What really matters in caring for babies may be different than commonly thought, says Lehigh University researcher Susan S. Woodhouse, an expert on infant attachment. In new research, she finds that caregivers need only "get it right" 50 percent of the time when responding to babies' need for attachment to have a positive impact on a baby. Securely attached infants are more likely to have better outcomes in childhood and adulthood, and based on Woodhouse's potentially paradigm-shifting work, there is more than one way to get there, particularly for low socioeconomic-status families.
Woodhouse, an associate professor of counseling psychology, studied 83 low socioeconomic-status mothers and infants at ages 4.5 months, 7 months, 9 months and 12 months to observe and assess attachment. Infants and mothers in the study were racially and ethnically diverse, and infants were selected for high levels of temperamental irritability.
Her findings are detailed in "Secure Base Provision: A New Approach to Examining Links Between Maternal Caregiving and Infant Attachment," which appears in the journal Child Development, co-authored with Julie R. Scott of Pennsylvania State University, Allison D. Hepsworth of the University of the Maryland School of Social Work, and Jude Cassidy of the University of Maryland.
The study scored mother-baby pairs based on a mother's responses to the infant while the baby was crying and not crying to assess the qualities of "secure base provision." This framework focuses on aspects of caregiving that tell an infant about the caregiver's availability to serve as a secure base, such as soothing to cessation of crying and providing a present and safe base from which to explore.
Researchers found that this framework significantly predicted infant attachment, and that babies learned their mothers were providing a secure base when mothers responded properly at least 50 percent of the time.
"The findings provide evidence for the validity of a new way of conceptualizing the maternal caregiving quality that actually works for low-income families," Woodhouse said.
Infant attachment is the bond infants form with their primary caregiver. A secure attachment allows babies to feel safe, which gives them both comfort in times of distress and the ability to explore, knowing they can return to their secure base when needed. Attachment is an infant's first bond with important caregivers and a critical phase in development, with a major impact on emotional and social development.
Numerous studies have shown the importance of secure infant attachment to developmental outcomes. But, for the past 30 years, the actual building blocks leading to attachment have been unresolved. Caregiver "sensitivity" -- the ability to accurately interpret infant needs and to respond promptly and appropriately -- was shown to be a key predictor of attachment. But studies showed sensitivity accounts for a surprisingly low percentage of variation in attachment, and has an even lower impact among families with low socioeconomic status.
"That's a real problem, because low-income babies face the most amount of risk, toxic stress and other factors that go along with being low income," Woodhouse said. Data suggest secure attachment may serve a protective function in children's socio-emotional development when in a context of high risk. Secure attachment is associated with better mental health outcomes in both childhood and adulthood -- including less incidence of externalizing behaviors such as acting out and internalizing behaviors such as depression and anxiety -- as well as greater school readiness.
"If we want to give advice to parents about what they can do to give their baby the best start in life, it would be really good to know what helps a baby to be secure," Woodhouse said.
Woodhouse's study seeks to address this critical gap in understanding what leads to secure attachment, through examining whether a new conceptualization of caregiving behavior, "secure base provision" -- the degree to which a caregiver is able to meet an infant's needs on both sides of the attachment-exploration continuum -- predicts attachment security in infants. It is the first time this conceptualization has been tested separately from sensitivity and as a predictor of infant attachment. The new way of conceptualizing caregiving focuses on the aspects of caregiving that theoretically should be most important to building infant attachment because of what an infant can learn from them about a caregiver's availability to serve as a secure base for the infant -- both when the infant needs comforting and when the infant is focused on exploring.
As frameworks, both sensitivity and secure base provision look at how caregivers perceive, interpret and appropriately respond to infant signals; and, in both, important infant signals occur at each end of the attachment-exploration continuum. But secure base provision looks only at certain key infant signals and more specific caregiver responses. It also focuses much less on prompt response and more on crying resolution (the ratio of infant crying episodes that end in chest-to-chest soothing until the infant is fully calmed, regardless of promptness).
