Parenting and Prematurity: Understanding Parent Experience and Preferences for Support

Infants born very preterm are at risk of developmental and behavioural problems and their parents are at risk of psychological distress and compromised parenting. This study has two key aims: (1) to identify, from the parents’ own perspective, the unique aspects of parenting an infant born very preterm and (2) to assess parent preferences for support including opinions of a new, tailored parenting intervention, Prem Baby Positive Parenting Program (Triple P). A qualitative approach was taken with focus groups of 18 parents of infants born preterm and a thematic analysis conducted. Parents identified several unique aspects of parenting an infant born preterm including: difficulty coping with the stress of hospitalisation; institutionalisation to the hospital environment; a lack of preparation for the transition to parenthood; grief; isolation; getting into “bad parenting habits” of overnurturance and a lack of certainty about developmental expectations. Parents preferred parenting support that is tailored to parents of infants born preterm, has flexible delivery, enhances coping skills and the spousal relationship and is sensitive to the emotional context of parenting an infant born preterm. Understanding the experiences and the preferences of parents of infants born preterm is an important step in tailoring parenting interventions to fit their needs.     

Attachment in preterm infants and their mothers: Neonatal risk status and maternal representations

High‐risk neonatal status, indexed by an intracranial hemorrhage (ICH), and maternal representations of past and present attachment relationships were examined as predictors of infant attachment in a sample of preterm infants. Participants included 50 19‐month‐old infants and their middle‐class, predominantly African American mothers. A maternal‐report questionnaire and a structured interview were used to assess past relationship history with mother and current relationship with infant, respectively. The Strange Situation Paradigm was used to assess attachment security. Multiple logistic regression analyses suggested that maternal representation of the infant—but not ICH or maternal childhood history—significantly predicted infant attachment security. ICH and maternal history of childhood rejection were predictive of disorganized infant attachment. The findings are consistent with previous data that suggest that maternal factors are more important than infant factors in determining infant attachment security. These data also suggest that neurological deficits may contribute to disorganized infant attachment. © 2000 Michigan Association for Infant Mental Health.     

Cumulative psychosocial and medical risk as predictors of early infant development and parenting stress in an African-American preterm sample

The present study examined predictive linkages between cumulative psychosocial and medical risk, assessed neonatally, and infant development and parenting stress at 4 months of infant corrected age. Predominantly low-income, African-American mothers and their preterm infants served as participants. Cumulative psychosocial risk predicted early mental, but not motor development, while cumulative medical risk predicted both mental and motor development. Cumulative psychosocial risk, but not medical risk, predicted parenting stress. Few studies of preterm infants have reported links between cumulative psychosocial risk and infant development at such an early age, nor has earlier work found associations between cumulative psychosocial risk and mothers' perceptions of parenting. Results support the premise that early intervention should target both the medical and psychosocial needs of low-income families with preterm infants, and that addressing psychosocial stressors shortly after birth may improve developmental outcomes in infancy.     

Exposure to child care,parenting style and attachment security

The present study addressed whether security of attachment is differentiated by quality of parenting and quantity of exposure to child care. Sixty mothers participated with their 14‐month‐old infants, who by the age of 12‐months had received either exclusive maternal care, or varying degrees of exposure to child care. Levels of attachment security were assessed through maternal completion of the Attachment Q‐Set(AQS); parenting quality was assessed through observations of mother–infant interactions during structured tasks. The scores that less sensitive mothers assign their toddlers is higher when their children are in child care for more hours per week; whereas the scores that more sensitive mothers assign their toddlers is lower when their children are in child care for more hours per week. These contrasting patterns suggest that the effects of parenting style on attachment security are moderated by quantity of exposure to child care. Copyright © 2003 John Wiley & Sons, Ltd.     

Maternal psychological distress after preterm birth: Disruptive or adaptive?

