1. What we can do antenatally to promote secure and happy relationships Penny Rackett Early Years Educational Psychologist, North Suffolk Phd student, Heriot-Watt University

2. A reminder of the negative consequences of poor early relationships Increased risk of depression especially early onset Children who have been severely abused or neglected, subjected to high levels of blood cortisol, can have head circumferences 25% smaller More social and behavioural problems lasting into adolescence (and beyond) (American study showing correlation between behaviour age 3 and antisocial behaviour as a teen) Poorer language development Poorer cognitive development, especially in boys and in families with other social problems Poor mental health: state at 12 months is correlated with state as a young adult

3. Consequences of disorganised attachment Incidence = 15% in low risk, 40 – 80% in high risk families (van IJzendoorn et al, 1999) Oppositional, hostile-aggressive behaviours, coercive style of interaction (Lyons-Ruth, 1996, 1997) Problems in early years, middle years, ODD in boys (Greenberg et al 1991); general EBD (Green et all 2000) Lower achievement in maths age 8 (Moss et al, 1998) Most frequently rejected by peers age 9 (Vershueren, 2001) Strong link to dissociation and Borderline Personality Disorder (see Nice guidelines) in adolescence (Hesse and van Ijzendoorn, 1998) and in adulthood (Lyons-Ruth et al 2005, 2009)

4. What are the financial implications of failing to ensure a secure start for infants? Petrou et al (2002) estimated that post-natal depression costs £34.4 - £43.3 million a year for initial support Scott et al (2001) estimated that the costs of dealing with the consequences, i.e. mental health and behavioural needs of the children, are 10 times higher Audit commision (2004) indicated that effective interventions could save over £100,000 per child in direct costs by the age of 16 An American study showed that over 25 years, every dollar spent on early prevention saved $5

5. But what can we talk about attachment in pregnancy? In Bowlbys terms – no. It is a universal, biological system that triggers caregiving behaviour when activated by fear and distress. It is what the infant learns to do to survive in the environment she finds herself in. 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 mothers bond towards her unborn child or to the prenatal caregiving system.

6. But there is research to show which conditions during the antenatal period seem to affect relationships post-birth

7. Why the antenatal period is so important for relationships The fetal period is a highly active time for organ development and epigentic modification from Early Experiences Can Alter Gene Expression and Affect Long-Term Development. Center on the Developing Child, Harvard University (2010) Women go through a range of hormonal and neurological changes in pregnancy that are thought to help prepare them for motherhood (increase of sensory perception, emotional calm and closeness, Fleming & Li 2002; changes to the hypothalamus and orbitofrontal cortex, dubbed the maternal circuit, Kinsley et al., 1999). Disturbance in these processes is likely to affect the post-birth relationship. There are clear links between between cortisol levels during pregnancy and the infants neurological state (Lundy et al., 1999). Some studies suggest a higher incidence of ADHD diagnoses among children exposed to higher cortisol levels during pregnancy.

8. Why stress can be harmful OConnor et al. (2007) found that high prenatal levels of maternal anxiety and depression are correlated with sleep difficulties in children at 18 and 30 months. Lundy et al.s (1999) research into the effects of prenatal depression on neonates found that a newborns cortisol, norepinephrine, dopamine levels and Brazelton scores could all be predicted from the mothers cortisol, norepinephrine and dopamine levels in pregnancy. Prenatal maternal stress and anxiety can predict an increase of infant illness: 10.7% for general illnesses, 9.3% for respiratory, 8.9% for skin and 7.6% for antibiotic use Beijers et al., 2010)

9. More stress… Statistical relationships have been reported between depression and pre-eclampsia (Kurki et al. 2000), pre- term delivery (Dunkel Schetter, 2009) and low birth weight (Halbreich, 2005). Stress, depression and other mood disturbances have a particularly high incidence during pregnancy, especially among vulnerable groups, such as ethnic minority and socio-economically disadvantaged groups (Halbreich, 2004). Women who experience domestic violence during pregnancy are less likely to report childhood physical and sexual abuse (Malone et al., 2010)

10. And more… Wurmser et al.s (2005) showed that negative life changes in the 12 months previous to birth affected the mother–infant relationship at 3 and 6 months Stevens-Simon et al. (2001) looked at stress (with the Family Stress Checklist (Murphy et al., 1985) and use of health services, with high risk teen mothers. They found that the only statistical predictor of maltreatment was high risk scores on the checklist. Del Carmen et al.s (1993) measured prenatal maternal anxiety and found that low levels of anxiety are correlated with secure attachment (Strange Situation) Bergman et al. (2008) showed that antenatal stress is significantly associated with attachment classification. Children with disorganised and avoidant attachments had mothers who reported higher levels of antenatal stress than children with secure and ambivalent attachments. No significant differences were found for postnatal life events.

