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The effects of an intervention on adolescent mothers' initiations toward their premature infants in the neonatal intensive care unit

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The effects of an intervention on adolescent mothers' initiations toward their premature infants in the neonatal intensive care unit
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Paolini, Stacy A., 1966-
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Adolescents ( jstor )
Caregivers ( jstor )
Child development ( jstor )
Child psychology ( jstor )
Infants ( jstor )
Mothers ( jstor )
Neonatal intensive care units ( jstor )
Observational research ( jstor )
Parents ( jstor )
Social interaction ( jstor )
Dissertations, Academic -- Special Education -- UF ( lcsh )
Special Education thesis, Ph. D ( lcsh )
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theses ( marcgt )
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Thesis (Ph. D.)--University of Florida, 2001.
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Includes bibliographical references (leaves 98-107).
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Printout.
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Vita.
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by Stacy A. Paolini.

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THE EFFECTS OF AN INTERVENTION ON ADOLESCENT MOTHERS'
INITIATIONS TOWARD THEIR PREMATURE INFANTS IN THE
NEONATAL INTENSIVE CARE UNIT













BY

STACY A. PAOLINI


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY





UNIVERSITY OF FLORIDA


2001















TABLE OF CONTENTS
page

ACKNOWLEDGMENTS ....................................................... iv

A B ST R A C T ........................................................................ v

CHAPTERS

INTRODUCTION TO THE PROBLEM ..............................

Purpose of the Study ...................................................... 6
Scope of the Study ...................................................... 7
Definition of Terms .................................................. 8
O v erview .............................................. ..................... 10

2 REVIEW OF RELATED LITERATURE .............................. 11

Introduction .... ... ............................. 11
Attachment Theory and Its Role in Infant Development ............... 11
Synactive Theory and the Relationship Between Neurobehavioral
Subsystems and Their Role In Mother-Infant Interactions ............ 18
Factors that Jeopardize Parent-Preterm Infant Interactions ............ 22
E arly Intervention .......................................................... 30
Sum m ary ............................................................ . . ....... 33

3 METHODS AND PROCEDURES ...................................... 35

Intro du ctio n ............................................... ................. 3 5
M etho d s .................. ... ..................................... . ..... .. 37
P ro ced u res ................ ..... ............................................ 4 5
Experimental Design ........................................................ 50
T reatm ent of D ata ............... ........................................ 50
Pilot Study ............................................. 51

4 RESULTS .......................................................... . _55
Intro du ctio n .................... ................................. 5 5
Interobserver Agreement & Treatment Fidelity .......................... 56
T reatm ent R esults .................................. .......................... 58
Social V alidity .......................................................... . ..... 63









5 D ISC U SSIO N .................................................................. . 66
Summary & Analysis of Results ............................................. 67
Summary of Previous Literature ............................................. 68
L im itatio n s ...... ................................................................. 72
Recommendations for Future Research ...................................... 73

A P P E N D IC E S ............................................................................ 77

A PERMISSION FORMS ....................................................... 77

B DATA COLLECTION FORM ............................................ 83

C INTERVENTION SCRIPT ................................................. 85

D SOCIAL VALIDITY QUESTIONAIRE ................................ 90

E PILOT STUDY GRAPH .................................................... 92

F GRAPHS (DYAD I & 2) ................................................... 94

G GRAPHS (DYAD 3 & 4) ................................................... 96

R E F E R E N C E S ................................................................ .......... 98

BIOGRAPHICAL SKETCH ............................................................ 108














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

THE EFFECTS OF AN INTERVENTION ON ADOLESCENT MOTHERS' SOCIAL INITIATIONS TOWARD THEIR PREMATURE INFANTS IN THE NEONATAL INTENSIVE CARE UNIT By

Stacy A.Paolini

August 2001

Chairwoman: Mary Brownell

Major Department: Special Education

The purpose of this study was to investigate the effects of a modified version of the Brazelton Neonatal Behavioral Assessment Scale. Four adolescent mothers were taught about infant behavior, soothing techniques, and social initiation skills in order to increase their appropriate social initiations toward their infants in the neonatal intensive care unit. Mothers participated in training sessions, which included watching a video, observing a certified NBAS examiner demonstrating the intervention at their infants' bedside, and practicing the intervention with their infants. Additionally, mothers were asked to provide information about the social validity of the intervention. One week after discharge the researcher contacted the mothers by telephone and asked about her judgments concerning the appropriateness of the intervention, including an evaluation of whether it was fair, reasonable, and consistent with conventional notions.














A multiple baseline design was used to evaluate the effects of the intervention. Data were visually analyzed to determine if nay differences existed between the baseline behaviosr and maintenance behaviors of each mother. After receiving information about infant behavior and training on how to appropriately interact with a premature infant adolescent mothers increased their appropriate social initiations toward their infant. Additionally, all participants maintained an increased level of social interaction compared to their baseline behavior. Three of the mothers were able to maintain the social initiation skills they learned compared to intervention training. The first mother's targeted behaviors decreased slightly during maintenance compared to intervention training.

The results of the social validation measures were favorable. Participants

reported satisfaction with the information they received about infant behavior and social initiations as well as the training procedures. Some mothers reported that they had shared the information they learned with other family members, and were continuing to use the techniques at home.














CHAPTER I
INTRODUCTION TO THE PROBLEM Introduction

One of the major features of attachment theory is the belief that attachment is a behavioral system that is innate in the human species (Slater & Muir 1999). John Bowlby's (1969) early research on attachment theory underpins subsequent work on mother-infant relationships. He reported that the need for attachment is a system operating within the infant to fill affectional needs (Klann-Deluis & Hofmeister 1997). The affectional needs are established by being in close proximity to another human being and engaging in reciprocal interactions (Slater & Muir 1999). Infants use certain behaviors to try to establish an affectional bond with other human beings, most likely, but not necessarily their caregivers.

The actions of the infant such as crying, sucking, following, smiling, and clinging are used to increase the mother's proximity to the infant (Ainsworth 1995; WendlantCarro et al. 1999). The infant's needs are complimented by the maternal behavior to nurture and protect the infant. Through these reciprocal interactions the infant and the caregiver become reciprocally attached (Isabella 1993).

A central premise of attachment theory is that the formation of a secure

attachment depends on the quality of the dyadic interaction (Meins 1997). Specifically, the mother's sensitive responsiveness to the infant's signals provides the context in which the infant's experiences and feelings of security are organized (De Wolf & Ijzendoorn

I









during infancy (Fish & Stifler 1995; Vondra et al. 1995, Leavitt 1999). Early parent infant and family interactions set the stage for each infant's growth and development (Leavitt 1999).

Attachment quality was found to be a good predictor of both cognitive and social competence. Attachment measured at 13 and 24 months predicted impulse inhibition, school performance, and social behaviors at age 6 (Olson et al. 1984; 1989). While attachment quality predicts later cognitive and social competence, an infant's innate ability to demonstrate behaviors that foster interaction also affects the attachment process. Thus, the infant's ability to socially interact, and to develop subsequent cognitive and social skills, is put at risk when the infant is unable to appropriately interact with the caregiver (Main & Cassidy 1988).

A sequence of negative transactions between caregiver and infant often starts when an infant has an abnormal medical history, appearance, or behavior (Zahr 1994). After a premature birth, parent must make psychological adjustments. A mother may perceive her infant as too fragile to touch and less attractive thus decreasing their social interactions (Stem & Karraker 1990).

A mother and a premature infant in the neonatal intensive care unit are at risk for negative interactions. The mother may respond negatively or insufficiently to her premature infant because of the mother's or infant's inappropriate behaviors, and the unnatural environment of the NICU (Niven et al. 1993). Most premature infants are unable to actively interact with their parents. This is because of the characteristics and capabilities that a premature infant brings to a social encounter (Wyly 1995). Premature infants often suffer from medical complications that place them at medical risk and they









Research findings strongly support the conclusion that desirable cognitive and social emotional development is related to the quality of the parent-child interaction during infancy (Fish & Stifter 1995; Vondra et al. 1995; Leavitt 1999). Early parent infant and family interactions set the stage for each infant's growth and development (Leavitt 1999).

Attachment quality was found to be a good predictor of both cognitive and social competence. Attachment measured at 13 and 24 months predicted impulse inhibition, school performance, and social behaviors at age 6 (Olson et al. 1984; 1989). While attachment quality predicts later cognitive and social competence, an infant's innate ability to demonstrate behaviors that foster interaction also affects the attachment process. Thus, the infant's ability to socially interact, and to develop subsequent cognitive and social skills, is put at risk when the infant is unable to appropriately interact with the caregiver (Main & Cassidy 1988).

A sequence of negative transactions between caregiver and infant often starts when an infant has an abnormal medical history, appearance, or behavior (Zahr 1994). After a premature birth, parent must make psychological adjustments. A mother may perceive her infant as too fragile to touch and less attractive thus decreasing their social interactions (Stem & Karraker 1990).

A mother and a premature infant in the neonatal intensive care unit are at risk for negative interactions. The mother may respond negatively or insufficiently to her premature infant because of the mother's or infant's inappropriate behaviors, and the unnatural environment of the NICU (Niven et al. 1993). Most premature infants are unable to actively interact with their parents. This is because of the characteristics and









capabilities that a premature infant brings to a social encounter (Wyly 1995). Premature infants often suffer from medical complications that place them at medical risk and they are unable physically to give clear attachment signals (Zahr 1993). Their health status results in disorganized behavioral responses or an inability to stabilize their social interactions. Social encounters with them may be nonexistent or very different from their full-term counterparts. Compared to full-term infants, premature infants with an immature nervous system may not be predisposed to respond to interaction stimuli such as a father's or mother's touch (Eckerman & Oehler 1992).

Both prematurity and adolescent mothering increase the risk for less-than-optimal development. Factors such as poverty, lack of knowledge about child development, depression, low self confidence and the infant's medical fragility contribute to poor development (Barnard et al. 1996). In addition, how the adolescent mother relates to and interacts with her infant during the neonatal period and beyond sets in motion a series of transactions that help determine the course of her infant's development. Almost I million teenagers become pregnant each year, and about 485,000 give birth (National Center for Health Statistics 1997). Regardless of gestational age, an infant born to a teenage mother is more at risk for certain medical problems than is a baby born to an older mother (Gottwald & Thurman 1990). Nine percent of mothers' 15 to19 years old have a low-birth weight baby (National Center for Health Statistics 1997). Ten percent of mothers between the ages of 15 and 17 years have a low birth weight baby (National Center for Health Statistics 1997).

The adolescent's lack of emotional maturity and knowledge of parenting skills

puts the infant at further risk. The premature birth of an infant and the hospitalization that









follows can be an intense time for an adolescent mother. In addition to being scared and anxious, young mothers may not have the parenting skills to interact with their premature infant (Barnard et al. 1996) and these factors may hinder the attachment and interaction process.

Adolescent mothers differ from their mature counterparts in their behavior

toward their infants (Gotwald & Thurman 1990). Fogel (1991) observed that teenage mothers used fewer typical adult behaviors (high-pitched voice, touching, and synchronous movements) when interacting with their infants. Others noted that teenage mothers exhibit much warmth and physical behavior but relatively little verbal interaction with their infants (Causbly 1991, Gottwald & Thurman 1990). Moreover, adolescent mothers express less realistic developmental expectations for their infants (Field et al. 1980; Sommer et al. 2000, Als 1992). For example, they tend to overestimate or underestimate linguistic or motor capabilities of their infant. Thus, children of adolescent mothers may be susceptible to developmental problems partly because of their exposure to a less optimal care-giving environment.

Because many adolescent mothers do not manage to stay in school, are not

knowledgeable about child development, and often seem to posses conflicting attitudes about mothering, these are the mothers whose premature infants are at-risk for social interaction problems and in need of early intervention (Boyce et al. 1991). An obvious goal of intervention studies is to develop procedures that would increase parental knowledge and enhance mother-infant interactions (Lamour & Lebovici 1991). Unfortunately, there is little research on early intervention treatments for improving interactions between adolescent mothers and premature infants despite a limited number









of studies that demonstrate poor social interactions between adolescent mothers and premature infants and that demonstrate insufficient attachments (Hamilton 1996). Therefore, it is necessary to develop and test more interventions that enhance the quality of adolescent mother's interactions by presenting information about the infant's behavior, soothing techniques, and appropriate social interactions.

Several studies have shown that increasing parental awareness of the infant's competencies can enhance parent-infant interaction (Brazelton et al. 1987, Nugent & Brazelton 1988). Mothers who have been familiarized with the infant's capacities are more likely to spend time stimulating the infant, to pay more attention to the infant, and to be more responsive to the infant's signals (Widmeyer & Field 1987). Moreover, mothers who were actively involved in the administration of the Neonatal Behavioral Assessment Scale increased their responsiveness to the infant compared to mothers who only observed the administration (Worobey & Belsky 1982). Worobey and Belsky (1982) suggested that the effect could be reciprocal, since the infant would, in response to increased responsiveness, make greater demands on the caregiver and would further enrich the interaction.

Purpose of the Study

The purpose of this study was to determine the effects of an intervention on

adolescent mothers' social initiations toward their premature infants while they are in the NICU. The research question answered through this study was as follows: Will teaching adolescent mothers about their premature infants' behavioral states, stress signals, soothing techniques, and social interactions increase their appropriate social initiations with their infants?









Specifically, a behavioral intervention was used that incorporated a modified

version of the Brazelton Neurobehavioral Assessment Scale. Results of this investigation added knowledge about the effects of using the modified NBAS on parents' knowledge of infant behavior and their subsequent ability to interact with their infant.

Scope of the Study

This study was conducted within a limited scope. The delimitations and limitations of this research are described in the following sections. Delimitations

The study was delimited by geographical location to Gainesville, Florida, a

medium-sized city located in the north central part of the state. The study was conducted at Shands Teaching Hospital Regional Neonatal Intensive Care Unit (NICU) at the University of Florida Health Science Center, Gainesville.

The NICU was a level III tertiary unit that provided state-of -the-art care to medically fragile infants. The NICU staff focused on family-centered care for infants and family members and excellent medical care for premature and medically fragile infants. Family-centered care offered families the opportunity to participate in nonmedical activities, such as feedings, baths, and diaper changes. In addition, informal family support groups were offered weekly to give families the opportunity to interact with each other. The hospital served infants and their families from southern Georgia to southern Florida.

Subjects

Four mother-infant dyads from the NICU were selected from Shands Teaching Hospital to participate in this research. Medical charts were used to identify mother-









infant dyads who met the following criteria: a) the mothers were between 15 and 19 years of age and delivered their infants in the NICU; and (b) the infants were of a singleton birth, were no older than 38 weeks gestational age, weighed 1 100 to 3300 grams, were without congenital malformations or disorders, were medically stable, and were admitted to the NICU. Someone other than the researcher reviewed the medical charts and made the initial contact with the mother to obtain verbal interest in participating in the project. After obtaining a verbal commitment the researcher talked with the mother and guardian to explain the research procedures and obtain written consent.

Permission for this study was obtained from the Shands Teaching Hospital Institutional Review Board and the guardian of the adolescent mothers. First, the researcher reviewed the medical charts to select mother-infant dyads. Next, eligible families were contacted and the researcher explained the purpose of the study and asked the families for their participation. The adolescent mother and her guardian reviewed the consent form. The mother and guardian had the option of signing the form or refusing to allow the mother to participate. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A.

Limitations

The findings of this study should not be generalized to mother-infant dyads

consisting of adult mothers of healthy or critically ill infants. Four mother-infant dyads participated in this study.

Definition of Terms

Adolescent mother. Mothers who are between 15 and 19 years of age









Brazelton Neonatal Assessment Scale. Test of a newborn's reflexes, behavior, and responses to his/her environment.

Full-term infant. infants born between 38 and 42 weeks gestation.

Infant stress. Critical problems commonly observed among preterm infants, which include, blue lips, increased heart rate (above 180 beats), decreased heart rate (below 100 beats), vomiting, and apnea.

Neonatal intensive care unit (NICU). The NICU is a unit of the hospital with trained staff and special equipment to provide medical care to critically ill newborn infants.

Neurobehavioral states. Organized periods of sleep and alertness that appears

with regularity. These periods are called infant states and are relatively stable clusters of functional patterns and physiological variables that are organized and repeated. They reflect the infant's level of arousal, determine their reaction to the environment, and can be modified in response to external stimulation. They are considered reliable indicators of the integrity of the central nervous system.

Premature infant. Infants who are less than 38 weeks gestational age.

Social initiation, Any motor or vocal behavior (clearly directed to the infant) that attempts to elicit social responses such as greeting, gaze, facial expression, touching, calling the infant's name, and any other socially directed behavior.

State 1. A sleep state defined as eyes closed, regular breathing, and little-to-no spontaneous body movements.

State 2. A drowsy or semi-dozing state. The infant's eyes may be open but dull and heavily lidded with low physical activity.









State 3. Defined as alert, with eyes opened and the infant seems to focus attention on a source of stimulation.

State 4. An irritable state with considerable motor activity. There are brief fussy vocalizations.

State 5. A crying state that is characterized as intense. It is difficult to stop this crying with soothing techniques.

Stimuli. An object that directly influences the activity of an organism.

Swaddle. Wrapping an infant in a blanket so that the body and movements are contained.

Overview

An investigation of the effects of an intervention on the social initiations of

adolescent mothers toward their premature infant was the focus of this study. Chapter 2 reviews and analyzes relevant professional literature in the areas of attachment theory, adolescent mothers and premature infants. Chapter 3 describes the methods and procedures to be used in this study. The results obtained from the intervention will be discussed in Chapter 4. Finally, Chapter 5 includes a discussion of the results as related to previous research, implications, and recommendations for future research.














CHAPTER 2
REVIEW OF RELATED LITERATURE Introduction

Chapter 2 includes a summary and analysis of the professional literature. The literature on the role of attachment on infant development, the importance of motherinfant social interactions, and the factors that jeopardize mother infant interactions are presented.

This chapter is divided into several sections. The theoretical and empirical basis for training adolescent mothers of premature infants in the NICU using a behavioral intervention is shown in the first section. The other sections summarize, analyze relevant studies about mother-infant social interaction and its effect on attachment; and discuss how the attachment process is jeopardized when the infant is born premature, and the increased risk these premature infants incur when they are born to adolescent mothers. I also examine early intervention in the neonatal intensive care unit. This chapter concludes with a summary of the research findings.


Attachment Theory and its Role in Infant Development

John Bowlby's theory of attachment (1958,1969) provides the basis for research examining the relationship between infants and caregivers that has spanned approximately five decades (Slater & Muir 1999). Bowlby (1969) concluded that there was a biologically-based need for social interaction in human infants that eventually









became focused primarily on specific figures such as the mother or father (Slater & Muir 1999). Bowlby (1960) explained that infants come equipped with a repertoire of behavioral cues that are designed to elicit responses from the caregiver. These cues, such as crying, sucking, following, smiling, and clinging are used to gain proximity to the caregiver (Main & Solomon 1990). For example, the infant's cry serves to elicit adult responses that usually involve an offer to pick up the infant, and thus the infant's crying ends. The efficacy of the infant's behavioral cues depends on the appropriateness of the caregiver's response. Infants become attached to individuals who consistently and appropriately respond to their signals. Thus, reciprocity between infant and caregiver becomes crucial in the attachment process (Main & Solomon 1990; Ainsworth 1990).

Infant attachment develops over time, moving through several phases that are

qualitatively different. The four phases of attachment are Phase 1, preattachment; Phase 2, attachment in the making; Phase 3, clear cut attachment; and Phase 4, goal corrected partnership (Slater & Muir 1999).

The preattachment phase begins at birth and continues for 3 to 4 weeks. From the beginning, the infant is more aware of certain stimuli than others. The infant is equipped with behaviors, such as crying, that operate to attract the caregiver to come near. At first these attachment behaviors are emitted, rather than directed toward any specific person, but gradually the baby begins to discriminate one person from another and to direct attachment behavior differentially (Main & Solomon 1990). Research indicates that the infants are more interested in people; however, they are unable to discriminate one person from another, and therefore do not differentially respond to caregivers versus other people (Slater & Muir 1999; Fox et al. 1991). The infant can orient toward anyone who









is in sufficiently close proximity, directing gaze toward that person and tracking his or her movements with his eyes. She is equipped with signaling behaviors such as crying and smiling, which she uses to induce people to approach and perhaps pick up the infant, thus promoting proximity and contact (Meins1997). These crying and smiling behaviors are classified as attachment behaviors (Slater & Muir 1999; Fox et al. 1991). Phase I comes to an end when the infant is capable of discriminating between people and, in particular, of discriminating his mother from others.

During Phase 2, attachment in the making, the infant not only clearly

discriminates unfamiliar from familiar figures, but also discriminates among other stimuli, such as toys. For instance, research shows that the infant discriminates among adults by directing attachment behaviors, such as reaching and grasping, which enable proximity, toward some adults and not others, and these people may also differ in how readily they interact with the infant (Slater & Muir 1999; Fox, Kimmerly & Schaffer 1991).

In Phase 3, clear-cut attachment, the infant is more active in seeking and

achieving proximity. He makes contact with his preferred caregiver on his own account. That is, the child moves toward the caregiver rather than relying on a signaling behavior and waiting for the caregiver to respond (Slater & Muir 1999). Although the infant is more active in seeking proximity, he does so intermittently. At this point the child becomes more independent. The infant is active in exploring his environment, manipulating the objects discovered, and learning about their properties. Although securely attached children seem to explore the environment independently, they still look









to their parents for comfort as they play. Parents thus, provide a secure background from which infants explore their environment (Slater & Muir 1999).

In the goal-corrected partnership phase, the last phase of early attachment, the child begins to see his mother's perspective, and is able to infer what feelings and motives might influence her behavior (Slater & Muir 1999). For example, the child may cry purposely to gain sympathy from a mother. When this point of development has been reached, mother and child develop a complex affectional bond that continues through the child's entire lifespan (Ainsworth 1995). While parent/child attachment may weaken as adulthood approaches and may be supplemented by other attachments, few, if any adults, cease to be influenced by their early attachments (Fox et al. 1991; Ainsworth 1990).

A main characteristic of securely attached children is their ability to use their mother as a secure base from which to explore their environment (Main & Hess 1990). When a child exhibits secure base behavior, he returns to the mother before venturing out for exploration, maybe bringing her back a toy or attracting attention with a vocalization (Main & Solomon 1990). Even if securely attached children do not physically return to their mothers, they often use visual referencing to emphasize their exploration (Leavitt 1999). That is, they sometimes look at their mother or hold up a toy to secure some type of response. If the mother can understand the child's cues, then she can interact with the child in ways that improve cognitive and social development (Leavitt 1999). Such children know that their mothers will be available for support and comfort if it is needed, and thus often explore their environment (Main & Hess 1990; Sroufe et al. 1990). The child's knowledge is not something that is instinctual; rather, it is based on the child's









past experiences and the mother's demonstration of her availability and nurturance over a long period of time (Slater & Muir 1999).

A central feature of optimal or secure attachment is the mother's ability to

respond to her infant's signals (Grossman & Grossman 1992), which is highly dependent on her perceptions and expectations of her infant's behavior (Leavitt 1999). Main and Solomon, (1990) found that mothers of securely attached children were more sensitive, accepting, cooperative, and accessible to their infants' requests than mothers of insecure infants. Moreover, mothers of securely attached infants were responsive to their infants' cries, had positive views about themselves and their infants, and were more skilled in feeding and playing. In contrast, mothers of insecure infants tended to be tense, irritable, and lacking confidence, reacting negatively to motherhood and handling their infants as little as possible or inappropriately. The mother who responded inappropriately tried to socialize with the infant when she/he was hungry, played with the infant when tired, or fed the infant when she was trying to initiate social interaction. The result was that their infants were less alert and did not appear to seek responsive interaction with their mothers (Main & Solomon 1990).

The types of caregiving characteristics Main and Solomon (1990) identified in mothers of securely attached infants, are referred to as maternal sensitivity (Ainsworth 1995). Maternal sensitivity is defined as the ability to be aware of the infant's signals, to interpret them accurately and to respond to them in a prompt and appropriate manner (Van den Boom 1997; Ainsworth 1995). Ainsworth (1995) asserted that the most important index of sensitivity was the mother's quality of interaction with her infant, and the appropriateness of her responses. The caregivers' ability to select an appropriate









reaction affects the development of reciprocal interactions between caregiver and infant, as the quality of the interaction depends on the infant's ability to communicate accurately through behavioral cues or language (Van den Boom 1997).

Ainsworth (1995) stated that attachment behavior is an active response by the

infant, and therefore requires the involvement of cognition. In order to become securely attached, the infant must have sufficient cognitive ability to search for objects or people and must have the ability to maintain contact with a desired object or person, which cannot be seen (De Wolff& Van Ijzendoorn 1997). The infant also must be able to form a mental representation of a hidden object or person, to search for it, and to use signaling behaviors or physical proximity to achieve maternal responses (Meins 1997).

The infant uses his or her cognitive ability to form attachments, how the mother responds to signaling effort, also affects the infant's future cognitive development (Ainsworth 1995). The mothers of securely attached children provide appropriate environmental support in everyday interactions and in novel situations. This support helps children feel in charge of their environment and subsequently, their sense of confidence and self-efficacy is increased (De Wolff& Van Ijzendoor 1997). The mother's manner of responding to the infant can help her/him develop the self-confidence she/he needs to persist with play tasks that are complex. Children who believe they are capable of accomplishing a task persist longer and are more successful at problem solving (Frankel & Baes 1990). This increased self-efficacy and confidence may explain why Hazen & Dunst (1982) found that securely attached infants explored their environment more independently and were more innovative in solving spatial problems.









Research examining the relationship between security of attachment and symbolic play shows that securely attached toddlers engage in more frequent and sophisticated sequences of imaginative play then do their insecurely attached peers (Bailargen 1994). Securely attached children are more likely to organize their play around a theme, and their play is enhanced by maternal involvement (Slade 1987). In contrast insecure children are dependent on others to structure their imaginative play.

Quality of attachment also seems to affect social development. Turner (1993)

found that children who had insecure attachments in infancy were rated by their teachers as being significantly more dependent than were their securely attached peers. The insecurely attached infants were more likely to seek help in self and social management, and spent more time in close proximity to their teachers or sitting on their teacher's lap. Children who were securely attached, in contrast, seemed more social. For instance, Grossman and Grossman (1985) reported that 3-year-olds who had been classified as securely attached in infancy interacted more quickly and smoothly with a stranger. This observation was made on the basis of the children's initial reaction to the researcher entering their home. The securely attached children tended to approach the researcher in their home without hesitation and talked to him without being asked to do so; whereas the insecure children were more likely to hide from the researcher, to cry or to cling to their mothers.

Predictive studies also suggest that quality of attachment predicts later cognitive and social competence. Olson and her colleagues (1984) investigated individual differences in cognitive competence for children assessed at 6,13, and 24 months old. Verbal interactions between mothers and infants at the three ages were associated with









school performance and social behaviors (Olson et al. 1984). These same children were assessed at 6 and 8 years old and early mother-child interactions were significant predictors of their cognition (Olson et al. 1992). Attachment quality at infancy also predicted later problem-solving skills and social competence with toddlers (Main & Cassidy 1988).

The preceding examples illustrate that interactions between child and parent

facilitate or hinder optimal development. A closer look at the abilities of the infant and the mother help researchers to understand how they can intervene in the process. The newborn's neurobehavioral organization affects how they interact with stimulus and form attachments with their caregivers. The quality of the caregiver's responses can be disturbed by the infant's immature neurological system. Without an intact neurobehavioral system, the infant can have difficulty sending clear signals to the mother, thus the mother has difficulty responding accurately; setting in motion a chain of events that can affect the attachment process negatively.

Synactive Theory and the Relationship Between Neurobehavioral Subsystems and their Role in Mother-Infant Interactions

Synactive theory is used to describe how the subsystems of the infant's central nervous system function and interact to affect the infant's neurobehavioral organization and ability to respond to external stimuli (Als 1992). Neurobehavioral organization refers to the infant's ability to maintain and manage the subsystems of autonomic stability, motor system, behavioral states, attentional interactions, and self-regulation in interactions with the environment (Wyly 1995; Als 1992; Brazelton 1990). The









organization of these subsystems affects the infant's interaction with the environment and caregivers (Als & Duffy 1990).

