Parental mentalization and children's externalizing problems: A systematic review and meta-analysis

Regular Article Parental mentalization and children’s externalizing problems: A systematic review and meta-analysis Maitane Nieto-Retuerto , Barbara Torres-Gomez and Itziar Alonso-Arbiol Department of Clinical and Health Psychology & Research Methods, University of the Basque Country UPV/EHU, Donostia-San Sebastian, Spain Abstract Parental mentalization, as the ability to understand mental states (e.g., desires) behind their children’s actions, may play a relevant role in the prevention of future externalizing problems. We conducted a meta-analysis to examine the relationship between parental mentalization and children’s externalizing problems. Six electronic databases were searched for studies, published in English or Spanish, linking empirically those two variables. Participants included caregivers and children between 0 and 18 years. The filtering process yielded 42 studies with 52 effect sizes. Random-effect analysis revealed higher parental mentalization associated with fewer externalizing problems, with an effect size of r=−.19 (95% CI [−.25, −.13]). Due to high heterogeneity (I2=83.750), further analyses were conducted to explore factors affecting such association. Parenting experience and children’s developmental stage moderated the relationship, but approaches to operationalize mentalization (MM or PRF), sample type (clinical/at-risk vs. community), and reporting figure (primary caregiver vs. other informants) did not. The study highlights the significance of parental mentalization as a potential contributor to the prevention of externalizing behaviors among infants, children, and adolescents. Our findings may underscore practical implications for equipping caregivers with mentalization skills, helping them to answer appropriately to their children needs. Keywords: Children’s externalizing problems; developmental stage; meta-analysis; parenting experience; parental mentalization (Received 16 January 2024; revised 26 July 2024; accepted 29 July 2024) Early manifestations of externalizing behaviors, such as tantrums, disobedience, and aggression (Peterson et al., 2018), are observed as early as infancy (Perra et al., 2021). Recent meta-analysis results in children aged 1–7 years (Vasileva et al., 2021) reveal a 10% prevalence of externalizing psychopathology, including attentiondeficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder. Failure to address these maladaptive behaviors in their early stages increases the risk of future issues, including substance abuse and violence (Moffit, 2017), antisocial personality disorder (Diamantopoulou et al., 2010), and criminal records (Bevilacqua et al., 2018). In fact, early externalizing problems have shown to predict criminal convictions two decades later (Kassing et al., 2019). Hence, it is essential to prevent the emergence of externalizing behaviors and/or to avoid their persistence at early ages. Externalizing behaviors result from a complex interplay of genetics, neurological changes, and environmental factors (Rovira et al., 2020), including biological disposition (Dodge & Pettit, 2003), parent–child relationship characteristics (Hewitt-Ramírez & Moreno-Méndez, 2018), and the interaction between genetics (e.g., temperament) and environmental (e.g., family) elements (Goodnight et al., 2016). Since interventions and preventive measures are not applicable to genetic factors, a relevant area of attention and intervention is the realm of the parent–child relationship. Parenting is considered a significant contributing factor of the children’s externalizing behavior (Rothbaum & Weisz, 1994). Thus, parental abilities become a primary target for interventions. Encouraging the development of specific parenting skills can enhance the bond between parents and children and reduce various adverse effects, particularly externalizing problems (e.g., see Cooke et al.’s2022, meta-analysis on parental sensitivity and child behavioral problems). Therefore, the parent–child relationship emerges as an explicative factor worth studying in preventing juvenile crime (Webster-Stratton & Reid, 2018). While the influence of parenting is well established in the case of both externalizing (Pinquart, 2017a) and internalizing problems (Lin et al., 2024; Pinquart, 2017b), the present review focuses on children’s and adolescents’externalizing behaviors since including both internalizing and externalizing problems is beyond the scope of the present review. From a developmental perspective, infants’survival hinges on their caregivers’capacity to interpret their thoughts, feelings, and behaviors to meet their needs (Lavender et al., 2023). Parental mentalization is closely linked to children’s inner growth, assisting them in managing emotional conflicts and promoting positive psychological development (Caldarera et al., 2022). In fact, there is evidence showing the links between parental mentalization and positive parenting behaviors (for a systematic review, see Stuhrmann et al., 2022). Specifically, parental mentalization has been robustly related to secure child–parent attachment (Zeegers Corresponding authors: Maitane Nieto-Retuerto; Email: [email protected], Barbara Torres-Gomez; Email: barbara[email protected] Cite this article: Nieto-Retuerto, M., Torres-Gomez, B., & Alonso-Arbiol, I. (2024). Parental mentalization and children’s externalizing problems: A systematic review and meta-analysis. Development and Psychopathology,1–17, https://doi.org/10.1017/ S0954579424001391 © The Author(s), 2024. Published by Cambridge University Press. