by Dr Sarah Little, General Practitioner MBChB BSc Hons MRCGP DCH DRCOG DFSRH
Attachment Theory– A Historical Context
Attachment is a deep and enduring emotional bond that connects one person to another across time and space1, 2. Attachment theory originates with the work of John Bowlby in 1958. He proposed that attachment can be understood within an evolutionary context, and that it is adaptive as it enhances the infant’s chance of survival (by way of protection and being fed).
Bowlby’s attachment theory has become the dominant approach to understanding early social development. Infants become attached to consistent caregivers who are sensitive and responsive in social interactions with the infant. Children begin to use attachment figures as a secure base to explore from and return to. Separation anxiety is a normal response in the attached infant3. Bowlby’s theory of the secure base fostering independent exploratory behaviour is in contrast to an earlier ‘dependency’ theory, which wrongly perceived attachment behaviour in children as regressive.
Bowlby and James Robertson (a psychoanalyst) collaborated in making the 1952 documentary ‘A Two Year Old Goes to the Hospital’, illustrating the suffering experienced by young children separated from their primary caregivers. This film was instrumental in the campaign to improve parental visiting hours4.
In 1969, Mary Ainsworth devised the ‘Strange Situation’ assessment technique to classify different types of attachment (secure, avoidant, anxious, and disorganised)5.
In the mid 1970s, the much replicated ‘Still Face Experiment’ was developed. Edward Tronick6 described a phenomenon in which an infant, after three minutes of ‘interaction’ with a non-responsive expressionless mother, “rapidly sobers and grows wary. He makes repeated attempts to get the interaction into its usual reciprocal pattern. When these attempts fail, the infant withdraws [and] orients his face and body away from his mother with a withdrawn, hopeless facial expression”.
Blurton Jones7 concluded that we are likely to be a carrying species as opposed to a caching species in terms of our evolutionary adaptations, and infants’ physiology and behaviours set them up to be frequent feeders. Rooting and sucking reflexes are precursor attachment behaviours (see also our webpage on ‘The Infant‘).
Attachment Theory– Current Thinking
The exclusively environmental explanation of attachment theory (ie. sensitive responsiveness of caregivers) has been challenged by results demonstrating some, albeit inconclusive, evidence of the effect of infant temperament. Perhaps a gene-environment theory is more probable8.
Why Attachment Matters
Compared to those with a history of poor attachment relationships, children with a secure and stable attachment history are more capable of developing and maintaining successful relationships, emotional regulation, and a positive sense of self as adults9. There is increasing recognition of the importance of fostering resilience, the roots of which relate to secure attachment in early childhood. Up to 40% of children in the UK lack secure bonds and 15% actively resist their parent. This calls for evidence based interventions10.
Two attachment disorders are described in the International Classification of Diseases11: reactive attachment disorder and disinhibited attachment disorder. Reactive attachment disorder starts in the first five years of life and is defined as follows:
[Reactive attachment disorder is] characterised by persistent abnormalities in the child’s pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling.
Clinically disordered attachment represents an extreme and impaired subgroup of children with insecure attachments. Disordered attachments are all insecure attachments, but most insecure attachments are not disordered12.
Cultural Variations in Child-Rearing Values
Cross-cultural research into maternal-infant interactions has previously recognised an Anglo-American preference to infant separateness and disapproval of displays of dependence13, 14. This is in contrast to other cultures eg. the Japanese, who typically value maternal-infant close proximity, creating early secure attachments thereby promoting future independence.
UNICEF Baby Friendly Initiative
The Baby Friendly Initiative promotes the importance of infant feeding and attachment in the context of responsive parenting. It has been working with public health services to improve standards of care in the UK since 1995. It is an evidence based global accreditation programme of Unicef and the World Health Organisation. The Baby Friendly Initiative may have given the opportunity to contribute to a gradual cultural change in responsive parenting.
Public Health Investment in Breastfeeding and Relationship Building
From a public health perspective, investing in breastfeeding and relationship building is now recognised as a positive, proactive mechanism to promote mother-infant attachment behaviours and improve the mental health and wellbeing for the mother and the child15-26.
Responsive feeding refers to a reciprocal relationship between an infant or child and his or her caregiver that is characterised by the child communicating feelings of hunger or satiety through verbal or non verbal cues, followed by an immediate response from the caregiver27.
It is known that humans are born with the capacity to self-regulate their energy intake. This ability is fostered through cause-effect learning, meaning that signals from the child should be interpreted by the parent or caregiver in the correct manner and in a supportive environment. The facilitation of self-regulation skills early in life may predict future food intake and optimal responses to hunger and satiety cues28.
Breastfeeding is a symbiotic, dynamic activity between a mother and infant, satisfying both nutritional and emotional needs. Oxytocin release promotes early attachment behaviours29. Breastfeeding on cue and non-nutritive suckling at the breast optimises milk supply and perhaps oral-facial development30, and may reduce crying31. Maternal neglect has been shown to be independently associated with decreasing breastfeeding duration32.
