Monica Hammer, MPH, OMS-III | A.T. Still University Kirksville College of Osteopathic Medicine
2022 Namey/Burnett Preventive Medicine Writing Award Submission

Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.

The emotional connection between mother and child begins in early pregnancy and is developed most critically during a child’s first three years of life. Early interactions form the foundation for social and emotional adaptation across the life course, impacting health and wellbeing for both mother and child.1

Attachment theory, developed by John Bowlby and Mary Ainsworth, defines the maternal-infant relationship as a secure base from which a child can explore and, when necessary, as a haven of safety and a source of comfort. Four major patterns of attachment have been identified (see Table 1)—secure, avoidant, resistant and disorganized. A secure attachment is built by mothers who are physically and emotionally attuned to their child, responding to their infant’s distress in sensitive and loving ways.2,3 Research indicates that a secure attachment shapes healthy brain architecture and supports the self-regulatory capacities of children.4,5 In contrast, impairments in the mother-infant bond marked by inconsistent, aggressive and disengaged parenting can have a detrimental impact on children. Mother-infant dyads with poor attachment can result in serious psychopathology and maladjustment. These infants are at a higher risk of experiencing delays in development, poor peer relationships, behavioral problems and disorders, or mental health disorders into adulthood.2,6,7

Table 1: Attachment Styles2

Type of AttachmentQuality of CaregiverStrategy to Deal With Distress
SecureSensitive, lovingParent picks up infant promptly, reassuring infant
Insecure – AvoidantInsensitive, rejectingParent ignores, ridicules or becomes annoyed
Insecure – ResistantInsensitive, inconsistentParent is unpredictable in response, amplifying child distress
Insecure – DisorganizedAtypical Parent is neglectful, abusive and/or frightening to child

Beginning in early pregnancy, there are many factors that work to undermine maternal-infant attachment, such as increased stress, chronic poverty, maternal depression and anxiety, or trauma.8–12 The interplay between these complex factors can have a significant negative impact on both early attachment formation as well as fetal, infant and maternal health outcomes.12 For example, mothers who are depressed are less sensitive to and responsive with their babies, exhibiting lower frequency smiling, vocalizing, visual engagement and body-based interactions, as well as a more negative affect toward their infants.12–15 Further, mothers who have experienced trauma demonstrate increased levels of avoidance and hostility toward their child, difficulty reflecting on their child’s needs and ultimately may transmit intergenerational trauma through poor parenting behavior.12

Families living in poverty are at significant risk for poor attachment, as they often experience greater levels of stress derived from social factors. High levels of parenting stress, most notably experienced when parenting demands exceed a parents’ sense of accessible resources, can lead to decreased parental sensitivity.11 Children who experience a prolonged, intense stress response in the absence of a sensitive caregiver demonstrate permanent alterations to immune function, behavioral and emotional development.16,17 A secure attachment plays a critical role in helping to regulate the child’s emotions during times of stress.18 The support of a nurturing caregiver, most notably through a strong and secure attachment, serves as a protective factor to the harmful effects of adversity on a child.16 Consistent, responsive parenting is key to breaking intergenerational cycles of stress and trauma, particularly for families living in poverty.

A myriad of evidence-based interventions exist to promote and strengthen maternal-infant attachment. Interventions target high-risk mother-infant dyads due to independent and interacting risk factors, such as poverty, trauma or maternal mental illness.12 Interventions use a strength-based approach with an emphasis on creating positive interactions between the mother-infant dyad. Program components incorporate guided self-reflection through videotaped interactions between mother and child, provide developmentally appropriate strategies for play, build parenting skills and provide tangible concrete services or learning materials for parents.12 Interventions are typically provided by a psychologist, social worker or trained interventionist. While most interventions are provided in the home, in an early care or education setting, a growing number are provided in appropriate primary care settings, with positive effects on parent-child interactions critical to early development.19 A summary of interventions addressing maternal-infant attachment within the first five years of life can be found in Table 2.

