Mother’s affection at 8 months predicts emotional
distress in adulthood
J Maselko,1L Kubzansky,2L Lipsitt,3S L Buka3
Background Long-standing theory suggests that quality
of the mother’s (or primary caregiver’s) interaction with
a child is a key determinant of the child’s subsequent
resilience or vulnerability and has implications for health
in adulthood. However, there is a dearth of longitudinal
data with both objective assessments of nurturing
behaviour during infancy and sustained follow-up
ascertaining the quality of adult functioning.
Methods We used data from the Providence, Rhode
Island birth cohort of the National Collaborative Perinatal
Project (mean age 34 at follow-up, final N¼482) to
conduct a prospective study of the association between
objectively measured affective quality of the
mothereinfant interaction and adult mental health.
Infantemother interaction quality was rated by an
observer when infants were 8 months old, and adult
emotional functioning was assessed from the Symptom
Checklist-90, capturing both specific and general types of
Results High levels of maternal affection at 8 months
were associated with significantly lower levels of
distress in adult offspring (1/2 standard deviation;
b¼?4.76, se¼1.7, p<0.01). The strongest association
was with the anxiety subscale. Mother’s affection did
not seem to be on the pathway between lower parental
SES and offspring distress.
Conclusion These findings suggest that early nurturing
and warmth have long-lasting positive effects on mental
health well into adulthood.
A growing emphasis on life-course epidemiology
has led researchers to examine the link between
early life experiences and subsequent adult mental
health. In fact, a recent JAMA article advocates for
a new framework of health promotion that aims
to understand how early experiences and expo-
sures are biologically embedded to have lifelong
consequences.1Growing out of attachment theory
and the notion that close loving bonds are neces-
sary and provide a secure base from which to
explore and navigate the world,2investigators
have focused on whether high levels of nurturing
may promote physical and mental health well
into adulthood. There is growing consensus that
levels of warmth and affection (especially between
mother and child) seem to moderate the stress
response and make children more resilient to
Additionally, although the association between
socioeconomic status (SES) and health varies
somewhat depending on
developed countries, warmth and affection have
been linked with higher SES, thus suggesting that
this could be one potential pathway through
which early lifetime SES is linked to adult health
Animal research on nurturing and social bonding
suggests that the neurohypophyseal hormone
oxytocin may serve a crucial function in creating
a powerful bond between mother and child,9 10
while disruptions in this bond can lead to dysre-
gulation of brain chemistry and, specifically, the
baby’s stress response.11For example, rat pups
observed with higher quality grooming and nursing
behaviours by their mothers exhibit lower adult
stress reactivity as evidenced by lower ACTH and
corticosterone plasma levels.12Lower stress reac-
tivity, related to both lower levels of sustained
sympathetic nervous system activation and HPA
axis dysregulation, has been linked with better
health outcomes in both animals and humans.13e17
While factors such as HPA reactivity appear to be
moderately heritable, purely genetic factors alone
do not seem to account for an intergenerational
transfer of these neuronal differences.12 18Based on
such findings, Meaney et al19
a model of environmental programming where
early experiences alter gene expression and, as
a result, HPA stress reactivity. In this view,
important developmental processes critical for
future stress regulatory capacity.
While the relatively short lifespan of research
animals allows researchers to link motherepup
interactions to adult rat functioning, similar studies
linking nurturing behaviours during infancy to
adult outcomes in humans are almost non-existent.
Most studies of adult health outcomes have relied,
largely by necessity, on retrospective reports of the
family environment during childhood.20
example, Russek and Schwarz found that those
who reported feeling greater warmth and closeness
with their parents during childhood were less likely
to develop coronary artery disease, hypertension,
duodenal ulcer and alcoholism 35 years later.22
Warmth and affection also appears to be indepen-
dent of parental involvement, which exhibits
a curvilinear association with mental health such
that both under- and over-involvement is linked
with worse mental health.23While suggestive, such
retrospective assessments can be subject to recall
bias and also do not allow for the examination of
family environment features that cannot be easily
remembered, such as infant experience. Objective
infancy provide a unique opportunity to examine
the relation between the earliest of life experiences
and adult outcomes.