11. Why being able to think about the baby as a person is crucial Siddiqui and Hägglöf (2000) found that the most important variable for predicting maternal involvement after birth was the ability to fantasise about the unborn child. This links with with research into mind- mindedness, eg Arnott and Meins (2008) study, in which parental ability to imagine what an unborn child will be like at six months of age was strongly correlated with a later secure attachment relationship.

12. The importance of support Hayes et al.(1990) explored womens perceptions of their own childhood experiences, their trait anxiety level, socioeconomic status and social support network and found that the only antenatal measure significantly predictive of attachment was perception of support (Strange Situation and infant temperament at 12 months) Simpson et al. (2003) looked at the changes in attachment orientations across the transition to parenthood found that the greater the perception by the woman of prenatal support and minimal anger from their partner, the greater the satisfaction for both partners. Also, women who perceived their husbands as being less supportive prenatally became more ambivalent postnatally, while women who were able to seek more support prenatally became less avoidant; and husbands who perceived themselves as being more supportive prenatally also became less avoidant.

13. Its the relationship that counts Cooper et al.s (2009) intervention was aimed at improving the quality of mother-infant relationships and infant attachment in a socioeconomically deprived community in South Africa. This was delivered from late pregnancy to 6 months post-birth and they achieved a higher rate of secure infant attachment at 18 months, despite not significantly reducing maternal depressive disorder. This demonstrates yet again that it is the relationship which is key; and that social inequalities can be addressed by appropriate interventions. Kaplan et al. (2007) found that antenatal psychiatric diagnoses do not predict infant-mother interaction: it is only when they are combined with low levels of maternal sensitivity and some women with antenatal psychiatric diagnoses demonstrate high levels of maternal sensitivity. Van Bakel et al. (2009) report on a brief antenatal and postnatal preventive intervention programme to enhance the quality of parent-infant interaction in at risk families – Baby Extra. This includes the use of Video Interactive Guidance: the pilot data show maternal sensitivity and infant responsiveness increase significantly while intrusiveness decreases markedly

14. What makes for a helpful intervention Being proactive and beginning in the antenatal period, MacLeod and Nelson (2000) Home visiting services that deliver a relationship-based intervention to mothers experiencing depression have positively influenced not only the mothers mood, but also the attachment relationship (Lyons-Ruth et al., 1990; Heinicke et al., 1999). Kitzman et al. (2010) found that prenatal and infancy home visiting reduced childrens use of substances and internalising mental health problems, and improved maths and reading scores, at age 12, compared to control group.

15. A summary of factors Groups supporting women with general personal issues can lift their mood and sense of being able to cope. General support in pregnancy (eg home visits and telephone contact) is helpful. Prenatal interventions that develop maternal sensitivity would moderate the effects of psychiatric illness. Mothers need to perceive they are being supported; and fathers/partners need to experience themselves as being supportive. Both partners may need to be helped to seek and value support. Greater support during pregnancy to help deal with life stresses. Programmes in pregnancy to support mothers experiencing depression with bearing and managing infant distress (and undoubtedly their own). Video Interactive Guidance is an effective method.

16. Factors which facilitate secure attachment Maternal reflective function (Fonagy et al., 2002; Slade 2005) Motivation and capacity to repair disruptions in the relationship (Tronick & Weinberg, 1997) Reduction of hostile behaviour (Lyons-Ruth, 1999a) Improvement in secure base provision (Cassidy et al 2005) Maternal sensitivity (Bakermans-Kranenburg et al., 2003) The capacity to reflect the infants internal state and represent it as a manageable experience (Fonagy et al., 2002; Slade 2005)

17. What can you do tomorrow? Each time you see the family, ask the parent(s) What have you been doing this week to make contact with your baby? Encourage them to visualise what the baby will be like when 6 months old Help the mother to think about how she can feel more supported (both within and beyond the family) Help the father to recognise how valuable his support is Encourage the mother to actively relax Know that having a good relationship with your parents is crucial for them

18. What could you plan to do? Teach the parent(s) relaxation skills Think how you can incorporate factors that support secure attachment, and elements of successful antenatal interventions, into your everyday practice Reflect in supervision/professional meetings how you offer the experience of containment and reciprocity to your parents Set up an intervention like Baby Extra

19. What are your thoughts?