N = 20), descriptive statistics were calculated, which revealed that all scales with the exception of positive mentalizing indicators for mothers were normally distributed. Mentalizing, on the whole, was lower than average, which would be expected for a psychiatric sample; however, variability seemed adequate. The final coding system was then subjected to a series of validity analyses in a second study, relying on a new sample of referred adolescents.

III. STUDY 2

EVALUATION OF THE VALIDITY OF THE OBSERVATIONAL CODING

SYSTEM FOR MOTHER-ADOLESCENT MENTALIZING

In this second study, a validation sample was recruited in order to test the construct and criterion validity of the coding system. The validation sample was comprised of treatment seeking adolescents in order to obtain a wide variation of psychopathology, in line with RDoC aims. More specifically, we first evaluated

psychometric properties in the form of interrater reliability and internal structure of scales. We were also interested in evaluating how mentalizing as assessed with the observational coding system (as well as other measures of mentalizing) related to demographic characteristics that have been shown to associate with mentalizing, including gender and age (described previously). Although less often studied, we evaluated whether ethnoracial identity and mother college education (as an index of

SES) were associated with mentalizing scores. Lastly, we included a measure of verbal ability in the current study; mentalizing development has been associated with language development in youths (Astington & Baird, 2005). Additionally, existing mentalizing measures have a strong verbal component suggesting that performance may be confounded by these abilities for both adolescents and adults. We examined convergent validity in terms of relations with other well-validated measures of mentalizing. Another aspect of construct validity was examined by testing predictive validity of observed mentalizing scales against related constructs, including interpersonal problems and relationship quality. Finally, we examined the incremental validity of observed mentalizing for adolescent borderline personality features above and beyond existing measures, which have previously been shown to relate to BPD

(i.e., the MASC).

We expected to find adequate interrater reliability and less than moderate overlap across scales, given that scales were developed to be independent of one another. We expected adolescent girls and older adolescents to demonstrate higher quality mentalizing, from both observed and other criterion scales. We did not expect

mentalizing to present differently based on ethnoracial identity or mother college education; however, we did expect performance on all mentalizing measures to correlate positively with verbal ability. In terms of construct validity, it was hypothesized that mentalizing deficits assessed by the newly developed coding system in mothers and adolescents, separately, would respectively relate to both mothers’ and adolescents’ mentalizing capacity assessed with existing measures as well as interpersonal problems. Second, we expected that parallel scales of mentalizing deficits would demonstrate unique relations to one another. Third, we expected that dyadic mentalizing would relate to relationship quality as perceived by both mothers and adolescents. Lastly, it was hypothesized that among adolescents, mentalizing assessed from the dyadic interaction would predict unique variance in their borderline features after accounting for variance accounted for by established task-based measures of mentalizing.

Methods

Participants

The validation sample consisted of 72 adolescents (ages 12-17; Mage = 14.29,

SD = 1.58; 61.1% female, 36.1% male, n = 2 unspecified gender) and their primary female caregivers (ages 28-80; Mage = 45.00, SD = 9.68). Adolescents were recruited from multiple outpatient psychology clinics in the Houston area. Inclusion criteria for participation in the validation portion of this study were mental health treatment seeking, ages 12-17, and having a female caregiver. Exclusion criteria included not speaking English in the home and having a full-scale IQ score at or below 2 SDs under

the mean (FSIQ =< 70). One adolescent was excluded based on their IQ score and an additional two dyads were not included in the analysis due to technological difficulties in videotaping. Racial/ethnic breakdown of adolescents was 26.4% White/Not

Hispanic, 31.9% White/Hispanic, 15.3% Black, 2.8% Asian/Pacific Islander, 2.8%

Native American, and 20.8% mixed race/other. The majority (91.7%) of caregivers were biological mothers; in addition, 3 were grandmothers, 2 were legal guardians, and 1 was an adoptive mother. Racial/ethnic breakdown of mothers was 36.1%

White/Not Hispanic, 37.5% White/Hispanic, 18.1% Black, 2.8% Asian/Pacific

Islander, and 5.6% mixed race/other.

Procedures

All caregiver-adolescent dyads were invited into the lab for a one-time assessment during which they completed a series of self-report, interview and task- based assessments, and ended with the parent-child conflict discussion task. The conflict discussion task followed the same procedures used in Study 1, and therefore are not described again. Conflict discussions were videotaped and transcribed prior to coding. Coders were the same four individuals as were trained in Study 1 in addition to Ms. Vanwoerden. For the current study, coders participated in twice-monthly interrater reliability meetings to discuss difficult cases and any questions that arose during the process. This data collection was approved by the appropriate institutional review board. Both youth and parents provided written informed consent and were compensated for their time. Assessments were conducted by doctoral-level clinical psychology students and/or trained clinical research assistants.

Measures

Mentalizing and Interpersonal Problems. In addition to our observational coding system, which is described in Study 1, mentalizing was evaluated with a task- based measure (MASC; completed by adolescents and mothers), a narrative-based procedure (PRFS; completed by mothers), and self-report (LOPF Perspective Taking

Scale; completed by adolescents). Interpersonal problems were assessed with a self- report that was completed by both adolescents and mothers.

The Movie Assessment for Social Cognition (MASC; Dziobek et al., 2006) is a video-based task assessing higher-order mentalizing that has been widely used across various types of adolescent samples (i.e., healthy, community, inpatient, and outpatient). The measure is ideal for use in adolescents and adults due to the lack of ceiling effects. The movie includes multiple characters and themes and assesses mentalizing through 45 multiple choice questions regarding the mental states of characters. The MASC evaluates three types of mentalizing deficits (hyper-, hypo-, and no mentalizing) in addition to a score indexing the overall number of correct items. The MASC has been demonstrated to be a valid social-cognitive assessment tool (Preißler et al., 2010). Additionally, the MASC has shown to be sensitive in discriminating adolescent patients with BPD from patients without BPD (Sharp, Pane, et al., 2011).

The Parent Development Interview (Slade et al., 2016) was completed by mothers and was coded using the Reflective Function Scale (PRFS; Slade et al., 2015), a narrative-based coding of mentalizing is referred to as reflective function, which can

be understood as mentalizing based in a specific relationship. Given the nature of the interview from which it is coded from, our measure of reflective function specifically reflected the parent-adolescent relationship. Reflective function ratings were coded on an 11-point dimensional scale, ranging from -1 to 9, and anchored at six points in terms of ability to reflect on self and others in mental state terms. A score between 5 and 6 reflects an overall average level of reflective function, with scores of 7 or higher indicating high reflective function, and scores of 4 or lower indicating low to impaired reflective function. A global reflective function score is assigned to the interview as a whole, which was used for the current study. The PRFS has been extensively used to study parents’ reflective capacity with their children from infancy to adolescence and has been shown to relate to quality of the parent-child relationship and child attachment (Slade, 2005). A random selection of n = 20 cases were selected to be coded by a second certified coder. Intraclass correlation coefficient using a two-way mixed model was calculated, revealing that interrater reliability was excellent for this measure (.88)

Finally, self-report of perspective taking among adolescents (as a proxy for mentalizing) was assessed through a subscale from the Levels of Personality

Functioning Scale (LOPF; Goth et al., 2018), which was developed to evaluate

Criterion A of the Alternative Model for the diagnosis of Personality Disorders

(AMPD; American Psychiatric Association, 2013) including Identity, Self-Direction,

Empathy, and Intimacy. The LOPF was specifically developed to assess these dimensions among adolescents ages 12 and up using self-report. While the full LOPF

consists of 97 items organized into eight subscales falling under the four main domains of the AMPD, we were particularly interested in the subscale of Perspective Taking

(falling under empathy; 10 items), which evaluates aspects of cognitive empathy or considering social causality with items such as “I often don’t understand other people’s reactions to my behavior.”. Items are rated on a 5-point Likert-type from 0

(“not at all”) to 4 (“extremely”) and are summed for subscales with higher scores indicating greater difficulties in perspective taking. The LOPF has demonstrated good evidence for validity among clinical and healthy adolescents in the initial development study (Goth et al., 2018). In the current study, scores on the Perspective Taking subscale demonstrated good internal consistency with a Cronbach’s alpha of .80.

The Inventory of Interpersonal Problems (IIP-32; Horowitz, Rosenberg, Baer,

Ureño, & Villaseñor, 1988) is a self-report measure of interpersonal problems originally developed and validated with adults, but used in several samples of adolescents (Fehon et al., 2000; Fichman et al., 1994; Mothersead et al., 1998). The

IIP-32, which was completed by both parents and adolescents, consists of 32 items that are rated on a 5-point Likert scale ranging from 0 (“not at all”) to 4 (“extremely”). The measure yields eight subscales representing different aspects of an individual’s interpersonal difficulties. The scales include problems relating to manipulation, control and/or aggressiveness (Domineering); mistrust, suspicion, and self-centeredness

(Vindictive); difficulties expressing affection and sympathy toward others and maintaining relationships (Cold); social anxiety, shyness, and inhibition (Socially

Inhibited); difficulties with assertiveness and forcefulness (Nonassertive); difficulties

expressing anger and being too trusting and exploitable (Overly Accommodating); trying too hard to please others or being too caring, trusting, and permissive (Self-

Sacrificing); and being overly intrusive, attention seeking, and inappropriately open

(Intrusive). For the purpose of the current study, we examined the total score of social problems (Total Problems), which is an average of all aforementioned subscales.

Cronbach’s alpha for the mother reports of Total Problems was .91 and was .93 for adolescent reports.

Relationship Quality and Attachment. Relationship quality was assessed in two ways. First, the Child Attachment Interview (CAI; Target et al., 1999) is a semi- structured interview based measure of attachment completed with adolescents. While the CAI was originally designed to be used with children ages 8-13, the interview has more recently been used extensively in adolescent populations (Privizzini, 2017; Venta et al., 2014). The interview consists of 19 questions addressing aspects of the child’s current and past relationship with their caregivers (e.g., “What happens when mom gets upset with you?”). These interviews were videotaped and then transcribed. Three trained and certified raters coded the interviews using eight nine-point scales

(idealization, preoccupied anger, overall narrative coherence, dismissal of attachment, emotional openness, use of examples, balance of positive and negative references to attachment figures, and resolution of conflict) with a score of 1 indicating the absence of a construct and 9 indicating a high level of a construct. Additionally, overall attachment is rated either as secure or insecure, and insecure attachment is further described as either dismissing, idealizing, preoccupied, or disorganized. Because the

current study will focus on the relationship between adolescents and their mothers, we focused on scales specifically referring to the mother-child relationship (i.e., idealization, dismissing, and preoccupied anger toward mother measured dimensionally and whether attachment with mother was secure or insecure).

Psychometric studies on the CAI among adolescent samples have found good reliability with Kappa statistics ranging from .70-.79 and intraclass correlations for scales ranging from .65-.94 (Glazebrook et al., 2015; Joseph et al., 2014; Scott et al.,

2011); however, interrater reliability was not tested in the current sample due to time restrictions of coding (each interview takes up to two hours to code and coders completing the CAI coding were also coding the conflict discussion for mentalizing).

Additionally, the Inclusion of the Other in the Self (IOS; Aron et al., 1992) is a simple pictorial measurement instrument assessing closeness of relationships. The IOS was completed by both parents and adolescents and asks the respondent to assess their relationship with the other by selecting one out of seven pairs of increasingly overlapping circles. In each pair of circles, one circle refers to the respondent and the other circle to the other individual. Respondents are asked to “select the pair of circles that best describes their relationship” with the other with greater overlap indicating more closeness. The IOS has been used to assess multiple forms of relationships, from romantic partners and close friends to non-close relationships such as acquaintances.

While developed for use in adults, the IOS has been used in adolescent samples

(Johnson, 2004) and has been used as an instrument to assess closeness of the parent-

adolescent relationship (Braams & Crone, 2017), although this is a more recent extension of the measure.

Adolescent Borderline Personality Disorder. BPD features were assessed using the 11-item version of the Borderline Features Scale for Children (BPFS-C;

Sharp et al., 2014), which is a self-report measure designed for use in youth ages 9-18 and has been adapted for parent report (BPFS-P; Sharp, Mosko, et al., 2011). Both measures assess indicators of childhood borderline features such as affective instability, identity problems, negative relationships, and self-harm. Each item is rated on a 5-point Likert scale ranging from “not true at all” to “always true” and all items are summed for a total score indicating level of severity. Examples of items include “I get into trouble because I do things without thinking” and “I feel that there is something important missing about me, but I don’t know what it is”. Research has supported the criterion validity of both parent and child reports of the BPFS and gender invariance of the 11-item BPFS-C among adolescents (Sharp et al., 2014;

Vanwoerden et al., 2018). Cronbach’s alpha of the BPFS-C was .86 and was .78 for the BPFS-P in the current sample.

Verbal Comprehension. The Wechsler Abbreviated Scale of Intelligence-II

(WASI-II; Wechsler, 1999) is a brief measure of intelligence validated for use from ages 6 and up. Both parents and adolescents completed this measure. The WASI-II consists of four subtests, which are aggregated into two indices of intelligence; Verbal

Comprehension and Perceptual Reasoning. The Verbal Comprehension Index will be

used as a covariate due to the strong relations between verbal ability and mentalizing

(Astington & Baird, 2005; Milligan et al., 2007).

Data Analytic Strategy

Sample Size and Power Analysis. Power analyses were conducted based on

Montecarlo simulations (Muthén & Muthén, 2002) performed with Mplus 7.0 (Muthén

& Muthén, 2012). Effect-size and variance components were based on previous studies using the parent-adolescent conflict discussion task and studies on the relations between parent and child mentalizing (Dixon-Gordon et al., 2015; Stepp, Scott, et al.,

2016; Whalen et al., 2015) and power was set at 0.80 for all estimates. Based on simulations of 10,000 samples, we expected adequate power to estimate small-to- medium effect sizes with 60 dyads. A larger sample (N = 75) was collected in order to account for the potential of exclusions and technology difficulties (i.e., video files getting corrupted or lost).

Preliminary Analyses. Scatter plots were inspected to detect outliers, apparent data trends, and missing data.

Psychometric Properties. First, interrater reliability was evaluated; all cases were randomly assigned to two independent coders and reliability was calculated with a one-way random effects model to produce intraclass correlation coefficients. A threshold of .70 was used to determine adequate interrater reliability. Internal structure of the coding system was evaluated by inspecting bivariate correlations between scales of mentalizing within each individual (i.e., correlations between positive mentalizing, hypermentalizing, and hypomentalizing in adolescents and mothers, respectively).

Demographics and Verbal Ability. Associations between performance on mentalizing measures and adolescent gender were tested with a series of independent samples t-tests. Hedges g was calculated as a measure of effect size due to different sample size and variance within each gender. Associations with age (of both mothers and adolescents) were evaluated with bivariate correlations. Ethnicity/race differences in performance were examined with a series of ANOVAs. Lastly, associations with mother education status was examined by creating a dichotomous variable measuring the presence/absence of a college education for mothers. Independent samples t-tests were calculated based on this variable. Bivariate correlations were calculated to examine the associations between WASI-II scores (of both mothers and adolescents) and respective performance on mentalizing measures.

Convergent Validity. Associations with other measures of mentalizing were examined by calculating bivariate correlations between individual scales of observed mentalizing (i.e., adolescent positive, hyper, and hypo-mentalizing and mother positive-, hyper-, and hypo-mentalizing), MASC scores, LOPF Perspective Taking scores, and PRFS ratings to determine whether they were related in the expected direction. We also examined subscale scores of the MASC (hyper-, hypo-, and no- mentalizing) in relation to the observed scales of maladaptive mentalizing (hyper- and hypo-mentalizing). We lastly examined bivariate correlations between all scales of mentalizing and self-reported interpersonal problems.

To evaluate convergent validity of the dyadic mentalizing scale, we calculated bivariate correlations between this scale and scales of attachment on the CAI

(preoccupied, dismissing, idealizing attachment, coherence scores as a proxy of attachment security, and the dichotomous variable indexing whether adolescents were secure or insecure in their attachment with mothers) and mother- and adolescent- rated relationship closeness (IOS).

In the case that correlations revealed associations between parallel constructs

(individual observed mentalizing with task-based mentalizing) within individuals in the expected direction, a series of actor-partner interdependence model (APIM; Cook

& Kenny, 2005; Kenny et al., 2006) were conducted in Mplus 8.0 (Muthén & Muthén,

1998), which is an approach to modeling dyadic data when the same measurements are taken from both members of the dyad, thereby allowing for interdependence. This approach allows one to study the influence of a person’s predictor variable on their outcome variable (actor effect), and on the outcome variable of the partner (partner effect), while accounting for interdependence (see Figures 2-3 for an illustration). In these models, four types of associations were examined: first, intercorrelations are estimated for each individuals’ performance within task (e.g., degree of association between one type of errors on the MASC correspond with the other type of errors for mothers and adolescents, separately), which is in line with our estimates of the internal structure described above. Secondly, actor paths represent the same convergent validity estimates that are evaluated in bivariate correlations described above. Partner paths represent how one individuals’ performance on the MASC relates to the others’ ratings of mentalizing during conflict. Similarly, our fourth and last estimates considered are the correlation paths are estimated to determine how performance on

the same task are correlated across individuals (e.g., degree of association between mothers’ MASC hypomentalizing errors with adolescents’ MASC hypomentalizing errors). We conducted these models using an SEM framework, which is recommended in distinguishable dyads (Hong & Kim, 2019) and controlled for demographic confounds and verbal ability when indicated. Therefore, using this model, we are able to determine the relations between observed adolescent mentalizing ability (positive indicators) and their mentalizing abilities and interpersonal problems as assessed with external measures while simultaneously evaluating the relations with parent mentalizing.

Incremental Validity for BPD Features. Incremental validity of observed mentalizing ability as coded with the newly developed system for adolescent BPD outcomes was tested with two separate linear regression analysis: one for each report of borderline features (BPFS mother and adolescent report), which was used as the dependent variable. More specifically, we explored to what extent observed mentalizing predicted unique variance in adolescent borderline features. Predictors included observed mentalizing ability, task-based mentalizing ability (MASC), and questionnaire-based mentalizing (LOPF Perspective Taking), as well as demographic confounds.

Results

Preliminary Analyses. In addition to inspecting scatter plots of variables, descriptive statistics were calculated to examine trends in the data. These are displayed in Table 2-4, which is broken down by subject (Table 2: Adolescent, Table 3: mother,

and Table 4: dyadic variables). It was found that all scales were normally distributed.

Outliers for these scales were examined for the potential of random responding; however, in the absence of any evidence to this effect, outlying cases were kept in the sample.

Psychometric Properties: Interrater Reliability. Interrater reliability for the observed scales were calculated and are displayed in Table 1 and reveal that again, while interrater reliability was relatively lower for codes relevant to mothers, all values were adequate (range for mothers: .721 - .769; range for adolescents: .775 - .885).

Additionally, the range of values for the validity sample were wider (ranging from 1-7 with the exception of two scales, which ranged from 2-7) than seen in the development sample, nearly covering all values of the scale across domains and average values of observed mentalizing were approximately at the middle of the scale suggesting that the codes adequately capture variability in mentalizing in the current sample.

Psychometric Properties: Internal Structure. As can be seen in Table 2, among adolescents, there was a strong positive correlation between observed positive mentalizing and hypomentalizing (scaled positively such that higher scores indicate less hypomentalizing and lower scores indicate greater hypomentalizing), suggesting that these scales were not wholly independent. There was a smaller positive correlation with positive mentalizing and hypermentalizing (which was also scaled positively, so this was the expected direction of association). However, the correlation between observed hypermentalizing and observed hypomentalizing scales did not reach statistical significance, confirming their relative independence of each other. Table 3

displays intercorrelations for mothers’ observed mentalizing scales. Similar to the pattern seen for adolescents, there was a strong correlation between observed positive indicators of mentalizing and hypomentalizing whereas the correlation between positive mentalizing and hypermentalizing was only small in magnitude. Again, the correlation between hypo- and hyper-mentalizing was not statistically significant.

Thus, when both adolescents and mothers were rated as higher in positive mentalizing, there was a small tendency for them to not display hypermentalizing and a strong tendency for them to be rated as low on hypomentalizing.

When examining correlations between observed ratings of dyadic mentalizing quality and individual observed mentalizing, we found that dyadic mentalizing corresponded most strongly with mother positive mentalizing. Correlations with adolescent positive mentalizing were moderate. Secondly, there were moderate correlations with both adolescents’ and mothers’ scores of observed hypomentalizing.

This suggests that when adolescents and mothers were observed to be more attentive, curious, and use more mental states with each other (i.e., higher scores of positive mentalizing in each individual), the dyad, as a whole, was rated as displaying higher quality of mentalizing. On the other hand, observed hypermentalizing in both mothers and adolescents was only correlated to a small degree with dyadic mentalizing. In sum, the dyadic mentalizing scale was largely independent of individuals’ observed mentalizing scales, although it appeared to have strongest overlap with mothers’ positive mentalizing scores.

Demographics: Adolescent Gender. Estimates of gender differences on observed mentalizing scales are displayed in Table 1 and show that while not statistically significant, there were small effect sizes for differences in positive indications of mentalizing and hypomentalizing by mothers based on their child’s gender. Mothers from mother-son dyads appeared to demonstrate higher quality mentalizing in these two domains.

Gender differences were also calculated for the rest of the variables in the current study. Female adolescents (M = 29.70, SD = 6.03) had higher scores on the total correct scale of the MASC than males (M = 26.65, SD = 4.36; t(68) = 2.25, p =

.028, g = 0.58). Female adolescents (Madolescent report = 32.31, SD = 8.75; Mmother report =

34.02, SD = 6.30) also received higher scores on the BPFS, based on both mother and child reports compared to male adolescents (Madolescent report = 26.46, SD = 9.33; Mmother report = 30.77, SD = 5.80; adolescent report: t(68) = 2.63, p = .010, g = 0.65; mother report: t(68) = 2.15, p = .035, g = 0.54).

