It may be possible to identify infants at risk of developing behavioural problems and to intervene early to improve outcomes. Atypical mother-infant attachment could be one indicator of risk. The primary aim of this study was to examine the association between self-assessed mother-infant attachment and the offspring´s behavioural problems in childhood and early adolescence. This study was based on data from the first Growing up in Scotland (GUS) birth cohort (n = 2225). Mother-infant attachment was assessed with the Maternal Postnatal Attachment Scale 10 months postnatally and child mental well-being was assessed with the Strengths and Difficulties Questionnaire collected when the child was 7–8 years, 10–11 years and 12 years old. Multinomial logistic regression was used to examine the association between mother-infant attachment and mental health. Weaker reported mother-infant bonds were associated with later higher risk of child problems in most SDQ subscales at ages 7–8 and 10–11. For boys, some risks persisted until age 12, while all associations faded for girls. The study confirms a link between maternally reported weak attachment and behavioural problems, with the strongest effects in boys.
Depression, anxiety, attention-deficit/hyperactivity disorder, conduct disorder and autism spectrum disorders during childhood and preadolescence are a global concern [39]. Behavioural problems associated with these conditions often have a negative impact upon a child’s academic ability, social capacity and emotional development both in and outside the school setting [8, 16, 41]. An examination of potential early risk factors for child and adolescent behavioural difficulties is one of the steps necessary for reducing or preventing behavioural problems.
Risk factors for behavioural problems include genetic factors [22] and family and/or social environmental factors [7, 38] including maltreatment in childhood [33]. Infancy regulation problems such as abnormal eating patterns and sleep disturbance also predict behavioural difficulties [20]. Although the emergence of behavioural difficulties is complex and multidimensional, the early parent-infant relationship is also associated with the infant’s development: atypical parent-infant interactions are independently associated with an increased risk of developing behavioural problems [1, 28]. The early attachment relationship between mothers and infants, including the more specific aspect of a mother’s self-assessed bond with her infant, may also predict a range of developmental outcomes, including behavioural problems and overt psychopathology [11]. The motivation for examining attachment, measured by the maternal self-assessed bond with her infant, as a potential factor in emerging behavioural problems is to allow early intervention, potentially reduce the risk of later psychopathology.
Several studies point towards a link between mother-infant attachment and psychopathology [6, 25, 27], although few have confirmed that the link remains through preadolescence [2, 32]. Given that existing studies are either based on small samples or unable to report on long-term follow-up, further work is needed to confirm the association. Supporting early mother-infant attachment may be an effective strategy for reducing offspring behavioural difficulties but we need to fully understand the long-term link between mother-infant attachment and later behavioural outcomes. This paper aims to examine the association between self-reported mother-infant attachment and behavioural problems measured in childhood and early adolescence in a cohort of Scottish families.
Methods
Aim
The aim of this study was to examine the association between self-reported mother-infant attachment and the offspring´s behavioural problems in childhood and early adolescence.
Design and Setting
This study was based on data from the Growing up in Scotland cohort (GUS) [3]. GUS is a nationally representative cohort tracking 5,217 children born in 2004 and 2005 from infancy. All participating families provided written informed consent. Data were analysed from the first (10 months), the seventh (7–8 years), the eighth (10–11 years) and the ninth (12 years) sweeps of birth cohort 1. The protocol for this study is available and registered at The Open Science Framework (https://osf.io/s6uyh/).
Participants
Families participating in the GUS cohort were selected at random from Child Benefit records, 97% of eligible Scottish families received this benefit at the time of recruitment. The families were recruited by stratified cluster sampling, and the sample equated to 10% of children born during the recruitment period. For more information, visit https://growingupinscotland.org.uk/.
Our analysis sample was restricted to singleton children living with their parent(s) (n = 5120), where the mother had completed the questionnaire regarding maternal attachment at 10 months (n = 4561) and with at least one completed Strengths and Difficulties Questionnaire in sweeps seven, eight or nine (n = 3116) ( Fig. 1).
Maternal attachment was based on a selection of six items from the original 19-item self-report Condon Maternal Postnatal Attachment Scale [9] which has been used to assess self-reported attachment in other UK populations (questions presented in Additional file 1) [30]. The modified Condon questionnaire has previously demonstrated strong internal reliability (alpha = 0.82) [15]. Each of the six items is scored on a scale with responses ranging from 1, suggesting low attachment security, to 4–6 suggesting high attachment security. A total mean score was calculated ranging from 1 to 5. This scoring method differs from the original MPAS, and the deviations are clearly outlined in Additional File 1. We followed the methods of Wadman et al. [30, 37] [30] and defined two categories: a weak attachment group with a threshold identifying the 10% with the weakest attachment compared to a strong attachment group including the remaining 90%.
