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V3...- . .5 7...: . 53.3 (2: .V. ., ... ..¥...%~'§t?l 05:32.: P6395913, .u.§§lihhfl~‘1§\)li§!li§l£\ 1.3.... f ,I . . . «a. V 5:... .AI v.ra\|91ht!§1|5\. . V354\\x.J\j\N¥WJPi~V)V-vttxxu . n VJ... . . Y: . . : ‘I‘IA- ‘ v ‘1 .‘V‘: .. a‘ A Q ”(‘4 4“.” ..-V. If p. p I) x all! .I.. Wufififim.fif$§¢fifi..tuwflwflé. :5 :,V4.V....¢.R.x.. ..c...:....\....c.w.... . . . . . . .f... .. . . I , . .. .V .. , . ... J, 2,2. T “V, .1 . _..........V ..;l!...:\ll,).‘uavl... . ; . .: .Anufidndjur ; u k \ \ Vi. 'w‘\ h .‘ ’ v .5! i r ,k .. ,i . . E1 W .. . ll... r V .x\‘.. .. ,.,3r).lw.n|. .4... 1.. . . , J M. —~ mullwillllglglllllllmllll L " mmnr . “unison State University This is to certify that the dissertation entitled THF‘ EFFECTS OF PFRINATAL COACHING ON MOTHER—INFANT INTERACTION presented by MARTHA WINGERD BRIS TOR has been accepted towards fulfillment of the requirements for Ph . D 0 degree in Fami 12 Ecology Major professor Date Ejebrnang 25, 1983 MSU;_"Am_ ,. . l ..1 m - . .-..- 0-12771 MSU LlBRARlES ‘RETURNING- MATERIALS?“ Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. “has L's-”247 THE EFFECTS OF PERINATAL COACHING 0N MOTHER-INFANT INTERACTIONS By Martha Wingerd Bristor A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR 0F PHILISOPHY Department of Family Ecology 1983 @Copyright by MARTHA WINGERD BRISTOR 1983 ABSTRACT THE EFFECTS OF PERINATAL COACHING ON MOTHER-INFANT INTERACTIONS By Martha Ningerd Bristor The objective of this study was to evaluate the effects of perinatal coaching on mother-infant interactions, stress in the parenting system, and nmternal adaptation. Perinatal coaching is aa program in which communication skills are taught to mothers. Forty- two first time mothers and their clinically well newborns delivered in Sparrow Hospital were the sample. All mothers and infants were from one private pediatric practice in Lansing, Michigan. Twenty-one of the mothers received perinatal coaching on days one, two, and seven postpartum, while the remaining 21 served as the control group. Three standardized self—report instruments, videotaped recordings of mother- infant interactions, and demographic information collected 28 days postpartum were used for evaluation. Three major hypotheses looking at mother-infant interactions, stress in the parenting system, and maternal adaptation were tested. Data related to the description of the sample and demographic information were also analyzed. The coached and control groups were found to be comparable on all descriptive data analyses performed. The test of the first hypothesis, in which nine mother-infant interactions coded from videotaped sessions in the home were examined, showed that the coached mother-infant pairs scored significantly higher on five of the nine behaviors (vocalizations, pitch (H: voice, feeding time, Inovement by mother, and engagement of baby). Pk) difference was found between groups on stress in the parenting system and maternal adaptation so the second and third hypotheses were rejected. Perinatal coaching was effective as documented by the behavioral assessments 28 days postpartum. To Stephen, Michael, and Kirk May you uncover the beauty to be found in books With love, ACKNOWLEDGEMENTS Giving due credit to those teachers, co-workers, friends, and family who have been helpful during this effort is difficult. Hopefully, they have been as aware of my appreciation as I have been of their support. Dr. Eileen Earhart has provided guidance and numerous opportunities as my advisor and chairperson. I have appreciated her support throughout my program. Dr. Ray Heifer has provided many learning opportunities, leadership, and constructive guidance as director of my research, and I have valued his insightful wisdom and encouragement. Other members of my committee, Dr. Linda Nelson and Dr. E. Jane Oyer, have been most helpful with their talents. Dr. Beatrice Paolucci and Dr. Dolores Borland, although not committee members, also contributed to my professional development. I am pleased to have had the opportunity to study with all of these fine people. Gratitude is extended to Dr. Andrea Doughty for guidance as a statistical consultant, and to Kathy Coy, who assisted in coding. The cooperation of the members of the Lansing Pediatric Associates was invaluable in carrying out the project in the comnunity, and their willing support throughout the project was greatly appreciated. Others who were most helpful were fellow graduate students and friends, especially Betty Abedor, Elizabeth Olson, and Judith Halters. I have valued ‘their ‘friendship, understanding, and (MH‘ intellectual exchanges. iv Finally, my sincere appreciation and love to my family, especially my three sons, Stephen, Michael, and Kirk, who asked the questions I sought answers for; to my husband, Jim; to my parents, Reverend Mark and Hannah Wingerd, who supported educational pursuits; and my sister, Janet, who was my first intellectual sparring partner. I have appreciated you all so much. TABLE OF CONTENTS LIST OF TABLES .......................... LIST OF FIGURES ......................... Chapter I. INTRODUCTION ....................... Background of the Problem ................ Purpose of the Study .................. Statement of the Problem ................ Research Questions ................... Conceptual Framework .................. Definitions ....................... Assumptions ....................... Hypotheses ....................... Overview ........................ II. REVIEW OF LITERATURE ................... Parental Attitude and Behavioral Influence ....... Family and Parenting Stress ............... Mother-Infant Interaction ................ The Social Interactive System ........... Infant States of Consciousness ........... Socially Responsive Capabilities of the Newborn ...................... Auditory Interaction ................ Visual Interaction ................. Olfactory Stimulation ............... Tactile and Vestibular Movement Stimulation . . . . Resources for Mother-Infant Interactions ........ Summary ......................... vi Chapter III. METHODOLOGY AND HYPOTHESIZED RELATIONSHIP ......... Sample Selection .................... Design and Procedure .................. Perinatal Coaching - The Intervention .......... Measurement Procedures ................. Videotaping .................... The Parenting Stress Index ............. The Postpartum Self-Evaluation Questionnaire . . . . Michigan Screening Profile of Parenting ...... Hypotheses ....................... Analysis ........................ Summary ......................... IV. FINDINGS .......................... Sample Description .................... Further Analysis of Perceptions of Childhood ....... Hypothesis 1 ....................... Activity ...................... Vocalization of Mother ............... Vocal Pitch of Mother ................ External Stimulation by Mother ........... Movement by Mother ................. Touch by Mother ................... Visual Gaze of Mother ................ Movement by Baby .................. Engagement - Involvement of Baby .......... Baby Vocal Behavior ................. Hypothesis 2 ....................... Hypothesis 3 ....................... Summary ......................... V. SUMMARY AND CONCLUSIONS .................. Conclusions ....................... Hypothesis 1 ....................... Activity ...................... Vocalization of Mother ............... Vocal Pitch of Mother ................ External Stimulation by Mother ........... Movement by Mother ................. Touch by Mother ................... Visual Gaze of Mother ................ Movement by Baby .................. Engagement - Involvement of Baby .......... Baby Vocal Behavior ................. vii Page 39 Chapter Page Hypothesis 2 ....................... 80 Hypothesis 3 ....................... 81 Additional Information .................. 81 The Perinatal Coaching Program .............. 83 Limitations of Study ................... 84 Implications for Family Theoretical Model ........ 84 Implications for Future Research ............. 85 Further Research Related to This Study .......... 86 Implications for Practical Use .............. 88 APPENDICES Appendix A. Consent Form ........................ 90 B. Letter to Recruit Control Group Mothers ........... 91 C. Behavioral Interaction Variables for Rating Videotapes ..................... 92 Definition of Variables ................... 94 Scoring Grid ........................ 97 D. Videotape Reliability of Interactional Analysis ...... 98 BIBLIOGRAPHY ........................... 100 viii LIST OF TABLES Table Page 1. Demographic Characteristics of Sample ............ 59 2. Chi-Square of Type of Feeding for Treatment and Control Group ................ 61 3. Student's t-tests Showing Behavioral Variables of Videotaped Mother-Infant Interactions ......... 64 4. Student's t-tests Showing Analysis of Parenting Stress Index .................. 68 5. Student's t-tests Showing Analysis of Postpartum Self-evaluation Questionnaire ......... 7O ix LIST OF FIGURES Figure Page 1. Resources for Mother-infant Interaction ........ ' . . . 37 2. Steps in Sample Selection . ................. 41 3. The Perinatal Coaching Program ............... 