Why such a complicated question?

1. Identifying difficulties in the antenatal phase that could affect the attachment relationship post-birth Why such a complicated question?

2. Can we measure ‘attachment’ prenatally? • Attachment, according to Bowlby (1969), is a universal, biological system that triggers caregiving behaviour when activated by fear and distress • “Evolution uses the early attachment relationship as a signalling system to the newborn as to the kind of an environment she or he might expect” (Fonagy, 2009). So is that a ‘maybe’?

3. but… Walsh (2009) notes that a foetus cannot demonstrate signals to activate caregiving behaviour and thus scales to measure attachment such as those developed by Cranley (1981) relate more accurately to the mother’s bond towards her unborn child or to the prenatal caregiving system.

4. and… • the lack of clarity in defining what is being assessed hinders our understanding • Yarcheski et al.’s (2008) meta-analysis of predictors of maternal-fetal attachment demonstrates that within this field each instrument is aimed at measuring different factors. • there are a number of scales currently in use to measure the mother-foetus relationship, but studies that evaluate their application often give contradictory findings and, crucially, there is not always an explicit connection to the postnatal attachment relationship.

5. What’s available • Adult Attachment Interview, predicts attachment around 70% of the time, but lengthy and expensive • The Edinburgh Post-natal Depression Scale (EPDS) has been used in pregnancy (Thorpe, 1993), but not followed up with post-birth relationship assessment • Prenatal Attachment Inventory (PAI) (Muller, 1993, as used by Siddiqui & Hägglöf, 2001) - predicts parental involvement but not sensitivity • Maternal Antenatal Attachment Scale (Condon, 1993) – looks at emotional involvement • Maternal-Fetal Attachment Scale (MFAS) (Cranley, 1981) – again, looks at involvement • ‘Mind-mindedness’, (Arnott & Meins, 2008) Pre- and post-birth assessments used; when administered postnatally, mind-mindedness predicts emotional regulation. Current study shows some correlation between predicting characteristics of (as yet unborn) child when 6 months old and mind-mindedness of parents at 6 months, but not conclusive Only the first of these has reliable validity

6. The role of anxiety • Wurmser et al (2005) – shows how stress affects the mother-infant relationship and perception/experience of crying • Del Carmen et al.(1993) measured prenatal maternal anxiety, with the Beck Depression Inventory; the STAI and the SE; and followed up with observations of dyadic behaviour at 3 months and Strange Situation coding They found that maternal characteristics relevant to the attachment relationship can be identified prenatally: low levels of anxiety are correlated with secure attachment • Bergman et al. (2008) – antenatal stress (measured by SLEQ) is significantly correlated with attachment classifications, with high levels of anxiety correlated to disorganised and avoidant patterns

7. Stress and safeguarding One study focusing on the severe consequences of stress was carried out by Stevens-Simon et al., (2001). By monitoring the use of health services and administering the Family Stress Checklist (Murphy et al., 1985) during pregnancy, it was possible to identify that high risk teen mothers use health care services more intensely as they struggle to interpret their infants’ distress signals and to soothe them, while high risk scores on the checklist were the only statistical predictor of maltreatment. The parent-infant relationship was measured by how many children were removed from their mothers: 11% were removed in the first year, 22% in the second year.

8. So what can we use? • Measures of mind-mindedness and stress seem to be offer a way to predict attachment difficulties, but need further validation • This could be said for nearly all the studies in this area… • Ideally, we need to link up with a university who can carry out post-birth measurements of attachment, such as the Strange Situation, Attachment Q Sort, Ambiance • Or measurements of the relationship, such as the CARE-Index, Emotional Availability Scales (see handout on CORC recommendations)