In full-term infants, these subsystems interact and support each other, reflecting a well-organized, mature nervous system. Full-term infants have little difficulty negotiating the environment because a stable autonomic and motor system allows the infant to control state behaviors, self-regulate their stress responses to the environment, and remain available for interaction with caregivers (Wyly 1995). These subsystems build upon one another and interact together to create a well-organized neurobehavioral system for the infant. Thus the functioning of these subsystems is described as synactive (Als 1982).

The functioning of the infant's subsystems is observable (Wyly 1995). The functioning of the autonomic system can be observed by assessing respiration, color changes, and visceral signals, such as gagging and hiccups (Als 1984). Autonomic stability is an absolute prerequisite for the emergence of the other subsystems. Without it, there can be no state regulation. The motor system is behaviorally observable in posture, tone, and movements and is assessed to determine functioning of the infant's motor system (Als 1984). States of consciousness, from sleeping to alert, identify the state organizational system (Als 1984). State regulation is the "glue" that holds the subsystems together, allowing the infant to effectively use all other subsystems (Als, 1984). The attention and interaction systems allow the infant to come to an alert attentive state and to use this state, attending to incoming cognitive and social emotional information and to subsequently respond to such information (Als 1984). The regulatory









system is defined by strategies that infants use to maintain a balanced, relatively stable and relaxed state of subsystem integration (Als 1984).

These subsystems build on each other, and the infant must have stability in the lowest subsystem before she/he can gain stability in the next subsytem (Fogel 1991). That is, the infant must have stability in the autonomic subsystems before appropriate motor control can be achieved. In order to achieve state regulation, the infant must have stability over the motor, as well as over the autonomic subsystems (Als 1984). In the same respect, in order to have interactive abilities, the infant must have stability in the attentional, motor, and autonomic subsystem (Als 1984). Optimal self-regulation occurs only when there is appropriate stability in all other subsystems.

The healthy full-term infant's subsystems interact simultaneously, reflecting a well-organized, mature central nervous system (Brazelton & Kramer 1991). The integrated function of the subsystems enables the healthy full term infant to interact with the environment in an organized, smooth, balanced, and stress-free way. Healthy infants use clear signals to communicate with their caregivers, and their states of consciousness are clear and easily recognized by the caregiver (Hiniker & Moreno 1994). Their autonomic stability in terms of respiratory control, temperature regulation, and digestive functioning, is restabilized after the birth process, as are smoothness of body movements including their flexor and extensor posture (Lefrak-Okikawa & Lund 1995). The same is true for state organization and transition between states. Healthy newborn infants have no difficulty achieving a robust crying state and can return to a sleep state (Hiniker & Moreno 1994).









In the first few weeks after birth, newborns begin to stabilize their

neurobehavioral subsystems (Brazelton & Krammer 1990). For example, they move from sleep to aroused crying states and back to a sleep state. A two-day-old infant still has difficulty coming to an alert state for long periods of time, but by three weeks these periods of alertness become increasingly reliable and solidified (Brazelton & Krammer 1990). By one month to six weeks many infants spend an hour or more in an alert, socially and cognitively available state, ready to interact with their caregiver (Brazelton & Krammer 1990). It is the infant's neurobehavioral organization that allows them to remain in alert states and transition to sleep states when appropriate.

Not all newborn infants are able to coordinate their subsystems to obtain this interactional, attentional capacity, particularly those who are born premature (Wyly 1995). After 24 to 27 weeks post-conception, the human fetus can be kept alive in an extrauterine environment due to the advances of medical technology. However, the infant is biologically expecting 13-16 more weeks of in-utero existence, with respiratory, cardiac, digestive, and temperature control aided by maternal blood flow and placenta functioning (Wells et al. 1994). Instead the infant has to make a dramatic adaptation to the NICU environment and relies on medical technology to control his autonomic functioning while the motor system, the state organizational system, and sensory functioning depends on the infant's environment. The premature infant has difficulty negotiating a balance between subsystems because of central nervous system and autonomic immaturity (Als 1992). The infant's subsystems are unable to operate in an integrated and supportive manner causing the infant to "shut out" environmental stimuli in order to stabilize autonomic functions that are necessary for survival (Tronik et al.









1997). As a result, they are unable to coordinate their neurobehavioral system to interact appropriately with the environment (Tronik et al. 1997; Als 1984).

The premature infant's immature central nervous system, and inability to integrate subsystems and maintain behavioral organization reduces the ability to interact with environmental stimuli, including the caregiver. Thus, the preterm infant may not be able to develop the reciprocal interactions noted between healthy infants and their caregivers. Moreover, preterm infants are placed at increased risk by both environmental and biological factors such as: the NICU environment, degree of prematurity, parental perceptions, and parental age. These environmental and biological risk factors combined can increase the developmental risk status of an infant.

Factors that jeopardize parent-preterm

infant interactions

Barriers Created in the NICU

Infants and their caregivers who are in the NICU do not always experience the positive results of a successful attachment process. For preterm infants in the NICU, the development of normal interactional processes, so essential to attachment, may be altered by many factors including the NICU environment, infant characteristics, parents' perceptions of their infant, and parental age. While preterm infants develop affectional ties with caregivers using the same mechanisms as full- term infants, the attachment process may be much slower to develop and difficult to identify because of the risk factors mentioned earlier.

The NICU environment, designed to medically sustain the life of a fragile

preterm infant is a sharp contrast to the peaceful intrauterine environment. The NICU not









only serves as a medical support for the infant but also as a backdrop for early social, emotional, and cognitive interactions (Stem & Karaker 1990). Unlike the home environment, which is often designed to foster developmental growth for the full term infant, the NICU environment taxes premature infants and makes it difficult to respond even minimally to caregivers (Perehudoff 1990). Preterm infants in the NICU are exposed to more adult speech, other infant cries, and generally higher levels of noise and light (Perehudoff 1990). Further, preterm NICU infants have little opportunity to experience contingent social interactions typically experienced by term infants (Stem & Karraker 1990). Heriza and Sweeny (1990) suggest that infants in the NICU receive the wrong kinds of stimulation administered by the wrong persons. Premature infants are frequently handled but for such procedures as intubation, heel sticks, and diapering or repositioning after medical care by medical personnel (Peters 1992). Specifically, Peters (1992) reported 120 to 245 contacts, such as taking blood, by health care providers per 24 hours. These contacts are associated with increased infant stress. These contacts can leave premature infants with little energy to interact with their caregivers.

Not only does the premature infant experience stress, but so do the parents. Parents often perceive the NICU environments as stressful and overwhelming. This contributes to difficulties in establishing positive parent-infant interactions (Miles & Carter 1983). Parent-infant interactions are often affected adversely by many aspects of the NICU environment such as noise, constant lighting, constant medical activity, and lack of privacy (Graven et al. 1992). The NICUs with limited visiting hours can also have a negative effect on parents' involvement with their infants. Paludetto et al. (1984) compared interaction patterns of parents in NICUs with limited visiting hours to those in









NICUs with unlimited visiting hours. Thirteen percent of the parents with limited visiting hours did not interact with their infants, compared to only 2.2 % of the parents with unlimited visits.

The NICU staff can also present barriers to parent's involvement and subsequent interactions with their infants. Sometimes, NICU staff may be unwilling to allow parents to participate in their infant's care. McCluskey-Fawcett et al. (1992) found that those who reported the most positive experiences in the NICU were parents who NICU staff viewed as interested and capable of caring for their infants. Risk Factors Presented by the Preterm Infant

The characteristics premature infants exhibit also can interfere with social

relationships with their parents. In fact, early social encounters of premature infants and their caregivers can differ dramatically in frequency and intensity (Lester et al. 1985). These differences can be due, in part, to the characteristics and capabilities premature infants bring to the social encounter. Often premature infants in the intensive care nursery are fragile and physically unable to give clear attachment signals (Minde 1993). Very low-birth -weight infants frequently experience a variety of medical problems that place them at medical risk: for example, apnea, bradycardia, hypoxia, and respiratory distress syndrome. Their precarious medical state can result in disorganized behavioral responses or the inability to stabilize their social interactions (Gustafson & Harris 1990). Thus, social encounters may be nonexistent or very different from those of full-term counterparts.

Additionally, the premature infant's central nervous system may be much less

developed than the nervous system of term babies. Premature infants, for example, have









greater difficulty regulating autonomic responses and states (Prechtl et al. 1979). They have been found to cry less and with less vigor than full-term infants (Divitto & Goldberg 1979). Compared to full-term newborns, premature infants may not respond as readily to interaction stimuli, such as a father's or mother's touch (Eckerman & Oehler 1992). When they do respond, their behavioral cues may be markedly different from the behavioral cues of full-term infants. Their cues may be weaker and more difficult to read. Moreover, premature infants present avoidance cues, such as gaze aversion or crying in their caregiver's presence, more often than full term infants. Because of these characteristics, preterm infants may not experience as many social encounters, or may have encounters that are dramatically different from their full term counterparts (Minde 1993).

A key component in any parent-infant interaction is the infant's signaling

behaviors (Leavitt 1999). If parents are to read, interpret, and respond accurately to their infant's signals, the infant's behaviors and cries must be clear (Harrison 1990; Landry et al. 1990). For premature infants, particularly very young premature ones, communication cues are unclear at best. Mixed or confusing signals of premature infants make it difficult for caregivers to respond appropriately (Harrison 1990; Landry et al. 1990). Consequently, communication cues are not reciprocated by caregivers which leads to less frequent social interactions (Leavitt 1999).

Prenatal Factors that Contribute to Poor Attachment

The difficulties the premature infant exhibits can heighten parents stress and

negative emotions, and these characteristics can affect their attitudes toward their infant, and psychosocial interactions with them (Bass 1991). The unexpected early birth and









lengthy hospital stay for the premature infant can increase stress associated with parenting a premature infant (Eckerman & Oehler 1992). After a premature birth, parents must make psychological adjustments. They must reconcile that their baby was born premature and mourn the perfect, imagined baby that they had dreamed about during their pregnancy (Brazelton & Krammer 1990). This mourning process can have a dramatic effect on infant/parent interaction. Mothers have been shown to be detached and withdrawn in interactions with their infants due to the premature birth of their infant (Wilfong et al.199 1).

Parents' perceptions of what premature babies are like may also influence

subsequent interactions with their premature infant (Padden & Glenn 1997). Despite the variety of backgrounds and experiences parents bring to the NICU, studies have shown that they have preconceived ideas about premature babies that affect their interaction with those babies (Stem & Hilderbrant 1986; Padden & Glennn 1997; Wilfong et al., 1991; Stem & Karraker 1990). Stem and Hilderbrandt (1986) asked mothers to interact with healthy full term infants who were labeled as either full term or premature. Mothers who believed they were interacting with premature infants touched them less and gave them more immature toys than did the mothers who believed they were interacting with full term infants. Mothers also rated premature infants as less active, more fragile, and less attractive than the full term infants and their perceptions decreased their interactions with premature infants (Stem & Hilderbrant 1986; Stem & Karraker 1990).

Perceptions, however, can be mediated by factors, such as social support. Studies focusing on family relationships, parental stresses, and social support found that parents with high levels of social support exhibited lower levels of stress and subsequently more









positive attitudes toward their premature infants ( Spiker et al. 1993; Parker et al. 1992; Obrien & Dale 1994). Moreover, these studies found that improved parental attitudes were often assosicated with greater behavioral responsiveness in both parents and infants. Thus, social support can improve the quality of interactions parents and their premature infants have.

Increased Risks for Adolescent Mothers

There is an increased risk for premature infants who are born to adolescent

mothers. The premature birth of an infant and the hospitalization that follows can be a time of intense feelings for an adolescent mother who has little experience in parenthood. She may feel depressed, happy, angry, scared, guilty, and incompetent, in combination or independently (Barnard et al. 1996). Clearly, these intense and often conflicting feelings can affect the manner in which the young mother interacts with her infant.

The mother's adolescent status also accrues additional risk factors that affect the premature infant in the long-term. Children of adolescent mothers are more likely to be born into and continue to live in poverty and to be physically, emotionally, and intellectually compromised as they develop (Sommer et al. 2000). Marecek (1980) reported that infants of adolescent mothers performed less well than infants of adult mothers on the Bayley developmental scales at eight months of age, the Stanford-Binet at four years, and the WISC at seven years Moreover, Browman's (1981) longitudinal study revealed a higher percentage of mild retardation among children of young mothers than was present in the general population. More recently, Culp, Osofsky and O'Brien, (1996) found that infants of adolescent mothers had fewer vocalizations than did infants of adult mothers. Aggressiveness, impulsivity, and distractibility have also been found to









be common in children of adolescent mothers (Hechtman 1989), along with a disproportionate percentage of insecure attachments (Ward & Carlson 1995). These factors, in combination with diminished intellectual capacities, set the stage for multiple developmental and academic problems during the early school years (Sommer et al., 2000).

The adolescent mother herself is educationally and economically disadvantaged. These young women are less likely to complete high school and are more likely to have larger families and to continue to live in poverty (Dukewhich 1997). Giving birth and the demands of motherhood usually decrease their school performance further and become precipitating factors in their decision to drop out (Prater 1997).

Although motherhood is demanding for any woman, it is particularly difficult for adolescent girls (Camerrena et al. 1998). The adolescent mother is not only trying to establish herself as a mother but as an independent being, but as a mother. Her newly found responsibilities as a mother affect her search for identity (Wartena 1997). While she is trying to establish herself as an independent adult, the adolescent mother still exhibits many child-like tendencies (Barnard et al. 1996, Stevens-Simon & Nelligan 1998). Her search for autonomy is now affected by the responsibilities she has in caring for her infant, which she often does not welcome. She has difficulty planning for the future, a necessary parenting skill, and is oriented toward the gratification available in the present environment (Hulbert et al. 1997). Thus, adolescent mothers often see responsibility for their infants as an impediment to gratification and autonomy (Boyce Chestman, & Winkleby, 1991). In turn, they may resent the infant and often display a









greater tendency toward child abuse (Barnard et al. 1996; McCullough 1998; Mylod Whitmanm, & Borkowski 1997).

Additionally, adolescent mothers are less adept at interacting with their infants compared to their older counterparts. Researchers assert that adolescent mothers, compared to their more mature counterparts, may a) engage in fewer verbal interactions with their infants, b) interpret their infants cues less accurately, and c) respond to their infants less frequently (Causby 1991; Gotwald & Thurman 1990). Thus, a higher risk exists for developing inappropriate social interactions between adolescent mothers and their premature infants (Causby 1991).

The NICU environment further affects the adolescent mother's ability to interact appropriately with her infant (Edwards & Saunders 1990). Bell (1997) examined adolescent mothers' perceptions of the stressors in the NICU environment. Bell concluded that adolescent mothers and their premature infants might fail to become attached because the mother's parenting role is insufficiently clear during the infant's hospitalization. These mothers reported that the most stressful aspects of the NICU were parental role alterations and the infant's appearance and behavior (Bell 1997). These stressors appeared to affect mothers' involvement and connection with their infant. For instance, parents were restricted in their role as daily caregiver and disappointed in their infants' ability to sustain an alert state.

The NICU environment can also be intimidating to an adolescent mother. The

ventilators, monitors, alarms, lack of privacy, preponderance of authority figures, and the infant's fragile condition all work against an adolescent mother's willingness to visit the NICU and spend time with her infant (Causby 1991). Besides her fear and anxiety, a









young mother may not have appropriate social skills to take advantage of resources offered in the NICU environment. Adolescents are excessively self-conscious (McGovern 1990), and may be hesitant to assert themselves as parents and more likely to rely on NICU staff for guidance. Given that many NICU staff have strong views about the role of parents in the NICU, the adolescent mother may be further disengaged from her infant.

The birth of a premature infant, the characteristics of that infant, and the NICU environment can have profound effects on the social development of the infant and the mother's attitudes toward her infant (Griffin 1990). For the adolescent, who is in the midst of profound life changes, the impact of mothering a premature infant may prove overwhelming. Thus, effective interventions that facilitate early interactions are needed in the NICU (Edwards & Saunders 1990). These interventions must help mothers become good observers of their preterm infant's behavior. Doing so should increase mothers' confidence to care for and interact with their infants, particularly in the case of preterm infants.

Early Intervention

The model for premature infants in the neonatal intensive care unit has been extended from a medical focus to include early developmental interventions (Wyly 1995). This approach requires NICU caregivers to assess each infant's development and plan an individualized developmental care program that nurtures the infant and optimizes development (Als, & Gilkerson 1995). Because of the important role that parents play in infant development, many NICU professionals have begun to incorporate family-centered care practices into their developmental care programs (Gorski 1991; Johnson 1995;). The









family-centered care approach empowers family members and promotes collaboration with health care providers. Providing family-centered care requires that professionals and families learn to work with one another and develop mutual trust and respect. Doing so heightens the probability for productive communication and family involvement that are important to an infant's long-term care (Nyqvist & Karlson 1997). Neonatal health professionals play an essential role in facilitating family participation in their infant's developmental care.

Involving families in the developmental care of their premature infant can foster positive attachments between parents and infants (Hughes et al. 1994; Flyn & McCollumn 1989). Hughes and his colleagues found that participation in an early intervention program resulted in increased mother/infant attachment, reduced family stress, and enhanced prenatal self-confidence for mothers (Hughes et al. 1994).

Available infant assessments may provide the foundation for developmental, family-centered practices in the NICU (Brazelton & Krammer 1990). Current assessments help parents and other caretakers know how to best interact with a preterm infant during family visits or procedures in the NICU (Merenstein 1994). Additionally, assessments help measure a preterm infant's progress, such as quality of their alertness, and assist caregivers in determining if their infant is ready to interact. The Neonatal Behavioral Assessment Scale (NBAS), which measures the interactions and behavioral organization of full-term newborns (Brazelton 1984), is one such assessment.

The NBAS was originally designed to be a clinical assessment but is frequently

used as an intervention by doctors, nurses, clinicians, early interventionists, and therapists to teach parents about their infant's behavior (Brazelton & Nugent 1995). A major









component of the NBAS is the determination of the infant's behavioral state and ability to interact with social stimuli.

Researchers in several different studies have shown that the NBAS can be used as an intervention to increase parental awareness of their infant's competence (Parker et al. 1992; Worobey & Belsky 1982; Widmeyer & Field 1987). Moreover, these researchers found that increased parental awareness enhanced parent-infant social interactions. Parker et al. (1992) solicited mothers to participate in an NBAS assessment with their infants in the NICU. Compared to mothers of preterm infants who received standard post-partum care, mothers in the intervention group rated the infants as having a less difficult temperament at 4 and 8 months and had home environments that were developmentally more appropriate at 4 months. Additionally, Winedmayer and Field (1987) conducted a study using the NBAS as an intervention with teenage mothers, and found these mothers were more aware of their infant's abilities after using the NBAS, and in turn, were more responsive to their infant's signals. Worobey and Belsky (1982) also found that actively involving mothers in the administration of the NBAS increased their responsivity to the infant compared to mothers who only observed the administration. Specifically, they reported that administering the NBAS affected the mother's social behavior toward their infant and subsequently, the infant's reciprocal behavior increased. These findings led Belsky (1986) to suggest that the NBAS promotes the mother's affectionate handling of her infant, which in turn may enhance the quality of interaction between mother and infant.

Limited research also supports the use of the NBAS as an intervention for parents of preterm infants. Using the NBAS as an intervention tool promoted parental self-









esteem and increased parental visits to the NICU. Ruth et al. (1990) tested an intervention based on the NBAS with a sample of low birth weight infants and their mothers and reported that the mothers were significantly more confident in their care taking abilities compared to mothers in the control group. Finally, Szajnberg et al. (1987) demonstrated the NBAS to mothers of low birth weight infants at 34 weeks gestational age. Mothers who used the NBAS intervention increased their visits to the NICU, compared to a control group of mothers who received no training in the NBAS. These studies confirm the importance of developing early interventions based on developmental assessment. Thus, there is clearly a need for developing early intervention that promotes these interactions between preterm infants and their adolescent mothers.

Summary

The literature reviewed in this chapter provides a theoretical and empirical basis for this study. Research has demonstrated that early social interactions are important in the development of attachment between infants and their mothers. The quality of the early mother-infant interactions is an important mediating factor between perinatal events and later developmental outcomes of the infant. The attachment process is jeopardized when the infant is born premature, particularly given the conditions present in the NICU. This attachment process is further jeopardized when premature infants are born to adolescent mothers. Typically, adolescent mothers are not aware of the possibility of premature birth, have a limited knowledge of its implications, and limited abilities to respond to the demands of a premature birth.

Clearly, there is a need for adolescent mothers to learn better ways of responding to their premature infant. To do so, interventions must be designed that focus on the






34


relationship between the adolescent mother and her premature infant. The purpose of this study is to determine the effects of a behavioral intervention on the social initiations of adolescent mothers toward their premature infants while in the NICU. Specifically, the goals of the study are to (1) train adolescent mothers of premature infants in the NICU using a behavioral intervention to read signs of stress, to sooth, and to socially engage their infant, and (2) evaluate the effects of this intervention on adolescent mother's ability to sooth her infant and initiate appropriate social interactions.














CHAPTER 3
METHODS AND PROCEDURES


Introduction

For both infant and caregivers, engaging in and completing a successful

attachment process results in a strong reciprocal bond that may be the cornerstone for subsequent developmental outcomes for the infant. Positive outcomes of this process also occur for the caregiver and include acquiring feelings of competence in their ability as a caregiver (Fogel 1991). Tronic et al. (1992) points out the necessity for a synchronous interaction between mother and infant to achieve a successful attachment. If the infant fails to engage the mother in an interaction or the mother fails to respond to the infant, a lack of synchrony may lead to a mismatch. This mismatch may lead the infant to develop non-interactive behaviors. These behaviors may include gaze aversion, focus on objects instead of on mother, and self-regulatory patterns such as fist in mouth when distressed (Tronik et al. 1992). The effects of these noninteractive behaviors are problematic because they disrupt the synchronous interaction between mother and infant, therefore, jeopardizing successful attachment.

How a mother interacts with her infant during the neonatal period and beyond

helps determine the infant's course of development. The quality of the early mother-infant interaction has been considered an important mediating factor between perinatal events and the infant's social, cognitive, and communication outcomes. In several studies, positive early mother-infant interactions were associated with secure relations between










the infant and mother at the end of the first year of life, a lower incidence of behavior problems at preschool age, and cognitive competence at school age (Fish, & Stifler 1995; Vondra et al., 1995; Landry et al. 1990).

There are many factors that jeopardize the development of supportive interaction patterns between preterm infants and their parents (Minde 1993). For example, preterm infants are often not as capable of responding to social interaction demands. In addition, their parents' social behavior may be qualitatively different within the context of the NICU where preterm infants are likely to remain for at least several weeks. The effects on parent-infant interactions are greater when infants are born prematurely to adolescent mothers (Christopher et al. 1999). Adolescent mothers may be less verbal in interacting with their infants, less adept at reading their infants cues, and unable to respond to their infants in consistent ways (Stevenson 1996).

The intent of this study was to determine if an intervention designed for

adolescent mothers could improve their social interactions with their premature infants in the neonatal intensive care unit. The research question that was answered through this study was:

Will teaching adolescent mothers about the premature infant's behavior, calming techniques and social initiations increase their appropriate social initiations toward their premature infant in the NICU?

Data was graphed and visually analyzed. Trends analysis was used to conclude if the adolescent mothers' appropriate social initiations toward their infant improved. In addition, the magnitude of the differences prior to and after training was analyzed to determine the significance of the effects of the intervention.










In this chapter, the methods and procedures to accomplish these goals are

presented. The first section is a description of the methods, including information about the participants, setting, materials, procedures, and measures. In subsequent sections the experimental design, data analysis, and pilot study are explained.

Methods

The methods section includes information about the setting, participants and

materials. First, the neonatal intensive care unit at Shands hospital is described. Second, the participant description includes criteria used to select the mothers and infants. The last section explains the materials used for data collection, as well as the mechanical equipment, training, training videos, and Brazelton Neurobehavioral Assessment Scale intervention.

Setting

The study was conducted at Shands Teaching Hospital Regional Neonatal

Intensive Care Center at the University of Florida Health Science Center, Gainesville. The neonatal intensive care unit (NICU) was a level III tertiary unit that provided state of the art care to medically fragile infants. The unit had 25 bed capacity, which was either open cribs or incubators. There were monitors at each beside that tracked the infant's heartbeat, respiration, and pulse. The NICU had fluorescent lighting in addition to spotlights above each crib that can be individually controlled for brightness. The NICU staff focuses on family-centered care for infants and family members, in addition to excellent medical care for premature and medically fragile infants. Family centered care offers families the opportunity to participate in non-medical activities such feedings, baths, and diaper changes. Infants' medical as well as individual developmental needs are










the focus of care in order to enhance developmental maturation. The hospital serves infants and their families from southern Georgia to the southern Florida region. Participants

Four mother-infant dyads from the NICU were selected from Shands Teaching Hospital to participate in this research. Medical charts were used to identify motherinfant dyads who meet the following criteria: a) mothers who are between 15 and 19 years of age and delivered their infants in the NICU, and (b) infants who are a product of a singleton birth, 38 weeks or less gestational age, 1100- 3300 grams, without congenital malformations or disorders, medically stable, and admitted to the NICU. Infants who were once critical but are currently medically stable were considered. A summary of descriptive information for the four-mother/infant dyads that participated in the study is presented in Table 1.

Mother 1 in this study was a 17-year-old white woman and this was her first

pregnancy. She had preaclapsia and delivered her baby 6 weeks early. She was married to her infant's father and he was incarcerated during the time of this study. The father was given permission to visit his baby in the NICU but was handcuffed and chaperoned. The pregnancy did not allow for the mother to finish high school, but she did intend to get her high school equivalency degree and wanted to work in a day care center.

Her infant was delivered at 34 weeks gestational age and weighed 1661 grams. He was enrolled in the study at 37 weeks adjusted gestational age and weighed 2815 grams. The baby spent two weeks in and incubator before being moved to an open crib. He had no medical complications and was in the NICU to feed and grown before being discharged.










Mother 2 in this study was a 15-year-old white girl. She breast fed her infant and was present in the NICU for daily feedings. She was married to her infant's father. Both parents visited the infant daily. Family members were often present at the infant's bedside.

The infant was delivered at 37 weeks gestational age and weighed 3010 and was admitted to the NICU because she had a seizure after delivery. She had various medical procedures to rule out insults to the brain and she was monitored while they began pharmaceutical treatment. The infant was medically stable and enrolled in the study at 37 weeks old and weighed 3072 grams.

Mother 3 was an 18-year-old white woman and this was her second pregnancy and birth. She had a 14-month-old daughter in addition to her newborn son. She was married to her children's father. There were no complications with the delivery. She had high blood pressure and went into premature labor. She did not finish high school and worked nights at a chicken factory where her husband worked during the day. Their work schedule allowed them to care for their children at home, which seemed important to her.

Her infant was delivered at 35 weeks gestational age and weighed 2301 grams. He was enrolled in the study at 37 weeks adjusted gestational age and weighed 3080 grams. He had no medical complications.

Mother number 4 was an 18-year-old white girl who was married to her infant's father. She went into preterm labor and there were no complications with the delivery. She wanted to breast feed but the infant was on gavage feedings and the mother had to pump the breast milk and put it into the feeding tube. Family members were often










present in the NICU and were very excited about the baby. The mother graduated from high school and worked as a secretary but intended to stop working and stay home with her baby.

The infant was born at 34 weeks gestational age and weighed 1716 grams. She was enrolled in the study at 36 weeks adjusted gestational age and weighed 2240 Grams. She had a feeding tube but at the time of the study was able to bottle feed twice a day. She was otherwise a healthy infant. During the study the feeding tube was removed and she was able to bottle feed.

Table 1

Descriptive Information for Subjects

Dyad I Dyad 2 Dyad 3 Dyad 4 Mother's age 17 years 15 years 18 years 18 years Infant's 37 weeks 37weeks 37 weeks 36 weeks adjusted
gestational age

Infant's weight 2815 3012 3080 2240



Permission for this study was obtained from Shands Teaching Hospital

Institutional Review Board; informed consent was asked of the guardian of the adolescent mothers. First, the developmental specialist reviewed the medical charts for appropriate selection criteria. The NICU nurses also informed the researcher about mothers and their infants who met the criteria of the study. Next, eligible families were contacted and the researcher explained the purpose of the study and asked for their participation. Last, the consent form was reviewed with the family; the adolescent mother as well as her










guardian signed the form. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A.

