Chapter 2: Pregnancy and Infant Mental Health

Home , Emotional competence, Emotional lability, Parental brain

CHAPTER 2

Pregnancy and Infant Mental Health

Arietta Slade Lois S. Sadler

Pregnancy is a “ ‘critical phase’ in the life of man, 2015a; Toepfer et al., 2017), the “parental a woman” (Benedek, 1970, p. 137), a time of caregiving network” (Feldman, 2015a), and the major transition, reorganization, and integra- “caregiving system” (Bowlby, 1969/1982). We tion for the mother-to-be, greatly affected by then discuss (1) the impact of early adversity, her biology, life experience, and psychology. It prenatal stress, and other risk factors on devel- is a period of enormous change in her relation- opment in the fetus and neonate; (2) prenatal ships with those around her: her partner, her attachment processes; (3) maternal represen- family, and her larger community. As such, it tations of the child; and (4) prenatal reflective is a period at once vulnerable and full of the functioning. We close with a consideration of potential for transformation and change for the the relevance of both biological and psychologi- mother-to-be, as well as the child-to-be.* cal perspectives for prenatal assessment and in- The literature on the biology and psychol- tervention. ogy of pregnancy has grown enormously in the last two decades. Advances in understanding the neurobiology of pregnancy, as well as the A Brief Overview of Pregnancy impact of trauma and disrupted attachments on The Contexts of Motherhood prenatal maternal representations make abun- dantly clear the sensitivity and vulnerability Pregnancy begins with conception, which, for of this period, and underscore the need to rou- the large majority of women, occurs as the re- tinely assess risk factors and to intervene in a sult of sexual intercourse during the fertile pe- comprehensive, timely way before and immedi- riod in the menstrual cycle. However, advances ately after the child is born so as to prevent the in reproductive technology over the past three intergenerational transmission of adversity and decades—which include in vitro fertilization, disrupted relationships. egg donation, and artificial insemination—have We begin this review with a discussion of what vastly increased the likelihood that women who is variously called the “parental brain” (Feld- struggle with infertility, are at risk for passing along genetic disorders, or past childbearing *Although we do not have the space here to discuss the age can bear children; they also make it possible relevant and important changes men experience during for lesbian women and gay men to raise their the transition to parenthood, they too are transformed own biological children (see Golombok, 2015). by the process of becoming a parent.

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primarily to the privileged, each profoundly af- stances—a working person, she is now also fects the psychology of pregnancy and—once becoming a mother, or becoming a mother to the child is born—the parents’ conscious and a new child, shifting prior attachments to make unconscious experience of the child, and him- room for the new. This process invariably re- or herself as a parent. In addition, in the case of awakens her relationship with her own mother. donated sperm or eggs, the “absent” biological Ideally, this leads to feeling identified with her parent becomes another “ghost in the nursery,” mother and other female caregivers in a posi- who may—to quote Fraiberg’s (1980) prescient tive and organizing way; often, however, these words—“take up residence” in parents’ minds experiences can be painful and profoundly dis- and hearts, and—ultimately—in the minds and ruptive. Every other significant relationship in hearts of their children as well. her life will change as well, and “who she is” The biological aspects of conception are in the eyes of the world, her intimates, and her- quite distinct from their psychological aspects. self will never be the same. It is a deep loss, Women become pregnant in a vast array of dif- a thrilling, hopeful gain, and everything in be- ferent personal, relational, and social circum- tween. As one father put it prosaically, “Once stances, all of which contribute in small and we are three, we can never be one again.” It is large ways to the psychological experience of thus unsurprising that emotional upheaval is the pregnancy, and to a woman’s acceptance of the sine qua non of pregnancy (despite the fact that pregnancy. These distinct circumstances es- many cultures mark it as a period of bliss and tablish the context for the beginning of a new quiescence). Bibring was the first to note that and—for the mother—lifelong relationship. affective instability—characterized to vary- ing degrees by mood swings, fear, anxiety, and affect dysregulation—often typifies even the Affective Upheaval in Pregnancy most “normal” and stable women during preg- John was in his mid-30s; Maggie, his wife of nancy. For the bulk of women, even when they 5 years, also in her mid-30s, was in her sev- are consciously thrilled to be pregnant (as Mag- enth month of pregnancy. The pregnancy was gie was), regression, conflict, anxiety, transient planned and welcome; the couple had a good depression, emotional lability, and ambivalence marriage, good jobs in their chosen careers, are inevitable—and profoundly adaptive, as were about to move into a new home, and had they prepare the mother in a variety of ways for no financial worries. John described waking up the enormous task before her. Women defend one morning to discover Maggie in floods of against the emotions of pregnancy in a number tears. Enraged at finding his work clothes from of different ways. Some rely on higher-order, the night before abandoned on the living room flexible defenses, whereas others resort to more floor, she had thrown them out their apartment primitive, rigid defenses; these variations will window and into the (locked) communal gar- have a direct impact on their later behavior with den five stories below. The car keys, which she the child, as well as the child’s attachment or- needed to go to work, were in the pocket of the ganization (Porcerelli, Huth-Bocks, Huprich, & pants that lay in a heap in the garden. “I’m giv- Richardson, 2015). ing her everything she wants! A baby! A house! The baby is largely an abstraction to the And this is what happens???” mother until she sees it and hears the heartbeat at 8–12 weeks, and feels the flutters of “quick- The emotional complexity of the transition ening” 4–5 months after conception; as the to parenthood has been well documented, be- pregnancy progresses, the baby slowly becomes ginning with the groundbreaking work of psy- more real to her. Throughout, the mother must choanalysts Grete Bibring (Bibring, Dwyer, grapple with the fact that the child is both a part Huntington, & Valenstein, 1961) and Therese of and separate from her, a reality she will re- Benedek (1970), and carried forward by a num- negotiate throughout the rest of her life with the ber of dynamic clinicians and scholars (for re- child. On the one hand, particularly during the views, see Leifer, 1980; Raphael-Leff, 1991). latter stages of pregnancy and the early postna- The essence of this complexity lies in the re- tal period, the woman must in some very real definition of self and of one’s relationship to sense abandon herself to her child. Winnicott others that is at the heart of the transition to (1956) called this “primary maternal preoccu- motherhood. In addition to being a woman, a pation,” referring to the mother’s utter absorp-

