Prenatal Substance Use and the Infant-Mother Attachment
Attachment is the emotional glue that connects a newborn to their caregiver, laying the foundation for emotional security, social development, and long-term mental health. But what happens when this critical bond is disrupted before it has a chance to form? Prenatal exposure to substances – including alcohol, nicotine (tobacco), cannabis, opioids, meth, and other drugs – has significant implications for early mother-infant attachment. The first bond between a baby and mother is critical for socioemotional development, but substance use during pregnancy can disrupt this process. Sacramento County is seeing the impact of maternal use of marijuana and methamphetamines on early attachment, and the opioid epidemic, especially the rise of potent synthetic opioids like fentanyl, has brought new urgency to this issue. Prenatal substance use can create challenges to the infant-mother bond, leading to frustrations for both the mother and the baby.
How Attachment Begins
Attachment is not just a feeling – it's a biological and emotional system rooted in survival. From birth, babies seek proximity to their caregivers, using cries, coos, and eye contact to ensure their needs are met. In response, caregivers help infants regulate their emotions and learn that the world is a safe and predictable place.
This feedback loop – baby sends a cue, caregiver responds appropriately – establishes the foundation of secure attachment. It teaches the infant that they are seen, heard, and valued. Over time, this builds the child’s internal working model of relationships: a blueprint for how they view themselves and others.
Impact of Substance Use on Attachment
Substance use during pregnancy – whether opioids, alcohol, marijuana, meth, or other drugs – can disrupt the development of this early attachment system. The placenta, a temporary organ, provides essential nutrients, oxygen, hormones, and immunity to the fetus and filters harmful waste and carbon dioxide. However, drugs and alcohol can still pass from the mother’s bloodstream through the placenta and the umbilical cord to the baby, impacting development and potentially straining early mother-child interactions.
Neurodevelopmental effects on the infant
Substances can alter the fetal brain, affecting the newborn’s ability to self-regulate, sleep, feed, and respond to stimuli. Babies may be irritable, have difficulty soothing, or appear disengaged, making them harder to read and comfort.
Opioids – particularly heroin, methadone, and now synthetic opioids like fentanyl – pose a distinct risk for neonatal opioid withdrawal syndrome (NAS). Babies born to opioid-dependent mothers frequently go through withdrawal after birth, as the supply of opioids from the placenta is suddenly cut off. These infants are often difficult to soothe and regulate and may require prolonged hospital stays for monitoring and treatment, making early bonding more challenging. A baby experiencing NAS might have trouble with the very activities that promote secure attachment – quiet alert interactions, regular feeding, or cuddling – simply because they are in discomfort much of the time.
Emotional and physical availability of the mother
Substance use during pregnancy doesn’t just affect the baby; it also impacts the mother’s emotional state and capacity to respond to her infant. Many women who use substances during pregnancy continue to grapple with addiction or its consequences postpartum, a period when consistent and sensitive caregiving is vital. Substance use can impair a mother’s sensitivity and responsiveness, making it harder to recognize and interpret her baby's signals and respond appropriately. A fussy, hard-to-console baby can contribute to a mother’s lack of confidence and increase her frustration, which then leads to less sensitive responses or withdrawal – and the negative cycle continues.
Environmental, psychological, and social stressors for the mother
Prenatal substance use rarely occurs in isolation – many mothers who use drugs or alcohol during pregnancy have also experienced trauma, face socioeconomic hardships, or struggle with co-occurring mental health disorders. The cumulative effect of these conditions adds strain to the caregiving relationship and contributes to attachment outcomes. Factors like unstable housing, domestic violence, or lack of social support can worsen the difficulties in the mother-infant relationship. For instance, a mother dealing with homelessness or an abusive partner while trying to care for a withdrawal-affected newborn is under immense stress; her capacity for sensitive, responsive parenting may be overwhelmed not just by her substance use disorder but by these external pressures.
Rates of postpartum depression and anxiety are elevated in mothers with SUDs, especially if they lack strong support networks. Unfortunately, these mothers often encounter significant barriers to bonding. Stigma and fear of legal consequences can lead women to avoid prenatal care or hide substance use, resulting in less help at birth and afterward. Prenatal substance exposure may also trigger involvement of child protective services (CPS). One consequence is that some infants are separated from their mothers soon after birth – either through brief hospital holds or longer-term foster placement – which disrupts the critical period of skin-to-skin contact and early attachment. Even when infants remain with their mothers, the stress of a child welfare investigation or the looming threat of custody loss can heighten a mother’s anxiety, potentially making her interactions with the baby more tense or hesitant. Logistical and social factors often keep these mothers away from their hospitalized newborns as well (they may lack transportation, have other children at home, or be undergoing treatment themselves). If an infant’s care is largely taken over by NICU staff or foster caregivers, the mother has fewer opportunities to bond and gain confidence in reading her baby.
