Early Motherhood in Migration : A First Report from FIRST STEPS-An Integration Project for Infants with an Immigrant Background

Background: Children with an immigrant background tend to underachieve in German education with respect to their German peers. Furthermore they are more likely to live in high-risk environments. Quite a number of projects for the integration of these children exist. However most of them are hardly scientifically evaluated. The project FIRST STEPS focuses on the earliest integration of children with an immigrant background by supporting parenting capacities in the critical phase of migration and early parenthood. Furthermore it serves as a scientifically evaluated model project. Methods: By using a prospective randomized comparison group design the effectiveness of a psychoanalytically oriented early prevention program (intervention A) is compared to the outcomes of groups offered by paraprofessionals with an immigrant background (intervention B). Both interventions begin during pregnancy and last until the commencement of kindergarten when the children are about three years old. Over 270 families have already been recruited in Frankfurt am Main and Berlin. A variety of different instruments is applied during as well as after the intervention in order to assess social and family stressors, the quality of the parent-child-interaction, child attachment security, the affective, cognitive and social-emotional development as well as language development of the children, the children’s stress level and the social integration of the families. Results and Conclusion: The project is still on-going and aims at evaluating the implementation as well as the shortand long-term effectiveness of the psychoanalytically oriented intervention A compared to the outcomes of intervention B (comparison group). First preliminary results show that FIRST STEPS is accepted by these “difficult-toreach” immigrant families and indeed can support early motherhood in migration. Journal of Pregnancy and Child Health J o u r na l o f P reg nancy anChild He a l t h


Introduction
Although politicians and most parts of society have begun to understand that Germany has become a country of immigration during the last years, children with an immigrant background are still disadvantaged in the German educational system [1][2][3][4]. In addition they are more likely to live in high-risk environments. In 2010, 48% of children living in families with an immigrant background grew up exposed to at least one situation of risk such as unemployed, lowincome earning or educationally disadvantaged parents [5]. Thereby the amount of children growing up exposed to at least one situation of risk was even higher for children from Turkish families (68%). Furthermore the amount of children with an immigrant background among the younger population in Germany still increases. In 2012 for example, 35% of the children in Germany who were younger than five years had an immigrant background [6].

Migration as risk factor for early motherhood
In the context of the disadvantage which children with an immigrant background are facing it needs to be kept in mind that it is not the immigrant background per se that puts these children at risk of becoming disadvantaged. It is rather the factors that are associated with their parents´ migration: psychological factors due to the different phases of migration on the one hand and socio-economic factors such as low socio-economic status, unemployment, insecure institutional status etc. that create difficult developmental environments for these children. Thereby children of mothers who have not lived in Germany for a long time are particularly disadvantaged, because their mothers often face significant challenges and are in an emotionally insecure situation themselves [7][8][9]. First of all immigrating to a new country is a demanding process which involves different practical, economic and emotional challenges in leaving the country of origin, moving to a new country and establishing a new life there [10]. Having arrived in the immigration country immigrants often struggle to cope with the insecurity of an uncertain future, the foreign culture, language difficulties and discrimination. In addition they have to get along in a new surrounding while often not having experienced attachment figures -such as their own parents and siblings -at reach for support [11]. Thereby mothers who recently immigrated feel particularly alone and isolated during the critical and often stressful time after the birth of a child. During this time the risks of social withdrawal, isolation and depression are significant. Research results indicate that immigrant women who are socially isolated, economically disadvantaged, and/ or experience cultural conflicts within their families are at risk for developing a range of social and psychological problems, including depression and psychosomatic disorders [12][13][14]. Compared to the Early Motherhood in Migration: A First Report from FIRST STEPS -An Integration Project for Infants with an Immigrant Background population in the host country immigrant women have a higher risk to be affected by postnatal depression [15]. The mother's stress can disturb the mother's maternal sensitivity and thus can have a negative impact on the emotional quality of the early mother-child relationship [7,9]. Thus it brings about an additional disadvantage for the children whose mothers came to Germany only recently, placing them in a special risk group among the immigrant population. Therefore, FIRST STEPS focuses on professional support of early mother-and parenthood of immigrant families.