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited. Development and Psychopathology (2024), 1–17 doi:10.1017/S0954579424001391 https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press et al., 2017), which, in turn, has been strongly associated with a lower incidence of externalizing problems (based on meta-analyses for results with mothers by Fearon et al., 2010, and with fathers by Deneault et al., 2021). Despite the existent growing number of studies in the field, there are discrepancies regarding the consistency of the relationship between parental mentalization and children’s externalizing behaviors. Specifically, research findings show varying degrees of such association. For example, research shows that parental mentalization and externalizing problems are positively associated (Meins et al., 2013, Wade et al., 2021), weakly negatively related (e.g., Dollberg et al., 2023), or strongly inversely correlated (e.g., Khoshroo & Seyed Mousavi, 2022). Such disparities across studies reveal the need of exploring potential reasons behind them. Therefore, the meta-analytic technique, including the use of metaregression, is instrumental in overcoming inconsistencies in results. The current study represents the first meta-analysis that synthesizes research examining the issue. Parental mentalization linked to children’s externalizing problems Overall, mentalization is a dynamic and developmental capacity mainly contextand relationship-specific. Parental mentalization primarily emerges within the context of secure attachment relationships, serving as a key construct in children’s development and beneficial parent–child relationships (Sharp & Fonagy, 2008). Within that framework, parental mentalization is a psychological mechanism that facilitates parental self-regulation and the coregulation of the child’s emotional states (Stuhrmann et al., 2022). It encompasses parents’capacity to perceive their child as a psychological entity, differentiating between their children’s mental experiences and their own. Parental ability to comprehend not only their child’s external behaviors but also the internal mental activity (e.g., motives and emotions) that drive those behaviors (Medrea & Benga, 2021), is closely associated to responding to the child appropriately through affectively attuned parenting behavior (Kelly et al., 2005). In contrast, parents with lower mentalizing capacities may struggle to perceive their children’s mental states, failing to comprehend the motivations behind their children’s actions and to meet their needs, especially in challenging situations. Consequently, this lower mentalizing capacity may result in punitive responses exacerbating the child’s distress and dysregulation (Dollberg et al., 2021; Ensink, Bégin et al., 2017). Evidence suggests that poor parental mentalization is correlated with heightened negative emotionality (Smaling et al., 2016), increased tendencies towards controlling behaviors (Suardi et al., 2020), and with issues in socioemotional development (Nijssens et al., 2020). In fact, when it comes to the relationship with children’s externalizing behaviors, it has been found that high parental mentalization can contribute to the prevention of the onset of these problems (Suardi et al., 2020), and poor parental mentalization is associated with higher externalizing behaviors (Khoshroo & Seyed Mousavi, 2022). Nevertheless, there are some studies that have reported a null (Zeegers et al., 2020) or even a positive relationship (Kochanska & An, 2023; Wade et al., 2021) between parental mentalization and externalizing problems. Therefore, it is evident the need to clarify the association between these variables. In view of the above, we expect a negative relationship. Yet, several circumstances need to be considered in the analysis. A brief account of possible moderators follows. Parental mentalization: operationalization approaches Mentalization consists of four primary dimensions: Aspect (automatic vs. controlled), Focus (internal vs. external), Person (self vs. other), and Mode (cognitive vs. affective), being essential that these dimensions maintain a balanced interaction for effective mentalization (Bateman & Fonagy, 2019). Parental mentalization is investigated through three approaches –mind-mindedness (MM; Meins, 2013), parental reflective functioning (PRF; Slade et al., 2005), and insightfulness (Oppenheim & KorenKarie, 2002)–all focusing on parents’comprehension of their children’s internal states (Zeegers et al., 2017). Each one operationalizes caregivers’capacities differently and offers a unique perspective on comprehending parent–child dialogue and interaction (Medrea & Benga, 2021). A simple way to understand how to operationalize parental mentalization is conceptualizing it, following the terminology of Meins and Fernyhough (2015), as ‘offline’(representational) and ‘online’ (interactional) mentalizing abilities. MM is the only measure that can be evaluated from both online and offline perspectives, while PRF and insightfulness are operationalized in a representational way (offline). Appropriate MM can be measured in: (a) parent–child interactions, where parents provide accurate and spontaneous comments on the child’s mental state, matching the infant’s experience or behavior (online) and (b) via the caregiver’s description of the child in terms of mental attributes (offline; Dollberg, 2022). PRF can be evaluated by coding an interview (e.g., the Parent Development Interview: PDI; Slade et al., 2005; Sleed et al., 2020), or via self-report using a questionnaire (e.g., The Parental Reflective Functioning Questionnaire: PRFQ; Carlone et al., 2023; Luyten et al., 2017). Within the PRFQ, the dimensions include pre-mentalizing (PM), certainty about mental states (CMS), and interest and curiosity (IC), with adequate mentalization characterized by low PM and average CMS and IC scores. The PM subscale, which assesses distortions