Mother infant relationship disorders

MOTHER-INFANT RELATIONSHIP DISORDERS

also called MATERNAL BONDING or ATTACHMENT DISORDERS

Introduction

The growth of the mother-infant relationship is the key psychological process in the puerperium. Many mothers do not develop an immediate ‘bond’ with their newborn infants, but experience a gradual increase in maternal love over the first few weeks. A disappointing lack of emotion, sometimes, accompanied by a feeling of estrangement, is quite common, and is not of great concern, because it is almost always brief. But a small minority of mothers develop a persistent aversion to the child . That is the subject of this annotation.

Symptoms

These can be placed in five groups:

(1) The core of the disorder is the emotional reaction to the baby - dislike, hostility, even hatred.

(2) In consequence of this emotional rejection, there is a lack of interaction (talking, playing and cuddling). It may even be difficult to look at the baby.

(3) These mothers regret the pregnancy, feel trapped and consider ways of escaping from the crushing burden of infant care. Some leave home. Others try to persuade their own mother, or another relative, to take over. If this is not possible, fostering or adoption is considered, at first privately then publicly.

(4) The most poignant manifestation is a secret wish that the baby ‘disappear’—be stolen, or die.

(5) In addition, irritation with the baby’s insistent demands, day and night, week after week, lead to shouting, cursing or screaming, aggressive impulses and, if self-control gives way, various forms of rough treatment (child abuse).

It is important to distinguish this disorder from the child-focused anxiety which some mothers develop: they love their babies, but feel so anxious in their presence that they avoid contact, that is, develop a phobia for the infant. It is also important to distinguish anger-based impulses to ‘batter’ the child, from the so-called obsessions of infanticide: some gentle, devoted women have extraordinary fantasies of destroying their infants – for example, by decapitation or throwing them into the fire. Anxiety and obsessional disorders are quite different from bonding disorders, and require a different form of help.

Course

This disorder sometimes clears up without help, even after months or years. But, if it is allowed to persist, it exposes children to an atmosphere of persistent hostility and persecution. Mothering is emotionally distant and unresponsive to the children’s need for comfort and help. They suffer emotional abuse , with belittling and humiliation, and critical or sarcastic comments conveying that they are worthless and unloved. They may also be maltreated in other ways. All this can have serious and long term effects, including learning deficits, poor peer-relationships and an increased risk of mental illness or criminality .

Screening and diagnosis

There are now several questionnaires that can be used for the early detection of disturbed ‘bonding’. Two scales with a rather different approach are the Parent-Infant Attachment Scale and the Postpartum Bonding Questionnaire . These can be completed in 5 minutes, and are useful for screening, but are not enough to make a sure diagnosis. For this, an interview is required, exploring the mother’s emotional response and behavior. Direct observation of mother-infant interaction confirms the diagnosis.

Frequency

In the general community, these disorders affect about one in a hundred mothers – rather more at the level of ‘threatened rejection’ – when the mother has an aversion to her child and seeks temporary escape from child care – and rather less when rejection is established and accompanied by loss of control over aggressive impulses. It is much higher – over 20% - in mothers who seek help for ‘postnatal depression’ .

Causes

These disorders are not confined to Caucasian mothers living in isolated nuclear families. They have been observed in Pakistani and Sikh mothers (living with their extended families), in Afro-Caribbean women, Maoris and the Japanese. Unwanted pregnancy is a factor . There may be signs during pregnancy of indifference or hostility to the unborn child . Infant temperament may be important: difficult babies – those that cry excessively or sleep poorly – can disturb the bonding process. Sick infants and those with delayed social responses may also be at risk.

The lack of early contact and breast-feeding probably has no major effect, nor (probably) does poor parenting by the mother’s own mother (because a mother may ‘bond’ normally to the first child and reject later children ).

The role of depression is important. Depression is both a cause and an effect of an impaired infant relationship. But severe disorders can occur in the absence of depression. It is not appropriate to regard this disorder as a manifestation of ‘postnatal depression’. It has its own symptoms, course, causes, effects and treatment.

Therapy

Handled with understanding and skill, these disorders usually have a favourable outcome.

The first step is explanation and reassurance: delayed development of the ‘bond’ is common. Usually a full relationship will develop as the mother recovers from the exhaustion and trauma of delivery, and as the baby develops its own charming social behaviour of smiling, laughter and babbling.

Reassurance is insufficient for mothers who suffer prolonged and increasingly severe negative feelings, or who have difficulty in controlling their irritation. The threshold for active intervention is threatened rejection or loss of control, leading to repeated verbal abuse of the infant.

