Parental Posttraumatic Stress Disorder and Attunement: Meta-Analysis

Julia Asanov, Neelofar Rehman


Background: Attunement between a primary carer and their infant plays a crucial role in infant brain development, attachment, sense of self and personality development, with long-term effects on risk of future psychopathology. The present study aimed at 1) identifying a comprehensive definition of attunement and 2) investigating parent-infant attunement in the context of parental posttraumatic stress disorder (PTSD).

Subjects and Method: Following PRISMA guidelines, a systematic review of the literature was conducted on parental PTSD and parent-infant attunement. Eligible studies were prospective, quantitative, published in peer-reviewed journals, included normal samples and samples with PTSD along with attunement variables, reporting correlational data, with mothers aged 16 or older and infants aged 0-18 months. 48 articles were examined in full-text and 18 selected for analysis. A National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was used to assess the quality of selected studies. Pooled effect sizes were calculated separately for positive and negative attunement variables under the random effects model, using comprehensive meta analysis (CMA).

Results: Analysis failed to reach statistical significance. The pooled effect size for parental PTSD and negative attunement was positive and small. The pooled effect size for parental PTSD and positive attunement was negative and small.

Conclusion: Due to the high heterogeneity among the included articles and statistically non-significant effect sizes, results need to be interpreted with caution. However, the results indicate that the presence of PTSD symptoms is likely to influence parents’ capacity to attune to their infants. Limitations and implications for future research and clinical practice are discussed.

Keywords: attunement, parental posttraumatic stress disorder

Correspondence: Neelofar Rehman. Senior Clinical Psychologist, Mercy Mental Health, Melbourne, Australia. email:

Journal of Maternal and Child Health (2022), 07(03): 243-260


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American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (Fifth ed.) [Online version]. Retrieved from:

Ammerman RT, Putnam FW, Chard KM, Stevens J, Van Ginkel JB (2012). PTSD in depressed mothers in home visitation. Psychol Trauma. 4(2):186–195.

Atkinson L, Jamieson B, Khoury J, Ludmer J, Gonzalez A (2016). Stress physio-logy in infancy and early childhood: cortisol flexibility, attunement and coordination. J Neuroendocrinol. 28-(8).

Ayers S, Wright DB, Wells N (2007). Symptoms of post-traumatic stress disorder in couples after birth: association with the couple’s relationship and parent-baby bond. J Reprod Infant Psychol. 25 (1): 40–50.

Banneyer KN, Koenig SA, Wang LA, Star, K (2017). A Review of the effects of parental PTSD: A focus on military children. Couple Fam Psychology. 6(4): 274–286.

Bartling K, Kopp F, Lindenberger U (2010). Maternal affect attunement: refinement and internal validation of a coding scheme. Eur J Dev Sci. 4(1): 1–17. DOI: 10.3233/DEV-2010-4101

Belt RH, Kouvo A, Flykl M, Punamaki Raija-Leena, Haltigan JD, Biringen Z, Tamminen T (2013). Intercepting the intergenerational cycle of maternal trauma and loss through mother–infant psychotherapy: A case study using attachment-derived methods. Clin Child Psychol Psychi-atry. 18(1): 100–120.

Bernard NK, Kashy DA, Levendosky AA, Bogat GA, Lonstein JS (2017). Do different data analytic approaches generate discrepant findings when measuring mother–infant HPA axis attunement?. Dev Psychobiol. 59(2): 174–184.

Blizard RA (2014). Relational trauma in infancy: Psychoanalytic, attachment and neuropsychological contributions to parent-infant psychotherapy. J Trauma Dissociation. 15(4): 512-514.

Borghini A, Habersaat S, Forcada-Guex, M, Nessi J, Pierrehumbert B, Ansermet F, Muller-Nix C (2014). Effects of an early intervention on maternal post-traumatic stress symptoms and the quality of mother–infant interaction: The case of preterm birth. Infant Behav Dev. 37(4): 624–631.

Bosquet EM, Kitts RL, Blood E, Bizarro A, Hofmeister M, Wright RJ (2011). Maternal posttraumatic stress symptoms and infant emotional reactivity and emotion regulation. Infant Behav Dev. 34(4): 487–503.

