My latest Child Health essay was about Attachment. It may sound boring but in fact, it’s an intriguing subject worth sharing. We were all once in need of attachment to someone and for all of us, it played out in an imperfect way, affecting who we are today.
Assignment 3: Principles and application of attachment theory
Scenario Three: During a health check for six-month-old Phoebe you notice a mild delay in her motor skills. Her mother speaks of her with a sense of frustration, indicating that Phoebe is so dependent on her, that she is bored and feels isolated compared to her lifestyle before the pregnancy. You are aware that this mother had a difficult labour, that resulted in a caesarean section delivery.
Healthy development, crucial to an infant’s life-long cognitive, socio-emotional and physical health outcomes, is intrinsically linked to the quality of the infant’s attachment with a primary caregiver4, 18. The infant brain grows most rapidly and is in its most pliable state from the prenatal period into the first three years, when the foundations of neurobiological architecture and processes are being laid6, 20. Healthy growth and development relies on the timing, nature and patterns of external experiences26, which impact on a child’s social, emotional and academic success throughout life27.
Sensitive and consistent caregiver interactions are required for healthy psychological and physical development6, but infant attachment to the primary caregiver occurs regardless of the quality of care, including when neglect or abuse are involved30. Positive early caregiving experiences promote healthy brain development while negative early experiences that may be threatening, uncertain, neglectful or abusive, over-activate the stress response system, affecting neurobiological processes and causing a disruption to development which can result in lifelong negative emotional and cognitive outcomes17, 30.
Factors that play a role in the caregiver-infant attachment process include but are not limited to genetics, family income, family size, parental age, education and mental health, marital relationships, social support systems, life stressors and social adversity14. The impact that early years experiences have on the developing infant’s quality of attachment and the implications for Maternal Child and Family Health (MCaFH) Nurse practice will be discussed herein with a focus on Scenario 3.
John Bowlby formulated the first comprehensive theories of attachment in the late 1950s and early 1960s and his work was built upon by a number of others, notably Mary Ainsworth and John Robertson31. Apart from physical attachment via the umbilical cord, newborn babies are unattached but physically dependent for all of their needs24. There is a biological predisposition to form emotional attachments11 which become established during the first two years of life through a number of phases16.
Referencing Mary Ainsworth’s Strange Situation Procedure, Mares et al18 describe the four different attachment behaviours which manifest in children when faced with a specific range of stressors. These attachment patterns are categorized as “secure” (seen in children who have experienced consistent and predictable caregiving); “insecure/avoidant” and “insecure/ambivalent” (both considered normal variants and seen in children who have anxieties about the availability of their caregiver); and “disorganized” (considered pathological and seen in children who have experienced distress and/or fear from their primary caregiver). Children with secure attachment are considered most likely to have positive long-term outcomes in terms of social, emotional and cognitive wellbeing18, while children with disorganized attachment are more likely to experience negative long-term outcomes30, 11.
Individual children will present with different attachment patterns based on interrelating factors such as genetic predisposition, specific external experiences, age at which and frequency with which the experiences occur26, 6, 27, 25. Appendix 1 provides a diagrammatic overview of the Circle of Security8 showing the characteristics of secure attachment whereby an infant experiences a safe haven (comforting caregiving responses); secure base (reliable and consistent caregiver); proximity maintenance (the caregiver is nearby while the child explores his/her world); and separation anxiety (the child expresses sorrow when separated from the caregiver)5.
As argued by Staples29, evidence about the impact that caregiving attachment has on long-term outcomes for infants highlights the need for early assessment and multidisciplinary intervention with appropriate support, care and education being a crucial role of the MCaFH Nurse. Effective communication, establishing and maintaining respectful, professional, therapeutic relationships with children, caregivers and families using a strengths-based approach are included in the required standards of practice for the MCaFH Nurses in Australia15.
