Parent-Child Attachment: A Principle-Based Concept Analysis. — TEI-tagged view

E. AlipersName, N. LetourneaupersName, K. BenziespersName (2021date). “Parent-Child Attachment: A Principle-Based Concept Analysis..” SAGE Open Nursingtitle·j.

Object of study — the concept of parent-child attachmentterm·dom across nursing, medicine and psychology

Research question — how parent-child attachmentterm·dom is described across psychology and nursing

Contribution — a clarification of parent-child attachmentterm·dom and its uses for nursing work with families

Full text — tagged

Parent-Child Attachmentterm·dom: A Principle-Based Concept Analysis.

Abstract Extensive evidence indicates that the quality of parent-child attachmentterm·dom is related to later socio-emotional and physical health outcomes. Yet, despite its clinical relevance, the parent-child attachmentterm·dom concept has been inconsistently applied across the disciplines of nursing, medicine and psychology and is often conflated with parent-child bondingterm·dom in nursing literature.

To provide readers with a critical analysis of the concept of parent-child attachmentterm·dom. Using a principle-based concept analysis, we clarify how parent-child attachmentterm·dom is understood from a multidisciplinary perspective to advance the use of this concept in nursing practiceterm·key.

Concept Description: Attachmentterm·dom is an affectionate, mutually satisfying relationship between a child and a caregiver that serves the purpose of making the child feel safe, secure, and protected.

In this principle-based concept analysis, each definitional (i.e., epistemological, pragmatic, linguistic, and logical) principle contributes to an understanding of the strengths and limitations of the state of science about this concept. The discussion highlights how applying the concept of parent-child attachmentterm·dom security may offer exciting and promising opportunities for nursing clinical work with families.

The understanding of the concept of parent-child attachmentterm·dom differs among disciplines of nursing, medicine and psychology and offers exciting and promising opportunities for clarity and collaborative, multi-disciplinary work.

Keywords: attachmentterm·dom, concept analysis, nursing practiceterm·key Introduction Attachmentterm·dom is an affectionate, mutually satisfying relationship between a child and a caregiver (e.g., a parent) who is involved in making the child feel safe, secure, and protected (Bowlby, 1969/1982). According to attachment theoryterm·key, a child who consistently experiences responsive and sensitive caregiving develops an expectation that others will be supportive and available in times of need (Fraley, 2002). The founder of attachment theoryterm·key, British psychoanalyst John Bowlby (1944, 1951 ), studied how the child’s early experiences with the caregiver impacted the child’s future mental health. Based on his work with hospitalized and institutionalized children, Bowlby (1951) concluded that to thrive emotionally and grow up mentally healthy, a child must experience a mutually affectionate relationship with the primary caregiver. Bowlby contended that when distressed or alarmed, infants were disposed to attain closeness with their caregiver through signals and movements, such as crying, smiling, sucking, clinging, and crawling. This disposition towards a caregiver was described as an “attachmentterm·dom system”, with the actions of the infant being termed “attachmentterm·dom behavior” (Bowlby, 1969/1982). Bowlby identified the emotional and physical availability of the caregiver as a “set-goal” of attachmentterm·dom in infancy. According to Bowlby (1982), attachmentterm·dom behaviors are rooted in evolution and increase the likelihood of survival by increasing caregiver-child proximity.

The attachmentterm·dom system serves to keep the caregiver close to protect the infant in case of a physical or psychological threat (Bowlby, 1982). Bowlby claimed that a well-loved infant will protest separation from parents, but will later develop more self-reliance ( Bretherton, 1992 ). In the first volume of his trilogy, Attachmentterm·dom, and Loss , Bowlby (1969) considered the antecedents of attachmentterm·dom, such as maternal sensitivityterm to an infant’s cues. Bowlby’s (1951) discovery of just how much children depend on their parents for support led to his famous quote that still rings true to this day: “if a community values its children it must cherish their parents” (p. 84). Bowlby’s collaboration with the Canadian psychologist Mary Ainsworth led to the development of attachment theoryterm·key. Parent-child attachmentterm·dom (PCAterm·dom) security is one of the factors in determining future socio-emotional functioning and mental and physical health ( Ranson & Urichuk, 2008 ). Insecure PCAterm·dom may increase the risk for later behavior problems, psychopathology, and physical illnesses, especially in the presence of other risk factors, such as poverty or abuse (Anderson et al., 2012; Cassidy et al., 2014; Puig et al., 2012; Sroufe et al., 1999).