in mentalizing, reveals particularly detrimental effects of serious mentalization impairments, and is the most closely related dimension to emotional unavailability and insecure attachment (Luyten et al., 2017). Insightfulness is assessed through caregivers’reflections on their relationship with the child in response to questions about the child’s thoughts and feelings (Oppenheim & Koren-Karie, 2002). Nevertheless, the strength and direction among these three approaches (MM, PRF, insightfulness) and children’s externalizing problems seems to vary across studies. For instance, the correlation between MM and externalizing problems has been reported as strong (Camisasca et al., 2018), weak (Dollberg et al., 2023), or nonexistent (Zeegers et al., 2020). Similarly, PRF’s association with externalizing has been observed as strongly negative (Khoshroo & Seyed Mousavi, 2022) or positive (Borelli et al., 2021). Lastly, analyses of the relationship between insightfulness and externalizing problems have showed positive (Gray et al., 2015) and negative associations (Feniger-Schaal & Koren-Karie, 2021). Therefore, in view of the aforementioned discrepancies between studies, further research is required. Thus, the present metaanalysis will explore whether MM, PRF or insightfulness has stronger power to predict the expected negative relationship between parental mentalization and children’s externalizing problems. We anticipate the relationship between parental mentalization and externalizing problems to vary depending on whether it is assessed representationally or through actual interactions. Some parents may possess adequate mentalization 2 Maitane Nieto-Retuerto et al. https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press skills at the representational level (assessed via PRF), but struggle to demonstrate them in real-time interactions, when measured online through their verbalizations about the child’s mental states during direct play (Shai et al., 2017). Hence, we expect that, when parental mentalization is analyzed in real-time (online) interactions, the relationship between mentalization and externalizing problems will be stronger than when the measure is a ‘representational’ approach (offline). Children’s developmental stage Following normative developmental trajectories, externalizing problems decrease from early childhood to preadolescence, increase during adolescence, and then decrease again from late adolescence into adulthood (Petersen et al., 2015). Yet the impact of parental mentalization on reducing these behaviors may vary depending on the child’s developmental stage. For example, some studies have found that the relationship between parental mentalization and externalizing problems in adolescents is close to zero (e.g., Benbassat & Priel, 2012; Borelli et al., 2019). However, it has been found to be negative during infancy (e.g., Salo et al., 2022; Smaling et al., 2016), in young children (e.g., Colonnesi et al., 2019; Dollberg et al., 2021) and during middle childhood (e.g., Condon et al., 2019; Ensink et al., 2016). Moreover, a study comparing both early and middle childhood found a stronger negative effect between parental mentalization and externalizing problems in the older group (Khoshroo & Seyed Mousavi, 2022). Thus, younger children may require higher parental mentalization skills to effectively regulate their emotions and behaviors. Considering the above findings, we may posit a stronger negative relationship between mentalization and externalizing problems during middle childhood and a smaller effect during early childhood and adolescence. Parenting experience Given the inconsistency of research evidence, we suggest that parenting experience may be another moderator. While certain studies involving first-time parents revealed a modest association (Salo et al., 2021), research involving experienced caregivers uncovered a higher correlation (Lunn et al., 2019). Hence, we hypothesize that the negative relationship between parental mentalization and children’s externalizing problems will be stronger in experienced parents as compared to first-time parents. Population type Given the processes underlying mentalization, psychopathology will invariably entail challenges related to mentalizing skills (Bateman, 2022). As a matter of fact, in a recent systematic review and meta-analysis (Georg et al., 2023), parental depression has been associated to lower parental mentalization. Yet, the relationship between parental mentalization and children’s externalizing problems might differ between clinical and nonclinical populations. In fact, there is research evidence showing a likely stronger effect of parental mentalization in clinical/at risk samples (e.g., Hughes et al., 2017). Specifically, maternal mentalization has been found to have a stronger protective role in mitigating externalizing symptoms in challenging situations or with at-risk families, as opposed to general community samples (Meins et al., 2013). Therefore, we expect the strength of the negative association between parental mentalization and externalizing behaviors to be more pronounced in clinical or at-risk samples compared to studies involving the general community. Parental education Research exploring various education levels has shown differential associations of parental mentalization with child externalizing problems. MM was a predictor of child externalizing problems at childhood, but only with parents with no secondary education (Meins et al., 2013). However, some studies reported no association between parental mentalization and externalizing behavior when controlling for parental education (e.g., Colonnesi et al., 2019; Dollberg et al., 2021). Given the mixed nature of the evidence, we refrain from proposing a specific hypothesis