The role of the MCaFH Nurse is complex but Fraser et al13 identified key practice areas as being: “child growth and development; maternal mental health; information provision to support behaviour/attitudinal change; and building parent capacity”, by establishing therapeutic relationships with clients, utilizing skills including enhanced communication, reflective practice, emotional intelligence and empathy.
Appendix 227 provides a diagrammatic view of age-dependent functional development of different parts of a human infant’s brain, showing that this infant with delayed motor skills may have some disruption of cerebellar development. MCaFH Nurse practice includes the use of “standardized, evidence-based assessment tools”3. An example of this is the NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) (see Appendix 3a). To ensure appropriate assessment and diagnosis, a full physical assessment, growth monitoring, physical development monitoring, sleep, nutrition and toileting patterns and/or concerns should be undertaken. Socioemotional and cognitive assessment are also required, and referral to other services as appropriate3.
Early intervention is imperative to positively alter the infant’s developmental course and enhance her long-term outcomes22. The NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) outlines legislation requiring that MCaFH Nurses obtain informed consent from the child’s legal guardian before making a referral to another service (see Appendix 3b). In this scenario a referral to Occupational Therapy is recommended for specialized early intervention of the infant’s motor skills delay23. Using a reference tool such as the Ages and Stages Questionnaire, described in Appendix 41, or the Red Flags Early Identification Guide7 will assist the MCaFH Nurse to facilitate discussion with the mother (and father or other caregivers as appropriate), to ensure informed consent and participation in all recommended interventions including referral to other services.
As recommended by the Australian Health Minister’s Advisory Council2, during individual consultation with the infant and her mother, the MCaFH Nurse should offer health education, anticipatory guidance and information for parental skill development based on their individual assessment and needs. This includes advice, support and referral for both the infant and the mother’s needs. Zanardo et al31 found a significant correlation between emergency caesarian section delivery and negatively altered mother-infant bonding experiences, which will be a significant consideration in this scenario. Women commonly feel unprepared for their transition to motherhood, lack confidence in parental skills and experience stress, distress and postnatal depression2. As discussed above, these factors may all affect the infant’s healthy development and indicate a need for early intervention. Providing a safe place for this mother to express her feelings and using a standardized assessment tool such as the Edinburgh Postnatal Depression Scale (EPDS)8 will allow the MCaFH Nurse to assess the mother’s needs, offer advice and guidance in a non-judgmental and supportive environment, and consider options for appropriate follow up and/or referral.
Depending on the EPDS score, it may be appropriate to refer the mother to a General Practitioner for further mental health care. There is mixed evidence of the effectiveness of home visits to children and families at risk10. However, Center on the Developing Child5 recommend coaching of parents should take place in a wide variety of settings, including home visits. The Australian Health Minister’s Advisory Council2 describe intuitive and anecdotal evidence that the MCaFH Nurse could provide support to this family in their home for a more complete assessment of the situation and perhaps more contextualized advice and support, involving the father, extended family or other caregivers and support people.
In this scenario the MCaFH Nurse must make an assessment of mother-infant interactions, to ensure appropriate interventions are based on individual circumstance and need. Intervention should involve promoting age-appropriate play and communication to encourage sensitive and nurturing responses of the mother to her child’s needs, not only improving the child’s external experiences but also the mother’s mental health, leading to an improved dyadic relationship9. An example of standardized resources available for use in this scenario is the Ages and Stages tool which offers age-specific developmental information and ideas for activities to promote development in communication, fine and gross motor skills, problem solving and personal/social skills (see Appendix 4)1.
Encouraging involvement of the father or other caregivers is an important part of the process, as evidence shows infants have better cognitive outcomes when their fathers are actively involved27. Linking the family into support systems such as play groups, Circle of Security sessions18 or Families as First Teachers20, would give the infant opportunities for stimulation and the mother a chance for social contact with others experiencing similar transitions to parenthood, as well as a range of useful information to implement on a practical level to improve the attachment process. It may also be appropriate to provide links to relevant websites offering practical and supportive information, such as www.raisingchildren.net.au.