Materials

Materials that were used to train the research assistants (RA) in data collection are two standard VHS training tapes, and a 12" Sony television!VCR. Materials needed to educate the mothers during the intervention are a standard VHS training tape, a 12' Sony television/VCR, a red ball, and a baby rattle.

Videotape was developed and used to train the RA and the mothers. The produced training tape was made that depict a caregiver and her premature baby at the infant's bedside in the NICU participating in appropriate soothing techniques and social interactions. The dyad appearing in the training video did not participate in the study.

A standard form was used to collect data during the baseline, procedural

reliability, intervention, and generalization phases of the study. The forms used to record infant behavior and mother behavior. The infant's behavioral state was recorded as Isleep, 2-drowsy, 3-alert, 4-irritable, 5-crying. The mother's ability to use soothing techniques as well as the social initiations was recorded by putting a check in the box located next to the behavior (Refer to Appendix B). Independent variable

Being able to identify if the infant is sleeping, drowsy or alert determines how

much, if any interaction, the infant can tolerate and helps the mother know when to sooth and when to interact. Therefore, teaching mothers about infant behavior is important for appropriate mother-infant interactions to occur. Mothers learned how to interact and










sooth their infant during training sessions, which included three portions: video training, demonstration, and practice.

The intervention was designed to educate mothers about social initiations and infant behaviors in an effort to increase the mother's natural social initiations with her infant. The foundation of the intervention was the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). The BNBAS assesses the newborn infant's behavioral repertoire on 28 behavioral items. The scale also includes an assessment of the infant's neurological status on 18 reflex items. The scale is organized into 5 packages: (1) habituation, (2) motor-oral, (3) truncal, (4) vestibular, and (5) social interactive. According to previous studies, BNBAS based interventions have had a positive impact on parenting and /or infant development (Britt & Myers, 1994; Parker, Zahr, Cole, & Brecht, 1992). Thus, the BNBAS provided the basis for the development of the intervention used in this study to promote a mother's interactions with her premature infant.

The researcher used the social interactive package, identifying infant states, and soothing techniques, and interactive responses of the NBAS. The shortened version of the BNBAS was used because premature infants often cannot tolerate a lengthy examination and the social interactive package was deemed most important. Dependent variable.

Data was collected prior to treatment, during treatment, and after treatment to determine the infant's behavioral state, mother's ability to sooth and calm, and mother's appropriate social initiations toward her infant in the NICU. The RA collected data at the infant's bedside in the NICU.










Infant measures

Infant behavioral states were defined as follows: State I was a sleep state and was defined as eyes closed, regular breathing, and little to no spontaneous body movements. State 2 was drowsy or semi-dozing; eyes may be open but dull and heavily lidded with the infant's activity level low. State 3 was defined as alert, with eyes opened and the infant seemed to focus attention on a source of stimulation. State 4 was defined as irritable with considerable motor activity. Brief fussy vocalizations occurred in this state. State 5 was defined as crying that is intense, which was difficult to stop with soothing techniques. Data was recorded for infant behavioral states during the baseline, treatment, and generalization phases of the study. RAs indicated the infant's behavior by writing down the number that correlates with the infant's behavior during that interval. For example, if the infant was in a sleep state, then the RA recorded the number one on the data collection sheet. Infant stress was also coded and was defined as hiccups, blue lips, eye aversion, increased heart rate or a physiological reaction that put the infant in danger. More than one stress sign was recorded when necessary. At any sign of stress the session was terminated.

Mother's measures

Mother's social initiations toward her premature infant were defined as any motor or vocal behavior clearly directed to the infant which attempted to elicit social responses such as, gentle vestibular stimulation, patting, swaddling, holding, using a pacifier, getting face to face, talking, shaking rattle, or showing ball. Touching was not recorded during purely functional activities such as changing diaper, feeding, and moving tubes. The RA placed a check mark next to the behavior to indicate if a social initiation did or










did not take place during the twenty-second interval. The mother's behaviors were considered appropriate and were not scored as such depending on the infant's behavioral states (Refer to Table 2). Table 2

Appropriate Behaviors

Infant Behavior Mother Behavior State 1- Sleepy Holding, Gentle Vestibular, If not awake after 3


State 2- Drowsy State 3- Alert State 4- Irritable State 5- Crying


Face, Voice intervals then terminate session.
Holding, Gentle Vestibular, Face, Voice Holding, Face, voice, Rattle, Ball Holding, Gentle Vestibular, Swaddling, Patting, Pacifier, Face, Voice Holding, Gentle Vestibular, If not calm after 3 intervals Swaddling, Patting, then terminate. Pacifier, Face, Voice


Treatment fidelity

The mother's ability to implement the treatment procedures reliably was

evaluated through observation. The collection of treatment fidelity data began with the research assistant directly observing the mother during the BNBAS training sessions. The mother's accuracy in implementing the intervention was measured at her infant's bedside in the NICU. Circling the number one, two, three, four, or five marked the infant's behavioral state. Mother's behaviors were recorded by putting a check in the box located next to each appropriate intervention behavior (Refer to Appendix B). The researcher examined the data after each observation session and the mothers were retrained based on










their ability to implement the intervention until 90% accuracy was obtained. The mother participated in training sessions until she recognized stress signs, used soothing techniques, and implemented social initiations toward her infant. When the mother did not reach criteria, she received corrective feedback, and further video training sessions and demonstrations until 90% accuracy was obtained.

Interobserver agreement. To determine interobserver agreement for data

collection procedures, a second observer recorded mother and infant data simultaneously but independently from the primary observer for 25% of the sessions. The occurrence only, point-by-point method was used to calculate interrater reliability. An agreement was noted when the observers record the same code within the same interval. A disagreement occurred when one observer coded something different from the other. The percentages of interobserver agreement were calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. Interobserver agreement was randomly collected for at least 25% of the sessions across all phases of the study. It has been reported that the point-by-point agreement method is the most commonly used method of agreement and 80% is considered a relatively high estimate of agreement (Kazdin, 1982).

Procedures

The instructional procedures are described in this section. First, data collection procedures during baseline are outlined. Next, an account the intervention and maintenance sessions are explained.

Baseline. During the baseline condition, the research assistant observed the mother at her infant's bedside and collect data on the infant's behavioral state, the










mothers' use of soothing techniques, and the mother's social initiations toward her infant using the partial interval recording method. Observations lasted five minutes and data was collected every 20 seconds. When more than one behavior occurs during the 20second period only the first behavior was recorded. During baseline, the mothers were not provided with any corrective feedback concerning their behavior. Also, the research assistant was instructed not to provide the mothers with any information about the types of behaviors being observed.

Intervention. The training session began with by the researcher explaining the

overall training procedures to the mother. First, the mother and researcher watched a 10minute intervention video of the modified BNBAS while the researcher identified the infant's behavioral states, stress signs and accompanying soothing techniques, and social interactions (e.g. demonstrating how to act with toys and mother's face and voice) (Refer to Appendix C). During the video session, the mothers had the opportunity to view all of the infant state behaviors.

After viewing the video, the researcher brought the mother to her infant's bedside where the researcher interacted with the infant in order to demonstrate the BNBAS to the mother. The researcher began the demonstration by identifying the infant's behavioral state (e.g. sleep, wake.). The researcher proceeded by demonstrating the soothing technique of swaddling the infant and lowering the lights in the nursery, or other soothing techniques as necessary. The researcher interacted with the infant using the red ball, rattle, and face and voice. The red ball was the visual stimuli, the rattle was the auditory stimuli, and the face and her voice combined both the auditory and visual stimuli. During the presentation of visual stimuli, the red ball was held 10 to 12 inches from the infant's










eyes. The researcher slowly moved the ball horizontally from one side of the infant's face to the other trying to elicit a response from the infant. The rattle was also used to elicit a response from the infant. The rattle was held 6 to 12 inches away from the infant's ear and out of sight. The rattle was continually shaken until the infant gave a response. With her face 10 to 12 inches in front of the infant's face, the researcher moved slowly in a horizontal motion while at the same time speaking in a soft, high-pitched voice. The researcher's voice was continuous while her face was moving. During social initiations or prior to, the researcher responded to infant behavior by using appropriate soothing techniques. When the infant was in a state 2 or 3, the researcher swaddled the infant with a blanket and hold the infant. When the infant was observed in state 4 or 5, then the use of a pacifier and the researcher's face/voice in addition to swaddling and holding was used in order to sooth and prepare the infant for social interaction.

After the demonstration session, the mother participated in practice sessions.

Practice sessions took place until mastery and were video taped. The mother went to the infant's bedside with the researcher to practice what she viewed during the video session and demonstration. First, the mother prepared her infant for social interaction by lowering the lights over the crib and swaddling the infant. Next, the mother began to use the red ball, rattle, her face, and her voice to socially interact with her infant. The mother used each type of stimuli as the opportunity presented itself When the infant was in state I or 2, the mother used vestibular stimulation or her face and voice to try and wake the infant. Once the infant was in state 3 the mother used the red ball, rattle, and her face and voice to socially interact. When the infant was in a state 4 or 5, then the mother used a soothing technique such as a pacifier to calm him.










During the social orientation, the researcher identified the infant's responses to stimuli, such as alerting, quieting, change in respiration, head turning, and eyes following or searching ("Look how baby's name is following the red ball with his eyes."). When the infant was showing signs of stress and was no longer in an optimal state for interaction, the mother was asked to terminate the session.

Prior to each practice session, the researcher and mother viewed her mother/infant interaction video and reviewed infant behavioral states, soothing techniques, and social interactions. In an effort to coach the mother, the researcher provided positive and corrective feedback during the practice session. There was not more than two training sessions per day.

However, if mastery was not met, then the mother viewed her most recent video practice tape and was provided with corrective feedback, observed a demonstration, and practiced the intervention again. Training continued until 90% mastery was obtained.

Maintenance. Following the practice sessions, the research assistant observed each mother's natural interactions with her infant. The mother knew that she was being observed. The research assistant did not prompt the mother to use any part of the intervention. Instead the research assistant observed the mother to see if she used the behaviors learned earlier from the intervention training. Specifically, the research assistant collected data on all appropriate social initiations, soothing techniques, and infant states. Mothers were at their infant's bedside and the researcher told them to "enjoy their baby". The researcher also placed items used in the training session (i.e., ball and rattle), at the infant's bedside, prior to the observation session. The mothers did not have to use these items, but they provided the mothers with the same opportunities for










interaction that existed during the intervention training. Sessions lasted for five minutes

and were conducted until the infant was discharged from the hospital.

Social Validity

Mothers were directly involved in this project and they received information

about their infant's behavior and how to socially interact. Additionally, mothers were

asked to provide information about the social validity of the intervention. One week after

discharge the researcher contacted the mothers by telephone and asked about her

judgments concerning the appropriateness of the intervention, including an evaluation of

whether it was fair, reasonable, and consistent with conventional notions. Specifically,

the mother's comments will be used to improve the intervention for future research

(Refer to Appendix D).

Table 2

Procedures

Phase Data Documentation I. Mother's interactions in Baseline Data record sheet & graph NICU prior to treatment II.
A). Training Session (repeat A). Treatment fidelity A). Data record sheet until 90% mastery)
a) Standard
Training Video
b) Demonstration c) Practice (video
tape).
Mother's practice video from prior training session will take the place of standard training video if subsequent sessions are necessary.

B). Continue data collection B). Intervention B). Data record sheet &










on mother's social graph interactions

III. Mother's interactions in Maintenance Data record sheet & graph NICU after treatment
IV. Social Validity Social Validity Questionnaire Questionnaire



Experimental Design

A modified multiple baseline design was used to evaluate the effects of the

BNBAS intervention. The modified multiple baseline across mother-infant dyads was suited for this project for two reasons: (a) the intervention should result in learned behaviors, and (b) there are a small number of participants. Each mother was exposed to the following conditions: baseline, BNBAS intervention, and maintenance. The design began with baseline observations. After the baseline was stable, the intervention was implemented with the mother. Following the intervention behaviors maintenance probes began. The procedures were repeated with the last two mothers. When the baseline data collection began for the second and forth mother the baselines were extended twice as long as mother number one and three in order to compensate for the data not being collected simultaneously.

Treatment of the Data

Data were analyzed to determine if any important differences existed between the mothers' behavior during baseline, intervention, and maintenance. Visual analysis was used to conclude if there was an increase in the adolescent mothers' appropriate social interactions and the magnitude of the differences were analyzed to determine the significance of the trend.










Pilot Study

Prior to implementing the research, a pilot study was conducted, with one motherinfant dyad, to develop and solidify the observation system and participant training sessions. The purpose of the pilot study was to determine the need for modifications in the intervention and data collection procedures prior to actual data collection and training. Feedback from this pilot study was used to make adjustments in the training and data collection procedures as needed. The material, procedures, dependent and independent variables were identical to those described earlier in this chapter. Participants

One mother-infant dyad from the NICU was selected from Shands Teaching

Hospital to participate in this research. Medical charts were used to identify a motherinfant dyad who met the following criteria: a) a mother who delivered their infant prematurely, and (b) an infant who was a product of a singleton birth, less than 38 weeks gestational age, without congenital malformations or disorders, and admitted to the NICU.

The mother was 41 -years-old and had delivered her infant prematurely by cesarean section due to preaclampsia and high blood pressure. There were no complications with the delivery. Although the mother was not an adolescent the pilot study helped test the procedures and intervention.

The infant was delivered at 34 weeks gestational age and 1661 grams. He was and enrolled in the study at 36 weeks gestational age. He had no medical complications and was in the NICU to feed and grow before being discharged.










Permission for this study was obtained from the Shands Teaching Hospital

Institutional Review Board and the mother. First, the researcher reviewed the medical charts for appropriate criteria. Next, the eligible mother was contacted and the researcher explained the purpose of the study and asked for her participation. Last, the consent form was reviewed with the mother. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A.

Experimental Design

An AB quasi-experimental design was used to evaluate the effects of the BNBAS intervention with one mother-infant dyad. A quasi-experimental design was suited for this project for two reasons (1) to evaluate the data collection procedures, and (2) to evaluate the intervention. One mother infant dyad was exposed to the following conditions: baseline, BNBAS intervention, and generalization. The design began with baseline observations for the mother. After the baseline was stable, the intervention was implemented with the mother. When the behaviors stabilized for the mother, then generalization probes began.

Treatment of the Data


Treatment Fidelity

The collection of treatment fidelity data began with the research assistant directly observing the mother during the three BNBAS training sessions. The mother's accuracy in implementing the intervention was measured at her infant's bedside in the NICU. The researcher examined the data after each observation session and the mother was retrained










based on her ability to implement the intervention until 90% accuracy was obtained. A minimum of three practice sessions with the mother occurred to teach her to recognize stress signs, use soothing techniques, and implement social interactions with her infant. The mother reached 95% accuracy during the last training session Interobserver Agreement

To determine the interobserver agreement of data collection procedures, a second observer recorded data simultaneously but independently from the primary observer. The occurrence only point-by-point method was used to calculate interrater reliability. An agreement was noted when the observers recorded the same code within the same interval. A disagreement occurred when one observer coded something different from the other. The percentages of interobserver agreement were calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. Interobserver agreement was randomly collected for at least 25% of the sessions across the three phases of the study. Interobserver agreement was computed and yielded a mean percent agreement of 85%.


Results of the Intervention

Data were analyzed to determine if any significant differences existed between the mother's behavior during baseline, intervention, and generalization. Trends analysis was used to conclude if there was an increase in the mother's appropriate use of soothing techniques and social interactions, and the magnitude of the difference was analyzed to determine the significance of the trend.










The mother was exposed to two conditions: baseline (A) and intervention (B). During the baseline condition (A) the mean level of appropriate interactions was 25%. Upon introduction of the intervention (B), there was a positive change in the mother's interactions toward her premature infant. During the three sessions, the mother's interactions increased by 40%. Maintenance resulted in a variable accelerated trend that stabilized at 65%. (Refer to Appendix E)

Modifications Made as a Result of the Pilot Study

Modifications to the pilot study were minimal. The data collection sheet was modified to include a space for the researcher to record unexpected mother behaviors, such as rocking the infant. This was considered important to record because of the effect the mother's behavior can have on the infant's behavioral state and future interactions during the observation session. The numbers 0 and I were removed from the data collection sheet because it was felt that a check mark in the box would serve the same purpose and be easier to record.














CHAPTER 4
RESULTS

Introduction

The purpose of this study was to determine if an intervention designed for

adolescent mothers would improve their social initiations with their premature infants in the neonatal intensive care unit. The general question of the study was as follows: Will teaching adolescent mothers about the premature infant's behavior, calming techniques and social initiations increase their appropriate social initiations toward their premature infant in the NICU?

To investigate this question, each mother was taught how to identify their infant's behavioral state, use calming techniques, and interact socially with their infant. The intervention used was a modified version of the Brazelton Neurobehavioral Assessment Scale. The researcher used the social interactive package: identifying infant states, calming techniques, and interactive responses of the NBAS. The modified version of the BNBAS was used because premature infants often cannot tolerate a lengthy examination and the social interactive package was deemed most important.

Data were collected before intervention training began and during the training sessions. The effects of the intervention training were measured by comparing the mother's social initiations toward their infant before and after the training sessions. Data were also collected after intervention training to determine if the mothers could maintain their appropriate social initiations toward their infant.











A multiple baseline design was used to evaluate the effects of the BNBAS

intervention. The multiple baseline across subjects was suited for this project for two reasons: (a) the intervention resulted in learned behaviors, and (b) there was a small number of participants. Due to difficulty in finding subjects, baseline data were not collected concurrently.

This chapter describes the results of the data analyses employed in this study. First, measurement reliability and treatment fidelity data are provided. Second, the results of the study for each mother are described. Finally, results of the social validation measures are provided.

Interobserver Agreement and Treatment Fidelity

Procedures were implemented during the study to establish measurement

reliability and treatment fidelity. Interobserver agreement checks were used to determine data collection reliability during baseline, intervention, and maintenance. In addition, the mother's ability to implement the intervention with 90% accuracy was assessed during intervention training. Fidelity checks were used to insure that the intervention was implemented with integrity.

Interobserver Agreement

To ensure that data collection on social initiations were collected reliably a second observer recorded mother and infant data simultaneously but independently from the primary observer for a total of 14 of 56 sessions across baseline, intervention, and maintenance. Interobserver agreement data was collected three times for mother number one and three, and four times for mother number two and four. Interobserver agreement









was calculated using the formula recommended by Tawny & Gast (1984). The number of agreements was divided by the number of agreements plus disagreements and then multiplied by one hundred, which equaled the percent of agreements. For each observation session interobserver agreement was 90% for the first mother. For the second mother agreement ranged from ninety to ninety-five percent. Interobserver agreement for the third mother ranged from ninety to ninety-five percent. For the fourth mother, interobserver agreement scores were 95% for each session. Fidelity of Treatment

To ensure that the mothers were implementing the intervention correctly, the

research assistant directly observed the mother during the BNBAS training sessions, and collected data on the mothers' targeted behaviors. The researcher examined the data after each observation session during training and a mother was retrained if she did not implement the intervention with at least 90% accuracy. The mothers were trained until they recognized stress signs, used calming techniques, and implemented social initiations with her infant with 90% accuracy. If a mother did not reach criteria, she received corrective feedback, and further video training sessions and demonstrations until 90% accuracy was obtained.

The first mother participated in three training sessions. Following the first session the mother implemented the intervention with 75% accuracy. A positive change occurred after the second training session, her accuracy rate increased to 85%. After the third session she reached a 95% accuracy rate.

The second mother participated in three training sessions. After the first session, the mother implemented the intervention with 70% accuracy. A positive change occurred









after the second training session, with the mother increasing her accuracy rate to 80% accuracy. After the third session, she reached a 90% accuracy rate.

The third mother required only two training sessions. Following the first session she implemented the intervention with 85% accuracy. After the second session, she implemented the intervention with 100% accuracy.

The last mother participated in three training sessions. Following the first session, her accuracy rate was 85%. After the second session, her accuracy rate was 85%. Her accuracy rate in implementing the intervention increased to 100% after the third training session.

Treatment Results

Data were collected on adolescent mothers social initiations toward her premature infant in the NICU. The data were analyzed to determine if any differences existed between the baseline behavior and maintenance behavior for each mother. The results of the effects of the intervention for each mother are discussed in the following section. Mother #1

Baseline & Intervention Data. During the initial baseline sessions, mother

number one was observed interacting with her infant in the NICU. She sat in a rocking chair at the infant's bedside, and her social initiations toward her infant were recorded during four five-minute sessions that took place over two days. The mother's appropriate social initiations ranged from twenty-five to forty percent. During the baseline condition the mean level of appropriate initiations was 35%.

Once the baseline stabilized, the mother began intervention training. The mother participated in two intervention-training sessions that took place over two days. The









mother's appropriate initiations toward her infant ranged from fifty to fifty-five percent during intervention training. There was a positive change that occurred in the percentage of appropriate mother's initiations toward her premature infant from baseline to intervention training conditions. During the first session in which intervention training began (Session 5), appropriate social interactions increased by 50% when compared to the last session of baseline condition (Session 4). During intervention, the mean level of the mother's appropriate social interactions was 48.3%, which was an increase of 13.3% from the mean of the mother's baseline behaviors.

Maintenance Data. Following the final training session, four observations of the mother's social initiations with her infant occurred over three days to determine if the level of appropriate initiations were maintained. During this time, the mother did not receive any further instruction or feedback regarding her behavior toward her infant. The mother's appropriate initiations toward her infant ranged from fifty to fifty-five percent. A positive change occurred in the percentage of appropriate interactions from intervention to maintenance conditions. The mean level of maintenance behaviors was 47.5% for appropriate social initiations. During the last session in which maintenance data were obtained (Session 10), appropriate social interactions were on the average, 10% less when compared to the last session of intervention condition (Session 7). Even though the mothers targeted behaviors decreased slightly during maintenance, the targeted behaviors increased by an average of, 12.5% from baseline. Mother # 2

Baseline & Intervention Data. Baseline data was collected on mother number two social interactions toward her infant in the NICU. The mother was observed during









seven five-minute sessions. Baseline data was collected over two days. Mother's appropriate social initiations toward her infant ranged from thirty to forty five percent. During the baseline condition, the mean level of the mother's appropriate interactions was 32.8%.

Once the baseline stabilized at 30% the mother began intervention training. The mothers appropriate initiations ranged from fifty-five to sixty percent. A positive change was noted in the percentage of the mother's appropriate social initiations from baseline to intervention training conditions. During the first session in which training data was obtained (Session 8), appropriate social interactions increased by 25% compared to the last day of baseline condition (Session 7). The mean level of the mother's interactions was 52% during intervention conditions, which is an increase of 19.2% from the mean level for baseline behavior.

Maintenance Data. Observations continued for three days following intervention training. The mother's appropriate social initiations were in the range of fifty-five to sixty percent. A positive change occurred in the percentage of appropriate social interactions from intervention to maintenance conditions. During the first session in which maintenance data were obtained (Session 13), appropriate social interactions were 60%, which is the same as the last session of intervention (Session 12) The mean for the mother's appropriate initiations during maintenance was 61.25%, which was 19.2% greater than the mean score for intervention. Mother #3

Baseline & Intervention Data. The mother was observed during four five-minute sessions during baseline. Data was collected over two days. The range of the mother's









social initiations toward her infant was in the range of thirty-five to forty percent. During the baseline condition the mean level of appropriate social interactions was 40%.

Once the baseline data stabilized at 35%, intervention training began with the mother. During intervention training data collection occurred over four five-minute sessions to record the mother's social interactions toward her infant. The percentage of the mother's appropriate social initiations ranged form seventy-five to eighty-five percent. Upon introduction of the intervention, there was a positive change in the mother's interactions toward her premature infant from baseline to intervention conditions. During the first intervention session (Session 5), appropriate social interactions increased by 40% compared to the last day of the baseline condition (Session 4). Over the three sessions, the mother's mean for appropriate social interactions was 78.3 %, which was 38.3 % greater than the baseline mean.

Maintenance Data. Data collection continued for three sessions following

intervention training. The mother's appropriate social initiations ranges from eighty to eighty-five percent during maintenance. A positive change occurred in the percentage of appropriate social interactions from intervention to maintenance conditions. During the first maintenance session (Session 8), appropriate social interactions increased by 33.3% compared to the last day of the intervention condition (Session 7). The mean for the mother's appropriate initiations during maintenance was 81%, which was on average,

3.3% greater than the mean score for intervention. Mother # 4

Baseline & Intervention Data. During the initial baseline sessions (1-7), the

mother's behaviors were observed at her infant's bedside in the NICU. Baseline data was









collected during seven sessions that took place over two days. During the baseline condition, the range of mother's appropriate social initiations was twenty-five to thirty percent, and the mean level of appropriate initiations was 38.5%.

Once the baseline stabilized at 30%, the intervention training began. The

percentage of mother's appropriate social initiations ranged from sixty to seventy percent. A positive change was noted in the percentage of appropriate social interactions from baseline to intervention training conditions. During the first session in which intervention data were obtained (Session 8), the mother's appropriate social interactions increased by 35% compared to the last session of the baseline condition (Session 7). Over five sessions, the mother's mean for appropriate social initiations was 64%, which was 35.5% greater than the mean for baseline.

Maintenance Data. Following the final intervention session, four observations of the mother's social initiations with her infant occurred to determine if the level of appropriate initiations were maintained. The percentage of mother's appropriate social initiations ranged form sixty-five to seventy percent. A positive change occurred in the percentage of appropriate social interactions from intervention to maintenance conditions. During the first session in which maintenance data were obtained (Session 13), the percentage of mother's appropriate social initiations was 70%, which was the same percentage compared to the last session of the intervention condition (Session 12). The mean for the mother's appropriate initiations during maintenance was 67.5%, which was

3.5% greater than the mean score for intervention.












Social Validation Measures


Participants were contacted one week after they were discharged from the hospital in order to ask their opinions about the importance, effectiveness, and practicality of the BNBAS intervention training. Specifically, the mother's comments will be used to improve the intervention for future research. Participants were asked to rate the importance of the intervention. If they found no importance in the intervention they were asked to explain why. All mothers reported that the information they acquired during the study was valuable in helping them calm and play with their babies in the hospital and home. Mothers indicated satisfaction with the procedures and did not feel uncomfortable or embarrassed by the observations. One mother revealed that she not only uses the developmental toys to play with her infant but she has shared the information with her husband. Another mother reported that she liked having someone to talk with during her visits to the hospital. All of the mothers recommended that other mothers should lean about their infant's behavior and ways to play with their baby while they are in the NICU. Procedures pertaining to the administration of the social validation questionnaire were described in Chapter III.

Summary

The purpose of this study was to investigate the effects of learning about infant behavior, calming techniques, and social initiations on adolescent mothers' social initiations toward their premature infant in the NICU. The four mothers who participated in the present investigation were adolescent mothers who had premature infants admitted









to the NICU directly after birth. The mothers were between the ages of fifteen and nineteen years old. The infants were between 32 and 38 weeks old and weighed between 1100- 3300 grams, without congenital malformations or disorders, medically stable, and admitted to the NICU. Infants who were once critical but were currently medically stable were considered. All participants, despite the differences in their age and infants medical status, received identical training in the NICU.

The effects of training on the level of the mother's social interactions compared to baseline were addressed. In all instances, mothers increased their appropriate social initiations after intervention training. Additionally, all participants maintained an increased level of social interaction compared to their baseline behavior. Three of the mothers were able to maintain the social initiation skills they learned compared to intervention training. The first mother's targeted behaviors decreased slightly during maintenance compared to intervention training. Her behaviors did not increase as much as the other mothers. One explanation for this difference between Mother I and Mothers 2, 3, & 4 could be that they had more social support than Mother 1.

The results of the social validation measures were favorable. Participants

reported satisfaction with the information they received about infant behavior and social initiations as well as the training procedures. Some mothers reported that they had shared the information they learned with other family members, and were continuing to use the techniques at home.

In summary, after receiving information about infant behavior and training on

how to appropriately interact with a premature infant adolescent mothers increased their appropriate social initiations toward their infant. The participants reported satisfaction






65


with their participation in the investigation and with the procedures used. Implications for these findings will be discussed in Chapter V.