The discipline of nursing has a strong interest in promoting child health ( Fuemmeler et al., 2017 ). Nurses work closely with families of young children, and parents often approach nurses for advice on their children’s health ( Ordway et al., 2014 ). Thus, nurses have a unique opportunity to promote secure PCAterm·dom, especially among families where children are at increased risk for developing insecure attachmentsterm·dom (e.g., families affected by poverty, intimate partner violence, stress, parental mental health problems, and substance use). However, descriptions of the PCAterm·dom concept have been inconsistent in nursing literature, slowing the advancement of nursing practiceterm·key in this area. For example, a previous concept analysis on maternal-infant attachmentterm·dom ( Goulet et al., 1998 ) and practice guidelines (Schenck et al., 2005) included several statements that described maternal-infant bondingterm·dom, thus confusing the distinction between attachmentterm·dom and bondingterm·dom in the nursing literature. We assert that nursing practiceterm·key will be enhanced by a clearer understanding of attachment theoryterm·key and that nurses will be better positioned to support parents, increasing the likelihood of secure attachmentterm·dom development, and subsequently, improving long-term child’s health outcomes.

Aims of Analysis We aimed to review how PCAterm·dom is described across the disciplines of psychology and nursing to advance the use of this concept for nursing practiceterm·key. A multidisciplinary perspective is important for nursing because other disciplines can add to the understanding of a concept of interest ( McCrae, 2012 ). While the concept of PCAterm·dom originated in the discipline of psychology, a clear definition and careful use of terminology are critical for this concept to be successfully adopted in nursing practiceterm·key.

Method Literature searches were conducted in MEDLINE, EMBASE, CINAHL, ERIC, and PsycINFO databases using combination sets of keywords (1: child; 2: parent; 3: attachmentterm·dom) in titles and abstracts of the articles ( Table 1 ). Search terms were pilot-tested with an academic librarian at the University of Calgary and refined for each database. No time limits were set. The literature searches were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Figure 1 , Moher et al., 2009 ). Articles were included if they met the following criteria: (1) published in English, (2) literature reviews or conceptual papers, (3) included children ≤ 18 years of age and their parents (mother or father), and (4) parent-child attachmentterm·dom identified as a focus. Articles were excluded if they were (1) primary studies, (2) focused on parental-fetal attachmentterm·dom, (3) focused on attachmentterm·dom disorders, and (4) editorials, letters, books, abstracts, and grey literature ( Table 2 ). Reference lists of publications were examined for further potentially relevant sources. A data file using an Excel spreadsheet was created to aid in the screening and synthesis of the literature. The data file captured the following: authors’ names, publication year, authors’ field of discipline, abstract, PCAterm·dom definition, children’s age in the publication, attachmentterm·dom to mother/father/both parents.

Search Strategy Key Words.

PRISMA 2009 Flow Diagram ( Moher et al., 2009 ).

Inclusion/Exclusion Criteria.

Results Two reviewers (first author and the scientific writer/methodologist at the Faculty of Nursing, University of Calgary) conducted an inter-rater reliability check ( McHugh, 2012 ) with 97% agreement, and independently screened 1013 abstracts. Ninety-nine abstracts were selected for full-text review. A total of 26 articles were identified as meeting the inclusion criteria of this analysis. The majority of included articles were from the discipline of psychology ( n = 22), three were from the discipline of nursing, and one article was from the medical discipline of medicine. Most of the articles were written in North America ( n = 20). Four articles focused on father-child attachmentterm·dom, while the rest examined either mother-child attachmentterm·dom ( n = 8), attachmentterm·dom between both parents and a child ( n = 5), or did not specify which parent was the focus ( n = 9) ( Table 3 ). Using the principle-based concept analysis method (Morse, 1995; Penrod & Hupcey, 2005), the articles were examined to clarify the definition of the PCAterm·dom concept (epistemological principle), appraising its applicability in practice (pragmatic principle), evaluating consistency in use within literature (linguistic principle), and differentiating it from related concepts (logical principle). See Table 4 for the description of the application of guiding principles to the analysis.

Included Studies.

Guiding Principles (Penrod & Hupcey, 2013) and Application to Concept of PCAterm·dom.

Epistemological Principle: Is the Concept Clearly Defined?