The common connection throughout the interventions discussed in this scenario is a MCaFH Nurse service that is able to establish and maintain a therapeutic relationship with the family. This requires a range of specialized skills to promote parental skill and confidence, support the needs of both mother and infant, ensure timely intervention for optimum long-term outcomes, and collaborate with a multi-disciplinary team of specialists and allied health professionals.
- Australian Government Department of Health (updated 20 May 2013). National Framework For Universal Child and Family Health Services, Appendix 3: Tools to assist in health surveillance and monitoring. Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/nat-fram-ucfhs-html~appendices~appendix3
- Australian Health Minister’s Advisory Council (2011). National Framework for Universal Child and Family Health Services. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/AFF3C1C460BA5300CA257BF0001A8D86/$File/NFUCFHS.PDF
- Barker, D, Barker, M, Fleming, T, Lampl, M (11 December 2013). Developmental biology: Support mothers to secure future public health, Nature International weekly journal of science, Vol. 504, Issue 7479, p. 209
- Bowlby, J (1982). Attachment and Loss, Volume 1 Attachment, Second Edition, Basic Books, New York. Retrieved from https://pdfs.semanticscholar.org/0cf3/524fa9a2f7989eaa64cf8f094d3182add3c7.pdf
- Center on the Developing Child (2007). The Impact of Early Adversity on Child Development (In Brief). Retrieved from developingchild.harvard.edu
- Child Development Program and Brisbane North Primary Health Network (July 2016). Red Flags Early Identification Guide for children aged birth to five years, Second Edition. Retrieved from https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/red-flags-a3.pdf
- Circle of Security Network (2013). Circle of Security®: Parent Attending to Child’s Needs. Retrieved from http://circleofsecuritynetwork.org/files/A%20Circle%20of%20Security.pdf
- Cox, JL, Holden, JM, Sagovsky, R (June 1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale, British Journal of Psychiatry, Vol. 150, pp. 782-786. Retrieved from https://www.blackdoginstitute.org.au/docs/default-source/psychological-toolkit/edinburgh-postnatal-depression-scale.pdf?sfvrsn=8
- Daelmans, B, Black, M, Lombardi, J, Lucas, J, Richter, L, Silver, K, Britto, P, Yoshikawa, H, Perez-Escamilla, R, Macmillan, H, Dua, T, Bouhouch, R, Bhutta, Z, Darmstadt, G L & Rao, N (14 September 2015). Effective interventions and strategies for improving early child development, British Medical Journal, Vol. 351. pp. 23-26
- Doyle, C, Cicchetti, D (June 2017). From the Cradle to the Grave: The Effect of Adverse Caregiving Environments on Attachment and Relationships Throughout the Lifespan, Clinical Psychology Science and Practice, Vol.24, No.2
- Doyle, O (July 2017). The First 2,000 Days and Child Skills: Evidence from a Randomised Experiment of Home Visiting, Life Course Centre Working Paper Series, No. 2017-13. Retrieved from http://www.lifecoursecentre.org.au/wp-content/uploads/2017/07/2017-13-LCC-Working-Paper-Doyle.pdf
- Fraser, S, Grant, J, Mannix, T (December 2016). Maternal Child and Family Health Nurses: Delivering a Unique Nursing Speciality, Maternal and Child Health Journal, Vol. 20, Issue 12, pp 2557-2564
- Gervai, J (2009). Environmental and genetic influences on early attachment, Child and Adolescent Psychiatry and Mental Health, Vol. 3, No. 25. Retrieved from https://capmh.biomedcentral.com/articles/10.1186/1753-2000-3-25
- Grant, L, Mitchell, C, Cuthbertson, L (2017). National Standards of Practice for Maternal, Child and Family Health Nurses in Australia, Adelaide, Flinders Press
- Institute for Learning and Brain Sciences (2012). Phases of Attachment Development, University of Washington. Retrieved from http://modules.ilabs.uw.edu/module/development-of-attachment/449-2/
- Jordan, B (August 2014). An overview of attachment theory, Community Paediatric Review, Current issues in children’s health and development, The Royal Chlidren’s Hospital Melbourne. Retrieved from https://www.rch.org.au/uploadedFiles/Main/Content/ccch/CPR_Vol22_No3.pdf
- Mares, S, Newman, L, Warren, B (2011). Clinical Skills in Infant Mental Health: The First Three Years.