Supporting early parenthood from pregnancy on
Results of the Frankfurt prevention study [16,17] indicated that reasons for a poor or missing early integration among children might lie beyond language barriers and rather be associated with a potential disruption of "natural attachment" in the course of migration and young motherhood. The following assumptions guided the development of FIRST STEPS and may help to understand the disruptive potential of attachment in the process of migration and young motherhood: On the one hand we know that both, the experience of migration, e.g. acquiring cultural competencies right at the beginning of immigration [18], as well as entering maternity are stressful and vulnerable phases [19] and when coinciding, stress load might be particularly high. On the other hand we noticed especially young parents' genuine wish that their child should lead a good life, a fact which means an enormous chance for the wish that the child (and the whole family) might be included in the country of immigration in the future. Mothers' growing worries about giving birth in the last trimester can also result in an opening of immigrant families towards the immigrant country's society during this phase. However, if experiences during this vulnerable phase are dominated by disappointments and frustration, mothers might withdraw socially. They need to actively process their new situation as immigrants and being psychologically fragile due to early motherhood at the same time bring about the danger of giving up both tasks or favouring one of the two and ignoring the other. If so, mothers will always feel that they have failed -one way or another; a feeling that contributes to the associations of migration, isolation and depression as we have learnt from the Frankfurt prevention study even without taking into account traumatic stress due to political persecution, torture as well as other dramatic losses [1,16]. Furthermore research results indicate that if children -closely attached to their primary caregivers -unconsciously notice that their parents, especially the mother, suffer from severe homesickness or have not really "arrived" at the country of immigration emotionally, the child will perceive turning to the culture and language of the immigration country as a betrayal and turning away from his/her parents or mother [20]. Often this kind of loyalty conflict keeps children with an immigrant background from successfully learning the language of the immigration country and integrating psychosocially [17,21,22]. Unconsciously they identify with their parents' losses, possibly leading to behaviour problems (e.g. hyperactivity), school failure and/or depression if not processed thoroughly [22,23].
In order to prevent intergenerational transmission of depressive reactions due to unprocessed grief, FIRST STEPS seeks to support families and in particular women, who have not lived in Germany for a long time, in acquiring cultural competencies, mourning losses as well as becoming a mother. Thereby the project seeks to improve early developmental environments of children at risk of growing up disadvantaged due to their parents' acute migration (stress) and strengthening their resilience [22,17]. In promoting infant-mother (father) relationships from the earliest point on -pregnancy -we hope that FIRST STEPS will facilitate successful mother-child interaction from the time the natural window for its development opens. In doing so, we hope to promote attachment security and therefore healthy child development.
Empirical attachment, neurobiological as well as epigenetic research show that attachment security is strongly associated with cognitive, socio-emotional and language development, stress reactivity as well as academic success [23,24]. Furthermore there is a consensus in the scientific literature that secure attachments can be seen as a protective factor for the development of behaviour disturbances and social competences [25][26][27]. Children who grow up in a positive and emotionally secure environment are more creative, show less aggressiveness and learn languages more easily [1,28,29]. We seek to promote parents' reflective functioning [30], adequate emotion regulation, parenting behaviour (e.g. responding to their infant's cues consistently) as well as cultural competencies and hope that parents' psychosocial integration will be facilitated.

Pilot study
Political reactions to the clarion call of the early PISA studies included the nationwide implementation of integration and German language courses in 2004. In 2007, these courses became compulsive 1 . A pilot study to FIRST STEPS, conducted in 2008/09 in Frankfurt, showed that about one third of all female integration course participants became pregnant during the courses 2 , dropped out of courses and unfortunately rarely returned for completion. These factors put these women at risk of not gaining the "required" cultural competencies -including knowledge of German -and thus of becoming socially isolated, with the corresponding consequences for their children. This is where FIRST STEPS seeks to step in and tries to support immigrant families and mothers with the aim to increase the rate of the women who are finishing their language courses successfully and support their cultural competences. At the same time FIRST STEPS also aims at supporting the development of the children (see below) [1].

Aims and general hypotheses of FIRST STEPS
FIRST STEPS aims at supporting early parenting of immigrant families. Two different prevention programs, a broader, more individual and complex, psychoanalytically oriented intervention, the FIRST STEPS intervention (A) and a less complex standard intervention B in form of self-organized open "mother-child groups" offered by paraprofessionals are compared and evaluated. In 2010 the project was first implemented in Frankfurt am Main. In order to test different recruitment strategies as well as possibly necessary adaptations of the project implementation in other cities FIRST STEPS has additionally been implemented in Berlin from 2012 on.
The first main hypothesis anticipates that both interventions A and B support the integration of immigrant families and have a positive impact on the development of their children during the first three years of their lives. This hypothesis will be tested by comparing the samples of the FIRST STEPS project with "matched pairs" of a large untreated sample of the Socio-economic Panel (Sozioökonomisches Panel, SOEP) of the German Institute for Economic Research (Deutsches Institut für Wirtschaftsforschung, DIW), Berlin [31]. Further hypotheses focus on the different short-term and long-term effects of intervention A and B. For example it is expected that supporting the earliest parent-childinteractions and parenting capacities as well as addressing the individual needs of the families in a professional psychoanalytically oriented intervention (A) will have a greater positive impact on the children's affective, socio-emotional, cognitive and language development as well as on their attachment style and the quality of the parent-child relationship than intervention B. Additionally it is assumed that the mothers of intervention A are less likely to stop taking part in the integration courses, learn German much better and are more likely to find a job and to participate in social activities of the immigration country. Thus it is expected that the whole family benefits more intensively from intervention A than from intervention B (for detailed description of the hypotheses see section "instruments" below).

Participants
FIRST STEPS addresses pregnant first-generation immigrant women (from the second trimester on, and their husbands) who have no or little knowledge of German language and have not been living in Germany for longer than three years (in accordance with the population of the integration courses [32]). Most of our participants have a low socio-economic status and are difficult-to-reach. In this context "difficult-to-reach" means that the participants often fail to access social and community services (e.g. family support services) and therefore remain un-provided [33]. It is difficult to recruit this population and a lot of effort is needed to get the participants to commit to the prevention program and to stay involved over time [34].