Demographics: Age. Pearson correlation estimates revealed that neither mom nor adolescent age was related to observed mentalizing. However, there was a positive association between age and accurate mentalizing as indicated by total MASC scores

(r = .25). On the contrary, there was a positive association on the perspective taking scale of the LoPF representing self-reported mentalizing (r = .27); however, because this subscale was scaled negatively, higher scores represented dysfunction. Thus, older adolescents reported lower levels of perspective taking. There was a positive association between age and borderline features for adolescents, although this didn’t

reach statistical significance for mother reports of borderline features (radolescent report =

.29; rmother report = .20). Lastly, there was a negative association between age and idealizing attachment, such that older adolescents were less likely to be rated as idealizing in their attachment strategy with moms (r = -.39). Mother age was not related to any study variables.

Demographics: Ethnicity/Race. We compared differences in variables across

White/Not Hispanic, Black, and White/Hispanic groups; we did not include those reporting to be of Asian/Pacific Islander or Native American race due to the low numbers in these groups. Of observed mentalizing variables, only dyadic mentalizing was coded differently based on mother and adolescent ethnicity/race (mother: omnibus

F(2, 65) = 9.77, p = .027; adolescent: omnibus F(3, 67) = 8.41, p = .022): dyads with adolescents and mothers identifying as White/Not Hispanic (mother: n = 26, M = 4.19,

SD = 1.63; adolescent: n = 19, M = 4.42, SD = 1.54) were rated as higher in dyadic mentalizing than dyads with mothers and adolescents identifying as Black (mother: n

= 13, M = 2.69, SD = 1.18; adolescent: n = 11, M = 2.82, SD = 1.25). Adolescents identifying as White/Not Hispanic were rated as higher in dyadic mentalizing than those with adolescents identifying as multiple ethnicities/races (n = 15, M = 3.13, SD =

1.55). Additionally, dyads with adolescents identifying as Black were rated as lower in dyadic mentalizing compared to dyads with adolescents identifying as White/Hispanic

(n = 23, M = 4.00, SD = 1.71).

There were no differences in adolescent scores on other variables based on race/ethnicity; however, there were several differences found for mothers based on

their race/ethnicity. WASI verbal IQ scores differed based on mother’s race/ethnicity

(omnibus F(2, 65) = 14.00, p < .001), as did total score on the MASC (omnibus F(2,

65) = 4.90, p = .010), number of hypomentalizing errors on the MASC (omnibus F(2,

65) = 6.95, p = .002), and PDI scores (omnibus F(2, 49) = 3.52, p = .038). Post-hoc comparisons revealed that mothers identifying as White/Hispanic (M = 42.04, SD =

9.03) scored significantly lower than both Black (M = 51.69, SD = 9.77) and

White/Not Hispanic (M = 53.19, SD = 5.85) mothers on the WASI verbal IQ scores.

On the MASC, White/Hispanic moms scored lower on the total score (M = 30.11, SD

= 6.66) and made more hypomentalizing errors (M = 7.07, SD = 3.86) than White/Not

Hispanic moms (total score: M = 34.77, SD = 3.20; hypomentalizing: M = 3.81, SD =

1.58). On the PDI, Black moms (M = 4.50, SD = 1.20) were rated as higher in mentalizing compared to White moms identifying as Hispanic (M = 3.58, SD = 1.07) and not Hispanic (M = 3.43, SD = 0.84). Additionally, college education was more prevalent among White/Not Hispanic (69.2%) and Black (61.5%) mothers compared to White/Hispanic mothers (25.9%; !"(2) = 10.80, , = .005).

Demographics: Mother Education. There were no differences in observed mentalizing based on college education status of mothers. However, mothers with college education scored higher on the total score of the MASC (Mcollegeed = 34.19, SD

= 3.89, n = 36; Mnocollegeed = 30.40, SD = 6.52, n = 35; t(55.20) = -2.97, p = .004) and made fewer hypomentalizing errors on the MASC (Mcollegeed = 4.56, SD = 2.10,

Mnocollegeed = 6.46, SD = 4.15; t(50.10) = 2.43, p = .019). Mothers with a college

education were more likely to be White/Not Hispanic whereas mothers without a college education were more likely to be White/Hispanic (!"(2) = 10.80, p = .005).

In sum, there were numerous differences on study variables based on demographic characteristics of subjects. For observed mentalizing scores, there seemed to be a slight bias of raters to code dyadic mentalizing lower among Black dyads compared to White/Not Hispanic dyads. Also, interestingly, when interacting with adolescent sons, mothers were coded as higher in positive mentalizing and lower in hypomentalizing. There were differences between adolescents based on gender (of improved MASC performance and higher severity of borderline symptoms in females) and age (increased borderline severity with age) that were in line with hypotheses.

Unexpected findings related to adolescent demographics were that older adolescents were also less likely to be rated as idealizing but had worse self-reported mentalizing on the LoPF. Regarding mothers, White/Hispanic mothers were less likely to have a college education. Likely related to this, these moms had lower scores on the WASI verbal ability scale, were less likely to have a college education, and performed worse on the MASC. Lastly, Black mothers were rated as having higher mentalizing on the

PDI compared to White moms (identifying as either Hispanic or not).

Verbal Ability. We also tested whether verbal comprehension was associated with performance on any study tasks. Adolescent verbal IQ was positively related to observed hypomentalizing (r = .24) as well as MASC total score (r = .40) and both hypomentalizing (r = -.39) and no mentalizing (r = -.31) errors. Mother verbal IQ scores was related to these same scores on the MASC (total score = .41 and

hypomentalizing errors = -.46). Interestingly, IOS ratings by mothers were negatively correlated with IQ scores of both adolescents (r = -.27) and mothers (r = -.36).

Therefore, adolescent verbal IQ scores were controlled for in further analyses examining convergence across forms of mentalizing.

Convergent Validity: Adolescents. Results from bivariate correlations for adolescent variables are listed in Table 2; it should be noted that all observed mentalizing scores are keyed positively, such that low scores indicate low quality of mentalizing (low positive indicators of mentalizing and high levels of either hypermentalizing or hypomentalizing). In terms of correlations between observed mentalizing and MASC scores, only observed hypomentalizing was correlated in the expected direction with MASC total score and hypomentalizing errors to a small degree. Interestingly, observed hypermentalizing correlated in the opposite direction as would be expected—adolescents who were rated as higher in hypermentalizing (i.e., making assumptions about mental states of others and over-certainty about mental states) actually performed better on the MASC, although this did not reach statistical significance and correlations were equal or less than .20 in magnitude. Correlations between observed mentalizing and self-reports of mentalizing and interpersonal problems did not reach statistical significance. In terms of correlations between task- based and self-reported mentalizing and interpersonal problems, the only scale of

MASC that correlated with self-reported mentalizing (LOPF) was no-mentalizing errors (to a small degree; r = .29). Self-reported mentalizing and interpersonal problems were correlated to a moderate degree in the expected direction (r = .49),

although this would be expected given overlap in methodology. Thus, it appears that self-reports of mentalizing did not have strong overlap with other measurement methods of mentalizing. Similarly, self-reported interpersonal problems were not predicted by observed or task-based mentalizing.

Convergent Validity: Mothers. Table 3 displays intercorrelations for mother scales. Beginning with correlations between observed mentalizing and task-based mentalizing, no observed mentalizing scales significantly correlated with MASC scales. However, there was a trend for the correlation between observed hypomentalizing and MASC hypermentalizing in the expected direction (r = -0.21, p =

.081). Therefore, it seems that while adolescent observed hypomentalizing was associated with a tendency to be less accurate on the MASC and make more hypomentalizing errors, mother observed hypomentalizing was associated with a tendency to make more hypermentalizing errors on the MASC. The correlation between observed mentalizing and narrative mentalizing (PDI – RFS) was not statistically significant, and neither was the correlation between narrative mentalizing and task-based mentalizing. Given that PDI – RFS scores did not relate to MASC scores or self-reported interpersonal problems suggests that this narrative measure of mentalizing was not adequately predictive of any related constructs measured. Finally, for correlations between task-based mentalizing and self-reported interpersonal problems, results were different than among adolescents: mothers’ MASC scores

(lower total scores and greater hypomentalizing errors) predicted increased interpersonal problems.

Convergent Validity: Dyadic Mentalizing. Lastly, we examined correlations between dyadic mentalizing and aspects of relationship quality (Table 4). Observed quality of dyadic mentalizing corresponded with ratings of preoccupied attachment with mother as well as adolescent reports of closeness, but not mother reports of closeness with their mother (IOS). While CAI scores of preoccupied attachment were associated with less closeness reported by adolescents on the IOS, scores of idealizing attachment predicted greater closeness (reported by adolescents), which is in line with how these scales are typically rated (idealization is characterized by reported high closeness with parents, which cannot be supported with adequate examples if probed).

Convergent Validity: Actor Partner Interdependence Models. Next, because there wasn’t clear correspondence between scales of mentalizing across forms of measurement and individuals in the dyad, two separate actor-partner interdependence models were run to compare relations between observed mentalizing scales and MASC subscales as a further test of construct validity. Because the no mentalizing errors subscale on the MASC did not correlate with any observed mentalizing scales, we focused on the MASC hypo- and hyper-mentalizing scales.

Also, because there was high correspondence between the observed scales of positive mentalizing and hypomentalizing, we only included the two maladaptive mentalizing scales from the observational coding system in these tests. Across these models, we controlled for the effect of gender on observed mother mentalizing and adolescent

MASC scores, the effect of adolescent WASI scores on both adolescent observed- and

MASC-mentalizing scores and lastly for the effect of mother Hispanic ethnicity on

MASC scores from mothers. Coefficients for these paths of confounding variables are not displayed in tables/figures for the interest of space.

The first model, pictured in Figure 2 utilized forms of maladaptive mentalizing from both the MASC and observed scales and fit well to the data (!"(14) = 16.87, p =

.263; RMSEA = .053; CFI = .957; SRMR = .050). Path coefficients are listed in Table

5. Our interpretation follows the structure described in the Data Analytic Section.

We first focused on intercorrelations for each individuals’ performance within task: for adolescents’ scores of observed mentalizing, there was no significant correlation between scales representing the two types of maladaptive mentalizing.

Similarly, on the MASC, the correlation between adolescents hypomentalizing errors and hypermentalizing errors only approached significance and was negative in direction. For mothers, there was a positive correlation between observed hypomentalizing and observed hypomentalizing. Similarly, there was a positive correlation between mothers’ MASC error scores among mothers. Thus, if raters observed hypermentalizing by mothers during conflict, they were more likely to also observe hypomentalizing, suggesting an overall pattern of maladaptive mentalizing when in conflict with their adolescent. Similarly, on the MASC, if mothers made more hypermentalizing errors, they were more likely to also make hypomentalizing errors, which was contrary to the trend seen for adolescents: if adolescents made more hypomentalizing errors on the MASC, they were less likely to make hypermentalizing errors, and vice versa.

Second, estimates for actor paths were examined. For adolescents, observed hypomentalizing corresponded to their MASC hypomentalizing scores, as hypothesized and in line with bivariate findings. There were no associations between observed and MASC scores of hypermentalizing. On the other hand, among mothers,

MASC hypermentalizing errors corresponded to observed hypomentalizing, in line with bivariate findings. MASC hypomentalizing errors did not relate to either observed mentalizing scales. This suggests that adolescents and mothers who tend to hypomentalize (use less mental state language, have less curiosity, and be less engaged) during conflict with each other will actually perform quite differently from each other when examining their task-based mentalizing performance (moms will make more hypermentalizing errors and adolescents will make more hypomentalizing errors).

Third, estimates for partner paths were examined, which illustrate correspondence across individuals for different forms of measurement of mentalizing.

While mothers’ MASC performance did not correspond with adolescent observed mentalizing, adolescent MASC performance corresponded with mother’s observed hypermentalizing. Specifically, when adolescents made more errors of either hypomentalizing and hypermentalizing on the MASC, their mothers tended to hypermentalize during conflict. This suggests that maladaptive task-based mentalizing

(of any form) in adolescents is more prominent among dyads for which mothers hypermentalize during conflict with their adolescent.

Lastly, we examined correlation paths, which estimated how performance on the same task was correlated between individuals (e.g., degree of association between mothers’ MASC hypomentalizing errors with adolescents’ MASC hypomentalizing errors). We examined correspondence across mothers and adolescence for the same method of measurement. As was seen in bivariate correlations, there was a positive correspondence between adolescents’ tendency to hypomentalize (observed) and mothers’ tendency to both hypo- and hyper-mentalize during conflict. Therefore, this overall pattern of maladaptive mentalizing (characterized by both hyper- and hypomentalizing) observed among mothers was more likely to be seen when adolescents were hypomentalizing.

The second APIM is displayed in Figure 3 with path coefficients listed in Table

6. This model included MASC total scores along with forms of maladaptive mentalizing observed during conflict and fit the data well (!"(11) = 14.33, p = .215;

RMSEA = .065; CFI = .948; SRMR = .054).

First, for intercorrelations between observed mentalizing scales within individual, adolescents observed mentalizing scores did not correlate with each other, as found in the previous model. Mothers’ observed mentalizing performance was correlated (if raters observed hypermentalizing by mothers during conflict, they were more likely to also observe hypomentalizing).

Second, actor paths for adolescents revealed that their MASC total scores corresponded in the expected direction with their observed hypomentalizing whereas neither of the actor paths for mothers were significant.

Third, the only partner path that emerged as significant in this model was from adolescent MASC performance to observed hypomentalizing among mothers. In dyads where adolescents performed better on the MASC (answered more items correctly), their mothers were less likely to hypomentalize during conflict.

Lastly, correlations within task across individuals mirrored the findings from the previous model: correlations between mothers’ and adolescents’ MASC scores were positive and approached significance, suggesting that among dyads in which one individual performed well on the MASC, the other individual was likely to perform well. Correlations between observed scores mirrored those found in the previous model and won’t be reiterated.

To summarize findings from our two APIM models, which accounted for demographic confounds as well as interrelations between different scales of measurement, it appeared that observed mentalizing demonstrated construct validity among both mothers and adolescents. However, this was not in the direction that was originally hypothesized, and also not in the same way across mothers and adolescents.

In terms of the patterns of mentalizing demonstrated, while adolescents’ tendency to hyper- and hypo-mentalize, both during conflict (observed) and on the MASC, were not associated with each other, mothers who showed one form of maladaptive mentalizing were also likely to show the other form (i.e., positive correlations between hyper- and hypo-mentalizing). Lastly, across models, adolescent performance on the

MASC corresponded to their mothers’ observed mentalizing scores during conflict:

worse adolescent performance on the MASC corresponded to lower quality observed mentalizing among mothers.

Incremental Validity: Associations with borderline pathology. Lastly, relations with adolescent borderline pathology were tested. Predictors included observed mentalizing ability, task-based mentalizing ability (MASC), and questionnaire-based mentalizing (LOPF Perspective Taking), as well as adolescent gender and age. Based on bivariate results, we included positive mentalizing from observed scores and hypo- and hyper-mentalizing scores from the MASC. Results are displayed in Table 7 and demonstrate that, unlike what has been reported by previous research, neither MASC scale was associated with adolescent borderline symptoms

(based on either report) and self-reported mentalizing was inversely associated with borderline symptoms (based on either report). However, an unexpected discrepant pattern of functioning of observed mentalizing based on whether the DV was mother- or adolescent- reported borderline symptoms. When examining the effect on adolescent reported borderline symptoms, positive mentalizing actually predicted greater borderline symptoms; however, when using mother reported borderline symptoms, positive observed mentalizing predicted fewer borderline symptoms, in line with our hypotheses. This suggests that when mothers’ view their adolescent children as displaying greater borderline pathology, those adolescent children are likely to be rated as displaying lower levels of mentalizing during conflict with their mothers.

However, adolescents who perceive themselves as displaying greater borderline

pathology are likely to be rated as displaying higher quality mentalizing during conflict with their mothers.

Given the unexpected nature of these findings, we conducted supplementary analyses to better understand the nature of the results. We ran a moderation analysis predicting observed positive mentalizing by adolescent- and mother-reported borderline symptoms as well as the interaction between reports of borderline symptoms. This would allow us to evaluate how observed mentalizing was associated with borderline symptoms across the spectrum of severity and as reported by each individual. Adolescent-reported borderline symptoms were entered as the independent variable and mother-reported symptoms were entered as the moderator. The interaction term of adolescent by mother-reported borderline symptoms was only marginally significant (coeff = -.004, se = .00, t = -1.76, p = .082). Regardless, we probed the interaction at +/- 1 SD of the mean of adolescent reported symptoms.

Simple slopes revealed that at all levels of the moderator (mother reported symptoms), there was a significant positive effect of adolescent reported symptoms on observed mentalizing. We plotted the simple slopes in Figure 4 and demarcated the threshold of clinical significance for the BPFS-11. Upon examination, in the region of clinical significance, when mother-reported symptoms were average (just below the level of clinical significance: M = 32.79) or higher, mentalizing was estimated to be at or below average on the observed mentalizing scale (£ 4). Thus, despite the fact that there was a positive association between adolescent-reported borderline symptoms and observed mentalizing, it appears that when both adolescent- and mother-reported

symptoms were in the level of clinical significance, mentalizing was observed to be below average, and therefore low quality. Additionally, we examined the Johnson-

Neyman region of significance for this test and found that the negative effect of borderline symptoms on observed mentalizing was only significant when borderline symptoms were at or below 39, which is just above the level of clinical significance.

Thus, it appears that while at lower levels of borderline severity, there appears to be a positive association between borderline symptoms and quality of observed mentalizing, this no longer applies among adolescents who are at higher levels of severity.

IV. GENERAL DISCUSSION

The goal of the current study was to develop and evaluate an observational coding system for mentalizing as it occurs during a conflict discussion between mothers and their adolescent children. In a first study, an archival dataset was used to develop an observational coding system to measure overall quality of mentalizing in mothers and adolescents, separately, but also as a dyad. Additionally, the coding system includes codes to evaluate forms of maladaptive mentalizing in mothers and adolescents, separately. The coding system demonstrated adequate face validity and interrater reliability. In a second study, with a sample of treatment seeking adolescents and their mothers, adequate interrater reliability was replicated. Furthermore, we found convergent validity of this novel coding system against an often-used task-based measure of mentalizing as well as with different indices of relationship quality. Lastly, our coding system, but not other measures of mentalizing, predicted adolescents’

borderline features. In sum, these studies present a promising new measure to capture mentalizing in-vivo among adolescents during conflict with their mothers.

This discussion will first detail psychometric properties of the coding system, including areas for potential improvement of the coding system and future research.

Second, we will discuss how using the coding system led to different estimates of observed mentalizing capacity based on demographic characteristics and the implications of these differences for use of this measure. Third, we will discuss convergent validity between observed mentalizing and other measures of mentalizing and related construct and how this relates to previous findings of overlap between different measures of mentalizing and associated constructs. We will also discuss findings related to associations between mothers and adolescent in terms of their mentalizing capacity as demonstrated across various measures and how this converges with previous evidence on associations between parent- and adolescent- mentalizing.

Fifth and lastly, we will discuss how observed mentalizing uniquely captured variance in adolescent borderline features, providing evidence not only supporting the predictive utility of this coding instrument, but also supporting previous hypotheses of a context specific impairment of mentalizing for individuals with borderline pathology.

Psychometric Properties

In developing the observational coding system, we utilized a racially diverse psychiatric sample of adolescents who participated with their primary female caregivers. The purpose of using a psychiatric sample to calibrate our coding system

was to ensure that our coding system captured variability in mentalizing that would be expected in adolescents experiencing various forms of psychiatric problems. Previous research has confirmed mentalizing deficits associated with a range of psychopathology (Luyten et al., 2020). Thus, we attempted to capture different styles of maladaptive mentalizing that may present based on classes of psychopathology.

Across two independent samples, the coding system adequately captured variability in mentalizing across the full scale, which is a noted limitation of other narrative coding systems for mentalizing (Taubner et al., 2013). This suggests that we successfully calibrated levels of mentalizing to capture variability that would be presented in a sample with significant psychiatric problems. Future research will be needed to understand how the current coding system operates in healthy samples.

After sufficient training, our team of graduate students reached adequate interrater reliability across two independent samples. Interestingly, we found that in both studies, there was relatively lower interrater reliability for codes assessing mothers’ quality of mentalizing compared to codes based on adolescents. It is possible that this reflects greater variability in mentalizing displayed by mothers making it more difficult to achieve interrater agreement in classifying behavior. However, it could also indicate that raters display systematic bias when rating mothers compared to adolescents. We conducted supplementary analysis to determine whether there were differences between the five graduate student coders in their ratings and found that there were no significant differences. Therefore, future research should focus on taking a closer evaluation of maternal behavior during conflict that reflects mentalizing.

Additionally, for future refinements of the scale, it will be beneficial to make clarifications for maternal mentalizing scales in order to achieve greater agreement between raters.

Lastly, while scales were developed to be independent of one another, there was high overlap in scores of positive indications of mentalizing and hypomentalizing for both mothers and adolescents, whereas hypermentalizing scores were independent of these other forms of mentalizing. Specifically, for individuals who were rated as displaying high levels of positive indications of mentalizing, they were more likely to be coded as displaying low levels of hypomentalizing. This is likely due to the fact that both of these scales included some aspect of the extent of mental state language used and interest displayed in the other partner (i.e., curious stance). Further refinements to our scale will thus be made such that the scale of hypomentalizing will only indicators of hypomentalizing, rather than the lack of positive indications of mentalizing.

