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Mother-infant bonding: Weighing the evidence
DEVELOPMENTAL REVIEW 4, 275-282 (1984)
Mother-Infant Bonding: Weighing the Evidence JOHN H. KENNELL
Division of Child Development, Department of Pediatrics, Case Western Reserve University AND MARSHALL H. KLAUS
Department of Pediatrics~Human Development, Michigan State University Questions have been raised (B. J. Myers, 1984, Developmental Review, 4, 240274) about the methodology and interpretation of some of the studies that have investigated the effects of early and extended postnatal contact on later motherto-infant attachment or bonding. Additional information about the first study that was published in 1972 (M. H. Klaus, R. Jerauld, N. Kreger, W. MeAlpine, M. Steffa, & J. H. Kennell, 1972, New England Journal of Medicine, 286, 460-463) and about the author's current concepts is provided in this report. Other studies that replicate and extend our understanding of the significance of events during the perinatal period are noted. Slight but possibly important alterations in routine practices at different hospitals may account for some of the apparent inconsistencies in outcome across studies. The many complex factors involved in the bonding process cannot be considered in isolation. It seems unlikely that such a life-sustaining relationship would be dependent on a single process. There are many fail-safe routes to attachment.
INTRODUCTION In her paper "Mother-Infant Bonding: The Status of this Critical-Period Hypothesis" Myers (1984) raised questions about the details of methodology and analysis of several studies that investigated the effects of early and extended postnatal contact on later mother-to-infant affectionate attachment or bonding. In this paper we present our current concepts and provide additional details about our original study reported in 1972. We also describe research that replicates some of the findings of that study, as well as other data that may explain apparent inconsistencies in outcome across studies, and that extends our understanding of the significance of events during the perinatal period. Initially our attention was directed to the events around birth and the first hours after birth by our clinical experiences with human mothers, not by animal studies of a sensitive period. We were particularly careful Requests for reprints should be sent to John H. Kennell, Department of Pediatrics, Rainbow Babies and Children's Hospital, 2101 Adelbert Road, Cleveland, OH 44106. 275 0273-2297/84 $3.00 Copyright© 1984by AcademicPress, Inc. All rightsof reproductionin any formreserved.
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to avoid generalizing findings from other species to human relationships, and to assess that studying maternal behavior in animals "is done not to explain human behavior but rather to view human beings within the context of evolutionary development" (Klaus & Kennell, 1982, p. 130). We were intrigued and our curiosity was aroused by a number of specific cases and observations during our tenure managing nurseries for premature infants as well as healthy newborns. Our focus on this short period of time was stimulated in part by the disastrous results observed after premature infants were discharged from intensive care units. Some of these babies returned to the hospital because they had been battered or were failing to thrive without organic disease, and then gained rapidly with routine care. Our early studies of parents with premature infants focused on the effects of the long period of mother-infant separation caused by the initial hospitalization. Our experiences with these studies helped us to realize the difficulty of obtaining clear answers in studies of parenting of prematures because of the wide range of parental backgrounds, health and obstetrical histories, and the complex and varying hospital courses of the infants. These investigations raised many questions about what happened when the pregnancy went to term and stimulated our interest in the effect of separation on healthy mothers and normal full-term infants. The major area of disagreement concerning studies of parent-infant bonding has revolved around whether or not for a small number of mothers there are any lasting effects of early maternal-infant contact on the mother's behavior toward her baby and on their subsequent relationship. We have speculated that there might be a sensitive period of several hours or days after birth during which contact with the baby might enhance a mother's relationship and bond with her baby. We have never suggested that early contact for additional hours or days after birth is the sole determining factor that will produce a certain maternal behavior or change in child development at some point far off in the future, independently of anything that might happen in between. Unfortunately Myers (1984) based much of her discussion on thefirst edition of our book (Klaus & Kennell, 1976) and failed to consider our current concepts and additional data on the subject that are presented in our new Janaury 1982 edition entitled Parent-Infant Bonding. We stress repeatedly in both editions that the many complex factors involved in the bonding process cannot be considered in isolation and that it therefore "seems unlikely that such a life-sustaining relationship would be dependent on a single process" (Klaus & Kennell, 1982, p. 70). We describe how a parent's behavior is affected by cultural and socioeconomic background, genetic endowments, parenting received by his or her own parents, hospital care practices, the nature and health of the