Secure base provision also does not consider attunement to a baby's state and mood in a moment-by-moment manner, as the sensitivity framework does. "Attunement is not key because the focus is on what the infant learns about his or her ability to, in the end, recruit the caregiver when needed -- even in the context of a fair degree of insensitive behavior," such as not picking up the baby right away, or saying, "Come on, don't cry," to the baby, the researchers said. "It is this infant learning about the availability of the caregiver to be recruited to provide a secure base (more often than not) that is central to the construct."
Specifically, secure base provision looks at the degree to which a parent, on average, soothes a crying infant to a fully calm and regulated state while in chest-to-chest contact. "It is at the end of each crying episode that the infant learns about whether, on average, the caregiver can be counted on to be available as the infant achieves a calm state or whether the infant typically must stop crying alone," the researchers said.
During infant exploration and other times when the infant is not distressed, the secure base provision approach focuses on whether the caregiver allows exploration to occur without terminating or interrupting it -- for example, by making the baby cry through play that is too sudden or rough -- and on "calm connectedness," which communicates the mother's ongoing availability if needed for regulation or protection: "I am here if you need me, and you can count on me."
In addition, there are behaviors that caregivers must not do, either when the baby needs comfort or during exploration, in order for secure base provision to occur. Specifically, caregivers must not frighten the baby or fail to protect the baby when real hazards are present, such as another child who is too rough.
The study scored mother-baby pairs based on maternal responses to the infant during episodes of infant crying and maternal responses outside of infant crying episodes. A separate group in another lab also scored for the commonly used sensitivity framework.
The researchers found the new maternal caregiving concept of secure base provision correlated significantly with infant attachment security: mothers who had higher scores on secure base provision were more likely to have more securely attached infants, with an effect eight times larger than that of sensitivity, based on a meta-analysis of findings for low socioeconomic-status families. This was true, even after controlling for maternal sensitivity. They also found that "maternal sensitivity" did not significantly predict infant attachment security.
"What this paper tells us is that we need to change not only how we measure sensitivity, but how we are thinking about the caregiving behaviors that really matter," Woodhouse said. "What we found was that what really matters is not really so much that moment-to-moment matching between what the baby's cue is and how the parent responds. What really matters is in the end, does the parent get the job done -- both when a baby needs to connect, and when a baby needs to explore?"
Research suggests that infants demonstrate statistical learning to identify complex underlying patterns in stimuli, the researchers said. "Thus, we expected that infants whom caregivers soothed from crying to calm in a chest-to-chest position for at least half of the observed episodes of infant crying would learn that, on average, they could trust their caregivers to provide a secure base," they said, which they found to be true.
Woodhouse calls the findings "paradigm shifting."
"It really is a different way of looking at the quality of parenting," she said. "It's looking at this idea of does the job get done in the end, and it allows us to see strengths in low-income parents that our previous ideas about sensitivity don't let us see."
Researchers also noted a number of problematic behaviors by mothers while their babies were crying that disrupted the process of comforting the infant. Such as: turning the baby away from their chests before crying ends; rough handling; harsh verbal tones; verbal instructions not to cry; and verbally attributing negative characteristics to the baby. They also documented presence or absence of frightening behavior, such as sudden looming into the baby's face or toward the baby, during crying episodes.
"If the mother did frightening things when the baby cried, like hard yelling or growling at the baby, or suddenly looming toward the baby's face while the baby was upset, even if it only happened one time, the baby would be insecure," Woodhouse said. "Similarly, if the mother did anything really frightening even when the baby wasn't in distress, like saying 'bye-bye' and pretending to leave, throwing the baby in the air to the point they would cry, failure to protect the baby, like walking away from the changing table or not protecting them from an aggressive sibling, or even what we call 'relentless play' -- insisting on play and getting the baby worked up when it is too much -- that also leads to insecurity."