CHAPTER 5
DISCUSSION


Research has demonstrated that early social interactions are important in the

development of attachment between infants and their mothers (Ainsworth 1995, Isabella 1993). The quality of early mother-infant interaction is an important mediating factor between prenatal events and later developmental outcomes of the infant (Leavitt 1999). The attachment process is jeopardized when the infant is born premature, particularly given the conditions present in the NICU (Niven et al. 1993). This attachment process is further jeopardized when premature infants are born to adolescent mothers (Barnard et al. 1996). Typically, adolescent mothers are not aware of the possibility of premature birth, have a limited knowledge of its implications, and limited abilities to respond to the demands of a premature birth (Sommer et al. 2000). Clearly, there is a need for adolescent mothers to learn better ways of responding to their premature infant. To do so, interventions must be designed that focus on the relationship between the adolescent mother and her premature infant.

The purpose of this study was to increase the appropriate social initiations of adolescent mothers toward their premature infants in the NICU. The foundation of the intervention used in this study was the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). The intervention was designed to educate adolescent mothers about social initiations and infant behaviors in an effort to increase the mother's natural social initiations with her infant. The chapter had been divided into four sections. First, a








summary and discussion of results related to the research question is discussed. Next, the findings in light of previous research are presented. Third, limitations to the present research are discussed. Finally, suggestions for future research have been presented.

Summary and Analysis of Results

In this study, the researcher wanted to determine if teaching adolescent mothers about calming techniques and appropriate social initiations would increase their appropriate social imitations toward their premature infants in the NICU. Social validity measures were also collected to determine if the mothers who participated were satisfied with the intervention procedures and found it to be valuable.

Overall, the effect of intervention training on subjects' targeted behavior was positive. Baseline data indicated that the mean level of appropriate social initiations across all mothers was 32.9%. During intervention training, the mean level of appropriate initiations increased to 61.8% across all mothers. The effects of strategy training on the maintenance of newly acquired behaviors were also positive. The mean level of appropriate social initiations for all mothers during maintenance was 66.2%, showing that participating mothers were continuing to improve appropriate initiations even after intervention.

The adolescent mothers' responses on the social validity questionnaire indicated that they found their participation in the intervention training to be a positive experience. They expressed satisfaction with the procedures and the information they received during training. One mother mentioned that she shared the information she learned during the training sessions with her husband who uses them too. All of the mothers said that their









infants enjoyed playing with the developmental toys they received for participating in the study.

In summary, subsequent to intervention training using the modified BNBAS, the participants demonstrated acquisition of the targeted and maintained these behaviors. Finally, as indicated by their social validity questionnaire responses, adolescent mothers reported that they had learned from the intervention training and were satisfied with the BNBAS intervention training in terms of importance, effectiveness, and practically.

Summary of Previous Literature

Attachment theory demonstrates that early social interactions are important to the development of attachment between infants and their mothers (Slater & Muir 1999), and the quality of these early mother-infant interactions are important ultimately to the infant's social and cognitive development (Leavitt 1999). The formation of a secure attachment depends on the mother's ability to respond appropriately to her infant's signals (Rosenblum et al. 1993). For instance, the mother who is sensitive to her infant's signals can lead the infant from an intense crying state to a calm and alert state by comforting the infant, thereby enabling the infant to engage in a harmonious interaction with the mother.

The development of secure attachments that lead to harmonious interactions are put at risk when the infant is premature. Premature infants often send signals that are unclear to the caregiver thus, the caregiver may respond inappropriately leading to further inappropriate interactions (Padden & Glenn 1997). This risk is compounded when the premature infant is born to an adolescent mother (Wyly 1995). Research has reported that adolescent mothers respond less and demonstrate more inappropriate responses









toward their premature infant due to the appearance and behavior of the infant (Edwards & Saunders 1990; Causby 1991; Bell 1997). The NICU environment may further affect the adolescent mother's ability to appropriately interact with her infant (Causby 1991). Infants and adolescent mothers may fail to become attached during the hospital stay due to stressful aspects of the NICU, such as, a) lack of privacy, b) noise, and c) preponderance of authority figures (Bell 1997). Thus, effective interventions that facilitate early interactions between adolescent mothers and their premature infants are needed in the NICU (Edwards & Saunder 1990).

Research in several different studies has shown that the BNBAS can be used as an intervention to increase parental awareness of the full term infant's competence (Parker et al. 1992; Worobey & Belesky 1982; Widemyer & Field 1987). Specifically, these researchers found that increased parental awareness influenced mothers' responsiveness toward their infants promoting appropriate social interactions.

Limited research supports the use of the BNBAS as an intervention for parents of preterm infants (Mylod et al. 1997); however, no research exists using the scale as an intervention to promote social initiations with adolescent mothers and their preterm infants. Therefore, there was a need to expand the current literature base by studying this population and using the BNBAS as an intervention with them. Researchers assert that adolescent mothers are less adept at interacting with their full term infants compared to their more mature counterparts. They engage in fewer verbal interactions with their infants, interpret their infant's cues less accurately, and respond to their infants less frequently (Gotwald, & Thurman 1990; Causby 1991). Thus, a higher risk exists for developing inappropriate social interactions between adolescent mothers and their








premature infants (Causby 1991). The fact that the earliest interactions between adolescent mothers and their premature infants take place in an NICU further effects the development of appropriate interactions with their infant (Edwards & Suanders 1990).

The intervention used in this study incorporated a modified version of the BNBAS, specifically the calming techniques and social interaction package. The intervention focused on increasing the adolescent mother's ability to appropriately respond to her infant's behavior. In past studies the use of demonstrations of the NBAS intervention for mature parents had only moderate effects on mother infant interaction (Das Eiden & Feifinan 1996). According to Brazelton & Nugent (1995), in order to use the BNBAS as an intervention for effecting parent-child relationships, parents need to see the BNBAS several times in the presence of a professional who can help them interpret the effect on the infant. However, several other researchers have discussed the possibility that demonstration and parental administration of the NBAS intervention may be more effective than only parent observation (Beeghly 1995; Britt & Meyers 1994; Meyer 1982; Woroby & Belsky 1982). This study expanded on training techniques used in previous research (Cardone & Gilkerson 1990; Parker et al. 1992; Beeghly & Tronik 1994) by including, a) video taped demonstration of the modified BNBAS and explanation, b) a demonstration of the intervention by the researcher at the infant's bedside, and c) guided practice sessions for the mother that involved her infant. As in previous studies, this study documented the usefulness of the modified BNBAS as an intervention tool.

The findings of this study support aforementioned literature concerning the use of the BNBAS as an intervention tool with mothers and their infants. Additionally, this









study expanded the current literature base by showing that the BNBAS may b e used to enhance adolescent mothers social initiations toward their premature infants in the NICU, These findings also justify the need stated in the literature for intervention to start as early as possible (VandenBerg 1985). The maturation of the infant dictates the types of interventions that can be used with the infant (Als 1992; Wyly 1995). However, as the infants developmental status matures interventions that include providing the infant with age appropriate stimuli can occur. Initial analysis revealed significant gains on dependent measures for all participating adolescent mothers. These findings are consistent with the results of previous research (Widmayer & Field 1980; Szajnberg et al. 1987; Parker et al. 1992; Britt & Myers 1994; Beeghly 1995) that showed that learning BNBAS interventions during the neonatal period have a beneficial effect on the quality of parental interactions for mature parents (Ainsworth 1995). However, the findings of this study were the first to show that the modified BNBAS was successful as an intervention with adolescent mothers and their premature infants in the NICU.

The social validity questionnaire reported that the adolescent mothers who

participated in this study found the intervention to be very informative and they enjoyed playing with their infant. This was consistent with previous research where mothers reported receiving benefit from participating in BNBAS training sessions, but gains from this study were achieved with an adolescent population (Raugh et al. 1990; Parker et al., 1992; Britt & Meyers 1994).

The results of this study confirm the importance of developing early interventions based on developmental assessment. The modified BNBAS intervention had positive effects on all of the adolescent mothers social initiation toward their premature infants in








the NICU. After the intervention mothers were able to maintain the effects their positive behaviors for the remanding days their infant was hospitalized. The social validity questionnaire reported that all of the mothers felt the intervention was helpful.

Limitations to the Present Study

There were several limitations to the study that threatened the external and

internal validity of this study. The number of participants, the ability to determine the long-term impact of the study on adolescent mothers' appropriate social initiations, the data collection system and procedures, and the design of the study may have threatened the external and internal validly of this study.

While it seemed to be generally positive that the intervention was equally

effective for all adolescent mother's of different ages The number of participants was a limitation that threatened the external validity of the study. The small number of participants threatened its generalizability to other adolescents and their premature infants.

An additional threat to eternal validity was the inability to determine the

generlizability of the interventions effects on the mother's targeted behavior over time. During the maintenance phase of the study data was collected over three to five sessions over the remainder of the time the infant was hospitalized. The data collection during maintenance was limited because the infants were discharged from the hospital. Therefore, we were unable to determine if the intervention would have lasting effects on the mother's social initiations toward her premature infant.

The internal validity of the study was threatened by the data collection system and procedures, as well as the design of the study. The data was collected using the partial








interval method. The partial interval recording system provides several advantages (Tawney & Gast, 1984). First, it reacts to behaviors with high frequency and low frequency. Second, it permits more precise statement of interobserver agreement by allowing computation of point-by-point reliability. Interobserver reliability was employed during this study, and the point-by-point method for computing the coefficient was used in this study to ensure the reliability of data collection. However, this method can over or underestimate the data and could adversely affect reliability.

The literature on attachment theory states that the quality of the interaction is affected by the way the mother reads her infant's cues and initiates social interaction toward her infant, thus affecting the attachment process (Ainsworth, 1996; Levit, 1999). However, internal validity is threatened because data was collected on only the mother's social initiations toward her infant. This data only allows us to understand the mother's behavior and not the interaction between the mother and infant, which is important for mother infant attachment.

Recommendations for Future Research & Practice

This study was conducted to examine the effects of a modified version of the BNBAS intervention on the social initiations of adolescent mothers toward their premature infants while in the NICU. Study results suggest that early intervention, which teaches adolescent mothers about infant behavior, calming techniques, and appropriate social initiations, has a positive effect on a mother's appropriate social initiations toward her premature infant in the NICU.

As a result, these findings have several implications for training parents to use a modified version of the BNBAS to read signs of stress, calm, and socially engage their








infants in the NICU. Doctors, nurses, and medical professional should understand that using the BNBAS with adolescent mothers and their infants can be a helpful tool for developing social interaction skills while their infant is hospitalized. Early interventionists should also understand that BNBAS instruction that includes practice of social interaction skills in a meaningful context might be beneficial to high-risk parents and infants after they have been discharged from the hospital.

This study establishes that adolescent mothers can learn social initiations

techniques in the NICU. However, it does not establish whether the techniques would have the same effects with fathers, in a different setting, or the longitudinal effects of the intervention. Therefore, it is important that future research focus on these areas.

Future research should focus on teaching the NBAS techniques to adolescent fathers. Harrison & Magill-Evans (1996) reported that mature fathers had fewer social interactions with their term and preterm infants than did mature mothers during the first year of being a parent. Another study reported that mature mothers of hospitalized preterm infants engaged in more social interactions than did fathers (Levy-Shiff, Sharir, & Mogliner, 1990). There is no research that exists concerning teaching adolescent fathers about appropriate social initiations toward their premature infant while they are in the NICU. Therefore, there is clearly a need for future research to take place.

Another area future research should focus on is the effectiveness of the NBAS intervention with adolescent mothers and their premature infants in various setting such as in the home or a daycare setting. Beginning intervention training while the infant is hospitalized and extending that training after discharge may help the lasting effects of the intervention on an adolescent mothers social initiations toward her infant.








In addition to studying the effects of the intervention on adolescent mothers

appropriate social initiations toward her infant in the NICU research should focus on the interventions longitudinal effects on social initiations and infant development. Researchers could follow two groups of adolescent mothers, those who received BNBAS intervention training and those who did not. Researchers could follow up on the mothers' social initiation behaviors at six months and the infants' development at one year to determine the long-term effects of the intervention of the mothers behaviors and infant development.

Future research should also examine the effects of social support for adolescent

mothers who have premature infants in the NICU. In addition to the BNBAS intervention an interview with the mother would take place at the beginning of the study and after discharge from the NICU. The goals of the interviews should be (a) to identify the needs that the mothers have, (b) to identify their perceptions of the support system the NICU, and (c) to determine the effectiveness of the NICU support system. This may increase the likelihood that the specific needs of families would be met.

In conclusion, the present study has shown that adolescent mothers social

initiations toward their premature infants can be influenced by early intervention. The birth of a premature infant to an adolescent mother in need of neonatal care implies a less than optimal condition for the development of positive interactions. Thus, future research should focus on using the BNBAS as an intervention with both adolescent mothers and fathers educating in understanding their premature infant's developmental needs, reading their behavioral cues, and initiating appropriate interactions. Specifically, future studies are needed to look at the use of the NBAS intervention in various setting and the long-






76


term effects of BNBAS intervention on attachment and infant development with these high-risk populations. When parents learn to read behavioral cues and carefully determine the appropriate interaction with their high-risk infant, they can help in the process of getting back on track toward a more optimal developmental outcome.
































APPENDIX A

PERMISSION FORMS








IRB# 483-1999


Informed Consent to Participate in Research


The University of Florida
Health Science Center, Gainesville, Florida Shands at Alachua General Hospital, Gainesville, Florida University Medical Center, Jacksonville, Florida



You are being asked to participate in a research study. This form provides you with information about the study. The Principal Investigator (the person in charge of this research) or his/her representative will also describe this study to you and answer all of your questions. Read the information below and ask questions about anything you don't understand before deciding whether or not to take part. Your participation is entirely voluntary and you can refuse to participate without penalty or loss of benefits to which you are otherwise entitled.


Name of the Subject




Title of Research Study

Effects of a Behavioral Intervention on Adolescent Mother's Initiations Toward Her Premature Infant in the NICU University of Florida Health Center
Principal Investigator(s) and Telephone Number(s) Institutional Review Board APPROVED FOR USE
Stacy A. Paolini, M.S. From L13\0L Through Ox\c\oj' ,. (352) 392-0701 wk. (352) 395-6451 hm. t"

If you are a parent of a minor mother who qualifies to be in this study, as you read the information in this Consent Form, you should put yourself in your child's place to decide whether or not to allow your child to take part. Therefore, for the rest of the form, the word "you" refers to your child.

If you are an adolescent mother reading this form, the word "you" refers to you.


What is the purpose of this study?
Early mother-infant interactions appear to help children have positive experiences later in life.

Preterm infants, tend not to be very active in interactions. The purpose of this study is to test a

78


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program designed to help adolescent mothers of preterm infants learn how to interact with their babies. We want to collect information on whether the program is actually helpful to adolescent mothers.

What will be done if you take part in this research study?

If you are willing to take part in this study, you will be asked to watch a 15 minute video of a mother and infant interacting and attend 3 practice sessions with your infant and the principal investigator in the NICU where you will practice interacting with your infant using rattles, a red ball and your face and voice. After the practice sessions a research assistant will observe your interactions with your infant at your infants bedside in the NICU. Observations will occur approximately 3 times per day for 5 minutes over 3 weeks time. At the end of the study you will be asked to fill out a questionnaire, which consists of 5 questions. The questionnaire will be used to obtain your suggestions in order to make changes to thte training sessions for future research.

What are the possible discomforts and risks?

There is a possibility that you will be uncomfortable during the observations and answering the questionnaire. At any time during the study you can stop taking part in it.

If you wish to discuss the information above or any other discomforts you may experience, you may ask questions now or call the Principal Investigator listed on the front page of this form.

What are the possible benefits to you or to others?

If the program is helpful, you may have better interactions with your preterm infant, but this cannot be guaranteed. The information we collect from this study may help us learn how to improve interactions between adolescent mothers and their preterm babies in the future.

If you choose to take part in this study, will it cost you anything?

Participation in this study will not cost you anything.

Will you receive compensation for your participation in this study?

For participating in this study you will receive a developmental toy at the end of each week worth $5.00. At the end of the study you will also receive a book on child development worth $10.00. Total worth of the items will be $25.00.

What if you are injured because of the study?

If you experience an injury that is directly caused by this study, only professional consultative care that you receive at the University of Florida Health Science Center, Shands at Alachua General Hospital, and University Medical Center will be provided without charge. However, hospital expenses will have to be paid by you or your insurance provider. No other compensation is offered.


Page 2 11/30/00









Signatures

As a representative of this study, I have explained the purpose, the procedures, the benefits, and the risks that are involved in this research study:


Signature of person obtaining consent


Date


You have been informed about this study's purpose, procedures, possible benefits and risks, and you have received a copy of this Form. You have been given the opportunity to ask questions before you sign, and you have been told that you can ask other questions at any time. You voluntarily agree to participate in this study. By signing this form, you are not waiving any of your legal rights.


Signature of Subject


Signature of Witness (if available)


Date


Date


If you are not the subject, please print your name and indicate one of the following:

_ The subject's parent

_ The subject's guardian

_ A surrogate

_ A durable power of attomc

_ A proxy

_ Other, please explain:


Page 4
11/30/00









How will your privacy and the confidentiality of your research records be protected?

Authorized persons from the University of Florida, the hospital or clinic (if any) involved in this research, and the Institutional Review Board have the legal right to review your research records and will protect the confidentiality of those records to the extent permitted by law. If the research project is sponsored or if it is being conducted under the authority of the United States Food and Drug Administration (FDA), then the sponsor, the sponsor's agent, and the FDA also have the legal right to review your research records. Otherwise, your research records will not be released without your consent unless required by law or a court order.

If the results of this research are published or presented at scientific meetings, your identity will not be disclosed.

Will the researchers benefit from your participation in this study (beyond publishing or presenting the results)?

The researcher will present the results of the study to a University of Florida doctoral committee and upon its approval will be granted a doctoral degree from the University of Florida.

What if you are under 18 years old or if you cannot give legal consent for another reason?

Because of your age you cannot give legal consent to take part in this study. Therefore, the researcher will ask for your assent. Assent is your agreement to be in the study. The researcher will explain the study to you in words that you can understand. You should ask questions about anything you don't understand. Then you should decide if you want to be in the research study. If you want to participate, your parent or someone who can sign a legal document for you must also give their permission and sign this form before you take part.

You agree to participate.


Subject's signature Date




Signature of Principal Investigator or Date Representative



Witness (if available) Date


Page 3 11/30/00









Videotape Consent

With your permission, you will be videotaped during this research. Your name or personal nformation will not be recorded on the videotape and confidentiality will be strictly maintained. however, you should be aware that the showing of these videotapes may result in others being ible to recognize you. The videotapes will be kept in a locked cabinet by Stacy A. Paolini. I'hese videotapes will be shown under Ms. Paolini's discretion to students, researchers, doctors, ind other professionals and persons.

Please sign the following statement that indicates under what condition Ms. Paolini has permission to use the videotape.

I give my permission to be videotaped solely for this research project under the conditions described.


Signature Date


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APPENDIX B

DATA COLLECTION FORMS


















- - - - - - -To
Date tal ( -00) o o Time 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Intervals
Infant's
Behavior
State 1 11 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 444 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 55 Pre-Stress H H H H H H HHHHHH HH H H H H H H
EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA EA Infant Rest I Stress B B B B B B B B B B BB BB B B B BB B
HB HB HB HB HB HB HB HB HB HB HB HB HB RB HB HB HB HB HB HB
R R R R R R R R R R R R R R R R R R R R V V V V V V V V V V V V V V V V V V V V Terminate
Total
Mother's
Behavior
Dim Lights
Swaddling
Gentle
Vestibular
Holding
Patting
Pacifier
Face/Voice
Rattle
Ball
Other:


Mother's Y Y Y Y Y Y Y Y Y Y YY Y Y Y Y Y Y Y Y Appropriate N N N N N N N N N N N N N N N N N N N N Interactions
Scoring Criteria:
Time Intervals- 20 seconds Infant's Behavioral State- 1-asleep: 2-drowsy, 3-awake: 4-irritable 5-crying Pre Stress- H-hiccups: . EA-eye aversion Stress- HB-heart beat; BL-blue lips. R-respiration. V- vomiting Mother's Behavior/Social Interaction- empt box = opportunity not recognized; 'i-opportunity recognized Interactions- Y-Appropriate Interactions; N- Not Appropriate Interactions


Data Recording Sheet


Table B 1.
































APPENDIX C

INTERVENTION SCRIPT














Intervention Script


Researcher:


We are going to talk about three things today and watch a short video where you will see a mother and her baby playing. The first thing we are gong to talk about is how to know when your baby is ready to play. Next we will talk about what to do when your baby is upset and crying. Last, we will talk about how to play with your baby when he/she is calm and awake. While we are watching the video I'll stop it so we can talk about what we saw. Do you have any questions before we begin?


Start Video On Screen are the words" Behavioral States"


Researcher:


Stop Video

Researcher:




Mother: Researcher:


This baby is asleep, his eyes are closed his breathing is regular and he is not moving (Video shows sleeping baby). This baby is irritable, his arms and legs are moving around and he is making a lot of noises.(Video shows an irritable baby) Here is a drowsy baby. His eyelids are heavy and he has a hard time keeping them open and he moves very little (Video shows a drowsy baby).

This baby is awake and alert. His eyes are open and he is moving his arms and legs. (Video shows awake baby). Here we see a crying baby. He is very upset, crying and moving his arms and legs. (Video shows a crying baby).


And now we are going to review some of the things we saw the baby doing in the video.

Can you tell me about a baby who is drowsy? What would he look like? Yes, his eyes are heavy and he is not moving around much. That's right; the baby we saw kept falling asleep and could not keep his eyes open.









Can you tell me about a baby who is irritable? Yes, the baby was making lots of grunting and short cries.


Start Video

Researcher:


On screen the words "Soothing Techniques"

Most premature infants don't really like too much playing like rocking, talking to or singing to especially if we do them all at the same time. They might get upset and cry or keep their eyes closed. These are signs that your baby may be getting stressed out and we should take a break from playing with him/her. It's important to know when your baby is getting stressed for two reasons 1. He may get too excited and this may cause unusual breathing and heart rates, 2. You want your baby to stay relaxed so you can interact with him.

The following are some of the stress signs you may see.
Crying
Hiccups
Looking away from you
Sneezing

When you see these stress signs you should stop playing with your baby and let him rest for a few a few minutes before you start to play again. There are some stress signs that are much more serious such as blue lips, stop breathing, drop in heartbeat. If these things happen then you should stop playing immediately and tell a nurse of doctor.

There are things you can do to help keep your baby relaxed so you can play with him. They are: swaddling, lowering lights, holding, using your face/voice, and using a pacifier.

Before you begin to play with your baby you want to swaddle him in a blanket. Swaddling the baby helps him feel safe and secure. It also helps keep his arms and legs from moving around too much. (Video shows swaddled baby).
Sometimes babies have a hard time opening their eyes when the light is too bright so you want to make sure to dim the lights over his bed.

Holding your baby can help calm him down when he/she is upset.

When you hold your baby you can rock him in a slow up and down movement to calm him.

Sucking is one way a baby calms himself when crying so you will want to give him his pacifier.


Mother:










You have probably been doing some of these things with your baby
already.

Stop Video

Researcher: Lets review some of the things we saw. When should you stop playing
with your baby?

Mother: If my baby hiccups, his lips turn blue, cries, or he keeps his eyes closed.

Researcher: That's right. How would you calm your baby if he became upset9

Mother: I would trying and use my face and voice and if he kept crying I would
give him his pacifier.

Start Video: "Social Interaction" appears on the screen.

Researcher: Now we are going to see a mother playing with her baby in the NICU.
During the video you may see the mother use the soothing techniques in
order to calm and play with the baby.


Here we see the mother at her baby's crib and she has swaddled her baby.
Next, she dims the lights. She is getting ready to play with him. She will
use a red ball, a rattle, and her face and voice.

On Screen: Red Ball

The mother takes another minute to let the baby rest and then she uses a
red ball to try and get her baby to following it to each side. She holds the
red ball 10-12 inches in front of the baby's eyes moving is slowly from
one side to the next. The baby is able to following the ball only with his
eyes to both sides.

On Screen: Rattle

Next, she picks up the rattle. She holds it 10 inches from the baby's ear and shakes the rattle trying to get the baby to move his eyes toward the
rattle or turn his head. She will shake it again on the other side. This baby
is able to turn his head to each side when the rattle is shaken.

On Screen: Face & Voice

She holds her baby and softly speaks to the baby calling his name etc.
See how the infant's eyes are following the mothers face. She stops for a


















Stop Video


Mother: Researcher: Mother: Researcher:



Mother: Researcher:


minute to give the baby a break then starts speaking to him in his other ear.


The mother is only doing one thing at a time with her baby. You do not want to use your voice and rattle or voice and red ball together because this will upset your baby and he will not be able to play with you. Most premature babies do not like too much play time because they get tired and need to rest.

Lets review some of the things we just saw in the video. What are some of the things the mom used to play with her baby? The face & voice, rattle, and red ball. Very good. Why should you use one toy when you play with your baby? Because the baby will get tired and upset. That's right your baby will get tired very quickly. Do you have any questions about playing with your baby? No.

Then why don't we go to your baby's crib and I can show you some of the things we just saw in the video.
































APPENDIX D

SOCIAL VALIDITY QUESTIONAIRE














Social Validity Questionnaire


1. The NBAS training was helpful for providing me with information about my
baby's behavior.

definitely was was a little definitely was not2. The NBAS training was helpful for providing me with tips on how to calm my
baby when he/she is upset.

definitely was was a little definitely was not _3. The NBAS training was helpful for providing me with tips on how to play with
my baby in the NICU.

definitely was was a little definitely was not 4. I continued to use the information about calming and playing with my baby at
home?

definitely have __ have a little definitely have not

5. 1 would recommend that other mothers learn the about their baby's behavior,
ways to calm and play with them while they are in the NICU.

definitely would maybe definitely would not If "no" please explain

































APPENDIX E

PILOT STUDY











Baseline Intervention Maintenance


80 70
" 60 . 50

C~ 40
0
~.30 0 20
0
10I
I.'


1 2 3 4 5 6 7 8 Sessions


9 10 11 12 13 14


Figure E-1. Pilot Study Graph
































APPENDIX F GRAPHS I & 2















Intervention Maintenance


I I







I I I I
I I







I I


4 6


Dyad 2


8 10 12 14 16 18

-...................


- - -I


100 80 -


Figure F-1.