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baby, family relations, experiences with past pregnancies, as .well as the presence or absence of mother-newborn contact in the early days after birth. We do not claim that early contact is magic, but that childbirth is a stressful event and "each parent does not react in a standard or predictable fashion to the multiple environmental influences that occur . . . . This fact is not evidence against a sensitive period but, more likely, represents multiple individual differences of mothers and fathers" (Klaus & Kennell, 1982, p. 56-57). At such a time, hospital care practices and sensitive professional support are easily changed aspects that can contribute to the initiation of new family relationships. In examining studies of early mother-infant contact, it is essential to appreciate the works of a student of the sensitive period, Bateson (1979), who notes, "The extent to which a sensitive period is replicated may frequently depend on the degree to which conditions in which it was first described are copied. Even small changes can cause the evidence to evaporate. These alterations in conditions are worth investigating because they probe the systems" (p. 482). Thus the slight but possibly important alterations in conditions in different hospitals may account for some of the apparent inconsistencies in outcome across studies. These variables include whether both the control and experimental infants are either dressed or undressed, whether the father is present or absent, and the conditions of privacy or no privacy. What is surprising is how similar the changes in maternal behavior are, even from widely varying cultures. This is important to remember when examining two studies (Svejda, Campos, & Emde, 1980; Taylor & Hall, 1979) that appear to refute the sensitive period, but which, in fact, contain a possible major design error. In both studies, mothers in the control group who supposedly experienced no early contact with their newborns, in reality held their babies for 5 min in the first hour after birth. Thus these studies do not test the effect of early contact versus no contact. Could 5 min be long enough to affect the mother's later behavior with her infant? Ideally, of course, in a study testing for a maternal sensitive period, the control group of mothers should not have received a n y contact with their babies. At present there are no definitive studies to either confirm or refute the presence of a sensitive period or to assess the length of time required in the first hours and days after birth to produce an effect. In answer to Myers' questions about the methods used for our patients and researchers in our original 1972 study (Klaus et al., 1972), neither group of mothers knew of this study in advance or to our knowledge was aware of the arrangements made for the other. The women in both groups had agreed to participate in a study of how mothers get started with their newborn infants. We never placed the experimental and control mothers
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together, and we were meticulous about providing equal amounts of nursing time and investigator time with the mothers in both groups. As we indicated in our report, "to eliminate any influence from the enthusiasm or interest of the nurse that might obscure the results, the special (research) nurses who cared for the mothers during the extended-contact period (5 h per day) spent an equal amount of time with the control mothers. After an initial standardized introductory statement they only answered questions, did not instruct any of the women in caretaking unless this was requested, and most of the time were available just outside the room" (Klaus et al., 1972; p. 461). The earliest any experimental mother in that study received her undressed baby (for the 1-h period of contact in privacy under a heat panel) was 61 min. For the majority the delay in contact was between 1 and 2 h. There were no programmed instructions. We let the mother interact with her infant as she wanted. The mothers said they planned to bottle feed so all the mothers were gowned during the early and extended contact and there was no skin-to-skin contact. In this and all our extra contact studies the outcome observers were blind to the group status of the mother being observed. Two reports that replicate and extend earlier studies that were not included in the review by Myers should be noted. First, Ali and Lowry (1981) in a study of 100 patients noted that mother-infant pairs with 45 min of additional early contact shortly after delivery were significantly different from controls in 7 of 14 outcome measures including the number of mothers solely breast feeding, mothers approaching their infants during the stress situation of a physical examination, gazing during feeding, and vocalizing to their child at 12 weeks, and the infants' behavioral state at 6 and 12 weeks. Second, in a recent study by Anisfeld and Lipper (1983) two matched groups of women were randomly assigned to either extra-contact procedures with their newborns (N = 29) or to routine-contact procedures (N = 30) during the first postpartum hour. Two days later an investigator, who did not know which group of mothers had experienced which procedures, observed maternal behavior during an infant feeding. They found that the group of mothers given extra contact at delivery showed more affectionate behavior than the group who had had routine contact with their infants, a replication of the findings of Hales, Lozoff, Sosa, and Kennell (1977). In addition, they found an interaction between early contact and the level of the m o t h e r ' s personal support system. All the mothers in the study were classified as having "higher" or "lower" levels of social support (based on a mother's score on marital status, receiving public assistance, education, and presence of father or other support person in the delivery room). The affectionate-contact scores for the
