ACOFP Blog
For Family, By Family—ACOFP Blog
Monica Hammer, MPH, OMS-III, discusses the role primary care physicians can play in helping foster relationships between mothers and their children, highlighting both risks of and potential solutions for attachment issues.
Monica Hammer, MPH, OMS-III | A.T. Still University Kirksville College of Osteopathic MedicineSponsored 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 Attachment | Quality of Caregiver | Strategy to Deal With Distress |
|---|---|---|
| Secure | Sensitive, loving | Parent picks up infant promptly, reassuring infant |
| Insecure – Avoidant | Insensitive, rejecting | Parent ignores, ridicules or becomes annoyed |
| Insecure – Resistant | Insensitive, inconsistent | Parent is unpredictable in response, amplifying child distress |
| Insecure – Disorganized | Atypical | 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
| Intervention | Population | Setting | Duration |
|---|---|---|---|
| Attachment and Biobehavioral Catch-Up (ABC)22 | Children with experiences of early adversity (6 months – 2 years old or 2–4 years old) | Home | 10 sessions at one hour each |
| Child-Parent Psychotherapy (CPP)23 | Children exposed to trauma (0–5 years old) | Home Clinic | One year (~32 sessions) at 1–1.5 hours each |
| Circle of Security (COS)24 | High-risk populations (prenatal – 5 years old) | Home Clinic Community Groups | Eight sessions at 1–1.5 hours each |
| Video-Interaction Project (VIP)25 | High-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 |
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