BackgroundMaternal postpartum distress is often construed as a marker of vulnerability to poor parenting. Less is known, however, about the impact of postpartum distress on parenting an infant born prematurely. The present study investigated whether high distress levels, which are particularly prevalent in mothers of preterm born infants, necessarily affect a mother’s quality of parenting.MethodLatent Class Analysis was used to group mothers (N = 197) of term, moderately, and very preterm born infants, based on their levels of distress (depression, anxiety, and PTSD symptoms) at one month postpartum, and their quality of parenting at one and six months postpartum. Parenting quality was assessed on the basis of maternal interactive behaviors (sensitivity, intrusiveness, and withdrawal) using observations, and maternal attachment representations (balanced, disengaged, or distorted) using interviews.ResultsA 5-Class model yielded the best fit to the data. The first Class (47%) of mothers was characterized by low distress levels and high-quality parenting, the second Class (20%) by low distress levels and low-quality parenting, the third Class (22%) by high distress levels and medium-quality parenting, the fourth Class (9%) by high distress levels and high-quality parenting, and finally the fifth Class (2%) by extremely high levels of distress and low-quality parenting.ConclusionsWhile heightened distress levels seem inherent to preterm birth, there appears to be substantial heterogeneity in mothers’ emotional responsivity. This study indicates that relatively high levels of distress after preterm birth do not necessarily place these mothers at increased risk with regard to poor parenting. Conversely, low distress levels do not necessarily indicate good-quality parenting. The results of the present study prompt a reconsideration of the association between postpartum distress and parenting quality, and challenge the notion that high levels of maternal distress always result in low-quality parenting practices.     

The relationship between sleep problems and working memory in children born very preterm

In two studies, the relationship between sleep and working memory performance was investigated in children born very preterm (i.e., gestation less than 32 weeks) and the possible mechanisms underlying this relationship. In Study 1, parent-reported measures of snoring, night-time sleep quality, and daytime sleepiness were collected on 89 children born very preterm aged 6 to 7 years. The children completed a verbal working memory task, as well as measures of processing speed and verbal storage capacity. Night-time sleep quality was found to be associated with verbal working memory performance over and above the variance associated with individual differences in processing speed and storage capacity, suggesting that poor sleep may have an impact on the executive component of working memory. Snoring and daytime sleepiness were not found to be associated with working memory performance. Study 2 introduced a direct measure of executive functioning and examined whether sleep problems would differentially impact the executive functioning of children born very preterm relative to children born to term. Parent-reported sleep problems were collected on 43 children born very preterm and 48 children born to term (aged 6 to 9 years). Problematic sleep was found to adversely impact executive functioning in the very preterm group, while no effect of sleep was found in the control group. These findings implicate executive dysfunction as a possible mechanism by which problematic sleep adversely impacts upon cognition in children born very preterm, and suggest that sleep problems can increase the cognitive vulnerability already experienced by many of these children.     

The predictive value of different infant attachment measures for socioemotional development at age 5 years

The predictive value of different infant attachment measures was examined in a community‐based sample of 111 healthy children (59 boys, 52 girls). Two procedures to assess infant attachment, the Attachment Q‐Set (applied on a relatively short observation period) and a shortened version of the Strange Situation Procedure (SSSP), were applied to the children at age 15 months and related to a comprehensive set of indicators of the children's socioemotional development at age 5 years. Three attachment measures were used as predictors: AQS security, SSSP security, and SSSP attachment disorganization. AQS security and SSSP security jointly predicted the security of the children's attachment representation at age 5. Apart from that, SSSP attachment disorganization was a better predictor of the children's later socioemotional development than were the other two early attachment measures. First, attachment disorganization was the only attachment measure to predict the children's later ego‐resiliency, school adjustment, and dissociation. Second, as for the socioemotional measures at age 5 that also were related to AQS or SSSP security (i.e., peer social competence and externalizing problems), the attachment security measures did not explain any extra variance beyond what was explained by attachment disorganization.     

Intrinsic and extrinsic factors associated with night waking in 9-month-old infants

This study examined relations between infant night waking and both daytime behaviors reflective of poor behavioral and emotional regulation (intrinsic factors) and parent behaviors that may contribute to infant night waking (extrinsic factors) in 41 infants. Mothers completed questionnaires and an infant sleep and crying diary. More time awake at night was related to separation distress, frequent daytime crying, dysregulation, co-sleeping with parents, breast feeding, and being put to bed asleep. More frequent waking was related to separation distress, frequent daytime crying, co-sleeping, and breast feeding. The combination of intrinsic and extrinsic factors predicted night waking better than behaviors from one category alone. Implications for parenting are discussed.     

Are parenting interventions effective in improving the relationship between mothers and their preterm infants?

Aim

To systematically review the efficacy of parenting interventions in improving the quality of the relationship between mothers and preterm infants.