Brand SR, Engel SM, Canfield RL, Yehuda R (2006). The effect of maternal ptsd following in utero trauma exposure on behavior and temperament in the 9-month-old infant. Ann N Y Acad Sci. 1071(1): 454–458.

Christiansen OM, Elklit A (2014). Parents bereaved by infant death: sex differrences and moderation in PTSD, attachment, coping and social support. Gen Hosp Psychiatry. 36(6): 655–661.

Comprehensive meta-analysis [CMA] (Version 3) [Computer software]. Englewood, NJ: Biostat.

Cozolino LJ (2014). The neuroscience of human relationships: attachment and the developing social brain. Second edition. New York: W.W. Norton & Company.

Cuijpers P (2016). Meta-analyses in mental health research: A practical guide. Retrieved from:

Davies J, Slade P, Wright I, Stewart P (2008). Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant Ment Health J. 29(6): 537–554.

Day E (2016). Field attunement for a strong therapeutic alliance: a perspective from relational gestalt psychotherapy. J Humanis Psychol. 56(1): 77–94. DOI: 10.1177/0022167-815569534

Diab SY, Isosävi S, Qouta SR, Kuittinen S, Punamäki RL (2018). The protective role of maternal posttraumatic growth and cognitive trauma processing among Palestinian mothers and infants. Infant Behav Dev. 50: 284–299. DOI: 10.1016/j.infbeh.2017.05.008.

Duval S, Tweedie R (2000). Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 56 (2): 455–463. DOI: 10.1111/j.0006-3-41X.2000.00455.x

Easterbrooks MA, Biringen Z (2000). Guest editors introduction to the special issue: mapping the terrain of emotional availability and attachment. Attach & Human Dev. 2(2): 123–129. DOI: 10.-1080/14616730050085518

Flacking R, Ewald U, Starrin B (2007). I wanted to do a good job: Experiences of ‘becoming a mother’ and breastfeeding in mothers of very preterm infants after discharge from a neo=natal unit. Soc Scie Med. 64(12): 2405-2416. DOI: 10.1016/j.socscimed.2007.03.008.

Fuchs A, Möhler E, Resch F, Kaess M (2016). Sex-specific differences in adrenocortical attunement in mothers with a history of childhood abuse and their 5-month-old boys and girls. J Neural Trans. 123(9): 1085–1094.

Garthus-Niegel S, Ayers S, Martini J, Von Soest T, Eberhard-Gran M (2017). The impact of postpartum post-traumatic stress disorder symptoms on child development: A population-based, 2-year follow-up study. 47(1): 161-170.

Haft W (1989). Affect attunement and maternal attachment: An observational study of the intergenerational transmission of mothers' internal representations of attachment (Doctoral Dissertation). Retrieved from Pro-Quest Dissertations and Theses.

Hairston IS, Handelzalts JE, Assis C, Kovo M (2018). Postpartum bonding difficulties and adult attachment styles: The mediating role of postpartum depression and childbirth-related PTSD. Infant Men Health J. 39(2): 198-208. DOI: 10.1002/imhj.21695

Harwood I (2006). Head start is too late: Integrating and applying infant observation studies, and attachment, trauma, and neurobiological research to groups with pregnant and new mothers. Int J of Group Psychother. 56 (1): 5-28. DOI: 10.1521/ijgp.2006.56.1.5

Ionio C, Blasio PD (2013). Post-traumatic stress symptoms after childbirth and early mother–child interactions: An exploratory study. J Reprod Infant Psychol. 32(2): 1-19. DOI: 10.1080/0-2646838.2013.8418

Jonsson C, Clinton D, Fahrman M, Mazzaglia G, Novak S, Sörhus K (2001). How do mothers signal shared fee-ling‐states to their infants? An investigation of affect attunement and imitation during the first year of life. Scand J Psychol. 42(4): 377-381. DOI: 10.1111/1467-9450.00249

Kokkinaki, TS (2003). A longitudinal, naturalistic and cross-cultural study on emotions in early infant-parent imitative interactions. Br J Dev Psychol. 21(2): 243–258. DOI: 10.1348/026151003765264066

Kokkinaki TS, Vasdekis VGS, Koufaki ZE, Trevarthen CB (2017). Coordination of emotions in mother–infant dialogues. Infant Child Dev. 26(2): 1–25. DOI: 10.1002/icd.1973

Laurent HK, Ablow JC, Measelle J (2011). Risky shifts: How the timing and course of mothers’ depressive symptoms across the perinatal period shape their own and infant’s stress response profiles. Dev Psychopathol. 23(2): 521–538.