The PCAterm·dom is a “psychological tether which binds infant and caregiver together” (L. Sroufe & Waters, 1977 , p. 1186). Bowlby (1951) argued that to thrive emotionally and grow up mentally healthy, a child must experience a mutually affectionate relationship with the primary caregiver (attachment figureterm·dom). When distressed or alarmed, children are disposed to attain closeness with their attachment figureterm·dom through cues and movements, such as crying, smiling, sucking, clinging, and crawling. This disposition towards an attachment figureterm·dom is described as an attachmentterm·dom system, with the actions of the child being termed attachmentterm·dom behaviors (Bowlby, 1969/1982). Attachmentterm·dom behaviors are influenced by situational context (e.g., setting, preceding events) and the child’s mood, and are not constant across situations (L. Sroufe & Waters, 1977 ). Attachmentterm·dom behaviors are differentiated from affiliative behaviors because they involve seeking proximity when experiencing distress ( Zeanah et al., 2011 ). Reciprocity of the behaviors between caregiver and child is the key factor in Bowlby and Ainsworth’s descriptions of attachmentterm·dom. Bowlby (1969) described attachmentterm·dom figure-child proximity as a set- goal of the attachmentterm·dom system, with attachmentterm·dom behaviors (smiling, clinging) serving to achieve this goal. Attachmentterm·dom behaviors change as children mature. For example, infants who seek proximity by crawling towards the caregiver at 12 months of age may smile and speak when they are older. Thus, multiple attachmentterm·dom behaviors can have a similar meaning, and serve as means of re-establishing contact ( Sroufe & Waters, 1977 ). The child decides which behaviors to use to maintain the proximity to the caregiver based on the situational context ( Sroufe & Waters, 1977 ). Sroufe and Waters (1977) suggested that the set- goal of the attachmentterm·dom system is “felt security”, where the child feels affection for the caregiver. There is a decreased need for proximity to the attachment figureterm·dom in the absence of distress as the child grows and develops.

Two hallmark ideas of attachment theoryterm·key are “secure baseterm·dom” and “internal working modelsterm·dom”. The concept of the secure baseterm·dom contains two interconnected phenomena: a “base” from which to explore and a “haven of safety” to which the child may return in times of distress ( Waters & Cummings, 2000 ). The attachment figureterm·dom for the child is regarded as a "secure baseterm·dom", a stronger and wiser person to turn to when the attachmentterm·dom system is activated (such as when a child is frightened or ill). Once comfort and reassurance in the presence of distress-inducing stimuli are achieved, the attachment figureterm·dom “shifts from being a safe haven to being a secure baseterm·dom from which to explore” (Ainsworth et al., 1978, p. 265). The feeling of security promotes the child’s return to play ( Sroufe & Waters, 1977 ). Bowlby (1988) proposed that across the lifespan “all of us…are happiest when life is organized as a series of excursions, long or short, from the secure baseterm·dom provided by our attachment figureterm·dom” (p. 62). A child’s committed relationship with at least one attachment figureterm·dom is central to healthy development ( Bretherton, 1992 ). An attachment figureterm·dom is someone who provides “physical and emotional care, continuity and consistency in a child’s life, and emotional investment in the child” (Howes, 1999, p. 675). Bowlby used the term “attachment figureterm·dom” rather than “mother” presuming that the nature of the interaction rather than the category of the individual (e.g., adoptive mothers, siblings, grandparents, fathers, childcare providers) would be of most importance to the child ( Ainsworth et al., 2015 ). Sir Richard Bowlby (2010) suggested that children can have a network of multiple attachment figuresterm·dom. All four attachmentterm·dom patterns are relationship-specific, such that a child may show secure attachmentterm·dom towards the mother, be avoidantly attached to the father, and display disorganized attachmentterm·dom behaviors towards the daycare worker.

The attachment figureterm·dom needs to be accessible and available to the child, along with being perceptive of the child's emotional needs. Parents function as attachment figuresterm·dom to children across the early years, preadolescence, and adolescence (Kerns & Brumariu, 2014). As children grow, they venture further from the secure baseterm·dom, and for an increasingly extended period of time (Bowlby, 1988). Thus, a parent's behavior is expected to shift from a protective role in the early years of a child's life to autonomy-support and encouragement of self-regulation as the child gets older ( Koehn & Kerns, 2018 ).

