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Emotional attachment
Evidence review O
NICE Guideline, No. 194
National Guideline Alliance (UK).
Emotional attachment
Review question
What interventions in the postnatal period are effective at promoting emotional attachment?
Introduction
Emotional attachment is a type of innate behaviour in children. It is the earliest relationship that a child develops with their primary caregiver(s), and is where a baby behaves in a way that ensures physical proximity and safety. It is affected by the primary caregiver’s behaviour. For example, responding sensitively to a baby’s distress provides a ‘secure base’ from which the baby can explore their physical surroundings and help with emotional and social development. This helps them to form positive relationships with others in the future. Disturbance of this attachment ‘system’ can have life-long adverse implications for the emotional and social development of the child. Bonding is the other side of the coin and means the positive emotional and psychological connection that the primary caregiver(s), usually the mother, develop with the baby. Sometimes emotional attachment and bonding are used interchangeably to describe the relationship between the mother and the baby. The aim of this review is to determine what interventions in the postnatal period (defined as up to 8 weeks following birth) are effective at promoting emotional attachment.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy until March 2018. From April 2018 until June 2019, declarations of interest were recorded according to NICE’s 2018 conflicts of interest policy. From July 2019 onwards, the declarations of interest were recorded according to NICE’s 2019 conflicts of interest policy. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).
Clinical evidence
Included studies
Four randomised controlled trials (RCTs) were included in this review (Guedeney 2013, Hans 2013, Kemp 2011, Walkup 2009). All studies compared different interventions: usual care plus the Parental Skills and Attachment in Early Childhood versus usual care only (Guedeney 2013), community doula intervention versus routine medical and social services (Hans 2013), a long-term nurse home visiting program versus standard practice (Kemp 2011), and a paraprofessional-delivered, home-visiting intervention versus breastfeeding/nutrition education program (Walkup 2009). In one study the population were African American women (Hans 2013) and in another young American Indian women (Walkup 2009).
The length of the interventions across the included studies differed greatly from 3 months (Hans 2013) to up to the child’s 2nd birthday (Guedeney 2013, Kemp 2011).
The included studies are summarised in Table 2.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review with reasons for their exclusion are provided in appendix K.
Summary of studies included in the evidence review
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included studies.
See the full evidence tables in appendix D. No meta-analysis was conducted (and so there are no forest plots in appendix E).
Quality assessment of studies included in the evidence review
See the evidence profiles in appendix F.
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline and additional economic searches were conducted that used search terms specific to this review question combined with a search filter for economic evaluations but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
No economic studies were reviewed at full text and excluded from this review.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Clinical evidence statements
Mother’s feelings towards the baby when the baby is 12 to 18 months of age
No evidence was identified for this outcome.
Quality of mother-baby interaction when the baby is 12 to 18 months of age
- Moderate to low quality evidence from 1 RCT (N=248) showed no clinically important difference between the intervention of a community doula compared to routine medical and social services in mother-child interaction, measured using the Parent-Child Observation Guide at 12 months of baby age.
- Very low quality evidence from 1 RCT (N=208) showed no clinically important difference between long-term nurse home visiting programme and standard practice in mother-child interaction measured using the National Institute for Child Health and Development (NICHD) scales of parent–child interaction at 18 months of baby age.
Proportion of babies displaying an insecure attachment type (which includes ambivalent, avoidance, disorganised) when the baby is 12 to 18 months of age
- Low and very low quality evidence from 1 RCT (N=440) showed no clinically important difference between the intervention of Parental Skills and Attachment in Early Childhood program and usual care neither in women with the prenatal depression scale score of >11 nor those women with the prenatal depression scale score of ≤11 in social withdrawal behaviour in babies, measured using the Alarm Distress Baby Scale at 18 months of baby age. Higher scores on the prenatal depression scale indicate higher levels of depressive symptoms.
The nature of the early mother-baby relationship (based on the mother’s subjective perception) when the baby is 12 to 18 months of age
No evidence was identified for this outcome.
Social behaviour of the baby when the baby is 12 to 18 months of age
- Very low quality evidence from 1 RCT (N=167) showed a clinically important difference between the paraprofessional-delivered home visiting (Family Spirit) intervention compared to a breastfeeding/nutrition education program in the baby’s social emotional problems and competencies in externalising domain suggesting fewer problems associated with activity/impulsivity, aggression/defiance and peer aggression in the intervention group, measured using the Infant Toddler Social Emotional Assessment at 12 months of baby age.
- Very low quality evidence from 1 RCT (N=167) showed no clinically important difference between the paraprofessional-delivered home visiting (Family Spirit) intervention compared to a breastfeeding/nutrition education program in the baby’s social behaviour in the other domains such as internalising domain (includes depression/ withdraw, general anxiety, separation distress, inhibition to novelty), dysregulation domain (includes sleep, negative emotionality, eating, sensory sensitivity) and competence domain (includes compliance, attention, imitation/play, mastery motivation, empathy, prosocial peer relations), measured using the Infant Toddler Social Emotional Assessment at 12 months of baby age.
