PARENTAL ATTACHMENT T0 PREMATURE AND SERIOUSLY ILL. INFANTS Thesis Tor The Degree 0‘ M. A. MICRTGAN STATE UNIVERSITY Barry Morgan Wright 1977 «T «2- "5‘ .11 4%? .9 .--6 Q9 ABSTRACT PARENTAL ATTACHMENT TO PREMATURE AND SERIOUSLY ILL INFANTS BY Barry Morgan Wright The present study is a correlational analysis of the relationship between characteristics of premature and seriously ill infants and parental attachment behaviors and attitudes. The fundamental assumption of this study is that there is an interaction between infant character- istics and parental attachment in the neonatal period. The major infant variables were sex, medical history, auditory and visual orientation, and visual fixation behavior. The major parent variables were visiting pat- terns, maternal feeding behaviors, parental distress, attitudes toward childrearing, and demographic character- istics. The 31 infants in the study were hospitalized from birth in a Regional Neonatal Intensive Care Unit, primarily due to complications of prematurity. The mean gestational age was 34 weeks and mean age at discharge Barry Morgan Wright was 28 days. Infants judged to have congenital defects or neurological damage were excluded from the sample. Just prior to discharge, the infants were assessed on the Animate Auditory Orientation and Animate Visual Orientation scales from the Brazelton Neonatal Assessment Scale (Brazelton, 1973). Visual fixation behavior was assessed using an apparatus similar to that developed by Fantz (1967) and used by Moss and Robson in their studies of attachment (1969, 1970). The three stimulus targets were a face, a scrambled face, and vertical stripes which were each presented three times in counterbalanced order. It was hypothesized that parental attachment would be related to infant competence in visual orientation and fixation. The parents of these infants completed a question- naire just prior to discharge, including the following measures: the Multiple Affect Adjective Checklist (Zuckerman & Lubin, 1965), the Post-Partum Research Inventory (Schaefer & Manheimer, 1960), the Social Readjustment Rating Scale (Holmes & Rahe, 1967), the Locke-Wallace Marital Inventory (1959), and items gen— erated from Green and Solonit's Vulnerable Child Syndrome (1964). Behavioral assessment of the parents included a record of visiting and feeding frequencies; the mother was also observed during a feeding. The feeding Barry Morgan Wright behaviors which were assumed to indicate attachment were the amount of time looking at the infant and the number of nonfunctional affectionate touches. Although the frequency of visiting and feeding behaviors were expected to cluster as attachment behaviors, they proved to be independent of each other. This may have been the result of a third unmeasured variable, the efforts of the medical staff to encourage visiting among uninvolved parents. As hypothesized, parental personality measures and attachment behaviors were related. Mothers with Ignoring attitudes touched their infants less often; also, Fearful, Hostile, and Stressed mothers made less contact with their infants. In contrast, fathers who reported distress made more contact with their infants. This suggests a sex role difference in parental response to the crisis of a sick infant. Fathers appear to take a more instrumental role in maintaining contact with the hospital. The expected association between high parental attachment and high infant visual fixation was confirmed. Specifically, high fixation on pictures of faces was related to high maternal looking and touching. Infants who fixated poorly on faces had mothers who were more Ignoring and blaming. Infants with high visual fixation had fathers who were more Responsive and less Irritable. Barry Morgan Wright It was hypothesized that parents who had developed an attachment to their infant would show less distress. The Opposite was found to be the case. Parents who were more involved with their infants showed more distress, presumably because of the potential loss of an infant to whom they had become attached. It has often been assumed that prematurity is an impediment to parental involvement. However, in this study mothers showed more consistent visual attention to more premature infants, when controlling for the degree of perinatal medical trauma. This suggests that pre- maturity, independent of perinatal trauma, need not have deleterious consequences for parental attachment. PARENTAL ATTACHMENT TO PREMATURE AND SERIOUSLY ILL INFANTS BY Barry Morgan Wright A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1977 TABLE OF CONTENTS Chapter Page I. INTRODUCTION . . . . . . . . . . . 1 II. REVIEW OF THE LITERATURE . . . . . . . 4 The Critical Period Approach . . . . . 4 The Crisis Theory Approach. . . . . . 9 The Interactional Approach. . . . . . 12 Hypotheses . . . . . . . . . . . 15 III. METHOD . . . . . . . . . . . . . 17 Subjects. . . . . . . . . . . . 17 Infants . . . . . . . . . . . 17 Parents . . . . . . . . . . . 18 Procedure . . . . . . . . . . . 18 Feeding Observation . . . . . . . 18 Infant Observation. . . . . . . . 19 Questionnaire . . . . . . . . . 21 IV. RESULTS . . . . . . . . . . . . 25 Infant Variables . . . . . . . . . 25 Medical History. . . . . . . . . 25 Infant Competence . . . . . . . . 26 Medical History and Infant Competence . 26 Mother Variables . . . . . . . . . 27 Feeding Behaviors . . . . . . . . 27 Contact Behaviors . . . . . . . . 28 Personality Variables. . . . . . . 28 Intercorrelations of Maternal Person- ality and Behaviors . . . . . . . 28 Feeding and Contact Behaviors . . . . 28 ii Chapter Contact Behaviors and Personality Variables . . . . . Feeding and Maternal Personality . Father Variables . . . . . . . . Contact Behavior and Personality Variables . . . . . . . . . Medical History and Parental Variables. Medical History and Maternal Feeding. Medical History and Maternal Contact. Medical History and Maternal Person- ality . . . . . . Medical History and Paternal Contact. Medical History and Paternal Person- ality . . . . . . . . . . Infant Competence and Parental Variables Infant Competence and Maternal Feeding Infant Competence and Maternal Person- ality . . . . . . . . . Infant Competence and Paternal Person- a1 lty O O O O O O O O O 0 Summary and Findings. . . . . . . V. DISCUSSION. . . . . . . . . . '. APPENDICES APPENDIX A. RESEARCH INSTRUMENTS . . . . . . . B. ADDITIONAL TABLES . . . . . . . . REFERENCES . . . . . . . . . . . . . iii Page 29 29 32 33 33 33 36 36 38 38 42 42 42 45 47 50 61 79 85 Chapter Contact Behaviors and Personality Variables . . . . . . . . . Feeding and Maternal Personality . Father Variables . . . . . . . . Contact Behavior and Personality Variables . . . . . . . . . Medical History and Parental Variables. Medical History and Maternal Feeding. Medical History and Maternal Contact. Medical History and Maternal Person- ality . . . . . . . . . . Medical History and Paternal Contact. Medical History and Paternal Person- ality . . . . . . . . . . Infant Competence and Parental Variables Infant Competence and Maternal Feeding Infant Competence and Maternal Person- ality O O O O O O O O O 0 Infant Competence and Paternal Person- ality O O O O O O O O I 0 Summary and Findings. . . . . . . V. DISCUSSION. . . . . . . . . . '. APPENDICES APPENDIX A. RESEARCH INSTRUMENTS . . . . . . . B. ADDITIONAL TABLES . . . . . . . . REFERENCES . . . . . . . . . . . . . iii Page 29 29 32 33 33 33 36 36 38 38 42 42 42 45 47 50 61 79 85 10. ll. 12. 73-1. B-2. B-3. LIST OF TABLES Parent Questionnaire Scales . . . . . . Infant Medical Variables . . . . . . . . Correlations of Maternal Personality Variables and Contact Behaviors . . . . . . . . Maternal Personality and Feeding Behaviors . . Correlations of Paternal Personality Variables and Contact Behaviors . . . . . . . . Correlations of Infant Medical Variables and Maternal Feeding Behaviors. . . . . . . Correlations of Infant Medical Variables and Maternal Personality Variables . . . . . Correlations of Infant Medical Variables and Paternal Contact Behaviors. . . . . . . Correlations of Infant Medical Variables and Paternal Personality Variables . . . . . Infant Competence and Maternal Feeding Behaviors . . . . . . . . . . . . Correlations of Infant Competence Measures and Maternal Personality Variables . . . . Correlations of Infant Competence Measures and Paternal Personality Variables . . . . Correlations of Infant Medical Variables. . . Correlations of Infant Competence Measures . . Correlations of Medical Variables and Infant Competence Measures . . . . . . . . . iv Page 22 24 30 31 34 35 37 39 40 43 44 46 79 80 81 Table Page 3-4. Correlations of Maternal Feeding Behaviors . . 82 B-5. Correlations of Maternal Contact Behaviors . . 83 B-6. Correlations of Maternal Personality Variables . . . . . . . . . . . . 