The responsiveness of the attachment figureterm·dom to the child’s signals of a need to explore is as important as the sensitivityterm to signals of proximity needs ( Grossmann et al., 2002 ). Children trust that their attachment figuresterm·dom will notice and respond to their needs ( Benoit, 2004 ). This trust facilitates the exploration of the environment and supports the development of social and cognitive competence ( Ainsworth et al., 2015 ). Ainsworth used the term “organization” to describe the way a child’s attachmentterm·dom behaviors are brought together to form a coherent pattern of security or insecurity ( Duschinsky & Solomon, 2017 ). Quality of PCAterm·dom is best assessed by reference to organization of attachmentterm·dom behaviors concerning the attachment figureterm·dom and in consideration of the situational context (L. Sroufe & Waters, 1977 ). Children with secure attachmentterm·dom (Type B) openly express their emotional needs and can accurately predict responses from their caregivers. Children with insecure/avoidant attachmentterm·dom (Type A) mask their emotional needs, typically after being consistently rejected by their caregivers in times of past distress. In insecure/ambivalent (Type C) attachmentterm·dom relationships, children exaggerate the display of their emotional needs in a desperate attempt to get the attention of the caregiver, who has typically demonstrated inconsistency in their past responses. Children with secure and insecure/avoidant and insecure/ambivalent patterns use organized strategies to maintain interaction with their attachment figureterm·dom, such that children know how to deal with distress ful situations to maintain a satisfying interaction with their attachment figureterm·dom ( Benoit, 2004 ). Children with insecure/disorganized (D) attachmentterm·dom, fail to develop and organized pattern and display contradictory and incoherent behaviors with caregivers. Secure attachmentterm·dom is the most prevalent and preferred pattern of PCAterm·dom across cultures. See Table 5 for the description of patterns of attachmentterm·dom.

Patterns of Attachmentterm·dom, Distribution, and Corresponding Responses.

Another key idea of attachment theoryterm·key, internal working modelsterm·dom (IWMsterm·dom), is defined as cognitive mental structures or mental schemas. IWMsterm·dom summarize early caregiving experiences and shape expectations about future interactions with significant others ( Bretherton, 1992 ). IWMsterm·dom are thought to develop as early as 12 months of age, constructed from a child’s actual experiences with the parent ( George, 1996 ), and influence how the children view themselves in relationships with others ( Rosmalen et al., 2014 ). The concept of IWMsterm·dom has received much attention in explaining the link between early caregiving experiences and children’s later health outcomes. For example, securely attached children develop IWMsterm·dom of available care and self-worth and tend to be more empathetic and responsive to others ( Sroufe et al., 1993 ). Children with insecure attachmentsterm·dom develop IWMsterm·dom of the self as unworthy and expectations of others as unavailable or insensitive. These children are more likely to inadequately cope with stress and behave in ways that bring about more adverse experiences ( Sroufe et al., 1993 ). As children grow, they begin to rely more on IWMsterm·dom than on the actual presence of the attachment figureterm·dom to guide their daily social interactions (Bowlby, 1982).

To conclude, the concept of PCAterm·dom is well-defined within the psychology literature. Most articles in this review employed Ainsworth et al. (1978) and/or Bowlby’s (1988) definitions of PCAterm·dom (see Table 3 ), with an exception of a nursing article by Goulet (1998) , where the definition of PCAterm·dom by Bowlby (1996) was mixed with the definition of maternal-infant bondingterm·dom by Klaus and Kennell (1983) . The definitions of PCAterm·dom in the nursing literature were mostly focused on infants, and not on older children.

Pragmatic Principle: Is the Concept Applicable and Useful?

