Here are don’ts for baby care.
Why Bonding is Critically Important
Why is bonding with your child so critically important? See what Aliene S. Linwood, RN, DPA, FACHE has to say in this article.
Definition
Bonding is the formation of a mutual emotional and psychological closeness between parents (or primary caregivers) and their newborn child. Babies usually bond with their parents in the minutes, hours, or days following birth.
Description
Bonding is essential for survival. The biological capacity to bond and form attachments is genetically determined. The drive to survive is basic in all species. Infants are defenseless and must depend on a caring adult for survival. The baby's primary dependence and the maternal response to this dependence causes bonding to develop.
Bonding and attachment are terms that describe the affectional relationships between parents and the infants. An increased awareness of the importance of bonding has led to significant improvements in routine birthing procedures and postpartum parent-infant contact. Bonding begins rapidly, shortly after birth, and reflects the feelings of parents toward the newborn; attachment involves reciprocal feelings between parent and infant and develops gradually over the first year. The focus of this entry is bonding in the newborn period. Attachment develops over the larger period of infancyand is treated in a separate entry.
Many parents, mothers in particular, begin bonding with their child before birth. The physical dependency the fetushas with the mother creates a basis for emotional and psychological bonding after birth. This attachment provides the foundation that allows babies to thrive in the world. When the umbilical cord is cut at birth, physical attachment to the mother ceases, and emotional and psychological bonding begins. A firm bond between mother and child affects all later development, and it influences how well children will react to new experiences, situations, and stresses.
Bonding Research
American pediatricians John Kennell and Marshall Klaus pioneered scientific research on bonding in the 1970s. Working with infants in a neonatal intensive care unit, they noted that infants were taken away from their mothers immediately after birth for emergency medical procedures. These babies remained in the nursery for several weeks before being allowed to go home with their families. Although the babies did well in the hospital, a troubling percentage of them seemed not to prosper at home and were even victims of battering and abuse. Kennell and Klaus also noted the mothers of these babies were often uncomfortable with them, sometimes not believing that their babies had survived birth. Even mothers who had successfully raised previous infants have special difficulties when their children had been in the intensive care nursery. Kennell and Klaus surmised the separation immediately after birth interrupted a fundamental relationship between the mother and the new baby. They experimented with giving mothers of both premature and healthy full-term babies extra contact with their infants immediately after birth and in the few days following birth. Mothers with more access to their babies in the hospital developed better rapport with their infants, held them more comfortably, and smiled at and talked to them more often.
Gradually bonding research brought about widespread changes in hospital obstetrical practice in the United States. Fathers and family members often remain with the mother during labor and delivery. Mothers hold their infants immediately after birth, and babies often remain with their mothers throughout their hospital stay. Bonding research has also led to increased awareness of the natural capabilities of the infant at birth, and so it has encouraged many others to deliver their babies without anesthesia (which depresses mother and infant responsiveness).
Infancy
Emotionally and physically healthy mothers and fathers are attracted to their infant. They naturally feel a physical longing to smell, cuddle, and rock their infant. They look at their baby and communicate to the baby. In turn the infant responds with snuggling, babbling, smiling, sucking, and clinging. Usually, the parents' behaviors bring pleasure and nourishment to the infant, and the infant's behaviors bring pleasures and satisfaction to the parents. This reciprocal positive maternal and paternal-infant interaction initiates attachment.
One important part in the parents' ability to bond with the infant after birth is the healthy, drug-free newborn is in a "quiet alert" state for 45 to 60 minutes after birth. Immediately after birth the newborn can see, can hear, will turn his head toward a spoken voice, and will move in rhythm to his mother's voice. Mothers and fathers who have the opportunity to interact with their newborns within an hour after birth bond with their baby quickly. The act of holding, rocking, laughing, singing, feeding, gazing, kissing, and other nurturing behaviors involved in caring for infants (and young children) are bonding experiences. The most important ways to create attachment is positive physical contact such as hugging, holding, and rocking. It should be no surprise that nurturing behaviors cause specific neurochemical actions in the brain. These actions lead to organization of brain systems responsible for attachment.
Physical changes occur in the mother after birth, such as hormonal increases triggered by the infant licking or sucking her nipples and increased blood flow to her breasts when she hears the infant cry. Instinctive behaviors triggered in the mother in response to the infant immediately after birth promote her bonding with the infant and thus support the infant's survival.