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extra-contact and routine-contact groups, subclassified by social support. were then compared. This analysis revealed that those women who had a higher level of social support showed the same amount of affectionate behavior, whether or not they received the extra contact. By contrast, women who had a lower level of social support and had the extra contact exhibited the highest level of affectionate behavior, whereas the women who had a lower level of social support and had routine contact exhibited the lowest level of affectionate behavior. The treatment thus had a significant effect on the women with a lower level of social support. This finding suggests that early contact may be particularly important for women who lack social support. It also allows for the reconciliation of the discrepancies found in previous studies, some of which were done with middle-class populations and others with populations more likely to be lacking social support. We agree with Myers that early contact should not be seen as an easy cure-all or as a quick and inexpensive solution to the problems of poverty and parenting failure. However, it is necessary to evaluate or determine whether additional contact in the first days of life significantly alters parenting disorders as suggested by the study of O'Connor, Vietze, Sherrod, Sandler, and Altemeier (1980). In a study of 277 mothers observed for at least one year, O'Connor noted that women who received 12 extra hours of time with their infants in the first two days of life had a significantly decreased incidence of parenting disorders, including child abuse and neglect. Siegel, Bauman, Schaefer; Saunders, and Ingram (1980) and Siegel (1982) did n o t find a significant difference in parenting disorders, but did observe significant differences in maternal attachment behaviors at 4 months and infant behaviors at 12 months, controlling for socioenvironmental variables. I n fact, O'Connor et al. found statistically significant differences for serious parenting inadequacy, i.e., physical abuse, nonorganic failure to thrive, and surrender of infant as disclosed by in-depth review and abstraction of the infants' medical records. Siegel et al. (1980) lacked access to medical records and depended upon reports of child abuse and neglect made to the county and state departments of social service. More importantly, O'Connor et al. (1980), with a larger sample, were able to generate greater power in their statistical analyses of parenting inadequacy. Because of the relatively small number of patients studied, the negative finding by Siegel et al. (1980) does not answer the important question of whether extended contact for all mothers in the United States would prevent child abuse in some of the 100,000 infants presently abused each year. A study with about 1500 patients would be needed to detect a reduction in child abuse from 3 to 1.5 %, eighty percent of the time. Thus although the majority of studies of additional early and extended contact
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do show changes in maternal and paternal behavior in the first days of weeks of life, the question remains concerning the clinical significance of the long-term effects. Multiple factors are obviously involved in the genesis of child abuse but from the work of O'Connor et al. (1980) it is just possible that early and extended contact might swing the balance in a way that will benefit a small b u t significant number of families. We strongly agree with Myers that extended contact should be just one of many care practices offered to support high-risk parents. In the 1972 report of our first study and in our recent books we emphasized that the results were not consistent with imprinting or a critical period. We said our data suggest that this may be a special attachment period for an adult w o m a n - - special in the sense that what happens during this time may alter the later behavior of the adult toward a young infant for at least as long as 1 month after delivery. It would be useful to have a special term for this period, such as "maternal sensitive period." Our thoughts run parallel to those of Myers (1984) who states that sensitive or optimal periods are less rigid than critical periods and "that there are times when an environmental factor will most easily produce an effect, but that the developing system retains plasticity" (p. 240). She adds that "these terms imply that with more effort or with appropriate intervention, the boundaries of the 'critical period' [her term] can be stretched further, or that deleterious effects can be undone" (p. 240). Donald Winnicott, an English pediatrician who became a distinguished psychoanalyst, made fascinating observations that suggest he was describing the sensitive period. From detailed and perceptive observations of his analytic patients he proposed that a healthy mother goes through a period of "Primary Maternal Preoccupation." It is my thesis that in the earliest phase we are dealing with a very special state of the mother, a psychological condition which deserves a name, such as Primary Maternal Preoccupation. I suggest that sufficient tribute has not yet been paid in our literature, or perhaps anywhere, to a special psychiatric condition of the mother, of which I would say the following things: It gradually develops and becomes a state of heightened sensitivity during, and especially toward the end of, the pregnancy. It lasts for a few weeks after the birth of the child. It is not easily remembered by mothers once they have recovered from it. I would go further and say that the memory mothers have of this state tends to become repressed. I do not believe that it is possible to understand the functioning of the mother at the very beginning of the infant's life without seeing that she must be able to reach this state of heightened sensitivity, almost an illness, and to recover from it. (I bring in the word "illness" because a woman must be healthy in order both to develop this state and to recover from it as the infant releases her. If the infant should die, the mother's state suddenly shows up as illness. The mother takes this risk.) The mother who develops this s t a t e . . , provides a setting for the infant's con-