An extensive amount of literature focused on the measurement of attachmentterm·dom in infancy and childhood. The development of a standardized procedure to observe and study attachmentterm·dom behavior was a major step in the establishment of an empirical knowledge base regarding the developmental significance of attachmentterm·dom (Ainsworth et al., 1978). A study of individual differences in child attachmentterm·dom in home- and laboratory-based observations in 26 middle-class families in Baltimore led to the development of the Strange Situation procedureterm (SSPterm) (Ainsworth et al., 1978; Bell & Ainsworth, 1972) to classify patterns of attachmentterm·dom. The SSPterm was designed to use cues of unfamiliarity and separation from a caregiver to elicit attachmentterm·dom behaviors. The SSPterm aimed to activate the child's expectations about what happens when the caregiver was not available in the past and allowed the observer to interpret these expectations from the child’s behavior ( Duschinsky, 2015 ). The first report on the use of SSPterm described 14 children from the Baltimore study who were divided into three groups based on their behavior during the procedure ( Ainsworth & Bell, 1970 ). The SSPterm consists of eight episodes (see Table 6 ). During SSPterm, a caregiver leaves the child twice in an unfamiliar environment (a laboratory room decorated as a playroom) with enticing toys, first with a stranger (an unknown female experimenter) and then alone, before returning (Ainsworth et al., 1978). Being separated twice in an unfamiliar ( strange ) environment activates the child’s attachmentterm·dom system and allows for observation of individual differences in attachmentterm·dom patterns ( Rosmalen et al., 2014 ). The decisive factor for attachmentterm·dom classification is the child's behavior at the reunion with the caregiver. The SSPterm is videotaped and the child's behaviors concerning the caregiver are coded on a 7-point Likert scale for the presence of proximity and contact-seeking, maintaining contact, resistance, avoidance, distance interaction, and search behaviors ( Shah & Strathearn, 2014 ).

The Strange Situation Procedureterm Episodes (Ainsworth et al., 1978; Rosemalen et al., 2014).

In 1986, Main and Solomon reviewed 200 cases from the early SSPterm tapes and added a fourth category (D) to describe a child’s inexplicable and fragmentary behaviors that were discrepant with the original ABC classification. A child’s behaviors coded as D were based on the following indices: (a) sequential and (b) simultaneous display of contradictory behavior, (c) misdirected or incomplete movements, (d) stereotypes and anomalous postures, (e) freezing or stilling, (f) display of apprehension of the caregiver, and (g) signs of disorganization ( Granqvist et al., 2017 ). A 9-point scale for coding disorganization is used, where observation of five or more disorganized behaviors is sufficient to place a child into the D category ( Duschinsky & Solomon, 2017 ). Combined with Ainsworth’s original attachmentterm·dom patterns, this discovery culminated in the ABC+D attachmentterm·dom classification model. The SSPterm remains one of the most widely used standardized, laboratory-based assessments of young children's attachmentterm·dom behaviors (Fearon et al., 2010).

The SSPterm is normally only used during infancy and toddlerhood because as the children grow, the goals of attachmentterm·dom shift from proximity-seeking to co-constructing of cooperative partnerships with their attachment figureterm·dom to ensure parents' ability and availability to act in child's best interests ( Fernandes et al., 2020 ). To account for the change in the attachmentterm·dom goal and behaviors, different measures of PCAterm·dom are used during middle childhood and adolescence. Some of the examples of these measures include Maternal Behavior Q-Set ( Pederson & Moran, 1995 ), Attachmentterm·dom Story Completion Task ( Bretherton et al., 1990 ), Adult/Adolescent Attachmentterm·dom Interview ( George et al., 1996 ), Security Scale ( Kerns et al., 2001 ), and separation-reunion procedures ( Solomon & George, 1999 ).

The SSPterm is validated against home observations of mother-child interactions, and some suggest that it may not capture the quality of attachmentterm·dom to fathers ( Bretherton, 2010 ; Grossmann et al., 2002 ). The mechanisms involved in the development of attachmentterm·dom relationships may differ for mothers and fathers, with a mother’s interactions with her child typically involving caregiving, while a father’s interactions typically involve play ( Lamb, 2000 ). Paquette (2004) proposed a new theory of father-child attachmentterm·dom, called activation relationship. The activation relationship theory stipulates that limit-setting and discipline are important in helping children feel safe when exploring their environment ( Paquette, 2004 ). The Risky Situation (RS) procedure has been developed to test the following dimensions of father-child attachmentterm·dom in children aged 12-18 months: stimulation (encourage the child to be open to the outside world), and discipline (setting limits for the child’s safety). According to the activation relationship theory, children are classified as activated (explore environment appropriately, and obey limits set by the father for their protection), under activated (fearful to explore, cautious and obedient), or overactivated (showing no hesitation or fear in exploration, even in the presence of risk, and are disobedient) ( Paquette, 2004 ).