Demographic Differences in Mentalizing

As part of Study 2, we evaluated differences in observed mentalizing based on key demographic differences that have been found to relate to mentalizing performance in previous research, most notably with gender and age. When creating the coding scheme, we attempted to build in a developmental lens by including explicit instructions to consider developmentally appropriate mentalizing (i.e., more complex mental state language would be expected among older individuals compared to those at the lower end of our age range). Because the aim was to develop a measure

that could be utilized in adolescents of all ages (12-17), it was explicit in the coding scheme to not ‘penalize’ younger adolescents for lack of complexity in mental state language. This differentiation by coders was reflected in no significant correlations between age and observational scores. Interestingly, though, we also did not find differences in adolescents’ observed mentalizing scores based on their gender.

Similarly, adolescents didn’t differ on self-reported mentalizing or interpersonal problems based on gender. However, female adolescents outperformed males on the total score of the MASC in line with other research using the MASC in adolescent samples (Poznyak et al., 2019). Thus, gender differences in the current sample were limited to task-based performance. This raises the question of the link between mentalizing abilities as would be demonstrated under relatively ‘clean’ conditions (i.e., low arousal, referring to characters with no personal connection to subjects, on topics not personally relevant to subjects) and the actual use of these abilities during interpersonal interactions (i.e., observed mentalizing ability in conflict or in interpersonal interactions with other individuals like peers, which is what was likely reported on in the self-report). The relative lack of in-vivo measures of mentalizing make it difficult to interpret these results; however, it does suggest that males may draw on other skills or processes to interact in a way that at least resembles mentalizing to a similar level as females of the same age. One previous study measured the amount of mental state talk during conversations (elicited conversations about fictional characters in a social dilemma or faux pas) among mothers and children

(ages 5-7 and ages 7-10) and found that boys and girls did not differ in either basic or

advanced mental state talk during conversations (Pearson & Pillow, 2016). However, the generalization from these non-self-referential conversations to conflict are difficult to make given the difference in arousal between these different conversational contexts. Future research should focus on understanding the gender-specific correlates of in-vivo mentalizing during mother-adolescent conflict to determine what skills or processes are being drawn on for performance.

On the other hand, mothers’ observed mentalizing scores were slightly different based on their adolescent child’s gender. Specifically, when interacting with sons, mothers were rated as demonstrating higher quality mentalizing. The differences in mothers’ mentalizing abilities depending on whether they were interacting with a male or female child poses another question for future research. It is well established that girls and boys are subject to different socialization practices by their parents

(Brown et al., 2015). Our findings suggest that this includes in-vivo mentalizing during conflict. Specifically, mothers were more likely to use mental state language, demonstrate more curiosity and interest about their child’s perspective, and display more warmth and shared positive affect if they were interacting with their sons.

Interestingly, other research examining maternal mind-mindedness or mental state talk with their children has not found differences based on child gender (e.g., Meins et al.,

2013; Pearson & Pillow, 2016); however, the bulk of this research was conducted among younger children and took place during relatively low arousal interactions (e.g., free play or during conversations about stories). It is known that mother-daughter dyads engage in less conflict than mother-son dyads (Ashraf & Najam, 2011),

suggesting that this particular context may actually be more familiar territory for mothers. Because female adolescents may be more interactive and relationship oriented, it is suggested that they receive more parental affection and less punishment.

Thus, conflict discussions are more rare and may elicit specific difficulties for the mother-daughter relationship potentially making it more difficult for mothers to demonstrate appropriate mentalizing. Previous research has found that boys are more assertive in relationships whereas girls tend to engage in more harmony-maintenance in relationships (i.e., appeasing others by suppressing their own desires; Rosenfield et al., 2000), which may actually make it more difficult for mothers to adequately mentalize their daughters. Because parent-adolescent conflict shows stronger links with girls’ psychopathology compared to boys’ (Weymouth et al., 2016), these contexts are especially important for mothers-daughter dyads to effectively navigate.

Future research should focus on the correspondence between mothers’ and adolescents’ mentalizing capacity and how this may differ based on adolescent gender.

Furthermore, it will be crucial for this line of research to extend the current coding system to be applied with fathers.

While none of our individual scores of observed mentalizing differed based on adolescent or mother race, we did find that dyads in which mothers identified as Black were rated as demonstrating lower quality mentalizing during conflict. This finding is interesting when contrasted with the finding that Black mothers were rated as higher quality on narrative mentalizing (Reflective Function on the PDI) than White mothers

(both of Hispanic and non-Hispanic backgrounds). This suggests differential

performance by black mothers when interacting with their children compared to when being asked individually to reflect upon the relationship between them and their adolescent children. Research using cross-cultural perspectives on mentalizing is relatively lacking (although see Aival-Naveh et al., 2020 for a review); however, there is greater research on cultural differences in children’s theory of mind development and on parent-child relationships. For one, it is suggested that among African

American mothers, those who have experienced more racism and have lower satisfaction are more likely to use emotion words in talking with their children (Odom et al., 2016). It has been suggested that this greater emotional discourse may ultimately foster a child’s own awareness of emotions in experiences of stereotypes or discrimination. Another study examined differences between Mexican-American,

European-Americans, and African-Americans on a self-report questionnaire assessing metaparenting, which includes aspects of metacognition similar to reflective function or mentalizing. This study found that African-American mothers reported higher levels of meta-parenting demonstrating that this group engaged in more metacognitive thoughts about their children (Holden et al., 2017). These findings are in line with suggestions that minority families carry extra burden in child-rearing, including preparing children to cope with discrimination, and thus may engage in more intentional thoughts about their children than non-minority parents. Given these conclusions, it is not surprising that in a narrative interview format, Black mothers in our current study engaged in more mentalizing when asked to reflect upon their relationships with children. The discrepancy between this finding and that of lower

quality dyadic mentalizing for dyads in which mothers identified as Black is mirrored in other observational research. Specifically, in ratings of parenting practices, observer bias emerged in the direction of lower ratings for African-American families; however, this bias was reduced upon further training (Yasui & Dishion, 2008). This suggests that differences in socialization practices across racial groups must be incorporated to a greater extent in the current coding system to minimize rater bias.

In addition to examining demographic differences, we evaluated associations between mentalizing and verbal ability. As expected, both observed and task based mentalizing scores were correlated with our measure of verbal ability. However, the correlation between observed mentalizing and verbal ability was only demonstrated among adolescents. The importance of language in the development of mentalizing is well established (Astington & Baird, 2005) and is further confounded when measures of mentalizing include a large verbal component. Therefore, it was unexpected that this effect was not seen for mothers in terms of their observed mentalizing scores, given that a large component of coding included the mental state language used by subjects. While adolescence is marked by continued maturation, both in terms of brain development and behavior acquisition, by adulthood, this has likely reached a plateau.

It has been suggested that verbal ability facilitates children’s involvement in social interactions, which have a positive effect on mentalizing ability and other social skills

(Imuta et al., 2016), whereas this effect may no longer be relevant once individuals reach adulthood. One challenge in understanding the varied and likely discrepant influences of mentalizing abilities across the life span is that existing research has been

siloed based on age. Specifically, within the domain of developmental psychology, a large focus of research has been on language, executive function, gender in their individual and combined effects on mentalizing development from infancy into adolescence. However, analogous studies have not been conducted in adulthood and this is further complicated by the use of different measurement instruments used in different age groups, scaled to the cognitive abilities of the specific populations being studied. Therefore, future research should capitalize on the presence of this novel mentalizing measure that can be applicable to different age groups in order to evaluate the role of language in displays of mentalizing across the lifespan.

Convergent Validity

In terms of construct validity, our study also examined associations between observationally coded mentalizing and mentalizing as measured by various methods: self-report, narrative, and task-based mentalizing. Bivariate findings demonstrated that overlap across these various measures was low; however, patterns of correlations differed slightly between mothers and adolescents. For adolescents, there was small magnitude of correlations between MASC and observed mentalizing, although only the observed hypomentalizing scale seemed to correspond with the MASC scales. The observed mentalizing scales did not correlate significantly with self-reported mentalizing or interpersonal problems. On the other hand, MASC scores (the no mentalizing scale only) correlated with self-reported mentalizing. Of the three measures of mentalizing, only self-reported mentalizing correlated with self-reported interpersonal problems. Among mothers, there were no significant correlations

between any of our measures of mentalizing; however, the MASC correlated as expected with self-reported interpersonal problems. Thus, convergent validity was only demonstrated for adolescents, albeit to a small degree. That being said, the low magnitude of correlations across all of our mentalizing measures was not entirely unexpected especially when considering differences in format and type of measurement. Previous studies have found correlations between different measures of mentalizing or theory of mind to be not significantly different from zero to moderate at best. One study examining the reliability and validity of some of the most broadly used measures of advanced theory of mind in typically developing children found that the highest magnitude correlation between seven measures they tested was .22 (2 correlations were above .20, 4 correlations were between .10 and .20). Furthermore, only three of the 21 correlations between measures emerged as statistically significant

(Hayward & Homer, 2017). Another study using a recently developed virtual reality test of mentalizing to examine correlations with three other advanced theory of mind tasks in a sample of healthy adults similarly found insignificant (magnitude of correlations £ .20) correlations with one of the tasks used. On the other hand, they found small to moderate level correlations between specific subscales of their measure and the other two tasks used (Canty et al., 2017).

An important consideration when evaluating these results is the domain- specificity of our measure of mentalizing. Specifically, we were uniquely testing the tendency of mothers and adolescents to utilize their mentalizing abilities during a conflict with one another. This is an important distinction: individuals may be able to

perform well on task-based mentalizing, indicating an underlying ability to infer mental states of others and distinguish between their own and others’ mental states.

However, this ability may not directly correspond with the use of this ability during on-line interactions, especially in situations that are characterized by high emotional arousal and in an attachment context (Fonagy & Luyten, 2009; Samson & Apperly,

2010). Furthermore, the correspondence between mentalizing as assessed in non- personally relevant tasks and relationship-specific aspects of mentalizing may be moderated by variables such as attachment representations (De Rosnay & Harris,

2002) and psychopathology (Vanwoerden et al., 2019). Thus, the domain specificity of different tasks may influence how much correspondence between measures one may find.

To this end, we included an observational code to indicate the quality of mentalizing in dyads as a whole. This measure was intended to capture the synchrony in mentalizing demonstrated, for example, how comfortably each dyad member offered and received mental state information to and from the other. Also included in this code were indications of play or comfort, which indicates how at ease the dyad members feel in communicating and learning about mental states of each other. We expected that this dyadic code would relate to indices of relationship quality, including adolescent’s attachment representations of their mother, and self-reports of relationship closeness. Interestingly, we found that lower quality dyadic mentalizing was present in dyads in which adolescents were rated as higher in preoccupation with their mother. This same finding was not demonstrated for the indices of dismissing

attachment (dismissive or idealizing). This is not surprising given that preoccupied attachment representations are tied to hyperactivated expressions of negative affect to elicit attention from attachment figures whereas those with a dismissive/ambivalent attachment representation may utilize deactivating strategies (Cassidy & Berlin, 1994).

Therefore, in terms of observed behavior, adolescents with dismissive representations of their mothers may turn to acquiescence or agreeableness during conflict or avoidance of conflict altogether, which may not be as easily captured in our coding scheme. Dyadic mentalizing also corresponded with adolescent reports of closeness with their mother, but not mother reports. Thus, it appears that behavior during conflict was more representative of the adolescents’ perceptions and representations of the mother-adolescent relationship. Future research should evaluate how mentalizing behavior during conflict relates to mothers’ representations using more comprehensive measures.

As part of our test of construct validity, we conducted a series of actor partner interdependence models, which allowed us to account for interdependence between mothers and adolescents in their mentalizing scores as well as confounding factors such as verbal ability and gender of adolescents and Hispanic ethnicity of mothers.

This approach also allowed us to estimate the associations between mothers and adolescents in terms of their mentalizing capacity both within and across measures.

Because observed ratings of mothers and adolescents were based on the same interaction between the two individuals, we would expect these scores to be related. In fact, research has shown that interpersonal behaviors influence the interpersonal

behaviors of interaction partners (e.g., Dermody et al., 2017) and mentalizing theory similarly states that mentalizing can influence others in a complementary way (Allen et al., 2008). Results from these models revealed a stronger pattern of convergence between observed mentalizing and MASC mentalizing scores compared to bivariate findings. Specifically, among mothers, MASC hypermentalizing scores corresponded with observed hypomentalizing scores, whereas among adolescents, observed hypomentalizing corresponded with MASC hypomentalizing and total scores providing greater evidence of convergent validity for our observational coding system.

That being said, the magnitude of these effects were still small.

Associations Between Adolescents’ and Mothers’ Mentalizing

While not a main aim of the current studies, when examining effects for paths estimating the correspondence between mothers’ and adolescents’ mentalizing scores, it appeared that when adolescents made more errors (of any type) on the MASC, their mothers were more likely to display hypermentalizing during the conflict discussion.

When adolescents made lower overall scores on the MASC, their mothers were more likely to hypomentalize during the conflict discussion. Similarly, if adolescents were more likely to hypomentalize during conflict discussion, their mothers were more likely to display both hypermentalizing and hypomentalizing during the discussion.

These findings, first of all, confirm theory regarding complementarity of mentalizing during the conflict discussion between mothers and their adolescent children.

However, it also reveals that maladaptive maternal mentalizing (during interactions between mothers and adolescents) is related to overall deficits in mentalizing (as

displayed in non-self-relevant tasks, i.e., the MASC). These difficulties may correspond with negative outcomes in different domains (as demonstrated in other research). While the majority of research on the correspondence between mother-child mentalizing abilities has been conducted in children, there is substantial evidence to suggest that mothers’ mentalizing capacity is an important predictor of their children’s mentalizing abilities, even once children reach adolescence (Quek et al., 2018). Our coding system offers promise for future research in this regard by offering an extension of previous research that has relied on tasks and questionnaires to actual performance and use of mentalizing abilities in real-time interactions.

Predictive Utility of Coding System for Adolescent Borderline Features

Lastly, in addition to testing convergence across different measures of mentalizing, we conducted a test of external validity by examining associations between mentalizing and adolescent borderline personality features. Borderline personality disorder has been studied extensively in terms of interpersonal and social- cognitive correlates (Ha et al., 2013; Herpertz & Bertsch, 2014; Lazarus et al., 2014).

Furthermore, it is conceptualized as a disorder of attachment (Levy et al., 2011), with robust findings suggesting that disturbances in the parent-child relationship are a central predictor for borderline pathology (Stepp, Lazarus, et al., 2016). Further, several studies have now found evidence that adolescent with borderline features are more likely to make hypermentalizing errors on the MASC (Goodman & Siever, 2011;

Quek et al., 2018; Sharp et al., 2013). Thus, we hypothesized that adolescents with higher levels of borderline features would be more likely to make hypermentalizing

errors on the MASC and be coded as lower on quality of mentalizing based on the observational coding system. Given that our coding system targeted the mother-child relationship, which is specifically hypothesized to be characterized by maladaptive dynamics, we expected that these scores would capture unique variance in adolescent borderline features after accounting for MASC performance. However, our findings were mixed. First of all, MASC performance was not associated with borderline features, contrary to previous evidence. Secondly, only when using mother reports of borderline features did we observe the association with lower quality mentalizing by behavioral coding. Interestingly, when using adolescent-reported borderline features, this effect was opposite: adolescents who reported being higher on borderline features were coded as displaying higher quality mentalizing. In a regression analysis, it was revealed that mother- and adolescent-reported borderline features predicted unique variance (in opposite directions) of observed mentalizing. Upon further examination, though, it was determined that among adolescents displaying clinical levels of borderline features, observed mentalizing was low in quality. Further research should examine moderators of these findings to better understand the discrepancy between our findings and previous research and theory.

Limitations, Strengths, and Future Directions

There are some limitations to consider when evaluating the results of the current study. For one, we did not have full overlap between measures across mothers and adolescents. While our original proposal had included the child version of the

Reflective Function scale (narrative mentalizing), our collaborators were unable to

complete the coding as expected. Additionally, our measure of self-reported mentalizing completed by adolescents was an adolescent specific measure, and therefore we did not have an analogous self-report measure for mothers. Second, a notable portion of the mothers in our sample consisted of immigrants for whom

English was a secondary language. We unfortunately did not include any questions about English as a primary or secondary language. However, all of our families reported that English was the main language spoken between mother and adolescent.

Third, our findings revealed that Hispanic mothers were less likely to have a college education and performed worse on our measure of verbal ability, subsequently performing worse on the MASC. This is notable given that dyads with at least some

Hispanic heritage made up almost a third of our sample although not unexpected based on the population makeup of the Houston area. Future validation work should attempt to examine group differences in observed mentalizing scores while matching on education experience and measures of verbal ability. Fourth, while global coding systems for parent-child relationship dynamics are common, there is valuable information that may be gleaned from micro-level coding. It is not uncommon for individuals to oscillate between various strategies of maladaptive mentalizing within the same interaction. In fact, our results suggested that especially mothers tended to show both forms of maladaptive mentalizing during conflict. By utilizing a micro- level approach, we could examine temporal patterns of mentalizing between mothers and adolescents. This may provide novel information about the specific ways that mothers and adolescents influence each other in terms of mentalizing. Last, while

using a psychiatric sample of adolescents and mothers was an advantage in that it allowed us to tailor our coding system to capture the types of maladaptive mentalizing one would expect to see in higher severity populations, there is the potential that having a specific sample caused a restriction of range in mentalizing abilities. This may have artificially attenuated the validity coefficients and contributed to some of the null findings in the current study. Future work will be needed to examine the utility of our coding system in samples of healthy adolescents and their mothers.

Despite these limitations, the findings of the current study are promising in that they demonstrate initial evidence of reliability and validity of our newly developed observational coding system for mentalizing. Our study not only provides evidence for the psychometric properties and utility of observationally coded mentalizing, but also fills an important methodological gap to address previously unanswered questions about how mentalizing can be used and demonstrated in real-time interactions in central attachment relationships. The current manuscript provides specific direction to improve properties of the coding system, including clarifying scale descriptions in order to better distinguish between scales of positive mentalizing and hypomentalizing; adding more specificity for mother scales; and educating and training adolescents to reduce coding bias against dyads with mothers identifying as

Black. In addition to improving psychometric properties of the coding system, future research will be needed to examine discriminant validity of the coding system as well as to evaluate the ability of observationally coded mentalizing to predict important outcomes in the domain of psychopathology and interpersonal functioning.

REFERENCES

Abu-Akel, A., & Shamay-Tsoory, S. (2011). Neuroanatomical and neurochemical

bases of theory of mind. Neuropsychologia, 49(11), 2971–2984.

https://doi.org/10.1016/j.neuropsychologia.2011.07.012

Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment

studies with borderline patients: A review. Harvard Review of Psychiatry,

12(2), 94–104. https://doi.org/10.1080/10673220490447218

Aival-Naveh, E., Rothschild-Yakar, L., & Kurman, J. (n.d.). Keeping culture in mind:

A systematic review and initial conceptualization of mentalizing from a cross-

cultural perspective. Clinical Psychology: Science and Practice, 0(0), e12300.

https://doi.org/10.1111/cpsp.12300

Allen, J. G., & Fonagy, P. (2006). The Handbook of Mentalization-Based Treatment.

John Wiley & Sons.

Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice.

American Psychiatric Pub.

https://books.google.com/books?hl=en&lr=&id=upyvBAAAQBAJ&oi=fnd&p

g=PA1&dq=allen+fonagy+batemen+mentalizing&ots=_DD-

0EiTU_&sig=eRhYR94TiL6yvqNNIQDl7k3utt0

Allen, J. P., Hauser, S. T., Bell, K. L., McElhaney, K. B., Tate, D. C., Insabella, G. M.,

& Schlatter, A. K. W. (2000). The autonomy and relatedness coding system.

Unpublished Manuscript, University of Virginia, Charlottesville.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of

Mental Disorders (DSM-5®). American Psychiatric Pub.

Aron, A., Aron, E. N., & Smollan, D. (1992). Inclusion of Other in the Self Scale and

the structure of interpersonal closeness. Journal of Personality and Social

Psychology, 63(4), 596–612. https://doi.org/10.1037/0022-3514.63.4.596

Ashraf, F., & Najam, N. (2011). Age and Gender Differences in Parent-Adolescent

Conflict. Journal of Behavioural Sciences, 21(2). Gale OneFile: Health and

Medicine.

http://link.gale.com/apps/doc/A278167698/HRCA?u=txshracd2588&sid=zoter

o&xid=0d23b327

Astington, J. W., & Baird, J. A. (2005). Why language matters for theory of mind: Vol.

xii. Oxford University Press.

Badcock, C., & Crespi, B. (2006). Imbalanced genomic imprinting in brain

development: An evolutionary basis for the aetiology of autism. Journal of

Evolutionary Biology, 19(4), 1007–1032. https://doi.org/10.1111/j.1420-

9101.2006.01091.x

Bakeman, R., & Gottman, J. M. (1997). Observing interaction: An introduction to

sequential analysis (2nd ed.): Vol. xiii. Cambridge University Press.

Baron-Cohen, S. (1994). How to build a baby that can read minds: Cognitive

mechanisms in mindreading. Cahiers de Psychologie Cognitive/Current

Psychology of Cognition, 13(5), 513–552.

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(2), 241–251.

https://doi.org/10.1111/1469-7610.00715

Bateman, A. W., & Fonagy, P. (2004). Mentalization-Based Treatment of BPD.

Journal of Personality Disorders, 18(1), 36–51.

https://doi.org/10.1521/pedi.18.1.36.32772

Bensalah, L., Caillies, S., & Anduze, M. (2016). Links among cognitive empathy,

theory of mind, and affective perspective taking by young children. The

Journal of Genetic Psychology: Research and Theory on Human Development,

177(1), 17–31. https://doi.org/10.1080/00221325.2015.1106438

Blakemore, S.-J. (2008). The social brain in adolescence. Nature Reviews

Neuroscience, 9(4), 267–277. https://doi.org/10.1038/nrn2353

Blakemore, S.-J. (2010). The Developing Social Brain: Implications for Education.