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very being. In this state, she and the baby are— growth and development as they begin to sup- profoundly —together as one. At the same time, port the infant’s emotional development (Kim the baby is a separate being, distinct from her et al., 2010). fantasies, desires, projections, and attributions. The Caregiving System Evolution, the Parental Brain, and the Caregiving Bowlby (1969/1982) talked about the parental System brain, too, but used a different language. He The Parental Brain described the presence, at birth, of a flexible, adaptive, and evolutionarily privileged attach- The manifest changes of pregnancy reflect an ment system aimed at ensuring the child’s sur- evolutionarily programmed transformation vival and ushering its entry into the human, that readies the mother to ensure the literal social world. As he saw it, the functioning of survival of the infant, and guarantee its entry this crucial biological system in the child is into the human, social world. Ruth Feldman, a completely dependent on a reciprocal, evolu- pioneering researcher who has studied the neu- tionarily privileged biological system in par- robiology of parenting for well over 20 years, ents, which he termed the “caregiving system.” describes parenthood as “the process most criti- This unfortunately mechanistic and behavioral cally implicated in the survival and continu- term refers to both the powerful urge to protect ity of life on Earth,” one that “contains more the child (of whatever age) from harm and the evolutionarily conserved components than all intense sense of connection and love a parent other social phenomena on the one hand and feels toward the child. Both allow the parent the greatest plasticity on the other” (2015a, p. to provide a safe, secure, and loving base from 387). By this she means that while the com- which the child can discover the world, and to mon components of parenting (e.g., protection bear the competing demands and emotional from danger, comfort, and nurture) have been complexity of parenting (also see Solomon & retained over millions of years of evolution, George, 1996). While the development of the these components are also enormously flexible parental brain begins with conception, women’s and can be expressed in a variety of ways and representations of their imagined child and contexts (e.g., by fathers, adoptive parents, and of themselves as mothers begin to take shape nonparental caregivers). when they are but children themselves (George Particularly crucial to parental caregiving & Solomon, 1996). Bowlby avoided using the is the activation of mentalizing, empathy, and term “attachment” to describe the parental side mirroring networks in the mother that together of the attachment system because for him at- promote the development of like and crucial so- tachment implied safety seeking and not safety cioemotional networks in the baby (Feldman, providing. But in fact, “attachment,” used in a 2015a). The activation of these networks in the more colloquial sense, seems far more descrip- parent depend on a delicate balance between tive of the intense feelings parents experience neuroendocrine systems. These include the toward their children than “caregiving system”; oxytocin [OT] system, which ensures attach- indeed, a number of researchers use the term ment and bonding (Feldman, 2015b; Feldman, “attachment” to describe a pregnant woman’s Weller, Zagoory-Sharon, & Levine, 2007; Gor- feelings of connection to her child. don, Zagoory-Sharon, Leckman, & Feldman, 2010; Toepfer et al., 2017); the hypothalamic– pituitary–adrenal [HPA] axis, which regulates Risk Factors during Pregnancy stress and ensures response to danger (Toepfer Early Life Stress et al., 2017); and, finally, dopaminergic reward centers, which activate pleasure centers in the It has been well established that early life stress brain (Strathearn, Fonagy, Amico, & Mon- (ELS) or adverse childhood experiences (ACEs) tague, 2009). The mother’s brain also readies it- have a profound effect on the health and mental self for social and emotional connection, as evi- health of the exposed individual (Felitti, et al., denced by widespread “pruning” and increased 1998). It now seems increasingly clear that there specificity of brain function in regions crucial is a “continuous intergenerational transmission for social exchange (Hoekzema et al., 2017). of maternal ELS that likely occurs during both

