Principles and practice A Tool to Facilitate MotherInfant Attachment SANDRA LsFEBVE REISER, RN, MSN Positive mother-infant attachment does not always occur naturally. Many mothers and infants need help in aa)usting to each other. A n objective assessment tool, which can facilitate positive earl,, mother-infant bonding, is described. The tool can provide a precise report on the mother-tnfant dyad and the nurse can intervene in areas ofthe relationship where help 1s needed.
C o n n i e , a single, 17-year-old Spanish girl, is afraid to leave the hospital with her newborn, Julia. The one-week-old infant is all Connie has; therefore, she wants everything to be just right. She dresses Julia in frilly pink dresses and checks her diaper everytime she moves. Having had an unhappy childhood, Connie wants desperately to be a good mother. Whenever Julia whimpers, her mother leans over the bassinet to put a bottle in her mouth. Julia sucks on the bottle for a minute only and then pushes it out and cries louder. Connie continues to jiggle t h e b o t t l e a r o u n d in h e r baby’s mouth, determined to meet hcr needs. Frustration mounts in both mother and child. Julia refuses to be fed and begins to scream. Connie frantically picks up the infant and tries to bounce her on her knee. Julia turns red with rage. H e r young, overwhelmed mother puts her down and walks away sobbing, “My baby doesn’t love me.” This painful scenario is a common one: two people who need each other, who reach out to each other, become frustrated and angry from not being able to understand the other’s needs. The first few postpartum days are crucial in setting the groundwork for mother-infant attachment. If a strong bond is to be formed then it must be built on positive interactions within the first few weeks.
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What can nurses do to facilitate b e t t e r c o m m u n i c a t i o n between mother and infant? Where do we begin? How can we describe to others exactly what is amiss? Is all of Connie’s mothering unsuccessful or is she effective in some areas? Does Connie cause Julia’s agitated behavior or is it just that Julia is a high-strung infant? What goes into attachment between mother and baby? These are all questions that must be considered in facilitating a positive relationship between mother and infant. What is needed is a tool to provide an objective assessment, to help analyze the mother-infant dyad. In reviewing the literature, there seemed to be a scarcity of comprehensive tools. Some tools covered special areas of expertise, but none covered all areas. For example, Brazelton studied the cycle of motherinfant interactions,’ a n d Bowlby studied separation and attachment between caretaker and baby.’,’ Each was helpful but neither provided a comprehensive approach for assessment. It was necessary to pool all the available information and devise a tool that would take into account all the interactions that are crucial to a positive mother-infant relationship.
Tool Development First, it was necessary to isolate the areas that the leading authorities considered most crucial in facilitating attachment. Four distinct cate-
gories were obtained. 1 ) T o u c h i n g : R u b i n states, “Touching is important in the interactions between mother and baby because an infant’s tactile sense is most highly developed and conveys t h e most i n f o r m a t i o n between mother and baby.”’ 2) Eye-to-Eye Contact: According to Kennel1 and Klaus, “eye-to-eye contact is crucial because it provides a powerful network for communication between mother and baby.”’ 3) Auditory: Stern emphasized the talking that goes on between mother and baby during play. “Oohs and aahs” were found to be the highest point of pleasure felt by both mother and infant.” 4) Feeding: Feeding is central to the mother-infant relationship because all their interactions together revolve around this activity.’ These four aspects of the motherchild relationship provided a foundation on which an evaluative instrument was built. However, it soon became evident that it was not enough to concentrate only on the mother’s behaviors; the infant’s reaction was equally important. How did the baby react to being held? T o being talked to? Did the infant establish eye-to-eye contact? Infants have an impact on the mother and, therefore, affect the type of mothering they receive.’ Thus, the evaluative tool is arranged in such a way that there is an area
for behavior initiated by the mother and an area for the infant’s response. These areas are differentiated from each other by color. There were then four areas to evaluate plus a separate section for both mother and infant. The tool also allows for gradations of mother-infant behavior. Examples of different types of possible behaviors are incorporated into the tool. There are four distinct columns of behavior labeled A-B-C-D. The very attentive mother and responsive infant would be under A, and at the other extreme, the nonattentive mother and unresponsive infant would be under D. Now, on one sheet, all the facets of the mother-infant relationship can be seen: the four areas that are crucial to the mother-infant interactions, a section for both mother and infant on the same inventory, and a scaling system for the gradations in mother-infant behaviors. This assessment device is called the Mother-Infant Screening Tool (MIST). (See Appendix.)