47 CHAPTER I INTRODUCTION Background of the Problem One commonplace miracle that has not been diminished by ‘this complex world is birth. The marvel of new life on earth, particularly a human life, has been cause for wonderment over the ages. While parenthood is instantly conferred on the mother and father, a kaleidoscope of complex interrelationships plays a role in how parenting begins. An accumulation of past experiences, communication skills, knowledge of infant communication skills, knowledge of infant development and child rearing practices affect parenting. Temperament, appearance, and sex of the child, as well as relationships with spouse, extended family, and others all impact significantly on how parenting begins. This time of exciting new beginnings affects the relationship between parents and child, between parent and parent, and how parenting proceeds during the important perinatal period. The perinatal period refers to the period of time from the 20th week of 'fetal life to 'the infant's 28th day of human life. ‘This period represents a crucial transition time in the life of both the baby and the family. In this critical time the neonate is adjusting to a new environment while the parents move from a dyad to a triad and face the experience of caring for an infant who is exclusively theirs as they continue to maintain their own relationship. This new way of life requires adjustments to a changing pattern of living and of responding to the constant needs of a dependent new member. This can become even more difficult when parents leave the security of the hospital and face the reality of total responsibility for child care alone, especially if they are ill prepared and/or without previous experiences in child care. Cultural trends have deprived new parents of the availability and dependence on the older generations. In past eras with larger families and less mobile society, learning to care for a child took place as a natural part of growing up. In larger families there was usually a younger sibling in need of care, or there was frequently a baby at every social gathering of the extended family. Children observed how babies were cared for, and often helped in child care. These family members provided social support while offering help to the new family. Experienced relatives and friends nurtured new parents as they adjusted to the Changing demands and experiences of being parents. There are far too few supports for new parents in our contemporary society. Today smaller families and a mobile society frequently create a different atmosphere for child rearing. New parents may live a distance from their extended families. Often they become mothers and fathers with little experience in child care, and frequently do not have the kind of help and companionship that is helpful at this critical time of demanding new experiences. Parents, especially mothers, can experience loneliness and confusion. All parents, even those with the most positive role models, nurturant early childhood experiences, and satisfying social relationships, at times find that an infant's behavior can be extremely exhausting. Disillusionment with so many demands may lead to frustration and a feeling of inadequacy to cope with such a time consuming situation. A set of beliefs that may be a further source of conflict for a new mother concerns the "joys of becoming a new parent." The woman in particular is expected to be ecstatic at becoming a new mother. Researchers (Lemasters, 1971; Hobbs, 1968) indicate that this is at times not the case. “Cabin fever", a feeling of exhaustion, and "postpartum blues" are a few reactions to the birth of a child. Even with knowledge of the demands of motherhood, many women who have these reactions often feel guilty because of their unrealistic concept of the time involved in child care along with maintaining a spouse relationship and a home, while dealing with the romantic myth of motherhood. The birth (H: a child often leaves the woman physically worn out for a period of weeks. An infant's need for constant attention adds to the lack of energy. A combination of exhaustion and frustration may seem insurmountable at times. The sad result of this stressful situation in its most extreme form for an isolated mother may be inadequate or inappropriate care of the infant. Many 'families have been unable to establish a positive communication pattern with their infant. They describe this time of early infancy as cHsappointing, non-rewarding, and even frightening. These parents are both anxious and angry that they were unable to establish an ongoing relationship and interact effectively with their newborn. The outcome, all too often, is child abuse, failure-to- thrive syndrome, multiple accidents or ingestion of harmful substances. Another issue of importance to the background of this study involves the changing perspective on child development. For years a child's development and behavior were considered to reflect care provided primarily by parents. In the late 60's a new way of viewing the development of the child was introduced (Bell, 1968). This view took on the elements of a feedback mechanism from the child to the mother. The realization and understanding of how children influenced their caregivers' reactions increased. Parent-child interactions, which were formerly viewed as a one-way system, began to be viewed as a two-way system with both the Child and the parents eliciting behavior. Today the baby is considered an active participant who contributes significantly' to the development of the evolving relationship (Stone, 1973). Becoming comfortable with :1 new baby requires more than knowing the basics of feeding, bathing, and diapering; it requires a recognition of the uniqueness and individuality cn= an infant's capabilities and personality, learning specific communication skills, and adjusting to a new pattern of living. Parents who cannot communicate with an infant suffer much frustration in trying to care for their baby. Some of these adults had been nurtured by "cold" and/or unresponsive caregivers; others not held at all. As children they often blocked out sounds which were too painful to listen to, and learned that touching was associated with pain instead of pleasure. A large number of these adults experienced a childhood that required them to “desensitize” their sensory communication system to survive. In general, their sensory system was conditioned negatively because of the association with pain, turmoil, and/or neglect (Helfer, 1978). Along with negative conditioning came suppression of senses. Helfer (1979) states that there is no handicap more detrimental to the establishment of a two-way interaction between mother and child than an adult reared to suppress the senses. Recognizing the need to help all adults adjust to the many new demands and experiences of parenthood, professionals and lay groups have taken an interest in developing programs for new parents. Prenatal care, expectant. parents' classes, changes “hi hospital care for mothers during labor and delivery, and the postpartum period have all been the focus of much discussion among those looking for ways to ease the transition to parenthood and the critical adjustment time of the perinatal period (Klaus and Kennel, 1981). Such programs are incorporated to create an atmosphere where mother and newborn may begin the adjustment of meshing their unique personalities to establish a foundation for a positive mother-infant relationship. The interest in programs of parent education to facilitate the adjustment of the mother-infant dyad reflects an increasing awareness on the part of professionals who are dealing with the outcome of parental disorders affecting children such as failure to thrive, multiple accidents, and abuse, to the value of these programs as preventive measures (Kaplan, 1981). Perinatal coaching, a program developed by Helfer and Wilson (1980), has been utilized in teaching parents how to apply basic knowledge of the fundamentals of infant devel0pment to learn skill development in communicating with a newborn in an effort to facilitate the transition to parenthood. Purpose of the Study The purpose of this study was to evaluate the effects of perinatal coaching on mother—infant interactions, stress in the parenting system, and "eternal adaptation. The effects of perinatal coaching were evaluated with first time mothers anui their clinically well newborns analyzing videotaped sessions of behavioral interactions of ‘feeding, burping, and diapering while self-report questionnaires were used to assess the attitudes of mothers. Statement of the Problem Many parents have demonstrated difficulty in establishing an effective communication system with the newborn resulting in the inappropriate treatment of the child often with an outcome of maltreatment or abuse. Further, in recent years, the perspective of infant development has changed with the recognition that the child is born with a highly developed sensory mechanism capable of interactions, and these senses are an important part of the communication system of the mother-infant dyad. Thus, the problem involves parents and newborns who are ready and eager to communicate with each other, however, the parent may be ineffective in observing, sending, or receiving cues in a way that is geared to the baby's receptive sensory mode of communication. Thus, the lack of skills to interact effectively hinders the development of satisfying communication between mother and infant. What has not been demonstrated is whether research findings can justify parent programs as effective in influencing positively the interactions between mother and infant. The question addressed in this study is whether Perinatal Coaching, one example of a parent program, is an effective approach to improving Inother-infant interactions as measured by behavioral interactional analysis and attitude assessments. Research Questions In an effort to assess the effects of perinatal coaching on mother-infant interactions, stress in the parenting system, and maternal adaptation, the following research questions are asked: 1. Will first time mothers who receive perinatal coaching differ in interactions with their newborns from a comparison group of mothers who did not receive perinatal coaching as measured by assessment of behavioral interactions recorded via videotaped sessions of feeding, burping, and diapering? 2. Will first time mothers who receive perinatal coaching experience less stress in the parenting system than a comparison group of mothers who did not receive perinatal coaching as measured by the self-report questionnaire, The Parenting Stress Index? 