sociated alterations in stress sensitive biological Maternal Depression and Anxiety systems, which may affect fetal development as Maternal depression and anxiety are considered well as the quality of postnatal dyadic mother– major sources of prenatal stress (O’Connor et child interactions” (Toepfer et al., 2017, p. 293). al., 2014). According to a meta-analysis car- In particular, Toepfer and his colleagues (2017) ried out over a decade ago, nearly one-fifth of argue, ELS has a profound effect on “the central availability and functioning of the OT system,” pregnant women report depressive symptoms which persists “into adulthood and may impact during the prenatal period, and 10–15% of functional integrity of the ‘parental brain’ ” women report postpartum depression (Gavin (p. 294). For example, OT concentrations are et al., 2005). In a more recent study of a large lower in adult women who have high levels of urban sample, Melville, Gavin, Guo, Fan, and ELS (Heim et al., 2009). These effects of adver- Katon (2010) reported that nearly 10% of preg- sity on the OT system are intergenerationally nant women seen in a university obstetric clinic transmitted to the fetus during pregnancy (see met criteria for major or minor depressive dis- Thompson, Kiff, & McLaughlin, Chapter 5, order. Panic disorder and suicidal ideation were this volume), with various downstream effects present to a lesser extent (between 2 and 3%). on the child’s social and emotional function- The odds of having a depressive disorder were ing. In addition, disruptions in the OT system increased significantly by psychosocial stress, are likely to affect the woman’s capacity to feel chronic medical conditions, and race, with connected to her infant, and to behave in ways Asian, African American or Hispanic women that will organize and regulate its social and being at higher risk. emotional functioning. The link between maternal depression and child outcomes have been comprehensively studied over the past 20 years, with both prena- Prenatal Stress tal and postpartum symptoms associated with “Prenatal stress” is a term that has been used to a range of negative child outcomes, including describe a range of different risk factors, among academic and behavioral/mental health diffi- them acute environmental stressors such as culties and problems with emotion regulation socioeconomic adversity, intimate partner vio- (Goodman, Rouse, Connell, Broth, & Hall, lence, or the prolonged stress of hunger and iso- 2011). Importantly, depression in the prenatal lation in times of war or other emergencies, or period has effects on the child that are indepen- internal stressors such as depression or anxiety dent of postnatal depression, however, includ- (Monk, Spicer, & Champagne, 2012). While ing impaired intellectual functioning (Barker, the literature on prenatal stress is quite diverse Jaffee, Uher, & Maughan, 2011) and behav- and complex, it is clear that any or all of these ior problems (Hay, Pawlby, Waters, Perra, & risk factors can impact a child’s capacities for Sharp, 2010). Most recently, Lebel and her col- stress and emotion regulation, cognitive func- leagues (2016) have linked higher depressive tioning, motor development, and physiology (as symptoms during pregnancy and the postnatal measured by birthweight, gestational age, fetal period with preschoolers’ gray matter structure; heart rate, and fetal heart rate variability). It can prenatal depression was specifically linked to also greatly increase risk for psychopathology premature brain development, particularly cor- in the child (for reviews, see Monk et al., 2012; tical thickness. Interestingly, OT concentration O’Connor, Monk, & Fitelson, 2014). in pregnancy has also been associated with the ELS and prenatal stress are transmitted to the development of depression (Skrundz, Bolten, baby in a variety of complex ways, including Nast, Hellhammer, & Meinlschmidt, 2011), un- gene methylation (Monk et al., 2016), or epigen- derscoring the complex relationship between etic changes in the OT, and dopaminergic and psychiatric disorders and neuroendocrine sys- stress regulation systems that “can give rise to tems. altered gene expression levels in multiple tis- sues, including the brain, with consequences Maternal Posttraumatic Stress Disorder for the functioning and connectivity of neural circuits, which can confer risk for physical and Trauma symptoms are also clearly a form of psychiatric disorders in later life” (Monk et al., prenatal stress. As many as 3–7% of pregnant 2012, p. 1361). In short, prenatal stress changes women meet diagnostic criteria for posttrau-

women are likely to have comorbid mood or ern countries, adolescent pregnancy is usually anxiety disorders (Morland, Goebert, & Onoye, part of a larger picture of socioeconomic risk: 2007; Smith, Poschman, Cavaleri, Howell, & single parenthood, limited schooling, poverty, Yonkers, 2006). They may also suffer from and ethnic/minority status (Dole & Shambley- complex trauma disorder (Courtois, 2004; van Ebron, 2016; Ford & Browning, 2013). Many der Kolk, 2014), which arises when traumata teenage parents have disrupted attachment extend over a range of developmental periods histories, significant mental health issues, and and lead to posttraumatic adaptations that pro- academic failures that predate their pregnancies foundly affect caregiving. Rates of PTSD are and stem from personal histories of abuse, de- considerably higher (24%) for teen mothers, pression, and PTSD. These often amplify their racial minorities, and mothers with less educa- environmental stressors (Hodgkinson, Beers, tion or who live in poverty (Seng et al., 2001). Southammakosane, & Lewin, 2014). Add to this Among the factors that lead to pregnancy-onset the fact that pregnant teens are still coping with PTSD are childhood maltreatment, prenatal in- the tremendous developmental demands of ado- timate partner violence (IPV), socioeconomic lescence (Moriarty Daley, Sadler, & Reynolds, risk, and lifetime prevalence of PTSD (Muzik et 2013). Recent descriptive studies of multicultur- al., 2016). Prenatal PTSD has been linked with al adolescent mothers demonstrate some of the pregnancy loss, early labor and delivery, and unique challenges faced by these young women low birthweight (Seng, Low, Sperlich, Ronis, as they anticipate motherhood (Sadler, Novick & Liberzon, 2011), with suicidality, substance & Meadows-Oliver, 2016) and search for par- use, and panic disorder, as well as major and enting supports in their environments (Dole minor depressive disorder (Rogal, Poschman, & & Shambley-Ebron, 2016), often experiencing Belanger, 2007; Smith et al., 2006). In a study negative or judgmental health care encounters of pregnant women with lifetime PTSD diag- during their pregnancies and parenting health noses, Muzik and her colleagues (2016) report care visits (Harrison, Clarkin, Rohde, Worth, & that those with the greatest increase in PTSD Fleming, 2017). symptoms during pregnancy were most likely These significant stressors leave pregnant to suffer from postpartum depression, and teens more vulnerable to anxiety, depression, manifest disrupted attachment to their children and PTSD, as well as the epigenetic effects of at 6 months postbirth. And, like other forms of long-term elevations of the HPA axis and con- prenatal stress, PTSD impacts fetal brain func- sequent disruptions in levels of circulating OT. tionality and development. They also contribute to difficulties becoming responsive nurturing parents, negotiating the Teenage Pregnancy critical family relationships needed to help raise their babies, remaining in school, and Adolescent women continue to bear children in limiting rapid subsequent pregnancies (Sadler large numbers in the United States. At present, et al., 2007). Emotional difficulties, and/or just under 230,000 teenagers give birth every conflicted relationships with key family mem- year, resulting in an annual birth rate of 22.3 bers (e.g., partners or their own mothers, who live births per 1,000 women between ages 15 themselves have mental health or substance and 19 (Martin, Hamilton, Osterman, Driscoll, abuse problems) can lead to outcomes such as & Mathews, 2017). Adolescent birthrates in incomplete schooling, child neglect or abuse, the United States have declined significantly homelessness, rapid subsequent pregnancies, since the peak of 61.8 births per 1,000 adoles- and further problems with depression or sub- cent women in 1990 (Hamilton & Matthews, stance abuse (Hodgkinson et al., 2014; Ober- 2016), yet the United States continues to have lander, Black, & Starr, 2007). much higher adolescent birth rates than other It is important to note that youth is not always industrialized nations (https://www.cdc.gov/ associated with poor outcomes, however. Out- teenpregnancy/about/index.htm). comes can be positive in families or communi- Many, if not all, of the risks described ear- ties where there is an extended network of sup- lier (ELS, prenatal stress, depression, anxiety, portive relatives, adults, and “other mothers” and PTSD) co-occur in pregnant teenagers. who can rally the teen’s strengths and provide While there are some cultures in which hav- the structures that she will need to continue ing a baby during adolescence is the norm, in her schooling, take care of herself and the baby

