The document discusses how hospitalization can disrupt the normal parental attachment process in neonates, infants, and young children. It describes the mechanisms through which attachment normally develops, such as skin-to-skin contact, breastfeeding, and responding to infant cues. However, the physical barriers and emotional stress of hospitalization can interrupt these attachment behaviors. The document recommends nursing interventions to promote attachment during hospitalization, such as encouraging parental involvement in care, holding, and visitation. Bowlby's Attachment Theory provides a useful framework for understanding the importance of the parent-child bond and for guiding practices to support attachment development even in stressful situations like hospitalization.

1. INTERRUPTED PARENTAL ATTACHMENT AMONG CRITICALLY ILL NEONATES, INFANTS, AND YOUNG CHILDREN Group F Amy Gutowski Gretchen McGuire Renee Muellenberg Arpita Patel AlexaPhiliips

2. The Issue: Hospitalization disrupts parent-child attachment Normal Attachment is a relationship, which develops between parent and child resulting in an interdependent, nurturing relationship through which the infant/child gains protection, nutrition, social interaction and the basis for future social and emotional development.

3. The Issue: Hospitalization disrupts parent-child attachment cont. A. Franklin (2006) suggests that attachment begins even before birth, which is called maternal-fetal attachment, and continues through infancy and childhood. B. Bonds of attachment between parent and infant/child are facilitated through several interactions. 1. “En Face” attachment develops when a mother and infant engage in a reciprocal gaze. 2. Cole, Cole, and Lightfoot (2005) note that an infants specific physical appearance referred to as “babyness” seem to appeal to adults and evoke bonding and caregiving behaviors. 3. Skin-to-skin contact is a major component of attachment development, and it is promoted in various ways. a. Breastfeeding b. Molding (process by which an infant and mother’s body form to each other). c. Reciprocal touch (Hockenberry and Wilson, 2007) 4. Mother responds to infant signals such as sucking, cooing, eye contact, and grasping, which contributes to the development of the interactive bond. 5. The father’s participation in feeding, holding, and skin-to-skin contact promotes the attachment with his child. a. In current research conducted by Fegran, Helseth, and Fagermoen, (2008), it was found that fathers’ engagement in skin-to-skin contact allowed them to emotionally and physically identify with their child. C. The literature suggests that initial contacts between parent and infant have a significant effect on the long-term relationship and the emotional well being of the child (Cole, Cole, and Lightfoot, 2005).

4. The Issue: Hospitalization disrupts parent-child attachment cont. For infants and children who receive intensive care hospitalization at birth and/or during the early years of childhood, the mechanisms of attachment are interrupted.

5. The Issue: Hospitalization disrupts parent-child attachment cont. A. Physical barriers existing in critical care settings create obstacles to the development of the parent-infant attachment process. 1. The immediate separation of a critically ill newborn from its parents deprives mother and father of their first interaction with their infant, which is crucial for attachment. a. In their 1976 work, Klaus and Kennel hypothesized that the initial hour after birth is crucial to secure long term attachment (as cited by Fegran, Helseth, and Fagermoen, 2008). 2. Further interruption of the attachment process occurs as a result of additional medical interventions and equipment. a. Physical barriers such as incubation, endotracheal intubation, ventilators, IV lines, chest tubes, and post-operative dressings prevent skin-to skin contact and impede the tactile component of attachment development. i. Feldman, Weller, Sirota, and Eidelman (2003) comment on the negative effects prematrity and incubation can have on attachment. “Among the negative sequelae of premature birth is the disruption in the attachment process, resulting in part from maternal-infant separation caused by standard incubator care. Maternal separation during the post- birth period exerts a negative impact not only on the infant's physiology and behavior (Hofer, 1995) but also on the mother's tie to her infant.” (p.95) b. Sedation of the infant becomes a barrier to social interaction and en face engagement.

6. The Issue: Hospitalization disrupts parent-child attachment cont. B. There are several psychological and emotional barriers that prevent the normal attachment process in critically ill infants and children. 1. Because parents grieve the loss of their idealized, healthy child, it is difficult for them to make an emotional and psychological attachment (“Barriers to Maternal-Infant Attachment,”2006). 2. Parents often become focused on the medicalization of their critically ill child rather than on the normal attachment process (“Barriers to Maternal-Infant Attachment”, 2006). 3. Because critically ill children require highly skilled nursing care, parents often feel left out or unneeded, and consequently they fail to participate in typical nurturing behaviors. a. Current literature notes that mother’s and father’s often feel unable to care for their child, and mother’s rely soley on their milk expression as their only task in caring for their baby (“Barriers to Maternal-Infant Attachment,” 2006). 4. Critically ill infants and children often have appearances that are disturbing for parents, which interferes with their ability to bond. a. Current literature supports that parents are often resistive and reluctant to touch and hold their critically ill infant due to fragility and physical anomalies (Fegran, Helseth, and Fagermoen, 2008) (“Barriers to Maternal-Infant Attachment,” 2006).