Recruitment and study design
By using a prospective randomized comparison group design the study aims at investigating the short and long-term effects of the FIRST STEPS intervention (intervention A) in comparison to an intervention offered by paraprofessionals with an immigrant background (selforganized open mother-child groups, intervention B). For the recruitment of participants in Frankfurt we made use of the abovementioned compulsory integration courses for new immigrants, offering pregnant women and young families support in the institutions where the integration courses are held. Project staff regularly presented the project in the integration courses and was informed by the integration course teachers when a woman was pregnant in order to contact her as soon as possible. In Frankfurt a cluster randomization was applied. The integration courses served as clusters and were randomly assigned to the two different interventions (see Figure 1). In Berlin the project is integrated into the offerings of the mother-child-centre (children's house of health) at the Vivantes Clinic Neukölln, where 80% of mothers have an immigrant background. The participants are recruited directly at maternity units and are randomised individually to the two interventions A and B. Due to the local circumstances (language courses and maternity units) it was necessary to randomise the women from the maternity units individually while in Frankfurt a clusterrandomization was applied (see Figure 1).

Intervention groups
In the following, the two interventions will be described which are both offered from the time of pregnancy until the commencement of kindergarten when the children are about three years old.

Intervention A -FIRST STEPS:
The psychoanalytically trained FIRST STEPS project staff, mostly mothers themselves with an immigrant background, supports the women (and their husbands) ideally already during pregnancy. Hence they build an emotional relationship with them in order to continue their support after the birth of the child. This support should help the women to avoid withdrawal into isolation. Afterwards the project staff continues to accompany and support the mothers and children both in group contacts (moderated weekly groups with two project staff members) and individual contacts (via telephone, home visits) until the children enter kindergarten at the age of three. The FIRST STEPS approach is curriculum-based. The training of the project staff includes psychoanalytic case-supervision, practice reflection with the practical project responsible 3 as well as supervision with child and adolescent psychotherapists. The manualised curriculum which has been developed by the practical project responsible in Frankfurt is based on psychoanalytic and empirical developmental psychology and will be published in the near feature. The conceptualisations included closely refer to other already evaluated psychoanalytically oriented parenting programs [35][36][37]. The training sensitizes the staff for the processes of transference and counter-transference allowing for a deeper understanding of the women's situation and children's needs. The project staff learns to develop a psychoanalytical "mind-set" and a holding and containing function [38] in contact with the individual women as well as during the group sessions. Thus they can serve as role models and as "secure base" [39] for the mothers, supporting them in the vulnerable phase of their early motherhood. Their consultation focuses on individual needs of the mothers and children as well as questions and concerns the families might have concerning the child´s development. The project staff thereby supports parenting competences (e.g. reflective functioning, adequate emotion regulation). Furthermore questions concerning the migration problems of the families (helping those consulting institutions, clinics, social and mental health care services, language courses, educational institutions etc.) are addressed and coping with losses associated with the women's and families' migration is supported.

Intervention B:
The mothers and children in intervention 3 Child and youth-psychoanalyst Claudia Burkhardt-Mußmann (in Frankfurt) and Rose Alheim (in Berlin).
B take part in self-organized open "mother-child groups" led by female paraprofessionals with an immigrant background 4 . These paraprofessionals are mostly mothers themselves and the idea is that they pass on their experiences to the mothers and invite for social exchange.
The paraprofessionals are only instructed and informed about the study very basically, including the aimed duration of the intervention until children enter kindergarten and research instruments. They are free to conduct and organize their groups according to their views and their experience as immigrants and mothers. They do not receive any support with regard to contents and have no contact with the project organization and implementation other than with the research team collecting data about mothers and children.