Toddlerhood
Bonding experiences lead to healthy relations for children in the earliest years of life. During the first three years of life, the human brain develops to 90 percent of adult size. The brain puts in place most of the systems and structures that are responsible for future emotional, behavioral, social, and physiological functioning. Bonding experiences must be present at certain critical times for the brain parts responsible for attachment to develop normally. These critical periods appear in the first year of life and are related to the capacity of the infant and parent or caregiver to develop a positive interactive relation. Problems with bonding and attachment can lead to a fragile biological and emotional foundation for later experiences.
Common Problems
Any problem with bonding experiences can interfere with attachment capacities. When the interactive, reciprocal "dance" between the parent and infant is disrupted or becomes difficult, bonding experiences are difficult to maintain. Disruptions can occur because of medical problems with the infant or the parent, the environment, or the fit between the infant and the parent.
The infant's personality or temperament influences bonding. If an infant is difficult to comfort, is irritable or unresponsive, the baby may have more difficulty developing a secure bond. Moreover, the infant's ability to take part in the maternal-infant interaction may be compromised because of a medical condition, such as prematurity, birth defect, or illness.
The parent's or caregiver's behavior can also hinder bonding. Critical, rejecting, and interfering parents have children who may avoid emotional intimacy. Abusive parents have children who become uncomfortable with intimacy and withdraw. The child's mother may be unresponsive to the child because of maternal depression, substance abuse, or overwhelming personal problems that interfere with her ability to be consistent and nurturing for the child.
The environment is also a factor. A major impediment to healthy bonding is fear. If an infant is distressed because of pain, pervasive threat, or a chaotic environment, the baby may have a difficult time engaging in a sympathetic care-giving relationship. Infants or children living amid domestic violence, in refugee shelters, in areas besieged by community violence, or in war zones are at risk for developing attachment problems.
The fit between the infant's temperament and capabilities and those of the mother and father is important. Some parents can bond with a calm infant but are overwhelmed by an irritable infant. Understanding each other's nonverbal cues and responding appropriately is essential to preserving the bonding experiences that build healthy attachments. Sometimes a style of communication and response familiar to a mother from one of her other children may not fit her new infant. The mutual frustration of being "out of sync" can undermine bonding.
Since the first phase of bonding takes place in the womb, researchers believe difficult and unwanted pregnancies and planned adoptions interfere with mother and infant bonding. Teenagers and immature mothers often conceal and reject their pregnancies. This behavior and feeling may result in abandonment, neglect, and the absence of bonding at birth. Often there is also an emotional detachment from a fetus that causes emotional or physical pain to the mother during pregnancy. Mothers may have difficulty bonding with an infant if prenatal testing suggests the child will have a birth defect or is likely to be mentally retarded and malformed. And babies planned for adoptionat birth may be "given up" emotionally by the birth mother during pregnancy. Any or all of these circumstances can interfere with the infant-parent bonding process.
Parental Concerns
The birth of a premature infant is documented to be a time of stress and crisis for parents and infants. Among these stressors are perceived losses and grief from the early abrupt termination of pregnancy, feelings of guilt and failure in inability to carry the infant to term, uncertainty regarding the infant's future health and developmental potential, and immediate and long-term separation of the infant from the family.
Parental involvement in the care of sick or premature newborns is a major concern of many pediatricians and nursery staff. Touching, stroking, and talking, and later, massaging are encouraged during frequent parental visits to the nursery. It is hoped that the emotional bonding of parents with low birth-weight infants will increase the baby's chance of doing well despite prematurity.
Because premature infants sometimes seem fragile, parents may handle them less. Skin to skin contact is important to the growing infant, premature or full term. Lack of this contact may predisposethe child to psychological problems as well as diminish opportunities for learning.
The practice of "kangaroo care," first introduced by two South American neonatologists, is a method of skin-to-skin contact to promote parent and infant bonding, especially for premature infants. This method involves holding infants dressed only in a diaper and a hat between the mother's bare breasts or against the father's chest, similar to a kangaroo carrying their young. Through contact with their parents' skin, the babies are kept warm and allowed close interaction with their parents. This decreases some of the stressors associated with premature births and helps infants needing neonatal intensive care.
