Predicting attachment in Portuguese infants born very or extremely preterm: Understanding the roles of infant regulatory behavior, maternal sensitivity, and risk factors.

A growing body of research shows that early attachment relationships are foundational for children's later developmental and psychosocial outcomes. However, findings are mixed regarding whether preterm birth predicts later attachment, but insecurity is generally more prevalent among infants at higher medical and/or social/familial risk. This longitudinal study aimed to identify specific relational, familial/demographic, and perinatal predictors of attachment in a sample of 63 Portuguese infants born very or extremely preterm (VEPT, <32 gestational weeks) and their mothers from diverse socioeconomic backgrounds. One-third of the mothers had social/family risk factors (e.g., single parent, immigrant, unemployed, low education, and/or low income). At 3 months (corrected age), dyads were observed during social interaction in the Face-to-Face Still-Face paradigm (FFSF) and during free play. At 12 months, mother-infant dyads were observed in Ainsworth's Strange Situation. Over half (58.7%) of the infants were classified as insecurely attached. Social-Positive Oriented regulatory behavior pattern, higher maternal sensitivity, higher infant cooperation during free play, number of siblings and an absence of social/family risk factors were associated with attachment security. Perinatal variables were unrelated to attachment. Findings indicate that both relational and social contextual factors contribute to attachment in this biologically vulnerable sample.

Un creciente cuerpo investigativo muestra que las relaciones afectivas tempranas son fundamentales para posteriores resultados de desarrollo y sicosociales de los niños. Sin embargo, los resultados son variados acerca de si el nacimiento prematuro predice la afectividad posterior, pero la inseguridad es generalmente más prevalente entre infantes bajo más alto riesgo médico y/o social/familiar. Este estudio longitudinal se propuso identificar factores específicos de predicción de la afectividad, relacionales, familiar/demográficos y perinatales en un grupo muestra de 63 infantes portugueses nacidos muy o extremadamente prematuros (VEPT, < 32 semanas gestacionales) y sus madres de diversos niveles socioeconómicos. Un tercio de las madres tenían factores de riesgo social/familiar (v.g. madre soltera, inmigrante, desempleada, de baja educación y/o de bajos recursos económicos). A los tres meses (edad corregida), se les observó a las díadas durante la interacción social en el paradigma de Cara a Cara y Rostro Inmutable (FFSF) y durante el juego libre. A los 12 meses, se les observó a las díadas madre-infante por medio de la Situación Extraña de Ainsworth. Se clasificó más de la mitad (58.7%) de los infantes como afectivamente inseguros. Entre los factores de predicción de la afectividad segura se incluyó un patrón de conducta regulatoria con orientación social positiva durante FFSF, una sensibilidad materna más alta y la cooperación del infante durante el juego libre, así como la ausencia de factores de riesgo sociales/familiares. Las variables perinatales no estuvieron relacionadas con la afectividad. Los resultados indican que los factores contextuales, tanto relacionales como sociales contribuyen a la afectividad en este grupo biológicamente vulnerable.

Cross-modal coherence and incoherence of early infant interactive behavior: links to attachment in infants born very preterm or full-term.

Infants exhibit flexibly organized configurations of facial, vocal, affective, and motor behavior during caregiver-infant interactions that convey convergent messages about their internal states and desires. Prior work documents that greater cross-modal discrepancy at 4 months predicts disorganized attachment. Here, we evaluated whether: very preterm (VPT) or full-term (FT) status predicts cross-modal coherence or incoherence in infants' behavior with the caregiver at 3 months; and, regardless of prematurity, whether cross-modal interactive coherence or incoherence predicts 12-month attachment. Participants included 155 infants (85 FT; 70 VPT), and their mothers followed from birth to 12 months (corrected age). Infants' cross-modal coherent and incoherent responses were scored microanalytically from videotaped en-face interactions. Infants' attachment security was evaluated during Ainsworth's Strange Situation. Infants born VPT exhibited more incoherent cross-modal responses and insecure attachment than infants born FT. Regardless of prematurity, infants' coherent and incoherent cross-modal interactive behaviors at 3 months predicted different attachment patterns at 12 months.

