Humans are designed for relationship with others, connection is therefore recognised as a basic human need (Hornor, 2020). Born with this intrinsic desire, research has well documented that the quality and consistency of interactions between infants and their primary caregiver within their first 1000 days of life will lay the foundations of their attachment style and impacts on their:
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- Emotional development and regulation
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(Weatherford, 2022; Potgieter & Adams, 2019; Hong & Park, 2012; Karakas & Dagli, 2019)
Attachment theory was first coined by John Bowlby while working with orphaned and homeless children in Europe after World War II (Hornor, 2020). He identified that the 3 fundamentals of a secure attachment are (1) the intrinsic need to connect with others and form intimate relationships, (2) the development of a child is powerfully influenced by how they are treated by their parents, especially mothers and (3) early experiences are strong predictors for relationship skills in later life (Hornor, 2020). The impact of attachment from infancy has been widely researched and has become a popular topic amongst health providers, recognising the long-term benefits when fosters and detriment when neglected (Weatherford, 2022).
Attachment vs bonding – aren’t they the same thing?
“One might ask why the distinction between attachment and ‘bonding’ matters. The answer may lie in the fact that bonding has not been shown to predict any aspect of child outcome, whereas attachment is a powerful predictor of a child’s later social and emotional outcome.” (Benoit, 2004)
While both terms are often used interchangeably, they are in fact different directions of the mother-infant dyad. In brief terms, bonding is the connection a mother experiences toward her baby and is established during pregnancy and directly after birth through direct skin-to-skin contact (Benoit, 2004; Karakas & Dagli, 2019).
Attachment refers to the connection the infant develops with their primary caregiver (usually the mother). The level of attachment directly impacts the child’s future ability to function in relationships, in social settings and within the wider community (Hong & Park, 2012). It is further defined as “a strong disposition to seek proximity to and contact with a specific figure and to do so in certain situations, notably when frightened, tired or ill.” (Bowlby cited in Ercelik & Yilmaz, 2023).
Recipe for a secure attachment – what is the secret?
Benoit (2004) explains that a secure and organised attachment results when provided with:
| Warmth: |
Sensitive and loving responses to infant’s cues (especially distress), offering and welcoming closeness and comfort appropriately.
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Predictable responses expected by infant over a multitude of interactions in response to infant distress.
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| Safe: |
Offering reassurance and comfort in distress, responding protectively.
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| Responsive: |
Appropriately recognising AND responding to infant cues.
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In the above environment, an infant learns the appropriate action when feeling distressed (seeking the caregiver) thus resulting in an organised and secure attachment. (Benoit, 2004)
Figure 1: Illustration of dynamic co-regulation adapted from Fair-Field, 2017
What happens in deviations of attachment when the warning light is activated?
Retreat!
As mentioned previously, secure attachment is formed when the primary caregiver (usually the mother) responds to the infant’s activated distress signal appropriately and quickly. What happens when this does not occur?
When a parent or caregiver consistently responds to the infants distress in a negative way devoid of sympathy this results in an organised but insecure attachment style. The infant learns that displaying negative emotions results in unpleasant and unwanted responses. They then minimise these pleas for help to avoid being ridiculed, ignored or chastised. (Benoit, 2004)
The absence of a safe and warm space to get help regulating their emotions results in an ‘insecure - avoidant’ attachment (Ercelik & Yilmaz, 2023). The infant learns to avoid the caregiver when experiencing distress, is denied co-regulation that further impacts their ability to self-regulate throughout their life (Benoit, 2004). This can have a huge impact as the infant concludes they need to guard their feelings, have trouble developing trust with others and therefore struggle to form healthy, intimate relationships later in life.
Failure to launch
The third type of organised attachment is the ‘insecure – resistant’ style. This is where the caregiver responds in inconsistent and unpredictable ways to the infant showing a distressed signal. The parent could be amplifying the infant’s distress or engaging the infant to be concerned about the caregiver’s own needs.
The infant in this environment learned to exaggerate their displays of distress and negative emotion in the hope of capturing their caregivers’ attention and response. This too results in social-emotional maladjustment when the pattern of displaying extreme negative emotions such as anger, distress and resistance is not effective in developing healthy relationships with other. (Benoit, 2004)
Mayday! MayDay!
Disorganised …. or disaster?
Disorganised attachment is the name given to an infant’s response to specific forms of distorted and unusual behaviours from their caregiver. Benoit (2004) further expands on this as “frightening, frightened, dissociated, sexualised or otherwise atypical “behaviours displayed by caregivers during interactions with the infant that are not limited to when the child is distressed.
This type of response is extremely detrimental to the infant’s development. In later life, individuals with a disorganised attachment tend to display unusual and disorganised behaviours including misdirected or stereotypical behaviour, simultaneous displays of contradictory behaviours, stilling and freezing and irrational fear/anxiety (Hornor, 2020).