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stitution to begin to make itself evident, for the developmental tendencies to start to unfold, and for the infant to experience spontaneous movement and become the owner of the sensations that are appropriate to this early phase of life. Only if a mother is sensitized in the way I am describing can she feel herself into her infant's place, and so meet the infant's needs. (Winnicott, 1958) It is interesting that the timing and course of Primary Maternal Preoccupation are similar to those described f o r the maternal sensitive period. It should be e m p h a s i z e d the first feelings of love for the infant are not necessarily instantaneous with the initial contact. The relation b e t w e e n the time w h e n a m o t h e r falls in love with her b a b y and a possible sensitive period is not clear. H o w e v e r , two English studies are helpful. MacFarlane and associates (1975) a s k e d 97 Oxford m o t h e r s , " W h e n did you first feel love for y o u r b a b y ? " The replies w e r e as follows: during pregnancy, 41%; at birth, 24%; first w e e k , 27%; and after the first w e e k , 8%. In a study o f two groups of primiparous m o t h e r s (Robson & K u m a r , 1980) ( N = 112 and N = 41), 40% recalled that their p r e d o m i n a n t emotional reaction w h e n holding their babies for the first time was one of indifference. T h e s a m e r e s p o n s e was r e p o r t e d by 25% of 40 multiparous mothers. F o r t y p e r c e n t of both groups felt immediate affection. M o s t of the m o t h e r s in b o t h groups had d e v e l o p e d affection for their babies within the first week. S o m e misinterpretations of studies of parent-to-infant att a c h m e n t m a y h a v e resulted f r o m a too literal a c c e p t a n c e of the word bonding and so h a v e suggested that the speed o f this reaction resembles that of e p o x y materials. We have also b e e n c o n c e r n e d a b o u t feelings of guilt, failure, and being cheated on the part of high-risk m o t h e r s , and our hope has b e e n to reduce s o m e o f t h e s e feelings b y c h a n g i n g the c l i m a t e o f the i n t e n s i v e c a r e nursery. Our current c o n c e p t s on early as well as extended contact are a m a t t e r of record (Klaus & Kennell, 1982): " O b v i o u s l y , in spite of a lack of early contact e x p e r i e n c e d b y m o t h e r s in hospital births in the past 20 to 30 years, almost all these parents b e c a m e bonded to their babies. The h u m a n is highly adaptable, and there are m a n y fail-safe routes to a t t a c h m e n t . Sadly, s o m e p a r e n t s w h o m i s s e d the b o n d i n g e x p e r i e n c e have felt that all was lost for their future relationship. This was (and is) c o m p l e t e l y incorrect (p. 55).
REFERENCES All, Z., & Lowry, M. (1981). Early maternal-child contact: Effects on later behaviour. Developmental Medicine and Child Neurology, 23, 337. Anisfeld, E., & Lipper, E. (1983). Early contact, social support, and mother-infant bonding. Pediatrics, 72, 79-83. Bateson, P. (1979). How do sensitive periods arise and what are they for? Animal Behavior, 27, 470-486.
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Hales, D. J., Lozoff, B., So sa, R., & Kennell, J. (1977). Defining the.limits of the maternal sensitive period. Developmental Medicine and Child Neurology, 19(4), 454-461. Klaus, M. H., Jerauld, R., Kreger, N., McAlpine, W., Steffa, M., & Kennell, J. H. (1972). Maternal attachment: Importance of the first postpartum days. New England Journal of Medicine, 286, 460-463. Klaus, M. H., & Kennell, J. H. (1976).. Maternal-infant bonding, St. Louis, MO: Mosby. Klaus, M. H., & Kennell, J. H. (1982). Parent-infant bonding, St. Louis, MO: Mosby. MacFarlane, J. A. (1975). Olfaction in the development of social preferences in the human neonate. In Parent-infant interaction, Ciba Foundation Symposium 33 (new series, pp. 103-113). Amsterdam: Elsevier. Myers, B. J. (1984). Mother-infant bonding: The status of this critical-period hypothesis. Developmental Review, 4, 240-274. O'Connor, S., Vietze, P. M., Sherrod, K. B., Sandier, H. M., & Attemeier, W. A. (1980). Reduced incidence of parenting inadequacy following rooming-in. Pediatrics~ 66, 176. Robson, K., & Kumar, R. (1980). Delayed onset of maternal affection after childbirth. British Journal of Psychiatry, 136, 347-353. Siegel, E., Bauman, K. E., Schaefer, E. S., Saunders, N. M., & Ingram, D. D. (1980). Hospital and home support during infancy: Impact on maternal attachment, child abuse and neglect, and health care utilization. Pediatrics, 66, 183. Siegel, E. (1982). Early and extended maternal-infant contact: A critical review. American Journal of Diseases of Childhood, 136, 251-257. Svejda, M. J., Campos, J. J., & Emde, R. N. (1980). Mother-infant bonding: Failure to generalize. Child Development, 51, 775. Taylor, P. M., & Hall, B. L. (1979). Parent-infant bonding: Problems and opportunities in a perinatal center. Seminars in Perinatology, 3, 73. Winnicott, D. W. (1958). Primary maternal preoccupation. In Collected papers: Through paediatrics to psycho-analysis, New York: Basic Books. RECEIVED: December 23, 1983; REVISED:January 20, 1984.