84 CHAPTER I INTRODUCTION It has become increasingly clear that the pre- mature or seriously ill infant continues to be psycho- logically disadvantaged long after hospital discharge. Much of the research on these infants has focused on correlating prematurity, in varying degrees, with intel- lectual deficits, mental retardation, hyperkinesis, autism, accident proneness, and later becoming a high school dropout or institutionalized (Caputo & Mandell, 1970). Most of these same researchers have focused on the aspects of reproductive casuality, emphasizing the probable role of poor prenatal care, nutrition, and attendant minimal brain damage in understanding the sequelae of prematurity. Another set of investigators have focused on the role of caretaking in these difficulties and, in par- ticular, on the vicissitudes of parental attachment to these infants. The most blatant indices of parenting difficulties are the disproportionately high incidences of child abuse and failure to thrive syndrome among medically high risk infants. Among the infants who fail to thrive in the absence of any medical reasons, 25-41% are premature (Shaheen, Truskowsky, & Barbero, 1968; Ambuel & Harris, 1963). Similarly, the premature or seriously ill infant may be three times as likely as a normal full-term infant to be the object of child abuse (Klein & Stern, 1971). Also, a serious illness in early infancy may have a more lasting impact on the parents than on the child (Green & Solnit, 1964). Clearly the problems of attachment between parents and seriously ill infants deserve further exploration. In their review of this research area, Sameroff and Chandler (1975) observed that "studies on high-risk infants have selectively focused attention on either reproductive or caretaking aspects of these casualities." The results of long-range predictions made from these studies have been disappointingly poor. This may be due to the inherent limitations of unilateral retrospective studies of what appears to be an evolving transactional process. In contrast to the retrospective study in which the outcome is clearly known, a prospective study requires the selection of theoretically important variables which may lead to the same or similar outcomes. A major variable of theoretical interest in this research is parental attachment, the vagarities of which have been blamed for a wide range of developmental disorders. Yet at this point in the study of the parent-infant inter- action in the early neonatal period, the presence or absence of parental attachment is presumed to be a factor in exacerbating the developmental disadvantages of these infants. However, this relationship has not been clearly established and, given the predictive failures of many studies of "high-risk" infants and parents, the long-range consequences of parental attachment must be considered conjectural. Nevertheless, a first step in unraveling potential consequences of parental attachment to premature or seriously ill infants can be made by examining the very early relationships between these infants and their parents. CHAPTER II REVIEW OF THE LITERATURE The research on the development of parental attachment to premature or seriously ill infants is not extensive, though it has focused rather clearly on two issues. The first, explored by Leifer, Seashore, and associates (Leifer et al., 1972; Seashore et al., 1973) and Klaus and Kennel (l970a,b,c,d) has tried to determine whether there exists in humans, as in many animal species, a critical period of attachment which is disrupted by the separation of the new mother from her premature or sick infant. The second perspective, developed by Gerald Caplan and associates, has examined parental reactions to prematures as an example of crisis behavior in an effort to correlate crisis management to mental health outcomes (Caplan, Mason, & Kaplan, 1965). The Critical Period Approach The search for a critical period of human attach- ment is based on extensive evidence of such periods in other species, which is extensively reviewed elsewhere (Rheingold, 1963). When it is so clear in infrahuman species that the lack of mother-infant contact can pro- duce grossly incompetent mothering, it is plausible to wonder whether there are deleterious consequences from the separation of human mothers from their neonates. To test this hypothesis Leifer and associates (1972) contrasted the behavior and attitudes of three groups of mothers. The separated group of 22 mothers had no physi- cal contact with their premature infants from birth until the time they were transferred from the intensive care unit to the discharge nursery. The group of contact mothers entered the intensive care unit within two to three days after birth and were allowed to handle and care for their premature infants as much as possible. The third group of mothers delivered full-term normal babies and had contact with their infants only at feeding times, in accord with traditional hospital policy. These groups were observed in caregiving activities prior to discharge and at one and four weeks thereafter. There were no significant differences between contact and separated groups on any of the behavioral measures such as holding, affectionate touching, ventral contact, glooking, and talking. Thus, the observational data did not reflect any consequences of maternal separation. In this study it was also hypothesized that the separated group of mothers would have lower maternal self-confidence than the contact mothers (Seashore et al., 1973). However, separation had no measurable impact on multiparous mothers and ambiguous impact on primiparous mothers. The authors found a significant difference between primiparous separated mothers and other mothers, but this may have been an effect of practice rather than separation. The difference between these groups reached significance at two observations, the day the baby left the intensive care nursery and entered the discharge nursery, and the day before discharge. Thus, the first observation was a comparison of mothers who had had con- tact and helped care for their infants for an average length of 36 days with mothers who were handling their babies for the very first time. Similarly at the second observation the contact group had been caretaking for 46 days and the separated group for 10 days. As one might expect from a practice effect, as distinct from an impaired ability to form an attachment, there were no differences between the separated and contact mothers at one month after discharge. Perhaps the greatest weakness in the study was that the contact mothers did not, in fact, have that much (more contact than the separated mothers. Unfortunately, accurate visiting records were not kept but it was esti- mated that the contact mothers visited the intensive care unit only once every six days to handle their infants. Incidental data, however, suggest that separation between mother and infant may have had an impact which was not captured in the mother-infant interaction behaviors: there were six divorces in the 49 couples, five in the separated group, three of the four mothers who tried to breast feed failed, and two mothers, both in the separated group, gave up custody of their infants. Whether these were the result of separation, as the authors suggest, or a more complicated interaction of the separation, variations in individual visiting patterns, and prior low maternal self-confidence cannot be answered from this study. It does suggest, however, that there may be greater and more complex consequences of prematurity for the family than the samples of mother-infant inter- action within these groups might indicate. In a similar study, Klaus and Kennel compared early and late contact mothers of premature infants (l970b,c). The early contact mothers cuddled their infants more and spent more time in en fagg_looking, defined as "the mother's face in such a position that her eyes and those of the infant meet fully in the same vertical plane of rotation" (l970b). At one month after . discharge there were no significant differences between groups. It is unclear why Klaus and Kennel obtained some significant results since their sample size was even smaller than Leifer's. It may be that their visiting frequencies were higher since they described fairly assertive and ingenious approaches to encouraging the mothers to visit their infants (Kennell & Klaus, 1970b). Testing the same hypothesis on a group of full- term mothers rather than mothers of prematures, Kennel and Klaus were able to establish clear and lasting dif- ferences between an extended contact and control group (Klaus, Jerauld et al., 1972). The 28 primiparous mothers of normal infants were assigned to two groups according to the day of delivery. The extended contact group of mothers were given their infants for an hour within the first 3-4 hours after birth and five addi- tional hours for the first three days for a total of 16 more hours than the control group mothers who only glanced at their babies after birth, made a brief visit at 6-12 hours, and then 2—30 minute visits at feeding intervals. At one month the extended contact mothers showed significantly more 33 fagg_and fondling, were more reluctant to leave their infants with others, and