What are the predicted outcomes of a disorganised attachment?
- Significantly higher predisposition to psychopathology
- Maladjustment and inability to organise and regulate emotions
- Higher levels of peer conflict
- Difficulty trusting anyone – resulting in isolation, poorer mental health
- Overly trusting without cause – resulting in increased risk of physical, sexual and emotional harm
- Lack of empathy – resulting in superficial, often unable to sustain long-term relationships
- Poor cognitive development
- Greater risk of mental health disorders and physical illness
- More vulnerable to stress and altered states of mind, such as dissociation
- Problems with regulation and control of negative emotions
- Display oppositional, hostile and aggressive behaviours & coercive interaction
- Higher risk of substance abuse
- Community interactions
- Genetic predisposition to illness, including cardiovascular disease, inflammatory disease & chronic pain (32)
- Domestic violence and child abuse/trauma
- Perpetuated cycle with future children
- Community cost of health care, prisons, rehab/reintroduction to society
(Hornor, 2020; Benoit, 2004; Gurol & Polat, 2012).
What is co-regulation and why is this important?
Self-regulation is a crucial skill to interacting with others – friends, family, wider community. It is the ability to manage individual thoughts and feelings to enable goal-directed actions and responses (Rosanbalm & Murray, 2017).
Co-regulation is defined as the supportive process between a caregiver and infant that fosters the development of self-regulation skills. The level of co-regulation required is directly proportionate to the infant’s ability to self-regulate. (Fair-Field, 2024)
For this ability to develop optimally, caregivers need to be able to recognise and respond appropriately and quickly to the cues/needs of the infant. For example, when hungry: feed them, when tired: help them to sleep, and when distressed or overwhelmed: offer comfort and cuddles. (Fair-Field, 2024)
By recognising the infant cues appropriately, caregivers are better equipped to respond to the needs effectively. This in turn improves the infants trust in the caregiver, promoting the development of neuropathways for a secure attachment (Rosanbalm & Murray, 2017). Additionally, parents experience satisfaction and increased confidence in their parenting abilities (Fair-Field, 2024). This in turn, fosters the development of secure attachment within the mother-infant dyad.
In the author’s observations, it can be difficult to distinguish between some of these cues, causing distress and feelings of inadequacy in the caregiver when they have not achieved success. Discouraged when they are not instinctively able to identify and resolve the infant’s distress, they tend to disengage, and a rupture or mismatch develops in the relationship as shown in the diagram (Fair-Field, 2024).
-(1).png "_Figure-2-A-mismatch-between-a-child-and-parent-when-the-child-bids-(Adapted-from-Fair-Field-2017)-(1).png")
Figure 2: A mismatch between a child and parent when the child bids, adapted from Fair-Field, 2017
How does massage promote healthy/secure attachment?
Infant massage, especially when provided by the caregiver, is a scientifically proven practice that has demonstrated positive effects on attachment, physical health, development and mental health for both mother and infant (Nousia, 2023).
Touch is the first form of communication that an infant learns (Ercelik & Yilmaz, 2023). It is recognised as fundamental to the infant’s psychosocial and physical development and plays an important part in strengthening/fortifying the bonding process and attachment (Weatherford, 2022).
Infant massage is an effective tool to promote attachment as it fosters close proximity, serve-and-return episodes of communication, prolonged eye contact, sensory stimulation with skin-to-skin contact, vocalisation and engagement through singing, talking and joint attention. (Weatherford, 2022; Mcclure, 2017; Gnazzo et al. 2015; Nousia, 2023)
Programs such as the IMIS (Infant Massage Information Service) promote attachment and enhance parent-infant interactions through nurturing touch and respectful communication.
What are some of the key-ways massage promotes attachment?
- Routine – offering infant massage daily, offers predictability and consistency in the infant’s day, one of the core requirements identified for a secure attachment.
- Fostering respectful communication and teaching ability to say ‘no’ (permission sequence) is another crucial step in recognising infant responses as well as teaching them self-regulation skills (Rosanbalm & Murray, 2017).
- Improving parent confidence in their ability to recognise cues, thus improving confidence in parenting abilities and reinforcing dynamic co-regulation (Fair-Field, 2024).
- Skin-to-skin contact improves bond and connection by increasing oxytocin levels in both mother and infant (Moussa et al. 2021).
- Massage provides quality, intimate, one-on-one time together which fosters connection and positive engagement (Porreca et al. 2017).
- Observable increases in the infant’s attentiveness, ‘livliness’ and happiness result in interactions that are mutually satisfying (Elgohail & Geller, 2021).
