Infant cardiac surgery and the father–infant relationship: Feelings of strength, strain, and caution

Abstract

Objective

The purpose of this study was to examine the father–infant relationship in infants with congenital heart disease (CHD).

Method

Sixty-three fathers whose infants had cardiac surgery before 3 months of age reported on their attachment relationship with their infant within two months of hospital discharge using both qualitative and quantitative methods.

Results

Mean scores on the Paternal Postnatal Attachment Scale and scores for patience and tolerance were not different from previously published community norms, ps > .05. Scores for pleasure and interaction (t[50] = − 2.383, p = .021, CI: − 2.93, − .25) and affection and pride subscale (t[56] = − 2.935, p = .005, CI: − 1.20, − .23) were significantly lower than community norms. Additionally, 37% of fathers described feeling a strong relationship with their infant whereas 17% reported initial apprehension or condition-specific worry. Fathers with infants who spent fewer days at home prior to admission reported feelings of relationship strain as well as lower pleasure in interaction, affection and pride, patience and tolerance, and overall attachment quality.

Conclusion

Having an infant with CHD affects some father–infant relationships differently than others with some fathers feeling closer to their infant and other fathers feeling reservation about getting too close. One explanation for these differences may be that spending a great deal of time in hospital restricts the number and quality of interactions infants have with their fathers. Opportunities for intervention include clinical psychosocial services encouraging fathers to interact with and provide physical care of their infant, especially if fathers perceive their infant as medically fragile.

Introduction

Congenital heart disease (CHD) occurs in approximately eight of every 1000 infants [1], [2], many of whom require at least one surgery to correct the defect [3]. Recent medical advances have led to dramatic increases in survival rates after surgery, leading researchers to become increasingly interested in the psychosocial impact of CHD on both the child and their family. Much of this research has focused on outcomes for parents [4], [5] and infants [6], [7]. The parent–infant relationship, however, is one of the central features of development yet one of the most understudied areas in terms of infants with CHD. Understanding parent–infant relationships in infants with CHD is important for informing clinical practice and improving the care of infants with CHD and their families.

The importance of secure attachment is evident throughout development. Compared to their insecurely attached counterparts, children who have secure attachment relationships in infancy (e.g., 12–18 months) are better adjusted and more socially skilled in early [8] and middle childhood [9]. Similarly, securely attached children demonstrate more harmonious relationships with peers [10], better emotional competence [11] and modulation [12], and fewer behavioral problems [13]. Furthermore, secure caregiver–infant attachment relationships in infancy serve as models for secure interpersonal and romantic relationships in adulthood [14], [15], [16].

Encouragingly, many researchers have reported no differences with respect to attachment security between infants with medical risk and healthy controls [17], [18], [19], [20]. This research, however, has primarily focused on the impact of medical risk on attachment in the second year of life, as this is the period during which traditional measures of attachment are most appropriate (e.g., Strange Situation [21]). Given that attachment systems are activated during times of threat to safety and security, parents may feel ‘heightened attachment’ closer to the time that their infant is in hospital or undergoes surgery. In contrast, parents may feel initial apprehension about protecting a baby that they have had limited opportunity to interact with due to sedation or connection to medical equipment, or that may not survive. Consistent with this hypothesis, Goldberg and colleagues found that 1-year-old children with CHD had fewer secure, more avoidant, and more disorganized mother–child attachment relationships than children with cystic fibrosis and health controls [22]. The child and family experience of CHD (e.g., undergoing surgery with potentially fatal outcomes) may also put the infant–caregiver attachment relationship at risk.

Understanding the parent–infant attachment relationship close in time to cardiac surgery or during hospitalization for young infants (i.e., < 6 months) may require use of non-traditional measures of attachment such as parent reports of feelings toward their infant as opposed to behavioral observations of parent–infant interactions. In his seminal work on attachment, Bowlby [23] acknowledged the importance of parental feelings toward the infant, suggesting them as part of the process by which parents make decisions about behavior (e.g., responding to the needs of a baby) that relate to attachment security. In empirical work, parental reports of relationship feelings including affection, desire for close proximity, and pride in early infancy have been linked to traditional measures of attachment security in toddlerhood [24], [25]. Thus, parents' feelings about their infant provide the first step to understanding the parent–infant relationship and subsequent attachment security.

The current literature is further limited in its focus on the mother–infant relationship, leaving the impact of medical risk on father–infant relationship largely unknown. Parent–child relationships are dyad specific and thus would not be expected to be identical for mothers and fathers [26], [27], [28], [29]. Few studies have examined fathers' feelings toward their unwell infant [27] with even fewer examining fathers of infants with CHD [30], [31]. In general, fathers tend to report feelings of fear (of their infant dying), worry, sadness, loss of control, and apprehension in touching or holding their infant. Additionally, in the study by Clark and Miles [30], uncertainty regarding illness severity and accompanying surgeries led fathers to question whether or not they should become attached to their infant. Each of these studies has focused on qualitative data exclusively and is limited by small sample sizes supporting the investigation of this area with multiple methods and larger sample sizes.

Fathers' role in typical child development is understudied in general, with an even greater dearth of information available on fathers' role in atypical development (e.g., children with medical illness, children with developmental or psychological disorders) [32]. In their review, Phares and colleagues [32] found that of the studies published on intra-familial relations in the context of physical, behavioral, or medical illness between 1996 and 2003, fewer than half (43%) included fathers and only approximately 10% examined fathers separate from mothers [32].

This study will contribute to the current literature by including a developmentally homogenous sample of infants who have undergone cardiac surgery before three months of age and who were examined within two months of discharge. The primary aim of this paper is to describe the father–infant relationship in infants with CHD using complementary qualitative and quantitative methods. Qualitative analyses have been proposed as a particularly useful tool in the exploration of psychosocial outcomes of medical conditions. The richness of qualitative data allows for both identification of disease-specific idiosyncrasies and examination of outcomes within context [33]. We were also interested in why the father–infant relationship might be different for some infants with CHD. Specifically, we wanted to identify potential medical risk factors (e.g., timing of diagnosis, condition type, surgery type) and duration of inpatient stay that might be associated with differences in the father–infant relationship.