Learning Objectives
By the end of this section, you will be able to:
- Identify behaviors that show emotional attachment between the newborn and family
- Describe nursing interventions that support attachment and bonding
- Describe sibling adjustment and grandparent adaptation to the newborn
Assessing attachment behaviors in parents or caregivers and their newborn requires skills beyond those required for a physical assessment. Nurses rely on their interviewing skills and keen observation of the interactions between the caregivers and their newborn. Bowlby introduced attachment theory in the 1950s and over the following decades worked with Ainsworth to further flesh out the theory over many different disciplines (Bowlby, 1979). Bowlby wrote, “The propensity to make strong emotional bonds to particular individuals is a basic component of human nature.”
Attachment or the lack of it has serious long-lasting effects on the child’s development and relationships throughout life, particularly with their significant other and with their own children. Having a caregiver who is responsive and present for the infant gives the infant a foundation to make good relationships in the future, to have confidence to explore their environment, and to have strong self-esteem (Cornell & Drew, 2022).
A positive, robust primary caregiver and infant relationship is paramount to healthy growth and development. For example, bonding results from the infant and caregiver having experiences they enjoy together. Also important for the relationship is attachment, the more integral provision of a secure environment for the infant throughout their progression and exploration (Winston & Chicot, 2016). A number of factors can affect bonding and attachment postdelivery. For example, the high-risk infant admitted to an ICU, NICU, PICU, or CICU may have anomalies to the face or body. The child and caregiver may be unable to bond during direct breast-feeding or direct skin-to-skin contact because of the infant’s acute instability (Kim et al., 2020). Advances in medical technology allow special needs infants to survive more often than they did in the past. However, impaired attachment in the hospital related to the alteration of the parental role, posttraumatic shock of families, and potentially neurodevelopmental disabilities of the infant continue to be an issue in their care (Kim et al., 2020).
Behaviors That Show Attachment
Attachment is assessed by the nurse as they assess the family and the newborn. Confirmation of strong attachment between the birthing person and infant includes multiple cues:
- A visually alert infant makes eye contact with their birthing person, tracking and following the parent with their eyes.
- The parent-infant dyad smile at one another.
- The infant cries only when hungry or wet.
- The parent anticipates feedings by reading the infant’s feeding cues.
- The infant enjoys being cuddled, clings to the parent, and is easily consolable. (Wittkowski et al., 2020)
Concerning actions or behaviors from the infant include crying for hours, appearing inconsolable or colicky, engaging in unpredictable feeding or sleeping patterns, showing no preference for parents over others, infrequently smiling or having a bland facial expression, and resisting being held or cuddled.
Four Stages of Attachment
The four stages of attachment derive from a psychologic study by Schaffer and Emerson in the 1960s. Sixty infant subjects, all living in Glasgow, Scotland, were visited for developmental assessment at monthly intervals for the first 18 months of life (Schaffer & Emerson, 1964). The study found that the caregiver who had the infant’s attachment was the one who was the most sensitive and responsive to the infant's signals. The development of attachment begins with the asocial stage. This stage lasts from 0 to 6 weeks, and infants in it display a general lack of attachment. In the indiscriminate stage, the 6-week-old to 6-month-old infant is interested in others but consolable by all. Between 6 and 10 months is the specific stage, in which usually only one person is able to console the infant. The infant older than 10 months has many attachments and people who can console them; they are in the multiple stage. This mirrors the stages Bowlby found in the late 1950s. Table 25.8 provides more information about the stages of attachment (Tutor2U, 2021).
| Name of Stage | Timeframe | Description |
|---|---|---|
| Asocial or preattachment | 0–6 weeks | Similar responses to objects and people Preference for faces/eyes |
| Indiscriminate or attachment in making | 6 weeks to 6 months | Preference for human company Ability to distinguish between people but comforted indiscriminately |
| Specific or clear-cut attachment | 6–8 months to 18–24 months | Infants show a preference for one caregiver, displaying separation and stranger anxiety The infant looks to particular people for security, comfort, and protection |
| Multiple or formation of reciprocal relationship | 18–24 months + | Attachment behaviors displayed toward several different people, such as siblings, grandparents, or other close family members or caregivers |
Factors Affecting Attachment
A parent or a caregiver who is undergoing their own illness related to labor and delivery or who is experiencing postpartum depression is unable to move toward attachment until first conquering these health-related issues. Unplanned pregnancy, a pregnancy that is a product of sexual assault, or general lack of social support can significantly affect bonding. A drug-exposed infant with a birthing parent who has a history of drug use and may be under other social and economic stressors may have more difficulty making appropriate attachment.
Nursing Interventions That Support Attachment and Bonding
The nurse uses their skills of assessing to determine what attachment behaviors in parents or caregivers and their newborn have occurred. This requires skills beyond those needed for a physical assessment. Nurses rely on their interviewing skills and keen observation of the interactions between the caregivers and their newborn to determine how well attachment and bonding are occurring.
Unexpected findings at birth, such as a genetic or congenital disorder along with subsequent hospitalization of the newborn, can interrupt and hinder attachment between the infant and their caregiver. Nursing interventions to support the attachment process are encouraging skin-to-skin contact when able and advocating for the caregiver to fulfill their role as much as possible in the inpatient setting. Emphasizing common characteristics or individualizing the actions of the newborn helps normalize the child’s behavior for the stressed parent of an inpatient infant. The nurse arranging or encouraging frequent parental visits to the NICU can significantly improve bonding and attachment.
Attachment and the Rest of the Family
In addition to parents, a newborn’s family may consist of siblings, aunts, uncles, cousins, and grandparents. Some of them may welcome their new family member wholeheartedly. Others may be more ambivalent.
Sibling Adjustment
A family is an open system where members can leave or be added at any time. The addition of a new sibling makes for change within the family and a new order for the siblings. The caregiver bringing home a high-risk infant may be caring not only for a fragile newborn but for other children as well. In that case, the caregiver must juggle the many needs of the infant with the needs of their siblings (Volling, 2017).
Temporary separation from the birthing parent or both parents, changes in parental behavior, and the arrival of the new sibling all affect the infant’s siblings. These responses can be positive or negative. Positive responses are more likely when the parents promote sibling acceptance of a new member into the family by including the siblings in preparing for the newborn and continuing to include them in care after the infant arrives home. Positive responses include interest in and concern for the new family member. Negative responses include regression in toileting and sleep. Jealousy of a sibling, sibling rivalry, is common as the new high-risk infant takes up more parental time and energy.
Grandparent Adaptation
Taking on the role of grandparent or even great-grandparent is often anticipated with excitement and happiness. The role of the grandparent is to support their child in becoming a parent. Grandparents can have mixed emotions about accepting a high-risk infant into the family. They may not understand the different responsibilities of their child or healthcare needs of their grandchild. Fear of hurting the infant or uncertainty about the potential outcomes can be scary for new grandparents of a high-risk infant. Including grandparents to the extent that they want to be included is the goal. It is important to acknowledge that parenting and caring for a medically fragile infant is different from the parenting they did in the past.
Increasingly, grandparents are taking on parental roles in providing permanent care for their grandchildren. Including these grandparents early in the care of the high-risk neonate will improve the process of attachment and ease when going home.
Link to Learning
Verywell Family provides information for families and has a resource to support new grandparents of premature grandchildren for bonding with the newborn and supporting the baby’s parents.