One of the central notions of attachment theoryterm·key is that the quality of early caregiving is crucial to child development, especially how the parent is sensitive and responsive to the child’s cues (Ainsworth et al., 1978; Bell & Ainsworth, 1972). Attachment-based interventions are usually aimed at helping parents become more sensitive, responsive, and reflective. Sensitivityterm is the parental ability to perceive and appropriately interpret the cues implicit in the child's behavior, verbalization, and words, and correctly respond to these signals (Ainsworth et al., 1978). Individual differences in the child’s attachmentterm·dom security were attributed to variations in maternal sensitivityterm, and mothers of securely attached children were deemed more consistent and sensitive than mothers of insecurely attached children (De Wolff & van Ijzendoorn, 1997). Numerous studies have replicated these findings, exploring how maternal capacity to organize thoughts was linked to the ability to sensitively respond to her infant (van Ijzendoorn, 1995). Reviews by Goldsmith and Alansky (1987) , van Ijzendoorn (1995), De Wolff and van Ijzendoorn (1997), and Madigan et al. (2006) supported the notion that maternal sensitivityterm was linked to attachmentterm·dom security. A review of interventions to increase infant security by enhancing parental sensitivityterm concluded that short-term interventions were more effective than long-term, and increase in parental sensitivityterm did not always impact an infant’s attachmentterm·dom security, and in some studies improvement in infant security was noted without an increase in parental sensitivityterm ( Mountain et al., 2017 ).

The security of a child's attachmentterm·dom is also associated with the parent’s reflective functioningterm (RFterm) ( Katznelson, 2014 ; Slade, 2005 ). Parental RFterm refers to a parent's capacity to reflect on their own childhood experiences, and make meaning of their child’s thoughts, feelings, and behaviors ( Slade, 2005 ). It is theorized that RFterm promotes the parental capacity to regulate their emotions, and enables them to respond sensitively to their children’s emotional and physical needs ( Fonagy & Target, 1997 ). Higher levels of maternal ( Stacks et al., 2014 ) and paternal ( Fonagy et al., 1991 ) RFterm have been linked to sensitive behavior and a child’s attachmentterm·dom security. Studies that have assessed maternal reflective functioningterm capacity have shown that mothers with moderate to high RFterm scores were more likely to respond to their children sensitively, and were more likely to have children with secure attachmentterm·dom, compared to mothers with lower RFterm scores ( Bakermans-Kranenburg et al., 2003 ; Sadler et al., 2013 ).

To conclude, the concept of PCAterm·dom can be measured by validated tools and is useful to nursing practiceterm·key because nursing practiceterm·key is concerned with child mental health ( Gordon et al., 2020 ).

Linguistic Principle: Is the Concept Used Consistently and Appropriately Within the Scientific Literature?

The most outstanding linguistic issue pertained to how PCAterm·dom differs from maternal-child bondingterm·dom. In the nursing literature, PCAterm·dom is often conflated with parent-child bondingterm·dom ( Bicking Kinsey & Hupcey, 2013 ; Klaus & Kennell, 1983 ). While screening abstracts to determine inclusion eligibility for this concept analysis, we noted that many nursing articles that included the term “attachmentterm·dom” in the title and/or abstract used the terms “attachmentterm·dom” and “bondingterm·dom” interchangeably. Maternal-infant bondingterm·dom is emotional affection experienced by the mother toward her infant emerging in the immediate postpartum period ( Condon & Corkindale, 1998 ). Bondingterm·dom is not attachmentterm·dom ( Benoit, 2004 ; Redshaw & Martin, 2013 ). Unlike PCAterm·dom, bondingterm·dom does not predict socio-emotional and physical health outcomes later in life. Blurred distinctions between the concepts of bondingterm·dom and PCAterm·dom and the subsequent practice recommendations from nursing articles ( Goulet et al., 1998 ; Hill & Flanagan, 2020 ; Schenk et al., 2005 ) suggest that a clarification of PCAterm·dom concept is needed.

There is a discrepancy in the description of the patterns of attachmentterm·dom within the psychology and nursing literature, indicating that nurses and psychologists may think differently about PCAterm·dom. The conventional terms (developed by Bowlby & Ainsworth) used in the psychology literature for quality of attachmentterm·dom are “secure”, “insecure”, or “disorganized”. In the nursing literature, terms such as “positive” or “negative” are used when referring to the quality of PCAterm·dom ( Schenk et al., 2005 ). Further, the terms “attachmentterm·dom” and “bondingterm·dom” are used interchangeably in nursing original research and conceptual articles ( Karl et al., 2006 ; Kearvell & Grant, 2010 ; Zauderer, 2008 ). From the nursing perspective, attachmentterm·dom begins immediately after birth (do Vale et al., 2006; Goulet et al., 1998 ; Schenk et al., 2005 ). For example, a descriptive nursing study suggested that “attachmentterm·dom initially occurs soon after birth in a very important manner through eye contact” ( do Vale et al., 2005 , p. 71). From the psychology perspective, this statement is problematic, because attachmentterm·dom is not an instantaneous process, and only develops by the age of six or eight months ( Zeanah et al., 2000 ).

