Postpartum Anxiety & Infant Attachment

Abstract

The postpartum period after birth can come with a lot of unknowns for women across the globe. Many are hit with depression, obsessive-compulsive disorder, and even psychosis. However, there is a lack of research and awareness to Generalized Anxiety Disorder with postpartum onset. This can leave many women on shaky ground and aware of what or when to speak to their provider. Depression has shown to have a negative impact on infants, however, with anxiety being on the opposite scale, it brings more positivity to the mother-infant bond. This study uses the Spielberg State-Trait Anxiety Inventory (STAI), Edinburgh Postnatal Depression Scale (EPDS) and Clinician Severity Scale to access the anxiety levels of new mothers throughout their first year. During the sessions, mothers physical touch and eye gaze was recorded to access increase physical touch between mothers with anxiety and infants. At the end of the 12 months, the child is given the Strange Situation Test to assess their levels of attachment.

Keywords: Postpartum anxiety, Generalized Anxiety Disorder, Infant Attachment, Edinburgh Postnatal Depression Scale.

In Connecticut, 10.4% of women will report experiencing depressive symptoms during or after pregnancy (Americas Health Ranking, 2018). This is not only an issue found within Connecticut or the United States but worldwide. Postpartum depression, anxiety, psychosis or mood-related issues do not target just those in low-income households but all income brackets. What has been studied with regard to postpartum depression is that those with mood-related issues have a higher risk factor of reoccurrence or worsening in the week's post birth. Generalized anxiety with postpartum onset, as described in the DSM V, is making its way into the forefront of the minds of practitioners and starting its way on to the general population’s radar (American Psychiatric Association, 2013). Postpartum can be a scary time for many women due to the fluctuating hormones and new circumstances they have found themselves in, whether it be their first child or their fourth. Not only can women have depression but anxiety as well, which is summarized as excessive worry and uncontrollable repetitive thoughts. Physical symptoms can also manifest such as dizziness, nausea, heart racing, in addition to possible obsessive-compulsive tendencies. The symptoms of anxiety are often misdiagnosed and placed under postpartum depression. Yet they are quite different both in symptoms as well as child’s wellbeing. One of the reasons to look more in-depth into anxiety with postpartum onset is that too often postpartum anxiety is overshadowed by that of postpartum depression. Surprisingly one study found postpartum anxiety was 11% and the prevalence of postpartum depression was only at 6.1% (Reck, Struben, Backenstrass, Stefenelli, Reinig, Fuchs, & Mundt, 2008). This corresponds with Perinatal Generalized Anxiety Disorder (GAD) having a prevalence of 8.5% —10.5% compared to 4.4% — 10.8% found to be depressed (Misri, Abizadeh, Sanders, & Swift, 2015). A lot of women are not aware that there are other emotional side effects of postpartum aside from the widely known depressive symptoms.

The more studies that are done on topics such as this, will create more awareness and allow for a wider support group for mothers in need of assistance. It is believed that due to the anxiety, mothers with postpartum will hold infants for longer amounts of time and hold longer periods of eye gaze. The act of physical closeness and holding the infant for long periods of time will create a strong physical and emotional bond with the infant that will last into childhood. The simple process of holding the child lowers rates of SIDS along with increasing cognitive developments. Psychiatrist John Bowlby, has studied this issue of mother and infant relationship through attachment. According to his Attachment Theory, it has been found that physical attachment is of critical importance biologically for the infant as well as the mother. Infants are naturally proximity-seeking due to the caregiver is there only means for safety and security (Sullivan, Perry, Sloan, Kleinhaus & Burtchen, 2011). This bond is crucial within the first year of life and if the infant does not receive an adequate amount of closeness or lack of needs being met, can result in trust or issues found late in adulthood as Freud has mentioned in a multitude of his articles. Another reason is that they will be more attentive to the child, allowing shorter cry times than that of a normal functioning or depressive mother. Those with GAD (Generalized Anxiety Disorder) have an easier time identifying happy faces at a lower intensity otherwise known as subtle cues, than that of the control group and depressed mothers. Arteche, et al, found that this enhanced sensitivity could be a mother’s way of seeking reassurance due to fear of negative events and worries over her parenting behaviors (Arteche, Joormann, Harvey, Craske, Gotib, Counsell, & Stein, 2011). Mothers with depressive symptoms tend to be less responsive to their infant hindering the bond formed between mother and child. However, mothers with anxiety tend to be hypersensitive to the child's needs and showed higher levels of bonding with their child (Maigun Edhborg & Hashima-E Nasreen & Zarina Nahar Kabir, 2011).