Neuron, 65(6), 744–747. https://doi.org/10.1016/j.neuron.2010.03.004

Blakemore, S.-J., & Mills, K. L. (2014). Is Adolescence a Sensitive Period for

Sociocultural Processing? Annual Review of Psychology, 65(1), 187–207.

https://doi.org/10.1146/annurev-psych-010213-115202

Bo, S., Sharp, C., Fonagy, P., & Kongerslev, M. (2017). Hypermentalizing,

attachment, and epistemic trust in adolescent BPD: Clinical illustrations.

Personality Disorders: Theory, Research, and Treatment, 8(2), 172–182.

http://dx.doi.org/10.1037/per0000161

Bora, E., Bartholomeusz, C., & Pantelis, C. (2016). Meta-analysis of Theory of Mind

(ToM) impairment in bipolar disorder. Psychological Medicine, 46(2), 253–

264. https://doi.org/10.1017/S0033291715001993

Bora, E., Velakoulis, D., & Walterfang, M. (2016). Social cognition in Huntington’s

disease: A meta-analysis. Behavioural Brain Research, 297, 131–140.

https://doi.org/10.1016/j.bbr.2015.10.001

Bora, E., Walterfang, M., & Velakoulis, D. (2015a). Theory of mind in behavioural-

variant frontotemporal dementia and Alzheimer’s disease: A meta-analysis.

Journal of Neurology, Neurosurgery & Psychiatry, 86(7), 714–719.

https://doi.org/10.1136/jnnp-2014-309445

Bora, E., Walterfang, M., & Velakoulis, D. (2015b). Theory of mind in Parkinson’s

disease: A meta-analysis. Behavioural Brain Research, 292, 515–520.

https://doi.org/10.1016/j.bbr.2015.07.012

Bosacki, S. L. (2015). Children’s theory of mind, self-perceptions, and peer relations:

A longitudinal study. Infant and Child Development, 24(2), 175–188.

https://doi.org/10.1002/icd.1878

Braams, B. R., & Crone, E. A. (2017). Peers and parents: A comparison between

neural activation when winning for friends and mothers in adolescence. Social

Cognitive and Affective Neuroscience, 12(3), 417–426.

https://doi.org/10.1093/scan/nsw136

Branje, S. (2018). Development of Parent–Adolescent Relationships: Conflict

Interactions as a Mechanism of Change. Child Development Perspectives,

12(3), 171–176. https://doi.org/10.1111/cdep.12278

Brown, G. L., Craig, A. B., & Halberstadt, A. G. (2015). Parent Gender Differences in

Emotion Socialization Behaviors Vary by Ethnicity and Child Gender.

Parenting, 15(3), 135–157. https://doi.org/10.1080/15295192.2015.1053312

Brüne, M., & Brüne-Cohrs, U. (2006). Theory of mind—Evolution, ontogeny, brain

mechanisms and psychopathology. Neuroscience & Biobehavioral Reviews,

30(4), 437–455. https://doi.org/10.1016/j.neubiorev.2005.08.001

Bruneau, E. G., Jacoby, N., & Saxe, R. (2015). Empathic control through coordinated

interaction of amygdala, theory of mind and extended pain matrix brain

regions. NeuroImage, 114, 105–119.

https://doi.org/10.1016/j.neuroimage.2015.04.034

Buhlmann, U., Wacker, R., & Dziobek, I. (2015). Inferring other people’s states of

mind: Comparison across social anxiety, body dysmorphic, and obsessive–

compulsive disorders. Journal of Anxiety Disorders, 34, 107–113.

https://doi.org/10.1016/j.janxdis.2015.06.003

Canty, A. L., Neumann, D. L., Fleming, J., & Shum, D. H. K. (2017). Evaluation of a

newly developed measure of theory of mind: The virtual assessment of

mentalising ability. Neuropsychological Rehabilitation, 27(5), 834–870.

https://doi.org/10.1080/09602011.2015.1052820

Caputi, M., Lecce, S., Pagnin, A., & Banerjee, R. (2012). Longitudinal effects of

theory of mind on later peer relations: The role of prosocial behavior.

Developmental Psychology, 48(1), 257–270. https://doi.org/10.1037/a0025402

Carpendale, J. I. M., & Lewis, C. (2004). Constructing an understanding of mind: The

development of children’s social understanding within social interaction.

Behavioral and Brain Sciences, 27(01), 79–96.

https://doi.org/10.1017/S0140525X04000032

Cassidy, J., & Berlin, L. J. (1994). The Insecure/Ambivalent Pattern of Attachment:

Theory and Research. Child Development, 65(4), 971–991.

https://doi.org/10.1111/j.1467-8624.1994.tb00796.x

Charman, T., Ruffman, T., & Clements, W. (2002). Is there a Gender Difference in

False Belief Development? Social Development, 11(1), 1–10.

https://doi.org/10.1111/1467-9507.00183

Clemmensen, L., van Os, J., Drukker, M., Munkholm, A., Rimvall, M. K., Væver, M.,

Rask, C. U., Bartels-Velthuis, A. A., Skovgaard, A. M., & Jeppesen, P. (2015).

Psychotic experiences and hyper-theory-of-mind in preadolescence – a birth

cohort study. Psychological Medicine.

https://doi.org/10.1017/S0033291715001567

Cook, W. L., & Kenny, D. A. (2005). The Actor-Partner Interdependence Model: A

model of bidirectional effects in developmental studies. International Journal

of Behavioral Development, 29(2), 101–109.

https://doi.org/10.1080/01650250444000405

Crespi, B., & Badcock, C. (2008). Psychosis and autism as diametrical disorders of the

social brain. Behavioral and Brain Sciences, 31(3), 241–261.

https://doi.org/10.1017/S0140525X08004214

De Rosnay, M., & Harris, P. L. (2002). Individual differences in children’s

understanding of emotion: The roles of attachment and language. Attachment

& Human Development, 4(1), 39–54.

https://doi.org/10.1080/14616730210123139

Dermody, S. S., Thomas, K. M., Hopwood, C. J., Durbin, C. E., & Wright, A. G. C.

(2017). Modeling the complexity of dynamic, momentary interpersonal

behavior: Applying the time-varying effect model to test predictions from

interpersonal theory. Journal of Research in Personality, 68, 54–62.

https://doi.org/10.1016/j.jrp.2017.03.001

Devine, R. T., & Hughes, C. (2013). Silent Films and Strange Stories: Theory of

Mind, Gender, and Social Experiences in Middle Childhood. Child

Development, 84(3), 989–1003. https://doi.org/10.1111/cdev.12017

Devine, R. T., White, N., Ensor, R., & Hughes, C. (2016). Theory of mind in middle

childhood: Longitudinal associations with executive function and social

competence. Developmental Psychology, 52(5), 758–771.

https://doi.org/10.1037/dev0000105

Dixon-Gordon, K. L., Whalen, D. J., Scott, L. N., Cummins, N. D., & Stepp, S. D.

(2015). The Main and Interactive Effects of Maternal Interpersonal Emotion

Regulation and Negative Affect on Adolescent Girls’ Borderline Personality

Disorder Symptoms. Cognitive Therapy and Research, 1–13.

https://doi.org/10.1007/s10608-015-9706-4

Dumontheil, I., Apperly, I. A., & Blakemore, S.-J. (2010). Online usage of theory of

mind continues to develop in late adolescence. Developmental Science, 13(2),

331–338. https://doi.org/10.1111/j.1467-7687.2009.00888.x

Dunn, J. (1995). Children as psychologists: The later correlates of individual

differences in understanding of emotions and other minds. Cognition and

Emotion, 9(2–3), 187–201. https://doi.org/10.1080/02699939508409008

Dunn, J., Cutting, A. L., & Fisher, N. (2002). Old Friends, New Friends: Predictors of

Children’s Perspective on Their Friends at School. Child Development, 73(2),

621–635. https://doi.org/10.1111/1467-8624.00427

Dvash, J., & Shamay-Tsoory, S. G. (2014). Theory of mind and empathy as

multidimensional constructs: Neurological foundations. Topics in Language

Disorders, 34(4), 282–295. https://doi.org/10.1097/TLD.0000000000000040

Dykas, M. J., & Cassidy, J. (2011). Attachment and the processing of social

information across the life span: Theory and evidence. Psychological Bulletin,

137(1), 19–46. https://doi.org/10.1037/a0021367

Dziobek, I., Fleck, S., Kalbe, E., Rogers, K., Hassenstab, J., Brand, M., Kessler, J.,

Woike, J. K., Wolf, O. T., & Convit, A. (2006). Introducing MASC: A Movie

for the Assessment of Social Cognition. Journal of Autism and Developmental

Disorders, 36(5), 623–636. https://doi.org/10.1007/s10803-006-0107-0

Eisenberg, N., Sadovsky, A., & Spinrad, T. L. (2005). Associations of emotion-related

regulation with language skills, emotion knowledge, and academic outcomes.

New Directions for Child and Adolescent Development, 109, 109–118.

Ekman, P., & Friesen, W. V. (1976). Pictures of Facial Affect, Consulting tion:

Implications for research on intervention with autism, J. Psychologists Press,

Palo Alto, CA.

Ensink, K., Target, M., & Oandasan, C. (2001). Child Reflective Functioning Scale

scoring manual: For application to the child attachment Interview. Unpublished

Manuscript. UK: Anna Freud Centre/University College London.

Epa, R., & Dudek, D. (2015). Theory of mind, empathy and moral emotions in patients

with affective disorders. Archives of Psychiatry and Psychotherapy, 17(2), 49–

56. https://doi.org/10.12740/APP/44569

Fehon, D. C., Grilo, C. M., & Martino, S. (2000). A Comparison of Dependent and

Self-Critically Depressed Hospitalized Adolescents. Journal of Youth and

Adolescence, 29(1), 93–106. https://doi.org/10.1023/A:1005125322629

Fichman, L., Koestner, R., & Zuroff, D. C. (1994). Depressive styles in adolescence:

Assessment, relation to social functioning, and developmental trends. Journal

of Youth and Adolescence, 23(3), 315–330.

https://doi.org/10.1007/BF01536722

Fink, E., Begeer, S., Peterson, C. C., Slaughter, V., & de Rosnay, M. (2015).

Friendlessness and theory of mind: A prospective longitudinal study. British

Journal of Developmental Psychology, 33(1), 1–17.

https://doi.org/10.1111/bjdp.12060

Fiske, A. P. (1991). Structures of social life: The four elementary forms of human

relations: Communal sharing, authority ranking, equality matching, market

pricing: Vol. xii. Free Press.

Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical

considerations in the treatment of a borderline patient. The International

Journal of Psychoanalysis, 72(4), 639–656.

Fonagy, P., & Bateman, A. (2008). The Development of Borderline Personality

Disorder—A Mentalizing Model. Journal of Personality Disorders, 22(1), 4–

21. https://doi.org/10.1521/pedi.2008.22.1.4

Fonagy, P., Gergely, G., & Jurist, E. L. (2004). Affect regulation, mentalization and

the development of the self. Karnac books.

https://books.google.com/books?hl=en&lr=&id=9-

jBw9_9zSgC&oi=fnd&pg=PR7&ots=zHCyQOaBRH&sig=7qd9ZsqJEky1Cyj

Nmclh0IyVbkk

Fonagy, P., Gergely, G., & Target, M. (2007). The parent-infant dyad and the

construction of the subjective self. Journal of Child Psychology and

Psychiatry, and Allied Disciplines, 48(3–4), 288–328.

https://doi.org/10.1111/j.1469-7610.2007.01727.x

Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to

the understanding and treatment of borderline personality disorder.

Development and Psychopathology, 21(4), 1355–1381.

https://doi.org/10.1017/S0954579409990198

Fonagy, P., Luyten, P., & Strathearn, L. (2011). Borderline personality disorder,

mentalization, and the neurobiology of attachment. Infant Mental Health

Journal, 32(1), 47–69. https://doi.org/10.1002/imhj.20283

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning

manual, version 5.0, for application to adult attachment interviews. London:

University College London.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.466.3207&rep=rep1

&type=pdf

Fosco, G. M., & Grych, J. H. (2013). Capturing the Family Context of Emotion

Regulation A Family Systems Model Comparison Approach. Journal of

Family Issues, 34(4), 557–578. https://doi.org/10.1177/0192513X12445889

Fretland, R. A., Andersson, S., Sundet, K., Andreassen, O. A., Melle, I., & Vaskinn,

A. (2015). Theory of mind in schizophrenia: Error types and associations with

symptoms. Schizophrenia Research, 162(1–3), 42–46.

https://doi.org/10.1016/j.schres.2015.01.024

Frith, C. D., & Frith, U. (2008). Implicit and Explicit Processes in Social Cognition.

Neuron, 60(3), 503–510. https://doi.org/10.1016/j.neuron.2008.10.032

Frith, C. D., & Frith, U. (2012). Mechanisms of Social Cognition. Annual Review of

Psychology, 63(1), 287–313. https://doi.org/10.1146/annurev-psych-120710-

100449

Frith, U., & Frith, C. D. (2003). Development and Neurophysiology of Mentalizing.

Philosophical Transactions: Biological Sciences, 358(1431), 459–473.

Furman, W., & Shomaker, L. B. (2008). Patterns of interaction in adolescent romantic

relationships: Distinct features and links to other close relationships. Journal of

Adolescence, 31(6), 771–788.

https://doi.org/10.1016/j.adolescence.2007.10.007

Gambin, M., Gambin, T., & Sharp, C. (2015). Social cognition, psychopathological

symptoms, and family functioning in a sample of inpatient adolescents using

variable-centered and person-centered approaches. Journal of Adolescence, 45,

31–43. https://doi.org/10.1016/j.adolescence.2015.08.010

Glazebrook, K., Townsend, E., & Sayal, K. (2015). The Role of Attachment Style in

Predicting Repetition of Adolescent Self-Harm: A Longitudinal Study. Suicide

& Life-Threatening Behavior, 45(6), 664–678.

https://doi.org/10.1111/sltb.12159

Gomez-Garibello, C., & Talwar, V. (2015). Can you read my mind? Age as a

moderator in the relationship between theory of mind and relational aggression.

International Journal of Behavioral Development, 39(6), 552–559.

https://doi.org/10.1177/0165025415580805

Goodman, M., & Siever, L. J. (2011). Hypermentalization in adolescents with

borderline personality traits: Extending the conceptual framework to younger

ages. Journal of the American Academy of Child & Adolescent Psychiatry,

50(6), 536–537. https://doi.org/10.1016/j.jaac.2011.02.013

Goth, K., Birkhölzer, M., & Schmeck, K. (2018). Assessment of Personality

Functioning in Adolescents With the LoPF–Q 12–18 Self-Report

Questionnaire. Journal of Personality Assessment, 100(6), 680–690.

https://doi.org/10.1080/00223891.2018.1489258

Guajardo, N. R., & Cartwright, K. B. (2016). The contribution of theory of mind,

counterfactual reasoning, and executive function to pre-readers’ language

comprehension and later reading awareness and comprehension in elementary

school. Journal of Experimental Child Psychology, 144, 27–45.

https://doi.org/10.1016/j.jecp.2015.11.004

Ha, C., Sharp, C., Ensink, K., Fonagy, P., & Cirino, P. (2013). The measurement of

reflective function in adolescents with and without borderline traits. Journal of

Adolescence, 36(6), 1215–1223.

https://doi.org/10.1016/j.adolescence.2013.09.008

Happé, F. G. E. (1994). An advanced test of theory of mind: Understanding of story

characters’ thoughts and feelings by able autistic, mentally handicapped, and

normal children and adults. Journal of Autism and Developmental Disorders,

24(2), 129–154. https://doi.org/10.1007/BF02172093

Hayward, E. O., & Homer, B. D. (2017). Reliability and validity of advanced theory-

of-mind measures in middle childhood and adolescence. British Journal of

Developmental Psychology, 35(3), 454–462.

https://doi.org/10.1111/bjdp.12186

Herpertz, S. C., & Bertsch, K. (2014). The social-cognitive basis of personality

disorders. Current Opinion in Psychiatry, 27(1), 73–77.

https://doi.org/10.1097/YCO.0000000000000026

Herpertz, S. C., Jeung, H., Mancke, F., & Bertsch, K. (2014). Social dysfunctioning

and brain in borderline personality disorder. Psychopathology, 47(6), 417–424.

https://doi.org/10.1159/000365106

Hezel, D. M., & McNally, R. J. (2014). Theory of mind impairments in social anxiety

disorder. Behavior Therapy, 45(4), 530–540.

https://doi.org/10.1016/j.beth.2014.02.010

Hill, C., Maskowitz, K., Danis, B., & Wakschlag, L. (2008). Validation of a Clinically

Sensitive, Observational Coding System for Parenting Behaviors: The

Parenting Clinical Observation Schedule. Parenting, 8(2), 153–185.

https://doi.org/10.1080/15295190802045469

Ho, K. K. Y., Lui, S. S. Y., Hung, K. S. Y., Wang, Y., Li, Z., Cheung, E. F. C., &

Chan, R. C. K. (2015). Theory of mind impairments in patients with first-

episode schizophrenia and their unaffected siblings. Schizophrenia Research,

166(1–3), 1–8. https://doi.org/10.1016/j.schres.2015.05.033

Holden, G. W., Hawk, C. K., Smith, M. M., Singh, J., & Ashraf, R. (2017).

Disciplinary Practices, Metaparenting, and the Quality of Parent–Child

Relationships in African-American, Mexican-American, and European-

American Mothers. International Journal of Behavioral Development, 41(4),

482–490. https://doi.org/10.1177/0165025416687414

Hong, S., & Kim, S. (2019). Comparisons of Multilevel Modeling and Structural

Equation Modeling Approaches to Actor-Partner Interdependence Model.

Psychological Reports, 122(2), 558–574.

https://doi.org/10.1177/0033294118766608

Hops, H., Davis, B., & Longoria, N. (1995). Methodological issues in direct

observation: Illustrations with the Living in Familial Environments (LIFE)

coding system. Journal of Clinical Child Psychology, 24(2), 193–203.

https://doi.org/10.1207/s15374424jccp2402_7

Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988).

Inventory of interpersonal problems: Psychometric properties and clinical

applications. Journal of Consulting and Clinical Psychology, 56(6), 885–892.

https://doi.org/10.1037/0022-006X.56.6.885

Hudson, A., & Jacques, S. (2014). Put on a happy face! Inhibitory control and

socioemotional knowledge predict emotion regulation in 5- to 7-year-olds.

Journal of Experimental Child Psychology, 123, 36–52.

https://doi.org/10.1016/j.jecp.2014.01.012

Hughes, C., & Leekam, S. (2004). What are the Links Between Theory of Mind and

Social Relations? Review, Reflections and New Directions for Studies of

Typical and Atypical Development. Social Development, 13(4), 590–619.

https://doi.org/10.1111/j.1467-9507.2004.00285.x

Hutchins, T. L., Prelock, P. A., Morris, H., Benner, J., LaVigne, T., & Hoza, B.

(2016). Explicit vs. applied theory of mind competence: A comparison of

typically developing males, males with ASD, and males with ADHD. Research

in Autism Spectrum Disorders, 21, 94–108.

https://doi.org/10.1016/j.rasd.2015.10.004

Imuta, K., Henry, J. D., Slaughter, V., Selcuk, B., & Ruffman, T. (2016). Theory of

mind and prosocial behavior in childhood: A meta-analytic review.

Developmental Psychology, 52(8), 1192–1205.

https://doi.org/10.1037/dev0000140

Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., Sanislow, C.,

& Wang, P. (2010). Research domain criteria (RDoC): Toward a new

classification framework for research on mental disorders. The American

Journal of Psychiatry, 167(7), 748–751.

http://dx.doi.org/10.1176/appi.ajp.2010.09091379

Johnson, H. D. (2004). Gender, Grade, and Relationship Differences in Emotional

Closeness within Adolescent Friendships. Adolescence, 39(154), 243–255.

Joseph, M. A., O’Connor, T. G., Briskman, J. A., Maughan, B., & Scott, S. (2014).

The formation of secure new attachments by children who were maltreated: An

observational study of adolescents in foster care. Development and

Psychopathology, 26(1), 67–80. https://doi.org/10.1017/S0954579413000540

Kaufman, E. A., Puzia, M. E., Godfrey, D. A., & Crowell, S. E. (2019). Physiological

and behavioral effects of interpersonal validation: A multilevel approach to

examining a core intervention strategy among self-injuring adolescents and

their mothers. Journal of Clinical Psychology, 1–22.

https://doi.org/10.1002/jclp.22902

Kenny, D. A., Kashy, D. A., & Cook, W. L. (2006). Dyadic Data Analysis. Guilford

Press.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, Severity,

and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity

Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

https://doi.org/10.1001/archpsyc.62.6.617

Keulers, E. H. H., Evers, E. A. T., Stiers, P., & Jolles, J. (2010). Age, Sex, and

Pubertal Phase Influence Mentalizing About Emotions and Actions in

Adolescents. Developmental Neuropsychology, 35(5), 555–569.

https://doi.org/10.1080/87565641.2010.494920

Kimhi, Y. (2014). Theory of mind abilities and deficits in autism spectrum disorders.

Topics in Language Disorders, 34(4), 329–343.

https://doi.org/10.1097/TLD.0000000000000033

Klin, A. (2000). Attributing Social Meaning to Ambiguous Visual Stimuli in Higher-

functioning Autism and Asperger Syndrome: The Social Attribution Task.