showed more soothing behaviors. Even at one year the extended contact mothers showed more soothing behaviors ,during the physical examination of their children and expressed missing them more when they had returned to work or school (Kennell, Jerauld et al., 1974). There are a number of possible hypotheses to explain the more significant results obtained with full-term infants rather than prematures. One of the stronger possibilities, however, is that in this latter study contact was controlled precisely, in contrast to simply allowing the mothers to visit at the intensive care nursery. This clearly suggests that the amount of con- tact between mother and infant as well as the personality correlates of different visiting patterns are variables which can no longer be ignored. The Crisis Theory Approach Caplan, Mason, and Kaplan (1965) conducted four studies of the parents of prematures, working from the perspective of crisis theory. Within this framework they hoped to tap four groups of factors: the influences of the situation itself (e.g., the degree of contact), the pre-existing personalities, cultural influences, and interactions with significant others. In their studies, however, the pre-crisis personality and cultural factors were not explored systematically. In the first study, Caplan (1960) compared the case records of "Healthy Outcomes" and "Unhealthy Out- comes." The three discriminating variables in the pat- terns of parental reactions were their cognitive grasp of the situation, the way they handled their feelings, and their ability to obtain help and support. In the "Healthy Outcome" cases the parents aggressively sought information about their baby without avoiding or denying 10 the extra dangers and burdens of having a premature infant. They could make a reality based appraisal of the situation without relying on global beliefs that every- thing would be either good or bad. In the "Healthy Out- come" cases there was a "continuous awareness of negative feelings throughout the crisis" (1966, p. 153). The Healthy Outcome parents were able to seek out and receive support from family and community while the Unhealthy Outcome parents only helped one another in their mutual denial of difficulties. The predictive validity of these hypotheses was tested on 28 mothers (Mason, 1963). Predictions could be made in only 19 cases, of which 17 correctly matched clinical judgments of mother-infant interactions at six ‘weeks. Unfortunately, the outcome criteria were largely unspecified so it is difficult to know-what was predicted by what. To refine the bases for predicted outcomes, Kaplan eand Mason (1960) further defined the tasks confronting the mother of a premature infant: to express anticipa- tKDry grief over the possible loss of the infant, to acknowledge her feelings of failure for not having a filll-term baby, to resume emotional investment in the irlfant, and to accomplish the instrumental functions of Hmouo Ham MOM Hm I z «mumsHHH mo muenm>mm .No xmz .musofle H on nomad sow mm H z “moussfle m on nomad Hem mm H z «msflxooq How mm H z amcwoosoe MOM om u 28 msflommm ummmno pom monsoomflo us was How mswaaouuooo .wuoz 35 om. ma. o~.n mm. mo. s~.n mm.n em. eo. monsosoe muocoHuomeme om.- e~.- -.- o~.u No.- .me.: «me.: he. mm. ossrooo mass 1.. He emu we we me We 9e In x TLA 1q+t. uvx rAe. e}: «as mg” mg” ua 83m 3 Sd 51. 1. 1.? 7:9 31 UP 80 T. U.U. 9 UI UI SI. 81 Hz 1 1. m. sh. MK n w... o mHoH>momm o e W m. w mowowmm J I. u I O u moanmwno> amoeomz posmoH mmuofl>momm mofiomom Hmsumumz pom meanneum> Hecate: nonmcH mo mGOwuwamHHoo o manta 36 Medical History and Maternal Contact These variables are unrelated, except that low birth weight infants were fed less often, a consequence of the longer period before these infants were large enough to be bottle fed by mothers. Medical History and Maternal Personality (see TabIe 7) Mothers were more Ignoring and Extrapunitive of males. When controlling for age, sex, and parity, a high Apgar at 1 minute is significantly associated with high Intrapunitive, Negative Attitudes, and Worry. These correlations remain significant even when Severity of Illness has been partialled out, suggesting that maternal feelings are far more tied to the condition of the infant in the early neonatal period than the subsequent course of the illness. Maternal variables are more strongly associated with the birth condition (sex, prematurity, and birth trauma) than to the source or duration of the illness. Other relationships are in the opposite direction than hypothesized. The fact that mothers of low birth weight infants show more visual involvement demonstrates heightened attachment. It should be noted that the staff in this NICU very actively encouraged parents to visit their infants from birth onwards, in sharp contrast to the traditional period of separation between a preemie m vac a v e do. mo. .uoaouaum> Hoowoea Honuo Has now an I z “muosaAH mo muwue>om .No as: .ouscde A no sound you an I z «nuances m um momma How aw I z «moanuwuu> h0aadd0nuom Hague Han Ham hN n z “huwawuuom one .soauuoumoa .sumwqu How mN u z “coauouuuauom depend: Mom vN I as sowuoameoo euwoscofluuosv no one u.usdmsfi How mowaaouusou .ouoz 37 m~.n Hm. va. no. mo. some. mm. wN. vn. stom. ~H. «a. no. mo.: Ho.u xom ma. ma. mo.u No. mN.u mo.u o~.| ca. mu. o~. mo. m~. ow. cw. Ho. assess nuuwm ma. no. mo. Ha. va.u ma.u H~.u no. «N. ma. so. ~N. em. cm. 00. mod Husowusumoo -.u Ho. mm. oH.I ea. «0.: tree. Ha. Ho. no. ha. vH.u no.1 nH.u mo. .sfla m named v~.I mo.n we. Ho.l mo. Ho. came. tree. oa. mo.n crew. on. mo. mo. an. .s«5 a named mN. No. ov. mm. an. Ad. no. ca. ow. vo.u hm. mm. ma.n ~m.| mu. nuosHHH mo huwuo>om mm. mm. wo.n ma. Hm.n oH.n oa.n hm. tam. mo. an. mm. ha. «N. ha. ouoo a>wnsousu huuaaum :4 when «A. mo.n on. ma. mm. an. Ad. mo. ma. ~H.I ow. aw. N~.n me. am. we assess: an. co. ma. mo. no.n oo. ma.n no. ~H.I Ho.u ma. em. we. mo. ma. Housuaoumx so memo m a m w. m m M... m. m. m n m w w u m w m u s e re: s 1 1 3 J 1 u n;b e s x .d 0 d u n I. d a I J .M T. O T. P I 3. T. I a o u s.+ o s e e a 1 44:. J t. e a d u a m_e u s d .a e r. n.: n T. 3 s 3.s o. .L s m m a. u “an I t. .A s. 1.9 e t. r. .b 91¢ 3 r m .4 w m n. .u a s x m 333.3, o M. M. assess: a a oaauflna> huaascouuom Housman: sumanmqus> mafiawcouuom Huououuz use nmanuwuo> Hoodoo: unumsH mo unawuuaouuoo h 9.509 38 and his parents. The absence of clear personality cor- relates of Looking suggests that the increased looking may be due to the stimulus value of an extremely tiny, helpless infant whose entire appearance is sharply dif— ferent from the popular image of babies. The unexpected association between low Apgars and low maternal distress begins to suggest that mothers of sicker infants must deny their distress to such an extent that they even express lg§§_worry than is medi- cally appropriate. Medical History and Paternal Contact (see Table 8) As predicted, fathers of sicker babies make more contact. Fathers call significantly more often and have more total contact with infants who scored poorly on the Apgar at 5 minutes. Fathers also called more frequently if their infants spent more time in Primary Intensive Care. Medical History and Paternal Personality (see Table 9) Low gestational age is significantly associated with low Depression and Anxiety. When Severity of I11— ness is partialled out, the essential association between prematurity and low distress remains. In contrast to prematurity, medical trauma is associated with increased paternal distress. While only . I Q Hoo v «as . I Q Ho v s« mo. w as .mmaomfium> nonuo Ham How Hm I z ammmoHHH mo >uanm>om .No xmz “owe a on usage new mm H 2 “see m um momma Hem mm H z “moaomwum> uomuooo smoumm MOM mm H zs .unommcouu was mmumsomwo us was MOM mcwaaouuoou .muoz 39 NN.I mm. mm. mm. mo. mm. mo. Hm.l Hm.l mH.I muflmw> van t mHHmo mo Seemsvmum HN.I mm. mm. mm. Ho. ma. mo. ma.l Nm.I v0.1 muHmH> m0 mocmsvmum eH.I mm. roe. em. NH. son. as. oo.- me.u ~e.- neaoo no mososoouo as «ea e To sure 9 ee_ elm... Mme TIM. SW IN. x In 121K x As .IJ as In m6 m6 nae e.em.s sad 6.4 3 e .99 Tie 9.4 use n. I. NIH e 9.4 u.i u_i set seer. so 1 .4 3 s.