Levendosky AA, Bogat GA, Lonstein JS, Martinez-Torteya C, Muzik M, Granger DG, Von EA (2016). Infant adrenocortical reactivity and beha-vioral functioning: Relation to early exposure to maternal intimate partner violence. Stress, 19(1): 37-44.

Lipsey MW, Wilson DB (2001). Practical meta-analysis [PDF]. Retrieved on 01-07-2018, from:

Matta D, Knudson‐Martin C (2006). Father responsivity: Couple processes and the coconstruction of fatherhood. Family Process. 45(1): 19-37. doi: 10.1111/j.1545-5300.2006.00078.x

Mehler K, Mainusch A, Hucklenbruch-Rother E, Hahn M, Hünseler C, Kribs, A (2014). Increased rate of parental postpartum depression and traumati-zation in moderate and late preterm infants is independent of the infant's motor repertoire. Early Hum Dev. 90 (12): 797-801. DOI: 10.1016/j.earlhu-mdev.2014.09.008

Meins E (2013). Sensitive attunement to infants’ internal states: Operationalizing the construct of mind-minded-ness. Attach Hum Dev. 15 (5-6): 524-544. DOI: 10.1080/14616734.2013.8-30388

Mendelsohn A (2005). Recovering reverie: Using infant observation in interventions with traumatised mothers and their premature babies. Infant Obs. 8 (3): 195-208. DOI: 10.1080/1369803-0500375693

Moher D, Liberati A, Tetzlaff J, Altman D (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med. 151(4): 264-9. DOI: 10.-7326/0003-4819-151-4-200908180-00135.

Morelen D, Menke R, Rosenblum KL, Beeghly M, Muzik, M (2016). Under-standing bidirectional mother-infant affective displays across contexts: Effects of maternal maltreatment history and postpartum depression and PTSD symptoms. Psychopatho-logy. 49(4): 305-314.

Muzik M, Cameron HG, Fezzey A, Rosen-blum K (2009). Motherhood in the Face of trauma: PTSD in the child-bearing year. Zero to Three. 29(5), 28-33.

Muzik M, McGinnis E, Bocknek E, Morelen D, Rosenblum K, Liberzon I, Seng J, et al. (2016). PTSD symptoms across pregnancy and early postpartum among women with lifetime PTSD diagnosis. Depress Anxiety. 33(7): 584-591. DOI: 10.1002/da.22465

National Heart, Lung, and Blood Institute [NHLBI], (n.d.). Study quality assess-ment tools. Retrieved from:

Noyman-Veksler G, Shirley-Herishanu-Gilutz O, Kofman G, Holchberg G, Shahar G (2015). Post-natal psychopathology and bonding with the infant among first-time mothers undergoing a caesarian section and vaginal delivery: Sense of coherence and social support as moderators. Psychol Health. 30(4): 1-34. DOI: 10.1080/08870446.2014.977281

Ostlund BD, Measelle JR, Laurent HK, Conradt E, Ablow JC (2017). Shaping emotion regulation: Attunement, symptomatology, and stress recovery within mother-infant dyads. Dev Psy-chobiol. 59(1): 15–25. DOI: 10.1002/dev.21448

Parfitt Y, Ayers S (2009). The effect of post‐natal symptoms of post‐traumatic stress and depression on the couple's relationship and parent–baby bond. J Reprod Infant Psychol. 27(2): 127-142.

Parfitt Y, Pike A, Ayers S (2013). The impact of parents’ mental health on parent–baby interaction: A prospective study. Infant Behav Dev. 36(4): 599-608. DOI: 10.1016/j.infbeh.-2013.06.003

Parfitt Y, Pike A, Ayers S (2014). Infant developmental outcomes: A family systems perspective. Infant Child Dev. 23(4): 353-373.