regarding this matter. Reporting figure From a methodological perspective, the reporting figure may also affect the relationship between parental mentalization and behavior. There may be differences between parents’and teachers’ reports of children’s externalizing problems, as these informants rely on distinct experiences (Deneault et al., 2023). In fact, a metaanalysis reported that parents often perceive more externalizing behaviors than teachers (Carneiro et al., 2021). In addition, when the same observer evaluates two different variables, the correlation between them may increase due to covariance bias (Hoyt, 2000). Thus, it is reasonable to think that the relationship between parental mentalization and children’s externalizing problems would be stronger when the primary caregivers are the reporting figure of the latter variable (as opposed to teachers or other reporting figures). Aims of the meta-analysis In summary, the evidence that parental mentalization is associated with a decrease in children’s externalizing problems is inconclusive. Therefore, one of the objectives of this meta-analysis is to confirm the type of relationship between these variables. We also seek to determine the magnitude of this association, as well as to investigate factors that may moderate this relationship. The present metaanalysis aims at examining the relationship among infants, children, and adolescents. It will consider the following moderators: (a) different approaches for the operationalization of parental mentalization (MM, PRF or insightfulness), (b) children’sdevelopmental stage (early childhood, middle childhood or adolescence), (c) parenting experience (first-time vs. experienced parenting), (d) sample type (clinical/at-risk vs. community), (e) parental education, and (f) reporting figure (primary caregiver vs. others). The main hypothesis is that higher parental mentalization will be associated with fewer externalizing problems in children and adolescents. Furthermore, we expect a stronger negative association between higher levels of parental mentalization and externalizing problems in real time interactions (vs. representational approaches), in middle childhood (vs. younger children and adolescents), in experienced (vs. first-time) parenting family situations, in clinical/ at-risk (vs. community), and in primary caregiver (vs. others’ reports). Lastly, based on conflicting evidence when examining the possible moderating effects of parental education, we will take an exploratory approach regarding this question. Methods Inclusion and exclusion criteria This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). For their inclusion, studies had to meet the following criteria: (a) written in English or Spanish; (b) empirical in nature; (c) reported in peer-reviewed Development and Psychopathology 3 https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press journal articles; and (d) included children aged between 0 and 18 years in the sample. Studies were excluded if: (a) they provided insufficient data for effect size analysis, and additional data could not be obtained from the respective authors; (b) they did not evaluate parental mentalization;1(c) they did not assess children’s externalizing behavior in the age range under analysis (0-18 years); (d) they did not investigate the relationship between parental mentalization and child externalizing symptoms; or (e) were dissertations or book chapters. Search strategy criteria and selection of studies The initial search was performed in June 2021; it was updated in January 2024 to retrieve documents included in databases until December 2023. First, six electronic databases were searched to identify records related to parental mentalization and externalizing problems. These databases included APA PsycArticles, APA PsycInfo, PsycBooks, PSICODOC, Scopus, and Web of Science. The following combination of terms was used in the abstract, keywords, and subjects: Mentali*OR reflective function*OR mind-mind*OR mind-related OR insightful AND external*OR internal*OR behav*disorder*OR behav*difficult*OR behav* problem*OR conduct disorder*OR conduct*difficult*OR conduct problem*OR disruptive behav*OR child*problem OR antisocial behav*OR ADHD OR CBCL. Initially, we retrieved 5,442 records; eventually, we included 42 studies (N=7,761 participants) with 52 effect sizes in the meta-analysis (see Figure 1). To ensure consistence and replicability of the meta-analysis, a random sample of every fifth screened paper was independently coded by the second author; disagreements were resolved by having the first author and the second author review the article in question and jointly come to a consensus regarding the appropriate coding. Subsequently, the first and the second author independently reviewed all full-text level records. A high agreement was obtained (Kappa =0.98). The third author resolved discrepancies. The first and the third authors independently assessed the risk of bias of each of the included studies and discussed their assessments to achieve consensus. An adapted version of the Newcastle–Ottawa Scale for cross-sectional studies (NOS; Herzog et al., 2013; Wells et al., 2000) was used to evaluate the quality of the methodology used in the included studies. The NOS is a checklist that assesses the appropriateness of research design, the recruitment strategy, the representativeness of sample, the objectivity/ reliability of outcome determination, the power calculation provided, and appropriate statistical analyses. Score disagreements were resolved by consensus and a final agreed-upon rating was assigned to each study (see S1 of Supplementary Online Materials). Finally, the data extraction process involved two stages. The first author retrieved the necessary data for analysis (see Table 1), and the third author independently checked the values. Any disagreements were resolved by all authors. Analysis plan Our primary analysis included 52 effect sizes assessing parental mentalization and externalizing problems (see Table 1for Figure 1. Flow diagram. 