The scales frequently used by nurses to assess bondingterm·dom have the term “attachmentterm·dom” in the title, such as the Maternal-Postnatal Attachmentterm·dom Scale ( Beirami et al., 2017 ; Ghadery-Sefat et al., 2016 ), which may also contribute to differences in how PCAterm·dom is understood in the nursing and psychology literature.

Schenk et al. (2005) claimed that the nature of maternal-child attachmentterm·dom “from birth” (p. 516) is associated with the child’s behavioral disorders. The latest research suggests that maternal mental health problems and perception of family support, not the quality of bondingterm·dom at birth, may influence the development of a child's behavior problems ( Maia et al., 2020 ). The discrepancy between how bondingterm·dom and attachmentterm·dom are understood is not just a “harmless misunderstanding” (Eyer, 1994, p. 90). New parents who have been separated from their newborn often feel anxiety about not being able to establish “bondingterm·dom” early on ( Redshaw & Martin, 2013 ), but bondingterm·dom has not been shown to impact long term emotional and physical health.

In sum, PCAterm·dom is not bondingterm·dom. The implied meaning of the PCAterm·dom concept in nursing literature is inconsistent with that of psychology and medicine. PCAterm·dom does impact health and development over the life span ( Puig et al., 2013 ; Sroufe, 2005 ; Weinfield et al., 2000 ). Claims regarding the effects of maternal-infant bondingterm·dom on long-term child health outcomes are not supported by current evidence.

Logical Principle: Does the Concept Hold Its Boundaries When Integrated With Other Concepts?

In applying the logical principle, we considered PCAterm·dom in the context of related concepts, such as “parenting” and “parent-child relationshipterm·dom”. There is often an overlap between concepts of “attachmentterm·dom” and “parenting” in the scientific literature ( Koehn & Kerns, 2018 ). There is much more to parenting than attachmentterm·dom ( Lyons-Ruth, 1996 ). Attachmentterm·dom is only one specific aspect of a relationship between a parent and a child. The purpose of an attachment figureterm·dom is to make the child feel safe, secure, and protected. Attachmentterm·dom is different from other aspects of parenting such as feeding, teaching, playing, and disciplining ( Benoit, 2004 ). However, attachment-based research has been used to identify parenting practices that can impact a child's socio-emotional health, such as frightening or frightened parental behavior that may contribute to attachmentterm·dom disorganization (Kindsvatter & Tansey, 2018; Lyons-Ruth, 1996 ; Ranson & Urichuk, 2008 ).

The parent-child relationshipterm·dom is another concept that frequently emerged during our review of the literature for this concept analysis. The relationship is defined as the state of being related or interrelated ( Merriam-Webster Dictionary, 2019 ). Parent-child relationshipsterm·dom influence the social and emotional development of the child ( Koehn & Kerns, 2018 ). Nonetheless, PCAterm·dom is not the same as the concept of a parent-child relationshipterm·dom. Rather, attachment theoryterm·key provides a framework for studying parent-child relationshipsterm·dom ( Van IJzendoorn, Goldberg et al., 1992 ). Attachmentterm·dom is a specific type of relationship with distinct goals and behaviors. Additionally, PCAterm·dom can function outside of parent-child relationshipsterm·dom, as in cases of securely attached children shown to have less difficulty in building and maintaining social relationships with peers ( Sroufe, 1988 ). To conclude, there are conceptually distinct boundaries between PCAterm·dom, parenting, and the parent-child relationshipterm·dom.

Recommendations for Nursing Practiceterm·key The concept of PCAterm·dom is useful and relevant to nursing practiceterm·key. A child's mental health is one of the top national priorities for nursing ( Eckardt et al., 2017 ). The nurse may be the first healthcare professional who comes in contact with parents and their children. Nurses in all areas of healthcare should be able to observe the interaction between a parent and a child (e.g., attachmentterm·dom behaviors), and assess the quality of PCAterm·dom. Nurse leaders must continue to advocate for the inclusion of attachment theoryterm·key knowledge in formal nursing programs to help ensure the implementation and sustainability of attachment-based interventions that support optimal child development. Nurses need to identify factors that interfere with PCAterm·dom, assess available supports, and provide necessary referrals. Specifically, the assessment of the PCAterm·dom should include an assessment of the family context (e.g., parental mental health, social support, socio-economic status) because children are highly dependent on their immediate family environment for their health and development.