Method

Randomized or quasi-randomized controlled trials (RCT) of parenting interventions for mothers of preterm infants where mother–infant relationship quality outcomes were reported. Databases searched: The Cochrane Library, PubMed, CINAHL, PsycINFO and Web of Science.

Results

Seventeen studies met the inclusion criteria, 14 with strong methodological quality. Eight parenting interventions were found to improve the quality of the mother–preterm infant relationship.

Conclusions

Heterogeneity of the interventions calls for an integrated new parenting program focusing on cue-based, responsive care from the mother to her preterm infant to improve the quality of the relationship for these mother–preterm infant dyads.     

Attachment security differs by later autism spectrum disorder: A prospective study

Although difficulties with social relationships are key to autism spectrum disorder (ASD), no previous study has examined infant attachment security prior to ASD diagnosis. We prospectively assessed attachment security at 15 months in high‐risk infants with later ASD (high‐risk/ASD, n = 16), high‐risk infants without later ASD (high‐risk/no‐ASD, n = 40), and low‐risk infants without later ASD (low‐risk/no‐ASD, n = 39) using the Strange Situation Procedure. High‐risk/ASD infants were disproportionately more likely to be classified as insecure (versus secure) and more likely to be classified as insecure‐resistant (versus secure or avoidant) than high‐risk/no‐ASD and low‐risk/no‐ASD infants. High‐risk infants with insecure‐resistant attachments were over nine times more likely to receive an ASD diagnosis than high‐risk infants with secure attachments. Insecure‐resistant attachment in high‐risk infants suggests a propensity toward negative affect with the parent in conditions of stress. Insecure‐resistant attachment may prove useful as a potential early index of propensity toward ASD diagnosis in high‐risk siblings, while insecure‐resistant attachment in the context of emergent autism may contribute to difficulties experienced by children with ASD and their families.     

Quality of attachment,perinatal risk,and mother–infant interaction in a high‐risk premature sample

Thirty‐three families, each with a premature infant born less than 33 gestational weeks, were observed in a longitudinal exploratory study. Infants were recruited in a neonatal intensive care unit, and follow‐up visits took place at 4 months and 12 months of corrected age. The severity of the perinatal problems was evaluated using the Perinatal Risk Inventory (PERI; A.P. Scheiner & M.E. Sexton, 1991 ). At 4 months, mother–infant play interaction was observed and coded according to the CARE‐index (P.M. Crittenden, 2003 ); at 12 months, the Strange Situation Procedure (SSP; M.D.S. Ainsworth, M.C. Blehar, E. Waters, & S. Wall, 1978 ) was administered. Results indicate a strong correlation between the severity of perinatal problems and the quality of attachment at 12 months. Based on the PERI, infants with high medical risks more frequently tended to be insecurely attached. There also was a significant correlation between insecure attachment and dyadic play interaction at 4 months (i.e., maternal controlling behavior and infant compulsive compliance). Moreover, specific dyadic interactive patterns could be identified as protective or as risk factors regarding the quality of attachment. Considering that attachment may have long‐term influence on child development, these results underline the need for particular attention to risk factors regarding attachment among premature infants.     

My mother is sensitive,but I am too tired to know: Infant sleep as a moderator of prospective relations between maternal sensitivity and infant outcomes

This study investigated the moderating role of infant sleep in the connections between maternal sensitivity and three indicators of infant functioning: attachment security, theory of mind, and executive functioning (EF). Maternal sensitivity was assessed when infants (27 girls and 36 boys) were 1 year of age. Infant sleep was assessed with actigraphy at age 2; attachment security, theory of mind, and EF were also assessed at age 2. Results indicated that maternal sensitivity was positively related to attachment security only among infants who got more sleep at night, and to conflict-EF and theory of mind only for infants who got greater proportions of their sleep during the night. These results suggest that sleep may enhance the benefits of maternal sensitivity for some aspects of infants’ functioning, providing further support for the importance of sleep maturation as a salient developmental task of infancy.     