1The study was excluded if the total or a nonvalidated version of the PRFQ scale was reported, and no further data could be obtained. 4 Maitane Nieto-Retuerto et al. https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press overall effect sizes and study characteristics). The following moderators were examined: approaches for the operationalization of parental mentalization (MM, PRF, or insightfulness), children’s developmental stage (early childhood, middle childhood, or adolescence), parenting experience (first-time vs. experienced), the sample type (clinical/at-risk vs. community), and reporting figure (primary caregiver vs. others). Only categorical moderator variables that had at least five contrasts in the categories were used (Bakermans-Kranenburg et al., 2003);thus,wewereunabletoanalyzeparentalinsightfulness (k=3). The data from parental education was noncomparable among the studies to perform moderation analyses (i.e., studies reporting the percentages of participants’educational attainment). When studies reported both maternal and paternal correlations, we chose the maternal correlation for consistency, as more studies focused on maternal mentalization. In longitudinal studies and interventions, we selected the effect size reported at baseline. In order to maintain a comparable number of studies, the operationalization of PRF was prioritized when both PRF and MM were reported, aiming to balance moderation analyses. Taking into account the three dimensions of PRFQ, we have not considered the CMS or the IC subscales. The reason is that the optimal levels of both subscales are at the midpoint; consequently, a curvilinear analysis might be more appropriate, but it complicates the linear regression required for meta-analytic techniques. Therefore, we have chosen the PM correlation in order to perform the analyses. Accordingly, correlation scores were reverted because it assesses a non-mentalizing stance, indicating that higher scores correspond to lower mentalizing abilities. Moreover, to test whether the relationship between mentalization and externalizing problems differed across the various approaches for the operationalization of mentalization, we compared effect sizes between offline vs. online measures. To define age groups, we have categorized individuals into early childhood (0-5 years), middle childhood (6-12 years), and adolescence (13-18 years) (see S2 of Supplementary Online Materials). The analysis was conducted using R v4.2.2 (R Core Team, 2022) and the metafor package v4.0.0. Random effects model was chosen due to its ability to account for the excess variance (Viechtbauer, 2010). Effect sizes (Pearson’sr) were computed to have the same statistic depicting the relationship between parental mentalization (MM or PRF) and externalizing problems. Standard formulas allowed for the transformation of diverse effect sizes, such as group differences (Wilson, 2023) and regression coefficients (Peterson & Brown, 2005). In order to reduce variability, pooled effect sizes were computed with corresponding 95% confidence intervals (Borenstein & Hedges, 2019). Results Characteristics of the studies The following lines provide a summary of some noteworthy aspects of the included research in the meta-analyses. A total of 42 studies with 52 effect sizes were incorporated in the meta-analysis. The investigations were conducted in various countries, including Australia, Belgium, Canada, Finland, Israel, Italy, the Netherlands, Switzerland, Türkiye, the UK, and the USA. The meta-analysis included 7,761 caregivers and their children. Most studies (k=38) included birth parents, while a few involved other caregivers (k=4), such as adoptive and foster parents. Twenty-six studies included participants from the community, nine studies used clinical or risk samples (i.e., children who experienced abuse or low socioeconomic families), and seven studies compared both sample types. Intervention programs were included in seven research papers. Studies analyzing parental mentalization as a mediator between parent/child mental health (i.e., parental depression or psychopathological impact of sexual abuse in children) on externalizing problems found higher levels of this ability related to fewer externalizing problems. This suggests both direct and indirect effects of parental mentalization on externalizing behaviors (see S3 of Supplementary Online Materials for details of variables analyzed in the studies). Meta-analytic effects Effect sizes (Pearson’sr) were computed to examine the relationship between parental mentalization and externalizing problems. The coefficient based on the random-effects model of rwas −.19 (95% [CI: −.24, −.13]), ranging from −.56 to .23, with most estimates being negative (83%). As expected, there was a negative relationship between parental mentalization and externalizing problems. This indicates a small to moderate negative relationship between the variables, implying that higher parental mentalization is associated with fewer externalizing problems observed in children. Figure 2displays a forest plot illustrating observed outcomes and estimates. The Q-test suggests heterogeneity among the true outcomes (Q(51) =383.760, p=.001, τ2=.029, I2=83.750), denoting that a significant proportion of the variability in effect sizes is due to differences between studies rather than sampling error. The high I2 value suggests that approximately 84% of the total variation across studies is attributable to heterogeneity. Consequently, despite