this new and profound attachment relationship AAI, or (to a lesser extent) had held her stillborn (Dole & Shambley-Ebron, 2016; Sadler et al., infant after delivery (Hughes, Turton, Hopper, 2013). McGauley, & Fonagy, 2001). Anecdoctal clinical evidence has long sup- Miscarriage/Pregnancy Loss ported the notion that the shadows of such losses can persist for generations. The woman Between 8 and 20% of pregnancies end in mis- has lost a part of herself, the part identified in carriage; all but a small minority of women a profound way with her baby, and has received (3%) miscarry after the fetal heartbeat is de- a “traumatizing blow” to revived identifica- tected, somewhere between 8 and 12 weeks. tions with her mother and with herself as a baby Most miscarriages occur as the result of chro- (Leon, 1986, p. 315). She has also lost an attach- mosomal anomalies, although maternal age, ment, not yet an actual child, but an attachment history of prior miscarriage, medical illness nevertheless. The severity of the trauma associ- in the mother or fetus, drug and alcohol abuse, ated with prenatal loss depends on the breadth smoking, and obesity also put pregnancies at and depth of that attachment, and what it has risk. Prior pregnancy loss often creates stress in meant to her—which brings us directly to an subsequent pregnancies; many studies (for a re- issue that has been implied in much of the lit- view, see Bennett, Litz, Lee, & Maguen, 2005) erature reviewed thus far: the role of attachment have confirmed that women experience much processes in pregnancy. greater grief following pregnancy loss than is commonly recognized, even in the case of Resilience Factors early miscarriage; however, fetal deaths beyond 20 weeks’ gestation and through infant death Often lost in the discussion of risk factors is the 1-month postpartum are especially devastating. fact that resilience factors may counter their im- Bennett and her colleagues note that although pact. In a recent study, Narayan, Rivera, Bern- a majority of women and their partners recover stein, Harris, and Lieberman (2017) examined from this traumatic loss, some 15–25% will the role of benevolent childhood experiences have ongoing mental health complications, in- (BCEs) in mitigating against psychopathol- cluding PTSD, depression, and anxiety. There ogy and stress in an ethnically diverse group is also an elevated risk (20%) for the devel- of pregnant women. Mothers-to-be were asked opment of PTSD in a subsequent pregnancy. whether, for example, they had a caregiver with Another long-term sequela of perinatal loss is whom they felt safe, a good friend, other lov- traumatic grief, which is a syndrome that is ing or supportive nonparental figures, and so likely distinct from grief, depression or PTSD on. Pregnant women with high BCEs had fewer (Bennett et al., 2005). PTSD symptoms and fewer stressful life events, Stillbirth is a particularly devastating form of above and beyond the effects of maternal ACEs. pregnancy loss. In a study of women pregnant Thus, “angels in the nursery” (Lieberman, Pa- following a stillbirth, over half were Unresolved drÓn, Van Horn, & Harris, 2005), namely ex- with respect to loss and mourning on the Adult periences of safety and support in childhood, Attachment Interview (AAI; George, Kaplan, served to protect pregnant women from some of & Main, 1996), and all but one of these were the deleterious effects of early adverse experi- Unresolved about the stillbirth itself (Hughes, ences. These kinds of experiences are likely to Turton, Hopper, McGauley, & Fonagy, 2004). have positive impacts on their children as well. While a history of maltreatment and the absence of family support were predictive of Unresolved status in relation to the stillbirth, and stillbirth Attachment, Representation, and Reflective was itself associated with postbirth PTSD, Functioning mothers who held the baby after a stillbirth or had a funeral for the infant were more likely to Each woman begins the journey to motherhood manifest depression, anxiety, and even PTSD. with a set of internalized representations of at- These common practices thus appear to be quite tachment, representations that reflect her “state traumatizing. Prior stillbirth also increased the of mind in relation to attachment” (Main, Ka- likelihood that a next-born child would be dis- plan, & Cassidy, 1985), namely, how she has organized in relation to attachment, particular- organized and made meaning of her childhood