Responsive bottle feeding involves cue-based feeds, paced feeds and holding the infant in a nursing position to facilitate contact33.
Responsive feeding of solids involves listening to hunger and satiety cues, and never forcing food. New foods may need to be offered several times before they are accepted34.
Although historically, research into attachment theory has concentrated on the maternal-infant bond, secure paternal-infant attachments are of equal relevance. There are many ways other than feeding to facilitate this.
Infant Mental Health
Infant mental health is described by the World Association for Infant Mental Health as the ability to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system.
‘Serve and Return’ interactions shape infant brain architecture. When the adult responds to an infant appropriately, neural connections are built and strengthened35.
The 1001 Critical Days cross party manifesto (2015) highlights the importance of acting early to enhance the outcomes for children. With a forward by the Chief Medical Officer (CMO), the manifesto calls for interventions that are evidence based and economically sound, have an emphasis on training of staff, and focus on prevention and early intervention.
Epigenetics– Future Research in Attachment Theory & Infant Feeding
Epigenetics is a field of evolutionary biology that focuses on non-heritable modifications in genetic material and the various factors that can alter gene expression36. Epigenetic modification of gene expression through environmental programming hypothetically plays a role in the development of early mother-infant relationships8. Epigenetic mechanisms can mediate the gene–environment dialogue in early life and give rise to persistent epigenetic programming of adult physiology and dysfunction, eventually resulting in disease37.
The benefits of breastfeeding against necrotising enterocolitis, infectious diseases, obesity and cancer might be partly explained by the epigenetic model. Breast milk, modulating gene expression without changing the nucleotide sequence of DNA, might positively modify the phenotype and the outcome even if there is a genetic predisposition for the development of diseases38.
Official 1001 Critical Days Cross Party and early years organisations joint manifesto on the importance of parent-infant services.
Wave Trust: Quick Guide to the Age of Opportunity Report explaining the importance of the period between conception to age 2 in contributing to infant physical and mental health.
World Association for Infant Mental Health (WAIMH) A not-for-profit organisation which aims to promote the mental wellbeing and healthy development of infants throughout the world, taking into account cultural, regional, and environmental variations, and to generate and disseminate scientific knowledge.
PIP UK Charity providing parent-infant interventions to promote secure attachment.
National Child and Maternal Health Intelligence Network (CHIMAT): Perinatal and Infant Mental Health The latest in UK policy and practice in perinatal and infant mental health. Includes a link to a regular e-bulletin with best practice updates.
Unicef UK Baby Friendly Initiative: Breastfeeding and Relationship Building- A Workbook for Health Visitors This workbook is part of the 2 day course offers by the BFI, which is also suitable for interested GPs.
Babies in Mind Online Learning Free online course produced by the University of Warwick.
- Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (Vol. 3, pp. 1-94) Chicago: University of Chicago Press.
- Bowlby, J. (1969). Attachment and loss: Vol. 1. Loss. New York: Basic Books.
- Bretherton I, Munholland KA (1999). “Internal Working Models in Attachment Relationships: A Construct Revisited”. In Cassidy J, Shaver PR. Handbook of Attachment, Guilford press. pp. 89–114.
- Schwartz J (1999). Cassandra’s Daughter: A History of Psychoanalysis. Viking/Allen Lane. 225.
- Ainsworth M, Bell S. Attachment, Exploration, and Separation: Illustrated by the behaviour of one-year-olds in a strange situation. Child Development. 1970;41(1):49-67.
- Tronick, E., Adamson, L.B., Als, H., & Brazelton, T.B. (1975, April). Infant emotions in normal and pertubated interactions. Paper presented at the biennial meeting of the Society for Research in Child Development, Denver, CO.
- Blurton Jones, N. (1972). Ethological studies of child behavior, Cambridge University Press, 1972.
- Gervai J. Environmental and genetic influences on early attachment. Child and Adolescent Psychiatry and Mental Health. 2009;3(1):25.
- Thomson, R.A. (2008). Early attachment and later development: familiar questions and new answers – in J. Cassidy and P.R. Shaver (eds) Handbook of Attachment, 2nd New York: The Guildford Press, pp. 348-65.
- Moullin et al (2014). Parenting, attachment and a secure base for children. Baby Bonds report by the Sutton Trust.
- International Statistical Classification of Diseases and Related Health Problems 10th Revision
- Zeanah C. Beyond insecurity: A reconceptualization of attachment disorders in infancy. Journal of Consulting and Clinical Psychology. 1996;64(1):42-52.
- Suizzo M. French parents’ cultural models and childrearing beliefs. International Journal of Behavioral Development. 2002;26(4):297-307.