Not only does the mother’s mood affect the child but anxiety during pregnancy can have an impact on the infant's temperament. This could make it difficult to assess whether the infant’s mood influences or triggers the mother’s anxiety and/or depression opposed to the mother influencing the infant. McGrath, Records, and Rice (2008) found infants with depressive mothers would cry more than other infants also being 3 months of age. Unfortunately, a lot of the research focuses on depression and little can be found with regards to anxiety as the sole diagnosis. Due to anxiety having so many facets to it, one of the symptoms of anxiety could be an obsessive-compulsive disorder (OCD). Mothers with anxiety have symptoms of OCD and are more hypersensitive to their infant’s needs. This can cause the mother to be more in tune with their newborns needs resulting with the infants being comforted more often compared to other mothers (Challacombe, Salkovskis, Woolgar, & Read, 2017). There is an abundance of literature showing negative effects of anxiety on infants’ development. This can be due to the implication’s anxiety has on the growing infant perinatally, however, the mothers' symptoms can be lessened or go away entirely once the child is born (Della Vedova, 2014). This is what makes it difficult to study, due to the anxiety is often found during pregnancy or for a lot of women only a short period of time thereafter. During the postpartum period, anxiety can be found comorbid with other disorders such as obsessive-compulsive disorder, depression, agoraphobia, and even psychosis. The services available for women suffering from postpartum are limited and unfortunately, the women would have to go searching for help on her own. The support groups are scattered through Connecticut and leave large areas without a local support group. The needs for women within Connecticut are not being met and practitioners need to bring awareness of this disorder to the public. Women do not need to suffer in silence along with more research to find out how this can impact the children so that we are aware of any issues that can arise.

Throughout a woman's pregnancy, she often meets, at least once a month, with her gynecologist. During these visits, they check weight, blood pressure, and the fetus' heartbeat. However, they do not check on the wellbeing of the mother. As Dr. Pam Haskin's has given me an overview on their process, they ask the mother, 'How are you doing/feeling' and this is the time when the mother is to speak up about any depressive or anxiety symptoms. This also corresponds with the process for the postpartum visits where the mother comes in within two weeks of delivering to check in and make sure everything is healing correctly. One of the tools that obstetrics uses to assess their mood level is the Patient Health Questionnaire (PHQ-9) or the EPDS assessment. Yet, it is not normal protocol for every mother to be given an inventory or questionnaire on their moods since delivering. If the mother is found to be positive for suffering from anxiety or depression, the gynecologist will put her on a Selective Serotonin Reuptake Inhibitor otherwise known as an SSRI, to assist with the symptoms. They may also request for her to seek mental health treatment in addition to the medication.

Another strategy for collecting information regarding the level of anxiety found in the community is a questionnaire given halfway through their pregnancy, again towards the end and then at their postpartum checkup to adequately assess how they are feeling without the woman having to say it. A lot of women may feel embarrassed about her feeling which may deter her from being upfront about it, but the questionnaire can pick up on their symptoms. As Dr. Haskins, who is a gynecologist located in Enfield, CT, mentioned there is a good amount of research regarding mothers with depressive symptoms and how they have a higher likelihood of having an irritable child who will cry more on average than those without a mother with postpartum depression. There is little data on the topic of how anxiety will impact the infant's temperament, especially regarding the fact that infants will react differently based on several factors such as their predisposed temperament (Britton, 2011). We both agreed that there is a need to look more into mothers with postpartum anxiety and its impact on an infant's attachment. Based on the data out there thus far for depressive mothers, we need more data on anxiety so that doctors can know how to handle it appropriately. Too often, women are put on medication as a band-aid for the symptoms but there may be a genetic reason for this, especially seeing a high number of women with anxiety. Infants may benefit more from having mothers who are quicker to tend to their needs, resulting in lower cortisol levels and higher trustworthiness in their parents (Gunner, R., & Donzella, B., 2002). The more women we have documented for anxiety, the better we are at knowing more about it and can access the connection between mother and infant.

