The Relationship Between Prenatal Alcohol Exposure and Infant/Child–Caregiver Attachment: A Scoping Review
Abstract
1. Introduction
2. Methods
2.1. Eligibility Criteria
Exclusion Criteria
2.2. Information Sources
2.3. Search and Study Selection
2.4. Data Collection Process and Data Items
Critical Appraisal of Individual Sources of Evidence
2.5. Synthesis Approach
3. Results
3.1. Study Selection
3.2. Quality of Studies
3.2.1. Measures of PAE and FASD
3.2.2. Measures of Attachment
3.2.3. The Relationship Between PAE/FASD and Attachment Security
3.2.4. Mediating Variables
3.2.5. Other Variables
4. Discussion
5. Practical Implications
6. Limitations and Future Directions
7. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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[56] California, USA | N = 46 mother–infant dyads. Infants aged 12 months, mothers aged 30+ Predominantly white (92%), highly educated (72% college or more education) and middle class (100%). | Cross-sectional | To assess relationships between amount of alcohol consumed by mothers before and during pregnancy and attachment styles in infants at 12 months | Alcohol consumption in pregnancy was measured by self-report questionnaire at 12 months postpartum. Attachment was determined using the SSP—infants were categorised as either securely attached, insecure–resistant, insecure–avoidant, or disorganised. | Higher PAE scores in insecure attachment group. |
[57] California, USA | 41 mother (30+ years) child (5–6 years) dyads from the same sample as [56]. Mothers were 88% white, 64% college educated, 100% middle class, and their average IQ score was 117. | Follow-up, cross-sectional. | To assess the consistency of attachment classifications measured at 12 months using the Strange Situation Procedure and at 5–6 years using the Separation Anxiety Test (SAT). To measure the relationship between prenatal alcohol exposure and attachment style in children aged 5–6 using the SAT. | Attachment style was measured with the Separation Anxiety Test. PAE was measured by maternal self-report. | SSP at 1 year and SAT at 6 years did not result in the same attachment categorisations. No relationship between SAT classifications and PAE. |
[58] California, USA | N = 44 firstborn infants (aged 1 year) of middle-class (100%) mothers aged 30+. English-speaking (first language), highly educated participants, with 70% who have achieved college or postgraduate education | Cross-sectional | To investigate possible mechanisms between PAE and insecure/disorganised attachment using structural equation modelling, including infant irritability, postnatal alcohol consumption, and mother-infant interaction. Attachment category was the dependant variable. | Alcohol consumption during and after pregnancy was measured by self-report questionnaire and operationalised as average drinks per drinking occasion. Child and maternal behaviours were rated using the Mother–Child Rating Scales. Attachment style was determined using the SSP. Attachment was dichotomous (secure or not), and alcohol was measured as average drinks per drinking occasion. Smoking and caffeine use during pregnancy were also measured. | Best-fitting model identified through structural equation modelling: PAE, negative infant affect, maternal responsiveness, less secure attachment. |
[59] California, USA | N = 51 mother–toddler (aged 18 months) dyads. Participants’ mean age was 27.80 (range: 19–45), with time spent in education (mean: 11.24; range: 7–14). 39.2% were employed, and 82.4% were from minoritised ethnic groups. | Cross-sectional | To examine the relationships between prenatal substance exposure, current substance use, caregiver sensitivity and hostility, and attachment styles. | Substance use was measured using self-report. Attachment was determined using the SSP. | PAE by maternal report was not associated with attachment classification. |
[60] California, USA | 42 children (aged 4–5 years) of low-income ‘high-risk’ mothers. Mothers were English-speaking with age range of 21–44 years. Majority were high school graduates (38%), followed by those who have had some college education (31%). Five percent were college graduates, and 26% were non-high school graduates. Ethnicity-wise, 83% were African Americans, followed by seven percent Hispanics and 10% from ‘other’ ethnicities. | Cross-sectional | Used structural equation modelling to test the hypothesis that higher PAE would be related to insecure/disorganised attachment styles via infant negative affect and less-optimal mother–child interaction. | PAE was measured by interview and operationalised as maximum number of drinks per drinking session. Attachment style was measured using the Attachment Q-Set. Mother supportive presence, child negative affect, and child coping were measured using the Family Interaction Puzzle Task. | PAE predicted negative child affect, insecure attachment and lower levels of maternal emotional support of the child. When mothers of PAE children provided high levels of support, children had better coping skills and more secure attachment. |
[61] Illinois, USA | 29 Russian children (age 1–7) adopted by US families. 10 of the children were diagnosed with “an ARND”. 21% of the mothers completed high school (12th grade), followed by 14% who undertook one or two years of undergraduate studies; 21% had four years of undergraduate education, and 43% completed graduate education (one to three years). | Cross-sectional | To assess relationships between parenting stress, attachment security, child behavioural difficulties, length of institutionalisation, and ARNDs. | Attachment was measured using the caregiver-report Attachment Security Questionnaire. The children either had a diagnosis of ARND or they did not. But it is unclear how/when/where they were assessed, which criteria were used, or whether any of the non-diagnosed children had PAE. | Parenting stress was significantly correlated with insecure attachment and increased child behavioural difficulties. Attachment insecurity was significantly correlated with the severity of behaviour problems. No differences were found with regard to gender or diagnosis of ARND. |