A self-comfort oriented pattern of regulatory behavior and avoidant attachment are more likely among infants born moderate-to-late preterm.

Infants born preterm (<37 gestational weeks, GW) are at increased risk for regulatory difficulties and insecure attachment. However, the association between infants' regulatory behavior patterns and their later attachment organization is understudied in the preterm population. We addressed this gap by utilizing a Portuguese sample of 202 mother-infant dyads. Specifically, we compared the regulatory behavior patterns of 74 infants born moderate-to-late preterm (MLPT, 32-36 GW) to those of 128 infants born full-term (FT, 37-42 GW) and evaluated the associations of these regulatory patterns with later attachment. Infants' regulatory behavior patterns (Social-Positive Oriented, Distressed-Inconsolable, or Self-Comfort Oriented) were evaluated in the Face-to-Face-Still-Face paradigm at 3 months, and their attachment organization (secure, insecure-avoidant, or insecure-ambivalent) was evaluated in the Strange Situation at 12 months corrected age. In both samples, the Social-Positive-Oriented regulatory pattern was associated with secure attachment; the Distressed-Inconsolable pattern with insecure-ambivalent attachment; and the Self-Comfort-Oriented pattern with insecure-avoidant attachment. However, compared to FT infants, infants born MLPT were more likely to exhibit a Self-Comfort-Oriented pattern and avoidant attachment. Most perinatal and demographic variables were not related to infant outcomes. However, infants with a higher 1-min Apgar were more likely to exhibit the Social-Positive-Oriented regulatory pattern and secure attachment.

Emerging patterns of infant regulatory behavior in the Still-Face paradigm at 3 and 9 months predict mother-infant attachment at 12 months.

Prior research described three stable patterns of organized behavior employed by infants to manage stressful interactive situations with their mothers in the Face-to-Face Still-Face paradigm (FFSF) at 3 and 9 months postpartum.  The current longitudinal study expands this research by examining the extent to which these patterns predict infants' later attachment quality. For that purpose, 108 full-term infants and their mothers participated in the FFSF at 3 and 9 months, and in the Strange Situation at 12 months. Cross-tabulation analyses indicated a significant association between (1) the Social-positive oriented pattern and secure attachment, (2) the Distressed-inconsolable pattern and insecure-ambivalent attachment, and (3) the Self-comfort oriented pattern and insecure-avoidant attachment. Our results contribute to a growing body of studies suggesting that patterns of infants' regulatory behavior assessed during the FFSF during the first year, may be early developmental precursors of attachment patterns at 12 months.

Maternal pre and perinatal experiences with their full-term, preterm and very preterm newborns.

BACKGROUND: Mothers' reports about pregnancy, maternity and their experiences during the perinatal period have been associated with infants' later quality of attachment and development. Yet, there has been little research with mothers of very preterm newborns. This study aimed to explore mothers' experiences related to pregnancy, premature birth, relationship with the newborn, and future perspectives, and to compare them in the context of distinct infants' at-birth-risk conditions. METHODS: A semi-structured interview was conducted with women after birth, within the first 72 h of the newborn's life. A total of 150 women participated and were divided in three groups: (1) 50 mothers of full-term newborns (Gestational Age (GA) ≥ 37 weeks; FT), (2) 50 mothers of preterm newborns (GA 32-36 weeks; PT) and (3) 50 mothers of very preterm newborns (GA < 32 weeks; VPT). RESULTS: Mothers of full-term infants responded more often that their children were calm and that they did not expect difficulties in taking care of and providing for the baby. Mothers of preterm newborns although having planned and accepted well the pregnancy (with no mixed or ambivalent feelings about it) and while being optimistic about their competence to take care of the baby, mentioned feeling frightened because of the unexpected occurrence of a premature birth and its associated risks. Mothers of very preterm newborns reported more negative and distressful feelings while showing more difficulties in anticipating the experience of caring for their babies. CONCLUSION: The results indicate that Health Care Systems and Neonatal Care Policy should provide differentiated psychological support and responses to mothers, babies and families, taking into account the newborns' GA and neonatal risk factors.