Dyad I Baseline


0 2 46 8 10 12 14 16 18


0-


Sessions




Full Text

PAGE 1

THE EFFECTS OF AN INTERVENTION ON ADOLESCENT MOTHERS' INITIATIONS TOWARD THEIR PREMATURE INFANTS IN THE NEONATAL INTENSIVE CARE UNIT BY STACY A. PAOLINI A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULHLLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY j i UNIVERSITY OF FLORIDA 2001

PAGE 2

TABLE OF CONTENTS page ACKNOWLEDGMENTS iv ABSTRACT v CHAPTERS 1 INTRODUCTION TO THE PROBLEM 1 Purpose of the Study 6 Scope of the Study 7 Definition of Terms 8 Overview 10 2 REVIEW OF RELATED LITERATURE 1 11 Introduction 11 Attachment Theory and Its Role in Infant Development 11 Synactive Theory and the Relationship Between Neurobehavioral Subsystems and Their Role In Mother-Infant Interactions 18 Factors that Jeopardize Parent-Preterm Infant Interactions 22 Early Intervention 30 Summary 33 3 METHODS AND PROCEDURES 35 Introduction 35 Methods 37 Procedures 45 Experimental Design 50 Treatment of Data 50 Pilot Study 51 4 RESULTS 55 Introduction 55 Interobserver Agreement & Treatment Fidelity 56 Treatment Resuhs 58 Social Validity 63 I ii

PAGE 3

5 DISCUSSION 66 Summary & Analysis of Results 67 Summary of Previous Literature 68 Limitations ^2 Recommendations for Future Research 73 APPENDICES 77 A PERMISSION FORMS 77 B DATA COLLECTION FORM 83 C INTERVENTION SCRIPT 85 D SOCIAL VALIDITY QUESTIONAIRE 90 E PILOT STUDY GRAPH 1 92 F GRAPHS (DYAD 1 & 2) 94 G GRAPHS (DYAD 3 & 4) 96 REFERENCES 98 BIOGRAPHICAL SKETCH ! 108 iii

PAGE 4

Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE EFFECTS OF AN INTERVENTION ON ADOLESCENT MOTHERS' SOCIAL INITIATIONS TOWARD THEIR PREMATURE INFANTS IN THE NEONATAL INTENSIVE CARE UNIT By Stacy A.Paolini August 2001 Chairwoman: Mary Brownell Major Department: Special Education The purpose of this study was to investigate the effects of a modified version of the Brazelton Neonatal Behavioral Assessment Scale. Four adolescent mothers were taught about infant behavior, soothing techniques, and social initiation skills in order to increase their appropriate social initiations toward their infants in the neonatal intensive care unit. Mothers participated in training sessions, which included watching a video, observing a certified NBAS examiner demonstrating the intervention at their infants' bedside, and practicing the intervention with their infants. Additionally, mothers were asked to provide information about the social validity of the intervention. One week after discharge the researcher contacted the mothers by telephone and asked about her judgments concerning the appropriateness of the intervention, including an evaluation of whether it was fair, reasonable, and consistent with conventional notions. iv

PAGE 5

A multiple baseline design was used to evaluate the effects of the intervention. Data were visually analyzed to determine if nay differences existed between the baseline behaviosr and maintenance behaviors of each mother. After receiving information about infant behavior and training on how to appropriately interact with a premature infant adolescent mothers increased their appropriate social initiations toward their infant. I Additionally, all participants maintained an increased level of social interaction compared to their baseline behavior. Three of the mothers were able to maintain the social initiation skills they learned compared to intervention training. The first mother's targeted behaviors decreased slightly during maintenance compared to intervention training. The results of the social validation measures were favorable. Participants reported satisfaction with the information they received about infant behavior and social initiations as well as the training procedures. Some mothers reported that they had shared the information they learned with other family members, and were continuing to use the techniques at home. V

PAGE 6

CHAPTER 1 INTRODUCTION TO THE PROBLEM Introduction One of the major features of attachment theory is the belief that attachment is a behavioral system that is innate in the human species (Slater & Muir 1999). John Bowlby's (1969) early research on attachment theory underpins subsequent work on mother-infant relationships. He reported that the need for attachment is a system operating within the infant to fill affectional needs (Klann-Deluis & Hofineister 1997). The affectional needs are established by being in close proximity to another human being and engaging in reciprocal interactions (Slater & Muir 1999). Infants use certain behaviors to try to establish an affectional bond with other human beings, most likely, but not necessarily their caregivers. The actions of the infant such as crying, sucking, following, smiling, and clinging are used to increase the mother's proximity to the infant (Ainsworth 1995; WendlantI Carro et al. 1999). The infant's needs are complimented by the maternal behavior to nurture and protect the infant. Through these reciprocal interactions the infant and the caregiver become reciprocally attached (Isabella 1993). A central premise of attachment theory is that the formation of a secure attachment depends on the quality of the dyadic interaction (Meins 1997). Specifically, the mother's sensitive responsiveness to the infant's signals provides the context in which the infant's experiences and feelings of security are organized (De Wolf & Ijzendoom 1

PAGE 7

2 during infancy (Fish & Stifter 1995; Vondra et al. 1995, Leavitt 1999). Eariy parent infant and family interactions set the stage for each infant's growth and development (Leavitt 1999). Attachment quality was found to be a good predictor of both cognitive and social competence. Attachment measured at 13 and 24 months predicted impulse inhibition, school performance, and social behaviors at age 6 (Olson et al. 1984; 1989). While attachment quality predicts later cognitive and social competence, an infant's irmate ability to demonstrate behaviors that foster interaction also affects the attachment process. Thus, the infant's ability to socially interact, and to develop subsequent cognitive and social skills, is put at risk when the infant is unable to appropriately interact with the caregiver (Main & Cassidy 1988). A sequence of negative transactions between caregiver and infant often starts when an infant has an abnormal medical history, appearance, or behavior (Zahr 1994). After a premature birth, parent must make psychological adjustments. A mother may perceive her infant as too fi^agile to touch and less attractive thus decreasing their social interactions (Stem & Karraker 1990). A mother and a premature infant in the neonatal intensive care unit are at risk for negative interactions. The mother may respond negatively or insufficiently to her premature infant because of the mother's or infant's inappropriate behaviors, and the unnatural environment of the NICU (Niven et al. 1993). Most premature infants are unable to actively interact with their parents. This is because of the characteristics and capabilities that a premature infant brings to a social encounter (Wyiy 1995). Premature infants often suffer from medical complications that place them at medical risk and they

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3 Research findings strongly support the conclusion that desirable cognitive and social emotional development is related to the quality of the parent-child interaction during infancy (Fish & Stifter 1995; Vondra et al. 1995; Leavitt 1999). Early parent infant and family interactions set the stage for each infant's growth and development (Leavitt 1999). Attachment quality was found to be a good predictor of both cognitive and social competence. Attachment measured at 13 and 24 months predicted impulse inhibition, school performance, and social behaviors at age 6 (Olson et al. 1984; 1989). While attachment quality predicts later cognitive and social competence, an infant's innate ability to demonstrate behaviors that foster interaction also affects the attachment process. Thus, the infant's ability to socially interact, and to develop subsequent cognitive and social skills, is put at risk when the infant is unable to appropriately interact with the caregiver (Main & Cassidy 1988). A sequence of negative transactions between caregiver and infant often starts when an infant has an abnormal medical history, appearance, or behavior (Zahr 1994). After a premature birth, parent must make psychological adjustments. A mother may perceive her infant as too fragile to touch and less attractive thus decreasing their social interactions (Stem & Karraker 1990). A mother and a premature infant in the neonatal intensive care unit are at risk for negative interactions. The mother may respond negatively or insufficiently to her premature infant because of the mother's or infant's inappropriate behaviors, and the unnatural environment of the NICU (Niven et al. 1993), Most premature infants are unable to actively interact with their parents. This is because of the characteristics and

PAGE 9

4 I capabilities that a premature infant brings to a social encounter (Wyly 1995). Premature infants often suffer from medical complications that place them at medical risk and they are unable physically to give clear attachment signals (Zahr 1993). Their health status resuhs in disorganized behavioral responses or an inability to stabilize their social interactions. Social encounters with them may be nonexistent or very diffierent from their full-term counterparts. Compared to fiill-term infants, premature infants with an immature nervous system may not be predisposed to respond to interaction stimuli such I as a father's or mother's touch (Eckerman & Oehler 1992). Both prematurity and adolescent mothering increase the risk for less-than-optimal development. Factors such as poverty, lack of knowledge about child development, depression, low self confidence and the infant's medical fragility contribute to poor development (Barnard et al. 1996). In addition, how the adolescent mother relates to and interacts with her infant during the neonatal period and beyond sets in motion a series of transactions that help determine the course of her infant's development. Almost 1 million teenagers become pregnant each year, and about 485,000 give birth (National Center for Health Statistics 1997). Regardless of gestational age, an infant bom to a teenage mother is more at risk for certain medical problems than is a baby bom to an older mother (Gottwald & Thurman 1990). Nine percent of mothers' 15 to 19 years old have a low-birth weight baby (National Center for Heahh Statistics 1997). Ten percent of mothers between the ages of 1 5 and 1 7 years have a low birth weight baby (National Center for Health Statistics 1997). The adolescent's lack of emotional maturity and knowledge of parenting skills puts the infant at fijrther risk. The premature birth of an infant and the hospitalization that

PAGE 10

5 follows can be an intense time for an adolescent mother. In addition to being scared and anxious, young mothers may not have the parenting skills to interact with their premature infant (Barnard et al. 1996) and these factors may hinder the attachment and interaction process. Adolescent mothers differ from their mature counterparts in their behavior toward their infants (Gotwald & Thurman 1990). Fogel (1991) observed that teenage mothers used fewer typical adult behaviors (high-pitched voice, touching, and synchronous movements) when interacting with their infants. Others noted that teenage mothers exhibit much warmth and physical behavior but relatively little verbal interaction with their infants (Causbly 1991, Gottwald & Thurman 1990). Moreover, adolescent mothers express less realistic developmental expectations for their infants (Field et al.l980; Sommer et al. 2000, Als 1992). For example, they tend to overestimate or underestimate linguistic or motor capabilities of their infant. Thus, children of adolescent mothers may be susceptible to developmental problems partly because of their exposure to a less optimal care-giving environment. Because many adolescent mothers do not manage to stay in school, are not knowledgeable about child development, and often seem to posses conflicting attitudes about mothering, these are the mothers whose premature infants are at-risk for social interaction problems and in need of early intervention (Boyce et al. 1991). An obvious goal of intervention studies is to develop procedures that would increase parental knowledge and enhance mother-infant interactions (Lamour & Lebovici 1991). Unfortunately, there is little research on early intervention treatments for improving interactions between adolescent mothers and premature infants despite a limited number

PAGE 11

of studies that demonstrate poor social interactions between adolescent mothers and premature infants and that demonstrate insufficient attachments (Hamilton 1996). Therefore, it is necessary to develop and test more interventions that enhance the quality of adolescent mother's interactions by presenting information about the infant's behavior, soothing techniques, and appropriate social interactions. Several studies have shown that increasing parental awareness of the infam's competencies can enhance parent-infant interaction (Brazehon et al. 1987; Nugent & Brazehon 1988). Mothers who have been familiarized with the infant's capacities are more likely to spend time stimulating the infant, to pay more attention to the infant, and to be more responsive to the infant's signals (Widmeyer & Field 1987). Moreover, mothers who were actively involved in the administration of the Neonatal Behavioral Assessment Scale increased their responsiveness to the infant compared to mothers who only observed the administration (Worobey & Belsky 1982). Worobey and Belsky (1982) suggested that the effect could be reciprocal, since the infant would, in response to increased responsiveness, make greater demands on the caregiver and would further I enrich the interaction. Purpose of the Study The purpose of this study was to determine the effects of an intervention on adolescent mothers' social initiations toward their premature infants while they are in the NICU. The research question answered through this study was as follows: Will teaching adolescent mothers about their premature infants' behavioral states, stress signals, soothing techniques, and social interactions increase their appropriate social initiations with their infants?

PAGE 12

7 Specifically, a behavioral intervention was used that incorporated a modified version of the Brazehon Neurobehavioral Assessment Scale. Results of this investigation added knowledge about the effects of using the modified NBAS on parents' knowledge of infant behavior and their subsequent ability to interact with their infant. Scope of the Study This study was conducted within a limited scope. The delimitations and limitations of this research are described in the following sections. I Delimitations The study was delimited by geographical location to Gainesville, Florida, a medium-sized city located in the north central part of the state. The study was conducted at Shands Teaching Hospital Regional Neonatal Intensive Care Unit (NICU) at the University of Florida Health Science Center, Gainesville. The NICU was a level III tertiary unit that provided state-of -the-art care to medically fi^agile infants. The NICU staff focused on family-centered care for infants and family members and excellent medical care for premature and medically fragile infants. Family-centered care offered families the opportunity to participate in nonmedical activities, such as feedings, baths, and diaper changes. In addition, informal family support groups were offered weekly to give families the opportunity to interact with each other. The hospital served infants and their families from southern Georgia to southern Florida. Subjects Four mother-infant dyads fi-om the NICU were selected fi-om Shands Teaching Hospital to participate in this research. Medical charts were used to identify mother-

PAGE 13

infant dyads who met the following criteria: a) the mothers were between 15 and 19 years of age and delivered their infants in the NICU; and (b) the infants were of a singleton birth, were no older than 38 weeks gestational age, weighed 1 100 to 3300 grams, were without congenital malformations or disorders, were medically stable, and were admitted to the NICU. Someone other than the researcher reviewed the medical charts and made the initial contact with the mother to obtain verbal interest in participating in the project After obtaining a verbal commitment the researcher talked with the mother and guardian to explain the research procedures and obtain written consent. Permission for this study was obtained from the Shands Teaching Hospital Institutional Review Board and the guardian of the adolescent mothers. First, the researcher reviewed the medical charts to select mother-infant dyads. Next, eligible families were contacted and the researcher explained the purpose of the study and asked the families for their participation. The adolescent mother and her guardian reviewed the consent form. The mother and guardian had the option of signing the form or refusing to allow the mother to participate. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A. Limitations The findings of this study should not be generalized to mother-infant dyads consisting of adult mothers of healthy or critically ill infants. Four mother-infant dyads participated in this study. Definition of Terms Adolescent mother . Mothers who are between 15 and 19 years of age.

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9 I Brazelton Neonatal Assessment Scale . Test of a newborn's reflexes, behavior, and responses to his/her environment. Full-term infant. Infants bom between 38 and 42 weeks gestation. Infant stress. Critical problems commonly observed among preterm infants, which include, blue lips, increased heart rate (above 180 beats), decreased heart rate I (below 100 beats), vomiting, and apnea. Neonatal intensive care unit rNICU ). The NICU is a unit of the hospital with trained staff and special equipment to provide medical care to critically ill newborn infants. Neurobehavioral states. Organized periods of sleep and alertness that appears with regularity. These periods are called infant states and are relatively stable clusters of functional patterns and physiological variables that are organized and repeated. They reflect the infant's level of arousal, determine their reaction to the environment, and can be modified in response to external stimulation. They are considered reliable indicators of the integrity of the central nervous system. Premature infant . Infants who are less than 38 weeks gestational age. Social initiation . Any motor or vocal behavior (clearly directed to the infant) that attempts to elicit social responses such as greeting, gaze, facial expression, touching, calling the infant's name, and any other socially directed behavior. State 1 . A sleep state defined as eyes closed, regular breathing, and little-to-no spontaneous body movements. State 2 . A drowsy or semi-dozing state. The infant's eyes may be open but dull and heavily lidded with low physical activity.

PAGE 15

10 State 3 . Defined as alert, with eyes opened and the infant seems to focus attention on a source of stimulation. State 4 . An irritable state with considerable motor activity. There are brief fiissy vocalizations. State 5 . A crying state that is characterized as intense. It is difficuh to stop this crying with soothing techniques. Stimuli. An object that directly influences the activity of an organism. Swaddle. Wrapping an infant in a blanket so that the body and movements are contained. Overview An investigation of the effects of an intervention on the social initiations of adolescent mothers toward their premature infant was the focus of this study. Chapter 2 reviews and analyzes relevant professional literature in the areas of attachment theory, adolescent mothers and premature infants. Chapter 3 describes the methods and procedures to be used in this study. The resuhs obtained fi^om the intervention will be discussed in Chapter 4. Finally, Chapter 5 includes a discussion of the results as related to previous research, implications, and recommendations for future research.

PAGE 16

CHAPTER 2 REVIEW OF RELATED LITERATURE Introduction Chapter 2 includes a summary and analysis of the professional literature. The literature on the role of attachment on infant development, the importance of motherinfant social interactions, and the factors that jeopardize mother infant interactions are presented. This chapter is divided into several sections. The theoretical and empirical basis for training adolescent mothers of premature infants in the NICU using a behavioral intervention is shown in the first section. The other sections summarize, analyze relevant studies about mother-infant social interaction and its effect on attachment; and discuss how the attachment process is jeopardized when the infant is bom premature, and the increased risk these premature infants incur when they are bom to adolescent mothers. I also examine early intervention in the neonatal intensive care unit. This chapter concludes with a summary of the research findings. Attachment Theory and its Role in Infant Development John Bowlby's theory of attachment (1958,1969) provides the basis for research examining the relationship between infants and caregivers that has spanned approximately five decades (Slater & Muir 1999). Bowlby (1969) concluded that there was a biologically-based need for social interaction in human infants that eventually 11

PAGE 17

12 became focused primarily on specific figures such as the mother or father (Slater & Muir 1999). Bowlby (1960) explained that infants come equipped with a repertoire of behavioral cues that are designed to elicit responses fi-om the caregiver. These cues, such as crying, sucking, following, smiling, and clinging are used to gain proximity to the caregiver (Main & Solomon 1990). For example, the infant's cry serves to elicit adult responses that usually involve an offer to pick up the infant, and thus the infant's crying ends. The efficacy of the infant's behavioral cues depends on the appropriateness of the caregiver's response. Infants become attached to individuals who consistently and appropriately respond to their signals. Thus, reciprocity between infant and caregiver becomes crucial in the attachment process (Main & Solomon 1990; Ainsworth 1990). Infant attachment develops over time, moving through several phases that are qualitatively different. The four phases of attachment are Phase 1, preattachment; Phase 2, attachment in the making; Phase 3, clear cut attachment; and Phase 4, goal corrected partnership (Slater & Muir 1999). The preattachment phase begins at birth and continues for 3 to 4 weeks. From the beginning, the infant is more aware of certain stimuli than others. The infant is equipped with behaviors, such as crying, that operate to attract the caregiver to come near. At first these attachment behaviors are emitted, rather than directed toward any specific person, but gradually the baby begins to discriminate one person fi-om another and to direct attachment behavior differentially (Main & Solomon 1990). Research indicates that the infants are more interested in people; however, they are unable to discriminate one person fi-om another, and therefore do not differentially respond to caregivers versus other people (Slater & Muir 1999; Fox et al. 1991). The infant can orient toward anyone who

PAGE 18

13 is in sufficiently close proximity, directing gaze toward that person and tracking his or her movements with his eyes. She is equipped with signaling behaviors such as crying and smiling, which she uses to induce people to approach and perhaps pick up the infant, thus promoting proximity and contact (Meinsl997). These crying and smiling behaviors are classified as attachment behaviors (Slater & Muir 1999; Fox et al. 1991). Phase 1 comes to an end when the infant is capable of discriminating between people and, in particular, of discriminating his mother fi-om others. During Phase 2, attachment in the making, the infant not only clearly discriminates unfamiliar fi^om familiar figures, but also discriminates among other stimuli, such as toys. For instance, research shows that the infant discriminates among adults by directing attachment behaviors, such as reaching and grasping, which enable proximity, toward some adults and not others, and these people may also differ in how readily they interact with the infant (Slater & Muir 1999; Fox, Kimmerly & Schaffer 1991). In Phase 3, clear-cut attachment, the infant is more active in seeking and achieving proximity. He makes contact with his preferred caregiver on his own account. That is, the child moves toward the caregiver rather than relying on a signaling behavior and waiting for the caregiver to respond (Slater & Muir 1999). Although the infant is more active in seeking proximity, he does so intermittently. At this point the child becomes more independent. The infant is active in exploring his environment, manipulating the objects discovered, and learning about their properties. Although securely attached children seem to explore the environment independently, they still look

PAGE 19

14 to their parents for comfort as they play. Parents thus, provide a secure background from which infants explore their environment (Slater & Muir 1999). In the goal-corrected partnership phase, the last phase of early attachment, the child begins to see his mother's perspective, and is able to infer what feelings and motives might influence her behavior (Slater & Muir 1999). For example, the child may cry purposely to gain sympathy from a mother. When this point of development has been reached, mother and child develop a complex afiFectional bond that continues through the child's entire lifespan (Ainsworth 1995). While parent/child attachment may weaken as adulthood approaches and may be supplemented by other attachments, few, if any adults, cease to be influenced by their early attachments (Fox et al.l991; Ainsworth 1990). A main characteristic of securely attached children is their ability to use their mother as a secure base from which to explore their environment (Main & Hess 1990). When a child exhibits secure base behavior, he returns to the mother before venturing out for exploration, maybe bringing her back a toy or attracting attention with a vocalization I (Main & Solomon 1990). Even if securely attached children do not physically return to their mothers, they often use visual referencing to emphasize their exploration (Leavitt 1999). That is, they sometimes look at their mother or hold up a toy to secure some type of response. If the mother can understand the child's cues, then she can interact with the child in ways that improve cognitive and social development (Leavitt 1999). Such children know that their mothers will be available for support and comfort if it is needed, and thus often explore their environment (Main & Hess 1990; Sroufe et al. 1990). The child's knowledge is not something that is instinctual; rather, it is based on the child's

PAGE 20

15 past experiences and the mother's demonstration of her availability and nurturance over a long period of time (Slater & Muir 1999). A central feature of optimal or secure attachment is the mother's ability to respond to her infant's signals (Grossman & Grossman 1992), which is highly dependent on her perceptions and expectations of her infant's behavior (Leavitt 1999). Main and Solomon, (1990) found that mothers of securely attached children were more sensitive, accepting, cooperative, and accessible to their infants' requests than mothers of insecure infants. Moreover, mothers of securely attached infants were responsive to their infants' cries, had positive views about themselves and their infants, and were more skilled in feeding and playing. In contrast, mothers of insecure infants tended to be tense, irritable, and lacking confidence, reacting negatively to motherhood and handling their infants as little as possible or inappropriately. The mother who responded inappropriately tried to socialize vAth the infant when she/he was hungry, played with the infant when tired, or fed the infant when she was trying to initiate social interaction. The resuh was that their infants were less alert and did not appear to seek responsive interaction with their mothers (Main & Solomon 1990). The types of caregiving characteristics Main and Solomon (1990) identified in mothers of securely attached infants, are referred to as maternal sensitivity (Ainsworth 1995). Maternal sensitivity is defined as the ability to be aware of the infant's signals, to interpret them accurately and to respond to them in a prompt and appropriate manner (Van den Boom 1997; Ainsworth 1995). Ainsworth (1995) asserted that the most important index of sensitivity was the mother's quality of interaction with her infant, and the appropriateness of her responses. The caregivers' ability to select an appropriate

PAGE 21

16 reaction affects the development of reciprocal interactions between caregiver and infant, as the quality of the interaction depends on the infant's ability to communicate accurately through behavioral cues or language (Van den Boom 1997). Ainsworth (1995) stated that attachment behavior is an active response by the infant, and therefore requires the involvement of cognition. In order to become securely attached, the infant must have suflBcient cognitive ability to search for objects or people and must have the ability to maintain contact with a desired object or person, which cannot be seen (De Wolff & Van Ijzendoom 1997). The infant also must be able to form a mental representation of a hidden object or person, to search for it, and to use signaling behaviors or physical proximity to achieve maternal responses (Meins 1997). The infant uses his or her cognitive ability to form attachments, how the mother responds to signaling eflFort, also affects the infant's future cognitive development (Ainsworth 1995). The mothers of securely attached children provide appropriate environmental support in everyday interactions and in novel situations. This support I helps children feel in charge of their enviromnent and subsequently, their sense of confidence and self-eflficacy is increased (De Wolff & Van Ijzendoor 1997). The mother's manner of responding to the infant can help her/him develop the self-confidence she/he needs to persist with play tasks that are complex. Children who believe they are capable of accomplishing a task persist longer and are more successful at problem solving (Frankel & Baes 1990). This increased self-eflficacy and confidence may explain why Hazen & Dunst (1982) found that securely attached infants explored their environment more independently and were more innovative in solving spatial problems.

PAGE 22

17 Research examining the relationship between security of attachment and symbolic play shows that securely attached toddlers engage in more frequent and sophisticated sequences of imaginative play then do their insecurely attached peers (Bailargen 1994). Securely attached children are more likely to organize their play around a theme, and their play is enhanced by maternal involvement (Slade 1987). In contrast insecure children are dependent on others to structure their imaginative play. Quality of attachment also seems to affect social development. Turner (1993) found that children who had insecure attachments in infancy were rated by their teachers as being significantly more dependent than were their securely attached peers. The insecurely attached infants were more likely to seek help in self and social management, and spent more time in close proximity to their teachers or sitting on their teacher's lap. Children who were securely attached, in contrast, seemed more social. For instance, Grossman and Grossman (1985) reported that 3-year-olds who had been classified as securely attached in infancy interacted more quickly and smoothly with a stranger. This observation was made on the basis of the children's initial reaction to the researcher entering their home. The securely attached children tended to approach the researcher in their home without hesitation and talked to him without being asked to do so; whereas the insecure children were more likely to hide from the researcher, to cry or to cling to their mothers. Predictive studies also suggest that quality of attachment predicts later cognitive and social competence. Olson and her colleagues (1984) investigated individual differences in cognitive competence for children assessed at 6,13, and 24 months old. Verbal interactions between mothers and infants at the three ages were associated with

PAGE 23

18 school performance and social behaviors (Olson et al. 1984). These same children were assessed at 6 and 8 years old and early mother-child interactions were significant predictors of their cognition (Olson et al. 1992). Attachment quality at infancy also predicted later problem-solving skills and social competence with toddlers (Main & Cassidy 1988). The preceding examples illustrate that interactions between child and parent facilitate or hinder optimal development. A closer look at the abilities of the infant and the mother help researchers to understand how they can intervene in the process. The newborn's neurobehavioral organization affects how they interact with stimulus and form attachments with their caregivers. The quality of the caregiver's responses can be disturbed by the infant's immature neurological system. Without an intact neurobehavioral system, the infant can have diflBculty sending clear signals to the mother, thus the mother has difficulty responding accurately; setting in motion a chain of events that can affect the attachment process negatively. Synactive Theory and the Relationship Between Neurobehavioral Subsystems and their Role in Mother-Infant Interactions Synactive theory is used to describe how the subsystems of the infant's central nervous system function and interact to affect the infant's neurobehavioral organization and ability to respond to external stimuli (Als 1992). Neurobehavioral organization refers to the infant's ability to maintain and manage the subsystems of autonomic stability, motor system, behavioral states, attentional interactions, and self-regulation in interactions with the environment (Wyly 1995; Als 1992, Brazehon 1990). The

PAGE 24

19 organization of these subsystems affects the infant's interaction with the environment and caregivers (Als & Duflfy 1990). In full-term infants, these subsystems interact and support each other, reflecting a well-organized, mature nervous system. Full-term infants have little difficulty negotiating the environment because a stable autonomic and motor system allows the infant to control state behaviors, self-regulate their stress responses to the environment, and remain available for interaction with caregivers (Wyly 1995). These subsystems build upon one another and interact together to create a well-organized neurobehavioral system for the infant. Thus the functioning of these subsystems is described as synactive (Als 1982). The functioning of the infant's subsystems is observable (Wyly 1995). The functioning of the autonomic system can be observed by assessing respiration, color changes, and visceral signals, such as gagging and hiccups (Als 1984). Autonomic stability is an absolute prerequisite for the emergence of the other subsystems. Without it, there can be no state regulation. The motor system is behaviorally observable in posture, tone, and movements and is assessed to determine functioning of the infant's motor system (Als 1984). States of consciousness, from sleeping to alert, identify the state organizational system (Als 1984). State regulation is the "glue" that holds the subsystems together, allowdng the infant to effectively use all other subsystems (Als, 1984). The attention and interaction systems allow the infant to come to an alert attentive state and to use this state, attending to incoming cognitive and social emotional information and to subsequently respond to such information (Als 1984). The regulatory

PAGE 25

system is defined by strategies that infants use to maintain a balanced, relatively stable and relaxed state of subsystem integration (Als 1984). These subsystems build on each other, and the infant must have stability in the lowest subsystem before she/he can gain stability in the next subsytem (Fogel 1991). That is, the infant must have stability in the autonomic subsystems before appropriate motor control can be achieved. In order to achieve state regulation, the infant must have stability over the motor, as well as over the autonomic subsystems (Als 1984). In the I same respect, in order to have interactive abilities, the infant must have stability in the attentional, motor, and autonomic subsystem (Als 1984). Optimal self-regulation occurs only when there is appropriate stability in all other subsystems. The healthy full-term infant's subsystems interact simultaneously, reflecting a well-organized, mature central nervous system (Brazehon & Kramer 1991). The integrated fiinction of the subsystems enables the healthy full term infant to interact with the environment in an organized, smooth, balanced, and stress-free way. Healthy infants use clear signals to communicate with their caregivers, and their states of consciousness are clear and easily recognized by the caregiver (Hiniker & Moreno 1994). Their autonomic stability in terms of respiratory control, temperature regulation, and digestive functioning, is restabilized after the birth process, as are smoothness of body movements including their flexor and extensor posture (Lefrak-Okikawa & Lund 1995). The same is true for state organization and transition between states. Healthy newborn infants have no difficulty achieving a robust crying state and can return to a sleep state (Hiniker & Moreno 1994).