The present study takes advantage of longitu-
dinal data in a prenatal cohort to examine the
1Duke University, Durham, North
2Harvard School of Public
Health, Boston, Massachusetts,
3Brown University, Providence,
Rhode Island, USA
Joanna Maselko, 114 Trent Hall,
Duke University, Box 90519,
Durham, NC 27708-0519, USA;
Accepted 8 February 2010
Maselko J, Kubzansky L, Lipsitt L, et al. J Epidemiol Community Health (2010). doi:10.1136/jech.2009.097873
Copyright Article author (or their employer) 2010. Produced by BMJ Publishing Group Ltd under licence.
1 of 5
JECH Online First, published on July 26, 2010 as 10.1136/jech.2009.097873
association between objective assessments of mothereinfant
nurturing at 8 months and symptoms of distress in middle
adulthood. We tested the hypothesis that greater warmth and
affection exhibited by a mother towards her child is associated
with less distress in the adult offspring. We also explored
potential links between parental SES, affection and distress.
The analysis relies on the adult offspring of participants in the
National Collaborative Perinatal Project (NCPP). The NCPP was
designed as a multi-site, community-based, observational cohort
of pregnant women and their children.24Major findings have
been summarised previously.25 26Reflecting the larger propor-
tion of minority participants in the study, SES in the original
NCPP was somewhat lower than census-based estimates of
a comparably aged population, but other socioeconomic groups
are reasonably well-represented.27
offspring (mean age 34) were sampled to participate in a study
examining health outcomes associated with childhood learning
disabilities,29and 720 were successfully interviewed. Those who
were followed up were comparable to the original NCPP study
sample in terms of race, but more women participated in the
follow-up than men (78% vs 66%). Similar to the original NCPP
sample, current study participants are slightly less educated and
report lower incomes when compared to their counterparts from
the census. Of those interviewed, 127 had missing values for
mother’s affection at 8 months and another 95 had incomplete
adult distress scores. An additional 16 respondents did not have
valid parental SES values resulting in a final sample of 482
respondents used in the analyses. Women were more likely to
have complete distress data as compared to men (87% vs 83%),
and there were no differences in mean distress scores between
those with and without mother’s affection data.
28In 1996, 1062 of the
At the 8-month evaluation, mothers and children came to the
test site, and observations of the motherechild interaction
were made by the examining NCPP psychologist during
cognitive and developmental testing of the children. At the end
of each interview, the psychologist completed an assessment of
how the mother managed the testing situation, her level of
affection and attention towards her infant and her reaction to
the test performance. Each of these items had a set of five
unique pre-determined categories (roughly ranging from low to
high) that the psychologist was asked to endorse. Because
trained psychologists rated the behaviours while administering
a standard assessment battery, the situational context was
specific and standardised. Further efforts were made to stan-
dardise assessments across the raters through rigorous training,
and quality control procedures were regularly implemented
The present analysis focuses on assessment of the mothers’
expression of affection towards her infant. Study psychologists
were asked to report levels of affection using the following
categories: “negative” (0.6% of sample), “occasionally negative”
(8.9%), “warm” (84.9%), “caressing” (4.2%) and “extravagant”
(1.5%). To maximise statistical power, while still being able to
detect non-linear associations, we created three categories of
mother’s affection: low (combining negative and occasionally
negative), normal (warm) and high (caressing and extravagant).
Results from preliminary analyses suggested a threshold effect
with the “high” group reporting lower distress levels; thus, for
the majority of analyses reported, the low and normal groups
were combined and compared with high maternal affection.
Perception of parental bonding
Items from the Parental Bonding Instrument (PBI) were used to
help establish the validity of the mothereinfant nurturing
variables. The PBI is a measure administered during the adult
follow-up interview to assess perceptions about being parented
through to the age of 16.30We use the specific item which asked
the respondent whether they agreed that the primary female
caregiver was affectionate towards them. Responses were on
a four-point Likert scale, ranging from “strongly agree” to
Emotional functioning was assessed during the adult follow-up
interview using four subscales from the Symptom Checklist-90
(SCL-90). The SCL-90 assesses a person’s recent experience of
various types of distress and has demonstrated reliability and
validity.31The NCPP follow-up included four of the subscales of
the SCL-90 that measured common types of distress, including
distress due to somatisation (12 items), interpersonal sensitivity
(9 items), anxiety (10 items) and hostility/anger (6 items). Each
symptom is measured on a Likert scale ranging from 1 (not at all
distressed by the symptom) to 5 (extremely distressed), and
responses are summed. A general distress score was also created
by combining the four subscales. Final symptom scores are
presented as t scores (standardisation based on non-clinical adult
male and female norms32); the mean score in the reference
population was 50, with a normal range of 40e60.