3. Will maternal adaptation be influenced by perinatal coaching in comparable groups of coached and non—coached mothers as measured by the self-report questionnaire, The Postpartum Self-evaluation Questionnaire? Conceptual Framework An individual is born into an on-going society with common symbols and established patterns. The phenomenon (M: the development of this individual integrates a variety of theoretical perspectives so that development may be viewed as a continuing reciprocal interaction between a, changing organisnl within a: changing environment (Hartup, 1978). In looking an: human development and human behavior, the systems approach is a valuable framework under which various theoretical perspectives may Ina applied. The family ecological approach constitutes a way of explaining a unit, such as the mother-infant dyad, and how this dyadic pair relates and interacts with both larger and smaller units or systems. The basis for this approach is the assumption that matter, in all its fbrms, living and non-living, can be regarded as forming systems that have discrete properties capable of being studied. Using a systems theory perspective, focus is on the interaction among the various parts of the system rather than describing the function of the parts themselves (Miller, 1971). The interaction and interdependence of the elements creates a unique functioning whole. The whole can be understood only by considering all the parts and their interactions simultaneously (Buckley, 1967; Kantor and Lehr, 1975). The ecological environment is conceived as a set of nestled structures, each inside the next. At the intermost level is the immediate or near environment containing the developing person, the infant within the family, as a system ecologically suspended in multiple systems. lime ecological systems approach requires looking beyohd this single near environment and viewing the relationship that occurs between individuals, the mother—infant dyad and the other dyadic relationships in the family. This perspective further considers that the person's development is affected by events occurring in settings in which the person is not present. These introduce elements in the family from outside the home. As part of this theoretical perspective, if one member of the family undergoes a change in the process of development, the other does also. It also recognizes that the capacity of a dyad to serve as an effective context for human develOpment is crucially dependent on the presence and participation of third parties, such as spouse, relatives, friends, and neighbors. Bronfenbrenner (1979) states that if such third parties are absent, or play a disruptive role, the developmental process considered as a system breaks down; "Like a three-legged stool, 'H: is more easily upset if one leg is broken, or shorter than others" (p. 58). The same triadic principle applies to relations between settings and in the hierarchy of settings from the near to the far environment of the community. Three environments have been defined and include the natural environment, the human-made environment, and the social- emotional environment (Morrison, 1974; Bubolz, Eicher and Sontag, 1979). Resources are available to families from each of the environments. Also inputs from the various environments, both positive and negative, influence the developing individual and family. An ecological-systems approach was utilized in this study of the mother-infant dyad within the family context. The view of mother- infant interaction as a subsystem within a developing family offers a productive way for studying interactions within natural human environments. The family-ecological approach allows ikn~ the conceptualization of the interdependent reciprocal relationship of the mother-infant dyad within the context of the social environment of parents, and physical environment of the hospital and home. Specifically, rather than look for a one-way cause and effect relationship, the developing mother~infant relationship is viewed as interdependent. For example, response from the infant tends to elicit further behaviors from the mother. According to an ecological systems 10 approach, a change in one part of the relationship can create changes in other parts. Changes cause the system to seek equilibrium and adjust. The family ecological approach allows a focus on the interrelationship between the mother-infant dyad and the environmental context. in which the dyad is having its beginning. According to systems theory, in the case of the mother-infant dyad, a change in the mother's attitude, health, or skill learning in infant care will cause change in the interaction with her newborn. The nature of such dynamic interactions occurring at this time of adding an additional member to the family environment requires a holistic model to consider the many aspects involved. As Sameroff (1975) notes, developmental outcomes are the product of the characteristics and environments of mother and child, and the transactions between the two. The ecological systems perspective allows a point of convergence among the disciplines of the biological, psychological, and social sciences as they bear on the evolution of the individual. By combining this type of holistic, integrative and systemic thinking, all the components that influence mother-infant interactions can be considered. This perspective gives an emphasis to the interactive processes and has reduced the proposed importance of any single variable. This conforms with suggestions that there is a: need to shift the emphasis from assessing outcome measures to identifying the process underlying the Changes that occur (Sameroff and Chandler, 1975). 11 Definitions The following terms and their definitions were used in this study: Perinatal Coaching. A skill devel0pment program, with a strong content base in which new parents are taught how to communicate and calm a newborn. Parents are shown how to apply knowledge of (1) states of consciousness, (2) social capabilities, (3) timing of interactions, and (4) unique behavioral traits. Specifically, perinatal coaching includes demonstrations and practice in the hospital with fOllow-up 'Hl the home. Helfer (1980) stated that the primary goal of the Perinatal Coaching Program is to develop patterns of interaction and to improve communication systems between new parents and their first born infants. Perinatal Coach. A resource person who coaches the new mother and father in the skills of interacting with the newborn. The coach, usually a volunteer, teaches ways to calm and communicate with the infant, provides modeling (H: important skills along with observation and feedback of skills to be learned. Mother-Infant Interaction. A communication exchange between mother and infant including vocalizations, touch, play, eye contact and other meaningful activities. Maternal Adaptation. The adaptation (H: a woman to the role of motherhood including caring ifin~ the newborn along with other tasks involved 'hi infant care. These include the instrumental and non- instrumental care giving activities. Human Resources. The abilities and characteristics of the individual which cannot be utilized independent of the individual. Specific human resources include time, skills, and abilities. 12 Assumptions The following assumptions are made in this study: 1. Early mother-infant interactions are critical for establishing a foundation of behaviors which will mediate the nature of the parenting relationship and the child's development. 2. All behaviors occur in interaction. The mother-infant relationship involves a dyadic system in which both parties contribute to the nature of the mutual interaction. 3. The mother's previous experiences and their views of parenting play a role in family interaction, the mother role, and how parenting will proceed. Hypotheses The following null hypotheses are tested: Hypothesis 1. There will be no differences in interactions between first time mothers who receive perinatal coaching and their newborns and a comparison group of mothers who did not receive perinatal coaching as measured by assessment of behavioral interactions recorded via videotaped sessions. Hypothesis 2. There will be no differences experienced in stress in the parenting system by mothers who receive perinatal coaching, and a comparison group of mothers who did not receive perinatal coaching as measured by The Parenting Stress Index. Hypothesis 3. There will be no differences in maternal adaptation between mothers who receive perinatal coaching, and a comparison group of mothers who do not receive perinatal coaching as measured by The Postpartum Self-evaluation Questionnaire. 13 Overview The importance of the perinatal period in establishing a workable system of adaptation and communication between parent and child has been discussed in Chapter I. Also a ‘theoretical perspective for viewing mother-infant interactions has been pr0posed. In Chapter II, the applicable literature is reviewed including the infant's socially responsive capabilities, the parent's ability to utilize these responsive capabilities to communicate with and calm the infant, and the stresses in the parenting system at a critical time in the development of the family system. In Chapter III, the methodology chapter, the sample is described along with a description of the operational measures used to examine the characteristics studied, the testable hypotheses, the design, and analysis of data. In Chapter IV, the findings from the analysis of the data and statements of significance are included. Discussion of results, conclusions, the theoretical impact of these findings, and speculation for future research along with the limitations and some practical application for the study will be presented in Chapter V. CHAPTER 11' REVIEW OF LITERATURE The research literature important in this study is reviewed to understand more fully the factors that contribute to the complexity of the mother-infant dyad, what influences this interactive process, and the impact of these on the developing child. The research literature pertinent to this study is reviewed under the following headings: parental attitude and