- Massage and success in responding to infant cues promotes positive perceptions of infant’s temperament, rather than forming thought patterns that they are ‘annoying’ or ‘sabotaging’ (Hartanti, Salimo & Widyaningsih, 2019).
- Promotes positive adaptation and attitudes towards being a mother (Elgohail & Geller, 2021).
- Parents providing regular infant massage also experience a reduction in the release of stress hormones (Mrljak et al. 2022).
- Many parents are limited in their ability to respond appropriately to their infants’ cues and be emotionally available as a result of their own adverse childhood experiences. Learning and providing infant massage promotes healing of parent’s own experiences of childhood trauma or sub-obtimal attachment themselves, enabling them to be the parent they wish to be, rather than the parent they had (Chamberlain et al. 2019).
- Infant massage promotes relaxation and improves sleep quality, resulting in reduced crying and increased maternal satisfaction (Hartanti, Salimo & Widyaningsih, 2019).
How does infant massage improve mental health outcomes?
Research has shown that participating in infant massage regularly results in a significantly faster reduction in PND symptoms (Dehkordi et al. 2018; Gnazza et al. 2015).
Furthermore, it allows the parent more intentional and meaningful interactions that have shown to improve the mother’s confidence in providing infant cares, and their ability to recognise and appropriately respond to their cues (Porreca et al. 2017; Danielsson et al. 2024). This in turn impacts maternal satisfaction, decrease in guilt and improved overall mood (Lotfalipour et al. 2019; Danielsson et al. 2024).
The regular provision of skin-to-skin contact promotes bonding and results in the release of oxytocin in both mother and infant, create more feelings of love, enjoyment and connection. (Geary, Grealish & Bright, 2023). The improved connection between mother and baby becomes a great motivator and catalyst for change. It provides opportunity for healing of past trauma and breaking cycle of adverse childhood events (Chamberlain et al. 2019).
But wait, there’s more!
Infant massage impact on the wider community
- Reducing abuse, violence and crime
- Improve health outcomes and weight gain, especially in pre-term infants resulting in shorter hospital stays
- Improved mental health outcomes for both mother and baby, improving connections and contributions in their communities
- Contributes to normal psychosomatic development that promotes healthy, respectful relationships through to adulthood
- Improved overall health, with less demand on healthcare systems and funding
- The improvement of bond/attachment between the parent and infant results in close family connection with strong foundations in the community.
(Nousia, 2023)
This sounds great! Where do we sign?
Infant massage is a cost-effective co-therapy that can be offered in a variety of settings. It requires very minimal equipment and is able to be replicated by the parents with ease. (Danielsson et al. 2024)
Child Health in particular, is ideally positioned to connect with mothers and infants, particularly those struggling with mental health or adjusting to motherhood. The ability of Child Health Nurses to provide infant massage instruction in small groups could also help to engage mothers with social anxieties that would otherwise not attend by providing a focused intent not dependant on peer engagement.
In a one-on-one setting this can also help to improve nurse-parent rapport and therefore better health outcomes for the mother, infant and wider family.
In conclusion, the power of touch is profound. Infant massage can lead to a wide range of physiological, psychological and social benefits for both the infant and their parent (Elgohail & Geller, 2021). While no one can respond perfectly all of the time, by enabling the caregiver to respond quickly and warmly ‘most of the time’, they will have created secure and organised attachment for their infant with all of the associated benefits. (Benoit, 2004).
References:
Benoit, D 2004, 'Infant-parent attachment: Definition, types, antecedents, measurement and outcome', Pediatric Child Health, vol. 9, no. 8, October, pp. 541-545, doi:10.1093/pch/9.8.541
Chamberlain, C, Ralph, N, Hokke, S, Clark, Y, Gee, G, Stansfield, C, Sutcliffe, K & Brown, S 2019, 'Healing The Past By Nurturing The Future: A qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment', PLoS One, vol. 14, no. 12, December, doi:10.1371/journal.pone.0225441
Danielsson, M, Lustig, H, Garmy, P & Einberg, E 2024, 'Mothers' experience of infant massage in child health care: A qualitative interview study', Nursing Open, vol. 11, no. 6, June, doi:10.1002/nop2.2206
