Bonding programs for women prisoners and their newborn children

Note: This report represents information on this subject as of December 1997.

Resolution 509, introduced by the District of Columbia Delegation, at the 1995 Interim meeting asked: "That the American Medical Association (AMA), in cooperation with the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the National Commission on Correctional Health Care, study the feasibility of a bonding program for women prisoners and their newborn children." This resolution was referred to the Board of Trustees. Board of Trustees Report 21 (A-96) summarized information on women prisoners and their newborn children. This report reviews the most recent literature on this subject.

Background

According to Department of Justice statistics, the state prison population of the United States has increased dramatically in recent years.¹ In 1996, there were 1,076,625 inmates in state prisons nationwide, which represents a 40 percent increase between 1991 and 1996. There were 1,182,169 inmates in both state and federal prisons combined. Of those inmates, 1,107,439 (93.6 percent) were male and 74,730 (6.3 percent) were female.² Although the prison population continues to be predominantly male, the proportional increase of incarcerated women has skyrocketed each year. The annual rate of growth of female inmates has averaged 11.2 percent since 1985, higher than the 7.9 percent average increase in male inmates.² By 1996 women accounted for 6.3 percent of all prisoners nationwide, compared to 4.6 percent in 1985.² In 1991 alone, women accounted for 7.6 percent of the inmates detained by the Federal Bureau of Prisons; 64 percent were incarcerated for drug related offenses.³ Of the women in state prisons in 1991, 6 percent were pregnant at the time of incarceration.¹

In 1991, the US Department of Justice conducted a comprehensive survey of women incarcerated in state prisons.¹ This survey, in which about 1 in every 11 women inmates were interviewed, found that female inmates were similar to male inmates in terms of race, ethnic background, and age. Most were over age 30, at least high school graduates or holders of a GED, and were racial or ethnic minorities. Additionally, a large majority were unmarried and mothers of children under the age of 18. Many incarcerated women were judged to be in need of treatment for substance abuse, sequelae of physical or sexual abuse, and/or mental illness. About 54 percent of the surveyed female inmates reported having used drugs in the month prior to their offense, 65 percent had previously used drugs on a regular basis, and 36 percent were under the influence of drugs at the time of their offense. Unlike men, women inmates were much more likely to be serving time for a drug offense and less likely to have been sentenced for a violent crime. In addition, the survey found that 60 percent of incarcerated females had grown up in one-parent households, 50 percent reported that a family member had served prison or jail sentences, and 40 percent reported prior history of physical or sexual abuse.¹

In a separate study conducted on women incarcerated in prisons over a 4-year period, 42.9 percent were diagnosed with a psychotic illness, such as a paranoid illness, manic-depressive psychosis, or major depressive illness.⁴ Antisocial personality disorder also was common among these women. Incarcerated women have been reported to often experience insomnia, panic attacks, eating disorders, or suicidal ideation.⁵

Prison nurseries

Given the growing female prison population, pregnancies during incarceration are becoming much more common.⁶ While the vast majority of children born to imprisoned women are then sent to live with family or in foster care, a small number each year are allowed to stay with their mothers in long-term prison nurseries. The decision to allow a newborn infant to remain in the prison with its mother is based on the results of rigorous screening processes. At the Bedford Hills and Taconic facilities in New York, this screening process includes investigation of the mother s background, and interviews with the mother, the mother's family, and with those responsible for the care of her other children, as well as with the correctional staff involved with the mother.⁷ The mothers' social history, parenting history, reasons for wanting to keep the baby in prison, disciplinary record, presentencing report, and relationship with the staff and other inmates are all considered, and a psychiatric evaluation is sometimes conducted.⁷

Long-term nurseries allow children to stay with their mothers from birth to age 1 year or 18 months.⁷ These nursery programs operate only in the states of New York, Nebraska, and Massachusetts. In contrast, interim nurseries are available in many states and allow infants to stay with their mothers from age 2 days to 6 weeks.⁷ Nursery staff seek to assure that the child has sufficient and appropriate food, clothing, medical attention, social stimulation, and contact with the mother. In general, mother-child bonding and improved parenting skills are the goals.⁷