Additional covariates used in the analyses include parental SES,
parental history of mental illness (parental self-report of prior
hospitalisation, out-patient treatment or problems with drugs or
alcohol: yes/no), as well as participant race (white/non-white),
high school completion and marital status (currently married vs
other). Parental SES and parental history of mental illness were
assessed directly from the parents during the original NCPP
study, while all other covariates were measured during the adult
interview. Parental SES is a measure ranging from 0 to 10 based
on the scale derived by the US Census Bureau based on the
education and occupation of the head of household together
with family income.27Finally, since persons with childhood
evidence of a learning disability were over-sampled for this
study, we also adjusted for this factor.29
ANOVAs and t tests were used to compare the PBI affection
scores and SCL-90 scores across levels of mother’s affection.
Ordinary least squares regression modelling was the main
method of analysis to examine the prospective association
between mother’s expression of affection and level of adult
offspring emotional distress. Multivariable regression models
adjust for parental SES and the respondent’s adult age, sex, race,
education level, marital status, maternal mental illness and
Demographic characteristics of the sample are presented in
table 1. At the 8-month assessment, 10% of the sample (N¼46)
were characterised by a low level of mother’s affection towards
the infant, 85% (N¼409) were characterised as having a normal
amount of affection and the remaining 6% (N¼27) had mothers
2 of 5 Maselko J, Kubzansky L, Lipsitt L, et al. J Epidemiol Community Health (2010). doi:10.1136/jech.2009.097873
who were highly affectionate. Parental SES was correlated with
maternal affection levels. For example, among those in the
bottom quartile of the sample SES distribution, only 2% of
mothers exhibited high affection levels versus 11% among those
in the top quartile (p value for trend <0.001).
Predictors of distress
The mean general distress score was 55.16 (SD¼8.55), with
M¼56.5 (SD¼10.0); anxiety M¼53.5 (SD¼11.8); hostility
M¼55.5 (SD¼10.5). There were no sex differences in any
individual subscale or general distress scores.
After adjusting for relevant covariates, each point on the
parental SES scale was associated with 0.68 point lower soma-
tisation score (SE¼0.23, p<0.01) and a 0.35 lower overall distress
score (SE¼0.20, p¼0.08). Parental SES was not significantly
associated with any of the other distress measures. Offspring
who had not completed high school reported higher levels of
distress on all SCL-90 subscales, as did those who were not
currently married, with the exception of the hostility scale.
Comparison of mother’s affection variable with retrospectively
Overall, 81% of respondents agreed or strongly agreed that their
mothers were affectionate towards them when interviewed as
adults. Among those whose mothers were observed to be highly
were affectionate; 81% of those observed with normal levels of
affection also agreedand73%ofthoseobservedwithlowlevelsof
maternal affection also reported their mothers to be affectionate
(p value for trend¼0.05). In other words, a higher proportion of
individuals recollected their mothers to be affectionate overall
during childhood than was observed at the 8-month assessment.
Affection and distress
Participants whose mothers exhibited a high level of affection
reported lower scores on each of the SCL-90 subscales as
compared to those whose interactions were characterised as
normal or low (figure 1). Of the four SCL-90 subscales, differ-
ences in anxiety were the largest in magnitude, with 7.15 point
difference betweenthe low/normal
offspring (53.86 vs 46.70, t(34)¼4.46, p<0.001). The hostility
subscale showed the smallest difference of 3.29 points (55.70 vs
52.40, t(480)¼1.59, p¼0.07). The general distress scores
differed by almost 5 points between the two groups (55.38 vs
50.39, t(35)¼4.52, p<0.001).
Table 2 presents linear regression results of mother’s affection
predicting each SCL subscale as well as the mean SCL score from
age and sex-only adjusted models (model 1) and the fully
adjusted models (model 2). High levels of mother’s affection
were independently associated with a 4.22-point reduction on
the overall general distress score (model 2). Across all the
symptom subscales, the direction of association was highly
consistent; more warmth was associated with less distress.
We did not find evidence that mother’s affection lies on the
path between parental SES and higher offspring distress scores.
For example, using the distress subscale most strongly linked
with parental SES, somatisation, as the outcome, the strength of
the association between SES and somatisation was not altered
through the inclusion of the mother’s affection variable.