Mother-Infant Bonding: Weighing the Evidence JOHN H. KENNELL
Division of Child Development, Department of Pediatrics, Case Western Reserve University AND MARSHALL H. KLAUS
Department of Pediatrics~Human Development, Michigan State University Questions have been raised (B. J. Myers, 1984, Developmental Review, 4, 240274) about the methodology and interpretation of some of the studies that have investigated the effects of early and extended postnatal contact on later motherto-infant attachment or bonding. Additional information about the first study that was published in 1972 (M. H. Klaus, R. Jerauld, N. Kreger, W. MeAlpine, M. Steffa, & J. H. Kennell, 1972, New England Journal of Medicine, 286, 460-463) and about the author's current concepts is provided in this report. Other studies that replicate and extend our understanding of the significance of events during the perinatal period are noted. Slight but possibly important alterations in routine practices at different hospitals may account for some of the apparent inconsistencies in outcome across studies. The many complex factors involved in the bonding process cannot be considered in isolation. It seems unlikely that such a life-sustaining relationship would be dependent on a single process. There are many fail-safe routes to attachment.
INTRODUCTION In her paper "Mother-Infant Bonding: The Status of this Critical-Period Hypothesis" Myers (1984) raised questions about the details of methodology and analysis of several studies that investigated the effects of early and extended postnatal contact on later mother-to-infant affectionate attachment or bonding. In this paper we present our current concepts and provide additional details about our original study reported in 1972. We also describe research that replicates some of the findings of that study, as well as other data that may explain apparent inconsistencies in outcome across studies, and that extends our understanding of the significance of events during the perinatal period. Initially our attention was directed to the events around birth and the first hours after birth by our clinical experiences with human mothers, not by animal studies of a sensitive period. We were particularly careful Requests for reprints should be sent to John H. Kennell, Department of Pediatrics, Rainbow Babies and Children's Hospital, 2101 Adelbert Road, Cleveland, OH 44106. 275 0273-2297/84 $3.00 Copyright© 1984by AcademicPress, Inc. All rightsof reproductionin any formreserved.
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to avoid generalizing findings from other species to human relationships, and to assess that studying maternal behavior in animals "is done not to explain human behavior but rather to view human beings within the context of evolutionary development" (Klaus & Kennell, 1982, p. 130). We were intrigued and our curiosity was aroused by a number of specific cases and observations during our tenure managing nurseries for premature infants as well as healthy newborns. Our focus on this short period of time was stimulated in part by the disastrous results observed after premature infants were discharged from intensive care units. Some of these babies returned to the hospital because they had been battered or were failing to thrive without organic disease, and then gained rapidly with routine care. Our early studies of parents with premature infants focused on the effects of the long period of mother-infant separation caused by the initial hospitalization. Our experiences with these studies helped us to realize the difficulty of obtaining clear answers in studies of parenting of prematures because of the wide range of parental backgrounds, health and obstetrical histories, and the complex and varying hospital courses of the infants. These investigations raised many questions about what happened when the pregnancy went to term and stimulated our interest in the effect of separation on healthy mothers and normal full-term infants. The major area of disagreement concerning studies of parent-infant bonding has revolved around whether or not for a small number of mothers there are any lasting effects of early maternal-infant contact on the mother's behavior toward her baby and on their subsequent relationship. We have speculated that there might be a sensitive period of several hours or days after birth during which contact with the baby might enhance a mother's relationship and bond with her baby. We have never suggested that early contact for additional hours or days after birth is the sole determining factor that will produce a certain maternal behavior or change in child development at some point far off in the future, independently of anything that might happen in between. Unfortunately Myers (1984) based much of her discussion on thefirst edition of our book (Klaus & Kennell, 1976) and failed to consider our current concepts and additional data on the subject that are presented in our new Janaury 1982 edition entitled Parent-Infant Bonding. We stress repeatedly in both editions that the many complex factors involved in the bonding process cannot be considered in isolation and that it therefore "seems unlikely that such a life-sustaining relationship would be dependent on a single process" (Klaus & Kennell, 1982, p. 70). We describe how a parent's behavior is affected by cultural and socioeconomic background, genetic endowments, parenting received by his or her own parents, hospital care practices, the nature and health of the
E V I D E N C E ON BONDING