behavioral influence; family and parenting stress; mother-infant interactions, including ‘the social-interactive system, infant states of consciousness; and the socially responsive capabilities of the newborn. Parental Attitude and Behavioral Influence The importance of what parents believe regarding the essence of what a child should be and the qualities valued by the family seem relevant for consideration as to how this may relate to the interactive process. Although the devel0pment of the child has been a t0pic of study for decades, theories concerning what is pertinent to the development of the child have changed considerably through the years. The present trend is to integrate a variety of theoretical perspectives so that development may be viewed as a continuing reciprocal interaction between a changing organism within a changing environment (Hartup, 1978). When the development of mother—infant interaction is studied, the ecological environment of the family must be considered. This includes the mother-infant dyad, the social environment of parents, and the physical environment of the home. 14 15 The family is often viewed as a semi-closed system of interacting persons, varying in age and sex, whose interaction is organized in terms of interrelated social positions (dyads) with norms and roles defined by both the society and the interacting persons who are unique to the system (Rollins and Cannon, 1974). Pregnancy' brings about reevaluation of the roles, norms, and attitudes (Soule, 1974; Brazelton, 1981). As a child is added to the family the number of dyads multiplies. The child can be influential in the husband-wife dyad through interactions in one of the parent-child dyads. Each generation of parents holds a set of beliefs regarding the essence of what a child should be, the qualities valued by the family, local community, and culture, and the experiences believed ix) enhance the child's acquisition of these qualities. These beliefs influence what parents believe important and their behavior toward their children. Stolz (1976) reported the result of interviews of 78 parents and their children. The interviews were conducted to obtain self-reports of what parents felt influenced their behavior toward their children. She categorized various factors under past childhood amd adult experiences; present personality factors, values, beliefs, and spouse interactions; and immediate parental goals, parental urges, perception of the child, and behavior setting. Brim (1959) after reviewing child rearing literature named six categories of parental behavior influences: ability factors including physical, intelligence, and health; unconscious factors including attitudes, and feelings; cultural values including all those things held important; interpersonal and social controls including rules from the culture, spouse, relatives, neighbors, child, person with decision 16 making power in the family, and sex roles within the family; group structural determinants such as family size and patterns of interaction; and ecological and physical factors including effects of poverty, labor force participation of parents, and housing. Family and Parentin973tress The family is considered to operate on a basis of interactions between family members holding various social positions and roles with resulting norms (Aldous, 1978). Each individual family member brings to the assigned role special and unique qualities that are blended with another person in the formation of the dyad. A stressor with resultant strain occurs which may cause dysfunction within the interactive system when a member is added to the family and the dyad becomes a triad. This is especially true if the new member does not live up to the expectations envisioned by the parents. Each role in the family is a demanding one with accompanying stress, and each role requires a kind of dedication for which individuals have already been shaped by past experiences (Brazelton, 1981). Hill (1958) states that the level of dysfunction a family experiences is dependent upon the level of family function at the onset of crisis and the significance of the crisis to family members. The family's ability to recover is dependent on two factors, the ability of family members to communicate and various family resources that can be utilized such as cultural, educational, economic, and medical. 17 According to Hans Selye: Stress is a non-specific respnse of the body to any demand . . . It is immaterial whether the agent or situation we face is pleasant or unpleasant; all that counts is the intensity of the demands for readjustment or adaptation (Selye, 1974, pp. 83-84). Pelletier (1977) further notes that general environmental and social stressors affect all people to some degree and include living and working conditions, increased mobility, and the constant influx of information from mass media. An individual is under stress every time an adaptation is required to adjust to personal, social, and environmental influences, positive or negative. Adaptation is necessary all the time to varying degrees (Pelletier, 1977). The system changes to seek a homeostatic condition (Buckley, 1967). Changes, both positive and negative, over the life span, are stress inducers that must be dealt with for adaptation and personal growth (Schneider, 1983). These stressors include such events as change in job status, income, or employment, change in familiar environments such as a move to a new location, and changes in the family such as the addition of a new member (Holmes and Rahl, 1967). Despite the romantic mythology that surrounds parenting, learning to be a parent is likely to be a complex process for most people and entails change in the individual with resulting stress. Pregnancy is well recognized as a time of normal psychological stress and turmoil (Bibring, 1959; Bibring, Owyer, and Huntington, 1961; Brazelton, 1963; Sherashefsky and Yarrow, 1973). This turmoil is present in all men and women who face new roles as parents. The importance of this stress in activating energy for the coming 18 adjustments to parental roles becomes obvious. Brazelton (1976, 1981) states that without the “disruption reaction" that serves ix) unseat old role adjustments, young parents might fall into an inflexible replica of their relationship with their own parents as they adjust to the new baby. During pregnancy, young parents rework their relationship with each other, with their own parents, and their life style in order to mobilize themselves for the task of parenthood. With the stress of anxiety as a: motivator, the couple reworks their relationship and develops sensitivities that will be helpful to the specific needs of the baby. Further, they are more likely to adjust to the infant as an individual with unique characteristics and specific needs (Brazelton, 1981). Added to the psychological adjustment of pregnancy is the physical stress and bodily change. Readjustment of bodily mechanisms takes much energy. During pregnancy a woman concurrently experiences two types of developmental changes: physical and emotional changes within herself, and the growth of the fetus within the uterus (Klaus and Kennel, 1981). Parents normally experience a: certain degree of stress to which they are able to adapt without dysfunctional consequences. These disturbing and often competitive feelings experienced during pregnancy stir up energy for attachment and adjustment to the baby. If these stresses are understood and dealt with in a positive way while the parents are gaining their equilibrium, they can become a renewing force for strengthening the parents' attachment to each other and the new member (Brazelton, 1981). However, the existence of stress at very high levels may result in adverse consequences. High levels of stress can interfere 19 with the development. of’ positive parent-child interactions. These adverse consequences affect the parent as an individual and the developing parent-child relationship at a critical time. This parent- child relationship, which serves as the foundation for the child's emotional and social development (Mahler, Pine, and Bergman, 1975), is very influential in the course of later development. A large body of research literature exists relevant to the topic of stressors that operate in families with young children. Studies on the influence of chlidren's temperamental characteristics on later development (Thomas, Chess, and Birch, 1968) and the development of maternal feelings toward children (Robson and Moss, 1970) are examples of the variety of existing research regarding the roles that social factors, child characteristics, and parent variables play in the development of children. Literature exists that has as ea focus the early identification of children who are at risk for later developmental difficulty in the cognitive domain (Abiden, 1979), while considerably less attention has been paid to the area of social- emotional development of children. Those efforts that focus on predicting the future emotional-behavioral development of children have approached the task by almost exclusively assessing the child's attributes (Carey, 1972; McInery' and Chamberlain, 1978). Research regarding the devel0pment of behavioral disorders (Thomas, Chess, and Birch, 1968) has identified the existence of excessive stressful characteristics of the child as only one of the major factors contributing to the development of behavioral disturbances. Stress in the parenting system during the initial encounter of the mother and infant, from birth through the first three years, is especially 20 critical “hi relation ix; the child's emotional-behavioral development and to the: parent-child relationship (Abidin, 1979). Child characteristics, situational factors, the interactional system, and life stressor events are some of the demands affecting the relationship. Understanding the stress in early parent-child relationships requires that this existing information be integrated within a framework that can account for the operation