Finally, all results were largely comparable when using the
retrospectively reported maternal affection levels as the main
independent variable, although fewer of the associations reached
statistical significance. For example, retrospectively reported
high levels of maternal affection were associated with somati-
sation (b¼?1.99, p¼0.04) in age and sex-only adjusted regres-
sion model (akin to model 1 in table 2) but failed to reach
significance in the fully adjusted model. No statistically signifi-
cant association was found with overall distress even in the
minimally adjusted model (b¼?1.02, p¼0.17)
In this study, we found that objectively observed high levels of
affection between mothers and their 8-month infants are asso-
ciated with fewer symptoms of distress 30 years later among the
offspring, as compared to offspring whose mothers exhibited
low or normal levels of affection. Furthermore, although we
found that lower parental SES was linked with lower levels of
maternal affection, there was no evidence of mediation of SES-
distress association. These results extend previous findings
showing either a relationship between early childhood experi-
ences and childhood outcomes33and those finding an association
between adult health outcomes and retrospective reports of
analysis according to observed levels of maternal affection during
infancy (at 8 months of age)
Demographic characteristics of NCPP offspring included in the
Completed high school
Different letters (a, b, c) denote difference between affection levels that are statistically
significant at p<0.05.
Interpersonal Anxiety Hostility Somatization
*denotes difference is statistically significant at <p0.05
scores at mean age 34. *denotes difference is statistically significant at
Observed level of mother’s affection at 8 months and SCL-90
affection during infancy predicting SCL scores in adult men and women
Linear regression model results of high levels of mother’s
(age and sex only)x
(full multivariate model)x
Mean SCL Score
xModel 1 adjusts for age and sex only; model 2 adjusts for parental SES, age, sex, race,
completion of high school education, marital status, maternal mental illness and study
Maselko J, Kubzansky L, Lipsitt L, et al. J Epidemiol Community Health (2010). doi:10.1136/jech.2009.097873 3 of 5
parental relationship quality.34e36Findings presented here thus
provide strong support to the assertion that even very early life
experiences can influence adult health and emphasise the
importance of having a strong nurturing relationship.12 37e39
High levels of maternal affection are likely to facilitate secure
levels of attachment and bonding, which then translate to lower
distress levels in both childhood and adulthood. Secure attach-
ment in infancy may either facilitate, or serve as an indicator of,
other environmental conditions that foster children’s ability to
learn effective strategies of emotional regulation, appropriate
social skills, a stronger sense of self and effective behavioural or
cognitive responses to stress.34Previous research has found that
parental bonding during childhood (reported retrospectively) is
linked with fewer depressive symptoms in young adults, higher
self-esteem and perceived social support and more adaptive
coping styles.34Children who report more secure attachments
to their mothers also have better peer interactions which in turn
have been linked to better functioning in middle adulthood.40
Thus, resilience factors laid down early in childhood may extend
into adulthood and protect an individual from psychological
High levels of warmth and affection are also related to posi-
tive affect. Positive maternal affect is likely to en sex recipro-
cating positive affect in her offspring.17According to the
“broaden and build” theory, positive emotions promote more
adaptive functioning by expanding one’s cognitive repertoire and
facilitating effective coping.44 45Recent work has identified
oxytocin as a neurobiological mechanism produced on receipt of
nurturing, which promotes social, psychological and physical
attachment may become a source of resilience that buffers
deleterious effects of future stressors.3
Somewhat surprisingly, we did not find a significant relation-
ship between low levels of mothers’ affection during infancy and
adult offspring distress. This may be related to the overall high
level of affection in the sample and potential lack of truly nega-
tive,deleterious interactions observed.Additionally,therelatively
low levels of distress exhibited by the sample are similar to those
found in other studies of non-patient comparably aged individ-
uals.48The low prevalence of highly distressed individuals
(comparable toanon-patientsample)together withhighlevelsof
affection may have resulted in a “floor effect” where it is more
difficult to observe any adverse effects of a low-nurturing envi-
distress were observed primarily among individuals whose
mothers exhibited “high” levels of affection, with few differences
observed between the “low” and “normal” affection groups may
suggest that the presence of ample affection matters as much as
levels of conflict and other aspects of adverse environments.