PAGE 26

In the first few weeks after birth, newborns begin to stabilize their neurobehavioral subsystems (Brazelton & Krammer 1990). For example, they move from sleep to aroused crying states and back to a sleep state. A two-day-old infant still has difBculty coming to an alert state for long periods of time, but by three weeks these periods of alertness become increasingly rehable and solidified (Brazehon & Krammer 1990). By one month to six weeks many infants spend an hour or more in an alert, socially and cognitively available state, ready to interact with their caregiver (Brazehon I & Krammer 1990). It is the infant's neurobehavioral organization that allows them to remain in alert states and transition to sleep states when appropriate. Not all newborn infants are able to coordinate their subsystems to obtain this interactional, attentional capacity, particularly those who are bom premature (Wyly 1995). After 24 to 27 weeks post-conception, the human fetus can be kept alive in an extrauterine environment due to the advances of medical technology. However, the infant is biologically expecting 13-16 more weeks of in-utero existence, with respiratory, I cardiac, digestive, and temperature control aided by maternal blood flow and placenta fiinctioning (Wells et al. 1994). Instead the infant has to make a dramatic adaptation to the NICU environment and relies on medical technology to control his autonomic functioning while the motor system, the state organizational system, and sensory functioning depends on the infant's environment. The premature infant has difficulty negotiating a balance between subsystems because of central nervous system and autonomic immaturity (Als 1992). The infant's subsystems are unable to operate in an integrated and supportive manner causing the infant to "shut out" environmental stimuli in order to stabilize autonomic functions that are necessary for survival (Tronik et al.

PAGE 27

22 1997). As a result, they are unable to coordinate their neurobehavioral system to interact appropriately with the environment (Tronik et al. 1997; Als 1984). The premature infant's immature central nervous system, and inability to integrate subsystems and maintain behavioral organization reduces the ability to interact with environmental stimuli, including the caregiver. Thus, the preterm infant may not be able to develop the reciprocal interactions noted between healthy infants and their caregivers. Moreover, preterm infants are placed at increased risk by both environmental and biological factors such as: the NICU environment, degree of prematurity, parental perceptions, and parental age. These environmental and biological risk factors combined can increase the developmental risk status of an infant. Factors that jeopardize parent-preterm infant interactions Barriers Created in the NICU Infants and their caregivers who are in the NICU do not always experience the positive resuhs of a successful attachment process. For preterm infants in the NICU, the development of normal interactional processes, so essential to attachment, may be altered by many factors including the NICU environment, infant characteristics, parents' perceptions of their infant, and parental age. While preterm infants develop aflFectional ties with caregivers using the same mechanisms as fullterm infants, the attachment process may be much slower to develop and difficuh to identify because of the risk factors mentioned earlier. The NICU environment, designed to medically sustain the life of a fragile preterm infant is a sharp contrast to the peaceful intrauterine environment. The NICU not

PAGE 28

23 only serves as a medical support for the infant but also as a backdrop for early social, emotional, and cognitive interactions (Stem & Karaker 1990). Unlike the home environment, which is often designed to foster developmental growth for the full term infant, the NICU environment taxes premature infants and makes it difficult to respond even minimally to caregivers (Perehudoff" 1990). Preterm infants in the NICU are exposed to more aduk speech, other infant cries, and generally higher levels of noise and light (Perehudoff" 1990). Further, preterm NICU infants have little opportunity to experience contingent social interactions typically experienced by term infants (Stem & Karraker 1990). Heriza and Sweeny (1990) suggest that infants in the NICU receive the wrong kinds of stimulation administered by the wrong persons. Premature infants are frequently handled but for such procedures as intubation, heel sticks, and diapering or repositioning after medical care by medical personnel (Peters 1992). Specifically, Peters (1992) reported 120 to 245 contacts, such as taking blood, by health care providers per 24 hours. These contacts are associated with increased infant stress. These contacts can leave premature infants with little energy to interact with their caregivers. Not only does the premature infant experience stress, but so do the parents. Parents often perceive the NICU environments as stressfiil and overwhelming. This contributes to difficuhies in establishing positive parent-infant interactions (Miles & Carter 1983). Parent-infant interactions are often affected adversely by many aspects of the NICU environment such as noise, constant lighting, constant medical activity, and lack of privacy (Graven et al. 1992). The NICUs with limited visiting hours can also have a negative effect on parents' involvement with their infants. Paludetto et al. (1984) compared interaction pattems of parents in NICUs with limited visiting hours to those in

PAGE 29

24 NICUs with unlimited visiting hours. Thirteen percent of the parents with limited visiting hours did not interact with their infants, compared to only 2.2 % of the parents with unlimited visits. The NICU staff can also present barriers to parent's involvement and subsequent interactions with their infants. Sometimes, NICU staff may be unwilling to allow parents to participate in their infant's care. McCluskey-Fawcett et al. (1992) found that those who reported the most positive experiences in the NICU were parents who NICU staff viewed as interested and capable of caring for their infants. Risk Factors Presented by the Preterm Infant The characteristics premature infants exhibit also can interfere with social relationships with their parents. In fact, early social encounters of premature infants and their caregivers can differ dramatically in frequency and intensity (Lester et al. 1985). These differences can be due, in part, to the characteristics and capabilities premature infants bring to the social encounter. Often premature infants in the intensive care nursery are fragile and physically unable to give clear attachment signals (Minde 1993). Very low-birth -weight infants frequently experience a variety of medical problems that place them at medical risk: for example, apnea, bradycardia, hypoxia, and respiratory distress syndrome. Their precarious medical state can result in disorganized behavioral responses or the inability to stabilize their social interactions (Gustafson & Harris 1990). Thus, social encounters may be nonexistent or very different from those of fiill-term counterparts. Additionally, the premature infant's central nervous system may be much less developed than the nervous system of term babies. Premature infants, for example, have

PAGE 30

25 greater difficulty regulating autonomic responses and states (Prechtl et al. 1979). They have been found to cry less and with less vigor than fiall-term infants (Divitto & Goldberg 1979). Compared to full-term newborns, premature infants may not respond as readily to interaction stimuli, such as a father's or mother's touch (Eckerman & Oehler 1992). When they do respond, their behavioral cues may be markedly different from the behavioral cues of full-term infants. Their cues may be weaker and more difficuU to read. Moreover, premature infants present avoidance cues, such as gaze aversion or crying in their caregiver's presence, more often than full term infants. Because of these characteristics, preterm infants may not experience as many social encounters, or may have encounters that are dramatically different from their fiill term counterparts (Minde 1993). A key component in any parent-infant interaction is the infant's signaling behaviors (Leavitt 1999). If parents are to read, interpret, and respond accurately to their infant's signals, the infant's behaviors and cries must be clear (Harrison 1990, Landry et al. 1990). For premature infants, particularly very young premature ones, communication cues are unclear at best. Mixed or confusing signals of premature infants make it difficuU for caregivers to respond appropriately (Harrison 1990; Landry et al. 1990). Consequently, communication cues are not reciprocated by caregivers which leads to less frequent social interactions (Leavitt 1999). Prenatal Factors that Contribute to Poor Attachment The difficulties the premature infant exhibits can heighten parents stress and negative emotions, and these characteristics can affect their attitudes toward their infant, and psychosocial interactions with them (Bass 1991). The unexpected early birth and

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26 lengthy hospital stay for the premature infant can increase stress associated with parenting a premature infant (Eckerman & Oehler 1992). After a premature birth, parents must make psychological adjustments. They must reconcile that their baby was bom premature and mourn the perfect, imagined baby that they had dreamed about during their pregnancy (Brazehon & Krammer 1990). This mourning process can have a dramatic effect on infant/parent interaction. Mothers have been shown to be detached and withdrawn in interactions with their infants due to the premature birth of their infant (Wilfongetal.1991). Parents' perceptions of what premature babies are like may also influence subsequent interactions with their premature infant (Padden & Glenn 1997). Despite the variety of backgrounds and experiences parents bring to the NICU, studies have shown that they have preconceived ideas about premature babies that affect their interaction with those babies (Stem & Hilderbrant 1986; Padden & Glennn 1997; Wilfong et al., 1991; Stem & Karraker 1990). Stem and Hilderbrandt (1986) asked mothers to interact with healthy full term infants who were labeled as either full term or premature. Mothers who believed they were interacting with premature infants touched them less and gave them more immature toys than did the mothers who believed they were interacting with fiill term infants. Mothers also rated premature infants as less active, more fragile, and less attractive than the fiill term infants and their perceptions decreased their interactions with premature infants (Stem & Hilderbrant 1986; Stem & Karraker 1990). Perceptions, however, can be mediated by factors, such as social support. Studies focusing on family relationships, parental stresses, and social support found that parents with high levels of social support exhibited lower levels of stress and subsequently more

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27 positive attitudes toward their premature infants ( Spiker et al. 1993; Parker et al. 1992; Obrien & Dale 1994). Moreover, these studies found that improved parental attitudes were often assosicated with greater behavioral responsiveness in both parents and infants. Thus, social support can improve the quality of interactions parents and their premature infants have. Increased Risks for Adolescent Mothers There is an increased risk for premature infants who are bom to adolescent mothers. The premature birth of an infant and the hospitalization that follows can be a time of intense feelings for an adolescent mother who has little experience in parenthood. She may feel depressed, happy, angry, scared, guilty, and incompetent, in combination or independently (Barnard et al. 1996). Clearly, these intense and often conflicting feelings can affect the manner in which the young mother interacts with her infant. The mother's adolescent status also accrues additional risk factors that affect the premature infant in the long-term. Children of adolescent mothers are more likely to be bom into and continue to live in poverty and to be physically, emotionally, and intellectually compromised as they develop (Sommer et al. 2000). Marecek (1980) reported that infants of adolescent mothers performed less well than infants of adult mothers on the Bayley developmental scales at eight months of age, the Stanford-Binet at four years, and the WISC at seven years. Moreover, Browman's (1981 ) longitudinal study revealed a higher percentage of mild retardation among children of young mothers than was present in the general population. More recently, Culp, Osofsky and O'Brien, (1996) found that infants of adolescent mothers had fewer vocalizations than did infants of adult mothers. Aggressiveness, impulsivity, and distractibility have also been found to

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28 be common in children of adolescent mothers (Hechtman 1989), along with a disproportionate percentage of insecure attachments (Ward & Carlson 1995). These factors, in combination with diminished intellectual capacities, set the stage for muhiple developmental and academic problems during the early school years (Sommer et al., 2000). The adolescent mother herself is educationally and economically disadvantaged. These young women are less likely to complete high school and are more likely to have larger families and to continue to live in poverty (Dukewhich 1997). Giving birth and the demands of motherhood usually decrease their school performance further and become precipitating factors in their decision to drop out (Prater 1997). Although motherhood is demanding for any woman, it is particularly diflficuh for adolescent girls (Camerrena et al. 1998). The adolescent mother is not only trying to establish herself as a mother but as an independent being, but as a mother. Her newly found responsibilities as a mother affect her search for identity (Wartena 1997). While she is trying to establish herself as an independent aduh, the adolescent mother still exhibits many child-like tendencies (Barnard et al. 1996, Stevens-Simon & Nelligan 1998). Her search for autonomy is now affected by the responsibilities she has in caring for her infant, which she often does not welcome. She has difficulty planning for the future, a necessary parenting skill, and is oriented toward the gratification available in the present environment (Hulbert et al.l997). Thus, adolescent mothers often see responsibility for their infants as an impediment to gratification and autonomy (Boyce Chestman, & Winkleby, 1991). In turn, they may resent the infant and often display a

PAGE 34

greater tendency toward child abuse (Barnard et al. 1996; McCullough 1998; Mylod Whitmanm, & Borkowski 1997). Additionally, adolescent mothers are less adept at interacting with their infants compared to their older counterparts. Researchers assert that adolescent mothers, compared to their more mature counterparts, may a) engage in fewer verbal interactions I with their infants, b) interpret their infants cues less accurately, and c) respond to their infants less frequently (Causby 1991; Gotwald & Thurman 1990). Thus, a higher risk exists for developing inappropriate social interactions between adolescent mothers and their premature infants (Causby 1 99 1 ). The NICU environment further affects the adolescent mother's ability to interact appropriately with her infant (Edwards & Saunders 1990). Bell (1997) examined adolescent mothers' perceptions of the stressors in the NICU environment. Bell concluded that adolescent mothers and their premature infants might fail to become attached because the mother's parenting role is insufficiently clear during the infant's hospitalization. These mothers reported that the most stressful aspects of the NICU were parental role aherations and the infant's appearance and behavior (Bell 1997). These stressors appeared to affect mothers' involvement and connection with their infant. For instance, parents were restricted in their role as daily caregiver and disappointed in their infants' ability to sustain an alert state. The NICU environment can also be intimidating to an adolescent mother. The ventilators, monitors, alarms, lack of privacy, preponderance of authority figures, and the infant's fragile condition all work against an adolescent mother's willingness to visit the NICU and spend time with her infant (Causby 1991). Besides her fear and anxiety, a

PAGE 35

30 young mother may not have appropriate social skills to take advantage of resources ofiFered in the NICU environment. Adolescents are excessively self-conscious (McGovem 1990), and may be hesitant to assert themselves as parents and more likely to rely on NICU staflFfor guidance. Given that many NICU staff have strong views about the role of parents in the NICU, the adolescent mother may be further disengaged fi-om her infant. The birth of a premature infant, the characteristics of that infant, and the NICU environment can have profound effects on the social development of the infant and the mother's attitudes toward her infant (Griffin 1990). For the adolescent, who is in the midst of profound life changes, the impact of mothering a premature infant may prove overwhelming. Thus, effective interventions that facilitate early interactions are needed in the NICU (Edwards & Saunders 1990). These interventions must help mothers become good observers of their preterm infant's behavior. Doing so should increase mothers' confidence to care for and interact with their infants, particularly in the case of preterm infants. Early Intervention The model for premature infants in the neonatal intensive care unit has been extended from a medical focus to include early developmental interventions (Wyly 1995). This approach requires NICU caregivers to assess each infant's development and plan an individualized developmental care program that nurtures the infant and optimizes development (Als, & Gilkerson 1995). Because of the important role that parents play in infant development, many NICU professionals have begun to incorporate family-centered care practices into their developmental care programs (Gorski 1991; Johnson 1995;). The

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31 family-centered care approach empowers family members and promotes collaboration with health care providers. Providmg family-centered care requires that professionals and families learn to work with one another and develop mutual trust and respect. Doing so heightens the probabihty for productive communication and family involvement that are important to an infant's long-term care (Nyqvist & Karlson 1997). Neonatal health professionals play an essential role in facilitating family participation in their infant's developmental care. Involving families in the developmental care of their premature infant can foster positive attachments between parents and infants (Hughes et al. 1994; Flyn & McCollumn 1989). Hughes and his colleagues found that participation in an early intervention program resuhed in increased mother/infant attachment, reduced family stress, and enhanced prenatal self-confidence for mothers (Hughes et al. 1994). Available infant assessments may provide the foundation for developmental, family-centered practices in the NICU (Brazehon & Krammer 1990). Current I assessments help parents and other caretakers know how to best interact vnth a preterm infant during family visits or procedures in the NICU (Merenstein 1994). Additionally, assessments help measure a preterm infant's progress, such as quality of their alertness, and assist caregivers in determining if their infant is ready to interact. The Neonatal Behavioral Assessment Scale (NBAS), which measures the interactions and behavioral organization of full-term newborns (Brazelton 1984), is one such assessment. The NBAS was originally designed to be a clinical assessment but is frequently used as an intervention by doctors, nurses, clinicians, early interventionists, and therapists to teach parents about their infant's behavior (Brazelton & Nugent 1995). A major

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32 component of the NBAS is the detennination of the infant's behavioral state and ability to interact with social stimuli. Researchers in several different studies have shown that the NBAS can be used as an intervention to increase parental awareness of their infant's competence (Parker et al. 1992; Worobey & Belskyl982; Widmeyer & Field 1987). Moreover, these researchers found that increased parental awareness enhanced parent-infant social interactions. Parker et al. (1992) solicited mothers to participate in an NBAS assessment with their infants in the NICU. Compared to mothers of preterm infants who received standard post-partum care, mothers in the intervention group rated the infants as having a less diflficuh temperament at 4 and 8 months and had home environments that were developmentally more appropriate at 4 months. Additionally, Winedmayer and Field (1987) conducted a study using the NBAS as an intervention with teenage mothers, and found these mothers were more aware of their infant's abilities after using the NBAS, and in turn, were more responsive to their infant's signals. Worobey and Belsky (1982) also found that actively involving mothers in the administration of the NBAS increased their responsivity to the infant compared to mothers who only observed the administration. Specifically, they reported that administering the NBAS affected the mother's social behavior toward their infant and subsequently, the infant's reciprocal behavior increased. These findings led Belsky (1986) to suggest that the NBAS promotes the mother's affectionate handling of her infant, which in turn may enhance the quality of interaction between mother and infant. Limited research also supports the use of the NBAS as an intervention for parents of preterm infants. Using the NBAS as an intervention tool promoted parental self-

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33 esteem and increased parental visits to the NICU. Ruth et al. (1990) tested an intervention based on the NBAS with a sample of low birth weight infants and their mothers and reported that the mothers were significantly more confident in their care taking abilities compared to mothers in the control group. Finally, Szajnberg et al. (1987) demonstrated the NBAS to mothers of low birth weight infants at 34 weeks gestational age. Mothers who used the NBAS intervention increased their visits to the NICU, compared to a control group of mothers who received no training in the NBAS. These studies confirm the importance of developing early interventions based on developmental assessment. Thus, there is clearly a need for developing early intervention that promotes these interactions between preterm infants and their adolescent mothers. Summary The literature reviewed in this chapter provides a theoretical and empirical basis I for this study. Research has demonstrated that early social interactions are important in the development of attachment between infants and their mothers. The quality of the early mother-infant interactions is an important mediating factor between perinatal events and later developmental outcomes of the infant. The attachment process is jeopardized when the infant is bom premature, particularly given the conditions present in the NICU. This attachment process is fiarther jeopardized when premature infants are bom to adolescent mothers. Typically, adolescent mothers are not aware of the possibility of premature birth, have a limited knowledge of its implications, and limited abilities to respond to the demands of a premature birth. Clearly, there is a need for adolescent mothers to leam better ways of responding to their premature infant. To do so, interventions must be designed that focus on the

PAGE 39

relationship between the adolescent mother and her premature infant. The purpose of this study is to determine the eflFects of a behavioral intervention on the social initiations of adolescent mothers toward their premature infants while in the NICU. Specifically, the goals of the study are to (1) train adolescent mothers of premature infants in the NICU using a behavioral intervention to read signs of stress, to sooth, and to socially engage their infant, and (2) evaluate the eflFects of this intervention on adolescent mother's ability to sooth her infant and initiate appropriate social interactions.

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CHAPTER 3 METHODS AND PROCEDURES Introduction For both infant and caregivers, engaging in and completing a successfial attachment process resuhs in a strong reciprocal bond that may be the cornerstone for I subsequent developmental outcomes for the infant. Positive outcomes of this process also occur for the caregiver and include acquiring feelings of competence in their ability as a caregiver (Fogel 1991). Tronic et al. (1992) points out the necessity for a synchronous interaction between mother and infant to achieve a successful attachment. If the infant fails to engage the mother in an interaction or the mother fails to respond to the infant, a lack of synchrony may lead to a mismatch. This mismatch may lead the infant to develop non-interactive behaviors. These behaviors may include gaze aversion, focus on objects instead of on mother, and self-regulatory patterns such as fist in mouth when distressed (Tronik et al. 1992). The effects of these noninteractive behaviors are problematic because they disrupt the synchronous interaction between mother and infant, therefore, jeopardizing successful iittachment. How a mother interacts with her infant during the neonatal period and beyond helps determine the infant's course of development. The quality of the early mother-infant interaction has been considered an important mediating factor between perinatal events and the infant's social, cognitive, and communication outcomes. In several studies, positive early mother-infant interactions were associated with secure relations between 35

PAGE 41

36 the infant and mother at the end of the first year of life, a lower incidence of behavior problems at preschool age, and cognitive competence at school age (Fish, & Stifter 1995; Vondra et al.,1995; Landry et al. 1990). There are many factors that jeopardize the development of supportive interaction patterns between preterm infants and their parents (Minde 1993). For example, preterm infants are often not as capable of responding to social interaction demands. In addition, their parents' social behavior may be qualitatively different within the context of the NICU where preterm infants are likely to remain for at least several weeks. The effects on parent-infant interactions are greater when infants are bom prematurely to adolescent mothers (Christopher et al. 1999). Adolescent mothers may be less verbal in interacting with their infants, less adept at reading their infants cues, and unable to respond to their infants in consistent ways (Stevenson 1996). The intent of this study was to determine if an intervention designed for adolescent mothers could improve their social interactions with their premature infants in the neonatal intensive care unit. The research question that was answered through this study was: Will teaching adolescent mothers about the premature infant's behavior, calming techniques and social initiations increase their appropriate social initiations toward their premature infant in the NICU? Data was graphed and visually analyzed. Trends analysis was used to conclude if the adolescent mothers' appropriate social initiations toward their infant improved. In addition, the magnitude of the differences prior to and after training was analyzed to determine the significance of the effects of the intervention.

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37 In this chapter, the methods and procedures to accomplish these goals are presented. The first section is a description of the methods, including information about the participants, setting, materials, procedures, and measures. In subsequent sections the experimental design, data analysis, and pilot study are explained. Methods The methods section includes information about the setting, participants and materials. First, the neonatal intensive care unit at Shands hospital is described. Second, the participant description includes criteria used to select the mothers and infants. The last section explains the materials used for data collection, as well as the mechanical equipment, training, training videos, and BrazeUon Neurobehavioral Assessment Scale intervention. Setting The study was conducted at Shands Teaching Hospital Regional Neonatal Intensive Care Center at the University of Florida Health Science Center, Gainesville. The neonatal intensive care unit (NICU) was a level III tertiary unit that provided state of the art care to medically fi-agile infants. The unit had 25 bed capacity, which was either open cribs or incubators There were monitors at each beside that tracked the infant's heartbeat, respiration, and pulse. The NICU had fluorescent lighting in addition to spotlights above each crib that can be individually controlled for brightness. The NICU staff focuses on family-centered care for infants and family members, in addition to excellent medical care for premature and medically fragile infants. Family centered care offers families the opportunity to participate in non-medical activities such feedings, baths, and diaper changes. Infants' medical as well as individual developmental needs are

PAGE 43

the focus of care in order to enhance developmental maturation. The hospital serves infants and their families from southern Georgia to the southern Florida region. Participants Four mother-infant dyads from the NICU were selected from Shands Teaching Hospital to participate in this research. Medical charts were used to identify motherinfant dyads who meet the following criteria: a) mothers who are between 15 and 19 years of age and delivered their infants in the NICU, and (b) infants who are a product of a singleton birth, 38 weeks or less gestational age, 11 003300 grams, without congenital malformations or disorders, medically stable, and admitted to the NICU. Infants who were once critical but are currently medically stable were considered. A summary of descriptive information for the four-mother/infant dyads that participated in the study is presented in Table 1. Mother 1 in this study was a 1 7-year-old white woman and this was her first pregnancy. She had preaclapsia and delivered her baby 6 weeks early. She was married to her infant's father and he was incarcerated during the time of this study. The father was given permission to visit his baby in the NICU but was handcuffed and chaperoned. The pregnancy did not allow for the mother to finish high school, but she did intend to get her high school equivalency degree and wanted to work in a day care center. Her infant was delivered at 34 weeks gestational age and weighed 1661 grams. He was enrolled in the study at 37 weeks adjusted gestational age and weighed 2815 grams. The baby spent two weeks in and incubator before being moved to an open crib. He had no medical complications and was in the NICU to feed and grown before being discharged.

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39 Mother 2 in this study was a 15-year-old white girl. She breast fed her infant and was present in the NICU for daily feedings. She was married to her infant's father. Both parents visited the infant daily. Family members were often present at the infant's bedside. The infant was delivered at 37 weeks gestational age and weighed 3010 and was admitted to the NICU because she had a seizure after delivery. She had various medical procedures to rule out insuhs to the brain and she was monitored while they began pharmaceutical treatment. The infant was medically stable and enrolled in the study at 37 weeks old and weighed 3072 grams. Mother 3 was an 18-year-old white woman and this was her second pregnancy and birth. She had a 14-month-old daughter in addition to her newborn son. She was married to her children's father. There were no complications with the delivery. She had high blood pressure and went into premature labor. She did not finish high school and worked nights at a chicken factory where her husband worked during the day. Their work schedule allowed them to care for their children at home, which seemed important to her. Her infant was delivered at 35 weeks gestational age and weighed 2301 grams. He was eru-olled in the study at 37 weeks adjusted gestational age and weighed 3080 grams. He had no medical complications. Mother number 4 was an 18-year-old white girl who was married to her infant's father. She went into preterm labor and there were no complications with the delivery. She wanted to breast feed but the infant was on gavage feedings and the mother had to pump the breast milk and put it into the feeding tube. Family members were often

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40 present in the NICU and were very excited about the baby. The mother graduated from high school and worked as a secretary but intended to stop working and stay home with her baby. The infant was bom at 34 weeks gestational age and weighed 1716 grams. She was enrolled in the study at 36 weeks adjusted gestational age and weighed 2240 Grams. She had a feeding tube but at the time of the study was able to bottle feed twice a day. She was otherwise a heahhy infant. During the study the feeding tube was removed and she was able to bottle feed. Table 1 Descriptive Information for Subjects Dyad 1 Dyad 2 Dyad 3 Dyad 4 Mother's age 17 years 15 years 18 years 18 years Infant's 37 weeks 37weeks 37 weeks 36 weeks adjusted gestational age Infant's weight 2815 3012 3080 2240 Permission for this study was obtained from Shands Teaching Hospital Institutional Review Board; informed consent was asked of the guardian of the adolescent mothers. First, the developmental specialist reviewed the medical charts for appropriate selection criteria. The NICU nurses also informed the researcher about mothers and their infants who met the criteria of the study. Next, eligible families were contacted and the researcher explained the purpose of the study and asked for their participation. Last, the consent form was reviewed with the family; the adolescent mother as well as her

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41 guardian signed the form. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A. Materials Materials that were used to train the research assistants (RA) in data collection are two standard VHS training tapes, and a 12" Sony televisionA^CR. Materials needed to educate the mothers during the intervention are a standard VHS training tape, a 12' Sony televisionA^CR, a red ball, and a baby rattle. Videotape was developed and used to train the RA and the mothers. The produced training tape was made that depict a caregiver and her premature baby at the infant's bedside in the NICU participating in appropriate soothing techniques and social interactions. The dyad appearing in the training video did not participate in the study. A standard form was used to collect data during the baseline, procedural reliability, intervention, and generalization phases of the study. The forms used to record infant behavior and mother behavior. The infant's behavioral state was recorded as 1sleep, 2-drowsy, 3-alert, 4-irritable, 5-crying. The mother's ability to use soothing techniques as well as the social initiations was recorded by putting a check in the box located next to the behavior (Refer to Appendix B). Independent variable Being able to identify if the infant is sleeping, drowsy or alert determines how much, if any interaction, the infant can tolerate and helps the mother know when to sooth and when to interact. Therefore, teaching mothers about infant behavior is important for appropriate mother-infant interactions to occur. Mothers learned how to interact and

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sooth their infant during training sessions, which included three portions: video training, demonstration, and practice. The intervention was designed to educate mothers about social initiations and infant behaviors in an effort to increase the mother's natural social initiations with her infant. The foundation of the intervention was the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). The BNBAS assesses the newborn infant's behavioral repertoire on 28 behavioral items. The scale also includes an assessment of the infant's neurological status on 18 reflex items. The scale is organized into 5 packages: (1) habituation, (2) motor-oral, (3) truncal, (4) vestibular, and (5) social interactive. According to previous studies, BNBAS based interventions have had a positive impact on parenting and /or infant development (Britt & Myers, 1994; Parker, Zahr, Cole, & Brecht, 1992). Thus, the BNBAS provided the basis for the development of the intervention used in this study to promote a mother's interactions with her premature infant. The researcher used the social interactive package, identifying infant states, and soothing techniques, and interactive responses of the NBAS. The shortened version of the BNBAS was used because premature infants often cannot tolerate a lengthy examination and the social interactive package was deemed most important. Dependent variable. Data was collected prior to treatment, during treatment, and after treatment to determine the infant's behavioral state, mother's ability to sooth and calm, and mother's appropriate social initiations toward her infant in the NICU. The RA collected data at the infant's bedside in the NICU.