The primary objective of prison nurseries is to create a stronger attachment between mother and infant.⁸ It has long been recognized that inmates who have strong ties with their families during incarceration have a greater chance of positive rehabilitation and run a much lower risk of recidivism.⁹ The nursery program facilitates this relationship by creating a supportive environment for the development of a powerful bond between the mother and her infant. Since female inmates in prison nursery programs have few other obligations, the children have almost continual contact with their mothers, and the ensuing relationship tends to be extremely close.¹⁰ With the addition of parenting, education, and treatment programs, the nursery program in its entirety creates the opportunity for a substantive change in the mother's lifestyle following release.⁹

Most child development experts stress the importance of the first year of life, when the foundation for intellectual, emotional, and social qualities of a lifetime are created, and attachment to a primary caregiver is established.¹⁰ Therefore, nursery programs can have a strong impact on the participating children. Most of these children are considered "at risk," because their mothers have a history of drug abuse or have been victims of abuse themselves and come from chaotic backgrounds.^8,9 Addressing the factors that inhibit these mothers from providing a stable and safe environment for their child is believed to convey positive developmental benefits for that child and improve mother-infant bonding. At the same time, the mothers receive training on basic care of the infant and parenting skills, as well as substance abuse treatment where appropriate.

Babies participating in the program have been described anecdotally as exceeding expectations. This benefit is attributed in part to the stability, structure, and social support imposed on the mothers' lives when they enter prison and the access to perinatal health care services as well as to the social stimulation provided to the infants during this early, critical stage of life.^7,8

General research indicates that social support to the mother increases the strength of infant-mother attachment.¹¹ In addition, numerous longitudinal studies have concluded that early attachment patterns can potentially predict social behaviors later in life.^10,12 One study indicated that the strongest predictor of excessive hostile behaviors toward peers in preschool was a disorganized attachment relationship during infancy,¹² which suggests that interventions aimed at increasing mother-infant bonding could benefit the infant and decrease the likelihood of behavior problems later in life.⁷ Whether prison nursery programs have in fact produced this benefit has not yet been empirically established.

History of prison nurseries

The nursery program at Bedford Hills, the New York state reformatory for women, was opened in 1901. Most of the participating women were unmarried mothers. The women were allowed to keep their infants with them in prison until their first birthday. Mothers who were to be released within the first 18 months after the child's birth were often allowed to keep their child with them for the duration of their sentences.¹³

In 1972, the Bedford Hills reformatory and the state prison for women merged under the name Bedford Hills Correctional Facility. Because of the rapid increase in the female inmate population, Taconic Correctional Facility, initially a men's facility, became a women's prison in 1989. In 1990, due to the increase in the Bedford Hills nursery population, the second prison nursery in New York was opened at Taconic.¹³

A 1992 report by the State of New York Department of Correctional Services provided a profile of participants in the Bedford Hills and Taconic Nursery Programs.⁹ A typical participant was a single woman in her late twenties who was already a mother, had been incarcerated for a drug offense, and had received a minimum sentence of under 2 years. This typical prisoner had been involved with the criminal justice system before and had served a prior jail or prison sentence. The average length of stay in the nursery program was 7.3 months.¹³

The Neil J. Houston House in Roxbury, MA, opened its nursery program in 1989.^14,15 Any incarcerated pregnant woman in the state of Massachusetts is eligible for the program, although most of the participants are from the Massachusetts Correction Institute in Framingham. Those accepted for inclusion are removed from the prison to live on the grounds of a local community health treatment center for the duration of their pregnancy and with their child for up to one year.^14,15

In 1994 the Nebraska Center for Women opened a nursery program for its inmates, modeled after the Bedford Hills Correctional facility.¹⁶ Unfortunately there are no published reports on the program, and the correctional facility did not have any internal evaluations that it could make available. In developing the facility, the Nebraska Center for Women contacted the Center for Children of Incarcerated Parents in Los Angeles, CA, for consultation. Although no one from that organization has visited the facility, a spokesperson for the Center for Children of Incarcerated Parents stated that the Nebraska Center for Women is assumed to be a high-quality institution.¹⁷

General research

Extensive literature search identified a paucity of research that specifically measures the long-term impact of nurseries on children. One set of authors concluded that the available anecdotal and scientific research suggests that there are few detrimental effects on these children when the programs are carefully implemented.¹⁸