Proposed Research

Design

This is a quantitative, within-group study looks at the naturalistic play between mother and infant in a controlled environment observing the difference between mothers with anxiety and the control group as the independent variable. The dependent variable will be found at the end of the one-year time frame with regards to the child’s attachment style. The physiological phenomena can better assess relationship building through physical touch and eye gaze. It is expected that children having anxious mothers will have a secure attachment due to the physical bond and increased eye gaze creating a stronger bond. During each session, the mothers and children would be placed together in a play center room. Each mother wearing eye trackers and researchers watching from a camera to track physical touch. The data will be coded and analyzed using SPSS.

Participants

The participants were found through local women’s centers, referred by doctors and responded to local ads. The participants were from Connecticut, in the United States within lower to middle-class American families. In order to limit the response bias, the advertisement said researchers are looking at mother and infant interaction throughout the first year. This would also hinder the mother focusing on her own reactions by getting relaxed with the process during the lengthy study time frame.Instruments

The mothers will be given Spielberg State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale (EPDS). The EPDS was found to effectively identify depression in women who are pregnant or post-delivery. While the STAI measures anxiety symptoms and caregiver distress and then distinguishes them from depressive symptoms. In order to find the severity of where they fall on the scale of depression or GAD, they were then given Clinician Severity Rating. Once the infant's hit 12 months, the Strange Situation (SS) was given to evaluate the infant's reaction to the caregiver. Upon reviewing the results, those found with anxiety will be placed within the testing group. Mothers with no depression or anxiety are put in the control group. The mother and infants will be in a videotaped room, meeting every three months for observation. During these sessions, the amount of physical touch will be counted via the researcher and assistants. Along with physical touch, the amount of average fixation eye contact will be measured through eye tracking optics.

Procedure

The families are coded into 2 groups. Group 1 was mothers with anxiety only symptoms, and group 2 being mothers with the absence of any depression or anxiety. These women were divided up based on how they scored on the self-report data of the EPDS and STAI. The study was done at a daycare center in Enfield, Connecticut. Upon entering, the mothers would sign the consent form, acknowledging their compliance with being recorded. Once in the room, the mother and infant pairs would be in a room suitable for that child's age. Toys were out and available to the child while the mother was given a questionnaire to fill out. During this time, the research assistants were observing on the camera how many times the mothers would make physical contact with the child. If the child cries, the observers would also time how quickly the mother would tend to the child. This procedure will be repeated with the same groups starting at 3 weeks of age and then every 3 months for the first year of the child’s life. Each session lasted 20 minutes on average. We also observed the eye tracking log to see how many times and how long eye gaze was held. The room was being recorded so that touch can be accessed more accurately. At the final session when the infant is a year, the mother and infant will return for The Strange Situation is set up with an 8 step procedure in 1969 by Mary Ainsworth and still widely used today. The steps are (1) Mother, baby, and experimenter (lasts less than one minute) (2) Mother and baby alone (3) A stranger joins the mother and infant (4) Mother leaves baby and stranger alone (5) Mother returns and stranger leaves (6) Mother leaves; infant left completely alone (7) Stranger returns and (8) Mother returns and stranger leaves. Each step will only last about 1-3 minutes.