Interestingly, overprotective-type behaviors, such as moms who don't let the baby explore more than an arm's length away, or interrupting or redirecting play (except for safety) also contributed to insecure baby attachment. "Some moms really had trouble allowing the baby to explore and were very insistent on the baby doing certain things or turning the baby's head to look at the mom," Woodhouse said. "In really intrusive parenting, if we saw that, the baby was insecure."
One application of the findings is improving effectiveness of intervention programs that aim to increase secure infant attachment. The results indicate that low socioeconomic-status mothers who do a better job of providing a secure base increase their infants' chances of developing a secure attachment from about 30% to 71%; while low-SES mothers who fail to provide a secure base decrease their infants' chances of developing a secure relationship from about 71% to 30%.
Knowing this can help those leading interventions to view caregiving behavior in a new way. For example, this framework allows them to shift focus from urging mothers to respond as promptly as possible to working with mothers to focus on relenting and ultimately picking up and soothing a crying infant in a chest-to-chest position until calm.
"Because low socioeconomic-status parents juggle multiple challenges associated with low socioeconomic status, it may be helpful for them to know that holding a crying infant until fully soothed, even 50% of the time, promotes security," the researchers said. "Such a message could help parents increase positive caregiving without raising anxiety regarding 'perfect parenting' or setting the bar so high as to make change unattainable in families that face multiple stressors."
Methods of engaging an infant in calm, regulating connectedness, such as being available for eye contact without actively making eye contact and carrying an infant on the hip during daily tasks, also promote secure attachment in the baby, they said.
Focusing on the secure base also avoids emphasizing the importance of parenting practices that are often associated with white, middle-class populations, such as moment-to-moment attunement, prompt responses, sweet tone of voice and affectionate verbal comments. The new approach "captures strengths that can be present in parents who may be under economic strain or who ascribe to 'no-nonsense parenting,''' the researchers said. This also makes the secure base provision approach potentially more culturally sensitive and likely to be accepted across diverse low socioeconomic-status families.
"Across cultures, social class and race, parents want the best for their kids," Woodhouse said, "so parents are excited to know about this when I talk with them." Clinicians such as psychologists, counselors, social workers, home visitors, Head Start programs, early child care providers and pediatricians will also find it as a valuable lens, she said. "It has the potential to change intervention for agencies and practitioners, and I think that is really valuable," Woodhouse said.
The research isn't meant to contradict sensitivity as a framework, which remains useful, Woodhouse argues. The findings also aren't a challenge to attachment theory, which assumes that infants universally form attachments with familiar caregivers based on evolutionary pressures. "Attachment theory is a really important theory that has guided lots of research," she said. "(These findings) are about enriching, deepening and adding to the theory in ways that support applicability in diverse contexts."
Woodhouse clarifies that this is different from commonly understood tenets of "attachment parenting" in popular culture, such as co-sleeping, baby-wearing, breastfeeding or organic foods. "None of these things is inherently good or bad for attachment or a guarantee of having secure children -- it's about how they are done," she said. "Moms get secure children in different ways. It is more of an attachment-informed perspective, that biologically babies do have certain needs -- for safety, comfort and connection, exploration of their world -- and how do we meet these needs? There is more than one way to get there."
For Woodhouse, the takeaway is two-fold:
"The first message gets at the core of getting the job done -- supporting the baby in exploration and not interrupting it and welcoming babies in when they need us for comfort or protection," Woodhouse said. "The other part is that you don't have to do it 100 percent -- you have to get it right about half of the time, and babies are very forgiving and it's never too late. Keep trying. You don't have to be perfect, you just have to be good enough."
Materials provided by Lehigh University
Susan S. Woodhouse, Julie R. Scott, Allison D. Hepworth, Jude Cassidy. Secure Base Provision: A New Approach to Examining Links Between Maternal Caregiving and Infant Attachment. Child Development, 2019; DOI: 10.1111/cdev.13224