Economic evidence statement
No economic evidence was identified which was applicable to this review question.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
This review focused on interventions aimed at promoting emotional attachment. The committee firstly agreed that all outcomes needed to be assessed at 12 to 18 months of the babies age as the committee felt that this is the earliest age range when emotional attachment can be appropriately measured.
The committee agreed that the critical outcomes were the mother’s feelings towards the baby when the baby is 12 to 18 months of age, the quality of the mother-baby interactions when the baby is 12 to 18 months of age and the proportion of babies displaying an insecure attachment type when the baby is 12 to 18 months of age. Important outcomes the committee were also interested in were the nature of the early mother-baby relationship (based on the mother’s subjective perception) when the baby is 12 to 18 months of age, the quality of the mother-baby interaction when the baby is 12 to 18 months of age and also the social behaviour of the bay with the baby is 12 to 18 months of age.
The quality of the evidence
The evidence was assessed using GRADE, the overall confidence in the review findings ranged from very low to moderate.
There were no serious concerns with the consistency of the evidence.
There were serious concerns with the indirectness for the outcomes from one study (Walkip 2009). This study used the Infant Toddler Social Emotional Assessment (ITSEA) as a proxy outcome for social behavior of the baby. In addition, this study was conducted among young American indigenous women, and the intervention was specifically tailored to reflect the local Native practices, making the study not very applicable to the UK context. There was no concern about indirectness with other outcomes.
With some outcomes, there was serious concerns with imprecision. Serious imprecision was detectedby the 95% confidence interval crossing the minimally important difference (MID) for continuous outcomes. For these outcomes default MIDs were calculated as half the median standard deviation (SD) of the control groups at baseline (or at follow-up if the SD is not available at baseline).
There were very serious to serious concerns with the risk of bias for the included studies had high attrition bias, there was no information provided on how women were randomised and either no information on assessor blinding to intervention allocations or both assessors and participants were aware of their allocations consequently increasing performance bias.
Benefits and harms
Although some evidence was identified, mainly of low quality, the interventions generally did not seem to have an effect on outcomes measuring emotional attachment. Only one study (Walkup 2009) reported a clinically important improvement in externalising behaviour domain at 12 months of age following the intervention. The committee noted that assessing externalising behaviours (for example aggression) at 12 months of age is challenging and perhaps not much can be read into this result alone. More importantly, this study was conducted among a very specific population group, among young (mean age 18 years) American indigenous women and the intervention was specifically tailored to reflect the local Native practices. Therefore, the committee agreed the results would not be applicable to the UK population.
Given that lack of evidence on effective interventions for promoting emotional attachment, the recommendations were based on the committee’s knowledge and experience. The evidence review sought to find evidence about interventions to promote bonding and emotional attachment between the mother and the baby because mother is usually the primary caregiver of the baby. However, the committee agreed that the recommendations would apply to both parents (or who ever are the main caregivers of the baby) because it was considered important that these issues are discussed with not just the mother but also other main caregivers (often the father) who are developing a relationship with the baby.
The committee discussed that the importance of emotional attachment and bonding is well documented in the wider literature. All babies are born with an innate potential to develop an attachment to their caregiver(s) and how this can be modified by the quality, intensity and responsivity of the care provided. The security of this attachment forms the building blocks for the baby’s socioemotional development. Disruptions in attachment (so-called insecure attachment styles) can lead to long term difficulties in the baby’s development, causing significant psychological, behavioural and functional impairment in later life. Bonding, on the other hand, refers to the positive relationship and connection that the mother (or another primary caregiver) forms with the baby. Bonding and emotional attachment are therefore closely linked.
The committee discussed how parents should be aware about the importance of bonding and emotional attachment in the antenatal period and to have discussions in both the antenatal and postnatal period about ways that can help in the process of bonding with their baby which in turn could promote the baby’s emotional attachment. . Emotional attachment could be promoted through spending ‘high-quality’ alone time with the baby, skin-to-skin contact and encouraging positive interactions, reacting and responding to babies’ cues in a minimally stressful, calm, quiet and distraction-free environment with no set agendas. The committee agreed that parents should be encouraged to value this type of time spent with the baby. The committee also discussed how it can be important for the woman’s partner (or whoever supports her) to also be aware of the importance of emotional attachment so that they can support the woman, including by helping with other tasks that would otherwise prevent the woman for spending this time with her baby for example by offering to help with domestic chores or other childcare demands.
