The Attachment During Stress Scale is for use with infants from birth to 18 months to detect aberrant mother-infant responsiveness in mild to moderately stressful situations.  The scale quantifies the reciprocal process of mother-infant attachment while the infant is under the stress of an ordinary physical examination.  The scale can also be used in other situations which produce tension tension in mother and baby.  When stressed, infants normatively seek out their mothers; mothers normatively seek out and comfort their infants when they perceive them to be in danger or in distress.  Such interactions fall within the general category of attachment behaviors.  The scale includes six basic attachment modalities:  gazing, vocalizing, touching, holding, affect and proximity.  These modalities are subdivided into components and correspond to mother and infant responses clinically seen in stressful situations which arouse tension and anxiety in mother and/or infant.  The responses in each modality are graded from 1 to 5 to indicate the increasing intensity of mother-infant involvement that may occur during a stress episode.  Generally, behavior at the low end of the scale (1) indicates abnormal isolation or avoidance of attachment, and responses at the high end (5) indicate abnormally anxious behavior or clinging.  The top of the single-page scale quantifies the infant's behavior with its mother, and the bottom half quantifies the mother's behavior with her infant during the stressful situation.


The A-D-S Scale is for use during the pediatric examination and other situations where a relatively standardized stress occurs for parents and babies.  For example, mental health or childcare workers can use the scale to assess mother-infant attachment at the moment of reunion following the stress of a brief separation between mother and child.  Likewise at the end of a baby's bath, mild tension and recovery often occur as the child is lifted from the water, dried and clothed.  In whatever setting it is used, the scale may serve some or all of the following functions:

    1) To organize and record the clinician's assessment of the adequacy of maternal-infant responsiveness.

    2) To document the need for developmental and psychological care to prevent the crystallization of pathological modes of social interaction.

    3) To document the efficacy of early therapeutic intervention by registering improvement in the clinical indicators of attachment when used longitudinally during the first 18 months of life with atypical mother-infant pairs.

    4) To teach by heightening clinicians' and parents' awareness of components of mother-infant interaction central to psychological development.

Instructions for Administration and Scoring

In the pediatric clinic, the clinician conducting the examination or an independent observer can administer the A-D-S Scale.  Generally, the mother should not be alerted to the details of the observation so that she does not modify her usual style; and for the same reason the examiner may choose to let the mother decide whether to hold the baby or place they baby on the examining table.

To use the scale observe the interaction between mother and infant while the infant is being physically examined (the stress episode) and immediately afterward (the reunion and recovery episode).  Together, they comprise a stress/recovery sequence.  In many pediatric examinations the final phase is the inspection of the head, eyes, ears, nose and throat.  This usually takes about 3 minutes and is often the most difficult for mother and infant.  The period immediately following this (about 3 minutes) is the time when mother and infant reunite and tension subsides.  Similarly, in non-pediatric settings there is a corresponding rise and fall of tension around a stressful event.  Assessment is made by focusing on the period of most heightened stress (for example, the final 3 minutes of the physical examination) and the period of tension decline (the first 3 minutes of the recovery phrase.)  immediately after observing the stress recovery sequence, circle the behavior description that best fits the mother's and infant's response in each attachment modality during the sequence.  Sometimes it is unclear exactly which description to circle.  In this case the rater should select the one that is closest, and may chose to add a qualifying note in the margin.  If a particular attachment modality, such as holding, has not occurred circle "not observed" so that an entry is made in each category.

Operational Definitions

Holding: the mutually reciprocated posturing of the infant and mother while the infant is supported in the arms of the mother.                                        

Gazing: eye-to-face contact within a dyad and the maintenance of this contact.                                                                                            

Vocalizing: sounds made for the benefit of the partner in the mother-infant dyad.  The infant's crying is considered a vocal signal of dismay during stress which alerts the mother to its tension.                                                                                                                                                        

Touching (a): skin-to-skin contact initiated by either the mother or the infant for play or attention, not physical support                                        

Touching (b): the withdrawal from skin-to-skin contact initiated by either the mother or infant.                                                                            

Affect:  The facial expressions signaling emotional stress.  A neutral expression is not unusual or abnormal for an individual  under stress.          

Proximity: the state of being near, close to, or beside another.  In the context of the A-D-S Scale it refers to the infant maintaining either physical or visual contact with the mother, and to the mother maintaining physical contact or being immediately accessible to her infant.                                 

Rarely: the behavior occurs once in a while, or seldom; it doesn't happen often during the observation period.                                                  

Occasionally: the behavior occurs from time to time, now and then during the observation period.                                                                                 

Frequently: the behavior happens often but not all the time during the observation period.

Interpretation of Scoring

Normal behaviors will usually rate at 3 and 4.  When an infant or mother rates at 1 or 2 it suggests that the infant or mother may be avoiding contact or not responding to the other's display of tension or attempts at attachment.  When there are scores of 5 it should raise concern that there is an over-anxious intense interaction or an unusually strong reaction to stress.  Further, in dyads where one member rates at 1 or 2 and the other at 5, there is a dissynchrony which may have pathological significance.  To derive a single or "correct" score is not the proper use of the scale.  The most productive way to interpret the ratings is to use the attachment indicators as a guide to the adequacy of interaction in a given mother-infant pair.  Studies indicate that disturbed attachment is associated with subsequent developmental problems such as depression, anxiety, aggression, and the inability to deal with frustration -- all with their attendant behavioral disturbances.  When behaviors of 1,2, or 5 occur in 2 successive observations, there should be a diagnostic evaluation since once established, unhealthy patterns of mother-infant interaction show little change without therapeutic intervention.  The exception occurs with some very young or premature infants who show a normal dampened responsiveness.  They may rate 2 for gazing, vocalizing, touching (a), and proximity in the first weeks of life.


An infant's ability to tolerate tension or respond to comforting may be affected by illness or hunger.  Likewise, a mother's capacities may be affected by concurrent problems in her life.  History taking should elicit this.  The A-D-S Scale can then help assess the capacity of the mother and infant to manage the additional stress, or their vulnerability to traumatic decompensation and disorganization.   Additionally, a disturbing examining situation can intensify the stress of customary events.  If there are unusual circumstances when the rating takes place, explain briefly in the space provided at the bottom of the scale.

Typically fathers accompany infants less frequently than mothers, but the A-D-S Scale can effectively describe father-infant interaction. When infants are older than 18 months, their behaviors become increasingly complex so that the A-D-S Scale is less useful.

2007, 2017 Revised Edition, HENRY MASSIE, M.D. & B.K. CAMPBELL, PH.D.