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43 Infant measures Infant behavioral states were defined as follows: State 1 was a sleep state and was defined as eyes closed, regular breathing, and little to no spontaneous body movements. State 2 was drowsy or semi-dozing; eyes may be open but dull and heavily lidded with the infant's activity level low. State 3 was defined as alert, with eyes opened I and the infant seemed to focus attention on a source of stimulation. State 4 was defined as irritable with considerable motor activity. Brief fiissy vocalizations occurred in this state. State 5 was defined as crying that is intense, which was difficuh to stop with soothing techniques. Data was recorded for infant behavioral states during the baseline, treatment, and generalization phases of the study. RAs indicated the infant's behavior by writing down the number that correlates with the infant's behavior during that interval. For example, if the infant was in a sleep state, then the RA recorded the number one on I the data collection sheet. Infant stress was also coded and was defined as hiccups, blue lips, eye aversion, increased heart rate or a physiological reaction that put the infant in danger. More than one stress sign was recorded when necessary. At any sign of stress the session was terminated. Mother's measures Mother's social initiations toward her premature infant were defined as any motor or vocal behavior clearly directed to the infant which attempted to elicit social responses such as, gentle vestibular stimulation, patting, swaddling, holding, using a pacifier, getting face to face, talking, shaking rattle, or showing ball. Touching was not recorded during purely fiinctional activities such as changing diaper, feeding, and moving tubes. The RA placed a check mark next to the behavior to indicate if a social initiation did or

PAGE 49

44 did not take place during the twenty-second interval. The mother's behaviors were considered appropriate and were not scored as such depending on the infant's behavioral states (Refer to Table 2). Table 2 Appropriate Behaviors Infant Behavior Mother Behavior State 1Sleepy State 2Drowsy State 3Alert State 4Irritable State 5Crying Holding, Gentle Vestibular, If not awake after 3 Face, Voice intervals then terminate I session. Holding, Gentle Vestibular, Face, Voice Holding, Face, voice. Rattle, Ball Holding, Gentle Vestibular, Swaddling, Patting, Pacifier, Face, Voice Holding, Gentle Vestibular, If not calm after 3 intervals Swaddling, Patting, Pacifier, Face, Voice then terminate. Treatment fidelity The mother's ability to implement the treatment procedures reliably was evaluated through observation. The collection of treatment fidelity data began with the research assistant directly observing the mother during the BNBAS training sessions. The mother's accuracy in implementing the intervention was measured at her infant's bedside in the NICU. Circling the number one, two, three, four, or five marked the infant's behavioral state. Mother's behaviors were recorded by putting a check in the box located next to each appropriate intervention behavior (Refer to Appendix B). The researcher examined the data after each observation session and the mothers were retrained based on

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45 their ability to implement the intervention until 90% accuracy was obtained. The mother participated in training sessions until she recognized stress signs, used soothing techniques, and implemented social initiations toward her infant. When the mother did not reach criteria, she received corrective feedback, and further video training sessions and demonstrations until 90% accuracy was obtained. Interobserver agreement. To determine interobserver agreement for data collection procedures, a second observer recorded mother and infant data simultaneously I but independently from the primary observer for 25% of the sessions. The occurrence only, point-by-point method was used to calculate interrater reliability. An agreement was noted when the observers record the same code within the same interval. A disagreement occurred when one observer coded something different from the other. The percentages of interobserver agreement were calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. Interobserver agreement was randomly collected for at least 25% of the sessions across I all phases of the study. It has been reported that the point-by-point agreement method is the most commonly used method of agreement and 80% is considered a relatively high estimate of agreement (Kazdin, 1982). Procedures The instructional procedures are described in this section. First, data collection procedures during baseline are outlined. Next, an account the intervention and maintenance sessions are explained. Baseline. During the baseline condition, the research assistant observed the mother at her infant's bedside and collect data on the infant's behavioral state, the

PAGE 51

46 mothers' use of soothing techniques, and the mother's social initiations toward her infant using the partial interval recording method. Observations lasted five minutes and data was collected every 20 seconds. When more than one behavior occurs during the 20second period only the first behavior was recorded. During baseline, the mothers were not provided with any corrective feedback concerning their behavior. Also, the research assistant was instructed not to provide the mothers with any information about the types of behaviors being observed. Intervention. The training session began with by the researcher explaining the overall training procedures to the mother. First, the mother and researcher watched a 10minute intervention video of the modified BNBAS while the researcher identified the infant's behavioral states, stress signs and accompanying soothing techniques, and social interactions (e.g. demonstrating how to act with toys and mother's face and voice) (Refer to Appendix C). During the video session, the mothers had the opportunity to view all of the infant state behaviors. After viewing the video, the researcher brought the mother to her infant's bedside where the researcher interacted with the infant in order to demonstrate the BNBAS to the mother. The researcher began the demonstration by identifying the infant's behavioral state (e.g. sleep, wake.). The researcher proceeded by demonstrating the soothing technique of swaddling the infant and lowering the lights in the nursery, or other soothing techniques as necessary. The researcher interacted with the infant using the red ball, rattle, and face and voice. The red ball was the visual stimuli, the rattle was the auditory stimuli, and the face and her voice combined both the auditory and visual stimuli. During the presentation of visual stimuli, the red ball was held 10 to 12 inches fi-om the infant's

PAGE 52

47 eyes. The researcher slowly moved the ball horizontally from one side of the infant's face to the other trying to elicit a response from the infant. The rattle was also used to ehcit a response from the infant. The rattle was held 6 to 12 inches away from the infant's ear and out of sight. The rattle was continually shaken until the infant gave a response. With her face 10 to 12 inches in front of the infant's face, the researcher moved slowly in a horizontal motion while at the same time speaking in a soft, high-pitched voice. The researcher's voice was continuous while her face was moving. During social initiations or prior to, the researcher responded to infant behavior by using appropriate soothing techniques. When the infant was in a state 2 or 3, the researcher swaddled the infant with a blanket and hold the infant. When the infant was observed in state 4 or 5, then the use of a pacifier and the researcher's face/voice in addition to swaddling and holding was used in order to sooth and prepare the infant for social interaction. After the demonstration session, the mother participated in practice sessions. Practice sessions took place until mastery and were video taped. The mother went to the infant's bedside with the researcher to practice what she viewed during the video session and demonstration. First, the mother prepared her infant for social interaction by lowering the lights over the crib and swaddling the infant. Next, the mother began to use the red ball, rattle, her face, and her voice to socially interact with her infant. The mother used each type of stimuli as the opportunity presented itself When the infant was in state lor 2, the mother used vestibular stimulation or her face and voice to try and wake the infant. Once the infant was in state 3 the mother used the red ball, rattle, and her face and voice to socially interact. When the infant was in a state 4 or 5, then the mother used a soothing technique such as a pacifier to calm him.

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48 EKiring the social orientation, the researcher identified the infant's responses to stimuli, such as alerting, quieting, change in respiration, head turning, and eyes following or searching ("Look how baby s name is following the red ball with his eyes "). When the infant was showing signs of stress and was no longer in an optimal state for interaction, the mother was asked to terminate the session. Prior to each practice session, the researcher and mother viewed her mother/infant interaction video and reviewed infant behavioral states, soothing techniques, and social interactions. In an effort to coach the mother, the researcher provided positive and corrective feedback during the practice session. There was not more than two training sessions per day. However, if mastery was not met, then the mother viewed her most recent video practice tape and was provided with corrective feedback, observed a demonstration, and practiced the intervention again. Training continued until 90% mastery was obtained. Maintenance . Following the practice sessions, the research assistant observed I each mother's natural interactions with her infant. The mother knew that she was being observed. The research assistant did not prompt the mother to use any part of the intervention. Instead the research assistant observed the mother to see if she used the behaviors learned earlier fi-om the intervention training. Specifically, the research assistant collected data on all appropriate social initiations, soothing techniques, and infant states. Mothers were at their infant's bedside and the researcher told them to "enjoy their baby". The researcher also placed items used in the training session (i.e., ball and rattle), at the infant's bedside, prior to the observation session. The mothers did not have to use these items, but they provided the mothers with the same opportunities for

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49 interaction that existed during the intervention training. Sessions lasted for five minutes and were conducted until the infant was discharged fi"om the hospital. Social Validity Mothers were directly involved in this project and they received information about their infant's behavior and how to socially interact. Additionally, mothers were asked to provide information about the social validity of the intervention. One week after discharge the researcher contacted the mothers by telephone and asked about her judgments concerning the appropriateness of the intervention, including an evaluation of whether it was fair, reasonable, and consistent with conventional notions. Specifically, the mother's comments will be used to improve the intervention for future research (Refer to Appendix D). Table 2 Procedures Phase Data Documentation I Mother's interactions in Baseline Data record sheet & graph NICU prior to treatment II. A). Training Session (repeat A). Treatment fidelity A). Data record sheet until 90% mastery) a) Standard Training Video b) Demonstration c) Practice (video tape). Mother's practice video fi^om prior training session will take the place of standard training video if subsequent sessions are necessary. B). Continue data collection B). Intervention B). Data record sheet &

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on mother's social interactions graph III. Mother's interactions in Maintenance NICU after treatment IV. Social Validity Social Validity Questionnaire Data record sheet & graph Questionnaire Experimental Design A modified multiple baseline design was used to evaluate the effects of the BNBAS intervention. The modified multiple baseline across mother-infant dyads was suited for this project for two reasons: (a) the intervention should result in learned behaviors, and (b) there are a small number of participants. Each mother was exposed to the following conditions: baseline, BNBAS intervention, and maintenance. The design began with baseline observations. After the baseline was stable, the intervention was implemented with the mother. Following the intervention behaviors maintenance probes began. The procedures were repeated with the last two mothers. When the baseline data collection began for the second and forth mother the baselines were extended twice as long as mother number one and three in order to compensate for the data not being collected simultaneously. Data were analyzed to determine if any important differences existed between the mothers' behavior during baseline, intervention, and maintenance. Visual analysis was used to conclude if there was an increase in the adolescent mothers' appropriate social interactions and the magnitude of the differences were analyzed to determine the significance of the trend. Treatment of the Data

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51 Pilot Study Prior to implementing the research, a pilot study was conducted, with one motherinfant dyad, to develop and solidify the observation system and participant training sessions. The purpose of the pilot study was to determine the need for modifications in the intervention and data collection procedures prior to actual data collection and training. Feedback fi^om this pilot study was used to make adjustments in the training and data collection procedures as needed. The material, procedures, dependent and independent variables were identical to those described earlier in this chapter. Participants One mother-infant dyad fi^om the NICU was selected fi^om Shands Teaching I Hospital to participate in this research. Medical charts were used to identify a motherinfant dyad who met the following criteria; a) a mother who delivered their infant prematurely, and (b) an infant who was a product of a singleton birth, less than 38 weeks gestational age, without congenital malformations or disorders, and admitted to the NICU. The mother was 41 -years-old and had delivered her infant prematurely by cesarean section due to preaclampsia and high blood pressure. There were no complications with the delivery. Although the mother was not an adolescent the pilot study helped test the procedures and intervention. The infant was delivered at 34 weeks gestational age and 1661 grams. He was and enrolled in the study at 36 weeks gestational age. He had no medical complications and was in the NICU to feed and grow before being discharged.

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52 Permission for this study was obtained from the Shands Teaching Hospital Institutional Review Board and the mother. First, the researcher reviewed the medical charts for appropriate criteria. Next, the eligible mother was contacted and the researcher explained the purpose of the study and asked for her participation. Last, the consent form was reviewed with the mother. The consent form included an explanation of the research procedures as well as the rights of the participants. A copy of the permission form is in Appendix A. Experimental Design An AB quasi-experimental design was used to evaluate the effects of the BNBAS intervention with one mother-infant dyad. A quasi-experimental design was suited for this project for two reasons ( 1 ) to evaluate the data collection procedures, and (2) to evaluate the intervention. One mother infant dyad was exposed to the following conditions: baseline, BNBAS intervention, and generalization. The design began with baseline observations for the mother. After the baseline was stable, the intervention was implemented with the mother. When the behaviors stabilized for the mother, then generalization probes began. Treatment of the Data Treatment Fidelity The collection of treatment fidelity data began with the research assistant directly observing the mother during the three BNBAS training sessions. The mother's accuracy in implementing the intervention was measured at her infant's bedside in the NICU. The researcher examined the data after each observation session and the mother was retrained

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53 based on her ability to implement the intervention until 90% accuracy was obtained. A minimum of three practice sessions with the mother occurred to teach her to recognize stress signs, use soothing techniques, and implement social interactions with her infant. The mother reached 95% accuracy during the last training session Interobserver Agreement To determine the interobserver agreement of data collection procedures, a second observer recorded data simultaneously but independently from the primary observer. The occurrence only point-by-point method was used to calculate interrater reliability. An agreement was noted when the observers recorded the same code within the same interval. A disagreement occurred when one observer coded something different from the other. The percentages of interobserver agreement were calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. Interobserver agreement was randomly collected for at least 25% of the sessions across the three phases of the study. Interobserver agreement was computed and yielded a mean percent agreement of 85%. Results of the Intervention Data were analyzed to determine if any significant differences existed between the mother's behavior during baseline, intervention, and generalization. Trends analysis was used to conclude if there was an increase in the mother's appropriate use of soothing techniques and social interactions, and the magnitude of the difference was analyzed to determine the significance of the trend.

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The mother was exposed to two conditions; baseline (A) and intervention (B). During the baseline condition (A) the mean level of appropriate interactions was 25%. Upon introduction of the intervention (B), there was a positive change in the mother's interactions toward her premature infant. During the three sessions, the mother's interactions increased by 40%. Maintenance resulted in a variable accelerated trend that stabilized at 65%. (Refer to Appendix E) Modifications Made as a Result of the Pilot Study Modifications to the pilot study were minimal. The data collection sheet was modified to include a space for the researcher to record unexpected mother behaviors, such as rocking the infant. This was considered important to record because of the effect the mother's behavior can have on the infant's behavioral state and fiiture interactions during the observation session. The numbers 0 and 1 were removed fi"om the data collection sheet because it was felt that a check mark in the box would serve the same purpose and be easier to record.

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CHAPTER 4 RESULTS Introduction The purpose of this study was to determine if an intervention designed for adolescent mothers would improve their social initiations with their premature infants in the neonatal intensive care unit. The general question of the study was as follows: Will teaching adolescent mothers about the premature infant's behavior, calming techniques and social initiations increase their appropriate social initiations toward their premature infant in the NICU? To investigate this question, each mother was taught how to identify their infant's behavioral state, use calming techniques, and interact socially with their infant. The intervention used was a modified version of the Brazehon Neurobehavioral Assessment Scale. The researcher used the social interactive package: identifying infant states, calming techniques, and interactive responses of the NBAS. The modified version of the BNBAS was used because premature infants often cannot tolerate a lengthy examination and the social interactive package was deemed most important. Data were collected before intervention training began and during the training sessions. The effects of the intervention training were measured by comparing the mother's social initiations toward their infant before and after the training sessions. Data were also collected after intervention training to determine if the mothers could maintain their appropriate social initiations toward their infant. 55

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56 A multiple baseline design was used to evaluate the effects of the BNBAS intervention. The multiple baseline across subjects was suited for this project for two reasons: (a) the intervention resuhed in learned behaviors, and (b) there was a small number of participants. Due to diflRculty in finding subjects, baseline data were not collected concurrently. This chapter describes the resuUs of the data analyses employed in this study. First, measurement reliability and treatment fidelity data are provided. Second, the results of the study for each mother are described. Finally, results of the social validation measures are provided. Interobserver Agreement and Treatment Fidelity Procedures were implemented during the study to establish measurement reliability and treatment fidelity. Interobserver agreement checks were used to determine data collection reliability during baseline, intervention, and maintenance. In addition, the mother's ability to implement the intervention with 90% accuracy was assessed during intervention training. Fidelity checks were used to insure that the intervention was implemented with integrity. Interobserver Agreement To ensure that data collection on social initiations were collected reliably a second observer recorded mother and infant data simultaneously but independently fi-om the primary observer for a total of 14 of 56 sessions across baseline, intervention, and maintenance. Interobserver agreement data was collected three times for mother number one and three, and four times for mother number two and four, Interobserver agreement

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57 was calculated using the formula recommended by Tawny & Gast (1984). The number of agreements was divided by the number of agreements plus disagreements and then muhiplied by one hundred, which equaled the percent of agreements. For each observation session interobserver agreement was 90% for the first mother. For the second mother agreement ranged fi^om ninety to ninety-five percent. Interobserver agreement for the third mother ranged fi^om ninety to ninety-five percent. For the fourth mother, interobserver agreement scores were 95% for each session. Fidelity of Treatment To ensure that the mothers were implementing the intervention correctly, the research assistant directly observed the mother during the BNBAS training sessions, and collected data on the mothers' targeted behaviors. The researcher examined the data after each observation session during training and a mother was retrained if she did not implement the intervention with at least 90% accuracy. The mothers were trained until they recognized stress signs, used calming techniques, and implemented social initiations with her infant with 90% accuracy. If a mother did not reach criteria, she received corrective feedback, and further video training sessions and demonstrations until 90% accuracy was obtained. The first mother participated in three training sessions. Following the first session the mother implemented the intervention with 75% accuracy. A positive change occurred after the second training session, her accuracy rate increased to 85%. After the third session she reached a 95% accuracy rate. The second mother participated in three training sessions. After the first session, the mother implemented the intervention with 70% accuracy. A positive change occurred

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58 after the second training session, with the mother increasing her accuracy rate to 80% accuracy. After the third session, she reached a 90% accuracy rate. The third mother required only two training sessions. Following the first session she implemented the intervention with 85% accuracy. After the second session, she implemented the intervention with 100% accuracy. The last mother participated in three training sessions. Following the first session, her accuracy rate was 85%. After the second session, her accuracy rate was 85%. Her accuracy rate in implementing the intervention increased to 100% after the third training session. Treatment Results Data were collected on adolescent mothers social initiations toward her premature infant in the NICU. The data were analyzed to determine if any differences existed between the baseline behavior and maintenance behavior for each mother. The resuhs of the effects of the intervention for each mother are discussed in the following section. Mother #1 Baseline & Intervention Data. During the initial baseline sessions, mother number one was observed interacting with her infant in the NICU. She sat in a rocking chair at the infant's bedside, and her social initiations toward her infant were recorded during four five-minute sessions that took place over two days. The mother's appropriate social initiations ranged from twenty-five to forty percent. During the baseline condition the mean level of appropriate initiations was 35%. Once the baseline stabilized, the mother began intervention training. The mother participated in two intervention-training sessions that took place over two days. The

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59 mother's appropriate initiations toward her infant ranged from fifty to fifty-five percent during intervention training. There was a positive change that occurred in the percentage of appropriate mother's initiations toward her premature infant from baseline to intervention training conditions. During the first session in which intervention training began (Session 5), appropriate social interactions increased by 50% when compared to the last session of baseline condition (Session 4). During intervention, the mean level of the mother's appropriate social interactions was 48.3%, which was an increase of 13.3% from the mean of the mother's baseline behaviors. Maintenance Data. Following the final training session, four observations of the mother's social initiations with her infant occurred over three days to determine if the level of appropriate initiations were maintained. During this time, the mother did not receive any fiirther instruction or feedback regarding her behavior toward her infant. The mother's appropriate initiations toward her infant ranged from fifty to fifty-five percent. A positive change occurred in the percentage of appropriate interactions from intervention to maintenance conditions. The mean level of maintenance behaviors was 47.5% for appropriate social initiations. During the last session in which maintenance data were obtained (Session 10), appropriate social interactions were on the average, 10% I less when compared to the last session of intervention condition (Session 7). Even though the mothers targeted behaviors decreased slightly during maintenance, the targeted behaviors increased by an average of, 12.5% from baseline. Mother # 2 Baseline & Intervention Data. Baseline data was collected on mother number two social interactions toward her infant in the NICU. The mother was observed during

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60 seven five-minute sessions. Baseline data was collected over two days. Mother's appropriate social initiations toward her infant ranged fi-om thirty to forty five percent. During the baseline condition, the mean level of the mother's appropriate interactions was 32.8%. Once the baseline stabilized at 30% the mother began intervention training. The mothers appropriate initiations ranged fi^om fifty-five to sixty percent. A positive change was noted in the percentage of the mother's appropriate social initiations fi"om baseline to intervention training conditions. During the first session in which training data was obtained (Session 8), appropriate social interactions increased by 25% compared to the last day of baseline condition (Session 7). The mean level of the mother's interactions I was 52% during intervention conditions, which is an increase of 19.2% fi-om the mean level for baseline behavior. Maintenance Data. Observations continued for three days following intervention training. The mother's appropriate social initiations were in the range of fifty-five to sixty percent. A positive change occurred in the percentage of appropriate social interactions fi-om intervention to maintenance conditions. During the first session in which maintenance data were obtained (Session 13), appropriate social interactions were 60%, which is the same as the last session of intervention (Session 12) The mean for the mother's appropriate initiations during maintenance was 61.25%, which was 19.2% greater than the mean score for intervention. Mother #3 Baseline & Intervention Data. The mother was observed during four five-minute sessions during baseline. Data was collected over two days. The range of the mother's

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61 social initiations toward her infant was in the range of thirty-five to forty percent. During the baseline condition the mean level of appropriate social interactions was 40%. Once the baseline data stabilized at 35%, intervention training began with the mother. During intervention training data collection occurred over four five-minute sessions to record the mother's social interactions toward her infant. The percentage of the mother's appropriate social initiations ranged form seventy-five to eighty-five percent. Upon introduction of the intervention, there was a positive change in the mother's interactions toward her premature infant fi-om baseline to intervention conditions. During the first intervention session (Session 5), appropriate social interactions increased by 40% compared to the last day of the baseline condition (Session 4). Over the three sessions, the mother's mean for appropriate social interactions was 78.3 %, which was 38.3 % greater than the baseline mean. Maintenance Data. Data collection continued for three sessions following intervention training. The mother's appropriate social initiations ranges fi"om eighty to eighty-five percent during maintenance. A positive change occurred in the percentage of appropriate social interactions fi"om intervention to maintenance conditions. During the first maintenance session (Session 8), appropriate social interactions increased by 33.3% compared to the last day of the intervention condition (Session 7). The mean for the mother's appropriate initiations during maintenance was 81%, which was on average, 3.3% greater than the mean score for intervention. Mother # 4 Baseline & Intervention Data. During the initial baseline sessions (1-7), the mother's behaviors were observed at her infant's bedside in the NICU. Baseline data was

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collected during seven sessions that took place over two days. During the baseline condition, the range of mother's appropriate social initiations was twenty-five to thirty percent, and the mean level of appropriate initiations was 38.5%. Once the baseline stabilized at 30%, the intervention training began. The percentage of mother's appropriate social initiations ranged from sixty to seventy percent. A positive change was noted in the percentage of appropriate social interactions fi"om baseline to intervention training conditions. During the first session in which intervention data were obtained (Session 8), the mother's appropriate social interactions increased by 35% compared to the last session of the baseline condition (Session 7). Over five sessions, the mother's mean for appropriate social initiations was 64%, which was 35.5% greater than the mean for baseline. Maintenance Data . Following the final intervention session, four observations of the mother's social initiations with her infant occurred to determine if the level of appropriate initiations were maintained. The percentage of mother's appropriate social initiations ranged form sixty-five to seventy percent. A positive change occurred in the percentage of appropriate social interactions fi^om intervention to maintenance conditions. During the first session in which maintenance data were obtained (Session 13), the I percentage of mother's appropriate social initiations was 70%, which was the same percentage compared to the last session of the intervention condition (Session 12). The mean for the mother's appropriate initiations during maintenance was 67.5%, which was 3 .5% greater than the mean score for intervention.

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63 Social Validation Measures Participants were contacted one week after they were discharged from the hospital in order to ask their opinions about the importance, effectiveness, and practicality of the BNBAS intervention training. Specifically, the mother's comments will be used to improve the intervention for future research. Participants were asked to rate the importance of the intervention. If they found no importance in the intervention they were asked to explain why. All mothers reported that the information they acquired during the study was valuable in helping them calm and play with their babies in the hospital and home. Mothers indicated satisfaction with the procedures and did not feel uncomfortable or embarrassed by the observations. One mother revealed that she not only uses the developmental toys to play with her infant but she has shared the information with her husband. Another mother reported that she liked having someone to talk with during her visits to the hospital. All of the mothers recommended that other mothers should lean about their infant's behavior and ways to play with their baby while they are in the NICU. Procedures pertaining to the administration of the social validation questionnaire were described in Chapter III. Summary The purpose of this study was to investigate the effects of learning about infant behavior, calming techniques, and social initiations on adolescent mothers' social initiations toward their premature infant in the NICU. The four mothers who participated in the present investigation were adolescent mothers who had premature infants admitted

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64 to the NICU directly after birth. The mothers were between the ages of fifteen and nineteen years old. The infants were between 32 and 38 weeks old and weighed between 11003300 grams, without congenital malformations or disorders, medically stable, and admitted to the NICU. Infants who were once critical but were currently medically stable were considered. All participants, despite the differences in their age and infants medical status, received identical training in the NICU. The effects of training on the level of the mother's social interactions compared to baseline were addressed. In all instances, mothers increased their appropriate social initiations after intervention training. Additionally, all participants maintained an increased level of social interaction compared to their baseline behavior. Three of the mothers were able to maintain the social initiation skills they learned compared to intervention training. The first mother's targeted behaviors decreased slightly during maintenance compared to intervention training. Her behaviors did not increase as much as the other mothers. One explanation for this difference between Mother 1 and Mothers 2, 3, & 4 could be that they had more social support than Mother 1. The resuhs of the social validation measures were favorable. Participants reported satisfaction with the information they received about infant behavior and social initiations as well as the training procedures. Some mothers reported that they had shared the information they learned with other family members, and were continuing to use the techniques at home. In summary, after receiving information about infant behavior and training on how to appropriately interact with a premature infant adolescent mothers increased their appropriate social initiations toward their infant. The participants reported satisfaction

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65 with their participation in the investigation and with the procedures used. Implications for these findings will be discussed in Chapter V.