ably “activates” representations of attachment ily, (3) developing a sense of “we-ness,” and in a number of ways; Thoughts, feelings, and (4) giving oneself to one’s baby. A number memories of her relationship with her mother of researchers, beginning with Mecca Cran- and/or other maternal caregivers that may have ley in 1981, built on these ideas in developing been quiescent for years are awakened at both brief self-report questionnaires to evaluate conscious and unconscious levels. Becoming a the strength of mothers’ “attachment” to their parent invariably awakens “ghosts” (Fraiberg, child during pregnancy (for reviews, see Alhu- 1980) and/or “angels” in the nursery (Lieber- sen, 2008; Brandon, Pitts, Denton, Stringer, & man et al., 2005). Thus, whatever her attach- Evans, 2009). Cranley (1981) focused primar- ment history, and whatever the nature of her at- ily on behavioral manifestations of prepared- tachment organization, the attachment system ness for the baby, such as whether a woman is is buffeted during pregnancy in a way that can making room for the baby in her life, or taking be overwhelming, terrifying, or—under the care of herself and her baby physically. The best of circumstances—soothing and organiz- limitations of this behavioral definition of at- ing. tachment led later researchers to focus more Women with more secure attachment orga- directly on the woman’s emotional investment nizations will be able to process and regulate in the fetus, or “the unique, affectionate rela- the onslaught of emotions, regression, ambiva- tionship that develops between a woman and lence, and hope of pregnancy, whereas others, her fetus” (Muller, 1993, p. 201). Condon simi- dismissing of attachment, will shut down and larly focused on “the emotional tie or bond try to control these experiences by keeping which normally develops between the preg- them at bay. Even the most intense avoidance nant woman and her unborn child” (Condon & can be overwhelmed by the power of pregnancy, Corklindale, 1997, p. 359). however, with frightening fantasies intruding in The two most widely used measures of pre- dreams and ruminations. For women preoccu- natal attachment are Cranley’s Maternal–Fetal pied in relation to attachment, pregnancy can Attachment Scale (MFAS; Cranley, 1981) and be an overwhelming time emotionally, bring- Condon’s Maternal Antenatal Attachment Scale ing to mind the sense of “inchoate negativity” (MAAS; Condon, 1993). To date, upwards of that Main saw as typical of this attachment or- 100 studies have used one or the other of these ganization (Slade & Cohen, 1996). For women measures, as they are easy to administer and who are unresolved or disorganized in relation score. While a review of these findings is be- to attachment, pregnancy can be retraumatiz- yond the scope of this chapter (but see Alhusen, ing in the ways it summons past memories of 2008; Brandon et al., 2009), these studies gen- abuse and trauma, of frightening or terrified erally confirm what we might expect, namely, caregivers, especially when the circumstances that the stronger the prenatal attachment, the of conception have themselves been traumatic greater the likelihood of a range of positive (as in the case of rape, incest, etc.). The preg- prenatal and postnatal outcomes in the mother, nant woman’s “state of mind in relation to at- and of positive developments in the child and in tachment” predicts in powerful ways the child’s the mother–child relationships. Prenatal attach- attachment organization at 1 year (Fonagy, ment also tends to be negatively associated with Steele, & Steele, 1991). symptoms of depression and anxiety, and is not In the sections below, we describe three dif- associated with prior perinatal loss. ferent approaches to assessing prenatal attach- The most striking limitation of this literature ment processes: the study of (1) prenatal feel- is that subjects of most studies have been low- ings of connection to the child, (2) prenatal risk, partnered, privileged women who have representations of the child, and (3) prenatal received consistent and good-quality prenatal reflective functioning. care (Alhusen, 2008), and therefore fail to shed light on the nature of prenatal attachment in The Study of Prenatal Attachment more vulnerable populations. Brandon and her colleagues (2009, p. 208) also raise the question Rubin (1967), whose work inspired the study of whether these instruments actually measure of prenatal attachment, delineated four cru- attachment quality or are simply attitudinal cial aspects of becoming a mother: (1) ensur- measures “confounded by social desirability ing safe passage for the self and the baby, (2) and adjustment (Waters, personal communica-