Behavioural Difficulties
English (UK) 4–16 year old versions of the Strengths and Difficulties Questionnaire (SDQ) [12] were parent-reported at 7–8 years, 10–11 years and 12 years of age. The SDQ is a screening instrument intended to assess five areas of social-behavioural development during childhood and adolescence: emotional symptoms, hyperactivity/inattention, conduct problems, peer relationship problems and pro-social behaviour. SDQ can be completed by parents, caregivers, teachers and children/adolescents themselves [12]. SDQ’s 25 questions are each rated on a 3-point Likert scale giving scores of 0, 1 or 2. In this study, we examined behavioural difficulties in all of the five subscales (five questions in each) together with the Total Difficulties Scale (obtained by summing all subscale scores except for the prosocial behaviour score). We applied the original 3-band categorisation: normal, borderline, abnormal, by using the sex-specific cut-off scores for each behavioural domain recommended for UK samples [13]. Abnormal scores were ≥ 17 for Total Difficulties, ≥ 4 for Conduct Problems and Peer Problems, ≥ 5 for Emotional Problems, ≥ 7 for Hyperactivity Problems, and ≤ 4 for Pro-social Behaviour [13].
Covariates
Covariate selection was informed by theoretical considerations and a directed acyclic diagram DAG (presented in Additional file 2) [14].
We chose to include information from Sweep 1 about the child’s birth order, maternal mental health during pregnancy (depression or other mental illness), maternal educational level (passed exams), father’s presence in household, prenatal alcohol consumption, smoking, low weight for gestational age (< 2,500 g) and colic.
Statistical Analyses
Multinomial Logistic Regression
The association between maternal attachment at 10 months of age and child behavioural outcomes in each subscale of the SDQ was evaluated in a multinomial logistic regression model and expressed as both crude and adjusted relative risk ratios with 95% confidence intervals (95% CI). In all analyses, the strong attachment group was considered the reference outcome. All three follow-ups were analysed separately and were conducted separately for boys and girls. Analyses were conducted in SAS 9.4 using proc logistic.
Accounting for Missing Data
In order to account for differential attrition inverse probability weights were included in an adjusted regression. Selective attrition was adjusted so respondents who had a low predicted probability of retention get a larger weight, increasing their representation in the sample at each follow-up. The propensity score was predicted by parity, maternal marital status, maternal cohabitation with natural father, maternal age at baseline, alcohol consumption during pregnancy, smoking during pregnancy, equivalised household income (in quintiles), urban/rural classification and highest household education at birth.
Results
15% (14.9) of the responding mothers were in the weak mother-infant attachment group. The mothers in the weak attachment group had similar sociodemographic characteristics to those of the mothers in the strong attachment group although they were slightly more educated, had higher income and consumed more alcohol during pregnancy. Infants in the weak mother-infant attachment group were more likely to suffer from problems with colic (Table 1).
Table 1
Sociodemographic characteristics of study population according to attachment
Maternal attachment
Strong
Weak
Missing
p-valuea
% (n)
% (n)
n
85.1 (2260)
14.9 (466)
Maternal age
5
< 0.01
Under 20
4.1
4.5
20–29
37.4
29.2
30–39
55.4
62.23
40 or older
3
4.1
Parity
-
0.6
0
48.4
48.3
1
24.4
36.7
≥ 2
27.2
15
Sex
0.11
Girl
50.3
54.3
Boy
49.7
45.7
Maternal mental illness during pregnancy
Present
38.31
38.3
38
0.99
Not present
61.69
61.69
Father in household
0.62
No
13.7
14.6
Yes
86.3
85.4
Maternal marital status
0.71
Single
31.8
33.2
Married and living with husband
62.7
61.8
Married and separated
2
1.3
Other*
3.5
3.7
Maternal educational status
8
< 0.0001
No qualifications
6
4.1
Lower standard grade or equivalent
26.6
24.6
Higher standard grades or equivalent
22.5
17.1
Higher grades or equivalent
14.1
11.7
Degree or higher
30.8
42.6
Equivalised household income
269
< 0.01
Bottom Quintile
14.5
14.2
2nd Quintile
19.9
14.4
3rd Quintile
19.8
18.2
4th Quintile
24.2
24.1
Top Quintile
21.7
29.1
Alcohol consumption during pregnancy
65
< 0.0001
Three times a week to every day
0.4
2.2
One to two times a week
2.7
5.9
Less than once a month to two times a month
22.5
35.5
Never - did not drink at all
74.4
56.5
Smoking during pregnancy
42
0.85
Yes, occasionally
9.7
9.5
Yes, most days
10.6
9.8
No
79.7
80.7
Child, small for gestational age
1
0.8
Yes
5.23
5.94
No
94.77
95.1
Colic
4
0.04
Yes, a big problem
18.3
21.5
Yes, a bit of a problem
29.3
32.4
No
52.4
46.1
a Chi-square test,
Behavioural problems
Table 2 reports the results of the association of mother-infant attachment with the offspring SDQ-scores. Including covariates and weights in the model did not change the associations substantially.