+ .Ixnu e r. A m mu m muofl>momm o o e uoossoo J u I Hmsumumm mmHooHum> amoeomz DesmcH mms0fl>msmm uomusou Hmsnmumm new meannenm> Hmowomz unemoH mo wooeumamuuou m mHQMB 4() Table 9 Correlations of Infant Medical Variables and Paternal Personality Variables Infant Medical Variablesb Paternal 3' a Personaligy 3 III Variables '3 H N '3 o “5‘ In I: O o a. 0 o 0 O U > >1 43 «U or! I: I! f: w-I 41 II a s u u c>u 5 vlm ~40 so go 3m ‘3 5: on a e no mg mg m + a 0 II 3 g. 3‘ "" g. 3 9 .5 Q. D: O H 0 «I 8 d I: 0 H «a 2M 45H 84 4g}? ea 2, oH ma Depression .05 -.49* -.22 .61:* .55: .35 .14 .56* .31 Anxiety .13 '-‘3.. -.ll .46 .51 .25 .09 .36 .17 Hostility .00 -.56 -.14 .24. .39 -.07 -.06 .25. -.17 Fearful .22 -.18 .09 .46 .61** .08 -.06 .45 -.02 Neg. Attitudes .07 -.19 .13 .25 .27 -.12 -.10 -.16 -.30 Ignoring .32 .19 .26 -.21 -.24 .03 -.22 -.l9 -.l8 Irritable .27 -.10* .15 .30 .26 -.07 .21 -.37 -.02 Worry -.21 -.56 -.31 .30 .44 -.10 .09 -.09** -.14 Intrapunitive .14 .34 .30 -.01 -.06 -.18 -.25 -.65 -.37 Extrapunitive .08 -.16 .16 .20 .39 -.04 -.09 -.13 -.26 Stress .21 -.06 .30 .23 .36 -.15 -.08 .21 -.16 Responsiveness .15 -.13 .05 .16 .11 .20 .14 .6o** .34 Marital ** Adjustment .14 .60* .23* .14 -.16 .17 .21 -.12 .29 Planned .36 .48 .54 .22 .05 -.03 -.35 .14 -.26 Response to Conception .07 .31 .19 -.03 —.30 .12 -.18 .34 -.02 Note. Controlling for age at discharge and sex of infant. aN s 21 for paternal personality variables. hN - 19 for marital adjustment; N - 28 for Apgar at 5; N - 29 for Apgar at 1; maximum 02; Severity of illness; N = 31 for all other medical variables. . it 41 8% of these correlations are significant, several are significant at the p E .01 level and the direction of the relationships is relatively clear. Low Apgar at 5 minutes is associated with high Worry and low Marital Satisfaction. When controlling for age, sex, and parity, Days on Respirator is correlated with Depression; Days in Primary Intensive Care is Associated with high Depres— sion, Anxiety, Fearfulness, and Responsiveness. For both fathers and mothers, prematurity showed positive correlates while the correlates of medical trauma were divergent: mothers of low Apgar infants were less negative and worried, while fathers were more worried, made more contact with infants, and reported more anxiety, fearfulness, and worry in response to subsequent medical difficulties. Assuming that mothers are more intensely invested in the infant perinatally than fathers, the experience of having "failed“ by producing a dangerously ill infant is such an overwhelming experience that they are forced to use more denial in coping with the crisis. In contrast, fathers, acting in the instrumental role suggested earlier, may deal with their distress by making more contact with the hospital and are in a position to operate with less denial. 42 Infant Competence and Parental Variables Infant Competence and Maternal Feeding (see Table 10) When controlling bottle feeding, number of people present during the feeding, sex, and age, several impor- tant relationships emerge. Maternal Looking is associated with high infant fixation on the first three targets (r=.74, p E .001) and maternal Touching with high fix- ation on the first face (r=.53, p 5 .05) and face mean (r=.66, p 5 .01). Whatever the causal origins of these associations, they suggest that a mutually reinforcing system of interaction has already developed before the infant is discharged from the hospital. The mother who Looks and Touches more has a baby who attends longer to faces. Infant Competence and Maternal Personality (see Table 11) In general, low orientation and fixation are posi- tively correlated with low maternal distress. This find- ing closely parallels the association between low Apgars and low maternal distress. In fact, mothers of infants who fixate poorly on faces are more Ignoring, Extrapuni- tive, and report less Stress. It seems likely that these mother/infant pairs are less attached: Ignoring mothers express less interest in social interaction with infants and also Touch their infants less often. Conversely, . I a doc v use . I m Ho v at 3. w 6. .uoaoowuo> sowuoxwm Hoouo Has How am I z «udowuu HammooOOSuoo one cocoouuo monouoam new on n z “sowuovcowuo muouaood How em I z «coauouoowuo Hosow> Mom m~ I n .moaxooq u0m m~ I z «mownosoa How ow I 2o .oouoououow Menace sou son: and: oamoom mo Hones: pom encououm mamoom .mmooaaw mo muauo>om .uowooom mauuoo .oms How mswaaouuoou .ouoz 43 vc.I no. sow. vo.I mm. 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NH. eemm. soNnuouooo In .3: ass a as 8 SJ Ia Lam mail Wd 0V 0A n... e... in we 3 m... P... 3 mew. mew 3. um. um 9.u “.9 9 s 9 3.3 1. 4:9 9 e.9 9 9.4 9.I .en In W W4 4 M d4 £3 41 a. un u4 us 80 a T T. T. 91 1.0 3.... . I .. m m m e... .3 e n m. m. t. r. smudndwuo> m. w m huHHooOuuom T. QUOHd—Uflg OUGUHOQEOU HGMNGH moanoaus> auHHMoOmuom anemone: one unsound: oocouomaoo poomoH mo osowuoaouuoo HA manna 45 infants who fixate poorly on the first face have mothers who Touch less often; infants who fixate less on the first three targets (two of which are faces) have mothers who look less often. The interactional process between these mothers and infants seems impaired. In contrast to the original hypothesis, it seems incorrect to attribute low distress (e.g., Depression and Anxiety as distinct from Ignoring) to nonattachment. Rather, these data suggest that the high competent infants have more depressed, anxious, and stressed mothers pre- cisely because the attachment has taken place. If the mother were not attached, she would express less distress because she would have less investment in her sick infant. Infant Competence and Paternal PersonaIity (see TaBle IZY As with mothers, fathers' personality measures were tied to infant competencies, yet they show a dif- ferent pattern. High fixation is associated with low Irritable and high Responsiveness scores. This suggests that high infant fixation may be an elicitor of respon- siveness in fathers and an inhibitor of irritability. In contrast, the infant who orients well to both people and sounds around him may appear to be a more active, "normal" infant. As a consequence, attachment may increase (with its concomitant anxieties) while the role demands for a highly involved, protective father may 46 Ho. no. a v at I n v a .QOHouHHo> 90Huome Macao HHo How mN I z .uHoHua Homouooosuso one cocoouud nousuOHm How on I z «ooHuouGOHuo muouHose How mN I z «oOHuouoOHuo HssuH> sou mN I an .ooHooHus> muHHosOuuom nonuo HHs HN I z «samenesnod HouHHoz Ham «H I 2o uuosHHH no huHuobon one .xou .oms msHHHouuooo .0902 em. on. HN. vH. nv. No. mo.I mN. vN.I ON. hn.I No.I mn.l noHumooaOU o» oasomaox mm. hH. NH. vo. aom. mo. NH.I vH. OH. Hv. mo.I mo. amm.I voccde nN.I so.u No.u on. «n. NH.I No.u we. me.u sH.I mm.u «N. we. usosuusnos assess: cv. Hm. mv. 5N. aH. Hv. NH. NN. com. one. No.I ov.I ccmw.I mmoafl>Hmcomumm on.I hH.I mo. mH.I MH.I mH. no. He. HN. vo.I on. no. HH. unouum NN.I Hm. oo.I oo.I vv.I ac. hO.I wo.I mN. NN. mm. «av. vN. o>HuHcamouuxfl co. mo. m°.I aN.I chm.I No.I oH.I vH.I mo. vH. cN. «av. mH. o>HuHG5mouucH vN.I no.I MH.I mm.I mn.I oN. hN.I mN.I mo.I wH.I me. uH. MN. KHknot Ho.I vn.I ac. mv.I MN.I «son.l Hv.I mo.I HN.I stow.l NN. vv. ch. OHQUHHHHH mo.I NH. mo.I on. we. mo.I oo.I mo. mo.I wN.I No.I vN. QH. maduoauH uH.I 9N. mv. wo.I co. NN.I 0N.I vH. oo. mo.I MH. MN. Ho. nousuHuud .moz ch.I NH.I v°.I vv.I mo.I Hn.l NH.I mo.I mN. on.I amv. mm. mm. Hnwudah Hm.I NH.I HH. ao.l ho. oo.l no. No. NO. mo.I co. vH. mH. hUHHHumom NN.I NH.I HH.I mH.I vo. MN.I mo.I no. no.I Hn.I 5H. no. «em. uuoncfl mN.I Hv.I mo. mN.I No. NN.I vo.I no. no. Nn.I aH. H°.I nv. :OHuloumon In as as... .a as S S... I: mam In. via 0V 0A H... e: 3.... me. an en an a... mum. mum .3. pm. we o.n m.. 9 “.9 e.s m.I 4:9 9 9.9 9 9.4 9.I e.n to m m 4 w M4 £4 4t 4 un u4 ufi ea 1 m. m. m. 3 no u s m. e u u u as an .4 someones; m. P P m... m... huHHocoouom m. u u Hsououom nauseous: oooouomaoo seamen aoHndHHo> huHHosouuom Hosuouom use monsoon! oosouomaoo NH GHnuB usuwsu no oOHuoHouHoo 47 decrease (with an attendent decrease in responsiveness and increase in irritability). This would explain the finding that high orienting infants have fathers who are more Anxious but also less Responsive and more Irritable. Summary of Findings 1. Infant auditory and visual orientation were unrelated to measures of visual fixation. 2. Infants with high Apgar scores at 1 minute fixated longer on the first presentation of each target. 3. Infants who had required longer hospitaliza- tion showed a more transient quiet-alert state. 4. Maternal looking and touching during feeding were not significantly related. 5. Breast feeding mothers touched their infants more often. 6. Mothers who scored high on Ignoring touched their infants less often during feeding. 7. Mothers looked more at low birth weight infants rather than less. 8. Maternal contact behaviors were unrelated to feeding behaviors. 9. Frequency of maternal contact was negatively related to the length of hOSpitalization, commuting dis- tance to the hospital, and levels of stress, hostility, and fearfulness. Mothers who planned their babies visited more often and Responsive mothers fed more often. 48 10. Fathers of sicker infants made more contact and showed more distress. They were more depressed, anxious, fearful, and responsive. However, fathers of infants who were more premature showed less Depression and Anxiety. 11. Mother and father pairs showed similar levels of depression, anxiety, hostility, irritability, extra- punitiveness, and marital adjustment. 12. New parents reported less distress. Primi- parous mothers scored lower on hostility, anxiety, and fearfulness. Their mates also showed less depression, anxiety, and hostility. 13. Mothers of infants with high Apgar scores were more intrapunitive, worried, and had more negative attitudes toward Childrearing. 14. Infant competence, specifically high fixation on pictures of faces, was related to high maternal looking and touching. Infants who fixated poorly on faces had mothers who were more Ignoring and Extrapunitive. 