Family care physicians are uniquely positioned to identify issues within the maternal-infant dyad and intervene within a critical timeframe. Potential warning signs that may indicate impaired maternal-infant attachment may be observed in primary care visits. For mothers, these include blunted affect, reduced eye contact with child, inappropriate or delayed response to a child’s emotions (both positive and negative) and irritability. Infants who are poorly attached may show reduced eye contact with mother, irritability and fussiness, restricted growth and development, and language delay.12,20,21 In addition, primary care offices can screen mothers and their infants for risk factors associated with poor attachment, such as depression, anxiety, trauma, parenting stress and social determinants of health, using validated questionnaires.

The primary care setting serves as a critical link to care, offering near universality of access, frequent contact across the perinatal continuum and access to existing resources for the support of the maternal-infant dyad. The trusting relationship built between the family care physician and the maternal-infant dyad is key to addressing factors that both positively and negatively effect attachment. Protection and support of the maternal-infant bond by the physician across this critical period of transition is key to health and wellbeing across the life course.

Table 2: Summary of Interventions to Promote Maternal-Infant Attachment

InterventionPopulationSettingDuration
Attachment and Biobehavioral Catch-Up (ABC)22Children with experiences of early adversity
(6 months – 2 years old or 2–4 years old)
Home10 sessions at one hour each
Child-Parent Psychotherapy (CPP)23Children exposed to trauma (0–5 years old) Home
Clinic
One year (~32 sessions) at 1–1.5 hours each
Circle of Security (COS)24High-risk populations (prenatal – 5 years old)Home
Clinic
Community Groups
Eight sessions at 1–1.5 hours each
Video-Interaction Project (VIP)25High-risk populations
(0–3 years old or 3–5 years old)
Clinic (at or after primary care visits) 14 sessions between 0–3 years old or nine sessions between 3–5 years old at 30 minutes each