7. Review of Bowlby's Attachment Theory The purpose of The Attachment Theory is to: describe the human attachment behavioral system during infancy, identify conditions that promote attachment development, and trace processes resulting from loss of mother figure in infancy and childhood (Bowlby, 1969).

8. Review of Bowlby's Attachment Theory cont. A. Origins of the theory involve Bowlby’s ethological perspective, and refer to the evolution of the attachment instinct in different mammals, including humans. 1. Bowlby (1969) supposes that the action of genes allows the behavioral system to develop, just as physiologic systems do. 2. Concepts of the theory were derived from physiology, engineering, neurophysiology, and physics. 3. Attachment behavior instinct is present in all humans at birth, but the form it takes is distinct To the individual. B. Assumptions regarding attachment behavior include: it is preprogrammed, ready to develop when elicited by conditions, and the patterns of attachment behaviors are learned. C. The attachment behavioral system regulates infant safety and survival. Behaviors that predictably provide proximity to the mother figure or primary caregiver are elicited by the attachment system.

9. Review of Bowlby's Attachment Theory cont. D. Infant attachment behavior develops during four phases; ages are approximate. Phases may be delayed in unfavorable conditions. 1. Orientation and social behaviors of non-discriminated figures, occurs from birth-3 months. Examples include orientation and tracking of person, grasping , reaching, smiling, and babbling. 2. Orientation and signals (friendly responses) increase to the discriminated mother figure, usually from 3-6 months of age. 3. Increased need to maintain proximity of mother figure; causes separation anxiety. The attachment to mother figure is very evident. The child has goal directed reaching and is able to walk (follow), develops between 6 months and 2-3 years. 4. In the final phase, called a goal-corrected partnership, the child notes the feelings, motives, and organized behavior of mother. A more complex relationship is formed, after 3 years of age. E. The Theory of Attachment is applicable through adulthood. The child continues to monitor accessibility, and seeks the mother/attachment figure in times of stress, fear, or anxiety. F. Development of attachment is based on social interaction. Parent contribution is very influential. A sense of security is gained when caregiver meets the infant’s needs. Responding to child’s proximity seeking behavior fosters exploration.

10. Review of Bowlby's Attachment Theory cont. Mary Ainsworth has made significant contributions to knowledge of attachment. She devised the strange situation procedure to study infants’ responses when a parent is present, leaves the room, and returns. It allows social and emotional development to be assessed. In addition to the role in infants, Ainsworth explains the role of attachment behavioral system in children, adolescents, and adults in her article, Attachment Beyond Infancy (Ainsworth, 1989).

11. Review of Bowlby's Attachment Theory cont. A. Childhood; after completion of phase 4 of attachment development, at approximately 4 years old. 1. Confidence and stability of the attachment partnership is created from mutual understanding, due to increased communication abilities. 2. This allows for a decrease in separation anxiety; separation is tolerated longer and causes less distress. An increase in exploration and connection with others, such as playmates is further facilitated. B. During adolescence, hormonal changes cause a great shift in attachment development. 1. At this age, development of a strong partnership with peer, usually opposite sex is formed. 2. In this relationship, the reproductive and caregiving systems are involved as well as the attachment behavioral system. C. Throughout adulthood, after achievement of a sense of autonomy from parents, an attachment to parental figures continues, and a relationship is usually maintained. 1. Role reversal may occur as parent ages; the child is then viewed as stronger and wiser. 2. Other important attachments in a person’s life include: siblings, extended family, sexual pair bonds, and friends.

12. Review of Bowlby's Attachment Theory cont. The article, Attachment-Past and Present: But What About the Future? By H. Keller, reviews the progress of attachment development knowledge in the past, present, and most importantly the future. She states the Attachment Theory has not been refined much since the 1970’s (Keller, 2006).

13. Review of Bowlby's Attachment Theory cont. B. The first of three main areas of The Attachment Theory that needs to be further developed is the evolutionary bases of attachment. 1. Is there only one universal healthy way of attachment development? 2. Attachment definition needs revising to include factors of context and the environment. C. Secondly, the cultural nature of attachment needs more attention. 1. Universal behavior tasks found not to be universal in non-western cultures. 2. An appropriate attachment strategy is defined by cultural goals and values. 3. Lastly, attachment and new developments in infancy research is needed. a. Recent advances have shown infants have more cognitive abilities to interact socially than previously thought. b. The teams secure and insecure need evaluation deeper than just the biologic function for reproductive success.