the average outcome being estimated as negative, some studies may indicate a positive true outcome (e.g., higher mentalization, elevated externalizing problems). Figure 3presents a funnel plot of the estimates. Neither the rank correlation (p=.894) nor the regression (p=.849) test indicated any funnel plot asymmetry, suggesting no publication bias. We conducted further exploration of the possible sources of heterogeneity through moderation analyses. The mixed-effects model indicated that the association between parental mentalization and externalizing behaviors varied significantly across different developmental stages. As hypothesized, it was stronger for the middle childhood category (r=−.328, p<.001) than for younger children (r=−.112, p=.002), but was nonsignificant in the adolescence group (r=−.129, p=.065). Also, in line with our expectations, parenting experience also turned out to be a significant moderator, such that the inverse relationship between parental mentalization and children’s externalizing problems was greater in the case of experienced parents (r=−.208, p<.001). In the rest of the moderation analyses –(a) different approaches for the operationalization of parental mentalization (MM or PRF), (b) sample type (clinical/at-risk or community), and (c) reporting figure (primary caregiver vs. others) –, there were no differences between the levels of the moderators (see Table 2). Therefore, our hypotheses in relation to these variables were not confirmed. Discussion The purpose of this study was to review the literature on the relationship between parental mentalization and children’s externalizing problems, analyzing results from a quantitative perspective. To the best of our knowledge, this is the first attempt at Development and Psychopathology 5 https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press Table 1. Information of the studies included in the meta-analysis Authors NCountry % girls % First −time parents Children’s mean age (months) Mentalization measure Externalizing behavior measure Main results Pearson r Benbassat & Priel (2012) 105 Israel nd nd 189.6 PDI YSR High levels of paternal control were associated with higher levels of adolescent externalizing problems, only in the presence of low levels of paternal RF. In the presence of higher levels of parental RF, these parenting behaviors were associated with greater positive adolescent outcomes. .06 Borelli et al. (2019) 265 US 49.4 nd 184.56 RFQ CBCL Higher parental reflective function was associated with less externalizing problems, only when reported by the adolescents. Parent reflective function was not associated with convergence of parent–adolescent reports with respect to externalizing symptoms. −.07 Borelli et al. (2019) 265 US 49.4 nd 184.56 RFQ CBCL When adolescents reported on externalizing problems, higher parental reflective function did not have a negative correlation with externalizing symptoms. .01 Borelli et al. (2021) 112 US 46 nd 150 PRFQ CBCL Eight-week intervention revealed significant pre−post increases in purported mechanisms of change (reflective functioning) and early intervention outcomes (externalizing problems). −.17 Brown et al. (2023) 44 US 50 nd 13.34 MM CBCL Mind-mindedness at 28 months did not predict behavioral difficulties in children from nonmaltreating families. −.12 Brown et al. (2023) 54 US 50 nd 13.34 MM CBCL Mind−mindedness at 28 months predicted fewer behavioral difficulties at 39 months in children from maltreating families. −.13 Camisasca et al. (2018) 46 Italy 58.7 nd 16.93 MM CBCL Somatic symptoms, conjointly with impaired mind-mindedness, predicted externalizing behaviors −.46 Carlone & Milan (2021) 212 US nd nd 108.12 PRFQ BESS Low maternal reflective function was associated with elevated child externalizing symptoms, and a greater perceived need for treatment. −.34 Centifanti et al. (2016) 203 UK 52.42 42.36 61 MM SDQ Appropriate mind-related talk indirectly predicted callous unemotional traits via its effect on children’s emotion understanding. −.15 Charpentier −Mora et al., (2022) 87 Italy 40 nd 121.2 PRFQ CBCL Parental mentalizing was significantly associated with child’s externalizing symptoms. −.35 Colonnesi et al. (2019) 104 The Netherlands 52.88 nd 53.41 MM SCBE −30 Infrequent use of appropriate mind-related comments of both parents predicted children’s externalizing problems. −.08 Colonnesi et al. (2022) 138 The Netherlands 49.27 nd 161.04 MM SDQ General, neutral, and positive mind-mindedness related negatively to externalizing problems. −.15 Condon et al. (2019) 54 US nd nd 80.16 PRFQ CBCL High parental reflective function was associated with fewer child emergency department visits, whereas impaired parental reflective function was associated with more externalizing problems. −.49 Dieleman et al. (2020) 268 Belgium 50.7 nd 181.68 PRFQ CBCL Externalizing problems related to both fathers’ and mothers prementalization. −.47 Dollberg et al. (2021) 144 Israel 55.2 50 50.04 MM CBCL Maternal mind-mindedness, but not paternal mind-mindedness, moderated the direct link between parents’general anxiety and the child’s externalizing behavior. −.01 Dollberg et al. (2023) 87 Israel 50 91.64 47.52 MM CBCL Mothers who demonstrated lower mentalization skills and higher anxiety symptoms reported more child externalizing behaviors. −.11 (Continued) 6 Maitane Nieto-Retuerto et al. https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press Table 1. (Continued ) Authors NCountry % girls % First −time parents Children’s mean age (months) Mentalization measure Externalizing behavior measure Main results Pearson r Dollberg et al. (2023) 53 Israel 50 91.64 54.36 MM CBCL When mothers showed higher mentalization skills, the indirect effect of anxiety on the link between COVID - 19 and children’s