15. High infant fixation was associated with high paternal responsiveness and low irritability, while high orientation competence was associated with less responsiveness and more anxiety and irritability. These findings do not confirm the hypothesized association between frequency of contact with the infant and feeding behaviors. While visiting, looking, and 49 touching are all attachment behaviors, they operate more independently than expected. The second hypothesis concerning the intercor- relation of parental behaviors and personality was con- firmed. Ignoring mothers fondled their infants less; fearful, hostile, stressed mothers made less contact with their infants. In contrast, fathers who reported distress made more contact with their infants. The third hypothesis concerning the correlation between parental attachment behaviors and infant compe— tence was confirmed: parental involvement and attachment is related to infant competence. The fourth hypothesis was not confirmed: attached parents showed greater anxiety, worry, and general dis— tress. Becoming attached to a sick infant clearly involved significant distress for these parents. CHAPTER V DISCUSSION An underlying assumption in this and other studies has been that premature infants are at a greater risk psychologically, presumably because of perinatal trauma, social labeling, or impaired parental attachment. This study has focused on this last element: the vicissitudes of parental attachment to premature and seriously ill infants. Since this sample does not include a comparison group of normal, full-term infants, the question which can be explored is whether greater prematurity is related to more impaired attachment. This restricted focus does have the advantage of controlling the effects of social labeling, since all infants in the study had been defined to the parents as high-risk infants. The prolonged separation between parents and infants in the neonatal period has been suggested as the factor which characteristically impedes parental attach- ment to premature infants. It is therefore important to note that this hospital actively encouraged parental contact in the intensive care nursery. The staff's 50 51 commitment to facilitating parental involvement was so effective that mothers visited three times as frequently as the free contact group of mothers in the Stanford study (Leifer et al., 1972). Within this supportive environment, the degree of prematurity, as distinct from the level of medical insults, seemed to be positively related to more consistent maternal visual attention. While this attention may have been motivated by a mixture of anxiety, curiosity, and fear, it does demonstrate involvement rather than the predicted disinterest and nonattachment. This unexpected finding suggests that a lower gestational age need not be a greater impediment to parental attachment. This is congruent with Parmelee and Haber's argument (1973) that prematurity, independent of perinatal trauma, need not have deleterious conse— quences. The question which then arises is whether medical insults are associated with impaired attachment. In Klein and Stern's study (1971) of the high incidence of child abuse among premature infants, 75% of the preemies in their small sample had had "major neonatal problems." It seems important, therefore, to try to unravel the independent effects of medical insults. In this sample, sickness was clearly associated with greater involvement, distress, and worry for fathers. For mothers, early medical difficulties (low Apgars) were associated with 52 less distress, presumably because they felt the crisis even more acutely than fathers and therefore denied more. The fact that these mothers continued to express less distress even when their infants were ready to be dis- charged, though, raises the issue of whether this con- tinued denial indicated less attachment. This interpre- tation is congruent with the clinical observation of parents of premature infants: a low level of parental anxiety before discharge is predictive of poor outcomes after discharge (Mason, 1963). Attenuated maternal attachment, therefore, seems to be a correlate of medical difficulties (presumably due to a protective withdrawal from a dangerously ill infant) rather than prematurity 295.22. While there are ambiguities in interpreting the association between medical variables and parental behaviors and attitudes, the situation is even more com- plex when considering the molar concepts of infant com- petence and parental attachment. It seems relevant to reconsider both the difficulties of operationalizing these concepts and assessing them at one point in a highly turbulent period for parents and infants. It is clear from the data that attachment behaviors were unexpectedly independent: there was only a low level of association between looking and touching and no association with the frequency of con- tact with the infant. 53 The degree of independence of these behaviors and the subtle complexity of the feeding situation was evident in the observation of a very distressed mother with her four-day-old infant. During the feeding she stared at her infant without interruption (thereby attain- ing the highest possible score on Looking) while her free hand slowly moved completely away from her infant's body and formed a tight fist which remained rigidly in front of her until the end of the feeding. The mother was Oriental, seriously ill herself, and seemed anxious about the feeding even before reluctantly consenting to the observation. It appeared to the observer that this mother visually fixated on her infant to avoid making eye contact with the observer rather than out of affection for her infant. In fact, her more basic feelings about her situation seemed to be acted out, perhaps uncon- sciously, by the clenched fist. This dyad dramatically illustrated principles which appeared to be operating in some of the other cases as well: (a) Touching and Looking can be negatively associated, (b) Touching seems a far less self-conscious expression of affect, (0) high Looking might simply be a method to avoid looking at the observer, expressing anxiety about the observation rather than involvement with the infant. While much of the independence of Looking and Touching could be attributed to these factors and 54 instability of the feeding observation, the fact that the behaviors are more related to personality variables than each other suggests both that: (a) these indi- vidual behaviors have a somewhat different meaning for a mother and (b) these meanings are different for dif- ferent mothers. This is clearly the weakest link in attempting to operationalize a concept such as attachment when it is ultimately defined as what an infant means to his parent. Yet, whatever the idiosyncratic meanings of these behaviors, it is still possible to link the presence of these individual behaviors with concepts of involvement and ultimately attachment. There is an analagous difficulty in the operation- alization of infant competence. In addition to the problem of generalizing from one assessment to broad behavior traits, this study did not directly tap the link between infant behavior and parental perception of that behavior. Specifically, some parents seem oblivious to their infant's lack of responses while others failed to notice highly accurate, stable social responses. This variability in parental perceptions raises two unanswered questions: 1. What factors influence parental perception of observable competencies; and, 2. What meanings do parents give to specific behavioral competencies? 55 It was clear that fathers reacted differently to infants who oriented competently than to those who attended com— petently, suggesting the tentative inference that the more mobile orienting responses signalled that the infant was "normal" and out of danger. Yet beyond the difficulties inherent in research- ing such concepts as infant competency and parental attachment, this study clearly indicates the need for a more complex model of the attachment process with premature and seriously ill infants. While the simple hypothesis was advanced that parents who felt less dis- tress would attach more readily, it has become evident that there are at least three distinct processes operat- ing simultaneously during this period: 1. the temporal development of attachment in the context of medical danger and infant competence, 2. the expression or denial of distress during different phases of the perinatal period, 3. the assumption of parental roles with respect to a sick infant. While the correlation design of this study does not allow conclusions about temporal or causal relationships, it seems appropriate to advance a process model which could have produced the data in this study. These pro- cesses, therefore, are not proven by, but are congruent with, the findings of this study. 