References

  1. Bowlby J. Attachment and loss: Retrospect and prospect. Am J Orthopsychiatry. 1982;52(4):664–678. doi:10.1111/j.1939-0025.1982.tb01456.x
  2. Benoit D. Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatr Child Health. 2004;9(8):541–545. doi:10.1093/pch/9.8.541
  3. Ainsworth MD. Patterns of infant-mother attachments: Antecedents and effects on development. Bull N Y Acad Med. 1985;61(9):771. PMCID: PMC1911899
  4. Pallini S, Chirumbolo A, Morelli M, Baiocco R, Laghi F, Eisenberg N. The relation of attachment security status to effortful self-regulation: A meta-analysis. Psychol Bull. 2018;144(5):501. doi:10.1037/bul0000134
  5. Groh AM, Fearon RMP, van IJzendoorn MH, Bakermans-Kranenburg MJ, Roisman GI. Attachment in the early life course: Meta-analytic evidence for its role in socioemotional development. Child Development Perspectives. 2017;11(1):70–76. doi:10.1111/cdep.12213
  6. Schneider BH, Atkinson L, Tardif C. Child–parent attachment and children’s peer relations: A quantitative review. Dev Psychol. 2001;37(1):86. PMID: 11206436
  7. Madigan S, Atkinson L, Laurin K, Benoit D. Attachment and internalizing behavior in early childhood: A meta-analysis. Dev Psychol. 2013;49(4):672–689. doi:10.1037/a0028793
  8. Kinsey CB, Baptiste-Roberts K, Zhu J, Kjerulff KH. Birth-related, psychosocial and emotional correlates of positive maternal-infant bonding in a cohort of first-time mothers. Midwifery. 2014;30(5):e188–194. doi:10.1016/j.midw.2014.02.006
  9. Moehler E, Brunner R, Wiebel A, Reck C, Resch F. Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding. Arch Womens Ment Health. 2006;9(5):273–278. doi:10.1007/s00737-006-0149-5
  10. Finegood ED, Blair C, Granger DA, Hibel LC, Mills-Koonce R. Psychobiological influences on maternal sensitivity in the context of adversity. Dev Psychol. 2016;52(7):1073–1087. doi:10.1037/dev0000123
  11. Nordahl D, Rognmo K, Bohne A, et al. Adult attachment style and maternal-infant bonding: the indirect path of parenting stress. BMC Psychol. 2020;8:58. doi:10.1186/s40359-020-00424-2
  12. Erickson N, Julian M, Muzik M. Perinatal depression, PTSD and trauma: Impact on mother–infant attachment and interventions to mitigate the transmission of risk. Int Rev Psychiatry. 2019;31(3):245–263. doi:10.1080/09540261.2018.1563529
  13. Berkule SB, Cates CB, Dreyer BP, et al. Reducing maternal depressive symptoms through promotion of parenting in pediatric primary care. Clin Pediatr (Phila). 2014;53(5):460–469. doi:10.1177/0009922814528033
  14. Righetti-Veltema M, Conne-Perréard E, Bousquet A, Manzano J. Postpartum depression and mother–infant relationship at 3 months old. J Affect Disord. 2002;70(3):291–306. doi:10.1016/s0165-0327(01)00367-6
  15. Muzik M, Morelen D, Hruschak J, et al. Psychopathology and parenting: An examination of perceived and observed parenting in mothers with depression and PTSD. J Affect Disord. 2017;207:242–250. doi:10.1016/j.jad.2016.08.035
  16. Coussons-Read ME, Okun ML, Nettles CD. Psychosocial stress increases inflammatory markers and alters cytokine production across pregnancy. Brain Behav Immun. 2007;21(3):343–350. doi:10.1016/j.bbi.2006.08.006
  17. Gunnar M, Quevedo K. The neurobiology of stress and development. Annu Rev Psychol. 2007;58:145–173. doi:10.1146/annurev.psych.58.110405.085605
  18. Shonkoff JP, Garner AS, Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–e246. doi:10.1542/peds.2011-2663
  19. Mendelsohn AL, Huberman HS, Berkule SB, et al. Primary care strategies for promoting parent-child interactions and school readiness in at-risk families: the Bellevue Project for Early Language, Literacy, and Education Success. Arch Pediatr Adolesc Med. 2011;165(1):33–41. doi:10.1001/archpediatrics.2010.254
  20. Kinsey CB, Hupcey JE. State of the science of maternal–infant bonding: A principle-based concept analysis. Midwifery. 2013;29(12):1314–1320. doi:10.1016/j.midw.2012.12.019
  21. Darvishvand M, Rahebi SM, Bostani Khalesi Z. Factors related to maternal-infant attachment. Shiraz E-Medical Journal. 2018;19(12). doi:10.5812/semj.80369
  22. HHS.gov. Attachment and Biobehavioral Catch-up (ABC) -infant. Effectiveness | Home Visiting Evidence of Effectiveness.  https://homvee.acf.hhs.gov/effectiveness/Attachment%20and%20Biobehavioral%20Catch-Up%20%28ABC%29%20-Infant/In%20brief
  23. NCTSN. CPP: Child Parent Psychotherapy Fact Sheet. National Child Traumatic Stress Network. https://www.nctsn.org/sites/default/files/interventions/cpp_fact_sheet.pdf
  24. Erickson N, Julian M, Muzik M. Perinatal depression, PTSD and trauma: Impact on mother–infant attachment and interventions to mitigate the transmission of risk. Int Rev Psychiatry. 2019;31(3):245–263. doi:10.1080/09540261.2018.1563529
  25. HHS.gov. Video-feedback intervention to promote positive parenting-sensitive discipline® (VIPP-SD). Effectiveness | Home Visiting Evidence of Effectiveness. https://homvee.acf.hhs.gov/effectiveness/Video-Feedback%20Intervention%20to%20promote%20Positive%20Parenting-Sensitive%20Discipline%C2%AE%20(VIPP-SD)/In%20Brief

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