14. Implications to promote attachment Applying Bowlby's Attachment Theory to interventions that promote parent-child attachment during hospitalization.

15. Implications to promote attachment cont. Why is promoting a healthy attachment in infants and children important? Healthy attachment with caregivers predicts higher probability of healthy relationships developed by the infant or child in the future, while poor attachment is associated with many emotional and behavioral problems (Perry, 2001). When an infant or a child is hospitalized or undergoing painful procedures, a secure attachment to a nurturing adult, will help the infant or child cope with the distress and promote a sense of well-being and security (Walsh, McGrath, & Symons, 2008). Secure children are able to find effective resolutions to decrease the distress they are experiencing. But, children who experience ambivalent attachment, where the caregiver is inconsistent or insensitive, exhibit excessive expressions of distress like crying (Walsh, McGrath, & Symons, 2008). Children, who experience disorganized attachment, where the caregiver is viewed as frightening, appraise the painful situation to be more distressful then they really are and have less effective distress resolutions (Walsh, McGrath, & Symons, 2008). Attachment affects the infant and child’s pain perception and coping ability; therefore it would be difficult for the nurse to appropriately assess and treat pain for an infant or child with poor attachment to their caregiver.

16. Implications to promote attachment cont. Why is promoting a healthy attachment in infants and children important? Cont. In addition, poor attachment to caregivers leads to ineffective ability to cope with stress (Walsh, McGrath, & Symons, 2008). According to Child Welfare Information Gateway (2008), “Research shows that babies who receive affection and nurturing from their parents have the best chance of healthy development. A child’s relationship with a consistent, caring adult in the early years is associated later in life with better academic grades, healthier behaviors, more positive peer interactions, and an increased ability to cope with stress”. The process of attachment occurs mainly infancy to the age of 5 years old (Walsh, McGrath, & Symons, 2008). When a baby is born that requires critical medical intervention it is immediately take to NICU and the mother does not have opportunity to bond with the newborn after a difficult labor. This may disrupt and delay the maternal/infant attachment process because NICU mothers sometimes cannot hold, touch, or see their newborns (Franklin, 2006). For hospitalized children and infant being in a hospital and being ill results in stress because of separation from parents, discontinuity of caregiving in hospital setting, and unfamiliar and sometimes painful procedures conducted in a hospital.

17. Nursing interventions to promote attachment Nursing Intervention to Promote Attachment In stressful situations where an infant or child is hospitalized nurses have a unique position to assess the family dynamics and facilitate positive attachment (Franklin, 2006). Provide continuity in caregiving to the hospitalized infant or child, and reduce stress of hospitalization (Turner, 2005). Involve Child Life Specialist in the care of the infant and child, so they can assess attachment and employ appropriate developmental teaching to decrease the stress of hospital procedures like role play and dolls (Turner, 2005). Provide explanation about the child’s condition and any machines or equipment that the infant or child may be connected to (Franklin, 2006). However, do not overwhelm the parents with information; instead focus talking about the child.

18. Nursing interventions to promote attachment cont. Nursing Intervention to Promote Attachment cont. Encourage the parents to touch, talk, provide emotional support, and if possible hold the infant or child (Franklin, 2006). Encourage the parents to visit regularly, participate in providing care, and advocate for the infant and child (Franklin, 2006). Follow up with parents, when the child is discharged from the hospital, to assess how the attachment experience is going with the baby and child (Franklin, 2006).

19. How the theory addresses the issue The central premise of the theory is that humans have a need for physical and emotional closeness. This premise guides interventions to guide healthy attachment when an infant or child is hospitalized. Studies have shown that early holding is one of the most important activities in promoting early attachment. Therefore, it is important for the nurse to encourage the parents to hold their infant as soon as possible. Kangaroo care is a form of early holding that encourages a sense of closeness between infant and parent (Franklin, 2006). Consistency in the closeness an infant feels with the parents is needed in order for the infant to form a secure attachment. Therefore, the nurse should create a welcoming environment when the parents are visiting, answering their questions and easing their stress as much as possible so the parents will feel comfortable visiting (Franklin, 2006). Premature infants express themselves differently then full term infants. Teaching parents about the cues preterm infants give the parents will be able to better respond to the infant emotionally, encouraging attachment (Karl, Beal, O‘Hare & Rissmiller, 2006). The theory expresses that there is no specific time period in which the relationship must be established. It is a process over many interactions between caregiver and infant. Therefore, parents must be supported throughout their child’s stay (Carlson, Sampson & Sroufe, 2003). Research that has been done on infants with multiple caregivers indicates that it is important for the parents to have individualized time with the child and social and emotional support for the parents (Carlson, Sampson & Sroufe, 2003).