Parental Representations of the Child (Theran et al., 2005). By contrast, women who had non-balanced representations in pregnancy A number of researchers have studied the de- had more negative interactions with the infant, velopment of a mother’s emotional bond with even if their classification had changed to bal- the child by examining prenatal representa- anced. These results suggest that positive pre- tions of the child. Prenatal representations are, natal representations serve as a buffer once the essentially, fantasies, as the baby is—at this baby is born. point—imagined rather than known. Thus, they In early studies of the WMCI, Benoit and are truly creations, based less on reality than on colleagues (1997) demonstrated a high rate of an amalgam of the mother’s projections, hopes, stability in WMCI categories from the third tri- dreams, attributions, and unconscious fanta- mester of pregnancy to the child’s first birthday, sies. The quality of prenatal representations of with the balanced and distorted categories being the child have most often been assessed using particularly stable. Huth-Bocks and her col- Zeanah’s Working Model of the Child Interview leagues (2004) later found that women exposed (WMCI; Zeanah, Benoit, Barton, & Hirsh- to domestic violence during pregnancy were berg, 1996). Ammaniti, Tambelli, and Odorisio more likely to have non-balanced representa- (2013) have also studied prenatal representations. In work with the same sample, Theran and tions using an adaptation of Slade’s Pregnancy her colleagues (2005) found that risk status— Interview (PI; 2003), called the IRMAG (Am- specifically low income, low socioeconomic maniti, 1991). status (SES), single parenthood, and exposure The WMCI was originally developed by to domestic violence—predicted non-balanced Zeanah and colleagues (1996) to study post- prenatal representations. Malone, Levendosky, natal maternal representations of the child. Dayton, and Bogat (2010) also reported that dis- However, they adapted the WMCI to evaluate torted prenatal representations were associated prenatal representations by simply changing the with higher rates of self-reported childhood wording of WMCI questions to the future tense physical neglect in women exposed to domestic (Benoit, Parker, & Zeanah, 1997); since then, it violence. In a paper published nearly a decade has been used by a number of researchers to as- later, Ammaniti, Tambelli, and Odorisio (2013) sess maternal representations in pregnancy. The found a prevalence of Integrated/Balanced rep- WMCI and the IRMAG have most commonly resentations in nonrisk women, and a higher been scored using a system developed by Zea- frequency of Not Integrated/Ambivalent repre- nah and colleagues, which classifies maternal sentations in at-risk women. These studies il- narratives about the unborn child as balanced luminate the critical impact of risk factors on (analogous to Main and colleagues’ (1985) maternal representations of the unborn child. Free-Autonomous classification), disengaged Recently, in an effort to identify a category of (analogous to the Dismissing classification) or representations analogous to the disorganized Distorted (analogous to the Preoccupied classi- category in infancy, Benoit and her colleagues fications). Differences in the quality of prenatal developed a fourth—“disrupted” classification representations have been linked to the qual- (WMCI-D), wherein caregivers “convey fright- ity of the child’s attachment at 1 year (Benoit ened or frightening discourse characteristics et al., 1997; Huth-Bocks, Levendosky, Bogat, similar to the frightened or frightening behav- & von Eye, 2004; Madigan, Hawkins, Plamon- iors” mothers of disorganized infants display in don, Moran, & Benoit, 2015), and to the qual- relation to their children (Crawford & Benoit, ity of the mother–infant interaction postbirth 2009, p. 132). They found that a prenatal Dis- (Ammaniti, 1991; Flykt et al., 2012; Tambelli, rupted classification on the WMCI was linked Odorisio, & Lucarelli, 2014; Theran, Leven- to unresolved maternal attachment on the AAI, dosky, Bogat, & Huth-Bocks, 2005). Generally disrupted affective communication with the in- speaking, more flexible, balanced, and positive fant, and disorganized attachment in the infant. representations were linked to secure maternal In related work, Terry (2018) adapted Lyons- attachment, secure infant attachment, and more Ruth’s Hostile/Helpless scale (Lyons-Ruth, positive, regulated mother–child interactions. Yellin, Melnick, & Atwood, 2005) for use with In addition, women who were balanced in preg- the PI (Slade, 2003) and discovered strong links nancy but nonbalanced postbirth had more pos- between helpless/hostile representations of the itive interactions with their infants than those caregiver/self /fetus and infant removal by child women who were non-balanced in pregnancy protective services within the first year of life. Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Prenatal Reflective Functioning whom were at high risk (based on the presence– absence of psychiatric diagnosis, substance use, The PI (Slade, 2003) invites the expectant as well as a range of socioeconomic risks, in- mother to reflect on her emotional experience cluding low maternal age, low social support, of pregnancy, the nature of her relationship with lack of education, single status, unemployment, her unborn child, her sense of self, and the ef- and poverty). Prenatal RF in the low-risk group fect her pregnancy has had on her relationship was significantly higher than RF in the high- with the father of the baby and her family. Re- risk group; in addition, the more risk factors a cently, the PI has been adapted for use with fa- woman had, the lower her RF. Maternal educa- thers during pregnancy (FaPI; Slade, 2017). It tion, social support, and prenatal substance use is most commonly scored for reflective func- were most predictive of prenatal RF. tioning (RF), which is broadly defined as the In a second study, Smaling and her col- capacity to envision the mental, or subjective, leagues (2016) examined the impact of prenatal psychological states of the self and other (Slade, RF and accumulated risk on mother–child in- 2005). An adult woman’s capacity to reflect on teractions at 6 months postpartum in a sample her childhood experience with her parents has of 133 women and their babies. They found that been assessed using the AAI, whereas a par- accumulated risk negatively and significantly ent’s capacity to reflect on her child’s internal correlated with prenatal RF. High prenatal RF experience and on her own experience as a par- was correlated with maternal behavior in a ent has been assessed using the Parent Develop- number of ways, specifically, more positive en- ment Interview (PDI; Slade, Aber, Berger, Bres- gagement during free-play and teaching tasks. gi, & Kaplan, 2003). RF in pregnancy involves Prenatal RF was negatively correlated with in- the mother’s capacity to reflect on her own in- trusiveness during the teaching task and inter- ternal states, and on those of the people closest nalizing–helplessness during more challenging to her, and to imagine that the child will have tasks. Using regression and mediational analy- a mind and feelings of his or her own, and in ses, they found that while prenatal RF and accu- that sense be separate from her. Prenatal RF is mulated risk uniquely predicted maternal sen- scored using a system developed by Slade, Pat- sitivity, the indirect effect of accumulated risk terson, and Miller (2004), in which lower scores on maternal sensitivity was mediated through indicate less reflectiveness and higher scores prenatal RF. indicate more. In our Minding the Baby® project (MTB; To date, there have been fewer studies of the Sadler et al., 2013), we found similar links be- PI than of the WMCI, as training for scoring RF tween risk and RF; very few women in our large on the PI has only recently become available. sample of high-risk pregnant women living in an The first study to examine prenatal RF was con- underresourced community were truly capable ducted by Pajulo and her colleagues (2012). The of stable, ongoing RF. A qualitative analysis of sample comprised women in residential treat- the PIs of 30 pregnant adolescents participating ment for substance abuse, and both prenatal RF in the MTB randomized clinical trial revealed and change in RF over the course of a mental- great variation in their ability to think about and ization-based intervention were assessed. Over- describe the many emotions experienced dur- all RF scores in pregnancy were quite low, and ing pregnancy and how they envisioned caring while postnatal scores were slightly higher, pre- for their soon-to-be-born infants (Sadler et al., natal and postnatal RF were correlated. When 2016). Differences in level of RF appeared to be change over the course of the intervention was linked to a number of factors, among them vari- evaluated, there was less positive change in RF ations in cognitive and brain development. The in mothers who had suffered from physical and teens also described complex and often disap- emotional abuse, and in whose families there pointing relationships with partners, and vitally were long-held secrets. In addition, lower pre- important relationships with family members. and postnatal RF was linked to a higher risk of To conclude, although a number of writers losing the child to foster care. have suggested that prenatal attachment pro- In two recent studies, Smaling and her col- cesses and representations of the infant develop leagues linked prenatal RF to a range of vari- slowly and over time, coalescing only toward ables. In the first (Smaling et al., 2015), links the end of the second or beginning of the third between prenatal RF and a range of risk factors trimester, there is great variation in when these were studied in a sample of 162 women, half of