Longitudinal Assessment of Sleep–Wake Regulation and Attachment Security with Parents

The development of sleep–wake regulation occurs within the context of the infant–parent relationship. The present study investigated (1) patterns of change in night waking across infancy and attachment to parents and (2) if dependency, a characteristic of secure subgroup B4 and insecure‐resistant infants, accounted for differences in night waking. Forty‐six families reported on the number of infant night wakings at 7, 12, and 14 months of age. Attachment was measured at 12 (infant–mother) and 14 (infant–father) months. Findings suggest that infants with a secure (including the dependent‐secure, B4) pattern of attachment with mothers decreased in the number of night wakings over time, whereas infants with an insecure‐resistant pattern of attachment with mothers continued to wake at night into the second year. Attachment dependency did not account for differences in night waking. These findings are important to understanding the mechanism(s) underlying the relation between attachment and sleep–wake regulation. Copyright © 2012 John Wiley & Sons, Ltd.     

Mothers’ self-reported emotion dysregulation: A potentially valid method in the field of infant mental health

In the current study, we evaluated the extent to which mothers reported emotion dysregulation on the Difficulties with Emotion Regulation Questionnaire (DERS) (a) converged with physiological indices of emotion dysregulation while parenting, (b) correlated with maternal sensitivity, and (c) predicted infant attachment disorganization and behavior problems in a sample of 259 mothers and their infants. When infants were 6 months old, mothers’ physiological arousal and regulation were measured during parenting tasks and mothers completed the DERS. Maternal sensitivity was observed during distress-eliciting tasks when infants were 6 and 14 months old. Infant attachment disorganization was assessed during the Strange Situation when infants were 14 months old and mothers reported on infants’ behavior problems when infants were 27 months old. Mothers who reported greater emotion regulation difficulties were more physiologically dysregulated during stressful parenting tasks and also showed lower levels of maternal sensitivity at 6 months. Mother-reported dysregulation predicted higher likelihood of infant attachment disorganization and more behavior problems. Results suggest that the DERS is a valid measure of maternal emotional dysregulation and may be a useful tool for future research and intervention efforts aimed toward promoting positive parenting and early child adjustment.     

Infant emotion regulation: Relations to bedtime emotional availability,attachment security,and temperament

The present study examines the influences of mothers’ emotional availability toward their infants during bedtime, infant attachment security, and interactions between bedtime parenting and attachment with infant temperamental negative affectivity, on infants’ emotion regulation strategy use at 12 and 18 months. Infants’ emotion regulation strategies were assessed during a frustration task that required infants to regulate their emotions in the absence of parental support. Whereas emotional availability was not directly related to infants’ emotion regulation strategies, infant attachment security had direct relations with infants’ orienting toward the environment and tension reduction behaviors. Both maternal emotional availability and security of the mother–infant attachment relationship interacted with infant temperamental negative affectivity to predict two strategies that were less adaptive in regulating frustration.     

Goodness of fit between prenatal maternal sleep and infant sleep: Associations with maternal depression and attachment security

The current study prospectively examined the ways in which goodness of fit between maternal and infant sleep contributes to maternal depressive symptoms and the mother-child relationship across the first years of life. In a sample of 173 mother-child dyads, maternal prenatal sleep, infant sleep, maternal depressive symptoms, and mother-child attachment security were assessed via self-report, actigraphy, and observational measures. Results suggested that a poor fit between mothers’ prenatal sleep and infants’ sleep at 8 months (measured by sleep diary and actigraphy) was associated with maternal depressive symptoms at 15 months. Additionally, maternal depression mediated the association between the interplay of mother and infant sleep (measured by sleep diary) and mother-child attachment security at 30 months. Findings emphasize the importance of the match between mother and infant sleep on maternal wellbeing and mother-child relationships and highlight the role of mothers’ perceptions of infant sleep.     

Infant communication and the mother–infant relationship: The importance of level of risk and construct measurement

Infants' emerging communication skills are understood to be associated with the maternal relationship, particularly for children experiencing high levels of social risk. This study attempts to determine the extent to which this association is influenced by (a) the mental health risk of the dyad and (b) different operational definitions and measurement of both the dyadic relationship and the construct of “communication.” Ninety‐six infants (10–30 months) and their mothers were recruited: A total of 46 were at‐risk dyads referred to a mental health clinic for relationship‐based emotional and/or behavioral difficulties, and 50 were nonrisk dyads not seeking mental health services and served as a normative reference or comparison group. Several factors were assessed: (a) developmental competence, (b) maternal psychopathology, (c) quality of mother–infant interaction during play, (d) attachment security classification, (e) prelinguistic and social‐affective communication, and (f) linguistic communication. In all infants studied, the quality of mother–infant interaction during play, rather than the attachment security classification, was associated with infants' prelinguistic and social‐affective communication abilities, but not with linguistic communication. Different aspects of mother–infant interaction predicted prelinguistic communication for clinic and comparison infants whereas only infant age predicted linguistic communication. All infants displayed communication abilities in the normal range, but the statistically poorer performance demonstrated by clinic‐referred infants could become clinically meaningful in later childhood. Best practices should include communication screening of infants presenting with attachment problems and screening for relational difficulties in infants presenting with communication delays. ©2004 Michigan Association for Infant Mental Health.     