20. Evaluation of the theory’s utility in helping to address the issue The Utility of Bowlby’s Attachment Theory Excellent theory for explaining the importance of the connect between a child and their parent. It also help guides nurses in the best ways to help an attachment form. Bowlby’s work still influences clinical practice today. His work regarding separation during hospitalization changed hospital policies regarding parents visiting their children. Today, much more priority is placed on the emotional needs of admitted children and as a result parents are encouraged to stay with their children (Alsop-Sheilds & Mohay, 2001). Criticism for the theory includes (Field, 1996): 1. The theory only considers the mother as the primary attachment figure. 2. The theory does not account for other degrees of attachment such as to a sibling or peer. 3. The theory does not account for multiple attachments at once, such as a child who is equally attached to their mother and father.

21. References Ainsworth, M.D.S. (1989). Attachments beyond infancy. American Psychologist, 44, 709-716. Alsop-Shields, L., & Mohay, H. (2001). John Bowlby and James Robertson: theorists, scientists and crusaders for improvements in the care of children in hospital. Journal of Advanced Nursing, 35(1), 50-58. Barriers to Maternal-Infant Attachment. (2009, March). Neonatal Transport: The Newsletter of the Maryland Regional Neonatal Transport Program. Retrieved from http://www.umm.edu/mrntp/pdf/mrntp_newsletter_03_08.pdf Bowlby, J. (1969). Attachment and loss: Volume I attachment. New York: Basic Books, Inc. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. London: Routledge; United States: Perseus. China Photos/Getty Images. (photographer). (2005). Retrieved on 11/13/2009 , from: http://cache1.asset-cache.net/xc/52640971.jpg?v=1&c=IWSAsset&k=2&d=17A4AD9FDB9CF193CC300C081D9F4700A4FFB8B47724D420EA513233346EC35CF06BF04B24B4128C Carlson, E., Sampson, M., & Sroufe, L. (2003). Implications of Attachment Theory and Research for Developmental-Behavioral Pediatrics. Journal of Developmental & Behavioral Pediatrics, 24(5), 364-379. doi:10.1097/00004703-200310000-00010. Cole, M, Cole, S.R., & Lightfoot, C. (2005). The Development of Children (5th ed.). New York: Worth Publishers. Fegran, L., Helseth, S., & Fagermoen, M.S. (2008) A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. Journal of Clinical Nursing 17, 810–816 doi: 10.1111/j.1365-2702.2007.02125 Feldman, R., Weller, A., Sirota, L., & Eidelman, A.I. (2003). Testing a family intervention hypothesis: The contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch. Journal of Family Psychology, 17(1), 94-107. doi: 10.1037/0893-3200.17.1.94

22. References cont. Field, T. (1996). Attachment and separation in young children. Annual Review of Psychology, 47541-561. doi:10.1146/annurev.psych.47.1.541. Franklin, C. (2006). The neonatal nurse’s role in parental attachment in the NICU. Critical Care Nursing Quarterly, 29(1) 81–85. Retrieved from http://ovidsp.tx.ovid.com.ezproxy.rush.edu/spa/ovidweb Hockenberry, M.J., & Wilson, D. (2007). Wong’s Nursing Care of Infants and Children (8th ed.). St. Louis: Mosby Inc. Karl, D., Beal, J., O'Hare, C., & Rissmiller, P. (2006). Reconceptualizing the nurse's role in the newborn period as an "attacher". MCN: The American Journal of Maternal Child Nursing, 31(4), 257-262. Keller, H. (2008). Attachment-past and present. But what about the future? Integr Psych Behav., 42, 406-415. Levene, M.I. Tudehope, D.I., & Thearle, M. (2000). Infant attachment. Essentials of Neonatal Medicine (3rd ed.). Malden, MA: Blackwell Science Ltd. Nurturing and Attachment. (2008, September 18). Child Welfare Information Gateway. Retrieved November 10, 2009, from http://www.childwelfare.gov/can/factors/nurture_attach.cfm Perry, B. D. (2001). Bonding and attachment in maltreated children. Child Trauma Academy: Parent and caregiver education series, 1(4). Retrieved November 10, 2009, from http://www.childtrauma.org/CTAMATERIALS/Attach_ca.asp Turner, J. C. (2005). A place for attachment theory in child life programming: The potential to assess the quality of parent–child relationships. Child & Youth Care Forum, 34(3), 195-207. Walsh, T. M., McGrath, P. J., & Symons, D. K. (2008). Attachment dimensions and young children’s response to pain. Pain Research & Management : The Journal of the Canadian Pain , 13(1), 33-40.