surements taken during the second trimester illness. Therefore, “intervention” beyond what may not be comparable to those taken toward is offered within the framework of a woman’s the end of the third trimester. Clearly, there is culture and community is rare (unless the fetus a need for researchers to systematically track is at risk). The vast majority of women living in these processes across the three trimesters of the United States and other Western countries pregnancy. It is also the case that little is known receive routine prenatal care beginning with about how attachment processes in a woman’s a positive pregnancy test, which typically in- first pregnancy differ from those in second and cludes regular checkups and monitoring of vital subsequent pregnancies, as many studies tend signs, sonograms as necessary, and childbirth to lump primparas with multiparas. education. They are also advised to exercise, eat properly, and supplement their nutritional intake, as well as to stop smoking, drinking al- Intervention cohol, and using substances. But even this absolutely crucial level of care In this chapter, we have provided an overview is often lacking for women living in urban or of the biological and psychological processes rural poverty, resulting in a national mater- of pregnancy, namely, the development of the nal mortality rate on par with India’s (18.5 “parental brain,” as well as the unfolding of pre- deaths/1,000 births). There are a number of natal attachment, representations of the child, causes, among them lack of access to prena- and RF. The evidence from this diverse litera- tal care, inadequate care during childbirth and ture makes clear the importance of the develop- the postpartum period, as well as diabetes and ment of (1) parental affiliative processes (aided obesity. The United States also has one of the by the functioning of the OT and dopaminergic highest rates of infant mortality among indus- reward systems, and the regulation of stress) trialized nations (5.3 deaths/1,000 births), with for the subsequent development of the infant’s double the rate of morality for non-Hispanic social and relational brain, (2) a strong positive blacks (11.1 deaths/1,000 births) (cdc.org). emotional connection to the fetus, (3) balanced, In the United States at least, much more positive representations of the unborn child, must be done to assess and intervene in situa- and (4) emerging capacities to imagine the sub- tions that risk both the mother’s and the child’s jective experience of the baby and appreciate safety and emotional development. While some the complexity of one’s own inner experience of the risks we have outlined are directly tied and changing relationships to others. Equally to poverty and other socioeconomic risks, oth- compelling is the evidence that a number of ers are tied to psychological vulnerability that risk factors—among them maternal psychopa- can transcend even the most robust protec- thology, attachment disorganization, prenatal tions of privilege. Virtually all obstetricians stress, poverty, early childhood adversity, sub- or midwives have a number of women in their stance use, single and/or teenage parenthood, practices whose anxiety about the pregnancy— lack of education, domestic violence—interrupt despite daily calls to the office—cannot be as- these developments in a number of ways. This suaged. They have patients who do not take care makes apparent and even urgent the importance of themselves, and patients who cannot get out of ameliorating risks during the prenatal period, of bed. And those professionals who work in as well as enhancing the experiences that lead high-risk communities see in innumerable and to regulation, balanced representations, and RF. stark ways the intergenerational transmission of From a public health standpoint, this is a adversity beginning with a positive pregnancy daunting challenge. The vast majority of women test; these realities often leave providers feeling in the world will become pregnant and bear a numb and helpless as they observe the impact child or children sometime between menarche on multiple generations of trauma and fractured and menopause. Although there are some cul- family life. tures in which pregnancy is treated as a time of We believe strongly that the frontline health retreat from the world, in today’s world, most professionals who interact with pregnant women women work hard, raise other children, take need the time and the resources to address these care of their families, and continue a range of risks—to at least some extent—within the normal activities. And in the grand scheme of framework of routine practice and/or to link life, it is a brief and nearly ubiquitous stage in women with services as they are needed. There