Using MIST The MIST is simple to use. The nurse can administer it while the mother is feeding her infant. This activity usually demonstrates a wide range of interaction between the mother and infant. As the nurse observes different behaviors and responses, she checks off the one that most closely approximates what is seen, starting under Tactile and going down. An example of this can be demonstrated with Connie a n d J u l i a : Tactile Connie holds the infant away from her body and uses the distal portion of her fingers. She is fearful of touching what she considers sensitive areas on the baby’s body, thus avoiding the head and umbilical cord and being very tentative in her approach. Julia responds to being held by crying and stiffening up. In the tactile area Connie gets two checks under column C and Julia gets two checks under column D. Visual Both Connie and Julia establish eye contact; therefore, they both get a check in column A . Connie embelishes these moments by smiling. She July/August 198 I JOCN Nursing
gets a check in column B. Julia looks unhappy, she gets a check in column
D. Auditory Connie and Julia get one check in each box in column D. Connie does not talk to Julia nor does Julia make any sounds. Connie does not know that babies utter different cries to indicate their varying needs but Julia seldom seems to vary her cries. Feeding Connie seems very unsure about feeding Julia, who is very restless during this time. Both get a check in column C. When the feeding is completed both Connie and Julia look agitated, hence they get a check in column D. Adding up the checks, Connie and Julia’s i n t e r a c t i o n s a r e predominantly in the C and D columns (Figure 1). Their behaviors seems to trigger a negative response to each other, not allowing positive interactions to occur. In observing Connie and Julia’s interactions one cannot be sure if Julia’s irritability causes Connie to be unsure of herself, if Connie’s insecurity causes Julia to be irritable, or if one has nothing to do with the other. But intervention is necessary to break the negative cycle and to help mother and infant toward a more positive relationship. Guidelines for Intervention O n the basis of the A-B-C-D categories, B describes a middle range of m o t h e r - i n f a n t i n t e r a c t i o n s . (These criteria need further testing.) Therefore, behaviors that fall below a B will need further screening and perhaps interventions. A mother or infant with 2 or more checks in C or D warrants re-evaluation. A mother or infant with 4 or more checks in C or D warrants reevaluation and nursing intervention. Re-evaluation and possible intervention is warranted if there is an inconsistency, either in the mother’s or in the infant’s results. For example, if the mother holds and feeds the infant tentatively but does not talk or look at the infant then re-screening is necessary. Nursing intervention is necessary if there is more than a 3point difference between mother’s score or infant’s score in any area A-
Mother Infant
ISCDl 1
1
1
0
’
4
3
1
6
Figure 1. Summary of MIST results for sample mother and infant.
B-C-D. For example, Connie’s total in C was 4 and Julia’s was 1. Taking the guidelines for intervention into account, Connie and Julia were visited in a week for reevaluation. T h e M I S T did not change significantly, therefore, intervention was begun. The nurse began intervention with weekly home visits which included counseling, teaching, and transporting Connie to a group for teenage mothers in the community. The MIST helped determine the strengths a n d weaknesses in Connie and Julia’s relationship and also gave a precise picture of any growth or decline in their interactions, which provided guidelines for re-evaluating the nursing care plan. Results Some of the mother-infant problems were mechanical and merely needed very specific instructions to the mother; others were emotional and required many weeks of counseling. After many weeks of being counseled, taught, and attending c o m m u n i t y groups, Connie a n d Julia interacted in a more positive manner. Connie grew more confident and Julia began to relax. Connie was able to hold Julia more often and found new ways to satisfy her between feedings. Julia started to smile and coo and Connie smiled and babbled back. Not only were these changes felt emotionally but there were documented objectively on the MIST. The experience with Connie was repeated over and over with other mothers that were visited. Again and again, the objective view that the MIST gave was tremendously helpful in working with new mothers. The benefits of the MIST are that it 1) provides a total picture of the interactions that occur between a mother-infant dyad, 2) enables the nurse to identify strengths and weaknesses within a mother-infant rela295
tionship, 3) enables t h e nurse to identify mother-infant dyads in a high-risk area, 4) provides criteria for updating the nursing care plan, a n d 5) provides objective criteria for assessing the growth or decline of a mother-infant relationship.