PsychAlive (Producer). (2014). Dr. Allan Schore on attachment trauma and effects of neglect and abuse on brain development [Video]. Retrieved from:

Reid M (2011). The impact of traumatic delivery on the mother–infant relationship. Infant Obser. 14(2): 117-128. DOI: 10.1080/13698036.2011.583424

Rocco D, Gennaro A, Salvatore S, Stoycheva V, Bucci W (2017). Clinical mutual attunement and the development of therapeutic process: A preliminary study. J Constr Psychol. 30(4): 371–387. DOI: 10.1080/10720537.2016.1-227950

Rollins P, Greenwald L (2013). Affect attunement during mother-infant interaction: How specific intensities predict the stability of infants' coordinated joint attention skills. Imagin Cogn Pers. 32(4): 339.

Rutherford H, Wallace N, Laurent H, Mayes L (2015). Emotion regulation in parenthood. Dev Review. 36(1).

Savelkoul EM, Zebrowski PM, Feldstein S, Cole-Harding S (2007). Coordinated interpersonal timing in the conversations of children who stutter and their Mothers and fathers. J Fluency Disord: 32(1): 1-32.

Schechter DS, Suardi SF, Manini A, Cordero MI, Rossignol AS, Merminod G, Gex-Fabry M, et al. (2015). How do maternal PTSD and alexithymia interact to impact maternal behavior?. Child Psychiatry Hum Dev. 46(3): 406-417.

Schore AN (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Ment Health J. (1‐2): 7-66.<7::AID-IMHJ2>3.0.CO;2-N.

Schore AN (2003a). Interdisciplinary rese-arch as a source of clinical models. In Affect regulation & the repair of the self (pp. 3-32). NY: W.W. Norton.

Schore AN (2003b). Parent-infant communications and the neurobiology of emotional development. In Affect dysregulation & disorders of the self (71-88). NY: W.W. Norton.

Schore AN (2003c). The experience-dependent maturation of an evaluative system in the cortex. In Affect dysregu-lation & disorders of the self (36-53). NY: W.W. Norton.

Schore AN (2017). Modern Attachment Theory. In S. N. Gold (Ed.), APA Handbook of Trauma Psychology: Vol. 1. Foundations in Knowledge. Washington, DC: American Psycholo-gical Association. DOI: 10.1037/00-00019-020.

Schore JR, Schore AN (2014). Regulation theory and affect regulation psychotherapy: A clinical primer. Smith Coll Stud Soc Work. 84(2-3): 178-195. DOI: 10.1080/00377317.2014.923719

Seng JS, Sperlich M, Low LK, Ronis DL, Muzik M, Liberzon I (2013). Child-hood abuse history, posttraumatic stress disorder, postpartum mental health, and bonding: a prospective cohort study. J Midwifery Women’s Health. 58(1): 57-68.

Shaw RJ, Lilo EA, Storfer-Isser A, Ball, MB, Proud, MS, Vierhaus, NS, Huntsberry, A, et al. (2014). Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants. Issues Ment Health Nurs. 35 (3): 198-207.

Siegel DJ (2012). The developing mind how relationships and the brain interact to shape who we are (2nd ed.). [Pro-Quest Ebook Central]. Retrieved from

Stacks AM, Muzik M, Wong K, Beeghly M, Huth-Bocks A, Irwin JL, Rosenblum KL (2014). Maternal reflective functioning among mothers with child-hood maltreatment histories: Links to sensitive parenting and infant attachment securety. Attach Hum Dev. 16(5): 1-19.

Stern D (1985). The sense of a subjective self: II. Affect attunement. In Stern, The interpersonal world of the infant: View from psychoanalysis and development psychology.[ProQuest Ebook Central]. Retrieved from

Stern T (2014). The development of reflective functioning in a mother traumatized by past and present events: Facilitating change in the parent-infant relationship. J Infant Child and Adolesc Psychother: 13(1): 24-36.

Tufekcioglu S, Muran J (2015). Case formulation and the therapeutic relationship: The role of therapist self‐reflection and self-revelation. J Clin Psychol. 71(5): 469-477. DOI: 10.1002/jclp.22183

Ullmann E, Bornstein SR, Lanzman RS, Kirschbaum C, Sierau S, Doehnert M, Zimmerman P, et al. (2018). Countering posttraumatic LHPA activation in refugee mothers and their infants. Mol Psychiatry. 23(1): 2-5. DOI: 10.-1038/mp.2017.235

Vignato J, Georges JM, Bush RA, Connelly CD (2017). Post‐traumatic stress disorder in the perinatal period: A concept analysis. J Clin Nurs. 26(23-24): 3859-3868.


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