Presence of high levels of warmth and affection may be an
independent source of resilience and act as a protective factor
regardless of other characteristics of the family environment.41
Findings from this unique prospective study must be consid-
ered preliminaryforseveralreasons. First,thesingle itemmeasure
of mother’s affection is clearly limited, and we had no additional
objective information on either attachment or the nurturing
nature of the motherechild bond. Subjectivity by the observing
psychologist may have introduced bias and the normative
meaning of terms such as “caressing” or “extravagant” might also
have been different during the early 1960s when the original
study was conducted compared with what they are understood
to mean today. Our finding of concordance between the observed
46 47Together, positive affection and strong
affection variable and the subjective recollection of maternal
affection offers some support for the validity of the observed
assessment. Furthermore, variation on the observed mother’s
affection variable was constrained, and the “normal” category by
which the majority of the sample was classified likely encom-
passed significant variation in actual affection levels. Combining
of low and normal groups for analyses presented here is not
meant to imply that these groups are not meaningfully different.
We were, however, underpowered to examine more detailed
gradations of the affectionedistress relationship. We also had
limited opportunity to examine other aspects of the early social
environment. The nature of this relationship is likely closely
linked with the overall family environment and interacts with
other factors that may foster resilience and positive outcomes.
There might also be a common prior cause of both mother’s
affection and offspring’s distress, such as genetic factors49
or personality factors, as well as the mother’s own emotional
well-being during pregnancy and during her child’s infancy.
Major strengths of this study are the long follow-up, measures
of key aspects of the early childhood environment (e.g. SES) and
observational measures of maternal affection, which have been
shown to be more predictive of outcomes than self-report
measures.50Much of the work on maternal nurturing and later
life emotional reactivity in the offspring has been conducted
either in animals or using retrospective reports of maternalechild
interactions in humans. Few studies have data for humans on
maternalechild interaction in early childhood with follow-up
through adulthood, making this study a unique and important
contribution to the literature in spite of this somewhat limited
and unusual measure of maternal warmth.
In conclusion, it is striking that a brief observation of level of
maternal warmth in infancy is associated with distress in adult
offspring 30 years later. These provocative findings add to the
growing evidence that early childhood helps set the stage for
later life experiences and provide support for the notion that
biological “memories” laid down early may alter psychological
and physiological systems and produce latent vulnerabilities or
resilience to problems emerging later in adulthood.1Thus, the
quality of early socio-emotional development may have more
What this paper adds
< Although there is a growing interest in the role of early life
experiences in adult health, there is a dearth of empirical
evidence from prospective studies linking experiences in
infancy to adult health and functioning. Studies with objective
measures of the early environment and sustained follow-up
into adulthood are needed to discern the true contribution to
adult health of such early experiences.
< The findings from this study show that objectively measured
levels of nurturing and affection experienced during infancy
are predictive of adult mental health three decades later.
< These findings have implications for the detection of risk early
in life and point to avenues for individual- and policy-level
interventions. For example, psychosocial and behavioural
interventions might need to be targeted at much younger ages
than is currently the norm. Increased support for policies
related to oversight and regulation of organisations that
provide caregiving and related services may be appropriate. A
combination of strategies which empower families, improve
access to high-quality childcare and provide targeted
interventions may improve overall population mental health.
4 of 5Maselko J, Kubzansky L, Lipsitt L, et al. J Epidemiol Community Health (2010). doi:10.1136/jech.2009.097873
far-reaching effects than previously believed. Additionally, it Download full-text
may be that focussing on early life assets rather than solely on
deficits or what is considered minimally sufficient may increase
our capacity to promote more resilient trajectories.
These findings have implications for the detection of risk early
in life and point to avenues for individual- and policy-level
interventions. For example, to be most effective, psychosocial
and behavioural interventions might need to be targeted at
much younger ages than is currently the norm and would need
to focus on preventing the “imprinting” of negative experiences.
Greater appreciation of the broad importance of the quality of
children’s relationship with their early caregivers (likely both in
and out of the home) may also alter policy priorities. For
example, it may lead to increased support for policies related to
oversight and regulation of organisations that provide caregiving
and related services. Ultimately, should findings from this study
be replicated, they suggest that a combination of strategies,
which empower families, improve access to high-quality child-
care and provide targeted interventions to those at risk, is needed
to improve overall population mental health.
Each b coefficient represents the absolute point difference in
the given SCL scale associated with a high level of mother’s
affection at 8 months.
Funding JM was partially funded by National Institutes of Mental Health grant
Competing interests None.
Ethics approval This study was conducted with the approval of the Brown
Provenance and peer review Not commissioned; externally peer reviewed.
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