Table 2
Mother-infant attachment and behavioural problems at 7–8 years, 10–11 years and 12 years of age
a Adjusted for parity, maternal mental health during pregnancy, maternal educational level, father’s presence in household, prenatal alcohol consumption, low weight and colic
b Inverse probability weighted
* p < 0.05
At 7–8 years of age, weak mother-infant attachment was associated with an increased risk of emotional problems (RRRborderline: 2.32, 95% CI:1.77–3.06), conduct problems (RRRborderline: 1.3, 95% CI 1.03–1.65) and hyperactivity problems (RRRabnormal: 2.19, 95% CI: 1.57–3.06) among the girls. For the boys, weak mother-infant attachment appeared to be associated with an increased risk of elevated problem scores on the three subscales of emotional problems (RRRabnormal: 1.67, 95% CI: 1.28–2.18), conduct problems (RRRabnormal: 1.47, 95% CI: 1.16–1.86) and prosocial problems (RRRabnormal: 1.76, 95% CI: 1.25–2.49) together with an increased risk of total behavioural problems (RRRabnormal: 1.56, 95% CI: 1.2–2.03).
At 10–11 years of age, a weak mother-infant attachment was associated with an increased risk of conduct problems (RRRborderline: 1.85, 95% CI: 1.38–2.48)* and prosocial problems (RRRabnormal: 1.93, 95% CI: 1.09–3.41) together with indications of increased risk of emotional problems among girls. Increased risk of elevated problem scores for the emotional scale (RRRabnormal: 1.43, 95% CI: 1.05–1.94), peer problem scale (RRRabnormal: 1.38, 95% CI: 1.05–1.8), prosocial scale (RRRabnormal: 1.62, 95% CI: 1.08–2.45) and the total behavioural scale (RRRabnormal:1.67, 95% CI: 1.22–2.28) was found for the boys in the weak mother-infant attachment group at the same age.
At 12 years of age, we observed that all associations diminished for the girls and we observed no clear associations. For the boys, a weak mother-infant attachment was continuously associated with increased risk of problem scores in the peer problem scale (RRRabnormal: 1.46, 95% CI: 1.15–1.85), prosocial problem scale (RRRabnormal: 1.46, 95% CI: 1-2.13) and the total behavioural problem scale (RRRborderline: 1.67, 95% CI: 1.16–2.38).
Discussion
This study aimed to examine the association between maternal attachment and offspring behavioural problems throughout childhood and early adolescence. Weak mother-infant attachment increased the risk of later behavioural problems in several SDQ-subscales. These associations were consistent for boys up to twelve years of age, however no association between mother-infant attachment and behavioural problems was found for girls at 12 years of age.
This study had several obvious strengths: first, our study was prospective with long-term follow-up data. Second, analyses for potential confounders were adjusted by including maternal mental illness and if the father was present in the household among, other important factors. An additional strength was that the analyses were based on a large nationally representative sample of Scottish families.
This study has several limitations. There may have been some bias due to selective attrition, although we conducted weighted analyses to adjust for this. The weights were purely based on baseline sociodemographic, so the bias has been limited but not avoided. The main limitation and potential source of bias was the mothers’ involvement in both the attachment assessment and the SDQ responses. The mother’s participation in both our independent and dependent variables means we cannot exclude the possibility that the mother’s personality/level of anxiety may have affected our results. The reliability of the short version of the Maternal Postnatal Attachment Scale has not been formally established, which should be taken into consideration when interpreting the findings. Finally, our analyses are entirely based on parental report SDQ-data and thus we do not get insights from the children. Our findings were not able to assess how children’s self-perception of their behavioural problems differs from their mothers’ perception, although we do know that children are less influenced by their mother/parents over time and become more influenced by siblings, close friends and activities outside their home [5]. This is something that would be worth considering in future work.
Our findings converge with existing literature [21, 27, 36] and provide partial support for maternal attachment as a predictor of behavioural problems. Because our results vary depending on the SDQ-subscale, sex and age, self-reported maternal attachment measured at 10 months of age cannot be considered a precise predictor of children’s behavioural problems. A possible explanation for the inconsistencies in our findings could be our necessarily simple approach to the assessment of mother–infant relationships. The multidimensional approach previously recommended by others [31] was not an option in our study, so we can only speculate whether a more in-depth measure of maternal attachment would change our results.