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baby, family relations, experiences with past pregnancies, as .well as the presence or absence of mother-newborn contact in the early days after birth. We do not claim that early contact is magic, but that childbirth is a stressful event and "each parent does not react in a standard or predictable fashion to the multiple environmental influences that occur . . . . This fact is not evidence against a sensitive period but, more likely, represents multiple individual differences of mothers and fathers" (Klaus & Kennell, 1982, p. 56-57). At such a time, hospital care practices and sensitive professional support are easily changed aspects that can contribute to the initiation of new family relationships. In examining studies of early mother-infant contact, it is essential to appreciate the works of a student of the sensitive period, Bateson (1979), who notes, "The extent to which a sensitive period is replicated may frequently depend on the degree to which conditions in which it was first described are copied. Even small changes can cause the evidence to evaporate. These alterations in conditions are worth investigating because they probe the systems" (p. 482). Thus the slight but possibly important alterations in conditions in different hospitals may account for some of the apparent inconsistencies in outcome across studies. These variables include whether both the control and experimental infants are either dressed or undressed, whether the father is present or absent, and the conditions of privacy or no privacy. What is surprising is how similar the changes in maternal behavior are, even from widely varying cultures. This is important to remember when examining two studies (Svejda, Campos, & Emde, 1980; Taylor & Hall, 1979) that appear to refute the sensitive period, but which, in fact, contain a possible major design error. In both studies, mothers in the control group who supposedly experienced no early contact with their newborns, in reality held their babies for 5 min in the first hour after birth. Thus these studies do not test the effect of early contact versus no contact. Could 5 min be long enough to affect the mother's later behavior with her infant? Ideally, of course, in a study testing for a maternal sensitive period, the control group of mothers should not have received a n y contact with their babies. At present there are no definitive studies to either confirm or refute the presence of a sensitive period or to assess the length of time required in the first hours and days after birth to produce an effect. In answer to Myers' questions about the methods used for our patients and researchers in our original 1972 study (Klaus et al., 1972), neither group of mothers knew of this study in advance or to our knowledge was aware of the arrangements made for the other. The women in both groups had agreed to participate in a study of how mothers get started with their newborn infants. We never placed the experimental and control mothers
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together, and we were meticulous about providing equal amounts of nursing time and investigator time with the mothers in both groups. As we indicated in our report, "to eliminate any influence from the enthusiasm or interest of the nurse that might obscure the results, the special (research) nurses who cared for the mothers during the extended-contact period (5 h per day) spent an equal amount of time with the control mothers. After an initial standardized introductory statement they only answered questions, did not instruct any of the women in caretaking unless this was requested, and most of the time were available just outside the room" (Klaus et al., 1972; p. 461). The earliest any experimental mother in that study received her undressed baby (for the 1-h period of contact in privacy under a heat panel) was 61 min. For the majority the delay in contact was between 1 and 2 h. There were no programmed instructions. We let the mother interact with her infant as she wanted. The mothers said they planned to bottle feed so all the mothers were gowned during the early and extended contact and there was no skin-to-skin contact. In this and all our extra contact studies the outcome observers were blind to the group status of the mother being observed. Two reports that replicate and extend earlier studies that were not included in the review by Myers should be noted. First, Ali and Lowry (1981) in a study of 100 patients noted that mother-infant pairs with 45 min of additional early contact shortly after delivery were significantly different from controls in 7 of 14 outcome measures including the number of mothers solely breast feeding, mothers approaching their infants during the stress situation of a physical examination, gazing during feeding, and vocalizing to their child at 12 weeks, and the infants' behavioral state at 6 and 12 weeks. Second, in a recent study by Anisfeld and Lipper (1983) two matched groups of women were randomly assigned to either extra-contact procedures with their newborns (N = 29) or to routine-contact procedures (N = 30) during the first postpartum hour. Two days later an investigator, who did not know which group of mothers had experienced which procedures, observed maternal behavior during an infant feeding. They found that the group of mothers given extra contact at delivery showed more affectionate behavior than the group who had had routine contact with their infants, a replication of the findings of Hales, Lozoff, Sosa, and Kennell (1977). In addition, they found an interaction between early contact and the level of the m o t h e r ' s personal support system. All the mothers in the study were classified as having "higher" or "lower" levels of social support (based on a mother's score on marital status, receiving public assistance, education, and presence of father or other support person in the delivery room). The affectionate-contact scores for the