of the many and varied factors relevant to stress. In summary, theoretical discussions and research concerning how families cope with stressful situations have produced information which often appears conflicting. Surprisingly, many of these stressful events seemed very positive in nature, such as marriage, a new baby, or an outstatnding achievement. Even happy events required some adjustment to change in che's life; this change induces stress, and stress and the resulting behaviors and outcomes may be viewed as either a positive or negative influence in the family system. Mother-Infant Interaction Most mothers are believed to experience positive feelings for their infant from birth. However, there has not been extensive research investigating the devel0pmental aspects of these affectional relationship bonds. Two pediatricians, Klaus and Kennell (1976, 1981), are concerned with the effects of forced separation of mothers and infants immediately postpartum which occurs in many hospital deliveries. They believe that the early interaction between mother and infant serves to promote mother-infant bonding and that there is a biological basis for early and continuing contact. They also believe 21 that the baby acts as a stimulus to elicit mothering behaviors and establishes the basis for the mother to provide care and comfort for the baby. Studies of premature infants have shown consistent findings that opportunities for .contact between mothers and premature infants increased mother's frequency of looking at, smiling, holding close, fondling, and caressing their infants (Barnett, Leiderman, Grobstein and Klaus, 1970; Leiderman, Leifer, Seashore, Barnett, and Grobstein, 1973 Klaus and Kennell, 1976). Ethological writings (Bowlby, 1969; Robson and Moss, 1970), provide further support for a relationship between extended contact and attachment behaviors. Despite the convincing nature of this research, one must question whether providing opportunities for mothers and infants to be together is sufficient for satisfying and nurturing mother-infant interactions. Egeland and Vaughn (1981) question whether contact results in bonding and write that it is not possible to conclude that limited contact between mother and infant immediately after birth results 'hi bonding failures which in turn cause disorders of mothering. However, the study did suggest the possibility that early and extended contact of the mother with her infant may enhance their relationship. The quality of the time spent in the contact experience must be considered. Mothers and infants are not always mutually satisfying to each other. Cases in which infants have shown only two states, sleeping and crying, have been extremely frustrating for parents (Brazelton, 1961, 1981). Parents often blame themselves although crying and lack of responsiveness are not the fault of the mother. However, she does have to make an adjustment in her care and behavior 22 when confronted with responses that do not match parental expected patterns of behavior. If maternal forces can be mobilized, the mother can facilitate the development of the infant. Rewarding communication between a baby and parents is critical to the development of a reciprocal relationship. Communication, our most important medimn for social contact, is utilized in most of the activities in our daily lives (Berlo, 1960). Communicating with others is necessary for our existence and helps us get what we need (Johnson, 1981). From the moment of birth, communication is a tool utilized to alter the environment to meet our needs. Although every person communicates, whether verbally or nonverbally, the skills to do so are learned by observing and listening. Any communication system requires a feedback mechanism from the environment. From a systems perspective, feedback (a process by which a system informs its component parts how to relate to one another and to the external environment in order to facilitate the understanding of the input) becomes a crucial feature. The parent must not only recognize and understand the methods of communication of the newborn, but also be able to transmit messages utilizing a similar system. Many times, in order for learned techniques to be an effective and satisfying means of interaction, they must be altered to fit the recipient, especially if the recipient is a newborn. Some adults are not able to communicate with the senses, the mechanism that can be received by the newborn, and often must learn new techniques to set up a mutually satisfying interaction (Helfer, 1979), while others feel uncomfortable using this sensory method of corrmunication. The 23 result is that when these ill prepared adults are forced to develop a communication system with the newborn, they often do not do well and set up a highly stressful environment. The Social Interactive System. In a social interaction system, the responses of each participant serve as stimuli for the other. The ability of the infant to influence the behavior of the caregivers has been demonstrated in work with infants (Bell, 1968; Korner, 1965, 1970, 1971, 1973; Osofsky and Danzger, 1974; Osofsky, 1976; Moss, 1967; Stern, 1974). The newborn is capable of reaching out to the parents with a great variety of abilities and responses and has a very developmentally advanced system of senses which are readily used at birth. A number of infant characteristics have been found to affect the mother-infant relationship. These characteristics include temperament (Carey, 1970; Fries and Wolff, 1953; Rutter, 1970; Thomas, Chess, Birch, Hertzig, and Korn, 1963; Thomas and Chess, 1977), sex (Korner, 1974; Moss, 1967, 1974; Moss and Robson, 1968; Wolff, 1966; Freedman, 1974), birth order (Brody, 1966; Thoman, Leiderman, and Olson, 1970, 1971, 1972), states of consciousness (Ashton, 1973; Bennett, 1971; Brazelton, 1961; Brown, 1964; Jones and Moss, 1971; Korner, 1973, 1974; Lewis, 1972; Moss, 1967), and responsiveness to tactile, visual, and auditory stimuli (Brazelton, Koslowski, and Main, 1974; Lusk and Lewis, 1972; Moss, 1967; Osofsky, 1976; Osofsky and Danzger, 1974; Robson and Moss, 1970; Wolff, 1971). Results from increasing numbers of studies with infants convincingly show the view of an infant as a complex individual with unique patterns of activity preferences from birth that coincide with, impinge upon, and influence maternal 24 interests. The infant is socially responsive, equipped to enter a social relationship, and respond to caregivers' overtures. The interaction between mother and infant can best be described as a fitting together of two complex organisms and personalities. Each infant is born with a unique rhythm and organization of the arousal and inhibitory systems (Bennet, 1976; Brazelton, 1976; Lazoff, Brittenham, Trause, Kennel and Klaus, 1976; Schaffer, 1974) and a characteristic temperament (Bonem, 1978; Thomas, Chess and Birch, 1963). One of the mother's tasks is to adjust to the infant's basal characteristics, to learn the infant's rhythms, and to learn to recognize and interpret the signals given by the infant (Sander, 1976, 1977; Thoman, 1975). The caregiver's mode of adaptation to these characteristics alters them and thus alters the stimuli to which a response is made. The infant appears to be in charge at this stage, with the caretaker adapting to the infant's needs and signals (Brazelton, 1976; Lozoff, Brittenham, Trause, Kennell, and Klaus, 1977). At the same time the mother is simultaneously shaping the infant's sleep—wake cycle (Sander, 1970, 1976) by using her particular style of caretaking and handling with the infant (Call and Marshak, 1976; Thoman, 1974). When the fit occurs in an optimal situation, mother and infant learn each other's characteristics and styles and learn to identify signals utilized by each of them. When behavioral synchrony has been achieved, mother-infant interactions generally are characterized by definite sequences of give and take (Brazelton, 1976; Sander, 1970, 1976; Schaffer, 1974). To complement the interactive process the infant possesses characteristics such as sighs, helplessness, appearance, and crying 25 that facilitate the initiation of care by the parents (Moss, 1967; Richards, 1971). The responses common in adult social relationships are important for parents to see in their infants so that parents feel that they' are relating socially' to 'their infants Robson and Moss (1970) and Bennett (1971) hypothesized that a combination of adult and infant characteristics are better elicitors of maternal attention than either one observed separately. Helfer (1982) suggests that the adult must learn to communicate with the newborn in the manner in which the infant is equipped to receive communication. These observations emphaisze the fact that actions, characteristics, and styles of behavior exhibited by the infant play an important role in determining the stimulation received and how the interactive process will proceed. Since the responsiveness of the infant to overtures provided by the mother may affect her feelings of attachment and competency, and the frequency of her attempts to elicit responses, these measures are important when considering the infant's role in the interactive process. The Perinatal Coaching Program (Helfer and Wilson, 1980) demonstrates techniques to stimulate socially responsive techniques to elicit infant responses. In addition, early behavioral characteristics such as self-quieting ability, irritability, consolability, and activity are included in the Program. These measures help identify those early behavior characteristics that will advance our understanding of what it is that the infant brings to the environment which makes a difference in how the infant develops (Helfer, 1981). Infant States of Consciousness. The importance of infant states has been stressed in the program to help parents identify the times when parent-infant communication will be most gratifying to both parents and infants. The states of sleep or consciousness of a newborn include deep sleep, light