Instruments, times of measurement and detail description of hypotheses
A variety of instruments is applied at five different times of measurement: three in the course of the intervention (t2: 2,5-5 months, t3: 13-15 months, t4: 24-27 months), one directly afterwards, when the children enter kindergarten (t5: 36-39 months), and one time of measurement after the intervention, when the children attend kindergarten 5 (t6: 8-14 months after kindergarten entrance). The assessed variables and times of measurement are presented in figure  2. Sociodemographic information of the families is assessed at the beginning of the intervention (t1) by using a self-report questionnaire, 4 Self-organized open mother-child groups have become a common form of similar early prevention projects in Germany [3]. 5 The Germany kindergarten is synonymous with preschool and in Germany preschools are for children between the ages of three and six. Normally children enter kindergarten when they turn three years old. . Thereby an additional set of questions is assessed, which concerns the mother's integration (called Hertie Belonging Scale) and has been developed by the research team. Furthermore family stressors and the social support of the families, the mothers' subjective daily stressors and life-satisfaction as well as the mothers' depressive symptoms are assessed with the help of a set of different questionnaires in the course of the intervention.
In addition the children's cognitive and motor development is assessed when the children are two years old (t4) (see Figure 2).
Additionally the emotional quality of mother-child interaction is measured at four different times of measurement (t2, t3, t4 and t5). Therefore videotaped mother-child interactions are blindly rated by independent and trained psychologists with the help of the Emotional Availability Scales (EAS) [40], an observational instrument with a dyadic focus. It is expected that at time of measurement t5 the children in intervention A show a better relationship to their primary caregiver (mother) compared to the children in intervention B. The EAS allow for a detailed look at caregiver-child interactions by rating the dyad on six dimensions, four focusing on the parent's behaviour (sensitivity, structuring, non-intrusiveness, non-hostility) and two focusing on the child's behaviour (child responsiveness, child involvement of the caregiver). Significant findings have been reported about the positive relationship between parental EA and children's attachment security [41]. It is of particular relevance that the EAS dimensions can be rated independently of the caregivers' cultural background and that the EAS are sensitive to change related to a program of intervention [42][43][44][45][46][47][48][49] (see Figure 2).
At the end of the intervention (t5) the mother's integration (among others mothers' successful completion of integration courses, employment/occupational comeback, interest in host country) is measured by the repeated assessment of a part of the BAMF questionnaire and the Hertie Belonging Scale as indicators of successful integration. It is expected that at the end of the project (t5) more mothers in intervention A have successfully completed the integration course in comparison to those in intervention B. Furthermore it is anticipated that the mothers in intervention A are socially more oriented towards the host country, in comparison to those in intervention B.
Furthermore several measurements take place when the children enter kindergarten as well as afterwards (follow-up). The children's hair cortisol level is measured as a marker of stress a week before kindergarten entrance as well as 6 weeks and 1 year afterwards. It is expected that when entering kindergarten (t5) as well as one year later (t6) the children in intervention A show lower levels of stress, compared to the children in intervention B. Measuring the concentration of cortisol in hair is a new and promising method to measure cortisol [50].
Furthermore the children's knowledge of the German language is assessed a year after kindergarten entrance by a trained linguist with the help of the LiSe-DaZ (Linguistische Sprachstandsdiagnostik -Deutsch als Zweitsprache) [48], a standardized language test. The LiSeDaZ enables to measure children's development in core grammatical areas and offers separate norms for multilingual children, which take into account the age of the children and the length of exposure to the German language [48]. It is hypothesised that the children in intervention A show a better language development one year after kindergarten entrance compared to the children in intervention B.
Additionally the children's socio-emotional development is evaluated at kindergarten age by kindergarten teachers using the Strengths and Difficulties Questionnaire (SDQ) [47]. With the help of the SDQ the following subscales can be assessed: prosocial behavior, hyperactivity, emotional problems and conduct problems with peers. Concerning the results of the SDQ it is expected that one year after kindergarten entrance (t6) the children in intervention A show a better socio-emotional development compared to the children in intervention B.
Finally the children's attachment style is assessed a year after kindergarten entrance by trained psychologists using the Manchester Child Attachment Story Task (MCAST) [49] one year after entering kindergarten (t6). The MCAST, a narrative story stem task that involves playing with dolls, is a validated, structured measure that evaluates young children's attachment representations through the use of play scenarios allowing for differentiation between four overall attachment classifications: secure attachment, insecure-ambivalent attachment, insecure-avoidant attachment und insecure-disorganized attachment representations. It is anticipated that after one year in kindergarten (t6) the children in intervention A show more often a secure attachment style (Type B) compared to the children in intervention B.

Results
The most important first descriptive results concern the acceptance of interventions A and B among the contacted "difficultto-reach" immigrant families. After a difficult and challenging phase of recruitment in Frankfurt as well as in Berlin both inventions have been accepted by the immigrant families and the participating mothers together with their children visit the offered weekly groups frequently.

First preliminary data concerning the project in Frankfurt
In Frankfurt the FIRST STEPS project has contacted over 400 families since 2010 and 224 families from 32 different countries were willing to participate in the project (see Table 1 and Figure 3). Already