56 The temporal relationship between the first two processes, the development of attachment and the expres- sion of distress, seem particularly important in inter- preting the unexpected association between high distress and high attachment. While high prenatal distress may have impeded the subsequent development of attachment (resulting in the hypothesized association between high distress and low attachment) this temporal relationship could not be examined since distress was measured only at discharge. The fact that low distress and low attach— ment were associated at discharge suggests an alternative temporal relationship: parents whose denial is high even at discharge have been less able to attach to their infant and consequently express less concern and distress about their infant's condition. These parents are often described by the staff as "foggy," difficult to make contact with, and oblivious to the medical difficulties of their infant. While they express positive attitudes toward their infant, the staff experiences more diffi— culty connecting with these parents. It seems likely that these parents have a similar difficulty connecting with their new infant. Their denial operates both on a cognitive level, so that they remain uncomprehending of medical difficulties, and on an emotional level, so that they express little anxiety or concern even when their baby is about to be discharged into their complete responsibility. 57 While Caplan et al. (1965) established that the parents of premature infants who expressed less distress had more difficulty with their infants after discharge, the present study demonstrates the additional link between expressed distress and infant competence: highly competent infants have parents who show more concern and distress, presumably because they are more invested in their infant. Unattached, ignoring mothers touched their infants less often and in turn had infants who fixated more poorly on faces. Similarly, infants who oriented less had parents who were less Depressed and Anxious. It seems likely that these parents are similar to the low anxious parents in the Caplan study who ultimately had more difficulty after discharge. Perhaps the most striking difference between Caplan's findings and the present study is in the inter- pretation of visiting data. While Caplan found visiting frequencies to be a better outcome predictor than all Other variables combined, visiting frequencies did not emerge as strong, central variables in this study. It is likely that this difference can be attributed to dif- ferent hospital policies regarding parental visiting. An examination of the very low visiting frequencies reported by Caplan suggests that parents were neither allowed inside the intensive care nursery nor actively encouraged to visit. While one-third of the mothers in 58 Caplan's study visited the hospital fewer than two times in the last two weeks preceding discharge, no mothers in the current study visited so infrequently. The explicit hospital policy at the E. W. Sparrow NICU was to encourage parents to visit frequently, even if that required per- sonal phone calls from the nurses or doctors. Any parents who had visited as infrequently as the bottom third of the parents in Caplan's sample would have been counseled by the medical and social service staffs to facilitate visiting. Given this general encouragement of visiting and intervention in the case of infrequent visiting, visiting frequencies are not "pure" measures in the present study. Rather, they reflect an interaction between parents and hospital staff in addition to the parent-infant relationship. Caplan's caveat, that the predictive powers of visiting frequencies " . . . might be invalidated by . . . policy changes in regard to mothers' visiting" was borne out (1965, p. 158). Another complication in understanding the attach- ment process is coming to terms with the differing experiences and role expectations of mothers and fathers. The data give some indications of role complementarity during this difficult period: fathers play a more involved, active, protective role when their child is particularly sick, even to the point of calling the NICU more often in response to their wives' anxiety. This 59 makes the interpretation of parental attachment more difficult since, as in this example, one spouse may act for the other, leaving the incorrect and otherwise puzzling conclusion that there was no relationship between the sickness of the infant and maternal contact behaviors. If the father's role is to be particularly active when his infant is sick, the converse may be to withdraw as his infant becomes more socially responsive. This would explain the finding that high orienting infants have fathers who are anxious (because they have become attached) yet assume less responsibility for infant caretaking, in accord with the more typical paternal role relationship with a small infant. In many ways the process of parental attachment to premature and seriously ill infants is fundamentally unique: the infant is immediately labeled as sick with the possibility of dying, parents have less contact with their infant in the neonatal period, and there is a lengthy moratorium on the parental assumption of full caregiving responsibilities. Yet within this unique context there are variables which appear to operate much the same as with healthy full-term infants. Specifically, there is a similar relationship between infant responsive- ness and maternal behaviors. In a sample of healthy infants, Moss and Robson (1968) found an association between high maternal vis-a-vis and, among girls, 60 fixation time for social stimuli at 3 1/2 months. The present study demonstrates additional correlations between maternal looking, touching, and high infant fixation on social stimuli at an even earlier age. These relationships are evident even though these mothers had less contact with their infants. It seems, therefore, that infant competence is a component of the reciprocal social interaction which enhances parental attachment to both healthy and sick infants. Although the data in this study were gathered at one point in time, just before the infant was dis- charged from the hospital, they still allow us to make some speculations about processes which change over time. The development of attachment, the phasic handling of distress and denial, and the assumption of parental roles appear as highly interwoven processes even before these infants leave the hospital. A longitudinal study, with a series of observations before and after discharge, would be necessary to unravel the development and inter— action of these processes. However, even within the limits of the present data, a number of conclusions can be advanced: that prematurity is not necessarily a threat to attachment, that infant competence is related to parental attachment even in the very early neonatal period, and, finally, that less distressed parents appear to be those at greatest risk as nonattached parents. APPENDICES APPENDIX A RESEARCH INSTRUMENTS APPENDIX A RESEARCH INSTRUMENTS BRAZELTON NEONATAL ASSESSMENT SCALES Orientation-Animate Visual 1. 2. 3. 4. 5. Does not focus on or follow stimulus. Stills with stimulus and brightens. Stills, focuses on stimulus when presented, brief following. Stills, focuses on stimulus, follows for 30°arc, jerky movements. Focuses and follows with eyes horizontally for at least a 30°arc. Smooth movement. Loses stimulus but finds it again. Follows for two 30°arcs, with eyes and head. Follows with eyes and head at least 60° horizon- tally, maybe briefly vertically, partly continuous movement, loses stimulus occasionally, head turns to follow. Follows with eyes and head 60° horizontally and 30° vertically. Repeatedly focuses on stimulus and follows with smooth, continuous head movement horizontally, vertically, and in a circle. Follows for 120° arc. Orientation-Animate Auditory 1. 2. 3. 4. 5. No reaction. Respiratory change or blink only. General quieting as well as blink and respiratory changes. Stills, brightens, no attempt to locate source. Shifting of eyes to sound, as well as stills and brightens. Alerting and shifting of eyes and head turns to source. Alerting, head turns to stimulus, and search with eyes. Alerting prolonged, head and eyes turn to stimulus repeatedly. Turning and alerting to stimulus presented on both sides on every presentation of stimulus. 