Some early childhood experts state that attachments between an infant and its primary caregiver are believed to develop in the first weeks and months of life, under stable conditions.¹⁰ Disruption of the bond between the ages of 6 months and 4 years is believed to have particularly devastating effects on the development of the child.^8,10 Further evidence suggest that young children who have repeated or sudden separations from their primary caregivers are more likely to develop psychiatric problems as children and as adults.¹⁰ They are more likely to have deviations in personality development that lead to aggressiveness, coldness in personal relationships, difficulties with learning, and difficulty with parenting as an adult.¹⁰ When an infant or child is separated from its primary caregiver, he or she may cry for long periods of time, evoking irritability in a new caregiver. A child over 6 months of age who is separated from its primary caregiver will generally exhibit fear and distress. He or she will eventually become attached to this new caregiver but may become extremely anxious and "clingy." If the child is then reunited with the original caregiver, this in turn can promote feelings of anger in the child, making it difficult to re-establish the previous bond.¹⁰ This literature suggests that an infant placed in foster care or with a relative directly after birth or in the months immediately following birth who is then returned to his or her mother after her release from prison may experience developmental problems, assuming the child is less than 4 years of age.

A study published in 1993 followed 62 low-income families and examined the relation between maternal and infant measures at 18 months and at 5 years of age.¹² The assessments included maternal psychosocial interaction and infant attachment security. Study findings indicated that children with disoriented/disorganized attachment patterns during infancy developed serious hostile behavior towards their peers in preschool children. Maternal psychosocial problems, which include depressive symptoms, child maltreatment, or a history of psychiatric hospitalization, also predicted hostile and aggressive behavior in preschool. In this study, disoriented/disorganized attachment patterns during infancy and maternal psychosocial problems independently predicted behavior problems in the children. However, a previous study indicated that infants of mothers with psychosocial problems were less likely to develop secure attachments than infants of other mothers, suggesting some overlap between disorganized attachment and maternal psychosocial deficits.¹² Although these studies did not take place in a prison nursery program, they do emphasize the importance of infant bonding. Considering the psychosocial problems common to the typical female inmate,^{1, 3-5} it may be reasonable to expect behavioral problems in some of these children, regardless of their participation in prison nursery programs.

Research on prison nurseries

In one observational study, the correctional and program staff of the prison nursery program at Taconic Correctional Facility were interviewed and expressed anecdotal support for the program.⁷ This included the superintendent, psychologist, nursery manager, and nurse. Both the psychologist and the nursery manager noted positive identification of infants with their mothers. In addition, they indicated that bonding was still evident for those inmates whose children left the nursery program and were only able to visit their mother during visitation periods.⁷ Similar anecdotal evidence supporting the nursery programs was expressed by the staff in Nebraska and Massachusetts through personal correspondence with officials at the correctional facility. However, such anecdotal evidence should be considered with caution, given the emotional investment of staff in the program.

In 1992 Catan completed a study of mother and baby dyads.¹⁸ The study consisted of an experimental group of 74 infants residing in prison units and a control group of 33 infants, two thirds of whom were looked after by extended family and one third by social services or foster parents. The author followed these infants for an extended period; infants in the experimental group were followed through their time in prison and for 3 months after their return to a nonprison environment. Catan's findings indicate that a significant number in the control group, those infants born in the prison nursery and then immediately placed with caregivers other than the mother, do not experience the benefits of continuity of care during infancy. However, the study did conclude that there was a strong, healthy attachment pattern among infants and their mothers in the prison nursery program.

In 1990 Busch-Rossnagel and colleagues¹⁹ completed a study on the cognitive and social-emotional attachment of 12 infants in the Bedford Hills Nursery program. One part of this study examined the strength of the mother-infant attachment. After videotaping the infants and their mothers and observing their behavior, Busch-Rossnagel et al reported "little wariness of the stranger," suggesting an imperfect attachment. Previous research has shown that older infants already attached to their mothers do display distress in the presence of a stranger.¹⁰ In addition to the lack of stranger wariness, Busch-Rossnagel et al¹⁹ reported that 50 percent of the infants seemed to be insecurely attached to their mothers. This may be related to the general finding that infants are less likely to develop secure attachments if their mothers have psychosocial problems.¹² The Busch-Rossnagel study does not indicate the same strong, healthy attachment patterns of infants in Catan's study; however, the Busch-Rossnagel study cannot be considered conclusive, since there was no longitudinal evaluation of the parent-child relationship.