externalizing behaviors was weaker, compared to when mothers showed lower mentalization skills in the risk sample. −.05 Ensink et al. (2016) 168 Canada 57.14 nd 112.06 PDI CBCL Maternal mentalization was an independent predictor of child externalizing difficulties, with higher maternal reflective function associated with less externalizing difficulties. −.3 Ensink, Bégin, Normandin, and Fonagy (2017) 154 Canada 61.92 nd 74 PDI CBCL Significant inverse relationships between maternal mentalizing and child externalizing difficulties were observed. −.31 Ensink, Bégin, Normandin, Godbout et al. (2017) 168 Canada 47.07 nd 91 PDI CBCL Maternal reflective function decreased the relationship between sexual abuse on externalizing difficulties. −.3 Ensink, Leroux et al. (2017) 85 Canada 49.27 nd 112.5 PDI CBCL A significant negative correlation was found between reflective parenting stance assessed by the teacher and externalizing difficulties reported by the parent. −.38 Ensink, Leroux et al. (2017) 158 Canada 49.27 nd 112.5 PDI CBCL The associations between reflective parenting stance and parent reports of child externalizing difficulties were small and not significant, in contrast to the significant and moderate strength associations between the reflective parenting stance and teacher reports of child difficulties. −.25 FenigerSchaal & Koren-Karie (2021) 28 Israel 50 nd 102 Insightful CBCL After the intervention program to increase parental reflective function, a significant decline in the children’s externalized and general behavioral problems was found. −.12 Ghanbari et al. (2023) 357 Iran 48.7 nd 87.12 PRFQ CBCL Prementalizing moderated the relationship between effortful control and externalizing problems, and between negative affectivity and externalizing behaviors. −.37 Gray et al. (2015) 39 US 53 nd 45.96 Insightful CBCL Among children not exposed to violence, insightfulness was not related to children’s externalizing behaviors, suggesting violencespecific processes. .23 Gray et al. (2015) 20 US 53 nd 45.96 Insightful CBCL Violence-exposed children with noninsightful caregivers demonstrated higher externalizing behaviors. −.37 Ha et al. (2011) 659 UK 48.40 nd 114.72 Social stories SDQ Poor maternal accuracy did not significantly predict the development of externalizing problems at 1-year follow-up when controlling for baseline externalizing problems and age. −.22 Hobby et al. (2023) 91 Australia 39.6 67 7 MM SDQ Higher early appropriate mind-mindedness in mothers with higher parenting distress at 36 months was associated with lower externalizing problems at 51 months. −.19 Hughes et al. (2017) 116 UK 45 nd 72.36 FMSS SDQ Mothers’mind-mindedness predicted unique variance in disruptive behavior. −.08 Khoshroo & Seyed Mousavi (2022) 224 Iran 51.7 47.7 48 PRFQ CBCL Mothers of school-aged children showed significantly higher levels of prementalizing than mothers of preschoolers. Certainty about mental states moderated the relationship between maternal depression and child externalizing behaviors in school-aged children. −.49 (Continued) Development and Psychopathology 7 https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press Table 1. (Continued ) Authors NCountry % girls % First −time parents Children’s mean age (months) Mentalization measure Externalizing behavior measure Main results Pearson r Khoshroo & Seyed Mousavi (2022) 461 Iran 51.7 47.7 48 PRFQ CBCL Parental mentalization was negatively correlated with externalizing problems. No moderating effect was found for prementalizing or interest and curiosity in mental states in the preschoolers group. −.43 Kochanska & An (2023) 175 US 49.14 nd 36 PRFQ ITSEA Mothers, but not fathers, who had more negative higher prementalizing scores rated their children as less disruptive. .15 Konijn et al. (2020) 48 The Netherlands 49.7 nd 116.4 MM SDQ Foster parents’mind-mindedness was not significantly related to children externalizing problems. −.21 Koren Swisa et al. (2024) 89 Israel 49 44 47.52 MM CBCL The positive associations between conflict exposure and children’s externalizing behaviors were mitigated when the parents’mentalization skills were matched or when the mother’s mentalization skills were high. −.1 Lunn et al. (2019) 67 UK 44 nd 123.6 Social Stories CBCL In the normative sample, lower maternal mind −mindedness predicted child externalizing problems. −.44 Lunn et al. (2019) 34 UK 44 nd 144 Social Stories CBCL Higher negative maternal mind-mindedness in children with epilepsy, predicted greater externalizing problems. −.51 Meins et al. (2013) 91 UK 49 47.7 52.71 MM SDQ Maternal mind-mindedness was not associated with externalizing behaviors in the high socioeconomic group. .14 Meins et al. (2013) 60 UK 49 47.7 52.71 MM SDQ In the low socioeconomic group, having a mindminded mother mitigated their negative effects on children’s externalizing behaviors at 44 months and in the first year of school. −.03 MenasheGrinberg & Atzaba-Poria (2023) 84 Israel 53 62 51.6 MM CBCL Improvement in the parent–child interaction, child reflective function, and child externalizing problems were related to improvement in PRF. −.08 Salo et al. (2021) 429 Finland nd 100 12 PRFQ BITSEA For mothers, earlier relationship satisfaction predicted later infant externalizing problems, also through the current level of parental reflective function. For fathers, both relationship satisfaction and parental reflective function had direct, but not mediated, effects, and on infant externalizing problems. −.04 Salo et al. (2022) 1016 Finland nd 100 24 PRFQ CBCL For both mothers and fathers, a low level of relationship satisfaction, but not PRF, predicted consistently higher levels of child externalizing problems at age 2. −.01 Shai & Belsky (2017) 200 US nd nd 54 TRF PEM Higher parental embodied