In these cases, the primary decision is whether to attempt treatment or not. The mother must be given freedom of choice; it is dangerous for her to feel trapped in unwelcome motherhood. At the same time, the father has his rights. The option of relinquishing the infant must be openly acknowledged, and fully discussed with both parents. Provided the infant is safe, this stage should not be rushed. It is often easy to arrange, for the short term, alternative care, safeguarding the baby and allowing the mother as much access as she wants.

Most mothers, even though they can see no solution to the problem, desire treatment. They are usually depressed, and this should be treated, with psychotherapy, drugs or (occasionally) electroconvulsive therapy. Since depression can be occult, it is wise to treat depression thoroughly in all cases. Sometimes this treatment gives mothers the energy and optimism to overcome the problem themselves. There have been dramatic ‘cures’ by energetic antidepressive treatment.

In other cases, this is unavailing, and specific psychological treatment is required. Treatment focused on the mother alone is inappropriate. It is necessary to work on the relationship itself. Like other relationships, this grows through shared pleasure. The baby has the power to awaken its mother’s feelings, so the aim is to create circumstances in which mother and child can enjoy each other. Various forms of play therapy have been used; it is a good idea to set up a threesome – mother, infant and therapist – so that the therapist can demonstrate how to play with the infant; the mother can copy this behaviour (‘participant modelling). If a trained professional, such as a psychologist or nurse, is not available, any experienced mother may be able to undertake this. Baby massage has also been used . Group therapy, attended by several mothers with their infants may be helpful. Videotape feedback has also been used in some centres.

It is a mistake to separate the mother and baby completely, because this merely compounds the problem by adding an element of avoidance. But, if there is any hint of abuse or aggressive impulses, the mother must never be left alone with her infant. She must be relieved of all irksome burdens of infant care. When mother and baby are calm, she is encouraged and helped to interact with him—to cuddle, talk, play, and bring out his smile and laughter.

This treatment can take place in various settings. Home treatment can be successful, provided there is enough support to relieve the mother of night care and stressful duties: the maternal grandmother, an understanding husband or a family group can sometimes achieve this. Day-hospital treatment provides individual support and group discussion, as well as specific therapies. In the most severe and refractory cases, the proper setting is an inpatient mother-and-baby unit, where an experienced team of psychiatric and nursery nurses, available 24 hours/day and 7 days a week, can provide full support. Even in the most severe cases, one can feel optimistic about a successful outcome.

Examples

A mother who could not look at her baby

A 33 year old mother gave birth to her second child. She sought help because she had not bonded, and was tearful and withdrawn. She said, “It is like he isn’t my baby. I feel quite cold and empty towards him. I don’t like to look at him if he looks at me. It’s his eyes. I can’t look at him. I don’t know why.” She felt like running away, or leaving him in the park, where someone would remove him. She sometimes got angry – “It’s his fault. He did it to annoy me”, and had impulses to put a hand over his mouth or shake him. Anti-depressive drugs had a slight effect on depression, but she still had difficulty looking at him, and, during massage therapy, was unable to touch him or stroke his hand. After 9 weeks, she was admitted to the Mother & Baby unit, where, within a few days, she started to bond; swimming therapy seemed to be the most effective form of play therapy for her. After 4 weeks, anti-depressants were stopped because of side effects, and her depression returned. But her relationship with her baby maintained its improvement.

The wish for cot (crib) death

A first-time mother looked forward to “a beautiful baby tucked up in bed”, or going for walks “proudly pushing a pram”. But her son went only one hour between feeds, and cried unless held. One night he screamed for 5 hours. In the pram he would scream constantly, and strangers would stop to tell her what was wrong. After 10 days she was exhausted - “It was the biggest mistake of my life”. She considered having him adopted, and moving house to start again. After treatment and recovery she shared her feelings with her husband - “We were surprised to learn that we both thought a cot death would be a welcome release”.

Spontaneous recovery after 3 years

A 35 year old mother presented after her 4th (unwanted) pregnancy. She “did not take to the baby”, who was looked after by her own mother, with whom she lived. When offered day hospital treatment, she panicked. Her mother (an impressive, forceful woman) intervened to explain that her daughter was ‘not maternal’ and she herself had brought up all four children. For the next 3 years the patient was given psychotherapy, mainly consisting of reassurance that that there was no problem – the baby was safe in its grandmother’s care. One day she entered the doctor’s office with a toddler on her knee. She said, “It’s the baby, Eleanor”. After 3 years, the little girl had wheedled her way into her mother’s affections, and they formed a good relationship.