Perinatal Depression effects on Attachment and Attunement

The relationship between a mother and her infant begins in utero. The quality of their affective dialogue is largely governed by fluctuating hormones, environmental stresses and the expectant mother’s psychological history.  The state of a woman’s mental health during both pregnancy and the postpartum period is critical, not only for her well-being, but for the overall health of her infant in utero and in the years following childbirth. When maternal mental health is compromised by perinatal illness, the security of attachment that is so necessary for healthy cognitive, social, and psychological development is disrupted. Disruptions in the growing attachment between a mother and her baby can begin as early as conception and continue into the postpartum period with grave consequences, particularly for that infant’s mental health across the lifespan.

Untreated depression during pregnancy is associated with adverse fetal outcomes, including low birth weight, prematurity, and decreased Apgar scores, while significantly raising the risk of maternal morbidity and vulnerability to postpartum illness (Bonari, 2004; Marcus, Flynn, Blow & Barry, 2003). Untreated anxiety during gestation elevates cortisol levels in the expectant mother that can affect fetal brain development or cause conduct and behavioral disturbances in that child as much as four years postpartum (Glover, 2011). In addition, the mother experiencing the disturbing symptoms of an antenatal mood or anxiety disorder is less likely to be attentive to regular prenatal care and more likely to use substances to manage the uncomfortable effects of depression or anxiety; she may even seek to terminate her pregnancy as a way of relieving her intolerable distress.

During the early weeks and months of the postpartum period, a mother and her infant are emotionally and psychologically entwined.  A mother’s capacity to attune herself to her baby’s needs creates meaning and gives voice to the infant’s experience. It is in response to the attachment figure’s appropriate reading of his/her signals that infants begin to acknowledge the existence of self. Based on a subjective appraisal of maternal reliability and responsiveness, the infant makes a pre-verbal evaluation not only of the caregiver’s ability to provide protection and care, but also of self and how much he or she deserves that protection and care, what attachment research refers to as an “internal working model,” of relationships. (Bowlby, 1988).

Because postpartum depression alters perception, causing frequent distortions in thought and impairment in judgments, it inevitably changes the sensitivity and consistency of a mother’s responsiveness. Consequently, the depressed mother may fail to respond appropriately or even at all to her baby’s signals for connection. At the other extreme, she may be overly intrusive or hostile towards her infant. Mothers with a perinatal depression often describe feeling emotionally disconnected or detached as they find themselves “going through the motions” of providing care for their infants.   It is the specialness of this very first attachment experience, in which the infant learns about trust and safety, that becomes the template for all other intimate attachments across the lifespan and lays a foundation for the infant’s psychological health.

A mother’s depression is a traumatic event for the growing infant who experiences the withdrawal and disengagement of this most important attachment figure.  Babies respond to their terror that they have been “left,” with valiant attempts to draw their mothers back into the relationship. An infant’s heighted awareness of his/her mother’s change in affect has never been demonstrated more clearly than in “The Still Face Experiment (Tronick,  Alys, Adamson, Wise & Brazelton, 1978) in which mothers were asked to maintain an expressionless face  as if they were depressed and to remain unresponsive to their infants for an extended period of time.  In reaction to their mothers’ withdrawal,  infants becomes noticeably distressed and alarmed and will even make desperate attempts to re-engage their mothers by assuming her depressed expression in what has been termed a “microdepression (Stern, 1994).  When infants’ repeated pleas to solicit some response from their mothers fails, they eventually withdraw physically and emotionally.

Research indicates that the infants of depressed mothers generally tend to be less engaged and re at greater risk for depression and anxiety themselves (Field, Healy, Goldstein, Perry & Bendell, et al). During infancy, they may cry more, soothe less easily, and have more problems with feeding and sleeping, in addition to possible delays in language and motor development. They’re apt to make less eye contact and be less responsive to their mothers. As they get older, they may display more behavioral symptoms like temper tantrums and extreme separation anxiety. The school-age children of depressed mothers may experience more academic as well as behavioral problems; they may be hyperactive, easily distracted and overly aggressive.  In the classroom, they may have any number of cognitive deficits that interfere with learning and ultimately lead to feelings of low self-esteem. Socially, they may have tremendous difficulty making friends.

“Existing in the heart and mind of another” and “feeling felt,” (Fosha, 2003) are critical to an infant’s healthy psychological development and the attachment security that protects against the development of psychopathology.   Mothers who suffer with perinatal illness are far less able to provide the quality of attunement that is so necessary for the development of that secure attachment, leaving their infants vulnerable to emotional and behavioral difficulties as they grow.  It is possible to begin determining a woman’s risk for a perinatal mood or anxiety disorder, even before conception, and to continue to screen and identify potential problems throughout pregnancy and into the first year postpartum.  Recognition of illness, early intervention and appropriate treatment are key to diminishing the severity of these potentially life-threatening disorders. When left untreated, perinatal illness creates emotional havoc for the entire family, leaving long-term psychological scars, particularly for the developing infant.

Headshot - Diana Lynn Barnes, Psy.D

Diana Lynn Barnes, Psy.D LMFT
The Center for Postpartum Health
President, Postpartum Support International (2002-2004).
Training Faculty, Los Angeles Perinatal Mental Health Task Force



  1. Bonari, L.; Bennett, H.; Einarson, A.; & Koren, G. (2004). The risks of untreated depression during pregnancy. California Family Physician, 50, 37-39.
  2. Bowlby, J. (1988). A secure base: The origins of attachment theory. London: Routledge.
  3. Field, T.; Healy, B.; Goldstein, S.; Perry, S.; Bendell, D. et al (1988). Infants of depressed mothers show  “depressed behavior” even with non-depressed adults. Child Development, 59(6), 1569-1579.
  4. Fosha, D (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books.
  5. Glover, V. (2011). Prenatal stress and the origins of psychopathology: An evolutionary perspective. Journal of Child Psychology and Psychiatry, 52(4), 356-367.
  6. Marcus, S.M.; Flynn, H.A.; Blow, F.C.;  & Barry, K.L. (2003). Depressive symptoms among pregnant women screened in obstetric settings. Journal of Women’s Health, 12(40), 373-380.
  7. Stern, D.N. (1994). One way to build a clinically relevant baby. Infant Mental Health Journal, 15(1), 9-25.
  8. Tronick e.; Als, H.; Adamson, L.; Wise, S.; & Brazelton, T.B. (1978). The infant’s response to entrapment between contradictory messages in face-to-face interaction. Journal of the American Academy of Child Psychiatry, 17(10, 1-13).


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