sleep, drowsy, alert, active and crying. The importance of infant states in research has been stressed by Ashton (1973), Brazelton (1961, 1973), Korner (1973, 1974), Levy (l958), Lewis (1972), Moss (1967), Yarrow and Goodwin (1965), and Jones and Moss (1971). States reflect the time of need as well as the availability of the infant for contact with the environment, and reflect an important element to attend to for mother-infant interactions. The state influences the infant's awareness of the environment and affects maternal behavior. An alert infant is usually very receptive to interactions and provides a gratifying experience for the mother. Efforts to arouse an infant from a sleep state or to calm an infant in a crying state provide mothers different experiences which are probably less gratifying. Infant modulation of state provides an index of the control an infant can exert over behavior (Osofsky and Connors, 1979). Levy (1958) reported differences in Inaternal greeting response which showed variance depending on the state of the infant. During the first week postpartum, mothers greeted quiet, alert infants one- third of the time, while the incidence with crying infants drOpped to one-sixth of the time. Moss (1974) observed that the amount of time an infant was awake and crying was an influential modifier of maternal treatment. Individuality of the infant along with variability of states related to stimulation affects the relationship between mothers and infants. Some infants are difficult to arouse while others are easily soothed. Responsiveness may be minimal or delayed. Infants who respond to any type of stimulation with rapid state change may be highly responsive to stimulation in general, and may be overstimulated. A mother's feelings of competence as a caregiver may be related to these variables (Osofsky and Connors, 1979). According to Wolff (1971), there has been insufficient recognition that infant's behavior influences a rmather's, behavioral responses as much as her past experiences. With the newborn, much of the change that occurs in interactions is based on maternal variations in response to the infant's state or feeding behavior; .A mother can be made aware of the states of consciousness so that she may learn appropriate ways to deal with the infant's states. Socially Responsive Capabilities of the Newborn Evidence exists to show that the infant is socially responsive, equipped to enter a social relationship, and responds to the caregivers' overtures. The major capabilities which help initiate and bind the early relationship include the elements of the sensory system. Not only is the infant equipped with auditory, visual, olfactory, tactile, and vestibular (movement) capabilities, but the infant responds to this type of stimulation which is provided by peeple in the environment. Further, the infant can effectively use vocal capabilities to elicit behavior. Auditory Interaction. Communication between mother and infant begins in the immediate postpartum period, but whether conmunication is the intended purpose of infant vocalization is not discernable. Intent to communicate is inferred by parents wishing to "Mnderstand" 28 the infant or believe that the infant is attempting to communicate. Purposeful communication on some level does appear to develop quickly, and the first cry, a reflex biological phenomenon (Tonkova- Yampol'skaya, 1969), does provide the mother with a sense of assurance that her infant is alive and responding as expected. Later, crying acquires a communicative function and remains the form of communication signaling discomfort, hunger, and pain (Wolff, 1971). Wolff noted that mothers could identify three distinct cries and categorize them according to hunger, pain, and anger. Discriminations were made on the basis of pitch, pattern, and intonation. Lind and his associates (1973) showed that a hunger cry causes a physiological reaction ‘hi nursing mothers, stimulating the flow of milk that makes nursing the most likely response. They also demonstrated that very early in the relationship, mothers as well as infants are set to respond to auditory stimulation produced by the other. Need and the expressive vocalization of need set up the dialogue betweeen the baby and the human partner. A model may be envisioned of the newborn as an "open system." The infant within the system is an active seeker and responder to environmental stimulation and employs a variety of alternative behaviors through which modifications of the world are made. The child filters stimuli from the environment, choosing what is wanted to be pulled in, and subsequently integrating new selected stimuli. A newborn is able to hear well and visually locate the source of auditory stimulation, while mothers are sensitive to their own infant's auditory cues. The infant has 21 heightened sensitivity to human-like auditory stimuli (Hutt, Hutt, Lenard, Bernuth, and 29 Muntjewerff, 1968). A newborn will turn his head and visually fixate upon a source of auditory stimuli (Muir and Field, 1979). Further, a newborn has demonstrated selected responsiveness to sounds resembling human speech (Eisenberg, 1976) and has been shown to be able to identify the sound of the mother's voice (DeCasper and Fifer, 1980). Infants listen selectively to auditory stimuli as early as two days of age. In their report of microanalysis of filmed sequences (Condon and Saunder, 1974), patterning of movement during speech was found to occur across cultures and involved interactional synchrony with the speaker's vocal patterns. This synchronous movement was observed between adult speech and infant movement. According to Condon and Saunder (1974), if the infant moves in shared rhythms with the organization of the speech structure of the culture, the infant participates developmentally' through repetitions. of linguistic ‘forms before using them later in spoken communication. Other studies have noted auditory responsivity in infants. Hammond (1970) found positive-orienting behavior in 25 of 31 two-week- old infants in response to calling the infant's name by the mother. Barrett-Goldfarb and Whitehurst (1973) found that infants who were vocalizing surpressed their vocalizations during records of the parents' voices. These results show that suppressed infant vocalization produced by adult vocal stimuli is a measure of selectivity when the infant wishes to listen. This ability to be selective and suppress sounds is a helpful adaptive mechanism for the infant. Ainsworth (1967, 1969) wrote (Hi the importance of vocalizations for imitative behavior and 'functional significance of infant 3O vocalizations as demonstrations of attachment behavior. Ainsworth cemented that even though physical contact was very important many significant interactions between caregiver and infant involved distance. receptors. Vocalization is one way infant contact and attachment can be maintained through distance. A number of different methods for studying auditory/vocal interchange in the context of mother—infant interaction have been used. Some have used time sampling (Lewis, 1972; Yarrow, Rubenstein, and Pedersen, 1973); others have videotaped or 'filmed interactions (Brazelton, Kozlowski, and Main, 1974; Condon and Saunder, 1974; Stern, 1974); while other investigators have coded mother-infant behaviors continuously (Jones and Moss, 1971). Results of these investigations have suggested that for the young infant between three and six months of age, maternal vocalization contingent on the vocal responding of the infant was positively related to the overall infant vocalization, although measures of total maternal vocal response were not related to infant vocalization (Jones anui Moss, 1971; Yarrow, Rubenstein, and Pederson, 1973). These findings provide evidence that babies are ready to respond to those who care for them. They are able to discriminate and preferentially respond to the sound of the human voice which has social significance for them. Knowing these facts can facilitate parents' ability to devel0p an auditory exchange with their infants, thus leading to a true communication. Visual Interaction. Newborns can see immediately following birth (Cohen, DeLoache, and Strauss, 1979). Accompanying the baby's visual skills is the ability to explore the environment visually. Very young 31 babies in the quiet alert state will scan the environment until they see an object of interest and fixate on it with compelling intensity. During this period mutual gazing is important to the mother. Eye-to-eye contact provides mothers with a feeling of familiarity with their baby (Robson, 1967). It also gives a sense that the baby is a real person, a social being who can enter into a social relationship and arouse positive feelings for the baby (Klaus and Kennell, 1981; Robson and Moss, 1970). When eye-to-eye contact is absent, as in blind infants, Fraiberg (1974) reports the effect is disruptive to the usual course of development of the mother-infant relationship. Eyes appear to be the most compelling of the infant's traits and mothers read character and personality traits by gazing in them (Bennett, 1971). The eyes serve as distance receptors and allow visual interaction to occur more often than just when the mother is in physical contact (Walters and Parke, 1965). Techniques developed by' Fantz (1961) have been used to investigate visual preferences of newborns. Fantz (1963) found by presenting two visual stimuli to infants and measuring how long they look at each configuration, the stimuli which are best able to attract babies' attention can be detected. These studies showed that new babies prefer patterns over plain stimuli and that they especially prefer configurations resembling the human face. Round shapes similar to eyes are particularly pleasing. Eye-to-eye gazing seems to be an elementary response that is a critical aspect of human interaction, which can be observed as the new infant responds to the caregiver. 