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CHAPTER 5 DISCUSSION Research has demonstrated that early social interactions are important in the development of attachment between infants and their mothers (Ainsworth 1995; Isabella 1993). The quality of early mother-infant interaction is an important mediating factor between prenatal events and later developmental outcomes of the infant (Leavitt 1999). The attachment process is jeopardized when the infant is bom premature, particularly given the conditions present in the NICU (Niven et al. 1993). This attachment process is further jeopardized when premature infants are bom to adolescent mothers (Bamard et al. 1996). Typically, adolescent mothers are not aware of the possibility of premature birth, have a limited knowledge of its implications, and limited abilities to respond to the demands of a premature birth (Sommer et al. 2000). Clearly, there is a need for adolescent mothers to leam better ways of responding to their premature infant. To do so, interventions must be designed that focus on the relationship between the adolescent mother and her premature infant. The purpose of this study was to increase the appropriate social initiations of adolescent mothers toward their premature infants in the NICU. The foundation of the intervention used in this study was the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). The intervention was designed to educate adolescent mothers about social initiations and infant behaviors in an effort to increase the mother's natural social initiations with her infant. The chapter had been divided into four sections. First, a 66

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67 summary and discussion of results related to the research question is discussed. Next, the findings in light of previous research are presented. Third, limitations to the present research are discussed. Finally, suggestions for future research have been presented Summary and Analysis of Resuhs In this study, the researcher wanted to determine if teaching adolescent mothers about calming techniques and appropriate social initiations would increase their appropriate social imitations toward their premature infants in the NICU. Social validity measures were also collected to determine if the mothers who participated were satisfied with the intervention procedures and found it to be valuable. Overall, the effect of intervention training on subjects' targeted behavior was positive. Baseline data indicated that the mean level of appropriate social initiations across all mothers was 32.9%. During intervention training, the mean level of appropriate initiations increased to 61.8% across all mothers. The effects of strategy training on the maintenance of newly acquired behaviors were also positive. The mean level of appropriate social initiations for all mothers during maintenance was 66 .2%, showing that participating mothers were continuing to improve appropriate initiations even after intervention. The adolescent mothers' responses on the social validity questionnaire indicated that they found their participation in the intervention training to be a positive experience. They expressed satisfaction with the procedures and the information they received during training. One mother mentioned that she shared the information she learned during the training sessions with her husband who uses them too. All of the mothers said that their

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68 infants enjoyed playing with the developmental toys they received for participating in the study. In summary, subsequent to intervention training using the modified BNBAS, the participants demonstrated acquisition of the targeted and maintained these behaviors. Finally, as indicated by their social validity questionnaire responses, adolescent mothers reported that they had learned fi-om the intervention training and were satisfied with the BNBAS intervention training in terms of importance, effectiveness, and practically. Summary of Previous Literature Attachment theory demonstrates that early social interactions are important to the development of attachment between infants and their mothers (Slater & Muir 1999), and the quality of these early mother-infant interactions are important uhimately to the infant's social and cognitive development (Leavitt 1999). The formation of a secure attachment depends on the mother's ability to respond appropriately to her infant's signals (Rosenblum et al. 1993). For instance, the mother who is sensitive to her infant's signals can lead the infant fi-om an intense crying state to a calm and alert state by comforting the infant, thereby enabling the infant to engage in a harmonious interaction with the mother. The development of secure attachments that lead to harmonious interactions are put at risk when the infant is premature. Premature infants often send signals that are unclear to the caregiver thus, the caregiver may respond inappropriately leading to further inappropriate interactions (Padden & Glenn 1997). This risk is compounded when the premature infant is bom to an adolescent mother (Wyly 1995). Research has reported that adolescent mothers respond less and demonstrate more inappropriate responses

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69 toward their premature infant due to the appearance and behavior of the infant (Edwards & Saunders 1990; Causby 1991; Bell 1997). The NICU environment may further affect the adolescent mother's ability to appropriately interact with her infant (Causby 1991). Infants and adolescent mothers may fail to become attached during the hospital stay due to stressful aspects of the NICU, such as, a) lack of privacy, b) noise, and c) preponderance of authority figures (Bell 1997). Thus, effective interventions that facilitate early interactions between adolescent mothers and their premature infants are needed in the NICU (Edwards & Saunder 1990). Research in several different studies has shovm that the BNBAS can be used as an intervention to increase parental awareness of the full term infant's competence (Parker et al. 1992; Worobey & Belesky 1982; Widemyer & Field 1987). Specifically, these researchers found that increased parental awareness influenced mothers' responsiveness toward their infants promoting appropriate social interactions. Limited research supports the use of the BNBAS as an intervention for parents of preterm infants (Mylod et al. 1997); however, no research exists using the scale as an intervention to promote social initiations with adolescent mothers and their preterm infants. Therefore, there was a need to expand the current literature base by studying this population and using the BNBAS as an intervention with them. Researchers assert that adolescent mothers are less adept at interacting with their full term infants compared to their more mature counterparts. They engage in fewer verbal interactions with their infants, interpret their infant's cues less accurately, and respond to their infants less frequently (Gotwald, & Thurman 1990; Causby 1991). Thus, a higher risk exists for developing inappropriate social interactions between adolescent mothers and their

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70 premature infants (Causby 1991). The fact that the earliest interactions between adolescent mothers and their premature infants take place in an NICU further effects the development of appropriate interactions with their infant (Edwards & Suanders 1990). The intervention used in this study incorporated a modified version of the BNBAS, specifically the calming techniques and social interaction package. The intervention focused on increasing the adolescent mother's ability to appropriately respond to her infant's behavior. In past studies the use of demonstrations of the NBAS I intervention for mature parents had only moderate effects on mother infant interaction (Das Eiden & Feifinan 1996). According to Brazelton & Nugent (1995), in order to use the BNBAS as an intervention for effecting parent-child relationships, parents need to see the BNBAS several times in the presence of a professional who can help them interpret the effect on the infant. However, several other researchers have discussed the possibility that demonstration and parental administration of the NBAS intervention may be more effective than only parent observation (Beeghly 1995; Britt & Meyers 1994; Meyer 1982; Woroby & Belsky 1982). This study expanded on training techniques used in previous research (Cardone & Gilkerson 1990; Parker et al. 1992; Beeghly & Tronik 1994) by including, a) video taped demonstration of the modified BNBAS and explanation, b) a demonstration of the intervention by the researcher at the infant's bedside, and c) guided practice sessions for the mother that involved her infant. As in previous studies, this study documented the usefulness of the modified BNBAS as an intervention tool. The findings of this study support aforementioned literature concerning the use of the BNBAS as an intervention tool with mothers and their infants. Additionally, this

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71 study expanded the current literature base by showing that the BNBAS may b e used to enhance adolescent mothers social initiations toward their premature infants in the NICU. These findings also justify the need stated in the literature for intervention to start as early as possible (VandenBerg 1985). The maturation of the infant dictates the types of interventions that can be used with the infant (Als 1992; Wyly 1995). However, as the infants developmental status matures interventions that include providing the infant with age appropriate stimuli can occur. Initial analysis revealed significant gains on dependent I measures for all participating adolescent mothers. These findings are consistent with the results of previous research (Widmayer & Field 1980; Szajnberg et al.l987; Parker et al. 1992; Britt & Myers 1994; Beeghly 1995) that showed that learning BNBAS interventions during the neonatal period have a beneficial effect on the quality of parental interactions for mature parents (Ainsworth 1995). However, the findings of this study I were the first to show that the modified BNBAS was successfiil as an intervention with adolescent mothers and their premature infants in the NICU. I The social validity questionnaire reported that the adolescent mothers who participated in this study found the intervention to be very informative and they enjoyed playing with their infant. This was consistent with previous research where mothers reported receiving benefit fi-om participating in BNBAS training sessions, but gains fi-om this study were achieved with an adolescent population (Raugh et al. 1990; Parker et al.,1992; Britt & Meyers 1994). The resuhs of this study confirm the importance of developing early interventions based on developmental assessment. The modified BNBAS intervention had positive effects on all of the adolescent mothers social initiation toward their premature infants in

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72 the NICU. After the intervention mothers were able to maintain the effects their positive behaviors for the remanding days their infant was hospitalized. The social validity questionnaire reported that all of the mothers feh the intervention was helpful. Limitations to the Present Study There were several limitations to the study that threatened the external and internal validity of this study. The number of participants, the ability to determine the long-term impact of the study on adolescent mothers' appropriate social initiations, the data collection system and procedures, and the design of the study may have threatened the external and internal validly of this study. While it seemed to be generally positive that the intervention was equally effective for all adolescent mother's of different ages The number of participants was a limitation that threatened the external validity of the study. The small number of participants threatened its generalizability to other adolescents and their premature infants. An additional threat to eternal validity was the inability to determine the generlizability of the interventions effects on the mother's targeted behavior over time. During the maintenance phase of the study data was collected over three to five sessions over the remainder of the time the infant was hospitalized. The data collection during maintenance was limited because the infants were discharged from the hospital. Therefore, we were unable to determine if the intervention would have lasting effects on the mother's social initiations toward her premature infant. The internal validity of the study was threatened by the data collection system and procedures, as well as the design of the study. The data was collected using the partial

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73 interval method. The partial interval recording system provides several advantages (Tawney & Gast, 1984). First, it reacts to behaviors with high frequency and low frequency. Second, it permits more precise statement of interobserver agreement by allowing computation of point-by-point reliability. Interobserver reliability was employed during this study, and the point-by-point method for computing the coefficient was used in this study to ensure the reliability of data collection. However, this method can over or underestimate the data and could adversely aflfect reliability. The literature on attachment theory states that the quality of the interaction is affected by the way the mother reads her infant's cues and initiates social interaction toward her infant, thus affecting the attachment process (Ainsworth, 1996; Levit, 1999). However, internal validity is threatened because data was collected on only the mother's social initiations toward her infant. This data only allows us to understand the mother's behavior and not the interaction between the mother and infant, which is important for mother infant attachment. Recommendations for Future Research & Practice This study was conducted to examine the effects of a modified version of the BNBAS intervention on the social initiations of adolescent mothers toward their premature infants while in the NICU. Study results suggest that early intervention, which teaches adolescent mothers about infant behavior, calming techniques, and appropriate social initiations, has a positive effect on a mother's appropriate social initiations toward her premature infant in the NICU. As a result, these findings have several implications for training parents to use a modified version of the BNBAS to read signs of stress, calm, and socially engage their

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74 infants in the NICU. Doctors, nurses, and medical professional should understand that using the BNBAS with adolescent mothers and their infants can be a helpful tool for developing social interaction skills while their infant is hospitalized. Early interventionists should also understand that BNBAS instruction that includes practice of social interaction skills in a meaningful context might be beneficial to high-risk parents and infants after they have been discharged from the hospital. This study establishes that adolescent mothers can learn social initiations I techniques in the NTCU. However, it does not establish whether the techniques would have the same effects with fathers, in a different setting, or the longitudinal effects of the intervention. Therefore, it is important that future research focus on these areas. Future research should focus on teaching the NBAS techniques to adolescent fathers. Harrison & MagiU-Evans (1996) reported that mature fathers had fewer social interactions with their term and preterm infants than did mature mothers during the first year of being a parent. Another study reported that mature mothers of hospitalized preterm infants engaged in more social interactions than did fathers (Levy-Shiflf, Sharir, & Mogliner, 1990). There is no research that exists concerning teaching adolescent fathers about appropriate social initiations toward their premature infant while they are in the NICU. Therefore, there is clearly a need for future research to take place. Another area future research should focus on is the effectiveness of the NBAS intervention with adolescent mothers and their premature infants in various setting such as in the home or a daycare setting. Beginning intervention training while the infant is hospitalized and extending that training after discharge may help the lasting effects of the intervention on an adolescent mothers social initiations toward her infant.

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75 In addition to studying the effects of the intervention on adolescent mothers appropriate social initiations toward her infant in the NICU research should focus on the interventions longitudinal effects on social initiations and infant development. Researchers could follow two groups of adolescent mothers, those who received BNBAS intervention training and those who did not. Researchers could follow up on the mothers' social initiation behaviors at six months and the infants' development at one year to determine the long-term effects of the intervention of the mothers behaviors and infant development. Future research should also examine the effects of social support for adolescent mothers who have premature infants in the NICU. In addition to the BNBAS intervention an interview with the mother would take place at the beginning of the study and after discharge from the NICU. The goals of the interviews should be (a) to identify the needs that the mothers have, (b) to identify their perceptions of the support system the NICU, and (c) to determine the effectiveness of the NICU support system. This may increase the likelihood that the specific needs of families would be met. In conclusion, the present study has shown that adolescent mothers social initiations toward their premature infants can be influenced by early intervention. The birth of a premature infant to an adolescent mother in need of neonatal care implies a less than optimal condition for the development of positive interactions. Thus, future research should focus on using the BNBAS as an intervention with both adolescent mothers and fathers educating in understanding their premature infant's developmental needs, reading their behavioral cues, and initiating appropriate interactions. Specifically, future studies are needed to look at the use of the NBAS intervention in various setting and the long-

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76 term effects of BNBAS intervention on attachment and infant development wdth these high-risk populations. When parents learn to read behavioral cues and careftiUy determine the appropriate interaction with their high-risk infant, they can help in the process of getting back on track toward a more optimal developmental outcome.

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APPENDIX A PERMISSION FORMS

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IRB^ 483-1999 Informed Consent to Participate in Research The University of Florida Health Science Center, Gainesville, Florida Shands at Alachua General Hospital, Gainesville, Florida University Medical Center, Jacksonville, Florida You are being asked to participate in a research study. This form provides you with information about the study. The Principal Investigator (the person in charge of this research) or his/her representative will also describe this study to you and answer all of your questions. Read the information below and ask questions about anything you don't understand before deciding whether or not to take part. Your participation is entirely voluntary and you can refuse to participate without penalty or loss of benefits to which you are otherwise entitled. Name of the Subject Title of Research Study Effects of a Behavioral Intervention on Adolescent Mother's Initiations Toward Her Premature Infant in the NICU University of Florida Health Center Institutionai Review Board APPROVED FOR USE Principal Investigator(s) and Telephone Number(s) Stacy A. Paolini, M.S. (352) 392-0701 wk. (352) 395-6451 hm. Fro m ia\\3\DO Through_Q \\(y\\ If you are a parent of a minor mother who qualifies to be in this study, as you read the information in this Consent Form, you should put yourself in your child's place to decide whether or not to allow your child to take part. Therefore, for the rest of the form, the word "you" refers to your child. If you are an adolescent mother reading this form, the word "you" refers to you. What is the purpose of this study? Early mother-infant interactions appear to help children have positive experiences later in life. Preterm infants, tend not to be very active in interactions. The purpose of this study is to test a 78 Page 1 11/30/00

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79 program designed to help adolescent nnothers of preterm infants learn how to interact with their babies. We want to collect information on whether the program is actually helpful to adolescent mothers. What will be done if you take part in this research study? If you are willing to take part in this study, you will be asked to watch a 15 minute video of a mother and infant interacting and attend 3 practice sessions with your infant and the principal investigator in the NICU where you will practice interacting with your infant using rattles, a red ball and your face and voice. After the practice sessions a research assistant will observe your interactions with your infant at your infants bedside in the NICU. Observations will occur approximately 3 times per day for 5 minutes over 3 weeks time. At the end of the study you will be asked to fill out a questionnaire, which consists of 5 questions. The questionnaire will be used to obtain your suggestions in order to make changes to tlie training sessions for future research. What are the possible discomforts and risks? There is a possibility that you will be uncomfortable during the observations and answering the questionnaire. At any time during the study you can stop taking part in it. If you wish to discuss the information above or any other discomforts you may experience, you may ask questions now or call the Principal Investigator listed on the front page of this form. What are the possible benefits to you or to others? If the program is helpful, you may have better interactions with your preterm infant, but this cannot be guaranteed. The information we collect from this study may help us learn how to improve interactions between adolescent mothers and their preterm babies in the future. If you choose to take part in this study, will it cost you anything? Participation in this study will not cost you anything. Will you receive compensation for your participation in this study? For participating in this study you will receive a developmental toy at the end of each week worth $5.00. At the end of the study you will also receive a book on child development worth $10.00. Total worth of the items will be $25.00. What if you are injured because of the study? If you experience an injury that is directly caused by this study, only professional consultative care that you receive at the University of Florida Health Science Center, Shands at Alachua General Hospital, and University Medical Center will be provided without charge. However, hospital expenses will have to be paid by you or your insurance provider. No other compensation is offered. Page 2 11/30/00

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80 Signatures As a representative of this study, I have explained the purpose, the procedures, the benefits, and the risks that are involved in this research study: Signature of person obtaining consent Date You have been informed about this study's purpose, procedures, possible benefits and risks, and you have received a copy of this Form. You have been given the opportunity to ask questions before you sign, and you have been told that you can ask other questions at any time. You voluntarily agree to participate in this study. By signing this form, you are not waiving any of your legal rights. Signature of Subject Date Signature of Witness (if available) Date If you are not the subject, please print your name and indicate one of the following: The subject's parent The subject's guardian A surrogate A durable power of attorney A proxy Other, please explain: Page 4 11/30/00

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81 How will your privacy and the confidentiality of your research records be protected? Authorized persons from the University of Rorida, the hospital or cHnic (if any) involved in this research, and the Institutional Review Board have the legal right to review your research records and will protect the confidentiality of those records to the extent permitted by law. If the research project is sponsored or if it is being conducted under the authority of the United States Food and Drug Administration (FDA), then the sponsor, the sponsor's agent, and the FDA also have the legal right to review your research records. Otherwise, your research records will not be released without your consent unless required by law or a court order. If the results of this research are published or presented at scientific meetings, your identity will not be disclosed. Will the researchers beneHt from your participation in this study (beyond publishing or presenting the results)? The researcher will present the results of the study to a University of Florida doctoral committee and upon its approval will be granted a doctoral degree from the University of Florida. What if you are under 18 years old or if you cannot give legal consent for another reason? Because of your age you cannot give legal consent to take part in this study. Therefore, the researcher will ask for your assenL Assent is your agreement to be in the study. The researcher will explain the study to you in words that you can understand. You should ask questions about anything you don't understand. Then you should decide if you want to be in the research study. If you want to participate, your parent or someone who can sign a legal document for you must also give their permission and sign this form before you take part. You agree to participate. Subject's signature Date Signature of Principal Investigator or Date Representative Witness (if available) " Date Page 3 11/30/00

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82 /ideotape Consent »Vith your permission, you will be videotaped during this research. Your name or personal nformation will not be recorded on the videotape and confidentiality will be strictly maintained, however, you should be aware that the showing of these videotapes may result m others being ible to recognize you. The videotapes will be kept in a locked cabinet by Stacy A. Paolini. rhese videotapes will be shown under Ms. Paolini' s discretion to students, researchers, doctors, and other professionals and persons. Please sign the following statement that indicates under what condition Ms. Paolini has permission to use the videotape. [ give my permission to be videotaped solely for this research project under the conditions described. Signature Date Page 5 11/30/00

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APPENDIX B DATA COLLECTION FORMS

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Table Bl. Data Recording Sheet Date ( -00) To tal % Time Intervals 20 20 20 20 20 20 20 20 20 20 20 >0 20 20 20 20 20 20 20 20 Infant's Behavior State 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 I 2 3 4 5 I 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 ) i 1 i 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 X It OUvoa H EA H EA H EA H EA H EA H EA H EA H EA H EA H EA H EA ] I :a H EA H EA H EA H EA H EA H EA H EA H EA Infant Rest Stress D HB R V b HB R D HB R D HB R Y a HB R Y B HB R Y B HB R Y B HB R Y B HB R Y^ B HB R B HB R \T V I I I \ 1 i iB I T B HB R V B HB R V B HB R v V B HB R B HB R B HB R \r \ B HB R V V B HB R \ Terminate Total Mother's Behavior Dim Lights Swaddling Gentle Vestibular Holding Patting Pacifier FaceA^oice Rattle Ball Other: Mothers Appropriate Interactions Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Time Intenals20 seconds Infant's Behavioral State1-asleep; 2-drowsv . 3-awake: 4-irritable; 5-crving Pre StressH-hiccups; ; EA-eye aversion StressHB-heart beat: BL-blue lips. R-respiration. Vvomiting Mother's Behavior/Social Interactionemptv box = opportunity not recognized; V-opportunity recognized InteractionsY-Appropriate Interactions; NNot Appropriate Interactions 84

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APPENDIX C INTERVENTION SCRIPT

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Intervention Script Researcher: We are going to talk about three things today and watch a short video where you will see a mother and her baby playing. The first thing we are gong to talk about is how to know when your baby is ready to play. Next we will talk about what to do when your baby is upset and crying. Last, we will talk about how to play with your baby when he/she is calm and awake. While we are watching the video I'll stop it so we can talk about what we saw. Do you have any questions before we begin? Start Video On Screen are the words " Behavioral States" Researcher: This baby is asleep; his eyes are closed his breathing is regular and he is not moving (Video shows sleeping baby). This baby is irritable, his arms and legs are moving around and he is making a lot of noises. (Video shows an irritable baby) Here is a drowsy baby. His eyelids are heavy and he has a hard time keeping them open and he moves very little (Video shows a drowsy baby). This baby is awake and alert. His eyes are open and he is moving his arms and legs. (Video shows awake baby). Stop Video Researcher: Mother: Researcher: Here we see a crying baby. He is very upset, crying and moving his arms and legs. (Video shows a crying baby). And now we are going to review some of the things we saw the baby doing in the video. Can you tell me about a baby who is drowsy? What would he look like? Yes, his eyes are heavy and he is not moving around much. That's right; the baby we saw kept falling asleep and could not keep his eyes open. 86

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87 Can you tell me about a baby who is irritable? Mother: Yes, the baby was making lots of grunting and short cries. Start Video On screen the words "Soothing Techniques" Researcher: Most premature infants don't really like too much playing like rocking, talking to or singing to especially if we do them all at the same time. They might get upset and cry or keep their eyes closed. These are signs that your baby may be getting stressed out and we should take a break from playing with him/her. It's important to know when your baby is getting stressed for two reasons 1 . He may get too excited and this may cause unusual breathing and heart rates, 2. You want your baby to stay relaxed so you can interact with him. The following are some of the stress signs you may see. Crying Hiccups Looking away from you Sneezing When you see these stress signs you should stop playing with your baby and let him rest for a few a few minutes before you start to play again. There are some stress signs that are much more serious such as blue lips, stop breathing, drop in heartbeat. If these things happen then you should stop playing immediately and tell a nurse of doctor. There are things you can do to help keep your baby relaxed so you can play with him. They are: swaddling, lowering lights, holding, using your face/voice, and using a pacifier. Before you begin to play with your baby you want to swaddle him in a blanket. Swaddling the baby helps him feel safe and secure. It also helps keep his arms and legs from moving around too much. (Video shows swaddled baby). Sometimes babies have a hard time opening their eyes when the light is too bright so you want to make sure to dim the lights over his bed. Holding your baby can help calm him down when he/she is upset. When you hold your baby you can rock him in a slow up and down movement to calm him. Sucking is one way a baby calms himself when crying so you will want to give him his pacifier.

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88 Stop Video Researcher: Mother: Researcher: Mother: Start Video; Researcher: You have probably been doing some of these things with your baby already. Lets review some of the things we saw. When should you stop playing with your baby? If my baby hiccups, his lips turn blue, cries, or he keeps his eyes closed. That's right. How would you calm your baby if he became upset? I would trying and use my face and voice and if he kept crying I would give him his pacifier. "Social Interaction" appears on the screen. Now we are going to see a mother playing vnth her baby in the NICU. During the video you may see the mother use the soothing techniques in order to calm and play with the baby. Here we see the mother at her baby's crib and she has swaddled her baby. Next, she dims the lights. She is getting ready to play with him. She will use a red ball, a rattle, and her face and voice. On Screen: Red Ball The mother takes another minute to let the baby rest and then she uses a red ball to try and get her baby to following it to each side. She holds the red ball 10-12 inches in fi-ont of the baby's eyes moving is slowly from one side to the next. The baby is able to following the ball only with his eyes to both sides. On Screen: Rattle Next, she picks up the rattle. She holds it 10 inches fi-om the baby's ear and shakes the rattle trying to get the baby to move his eyes toward the rattle or turn his head. She will shake it again on the other side. This baby is able to turn his head to each side when the rattle is shaken. On Screen: Face & Voice She holds her baby and softly speaks to the baby calling his name etc. See how the infant's eyes are following the mothers face. She stops for a

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89 minute to give the baby a break then starts speaking to him in his other ear. Stop Video Mother: Researcher; Mother: Researcher: Mother: The mother is only doing one thing at a time with her baby. You do not want to use your voice and rattle or voice and red ball together because this will upset your baby and he will not be able to play with you. Most premature babies do not like too much play time because they get tired and need to rest. Lets review some of the things we just saw in the video. What are some of the things the mom used to play with her baby? The face & voice, rattle, and red ball. Very good. Why should you use one toy when you play with your baby? Because the baby will get tired and upset. That's right your baby will get tired very quickly. Do you have any questions about playing with your baby? No. Researcher: Then why don't we go to your baby's crib and I can show you some of the things we just saw in the video.

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APPENDIX D SOCIAL VALIDITY QUESTIONAIRE

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Social Validity Questionnaire 1 . The NBAS training was helpful for providing me with information about my baby's behavior. definitely was was a little definitely was not 2. The NBAS training was helpfiil for providing me with tips on how to calm my baby when he/she is upset. I definitely was was a little definitely was not 3 . The NBAS training was helpfiil for providing me with tips on how to play with my baby in the NICU. definitely was was a little definitely was not 4. I continued to use the information about calming and playing with my baby at home'' definitely have have a little definitely have not 5. I would recommend that other mothers learn the about their baby's behavior, ways to calm and play with them while they are in the NICU. definitely would maybe definitely would not If "no" please explain 91

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APPENDIX E PILOT STUDY

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Baseline Intervention Maintenance Figure E-1. Pilot Study Graph 93

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APPENDIX F GRAPHS 1 & 2

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Dyad 1 Baseline 100 80 60 40 20 Dyad: 100 80 60 40 20 Figure F-1. Intervention Maintenance L. oo8 10 Sessions 95

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APPENDIX G GRAPHS 3 & 4

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Dyad 3 Baseline Intervention Maintenance 100

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101 Fogel, A. (1991). Infancy. St. Paul, MN: West Publishing Company. Fox, N., Kimerly, N.L., & Schafer, W.D., (1991). Attachment to mother/attachment to father: Meta analysis. Child Development, 62, 210-225. Frankel, K.A. & Bates, J.E. (1990). Mother-toddler problem solving: Antecedents in attachment, home behavior, and temperament. Child Development, 61, 810-819. Gorski, P. A. (1991). Developmental intervention during neonatal hospitalization: Critiquing the state of the science. Pediatric Clinical North American, 38, 1,469-1,479. Gottwald, S.R., & Thurman, S.K. (1990). Parent-infant interaction in neonatal intensive care units: Implications for research and service delivery. Infants and Young Children, 2, 1-9. Graven, S.N., Bowen, F.W., Brooten, D., Eaton, A., Graven, M.N., Hack, M., Hall, L.A., Hansen, N., Hurt, H., Kavalhuma, R., Little, G.A., Mahan, C, Morrow, G., Ill, Oehler, J.M., Poland, R., Ram, B., Sauve, R., Taylor, P.M., Ward, S.E., Sommers, J. G (1992). The high-risk infant environment art 1. The role of the neonatal intensive care unit in the outcome of high-risk infants. Journal of Perinatology, 12 (2), \(A-\11. Griffin, T. (1990). Nurse barriers to parenting in the special care nursery. Infants and Young Children, 4, 3 1-42. Grossman, K., &. Grossman, K.E. (1985). Maternal sensitivity and newborns orientation responses as related to quality of attachment. Child Development, 50, 233256. Grossman K., &. Grossman, K.E. (1992). Newborn behavior the quality of early parenting and later toddler-parent relationships in a group of German infants. In J.K. Nugent, B.M Lester, & T.B. Brazelton (Eds), The adtural context of infancy. Norwood NJ: Ablex. Gustafson, G. E. & Harris, K.L. (1990). Women's responses to young infant's cries.Developmental Psychology, 26, 144-152. Hamihon, L A. (1996). Dyadic family relationships and gender in adolescent identity formation: A social relations analysis. (Doctoral dissertation. University of Texas @ Austin, 1996). Dissertation Abstracts International, 57, 4056. Harrison, M.J. (1990). A comparison of parental interactions with term and preterm infants. Research in Nursing & Health, 12, 1 731 79. Hazen, N.L. & Dunst, M E. (1982). Relationship of security of attachment to

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BIOGRAPHICAL SKETCH Stacy Ann Paolini was born in Long Island, New York, on October 28, 1966. The youngest of three children, Stacy graduated from Madonna Academy Catholic High School in Hollywood, Florida in 1984. Stacy received her B.S. in business administration from Flagler College in 1988, She received her M.S. in special education from Nova Southeastern University in 1991. During the period of 1991 through 1995, Stacy taught in inclusive and special education classrooms in Broward and Alachua counties in Florida. Her teaching experiences included teaching students with mild to severe intellectual, behavioral, and learning disabilities. Most of her teaching experiences were at the elementary level, but she taught students of middle school age, as well. While completing her doctoral studies at the University of Florida, Stacy served as a graduate research assistant in the Department of Special Education. She also served as a liaison consuhant at the Muhidisciplinary Diagnostic Training Program, a joint project with the Department of Pediatrics and Special Education. She also participated in an internship in the neonatal intensive care unit at Shands Teaching Hospital at the University of Florida. Her responsibilities included providing developmental assessment, interventions, and support for infants and their families. She was fortunate to have participated in an extemship with the Associate Vice President for Health Atfairs for 108

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109 External Relations at the University of Florida in government relations activities at the state level in Tallahassee, Florida. During her doctoral program, Stacy was also active in Special Education Association of Graduate Students, serving as vice president. She was also a representative on the Graduate Student Council. She is a member of the Council for Exceptional Children. In the future, Stacy plans to work in government relations and lobby for legislation that addresses education and heahh issues, especially those about persons with special needs and their families.

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I certify that I have read this study and that, in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Mary T. EfAwnell, Chair Associate Professor of Special Education I certify that I have read this study and that, in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Vivian I. Correa, Co-Chair Professor of Special Education I certify that I have read this study and that, in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Maureen Conroy Assistant Professor of Special Education I certify that I have read this study and that, in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Tina M. Smith-Bonahue Assistant Professor of Educational Psychology I certify that I have read this study and that, in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

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Professor of Pediatrics This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. August 2001 Dean, College of Education Dean, Graduate School