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The first bonding

Instructional home visits by nurses help teen mothers bond with their babies and contribute to child development

Théo and his mother, Carolina, being tested on May 18 by the Primeiros Laços program staff

Léo Ramos Chaves

Théo, a 23-month-old who lives with his parents in the far west side of São Paulo, had a busy morning on Tuesday, May 18. At 10 a.m., he was taken to Educandário Dom Duarte—an institution that offers early childhood education for children in need, vocational training for teenagers, and literacy courses for adults, maintained by the NGO Liga Solidária (Solidarity League). Over the next three hours, Théo, accompanied by his mother, Carolina Nogueira, and his father, Diego Cruz, performed a series of activities to assess his physical, emotional, and cognitive development. These tests took place in one of the large houses on the old farm, which was turned into a laboratory by researchers from the University of São Paulo (USP). There, Théo climbed and descended stairs, threw balls, played with toy cars, fit building blocks together, and looked at pictures of animals and objects while interacting with psychologist Maria Lucimar de Oliveira. He later underwent a test that recorded the electrical activity in his brain while he watched a screen with alternating photos of his mother and an unknown woman. On the day before, Carolina had already answered a series of questions about her health and feelings, as well as about her son’s well-being and development.

These tests and surveys are part of the final assessment phase of the Primeiros Laços (First Bonds) program. Over the last three years, the program has been supporting 167 socially and economically vulnerable teen mothers from the west side of São Paulo. Established by USP psychiatrists, psychologists, and nurses, the project consists of about 60 home visits to these first-time mothers. From the beginning of the pregnancy, the program follows them until the child is two years old.

Eighty mothers were part of the first phase of the project, completed in 2018; 57 of them made it to the end, while the others either lost their baby or moved away. Half were randomly selected to get their prenatal and follow-up care in their local Unidade Básica de Saúde (UBS – Basic Care Unit). In addition to this care, the other half of the participants also received instructional home visits from nurses. At three points during their pregnancy and when the baby turned 3, 6, 12, 18, and 24 months old, they were all assessed by a psychologist, who was unaware of which women had or had not received the home visits. “Just talking to the psychologists was beneficial, because it made me realize details relevant to Théo’s development that I might not have noticed otherwise,” shares Carolina, who was 20 years old at the start of the program; she is now 22.

Initial results are encouraging. The data that are now being published in scientific journals indicate that the participants who got the visits had a more positive outlook on motherhood, and a greater number of them developed habits like telling stories, singing, and reading books to their child. Overall, the children of these women were also able to establish a more trusting relationship with their mothers and felt safer in challenging situations. By the age of two, they were also better at expressing themselves, pointing at objects, and speaking.

“These are encouraging results,” says psychiatrist Guilherme Polanczyk, a professor at the USP School of Medicine and coordinator of Primeiros Laços, which is supported by FAPESP, the Brazilian National Council for Scientific and Technological Development (CNPq), Grand Challenges Canada, and the Maria Cecília Souto Vidigal and Bill & Melinda Gates Foundations, in addition to the Brazilian Metallurgy and Mining Company. Polanczyk believes it is vital that these changes take place during the child’s first two years of life: a key period in child development with proven impact on school performance, educational attainment, physical and mental health, and even earning potential in adulthood. “We had seen evidence that similar projects had been effective in other countries. But we were missing data on our particular situation, especially involving pregnant teenagers.”

Teenage pregnancy is typical in countries with medium to low economic development and is considered a perpetuating factor for poverty. Girls from poorer populations often become pregnant for the first time during adolescence. Their children, in turn, develop less than the children of older women in terms of language, cognitive skills, and social skills. According to a 2015 document from the United Nations Population Fund (UNFPA), each year about 18 million girls between the ages of 10 and 19 become pregnant worldwide, and they are almost always married. Half of these girls are from Brazil and six other countries. Here, of the 2.8 million women who had a child in 2019, almost 420,000 (15%) were teenagers.