Journal of Child Psychology and Psychiatry, 41(7), 831–846.

https://doi.org/10.1111/1469-7610.00671

Kokkinos, C. M., Voulgaridou, I., Mandrali, M., & Parousidou, C. (2016). Interactive

links between relational aggression, theory of mind, and moral disengagement

among early adolescents. Psychology in the Schools.

https://doi.org/10.1002/pits.21902

Krach, S., Blümel, I., Marjoram, D., Lataster, T., Krabbendam, L., Weber, J., van Os,

J., & Kircher, T. (2009). Are women better mindreaders? Sex differences in

neural correlates of mentalizing detected with functional MRI. BMC

Neuroscience, 10, 9. https://doi.org/10.1186/1471-2202-10-9

Laghi, F., Cotugno, A., Cecere, F., Sirolli, A., Palazzoni, D., & Bosco, F. M. (2014).

An exploratory assessment of theory of mind and psychological impairment in

patients with bulimia nervosa. British Journal of Psychology, 105(4), 509–523.

https://doi.org/10.1111/bjop.12054

Langdon, R., Siegert, R. J., McClure, J., & Harrington, L. (2005). Schizophrenia,

theory of mind, and persecutory delusions. Cognitive Neuropsychiatry, 10(2),

87–104. https://doi.org/10.1080/13546800344000327

Laursen, B., & Collins, W. A. (2009). Parent—Child relationships during adolescence.

Handbook of Adolescent Psychology.

http://onlinelibrary.wiley.com/doi/10.1002/9780470479193.adlpsy002002/full

Lazarus, S. A., Cheavens, J. S., Festa, F., & Zachary Rosenthal, M. (2014).

Interpersonal functioning in borderline personality disorder: A systematic

review of behavioral and laboratory-based assessments. Clinical Psychology

Review, 34(3), 193–205. https://doi.org/10.1016/j.cpr.2014.01.007

Levy, K. N., Beeney, J. E., & Temes, C. M. (2011). Attachment and its Vicissitudes in

Borderline Personality Disorder. Current Psychiatry Reports, 13(1), 50–59.

https://doi.org/10.1007/s11920-010-0169-8

Lindsey, E. W., Colwell, M. J., Frabutt, J. M., Chambers, J. C., & MacKinnon-Lewis,

C. (2008). Mother-Child Dyadic Synchrony in European American and African

American Families during Early Adolescence: Relations with Self-Esteem and

Prosocial Behavior. Merrill-Palmer Quarterly, 54(3), 289–315.

Lorey, B., Kaletsch, M., Pilgramm, S., Bischoff, M., Kindermann, S., Sauerbier, I.,

Stark, R., Zentgraf, K., & Munzert, J. (2012). Confidence in emotion

perception in point-light displays varies with the ability to perceive own

emotions. PloS One, 7(8), e42169.

https://doi.org/10.1371/journal.pone.0042169

Luyten, P., Campbell, C., Allison, E., & Fonagy, P. (2020). The Mentalizing Approach

to Psychopathology: State of the Art and Future Directions. Annual Review of

Clinical Psychology, 16(1), null. https://doi.org/10.1146/annurev-clinpsy-

071919-015355

Lyons-Ruth, K., Hennighausen, K., & Holmes, B. (2005). Goal-corrected partnership

in adolescence coding system (GPACS): Coding manual, Version 2.

Unpublished Manuscript. Department of Psychiatry, Harvard Medical School,

Cambridge, MA.

Margolin, G., Oliver, P. H., Gordis, E. B., O’Hearn, H. G., Medina, A. M., Ghosh, C.

M., & Morland, L. (1998). The nuts and bolts of behavioral observation of

marital and family interaction. Clinical Child And Family Psychology Review,

1(4), 195–213.

Mayes, L. C. (2006). Arousal regulation, emotional flexibility, medial amygdala

function, and the impact of early experience: Comments on the paper of Lewis

et al. Annals of the New York Academy of Sciences, 1094, 178–192. Scopus.

https://doi.org/10.1196/annals.1376.018

Mayseless, O., Wiseman, H., & Hai, I. (1998). Adolescents’ relationships with father,

mother, and same-gender friend. Journal of Adolescent Research, 13(1), 101–

123. https://doi.org/10.1177/0743554898131006

McDonald, S. (2012). New Frontiers in Neuropsychological Assessment: Assessing

Social Perception Using a Standardised Instrument, The Awareness of Social

Inference Test. Australian Psychologist, 47(1), 39–48.

https://doi.org/10.1111/j.1742-9544.2011.00054.x

Meins, E., Centifanti, L. C. M., Fernyhough, C., & Fishburn, S. (2013). Maternal

Mind-Mindedness and Children’s Behavioral Difficulties: Mitigating the

Impact of Low Socioeconomic Status. Journal of Abnormal Child Psychology,

41(4), 543–553. https://doi.org/10.1007/s10802-012-9699-3

Merikangas, K. R., He, J.-P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L.,

Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime prevalence of

mental disorders in U.S. adolescents: Results from the National Comorbidity

Survey Replication--Adolescent Supplement (NCS-A). Journal of the

American Academy of Child and Adolescent Psychiatry, 49(10), 980–989.

https://doi.org/10.1016/j.jaac.2010.05.017

Milligan, K., Astington, J. W., & Dack, L. A. (2007). Language and Theory of Mind:

Meta-Analysis of the Relation Between Language Ability and False-belief

Understanding. Child Development, 78(2), 622–646.

https://doi.org/10.1111/j.1467-8624.2007.01018.x

Mills, K. L., Lalonde, F., Clasen, L. S., Giedd, J. N., & Blakemore, S.-J. (2014).

Developmental changes in the structure of the social brain in late childhood

and adolescence. Social Cognitive and Affective Neuroscience, 9(1), 123–131.

https://doi.org/10.1093/scan/nss113

Montag, C., Ehrlich, A., Neuhaus, K., Dziobek, I., Heekeren, H. R., Heinz, A., &

Gallinat, J. (2010). Theory of mind impairments in euthymic bipolar patients.

Journal of Affective Disorders, 123(1–3), 264–269.

https://doi.org/10.1016/j.jad.2009.08.017

Moreau, N., Rauzy, S., Viallet, F., & Champagne-Lavau, M. (2016). Theory of mind

in Alzheimer disease: Evidence of authentic impairment during social

interaction. Neuropsychology, 30(3), 312–321.

https://doi.org/10.1037/neu0000220

Mothersead, P. K., Kivlighan Jr., D. M., & Wynkoop, T. F. (1998). Attachment,

family dysfunction, parental alcoholism, and interpersonal distress in late

adolescence: A structural model. Journal of Counseling Psychology, 45(2),

196–203. https://doi.org/10.1037/0022-0167.45.2.196

Muthén, L. K., & Muthén, B. O. (1998). MPlus User’s Guide. Eighth Edition. Muthén

& Muthén.

Muthén, L. K., & Muthén, B. O. (2002). How to Use a Monte Carlo Study to Decide

on Sample Size and Determine Power. Structural Equation Modeling: A

Multidisciplinary Journal, 9(4), 599–620.

http://dx.doi.org/10.1207/S15328007SEM0904_8

Muthén, L. K., & Muthén, B. O. (2012). Mplus. The Comprehensive Modelling

Program for Applied Researchers: User’s Guide, 5.

http://statmodel2.com/virg_nov_course.shtml

O’Connor, T. G., Hetherington, E. M., Reiss, D., & Plomin, R. (1995). A Twin-Sibling

Study of Observed Parent-Adolescent Interactions. Child Development, 66(3),

812–829. https://doi.org/10.2307/1131952

Odom, E. C., Garrett-Peters, P., & Vernon-Feagans, L. (2016). Racial Discrimination

as a Correlate of African American Mothers’ Emotion Talk to Young Children.

Journal of Family Issues, 37(7), 970–996.

https://doi.org/10.1177/0192513X14521196

Pears, K. C., & Moses, L. J. (2003). Demographics, parenting, and theory of mind in

preschool children. Social Development, 12(1), 1–19.

https://doi.org/10.1111/1467-9507.00219

Pearson, R. M., & Pillow, B. H. (2016). Mother-Child Conversation and Children’s

Social Understanding During Middle Childhood. Journal of Genetic

Psychology, 177(4), 103–121. https://doi.org/10.1080/00221325.2016.1188054

Peterson, C., Slaughter, V., Moore, C., & Wellman, H. M. (2016). Peer social skills

and theory of mind in children with autism, deafness, or typical development.

Developmental Psychology, 52(1), 46–57. https://doi.org/10.1037/a0039833

Popolo, R., Dimaggio, G., Luther, L., Vinci, G., Salvatore, G., & Lysaker, P. H.

(2016). Theory of mind in schizophrenia: Associations with clinical and

cognitive insight controlling for levels of psychopathology. Journal of Nervous

and Mental Disease, 204(3), 240–243.

https://doi.org/10.1097/NMD.0000000000000454

Poznyak, E., Morosan, L., Perroud, N., Speranza, M., Badoud, D., & Debbané, M.

(2019). Roles of age, gender and psychological difficulties in adolescent

mentalizing. Journal of Adolescence, 74, 120–129.

https://doi.org/10.1016/j.adolescence.2019.06.007

Preißler, S., Dziobek, I., Ritter, K., Heekeren, H. R., & Roepke, S. (2010). Social

Cognition in Borderline Personality Disorder: Evidence for Disturbed

Recognition of the Emotions, Thoughts, and Intentions of others. Frontiers in

Behavioral Neuroscience, 4. https://doi.org/10.3389/fnbeh.2010.00182

Privizzini, A. (2017). The Child Attachment Interview: A Narrative Review. Frontiers

in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.00384

Quek, J., Bennett, C., Melvin, G. A., Saeedi, N., Gordon, M. S., & Newman, L. K.

(2018). An investigation of the mentalization-based model of borderline

pathology in adolescents. Comprehensive Psychiatry, 84, 87–94.

https://doi.org/10.1016/j.comppsych.2018.04.005

Raffo De Ferrari, A., Lagravinese, G., Pelosin, E., Pardini, M., Serrati, C.,

Abbruzzese, G., & Avanzino, L. (2015). Freezing of gait and affective theory

of mind in Parkinson disease. Parkinsonism & Related Disorders, 21(5), 509–

513. https://doi.org/10.1016/j.parkreldis.2015.02.023

Rathus, J. H., & Miller, A. L. (2000). DBT for adolescents: Dialectical dilemmas and

secondary treatment targets. Cognitive and Behavioral Practice, 7(4), 425–

434. https://doi.org/10.1016/S1077-7229(00)80054-1

Redcay, E., Dodell-Feder, D., Pearrow, M. J., Mavros, P. L., Kleiner, M., Gabrieli, J.

D. E., & Saxe, R. (2010). Live face-to-face interaction during fMRI: A new

tool for social cognitive neuroscience. NeuroImage, 50(4), 1639–1647.

https://doi.org/10.1016/j.neuroimage.2010.01.052

Rominger, C., Bleier, A., Fitz, W., Marksteiner, J., Fink, A., Papousek, I., & Weiss, E.

M. (2016). Auditory top-down control and affective theory of mind in

schizophrenia with and without hallucinations. Schizophrenia Research.

https://doi.org/10.1016/j.schres.2016.05.006

Rosenblum, L. A. (1978). The creation of a behavioral taxonomy. Observing

Behavior, 2, 15–24.

Rosenfield, S., Vertefuille, J., & Mcalpine, D. D. (2000). Gender Stratification and

Mental Health: An Exploration of Dimensions of the Self. Social Psychology

Quarterly, 63(3), 208–223. JSTOR. https://doi.org/10.2307/2695869

Rutherford, M. D., Baron-Cohen, S., & Wheelwright, S. (2002). Reading the mind in

the voice: A study with normal adults and adults with Asperger syndrome and

high functioning autism. Journal of Autism and Developmental Disorders,

32(3), 189–194.

Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance

outlived its usefulness? Psychotherapy: Theory, Research, Practice, Training,

43(3), 286–291. https://doi.org/10.1037/0033-3204.43.3.286

Samson, D., & Apperly, I. A. (2010). There Is More to Mind Reading than Having

Theory of Mind Concepts: New Directions in Theory of Mind Research. Infant

and Child Development, 19(5), 443–454. https://doi.org/10.1002/icd.678

Schuwerk, T., Vuori, M., & Sodian, B. (2015). Implicit and explicit Theory of Mind

reasoning in autism spectrum disorders: The impact of experience. Autism,

19(4), 459–468. https://doi.org/10.1177/1362361314526004

Scott, S., Briskman, J., Woolgar, M., Humayun, S., & O’Connor, T. G. (2011).

Attachment in adolescence: Overlap with parenting and unique prediction of

behavioural adjustment. Journal of Child Psychology and Psychiatry, and

Allied Disciplines, 52(10), 1052–1062. https://doi.org/10.1111/j.1469-

7610.2011.02453.x

Sharp, C., Ha, C., Carbone, C., Kim, S., Perry, K., Williams, L., & Fonagy, P. (2013).

Hypermentalizing in Adolescent Inpatients: Treatment Effects and Association

With Borderline Traits. Journal of Personality Disorders, 27(1), 3–18.

https://doi.org/10.1521/pedi.2013.27.1.3

Sharp, C., Mosko, O., Chang, B., & Ha, C. (2011). The cross-informant concordance

and concurrent validity of the Borderline Personality Features Scale for

Children in a community sample of boys. Clinical Child Psychology and

Psychiatry, 16(3), 335–349. https://doi.org/10.1177/1359104510366279

Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., & Fonagy, P. (2011).

Theory of Mind and Emotion Regulation Difficulties in Adolescents With

Borderline Traits. Journal of the American Academy of Child & Adolescent

Psychiatry, 50(6), 563-573.e1. https://doi.org/10.1016/j.jaac.2011.01.017

Sharp, C., Steinberg, L., Temple, J., & Newlin, E. (2014). An 11-item measure to

assess borderline traits in adolescents: Refinement of the BPFSC using IRT.

Personality Disorders: Theory, Research, and Treatment, 5(1), 70–78.

https://doi.org/10.1037/per0000057

Sharp, C., & Vanwoerden, S. (2015). Hypermentalizing in Borderline Personality

Disorder: A Model and Data. Journal of Infant, Child, and Adolescent

Psychotherapy, 14(1), 33–45. https://doi.org/10.1080/15289168.2015.1004890

Slade, A. (2005). Parental reflective functioning: An introduction. Attachment &

Human Development, 7(3), 269–281.

https://doi.org/10.1080/14616730500245906

Slade, A., Aber, J. L., Berger, B., Bresgi, I., & Kaplan, M. (2016). Parent

Development Interview—Revised; Short Version. Unpublished protocol.

Slade, A., Bernbach, E., Grienenberger, J., Levy, D. W., & Locker, A. (2015).

Addendum to Reflective Function Scoring Manual. For use with the Parent

Development Interview. Unpublished protocol.

Slaughter, V., Imuta, K., Peterson, C. C., & Henry, J. D. (2015). Meta-Analysis of

Theory of Mind and Peer Popularity in the Preschool and Early School Years.

Child Development, 86(4), 1159–1174. https://doi.org/10.1111/cdev.12372

Slaughter, V., & Repacholi, B. (2003). Introduction: Individual differences in theory

of mind: What are we investigating?

http://espace.library.uq.edu.au/view/UQ:69616

Smetana, J. G., Campione-Barr, N., & Metzger, A. (2006). Adolescent development in

interpersonal and societal contexts. Annual Review of Psychology, 57, 255–

284. https://doi.org/10.1146/annurev.psych.57.102904.190124

Steinberg, L., & Morris, A. S. (2001). Adolescent development. Journal of Cognitive

Education and Psychology, 2(1), 55–87.

https://doi.org/10.1891/194589501787383444

Stemler, S. E. (2004). A comparison of consensus, consistency, and measurement

approaches to estimating interrater reliability. Practical Assessment, Research

& Evaluation, 9(4), 1–11.

Stepp, S. D., Lazarus, S. A., & Byrd, A. L. (2016). A systematic review of risk factors

prospectively associated with borderline personality disorder: Taking stock and

moving forward. Personality Disorders: Theory, Research, and Treatment,

7(4), 316–323. http://dx.doi.org/10.1037/per0000186

Stepp, S. D., Scott, L. N., Jones, N. P., Whalen, D. J., & Hipwell, A. E. (2016).

Negative emotional reactivity as a marker of vulnerability in the development

of borderline personality disorder symptoms. Development and

Psychopathology, 28(1), 213–224.

https://doi.org/10.1017/S0954579415000395

Symeonidou, I., Dumontheil, I., Chow, W.-Y., & Breheny, R. (2015). Development of

online use of theory of mind during adolescence: An eye-tracking study.

Journal of Experimental Child Psychology.

https://doi.org/10.1016/j.jecp.2015.11.007

Target, M., Fonagy, P., Shmueli-Goetz, Y., Datta, A., & Schneider, T. (1999). The

child attachment interview (CAI) protocol. Unpublished Manuscript,

University College London.

Taubner, S., Hörz, S., Fischer-Kern, M., Doering, S., Buchheim, A., & Zimmermann,

J. (2013). Internal structure of the Reflective Functioning Scale. Psychological

Assessment, 25(1), 127–135. https://doi.org/10.1037/a0029138

Thomas, S. A., Wilson, T., Jain, A., Deros, D. E., Um, M., Hurwitz, J., Jacobs, I.,

Myerberg, L., Ehrlich, K. B., Dunn, E. J., Aldao, A., Stadnik, R., & Reyes, A.

D. L. (2017). Toward Developing Laboratory-Based Parent–Adolescent

Conflict Discussion Tasks that Consistently Elicit Adolescent Conflict-Related

Stress Responses: Support from Physiology and Observed Behavior. Journal of

Child and Family Studies, 26(12), 3288–3302. https://doi.org/10.1007/s10826-

017-0844-z

Vanwoerden, S., Garey, L., Ferguson, T., Temple, J. R., & Sharp, C. (2018).

Borderline Personality Features Scale for Children-11: Measurement

invariance over time and across gender in a community sample of adolescents.

Psychological Assessment. https://doi.org/10.1037/pas0000640

Vanwoerden, S., Greiner, I., Ensink, K., & Sharp, C. (2019). The relations between

self- and caregiver- focused reflective function and theory of mind in the

context of borderline pathology in adolescence. Psychiatry Research, 273,

274–280. https://doi.org/10.1016/j.psychres.2019.01.042

Vanwoerden, S., Kalpakci, A. H., & Sharp, C. (2015). Experiential avoidance

mediates the link between maternal attachment style and theory of mind.

Comprehensive Psychiatry, 57, 117–124.

https://doi.org/10.1016/j.comppsych.2014.11.015

Vaskinn, A., Antonsen, B. T., Fretland, R. A., Dziobek, I., Sundet, K., & Wilberg, T.

(2015). Theory of mind in women with borderline personality disorder or

schizophrenia: Differences in overall ability and error patterns. Frontiers in

Psychology, 6. https://doi.org/10.3389/fpsyg.2015.01239

Venta, A., & Sharp, C. (2015). Mentalizing Mediates the Relation Between

Attachment and Peer Problems Among Inpatient Adolescents. Journal of

Infant, Child, and Adolescent Psychotherapy, 14(3), 323–340.

https://doi.org/10.1080/15289168.2015.1071997

Venta, A., Shmueli-Goetz, Y., & Sharp, C. (2014). Assessing attachment in

adolescence: A psychometric study of the Child Attachment Interview.

Psychological Assessment, 26(1), 238–255. https://doi.org/10.1037/a0034712

Vetter, N. C., Weigelt, S., Döhnel, K., Smolka, M. N., & Kliegel, M. (2014). Ongoing

neural development of affective theory of mind in adolescence. Social

Cognitive and Affective Neuroscience, 9(7), 1022–1029.

https://doi.org/10.1093/scan/nst081

Vonk, J., Zeigler-Hill, V., Ewing, D., Mercer, S., & Noser, A. E. (2015). Mindreading

in the dark: Dark personality features and theory of mind. Personality and

Individual Differences, 87, 50–54. https://doi.org/10.1016/j.paid.2015.07.025

Washburn, D., Wilson, G., Roes, M., Rnic, K., & Harkness, K. L. (2016). Theory of

mind in social anxiety disorder, depression, and comorbid conditions. Journal

of Anxiety Disorders, 37, 71–77. https://doi.org/10.1016/j.janxdis.2015.11.004

Wechsler, D. (1999). Wechsler abbreviated scale of intelligence. Psychological

Corporation.

Weymouth, B. B., Buehler, C., Zhou, N., & Henson, R. A. (2016). A Meta-Analysis of

Parent–Adolescent Conflict: Disagreement, Hostility, and Youth

Maladjustment. Journal of Family Theory & Review, 8(1), 95–112.

https://doi.org/10.1111/jftr.12126

Whalen, D. J., Kiel, E. J., Tull, M. T., Latzman, R. D., & Gratz, K. L. (2015). Maternal

Borderline Personality Disorder Symptoms and Convergence Between

Observed and Reported Infant Negative Emotional Expressions. Personality

Disorders: Theory, Research, and Treatment.

https://doi.org/10.1037/per0000116

Yasui, M., & Dishion, T. J. (2008). Direct Observation of Family Management:

Validity and Reliability as a Function of Coder Ethnicity and Training.