Dehkordi, Z, Hosseini-Baharanchi, F, Kazemian, A, Madiseh, M, Reisi, M & Motaghi, B 2018, 'The Effects of Infant Massage on Maternal Postpartum Depression: A Randomized Controlled Trial', Nursing and Midwifery Studies, vol. 8, no. 1, Jan-Mar, pp. 28-33, doi:10.4103/nms.nms_80_17
Elgohail, M & Geller, P 2021, 'The Power of Touch: Benefits of Infant Massage for Infants and Their Parents', Neonatology Today, vol. 16, no. 5, May, pp. 73-76, doi:10.51362/neonatology.today/202151657376
Ercelik, Z & Yilmaz, H 2023, 'Effectiveness of infant massage on babies growth, mother-baby attachment and mothers' self-confidence: A randomized controlled trial', Infant Behavior and Development, vol. 73, November, doi:10.1016/j.infbeh.2023.101897
Fair-Field, T 2024, Early Co-Regulation In The Infant And Parent Dyad, Occupationaltherapy.com, viewed 1 September 2024, <https://www.occupationaltherapy.com/articles/early-co-regulation-in-infant-5701>
Geary, O, Grealish, A & Bright, A 2023, 'The effectiveness of mother-led infant massage on symptoms of maternal postnatal depression: A systematic review', PLoS ONE, vol. 18, no. 12, December, doi:10.1371/journal.pone.0294156
Gnazzo, A, Guerriero, V, Di Folco, S, Zavattini, G & De Campora, G 2015, 'Skin to skin interactions. Does the infant massage improve the couple functioning?', Frontiers in Psychology, vol. 6, September, doi:10.3389/fpsyg.2015.01468
Gurol, A & Polat, S 2012, 'The effects of baby massage on attachment between mother and their infants', Asian Nursing Research, vol. 6, no. 1, Mar, pp. 35-41, doi:10.1016/j.anr.2012.02.006
Hong, Y & Park, J 2012, 'Impact of attachment, temperament and parenting on human development', The Korean Pediatric Society, vol. 55, no. 12, pp. 449-454, doi:10.3345/kjp.2012.55.12.449
Hornor, G 2020, 'Attachment Disorders', Journal of Pediatric Health Care, vol. 34, no. 1, Jan-Feb, doi:10.1016/j.pedhc.2019.09.005
Karakas, N & Dagli, F 2019, 'The importancec of attachment in infant and influencing factors', Turkish Pediatric Association, vol. 54, no. 2, Jul, pp. 76-81, doi:10.14744/TurkPediatriArs.2018.80269
Lotfalipour, B, Tirgari, B, Pouraboli, B & Mirzaee, M 2019, 'Effect of Preterm Infant Massage by the Mother on the Mood of Mothers Having Preterm Infants', Journal of Chiropractic Medicine, vol. 18, no. 1, Mar, pp. 67-76, doi:10.1016/j.jcm.2018.11.001
McClure, V 2017, Infant Massage: A Handbook for Loving Parents, 4th edn, Random House USA Inc, US.
McLoughlin, H 2017, Infant Massage Training Manual and student handbook for correspondence study, 3rd edn, Infant Massage Information Service, Australia.
Moussa, S, Fawaz, L, Ibrahim, W, Elsayed, M & Ahmed, M 2021, 'Effect of Infant Massage on Salivary Oxytocin Level of Mothers and Infants with Normal and Disordered Bonding', Journal of Primary Care & Community Health, vol. 12, no. 1-8, Jan-Dec, doi:10.1177/21501327211012942
Mrljak, R, Danielsson, A, Hedov, G & Garmy, P 2022, 'Effects of Infant Massage: A Systematic Review', International Journal of Environmental Research and Public Health, vol. 19, no. 11, May, doi:10.3390/ijerph19116378
Nousia, A 2023, 'Healthy touch and infant massage: Two main factors in infants daily care and healthy development', European Journal of Education Studies, vol. 10, no. 6, doi:10.46827/ejes.v10i6.4854
Porreca, A, Parolin, M, Bozza, G, Freato, S & Simonelli, A 2017, 'Infant Massage and Quality of Early Mother–Infant Interactions: Are There Associations with Maternal Psychological Wellbeing, Marital Quality, and Social Support?', Frontiers In Psychology, vol. 7, January, doi:10.3389/fpsyg.2016.02049
Potgieter, K & Adams, F 2019, 'The influence of mother-infant skin-to-skin contact on bonding and touch', South African Journal of Occupational Therapy, vol. 49, no. 2, Aug, pp. 11-17, doi:10.17159/2310-3833/2019/vol49n2a3
Rosanbalm, K & Murray, D 2017, Co-Regulation From Birth Through Young Adulthood: A Practice Brief, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services, viewed 1 September 2024, <https://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://fpg.unc.edu/sites/fpg.unc.edu/files/resources/reports-and-policy-briefs/Co-RegulationFromBirthThroughYoungAdulthood.pdf>
Tri Hartanti, A, Salimo, H & Widyaningsih, V 2019, 'Effectiveness of Infant Massage on Strengthening Bonding and Improving Sleep Quality', Indonesian Journal of Medicine, vol. 4, no. 2, pp. 165-175, doi:10.26911/theijmed.2019.04.02.10
Weatherford, C 2022, 'The International Association of Infant Massage Programme and Parent-Infant Relationship Outcomes: A Systematic Review ', University of Canterbury. April, doi:10.26021/12937