Excursus: Cortisol, early experiences of stress and parent-child-relationship
Cortisol is an endogenous hormone which is increasingly released during stress. It is an end-product of the hypothalamic-pituitary-adrenocortical axis (HPAaxis), a part of the physiological stress system [50]. Acute stress may induce an individual's adaptive response to environmental demands. However, chronic, excessive stress causes cumulative, negative impacts on health outcomes. Studies indicate that particularly early overwhelming and prolonged experiences of stress can have a negative impact on the brain development and physiological stress systems and thus may lead to a permanent sensitization of the HPA-axis [51,52]. This in turn can induce an increased responsiveness to stress (stress reactivity) and therefore leads to an increased release of stress hormones such as cortisol [53,54]. Furthermore early prolonged stress experiences increase the risk of physical and mental health problems, such as depression [55]. These results indicate how important it is to decrease early stressful experiences and to support children's ability to cope with stressful events effectively.
Both the parent-child-relationship as well as the associated attachment security play an important role in the context of children's ability to cope with stress and thus influence in how far early stressful experiences have an impact on physiological stress systems [54,[56][57][58]. Studies show that compared to securely attached children, insecurely and particularly disorganized attached children tend to show increased elevations of cortisol in stressful situations [59][60][61]. Furthermore studies indicate a relationship between low maternal sensitivity and children's increased responsiveness to stress during emotionally stressful events [62,63]. Thus a secure attachment seems to act as a social buffer and seems to protect children from an overreaction to a stressor and helps them to cope with stressors effectively [57,64,65]. In addition family stressors as well as parents' stress seem to promote an increase of the cortisol level as well as a sensitization of children's HPA-axis [66,67]. Thereby it is assumed that prolonged parental stress leads to a decreased parental sensitivity and thus promotes an unsecure attachment style. Thereby the children receive less emotional support in stressful situations [59,63]. This in turn can have a negative impact on the development of the children's stress systems and can lead to an increased baseline activity of the HPA-axis and thus to elevations of cortisol in stressful situations [67].  Table 1) and follow-up assessments have already started.
First results regard the attendance of the participating mothers in intervention A and B in Frankfurt. A similar amount of participants has been contacted in integration courses which were assigned to both interventions A and B (see total number of contacted women in Table  1). Thus for both interventions a similar amount of women has been invited to participate in the project (see Table 1). However much less women who were assigned to intervention B ended up participating in the project compared to those women who were assigned to intervention A (see number of participants in Table 1). Furthermore the participants of intervention B seem to be more likely to drop out before they have successfully accomplished the intervention because the relative amount of drop-outs is higher in intervention B (see number of drop-outs in Table 1). Furthermore first observations indicate that the participants of intervention A visit the weekly groups more frequently 6 .
In addition first descriptive observations indicate that the mothers of intervention A tend to finish their integration courses more frequently than those mothers who have taken part in intervention B. The definitive data must still be analysed carefully. However first observations indicate that intervention A supports the children as well as the mothers in feeling more accepted in the German society and help the children to find a new secure base for their development.

Description of the sample in Frankfurt
In Frankfurt most of the participating families come from Ethiopia (13,2%), Eritrea (12,7%) and Turkey (12,2%). The distribution of the countries is partly similar to the distribution of the countries of origin which was found in a representative survey of the BAMF (German Federal Office for Migration and Refugees [32]). This survey was conducted nationwide in Germany in 2007 and included N=3960 immigrants who were all participating in integration courses [32]. 6 The weekly attendances of the women in the groups are being recorded and will be analysed as soon as most of the participants have accomplished the project.
The amount of participants who come from North Africa (15,3%) and other African countries (46,4%) is much higher in our sample in Frankfurt compared to the representative survey of the BAMF (North Africa: 2,7%; other African countries: 5,5%). On the other hand the amount of participants who come from East-and Southeast Asia (FIRST STEPS: 4,1%; BAMF: 15,4%) and Middle-and South America (FIRST STEPS: 1,5%; BAMF: 6,5%) is higher in the survey of the BAMF compared to our sample in Frankfurt. However the amounts of participants who come from Turkey (FIRST STEPS: 12,2%; BAMF: 18,8%), Middle-, Central-and South Asia (FIRST STEPS: 11,2%; BAMF: 10,5%), Eastern European countries (FIRST STEPS: 4,1%; BAMF: 7,8%), and South-eastern European countries (e.g. Croatia, Kosovo, Montenegro and Serbia) are relatively similar (FIRST STEPS: 5,1%; BAMF: 7%) (see Figure 3). Furthermore compared to the survey of the BAMF the mothers in our sample are slightly younger and more frequently singles (FIRST STEPS: 17%; BAMF: 9,6%) than the women who were included in the BAMF-survey [32]. Furthermore our participants in Frankfurt have a lower level of education and the amount of Muslim participants (FIRST STEPS: 55%; BAMF: 39,3%) is higher while the amount of Christian participants is lower (FIRST STEPS: 34%; BAMF: 41%) compared to the women and men who were included in the BAMF-survey (see Table  2) [32].
In addition first data of a first subsample in Frankfurt indicates difficulties concerning the mother-child-relationships among the mothers and children who are participating in the FIRST STEPS project. Baseline videos of mother-child-interactions of this subsample have already been rated with the help of the Emotional Availability Scales (EAS, see Table 3). Regarding the EAS scores our subsample seems to be similar to a sample of refugees and asylum seekers who were included in a study in the Netherlands (see Table 3) [68]. In this study van Ee and colleagues [68] investigated the relationships between maternal posttraumatic stress symptoms, parent-child interaction (emotional availability) as well as infants' psychosocial functioning and development among asylum-seeker and refugee mothers and their  Since a dimension score of four and below indicates a problematic mother-child-interaction the EAS data of the FIRST STEPS subsample indicates a decreased emotional availability within the motherchild-relationships of this subsample [41]. This decreased emotional availability might result from the stressful life circumstances which most of our participating mothers are facing.When comparing the results of the FIRST STEPS subsample and the data of van Ee and colleagues [68] it is striking that the mean values concerning the dimensions "structuring by the mothers" and "involvement of the caregiver" are even lower in the FIRST STEPS subsample than in the sample investigated by van Ee et al. [68] (see Table 3).