32 The neonate can best focus upon an object approximately six to eight inches away (Cohen, et al. 1979), which is the visual distance between the infant and the person caring for them when in an enface, or face-to-face position. This establishes the possibility that the visual modality can be used for making and maintaining contact with the social environment. In review of the then available evidence on the role of the distance receptors in infancy, Walters and Parke (1965) concluded that the visual as well as auditory modalities served to facilitate the development of social responsiveness. Since 1965 other investigators have suggested that the visual regard of infant and caregiver for one another serves a number of functions. In the above mentioned study by Walters and Parke (1965) of early contact between mothers and newborns, the enface position was stressed. Klaus and Kennell (1976, 1980) suggested the Inutual visual gazing facilitated by the enface position is one of the most powerful mechanisms for the stimulus of maternal attachment. Robson (1967) repeats that eye-to-eye contact may act as an innate releasing mechanism for maternal caregiving responses. In their study of 54 firstborns and their mothers, Moss and Robson (1968) studied the visual behavior of the dyads in relation to maternal attitudes. They found a positive correlation between the amount of time the infant and mother spent looking at each other's faces and prenatal attitudes toward infants. The infant appears to regulate social behavior with other people in the environment through selective visual attention. The relationship between mutual visual regard and facial expressions have also been noted. Tronick and colleagues (Tronick, Als, Adamson, 1978) described what occurred when a mother approached - .-_A~ mm... -.- - 33 the infant and made eye contact, but failed to smile or move her face, the infant eventually turned his/her head away and avoided looking at the mother. This finding may indicate that mutual eye contact is a signal that positive interaction and facial expression are going to take place. When the expected behavior does not occur, the infant withdraws. Since the mother is the major mediator of stimulation, her visual attentiveness affects the visual activity pattern of her infant. Bennett (1971) emphasized the importance of the infant's alertness, which is necessary for interactions with the environment. In addition to the infant's capacity to remain in an alert state, infant awareness is dependent on the mother's norms that influence the attainment and maintenance of awake and alert states (Osofsky, 1979). The combined research on visual communication between mother and infant suggests that the mother's visual attention functions as a setting within which the infant may or may not establish and maintain contact. The infant appears to use the visual regard of the mother to signal the beginning of a communication. The visual modality also seems to serve as a signal of positive affect for mother and infant. Most of the smiling within the social context occurs when the two are looking at each other. Merely focusing or mutual gazing is not sufficient for understanding the mother-infant interactive system. Olfactory Stimulation. Olfactory stimulation has been the most difficult type of stimulation to demonstrate in studies of infant social awareness and responsiveness. Macfarlane (1975), observed that infants could recognize maternally produced olfactory cues. Although the study was not conducted using a naturalistic setting, the findings 34 are relevant. Macfarlane determined that infants could differentiate their own mother's odor from another woman's by giving a choice of breast pads. The results indicated that when the infants were six days or older, they turned to their own mother's pads significantly more often than to other pads. The results reveal that not only do infants have differential sensitivity to odor, but their discriminatory ability becomes keener with age. In another study, findings indicate that newborns are innately responsive to odors and will, by turning away from, avoid an offensive odor such as ammonia hydroxide (Rieser, Yonas, and Wilkner, 1976). Research also indicates that newborn babies show differential responses to various tastes (Crook, 1978). Other olfactory cues are probably given off by the mother and there are questions as to the mother's olfactory sensitivity to her infant. Mothers report that they can detect a lovely odor that is distinct to their own infant. Tactile and Vestibular Movement Stimulation. A maternal calming response is the usual reaction to crying, one of the infant's most powerful signaling behaviors (Bowlby, 1969). A likely response is to pick up the crying infant after which a variety of possible events can occur. A crying newborn demonstrates proprioceptive responsiveness by quieting and becoming alert when lifted to a caretaker's shoulder (Korner and Thoman, 1970). Infant researchers have included such behaviors as touching, rocking, jiggling, caressing, and tactile playing (Lewis, 1972; Moss, 1976). The studies which use some form of manual holding are sometimes unclear as to whether contact or vestibular, proprioceptive or kinesthetic stimulation is primary in 35 producing acceleration of development. Since most handling of the infant involves changing the infant's position or otherwise moving his body, all three probably play a part. Despite the fact that several investigators have noted the importance of tactile and vestibular stimulation of healthy development in infrahuman organisms such as with rhesus monkeys (Harlow 1971), with rats (Denenberg 1964), and with rabbits (Dennenberg, DeSantis, Waite, and Thoman, 1977), there are few studies of the effect of these kinds of stimulation on human infants. Controversy in the animal literature exists as to whether tactile and vestibular stimulation has beneficial effects or whether other kinds of stimulation can produce the same beneficial outcome. Although the results of animal studies can be generalized to humans only with great caution, there is little doubt that human studies, such as those of Spitz (1945) and Mason (1942) of stimulus deprivation and the infant studies of the effects of extra stimulation on newborns, confirm the results of the animal studies (that stimulus deprivation is deleterious and stimulus enrichment beneficial). Among the salutory effects reported for human infants who receive extra tactile or vestibular stimulation are increased weight gain for premature infants (Hasselmeyer, 1964; Solkoff, Yaffee, Weintraub, and Blase, 1969), enhanced visual alertness (Korner, 1972); higher developmental scores on the Gesell Developmental Schedule (Casler, 1965); and lower levels of crying (Ambrose, 1969). However, there has been little focus on such behaviors in the study of human infants in interaction with mothers. Perhaps one important outcome has been the practice of earlier maternal contact, thus, bringing the nursery back _‘ I / 36 into a holistic model of medical care, and allowing earlier and more frequent contact between mother and infant. Resources for Mother-Infant Interactions The variables mentioned in the research literature influencing mother-infant interactions are many and varied. By looking at these resources in a systemic and integrative way a holistic approach to mother-infant interactions emerges. The varied nature of these resources illustrates the interactive processes and reduces the pr0posed importance of any single variable. This conforms with suggestions that there is a need to shift the emphasis from assessing outcome measures to identifying the process underlying the changes that occur (Sameroff and Chandler, 1975). In Figure l, resources for mother-infant interactions are given. Summary In this chapter, the factors related to parental attitudes and behavioral influences as to what parents believe a family and a child in the family should be are influential in the qualities the parents believe are important. The family is viewed as a dynamic system and the introduction (H: a new member into the parental dyad is a stress inducer. The family's ability to recover is dependent both on the ability of each member to communicate with one another and their various resources. Mother-infant interactions are believed to be positive from birth, but the question is raised if just time together is sufficient. The quality of the time and communication skill learning is believed 37 Maternal Resources Biological and genetic endowment Mother's care by own mother What was childhood like? Experience in child care with younger siblings or baby sitting Life experiences Relationship with parents while in family of origin Education--especially as related to child development Parent education classes Health of mother Ability to respond and pick up on baby's cues Family stability Relationship with husband On-going relationship with family of origin Relationship with others Course of pregnancy and delivery Planning, course, and events during pregnancy Experience with previous preg- nancies (terminated by voluntary or spontaneous abortion) ' Type of delivery Coached vs. alone Vaginal vs. Ceasarian Section Drugs received during pregnancy and delivery Supply of milk Ability to respond to infant Time allowed for mother-infant contact-~especially during first hour of life and during hospital stay Course of Postpartum Attitudes, statements, and behavior of hospital personnel Hospital routine--time allowed for mother-infant contact Figure 1 Infant Resources Biological and genetic endowment Appearance of infant Life experiences Health of infant Ease or difficulty of delivery Effects of drugs prenatally and from delivery Effects of eye medication on eye-to-eye contact Ability to suck Amount of contact during first hours of life Attitudes, statements, and behavior of hospital personnel Amount of ongoing mother-infant contact Resources for Mother-Infant Interaction 38 to facilitate positive interactions. The social interactive system of the newborn is well developed and receptive to stimuli. The