61 62 All potential subjects were given the following initial explanation: We're conducting a study of families who have babies here in the NICU. We know this is a difficult time for most parents but would like to understand better what things make this period more difficult or less dif- ficult for you and your baby. We hope that this infor- mation will help us to be more helpful to families in the future. Participation would involve filling out a questionnaire about how you are feeling, an observation of how feedings are going for you and your baby, and my showing your baby some pictures. If parents agreed to participate, they signed a research consent form and were given the questionnaires found on the following pages. The order of the instru- ments are as follows: 1. Multiple Affect Adjective Checklist . Post-Partum Research Inventory 2 3. Social Readjustment Rating Scale 4. Lock-Wallace Marital Inventory 5 . Demographic Data 63 Participant Number Date PARENT QUESTIONNAIRE In our research we are interested in finding out more about the feelings and attitudes of parents of premature infants. All answers will be confidential. Your name should not appear anywhere on the questionnaire. On the following sheet you will find words which describe different kinds of moods and feelings. Mark an X in the boxes beside the words which describe how you generally feel. Some of the words may sound alike, but we want you to check all the words that describe your feelings. Work rapidly. 1 C] active 2 D adventurous 3 C] affectionate 4 [j afraid 5 ' [j agitated 6 C] agreeable 7 C] aggressive 8 C] alive 9 [I] alone 10 D amiable 11 D amused 12 D angry 13 D annoyed 14 [j awful 15 D bashful 16 CI bitter 17 ['3 blue 18 C] bored 19 Cl calm 20 D cautious 21 Cl cheerful 22 C] clean 23 U complaining 24 C] contented 25 U contrary 26 Cl cool 27 C] cooperative 28 [:1 critical 29 [3 cross 30 C] cruel 31 Ddaring 32 E] desperate 33 Ddsstroyed 34 D devoted 35 Ddisagreeable 36 CI discontented 37 [j discouraged 38 C] disgusted 39 Cl displeased . 40 Clenergetic 41 [j enraged 42 Clenthusiastic - 43 C] fearful 44 C] fine 64 45 D fit 46 CI forlorn 47 Dfrank , 48 Dfree 49' C] friendly 50 [jfrightened 51 Dfurious 52 Elm 53 [jgentle 54 Uglad 55 Ugloomy 56 [jgood 57 Dgood-nstured 58 [jgrim 59 [Happy 60 Uhealthy 61 Dhopeless 62 Uhostile 63 Dimpatient 64 [J incensed 65 [J indignant 66 C] inspired 67 [:1 interested 68 C] irritated 69 E] jealous 70 Dloyful 71 Dkindly 72 Dionely 73 Client 74 CJloving 75 Blow 76 Dlucky 77 Umad 78 [I mean 79 D meek 80 [j merry 81 [:1de 82 Dmiserable 83 [jnervous 84 [10le 85 [jofiended 86 Donn-180d 87 Clpanicky 88 Dpatient 89 D peaceful 90 C] pleased 91 D pleasant 92 [j polite 93 D powerful 94 [j quiet 95 E] reckless 96 D rejected 97 El rough. 98 [3 and 99 C] safe 100 D satisfied 101 D secure 102 E] shaky 103 D shy 104 D soothed 105 C] steady 106 [j stubborn 107 C] stormy 108 C] strong 109 C] suffering 110 E] sullen 111 D sunk 112 El sympathetic A 113 CI tame 114 D tender 115 CI tense 116 D terrible 117 [j terrified 118 CI thoughtful 119 CI timid 120 CI tormented 121 C] understanding 122 El tmhappy 123 [J unsociable 124 CI upset . 125 C] vexed 126 CI warm 127 [3 whole 128 D wild 129 C] willful 130 CI wilted 131 [j worrying 132 [3 mm 65 The next set of questions are about bringing up children. Some of the situations mentioned below may not have hap- pened to you yet with your new baby. In that case, mark how you think you will feel when the situation comes up. Please answer all questions. There are no right or wrong answers. 10. 11. 12. 13. 66 I'm afraid I'll lose my temper with the baby. Often ; Sometimes ; Rarely : Never . I worry about whether my baby is getting the right amount or right kind of food. Often ; Sometimes ; Rarely ; Never . I anticipated having difficulty with this baby. Often ; Sometimes ; Rarely ; Never . I miss my freedom since having a baby. Often ; Sometimes ; Rarely : Never . When the baby cries a lot, I worry about what I'm doing wrong. Often ; Sometimes ; Rarely ; Never . I think that a young baby should be handled only as much as is necessary to care for him. . Strongly agree : Mildly agree ; Mildly disagree ; Strongly disagree . It would have been easier for me to take care of the baby if I didn't have to leave the hospital so soon. Strongly agree 2 Mildly agree ; Mildly disagree ; Strongly disagree . Even now I'm afraid that my baby won't be normal. Often ; Sometimes ; Rarely ; Never . I was happy when I found out that this baby was on the way. Strongly agree ; Mildly agree : Mildly disagree : Strongly disagree . Whenever the baby has a bowel movement I change the diaper: Immediately ; Within a few minutes ; Within fifteen minutes ; Within the hour : In an hour or so . I've wished that I could have someone to tell me if I am doing a good job in caring for my baby. Often ; Sometimes ; Rarely ; Never . Taking care of the baby leaves me on edge and tense. Often : Sometimes ; Rarely ; Never . I worry about how much clothing or how many blankets the baby should have. Often ; Sometimes : Rarely ; Never . 15. 16. 17. 18. 19. 20. 21. 22. 23. 67 I haven't had time to rest or relax since I came home. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . I'm sometimes still afraid that my baby won't live very long. Often ; Sometimes ; Rarely : Never . If I could only be more sure of myself in caring for the baby, I think the baby would be more relaxed. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . There's no use in talking to a baby until he gets a little older. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . I think that my family and friends could have been more helpful to me when I came home from the hospital. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . When my baby wets his diaper I change him: Immediately ; Within a few minutes ; Within a half hour ; Within an hour : Whenever I get around to it . I'd feel encouraged if people would tell me my baby looks strong and healthy. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . I think my baby will catch up with full term babies before too long. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . A baby's crying gets on your nerves after a while. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . I worry that my baby is sicker than the doctors and nurses told me. Often ; Sometimes ; Rarely : Never . 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 68 I worry that something might happen to the baby when I bathe him. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . We can't manage to go out since having the baby. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . If I had paid more attention to what I was told by doctors and nurses, I wouldn't have as many problems in caring for my baby as I do. Strongly agree : Mildly agree ; Mildly disagree ; Strongly disagree . The best way to bring up a baby is to put him on a regular feeding schedule from the beginning. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . I wish my husband would give me more help with the baby than he does. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . I'm afraid my baby will be terribly hard to care for at home. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . If my baby cries for something to eat. I feed him: Immediately ; Within five munutes ; Within fifteen minutes ; Only if it's time for a feeding . I've wished a doctor would see my baby more often so he could tell me if he or she was all right. Often : Sometimes : Rarely ; Never . Cleaning, diapering and caring for a baby can get a woman down. Strongly agree_ ; Mildly agree : Mildly disagree ; Strongly disagree . I am concerned whether the baby is growing as he should. Strongly agree ; Mildly agree ; Mildly disagree ; Strongly disagree . 69 The nurses were helpful to me in learning to take care of my baby. Often ; Sometimes ; Rarely ; Never . I blame myself for problems the baby has. Often ; Sometimes ; Rarely : Never . A very young baby is not social enough to be fun. Strongly agree ; Mildly agree : Mildly disagree_____ Strongly disagree . The staff at the hospital didn't take enough time to explain things to me or help me. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . When the baby cries at night, I get up to see what might be causing it: Immediately ; Within a few minutes ; Within ten minutes : After more than ten minutes ; Not at all . I've felt that it would help if an experienced woman would tell me if my baby was all right. Often ; Sometimes ; Rarely ; Never . I've been nervous and jumpy since having the baby. Often : Sometimes ; Rarely ; Never . I've worried that something was wrong with my baby. Often ; Sometimes ; Rarely ; Never . Taking care of a young baby keeps me from doing many things I would like to do. Often ; Sometimes :Rarely :Never . If I tried to learn more about caring for my baby, I wouldn't have as many problems with him. Strongly agree ; Mildly agree : Mildly disagree Strongly disagree . A baby gets spoiled if you pick him up when he cries. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . I've needed more help than I've gotten in caring for the baby and doing my housework. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree . 70 46. I feel the mother should always be close enough to her baby to hear him if he cries. Strongly agree ; Mildly agree ; Mildly disagree Strongly disagree 4; 71. SURVEY on BRINGING UP CHILDREN Answer each of the following statements using the following scale: 1 2 3 b 5 6 7 Strongly Moderately Agree Neither Disagree Moderately Strongly agree agree disagree disagree Example: Sunday is the first day of the week. 1 Statement: Your answer 1.. Families usually understand when a mother tries to do the right things for her children. 