The dissimilarities we observed between boys and girls in our examination of the association between attachment and behavioural problems could be explained by several factors. Pasco et al. 2011 also found that attachment was differently associated with behavioural problems among boys and girls [27]. Pasco et al. established that the association between attachment and externalising behavioural problems strengthened with age, but primarily for boys, which is in line with the findings of our study. This could indicate that there is some kind of sensitivity in the link between the mother-infant attachment and boys’ behavioural problems. Another possible explanation for the differences in our findings is that boys may be more likely to be negatively parented than girls [34], so differences in the apparent strength of association could be explained by a sex bias in the reported attachment measure. A third explanation could simply be the substantial differences in behavioural problems among boys and girls [4], which is not reflected in our use of the Strengths and Difficulties Questionnaire. In this study, we have applied identical cut-offs for boys and girls, contrary to the tradition in other countries [19] where boys and girls have different cut-off values for normal, borderline and abnormal scores. Previous studies have moreover demonstrated that boys appear to be more genetically predisposed to behavioural problems than girls [23]. Taking this genetic effect into account, it is possible that the association between attachment and behavioural problems is more confounded among boys compared to among girls. Given the above considerations, it is not surprising that our findings suggest a stronger and more prolonged association for the boys than for the girls.
Comparing the weak attachment group and the strong attachment group’s sociodemographic characteristics we found that the mothers in the weak attachment group had higher education and income, they consumed more alcohol and their infants were more likely to have symptoms of colic. Although educational level has been shown to affect the quality of the mother-infant attachment [40], our findings appear counter-intuitive, i.e. we observed a small tendency for mothers in the weak attachment group to have higher education. Parkes et al. found higher parenting stress among mothers with both the highest and lowest educational level compared with mothers with intermediate educational level and linked it back to lack of family support for more highly educated women [26], and this could be relevant to our findings. Previous studies have also found that mothers with low educational level had higher attachment to their infants compared to mothers with a high education [10]. One explanation besides family support, could be that mothers with lower levels of education may be more likely to be either unemployed or not working at the time the attachment assessment was conducted at infant age 10 months [18]. A third explanation suggested by Reck et al. [29] could be that mothers with higher educational level tend to reply more honestly and their answers might be less biased by social desirability than mothers with less education. Our findings emphasised that colic and alcohol consumption during pregnancy were associated with weak maternal attachment [24, 35]. We included colic in our analyses as a potential confounder, as it has been shown previously that emotional regulation problems in infancy such as excessive crying could be directly linked to behavioural problems later in life [17]. We also included alcohol consumption in our regression model to avoid confounding.
We applied the detailed approach with the five subscales to the SDQ-scores, although the broader division (internalizing, externalizing) approach has been recommended in low-risk samples like GUS (30). While the detailed five-subscale approach had the advantage of examining the behavioural problems in detail, the broader division would potentially have increased our statistical power.
Conclusions and Implications
In conclusion, our study confirms an association between weak maternally-rated attachment and overall child behavioural problems among a cohort of Scottish families although we acknowledge the limitations of relying on a self-reported measure to capture the complexity of the mother-infant relationship. The association was strongest and most persistent for boys. The presence and strength of the association varied according to SDQ-subscale for both sexes.
Future studies that aim to examine the association of mother–infant relationships with child mental health should focus on why we observe differences according to sex and should strive to understand the detailed mechanism for boys. We have proposed a few of the potential explanations in our discussion, but we have only touched upon the theme briefly. Our findings suggest important implications for early intervention and support in primary healthcare settings. Specifically, healthcare professionals working with families of young children should prioritize support for mother-infant dyads where the mother reports a weak emotional bonding to her infant, regardless of the mother’s educational background. Furthermore, our results draw attention to the heightened vulnerability of mothers of colicky infants. Given the added strain excessive infant crying can place on the early parent-child bond, these mothers may require targeted guidance and support to establish a strong mother-infant relationship during this critical developmental period.
Acknowledgements
Bonnie Auyeung was supported by the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No.813546, the Baily Thomas Charitable Fund TRUST/VC/AC/SG/469207686, the Data Driven Innovation and the UK Economic and Social Research Council (ES/W001519/1) during the course of this work.
Declarations
Competing Interests
The authors declare no competing interests.
Ethics approval and consent to participate
All parents of all the children interviewed gave their informed consent prior to inclusion in the study. Growing Up in Scotland has received ethical approval at each sweep from the Scotland Multi-Centre Research Ethics Committee. Ethical approval was not required for this specific study since we examined only anonymous secondary data, thus ethical approval for this study was waived by University of Edinburgh Psychology Research Ethics Committee.
Consent for publication
Not applicable.
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