Discussion
In Germany children with an immigrant background are still educationally disadvantaged and have a higher risk to grow up under stressful circumstances. FIRST STEPS as an early prevention program for immigrant children focuses on optimizing the earliest parentchild relationship by supporting parenting competencies as well as the integration of mothers (and fathers). Thereby FIRST STEPS hopes to have a positive impact on the attachment as well as on the socio-emotional and cognitive development of the children. On the basis of empirical findings of interdisciplinary research studies [20], it is expected that professionally supported good early relationship experiences improve long term integration of immigrant families and the development of the children.
In the first months of the project it took a lot of effort to gain the trust of the participating immigrant families who are often severely traumatized. As mentioned above, first results indicate that the FIRST STEPS project has been well accepted by these "difficult-to-reach" families. These first results lead to the preliminary assumption that the psychoanalytically oriented intervention A has reached more mothers and children and could thus support the development of a higher amount of children than intervention B. Thereby it is particularly interesting that less women who were assigned to intervention B ended up participating in the project compared to those women who were assigned to the intervention A and that relatively more women in intervention B have dropped out before the actual end of the project. Regarding the first result it is important to mention that the women are recruited for both interventions by the same strategy: The project is presented in the integration courses and the women are invited by the same staff members to participate in the weekly groups. Furthermore it is important to mention that the women who end up visiting a group do not sign a written informed consent form directly at their first group visit. Most of them rather visit the group for two or three times before they actually decide to take part in the project or not. Thus a written informed consent form isn't obtained directly. It is assumed that the broader and more individual intervention A which focuses on the specific needs of the participants and includes psychoanalytically trained project staff is more appealing to the women who end up visiting the group. Furthermore the project staff in intervention A visits the families at home in order to build up an emotional relationship to the families while home visits are not part of intervention B. Due to these reasons it might be more likely that the women who were assigned to intervention A decide to participate in the project in the first place and that less women in intervention A drop out in the course of the intervention compared to women in intervention B.

Some case illustrations
The presentation of the FIRST STEPS curriculum would go beyond the scope of this paper. Instead we would like to give FIRST STEPS (Frankfurt) BAMF-Survey [32] Mean age (in years) 31,6 (SD = 39,3%*** 41%*** 11,3% *** 9,4%*** Table 2: Socio-demographic information of the sample in Frankfurt. SD = standard deviation; ***: data refers to interviewed female and male participants of integration courses, **: data refers only to interviewed female participants of integration courses.  some first impressions of the philosophy of the psychoanalytically oriented intervention A which has been described above. Based on a psychoanalytical understanding of the specific situation of the immigrant families and of specific fantasies and conflicts concerning early parenting in a foreign country the members of the project team are trying to offer a very individual and specific support to the participating women and families. First observations show that this individual support proves to be a great help for the psychic and psychosocial situation of the immigrant parents as well as for their children [28].

Pregnancy in a foreign country:
Many immigrant families participating in the FIRST STEPS project suffer from severe social isolation as the following example may illustrate: Mr. R. from Pakistan was desperately seeking support for his pregnant wife. A staff member of the FIRST STEPS intervention (intervention A) visited the couple at home. She entered the flat. From the corridor an unbearable heat hit her through the opened door. A 20 year old pregnant woman was lying apathetically on a sofa and did not take any notice of her. In the meantime the woman's husband was complaining about the heating costs which he could not afford anymore. It was obvious that the young expectant mother was in a state of a severe depression. In contrast to other immigrants who follow already immigrated relatives to Germany, this young couple did not know anybody in Germany. Our project staff member began to visit the mother on a weekly basis. Luckily the expectant mother and the FIRST STEPS staff member both came from the same cultural region and spoke the same language, which enabled them to communicate with each other. The staff member provided the couple with access to further social networks, supported the husband and helped him to understand his wife.