Maternal perinatal representations and their associations with mother-infant interaction and attachment: A longitudinal comparison of Portuguese and Brazilian dyads.

Prior research in Western countries (mostly the US, Canada and northern Europe) indicates that mothers' representations are associated with mother-infant interaction quality and their child's attachment security later in the first year. Fewer studies, however, have evaluated whether these associations hold for mother-infant dyads in other countries, such as Brazil and Portugal. Although these countries share a similar language and culture, they differ on societal dimensions that may affect parenting attitudes and mother-infant relationships, such as economic stress, social organisation, social policy, and the availability of services for young families. In this longitudinal study, we followed two independent samples of Brazilian and Portuguese mother-infant dyads from the perinatal period to 12 months post-partum. We assessed mothers' perinatal representations using semi-structured interviews in the first 48 hours after the infant's birth, and evaluated the associations of these representations with mother interaction quality at 9 months and infant attachment at 12 months. Results were similar in each country, corroborating prior research in single Western countries: Mothers with more positive perinatal representations were more sensitive to their infants during free play at 9 months and were more likely to have infants classified as securely attached at 12 months.

Predicting Patterns of Regulatory Behavior in the Still-Face Paradigm at 3 Months.

The current study addressed two aims: (1) to describe different patterns of infant regulatory behavior during the Face-to-Face Still-Face (FFSF) paradigm at 3 months of age and (2) to identify specific, independent predictors of these patterns from an a priori set of demographic, infant (e.g., temperament), and maternal (e.g., sensitivity) variables. Analyses were based on data collected for 121 mother-infant dyads assessed longitudinally in the newborn period and again at 3 months. In the newborn period, infants' neurobehavior was evaluated using the Neonatal Behavioral Assessment Scale (NBAS) and mothers reported on their caregiving confidence and their newborns' irritability and alertness. At 3 months, mothers reported on their infant's temperament, and mother-infant interactions were videotaped during free play and the FFSF. Three patterns of infant regulatory behavior were observed. The most common was a Social-Positive Oriented Pattern, followed by a Distressed-Inconsolable Pattern, and a Self-Comfort Oriented Pattern. Results of multinomial logistic regression indicated that categorical assignment was not associated with demographic or infant characteristics, but rather with dyadic regulatory processes in which maternal reparatory sensitivity played a crucial role.

It's You and Me: Infants' cross-modal communicative signals and mother-infant interactive behavior predict infant regulatory patterns in the still-face paradigm at 3 months.

Infant regulatory behavior develops since birth and impacts their early social interactions. Infants differ in the relative coherence and incoherence of their cross-modal communicative signals during en-face infant-caregiver interactions. We expand this research by evaluating whether different infant regulatory patterns observed during the Face-to-Face Still-Face (FFSF) at 3 months are associated with the coherence or incoherence of infants' cross-modal communicative behaviors during en-face interactions or with multiple dimensions of mother-infant interactive behavior during free-play. Analyses were based on data collected from 100 mother-infant dyads from urban, working- and middle-class backgrounds in Portugal who were videotaped during the FFSF and free play at 3 months. Results confirm that infants' different regulatory behavior patterns in the FFSF at 3 months are associated with the coherence and incoherence of their cross-modal interactive behaviors and specific aspects of mother-infant interaction. Infants with a Social-Positive oriented regulatory pattern during the FFSF displayed more coherent and less incoherent communicative behaviors with their mothers and were more cooperative during free play. In turn, their mothers were more sensitive. Our findings support the perspective that infants' regulatory behavior strategies in the context of caregiver regulatory support and sensitivity are likely to increase dyadic correspondence and infant ability to engage with the world.