Behavior Therapy, 39(4), 336–347. https://doi.org/10.1016/j.beth.2007.10.001

Zaki, J., & Ochsner, K. (2009). The Need for a Cognitive Neuroscience of Naturalistic

Social Cognition. Annals of the New York Academy of Sciences, 1167, 16–30.

https://doi.org/10.1111/j.1749-6632.2009.04601.x

APPENDICES

A. OBSERVATIONAL CODING SYSTEM

Index of (Positive) Mentalizing This code is meant to capture the indices of positive mentalizing within each member of the dyad. Coding this scale first can facilitate coding of the remaining scales. To code this scale, coders should attend to the responsiveness of the target to their partner as mentalizing refers to the appropriateness of one’s response to the actions of another. Therefore, codes cannot be determined without attention to both members of the dyad. Mentalizing can be conceptualized as adopting a curious stance in interactions (e.g., asking for the others’ perspective or to elaborate on a perspective as well as clearly expressing own perspective) such that one demonstrates interest and acknowledges agency of the other. Nonverbal displays of interest include mirroring, both in terms of tone of voice and body posture as well as behaviors that demonstrate that one is attentive to the other, such as holding eye contact, sitting up and facing the partner, and nodding or other non-verbal indications that one is following the other. It also includes demonstrating patience and warmth in order to give the other person space and comfort so they are able to mentalize and express themselves. Particularly for mothers, mentalizing can be modeled for the child by presenting alternative perspectives (i.e., discussing the perspective of a third person) or being explicit about their recognition of their own and their child’s mental states. Other indicators of mentalizing include authenticity, flexibility, and playfulness. While authenticity is difficult to operationalize, in order to evaluate its presence, the coder should focus on the alignment between the content of one’s discourse and nonverbal displays. When an individual is demonstrating authenticity, there should a connection between these two things with a coder having the sense that the individual is genuine and non-defensive. The ability to maintain mentalizing during painful or emotionally charged situations indicates high mentalizing capacity in an individual. Codes from 1-7 can be assigned to individuals. Anchor points are described for the odd points of the scale; however, even numbered codes can be assigned if an individual displays mentalizing that lies in between two anchor points. While each member of the dyad is coded using the same scale, there are behavioral examples to illustrate each anchor point as would be demonstrated by a parent or adolescent given that behaviors are often displayed differently given different developmental stages and respective places in the relationship hierarchy.

1 – No displays of mentalizing • An individual should be assigned this code if there are no indications that one is engaging in mentalizing • There is no use of mental state language (both in terms of thoughts or feelings) for the self or other, so discourse is focused on concrete or observable things

• If the partner states their perspective, an individual may acknowledge the perspective, but they will not ask for elaboration and will not respond with their own perspective o Additionally, there is no change of behavior or discourse in response to the partner. As seen in the first example for parents below, the child is being minimally responsive, but the mother is not showing any curiosity toward his mind and therefore the discussion is quite one- sided • Absence of positive displays of mentalizing also include non-verbal displays— while a dyad may be making eye contact and talking to each other, indicators of interest and curiosity are not present—the individual may not be sitting forward or using any warm gestures/nonverbals to invite the other to share their mental state. Affect may be neutral or even negative • Discussion may revolve around concrete events or facts • Assigning somebody this score does not necessarily indicate a negative interaction or high emotional intensity; however, it is purely based on concrete, observable events. It is possible, though, that the interaction is marked by negativity and discord and still does not indicate any mentalizing Adolescent Specific Notes • Adolescents may be responsive to their mother; however, the discourse never enters the realm of mental states. If asked specifically about mental states (as in the example below), the adolescent either actively refuses to respond or provides a concrete response. Examples for Adolescents Examples for Parents P: So, what is your thought whenever we In a discussion about fighting with the ask you to put down the iPad? What adolescents’ younger siblings: are you thinking when you continue to play? P: You can’t lock him out of his room, C: Hmmm.. if it’s his room too. Right? So P: Do you think about the consequences? that’s the problem. Because that C: *makes noise* starts arguing, right? With that P: Do you think about just continuing to being their room too, you know playing the game and ignoring us? that’s what starts the arguments. C: *mumbles* You’re not allowed to just lock him P: What did we tell you about thinking out of his room. It’s his room too, about your actions and what the where is he supposed to go? Right? consequences are. You don’t like Now how about me being left being grounded or having your iPad alone? I like my space. You crawl taken away. Also we deserve more in my room too much. Mhm? You respect so when you ignore us like know you do. Why? that, it’s showing us disrespect. I know C: Cause I’m mommy’s kangaroo! 98

you know that. So what can we think P: *laughs* You’re mommy’s of or do the next time we ask you to kangaroo? Yeah. Um, you know put down the iPad? when mommy is frustrated? And I C: Go up and get ready. tell you to go ahead? And you don’t want to, and then I get Here the child is being relatively louder. And I tell you for real S, get responsive to their mother, and the out of my face. Go ahead. And you discussion is not necessarily getting wanna get up and stomp down the heated, but the child is not hallway and shut the door – slam acknowledging any mental states. the door. What are we gonna do to P: See? You should keep your room tidy fix that hmm? so you don’t have to worry about C: Take deep breaths. spiders. Um, also, I feel like other stuff P: And? gets lost in there, that’s part of the C: Um, try to talk it out. reason. Like, I lost my screwdriver P: That works. Um, so… The sets. I don’t know where they are. But, discussions haven’t gone very well I don’t really know how we can at all, right? You all have started to actually make progress on it or come play up all around the living room to an agreement on it, because I wish like my living room is a play area. your room was not a mess, and I feel And I tell you all don’t play, and like you would rather spend your time for some reason you act like they doing things other than cleaning. have hearing problems then. And C: Yeah. then I have to get loud right? But I P: I dunno, it’s frustrating because, I’ve have to tell you once again, I’m not tried a lot of different, like, playing with y’all, go down the organizational systems or whatever to hallway. Then y’all just wanna give you options for like, getting your storm and do whatever down there. stuff put away. I don’t know why but And then it comes down to the spiders don’t seem to like junk piled wrestling. You pick them up and up in bins compared with junk piled slam them and all that, when, what up on the floor, so… did I tell you about wrestling? They C: Maybe if they go in the bin, shut the could get really hurt and that’s not lid, and they get like suffocated, alright, right? maybe that’s why they don’t like it. C: Mhm P: I have no idea, like they can climb as P: And, I understand that you want to well, so… be left by yourself sometimes, you C: Maybe they watch their friends die don’t want to play with your slowly in the bin - younger brothers, I understand that. P: That’s terrible. [Laughs] I don’t know. So then what happens if you take Do you think there’s anything we can one of your Goosebump books and do to, like, get your room into a tidier going and laying down in state? Mommy’s bed to read it? Cause you can’t tell them to get out of a room that’s theirs, right? So instead

C: Maybe like, I don’t know. If we have of wanting to blast music and like a big break or something I could ignore everybody, why don’t you do it then. Like, the weekend, or - just go and make good use of it and P: We have one coming up. take one of your books and go into C: Normally for the weekend that’s like my room, lay down and start the only time I have off from school, reading, right? That would be a so… good solution wouldn’t it?

While mom is being quite patient and While this mother is using some calm in this interaction (her tone and mental state talk (usually with regard posture is warm and accepting), son is to herself), she is not calibrating the merely being responsive without discussion to the mental states of her mentalizing. At the end, he comes close to son who is being compliant, but mentalizing (saying that he doesn’t feel minimally engaged. Mom is not like cleaning when he is on break), but he eliciting his perspective or checking in ends up keeping it on a concrete basis. with him in an authentic way. This is particularly apparent in the way that multiple themes come up in a row without any input from the child.

3 – Low level displays of mentalizing • There is some use of mental state language; however, this may not be consistent throughout the interaction and there is a failure to consider complexity of mental states o Individuals may discuss their experience without providing a broader context with any physical or material reality o Use of global statements (e.g., never, always) o Somewhat simple mental state attribution • Only slight calibration of own ideas via the perspective of partner o This does not necessarily mean that an individual is actively refuting the mental states or perspective of the other, but they are not demonstrating a shift in their own behavior or discourse in response to the perspective of the other • Slight expectation that own views will be extended by partner • One or more instances where the individual was expected to respond in a mentalizing way, for example after being explicitly asked to reason about mental states, and failed to do so (e.g., “why did you do that?” “I don’t know”) Examples for Adolescents Examples for Parents The difference from “absent Child: (hand on face and looking down mentalizing” is that here the child may after stating a fact that is contrary to be giving some indications of their mom’s argument) whatever

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mental state or an attempt to still Parent: don’t get defensive! That’s what engage with the parent. They may be we argue about all the time. doing this with ineffective means. For example, in an argument where the Here the parent has lowered her voice to parent is talking to the child about match the child who is starting to shut lying, the parent has switched to more down. The mom is making an attempt to authentic discussion about why the keep the child engaged; however, in lying is a problem rather than labeling the child’s behavior as defensive accusations. The child responds with she is making an assumption of the child’s “oh well”, but her voice is also soft (so mental state and not acknowledging the not matching with the potential possibility that it is more complex. sarcasm of the comment), which Sometimes when adolescents have shut indicates (via implicit/automatic down (either over- mentalizing) that she is also troubled agreeable/accommodating or stopped by the situation. Here the child is talking all together), parents will shift to unable to explicitly acknowledge her the next conflict topic. While in these mental state, but is giving a nonverbal situations, parents have acknowledged that acknowledgement. the child is unable to engage (minor index of mentalizing), they do not realize that another topic of conflict will not shift the child’s mental state. In a back and forth between a parent In this example, the discussion is about a and son where mom is trying to get son bothering his mom. Here mom is information about the people her son doing some self-mentalizing to try and hangs out with; son is mostly describe that she wants to be left alone responding with one-word answers, and this has nothing to do with how she although he is representing his mental feels about her son and is trying to relate it state it is overly simplistic and he can’t to his own feelings of frustration with his quite elaborate on what is happening siblings. However, her expectation that he internally just change his attitude toward it is over simplistic; therefore, she is not extending P: So like when I found stuff out that I her mentalizing toward her son and is also know is happening, does it make you not providing a fully elaborate description mad? of her own mental states in these C: Yeah, it just bugs me. situations. P: But I mean, how else would I find this stuff out? And, I don’t know a solution to help you C: It’s just so weird that you know – with when I feel frustrated and I want like that you get on my phone that way. to be left alone. I just want to be left It’s so weird cause like, it’s just weird. alone. That’s just it. I don’t know what P: But I mean like how could we fix it? they want me to say about that. I just C: I don’t know.. want to be left alone sometimes, so. You can change your attitude on how you take it, because it’s not like we

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don’t see each other every day and spend time and all that other extra good stuff, right? But when I want to be left alone, I just want to be left alone. No reason to have an attitude about it, right? You can be my kangaroo when I’m done being all frustrated. And am asking for a minute to myself. Cause didn’t you just say that sometimes your brothers just get on your nerves and you want to be left alone like me? So you know, kids can be frustrating to people. Right?

5 – Moderate level of mentalizing • Mentalizing is apparent during approximately half of the discussion • Use of mental state language is present during non-emotionally charged instances of the discussion (i.e., able to identify mental states in the self and other). This language is elaborate and demonstrates an understanding of the multifaceted nature of mental states • There is some attempt to reach shared perspective o Hostility is mostly absent through the interaction • May not demonstrate change in behavior in response to ruptures/stop in the flow of interaction • An individual will show interest in the partner, in the case of mothers, this will be done by both explicitly asking questions about the child’s mental state and perspective as well as nonverbally with body posture, tone of voice, and warmth to demonstrate curiosity and openness to the perspective to the other. With adolescents, this will be demonstrated primarily through an openness to the perspective of mothers. An adolescent may not necessarily explicitly ask the mother for her perspective. Examples for Adolescents Examples for Parents In a slightly heated discussion about Parent: It’s not ‘oh well’, this is a big behavior toward siblings, a mom is issue between us. I don’t like explaining to the child that the older feeling like I can’t believe what you brother is picking on the child because he say. I know that most of the time, is trying to get a reaction and that he you are telling the truth, but then I should try to ignore it because when the second guess myself because prior older brother gets a reaction, he keeps to that you lied about something doing it. The child responds (in a whiney voice) “it’s hard!” Here mom is making an acknowledgement that this conflict is 102

Here the child is recognizing his own an issue for her by expressing some limitations, which has an underlying sense vulnerability. She is also taking of self-understanding, but he can’t make responsibility that she may be making the explicit link between what is assumptions about the child lying happening internally during those moments and his behaviors. Also his response is unelaborated. P: [sighs] I never knew that you were- we In a discussion about the child lying were shoving it down your throat. [talking about schoolwork and getting trouble about church] for misbehaving in school, mom shows C: Yeah. good attention to mental states and is P: Yeah, but you went with us. able to identify her own and her child’s C: I have to. I have to go to- with you. mental states. For example: P: Yeah.. “I think that you perceive things—like C: I don’t want to. I think you take them very personal. I P: Why? think you take things like you're being C: Cause I don’t believe in everything that treated unfairly and I don’t think that's you believe in. the case.” P: But there may not belief in it, but I And think it’s good for you. “it’s stressing me out thinking that your C: Well, it’s not good. I don’t think it’s grade is going to drop” good for me. P: Well you liked it before didn’t you? While mom seems to show complexity C: Not really. I would call myself a non- of thinking and acknowledgement of practicing Christian because I don’t both her and her son’s mental states, actually care. So it would be like, I know she does not stop to check in with her that God’s real but I don’t care, cause I son. While there is not a clear rupture don’t believe in all the things that you in the interaction, mom does not seem guys believe in. Like you think that gay attuned to the possibility that her son people are bad and I don’t believe that may not be following her. In a discussion about schoolwork that Here in this discussion about religious the child has not been completing, beliefs, there is an attempt by the daughter mom is trying to encourage the child to in a relaxed manner to explain how her boost his confidence (e.g., “I know you perspective differs. It’s notable that she can do this, you’re a straight A switches her statement from “it’s not student”); however, she is not stopping good” to “I don’t think it’s good for me” to check in about his perspective (what may be getting in the way of doing his work). So while mom has interest in her son and is maintaining positive shared affect, she is not fully attuned to an alternative perspective of the child.

7 – High quality of mentalizing

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• Mental state language is prevalent and demonstrates some degree of complexity o Complexity and elaboration of mentalizing will be somewhat less in adolescents compared to mothers, particularly younger adolescents o For mothers, especially, there is an ability to elaborate on the other’s experience (e.g., validation) o Consistent responses to demands for mentalizing, such that if explicitly prompted, one can label a mental state and possibly elaborate on it • One will convey ownership of own behavior and therefore indicating an acknowledgement of one’s own agency and a clear understanding that one’s behaviors are driven by complex mental states • The interaction is relaxed and flexible, such that one can discuss even highly contentious matters without losing a mentalizing stance. Additionally, even when the interaction gets contentious, there is still the sense that one is open to the perspective to the other o The curious stance is prevalent, but may become limited during more contentious aspects of the interaction as indicated with nonverbal and verbal displays o There is a use of play and humor to indicate warmth and openness to the other • There is an earnest attempt toward a give and take between self and partner, which can be seen often through a curious stance and non-hostile and non- intrusive attempts to elicit the perspective of the other o A shared perspective can be reached and feels authentic. This indicates that the individual understand and appreciates the mental state of the other; it does not necessarily mean that there is a resolution to the conflict being discussed • Shared affect is present for at least half of the interaction • There is a consistent balance between polarities of mentalizing during less contentious aspects of the interaction • Use of third person perspective when relevant • Mentalizing in response to ruptures (if the partner is quiet or struggling to express themselves) • Ability to balance concern and interest in both the self and other with obvious attention toward the relationship Adolescent Specific Notes • Even among adolescents with high levels of mentalizing, it is not expected that adolescents will strongly mentalize their parents, given the hierarchical nature of the parent-child relationship. However, adolescents receiving this code should demonstrate some appreciation of their mothers’ mental states if they 104

are presented to them. Therefore, there will be no active derogation toward their mother’s perspective. Examples for Adolescents Examples for Parents In a discussion about the child’s In a conflict about the child’s behavior behavior in school, the child refers to toward his older brother—they are an incident that happened recently discussing how the child feels as if his (here the use of a concrete example is brother doesn’t want to play with him helpful to root perspective in a anymore. The mom is suggesting context) organizing toys and restructuring “Sometimes teachers are really activities, but in doing so she first listens annoying and I don’t want to do their to the child’s description of the game he work (and gives his example where a likes to play and then uses this game as teacher said something condescending an example of how things can be to him)…and that made me really mad restructured. Rather than the solution she so I didn’t want to do his work” offers, it is a positive indication that she listens to the child and demonstrates that The child is taking some ownership of she listens and understands by speaking his behavior (not doing school work) the details back to him. as a result of a negative reaction to somebody’s behavior. While he could She also discusses the older sibling’s be a little more reflective and perspective by saying that he is older and complex, the fact that he is able to has different interests (use of third acknowledge his own affective person’s perspective) vulnerability and recognize that maladaptive behavior is due to this is a positive indicator of mentalizing In a discussion about the child staying In a discussion about a child shutting in bed too long in the mornings: down:

C: Well, for one, who doesn’t have P: We were talking about how I respond. trouble getting out of bed in the My issue is how you walk away with an morning attitude. I’ve told you how it bothers me P: *laughs* of course C: But I just have a flat face. It doesn’t C: And when I press the snooze mean I have an attitude. button, I really actually believe in my P: I know, but if we just have an mind that I will only stay in bed for argument and then you walk away five more minutes…but then five without saying anything with a flat face, I minutes becomes 10 and so on.. assume that you’re upset. P: Yea C: Sometime I just get irritated. C: And sometimes I lay there and I P: Could we work toward you expressing think ‘is it even worth it to get out of yourself differently? bed,’ like I really don’t think I can handle the day and think to myself Here the mom walks through, in an explicit way, how she arrives at her 105

‘it’s easier if I just sit here in my bed mental state attribution. She does so in a where it’s safe’ non-blaming way so that she leaves room I know that if I get out of bed and get for her daughter to insert her own moving I will feel better about it later, perspective. but in that moment, I can’t take my mind there.

The child is able to mentalize herself quite well—she is relaxed and open while talking about something quite vulnerable In a discussion about fighting with siblings, the child starts off (upset and high tone of voice) by saying that his sibling “always” starts it. Mom responds in a slightly teasing voice “I understand that it’s your opinion that aaalways the other person starts it”

Here, mom uses gentle teasing, while her body language is engaged (leaning slightly forward, half smile) to challenge the child’s non-mentalizing stance. By maintaining a positive affect and staying regulated while doing this, she is able to move the child a little bit in his position in order to have a productive conversation.

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Indices of Negative or Maladaptive Mentalizing Based on previous research and clinical observations, maladaptive mentalizing can take on various forms. One model of mentalizing suggests a curvilinear relationship between arousal and mentalizing such that at very low levels of arousal, there is an under-attribution of mental states and focus on the concrete (hypomentalizing), but at high levels of arousal, there is an over-attribution of mental states that sometimes go beyond observable data (hypermentalizing). These forms of maladaptive mentalizing largely refer to the degree of mental state attribution The following two scales are coded independently to capture the degree to which individuals may engage in these forms of maladaptive mentalizing. Because an individual may oscillate between different strategies of maladaptive mentalizing, these codes are not mutually exclusive of one another and should be coded independently of one another. There is a possibility that an individual does not display particularly high quality mentalizing, but will still score highly on these scales. High points on these scales simply indicate that one does not engage in that particular form of maladaptive mentalizing.

Hypermentalizing Hypermentalizing can be defined as the over-attribution of mental states to the self or other. The return to psychic equivalence (mental reality = outer reality) is an example of hypermentalizing with individuals unable to take an alternative perspective. Here, mental states feel very real, even when they do not match with the facts of a situation. It is common to see a move toward over-certainty and at extreme levels, paranoia or suspicion as it often includes attributions of malintent to others. However, this is not a necessary indication of hypermentalizing as it generally refers to a tendency to attribute mental states to others that go beyond factual or likely reasons for behavior. Additionally, there is an intolerance of alternative perspectives. There are instances that an individual may be hypermentalizing by making statements about the other’s behavior that imply an assumption of intention behind behavior that is malevolent (e.g., lying, manipulating, doing something on purpose). This is particularly apparent if these statements are accompanied by emotion dysregulation or arousal—these assumptions feel very real to the individual.

1 – High Hypermentalizing • Mentalizing is predominantly automatic—in this case you will see quick reactions to the other person, which do not seem thought through or reflected on • Hypermentalizing is likely to occur at high levels of arousal when individuals are struggling to regulate emotions and therefore have difficulty integrating the cognitive and affective aspects of mentalizing (i.e., slow down to reflect when their affects are dominating their behavior and thinking). • Explanations for behavior may be overly complex and don’t necessarily seem plausible given the facts of the discussion 107

• Hypersensitivity to partner’s cues (e.g., “why are you looking at me like that!?”) • Rigid, polarized thinking such that global statements are prevalent throughout the interaction and there is an inability to shift perspectives based on information being presented by the other. • One’s perspective (e.g., I am being victimized) can lead to extreme reactions (I’m never speaking to you again) because mental states feel very real and there is extreme difficulty in shifting perspective. These reactions feel justified because the seriousness in which they experience mental states. • Defensiveness or punishment when partner’s perspective is shared. This may lead to doubling down on one’s own perspective Examples for Adolescents Examples for Parents P: She says the attitude and manners, I Parent: How will we fix the whole mean, I don’t have no problems with homework situation? manners, but I have a problem with Child: I do my homework. your attitude when you embarrass me Parent: No, you don’t and stuff. C: It sucks because like, even if I just Here, the parent doubles down on wanna talk to you about stuff, like, I insisting that the child is wrong stayed up last night ‘cause I thought rather than slowing down because you were gonna come up and just talk the child may be feeling defensive. to me for a minute after we got back The parent also does not adjust her from dinner or something. tone to match the child who has P: Yeahhh but I keep telling you like, I’m started to speak softer and look not a mind reader and if you want to down rather than make eye contact. talk to me or talk about something else you need to let me know C: And really I just wanted to- wanted to be out of the house. P: But you can’t walk away from your problems, like you can’t, like, escape, you can’t- C: They’re actually not even my problems, they’re your and Tony’s problems. This example is from an interaction between a mom and her son; she is confronting him about bullying his siblings. Mom focuses on the external features of her son (an expression he has on his face) and gets set on what he must be thinking because of this look. Mom’s 108

response is automatic and rigid and as she focuses in on what she believes her son is thinking, she becomes more dysregulated, which pushes her further into her belief about what is happening.