The committee discussed how both the birth and caring for a newborn baby are major life events that are typically normalised in society as being everyday events, however, there are various reasons why this period can be overwhelming and challenging, which in turn may have an impact on developing emotional attachment. The most important thing promoting emotional attachment is the wellbeing of the caregiver. The committee wanted to ensure that healthcare professionals have discussions with parents about what to expect and the potentially challenging aspects of the postnatal period. Such information would encompass the physical and emotional recovery from the birth, the challenges of baby feeding, the demands of parenthood, and to highlight the inevitable challenge of coping with sleep-deprivation which is a subjectively unpleasant and stressful state. Traumatic birth or birth complications can also bring further challenges the postnatal period which could impact bonding and emotional attachment. Parents may need to be reminded that everything may not go according to plan and that the experience will inevitably comprise an array of very intense emotions which is universal to all new parents and represents an expected adjustment period. Parents may need encouragement that these feelings are normal, that they can ask for help and that there is additional support available to them. Preparing, informing and encouraging women of these changes will hopefully improve their own sense of well-being, which in turn will encourage the natural development of emotional attachment.
The committee discussed how particular groups of parents may be more susceptible to challenges in bonding and their baby developing emotional attachment and may need more support. The committee were aware of longitudinal observational studies showing that often how one reacts to one’s child might be similar to how one was reacted to as a child. Therefore, parents who have been through the care system or who have experienced adverse childhood events might need more support in developing bonding and emotional attachment. Some parents who have experienced a traumatic birth might also have additional challenges with bonding. Furthermore, some parents with complex psychosocial needs, which might include people with complex mental health problems, and those needing a high level of support with many aspects of their daily life due an illness, disability, broader life circumstances or a combination of these, may have need additional support with bonding with their baby.
The committee discussed the harms that could potentially result from these recommendations are small and will be outweighed by the improvement in the emotional attachment between the mother and the baby. The main harm considered would be the additional pressure and anxiety parents may face striving to achieve emotional attachment and finding the time to spend one-to-one time with their baby.
The committee acknowledged the need for research in this area, particularly research exploring longer term outcomes. However, the committee were aware of at least 4 concurrent longitudinal studies currently being conducted in the UK. The committee considered that this research would likely provide valuable evidence for future updates and so did not make their own research recommendation in order to prioritise other topics. The committee particularly emphasised the importance of exploring intergenerational impact on bonding and emotional attachment.
Cost-effectiveness and resource use
No economic evidence is available for this review question. The committee agreed that providing information and support to mothers to enhance emotional attachment with their babies should be part of the routine postnatal care contacts. There may be minor resource implications relating to the time spent by the health professionals on providing such information and support, however, the anticipated emotional benefits for mothers and babies are expected to outweigh related costs. Therefore, the committee agreed that the recommendations ensure efficient use of healthcare resources.
Other factors the committee took into account
The committee noted during protocol development that certain subgroups of women and health care professionals may require special consideration:
- young women (19 years or under)
- women with physical and cognitive disabilities
- women who had difficulty accessing postnatal care services.
A stratified analysis was therefore predefined in the protocol based on these subgroups. However, considering the lack of evidence for these sub-groups, the committee agreed not to make separate recommendations and that the recommendations they did make should apply universally.
References
Guedeney 2013
Guedeney A, Wendland J, Dugravier R, Saias T, Tubach F, Welniarz B, Greacen T, Tereno S, Pasquet B. Impact of a randomized home-visiting trial on infant social withdrawal in the CAPEDP prevention study. Infant Mental Health Journal, 36(4), 594–601, 2013.Hans 2013
Hans SL, Thullen M, Henson LG, Lee H, Edwards RC, Bernstein VJ. Promoting Positive Mother-Infant Relationships: A Randomized Trial of Community Doula Support for Young Mothers. Infant Mental Health Journal, 34(5), 446–457, 2013.Kemp 2011
Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H, Zapart S. Child and family outcomes of a long-term nurse home visitation programme: a randomised controlled trial. Archives of disease in childhood, 96 (6), 533–540, 2011. [PubMed: 21429975]Walkup 2009
Walkup J, Barlow A, Mullany B, Pan W, Goklish N, Hasting R, Cowboy B, Fields P, Baker E, Speakman K, Ginsburg G. Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers. Journal of the American Academy of Child & Adolescent Psychiatry, 48(6), 591–601, 2009 [PMC free article: PMC6432645] [PubMed: 19454915]
Appendices
Appendix A. Review protocol
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Appendix D. Clinical evidence tables
Appendix E. Forest plots
Forest plots for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. GRADE tables
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded studies for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
Clinical studies
Download PDF (321K)
Economic studies
No economic evidence was identified for this review.
Appendix L. Research recommendations
Research recommendations for review question: What interventions in the postnatal period are effective at promoting emotional attachment?
No research recommendations were made for this review question.
Final
Evidence review underpinning recommendations 1.3.15 to 1.3.18
These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
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- Emotional attachmentEmotional attachment
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