Autonomy development and separation conflicts:
The support of the FIRST STEPS intervention proved to be very helpful not only during the vulnerable months after birth. As shortly mentioned in the introduction, many immigrant mothers, particularly those who are suffering from severe homesickness or even depression, often have significant problems to accept the separation of their babies and the children's wish to develop an independent self. They often feel unconsciously threatened by the process of the child's individuation and separation, as the following example may illustrate: The Korean mother Mrs. S. visited the weekly FIRST STEPS group with her 8 month old son. She reported that she could not leave him alone for any minute. If she did leave him with his father however, he would throw up immediately. In a long process which lasted more than a year we learned together with the other group members that the children often represent the only thing which the mothers feel safe of. Mrs. S. who had achieved a university degree did not dare to find a job in Germany. Furthermore she did not want any contact to the Korean community in Frankfurt. But she also did not feel comfortable in the interaction with Germans. The relationship to her parents in Korea was burdened by feelings of guilt because Mrs. S. had become detached from them. These ambivalences which are difficult to resolve were reflected in her relationship to her son. Other mothers of the group know this conflict. The project staff members actively supported the separation of K. (e.g. encouraging him to "help" the group by walking out of the room with the intern to get milk from the kitchen). Mrs. S. was encouraged to "name" problems and discuss her negative feelings. In addition small separation attempts of K. were observed together with Mrs. S. and the other group members. Particularly the precise observations during the group in which all mothers are involved helped Mrs. S. The observations demonstrated the great joy which little K. expressed when he achieved something on his own. For example when he approached other children with a transitional object in his hand, when he argued with other children about a toy or when he allowed a staff member to offer him a piece of mandarin.
Motherhood and the mother's own interests: Immigrants leave their home country for many different reasons, for example war or economic hardships. Some of the immigrant women in the FIRST STEPS project come to Germany with the desire for education and the wish to develop their own identity and a creative self as woman. A lot of these women are disappointed bitterly if they are pressed to become a mother instead of for example receiving the education they had hoped for. From a psychoanalytical point of view this can be a heavy burden for the early mother-child-relationship and can even create an unconscious hatred of the mother towards her own baby, who unconsciously prevents the mother form fulfilling her own professional career as it was the case with Mrs. A.: In a supervision one of the young women A. who works in the FIRST STEP intervention (A) reported impulsively: "I could not stand seeing the Afghan women S. feeding her baby boy -she did not even touch him. He was laying on the ground and she seemed not to be interested in him at all. I think she deeply hates and rejects him... . " The supervisor motivated A. to elaborate her negative reaction which psychoanalysts call a negative transference reaction. Afterwards the supervision group watched the above mentioned scene which had been videotaped. In this scene S. gave the bottle to her baby boy. Indeed the little boy was lying on the ground trying to touch his mother´s hand repeatedly. S. seemed not to notice his attempt to encounter body contact with her. She withdrew her hand again and again. Furthermore she did not seek eye contact with her baby but was talking to A. and other women in the room. In the supervision the videotape was analysed carefully. The negative counter transference reaction of A. was taken seriously. "Maybe S. really has a problem with her motherhood and perhaps your negative feelings are an indicator for these unconscious conflicts. Of course, we don´t know. Why don´t you watch the video together with her and try to show her the attempts of her baby boy to get into contact with herand try to find out, if she has a conflict with the closeness to her baby... . " Indeed when S. looked at the video it became obvious that she had not noticed that her little boy tried to touch her hand repeatedly. S. asked: "Do you really think he notices me? He is so small. He probably does not even know that I am his mother. " A. answered "But look at it again: he tries to touch your hand again and again. He wants to feel your body. He is in love with you. You are his mother. Babies do recognize their mothers from the very first minute of their lives onward -they notice their mothers' specific smell, touch, voice etc. " S. replied: "Do you really think so?" To make a long story short: A. finally found out that S., a well-educated 19 year old woman from Afghanistan, came to Germany because she wanted to study medicine just like her husband. The young couple lived with her parents in law in a very narrow apartment. The family in law had put S. under a lot of pressure to become pregnant "because otherwise your husband will be too old" (he was 26 years old at that time!). Due to her insecure inner state (S. was suffering from homesickness a lot) she had agreed to become pregnant. Indeed the FIRST STEP team had the impression that she was unconsciously suffering from deeply ambivalent or even hateful feelings towards her baby boy, because from her point of view he was the reason why she was not able to realize her dream -to study medicine. A. explained to S.: "But you know -here in Germany women can combine motherhood with a professional career. I am also trying to do this. Why don´t you wait until your little son is in kindergarten. Then you can start to go to university, if you want. " It was amazing how S. reacted to the attempt to understand her conflict with her motherhood. In the next video interactions she made the impression of a caring and loving mother and the baby seemed well developed and happy.
Of course these short summaries simplify the work of FIRST STEPS (intervention A). Nevertheless we hope to give an impression of the project work which aims at understanding the individual and specific conflicts of the participating immigrant women. This proves to be of great help for the participating mothers and children as it was for S. and her baby.
Trauma, sexual abuse and burdened motherhood: FIRST STEPS includes several mothers from Africa who have gone through severe traumatization during their flight and immigration to Germany. As X. some of these women have been kept in houses hosting more than 100 women in Sudan. Many of these women have experienced sexual abuses and became pregnant under enormous traumatic circumstances. Most of the time women like X. are only able to talk about these traumatic secrets after having participated in the project for months. They need time to build up some basic trust in the other participating women of the group and the members of the project team.
The young woman X., with a girlish face, turned up at the FIRST STEPS project picnic together with another mother from Eritrea. The picnic takes place once a year at the end of the summer. She was wearing a thick padded jacket in order to keep her body warm which was clearly in an advanced stage of pregnancy. She was sitting between all the other women who were talking, eating and dancing while most of the children were playing. It was uncertain whether she was holding her jacket or whether the jacket was holding her. Attempts to integrate her by mime and gesture and friendly inviting her to eat something did not reach her. Her heavy jacket which was wrapped around her body mainly seemed to protect her. We experienced her in a similar way in the following weeks until the birth of her child. She kept aloof from the group activities and seemed not to understand any of our offers. However she did come and visited the group. Then, one day, she took off her jacket. This happened just before the birth of her daughter. When she returned together with her baby girl, she visibly enjoyed that the members of project staff were so happy about her baby. But not only the project staff also the other mothers were touched when they looked at the small baby who X. was lovingly holding in her arm. X. breastfed the baby well from the very beginning. We recognized that X. spoke English quite well. The communication improved and soon X. was even able to speak German rudimentarily. During a home visit at the mother-child house where X. was accommodated, X. showed a picture of her family to a member of the project team. She told the member of project staff that it comforted her to talk to them on the phone. However at the same time she felt guilty because she wasn't able to send them any money. Her family had probably saved money for her to flee so that she could build up a better life in the Western world. However she had never talked about her dangerous flight before. She told the member of project staff about the crossing on an overcrowded boat while she was pregnant. She described how she had been freezing, scared to death, motionless and had sat huddled up and petrified on her seat. The member of project staff fought back her tears while X. was talking and thought that X. had sat similarly at the picnic -as if she had still been on that boat. The information concerning her daughter's father are vague and inconsistent. Her parents were not allowed to know that she has a child. Why not?
From a Spanish nun who offers medical support to stranded immigrants one can learn that many women from Eritrea end their flight with a pregnancy. "As a woman you need a protector, thus the women travel with him and thus they become pregnant. " (Newspaper "Süddeutsche Zeitung" 22.10.2014). The question arises whether these mothers develop lies concerning this part of her flight, secrets which they also might not disclose to their children? However we do know that such secrets can unconsciously effect the development of the children.
As illustrated by the shortly presented case descriptions FIRST STEPs tries to offer a very individual support to the immigrant mothers (and fathers). By following a psychoanalytical attitude FIRST STEPS tries to understand their conscious and unconscious needs, conflicts and fantasies during the vulnerable months of early parenthood in a foreign country. In a "psychoanalytical mind state" no simplifying "recipes" are offered. Instead a holding and containing position is established which allows the immigrant mothers (and fathers) to understand their own inner wishes and conflicts as well as those of their babies. This understanding is the presupposition for reflecting possible "solutions" as well as to re-gain pleasure, joy and proud in mother-and fatherhood as well as their babies and children. As many clinical and empirical studies have shown: the brightness in the eyes of the mother (and father) is essential for the emergent self of the baby, the baby's development of a basic trust ("Urvertrauen" according to Erikson) as well as a secure attachment pattern during the first year of life [19].
The status of immigrants who recently arrived in Germany can lead into severe depression as the case examples might have illustrated. They are often isolated from the origin homeland and emotional network of their families. FIRST STEPS tries to offer a kind of secure "home base" for these mothers (and fathers) and, as in the example of Ms. X., a setting where severe external as well as inner problems or even traumatizing experiences can be discussed. According to many observations in the project this understanding often means a first step of basic experiences to be understood and welcomed in a foreign country.
As was shown by the case description of the immigrant women Mrs. S. homesickness and depression can create pathological mother-childinteractions which are a burden for the early self-and development of early affective regulations as well as for the separation/individuation process in the second year of life. FIRST STEPS tries to offer a sensitive, empathetic and professional support for the mothers and fathers as well as for the development of the children. First results indicate that FIRST STEPS achieves some of these goals. However definitive results can only be published at the end of 2015 because the study is still ongoing.