Attachment and mother-infant interactions in dyads with infants born full-term, moderate-to-late preterm, and very-to-extreme preterm.

BACKGROUND: The impact of prematurity status on attachment quality remains indeterminate. Some studies found no differences between infants born preterm (PT) and infants born full-term (FT), while other investigations present opposite results. AIMS: We aim to contribute to this body of research by studying mother-infant interactive behaviors and quality of attachment in 3 independent samples: Full-Term (FT), Moderate-to-Late Preterm (MLPT) and Very-to-Extreme Preterm (VEPT). STUDY DESIGN: This is a longitudinal laboratory study conducted from 3 to 12 months of age (corrected-age in the case of infants born PT). SUBJECTS: The participants are 213 Portuguese infants (FT = 105; MLPT = 52; VEPT = 56) and their mothers. OUTCOME MEASURES: Mother-infant interactive behavior was observed in free-play at 3 and 9 months (corrected-age). Infant attachment was observed in Strange Situation at 12 months. RESULTS: Secure attachment is more prevalent in infants born FT, and ambivalent attachment is more prevalent in infants born VEPT. Infants with a secure attachment have higher gestational age and weight at birth. Infant and maternal interactive behavior quality is associated with attachment patterns and varies according to infant prematurity status. Last, the results indicate changes in maternal sensitivity and infant difficult behavior from 3 to 9 months of infant's age. CONCLUSIONS: Our findings indicate that prematurity status impacts attachment quality. Changes in maternal and infant behavior from 3 to 9 months suggest a period of rapid non-linear development, supporting a transactional multilayered approach to the study of mother-infant relationship.

Corrigendum: Differential effects of attachment security on visual fixation to facial expressions of emotion in 14-month-old infants: an eye-tracking study.

[This corrects the article DOI: 10.3389/fpsyg.2024.1302657.].

Differential effects of attachment security on visual fixation to facial expressions of emotion in 14-month-old infants: an eye-tracking study.

Introduction: Models of attachment and information processing suggest that the attention infants allocate to social information might occur in a schema-driven processing manner according to their attachment pattern. A major source of social information for infants consists of facial expressions of emotion. We tested for differences in attention to facial expressions and emotional discrimination between infants classified as securely attached (B), insecure-avoidant (A), and insecure-resistant (C). Methods: Sixty-one 14-month-old infants participated in the Strange Situation Procedure and an experimental task of Visual Habituation and Visual Paired-Comparison Task (VPC). In the Habituation phase, a Low-Arousal Happy face (habituation face) was presented followed by a VPC task of 6 trials composed of two contrasting emotional faces always involving the same actress: the one used in habituation (trial old face) and a new one (trial new face) portraying changes in valence (Low-Arousal Angry face), arousal (High-Arousal Happy face), or valence + arousal (High-Arousal Angry face). Measures of fixation time (FT) and number of fixations (FC) were obtained for the habituation face, the trial old face, the trial new face, and the difference between the trial old face and the trial new face using an eye-tracking system. Results: We found a higher FT and FC for the trial new face when compared with the trial old face, regardless of the emotional condition (valence, arousal, valence + arousal contrasts), suggesting that 14-month-old infants were able to discriminate different emotional faces. However, this effect differed according to attachment pattern: resistant-attached infants (C) had significantly higher FT and FC for the new face than patterns B and A, indicating they may remain hypervigilant toward emotional change. On the contrary, avoidant infants (A) revealed significantly longer looking times to the trial old face, suggesting overall avoidance of novel expressions and thus less sensitivity to emotional change. Discussion: Overall, these findings corroborate that attachment is associated with infants' social information processing.

Psychological and cultural factors influencing antibiotic prescription.

Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.

The Association between Prematurity, Antibiotic Consumption, and Mother-Infant Attachment in the First Year of Life.