Even maltreated and neglected children become attached, although usually in an insecure or disorganized way ( Benoit, 2004 ). When assessing PCAterm·dom, the question should be what is the quality of PCAterm·dom instead of is there a PCAterm·dom ( Benoit, 2004 ). PCAterm·dom can be disrupted by conditions that limit children’s behavior, such as neurological disorders, illness, and fatigue, or conditions that can interfere with the parent’s ability to provide care, such as poverty and mental health problems. However, the parent plays a more important role than the child in shaping the quality of attachmentterm·dom ( O'Connor et al., 2019 ). This is important to know because attachmentterm·dom outcomes can be altered by changes in the immediate environment, such as changes in parenting behaviors ( Belsky & Fearon, 2002 ).

Attachmentterm·dom behaviors are most likely to be evident when the child is in an unfamiliar environment or feeling ill or in pain ( Feeney, 2000 ). During the visit to a healthcare setting, a frightened child may crawl to the parent, looking to be picked up and comforted ( George, 1996 ). Nurses can point out the child's attachmentterm·dom behaviors, such as clinging to the parent when upset, resisting separation, and calming when held by the parent. In toddlers, controlling behaviors (e.g., being punitive, bossy, assuming inappropriate caregiving behaviors towards a parent) can be noted as possible signs of attachmentterm·dom insecurity/disorganization ( Zeanah et al., 2011 ). It is important to note that a secure or insecure attachmentterm·dom quality cannot be inferred from any single behavior (e.g., crying, resistance), but needs to be inferred from the pattern of behavior within situational context (separating or reuniting with a parent) ( Sroufe & Waters, 1977 ). Parenting behaviors that encourage autonomy and maintain relatedness (e.g., respecting that children have their own thoughts and feelings) are important indicators of attachmentterm·dom security in parents with adolescents. To enhance PAC, nurses can use positive reinforcement of parenting skills, such as modeling appropriate responses (e.g., warm, supportive, sensitive, responsive, and prompt) to the child’s behaviors to encourage parents to assume similar responses to promote feelings of security in a child. Nurses should provide education on ways to increase parental sensitivityterm and responsiveness (child cue-based interactions, normal child growth, and development).

Both mother and father are important in fostering secure attachmentterm·dom ( Bretherton, 2010 ). Fathers are still marginal to the majority of parenting interventions to enhance PCAterm·dom ( Panter-Brick et al., 2014 ), and more research that evaluates parenting programs that include the participation of fathers is needed to better understand the impact of fathering on a child's attachmentterm·dom security. Because attachment-based intervention programs have primarily targeted the mother-child relationship, there are no guidelines for effective father-child attachmentterm·dom programs to date ( Henry et al., 2020 ). Adverse socio-demographic factors have been shown to have a more negative impact on the fathering role, compared to the mothering role ( Bretherton, 2010 ; Palm, 2014 ; Paquette, 2004 ). Thus, the most effective programs to support fathers should include efforts to access and minimize socio-demographic barriers (e.g., lack of social support and unemployment, marital discord, mental illness, lack of education) along with parenting skills (e.g., sensitivityterm, responsiveness towards their children) and knowledge of child development ( Bretherton, 2010 ; Palm, 2014 ). With the support of nurses, fathers can develop parenting competencies and confidence in both play and caregiving contexts which can enhance father-child attachmentterm·dom security.

To advance the use of the PCAterm·dom concept for nursing practiceterm·key, we propose the definition of the PCAterm·dom as a bi-directional relationship between a child of 0 to 18 years of age and a primary caregiver, where a child uses the caregiver as a secure baseterm·dom from which to explore and as a haven of safety and source of comfort in times of distress (Ainsworth et al., 1978; Bowlby, 1988).

Conclusions This article aimed to describe how the concept of PCAterm·dom is understood from a multidisciplinary perspective. Attachment theoryterm·key offers nurses promising practice opportunities to provide an umbrella of supports that embraces and promotes life-long emotional and physical health of children and their families. The concept of PCAterm·dom is poorly understood in nursing literature due to inconsistencies and confusion of this concept with the concept of bondingterm·dom.

Footnotes References