EVIDENCE ON BONDING
279
extra-contact and routine-contact groups, subclassified by social support. were then compared. This analysis revealed that those women who had a higher level of social support showed the same amount of affectionate behavior, whether or not they received the extra contact. By contrast, women who had a lower level of social support and had the extra contact exhibited the highest level of affectionate behavior, whereas the women who had a lower level of social support and had routine contact exhibited the lowest level of affectionate behavior. The treatment thus had a significant effect on the women with a lower level of social support. This finding suggests that early contact may be particularly important for women who lack social support. It also allows for the reconciliation of the discrepancies found in previous studies, some of which were done with middle-class populations and others with populations more likely to be lacking social support. We agree with Myers that early contact should not be seen as an easy cure-all or as a quick and inexpensive solution to the problems of poverty and parenting failure. However, it is necessary to evaluate or determine whether additional contact in the first days of life significantly alters parenting disorders as suggested by the study of O'Connor, Vietze, Sherrod, Sandler, and Altemeier (1980). In a study of 277 mothers observed for at least one year, O'Connor noted that women who received 12 extra hours of time with their infants in the first two days of life had a significantly decreased incidence of parenting disorders, including child abuse and neglect. Siegel, Bauman, Schaefer; Saunders, and Ingram (1980) and Siegel (1982) did n o t find a significant difference in parenting disorders, but did observe significant differences in maternal attachment behaviors at 4 months and infant behaviors at 12 months, controlling for socioenvironmental variables. I n fact, O'Connor et al. found statistically significant differences for serious parenting inadequacy, i.e., physical abuse, nonorganic failure to thrive, and surrender of infant as disclosed by in-depth review and abstraction of the infants' medical records. Siegel et al. (1980) lacked access to medical records and depended upon reports of child abuse and neglect made to the county and state departments of social service. More importantly, O'Connor et al. (1980), with a larger sample, were able to generate greater power in their statistical analyses of parenting inadequacy. Because of the relatively small number of patients studied, the negative finding by Siegel et al. (1980) does not answer the important question of whether extended contact for all mothers in the United States would prevent child abuse in some of the 100,000 infants presently abused each year. A study with about 1500 patients would be needed to detect a reduction in child abuse from 3 to 1.5 %, eighty percent of the time. Thus although the majority of studies of additional early and extended contact
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do show changes in maternal and paternal behavior in the first days of weeks of life, the question remains concerning the clinical significance of the long-term effects. Multiple factors are obviously involved in the genesis of child abuse but from the work of O'Connor et al. (1980) it is just possible that early and extended contact might swing the balance in a way that will benefit a small b u t significant number of families. We strongly agree with Myers that extended contact should be just one of many care practices offered to support high-risk parents. In the 1972 report of our first study and in our recent books we emphasized that the results were not consistent with imprinting or a critical period. We said our data suggest that this may be a special attachment period for an adult w o m a n - - special in the sense that what happens during this time may alter the later behavior of the adult toward a young infant for at least as long as 1 month after delivery. It would be useful to have a special term for this period, such as "maternal sensitive period." Our thoughts run parallel to those of Myers (1984) who states that sensitive or optimal periods are less rigid than critical periods and "that there are times when an environmental factor will most easily produce an effect, but that the developing system retains plasticity" (p. 240). She adds that "these terms imply that with more effort or with appropriate intervention, the boundaries of the 'critical period' [her term] can be stretched further, or that deleterious effects can be undone" (p. 240). Donald Winnicott, an English pediatrician who became a distinguished psychoanalyst, made fascinating observations that suggest he was describing the sensitive period. From detailed and perceptive observations of his analytic patients he proposed that a healthy mother goes through a period of "Primary Maternal Preoccupation." It is my thesis that in the earliest phase we are dealing with a very special state of the mother, a psychological condition which deserves a name, such as Primary Maternal Preoccupation. I suggest that sufficient tribute has not yet been paid in our literature, or perhaps anywhere, to a special psychiatric condition of the mother, of which I would say the following things: It gradually develops and becomes a state of heightened sensitivity during, and especially toward the end of, the pregnancy. It lasts for a few weeks after the birth of the child. It is not easily remembered by mothers once they have recovered from it. I would go further and say that the memory mothers have of this state tends to become repressed. I do not believe that it is possible to understand the functioning of the mother at the very beginning of the infant's life without seeing that she must be able to reach this state of heightened sensitivity, almost an illness, and to recover from it. (I bring in the word "illness" because a woman must be healthy in order both to develop this state and to recover from it as the infant releases her. If the infant should die, the mother's state suddenly shows up as illness. The mother takes this risk.) The mother who develops this s t a t e . . , provides a setting for the infant's con-