Antibiotics have individual and public-health drawbacks. Nevertheless, mother-infant attachment quality and maternal sensitivity are associated with antibiotic use. Ambivalent-attached infants are more likely to consume antibiotics than other infants. Conceivably, the emotional over-externalization of ambivalent-attached infants and maternal anxiety when infants are ill raise concerns in healthcare professionals, leading to antibiotic over-prescriptions. However, because infants prematurely born, particularly those with less than 32 weeks of gestation, are under more accurate health vigilance, the impact of infant and maternal behavior on antibiotic prescription may vanish in this sample. To test this hypothesis, we performed a longitudinal study to compare antibiotic use and the quality of mother-infant attachment in three groups: 86 infants born at full-term, 44 moderate-to-late preterm infants (32-36 gestation weeks), and 58 very-to-extreme preterm infants (<32 gestation weeks). Infants' attachment was observed with the Ainsworth Strange Situation's experimental paradigm at 12 months of corrected age. Findings indicate that infant attachment strategy is associated with antibiotics uptake, but results vary across samples. The proportion of infants that used antibiotics is highest among ambivalent-attached infants in the full-term sample but highest among avoidant-attached infants in the very-to-extreme premature sample. Moreover, higher infant gestational age and lower maternal sensitivity determine higher antibiotic use.

Antibiotic Consumption, Illness, and Maternal Sensitivity in Infants with a Disorganized Attachment.

Prior research found an association between mother-infant attachment and antibiotic use. Ambivalent-attached infants are more likely to take antibiotics than other infants, and their mothers tend to be less sensitive to their needs than most. This finding is important because it shows the association between psychological processes, early relationships, and health outcomes. We aim to learn about children with high-risk attachment relationships, such as disorganized-attached infants. This study compares antibiotic use, infant-mother interactive behavior, and health indicators according to infant attachment patterns (including disorganized attachment). For this purpose, we observed mothers-infants' interactive behavior in free play at nine months and infants' attachment in the Ainsworth Strange Situation at twelve months. Participants included 77 girls and 104 boys (full-term and preterm) and their mothers. Paradoxically, mothers of disorganized-attached infants reported that their children were ill only 1.56 times on average, but 61% of their children used antibiotics in the first nine months. The other mothers reported that their children were sick 5.73 times on average, but only 54% of their children used antibiotics in the same period. Infants with disorganized attachment had mothers who were more literate and less sensitive. These results add to a body of research that shows that early high-risk relationships affect children's lives at multiple levels.

The impact of low birthweight in infant patterns of regulatory behavior, mother-infant quality of interaction, and attachment.

It remains unclear whether infants born preterm are more likely to develop an insecure attachment with their mothers. In this study, instead of using gestational age criteria, we observe attachment in infants born with very low birthweight. Although the collinearity between gestational age and birthweight is high, infants born with very low birthweight for their gestational age tend to stay more days in NICU and to have more comorbidities than other infants with the same gestational age. Thus, we wonder about the impact of low gestational birth (per se) in infants' regulatory behavior, the quality of mother-infant interactions, and attachment security. The participants are 71 infants' weight lower than 1599 g of gestational weight (varying between 23 and 34 weeks of gestational) and their mothers. Dyads were observed in free play and during Face to Face Still-Face paradigm with infants at 3 months of corrected age. At 12 months of corrected age, mother-infant attachment was observed during Strange Situation. Results indicate that infants with low/very low gestational birthweight have high levels of insecure attachment (70 %) and non-positive patterns of regulatory behavior (64 %). Maternal and infant interactive behavior is highly associated with infant attachment. In turn, maternal interactive behavior is associated with gestational age, birthweight, and number of days in NICU.

Emotional Availability in Mother-Child and Father-Child Interactions as Predictors of Child's Attachment Representations in Adoptive Families.