- Valentin (2005). In Vaughn L (2010) Psychology & Culture: Thinking, feeling and behaving in a global context. Taylor & Francis.
- Britton JR.et al. (2011) Breastfeeding – sensitivity and attachment pediatrics.aapublications.org
- Ekstrom A, Widstrom A, Nissen E. Does Continuity of Care by Well-Trained Breastfeeding Counselors Improve a Mother’s Perception of Support?. Birth. 2006;33(2):123-130.
- Groer M. Differences Between Exclusive Breastfeeders, Formula-Feeders, and Controls: A Study of Stress, Mood, and Endocrine Variables. Biological Research For Nursing. 2005;7(2):106-117.
- Gutman et al. (2009). Gutman LM, Brown J, Akerman R. Nurturing Parenting Capability: The Early Years. Centre for Research on the Wider Benefits of Learning, Institute of Education, University of London; London.
- Heikkila K, Sacker A, Kelly Y, Renfrew M, Quigley M. Breast feeding and child behaviour in the Millennium Cohort Study. Archives of Disease in Childhood. 2011;96(7):635-642.
- Kim P, Feldman R, Mayes L, Eicher V, Thompson N, Leckman J et al. Breastfeeding, brain activation to own infant cry, and maternal sensitivity. Journal of Child Psychology and Psychiatry. 2011;52(8):907-915.
- Oddy W, Kendall G, Li J, Jacoby P, Robinson M, de Klerk N et al. The Long-Term Effects of Breastfeeding on Child and Adolescent Mental Health: A Pregnancy Cohort Study Followed for 14 Years. The Journal of Pediatrics. 2010;156(4):568-574.
- Oddy W, Robinson M, Kendall G, Li J, Zubrick S, Stanley F. Breastfeeding and early child development: a prospective cohort study. Acta Paediatrica. 2011;100(7):992-999.
- Sacker A, Quigley M, Kelly Y. Breastfeeding and Developmental Delay: Findings From the Millennium Cohort Study. Pediatrics. 2006;118(3):e682-e689.
- Strathearn L, Fonagy P, Amico J, Montague P. Adult Attachment Predicts Maternal Brain and Oxytocin Response to Infant Cues. Neuropsychopharmacology. 2009;34(13):2655-2666.
- Sunderland M (2007) What Every Parent Needs to Know:The incredible effects of love, nurture and play on your child’s development. Dorling Kindersley.
- Unite/CPHVA (2008) Distinctive contribution of Health Visiting to Public Health and Wellbeing November, Unite the Union
- Harbron et al. (2013) Responsive feeding: establishing healthy eating behaviour early on in life. Paediatric food-based dietary guidelines for South Africa.
- Isselmann DiSantis K, Collins B, Fisher J, Davey A. Do infants fed directly from the breast have improved appetite regulation and slower growth during early childhood compared with infants fed from a bottle?. International Journal of Behavioral Nutrition and Physical Activity. 2011;8(1):89.
- Winberg J. Mother and newborn baby: Mutual regulation of physiology and behavior A selective review. Developmental Psychobiology. 2005;47(3):217-229.
- Narbutytė i, Narbutytė A, Linkevičienė L. Relationship between breastfeeding, bottle-feeding and development of malocclusion. Stomatologija, Baltic Dental and Maxillofacial Journal. 2013;15:67-72.
- Barr R, Elias M. Nursing Interval and maternal responsivity: effect on early infant crying. Paediatrics. 1988;81(4):529-536
- Strathearn L, Mamun A, Najman J, O’Callaghan M. Does Breastfeeding Protect Against Substantiated Child Abuse and Neglect? A 15-Year Cohort Study. Pediatrics. 2009;123(2):483-493.
- Unicef (2015). Nutrition in emergencies training package.
- Caton S, Ahern S, Remy E, Nicklaus S, Blundell P, Hetherington M. Repetition counts: repeated exposure increases intake of a novel vegetable in UK pre-school children compared to flavour–flavour and flavour–nutrient learning. British Journal of Nutrition. 2012;109(11):2089-2097.
- Center on the Developing Child at Harvard University (2016). From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families. Retrieved from developingchild.harvard.edu.
- Lillycrop K, Slater-Jefferies J, Hanson M, Godfrey K, Jackson A, Burdge G. Induction of altered epigenetic regulation of the hepatic glucocorticoid receptor in the offspring of rats fed a protein-restricted diet during pregnancy suggests that reduced DNA methyltransferase-1 expression is involved in impaired DNA methylation and changes in histone modifications. British Journal of Nutrition. 2007;97(06):1064.
- Murgatroyd C, Spengler D. Epigenetics of Early Child Development. Frontiers in Psychiatry. 2011;2.
- Verduci E, Banderali G, Barberi S, Radaelli G, Lops A, Betti F et al. Epigenetic Effects of Human Breast Milk. Nutrients. 2014;6(4):1711-1724.