mentalizing negatively predicted externalizing problems. Higher maternal sensitivity, after controlling for parental embodied mentalizing, was related with more externalizing problems. −.19 Shalev et al. (2023) 106 Israel 50.49 nd 48.84 PDI CBCL Externalizing problems were related to greater intensity of parental guilt only when PRF levels were low. −.24 Smaling et al. (2016) 123 The Netherlands 44 100 19.97 PDI CBCL Postnatal self-focused reflective function was positively linked to externalizing behavior and negative emotionality in offspring, while relationfocused reflective function scores were negatively associated with child physical aggression. .08 Suardi et al. (2020) 23 Switzerland 52 48 26.7 Working Model of the Child Interview ITSEA Maternal reflective function was negatively correlated with externalizing behaviors in the general sample. −.31 (Continued) 8 Maitane Nieto-Retuerto et al. https://doi.org/10.1017/S0954579424001391 Published online by Cambridge University Press summarizing the empirical results on the topic. The included studies were conducted in different countries, predominantly involved biological parents with their children, and were drawn from a combination of community and clinical/at-risk samples. We observed that the expected negative association between parental mentalization and child externalizing problems was predominantly consistent across studies. The magnitude of the effect size may be considered small to moderate (Funder & Ozer, 2019), being slightly stronger than similar meta-analyses in the field, such as those reviewing the predictive power of parental sensitivity on children’s behavior problems –e.g., r=−.14 in Cooke et al.’s(2022) and r=−.08 in Rodrigues et al.’s(2021). Thus, it seems that parental ability to understand a child’s mental states allows caregivers to better respond to the child’s needs, likely prompting a decrease in externalizing problems and confirming the relevance of paying special attention to parenting mentalization. This finding reveals substantive effects that underline the importance of intervening with parents on mentalization as a useful strategy that can contribute to prevent later children’s externalizing problems. Beyond the overall negative association between parental mentalization and externalizing problems in offspring, the significant heterogeneity in this relationship suggests the need to consider potential moderators. With respect to the possible moderators examined, the different approaches and measures to parental mentalization did not reveal significant effects. Children’s developmental stage (early and middle childhood) and parenting experience (experienced parenting vs. first-time parents) were found to strengthen the negative relationship between parental mentalization and externalizing problems. Population type (clinical/at risk vs. community), and reporting figure (primary caregivers vs. others) failed to reach statistical significance. Insightfulness and parental education could not be analyzed due to lack of data. Below we outline some reflections on the possible meaning of our results. Contrary to what expected, different operationalization of parental mentalization (offline-representational vs. online-interactional) did not moderate the relationship between parental mentalization and externalizing problems. Although different approaches to parental mentalization are reported in the literature (e.g., Medrea & Benga, 2021), our results suggest that these may be closer to each other. This may indicate that parental mentalization might be a singular construct that can be operationalized in various ways. In line with our results, Yatziv et al. (2020) found PRF (offline-representational) and MM (online-interactional) to be positively correlated, that is, mothers who tended to spontaneously describe their child in a mentalistic manner during interactions (MM) were more likely to have more elaborated representations of their child’s mind (PRF). Hence, both operationalizations appear to explore the common domain of the parent–child relationship through the lenses of parent’s mentalizing abilities. In line with our expectations, children’s developmental stage moderated the negative relationship between parental mentalization and externalizing behaviors. These results show that parental Table 1. (Continued ) Authors NCountry % girls % First −time parents Children’s mean age (months) Mentalization measure Externalizing behavior measure Main results Pearson r Suardi et al. (2020) 33 Switzerland 52 48 27.5 Working Model of the Child Interview ITSEA Maternal reflective function was negatively correlated with externalizing behaviors in the posttraumatic sample. −.4 Wade et al. (2021) 501 Canada 49.3 nd 18 FMSS BITSEA Lower maternal reflective capacity was associated marginally with lower externalizing psychopathology. .2 Walker et al. (2012) 21 UK 56 44 47.21 MM SDQ In the community group there was a strong negative correlation between mind-mindedness and children’s externalizing problems. −.56 Walker et al. (2012) 25 UK 56 44 44.68 MM SDQ In the clinical group there was no significant correlation between mind-mindedness and children’s externalizing problems. −.23 Yatziv et al. (2020) 98 Israel nd 32 66.03 PDI SDQ The links between executive functions and parental reflective functioning were stronger when children were perceived as more difficult, that is, as having negative affectivity, externalizing problems, and difficulties in adjustment. .09 Zeegers et al. (2020) 53 Amsterdam 54.7 nd 97.44 MM CBCL Parents reported less child externalizing problems at posttest and follow-up. Parents’ mind-mindedness increased from preto posttest but not from pretest to follow-up. .00 ZimmerGembeck et al. 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