Catan's study¹⁸ used the Griffiths Mental Developmental Scales, a standardized infant test that provides developmental norms for locomotor, social, and cognitive development. Although no long-term effects on the infants' development were found, some short-term detrimental effects were evident in those who spent 4 months or longer in the prison units.¹⁸ These deficits disappeared soon after the infants' transition to a nonprison environment. The researchers concluded that, although the nursery units were able to promote the development of basic skills, they were unable to promote the extended use of these skills that is necessary to developmental growth as the child gets older. The inability of infants to build on their basic skill set was believed to be a direct result of the limitations in the design of the nurseries, not due to the concept of nurseries itself.¹⁸

The restricted environment of the nurseries impeded both locomotor and cognitive development of the infants who remained in the nurseries for longer periods of time. Lack of locomotor development was attributed to spending extended periods of awake time physically confined. This was the result of a combination of factors, including the lack of physical space available in the nurseries as well as suboptimal use of the facilities.¹⁸ The cognitive ability of a child---his or her ability to respond, including developmental skills and problem solving tasks---is partly developed through interaction with educational toys, which were lacking for the older children at the nursery.¹⁸

Findings of the Busch-Rossnagel et al study¹⁹ were similar to those of Catan¹⁸ regarding developmental effects. Using the Bayley scale to assess developmental status, the authors found that 33 percent of the infants were greater than one standard deviation below the mean in overall development.¹⁹ Busch-Rossnagel and colleagues found a lack of variety in daily stimulation, regardless of the presence of adequate play materials. They concluded that prison nursery infants were at risk for developmental problems.¹⁹ This study indicates short-term detrimental effects, but does not have follow-up data on these infants to assess their progress once they enter a nonprison environment.

There is little information on the effects of prison nursery programs on the mother. However, according to Children of Incarcerated Parents,⁷ the superintendent of the prison nursery program at Taconic Correctional Facility keeps in touch with a number of former nursery program attendees. She believes that the bond built between mother and child provided a strong incentive for the mother to pull her life together once she left the facility. In addition, both the psychologist and the nursery manager noticed a nurturing demeanor in the mother as she interacted with her child during the mother's participation in the nursery program.

Catan¹⁸ argues that the most important determinant of positive outcomes is the training of nursery staff. Prison staff are accustomed to maintaining an ordered structure and to enforcing a strict regimen. While this structure may help the mothers change their behavior, which in turn might benefit the future lives of their children, the inherent nature of the prison environment may not optimally serve the developmental needs of the child.

Catan¹⁸ states that the ideal staff for a prison nursery program are trained in child care and focus all their work efforts solely in the nursery. This allows them to develop a close relationship with the mothers and the infants. Catan concluded that prison nurseries can potentially provide a healthy environment; therefore, emphasis should be placed on how to meet the needs of the child and provide skills to the mother so that she can continue providing a supportive and safe environment upon her return to the community.¹⁸

Discussion

In considering the potential benefit of prison nursery programs, several issues are pertinent. The limited research available precludes certainty regarding the long-term effects of prison nurseries; information is either anecdotal, observational, or limited by methodology.

Many women inmates have previously experienced physical and/or sexual abuse,¹ which places them at increased risk of abusing or neglecting their own children. Although nursery programs screen out potentially violent and aggressive mothers from participating in the programs, emotional or physical neglect of the child may be a risk.⁸ In a study on the health status of babies incarcerated with their mothers at the Bedford Hills Correctional Facility,⁸ there were 2 suspected cases of child abuse by means of physical aggression: one infant's subarachnoid bleeding caused suspicion of shaken baby syndrome; another infant had 6 reported accidents, one of which was a cigarette burn. Both children were subsequently removed from the prison nursery.