- Mercer, J (2015). Examining Circle of SecurityTM: A Review of Research and Theory, Research on Social Work Practice, Vol 25, No. 3, pp 382-392.
- Newman, L, Judd, F, Olsson, CA, Castle, D, Bousman, C, Sheehan, P, Pantelis, C, Craig, JM, Komiti, A, Everall, I (2016). Early origins of mental disorder – risk factors in the perinatal and infant period, BMC Psychiatry, Vol. 16, No. 270.
- NT Government Department of Education (last updated November 2017). Families as First Teachers. Retrieved from https://education.nt.gov.au/education/support-for-teachers/faft
- Oberklaid, F, Drever, K (September 2011). Is my child normal? Milestones and red flags for referral, Australian Family Physician, Vol. 40, No. 9. Retrieved from https://www.racgp.org.au/download/documents/AFP/2011/September/201109oberklaid.pdf
- Occupational Therapy Australia (2016). Occupational Therapy Guide to Good Practice: Working with Children. Retrieved from http://www.otaus.com.au/sitebuilder/advocacy/knowledge/asset/files/87/guidetogoodpractice-workingwithchildren[may2016]-finalweb.pdf
- Perry, B (October 2001). Keep the Cool in School: Attachment – The First Core Strength, Early Childhood Today. Retrieved from https://www.scholastic.com/teachers/articles/teaching-content/keep-cool-school-attachment-first-core-strength/
- Perry, B, Szalavitz, M (2007). The Boy Who Was Raised as a Dog And Other Stories From a Child Psychiatrist’s Notebook, Basic Books, New York
- Perry, B, Szalavitz, M (March 2010). Born For Love, HarperCollins e-books
- Rowley, S, Williams, J (2015). Research Review Educational Series, Multi-sensory stimulation and infant development. Retrieved from https://www.researchreview.co.nz/getmedia/309bffda-42ba-4b5c-9e32-a170bf1cf3d2/Educational-Series-Multisensory-Stimulation-and-infant-development_1.pdf.aspx?ext=.pdf
- Sethna, V, Perry, E, Domoney, J, Iles, J, Psychogiou, L, Rowbotham, NEL, Stein, A, Murray, L, Ramchandani, PG (May-June, 2017). Father-child interactions at 3 months and 24 months: Contributions to children’s cognitive development at 24 months, Infant Mental Health Journal, Vol. 38, Issue 3, pp. 378-390
- Staples, J (June 2016). Neuroscience research into infant mental health: the impact on child and family health nursing policy and practice, Australian Journal of Child and Family Health Nursing, Vol. 13, Issue 1
- Sullivan, RM (August 2012). The Neurobiology of Attachment to Nurturing and Abusive Caregivers, The Hastings Law Journal, Vol. 63, No. 6, pp 1553-1570
- Van der Horst, FCP (2011). John Bowlby – From Psychoanalysis to Ethology, Unraveling the Roots of Attachment Theory, Wiley-Blackwell
- Zanardo, V, Soldera, G, Volpe, F, Giliberti, L, Parotto, M, Giustardi, A, Straface, G (24 May, 2016). Influence of elective and emergency cesarean delivery on mother emotion and bonding, Early Human Development, Vol. 99
Appendix One: Circle of Security
Circle of Security Network 2013
Appendix Two: Age-Dependent Brain Development
Rowley and Williams (2015)