P: Cause you’re his little brother and you’re getting on his nerves. Right? But your face don’t look like that’s right. Your face look like its saying no. is it? C: No. P: Is your face saying no? Cause you don’t agree with that because that’s not right. I wish they could pull the camera in on your face right now, cause that’s the dumb look I always tell them about when you’re being confronted about things that you should not be doing, how you always get this simple grin stare on your face like you’re a deer caught in headlights. Cause you got it right now. Just to zoom in on you and just pull it up ‘I don’t know what she’s talking about’.

3 – Moderately High Hypermentalizing • Explanations for behavior may be overly complex in some instances, but this is not necessarily prevalent. Inaccurate attributions of the other’s perspective do not only take place when arousal is high and are occurring for more than half of the interaction. • Also during highly arousing situations will an individual punish the others’ perspective • Black and white (all or nothing) thinking is apparent and global statements are used often • There is difficulty shifting perspective about the mental states of the self or other, although when arousal is low, it may be possible. However, even when arousal is low, there still may be indications that the individual is overly certain about their perspective,

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o It should be noted that perspective rigidity is not the same as stubbornness or arguments about the facts of a situation, which will be quite common. It is more referring to assumptions about the mental states (e.g., “you don’t want me to have fun”) Examples for Adolescents Examples for Parents In a discussion about time a mother’s When asked why the child lies: boyfriend: C: The reason I like lying so much is because sometimes I get really C: He hates theatre people nervous and I just lie. P: No he doesn’t, he just isn’t interested in P: (partly interrupting the child) it the same way that you are That’s not why you like lying, I C: No, he hates it—every time I bring up asked why you like lying my theatre group, he changes the subject While the child is having some difficulty expressing herself, the parent is unable to slow down and facilitate this for the child, who has given some indication of what tends to happen when they lie. After a son says that he won’t follow his mom’s suggestion for a resolution to their conflict

P: Why does that make you upset? You just want to do what you want to do, whatever you want to do, for however long you want to do it? You think that’s reasonable?

5 – Moderately Low Hypermentalizing • Only in highly contentious situations will an individual may make inaccurate attributions of mental states; however, they are able to shift perspective if given feedback o Feedback is clearly being processed by an individual because they shift their behavior, even if there is not a verbal acknowledgement of this feedback • Extreme statements are only made at extreme levels of arousal • When arousal is not high, there still may be indications that the individual is certain about their perspective, although they will not actively discount or refute the perspective of the other

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Examples for Adolescents Examples for Parents C: Mom, there’s so many reasons that I P: So I understand, we have cannot tell you everything. You will – differences, but part of it, and it you punish me sometimes for telling goes into different things, it feels you things. I’m surprised that I’m not to me like you only wanna do punished now for telling you that. things your way, and if it’s not P: Well, what can I do? your way you won’t even C: I don’t know…but when you punish entertain it. Like even the me, it makes me not feel like I can tell school activities, today, what did you stuff I tell you before we left? P: Well – I – how can I? C: To do my school. C: Yeah. P: And what did you do? P: So you have a boyfriend? C: I made jewelry. C: Yeah and we’re – ok bi- bi means that P: So, I need you to understand that you like girls- Daddy and I are the parents, and P: I know- you’re the kid. And yes, I try to C: -and guys. understand your point of view, P: - what it means! and I’m not always gonna get it C: Yeah. perfect, but I do try, but it’s P: [deep sigh] We’re off the topic. frustrating to me when I think C: Not really. I know it makes you you want to run the show. And uncomfortable to take about this and you only want to do things when that you don’t believe that people you want to do them. Right? should be gay or bi, but it doesn’t And every single day I have to change how I am bother you about school, right? P: Yeah. “Ava, are you doing school?” *pause* “No, I’m gonna do this!” “Ava P: Well why didn’t you tell me this? Why do your math,” “No can I just do did you have to tell me this now? history first?” Always. And- C: Because I wanted to get it off my chest. C: I like my math now though. I told dad about this, but I was having P: Ok. But what I’m afraid of- trouble getting myself to tell you C: Is when I go to college? because I was worried you’d get angry P: And your life. I can’t tell my- I at me can actually tell, you know I’m very fortunate I can choose what Daughter is displaying some over- tickets I want to do first and stuff certainty with regard to her mother’s like that, but there’s certain responses and mental states (that she will things I just have to do, and my punish her if she tells her something). boss doesn’t- C: But I did make exactly what you wanted me to make. I did. P: Okay, but we had to fight to get it done. And sometimes I want you to see that I’m doing stuff for

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your benefit. And you know the whole art thing, I’m trying to understand that, too, because I don’t have an artist brain, so I want us to have some type of compromise, right? Where I say “Ok, I don’t understand the artist brain, you’re not just gonna be a production line, I get that. But at the same time, I know what’s going to happen when you want money and you don’t have it. And this is an amazing opportunity to make money.

This mother is demonstrating a slight degree of hypermentalizing because she is somewhat rigidly emphasizing her perspective without stopping to take in the perspective of her daughter. Her perspective is global and overly certain (i.e., she knows that she is right)

7 – Absence of Hypermentalizing • Statements about the self and other include a degree of uncertainty and the individual is able to shift perspective after feedback • There is a good balance between automatic and controlled/reflective responses; you may be able to see a quick nonverbal reaction to something, but it can be tempered by a verbal response that is slowed down • Individual does not make claims/assumptions about the others’ behavior o If a statement of the other person’s mental state is made, it is done so in either a question form or in a way that seeks clarification from the other • Mental state talk is plausible given relevant and available information • Understanding that perspectives are not shared by all and ability to flexibly shift to consider alternatives • Alternatively, there may be no positive indicators (as listed above), but merely an absence of the signs of hypermentalizing and therefore the individual should receive this code (it does not necessarily indicate high quality mentalizing)

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Hypomentalizing This style of thinking is characterized by a tendency to equate mental states with observable behavior rather than by making use of the mind to understand behavior. Experience is only felt to be valid when consequences are visible and apparent. There is a distinction from what is seen in hypermentalizing when mental states are seen as an indication of reality (I feel hurt and therefore your anger must mean that you disapprove of me), in that when hypomentalizing, it is assumed that the reasons underlying behavior are concrete or observable (you are speaking loudly because it is hard to hear) rather than due to some internal state (you are speaking loudly because you may be angry). Therefore, there is a reduced use of mental state language in hypomentalizing whereas when somebody is hypermentalizing, mental states are used, but are likely to be used incorrectly. Hypomentalizing is likely to be seen when an individual is in the pre-mentalizing stance of teleological mode in which expectations of others are formulated in concrete, purely observable terms; actions are understood in terms of their physical (not mental) outcomes; and actions with physical impact are felt to be able to alter mental states in self/other (e.g., demanding for another to physically demonstrate affect toward you).

1 – High Hypomentalizing • There is a lack of mental state language throughout the interaction. Discourse is primarily about concrete, observable behaviors or situations (e.g., behavior- consequence connections). AND • Lack of demonstration of nonverbal indicators of curious stance/interest (e.g., closed body posture, lack of eye contact, looking away or distracted behavior). o This is very common in adolescents, especially, when they are being faced with something they don’t want to discuss or if they are feeling defensive.

• There may be a complete disavowal to the perspectives of the other at the very extreme (e.g,. “I don’t care what you were thinking”); however, receiving this score does require that the interaction be marked by high arousal and discord, but rather that mental states do not seem to be attended to or utilized to understand behavior. • Especially for parents, this code can be assigned if a child seems to be indicating some underlying mental state, but the parent misses this sign and continues to focus on the concrete aspects of the discussion (see first example for parents below). They may be focused on their own agenda without considering child’s perspective. • For adolescents, this code can be assigned when a child is non-responsive to their parent—they do not seem to be making attempts to engage with their

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parent. They also may be entering into conflict, but it is focused on concrete events. Examples for Adolescents Examples for Parents In a discussion about fighting P: Ok, so just try to process this: like, I’m between siblings, mom is trying to not attacking you. I’m just trying to shift the child to consider the figure out how we can manage the brother’s perspective: amount of time you spend on your phone. I’m not saying you can’t spend P: When Andrew picks on you, what any time. is he trying to get? (after no C: How? That’s like the only thing I can response from child) A reaction? do in this stupid neighborhood. C: I don’t know what he’s trying to P: Well, there was something else that I get, I’m not him said that I was hoping for, and that was that you would read a book this Here the child is refusing to engage summer. in mentalizing, which is a more C: I don’t have books. overt form of hypomentalizing P: Well, we can arrange for that. Like, When asked how the child is going there are books in the house, you just to stop lying: have to select one and decide to read it. C: Well, I am going to stop lying C: Yeah, those ones are from like five today. years ago. P: And how do you expect to do P: No, not really, and besides that, like, that? there’s a whole library full of books, C: Not lie and you can download books- not until we solve the internet issue- but, we The child offers no elaboration and can get a book. And so part of that there is no reflection or attention to time during the day can be spent with the mental states that may be at play the book. And also, I said one chore a when the child usually lies, which day, while I’m gone. And I might, also suggests that the child may be depending on how time is spent, I operating in teleological mode might have to make it two. Because like when I get home from work I don’t want to have to have extra work that’s created while you guys were home using plates and stuff like that.

Here the child early on calls the neighborhood stupid, suggesting that there is some aspect of their current living situation that he is unsatisfied with; however, instead of probing into the child’s mental states, mom continues to try and problem solve about finding a 114

book. This strategy is not effective because it doesn’t address the underlying emotion or issue.

3 – Moderately High Hypomentalizing • Individual may make some mental state attributions; however, these are minimal (1-2 instances for adolescents, 3-4 instances for parents) and overly simplistic AND • There may be minimal nonverbal indicators of interest (e.g., eye contact); however, these are largely diminished once conflict escalates and if emotions are high

• Problem solving is overly simplistic and not necessarily realistic (i.e., an adolescent agreeing that they will start to wake up early every day when it has clearly been an issue for a long time) • While there is not a rejection of the mental states of others as in a score of 1, there may instances where the individual is apathetic to the perspectives of others. • For parents, this code may be assigned if the parent fails to check in on the child’s perspective. While for a code of 1, a parent is either actively ignoring or missing signals sent by the child who is trying to express their mental state, this code will be assigned if the child doesn’t provide any attempts to express themselves, but the parent doesn’t make the initiative to check in on the child o The parent will often also move on to another topic without having a full agreement or understanding from the child. This is common in conversations that end up getting dominated by the parent and the child becomes overly-acquiescent. However, this agreement is not genuine and is merely a strategy by the child to get through the discussion. The parent’s inability to recognize or address this should be coded as hypomentalizing at a level of 3 Examples for Adolescents Examples for Parents P: Like, you have to be careful with her, P: But you do understand that lying letting her know, like “I’m skinnier is- than you, my feet are smaller than C: Gets get me in more trouble- yours.” P: Exactly. C: My feet aren’t smaller than hers, my C: But it shouldn’t. I don’t think feet are bigger than hers. before I talk, mostly. P: Just the way you compare yourself to P: That’s one problem, you need to. her… hurts her feelings sometimes. C: I know. C: Oh.

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P: You know what I mean? So can you be P: And that’s just not not lying. more sensitive to your sister’s Your situation is about anything. feelings? C: Yeah C: I’ll try. P: Get yourself into a lot of trouble P: “I’ll try.” I’m not convinced. How do if you start talking before you do you think you can not make her feel anything. If like at my job, if I bad about herself when you’re go to a customer’s home and tell discussing clothes and shoes and stuff them they’re getting all this stuff like that? for free before I even look up the C: Say… well there’s no way because she account. I can now be in trouble is shaped differently from me, so… because now we have to honor that’s why if I say, “That bra doesn’t what we give what they’re not fit you,” it’s because I am smaller and supposed to be getting for free. it won’t actually fit her. And then she It’s just always the little things. gets all upset about that. Did you brush your teeth? Little P: Well that’s because you say things like, things like that. You would say “I’m smaller than you.” no and we’d tell you to brush C: I didn’t mean it like - your teeth. You’re not in trouble. P: I’m trying to figure - You say yes now you’re in C: - a mean way, I was just saying it trouble because you lied. Even because it’s true. little lies like you washed your P: She says it really upsets her. face. Didn’t hear the water running and all of sudden you’re Here the adolescent is demonstrating back in there washing your face. overly simplistic thinking around her Just little things like that and we sister’s emotions. She is demonstrating an can hear the water running when inability (or lack of desire) to you wash your face. Right? acknowledge how her actions have C: Yeah implications on her sister’s emotions P: That’s one thing you gotta do you based on underlying vulnerabilities that gotta think about it. Now her sister seems to have cleaning your room. I know your brother is in there a lot and I’m not up there so I don’t really know what you guys do when you’re up there. You have a big room upstairs. You have lots of I know you have a lot of stuff. But you can find a place for everything. When we do when me and mom go up and clean you guys rooms we clean them pretty well. I don’t understand why they can’t stay like that.

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What do you have to say about that? C: Okay I’ll try and keep up.

5 – Moderately Low Hypomentalizing • For at least half of the discussion, there is use of mental state talk; however, attributions are not overly complex. This should be adjusted for the developmental level (younger adolescents will naturally have less complex mental state attribution than older adolescents and compared to mothers). OR • Nonverbal interest is displayed—the individual is clearly following the perspective of the other, even though they aren’t verbalizing mental state attributions of the self and other.

• In general for adolescents, mental state labels are provided when prompted for; however, unless specifically asked for, mental states will not be elaborated on. • This code can be assigned if problem solving seems to miss the mark in terms of the perspective of the other. For example, in a discussion where a daughter is talking about her difficulty in getting up in the morning, she describes her lack of motivation due to depression. Mom’s response is to set the alarm for a little earlier so there is less rush in the morning and the daughter has time to play with her kittens. Mom is trying to address the stress of the situation and is not necessarily ignoring the child’s affective state, but her solution does not fit the actual nature of the child’s mental state Examples for Adolescents Examples for Parents C: See, I’m braindead when I come home. This example is from a parent’s Braindead! statement about her son giving his P: But, even after like an hour break you sister things that she’s not supposed won’t start your homework. Like the to have. Here the mom is clear that other night, it was 5.5 hours between she believes her son’s behavior is the time you got home from school due to him being annoyed; however, and by the time you started your she does not explore further than this homework, and then you saw how that and her solution is oversimplified played out, you didn’t finish - without taking into account any C: Well, I get distracted unless I’ve eaten! further complexities of the situation: P: But you had a snack. C: Well I get distracted! I can’t work well P: work on that breaking down and during the day, I get distracted! giving her things that she’s not P: Well why can’t you take your break, supposed to have cause she’s and at least do some of your getting on your nerves. And you homework before we get home. I need to work on not giving her don’t understand why you have to wait stuff that she needs or really 117

until after dinner to do your wants because she’s getting on homework. your nerves. At the end of that C: I don’t know, I like it better. I don’t get day that’s always gone be your as easily distracted and - little sister and she’s not going P: [talking over each other] you’re tired, nowhere, she’s been here 6 and then there’s not enough time to years. That’s like you’re his little finish, like the other night. brother and you aren’t going C: Well it’s not my fault. anywhere, he been here 14 years. After he treat you mean and Here the adolescent is easily able to talk you’re starting to treat her mean. about her mental state (being ‘braindead’ And if I was to die today or and distracted) when she gets home; tomorrow y’all all y’all got. however, it is not very complex and she is Y’all gotta stick together. You having difficulty going beyond this very hear me? straightforward representation of her mental state

7 – Absence of Hypomentalizing • The individual makes plausible inferences about mental states from others’ communications or behaviors and can articulate their own mental states. While mental state attribution are made easily, they may not always be elaborated on (particularly for adolescents). AND • Responsiveness and engagement are physically and verbally apparent.

• Individual uses mental state language consistently and with elaboration/reflection. o The individual can provide their own interpretations of mental states that show reflective thought • There is no defensiveness around perspectives of the self or other.

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Overall Index of Dyadic Mentalizing Quality This code is meant to indicate the quality of mentalizing that takes place as a dyad. Theoretically, if both members of the dyad are engaging in mentalizing, the flow of socially and individually relevant information between the parent and child should be facilitated. While this code will likely follow in a similar direction of each person’s individual level of mentalizing, it may be the case that when there is greater discrepancy between mother and child, overall quality is lower than the mentalizing of a single member. To complete this code, raters should focus especially on ruptures in the interaction. Ruptures have been described most often in the context of therapeutic alliance, but can be defined as an instance of tension or a breakdown in the relationship or communication between members (Safran & Muran, 2006). We believe that ruptures in the parent-child relationship may provide a crucial opportunity for mentalizing to be used to repair ruptures and therefore make the relationship stronger. Therefore, the mentalizing that takes place around ruptures in interactions may be especially predictive for outcomes.

1 – Poor or absent mentalizing • At this level, there is no meeting of minds throughout the interaction. This can seem like the two individuals are on completely different playing fields, but there also does not seem to be an awareness that this dynamic is taking place o This can either manifest as a single member of the dyad commandeering a conversation (more often than not, this is the parent or not the child) or alternatively, a quick back and forth (as seen in the example below) but that has no direction • At this level, there is some actual refuting of what the other person says (i.e., denying them their perspective or communicating that their perspective is wrong) • Other indications for this code may include nonengagement, deflection, distraction, or interrupting during the discussion as an attempt to either change emotional state of partner or capture the partner’s attention. These interruptions typically don’t acknowledge the mental state of the other, but rather may include concrete statements, for example “you’re beautiful” Examples In this discussion, there is constant interruption of each other and no actual information exchange has taken place with each person not taking the mind of the other into consideration

P: They want us to talk about you botherin’ me when I don’t wanna be bothered, ya know? I don’t wanna be bothered all the time. I ain’t want someone to be knocking on my door five six times every day. C: But, why you gotta close your door anyway?

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P: Cause I want privacy sometime, and I don’t wanna hear y’all. Y’all are loud down. Who wants to be- C: So we knock on your door because you don’t lock your door closed. I mean open. Therefore- P: I don’t mean every five minutes you knock on the door. C: But, if I need you every five minutes- P: Nobody need nobody every five minutes. Get everything out at one time. C: What if I think of something new that I need to ask you? P: You always think of something new every five minutes. If you could sit in there with me on a regular basis, you would every five minutes ask me a question so what difference does that make. C: Exactly, that’s my point. P: That means you don’t need to be askin’ questions every five minutes. That’s my point. If I don’t wanna be bothered… if it’s important, then my privacy can be violated, if it’s not… Stop drinkin’ my juice. Ask for another one. C: [Mumbles]. I don’t think you should close your door. P: My door be closed. C: I said I don’t think you should close your door. P: Why not? C: Because what if we need you? P: I don’t wanna hear all that noise y’all make. Especially last night, y’all was loud.

3 – Moderately low mentalizing • There may not be any refuting of what the other person says, but there is a tendency to ignore or skip over the message the other person is trying to send. • There may be an attempt to bring somebody back into the interaction if there is a rupture; however, this is often ineffective (e.g., “you’re beautiful” or changing the subject) because it is more of a redirection or changing of the topic rather than engaging in the mental state of the partner. • There is only reciprocation around concrete or non-controversial topics Examples In this example, a daughter is trying to talk about how her mother’s smoking habit makes her feel and the mother doesn’t engage in the conversation. Toward the end, she moves into complimenting her daughter’s hair, which seems to be a concrete strategy to repair the rupture.

C: I just said I just don’t like it when you smoke around me. And, I feel like that kinda makes my eczema worse. And I, I keep telling you, can you stop doing that and you keep doing it. And you would tell me to go somewhere else but.. the doctor told you to go somewhere else to do that. And.. Mom, why’d you start- start up- start back up anyways? P: By habits of people who I was around.

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C: I can’t inhale that, like I can’t breathe when I smell that. Which *mentions a name* can, she said it smells good, but I can’t. I, I don’t know, I can’t smell that. I don’t think the doctor wants you to smoke anyways. I don’t wanna keep smelling that, ‘cause that stinks. Sometimes that gives me a headache or something. *pause* C: I’m done. P: Well.. guess that’s all we have to say then. *pause* Uh.. C: *sighs* So tired. P: I am, too, a little bit. *pause* C: Oh, also when you smoke, that gets into my clothes. And people ask, um.. do ask me do I smoke and I was like, no. ‘Cause- P: So they can really smell it. C: Yeah. And Nana can- sometimes, if she smells my hair she can smell it in my hair, too. And after when I wash my hair and that’s when you smoke it, that’s what gets into my scalp and that’s what I was saying. If somebody- somebody’s hair stinks. But that gets into my scalp and it makes the shampoo and all the stuff that smelled good in my scalp, stink. Makes it not smell good anymore. P: I like how you smoothed your hair out. C: Hm? P: Are the roots hard? C: Yeah. ‘Cause- ‘cause, when you lay a scarf on it, it’s gon’ dry. It’s gon’ stay slick. P: Very good for no perm, very good. C: Every- everybody says I have nice hair and stuff. They was like you have nice, thick hair, and stuff. P: Yeah you do, it’s very nice and thick.