Furthermore, although inmates included in the nursery programs are provided with parenting skills training, as well as the opportunity to bond with their children, it is not certain that these skills and bonds are maintained after leaving the facility. Participating women have an incentive to present themselves as mothers who understand the importance of bonding and good parenting skills so as not to be returned to the general prison population.⁷ Similarly, although inmates are provided with substance abuse treatment, it is not certain that abstinence is maintained after release from the prison. Finally, if maternal psychosocial or emotional problems inhibit the women's ability to create a secure bond between mother and child, the value of the prison nursery programs is unclear.

Studies show that there can be devastating emotional consequences when a child is separated from its primary caregiver between the ages of 6 months and 4 years.^8,10 If an incarcerated mother is not released within the first year to 18 months after the child's birth, the child is inevitably separated from its mother, and a break in the mother-child bond occurs. Such a break inhibits a child's ability to handle stress and fear, become independent, give and receive love, and reach his or her full intellectual potential.^10,20 Decision-making that maximizes the chance of having a consistent caregiver during the first 4 years of life is in the best interest of the child.

In gauging the value of prison nursery programs, the related costs and benefits to the mothers versus the children must be weighed. In prisons, only 24.2 percent of all incarcerated women have a maximum sentence of less than 36 months.¹ If these programs were made universal, there is no certainty of a continuous mother-child bond. It is possible that many infants would be abruptly separated from their mother at critical ages, which research has shown can create adverse consequences.¹⁰ In addition, a securely attached infant could be separated from its mother if the mother displays inappropriate behavior, if the safety of her child or other nursery babies is at risk, or if it is uncertain that the health and well-being of the baby is being maintained.¹⁰ Although there are strict guidelines for participation in nursery programs, the background of the typical female inmate makes her susceptible to aggressive or violent behavior, which further increases the risk to continuity of care.

Anecdotal evidence suggests that the guidelines presently established for inclusion into and exclusion from nursery programs may be sufficient to screen out mothers likely to fail. Nursery programs provide mothers with a strong incentive to behave appropriately and pull their lives together. Rigorous screening processes can decrease the chance of inappropriate behavior by the mother, minimizing the potential for the removal of the infant from her care. If additional guidelines on the duration of the prison sentence for female inmates are considered, the continuity of care provided to the infant could be maintained. If a pregnant inmate fits the inclusion guidelines but nursery facilities are not available, an infant placed in foster care or with a family member shortly after birth and then returned to its mother after her release from prison will be deprived of continuity of care.

Nursery programs also provide mothers with parenting training, education, and treatment programs, thus giving them an opportunity to improve their skills as parents and prepare for transition into the nonprison environment.⁹ However, it has not been proven that the skills provided to these mothers and the bonds created between the mother and infant are maintained after they leave the facility.⁷ In addition, these programs are expensive and currently reach only a small population.¹⁷ Therefore, it is unclear if the money invested in the mother and her child could have been better spent elsewhere.

Another dilemma lies in the question of whether children should be subjected to the same conditions of deprivation as their incarcerated mother. Research indicates that infants placed in nursery programs are at risk for short-term developmental problems due to the lack of physical activity as well as an inadequate variety of educational toys.^8,18,19 However, these detrimental effects may disappear soon after the child enters a nonprison environment.¹⁸ In addition, imprisoned children have little contact with their father, grandparents, or other siblings except for visiting hours or under artificial conditions.¹⁰ This problem can be remedied if children are provided frequent access to external relatives and have opportunities for off-site visits.

A study of the status of mothers and children in prison in 70 countries was conducted in 1987 by the United Nations Alliance of Non-Governmental Organizations (NGO) on Crime Prevention and Criminal Justice.²¹ Based on this study, the NGO recommended alternatives to imprisonment for mothers, including suspended or conditional sentences, house arrest, community service, restitution, and provision of community centers for mothers who require more supervision than can be accorded in the home setting. The NGO further states that when prison is the only alternative as dictated by society, separate units for the children outside but adjacent to the prison should be constructed, allowing mothers to see their children on a daily basis. The NGO argues that placing children inside a prison should be a last resort, and such children should be allowed frequent opportunities to leave the institution.

Summary

It should be acknowledged that present prison nursery programs may not provide children with a supportive, stimulating, and safe environment. Furthermore, it is extremely expensive to implement a nursery program, which can serve only a small percentage of the incarcerated women giving birth. In addition, establishing guidelines and policies for present and potential future prison nurseries will be difficult since there is little, if any, regulation of prison nurseries. These institutions develop their own guidelines and policies regarding their nursery programs.