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stitution to begin to make itself evident, for the developmental tendencies to start to unfold, and for the infant to experience spontaneous movement and become the owner of the sensations that are appropriate to this early phase of life. Only if a mother is sensitized in the way I am describing can she feel herself into her infant's place, and so meet the infant's needs. (Winnicott, 1958) It is interesting that the timing and course of Primary Maternal Preoccupation are similar to those described f o r the maternal sensitive period. It should be e m p h a s i z e d the first feelings of love for the infant are not necessarily instantaneous with the initial contact. The relation b e t w e e n the time w h e n a m o t h e r falls in love with her b a b y and a possible sensitive period is not clear. H o w e v e r , two English studies are helpful. MacFarlane and associates (1975) a s k e d 97 Oxford m o t h e r s , " W h e n did you first feel love for y o u r b a b y ? " The replies w e r e as follows: during pregnancy, 41%; at birth, 24%; first w e e k , 27%; and after the first w e e k , 8%. In a study o f two groups of primiparous m o t h e r s (Robson & K u m a r , 1980) ( N = 112 and N = 41), 40% recalled that their p r e d o m i n a n t emotional reaction w h e n holding their babies for the first time was one of indifference. T h e s a m e r e s p o n s e was r e p o r t e d by 25% of 40 multiparous mothers. F o r t y p e r c e n t of both groups felt immediate affection. M o s t of the m o t h e r s in b o t h groups had d e v e l o p e d affection for their babies within the first week. S o m e misinterpretations of studies of parent-to-infant att a c h m e n t m a y h a v e resulted f r o m a too literal a c c e p t a n c e of the word bonding and so h a v e suggested that the speed o f this reaction resembles that of e p o x y materials. We have also b e e n c o n c e r n e d a b o u t feelings of guilt, failure, and being cheated on the part of high-risk m o t h e r s , and our hope has b e e n to reduce s o m e o f t h e s e feelings b y c h a n g i n g the c l i m a t e o f the i n t e n s i v e c a r e nursery. Our current c o n c e p t s on early as well as extended contact are a m a t t e r of record (Klaus & Kennell, 1982): " O b v i o u s l y , in spite of a lack of early contact e x p e r i e n c e d b y m o t h e r s in hospital births in the past 20 to 30 years, almost all these parents b e c a m e bonded to their babies. The h u m a n is highly adaptable, and there are m a n y fail-safe routes to a t t a c h m e n t . Sadly, s o m e p a r e n t s w h o m i s s e d the b o n d i n g e x p e r i e n c e have felt that all was lost for their future relationship. This was (and is) c o m p l e t e l y incorrect (p. 55).
REFERENCES All, Z., & Lowry, M. (1981). Early maternal-child contact: Effects on later behaviour. Developmental Medicine and Child Neurology, 23, 337. Anisfeld, E., & Lipper, E. (1983). Early contact, social support, and mother-infant bonding. Pediatrics, 72, 79-83. Bateson, P. (1979). How do sensitive periods arise and what are they for? Animal Behavior, 27, 470-486.
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Hales, D. J., Lozoff, B., So sa, R., & Kennell, J. (1977). Defining the.limits of the maternal sensitive period. Developmental Medicine and Child Neurology, 19(4), 454-461. Klaus, M. H., Jerauld, R., Kreger, N., McAlpine, W., Steffa, M., & Kennell, J. H. (1972). Maternal attachment: Importance of the first postpartum days. New England Journal of Medicine, 286, 460-463. Klaus, M. H., & Kennell, J. H. (1976).. Maternal-infant bonding, St. Louis, MO: Mosby. Klaus, M. H., & Kennell, J. H. (1982). Parent-infant bonding, St. Louis, MO: Mosby. MacFarlane, J. A. (1975). Olfaction in the development of social preferences in the human neonate. In Parent-infant interaction, Ciba Foundation Symposium 33 (new series, pp. 103-113). Amsterdam: Elsevier. Myers, B. J. (1984). Mother-infant bonding: The status of this critical-period hypothesis. Developmental Review, 4, 240-274. O'Connor, S., Vietze, P. M., Sherrod, K. B., Sandier, H. M., & Attemeier, W. A. (1980). Reduced incidence of parenting inadequacy following rooming-in. Pediatrics~ 66, 176. Robson, K., & Kumar, R. (1980). Delayed onset of maternal affection after childbirth. British Journal of Psychiatry, 136, 347-353. Siegel, E., Bauman, K. E., Schaefer, E. S., Saunders, N. M., & Ingram, D. D. (1980). Hospital and home support during infancy: Impact on maternal attachment, child abuse and neglect, and health care utilization. Pediatrics, 66, 183. Siegel, E. (1982). Early and extended maternal-infant contact: A critical review. American Journal of Diseases of Childhood, 136, 251-257. Svejda, M. J., Campos, J. J., & Emde, R. N. (1980). Mother-infant bonding: Failure to generalize. Child Development, 51, 775. Taylor, P. M., & Hall, B. L. (1979). Parent-infant bonding: Problems and opportunities in a perinatal center. Seminars in Perinatology, 3, 73. Winnicott, D. W. (1958). Primary maternal preoccupation. In Collected papers: Through paediatrics to psycho-analysis, New York: Basic Books. RECEIVED: December 23, 1983; REVISED:January 20, 1984.