The Hopeful News
Many children can develop healthy relationships and coping skills with early intervention and stable, nurturing caregiving (whether from the mother or alternate caregivers). The plasticity of the infant brain and the resiliency of the attachment system mean there are multiple opportunities to repair and strengthen the parent-child bond after a rough start. Repair often begins with learning to read and respond to the baby's cues. These nonverbal signals – fussing, looking away, rooting, smiling – are the baby’s language.
Interventions aimed at improving attachment security in substance-affected families are vital:
Early hospital interventions: Hospitals are adapting care protocols for substance-exposed newborns to prioritize the mother-baby bond. Immediate post-birth interventions set a positive foundation for attachment or at least prevent further erosion of the relationship during a critical window.
Parenting programs for mothers in recovery: Traditional parenting classes often fall short for mothers with substance use disorders, so specialized interventions have been developed. Programs like Mothering from the Inside Out (MIO) and Sacramento’s Bridges Sober Living and Recovery are tailored for women with children who are struggling with SUDs and address the mother’s history of trauma or adversity, which is often the root of both her attachment difficulties and substance use.
Social support services with home visits: On a broader level, early childhood home visiting programs, such as the Nurse-Family Partnership, Healthy Start, or Early Head Start home-based services, have adapted their curricula to better serve infants exposed to substances and their mothers. Home visitors provide regular coaching on infant care, help mothers establish routines, and model responsive interactions. They also connect families with resources for substance use treatment, mental health counseling, and social services.
Foster care and reunification practices: When infants are placed in foster care due to prenatal substance exposure, child welfare agencies increasingly aim to maintain and repair the mother-infant bond.
Prenatal substance use creates barriers, but it doesn’t make healthy attachment impossible. With patience, consistent caregiving, and often therapeutic guidance, many mother-infant pairs can overcome a difficult start. Understanding the role of cues, being present, and fostering a safe, responsive environment can go a long way in repairing what was disrupted, nurturing a child’s growth and a mother’s healing.
For those struggling with substance use during or after pregnancy, help is available. Please don’t hesitate to reach out. It’s never too late! To learn more about available public county health programs and resources, visit the SACCounty Healthy Beginnings County Programs page or the Behavioral Health Services page for additional mental health and substance use needs.
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Allegaert, K., & Oei, J.-L. (2022). Neonatal abstinence syndrome: Prevention, management and outcomes: From birth to adulthood. Children, 9(8), 1151. https://doi.org/10.3390/children9081151
Daigle, K. M., Heller, N. A., Sulinski, E. J., Shim, J., Lindblad, W., Brown, M. S., Gosse, J. A., & Hayes, M. J. (2019). Maternal responsivity and oxytocin in opioid‐dependent mothers. Developmental Psychobiology, 62(1), 21–35. https://doi.org/10.1002/dev.21897
Eiden, R. D., Perry, K. J., Ivanova, M. Y., & Marcus, R. (2023). Prenatal substance exposure. Annual Review of Developmental Psychology, 5(1), 19–44. https://doi.org/10.1146/annurev-devpsych-120621-043414
Hyysalo, N., Gastelle, M., & Flykt, M. (2021). Maternal pre- and postnatal substance use and attachment in young children: A systematic review and meta-analysis. Development and Psychopathology, 34(4), 1–18. https://doi.org/10.1017/s0954579421000134
Lowell, A. F., Peacock-Chambers, E., Zayde, A., DeCoste, C. L., McMahon, T. J., & Suchman, N. E. (2021). Mothering from the inside out: Addressing the intersection of addiction, adversity, and attachment with evidence-based parenting intervention. Current Addiction Reports, 8(4), 605–615. https://doi.org/10.1007/s40429-021-00389-1
Pacho, M., Clàudia Aymerich, Borja Pedruzo, Salazar, G., Sesma, E., Bordenave, M., Diéguez, R., Itziar Lopez-Zorroza, Herrero, J., María Laborda, Aranzazu Fernández‐Rivas, García-Rizo, C., Miguel Ángel González‐Torres, & Catalán, A. (2023). Substance use during pregnancy and risk of postpartum depression: A systematic review and meta-analysis. Frontiers in Psychiatry, 14(1264998). https://doi.org/10.3389/fpsyt.2023.1264998
Palicka, I., Klecka, M., & Jacek Przybyło. (2016). Neurodevelopmental disorders of children as the challenging context of caregiving and attachment development: An example of children with FAS/FASD. Ukw.edu.pl. https://pfp.ukw.edu.pl/archive/article-full/303/palicka_neurodevelopmental_disorders/
Romanowicz, M., Vande Voort, J. L., Shekunov, J., Oesterle, T. S., Thusius, N. J., Rummans, T. A., Croarkin, P. E., Karpyak, V. M., Lynch, B. A., & Schak, K. M. (2019). The effects of parental opioid use on the parent–child relationship and children’s developmental and behavioral outcomes: A systematic review of published reports. Child and Adolescent Psychiatry and Mental Health, 13(1). https://doi.org/10.1186/s13034-019-0266-3
Shannon, J., Peters, K., & Blythe, S. (2021). The challenges to promoting attachment for hospitalised infants with NAS. Children, 8(2), 167. https://doi.org/10.3390/children8020167