Outlook
Based on these positive preliminary results of the FIRST STEPS project in Frankfurt (2010-14), the project has already been implemented in Berlin from 2012 on. In Berlin the project is integrated into the offerings of the mother-child-centre (children's house of health) at the Vivantes Clinic Neukölln. Until now 600 mothers have been contacted in Berlin whereby 380 of them showed interest in participating in the project and 50 of them are now regularly present in the groups. A third implementation is planned in Stuttgart (Robert Bosch Krankenhaus). Taking together the samples from Frankfurt, Berlin and Stuttgart we will include around 1000 families in the FIRST STEPS programs. First results of the empirical parts of the study will be published at end of 2015. As mentioned before, it is also planned to compare the samples of FIRST STEPS with "matched pairs" of a large untreated sample of the Socio-economic Panel of the German Institute for Economic Research, Berlin [31]. This would enable to investigate the long-term effects of FIRST STEPS in a large follow-up study. The most cruel terror attacks in Paris during the second week of January 2015 might remind us once more in a very tragic way how important it is for Western countries to welcome immigrant families and to offer them and their children a positive life perspective in their host countries. FIRST STEPS is only one small contribution to this human societal attempt to protect Western democracies from a regression to terror, fragmentation and social disintegration.

Ethical Issues
The Ethic Review Commission of the Federal Chamber of Psychotherapists of the State of Hessen, Germany, has approved the final study protocol and the final version of the written informed consent form. Written consent was obtained from each participating family. The study is carried out in keeping with local legal and regulatory requirements.