The presence of lullabies cross-culturally and in folk and classical music attests to the universality of the unsettled infant (Bargiel, 2004). Unsettled behaviour is a developmental phenomenon that is common in the early months of life (St James-Roberts, 2012). Behaviours such as crying and fussiness are ways in which infants communicate with others about their needs. These behaviours reach a peak around six weeks and usually resolve by three to four months of age (Douglas & Hiscock, 2010; St James-Roberts, 2012).
Unsettled infants can be confusing for parents (Ellett & Swenson, 2005; Megel et al., 2011), who can feel overwhelmed (St James-Roberts et al., 2019, p. 20). Their behaviour can have negative impacts on parents’ wellbeing (Megel et al., 2011; Oldbury & Adams, 2015), on feeding practices (Vilar‐Compte et al., 2022), on the parenting they receive (Oldbury & Adams, 2015; Papousek & von Hafacker, 1998), and on their longer-term outcomes, particularly infants who continue with excessive crying beyond three to four months of age (Brown et al., 2009; Cook et al., 2018; Santos et al., 2015). The peak period of unsettled infant behaviour coincides with the peak time for shaken baby syndrome that can result in lifelong disability or even death (Barr, 2012).
Given the potential adverse outcomes for infants it is essential that when parents seek help that the help offered is appropriate and meets their needs. Effective intervention is needed to avoid the pathologizing of normal behaviours, to ameliorate the potential adverse outcomes for parents and their infants, and to prevent the need for more costly secondary, tertiary, and residential interventions (Douglas et al., 2015). For parents there can be barriers to seeking help or seeking help early. These can include cultural (Zanetti et al., 2023) and mental health issues (Sorsa et al., 2021). Another factor that appears to impact help seeking behaviour is attachment style (Ciechanowski et al., 2002).
Attachment styles impact help seeking behaviour for both physical and mental health conditions. In areas such as diabetes, lupus and heart disease research it has been found that people with a negative view of others tend to seek help later than those with a positive view of others and their symptom levels tend to be higher at initial presentation (Blom et al., 2009; Ciechanowski et al., 2002; Morris et al., 2009; Porter et al., 2007; Vogel & Wei, 2005) Likewise, Adams et al. (2018), in a systematic review, found that people with attachment avoidance (i.e. people with a negative view of others) were less likely to seek “help for mental health concerns and less likely to comply with or complete treatments” (Adams et al., 2018, p. 657).
To tailor interventions knowing a parent’s attachment style would be helpful. One way would be to include an assessment of attachment style in the initial assessment. There are a variety of ways to measure attachment style including extensive interviews which are time consuming and expensive to administer, and self-report questionnaires (see Adshead and Guthrie, 2015, for a brief review). Another alternative is to use unstructured interview questions to ascertain a person’s attachment style (Demyan & Cosio, 2023). This requires considerable staff training.
One self-report questionnaire that has been used across a range of populations including primary care clinics (Ciechanowski et al., 2001) and breast feeding women (Wilkinson & Scherl, 2006) is the Relationship Questionnaire (RQ) (Bartholomew & Horowitz, 1991). It is easy to administer and requires little time. This can be administered in one of two ways, one that establishes the degree to which the person perceives each style is like them and the other that establishes their perceived predominant style. Ciechanowski (2002) argues that it is “often more useful, clinically, to determine an individuals’ predominant attachment style” p. 661.
In New South Wales, Australia, Child and Family Health Nurses can follow children from birth to school age and parents can seek help from them when concerned about their unsettled infants. Parents complete a number of questionnaires as part of the initial assessment process (Health, 2009). Proposed research in this field includes an assessment of a parents’ attachment style, for example, using the RQ. The RQ has been shown to be both valid and reliable. If administered to establish the parents’ predominant style as suggested by Ciechanowski (2002, 2003) it would only involve parents reading brief descriptive statements of four attachment styles and indicating the one that is most like them. Including the RQ into the assessment process would not significantly increase the demands on parents or the time involved but could impact on the effectiveness of interventions offered if nurses delivered interventions in line with the parent’s attachment style.
Evidence from a variety of studies supports the idea that people with different attachment styles benefit from different interventions (Adshead & Guthrie, 2015; Ciechanowski, 2003; Demyan & Cosio, 2023). For example, as people with dismissing or fearful styles, those with a negative view of others have difficulty forming a trusting relationship, clinicians need to invest effort in the formation of a working relationship before engaging in treatment. Use of the BATHE (Background, Affect, Troubling, Handling and Empathy) model may offer an appropriate way of engaging with these parents (Grabbe, 2015). For these parents the opportunity to talk about how difficult it is to care for a baby who cries persistently as recommended in the clinical guidelines (The Royal Children’s Hospital, 2019) would appear to be important. These parents are likely to have delayed seeking help because of their mistrust of others and may have higher levels of distress. Therefore, focusing on their needs rather than providing education about normal development in the early stages of treatment may be more appropriate and result in longer term engagement. Reframing techniques maybe helpful once trust has been developed. For example, reframing infants’ crying from a sign that they are in pain to a sign that they are “a vigorous baby” (St James-Roberts, 2012). In addition, nurses could support them to find ways to contain or minimize the crying (St James-Roberts, 2012).
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Authors
Kathryn Thornton,
Australia
Agatha Conrad,
Australia
Emily Freeman,
Australia
Linda Campbell,
Australia