Summary Although the MIST is helpful, i t is still in its embryonic stage of development. It will need to be refined f u r t h e r by practitioners a n d researchers to see if i t is relevant to them a n d to different cultures a n d socioeconomic groups. Research must be d o n e to see i f e a c h researcher finds the same results a n d if the items are significant, or if the different gradations are just arbitrary. These are important questions to be asked. W e must begin to look at
tools for evaluating mother-infant interactions because, until we have a tool, significant mother-infant intervention cannot begin.
References
7. Brody S: Patterns of Mothering. International Universities Press Inc, 1956, p 123 8. Clark A, Affonso D: Infant behavior maternal attachment: Two sides to the coin. Matern Child Nurs J 1:94, March/April 1976
1. Brazelton T B : Neo-natal Behavior
Assessment Scale. Philadelphia, JB Lippincott, 1973 2. Bowlby J: Attachment. New York, Address for correspondence: Sandra LeBasic Books, Inc, 1969 Febve Reiser, RN, 19 Ferncliff Road 3. Bowlby J: Child Care the Growth of Scarsdale, NY 10583. Love. 2nd edition. London, Penguin Books, 1965 4. Ruhin R : Maternal Touch. Nurs Outlook, Nov 1963, p 828 Sandra Keiser received her diploma in nursing 5. Klaus M, Kennell J: Maternal-Infant Bonding. St. Louis, CV Mosby, 1976, jkom St. Elizabeth HoJpital School of Nursing, Chicago, and her B S N and MSN from LehP 77 6. Stern D: Infant Mother at Play. Ma- man College of the City IJniuersity of New ternal Attachment Mothering Dis- York. Ms. Keiser has been a postgraduate stuorders: A Round Table. Oct 18, 1974, dent at Los Angeles Fami4 Institute and an intern therapis! at Learning f o r Health. P 56
APPENDIX ON FACING PAGE
INFANT AND YOUNG CHILD HEALTH CARE The Second Annual Napa Valley Conference on the Infant and Young Child with Special Needs will be held October 9-1 1, 1981, at the Napa Valley holiday Inn in Napa, California. This year’s conference will focus on “Stressed Families”; speakers include Bettye M. Caldwell, PhD, John Kennell, MD, and Kenneth Moses, PhD. Course credit will be offered in Special and Early Childhood Education. Registration fee: $98, lodging not included. For further information contact the Conference Committee, Napa County Office of Education, 4032 Mahr Street, Napa, CA 94558, Attn: Sue Martin, (707) 224-31 51.
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Appendix:
Mother-Infant Screening Tool (MIST) C
D
Holds infant on forearm
Holds infant away from body
Doesn't hold infant
Infant Curls up close to mother
Keeps some distance
Moves away when touched
Stiffens-up when held
Mother Comfortable touching infant, strokes head or face
Looks comfortable, pats infant's back
Tentative when touching infant
Avoids touching infant
Infant At ease; turns toward mother's touch
Looks at ease
Looks tense
Cries when touched
Mother Establishes eye contact
Looks at infant's face
Does not look at infant's face
Does not look at infant
Infant Establishes eye contact
Looks at mother's face
Does not look at mother's face
Does not look at mother
Smiles
No special facial expressions
Looksunhappy
Smiles
No special facial expression
Looksunhappy
Mother Talks to infant in soothing or playful way
Talks to infant in calm way
Talks but just gives directions
Doesn't talk to infant
Infant Infant makes happy sounds, coos and goos
Makesah-ahsounds
Cries
Doesn't talk
Differentiates most of infant's cries
Seldom differentiates infant's cries
Never differentiates infant's cries
Usually exhibits different cries
Seldom exhibits different cries
Never exhibits different cries
Looks content during feeding
Acts unsure during feeding-stops and starts
Agitated or irritable
Infant Shows pleasure in being fed-smiles, coos
Looks content during feeding
Restless during feeding
Agitated-cries during feeding
Mother Looks pleased after feeding
Looks satisfied after feeding
Looks uneasy after feeding
Looks agitated after feeding
Infant Looks happy after feeding
Looks satisfied after feeding
Looks restless after feeding
Looks agitated after feeding
0
A
Mother Holds infant close to her body T A C I
L E
v I S
A
Mother Smiles and makes faces in play Infant Laughs or big smile
Mother Understands meaning of infant's cries Infant Exhibits different cries Mother Shows signs of pleasure during feeding-smiles, rocks, sings
F E
I N G
TOTAL SCORE
MOTHER INFANT
DATE
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