ogy and psychology of pregnancy available to many of whom do not have special training in these overworked professionals, and deeper lay- the prenatal period. Because both untreated ers of supportive services for pregnant women depression and selective serotonin reuptake (including those who endure miscarriages and inhibitor (SSRI) use put pregnant women and stillbirths) are largely lacking in the vast major- their infants at risk (Yonkers et al., 2009), short- ity of communities (and, at least in the United term behavioral or dynamic treatments are pre- States, likely to be lacking for some time). And ferred, although, again, targeted treatments for yet, if we are to take seriously the science of the prenatal and perinatal periods are in short the last decade, and apply it to the everyday re- supply and desperately needed, as are trained ality of women of childbearing age, we cannot professionals with the competencies necessary overstate the importance of more comprehen- to address the particular concerns of pregnancy. sive care for women in this vulnerable yet won- Another “midlevel” of care is provided for preg- derful “crisis” (Benedek, 1970) in their lives, a nant teens through specialized teen parent sup- crisis that in truth includes not only the prenatal port programs (Harrison et al., 2017; Thomp- period but also the 6- to 12-month period after son, 2016), typically offered in partnership with birth. Given that the aim of infant mental health school districts. practice is to promote secure, resilient, robust, Home visiting is the treatment of choice for and smooth development in infants and tod- pregnant women coping with multiple layers of dlers, who, of course, will be the parents of the adversity. In the United States, only a handful generations to come, the developmental signifi- of the government-sanctioned home visiting cance of this period for our work simply cannot programs begin before the baby is born. The be underestimated. most widely disseminated of these programs is Such “comprehensive care” would ideally the Nurse–Family Partnership (NFP). In this include much more screening of pregnant model, first-time pregnant women are enrolled women for mental health difficulties, ACEs, toward the end of the second or beginning of and ongoing prenatal stress. And ideally, the third trimester, and followed with their there would be a menu of services available baby until the child’s second birthday. NFP has to address the needs identified in screening, been tested in three randomized controlled tri- ranging from less intensive services for rou- als (RCTs) (see Olds, 2002; P. Zeanah & Korf- tine pregnancies to more intensive services macher, Chapter 38, this volume) and the chil- for those with diagnosable mental health dis- dren have been followed longitudinally well orders, or those coping with massive “toxic into their late teens (Olds et al., 1997, 2004). stress” (Shonkoff, 2012) and early or current At present, there are NFP programs in 41 states trauma (who may or may not also be dealing in the United States, and in Canada, Australia, with significant mental health issues). Group and six countries in Western Europe as well. interventions that involve psychoeducation, MTB, the home visiting program we devel- stress reduction, and activities to enhance oped in collaboration with colleagues at the Yale women’s feelings of connection to the unborn Child Study Center, Yale School of Nursing, and child are likely to be sufficient for women a number of community partners, likewise be- with low levels of risk, and indeed, programs gins in pregnancy (see Sadler et al., 2013, 2016; such as this exist in some (though not nearly Slade et al., 2018b), and continues until the enough) communities in the United States and child is 2 years old. MTB is aimed specifically Europe (e.g., see Duncan & Barnacke, 2010; at addressing both the health and mental health Puckering, 2011). Recently, practitioners of needs of those whose risks in both domains are group parenting interventions that typically amplified by the multiple stressors of poverty, begin postnatally (e.g., the Circle of Security youth, and multiple generations of adversity. As intervention; Powell, Cooper, Hoffman, & such, we combine what van der Kolk (2014) has Marvin, 2013) have begun experimenting with described as “top-down approaches (to activate engaging women before the birth of the baby. social engagement) with bottom-up methods (to The depth, breadth, and accessibility of these calm physical tensions in the body)” (p. 86). We programs desperately need expansion. believe that an atmosphere of safety, made pos- Women who manifest significant depression, sible through relationships with both clinicians, anxiety, or PTSD (or worse, psychosis) during and quieting the body (incorporating practices pregnancy are often referred by their prenatal such as mindfulness, to develop stress regula-

an attachment to the baby, positive represen- in her transition to parenthood is crucial to giv- tations of the child, and reflective capacities. ing her child the very best start possible. Results of our RCT indicate a range of positive health and attachment outcomes, notably, higher levels of secure attachment in infants, lower REFERENCES levels of disorganized attachment, greater in- creases in RF in the most vulnerable mothers, Alhusen, J. (2008). A literature update on maternal– lower levels of obesity in toddlers, and lower fetal attachment. Journal of Obstetric, Gynecologic, levels of externalizing behaviors postgradu- and Neonatal Nursing, 37, 315–328. Ammaniti, M. (1991). Maternal representations during ation (Ordway et al., 2014, 2018; Sadler et al., pregnancy and early infant–mother interactions. In- 2013; Slade et al., 2018a). Unfortunately, neither fant Mental Health Journal, 12, 246–255. 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