اضطراب جدایی بزرگسالان و رفتار بی قراری نوزاد: ارتباط معکوس با پدر و مادر در طول دوران کودکی و دلبستگی ناامن بزرگسالان

This study examined the prevalence and correlates of Adult Separation Anxiety Disorder (ASAD) and Adult Separation Anxiety (ASA) symptoms in a sample of first-time mothers with an unsettled infant during the first postpartum year. Methods Eighty-three primiparous women admitted to a residential parent–infant program participated in a structured clinical interview for DSM-IV diagnosis and questionnaires assessing ASA symptoms, adult attachment and childhood parenting experiences. Nurses recorded infant behavior using 24-hour charts. Results The prevalence of ASAD in this sample was 19.3% and women with ASAD were, on average, more likely to be diagnosed with depression and anxiety disorders, report aversive parenting experiences during childhood and show adult attachment style insecurity. Both ASAD and ASA symptoms were predicted by adult attachment anxiety, and ASAD was associated with unsettled infant behavior. Attachment anxiety and attachment avoidance mediated relations between parental over-control and ASAD diagnosis, and between parental abuse and ASAD diagnosis. Attachment anxiety mediated the relation between parental over-control and ASA symptoms, and attachment avoidance mediated the relations of parental over-control and parental abuse with ASA symptoms. Conclusions This study highlights the prevalence of ASAD among first time mothers experiencing early parenting difficulties and the roles of childhood parenting experiences and adult attachment style in the development of the disorder. This points to the importance of introducing universal screening for ASAD in postnatal settings, and for the development of targeted interventions.

It is common for infants to display unsettled behavior in the first few months of life [1] and, while most infants undergo natural improvements by around 3 months [2], difficulties can continue throughout the first postnatal year and beyond [3]. While the direction of causation is difficult to determine [9] and [10], ongoing unsettled infant behavior is unfortunately associated with a higher likelihood of maternal depression [4], [5], [6], [7] and [8]. Similarly, evidence also points to the prevalence of anxiety disorders among new mothers struggling with unsettled infants [5], [7], [11] and [12]. Rates of anxiety disorders among mothers attending Australian intervention programs for unsettled infant behavior, for example, have been reported to be in the range of 25–30% [11] and [13]. A limitation of research to date, however, has been a focus on the most common disorders or use of symptom-based measures, resulting in limited understanding of lesser-known sub-groups. Given the highly interpersonal and thus attachment-activating nature of the early parenting experience, fears about separation may be a major underlying factor for a sub-group of anxious women presenting with an unsettled infant. In the general postnatal literature, most of the research about separation anxiety has focussed on fears about separating from the infant [14], [15] and [16], but a growing body of evidence in the general psychiatric literature about adult separation anxiety disorder (ASAD) (including inclusion in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders) [17], [18], [19], [20], [21] and [28], together with initial evidence about the prominence of ASAD in the perinatal period [22], suggest that a broader view of the condition in this population is warranted. The primary anxiety associated with ASAD is the fear of actual or possible separation from close attachment figures and a consequent preoccupation with the safety and whereabouts of those persons. While co-morbidity with other anxiety disorders is high [23], evidence of a putative ASAD diagnosis lies in findings that (i) in most cases separation anxiety symptoms predate co-morbid disorders, (ii) the level of distress caused by separation concerns is usually equivalent to that caused by the co-morbid disorders, and (iii) panic attacks, worry and agoraphobia are often primarily related to separation concerns [17] and [19]. Lifetime and point prevalence rates for ASAD are estimated at 6.6% and 1.9%, respectively [23], but there is evidence of increased incidence in the perinatal period. Eapen et al. [22] found that of 331 pregnant women attending an Australian antenatal clinic, 81 (24.5%) reached an established threshold for clinically significant Adult Separation Anxiety (ASA) symptoms, representing a significantly higher prevalence than those recorded at a population level. In a subsequent study at the same site, Eapen et al. [24] examined 127 women during pregnancy and followed 57 of them up at 3-month postpartum. The rate of clinically significant ASA symptoms at 3-month postpartum was 26%, highlighting this as an issue of relevance across this important transition period. Given the demonstrated links between maternal postnatal anxiety and unsettled infant behavior [5], [7] and [11], rates may be even higher among women presenting for professional assistance with an unsettled infant. To our knowledge, there have been no studies looking at rates of ASAD in this group. Clearly, better understanding of the heterogeneous mix of anxiety presentations in this group will provide opportunity for more targeted support and intervention, thus enhancing treatment efficacy. Predisposing factors for ASAD have also not been well explored, in postnatal or general non-postnatal populations. While there is strong evidence from the general psychiatric literature of links between adverse parenting style and the development of anxiety disorders, in particular maternal over-protection and control [25] and [26], little is known about the role of early parenting experiences in the development of ASAD. In one of the only studies to examine this issue, Manicavasagar et al. [27] examined parental representations in three groups: patients with separation anxiety concerns, patients with panic disorder and a general community comparison group. They found patients in the ASAD group to have recollections of higher levels of maternal overprotection in childhood. Attachment theory [29] provides a theoretical framework for conceptualizing the connection between the nature of care-giving received in childhood and the development of separation anxiety. According to this theory, the child develops an ‘internal working model’ of the self in relation to others, based on repeated interactions with caregivers. Secure attachment develops in the context of appropriately sensitive and responsive care-giving and insecure attachment develops in the context of care-giving that is intrusive, excessively stimulating, unresponsive or unpredictable [30]. Attachment insecurity has been linked with a range of psychopathologies in adulthood [31] and [32] and preliminary evidence with respect to ASAD suggests a similar picture. Manicavasagar et al. [33] studied associations between attachment insecurity and ASAD in a sample of 83 anxiety clinic patients diagnosed with PD/PD-AG, and/or ASAD. Results showed patients with co-morbid ASAD to be more likely to have an insecure attachment style (particularly an anxious attachment style), than those with PD/PD-AG alone. A recent study in a perinatal sample identified an association between anxious attachment and postpartum depression symptoms, and found the relation to be mediated by ASA symptoms [24]. Bowlby [29] described human development as a transactional pathway that “turns at each and every stage of the journey in an interaction between the organism as it has developed up to that moment and the environment in which it then finds itself” (p. 412). Current evidence supports this view, with attachment insecurity thought to interact with other childhood adversity factors (e.g., ongoing ineffective parenting, atypical childhood characteristics and high family adversity) to predict poor psychological outcomes in adulthood [31] and [34]. Thus, rather than there being a direct link between adverse early parenting experiences and ASAD, the relation is likely to occur through the mediating effect of adult attachment insecurity. To our knowledge this has not yet been investigated; improved understanding of relations between these variables will lead to better understanding of the etiology of ASAD and of protective/risk factors for individuals who experience adversity in childhood. Taken together, available evidence suggests that ASAD may be an under-recognized clinical condition among new mothers with unsettled infants, and that it may be associated with dysfunctional parenting in childhood and adult attachment insecurity. Improved understanding of this sub-type of postnatal anxiety will pave the way for the development and provision of tailored interventions. Given the lack of research in this area, this study was conducted to explore the prevalence and correlates of ASAD in a sample of first time mothers presenting to a treatment program for unsettled infant behavior. Specific hypotheses were that: (1) ASAD would be more common in this sample compared to the general population and available perinatal data; (2) ASAD would be associated with recollections of maternal over-protection in childhood, adult attachment insecurity and infant crying and sleep disturbance. (3) Attachment insecurity would mediate the relation between adverse early parenting experiences and ASAD.