Parents who have experienced kangaroo care have expressed excitement and joy with the practice and many have felt like parents for the first time since their infant's birth. Infants have been observed in a restful sleepstate while in the kangaroo position. As well, kangaroo care has been found to promote parent and infant bonding, breastfeeding, and early discharge for premature infants.
Kangaroo care is offered to stable babies who are less than 1,500 grams and are breathing on their own. Babies needing oxygen or nasal continuous positive airway pressure (CPAP) may also be eligible. Cardiopulmonary monitoring and oximetry may be continued during kangaroo care. The nurse remains nearby to monitor the infant as necessary.
Resources
Books
Rhatigan, Pamela. Soothe Your Baby the Natural Way: Bonding, Calming Rituals, Massage Techniques, Natural Remedies.London: Hamlyn, 2005.
Web Sites
"Bonding Period." Birthing Naturally, October 2003. Available online at www.birthingnaturally.net/barp/bonding.html (accessed December 14, 2004).
Perry, Bruce D. "Bonding and Attachment in Maltreated Children: Consequences of Emotional Neglect in Childhood." Scholastic.Available online at (accessed December 14, 2004).
[Article by: Aliene S. Linwood, RN, DPA, FACHE]
What's the Impact of Abuse and Neglect on the Developing Brain?
The Impact of Abuse and Neglect on the Developing Brain was originally written by Bruce D. Perry, M.D., Ph.D., and John Marcellus, M.D. You can find the article here: Scholastic.
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Each year in the United States alone, there are over three million children that are abused or neglected. These destructive experiences impact the developing child, increasing risk for emotional, behavioral, academic, social and physical problems throughout life. The purpose of this article is to outline how these experiences may result in increased risk by influencing the development and functioning of the child’s brain.
The Brain
The human brain is an amazing and complex organ. It allows us to think, act, feel, laugh, speak, create and love. The brain mediates all of the qualities of humanity, good and bad. Yet the core “mission” of the brain is to sense, perceive, process, store, and act on information from the external and internal environment to promote survival. In order to do this, the human brain has evolved an efficient and logical organization structure.
The brain has a bottom-up organization. The bottom regions (i.e., brainstem and midbrain) control the most simple functions such as respiration, heart rate, and blood pressure regulation while the top areas (i.e., limbic and cortex) control more complex functions such as thinking and regulating emotions.
Brain Development
At birth, the human brain is undeveloped. Not all of the brain’s areas are organized and fully functional. It is during childhood that the brain matures and the whole set of brain-related capabilities develop in a sequential fashion. We crawl before we walk, we babble before we talk.
The development of the brain during infancy and childhood follows the bottom-up structure. The most regulatory, bottom regions of the brain develop first; followed, in sequence, by adjacent but higher, more complex regions.
The process of sequential development of the brain and, of course, the sequential development of function, is guided by experience. The brain develops and modifies itself in response to experience. Neurons and neuronal connections (synapses) change in an activity-dependent fashion. This “use-dependent” development is the key to understanding the impact of neglect and trauma on children.
These areas organize during development and change in the mature brain in a “use-dependent” fashion. The more a certain neural system is activated, the more it will “build-in” this neural state: what occurs in this process is the creation of an “internal representation” of the experience corresponding to the neural activation. This “use-dependent” capacity to make an “internal representation” of the external or internal world is the basis for learning and memory. The simple and unavoidable result of this sequential neurodevelopment is that the organizing, “sensitive” brain of an infant or young child is more malleable to experience than a mature brain. While experience may alter and change the functioning of an adult, experience literally provides the organizing framework for an infant and child.
The brain is most plastic (receptive to environmental input) in early childhood. The consequence of sequential development is that as different regions are organizing, they require specific kinds of experience targeting the region’s specific function (e.g., visual input while the visual system is organizing) in order to develop normally. These times during development are called critical or sensitive periods.
Traumatic Experiences and Development
With optimal experiences, the brain develops healthy, flexible and diverse capabilities. When there is disruption of the timing, intensity, quality or quantity of normal developmental experiences, however, there may be devastating impact on neurodevelopment — and, thereby, function. For millions of abused and neglected children, the nature of their experiences adversely influences the development of their brains. During the traumatic experience, these children’s brains are in a state of fear-related activation. This activation of key neural systems in the brain leads to adaptive changes in emotional, behavioral and cognitive functioning to promote survival. Yet, persisting or chronic activation of this adaptive fear response can result in the maladaptive persistence of a fear state. This activation causes hypervigilance, increased muscle tone, a focus on threat-related cues (typically non-verbal), anxiety, behavioral impulsivity — all of which are adaptive during a threatening event yet become maladaptive when the immediate threat has passed.