Data Analysis

In order to convey the prevalence found within the data between these groups, the descriptive analysis will be used with a one-way analysis. If the data is found to be significant, a posthoc test will be used to compare the differences in group means. To analyze the data we will be using a two-way ANOVA to look at the two independent variables, those being the amount of physical touch and eye gaze. These will be put against those with the anxiety group and the control group by level of change in the dependent variable which is the infant’s attachment style. Another statistical analysis that will be used is a chi-square because we expect a high number between the independent variables of eye gaze and physical touch between mother and child when compared to that of the control group. The Strange Situation test will be scored using the data marked on the graph observing proximity and contact Seeking, contact maintaining, avoidance of proximity and contact and resistance to contact and comforting which will be recorded every 15 seconds. Lastly, correlations between the variables will be accessed through a Pearson correlation analysis with the scores found on the Strange Situations Test measuring attachment.

Results

Based off anticipated results the mothers with anxiety will be more attentive to their infants needs however this is a hard concept to say for sure due to the lack of previous research. The expected results between the anxiety group and the infant is an increased amount of physical contact along with prolonged eye gaze held. The infants in this group will show increased distress while the mother leaves the room during the (SS) test. The increase distress with separation anxiety will show a more secure attachment with the mother. This can be due to the caregiver being routinely sensitive to their needs and often having that constant physical contact bond already built.

Discussion

It is expected that children having anxious mothers will have a secure attachment due to the physical bond and increased eye gaze creating a stronger bond. Based on our expected data, doctors should begin testing for anxiety beginning during pregnancy and carry those questionnaires into their postpartum appointments. The more we know about when the anxiety symptoms start, the better we can identify possible temperamental issues infants will show during their first year. These questionnaires and mental checkups will also bring awareness to the mothers of other outcomes they may be met with post-delivery. Postpartum depression is well-known alongside the serious issue of psychosis. Psychosis being the serious mental illness where a mother is not only depressed but shows signs or admits to wanting to hurt herself and her child/children (Rai, Pathak, & Sharma, 2015). Women may find themselves caught off guard with the anxiety portion seeing as it is not expected as well as be less likely to admit it to a healthcare provider due to not knowing that it is a disorder. Most new mothers are bound to be met with fear and anxiety and think what they are feeling is normal but there is a fine line where it becomes Generalized Anxiety Disorder and women need to know what is deemed normal and when they need to speak up to their doctor. As with many aspects of life, if one aspect is thrown off, the repercussions tend to trickle down the line. The new way of life found for mothers followed delivery of their child can be a rough, especially if they do not feel they are being supported.

This can be transferred onto the father in the home, with feelings of uncertainty on how to help their significant other at this time. The fathers may also be brushing off her emotions as hormones and this can also lead down to the infant. Joining the world can also take some getting used to her newborns and their inability to provide anything for themselves. There can be a scale of ways for parents to provide or not provide for their young, as seen in failure to thrive as a more serious outcome. During this time however is when young start building their knowledge of trust within their caregivers so there can be difference found between those children who are left to cry for a certain period of time versus those whose needs are met as soon as possible. The most physical contact and quicker response time found in mothers with anxiety can aid in the child's sense of safety and security.

The results of this research are important in building on the limited research that is out there focusing solely on anxiety. Depression has been seen as a negative in regards to the child's safety and attachment style so it is time to separate these two diagnoses. There were a few limitations in this study. The first limitation is that the mothers knew they were being watched so their reactions or reaction time may not be transferable to their real-world response times. New mothers may also be hyper-sensitive to being critiqued on their parenting so they will be less likely to respond to their child as they normally would. The second limitation is the study is focusing on the mothers. In households nowadays, fathers are just as big of a part of child rearing as the mothers are. In instances the mother lacks, the fathers may pick up or vice versa.

This can be an area to look at for future research. Looking at the family as a whole unit, involving the mother and the father in studies can give us better insight into what dynamics play into attachment. In previous research, like the study done by Geoffrey Brown, that there may be something to the term, 'Daddy issues' that we hear so much with the movies. In his study, he found that the infant-attachment was strongest between the infant-father instead of the infant-mother group. They also found that the child's gender, as well as the co-parenting relationship, can play a role in the attachment style to a particular parental figure (Brown, Schoppe-Sullivan, Mangelsdorf, & Neff, C., 2010). A final aspect to take into account is that some women will opt to be placed on medication. This can skew the data responses as well increase the dropout rate, especially for a longer study such as this.