1. 2. I was not criticised too much by either of my parents. 2. 3. I usually felt I did not deserve the punishment I got as a child. 3. 4. I sometimes fear that my mate is too easy on the children and is spoiling them. 4. 5. In order for them to grow into decent human beings, children must be punished in a firm way. 5. 6. I am close to other people. 6. 7. I never become angry with my children. 7. 8. ‘My mother and I have always gotten along well. 8. 9. Children should know, even before the age of 2 years. what parents want them to do. 9. 10. No one has ever really listened to me. 10. 11. Sometimes it is hard for me not to feel jealous of my mate. ll. 12. I am always good to other people. 12. 13. When people try to help me with my baby, I feel awful. 13. 14. Whenever I have a problem, there is always someone to whom I can turn for help. 14.. 15. I am afraid of many things. 15. 16. I plan to raise my children basically in the way my parents raised me. 16. 17. When I am pregnant I become very depressed. (or) When my mate is pregnant she becomes very depressed. 17. 72 l 2 3 4 5 6 7 Strongly Moderately Agree Neither Disagree Moderately Strongly agree agree disagree disagree 18. Children are rarely ready to be toilet trained at one year of age. 18. 19. I am always being criticized by other people. 19. 20. My child(ren) is (are) always good. 20. 21. The main thing that I remember from my childhood is the love and warm feelings my parents showed me. 21. 22. At least one of my parents wanted too much from me. 22. 23. My marriage couldn't be happier. 23. 24. Most children should walk well by 9 or 10 months of age. 24. 25. Sometimes my mate doesn't seem to want to talk to me and this really bothers me. 25. 26. I have never felt really loved. 26. 27. At least one of my children remind me of someone I don't like. 27. 28. When I was a child my parents used severe physical punishment on me or at least one of my siblings. 28. 29. Most people say parents automatically feel love for their children, but it's not that easy. 29. 30. It seems that when I needed her the most, my mother has been least helpful. 30. 31. Although my mother tries (tried) to make helpful hints to me, it ends up sounding more like criticism. 31. 32. Children need to be taught, before the age of 2, to respect and obey their parents. 32. 33. I am very well liked by everyone. 33. 34. At least one of my parents didn't really listen to me or understand my feelings. 34. 35. A good mother should be home all of the time with her children. 35. 36. I have often felt that my mother would (or would have) take over completely and run my life if I gave her half a chance. 36. 73 l 2 3 4 5 6 7 Strongly Moderately Agree Neither Disagree Moderately Strongly agree agree disagree disagree 37. It is extremely important for me to have my children behave well even when they are babies. 37. 38. Children under 3 years of age often play with their food. 38. 39. It bothers me alot when my baby grabs the spoon and food gets slopped all over while he is eating. 39. 40. My mate understands my problems. 40. 41. I am always friendly to others. 41. 42. Often when my baby cries, I don't know what to do about it. 42. 43. Sometimes I just feel like running away. 43. 44. It bothers me alot when anybody criticizes the way I take care of my children. 44. 45. I have always been very close to my mother. 45. 46. I go through times when I feel helpless and unable to do the things I should do. 46. 74 We also want to ask you about what else has been going on in your life in addition to dealing with a new baby. The first set of questions are about what things have happened in your life recently, some of which are good and others not as good. The second set of questions are about your feelings about your relationship with your mate. 75 Check all of the following events which have happened in your life in the last 3 months. 10. 11. 12. 13. 14. 15. 16. 17. 18. Marriage Troubles with the boss Detention in jail or other institution Death of a spouse Major changes in sleeping habits (a lot more or a lot less sleep, or change in part of day when asleep) Death of a close family member Major change in eating habits (eating a lot more or a lot less, or very different meal times or surroundings) Foreclosure on a mortgage or loan Change of personal habits (dress, manners, associations, etc.) Death of a close friend Minor violations of the law (such as traffic tickets, jaywalking, disturbing the peace, etc.) Outstanding personal achievement Major change in the health or behavior of a family member Sexual difficulties In-law troubles Major changes in number of family get~togethers Major change in financial state (a lot worse off or a lot better off than usual) Gaining a new family member other than your new baby (such as through adOption or an oldster moving in) 19. 20. 21. 22. 28. 29. 30. 31. 32. 33. 36. 37. 76 Change in residence Son or daughter leaving home Marital separation from mate Major change in church activities (a lot more or less than usual) Marital reconciliation with mate Being fired from work Divorce Changing to a different line of work Major change in the number of arguments with spouse (either a lot more or a lot less than usual regarding childrearing, personal habits, money, etc.) Major change in responsibilities at work (such as promotion, demotion, or transfer) The woman of the house starting or stopping work outside the home Major change in working hours or conditions Major change in usual type and/or amount of recreation Taking on mortgage greater than $10,000 (such as for purchasing a home or business) Taking on a mortgage or loan less than $10,000 (such as for purchasing a car, TV, freezer, etc.) Major personal injury or illness Major business readjustment (such as bankruptcy, merger, or reorganization) Major change in social activities (such as clubs, visiting, movies, etc.) Major change in living conditions (such as building a new home, eviction, deterioration of home or neighborhood, etc.) * 77 38. Retirement from work 39. Vacation 40. Changing to a new school 41. Beginning or ceasing formal schooling 1. 10. ll. 12. 13. 14. 15. 78 Encircle the dot on the scale below which best describes the degree of happiness, everything considered, of your present marriage or relation- ship with your mate. The middle point, “happy," represents the degree of happiness which most people get from their relationship. The scale gradually ranges on one side to those few who are very unhappy in their relationship and on the other, to those few who experience extreme joy or felicity in their relationship. Very Happy Perfectly Unhappy Happy State the approximate extent of agreement between you and your mate on the following items. Please encircle the appropriate dots. Almost Almost Occa- Fre— Always Always Always Always sionally quently Dis- Dis- Agree Agree Disagree Disagree agree agree Handling family finances: . . . . . . matters of recreation: . . . . . . Demonstrations of affection . . . . . . Friends . . . . . . Sex Relations . . . . . . Conventionality (right, good or proper conduct) . . . . . . Philosophy of life . . . . . . Ways of dealing with in-laws . . . . . . When disagreements arise, they usually result in: husband/man giving in , wife/woman giving in , agreement by mutual give and take . Do you and your mate engage in outside interests together? All of them , some of them , very few of them , none of them ? In leisure time do you generally prefer: to be "on the go" , to stay at home ? Does your mate generally prefer: to be "on the gov , to stay at home ? Do you ever wish you had not married or decided to live with your mate? Frequently 3 occasionally , rarely _ , never . If you had your life to live over, do you think you would: marry or live with the same person , marry or live with a different person , not marry or live with a mate at all ? Do you confide in your mate: almost never , rarely , in most things , in everything ? APPENDIX B ADDITIONAL TABLES . 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H«.: 0.. m«.: o«. oo. 0.. mo.: uaauoaun oo o.. mm. oo. ma. .H~.: Ho. mu. .cmm. ...Ho. 0..: aqueous»: .00: oo. . as. oo. oa.: 0a.: «o. 44.: .44. .aam. oa. «Ian. uaoeasuuneu n«.: oo.: oo.: 04.: 0a.: 0a.: 0a.: oo. on. oo. oo. .04. auaaauuom .no. 0H. «on: oo.: «H.: 44.: "a” ma” Inc. 00. on” 0n” c.~mn . assumes 0H : o« as : ow : ma : n. : oo mu ace. 0. : on .«ooo canm c..~o ace-sou on S M .1 I N J H A m u mm m Mm m n m. n a a m m .m. m I o . u m 3 m m n. a . a .. u. v o u .... o .d .a sou m. mm“ m s n. u .4 I I. .A I m m 4......” I. I. 5 .4 .4 9 r. r. o u M n” n. .A 3 3 ".m. a. u 3 n I. I. .6 D. a a a . 8 I moaneauo> unwassOmuom anemone: omoansauo> huwaesOnuom assumes: no usoHuoHouuoo win OHAUB REFERENCES REFERENCES Ambuel, J., & Harris, B. Failure to thrive: A study of failure to grow in height and weight. Ohio Medical Journal, 1963, 59, 997-1001. Brazelton, T. B. Neonatal behavioral assessment scale. Cambridge: Harvard University Press, 1972. Caplan, G. 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