interaction of mother and infant is pictured as a fitting together of two complex systems which are interrelated and interdependent. The infant's states of consciousness have been reviewed to identify the times when parent-infant communication will be most gratifying to both parents and infants. The quiet alert state is identified as the most rewarding time for interactions. Finally, the socially responsive capabilities of the neonate are discussed including all the highly developed senses of the newborn. The newborn responds dramatically to the touch, warmth, and closeness of another human being. If this sensory system of the newborn is matched with a caregiver who is sensitive and receptive to the infant's communication system, the result is an intensity and awareness that exceeds vocal exchange, and a positive communication pattern will ensue. CHAPTER III METHODOLOGY AND HYPOTHESIZED RELATIONSHIP The purpose of this study was to determine the effects of perinatal ‘coaching on mother-infant interactions, stress in the parenting system, and "eternal adaptation. Three standardized self- report instruments, videotaped recordings of mother-infant interactions, and demographic information were used in the evaluation. Two different methods of assessment were used in the evaluation of this study. Videotaped sequences were analyzed to examine behavioral interactions between mother and infant while self—report questionnaires were used to assess the attitudes of the mothers in the sample. This chapter includes e1 description of the sample selection and the research design procedure used in the study including the description of the intervention program, the testable hypotheses, and finally, the analysis to be used to interpret the data. Sample Selection Since this was research involving families in the community, the research proposal for this study was reviewed by the University Committee on Research Involving Human Subjects for approval before beginning sample selection. Further, an informed consent form (Appendix A) was signed by each participant in the study. The sample consisted of 42 first time mothers and their newborns derived from one private pediatric practice, the Lansing Pediatric Associates, in Lansing, Michgan. The practice was selected because it 39 40 is the largest pediatric practice in the area. The size of the practice and the diversity of population served offered a representative sample (fl: private pediatric families living in Lansing and the surrounding area. Each subject was in command of the English language. Each first tinwa mother who had a. normal pregnancy and Clinically normal full term infant, who was delivered in Sparrow Hospital and cared for in the regular postnatal floor of the hOSpital was asked to participate. To gather 42 first time mothers who met these criteria and were living in Ingham, Eaton, or Clinton Counties in Michgan, 65 primiparious women who delivered between November 1981 and May 1982 were asked to participate in the study. Thus the subjects were random by time of birth which can be argued to be one of the most effective randomization methods of all. First time mothers were selected to avoid the intervening variable of learning experienced in caring for another child of the family. A normal pregnancy and a well baby were included as criteria to avoid the effects of illness or other pathology either in the mother or newborn. The women were required to be English speaking to assure understanding of both the program and questionnaires utilized in the evaluation. Residence in Ingham, Eaton, and Clinton Counties was specified to limit the distance the researcher would need to travel for in-home data collection. The sample size (see Figure 2) was limited to 42 because it was the largest sample size manageable within the limits of the researcher's resources. All women who met the criteria were asked to participate until the sample size was fulfilled. The women had the right to refuse to participate or withdraw from the study at any time. 41 :mcmmmmm cow :onmmHmm quEmm :H mmmpm .N mesmwm mmwweo m.:eHmHeumvaa muwmeo m_cmwuwcpmwuma meomme mmwwwo neomme moweeo mausoHHom a:-3oHHoa mchcmmma com meeoga mcwcmmcmm cwawcmwz cowpmaHm>m mHmm Ezacmqpmoa mmmcH mmmcpm mcwmcmcma coHHmmmecH emamuomuH> msozupcmsmmmmm<-coHpm>mmmno HHmu mcocamHmH mcwpcmema Low mHHwoca mcwcmmeum :mmwgowz cowumaHm>u mHmm Eapceqpmoa xmucH mmmgum mcwpcmcma compmmemucH mmamuommm> meoz-ucmsmmmmmcmmao HHmu mcocamHmp mEozuumcwsmmoo HmpmcHLma memo Hmmwamox mcwpsom memo Hmpwamoz mcwmzom memo Hmqumoz mcwmzom . mcwzumou Hmumcwema memo Hmqumo: mcwusom memo Hmmwmmoz mewpaom menu Hmuwamoz mcwusom mcwcmmou HmpmcHema amoew comwemasouuummmzwmm HN umgmmomcozulummmmum< Hm azoeo pszHmmep Hm / \ ,/ \\ HemEmmmmmm Low gmHHmcm Hammmwwmsmcw H , \ vmmeuomvw> ma op use: we: ewe H x \ UwzquUcOZIImpMQwaHLGQ ow Umxm< NU .Hmummmm mauapcom mm umsmmoouumpmawuwmemm o» mmxm< mN Hcmsummeh m-¢ mcpcoz mm HNuvH H .Nmm saucmmumoa 42 The first 21 mother-infant pairs were placed in the control group. However, 42 mothers were contacted before 21 agreed to participate as the control group. The names of those who refused to participate were recorded and later those women's records were used as a second comparison group. The next 21 mother-infant pairs who met the same criteria as the comparison groups made up the treatment group and were contacted in Sparrow Hospital, Lansing, Michgan. To obtain 21 mother-infant pairs, 23 mothers were offered perinatal coaching. All of these mothers completed the three coaching sessions in the hospital and home, however, two mothers did not complete the fourth session. One preferred that the follow-up session not be completed because of an objection to being videotaped. Another mother was unable to read and understand sufficient English to complete the written assessments. The two mothers who did not complete the program were eliminated from the study. Design and Procedure The total sample (n=42) was divided into two groups. The control group of mothers (n=21) received routine postpartum hospital care while the treatment group (n=21) received routine postpartum care plus perinatal coaching on days one, two, and seven postpartum. The independent variable was perinatal coaching. The dependent variables were inother-infant interactions as uneasured by 'frequency counts of interactions recorded (n1 videotape sequences ~ac> c301 71 situational/demographic domain. However, statistical significance was not reached. Little support was shown for hypothesis 3, the analysis of maternal adaptation. CHAPTER V SUMMARY AND CONCLUSIONS This study was designed to explore the effects of perinatal coaching on the dependent variables of mother-infant interaction, stress in the parenting system and maternal adaptation. Forty-two first time mothers and their clinically-well newborns who were delivered in Sparrow Hospital served as the sample, All mothers and infants were from one private pediatric practice in Lansing, Michigan. Twenty-one of the mothers received perinatal coaching on days one, two, and seven postpartum, while the remaining served as the control group. Three standardized self-report instruments, videotaped recordings => I ’ .0393 9> I I m-o>oEm> 'i BI .325 w .303 > cone n> I .2 - o>oE mm> Ii ES... m HXQ > e88 e> .2-_moo> m> cogwoa ~> Ii 9.68. F> Ii APPENDIX D VIDEOTAPE RELIABILITY OF INTERACTIONAL ANALYSIS 98 Videotape Reliability of Interactional Analysis Reported in Percentages Tape Tape Tape Tape Variable 1 1 2 1 1 2 Activity Play 27 27 6 3 8 10 14 15 Breast Feed 48 49 58 58 O 0 O 0 Bottle Feed 0 0 0 O 70 70 48 52 Diapering 11 12 18 20 10 11 24 25 Burping 14 12 18 19 12 10 13 8 Position of Baby, —— Sitting on Mother 9 10 10 14 14 14 3 1 Supine on Mother 76 76 65 59 76 75 63 6O Prone on Mother 0 O 5 5 O 0 O O Upright on Shoulder 4 2 5 6 O O 10 12 Sitting-Inanimate O O O O 0 0 O O Sitting-Animate 12 12 16 16 10 11 24 27 Prone-Inanimate O 0 O 0 0 0 O 0 Vocalization of Mother Absent 49 . 54 34 32 O 0 30 29 Present 51 46 66 68 100 100 70 71 1 Vocal Pitch of Mother r Absent 53 54 34 35 O 0 3O 30 Normal Tenor O 0 O O O 0 1 0 High Pitch 47 46 66 65 100 100 68 70 M0vement by Mother Absent 72 75 79 83 90 93 42 39 Carry O O O O O 0 1 2 Shift Position 12 10 21 17 8 7 12 10 Rock/Bounce 16 15 O 0 1 O 45 49 Touch by Mother Absent 0 0 15 0 O O O O Caregiving 65' 73 48 45 9O 9O 58 97 Emotion Transmitting 35 27 37 55 10 10 42 3 Touch 99 Tape Tape Tape Tape Variable 1 2 1 2 1 2 1 2 Facial Orientation of Mother Focused (enface)-5 sec. 90 88 76 83 93 92 93 Focused (except face) 10 11 24 17 7 8 7 4 Nonfocused attention 0 1 O O O O O Movement of Baby Quiet 95 83 7O 75 8O 78 62 63 Disengaged 5 17 3O 25 20 22 38 37 Engagement of Baby Engaged 95 91 59 76 9O 89 93 84 Disengaged 5 9 41 24 10 11 7 16 Baby Vocal Behavior Absent 78 82 73 75 82 78 75 79 Cry, Scream 5 4 O O 11 12 4 3 Vocalization 14 14 27 23 7 8 17 15 Smile O O O O O 1 2 2 Burp 2 O O 2 O O 1 0 Total . 84 133 27 148 Average 2.33 3.69 .75 4.11 The results are reported in percentages. Within each variable the percentages total 100 percent. Therefore, an error in one response option is reflected by an error with the same variable in another response option, making this a very conservative estimate of reliability. To determine the intrarater reliability of the videotaped inter- actional analysis, the researcher calculated the total differences in the response options between the first and second videotapes. This total difference score was divided by 36 (the number of response options). The result indicates the average percent difference occurring across the response options for that test tape pair. BIBLIOGRAPHY g1? BIBLIOGRAPHY er ’ 91)” “*5 Abiden, R. Parenting stress index: clinical interpretation of scores. Unpublished manuscript, 1979. (Available from R. Abiden, Institute of Clinical Psychology, Room 140, Ruffner Hall, Univegsity of Virginia, 405 Emmet Street, Charlottesville, VA 22903 . Abiden, R. Parent Education and Intervention Handbook. 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