Léo Ramos Chaves The boy underwent an assessment of his cognitive abilities and an electroencephalography scan to analyze the maturity of his neural networks…Léo Ramos Chaves

Adolescence is already a troubled life stage, marked by rapid transformations. Emotions are unstable and the brain undergoes key changes: the connections between its cells that are used less often are eliminated, while those associated with reasoning and impulse control become more robust. Studies suggest that teenage mothers are often less attentive to their baby’s needs and stimulate them less, increasing the likelihood of their children becoming more insecure, clingy, and anxious.

The goal of Primeiros Laços is training these girls to care for their own health and helping them develop the skills they need to care for their baby and help their child achieve full development. Studies assessing the outcome of this pilot project seek to understand whether continued guidance from nurses is more beneficial than just the usual prenatal and follow-up care.

During each visit, a nurse talks to the teenage mother about one of more than 50 topics addressed over a period of almost three years. They talk about issues like accepting the pregnancy, breastfeeding, childbirth, and child development. They also address future changes in the mother’s daily life, recognizing the baby’s complaints and needs, healthy lifestyles, family relationships, sex life, and plans for the future. “We want to help these mothers understand what they are experiencing and, with the resources available to them, develop the best possible bonds with their child,” says Lislaine Fracolli, a professor at the USP Nursing School and creator of the pilot project.

Created by psychiatrist Euripedes Miguel, also from FM-USP, Primeiros Laços was inspired by two US programs for first-time mothers: Nurse-Family Partnership (NFP) and Minding the Baby. Both involved visits from nurses—and sometimes social workers—to women who were pregnant or had recently given birth; they helped promote health and care efforts that help improve the child’s physical, cognitive, and social development. Besides supporting pregnant women, the goal is to help parents become more aware and responsive to their baby’s physical and emotional needs, so that he or she feels loved and protected.

Primeiros Laços is based on attachment theory, proposed in the 1960s by British psychiatrist John Bowlby (1907–1990) and his American collaborator Mary Ainsworth (1913–1999). According to this theory, during the first months of life, children establish more intense emotional connections with primary caregivers, usually their parents. Only later do they bond with other people. The quality of this initial bond, influenced by the physical and social environment of the child, helps shape the way he or she will relate to the world.

When their mothers respond appropriately to their needs, children feel more secure and become more independent as adults, able to explore the world more confidently, relate better to other people, and cope well with frustrations. If the child’s physical or emotional needs are ignored or not properly met by the caregiver, he or she can develop forms of attachment that are less supportive of development, which usually results in more distrustful or insecure adults.

Léo Ramos ChavesThere may be biological reasons behind this behavior. Through his experiments with mice in the 1990s, psychiatrist Michael Meaney, from McGill University in Canada, demonstrated that the type of care provided by the mother early in life helps modulate how the brain responds to situations that generate stress and anxiety. The pups that got more attention (licking) from their mothers became less fearful of new things than the pups that were licked less often. The former had fewer receptors for anxiety-generating hormones and more receptors for calming substances in the area of the brain associated with processing emotions (the amygdala), such as fear.

Later, Meaney and his group found that this behavior was due to the gene activation pattern, which could be reversed by changes in the environment. After staying with their mothers for a brief period, the pups from attentive mothers were then assigned to be raised by uncaring females and became anxious. Pups born to females with little inclination to caring for them were placed under the care of more attentive mothers and grew into calmer animals. Published in 2004 in Nature Medicine, these results furthered the idea that interventions early in life, such as those carried out through visitation programs, can alter child development.