[62] Michigan, USA | N = 130 inner-city, African American adolescents (mean age = 14.3 years). Mothers were Low SES, 75% were unmarried, and their average number of years of education was 12.6. | Cross-sectional follow-up. Mothers had been recruited during pregnancy. | To assess the relationships between PAE, childhood trauma, attachment, and behavioural functioning in adolescents. | PAE measured by maternal interview during pregnancy. Attachment measured in adolescents using the Child Attachment Interview. | PAE was not related to attachment classification, but severity of maternal drinking problems during pregnancy did predict disorganised attachment. |
[63] Ohio, USA | Low-income (“high risk”) mothers (n = 41) with their substance-exposed 12-month-olds. Majority of participants with substance exposed toddlers received Medicaid due to poverty (93%) and were of African American origin (86%). | Matched pairs | Substance-exposed infants were compared with a nonexposed group matched for other risk factors (poverty, race, gender, gestational age, birth weight, mothers’ age at delivery, and parity). Outcomes measured were attachment, maternal sensitivity, quality of caregiving. | PAE was measured with urine toxicology at antenatal care and postnatally, as well as by interview. Maternal sensitivity and involvement were analysed from 2 h of videotaped interaction. Attachment was assessed using the Attachment Q-Set. | Attachment security and quality of caregiving were quite low for both groups, with no significant differences. Regression analyses revealed that quality of caregiving predicted attachment, but amount of alcohol and cocaine exposure did not. |
[64] Rossen 2016 New South Wales and Western Australia, Australia | 372 pregnant women (data collected throughout pregnancy and at 8 weeks postpartum) Maternal age (median) was 33.0 years; 1.1% had indigenous background and 2.5% were indigenous, and 41.1% were born overseas. | Cross-sectional | To assess the relationships between pre- and post-natal bonding between mothers and infants, and the impact of substance use on bonding. | Mothers’ feelings of attachment towards their infant were measured using the Maternal Antenatal Attachment Scale, and Maternal Postnatal Attachment Scale. Depression and anxiety were measured using the Edinburgh Antenatal and Postnatal Depression Scale and the Depression and Anxiety Scales. Information about alcohol and drug use was collected from mothers at each trimester and eight weeks postpartum. | Higher antenatal bonding predicted higher postnatal bonding. Maternal depressive symptoms in pregnancy predicted better mother-infant bonding 8 weeks. No evidence that alcohol use during pregnancy is associated with postpartum bonding (alcohol tended to be low level). |
[65] Silesian Voivodeship, Poland | Young adults with foetal alcohol syndrome (n = 30) and control group without FAS (n = 30, although in places n = 39) Participants with confirmed FASD | Case-control with longitudinal follow-up | Longitudinal design. | FAS in children was diagnosed using the 4-digit code system between 1990 and 2000. Attachment style in young adults was assessed with the Polish version of the Experience in Close Relationships—Revised questionnaire in 2017. | Adults diagnosed with FAS achieved higher scores in insecure attachment than adults without FAS. |
[66] Western Cape, South Africa | N = 77 adolescents in total: 50 with FASD, 27 controls with minimal or no PAE. | Cross-sectional follow-up study | To examine the association between FASD facial dysmorphism and insecure, as well as disorganised, attachment. To examine the extent to which FASD facial dysmorphism was associated with emotion regulation difficulties in adolescence after controlling for the effects of attachment security in infancy. | Attachment measured using the Strange Situation Procedure. FASD dysmorphism assessed clinically by specialist dysmorphologists using the Institute of Medicine Criteria. | No difference in attachment security between dysmorphic and non-dysmorphic groups. Did not compare FASD and control groups on attachment security using a statistical test, but the control group did have the highest rate of secure attachment. |
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Gilbert, D.J.; Price, A.D.; Cook, P.A.; Mukherjee, R.A.S. The Relationship Between Prenatal Alcohol Exposure and Infant/Child–Caregiver Attachment: A Scoping Review. Children 2025, 12, 1133. https://doi.org/10.3390/children12091133
Gilbert DJ, Price AD, Cook PA, Mukherjee RAS. The Relationship Between Prenatal Alcohol Exposure and Infant/Child–Caregiver Attachment: A Scoping Review. Children. 2025; 12(9):1133. https://doi.org/10.3390/children12091133
Chicago/Turabian StyleGilbert, David J., Alan D. Price, Penny A. Cook, and Raja A. S. Mukherjee. 2025. "The Relationship Between Prenatal Alcohol Exposure and Infant/Child–Caregiver Attachment: A Scoping Review" Children 12, no. 9: 1133. https://doi.org/10.3390/children12091133
APA StyleGilbert, D. J., Price, A. D., Cook, P. A., & Mukherjee, R. A. S. (2025). The Relationship Between Prenatal Alcohol Exposure and Infant/Child–Caregiver Attachment: A Scoping Review. Children, 12(9), 1133. https://doi.org/10.3390/children12091133