Mother's attachment representations of their premature infant at 6 and 18 months after birth

The effects of premature birth on attachment have generally been examined from the infant's perspective. There is a lack of data concerning parental attachment representations toward a premature child. Because of the psychological stress engendered in parents confronted with a premature birth, we hypothesized that their attachment representations would be altered during the first months after the hospital discharge. Fifty families with a premature infant (25–33 gestation weeks) and a control group of 30 families with a full‐term infant participated to the study. Perinatal risks were evaluated during hospitalization. To assess mothers' representations of their infant, the Working Model of the Child Interview (WMCI, Zeanah & Benoit, 1995 & Benoit, Zeanah, Parker, Nicholson, & Coolbear, 1997) were administered when their children were 6 and 18 months old. The severity of the perinatal risks was found to have an impact on the mothers' attachment representations. At six months, only 20% of the mothers of a prematurely born infant (30% at 18 months) had secure attachment representations, vs. 53% for the control group (57% at 18 months). Furthermore, mothers of low‐risk premature infants more often had disengaged representations, whereas distorted representations were more frequent in the high‐risk group of premature children. These findings suggest that the parental response to a premature birth is linked to the severity of postnatal risks. The fact that secure attachment representations are affected in mothers of low‐risk infants just as much as they are in mothers of high‐risk infants points to the need to conduct further studies aimed at evaluating whether preventive intervention for both low‐risk and high‐risk premature will be helpful.     

COGNITIVE AND SOCIOEMOTIONAL FUNCTIONING AT 4½ YEARS IN CHILDREN BORN TO MOTHERS WHO HAVE RECEIVED TREATMENT FOR SUBSTANCE‐ABUSE PROBLEMS WHILE PREGNANT

Cognitive and socioemotional functioning at 4½ years of age were examined in children born to mothers with substance‐abuse problems (n = 22) recruited from residential treatment institutions while pregnant, and then compared to children born to mothers with mental health problems (n = 18) and children from a low‐risk group (n = 26). No significant group differences in cognitive functioning were found, but the children born to mothers with substance‐abuse problems showed more caregiver‐reported socioemotional problems than did the low‐risk children, like the children born to mothers with mental health problems. Birth weight had an effect on internalizing problems at 4½ years and mediated the relation between group and socioemotional problems, although not when controlling for caregiver education, single parenthood, and anxiety and depression. At 4½ years, 7 children born to mothers with substance‐abuse problems were placed in foster care. These children had lower birth weight and higher caregiver‐rated internalizing problems. In addition to emphasizing the importance of the quality of the prenatal environment, this study suggests that families with previous substance abuse are in need of long‐term follow‐up to address socioemotional problems and enhance further positive child cognitive development. The foster‐placed children may be in particular need of long‐term follow‐up.     

Development of self‐produced locomotion in the first year: changes in parent perceptions and infant behaviour

Self‐produced locomotion is regarded as a setting event for other developmental transitions in infancy with important implications for socioemotional development and parent–child interaction. Using an age‐held‐constant design, this study examined changes in reported infant behaviour and maternal proactive/reactive control and compared them with direct observations of infant and maternal behaviour associated with the development of self‐produced locomotion. Maternal reports were obtained prior to the locomotor transition and, for half the sample, after infants had transitioned to effective mobility. Observations of all infants were conducted shortly after the second interview. Prelocomotor and transitioning infants showed none of the expected behavioural differences (e.g. emotionality and compliance) associated with the locomotor transition. There was modest confirmation of expected differences in maternal behaviour, particularly in the use of reactive control techniques, and mothers of transitioning infants showed higher proactive controls before their infants began to crawl. These findings suggest that the changes in parent–child interaction associated with the locomotor transition may have as much to do with parental expectations than with changes in infant socioemotional behaviour. Copyright © 2010 John Wiley & Sons, Ltd.