Emotional availability (EA) in parent-child interactions is associated with positive child outcomes, including attachment security. However, little is known about EA in adoptive families. This study investigated the associations between secure representations of attachment in adopted children and the adoptive parents' EA. The participants (n = 75) included 26 mothers, 23 fathers, and 26 children who were aged 3 to 9 years. Children completed the Attachment Story Completion Task. Adult-child dyadic relationships were assessed using the EA® System. The results showed that the children's and parents' EA, age when adopted, and time elapsed since adoption were associated with more secure children's attachment representations. Implications for family support and public policy are discussed.

Maternal sensitivity and mother-infant attachment are associated with antibiotic uptake in infancy.

Attachment security has been associated with health status and symptom reporting. In this longitudinal study, we investigated the association between antibiotics uptake by infants at 9-months and mother-infant attachment at 12-months. Logistic regression analyses indicated that lower maternal sensitivity was associated with increased odds of antibiotic uptake. Furthermore, 89.7% of insecure-ambivalent infants consumed antibiotics, which contrasted with 32.5% of avoidant infants and 21.5% of secure infants. This study suggests that maternal behavior and mother-infant attachment impact on antibiotic consumption, which is worrying because antibiotics may lead to several health problems later in life and antibiotic-resistance.

Patterns of regulatory behavior in the still-face paradigm at 3 months: A comparison of Brazilian and Portuguese infants.

Three infant regulatory behavior patterns have been identified during the Face-to-Face Still-Face paradigm (FFSF) in prior research samples: a Social-Positive Oriented pattern (i.e., infants exhibit predominantly positive social engagement), a Distressed-Inconsolable pattern (i.e., infants display conspicuous negative affect that persists or increases across FFSF episodes), and a Self-Comfort Oriented pattern (e.g., infants primarily engage in self-comforting behaviors such as thumb-sucking). However, few studies have examined these patterns outside US and European countries or evaluated potential cross-country differences in these patterns. In this study, we compared the regulatory behavior patterns of 74 Brazilian and 124 Portuguese infants in the FFSF at 3 months of age, and evaluated their links to demographic and birth variables. The prevalence of the three regulatory patterns varied by country. The most frequent pattern in the Portuguese sample was the Social-Positive Oriented, followed by the Distressed-Inconsolable and the Self-Comfort Oriented. However, in the Brazilian sample, the Distressed-Inconsolable pattern was the most prevalent, followed by the Social-Positive Oriented and the Self-Comfort Oriented. Moreover, in the Brazilian sample, familial SES was higher among infants with a Social-Positive pattern whereas 1st-minute Apgar scores were lower among Portuguese infants with a Distressed-Inconsolable Oriented pattern of regulatory behavior. In each sample, Social Positive pattern of regulatory behavior was associated with maternal sensitivity, Self-Comfort Oriented pattern of regulatory behavior with maternal control, and Distressed-Inconsolable pattern with maternal unresponsivity.

Family SES and maternal sensitivity predict infant patterns of regulatory behavior in Brazilian dyads.

Infant's patterns of regulatory behavior contribute to infant socioemotional development and attachment. These behavioral patterns affect and are affected by the quality of mother-infant interaction. In most studies with full-term infants, the Social-Positive Oriented pattern (i.e., the infant's ability to soothe his/her emotions in the context of reciprocal and positive interactions) is the most prevalent pattern, followed by the Distressed-Inconsolable and by the Self-Comfort Oriented patterns. However, these patterns are understudied in other populations beyond the US and European countries. The current research addresses this gap by studying the regulatory behavior patterns and their association with mother-infant interactions in Brazilian dyads and evaluating the association of these regulatory patterns with demographics. Analyses were based on data collected for 40 infants (20 boys, 20 girls) and their mothers. Infants' regulatory behavior patterns were evaluated in the Face-to-Face Still-Face paradigm and mother-infant interaction was evaluated during free play at 3 months age. Notably, our findings indicate that Distressed-Inconsolable was the most prevalent pattern in this sample; followed by the Social-Positive Oriented and the Self-Comfort Oriented patterns. Furthermore, we found that maternal sensitivity and family SES (social-economic status) predicted infant patterns of regulatory behavior.