The evidence presented is based on the limited research available on this topic. In light of the available evidence, it is difficult to argue that implementation of additional nursery programs is the best way to ensure that children of incarcerated parents grow up in a supportive, safe, and nurturing environment. These resources could be redirected to provide parenting skills training and mental health and substance abuse services in order to ensure that all female inmates are better prepared to re-enter the nonprison environment as mothers.

Recommendations

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1997 AMA Interim Meeting.

1. Because at this time there are insufficient data to draw conclusions about the long-term effects of prison nursery programs on mothers and their children, the AMA supports and encourages further research on the impact of infant bonding programs on incarcerated women and their children.
2. The AMA recognizes the prevalence of mental health and substance abuse problems among incarcerated women and continues to support access to appropriate services for women in prisons.
3. The AMA recognizes that a large majority of female inmates who may not have developed appropriate parenting skills are mothers of children under the age of 18. Therefore, the AMA encourages correctional facilities to provide parenting skills training to all female inmates in preparation for their release from prison and return to their children.
4. The AMA supports and encourages further investigation into the long-term effects of prison nurseries on mothers and their children.

References

1. Department of Justice. Women in Prison. Washington, DC: Bureau of Justice Statistics. March 1994. (Report No., NCJ-145321.)
2. Department of Justice. Prisoners in 1996. Washington, DC: Bureau of Justice Statistics. June 1997. (Report No.,NCJ-145321.)
3. Kline S. A profile of offenders in the Federal Bureau of Prisons. Fed Bur Pris J. 1992;3:15.
4. Brownstone DY, Swaminath RS. Violent behavior and psychiatric diagnosis in female offenders. Can J Psych. 1989;34:190-194.
5. Jose-Kampfner C. Reflections from the inside. Health/Pac Bull. 1992;1:15-19.
6. Safyer SM, Richmond L. Pregnancy behind bars. Semin Perinatol. 1995;19 (4):314-22.
7. Gabel K, Girard K. Long-term care nurseries in prisons: a descriptive study. In: Gabel K, Johnston D, eds. Children of Incarcerated Parents. New York:Lexington Books;1995:237-254.
8. Lennon A. Infants in prison. A Thesis in the Program in Maternal and Child Health. Submitted to and accepted by the faculty of the Graduate School of Health Sciences at New York Medical College. 1992.
9. State of New York Department of Correctional Services. The Prison Nursery Programs at Bedford Hills Correctional Facility and Taconic Correctional Facility. New York;1992.
10. Black D. Imprisoned children. Med-Leg J. 1988;56 (3):139-149.
11. Jacobson SW, Frye KF. Effect of maternal social support on attachment: experimental evidence. Child Development. 1991;62:572-582.
12. Lyons-Ruth K, Alpern L, Repacholi B. Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Development. 1993;64:572-585.
13. State of New York Department of Correctional Services. Profile of Participants: The Bedford Hills and Taconic Nursery Program in 1992. New York; 1993.
14. Innovative programs up for awards; innovations in state and local government: awards by Harvard University and Ford Foundation. Alcohol Drug Abuse Week. 1991;3(28):2.
15. Personal communication with Barbara Molla, Director of Neil J. Houston House, Massachusetts. May 1997.
16. Stuart R. Behind bars: the growing number of black women in prison snaps families and meager community resources. Ethnic News Watch. 1997;8(5):44.
17. Personal communication with Denise Johnston, Center for Children of Incarcerated Parents, Los Angeles, California. May 1997.
18. Catan L. Infants with mothers in prison. In: Shaw R, ed. Prisoners Children. New York: Routledge, Chapman and Hall Inc.;1992:13-28.
19. Busch-Rossnagel. NA, Towle PO, Juster F. Babies behind bars: cognitive and social-emotional development. Abstract submitted October 1990.
20. Huie V. Mom's in prison - where are the kids? USA Today (Magazine). November 1993; 122 (2582):30.
21. Alliance of Non-Governmental Organizations on Crime Prevention and Criminal Justice. Children in Prison with their Mothers. A Report of the Working Party of the Alliance of Non-Governmental Organization on Crime Prevention and Criminal Justice. September 1987.

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