This is the dilemma that traumatic abuse brings to the child’s developing brain. The very process of using the proper adaptive neural response during a threat will also be the process that underlies the neural pathology, which causes so much distress and pain through the child’s life. The chronically traumatized child will develop a host of physical signs (e.g., altered cardiovascular regulation) and symptoms (e.g., attentional, sleep and mood problems) which make their lives difficult.
There is hope, however. The brain is very “plastic” — meaning it is capable of changing in response to experiences, especially repetitive and patterned experiences. Furthermore, the brain is most plastic during early childhood. Aggressive early identification and intervention with abused and neglected children has the capacity to modify and influence development in many positive ways.
The elements of successful intervention must be guided by the core principles of brain development. The brain changes in a use-dependent fashion. Therapeutic interventions that restore a sense of safety and control are very important for the acutely traumatized child. In cases of chronic abuse and neglect, however, the very act of intervening can contribute to the child’s catalogue of fearful situation. Investigation, court, removal, placement, re-location, and re-unification all contribute to the unknown, uncontrollable and, often, frightening experiences of the abused child. Our systems, placements and therapeutic activities can diminish the fearful nature of these children’s lives by providing consistency, repetition (familiarity), nurturance, predictability and control (returned to the child). Yet the poorly coordinated, over-burdened and reactive systems mandated to help these children rarely can provide those key elements.
Prevention and Policy
What we are as adults is the product of the world we experienced as children. The way a society functions is a reflection of the childrearing practices of that society. Today, we reap what we have sown. Despite the well-documented critical nature of early life experiences, we dedicate few resources to this time of life. We do not educate our children about development, parenting or about the impact of neglect and trauma on children. As a society we put more value on requiring hours of formal training to drive a car than we do on any formal training in childrearing.
In order to prevent the development of impaired children, we need to dedicate resources of time, energy and money to the complex problems related to child maltreatment. We need to understand the indelible relationship between early life experiences and cognitive, social, emotional, and physical health. Providing enriching cognitive, emotional, social and physical experiences in childhood could transform our culture. But before our society can choose to provide these experiences, it must be educated about what we now know regarding child development. Education of the public must be coupled with the continuing generation of data regarding the impact of both positive and negative experiences on the development of children. All of this must be paired with the implementation and testing of programs dedicated to enrich the lives of children and families and programs to provide early identification of, and proactive intervention for, at-risk children and families.
The problems related to maltreatment of children are complex and they have complex impact on our society. Yet there are solutions to these problems. The choice to find solutions is up to us. If we choose, we have some control of our future. If we, as a society, continue to ignore the laws of biology, and the inevitable neurodevelopmental consequences of our current childrearing practices and policies, our potential as a humane society will remain unrealized. The future will hold sociocultural devolution — the inevitable consequence of the competition for limited resources and the implementation of reactive, one-dimensional and short-term solutions.
Acknowledgments
The clinical and clinical research work related to this paper has been supported, in part, by the CIVITAS Initiative, the Child Protective Services Fund Board of Harris County, Maconda Brown O’Connor and Anonymous X.
About the author
Dr. Bruce D. Perry, M.D., Ph.D., is an internationally recognized authority on brain development and children in crisis. Dr. Perry leads the ChildTrauma Academy, a pioneering center providing service, research and training in the area of child maltreatment (www.ChildTrauma.org). In addition he is the Medical Director for Provincial Programs in Children’s Mental Health for Alberta, Canada. Dr. Perry served as consultant on many high-profile incidents involving traumatized children, including the Columbine High School shootings in Littleton, Colorado; the Oklahoma City Bombing; and the Branch Davidian siege. His clinical research and practice focuses on traumatized children-examining the long-term effects of trauma in children, adolescents and adults. Dr. Perry’s work has been instrumental in describing how traumatic events in childhood change the biology of the brain. The author of more than 200 journal articles, book chapters, and scientific proceedings and is the recipient of a variety of professional awards.