5 – Moderately High Mentalizing • There is an attempt to address ruptures in a way that is sensitive and genuine, although these may not be reciprocated or productive. Attempts may be focused on problem solving rather than understanding the other’s mind • There is a general sense that both members of the dyad are engaged to some extent; however, during ruptures, the affect may interfere with individuals mentalizing to the fullest capacity Examples This example comes from an interaction in which a mother is suggesting possibilities to help her son get to sleep earlier so that he functions better the next day in school. The son has given reasons why her suggestions don’t work, but his responses are relatively terse and he has not been reciprocating:

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P: Do you not want to have discussion about this stuff? C: What do you mean? P: Well you’re not really participating much in this conversation. C: I just don’t see the point of having it because school’s over. P: Well let’s just think like we were still in school. C: I don’t know…

There is an attempt by the mother to engage her son in a non-intrusive way once he has disengaged from the interaction; however, it falls short because he continues to not participate. However, his mom has at least acknowledged his space and shifted her behavior to match where he is

7 – High Quality Mentalizing • There is a change in tone to mirror the state of the interaction partner • There is a consistent back and forth between mother and adolescent that is reciprocal and contingent o Positive affect is present throughout the interaction and a playful manner may be used by either members of the dyad • The mother acknowledges the autonomy of her child and respects the child’s perspective, which can be demonstrated when a mother explicitly asks for her child’s perspective but also in her validation of their perspective when it is stated • The adolescent shows some curiosity toward mental state of their mother; however, this does not have to be prevalent. Rather, the adolescent must not reject the parent’s perspective • After a rupture, there is a clear change of behavior in the direction of re- engaging the partner • There is a consistent use of mental state language throughout the discourse Examples P: How do you plan to work in these areas so in the future – so what are we supposed to do next time when you mouth off to daddy? C: You just need to tell me what I did wrong, like say, because I don’t hear it and then you yell at me, like, I don’t know what I did. That’s the thing. And that’s why I would get annoyed with you, ‘cause I feel like I did nothing. And then you start yelling at me. P: Do you see how, when you yell to daddy, “Stop yelling at me!” He’s like, “I’m not yelling at you”, he’s feeling the same way you are. Where he’s like, “I’m not yelling.” But you’re sensitive to his… to his voice.

This interaction received a score of 7 for this scale because even though the mother and adolescent continue to disagree, they are demonstrating respect for

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each other’s perspective. The discussion seems to move forward as there is a clear transfer of information P: Do you think you can behave better at school? C: Ya. P: You think you’ll be better next year? I think it’s going to be kind of crazy at the high school C: What do you mean P: Crazy like hectic and busy because they’re adding 3 grades there. C: Ya. (thoughtfully) P: I think it could possibly make things harder. C: It’s not. P: Why not? C: Because I’m not going to be seeing all the eighth graders every day.

In this example, with every exchange, the parent and adolescent are on the same page—there is a clear recognition and acknowledgement of the others’ perspective (even if not explicit)

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Table 1. Interrater reliability and descriptive statistics for observational codes Positive-M. Positive-A. Hyper-M. Hyper-A. Hypo-M. Hypo-A. Dyadic Study 1 ICC .701 .848 .754 .803 .713 .859 .854 Range 2-6 1-6 3-6 3-7 2-6 1-6 1-6 Mean (SD) 3.25 (.91) 3.00 (1.38) 4.70 (1.22) 5.95 (1.15) 3.65 (1.23) 3.40 (1.85) 3.00 (1.52) Study 2 ICC .769 .775 .758 .885 .721 .816 .839 Range 1-7 1-7 2-7 1-7 2-7 1-7 1-7 Mean (SD) 4.07 (1.45) 3.54 (1.46) 5.60 (1.34) 5.69 (1.72) 4.63 (1.38) 4.33 (1.46) 3.74 (1.64) Males – Mean (SD) 4.27 (1.34) 3.35 (1.50) 5.54 (1.45) 5.54 (1.79) 4.85 (1.32) 4.23 (1.48) 3.65 (1.50) Females – Mean (SD) 3.95 (1.52) 3.55 (1.37) 5.61 (1.30) 5.77 (1.71) 4.50 (1.44) 4.30 (1.42) 3.73 (1.73) t, p, -0.87, .387, 0.57, .572, 0.22, .823, 0.54, .588, -1.00, .319, 0.18, .857, 0.18, .858, Hedge’s g -0.22 0.14 -0.05 0.13 -0.25 0.05 0.05 Note. For Study 1, ICC values were based on two-way mixed effects model with twenty cases rated by five independent raters; descriptive statistics were based on ratings made by the first author. For Study 2, ICC values were based on one-way random effects model, with all cases being randomly assigned to be rated by two independent coders; descriptive statistics are based on ratings made by the first coder, which varied case by case. M. indicate ratings regarding Mother and A. indicates ratings regarding Adolescent. Positive = Positive Mentalizing Indicators, Hyper = Hypermentalizing, Hypo = Hypomentalizing, Dyadic = Quality of Mentalizing for the Dyad.

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Table 2. Correlations and descriptive statistics for main study variables (focused on adolescent variables)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Adolescent 1. Obs. – Positive MZ 2. Obs. – Hyper MZ .24* 3. Obs. – Hypo MZ .84** -.13 4. MASC – Total .13 -.20 .31** 5. MASC – Hyper .03 .11 -.11 -.45** 6. MASC – Hypo -.18 .16 -.27* -.73** -.16 7. MASC – No MZ -.09 .11 -.21 -.78** .04 .53** 8. LOPF – Persp. .06 -.08 -.01 -.11 -.19 .14 .29* 9. IIP Total Problems .20 .03 .08 -.12 .08 .01 .16 .49** 10. Borderline-Youth .31** -.05 .29* .05 -.09 -.02 .02 .56** .54** 11. Borderline-Mother -.26* -.05 -.30* -.03 -.17 .17 .05 .32** .17 .32** 12. Verbal Compr. .15 -.22 .24* .40** -.08 -.39** -.31** -.05 -.12 -.09 -.19 13. Gender (male) -.07 -.07 -.02 -.26* .18 .13 .21 -.21 -.23 -.30* -.25* -.11 14. Age .17 .03 .16 .25* -.16 -.22 -.10 .27* .21 .29* .20 -.15 -.37** Mother 15. Obs. – Positive MZ .53** .16 .52** .22 -.06 -.16 -.21 -.25* -.03 .02 -.23* .16 .11 -.08 16. Obs. – Hyper MZ .24* .19 .21 -.17 .01 .26* .03 .05 .07 .09 -.07 .05 -.03 -.15 17. Obs. – Hypo MZ .42** .03 .52** .25* -.17 -.14 -.19 -.22 .02 .06 -.21 .13 .12 -.05 18. MASC – Total .14 -.11 .12 .24* -.07 -.24* -.15 -.15 -.10 -.19 .00 .23* .08 .15 19. MASC – Hyper -.21 -.01 -.15 -.03 .00 .06 .00 .15 -.01 .13 .11 -.06 .10 -.10 20. MASC – Hypo -.04 .08 -.04 -.23 .17 .16 .11 .05 .10 .13 -.07 -.27* -.04 -.19 21. MASC – No MZ -.08 .19 -.10 -.23 -.09 .31** .23 .17 .12 .16 -.02 -.13 -.27* .01 22. PDI - RFS .16 -.05 .12 .21 -.14 -.13 -.15 -.09 -.10 -.15 -.22 .26 .02 -.06 23. IIP Total Problems .09 .23 -.04 -.12 .10 .14 -.03 -.03 .07 .19 .21 -.01 -.12 -.18 24. Verbal Compr. .16 -.04 .19 .22 -.09 -.23 -.09 -.07 -.23 -.24* -.20 .37** .05 .00 25. Age .05 .10 .11 .13 -.10 -.09 -.05 -.08 -.07 .00 -.07 .07 -.24* .25* Dyad 26. Obs. – Dyadic MZ .73** .30** .63** .12 .04 -.16 -.11 -.20 .12 .11 -.23* .19 -.02 .04 27. CAI Idealizing .01 -.10 -.06 -.16 .17 .06 .11 -.14 -.11 -.20 .05 .08 .22 -.39** 28. CAI Dismissing -.04 .00 -.07 -.26 .12 .15 .25 .08 -.13 -.01 .35* .03 .06 .00 29. CAI Preoccupied -.26 -.42** -.01 .06 -.09 -.01 -.04 .20 -.04 .22 .12 .18 .07 .16 30. CAI Secure Att. -.04 .14 -.05 .14 .08 -.09 -.28 -.29* .04 -.16 -.44** -.09 .03 -.15 31. IOS Closeness (A) .10 .05 -.05 -.17 .23 .04 .07 -.15 .12 -.25* -.19 -.03 .13 -.18 32. IOS Closeness (M) -.09 .01 -.13 -.05 .15 .01 -.08 -.03 .19 -.03 .12 -.27* .01 .08 33. Mom Education .15 .12 .09 .00 -.11 .10 -.01 .00 -.01 -.03 .02 .08 -.02 -.01

Mean 3.54 5.69 4.33 28.64 7.49 6.11 2.76 16.62 73.91 30.27 32.79 51.00 37% 14.29 SD 1.46 1.72 1.46 5.60 2.91 3.17 2.55 7.32 23.76 9.26 6.23 8.36 1.58 Skew 0.32 -1.05 0.06 -0.31 0.40 0.79 1.58 0.36 -0.11 -0.10 0.22 -0.13 0.14 Kurtosis -0.51 -0.11 -0.67 -0.40 -0.24 1.18 4.12 0.57 -0.85 -0.67 0.34 -0.54 -1.09

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Table 3. Correlations and descriptive statistics for main study variables (focused on mother variables)

15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Mother 15. Obs. – Positive MZ 16. Obs. – Hyper MZ .31** 17. Obs. – Hypo MZ .85** .17 18. MASC – Total .18 -.15 .16 19. MASC – Hyper -.14 .09 -.21 -.57** 20. MASC – Hypo -.11 .11 -.04 -.87** .24* 21. MASC – No MZ -.16 .14 -.13 -.67** .06 .47** 22. PDI – RFS -.01 -.13 -.10 .17 -.19 -.04 -.13 23. IIP Total Problems .02 .14 -.05 -.29* .11 .29* .19 -.08 24. Verbal Compr. .15 .09 .09 .41** -.13 -.46** -.22 .00 -.19 25. Age -.01 .07 -.04 -.07 .08 -.07 .22 -.01 -.20 .12 Dyad 26. Obs. – Dyadic MZ .81** .39** .72** .16 -.21 -.06 -.09 .00 .17 .15 .81** 27. CAI Idealizing .14 .21 -.02 -.02 .07 .12 -.17 .10 .03 .00 .14 28. CAI Dismissing -.19 .08 -.26 -.01 .04 -.04 .04 .03 .14 .14 -.19 29. CAI Preoccupied -.28 -.29* -.09 .04 .23 -.15 -.07 -.28 -.23 .04 -.28 30. CAI Secure Att. .21 .03 .24 -.09 .01 .14 -.01 .18 .01 -.21 .21 31. IOS Closeness (A) .20 -.05 .09 .21 -.15 -.13 -.20 .11 -.06 .04 .20 32. IOS Closeness (M) -.13 -.09 -.16 -.02 .01 .10 -.13 .05 .12 -.36** -.13 33. Mother Education .14 .12 .16 .34** -.21 -.28* -.22 .10 -.09 .19 .14

Mean 4.07 5.60 4.63 32.32 4.76 5.49 2.42 3.73 66.53 48.60 45.00 SD 1.45 1.34 1.38 5.64 2.30 3.39 2.07 1.06 18.26 9.45 9.68 Range 1-7 2-7 2-7 13-44 1-11 0-18 0-10 2-6 36-116 22-70 28-80 Skew -0.27 -1.10 -0.42 -1.31 0.58 1.66 1.34 0.29 0.71 -0.29 1.28 Kurtosis 0.28 0.28 0.28 2.38 -0.02 3.68 2.05 -0.49 0.07 0.16 2.88

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Table 4. Correlations and descriptive statistics for main study variables (focused on dyadic variables)

26. 27. 28. 29. 30. 31. 32. 33. Dyad 26. Obs. – Dyadic MZ 27. CAI Idealizing .22 28. CAI Dismissing -.08 .22 29. CAI Preoccupied -.42** -.37** -.01 30. CAI Secure Att. .12 -.15 -.74** -.27 31. IOS Closeness (A) .27* .41** -.04 -.35* .20 32. IOS Closeness (M) -.10 -.05 .11 .04 .12 .16 33. Mother Education .18 .15 .02 -.21 .07 .12 -.17

Mean 3.74 2.45 3.66 1.83 49% 4.79 4.46 51% SD 1.64 1.41 2.25 1.50 1.81 1.51 Range 1-7 1-6 1-7.5 1-7 1-7 1-7 Skew 0.06 0.78 0.42 2.03 -0.46 -0.35 Kurtosis 0.28 0.00 -1.23 3.77 -0.71 -0.83 Note. *p < .05, **p < .01.

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Table 5. Results from APIM model with forms of maladaptive mentalizing

Path Unstd. Est. (SE) p Std. Est. 95% CI Actor (Mother) Hypo -> Hypo 0.04 (0.05) .375 .10 -0.05, 0.14 Hypo -> Hyper 0.01 (0.07) .834 .03 -0.08, 0.10 Hyper -> Hyper 0.04 (0.07) .525 .08 -0.09, 0.18 Hyper -> Hypo -0.15 (0.07) .031 -.24 -0.29, -0.01 Actor (Adolescent) Hypo -> Hypo -0.13 (0.06) .025 -.27 -0.23, -0.02 Hypo -> Hyper 0.05 (0.07) .453 .09 -0.08, 0.19 Hyper -> Hyper 0.07 (0.07) .348 .11 -0.07, 0.20 Hyper -> Hypo -0.08 (0.06) .160 -.16 -0.19, 0.03

Partner (M to A) Hypo -> Hypo 0.04 (0.05) .492 .08 -0.07, 0.14 Hypo -> Hyper -0.00 (0.06) .987 -.00 -0.13, 0.12 Hyper -> Hyper -0.02 (0.09) .801 -.03 -0.20, 0.15 Hyper -> Hypo -0.09 (0.07) .198 -.15 -0.24, 0.05 Partner (A to M) Hypo -> Hypo -0.09 (0.05) .062 -.21 -0.19, 0.01 Hypo -> Hyper 0.12 (0.05) .020 .27 0.02, 0.21 Hyper -> Hyper 0.03 (0.06) .564 .07 -0.08, 0.14 Hyper -> Hypo -0.13 (0.06) .022 -.26 -0.23, -0.02

Same Measurement Corr. Mother MASC 1.72 (0.87) .048 .24 0.02, 3.42 Adolescent MASC -1.85 (0.99) .062 -.23 -3.79, 0.10 Mother Observed 0.45 (0.20) .022 .28 0.06, 0.84 Adolescent Observed -0.12 (0.26) .664 -.05 -0.64, 0.40

Cross Person Corr. (MASC) Mother Hypo ~ Adol Hypo 0.70 (1.11) .525 .08 -1.47, 2.87 Mother Hypo ~ Adol Hyper 1.65 (1.09) .131 .19 -0.49, 3.80 Mother Hyper ~ Adol Hyper -0.19 (0.78) .806 -.03 -1.71, 1.33 Mother Hyper ~ Adol Hypo 0.23 (0.80) .775 .04 -1.33, 1.79 Cross Person Corr. (Observed) Mother Hypo ~ Adol Hypo 0.81 (0.22) .000 .47 0.37, 1.25 Mother Hypo ~ Adol Hyper 0.27 (0.25) .276 .13 -0.22, 0.76 Mother Hyper ~ Adol Hyper 0.38 (0.26) .143 .18 -0.13, 0.88 Mother Hyper ~ Adol Hypo 0.56 (0.22) .009 .33 0.14, 0.99

Covariates Mother Hispanic -> Mother MASC Hypo 2.54 (0.75) .001 .37 1.07, 4.00 Mother Hispanic -> Mother MASC Hyper 0.15 (0.56) .794 .03 -0.95, 1.24 Child Gender -> Mother Obs. Hypo 0.64 (0.29) .027 .23 0.07, 1.21 Child Gender -> Mother Obs. Hyper -0.23 (.31) .447 -.09 -0.83, 0.37 Child Gender -> Child MASC Hypo 0.63 (0.71) .380 .10 -0.77, 2.02 Child Gender -> Child MASC Hyper 1.06 (0.69) .123 .18 -0.29, 2.41 Child Verbal -> Child Obs. Hypo 0.01 (0.02) .510 .07 -0.03, 0.05 Child Verbal -> Child Obs. Hyper -0.04 (0.03) .099 -.21 -0.10, 0.01 Child Verbal -> Child MASC Hypo -0.14 (0.04) .001 -.36 -0.22, -0.06 Child Verbal -> Child MASC Hyper -0.01 (0.04) .864 -.02 -0.09, 0.07 Child Gender ~ Child Verbal -0.51 (0.49) .301 -.13 -1.48, 0.46 Child Gender ~ Mother Hispanic -0.04 (0.03) .171 -.17 -0.10, 0.02 Child Verbal ~ Mother Hispanic -1.06 (0.49) .031 -.26 -2.02, -0.10 Note. Unstd. Est. = Unstandardized Estimate; Std. Est. = Standardized Estimate.

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Table 6. Results from APIM models with forms of maladaptive observed mentalizing and total MASC scores

Path Unstd. Est. (SE) p Std. Est. 95% CI Actor (Mother) Total -> Hypo 0.02 (0.03) .510 .08 -0.04, 0.07 Total -> Hyper -0.03 (0.03) .387 -.11 -0.08, 0.03 Actor (Adolescent) Total -> Hypo 0.07 (0.03) .032 .26 0.01, 0.13 Total -> Hyper -0.03 (0.04) .378 -.11 -0.11, 0.04

Partner (M to A) Total -> Hypo 0.01 (0.03) .746 .04 -0.05, 0.07 Total -> Hyper -0.01 (0.04) .721 -.04 -0.08, 0.06 Partner (A to M) Total -> Hypo 0.07 (0.03) .016 .28 0.01, 0.13 Total -> Hyper -0.04 (0.03) .198 -.16 -0.10, 0.02

Same Measurement Corr. Mother Observed 0.43 (0.20) .037 .25 0.03, 0.83 Adolescent Observed -0.11 (0.27) .675 -.05 -0.64, 0.41

Cross Person Corr. (MASC) Mother Total ~ Adol Total 5.80 (3.23) .073 .22 -0.54, 12.13 Cross Person Corr. (Observed) Mother Hypo ~ Adol Hypo 0.85 (0.23) .000 .48 0.39, 1.30 Mother Hypo ~ Adol Hyper 0.27 (0.26) .288 .13 -0.23, 0.77 Mother Hyper ~ Adol Hyper 0.38 (0.26) .144 .18 -0.13, 0.89 Mother Hyper ~ Adol Hypo 0.50 (0.22) .022 .28 0.07, 0.94

Covariates Mother Hispanic -> Mother MASC Total -3.67 (1.27) .004 -.32 -6.16, -1.17 Child Gender -> Mother Obs. Hypo 0.53 (0.29) .069 .19 -0.04, 1.11 Child Gender -> Mother Obs. Hyper -0.14 (0.32) .654 -.05 -0.76, 0.48 Child Gender -> Child MASC Total -2.64 (1.19) .027 -.23 -4.98, -0.31 Child Verbal -> Child Obs. Hypo 0.02 (0.02) .383 .09 -0.02, 0.05 Child Verbal -> Child Obs. Hyper -0.04 (0.03) .129 -.19 -0.09, 0.01 Child Verbal -> Child MASC Total 0.23 (0.07) .001 .34 0.09, 0.37 Child Gender ~ Child Verbal -0.48 (0.49) .325 -.12 -1.45, 0.48 Child Gender ~ Mother Hispanic -0.04 (0.03) .183 -.16 -0.09, 0.02 Child Verbal ~ Mother Hispanic -1.06 (0.49) .031 -.26 -2.02, -0.10 Note. Unstd. Est. = Unstandardized Estimate; Std. Est. = Standardized Estimate.

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Table 7. Linear regression predicting borderline symptoms from indicators of mentalizing including MASC error scores

Youth Report Mother Report B (SE) Beta t B (SE) Beta t Gender -3.03 (2.04) -.16 -1.49 -2.53 (1.56) -.20 -1.63 Age 0.40 (0.66) .07 0.62 0.49 (0.50) .12 0.98 Obs. – Positive MZ 1.75 (0.66) .26 2.66* -1.26 (0.50) -.28 -2.52* MASC – Hypo MZ -0.00 (0.31) -.00 -0.01 0.28 (0.24) .14 1.21 MASC – Hyper MZ 0.13 (0.32) .04 0.40 -0.08 (0.25) -.04 -0.33 LOPF – Persp. 0.64 (0.13) .50 4.83** 0.20 (0.10) .24 2.00* Note. *p < .05, **p < .01.

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Optimal Mentalizing

Undermentalizing Hypermentalizing Mentalizing Ability

No Mentalizing

Low Medium High Arousal Level Figure 1. Theoretical model of mentalizing Note. Figure adapted from Gambin et al., (2015).

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MASC Observed

Hypomentalizing Hypomentalizing

-0.15 (0.07)* Mother 1.77 (0.88)* 0.45 (0.20)*

Hypermentalizing Hypermentalizing

0.81 (0.22)**

0.56 (0.22)**

0.12 (0.05)* -0.09 (0.05)- Hypomentalizing Hypomentalizing -0.13 (0.06)*

Adolescent -1.85 (0.99)

-0.13 (0.06)* Hypermentalizing Hypermentalizing

Figure 2. Significant results from APIM model with forms of maladaptive mentalizing

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MASC Observed

Hypomentalizing

Mother Total Score 0.43 (.20)*

Hypermentalizing

0.85 (.23)**

5.80 (3.23) 0.50 (.22)*

0.07 (0.03)* Hypomentalizing 0.07 (0.03)* Adolescent Total Score

Hypermentalizing

Figure 3. Significant results from APIM model with MASC total score and maladaptive observed mentalizing

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5.5

Low Borderline 5 Symptoms Average Borderline Symptoms

4.5

3.5 Positive Mentalizing

2.5

2 21 30 39 Adolescent-Reported Borderline Symptoms

Figure 4. Simple slopes analysis of the effect of adolescent-reported borderline features on observed mentalizing at different levels of mother-reported borderline features

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