After assessing 56 mother-infant pairs who completed the first phase of Primeiros Laços, psychologist Fernanda Alarcão, who was a post-doctoral intern with the team, found that the program increased the rate of development of secure attachment between the teen girls and their children. By the time they turned one, 65% of the children of the teenage girls who were visited by the nurses had the healthiest form of bonding with their mothers—a rate similar to that of older mothers, according to an April 12 article in Developmental Science. This number is nearly twice as high as that of the children whose mothers were seen only at the UBS (36%). International studies have already shown that only around 30% of babies of adolescent mothers develop secure attachment. “Thanks to our instructional program, we observed attachment levels comparable to those of mothers who are not in vulnerable conditions,” says Alarcão.

Preliminary analyses of electroencephalography scans, which measure the brain’s electrical activity, indicate that, at six months, the brains of babies whose mothers underwent the intervention responded more quickly to their mother’s presence. “The data suggest that they had more interaction with their mother than those in the group that did not receive the visits,” says Scottish neuroscientist Elizabeth Shepard, also on the team. Shepard is currently repeating the tests with a larger number of participants. At 12 months, these children were also more relaxed when interacting with other people. In a 2019 paper, published in Biological Psychiatry, Shepard had found that the children of teenage mothers who were more anxious and less educated had a lower cognitive development at 12 months of age.

In another study, psychologist Daniel Fatori, a post-doctoral intern with the team, compared the performance of the children from the two groups in different areas of development and at different ages. At the age of two, the children whose mother had received the visits from nurses showed a higher ability to express themselves than those from the other group. They babbled more and tried to form words when interacting with their mothers; they also responded better when communicating with their mothers. In addition, they were better able to point out objects in their environment, according to a paper submitted for publication in a scientific journal. These mothers, in turn, were more emotionally stable and attentive to their children’s demands and stimulated them more at home.

“Children born to poorer families can face many issues throughout their lives, often originating from these interactions during their early years,” says economist Naercio Menezes, a professor at USP and the Insper Education and Research Institute (INSPER), and coordinator for the recently established Brazilian Center for Early Childhood Development (BCECD). Supported by FAPESP, the BCECD will conduct studies on child development and the effectiveness of interventions to improve how parents raise their children. “The work of American economist James Heckman (winner of the Nobel Prize in 2000) shows that investing in child development brings economic, social, and health returns for individuals and society. The earlier the investment, the greater the return,” he adds.

The initial results of Primeiros Laços have been drawing attention. The cities of Indaiatuba and Jaguariúna, both in the state of São Paulo, have already shown interest in adopting the project as a public policy to care for teenage mothers. Last year, the Brazil branch of the United Nations Children’s Fund (UNICEF) requested that the Primeiros Laços team adapt their protocols to be incorporated into the federal government program Criança Feliz (Happy Child), in which trainee psychologists monitor pregnant women and children from low-income families.

1. Early childhood interventions and cognitive, social, and emotional development trajectories (nº 16/22455-8); Grant Mechanism Thematic Project; Principal Investigator Guilherme Vanoni Polanczyk (USP); Investment R$3,403,455.79.
2. INCT 2014: developmental psychiatry for children and adolescents (nº 14/50917-0); Grant Mechanism Thematic Project; Principal Investigator Euripedes Constantino Miguel Filho (USP); Investment R$4,634,706.26.

Scientific articles
ALARCÃO, F. S. P. et al. Promoting mother-infant relationships and underlying neural correlates: Results from a randomized controlled trial of a home-visiting program for adolescent mothers in Brazil. Developmental Science. Apr. 12, 2021.
FATORI, D. et al. A nurse home visiting program for pregnant adolescents: A randomized controlled trial. Scientific Reports. In prepress.
SHEPARD, E. et al. Effects of Maternal Psychopathology and Education Level on Neurocognitive Development in Infants of Adolescent Mothers Living in Poverty in Brazil. Biological Psychiatry. Oct. 2019.
CALDJI, C. et al. Maternal care during infancy regulates the development of neural systems mediating the expression of fearfulness in the rat. PNAS. Apr. 28, 1998.
WEAVER, I. C. G. et al. Epigenetic programming by maternal behavior. Nature Medicine. June 27, 2004.